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.

EMPLOYEE ONLY EMPLOYEE & SPOUSE EMPLOYEE & CHILDREN EMPLOYEE & FAMILY MEDICAL PLANS HDHP

26 PAYS $0.00 $211.85 $161.08 $352.62 22 PAYS $0.00 $250.36 $190.36 $416.73

22 PAYS $0.00 $13.56 $13.82 $27.58 COPAY PLAN

26 PAYS $0.00 $281.54 $214.15 $469.38 22 PAYS $0.00 $332.73 $253.09 $554.73

EMPLOYEE ONLY EMPLOYEE & SPOUSE EMPLOYEE & CHILDREN EMPLOYEE & FAMILY DENTAL PLANS BASE

26 PAYS $0.00 $11.47 $11.70 $23.34 BUY UP

26 PAYS $8.10 $27.66 $32.24 $56.32 22 PAYS $9.57 $32.69 $38.11 $66.56 VISION PLAN

26 PAYS $0.00 $2.29 $3.37 $4.89 22 PAYS $0.00 $2.71 $3.98 $5.78