Page 13 - 2015 OE Sample Guidebook
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MEDICAL PLAN CONTRIBUTIONS
Our plan design is focused on your well-being. When you enroll in the MEDICAL PLAN MONTHLY
medical plan, you must indicate whether or not you, your spouse (if CONTRIBUTIONS (WITH
you are married), or dependent are tobacco users. If you, your spouse, HEALTHY LIFESTYLE
or dependent currently are tobacco users, you can receive the Healthy CREDITS)
Lifestyle Credit if you, your spouse, and/or dependent successfully
complete a tobacco-cessation program or stop using tobacco products.
Option 1—HRA Plan Option 2—HSA Plan
Monthly Rates Medical with Dental Medical Only Medical with Dental Medical Only
Employee $ $ $ $
Employee + spouse $ $ $ $
Employee + 1 child $ $ $ $
Employee + 2 children $ $ $ $
Employee + 3 or more children $ $ $ $
Family + 1 child $ $ $ $
Family + 2 children $ $ $ $
Family + 3 or more children $ $ $ $
Healthy Lifestyle Credit
For tobacco users, the Healthy Lifestyle Credit does not apply. Add $75 per month for each tobacco user covered
on the plan as follows:
Employee Spouse Each Dependent
Tobacco user: discount does Tobacco user: discount does Tobacco user: discount does
not apply; add $75 per month to not apply; add $75 per month to not apply; add $75 per month to
discounted rate in the above table to discounted rate in the above table to discounted rate in the above table to
relect full premium relect full premium relect full premium
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Our plan design is focused on your well-being. When you enroll in the MEDICAL PLAN MONTHLY
medical plan, you must indicate whether or not you, your spouse (if CONTRIBUTIONS (WITH
you are married), or dependent are tobacco users. If you, your spouse, HEALTHY LIFESTYLE
or dependent currently are tobacco users, you can receive the Healthy CREDITS)
Lifestyle Credit if you, your spouse, and/or dependent successfully
complete a tobacco-cessation program or stop using tobacco products.
Option 1—HRA Plan Option 2—HSA Plan
Monthly Rates Medical with Dental Medical Only Medical with Dental Medical Only
Employee $ $ $ $
Employee + spouse $ $ $ $
Employee + 1 child $ $ $ $
Employee + 2 children $ $ $ $
Employee + 3 or more children $ $ $ $
Family + 1 child $ $ $ $
Family + 2 children $ $ $ $
Family + 3 or more children $ $ $ $
Healthy Lifestyle Credit
For tobacco users, the Healthy Lifestyle Credit does not apply. Add $75 per month for each tobacco user covered
on the plan as follows:
Employee Spouse Each Dependent
Tobacco user: discount does Tobacco user: discount does Tobacco user: discount does
not apply; add $75 per month to not apply; add $75 per month to not apply; add $75 per month to
discounted rate in the above table to discounted rate in the above table to discounted rate in the above table to
relect full premium relect full premium relect full premium
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