Page 17 - Siemens Gamesa 2022 PY Benefits Guide

Premiums

All rates below are for full-time employees and are shown as monthly contributions

Medical (pre-tax)* Dental (pre-tax)*

Blue Cross Basic
Blue Cross HSA Plan Blue Cross HRA Plan
Traditional PPO Plan Employee $5.48
Employee $53.70 $96.04 $128.19 Employee & Spouse $11.91
Employee & Spouse $169.40 $292.11 $360.78 Employee & Child(ren) $9.96
Employee & Child(ren) $153.80 $254.50 $321.72 Family $16.29
Family $299.68 $450.59 $554.30
Enhanced
Employee $10.60
Supplemental Life and Supplemental AD&D (post-tax) Employee & Spouse $22.18
Employee & Child(ren) $25.72
Employee & Spouse
Age Band Child Rate Family $40.04
rate per $1,000
< 34 $0.054
35-39 $0.072
40-44 $0.095 Vision (pre-tax)*
45-49 $0.134
50-54 $0.197 Basic
$0.125
55-59 $0.356 Employee $0
60-64 $0.538 Employee & Spouse $0
65-69 $1.024 Employee & Child(ren) $0
70-74 $1.838 Family $0
75+ $1.995
Enhanced
Employee $4.44
Long-Term Disability (post-tax) Employee & Spouse $8.89
Employee & Child(ren) $8.00
Rate per $100 Family $13.34
Post-Tax
Voluntary LTD $0.288
Monthly Premier
Employee $7.62
Employee & Spouse $15.22
Employee & Child(ren) $13.70
Family $22.84

* Tax note: employers are required
to report as compensation the
value of medical, dental, and
vision insurance provided to
domestic partners and the
children of these relationships
and to withhold taxes on that
amount. The value of the health
insurance coverage provided to
these dependent relationships is
referred to as imputed income.

16 Your Benefits | Your Decisions Your Benefits | Your Decisions 17