Plan comparison of contributions and
time-of-service fees
PPO Plan*
HMO Plan
Medicare Advantage Plans**
With Medicare
Without Medicare
With Medicare
Without Medicare
With Medicare
Without Medicare
Retiree's monthly contribution
$221.38 Retiree only
$408.78 Retiree only
$98.66 Retiree only
$316.24 Retiree only
$15 Easch person
$7.50
Each person
PCP office visits
$30
$30
$20
$20
$5
$10
Specialist office visits
$50
$50
$45
$45
$25
$25
Emergency room
$150
$150
$150
$150
$50
$50
Hospital inpatient
$500 + 20 %
$500 + 20 %
$500
$500
$300
$275
*Benefits are for PPO in-network. For you to pay the lower monthly contribution for the HMO or PPO plan, the benefits division needs a copy of your dependent's or your Medicare card.
**Contributions may change 1/1/06.
