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) AVMED, INC. d/b/a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application AvMED HEALTII PLANS Contract Number(s): Subscribing Group Name: Effective Date: 108497 City of Sunny Isles Beach 03101/10 Group Contract This Group Contract provides the benefits listed below: o Identifier A V-CHOICE-3DD-09 A V-LG-RX-2x-1 0/20/30/75/50%-OC-B-09 AV-CHOICE-MHPH-09 RI-SA-CH-5299 AV-Choice-ETP-Co-insurance OOP-05 Descriotion Summary of Benefits Prescription Drug IP Mental Health Substance Abuse ETOP Eliaibilitv Active Employees (Class 1) are required to work 25 hours per week to become eligible for coverage under this Contract. Employees will become eligible for coverage on the first of the month following the first day of employment. Management Employees (Class 1) are required to work 25 hours per week to become eligible for coverage under this Contract. Employees will become eligible for coverage on the first of the month following the first day of employment. Termination For Active Employees (Class 1), termination of coverage under this Contract shall become effective End of Month. For Management Employees (Class 1), termination of coverage under this Contract shall become effective End of Month. I J Monthlv Membershio Charaes Subscriber Only $515.78 Subscriber plus Spouse ...................... $1,145.05 $964.36 $964.36 $1,459.36 Subscriber plus One Dependent (No Spouse) .......... Subscriber plus Two or More Dependents ................ Subscriber plus Spouse and One or More Dependents ....... AV-Master Application-07 MP-2027 (1107)