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Attachment 9 <br />North Carolina Association of County Commissioners ~~.--~ <br />Group Benefits Pool <br />Rates Effective January 1, 2008 to January 1, 2009 <br />for Orange County . <br />Alternate #4: Add Employee /Child Rate and Change Rx Copays <br />Standard Funding Rates <br /> PPO Rates HMO HMO Rates <br /> PPO <br />'Monthly Rates Contracts Current Renewal Contracts Current <br />64 <br />$405 Renewal <br />34 <br />$429 <br />Employee 47 <br />7 $475.84 <br />94 <br />003 <br />$1 $503.64 <br />062.60 <br />$1 473 <br />114 . <br />$855.52 . <br />$905.52 <br />Employee /Spouse . <br />, , <br />08 <br />$705 0 na $601.06 <br />Emp /Child <br />Employee /Children 0 <br />3 na <br />$918.30 . <br />$971.96 145 <br />8 $782.90 <br />92 <br />216 <br />$1 $828.64 <br />288.04 <br />$1 <br />Family 0 <br />57 $1,427.46 <br />764 <br />$385 $1,510.86 <br />302 <br />$408 11 <br />850 . <br />, <br />$6,558,169 , <br />$6,941,383 <br />Total !Annual Amount , , 5 <br />8% <br /> 5.8% . <br />Rate Chan a <br />Health Benefits Current PPO Renewal PPO Current HMO Renewal HMO <br />PCP Copay $10 <br />$20 $10 <br />$20 $10 <br />$20 $10 <br />$20 <br />Specialist Copay <br />Emergency Room Copay $150 $150 $150 $150 <br />In-Network Deductible $250 $250 $250., $250 <br />$0 <br />In-Network Out-of-Pocket $1,000 <br />3 times $1,000 <br />3 times $0 <br />3 times 3 times <br />Family Limit 90% 90% 100% 100% <br />In-Network Coinsurance <br />!n-Network OP Laboratory Services 100% 100% .100% 100% <br />Preventive Care Program 100% 100% 100% 100% <br />Rx Copay -Retail $5-15-30 $90-25-40 $5-15-30 $90-25-4Q <br />Rx Copay -Mail Order $13-26-60 $25-49-87 $13-26-60 $2~_4g_g7 <br />$10 <br />Vision Exam Deductible $10 $10 $10 <br />Vision Hardware na na na na <br />Please Note: <br />1. Annual cost projections are based upon "Number Enrolled" as shown above. Actual cost will vary <br />based upon actual enrollment. <br />2. At least 75% of eligible employees must participate in this plan. <br />3. Standard Funding covers eligible claims which are incurred during.the contract period. <br />4. Please indicate your acceptance of this renewal offer by signing below. Please submit to NCACC at least 30 days <br />prior to the effective date of the contract period. <br />Accepted by the County or Group <br />Name: <br />Title: <br />Date: <br />This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act. <br />Financial Officer Date: <br />