Effective 5/1/2010 - Rogers Benefit Group · and San Mateo Value Network HMO products: San...

Rate Guide

CALIFORNIA

2–50 employees

Effective 5/1/2010

1 Pacifi Care SignatureValue® Advantage only available in Los Angeles, Orange, Riverside, San Bernardino, San Diego, Kern, San Francisco, Santa Barbara (specifi ed ZIP Codes), Santa Clara and Ventura counties. Pacifi Care SignatureValue HealthCare Partners Network only available in specifi ed ZIP Codes within Los Angeles, Orange and Ventura counties.

Contents

Medical1

Area 1 Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

HMO products: Throughout Los AngelesValue Network HMO products: Throughout Los AngelesHCP Network HMO products: Los Angeles (90001–90084, 90086–90089, 90091, 90093–90097, 90099,

90101–90103, 90174, 90185, 90189, 90201, 90202, 90209–90213, 90220–90224, 90230–90233, 90239–90242, 90245, 90247–90251, 90254, 90255, 90260–90262, 90266, 90267, 90270, 90274, 90275,

90277, 90278, 90280, 90290, 90292, 90293, 90295, 90296, 90301–90313, 90397, 90398, 90501–90510, 90601–90610, 90612, 90637–90640, 90650–90652, 90659–90662, 90665, 90670, 90671, 90701–90703, 90706, 90707, 90710–90717, 90723, 90731–90734,

90744–90749, 90755, 90801–90810, 90813–90815, 90822, 90831–90835, 90840, 90842, 90844–90848, 90853, 90888, 90895, 90899, 91001, 91003, 91006–91008, 91010–91012, 91016, 91017, 91020, 91021, 91023–91025, 91030, 91031, 91040–91043, 91046,

91066, 91077, 91101–91110, 91114–91118, 91121, 91123–91126, 91129, 91131, 91175, 91182, 91184–91189, 91191, 91199, 91201–91210, 91214, 91221, 91222, 91224–91226, 91301–91309, 91311–91313, 91316, 91321, 91322, 91324–91331,

91333–91335, 91337, 91340–91346, 91350–91357, 91363–91365, 91367, 91371, 91372, 91376, 91380–91383, 91385–91388, 91390, 91392–91396, 91399, 91401–91413, 91416, 91423, 91426, 91436, 91470, 91482, 91495–91497, 91499, 91501–91508, 91510,

91521–91523, 91526, 91601–91612, 91614–91618, 91702, 91706, 91711, 91714–91716, 91722–91724, 91731–91735, 91740, 91741, 91744–91750, 91754–91756, 91765–91773, 91775, 91776, 91778, 91780, 91788–91793, 91795, 91797, 91799, 91801–91804, 91841, 91896, 91899, 93532, 93563)

All other products: Los Angeles #1 (ZIP Codes beginning with 900–905, 913, 914, 916 and all other Los Angeles ZIP Codes except ZIP Codes in Los Angeles #2)

Area 2 Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

HMO products: OrangeValue Network HMO products: OrangeHCP Network HMO products Orange (90620–90624, 90630–90633, 90680, 90720, 90721,

90740, 92605, 92647–92649, 92655, 92683–92685, 92708, 92728, 92821–92823, 92831–92838, 92840–92846)

All other products: Orange

Area 3 Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8HMO products: San Diego #1 (ZIP Codes beginning with 921), Imperial,

San Diego #2 (ZIP Codes beginning with 919 and 920), Riverside and San Bernardino

Contents (continued)

Value Network HMO products: San Diego #1 (ZIP Codes beginning with 921), San Diego #2 (ZIP Codes beginning with 919 and 920), Riverside and San Bernardino

HCP Network HMO products Not available in this areaAll other products: San Diego #1 (ZIP Codes beginning with 921), Imperial,

Santa Barbara, Ventura, and Santa Clara

Area 4 Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10HMO products: Alameda, El Dorado, Merced, Placer, Sacramento, Stanislaus,

Santa Clara, San Francisco, Santa Barbara, Santa Cruz, Yolo and San Mateo

Value Network HMO products: San Francisco, Santa Clara and Santa Barbara (93013, 93014, 93067, 93101–93103, 93105–93111, 93116–93118, 93120, 93121, 93130, 93140, 93150, 93160, 93190, 93199)

HCP Network HMO products Not available in this areaAll other products: San Luis Obispo, San Bernardino and Riverside

Area 5 Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12HMO products: Fresno, Kern, Kings, San Luis Obispo and TulareValue Network HMO products: KernHCP Network HMO products: Not available in this areaAll other products: Kern, Fresno, Kings, Tulare and Madera

Area 6 Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14HMO products: Marin, San JoaquinValue Network HMO products: Not available in this areaHCP Network HMO products Not available in this areaAll other products: Los Angeles #2 (ZIP Codes beginning with 906–912, 915,

917, 918, 935), Alameda, Marin, Napa, Nevada, San Francisco, San Mateo, Santa Cruz, Sonoma, Yolo

Area 7 Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16HMO products: Not available in this areaValue Network HMO products: Not available in this areaHCP Network HMO products Not available in this areaAll other products: Contra Costa, Alpine, Amador, Butte, Calaveras, Colusa,

Del Norte, Glenn, Humboldt, Inyo, Lake, Lassen, Mariposa, Mendocino, Modoc, Mono, Monterey, Plumas, San Benito, Shasta, Sierra, Siskiyou, Solano, Sutter, Tehama, Trinity, Tuolumne and Yuba

Area 8 Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18HMO products: VenturaValue Network HMO products: VenturaHCP Network HMO products Ventura (91358-91362)All other products: El Dorado, Merced, Placer, Sacramento, San Joaquin and Stanislaus

Area 9 Counties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20HMO products: Madera, Solano, Contra Costa, Nevada and SonomaValue Network HMO products: Not available in this areaHCP Network HMO products Not available in this areaAll other products: San Diego #2 (ZIP Codes beginning with 919 and 920)

Chiropractic and Acupuncture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

This guide is a listing of standard employee risk rates for the Small Business plans offered by UnitedHealthcare and its affi liates. Your fi nal risk-adjusted rates are contingent upon receipt of all relevant medical information pertaining to your Small Business. For more information, please call your sales representative.

Every effort has been made to ensure accuracy in information printed in this book; however, UnitedHealthcare and its affi liates cannot guarantee that there are no errors.

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3

Medical Rates

As required by law, we are advising you that the medical care ratio incurred for Small Business 2-50 Plans for 2009 was 83.2 percent for Pacifi Care of California, UnitedHealthcare Insurance Company and its affi liated entities. This ratio was calculated after provider discounts were applied.

4 These are standard rates and subject to risk adjustment of ±10%. Plan issuance is subject to eligibility, contribution and participation requirements.

Area #1 Counties

Pacifi Care SignatureValue® (HMO) HealthCare Partners Network

AgeCategory

25-50/500ded

25-75/500ded

25-75/1500ded

EM

PLO

YE

E O

NLY

0 to 29 $182.07 $176.03 $150.96

30 to 39 $211.52 $204.50 $175.37

40 to 49 $262.32 $253.61 $217.49

50 to 54 $356.28 $344.45 $295.40

55 to 59 $458.10 $442.90 $379.82

60 to 64 $581.51 $562.21 $482.14

65 plus $811.46 $784.53 $672.80

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $434.27 $419.86 $360.07

30 to 39 $485.08 $468.98 $402.19

40 to 49 $579.03 $559.82 $480.09

50 to 54 $741.10 $716.50 $614.46

55 to 59 $941.38 $910.14 $780.52

60 to 64 $1,119.63 $1,082.47 $928.31

65 plus $1,455.00 $1,406.71 $1,206.37

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $407.30 $393.78 $337.70

30 to 39 $453.83 $438.77 $376.28

40 to 49 $491.82 $475.50 $407.78

50 to 54 $571.84 $552.86 $474.13

55 to 59 $639.95 $618.71 $530.60

60 to 64 $784.93 $758.88 $650.80

65 plus $1,033.09 $998.80 $856.56

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $668.72 $646.53 $554.45

30 to 39 $737.28 $712.81 $611.29

40 to 49 $817.97 $790.83 $678.20

50 to 54 $965.43 $933.39 $800.46

55 to 59 $1,130.87 $1,093.34 $937.63

60 to 64 $1,331.37 $1,287.19 $1,103.87

65 plus $1,685.63 $1,629.68 $1,397.59

HMO products: Throughout Los AngelesValue Network HMO products: Throughout Los AngelesHCP Network HMO products: Los Angeles County ZIP Codes listed in Table of Contents

All other products: Los Angeles #1 (ZIP Codes beginning with 900-905, 913, 914, 916 and all other Los Angeles ZIP Codes except ZIP Codes in Los Angeles #2)

Pacifi Care SignatureValue® (HMO)

AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $295.49 $266.56 $247.22 $233.49 $218.76 $207.75 $208.37 $193.44 $178.85

30 to 39 $343.28 $309.67 $287.20 $271.25 $254.14 $241.35 $242.07 $224.72 $207.77

40 to 49 $425.72 $384.05 $356.18 $336.40 $315.17 $299.31 $300.21 $278.69 $257.67

50 to 54 $578.21 $521.61 $483.76 $456.89 $428.06 $406.52 $407.74 $378.51 $349.97

55 to 59 $743.46 $670.69 $622.02 $587.47 $550.40 $522.71 $524.28 $486.69 $449.99

60 to 64 $943.74 $851.36 $789.58 $745.73 $698.67 $663.51 $665.51 $617.80 $571.21

65 plus $1,316.93 $1,188.01 $1,101.81 $1,040.62 $974.95 $925.89 $928.67 $862.10 $797.09

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $704.79 $635.80 $589.67 $556.92 $521.78 $495.52 $497.01 $461.38 $426.59

30 to 39 $787.24 $710.18 $658.64 $622.07 $582.81 $553.48 $555.15 $515.35 $476.49

40 to 49 $939.72 $847.74 $786.22 $742.56 $695.70 $660.69 $662.68 $615.17 $568.78

50 to 54 $1,202.75 $1,085.01 $1,006.28 $950.39 $890.42 $845.61 $848.15 $787.36 $727.98

55 to 59 $1,527.78 $1,378.23 $1,278.22 $1,207.23 $1,131.05 $1,074.14 $1,077.36 $1,000.14 $924.71

60 to 64 $1,817.07 $1,639.20 $1,520.25 $1,435.82 $1,345.22 $1,277.53 $1,281.36 $1,189.51 $1,099.80

65 plus $2,361.35 $2,130.20 $1,975.62 $1,865.91 $1,748.16 $1,660.20 $1,665.18 $1,545.82 $1,429.24

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $661.02 $596.31 $553.04 $522.33 $489.37 $464.74 $466.14 $432.72 $400.09

30 to 39 $736.53 $664.43 $616.22 $582.00 $545.27 $517.83 $519.39 $482.16 $445.80

40 to 49 $798.18 $720.05 $667.80 $630.71 $590.91 $561.18 $562.86 $522.52 $483.11

50 to 54 $928.05 $837.20 $776.45 $733.33 $687.06 $652.49 $654.44 $607.53 $561.72

55 to 59 $1,038.59 $936.92 $868.93 $820.68 $768.89 $730.20 $732.39 $679.89 $628.62

60 to 64 $1,273.88 $1,149.18 $1,065.79 $1,006.60 $943.08 $895.63 $898.32 $833.92 $771.03

65 plus $1,676.62 $1,512.50 $1,402.75 $1,324.84 $1,241.24 $1,178.78 $1,182.32 $1,097.57 $1,014.80

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,085.28 $979.04 $908.00 $857.57 $803.46 $763.03 $765.32 $710.46 $656.88

30 to 39 $1,196.54 $1,079.42 $1,001.09 $945.49 $885.83 $841.25 $843.78 $783.30 $724.22

40 to 49 $1,327.51 $1,197.56 $1,110.66 $1,048.98 $982.78 $933.33 $936.13 $869.03 $803.49

50 to 54 $1,566.82 $1,413.44 $1,310.88 $1,238.08 $1,159.95 $1,101.58 $1,104.89 $1,025.69 $948.34

55 to 59 $1,835.31 $1,655.65 $1,535.51 $1,450.24 $1,358.72 $1,290.35 $1,294.22 $1,201.45 $1,110.84

60 to 64 $2,160.71 $1,949.20 $1,807.76 $1,707.36 $1,599.62 $1,519.13 $1,523.69 $1,414.47 $1,307.80

65 plus $2,735.64 $2,467.85 $2,288.77 $2,161.66 $2,025.25 $1,923.34 $1,929.12 $1,790.84 $1,655.78

Pacifi Care SignatureValue® Advantage (Value Network HMO)

AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 -

60/2000ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $274.79 $247.89 $229.91 $217.14 $203.44 $193.20 $181.62 $193.78 $179.89 $166.33

30 to 39 $319.23 $287.98 $267.09 $252.25 $236.34 $224.45 $210.99 $225.12 $208.99 $193.23

40 to 49 $395.90 $357.15 $331.24 $312.84 $293.10 $278.35 $261.66 $279.18 $259.18 $239.64

50 to 54 $537.71 $485.07 $449.89 $424.89 $398.09 $378.05 $355.39 $379.18 $352.01 $325.48

55 to 59 $691.39 $623.71 $578.47 $546.33 $511.86 $486.10 $456.96 $487.55 $452.62 $418.50

60 to 64 $877.64 $791.73 $734.29 $693.50 $649.75 $617.05 $580.06 $618.89 $574.55 $531.24

65 plus $1,224.69 $1,104.80 $1,024.66 $967.73 $906.69 $861.06 $809.43 $863.62 $801.74 $741.31

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $655.43 $591.27 $548.38 $517.91 $485.24 $460.82 $433.19 $462.19 $429.08 $396.74

30 to 39 $732.10 $660.43 $612.53 $578.50 $542.00 $514.73 $483.87 $516.26 $479.27 $443.15

40 to 49 $873.91 $788.36 $731.17 $690.55 $646.99 $614.43 $577.59 $616.26 $572.10 $528.98

50 to 54 $1,118.51 $1,009.01 $935.82 $883.83 $828.07 $786.40 $739.25 $788.74 $732.23 $677.04

55 to 59 $1,420.78 $1,281.70 $1,188.72 $1,122.68 $1,051.86 $998.92 $939.03 $1,001.90 $930.11 $860.01

60 to 64 $1,689.80 $1,524.39 $1,413.81 $1,335.26 $1,251.03 $1,188.07 $1,116.84 $1,191.60 $1,106.23 $1,022.85

65 plus $2,195.97 $1,981.00 $1,837.30 $1,735.22 $1,625.76 $1,543.94 $1,451.38 $1,548.54 $1,437.59 $1,329.23

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $614.72 $554.54 $514.32 $485.74 $455.10 $432.20 $406.29 $433.48 $402.43 $372.09

30 to 39 $684.95 $617.89 $573.07 $541.23 $507.09 $481.57 $452.70 $483.01 $448.40 $414.60

40 to 49 $742.28 $669.62 $621.04 $586.54 $549.54 $521.88 $490.59 $523.44 $485.93 $449.31

50 to 54 $863.05 $778.57 $722.09 $681.97 $638.95 $606.79 $570.42 $608.60 $565.00 $522.41

55 to 59 $965.84 $871.30 $808.09 $763.20 $715.05 $679.07 $638.35 $681.09 $632.29 $584.63

60 to 64 $1,184.66 $1,068.69 $991.17 $936.10 $877.05 $832.91 $782.98 $835.39 $775.54 $717.08

65 plus $1,559.19 $1,406.56 $1,304.53 $1,232.05 $1,154.33 $1,096.24 $1,030.52 $1,099.50 $1,020.73 $943.79

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,009.27 $910.47 $844.42 $797.51 $747.20 $709.60 $667.05 $711.71 $660.72 $610.92

30 to 39 $1,112.74 $1,003.81 $931.00 $879.27 $823.80 $782.35 $735.44 $784.67 $728.46 $673.55

40 to 49 $1,234.53 $1,113.68 $1,032.89 $975.51 $913.97 $867.97 $815.94 $870.56 $808.19 $747.27

50 to 54 $1,457.08 $1,314.44 $1,219.09 $1,151.36 $1,078.73 $1,024.44 $963.02 $1,027.49 $953.88 $881.98

55 to 59 $1,706.77 $1,539.69 $1,428.00 $1,348.66 $1,263.59 $1,199.99 $1,128.05 $1,203.57 $1,117.33 $1,033.12

60 to 64 $2,009.38 $1,812.67 $1,681.18 $1,587.78 $1,487.62 $1,412.75 $1,328.06 $1,416.96 $1,315.44 $1,216.29

65 plus $2,544.04 $2,294.99 $2,128.52 $2,010.26 $1,883.45 $1,788.66 $1,681.43 $1,793.99 $1,665.45 $1,539.92

5

Choice PlusAge

Category20/250/90%

5E-A30/250/80%

5E-D30/500/80%

5E-F40/500/70%

5E-K30/1000/80%

5E-C40/1000/70%

5E-I40/1000/50%

5E-G40/1500/70%

5E-J40/2000/50%

5E-H30/2500/80%

5E-E20/3000/90%

5E-B

EM

PLO

YE

EO

NLY

0 to 29 $439.39 $398.17 $343.26 $306.88 $297.80 $258.51 $246.90 $251.08 $230.78 $251.63 $253.01

30 to 39 $543.80 $492.78 $424.83 $379.80 $368.56 $319.94 $305.57 $310.74 $285.62 $311.42 $313.13

40 to 49 $730.25 $661.74 $570.48 $510.02 $494.93 $429.63 $410.34 $417.28 $383.55 $418.20 $420.49

50 to 54 $1,011.78 $916.86 $790.42 $706.65 $685.74 $595.27 $568.53 $578.16 $531.41 $579.43 $582.60

55 to 59 $1,251.67 $1,134.25 $977.83 $874.20 $848.33 $736.41 $703.33 $715.24 $657.41 $716.81 $720.74

60 to 64 $1,633.26 $1,480.04 $1,275.94 $1,140.71 $1,106.96 $960.91 $917.76 $933.29 $857.84 $935.34 $940.47

65 plus $1,923.50 $1,743.05 $1,502.67 $1,343.41 $1,303.66 $1,131.67 $1,080.84 $1,099.14 $1,010.27 $1,101.55 $1,107.59

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $1,254.78 $1,137.07 $980.26 $876.37 $850.44 $738.23 $705.08 $717.02 $659.05 $718.59 $722.53

30 to 39 $1,473.54 $1,335.31 $1,151.16 $1,029.15 $998.70 $866.94 $828.01 $842.02 $773.95 $843.87 $848.50

40 to 49 $1,586.03 $1,437.24 $1,239.04 $1,107.72 $1,074.94 $933.12 $891.21 $906.30 $833.03 $908.29 $913.27

50 to 54 $2,091.30 $1,895.11 $1,633.76 $1,460.61 $1,417.39 $1,230.39 $1,175.13 $1,195.03 $1,098.41 $1,197.64 $1,204.21

55 to 59 $2,593.46 $2,350.16 $2,026.06 $1,811.33 $1,757.74 $1,525.83 $1,457.30 $1,481.98 $1,362.16 $1,485.22 $1,493.37

60 to 64 $3,233.59 $2,930.24 $2,526.14 $2,258.41 $2,191.59 $1,902.44 $1,817.00 $1,847.76 $1,698.37 $1,851.81 $1,861.97

65 plus $4,438.03 $4,021.69 $3,467.07 $3,099.62 $3,007.91 $2,611.06 $2,493.79 $2,536.01 $2,330.98 $2,541.57 $2,555.51

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $995.62 $902.22 $777.80 $695.36 $674.79 $585.76 $559.45 $568.93 $522.93 $570.17 $573.30

30 to 39 $1,091.33 $988.95 $852.57 $762.21 $739.66 $642.07 $613.23 $623.62 $573.20 $624.98 $628.41

40 to 49 $1,123.02 $1,017.67 $877.33 $784.35 $761.14 $660.72 $631.04 $641.73 $589.84 $643.13 $646.66

50 to 54 $1,359.19 $1,231.68 $1,061.82 $949.29 $921.20 $799.66 $763.75 $776.68 $713.88 $778.38 $782.65

55 to 59 $1,607.16 $1,456.39 $1,255.55 $1,122.48 $1,089.27 $945.55 $903.09 $918.38 $844.13 $920.39 $925.44

60 to 64 $2,006.78 $1,818.52 $1,567.73 $1,401.58 $1,360.11 $1,180.66 $1,127.64 $1,146.73 $1,054.02 $1,149.24 $1,155.54

65 plus $2,269.04 $2,056.18 $1,772.62 $1,584.75 $1,537.86 $1,334.96 $1,275.01 $1,296.60 $1,191.76 $1,299.44 $1,306.56

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,570.49 $1,423.16 $1,226.90 $1,096.87 $1,064.41 $923.98 $882.48 $897.42 $824.87 $899.39 $904.32

30 to 39 $1,783.66 $1,616.33 $1,393.43 $1,245.75 $1,208.89 $1,049.40 $1,002.27 $1,019.24 $936.83 $1,021.47 $1,027.07

40 to 49 $1,809.14 $1,639.42 $1,413.34 $1,263.55 $1,226.16 $1,064.39 $1,016.59 $1,033.80 $950.21 $1,036.06 $1,041.74

50 to 54 $2,288.31 $2,073.64 $1,787.67 $1,598.21 $1,550.92 $1,346.30 $1,285.84 $1,307.60 $1,201.88 $1,310.47 $1,317.66

55 to 59 $2,795.44 $2,533.19 $2,183.85 $1,952.40 $1,894.63 $1,644.66 $1,570.80 $1,597.39 $1,468.24 $1,600.89 $1,609.67

60 to 64 $3,444.89 $3,121.72 $2,691.22 $2,405.99 $2,334.80 $2,026.76 $1,935.74 $1,968.51 $1,809.35 $1,972.82 $1,983.64

65 plus $4,634.41 $4,199.65 $3,620.49 $3,236.78 $3,141.01 $2,726.60 $2,604.15 $2,648.24 $2,434.13 $2,654.04 $2,668.59

These are standard rates and subject to risk adjustment of ±10%. Plan issuance is subject to eligibility, contribution and participation requirements.

Choice Plus Value30/1000/80%

5E-P40/1000/70%

5E-S40/1000/50%

5E-Q40/1500/70%

5E-T40/2000/50%

5E-R

$251.80 $233.09 $220.27 $223.02 $204.15

$311.63 $288.48 $272.61 $276.01 $252.66

$418.48 $387.38 $366.08 $370.65 $339.29

$579.82 $536.73 $507.21 $513.55 $470.09

$717.29 $663.99 $627.47 $635.31 $581.55

$935.97 $866.42 $818.77 $828.99 $758.85

$1,102.29 $1,020.39 $964.27 $976.30 $893.70

$719.07 $665.64 $629.03 $636.88 $583.00

$844.44 $781.69 $738.70 $747.92 $684.64

$908.90 $841.37 $795.09 $805.02 $736.90

$1,198.45 $1,109.40 $1,048.39 $1,061.47 $971.66

$1,486.23 $1,375.79 $1,300.12 $1,316.35 $1,204.98

$1,853.06 $1,715.37 $1,621.03 $1,641.26 $1,502.39

$2,543.29 $2,354.31 $2,224.82 $2,252.60 $2,062.00

$570.56 $528.16 $499.11 $505.34 $462.59

$625.40 $578.93 $547.09 $553.92 $507.05

$643.57 $595.75 $562.98 $570.01 $521.78

$778.91 $721.03 $681.37 $689.88 $631.51

$921.01 $852.58 $805.68 $815.74 $746.72

$1,150.02 $1,064.57 $1,006.01 $1,018.57 $932.39

$1,300.31 $1,203.69 $1,137.49 $1,151.69 $1,054.25

$900.00 $833.12 $787.30 $797.13 $729.68

$1,022.16 $946.21 $894.17 $905.33 $828.73

$1,036.76 $959.72 $906.94 $918.26 $840.57

$1,311.35 $1,213.91 $1,147.15 $1,161.47 $1,063.20

$1,601.98 $1,482.94 $1,401.38 $1,418.87 $1,298.82

$1,974.15 $1,827.47 $1,726.95 $1,748.51 $1,600.57

$2,655.83 $2,458.49 $2,323.27 $2,352.28 $2,153.25

Defi nitySM HSA

AgeCategory

1500/80%Z6-Q

2000/100%5E-N

2000/80%Q3-M

3000/100%5E-O

3000/80%5E-L

4000/80%5E-M

EM

PLO

YE

EO

NLY

0 to 29 $246.24 $247.07 $225.99 $215.26 $200.90 $189.56

30 to 39 $304.75 $305.78 $279.69 $266.41 $248.64 $234.60

40 to 49 $409.24 $410.62 $375.58 $357.75 $333.89 $315.04

50 to 54 $567.01 $568.92 $520.38 $495.68 $462.61 $436.50

55 to 59 $701.45 $703.82 $643.77 $613.20 $572.30 $539.99

60 to 64 $915.30 $918.39 $840.03 $800.15 $746.77 $704.62

65 plus $1,077.95 $1,081.59 $989.31 $942.33 $879.47 $829.83

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $703.19 $705.56 $645.37 $614.72 $573.72 $541.33

30 to 39 $825.79 $828.58 $757.88 $721.90 $673.74 $635.71

40 to 49 $888.83 $891.83 $815.74 $777.01 $725.17 $684.24

50 to 54 $1,171.99 $1,175.94 $1,075.61 $1,024.54 $956.19 $902.22

55 to 59 $1,453.41 $1,458.31 $1,333.88 $1,270.55 $1,185.79 $1,118.86

60 to 64 $1,812.15 $1,818.25 $1,663.12 $1,584.16 $1,478.48 $1,395.02

65 plus $2,487.13 $2,495.51 $2,282.59 $2,174.22 $2,029.18 $1,914.64

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $557.96 $559.84 $512.07 $487.76 $455.22 $429.53

30 to 39 $611.59 $613.66 $561.30 $534.65 $498.98 $470.82

40 to 49 $629.36 $631.48 $577.60 $550.18 $513.47 $484.49

50 to 54 $761.71 $764.27 $699.07 $665.87 $621.45 $586.38

55 to 59 $900.67 $903.71 $826.61 $787.36 $734.83 $693.36

60 to 64 $1,124.62 $1,128.41 $1,032.14 $983.13 $917.55 $865.76

65 plus $1,271.60 $1,275.89 $1,167.03 $1,111.62 $1,037.46 $978.90

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $880.13 $883.09 $807.75 $769.39 $718.07 $677.54

30 to 39 $999.59 $1,002.96 $917.39 $873.83 $815.53 $769.50

40 to 49 $1,013.87 $1,017.29 $930.49 $886.31 $827.19 $780.49

50 to 54 $1,282.40 $1,286.72 $1,176.94 $1,121.06 $1,046.27 $987.21

55 to 59 $1,566.60 $1,571.88 $1,437.77 $1,369.50 $1,278.14 $1,206.00

60 to 64 $1,930.56 $1,937.07 $1,771.80 $1,687.67 $1,575.09 $1,486.18

65 plus $2,597.19 $2,605.94 $2,383.60 $2,270.43 $2,118.97 $1,999.36

Defi nitySM HRA Non-Differential

PPO

AgeCategory

1500/80%C3-U

2000/70%C3-S

2500/80%C3-V

3000/70%C3-T

2000/80%6H-F

EM

PLO

YE

EO

NLY

0 to 29 $278.05 $252.90 $245.42 $234.19 $683.49

30 to 39 $344.12 $313.00 $303.74 $289.84 $845.90

40 to 49 $462.11 $420.31 $407.88 $389.21 $1,135.93

50 to 54 $640.26 $582.35 $565.13 $539.27 $1,573.86

55 to 59 $792.07 $720.43 $699.12 $667.13 $1,947.03

60 to 64 $1,033.54 $940.06 $912.25 $870.51 $2,540.61

65 plus $1,217.21 $1,107.11 $1,074.36 $1,025.20 $2,992.08

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $794.04 $722.21 $700.85 $668.78 $1,951.86

30 to 39 $932.47 $848.13 $823.04 $785.38 $2,292.16

40 to 49 $1,003.65 $912.87 $885.87 $845.34 $2,467.14

50 to 54 $1,323.39 $1,203.69 $1,168.09 $1,114.64 $3,253.10

55 to 59 $1,641.16 $1,492.72 $1,448.57 $1,382.28 $4,034.23

60 to 64 $2,046.24 $1,861.16 $1,806.11 $1,723.47 $5,029.98

65 plus $2,808.42 $2,554.40 $2,478.85 $2,365.42 $6,903.54

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $630.04 $573.05 $556.10 $530.65 $1,548.73

30 to 39 $690.60 $628.14 $609.56 $581.67 $1,697.61

40 to 49 $710.66 $646.38 $627.26 $598.56 $1,746.91

50 to 54 $860.11 $782.31 $759.17 $724.43 $2,114.28

55 to 59 $1,017.03 $925.03 $897.67 $856.60 $2,500.01

60 to 64 $1,269.91 $1,155.04 $1,120.88 $1,069.59 $3,121.63

65 plus $1,435.87 $1,305.99 $1,267.37 $1,209.37 $3,529.59

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $993.82 $903.93 $877.19 $837.06 $2,442.97

30 to 39 $1,128.72 $1,026.62 $996.26 $950.67 $2,774.56

40 to 49 $1,144.84 $1,041.29 $1,010.49 $964.25 $2,814.20

50 to 54 $1,448.06 $1,317.08 $1,278.13 $1,219.64 $3,559.56

55 to 59 $1,768.98 $1,608.97 $1,561.38 $1,489.94 $4,348.43

60 to 64 $2,179.96 $1,982.78 $1,924.13 $1,836.09 $5,358.68

65 plus $2,932.70 $2,667.43 $2,588.54 $2,470.09 $7,209.03

6

Area #2 CountiesHMO products: OrangeValue Network HMO products: OrangeHCP Network HMO products: Orange County ZIP Codes listed in Table of Contents

All other products: Orange



AgeCategory

25-50/500ded

25-75/500ded

25-75/1500ded

EM

PLO

YE

E O

NLY

0 to 29 $182.07 $176.03 $150.96

30 to 39 $211.52 $204.50 $175.37

40 to 49 $262.32 $253.61 $217.49

50 to 54 $356.28 $344.45 $295.40

55 to 59 $458.10 $442.90 $379.82

60 to 64 $581.51 $562.21 $482.14

65 plus $811.46 $784.53 $672.80

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $434.27 $419.86 $360.07

30 to 39 $485.08 $468.98 $402.19

40 to 49 $579.03 $559.82 $480.09

50 to 54 $741.10 $716.50 $614.46

55 to 59 $941.38 $910.14 $780.52

60 to 64 $1,119.63 $1,082.47 $928.31

65 plus $1,455.00 $1,406.71 $1,206.37

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $407.30 $393.78 $337.70

30 to 39 $453.83 $438.77 $376.28

40 to 49 $491.82 $475.50 $407.78

50 to 54 $571.84 $552.86 $474.13

55 to 59 $639.95 $618.71 $530.60

60 to 64 $784.93 $758.88 $650.80

65 plus $1,033.09 $998.80 $856.56

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $668.72 $646.53 $554.45

30 to 39 $737.28 $712.81 $611.29

40 to 49 $817.97 $790.83 $678.20

50 to 54 $965.43 $933.39 $800.46

55 to 59 $1,130.87 $1,093.34 $937.63

60 to 64 $1,331.37 $1,287.19 $1,103.87

65 plus $1,685.63 $1,629.68 $1,397.59


AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $335.15 $302.34 $280.41 $264.84 $248.13 $235.64 $236.34 $219.40 $202.86

30 to 39 $389.36 $351.24 $325.76 $307.67 $288.26 $273.75 $274.56 $254.88 $235.66

40 to 49 $482.87 $435.59 $404.00 $381.56 $357.49 $339.49 $340.51 $316.09 $292.26

50 to 54 $655.83 $591.62 $548.71 $518.23 $485.53 $461.09 $462.47 $429.31 $396.95

55 to 59 $843.26 $760.70 $705.54 $666.34 $624.30 $592.87 $594.65 $552.01 $510.40

60 to 64 $1,070.42 $965.62 $895.59 $845.85 $792.48 $752.58 $754.83 $700.71 $647.89

65 plus $1,493.71 $1,347.47 $1,249.75 $1,180.33 $1,105.85 $1,050.19 $1,053.33 $977.80 $904.09

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $799.40 $721.14 $668.84 $631.69 $591.83 $562.04 $563.72 $523.30 $483.85

30 to 39 $892.92 $805.50 $747.08 $705.58 $661.06 $627.78 $629.66 $584.52 $540.45

40 to 49 $1,065.87 $961.52 $891.79 $842.25 $789.11 $749.38 $751.63 $697.74 $645.13

50 to 54 $1,364.20 $1,230.64 $1,141.39 $1,077.99 $1,009.97 $959.13 $962.00 $893.03 $825.70

55 to 59 $1,732.87 $1,563.21 $1,449.84 $1,369.31 $1,282.91 $1,218.33 $1,221.97 $1,134.36 $1,048.84

60 to 64 $2,060.99 $1,859.21 $1,724.37 $1,628.59 $1,525.83 $1,449.02 $1,453.36 $1,349.15 $1,247.44

65 plus $2,678.33 $2,416.11 $2,240.89 $2,116.41 $1,982.87 $1,883.06 $1,888.69 $1,753.28 $1,621.10

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $749.75 $676.35 $627.30 $592.45 $555.07 $527.13 $528.71 $490.80 $453.80

30 to 39 $835.40 $753.61 $698.96 $660.13 $618.48 $587.35 $589.10 $546.87 $505.64

40 to 49 $905.33 $816.69 $757.46 $715.39 $670.25 $636.51 $638.41 $592.64 $547.96

50 to 54 $1,052.63 $949.57 $880.71 $831.79 $779.30 $740.08 $742.29 $689.07 $637.12

55 to 59 $1,178.00 $1,062.67 $985.60 $930.86 $872.12 $828.22 $830.70 $771.14 $713.00

60 to 64 $1,444.88 $1,303.42 $1,208.90 $1,141.74 $1,069.70 $1,015.86 $1,018.90 $945.84 $874.54

65 plus $1,901.69 $1,715.50 $1,591.09 $1,502.71 $1,407.89 $1,337.02 $1,341.02 $1,244.87 $1,151.02

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,230.97 $1,110.45 $1,029.92 $972.71 $911.33 $865.46 $868.05 $805.81 $745.06

30 to 39 $1,357.17 $1,224.29 $1,135.50 $1,072.43 $1,004.76 $954.18 $957.04 $888.42 $821.44

40 to 49 $1,505.71 $1,358.29 $1,259.79 $1,189.81 $1,114.73 $1,058.62 $1,061.79 $985.66 $911.35

50 to 54 $1,777.14 $1,603.15 $1,486.89 $1,404.29 $1,315.69 $1,249.46 $1,253.20 $1,163.34 $1,075.64

55 to 59 $2,081.68 $1,877.87 $1,741.68 $1,644.94 $1,541.15 $1,463.57 $1,467.95 $1,362.70 $1,259.96

60 to 64 $2,450.76 $2,210.82 $2,050.48 $1,936.58 $1,814.39 $1,723.06 $1,728.21 $1,604.30 $1,483.36

65 plus $3,102.86 $2,799.08 $2,596.08 $2,451.87 $2,297.17 $2,181.53 $2,188.06 $2,031.18 $1,878.05


AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 -

60/2000ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $289.90 $261.51 $242.54 $229.08 $214.63 $203.82 $191.60 $204.43 $189.78 $175.47

30 to 39 $336.78 $303.80 $281.76 $266.12 $249.35 $236.78 $222.58 $237.49 $220.48 $203.85

40 to 49 $417.67 $376.77 $349.43 $330.04 $309.23 $293.65 $276.04 $294.53 $273.43 $252.81

50 to 54 $567.27 $511.72 $474.60 $448.25 $419.99 $398.83 $374.92 $400.02 $371.37 $343.36

55 to 59 $729.40 $657.97 $610.24 $576.37 $540.03 $512.82 $482.07 $514.35 $477.50 $441.49

60 to 64 $925.89 $835.21 $774.63 $731.63 $685.50 $650.97 $611.93 $652.91 $606.13 $560.42

65 plus $1,292.02 $1,165.49 $1,080.94 $1,020.94 $956.58 $908.38 $853.91 $911.09 $845.82 $782.03

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $691.46 $623.75 $578.50 $546.39 $511.94 $486.15 $457.00 $487.60 $452.67 $418.53

30 to 39 $772.35 $696.71 $646.17 $610.30 $571.83 $543.02 $510.45 $544.64 $505.62 $467.49

40 to 49 $921.95 $831.66 $771.33 $728.52 $682.59 $648.20 $609.33 $650.13 $603.56 $558.04

50 to 54 $1,180.00 $1,064.44 $987.22 $932.42 $873.64 $829.62 $779.87 $832.10 $772.49 $714.23

55 to 59 $1,498.89 $1,352.10 $1,254.01 $1,184.41 $1,109.74 $1,053.83 $990.63 $1,056.97 $981.25 $907.25

60 to 64 $1,782.70 $1,608.12 $1,491.46 $1,408.68 $1,319.87 $1,253.37 $1,178.21 $1,257.10 $1,167.05 $1,079.03

65 plus $2,316.69 $2,089.81 $1,938.21 $1,830.63 $1,715.22 $1,628.80 $1,531.12 $1,633.66 $1,516.62 $1,402.25

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $648.51 $585.00 $542.57 $512.45 $480.14 $455.95 $428.61 $457.31 $424.55 $392.53

30 to 39 $722.60 $651.83 $604.55 $570.99 $534.99 $508.04 $477.57 $509.56 $473.05 $437.38

40 to 49 $783.09 $706.40 $655.15 $618.79 $579.78 $550.57 $517.55 $552.21 $512.65 $473.99

50 to 54 $910.50 $821.33 $761.75 $719.47 $674.11 $640.15 $601.76 $642.05 $596.06 $551.11

55 to 59 $1,018.94 $919.15 $852.48 $805.16 $754.40 $716.39 $673.43 $718.53 $667.05 $616.75

60 to 64 $1,249.79 $1,127.39 $1,045.61 $987.57 $925.31 $878.69 $826.00 $881.31 $818.18 $756.47

65 plus $1,644.91 $1,483.82 $1,376.18 $1,299.79 $1,217.85 $1,156.49 $1,087.14 $1,159.94 $1,076.84 $995.63

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,064.75 $960.48 $890.80 $841.36 $788.32 $748.60 $703.71 $750.83 $697.04 $644.47

30 to 39 $1,173.91 $1,058.95 $982.13 $927.62 $869.13 $825.35 $775.85 $827.81 $768.50 $710.55

40 to 49 $1,302.40 $1,174.85 $1,089.63 $1,029.15 $964.26 $915.68 $860.77 $918.41 $852.62 $788.32

50 to 54 $1,537.18 $1,386.64 $1,286.05 $1,214.67 $1,138.09 $1,080.75 $1,015.94 $1,083.97 $1,006.32 $930.43

55 to 59 $1,800.59 $1,624.26 $1,506.43 $1,422.82 $1,333.11 $1,265.95 $1,190.03 $1,269.72 $1,178.76 $1,089.87

60 to 64 $2,119.84 $1,912.24 $1,773.52 $1,675.08 $1,569.48 $1,490.40 $1,401.03 $1,494.85 $1,387.76 $1,283.10

65 plus $2,683.89 $2,421.05 $2,245.43 $2,120.79 $1,987.09 $1,886.97 $1,773.81 $1,892.60 $1,757.02 $1,624.51

7


Choice PlusAge

Category20/250/90%

5E-A30/250/80%

5E-D30/500/80%

5E-F40/500/70%

5E-K30/1000/80%

5E-C40/1000/70%

5E-I40/1000/50%

5E-G40/1500/70%

5E-J40/2000/50%

5E-H30/2500/80%

5E-E20/3000/90%

5E-B

EM

PLO

YE

EO

NLY

0 to 29 $416.60 $377.53 $325.46 $290.97 $282.36 $245.11 $234.10 $238.06 $218.81 $238.59 $239.89

30 to 39 $515.59 $467.24 $402.80 $360.11 $349.46 $303.35 $289.73 $294.63 $270.80 $295.28 $296.89

40 to 49 $692.37 $627.44 $540.90 $483.58 $469.27 $407.36 $389.06 $395.64 $363.65 $396.53 $398.69

50 to 54 $959.30 $869.33 $749.43 $670.01 $650.19 $564.41 $539.06 $548.18 $503.85 $549.40 $552.39

55 to 59 $1,186.75 $1,075.45 $927.12 $828.87 $804.35 $698.23 $666.87 $678.15 $623.31 $679.66 $683.36

60 to 64 $1,548.55 $1,403.32 $1,209.77 $1,081.57 $1,049.56 $911.10 $870.18 $884.90 $813.34 $886.87 $891.70

65 plus $1,823.73 $1,652.69 $1,424.75 $1,273.77 $1,236.07 $1,073.01 $1,024.81 $1,042.14 $957.87 $1,044.46 $1,050.15

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $1,189.70 $1,078.12 $929.43 $830.93 $806.34 $699.97 $668.53 $679.83 $624.86 $681.35 $685.06

30 to 39 $1,397.11 $1,266.09 $1,091.46 $975.80 $946.92 $822.00 $785.08 $798.36 $733.80 $800.14 $804.50

40 to 49 $1,503.77 $1,362.74 $1,174.79 $1,050.29 $1,019.21 $884.75 $845.01 $859.31 $789.82 $861.22 $865.91

50 to 54 $1,982.83 $1,796.87 $1,549.04 $1,384.89 $1,343.91 $1,166.61 $1,114.21 $1,133.06 $1,041.44 $1,135.58 $1,141.77

55 to 59 $2,458.94 $2,228.33 $1,921.00 $1,717.42 $1,666.60 $1,446.74 $1,381.75 $1,405.13 $1,291.51 $1,408.25 $1,415.93

60 to 64 $3,065.87 $2,778.34 $2,395.15 $2,141.33 $2,077.96 $1,803.83 $1,722.80 $1,751.95 $1,610.28 $1,755.85 $1,765.41

65 plus $4,207.84 $3,813.21 $3,287.28 $2,938.92 $2,851.96 $2,475.72 $2,364.51 $2,404.51 $2,210.07 $2,409.86 $2,422.99

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $943.98 $855.45 $737.46 $659.31 $639.80 $555.40 $530.45 $539.42 $495.80 $540.62 $543.57

30 to 39 $1,034.72 $937.68 $808.36 $722.69 $701.31 $608.79 $581.44 $591.28 $543.47 $592.59 $595.82

40 to 49 $1,064.78 $964.92 $831.83 $743.68 $721.68 $626.47 $598.33 $608.45 $559.25 $609.80 $613.13

50 to 54 $1,288.69 $1,167.83 $1,006.76 $900.07 $873.44 $758.21 $724.15 $736.40 $676.86 $738.04 $742.06

55 to 59 $1,523.80 $1,380.89 $1,190.44 $1,064.28 $1,032.79 $896.54 $856.27 $870.75 $800.34 $872.69 $877.45

60 to 64 $1,902.69 $1,724.25 $1,486.44 $1,328.91 $1,289.59 $1,119.46 $1,069.18 $1,087.26 $999.35 $1,089.68 $1,095.62

65 plus $2,151.35 $1,949.59 $1,680.70 $1,502.59 $1,458.13 $1,265.77 $1,208.91 $1,229.36 $1,129.95 $1,232.10 $1,238.81

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,489.04 $1,349.39 $1,163.28 $1,040.00 $1,009.23 $876.09 $836.73 $850.89 $782.08 $852.78 $857.43

30 to 39 $1,691.15 $1,532.55 $1,321.17 $1,181.17 $1,146.21 $995.00 $950.31 $966.38 $888.24 $968.53 $973.81

40 to 49 $1,715.31 $1,554.44 $1,340.05 $1,198.04 $1,162.59 $1,009.22 $963.88 $980.19 $900.93 $982.37 $987.72

50 to 54 $2,169.62 $1,966.15 $1,694.97 $1,515.35 $1,470.51 $1,276.51 $1,219.17 $1,239.80 $1,139.55 $1,242.56 $1,249.33

55 to 59 $2,650.45 $2,401.88 $2,070.61 $1,851.18 $1,796.40 $1,559.41 $1,489.37 $1,514.56 $1,392.09 $1,517.93 $1,526.20

60 to 64 $3,266.21 $2,959.90 $2,551.66 $2,281.25 $2,213.75 $1,921.70 $1,835.38 $1,866.43 $1,715.51 $1,870.59 $1,880.78

65 plus $4,394.04 $3,981.95 $3,432.75 $3,068.97 $2,978.16 $2,585.27 $2,469.14 $2,510.91 $2,307.87 $2,516.50 $2,530.21


5E-P40/1000/70%

5E-S40/1000/50%

5E-Q40/1500/70%

5E-T40/2000/50%

5E-R

$238.74 $221.00 $208.85 $211.46 $193.56

$295.47 $273.51 $258.48 $261.71 $239.55

$396.77 $367.29 $347.10 $351.44 $321.69

$549.74 $508.89 $480.92 $486.93 $445.71

$680.09 $629.55 $594.94 $602.38 $551.39

$887.42 $821.48 $776.32 $786.02 $719.48

$1,045.12 $967.46 $914.27 $925.70 $847.34

$681.78 $631.12 $596.42 $603.87 $552.75

$800.64 $741.15 $700.40 $709.15 $649.12

$861.76 $797.73 $753.87 $763.29 $698.68

$1,136.29 $1,051.86 $994.03 $1,006.45 $921.26

$1,409.14 $1,304.43 $1,232.72 $1,248.12 $1,142.47

$1,756.95 $1,626.40 $1,536.98 $1,556.19 $1,424.46

$2,411.38 $2,232.19 $2,109.47 $2,135.84 $1,955.04

$540.96 $500.77 $473.24 $479.15 $438.59

$592.97 $548.91 $518.73 $525.21 $480.75

$610.19 $564.85 $533.79 $540.46 $494.71

$738.51 $683.63 $646.05 $654.12 $598.75

$873.24 $808.35 $763.91 $773.46 $707.99

$1,090.37 $1,009.35 $953.86 $965.78 $884.02

$1,232.87 $1,141.26 $1,078.52 $1,091.99 $999.56

$853.32 $789.91 $746.48 $755.81 $691.83

$969.14 $897.13 $847.81 $858.40 $785.74

$982.99 $909.94 $859.92 $870.66 $796.96

$1,243.34 $1,150.95 $1,087.67 $1,101.27 $1,008.05

$1,518.89 $1,406.02 $1,328.72 $1,345.33 $1,231.45

$1,871.76 $1,732.68 $1,637.42 $1,657.88 $1,517.54

$2,518.08 $2,330.97 $2,202.82 $2,230.35 $2,041.55

Defi nitySM HSA

AgeCategory

1500/80%Z6-Q

2000/100%5E-N

2000/80%Q3-M

3000/100%5E-O

3000/80%5E-L

4000/80%5E-M

EM

PLO

YE

EO

NLY

0 to 29 $233.47 $234.26 $214.27 $204.10 $190.48 $179.73

30 to 39 $288.95 $289.93 $265.19 $252.60 $235.74 $222.44

40 to 49 $388.02 $389.33 $356.11 $339.20 $316.57 $298.70

50 to 54 $537.61 $539.43 $493.40 $469.98 $438.62 $413.86

55 to 59 $665.08 $667.33 $610.38 $581.41 $542.61 $511.99

60 to 64 $867.83 $870.77 $796.47 $758.66 $708.04 $668.08

65 plus $1,022.05 $1,025.51 $938.00 $893.48 $833.86 $786.80

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $666.73 $668.98 $611.90 $582.85 $543.96 $513.26

30 to 39 $782.97 $785.62 $718.58 $684.47 $638.80 $602.74

40 to 49 $842.74 $845.59 $773.43 $736.72 $687.56 $648.76

50 to 54 $1,111.21 $1,114.97 $1,019.83 $971.42 $906.60 $855.43

55 to 59 $1,378.03 $1,382.70 $1,264.71 $1,204.68 $1,124.29 $1,060.84

60 to 64 $1,718.17 $1,723.98 $1,576.87 $1,502.03 $1,401.79 $1,322.68

65 plus $2,358.15 $2,366.13 $2,164.22 $2,061.50 $1,923.93 $1,815.35

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $529.02 $530.81 $485.52 $462.47 $431.61 $407.25

30 to 39 $579.88 $581.84 $532.19 $506.93 $473.10 $446.40

40 to 49 $596.72 $598.74 $547.65 $521.65 $486.84 $459.37

50 to 54 $722.20 $724.65 $662.81 $631.35 $589.22 $555.97

55 to 59 $853.97 $856.85 $783.74 $746.54 $696.72 $657.40

60 to 64 $1,066.30 $1,069.91 $978.61 $932.16 $869.96 $820.86

65 plus $1,205.66 $1,209.74 $1,106.51 $1,053.99 $983.65 $928.14

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $834.48 $837.31 $765.86 $729.51 $680.82 $642.40

30 to 39 $947.75 $950.96 $869.81 $828.52 $773.24 $729.60

40 to 49 $961.29 $964.54 $882.23 $840.36 $784.28 $740.02

50 to 54 $1,215.89 $1,220.01 $1,115.90 $1,062.94 $992.00 $936.02

55 to 59 $1,485.36 $1,490.38 $1,363.21 $1,298.50 $1,211.85 $1,143.46

60 to 64 $1,830.44 $1,836.64 $1,679.91 $1,600.18 $1,493.40 $1,409.11

65 plus $2,462.50 $2,470.83 $2,259.99 $2,152.72 $2,009.07 $1,895.68


PPO

AgeCategory

1500/80%C3-U

2000/70%C3-S

2500/80%C3-V

3000/70%C3-T

2000/80%6H-F

EM

PLO

YE

EO

NLY

0 to 29 $263.63 $239.79 $232.69 $222.05 $683.49

30 to 39 $326.27 $296.77 $287.98 $274.81 $845.90

40 to 49 $438.14 $398.52 $386.72 $369.04 $1,135.93

50 to 54 $607.06 $552.16 $535.81 $511.31 $1,573.86

55 to 59 $750.99 $683.08 $662.85 $632.54 $1,947.03

60 to 64 $979.94 $891.33 $864.94 $825.39 $2,540.61

65 plus $1,154.08 $1,049.72 $1,018.64 $972.06 $2,992.08

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $752.86 $684.78 $664.50 $634.11 $1,951.86

30 to 39 $884.11 $804.16 $780.35 $744.67 $2,292.16

40 to 49 $951.60 $865.55 $839.92 $801.52 $2,467.14

50 to 54 $1,254.76 $1,141.29 $1,107.50 $1,056.86 $3,253.10

55 to 59 $1,556.05 $1,415.34 $1,373.43 $1,310.63 $4,034.23

60 to 64 $1,940.12 $1,764.68 $1,712.43 $1,634.12 $5,029.98

65 plus $2,662.77 $2,421.98 $2,350.27 $2,242.80 $6,903.54

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $597.36 $543.34 $527.26 $503.15 $1,548.73

30 to 39 $654.79 $595.57 $577.94 $551.51 $1,697.61

40 to 49 $673.80 $612.87 $594.73 $567.53 $1,746.91

50 to 54 $815.50 $741.75 $719.79 $686.88 $2,114.28

55 to 59 $964.28 $877.08 $851.11 $812.19 $2,500.01

60 to 64 $1,204.05 $1,095.17 $1,062.74 $1,014.14 $3,121.63

65 plus $1,361.40 $1,238.29 $1,201.63 $1,146.68 $3,529.59

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $942.28 $857.07 $831.69 $793.66 $2,442.97

30 to 39 $1,070.18 $973.40 $944.58 $901.39 $2,774.56

40 to 49 $1,085.47 $987.31 $958.08 $914.27 $2,814.20

50 to 54 $1,372.96 $1,248.81 $1,211.83 $1,156.42 $3,559.56

55 to 59 $1,677.24 $1,525.57 $1,480.40 $1,412.70 $4,348.43

60 to 64 $2,066.90 $1,879.99 $1,824.33 $1,740.91 $5,358.68

65 plus $2,780.61 $2,529.16 $2,454.27 $2,342.05 $7,209.03

8

Area #3 CountiesHMO products: San Diego #1 (ZIP Codes beginning with 921), Imperial, San Diego #2

(ZIP Codes beginning with 919 and 920), Riverside and San BernardinoValue Network HMO products: San Diego #1 (ZIP Codes beginning with 921), San Diego #2 (ZIP Codes beginning

with 919 and 920), Riverside and San BernardinoHCP Network HMO products: Not available in this areaAll other products: San Diego #1 (ZIP Codes beginning with 921), Imperial, Santa Barbara, Ventura,

and Santa Clara



AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $355.69 $320.87 $297.59 $281.07 $263.34 $250.08 $250.83 $232.85 $215.29

30 to 39 $413.21 $372.77 $345.72 $326.53 $305.93 $290.52 $291.40 $270.51 $250.11

40 to 49 $512.45 $462.30 $428.76 $404.95 $379.40 $360.30 $361.38 $335.48 $310.18

50 to 54 $696.01 $627.88 $582.33 $550.00 $515.30 $489.35 $490.83 $455.64 $421.28

55 to 59 $894.93 $807.33 $748.76 $707.19 $662.57 $629.21 $631.11 $585.86 $541.68

60 to 64 $1,136.00 $1,024.81 $950.46 $897.69 $841.06 $798.71 $801.12 $743.68 $687.60

65 plus $1,585.22 $1,430.07 $1,326.31 $1,252.67 $1,173.65 $1,114.55 $1,117.91 $1,037.77 $959.50

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $848.38 $765.34 $709.82 $670.40 $628.11 $596.49 $598.28 $555.39 $513.51

30 to 39 $947.62 $854.87 $792.85 $748.83 $701.59 $666.26 $668.27 $620.36 $573.57

40 to 49 $1,131.17 $1,020.46 $946.42 $893.87 $837.48 $795.31 $797.71 $740.52 $684.68

50 to 54 $1,447.78 $1,306.07 $1,211.32 $1,144.06 $1,071.89 $1,017.92 $1,020.98 $947.79 $876.31

55 to 59 $1,839.03 $1,659.03 $1,538.67 $1,453.24 $1,361.56 $1,293.00 $1,296.90 $1,203.92 $1,113.13

60 to 64 $2,187.26 $1,973.17 $1,830.02 $1,728.41 $1,619.37 $1,537.83 $1,542.47 $1,431.89 $1,323.90

65 plus $2,842.42 $2,564.21 $2,378.18 $2,246.13 $2,104.44 $1,998.47 $2,004.49 $1,860.79 $1,720.46

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $795.69 $717.81 $665.73 $628.76 $589.10 $559.44 $561.12 $520.90 $481.61

30 to 39 $886.58 $799.81 $741.78 $700.59 $656.40 $623.35 $625.22 $580.40 $536.63

40 to 49 $960.79 $866.75 $803.87 $759.24 $711.34 $675.52 $677.56 $628.98 $581.55

50 to 54 $1,117.12 $1,007.78 $934.67 $882.77 $827.08 $785.43 $787.80 $731.32 $676.17

55 to 59 $1,250.17 $1,127.81 $1,045.99 $987.91 $925.59 $878.98 $881.63 $818.43 $756.70

60 to 64 $1,533.41 $1,383.32 $1,282.96 $1,211.72 $1,135.28 $1,078.12 $1,081.37 $1,003.85 $928.14

65 plus $2,018.20 $1,820.66 $1,688.57 $1,594.81 $1,494.21 $1,418.97 $1,423.24 $1,321.21 $1,221.57

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,306.38 $1,178.52 $1,093.02 $1,032.33 $967.20 $918.50 $921.27 $855.22 $790.73

30 to 39 $1,440.31 $1,299.34 $1,205.07 $1,138.16 $1,066.36 $1,012.67 $1,015.72 $942.90 $871.79

40 to 49 $1,597.96 $1,441.55 $1,336.97 $1,262.73 $1,183.08 $1,123.50 $1,126.89 $1,046.10 $967.21

50 to 54 $1,886.02 $1,701.42 $1,577.98 $1,490.37 $1,396.35 $1,326.04 $1,330.03 $1,234.68 $1,141.57

55 to 59 $2,209.21 $1,992.98 $1,848.39 $1,745.76 $1,635.63 $1,553.27 $1,557.95 $1,446.26 $1,337.19

60 to 64 $2,600.91 $2,346.34 $2,176.11 $2,055.28 $1,925.63 $1,828.67 $1,834.18 $1,702.68 $1,574.27

65 plus $3,292.96 $2,970.65 $2,755.13 $2,602.15 $2,438.00 $2,315.24 $2,322.22 $2,155.74 $1,993.16


AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 -

60/2000ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $330.78 $298.40 $276.75 $261.39 $244.90 $232.57 $218.63 $233.27 $216.55 $200.22

30 to 39 $384.28 $346.66 $321.51 $303.66 $284.51 $270.18 $253.99 $271.00 $251.58 $232.61

40 to 49 $476.57 $429.92 $398.73 $376.59 $352.84 $335.07 $314.98 $336.08 $312.00 $288.47

50 to 54 $647.27 $583.91 $541.55 $511.48 $479.22 $455.09 $427.81 $456.46 $423.75 $391.80

55 to 59 $832.26 $750.80 $696.32 $657.66 $616.19 $585.15 $550.08 $586.92 $544.86 $503.77

60 to 64 $1,056.45 $953.05 $883.90 $834.82 $782.18 $742.78 $698.26 $745.03 $691.63 $639.48

65 plus $1,474.22 $1,329.92 $1,233.43 $1,164.95 $1,091.48 $1,036.50 $974.38 $1,039.64 $965.13 $892.36

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $788.97 $711.75 $660.11 $623.46 $584.14 $554.72 $521.47 $556.40 $516.52 $477.57

30 to 39 $881.26 $795.01 $737.32 $696.39 $652.47 $619.60 $582.47 $621.48 $576.94 $533.44

40 to 49 $1,051.96 $949.00 $880.14 $831.28 $778.85 $739.62 $695.29 $741.86 $688.69 $636.76

50 to 54 $1,346.40 $1,214.61 $1,126.49 $1,063.94 $996.85 $946.63 $889.89 $949.50 $881.45 $814.99

55 to 59 $1,710.25 $1,542.86 $1,430.91 $1,351.47 $1,266.24 $1,202.46 $1,130.38 $1,206.10 $1,119.66 $1,035.23

60 to 64 $2,034.09 $1,835.00 $1,701.86 $1,607.37 $1,506.01 $1,430.14 $1,344.42 $1,434.48 $1,331.67 $1,231.25

65 plus $2,643.38 $2,384.65 $2,211.63 $2,088.84 $1,957.11 $1,858.53 $1,747.13 $1,864.16 $1,730.56 $1,600.06

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $739.97 $667.54 $619.11 $584.73 $547.86 $520.26 $489.08 $521.84 $484.44 $447.91

30 to 39 $824.50 $743.80 $689.83 $651.53 $610.44 $579.70 $544.95 $581.45 $539.78 $499.08

40 to 49 $893.51 $806.06 $747.57 $706.07 $661.54 $628.22 $590.56 $630.12 $584.96 $540.85

50 to 54 $1,038.89 $937.21 $869.21 $820.95 $769.18 $730.43 $686.65 $732.65 $680.14 $628.85

55 to 59 $1,162.63 $1,048.83 $972.73 $918.73 $860.79 $817.43 $768.43 $819.91 $761.15 $703.75

60 to 64 $1,426.03 $1,286.45 $1,193.11 $1,126.87 $1,055.81 $1,002.62 $942.53 $1,005.66 $933.59 $863.19

65 plus $1,876.87 $1,693.17 $1,570.32 $1,483.13 $1,389.60 $1,319.60 $1,240.51 $1,323.60 $1,228.74 $1,136.09

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,214.90 $1,095.99 $1,016.47 $960.03 $899.49 $854.18 $802.98 $856.77 $795.37 $735.39

30 to 39 $1,339.45 $1,208.35 $1,120.68 $1,058.46 $991.71 $941.75 $885.30 $944.61 $876.91 $810.78

40 to 49 $1,486.06 $1,340.61 $1,243.34 $1,174.31 $1,100.25 $1,044.83 $982.20 $1,048.00 $972.89 $899.52

50 to 54 $1,753.95 $1,582.28 $1,467.47 $1,386.00 $1,298.59 $1,233.18 $1,159.26 $1,236.92 $1,148.27 $1,061.68

55 to 59 $2,054.51 $1,853.42 $1,718.94 $1,623.50 $1,521.12 $1,444.50 $1,357.92 $1,448.88 $1,345.04 $1,243.61

60 to 64 $2,418.78 $2,182.03 $2,023.71 $1,911.35 $1,790.82 $1,700.61 $1,598.68 $1,705.76 $1,583.51 $1,464.11

65 plus $3,062.37 $2,762.63 $2,562.18 $2,419.93 $2,267.32 $2,153.11 $2,024.06 $2,159.64 $2,004.86 $1,853.68

9These are standard rates and subject to risk adjustment of ±10%. Plan issuance is subject to eligibility, contribution and participation requirements.

Choice PlusAge

Category20/250/90%

5E-A30/250/80%

5E-D30/500/80%

5E-F40/500/70%

5E-K30/1000/80%

5E-C40/1000/70%

5E-I40/1000/50%

5E-G40/1500/70%

5E-J40/2000/50%

5E-H30/2500/80%

5E-E20/3000/90%

5E-B

EM

PLO

YE

EO

NLY

0 to 29 $389.22 $352.71 $304.06 $271.84 $263.80 $229.00 $218.71 $222.42 $204.43 $222.90 $224.12

30 to 39 $481.71 $436.52 $376.31 $336.44 $326.49 $283.42 $270.68 $275.27 $253.01 $275.87 $277.38

40 to 49 $646.86 $586.19 $505.33 $451.79 $438.42 $380.59 $363.49 $369.65 $339.75 $370.45 $372.48

50 to 54 $896.25 $812.18 $700.16 $625.96 $607.45 $527.32 $503.62 $512.16 $470.74 $513.27 $516.08

55 to 59 $1,108.75 $1,004.75 $866.16 $774.38 $751.48 $652.34 $623.03 $633.60 $582.35 $634.97 $638.44

60 to 64 $1,446.78 $1,311.06 $1,130.23 $1,010.46 $980.57 $851.22 $812.97 $826.76 $759.89 $828.54 $833.08

65 plus $1,703.87 $1,544.04 $1,331.07 $1,190.02 $1,154.82 $1,002.48 $957.44 $973.68 $894.92 $975.78 $981.12

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $1,111.51 $1,007.24 $868.31 $776.30 $753.34 $653.96 $624.58 $635.17 $583.80 $636.54 $640.03

30 to 39 $1,305.29 $1,182.85 $1,019.70 $911.64 $884.68 $767.98 $733.47 $745.91 $685.58 $747.52 $751.61

40 to 49 $1,404.94 $1,273.15 $1,097.54 $981.24 $952.22 $826.60 $789.46 $802.85 $737.91 $804.58 $808.99

50 to 54 $1,852.51 $1,678.74 $1,447.19 $1,293.84 $1,255.57 $1,089.94 $1,040.96 $1,058.62 $972.99 $1,060.90 $1,066.71

55 to 59 $2,297.33 $2,081.84 $1,794.69 $1,604.51 $1,557.05 $1,351.65 $1,290.91 $1,312.81 $1,206.63 $1,315.65 $1,322.85

60 to 64 $2,864.37 $2,595.69 $2,237.66 $2,000.54 $1,941.37 $1,685.27 $1,609.54 $1,636.85 $1,504.45 $1,640.38 $1,649.36

65 plus $3,931.29 $3,562.52 $3,071.14 $2,745.70 $2,664.49 $2,313.00 $2,209.06 $2,246.54 $2,064.83 $2,251.38 $2,263.71

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $881.94 $799.21 $688.97 $615.97 $597.75 $518.89 $495.58 $503.98 $463.22 $505.07 $507.84

30 to 39 $966.72 $876.04 $755.20 $675.18 $655.21 $568.78 $543.22 $552.43 $507.75 $553.62 $556.65

40 to 49 $994.80 $901.48 $777.14 $694.79 $674.24 $585.29 $558.99 $568.48 $522.50 $569.70 $572.82

50 to 54 $1,203.99 $1,091.06 $940.56 $840.90 $816.03 $708.38 $676.55 $688.02 $632.37 $689.51 $693.28

55 to 59 $1,423.65 $1,290.11 $1,112.16 $994.31 $964.90 $837.62 $799.98 $813.55 $747.75 $815.30 $819.77

60 to 64 $1,777.64 $1,610.89 $1,388.70 $1,241.54 $1,204.82 $1,045.89 $998.89 $1,015.83 $933.67 $1,018.03 $1,023.60

65 plus $2,009.96 $1,821.42 $1,570.19 $1,403.80 $1,362.28 $1,182.57 $1,129.43 $1,148.59 $1,055.69 $1,151.07 $1,157.37

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,391.17 $1,260.68 $1,086.79 $971.63 $942.89 $818.50 $781.73 $794.99 $730.69 $796.70 $801.06

30 to 39 $1,580.00 $1,431.79 $1,234.30 $1,103.51 $1,070.87 $929.60 $887.83 $902.89 $829.86 $904.84 $909.79

40 to 49 $1,602.57 $1,452.25 $1,251.94 $1,119.27 $1,086.17 $942.88 $900.52 $915.79 $841.72 $917.77 $922.79

50 to 54 $2,027.03 $1,836.89 $1,583.52 $1,415.72 $1,373.85 $1,192.61 $1,139.02 $1,158.35 $1,064.66 $1,160.85 $1,167.20

55 to 59 $2,476.25 $2,243.97 $1,934.46 $1,729.47 $1,678.32 $1,456.92 $1,391.45 $1,415.06 $1,300.60 $1,418.11 $1,425.87

60 to 64 $3,051.55 $2,765.31 $2,383.88 $2,131.27 $2,068.24 $1,795.40 $1,714.72 $1,743.81 $1,602.77 $1,747.57 $1,757.14

65 plus $4,105.25 $3,720.17 $3,207.04 $2,867.20 $2,782.40 $2,415.35 $2,306.82 $2,345.95 $2,156.20 $2,351.01 $2,363.88


5E-P40/1000/70%

5E-S40/1000/50%

5E-Q40/1500/70%

5E-T40/2000/50%

5E-R

$223.05 $206.48 $195.12 $197.56 $180.84

$276.05 $255.54 $241.49 $244.50 $223.81

$370.70 $343.16 $324.28 $328.34 $300.55

$513.61 $475.46 $449.30 $454.92 $416.42

$635.39 $588.19 $555.83 $562.78 $515.15

$829.10 $767.51 $725.28 $734.35 $672.20

$976.44 $903.90 $854.17 $864.85 $791.65

$636.97 $589.65 $557.21 $564.18 $516.43

$748.02 $692.45 $654.36 $662.54 $606.47

$805.13 $745.31 $704.31 $713.12 $652.76

$1,061.62 $982.75 $928.68 $940.30 $860.72

$1,316.53 $1,218.73 $1,151.68 $1,166.08 $1,067.39

$1,641.48 $1,519.54 $1,435.94 $1,453.90 $1,330.85

$2,252.90 $2,085.54 $1,970.79 $1,995.44 $1,826.56

$505.41 $467.87 $442.12 $447.65 $409.77

$554.00 $512.84 $484.63 $490.69 $449.16

$570.09 $527.74 $498.70 $504.94 $462.20

$689.97 $638.72 $603.57 $611.12 $559.40

$815.85 $755.24 $713.69 $722.62 $661.46

$1,018.71 $943.03 $891.15 $902.29 $825.93

$1,151.85 $1,066.28 $1,007.61 $1,020.21 $933.87

$797.24 $738.01 $697.41 $706.13 $646.37

$905.45 $838.19 $792.07 $801.98 $734.10

$918.39 $850.16 $803.39 $813.43 $744.59

$1,161.63 $1,075.33 $1,016.17 $1,028.88 $941.80

$1,419.06 $1,313.65 $1,241.37 $1,256.90 $1,150.52

$1,748.75 $1,618.84 $1,529.77 $1,548.90 $1,417.82

$2,352.59 $2,177.82 $2,058.01 $2,083.74 $1,907.39

Defi nitySM HSA

AgeCategory

1500/80%Z6-Q

2000/100%5E-N

2000/80%Q3-M

3000/100%5E-O

3000/80%5E-L

4000/80%5E-M

EM

PLO

YE

EO

NLY

0 to 29 $218.13 $218.86 $200.19 $190.68 $177.96 $167.92

30 to 39 $269.96 $270.87 $247.76 $235.99 $220.25 $207.82

40 to 49 $362.52 $363.73 $332.71 $316.90 $295.76 $279.07

50 to 54 $502.29 $503.97 $460.97 $439.08 $409.79 $386.67

55 to 59 $621.38 $623.46 $570.27 $543.18 $506.95 $478.35

60 to 64 $810.81 $813.53 $744.13 $708.78 $661.50 $624.18

65 plus $954.90 $958.09 $876.36 $834.73 $779.05 $735.10

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $622.92 $625.00 $571.69 $544.53 $508.21 $479.53

30 to 39 $731.52 $733.97 $671.36 $639.47 $596.81 $563.14

40 to 49 $787.37 $790.00 $722.61 $688.28 $642.37 $606.13

50 to 54 $1,038.20 $1,041.67 $952.81 $907.55 $847.01 $799.22

55 to 59 $1,287.49 $1,291.80 $1,181.60 $1,125.47 $1,050.39 $991.13

60 to 64 $1,605.28 $1,610.65 $1,473.25 $1,403.26 $1,309.65 $1,235.77

65 plus $2,203.21 $2,210.58 $2,022.00 $1,925.95 $1,797.47 $1,696.06

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $494.26 $495.92 $453.61 $432.06 $403.24 $380.49

30 to 39 $541.78 $543.59 $497.22 $473.60 $442.01 $417.07

40 to 49 $557.51 $559.38 $511.66 $487.35 $454.84 $429.18

50 to 54 $674.75 $677.01 $619.26 $589.84 $550.49 $519.44

55 to 59 $797.86 $800.53 $732.24 $697.45 $650.93 $614.20

60 to 64 $996.24 $999.57 $914.30 $870.87 $812.78 $766.92

65 plus $1,126.44 $1,130.21 $1,033.80 $984.69 $919.00 $867.15

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $779.65 $782.26 $715.53 $681.54 $636.07 $600.19

30 to 39 $885.48 $888.44 $812.65 $774.05 $722.41 $681.66

40 to 49 $898.13 $901.13 $824.26 $785.11 $732.73 $691.39

50 to 54 $1,136.00 $1,139.81 $1,042.57 $993.05 $926.80 $874.51

55 to 59 $1,387.76 $1,392.41 $1,273.63 $1,213.12 $1,132.20 $1,068.32

60 to 64 $1,710.18 $1,715.90 $1,569.52 $1,494.96 $1,395.24 $1,316.52

65 plus $2,300.70 $2,308.40 $2,111.48 $2,011.18 $1,877.01 $1,771.12


PPO

AgeCategory

1500/80%C3-U

2000/70%C3-S

2500/80%C3-V

3000/70%C3-T

2000/80%6H-F

EM

PLO

YE

EO

NLY

0 to 29 $246.30 $224.02 $217.39 $207.45 $683.49

30 to 39 $304.83 $277.25 $269.05 $256.75 $845.90

40 to 49 $409.34 $372.31 $361.29 $344.77 $1,135.93

50 to 54 $567.15 $515.85 $500.58 $477.69 $1,573.86

55 to 59 $701.62 $638.16 $619.27 $590.95 $1,947.03

60 to 64 $915.53 $832.71 $808.06 $771.12 $2,540.61

65 plus $1,078.22 $980.68 $951.66 $908.14 $2,992.08

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $703.37 $639.74 $620.81 $592.42 $1,951.86

30 to 39 $825.99 $751.27 $729.04 $695.71 $2,292.16

40 to 49 $889.05 $808.63 $784.69 $748.82 $2,467.14

50 to 54 $1,172.28 $1,066.23 $1,034.68 $987.37 $3,253.10

55 to 59 $1,453.76 $1,322.26 $1,283.12 $1,224.45 $4,034.23

60 to 64 $1,812.59 $1,648.62 $1,599.83 $1,526.68 $5,029.98

65 plus $2,487.73 $2,262.70 $2,195.73 $2,095.33 $6,903.54

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $558.09 $507.61 $492.59 $470.06 $1,548.73

30 to 39 $611.74 $556.41 $539.94 $515.25 $1,697.61

40 to 49 $629.51 $572.57 $555.62 $530.22 $1,746.91

50 to 54 $761.89 $692.97 $672.46 $641.72 $2,114.28

55 to 59 $900.89 $819.40 $795.15 $758.79 $2,500.01

60 to 64 $1,124.90 $1,023.14 $992.86 $947.46 $3,121.63

65 plus $1,271.91 $1,156.86 $1,122.62 $1,071.29 $3,529.59

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $880.34 $800.71 $777.01 $741.48 $2,442.97

30 to 39 $999.83 $909.39 $882.47 $842.12 $2,774.56

40 to 49 $1,014.11 $922.38 $895.08 $854.15 $2,814.20

50 to 54 $1,282.71 $1,166.68 $1,132.15 $1,080.38 $3,559.56

55 to 59 $1,566.98 $1,425.24 $1,383.06 $1,319.82 $4,348.43

60 to 64 $1,931.03 $1,756.35 $1,704.37 $1,626.44 $5,358.68

65 plus $2,597.82 $2,362.82 $2,292.90 $2,188.05 $7,209.03

10

Area #4 CountiesHMO products: Alameda, El Dorado, Merced, Placer, Sacramento, Stanislaus, Santa Clara,

San Francisco, Santa Barbara, Santa Cruz, Yolo and San MateoValue Network HMO products: San Francisco, Santa Clara and Santa Barbara (93013, 93014, 93067, 93101–93103,

93105–93111, 93116–93118, 93120, 93121, 93130, 93140, 93150, 93160, 93190, 93199)HCP Network HMO products: Not available in this areaAll other products: San Luis Obispo, San Bernardino and Riverside



AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $436.37 $393.65 $365.09 $344.82 $323.07 $306.81 $307.72 $285.67 $264.13

30 to 39 $506.94 $457.32 $424.14 $400.58 $375.32 $356.43 $357.49 $331.87 $306.85

40 to 49 $628.70 $567.15 $526.00 $496.79 $465.46 $442.04 $443.34 $411.58 $380.55

50 to 54 $853.89 $770.29 $714.41 $674.73 $632.18 $600.37 $602.14 $559.00 $516.85

55 to 59 $1,097.93 $990.45 $918.59 $867.58 $812.86 $771.95 $774.24 $718.76 $664.57

60 to 64 $1,393.69 $1,257.26 $1,166.04 $1,101.29 $1,031.82 $979.90 $982.80 $912.38 $843.59

65 plus $1,944.82 $1,754.42 $1,627.14 $1,536.78 $1,439.85 $1,367.40 $1,371.44 $1,273.17 $1,177.18

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $1,040.83 $938.93 $870.81 $822.45 $770.58 $731.80 $733.97 $681.38 $630.01

30 to 39 $1,162.58 $1,048.77 $972.68 $918.66 $860.72 $817.41 $819.82 $761.08 $703.70

40 to 49 $1,387.77 $1,251.91 $1,161.08 $1,096.60 $1,027.44 $975.74 $978.62 $908.50 $840.01

50 to 54 $1,776.19 $1,602.31 $1,486.06 $1,403.53 $1,315.01 $1,248.84 $1,252.53 $1,162.79 $1,075.12

55 to 59 $2,256.20 $2,035.33 $1,887.66 $1,782.83 $1,670.38 $1,586.33 $1,591.02 $1,477.02 $1,365.66

60 to 64 $2,683.41 $2,420.72 $2,245.09 $2,120.41 $1,986.67 $1,886.70 $1,892.28 $1,756.70 $1,624.25

65 plus $3,487.20 $3,145.81 $2,917.58 $2,755.56 $2,581.76 $2,451.84 $2,459.09 $2,282.90 $2,110.78

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $976.18 $880.61 $816.72 $771.37 $722.72 $686.35 $688.38 $639.06 $590.88

30 to 39 $1,087.70 $981.21 $910.02 $859.49 $805.28 $764.76 $767.02 $712.06 $658.38

40 to 49 $1,178.74 $1,063.35 $986.20 $931.43 $872.68 $828.77 $831.22 $771.66 $713.48

50 to 54 $1,370.53 $1,236.36 $1,146.66 $1,082.98 $1,014.67 $963.62 $966.47 $897.22 $829.57

55 to 59 $1,533.76 $1,383.61 $1,283.23 $1,211.97 $1,135.53 $1,078.39 $1,081.58 $1,004.08 $928.38

60 to 64 $1,881.25 $1,697.08 $1,573.95 $1,486.54 $1,392.78 $1,322.70 $1,326.61 $1,231.56 $1,138.71

65 plus $2,476.00 $2,233.61 $2,071.56 $1,956.52 $1,833.11 $1,740.87 $1,746.02 $1,620.92 $1,498.71

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,602.72 $1,445.82 $1,340.92 $1,266.46 $1,186.58 $1,126.87 $1,130.20 $1,049.22 $970.12

30 to 39 $1,767.03 $1,594.05 $1,478.39 $1,396.30 $1,308.23 $1,242.40 $1,246.07 $1,156.79 $1,069.58

40 to 49 $1,960.44 $1,768.52 $1,640.21 $1,549.12 $1,451.42 $1,378.38 $1,382.46 $1,283.40 $1,186.64

50 to 54 $2,313.85 $2,087.33 $1,935.89 $1,828.38 $1,713.06 $1,626.86 $1,631.67 $1,514.76 $1,400.56

55 to 59 $2,710.35 $2,445.02 $2,267.62 $2,141.70 $2,006.61 $1,905.64 $1,911.28 $1,774.33 $1,640.56

60 to 64 $3,190.90 $2,878.52 $2,669.67 $2,521.42 $2,362.39 $2,243.51 $2,250.15 $2,088.92 $1,931.43

65 plus $4,039.94 $3,644.44 $3,380.02 $3,192.32 $2,990.98 $2,840.47 $2,848.87 $2,644.75 $2,445.35


AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 -

60/2000ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $436.37 $393.65 $365.09 $344.82 $323.07 $306.81 $288.41 $307.72 $285.67 $264.13

30 to 39 $506.94 $457.32 $424.14 $400.58 $375.32 $356.43 $335.05 $357.49 $331.87 $306.85

40 to 49 $628.70 $567.15 $526.00 $496.79 $465.46 $442.04 $415.52 $443.34 $411.58 $380.55

50 to 54 $853.89 $770.29 $714.41 $674.73 $632.18 $600.37 $564.36 $602.14 $559.00 $516.85

55 to 59 $1,097.93 $990.45 $918.59 $867.58 $812.86 $771.95 $725.65 $774.24 $718.76 $664.57

60 to 64 $1,393.69 $1,257.26 $1,166.04 $1,101.29 $1,031.82 $979.90 $921.13 $982.80 $912.38 $843.59

65 plus $1,944.82 $1,754.42 $1,627.14 $1,536.78 $1,439.85 $1,367.40 $1,285.38 $1,371.44 $1,273.17 $1,177.18

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $1,040.83 $938.93 $870.81 $822.45 $770.58 $731.80 $687.91 $733.97 $681.38 $630.01

30 to 39 $1,162.58 $1,048.77 $972.68 $918.66 $860.72 $817.41 $768.38 $819.82 $761.08 $703.70

40 to 49 $1,387.77 $1,251.91 $1,161.08 $1,096.60 $1,027.44 $975.74 $917.21 $978.62 $908.50 $840.01

50 to 54 $1,776.19 $1,602.31 $1,486.06 $1,403.53 $1,315.01 $1,248.84 $1,173.93 $1,252.53 $1,162.79 $1,075.12

55 to 59 $2,256.20 $2,035.33 $1,887.66 $1,782.83 $1,670.38 $1,586.33 $1,491.18 $1,591.02 $1,477.02 $1,365.66

60 to 64 $2,683.41 $2,420.72 $2,245.09 $2,120.41 $1,986.67 $1,886.70 $1,773.53 $1,892.28 $1,756.70 $1,624.25

65 plus $3,487.20 $3,145.81 $2,917.58 $2,755.56 $2,581.76 $2,451.84 $2,304.78 $2,459.09 $2,282.90 $2,110.78

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $976.18 $880.61 $816.72 $771.37 $722.72 $686.35 $645.18 $688.38 $639.06 $590.88

30 to 39 $1,087.70 $981.21 $910.02 $859.49 $805.28 $764.76 $718.89 $767.02 $712.06 $658.38

40 to 49 $1,178.74 $1,063.35 $986.20 $931.43 $872.68 $828.77 $779.06 $831.22 $771.66 $713.48

50 to 54 $1,370.53 $1,236.36 $1,146.66 $1,082.98 $1,014.67 $963.62 $905.82 $966.47 $897.22 $829.57

55 to 59 $1,533.76 $1,383.61 $1,283.23 $1,211.97 $1,135.53 $1,078.39 $1,013.70 $1,081.58 $1,004.08 $928.38

60 to 64 $1,881.25 $1,697.08 $1,573.95 $1,486.54 $1,392.78 $1,322.70 $1,243.36 $1,326.61 $1,231.56 $1,138.71

65 plus $2,476.00 $2,233.61 $2,071.56 $1,956.52 $1,833.11 $1,740.87 $1,636.45 $1,746.02 $1,620.92 $1,498.71

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,602.72 $1,445.82 $1,340.92 $1,266.46 $1,186.58 $1,126.87 $1,059.28 $1,130.20 $1,049.22 $970.12

30 to 39 $1,767.03 $1,594.05 $1,478.39 $1,396.30 $1,308.23 $1,242.40 $1,167.88 $1,246.07 $1,156.79 $1,069.58

40 to 49 $1,960.44 $1,768.52 $1,640.21 $1,549.12 $1,451.42 $1,378.38 $1,295.70 $1,382.46 $1,283.40 $1,186.64

50 to 54 $2,313.85 $2,087.33 $1,935.89 $1,828.38 $1,713.06 $1,626.86 $1,529.28 $1,631.67 $1,514.76 $1,400.56

55 to 59 $2,710.35 $2,445.02 $2,267.62 $2,141.70 $2,006.61 $1,905.64 $1,791.34 $1,911.28 $1,774.33 $1,640.56

60 to 64 $3,190.90 $2,878.52 $2,669.67 $2,521.42 $2,362.39 $2,243.51 $2,108.94 $2,250.15 $2,088.92 $1,931.43

65 plus $4,039.94 $3,644.44 $3,380.02 $3,192.32 $2,990.98 $2,840.47 $2,670.09 $2,848.87 $2,644.75 $2,445.35


Choice PlusAge

Category20/250/90%

5E-A30/250/80%

5E-D30/500/80%

5E-F40/500/70%

5E-K30/1000/80%

5E-C40/1000/70%

5E-I40/1000/50%

5E-G40/1500/70%

5E-J40/2000/50%

5E-H30/2500/80%

5E-E20/3000/90%

5E-B

EM

PLO

YE

EO

NLY

0 to 29 $396.84 $359.62 $310.02 $277.17 $268.97 $233.48 $223.00 $226.77 $208.43 $227.27 $228.51

30 to 39 $491.14 $445.07 $383.69 $343.03 $332.88 $288.96 $275.99 $280.66 $257.96 $281.27 $282.81

40 to 49 $659.53 $597.67 $515.24 $460.64 $447.02 $388.03 $370.62 $376.88 $346.40 $377.71 $379.77

50 to 54 $913.80 $828.09 $713.88 $638.24 $619.35 $537.63 $513.50 $522.18 $479.95 $523.33 $526.19

55 to 59 $1,130.46 $1,024.43 $883.14 $789.56 $766.20 $665.10 $635.25 $645.99 $593.75 $647.41 $650.95

60 to 64 $1,475.10 $1,336.75 $1,152.38 $1,030.27 $999.79 $867.87 $828.92 $842.93 $774.76 $844.79 $849.40

65 plus $1,737.23 $1,574.29 $1,357.16 $1,213.35 $1,177.46 $1,022.09 $976.22 $992.72 $912.43 $994.91 $1,000.34

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $1,133.27 $1,026.98 $885.33 $791.52 $768.11 $666.76 $636.83 $647.59 $595.22 $649.02 $652.56

30 to 39 $1,330.85 $1,206.02 $1,039.69 $929.52 $902.02 $783.00 $747.85 $760.50 $698.99 $762.17 $766.33

40 to 49 $1,432.44 $1,298.09 $1,119.05 $1,000.48 $970.88 $842.77 $804.94 $818.55 $752.35 $820.36 $824.83

50 to 54 $1,888.78 $1,711.63 $1,475.55 $1,319.20 $1,280.18 $1,111.26 $1,061.38 $1,079.32 $992.03 $1,081.70 $1,087.60

55 to 59 $2,342.31 $2,122.62 $1,829.86 $1,635.97 $1,587.57 $1,378.09 $1,316.24 $1,338.49 $1,230.24 $1,341.44 $1,348.76

60 to 64 $2,920.45 $2,646.54 $2,281.52 $2,039.77 $1,979.42 $1,718.24 $1,641.12 $1,668.86 $1,533.89 $1,672.54 $1,681.67

65 plus $4,008.25 $3,632.31 $3,131.33 $2,799.53 $2,716.71 $2,358.25 $2,252.39 $2,290.47 $2,105.23 $2,295.52 $2,308.05

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $899.20 $814.87 $702.48 $628.04 $609.46 $529.05 $505.30 $513.84 $472.28 $514.97 $517.78

30 to 39 $985.65 $893.20 $770.01 $688.42 $668.05 $579.90 $553.87 $563.24 $517.68 $564.48 $567.56

40 to 49 $1,014.27 $919.14 $792.37 $708.41 $687.45 $596.74 $569.96 $579.59 $532.72 $580.87 $584.04

50 to 54 $1,227.57 $1,112.43 $959.00 $857.38 $832.02 $722.24 $689.82 $701.48 $644.75 $703.03 $706.86

55 to 59 $1,451.53 $1,315.39 $1,133.96 $1,013.81 $983.81 $854.00 $815.67 $829.46 $762.38 $831.29 $835.82

60 to 64 $1,812.44 $1,642.45 $1,415.92 $1,265.89 $1,228.44 $1,066.35 $1,018.48 $1,035.70 $951.94 $1,037.98 $1,043.65

65 plus $2,049.31 $1,857.10 $1,600.97 $1,431.33 $1,388.98 $1,205.71 $1,151.59 $1,171.06 $1,076.35 $1,173.64 $1,180.04

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,418.41 $1,285.37 $1,108.09 $990.68 $961.37 $834.52 $797.06 $810.53 $744.98 $812.32 $816.75

30 to 39 $1,610.93 $1,459.84 $1,258.50 $1,125.15 $1,091.86 $947.79 $905.25 $920.55 $846.10 $922.58 $927.61

40 to 49 $1,633.95 $1,480.70 $1,276.48 $1,141.22 $1,107.46 $961.33 $918.18 $933.70 $858.19 $935.76 $940.87

50 to 54 $2,066.71 $1,872.87 $1,614.56 $1,443.48 $1,400.77 $1,215.95 $1,161.37 $1,181.00 $1,085.49 $1,183.60 $1,190.06

55 to 59 $2,524.73 $2,287.94 $1,972.38 $1,763.38 $1,711.21 $1,485.42 $1,418.75 $1,442.73 $1,326.05 $1,445.91 $1,453.80

60 to 64 $3,111.29 $2,819.48 $2,430.61 $2,173.06 $2,108.77 $1,830.52 $1,748.36 $1,777.92 $1,634.13 $1,781.84 $1,791.56

65 plus $4,185.62 $3,793.05 $3,269.90 $2,923.42 $2,836.93 $2,462.60 $2,352.07 $2,391.83 $2,198.39 $2,397.10 $2,410.18


5E-P40/1000/70%

5E-S40/1000/50%

5E-Q40/1500/70%

5E-T40/2000/50%

5E-R

$227.42 $210.52 $198.94 $201.43 $184.38

$281.46 $260.54 $246.21 $249.29 $228.19

$377.96 $349.87 $330.63 $334.77 $306.43

$523.68 $484.76 $458.10 $463.83 $424.57

$647.84 $599.70 $566.71 $573.80 $525.24

$845.35 $782.53 $739.48 $748.74 $685.36

$995.57 $921.58 $870.89 $881.79 $807.15

$649.45 $601.19 $568.12 $575.23 $526.54

$762.68 $706.00 $667.17 $675.52 $618.34

$820.90 $759.90 $718.10 $727.09 $665.54

$1,082.42 $1,001.98 $946.86 $958.72 $877.57

$1,342.32 $1,242.57 $1,174.22 $1,188.92 $1,088.29

$1,673.64 $1,549.27 $1,464.05 $1,482.38 $1,356.90

$2,297.04 $2,126.34 $2,009.38 $2,034.53 $1,862.32

$515.31 $477.02 $450.78 $456.42 $417.79

$564.85 $522.88 $494.11 $500.30 $457.95

$581.26 $538.06 $508.46 $514.83 $471.25

$703.49 $651.21 $615.39 $623.09 $570.35

$831.84 $770.02 $727.66 $736.77 $674.41

$1,038.67 $961.48 $908.60 $919.97 $842.10

$1,174.41 $1,087.14 $1,027.34 $1,040.20 $952.15

$812.86 $752.45 $711.06 $719.96 $659.02

$923.19 $854.59 $807.58 $817.69 $748.47

$936.38 $866.79 $819.12 $829.37 $759.17

$1,184.39 $1,096.37 $1,036.06 $1,049.03 $960.24

$1,446.87 $1,339.35 $1,265.67 $1,281.52 $1,173.04

$1,783.01 $1,650.51 $1,559.72 $1,579.25 $1,445.57

$2,398.69 $2,220.44 $2,098.30 $2,124.56 $1,944.73

Defi nitySM HSA

AgeCategory

1500/80%Z6-Q

2000/100%5E-N

2000/80%Q3-M

3000/100%5E-O

3000/80%5E-L

4000/80%5E-M

EM

PLO

YE

EO

NLY

0 to 29 $222.40 $223.14 $204.11 $194.42 $181.45 $171.21

30 to 39 $275.25 $276.16 $252.61 $240.62 $224.57 $211.89

40 to 49 $369.62 $370.85 $339.22 $323.12 $301.56 $284.54

50 to 54 $512.12 $513.82 $470.00 $447.69 $417.82 $394.24

55 to 59 $633.54 $635.65 $581.44 $553.84 $516.89 $487.72

60 to 64 $826.69 $829.44 $758.70 $722.68 $674.47 $636.41

65 plus $973.59 $976.83 $893.52 $851.10 $794.32 $749.50

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $635.11 $637.23 $582.88 $555.21 $518.17 $488.93

30 to 39 $745.84 $748.32 $684.50 $652.01 $608.51 $574.17

40 to 49 $802.78 $805.45 $736.76 $701.78 $654.97 $618.00

50 to 54 $1,058.52 $1,062.05 $971.47 $925.35 $863.62 $814.88

55 to 59 $1,312.69 $1,317.06 $1,204.74 $1,147.55 $1,070.99 $1,010.55

60 to 64 $1,636.70 $1,642.15 $1,502.10 $1,430.79 $1,335.34 $1,259.98

65 plus $2,246.33 $2,253.81 $2,061.60 $1,963.72 $1,832.72 $1,729.29

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $503.94 $505.62 $462.50 $440.54 $411.15 $387.95

30 to 39 $552.38 $554.22 $506.95 $482.89 $450.67 $425.24

40 to 49 $568.43 $570.32 $521.68 $496.91 $463.76 $437.59

50 to 54 $687.96 $690.25 $631.38 $601.41 $561.29 $529.61

55 to 59 $813.47 $816.18 $746.57 $711.13 $663.69 $626.24

60 to 64 $1,015.74 $1,019.12 $932.21 $887.95 $828.72 $781.95

65 plus $1,148.49 $1,152.31 $1,054.04 $1,004.00 $937.02 $884.14

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $794.91 $797.56 $729.54 $694.91 $648.55 $611.95

30 to 39 $902.81 $905.82 $828.57 $789.23 $736.58 $695.01

40 to 49 $915.71 $918.76 $840.40 $800.50 $747.10 $704.94

50 to 54 $1,158.24 $1,162.10 $1,062.99 $1,012.52 $944.98 $891.65

55 to 59 $1,414.93 $1,419.64 $1,298.57 $1,236.92 $1,154.40 $1,089.25

60 to 64 $1,743.65 $1,749.46 $1,600.26 $1,524.29 $1,422.60 $1,342.32

65 plus $2,345.74 $2,353.54 $2,152.83 $2,050.62 $1,913.82 $1,805.82


PPO

AgeCategory

1500/80%C3-U

2000/70%C3-S

2500/80%C3-V

3000/70%C3-T

2000/80%6H-F

EM

PLO

YE

EO

NLY

0 to 29 $251.12 $228.41 $221.65 $211.51 $683.49

30 to 39 $310.79 $282.69 $274.32 $261.77 $845.90

40 to 49 $417.35 $379.61 $368.37 $351.52 $1,135.93

50 to 54 $578.25 $525.96 $510.39 $487.04 $1,573.86

55 to 59 $715.35 $650.66 $631.40 $602.52 $1,947.03

60 to 64 $933.44 $849.03 $823.90 $786.21 $2,540.61

65 plus $1,099.32 $999.90 $970.31 $925.92 $2,992.08

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $717.13 $652.28 $632.97 $604.02 $1,951.86

30 to 39 $842.16 $766.00 $743.33 $709.32 $2,292.16

40 to 49 $906.45 $824.47 $800.07 $763.47 $2,467.14

50 to 54 $1,195.22 $1,087.13 $1,054.95 $1,006.69 $3,253.10

55 to 59 $1,482.21 $1,348.17 $1,308.27 $1,248.42 $4,034.23

60 to 64 $1,848.06 $1,680.93 $1,631.18 $1,556.56 $5,029.98

65 plus $2,536.42 $2,307.04 $2,238.76 $2,136.34 $6,903.54

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $569.02 $517.56 $502.24 $479.26 $1,548.73

30 to 39 $623.72 $567.31 $550.52 $525.33 $1,697.61

40 to 49 $641.83 $583.79 $566.51 $540.59 $1,746.91

50 to 54 $776.80 $706.55 $685.64 $654.27 $2,114.28

55 to 59 $918.52 $835.46 $810.73 $773.64 $2,500.01

60 to 64 $1,146.91 $1,043.19 $1,012.32 $966.01 $3,121.63

65 plus $1,296.80 $1,179.53 $1,144.62 $1,092.25 $3,529.59

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $897.57 $816.40 $792.23 $755.99 $2,442.97

30 to 39 $1,019.40 $927.21 $899.77 $858.60 $2,774.56

40 to 49 $1,033.96 $940.45 $912.62 $870.87 $2,814.20

50 to 54 $1,307.81 $1,189.54 $1,154.34 $1,101.53 $3,559.56

55 to 59 $1,597.65 $1,453.17 $1,410.16 $1,345.65 $4,348.43

60 to 64 $1,968.82 $1,790.77 $1,737.77 $1,658.27 $5,358.68

65 plus $2,648.66 $2,409.13 $2,337.83 $2,230.88 $7,209.03

12

Area #5 CountiesHMO products: Fresno, Kern, Kings, San Luis Obispo and TulareValue Network HMO products: KernHCP Network HMO products: Not available in this areaAll other products: Kern, Fresno, Kings, Tulare and Madera



AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $383.04 $345.54 $320.48 $302.68 $283.59 $269.31 $270.12 $250.76 $231.85

30 to 39 $444.99 $401.42 $372.31 $351.63 $329.45 $312.86 $313.80 $291.31 $269.34

40 to 49 $551.86 $497.83 $461.72 $436.08 $408.58 $388.00 $389.17 $361.28 $334.03

50 to 54 $749.53 $676.15 $627.11 $592.28 $554.92 $526.98 $528.57 $490.68 $453.67

55 to 59 $963.75 $869.39 $806.33 $761.56 $713.52 $677.59 $679.63 $630.92 $583.34

60 to 64 $1,223.37 $1,103.59 $1,023.55 $966.71 $905.73 $860.13 $862.71 $800.88 $740.48

65 plus $1,707.13 $1,539.99 $1,428.30 $1,348.98 $1,263.90 $1,200.25 $1,203.86 $1,117.58 $1,033.29

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $913.62 $824.17 $764.40 $721.95 $676.41 $642.35 $644.28 $598.11 $553.00

30 to 39 $1,020.50 $920.58 $853.81 $806.40 $755.54 $717.49 $719.65 $668.07 $617.68

40 to 49 $1,218.16 $1,098.90 $1,019.19 $962.60 $901.88 $856.47 $859.04 $797.48 $737.33

50 to 54 $1,559.12 $1,406.47 $1,304.46 $1,232.02 $1,154.31 $1,096.19 $1,099.48 $1,020.69 $943.70

55 to 59 $1,980.46 $1,786.56 $1,656.98 $1,564.97 $1,466.26 $1,392.43 $1,396.61 $1,296.52 $1,198.73

60 to 64 $2,355.47 $2,124.84 $1,970.73 $1,861.30 $1,743.90 $1,656.08 $1,661.06 $1,542.02 $1,425.71

65 plus $3,061.02 $2,761.32 $2,561.04 $2,418.83 $2,266.26 $2,152.14 $2,158.62 $2,003.91 $1,852.77

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $856.88 $772.98 $716.92 $677.11 $634.40 $602.45 $604.27 $560.96 $518.65

30 to 39 $954.76 $861.29 $798.82 $754.46 $706.87 $671.28 $673.30 $625.04 $577.90

40 to 49 $1,034.68 $933.38 $865.68 $817.61 $766.04 $727.47 $729.65 $677.36 $626.27

50 to 54 $1,203.03 $1,085.24 $1,006.53 $950.64 $890.68 $845.83 $848.37 $787.57 $728.17

55 to 59 $1,346.32 $1,214.50 $1,126.42 $1,063.87 $996.76 $946.57 $949.42 $881.37 $814.90

60 to 64 $1,651.33 $1,489.65 $1,381.61 $1,304.89 $1,222.58 $1,161.02 $1,164.51 $1,081.05 $999.52

65 plus $2,173.40 $1,960.61 $1,818.41 $1,717.43 $1,609.11 $1,528.08 $1,532.67 $1,422.83 $1,315.51

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,406.85 $1,269.11 $1,177.06 $1,111.70 $1,041.58 $989.13 $992.10 $921.00 $851.53

30 to 39 $1,551.08 $1,399.22 $1,297.73 $1,225.67 $1,148.36 $1,090.53 $1,093.81 $1,015.42 $938.83

40 to 49 $1,720.85 $1,552.36 $1,439.77 $1,359.82 $1,274.05 $1,209.89 $1,213.53 $1,126.56 $1,041.59

50 to 54 $2,031.06 $1,832.20 $1,699.32 $1,604.96 $1,503.72 $1,428.00 $1,432.30 $1,329.65 $1,229.36

55 to 59 $2,379.11 $2,146.17 $1,990.52 $1,879.98 $1,761.40 $1,672.71 $1,677.74 $1,557.50 $1,440.02

60 to 64 $2,800.93 $2,526.69 $2,343.43 $2,213.31 $2,073.70 $1,969.28 $1,975.20 $1,833.64 $1,695.34

65 plus $3,546.20 $3,199.00 $2,966.98 $2,802.23 $2,625.47 $2,493.27 $2,500.77 $2,321.54 $2,146.44


AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 -

60/2000ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $350.48 $316.16 $293.23 $276.95 $259.48 $246.42 $231.64 $247.15 $229.44 $212.14

30 to 39 $407.16 $367.29 $340.65 $321.74 $301.45 $286.27 $269.11 $287.12 $266.55 $246.45

40 to 49 $504.95 $455.50 $422.47 $399.01 $373.85 $355.02 $333.74 $356.08 $330.56 $305.64

50 to 54 $685.81 $618.66 $573.79 $541.93 $507.75 $482.19 $453.28 $483.62 $448.97 $415.11

55 to 59 $881.82 $795.47 $737.78 $696.81 $652.87 $620.00 $582.83 $621.83 $577.28 $533.75

60 to 64 $1,119.37 $1,009.76 $936.52 $884.52 $828.75 $787.02 $739.83 $789.35 $732.79 $677.54

65 plus $1,562.01 $1,409.06 $1,306.86 $1,234.30 $1,156.46 $1,098.23 $1,032.39 $1,101.48 $1,022.57 $945.46

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $835.96 $754.10 $699.40 $660.57 $618.92 $587.75 $552.51 $589.49 $547.26 $505.99

30 to 39 $933.75 $842.31 $781.22 $737.84 $691.32 $656.51 $617.14 $658.45 $611.28 $565.18

40 to 49 $1,114.61 $1,005.46 $932.54 $880.76 $825.22 $783.67 $736.68 $785.99 $729.68 $674.65

50 to 54 $1,426.58 $1,286.89 $1,193.55 $1,127.28 $1,056.19 $1,003.01 $942.88 $1,005.98 $933.91 $863.48

55 to 59 $1,812.11 $1,634.66 $1,516.10 $1,431.92 $1,341.63 $1,274.07 $1,197.68 $1,277.84 $1,186.29 $1,096.84

60 to 64 $2,155.23 $1,944.18 $1,803.17 $1,703.05 $1,595.66 $1,515.32 $1,424.47 $1,519.80 $1,410.92 $1,304.52

65 plus $2,800.80 $2,526.54 $2,343.29 $2,213.18 $2,073.63 $1,969.22 $1,851.15 $1,975.04 $1,833.54 $1,695.28

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $784.03 $707.26 $655.96 $619.54 $580.47 $551.25 $518.20 $552.88 $513.27 $474.56

30 to 39 $873.60 $788.06 $730.90 $690.32 $646.79 $614.22 $577.39 $616.04 $571.90 $528.78

40 to 49 $946.73 $854.02 $792.08 $748.10 $700.93 $665.63 $625.72 $667.60 $619.77 $573.04

50 to 54 $1,100.76 $992.97 $920.95 $869.82 $814.97 $773.94 $727.53 $776.23 $720.61 $666.27

55 to 59 $1,231.87 $1,111.24 $1,030.64 $973.42 $912.04 $866.11 $814.19 $868.68 $806.44 $745.63

60 to 64 $1,510.95 $1,363.00 $1,264.14 $1,193.95 $1,118.66 $1,062.34 $998.64 $1,065.48 $989.14 $914.55

65 plus $1,988.64 $1,793.91 $1,663.80 $1,571.42 $1,472.33 $1,398.20 $1,314.36 $1,402.33 $1,301.86 $1,203.69

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,287.25 $1,161.20 $1,076.98 $1,017.18 $953.04 $905.05 $850.79 $907.73 $842.70 $779.15

30 to 39 $1,419.22 $1,280.25 $1,187.39 $1,121.46 $1,050.75 $997.84 $938.01 $1,000.79 $929.09 $859.03

40 to 49 $1,574.56 $1,420.37 $1,317.35 $1,244.21 $1,165.75 $1,107.06 $1,040.68 $1,110.33 $1,030.78 $953.05

50 to 54 $1,858.40 $1,676.42 $1,554.83 $1,468.50 $1,375.90 $1,306.62 $1,228.28 $1,310.49 $1,216.60 $1,124.86

55 to 59 $2,176.86 $1,963.70 $1,821.27 $1,720.15 $1,611.68 $1,530.53 $1,438.77 $1,535.06 $1,425.08 $1,317.62

60 to 64 $2,562.82 $2,311.87 $2,144.19 $2,025.13 $1,897.43 $1,801.90 $1,693.86 $1,807.23 $1,677.75 $1,551.23

65 plus $3,244.74 $2,927.01 $2,714.71 $2,563.98 $2,402.30 $2,281.35 $2,144.56 $2,288.09 $2,124.17 $1,963.99


Choice PlusAge

Category20/250/90%

5E-A30/250/80%

5E-D30/500/80%

5E-F40/500/70%

5E-K30/1000/80%

5E-C40/1000/70%

5E-I40/1000/50%

5E-G40/1500/70%

5E-J40/2000/50%

5E-H30/2500/80%

5E-E20/3000/90%

5E-B

EM

PLO

YE

EO

NLY

0 to 29 $340.00 $308.10 $265.61 $237.46 $230.44 $200.04 $191.05 $194.29 $178.58 $194.71 $195.78

30 to 39 $420.79 $381.31 $328.73 $293.89 $285.20 $247.57 $236.45 $240.46 $221.01 $240.98 $242.30

40 to 49 $565.06 $512.05 $441.43 $394.65 $382.98 $332.46 $317.52 $322.90 $296.79 $323.60 $325.38

50 to 54 $782.91 $709.46 $611.62 $546.80 $530.63 $460.63 $439.93 $447.39 $411.21 $448.36 $450.82

55 to 59 $968.54 $877.67 $756.63 $676.44 $656.44 $569.85 $544.24 $553.47 $508.71 $554.66 $557.71

60 to 64 $1,263.82 $1,145.24 $987.30 $882.67 $856.57 $743.57 $710.15 $722.20 $663.80 $723.76 $727.74

65 plus $1,488.40 $1,348.75 $1,162.75 $1,039.52 $1,008.79 $875.71 $836.35 $850.53 $781.76 $852.37 $857.06

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $970.95 $879.85 $758.51 $678.12 $658.07 $571.26 $545.59 $554.84 $509.98 $556.04 $559.09

30 to 39 $1,140.23 $1,033.25 $890.75 $796.35 $772.81 $670.86 $640.71 $651.57 $598.89 $652.98 $656.57

40 to 49 $1,227.27 $1,112.12 $958.75 $857.14 $831.80 $722.07 $689.62 $701.31 $644.61 $702.83 $706.69

50 to 54 $1,618.25 $1,466.42 $1,264.18 $1,130.20 $1,096.79 $952.10 $909.31 $924.73 $849.96 $926.73 $931.82

55 to 59 $2,006.82 $1,818.53 $1,567.74 $1,401.58 $1,360.15 $1,180.72 $1,127.65 $1,146.78 $1,054.05 $1,149.26 $1,155.57

60 to 64 $2,502.15 $2,267.39 $1,954.69 $1,747.53 $1,695.87 $1,472.15 $1,405.99 $1,429.83 $1,314.22 $1,432.92 $1,440.80

65 plus $3,434.14 $3,111.94 $2,682.77 $2,398.45 $2,327.54 $2,020.49 $1,929.69 $1,962.41 $1,803.73 $1,966.65 $1,977.46

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $770.41 $698.13 $601.85 $538.06 $522.16 $453.27 $432.90 $440.24 $404.65 $441.20 $443.62

30 to 39 $844.47 $765.24 $659.70 $589.79 $572.35 $496.85 $474.52 $482.56 $443.55 $483.61 $486.27

40 to 49 $869.00 $787.46 $678.86 $606.92 $588.97 $511.28 $488.30 $496.58 $456.43 $497.65 $500.39

50 to 54 $1,051.74 $953.06 $821.63 $734.55 $712.83 $618.79 $590.98 $601.01 $552.41 $602.31 $605.62

55 to 59 $1,243.62 $1,126.94 $971.52 $868.56 $842.88 $731.69 $698.81 $710.66 $653.19 $712.19 $716.11

60 to 64 $1,552.84 $1,407.15 $1,213.09 $1,084.52 $1,052.46 $913.62 $872.56 $887.36 $815.61 $889.28 $894.16

65 plus $1,755.79 $1,591.05 $1,371.63 $1,226.26 $1,190.01 $1,033.02 $986.60 $1,003.33 $922.20 $1,005.50 $1,011.02

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,215.25 $1,101.23 $949.36 $848.74 $823.65 $714.99 $682.86 $694.44 $638.29 $695.94 $699.77

30 to 39 $1,380.20 $1,250.70 $1,078.22 $963.95 $935.45 $812.04 $775.55 $788.70 $724.93 $790.41 $794.75

40 to 49 $1,399.92 $1,268.57 $1,093.62 $977.72 $948.81 $823.64 $786.63 $799.97 $735.28 $801.70 $806.10

50 to 54 $1,770.69 $1,604.56 $1,383.28 $1,236.67 $1,200.11 $1,041.79 $994.97 $1,011.85 $930.03 $1,014.03 $1,019.61

55 to 59 $2,163.11 $1,960.16 $1,689.84 $1,510.74 $1,466.08 $1,272.67 $1,215.48 $1,236.09 $1,136.14 $1,238.76 $1,245.57

60 to 64 $2,665.66 $2,415.56 $2,082.43 $1,861.73 $1,806.69 $1,568.35 $1,497.86 $1,523.27 $1,400.10 $1,526.56 $1,534.95

65 plus $3,586.11 $3,249.65 $2,801.49 $2,504.58 $2,430.54 $2,109.90 $2,015.08 $2,049.25 $1,883.55 $2,053.68 $2,064.97


5E-P40/1000/70%

5E-S40/1000/50%

5E-Q40/1500/70%

5E-T40/2000/50%

5E-R

$194.84 $180.36 $170.44 $172.57 $157.97

$241.14 $223.22 $210.94 $213.58 $195.51

$323.81 $299.75 $283.26 $286.80 $262.54

$448.66 $415.31 $392.47 $397.37 $363.76

$555.03 $513.78 $485.52 $491.59 $450.00

$724.24 $670.42 $633.55 $641.46 $587.19

$852.94 $789.55 $746.13 $755.45 $691.54

$556.41 $515.06 $486.73 $492.81 $451.12

$653.42 $604.86 $571.59 $578.73 $529.77

$703.30 $651.03 $615.22 $622.91 $570.21

$927.35 $858.43 $811.22 $821.36 $751.87

$1,150.02 $1,064.56 $1,006.01 $1,018.58 $932.40

$1,433.88 $1,327.32 $1,254.31 $1,269.99 $1,162.54

$1,967.97 $1,821.71 $1,721.52 $1,743.03 $1,595.56

$441.49 $408.68 $386.20 $391.03 $357.95

$483.93 $447.97 $423.33 $428.62 $392.36

$497.99 $460.98 $435.62 $441.07 $403.75

$602.71 $557.92 $527.23 $533.82 $488.66

$712.67 $659.70 $623.42 $631.21 $577.81

$889.87 $823.74 $778.43 $788.16 $721.48

$1,006.17 $931.39 $880.16 $891.16 $815.77

$696.41 $644.65 $609.20 $616.81 $564.63

$790.93 $732.15 $691.89 $700.53 $641.26

$802.23 $742.61 $701.77 $710.54 $650.43

$1,014.71 $939.30 $887.64 $898.73 $822.70

$1,239.59 $1,147.47 $1,084.36 $1,097.91 $1,005.02

$1,527.58 $1,414.05 $1,336.28 $1,352.98 $1,238.51

$2,055.05 $1,902.33 $1,797.70 $1,820.16 $1,666.17

Defi nitySM HSA

AgeCategory

1500/80%Z6-Q

2000/100%5E-N

2000/80%Q3-M

3000/100%5E-O

3000/80%5E-L

4000/80%5E-M

EM

PLO

YE

EO

NLY

0 to 29 $190.54 $191.18 $174.87 $166.57 $155.45 $146.68

30 to 39 $235.82 $236.61 $216.42 $206.15 $192.39 $181.53

40 to 49 $316.67 $317.73 $290.63 $276.83 $258.35 $243.78

50 to 54 $438.75 $440.23 $402.67 $383.56 $357.95 $337.76

55 to 59 $542.78 $544.61 $498.14 $474.50 $442.82 $417.84

60 to 64 $708.26 $710.64 $650.01 $619.16 $577.83 $545.23

65 plus $834.12 $836.92 $765.52 $729.19 $680.51 $642.11

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $544.13 $545.96 $499.38 $475.68 $443.92 $418.88

30 to 39 $639.00 $641.14 $586.45 $558.61 $521.32 $491.91

40 to 49 $687.78 $690.09 $631.21 $601.25 $561.12 $529.46

50 to 54 $906.88 $909.93 $832.30 $792.80 $739.87 $698.13

55 to 59 $1,124.64 $1,128.42 $1,032.15 $983.16 $917.53 $865.76

60 to 64 $1,402.23 $1,406.94 $1,286.91 $1,225.83 $1,144.00 $1,079.46

65 plus $1,924.53 $1,931.00 $1,766.26 $1,682.43 $1,570.11 $1,481.53

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $431.75 $433.20 $396.24 $377.43 $352.24 $332.36

30 to 39 $473.25 $474.84 $434.33 $413.72 $386.10 $364.31

40 to 49 $487.00 $488.63 $446.94 $425.73 $397.31 $374.89

50 to 54 $589.41 $591.39 $540.93 $515.26 $480.86 $453.73

55 to 59 $696.94 $699.28 $639.62 $609.26 $568.59 $536.51

60 to 64 $870.23 $873.15 $798.66 $760.76 $709.97 $669.91

65 plus $983.96 $987.27 $903.04 $860.18 $802.76 $757.47

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $681.04 $683.33 $625.03 $595.36 $555.62 $524.27

30 to 39 $773.48 $776.08 $709.87 $676.18 $631.03 $595.43

40 to 49 $784.53 $787.16 $720.01 $685.83 $640.05 $603.94

50 to 54 $992.32 $995.65 $910.71 $867.48 $809.57 $763.90

55 to 59 $1,212.23 $1,216.31 $1,112.54 $1,059.73 $988.99 $933.19

60 to 64 $1,493.87 $1,498.88 $1,371.01 $1,305.94 $1,218.75 $1,150.00

65 plus $2,009.70 $2,016.45 $1,844.42 $1,756.88 $1,639.59 $1,547.09


PPO

AgeCategory

1500/80%C3-U

2000/70%C3-S

2500/80%C3-V

3000/70%C3-T

2000/80%6H-F

EM

PLO

YE

EO

NLY

0 to 29 $215.15 $195.69 $189.90 $181.22 $683.49

30 to 39 $266.27 $242.19 $235.02 $224.28 $845.90

40 to 49 $357.57 $325.23 $315.60 $301.18 $1,135.93

50 to 54 $495.42 $450.61 $437.28 $417.29 $1,573.86

55 to 59 $612.89 $557.45 $540.96 $516.23 $1,947.03

60 to 64 $799.74 $727.40 $705.88 $673.62 $2,540.61

65 plus $941.85 $856.66 $831.32 $793.32 $2,992.08

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $614.41 $558.84 $542.30 $517.52 $1,951.86

30 to 39 $721.53 $656.27 $636.85 $607.74 $2,292.16

40 to 49 $776.61 $706.37 $685.47 $654.13 $2,467.14

50 to 54 $1,024.02 $931.40 $903.84 $862.53 $3,253.10

55 to 59 $1,269.90 $1,155.04 $1,120.87 $1,069.63 $4,034.23

60 to 64 $1,583.35 $1,440.13 $1,397.52 $1,333.65 $5,029.98

65 plus $2,173.11 $1,976.55 $1,918.07 $1,830.40 $6,903.54

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $487.51 $443.42 $430.30 $410.63 $1,548.73

30 to 39 $534.38 $486.04 $471.66 $450.10 $1,697.61

40 to 49 $549.90 $500.16 $485.36 $463.17 $1,746.91

50 to 54 $665.53 $605.34 $587.43 $560.58 $2,114.28

55 to 59 $786.96 $715.78 $694.60 $662.85 $2,500.01

60 to 64 $982.63 $893.75 $867.31 $827.67 $3,121.63

65 plus $1,111.05 $1,010.56 $980.66 $935.83 $3,529.59

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $769.00 $699.45 $678.75 $647.73 $2,442.97

30 to 39 $873.38 $794.39 $770.88 $735.65 $2,774.56

40 to 49 $885.86 $805.73 $781.89 $746.15 $2,814.20

50 to 54 $1,120.48 $1,019.14 $988.98 $943.78 $3,559.56

55 to 59 $1,368.80 $1,245.00 $1,208.16 $1,152.94 $4,348.43

60 to 64 $1,686.81 $1,534.24 $1,488.85 $1,420.80 $5,358.68

65 plus $2,269.27 $2,064.02 $2,002.95 $1,911.40 $7,209.03

14

Area #6 CountiesHMO products: Marin, San Joaquin Value Network HMO products: Not available in this areaHCP Network HMO products: Not available in this area

All other products: Los Angeles #2 (ZIP Codes beginning with 906–912, 915, 917, 918, 935), Alameda, Marin, Napa, Nevada, San Francisco, San Mateo, Santa Cruz, Sonoma, Yolo


Choice PlusAge

Category20/250/90%

5E-A30/250/80%

5E-D30/500/80%

5E-F40/500/70%

5E-K30/1000/80%

5E-C40/1000/70%

5E-I40/1000/50%

5E-G40/1500/70%

5E-J40/2000/50%

5E-H30/2500/80%

5E-E20/3000/90%

5E-B

EM

PLO

YE

EO

NLY

0 to 29 $404.56 $366.61 $316.05 $282.56 $274.20 $238.02 $227.33 $231.18 $212.49 $231.69 $232.95

30 to 39 $500.69 $453.73 $391.15 $349.70 $339.36 $294.58 $281.35 $286.11 $262.98 $286.75 $288.30

40 to 49 $672.36 $609.29 $525.26 $469.60 $455.71 $395.58 $377.81 $384.21 $353.15 $385.06 $387.15

50 to 54 $931.58 $844.19 $727.76 $650.65 $631.40 $548.09 $523.47 $532.34 $489.30 $533.51 $536.41

55 to 59 $1,152.45 $1,044.35 $900.32 $804.92 $781.10 $678.04 $647.59 $658.55 $605.31 $660.01 $663.59

60 to 64 $1,503.80 $1,362.73 $1,174.79 $1,050.31 $1,019.23 $884.75 $845.01 $859.32 $789.85 $861.22 $865.90

65 plus $1,771.02 $1,604.89 $1,383.56 $1,236.95 $1,200.35 $1,041.97 $995.17 $1,012.03 $930.21 $1,014.26 $1,019.77

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $1,155.31 $1,046.94 $902.55 $806.91 $783.04 $679.72 $649.19 $660.19 $606.81 $661.64 $665.24

30 to 39 $1,356.74 $1,229.47 $1,059.91 $947.60 $919.56 $798.23 $762.38 $775.29 $712.61 $777.00 $781.22

40 to 49 $1,460.31 $1,323.32 $1,140.82 $1,019.93 $989.76 $859.16 $820.57 $834.47 $767.01 $836.31 $840.86

50 to 54 $1,925.52 $1,744.90 $1,504.25 $1,344.86 $1,305.07 $1,132.87 $1,081.99 $1,100.31 $1,011.36 $1,102.74 $1,108.74

55 to 59 $2,387.88 $2,163.88 $1,865.45 $1,667.78 $1,618.44 $1,404.89 $1,341.79 $1,364.52 $1,254.20 $1,367.53 $1,374.97

60 to 64 $2,977.26 $2,697.98 $2,325.90 $2,079.43 $2,017.91 $1,751.65 $1,672.98 $1,701.31 $1,563.77 $1,705.07 $1,714.34

65 plus $4,086.23 $3,702.92 $3,192.24 $2,853.98 $2,769.54 $2,404.10 $2,296.13 $2,335.02 $2,146.24 $2,340.17 $2,352.89

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $916.70 $830.71 $716.14 $640.26 $621.31 $539.33 $515.11 $523.83 $481.48 $524.99 $527.84

30 to 39 $1,004.82 $910.56 $784.98 $701.80 $681.04 $591.18 $564.63 $574.19 $527.77 $575.46 $578.59

40 to 49 $1,034.00 $937.01 $807.78 $722.19 $700.82 $608.35 $581.03 $590.87 $543.10 $592.17 $595.39

50 to 54 $1,251.45 $1,134.05 $977.65 $874.06 $848.20 $736.28 $703.21 $715.12 $657.31 $716.70 $720.60

55 to 59 $1,479.76 $1,340.95 $1,156.02 $1,033.52 $1,002.94 $870.61 $831.51 $845.59 $777.23 $847.45 $852.06

60 to 64 $1,847.70 $1,674.38 $1,443.46 $1,290.50 $1,252.32 $1,087.08 $1,038.26 $1,055.84 $970.48 $1,058.17 $1,063.93

65 plus $2,089.18 $1,893.20 $1,632.11 $1,459.16 $1,415.99 $1,229.15 $1,173.95 $1,193.83 $1,097.31 $1,196.46 $1,202.97

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,446.00 $1,310.36 $1,129.64 $1,009.94 $980.06 $850.74 $812.54 $826.30 $759.49 $828.12 $832.62

30 to 39 $1,642.27 $1,488.22 $1,282.98 $1,147.03 $1,113.09 $966.22 $922.82 $938.45 $862.58 $940.52 $945.64

40 to 49 $1,665.73 $1,509.48 $1,301.30 $1,163.41 $1,128.99 $980.02 $936.01 $951.86 $874.91 $953.96 $959.15

50 to 54 $2,106.92 $1,909.28 $1,645.96 $1,471.55 $1,428.01 $1,239.59 $1,183.92 $1,203.97 $1,106.63 $1,206.62 $1,213.19

55 to 59 $2,573.85 $2,332.41 $2,010.74 $1,797.67 $1,744.49 $1,514.31 $1,446.29 $1,470.79 $1,351.88 $1,474.03 $1,482.05

60 to 64 $3,171.82 $2,874.28 $2,477.89 $2,215.32 $2,149.77 $1,866.12 $1,782.31 $1,812.49 $1,665.96 $1,816.49 $1,826.37

65 plus $4,267.05 $3,866.78 $3,333.50 $2,980.27 $2,892.09 $2,510.49 $2,397.74 $2,438.34 $2,241.21 $2,443.72 $2,457.01


AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $468.12 $422.29 $391.66 $369.91 $346.58 $329.13 $330.11 $306.45 $283.35

30 to 39 $543.83 $490.59 $455.00 $429.74 $402.64 $382.36 $383.50 $356.01 $329.17

40 to 49 $674.44 $608.42 $564.28 $532.95 $499.34 $474.19 $475.60 $441.51 $408.23

50 to 54 $916.02 $826.34 $766.40 $723.84 $678.19 $644.03 $645.95 $599.65 $554.45

55 to 59 $1,177.82 $1,062.51 $985.43 $930.71 $872.02 $828.10 $830.57 $771.04 $712.91

60 to 64 $1,495.10 $1,348.73 $1,250.89 $1,181.43 $1,106.93 $1,051.18 $1,054.31 $978.74 $904.96

65 plus $2,086.33 $1,882.07 $1,745.54 $1,648.61 $1,544.65 $1,466.85 $1,471.22 $1,365.77 $1,262.81

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $1,116.56 $1,007.25 $934.18 $882.31 $826.66 $785.03 $787.37 $730.93 $675.83

30 to 39 $1,247.17 $1,125.07 $1,043.46 $985.52 $923.37 $876.86 $879.47 $816.44 $754.89

40 to 49 $1,488.75 $1,343.00 $1,245.57 $1,176.41 $1,102.22 $1,046.71 $1,049.82 $974.58 $901.11

50 to 54 $1,905.44 $1,718.89 $1,594.20 $1,505.67 $1,410.72 $1,339.67 $1,343.66 $1,247.35 $1,153.32

55 to 59 $2,420.37 $2,183.41 $2,025.02 $1,912.58 $1,791.96 $1,701.71 $1,706.78 $1,584.45 $1,465.00

60 to 64 $2,878.67 $2,596.84 $2,408.46 $2,274.72 $2,131.27 $2,023.93 $2,029.96 $1,884.46 $1,742.40

65 plus $3,740.94 $3,374.70 $3,129.89 $2,956.09 $2,769.67 $2,630.17 $2,638.01 $2,448.93 $2,264.32

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $1,047.21 $944.69 $876.16 $827.50 $775.32 $736.27 $738.46 $685.53 $633.86

30 to 39 $1,166.84 $1,052.61 $976.25 $922.04 $863.89 $820.38 $822.82 $763.85 $706.27

40 to 49 $1,264.51 $1,140.71 $1,057.96 $999.22 $936.20 $889.05 $891.70 $827.79 $765.38

50 to 54 $1,470.25 $1,326.31 $1,230.10 $1,161.79 $1,088.53 $1,033.70 $1,036.78 $962.47 $889.92

55 to 59 $1,645.37 $1,484.28 $1,376.61 $1,300.17 $1,218.17 $1,156.82 $1,160.27 $1,077.11 $995.91

60 to 64 $2,018.13 $1,820.55 $1,688.49 $1,594.73 $1,494.16 $1,418.90 $1,423.13 $1,321.13 $1,221.54

65 plus $2,656.17 $2,396.12 $2,222.30 $2,098.90 $1,966.54 $1,867.49 $1,873.05 $1,738.80 $1,607.73

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,719.34 $1,551.02 $1,438.50 $1,358.62 $1,272.94 $1,208.83 $1,212.43 $1,125.53 $1,040.68

30 to 39 $1,895.61 $1,710.03 $1,585.98 $1,497.91 $1,403.45 $1,332.76 $1,336.73 $1,240.92 $1,147.38

40 to 49 $2,103.09 $1,897.19 $1,759.57 $1,661.86 $1,557.06 $1,478.63 $1,483.04 $1,376.74 $1,272.96

50 to 54 $2,482.21 $2,239.20 $2,076.76 $1,961.44 $1,837.74 $1,745.19 $1,750.38 $1,624.93 $1,502.43

55 to 59 $2,907.57 $2,622.91 $2,432.64 $2,297.56 $2,152.66 $2,044.25 $2,050.33 $1,903.38 $1,759.89

60 to 64 $3,423.08 $3,087.96 $2,863.95 $2,704.92 $2,534.33 $2,406.69 $2,413.86 $2,240.85 $2,071.92

65 plus $4,333.90 $3,909.60 $3,625.99 $3,424.64 $3,208.67 $3,047.07 $3,056.14 $2,837.10 $2,623.23


Choice Plus ValueAge

Category30/1000/80%

5E-P40/1000/70%

5E-S40/1000/50%

5E-Q40/1500/70%

5E-T40/2000/50%

5E-R

EM

PLO

YE

EO

NLY

0 to 29 $231.84 $214.61 $202.81 $205.34 $187.96

30 to 39 $286.93 $265.61 $251.00 $254.13 $232.62

40 to 49 $385.31 $356.67 $337.06 $341.27 $312.38

50 to 54 $533.86 $494.18 $467.01 $472.83 $432.81

55 to 59 $660.43 $611.35 $577.74 $584.94 $535.43

60 to 64 $861.78 $797.73 $753.87 $763.27 $698.67

65 plus $1,014.91 $939.49 $887.83 $898.91 $822.82

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $662.07 $612.87 $579.17 $586.40 $536.76

30 to 39 $777.50 $719.72 $680.14 $688.63 $630.34

40 to 49 $836.85 $774.66 $732.07 $741.20 $678.46

50 to 54 $1,103.45 $1,021.45 $965.28 $977.33 $894.60

55 to 59 $1,368.41 $1,266.72 $1,197.07 $1,212.00 $1,109.42

60 to 64 $1,706.17 $1,579.37 $1,492.53 $1,511.15 $1,383.25

65 plus $2,341.68 $2,167.65 $2,048.47 $2,074.02 $1,898.48

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $525.33 $486.29 $459.55 $465.28 $425.90

30 to 39 $575.83 $533.03 $503.73 $510.01 $466.84

40 to 49 $592.55 $548.52 $518.36 $524.82 $480.40

50 to 54 $717.16 $663.86 $627.36 $635.19 $581.43

55 to 59 $848.00 $784.98 $741.82 $751.07 $687.50

60 to 64 $1,058.86 $980.16 $926.27 $937.83 $858.45

65 plus $1,197.24 $1,108.26 $1,047.33 $1,060.39 $970.64

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $828.66 $767.07 $724.90 $733.94 $671.82

30 to 39 $941.13 $871.19 $823.29 $833.56 $763.01

40 to 49 $954.58 $883.63 $835.05 $845.47 $773.91

50 to 54 $1,207.40 $1,117.67 $1,056.22 $1,069.39 $978.88

55 to 59 $1,474.99 $1,365.37 $1,290.30 $1,306.39 $1,195.82

60 to 64 $1,817.66 $1,682.58 $1,590.06 $1,609.90 $1,473.64

65 plus $2,445.31 $2,263.57 $2,139.11 $2,165.80 $1,982.49

Defi nitySM HSA1500/80%

Z6-Q2000/100%

5E-N2000/80%

Q3-M3000/100%

5E-O3000/80%

5E-L4000/80%

5E-M

$226.72 $227.48 $208.08 $198.20 $184.97 $174.54

$280.59 $281.53 $257.52 $245.30 $228.92 $216.01

$376.80 $378.06 $345.82 $329.40 $307.41 $290.08

$522.07 $523.82 $479.14 $456.39 $425.93 $401.91

$645.85 $648.01 $592.75 $564.60 $526.92 $497.20

$842.74 $845.57 $773.46 $736.73 $687.55 $648.79

$992.50 $995.83 $910.90 $867.65 $809.73 $764.08

$647.45 $649.62 $594.22 $566.01 $528.22 $498.44

$760.33 $762.88 $697.82 $664.68 $620.32 $585.34

$818.37 $821.12 $751.09 $715.43 $667.67 $630.02

$1,079.08 $1,082.70 $990.37 $943.34 $880.37 $830.73

$1,338.19 $1,342.68 $1,228.17 $1,169.86 $1,091.77 $1,030.21

$1,668.49 $1,674.09 $1,531.32 $1,458.61 $1,361.24 $1,284.49

$2,289.97 $2,297.64 $2,101.70 $2,001.90 $1,868.28 $1,762.93

$513.73 $515.45 $471.49 $449.10 $419.13 $395.49

$563.11 $565.00 $516.82 $492.28 $459.42 $433.51

$579.47 $581.41 $531.83 $506.57 $472.76 $446.10

$701.32 $703.68 $643.66 $613.10 $572.18 $539.91

$829.28 $832.06 $761.10 $724.96 $676.57 $638.42

$1,035.47 $1,038.94 $950.34 $905.22 $844.79 $797.16

$1,170.80 $1,174.72 $1,074.54 $1,023.52 $955.20 $901.34

$810.36 $813.07 $743.73 $708.42 $661.13 $623.85

$920.35 $923.43 $844.68 $804.57 $750.87 $708.53

$933.50 $936.63 $856.75 $816.07 $761.60 $718.65

$1,180.74 $1,184.70 $1,083.66 $1,032.21 $963.31 $908.99

$1,442.41 $1,447.25 $1,323.82 $1,260.97 $1,176.80 $1,110.44

$1,777.52 $1,783.48 $1,631.38 $1,553.92 $1,450.20 $1,368.42

$2,391.30 $2,399.32 $2,194.70 $2,090.49 $1,950.95 $1,840.94


PPO

AgeCategory

1500/80%C3-U

2000/70%C3-S

2500/80%C3-V

3000/70%C3-T

2000/80%6H-F

EM

PLO

YE

EO

NLY

0 to 29 $256.01 $232.85 $225.96 $215.63 $683.49

30 to 39 $316.84 $288.18 $279.65 $266.87 $845.90

40 to 49 $425.48 $386.99 $375.53 $358.37 $1,135.93

50 to 54 $589.51 $536.18 $520.32 $496.53 $1,573.86

55 to 59 $729.28 $663.31 $643.68 $614.26 $1,947.03

60 to 64 $951.62 $865.53 $839.92 $801.52 $2,540.61

65 plus $1,120.72 $1,019.34 $989.17 $943.95 $2,992.08

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $731.10 $664.96 $645.28 $615.78 $1,951.86

30 to 39 $858.56 $780.89 $757.78 $723.14 $2,292.16

40 to 49 $924.10 $840.50 $815.63 $778.34 $2,467.14

50 to 54 $1,218.49 $1,108.26 $1,075.47 $1,026.30 $3,253.10

55 to 59 $1,511.07 $1,374.37 $1,333.71 $1,272.74 $4,034.23

60 to 64 $1,884.05 $1,713.60 $1,662.90 $1,586.88 $5,029.98

65 plus $2,585.81 $2,351.88 $2,282.29 $2,177.95 $6,903.54

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $580.10 $527.62 $512.01 $488.60 $1,548.73

30 to 39 $635.86 $578.34 $561.22 $535.57 $1,697.61

40 to 49 $654.33 $595.13 $577.52 $551.12 $1,746.91

50 to 54 $791.93 $720.29 $698.97 $667.02 $2,114.28

55 to 59 $936.41 $851.70 $826.50 $788.71 $2,500.01

60 to 64 $1,169.25 $1,063.47 $1,032.00 $984.82 $3,121.63

65 plus $1,322.05 $1,202.45 $1,166.87 $1,113.53 $3,529.59

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $915.05 $832.27 $807.64 $770.72 $2,442.97

30 to 39 $1,039.25 $945.23 $917.26 $875.33 $2,774.56

40 to 49 $1,054.09 $958.74 $930.37 $887.83 $2,814.20

50 to 54 $1,333.28 $1,212.66 $1,176.78 $1,122.98 $3,559.56

55 to 59 $1,628.76 $1,481.41 $1,437.58 $1,371.86 $4,348.43

60 to 64 $2,007.16 $1,825.58 $1,771.56 $1,690.58 $5,358.68

65 plus $2,700.24 $2,455.96 $2,383.29 $2,274.33 $7,209.03

16

Area #7 CountiesHMO products: Not available in this areaValue Network HMO products: Not available in this areaHCP Network HMO products: Not available in this area All other products: Contra Costa, Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt,

Inyo, Lake, Lassen, Mariposa, Mendocino, Modoc, Mono, Monterey, Plumas, San Benito, Shasta, Sierra, Siskiyou, Solano, Sutter, Tehama, Trinity, Tuolumne and Yuba


Choice PlusAge

Category20/250/90%

5E-A30/250/80%

5E-D30/500/80%

5E-F40/500/70%

5E-K30/1000/80%

5E-C40/1000/70%

5E-I40/1000/50%

5E-G40/1500/70%

5E-J40/2000/50%

5E-H30/2500/80%

5E-E20/3000/90%

5E-B

EM

PLO

YE

EO

NLY

0 to 29 $515.77 $467.39 $402.93 $360.23 $349.57 $303.45 $289.82 $294.73 $270.90 $295.38 $296.99

30 to 39 $638.33 $578.45 $498.68 $445.83 $432.64 $375.56 $358.69 $364.76 $335.27 $365.57 $367.56

40 to 49 $857.18 $776.78 $669.65 $598.68 $580.97 $504.32 $481.67 $489.83 $450.22 $490.91 $493.58

50 to 54 $1,187.66 $1,076.25 $927.82 $829.50 $804.95 $698.75 $667.36 $678.67 $623.80 $680.17 $683.88

55 to 59 $1,469.25 $1,331.43 $1,147.81 $1,026.17 $995.80 $864.42 $825.60 $839.58 $771.70 $841.44 $846.02

60 to 64 $1,917.18 $1,737.34 $1,497.74 $1,339.02 $1,299.39 $1,127.96 $1,077.29 $1,095.55 $1,006.97 $1,097.96 $1,103.95

65 plus $2,257.86 $2,046.07 $1,763.89 $1,576.96 $1,530.30 $1,328.40 $1,268.73 $1,290.23 $1,185.91 $1,293.07 $1,300.12

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $1,472.90 $1,334.74 $1,150.66 $1,028.72 $998.28 $866.57 $827.65 $841.67 $773.62 $843.53 $848.12

30 to 39 $1,729.69 $1,567.44 $1,351.27 $1,208.07 $1,172.32 $1,017.65 $971.94 $988.41 $908.49 $990.59 $995.99

40 to 49 $1,861.73 $1,687.10 $1,454.42 $1,300.29 $1,261.81 $1,095.34 $1,046.14 $1,063.86 $977.85 $1,066.21 $1,072.02

50 to 54 $2,454.83 $2,224.56 $1,917.76 $1,714.53 $1,663.79 $1,444.28 $1,379.41 $1,402.78 $1,289.36 $1,405.88 $1,413.54

55 to 59 $3,044.28 $2,758.72 $2,378.26 $2,126.22 $2,063.30 $1,791.08 $1,710.63 $1,739.62 $1,598.96 $1,743.45 $1,752.96

60 to 64 $3,795.69 $3,439.65 $2,965.27 $2,651.03 $2,572.58 $2,233.17 $2,132.86 $2,169.00 $1,993.62 $2,173.78 $2,185.63

65 plus $5,209.50 $4,720.84 $4,069.76 $3,638.48 $3,530.81 $3,064.97 $2,927.30 $2,976.90 $2,736.20 $2,983.46 $2,999.73

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $1,168.69 $1,059.06 $913.00 $816.25 $792.09 $687.59 $656.71 $667.83 $613.84 $669.31 $672.95

30 to 39 $1,281.04 $1,160.87 $1,000.77 $894.72 $868.24 $753.69 $719.84 $732.03 $672.84 $733.65 $737.64

40 to 49 $1,318.24 $1,194.59 $1,029.84 $920.70 $893.46 $775.58 $740.74 $753.29 $692.39 $754.95 $759.07

50 to 54 $1,595.46 $1,445.80 $1,246.40 $1,114.32 $1,081.34 $938.68 $896.52 $911.70 $837.99 $913.71 $918.69

55 to 59 $1,886.54 $1,709.58 $1,473.80 $1,317.62 $1,278.63 $1,109.93 $1,060.08 $1,078.04 $990.87 $1,080.41 $1,086.30

60 to 64 $2,355.62 $2,134.66 $1,840.26 $1,645.24 $1,596.55 $1,385.91 $1,323.66 $1,346.09 $1,237.25 $1,349.06 $1,356.41

65 plus $2,663.47 $2,413.64 $2,080.76 $1,860.25 $1,805.21 $1,567.04 $1,496.65 $1,522.01 $1,398.95 $1,525.36 $1,533.68

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,843.49 $1,670.57 $1,440.18 $1,287.55 $1,249.45 $1,084.61 $1,035.89 $1,053.44 $968.27 $1,055.76 $1,061.52

30 to 39 $2,093.72 $1,897.33 $1,635.66 $1,462.32 $1,419.05 $1,231.83 $1,176.50 $1,196.43 $1,099.69 $1,199.07 $1,205.60

40 to 49 $2,123.63 $1,924.43 $1,659.02 $1,483.21 $1,439.32 $1,249.42 $1,193.30 $1,213.52 $1,115.40 $1,216.20 $1,222.83

50 to 54 $2,686.09 $2,434.13 $2,098.43 $1,876.05 $1,820.53 $1,580.34 $1,509.36 $1,534.93 $1,410.83 $1,538.32 $1,546.70

55 to 59 $3,281.38 $2,973.58 $2,563.48 $2,291.82 $2,224.00 $1,930.58 $1,843.86 $1,875.10 $1,723.49 $1,879.24 $1,889.48

60 to 64 $4,043.72 $3,664.42 $3,159.04 $2,824.26 $2,740.69 $2,379.10 $2,272.24 $2,310.73 $2,123.90 $2,315.83 $2,328.45

65 plus $5,440.02 $4,929.74 $4,249.86 $3,799.48 $3,687.05 $3,200.60 $3,056.84 $3,108.63 $2,857.29 $3,115.49 $3,132.47


Category30/1000/80%

5E-P40/1000/70%

5E-S40/1000/50%

5E-Q40/1500/70%

5E-T40/2000/50%

5E-R

EM

PLO

YE

EO

NLY

0 to 29 $295.57 $273.61 $258.56 $261.79 $239.64

30 to 39 $365.80 $338.63 $320.00 $324.00 $296.58

40 to 49 $491.22 $454.73 $429.71 $435.08 $398.27

50 to 54 $680.61 $630.04 $595.38 $602.82 $551.82

55 to 59 $841.98 $779.42 $736.55 $745.75 $682.65

60 to 64 $1,098.67 $1,017.04 $961.10 $973.10 $890.77

65 plus $1,293.90 $1,197.77 $1,131.89 $1,146.03 $1,049.06

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $844.07 $781.36 $738.38 $747.60 $684.35

30 to 39 $991.23 $917.58 $867.11 $877.94 $803.66

40 to 49 $1,066.89 $987.63 $933.30 $944.96 $865.01

50 to 54 $1,406.78 $1,302.26 $1,230.63 $1,246.00 $1,140.58

55 to 59 $1,744.57 $1,614.96 $1,526.13 $1,545.19 $1,414.45

60 to 64 $2,175.18 $2,013.57 $1,902.81 $1,926.58 $1,763.57

65 plus $2,985.38 $2,763.58 $2,611.57 $2,644.19 $2,420.47

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $669.74 $619.98 $585.87 $593.19 $543.00

30 to 39 $734.12 $679.57 $642.19 $650.22 $595.20

40 to 49 $755.44 $699.31 $660.85 $669.10 $612.49

50 to 54 $914.30 $846.37 $799.82 $809.81 $741.29

55 to 59 $1,081.11 $1,000.79 $945.74 $957.55 $876.53

60 to 64 $1,349.92 $1,249.63 $1,180.89 $1,195.64 $1,094.48

65 plus $1,526.35 $1,412.94 $1,335.22 $1,351.90 $1,237.52

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,056.44 $977.95 $924.16 $935.70 $856.54

30 to 39 $1,199.84 $1,110.69 $1,049.60 $1,062.71 $972.80

40 to 49 $1,216.98 $1,126.56 $1,064.59 $1,077.89 $986.69

50 to 54 $1,539.31 $1,424.94 $1,346.56 $1,363.38 $1,248.03

55 to 59 $1,880.44 $1,740.73 $1,644.98 $1,665.53 $1,524.61

60 to 64 $2,317.32 $2,145.15 $2,027.15 $2,052.48 $1,878.82

65 plus $3,117.49 $2,885.87 $2,727.13 $2,761.20 $2,527.57


Z6-Q2000/100%

5E-N2000/80%

Q3-M3000/100%

5E-O3000/80%

5E-L4000/80%

5E-M

$289.05 $290.02 $265.28 $252.68 $235.82 $222.52

$357.74 $358.94 $328.32 $312.72 $291.86 $275.40

$480.39 $482.00 $440.88 $419.94 $391.92 $369.82

$665.59 $667.83 $610.86 $581.84 $543.02 $512.39

$823.40 $826.17 $755.69 $719.80 $671.77 $633.88

$1,074.43 $1,078.04 $986.08 $939.24 $876.57 $827.13

$1,265.36 $1,269.61 $1,161.30 $1,106.15 $1,032.34 $974.12

$825.45 $828.22 $757.57 $721.59 $673.44 $635.46

$969.36 $972.61 $889.64 $847.39 $790.85 $746.24

$1,043.36 $1,046.86 $957.56 $912.08 $851.22 $803.21

$1,375.75 $1,380.36 $1,262.61 $1,202.64 $1,122.40 $1,059.09

$1,706.09 $1,711.82 $1,565.79 $1,491.42 $1,391.91 $1,313.40

$2,127.20 $2,134.33 $1,952.27 $1,859.54 $1,735.46 $1,637.58

$2,919.53 $2,929.33 $2,679.44 $2,552.18 $2,381.88 $2,247.55

$654.96 $657.16 $601.10 $572.55 $534.35 $504.21

$717.92 $720.33 $658.88 $627.59 $585.71 $552.68

$738.77 $741.25 $678.02 $645.82 $602.73 $568.73

$894.13 $897.13 $820.60 $781.63 $729.47 $688.33

$1,057.26 $1,060.81 $970.32 $924.23 $862.56 $813.91

$1,320.14 $1,324.58 $1,211.58 $1,154.04 $1,077.03 $1,016.29

$1,492.68 $1,497.68 $1,369.93 $1,304.86 $1,217.79 $1,149.11

$1,033.14 $1,036.61 $948.18 $903.14 $842.88 $795.34

$1,173.37 $1,177.31 $1,076.88 $1,025.73 $957.29 $903.30

$1,190.13 $1,194.13 $1,092.26 $1,040.38 $970.96 $916.20

$1,505.35 $1,510.40 $1,381.56 $1,315.94 $1,228.13 $1,158.87

$1,838.96 $1,845.13 $1,687.74 $1,607.57 $1,500.31 $1,415.69

$2,266.20 $2,273.81 $2,079.84 $1,981.05 $1,848.87 $1,744.59

$3,048.72 $3,058.95 $2,798.01 $2,665.11 $2,487.28 $2,347.00

17



PPO

AgeCategory

1500/80%C3-U

2000/70%C3-S

2500/80%C3-V

3000/70%C3-T

2000/80%6H-F

EM

PLO

YE

EO

NLY

0 to 29 $326.38 $296.86 $288.08 $274.90 $683.49

30 to 39 $403.94 $367.40 $356.53 $340.22 $845.90

40 to 49 $542.43 $493.37 $478.78 $456.87 $1,135.93

50 to 54 $751.55 $683.58 $663.36 $633.01 $1,573.86

55 to 59 $929.74 $845.65 $820.64 $783.10 $1,947.03

60 to 64 $1,213.19 $1,103.46 $1,070.83 $1,021.83 $2,540.61

65 plus $1,428.78 $1,299.55 $1,261.11 $1,203.42 $2,992.08

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $932.05 $847.75 $822.68 $785.04 $1,951.86

30 to 39 $1,094.55 $995.55 $966.11 $921.91 $2,292.16

40 to 49 $1,178.11 $1,071.55 $1,039.86 $992.28 $2,467.14

50 to 54 $1,553.42 $1,412.92 $1,371.13 $1,308.40 $3,253.10

55 to 59 $1,926.43 $1,752.19 $1,700.36 $1,622.57 $4,034.23

60 to 64 $2,401.92 $2,184.67 $2,120.06 $2,023.06 $5,029.98

65 plus $3,296.58 $2,998.41 $2,909.73 $2,776.61 $6,903.54

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $739.55 $672.66 $652.76 $622.90 $1,548.73

30 to 39 $810.64 $737.32 $715.51 $682.78 $1,697.61

40 to 49 $834.18 $758.74 $736.29 $702.61 $1,746.91

50 to 54 $1,009.61 $918.29 $891.13 $850.36 $2,114.28

55 to 59 $1,193.80 $1,085.83 $1,053.71 $1,005.50 $2,500.01

60 to 64 $1,490.64 $1,355.81 $1,315.71 $1,255.52 $3,121.63

65 plus $1,685.45 $1,533.01 $1,487.67 $1,419.60 $3,529.59

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,166.57 $1,061.05 $1,029.67 $982.56 $2,442.97

30 to 39 $1,324.91 $1,205.08 $1,169.43 $1,115.93 $2,774.56

40 to 49 $1,343.84 $1,222.29 $1,186.14 $1,131.87 $2,814.20

50 to 54 $1,699.76 $1,546.02 $1,500.30 $1,431.66 $3,559.56

55 to 59 $2,076.46 $1,888.65 $1,832.79 $1,748.94 $4,348.43

60 to 64 $2,558.87 $2,327.43 $2,258.60 $2,155.26 $5,358.68

65 plus $3,442.45 $3,131.10 $3,038.49 $2,899.48 $7,209.03

18

Area #8 CountiesHMO products: VenturaValue Network HMO products: VenturaHCP Network HMO products: Ventura (91358-91362)All other products: El Dorado, Merced, Placer, Sacramento, San Joaquin and Stanislaus



AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $346.80 $312.85 $290.16 $274.04 $256.76 $243.83 $244.56 $227.03 $209.92

30 to 39 $402.89 $363.44 $337.09 $318.36 $298.29 $283.26 $284.12 $263.74 $243.87

40 to 49 $499.65 $450.73 $418.04 $394.82 $369.93 $351.29 $352.35 $327.09 $302.44

50 to 54 $678.62 $612.17 $567.78 $536.24 $502.43 $477.12 $478.56 $444.24 $410.77

55 to 59 $872.57 $787.14 $730.05 $689.50 $646.03 $613.48 $615.33 $571.21 $528.17

60 to 64 $1,107.62 $999.18 $926.72 $875.23 $820.05 $778.74 $781.09 $725.08 $670.45

65 plus $1,545.62 $1,394.29 $1,293.17 $1,221.34 $1,144.33 $1,086.68 $1,089.97 $1,011.81 $935.57

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $827.19 $746.20 $692.08 $653.63 $612.42 $581.57 $583.33 $541.50 $500.70

30 to 39 $923.95 $833.48 $773.04 $730.09 $684.06 $649.60 $651.56 $604.84 $559.27

40 to 49 $1,102.91 $994.93 $922.77 $871.51 $816.57 $775.43 $777.77 $722.00 $667.60

50 to 54 $1,411.61 $1,273.40 $1,181.05 $1,115.44 $1,045.12 $992.46 $995.46 $924.08 $854.45

55 to 59 $1,793.09 $1,617.53 $1,500.23 $1,416.88 $1,327.55 $1,260.67 $1,264.48 $1,173.81 $1,085.36

60 to 64 $2,132.62 $1,923.81 $1,784.29 $1,685.17 $1,578.93 $1,499.38 $1,503.91 $1,396.07 $1,290.88

65 plus $2,771.41 $2,500.07 $2,318.76 $2,189.95 $2,051.88 $1,948.50 $1,954.39 $1,814.25 $1,677.54

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $775.81 $699.85 $649.09 $613.04 $574.39 $545.45 $547.10 $507.87 $469.60

30 to 39 $864.43 $779.80 $723.25 $683.07 $640.00 $607.76 $609.60 $565.89 $523.24

40 to 49 $936.79 $845.07 $783.79 $740.24 $693.57 $658.63 $660.62 $613.25 $567.04

50 to 54 $1,089.21 $982.57 $911.31 $860.69 $806.42 $765.79 $768.11 $713.03 $659.30

55 to 59 $1,218.94 $1,099.60 $1,019.85 $963.20 $902.47 $857.00 $859.59 $797.96 $737.83

60 to 64 $1,495.10 $1,348.72 $1,250.90 $1,181.41 $1,106.93 $1,051.16 $1,054.34 $978.74 $904.99

65 plus $1,967.78 $1,775.11 $1,646.38 $1,554.92 $1,456.89 $1,383.49 $1,387.67 $1,288.17 $1,191.10

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,273.75 $1,149.03 $1,065.70 $1,006.50 $943.05 $895.53 $898.24 $833.83 $771.00

30 to 39 $1,404.33 $1,266.83 $1,174.96 $1,109.69 $1,039.73 $987.35 $990.33 $919.32 $850.04

40 to 49 $1,558.04 $1,405.49 $1,303.56 $1,231.15 $1,153.53 $1,095.41 $1,098.72 $1,019.94 $943.08

50 to 54 $1,838.90 $1,658.86 $1,538.55 $1,453.08 $1,361.47 $1,292.88 $1,296.79 $1,203.80 $1,113.09

55 to 59 $2,154.02 $1,943.12 $1,802.20 $1,702.09 $1,594.78 $1,514.43 $1,519.01 $1,410.09 $1,303.83

60 to 64 $2,535.93 $2,287.64 $2,121.74 $2,003.87 $1,877.53 $1,782.94 $1,788.33 $1,660.10 $1,535.00

65 plus $3,210.70 $2,896.34 $2,686.29 $2,537.06 $2,377.11 $2,257.35 $2,264.17 $2,101.82 $1,943.44


AgeCategory

25-50/500ded

25-75/500ded

25-75/1500ded

EM

PLO

YE

E O

NLY

0 to 29 $182.07 $176.03 $150.96

30 to 39 $211.52 $204.50 $175.37

40 to 49 $262.32 $253.61 $217.49

50 to 54 $356.28 $344.45 $295.40

55 to 59 $458.10 $442.90 $379.82

60 to 64 $581.51 $562.21 $482.14

65 plus $811.46 $784.53 $672.80

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $434.27 $419.86 $360.07

30 to 39 $485.08 $468.98 $402.19

40 to 49 $579.03 $559.82 $480.09

50 to 54 $741.10 $716.50 $614.46

55 to 59 $941.38 $910.14 $780.52

60 to 64 $1,119.63 $1,082.47 $928.31

65 plus $1,455.00 $1,406.71 $1,206.37

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $407.30 $393.78 $337.70

30 to 39 $453.83 $438.77 $376.28

40 to 49 $491.82 $475.50 $407.78

50 to 54 $571.84 $552.86 $474.13

55 to 59 $639.95 $618.71 $530.60

60 to 64 $784.93 $758.88 $650.80

65 plus $1,033.09 $998.80 $856.56

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $668.72 $646.53 $554.45

30 to 39 $737.28 $712.81 $611.29

40 to 49 $817.97 $790.83 $678.20

50 to 54 $965.43 $933.39 $800.46

55 to 59 $1,130.87 $1,093.34 $937.63

60 to 64 $1,331.37 $1,287.19 $1,103.87

65 plus $1,685.63 $1,629.68 $1,397.59


AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 -

60/2000ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $318.35 $287.18 $266.35 $251.56 $235.69 $223.83 $210.41 $224.50 $208.40 $192.69

30 to 39 $369.83 $333.62 $309.43 $292.25 $273.81 $260.03 $244.44 $260.81 $242.10 $223.85

40 to 49 $458.65 $413.75 $383.74 $362.44 $339.57 $322.48 $303.15 $323.45 $300.25 $277.62

50 to 54 $622.94 $561.95 $521.20 $492.25 $461.20 $437.98 $411.74 $439.30 $407.79 $377.06

55 to 59 $800.97 $722.55 $670.16 $632.94 $593.02 $563.16 $529.41 $564.85 $524.34 $484.82

60 to 64 $1,016.74 $917.19 $850.68 $803.44 $752.77 $714.87 $672.02 $717.01 $665.58 $615.42

65 plus $1,418.80 $1,279.89 $1,187.08 $1,121.16 $1,050.44 $997.55 $937.77 $1,000.55 $928.78 $858.78

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $759.31 $684.97 $635.30 $600.02 $562.17 $533.87 $501.88 $535.47 $497.06 $459.60

30 to 39 $848.14 $765.10 $709.62 $670.21 $627.93 $596.32 $560.58 $598.11 $555.21 $513.37

40 to 49 $1,012.42 $913.30 $847.07 $800.03 $749.56 $711.83 $669.17 $713.96 $662.75 $612.80

50 to 54 $1,295.79 $1,168.92 $1,084.15 $1,023.95 $959.36 $911.06 $856.46 $913.80 $848.25 $784.32

55 to 59 $1,645.97 $1,484.81 $1,377.14 $1,300.67 $1,218.62 $1,157.27 $1,087.92 $1,160.75 $1,077.49 $996.28

60 to 64 $1,957.63 $1,765.96 $1,637.90 $1,546.95 $1,449.37 $1,376.40 $1,293.91 $1,380.53 $1,281.51 $1,184.93

65 plus $2,544.02 $2,294.94 $2,128.52 $2,010.32 $1,883.51 $1,788.68 $1,681.49 $1,794.06 $1,665.37 $1,539.86

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $712.15 $642.43 $595.84 $562.75 $527.26 $500.71 $470.70 $502.21 $466.19 $431.06

30 to 39 $793.51 $715.82 $663.91 $627.04 $587.49 $557.91 $524.48 $559.59 $519.45 $480.30

40 to 49 $859.93 $775.73 $719.48 $679.53 $636.66 $604.61 $568.38 $606.43 $562.93 $520.50

50 to 54 $999.84 $901.95 $836.54 $790.09 $740.25 $702.98 $660.85 $705.10 $654.52 $605.19

55 to 59 $1,118.93 $1,009.38 $936.18 $884.19 $828.42 $786.71 $739.57 $789.07 $732.48 $677.27

60 to 64 $1,372.43 $1,238.05 $1,148.27 $1,084.51 $1,016.10 $964.94 $907.12 $967.84 $898.42 $830.71

65 plus $1,806.32 $1,629.47 $1,511.30 $1,427.38 $1,337.34 $1,270.01 $1,193.90 $1,273.83 $1,182.46 $1,093.34

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,169.23 $1,054.76 $978.27 $923.95 $865.67 $822.08 $772.82 $824.55 $765.41 $707.72

30 to 39 $1,289.11 $1,162.89 $1,078.56 $1,018.67 $954.41 $906.36 $852.05 $909.08 $843.88 $780.28

40 to 49 $1,430.20 $1,290.17 $1,196.61 $1,130.16 $1,058.88 $1,005.56 $945.30 $1,008.59 $936.24 $865.68

50 to 54 $1,688.02 $1,522.75 $1,412.32 $1,333.90 $1,249.76 $1,186.84 $1,115.71 $1,190.40 $1,105.02 $1,021.74

55 to 59 $1,977.28 $1,783.69 $1,654.34 $1,562.48 $1,463.92 $1,390.22 $1,306.90 $1,394.39 $1,294.38 $1,196.82

60 to 64 $2,327.86 $2,099.94 $1,947.66 $1,839.51 $1,723.47 $1,636.70 $1,538.62 $1,641.62 $1,523.87 $1,409.02

65 plus $2,947.26 $2,658.70 $2,465.90 $2,328.96 $2,182.06 $2,072.20 $1,948.02 $2,078.42 $1,929.34 $1,783.94

19

Choice PlusAge

Category20/250/90%

5E-A30/250/80%

5E-D30/500/80%

5E-F40/500/70%

5E-K30/1000/80%

5E-C40/1000/70%

5E-I40/1000/50%

5E-G40/1500/70%

5E-J40/2000/50%

5E-H30/2500/80%

5E-E20/3000/90%

5E-B

EM

PLO

YE

EO

NLY

0 to 29 $460.50 $417.31 $359.75 $321.63 $312.11 $270.94 $258.77 $263.15 $241.87 $263.73 $265.17

30 to 39 $569.93 $516.47 $445.24 $398.06 $386.27 $335.32 $320.26 $325.68 $299.34 $326.40 $328.18

40 to 49 $765.33 $693.55 $597.89 $534.53 $518.71 $450.29 $430.06 $437.34 $401.98 $438.31 $440.70

50 to 54 $1,060.39 $960.93 $828.39 $740.61 $718.69 $623.89 $595.87 $605.95 $556.95 $607.29 $610.60

55 to 59 $1,311.81 $1,188.77 $1,024.80 $916.21 $889.09 $771.81 $737.15 $749.62 $689.00 $751.28 $755.38

60 to 64 $1,711.73 $1,551.19 $1,337.23 $1,195.54 $1,160.15 $1,007.12 $961.88 $978.16 $899.06 $980.31 $985.67

65 plus $2,015.91 $1,826.84 $1,574.86 $1,407.98 $1,366.31 $1,186.08 $1,132.81 $1,151.98 $1,058.82 $1,154.52 $1,160.82

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $1,315.06 $1,191.72 $1,027.35 $918.49 $891.30 $773.73 $738.98 $751.48 $690.72 $753.14 $757.25

30 to 39 $1,544.34 $1,399.49 $1,206.46 $1,078.62 $1,046.69 $908.63 $867.81 $882.50 $811.14 $884.45 $889.28

40 to 49 $1,662.23 $1,506.33 $1,298.56 $1,160.96 $1,126.60 $977.99 $934.06 $949.87 $873.06 $951.96 $957.16

50 to 54 $2,191.77 $1,986.21 $1,712.25 $1,530.81 $1,485.50 $1,289.55 $1,231.63 $1,252.47 $1,151.19 $1,255.24 $1,262.09

55 to 59 $2,718.06 $2,463.13 $2,123.39 $1,898.39 $1,842.20 $1,599.20 $1,527.37 $1,553.22 $1,427.61 $1,556.64 $1,565.14

60 to 64 $3,388.94 $3,071.09 $2,647.50 $2,366.96 $2,296.90 $1,993.92 $1,904.36 $1,936.59 $1,779.99 $1,940.86 $1,951.46

65 plus $4,651.25 $4,215.01 $3,633.63 $3,248.60 $3,152.44 $2,736.61 $2,613.69 $2,657.93 $2,442.99 $2,663.78 $2,678.33

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $1,043.45 $945.59 $815.16 $728.79 $707.21 $613.93 $586.35 $596.27 $548.06 $597.59 $600.85

30 to 39 $1,143.76 $1,036.49 $893.52 $798.84 $775.20 $672.94 $642.72 $653.59 $600.74 $655.04 $658.61

40 to 49 $1,176.98 $1,066.59 $919.47 $822.04 $797.71 $692.49 $661.38 $672.58 $618.19 $674.06 $677.74

50 to 54 $1,424.49 $1,290.89 $1,112.83 $994.91 $965.47 $838.11 $800.47 $814.02 $748.19 $815.81 $820.26

55 to 59 $1,684.37 $1,526.40 $1,315.86 $1,176.43 $1,141.61 $991.02 $946.51 $962.53 $884.69 $964.65 $969.91

60 to 64 $2,103.19 $1,905.93 $1,643.04 $1,468.94 $1,425.46 $1,237.43 $1,181.85 $1,201.85 $1,104.67 $1,204.50 $1,211.08

65 plus $2,378.06 $2,155.02 $1,857.78 $1,660.92 $1,611.76 $1,399.15 $1,336.31 $1,358.93 $1,249.03 $1,361.92 $1,369.36

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,645.95 $1,491.57 $1,285.84 $1,149.59 $1,115.56 $968.41 $924.91 $940.57 $864.51 $942.64 $947.79

30 to 39 $1,869.36 $1,694.03 $1,460.37 $1,305.63 $1,266.98 $1,099.86 $1,050.45 $1,068.23 $981.85 $1,070.59 $1,076.43

40 to 49 $1,896.06 $1,718.23 $1,481.23 $1,324.28 $1,285.08 $1,115.57 $1,065.46 $1,083.49 $995.87 $1,085.88 $1,091.81

50 to 54 $2,398.25 $2,173.32 $1,873.55 $1,675.02 $1,625.44 $1,411.03 $1,347.65 $1,370.46 $1,259.64 $1,373.48 $1,380.98

55 to 59 $2,929.74 $2,654.97 $2,288.76 $2,046.24 $1,985.67 $1,723.75 $1,646.32 $1,674.18 $1,538.80 $1,677.87 $1,687.04

60 to 64 $3,610.40 $3,271.78 $2,820.50 $2,521.63 $2,447.00 $2,124.22 $2,028.80 $2,063.14 $1,896.30 $2,067.69 $2,078.98

65 plus $4,857.07 $4,401.53 $3,794.42 $3,392.35 $3,291.94 $2,857.71 $2,729.35 $2,775.54 $2,551.10 $2,781.66 $2,796.85


5E-P40/1000/70%

5E-S40/1000/50%

5E-Q40/1500/70%

5E-T40/2000/50%

5E-R

$263.90 $244.29 $230.85 $233.74 $213.96

$326.61 $302.34 $285.71 $289.28 $264.80

$438.59 $406.00 $383.66 $388.46 $355.59

$607.68 $562.52 $531.58 $538.23 $492.68

$751.76 $695.90 $657.61 $665.84 $609.50

$980.95 $908.05 $858.10 $868.84 $795.31

$1,155.26 $1,069.42 $1,010.58 $1,023.23 $936.64

$753.63 $697.63 $659.24 $667.50 $611.01

$885.02 $819.25 $774.18 $783.87 $717.54

$952.58 $881.79 $833.28 $843.71 $772.31

$1,256.04 $1,162.71 $1,098.74 $1,112.50 $1,018.35

$1,557.64 $1,441.90 $1,362.57 $1,379.63 $1,262.88

$1,942.11 $1,797.79 $1,698.89 $1,720.15 $1,574.59

$2,665.50 $2,467.43 $2,331.68 $2,360.87 $2,161.09

$597.97 $553.54 $523.09 $529.63 $484.81

$655.46 $606.75 $573.37 $580.55 $531.42

$674.49 $624.37 $590.02 $597.41 $546.85

$816.34 $755.68 $714.10 $723.04 $661.85

$965.27 $893.54 $844.38 $854.95 $782.60

$1,205.28 $1,115.72 $1,054.33 $1,067.53 $977.19

$1,362.80 $1,261.53 $1,192.13 $1,207.05 $1,104.91

$943.25 $873.16 $825.12 $835.45 $764.75

$1,071.28 $991.67 $937.11 $948.85 $868.55

$1,086.58 $1,005.84 $950.50 $962.40 $880.96

$1,374.37 $1,272.24 $1,202.25 $1,217.30 $1,114.29

$1,678.96 $1,554.20 $1,468.69 $1,487.08 $1,361.23

$2,069.02 $1,915.28 $1,809.90 $1,832.56 $1,677.48

$2,783.45 $2,576.62 $2,434.86 $2,465.35 $2,256.72

Defi nitySM HSAAge

Category1500/80%

Z6-Q2000/100%

5E-N2000/80%

Q3-M3000/100%

5E-O3000/80%

5E-L4000/80%

5E-M

EM

PLO

YE

EO

NLY

0 to 29 $258.08 $258.94 $236.85 $225.61 $210.55 $198.67

30 to 39 $319.41 $320.47 $293.13 $279.22 $260.58 $245.88

40 to 49 $428.92 $430.35 $393.63 $374.95 $349.92 $330.18

50 to 54 $594.28 $596.26 $545.39 $519.51 $484.83 $457.47

55 to 59 $735.18 $737.63 $674.70 $642.69 $599.78 $565.94

60 to 64 $959.31 $962.51 $880.40 $838.62 $782.64 $738.48

65 plus $1,129.78 $1,133.55 $1,036.85 $987.64 $921.71 $869.71

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $737.01 $739.46 $676.38 $644.28 $601.27 $567.35

30 to 39 $865.50 $868.38 $794.30 $756.61 $706.10 $666.26

40 to 49 $931.57 $934.67 $854.94 $814.37 $760.01 $717.12

50 to 54 $1,228.34 $1,232.44 $1,127.30 $1,073.80 $1,002.12 $945.58

55 to 59 $1,523.29 $1,528.37 $1,397.98 $1,331.64 $1,242.75 $1,172.63

60 to 64 $1,899.28 $1,905.61 $1,743.04 $1,660.32 $1,549.49 $1,462.07

65 plus $2,606.72 $2,615.40 $2,392.29 $2,278.76 $2,126.64 $2,006.65

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $584.79 $586.74 $536.68 $511.21 $477.09 $450.17

30 to 39 $641.00 $643.14 $588.27 $560.36 $522.95 $493.44

40 to 49 $659.62 $661.82 $605.36 $576.63 $538.14 $507.77

50 to 54 $798.33 $800.99 $732.66 $697.89 $651.31 $614.56

55 to 59 $943.98 $947.13 $866.33 $825.22 $770.13 $726.68

60 to 64 $1,178.70 $1,182.63 $1,081.74 $1,030.40 $961.62 $907.36

65 plus $1,332.74 $1,337.19 $1,223.11 $1,165.07 $1,087.30 $1,025.95

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $922.44 $925.52 $846.56 $806.39 $752.56 $710.10

30 to 39 $1,047.65 $1,051.14 $961.47 $915.84 $854.71 $806.48

40 to 49 $1,062.62 $1,066.16 $975.21 $928.93 $866.92 $818.00

50 to 54 $1,344.06 $1,348.54 $1,233.50 $1,174.96 $1,096.53 $1,034.66

55 to 59 $1,641.93 $1,647.40 $1,506.86 $1,435.35 $1,339.54 $1,263.96

60 to 64 $2,023.39 $2,030.13 $1,856.94 $1,768.82 $1,650.75 $1,557.61

65 plus $2,722.07 $2,731.14 $2,498.15 $2,379.60 $2,220.75 $2,095.45

Non-Differential

Defi nitySM HRA PPO

AgeCategory

1500/80%C3-U

2000/70%C3-S

2500/80%C3-V

3000/70%C3-T

2000/80%6H-F

EM

PLO

YE

EO

NLY

0 to 29 $291.41 $265.05 $257.21 $245.45 $683.49

30 to 39 $360.66 $328.03 $318.33 $303.77 $845.90

40 to 49 $484.31 $440.50 $427.47 $407.93 $1,135.93

50 to 54 $671.03 $610.33 $592.27 $565.19 $1,573.86

55 to 59 $830.13 $755.04 $732.70 $699.20 $1,947.03

60 to 64 $1,083.20 $985.22 $956.08 $912.37 $2,540.61

65 plus $1,275.69 $1,160.30 $1,125.98 $1,074.49 $2,992.08

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $832.19 $756.91 $734.52 $700.94 $1,951.86

30 to 39 $977.27 $888.87 $862.58 $823.14 $2,292.16

40 to 49 $1,051.88 $956.73 $928.43 $885.98 $2,467.14

50 to 54 $1,386.98 $1,261.52 $1,224.20 $1,168.23 $3,253.10

55 to 59 $1,720.02 $1,564.43 $1,518.16 $1,448.75 $4,034.23

60 to 64 $2,144.56 $1,950.57 $1,892.88 $1,806.33 $5,029.98

65 plus $2,943.36 $2,677.12 $2,597.93 $2,479.15 $6,903.54

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $660.31 $600.58 $582.82 $556.17 $1,548.73

30 to 39 $723.78 $658.31 $638.84 $609.63 $1,697.61

40 to 49 $744.81 $677.43 $657.40 $627.34 $1,746.91

50 to 54 $901.43 $819.89 $795.64 $759.26 $2,114.28

55 to 59 $1,065.89 $969.48 $940.80 $897.78 $2,500.01

60 to 64 $1,330.92 $1,210.53 $1,174.73 $1,121.02 $3,121.63

65 plus $1,504.86 $1,368.74 $1,328.25 $1,267.52 $3,529.59

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,041.57 $947.36 $919.33 $877.30 $2,442.97

30 to 39 $1,182.95 $1,075.95 $1,044.12 $996.38 $2,774.56

40 to 49 $1,199.85 $1,091.32 $1,059.04 $1,010.62 $2,814.20

50 to 54 $1,517.64 $1,380.36 $1,339.53 $1,278.28 $3,559.56

55 to 59 $1,853.98 $1,686.27 $1,636.39 $1,561.58 $4,348.43

60 to 64 $2,284.70 $2,078.04 $2,016.57 $1,924.37 $5,358.68

65 plus $3,073.61 $2,795.58 $2,712.89 $2,588.86 $7,209.03

20

Area #9 CountiesHMO products: Madera, Solano, Contra Costa, Nevada and SonomaValue Network HMO products: Not available in this areaHCP Network HMO products: Not available in this areaAll other products: San Diego #2 (ZIP Codes beginning with 919 and 920)


Choice PlusAge

Category20/250/90%

5E-A30/250/80%

5E-D30/500/80%

5E-F40/500/70%

5E-K30/1000/80%

5E-C40/1000/70%

5E-I40/1000/50%

5E-G40/1500/70%

5E-J40/2000/50%

5E-H30/2500/80%

5E-E20/3000/90%

5E-B

EM

PLO

YE

EO

NLY

0 to 29 $424.54 $384.72 $331.66 $296.52 $287.74 $249.78 $238.56 $242.60 $222.98 $243.13 $244.46

30 to 39 $525.42 $476.14 $410.47 $366.98 $356.11 $309.13 $295.25 $300.25 $275.97 $300.90 $302.55

40 to 49 $705.57 $639.39 $551.20 $492.80 $478.21 $415.12 $396.48 $403.19 $370.58 $404.07 $406.28

50 to 54 $977.58 $885.89 $763.71 $682.79 $662.58 $575.17 $549.33 $558.63 $513.45 $559.85 $562.91

55 to 59 $1,209.37 $1,095.94 $944.79 $844.68 $819.67 $711.54 $679.58 $691.08 $635.19 $692.59 $696.38

60 to 64 $1,578.06 $1,430.05 $1,232.82 $1,102.20 $1,069.56 $928.46 $886.75 $901.77 $828.84 $903.74 $908.69

65 plus $1,858.49 $1,684.17 $1,451.89 $1,298.06 $1,259.63 $1,093.45 $1,044.33 $1,062.02 $976.13 $1,064.34 $1,070.16

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $1,212.37 $1,098.66 $947.13 $846.78 $821.71 $713.30 $681.26 $692.80 $636.77 $694.31 $698.11

30 to 39 $1,423.74 $1,290.20 $1,112.26 $994.41 $964.97 $837.66 $800.04 $813.59 $747.79 $815.36 $819.82

40 to 49 $1,532.43 $1,388.69 $1,197.17 $1,070.32 $1,038.63 $901.61 $861.11 $875.69 $804.87 $877.61 $882.41

50 to 54 $2,020.62 $1,831.09 $1,578.55 $1,411.30 $1,369.51 $1,188.84 $1,135.44 $1,154.67 $1,061.28 $1,157.19 $1,163.52

55 to 59 $2,505.81 $2,270.77 $1,957.59 $1,750.18 $1,698.36 $1,474.30 $1,408.08 $1,431.92 $1,316.12 $1,435.05 $1,442.90

60 to 64 $3,124.30 $2,831.26 $2,440.77 $2,182.17 $2,117.55 $1,838.20 $1,755.63 $1,785.36 $1,640.97 $1,789.26 $1,799.05

65 plus $4,288.03 $3,885.84 $3,349.91 $2,994.98 $2,906.30 $2,522.88 $2,409.56 $2,450.36 $2,252.19 $2,455.72 $2,469.15

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $961.97 $871.74 $751.51 $671.89 $651.99 $565.98 $540.56 $549.71 $505.25 $550.91 $553.92

30 to 39 $1,054.44 $955.54 $823.76 $736.48 $714.67 $620.39 $592.52 $602.55 $553.82 $603.87 $607.17

40 to 49 $1,085.07 $983.29 $847.68 $757.87 $735.43 $638.41 $609.73 $620.05 $569.91 $621.41 $624.81

50 to 54 $1,313.25 $1,190.07 $1,025.94 $917.24 $890.08 $772.66 $737.95 $750.45 $689.76 $752.09 $756.20

55 to 59 $1,552.84 $1,407.19 $1,213.12 $1,084.58 $1,052.47 $913.62 $872.58 $887.36 $815.60 $889.30 $894.16

60 to 64 $1,938.95 $1,757.09 $1,514.75 $1,354.26 $1,314.16 $1,140.79 $1,089.55 $1,108.00 $1,018.39 $1,110.42 $1,116.49

65 plus $2,192.36 $1,986.72 $1,712.72 $1,531.25 $1,485.91 $1,289.88 $1,231.94 $1,252.80 $1,151.49 $1,255.54 $1,262.41

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,517.42 $1,375.09 $1,185.44 $1,059.84 $1,028.46 $892.78 $852.67 $867.11 $796.99 $869.01 $873.76

30 to 39 $1,723.38 $1,561.73 $1,346.34 $1,203.70 $1,168.05 $1,013.96 $968.41 $984.81 $905.17 $986.96 $992.36

40 to 49 $1,748.00 $1,584.05 $1,365.58 $1,220.89 $1,184.74 $1,028.44 $982.25 $998.88 $918.10 $1,001.06 $1,006.54

50 to 54 $2,210.97 $2,003.59 $1,727.26 $1,544.25 $1,498.53 $1,300.83 $1,242.40 $1,263.44 $1,161.26 $1,266.20 $1,273.13

55 to 59 $2,700.96 $2,447.62 $2,110.05 $1,886.49 $1,830.63 $1,589.12 $1,517.74 $1,543.44 $1,418.62 $1,546.82 $1,555.28

60 to 64 $3,328.47 $3,016.27 $2,600.27 $2,324.77 $2,255.93 $1,958.32 $1,870.35 $1,902.03 $1,748.20 $1,906.18 $1,916.61

65 plus $4,477.79 $4,057.79 $3,498.15 $3,127.51 $3,034.90 $2,634.53 $2,516.18 $2,558.80 $2,351.86 $2,564.39 $2,578.41


AgeCategory

10 - 30/100% 15 - 30/300a 20 - 40/300d 30 - 40/500d 40 - 60/800d20 -

40/1500ded40 - 60/60%

20 - 40/70%/1500ded

40 - 60/70%/2000ded

EM

PLO

YE

E O

NLY

0 to 29 $519.34 $468.50 $434.51 $410.39 $384.50 $365.15 $366.24 $339.98 $314.35

30 to 39 $603.33 $544.27 $504.78 $476.76 $446.68 $424.20 $425.47 $394.97 $365.19

40 to 49 $748.23 $674.99 $626.01 $591.26 $553.96 $526.08 $527.66 $489.82 $452.90

50 to 54 $1,016.24 $916.76 $850.24 $803.04 $752.38 $714.52 $716.66 $665.27 $615.12

55 to 59 $1,306.68 $1,178.78 $1,093.24 $1,032.55 $967.42 $918.73 $921.48 $855.41 $790.93

60 to 64 $1,658.68 $1,496.32 $1,387.74 $1,310.70 $1,228.02 $1,166.22 $1,169.71 $1,085.84 $1,003.99

65 plus $2,314.59 $2,088.02 $1,936.51 $1,829.01 $1,713.63 $1,627.39 $1,632.26 $1,515.23 $1,401.00

EM

PLO

YE

E &

S

PO

US

E

0 to 29 $1,238.72 $1,117.47 $1,036.38 $978.85 $917.10 $870.95 $873.55 $810.92 $749.79

30 to 39 $1,383.62 $1,248.19 $1,157.62 $1,093.35 $1,024.38 $972.83 $975.74 $905.78 $837.50

40 to 49 $1,651.63 $1,489.96 $1,381.84 $1,305.13 $1,222.80 $1,161.26 $1,164.74 $1,081.22 $999.72

50 to 54 $2,113.90 $1,906.98 $1,768.61 $1,670.43 $1,565.05 $1,486.29 $1,490.74 $1,383.85 $1,279.53

55 to 59 $2,685.18 $2,422.34 $2,246.57 $2,121.85 $1,988.00 $1,887.95 $1,893.60 $1,757.83 $1,625.32

60 to 64 $3,193.62 $2,881.01 $2,671.96 $2,523.62 $2,364.43 $2,245.43 $2,252.16 $2,090.68 $1,933.08

65 plus $4,150.23 $3,743.98 $3,472.31 $3,279.55 $3,072.67 $2,918.03 $2,926.77 $2,716.91 $2,512.11

EM

PLO

YE

E &

C

HIL

D(R

EN

)

0 to 29 $1,161.78 $1,048.06 $972.01 $918.05 $860.14 $816.85 $819.30 $760.55 $703.22

30 to 39 $1,294.50 $1,167.79 $1,083.05 $1,022.93 $958.40 $910.17 $912.89 $847.43 $783.55

40 to 49 $1,402.86 $1,265.54 $1,173.71 $1,108.55 $1,038.62 $986.35 $989.30 $918.37 $849.14

50 to 54 $1,631.11 $1,471.45 $1,364.68 $1,288.92 $1,207.61 $1,146.84 $1,150.27 $1,067.79 $987.30

55 to 59 $1,825.38 $1,646.70 $1,527.22 $1,442.43 $1,351.44 $1,283.43 $1,287.27 $1,194.97 $1,104.89

60 to 64 $2,238.93 $2,019.77 $1,873.21 $1,769.22 $1,657.62 $1,574.19 $1,578.91 $1,465.70 $1,355.21

65 plus $2,946.77 $2,658.33 $2,465.43 $2,328.56 $2,181.68 $2,071.88 $2,078.08 $1,929.08 $1,783.66

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $1,907.45 $1,720.74 $1,595.88 $1,507.28 $1,412.20 $1,341.13 $1,345.15 $1,248.70 $1,154.57

30 to 39 $2,103.00 $1,897.15 $1,759.49 $1,661.81 $1,556.98 $1,478.62 $1,483.05 $1,376.71 $1,272.94

40 to 49 $2,333.18 $2,104.80 $1,952.07 $1,843.70 $1,727.40 $1,640.46 $1,645.37 $1,527.40 $1,412.26

50 to 54 $2,753.78 $2,484.23 $2,303.97 $2,176.06 $2,038.79 $1,936.19 $1,941.98 $1,802.74 $1,666.85

55 to 59 $3,225.68 $2,909.93 $2,698.78 $2,548.96 $2,388.17 $2,267.97 $2,274.77 $2,111.66 $1,952.48

60 to 64 $3,797.59 $3,425.86 $3,177.27 $3,000.89 $2,811.59 $2,670.09 $2,678.08 $2,486.06 $2,298.66

65 plus $4,808.06 $4,337.42 $4,022.69 $3,799.37 $3,559.70 $3,380.55 $3,390.67 $3,147.56 $2,910.29

21


Category30/1000/80%

5E-P40/1000/70%

5E-S40/1000/50%

5E-Q40/1500/70%

5E-T40/2000/50%

5E-R

EM

PLO

YE

EO

NLY

0 to 29 $243.29 $225.22 $212.83 $215.49 $197.25

30 to 39 $301.10 $278.74 $263.40 $266.70 $244.12

40 to 49 $404.34 $374.30 $353.71 $358.13 $327.82

50 to 54 $560.22 $518.61 $490.08 $496.21 $454.21

55 to 59 $693.05 $641.57 $606.28 $613.86 $561.90

60 to 64 $904.34 $837.17 $791.11 $801.00 $733.20

65 plus $1,065.04 $985.93 $931.70 $943.34 $863.49

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $694.77 $643.17 $607.78 $615.38 $563.29

30 to 39 $815.90 $755.30 $713.75 $722.67 $661.50

40 to 49 $878.18 $812.96 $768.24 $777.84 $712.00

50 to 54 $1,157.95 $1,071.95 $1,012.97 $1,025.63 $938.82

55 to 59 $1,436.00 $1,329.34 $1,256.21 $1,271.91 $1,164.25

60 to 64 $1,790.44 $1,657.45 $1,566.27 $1,585.85 $1,451.61

65 plus $2,457.33 $2,274.82 $2,149.67 $2,176.54 $1,992.31

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $551.27 $510.33 $482.25 $488.28 $446.95

30 to 39 $604.27 $559.39 $528.61 $535.22 $489.92

40 to 49 $621.82 $575.63 $543.97 $550.76 $504.15

50 to 54 $752.58 $696.68 $658.36 $666.59 $610.16

55 to 59 $889.88 $823.79 $778.47 $788.20 $721.48

60 to 64 $1,111.15 $1,028.62 $972.03 $984.18 $900.88

65 plus $1,256.37 $1,163.05 $1,099.07 $1,112.81 $1,018.61

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $869.58 $804.99 $760.71 $770.22 $705.02

30 to 39 $987.61 $914.26 $863.96 $874.76 $800.72

40 to 49 $1,001.72 $927.32 $876.31 $887.26 $812.16

50 to 54 $1,267.04 $1,172.93 $1,108.40 $1,122.25 $1,027.26

55 to 59 $1,547.83 $1,432.87 $1,354.04 $1,370.97 $1,254.92

60 to 64 $1,907.43 $1,765.76 $1,668.62 $1,689.48 $1,546.47

65 plus $2,566.07 $2,375.48 $2,244.80 $2,272.86 $2,080.47


Z6-Q2000/100%

5E-N2000/80%

Q3-M3000/100%

5E-O3000/80%

5E-L4000/80%

5E-M

$237.92 $238.72 $218.36 $207.99 $194.11 $183.16

$294.46 $295.45 $270.25 $257.41 $240.24 $226.68

$395.41 $396.74 $362.90 $345.67 $322.60 $304.40

$547.86 $549.70 $502.81 $478.94 $446.97 $421.76

$677.75 $680.03 $622.03 $592.49 $552.95 $521.76

$884.38 $887.35 $811.67 $773.12 $721.53 $680.83

$1,041.53 $1,045.03 $955.90 $910.51 $849.75 $801.81

$679.43 $681.72 $623.58 $593.96 $554.33 $523.06

$797.89 $800.57 $732.29 $697.52 $650.97 $614.25

$858.80 $861.69 $788.20 $750.76 $700.66 $661.14

$1,132.39 $1,136.20 $1,039.29 $989.94 $923.88 $871.76

$1,404.30 $1,409.02 $1,288.85 $1,227.64 $1,145.72 $1,081.08

$1,750.92 $1,756.80 $1,606.97 $1,530.65 $1,428.51 $1,347.92

$2,403.09 $2,411.17 $2,205.53 $2,100.79 $1,960.59 $1,849.99

$539.11 $540.92 $494.78 $471.29 $439.84 $415.02

$590.93 $592.92 $542.35 $516.59 $482.12 $454.92

$608.09 $610.14 $558.10 $531.60 $496.12 $468.13

$735.97 $738.45 $675.46 $643.39 $600.45 $566.58

$870.24 $873.17 $798.70 $760.77 $710.00 $669.95

$1,086.62 $1,090.28 $997.29 $949.93 $886.54 $836.53

$1,228.64 $1,232.77 $1,127.63 $1,074.08 $1,002.40 $945.85

$850.39 $853.25 $780.47 $743.41 $693.80 $654.66

$965.81 $969.06 $886.41 $844.32 $787.97 $743.52

$979.61 $982.91 $899.07 $856.38 $799.23 $754.14

$1,239.07 $1,243.23 $1,137.20 $1,083.20 $1,010.91 $953.88

$1,513.67 $1,518.76 $1,389.23 $1,323.25 $1,234.95 $1,165.28

$1,865.33 $1,871.61 $1,711.98 $1,630.68 $1,521.86 $1,436.01

$2,509.43 $2,517.87 $2,303.13 $2,193.75 $2,047.35 $1,931.86


PPO

AgeCategory

1500/80%C3-U

2000/70%C3-S

2500/80%C3-V

3000/70%C3-T

2000/80%6H-F

EM

PLO

YE

EO

NLY

0 to 29 $268.65 $244.36 $237.13 $226.28 $683.49

30 to 39 $332.49 $302.43 $293.48 $280.05 $845.90

40 to 49 $446.48 $406.11 $394.10 $376.07 $1,135.93

50 to 54 $618.62 $562.68 $546.04 $521.05 $1,573.86

55 to 59 $765.29 $696.10 $675.50 $644.59 $1,947.03

60 to 64 $998.60 $908.31 $881.44 $841.11 $2,540.61

65 plus $1,176.06 $1,069.72 $1,038.07 $990.58 $2,992.08

EM

PLO

YE

E &

SP

OU

SE 0 to 29 $767.19 $697.83 $677.18 $646.19 $1,951.86

30 to 39 $900.95 $819.49 $795.24 $758.85 $2,292.16

40 to 49 $969.72 $882.05 $855.95 $816.78 $2,467.14

50 to 54 $1,278.65 $1,163.04 $1,128.63 $1,076.99 $3,253.10

55 to 59 $1,585.68 $1,442.31 $1,399.64 $1,335.60 $4,034.23

60 to 64 $1,977.07 $1,798.31 $1,745.10 $1,665.25 $5,029.98

65 plus $2,713.48 $2,468.14 $2,395.11 $2,285.52 $6,903.54

EM

PLO

YE

E&

CH

ILD

(RE

N)

0 to 29 $608.74 $553.70 $537.32 $512.73 $1,548.73

30 to 39 $667.26 $606.93 $588.97 $562.02 $1,697.61

40 to 49 $686.63 $624.55 $606.07 $578.34 $1,746.91

50 to 54 $831.03 $755.89 $733.53 $699.96 $2,114.28

55 to 59 $982.64 $893.80 $867.35 $827.67 $2,500.01

60 to 64 $1,226.97 $1,116.04 $1,083.02 $1,033.46 $3,121.63

65 plus $1,387.33 $1,261.89 $1,224.56 $1,168.53 $3,529.59

EM

PLY

/SP

/CH

(S)

FAM

ILY

0 to 29 $960.22 $873.41 $847.56 $808.78 $2,442.97

30 to 39 $1,090.56 $991.96 $962.61 $918.56 $2,774.56

40 to 49 $1,106.14 $1,006.13 $976.36 $931.68 $2,814.20

50 to 54 $1,399.11 $1,272.61 $1,234.95 $1,178.45 $3,559.56

55 to 59 $1,709.18 $1,554.64 $1,508.64 $1,439.61 $4,348.43

60 to 64 $2,106.26 $1,915.82 $1,859.14 $1,774.07 $5,358.68

65 plus $2,833.55 $2,577.36 $2,501.10 $2,386.66 $7,209.03

Chiropractic and Acupuncture Rates

22

23

$10/30

Employee Only $3.64

Employee & Spouse $7.28

Employee & Child(ren) $9.10

Employee & Spouse & Child(ren) $14.56

Supplemental chiropractic/acupuncture coverage available with Pacifi Care’s HMO plans through an arrangement with ACN Group® of California, Inc.

Chiropractic and Acupuncture Rates

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Note: Health Savings Accounts are offered by OptumHealth Bank, Member FDIC, and are subject to eligibility. Please contact a competent legal or tax professional for personal advice on eligibility, tax treatment and restrictions. Federal and state regulations are subject to change.

Health plan coverage provided by or through UnitedHealthcare Insurance Company and Pacifi Care of California. Administrative services provided by United HealthCare Insurance Company, United HealthCare Services, Inc., Pacifi Care Health Plan Administrators, Inc., Prescription Solutions, Ingenix, Inc. or ACN Group. Behavioral health products are provided by Pacifi Care Behavioral Health of California (PBHC), Pacifi Care Behavioral Health, Inc. (PBHI) or United Behavioral Health (UBH).

The Defi nitySM Health Savings Account (HSA) high deductible health plan (HDHP) is designed to comply with IRS requirements so eligible enrollees may open a Health Savings Account with a bank of their choice or through OptumHealth Bank, Member of FDIC. Defi nitySM HSA product, which includes a HDHP, although at times “Defi nity HSA” may refer only and specifi cally to the Defi nity Health Savings Account, provided in conjunction with OptumHealth Bank and not to the associated HDHP.

UnitedHealthcare's Defi nitySM Health Reimbursement Account, or HRA, combines the fl exibility of a medical benefi t plan with an employer-funded account.

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Effective 5/1/2010 - Rogers Benefit Group · and San Mateo Value Network HMO products: San...

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Transcript of Effective 5/1/2010 - Rogers Benefit Group · and San Mateo Value Network HMO products: San...