Page 11 - Identity MSO 2021 Employee Benefits - Semi Monthly

Identity MSO
2021 Employee Benefits Brochure

Employee Contributions

Contributions toward the cost of benefits are automatically deducted from your paycheck on a pre-tax basis. Rates below
are semi-monthly. The amount depends on the plan and if you choose to cover eligible family members.

Medical Trio HMO 40 -1000 Full Network HMO Trio HMO Zero Admit
Employee Only $0.00 $148.31 $36.87
Employee + Spouse $368.90 $695.15 $449.99
Employee + Child(ren) $245.94 $512.86 $312.28
Employee + Family $645.55 $1,105.27 $759.82

Medical Split Ded PPO PPO H.S.A.
Employee Only $281.10 $164.23
Employee + Spouse $987.29 $730.18
Employee + Child(ren) $751.89 $541.53
Employee + Family $1,517.00 $1,154.64

Dental HMO Low HMO High PPO
Employee Only $0.00 $0.00 $18.09
Employee + Spouse $5.36 $8.95 $75.46
Employee + Child(ren) $5.36 $8.95 $41.80
Employee + Family $14.30 $20.13 $47.49

Vision
Employee Only $0.00
Employee + Spouse $3.39
Employee + Child(ren) $3.88
Employee + Family $8.24

PAGE 11