Rate Sheet

Per Paycheck Rates

Medical Plans
PPO Plan

Tier

Per Paycheck Rates
(Base Premiums / With Wellness Incentive)

Employee-Only

$91.38 / $68.31

Employee & Spouse

$253.85 / $196.15

Employee & Child(ren)

$169.85 / $146.77

Family

$337.38 / $279.69
HDHP with HSA Plan

Tier

Per Paycheck Rates
(Base Premiums / With Wellness Incentive)

Employee-Only

$78.00 / $54.92

Employee & Spouse

$216.46 / $158.77

Employee & Child(ren)

$145.38 / $122.31

Family

$288.00 / $230.31
Dental Plans
Low Plan

Tier

Per Paycheck Rates

Employee-Only

$12.75

Employee & Spouse

$25.89

Employee & Child(ren)

$33.81

Family

$50.19
High Plan

Tier

Per Paycheck Rates

Employee-Only

$20.40

Employee & Spouse

$41.10

Employee & Child(ren)

$54.16

Family

$80.08
Vision Plan
Vision Service Plan

Tier

Per Paycheck Rates

Employee-Only

$3.50

Employee & Spouse

$5.59

Employee & Child(ren)

$5.71

Family

$9.21
Voluntary Life Insurance
Click here for Premiums Table
Legal Plan
LegalEASE

Tier

Per Paycheck Rates

Standard Enrollment

$10.84
Accident Plan
Mutual of Omaha

Tier

Per Paycheck Rates

Employee-Only

$5.03

Employee & Spouse

$7.84

Employee & Child(ren)

$10.06

Family

$13.64
Hospital Indemnity Plan
Mutual of Omaha

Tier

Per Paycheck Rates

Employee-Only

$5.25

Employee & Spouse

$12.06

Employee & Child(ren)

$7.24

Family

$14.48
Identity Theft Plan
LifeLock

Tier

Per Paycheck Rates

Employee

$6.69

Family

$11.53