Page 15 - PriMed 2022 Benefits Guide

Benefit Plan Costs Effective January 1, 2022

To keep health care coverage affordable, PriMed pays the majority of the medical, dental, and vision premiums
for you and your dependents. Your monthly and per pay period (24 paychecks per year) payroll deductions are
shown in the table below:
Benefit Plan Total Monthly Cost PriMed Monthly Employee Monthly Employee Per Pay Period
Contribution Contribution (pre-tax) 3 Contribution (pre-tax)
3
Health Net HMO/Canopy (Non-Tobacco) 1
Employee Only $750.60 $597.00 $153.60 $76.80
Employee +1 $1,396.16 $1,032.00 $364.16 $182.08
Employee +2 or more $2,176.94 $1,597.00 $579.94 $289.97
Health Net HMO/Canopy (Tobacco) 2
Employee Only $750.60 $557.00 $193.60 $96.80
Employee +1 $1,396.16 $982.00 $414.16 $207.08
Employee +2 or more $2,176.94 $1,537.00 $639.94 $319.97
Health Net HMO/SmartCare (Non-Tobacco) 1
Employee Only $876.36 $702.00 $174.36 $87.18
Employee +1 $1,630.08 $1,231.00 $399.08 $199.54
Employee +2 or more $2,541.68 $1,896.00 $645.68 $322.84
Health Net HMO/SmartCare (Tobacco) 2
Employee Only $876.36 $662.00 $214.36 $107.18
Employee +1 $1,630.08 $1,181.00 $449.08 $224.54
Employee +2 or more $2,541.68 $1,836.00 $705.68 $352.84
1
Health Net Full Network HMO (Non-Tobacco)
Employee Only $1,100.68 $702.00 $398.68 $199.34
Employee +1 $2,047.52 $1,231.00 $816.52 $408.26
Employee +2 or more $3,192.64 $1,896.00 $1,296.64 $648.32
Health Net Full Network HMO (Tobacco) 2
Employee Only $1,100.68 $662.00 $438.68 $219.34
Employee +1 $2,047.52 $1,181.00 $866.52 $433.26
Employee +2 or more $3,192.64 $1,836.00 $1,356.64 $678.32
Health Net PPO (Non-Tobacco) 1
Employee Only $905.94 $702.00 $203.94 $101.97
Employee +1 $1,684.72 $1,231.00 $453.72 $226.86
Employee +2 or more $2,627.64 $1,896.00 $731.64 $365.82
Health Net PPO (Tobacco) 2
Employee Only $905.94 $662.00 $243.94 $121.97
Employee +1 $1,684.72 $1,181.00 $503.72 $251.86
Employee +2 or more $2,627.64 $1,836.00 $791.64 $395.82
Delta Dental PPO
Employee Only $63.70 $50.20 $13.50 $6.75
Employee +1 $106.66 $68.38 $38.28 $19.14
Employee +2 or more $157.32 $101.04 $56.28 $28.14
Vision Service Plan (VSP) Core Plan
Employee Only $6.08 $4.48 $1.60 $.80
Employee +1 $9.48 $4.64 $4.84 $2.42
Employee +2 or more $15.02 $4.96 $10.06 $5.03
Vision Service Plan (VSP) Enhanced Plan
Employee Only $13.18 $4.48 $8.70 $4.35
Employee +1 $20.58 $4.64 $15.94 $7.97
Employee +2 or more $32.60 $4.96 $27.64 $13.82
1 Non-Tobacco Insured Household - Applies if all insured members of the household (i.e., employee, spouse, and/or child(ren) are non-tobacco users (and have been
so for at least the last 90 consecutive calendar days before election of benefits). Note: If coverage is for employee only and employee is tobacco free, but family is not,
then he/she would pay the non-tobacco insured household rate. Tobacco Insured Household - If any insured member of the household (i.e. employee, spouse,
2
3
and/or child(ren) are tobacco users, then employee pays tobacco insured household rate. Contributions for domestic partners (same sex or opposite sex) and for
children of domestic partners will be treated as post-tax. If you have recently completed a tobacco cessation program, see People Services as you might qualify for
Non-Tobacco contributions.

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