COST OF COVERAGE Monthly Premiums Monthly Premiums Monthly Premiums MEDICAL DENTAL VISION $2,500 $4,000 Copay HDHP LOW HIGH Employee Only $25.67 $30.51 Employee Only $129 $50 Employee Only $5.72 Employee + $52.01 $61.88 Employee + $592 $475 Family $12.31 Spouse Spouse Employee + $72.63 $86.38 Child(ren) Employee + $475 $317 Child(ren) Family $104.95 $124.83 Family $694 $525