Benefits Cost Worksheet

This is NOT an enrollment form. This worksheet is intended to assist you in estimating your out-of-pocket cost for benefits. It is valid for active employees and retired employees only, and does not include supplemental premium sharing offered by individual UT institutions.

Please remember this worksheet only provides you (the subscriber) with an estimate of your total out-of-pocket cost per month based on state-appropriated funds and contracted premium rates. Be sure to review available benefits information and provider directories for more information on the plans listed.

Evidence of Insurability may be required to enroll in some of the plans. For details, see your UT Group Benefits Handbook or contact your Campus Benefit Office.

Use the online Cost Worksheet or download a PDF version here



The Seal of the University of Texas System

  • © 2013 The University of Texas System
  • 702 Colorado Street, Suite 2.100
  • Austin, TX 78701
  • Phone: (512)499-4616