Page 6 - Optima Tax EE Guide 01-19 CA_FINAL

Contributions

Your cost per paycheck

Biweekly - 26 Payroll Deductions/Year

Medical Options

Plan Trio HMO Access+ HMO PPO High PPO Low
Employee Only $61.02 $84.68 $166.27 $123.28
Employee + Spouse $194.60 $249.01 $423.95 $325.08
Employee + Child(ren) $141.82 $182.03 $287.27 $260.34
Employee + Family $247.36 $315.95 $606.79 $482.12
Dental Options

Plan DHMO PPO
Employee Only $0.92 $14.63
Employee + Spouse $9.87 $39.58
Employee + Child(ren) $11.62 $44.46
Employee + Family $23.30 $77.02
Vision Option

Plan PPO
Employee Only $0.92
Employee + Spouse $3.53
Employee + Child(ren) $3.19
Employee + Family $5.96

IRS Code Section 125
The Optima Tax Relief employee benefit 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 are 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. You may
waive participation in the Section 125 Plan and elect to pay all contributions with after-tax dollars. Contact the
Human Resources Department if you wish to pay for your benefits with after-tax dollars.

6 Employee Benefits