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B1ueCross . , � � � � � , <br /> B1ueShield ►�� <br /> . . . . . . <br /> of IIlinois � � <br /> Group Name_ cztv of Decatur <br /> Group Number(s) 9�2844 Section No. (s) oioo II <br /> Effective Date___ i�/o�/�7 ERISA Plan Year 11/1 Cycle '', <br />�ENEWAr, ❑ NEW GROUP/SECTION ❑ CONTRACT CNANGE ❑ CLARIFICATION/CORRECTION �I <br /> Funding: ❑Prospective Premium ORetrospective Premium ❑Minimum Premium ❑Cost Plus �]ASO <br /> Avera e Discount Percenta e ADP Indicators: <br /> 9 9 ( ) <br />' Group Number(s) g�2844 Section No. (s) �7-00 <br /> Discount Product Type: CMM <br /> Employer: �J (02) Corporate Standard � (04) Home Hospital <br /> Subscriber: �7 (02) Corporate Standard � (04) Home Hospital ❑ (00) No SubShare (ASO only) 'I <br /> General Program Payment Provisions* <br /> Lifetime Maximum:$ ($1,000,000 or$2,000,000) <br /> Program Deductible: <br /> (per c��lendar year) <br /> Individual: $ ($50—$1,000 in$50 increments) <br /> Family: times(2 or 3) individual or $ (aggregate) <br /> Prior Deductible Credit Applies: ❑ Yes ❑ No <br /> Out-of-Pocket Expense Limit(OPX): <br /> (per calendar year) <br /> Individual: $ (None, $500—$2,500) <br /> Family: times(2 or 3) individual or $ (aggregate) <br /> Prior OPX Credit Applies: ❑Yes ❑ No OPX: ❑ includes deductible ❑ excludes deductible <br /> Program Payment Level: % (80%—95%in 5%increments) <br /> (applies to Hospital, MedicaVSurgical &Other Covered Services unless specified othenvise below) <br /> Payment Levels Differing from General Program Payment Provisions* <br /> Inpatient Hospital Services: <br /> Deductible per Admission: ❑ Yes$ ($50—$500) ❑ No; If yes, applies to OPX: ❑ Yes � No (std) <br /> First Dollar Coverage: ❑Yes ❑ No If yes, 100%up to$ per calendar year($1,000—$10,000) <br /> Outpatie�t Surgery: % Program Deductible Applies(Hospital& Physician): ❑ Yes ❑ No <br /> Outpatient Diagnostic Tests: % Program Deductible Applies(Hospital& Physician): ❑Yes ❑ No <br /> Outpatient Therapies—Physical,Occupational and Speech—Calendar Year Maximum: $ per therapy <br /> (paid at Program Payment Level; coinsurance not applicable to OPX) ($1,000 [std], $2,000 or$3,000) <br /> Private Duty Nursing Maximum: $ _per month ($1,000[std],$2,000 or$3,000) <br /> (paid at Program Payment Level; coinsurance not applicable to OPX) <br /> An Independent Licensee of the Blue Cross and Blue Shield Association <br /> OB 3172 Rev.7/97 'Any variations other than those specified require Start-Up Committee approval page 1 <br />