Page 17 - HCSC2019EG

Benefit Contributions - Medical
15
FULL-TIME AND PART-TIME (30 OR MORE HOURS PER WEEK)
Find the plan option (HSA, HMO, etc.) across the top and then scan down to find your salary tier. Your monthly contribution is labeled “Employee Contribution.” The amount in the next column to the right is your total monthly premium. The Company pays the difference.
Medical Coverage Monthly Contribution
Tier 1 ($39,999 and under)
Employee
Employee/Spouse
Employee/Children $1,071
HSA – OPTION 1
HSA – OPTION 2
BLUE ADVANTAGE HMO
Total Premium
$1,690
Total Premium
$563 $1,183 $1,071 $1,690
Total Premium
$563 $1,183 $1,071 $1,690
Total Premium
$563 $1,183 $1,071 $1,690
Total Premium
$563 $1,183 $1,071 $1,690
Total Premium
$563 $1,183 $1,071 $1,690
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Contribution
$37
$481
$28
$356
$44
$109
$1,012
$82
$748
$131
$90
$919
$66
$678
$105
$156
$1,447
$114
$1,067
$184
$563 $1,183
Employee/Family
Tobacco User Surcharge $50 Per Month
Employee
Employee/Spouse
Employee/Children
Employee/Family
Tobacco User Surcharge $50 Per Month
Employee
Employee/Spouse
Employee/Children
Employee/Family
Tobacco User Surcharge $75 Per Month
Employee
Employee/Spouse
Employee/Children
Employee/Family
Tobacco User Surcharge $75 Per Month
Employee
Employee/Spouse
Employee/Children
Employee/Family
Tobacco User Surcharge $75 Per Month
Tier 2 ($40,000 – $55,000)
Tier 3 ($55,001 – $75,000)
Tier 4 ($75,001 – $150,000)
Tier 5 ($150,001 and up)
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Contribution
$67
$481
$48
$356
$72
$183
$1,012
$133
$748
$188
$144
$919
$107
$678
$155
$259
$1,447
$190
$1,067
$273
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Contribution
$91
$481
$67
$356
$99
$233
$1,012
$172
$748
$247
$192
$919
$144
$678
$209
$333
$1,447
$247
$1,067
$357
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Contribution
$108
$481
$81
$356
$117
$266
$1,012
$199
$748
$282
$224
$919
$167
$678
$243
$380
$1,447
$284
$1,067
$409
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Contribution
$116
$481
$86
$356
$127
$283
$1,012
$211
$748
$301
$240
$919
$179
$678
$260
$404
$1,447
$300
$1,067
$436
Tier 6 (Executive Leadership Group - Vice Presidents and above)
Employee
Employee/Spouse
Employee/Children
Employee/Family
Tobacco User Surcharge $75 Per Month
Employee Contribution
Total Premium
Employee Contribution
Total Premium
Employee Contribution
$169
$481
$96
$356
$190
$410
$1,012
$302
$748
$452
$349
$919
$261
$678
$389
$585
$1,447
$430
$1,067
$654