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7111 nn17 <br />'Dental and vision coverage Is an additional $38.00 per member per month premium. You will be billed directly for this amount. <br />2Dental benefit is an additional $15.05 per member per month premium. You will be billed directly for this amount. <br />'Dental and Vision coverage Is an additional $27.65 per member per month premium. You will be billed directly for this amount. <br />EXHIBIT A <br />25E-5 <br />CalPERS 2018 Monthly Premiums for Contracting Agencies <br />Other Southern California Region <br />Fresno, Imperial, Inyo, Kern, Kings, Madera, Orange, Riverside, San Diego, San Luis Obispo, <br />Santa Barbara, Tulare <br />Actives and Annuitants <br />Effective Date: 1/1/2018 - 12131/2018 <br />Basic;MontW Rate <br />PLATY <br />_ Employee Party '.1- ..Employee& <br />Plan Cede <br />Only Rata t Dependent <br />Party <br />Plan Code <br />Rate <br />EmPluyee8 <br />2+ Dependents <br />° Parry, <br />Plan Cotle <br />Rate <br />Anthem HMO select <br />$659.69 478 1 1 1 $1,319.38478 <br />2 <br />2 <br />$1,715.19 <br />47831 <br />3 <br />Anthem HMO Traditional <br />735.08 407 1 1 1,470.16 <br />072 <br />40721 <br />2 <br />1,911.21 <br />40731 <br />3 <br />BSC Access+ <br />695.97 142 1 1 1 1,391.94 <br />1422 <br />2 <br />1,809.52 <br />142 31 <br />3 <br />Health Net Salud y Mas <br />461.56 412 1 1 923.12 <br />412 2 <br />2 <br />1,200.06 <br />412 3 <br />3 <br />Health Net SmartCare <br />607.68 414 1 1 1,215.36 <br />4142 <br />2 <br />1,579.97 <br />4143 <br />3 <br />Kaiser Permanente <br />666.80 308 1 1 1,333.60 <br />308 2 <br />2 <br />1,733.68 <br />308 3 <br />3 <br />PERS Choice <br />698.96 323 1 1 1,397.92 <br />3232 <br />2 <br />1,817.30 <br />3233 <br />3 <br />PERS Select <br />654.74 082 1 1 1,309.48 .0822 <br />2 <br />1,702.32 <br />0823 <br />3 <br />PERSCare <br />733.50 328 1 1 1,467.00 <br />328 2 <br />2 <br />1,907.10 <br />328 3 <br />3 <br />PORAC <br />734.00 207 1 1 1,540.00 <br />2072 <br />2 <br />1,970.00 <br />2073 <br />3 <br />Sharp <br />UnitedHeaithcare <br />618.14 420 1 1 1,236.28 <br />616.66 432 1 1 1 1,233.32 <br />4202 <br />432 2 <br />2 <br />2 <br />1,607.16 <br />1,603.32 <br />4203 <br />432 3 <br />3 <br />3 <br />Supplement/Managed-Medicare" Monthly Rate (M) <br />- - "- <br />PLAN <br />EmPI%ee, <br />Only <br />< <br />Plan Gotle <br />.Pony Empl%¢oa <br />Rale 10ependent <br />Plzn Calle <br />Party <br />Rate <br />�Employeea <br />'Plan <br />2. Dependents <br />Cotle <br />Party <br />Rate <br />Anthem Traditional <br />Med Adv Health Only <br />$370.34 <br />259 1 <br />4 $740.68 <br />2592 <br />5 1 <br />$1,111.02 <br />2593 <br />6 <br />Anthem Traditional' <br />Med Adv Healthmentauvision <br />370.34 <br />109 1 <br />4 740.68 <br />109 2 <br />5 1 <br />1,111.02 <br />1093 <br />6 <br />Kaiser Senior Adv <br />316.34 <br />318 1 <br />4 632.68 <br />3182 <br />5 <br />949.02 <br />3183 <br />6 <br />Kaiser Senior Advloental2 <br />316.34 <br />492 1 <br />4 632.68 <br />4922 <br />5 <br />949.02 <br />4923 <br />6 <br />PERS Choice Med Supp <br />345.97 <br />333 1 <br />4 691.94 <br />3332 <br />5 <br />1,037.91 <br />3333 <br />6 <br />PERS Select Med Supp <br />345.97 <br />0831 <br />4 691.94 <br />0832 <br />5 <br />1,037.91 <br />0833 <br />6 <br />PERSCare Med Supp <br />382.30 <br />338 1 <br />4 764.60 <br />5382 <br />5 <br />1,146.90 <br />3383 <br />6 <br />PORAC Med Supp <br />487.00 <br />208 T-4 <br />970.00 <br />2082 <br />5 <br />1,651.00 <br />208 3 <br />6 <br />UnitedHeaithcare <br />Grp Med Adv/PPO Health Only <br />330.76 <br />386 1 <br />4 661.52 <br />3862 <br />5 <br />992.28 <br />386 3 <br />6 <br />UnitedHeaithcare' <br />Gr Med Adv PPO HWthlDentaliyision <br />330.76 <br />387 1 <br />4 661.52 <br />3872 <br />5 <br />992.28 <br />387 3 <br />6 <br />'Dental and vision coverage Is an additional $38.00 per member per month premium. You will be billed directly for this amount. <br />2Dental benefit is an additional $15.05 per member per month premium. You will be billed directly for this amount. <br />'Dental and Vision coverage Is an additional $27.65 per member per month premium. You will be billed directly for this amount. <br />EXHIBIT A <br />25E-5 <br />