FY 2019-20 DENTAL PLANS EXHIBIT A PREMIUM REFUNDS_VER3.DOCX

Employee Benefits – Plan Year 2020 Premium Rates and Adjustments – Exhibit A
FY 2019-20 Dental
Full-time Active Employees
Plan 
 Tier 
 Monthly 
Total 
Premium 
 Monthly 
Employer 
Premium 
 Monthly 
Employee 
Premium 
Maximum 
Employee 
Refund   
(April & May)
Employee
35.80
19.34
16.46
0.00
Employee + Spouse
78.86
42.62
36.24
0.00
Employee + Child(ren)
85.30
46.06
39.24
0.00
CIGNA (PPO) - Self 
Insured
Employee + Family
109.50
59.06
50.44
0.00
Employee
43.16
19.26
23.90
11.95
Employee + Spouse
95.10
42.44
52.66
26.33
Employee + Child(ren)
102.88
45.86
57.02
28.51
Delta (PPO) - Fully 
Insured
Employee + Family
132.28
58.82
73.46
36.73
Employee
9.26
4.52
4.74
0.00
Employee + Spouse
15.66
6.72
8.94
0.00
Employee + Child(ren)
21.68
10.04
11.64
0.00
Cigna (DHMO) – 
Prepaid
Employee + Family
25.52
12.14
13.38
0.00
Part-time Active Employees
Plan 
 Tier 
 Monthly 
Total 
Premium 
 Monthly 
Employer 
Premium 
 Monthly 
Employee 
Premium 
Maximum 
Employee 
Refund   
(April & May)
Employee
35.80
9.68
26.12
0.00
Employee + Spouse
78.86
21.32
57.54
0.00
Employee + Child(ren)
85.30
23.04
62.26
0.00
CIGNA (PPO) - Self 
Insured
Employee + Family
109.50
29.54
79.96
0.00
Employee
43.16
9.64
33.52
16.76
Employee + Spouse
95.10
21.22
73.88
36.94
Employee + Child(ren)
102.88
22.94
79.94
39.97
Delta (PPO) - Fully 
Insured
Employee + Family
132.28
29.42
102.86
51.43
Employee
9.26
2.26
7.00
0.00
Employee + Spouse
15.66
3.36
12.30
0.00
Employee + Child(ren)
21.68
5.02
16.66
0.00
Cigna (DHMO) – 
Prepaid
Employee + Family
25.52
6.08
19.44
0.00