Page 16 - Premier EE Guide 12-17 - Texas Final

EMPLOYEE CONTRIBUTIONS

This chart compares the per paycheck contributions for our Employee Benefit plans. Your cost for coverage will vary depending on
the option and level of coverage you choose. Employee contributions for Medical, Dental, and Vision are deducted from your
paycheck with pre-tax dollars. This means that contributions are taken from your earnings before taxes, resulting in lower taxes
and increased take home pay. For your convenience, your age-banded Voluntary Life and AD&D and premiums have been pre-
calculated for you in ADP.

Medical Anthem Blue Cross Anthem Blue Cross
PPO Lumenos H.S.A. PPO
Employee Only $106.24 $60.00
Employee + Spouse $350.58 $194.53
Employee + Child(ren) $286.84 $159.16
Employee + Family $494.01 $274.11
Dental United Concordia
PPO
Employee Only $21.17
Employee + 1 Dependent $46.11
Employee + Family $69.60
Vision Blue View Vision
PPO
Employee Only $3.21
Employee + 1 Dependent $5.13
Employee + Family $8.34

Spousal/Domestic Partner Surcharge - A $100 monthly spousal/domestic partner surcharge will be added to
your medical insurance premium if you have elected coverage for your spouse/domestic partner and they
are eligible for subsidized coverage through his/her employer but elect not to enroll with his/her employer. If
your spouse/domestic partner is not eligible for coverage as an employee with their own employer or their
employer does not subsidize a portion of the premium, the spousal/domestic partner surcharge does not ap-
ply. All employees enrolling their spouse/domestic partner in the coverage for the 2017/2018 plan year with
PACU will be required to complete an affidavit pertaining to the spousal/domestic partner surcharge.

The following benefits are provided to you at no charge and are paid by PACU
• Basic Life and AD&D
• Employee Assistance Program
• Short Term disability

The following benefit is paid by PACU, but you also have the option to pay for this benefit yourself with post-tax
payroll contributions to receive a tax-free benefit at the time of disability:
• Long Term Disability

PACU Pays You Pay
Disability Benefits are TAXED Disability Benefits are NOT TAXED
Employee Annual Salary $70,000 Employee Annual Salary $70,000
Annual LTD Benefit $35,000 OR Annual LTD Benefit $35,000
(50% of Salary Max $6,000/Month) (50% of Salary Max $6,000/Month)
Annual Taxes (assumed at 30%) $10,500 Annual Taxes (assumed at 30%) $0

Final Annual LTD Claim Payment $24,500 Final Annual LTD Claim Payment $35,000

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