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BlueC <br /> of Florida <br /> rBlueshield EMPLOYER APPLICATION <br /> r � � of Flo <br /> Health Options. (True Group Application) <br /> a�dwn �°~a~E°: <br /> w en.anwiawee.a. <br /> 111 . 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 /> ❑ ❑ R Mental & Nervous Disorder <br /> ❑X ❑ ❑ Alcohol & Drug Dependency <br /> ❑X ❑ ❑ Mammograms Waiver of Deductible & Coinsurance <br /> 0 ❑ ❑ Enteral Formulas <br /> RSingle Plan ❑ Blue Packages <br /> Health Plan Name Rx Option (indicate copayments) <br /> 13111eChoice PPO PlrvCopay 704 - NStd 6luescript V 10/25/40 - Std <br /> Calendar Year Deductible : Coinsurance: <br /> Per Person53011 In -Network / Participating <br /> Out-of-Network / Non - Participating fi0u/, <br /> Per Family 5600 <br /> Office Visit Copay: <br /> Pre- ExistingFamily Phy. <br /> Prc- Existing Applies 3/12 $ l5 <br /> Rates. All Other Providers S35 <br /> Employee S64A0 Employee/SpouseOEmployee/Child (ren Family 564.00 Othe � <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 1 <br /> HMO : <br /> E . Rate Comments: <br /> 13123-995 SR (Rev 0805) 7/17/2006 10: 17:30AM <br />