Page 5 - Open Sky Brochure - Salaried 2021-2022

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

Employee Contributions

Your contributions toward the cost of benefits are automatically deducted from your paycheck on a pre-
tax basis. The rates below are per pay period. 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 $111.27 $155.25
Employee + Spouse $265.14 $368.45
Employee + Child(ren) $388.24 $539.01
Employee + Family $588.26 $816.16

Medical Mountain Enhanced HMO Plan PPO H.S.A.
Employee only $135.55 $108.98
Employee + Spouse $320.07 $258.87
Employee + Child(ren) $467.70 $378.78
Employee + Family $707.58 $573.63

Dental PPO
Employee only $13.86
Employee + Spouse $26.25
Employee + Child(ren) $26.42
Employee + Family $43.57

Vision
Employee only $3.79
Employee + Spouse $7.59
Employee + Child(ren) $7.78
Employee + Family $11.57

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.

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