Page 20 - 2022 Penn Engineering Guide

Rate Information

2022 Medical Plan Rates: 2022 Medical COBRA Monthly Rates

PPO Plan PPO Plan
Single: $50.19 /Week Single: $880.77/mo
EE + Spouse: $86.31/Week EE + Spouse: $2,026.69/mo
EE + Child(ren): $71.77/Week EE + Child(ren) $1,688.92/mo
Family: $113.51 / Week Family: $2,635.27/mo

CDHP High Deductible PPO Plan CDHP High Deductible PPO Plan
(Eligible for H S A Company Contribution)
Single: $17.96/Week Single: $706.58/mo
EE + Spouse: $42.68/Week EE + Spouse: $1,640.98/mo
EE + Child(ren) $39.06/Week EE + Child(ren) $1,359.02/mo
Family: $52.50/Week Family: $2,065.27/mo

For All Medical Plans:
Dependent/Spouse Weekly Surcharge
All Levels: $25.00/week per dependent

This Surcharge applies to any Employee whose Spouse or Dependent has health coverage
available through his/her Employer, but chooses to be covered as a dependent under the
PennEngineering Employee Health Plan.

Tobacco Surcharge
This weekly Surcharge applies to any Employee or Spouse of an Employee who uses Tobacco
products in any form and is covered under the PennEngineering Health Plan. The Company
offers incentives to participate in a Smoking Cessation program through LifeWorks®. Must be
Tobacco-free for 12 months to be eligible for a reduction in premium.

Employee: $25.00/week
Spouse: $25.00/week

2022 Dental Plan Rates:
MetLife Dental

Low PPO Plan: High PPO Plan:

Single: $3.45/Week Single: $4.33/Week
Family: $9.95 /Week Family: $12.50/Week

Aetna DMO Plan (PA/NJ Only)
Single: $2.80/Week
Family: $8.10/Week

2022 Vision Plan Rates:
Vision Benefits of America (VBA)
Employee: No Cost
Two-party: $.95/Week
Family: $1.86/Week 19