10/7/2016 City of MilwaukeeDepartment of Employee Relations

FINAL 2017 RETIREE Rate Charts.xlsx\RC_1

1 General City, Fire or Police Retirees age 65 and over.2 Ordinary Disability Retiree3 Certain General City Retirees under age 60, or between 60-65 paying for health coverage.4 Surviving Spouses of certain General City, Fire or Police Service Retirees.

UHC Choice Plus (PPO)

UHC Choice (EPO)

$831.00 $768.75

$1,663.50 $1,536.00

$2,494.50 $2,304.00

$282.00 $330.00

$533.25 $660.00

$1,221.75 $1,057.50

$1,431.75 $1,420.50

$747.00 $1,023.75

$1,248.00 $1,152.00

$692.25 $693.75

"With Medicare" means having both parts of Medicare, Hospital (Part A) and Medical (Part B).

2017 MONTHLY RATE CHARTFOR RETIREES & SURVIVING SPOUSES

These rates are effective January 1, 2017

RATE CHART 1 - These Rates Apply To You If You Are:

2017 Monthly Health Premium Rates - 75% of Full Premium

We will deduct the new rates effective with your December, 2016 pension check.This is official notification of health plan rates for 2017. DO NOT discard this rate chart.

If you are or your family consists of:Plan Code

1 One Adult No Medicare

3

2 Two Adults no Medicare

Two Adults & Dependent Child(ren) no Medicare

ACA NOTICE: If a retiree waives their health insurance and if the retiree does not have other health insurance benefits or coverage through a spouse or family member, the retiree will be subject to the Affordable Care Act and any financial penalties associated with not having health insurance benefits. 

One Adult with Medicare

Two Adults with Medicare

One Adult with Medicare, One Adult w/o Medicare & Dependent Child(ren)

6

7

One Adult with Medicare, One Adult w/o Medicare

4

5

10

8

Adult with Medicare & Dependent Child(ren)

9

Two Adults with Medicare & Dependent Child(ren)

Adult & Dependent Child(ren) no Medicare

10/7/2016 City of MilwaukeeDepartment of Employee Relations

FINAL 2017 RETIREE Rate Charts.xlsx\RC_7

We will deduct the new rates effective with your December, 2016 pension check.This is official notification of health plan rates for 2017. DO NOT discard this rate chart.

DO NOT discard this rate chart.

RATE CHART 7 - These Monthly Rates Apply To You If You Are:

1 Fire Service Retiree on or after 3/1/85, up to age 65.2 Police Service Retiree on or after 1/1/85, up to age 65.

2017 Monthly Health Premium Rates - 75% of Full Premium

UHC Choice Plus (PPO) UHC Choice (EPO)

City of Milwaukee

Employes' Retirement System (ERS)

789 N. Water St, Suite 300

Milwaukee, WI 53202

"With Medicare" means having both parts of Medicare, Hospital (Part A) and Medical (Part B).

2017 MONTHLY RATE CHARTFOR RETIREES & SURVIVING SPOUSES

These rates are effective January 1, 2017

Plan Code

If you are or your family consists of:

4

6

One Adult No Medicare

Two Adults no Medicare2

One Adult with Medicare

Because of the compexity of the rate schedule for your Retiree Group, we are unable to produce a Rate Chart for you that would show all the rates. Each Plan Code shown at left can have 35 different rate permutations.

We could not possibly reproduce all those rates on this one sheet. We therefore ask that if you want to know how much your rate will be for the coming plan year, that you write to Sue at the address shown below.

Please keep in mind that we are especially busy during the Open Enrollment. Even if you call our office for your rate, we may only be able to record your name and address for follow-up in writing.

Two Adults & Dependent Child(ren) no Medicare

1

3

7

One Adult with Medicare, One Adult w/o Medicare

One Adult with Medicare, One Adult w/o Medicare & Dependent Child(ren)

5 Two Adults with Medicare

ACA NOTICE: If a retiree waives their health insurance and if the retiree does not have other health insurance benefits or coverage through a spouse or family member, the retiree will be subject to the Affordable Care Act and any financial penalties associated with not having health insurance benefits. 

10

8

9

Two Adults with Medicare & Dependent Child(ren)

Adult & Dependent Child(ren) no Medicare

Adult with Medicare & Dependent Child(ren)

10/7/2016 City of MilwaukeeEmployes' Retirement System

FINAL 2017 RETIREE Rate Charts.xlsx\RC_8_DDGC_Post12-31-90

These rates are effective January 1, 2017

HEALTH PLAN "EMPLOYEE RATE" INFORMATIONA Duty Disability Retiree will pay the rate listed below under "Employee Rate" for the plan selected each month

CHART 8 - 2017

HEALTH PLAN UHC CHOICE PLAN City Share

Employee Rate

UHC CHOICE PLUS PLAN City Share

Employee Rate

Single 617.00$ 542.96$ 74.04$ 726.00$ 542.96$ 183.04$

Employee + Spouse 1,234.00$ 1,085.92$ 148.08$ 1,452.00$ 1,085.92$ 366.08$

Employee + Child(ren) 926.00$ 814.88$ 111.12$ 1,089.00$ 814.88$ 274.12$

Family 1,851.00$ 1,628.88$ 222.12$ 2,178.00$ 1,628.88$ 549.12$

ACA NOTICE: If a retiree waives their health insurance and if the retiree does not have other health insurance benefits or coverage through a spouse or family member, the retiree will be subject to the Affordable Care Act and any financial penalties associated with not having health insurance benefits. 

The "Employee Rate" will be deducted from the Retiree's monthly pension.

UHC CHOICE PLAN (EPO) UHC CHOICE PLUS PLAN (PPO)

2017 MONTHLY RATE CHART FOR DUTY DISABILITY RETIREES

This Chart applies to all Duty Disability Retirees whose positions are represented by any of the following units:

RATE CHART 8

GC Management; District Council #48; NMNR; TEAM; Assc of Scientific Pers; Assc of Muni Attys; SNC; Loc 510 IAM; Loc 494 Mach; Loc 75 Plumbers; Loc 195 Bridge Operators; Loc 139; Loc 61 Sanitation; ALEASP; Police Aides; Loc 494 FEDS;

LOC 494, MBCTC

10/7/2016 City of MilwaukeeEmployes' Retirement System

FINAL 2017 RETIREE Rate Charts.xlsx\RC_13_DD MPA

These rates are effective January 1, 2017

CHART 13 - 2017

HEALTH PLAN UHC CHOICE PLAN City Share

Employee Rate

UHC CHOICE PLUS PLAN City Share

Employee Rate

Single 617.00$ 542.96$ 74.04$ 726.00$ 638.88$ 87.12$

Employee + Spouse 1,234.00$ 1,085.92$ 148.08$ 1,452.00$ 1,277.76$ 174.24$

Employee + Child(ren) 926.00$ 814.88$ 111.12$ 1,089.00$ 958.32$ 130.68$

Family 1,851.00$ 1,628.88$ 222.12$ 2,178.00$ 1,916.64$ 261.36$

ACA NOTICE: If a retiree waives their health insurance and if the retiree does not have other health insurance benefits or coverage through a spouse or family member, the retiree will be subject to the Affordable Care Act and any financial penalties associated with not having health insurance benefits. 

2017 MONTHLY RATE CHART FOR DUTY DISABILITY RETIREES

This Chart applies to all duty disability retirees whose positions are represented by any of the following units:

UHC CHOICE PLAN (EPO) UHC CHOICE PLUS PLAN (PPO)

RATE CHART 13

Milwaukee Police Association (MPA); Sworn Police Mgmt; Milwaukee Police Supervisors Organization (MPSO); Sworn Fire Mgmt; Milwaukee Professional Firefighters Assc, Loc 215;

The "Employee Rate" will be deducted from the Retiree's monthly pension.

10/7/2016 City of MilwaukeeDepartment of Employee Relations

FINAL 2017 RETIREE Rate Charts.xlsx\RC_16_MGT>0104<0109

These rates are effective January 1, 2017

COMPUTATION METHOD OF "CITY SHARE"

CHART 16 - 2017

HEALTH PLAN UHC CHOICE PLAN City Share

Retiree Rate

UHC CHOICE PLUS PLAN City Share

Retiree Rate

Single 1,025.00$ 1,025.00$ -$ 1,108.00$ 1,025.00$ 83.00$

Employee + Spouse 2,048.00$ 2,048.00$ -$ 2,218.00$ 2,048.00$ 170.00$

Employee + Child(ren) 1,536.00$ 1,536.00$ -$ 1,664.00$ 1,536.00$ 128.00$

Family 3,072.00$ 3,072.00$ -$ 3,326.00$ 3,072.00$ 254.00$

ACA NOTICE: If a retiree waives their health insurance and if the retiree does not have other health insurance benefits or coverage through a spouse or family member, the retiree will be subject to the Affordable Care Act and any financial penalties associated with not having health insurance benefits. 

The "Retiree Rate" will be deducted from the Retiree's monthly pension.

UHC CHOICE PLAN (EPO) UHC CHOICE PLUS PLAN (PPO)

2017 MONTHLY RATE CHART FOR RETIREES & SURVIVING SPOUSES

RATE CHART 16This Chart applies to all Normal Service Retirees under 65 whose positions are represented by any of the following units and retired on or after

1/1/04 and prior to 1/1/09:

General City Management

The CITY will pay, monthly, 100% of the lowest cost single or lowest cost family plan. This is official notification of health plan rates for 2017. DO NOT discard this rate chart.

10/7/2016 City of MilwaukeeDepartment of Employee Relations

FINAL 2017 RETIREE Rate Charts.xlsx\RC_17_GC>010105

These rates are effective January 1, 2017

*For Loc 494 Elec on or after 1/1/05 and prior to May 31, 2012;*For MBCTC on or after 1/1/05 and prior to July 31, 2012.

CHART 17 - 2017The "Retiree Rate" will be deducted from the Retiree's monthly pension.

HEALTH PLAN UHC CHOICE PLAN City Share

Retiree Rate

UHC CHOICE PLUS PLAN City Share

Retiree Rate

Single 1,025.00$ 1,025.00$ NO COST 1,108.00$ 1,078.00$ 30.00$

Employee + Spouse 2,048.00$ 2,048.00$ NO COST 2,218.00$ 2,158.00$ 60.00$

Employee + Child(ren) 1,536.00$ 1,536.00$ NO COST 1,664.00$ 1,604.00$ 60.00$

Family 3,072.00$ 3,072.00$ NO COST 3,326.00$ 3,266.00$ 60.00$

ACA NOTICE: If a retiree waives their health insurance and if the retiree does not have other health insurance benefits or coverage through a spouse or family member, the retiree will be subject to the Affordable Care Act and any financial penalties associated with not having health insurance benefits. 

UHC CHOICE PLAN (EPO) UHC CHOICE PLUS PLAN (PPO)

2017 MONTHLY RATE CHART FOR GENERAL CITY RETIREES

This Chart applies to all Retirees whose positions are represented by any of the following units:For General City Retirees under 65 retired on or after 1/1/05 and prior to 1/1/12:

RATE CHART 17

District Council 48; Loc 139; Loc 75 Plumbers; Loc 61 Sanitation; SNC; TEAM; Assc of Scient Pers; Assc of Muni Attys; Loc 494 Mach Shop; Loc 510 IAM Dist 10; ALEASP (Clerical & PSS); NMNR; Fire Equip Dispatchers;

10/7/2016 City of MilwaukeeDepartment of Employee Relations

FINAL 2017 RETIREE Rate Charts.xlsx\RC_18_GC<0105

2017 MONTHLY RATE CHART FOR GENERAL CITY RETIREESThese rates are effective January 1, 2017

A General City Retirees retired prior to 1/1/05

A Management retiree retired prior to 1/1/04

A General City or Manangement Duty Disability retiree prior to 1/1/91

Sworn Police Management, MPA & MPSO Duty Disability retired prior to 1/1/90Sworn Fire Management Duty Disability retired prior to 3/1/89

Local 215 Duty Disability retired prior to 1/1/90

COMPUTATION METHOD OF "RETIREE SHARE"

CHART 18 - 2017The "Retiree Rate" will be deducted from the Retiree's monthly pension.

HEALTH PLAN UHC CHOICE PLAN City Share

Retiree Rate

UHC CHOICE PLUS PLAN City Share Retiree Rate

Single 1,025.00$ 1,025.00$ NO COST 1,108.00$ 1,108.00$ NO COST

Employee + Spouse 2,048.00$ 2,048.00$ NO COST 2,218.00$ 2,218.00$ NO COST

Employee + Child(ren) 1,536.00$ 1,536.00$ NO COST 1,664.00$ 1,664.00$ NO COST

Family 3,072.00$ 3,072.00$ NO COST 3,326.00$ 3,326.00$ NO COST

ACA NOTICE: If a retiree waives their health insurance and if the retiree does not have other health insurance benefits or coverage through a spouse or family member, the retiree will be subject to the Affordable Care Act and any financial penalties associated with not having health insurance benefits. 

The CITY will pay, monthly, up to 100% of the UHC Choice Plus (PPO) (Basic Plan) single or UHC Choice Plus (PPO) (Basic Plan) family premium cost to the City. For 2017, this contribution ("Retiree Rate") will be no more than $1,108 (Single) or $3,326 (Family) toward the cost of Health Plan of your choice. We will deduct the new rates effective with your December, 2016 pension check. This is official notification of health plan rates for 2017. DO NOT discard this rate chart.

This Chart applies to all Retirees under 65 whose positions are represented by any of the following units:

RATE CHART 18

UHC CHOICE PLAN (EPO) UHC CHOICE PLUS PLAN (PPO)

10/7/2016 City of MilwaukeeEmployes' Retirement System

FINAL 2017 RETIREE Rate Charts.xlsx/RC_20_MGM>0110

These rates are effective January 1, 2017

The "Retiree Rate" will be deducted from the Retiree's monthly pension.

CHART 20 - 2017

HEALTH PLAN UHC CHOICE PLAN City Share

Retiree Rate

UHC CHOICE PLUS PLAN City Share

Retiree Rate

Single 1,025.00$ 902.00$ 123.00$ 1,108.00$ 975.04$ 132.96$

Employee + Spouse 2,048.00$ 1,802.24$ 245.76$ 2,218.00$ 1,951.84$ 266.16$

Employee + Child(ren) 1,536.00$ 1,351.68$ 184.32$ 1,664.00$ 1,464.32$ 199.68$

Family 3,072.00$ 2,703.36$ 368.64$ 3,326.00$ 2,926.88$ 399.12$

ACA NOTICE: If a retiree waives their health insurance and if the retiree does not have other health insurance benefits or coverage through a spouse or family member, the retiree will be subject to the Affordable Care Act and any financial penalties associated with not having health insurance benefits. 

UHC CHOICE PLAN (EPO) UHC CHOICE PLUS PLAN (PPO)

2017 MONTHLY RATE CHART FOR RETIREES & SURVIVING SPOUSES

RATE CHART 20

This Chart applies to all Normal Service Retirees under 65 whose positions are represented by any of the following units and retired on or after 1/1/12 through 12/31/2013:

GC Management on or after January 1, 2009 through 12/31/2013;For Loc 494 Elec, on or after May 31, 2012 through 12/31/2013;

For MBCTC, on or after July 31, 2012 through 12/31/2013.

District Council #48; NMNR; TEAM;Assc of Scientific Pers; Assc of Muni Attys; SNC: Loc 510 IAM; Loc 494 Mach; Loc 75 Plumbers;

Loc 195 Bridge Operators; Loc 139; Loc 61 Sanitation; ALEASP; Police Aides; Loc 494 FEDS

10/7/2016 City of MilwaukeeEmployes' Retirement System

FINAL 2017 RETIREE Rate Charts.xlsx/RC_21_GC>0114

These rates are effective January 1, 2017

District Council #48; NMNR; TEAM;

Assc of Scientific Pers; Assc of Muni Attys; SNC: Loc 510 IAM; Loc 494 Mach; Loc 75 Plumbers; 195 Bridge Operators;

Loc 139; Loc 61 Sanitation; ALEASP; Police Aides; Loc 494 FEDS; GC Management; Loc 494 Elec; MBCTS

The "Retiree Rate" will be deducted from the Retiree's monthly pension.

CHART 21 - 2017

HEALTH PLAN UHC CHOICE PLAN City Share

Retiree Rate

UHC CHOICE PLUS PLAN City Share

Retiree Rate

Single 1,025.00$ 902.00$ 123.00$ 1,108.00$ 902.00$ 206.00$

Employee + Spouse 2,048.00$ 1,802.24$ 245.76$ 2,218.00$ 1,802.24$ 415.76$

Employee + Child(ren) 1,536.00$ 1,351.68$ 184.32$ 1,664.00$ 1,351.68$ 312.32$

Family 3,072.00$ 2,703.36$ 368.64$ 3,326.00$ 2,703.36$ 622.64$

ACA NOTICE: If a retiree waives their health insurance and if the retiree does not have other health insurance benefits or coverage through a spouse or family member, the retiree will be subject to the Affordable Care Act and any financial penalties associated with not having health insurance benefits. 

2017 MONTHLY RATE CHART FOR RETIREES & SURVIVING SPOUSES

RATE CHART 21This Chart applies to all Normal Service Retirees under 65 whose positions are represented by any of the following units and retired on or after 1/1/14:

UHC CHOICE PLAN (EPO) UHC CHOICE PLUS PLAN (PPO)

10/7/2016 2017 Police thru Age 60 (40hrs/wk) Contribution Rate Matrix

FINAL 2017 RETIREE Rate Charts.xlsx\Police thru age 60 40HRWK_2017 10 of 51

100% RETIREE PLAN RATES

PC Description UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 1,108.00$ 1,025.00$ 2 Two Adults w/o Medicare 2,218.00$ 2,048.00$ 3 Two Adults & Dependent Child(ren) 3,326.00$ 3,072.00$ 4 One Adult with Medicare 376.00$ 440.00$ 5 Two Adults with Medicare 711.00$ 880.00$ 6 One Adult with Medicare, One person w/o Medicare 1,629.00$ 1,410.00$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 1,909.00$ 1,894.00$ 8 Two Adults with Medicare & Dependent Child(ren) 996.00$ 1,365.00$ 9 Adult & Dependent Child(ren) 1,664.00$ 1,536.00$

10 Adult with Medicare & Dependent Child(ren) 923.00$ 925.00$ @ 65% City Contribution - POLICE (40hrs/wk) - Unused S/L - Less than 150 work days

PC @65% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 387.80 304.80 2 Two Adults w/o Medicare 776.30 606.30 3 Two Adults & Dependent Child(ren) 1,164.10 910.10 4 One Adult with Medicare 131.60 195.60 5 Two Adults with Medicare 248.85 417.85 6 One Adult with Medicare, One person w/o Medicare 570.15 351.15 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 668.15 653.15 8 Two Adults with Medicare & Dependent Child(ren) 348.60 717.60 9 Adult & Dependent Child(ren) 582.40 454.40

10 Adult with Medicare & Dependent Child(ren) 323.05 325.05 @ 66% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 150 but less than 159 work days.

PC @66% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 376.72 293.72 2 Two Adults w/o Medicare 754.12 584.12 3 Two Adults & Dependent Child(ren) 1,130.84 876.84 4 One Adult with Medicare 127.84 191.84 5 Two Adults with Medicare 241.74 410.74 6 One Adult with Medicare, One person w/o Medicare 553.86 334.86 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 649.06 634.06 8 Two Adults with Medicare & Dependent Child(ren) 338.64 707.64 9 Adult & Dependent Child(ren) 565.76 437.76

10 Adult with Medicare & Dependent Child(ren) 313.82 315.82 @ 67% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 159 but less than 167 work days.

PC @67% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 365.64 282.64 2 Two Adults w/o Medicare 731.94 561.94 3 Two Adults & Dependent Child(ren) 1,097.58 843.58 4 One Adult with Medicare 124.08 188.08 5 Two Adults with Medicare 234.63 403.63 6 One Adult with Medicare, One person w/o Medicare 537.57 318.57 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 629.97 614.97 8 Two Adults with Medicare & Dependent Child(ren) 328.68 697.68 9 Adult & Dependent Child(ren) 549.12 421.12

10 Adult with Medicare & Dependent Child(ren) 304.59 306.59

POLICE RATE CHART 7 - FULL 2017 RATE

UHC CHOICE PLUS (PPO)UHC CHOICE (EPO)

10/7/2016 2017 Police thru Age 60 (40hrs/wk) Contribution Rate Matrix

FINAL 2017 RETIREE Rate Charts.xlsx\Police thru age 60 40HRWK_2017 11 of 51

@ 68% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 167 but less than 176 work days.

PC @68% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 354.56 271.56 2 Two Adults w/o Medicare 709.76 539.76 3 Two Adults & Dependent Child(ren) 1,064.32 810.32 4 One Adult with Medicare 120.32 184.32 5 Two Adults with Medicare 227.52 396.52 6 One Adult with Medicare, One person w/o Medicare 521.28 302.28 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 610.88 595.88 8 Two Adults with Medicare & Dependent Child(ren) 318.72 687.72 9 Adult & Dependent Child(ren) 532.48 404.48

10 Adult with Medicare & Dependent Child(ren) 295.36 297.36 @ 69% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 176 but less than 184 work days.

PC @69% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 343.48 260.48 2 Two Adults w/o Medicare 687.58 517.58 3 Two Adults & Dependent Child(ren) 1,031.06 777.06 4 One Adult with Medicare 116.56 180.56 5 Two Adults with Medicare 220.41 389.41 6 One Adult with Medicare, One person w/o Medicare 504.99 285.99 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 591.79 576.79 8 Two Adults with Medicare & Dependent Child(ren) 308.76 677.76 9 Adult & Dependent Child(ren) 515.84 387.84

10 Adult with Medicare & Dependent Child(ren) 286.13 288.13 @ 70% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 184 but less than 193 work days.

PC @70% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 332.40 249.40 2 Two Adults w/o Medicare 665.40 495.40 3 Two Adults & Dependent Child(ren) 997.80 743.80 4 One Adult with Medicare 112.80 176.80 5 Two Adults with Medicare 213.30 382.30 6 One Adult with Medicare, One person w/o Medicare 488.70 269.70 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 572.70 557.70 8 Two Adults with Medicare & Dependent Child(ren) 298.80 667.80 9 Adult & Dependent Child(ren) 499.20 371.20

10 Adult with Medicare & Dependent Child(ren) 276.90 278.90 @ 71% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 193 but less than 201 work days.

PC @71% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 321.32 238.32 2 Two Adults w/o Medicare 643.22 473.22 3 Two Adults & Dependent Child(ren) 964.54 710.54 4 One Adult with Medicare 109.04 173.04 5 Two Adults with Medicare 206.19 375.19 6 One Adult with Medicare, One person w/o Medicare 472.41 253.41 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 553.61 538.61 8 Two Adults with Medicare & Dependent Child(ren) 288.84 657.84 9 Adult & Dependent Child(ren) 482.56 354.56

10 Adult with Medicare & Dependent Child(ren) 267.67 269.67

10/7/2016 2017 Police thru Age 60 (40hrs/wk) Contribution Rate Matrix

FINAL 2017 RETIREE Rate Charts.xlsx\Police thru age 60 40HRWK_2017 12 of 51

@ 72% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 201 but less than 210 work days.

PC @72% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 310.24 227.24 2 Two Adults w/o Medicare 621.04 451.04 3 Two Adults & Dependent Child(ren) 931.28 677.28 4 One Adult with Medicare 105.28 169.28 5 Two Adults with Medicare 199.08 368.08 6 One Adult with Medicare, One person w/o Medicare 456.12 237.12 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 534.52 519.52 8 Two Adults with Medicare & Dependent Child(ren) 278.88 647.88 9 Adult & Dependent Child(ren) 465.92 337.92

10 Adult with Medicare & Dependent Child(ren) 258.44 260.44 @ 73% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 210 but less than 219 work days.

PC @73% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 299.16 216.16 2 Two Adults w/o Medicare 598.86 428.86 3 Two Adults & Dependent Child(ren) 898.02 644.02 4 One Adult with Medicare 101.52 165.52 5 Two Adults with Medicare 191.97 360.97 6 One Adult with Medicare, One person w/o Medicare 439.83 220.83 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 515.43 500.43 8 Two Adults with Medicare & Dependent Child(ren) 268.92 637.92 9 Adult & Dependent Child(ren) 449.28 321.28

10 Adult with Medicare & Dependent Child(ren) 249.21 251.21 @ 74% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 219 but less than 227 work days.

PC @74% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 288.08 205.08 2 Two Adults w/o Medicare 576.68 406.68 3 Two Adults & Dependent Child(ren) 864.76 610.76 4 One Adult with Medicare 97.76 161.76 5 Two Adults with Medicare 184.86 353.86 6 One Adult with Medicare, One person w/o Medicare 423.54 204.54 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 496.34 481.34 8 Two Adults with Medicare & Dependent Child(ren) 258.96 627.96 9 Adult & Dependent Child(ren) 432.64 304.64

10 Adult with Medicare & Dependent Child(ren) 239.98 241.98 @ 75% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 227 but less than 236 work days.

PC @75% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 277.00 194.00 2 Two Adults w/o Medicare 554.50 384.50 3 Two Adults & Dependent Child(ren) 831.50 577.50 4 One Adult with Medicare 94.00 158.00 5 Two Adults with Medicare 177.75 346.75 6 One Adult with Medicare, One person w/o Medicare 407.25 188.25 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 477.25 462.25 8 Two Adults with Medicare & Dependent Child(ren) 249.00 618.00 9 Adult & Dependent Child(ren) 416.00 288.00

10 Adult with Medicare & Dependent Child(ren) 230.75 232.75

10/7/2016 2017 Police thru Age 60 (40hrs/wk) Contribution Rate Matrix

FINAL 2017 RETIREE Rate Charts.xlsx\Police thru age 60 40HRWK_2017 13 of 51

@ 76% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 236 but less than 244 work days.

PC @76% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 265.92 182.92 2 Two Adults w/o Medicare 532.32 362.32 3 Two Adults & Dependent Child(ren) 798.24 544.24 4 One Adult with Medicare 90.24 154.24 5 Two Adults with Medicare 170.64 339.64 6 One Adult with Medicare, One person w/o Medicare 390.96 171.96 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 458.16 443.16 8 Two Adults with Medicare & Dependent Child(ren) 239.04 608.04 9 Adult & Dependent Child(ren) 399.36 271.36

10 Adult with Medicare & Dependent Child(ren) 221.52 223.52 @ 77% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 244 but less than 253 work days.

PC @77% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 254.84 171.84 2 Two Adults w/o Medicare 510.14 340.14 3 Two Adults & Dependent Child(ren) 764.98 510.98 4 One Adult with Medicare 86.48 150.48 5 Two Adults with Medicare 163.53 332.53 6 One Adult with Medicare, One person w/o Medicare 374.67 155.67 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 439.07 424.07 8 Two Adults with Medicare & Dependent Child(ren) 229.08 598.08 9 Adult & Dependent Child(ren) 382.72 254.72

10 Adult with Medicare & Dependent Child(ren) 212.29 214.29 @ 78% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 253 but less than 261 work days.

PC @78% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 243.76 160.76 2 Two Adults w/o Medicare 487.96 317.96 3 Two Adults & Dependent Child(ren) 731.72 477.72 4 One Adult with Medicare 82.72 146.72 5 Two Adults with Medicare 156.42 325.42 6 One Adult with Medicare, One person w/o Medicare 358.38 139.38 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 419.98 404.98 8 Two Adults with Medicare & Dependent Child(ren) 219.12 588.12 9 Adult & Dependent Child(ren) 366.08 238.08

10 Adult with Medicare & Dependent Child(ren) 203.06 205.06 @ 79% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 261 but less than 270 work days.

PC @79% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 232.68 149.68 2 Two Adults w/o Medicare 465.78 295.78 3 Two Adults & Dependent Child(ren) 698.46 444.46 4 One Adult with Medicare 78.96 142.96 5 Two Adults with Medicare 149.31 318.31 6 One Adult with Medicare, One person w/o Medicare 342.09 123.09 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 400.89 385.89 8 Two Adults with Medicare & Dependent Child(ren) 209.16 578.16 9 Adult & Dependent Child(ren) 349.44 221.44

10 Adult with Medicare & Dependent Child(ren) 193.83 195.83

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@ 80% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 270 but less than 278 work days.

PC @80% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 221.60 138.60 2 Two Adults w/o Medicare 443.60 273.60 3 Two Adults & Dependent Child(ren) 665.20 411.20 4 One Adult with Medicare 75.20 139.20 5 Two Adults with Medicare 142.20 311.20 6 One Adult with Medicare, One person w/o Medicare 325.80 106.80 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 381.80 366.80 8 Two Adults with Medicare & Dependent Child(ren) 199.20 568.20 9 Adult & Dependent Child(ren) 332.80 204.80

10 Adult with Medicare & Dependent Child(ren) 184.60 186.60 @ 81% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 278 but less than 285 work days.

PC @81% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 210.52 127.52 2 Two Adults w/o Medicare 421.42 251.42 3 Two Adults & Dependent Child(ren) 631.94 377.94 4 One Adult with Medicare 71.44 135.44 5 Two Adults with Medicare 135.09 304.09 6 One Adult with Medicare, One person w/o Medicare 309.51 90.51 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 362.71 347.71 8 Two Adults with Medicare & Dependent Child(ren) 189.24 558.24 9 Adult & Dependent Child(ren) 316.16 188.16

10 Adult with Medicare & Dependent Child(ren) 175.37 177.37 @ 82% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 285 but less than 291 work days.

PC @82% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 199.44 116.44 2 Two Adults w/o Medicare 399.24 229.24 3 Two Adults & Dependent Child(ren) 598.68 344.68 4 One Adult with Medicare 67.68 131.68 5 Two Adults with Medicare 127.98 296.98 6 One Adult with Medicare, One person w/o Medicare 293.22 74.22 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 343.62 328.62 8 Two Adults with Medicare & Dependent Child(ren) 179.28 548.28 9 Adult & Dependent Child(ren) 299.52 171.52

10 Adult with Medicare & Dependent Child(ren) 166.14 168.14 @ 83% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 291 but less than 298 work days.

PC @83% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 188.36 105.36 2 Two Adults w/o Medicare 377.06 207.06 3 Two Adults & Dependent Child(ren) 565.42 311.42 4 One Adult with Medicare 63.92 127.92 5 Two Adults with Medicare 120.87 289.87 6 One Adult with Medicare, One person w/o Medicare 276.93 57.93 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 324.53 309.53 8 Two Adults with Medicare & Dependent Child(ren) 169.32 538.32 9 Adult & Dependent Child(ren) 282.88 154.88

10 Adult with Medicare & Dependent Child(ren) 156.91 158.91

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@ 84% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 298 but less than 304 work days.

PC @84% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 177.28 94.28 2 Two Adults w/o Medicare 354.88 184.88 3 Two Adults & Dependent Child(ren) 532.16 278.16 4 One Adult with Medicare 60.16 124.16 5 Two Adults with Medicare 113.76 282.76 6 One Adult with Medicare, One person w/o Medicare 260.64 41.64 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 305.44 290.44 8 Two Adults with Medicare & Dependent Child(ren) 159.36 528.36 9 Adult & Dependent Child(ren) 266.24 138.24

10 Adult with Medicare & Dependent Child(ren) 147.68 149.68 @ 85% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 304 but less than 311 work days.

PC @85% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 166.20 83.20 2 Two Adults w/o Medicare 332.70 162.70 3 Two Adults & Dependent Child(ren) 498.90 244.90 4 One Adult with Medicare 56.40 120.40 5 Two Adults with Medicare 106.65 275.65 6 One Adult with Medicare, One person w/o Medicare 244.35 25.35 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 286.35 271.35 8 Two Adults with Medicare & Dependent Child(ren) 149.40 518.40 9 Adult & Dependent Child(ren) 249.60 121.60

10 Adult with Medicare & Dependent Child(ren) 138.45 140.45 @ 86% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 311 but less than 317 work days.

PC @86% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 155.12 72.12 2 Two Adults w/o Medicare 310.52 140.52 3 Two Adults & Dependent Child(ren) 465.64 211.64 4 One Adult with Medicare 52.64 116.64 5 Two Adults with Medicare 99.54 268.54 6 One Adult with Medicare, One person w/o Medicare 228.06 9.06 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 267.26 252.26 8 Two Adults with Medicare & Dependent Child(ren) 139.44 508.44 9 Adult & Dependent Child(ren) 232.96 104.96

10 Adult with Medicare & Dependent Child(ren) 129.22 131.22 @ 87% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 317 but less than 324 work days.

PC @87% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 144.04 61.04 2 Two Adults w/o Medicare 288.34 118.34 3 Two Adults & Dependent Child(ren) 432.38 178.38 4 One Adult with Medicare 48.88 112.88 5 Two Adults with Medicare 92.43 261.43 6 One Adult with Medicare, One person w/o Medicare 211.77 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 248.17 233.17 8 Two Adults with Medicare & Dependent Child(ren) 129.48 498.48 9 Adult & Dependent Child(ren) 216.32 88.32

10 Adult with Medicare & Dependent Child(ren) 119.99 121.99

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@ 88% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 324 but less than 330 work days.

PC @88% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 132.96 49.96 2 Two Adults w/o Medicare 266.16 96.16 3 Two Adults & Dependent Child(ren) 399.12 145.12 4 One Adult with Medicare 45.12 109.12 5 Two Adults with Medicare 85.32 254.32 6 One Adult with Medicare, One person w/o Medicare 195.48 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 229.08 214.08 8 Two Adults with Medicare & Dependent Child(ren) 119.52 488.52 9 Adult & Dependent Child(ren) 199.68 71.68

10 Adult with Medicare & Dependent Child(ren) 110.76 112.76 @ 89% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 330 but less than 336 work days.

PC @89% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 121.88 38.88 2 Two Adults w/o Medicare 243.98 73.98 3 Two Adults & Dependent Child(ren) 365.86 111.86 4 One Adult with Medicare 41.36 105.36 5 Two Adults with Medicare 78.21 247.21 6 One Adult with Medicare, One person w/o Medicare 179.19 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 209.99 194.99 8 Two Adults with Medicare & Dependent Child(ren) 109.56 478.56 9 Adult & Dependent Child(ren) 183.04 55.04

10 Adult with Medicare & Dependent Child(ren) 101.53 103.53 @ 90% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 336 but less than 343 work days.

PC @90% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 110.80 27.80 2 Two Adults w/o Medicare 221.80 51.80 3 Two Adults & Dependent Child(ren) 332.60 78.60 4 One Adult with Medicare 37.60 101.60 5 Two Adults with Medicare 71.10 240.10 6 One Adult with Medicare, One person w/o Medicare 162.90 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 190.90 175.90 8 Two Adults with Medicare & Dependent Child(ren) 99.60 468.60 9 Adult & Dependent Child(ren) 166.40 38.40

10 Adult with Medicare & Dependent Child(ren) 92.30 94.30 @ 91% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 343 but less than 349 work days.

PC @91% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 99.72 16.72 2 Two Adults w/o Medicare 199.62 29.62 3 Two Adults & Dependent Child(ren) 299.34 45.34 4 One Adult with Medicare 33.84 97.84 5 Two Adults with Medicare 63.99 232.99 6 One Adult with Medicare, One person w/o Medicare 146.61 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 171.81 156.81 8 Two Adults with Medicare & Dependent Child(ren) 89.64 458.64 9 Adult & Dependent Child(ren) 149.76 21.76

10 Adult with Medicare & Dependent Child(ren) 83.07 85.07

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@ 92% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 349 but less than 356 work days.

PC @92% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 88.64 5.64 2 Two Adults w/o Medicare 177.44 7.44 3 Two Adults & Dependent Child(ren) 266.08 12.08 4 One Adult with Medicare 30.08 94.08 5 Two Adults with Medicare 56.88 225.88 6 One Adult with Medicare, One person w/o Medicare 130.32 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 152.72 137.72 8 Two Adults with Medicare & Dependent Child(ren) 79.68 448.68 9 Adult & Dependent Child(ren) 133.12 5.12

10 Adult with Medicare & Dependent Child(ren) 73.84 75.84 @ 93% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 356 but less than 362 work days.

PC @93% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 77.56 - 2 Two Adults w/o Medicare 155.26 - 3 Two Adults & Dependent Child(ren) 232.82 - 4 One Adult with Medicare 26.32 90.32 5 Two Adults with Medicare 49.77 218.77 6 One Adult with Medicare, One person w/o Medicare 114.03 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 133.63 118.63 8 Two Adults with Medicare & Dependent Child(ren) 69.72 438.72 9 Adult & Dependent Child(ren) 116.48 -

10 Adult with Medicare & Dependent Child(ren) 64.61 66.61 @ 94% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 362 but less than 369 work days.

PC @94% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 66.48 - 2 Two Adults w/o Medicare 133.08 - 3 Two Adults & Dependent Child(ren) 199.56 - 4 One Adult with Medicare 22.56 86.56 5 Two Adults with Medicare 42.66 211.66 6 One Adult with Medicare, One person w/o Medicare 97.74 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 114.54 99.54 8 Two Adults with Medicare & Dependent Child(ren) 59.76 428.76 9 Adult & Dependent Child(ren) 99.84 -

10 Adult with Medicare & Dependent Child(ren) 55.38 57.38 @ 95% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 369 but less than 375 work days.

PC @95% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 55.40 - 2 Two Adults w/o Medicare 110.90 - 3 Two Adults & Dependent Child(ren) 166.30 - 4 One Adult with Medicare 18.80 82.80 5 Two Adults with Medicare 35.55 204.55 6 One Adult with Medicare, One person w/o Medicare 81.45 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 95.45 80.45 8 Two Adults with Medicare & Dependent Child(ren) 49.80 418.80 9 Adult & Dependent Child(ren) 83.20 -

10 Adult with Medicare & Dependent Child(ren) 46.15 48.15

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@ 96% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 375 but less than 381 work days.

PC @96% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 44.32 - 2 Two Adults w/o Medicare 88.72 - 3 Two Adults & Dependent Child(ren) 133.04 - 4 One Adult with Medicare 15.04 79.04 5 Two Adults with Medicare 28.44 197.44 6 One Adult with Medicare, One person w/o Medicare 65.16 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 76.36 61.36 8 Two Adults with Medicare & Dependent Child(ren) 39.84 408.84 9 Adult & Dependent Child(ren) 66.56 -

10 Adult with Medicare & Dependent Child(ren) 36.92 38.92 @ 97% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 381 but less than 388 work days.

PC @97% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 33.24 - 2 Two Adults w/o Medicare 66.54 - 3 Two Adults & Dependent Child(ren) 99.78 - 4 One Adult with Medicare 11.28 75.28 5 Two Adults with Medicare 21.33 190.33 6 One Adult with Medicare, One person w/o Medicare 48.87 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 57.27 42.27 8 Two Adults with Medicare & Dependent Child(ren) 29.88 398.88 9 Adult & Dependent Child(ren) 49.92 -

10 Adult with Medicare & Dependent Child(ren) 27.69 29.69 @ 98% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 388 but less than 394 work days.

PC @98% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 22.16 - 2 Two Adults w/o Medicare 44.36 - 3 Two Adults & Dependent Child(ren) 66.52 - 4 One Adult with Medicare 7.52 71.52 5 Two Adults with Medicare 14.22 183.22 6 One Adult with Medicare, One person w/o Medicare 32.58 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 38.18 23.18 8 Two Adults with Medicare & Dependent Child(ren) 19.92 388.92 9 Adult & Dependent Child(ren) 33.28 -

10 Adult with Medicare & Dependent Child(ren) 18.46 20.46 @ 99% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 394 but less than 400 work days.

PC @99% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 11.08 - 2 Two Adults w/o Medicare 22.18 - 3 Two Adults & Dependent Child(ren) 33.26 - 4 One Adult with Medicare 3.76 67.76 5 Two Adults with Medicare 7.11 176.11 6 One Adult with Medicare, One person w/o Medicare 16.29 - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 19.09 4.09 8 Two Adults with Medicare & Dependent Child(ren) 9.96 378.96 9 Adult & Dependent Child(ren) 16.64 -

10 Adult with Medicare & Dependent Child(ren) 9.23 11.23

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@ 100% City Contribution - POLICE (40hrs/wk) - Unused S/L - At least 400 work days.

PC @100% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare - - 2 Two Adults w/o Medicare - - 3 Two Adults & Dependent Child(ren) - - 4 One Adult with Medicare - 64.00 5 Two Adults with Medicare - 169.00 6 One Adult with Medicare, One person w/o Medicare - - 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) - - 8 Two Adults with Medicare & Dependent Child(ren) - 369.00 9 Adult & Dependent Child(ren) - -

10 Adult with Medicare & Dependent Child(ren) - 2.00

10/7/2016 2017 HEALTH PLAN RATES FOR POLICE AGE 60-64 (Less than 65) Rev: 9/??/2016

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A B C D E F G I J K L M N O

UHC CHOICE PLUS

UHC CHOICE PLUS

UHC CHOICE PLUS

UHC CHOICE PLUS UHC CHOICE

UHC CHOICE PLUS

UHC CHOICE PLUS

UHC CHOICE PLUS

UHC CHOICE PLUS UHC CHOICE

Plan 100% 100% 65% > of Retiree Retiree Plan 100% 100% 66% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 720.20 1,108.00 0.00 0.00 1 1,108.00 1,108.00 731.28 1,108.00 0.00 0.002 2,218.00 1,108.00 1,441.70 1,441.70 776.30 606.30 2 2,218.00 1,108.00 1,463.88 1,463.88 754.12 584.123 3,326.00 1,108.00 2,161.90 2,161.90 1,164.10 910.10 3 3,326.00 1,108.00 2,195.16 2,195.16 1,130.84 876.844 376.00 1,108.00 244.40 1,108.00 0.00 0.00 4 376.00 1,108.00 248.16 1,108.00 0.00 0.005 711.00 1,108.00 462.15 1,108.00 0.00 0.00 5 711.00 1,108.00 469.26 1,108.00 0.00 0.006 1,629.00 1,108.00 1,058.85 1,108.00 521.00 302.00 6 1,629.00 1,108.00 1,075.14 1,108.00 521.00 302.007 1,909.00 1,108.00 1,240.85 1,240.85 668.15 653.15 7 1,909.00 1,108.00 1,259.94 1,259.94 649.06 634.068 996.00 1,108.00 647.40 1,108.00 0.00 257.00 8 996.00 1,108.00 657.36 1,108.00 0.00 257.009 1,664.00 1,108.00 1,081.60 1,108.00 556.00 428.00 9 1,664.00 1,108.00 1,098.24 1,108.00 556.00 428.0010 923.00 1,108.00 599.95 1,108.00 0.00 0.00 10 923.00 1,108.00 609.18 1,108.00 0.00 0.00

UHC CHOICE PLUS

UHC CHOICE PLUS

UHC CHOICE PLUS

UHC CHOICE PLUS UHC CHOICE

UHC CHOICE PLUS

UHC CHOICE PLUS

UHC CHOICE PLUS

UHC CHOICE PLUS UHC CHOICE

Plan 100% 100% 67% > of Retiree Retiree Plan 100% 100% 68% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 742.36 1,108.00 0.00 0.00 1 1,108.00 1,108.00 753.44 1,108.00 0.00 0.002 2,218.00 1,108.00 1,486.06 1,486.06 731.94 561.94 2 2,218.00 1,108.00 1,508.24 1,508.24 709.76 539.763 3,326.00 1,108.00 2,228.42 2,228.42 1,097.58 843.58 3 3,326.00 1,108.00 2,261.68 2,261.68 1,064.32 810.324 376.00 1,108.00 251.92 1,108.00 0.00 0.00 4 376.00 1,108.00 255.68 1,108.00 0.00 0.005 711.00 1,108.00 476.37 1,108.00 0.00 0.00 5 711.00 1,108.00 483.48 1,108.00 0.00 0.006 1,629.00 1,108.00 1,091.43 1,108.00 521.00 302.00 6 1,629.00 1,108.00 1,107.72 1,108.00 521.00 302.007 1,909.00 1,108.00 1,279.03 1,279.03 629.97 614.97 7 1,909.00 1,108.00 1,298.12 1,298.12 610.88 595.888 996.00 1,108.00 667.32 1,108.00 0.00 257.00 8 996.00 1,108.00 677.28 1,108.00 0.00 257.009 1,664.00 1,108.00 1,114.88 1,114.88 549.12 421.12 9 1,664.00 1,108.00 1,131.52 1,131.52 532.48 404.4810 923.00 1,108.00 618.41 1,108.00 0.00 0.00 10 923.00 1,108.00 627.64 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 69% > of Retiree Retiree Plan 100% 100% 70% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 764.52 1,108.00 0.00 0.00 1 1,108.00 1,108.00 775.60 1,108.00 0.00 0.002 2,218.00 1,108.00 1,530.42 1,530.42 687.58 517.58 2 2,218.00 1,108.00 1,552.60 1,552.60 665.40 495.403 3,326.00 1,108.00 2,294.94 2,294.94 1,031.06 777.06 3 3,326.00 1,108.00 2,328.20 2,328.20 997.80 743.804 376.00 1,108.00 259.44 1,108.00 0.00 0.00 4 376.00 1,108.00 263.20 1,108.00 0.00 0.005 711.00 1,108.00 490.59 1,108.00 0.00 0.00 5 711.00 1,108.00 497.70 1,108.00 0.00 0.006 1,629.00 1,108.00 1,124.01 1,124.01 504.99 285.99 6 1,629.00 1,108.00 1,140.30 1,140.30 488.70 269.707 1,909.00 1,108.00 1,317.21 1,317.21 591.79 576.79 7 1,909.00 1,108.00 1,336.30 1,336.30 572.70 557.708 996.00 1,108.00 687.24 1,108.00 0.00 257.00 8 996.00 1,108.00 697.20 1,108.00 0.00 257.009 1,664.00 1,108.00 1,148.16 1,148.16 515.84 387.84 9 1,664.00 1,108.00 1,164.80 1,164.80 499.20 371.2010 923.00 1,108.00 636.87 1,108.00 0.00 0.00 10 923.00 1,108.00 646.10 1,108.00 0.00 0.00

POLICE SINGLE ENROLLMENT - For a retiree with single enrollment status, the City will contribute an amount up to the percentage of the subscriber cost for single enrollment in the Basic Plan that is determined by the percentage formula during the period the retiree is at least age 52 but less than age 60 and an amount up to 100% of the subscriber cost for single enrollment in the Basic Plan during the period after retirement the retiree is at least age 60 but less than age 65.

POLICE FAMILY ENROLLMENT - For a retiree with other than single enrollment status, the City will contribute an amount up the percentage of the subscriber cost for his/her enrollment status in the Basic Plan that is determined by the percentage formula during the period after retirement the retiree is at least age 52 but less than age 60 and the greater of either such amount or an amount up to 100% of the subscriber cost for single enrollment in the Basic Plan during the period after retirement the retiree is at least age 60 but less than age 65.

RATE CHART 7 - POLICE 2017 HEALTH PLAN RATES

10/7/2016 2017 HEALTH PLAN RATES FOR POLICE AGE 60-64 (Less than 65) Rev: 9/??/2016

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A B C D E F G I J K L M N OUHC CHOICE

PLUS UHC CHOICE UHC CHOICE PLUS UHC CHOICE

Plan 100% 100% 71% > of Retiree Retiree Plan 100% 100% 72% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 786.68 1,108.00 0.00 0.00 1 1,108.00 1,108.00 797.76 1,108.00 0.00 0.002 2,218.00 1,108.00 1,574.78 1,574.78 643.22 473.22 2 2,218.00 1,108.00 1,596.96 1,596.96 621.04 451.043 3,326.00 1,108.00 2,361.46 2,361.46 964.54 710.54 3 3,326.00 1,108.00 2,394.72 2,394.72 931.28 677.284 376.00 1,108.00 266.96 1,108.00 0.00 0.00 4 376.00 1,108.00 270.72 1,108.00 0.00 0.005 711.00 1,108.00 504.81 1,108.00 0.00 0.00 5 711.00 1,108.00 511.92 1,108.00 0.00 0.006 1,629.00 1,108.00 1,156.59 1,156.59 472.41 253.41 6 1,629.00 1,108.00 1,172.88 1,172.88 456.12 237.127 1,909.00 1,108.00 1,355.39 1,355.39 553.61 538.61 7 1,909.00 1,108.00 1,374.48 1,374.48 534.52 519.528 996.00 1,108.00 707.16 1,108.00 0.00 257.00 8 996.00 1,108.00 717.12 1,108.00 0.00 257.009 1,664.00 1,108.00 1,181.44 1,181.44 482.56 354.56 9 1,664.00 1,108.00 1,198.08 1,198.08 465.92 337.9210 923.00 1,108.00 655.33 1,108.00 0.00 0.00 10 923.00 1,108.00 664.56 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 73% > of Retiree Retiree Plan 100% 100% 74% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 808.84 1,108.00 0.00 0.00 1 1,108.00 1,108.00 819.92 1,108.00 0.00 0.002 2,218.00 1,108.00 1,619.14 1,619.14 598.86 428.86 2 2,218.00 1,108.00 1,641.32 1,641.32 576.68 406.683 3,326.00 1,108.00 2,427.98 2,427.98 898.02 644.02 3 3,326.00 1,108.00 2,461.24 2,461.24 864.76 610.764 376.00 1,108.00 274.48 1,108.00 0.00 0.00 4 376.00 1,108.00 278.24 1,108.00 0.00 0.005 711.00 1,108.00 519.03 1,108.00 0.00 0.00 5 711.00 1,108.00 526.14 1,108.00 0.00 0.006 1,629.00 1,108.00 1,189.17 1,189.17 439.83 220.83 6 1,629.00 1,108.00 1,205.46 1,205.46 423.54 204.547 1,909.00 1,108.00 1,393.57 1,393.57 515.43 500.43 7 1,909.00 1,108.00 1,412.66 1,412.66 496.34 481.348 996.00 1,108.00 727.08 1,108.00 0.00 257.00 8 996.00 1,108.00 737.04 1,108.00 0.00 257.009 1,664.00 1,108.00 1,214.72 1,214.72 449.28 321.28 9 1,664.00 1,108.00 1,231.36 1,231.36 432.64 304.6410 923.00 1,108.00 673.79 1,108.00 0.00 0.00 10 923.00 1,108.00 683.02 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 75% > of Retiree Retiree Plan 100% 100% 76% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 831.00 1,108.00 0.00 0.00 1 1,108.00 1,108.00 842.08 1,108.00 0.00 0.002 2,218.00 1,108.00 1,663.50 1,663.50 554.50 384.50 2 2,218.00 1,108.00 1,685.68 1,685.68 532.32 362.323 3,326.00 1,108.00 2,494.50 2,494.50 831.50 577.50 3 3,326.00 1,108.00 2,527.76 2,527.76 798.24 544.244 376.00 1,108.00 282.00 1,108.00 0.00 0.00 4 376.00 1,108.00 285.76 1,108.00 0.00 0.005 711.00 1,108.00 533.25 1,108.00 0.00 0.00 5 711.00 1,108.00 540.36 1,108.00 0.00 0.006 1,629.00 1,108.00 1,221.75 1,221.75 407.25 188.25 6 1,629.00 1,108.00 1,238.04 1,238.04 390.96 171.967 1,909.00 1,108.00 1,431.75 1,431.75 477.25 462.25 7 1,909.00 1,108.00 1,450.84 1,450.84 458.16 443.168 996.00 1,108.00 747.00 1,108.00 0.00 257.00 8 996.00 1,108.00 756.96 1,108.00 0.00 257.009 1,664.00 1,108.00 1,248.00 1,248.00 416.00 288.00 9 1,664.00 1,108.00 1,264.64 1,264.64 399.36 271.3610 923.00 1,108.00 692.25 1,108.00 0.00 0.00 10 923.00 1,108.00 701.48 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 77% > of Retiree Retiree Plan 100% 100% 78% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 853.16 1,108.00 0.00 0.00 1 1,108.00 1,108.00 864.24 1,108.00 0.00 0.002 2,218.00 1,108.00 1,707.86 1,707.86 510.14 340.14 2 2,218.00 1,108.00 1,730.04 1,730.04 487.96 317.963 3,326.00 1,108.00 2,561.02 2,561.02 764.98 510.98 3 3,326.00 1,108.00 2,594.28 2,594.28 731.72 477.724 376.00 1,108.00 289.52 1,108.00 0.00 0.00 4 376.00 1,108.00 293.28 1,108.00 0.00 0.005 711.00 1,108.00 547.47 1,108.00 0.00 0.00 5 711.00 1,108.00 554.58 1,108.00 0.00 0.006 1,629.00 1,108.00 1,254.33 1,254.33 374.67 155.67 6 1,629.00 1,108.00 1,270.62 1,270.62 358.38 139.387 1,909.00 1,108.00 1,469.93 1,469.93 439.07 424.07 7 1,909.00 1,108.00 1,489.02 1,489.02 419.98 404.988 996.00 1,108.00 766.92 1,108.00 0.00 257.00 8 996.00 1,108.00 776.88 1,108.00 0.00 257.009 1,664.00 1,108.00 1,281.28 1,281.28 382.72 254.72 9 1,664.00 1,108.00 1,297.92 1,297.92 366.08 238.0810 923.00 1,108.00 710.71 1,108.00 0.00 0.00 10 923.00 1,108.00 719.94 1,108.00 0.00 0.00

10/7/2016 2017 HEALTH PLAN RATES FOR POLICE AGE 60-64 (Less than 65) Rev: 9/??/2016

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A B C D E F G I J K L M N OUHC CHOICE

PLUS UHC CHOICE UHC CHOICE PLUS UHC CHOICE

Plan 100% 100% 79% > of Retiree Retiree Plan 100% 100% 80% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 875.32 1,108.00 0.00 0.00 1 1,108.00 1,108.00 886.40 1,108.00 0.00 0.002 2,218.00 1,108.00 1,752.22 1,752.22 465.78 295.78 2 2,218.00 1,108.00 1,774.40 1,774.40 443.60 273.603 3,326.00 1,108.00 2,627.54 2,627.54 698.46 444.46 3 3,326.00 1,108.00 2,660.80 2,660.80 665.20 411.204 376.00 1,108.00 297.04 1,108.00 0.00 0.00 4 376.00 1,108.00 300.80 1,108.00 0.00 0.005 711.00 1,108.00 561.69 1,108.00 0.00 0.00 5 711.00 1,108.00 568.80 1,108.00 0.00 0.006 1,629.00 1,108.00 1,286.91 1,286.91 342.09 123.09 6 1,629.00 1,108.00 1,303.20 1,303.20 325.80 106.807 1,909.00 1,108.00 1,508.11 1,508.11 400.89 385.89 7 1,909.00 1,108.00 1,527.20 1,527.20 381.80 366.808 996.00 1,108.00 786.84 1,108.00 0.00 257.00 8 996.00 1,108.00 796.80 1,108.00 0.00 257.009 1,664.00 1,108.00 1,314.56 1,314.56 349.44 221.44 9 1,664.00 1,108.00 1,331.20 1,331.20 332.80 204.8010 923.00 1,108.00 729.17 1,108.00 0.00 0.00 10 923.00 1,108.00 738.40 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 81% > of Retiree Retiree Plan 100% 100% 82% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 897.48 1,108.00 0.00 0.00 1 1,108.00 1,108.00 908.56 1,108.00 0.00 0.002 2,218.00 1,108.00 1,796.58 1,796.58 421.42 251.42 2 2,218.00 1,108.00 1,818.76 1,818.76 399.24 229.243 3,326.00 1,108.00 2,694.06 2,694.06 631.94 377.94 3 3,326.00 1,108.00 2,727.32 2,727.32 598.68 344.684 376.00 1,108.00 304.56 1,108.00 0.00 0.00 4 376.00 1,108.00 308.32 1,108.00 0.00 0.005 711.00 1,108.00 575.91 1,108.00 0.00 0.00 5 711.00 1,108.00 583.02 1,108.00 0.00 0.006 1,629.00 1,108.00 1,319.49 1,319.49 309.51 90.51 6 1,629.00 1,108.00 1,335.78 1,335.78 293.22 74.227 1,909.00 1,108.00 1,546.29 1,546.29 362.71 347.71 7 1,909.00 1,108.00 1,565.38 1,565.38 343.62 328.628 996.00 1,108.00 806.76 1,108.00 0.00 257.00 8 996.00 1,108.00 816.72 1,108.00 0.00 257.009 1,664.00 1,108.00 1,347.84 1,347.84 316.16 188.16 9 1,664.00 1,108.00 1,364.48 1,364.48 299.52 171.5210 923.00 1,108.00 747.63 1,108.00 0.00 0.00 10 923.00 1,108.00 756.86 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 83% > of Retiree Retiree Plan 100% 100% 84% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 919.64 1,108.00 0.00 0.00 1 1,108.00 1,108.00 930.72 1,108.00 0.00 0.002 2,218.00 1,108.00 1,840.94 1,840.94 377.06 207.06 2 2,218.00 1,108.00 1,863.12 1,863.12 354.88 184.883 3,326.00 1,108.00 2,760.58 2,760.58 565.42 311.42 3 3,326.00 1,108.00 2,793.84 2,793.84 532.16 278.164 376.00 1,108.00 312.08 1,108.00 0.00 0.00 4 376.00 1,108.00 315.84 1,108.00 0.00 0.005 711.00 1,108.00 590.13 1,108.00 0.00 0.00 5 711.00 1,108.00 597.24 1,108.00 0.00 0.006 1,629.00 1,108.00 1,352.07 1,352.07 276.93 57.93 6 1,629.00 1,108.00 1,368.36 1,368.36 260.64 41.647 1,909.00 1,108.00 1,584.47 1,584.47 324.53 309.53 7 1,909.00 1,108.00 1,603.56 1,603.56 305.44 290.448 996.00 1,108.00 826.68 1,108.00 0.00 257.00 8 996.00 1,108.00 836.64 1,108.00 0.00 257.009 1,664.00 1,108.00 1,381.12 1,381.12 282.88 154.88 9 1,664.00 1,108.00 1,397.76 1,397.76 266.24 138.2410 923.00 1,108.00 766.09 1,108.00 0.00 0.00 10 923.00 1,108.00 775.32 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 85% > of Retiree Retiree Plan 100% 100% 86% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 941.80 1,108.00 0.00 0.00 1 1,108.00 1,108.00 952.88 1,108.00 0.00 0.002 2,218.00 1,108.00 1,885.30 1,885.30 332.70 162.70 2 2,218.00 1,108.00 1,907.48 1,907.48 310.52 140.523 3,326.00 1,108.00 2,827.10 2,827.10 498.90 244.90 3 3,326.00 1,108.00 2,860.36 2,860.36 465.64 211.644 376.00 1,108.00 319.60 1,108.00 0.00 0.00 4 376.00 1,108.00 323.36 1,108.00 0.00 0.005 711.00 1,108.00 604.35 1,108.00 0.00 0.00 5 711.00 1,108.00 611.46 1,108.00 0.00 0.006 1,629.00 1,108.00 1,384.65 1,384.65 244.35 25.35 6 1,629.00 1,108.00 1,400.94 1,400.94 228.06 9.067 1,909.00 1,108.00 1,622.65 1,622.65 286.35 271.35 7 1,909.00 1,108.00 1,641.74 1,641.74 267.26 252.268 996.00 1,108.00 846.60 1,108.00 0.00 257.00 8 996.00 1,108.00 856.56 1,108.00 0.00 257.009 1,664.00 1,108.00 1,414.40 1,414.40 249.60 121.60 9 1,664.00 1,108.00 1,431.04 1,431.04 232.96 104.9610 923.00 1,108.00 784.55 1,108.00 0.00 0.00 10 923.00 1,108.00 793.78 1,108.00 0.00 0.00

10/7/2016 2017 HEALTH PLAN RATES FOR POLICE AGE 60-64 (Less than 65) Rev: 9/??/2016

23 of 51 FINAL 2017 RETIREE Rate Charts.xlsx\POL 6064 2017

A B C D E F G I J K L M N OUHC CHOICE

PLUS UHC CHOICE UHC CHOICE PLUS UHC CHOICE

Plan 100% 100% 87% > of Retiree Retiree Plan 100% 100% 88% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 963.96 1,108.00 0.00 0.00 1 1,108.00 1,108.00 975.04 1,108.00 0.00 0.002 2,218.00 1,108.00 1,929.66 1,929.66 288.34 118.34 2 2,218.00 1,108.00 1,951.84 1,951.84 266.16 96.163 3,326.00 1,108.00 2,893.62 2,893.62 432.38 178.38 3 3,326.00 1,108.00 2,926.88 2,926.88 399.12 145.124 376.00 1,108.00 327.12 1,108.00 0.00 0.00 4 376.00 1,108.00 330.88 1,108.00 0.00 0.005 711.00 1,108.00 618.57 1,108.00 0.00 0.00 5 711.00 1,108.00 625.68 1,108.00 0.00 0.006 1,629.00 1,108.00 1,417.23 1,417.23 211.77 0.00 6 1,629.00 1,108.00 1,433.52 1,433.52 195.48 0.007 1,909.00 1,108.00 1,660.83 1,660.83 248.17 233.17 7 1,909.00 1,108.00 1,679.92 1,679.92 229.08 214.088 996.00 1,108.00 866.52 1,108.00 0.00 257.00 8 996.00 1,108.00 876.48 1,108.00 0.00 257.009 1,664.00 1,108.00 1,447.68 1,447.68 216.32 88.32 9 1,664.00 1,108.00 1,464.32 1,464.32 199.68 71.6810 923.00 1,108.00 803.01 1,108.00 0.00 0.00 10 923.00 1,108.00 812.24 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 89% > of Retiree Retiree Plan 100% 100% 90% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 986.12 1,108.00 0.00 0.00 1 1,108.00 1,108.00 997.20 1,108.00 0.00 0.002 2,218.00 1,108.00 1,974.02 1,974.02 243.98 73.98 2 2,218.00 1,108.00 1,996.20 1,996.20 221.80 51.803 3,326.00 1,108.00 2,960.14 2,960.14 365.86 111.86 3 3,326.00 1,108.00 2,993.40 2,993.40 332.60 78.604 376.00 1,108.00 334.64 1,108.00 0.00 0.00 4 376.00 1,108.00 338.40 1,108.00 0.00 0.005 711.00 1,108.00 632.79 1,108.00 0.00 0.00 5 711.00 1,108.00 639.90 1,108.00 0.00 0.006 1,629.00 1,108.00 1,449.81 1,449.81 179.19 0.00 6 1,629.00 1,108.00 1,466.10 1,466.10 162.90 0.007 1,909.00 1,108.00 1,699.01 1,699.01 209.99 194.99 7 1,909.00 1,108.00 1,718.10 1,718.10 190.90 175.908 996.00 1,108.00 886.44 1,108.00 0.00 257.00 8 996.00 1,108.00 896.40 1,108.00 0.00 257.009 1,664.00 1,108.00 1,480.96 1,480.96 183.04 55.04 9 1,664.00 1,108.00 1,497.60 1,497.60 166.40 38.4010 923.00 1,108.00 821.47 1,108.00 0.00 0.00 10 923.00 1,108.00 830.70 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 91% > of Retiree Retiree Plan 100% 100% 92% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 1,008.28 1,108.00 0.00 0.00 1 1,108.00 1,108.00 1,019.36 1,108.00 0.00 0.002 2,218.00 1,108.00 2,018.38 2,018.38 199.62 29.62 2 2,218.00 1,108.00 2,040.56 2,040.56 177.44 7.443 3,326.00 1,108.00 3,026.66 3,026.66 299.34 45.34 3 3,326.00 1,108.00 3,059.92 3,059.92 266.08 12.084 376.00 1,108.00 342.16 1,108.00 0.00 0.00 4 376.00 1,108.00 345.92 1,108.00 0.00 0.005 711.00 1,108.00 647.01 1,108.00 0.00 0.00 5 711.00 1,108.00 654.12 1,108.00 0.00 0.006 1,629.00 1,108.00 1,482.39 1,482.39 146.61 0.00 6 1,629.00 1,108.00 1,498.68 1,498.68 130.32 0.007 1,909.00 1,108.00 1,737.19 1,737.19 171.81 156.81 7 1,909.00 1,108.00 1,756.28 1,756.28 152.72 137.728 996.00 1,108.00 906.36 1,108.00 0.00 257.00 8 996.00 1,108.00 916.32 1,108.00 0.00 257.009 1,664.00 1,108.00 1,514.24 1,514.24 149.76 21.76 9 1,664.00 1,108.00 1,530.88 1,530.88 133.12 5.1210 923.00 1,108.00 839.93 1,108.00 0.00 0.00 10 923.00 1,108.00 849.16 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 93% > of Retiree Retiree Plan 100% 100% 94% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 1,030.44 1,108.00 0.00 0.00 1 1,108.00 1,108.00 1,041.52 1,108.00 0.00 0.002 2,218.00 1,108.00 2,062.74 2,062.74 155.26 0.00 2 2,218.00 1,108.00 2,084.92 2,084.92 133.08 0.003 3,326.00 1,108.00 3,093.18 3,093.18 232.82 0.00 3 3,326.00 1,108.00 3,126.44 3,126.44 199.56 0.004 376.00 1,108.00 349.68 1,108.00 0.00 0.00 4 376.00 1,108.00 353.44 1,108.00 0.00 0.005 711.00 1,108.00 661.23 1,108.00 0.00 0.00 5 711.00 1,108.00 668.34 1,108.00 0.00 0.006 1,629.00 1,108.00 1,514.97 1,514.97 114.03 0.00 6 1,629.00 1,108.00 1,531.26 1,531.26 97.74 0.007 1,909.00 1,108.00 1,775.37 1,775.37 133.63 118.63 7 1,909.00 1,108.00 1,794.46 1,794.46 114.54 99.548 996.00 1,108.00 926.28 1,108.00 0.00 257.00 8 996.00 1,108.00 936.24 1,108.00 0.00 257.009 1,664.00 1,108.00 1,547.52 1,547.52 116.48 0.00 9 1,664.00 1,108.00 1,564.16 1,564.16 99.84 0.0010 923.00 1,108.00 858.39 1,108.00 0.00 0.00 10 923.00 1,108.00 867.62 1,108.00 0.00 0.00

10/7/2016 2017 HEALTH PLAN RATES FOR POLICE AGE 60-64 (Less than 65) Rev: 9/??/2016

24 of 51 FINAL 2017 RETIREE Rate Charts.xlsx\POL 6064 2017

A B C D E F G I J K L M N OUHC CHOICE

PLUS UHC CHOICE UHC CHOICE PLUS UHC CHOICE

Plan 100% 100% 95% > of Retiree Retiree Plan 100% 100% 96% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 1,052.60 1,108.00 0.00 0.00 1 1,108.00 1,108.00 1,063.68 1,108.00 0.00 0.002 2,218.00 1,108.00 2,107.10 2,107.10 110.90 0.00 2 2,218.00 1,108.00 2,129.28 2,129.28 88.72 0.003 3,326.00 1,108.00 3,159.70 3,159.70 166.30 0.00 3 3,326.00 1,108.00 3,192.96 3,192.96 133.04 0.004 376.00 1,108.00 357.20 1,108.00 0.00 0.00 4 376.00 1,108.00 360.96 1,108.00 0.00 0.005 711.00 1,108.00 675.45 1,108.00 0.00 0.00 5 711.00 1,108.00 682.56 1,108.00 0.00 0.006 1,629.00 1,108.00 1,547.55 1,547.55 81.45 0.00 6 1,629.00 1,108.00 1,563.84 1,563.84 65.16 0.007 1,909.00 1,108.00 1,813.55 1,813.55 95.45 80.45 7 1,909.00 1,108.00 1,832.64 1,832.64 76.36 61.368 996.00 1,108.00 946.20 1,108.00 0.00 257.00 8 996.00 1,108.00 956.16 1,108.00 0.00 257.009 1,664.00 1,108.00 1,580.80 1,580.80 83.20 0.00 9 1,664.00 1,108.00 1,597.44 1,597.44 66.56 0.0010 923.00 1,108.00 876.85 1,108.00 0.00 0.00 10 923.00 1,108.00 886.08 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 97% > of Retiree Retiree Plan 100% 100% 98% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 1,074.76 1,108.00 0.00 0.00 1 1,108.00 1,108.00 1,085.84 1,108.00 0.00 0.002 2,218.00 1,108.00 2,151.46 2,151.46 66.54 0.00 2 2,218.00 1,108.00 2,173.64 2,173.64 44.36 0.003 3,326.00 1,108.00 3,226.22 3,226.22 99.78 0.00 3 3,326.00 1,108.00 3,259.48 3,259.48 66.52 0.004 376.00 1,108.00 364.72 1,108.00 0.00 0.00 4 376.00 1,108.00 368.48 1,108.00 0.00 0.005 711.00 1,108.00 689.67 1,108.00 0.00 0.00 5 711.00 1,108.00 696.78 1,108.00 0.00 0.006 1,629.00 1,108.00 1,580.13 1,580.13 48.87 0.00 6 1,629.00 1,108.00 1,596.42 1,596.42 32.58 0.007 1,909.00 1,108.00 1,851.73 1,851.73 57.27 42.27 7 1,909.00 1,108.00 1,870.82 1,870.82 38.18 23.188 996.00 1,108.00 966.12 1,108.00 0.00 257.00 8 996.00 1,108.00 976.08 1,108.00 0.00 257.009 1,664.00 1,108.00 1,614.08 1,614.08 49.92 0.00 9 1,664.00 1,108.00 1,630.72 1,630.72 33.28 0.0010 923.00 1,108.00 895.31 1,108.00 0.00 0.00 10 923.00 1,108.00 904.54 1,108.00 0.00 0.00

UHC CHOICE PLUS UHC CHOICE UHC CHOICE

PLUS UHC CHOICE

Plan 100% 100% 99% > of Retiree Retiree Plan 100% 100% 100% > of Retiree RetireeCode Rate Sgle Rate Formula C or D Pays Pays Code Rate Sgle Rate Formula C or D Pays Pays

1 1,108.00 1,108.00 1,096.92 1,108.00 0.00 0.00 1 1,108.00 1,108.00 1,108.00 1,108.00 0.00 0.002 2,218.00 1,108.00 2,195.82 2,195.82 22.18 0.00 2 2,218.00 1,108.00 2,218.00 2,218.00 0.00 0.003 3,326.00 1,108.00 3,292.74 3,292.74 33.26 0.00 3 3,326.00 1,108.00 3,326.00 3,326.00 0.00 0.004 376.00 1,108.00 372.24 1,108.00 0.00 0.00 4 376.00 1,108.00 376.00 1,108.00 0.00 0.005 711.00 1,108.00 703.89 1,108.00 0.00 0.00 5 711.00 1,108.00 711.00 1,108.00 0.00 0.006 1,629.00 1,108.00 1,612.71 1,612.71 16.29 0.00 6 1,629.00 1,108.00 1,629.00 1,629.00 0.00 0.007 1,909.00 1,108.00 1,889.91 1,889.91 19.09 4.09 7 1,909.00 1,108.00 1,909.00 1,909.00 0.00 0.008 996.00 1,108.00 986.04 1,108.00 0.00 257.00 8 996.00 1,108.00 996.00 1,108.00 0.00 257.009 1,664.00 1,108.00 1,647.36 1,647.36 16.64 0.00 9 1,664.00 1,108.00 1,664.00 1,664.00 0.00 0.0010 923.00 1,108.00 913.77 1,108.00 0.00 0.00 10 923.00 1,108.00 923.00 1,108.00 0.00 0.00

10/7/2016 2017 FIRE CONTRIBUTION RATE MATRIX THRU AGE 60 (Exceed 40hrs/wk)

RATES/FINAL 2017 RETIREE Rate Charts.xlsx 25 of 51Department of Employee Relations

City Hall, Room 706

UHC CHOICE PLUS (PPO)UHC CHOICE (EPO)

100% RETIREE PLAN RATES

PC Description UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 1,108.00$ 1,025.00$ 2 Two Adults w/o Medicare 2,218.00$ 2,048.00$ 3 Two Adults & Dependent Child(ren) 3,326.00$ 3,072.00$ 4 One Adult with Medicare 376.00$ 440.00$ 5 Two Adults with Medicare 711.00$ 880.00$ 6 One Adult with Medicare, One person w/o Medicare 1,629.00$ 1,410.00$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 1,909.00$ 1,894.00$ 8 Two Adults with Medicare & Dependent Child(ren) 996.00$ 1,365.00$ 9 Adult & Dependent Child(ren) 1,664.00$ 1,536.00$

10 Adult with Medicare & Dependent Child(ren) 923.00$ 925.00$

RATE CHART 7 - FULL 2017 RATEFIRE - EXCEED 40 HRS PER WEEK

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 26 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 65% City Contribution Unused S/L - Less than 70 work days

PC Description @65% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 387.80$ 304.80$ 2 Two Adults w/o Medicare 776.30$ 606.30$ 3 Two Adults & Dependent Child(ren) 1,164.10$ 910.10$ 4 One Adult with Medicare 131.60$ 195.60$ 5 Two Adults with Medicare 248.85$ 417.85$ 6 One Adult with Medicare, One person w/o Medicare 570.15$ 351.15$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 668.15$ 653.15$ 8 Two Adults with Medicare & Dependent Child(ren) 348.60$ 717.60$ 9 Adult & Dependent Child(ren) 582.40$ 454.40$

10 Adult with Medicare & Dependent Child(ren) 323.05$ 325.05$ FIRE (Exceed 40hrs/wk)

@ 66% City Contribution Unused S/L - At least 70 but less than 74

work days

PC Description @66% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 376.72$ 293.72$ 2 Two Adults w/o Medicare 754.12$ 584.12$ 3 Two Adults & Dependent Child(ren) 1,130.84$ 876.84$ 4 One Adult with Medicare 127.84$ 191.84$ 5 Two Adults with Medicare 241.74$ 410.74$ 6 One Adult with Medicare, One person w/o Medicare 553.86$ 334.86$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 649.06$ 634.06$ 8 Two Adults with Medicare & Dependent Child(ren) 338.64$ 707.64$ 9 Adult & Dependent Child(ren) 565.76$ 437.76$

10 Adult with Medicare & Dependent Child(ren) 313.82$ 315.82$ FIRE (Exceed 40hrs/wk)

@ 67% City Contribution Unused S/L - At least 74 but less than 78

work days

PC Description @67% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 365.64$ 282.64$ 2 Two Adults w/o Medicare 731.94$ 561.94$ 3 Two Adults & Dependent Child(ren) 1,097.58$ 843.58$ 4 One Adult with Medicare 124.08$ 188.08$ 5 Two Adults with Medicare 234.63$ 403.63$ 6 One Adult with Medicare, One person w/o Medicare 537.57$ 318.57$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 629.97$ 614.97$ 8 Two Adults with Medicare & Dependent Child(ren) 328.68$ 697.68$ 9 Adult & Dependent Child(ren) 549.12$ 421.12$

10 Adult with Medicare & Dependent Child(ren) 304.59$ 306.59$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 27 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 68% City Contribution Unused S/L - At least 78 but less than 82

work days

PC Description @68% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 354.56$ 271.56$ 2 Two Adults w/o Medicare 709.76$ 539.76$ 3 Two Adults & Dependent Child(ren) 1,064.32$ 810.32$ 4 One Adult with Medicare 120.32$ 184.32$ 5 Two Adults with Medicare 227.52$ 396.52$ 6 One Adult with Medicare, One person w/o Medicare 521.28$ 302.28$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 610.88$ 595.88$ 8 Two Adults with Medicare & Dependent Child(ren) 318.72$ 687.72$ 9 Adult & Dependent Child(ren) 532.48$ 404.48$

10 Adult with Medicare & Dependent Child(ren) 295.36$ 297.36$ FIRE (Exceed 40hrs/wk)

@ 69% City Contribution Unused S/L - At least 82 but less than 86

work days

PC Description @69% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 343.48$ 260.48$ 2 Two Adults w/o Medicare 687.58$ 517.58$ 3 Two Adults & Dependent Child(ren) 1,031.06$ 777.06$ 4 One Adult with Medicare 116.56$ 180.56$ 5 Two Adults with Medicare 220.41$ 389.41$ 6 One Adult with Medicare, One person w/o Medicare 504.99$ 285.99$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 591.79$ 576.79$ 8 Two Adults with Medicare & Dependent Child(ren) 308.76$ 677.76$ 9 Adult & Dependent Child(ren) 515.84$ 387.84$

10 Adult with Medicare & Dependent Child(ren) 286.13$ 288.13$ FIRE (Exceed 40hrs/wk)

@ 70% City Contribution Unused S/L - At least 86 but less than 90

work days

PC Description @70% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 332.40$ 249.40$ 2 Two Adults w/o Medicare 665.40$ 495.40$ 3 Two Adults & Dependent Child(ren) 997.80$ 743.80$ 4 One Adult with Medicare 112.80$ 176.80$ 5 Two Adults with Medicare 213.30$ 382.30$ 6 One Adult with Medicare, One person w/o Medicare 488.70$ 269.70$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 572.70$ 557.70$ 8 Two Adults with Medicare & Dependent Child(ren) 298.80$ 667.80$ 9 Adult & Dependent Child(ren) 499.20$ 371.20$

10 Adult with Medicare & Dependent Child(ren) 276.90$ 278.90$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 28 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 71% City Contribution Unused S/L - At least 90 but less than 94

work days

PC Description @71% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 321.32$ 238.32$ 2 Two Adults w/o Medicare 643.22$ 473.22$ 3 Two Adults & Dependent Child(ren) 964.54$ 710.54$ 4 One Adult with Medicare 109.04$ 173.04$ 5 Two Adults with Medicare 206.19$ 375.19$ 6 One Adult with Medicare, One person w/o Medicare 472.41$ 253.41$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 553.61$ 538.61$ 8 Two Adults with Medicare & Dependent Child(ren) 288.84$ 657.84$ 9 Adult & Dependent Child(ren) 482.56$ 354.56$

10 Adult with Medicare & Dependent Child(ren) 267.67$ 269.67$ FIRE (Exceed 40hrs/wk)

@ 72% City Contribution Unused S/L - At least 94 but less than 98

work days

PC Description @72% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 310.24$ 227.24$ 2 Two Adults w/o Medicare 621.04$ 451.04$ 3 Two Adults & Dependent Child(ren) 931.28$ 677.28$ 4 One Adult with Medicare 105.28$ 169.28$ 5 Two Adults with Medicare 199.08$ 368.08$ 6 One Adult with Medicare, One person w/o Medicare 456.12$ 237.12$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 534.52$ 519.52$ 8 Two Adults with Medicare & Dependent Child(ren) 278.88$ 647.88$ 9 Adult & Dependent Child(ren) 465.92$ 337.92$

10 Adult with Medicare & Dependent Child(ren) 258.44$ 260.44$ FIRE (Exceed 40hrs/wk)

@ 73% City Contribution Unused S/L - At least 98 but less than 102

work days

PC Description @73% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 299.16$ 216.16$ 2 Two Adults w/o Medicare 598.86$ 428.86$ 3 Two Adults & Dependent Child(ren) 898.02$ 644.02$ 4 One Adult with Medicare 101.52$ 165.52$ 5 Two Adults with Medicare 191.97$ 360.97$ 6 One Adult with Medicare, One person w/o Medicare 439.83$ 220.83$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 515.43$ 500.43$ 8 Two Adults with Medicare & Dependent Child(ren) 268.92$ 637.92$ 9 Adult & Dependent Child(ren) 449.28$ 321.28$

10 Adult with Medicare & Dependent Child(ren) 249.21$ 251.21$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 29 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 74% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 102 but less than 106 work days

PC Description @74% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 288.08$ 205.08$ 2 Two Adults w/o Medicare 576.68$ 406.68$ 3 Two Adults & Dependent Child(ren) 864.76$ 610.76$ 4 One Adult with Medicare 97.76$ 161.76$ 5 Two Adults with Medicare 184.86$ 353.86$ 6 One Adult with Medicare, One person w/o Medicare 423.54$ 204.54$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 496.34$ 481.34$ 8 Two Adults with Medicare & Dependent Child(ren) 258.96$ 627.96$ 9 Adult & Dependent Child(ren) 432.64$ 304.64$

10 Adult with Medicare & Dependent Child(ren) 239.98$ 241.98$ FIRE (Exceed 40hrs/wk)

@ 75% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 106 but less than 110 work days

PC Description @75% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 277.00$ 194.00$ 2 Two Adults w/o Medicare 554.50$ 384.50$ 3 Two Adults & Dependent Child(ren) 831.50$ 577.50$ 4 One Adult with Medicare 94.00$ 158.00$ 5 Two Adults with Medicare 177.75$ 346.75$ 6 One Adult with Medicare, One person w/o Medicare 407.25$ 188.25$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 477.25$ 462.25$ 8 Two Adults with Medicare & Dependent Child(ren) 249.00$ 618.00$ 9 Adult & Dependent Child(ren) 416.00$ 288.00$

10 Adult with Medicare & Dependent Child(ren) 230.75$ 232.75$ FIRE (Exceed 40hrs/wk)

@ 76% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 110 but less than 114 work days

PC Description @76% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 265.92$ 182.92$ 2 Two Adults w/o Medicare 532.32$ 362.32$ 3 Two Adults & Dependent Child(ren) 798.24$ 544.24$ 4 One Adult with Medicare 90.24$ 154.24$ 5 Two Adults with Medicare 170.64$ 339.64$ 6 One Adult with Medicare, One person w/o Medicare 390.96$ 171.96$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 458.16$ 443.16$ 8 Two Adults with Medicare & Dependent Child(ren) 239.04$ 608.04$ 9 Adult & Dependent Child(ren) 399.36$ 271.36$

10 Adult with Medicare & Dependent Child(ren) 221.52$ 223.52$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 30 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 77% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 114 but less than 118 work days

PC Description @77% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 254.84$ 171.84$ 2 Two Adults w/o Medicare 510.14$ 340.14$ 3 Two Adults & Dependent Child(ren) 764.98$ 510.98$ 4 One Adult with Medicare 86.48$ 150.48$ 5 Two Adults with Medicare 163.53$ 332.53$ 6 One Adult with Medicare, One person w/o Medicare 374.67$ 155.67$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 439.07$ 424.07$ 8 Two Adults with Medicare & Dependent Child(ren) 229.08$ 598.08$ 9 Adult & Dependent Child(ren) 382.72$ 254.72$

10 Adult with Medicare & Dependent Child(ren) 212.29$ 214.29$ FIRE (Exceed 40hrs/wk)

@ 78% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 118 but less than 122 work days

PC Description @78% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 243.76$ 160.76$ 2 Two Adults w/o Medicare 487.96$ 317.96$ 3 Two Adults & Dependent Child(ren) 731.72$ 477.72$ 4 One Adult with Medicare 82.72$ 146.72$ 5 Two Adults with Medicare 156.42$ 325.42$ 6 One Adult with Medicare, One person w/o Medicare 358.38$ 139.38$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 419.98$ 404.98$ 8 Two Adults with Medicare & Dependent Child(ren) 219.12$ 588.12$ 9 Adult & Dependent Child(ren) 366.08$ 238.08$

10 Adult with Medicare & Dependent Child(ren) 203.06$ 205.06$ FIRE (Exceed 40hrs/wk)

@ 79% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 122 but less than 126 work days

PC Description @79% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 232.68$ 149.68$ 2 Two Adults w/o Medicare 465.78$ 295.78$ 3 Two Adults & Dependent Child(ren) 698.46$ 444.46$ 4 One Adult with Medicare 78.96$ 142.96$ 5 Two Adults with Medicare 149.31$ 318.31$ 6 One Adult with Medicare, One person w/o Medicare 342.09$ 123.09$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 400.89$ 385.89$ 8 Two Adults with Medicare & Dependent Child(ren) 209.16$ 578.16$ 9 Adult & Dependent Child(ren) 349.44$ 221.44$

10 Adult with Medicare & Dependent Child(ren) 193.83$ 195.83$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 31 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 80% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 126 but less than 130 work days

PC Description @80% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 221.60$ 138.60$ 2 Two Adults w/o Medicare 443.60$ 273.60$ 3 Two Adults & Dependent Child(ren) 665.20$ 411.20$ 4 One Adult with Medicare 75.20$ 139.20$ 5 Two Adults with Medicare 142.20$ 311.20$ 6 One Adult with Medicare, One person w/o Medicare 325.80$ 106.80$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 381.80$ 366.80$ 8 Two Adults with Medicare & Dependent Child(ren) 199.20$ 568.20$ 9 Adult & Dependent Child(ren) 332.80$ 204.80$

10 Adult with Medicare & Dependent Child(ren) 184.60$ 186.60$ FIRE (Exceed 40hrs/wk)

@ 81% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 130 but less than 133 work days

PC Description @81% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 210.52$ 127.52$ 2 Two Adults w/o Medicare 421.42$ 251.42$ 3 Two Adults & Dependent Child(ren) 631.94$ 377.94$ 4 One Adult with Medicare 71.44$ 135.44$ 5 Two Adults with Medicare 135.09$ 304.09$ 6 One Adult with Medicare, One person w/o Medicare 309.51$ 90.51$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 362.71$ 347.71$ 8 Two Adults with Medicare & Dependent Child(ren) 189.24$ 558.24$ 9 Adult & Dependent Child(ren) 316.16$ 188.16$

10 Adult with Medicare & Dependent Child(ren) 175.37$ 177.37$ FIRE (Exceed 40hrs/wk)

@ 82% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 133 but less than 136 work days

PC Description @82% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 199.44$ 116.44$ 2 Two Adults w/o Medicare 399.24$ 229.24$ 3 Two Adults & Dependent Child(ren) 598.68$ 344.68$ 4 One Adult with Medicare 67.68$ 131.68$ 5 Two Adults with Medicare 127.98$ 296.98$ 6 One Adult with Medicare, One person w/o Medicare 293.22$ 74.22$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 343.62$ 328.62$ 8 Two Adults with Medicare & Dependent Child(ren) 179.28$ 548.28$ 9 Adult & Dependent Child(ren) 299.52$ 171.52$

10 Adult with Medicare & Dependent Child(ren) 166.14$ 168.14$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 32 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 83% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 136 but less than 139 work days

PC Description @83% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 188.36$ 105.36$ 2 Two Adults w/o Medicare 377.06$ 207.06$ 3 Two Adults & Dependent Child(ren) 565.42$ 311.42$ 4 One Adult with Medicare 63.92$ 127.92$ 5 Two Adults with Medicare 120.87$ 289.87$ 6 One Adult with Medicare, One person w/o Medicare 276.93$ 57.93$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 324.53$ 309.53$ 8 Two Adults with Medicare & Dependent Child(ren) 169.32$ 538.32$ 9 Adult & Dependent Child(ren) 282.88$ 154.88$

10 Adult with Medicare & Dependent Child(ren) 156.91$ 158.91$ FIRE (Exceed 40hrs/wk)

@ 84% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 139 but less than 142 work days

PC Description @84% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 177.28$ 94.28$ 2 Two Adults w/o Medicare 354.88$ 184.88$ 3 Two Adults & Dependent Child(ren) 532.16$ 278.16$ 4 One Adult with Medicare 60.16$ 124.16$ 5 Two Adults with Medicare 113.76$ 282.76$ 6 One Adult with Medicare, One person w/o Medicare 260.64$ 41.64$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 305.44$ 290.44$ 8 Two Adults with Medicare & Dependent Child(ren) 159.36$ 528.36$ 9 Adult & Dependent Child(ren) 266.24$ 138.24$

10 Adult with Medicare & Dependent Child(ren) 147.68$ 149.68$ FIRE (Exceed 40hrs/wk)

@ 85% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 142 but less than 145 work days

PC Description @85% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 166.20$ 83.20$ 2 Two Adults w/o Medicare 332.70$ 162.70$ 3 Two Adults & Dependent Child(ren) 498.90$ 244.90$ 4 One Adult with Medicare 56.40$ 120.40$ 5 Two Adults with Medicare 106.65$ 275.65$ 6 One Adult with Medicare, One person w/o Medicare 244.35$ 25.35$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 286.35$ 271.35$ 8 Two Adults with Medicare & Dependent Child(ren) 149.40$ 518.40$ 9 Adult & Dependent Child(ren) 249.60$ 121.60$

10 Adult with Medicare & Dependent Child(ren) 138.45$ 140.45$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 33 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 86% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 145 but less than 148 work days

PC Description @86% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 155.12$ 72.12$ 2 Two Adults w/o Medicare 310.52$ 140.52$ 3 Two Adults & Dependent Child(ren) 465.64$ 211.64$ 4 One Adult with Medicare 52.64$ 116.64$ 5 Two Adults with Medicare 99.54$ 268.54$ 6 One Adult with Medicare, One person w/o Medicare 228.06$ 9.06$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 267.26$ 252.26$ 8 Two Adults with Medicare & Dependent Child(ren) 139.44$ 508.44$ 9 Adult & Dependent Child(ren) 232.96$ 104.96$

10 Adult with Medicare & Dependent Child(ren) 129.22$ 131.22$ FIRE (Exceed 40hrs/wk)

@ 87% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 148 but less than 151 work days

PC Description @87% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 144.04$ 61.04$ 2 Two Adults w/o Medicare 288.34$ 118.34$ 3 Two Adults & Dependent Child(ren) 432.38$ 178.38$ 4 One Adult with Medicare 48.88$ 112.88$ 5 Two Adults with Medicare 92.43$ 261.43$ 6 One Adult with Medicare, One person w/o Medicare 211.77$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 248.17$ 233.17$ 8 Two Adults with Medicare & Dependent Child(ren) 129.48$ 498.48$ 9 Adult & Dependent Child(ren) 216.32$ 88.32$

10 Adult with Medicare & Dependent Child(ren) 119.99$ 121.99$ FIRE (Exceed 40hrs/wk)

@ 88% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 151 but less than 154 work days

PC Description @88% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 132.96$ 49.96$ 2 Two Adults w/o Medicare 266.16$ 96.16$ 3 Two Adults & Dependent Child(ren) 399.12$ 145.12$ 4 One Adult with Medicare 45.12$ 109.12$ 5 Two Adults with Medicare 85.32$ 254.32$ 6 One Adult with Medicare, One person w/o Medicare 195.48$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 229.08$ 214.08$ 8 Two Adults with Medicare & Dependent Child(ren) 119.52$ 488.52$ 9 Adult & Dependent Child(ren) 199.68$ 71.68$

10 Adult with Medicare & Dependent Child(ren) 110.76$ 112.76$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 34 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 89% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 154 but less than 157 work days

PC Description @89% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 121.88$ 38.88$ 2 Two Adults w/o Medicare 243.98$ 73.98$ 3 Two Adults & Dependent Child(ren) 365.86$ 111.86$ 4 One Adult with Medicare 41.36$ 105.36$ 5 Two Adults with Medicare 78.21$ 247.21$ 6 One Adult with Medicare, One person w/o Medicare 179.19$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 209.99$ 194.99$ 8 Two Adults with Medicare & Dependent Child(ren) 109.56$ 478.56$ 9 Adult & Dependent Child(ren) 183.04$ 55.04$

10 Adult with Medicare & Dependent Child(ren) 101.53$ 103.53$ FIRE (Exceed 40hrs/wk)

@ 90% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 157 but less than 160 work days

PC Description @90% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 110.80$ 27.80$ 2 Two Adults w/o Medicare 221.80$ 51.80$ 3 Two Adults & Dependent Child(ren) 332.60$ 78.60$ 4 One Adult with Medicare 37.60$ 101.60$ 5 Two Adults with Medicare 71.10$ 240.10$ 6 One Adult with Medicare, One person w/o Medicare 162.90$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 190.90$ 175.90$ 8 Two Adults with Medicare & Dependent Child(ren) 99.60$ 468.60$ 9 Adult & Dependent Child(ren) 166.40$ 38.40$

10 Adult with Medicare & Dependent Child(ren) 92.30$ 94.30$ FIRE (Exceed 40hrs/wk)

@ 91% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 160 but less than 163 work days

PC Description @91% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 99.72$ 16.72$ 2 Two Adults w/o Medicare 199.62$ 29.62$ 3 Two Adults & Dependent Child(ren) 299.34$ 45.34$ 4 One Adult with Medicare 33.84$ 97.84$ 5 Two Adults with Medicare 63.99$ 232.99$ 6 One Adult with Medicare, One person w/o Medicare 146.61$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 171.81$ 156.81$ 8 Two Adults with Medicare & Dependent Child(ren) 89.64$ 458.64$ 9 Adult & Dependent Child(ren) 149.76$ 21.76$

10 Adult with Medicare & Dependent Child(ren) 83.07$ 85.07$

10/7/2016 2017 FIRE CONTRIBUTION RATE MATRIX THRU AGE 60 (Exceed 40hrs/wk)

RATES/FINAL 2017 RETIREE Rate Charts.xlsx 35 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 92% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 163 but less than 166 work days

PC Description @92% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 88.64$ 5.64$ 2 Two Adults w/o Medicare 177.44$ 7.44$ 3 Two Adults & Dependent Child(ren) 266.08$ 12.08$ 4 One Adult with Medicare 30.08$ 94.08$ 5 Two Adults with Medicare 56.88$ 225.88$ 6 One Adult with Medicare, One person w/o Medicare 130.32$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 152.72$ 137.72$ 8 Two Adults with Medicare & Dependent Child(ren) 79.68$ 448.68$ 9 Adult & Dependent Child(ren) 133.12$ 5.12$

10 Adult with Medicare & Dependent Child(ren) 73.84$ 75.84$ FIRE (Exceed 40hrs/wk)

@ 93% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 166 but less than 169 work days

PC Description @93% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 77.56$ -$ 2 Two Adults w/o Medicare 155.26$ -$ 3 Two Adults & Dependent Child(ren) 232.82$ -$ 4 One Adult with Medicare 26.32$ 90.32$ 5 Two Adults with Medicare 49.77$ 218.77$ 6 One Adult with Medicare, One person w/o Medicare 114.03$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 133.63$ 118.63$ 8 Two Adults with Medicare & Dependent Child(ren) 69.72$ 438.72$ 9 Adult & Dependent Child(ren) 116.48$ -$

10 Adult with Medicare & Dependent Child(ren) 64.61$ 66.61$ FIRE (Exceed 40hrs/wk)

@ 94% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 169 but less than 172 work days

PC Description @94% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 66.48$ -$ 2 Two Adults w/o Medicare 133.08$ -$ 3 Two Adults & Dependent Child(ren) 199.56$ -$ 4 One Adult with Medicare 22.56$ 86.56$ 5 Two Adults with Medicare 42.66$ 211.66$ 6 One Adult with Medicare, One person w/o Medicare 97.74$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 114.54$ 99.54$ 8 Two Adults with Medicare & Dependent Child(ren) 59.76$ 428.76$ 9 Adult & Dependent Child(ren) 99.84$ -$

10 Adult with Medicare & Dependent Child(ren) 55.38$ 57.38$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 36 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 95% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 172 but less than 175 work days

PC Description @95% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 55.40$ -$ 2 Two Adults w/o Medicare 110.90$ -$ 3 Two Adults & Dependent Child(ren) 166.30$ -$ 4 One Adult with Medicare 18.80$ 82.80$ 5 Two Adults with Medicare 35.55$ 204.55$ 6 One Adult with Medicare, One person w/o Medicare 81.45$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 95.45$ 80.45$ 8 Two Adults with Medicare & Dependent Child(ren) 49.80$ 418.80$ 9 Adult & Dependent Child(ren) 83.20$ -$

10 Adult with Medicare & Dependent Child(ren) 46.15$ 48.15$ FIRE (Exceed 40hrs/wk)

@ 96% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 175 but less than 178 work days

PC Description @96% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 44.32$ -$ 2 Two Adults w/o Medicare 88.72$ -$ 3 Two Adults & Dependent Child(ren) 133.04$ -$ 4 One Adult with Medicare 15.04$ 79.04$ 5 Two Adults with Medicare 28.44$ 197.44$ 6 One Adult with Medicare, One person w/o Medicare 65.16$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 76.36$ 61.36$ 8 Two Adults with Medicare & Dependent Child(ren) 39.84$ 408.84$ 9 Adult & Dependent Child(ren) 66.56$ -$

10 Adult with Medicare & Dependent Child(ren) 36.92$ 38.92$ FIRE (Exceed 40hrs/wk)

@ 97% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 178 but less than 181 work days

PC Description @97% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 33.24$ -$ 2 Two Adults w/o Medicare 66.54$ -$ 3 Two Adults & Dependent Child(ren) 99.78$ -$ 4 One Adult with Medicare 11.28$ 75.28$ 5 Two Adults with Medicare 21.33$ 190.33$ 6 One Adult with Medicare, One person w/o Medicare 48.87$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 57.27$ 42.27$ 8 Two Adults with Medicare & Dependent Child(ren) 29.88$ 398.88$ 9 Adult & Dependent Child(ren) 49.92$ -$

10 Adult with Medicare & Dependent Child(ren) 27.69$ 29.69$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 37 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 98% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 181 but less than 184 work days

PC Description @98% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 22.16$ -$ 2 Two Adults w/o Medicare 44.36$ -$ 3 Two Adults & Dependent Child(ren) 66.52$ -$ 4 One Adult with Medicare 7.52$ 71.52$ 5 Two Adults with Medicare 14.22$ 183.22$ 6 One Adult with Medicare, One person w/o Medicare 32.58$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 38.18$ 23.18$ 8 Two Adults with Medicare & Dependent Child(ren) 19.92$ 388.92$ 9 Adult & Dependent Child(ren) 33.28$ -$

10 Adult with Medicare & Dependent Child(ren) 18.46$ 20.46$ FIRE (Exceed 40hrs/wk)

@ 99% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 184 but less than 187 work days

PC Description @99% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare 11.08$ -$ 2 Two Adults w/o Medicare 22.18$ -$ 3 Two Adults & Dependent Child(ren) 33.26$ -$ 4 One Adult with Medicare 3.76$ 67.76$ 5 Two Adults with Medicare 7.11$ 176.11$ 6 One Adult with Medicare, One person w/o Medicare 16.29$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 19.09$ 4.09$ 8 Two Adults with Medicare & Dependent Child(ren) 9.96$ 378.96$ 9 Adult & Dependent Child(ren) 16.64$ -$

10 Adult with Medicare & Dependent Child(ren) 9.23$ 11.23$ FIRE (Exceed 40hrs/wk)

@ 100% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 187 work days

PC Description @100% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare -$ -$ 3 Two Adults & Dependent Child(ren) -$ -$ 4 One Adult with Medicare -$ 64.00$ 5 Two Adults with Medicare -$ 169.00$ 6 One Adult with Medicare, One person w/o Medicare -$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) -$ -$ 8 Two Adults with Medicare & Dependent Child(ren) -$ 369.00$ 9 Adult & Dependent Child(ren) -$ -$

10 Adult with Medicare & Dependent Child(ren) -$ 2.00$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 38 of 51Department of Employee Relations

City Hall, Room 706

UHC CHOICE PLUS (PPO)UHC CHOICE (EPO)

100% RETIREE PLAN RATES

PC Description UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 2,218.00$ 2,048.00$ 3 Two Adults & Dependent Child(ren) 3,326.00$ 3,072.00$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 711.00$ 880.00$ 6 One Adult with Medicare, One person w/o Medicare 1,629.00$ 1,410.00$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 1,909.00$ 1,894.00$ 8 Two Adults with Medicare & Dependent Child(ren) 996.00$ 1,365.00$ 9 Adult & Dependent Child(ren) 1,664.00$ 1,536.00$

10 Adult with Medicare & Dependent Child(ren) 923.00$ 925.00$

RATE CHART 7 - FULL 2017 RATEFIRE - EXCEED 40 HRS PER WEEK - Ages 60 - 64

FIRE SINGLE ENROLLMENT - For a retiree with single enrollment status, the City will contribute an amount up to the percentage of the subscriber cost for single enrollment in the Basic Plan that is determined by the percentage formula

during the period the retiree is at least age 52 but less than age 60 and an amount up to 100% of the subscriber cost for single enrollment in the Basic Plan during the period after retirement the retiree is at least age 60 but less than age 65.

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 39 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 65% City Contribution Unused S/L - Less than 70 work days

PC Description @65% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 776.30$ 606.30$ 3 Two Adults & Dependent Child(ren) 1,164.10$ 910.10$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 248.85$ 417.85$ 6 One Adult with Medicare, One person w/o Medicare 570.15$ 351.15$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 668.15$ 653.15$ 8 Two Adults with Medicare & Dependent Child(ren) 348.60$ 717.60$ 9 Adult & Dependent Child(ren) 582.40$ 454.40$

10 Adult with Medicare & Dependent Child(ren) 323.05$ 325.05$ FIRE (Exceed 40hrs/wk)

@ 66% City Contribution Unused S/L - At least 70 but less than 74

work days

PC Description @66% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 754.12$ 584.12$ 3 Two Adults & Dependent Child(ren) 1,130.84$ 876.84$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 241.74$ 410.74$ 6 One Adult with Medicare, One person w/o Medicare 553.86$ 334.86$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 649.06$ 634.06$ 8 Two Adults with Medicare & Dependent Child(ren) 338.64$ 707.64$ 9 Adult & Dependent Child(ren) 565.76$ 437.76$

10 Adult with Medicare & Dependent Child(ren) 313.82$ 315.82$ FIRE (Exceed 40hrs/wk)

@ 67% City Contribution Unused S/L - At least 74 but less than 78

work days

PC Description @67% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 731.94$ 561.94$ 3 Two Adults & Dependent Child(ren) 1,097.58$ 843.58$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 234.63$ 403.63$ 6 One Adult with Medicare, One person w/o Medicare 537.57$ 318.57$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 629.97$ 614.97$ 8 Two Adults with Medicare & Dependent Child(ren) 328.68$ 697.68$ 9 Adult & Dependent Child(ren) 549.12$ 421.12$

10 Adult with Medicare & Dependent Child(ren) 304.59$ 306.59$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 40 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 68% City Contribution Unused S/L - At least 78 but less than 82

work days

PC Description @68% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 709.76$ 539.76$ 3 Two Adults & Dependent Child(ren) 1,064.32$ 810.32$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 227.52$ 396.52$ 6 One Adult with Medicare, One person w/o Medicare 521.28$ 302.28$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 610.88$ 595.88$ 8 Two Adults with Medicare & Dependent Child(ren) 318.72$ 687.72$ 9 Adult & Dependent Child(ren) 532.48$ 404.48$

10 Adult with Medicare & Dependent Child(ren) 295.36$ 297.36$ FIRE (Exceed 40hrs/wk)

@ 69% City Contribution Unused S/L - At least 82 but less than 86

work days

PC Description @69% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 687.58$ 517.58$ 3 Two Adults & Dependent Child(ren) 1,031.06$ 777.06$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 220.41$ 389.41$ 6 One Adult with Medicare, One person w/o Medicare 504.99$ 285.99$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 591.79$ 576.79$ 8 Two Adults with Medicare & Dependent Child(ren) 308.76$ 677.76$ 9 Adult & Dependent Child(ren) 515.84$ 387.84$

10 Adult with Medicare & Dependent Child(ren) 286.13$ 288.13$ FIRE (Exceed 40hrs/wk)

@ 70% City Contribution Unused S/L - At least 86 but less than 90

work days

PC Description @70% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 665.40$ 495.40$ 3 Two Adults & Dependent Child(ren) 997.80$ 743.80$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 213.30$ 382.30$ 6 One Adult with Medicare, One person w/o Medicare 488.70$ 269.70$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 572.70$ 557.70$ 8 Two Adults with Medicare & Dependent Child(ren) 298.80$ 667.80$ 9 Adult & Dependent Child(ren) 499.20$ 371.20$

10 Adult with Medicare & Dependent Child(ren) 276.90$ 278.90$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 41 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 71% City Contribution Unused S/L - At least 90 but less than 94

work days

PC Description @71% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 643.22$ 473.22$ 3 Two Adults & Dependent Child(ren) 964.54$ 710.54$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 206.19$ 375.19$ 6 One Adult with Medicare, One person w/o Medicare 472.41$ 253.41$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 553.61$ 538.61$ 8 Two Adults with Medicare & Dependent Child(ren) 288.84$ 657.84$ 9 Adult & Dependent Child(ren) 482.56$ 354.56$

10 Adult with Medicare & Dependent Child(ren) 267.67$ 269.67$ FIRE (Exceed 40hrs/wk)

@ 72% City Contribution Unused S/L - At least 94 but less than 98

work days

PC Description @72% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 621.04$ 451.04$ 3 Two Adults & Dependent Child(ren) 931.28$ 677.28$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 199.08$ 368.08$ 6 One Adult with Medicare, One person w/o Medicare 456.12$ 237.12$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 534.52$ 519.52$ 8 Two Adults with Medicare & Dependent Child(ren) 278.88$ 647.88$ 9 Adult & Dependent Child(ren) 465.92$ 337.92$

10 Adult with Medicare & Dependent Child(ren) 258.44$ 260.44$ FIRE (Exceed 40hrs/wk)

@ 73% City Contribution Unused S/L - At least 98 but less than 102

work days

PC Description @73% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 598.86$ 428.86$ 3 Two Adults & Dependent Child(ren) 898.02$ 644.02$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 191.97$ 360.97$ 6 One Adult with Medicare, One person w/o Medicare 439.83$ 220.83$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 515.43$ 500.43$ 8 Two Adults with Medicare & Dependent Child(ren) 268.92$ 637.92$ 9 Adult & Dependent Child(ren) 449.28$ 321.28$

10 Adult with Medicare & Dependent Child(ren) 249.21$ 251.21$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 42 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 74% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 102 but less than 106 work days

PC Description @74% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 576.68$ 406.68$ 3 Two Adults & Dependent Child(ren) 864.76$ 610.76$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 184.86$ 353.86$ 6 One Adult with Medicare, One person w/o Medicare 423.54$ 204.54$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 496.34$ 481.34$ 8 Two Adults with Medicare & Dependent Child(ren) 258.96$ 627.96$ 9 Adult & Dependent Child(ren) 432.64$ 304.64$

10 Adult with Medicare & Dependent Child(ren) 239.98$ 241.98$ FIRE (Exceed 40hrs/wk)

@ 75% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 106 but less than 110 work days

PC Description @75% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 554.50$ 384.50$ 3 Two Adults & Dependent Child(ren) 831.50$ 577.50$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 177.75$ 346.75$ 6 One Adult with Medicare, One person w/o Medicare 407.25$ 188.25$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 477.25$ 462.25$ 8 Two Adults with Medicare & Dependent Child(ren) 249.00$ 618.00$ 9 Adult & Dependent Child(ren) 416.00$ 288.00$

10 Adult with Medicare & Dependent Child(ren) 230.75$ 232.75$ FIRE (Exceed 40hrs/wk)

@ 76% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 110 but less than 114 work days

PC Description @76% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 532.32$ 362.32$ 3 Two Adults & Dependent Child(ren) 798.24$ 544.24$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 170.64$ 339.64$ 6 One Adult with Medicare, One person w/o Medicare 390.96$ 171.96$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 458.16$ 443.16$ 8 Two Adults with Medicare & Dependent Child(ren) 239.04$ 608.04$ 9 Adult & Dependent Child(ren) 399.36$ 271.36$

10 Adult with Medicare & Dependent Child(ren) 221.52$ 223.52$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 43 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 77% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 114 but less than 118 work days

PC Description @77% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 510.14$ 340.14$ 3 Two Adults & Dependent Child(ren) 764.98$ 510.98$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 163.53$ 332.53$ 6 One Adult with Medicare, One person w/o Medicare 374.67$ 155.67$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 439.07$ 424.07$ 8 Two Adults with Medicare & Dependent Child(ren) 229.08$ 598.08$ 9 Adult & Dependent Child(ren) 382.72$ 254.72$

10 Adult with Medicare & Dependent Child(ren) 212.29$ 214.29$ FIRE (Exceed 40hrs/wk)

@ 78% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 118 but less than 122 work days

PC Description @78% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 487.96$ 317.96$ 3 Two Adults & Dependent Child(ren) 731.72$ 477.72$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 156.42$ 325.42$ 6 One Adult with Medicare, One person w/o Medicare 358.38$ 139.38$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 419.98$ 404.98$ 8 Two Adults with Medicare & Dependent Child(ren) 219.12$ 588.12$ 9 Adult & Dependent Child(ren) 366.08$ 238.08$

10 Adult with Medicare & Dependent Child(ren) 203.06$ 205.06$ FIRE (Exceed 40hrs/wk)

@ 79% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 122 but less than 126 work days

PC Description @79% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 465.78$ 295.78$ 3 Two Adults & Dependent Child(ren) 698.46$ 444.46$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 149.31$ 318.31$ 6 One Adult with Medicare, One person w/o Medicare 342.09$ 123.09$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 400.89$ 385.89$ 8 Two Adults with Medicare & Dependent Child(ren) 209.16$ 578.16$ 9 Adult & Dependent Child(ren) 349.44$ 221.44$

10 Adult with Medicare & Dependent Child(ren) 193.83$ 195.83$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 44 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 80% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 126 but less than 130 work days

PC Description @80% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 443.60$ 273.60$ 3 Two Adults & Dependent Child(ren) 665.20$ 411.20$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 142.20$ 311.20$ 6 One Adult with Medicare, One person w/o Medicare 325.80$ 106.80$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 381.80$ 366.80$ 8 Two Adults with Medicare & Dependent Child(ren) 199.20$ 568.20$ 9 Adult & Dependent Child(ren) 332.80$ 204.80$

10 Adult with Medicare & Dependent Child(ren) 184.60$ 186.60$ FIRE (Exceed 40hrs/wk)

@ 81% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 130 but less than 133 work days

PC Description @81% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 421.42$ 251.42$ 3 Two Adults & Dependent Child(ren) 631.94$ 377.94$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 135.09$ 304.09$ 6 One Adult with Medicare, One person w/o Medicare 309.51$ 90.51$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 362.71$ 347.71$ 8 Two Adults with Medicare & Dependent Child(ren) 189.24$ 558.24$ 9 Adult & Dependent Child(ren) 316.16$ 188.16$

10 Adult with Medicare & Dependent Child(ren) 175.37$ 177.37$ FIRE (Exceed 40hrs/wk)

@ 82% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 133 but less than 136 work days

PC Description @82% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 399.24$ 229.24$ 3 Two Adults & Dependent Child(ren) 598.68$ 344.68$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 127.98$ 296.98$ 6 One Adult with Medicare, One person w/o Medicare 293.22$ 74.22$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 343.62$ 328.62$ 8 Two Adults with Medicare & Dependent Child(ren) 179.28$ 548.28$ 9 Adult & Dependent Child(ren) 299.52$ 171.52$

10 Adult with Medicare & Dependent Child(ren) 166.14$ 168.14$

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RATES/FINAL 2017 RETIREE Rate Charts.xlsx 45 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 83% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 136 but less than 139 work days

PC Description @83% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 377.06$ 207.06$ 3 Two Adults & Dependent Child(ren) 565.42$ 311.42$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 120.87$ 289.87$ 6 One Adult with Medicare, One person w/o Medicare 276.93$ 57.93$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 324.53$ 309.53$ 8 Two Adults with Medicare & Dependent Child(ren) 169.32$ 538.32$ 9 Adult & Dependent Child(ren) 282.88$ 154.88$

10 Adult with Medicare & Dependent Child(ren) 156.91$ 158.91$ FIRE (Exceed 40hrs/wk)

@ 84% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 139 but less than 142 work days

PC Description @84% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 354.88$ 184.88$ 3 Two Adults & Dependent Child(ren) 532.16$ 278.16$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 113.76$ 282.76$ 6 One Adult with Medicare, One person w/o Medicare 260.64$ 41.64$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 305.44$ 290.44$ 8 Two Adults with Medicare & Dependent Child(ren) 159.36$ 528.36$ 9 Adult & Dependent Child(ren) 266.24$ 138.24$

10 Adult with Medicare & Dependent Child(ren) 147.68$ 149.68$ FIRE (Exceed 40hrs/wk)

@ 85% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 142 but less than 145 work days

PC Description @85% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 332.70$ 162.70$ 3 Two Adults & Dependent Child(ren) 498.90$ 244.90$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 106.65$ 275.65$ 6 One Adult with Medicare, One person w/o Medicare 244.35$ 25.35$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 286.35$ 271.35$ 8 Two Adults with Medicare & Dependent Child(ren) 149.40$ 518.40$ 9 Adult & Dependent Child(ren) 249.60$ 121.60$

10 Adult with Medicare & Dependent Child(ren) 138.45$ 140.45$

10/7/2016 2017 FIRE CONTRIBUTION RATE MATRIX THRU AGE 60 (Exceed 40hrs/wk)

RATES/FINAL 2017 RETIREE Rate Charts.xlsx 46 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 86% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 145 but less than 148 work days

PC Description @86% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 310.52$ 140.52$ 3 Two Adults & Dependent Child(ren) 465.64$ 211.64$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 99.54$ 268.54$ 6 One Adult with Medicare, One person w/o Medicare 228.06$ 9.06$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 267.26$ 252.26$ 8 Two Adults with Medicare & Dependent Child(ren) 139.44$ 508.44$ 9 Adult & Dependent Child(ren) 232.96$ 104.96$

10 Adult with Medicare & Dependent Child(ren) 129.22$ 131.22$ FIRE (Exceed 40hrs/wk)

@ 87% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 148 but less than 151 work days

PC Description @87% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 288.34$ 118.34$ 3 Two Adults & Dependent Child(ren) 432.38$ 178.38$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 92.43$ 261.43$ 6 One Adult with Medicare, One person w/o Medicare 211.77$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 248.17$ 233.17$ 8 Two Adults with Medicare & Dependent Child(ren) 129.48$ 498.48$ 9 Adult & Dependent Child(ren) 216.32$ 88.32$

10 Adult with Medicare & Dependent Child(ren) 119.99$ 121.99$ FIRE (Exceed 40hrs/wk)

@ 88% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 151 but less than 154 work days

PC Description @88% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 266.16$ 96.16$ 3 Two Adults & Dependent Child(ren) 399.12$ 145.12$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 85.32$ 254.32$ 6 One Adult with Medicare, One person w/o Medicare 195.48$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 229.08$ 214.08$ 8 Two Adults with Medicare & Dependent Child(ren) 119.52$ 488.52$ 9 Adult & Dependent Child(ren) 199.68$ 71.68$

10 Adult with Medicare & Dependent Child(ren) 110.76$ 112.76$

10/7/2016 2017 FIRE CONTRIBUTION RATE MATRIX THRU AGE 60 (Exceed 40hrs/wk)

RATES/FINAL 2017 RETIREE Rate Charts.xlsx 47 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 89% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 154 but less than 157 work days

PC Description @89% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 243.98$ 73.98$ 3 Two Adults & Dependent Child(ren) 365.86$ 111.86$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 78.21$ 247.21$ 6 One Adult with Medicare, One person w/o Medicare 179.19$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 209.99$ 194.99$ 8 Two Adults with Medicare & Dependent Child(ren) 109.56$ 478.56$ 9 Adult & Dependent Child(ren) 183.04$ 55.04$

10 Adult with Medicare & Dependent Child(ren) 101.53$ 103.53$ FIRE (Exceed 40hrs/wk)

@ 90% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 157 but less than 160 work days

PC Description @90% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 221.80$ 51.80$ 3 Two Adults & Dependent Child(ren) 332.60$ 78.60$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 71.10$ 240.10$ 6 One Adult with Medicare, One person w/o Medicare 162.90$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 190.90$ 175.90$ 8 Two Adults with Medicare & Dependent Child(ren) 99.60$ 468.60$ 9 Adult & Dependent Child(ren) 166.40$ 38.40$

10 Adult with Medicare & Dependent Child(ren) 92.30$ 94.30$ FIRE (Exceed 40hrs/wk)

@ 91% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 160 but less than 163 work days

PC Description @91% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 199.62$ 29.62$ 3 Two Adults & Dependent Child(ren) 299.34$ 45.34$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 63.99$ 232.99$ 6 One Adult with Medicare, One person w/o Medicare 146.61$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 171.81$ 156.81$ 8 Two Adults with Medicare & Dependent Child(ren) 89.64$ 458.64$ 9 Adult & Dependent Child(ren) 149.76$ 21.76$

10 Adult with Medicare & Dependent Child(ren) 83.07$ 85.07$

10/7/2016 2017 FIRE CONTRIBUTION RATE MATRIX THRU AGE 60 (Exceed 40hrs/wk)

RATES/FINAL 2017 RETIREE Rate Charts.xlsx 48 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 92% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 163 but less than 166 work days

PC Description @92% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 177.44$ 7.44$ 3 Two Adults & Dependent Child(ren) 266.08$ 12.08$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 56.88$ 225.88$ 6 One Adult with Medicare, One person w/o Medicare 130.32$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 152.72$ 137.72$ 8 Two Adults with Medicare & Dependent Child(ren) 79.68$ 448.68$ 9 Adult & Dependent Child(ren) 133.12$ 5.12$

10 Adult with Medicare & Dependent Child(ren) 73.84$ 75.84$ FIRE (Exceed 40hrs/wk)

@ 93% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 166 but less than 169 work days

PC Description @93% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 155.26$ -$ 3 Two Adults & Dependent Child(ren) 232.82$ -$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 49.77$ 218.77$ 6 One Adult with Medicare, One person w/o Medicare 114.03$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 133.63$ 118.63$ 8 Two Adults with Medicare & Dependent Child(ren) 69.72$ 438.72$ 9 Adult & Dependent Child(ren) 116.48$ -$

10 Adult with Medicare & Dependent Child(ren) 64.61$ 66.61$ FIRE (Exceed 40hrs/wk)

@ 94% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 169 but less than 172 work days

PC Description @94% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 133.08$ -$ 3 Two Adults & Dependent Child(ren) 199.56$ -$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 42.66$ 211.66$ 6 One Adult with Medicare, One person w/o Medicare 97.74$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 114.54$ 99.54$ 8 Two Adults with Medicare & Dependent Child(ren) 59.76$ 428.76$ 9 Adult & Dependent Child(ren) 99.84$ -$

10 Adult with Medicare & Dependent Child(ren) 55.38$ 57.38$

10/7/2016 2017 FIRE CONTRIBUTION RATE MATRIX THRU AGE 60 (Exceed 40hrs/wk)

RATES/FINAL 2017 RETIREE Rate Charts.xlsx 49 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 95% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 172 but less than 175 work days

PC Description @95% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 110.90$ -$ 3 Two Adults & Dependent Child(ren) 166.30$ -$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 35.55$ 204.55$ 6 One Adult with Medicare, One person w/o Medicare 81.45$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 95.45$ 80.45$ 8 Two Adults with Medicare & Dependent Child(ren) 49.80$ 418.80$ 9 Adult & Dependent Child(ren) 83.20$ -$

10 Adult with Medicare & Dependent Child(ren) 46.15$ 48.15$ FIRE (Exceed 40hrs/wk)

@ 96% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 175 but less than 178 work days

PC Description @96% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 88.72$ -$ 3 Two Adults & Dependent Child(ren) 133.04$ -$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 28.44$ 197.44$ 6 One Adult with Medicare, One person w/o Medicare 65.16$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 76.36$ 61.36$ 8 Two Adults with Medicare & Dependent Child(ren) 39.84$ 408.84$ 9 Adult & Dependent Child(ren) 66.56$ -$

10 Adult with Medicare & Dependent Child(ren) 36.92$ 38.92$ FIRE (Exceed 40hrs/wk)

@ 97% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 178 but less than 181 work days

PC Description @97% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 66.54$ -$ 3 Two Adults & Dependent Child(ren) 99.78$ -$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 21.33$ 190.33$ 6 One Adult with Medicare, One person w/o Medicare 48.87$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 57.27$ 42.27$ 8 Two Adults with Medicare & Dependent Child(ren) 29.88$ 398.88$ 9 Adult & Dependent Child(ren) 49.92$ -$

10 Adult with Medicare & Dependent Child(ren) 27.69$ 29.69$

10/7/2016 2017 FIRE CONTRIBUTION RATE MATRIX THRU AGE 60 (Exceed 40hrs/wk)

RATES/FINAL 2017 RETIREE Rate Charts.xlsx 50 of 51Department of Employee Relations

City Hall, Room 706

FIRE (Exceed 40hrs/wk)

@ 98% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 181 but less than 184 work days

PC Description @98% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 44.36$ -$ 3 Two Adults & Dependent Child(ren) 66.52$ -$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 14.22$ 183.22$ 6 One Adult with Medicare, One person w/o Medicare 32.58$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 38.18$ 23.18$ 8 Two Adults with Medicare & Dependent Child(ren) 19.92$ 388.92$ 9 Adult & Dependent Child(ren) 33.28$ -$

10 Adult with Medicare & Dependent Child(ren) 18.46$ 20.46$ FIRE (Exceed 40hrs/wk)

@ 99% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 184 but less than 187 work days

PC Description @99% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare 22.18$ -$ 3 Two Adults & Dependent Child(ren) 33.26$ -$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare 7.11$ 176.11$ 6 One Adult with Medicare, One person w/o Medicare 16.29$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) 19.09$ 4.09$ 8 Two Adults with Medicare & Dependent Child(ren) 9.96$ 378.96$ 9 Adult & Dependent Child(ren) 16.64$ -$

10 Adult with Medicare & Dependent Child(ren) 9.23$ 11.23$ FIRE (Exceed 40hrs/wk)

@ 100% City Contribution FIRE (Exceed 40hrs/wk) - Unused S/L - At

least 187 work days

PC Description @100% UHC CHOICE PLUS UHC CHOICE1 One Adult w/o Medicare -$ -$ 2 Two Adults w/o Medicare -$ -$ 3 Two Adults & Dependent Child(ren) -$ -$ 4 One Adult with Medicare -$ -$ 5 Two Adults with Medicare -$ 169.00$ 6 One Adult with Medicare, One person w/o Medicare -$ -$ 7 One Adult with Medicare, One person w/o Medicare & Dependent Child(ren) -$ -$ 8 Two Adults with Medicare & Dependent Child(ren) -$ 369.00$ 9 Adult & Dependent Child(ren) -$ -$

10 Adult with Medicare & Dependent Child(ren) -$ 2.00$

10/7/2016

DENTAL PLAN SINGLE PREMIUM

FAMILY PREMIUM

MetLife 27.52$ 95.09$

Care-Plus 51.09$ 150.55$

DentalBlue 54.59$ 163.78$

FireMetLife 33.02$ 94.57$

PoliceMetLife 33.11$ 100.73$

2% COBRA Rate NOT included in these rates.2017 DENTAL PLAN RATES