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MEDICAL & VISION PLANS $250 ind/$750 fam ded, plus $2000 ind/$4000 fam out of pocket max, 15% office visit co‐pay, 15%/40% hospital co‐insurance 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months EMPLOYEE 714.68 714.68 300‐1 EMPLOYEE & SPOUSE 1,285.43 1,114.21 300‐2 EMPLOYEE & CHILDREN 1,142.74 1,014.32 300‐3 EMPLOYEE & FAMILY 1,713.49 1,413.85 300‐4 HEALTH SAVINGS ACCOUNT (HSA) & VISION PLANS Must Pay ALL of Ded 1st, then pays 15%/40% of medical, hospital, emergency room, prescriptions until total out of pocket is met. $1400 ind/$2800 fam ded, plus $4200/$8400 out of pocket max, 301‐11 5%/10%/$100 ded/30%/50%, $2000 OOP, Prescription Vision: No co‐pay on annual exam, $150 hardware every 24 months Contribution Limits: Under 55‐$3350 ind/$6750 fam. Over 55: $4350 ind/$7,700 fam EMPLOYEE 660.37 714.68 54.31 0.00 301‐1 EMPLOYEE & SPOUSE 1,171.52 1,114.21 0.00 57.31 301‐2 EMPLOYEE & CHILDREN 1,058.32 1,014.32 0.00 44.00 301‐3 EMPLOYEE & FAMILY 1,511.14 1,413.85 0.00 97.29 301‐4 143.93 302‐1 25.00 302‐90 50.00 302‐91 $50 deductible in‐network,100% Preventive, $1750 annual max, 80% basic, 50% major, adult & child orthodontia EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 2) WILLAMETTE or IN NETWORK ONLY ‐ Managed Care Plans, No Ded or General Max PREMIUM County Pays EMPLOYEE 0.00 0.00 EMPLOYEE & SPOUSE 0.00 0.00 EMPLOYEE & CHILDREN 0.00 0.00 EMPLOYEE & FAMILY 0.00 0.00 LIFE INSURANCE & AD & D Life & LTD Only Applicable only IF enrolled in Medical PREMIUM County Pays Employee $25,000 & Additional $5000 for accidental death 0.00 0.00 X LONG TERM DISABILITY (LTD) ‐ Standard Insurance Co. 0.00 0.00 X Mark DC Flexible Spending Account (FSA), Max $2,550 ‐ Plus Point FSA/DCR Fee $5.00 92‐95 $ 92‐5 Dependent Care Reimbursement (DCR) Max $2,500/$5,000 ‐ Plus Point 92‐15 VOLUNTARY ADD'L LIFE INSURANCE ‐ PEBB 312‐1 VOLUNTARY ADD'L DISABILITY PLAN ‐ PEBB 316‐1 MARK ONE EMPLOYEE PAYS EMPLOYEE PAYS MARK ONE EMPLOYEE PAYS 0.00 or, MARK ONE Selection Sheet for PEBB Insurance Deductions - Klickitat County Full Time - Effective January 1, 2016, premiums reflected on your Dec. 25th payroll check Go to the Web - Health Care Authority, Public Employees Benefits Board, for Benefit Descriptions at: Print Last Name: Signature: Emp No: www.hca.wa.gov/pebb Date: MARK ONE Ded Code Uniform Medical Plan (UMP) ‐ Classic Premium Includes: Dental, Vision, Life Insurance & EE LTD Coverage ‐ administered by Regence Emp HSA Contribution: County contributes 100% for Employee Medical, Dental, Vision, Life Insurance and LTD & COUNTY PAYS 0.00 I hereby authorize the deductions below and acknowledge that I have been informed of my COBRA rights. C h o o s e O n e P l a n 0.00 EMPLOYEE PAYS 171.22 128.42 299.64 0.00 C h o o s e O n e P l a n PREMIUM 70% of the Additional Cost for Dependent Medical, Dental, Vision and Life Insurance Coverage (County Pays an avg of 86%) Tobacco Surcharge: If you, or a dependent covered by the plan, use tobacco products PREMIUM MARK IF CONTRIB. TO HSA PREMIUM $ MARK ONE Ded Code COUNTY PAYS COUNTY PAYS 3) DELTA CARE (Group 3100) UMP Consumer‐Directed Health Plan (CDHP) (HSA) ‐ Premium Includes: Dental, Vision, Basic Life Insurance & EE LTD Coverage‐Regence EMPLOYEE PAYS Spouse or Dom. Partner Coverage Surcharge (go to Spousal Plan Calculator on the web) Waiver Fee: If you waive medical, you must be on dental, life & LTD COUNTY PAYS TO YOUR HSA Dental Plans You May Select One of the Following (place in small box) Employees can place dep on dental plans, without placing on medical. 1) Uniform Dental Plan (Group 3000) or All Self‐ Paid $ After 90 days being disabled, 60% of 1st $400 of current earnings. Min $50 & Max $240 per month 0.00 0.00 VOLUNTARY TAX SAVING PLANS OR ADDITIONAL INSURANCE SELECTION 0.00 Voya Life Insurance Company Amount 0.00 0.00 0.00 0.00 All Self‐ Paid All Self‐ Paid