Page 9 - QSC EE Guide 01-20 SLO

Your cost per paycheck

Biweekly / 26 Payroll Deductions/Year

Medical Options
Plan HSA PPO HMO Full PPO
Discounted Rates* Discounted Rates* Discounted Rates*
Employee Only $40 $70 $90
Employee + Spouse $145 $195 $265
Employee + Child(ren) $90 $140 $200
Employee + Family $188 $245 $310

Standard Rates** Standard Rates** Standard Rates**
Employee Only $90 $120 $140
Employee + Spouse $195 $245 $315
Employee + Child(ren) $140 $190 $250
Employee + Family $238 $295 $360
Dental Options
Plan DMO Base PPO Premier PPO

Employee Only $3 $10 $20
Employee + Spouse $6 $15 $30
Employee + Child(ren) $4 $14 $25
Employee + Family $9 $25 $40
Vision Option
Plan PPO
Employee Only $2
Employee + Spouse $3
Employee + Child(ren) $4
Employee + Family $5
Identity Theft
Plan Benefit Elite Ultimate Plus

Employee $3.92 $11.76
Employee + Dependents $7.84 $23.53

*Discounted Rates - Employees that participated in biometrics and are non-tobacco users.
**Standard Rates - Employees that did not participate in biometrics and/or are tobacco users.

For your convenience, your age-banded Voluntary Life/AD&D premiums have
been pre-calculated for you in UltiPro.

IRS Code Section 125
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 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.