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• • <br />r~ <br />RATE SCHEDULE <br />Employee Retiree w/o Medicare <br />Single $ 63.84 $ 79.80/$15.96* <br />With Spouse $162.77 $203.46/$40.69* <br />With Children $121.89 $152.36/$30.47* <br />Family $220.82 $216.03/$55.21* <br />* 25K increase to be contributed by retiree <br />Retiree w Medicare <br />$31 .92 <br />$81 .39 <br />$60.95 <br />$110.41 <br />MEDICARE INTEGRATION (CARVE-OUT) ILLUSTRATION <br />Sample claim with eligible expenses of: $2,500 <br />After deductible and co-insurance, <br />assume that City of La Porte Plan would, <br />as primary payor, pay: $1,800 <br />If Medicare's payment on the same $2,500 was: $1,400 <br />City of La Porte Plan would, as secondary <br />payor, pay: $ 400 <br />(or no greater total benefit than for an <br />employee or retiree not eligible for <br />Medicare.) <br />~IT1E5 BEr1Ef~5 <br />