PLAN #1

Group 40311G

Plan #2

Group 40311H

Prudent Buyer Classic 100% - C

Deductible Indiv/Family   $200/$400

Maximum Co-Insurance               -0-

Office Visit                 $30                        

Prudent Buyer Classic 90% - E

Deductible Indiv/Family       $300/$600

Maximum Co-Insurance     $600/1800

Office Visit                                  $30

RX G 2-Tier                    $3/$15

BHP 2000

Delta Dental Premier Incentive    $1,000

  Or

Delta Dental DPO (PPO)/ Ortho

             $2,000/$2,000

Vision Services Plan B              $15/$25

Inc Protection (paid by District)   

RX $10/$35 ($200 deductible/brands)

BHP 2000

Delta Dental Premier Incentive   $1,000    

  Or

Delta Dental DPO (PPO)/ Ortho            $2,000/$2,000

Vision Service Plan B                $15/$25

Inc Protection (paid by District)   

     ANNUAL COST \  Contract CAP

         $13,874.40 / $9392.00

   ANNUAL COST \  Contract CAP 

         $11,606.40 / $9,392.00

PAYROLL DEDUCTION WITH DELTA INCENTIVE – C1   $446.19 / MO

includes deduction of 1/10 of $180

 dual-insured savings

PAYROLL DEDUCTION WITH DELTA INCENTIVE – C3   $219.39 / MO

includes deduction of 1/10 of $180

 dual-insured savings

PAYROLL DEDUCTION WITH

 DELTA DPO – C2   $471.51 / MO

includes deduction of 1/10 of $180

 dual-insured savings

PAYROLL DEDUCTION WITH DELTA  DPO – C4   $244.71 / MO

includes deduction of 1/10 of $180

 dual-insured savings

Plan #3

Group 40312F

Plan #4

Group 40312C

Prudent Buyer PBC 80% - G

Deductible Indiv/Family      $500/$l,000

Maximum Co-Insurance $1,000/$3,000

Office Visit                               $30

Prudent Buyer Base Plan 80% -BASE

Deductible Indiv/Family$2,000/$4,000

Co-Insurance                $3,000/$6,000

Office Visit                                   $30

RX $15/$50 ($200 deductible/brands)

BHP 2000

Delta Dental Premier Incentive     $1,000    

  Or

Delta Dental DPO (PPO)/ Ortho

            $2,000/$2,000

Vision Service Plan B                  $15/$25

Inc Protection (paid by District)   

RX $10/$35 ($200 deductible/brands)

Behavioral Health Plan Included

Delta Dental Premier Incentive       1,000

  Or                  

Delta Dental DPO/ Ortho            

           $2,000/$2,000

Vision Service Plan B                  $15/$25

Inc Protection (paid by District)    $15.95

    ANNUAL COST \ Contract CAP

          $10,490.40  / $9,392.00

   ANNUAL COST  \  Contract CAP 

          $9,518.40 / $9,392.00

PAYROLL DEDUCTION WITH       DELTA INCENTIVE – C5  $107.79/ MO

includes deduction of 1/10 of $180

 dual-insured savings

PAYROLL DEDUCTION WITH       WITH  DELTA INCENTIVE – C7

$10.59 / MO

PAYROLL DEDUCTION WITH

 DELTA DPO – C6   $141.75 / MO

includes deduction of 1/10 of $180

 dual-insured savings

PAYROLL DEDUCTION WITH

DELTA DPO – C8

$35.91 / MO