Page 7 - Incipio EE Guide 01-19 CA Semi-Monthly

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. Please see ADP for Voluntary Life and AD&D premiums.

MEDICAL OPTIONS DENTAL OPTIONS

ANTHEM UNITED CONCORDIA
HMO (CA CARE) DHMO

Employee Only $0.00 Employee Only $6.25
Employee + Spouse $150.92 Employee + Spouse $12.50
Employee + Child(ren) $123.48 Employee + Child(ren) $12.70
Employee + Family $213.87 Employee + Family $18.90

KAISER UNITED CONCORDIA
HMO DPPO
Employee Only $55.76 Employee Only $13.53
Employee + Spouse $296.30 Employee + Spouse $27.06
Employee + Child(ren) $244.28 Employee + Child(ren) $28.96
Employee + Family $365.51 Employee + Family $44.11
ANTHEM VISION OPTION
PPO 2500 DEDUCTIBLE
(PRUDENT BUYER)
ANTHEM
Employee Only $42.10 PPO
Employee + Spouse $231.53
Employee + Child(ren) $189.43 Employee Only $4.63
Employee + Family $326.24 Employee + Spouse $7.87
Employee + Child(ren) $8.33
ANTHEM Employee + Family $12.49
PPO 500 DEDUCTIBLE
(PRUDENT BUYER)
Employee Only $135.88
Employee + Spouse $437.86
Employee + Child(ren) $358.25
Employee + Family $617.00

The following benefits are provided to you at no charge and are paid by Incipio:
• Basic Life and AD&D
• Long Term Disability
• Employee Assistance Plan & Travel Assistance Services

The following benefits are available to you at discounted group rates.
• Voluntary Life and AD&D
• Supplemental Benefits
• Pet Discount Program

Educational Video
Benefits terminology can get confusing. Click here to watch a quick video to learn the basics
of how our medical plans work.

Deductibles, Copays, Coinsurance, and Out-of-Pocket Maximums
http://video.burnhambenefits.com/terms/
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