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03/17/00 11:00 FAX <br />PHIL BRETT <br />MAYFIEI.® VILLAGE <br />S61Z05901 <br />Rertewa! Effective: April 1, 2000 <br />-~ LAW DIR ~ 005 <br />OOMIUIUNITY PREFERRED FIRST DOLLAR <br />Calendar Year Oeducti6le Calendar Yeor Co-rnlurarlee '~+P'Ouf of Faesmr ~°~~~+++~ <br />Network Nan-Netwatk <br />Network Non-Network o% of first 20% O/ first Network Nan-Network <br />ual 50 SO 50 52.000 SO 3400 <br />SO SO 30 54.000 SO 5800 <br />Benefit Ptarr Highlights <br />Inpatient/Outpatient Hospital Care ~ Health Care Management Program <br />Physician Charges: SBt515 Emergency and Accident Care <br />Prescription Drugs: 55 Diagnostic Services <br />Maternity, Wekl Baby & Welk Child Care lifetime Maximum Benefit of 52.000.000 <br />12 Month Pre-Existing Clause Psychiatric Care 8 Substance Abuse <br />Sexuai Dysfunction Coverage Excluded <br />~Rer the emo:ayee raecnes :he mer,mum. Anthem 31ue Cross and 91ue Sh~eid covers the remamrng eGgiCle charges. <br />!Reler :a your Commurnty insurance Camaany benefit baokletrsl far oeneiit detaus and I~mttationsl <br />PR>oMIUM RENEWAL INFORMATION <br />Coverage Contracts HEALTH urug vemat ~~a~~~~ ~ .~....~... <br />Employee 10 <br />Family 37 5235.30 <br />3712.59 50.00 30.00 <br />30.00 50.00 50.00 52.353.00 <br />50.00 326.365.83 <br />TOTAL 47 528,718.83 S0.00 30.00 50.00 528,718-83 <br />Coverage Contracts HEAt_TH Drug Oentat Vision Premium <br />Employee 10 5258.83 50.00 50.00 <br />' 50.00 52.588.30 <br />~ <br />EmplSps t1 5618.66 50.00 50.00 50.00 58,805.26 <br />Emp/Child 1 5475.t1~ 50.00 30.00 30.00 5475.11 <br />Family 25 5868.88 50.00 50.00 SO.00 521,722.00 <br />vorA~ 47 531-,590.6% 50.00 50.00 50.00 531,590.67 <br /> Premium is increasing by t0% <br />`~ A <br />