Page 10 - 2022 Fantasea Benefit Guide English_Spanish

Employee Contributions

CIGNA HORIZON VISION
CIGNA MEDICAL
DENTAL

OAP/LCP BASE
OAP/LCP OAP/LCP DPPO WITH WITHOUT
COVERAGE HSA BUY-UP MEDICAL MEDICAL
HIRED
PRIOR TO 7/1/11 AFTER 7/1/11

EE ONLY $36.21 $64.52 $81.28 $186.81 $2.45 $0.00 $1.13

EE + SPOUSE $159.12 $134.27 $242.28 $379.13 $3.60 $1.03 $2.17

$3.60
EE +CHILD(REN) $152.40 $127.77 $232.02 $315.40 MUST SELECT FAMILY) N/A N/A
(MORE THAN 1 CHILD

FAMILY $228.61 $198.20 $348.79 $572.30 $5.45 $2.38 $3.52

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