Medical Plan Rates

Part-time .6-.75 FTE, 9-month Appointed Active Employees

This is the amount that you will pay from each paycheck.

TIER 1 ($22,500 and Below)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$142.56	$492.84	$660.96	$844.10
BlueLincs HMO	$94.43	$374.97	$512.07	$661.08
BlueEdge HCA	$120.83	$451.53	$608.79	$779.97
Community Care HMO (Tulsa Area)	$119.07	$448.20	$604.58	$774.78

TIER 2 ($22,501 to $31,500)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$163.20	$508.59	$700.34	$911.60
BlueLincs HMO	$101.16	$390.72	$551.45	$728.58
BlueEdge HCA	$141.47	$467.28	$648.17	$847.47
Community Care HMO (Tulsa Area)	$139.71	$463.95	$643.95	$842.28

TIER 3 ($31,501 to $45,000)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$174.24	$545.72	$752.09	$979.10
BlueLincs HMO	$112.20	$427.85	$603.20	$796.08
BlueEdge HCA	$152.51	$504.41	$699.92	$914.97
Community Care HMO (Tulsa Area)	$150.75	$501.08	$695.70	$909.78

TIER 4 ($45,001 to $75,000)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$185.49	$558.09	$803.84	$1,046.60
BlueLincs HMO	$123.45	$440.22	$654.95	$863.58
BlueEdge HCA	$163.76	$516.78	$751.67	$982.47
Community Care HMO (Tulsa Area)	$162.00	$513.45	$747.45	$977.28

TIER 5 ($75,001 to $138,750)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$206.87	$569.34	$858.96	$1,114.10
BlueLincs HMO	$144.83	$451.47	$710.07	$931.08
BlueEdge HCA	$185.13	$528.03	$806.79	$1,049.97
Community Care HMO (Tulsa Area)	$183.38	$524.70	$802.58	$1,044.78

TIER 6 ($138,751 and Above)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$229.37	$578.34	$914.09	$1,170.35
BlueLincs HMO	$167.33	$460.47	$765.20	$987.33
BlueEdge HCA	$207.63	$537.03	$861.92	$1,106.22
Community Care HMO (Tulsa Area)	$205.88	$533.70	$857.70	$1,101.03