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Benefit Contributions - Medical 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 Employee $48 Employee/Spouse $139 Employee/Children $115 Employee/Family $206
Tobacco User Surcharge $50 Per Month Employee Total Contribution Premium
$51
$145
$120
$215
$653 $1 384 $1 258 $1 995
$46 $137 $110 $193
Employee $84 Employee/Spouse $240 Employee/Children $181 Employee/Family $331
Tobacco User Surcharge $50 Per Month Employee Total Contribution Premium
$90 $653 $260 $1 384 $194 $1 $1 258 $357 $1 995
Tier 3 ($55 001 – $75 000)
$87
$243
$190
$341
Employee $115 Employee/Spouse $305 Employee/Children $242 Employee/Family $426
Tobacco User Surcharge $75 Per Month Employee Total Contribution Premium
$124 $653 $332 $1 384 $260 $1 258 $460 $1 995
Tier 4 ($75 001 – $150 000)
$118 $306 $248 $432
Employee $137 Employee/Spouse $349 Employee/Children $282 Employee/Family $488
Tobacco User Surcharge $75 Per Month Employee Total Contribution Premium
$146 $653 $376 $1 384 $302 $1 258 $525 $1 995
Tier 5 5 ($150 001 and up)
$139 $348
$290
$494
Employee $146 Employee/Spouse $368 Employee/Children $302 Employee/Family $517
Tobacco User Surcharge $75 Per Month $157
$398
$324
$557
$653 $1 384 $1 258 $1 995
$152 $373 $311 $529
Employee Employee/Spouse Employee/Children Employee/Family Tobacco User Surcharge $75 Per Month HMO IL
Medical Coverage Monthly Contribution HMO HMO Blue Blue Texas & Blue Blue Choice Select PPO PPO PPO PPO Employee Contribution Premium
HMO-NM OK
Tier 1 ($39 999 and under)
Employee Employee Total Employee Employee Contribution Contribution Premium
Contribution Contribution Total Total Premium
Premium
Employee Total Total Contribution Premium
$570 $61 $655 $1 $1 $1 199 $172 $1 $1 $1 377 $1 $1 $1 087 $145
$1 $1 $1 249 $1 $1 712 $243
$1 $1 967
Total Total Premium
Premium
Employee Total Total Contribution Premium
$570 $115 $655 $1 $1 199 $309 $1 $1 377 $1 $1 087 $249 $1 $1 249 249 $1 $1 712 $439 $1 $1 967
Total Total Premium
Premium
Employee Total Total Contribution Premium
$570 $155 $655 $1 $1 199 $390 $1 $1 377 $1 $1 087 $327 $1 $1 249 $1 $1 712 $556 $1 $1 967
Total Total Premium
Premium
Employee Total Total Contribution Premium
$570 $182 $655 $1 $1 199 $446 $1 $1 377 $1 $1 087 $380 $1 $1 249 $1 $1 712 $639 $1 $1 967
Total Total Premium
Premium
Employee Total Total Contribution Premium
$570 $196 $655 $1 $1 199 $472 $1 $1 377 $1 $1 087 $407 $1 $1 249 $1 $1 712 $678 $1 $1 967
Total $597 $1 254 $1 134 $1 791
$597 $1 254 $1 134 $1 791
$597 $1 254 $1 134 $1 791
$597 $1 254 $1 134 $1 791
$597 $1 254 $1 134 $1 791
Tier 2 ($40 000 000 – $55 000)
Employee Employee Total Employee Employee Contribution Contribution Premium
Contribution Contribution Employee Employee Total Employee Employee Contribution Contribution Premium
Contribution Contribution Employee Employee Total Employee Employee Contribution Contribution Premium
Contribution Contribution Employee Employee Total Employee Employee Contribution Contribution Premium
Contribution Contribution Tier 6
(Executive Leadership Group - Vice Presidents and above)
Employee Employee Total Employee Employee Contribution Contribution Premium
Contribution Contribution Total Employee Premium
Contribution $653 $208 $1 384 $507 $1 258 $428 $1 995
$720
Total Total Premium
Premium
Employee Total Total Contribution Premium
$570 $268 $655 $1 $1 199 $627 $1 $1 377 $1 $1 087 $558 $1 $1 249 $1 $1 712 $900 $1 $1 967
$220 $597 $230 $524 $1 254 $549 $454 $1 134 $483 $777 $1 791
$813
(Illinois only)