RATES SHEET ADMIN & SUPTER TECH 2022-2023

	A	B	C	D	E	G	H	I	K
1	ADMIN & SUPER TECH 2022-2023
2	MEDICAL (Deductible / MOP*)	EMPLOYEE ONLY	EMPLOYEE + SPOUSE	EMPLOYEE + CHILD(REN)	FAMILY	Admin Flex Pay or Opt Out - Step 2
3	*Kaiser 1 ($0 / $1,500)	$663.25	$1,459.17	$1,260.18	$2,056.10	$1,330.00
4	*Kaiser 2B Preferred Plan ($0 / $2,000) W/HRA	$532.16	$1,171.49	$1,011.04	$1,650.48	$1,330.00
5	*Kaiser 3 ($1,600 / $6,550)	$404.50	$890.43	$768.23	$1,254.20
6						Step 1	Add the medical, dental &/or vision of your choice. These deductions are pre-taxed.
7	*Moda - Plan 2 ($800 or $900 / $3,850 or $4,250)	$686.74	$1,510.83	$1,304.84	$2,128.93
8	*Moda - Plan 5 Preferred Plan ($350 / $2,500 or $2,520) W/HRA	$561.97	$1,236.34	$1,067.77	$1,742.16
9	*Moda - Plan 6 ($1,600 or $1,700 / $6,400 or $6,750)	$573.23	$1,261.10	$1,089.16	$1,777.05	The Admin Flex Benefit is yours to keep regardless if you choose medical, dental or vision and is taxable income. If you choose to receive benefits, prices are in the column to the left, these are pre-taxed. (If you decline medical, make sure to "Waive" instead of opt out in OEBB)
10	VISION	EMPLOYEE ONLY	EMPLOYEE + SPOUSE	EMPLOYEE + CHILD(REN)	FAMILY
11	Kaiser	$8.28	$18.20	$15.72	$25.66
12	Moda Opal	$22.64	$49.78	$42.95	$70.12
13	Moda Quartz	$13.05	$28.74	$24.80	$40.45
14	VSP CHOICE PLUS	$16.54	$36.41	$31.44	$51.30	Example for Family
15	DENTAL	EMPLOYEE ONLY	EMPLOYEE + SPOUSE	EMPLOYEE + CHILD(REN)	FAMILY	Step 1	Medical	$2,056.10	Add the Medical rate
16	Delta Dental 1	$64.79	$128.37	$142.74	$211.39		Vision	$226.53	Add the Dental rate or .00 if not selected
17	Delta Dental 5	$57.23	$113.37	$126.08	$186.71		Dental	$25.66	Add the Vision rate or .00 if not selected
18	Delta Dental 6	$43.70	$86.50	$87.81	$134.14			$2,308.29	Total
19	Kaiser	$73.07	$160.77	$138.84	$226.53	Step 2		$1,330.00	Subtract the Admin Flex Pay
20	Willamette	$46.60	$93.20	$99.27	$148.91			$978.29	Additional Out-of-Pocket plus taxes on the Admin Flex Benefit
21	*Deductible and Max Out of Pocket listed is for single employees. See Plan Designs for Additional Details.							$978.29
22
23	Revised 07/14/2022
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100