8/3/2019 Insurance Quote for GLOBAL POWER GROUP - Adobe Reader
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Group InsuranceProposal
Cov r g
Prepared for
GLOBAL POWER GROUP
These rates were quoted for the proposed
effective date of January 1, 2012 . If another
ef fec t ive date is se lec ted or you are
requesting an effective date more than 30
days in advance please confirm the rates
quoted.
Presented By
SNAPP & ASSOC INS SVC
CAROLYN LOUIE
(619) 908-3100
License No. 0E00422
QUOT-O-MATIC 658360 November 3, 2011
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GLOBAL POWER GROUP
Quote 658360 November 3, 2011
We have endeavored to provide you with an accurate proposal based on the information collected from sources that are considered reliable including, without limitation, rate information
provided by carriers. We have not verified nor can we guarantee the accuracy, timeliness or completeness of such information. This proposal is provided on an "AS-IS" basis. The rates
quoted are the carriers standard risk rates, unless otherwise stated. We assume no liability for rate differences and ask that you advise your client not to cancel their prior coverage until
final rating information and underwriting approval have been received from the carrier. This proposal is a summary of plan benefits: for complete details refer to the master contract,
benefit booklet, or similar document.
All Rights Reserved. No portion of this material may be reproduced in any form or by any electronic or mechanical systems, without permission from the publisher.
Quote Report
COMPANY BROKER (Code: )
GLOBAL POWER GROUP CAROLYN LOUIE
LAKESIDE, CA 92040 SNAPP & ASSOC INS SVC
SAN DIEGO COUNTY 438 CAMINO DEL RIO SOUTH STE 112
SAN DIEGO, CA 92108
Phone: (619) 908-3100
Fax: (619) 908-3110
Quote Information
RAF Specials Requested ? Yes
Current or Renewing Carrier Kaiser Permanente
Other Carrier within the last 12 months
Current RAF 0.95
Renewal RAF 0.95
Renewal Date 01/01/2012
RAF Specials this Group qualifies for:
Aetna: 0.90 Anthem Blue Cross: 0.90
Blue Shield: 0.90 Blue Shield Simplesync: 0.90
HSA California: 0.90 Seechange Health: 0.90
Sharp: 0.90 Unitedhealthcare: 0.90
Benefit Type Quoted Medical,Dental,Life,Vision,Riders
Nature of Business PLUMBING & HYDRONIC SUPPLIES
SIC Code 5074
Multiple Locations NO
Out of State Employees NO
Full Time 31
Part Time 0
COBRA 0Employees Paid
By CommissionAs Independent Contractors
NONO
Percent of Insurance Cost Paid by EmployerEmployeeDependents
100%0%
Expected Dental Participation 75%
Number of Complete Years of Prior Dental 0
Requested Effective Date: January 1, 2012
Quo por
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GLOBAL POWER GROUP
Quote 658360 November 3, 2011
Census Page
The Average Age of all 31 employees is 43 (excludes COBRA Employees). COBRA employees are included in the rates. However, the employer is not responsible for this amount. Employee zip code unknown. Employer zip code used for rating.
NAMELIFE
ONLY SEX DOB AGE
SPOUSE/PARTNER
DOB
SPOUSE/PARTNER
AGE
NUMBEROF ELIGIBLECHILDREN COBRA
AMOUNTOF LIFE
INSURANCE ZIP CODE
1. Gabriel Ayala NO MALE 06/15/82 29 06/15/82 29 2 NO MINIMUM 91901
2. Salvador Ceballos NO MALE 06/15/67 44 06/15/67 44 2 NO MINIMUM 91914
3. Gabriel Chavez NO MALE 07/15/77 34 -- -- 2 NO MINIMUM 92020
4. Robert Coombes NO MALE 07/15/69 42 -- -- 2 NO MINIMUM 92065
5. Erwin Dennis (92251) NO MALE 06/15/71 40 06/15/71 40 2 NO MINIMUM 92040
6. Henry Freow II NO MALE 06/15/62 49 06/15/62 49 2 NO MINIMUM 92114
7. Michael Galceran NO MALE 07/15/72 39 -- -- 0 NO MINIMUM 91010
8. James Harris NO MALE 06/15/73 38 06/15/73 38 2 NO MINIMUM 92154
9. Ramon Hernandez NO MALE 06/15/67 44 -- -- 0 NO MINIMUM 92105
10. Dennis Hill NO MALE 06/15/54 57 -- -- 0 NO MINIMUM 92071
11. Myrna Holmes NO FEMALE 07/15/72 39 -- -- 0 NO MINIMUM 91977
12. Terrance Hurley NO MALE 06/15/80 31 06/15/80 31 0 NO MINIMUM 9193513. Dante Jerig NO MALE 07/15/81 30 07/15/81 30 2 NO MINIMUM 92020
14. Douglas Knight NO MALE 07/15/64 47 07/15/64 47 2 NO MINIMUM 92234
15. Michael Kunkel NO MALE 07/15/57 54 07/15/57 54 0 NO MINIMUM 92867
16. Gerry LaFargue NO MALE 06/15/56 55 -- -- 0 NO MINIMUM 92019
17. Tai Le NO MALE 06/15/75 36 06/15/75 36 0 NO MINIMUM 92115
18. Terry Mammen NO MALE 06/15/50 61 06/15/50 61 2 NO MINIMUM 92064
19. David Marcos NO MALE 06/15/59 52 -- -- 0 NO MINIMUM 92105
20. Anthony Martorana NO MALE 06/15/39 72 -- -- 0 NO MINIMUM 92071
21. Jamie Mellinger NO MALE 07/15/76 35 -- -- 0 NO MINIMUM 92071
22. Anthony Monroig NO MALE 06/15/85 26 -- -- 0 NO MINIMUM 91942
23. Donald Patterson NO MALE 07/15/67 44 07/15/67 44 0 NO MINIMUM 92346
24. Daniel Pearson NO MALE 07/15/89 22 07/15/89 22 0 NO MINIMUM 92020
25. Brian Pena NO MALE 06/15/69 42 -- -- 2 NO MINIMUM 91730
26. Robert Petraglia NO MALE 06/15/53 58 06/15/53 58 0 NO MINIMUM 92029
27. Santos Ramos NO MALE 07/15/60 51 -- -- 0 NO MINIMUM 92404
28. Maria Rivas NO FEMALE 07/15/77 34 -- -- 2 NO MINIMUM 92124
29. David Santos NO MALE 07/15/59 52 -- -- 0 NO MINIMUM 92103
30. Steven Waltman NO MALE 06/15/51 60 06/15/51 60 0 NO MINIMUM 92071
roup Cnsus
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GLOBAL POWER GROUP
Quote 658360 November 3, 2011
Census Page
The Average Age of all 31 employees is 43 (excludes COBRA Employees). COBRA employees are included in the rates. However, the employer is not responsible for this amount.
NAMELIFE
ONLY SEX DOB AGE
SPOUSE/PARTNER
DOB
SPOUSE/PARTNER
AGE
NUMBEROF ELIGIBLECHILDREN COBRA
AMOUNTOF LIFE
INSURANCE ZIP CODE
31. Justin Yancovich NO MALE 06/15/78 33 06/15/78 33 2 NO MINIMUM 92020
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This comparison is for illustrative purposes only. Please refer to plan brochures for complete benefit and rate information. Rates assume Employees Age 65 and over have Medic This RAF is the renewal RAF for this carrier. RAF specials and rules have been applied.
GLOBAL POWER GROUP
Quote 658360
Detailed Benefits & Rate Comparison with Census
J HIJPlan Name HMO $30/$1,500 GOLD VALUE $1500 DED/40/40
Network HMO HMO
Deductible
Individual $1,500 $1,500Family $3,000 $3,000
Maximum Out of Pocket
Individual $3,500 $4,000
Family $7,000 $8,000
Lifetime Maximum NO MAXIMUM NO MAXIMUM
Outpatient Services
Doctor Office Copay DED WAIVED-$30 COPAY $40 COPAY
Preventive Care DED WAIVED-100% DED WAIVED-100%
Physical Therapy $30 COPAY $40 COPAY
Lab X-Ray $10/$50 SOME SVCS 100%
Outpatient Surgery $250 COPAY DED-60%
Inpatient Services
Hospitalization $500 PER DAY DED-60%
Inpatient Physician Fee INCL W/HOSPITAL SVCS 100%
Emergency Room $100 COPAY $150 COPAYAmbulance $75 COPAY $150 COPAY
Non-Severe Mental Health/Substance Abuse
Mental - Inpatient $500/DAY-MAX 30/YR NOT COVERED
Mental - Outpatient $30-MAX 20 VISITS/YR $40-MAX 20 VISITS/YR
Chemical - Inpatient $500/DAY-DETOX ONLY NOT COVERED
Chemical - Outpatient $30 COPAY $150 COPAY-DETOX
Durable Medical Equipment NOT COVERED 50%-MAX $2,000/YR
Prescription Drugs
Formulary Generic Copay $10 $20
Formulary Brand Copay $30 $150 Rx DED + $35
Non-Formulary Copay NOT COVERED $150 Rx DED + $70
Separate RX Deductible NONE NONE
Formulary Brand RX Deductible NONE $150
Cost Comparison KAISER PERMANENTE SHARP
Risk Adjustment Factor 0.95 0.90
Premium
Average Employee Premium 305.44 283.00
Employee Total 9,468.65 8,773.04
Dependent Total 7,619.00 8,218.16
Total Monthly Group Premium 17,087.65 16,991.20
Sn p sh D il n f i n d C omp r ison
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This comparison is for illustrative purposes only. Please refer to plan brochures for complete benefit and rate information. Rates assume Employees Age 65 and over have Medic This RAF is the renewal RAF for this carrier. RAF specials and rules have been applied.
GLOBAL POWER GROUP
Quote 658360
Detailed Benefits & Rate Comparison with Census
PQR PQRPlan Name HMO COINSURANCE 70% AVN HMO $40/$50
Network HMO DED NETWORK HMO VALUE NETWORK
Deductible
Individual NONE NONEFamily
Maximum Out of Pocket
Individual $3,500 $3,500
Family $7,000 $7,000
Lifetime Maximum NO MAXIMUM NO MAXIMUM
Outpatient Services
Doctor Office Copay $40/$50 SPECIALIST $40/$50 SPECIALIST
Preventive Care 100% 100%
Physical Therapy $50-MAX 20 VISITS/YR $50-MAX 20 VISITS/YR
Lab X-Ray $40 COPAY $40 COPAY
Outpatient Surgery 70% $400 COPAY
Inpatient Services
Hospitalization 70% $800/DAY-1ST 3 DAYS
Inpatient Physician Fee INCL W/HOSPITAL SVCS INCL W/HOSPITAL SVCS
Emergency Room $200 COPAY $100 COPAYAmbulance 70% $100 COPAY
Non-Severe Mental Health/Substance Abuse
Mental - Inpatient NOT COVERED NOT COVERED
Mental - Outpatient $50-MAX 20 VISITS/YR $50-MAX 20 VISITS/YR
Chemical - Inpatient 70%-DETOX ONLY $800/DAY-1ST 3 DAYS
Chemical - Outpatient $50 COPAY-DETOX ONLY $50 COPAY-DETOX
Durable Medical Equipment 50%-MAX $2,000/YR 50%-MAX $2,000/YR
Prescription Drugs
Formulary Generic Copay $20 $20
Formulary Brand Copay $40 $40
Non-Formulary Copay $60 $60
Separate RX Deductible NONE NONE
Formulary Brand RX Deductible NONE NONE
Cost Comparison AETNA AETNA
Risk Adjustment Factor 0.90 0.90
Premium
Average Employee Premium 311.55 373.16
Employee Total 9,658.00 11,568.00
Dependent Total 9,177.00 10,982.00
Total Monthly Group Premium 18,835.00 22,550.00
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Medical Section - 9
GLOBAL POWER GROUP
Quote 658360 Plan 138102 November 3, 2011
Premiums
Area 5 Rate Grid0.95 RAF (Additional amounts for dependents are shown in each category)
Family deductible has embedded individual ded. Indiv must only meet own ded before receiving benefits. Ded applies to all services unless noted.
Out-of-Pocket Maximum includes deductible.
Please refer to the Evidence of Coverage for more information, most DME is not covered.
Rates assume Employees Age 65 and over have Medicare. Medicare rates are based on employee info only & subject to final review. Dependent
Medicare status may cause rates to change. Rates dont include optional riders.
This RAF is the renewal RAF for this carrier.
Medical Benefits and Premiums
JHMO $30/$1,500Benefits HMOGeneral
Deductible - Individual/Family $1,500/$3,000
Max Out of Pocket - Individual/Family $3,500/$7,000
Lifetime Benefit Maximum NO MAXIMUMPhysician Services:
Doctor Office Visit DED WAIVED-$30 COPAY
Preventive Care DED WAIVED-100%
Physical/Occupational Therapy $30 COPAY
Lab & X-Ray Outpatient $10/$50 SOME SVCS
Durable Medical Equipment NOT COVERED
Chiropractic OPTIONAL RIDER AVAIL
Hospital Services:
Inpatient Hospital Services $500 PER DAY
Inpatient Physician Fee INCL W/HOSPITAL SVCS
Outpatient Surgery $250 COPAY
Emergency Room $100 COPAY
Ambulance $75 COPAY
Non Severe Mental Health:
Outpatient $30-MAX 20 VISITS/YRInpatient $500/DAY-MAX 30/YR
Chemical Dependency:
Outpatient $30 COPAY
Inpatient $500/DAY-DETOX ONLY
Prescription Drugs:
PharmacyKAISER PERMANENTE
Formulary Generic Copay $10
Formulary Brand Copay $30
Non Formulary Copay NOT COVERED
Brand Name Deductible NONE
Separate Deductible NONE
Rx Annual Maximum Benefits NO MAXIMUM
Mail Order Prescriptions AVAILABLE
Employees Dependents Subtotal Addtnl. for COBRA Grand Total
RAF 0.95 Standard Total Premium $ 9,469 $ 7,619 $ 17,088 $ 0 $ 17,088
Note: This group may qualify for a 0.95 RAF. The final RAF is decided during the Underwriting Process by the Carrier.
Age Employee Additional for Spouse Additional for Child(ren) Additional for Family
0-29 $ 171.95 $ 299.25 $ 217.55 $ 396.15
30-39 $ 203.30 $ 340.10 $ 207.10 $ 433.20
40-49 $ 275.50 $ 285.95 $ 154.85 $ 437.95
50-54 $ 367.65 $ 395.20 $ 135.85 $ 476.90
55-59 $ 456.00 $ 492.10 $ 134.90 $ 583.30
60-64 $ 584.25 $ 585.20 $ 137.75 $ 709.6565-99 $ 708.70 $ 908.20 $ 132.05 $ 987.05
ADEA 65-99 $ 708.70 $ 908.20 $ 132.05 $ 987.05
HMO$30/$1,500 - Benefits/Premiums
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Medical Section - 10
GLOBAL POWER GROUP
Quote 658360 Plan 113809 November 3, 2011
Premiums
Area 1 Rate Grid0.90 RAF (Additional amounts for dependents are shown in each category)
Rates assume Employees Age 65 and over have Medicare. Medicare rates are based on employee info only & subject to final review. Dependent
Medicare status may cause rates to change. Rates dont include optional riders.
RAF specials and rules have been applied.
Medical Benefits and Premiums
HIJ GOLD VALUE $1500 DED/40/40Benefits HMOGeneral
Deductible - Individual/Family $1,500/$3,000
Max Out of Pocket - Individual/Family $4,000/$8,000
Lifetime Benefit Maximum NO MAXIMUMPhysician Services:
Doctor Office Visit $40 COPAY
Preventive Care DED WAIVED-100%
Physical/Occupational Therapy $40 COPAY
Lab & X-Ray Outpatient 100%
Durable Medical Equipment 50%-MAX $2,000/YR
Chiropractic OPTIONAL RIDER AVAIL
Hospital Services:
Inpatient Hospital Services DED-60%
Inpatient Physician Fee 100%
Outpatient Surgery DED-60%
Emergency Room $150 COPAY
Ambulance $150 COPAY
Non Severe Mental Health:
Outpatient $40-MAX 20 VISITS/YRInpatient NOT COVERED
Chemical Dependency:
Outpatient $150 COPAY-DETOX
Inpatient NOT COVERED
Prescription Drugs:
PharmacyPARTICIPATING
Formulary Generic Copay $20
Formulary Brand Copay $150 Rx DED + $35
Non Formulary Copay $150 Rx DED + $70
Brand Name Deductible $150
Separate Deductible NONE
Rx Annual Maximum Benefits NO MAXIMUM
Mail Order Prescriptions 2X COPAY-90 DAYS
Employees Dependents Subtotal Addtnl. for COBRA Grand Total
RAF 0.90 Best Total Premium $ 8,773 $ 8,218 $ 16,991 $ 0 $ 16,991
RAF 0.90 Maximum Total Premium $ 8,773 $ 8,218 $ 16,991 $ 0 $ 16,991
Note: This group may qualify for a 0.90 RAF. The final RAF is decided during the Underwriting Process by the Carrier.
Age Employee Additional for Spouse Additional for Child(ren) Additional for Family
0-29 $ 174.18 $ 262.96 $ 255.32 $ 501.21
30-39 $ 203.00 $ 297.89 $ 264.37 $ 521.96
40-49 $ 250.04 $ 297.17 $ 237.03 $ 512.87
50-54 $ 317.14 $ 335.85 $ 205.75 $ 564.27
55-59 $ 398.62 $ 433.21 $ 198.96 $ 604.01
60-64 $ 511.90 $ 490.29 $ 164.00 $ 681.53
65-99 $ 731.96 $ 636.33 $ 216.79 $ 811.67
ADEA 65-99 $ 731.96 $ 636.33 $ 216.79 $ 811.67
GOLD VALUE$1500 DED/40/40- Benefits/Premiums
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Medical Section - 11
GLOBAL POWER GROUP
Quote 658360 Plan 113808 November 3, 2011
Premiums
Area 1 Rate Grid0.90 RAF (Additional amounts for dependents are shown in each category)
Rates assume Employees Age 65 and over have Medicare. Medicare rates are based on employee info only & subject to final review. Dependent
Medicare status may cause rates to change. Rates dont include optional riders.
RAF specials and rules have been applied.
Medical Benefits and Premiums
HIJ GOLD VALUE $1000 DED/30/40Benefits HMOGeneral
Deductible - Individual/Family $1,000/$2,000
Max Out of Pocket - Individual/Family $3,500/$7,000
Lifetime Benefit Maximum NO MAXIMUMPhysician Services:
Doctor Office Visit $30/$40 SPECIALIST
Preventive Care DED WAIVED-100%
Physical/Occupational Therapy $40 COPAY
Lab & X-Ray Outpatient 100%
Durable Medical Equipment 50%-MAX $2,000/YR
Chiropractic OPTIONAL RIDER AVAIL
Hospital Services:
Inpatient Hospital Services DED-70%
Inpatient Physician Fee 100%
Outpatient Surgery DED-70%
Emergency Room $150 COPAY
Ambulance $150 COPAY
Non Severe Mental Health:
Outpatient $40-MAX 20 VISITS/YRInpatient NOT COVERED
Chemical Dependency:
Outpatient $150 COPAY-DETOX
Inpatient NOT COVERED
Prescription Drugs:
PharmacyPARTICIPATING
Formulary Generic Copay $20
Formulary Brand Copay $150 Rx DED + $35
Non Formulary Copay $150 Rx DED + $70
Brand Name Deductible $150
Separate Deductible NONE
Rx Annual Maximum Benefits NO MAXIMUM
Mail Order Prescriptions 2X COPAY-90 DAYS
Employees Dependents Subtotal Addtnl. for COBRA Grand Total
RAF 0.90 Best Total Premium $ 9,397 $ 8,804 $ 18,201 $ 0 $ 18,201
RAF 0.90 Maximum Total Premium $ 9,397 $ 8,804 $ 18,201 $ 0 $ 18,201
Note: This group may qualify for a 0.90 RAF. The final RAF is decided during the Underwriting Process by the Carrier.
Age Employee Additional for Spouse Additional for Child(ren) Additional for Family
0-29 $ 186.55 $ 281.69 $ 273.51 $ 536.91
30-39 $ 217.43 $ 319.11 $ 283.19 $ 559.13
40-49 $ 267.82 $ 318.33 $ 253.92 $ 549.39
50-54 $ 339.71 $ 359.77 $ 220.40 $ 604.47
55-59 $ 426.98 $ 464.06 $ 213.13 $ 647.04
60-64 $ 548.33 $ 525.22 $ 175.69 $ 730.09
65-99 $ 784.07 $ 681.64 $ 232.23 $ 869.48
ADEA 65-99 $ 784.07 $ 681.64 $ 232.23 $ 869.48
O LD V AL U 1 0 00 D D 0 4 0 n f i s r m i u ms
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Medical Section - 12
GLOBAL POWER GROUP
Quote 658360 Plan 109007 November 3, 2011
Premiums
Area 1 Rate Grid0.90 RAF (Additional amounts for dependents are shown in each category)
First copay shown is for Non-Specialist office visits. Second copay is for Specialist office visits.
Rates assume Employees Age 65 and over have Medicare. Medicare rates are based on employee info only & subject to final review. Dependent
Medicare status may cause rates to change. Rates dont include optional riders.
RAF specials and rules have been applied.
Medical Benefits and Premiums
PQR HMO COINSURANCE 70%Benefits HMO DED NETWORKGeneral
Deductible - Individual/Family NONE
Max Out of Pocket - Individual/Family $3,500/$7,000
Lifetime Benefit Maximum NO MAXIMUMPhysician Services:
Doctor Office Visit $40/$50 SPECIALIST
Preventive Care 100%
Physical/Occupational Therapy $50-MAX 20 VISITS/YR
Lab & X-Ray Outpatient $40 COPAY
Durable Medical Equipment 50%-MAX $2,000/YR
Chiropractic $15-MAX 20 VISITS/YR
Hospital Services:
Inpatient Hospital Services 70%
Inpatient Physician Fee INCL W/HOSPITAL SVCS
Outpatient Surgery 70%
Emergency Room $200 COPAY
Ambulance 70%
Non Severe Mental Health:
Outpatient $50-MAX 20 VISITS/YRInpatient NOT COVERED
Chemical Dependency:
Outpatient $50 COPAY-DETOX ONLY
Inpatient 70%-DETOX ONLY
Prescription Drugs:
PharmacyPARTICIPATING
Formulary Generic Copay $20
Formulary Brand Copay $40
Non Formulary Copay $60
Brand Name Deductible NONE
Separate Deductible NONE
Rx Annual Maximum Benefits NO MAXIMUM
Mail Order Prescriptions AVAILABLE
Employees Dependents Subtotal Addtnl. for COBRA Grand Total
RAF 0.90 Best Total Premium $ 9,658 $ 9,177 $ 18,835 $ 0 $ 18,835
RAF 0.90 Maximum Total Premium $ 9,658 $ 9,177 $ 18,835 $ 0 $ 18,835
Note: This group may qualify for a 0.90 RAF. The final RAF is decided during the Underwriting Process by the Carrier.
Age Employee Additional for Spouse Additional for Child(ren) Additional for Family
0-29 $ 183.00 $ 304.00 $ 329.00 $ 551.00
30-39 $ 219.00 $ 366.00 $ 317.00 $ 597.00
40-49 $ 280.00 $ 329.00 $ 292.00 $ 560.00
50-54 $ 359.00 $ 373.00 $ 262.00 $ 628.00
55-59 $ 441.00 $ 495.00 $ 253.00 $ 586.00
60-64 $ 573.00 $ 505.00 $ 182.00 $ 639.00
65-99 $ 569.00 $ 568.00 $ 213.00 $ 781.00
ADEA 65-99 $ 774.00 $ 742.00 $ 213.00 $ 913.00
HMO COINSURANCE70% -Benefits/Premiums
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Medical Section - 13
GLOBAL POWER GROUP
Quote 658360 Plan 109104 November 3, 2011
Premiums
Area 1 Rate Grid0.90 RAF (Additional amounts for dependents are shown in each category)
First copay shown is for Non-Specialist office visits. Second copay is for Specialist office visits.
Rates assume Employees Age 65 and over have Medicare. Medicare rates are based on employee info only & subject to final review. Dependent
Medicare status may cause rates to change. Rates dont include optional riders.
RAF specials and rules have been applied.
Medical Benefits and Premiums
PQR AVN HMO $40/$50Benefits HMO VALUE NETWORKGeneral
Deductible - Individual/Family NONE
Max Out of Pocket - Individual/Family $3,500/$7,000
Lifetime Benefit Maximum NO MAXIMUMPhysician Services:
Doctor Office Visit $40/$50 SPECIALIST
Preventive Care 100%
Physical/Occupational Therapy $50-MAX 20 VISITS/YR
Lab & X-Ray Outpatient $40 COPAY
Durable Medical Equipment 50%-MAX $2,000/YR
Chiropractic $15-MAX 20 VISITS/YR
Hospital Services:
Inpatient Hospital Services $800/DAY-1ST 3 DAYS
Inpatient Physician Fee INCL W/HOSPITAL SVCS
Outpatient Surgery $400 COPAY
Emergency Room $100 COPAY
Ambulance $100 COPAY
Non Severe Mental Health:
Outpatient $50-MAX 20 VISITS/YRInpatient NOT COVERED
Chemical Dependency:
Outpatient $50 COPAY-DETOX
Inpatient $800/DAY-1ST 3 DAYS
Prescription Drugs:
PharmacyPARTICIPATING
Formulary Generic Copay $20
Formulary Brand Copay $40
Non Formulary Copay $60
Brand Name Deductible NONE
Separate Deductible NONE
Rx Annual Maximum Benefits NO MAXIMUM
Mail Order Prescriptions AVAILABLE
Employees Dependents Subtotal Addtnl. for COBRA Grand Total
RAF 0.90 Best Total Premium $ 11,568 $ 10,982 $ 22,550 $ 0 $ 22,550
RAF 0.90 Maximum Total Premium $ 11,568 $ 10,982 $ 22,550 $ 0 $ 22,550
Note: This group may qualify for a 0.90 RAF. The final RAF is decided during the Underwriting Process by the Carrier.
Age Employee Additional for Spouse Additional for Child(ren) Additional for Family
0-29 $ 219.00 $ 364.00 $ 394.00 $ 660.00
30-39 $ 263.00 $ 437.00 $ 379.00 $ 714.00
40-49 $ 335.00 $ 394.00 $ 350.00 $ 671.00
50-54 $ 429.00 $ 447.00 $ 315.00 $ 752.00
55-59 $ 528.00 $ 592.00 $ 303.00 $ 702.00
60-64 $ 687.00 $ 603.00 $ 217.00 $ 764.00
65-99 $ 681.00 $ 681.00 $ 255.00 $ 936.00
ADEA 65-99 $ 927.00 $ 889.00 $ 255.00 $ 1,093.00
A VN M O 4 0 0 n f i s r m i u ms
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GLOBAL POWER GROUP
Quote 658360 Plan 109103 November 3, 2011
Premiums
Area 1 Rate Grid0.90 RAF (Additional amounts for dependents are shown in each category)
First copay shown is for Non-Specialist office visits. Second copay is for Specialist office visits.
Rates assume Employees Age 65 and over have Medicare. Medicare rates are based on employee info only & subject to final review. Dependent
Medicare status may cause rates to change. Rates dont include optional riders.
RAF specials and rules have been applied.
Medical Benefits and Premiums
PQR AVN HMO $30/$40Benefits HMO VALUE NETWORKGeneral
Deductible - Individual/Family NONE
Max Out of Pocket - Individual/Family $3,000/$6,000
Lifetime Benefit Maximum NO MAXIMUMPhysician Services:
Doctor Office Visit $30/$40 SPECIALIST
Preventive Care 100%
Physical/Occupational Therapy $40-MAX 20 VISITS/YR
Lab & X-Ray Outpatient $30 COPAY
Durable Medical Equipment 50%-MAX $2,000/YR
Chiropractic $15-MAX 20 VISITS/YR
Hospital Services:
Inpatient Hospital Services $600/DAY-1ST 3 DAYS
Inpatient Physician Fee INCL W/HOSPITAL SVCS
Outpatient Surgery $300 COPAY
Emergency Room $100 COPAY
Ambulance $100 COPAY
Non Severe Mental Health:
Outpatient $40-MAX 20 VISITS/YRInpatient NOT COVERED
Chemical Dependency:
Outpatient $40 COPAY-DETOX
Inpatient $600/DAY-1ST 3 DAYS
Prescription Drugs:
PharmacyPARTICIPATING
Formulary Generic Copay $20
Formulary Brand Copay $40
Non Formulary Copay $60
Brand Name Deductible NONE
Separate Deductible NONE
Rx Annual Maximum Benefits NO MAXIMUM
Mail Order Prescriptions AVAILABLE
Employees Dependents Subtotal Addtnl. for COBRA Grand Total
RAF 0.90 Best Total Premium $ 12,214 $ 11,609 $ 23,823 $ 0 $ 23,823
RAF 0.90 Maximum Total Premium $ 12,214 $ 11,609 $ 23,823 $ 0 $ 23,823
Note: This group may qualify for a 0.90 RAF. The final RAF is decided during the Underwriting Process by the Carrier.
Age Employee Additional for Spouse Additional for Child(ren) Additional for Family
0-29 $ 231.00 $ 385.00 $ 416.00 $ 697.00
30-39 $ 277.00 $ 462.00 $ 401.00 $ 755.00
40-49 $ 354.00 $ 416.00 $ 370.00 $ 709.00
50-54 $ 454.00 $ 472.00 $ 332.00 $ 794.00
55-59 $ 558.00 $ 626.00 $ 320.00 $ 742.00
60-64 $ 725.00 $ 638.00 $ 230.00 $ 808.00
65-99 $ 719.00 $ 720.00 $ 270.00 $ 989.00
ADEA 65-99 $ 979.00 $ 939.00 $ 270.00 $ 1,155.00
AVN MO 0 4 0 n f is r miums
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