through MHL Business Associates

through MHL Business Associates, Ltd.
HIP HMO Rates For Sole Proprietors
Effective 4/1/03 to 3/31/04

1	HIP PRIME VALUE (20/500/75/50) without Rx (PHSTD 1106) $20 PCP & Specialists & Diabetic Supplies $500 Hospital Admissions Copay $50 ER Copay $75 Abulatory/OP Surgery Copay Prescription Drugs NOT COVERED Eyeglasses - $45 Copay every 24 months.
	Single $249	Emp/Spouse $482	Emp/Child $450	Family $729

2	HIP PRIME VALUE (20/500/75/50) with $100 Deductible $10/$20 Rx Rider - (PHSTD 1103) $20 PCP & Specialists & Diabetic Supplies Copay $500 Hospital Admissions Copay $50 ER Copay $75 Ambulatory/Op Surgery Copay Rx: $100 deductible, $10 generic/$20 brand
	Employee $272	Emp/Spouse $527	Emp/Child $491	Family $798

3	HIP PRIME (15/0/35) with $10/$20/$40 Rx rider (PHSTD 1962) $15 Office Copay $0 Hospital Copay $35 ER Copay Rx: $10 generic/$20 brand/$40 Non-Formulary.
	Employee $299	Emp/Spouse $583	Emp/Child $543	Family $883

4	HIP PRIME (10/0/35) with $10/$20/$40 Rx Rider & other Riders (PHSTD 2395) $10 Office Copay $0 Hospital Copay $35 ER Copay Rx: $10 generic/$20 brand/$40 Non-Formulary. DME-appliances covered in full after $50 deductibles. Private Duty Nursing-Covered 80% (hours 73-504)
	Employee $305	Emp/Spouse $594	Emp/Child $554	Family $901

*** All Plans Include Preventive Dental ***
The above rates include a $16 administrative fee.

All rates subject to NY State Insurance Department Approval
Rates are subject to home office approval.