Page 5 - Open Sky BROCHURE - HOURLY 2021-2022

9/1/2021-8/31/2022 Employee Benefits Brochure
Hourly

Employee Contributions

Your contributions toward the cost of benefits are automatically deducted from your paycheck
on a pre- tax basis. The rates below are MONTHLY. The amount will depend on the plan you
select and if you choose to cover eligible family members.

Medical Blue Classic 28 PPO Blue Classic PPO 11
Employee only $241.10 $336.38
Employee + Spouse $574.48 $798.32
Employee + Child(ren) $841.18 $1,167.85
Employee + Family $1,274.57 $1,768.36

Medical Mountain Enhanced HMO PPO H.S.A.
Employee only $293.69 $236.12
Employee + Spouse $693.49 $560.89
Employee + Child(ren) $1,013.35 $820.69
Employee + Family $1,533.09 $1,242.87

Dental PPO
Employee only $30.02
Employee + Spouse $56.87
Employee + Child(ren) $57.24
Employee + Family $94.40

Vision
Employee only $8.22
Employee + Spouse $16.44
Employee + Child(ren) $16.85
Employee + Family $25.07

PLEASE NOTE: This booklet provides a summary of the benefits available but is not your Summary Plan Description
(SPD). The Company reserves the right to modify, amend, suspend, or terminate any plan at any time, and for any
reason without prior notification. The plans described in this book are governed by insurance contracts and plan
documents, which are available for examination upon request. We have attempted to make the explanations of the
plans in this booklet as accurate as possible. However, should there be a discrepancy between this booklet and the
provisions of the insurance contracts or plan documents, the provisions of the insurance contracts or plan
documents will govern. In addition, you should not rely on any oral descriptions of these plans, since the written
descriptions in the insurance contracts or plan documents will always govern.

PAGE 5