John 2014

Date Child Expense Total Cost 50% Of Cost Payments Balance

1/1/2014 Prior Year Balance $ (32.15)
1/2/2014 John Payment - 100.00 (132.15)
1/6/2014 Daycare 165.00 82.50 (49.65)
1/7/2014 John Payment - 75.00 (124.65)
1/13/2014 Daycare 165.00 82.50 (42.15)
1/15/2014 Health/Dental/Vision 17.18 8.59 (33.56)
1/20/2014 Daycare 165.00 82.50 48.94
1/27/2014 Daycare 165.00 82.50 131.44
1/31/2014 Health/Dental/Vision 17.18 8.59 140.03
1/31/2014 John Payment - 100.00 40.03
2/3/2014 Daycare 165.00 82.50 122.53
2/3/2014 John Payment - 100.00 22.53
2/10/2014 Daycare 165.00 82.50 105.03
2/15/2014 Health/Dental/Vision 17.18 8.59 113.62
2/17/2014 Daycare 165.00 82.50 196.12
2/21/2014 John Payment - 200.00 (3.88)
2/24/2014 Daycare 165.00 82.50 78.62
2/28/2014 Health/Dental/Vision 17.18 8.59 87.21
3/1/2014 Rachel Amoxicillin 9.20 4.60 91.81
3/3/2014 Daycare 165.00 82.50 174.31
3/5/2014 John Payment - 200.00 (25.69)
3/5/2014 John Payment 100.00 (125.69)
3/10/2014 Daycare 165.00 82.50 (43.19)
3/14/2014 Health/Dental/Vision 17.18 8.59 (34.60)
3/17/2014 Daycare 165.00 82.50 47.90
3/22/2014 John Payment - 150.00 (102.10)
3/24/2014 Health/Dental/Vision 17.18 8.59 (93.51)
3/31/2014 Daycare 165.00 82.50 (11.01)
3/31/2014 John Payment - 100.00 (111.01)
 Charge Covered Our Cost
Exam 165 -155 10 copay
Refraction 44 -44 0 part of exam
Frame 180 -156 24 Frame Allowance+20% Off
SV Essilor 125 -25 100 20% discount
Polycarbonate 55 -11 44 20% discount
Aspheric 25 -25 0 Single lens
AR-Crizal 130 -26 104 20% discount
724 -442 282
 John 2022

Date Child Expense Total Cost 50% Of Cost Payments

1/1/2022 Previous Balance
1/1/2022 Medical, Dental, Vision 85.10 42.55
1/9/2022 John Payment - 150.00
1/31/2022 Rachel Meds 10.00 5.00
2/1/2022 Medical, Dental, Vision 85.10 42.55
2/26/2022 Rachel Meds 10.00 5.00
3/1/2022 Medical, Dental, Vision 85.10 42.55
3/26/2022 Rachel Meds 10.00 5.00
4/1/2022 Medical, Dental, Vision 85.10 42.55
5/1/2022 Medical, Dental, Vision 85.10 42.55
5/2/2022 Rachel Meds 10.00 5.00
5/24/2022 John Payment - 150.00
5/26/2022 Rachel Eye Dr. & Glasses 284.40 142.20
6/1/2022 Medical, Dental, Vision 85.10 42.55
6/9/2022 Rachel Meds 10.00 5.00
7/1/2022 Medical, Dental, Vision 85.10 42.55
7/7/2022 Rachel Meds 10.00 5.00
7/9/2022 John Payment - 200.00
8/1/2022 Medical, Dental, Vision 85.10 42.55
8/9/2022 Rachel Meds 10.00 5.00
8/11/2022 Rachel Dr. - Catalpa Health 55.00 27.50
8/12/2022 John Payment - 100.00
8/17/2022 Pictures 26.00 13.00
9/1/2022 Medical, Dental, Vision 85.10 42.55
9/19/2022 Rachel Meds 10.00 5.00
10/1/2022 Medical, Dental, Vision 85.10 42.55
10/4/2022 John Payment - 100.00
10/1/2022 Rachel Dr. - Catalpa Health 55.00 27.50
10/19/2022 Rachel Meds 10.00 5.00
11/1/2022 Medical, Dental, Vision 85.10 42.55
11/8/2022 John Payment - 100.00
12/1/2022 Medical, Dental, Vision 85.10 42.55
Balance
$ 39.20
$ 81.75
$ (68.25)
$ (63.25)
$ (20.70)
$ (15.70)
$ 26.85
$ 31.85
$ 74.40
$ 116.95
$ 121.95
$ (28.05)
$ 114.15
$ 156.70
$ 161.70
$ 204.25
$ 209.25
$ 9.25
$ 51.80
$ 56.80
$ 84.30
$ (15.70)
$ (2.70)
$ 39.85
$ 44.85
$ 87.40
$ (12.60)
$ 14.90
$ 19.90
$ 62.45
$ (37.55)
$ 5.00
 Charge Covered Our Cost
Exam 175 -165 10.00 copay
Refraction 46 -46 - part of exam
Frame 291 -178.2 112.80 Frame Allowance+20% Off
SV Essilor 140 -28 112.00 20% discount
Polycarbon 55 -11 44.00 20% discount
Aspheric 25 -25 - Single lens
AR-Crizal 140 -28 112.00 20% discount
872 -481.2 $ 390.80
 2013 Employee Employee/Child Difference
Medical UHV/HSP 26.79 54.92 28.13
Dental 8.98 20.89 11.91
Vision VSP Full Feature 3.67 7.86 4.19
Total 44.23

2014 Employee Employee/Child Difference

Medical UHV/HSP 33.42 68.5 35.08
Dental 9.53 21.72 12.19
Vision VSP Full Feature 3.75 8.02 4.27
Total 51.54

2014 - COBRA & Badger Employee Employee/Child Difference

BadgerCare 0 69 69
Dental 38.88 88.62 49.74
Vision VSP Full Feature 7.64 16.36 8.72
Total 127.46

2015 Employee Employee/Child Difference

Medical High Deductible (HRA-NonTobacco) 154.76 250.42 95.66
Dental 17.7 41.08 23.38
Vision VSP Full Feature (COBRA) 3.75 8.02 4.27
Total 123.31

2016 Employee Employee/Child Difference

Premier HAS 197.70 324.78 127.08
Delta Dental 18.06 41.90 23.84
Superior Vision 12.50 25.00 12.5
Total 163.42

2017 Employee Employee/Child Difference

BadgerCare - - -
Delta Dental 19.14 44.42 25.28
Superior Vision 13.00 26.00 13.00
Total 38.28

2018 Employee Employee/Child Difference

BadgerCare - - -
Delta Dental 21.44 49.74 28.30
Superior Vision 13.00 26.00 13.00
Total 41.3

2018-June Employee Employee/Child Difference

BadgerCare - - -
Delta Dental 21.44 49.74 28.30
Superior Vision 13.00 26.00 13.00
Total 41.3

2019 Employee Employee/Child Difference

BadgerCare - - -
Delta Dental 23.36 54.22 30.86
VPS 9.88 25.52 15.64
Total 46.5

2020 Employee Employee/Child Difference

BadgerCare - - -
Delta Dental 23.36 54.22 30.86
VPS 9.82 25.52 15.70
Total 46.56

2020-November Employee Employee/Child Difference

UHC Traditional 167.00 315.00 148.00
Delta Dental 23.36 54.22 30.86
VPS 9.82 25.52 15.70
Total 194.56

2021 Employee Employee/Child Difference

UHC Traditional 167.00 315.00 148.00
Delta Dental (Family Rates) 12.42 20.76 8.34
Eyemed 5.40 10.26 4.86
Total 161.2

2022 Employee Employee/Child Difference

UHC Traditional 177.00 334.00 157.00
Delta Dental (Family Rates) 12.42 20.76 8.34
Eyemed 5.40 10.26 4.86
Total 170.2

2023 Employee Employee/Child Difference

UHC Traditional 186.00 350.00 164.00
Delta Dental (Family Rates) 12.42 20.76 8.34
Eyemed 5.40 10.26 4.86
Total 177.2

2024 Employee Employee/Child Difference

UHC Traditional 194.50 366.50 172.00
Delta Dental (Family Rates) 12.42 20.76 8.34
Eyemed 5.40 14.86 9.46
Total 189.8
1/3 of Premium Parent Portion
9.38 4.69
3.97 1.98
1.40 0.70
14.74 7.37

1/3 of Premium Parent Portion

11.69 5.85
4.06 2.03
1.42 0.71
17.18 8.59

1/3 of Premium Parent Portion

23.00 11.50
16.58 8.29
2.91 1.45
42.48 21.24

1/3 of Premium Parent Portion

31.88 15.94 ***Rates listed on form are per pay period (24 per year)
7.79 3.90 ***Rates listed on form are per pay period (24 per year)
1.42 0.71
41.10 20.55

1/3 of Premium Parent Portion

42.36 21.18 ***Rates listed on form are per pay period (24 per year)
7.95 3.97 ***Rates listed on form are per pay period (24 per year)
4.17 2.08 ***Rates listed on form are per pay period (24 per year)
54.47 27.23

1/3 of Premium Parent Portion

- - *Copays for Visits and Medication
8.43 4.21 ***Rates listed on form are per pay period (24 per year)
4.33 2.17 ***Rates listed on form are per pay period (24 per year)
12.76 6.38

1/3 of Premium Parent Portion

- - *Copays for Visits and Medication
9.43 4.72 ***Rates listed on form are per pay period (24 per year)
4.33 2.17 ***Rates listed on form are per pay period (24 per year)
13.77 6.88

1/2 of Premium Parent Portion

- - *Copays for Visits and Medication
14.15 7.08 ***Rates listed on form are per pay period (24 per year)
6.50 3.25 ***Rates listed on form are per pay period (24 per year)
20.65 10.33

1/2 of Premium Parent Portion

- - *Copays for Visits and Medication
 15.43 7.72 ***Rates listed on form are per pay period (24 per year)
7.82 3.91 ***Rates listed on form are per pay period (24 per year)
23.25 11.63

1/2 of Premium Parent Portion

- - *Copays for Visits and Medication
15.43 7.72 ***Rates listed on form are per pay period (24 per year)
7.85 3.93 ***Rates listed on form are per pay period (24 per year)
23.28 11.64

1/2 of Premium Parent Portion

74.00 37.00 ***Rates listed on form are monthly
15.43 7.72 ***Rates listed on form are per pay period (24 per year)
7.85 3.93 ***Rates listed on form are per pay period (24 per year)
97.28 48.64

1/2 of Premium Parent Portion

74.00 37.00 ***Rates listed on form are monthly
4.17 1.04 *Rates listed on form are monthly. Discounted out my portion.
2.43 1.21 ***Rates listed on form are monthly
80.60 40.30

1/2 of Premium Parent Portion

78.50 39.25 ***Rates listed on form are monthly
4.17 1.04 *Rates listed on form are monthly. Discounted out my portion.
2.43 1.21 ***Rates listed on form are monthly
85.10 42.55

1/2 of Premium Parent Portion

82.00 41.00 ***Rates listed on form are monthly
4.17 1.04 *Rates listed on form are monthly. Discounted out my portion.
2.43 1.21 ***Rates listed on form are monthly
88.60 44.30

1/2 of Premium Parent Portion

86.00 43.00 ***Rates listed on form are monthly
4.17 1.04 *Rates listed on form are monthly. Discounted out my portion.
4.73 2.36 ***Rates listed on form are monthly
94.90 47.45
 John 2023

Date Child Expense Total Cost 50% Of Cost Payments

1/1/2023 Previous Balance
1/1/2023 Medical, Dental, Vision 88.60 44.30
2/1/2023 John Payment - 100.00
2/1/2023 Medical, Dental, Vision 88.60 44.30
2/17/2023 Rachel Meds 40.00 20.00
2/22/2023 Camp Fee + Bus 525.00 262.50
2/28/2023 John Payment - 100.00
3/1/2023 Medical, Dental, Vision 88.60 44.30
3/9/2023 Orthodontics 3,650.00 1,825.00
3/10/2023 John Payment - 350.00
3/18/2023 Rachel Meds 40.00 20.00
3/28/2023 John Payment - 100.00
4/1/2023 Medical, Dental, Vision 88.60 44.30
4/11/2023 John Payment - 100.00
4/15/2023 Rachel Meds 40.00 20.00
4/25/2023 John Payment - 100.00
5/1/2023 Medical, Dental, Vision 88.60 44.30
5/9/2023 John Payment - 100.00
5/12/2023 Rachel ADHD Med 42.00 21.00
5/23/2023 Rachel Anxiety Med 4.53 2.27
5/23/2023 John Payment - 100.00
6/1/2023 Medical, Dental, Vision 88.60 44.30
6/6/2023 John Payment - 100.00
6/12/2023 Rachel Catalpa Visit (5/23/23) 55.00 27.50
6/13/2023 Rachel Eye Exam & Glasses 390.80 195.40
6/18/2023 Rachel ADHD Med 42.00 21.00
6/21/2023 John Payment - 100.00
6/26/2013 Rachel Anxiety Med 4.69 2.35
7/1/2023 Medical, Dental, Vision 88.60 44.30
7/5/2023 John Payment - 100.00
7/17/2023 Rachel ADHD Med 42.00 21.00
7/18/2023 John Payment - 100.00
7/21/2023 School Pictures 26.00 13.00
7/27/2023 Rachel Anxiety Med 4.69 2.35
8/1/2023 John Payment - 100.00
8/1/2023 Medical, Dental, Vision 88.60 44.30
8/11/2023 John Payment - 200.00
8/15/2023 Catalpa Health 55.00 27.50
8/17/2023 Rachel Anxiety Med 90 Days 12.12 6.06
8/29/2023 John Payment - 200.00
8/30/2023 Rachel ADHD Med 45.00 22.50
9/1/2023 Medical, Dental, Vision 88.60 44.30
9/12/2023 John Payment - 200.00
9/26/2023 John Payment - 200.00
10/1/2023 Medical, Dental, Vision 88.60 44.30
10/10/2023 Rachel ADHD Med 42.00 21.00
10/11/2023 John Payment - 100.00
10/24/2023 John Payment - 200.00
11/1/2023 Medical, Dental, Vision 88.60 44.30
11/3/2023 John Payment - 100.00
11/17/2023 John Payment - 100.00
11/25/2023 Catalpa Health (10/17 Visit) 55.00 27.50
12/1/2023 Medical, Dental, Vision 88.60 44.30
12/1/2023 John Payment 200.00
12/15/2023 John Payment 100.00
Balance
$ 5.00
$ 49.30
$ (50.70)
$ (6.40)
$ 13.60
$ 276.10
$ 176.10
$ 220.40
$ 2,045.40
$ 1,695.40
$ 1,715.40
$ 1,615.40
$ 1,659.70
$ 1,559.70
$ 1,579.70
$ 1,479.70
$ 1,524.00
$ 1,424.00
$ 1,445.00
$ 1,447.26
$ 1,347.26
$ 1,391.56
$ 1,291.56
$ 1,319.06
$ 1,514.46
$ 1,535.46
$ 1,435.46
$ 1,437.81
$ 1,482.11
$ 1,382.11
$ 1,403.11
$ 1,303.11
$ 1,316.11
$ 1,318.45
$ 1,218.45
$ 1,262.75
$ 1,062.75
$ 1,090.25
$ 1,096.31
$ 896.31
$ 918.81
$ 963.11
$ 763.11
$ 563.11
$ 607.41
$ 628.41
$ 528.41
$ 328.41
$ 372.71
$ 272.71
$ 172.71
$ 200.21
$ 244.51
$ 44.51
$ (55.49)
 John 2024

Date Child Expense Total Cost 50% Of Cost Payments

1/1/2024 Previous Balance
1/1/2024 Medical, Dental, Vision 94.90 47.45
1/4/2024 Rachel ADHD Med 37.00 18.50
1/30/2024 John Payment 100.00
2/1/2024 Medical, Dental, Vision 94.90 47.45
2/19/2024 Rachel ADHD Med 43.00 21.50
2/19/2024 Catalpa Health 30.00 15.00
3/1/2024 Medical, Dental, Vision 94.90 47.45
3/7/2024 Dental Visit Bill (2/15/2024) 37.40 18.70
4/1/2024 Medical, Dental, Vision 94.90 47.45
4/9/2024 John Payment - 100.00
4/16/2024 Rachel ADHD Med 43.00 21.50
5/1/2024 Medical, Dental, Vision 94.90 47.45
5/7/2024 John Payment - 100.00
5/26/2024 Rachel ADHD Med 42.00 21.00
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-
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Balance
$ (55.49)
$ (8.04)
$ 10.46
$ (89.54)
$ (42.09)
$ (20.59)
$ (5.59)
$ 41.86
$ 60.56
$ 108.01
$ 8.01
$ 29.51
$ 76.96
$ (23.04)
$ (2.04)