14 / 21
Sugar Creek Capital
13
EMPLOYEE COST PER PAY PERIOD
Medical
E9F
$1,000 Ded
E9J
$1,500 Ded
E9B
$5,000 Ded
E9Y (HSA)
$3,000 Ded
Employee
$68.65
$39.95
$25.35
$12.45
Employee & Spouse
$317.80
$257.55
$226.90
$199.75
Employee & Child(ren)
$272.50
$218.00
$190.25
$165.70
Family
$499.00
$415.80
$373.45
$335.95
Dental
P5430
Employee
$12.00
Employee & Spouse
$24.00
Employee & Child(ren)
$24.25
Family
$37.35
Vision
V1008
Employee
$3.30
Employee & Spouse
$6.28
Employee & Child(ren)
$7.33
Family
$10.33
Health Savings Account (HSA)
If participating, what is your monthly contribution?
(Yearly Maximums: Individual $3,400; Family $6,750
and if you are 55 or older, you can make “catch-up” contributions of an additional $1,000 per year.)
Contact Human Resources to obtain the H.S.A. contribution form.