2013 benefits summary

8/13/2019 2013 Benefits Summary

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2013 U.S. Benefits Highlights


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Benefits EligibilitySilver Spring Networks offers these benefits to active, full-time employees normally scheduledto work at least 25 hours per week. Eligible employees may enroll themselves and eligibledependents in benefits. You can cover yourself, your spouse, including a same gender domesticpartner1if the partnership is legally recognized by the state in which the license or certificate isissued, and any dependent children up to age 26.

What Happens if You Dont EnrollIf you do not make any enrollment elections, you will only be enrolled in the Basic Life/AD&Dand Short and Long Term Disability plans.

Medical CoverageAs a participant in Silver Spring Networks benefits program, you may choose the medical planthats right for you and for your family. Your choices include:

Blue Shield PPO Plans Offers two PPO plans with varying levels of comprehensivecoverage and benefits for routine care with the freedom to obtain care from in- and out-of-network providers. Includes a network of participating doctors, hospitals and other healthcare providers. Your out-of-pocket expenses will be lower and you will receive a higher levelof coverage when you use PPO network providers.

Shield Savings Plus 1800 with Health Savings Account (HSA) Plan Similar in designto the PPO plan, but allows you to pay for your deductible and eligible out-of-pocketexpenses using a Health Savings Account (HSA), which both you and Silver SpringNetworks can contribute money into. If funds in your HSA are not used in a year, they arecarried over to the next plan year. See page 7 for more details about this new medical planoption.

Kaiser Permanente HMO Plan(California) Generally costs less money at the time youseek services than a PPO plan, but requires you to receive all of your care and servicesthrough the HMOs network providers.

Waive You can also choose to waive medical coverage.

1A domestic partner is someone with whom you live in an exclusive, committed relationship and expect to do so indefinitely. You and your domestic partnermust consider themselves to be life partners, not be married to any other person, and be financially interdependent and can provide evidence if requested.


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The chart below compares some of the main features of the medical plans so you can evaluatethem side-by-side. The percentages and copayments below reflect your responsibility.

Plan Feature

Blue Shield PPO

100/50 250

Blue Shield PPO

90/70 250

Shield Savings Plus 1800

w/HSA Plan *

Kaiser HPlan

(Califor

In-NetworkOut-of-

NetworkIn-Network Out-of-Network

In-NetworkOut-of-

Network

Providers You may use any licensed

provider but your out-of-pocketcosts will be less when you use

in-network providers

You may use any licensed

provider but your out-of-pocketcosts will be less when you use

in-network providers

You may use any licensed

provider but your out-of-pocketcosts will be less when youuse in-network providers

You mus

the HMprovide

otherwisPlan wilpay ben

Preventive Care: No charge 50% afterdeductible

No charge 30% afterdeductible

No charge Not Covered No cha

Annual Deductible(Individual/Family)

$250/$500

$500/$1,000

$250/$500

$1,800/

$3,600

$1,800/

$3,600

NA

Coinsurance No charge afterdeductible

50% afterdeductible

10% afterdeductible

30% afterdeductible

10% afterdeductible

30% afterdeductible

NA

Out-of-Pocket Max(individual/family) $2,000/$4,000 $5,000/$10,000 $2,000/$4,000 $10,000/$20,000 $4,000/$8,000 $8,000/$16,000 $3,00$6,00

Office Visits $20 copay

(no deductible)

50% afterdeductible

$20 copay 30% afterdeductible

10% afterdeductible

30% afterdeductible

$15 co

Lab/x-ray $20 copay

after deductible

50% afterdeductible

$20 copay 30% afterdeductible

10%** afterdeductible

30% afterdeductible

$10 pencoun

Outpatientsurgery

$100 persurgery afterdeductible

50%+ allcharges inexcess of

$350 per day

10% afterdeductible

30%+ allcharges in

excess of $350per day

10% afterdeductible

30%+ allcharges inexcess of

$350 per day

$15 pproced

Inpatienthospitalization

$200 per admitafter deductible

50% afterdeductible +

all charges inexcess of

$600 per day

10% afterdeductible

30%+ allcharges in

excess of $600per day

10% afterdeductible

30% afterdeductible +

all charges inexcess of

$600 per day

$200 per

Emergency Room $100 per visit 10% afterdeductible

10% afterdeductible

10% afterdeductible

10% afterdeductible

$100 pe

Chiropractic $25/visit

(12 visits/year)

50% afterdeductible

(12 visits/year)

$25/visit

(12 visits/year)

50% afterdeductible

(12 visits/year)

10% afterdeductible

(20 visits/yr)

50% afterdeductible

(20 visits/yr)

$15/v

(20 visits

*When enrolling dependents on the Shield Savings 1800 plan the full family deductible must be satisfied before the plan will pay.

**Lab/X-Ray performed in a hospital setting are subject to an additional $25 copay for basic lab/x-ray or a $100 copay for high cost procedures.


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Health Savings Account (HSA) Medical PlanWhen you enroll in theShield Savings Plus 1800 with HSA Plan, you are able to use a HSA tohelp you pay deductibles and eligible out-of-pocket expenses. This plan has lower premiumsand includes a portable savings account.

The basic concept behind the HSA Medical Plan is simply to encourage you to:

Take care of yourself, by providing full coverage for preventive care

Shop smart and share in the cost, when you need care

If you have a serious health issue, after you meet the deductible and reach your out-of-pocket maximum, your eligible expenses are 100% covered.

Heres how it works:

1. Health Savings AccountEssentially, a Health Savings Account is similar to a personal bank account that both you andSilver Spring Networks can contribute pre-tax money to. Then, when you need care, you canuse those funds to help pay for eligible medical expenses.

Silver Spring Networks will contribute the following pre-tax amounts to your HSA in 2013:

$900 if you enroll yourself

$1,800 if you enroll yourself and eligible dependents

You can also contribute to your HSA, up to the IRS maximum of $3,250 (individual) or $6,450(family). These maximums include the amounts Silver Spring Networks contributes on yourbehalf. If you are age 55 or older, you can also contribute up to $1,000 in catch-upcontributions each year.

Any pre-tax contributions you make to your HSA will be deducted from your pay in equalinstallments throughout the year; likewise, Silver Spring Networks contribution is made per payperiod.

If you dont use all of the HSA fundsaccumulated by year end, these fundsroll over for future use. There is nolimit to how much you can roll overyear to year. The result is that infuture years you may not necessarilyhave to use your own money to meetyour deductible or even your out-of-pocket maximum.

So over the long-term, you canaccumulate money in the HSA to helppay for your future health care needs.

And, perhaps more importantly, youcan use the HSA to fund your long-term health care needs such aspaying for health care coverage whenyou are retired with tax-free money.Thats because if you leave Silver Spring Networks, you take any money accumulated in yourHSA with you (HSA funds used for non-medical expenses will be subject to applicable taxes).


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Questions about the HSA Medical Plan?

If you have questions about the HSAMedical Plan or your benefits in general,ClearBenefits representatives [email protected] or(888) 423-6457.

BlueShield also offers helpful informationabout the plan as well as consumer toolsand information to assist with pricing healthcare services at www.blueshieldca.com.

2. Bridging the DeductibleThe Plan has a deductible. This is the amount of expense that must be incurred before the Planbegins paying traditional benefits. You can meet your deductible one of two ways: by paying forit with after-tax out-of-pocket dollars or with money from your HSA.

In the first year you participate in the Plan, to meet your deductible you can use the moneySilver Spring Networks contributes to your HSA plus your own funds (either tax-free HSA fundsor after-tax dollars). However, if you roll over funds in your HSA from one year to the next, its

possible that in future years you will have enough money in your HSA to fully meet your annualdeductible.

3. Traditional CoverageAfter the deductible is met, you pay a percentage of any additional medical services you receive(coinsurance), up to your annual out-of-pocket maximum. The plan pays:

90% when you use network providers you pay the remaining 10%, and

70% when you use non-network providers you pay the remaining 30%

The HSA Plan uses the same Blue Shield network as currently offered under the PPO plan.

With the Plan as with more traditional medical

plans you are protected from significant financialloss due to a serious medical situation. The planpays 100% once you reach the following out-of-pocket maximums (including deductible &coinsurance):

$4,000 individual/$8,000 family, when you usein-network providers, and

$8,000 individual/$16,000 family, when you useout-of-network providers

Important Considerations about the HSA Medical PlanThe IRS sets limits on the total HSA contributions allowed in a year - HSA contributionscannot exceed $3,250 individual or $6,450 for you and your family. This includes theamounts contributed by Silver Spring Networks and the funds that you contribute on a pre-tax basis. If you are enrolled in the HSA plan for the entire calendar year and receive SilverSpring Networks full annual contribution (funded on a per-pay period basis), you maycontribute up to $2,350 individual or $4,650 family.

HSAs are federally tax-free; however, they may be subject to state tax.

The money in your account earns interest that compounds tax-free.

If you and/or your spouse/domestic partner are age 55 or older, you may contribute more toyour HSA in a year than those under age 55. You are entitled to make additional catch-upcontributions of up to $1,000 in 2013.


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Health Care Terms to Know

Annual Deductible Theamount you must pay before thePlan begins paying benefits. Thedeductible generally doesntapply, however, for servicessubject to a copayment.

Coinsurance The percentageamount both you and the Planpay when you obtain medicaland/or dental care. In general,you must first meet yourdeductible before the Planscoinsurance payments begin.

Copayment A flat dollaramount you pay when you obtaincertain services; copaymentsgenerally apply when you obtainyour care from in-networkproviders.

Health Savings Account (HSA) A tax privileged account thatyou and your employer cancontribute funds to on a pre-taxbasis. The funds may be used tohelp pay for eligible health careexpenses.

Consumer-Driven PlanYoushare in the responsibility of howyour health care dollars arespent. Like the BlueShield HSA,most consumer-driven plans havea deductible to meet beforebenefits are paid, but also providetools to educate you about healthcare options and empower you totake control of your health.

Bridge - The bridge is theamount you need to pay afteryou have used your availableHSA dollars (or if you choose notto use your HSA dollars to payfor covered services) before theplan pays covered expenses.You must pay the entire bridgeamount in order to satisfy yourplans deductible, before thetraditional health coveragecomponent of the plan begins.

Plan Lifetime Maximum Themaximum amount the Plan willpay over the course of a coveredindividuals lifetime.

Plan Annual Maximum Themaximum amount the Plan willpay in any year toward the costof covered services.

Out-of-Pocket Maximum Themaximum amount you must payin a given Plan Year before thePlan pays 100% of all remainingeligible expenses. The out-of-pocket maximum generally onlyapplies under the medical plans.

Usual and Customary (U&C)The average dollar amounthealth care providers charge fora specific service within aspecific geographical area. If youparticipate in the PPO medicalplan and use out-of-networkproviders, youre responsible foryour portion of the U&C charge(coinsurance), plus any amountabove U&C that the particularprovider charges.


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Prescription DrugsWhen you elect a medical plan option, you also receive prescription drug coverage. The chartbelow shows what you can expect to pay for prescription drugs under the Blue Shield PPOPlans, the Shield Savings Plus 1800 w/HSA Plan and the Kaiser Permanente HMO:

BlueShield

PPO Plans

Shield Savings Plus 1800

HSA PlanKaiser HMO

Plan(California)1In-Network

Out-of-Network

In-NetworkOut-of-

Network

RetailPrescriptionDrugsUp to 30-daySupply

Generic: $10Brand Formulary: $25

Brand Non-Formulary: $40

Copay + 25% PlanDeductible

Applies, then

Generic: $10Brand

Formulary:$25

Brand Non-Formulary:

$40

PlanDeductibleApplies

Copay + 25%

Generic: $10Brand: $25

Mail OrderPrescriptionDrugsup to a 90-daySupply

Generic: $20Brand Formulary: $50

Brand Non-Formulary: $80

Not Covered PlanDeductible

Applies, then

Generic: $20Brand

Formulary:$50

Brand Non-Formulary:

$80

Not Covered Generic: $20Brand: $50

(up to a 100day supply)

1No benefits are paid for Kaiser members prescriptions filled through a non-HMO pharmacy

Using generic drugs and taking advantage of the plans mail order service can save you

money. Generic drugs contain the same active ingredients, safety, dosage, quality and strengthas their brand-name counterparts and are often sold under the chemical or scientific name forthe drug. They are often made by the same companies in the same factories, but the brand-name versions can cost much more.

The prescription drug mail order option helps you spend less on your maintenance drugs suchas medication to treat high blood pressure, high cholesterol or thyroid conditions. Employeesusing maintenance medications are encouraged to switch to the mail order program through thevendor. To learn more or to sign up for the mail order program, contact the vendors: BlueShieldat www.blueshieldca.comor Kaiser at www.kaiserpermanente.org.


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Dental CoverageMetLife administers Sliver Spring Networks dental plan. Your dental plan benefits allow you to:

Visit any licensed dentist you choose (with the flexibility to select a different dentist for eachmember of your family).

Save on out-of-pocket expenses when you visit an in-network Dental PPO dentist as such

dentists have agreed to charge plan participants no more than the (usually lower) negotiatedfee.

The following chart outlines the 2013 dental coverage benefits administered through MetLife.

Participating Providers*Non-participating

Providers**

Annual Deductible None$50 per person$150 per family

Preventive and Diagnostic Care

Cleanings and Consultations

Plan pays 100% (nodeductible)

Plan pays 100% of R&C(no deductible)

Basic Care

Fillings, Root Canals, and Oral SurgeryPlan pays 80% Plan pays 80%

Major Restorative Care

Bridges, Crowns, and DenturesPlan pays 50% Plan pays 50%

Orthodontia Treatment50%, lifetime max of

$1,500 per adult and/orchild

50%, lifetime max of$1,500 per adult and/or

child

Annual Benef it Maximum$1,750 per person,

excluding orthodontia$1,750 per person,

excluding orthodontia

*The participating percentage of benefits is based on the discounted fee negotiated with the provider.

**The non-participating percentage of benefits is based on the Reasonable and Customary (R&C) charges for your geographic area

Vision CoverageThe Vision Plan, through VSP, provides comprehensive vision care coverage, paying benefitsboth for regular eye exams and corrective eyewear (lenses and frames or contact lenses). Theplan does not provide benefits for cosmetic eye wear or corrective eye surgery, thoughdiscounts may be available for some services. The following chart highlights the vision plancoverage:

VSP Coverage*

Exams $20 copay; once every year

Glasses $25 copay; once every year

Lenses Every 12 months

Frames Up to $130, every 24 months

Contacts, in lieu of lenses and frames Up to $130, every 12 months

*VSP reimbursement amounts for using non-VSP providers varies. Please see Summary Plan Description for details.


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Life and Accident InsuranceTo help you provide for your family if something were to happen to you, Silver Spring Networksprovides you with a basic amount of Life and Accidental Death & Dismemberment (AD&D)insurance coverage. You can purchase additional voluntary insurance for yourself and yourfamily. CIGNA is the carrier for these benefits.

The company pays the full cost of basic life insurance for you in the amount of two times your

base annual salary to a maximum of $500,000. Under the voluntary life insurance program, youhave the option of purchasing an increased benefit amount for yourself and your family.

You can purchase optional voluntary life and AD&D insurance, as follows:

$30,000 to $150,000 in increments of $30,000 for yourself

$25,000 for your spouse/domestic partner (employee coverage required)

$1,000 for dependents from birth to 6 months of age; $10,000 for dependents 6 months to19 years old (employee coverage required).

For this year only, if you are currently enrolled in the employee voluntary life program and wishto increase your level of coverage up to the Guarantee Issue amount, you will not need tocomplete the online Evidence of Insurability (EOI) form. If you would like to enroll in thevoluntary life insurance program and have waived coverage in the past, full underwriting will notbe required.

Income ReplacementDisability insurance pays a portion of your income if you are unable to work for an extendedperiod of time due to pregnancy, personal illness or a non-work-related injury. The companyprovides basic disability benefits at no cost to you.

Short-Term DisabilityCompany-paid basic short-term disability (STD) insurance, through CIGNA, pays a benefit of 60percent of your weekly base salary up to $3,464 for up to 12 weeks (with 7 day waiting period).

You have to opportunity to elect a buy-up option to increase your income replacement for short-term disability. This benefit is 100% employee paid. When you elect the buy-up option, yourshort-term disability benefit increases your income replacement benefit to 66 2/3 percent of yourweekly base salary up to $3,464 for up to 12 weeks (with 7 day waiting period).

Long-Term DisabilityCompany-paid basic long-term disability insurance, through CIGNA, pays a benefit of 60percent of your base salary, up to a maximum monthly benefit of $15,000. This amount is offset

by benefits from other sources, such as Social Security. Benefits begin after 90 days of disabilityand can continue as long as your remain disabled up to your normal retirement age.

You have to opportunity to elect a buy-up option to increase your income replacement for long-term disability. This benefit is 100% employee paid. When you elect the buy-up option, yourlong-term disability increases your income replacement benefit to 66 2/3 percent of yourmonthly base salary up to $15,000.


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Sample Elig ible FSA Expenses

Health Care

Some sample eligible Health Care FSAexpenses include, but are not limited

to:Deductibles, coinsurance, andcopayments

Prescription eyeglasses andsunglasses, or contact lenses andassociated supplies

Lasik surgery

Prescription drugs

Dependent Care

Eligible expenses include amounts youpay for:

In-home child or elder careservices

Services provided by a day carefacility

Fees you pay for a specialty camp,such as soccer or computer camp,if the camp also serves asnecessary day care

Flexible Spending AccountsSilver Spring Networks offers benefits that can help you save money on your taxes our tax-free Flexible Spending Accounts or FSAs. You can use the FSAs to help pay for many healthcare and dependent (i.e., child or elder) care expenses.

Participating in an FSA is voluntary, and you can participate in the FSAs even if you (or yourdependents) are not enrolled in any of Silver Spring Networks health care plans. Silver Spring

Networks offers two FSAs, the:

Health Care FSA: An account you can use to pay eligible health care expenses that are notcovered or fully covered by your Silver Spring Networks health care plans (such ascopayments, deductible and coinsurance amounts, and amounts spent on health careexpenses eligible for reimbursement under the FSA but not covered by any other healthcare plans in which you are enrolled). Please note: Ifyou enroll in the Blue Shield HSA plan, you will not beeligible to participate in the Health Care FSA.

Dependent Care FSA:An account you can use to payfor dependent care expenses you incur on behalf of aneligible dependent so that you (and your spouse) can

work, go to school full-time, or look for work.

How FSAs WorkMoney you contribute to an FSA is not subject to federalincome or FICA (Social Security) taxes, or state incometaxes in most instances. They extend your buying powerbecause you pay less tax. Each year you specify howmuch of your pay you want to put into each FSA. You canselect any whole dollar amounts up to the followingmaximums:

Health Care FSA Yearly Maximum:$2,500

Dependent Care FSA Yearly Maximum:Up to $5,000(depending on your marital and income-tax filing status;$2,500 if married, filing separately)

Silver Spring Networks will deduct from your paycheck theamount you elect to contribute, before taxes, in equalamounts each pay period and deposited into your FSAaccount(s).

When you have an eligible expense and a claim issubmitted to the FSA administrator, the money in your FSAaccount is then used to reimburse you.

Some Important Rules for FSAsFor the Dependent CareFSA2, you are reimbursed up to the amount you currently havedeposited in the account. If your claim exceeds your current deposit, the excess will be helduntil you have deposited enough money to cover it.

2You can use the Dependent Care FSA to pay for the day care expenses you (or you and your spouse) incur in order to work, look for work or attend school.

Expenses must be incurred on behalf of an eligible dependent, generally a child up to the age of 13 or an elder who requires care and is dependent on you forsupport.


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For the Health CareFSA, however, you can claim up to the full amount of your annualdeposit as soon as you incur an eligible expense. You dont have to wait until thecontributions are actually in your account.

Once you have chosen the amount of your FSA deposit for the year, you cannot changeyour mind until the next annual enrollment period unless you experience a qualifiedchange in status, such as a marriage or birth of a child.

Health Care and Dependent Care Flexible Spending Accounts are use it or lose it

accounts. That means that you have until December 31, 2013 to use the funds in youraccount(s). If you dont use whats in your Health Care FSA or Dependent Care FSA byDecember 31, 2013, you forfeit any money left in your account(s). Claims for expensesincurred in the 2013 plan year must be submitted no later than March 31 of the followingyear.

You are only able to receive reimbursement for expenses for certain over-the-counter(OTC) medications if you have a prescription. Generally, this change only affects OTCmedicationsnot supplies. Certain OTC items are eligible without a prescription.

The following chart is not a complete list, but outlines examples that will or will notrequire a prescription to receive reimbursement:

OTC Requiring Prescription OTC No Prescription Required

Allergy medications Contact lens supplies & solution

Cough, cold & flu medications Crutches

Pain relief medications Band-Aids & first-aid supplies

Sleep aids & sedatives Diabetic supplies (blood sugar test kits & Insulin)

Expenses for which you receive reimbursement from the FSAs cannot be claimed as adeduction (health care) or credit (dependent care) on your income taxes.

Due to IRS regulations, you generally cannot use an FSA to pay expenses incurred onbehalf of a domestic partner or your partners children.

If you enroll in the BlueShield HSA plan for 2013, you will not be able to participate in theHealth Care FSA.

FSAs can be used only for expenses considered eligible by the IRS as determined by our FSAadministrator, Flex-Plan. For a listing of eligible expenses, visit their website atwww.flex-plan.comor the IRS Web site atwww.irs.govand look for Publications 502 and 503.3

3Please keep in mind that not all expenses eligible for reimbursement are considered eligible under the IRS-allowed health care deduction and dependent caretax credit; therefore, there are differences between what is listed as an eligible expense in the IRS publications and what you may reimburse yourself for throughthe FSAs. For example, you may use Health Care FSA funds to reimburse yourself for over-the-counter medications (with a prescription); however, suchexpenses are not eligible for a tax deduction and thus are not listed as an eligible expense in the IRS publication.
http://www.flex-plan.com/http://www.flex-plan.com/http://www.flex-plan.com/http://www.flex-plan.com/http://www.irs.gov/http://www.irs.gov/http://www.irs.gov/http://www.irs.gov/http://www.flex-plan.com/http://www.flex-plan.com/


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Commuter BenefitsSilver Spring Networks offers commuter benefits that allow you to pay for work-relatedtransportation with before-tax dollars. The cost of commuting and/or parking is deducted fromyour paycheck before payroll taxes are calculated, which saves you money on income tax andFICA (Social Security). The commuter benefits are for use by employees who take publictransportation or ride a vanpool to get to work or who pay to park their cars in public lots at or

near their places of work, or to commute by public transportation.A unique feature of commuter benefits is that you can participate in these accounts as you needthem. You can sign up for an entire year, or just one month at a time. Log onto the Flex-PlanServices website atwww.flex-plan.comto purchase transit and parking benefits or to learn moreabout the program.

Employee Assistance Program (EAP)The EAP or Life Assistance plan, administered by Cigna, is designed to help you manage lifeschallenges. Everyone needs a helping hand once in a while, and your EAP can provide it. It canrefer you to professional counselors and services that can help you resolve emotional health,family and work issues. This benefit is provided at no cost to you, and is available to allhousehold members. There is no enrollment; and, you do not need to be enrolled in the SilverSpring Network medical plans.

Resources available to you include:

Up to three (3) face-to-face meetings with a consultant per issue

Childcare and/or eldercare referrals

Personal relationship information

Health information and online tools

Legal consultations with licensed attorneys

Financial planning assistance

Stress management

Career development

Information about EAP is available by calling (800) 538-3543 or online atwww.Cignabehavioral.com/CGI (username: rewards; password: savings)

Hyatt Legal PlanWhether youre buying a new home, drawing up a will, or just need some legal advice, HyattLegal Plan can give you easy access to highly experienced, participating attorneys, plus a wide

range of covered legal services at an affordable cost of $9.75 per pay period. When you enrollin the Hyatt Legal Plan, you are enrolling for the entire year. You can only make a change if youexperience a qualified change in status such as a marriage or birth. For more information call(800) 821-6400 or go online towww.legalplans.com(select Thinking about Enrolling).
http://www.flex-plan.com/http://www.flex-plan.com/http://www.flex-plan.com/http://www.legalplans.com/http://www.legalplans.com/http://www.legalplans.com/http://www.legalplans.com/http://www.flex-plan.com/


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Your Semi-Monthly ContributionsThis chart shows Silver Spring Networks and your semi-monthly premium contributions for the2013 Plan Year.

Medical/Dental/Vision

Short-term & Long-term Disability Buy-upThe cost for Short-term and/or long term disability Buy-up is covered through post-tax payrolldeductions and varies based on your income and benefit eligibility.

Example:

An employee earns an annual salary of $115,000.

Buy-up Short-term Disability: $115,000 / 52 x 0.6667 = $1,474.43 total weekly benefit

$1,474.43 / $10 x $0.015 = $2.21 cost per pay period

Buy-up Long-term Disability: $115,000 / 12 = $9,583.33 of monthly base salary

$9,583.33 / $100 x 0.060 = $5.75 cost per pay period

Note: due to policy limitations, employees earning over $270,000 should use a $270,000 annualsalary to estimate their cost per pay period.

YouOnly

You +spouse/

domestic partnerYou + Child

You +Child(ren)

You + Family

Blue Shield PPO

(100/50 250)$64.00 $157.00 $148.00 $148.00 $294.25

Blue Shield PPO

(90/70 250)$33.00 $107.50 $102.00 $102.00 $192.50

Blue Shield

Plus 1800 HSASavings

$12.50 $45.00 $40.00 $40.00 $72.50

Kaiser HMO CA $13.25 $45.00 $42.50 $42.50 $61.00Dental MetLife $2.50 $8.25 $8.25 $16.50 $16.50

Vision VSP $1.00 $1.50 $1.50 $3.00 $3.00

Employee Only You pay (semi-monthly)

Short-term Disability

Buy-up Option

$0.015 for each $10 of

weekly benefit

Long-term Disability

Buy-up Option

$0.060 for each $100 of

your monthly base salary


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Voluntary Life and AD&D InsuranceThe cost for Voluntary Life and Accidental Death and Dismemberment insurance is coveredthrough post-tax payroll deductions. The cost of the benefit varies based on your (or yourspouses/domestic partners) age, volume of coverage, and whether or not you are a tobaccouser. The chart below can be used to help you estimate your bi-weekly costs for Voluntary Lifeand AD&D Insurance.

ADDITIONAL LIFE AND AD&D INSURANCE

Age Semi-monthly Rate / $1,000 of Coverage

Voluntary Life and AD&DInsurance

Employee

non-tobacco user

Employee

tobacco user

Spouse

< 25 $0.0175 $0.0260 $0.0390

25 29 $0.0195 $0.0290 $0.0190

30 34 $0.0235 $0.0350 $0.0265

35 39 $0.0320 $0.0510 $0.0420

40 44 $0.0435 $0.0765 $0.0620

45 49 $0.0695 $0.1215 $0.0970

50 54 $0.1070 $0.2060 $0.1500

55 59 $0.1765 $0.2930 $0.2275

60 64 $0.2860 $0.4455 $0.3785

65 69 $0.5075 $0.7530 $0.6310

70 74 $0.9175 $1.3255 $1.1220

75 or older $1.8295 $2.3605 $2.3285

Voluntary Child

Life and AD&D

All Ages

$0.1160

Example:A 38 year old non-tobacco user elects $90,000 of Life and AD&D coverage for himself; $25,000for his 34 year old spouse; $10,000 for his 5 year old child.

Cost for employee = $90,000 / $1,000 x $0.0320 = $2.88 per pay period

Cost for spouse = $25,000 / $1,000 x $0.0265 = $0.66 per pay period

Cost for child = $10,000 / $1,000 x $0.1160 = $1.16 per pay period

2013 benefits summary

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