Page 21 - TruckPro-2022-Benefit Guide-FINAL

Benefit costs

)
Your payroll contributions for medical, dental and vision benefits are shown here.

Platinum HSA Plan Bronze HSA Plan Silver PPO Plan
BCBS Medical
(without tobacco surcharge)
Bi-weekly Monthly Bi-weekly Monthly Bi-weekly Monthly
Employee Only $122.24 $264.85 $78.42 $169.90 $106.33 $230.38
Employee + Spouse/DP $291.89 $632.42 $207.47 $449.52 $285.32 $618.19

Employee + Child(ren) $232.67 $504.12 $163.31 $353.83 $218.23 $472.83
Family $352.80 $764.40 $237.50 $514.59 $349.52 $757.30

Tobacco Surcharge – If you, your spouse/DP, and/or child(ren) over the age of 18 smoke, chew tobacco, use electronic cigarettes
or other tobacco products, you will be subjected to an additional surcharge of $85.00 per person per month or $39.23 biweekly
(up to three people).
As a reminder: If you make any intentional false statements about your tobacco use, you will be subject to disciplinary action,
up to and including termination.

Incentive PPO Passive PPO DHMO
Cigna Dental
Bi-weekly Monthly Bi-weekly Monthly Bi-weekly Monthly

Employee Only $6.80 $14.73 $10.44 $22.62 $4.01 $8.68
Employee + Spouse/DP $11.51 $24.93 $18.61 $40.33 $5.83 $12.64

Employee + Child(ren) $12.97 $28.11 $20.98 $45.46 $6.87 $14.89
Family $20.60 $44.63 $33.32 $72.19 $10.16 $22.02

Vision Blue
BCBS Vision
Bi-weekly Monthly

Employee Only $1.94 $4.20
Employee + Spouse/DP $5.04 $10.92

Employee + Child(ren) $5.04 $10.92
Family $5.04 $10.92

21