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2012 RENEWAL Group Name:

Carrollton Public Schools

Effective Date: Account Executive: Underwriter: Region: Agency:

7/1/2012

`

Condon, B

Rate Development

Underwriter 3

Age Factor

1.4839

TCR

Regional Factor

0.9612

Valley United Insurance Agency

Industry Factor Broker Commission

0.9500 3.00%

Alts 4/25/12

380080-0000

Plan Type Medical Plan Coinsurance Inpatient Co-pay Office Visit Primary Co-pay Office Visit Specialist Co-pay Emergency Room Co-Pay Urgent Care Co-Pay Deductible OOP Max (Includes Deductible) Prescription Drug Plan RX Drug Co-Pay Generic RX Drug Co-Pay Brand RX Drug Co-Pay Non-Formulary RX Ask for "90" Single EE + Spouse EE + Ch EE+ Children Family Total

Contracts 40 1 0 0 1 42

Members 40 2 0 0 4 46

PMPM (Monthly) Premium Relative to Current Rates Medical Plan Single EE + Spouse EE + Ch EE+ Children Family

Prescription Drug Plan

Single EE + Spouse EE + Ch EE+ Children Family

H.S.A COMPATIBLE PLAN

Current Rates HMO IF 0% $0 $10 $10 $25 $25 $0 $0 RXIF $5 $5 $5 $0 Total Rates $633.48 $1,417.42 $1,417.42 $1,574.47 $1,574.47

Renewal Rates HMO IF 0% $0 $10 $10 $25 $25 $0 $0 RXIF $5 $5 $5 $0 Total Rates $680.94 $1,523.60 $1,523.60 $1,692.41 $1,692.41

Alternative 1 HMO ZE 0% $0 $10 $10 $50 $25 $0 $0 RN-5/10 $5 $10 $10 2x Total Rates $670.84 $1,501.00 $1,501.00 $1,667.30 $1,667.30

Alternative 2 HMO Ded DUDA 10% 10% $20 $20 $50 $35 $250/$500 $1,000/$2,000 RN-5/10 $5 $10 $10 2x Total Rates $637.23 $1,425.80 $1,425.80 $1,583.77 $1,583.77

Alternative 3 HMO HDHP 07YKXB 0% 0% After Ded $15 After Ded $15 After Ded $100 After Ded $50 After Ded $1,250/$2,500 $2,250/$3,500 XB $5 After Ded $10 After Ded $10 After Ded 2x Total Rates $557.91 $1,248.33 $1,248.33 $1,386.63 $1,386.63

$615.89 $28,331.09

$662.03 $30,453.60 7.49%

$652.21 $30,001.84 5.90% ZE Medical Rates $562.66 $1,258.95 $1,258.95 $1,398.43 $1,398.43

$619.54 $28,498.73 0.59% DUDA Medical Rates $529.05 $1,183.75 $1,183.75 $1,314.90 $1,314.90

$542.42 $24,951.40 -11.93%

IF Medical Rates $569.92 $1,275.20 $1,275.20 $1,416.49 $1,416.49

RXIF

RN-5/10

RN-5/10

Built In RX Plan**

Stand Alone RX Plan

Stand Alone RX Plan

Pharmacy Rates $111.02 $248.40 $248.40 $275.92 $275.92

Pharmacy Rates $108.18 $242.05 $242.05 $268.87 $268.87

Pharmacy Rates $108.18 $242.05 $242.05 $268.87 $268.87

07YKXB Medical Rates $514.91 $1,152.12 $1,152.12 $1,279.76 $1,279.76

XB Built In RX Plan**

Pharmacy Rates $43.00 $96.21 $96.21 $106.87 $106.87

**Built in Rx plan may not be separated from, and can only be rated with, the medical plan it is associated with.

Your rates do not include taxes or assessments required by Federal and/or State governments. Any taxes or assessments will be added as a separate line item on your bill. The above rates were calculated using the group specific data as provided by your group (or your group's representative). HealthPlus has the right to adjust rates if any of the assumptions or calculations used in the quoting process are incorrect. Benefit Plan Year begins on effective date of coverage. Final Rates will be determined by HPM underwriting based on the actual enrollment of your group and will include a review of group participation. Group rates will be guaranteed for each enrolled group for a period of not less than one year. Final acceptance of your group by HPM is subject to HPM underwriting guidelines. Rates are subject to OFIR approval and may change. Rates are not final until all requested documents are received and reviewed by HPM All employees opting out of HPM must complete a waiver form. Employer must continue to satisfy all eligibility requirements. Please refer to the underwriting guidelines for participation and group eligibility requirements. Group rates are the complete HealthPlus of Michigan benefit package, including medical and hospital services, prescription drugs, extended care facilities, etc., as described in the Group Subscriber Contract and applicable benefit rider(s). If there is a conflict between the coverage description in this report and the Group Subscriber Contract and/or any applicable benefit rider(s), the terms of the Group Subscriber Contract and/or applicable benefit rider(s) shall control. Carrollton Schools_042512 4/25/20123:55 PM

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