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12 / 19

1

$

11.07

$

210.34

$

110.70

$

110.70

2

$

22.14

$

420.67

$

221.40

$

221.40

3

$

19.48

$

370.17

$

194.82

$

194.82

4

$

30.55

$

580.52

$

305.54

$

305.54

1

$

13.01

$

247.17

$

130.09

$

130.09

2

$

26.02

$

494.35

$

260.18

$

260.18

3

$

22.90

$

435.02

$

228.96

$

228.96

4

$

35.91

$

682.20

$

359.05

$

359.05

1

$

15.26

$

248.44

$

131.85

$

131.85

2

$

30.52

$

496.87

$

263.70

$

263.70

3

$

26.86

$

437.25

$

232.05

$

232.05

4

$

42.10

$

685.68

$

363.89

$

363.89

1

$

15.26

$

248.44

$

131.85

$

131.85

2

$

30.52

$

496.87

$

263.70

$

263.70

3

$

26.86

$

437.25

$

232.05

$

232.05

4

$

42.10

$

685.68

$

363.89

$

363.89

1

$

15.26

$

248.44

$

131.85

$

131.85

2

$

30.52

$

496.87

$

263.70

$

263.70

3

$

26.86

$

437.25

$

232.05

$

232.05

4

$

42.10

$

685.68

$

363.89

$

363.89

1

$

9.00

$

171.04

$

90.02

$

90.02

2

$

20.71

$

393.39

$

207.05

$

207.05

3

$

17.10

$

324.98

$

171.04

$

171.04

4

$

24.31

$

461.81

$

243.06

$

243.06

1

$

1.08

$

20.48

$

10.78

$

10.78

2

$

1.97

$

37.38

$

19.67

$

19.67

3

$

2.40

$

45.52

$

23.96

$

23.96

4

$

3.28

$

62.36

$

32.82

$

32.82

1

$

0

$

2.99

$

1.50

$

1.50

2

$

0

$

5.21

$

2.61

$

2.61

3

$

0

$

5.21

$

2.61

$

2.61

4

$

0

$

7.42

$

3.71

$

3.71

1

$

0

$

15.99

$

8.00

$

8.00

2

$

0

$

15.99

$

8.00

$

8.00

3

$

0

$

15.99

$

8.00

$

8.00

4

$

0

$

15.99

$

8.00

$

8.00

Total Health Care

1

$

0

$

2.80

$

1.40

$

1.40

2

$

0

$

4.93

$

2.46

$

2.46

3

$

0

$

6.02

$

3.01

$

3.01

4

$

0

$

8.16

$

4.08

$

4.08

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

Priority Health Plan, East This HMO is not authorized to accept employees in bargaining units W22 and W41 (UAW) in some zip codes as new members.

Priority Health Plan, South

12

Priority Health Plan, West

Preventive Dental Plan Employees in the Preventive Dental plan will receive a $100.00 lump sum payment on October 27, 2011.

State Vision Plan

Decline Vision Insurance

State Dental Plan

VISION PLANS

DENTAL PLANS

Civil Service Commission, Employee Benefits Division

Midwestern Dental Plan (DMO)

FY 2011-2012 GROUP INSURANCE PREMIUM RATES FOR EMPLOYEES HIRED PRIOR TO APRIL 1, 2010, EFFECTIVE OCTOBER 2, 2011

Decline Dental Insurance

3

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

1 BIWEEKLY Part-time employees

1 2 3

Part-time employees hired after 1/1/2000 whose regular work schedule is 40 hours or less per biweekly pay period pay premiums according to column (d). Health, dental and vision option codes are: 1 = Employee only coverage, 2 = Employee & Spouse, 3 = Employee & Child(ren), 4 = Full Family. Employees who opt out of dental coverage (because they have “primary” coverage through a non-State employee or non-State retired spouse) will receive a rebate identical to the Preventive Dental Plan.

Employee

State

(d)

(e)

For Bargaining Units: NERE, UAW (W22, W41), SEIU 517M (E42, H21, L32)

PLAN NAME/CODE McLaren Health Plan

This HMO is not authorized to accept employees in bargaining units W22 and W41 (UAW) as new members.

Physicians Health Plan

BIWEEKLY

State

(c)

2

Employee

(b)

Option

(a)

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