| Coverage Amount | Individual Plan Annual Cost | Individual and Spouse/Same-Sex Domestic Partner Annual Cost |
| $10,000 | $10.00 | $15.50 |
| $25,000 | $25.00 | $38.75 |
| $50,000 | $50.00 | $77.50 |
| $100,000 | $100.00 | $155.00 |
Retirees who continued their employee coverage for a different amount will pay an annual cost of $1.00 per $1,000 of coverage for individuals and $1.55 per $1,000 of coverage for individual and spouse/same-sex domestic partner.