Page 26 - 2021 Team Member Benefit Guide - English

Medical Plans Rates

Bi-Weekly Payroll Deductions - PPO (Standard Plan)
Earning < $25k $25-39.9k $40-69.9k $70-99.9k $100k+
Employee Only 48.95 54.11 56.35 67.84 82.27
Employee + Spouse 137.48 155.63 162.80 197.79 254.23
Employee + Children 113.72 128.83 134.38 151.34 175.16
Employee + Family 168.13 188.10 205.19 229.62 291.92

Weekly Employee Payroll Deductions - PPO (Standard Plan)
Earning < $25k $25-39.9k $40-69.9k $70-99.9k $100k+
Employee Only 24.47 27.05 28.17 33.92 41.13
Employee + Spouse 68.74 77.81 81.40 98.90 127.11
Employee + Children 56.86 64.41 67.19 75.67 87.58
Employee + Family 84.06 94.05 102.59 114.81 145.96

Bi-Weekly Payroll Deductions - HSA Eligible HDHP (Consumer Plan)
Earning < $25k $25-39.9k $40-69.9k $70-99.9k $100k+
Employee Only 35.07 40.22 42.46 53.95 68.39
Employee + Spouse 108.30 126.46 133.63 168.61 225.05
Employee + Children 86.77 101.88 107.43 124.39 148.21
Employee + Family 124.64 144.62 161.70 186.14 248.44

Weekly Payroll Deductions - HSA Eligible HDHP (Consumer Plan)
Earning < $25k $25-39.9k $40-69.9k $70-99.9k $100k+
Employee Only 17.54 20.11 21.23 26.97 34.19
Employee + Spouse 54.15 63.23 66.81 84.30 112.52
Employee + Children 43.38 50.94 53.72 62.19 74.10
Employee + Family 62.32 72.31 80.85 93.07 124.22

Tobacco users pay an additional $23.08 biweekly or $11.54 weekly (applies to EACH of the
employee and spouse, if enrolled). Want to remove the Tobacco surcharge? Check out page 10.

Scott S. Baker,Component Sales Rep
25 New Hampton, IA
25