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Home My WebLink About179621 11/24/2009 CITY OF CARMEL, INDIANA VENDOR: 362529 Page 1 of 1 ONE CIVIC SQUARE DON CLEVELAND CHECK AMOUNT: $807.60 CARMEL, INDIANA 46032 141 STONY CREEK OVERLOOK NOBLESVILLE IN 46060 CHECK NUMBER: 179621 CHECK DATE: 11/24/2009 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4347500 807.60 INSURANCE Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland Nov -09 Donald: Medicare Part B $96.40 Amount due for November 2009 Humana Choice PPO 44.00 Total Don 140.40 Approved by Ron Carter Barbara: Anthem 809.72 Total Monthly 950.12 85% 807.60 Portion paid by City 15% 142.52 2 ANTHEM BCBS IN INDIVIDUAL INDI -MB1 KY0303A645 001855 1351 Will Howard Taft Anthem. 0. Cincinnati, OH 45206 -1775 Au iuJcicuJau li.'cusee ut tle lilac Gocurxl Blue- Shieli A ».ci Wiou. Auncm llliu C'ruyy Bhic JlucLl iehc uuJe nuuc of the Ant aro..mA 131uc SI-Id A—,imio IDENTIFICATION #:018M62629 1011V I VBI_2 I NIND 1455 01 Due Date: 11-01-2009 IIIIIIIIIIIIIIIJ1111IIIIIII111 Billing Date: 10 -I1 -2009 #BWNCQXF Coverage Period From: 11-01-2009 Q #A[MO0000000OODS(.)#INDI -MB I KY0303A645 Coverage Period Through: 11 -30 -2009 0 o Cleveland, Barbara L 141- Stony Creek Overlook Total Amount Due: $809.72 Noblesville, IN 46060 -5427 SEE REVERSE SIDE FOR BILLING DETAILS. Questions about your bill or interested in other payment options? Did you know you can nuke your payment over the phone? For assistance, please call the Customer Service phone number listed on the back of your Identification Card. Choosing to mail i► your payment.? Please allow 7 to 10 days to ensure timely processing of your payment. Please remember to list your 9 -digit Identification Number on your check, include the lower portion of this page and mail to the address specified. if you have already mailed in your payment, thank you 1'or your continued membership with us. IMPORTANT NOTICE: If you have received a reminder notice from Anthers Blue Cross and Blue Shield regarding a past due payment, this bill includes all amounts that you owe to keep your policy in force. To avoid any lapse in coverage, the Total Amorint Due listed on this bill must be received by the Due Date. Anthem Blue Cross and Blue Shield's issuance of this bill does not waive its contractual right to automatically terminate your coverage for failure to pay premiums in a timely ►lwnner. Payments recently nailed may not be reflected. DETACH AND RETURN THIS SECTION WITH YOUR PAYMENT- DO NOT STAPLE MAKE CHECKS PAYABLE TOANTHEM BLUE CROSS BLUE SHIELD Cleveland, Barbara L AND MAIL TO THE ADDRESS BELOW Subscriber ID From Date Through Date Due Date 01811162629 11/01/2009 11/30/2009 1 Ulll /2(H )9 Amount Due Amount Paid $809.72 8 q O l -7 L Unit No. 002 INDI -MB l _z�; —0 IIIIIIIIIIIIIIIIIIIIIIIIIII1111111111111111 ANTHEM BCBS IN INDIVIDUAL PO Box 105674 Atlanta GA 30348 -5674 1 4001954140000018226262971101200900000809720026 Jl lieCCS11cl (IVll(1c1 P11 PSlxl,lOt pares cn/cnLlcr eSIP (locttl"nclllo, pllelle sollcnalYa sill costo a(licional, llamaildo al Inimero de Verricio ell cliente elite aparecc al dorso dP .tilt tarjela de identilicacion o en el fullelo de inscripci(in. Invoice 060693448 PRIOR BILLING PERIOD COVERAGE FROM 10/01/2009 THRU 10/31/2009 PrCV1C)US Total Dnc $809.72 Payment Received on 09/29/2009 ($809.72) Outstanding Balance as of 10 -11- 2009 $0.00 CURRENT PERIOD COVERAGE FROM 11 /01/2009 'I'll RU 11/30 /2009 Plan I I $809.72 Current Period Total $809.72 (TEASE PAY THIS AMOUNT $6119.72, i613HIND2 /11313 B INU OW01315 0049I(0623448 11 111i RXI Your 200S K,lth[y Premtu s rfcar Meduflicare Part A (Hospital Insurance) Monthly Premium Most people don't pay a Part A premium because they paid Medicare taxes while working. You pay up to $443" each month if you don't get premium -free Part A. Part B (Medical Insurance) Monthly Premium If Your Yearly Income Is You Pay File Individual Tax Return File Joint Tax Return $85,000 or below $170,000 or below $96.40" $85,001 $107,000 $170,001- $214,000 1 $134.90" $107,001 $160,000 $214,001- $320,000 $192.70' $160,001 $213,000 $320,001 $426,000 $250.50" above $213,000 above $426,000 $308.30' Note: If you get a monthly benefit payment from Social Security, the RRB, or the Civil Service, you must have your Part B premiums deducted from your monthly benefit payment. If you don't get any of these benefit: payments and choose to sign up for Part B, you, will get a bill. If you choose to buy Part A, you will always get a bill for your premium. You can mail your premium payments to the Medicare Premium Collection Center, P.O. Box 790355, St. Louis, MO 63179 -0355. If you get a bill from the RRB, mail your premium payments to RRB, Medicare Premium Payments, P.O. Box 9024, St. Louis, MO 63197 -9024. Part en espanol M ed icare Toll -free: 1 800 372 2147 wkcai you uccd it mom TTY users: 1 877 833 4486 E Print This Pag Enlarae Text L He Return to Previous Screen Plan Details Humana Choice PPO Plans PPO R5826 -008 Monthly Plan Premium: $44.00 PI n Premiums for Peo with Extra Help Rx C Annual Part D Deductible $0.00 An M edical Deductible: $0.00 Maximum Medical Out -of- $5,000.00 Pocket: Prescription Drug Coverage: Amount you pay per prescription Type of Drug Stage 1 Stage 2 Stage 3 Stage $0 -$295 $296- Over 4 $2700 $2700 Over $4350 Preferred $7 $7 100% 5% Generic Preferred $40 $40 100% 5% Brand Non Preferred $65 $65 100% 5% Brand Specialty 33% 33% 100% 5% Physician Detail: Option to see physicians in- or out- of the plan's network. r No referrals required. You pay more for out -of- network services. Doctor Office Visits: Primary Care Phys $15.00 Copay Speciali 35.00 C Hospitalization: $800.00 per admit https: /www.humana- medicare. coin/ SeniorWizardl \TET/PlanDetails.aspx 3/27/2009 8:. a FIFTH THIRD BANK Page 1 of 4 PROFESSIONAL MASTERCARD 5293 0665 0006 -7869 Account Summary for Period Previous Balance $973.29 October 7, 2009 November 6, 2009 Payments Credits $1,039.60 Total Credit Limit $7,000 Purchases Cash Advances $876.03 Cash Limit $3,500 Other Charges $0.00 Available Credit $6,190 FINANCE CHARGES $0.00 Portion Available for Cash $3,500 New Balance $809.72 The Cash Limit is a portion of the Total Credit Limit. Minimum Payment Due $16.00 Payment Due Date December 3, 2009 Transactions TRAN POST Questions? Call Us DATE DATE REFERENCE NUMBER DESCRIPTION AMOUNT Customer Service Payments Credits 10/02 10/08 92806982 CBSA 952 5936471 MN $66.31 1.800.972.3030 10/29 10/30 7835 MAIL PAYMENT BRANCH CINCINNATI OH 973.29 Send Payments to Purchases, Cash Advances Other Charges Fifth Third Bank 10/29 11102 93033575 ANTHEM BCBS INS PMT IN 866- 649 -2034 OH $809.72 11102 11103 93065828 CBSA 952 5936471 MN 66.31 PO Box 740789 Cincinnati, OH 45274 -0789 Send Billinq Inquiries to Customer Service MD 1 MOC2G -4050 38 Fountain Square Plaza Cincinnati, OH 45263 Z 3 m 0 U U Please write your account number on your check made payable to Fifth Third Bank and mail portion below in return envelope. FIFTH THIRD BANK MADISONVILLE OPERATIONS CENTER Print address changes below. MD 1MOC2G CINCINNATI, OH 45263 Street Apt.# {1 {11 {111 {11 111{{ 111 {11 {n {n {11 {In {n�ln {n11� City State Zip DONALD H CLEVELAND 008904 141 STONY CREEK OVERLOOK Home Phone Alternate Phone NOBLESVILLE IN 46060 -5427 Account Number New Balance $809.72 Minimum Amount Due $16.00 {1111 {n1 {n+ {n 1111 {1111 {11 {1 {n {n {111{u Payment Due Date December 3 2009 FIFTH THIRD BANK PO BOX 740789 CINCINNATI OH 45274 -0789 Total Enclosed Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) CITY OF CARMEL An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee 0 00 Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 4 Total 6Q I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance with IC 5- 11- 10 -1.6. 20 Clerk- Treasurer VOUCHER NO. WARRANT NO. ALLOWED 20 IN SUM OF ON ACCOUNT OF APPROPRIATION FOR G 4/ 75 00 Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. 1 hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except G 9 Director operations Title Cost distribution ledger classification if claim paid motor vehicle highway fund