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. M ..,.Q.o~. ticamas dar Py. Oo. d &I.. Aai. A.oAOtoa <br />_ MAYFIELD VILLAGE <br />Renewal Effective: 3/1/98 <br />GID: 561305901 <br />Community Preferred First Dollar <br />Renefrt Plan Highlights <br />- Major Medical (Deductibles and Coinsurance may Apply) -Health Care Management Program <br />- InpatiendOutpatient Hospital Care - Emergrncy and Accident Care <br />- Physicip~i Charges: 58 net./$15 non-act. Co-pay -Diagnostic Services <br />-Prescription Drugs: $5 Co-pny -Lifetime Maximum Benefit of $1,000,000 <br />- Maternity, WeII Baby 8c Well Child Care -Psychiatric Care & Substance Abase <br />- 12 Month Pre-existing Clause -Human Organ Transplant (Limitations Apply) <br />caner taa employee rrxhea tacit maietueq Commimiq ]nsuaanx •' . apaoy ewm rho the rvaainvig eligible ~ <br />(Refer to your Comntt+wry imtuance Company benefit boolaEt(a) frn benef t deteik and titnitasinna) <br />Caarrent Monthly Heahlr Prvmierme <br />Coves a Ems Health Dru Dental VLsibn TOTAL <br />Em to ee 9 $193.00 $24.53 * * $2 17.53 <br />Famil 33 $603.36 -$55.42 * * X58,78 <br />Month 42 S21 7.88 S2 049.63 * * $23 97,$1 <br /> Renewal Month! Health Premiums <br />ji Covera a Em ~ Heakh i Dru Dental Vislon TOTAL <br />~: <br />'~ Em to ee <br />9 <br />5212.30 <br />$26.98 * <br />* <br />$239.28 <br />!` Famil I 33 5663,70' $60.961 * 5724.66 <br />~_ Month! 42 523 12.80' S2 5450 * S26 067.30 <br />...,.~ aty~ ~~,~ x, ...„ <br />Premiums are increasing by 10.0% <br />The above ptetmuma include SO.t77 per month per cmployec uvtbutable to a guaranty poltry issued by Araoeiated lttstaatoce Compame>. Inc <br /> <br />Bo Registered marlea Blue Croaa and Blue Shiold Aaaoci.tion. Antlxm Blua Cmaa and Biux sluetd to the wade name of emuatatiry Irtataaoee Company. Page I <br />