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BlueCross ,, , � � � . , <br /> . B1uexShield ►�� � <br /> . . . . • . . . . . <br /> of•Illinois. � � <br /> ' . � . . <br /> Group Name city of Deca�ur <br /> Group Number(s) Po6856 � Section No. (s) oioo <br /> Effective Date ii�oi�9� ERISA Plan Year ].1/1 Cwcle <br /> � NEWAL ❑ NEW GROUP/SECTION ❑ CONTRACT CHANGE ❑ CLARIFICATION/CORRECTION <br /> Funding: ❑ Prospective Premium ❑ Retrospective Premium ❑ Minimum Premium O Cost Plus �J ASO <br /> Average Discount Percentage (ADP) Indicators: <br /> Group Number(s) P06856 Section No. (s) O10o <br /> Discount Product Type: ❑ PPO (Participating Provider Option(PPO)) or �fl PPN (PPo P�us) <br /> Employer: �] (02) Corporate Standard O (04) Home Hospital <br /> Subscriber: � (02) Corporate Standard ❑ (04) Home Hospital ❑ (00) No SubShare (ASO only) <br /> Group Number(s) Section No. (s) <br /> Discount Product Type: � CMM (std) or ❑ Other: <br /> Employer: ❑ (02) Corporate Standard ❑ (04) Home Hospital <br /> Subscriber: ❑ (02) Corporate Standard ❑ (04) Home Hospital ❑ (00) No SubShare (ASO only) <br /> ❑Standard PPO Plan Number: ❑Standard PPO Plus Plan Number: <br /> ❑Modification of standard PPO or PPO Plus Plan Number: (Complete on�y modules to explain variations) <br /> General Program Provisions* <br /> i etime aximum: 1, 00,000 or 2,000,000 <br /> Program Deductible: ❑ Common PPO/Non-PPO Deductible or ❑Separate PPO/Non-PPO Deductible <br /> Program Deductible: PPO Non-PPO <br /> (per calendar year) <br /> Individual: $ $ <br /> Family: times(2 or 3)individual times(2 or 3)individual <br /> or $ (aggregate) or $ (aggregate) <br /> Prior Deductible Credit Applies: ❑ Yes ❑ No <br /> Out-of-Pocket Expense Limit(OPX): <br /> (per calendar year) <br />� Individual: $ $ <br /> Family: times(2 or 3)individual times(2 or 3)individual <br /> or $ (aggregate) or $ (aggregate) <br /> Prior OPX Credit Applies: ❑ Yes ❑ No OPX: ❑ includes deductible ❑ excludes deductible <br /> Hospital Benefits* <br /> Inpatient(IP)Hospital/Facility Services: PPO Non-PPO <br /> Payment Level: o�o o�o <br /> Program Deductible Applies: ❑ Yes ❑ No ❑Yes ❑ No <br /> Inpatient Hospital Deductible <br /> per Admission: ❑ Yes p No ❑Yes ❑ No <br /> If yes; IP Hospital <br /> Deductible Amount: $ $ <br /> Applies to OPX: ❑ Yes ❑ No ❑ Yes ❑ No <br /> Outpatient Hospital/Facility Services: <br /> Payment Level: % a�o <br /> Program Deductible Applies: ❑ Yes ❑ No ❑Yes ❑ No <br /> utpatient urgica ervices: <br /> Payment Level: % % <br /> Program Deductible Applies: ❑ Yes ❑ No ❑Yes ❑ No <br /> utpatient iagnostic ervices: <br /> Payment Level: % % <br /> Program Deductible Applies: ❑ Yes ❑ No ❑ Yes ❑ No <br /> An Independent Licensee of the Blue Cross and Blue Shietd Association <br /> OB 316s Rev.7/97 *Any variations other than those specified require Start-Up Committee Approval page i <br />