MEDICAL CONTRIBUTION SCHEDULE
BRONZE HSA Plan
Employee Cost Per Pay Period
Employee Only
$ 57.50 $187.50 $137.50 $287.50
Employee + Spouse
Employee + Child(ren)
Family
Employee Cost Per Pay Period
SILVER
Employee Only
$100.00 $275.00 $225.00 $387.50
Employee + Spouse
Employee + Child(ren)
Family
Employee Cost Per Pay Period
GOLD
Employee Only
$137.50 $325.00 $275.00 $437.50
Employee + Spouse
Employee + Child(ren)
Family
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