APPENDIX B - 2020 Rates Medical / Pharmacy , Dental , Vision
MEDICAL / PHARMACY COVERAGE LEVEL
HDHP ( High Deductible Plan ) Medical Plan - MED4
WELLNESS Employee Rate
NON WELLNESS Employee Rate
CITY Rate
Biweekly Annual Biweekly Annual Biweekly Annual
EE Only $ 13.68 $ 355.68 $ 33.68 $ 875.68 $ 279.33 $ 7,262.71 EE + Spouse $ 57.87 $ 1,504.62 $ 77.87 $ 2,024.62 $ 550.13 $ 14,303.26 EE + Child ( ren ) $ 22.80 $ 592.80 $ 42.80 $ 1,112.80 $ 456.41 $ 11,866.71 EE + Family $ 81.28 $ 2,113.28 $ 101.28 $ 2,633.28 $ 772.48 $ 19,312.00
EPO ( Exclusive Provider Plan ) Medical Plan - MED1
Biweekly Annual Biweekly Annual Biweekly Annual
EE Only $ 30.44 $ 791.44 $ 50.44 $ 1,311.44 $ 293.90 $ 7,641.49 EE + Spouse $ 128.78 $ 3,348.28 $ 148.78 $ 3,868.28 $ 547.63 $ 14,238.28 EE + Child ( ren ) $ 76.13 $ 1,979.38 $ 96.13 $ 2,499.38 $ 457.01 $ 11,882.26 EE + Family $ 180.84 $ 4,701.84 $ 200.84 $ 5,221.84 $ 769.01 $ 19,994.18
NOTE : Payroll deductions may differ slightly due to rounding .
DENTAL
Coverage Level
Dental Health Maintenance Organization ( DHMO ) Plan
Low Participating Provider Organization ( PPO ) Plan
High Participating Provider Organization ( PPO ) Plan
Biweekly Annual Biweekly Annual Biweekly Annual
EE Only $ 5.19 $ 134.97 $ 6.71 $ 174.46 $ 16.20 $ 421.20 EE + 1 $ 10.47 $ 272.22 $ 13.30 $ 345.80 $ 32.07 $ 833.82 EE + Family $ 15.72 $ 408.72 $ 23.41 $ 608.66 $ 56.43 $ 1,467.18
VISION |
LOW PLAN |
HIGH PLAN |
Coverage Level |
Biweekly |
Annual |
Biweekly |
Annual |
EE Only |
$ 1.97 |
$ 51.24 |
$ 2.24 |
$ 58.32 |
EE + 1 |
$ 4.09 |
$ 106.44 |
$ 4.67 |
$ 121.32 |
EE + Family |
$ 6.24 |
$ 162.36 |
$ 7.12 |
$ 185.16 |
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