Page 26 - QSC Benefit Summary 7-18 SO CALIFORNIA

YOUR COST FOR COVERAGE

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

BIWEEKLY RATES

Best Discounted Rates Standard Rates
Medical with All Incentives with No Incentives
Medical Option 1
Choice Fund OAP HSA PPO
Employee Only $35.00 $104.00
Employee + Spouse $143.00 $212.00
Employee + Child(ren) $88.00 $157.00
Employee + Family $185.00 $254.00
Medical Option 2
HMO Select Narrow Network
Employee Only $37.00 $106.00
Employee + Spouse $129.00 $198.00
Employee + Child(ren) $74.00 $143.00
Employee + Family $166.00 $235.00
Medical Option 3
HMO Full Network
Employee Only $58.00 $127.00
Employee + Spouse $162.00 $231.00
Employee + Child(ren) $115.00 $185.00
Employee + Family $208.00 $277.00
Medical Option 4
OAP PPO
Employee Only $69.00 $138.00
Employee + Spouse $203.00 $272.00
Employee + Child(ren) $150.00 $219.00
Employee + Family $249.00 $318.00

Best Discounted Medical Rates
The following are biweekly incentives offered to provide a discount to the Standard Rates. If you are a tobacco user and did
not obtain a biometric screening, you will receive the standard rate.

Wellness Incentives
No Biometric Screening | Tobacco User See Standard Rates with No Incentives Above
With Biometric Screening | Tobacco User Up to $12 Credit to Standard Rates with No Incentives
No Biometric Screening | Non-Tobacco User Up to $23 Credit to Standard Rates with No Incentives
With Biometric Screening | Non-Tobacco User Up to $70 Credit to Standard Rates with No Incentives
See Best Discounted Rates with All Incentives

QSC wants to help you take charge of your health. Incentive rewards are available to all employees who successfully obtain
the wellness incentives noted above. If it is medically inadvisable for you to achieve the standards of the program, we will
work with you and your doctor to find an alternative plan that is right for you.

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