Page 7 - SC Fuels EE Guide 2020 Imperial & SD

CONTRIBUTIONS

Your cost per paycheck

24 Payroll Deductions/Year

Medical Options
PLAN SIMNSA HMO ANTHEM PPO ANTHEM HDHP PPO

Team Member Only $26.86 $67.00 $49.50
Team Member + Spouse* $130.60 $192.00 $176.50
Team Member + Child(ren) $181.92 $148.00 $130.50
Team Member + Family* $202.80 $284.50 $241.00
SC Fuels HSA SC Fuels HSA SC Fuels HSA
Team Member Only Contribution Contribution Contribution
Team Member + Family N/A N/A $25.00
N/A N/A $41.67
Dental Options
PLAN SIMNSA DHMO ANTHEM PPO

Team Member Only $2.27 $9.00
Team Member + Spouse $8.57 $29.00
Team Member + Child(ren) $13.82 $26.10
Team Member + Family $15.00 $54.25
Vision Options
PLAN EYEMED NETWORK VSP NETWORK PPO
PPO
Team Member Only $4.02 $5.78
Team Member + Spouse $8.04 $11.30
Team Member + Child(ren) $7.10 $10.16
Team Member + Family $11.12 $15.66
*Medical Coverage Only: Spouses and registered domestic partners who have other medical coverage
available to them through their employer are not eligible to enroll in our plan.

For your convenience, your age-banded Voluntary Life/AD&D, Short Term
Disability, and Long Term Disability premiums have been pre-calculated
for you in bswift.

IRS CODE Section 125
The SC Fuels team member benefits plans are designed under Section 125 of the IRS Code. This allows you to take
advantage of federal laws by purchasing some of your benefits with pre-tax dollars. Under Section 125, your Medical, Dental,
Vision, and Flexible Spending Account contributions are deducted before taxes are withheld which saves you tax dollars.
Paying for benefits before-tax means that your share of the costs is deducted before taxes are determined, resulting in more
take-home pay for you. As a result, the IRS requires that your elections remain in effect for the entire year. You cannot drop
or change coverage unless you experience a qualifying event.

NOTE: IRS W-2 Reporting Requirements Section 9002(a) of PPACA provides that employers must disclose the aggregate cost
of applicable employer-sponsored coverage provided to team members on Form W-2. Your W-2 will reflect the aggregate
cost of the medical plan and all pre-tax supplemental plans in Box 12 as code DD.

TEAM MEMBER BENEFITS | 7