MEDICAL CONTRIBUTION SCHEDULE
BRONZE HSA Plan
Employee Cost Per Pay Period
Employee Only
$ 28.75 $ 93.75 $ 68.75 $143.75
Employee + Spouse
Employee + Child(ren)
Family
Employee Cost Per Pay Period
SILVER
Employee Only
$ 50.00 $137.50 $112.50 $193.75
Employee + Spouse
Employee + Child(ren)
Family
GOLD Choice AQOI
Employee Cost Per Pay Period
Employee Only
$ 68.75 $162.50 $137.50 $218.75
Employee + Spouse
Employee + Child(ren)
Family
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