Salary: $250,000 and above
Medical plan coverege level: Employee + spouse

Calculate the deduction from your paycheck		Health Plan Options Monthly Employee Contribution HDHP PPO & HSA $261.71 IU Health Quality Partners $547.16 PPO $900 Deductible $527.40 PPO Blue Access $400 $648.39 Subtract $25 per month for an employee or spouse ($50 for both) who do not use tobacco. PPO Dental    Employee only    Employee + child(ren)    Employee + spouse    Family $  8.97 $16.14 $21.06 $30.71
Medical plan	Choose HDHP PPO & HSA IUHQP PPO $900 PPO $400
Tobacco-free affidavit has been/will be completed by	Choose Employee Spouse Both Neither
PPO Dental	Choose Employee only Employee + child(ren) Employee + spouse Family None
How often is employee paid	Choose Bi-weekly Monthly
Estimated deduction (per pay period)	$

This tool is for illustrative purposes only. It is NOT an enrollment worksheet, and no entries will be saved. The medical premium will be based on the actual medical plan selection, coverage category, salary level, and tobacco-affidavit.