|
6117/2016
<br />Monthly Premiums for Contracting Agencies
<br />Other Southern California Region
<br />Fresno, imperial, Inyo, Kern, Kings, Madera, Riverside, Orange, San Diego, San Luis Obispo,
<br />Santa Barbara, Tulare
<br />Actives and Annuitants
<br />Effective Date: 1111201 7 -1213l/2017
<br />r
<br />am HMO Select
<br />Dm HMO Traditional
<br />Access+,
<br />h Not Salud y Mis
<br />,h
<br />at SmariCare
<br />or Permanents
<br />i Choice _.._
<br />i Select
<br />r senior Adv /Dore
<br />Choice Mod Supp
<br />Select Mad Supp
<br />Caro Med Supp
<br />C Med Supp
<br />Employee Plan Cade ee I Party I Plan Coda Employee Plan Cotla yee 8 j Party I Empl yes 8. Party
<br />n
<br />Only Rate 1 Dependent Rate Z} Dependents Rata
<br />659.03 478 1 1
<br />799.15 4071 1
<br />778.45 142 1 1
<br />473.46 412 1 1
<br />537.20 414 1 1
<br />599.54 308 1 1
<br />714.43 323 1 1
<br />633.46 0821 1
<br />802.24 3281 1
<br />699.00 2071 1
<br />614.46 420 1 1
<br />549.76 4321 1
<br />1,598,30
<br />407 2
<br />2
<br />1,556,90
<br />1422
<br />2
<br />946.92
<br />4122
<br />2
<br />1,074.40
<br />4142
<br />2
<br />1,199.08
<br />3082
<br />2
<br />1,428.86
<br />3232
<br />2
<br />1,266.92
<br />0822,
<br />2
<br />1,604.48
<br />32821
<br />2
<br />1,467.00
<br />207 2
<br />2
<br />1,228.92
<br />420 2
<br />2
<br />1,099.52
<br />432 2
<br />2
<br />Employee
<br />Only
<br />Plan Code
<br />Party
<br />Rata
<br />.Employee&
<br />1 Dependent
<br />Plan Code
<br />Party
<br />Rate.
<br />$300.4B
<br />3181
<br />4
<br />$600.96
<br />387 1
<br />5
<br />1,396,72
<br />492 1
<br />4
<br />. 6
<br />492 2
<br />5
<br />353.63
<br />'315;;;k-;;
<br />3
<br />707.26
<br />333 2
<br />5
<br />353.63.
<br />3283
<br />4
<br />6
<br />083 2
<br />5
<br />affT 6
<br />338 1
<br />1 4
<br />464.00
<br />2081
<br />4
<br />324.21
<br />386 1
<br />4
<br />324.21
<br />387 1
<br />4
<br />924.00
<br />1208 2
<br />1 5
<br />648.42
<br />386 2
<br />5
<br />648.42
<br />387 2
<br />5
<br />1,713.48
<br />4783
<br />3
<br />2,077.79
<br />4073
<br />3
<br />2,023.97
<br />1423
<br />3
<br />1,231.00
<br />4123
<br />3
<br />1,396,72
<br />4143
<br />3
<br />1,558,80
<br />3083
<br />3
<br />1,857.52
<br />3233
<br />3
<br />1,647.00
<br />0823
<br />3
<br />2,085.82
<br />3283
<br />3
<br />1,876.00
<br />2073
<br />3
<br />1,597.60
<br />4203
<br />3
<br />1,429.38
<br />4323
<br />3
<br />r
<br />aploya onto
<br />1Pie. Code
<br />Ra�
<br />901.44
<br />492 3
<br />6
<br />060.89
<br />3333
<br />6
<br />060.89
<br />0833
<br />6
<br />169,28
<br />3383
<br />6
<br />477.00
<br />2083
<br />6
<br />97 .
<br />3
<br />6
<br />972.63 1 387 3
<br />Employee in M &
<br />Dependent In Bate Employee tsI PadY p
<br />1 Oepondanr in D Plantodo Rate xt 1lapandonix An a Plan Code Rate A Dependent to M Plan Cods a
<br />1 +0ependants lRb. -
<br />ad AdVIPPO Naeltninontal Ilion
<br />EXHIBIT 4
<br />'Dental benefit Is an additional $14.33 per member per month premium. You will be billed directly for this amount.
<br />2Dental and Vision coverage is an addilonal $27.47 per member per m2W.46 wlll be billed directly for this amount.
<br />Kaiser Senior Adv /Dental'
<br />502 4
<br />7
<br />1,259.74
<br />602 5
<br />8
<br />960.68
<br />502 61
<br />9
<br />PIERS CboicelMed Supp
<br />1,068.06
<br />34
<br />1,496,7
<br />8
<br />1,135.92
<br />348 6
<br />9
<br />PERS Select/ModSupp
<br />987.09
<br />354 4
<br />7
<br />354 5
<br />8
<br />1,087.34
<br />354 6
<br />9
<br />PERSCarolMod Supp
<br />1,192.00
<br />r
<br />7
<br />1,673.34
<br />3
<br />1,260.86
<br />3596
<br />9
<br />PORACIMod Supp
<br />_. 0
<br />158 4
<br />7
<br />1,641.00
<br />1585
<br />8
<br />0
<br />1586
<br />9
<br />UnitedHealthcare
<br />Group Mod AdvIP On7
<br />873.97
<br />3734
<br />7
<br />1,203,83
<br />3735
<br />8
<br />978.28
<br />3
<br />United care'
<br />873.97
<br />3744
<br />7
<br />1,203.83
<br />3746
<br />8
<br />978.28
<br />3746
<br />9
<br />ad AdVIPPO Naeltninontal Ilion
<br />EXHIBIT 4
<br />'Dental benefit Is an additional $14.33 per member per month premium. You will be billed directly for this amount.
<br />2Dental and Vision coverage is an addilonal $27.47 per member per m2W.46 wlll be billed directly for this amount.
<br />
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