6414 - Administrative Servies Only (ASO) for Medical and Pharmacy Benefits, 4.Drawings/ Plans (6)City Contributions
Coverage Monthly Annual Emp Bi-Wkly
Ee Only $1,218.00 $14,616.00 $1,218.00 $14,616.00
Ee + Spouse $1,218.00 $14,616.00 $1,218.00 $14,616.00
Ee + Child(ren)$1,218.00 $14,616.00 $1,218.00 $14,616.00
Ee + Family $1,218.00 $14,616.00 $1,218.00 $14,616.00
Retiree Subsidies -- By Years of Service
Years of Service Subsidy Amount
<5 years $40.00
5 - 9 years $80.00
10 - 14 years $120.00
15 - 19 years $160.00
20+ years $200.00
2017 CITY CONTRIBUTIONS
Rates effective 1/1/17 thru 12/31/17
GOLD PLAN SILVER PLAN
S:\Risk Management\Linda Compton\2017 RFPs\6414 ASO Med-Pharmacy RFP\6414 Exhibit 4 Supplement Documents\Supplemental E - Rates & Contributions
Coverage Emp Bi-Wkly Pay Code Emp Bi-Wkly Pay Code
Ee Only $110.00 $55.00 Gold EE $42.00 $21.00 Silver EE
Ee + Spouse $242.00 $121.00 Gold ES $138.00 $69.00 Silver ES
Ee + Child(ren)$308.00 $154.00 Gold EC $170.00 $85.00 Silver EC
Ee + Family $448.00 $224.00 Gold FAM $228.00 $114.00 Silver FAM
Coverage Emp Bi-Wkly Pay Code Emp Bi-Wkly Pay Code
Ee Only $70.00 $35.00 Gold EE HIP $0.00 $0.00 Silver EE HIP
Ee + Spouse $202.00 $101.00 Gold ES HIP $98.00 $49.00 Silver ES HIP
Ee + Child(ren)$268.00 $134.00 Gold EC HIP $130.00 $65.00 Silver EC HIP
Ee + Family $408.00 $204.00 Gold FAM HIP $188.00 $94.00 Silver FAM HIP
Coverage Emp Bi-Wkly Pay Code Emp Bi-Wkly Pay Code
Ee Only N/A N/A Gold EE N/A N/A Silver EE
Ee + Spouse $292.00 $146.00 Gold ES $188.00 $94.00 Silver ES
Ee + Child(ren)N/A N/A Gold EC N/A N/A Silver EC
Ee + Family $498.00 $249.00 Gold FAM $278.00 $139.00 Silver FAM
Coverage Emp Bi-Wkly Pay Code Emp Bi-Wkly Pay Code
Ee Only N/A N/A Gold EE HIP N/A N/A Silver EE HIP
Ee + Spouse $252.00 $126.00 Gold ES HIP $148.00 $74.00 Silver ES HIP
Ee + Child(ren)N/A N/A Gold EC HIP N/A N/A Silver EC HIP
Ee + Family $458.00 $229.00 Gold FAM HIP $238.00 $119.00 Silver FAM HIP
GOLD PLAN SILVER PLAN
UNITED HEALTHCARE PPO MEDICAL (WITH HIP) -- WITH SPOUSAL SURCHARGE
FULL TIME AND ¾ TIME EMPLOYEES
GOLD PLAN SILVER PLAN
GOLD PLAN SILVER PLAN
UNITED HEALTHCARE PPO MEDICAL (WITHOUT HIP) -- WITH SPOUSAL SURCHARGE
FULL TIME AND ¾ TIME EMPLOYEES
2017 MONTHLY MEDICAL FUNDING RATES
Rates effective 1/1/17 thru 12/31/17
HEALTH INSURANCEUNITED HEALTHCARE PPO MEDICAL (WITHOUT HIP)
FULL TIME AND ¾ TIME EMPLOYEES
GOLD PLAN SILVER PLAN
UNITED HEALTHCARE PPO MEDICAL (WITH HIP)
FULL TIME AND ¾ TIME EMPLOYEES
S:\Risk Management\Linda Compton\2017 RFPs\6414 ASO Med-Pharmacy RFP\6414 Exhibit 4 Supplement Documents\Supplemental E - Rates & Contributions
GOLD No Subsidy < 5 Yrs 5-9 Yrs 10-14 Yrs 15-19 Yrs 20+ Yrs
Retiree Only $783 $743 $703 $663 $623 $583
Retiree+Spouse $1,646 $1,606 $1,566 $1,526 $1,486 $1,446
Retiree+Child(ren)$1,460 $1,420 $1,380 $1,340 $1,300 $1,260
Retiree+Family $2,508 $2,468 $2,428 $2,388 $2,348 $2,308
SILVER No Subsidy < 5 Yrs 5-9 Yrs 10-14 Yrs 15-19 Yrs 20+ Yrs
Retiree Only $541 $501 $461 $421 $381 $341
Retiree+Spouse $1,213 $1,173 $1,133 $1,093 $1,053 $1,013
Retiree+Child(ren)$1,036 $996 $956 $916 $876 $836
Retiree+Family $1,765 $1,725 $1,685 $1,645 $1,605 $1,565
UNITED HEALTHCARE PPO
MEDICAL & PRESCRIPTION
Years of Service
Years of Service
S:\Risk Management\Linda Compton\2017 RFPs\6414 ASO Med-Pharmacy RFP\6414 Exhibit 4 Supplement Documents\Supplemental E - Rates & Contributions