GE Health Choice

2014-A-O

2014 Rate Sheet - Active Employees

The chart below shows, by options and salary, your payroll

Options 1 and 2 come with a GE-funded HRA:

contributions and the most you may have to pay each year

$500 for
1-person coverage
each year

for deductible and co-insurance maximum. If you utilize

in-network doctors and hospitals.
To determine the highest amount you may have to pay,

$750 for
2-person coverage
each year

$1,000 for
3-or-more persons
each year

Dental and Vision Plan

add across the chart. GE helps offset the costs in Options 1

and 2 by funding a Health Reimbursement Account (HRA).

Annual Employee Contribution

Dental Premium Option
Vision Plus Option

Keep in mind your total costs depend upon the health care
you actually receive during the year and whether you utilize

1 Person

2 Person

3+ Persons

Coverage

Coverage

Coverage

$
$

168 $
96 $

336 $
192 $

504
288

in-network doctors and hospitals.

Medical Contributions*
Annual Payroll Contribution (b)
Option 1
Option 2
Option 3

Annual Deductible
Option 1
Option 2
Option 3

Annual Co-insurance Maximum

Option 1
Option 2
Option 3

Annual Salary Range (a)

1-Person
Up to $24,999
$25,000-$37,499
$37,500-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$149,999
$150,000 or more

$
$
$
$
$
$
$

792
933
1,018
1,272
1,582
1,976
2,624

$
$
$
$
$
$
$

272
413
654
908
1,218
1,612
2,260

$
$
$
$
$
$
$

32
32
45
157
386
754
1,272

$
$
$
$
$
$
$

800
800
800
800
800
800
800

$
$
$
$
$
$
$

1,200
1,200
1,200
1,200
1,200
1,200
1,200

$
$
$
$
$
$
$

1,600
1,600
1,600
1,600
1,600
1,600
1,600

$
$
$
$
$
$
$

500
500
1,000
1,750
1,750
2,500
2,500

$
$
$
$
$
$
$

1,500
1,500
1,500
2,250
2,250
3,000
3,000

$
$
$
$
$
$
$

2,000
2,000
2,000
2,750
2,750
3,500
3,500

2-Persons
Up to $24,999
$25,000-$37,499
$37,500-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$149,999
$150,000 or more

$
$
$
$
$
$
$

1,585
1,867
2,036
2,543
3,163
3,952
5,249

$
$
$
$
$
$
$

545
827
1,308
1,815
2,435
3,224
4,521

$
$
$
$
$
$
$

115
115
130
315
771
1,508
2,545

$
$
$
$
$
$
$

1,600
1,600
1,600
1,600
1,600
1,600
1,600

$
$
$
$
$
$
$

2,400
2,400
2,400
2,400
2,400
2,400
2,400

$
$
$
$
$
$
$

3,200
3,200
3,200
3,200
3,200
3,200
3,200

$
$
$
$
$
$
$

750
750
1,500
2,625
2,625
3,750
3,750

$
$
$
$
$
$
$

2,250
2,250
2,250
3,375
3,375
4,500
4,500

$
$
$
$
$
$
$

3,000
3,000
3,000
4,125
4,125
5,250
5,250

3-or-More Persons
Up to $24,999
$25,000-$37,499
$37,500-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$149,999
$150,000 or more

$
$
$
$
$
$
$

2,025
2,381
2,595
3,226
4,005
4,984
6,608

$
$
$
$
$
$
$

725
1,081
1,685
2,316
3,095
4,074
5,698

$
$
$
$
$
$
$

230
230
239
441
1,013
1,933
3,228

$
$
$
$
$
$
$

2,000
2,000
2,000
2,000
2,000
2,000
2,000

$
$
$
$
$
$
$

3,000
3,000
3,000
3,000
3,000
3,000
3,000

$
$
$
$
$
$
$

4,000
4,000
4,000
4,000
4,000
4,000
4,000

$
$
$
$
$
$
$

1,000
1,000
2,000
3,500
3,500
5,000
5,000

$
$
$
$
$
$
$

3,000
3,000
3,000
4,500
4,500
6,000
6,000

$
$
$
$
$
$
$

4,000
4,000
4,000
5,500
5,500
7,000
7,000

Deductible + Co-insurance Maximum = Out-of-Pocket Maximum

(a) Pay is Normal Straight Time Annual Earnings, it may also include a portion of commissions and other variable compensation.
(b) Contribution amounts are for non-smokers. Smokers pay an additional $652 in payroll contributions. Additional working spouse payroll contributions still apply.
* State surcharges will apply to residents in New York, Vermont, Maine, Michigan and Idaho.