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BlueCross <br /> ofHoridaa BlueShield EMPLOYER APPLICATION <br /> of Flori <br /> • HealthOptlons• (True Group Application) <br /> .bee. sn.ierw.a . <br /> III . Health Plan Summary Information (select the appropriate boxlsl ) : <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 /> ElEl Ex Mental & Nervous Disorder <br /> QX El ❑ Alcohol & Drug Dependency <br /> ❑X ❑ Mammograms Waiver of Deductible & Coinsurance <br /> 0 El ❑ Enteral Formulas <br /> 0 Single Plan Blue Packages <br /> Health Plan Name Rx Option (indicate copayments) <br /> IBIueChoice PPO PhyCopay 704 - NStd Bluescript V 10/25/40 - Std <br /> Calendar Year Deductible : Coinsurance: <br /> Per Person $$00 In - Network / Participating 80 °U <br /> Out-of- Network / Non - Participating <br /> Per Family $600 <br /> Office Visit Copay: <br /> Family Phy. <br /> Pre-Existing Pre- ExistingApplies 3/ 12 $ IS <br /> Rates. All Other Providers $35 <br /> Employee $64.(10 Employee/SpouseEmployee/Child ( ren Family $64.UU 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 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 1 <br /> HMO : <br /> E. Rate Comments : <br /> 13123-995 SR ( Rev 0805) 7/17/2006 10: 16:52AM <br />