Page 18 - California Eye Management EE Guide 2020

Employee Contributions

This chart compares the monthly and bi-weekly 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. This means that contributions are taken from your earnings before taxes, resulting in
lower taxes and increased take home pay.

California Eye Specialists’ Your Your
Monthly Premium Monthly Cost Bi-Weekly Cost
(26 Pay Periods)
Medical Options
Plan Type: HMO Harmony Plan (Plan XIF)

Employee Only $342.28 $119.80 $55.29
Employee + Spouse $752.98 $530.50 $244.84
Employee + Child(ren) $616.08 $393.59 $181.66
Employee + Family $1,061.02 $838.53 $387.01

Plan Type: HMO SignatureValue Plan (Plan UJ7)
Employee Only $401.07 $178.58 $82.42
Employee + Spouse $882.29 $659.81 $304.53
Employee + Child(ren) $721.87 $499.39 $230.49
Employee + Family $1,243.23 $1,020.75 $471.11

Plan Type: PPO Select Plus Balanced (Plan AKK6)
Employee Only $593.78 $417.47 $192.68
Employee + Spouse $1,303.32 $1,172.49 $541.15
Employee + Child(ren) $1,068.73 $920.80 $424.99
Employee + Family $1,840.59 $1,738.75 $802.50
Plan Type: PPO Select Plus HDHP HSA (Plan AYHB)
Employee Only $415.89 $235.03 $108.48
Employee + Spouse $914.89 $771.14 $355.91
Employee + Child(ren) $748.55 $592.43 $273.43
Employee + Family $1,289.17 $1,173.20 $541.48
Dental
Plan Type: DHMO Dental Plan

Employee Only $12.22 $4.28 $1.97
Employee + Spouse $24.43 $16.49 $7.61
Employee + Child(ren) $24.43 $16.49 $7.61
Employee + Family $39.72 $31.78 $14.67
Plan Type: DPPO Dental Plan

Employee Only $37.07 $29.13 $13.44
Employee + Spouse $75.62 $67.68 $31.24
Employee + Child(ren) $84.47 $76.53 $35.32
Employee + Family $128.39 $120.45 $55.59

Vision
Plan Type: Voluntary PPO Vision Plan
Employee Only $10.41 $10.41 $4.80
Employee + Spouse $19.75 $19.75 $9.12
Employee + Child(ren) $23.17 $23.17 $10.69
Employee + Family $32.61 $32.61 $15.05

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