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sourcewellmn.gov/health <br />CompanyName:CityofElkRiver <br />EffectiveDate:1/1/2022 <br />RenewalDate:1/1/2023RateCap:12% <br />ProposedRates <br />Pleasereviewadditionaldetailsaboutourjointselfinsuredpool'sratesonthefollowingpage. <br />ActuarialEmployeeTotalBilled <br />Plan#PlanName/DescriptionNetworkValue(AV)Count(Est)TierRate <br />8500802000CopayRxOpenAccess87.59Single$591.74 <br />8500802000CopayRxOpenAccess87.53EE+Sp$1,291.76 <br />8500802000CopayRxOpenAccess87.52EE+Ch$1,281.88 <br />8500802000CopayRxOpenAccess87.52Family$1,870.11 <br />3SmartPlan3:28001002800PrevRxOpenAccess80.50Single$512.62 <br />3SmartPlan3:28001002800PrevRxOpenAccess80.50EE+Sp$1,121.65 <br />3SmartPlan3:28001002800PrevRxOpenAccess80.50EE+Ch$1,113.23 <br />3SmartPlan3:28001002800PrevRxOpenAccess80.50Family$1,614.73 <br />3BSmartPlan3:28001002800PrevRxAchieve80.50Single$485.17 <br />3BSmartPlan3:28001002800PrevRxAchieve80.50EE+Sp$1,062.64 <br />3BSmartPlan3:28001002800PrevRxAchieve80.50EE+Ch$1,054.72 <br />3BSmartPlan3:28001002800PrevRxAchieve80.50Family$1,526.14 <br />Authorization: <br />Onbehalfofthisgroup,IapproveSourcewelltobillusingthehealthrateslistedaboveandupdatedenrollmentsforthetimeperiodbetweenthe <br />effectiveandrenewaldateslistedabove. <br />Signature: <br />Date: <br />Name: <br />Title: <br />