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MEDICAL & PHARMACY COSTS
Plan B
Below are your 2019 pre-tax deductions for Plan B.
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
$0
$277
$327
$120.51
$161
$425
$475
$153
$0
$138.50
$163.50
$61
$80.50
$212.50
$237.50
$76.50
$40
$317
$367
$160.51
$201
$465
$515
$193
TOBACCO USER
MONTHLY
PER CHECK DEDUCTIONS
MONTHLY
PER CHECK DEDUCTIONS
$20
$158.50
$183.50
$80.26
$100.50
$232.50
$257.50
$96.50
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
$40
$317
$367
$160.51
$201
$465
$515
$193
$20
$158.50
$183.50
$80.26
$100.50
$232.50
$257.50
$96.50
$80
$357
$407
$200.51
$241
$505
$555
$233
TOBACCO USER
MONTHLY
PER CHECK DEDUCTIONS
MONTHLY
PER CHECK DEDUCTIONS
$40
$178.50
$203.50
$100.26
$120.50
$252.50
$277.50
$116.50
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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