$ $ $ Employee and Children $ 189.98 $ 865.46 $ 1,055.44 176.82 805.50 982.32 $ $ Employee and Spouse $ 306.63 $ 1,026.54 $ 1,333.17 210.95 $ 1,029.91 1,240.86 $ Employee and Family $ 393.29 $ 1,245.42 $ 1,638.71 335.54 $ 1,189.65 $ 1,525.19 Tier 2 - $50,000.01-$100,000 Blue Options PPO Blue Edge HSA Employee Plan Share OU Share Rate Share OU Share Rate $ $ $ Employee Only $ 77.77 $ 477.75 $ 555.52 72.39 444.65 517.04 $ $ $ Employee and Children $ 284.97 $ 770.47 $ 1,055.44 245.58 736.74 982.32 $ $ Employee and Spouse $ 439.95 $ 893.22 $ 1,333.17 384.67 856.19 $ 1,240.86 $ Employee and Family $ 540.77 $ 1,097.94 $ 1,638.71 503.31 $ 1,021.88 $ 1,525.19 Tier 3 - $100,000.01 & Above Blue Options PPO Blue Edge HSA Employee Plan Share OU Rate Share OU Share Rate $ $ $ Employee Only $ 111.10 $ 444.42 $ 555.52 87.90 429.14 517.04 $ $ $ Employee and Children $ 316.63 $ 738.81 $ 1,055.44 275.05 707.27 982.32 $ $ Employee and Spouse $ 626.59 $ 706.58 $ 1,333.17 608.02 632.84 $ 1,240.86 $ $ Employee and Family $ 721.03 $ 917.68 $ 1,638.71 671.08 854.11 $ 1,525.19 Tobacco - Additional $20 per month added to above rates
Employee and Children $ 189.98 $ 865.46 $ 1,055.44 $ 176.82 $ 805.50 $ 982.32 Employee and Spouse $ 306.63 $ 1,026.54 $ 1,333.17 $ 210.95 $ 1,029.91 $ 1,240.86 Employee and Family $ 393.29 $ 1,245.42 $ 1,638.71 $ 335.54 $ 1,189.65 $ 1,525.19 Tier 2 - $50,000.01-$100,000 Blue Options PPO Blue Edge HSA Plan Employee Share OU Share Rate Share OU Share Rate Employee Only $ 77.77 $ 477.75 $ 555.52 $ 72.39 $ 444.65 $ 517.04 Employee and Children $ 284.97 $ 770.47 $ 1,055.44 $ 245.58 $ 736.74 $ 982.32 Employee and Spouse $ 439.95 $ 893.22 $ 1,333.17 $ 384.67 $ 856.19 $ 1,240.86 Employee and Family $ 540.77 $ 1,097.94 $ 1,638.71 $ 503.31 $ 1,021.88 $ 1,525.19 Tier 3 - $100,000.01 & Above Blue Options PPO Blue Edge HSA Plan Employee Share OU Rate Share OU Share Rate Employee Only $ 111.10 $ 444.42 $ 555.52 $ 87.90 $ 429.14 $ 517.04 Employee and Children $ 316.63 $ 738.81 $ 1,055.44 $ 275.05 $ 707.27 $ 982.32 Employee and Spouse $ 626.59 $ 706.58 $ 1,333.17 $ 608.02 $ 632.84 $ 1,240.86 Employee and Family $ 721.03 $ 917.68 $ 1,638.71 $ 671.08 $ 854.11 $ 1,525.19 Tobacco - Additional $20 per month added to above rates