MEDICAL CONTRIBUTION SCHEDULE
HDHP Plan Options, compatible with a Health Savings Account (H.S.A)
BlueCare 126/127 FBA 201/202 HMO H.S.A
Employee Pays Semi-Monthly
Employee Only
$46.47
Employee + Spouse
$216.57
Employee + Child(ren)
$160.80 $335.08
Family
BlueOptions 0314/0315 FBA 105/160 PPO H.S.A.
Employee Pays Semi-Monthly
Employee Only
$49.94
Employee + Spouse
$149.56 $104.62 $245.07
Employee + Child(ren)
Family
BlueOptions 0212/0213 FBA 103/104 PPO H.S.A.
Employee Pays Semi-Monthly
Employee Only
$57.60
Employee + Spouse
$226.10 $197.40 $412.09
Employee + Child(ren)
Family
Employer Health Savings Account (H.S.A) Contribution
Employee Only
$750.00
Employee & Dependent(s)
$1,500.00
Copay Plan Options
BlueOptions 0307 FBA 004 PPO
Employee Pays Semi-Monthly
Employee Only
$71.20
Employee + Spouse
$331.80 $246.36 $513.36
Employee + Child(ren)
Family
BlueCare 0402 FBA 305 HMO
Employee Pays Semi-Monthly
Employee Only
$46.47
Employee + Spouse
$216.55 $160.78 $335.04
Employee + Child(ren)
Family
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