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Prescription Drug Benefits* <br /> Covered under Other Covered Services: ❑ Yes ❑ No <br /> Prescription Drug Card Program: ❑ Yes ❑ No <br /> Copay: $ Generic/Brand with no Generic available $ Brand with Generic available <br /> Injectables: ❑Yes ❑ No <br /> Mail Order: ❑ Yes ❑ No <br /> If yes; $ Generic/Brand with no Generic available $ Brand with Generic available <br /> Oral Contraceptives: ❑ Yes ❑ No <br /> Nicotine Patches: �Yes ❑ No <br /> Benefit Variables for ASO Groups Only* <br /> Infertility Coverage: ❑ Yes ❑ No /f yes; ❑State-mandated benefits or❑ Other(please describe below in Other Special Provi- <br /> sions) Lifetime Maximum: ❑ Yes ❑ No /f yes,$ <br /> Speciai Human Organ Transplants(HOTs)Coverage-Subject to Program Maximum: ❑ es 0 No <br /> Separate HOTs Lifetime Maximum: ❑ Yes $ ❑ No <br /> Licensed Clinical Social Workers Exc/uded: ❑ Yes ❑ No Licensed Ciinical Professional Counselors Excluded: ❑ Yes ❑ No <br /> Coordination of Benefits(COB) Gender Rule: ❑Yes ❑ NO(Birthday Rule is std) COB Non-Duplication of Benefits: ❑Yes ❑ No <br /> Subscriber Share Methodology for Claims Processing Applies: ❑Yes ❑ No <br /> (Ifno;a letter declining Subscriber Share participation required at each renewal attached to BPA.) <br /> Pre-Dent Coverage* � ❑ Yes ❑ No (If yes, complete the modules below) <br /> Total number of employees and dependents with dental coverage <br /> Package Plan: <br /> Benefit Period: ❑Calendar Year or ❑ Contract Year If Contract Year: to <br /> Benefit Period Maximum: $ ($50-$2000 in$50 increments or Unlimited)(not applicable to Orthodontic Benefits,if any) <br /> Individual Deductible: $ ($25-$150 in$5 increments)per benefit period <br /> Family Deductible: times(2 or 3) individual or$ (aggregate) <br /> Deductible applicable to Preventive Services: o Yes ❑ No�scd� Prior Deductible Credit: ❑ Yes ❑ No <br /> Carry Over Credit: O Yes � No(only available if benefit period is calendar year) <br /> Preventive Dental Services: ❑ %of U&C(so°io-iooi in s�i incremencs�or❑ Indemnity Schedule <br /> (entire progrem must be paid at elther U6C or Indemnity Schedule except that Preventive Services may be paid at 100%wlth the rest of the program pafd on an indemnity basis) <br /> Primary Dental Services: ❑ %of U&C(so�/-100°�o in 5%increments) or ❑ Indemnity Schedule <br /> Major Dental Services: ❑Yes � No If yes, ❑ %of U&C(so°i-ioo�i in si increments) or ❑ Indemnity Schedule <br /> Orthodontic Benefits: ❑ Yes ❑ No If yes; ❑ %of U&C(50%or s0%) or ❑ Indemnity Schedule <br /> Orthodontic Lifetime Maximum: $ Age Limit for Orthodontic Benefits: <br /> OTHER SPECIAL PROVISIONS: <br /> Standard Pre--exrstin ap �i,es. Plan vear cvcle ii�oi <br /> No changes tp �urrent plan at tTiis txme. <br /> - . . - • <br /> ��s� �p � �/,.S�j <br /> Author' ed Purch r/Title/Date <br /> Marketing Representative/Date <br /> Underwriter/Date <br /> An Independent Licensee of the Blue Cross and Blue Shield Association <br /> OB 3169 Rev.7/97 *Any variations other than those specified require Start-Up Committee Approval page 4 <br />