10 / 16
FamilyCareHealthCenters
9
EMPLOYEE COST PER PAY PERIOD
Medical
BASE
ENRICHED
HSA
Employee
$134.84
$190.98
$75.47
Employee & Spouse
$363.07
$461.32
$258.90
Employee & Child(ren)
$306.02
$393.73
$213.01
Family
$534.25
$664.07
$396.59
Dental
Employee
$5.77
Employee & Spouse
$11.62
Employee & Child(ren)
$11.15
Family
$18.94
Employee
$__________ ÷ 1,000 X $__________ = $___________
Amount of
Coverage
Unit Cost from
Rate Table
Employee
Monthly Cost
Spouse
$__________ ÷ 1,000 X $__________ = $___________
Amount of
Coverage
Unit Cost from
Rate Table
Spouse Monthly
Cost
Child(ren)
$__________ ÷ 1,000 X $__________ = $___________
Amount of
Coverage
Unit Cost from
Rate Table
Child(ren)
Monthly Cost
How to Calculate Your Voluntary Life Premium
Vision
Employee
$3.46
Employee & Spouse
$5.54
Employee & Child(ren)
$5.65
Family
$9.12
NOTE: You have the option of paying for your portion of the premiums on a “pre-tax” or “post-tax” basis. You will be
asked through the EMS portal which method you would like. Keep in mind that by electing to have your premiums
taken out of your check on a “pre-tax” basis, this will lock you in for coverage until next open enrollment (or one year).