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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 #10: Add Employee /Child Rate, Change Dr Copays and RX Copays <br />Attachment 10 <br />~~ <br />Standard Funding Rates <br /> PPO PPO Rates HMO HMO Rates <br />Monthly Rates Contracts Current Renewal Contracts Current Renewal <br />Employee 47 $475.84 $499.10 473 $405.64 $425.46 <br />Employee /Spouse 7 $1,003.94 $1,053.04 114 $855.52 $897.36 <br />Emp /Child 0 na $698.74 0 na $595.64 <br />Employee /Children 3 $918.30 $963.20 145 $782.90 $821.18 <br />Family 0 $1,427.46 $1,497.26 118 $1,216.92 $1,276.44 <br />Total /Annual Amount 57 $385,764 $404,623 850 $6,558,169 $6,878,792 <br />Rate Chan a 4.9% 4.9% <br />Health Benefits Current PPO Renewal PPO 1 Current HMO Renewal HMO 1 <br />PCP Copay $10 $15 $10 $15 <br />Specialist Copay $20 $30 $20 $30 <br />Emergency Room Copay $150 $150 $150 $150 <br />In-Network Deductible $250 $250 $250 $250 <br />In-Network Out-of-Pocket $1,000 $1,000 $0 $0 <br />Family Limit 3 times 3 times 3 times 3 times <br />In-Network Coinsurance 90% 90% 100% 100% <br />In-Network OP Laboratory Services 100% 100% 100% 100% <br />Preventive Care Program 100% 100% 100% 100% <br />Rx Copay -Retail $5-15-30 $10-25-40 $5-15-30 $10-25-40 <br />Rx Copay -Mail Order $13-26-60 $25-49-$7 $13-26-60 $25-49-87 <br />Vision Exam Deductible $10 $15 $10 $15 <br />Vision Hardware na na na na <br />1.Chanoe the PCP / Specialist CopaVS to $15 / $30 and the Rx Copays to $10-25-40 (mail order at $25-49-87) _ _ <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 />