Employee Medical Rates Full-Time Employees: Bi-Weekly 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 $268.88 $284.31 -$15.43 $344.94 $344.59 $0.35 $365.29 $344.59 $20.70 Employee & $537.74 $457.73 $80.02 $689.86 $485.66 $204.20 $730.56 $485.66 $244.90 Spouse Employee & $470.81 $408.89 $61.92 $603.99 $430.72 $173.27 $639.62 $430.72 $208.90 Child(ren) Family $672.18 $569.85 $102.33 $862.33 $612.42 $249.91 $913.21 $612.42 $300.79 Regular Annual Salary $51,000 to $149,999 Employee Only $268.88 $257.16 $11.72 $344.94 $303.89 $41.05 $365.29 $303.89 $61.40 Employee & $537.74 $439.98 $97.76 $689.86 $476.00 $213.86 $730.56 $476.00 $254.56 Spouse Employee & $470.81 $391.00 $79.81 $603.99 $420.45 $183.54 $639.62 $420.45 $219.17 Child(ren) Family $672.18 $542.29 $129.89 $862.33 $592.59 $269.74 $913.21 $592.59 $320.62 Regular Annual Salary $150,000+ Employee Only $268.88 $243.44 $25.44 $344.94 $293.54 $51.40 $365.29 $293.54 $71.75 Employee & $537.74 $412.55 $125.19 $689.86 $444.96 $244.90 $730.56 $444.96 $285.60 Spouse Employee & $470.81 $368.40 $102.41 $603.99 $399.91 $204.08 $639.62 $399.91 $239.71 Child(ren) Family $672.18 $510.69 $161.49 $862.33 $556.37 $305.96 $913.21 $556.37 $356.84 **Includes Flex Credit of $20.00 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 4