HomeMy WebLinkAboutResolution #5049 (BCBS Group Health) RESOLUTION NO. 5049
A RESOLUTION APPROVING A GROUP ENROLLMENT AGREEMENT BETWEEN THE CITY
OF CANTON AND BLUECROSS BLUESHIELD FOR THE GROUP HEALTH INSURANCE PLAN
AND DIRECTING THE MAYOR ANI-IE ,_'ITY CLERK TO EXECUTE AND DELIVER SAID
AGREEMENT ON BEHALF OF THE CITY OF CANTON, ILLINOIS.
WHEREp�, ie Ins_ir nhe C_ty cf Canton has determined that :tis necessary and in
the best it acre:,t to �".n a.r n v ti- 31u�'Cross BlueShield to administer the City's Group
Health Ins_ra_._�e Pyr as ;et a:t,-.cr_ed hereto and incorporated herein; and
WHERE �;, �.e :; �.;___�_�_ c�`� =i =_� Wntor- Las made similar determination.
NOW, MAYOR AND THE CITY COUNCIL OF THE
CITY OF CA tiITON, 'F 1,'L=,ON CO.:N_-Y, INOIS, as follows:
1. That the a reen-_�n, a
�. _,l -� r�e o �.� -:,_corporuted herein as Exhibit A is hereby approved by the
Canto._ y C:; e--
2. That t!. _ayo :r_<< City 'cra �� r'ir �i`Canton, Illinois is hereby authorized and directed to
execu*=- aA of the City of Canton.
3. That t' ct_y,e immediately apon its p�_ssage by the City
Count' apprc.gal by the Mayor thereof.
PASSED ' '!.., ��.�� o -::s 19th day of April, 2016.
AYES: Nelson, Ryan Mayhew, Justin Nelson, John
NAYS: Alderman Geral. !alis
ABSENT: ivon
APPROVED:
dt(e4/42
Jeffrey A. 1- itz, :Mayor
ATT T:
Diana Pavley-Roc�, it
RD. 9
B1ueCross BlueShield
of Illinois
Account Name: CITY OF CANTON Account Number: 389388 Renewal Date: 06101116
TO BE SIGNED BY THE GROUP REPRESENTATIVE:
I,the undersigned, a duly authorized representative of the policyholder named above("Policyholder"), hereby: (i)
represent that I am knowledgeable as to standards associated with a"grandfathered health plan"as set forth in the
Affordable Care Act and applicable regulations,and that the information contained in this Grandfathered Health Plan
Form, and any subsequent updates to such Form, are true,complete and accurate; (ii)agree that the Policyholder will
immediately provide BCBSIL with written notice prior to renewal (and during the plan year,with at least 60 days advance
written notice)of any changes to the employer's or employee organization's contribution rate toward the cost of any tier
of coverage;and (iii)agree that BCBSIL retains the authority to determine, at its sole discretion,whether any health
insurance coverage constitutes a grandfathered health plan under the Affordable Care Act, applicable regulations and
interpretations thereof.
�� - C ► (erl�/ l
Prl ama �— Prl t Title
c Y19_
Signa Date
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield A-mcabon.
Grandfathered Health Plan Form-SGFI-1011
Excess Amounts of Life Insurance:
Evidence of Insurability will be required for individual life insurance amounts in excess of$ . Such excess insurance amounts shall become effective on
the date Evidence of Insurability is approved by Dearborn National"'Life Insurance Company.Waiver of Premium,in the event of total disability,will terminate at
age 65 or when no longer disabled,whichever is earlier.Being Actively at Work is a requirement for coverage.If an employee Is not Actively at Work on the day
coverage would otherwise be effective,the effective date of coverage will be the date of return to Active Work.If an employee does not return to Active Work,
he/she will not be covered.
2. Dependent Life
❑Yes No Spouse Children-age birth to 14 Children-age 14 days to 6 Children-age 6 months to
days months 26 years/student 26
❑Option 1 $10,000 $100 $100
$5,000
Choose a ❑Option 2
Plan: $5,000 $100 $100 $5,000
❑Option 3 $5,000 $100 $100 1 $2,000
Short3. •
❑Yes dNo Complete Item 4 below if Short Term Disability benefits vary by lass
Benefit will not exceed 66 2/3%of Basic Weekly Salary and is payable for non-occupational disabilities only
Choose a Benefit:
❑Flat$ weekly(not to exceed$250)
❑Salary Based(select one)- ❑50% (:160% ❑66 2/3%of Basic Weekly Salary up to a maximum of$
Choose a Plan:Accident/Sickness/Duration
❑1/8/13 weeks ❑8/8113 weeks ❑15/15/13 weeks 'Q 31/31/13 weeks 'Only available to groups with 10 or more lives enrolled
❑1 /8/26 weeks ❑8/8/26 weeks ❑15 115/26 weeks '❑31/31/26 weeks
Please complete this chart if Term Life or Short Term Disability benefits vary by Gass(3 Max 2-9 lives) (6 Max 10+lives)
Class Description Term Life/AD&D Short Term Disability
I
I
—_ ____ ----_---
Electronic
-Electronic Issuance:
(Non-HMO Health and Dental Pians only) The Policyholder consents to receive,via an electronic file or access to an electronic file,a Certificate Booklet
provided by HCSC to the Policyholder for delivery to each Insured. The Policyholder further agrees that it is solely responsible for providing each Insured access.
via the Internet,intranet or otherwise,to the most current version of any electronic file provided by HCSC to the Policyholder and,upon the Insured's request,a
paper copy of the Certificate Booklet.
Additional Provisions:
Use this section to indicate if the account is retaining any plan(s)not shown above,or need to indicate any other instruction or important information.
Section 6-Signatures:
Signatures
Employer/Authorized Purchaser Title C44 C(eiV k- R'P, Date
Underwriter Title Date
*Products and services marketed under the Dearborn National's brand and the star logo are underwritten and or provided by Dearborn National*Life Insurance Company(Downers Grove.IL)in all
states(excluding New York)and certain of its affiliates. Dearborn National*Lite Insurance Company is a separate company that does not provide Blue Cross and Blue Shield of Illinois products or
services. Ikarborn Nationalae Lite Insurance Company is solely responsible fir the life and disability products described in this illustration.
k,A Division of Health Care Sem tee Corporation.a Mutual Legal Reserve Company,an Independent Licensee of rhe Blue Cross and Blue Shield Association
GA-10-9-SMGRP BPSF HCSC MM Rev.02/18/16 5
.Fs
CURRENT BPP72322 RENEWAL BPP72322
Lim Rates Lim Rates
HCSC Primary
Single 30 $679.76 30 $733.95
Single + Spouse 30 $1,360.17 30 $1,462.74
Single + Child(ren) 19 $1,264.85 19 $1,326.47
Family 38 $1,945.26 38 $2,055.25
Medicare Primary
Single 0 $396.09 0 $420.54
Family 0 $792.17 0 $841.08
Monthly Total 117 $159,149.93 117 $169,203.13
Annual Total $1,909,799.16 $2,030,437.56
CURRENT NPS91605 RENEWAL MPS91605
Lim Rates Lim Rates
HCSC Primary
Single 5 $580.55 5 $626.55
Single + Spouse 3 $1,161.66 3 $1,248.68
Single + Child(ren) 4 $1,080.25 4 $1,132.36
Family 0 $1,661.36 0 $1,754.49
Medicare Primary
Single 0 $338.28 0 $359.00
Family 0 $676.56 0 $718.00
Monthly Total 12 $10,708.73 12 $11,408.23
Annual Total $128,504.76 $136,898.76
Total $2,038,303.92 $2,167,336.32
Rates include Taxes and Fees Renewal Increase 106.33%
BlueCrm BlueShield
►.� of Illinois
CITY OF CANTON
SIC Code:9111 Coverage Effective Date:05/01/16
Rated ZIP Code:61520 Proposal Expires:05/31/16
Date Preoared:03/29/2016
Illinois Dental Plans
Coinsurance
Deductible Annual Total
Plan In/Out Benefit Out-of- Out of Orthodontia Employee Employee Employee Monthly
Plan Type (Pam:3 x Network e
Network In Network Lifetime + + Family
Ind)
2 In//Out Reimb. Max only Spouse ChildrenDental
True
High Allocation
DINHMI2 Passive $25/$75 $750 MAC 100/80 100/80 NA $9.43 $20.27 $29.64 $44.22 $0.00
DINHMIO*� Active $50/$50 $1500/1000 MAC 100/80/50 80/60/40 NA $19.98 $42.89 $51.25 $79.97 $0.00
DINHM08 Passive $50/$50 $1000 Ma"- 100/80150/50 100/80/50/50 $1000 $22.57 $48.49 $62.51 $95.82 $0.00 1
.-to DINHR03 Passive $5q'$50 $1500 90th 100;80/50i5u 100,180%50;50 $1500 $33.79 $72.58 $87.63 $136.40 $0.00
R&C
DINHRO2 Passive $50/$50 $2000 90th 100/80/50/50 100/80/50/50 $2000 $34.94 $75.06 $91.25 $141.78 $0.00
R&C
DINHROI Passive $25/$25 $3000 90th 100/80/50/50 100/80/50/50 $2000 $36.92 $79.31 $93.97 $146.91 $0.00
R&C
DINHR04 Active $50/$75 $1500/1000 90th 100/80/50/50 80/60/50/50 $1000 $26.69 $57.33 $69.51 $108.08 $0.00
R&C
Low Allocation
DINLR06 Passive $50/$50 $1000 90th 100/80/50 100/80/50 NA $27.35 $58.74 $68.73 $107.78 $0.00
R&C
DINLM09 Passive $50/$50 $1000 MAC 100/80/50 100/80/50 NA $19.92 $42.78 $51.70 $80.45 $0.00
DINLRO5 Passive $50/$50 $1000 90th 100/80/50/50 100/80/50/50 $1000 $27.96 $60.04 $74.56 $115.27 $0.00
R&C
DINLMII Active $75/$75 $1000 MAC 90/70/50 70/50/30 NA $15.16 $32.56 $39.78 $61.73 $0.00
DINLR07 Passive $75/$75 $1000 90th 90/70/50 90/70/50 NA $23.40 $50.27 $58.21 $91.52 $0.00
R&C
Voluntary
High Allocation
DINHMI6 Passive $25/$75 $750 MAC 100/80 100/80 NA $10.34 $22.21 $32.56 $48.55 $0.00
DINHMI4 Active $50/$50 $1500/1000 MAC 100/80/50 80/60/40 NA $21.95 $47.14 $56.41 $87.98 $0.00
DINHR13 Passive $50/$50 $1500 90th 100/80/50/50 100/80/50/50 $1500 $35.36 $75.95 $94.39 $145.91 $0.00
R&C
Low Allocation
DINLMI5 Active $75/$75 $1000 MAC 90/70/50 70/50/30 NA $16.69 $35.84 $43.74 $67.91 $0.00
Coinsurance Type-I :Exams/Cleanings/X-Rays(both High&Low Coverage)
Coinsurance Type-II:Basic Restorative,Simple Extractions,Non-surg Perio(both High&Low Coverage),Endodontics,Oral Surgery,Surgical Perio(High)
Coinsurance Type III:Major Restorative,Prothodontics,Prothsodontics(both High&Low Coverage),Endodontics,Oral Surgery,Surgical Perio(Low)
Coinsurance Type-IV:Ortho(both High&Low Coverage)
R&C: Reasonable and Customary,MAC:Max.Allowed Charge
*Waived Deductible applies to all Class I services and 3x family deductible limit.
**Waiting Period 12 month applicable for Surgical Perio/Major Restorative/Prothodonhcs/Mist Rest&Prosth Services
True Group a(>70%Participation AND>50%Employer Contribution),Voluntary Group-(>25%Participation AND c50%Employer Contribution)
A Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
Page 17 of 18 03/29/2016 11:32 AM
•.• pB1ueCross B1ueSWeld BlueCare Dental PPOS"'
of Illinois
Plan ID:DINHM08
This information only provides a summary of the benefits for this Dental Plan.Please refer to your Dental Benefit Booklet for additional benefit
information. The Deductibles,Coinsurance and Benefit Period Maximum shown below are subject to change as permitted by applicable law.
Summary of Dental Benefits
Out of Network"
Benefit Period Maximum
$1,000 $1,000
Deductible
$50 Individual/$150 Family $50 Individual/$150 Family
Covered Services
Diagnostic Evaluations
Periodic oral evaluations 100% 100%
Problem focused oral evaluations
(Deductible waived) (Deductible waived)
Comprehensive oral evaluations
Preventive Services
Prophylaxis(cleanings) 100% 100%
Topical fluoride applications (Deductible waived) (Deductible waived)
Diagnostic Radiographs
Full-mouth and panoramic films 100% 100%
Bitewing films
Periapical films (Deductible waived) (Deductible waived)
Miscellaneous Preventive Services
Sealants 100% 100%
Space maintainers (Deductible waived) (Deductible waived)
Basic Restorative Dental Services
Amalgams
Resin-based composite restorations 80% 80%
Non-Surgical Extractions
Removal of retained coronal remnants 80% 80%
Removal of erupted tooth or exposed root
Non-Surgical Periodontal Services
Periodontal scaling and root planing
Full-mouth debridement 80% 80%
Periodontal maintenance procedures
Adjunctive Services
Palliative treatment(emergency) 809'e 80%
Deep sedation/general anesthesia
Endodontic Services
Therapeutic pulpotomy and pulpal debridement
Root canal therapy 80% 80%
Apexification/recalcification
In Network
Covered Services (continued)
ral Surgery Services
Surgical tooth extractions
Alveoloplasty and vestibuloplasty
Excision of benign odontogenic tumor/cyst 80% 80%
Excision of bone tissue
Incision and drainage of an intraoral abscess
Surgical Periodontal Services
Gingivectomy or gingivoplasty and gingival flap procedures
Clinical crown lengthening
Osseous surgery
Osseous grafts 80% 80%
Soft tissue grafts/allografts
Distal or proximal wedge procedure
Anatomical crown exposures
Major Restorative Services
Single crown restorations
Gold foil and inlay/onlay restorations 50% 50%
Labial veneer restorations
Crowns placed over implants
rosthodontic Services
Complete and removable partial dentures
Denture reline/rebase procedures 50% 50°x6
Fixed bridgework
Prosthetics placed over implants
Miscellaneous Restorative and Prosthodontic Services
Prefabricated crowns
Recementations
Post and core,pin retention and crown/bridge repairs 50% 50%
Adjustments
Orthodontic Se
rt o ont c ver,.ces
Orthodontic Diagnostic Procedures and Treatment 50%
Lifetime Maximum per Participant $1,000
(Deductible waived)
Dental implants are not covered.
The above is a listing of common services available through your network of Participating Dentists.
The Member's share of the cost is determined by whether care is received from a Participating or Non-Participating Dentist.
"For services rendered by a Non-Participating Dentist(out of network),the Allowable Charge is the Provider's usual charge,not to exceed the amount
that the Plan would reimburse a Participating Dentist rendering the same services. The Member will be responsible for the full amount by which the
Non-Participating Dentist's actual charges exceed the Allowable Charge.
Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue
Shield Association
228615.0815
B1ueCross BlueShield Dearborn national*
�•� of Illinois
BENEFIT PLAN SELECTION (BPS)
(To Be Used for Mid-Market Group Accounts)
Please complete&return this form in its entirety, including the required signatures
Section 1 -Account Information:
Employer Name:
BlueSTAR Account#: r , Effective Date: r ( aOf b Anniversary Date: 1511 qu-1
Health Products/Mid-Market Benefit Plan Selection:
• The OPX in all non-HSA plans listed below will not exceed$1,000 for RX or$5,600 for Medical for Individual;and$3,000 for RX or
$10,200 for Medical for Family.For HSA plans,the OPX will not exceed$6,450.The OPX is inclusive of all deductibles,copays and
coinsurance costs incurred on in-network benefits.
• There are four health product categories which include multiple products(i.e.Blue Choice PPO)and their applicable benefit plans.
• A group may select up to six health plan options.
• The Prescription Drug Card may vary between products.
Section 2a-Renewing Groups Onl *If New Business, skip to Section 3
Current Plan: Retaining Plan: Replacing Plan:
Please list current plan(s)below Please list replacement plan in space below.
1. ❑Yes ❑ No
2. ❑Yes ❑ No
3. ❑Yes ❑ No
4. ❑Yes ❑ No
5. ❑Yes ❑ No
6. ❑Yes ❑ No
Section 21b-Renewing Groups Only: (*If New Business skip to Section 3)
Adding Plan(Medical and/or Dental):
Please list new plan(s)below
1.
2.
3.
4.
5.
6.
Section 3—HSA/FSA Plans:
HSA Vendor: FSA Vendor:
*If HSA is selected,a vendor will need to be selected. *If FSA is selected,a vendor will need to be selected.
(If no selection is made,HSA Vendor will default to Other 1 None.) If no selection is made,FSA Vendor will default to Other/None.
❑ Option A: BenefitWallet ❑ Option D: FSA ConnectYourCare
❑ Option B: FlexHSA Plan ❑ Option E: FSA Other/None
❑Option C: HSA Bank ❑ Option F: HSA Other/None
.Products and services marketed under the Dearborn National•brand and the star logo are underwritten and or provided by Dearborn Nationale Life Insurance Company(Dewners Grove,Il.)in all
stales(excluding New York)and certain of its affiliates, Dearborn National's Life Insurance Company is a separate company that does nut provide Blue Cross and Blue Shield of Illinois products or
services. Dearborn National,a Life Insurance Company is solely responsible for the lilt:and disabilhy products described in this illustration.
,V A Division of Health C'arc Service Corporation,a Mutual legal Resen a Company,an Independent I icensee of(he Blue Cross and Blue Shield Association
GA-10-9-SMGRP BPSF HCSC MM Rev.02/18/16 1
Section 4-New Business:
Please select plan designs (Up to a maximum of 6 plans) GROUP NUMBER:
OptionsA, Blue Choice
Tiered Network(1311-le Choice OPT PPO-BC/PPO-PPO/Old of Network-OON)
MTP72C2F $500/$1,5001$3,000 1 90%/70%150% $4,000/$5,600/$12,0004/N/A
$20/$50 $400'/$400' $01$10/$35/$75/$150
MTP8274F $1,0001 2,500/$5,000 90%/70%/50% $2,500/$5,500/$11,000 $25/$50 $400'1$400' $0/$10/$35/$75/$150
MTETI V07 2,600/ 500/$9,000 100%/80%/60% $2 600/$6,450/$12,900 N/A/N/A 100%
MTPF305F 4 000/$5,000/$10 000 80%/60%/50% $5 600/ 5 600/ 13,200 500'/ 500' 0/$10/$3 75/ 150MTP7122F $500/$1,500/$3,000 100%/70%/50% $500/$3,000/$6,000 0 $400'/$400' $0/$10/$351$75/$150
MTP7272F 500/$1 500/$3,000 90%170%/50% $2 500/$5 500/$11,0000 $400'/$400' $0/$10/$35/$75 150
LJ MTP9253F $1,500/$3,500/$7,000 90%/70%/50% $3,000/$5,5001$11,0000 $400'/$400` $0/$10/$35/$75/$150
MTPC173F $2,5001$4,500/$9,000 100%/80%/60% $2,500/$5,550/$11,000 $30/$50 $400'/$400' $0/$10/$35/$75/$150
17MBP8353G
$1 0001$2 000 80%/60% $3,000/$6 000 $30 $400" $0/$101$50/$100/$150
$2,500/$5,000 80%150% $4,500/$9,000 $30 $150 $10/$40/$60
500/ 1 000 90%/60% $1500/$3 000 $20 $150 10/ 0/ 60
$1,500/$3,000 90%/60% $2500/$5 000 $20 $150 $10/$40/$60
$1,500/$3,000 80%150% $3,500/$7,000 $30 $150 $8/$35/$75/$150
MBP8343C $1,000/$2,000 80%/50% $3,000/$6,000 $30 $150 $8/$35/$75/$150
Lj MBP82328 $1,000/$2,000 90%/60% $2,000/$4,000 $20 $150 1 $10/$40/$60
M 4242326 $250/$500 90%/60% $1,250/$2,500 $20 $150 $10/$40/$60
MSP73436 $500/$1,000 80%/50% $2,500/$5,000 $30 $150 $101$40/$60
MBPA3C3F $2,0001$4,000 80%/60% $4,000/$8,000 $30 $150 $0/$10/$35/$75/$150
MBPA303F $2,000/$4,000 80%/60% $5,500/$11,000 $30 $150 $0/$10/$35/$75/$150
MBPFIC3F $4,000/$8,000 100%/100 $4,0001$8,000 1 $30 $150 $0/$10/$35/$75/$150
MBPF303F 1 $4,0001$8,000 80%160 $5 500/$11,000 1 $30 $150 $0/$101$35475/$150
C, ElftleEdge W Select HSA-Asterisk(*)Indicates Aggregate Plan
LJ MBSCI807' 1 $2,500/$5,000 100%/70% 1 $2,500/$5,000 100% 100% 1 100%
Lj MBSC3805" 1 $2,500/$5,000 80%/50% $5,000/$10,000 80% 1 80% 80%
D CPO-This PrOCILICt is notavailable in all geographic areas(Network: BILle Choice/PPOIOUT)
MCP7202C 500 90% $2,500 1 $20 $150 1 $8/$35/$70150
$1,000 80% $5,000 1 $20 $150 1 $8/$35/$75/$150
$2,000 60% $14,000 60% $150 1 $&$35/$75/$150
CO #of Ees
CO #of Ees
Initial Employee Enrollment by CPO Network CO #of Ees
Total#of Em to ees Enrolled:
E.131tieEdge HSA- Asterisk I')Indicates Aggregate Plan
MPET290H $2,600!$5,200 90%/70% $3,500/$7,000 N/A N/A 90%
MPSC11807 $2,500 100%/80% $5,000 100% 100% 1000%
❑MPET1V07 $2,600/$5,200 100%/80% $2,600/$10,400 100% 100% 100%
MPET3Y05 $2,600/$5,200 80%/60% $5,200/$10,400 80% 90% 80%
MPS91605 $1,500 100%/80% $3,000 100% 90% 80%
0 MPS93505 $1,500/$3,000 80%/60% $3,0001$6,000 80% 90% 80%
MPSC3805' $2,500/$5,000 80%/60% $5,000/$10,000 80% 90% 80%
MPSE3X05' $3,500/$7,000 80%/60% $5,800/$11,600 80% 90% 80%
❑MPP01Q07 $6,000/$12,000 100%/100% $6,0001$12,000 N/A N/A 100%
F. CPO Value Choice-This ProdLlCt is riot available in all geographic areas(Network:CPO fPPO/OUT)
MCV82305 $1,000 90% $2,000 90% 1 $150 1 80%
$2,000 80% $4,000 90% $150 1 80%
$4 000 50% $8,000 90% $150 1 80%
CO #of Ees
CO #of Ees
Initial Employee Enrollment by CPO Network CO #of Ees
Total#of Em to ees Enrolled:
r uc s an semces mar e e un er a rn National- rat an to stair ogo are u erwn en a or prow e y . a orn atone Life insurance .ompany(Downers rove, m a
states(excluding New York)and certain of its affiliates. Dearborn National"'Life Insurance Company is a separate company that does not provide Blue Cross and Blue Shield of Illinois products or
services. Dearborn Nationale,Life Insurance Company is solely responsible for the life and disability products described in this illustration
X A Division of Health Care Service Corporation,a Mutual Legal Reserve Company.an Independent Licensee of the Blue Cross and Blue Shield Association
GA-10-9-SMGRP BPSF HCSC MM Rev.02/18/16 2
G.BlueAdvantaqu HMO
MHHB196 N/A N/A $1 500 $30 i $150 S10440460
O:MHH6106 N/A N/A $1500 $20 $150 $101 0/$60
HB166 N/A N/A $1,500 $30 $150 10/$40/ 60
H019C N/A N/A $1,500 $30 $150 $ 35 751$150
H1133F $0 100% $5,500 $30 $0/� Value Choice $10!$35/$75/$150
H. Blue Adva ritage •
MHVBV02C N/A N/A $3000 $40 $250 35 75 150
MHVBV03C WA N/A $3 000 50 $300 8/ 3 75/$150
1. ••
MPP11T3F $0/$6,600
100%180% $5,600/$13,200 $301 $400• 10/ 10/ 35 75/$150
MPNW= $0/$0 90%/70% $2501$1,000 $20 $150 $0/$101$50/ 1001$150
MPPH3T8(i 5 0001 10 000 80%/60% 5 6001$12,200 0 $250 $0/$10/$50/$100/$150
MPP43M4F 50/$500 80%/60% $1,250/$2.500 $25 $300' $Q/$10/$35/$75/$150
MPP8353G $1,000/$2,000 80%/60% $3,000/$6,000 $30 $400' $0/$10/$50/$l / 150
MPP73863 $500/$1,000 80%/60% $5,000/$10,000 $40 $400' $15/$30/$50
MPP9391F $1,500/$,3,000 80%/60% $3,500/$7,000 $10 $400" $0/$10/$35/$75/$150
MPP83436 $1,000/$2,000 80%/60% $3,000/$6,000 $30 $150 $10/$40/$60
MPP82326 $1,000/$2,000 90%170% $2,000/$4,000 20 $150 $10/$4Q/$60
MPP53038 1 000/ 2 000 80%/60% $4,000/$8,000 $30 $150 $10/$40 0
MPP8343C $1,000/$2 000 80%/60% $3,0001$6,000 $30 $150 $8/$35/$75/150
MPP93C36 $1 500/$3,000 80%/60% 3,500 I$7,000 $30 $150 10/ 60
MPP9383C $1 500/$3,000 80%/60% $4 5001$9 000 $30 $150 $8/$35/$751150
MPPC3836 $2 500/$5,000 80%/60% $4,500/$9,000 $30 $150 $10/$40 60
MPPC3036 2 5001 5 000 80%/60% $5 500/$11,000 $30 $150 $10/$40/$60
MPPC3826 $2,500/$5,000 80%/60% $4,500/$9,000 20 15010 60
MPPC2C28 $2,500/$5,000 90%/70% $3,500/$7,000 $20 $150 -,,,,,,,$10/$40/$60
MPP43323 $250/$500 80%/60% $1,250/$2,500 $20 $150 $15/$30/$50
MPPE3026 $3,500/$7,000 80%/60% $5,500/$11,000 $20 $150 $10/$40/$60
MPP73426 $500/$1,000 80%/60% $2,500/$5,000 $20 $150 $10/$40/$60
MPP72326 $5001$1 000 90%/70% $1,500/$3,000 $20 150 $10/S40/$60
MPP73436 $500/$1, 80%/60% $2,500!$5,000 $30 $15010 / 80
MPP72226 $500/$1,000 90%/70% $1,000/$2,000 $20 $150 $10/$
MPP73C3C $500/$1,000 80%/60% $3 $10/$40/$60
500/$7,000 $30 $150 $$10/$ 75/150
MPP93C28 $1,500/$3,000 80%/60% $3,500/$7 000 $20 $150 $10/$40/$60
-LLMPP93C3C $1,500/$3,000 80%/60% $3,500!$7,000 $30 $150 $8/$35/$75/150
MPPA3C3F $2,000/$4,000 80%/60% $4,0001$8,000 $30 $150 $0410435375/35/ 75/ 150
MPPA303F $2,000/$4,000 80%/60% $5,500/$11,000 30 150 $0/$10/$35/S75/$150
MPPF1 C3F 4 000/$8,000 1000%/100% $4,000/$8,000 30 $150 0 10/ 3 75 150
MPPF303F $4,000/$8 000 80%!60% $5 500/$11,0001
1150
`ER Copay is Per Occurrence
*Products and services marketed under the Dearborn Nationals brand and the star logo are underwritten and or provided by Dearborn Nationals Life Insurance Company(Downers(irove.IL)in all
states(excluding New York)and certain of its affiliates. Dearborn National°o Life Insurance Company is a separate company that does not provide Blue Cross and Blue Shield of Illinois products or
services. Dearborn Nationalx Life Insurance Company is solely responsible for the lite and disability products described in this illustration.
.R,A Division of Health Care Service Corporation.a Mutual D.egal Reserve Company,an Independent Licensee of the Blue Cross.and Blue Shield Association
GA-10-9-SMGRP BPSF HCSC MM Rev.02/18/16
3