BENEFIT PLAN RATE SHEET

Benefit Plan

No Co-pay

Co-pay

Frequent use option

Co-pay and Frequent use

Plan I – Civil, Criminal, Administrative

$15

$12

$12

$10

Plan I(a)(i) – Plan I with non-scope administrative coverage*

$20

$17

$17

$15

Plan II – Civil and criminal

$5

$4

$4

$3

Plan III- Civil, criminal and limited administrative

$9

$8

$8

$7

Plan IV – Reserve officer criminal and civil only

$4

$3

$3

$2

Plan V - Retired officer criminal and civil only

$3

$2

N/A

N/A