Medical Plan Rates

Part-time .5-.59 FTE, Salaried 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	$190.08	$459.81	$597.89	$748.98
BlueLincs HMO	$154.90	$381.23	$498.63	$626.97
BlueEdge HCA	$175.59	$432.27	$563.11	$706.23
Community Care HMO (Tulsa Area)	$174.42	$430.05	$560.30	$702.77
TIER 2 ($15,000.01 to $21,000)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$199.26	$466.81	$615.39	$778.98
BlueLincs HMO	$157.90	$388.23	$516.13	$656.97
BlueEdge HCA	$184.77	$439.27	$580.61	$736.23
Community Care HMO (Tulsa Area)	$183.60	$437.05	$577.80	$732.77
TIER 3 ($21,000.01 to $30,000)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$204.16	$483.31	$638.39	$808.98
BlueLincs HMO	$162.80	$404.73	$539.13	$686.97
BlueEdge HCA	$189.67	$455.77	$603.61	$766.23
Community Care HMO (Tulsa Area)	$188.50	$453.55	$600.80	$762.77
TIER 4 ($30,000.01 to $50,000)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$209.16	$488.81	$661.39	$838.98
BlueLincs HMO	$167.80	$410.23	$562.13	$716.97
BlueEdge HCA	$194.67	$461.27	$626.61	$796.23
Community Care HMO (Tulsa Area)	$193.50	$459.05	$623.80	$792.77
TIER 5 ($50,000.01 to $92,500)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$218.66	$493.81	$685.89	$868.98
BlueLincs HMO	$177.30	$415.23	$586.63	$746.97
BlueEdge HCA	$204.17	$466.27	$651.11	$826.23
Community Care HMO (Tulsa Area)	$203.00	$464.05	$648.30	$822.77
TIER 6 ($92,500.01 and Above)	EMPLOYEE ONLY	EMPLOYEE AND CHILD(REN)	EMPLOYEE AND SPOUSE	EMPLOYEE AND FAMILY
BlueChoice PPO	$228.66	$497.81	$710.39	$893.98
BlueLincs HMO	$187.30	$419.23	$611.13	$771.97
BlueEdge HCA	$214.17	$470.27	$675.61	$851.23
Community Care HMO (Tulsa Area)	$213.00	$468.05	$672.80	$847.77