Page 21 - Benefit Guide 2019.2020 - Final

EMPLOYEE CONTRIBUTIONS

This chart compares the weekly 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 HSA funds 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 premiums have
been pre-calculated for you in Dayforce.

MEDICAL HMO PRIORITY HMO FULL
SELECT NETWORK NETWORK HSA PPO PPO
Employee Only $65.30 $89.75 $78.56 $101.94
Employee + Spouse $235.08 $323.11 $282.82 $366.98
Employee + Child(ren) $156.72 $215.40 $188.55 $244.66
Employee + Family $313.44 $430.81 $377.09 $489.31
DENTAL DHMO PPO

Employee Only $2.73 $5.06
Employee + Spouse $8.42 $20.26
Employee + Child(ren) $9.53 $25.62
Employee + Family $16.46 $29.76

The following benefits are provided to you at no
charge and are paid by Total Vision:
 Basic Life and AD&D
 Long Term Disability
 Employee Assistance Program
 Identity Theft
 Travel Assistance Plan

The following benefits are available to you at
discounted group rates. Should you elect these
benefits, you will pay 100% of the cost:
 Voluntary Life and AD&D
 Voluntary Short Term Disability (for CA employees)
 Voluntary Accident

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