Page 23 - Rauxa EE Guide 04-19 CA

Employee Contributions Per Pay Period

This chart compares the semi-monthly contributions for our employee benefit plans. Your cost for coverage will vary
depending on the option and level of coverage you choose. For your convenience, your age-banded Voluntary Life and
AD&D premiums have been pre-calculated for you in Paylocity.

1 Member 2 Members No Wellness
Wellness Participation Wellness Participation Participation
Rauxa Pays You Pay Rauxa Pays You Pay Rauxa Pays You Pay
MEDICAL
HMO
Employee Only $307.77 $0.00 N/A N/A $277.77 $30.00
Employee + Spouse $364.10 $313.00 $394.10 $283.00 $334.10 $343.00
Employee + Child(ren) $394.10 $159.89 N/A N/A $364.10 $189.89
Employee + Family $364.10 $589.99 $394.10 $559.99 $334.10 $619.99
HSA
Employee Only $307.48 $0.00 N/A N/A $277.48 $30.00
Employee + Spouse $364.10 $312.37 $394.10 $282.37 $334.10 $342.37
Employee + Child(ren) $394.10 $159.38 N/A N/A $364.10 $189.38
Employee + Family $364.10 $589.10 $394.10 $559.10 $334.10 $619.10
PPO Low
Employee Only $394.10 $0.00 N/A N/A $364.10 $30.00
Employee + Spouse $364.10 $502.92 $394.10 $472.92 $334.10 $532.92
Employee + Child(ren) $394.10 $315.28 N/A N/A $364.10 $345.28
Employee + Family $364.10 $857.60 $394.10 $827.60 $334.10 $887.60
PPO High
Employee Only $394.10 $55.70 N/A N/A $364.10 $85.70
Employee + Spouse $364.10 $625.46 $394.10 $595.46 $334.10 $655.46
Employee + Child(ren) $394.10 $415.54 N/A N/A $364.10 $445.54
Employee + Family $364.10 $1,030.27 $394.10 $1,000.27 $334.10 $1,060.27

Rauxa Pays You Pay
DENTAL
DHMO
Employee Only $7.55 $0.00
Employee + Spouse $7.55 $7.26
Employee + Child(ren) $7.55 $8.02
Employee + Family $7.55 $15.58
PPO
Employee Only $7.55 $25.56
Employee + Spouse $7.55 $58.12
Employee + Child(ren) $7.55 $69.70
Employee + Family $7.55 $102.84
VISION
Employee Only $4.50 $0.00
Employee + Spouse $4.50 $4.05
Employee + Child(ren) $4.50 $4.50
Employee + Family $4.50 $8.73

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