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The University of Texas at Tyler
Benefits Summary Sheet
Monthly
Rates For Insurance Plans - Effective Sept.
1, 2007
MEDICAL OUT-OF-POCKET COST PER MONTH |
Full Time
Employees and Retirees** |
| |
Category |
Total
Premium |
Premium
Sharing |
Cost
to Employee |
|
| |
Subscriber
Only |
$369.12 |
$369.12 |
$
0.00 |
|
| |
Subscriber & Spouse |
721.40 |
562.54 |
158.86 |
|
| |
Subscriber & Children |
659.02 |
492.87 |
166.15 |
|
| |
Subscriber & Family |
1000.29 |
687.44 |
312.85 |
|
| |
Waiving Medical |
|
$184.56 |
|
|
|
|
Part
Time Employees |
| |
Category |
Total
Premium |
Premium
Sharing |
Cost
to Employee |
|
| |
Subscriber
Only |
$369.12 |
$184.56 |
$184.56 |
|
| |
Subscriber & Spouse |
721.40 |
281.27 |
440.13 |
|
| |
Subscriber & Children |
659.02 |
246.44 |
412.58 |
|
| |
Subscriber & Family |
1000.29 |
348.72 |
656.57 |
|
| |
Waiving
Medical |
|
$92.28 |
|
|
|
Plan self insured by UT and
administered by Blue Cross Blue Shield.
www.bcbstx.com/ut 1-866-882-2034 |
|
|
|
Medco
Health Prescription Drug Program |
The premiums for this plan
are included in the medical rates listed above.
www.medcohealth.com 1-800-818-0155 |
Annual Deductible: $50 per
person per year
(Deductible does not apply to medical
plan deductible) |
|
Access
Options |
Generic |
Preferred
Drug |
Non-Preferred
Drug |
|
| |
Retail
Pharmacy: (Up to 30 day supply) |
$10.00 |
$30.00 |
$45.00 |
|
| |
Mail
Order Pharmacy: (Up to 90 day supply) |
20.00 |
75.00 |
112.50 |
|
|
|
|
|
DENTAL
COVERAGE OUT-OF-POCKET COST PER MONTH |
| |
Category |
Rate |
|
| |
Subscriber
Only |
$28.26 |
|
| |
Subscriber & Spouse |
53.65 |
|
| |
Subscriber & Children |
59.14 |
|
| |
Subscriber & Family |
84.09 |
|
Plan self insured and administered
by
Delta Dental. www.deltadentalins.com
1-800-893-3582 |
|
|
VISION
CARE PLAN OUT-OF-POCKET COST PER MONTH |
| |
Category |
Rate |
|
| |
Subscriber
Only |
$7.36 |
|
| |
Subscriber& Spouse |
11.48 |
|
| |
Subscriber& Children |
11.74 |
|
| |
Subscriber& Family |
18.90 |
|
|
|
| |
|
|
LONG
TERM CARE |
| Coverage offered through CNA. Rates
available by calling 1-888-825-0353. |
|
| |
|
|
DISABILITY OUT-OF-POCKET COST PER MONTH |
Short Term Disability
(30 day Elimination Period) |
Basic Monthly Earnings (capped
at $ 5,000) times $ 0.0051=Monthly Premium |
Long Term Disability
(90 day Elimination Period) |
Basic Monthly Earnings (capped
at $ 12,025) times $ 0.0041=Monthly Premium |
| Insured by The Hartford. |
|
|
| |
|
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AD&D INSURANCE OUT-OF-POCKET COST PER MONTH |
| Monthly
Rate (per each $10,000 unit) = $ 0.16 Insured
by Fort Dearborn Life * |
| ($10,000 Employee Life & AD&D furnished at no cost with medical election.) |
|
| |
|
|
| VOLUNTARY TERM LIFE INSURANCE OUT-OF-POCKET
COST PER MONTH FOR ACTIVE EMPLOYEES |
| EMPLOYEE & RETIREES
RATESr |
Age
of Employee
9/1/07 |
Voluntary
Group Term Life per $1000 of coverage
|
|
| < 35 |
$.041 |
|
| 35-39 |
$.053 |
|
| 40-44 |
$.074 |
|
| 45-49 |
$.114 |
|
| 50-54 |
$.177 |
|
| 55-59 |
$.278 |
|
| 60-64 |
$.422 |
|
| 65-69 |
$.760 |
|
| 70 and
over |
$.792 |
|
| |
|
|
| |
DEPENDENT
RATES |
Age
of Spouse on 9/1/07
|
Voluntary
Term Life Rates per $1000 for coverage of either
$15,000 or $40,000 |
Dependent
Life |
| 15-24 |
$.055 |
Family
coverage option: $2.87 |
| 25-29 |
$.056 |
Provides
$10,000 for each dependent |
| 30-34 |
$.059 |
Insured
by Fort Dearborn Life * |
| 35-39 |
$.074 |
|
| 40-44 |
$.104 |
|
| 45-49 |
$.159 |
|
| 50-54 |
$.248 |
|
| 55-59 |
$.388 |
|
| 60-64 |
$.592 |
*
$10,000 Employee Life & AD&D |
| 65-69 |
$.884 |
furnished at no cost with
medical |
| 70 and
over |
$1.167 |
election. |
|
|
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|
Contact the Benefits Office at (903) 566-7358 to schedule
an appointment to enroll any eligible dependent and/or
select optional coverage within 31 days of employment.
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