Employee Medical Rates Part-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 $251.64 $17.24 $344.94 $253.17 $91.77 $365.29 $253.17 $112.12 Employee & $537.74 $372.97 $164.77 $689.86 $308.04 $381.82 $730.56 $308.04 $422.52 Spouse Employee & $470.81 $337.73 $133.08 $603.99 $275.40 $328.59 $639.62 $275.40 $364.22 Child(ren) Family $672.18 $467.69 $204.49 $862.33 $400.37 $461.96 $913.21 $400.37 $512.84 Regular Annual Salary $51,000 to $149,999 Employee Only $268.88 $88.22 $180.66 $344.94 $49.63 $295.31 $365.29 $49.63 $315.66 Employee & $537.74 $341.20 $196.54 $689.86 $290.24 $399.63 $730.56 $290.24 $440.33 Spouse Employee & $470.81 $305.93 $164.87 $603.99 $257.58 $346.41 $639.62 $257.58 $382.04 Child(ren) Family $672.18 $420.03 $252.15 $862.33 $364.75 $497.58 $913.21 $364.75 $548.46 Regular Annual Salary $150,000+ Employee Only $268.88 $51.90 $216.98 $344.94 $10.00 $334.94 $365.29 $10.00 $355.29 Employee & $537.74 $257.22 $280.52 $689.86 $236.81 $453.05 $730.56 $236.81 $493.76 Spouse Employee & $470.81 $235.53 $235.28 $603.99 $221.94 $382.05 $639.62 $221.94 $417.68 Child(ren) Family $672.18 $319.03 $353.15 $862.33 $302.42 $559.91 $913.21 $302.42 $610.79 **Includes Flex Credit of $10 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 6