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Bluecross B1ueShield <br /> of Horida EMPLOYER APPLICATION <br /> Health options. (True Group Application) <br /> awrw. .. imc. e.au:.�..aw aW a® <br /> aw.snine.waaa. <br /> III . Health Plan Summary Information (select the appropriate box [ si ) : <br /> Mandated Benefit Offerings : (Optional) Applicant has been advised of the following benefit offerings mandated <br /> by the Federal and/or State Law. Applicant's decision to accept or decline these benefits is indicated below . <br /> Included in <br /> product Accept Decline <br /> ❑ ❑ ❑X Mental & Nervous Disorder <br /> ❑X ❑ ❑ Alcohol & Drug Dependency <br /> ❑X ❑ ❑ Mammograms Waiver of Deductible & Coinsurance <br /> ❑X ❑ ❑ Enteral Formulas <br /> Single Plan ❑ Blue Packages <br /> Health Plan Name Rx Option (indicate copayments) <br /> f3lueChoice PPO PliyCopay 704 - NStd Bluescript V 10/25/40 - Std <br /> Calendar Year Deductible : Coinsurance : <br /> Per Person $300 In - Network / Participating g0 % <br /> Out-of- Network / Non - Participating <br /> Per Family $600 <br /> Office Visit Copay: <br /> Pre- ExistingFamily Phy. <br /> Prtitixisting Applies 3/ 12 $ 15 <br /> Rates. All Other Providers $35 <br /> Employee $(,4 .00 Employee/SpouseEmployee/Child (ren Family $64.00 Other <br /> See the Group Master Policy for a complete description of benefits . <br /> IV. Health Saving Account (HSA) Banking Arrangement (optional with HSA Compatible health plans) <br /> A . Are you choosing BCBSF's integrated HSA banking arrangement? Yes IR No <br /> (if left blank , the response is assumed to be No . ) <br /> V. Rate Information <br /> A . Premium/Prepayment fee are payable monthly on or before the due date which will be: 1st. <br /> B. Regular Billing- Employee applications should be submitted thirty (30) days prior to proposed Effective Date . <br /> Employee cancellations must be submitted within 30 days of the Effective Date of the Termination . <br /> C . The Rates established for this Policy will not be changed for the first twelve ( 12) months following the initial Effective <br /> Date of Coverage unless there is a change in benefits or a 15% or more change in the composition of the group . <br /> However. BCBSF/HOI may change the Rates that are to be effective after this initial twelve ( 12) month period of <br /> coverage by providing notice to the employer of such changed Rates forty-five (45 ) days prior to their Effective Date. <br /> D . Funding Arrangements : BCBSF: ASO i <br /> HMO : <br /> E . Rate Comments : 1: <br /> 13123-995 SR (Rev 0805) 7/17/2006 1017:08AM <br />