Benefits Enrollment for Medical, Vision and Dental effective Jan. 2025.

All MLEDP employees who work a minimum of 25 hours per week are eligible to enroll in one or more of the benefits below. 

After making your selections to accept or waive coverage for each option, please be sure to sign the bottom of the page. 

Employees are responsible for paying 25% of the cost of the single premium through payroll deduction and MLEDP pays 75% of the monthly premium for single coverage and applies that amount to all other coverage levels.

Instructions:

Please read through the benefit options below and select "Accept (Level of coverage you would like)" or "Waive Coverage" for each option. (Medical, Dental and Vision). If you do not wish to be enrolled, please be sure to click "Waive Coverage"

UPMC/ Monthly Payroll Deduction Group Plan

Highmark Fashion Advantage Gold - Opt I/Monthly Payroll Deduction

SunLife/Monthly Payroll Deduction

NOTE: 

• If you elect Single coverage for medical, dental and vision, your monthly payroll deduction will total $214.00
• If you elect Emp/Spouse coverage for medical, dental, and vision, your monthly payroll deduction will total: $1632.87
• If you elect P/C coverage for medical, dental and vision, your monthly payroll deduction will total $1083.71
• If you elect Family coverage for medical, dental and vision, your monthly payroll deduction will total $1759.55

Benefit Options

AFLAC Benefit Options - To enroll in this program, you will need to work with the AFLAC representative. MLEDP does not pay any portion of the premium.

Sickness, Accident and Short-Term Disability plans are offered through AFLAC.

If you would like more information about AFLAC, contact the MLEDP executive director

All Eligible Employees Please Read and Sign below:

After the enrollment period, you will not be able to make any additional changes during the year unless you experience a qualified life event, such as a birth, death, or spousal job loss.

I have read the information presented on this enrollment form and understand that the costs of the benefit elections I choose will be deducted from my paycheck each month.

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