Page 10 - Deweys Benefits Enrollments Guide

Employee per Pay Period

Contributions

The per pay period payroll deductions, based on bi-weekly (26) pay periods, are outlined below for the medical
plan based on Wellness and Standard/Non-Wellness participation.

BCBSNC Core Medical Plan with Wellness Participation
Rates per Pay Period
Employee Employee + Employee + Employee +

Only Spouse Child(ren) Family
$25.00 $105.08 $94.92 $214.92

BCBSNC Buy Up Medical Plan with Wellness Participation
Rates per Pay Period
Employee Employee + Employee + Employee +

Only Spouse Child(ren) Family
$69.00 $181.56 $228.02 $274.86

BCBSNC Core Medical Plan with Standard/Non-Wellness
Participation Rates per Pay Period
Employee Employee + Employee + Employee +

Only Spouse Child(ren) Family
$54.14 $155.07 $144.92 $264.92

BCBSNC Buy Up Medical Plan with Standard/Non-Wellness
Participation Rates per Pay Period

Employee Employee + Employee + Employee +
Only Spouse Child(ren) Family
$119.00 $221.55 $268.02 $314.86

In order to qualify for the reduced wellness medical rates above, a Wellness Program Participation Agreement
must be completed upon benefit eligibility or during subsequent annual enrollment periods. This agreement will
outline the parameters of the program and your intent to participate with the criteria throughout the plan year. If
you elect not to complete the Wellness Program Participation Agreement or do not satisfy your wellness
participation requirements, your medical plan deduction will be based on the Standard/Non-Wellness Participation
rates above.
-Tobacco Use Surcharge of $25.00 per pay period will apply if you have used tobacco products in the last 90 days.
Surcharge will only apply if you are covered under Dewey’s group medical plan. You may re-certify in December
2018 if you have ceased using tobacco products and surcharge may be removed in January 2019.

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