Page 4 - Excelligence 2022 Benefit Guide

Benefit costs
Your 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 you enroll, 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
Bi-Weekly
$38.68
Weekly
$19.34
$65.24
Bi-Weekly
$42.09
$209.91
HSA PLAN
Salary $40,000 - $80,000
EE $ Contributions
Weekly
$21.04
$104.96
Salary >$80,000
EE $ Contributions
Bi-Weekly
$42.09
Weekly
$223.95
$21.04
$130.49
$111.98
$106.76
$183.86
$53.38
$91.93
$171.74
$295.78
$85.87
$147.89
$183.23
$315.57
$91.62
$157.79
Bi-Weekly
$83.39
$228.87
Weekly
$41.69
Bi-Weekly
$85.62
HRA PLAN
Coverage Tier
EE $ Contributions
EE $ Contributions
Weekly
$42.81
EE $ Contributions
Bi-Weekly
$85.62
Weekly
$42.81
$114.44
$308.30
$154.15
$319.75
$159.88
$187.26
$93.63
$252.24
$126.12
$261.62
$130.81
$322.49
$161.25
$434.41
$217.20
$450.56
$225.28
Coverage Tier
EE $ Contributions
Bi-Weekly
$132.76
$337.43
Weekly
$66.38
$168.71
Bi-Weekly
PPO PLAN
EE $ Contributions
$133.68 $66.84
$416.85 $208.43
Weekly
EE $ Contributions
Bi-Weekly
$133.68
Weekly
$66.84
$425.45
$212.73
$276.07
$475.46
$138.04
$237.73
$341.06 $170.53
$348.09
$174.04
$587.38 $293.69
$599.50
$299.75
Dental
Bi-Weekly
$18.76
High Plan
Weekly
$9.38
Bi-Weekly
$16.24
Low Plan
Weekly
$8.12
Bi-Weekly
$9.84
DHMO
Weekly
$4.92
$44.81
$22.40
$33.14
$16.57
$20.07
$10.03
$65.03
$32.52
$51.05
$25.52
$30.88
$15.44
Bi-Weekly
$3.29
$6.06
Weekly
$1.64
$3.03
$8.60
$4.30
4
Vision
VSP