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The Desco Group
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ENROLLMENT WORKSHEET
Medical
Plan 1
Plan 2 (HSA) Monthly Cost
Employee
$60.25
$33.31
Employee & Spouse
$117.48
$64.25
Employee & Child(ren)
$126.52
$69.14
Family
$183.75
$100.08
Dental
Plan 1
Monthly Cost
Employee
$14.02
Employee & Spouse
$32.45
Employee & Child(ren)
$28.35
Family
$46.26
Vision
Plan 1
Monthly Cost
Employee
$4.04
Employee & Spouse
$7.87
Employee & Child(ren)
$8.27
Family
$11.50
Health Savings Account (HSA)
Monthly Cost
If participating, what is your monthly contribution?
(Yearly Maximums: Individual $3,350; Family
$6,750 and if you are 55 or older, you can make “catch-up” contributions of an additional $1,000
per year.)
TDG will contribute $1,320 for Employee coverage and $2,640 for Employee plus
dependents for the 2016 plan year.
Medical Flexible Spending Account
Monthly Cost
If participating, what is your monthly contribution?
($2,550 Yearly Maximum)
Limited Flexible Spending Account
(with an HSA)
Monthly Cost
If participating, what is your monthly contribution?
($2,550 Yearly Maximum)
Dependent Care Flexible Spending Account
Monthly Cost
If participating, what is your monthly contribution?
($5,000 Yearly Maximum )