15 / 22
2018 Benefits Guide
14
EMPLOYEE COST PER PAY PERIOD
Medical
E9F
$1,000 Ded
E9J
$1,500 Ded
E9B
$5,000 Ded
E9Y (HSA)
$3,000 Ded
Employee
$86.78
$55.79
$40.02
$26.06
Employee & Spouse
$355.86
$290.78
$257.65
$228.34
Employee & Child(ren)
$306.93
$248.05
$218.09
$191.57
Family
$551.55
$461.68
$415.99
$375.46
Dental
P5430
Employee
$12.97
Employee & Spouse
$25.93
Employee & Child(ren)
$26.18
Family
$40.34
Vision
V1008
Employee
$3.30
Employee & Spouse
$6.27
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.