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.I <br /> I <br /> Niue Cros a+ui Nli:r Shicid rssociil;iun STOP LOSS PROPOSAL FOR <br /> -- --____ Indian River County BOCC <br /> Sales Representative: George Eppl <br /> Broker: Gehring Group Effective Date: 10/01/2015 <br /> TPA: Florida Blue Through Date: 09/30/2016 <br /> Provider Network(s): Florida Blue <br /> Utilization Review Vendor(s): Florida Blue <br /> Specific Deductible(per Covered Individual) ' =f: �A�>-__ s_�-_•__ a' <br /> 330. <br /> Policy <br /> cy Year ? $2750001'• .'$300.000 <br /> Poli Maximum Specific Benefit . ; ; . <br /> Urillmite`d. '.�rriUiiliimted -Unlimi!ted <br /> Lifetime Maximum Specific Benefit .mie+d' �tCovered Benefits U�iut <br /> ed <br /> --. MedRx;Cartl � ? =��nj <br /> Specific.Premium ----- --- __ - ----- -= 4' ----- <br /> Composite88 <br /> Rate _ -------- -- - _.: . - - <br /> -24 <br /> Total Lives 1,565 °` " <br /> 1,565 <br /> Estimated Contract Specific Premium - <br /> Contract Aggregating Specific Loss Fund <br /> $'14 <br /> `314$'751) <br /> 8,150 <br /> • <br /> Contract Basis <br /> $J48;760 <br /> _ --- _ .,. ;;t,`�;�:;�.:.,,=--,-�_• -. -�,�-.�_ <br /> '024112 <br /> Commission <br /> 00ie .. <br /> % <br /> •• <br /> Covered Benefits : _ ,- <br /> :`-, Med Rxit a . F Card <br /> Qa fir•-.6T.�-�-,�.s <br /> Policy Mei RX �1 , <br /> P Year Maximum �"1'�a:�; y- ': g:;-� ���-: ,.<� Wc,Card`. <br /> _ Viz',--. <br /> A99ni3gate_Facto --------------- 'i$1;000,000 .1� YVKMS�1f00ppp0� _ S 000 <br /> Composite Med&Rx Card Factor _-------- '--- `�� :.`:;`" — t, -' <br /> _ _ 1,565 $t1 00153'; �sE:100654;, f <br /> Estimated Contract Attachment Point __- -3 - <br /> - 1 565 -'-�-- .,�,-�-r.� <br /> __ $x8;808;733, .z $18,902,82;1k, 18 9T11 <br /> Contract Minimum Attachment Point(100%) - ,jgf � ���-���-�=Pei $18�9,7�7941 <br /> Aggregate Corridor <br /> '3125'�i �125°K <br /> Contract Basis i. 125.E <br /> - ----------- •24/:1.2:' �:����.�=_-� ;24/12. <br /> Composite Rate -------- 1,565----- --. ---- <br /> $1`41'...6` ,u:. T44 } <br /> Estimated Contract Aggregate Premium 1,565 K "' � $ '{ ?$1.471 <br /> $26;480' l '`:,' •r$ 7,043 $27;607 <br /> Commission <br /> -Total Combined Estimated Contract Premium $563,024 -- -- <br /> -----�-- ----- $492,036---- $441,142 <br /> Note:This proposal is not complete unless accompanied by the proposal notes and the basis of offer noted on the following pages. <br /> Individual Special Requirements: <br /> t•1 <br /> 56 <br />