2012-2013 Employee Benefits Guide

GBS Benefits, Inc.

Rocky Mountain Health Plans Medical (970) 244-7760 2775 Crossroads Blvd. Dental www.rmhp.org Grand Junction, CO 81506

GBS Benefits, Inc. Don McKean (800) 427-6586 x1153 465 South 400 East, Ste. 300 Account Executive (801) 364-7233 x1153 Salt Lake City, UT 84111 don.mckean@gbsbenefits.com

GBS Benefits, Inc. Heather Williams (800) 427-6586 x1163 465 South 400 East, Ste. 300 Account Manager (801) 364-7233 x1163 Salt Lake City, UT 84111 heather.williams@gbsbenefits.com In an effort to make your benefits more understandable, this brief summary of your benefits has been prepared. The benefit booklet is provided as a summary of your employee benefits only. While the benefits listed are considered accurate, they are not a guarantee of service, or payment by the insurance company. For complete details regarding any of your employee benefits, please see plan summaries.

This summary of benefits is a cursory description of your employee benefits and should be considered such.

Table of Contents Enrollment Guidelines ...................................................................................................... 5

Eligibility & Open Enrollment ........................................................................................ 6

Medical – Rocky Mountain Health Plans............................................................................. 7

Good Health HMI 500/80 .............................................................................................. 8

Dental – Delta Dental / RMHP ............................................................................................ 9

Delta Dental Premier – High Option Plan ....................................................................... 10

Additional Information ..................................................................................................... 12

Health Care Reform Notices ........................................................................................... 13

Medicare Part D ............................................................................................................. 14

CHIP & Medicaid Model Notice ....................................................................................... 15

$4 Generic Prescriptions ................................................................................................ 17

Premiums .......................................................................................................................... 18

Employee Cost Per Pay Period ........................................................................................ 19

ENROLLMENT GUIDELINES

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Enrollment Guidelines Welcome to the Grand Junction Gold’s Gym 2012-2013 Benefit Booklet. This Book provides a quick overview of our benefits program and helps to remove confusion that sometimes surrounds employee benefits. This Book helps clarify plan concepts and philosophy and prepares you to make informed choices about your benefit options. We have structured our benefits program to provide comprehensive coverage for you and your family. Benefit programs provide a financial safety net in the event of unexpected and potentially catastrophic events. Eligibility You are eligible to enroll for benefits if you are a full-time employee, working at least 32 hours per week. Benefits commence on the first of the month following 180 days after the date of hire. Your dependents are eligible if less than 26 years of age. Open Enrollment Open enrollment for benefit programs is once a year and all elections will take effect September 1, 2012. After the enrollment deadline you may not change your benefit elections until the next open enrollment. The elections you make now stay in effect, unless a qualifying life event occurs. Qualified life events are:

• Marriage • Divorce • Birth • Adoption • Change in Custody • Death • Loss of Coverage

When you have a qualifying event, you have 30

days to complete and return a new enrollment/change form.

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MEDICAL

ROCKY MOUNTAIN HEALTH PLANS

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Good HealtH HMo 500/80Underwritten by rocky MoUntain HMo

www.rmhp.org800-453-2981

MK474R0710

Rocky Mountain Good Health HMO plan designs include a wide selection of coverage options and access to one of the largest provider networks in Colorado. Plan benefit choices range from classic HMO coverage with traditional office visit copayments to more creative plans that offer deductibles and the benefit of lower premiums.

Annual Deductible $500 Individual; $1,000 Family

Maximum Out-of-Pocket Costs$3,000 Individual; $6,000 Family

(does not include deductible)

Coverage 80%

Health Care Service Copayment or CoinsuranceMust meet

deductible first

Routine Office VisitPCP/Specialist

$35/$50 per visit No

Child Preventive Services Covered in full No

Adult Preventive Services Covered in full No

Immunizations (shots) Covered in full No

Routine Screenings: mammogram, Pap smear, prostate screening, colorectal cancer screening

Covered in full No

Hospital Stay 20% per admission* Yes

Outpatient Surgery 20% per surgery* Yes

Lab Services $25 per visit No

X-Rays $50 per visit No

Scans — MRI/CAT/PET 20% per visit* Yes

Ambulance 20% per trip* Yes

Emergency Care 20% after $150 per visit* No

Urgent Care $50 per visit No

Prescription Drug$15/$50/$65/20%/30% or

$10 Generic SelectNo

* Services apply toward maximum out-of-pocket costs

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Note: All coverage under RMHP health plans is subject to the Maximum Benefit Allowance, which is RMHP’s determination of the maximum amount that will be approved as a charge for a particular health care service.

Plan Limitations and Exclusions

For complete details on plan benefits and limitations and exclusions, see the applicable RMHP contract.

Pre-Existing Conditions

Groups 2-50: Excluded from coverage for up to six months (up to 18 months for late enrollees) unless reduced by prior creditable coverage. Does not apply to pregnancy, newborns, children newly adopted or placed for adoption, children under the age of 19, or employer groups with more than 50 employees.

Business Groups of One (BG1): Excluded from coverage for up to 12 months (up to 18 months for late enrollees) unless reduced by prior creditable coverage. Does not apply to pregnancy, newborns, children newly adopted or placed for adoption, children under the age of 19, or employer groups with more than 50 employees.

Patient Protection and Affordable Care Act

This plan is available to both grandfathered and non-grandfathered health plans under the Patient Protection and Affordable Care Act (“the Affordable Care Act”). Grandfathered health plans are group health plans in which an individual was enrolled on March 23, 2010, and which maintain grandfathered status in accordance with Affordable Care Act regulations. Your group health plan may be a grandfathered health plan under the Patient Protection and Affordable Care Act. Your Evidence of Coverage will state if Rocky Mountain Health Plans (“RMHP”) believes that your group health plan is a grandfathered health plan.

As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your Evidence of Coverage may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to your employer, your plan administrator identified in your Summary Plan Description, or RMHP at 800-346-4643. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1–866–444–3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.

Colorado law requires carriers to make available a Colorado Health Benefit Plan Description Form, which is intended to facilitate comparison of health plans. The form must be provided automatically within three (3) business days to a potential policyholder who has expressed interest in a particular plan or who has selected the plan as a finalist from which the ultimate selection will be made. The carrier also must provide the form, upon oral or written request, within three (3) business days to any person who is interested in coverage under or who is covered by a health benefit plan of the carrier.

An access plan is available for each managed care network offered by Rocky Mountain Health Plans to any interested party upon request. Such access plans contain information on providers, hospitals, referral and grievance procedures, quality assurance, access for members with special needs, emergency coverage provisions, and other information on how to access services.

COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE ANY HEALTH BENEFIT PLAN IT MARKETS IN COLORADO TO SMALL EMPLOYERS OF 2-50 EMPLOYEES, INCLUDING A BASIC OR STANDARD HEALTH BENEFIT PLAN, UPON THE REQUEST OF A SMALL EMPLOYER TO THE ENTIRE SMALL GROUP, REGARDLESS OF THE HEALTH STATUS OF ANY OF THE INDIVIDUALS IN THE GROUP. BUSINESS GROUPS OF ONE CANNOT BE REJECTED UNDER A BASIC OR STANDARD HEALTH BENEFIT PLAN DURING OPEN ENROLLMENT PERIODS AS SPECIFIED BY LAW.

For small employer groups, see the enclosed Disclosure Notice for Small Employer Groups, which is incorporated into this document by reference.

The contents of this benefits summary are subject to the provisions of the Evidence of Coverage and Plan Attachments, which contain all terms and conditions of membership and benefits.

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DENTAL

DELTA DENTAL

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11

ADDITIONAL INFORMATION

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IMPORTANT INFORMATION REGARDING HEALTH CARE REFORM AND CHANGES TO YOUR BENEFITS

Notice Lifetime Limit No Longer Applies and Enrollment Opportunity The lifetime limit on the dollar value of benefits under SelectHealth no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. For more information contact SelectHealth or Mountainville Academy Human Resources.

Notice of Opportunity to Enroll in connection with Extension of Dependent Coverage to Age 26 Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because of the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in Mountainville Academy’s group health plan coverage. Enrollment will be effective September 1, 2011. For more information contact SelectHealth or Mountainville Academy Human Resources.

Health Care Reform Impacts OTC Purchases Beginning Jan. 1, 2011 The Health care reform Legislation signed into law in March 2010 by the President will impact over the counter (OTC) purchases with Health Care FSA, HRA and HSA accounts beginning January 1, 2011.

OTC drugs, medicines and biological remain eligible with a directive from a provider. You may still be reimbursed for these items; however, you must obtain a letter of medical necessity from your provider and submit a copy of the letter along with the receipt as a manual reimbursement.

It is important to note that not all OTC items will be affected; items such as band aids, contact lens cleaning solution, thermometers, etc. will remain eligible without a letter of medical necessity. The items affected include items in the following categories:

Please be sure to take these changes into account when making your election.

o Acid Controllers o Allergy & Sinus o Antibiotic Products o Anti-Diarrheal o Anti-Gas o Anti-Itch & Insect Bite o Baby Rash Ointments / Cream

o Cold Sore Remedies o Cold, Cough & Flu o Digestive Aids o Feminine Anti-Fungal / Anti-

Itch o Hemorrhoid Preps o Laxatives

o Motion Sickness o Pain Relief o Respiratory Treatment o Sleep Aids & Sedatives o Stomach Remedies

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Medicare Part D

− IF…

− You or your spouse are age 65 or older;

− You or your spouse are eligible for Medicare due to having end stage renal disease, or

You or your spouse are eligible for Medicare due to disability –

Then this information is for you Mountainville Academy has determined that the prescription drug coverage offered by SelectHealth is expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage. Because your existing coverage is at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in Medicare prescription drug coverage. Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from November 15th through December 31st

.

You should also know that if you drop or lose your coverage through Mountainville Academy and don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more to enroll in Medicare prescription drug coverage later. If you go 63 days or longer without prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage, your monthly premium will go up at least 1% per month for every month that you did not have coverage. For example, if you go nineteen months without coverage, your premium will always be at least 19% higher than what many other people pay. You’ll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to enroll. For more information about this notice or your current prescription drug coverage… If you have questions about this notice, check with your medical carrier at an Open Enrollment meeting or contact Human Resources. You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage changes. You also may request a Certificate of Creditable Coverage. For more information about your options under Medicare prescription drug coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more information about Medicare prescription drug plans:

− Visit www.medicare.gov

− Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help.

− Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

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Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage To Children And Families

If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.

If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of January 31, 2011. You should contact your State for further information on eligibility –

ALABAMA – Medicaid CALIFORNIA – Medicaid

Website: http://www.medicaid.alabama.gov Phone: 1-800-362-1504

Website: http://www.dhcs.ca.gov/services/Pages/ TPLRD_CAU_cont.aspx Phone: 1-866-298-8443

ALASKA – Medicaid COLORADO – Medicaid and CHIP

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529

Medicaid Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943 CHIP Website: http:// www.CHPplus.org CHIP Phone: 303-866-3243

ARIZONA – CHIP

Website: http://www.azahcccs.gov/applicants/default.aspx Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437

ARKANSAS – CHIP FLORIDA – Medicaid

Website: http://www.arkidsfirst.com/ Phone: 1-888-474-8275

Website:http://www.fdhc.state.fl.us/Medicaid/index.shtml Phone: 1-877-357-3268

GEORGIA – Medicaid MISSOURI – Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid Phone: 1-800-869-1150

Website:http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

IDAHO – Medicaid and CHIP MONTANA – Medicaid Medicaid Website: www.accesstohealthinsurance.idaho.gov Medicaid Phone: 1-800-926-2588 CHIP Website: www.medicaid.idaho.gov CHIP Phone: 1-800-926-2588

Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml Phone: 1-800-694-3084

INDIANA – Medicaid NEBRASKA – Medicaid

Website: http://www.in.gov/fssa Phone: 1-800-889-9948

Website: http://www.dhhs.ne.gov/med/medindex.htm Phone: 1-877-255-3092

IOWA – Medicaid NEVADA – Medicaid and CHIP

Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 Medicaid Website: http://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900 CHIP Website: http://www.nevadacheckup.nv.org/ CHIP Phone: 1-877-543-7669

KANSAS – Medicaid

Website: https://www.khpa.ks.gov Phone: 1-800-792-4884 15

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Website: www.dhhs.nh.gov/ombp/index.htm Phone: 603-271-4238

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-342-6207 Medicaid Website: http://www.state.nj.us/humanservices/

dmahs/clients/medicaid/ Medicaid Phone: 1-800-356-1561 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MAINE – Medicaid

Website: http://www.maine.gov/dhhs/OIAS/public-assistance/index.html Phone: 1-800-321-5557

MASSACHUSETTS – Medicaid and CHIP NEW MEXICO – Medicaid and CHIP

Medicaid & CHIP Website: http://www.mass.gov/MassHealth Medicaid & CHIP Phone: 1-800-462-1120 Medicaid Website: http://www.hsd.state.nm.us/mad/index.html

Medicaid Phone: 1-888-997-2583 CHIP Website: http://www.hsd.state.nm.us/mad/index.html Click on Insure New Mexico CHIP Phone: 1-888-997-2583

MINNESOTA – Medicaid Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone (Outside of Twin City area): 800-657-3739 Phone (Twin City area): 651-431-2670

NEW YORK – Medicaid TEXAS – Medicaid

Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831

Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493

NORTH CAROLINA – Medicaid UTAH – Medicaid Website: http://www.nc.gov Phone: 919-855-4100

Website: http://health.utah.gov/upp Phone: 1-866-435-7414

NORTH DAKOTA – Medicaid VERMONT– Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

OKLAHOMA – Medicaid VIRGINIA – Medicaid and CHIP

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Medicaid Website: http://www.dmas.virginia.gov/rcp-HIPP.htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1-866-873-2647

OREGON – Medicaid and CHIP WASHINGTON – Medicaid

Medicaid & CHIP Website: http://www.oregonhealthykids.gov Medicaid & CHIP Phone: 1-877-314-5678

Website: http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm Phone: 1-800-562-3022 ext. 15473

PENNSYLVANIA – Medicaid WEST VIRGINIA – Medicaid

Website:http://www.dpw.state.pa.us/partnersproviders/medicalassistance/doingbusiness/003670053.htm Phone: 1-800-644-7730

Website: http://www.wvrecovery.com/hipp.htm Phone: 304-342-1604

RHODE ISLAND – Medicaid WISCONSIN – Medicaid Website: www.dhs.ri.gov Phone: 401-462-5300

Website: http://www.badgercareplus.org/pubs/p-10095.htm Phone: 1-800-362-3002

SOUTH CAROLINA – Medicaid WYOMING – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820

Website: http://www.health.wyo.gov/healthcarefin/index.html Phone: 307-777-7531

To see if any more States have added a premium assistance program since January 31, 2011, or for more information on special enrollment rights, you can contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565 OMB Control Number 1210-0137 (expires 09/30/2013)

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GENERIC PRESCRIPTIONS $4 30-Day Supply or $10 90-Day Supply

These programs may assist you in paying a reduced amount for generic medications, as well as, reducing utilization of the medical prescription benefits. DID YOU KNOW? Even if the generic substitute for one of your prescription drugs is not on one of the $4 lists, generic drugs are often 80% less expensive than brand name drugs, so switching to a generic will have a large impact on your pocketbook whether you switch pharmacies or not. To see if you would benefit from a switch to a generic drug, do some comparison shopping. One of the better places to do this is at www.crbestbuydrugs.org, a Consumer Reports site.

TIPS - When you receive a prescription from your doctor, ask if a generic equivalent is

available. - The member must present the written prescription to the pharmacist and request the

$4-Generic price. - The member should not present the medical ID card. The pharmacy will not submit a

claim to the insurance carrier.

How can I find out if my prescription is on the $4-Generic Drug List? - Most of the generic programs offer approximately 150 to 300 generic drugs at a

discounted price. - The generic drugs offered cover most diseases and most chronic conditions such as

arthritis, heart disease, high blood pressure, depression and diabetes. - You may search for the generic medication on the pharmacy’s website below or

contact the pharmacy to inquire if the generic medication the provider prescribed is on the pharmacy’s $4-Generic Drug List.

Target http://sites.target.com/site/en/health/page.jsp?contentId=WCMP04-040590 Wal-Mart & Sam’s Club http://i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf Walgreens https://webapp.walgreens.com/MYWCARDWeb/pdf/Value-PricedGenericsList.pdf Smiths Pharmacy http://www.smithsfoodanddrug.com/generic/Pages/alpha_listing.aspx

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PREMIUMS

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Grand Junction Gold’s Gym Employee Contributions & Premiums

2012 – 2013

Medical

Rocky Mountain Health Plans

Employee Only

Age Total Premium

Per Month

GJGG Contribution Per Month

Employee Cost Per Month

Employee Cost Per Pay Period

<19 $276.62 $248.96 $27.66 $13.83

20-24 $284.19 $255.77 $28.42 $14.21

25-29 $308.50 $277.65 $30.85 $15.43

30-34 $337.60 $303.84 $33.76 $16.88

35-39 $376.66 $338.99 $37.67 $18.83

40-44 $430.47 $387.42 $43.05 $21.52

45-49 $507.00 $456.30 $50.70 $25.35

50-54 $608.63 $547.77 $60.86 $30.43

55-59 $782.42 $704.18 $78.24 $39.12

60-64 $1,017.18 $915.46 $101.72 $50.86

65+ $1,050.66 $945.59 $105.07 $52.53

Employee + Spouse

Age Total Premium

Per Month

GJGG Contribution Per Month

Employee Cost Per Month

Employee Cost Per Pay Period

<19 $553.23 $276.62 $276.62 $138.31

20-24 $568.38 $284.19 $284.19 $142.10

25-29 $617.00 $308.50 $308.50 $154.25

30-34 $675.20 $337.60 $337.60 $168.80

35-39 $753.72 $376.86 $376.86 $188.43

40-44 $860.94 $430.47 $430.47 $215.24

45-49 $1,013.99 $507.00 $507.00 $253.50

50-54 $1,217.27 $608.64 $608.64 $304.32

55-59 $1,564.83 $782.42 $782.42 $391.21

60-64 $2,034.36 $1,017.18 $1,017.18 $508.59

65+ $2,061.06 $1,030.53 $1,030.53 $515.27

Employee + Children

Age

Total Premium

Per Month

GJGG Contribution

Per Month

Employee Cost

Per Month

Employee Cost

Per Pay Period

<19 $636.14 $318.07 $318.07 $159.04

20-24 $653.67 $326.84 $326.84 $163.42

25-29 $678.38 $339.19 $339.19 $169.60

30-34 $709.08 $354.54 $354.54 $177.27

35-39 $753.72 $376.86 $376.86 $188.43

40-44 $817.89 $408.95 $408.95 $204.47

45-49 $887.24 $443.62 $443.62 $221.81

50-54 $973.73 $486.87 $486.87 $243.43

55-59 $1,173.82 $586.91 $586.91 $293.46

60-64 $1,475.15 $737.58 $737.58 $368.79

65+ $1,470.76 $735.38 $735.38 $367.69

Family

Age Total Premium

Per Month

GJGG Contribution Per Month

Employee Cost Per Month

Employee Cost Per Pay Period

<19 $912.75 $456.38 $456.38 $228.19

20-24 $937.86 $468.93 $468.93 $234.47

25-29 $986.89 $493.45 $493.45 $246.72

30-34 $1,046.67 $523.34 $523.34 $261.67

35-39 $1,130.38 $565.19 $565.19 $282.60

40-44 $1,248.36 $624.18 $624.18 $312.09

45-49 $1,394.24 $697.12 $697.12 $348.56

50-54 $1,582.37 $791.19 $791.19 $395.59

55-59 $1,956.24 $978.12 $978.12 $489.06

60-64 $2,492.33 $1,246.17 $1,246.17 $623.08

65+ $2,481.17 $1,240.59 $1,240.59 $620.29 Dental

Delta Dental

PPO/MAC Plan A

Status Total Premium

Per Month

GJGG Contribution Per

Month Employee Cost

Per Month

Single $34.88 $17.44 $17.44

Two-Party $69.50 $34.75 $34.75

Employee + Children $71.03 $35.52 $35.52

Family $106.70 $53.35 $53.35

GBSB E N E F I T S , I N C .

465 South 400 East, Suite 300Salt Lake City, UT 84111Phone: (801) 364-7233