Group Name:

HMO 25/40A

HMO 20A

HMO 25/40

HMO 20

HMO 25/40 Plus

HMO 20 Plus

POS 25/40 2000A

POS 20/2000

POS 25/40 2000

POS 20/1000

POS 25/40 1000 Plus

POS 20/500

2 Tier 4 Tier

CS EPO 40/1000A

CS EPO 40/2000

CS EPO 40/1000

CS EPO 30/1000

CS EPO 30/500

CS PPO 30/2000

CS PPO 30/2000A

EPO 40/1000

EPO 30/1000A

EPO 30/1000

EPO 30/500

EPO 20A

EPO 20

PPO 30/1000

PPO 25/1000

PPO 20/500

2 Tier 4 Tier

3 Tier

EPO 30/50 1000A Select

EPO 30/50 1000 Select

EPO 25/1000 Select

EPO 15/1000 Select

PPO 15/1000 Select

PPO 30/50 1000 Select

PPO 25/1000 Select

HMO Super Value

HMO 25/40A

HMO Value

HMO 20

HMO 5

HMO 15

HMO 10

POS 20/1000

2 Tier 3 Tier 4 Tier

Direct Access HMO 20

Direct Access HMO 15

Direct Access HMO 10

POS 20/1000

POS 15/500

POS 10/250

2 Tier 3 Tier 4 Tier

POS 20/2000 HRA Option #1

POS 20/2000 HRA Option #2

POS 20/2000 HRA Option #3

POS 20/2000 HRA Option #4

4 Tier

HSA High Deductible EPO Option #1

HSA High Deductible EPO Option #2

HSA High Deductible EPO Option #3

HSA High Deductible EPO Option #4

HSA High Deductible PPO Option #1

HSA High Deductible PPO Option #2

HSA High Deductible PPO Option #3

HSA High Deductible PPO Option #4

2 Tier 4 Tier

PPO HSA PLAN 22P

PPO HSA PLAN 30P

PPO HSA PLAN 22G (Renewals Only)

PPO HSA PLAN 29G (Renewals Only)

4 Tier

 

	# Employees	Monthly Employer Contribution
EE Only:
EE + Spouse /EE + One:
EE + Child(ren):
Family:

 
Select Pay Period: Monthly Bi-Monthly Every 2 weeks Weekly  Percentage Contributions: No Yes
 

Proposal	Rate Sheet	Proposal & Rate Sheet
Show Money Funded into HSA: yes    no