Cost of Coverage - Medical HMO
| Signature Value Advantage (TEJ) | Signature Value Alliance (2J4) | Signature Value Full HMO (TDF) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| EE Monthly Cost | EE Per Pay Cost | EE Monthly Cost | EE Per Pay Cost | EE Monthly Cost | EE Per Pay Cost | |||||||
| Tier 1 (< $80.000) | ||||||||||||
| Employee | $276.00 | $138.00 | $232.00 | $116.00 | $338.00 | $169.00 | ||||||
| Employee + 1 Dependent | $338.00 | $169.00 | $285.00 | $142.50 | $467.00 | $233.50 | ||||||
| Employee + 2 Dependents | $355.00 | $177.50 | $299.00 | $149.50 | $549.00 | $274.50 | ||||||
| Tier 2 ($80,001 - $120,000) | ||||||||||||
| Employee | $296.00 | $148.00 | $249.00 | $124.50 | $358.00 | $179.00 | ||||||
| Employee + 1 Dependent | $381.00 | $190.50 | $321.00 | $160.50 | $510.00 | $255.00 | ||||||
| Employee + 2 Dependents | $411.00 | $205.50 | $346.00 | $173.00 | $614.00 | $307.00 | ||||||
| Tier 3 ($120,001 - $200,000) | ||||||||||||
| Employee | $330.00 | $165.00 | $278.00 | $139.00 | $390.00 | $195.00 | ||||||
| Employee + 1 Dependent | $460.00 | $230.00 | $387.00 | $193.50 | $588.00 | $294.00 | ||||||
| Employee + 2 Dependents | $508.00 | $254.00 | $428.00 | $214.00 | $722.00 | $361.00 | ||||||
| Tier 4 (> $200,001) | ||||||||||||
| Employee | $365.00 | $182.50 | $307.00 | $153.50 | $425.00 | $212.50 | ||||||
| Employee + 1 Dependent | $506.00 | $253.00 | $426.00 | $213.00 | $638.00 | $319.00 | ||||||
| Employee + 2 Dependents | $558.00 | $279.00 | $470.00 | $235.00 | $772.00 | $386.00 | ||||||
Cost of Coverage - Medical PPO
| Signature Value Low PPO (CQI2) |
Signature Value High PPO CUI9_Mod1 |
Signature Value HDHP/HSA PPO (DIWC) |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| EE Monthly Cost | EE Per Pay Cost | EE Monthly Cost | EE Per Pay Cost | EE Monthly Cost | EE Per Pay Cost | |||||||
| Tier 1 (< $80.000) | ||||||||||||
| Employee | $210.00 | $105.00 | $370.00 | $185.00 | $20.00 | $10.00 | ||||||
| Employee + 1 Dependents | $330.00 | $165.00 | $576.00 | $288.00 | $40.00 | $20.00 | ||||||
| Employee + 2 Dependents | $370.00 | $185.00 | $646.00 | $323.00 | $80.00 | $40.00 | ||||||
| Tier 2 ($80,001 - $120,000) | ||||||||||||
| Employee | $230.00 | $115.00 | $396.00 | $198.00 | $40.00 | $20.00 | ||||||
| Employee + 1 Dependents | $355.00 | $177.50 | $620.00 | $310.00 | $80.00 | $40.00 | ||||||
| Employee + 2 Dependents | $395.00 | $197.50 | $715.00 | $357.50 | $120.00 | $60.00 | ||||||
| Tier 3 ($120,001 - $200,000) | ||||||||||||
| Employee | $260.00 | $130.00 | $425.00 | $212.50 | $60.00 | $30.00 | ||||||
| Employee + 1 Dependents | $400.00 | $200.00 | $670.00 | $335.00 | $100.00 | $50.00 | ||||||
| Employee + 2 Dependents | $440.00 | $220.00 | $760.00 | $380.00 | $140.00 | $70.00 | ||||||
| Tier 4 (> $200,001) | ||||||||||||
| Employee | $300.00 | $150.00 | $451.00 | $225.50 | $100.00 | $50.00 | ||||||
| Employee + 1 Dependents | $460.00 | $230.00 | $720.00 | $360.00 | $140.00 | $70.00 | ||||||
| Employee + 2 Dependents | $510.00 | $255.00 | $820.00 | $410.00 | $200.00 | $100.00 | ||||||
Cost of Coverage - Dental
| Dental Rates | Met Life Dental PPO EE Monthly Rate | EE Per Pay Cost | MetLife Dental HMO | EE Per Pay Cost |
|---|---|---|---|---|
| Employee | $8.00 | $4.00 | $3.00 | $1.50 |
| Employee + 1 Dependent | $17.00 | $8.50 | $5.00 | $2.50 |
| Employee + 2 Dependents | $22.00 | $11.00 | $7.00 | $3.50 |
Cost of Coverage - Vision
| Dental Rates | Met Life Vision EE Cost |
|---|---|
| Employee | $0.00 |
| Employee + 1 Dependent | $0.00 |
| Employee + 2 Dependents | $0.00 |