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Ben Sum 0307 Med Anc Upd 061307 FL Cap Bk

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Ben Sum 0307 Med Anc Upd 061307 FL Cap Bk Powered By Docstoc
					                                                              Benefits Summary for Florida Capital Bank
                                                                  March 1, 2007 - February 29, 2008
                                                                                            Eligibility: First of the Month Following 60 Days of Employemnt

    BENEFITS                  PROVIDER                                 Benefit Descriptions - In Network Only                                           Monthly Rate Billed to FCB                     Employee Semi-Monthly Cost
                                                                               HMO - OAH Choice Plan S56                                                             HMO Rates                            HMO Semi-Monthly Rates
                                                      •      Unlimited Lifetime Maximum Benefit
                                                                                                                                                       Employee                    $341.09           Employee                          $18.03
                                                      •      No Deductible or Coinsurance
                                                      •      Physician Office Visit: $15 Copay / Specialist $25 Copay                                  Employee /                                    Employee /
                                                                                                                                                                                   $759.17                                            $128.54
                                                      •      Hospital Copay: $500 / Inpatient Stay                                                     Spouse                                        Spouse
                                                      •      Outpatient Surgery: $250 Per Surgical Procedure                                           Employee /                                    Employee /
                                                                                                                                                                                   $639.30                                             $96.86
                                                      •      Emergency Room: $150 Copay                                                                Child(ren)                                    Child(ren)
                                                      •      Urgent Care: $50 Copay
                                                                                                                                                            Family                 $996.95               Family                       $191.40
                                                      •      Rx Copay: $10 / $30 / $50
                                                      •      Max Out-Of-Pocket: Individual $2,500 / Family $5,000
                                                                               IN-NETWORK BENEFITS ONLY
                                                                           POS - FEE Choice Plus Plan S52                                                            POS Rates                             POS Semi-Monthly Rates
                                                      • Unlimited Lifetime Maximum Benefit
                                                                                                                                                       Employee                    $379.02           Employee                          $21.83
                                                      • No Deductible or Coinsurance
                                                      • Physician Office Visit: $15 Copay / Specialist $15 Copay                                       Employee /                                    Employee /
                                                                                                                                                                                   $843.59                                            $139.80
                                                      • Hospital Copay: $500 / Inpatient Stay                                                          Spouse                                        Spouse
                                United
      HEALTH                                          • Outpatient Surgery: No Copay                                                                   Employee /                                    Employee /
                               Healthcare                                                                                                                                          $710.39                                            $105.60
                                                      • Emergency Room Copay: $100 / Visit                                                             Child(ren)                                    Child(ren)
                                                      • Urgent Care: $50 Copay
                                                                                                                                                       Family                     $1,107.82          Family                           $206.92
                                                      • Rx Copay: $10 / $30 / $50
                                                      • Max Out-Of-Pocket: Individual $2,500 / Family $5,000
                                                               See Certificate of Coverage for Out-of-Network Benefits
                                                                    High Deductible Health Plan H S A BD-F 116 C                                                                              HDHP Rates
                                                      • Unlimited Lifetime Maximum Benefit
                                                                                                                                                       Employee
                                                      • Deductible: Individual $2,000 / Family $4,000
                                                      • Physician / Specialist Office Visit: 100% After Deductible                                     Employee /
                                                      • Hospital Inpatient: 100% After Deductible                                                      Spouse
                                                                                                                                                                                   See Benefits Payroll Deduction Sheet for Rates
                                                      • Outpatient Surgery: 100% After Deductible                                                      Employee /
                                                      • Emergency Room: 100% After Deductible                                                          Child(ren)
                                                      • Urgent Care: 100% After Deductible
                                                                                                                                                       Family
                                                      • After Deductible - Rx Copay: $10 / $30 / $50
                                                      • Max Out-Of-Pocket: Individual $2,000 / Family $4,000
                                                               See Certificate of Coverage for Out-of-Network Benefits
                                                                                    PPO-Dental Solutions                                                           Dental Rates                          Dental Semi-Monthly Rates
                                                      • Preventive @ 100%
                                                                                                                                                       Employee                     $30.60           Employee                           $1.53
                                                      • Basic @ 90% / $50 Annual Deductible
                                                      • Major @ 60% / $50 Annual Deductible                                                            Employee /                                    Employee /
                                                                                                                                                                                    $66.01                                             $10.38
   DENTAL PPO                    Assurant             • $1,500 Annual Max Benefit for Above                                                            Spouse                                        Spouse
                                                      • Orthodontia @ 50%                                                                              Employee /                                    Employee /
                                                                                                                                                                                    $75.36                                             $12.72
                                                      • $1,000 Lifetime Benefit for Orthodontia                                                        Child(ren)                                    Child(ren)

                                                                                                                                                       Family                      $110.77           Family                            $21.57
                                                             See Certificate of Coverage for Out-of-Network Benefits
                                                      • Exam $10                                                                                                                                           Vision Semi-Monthly Rates
                                                      • Contact Lenses Allowance: $105.00                                                                                                                Employee                       $3.15
                                                                                                                                                                                                         Employee /
        Vision               CompBenefits             • Lenses: No Cost / Frames: $40 Allowance                                                                   100% Voluntary                                                        $6.29
                                                                                                                                                                                                         Spouse
                                                                                                                                                                                                         Employee /
                                                      • LASIK - Discount Program                                                                                                                                                        $5.98
                                                                                                                                                                                                         Child(ren)
                                                               See Certificate of Coverage for Out-of-Network Benefits                                                                                   Family                         $9.39

                                                      • 1 x Salary                                                                                                                        Employer Paid
   Life & AD&D                   Assurant                                                                                                                                              No Cost to Employee
                                                      • AD&D Equal to Employee Life Benefit                                                                                       Enrolled Upon Meeting Eligibility
                                                      • Voluntary Life Insurance
  Voluntary Life                 Assurant             • You May Purchase Up to 5 x Salary                                                                                See Customized Personal Enrollment Form
                                                      • Guarantee Issue $100,000 Associate / $50,000 Spouse
                                                      • 15th Day Accident
    Short Term                 Lincoln -              • 15th Day Sickness
     Disability             Jefferson Pilot           • 13 Week Duration                                                                                                                  Employer Paid
                                                      • 60% to Maximum $1,000 Weekly Benefit                                                                                           No Cost to Employee
                                                                                                                                                                                  Enrolled Upon Meeting Eligibility
                                                      • 90 Day Elimination Period
    Long Term                  Lincoln -
                                                      • 60% to Maximum $10,000 Monthly Benefit
     Disability             Jefferson Pilot
                                                      • Benefits Payable till Social Security Retirement Age

 Voluntary Long                                                                                                                                                                  To Request Quote: Enter Salary
                                 Principal            • Option to Purchase an Additional 15% Income Replacement
 Term Disability                                                                                                                                                                on Benefits Payroll Deduction Sheet

                                                        All active partners who have completed 90 days of service and are
      Quarterly              AMI Benefit                                                                                                                Matching is 100% on the 1st 3% of Deferral and 50% on the Next 2% of
                                                      • 21 yrs of age become eligible to participate in the plan. Entry dates
       401(k)               Administrators                                                                                                                   Deferral Maximum Deferral is $15,500 ($20,500 if over 50)
                                                        are on the 1st day of January, April, July & October.
                                                                                                         c66ace08-5b65-41ce-a7ea-baa8b458d9e9.xls
This chart is intended to highlight some of the principle provisions of the plans offered by your employer. In case of a conflict between the Group Master Contract, Certificate of Coverage, and this chart, then the Group Master Contract and
Certificate of Coverage will govern.
                                           Florida Capital Group
                         EMPLOYEE BENEFIT QUESTIONS / CLAIMS- WHO TO CONTACT
                                  ENROLLMENT /BENEFIT INFORMATION CONTACT:

                                      Michelle Sammet - (904) 472-2747
                                   CLAIMS ISSUES / TECHNICAL QUESTIONS CONTACT THE FOLLOWING:



                                                                                      IF THE INSURANCE COMPANY DID NOT HANDLE
• United Healthcare          (Listed on ID card)                                                 YOUR REQUEST TO YOUR
                                                                                            SATISFACTION PLEASE CONTACT:
  Policy (HMO) #_______ (POS) #_______ (H S A) #_______
     Medical Customer Services #800-357-0978
     Register Online with United Healthcare
     www.MyUHC.com

• Assurant Dental Policy # K1900365
     Group Voluntary Dental PPO
     Dental Member Services #800-442-7742
     www.dha.com
                                                                                                  H.W. Montoya,CLU
• CompBenefits Policy # VS5271                                                                     B. Darby Brower
     Vision Member Services # 800-865-3676                                                         Trevor Harkness
     www.compbenefits.com
                                                                                                PHONE: (904) 280-1669
• Assurant Life Policy # G4049516                                                                FAX: (904) 280-1602
     Life Member Services #800-733-7879
                                                                                                  Employee Benefits
• Lincoln - Jefferson Pilot Disability Policy # 10067646                                     Susan L. Rabe, Ext #411
     Short and Long Term Disability Member Services #800-423-2765                           SusanR@montoyabrower.com
     www.lfg.com

• Principal Buy-up Disability Policy # Pending
    Customer Service # 800-247-9988 ext 55866

• 401(k) AMI Benefits Administrators
    VRU # 866-793-0449                                                                    Retirement/Financial Services
    Customer Service # 800-451-2865                                                             Nicki Cromer, Ext #419
     www.amibenefit.com                                                                            Nicki.Jones@lfg.com

				
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