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
EMPLOYEE ONLY EMPLOYEE & SPOUSE EMPLOYEE & CHILDREN EMPLOYEE & FAMILY
EMPLOYEE ONLY EMPLOYEE & SPOUSE EMPLOYEE & CHILDREN EMPLOYEE & FAMILY
EMPLOYEE ONLY EMPLOYEE & SPOUSE EMPLOYEE & CHILDREN EMPLOYEE & FAMILY
10
HMO 3500
PPO 3500
PPO 1500
PER PAY $ 68.31 $322.12 $309.43 $652.07
PER PAY $ 130.03 $ 445.57 $ 429.79 $ 855.76
PER PAY $ 168.91 $ 523.33 $ 505.61 $ 984.06
DENTAL PLAN
VISION PLAN
DENTAL PPO
EYEMED
PER PAY $ 18.49 $ 36.99 $ 47.16 $ 65.65
PER PAY $ 3.60 $ 7.19 $ 6.83 $ 10.73
TELEMEDICINE PLAN
DISABILITY PLAN
HEALTHIEST YOU
VOLUNTARY
PER PAY $ 5.00 $ 5.00 $ 5.00 $ 5.00
PER PAY $ 1.22
