Page 6 - Test1

MEDICAL & PHARMACY COSTS
Plan A
Below are your 2019 pre-tax deductions for Plan A.
COMPLIANT TAKES HEALTH RISK ASSESSMENT
Employee Only
Employee + Spouse
Employee + Spousal Surcharge
Employee + Child
Employee + Children
Employee + Family
Family w/ Spousal Surcharge
Split Family
NOT A TOBACCO USER
$46
$401
$451
$192
$256
$605
$655
$213
$23
$200.50
$225.50
$95.79
$128
$302.50
$327.50
$106.50
$91
$446
$496
$236.58
$301
$650
$700
$258
TOBACCO USER
MONTHLY
PER CHECK DEDUCTIONS
MONTHLY
PER CHECK DEDUCTIONS
$45.50
$223
$248
$118.29
$150.50
$325
$350
$129
NON-COMPLIANT NO HEALTH RISK ASSESSMENT
Employee Only
Employee + Spouse
Employee + Spousal Surcharge
Employee + Child
Employee + Children
Employee + Family
Family w/ Spousal Surcharge
Split Family
NOT A TOBACCO USER
$91
$446
$496
$236.58
$301
$650
$700
$258
$45.50
$223
$248
$118.29
$150.50
$325
$350
$129
$136
$491
$541
$281.58
$346
$695
$745
$303
TOBACCO USER
MONTHLY
PER CHECK DEDUCTIONS
MONTHLY
PER CHECK DEDUCTIONS
$68
$245.50
$270.50
$140.79
$173
$347.50
$372.50
$151.50
Compliant:
No HRA/Non-Tobacco User:
HRA/Tobacco User: Non-Compliant:
Employee completed Biometric Screening, Health Risk Assessment, and Non-Tobacco User Attestation Form.
Employee did not complete Biometric Screening and/or Health Risk Assessment but completed Non-Tobacco User Attestation Form.
Employee completed Biometric Screening and Health Risk Assessment but did not complete Non-Tobacco User Attestation Form.
Employee did not complete Biometric Screening, Health Risk Assessment, and Non-Tobacco User Attestation Form.
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