Benefit Election Form

If you have met the definition of Full-time employee under the ACA guidelines, you may be determined to be eligible for health benefits. Below you will find a short summary of your benefit plan coverage and projected cost.


Benefits In-Network Out-of-Network
Contract Year Deductible

(Dec1 –Nov 30)

$5,000 Individual

$10,000 Family

$7,500 Individual
$15,000 Family
Out-of-Pocket Maximum
(includes deductible, coinsurance, and copays)
$6,650 Individual

$12,700 Family


$15,000 Individual

$30,000 Family

Preventative Care 0% 50%
Physician Office Visit 0%* 50%*
Specialist Office Visit 0%* 50%*
Urgent Care Center 0%* 50%*
Emergency Room  0%*                                              50%*
Hospital InPatient Stay 0%* 50%*
Routine Lab/Radiology 0%* 50%*
Complex Imaging (CT/PET, MRI)


0%* 50%*
Prescription Benefits Retail
(30-day supply)
(90-day supply)
Low cost Generic $5 co-pay* 50%”
Generic $20 copay*
Preferred Brand  $40 copay*  50%
Non-Preferred Brand $70 copay after deductible $140 copay after deductible
Self Administered Specialty Drugs 50% to $500 per script* 50%*

* After deductible

Your cost for employee only coverage will vary based on your individual hourly pay rates and number of hours worked and is calculated at 9.5% of your gross income deducted after taxes.  Below you will find numerous examples of projected costs for employee only benefits:

Example chart for various pay rates

Hourly Rate Yearly Cost Monthly Cost Weekly Cost Hours Worked in Month
$20.00 $3,944.40 $328.70 $75.85 173
$15.00 $3,078.00 $256.50 $59.19 180
$13.00 $3,186.24 $265.52 $61.27 215
$11.00 $2,193.00 $182.75 $42.17 175
$9.00 $1,282.44 $106.87 $24.66 125

*The example rates shown above are for employee only single coverage. If you intend to cover your children dependents as well under this health plan, you will be responsible for an additional $4,101 annually, $341.75 Per Month, $78.87 per week.*


You must opt in, or opt out of this program at this time, please complete all of the information on the form below to make your selection, then click the Submit button.

Please complete the following information:

Benefit Election Form

  • Click Submit to send your election information to PeopleShare.

If you chose to OPT IN, please click here to to complete your 2018 -2019 ACA Benefit Enrollment Form