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14 / 19

1

$

11.02

$

209.29

$

110.15

$

110.15

2

$

22.03

$

418.58

$

220.30

$

220.30

3

$

19.39

$

368.33

$

193.86

$

193.86

4

$

30.40

$

577.63

$

304.02

$

304.02

1

$

12.98

$

246.56

$

129.77

$

129.77

2

$

25.95

$

493.11

$

259.53

$

259.53

3

$

22.84

$

433.93

$

228.39

$

228.39

4

$

35.82

$

680.49

$

358.15

$

358.15

1

$

13.88

$

247.20

$

130.54

$

130.54

2

$

27.77

$

494.40

$

261.08

$

261.08

3

$

24.44

$

435.07

$

229.75

$

229.75

4

$

38.32

$

682.27

$

360.30

$

360.30

1

$

13.88

$

247.20

$

130.54

$

130.54

2

$

27.77

$

494.40

$

261.08

$

261.08

3

$

24.44

$

435.07

$

229.75

$

229.75

4

$

38.32

$

682.27

$

360.30

$

360.30

1

$

13.88

$

247.20

$

130.54

$

130.54

2

$

27.77

$

494.40

$

261.08

$

261.08

3

$

24.44

$

435.07

$

229.75

$

229.75

4

$

38.32

$

682.27

$

360.30

$

360.30

1

$

8.96

$

170.19

$

89.57

$

89.57

2

$

20.60

$

391.44

$

206.02

$

206.02

3

$

17.02

$

323.33

$

170.18

$

170.18

4

$

24.19

$

459.51

$

241.85

$

241.85

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

Part-time employees hired after 1/1/2000 (1/1/2002 for MSEA represented bargaining units A02 and A31) whose regular work schedule is 40 hours or less per biweekly pay period pay premiums according to column (d).

2

Health, dental and vision option codes are: 1 = Employee only coverage, 2 = Employee & Spouse, 3 = Employee & Child(ren), 4 = Full Family.

3

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. 14

Priority Health Plan, South

State Vision Plan

Decline Vision Insurance

State Dental Plan

Preventive Dental Plan Employees in the Preventive Dental plan will receive

a $100.00 lump sum payment on October 27, 2011.

Midwestern Dental Plan (DMO)

Decline Dental Insurance

3

(n/a)

(n/a)

(n/a)

(n/a)

(n/a)

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

Priority Health Plan, East

VISION PLANS

Priority Health Plan, West

(n/a)

Physicians Health Plan

(n/a)

Civil Service Commission, Employee Benefits Division

(n/a)

(n/a) DENTAL PLANS

(n/a)

FY 2011-2012 GROUP INSURANCE PREMIUM RATES FOR EMPLOYEES HIRED PRIOR TO APRIL 1, 2010, EFFECTIVE OCTOBER 2, 2011 For Bargaining Units: MSEA (A02, A31), MCO (C12), AFSCME (U11)

PLAN NAME/CODE McLaren Health Plan

BIWEEKLY

BIWEEKLY Part-time employees 1

Employee

State

(d)

(e)

State

(c)

2

e

Option

(a)

Employe

(b)

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