East Coast Health Insurance Proposal INDIVIDUAL FAMILY PLANS Proposal for Individual Benefits by icm12814

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									East Coast Health Insurance Proposal


                                                          INDIVIDUAL & FAMILY PLANS




                    Proposal for Individual Benefits




                    July 24, 2009

                    Prepared by:
                    Caroline L Ehrenthal

                    10 Fairway Drive
                    Deerfield Beach, FL 33441
                    (954) 571-4177




                                                Page 1 / 11
East Coast Health Insurance Proposal

           CIGNA Medical & Pharmacy Quote
           Prepared by: Caroline L Ehrenthal                                                                  Effective Date: September 1, 2009
                        (954) 571-4177                                                                             Quote ID: 215873 - 1

           Applicant Information
                                                  Gender                         Age                  Tobacco usage                      Zip Code                         State
           John Doe                                  Male                         60                       No                              33441                            FL
            Spouse                                Female                          60                       No                             33441                            FL

                                                                                Open Access                 Open Access                 Open Access                Open Access
                                                                                     5000                       3000                        2000                       1000
            Individual Deductible*                                               $5,000/$10,000              $3,000/$6,000               $2,000/$4,000              $1,000/$2,000
            Family Deductible                                                   $10,000/$20,000             $6,000/$12,000               $4,000/$8,000              $2,000/$4,000
            Coinsurance*                                                            80%/60%                    80%/60%                     80%/60%                    80%/60%
            Individual Out-of-Pocket Maximum*                                    $5,000/$10,000              $4,000/$8,000               $3,000/$6,000              $2,000/$4,000
            Family Out-of-Pocket Maximum*                                       $10,000/$20,000             $8,000/$16,000              $6,000/$12,000              $4,000/$8,000
            Office Visit - Primary Care/Specialist                               $30/$60 Copay               $30/$60 Copay               $25/$50 Copay              $25/$50 Copay
            Emergency Care                                                       $100 Additional            $100 Additional             $100 Additional            $100 Additional
                                                                                Deductible, 80%             Deductible, 80%             Deductible, 80%            Deductible, 80%
            Urgent Care                                                               80%                         80%                         80%                        80%
            Lifetime Max                                                           $5,000,000                 $5,000,000                  $5,000,000                 $5,000,000
            Preventive Care - Primary Care/Specialist                            $30/$60 Copay               $30/$60 Copay               $25/$50 Copay              $25/$50 Copay
            PRESCRIPTION DRUGS
                                                                               $10/$35/$60 Copay           $10/$35/$60 Copay            $10/$35/$60 Copay         $10/$35/$60 Copay
            RX                                                                 Mail: $25/$85/$150          Mail: $25/$85/$150           Mail: $25/$85/$150        Mail: $25/$85/$150
                                                                                      Copay                       Copay                        Copay                     Copay

            David Walzak                                                            $325.00                     $358.00                     $428.00                       $565.00
            Spouse                                                                  $314.00                     $346.00                     $412.00                       $546.00
            Total Monthly Premium                                                  $639.00                     $704.00                     $840.00                       $1111.00
            *In-network/Out-of-network benefits                                APPLY for this              APPLY for this               APPLY for this             APPLY for this
            **Generic/Preferred Brand Name/Non-preferred Brand                     Plan                        Plan                         Plan                       Plan
            Name




           Coinsurance percentage represents what CIGNA pays; deductible may apply. Copay is a flat service charge that plan members are responsible to pay for
           services; deductible may apply.

           You may be eligible for additional plans. Please contact CIGNA Sales at 1-877-CIGNA-15 (877-244-6215) for further details.

           For additional information see disclaimer page(s).

           This material is for information purposes only and not an offer or contract. Plans may be subject to medical underwriting or other restrictions. Rates and
           benefits vary by location. Rates are subject to change based on rate increases, demographics and underwriting guidelines. Information is subject to change.
           This document highlights some of the benefits available under these plans. For specific costs and further detail of the coverage, including exclusions, any
           reductions or limitations and the terms under which the policy may be continued in force, consult the Summary of Benefits or Policy Booklet.
           a July 24, 2009             Effective Date: September 1, 2009                      Page 215873
                                                                                         Quote ID:2 / 11 - 1                                        Page 2 of 4
East Coast Health Insurance Proposal



                                                                    60 Male and 60 Female     33441         Eff Date 9.1.09




              AvMed Plus 2500                         POS Open Access 2500                      Copay Select 80 - 2500               OAC20-2500



              Estimated Cost                          Estimated Cost                            Estimated Cost                       Estimated Cost

              $890.28 monthly                         $1081.00 monthly                          $775.42 monthly                      $988.34 monthly

              Plan Type                               Plan Type                                 Plan Type                            Plan Type
              POS                                     POS                                       Network                              HMO

              Office Visit for Primary Doctor         Office Visit for Primary Doctor           Office Visit for Primary Doctor      Office Visit for Primary Doctor

              $35 Copayment                           $30 Copay                                 History and Exam: $35 Copay          $20 Copay

              Office Visit for Specialist             Office Visit for Specialist               Office Visit for Specialist          Office Visit for Specialist

              $50 Copayment                           $40 Copay                                 History and Exam: $35 Copay          $40 Copay

              Coinsurance                             Coinsurance                               Coinsurance                          Coinsurance

              20% after deductible                    20% after deductible                      20% after deductible                 20% after deductible

              Annual Deductible                       Annual Deductible                         Annual Deductible                    Annual Deductible

              Individual:$2,500                       Individual:$2,500                         Individual:$2,500                    Individual:$2,500

                                                                                                                                     Hospital Services Only


              Annual Out-of-Pocket Limit              Annual Out-of-Pocket Limit                Annual Out-of-Pocket Limit           Annual Out-of-Pocket Limit

              Individual:$2,000                       Individual:$5,000                         Individual:$3,000                    Individual:$2,000
              Does not include deductible             Includes deductible                       Does not include deductible          Does not include deductible


              Lifetime Maximum                        Lifetime Maximum                          Lifetime Maximum                     Lifetime Maximum

              $5 Million per person                   $5 Million per person                     $3 Million per person                Unlimited

                                                                                                Health Savings Account (HSA)         Health Savings Account (HSA)
              Health Savings Account (HSA) Eligible   Health Savings Account (HSA) Eligible     Eligible                             Eligible

              No                                      No                                        No                                   No

              Out-of-Network Coverage                 Out-of-Network Coverage                   Out-of-Network Coverage              Out-of-Network Coverage
              Yes                                     Yes                                       Yes                                  No

              Out of Country Coverage                 Out of Country Coverage                   Out of Country Coverage              Out of Country Coverage


              Emergency Care Only                     Yes. Paid as out-of-network benefits      Emergency Care Only                  Emergency Care Only

              Optional Benefits                       Optional Benefits                         Optional Benefits                    Optional Benefits

              Yes                                     Yes                                       Yes                                  No
              Physicians

                                                                                                Primary Care Physician (PCP)         Primary Care Physician (PCP)
              Primary Care Physician (PCP) Required   Primary Care Physician (PCP) Required     Required                             Required
              No                                      Yes                                       No                                   Yes

              Specialist Referrals Required           Specialist Referrals Required             Specialist Referrals Required        Specialist Referrals Required
              No                                      No                                        No                                   No
              Preventive Care Coverage

              Periodic Health Exam                    Periodic Health Exam                      Periodic Health Exam                 Periodic Health Exam



              $35 PCP Copayment/$50 Specialist                                                  $35 copay (3 month waiting
                                                      $30 Copay                                                                      $20 Copay
              Copayment                                                                         period, not subject to deductible)

              Periodic OB-GYN Exam                    Periodic OB-GYN Exam                      Periodic OB-GYN Exam                 Periodic OB-GYN Exam




                                                                                         Page 3 / 11
East Coast Health Insurance Proposal


                                                              David and Rebecca Walzak 2500 Deductible Rate and Benefit Comparison
                                                                     60 Male and 60 Female      33441        Eff Date 9.1.09




              AvMed Plus 2500                           POS Open Access 2500                       Copay Select 80 - 2500               OAC20-2500


              $35 PCP Copayment/$50 Specialist                                                     Mammogram, Pap Smear, PSA
              Copayment                                 No Charge                                  Testing: 20% Coinsurance             $40 Copay


              Well Baby Care                            Well Baby Care                             Well Baby Care                       Well Baby Care


              $35 PCP Copayment/$50 Specialist          $30 Copay, Age and frequency schedule
                                                                                                   Please refer to Plan Brochure        $20 Copay
              Copayment                                 apply

              Prescription Drug Coverage

              Generic Prescription Drugs                Generic Prescription Drugs                 Generic Prescription Drugs           Generic Prescription Drugs
              $20 Copay                                 $15 Copay                                  N/A                                  $20 Copay

              Brand Prescription Drugs                  Brand Prescription Drugs                   Brand Prescription Drugs             Brand Prescription Drugs
              $40 Copay after deductible                $35 Copay                                  N/A                                  $35 Copay

              Non-formulary Prescription Drugs                                                    Non-formulary Prescription Drugs      Non-formulary Prescription Drugs
              Coverage                                  Non-formulary Prescription Drugs Coverage Coverage                              Coverage

              $60 Copay after deductible                $50 Copay                                  N/A                                  $50 Copay

                                                                                                   Prescription Drugs Other             Prescription Drugs Other
              Prescription Drugs Other Coverage         Prescription Drugs Other Coverage          Coverage                             Coverage

              N/A                                       N/A                                        Tier 1: $15 copay                    N/A
                                                                                                   Tier 2: $35 copay

                                                                                                   Tier 3: $65 copay

                                                                                                   Tier 4: You pay 25% coinsurance
                                                                                                   (Maximum $3,000 per covered
                                                                                                   person, per calendar year)



                                                                                                   View Sample List of Drugs (pdf)

              Mail Order for Prescription Drugs         Mail Order for Prescription Drugs          Mail Order for Prescription Drugs    Mail Order for Prescription Drugs

              Generic: $40 Copayment                    Generic: $30 Copay                         Not Available                        Generic: $60 Copay
              Brand: $80 Copay after deductible         Brand: $70 Copay                                                                Brand: $105 Copay


              Non-Formulary: $120 Copay after deductible Non-Formulary: $100 Copay                                                      Non-Formulary: Not Covered

              Days Supply: 90                           Days Supply: 60                                                                 Days Supply: 90


                                                                                                   Separate Prescription Drugs          Separate Prescription Drugs
              Separate Prescription Drugs Deductible    Separate Prescription Drugs Deductible     Deductible                           Deductible
                                                                                                   Tiers 2-4: Combined $200 per
              $500 Individual                           $500 Individual                            person, per calendar year            $250 Individual
                                                                                                   deductible
              applies to                                applies to

              Brand, Non-Formulary                      Brand, Non-Formulary

              Hospital Services Coverage


              Emergency Room                            Emergency Room                             Emergency Room                       Emergency Room


                                                                                                   Illness: 20% Coinsurance after
              20% Coinsurance plus $100 when due to
                                                         $150 Copay (waived if admitted), after    deductible, additional $100 Copay
              illness, after deductible (Copay waived if                                                                                $100 Copay (waived if admitted)
                                                         deductible                                per visit if not admitted; Injury:
              admitted)
                                                                                                   20% Coinsurance after deductible


              Outpatient Lab/X-Ray                      Outpatient Lab/X-Ray                       Outpatient Lab/X-Ray                 Outpatient Lab/X-Ray




                                                                                            Page 4 / 11
East Coast Health Insurance Proposal


                                                     David and Rebecca Walzak 2500 Deductible Rate and Benefit Comparison
                                                            60 Male and 60 Female      33441        Eff Date 9.1.09




              AvMed Plus 2500                    POS Open Access 2500                         Copay Select 80 - 2500             OAC20-2500


              20% Coinsurance after deductible   20% Coinsurance after deductible             20% Coinsurance after deductible   No Charge

              Outpatient Surgery                 Outpatient Surgery                           Outpatient Surgery                 Outpatient Surgery
                                                                                                                                 Hospital: 20% Coinsurance after
              20% Coinsurance after deductible   20% Coinsurance after deductible             20% Coinsurance after deductible   Deductible; Freestanding: $200
                                                                                                                                 Copay

              Hospitalization                    Hospitalization                              Hospitalization                    Hospitalization


              20% Coinsurance after deductible   20% Coinsurance after deductible             20% Coinsurance after deductible   20% Coinsurance after deductible
              Maternity Coverage

              Pre & Postnatal Office Visit       Pre & Postnatal Office Visit                 Pre & Postnatal Office Visit       Pre & Postnatal Office Visit

                                                 Not covered (except for pregnancy
              Optional Rider Available           complications)                               Optional Benefit                   Optional Benefits
              Labor & Delivery Hospital Stay     Labor & Delivery Hospital Stay               Labor & Delivery Hospital Stay     Labor & Delivery Hospital Stay
                                                 Not covered (except for pregnancy
              Optional Rider Available           complications)                               Optional Benefit                   Optional Benefits
              Additional Coverage

              Chiropractic Coverage              Chiropractic Coverage                        Chiropractic Coverage              Chiropractic Coverage


                                                 20% Coinsurance after deductible (Aetna      20% Coinsurance after deductible
                                                                                                                                 $40 Copay; 20 Visits per Contract
              20% Coinsurance after deductible   will pay $25 Max. per visit/ 24 visits per   (limited to $2,000 of covered
                                                                                                                                 Year
                                                 year)                                        expenses per calendar year)

              Mental Health Coverage             Mental Health Coverage                       Mental Health Coverage             Mental Health Coverage

                                                                                              20% Coinsurance after
                                                                                              deductible, $50 Max. Benefit Per
              20% Coinsurance after deductible   Not Covered                                                                     Not Covered
                                                                                              Visit, $3,000 Max. Benefit for
                                                                                              lifetime
              Additional Information


              A.M. Best Rating                   A.M. Best Rating                             A.M. Best Rating                   A.M. Best Rating
              B++ as of 06/12/2008               A as of 06/16/2008                           A as of 06/15/2009                 B as of 11/19/2008




                                                                                     Page 5 / 11
East Coast Health Insurance Proposal
                                                                                                                                   Page 1 of 6




                                          Review Proposals for John and Jane Doe

    Individuals on Proposals
    Relationship                                                                First Name       Gender        Date of Birth


    John Doe                                                                            Male              06/25/1949
    Jane Doe                                                                             Female         11/17/1948



  The following products and plans have been added to your proposal based on your saved favorites and
  recommendations by BCBSF. You may add, remove, or change plans here before saving your proposal.



    Your Proposals

      Remove all Health                Health Proposal
   Health Proposal Proposed Effective Date: 09/01/2009
    Plans                                                 CYD              Monthly
                                                                          Premium

     BlueOptions 504                              $2500.00                $1156.00

    Relationship                                 First Name                   Gender     Date of Birth                Premium


    Applicant                                    David                        Male       06/25/1949                      $603.00
    Spouse / Domestic Partner                    Rebecca                      Female     11/17/1948                      $553.00
                                                                                                             Total:     $1156.00

     BlueOptions 505                              $3500.00                $1077.00

    Relationship                                 First Name                   Gender     Date of Birth                Premium


    Applicant                                    John                         Male       06/25/1949                      $562.00
    Spouse / Domestic Partner                    Jane                         Female     11/17/1948                      $515.00
                                                                                                             Total:     $1077.00

     BlueOptions 597                              $2500.00                $1156.00

    Relationship                                 First Name                   Gender     Date of Birth                Premium


    Applicant                                    John                         Male       06/25/1949                      $602.00
    Spouse / Domestic Partner                      Jane                       Female     11/17/1948                      $554.00
                                                                                                             Total:     $1156.00

     BlueOptions 598                              $3000.00                    $886.00

    Relationship                                 First Name                    Gender        Date of Birth            Premium


    Applicant                                    John           Page 6 / 11   Male       06/25/1949                      $461.00
    Spouse / Domestic Partner                       Jane                      Female     11/17/1948                      $425.00
East Coast Health Insurance Proposal
                                                                                                                                                 Page 2 of 6

                                                                                                                          Total:      $886.00

     Miami-Dade Blue 1                                            $250.00                  $495.00

    Relationship                                               First Name                   Gender        Date of Birth            Premium


    Applicant                                                  David                        Male          06/25/1949                  $269.00
    Spouse / Domestic Partner                                  Rebecca                      Female        11/17/1948                  $226.00
                                                                                                                          Total:      $495.00




      Remove all Dental                Dental Proposal
   Dental Proposal Proposed Effective Date: 09/01/2009
    Plans                                                                               Monthly
                                                                                       Premium

     BlueDental Care Pl210                                                              $18.19

    Relationship                                              First Name                   Gender         Date of Birth            Premium


    Applicant                                                 David                        Male          06/25/1949                    $18.19
    Spouse / Domestic Partner                                 Rebecca                      Female        11/17/1948                 Included *
                                                                                                                          Total:       $18.19

   * Note: Rate is based on the number of applicants, there is no additional cost for the sixth (or more) applicants.


     Individual BlueDental Choice CoPayment                                             $43.64

    Relationship                                              First Name                   Gender         Date of Birth            Premium


    Applicant                                                 David                        Male          06/25/1949                    $43.64
    Spouse / Domestic Partner                                 Rebecca                      Female        11/17/1948                 Included *
                                                                                                                          Total:       $43.64

   * Note: Total premium rate includes all applicants listed above.


     Individual BlueDental Choice Plus                                                  $61.77

    Relationship                                              First Name                   Gender         Date of Birth            Premium


    Applicant                                                 David                        Male          06/25/1949                    $61.77
    Spouse / Domestic Partner                                 Rebecca                      Female        11/17/1948                 Included *
                                                                                                                          Total:       $61.77

   * Note: Total premium rate includes all applicants listed above.




      Remove all Life              Life Proposals
                                                        Select Individual         Configure Plan


             No plans have been added to the current
             proposal.
                                                                             Page 7 / 11
East Coast Health Insurance Proposal
                                                                                                                                Page 3 of 6




                                               Proposal for David Walzak

    Proposal Created: Fri Jul 24 02:36:05 EDT 2009 Proposal Expiration Date: Tue Mar 16
    02:36:05 EDT 2010

      Prepared for                                 Prepared By                                  Agency Contact Information
      David Walzak                                 CAROLINE EHRENTHAL                           Email: cehrenthal@gmail.com
      FL 33441                                     CAROLINE AND JEREMY INC -                    Phone: 954-571-4177
                                                   6960
                                                   10 FAIRWAY DRIVE, SUITE 303
                                                   DEERFIELD BEACH FL 33441



    Eligible Applicant(s)
      Name                              Age           Sex         Relationship                               Zip           County
      John Doe                          60 Years     Male         Self                                       33441 BROWARD
      Jane Doe                          60 Years     Female       Spouse/Domestic Partner                    33441 BROWARD


                                                                                                                             Miami Dade
                                           BlueOptions          BlueOptions         BlueOptions         BlueOptions             Blue
                                          BlueOptions          BlueOptions         BlueOptions         BlueOptions          Miami-Dade
                                          504                  505                 597                 598                  Blue 1
   Monthly Premium                        $1156.00             $1077.00            $1156.00            $886.00              $495.00
                                             None          None          None          None          None
                                             $1500 ded.    $1500 ded.    $1500 ded.    $1500 ded.    $1500 ded.
     Maternity Option                     ($155.00)     ($155.00)     ($155.00)     ($155.00)     ($132.00)
                                             $2500 ded.    $2500 ded.    $2500 ded.    $2500 ded.
                                          ($105.00)     ($105.00)     ($105.00)     ($106.00)
     Integrated Rx                        Not Available        Not Available       Not Available       Not Available        Not Available
               Total Monthly Cost: $1156.00                    $1077.00            $1156.00            $886.00              $495.00

   Cost Sharing
    Calendar Year Deductible (CYD)         $2,500 / $7,500     $3,500 / $10,500    $2,500 / $7,500     $3,000 per           $250 per
    (per person / family aggregate)                                                                    Individual           Individual
    Coinsurance (Amount you pay)           0% of the Allowed   0% of the Allowed   0% of the Allowed   25% of the           10% of allowed
                                           Amount              Amount              Amount              Allowed Amount       amount
    Out-of-Pocket Maximum (per             $2,500/ $7,500      $3,500/ $10,500     $2,500 / $7,500     $7,500 / $15,000     $2,500 per
    person / family aggregate)                                                                                              Individual
    Calendar Year Deductible (CYD)         Not Available       Not Available       $75 / $225          $75 / $225           $0 Deductible
    for Dental Benefits (per person /
    family aggregate)

   Other Benefits
    Physician Services                     Family Physician:   Family Physician:   Family Physician:   Family Physician:    $50 maximum
                                           $35 Copayment       $35 Copayment       $25 copayment       $35 copayment        applied towards
                                           Specialist: $50         Page $50
                                                               Specialist:8 / 11   Specialist: $45     Specialist: $50      the visit
                                           Copayment           Copayment           copayment           copayment
East Coast Health Insurance Proposal
                                                                                                                             Page 4 of 6

    Well Child                           Family Physician:   Family Physician:   Family Physician:   Family Physician:   $50 maximum
                                         $35 copayment       $35 copayment       $25 copayment       $35 copayment       applied towards
                                         Specialist: $50     Specialist: $50     Specialist: $45     Specialist: $50     the visit
                                         copayment           copayment           copayment           copayment
    E-visits                             $10 copayment       $10 copayment       $10 copayment       $10 copayment       $50 maximum
                                                                                                                         applied towards
                                                                                                                         the visit
    Urgent Care Centers                  $60 copayment       $60 copayment       $50 Copayment       $55 copayment       $50 maximum
                                                                                                                         applied towards
                                                                                                                         the visit
    Rx Benefits - Retail                 Generic: $10        Generic: $10        Generic: $10        Generic: $10        Generic drugs:
                                         copay Brand:        copay Brand:        Copay Brand: Not    Copay Brand: Not    $10 Copayment
                                         $300 Brand          $300 Brand          covered Non         covered Non         Brand name and
                                         Deductible + 40%    Deductible + 40%    Preferred: Not      Preferred: Not      non-preferred
                                         Coinsurance Non-    Coinsurance Non-    covered Diabetic    covered Diabetic    drugs: discount
                                         Preferred: 50%      Preferred: 50%      equipment and       equipment and       only
                                         Coinsurance         Coinsurance         supplies covered    supplies covered
                                         Diabetic            Diabetic            under pharmacy      under pharmacy
                                         equipment and       equipment and       benefit             benefit
                                         supplies covered    supplies covered
                                         under pharmacy      under pharmacy
                                         benefit             benefit
    Rx Benefits - Mail Order             Mail Order (90      Mail Order (90      Mail Order (90      Mail Order (90      Mail Order:
                                         day supply):        day supply):        day supply):        day supply):        Generic, Brand
                                         Generic: $25        Generic: $25        Generic: $25        Generic: $25        Name, & Non-
                                         Copay Brand:        Copay Brand:        Copay Brand: Not    Copay Brand: Not    preferred Drugs
                                         $300 Brand          $300 Brand          Covered Non-        Covered Non-        are not covered
                                         Deductible + $125   Deductible + $125   Preferred: Not      Preferred: Not
                                         Copay Non-          Copay Non-          Covered             Covered
                                         Preferred: $300     Preferred: $300
                                         Brand Deductible    Brand Deductible
                                         + $200 Copay        + $200 Copay
    Inpatient Hospital Facility          Option 1 = CYD      Option 1 = CYD      Option 1 = CYD      Option 1 = CYD +    CYD + 10%
    Services (per admission)             Option 2 = CYD      Option 2 = CYD      Option 2 = CYD      25% Coinsurance     Coinsurance
                                                                                                     Option 2 = CYD +
                                                                                                     25% Coinsurance
    Physician Services at Hospital &     CYD                 CYD                 CYD                 CYD + 25%           CYD + 10%
    ER                                                                                               Coinsurance         Coinsurance
    Independent Clinical Lab             $0                  $0                  $0                  $0                  $0 Copayment
    Outpatient Hospital Facility         Option 1 = CYD      Option 1 = CYD      Option 1 = CYD      Option 1 = CYD +    CYD + 10%
    Services (per visit)                 Option 2 = CYD      Option 2 = CYD      Option 2 = CYD      25% Coinsurance     Coinsurance
                                                                                                     Option 2 = CYD +    (surgical and
                                                                                                     25% Coinsurance     related services
                                                                                                                         only)
    Dental Benefits                      Not Available       Not Available       Preventative:       Preventative:       $50 towards the
                                                                                 100%                100%                visit for basic and
                                                                                 Covered/Basic:      Covered/Basic:      preventative care
                                                                                 80% covered/        80% covered/
                                                                                 Major: Not          Major: Not
                                                                                 Covered             Covered
    Emergency Room Facility              CYD                 CYD                 $300 Copayment      $300 Copayment      $500 + CYD +
    Services (per Visit)                                                         (waived if          (waived if          10% Coinsurance
                                                                                 admitted)           admitted)           (for non-surgical
                                                                                                                         services only)
                                                                                                                         CYD + 10%
                                                                                                                         Coinsurance (for
                                                                                                                         surgical services
                                                                                                                         or admissions)


  This is only a partial description of the many benefits and services provided by Blue Cross and Blue Shield of Florida (an independent
  licensee of the Blue Cross and Blue Shield Association) and/or Health Options, Inc. (an HMO subsidiary of Blue Cross and Blue Shield
  of Florida, Inc.). BCBSF offers only the BlueOptions high-deductible health plans specifically designed to be used in conjunction with a
  Health Savings Account (HSA). For more information on tax advantages and implications of HSAs as used with a high-deductible
                                                                   Page 9 / 11
  health plan, contact your legal or tax advisor. BlueCare products are offered by Health Options. This matrix does not constitute a
  Contract. These products may have limitations and exclusions. The amount of benefits provided depends upon the plan selected and
East Coast Health Insurance Proposal
                                                                                                                                       Page 5 of 6

  the premium will vary with the amount of benefits selected. For a complete description of benefits and exclusions, please refer to the
  Contract for the specific product; its terms prevail.


                                                  Proposal for John and Jane Doe

    Proposal Created: Fri Jul 24 02:36:05 EDT 2009 Proposal Expiration Date: Tue Mar 16
    02:36:05 EDT 2010

      Prepared for                                   Prepared By                                      Agency Contact Information
      David John Doe                                   AROLINE EHRENTHAL                              Email: cehrenthal@gmail.com
      FL 33441                                       CAROLINE AND JEREMY INC -                        Phone: 954-571-4177
                                                     6960
                                                     10 FAIRWAY DRIVE, SUITE 303
                                                     DEERFIELD BEACH FL 33441



    Eligible Applicant(s)
      Name                                Age           Sex          Relationship                                     Zip       County
                        John Doe          60 Years      Male        Self                                              33441 BROWARD
                        Jane Doe          60 Years      Female      Spouse/Domestic Partner                           33441 BROWARD


                                                                                    Individual BlueDental              Individual BlueDental
                                                BlueDental Care Pl210                Choice CoPayment                       Choice Plus
             Total Monthly Cost: $18.19                                          $43.64                               $61.77
                                            No charge or low copay for most         Visit any dentist anywhere,       Predictable copay on all
                                            procedures.                             with the added benefit of lower   services performed in-
                                                                                    out-of-pocket expenses when       network.
                                                                                    using an in-network provider.

   Cost Sharing
    Preventive: (cleaning, exam,            In-Network = 100% coinsurance           $10 cleaning Copay, In-           In-Network = 100%
    bitewing x-rays, fluoride for           based on fee schedule, OON =            Network = Copay, OON =            coinsurance based on fee
    children)                               100% coinsurance based on UCR           80% based on fee schedule         schedule, OON = 100%
                                                                                                                      coinsurance based on UCR
    Basic:(complete mouth x-rays,           No waiting period, No deductible,       No waiting period, $50            0 or 6 months waiting period,
    denture/partial repair,                 Low copay for covered procedures        deductible per person, In-        $50 deductible per person, In-
    extractions, fillings, sealants for                                             Network = Copay, OON =            Network = 80% coinsurance
    children)                                                                       60% based on fee schedule         based on fee schedule, OON
                                                                                                                      = 80% coinsurance based on
                                                                                                                      UCR
    Major:(crowns, bridges, partials,       No waiting period, No deductible,       0 or 12 months waiting period,    0 or 12 months waiting period,
    dentures, root canals,                  Low copay for covered procedures        $50 deductible per person, In-    $50 deductible per person, In-
    periodontal treatment)                                                          Network = 50% coinsurance         Network = Copay, OON =
                                                                                    based on fee schedule, OON        40% based on fee schedule
                                                                                    = 50% coinsurance based on
                                                                                    UCR
    Plan Features                           $35 enrollment fee, No annual max,      No enrollment fee, $1,000         No enrollment fee, $1,000
                                            No free look, No missing tooth          Annual max., 10-day free look,    Annual max., 10-day free look,
                                            clause, In-Network coverage only,       Permanent missing tooth           Permanent missing tooth
                                            25% discount on Specialist,             clause, In and OON coverage,      clause, In and OON coverage,
                                            Requires 12 month participation         Value Added benefits,             Value Added benefits,
                                                                                    Specialist coverage               Specialist coverage
                                                                     Page 10 / 11
  The information provided is a summary of benefits. It is intended to highlight key points of the Dental Plans and is provided as an aid in
East Coast Health Insurance Proposal
                                                                                                                          Page 6 of 6

  deciding whether to enroll in the Plan. This summary should in no way be construed as part of the contract. Possession of this
  summary in no way implies coverage nor does it guarantee benefits under the plan.




                                                                Page 11 / 11

								
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