Page 4 - Excelligence 2022 Benefit Guide

Benefit costs
Your bi-weekly payroll contributions for medical, dental and vision benefits are shown here. The premiums you pay are based on the plan you select, your salary band and coverage level. Your salary band is based on your current annual base earnings. Even if your annual base earnings increases after Open Enrollment ends, your salary band will not change until next year’s Open Enrollment.
Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
Employee Only Employee + 1 Employee + 2 or more
Employee Only Employee + 1 Employee + 2 or more
Coverage Tier
Salary <$40,000
EE $ Contributions
$38.68
HSA PLAN
Salary $40,000 - $80,000
EE $ Contributions
$42.09
Salary >$80,000
EE $ Contributions
$130.49
$209.91
$42.09
$223.95
$106.76
$171.74
$295.78
$183.23
$183.86
$315.57
HRA PLAN
Coverage Tier
EE $ Contributions
$83.39
EE $ Contributions
$85.62
EE $ Contributions
$85.62
$228.87
$187.26
$132.76
$337.43
$308.30
$133.68
$416.85
$319.75
$261.62
$322.49
EE $ Contributions
$252.24
$434.41
$450.56
Coverage Tier
EE $ Contributions
EE $ Contributions
$133.68
$425.45
$276.07
$475.46
$341.06
$348.09
$587.38
$599.50
PPO PLAN
Dental
High Plan
$18.76
Low Plan
$16.24
DHMO
$9.84
$44.81
$33.14
$20.07
$65.03
$51.05
$30.88
Vision
VSP
$3.29
$6.06
$8.60
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