Rates 2006 - Dallas County by zhouwenjuan

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									                                                    2013 Employee Benefit Plan Rates
                                                             Dallas County
Except for optional life insurance premiums, benefit premiums are deducted from your paycheck on a pre-tax basis and are
shown on a per pay period basis. Optional life insurance is deducted on a post-tax basis. Optional life insurance rates (see #4
below) are shown as a monthly cost per $1000 of coverage.
1. Medical Per Pay Period Rates—Full Time Active Employees
                  Medical Option                           Employee Only                 Employee Plus                 Employee Plus           Employee Plus
                                                                                           Spouse                        Child(ren)               Family
                                                          Discount       Without      Discount       Without        Discount       Without    Discount     Without
If you are claiming the Non-Tobacco Use Discount,           Rate         Discount       Rate         Discount         Rate         Discount     Rate       Discount
refer to the rate shown in red (Discount Rate).                            Rate                        Rate                          Rate                    Rate

PPO Plan (UnitedHealthcare Choice Network)                $ 30.34                     $197.19                       $112.24                   $279.09
  One Tobacco User                                                      $ 53.42                      $220.27                    $135.32                   $302.17
  Two Tobacco Users (children count as 1)                                                            $243.35                    $158.40                   $325.25
  Three Tobacco Users (children count as 1)                                                                                                               $348.33

EPO Plan (UnitedHealthcare Choice Network)              $ 33.07                      $214.93                        $122.35                   $304.21
  One Tobacco User                                                      $ 56.15                      $238.01                    $145.43                   $327.29
  Two Tobacco Users (children count as 1)                                                            $261.09                    $168.51                   $350.37
  Three Tobacco Users (children count as 1)                                                                                                               $373.45
If you choose to Opt-Out of medical coverage, you must show proof of other comparable coverage and complete a “Certification of Other Coverage” form.
2. Dental Per Pay Period Rates—Full Time Active Employees
                   Dental Option                           Employee Only                 Employee Plus                 Employee Plus           Employee Plus
                                                                                           Spouse                        Child(ren)               Family
ANT Assurant DHMO Dental Plan                                 $ 5.94                        $ 10.13                       $ 13.36                  $ 17.07
PEB PEBC PPO Dental Plan (Delta Dental)                       $ 14.40                       $ 26.62                       $ 33.10                  $ 46.06

3. Vision Per Pay Period Rates—Full Time Active Employees
                    Vision Option                          Employee Only                 Employee Plus                 Employee Plus           Employee Plus
                                                                                           Spouse                        Child(ren)               Family
VIS VSP Choice Vision Plan                                    $ 2.84                        $ 5.31                        $ 5.66                   $ 8.82


4. Optional Term Life and AD&D Monthly Rate – to calculate pay period cost, multiply your calculated monthly cost x 12, divide by 26
              Your Age                        Monthly cost per $1,000                             Your Age                          Monthly cost per $1,000
Based on age at later of January 1, 2013   TLF Employee       SLF Spouse            Based on age at later of January 1, 2013   TLF Employee         SLF Spouse
      or coverage effective date                                                          or coverage effective date
                                             Term Life         Term Life                                                         Term Life           Term Life
              Under 30                        $   .09                $ .05                        50 – 54                            $ .35               $ .31
               30 – 34                        $   .11                $ .07                        55 – 59                            $ .53               $ .49
               35 – 39                        $   .13                $ .09                        60 – 64                            $ .87               $ .83
               40 – 44                        $   .17                $ .13                        65 – 69                            $1.41               $1.37
               45 – 49                        $   .24                $ .20                     70 and above                          $2.38               $2.34
Employee Term Life (TLF) cost is the same as spouse term life (SLF), except that TLF rates includes AD&D coverage of $.04/$1,000 for one times TLF coverage
amount. AD&D coverage is not available with Spouse Term Life. Evidence of Insurability (EOI) may be required. Check the Enrollment Guide for important
TLF, SLF and EOI information. Spouse (SLF) coverage can be in addition to DGL coverage (below).
5. Dependent Group Term Life Insurance
                                  DGL Option I                                                                       DGL Option II
        Spouse                                    $ 5,000                                    Spouse                                    $ 10,000
        Child(ren) Live birth up to age 25       $ 2,500                                     Child(ren) Live birth up to age 25        $ 5,000
       Per pay period cost is $ 0.49 regardless of the number                               Per pay period cost is $ .97 regardless of the number
                         of eligible children                                                                of eligible children

Evidence of Insurability (EOI) may be required. Check the Enrollment Guide for important EOI information. Select either DGL or SLF coverage or both.

                                                                                                                                                    Form 7-13AC-a

								
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