Level A Level B Level C Coinsurance Big Sky Select Out-of-Pocket Office Visit Deductible Deductible (Individual/Family) Copay (Individual/Family) (Individual/Family) Plan: $ / $ $ / $ %/ % $ / $ $ Plan: $ / $ $ / $ %/ % $ / $ $ Blue Select Deductible for Emergency Inpatient Office Visit Specialist Out-of-Pocket Prescription Room Admission Copayment Copayment (Individual/Family) Drugs Copayment Copayment Plan: $ $ $ $ $ $ /$ Plan: $ $ $ $ $ $ / $ Health Care Management Services: Total Health Management (THM) (additional charges apply) Employee Assistance Program (EAP) Yes If Yes, please list plan: Dental Coverage No Vision Coverage Yes, Standard Coverage Yes, Custom Coverage No Life & Disability (if checked, attach separate Dearborn National application) HCSC COBRA Administrative Services - If selected, complete separate COBRA Administrative Services Addendum. If not selected, please provide name of entity administering COBRA: COMMENTS: ACCOUNT EXPERIENCE NEW GROUPS ONLY – Has there been a significant change in the claims experience previously provided? No skip the rest of this (Account Experience) section – Yes Please answer the below questions to the best of your knowledge. Note: any changes indicated below may impact – rates and will means all Eligible Employees, Dependent children, Retirees require Underwriter approval. “Member” and COBRA Continuants. 1. Has any Member received more than $20,000 in medical benefits during the last 12 months? Yes No 2. Is any Member expected to have claims in excess of $20,000 during the next 12 months? Yes No 3. Is any Member mentally or physically handicapped or disabled or not actively at work? Yes No 4. Has any Member been diagnosed as having a high risk condition? Yes No If any question is details must be provided below: answered “yes,” Member Diagnosis or Nature of Prognosis/Current Dates of Treatment $ Amount of Claims Age the Disorder Treatment $ $ $ $ $ $
Big Sky Select Level B Deductible (Individual/Family) Level C Deductible (Individual/Family) Coinsurance Out-of-Pocket (Individual/Family) Level A Office Visit Copay Plan: $ / $ $ / $ %/ % $ / $ $ Plan: $ / $ $ / $ %/ % $ / $ $ Blue Select Deductible for Prescription Drugs Office Visit Copayment Specialist Copayment Emergency Room Copayment Inpatient Admission Copayment Out-of-Pocket (Individual/Family) Plan: $ $ $ $ $ $ /$ Plan: $ $ $ $ $ $ / $ Health Care Management Services: Total Health Management (THM) (additional charges apply) Employee Assistance Program (EAP) Dental Coverage Yes If Yes, please list plan: No Vision Coverage Yes, Standard Coverage Yes, Custom Coverage No Life & Disability (if checked, attach separate Dearborn National application) HCSC COBRA Administrative Services - If selected, complete separate COBRA Administrative Services Addendum. If not selected, please provide name of entity administering COBRA: COMMENTS: ACCOUNT EXPERIENCE – NEW GROUPS ONLY Has there been a significant change in the claims experience previously provided? No – skip the rest of this (Account Experience) section Yes – Please answer the below questions to the best of your knowledge. Note: any changes indicated below may impact rates and will require Underwriter approval. “Member” means all Eligible Employees, Dependent children, Retirees and COBRA Continuants. 1. Has any Member received more than $20,000 in medical benefits during the last 12 months? Yes No 2. Is any Member expected to have claims in excess of $20,000 during the next 12 months? Yes No 3. Is any Member mentally or physically handicapped or disabled or not actively at work? Yes No 4. Has any Member been diagnosed as having a high risk condition? Yes No If any question is answered “yes,” details must be provided below: Member Age Diagnosis or Nature of the Disorder Dates of Treatment $ Amount of Claims Prognosis/Current Treatment $ $ $ $ $ $