Page 8 - TNJH 2019 Benefits Guide

MEDICAL BI-WEEKLY PAYROLL CONTRIBUTIONS: NON-TOBACCO USER
Annual Salary Band Employees Earning < Employees Earning Employees Earning Employees Earning
$50K $50K BLT $75K $75K BLT $100K $100K & over
HEALTH FUND (HRA) PLAN
Employee $45.10 $64.97 $72.06 $102.76
Employee + Spouse $97.08 $183.09 $197.26 $248.06
Employee + Child(ren) $87.70 $131.11 $142.94 $178.37
Employee + Family $148.62 $230.34 $251.61 $289.40
HEALTH SAVINGS ACCOUNT (HSA) PLAN
Employee $49.66 $72.06 $79.15 $109.86
Employee + Spouse $110.49 $200.82 $214.99 $265.79
Employee + Child(ren) $94.12 $140.56 $154.74 $190.18
Employee + Family $200.64 $265.79 $287.04 $324.84

MEDICAL BI-WEEKLY PAYROLL CONTRIBUTIONS: TOBACCO USER
Annual Salary Band Employees Earning < Employees Earning Employees Earning Employees Earning
$50K $50K BLT $75K $75K BLT $100K $100K & over

HEALTH FUND (HRA) PLAN
Employee $55.20 $77.32 $85.01 $131.28
Employee + Spouse $118.83 $217.43 $233.17 $310.20
Employee + Child(ren) $107.34 $155.83 $168.80 $228.12
Employee + Family $181.91 $267.07 $288.78 $356.07
HEALTH SAVINGS ACCOUNT (HSA) PLAN
Employee $60.79 $85.64 $93.63 $127.11
Employee + Spouse $122.83 $216.96 $232.18 $285.78
Employee + Child(ren) $106.14 $155.51 $170.74 $209.04
Employee + Family $214.79 $283.24 $305.69 $346.41

DENTAL BI-WEEKLY PAYROLL CONTRIBUTIONS
COVERAGE TIER DENTAL PPO PLAN DHMO PLAN
Employee $16.70 No Charge
Employee + Spouse $34.29
Employee + Child(ren) $41.52
Employee + Family $65.84

VISION BI-WEEKLY PAYROLL CONTRIBUTIONS
COVERAGE TIER VISION PLAN
Employee $2.64
Employee + Spouse $4.88
Employee + Child(ren) $5.15
Employee + Family $7.63

HYATT LEGAL BI-WEEKLY PAYROLL
CONTRIBUTIONS (24 PAY PERIODS)
COVERAGE TIER HYATT LEGAL PLAN
Employee $9.75

Your Benefits Guide 8
2019