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BlueC <br /> � of rossBlueshiela EMPLOYER APPLICATION <br /> of FloridaFlo <br /> • • Health Options. (True Group Application ) <br /> �. w <br /> IH . Health Plan Summary Information (select the appropriate boxjsj) : <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 /> 0 ❑ ❑ Alcohol & Drug Dependency <br /> Q ❑ ❑ Mammograms Waiver of Deductible & Coinsurance <br /> Q ❑ ❑ Enteral Formulas <br /> 0 Single Plan ❑ Blue Packages <br /> Health Plan Name Rx Option (indicate copayments) <br /> BlueChoice PPO P111'Copay 704 - NStd Bluescript V 10/25/40 - Std <br /> Calendar Year Deductible: Coinsurance: <br /> Per Person $300 In-Network / Participating <br /> Per Family <br /> Out-of-Network / Non - Participating fi0 <br /> 8600 <br /> Office Visit Copay: <br /> Pre- Existingpp Family Phy. <br /> 1 re- Existin � Applies 3/ 12 $15 <br /> Rates. All Other Providers $35 <br /> Employee $64.(1(1 Employee/SpouseEmployee/Child (ren Family $64.00 Othei�� <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? <br /> ( if left blank , the response is assumed to be No. ) ❑ Yes ❑X No <br /> V. Rate Information <br /> A . Premium/Prepayment fee are payable monthly on or before the due date which will be: Ist. <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: 16:56AM <br />