Page 5 - Remita Guide 2020 - CA FINAL

Your cost per paycheck

IRS Code Section 125 The Remita Health 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, Flexible Spending and Health Savings 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. 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.

Per Pay Period Company You Pay Per Pay Period Company You Pay
Deductions Pays Deductions Pays
Medical HMO | Blue Shield Trio Dental DHMO | Cigna
Employee Only $179.74 $54.61 Employee Only $3.33 $2.17
Employee + Spouse $357.09 $181.90 Employee + One Dependent $4.24 $5.66
Employee + Child(ren) $271.66 $126.74 Employee + Family $5.01 $10.60
Employee + Family $433.44 $246.16 Dental PPO | Cigna
Medical Deductible HMO | Kaiser
Employee Only $11.28 $8.58
Employee Only $181.85 $59.52 Employee + One Dependent $14.78 $30.96
Employee + Spouse $320.17 $210.83 Employee + Family $19.23 $52.39
Employee + Child(ren) $274.06 $160.39
Employee + Family $424.41 $323.81 Vision | Cigna
Medical HMO | Kaiser Buy-up Employee Only $2.57 $1.38
Employee + One Dependent $3.86 $3.69
Employee Only $182.36 $99.19 Employee + Family $3.50 $8.77
Employee + Spouse $321.31 $298.11
Employee + Child(ren) $274.99 $231.81
Employee + Family $426.01 $446.80
Medical HMO | Blue Shield Full Network Access+ HMO Voluntary Benefits

Employee Only $179.74 $170.50 All premiums for voluntary lines of coverage are
Employee + Spouse $357.09 $448.46 calculated for you online.
Employee + Child(ren) $271.66 $323.75
Employee + Family $433.44 $582.25 • Voluntary Life/AD&D
Medical HSA PPO | Blue Shield • Buy-up STD
Employee Only $254.64 $88.09 • Accident
Employee + Spouse $524.24 $264.04 • Critical Illness
Employee + Child(ren) $377.08 $205.56 • Hospital Indemnity
Employee + Family $597.92 $396.00
Medical PPO | Blue Shield
Employee Only $300.60 $132.47
Employee + Spouse $526.73 $461.03
Employee + Child(ren) $419.21 $317.02
Employee + Family $675.70 $580.21