Page 25 - QSC Benefits Guide 7-17 COLORADO

YOUR COST FOR COVERAGE - PER PAYCHECK

This chart compares the per paycheck contributions for our Employee Benefit plans. Your cost for coverage will vary depending
on the options and level of coverage you choose.

Medical Option 1 - HMO - Cigna
Non-Tobacco Non-Tobacco with Tobacco Tobacco with
Standard Biometric Screening Standard Biometric Screening
Employee Only $60.00 $50.00 $105.00 $75.00
Employee + Spouse $160.00 $135.00 $205.00 $160.00
Employee + Child(ren) $115.00 $95.00 $160.00 $120.00
Employee + Family $200.00 $170.00 $245.00 $195.00

Medical Option 2 - OAP PPO - Cigna

Non-Tobacco Non-Tobacco with Tobacco Tobacco with
Standard Biometric Screening Standard Biometric Screening
Employee Only $90.00 $65.00 $135.00 $90.00
Employee + Spouse $215.00 $170.00 $260.00 $195.00
Employee + Child(ren) $170.00 $130.00 $215.00 $155.00
Employee + Family $290.00 $210.00 $335.00 $235.00

Medical Option 3 - Choice Fund OAP HSA PPO - Cigna
Non-Tobacco Non-Tobacco with Tobacco Tobacco with
Standard Biometric Screening Standard Biometric Screening
Employee Only $55.00 $40.00 $100.00 $65.00
Employee + Spouse $165.00 $130.00 $210.00 $155.00
Employee + Child(ren) $110.00 $95.00 $155.00 $120.00
Employee + Family $210.00 $175.00 $255.00 $200.00

Note
You have the option for your Medical, HSA, Vision, Dental and Flexible Spending Account premiums to be deducted from
your paycheck on a pre-tax or post-tax basis. If you elect pre-tax, your premiums will be deducted from your paycheck
before federal (and in some cases, state) income and Social Security taxes are deducted, thereby lowering your taxes and
increasing the amount of your take-home pay.

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