Premiums

• Medical

  ENROLLMENT TIER	LOW PLAN		HIGH PLAN
  Full-Time Premiums (Pre-Tax)	Monthly	Biweekly	Monthly	Biweekly
  Employee Only	$115	$53	$235	$108
  Employee and Spouse	$368	$170	$631	$291
  Employee and Child	$241	$111	$412	$190
  Employee and Children	$321	$148	$549	$253
  Family	$466	$215	$796	$367
  Part-Time Premiums (Pre-Tax)	Monthly	Biweekly	Monthly	Biweekly
  Employee Only	$603.64	$278.60	$694.37	$320.48
  Employee and Spouse	$1,388.38	$640.79	$1,597.05	$737.10
  Employee and Child	$905.46	$417.90	$1,041.56	$480.72
  Employee and Children	$1,207.28	$557.21	$1,388.74	$640.96
  Family	$1,750.56	$807.95	$2,013.67	$929.39

• Dental

  ENROLLMENT TIER	LOW PLAN		HIGH PLAN
  Full-Time Premiums (Pre-Tax)	Monthly	Biweekly	Monthly	Biweekly
  Employee Only	$18	$8.25	$34	$16
  Employee and Spouse	$38	$18	$68	$31
  Employee and Child	$32	$15	$55	$25
  Employee and Children	$41	$19	$71	$33
  Family	$59	$27	$106	$49
  Part-Time Premiums (Pre-Tax)	Monthly	Biweekly	Monthly	Biweekly
  Employee Only	$26.72	$12.33	$48.35	$22.32
  Employee and Spouse	$56.35	$26.01	$100.65	$46.45
  Employee and Child	$45.39	$20.95	$80.33	$37.08
  Employee and Children	$60.71	$28.02	$104.18	$48.08
  Family	$86.79	$40.06	$154.24	$71.19

• Vision

  Enrollment Tier	Monthly	Biweekly
  Employee Only	$6.18	$2.85
  Employee and One Dependent	$11.96	$5.52
  Family	$17.58	$8.12

• Flexible Spending

  MAXIMUM CONTRIBUTION LEVELS
  Health Care FSA	$2,850/ per employee
  Dependent Care FSA	$5,000/ per employee

• Legal

  Enrollment Tier	Monthly	Biweekly
  Ultimate Advisor	$18.25	$8.42
  Ultimate Advisor Plus	$22.00	$10.15

• Voluntary Life Insurance

  Rates per $1,000
  Age	Monthly	Biweekly
  Less than 25	$0.06	$0.03
  25-29	$0.07	$0.03
  30-34	$0.09	$0.04
  35-39	$0.10	$0.05
  40-44	$0.11	$0.05
  45-49	$0.17	$0.08
  50-54	$0.25	$0.12
  55-59	$0.47	$0.22
  60-64	$0.73	$0.34
  65-69	$1.40	$0.65
  70-74	$2.27	$1.05
  75 and older	$3.40	$1.57

• Voluntary Dependent Life Insurance

  Option	Benefit	Monthly Premium	Biweekly Premium
  Option 1 – Spouse and Children	$25,000/$10,000	$5.25	$2.42
  Option 2 – Spouse and Children	$10,000/$5,000	$2.25	$1.04
  Option 3 – Spouse	$25,000	$4.05	$1.87
  Option 4 – Children	$10,000	$1.20	$0.55
  Option 5 – Spouse	$10,000	$1.65	$0.76
  Option 6 – Children	$5,000	$0.60	$0.28

• Accident Plan

  Enrollment Tier	Full & Part-Time Monthly Faculty & Staff	Full & Part-Time Biweekly Faculty & Staff
  Employee Age 18-75	$17.29	$7.98
  Employee and Spouse Age 18-75	$24.57	$11.34
  One-Parent Family Age 18-75	$29.25	$13.50
  Two-Parent Family Age 18-75	$38.22	$17.64

• Specified Health Event Plan

  Enrollment Tier	Full & Part-Time Monthly Faculty & Staff	Full & Part-Time Biweekly Faculty & Staff
  Employee Age 18-35	$11.70	$5.40
  Employee Age 36-45	$18.85	$8.70
  Employee Age 46-55	$25.35	$11.70
  Employee Age 56-64	$32.89	$15.18
  One-Parent Family Age 18-35	$12.87	$5.94
  One-Parent Family Age 36-45	$19.63	$9.06
  One-Parent Family Age 46-55	$26.13	$12.06
  One-Parent Family Age 56-64	$33.80	$15.60
  Two-Parent Family Age 18-35	$20.28	$9.36
  Two-Parent Family Age 36-45	$33.54	$15.48
  Two-Parent Family Age 46-55	$46.67	$21.54
  Two-Parent Family Age 56-64	$63.96	$29.52
  Employee and Spouse Age 18-35	$18.07	$8.34
  Employee and Spouse Age 36-45	$30.94	$14.28
  Employee and Spouse Age 46-55	$43.68	$20.16
  Employee and Spouse Age 56-64	$60.32	$27.84

• Cancer Plan

  Enrollment Tier	Full & Part-Time Monthly Faculty & Staff	Full & Part-Time Biweekly Faculty & Staff
  Employee Age 18-75	$38.48	$17.76
  Employee and Spouse Age 18-75	$68.64	$31.68
  One-Parent Family Age 18-75	$38.48	$17.76
  Two-Parent Family Age 18-75	$68.64	$31.68

Retiree Premiums

• Retiree Medical

  ENROLLMENT TIER	LOW PLAN	HIGH PLAN
  Retirees (under 65) &  Dependents on BCBS Medical
  Retiree Only	$473.14	$557.33
  Surviving Spouse Only	$560.14	$644.33
  Retiree and Spouse	$1,288.33	$1,481.97
  Retiree on BCBS, Spouse on OneExchange	$473.14	$557.33
  Retiree on OneExchange, Spouse on BCBS	$560.14	$644.33
  Retiree on OneExchange, Spouse & Child on BCBS	$840.22	$966.50
  Retiree on OneExchange, Spouse & Children on BCBS	$1,120.29	$1,288.67
  Retiree on OneExchange, Child on BCBS	$280.07	$322.17
  Retiree on OneExchange, Children on BCBS	$560.14	$644.33

• Retiree Dental

  ENROLLMENT TIER	LOW PLAN	HIGH PLAN
  Retiree or Surviving Spouse Only	$25.32	$45.83
  Retiree and Spouse	$53.41	$95.40
  Retiree and Child	$43.03	$76.15
  Retiree and Children	$57.55	$98.75
  Family	$82.26	$146.21

• Retiree Vision

  ENROLLMENT TIER	Premium
  Retiree or Surviving Spouse Only	$6.18
  Retiree and Spouse	$11.96
  Family	$17.58

COBRA Premiums

• COBRA Medical (January 1 – December 31, 2021)

  Medical

  ENROLLMENT TIER	LOW PLAN	HIGH PLAN
  Employee Only	$571.35	$657.22
  Employee and Spouse	$1,314.10	$1,511.61
  Employee and Child	$857.02	$985.83
  Employee and Children	$1,142.69	$1,314.44
  Family	$1,656.90	$1,905.94

• COBRA Dental (January 1 – December 31, 2021)

  ENROLLMENT TIER	LOW PLAN	HIGH PLAN
  Employee Only	$25.83	$46.75
  Employee and Spouse	$54.48	$97.31
  Employee and Child	$43.89	$77.67
  Employee and Children	$58.70	$100.73
  Family	$83.91	$149.13

• COBRA Vision

  ENROLLMENT TIER	Premium
  Employee Only	$6.30
  Employee and One Dependent	$12.20
  Family	$17.93