Page 18 - 2022 Arabella Advisors Benefit Guide

Cost-share Amounts

Medical Plan Coverage Cost (Per pay period – 24 pay periods a year)

Aetna Medical HRA Plan

Medical Plan Coverage Election Participant Cost Share

Employee Only $52.13
Employee + Child(ren) $62.46

Employee & Spouse $106.87

Family $145.55

Aetna Medical HSA Plan

Medical Plan Coverage Election Participant Cost Share

Employee Only $35.15

Employee + Child(ren) $50.92
Employee & Spouse $67.26

Family $91.60

Dental Plan Coverage Cost (Per pay period – 24 pay periods a year)

MetLife

Dental Plan Coverage Election Participant Cost Share

Employee Only $3.66

Employee & Child(ren) $7.52
Employee & Spouse $7.25

Family $11.92

Vision Plan Coverage Cost (Per pay period – 24 pay periods a year)

MetLife

Vision Plan Coverage Election Participant Cost Share

Employee Only $0
Employee & Child(ren) $0

Employee & Spouse $0
Family $0

• All cost-share amounts are deducted pre-tax
• Arabella covers on average 86% of total premium

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