Employee Cost: Medical PPO PLAN A PPO PLAN B HDHP C HDHP D Goshen You Pay Goshen You Pay Goshen You Pay Goshen You Pay Goshen You Pay Goshen You Pay Goshen You Pay Goshen You Pay Pays (26 Pays) Pays (20 Pays) Pays (26 Pays) Pays (20 Pays) Pays (26 Pays) Pays (20 Pays) Pays (26 Pays) Pays (20 Pays) (26 Pays) (20 Pays) (26 Pays) (20 Pays) (26 Pays) (20 Pays) (26 Pays) (20 Pays) Employee $199.00 $119.36 $258.70 $155.17 $199.00 $94.72 $258.70 $123.14 $199.00 $99.95 $258.70 $129.93 $199.00 $69.11 $258.70 $89.84 ALL ELIGIBLE Employee + $438.27 $262.12 $569.75 $340.76 $438.27 $207.91 $569.75 $270.28 $438.27 $219.41 $569.75 $285.23 $438.27 $151.56 $569.75 $197.03 EMPLOYEES Spouse (Including Employee + 75/80/90/100 Child(ren) $356.94 $216.11 $464.03 $280.94 $356.94 $171.75 $464.03 $223.27 $356.94 $181.16 $464.03 $235.51 $356.94 $125.65 $464.03 $163.34 % Teachers) Goshen Goshen Total Goshen Goshen Total Goshen Goshen Total Goshen Goshen Total Family $630.55 $324.54 $819.71 $421.90 $630.55 $250.61 $819.71 $325.79 $630.55 $266.28 $819.71 $346.17 $630.55 $173.78 $819.71 $225.91 Schools Employee Cost Schools Employee Cost Schools Employee Cost Schools Employee Cost Pays Pays Pays Pays Pays Pays Pays Pays Employee $139.30 $179.06 $181.09 $232.78 $139.30 $154.42 $181.09 $200.75 $139.30 $159.65 $181.09 $207.54 $139.30 $128.81 $181.09 $167.45 Employee Only Employee + Employee Only Employee Only $9.88 $19.76 $30.00 Employee Only $9.88 $19.76 $30.00 $9.88 $19.76 $30.00 $9.88 $19.76 $30.00 40/50/60/70 Spouse $306.79 $393.60 $398.83 $511.68 $306.79 $339.39 $398.83 $441.21 $306.79 $350.89 $398.83 $456.15 $306.79 $283.05 $398.83 $367.96 % TEACHER Employee + Employee + Employee + Employee + Employee + $249.86 $278.83 $324.82 $362.48 $249.86 $323.19 $324.82 $420.15 $249.86 $288.24 $324.82 $374.71 $249.86 $232.73 $324.82 $302.55 Child(ren) $39.17 $78.34 $59.00 $39.17 $78.34 $59.00 Spouse $39.17 $78.34 $59.00 Spouse $39.17 $78.34 $59.00 Spouse Spouse Family $441.38 $513.70 $573.80 $667.81 $441.38 $439.77 $573.80 $571.70 $441.38 $455.45 $573.80 $592.08 $441.38 $362.94 $573.80 $471.83 Employee + Employee Employee + Employee + Employee + $28.66 $57.32 $49.00 $119.36 $155.17 $199.00 $94.72 $258.70 $123.14 $28.66 $57.32 $49.00 $199.00 $258.70 $229.68 $69.27 $298.58 $90.05 $229.68 $38.43 $298.58 $49.96 Child(ren) $28.66 $57.32 $49.00 Child(ren) $28.66 $57.32 $49.00 Child(ren) Child(ren) SUPPORT Employee + $438.27 $262.12 $569.75 $340.76 $438.27 $207.91 $569.75 $270.28 $438.27 $219.41 $569.75 $285.23 $438.27 $151.56 $569.75 $197.03 Family Spouse Family Family $53.62 $107.84 $74.00 Family $53.62 $107.84 $74.00 SCHOOL $53.62 $107.84 $74.00 $53.62 $107.84 $74.00 YEAR / SEC / Employee + $356.94 $216.11 $464.03 $280.94 $356.94 $171.75 $464.03 $223.27 $356.94 $181.16 $464.03 $235.51 $356.94 $125.65 $464.03 $163.34 BOOKKEEP Child(ren) Family $630.55 $324.54 $819.71 $421.90 $630.55 $250.61 $819.71 $325.79 $630.55 $266.28 $819.71 $346.17 $630.55 $173.78 $819.71 $225.91 Employee $304.51 $13.85 $395.87 $18.00 $284.49 $9.23 $369.83 $12.00 $294.33 $4.62 $382.63 $6.00 $267.65 $0.46 $347.94 $0.60 GOSHEN Employee + $686.55 $13.85 $892.51 $18.00 $636.95 $9.23 $828.04 $12.00 $653.06 $4.62 $848.98 $6.00 $589.38 $0.46 $766.19 $0.60 EMLOYEE Spouse MARRIED TO Employee + GOSHEN Child(ren) $559.20 $13.85 $726.97 $18.00 $519.46 $9.23 $675.30 $12.00 $533.49 $4.62 $693.53 $6.00 $482.13 $0.46 $626.77 $0.60 EMPLOYEE Family $941.24 $13.85 $1,223.61 $18.00 $871.92 $9.23 $1,133.50 $12.00 $892.22 $4.62 $1,159.88 $6.00 $803.87 $0.46 $1,045.03 $0.60