Page 7 - University of the South-2022-Benefit Guide REVISED 3.30.22 FSA WAIT PERIOD

2022 MONTHLY RATES

MEDICAL
PPO PLAN - OPTION 1
Salary Tier Employee Only Employee + Spouse Employee + Child(ren) Family
1 $14,820.00 - $19,999.00 $264.28 $528.55 $515.34 $792.83
2 $20,000.00 - $25,365.00 $267.06 $534.10 $520.76 $801.16
3 $25,366.00 - $39,999.00 $272.99 $545.99 $532.34 $818.98
4 $40,000.00 - $54,999.00 $285.10 $570.21 $555.95 $855.31
5 $55,000.00 - $69,999.00 $299.45 $598.90 $583.93 $898.35

6 $70,000.00 - $84,999.00 $320.20 $640.40 $624.39 $960.60
7 $85,000.00 - $124,999.00 $339.79 $679.59 $662.60 $1,019.38
8 $125,000.00 and above $357.84 $715.69 $697.80 $1,073.53
MEDICAL
HDHP PLAN - OPTION 2

Salary Tier Employee Only Employee + Spouse Employee + Child(ren) Family
1 $14,820.00 - $19,999.00 $118.22 $329.23 $321.00 $493.85
2 $20,000.00 - $25,365.00 $136.36 $335.05 $326.67 $502.58
3 $25,366.00 - $29,999.00 $170.56 $347.50 $338.81 $521.24
4 $30,000.00 - $39,999.00 $197.44 $394.88 $385.01 $592.32

5 $40,000.00 - $54,999.00 $211.86 $423.72 $413.12 $635.57
6 $55,000.00 - $69,999.00 $228.94 $457.88 $446.43 $686.82
7 $70,000.00 - $84,999.00 $253.64 $507.28 $494.60 $760.92
8 $85,000.00 - $124,999.00 $276.97 $553.93 $540.08 $830.90
9 $125,000.00 and above $298.45 $596.91 $581.99 $895.37

DENTAL
Salary Tier Employee Only Employee + Spouse Employee + Child(ren) Family

Not Applicable $28.52 $51.00 $52.58 $86.88

VISION
Salary Tier Employee Only Employee + Spouse Employee + Child(ren) Family
Not Applicable $7.57 $12.10 $12.36 $19.92

7