Cost of Coverage - Medical HMO
| California Care HMO Classic | Priority Select HMO Classic | Vivity HMO Value Ded | ||||
|---|---|---|---|---|---|---|
| EE Monthly Cost | ||||||
| Tier 1 (< $80.000) | ||||||
| Employee | $358.00 | $236.00 | $192.00 | |||
| Employee + 1 Dependent | $487.00 | $298.00 | $245.00 | |||
| Employee + 2 Dependents | $569.00 | $315.00 | $259.00 | |||
| Tier 2 ($80,001 - $120,000) | ||||||
| Employee | $388.00 | $256.00 | $209.00 | |||
| Employee + 1 Dependent | $540.00 | $341.00 | $281.00 | |||
| Employee + 2 Dependents | $644.00 | $371.00 | $306.00 | |||
| Tier 3 ($120,001 - $199,999) | ||||||
| Employee | $420.00 | $300.00 | $248.00 | |||
| Employee + 1 Dependent | $618.00 | $430.00 | $357.00 | |||
| Employee + 2 Dependents | $752.00 | $478.00 | $398.00 | |||
| Tier 4 ($200,000-$249,000) | ||||||
| Employee | $465.00 | $345.00 | $287.00 | |||
| Employee + 1 Dependent | $678.00 | $486.00 | $406.00 | |||
| Employee + 2 Dependents | $812.00 | $538.00 | $450.00 | |||
| Tier 5 ($250,000) | ||||||
| Employee | $500.00 | $365.00 | $307.00 | |||
| Employee + 1 Dependent | $700.00 | $506.00 | $426.00 | |||
| Employee + 2 Dependents | $850.00 | $568.00 | $470.00 | |||
Cost of Coverage - Medical PPO
| Prudent Buyer PPO 1500 | Prudent Buyer PPO HSA | |||
|---|---|---|---|---|
| EE Monthly Cost | ||||
| Tier 1 (< $80.000) | ||||
| Employee | $390.00 | $120.00 | ||
| Employee + 1 Dependents | $596.00 | $140.00 | ||
| Employee + 2 Dependents | $665.00 | $180.00 | ||
| Tier 2 ($80,001 - $120,000) | ||||
| Employee | $416.00 | $140.00 | ||
| Employee + 1 Dependents | $640.00 | $180.00 | ||
| Employee + 2 Dependents | $735.00 | $220.00 | ||
| Tier 3 ($120,001 - $200,000) | ||||
| Employee | $455.00 | $160.00 | ||
| Employee + 1 Dependents | $700.00 | $200.00 | ||
| Employee + 2 Dependents | $790.00 | $240.00 | ||
| Tier 4 ($200,000 - $249,000) | ||||
| Employee | $300.00 | $200.00 | ||
| Employee + 1 Dependents | $460.00 | $250.00 | ||
| Employee + 2 Dependents | $510.00 | $300.00 | ||
| Tier 4 ($250,000) | ||||
| Employee | $520.00 | $250.00 | ||
| Employee + 1 Dependent | $800.00 | $300.00 | ||
| Employee + 2 Dependents | $900.00 | $400.00 | ||
Cost of Coverage - Dental
| Dental Rates | Dental PPO EE Monthly Rate | Dental HMO EE Monthly Rate |
|---|---|---|
| Employee | $8.00 | $3.00 |
| Employee + 1 Dependent | $17.00 | $5.00 |
| Employee + 2 Dependents | $22.00 | $7.00 |
Cost of Coverage - Vision
| Dental Rates | Vision EE Cost |
|---|---|
| Employee | $0.00 |
| Employee + 1 Dependent | $0.00 |
| Employee + 2 Dependents | $0.00 |