Monthly Benefits Rates

For Benefits Plans Effective

October 1, 2013 thru September 30, 2014

Health Plans
Plans
Medical Choice Plus Plan
Medical High Deductible Plan
Dental
Vision

Associate Only
$126.00
$75.00
$30.41
$6.50

Associate and
Spouse
$335.00
$232.00
$55.93
$12.40

Associate and
Child(ren)
$283.00
$189.00
$59.19
$13.00

Associate and
Family
$463.00
$309.00
$87.42
$20.00

Health Savings Account Annual Contributions

(Contributed by Mattress Firm for Associates Participating in the Medical High Deductible Plan)
Associate Only

Associate and Spouse

Up to $240

Up to $360

Associate and
Child(ren)
Up to $360

Associate and Family

Up to $480

Voluntary Term Life

*Associates Coverage
$10,000 - $500,000

*Spousal Coverage
$10,000 - $250,000

Cost Per
$10,000 of
Coverage
<25
0.53
25-29
0.64
30-34
0.85
35-39
0.95
40-44
1.06
45-49
1.59
50-54
2.43
55-59
4.55
60-64
6.98
65-69
13.43
*EOI required for coverage
in excess of $200,000
Age

Child(ren) Coverage

Based on
Cost Per
Associates
$10,000 of
Age
Coverage
<25
0.53
25-29
0.64
30-34
0.85
35-39
0.95
40-44
1.06
45-49
1.59
50-54
2.43
55-59
4.55
60-64
6.98
65-69
13.43
*EOI required for coverage
in excess of $100,000

Coverage
$2,000
$4,000
$6,000
$8,000
$10,000

Cost Per
$2,000 of
Coverage
0.240
0.480
0.720
0.960
1.200

Voluntary Accidental Death and Dismemberment (AD&D)

Associates AD&D
Coverage
$10,000 to $500,000

Cost Per
$10,000 of
Coverage
0.30

Spousal AD&D
Coverage
$10,000 to $250,000

Cost Per
$10,000 of
Coverage

Child(ren)
AD&D
Coverage

Cost Per
$2,000 of
Coverage

0.30

$2,000
$4,000
$6,000
$8,000
$10,000

0.240
0.480
0.720
0.960
1.200

Information contained in this document are summarizations and not intended to replace the full details regarding eligibility,
covered expenses, exclusions, limitations, definitions and other provisions of each plan contained in legal documents,
handbooks and group contracts. Legal documents shall govern any differences.