Page 27 - Vistra Demo

Plan Costs

Monthly Employee Contributions PLAN COST AND NOTICES
You + You +
Medical You Only Spouse Child(ren) You + Family
MyHealth HSA Plan $5.25 $74.85 $62.18 $138.22

Dental You Only You + Spouse You + Child(ren) You + Family
Dental Plan A $13.82 $28.41 $26.59 $44.21 Working Spouse Surcharge
Dental Plan B $5.00 $9.00 $10.00 $15.00
If your spouse is employed and
eligible for medical coverage through
Vision You Only You + Spouse You + You + Family his/her employer and you enroll
Child(ren) him/her in the MyHealth HSA plan,
Vision Plan $6.20 $11.65 $13.62 $20.52 you will be charged an extra $250 a
month for coverage.
AD&D Coverage Level Supplemental Rate per $1,000 of Coverage
Employee Only $0.026
Employee + Family $0.041

Long-Term Disability Rate per $100 of Covered Monthly Base Pay
Taxation Rate
60% of base pay Before-tax $0.000
60% of base pay After-tax $0.090

Employee and
Spouse Life Supplemental Rate per $1,000 of Coverage
Age Non-Tobacco User Rate Tobacco User Rate
<30 $0.046 $0.060
30–34 $0.055 $0.080
35–39 $0.070 $0.090
40–44 $0.077 $0.100
45–49 $0.115 $0.150
50–54 $0.212 $0.250
55-59 $0.400 $0.470
60–64 $0.610 $0.720
65–69 $1.176 $1.389
70–74 $1.906 $2.251
75-79 $3.091 $3.650
80+ $5.007 $5.913
Child Life Coverage Level Monthly Contribution
$10,000 $2.232
$15,000 $3.348
$20,000 $4.464

25