MEDICAL CONTRIBUTION SCHEDULE
LOW BlueCare 15572 (HSA)
HIGH BlueCare 14256 (All Copay)
Employee Cost Per Pay Period (24)
Employee Only
$ 48.43
$110.02
Employee + Spouse
$242.13
$365.31
Employee + Child(ren)
$213.07
$327.01
Family
$406.77
$582.30
4
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