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In consideration of the payment of Premiums when due and subject to all of the terms of this Agreement. <br />Blue Cross Blue Shield of I'lorida. Inc. hereby agrees to provide each enrollee of Indian River Count•. <br />ROCC benefits of this Agreeinent is set forth in the attached Evidence of Coverage beginnin,, on each <br />enrollee's effective date. <br />The Group has selected the following plan and premium: <br />PP02Rx1 <br />Medical: ($37.15) <br />Rx1 $283.39 <br />D/V/H $7.00 <br />Fitness: $4.00 <br />TOTAL: $257.24 pmpm <br />The Group's Agreement is effective as ofOctober 1, 2020. <br />IN WITNESS WHEREOF, the parties have executed this Agreement as of <br />(date) <br />Blue Cross Blue Shield of Florida, Inc. Indian I <br />(DBA Florida Blue) <br />By: By: <br />(Signature) <br />Name: Lynn Esposito Name <br />(Please Print or Type) <br />Title: Vice President, Sales Operations Title: <br />121 <br />(Please Print or Type) <br />�C� Y'►��� i1 i� YGdf'� <br />