CalPERS 2019 Monthly Premiums for Contracting Agencies: Los

6/26/2018

CalPERS 2019 Monthly Premiums for Contracting Agencies Los Angeles Area Region
Los Angeles, San Bernardino, Ventura
Actives and Annuitants
Effective Date: 1/1/2019 - 12/31/2019 Basic Monthly Rate (B)

PLAN

Employee Only

Plan Code Party Rate

Employee & 1 Dependent

Plan Code Party Rate

Employee & 2+ Dependents

Plan Code Party Rate

Anthem HMO Select Anthem HMO Traditional BSC Access+ Health Net Salud y Más Health Net SmartCare Kaiser Permanente PERS Choice PERS Select PERSCare PORAC UnitedHealthcare

$627.07 413 1 1

$1,254.14 413 2 2

878.48 402 1 1

1,756.96 402 2 2

669.75 144 1 1

1,339.50 144 2 2

356.50 443 1 1

713.00 443 2 2

584.27 408 1 1

1,168.54 408 2 2

618.64 306 1 1

1,237.28 306 2 2

654.50 321 1 1

1,309.00 321 2 2

420.77 080 1 1

841.54 080 2 2

843.78 326 1 1

1,687.56 326 2 2

774.00 207 1 1

1,623.00 207 2 2

669.61 428 1 1

1,339.22 428 2 2

Supplement/Managed Medicare Monthly Rate (M)

$1,630.38 413 3 3 2,284.05 402 3 3 1,741.35 144 3 3 926.90 443 3 3 1,519.10 408 3 3 1,608.46 306 3 3 1,701.70 321 3 3 1,094.00 080 3 3 2,193.83 326 3 3 2,076.00 207 3 3 1,740.99 428 3 3

PLAN

Employee Only

Plan Code Party Rate

Employee & 1 Dependent

Plan Code Party Rate

Employee & 2+ Dependents

Plan Code Party Rate

Anthem Traditional
Med Adv Health Only
Anthem Traditional1
Med Adv Health/Dental/Vision
Kaiser Senior Adv Kaiser Senior Adv/Dental2 PERS Choice Med Supp
PERS Select Med Supp
PERSCare Med Supp
PORAC Med Supp UnitedHealthcare
Grp Med Adv/PPO Health Only
UnitedHealthcare3
Grp Med Adv/PPO Health/Dental/Vision

$357.44 271 1 4
357.44 166 1 4 323.74 316 1 4 323.74 493 1 4 360.41 331 1 4 360.41 081 1 4 394.83 336 1 4 513.00 208 1 4 299.37 382 1 4
299.37 383 1 4

$714.88 271 2 5
714.88 166 2 5 647.48 316 2 5 647.48 493 2 5 720.82 331 2 5 720.82 081 2 5 789.66 336 2 5 1,022.00 208 2 5 598.74 382 2 5
598.74 383 2 5

$1,072.32 271 3 6
1,072.32 166 3 6 971.22 316 3 6 971.22 493 3 6
1,081.23 331 3 6 1,081.23 081 3 6 1,184.49 336 3 6 1,635.00 208 3 6
898.11 382 3 6
898.11 383 3 6

1Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount.
2Dental benefit is an additional $15.05 per member per month premium. You will be billed directly for this amount. 3Dental and Vision coverage is an additional $27.65 per member per month premium. You will be billed directly for this amount.

6/26/2018

CalPERS 2019 Monthly Premiums for Contracting Agencies Los Angeles Area Region
Los Angeles, San Bernardino, Ventura Actives and Annuitants
Effective Date: 1/1/2019 - 12/31/2019 Combination Monthly Rate

PLAN

Employee in M Plan Code Party

1 Dependent in B

Rate

Employee in M 2+ Dependents in B

Plan Code Party Rate

Employee in M & 1 Dependent in M 1+ Dependents in B

Plan Code Party Rate

Anthem Traditional/
Med Adv Health Only
Anthem Traditional1/
Med Adv Health/Dental/Vision
Kaiser/Senior Adv Kaiser/Senior Adv/Dental2 PERS Choice/Med Supp
PERS Select/Med Supp
PERSCare/Med Supp
PORAC/Med Supp UnitedHealthcare/
Grp Med Adv/PPO Health Only
UnitedHealthcare3/
Grp Med Adv/PPO Health/Dental/Vision

$1,235.92 389 4 7

$1,763.01 389 5 8

1,235.92 198 4 7
942.38 342 4 7 942.38 503 4 7 1,014.91 347 4 7 781.18 353 4 7 1,238.61 358 4 7 1,362.00 158 4 7
968.98 369 4 7

1,763.01 198 5 8
1,313.56 342 5 8 1,313.56 503 5 8 1,407.61 347 5 8 1,033.64 353 5 8 1,744.88 358 5 8 1,815.00 158 5 8
1,370.75 369 5 8

968.98 370 4 7

1,370.75 370 5 8

Combination Monthly Rate

$1,241.97 389 6 9
1,241.97 198 6 9 1,018.66 342 6 9 1,018.66 503 6 9 1,113.52 347 6 9
973.28 353 6 9 1,295.93 358 6 9 1,475.00 158 6 9 1,000.51 369 6 9
1,000.51 370 6 9

PLAN

Employee in B Plan Code Party

1 Dependent in M

Rate

Employee in B

Plan Code Party

2+ Dependents in M

Rate

Employee in B & 1 Dependent in B 1+ Dependents in M

Plan Code Party Rate

Anthem Traditional/
Med Adv Health Only
Anthem Traditional1/
Med Adv Health/Dental/Vision
Kaiser/Senior Adv Kaiser/Senior Adv/Dental2 PERS Choice/Med Supp
PERS Select/Med Supp
PERSCare/Med Supp
PORAC/Med Supp UnitedHealthcare/
Grp Med Adv/PPO Health Only
UnitedHealthcare3/
Grp Med Adv/PPO Health/Dental/Vision

$1,235.92
1,235.92
942.38 942.38 1,014.91 781.18 1,238.61 1,283.00 968.98
968.98

389 7 10
198 7 10 342 7 10 503 7 10 347 7 10 353 7 10 358 7 10 158 7 10 369 7 10
370 7 10

$1,593.36
1,593.36
1,266.12 1,266.12 1,375.32 1,141.59 1,633.44 1,896.00 1,268.35
1,268.35

389 8 11
198 8 11 342 8 11 503 8 11 347 8 11 353 8 11 358 8 11 158 8 11 369 8 11
370 8 11

$1,763.01
1,763.01
1,313.56 1,313.56 1,407.61 1,033.64 1,744.88 1,736.00 1,370.75
1,370.75

389 9 12
198 9 12 342 9 12 503 9 12 347 9 12 353 9 12 358 9 12 158 9 12 369 9 12
370 9 12

1Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 2Dental benefit is an additional $15.05 per member per month premium. You will be billed directly for this amount. 3Dental and Vision coverage is an additional $27.65 per member per month premium. You will be billed directly for this amount.