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') AVMED, INC. d/b/a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application AvMED HUAL1'1I PLANS Contract Number(s): Subscribing Group Name: Effective Date: 108496 City of Sunny Isles Beach 03/01/10 Group Contract This Group Contract provides the benefits listed below: q Identifier AV-LG-l 0/150/750/1 0%-09 AV-Deductible/Co-insurance Amendment-09 AV-Open Acess-09 A V-LG-RX-2x-l0/20/30/75/50%-OC-B-09 AV-Gl00-MHPH-09 AV-Gl00-SAPH-09 A V-Gl00-ETP-R-97 AV-Mamm09ram-05 Descriotion Summary of Benefits Ded & Co-ins Open Access Prescription Drug IP Mental Health Substance Abuse ETOP Mammogram 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. Monthlv MembershiD Charaes Subscriber plus Spouse and One or More Dependents. $470.17 $1,043.78 $879.08 $879 08 $1,330.30 Subscriber Only......................... Subscriber plus Spouse Subscriber plus One Dependent (No Spouse) .... Subscriber plus Two or More Dependents .................... AV-Masler Application-07 MP-2027 (1107)