ACCIDENT , CRITICAL ILLNESS & CANCER CARE What ' s the actual cost if I get my physical ? The right column shows your " net " cost after the wellness benefit for each plan . Accident Premium Critical Illness Premium Cancer Premium Annual Wellness Benefit * ( Combined Amounts ) ** Monthly Out - of - Pocket Age 18 - 29 Employee Only $ 12 . 50 $ 7 . 00 $ 15 . 00 $ 375 $ 3 . 25 Employee + Spouse $ 20 . 00 $ 14 . 00 $ 29 . 00 $ 750 $ 0 . 50 Employee + Child ( ren ) $ 21 . 50 $ 7 . 00 $ 17 . 00 $ 500 *** $ 3 . 83 Family $ 29 . 00 $ 14 . 00 $ 31 . 00 $ 875 *** $ 1 . 08 Age 30 - 39 Employee Only $ 12 . 50 $ 10 . 50 $ 15 . 00 $ 375 $ 6 . 75 Employee + Spouse $ 20 . 00 $ 21 . 00 $ 29 . 00 $ 750 $ 7 . 50 Employee + Child ( ren ) $ 21 . 50 $ 10 . 50 $ 17 . 00 $ 500 *** $ 7 . 33 Family $ 29 . 00 $ 21 . 00 $ 31 . 00 $ 875 *** $ 8 . 08 Age 40 - 49 Employee Only $ 12 . 50 $ 17 . 50 $ 15 . 00 $ 375 $ 13 . 75 Employee + Spouse $ 20 . 00 $ 35 . 00 $ 29 . 00 $ 750 $ 42 . 33 Employee + Child ( ren ) $ 21 . 50 $ 17 . 50 $ 17 . 00 $ 500 *** $ 27 . 27 Family $ 29 . 00 $ 35 . 00 $ 31 . 00 $ 875 *** $ 22 . 08 Age 50 - 59 Employee Only $ 12 . 50 $ 31 . 50 $ 15 . 00 $ 375 $ 27 . 75 Employee + Spouse $ 20 . 00 $ 63 . 00 $ 29 . 00 $ 750 $ 49 . 50 Employee + Child ( ren ) $ 21 . 50 $ 31 . 50 $ 17 . 00 $ 500 *** $ 28 . 33 Family $ 29 . 00 $ 63 . 00 $ 31 . 00 $ 875 *** $ 50 . 08 Age 60 - 69 Employee Only $ 12 . 50 $ 51 . 00 $ 15 . 00 $ 375 $ 47 . 25 Employee + Spouse $ 20 . 00 $ 102 . 00 $ 29 . 00 $ 750 $ 88 . 50 Employee + Child ( ren ) $ 21 . 50 $ 51 . 00 $ 17 . 00 $ 500 *** $ 47 . 83 Family $ 29 . 00 $ 102 . 00 $ 31 . 00 $ 875 *** $ 89 . 08 * A qualified health screening or exam during the plan year is required to receive the Wellness Benefit for each covered person . ** Your net monthly cost after premiums and the Wellness Benefit . Premiums are deducted per pay period ; the benefit is reimbursed as a lump sum . *** Includes a $ 125 wellness benefit for one child . The Family Wellness Benefit depends on how many children complete an annual wellness screening . For illustrative purposes only . Refer to the Guardian brochures for details and exclusions .