MEDICAL CONTRIBUTION SCHEDULE
US – Option 1
Employee Cost Per Pay Period
Employee Only
$ 48.46 $216.92 $122.31 $258.46
Employee + Spouse Employee + Child(ren)
Family
US – Option 2
Employee Cost Per Pay Period
Employee Only
$ 57.69 $244.62 $150.00 $320.77
Employee + Spouse Employee + Child(ren)
Family
US – Option 3
Employee Cost Per Pay Period
Employee Only
$115.38 $323.08 $258.46 $408.46
Employee + Spouse Employee + Child(ren)
Family
US – Option 4
Employee Cost Per Pay Period
Employee Only
$145.38 $438.46 $346.15 $588.46
Employee + Spouse Employee + Child(ren)
Family
All employees = 26 pay periods
4
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