What Your Benefits Will Cost
These premiums are deducted from your paycheck on a pre-tax basis through a Premium-Only Section 125 Plan. Due to IRS Regulations, the premiums your pay for a non-tax dependent domestic partner coverage are not eligiible for Section 125 tax savings.
Medical
| Medical - BCBS Coupe Health (PPO Copay Plan) | ||||
|---|---|---|---|---|
| Employee Monthly Rate | Employee Per Pay Rate | |||
| Employee | $230.51 | $106.39 | ||
| Employee + Spouse | $446.23 | $205.95 | ||
| Employee+ Child(ren) | $423.48 | $195.45 | ||
| Family | $679.18 | $313.47 | ||
| Medical· BCBS High Deductible Health Plan (Qualified HSA Plan) | ||||
|---|---|---|---|---|
| Employee Monthly Rate | Employee Per Pay Rate | |||
| Employee | $133.88 | $61.79 | ||
| Employee + Spouse | $422.15 | $194.84 | ||
| Employee+ Child(ren) | $324.98 | $149.99 | ||
| Family | $620.56 | $286.41 | ||
| Medical· Allied Minimum Essential Coverage Plan (MEC Plus) | ||||
|---|---|---|---|---|
| Employee Monthly Rate | Employee Per Pay Rate | |||
| Employee | $58.34 | $26.92 | ||
| Employee + Spouse | $215.19 | $99.32 | ||
| Employee+ Child(ren) | $198.23 | $91.49 | ||
| Family | $319.97 | $319.97 | ||
Dental
| Dental - Guardian Management Plan | ||||
|---|---|---|---|---|
| Employee Monthly Rate | Employee Per Pay Rate | |||
| Employee | $12.96 | $5.98 | ||
| Family | $27.16 | $12.54 | ||
| Dental - Guardian Hourly Plan | ||||
|---|---|---|---|---|
| Employee Monthly Rate | Employee Per Pay Rate | |||
| Employee | $12.91 | $5.96 | ||
| Family | $36.11 | $16.67 | ||
Vision
| Vision· Guardian | ||||
|---|---|---|---|---|
| Employee Monthly Rate | Employee Per Pay Rate | |||
| Employee | $7.36 | $3.40 | ||
| Family | $15.83 | $7.31 | ||
English 
Español