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7/11/2017 <br />'Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. <br />'Dental 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 />25E-6 <br />CalPERS 2018 Monthly Premiums for Contracting Agencies <br />Los Angeles Area Region <br />Los Angeles, San Bernardino, Ventura <br />Actives and Annuitants <br />Effective Date: 1/1/2018 -12/31/2018 <br />`Basic_Mon thl 'Rate B':; <br />PLAN <br />Employee Plan Cod Farcy 'Employee& - <br />Only 1Deendent 'Plan Code <br />Dependent <br />Party <br />,Employee& <br />Party' <br />Plan Code arty <br />,Rate <br />Rate <br />2a Dependents <br />Rate <br />Anthem HMO Select <br />$660.17 4131 1 $1,320.34 4132 <br />2 <br />$1,716.44 <br />4133 <br />3 <br />Anthem HMO Traditional <br />784.72 402 1 1 1,569.44 402 2 <br />2 <br />2,040.27 <br />402 3 <br />3 <br />BSC Access+ <br />613.29 144 1 1 1,226.58 14421 <br />2 <br />1,594.55 <br />1443 <br />3 <br />Health Net Salud y Mas <br />404.32 443 1 1 808.64 4432 <br />2 <br />1,051.23 <br />443 3 <br />3 <br />Health Net SmartCare <br />577.15 408 1 1 1,154.30 408 2 <br />2 <br />1,500.59 <br />4083 <br />3 <br />Kaiser Permanente <br />642.70 306 1 1 1,285.40 306 2 <br />2 <br />1,671.02 <br />306 3 <br />3 <br />PERS Choice <br />620.39 321 1 1 1,240.78 321 2 <br />2 <br />1,613.01 <br />321 3 <br />3 <br />PERS Select <br />573.21 080 1 1 1,146.42 0802 <br />2 <br />1,490.35 <br />080 3 <br />3 <br />PERScare <br />673.73 326 1 1 1,347.46 3262 <br />2 <br />1,751.70 <br />326 3 <br />3 <br />PORAc <br />734.00 207 1 1 1,540.00 207 2 <br />2 <br />1,970.00 <br />12073 <br />3 <br />UnitedHealthcare <br />602.78 14281 1 1 1 1,205.56 4282 <br />2 <br />1,56723 <br />142831 <br />3 <br />Su pplenient/Managed Medicare Monthly Rate (M) <br />,PLAN <br />Employee- - <br />Only <br />Plan Code Party Employee'& <br />Rate IDependent <br />Plan Code <br />- <br />Party <br />Rate <br />Employ", .Plan <br />CodcParty <br />l <br />2+pependents <br />Rate <br />Anthem Traditional <br />Med Adv Health Only <br />$370.34 <br />2711 4 $740.68 <br />271 2 <br />5 <br />$1,111.020 <br />Anthem TradtUonal' <br />Med Adv HealthlOentalNislan <br />370.34 <br />166 1 4 740.68 <br />166 2 <br />5 <br />1,111.02 <br />Kaiser Senior Adv <br />316.34 <br />316 1 4 632.68 <br />3162 <br />5 <br />949.02 <br />Kaiser Senior Adv/Dental' <br />316.34 <br />493 1 4 632.68 <br />4932 <br />5 <br />949.02 <br />493 3 <br />6 <br />PERS Choice Med Supp <br />345.97 <br />331 1 4 691.94 <br />331 2 <br />5 <br />1,037.91 <br />331 3 <br />6 <br />PERS Select Med Supp <br />345.97 <br />081 1 4 I691.94 <br />081 2 <br />5 <br />1,037.91 <br />081 3 <br />6 <br />PERScare Med Supp <br />382.30 <br />3361 4 764.60 <br />3362 <br />5 <br />1,146.90 <br />3363 <br />6 <br />PORAC Med Supp <br />487.00 <br />208 1 4 970 .00 <br />208 2 <br />5 <br />1,551.00 <br />2083 <br />6 <br />UnitedHealthcare <br />Grp Med AdvIPPO Health Only <br />330.76 <br />382 1 4 661.52 <br />382 2 <br />5 <br />992.28 <br />3823 <br />6 <br />Grp hie Adv1P 0Hea <br />Gr hied Ativ/PPO HeaIthlDentalMslon <br />330.76 <br />383 1 4 661.52 <br />383 2 <br />5 <br />99228 <br />383 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 />'Dental 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 />25E-6 <br />