EMPLOYEE RATE WORKSHEET Use this worksheet to provide a general estimate of your benefits costs for the upcoming plan year. This is a great place to start planning for you and your family’s health and wellness for next year.
MEDICAL PLANS HDHP 26 PAYS EMPLOYEE ONLY $0.00 EMPLOYEE & SPOUSE $211.85 EMPLOYEE & CHILDREN $161.08 EMPLOYEE & FAMILY $352.62
26 PAYS $0.00 $281.54 $214.15 $469.38
22 PAYS $0.00 $250.36 $190.36 $416.73
DENTAL PLANS BASE 26 PAYS $0.00 EMPLOYEE ONLY EMPLOYEE & SPOUSE $11.47 EMPLOYEE & CHILDREN $11.70 EMPLOYEE & FAMILY $23.34
COPAY PLAN
22 PAYS $0.00 $13.56 $13.82 $27.58
22 PAYS $0.00 $332.73 $253.09 $554.73
VISION PLAN BUY UP 26 PAYS $8.10 $27.66 $32.24 $56.32
22 PAYS $9.57 $32.69 $38.11 $66.56
26 PAYS $0.00 $2.29 $3.37 $4.89
22 PAYS $0.00 $2.71 $3.98 $5.78
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