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City of Laramie COST SUMMARY OF HEALTH INSURANCE COVERAGE Approved by the Health Insurance Committee: effective date August 1, 2011 Employees will have the option of accepting the standard coverage or “buying up” to the coverage with the lower deductible. The City of Laramie has a self-insured health insurance plan that is processed through a third party administrator. Types of Coverage Employee Cost Employee Cost w/Buy-up Single $ 10.10 $ 49.43 Employee & Dependent $131.00 $196.52 Employee & Spouse $171.50 $240.09 Family $255.31 $340.41 Types of Benefit Costs Standard Deductible: Single $1,000 $ 500 Family $2,000 $1,000 Coinsurance: 50/50 50/50 Out of Pocket (Annual Maximum): Single $2,000 $1,500 Family $4,000 $3,000 Office Visit Co-Pay: $30.00 per visit N/A Accident Rider (not subject to deductible): $1,500 per year $ 600 accident Wellness (not subject to deductible): $ Unlimited $ Unlimited Prescriptions: Generic $0 + 20% $0 + 20% Listed Brand $15 + 20% $15 + 20% Non-Listed Brand $30 + 50% $30 + 50% Out-of-Pocket $1,500/person $1,500/person Dental Deductible: Single $ 50 $ 50 Family $ 100 $ 100 This comparison of coverage’s is intended only as a general description for the principle features of the benefit plans. Please refer to the benefit document for details.