Page 17 - Demo

Benefit Contributions - Medical
15
FULL-TIME AND PART-TIME (30 OR OR MORE HOURS PER WEEK)
Find the the the plan option (HSA HMO etc )
across the the the top and then scan down to to find your salary tier Your monthly contribution is is labeled “Employee Contribution ” The amount in the the next column to to the the right is is your total monthly premium The Company pays the difference Medical
Coverage Monthly Contribution Tier 1 ($39 999 and under)
Employee Employee/Spouse
Employee/Children $1 $1 071
HSA – OPTION 1 HSA – OPTION 2
BLUE ADVANTAGE HMO Total Premium
$1 690
Total Premium
$563 $1 183 $1 071
$1 690
Total Premium
$563 $1 183 $1 071
$1 690
Total Premium
$563 $1 183 $1 071
$1 690
Total Premium
$563 $1 183 $1 071
$1 690
Total Premium
$563 $1 183 $1 071
$1 690
Employee Contribution Total Premium
Employee Contribution Total Premium
Employee Contribution $37
$481
$28
$356
$44
$109
$1 012
$82
$748
$131
$90
$919
$66
$678
$105
$156
$1 447
$114
$1 067
$184
$563 $1 183 Employee/Family
Tobacco User Surcharge $50 Per Month Employee Employee/Spouse
Employee/Children Employee/Family
Tobacco User Surcharge $50 Per Month Employee Employee/Spouse
Employee/Children Employee/Family
Tobacco User Surcharge $75 Per Month Employee Employee/Spouse
Employee/Children Employee/Family
Tobacco User Surcharge $75 Per Month Employee Employee/Spouse
Employee/Children Employee/Family
Tobacco User Surcharge $75 Per Month Tier 2
($40 000 000 – $55 000)
Tier 3 ($55 001 – $75 000)
Tier 4
($75 001 – $150 000)
Tier 5
5
($150 001 and up)
Employee Contribution Total Premium
Employee Contribution Total Premium
Employee Contribution $67 $481
$48 $356
$72
$183
$1 012
$133
$748
$188
$144
$919
$107
$678
$155
$259
$1 447
$190
$1 067
$273
Employee Contribution Total Premium
Employee Contribution Total Premium
Employee Contribution $91 $481
$67 $356
$99
$233
$1 012
$172
$748
$247
$192
$919
$144
$678
$209
$333
$1 447
$247
$1 067
$357
Employee Contribution Total Premium
Employee Contribution Total Premium
Employee Contribution $108
$481
$81
$356
$117
$266
$1 012
$199
$748
$282
$224
$919
$167
$678
$243
$380
$1 447
$284
$1 067
$409
Employee Contribution Total Premium
Employee Contribution Total Premium
Employee Contribution $116
$481
$86
$356
$127
$283
$1 012
$211
$748
$301
$240
$919
$179
$678
$260
$404
$1 447
$300
$1 067
$436
Tier 6 (Executive Leadership Group - Vice Presidents and above)
Employee Employee/Spouse
Employee/Children Employee/Family
Tobacco User Surcharge $75 Per Month Employee Contribution Total Premium
Employee Contribution Total Premium
Employee Contribution $169
$481
$96
$356
$190
$410
$1 012
$302
$748
$452
$349
$919
$261
$678
$389
$585
$1 447
$430
$1 067
$654