SOMA Insurance Plan

08/01/10-07/31/11
MONTHLY PREMIUM
	Medical Plan		Vision	Dental
Plan Types	Plan 1 Co-Pay Plan	Plan 2 High Deductible (HDHP)	Vision Plan	Dental Plan
Student Under Age 30 Age 30 & Over	$175 $208	$104 $123	$16	$38
Spouse Under Age 30 Age 30 & Over	$354 $426	$198 $237	$9.30	$32
Child(ren) Under Age 30 Age 30 & Over	$262 $262	$159 $159	$16.50	$43

PAYMENT OPTIONS

Applicants Who Wish To Have Their Monthly Premiums Charged To Their Credit or Debit Card

Complete the Enrollment Form

Do not send any payment - premium will be charged to your Master Card or VISA Credit or Debit Card

Applicants Who Wish To Have Their Monthly Premiums Debited From a Checking Account

1) Complete the Enrollment Form and Monthly Automatic Enrollment Form

2) Send 2 checks; 1st check equal to the monthly payment payable to Mass Marketing Insurance Consultants, Inc. and the 2nd check marked "void" and unsigned.

Applicants Who Wish To Have Direct Billing

Call 1-800-349-1039

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Exclusions & Limitations / Vision Option / Dental Option / How to Apply / Schedule of Premiums / Enrollment Form / Online Enrollment Form / Monthly Automatic Pay Plan Form / RX Information / PPO Information / PPO Networks / FAQ
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