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Benefit Associates, LLC
1501 South Alexander Street,
Suite 104
Plant City, FL 33565

(813) 719-3937

www.benefitassociatesllc.com
The Sample Company medical insurance is provided by Health Insurance Company.
All full-time employees are eligible for benefits the first of the month following 90 days.
A summary of your benefits is below.

In-Network: Individual / Family
$1,500 / $3000
Out-of-Network $4,500 / $9,000
Co-Insurance: In-Network: 10%
Out-of-Network: 40%
Individual: In-Network: $2,500
Out-of-Network: $6,800
Family: In-Network: $5,500
Out-of-Network: $12,800
Office Visit: In-Network: $20 per visit
Out-of-Network: 40% after deductible
Specialist Office Visit: In-Network: $40 per visit
Out-of-Network: 40% after deductible
Chiropractic: In-Network: $40 per visit
Out-of-Network: 40% after deductible
20 visits per calendar year
Emergency Room: In-Network: $150 per visit
Out-of-Network: $150 per visit
Waived if admitted
Inpatient Care: In-Network: 10% after deductible
Out-of-Network: 40% after deductible
Child Wellness: In-Network: $20 per visit
Out-of-Network: 40%
Adult Routine Physicals: In-Network: $20 per visit
Out-of-Network: 40% after deductible
Outpatient Surgery: In-Network: 10% after deductible
Out-of-Network: 40% after deductible
30 day supply (retail)
Level 1 $20
Level 2 $45
Level 3 $65
Level 4 45%
Mail order prescriptions (90 day supply) is 2.5x copayment
To Enroll: To enroll in this plan, use the "Medical Enrollment Form" located on the enrollment tab.
National POS Rate Structure*
Single $38.85
Single + Spouse $69.69
Single + Child $64.61
Family $108.70
Note: * Employee Cost Per Pay Period