Medical Plan Rates

Part-time .5-.59 FTE, Biweekly Active Employees

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

TIER 1 ($15,000 and Below)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$95.04	$229.91	$298.95	$374.49
BlueLincs HMO	$77.45	$190.62	$249.32	$313.49
BlueEdge HCA	$87.80	$216.14	$281.56	$353.12
Community Care HMO (Tulsa Area)	$87.21	$215.03	$280.15	$351.39

TIER 2 ($15,000.01 to $21,000)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$99.63	$233.41	$307.70	$389.49
BlueLincs HMO	$78.95	$194.12	$258.07	$328.49
BlueEdge HCA	$92.38	$219.64	$290.31	$368.12
Community Care HMO (Tulsa Area)	$91.80	$218.53	$288.90	$366.39

TIER 3 ($21,000.01 to $30,000)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$102.08	$241.66	$319.20	$404.49
BlueLincs HMO	$81.40	$202.37	$269.57	$343.49
BlueEdge HCA	$94.84	$227.89	$301.81	$383.12
Community Care HMO (Tulsa Area)	$94.25	$226.78	$300.40	$381.39

TIER 4 ($30,000.01 to $50,000)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$104.58	$244.41	$330.70	$419.49
BlueLincs HMO	$83.90	$205.12	$281.07	$358.49
BlueEdge HCA	$97.34	$230.64	$313.31	$398.12
Community Care HMO (Tulsa Area)	$96.75	$229.53	$311.90	$396.39

TIER 5 ($50,000.01 to $92,500)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$109.33	$246.91	$342.95	$434.49
BlueLincs HMO	$88.65	$207.62	$293.32	$373.49
BlueEdge HCA	$102.09	$233.14	$325.56	$413.12
Community Care HMO (Tulsa Area)	$101.50	$232.03	$324.15	$411.39

TIER 6 ($92,500.01 and Above)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$114.33	$248.91	$355.20	$446.99
BlueLincs HMO	$93.65	$209.62	$305.57	$385.99
BlueEdge HCA	$107.09	$235.14	$337.81	$425.62
Community Care HMO (Tulsa Area)	$106.50	$234.03	$336.40	$423.89