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GA Page 227 <br />Current <br />Renewal <br />Option 1 <br />Option 2 <br />CIGNA <br />Self- funded OAP <br />CIGNA <br />Self- funded HSA <br />CIGNA <br />Self- funded OAP <br />CIGNA <br />Self- funded HSA <br />CIGNA <br />Self- funded OAP <br />CIGNA <br />Self- funded HSA <br />CIGNA <br />Self- funded HSA <br />2012 -2013 Costs <br />2012 -2013 Costs <br />2013 -2014 Costs <br />2013 - 2014 Costs <br />2013 -2014 Costs <br />2013 - 2014 Costs <br />2013 - 2014 Costs <br />In- Network <br />In- Network <br />In- Network <br />In- Network <br />In- Network <br />In- Network <br />In- Network <br />OAP <br />Health Savings <br />Account <br />OAP <br />Health Savings <br />Account <br />OAP <br />Health Savings <br />Account <br />Health Savings <br />Account <br />County Contribution to an <br />HSA Account <br />None <br />$1,000 <br />None <br />$1,000 <br />None <br />$1,000 <br />$1,000 <br />Coinsurance Limit <br />Single $3,000 <br />Family $6,000 <br />Single $2,000 <br />Family $2,000 <br />Single $3,000 <br />Family $6,000 <br />Single $2,000 <br />Family $2,000 <br />Single $3,000 <br />Family $6,000 <br />Single $2,000 <br />Family $2,000 <br />Single $2,000 <br />Family $2,000 <br />Lifetime Maximum <br />None <br />None <br />None <br />None <br />None <br />None <br />None <br />Deductible - Individual <br />$1,000 <br />$1,500 <br />$1,000 <br />$1,500 <br />$1,000 <br />$1,500 <br />$1,500 <br />Deductible - Family <br />$3,000 <br />$3,000 <br />$3,000 <br />$3,000 <br />$3,000 <br />$3,000 <br />$3,000 <br />Office Visits to Your PCP <br />$30 Copay <br />Ded /Coinsurance <br />$30 Copay <br />Ded /Coinsurance <br />$30 Copay <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Office Visit to a Specialist <br />$60 Copay <br />Ded /Coinsurance <br />$60 Copay <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Wellness Benefits <br />100% <br />100% <br />100% <br />100% <br />100% <br />100% <br />100% <br />Inpatient Hospital Care <br />None <br />Ded /Coinsurance <br />None <br />Ded /Coinsurance <br />None <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Outpatient Surgery <br />None <br />Ded /Coinsurance <br />None <br />Ded /Coinsurance <br />None <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Emergency Room Visit <br />$150 Copay <br />Ded /Coinsurance <br />$150 Copay <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Urgent Care <br />$60 Copay <br />Ded /Coinsurance <br />$60 Copay <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Prescription Drugs <br />$5/$45/$60 - 2x <br />Mail <br />Ded /Coinsurance <br />$5/$45/$60 - 2x Mail <br />Ded /Coinsurance <br />$150 Deductible <br />Brand Only <br />$5/$45/$60 - 2x Mail <br />Ded /Coinsurance <br />Ded /Coinsurance <br />Benefit Percentage <br />80% <br />80% <br />80% <br />80% <br />80% <br />80% <br />80% <br />Health <br />Reimbursement <br />Account - $300 <br />Change <br />N/A <br />N/A <br />118.62% <br />118.62% <br />7.50% <br />7.50% <br />0.00% <br />Dollars <br />$1,450,028.32 <br />$541,189.56 <br />$0.00 <br />GA Page 227 <br />