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UT-System Medical Foundation
INSURANCE BENEFIT RATES
Health and Dental Plan
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Coverage
|
Health EPO
|
Health PHCS-PPO |
Dental
|
|
Employee
|
$0.00
|
$58.28 |
$0.00
|
|
Spouse
|
$193.40
|
$309.97 |
$11.67
|
|
Child (ren)
|
$90.71
|
$186.56 |
$19.00
|
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Family
|
$428.14
|
$591.33 |
$31.79
|
Superior Vision Plan
|
Coverage (Co-Payment)
|
$10 Materials Only
|
|
Employee
|
$0.00
|
|
Employee & 1 Dependent
|
$6.40
|
|
Employee & Family (2 or
more Dependent)
|
$12.68
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COBRA Rates
|
Coverage
|
Health EPO
|
Health PHCS-PPO |
Dental
|
|
Employee Only
|
$320.88
|
$385.06 |
$21.50
|
|
Emp & Spouse
|
$671.98
|
$806.37 |
$33.41
|
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Emp & Child (ren)
|
$529.30
|
$635.16 |
$40.88
|
|
Family
|
$932.76
|
$1,119.31 |
$53.93
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COBRA Application
DENTAL COBRA
Mail to:
Delta Dental Insurance
c/o Morgan-White Administrators
P.O. Box 14067 Jackson, MS 39236-4067
Attention: Jane Williams
EMPLOYEE PREMIUM ARE PAID
FOR BY THE
UT SYSTEM MEDICAL FOUNDATION
Monthly dependent subsidy amount
per resident $100
(Health Only) is included in
the amounts listed above.
For questions, please call:
(713) 500-5243
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