Employee Medical Rates Full-Time Employees: Semi-Monthly Rates $5,000 HDHP Plan $1,500 PPO Plan $500 PPO Plan Tier Total DMEI You Total DMEI You Total DMEI You Cost Pays Pay** Cost Pays Pay** Cost Pays Pay** Regular Annual Salary Up to $50,999 Employee Only $291.29 $308.00 -$16.72 $373.69 $373.31 $0.38 $395.74 $373.31 $22.43 Employee & $582.56 $495.87 $86.69 $747.35 $526.13 $221.22 $791.45 $526.13 $265.31 Spouse Employee & $510.04 $442.96 $67.08 $654.32 $466.61 $187.71 $692.93 $466.61 $226.32 Child(ren) Family $728.20 $617.33 $110.86 $934.19 $663.46 $270.73 $989.31 $663.46 $325.85 Regular Annual Salary $51,000 to $149,999 Employee Only $291.29 $278.59 $12.70 $373.69 $329.22 $44.47 $395.74 $329.22 $66.52 Employee & $582.56 $476.65 $105.91 $747.35 $515.67 $231.68 $791.45 $515.67 $275.78 Spouse Employee & $510.04 $423.58 $86.46 $654.32 $455.49 $198.83 $692.93 $455.49 $237.44 Child(ren) Family $728.20 $587.48 $140.72 $934.19 $641.97 $292.22 $989.31 $641.97 $347.34 Regular Annual Salary $150,000+ Employee Only $291.29 $263.73 $27.56 $373.69 $318.00 $55.69 $395.74 $318.00 $77.74 Employee & $582.56 $446.94 $135.62 $747.35 $482.04 $265.31 $791.45 $482.04 $309.41 Spouse Employee & $510.04 $399.10 $110.94 $654.32 $433.24 $221.08 $692.93 $433.24 $259.69 Child(ren) Family $728.20 $553.25 $174.95 $934.19 $602.73 $331.46 $989.31 $602.73 $386.58 **Includes Flex Credit of $21.67 per pay period Tobacco Use Surcharge: An additional $100 will apply to premiums if you or your eligible dependents use tobacco products. Contact HR to learn more about tobacco cessation options 5