Small Business Rate Tables - Blue Shield of California · 0-29 $ .19 30-34 .20 35-39 .21 60-64 2.25...

blueshieldca.com

Small Business Rate TablesIncludes rates for standard plans

Effective October 2017

Rate Book 9Rating region 9: Santa Cruz, Monterey, San Benito

AMADOR

DELNORTE

TRINITYHUMBOLDT

PLUMAS

SIERRA

NEVADA

PLACER

TEHAMA

COLUSA

SUTTER

YUBA

SACRA-MENTO

YOLO

LAKE

BUTTEGLENN

MENDOCINO

SONOMA

MARIN

EL DORADO

ALPINENAPA

SOLANO

CONTRA-COSTA

SAN JOAQUIN

STANISLAUS

MERCED

FRESNO

MADERA

MARIPOSA

MONO

INYO

TULARE

KINGS

SAN BERNARDINO

KERN

LOS ANGELESVENTURA

SANTA BARBARA

SAN LUIS OBISPO

MONTEREY

SAN BENITO

ORANGE RIVERSIDE

SAN DIEGO

IMPERIAL

TUOLUMNE

ALAMEDA

MODOCSISKIYOU

SHASTA LASSEN

AMADOR

CALAVER

AS

SANTACLARA

SAN FRANCISCO

SAN MATEO

SANTA CRUZ

1 Counties where Full network HMO is available. 2 Counties where Dental HMO is available.

Blue Shield of California county grouping for Rate Book 9Region 9 – Monterey Bay: Santa Cruz,1,2 Monterey,1,2 San Benito1,2

CONTENTSLife Insurance Rates

Small Business Rate Tables

Small Business Rates:

Regional Groupings

Region 9

..................................................................

..................................................................23

.................................................................. 6

Region 1 - 19Life Insurance Rates

Age Rate/$1,000

*Includes $.05 Accidental Death & Dismemberment Insurance

Dependent Life Insurance Rates for 2-9 eligible employees are $.45/$1,000.

Benefits Allowed for new groups of 2 to 100 eligible employees:Flat, Graded, or Salaried Plans

2

40-44 .3345-49 .4650-54 .7455-59 1.15

0-29 $ .1930-34 .2035-39 .21

60-64 2.2565-69¹ 3.7570-74² 5.3375-79² 8.3980-84² 12.0585+² 18.04

Life Insurance Rates forBlue Shield of California Group Plans

2-9 Eligible Employee Rate TableEffective October 2017

Basic group term life and AD&D insurance is underwritten by Blue Shield of CaliforniaLife & Health Insurance Company.

Groups with 10 to 100 eligible employees will be composite rated.Contact your Blue Shield sales representative for a quote.

¹Benefit amount is reduced by 35% of the original amount at age 65.²Benefit amount is reduced by 50% of the original amount at age 70.

2

SMALL BUSINESS OFF EXCHANGE RATING REGION DEFINITIONS AND ACCESS+ HMO® & INO AVAILABILITY


RatingRegion County

Access+HMO®Network

Availability

DentalHMO

Availability

DentalINO

Availability

RatingRegion County

Access+HMO®Network

Availability

DentalHMO

Availability

DentalINO

Availability

1 Alpine 8 San Mateo

Amador

Butte 9 Monterey

Calaveras San Benito

Colusa Santa Cruz

Del NorteGlenn 10 Mariposa

Humboldt Merced

Lake San Joaquin

Lassen Stanislaus

Mendocino Tulare

Modoc

Nevada 11 Fresno

Plumas Kings

Shasta Madera

SierraSiskiyou 12 San Luis Obispo

Sutter Santa Barbara

Tehama Ventura

Trinity

Tuolumne 13 Imperial

Yuba Inyo

Mono2 Marin

Napa 14 Kern

Solano

Sonoma 15 Los Angeles ZIP Codes*

3 El Dorado 16 Los Angeles - Except

Placer ZIP Codes in Region 15Sacramento

Yolo 17 Riverside

San Bernardino

4 San Francisco

18 Orange

5 Contra Costa

19 San Diego

6 Alameda

7 Santa Clara

* Los Angeles Region 15 ZIP Codes: 90601-90610, 90612, 90637-90639, 90640, 90650-90652, 90659-90662, 90665, 90670-90671, 90701-90704, 90706-90707, 90710-90717, 90723, 90731-90734, 90744-90749, 90755, 90800-90810, 90813-90815, 90822, 90831-90835, 90840, 90842, 90844-90848, 90853, 90888, 90895, 90899, 91001-91003, 91006-91012, 91016-91017, 91020-91021, 91023-91025, 91030-91031, 91040-91043, 91046, 91050-91051, 91066, 91077, 91100-91110, 91114-91118, 91121, 91123-91126, 91129, 91131, 91175, 91182, 91184-91189, 91191, 91199-91210, 91214, 91221-91222, 91224-91226, 91500-91508, 91510, 91521-91523, 91526, 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, 91799-91804, 91841, 91896, 91899, 93510, 93532, 93534-93536, 93539, 93543-93544, 93550-93553, 93563, 93584, 93586, 93590-93591, 93599.

33

SMALL BUSINESS OFF EXCHANGE LOCAL ACCESS+ HMO® NETWORK RATING REGION DEFINITIONS AND AVAILABILITY


RatingRegion County Rating

Region County

1 None. 15 Los Angeles zip codes: 90601-90610, 90637-90640,90650-90652, 90660-90662, 90670-90671, 90701-90703,

2 Marin, Sonoma. 90706-90707, 90710-90717, 90723, 90731-90734, 90744-90749, 90755, 90801-90810, 90813-90815, 90822, 90831-90835, 90840,

3 Sacramento except zip codes: 95632, 95638-95639, 95641, 90842, 90844, 90846-90848, 90853, 90895, 90899, 91001, 95671, 95680, 95683, 95690, 95693, 95798, 95799. 91006-91012, 91016-91017, 91020-91021, 91023-91025,

91030-91031, 91040-91043, 91046, 91066, 91077, 91101-91110, Yolo. 91114-91118, 91121, 91123-91126, 91129, 91182, 91184-91185,

91188-91189, 91199, 91201-91210, 91214, 91221-91222, 4 San Francisco. 91224-91226, 91501-91508, 91510, 91521-91523, 91526, 91702,

91706, 91711, 91714-91716, 91722-91724, 91731-91735, 5 Contra Costa except zip codes: 94525, 94530, 94547, 94551, 91740-91741, 91744-91750, 91754-91756, 91765-91773,

94564, 94569, 94572, 94801-94808, 94820, 94850. 91775-91776, 91778, 91780, 91788-91793, 91795, 91797, 91801-91804, 91896, 91899, 93563.

6 None.16 Los Angeles except zip codes in Rating Region 15 and except

7 Santa Clara. zip codes: 90704, 93510, 93532, 93534-93536, 93539, 93543-93544, 93550-93553, 93584, 93586, 93590-93591, 93599.

8 San Mateo except zip codes: 94018-94021, 94028, 94037-94038,94060, 94074. 17 Riverside except zip codes: 92225-92226, 92239, 92275, 92539.

9 Santa Cruz. San Bernardino except zip codes: 91759, 92242, 92252, 92256,92267-92268, 92277-92278, 92280, 92284-92286, 92304-92305,

10 Stanislaus. 92309-92310, 92314-92315, 92317, 92321-92323, 92325-92327, 92332-92333, 92338, 92341-92342, 92347, 92352, 92356, 92358,

11 None. 92363-92366, 92368, 92372, 92378, 92382, 92385-92386, 92391, 92395, 92397-92398, 92407, 93562, 93592.

12 San Luis Obispo. 18 Orange.

Ventura except zip codes: 00061, 93013. 93225, 93252.19 San Diego except zip codes: 91905-91906, 91934, 91963, 91980,

13 None. 91987, 92004, 92036, 92066, 92086.

14 Kern except zip codes: 93205-93206, 93220, 93222,93224-93226, 93238, 93240, 93243, 93249, 93251-93252, 93255, 93268, 93283, 93285, 93287, 93501-93502, 93504-93505, 93516, 93518-93519, 93524, 93555, 93558, 93560, 93596.

44

SMALL BUSINESS OFF EXCHANGE AND MIRROR ACO HMO NETWORK RATING REGION DEFINITIONS AND AVAILABILITY


RatingRegion County Rating

Region County

1 Nevada zip codes: 95712, 95924, 95945-95946, 95949, 95959-95960, 14 Kern zip codes: 93203, 93205-93206, 93215-93216, 93220, 93224-93226, 95975, 95986. 93240-93241, 93250-93252, 93255, 93263, 93268, 93276, 93280, 93283,

93285, 93287, 93301-93309, 93311-93314, 93380, 93383-93390,2 Solano zip codes: 94503, 94510, 94589, 94592, 95620. 93501-93502, 93504-93505, 93516, 93518, 93531, 93560-93561, 93596.

3 El Dorado zip codes: 95664, 95672, 95682, 95762.15 Los Angeles zip codes: 90601-90610, 90637-90640, 90650-90652,

Placer zip codes: 95602-95604, 95648, 95650, 95658, 95661, 95663, 90660-90662, 90670, 90701-90703, 90706-90707, 90710-90717,95677-95678, 95713, 95746-95747, 95765. 90723, 90731-90734, 90744-90749, 90755, 90801-90810, 90813-90815,

90822, 90831-90835, 90840, 90842, 90844, 90846-90848, 90853, 90895,Sacramento zip codes: 94203-94206, 92409, 94229-94230, 94232, 90899, 91001, 91003, 91006-91012, 91016-91017, 91020-91025, 94235-94237, 94239-94240, 94244, 94247-94250, 94252, 94254, 91030-91031, 91040-91043, 91046, 91066, 91077, 91101-91110,94256-94259, 94261-94263, 94267-94269, 94271, 94273-94274, 91114-91118, 91121, 91123-91126, 91129, 91182, 91184-91185,94277-94280, 94283-94290, 94293, 94298, 95608-95611, 95615, 95621, 91188-91189, 91199, 91201-90210, 91214, 91221-91222, 91224-91226,95624, 95626, 95628, 95630, 95632, 95638-95639, 95652, 95655, 95660, 91501-91508, 91510, 91521-91523, 91702, 91706, 91711, 91715-91716, 95662, 95670-95671, 95673, 95683, 95693, 95741-95742, 95757-95759, 91722-91724, 91731-91735, 91740-91741, 91744-91750, 91754-91756, 95763, 95812-95838, 95840-95843, 95851-95853, 95860, 95864-95867, 91765-91773, 91775-91776, 91778, 91780, 91788-91793, 91801-91803, 95894, 95899. 91899, 93510, 93563.

Yolo zip codes: 95605-95607, 95612, 95616-95618, 95627, 95637, 95645, 16 Los Angeles zip codes: 90001-90084, 90086-90091, 90093-90096, 95653, 95691, 95694-95695, 95697-95698, 95776, 95798-95799, 95937. 90189, 90201-90202, 90209-90213, 90220-90224, 90230-90232,

90239-90242, 90245, 90247-90251, 90254-90255, 90260-90267, 90270, 4 San Francisco. 90272, 90274-90275, 90277-90278, 90280, 90290-90296, 90301-90312,

90401-90411, 90501-90510, 91301-91311, 91313, 91316, 91321-91322,5 Contra Costa zip codes: 94506-94507, 94509, 94511, 94513-94514, 91324-91331, 91333-91335, 91337, 91340-91346, 91350-91357,

94516-94529, 94531, 94548-94549, 94553, 94556, 94561, 94563-94565, 91364-91365, 91367, 91371-91372, 91376, 91380-91381, 91383-91387,94570, 94575, 94582-94583, 94595-94598. 91390, 91392-91396, 91401-91413, 91416, 91423, 91426, 91436, 91470,

91482, 91495-91496, 91499, 91601-91612, 91614-91617.6 Alameda zip codes: 94550-94551, 94566, 94568, 94588.

17 Riverside zip codes: 91752, 92220, 92223, 92230, 92320, 92501-92509, 7 Santa Clara. 92513-92514, 92516-92519, 92521-92522, 92530-92532, 92543-92546,

92548, 92551-92557, 92562-92564, 92567, 92570-92572, 92581-92587, 8 San Mateo. 92589-92593, 92595-92596, 92599, 92860, 92877-92883.

9 Santa Cruz. San Bernardino zip codes: 91701, 91708-91710, 91729-91730, 91737,91739, 91743, 91758, 91761-91764, 91784-91786, 92301, 92305,

10 San Joaquin. 92307-92308, 92313-92318, 92321-92322, 92324-92325, 92329,92331, 92333-92337, 92339-92342, 92344-92346, 92350, 92352,

Stanislaus zip codes: 95307, 95313, 95316, 95319, 95323, 95326, 92354, 92356-92359, 92368-92369, 92371-92378, 92382, 92385-92386, 95328-95329, 95350-95358, 95361, 95363, 95367-95368, 95380-95382, 92391-92395, 92397, 92399, 92401-92408, 92410-92411, 92413, 92415, 95386-95387, 95397. 92418, 92423, 92427.

Tulare zip codes: 93219, 93256, 93260. 18 Orange.

11 None. 19 San Diego zip codes: 91901-91903, 91905-91906, 91908-91917,91921, 91931-91933, 91935, 91941-91946, 91948, 91950-91951,

12 Ventura zip codes: 91319-91320, 91358-91362, 91377, 93010-93012, 91962-91963, 91976-91980, 91987, 92003, 92007-92011, 92013-92014, 93015-93016, 93020-93021, 93040, 93062-93066, 93094, 93099. 92018-92030, 92033, 92036-92040, 92046, 92049, 92051-92052,

92054-92061, 92064-92065, 92067-92069, 92071-92072, 92074-92075,13 None. 92078-92079, 92081-92085, 92088, 92091-92093, 92096, 92101-92124,

92126-92132, 92134-92140, 92142-92143, 92145, 92147, 92149-92150,92152-92155, 92158-92161, 92163, 92165-92179, 92182, 92186-92187, 92190-92193, 92195-92199.

55

Blue Shield Bronze 60 PPO 6300/75 + Child DentalRegion-9

AgeMember

RateAge

Member

Rate

228.930-20

360.5321

360.5322

360.5323

360.5324

361.9725

369.1826

377.8327

391.8928

403.4329

409.2030

417.8531

426.5032

431.9133

437.6834

440.5635

443.4536

446.3337

449.2238

454.9939

460.7540

469.4141

477.7042

489.2443

503.6644

520.6045

540.7946

563.5047

589.4648

615.0649

643.9050

672.3851

703.7552

735.4853

769.7354

803.9855

841.1156

878.6057

918.6258

938.4559

978.4760

1,013.0861

1,035.7962

1,064.2863

1,081.5864

1,081.5865 & over

9-105/16/2017

Regions may vary by product. The Small Business Off Exchange Rating Region Definitions chart located near the front of this booklet identifies the counties

located in each region.

05/16/2017 6

Bronze Full PPO 5100/60 OffExRegion-9

AgeMember

RateAge

Member

Rate

261.010-20

411.0421

411.0422

411.0423

411.0424

412.6825

420.9026

430.7727

446.8028

459.9529

466.5330

476.3931

486.2632

492.4233

499.0034

502.2935

505.5836

508.8737

512.1538

518.7339

525.3140

535.1741

544.6342

557.7843

574.2244

593.5445

616.5646

642.4547

672.0548

701.2349

734.1150

766.5951

802.3552

838.5253

877.5754

916.6255

958.9556

1,001.7057

1,047.3358

1,069.9359

1,115.5660

1,155.0261

1,180.9162

1,213.3963

1,233.1164

1,233.1165 & over

9-305/16/2017



05/16/2017 7

Bronze Full PPO 3750/65 OffExRegion-9

AgeMember

RateAge

Member

Rate

258.460-20

407.0221

407.0222

407.0223

407.0224

408.6525

416.7926

426.5627

442.4328

455.4629

461.9730

471.7431

481.5132

487.6133

494.1334

497.3835

500.6436

503.9037

507.1538

513.6639

520.1840

529.9441

539.3142

552.3343

568.6144

587.7445

610.5446

636.1847

665.4848

694.3849

726.9450

759.1051

794.5152

830.3353

869.0054

907.6655

949.5956

991.9257

1,037.1058

1,059.4859

1,104.6660

1,143.7461

1,169.3862

1,201.5363

1,221.0764

1,221.0765 & over

9-405/16/2017



05/16/2017 8

Blue Shield Silver 70 PPO 2000/45 + Child DentalRegion-9

AgeMember

RateAge

Member

Rate

299.380-20

471.4721

471.4722

471.4723

471.4724

473.3625

482.7926

494.1027

512.4928

527.5829

535.1230

546.4331

557.7532

564.8233

572.3734

576.1435

579.9136

583.6837

587.4538

595.0039

602.5440

613.8641

624.7042

639.7943

658.6444

680.8045

707.2146

736.9147

770.8548

804.3349

842.0550

879.2951

920.3152

961.8053

1,006.5954

1,051.3855

1,099.9456

1,148.9757

1,201.3158

1,227.2459

1,279.5760

1,324.8361

1,354.5462

1,391.7863

1,414.4164

1,414.4165 & over

9-505/16/2017



05/16/2017 9

Silver Full PPO 1700/40 OffExRegion-9

AgeMember

RateAge

Member

Rate

286.210-20

450.7221

450.7222

450.7223

450.7224

452.5325

461.5426

472.3627

489.9428

504.3629

511.5730

522.3931

533.2132

539.9733

547.1834

550.7935

554.3936

558.0037

561.6038

568.8139

576.0340

586.8441

597.2142

611.6343

629.6644

650.8545

676.0946

704.4847

736.9348

768.9449

804.9950

840.6051

879.8152

919.4853

962.3054

1,005.1255

1,051.5456

1,098.4257

1,148.4558

1,173.2459

1,223.2760

1,266.5461

1,294.9362

1,330.5463

1,352.1764

1,352.1765 & over

9-705/16/2017



05/16/2017 10

Silver Full PPO 1300/45 OffExRegion-9

AgeMember

RateAge

Member

Rate

285.540-20

449.6721

449.6722

449.6723

449.6724

451.4725

460.4726

471.2627

488.7928

503.1829

510.3830

521.1731

531.9632

538.7133

545.9034

549.5035

553.1036

556.7037

560.2938

567.4939

574.6840

585.4741

595.8242

610.2143

628.1944

649.3345

674.5146

702.8447

735.2248

767.1449

803.1250

838.6451

877.7652

917.3353

960.0554

1,002.7755

1,049.0956

1,095.8557

1,145.7758

1,170.5059

1,220.4160

1,263.5861

1,291.9162

1,327.4463

1,349.0264

1,349.0265 & over

9-805/16/2017



05/16/2017 11

Gold Full PPO 1000/35 OffExRegion-9

AgeMember

RateAge

Member

Rate

314.620-20

495.4721

495.4722

495.4723

495.4724

497.4525

507.3626

519.2527

538.5728

554.4329

562.3530

574.2431

586.1432

593.5733

601.5034

605.4635

609.4236

613.3937

617.3538

625.2839

633.2140

645.1041

656.4942

672.3543

692.1744

715.4545

743.2046

774.4147

810.0948

845.2649

884.9050

924.0451

967.1552

1,010.7553

1,057.8254

1,104.8955

1,155.9256

1,207.4557

1,262.4558

1,289.7059

1,344.6960

1,392.2661

1,423.4762

1,462.6163

1,486.4064

1,486.4065 & over

9-905/16/2017



05/16/2017 12


AgeMember

RateAge

Member

Rate

326.300-20

513.8521

513.8522

513.8523

513.8524

515.9125

526.1826

538.5227

558.5628

575.0029

583.2230

595.5531

607.8932

615.5933

623.8234

627.9335

632.0436

636.1537

640.2638

648.4839

656.7040

669.0441

680.8542

697.3043

717.8544

742.0045

770.7846

803.1547

840.1548

876.6349

917.7450

958.3351

1,003.0452

1,048.2653

1,097.0754

1,145.8955

1,198.8256

1,252.2657

1,309.2958

1,337.5659

1,394.5960

1,443.9261

1,476.3062

1,516.8963

1,541.5664

1,541.5665 & over

9-1005/16/2017



05/16/2017 13


AgeMember

RateAge

Member

Rate

336.120-20

529.3221

529.3222

529.3223

529.3224

531.4425

542.0226

554.7327

575.3728

592.3129

600.7830

613.4831

626.1832

634.1233

642.5934

646.8335

651.0636

655.3037

659.5338

668.0039

676.4740

689.1741

701.3542

718.2843

739.4644

764.3445

793.9846

827.3247

865.4348

903.0249

945.3650

987.1851

1,033.2352

1,079.8153

1,130.0954

1,180.3855

1,234.9056

1,289.9557

1,348.7058

1,377.8159

1,436.5760

1,487.3861

1,520.7362

1,562.5563

1,587.9564

1,587.9565 & over

9-1105/16/2017



05/16/2017 14

Blue Shield Gold 80 PPO 0/30 + Child DentalRegion-9

AgeMember

RateAge

Member

Rate

348.770-20

549.2521

549.2522

549.2523

549.2524

551.4525

562.4326

575.6227

597.0428

614.6129

623.4030

636.5831

649.7632

658.0033

666.7934

671.1935

675.5836

679.9737

684.3738

693.1639

701.9440

715.1341

727.7642

745.3343

767.3044

793.1245

823.8846

858.4847

898.0348

937.0249

980.9650

1,024.3551

1,072.1452

1,120.4753

1,172.6554

1,224.8355

1,281.4056

1,338.5357

1,399.4958

1,429.7059

1,490.6760

1,543.4061

1,578.0062

1,621.3963

1,647.7564

1,647.7565 & over

9-1205/16/2017



05/16/2017 15


AgeMember

RateAge

Member

Rate

333.090-20

524.5521

524.5522

524.5523

524.5524

526.6425

537.1326

549.7227

570.1828

586.9729

595.3630

607.9531

620.5432

628.4133

636.8034

640.9935

645.1936

649.3937

653.5838

661.9839

670.3740

682.9641

695.0242

711.8143

732.7944

757.4445

786.8246

819.8647

857.6348

894.8749

936.8450

978.2851

1,023.9152

1,070.0753

1,119.9054

1,169.7455

1,223.7656

1,278.3257

1,336.5458

1,365.3959

1,423.6260

1,473.9761

1,507.0262

1,548.4663

1,573.6464

1,573.6465 & over

9-1405/16/2017



05/16/2017 16

Platinum Full PPO 150/15 OffExRegion-9

AgeMember

RateAge

Member

Rate

385.550-20

607.1621

607.1622

607.1623

607.1624

609.5925

621.7326

636.3027

659.9828

679.4129

689.1230

703.7031

718.2732

727.3833

737.0934

741.9535

746.8036

751.6637

756.5238

766.2339

775.9540

790.5241

804.4842

823.9143

848.2044

876.7445

910.7446

948.9947

992.7048

1,035.8149

1,084.3850

1,132.3551

1,185.1752

1,238.6053

1,296.2854

1,353.9655

1,416.5056

1,479.6457

1,547.0458

1,580.4359

1,647.8360

1,706.1161

1,744.3762

1,792.3363

1,821.4764

1,821.4765 & over

9-1505/16/2017



05/16/2017 17

Blue Shield Platinum 90 PPO 0/15 + Child DentalRegion-9

AgeMember

RateAge

Member

Rate

390.650-20

615.2021

615.2022

615.2023

615.2024

617.6625

629.9726

644.7327

668.7228

688.4129

698.2530

713.0231

727.7832

737.0133

746.8534

751.7835

756.7036

761.6237

766.5438

776.3839

786.2340

800.9941

815.1442

834.8343

859.4444

888.3545

922.8046

961.5647

1,005.8548

1,049.5349

1,098.7550

1,147.3551

1,200.8752

1,255.0153

1,313.4654

1,371.9055

1,435.2656

1,499.2557

1,567.5358

1,601.3759

1,669.6660

1,728.7261

1,767.4762

1,816.0763

1,845.6064

1,845.6065 & over

9-1605/16/2017



05/16/2017 18

Platinum Full PPO 0/10 OffExRegion-9

AgeMember

RateAge

Member

Rate

400.370-20

630.5021

630.5022

630.5023

630.5024

633.0325

645.6426

660.7727

685.3628

705.5329

715.6230

730.7531

745.8932

755.3433

765.4334

770.4835

775.5236

780.5637

785.6138

795.7039

805.7840

820.9241

835.4242

855.5943

880.8144

910.4545

945.7646

985.4847

1,030.8748

1,075.6449

1,126.0850

1,175.8951

1,230.7452

1,286.2353

1,346.1354

1,406.0255

1,470.9756

1,536.5457

1,606.5258

1,641.2059

1,711.1960

1,771.7261

1,811.4462

1,861.2563

1,891.5164

1,891.5165 & over

9-1805/16/2017



05/16/2017 19

Bronze Full PPO Savings 5500/40% OffExRegion-9

AgeMember

RateAge

Member

Rate

243.160-20

382.9321

382.9322

382.9323

382.9324

384.4625

392.1226

401.3127

416.2528

428.5029

434.6330

443.8231

453.0132

458.7533

464.8834

467.9435

471.0136

474.0737

477.1338

483.2639

489.3940

498.5841

507.3942

519.6443

534.9644

552.9545

574.4046

598.5247

626.0948

653.2849

683.9250

714.1751

747.4852

781.1853

817.5654

853.9455

893.3856

933.2157

975.7158

996.7759

1,039.2860

1,076.0461

1,100.1762

1,130.4263

1,148.8064

1,148.8065 & over

9-1905/16/2017



05/16/2017 20

Bronze Full PPO Savings 4700/40% OffExRegion-9

AgeMember

RateAge

Member

Rate

245.830-20

387.1321

387.1322

387.1323

387.1324

388.6825

396.4226

405.7127

420.8128

433.2029

439.3930

448.6831

457.9832

463.7833

469.9834

473.0735

476.1736

479.2737

482.3638

488.5639

494.7540

504.0441

512.9542

525.3443

540.8244

559.0245

580.7046

605.0947

632.9648

660.4449

691.4250

722.0051

755.6852

789.7553

826.5254

863.3055

903.1856

943.4457

986.4158

1,007.7059

1,050.6760

1,087.8461

1,112.2362

1,142.8163

1,161.3964

1,161.3965 & over

9-2005/16/2017



05/16/2017 21

Region-9Silver Full PPO Savings 2000/20% OffEx

AgeMember

RateAge

Member

Rate

304.820-20

480.0321

480.0322

480.0323

480.0324

481.9525

491.5526

503.0827

521.8028

537.1629

544.8430

556.3631

567.8832

575.0833

582.7634

586.6035

590.4436

594.2837

598.1238

605.8039

613.4840

625.0041

636.0542

651.4143

670.6144

693.1745

720.0546

750.2947

784.8648

818.9449

857.3450

895.2651

937.0352

979.2753

1,024.8754

1,070.4855

1,119.9256

1,169.8457

1,223.1358

1,249.5359

1,302.8160

1,348.9061

1,379.1462

1,417.0663

1,440.1064

1,440.1065 & over

9-2105/16/2017



05/16/2017 22

Blue Shield Silver 70 HMO 2000/45 + Child Dental INF*Region-9

AgeMember

RateAge

Member

Rate

199.230-20

313.7521

313.7522

313.7523

313.7524

315.0125

321.2826

328.8127

341.0528

351.0929

356.1130

363.6431

371.1732

375.8733

380.8934

383.4035

385.9136

388.4237

390.9338

395.9539

400.9740

408.5041

415.7242

425.7643

438.3144

453.0645

470.6346

490.3947

512.9848

535.2649

560.3650

585.1451

612.4452

640.0553

669.8654

699.6655

731.9856

764.6157

799.4458

816.6959

851.5260

881.6461

901.4062

926.1963

941.2564

941.2565 & over

9-2205/16/2017

*Enrolled employees and their dependents must live or work in the Trio ACO HMO plan service area to be eligible for coverage. Regions may vary by product.

The Small Business Off Exchange Rating Region Definitions chart located near the front of this booklet identifies the counties located in each region.

05/16/2017 23

Silver Access+ HMO® 1700/55 OffEx*Region-9

AgeMember

RateAge

Member

Rate

259.810-20

409.1521

409.1522

409.1523

409.1524

410.7925

418.9726

428.7927

444.7428

457.8429

464.3830

474.2031

484.0232

490.1633

496.7134

499.9835

503.2536

506.5337

509.8038

516.3539

522.8940

532.7141

542.1242

555.2143

571.5844

590.8145

613.7246

639.5047

668.9648

698.0149

730.7450

763.0651

798.6652

834.6653

873.5354

912.4055

954.5456

997.1057

1,042.5158

1,065.0159

1,110.4360

1,149.7161

1,175.4862

1,207.8163

1,227.4564

1,227.4565 & over

9-2405/16/2017

*The employer must be located in, and all enrolled employees and family members must live or work in, the Blue Shield of California Access+ HMO® service

area in order to be eligible to purchase. Regions may vary by product. The Small Business Off Exchange Rating Region Definitions chart located near the front

of this booklet identifies the counties located in each region.

05/16/2017 2405/16/2017 24

Silver Local Access+ HMO® 1700/55 OffEx*Region-9

AgeMember

RateAge

Member

Rate

246.450-20

388.1121

388.1122

388.1123

388.1124

389.6625

397.4226

406.7427

421.8728

434.2929

440.5030

449.8231

459.1332

464.9533

471.1634

474.2735

477.3736

480.4837

483.5838

489.7939

496.0040

505.3241

514.2442

526.6643

542.1944

560.4345

582.1646

606.6147

634.5648

662.1149

693.1650

723.8251

757.5952

791.7453

828.6154

865.4855

905.4656

945.8257

988.9058

1,010.2559

1,053.3360

1,090.5961

1,115.0462

1,145.7063

1,164.3364

1,164.3365 & over

9-2505/16/2017

*Local Access+ HMO plans are only available to employers that are located in a Local Access+ HMO service area. Employees and their dependents must live or work in the service area to be eligible for coverage. Local Access+ HMO products are only available in designated counties: portions of Contra Costa, Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Mateo, and Ventura counties, as well as in all of Marin, Orange, San Francisco, San Luis Obispo, Santa Clara, Santa Cruz, Sonoma, Stanislaus, and Yolo counties. Please review the Benefit Summary Guide (A16609) for detailed information regarding the Local Access+HMO service area. Regions may vary by product. The Small Business Off Exchange Rating Region Definitions chart located near the front of this booklet identifies the counties located in each region.

05/16/2017 25

Silver Trio ACO HMO 1700/55 OffEx*Region-9

AgeMember

RateAge

Member

Rate

188.370-20

296.6421

296.6422

296.6423

296.6424

297.8325

303.7626

310.8827

322.4528

331.9429

336.6930

343.8131

350.9332

355.3833

360.1334

362.5035

364.8736

367.2537

369.6238

374.3639

379.1140

386.2341

393.0542

402.5543

414.4144

428.3545

444.9746

463.6547

485.0148

506.0749

529.8150

553.2451

579.0552

605.1553

633.3454

661.5255

692.0756

722.9257

755.8558

772.1659

805.0960

833.5761

852.2662

875.6963

889.9364

889.9365 & over

9-2605/16/2017



05/16/2017 26

Gold Access+ HMO® 1700/30 OffEx*Region-9

AgeMember

RateAge

Member

Rate

289.120-20

455.3021

455.3022

455.3023

455.3024

457.1225

466.2326

477.1527

494.9128

509.4829

516.7730

527.6931

538.6232

545.4533

552.7334

556.3835

560.0236

563.6637

567.3038

574.5939

581.8740

592.8041

603.2742

617.8443

636.0544

657.4545

682.9546

711.6347

744.4148

776.7449

813.1750

849.1351

888.7452

928.8153

972.0654

1,015.3255

1,062.2156

1,109.5757

1,160.1058

1,185.1459

1,235.6860

1,279.3961

1,308.0862

1,344.0463

1,365.9064

1,365.9065 & over

9-2705/16/2017




05/16/2017 27

Gold Local Access+ HMO® 1700/30 OffEx*Region-9

AgeMember

RateAge

Member

Rate

274.170-20

431.7621

431.7622

431.7623

431.7624

433.4925

442.1226

452.4827

469.3228

483.1429

490.0530

500.4131

510.7732

517.2533

524.1634

527.6135

531.0636

534.5237

537.9738

544.8839

551.7940

562.1541

572.0842

585.9043

603.1744

623.4645

647.6446

674.8447

705.9348

736.5849

771.1250

805.2351

842.8052

880.7953

921.8154

962.8255

1,007.3056

1,052.2057

1,100.1258

1,123.8759

1,171.8060

1,213.2561

1,240.4562

1,274.5663

1,295.2864

1,295.2865 & over

9-2805/16/2017


05/16/2017 28

Gold Trio ACO HMO 1700/30 OffEx*Region-9

AgeMember

RateAge

Member

Rate

209.060-20

329.2421

329.2422

329.2423

329.2424

330.5525

337.1426

345.0427

357.8828

368.4229

373.6830

381.5831

389.4932

394.4233

399.6934

402.3335

404.9636

407.5937

410.2338

415.5039

420.7640

428.6741

436.2442

446.7743

459.9444

475.4245

493.8546

514.6047

538.3048

561.6849

588.0250

614.0351

642.6752

671.6453

702.9254

734.2055

768.1156

802.3557

838.8958

857.0059

893.5560

925.1561

945.9062

971.9063

987.7164

987.7165 & over

9-2905/16/2017



05/16/2017 29

Gold Access+ HMO® 500/35 OffEx*Region-9

AgeMember

RateAge

Member

Rate

298.650-20

470.3121

470.3122

470.3123

470.3124

472.1925

481.6026

492.8827

511.2228

526.2729

533.8030

545.0931

556.3732

563.4333

570.9534

574.7235

578.4836

582.2437

586.0038

593.5339

601.0540

612.3441

623.1642

638.2143

657.0244

679.1245

705.4646

735.0947

768.9548

802.3549

839.9750

877.1251

918.0452

959.4353

1,004.1154

1,048.7955

1,097.2356

1,146.1457

1,198.3458

1,224.2159

1,276.4260

1,321.5661

1,351.1962

1,388.3563

1,410.9264

1,410.9265 & over

9-3005/16/2017




05/16/2017 30

Gold Local Access+ HMO® 500/35 OffEx*Region-9

AgeMember

RateAge

Member

Rate

283.180-20

445.9521

445.9522

445.9523

445.9524

447.7425

456.6626

467.3627

484.7528

499.0229

506.1630

516.8631

527.5632

534.2533

541.3934

544.9635

548.5236

552.0937

555.6638

562.8039

569.9340

580.6341

590.8942

605.1643

623.0044

643.9645

668.9346

697.0347

729.1448

760.8049

796.4850

831.7151

870.5052

909.7553

952.1154

994.4855

1,040.4156

1,086.7957

1,136.2958

1,160.8259

1,210.3260

1,253.1361

1,281.2362

1,316.4663

1,337.8664

1,337.8665 & over

9-3105/16/2017


05/16/2017 31

Gold Trio ACO HMO 500/35 OffEx*Region-9

AgeMember

RateAge

Member

Rate

215.800-20

339.8321

339.8322

339.8323

339.8324

341.1925

347.9926

356.1527

369.4028

380.2829

385.7130

393.8731

402.0232

407.1233

412.5634

415.2835

418.0036

420.7237

423.4338

428.8739

434.3140

442.4641

450.2842

461.1643

474.7544

490.7245

509.7546

531.1647

555.6348

579.7649

606.9550

633.7951

663.3652

693.2653

725.5554

757.8355

792.8356

828.1857

865.9058

884.5959

922.3160

954.9461

976.3562

1,003.1963

1,019.5064

1,019.5065 & over

9-3205/16/2017



05/16/2017 32

Blue Shield Gold 80 HMO 0/30 + Child Dental INF*Region-9

AgeMember

RateAge

Member

Rate

214.750-20

338.1921

338.1922

338.1923

338.1924

339.5525

346.3126

354.4327

367.6228

378.4429

383.8530

391.9731

400.0832

405.1533

410.5734

413.2735

415.9836

418.6837

421.3938

426.8039

432.2140

440.3341

448.1142

458.9343

472.4644

488.3545

507.2946

528.6047

552.9548

576.9649

604.0150

630.7351

660.1552

689.9153

722.0454

754.1755

789.0056

824.1857

861.7258

880.3259

917.8660

950.3261

971.6362

998.3463

1,014.5864

1,014.5865 & over

9-3305/16/2017



05/16/2017 33

Platinum Access+ HMO® 0/30 OffEx*Region-9

AgeMember

RateAge

Member

Rate

326.000-20

513.3821

513.3822

513.3823

513.3824

515.4425

525.7026

538.0227

558.0528

574.4729

582.6930

595.0131

607.3332

615.0333

623.2534

627.3535

631.4636

635.5737

639.6738

647.8939

656.1040

668.4241

680.2342

696.6643

717.2044

741.3245

770.0746

802.4247

839.3848

875.8349

916.9050

957.4651

1,002.1252

1,047.3053

1,096.0754

1,144.8455

1,197.7256

1,251.1157

1,308.1058

1,336.3359

1,393.3260

1,442.6061

1,474.9562

1,515.5063

1,540.1564

1,540.1565 & over

9-3505/16/2017




05/16/2017 34

Platinum Local Access+ HMO® 0/30 OffEx*Region-9

AgeMember

RateAge

Member

Rate

309.050-20

486.7021

486.7022

486.7023

486.7024

488.6425

498.3826

510.0627

529.0428

544.6129

552.4030

564.0831

575.7632

583.0633

590.8534

594.7435

598.6436

602.5337

606.4238

614.2139

622.0040

633.6841

644.8742

660.4543

679.9144

702.7945

730.0446

760.7147

795.7548

830.3049

869.2450

907.6951

950.0352

992.8653

1,039.1054

1,085.3355

1,135.4656

1,186.0857

1,240.1058

1,266.8759

1,320.8960

1,367.6261

1,398.2862

1,436.7363

1,460.0964

1,460.0965 & over

9-3605/16/2017


05/16/2017 35

Platinum Trio ACO HMO 0/30 OffEx*Region-9

AgeMember

RateAge

Member

Rate

235.110-20

370.2521

370.2522

370.2523

370.2524

371.7425

379.1426

388.0327

402.4728

414.3129

420.2430

429.1231

438.0132

443.5633

449.4934

452.4535

455.4136

458.3737

461.3438

467.2639

473.1940

482.0741

490.5942

502.4443

517.2544

534.6545

555.3846

578.7147

605.3748

631.6549

661.2750

690.5251

722.7452

755.3253

790.4954

825.6755

863.8056

902.3157

943.4158

963.7759

1,004.8760

1,040.4161

1,063.7462

1,092.9963

1,110.7664

1,110.7665 & over

9-3705/16/2017



05/16/2017 36


AgeMember

RateAge

Member

Rate

330.050-20

519.7621

519.7622

519.7623

519.7624

521.8425

532.2426

544.7127

564.9828

581.6129

589.9330

602.4031

614.8832

622.6833

630.9934

635.1535

639.3136

643.4737

647.6238

655.9439

664.2640

676.7341

688.6942

705.3243

726.1144

750.5445

779.6446

812.3947

849.8148

886.7249

928.3050

969.3651

1,014.5852

1,060.3253

1,109.6954

1,159.0755

1,212.6156

1,266.6657

1,324.3658

1,352.9459

1,410.6460

1,460.5361

1,493.2862

1,534.3463

1,559.2964

1,559.2965 & over

9-3805/16/2017




05/16/2017 37


AgeMember

RateAge

Member

Rate

312.880-20

492.7321

492.7322

492.7323

492.7324

494.7025

504.5626

516.3827

535.6028

551.3729

559.2530

571.0731

582.9032

590.2933

598.1734

602.1235

606.0636

610.0037

613.9438

621.8339

629.7140

641.5441

652.8742

668.6443

688.3444

711.5045

739.1046

770.1447

805.6148

840.6049

880.0250

918.9451

961.8152

1,005.1753

1,051.9854

1,098.7955

1,149.5456

1,200.7857

1,255.4858

1,282.5859

1,337.2760

1,384.5761

1,415.6162

1,454.5463

1,478.1964

1,478.1965 & over

9-3905/16/2017


05/16/2017 38


AgeMember

RateAge

Member

Rate

237.970-20

374.7621

374.7622

374.7623

374.7624

376.2625

383.7526

392.7527

407.3628

419.3629

425.3530

434.3531

443.3432

448.9633

454.9634

457.9635

460.9536

463.9537

466.9538

472.9539

478.9440

487.9441

496.5642

508.5543

523.5444

541.1545

562.1446

585.7547

612.7348

639.3449

669.3250

698.9351

731.5352

764.5153

800.1154

835.7155

874.3256

913.2957

954.8958

975.5059

1,017.1060

1,053.0861

1,076.6962

1,106.2963

1,124.2864

1,124.2865 & over

9-4005/16/2017



05/16/2017 39


AgeMember

RateAge

Member

Rate

337.270-20

531.1321

531.1322

531.1323

531.1324

533.2525

543.8826

556.6227

577.3428

594.3329

602.8330

615.5831

628.3332

636.2933

644.7934

649.0435

653.2936

657.5437

661.7938

670.2939

678.7840

691.5341

703.7542

720.7443

741.9944

766.9545

796.6946

830.1547

868.4048

906.1149

948.6050

990.5651

1,036.7652

1,083.5053

1,133.9654

1,184.4255

1,239.1256

1,294.3657

1,353.3258

1,382.5359

1,441.4860

1,492.4761

1,525.9362

1,567.8963

1,593.3964

1,593.3965 & over

9-4105/16/2017




05/16/2017 40


AgeMember

RateAge

Member

Rate

319.710-20

503.4821

503.4822

503.4823

503.4824

505.5025

515.5626

527.6527

547.2828

563.4029

571.4530

583.5331

595.6232

603.1733

611.2334

615.2535

619.2836

623.3137

627.3438

635.3939

643.4540

655.5341

667.1142

683.2243

703.3644

727.0345

755.2246

786.9447

823.1948

858.9449

899.2250

938.9951

982.8052

1,027.1053

1,074.9354

1,122.7655

1,174.6256

1,226.9857

1,282.8758

1,310.5659

1,366.4560

1,414.7861

1,446.5062

1,486.2863

1,510.4464

1,510.4465 & over

9-4205/16/2017


05/16/2017 41


AgeMember

RateAge

Member

Rate

243.070-20

382.7921

382.7922

382.7923

382.7924

384.3225

391.9726

401.1627

416.0928

428.3429

434.4630

443.6531

452.8432

458.5833

464.7034

467.7735

470.8336

473.8937

476.9538

483.0839

489.2040

498.3941

507.1942

519.4443

534.7544

552.7445

574.1846

598.3047

625.8648

653.0349

683.6650

713.9051

747.2052

780.8953

817.2554

853.6255

893.0456

932.8557

975.3458

996.3959

1,038.8860

1,075.6361

1,099.7562

1,129.9963

1,148.3664

1,148.3665 & over

9-4305/16/2017



05/16/2017 42

Blue Shield Platinum 90 HMO 0/15 + Child Dental INF*Region-9

AgeMember

RateAge

Member

Rate

235.760-20

371.2721

371.2722

371.2723

371.2724

372.7625

380.1826

389.0927

403.5728

415.4529

421.3930

430.3031

439.2132

444.7833

450.7234

453.6935

456.6636

459.6337

462.6038

468.5539

474.4940

483.4041

491.9442

503.8243

518.6744

536.1245

556.9146

580.3047

607.0348

633.3949

663.0950

692.4251

724.7252

757.3953

792.6754

827.9455

866.1856

904.7957

946.0058

966.4259

1,007.6360

1,043.2761

1,066.6662

1,095.9963

1,113.8264

1,113.8265 & over

9-4405/16/2017



05/16/2017 43

Employee

Specialty Benefits Dental Region 9

Employee+ spouse

Employee+ child(ren)

Employee+ familyRates are for groups with 1-50 eligible employees.

DENTAL PPOSmile (SM) Basic Voluntary 75/1000/No Ortho/MAC 32.40 64.10 79.20 108.70Smile (SM) Basic 75/1000/No Ortho/MAC 27.50 55.00 66.30 95.90Smile (SM) Plus Gold 50/1500/Ortho/U85 64.10 129.10 162.90 190.80Smile (SM) Value 50/1500/No Ortho/MAC 34.80 72.80 82.10 106.70Smile (SM) Plus 50/1500/Ortho/MAC 48.60 97.00 121.80 142.40Smile (SM) 50/1500/No Ortho/MAC 43.40 85.80 98.00 127.10Smile (SM) Deluxe Gold 50/1500/Ortho/U85 76.70 153.50 194.30 260.60Smile (SM) Deluxe 50/1500/Ortho/MAC 51.50 103.10 130.70 174.20Smile (SM) Deluxe Plus 2000 50/2000/Ortho/MAC 61.50 123.90 156.20 209.10Smile (SM) Deluxe 2000 50/2000/No Ortho/MAC 60.80 122.60 148.10 207.80ULTIMATE DENTAL PPO FOR SMALL BUSINESSUltimate Dental PPO for Small Business 50/2000 58.20 117.50 141.90 199.10Ultimate Dental Plus PPO for Small Business 50/2000 59.70 120.30 151.70 203.00SMILE(SM) IN-NETWORK ONLY DENTAL PLAN*50/1500/Endo-Perio 80%/No Ortho 34.30 71.80 80.80 105.2050/1500/Endo-Perio 80%/Ortho 37.10 77.60 87.30 113.7050/2500/Endo-Perio 80%/No Ortho 60.80 123.60 148.90 208.6050/2500/Endo-Perio 80%/Ortho 61.80 124.60 157.10 209.70SMILE(SM) IN-NETWORK ONLY DENTAL VOLUNTARY PLAN*50/1500/EndoPerio 50%/No Ortho 32.60 68.20 76.80 99.9050/1500/EndoPerio 50%/Ortho 40.10 83.90 94.40 122.9050/2500/Endo-Perio 50%/No Ortho 57.70 117.40 141.30 198.1050/2500/Endo-Perio 50%/Ortho 66.80 134.70 169.80 226.70DENTAL HMO¹DHMO Basic 14.70 30.60 36.20 46.30DHMO Voluntary 21.00 42.00 48.20 62.90DHMO Plus 24.50 48.80 57.10 73.30DHMO Deluxe 25.90 51.90 61.00 78.00

08/23/2016 9-39

*Underwritten by Blue Shield of California Life & Health Insurance Company.¹Plan not available in all regions. See page 3 for product availability.Regions may vary by product. The "Small Business Off Exchange Rating Region Definitions" chart located near the front of this booklet identifies the counties locatedin each region.

08/23/2016 44

Employee

Specialty Benefits Dental Region 9

Employee+ spouse



DENTAL PPOSmile (SM) Basic Voluntary 75/1000/No Ortho/MAC 24.30 48.10 59.40 81.50Smile (SM) Basic 75/1000/No Ortho/MAC 20.70 41.20 49.70 72.00Smile (SM) Plus Gold 50/1500/Ortho/U85 48.10 96.80 122.20 143.10Smile (SM) Value 50/1500/No Ortho/MAC 26.10 54.60 61.60 80.10Smile (SM) Plus 50/1500/Ortho/MAC 36.50 72.80 91.30 106.80Smile (SM) 50/1500/No Ortho/MAC 32.50 64.30 73.50 95.30Smile (SM) Deluxe Gold 50/1500/Ortho/U85 57.50 115.20 145.70 195.50Smile (SM) Deluxe 50/1500/Ortho/MAC 38.60 77.30 98.00 130.70Smile (SM) Deluxe Plus 2000 50/2000/Ortho/MAC 46.10 92.90 117.20 156.80Smile (SM) Deluxe 2000 50/2000/No Ortho/MAC 45.60 91.90 111.10 155.90ULTIMATE DENTAL PPO FOR SMALL BUSINESSUltimate Dental PPO for Small Business 50/2000 43.70 88.10 106.40 149.30Ultimate Dental Plus PPO for Small Business 50/2000 44.80 90.20 113.80 152.30SMILE(SM) IN-NETWORK ONLY DENTAL PLAN*50/1500/Endo-Perio 80%/No Ortho 25.70 53.90 60.60 78.9050/1500/Endo-Perio 80%/Ortho 27.80 58.20 65.50 85.3050/2500/Endo-Perio 80%/No Ortho 45.60 92.70 111.60 156.5050/2500/Endo-Perio 80%/Ortho 46.40 93.40 117.80 157.30SMILE(SM) IN-NETWORK ONLY DENTAL VOLUNTARY PLAN*50/1500/EndoPerio 50%/No Ortho 24.40 51.20 57.60 74.9050/1500/EndoPerio 50%/Ortho 30.00 62.90 70.80 92.2050/2500/Endo-Perio 50%/No Ortho 43.30 88.00 106.00 148.6050/2500/Endo-Perio 50%/Ortho 50.10 101.00 127.40 170.00DENTAL HMO¹DHMO Basic 12.60 26.20 31.10 39.70DHMO Voluntary 18.00 36.00 41.30 53.90DHMO Plus 21.00 41.90 49.00 62.80DHMO Deluxe 22.20 44.50 52.30 66.90

08/23/2016 9-40

*Underwritten by Blue Shield of California Life & Health Insurance Company.¹Plan not available in all regions. See page 3 for product availability.Regions may vary by product. The "Small Business Off Exchange Rating Region Definitions" chart located near the front of this booklet identifies the counties locatedin each region.

08/23/2016 45

Employee

Specialty Benefits Vision and Optional Product Region 9

Employee+ spouse



ENHANCED VISION FOR SMALL BUSINESS*Enhanced Vision Voluntary¹ for Small Business 15/25/120 9.80 18.60 17.10 24.20Enhanced Vision for Small Business 15/25/120 6.90 13.00 12.00 17.00Enhanced Vision for Small Business 0/0/120 9.00 17.10 15.80 22.30Enhanced Vision for Small Business 15/25/150 8.00 15.10 13.90 19.80Enhanced Vision Plus for Small Business 15/25/150/120 10.60 20.00 18.40 26.00Enhanced Vision for Small Business 0/0/150 10.50 19.80 18.20 25.80Enhanced Vision Plus for Small Business 0/0/150/120 13.00 24.70 22.70 32.20PREFERRED VISION FOR SMALL BUSINESS*Preferred Vision Voluntary¹ for Small Business 15/25/120 10.60 20.20 18.50 26.20Preferred Vision for Small Business 15/25/120 7.40 14.10 13.00 18.30Preferred Vision for Small Business 0/0/120 9.80 18.60 17.10 24.20Preferred Vision for Small Business 15/25/150 8.70 16.50 15.20 21.50Preferred Vision Plus for Small Business 15/25/150/120 11.40 21.50 19.80 28.00Preferred Vision for Small Business 0/0/150 11.40 21.50 19.80 28.00Preferred Vision Plus for Small Business 0/0/150/120 14.00 26.50 24.40 34.50ULTIMATE VISION FOR SMALL BUSINESS*Ultimate Vision for Small Business 15/25/120 10.60 20.20 18.50 26.20Ultimate Vision for Small Business 0/0/120 13.80 26.10 23.90 33.90Ultimate Vision Voluntary¹ for Small Business 15/25/150 17.70 33.40 30.80 43.60Ultimate Vision for Small Business 15/25/150 12.40 23.40 21.60 30.60Ultimate Vision Plus for Small Business 15/25/150/120 16.60 31.50 29.00 41.00Ultimate Vision for Small Business 0/0/150 16.00 30.30 27.80 39.40Ultimate Vision Plus for Small Business 0/0/150/120 20.20 38.20 35.10 49.70

LIFE INSURANCE RATESSee page 2.Dental, life insurance, and vision plans are available alongside medical coverage or on a standalone basis.

OPTIONAL PRODUCT All Ages_____________________INFERTILITY**PPO and HSA-HDHP Only 15.90

08/23/2016 9-41

*Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).**Additional Infertility Treatment Benefits are available as supplemental coverage to the PPO and HSA-HDHP plans from the Blue Shield of California Off ExchangePackage for Small Business and the Select PPO Network from the Blue Shield of California Mirror Package for Small Business.¹Voluntary vision plans require a minimum of 3 enrolled employees.Regions may vary by product. The "Small Business Off Exchange Rating Region Definitions" chart located near the front of this booklet identifies the counties locatedin each region.

08/23/2016 46

Employee

Specialty Benefits Vision and Optional Product Region 9

Employee+ spouse



ENHANCED VISION FOR SMALL BUSINESS*Enhanced Vision Voluntary¹ for Small Business 15/25/120 7.90 14.90 13.70 19.40Enhanced Vision for Small Business 15/25/120 5.50 10.40 9.60 13.60Enhanced Vision for Small Business 0/0/120 7.20 13.70 12.60 17.90Enhanced Vision for Small Business 15/25/150 6.40 12.10 11.10 15.80Enhanced Vision Plus for Small Business 15/25/150/120 8.40 16.00 14.70 20.80Enhanced Vision for Small Business 0/0/150 8.40 15.90 14.60 20.70Enhanced Vision Plus for Small Business 0/0/150/120 10.40 19.80 18.20 25.70PREFERRED VISION FOR SMALL BUSINESS*Preferred Vision Voluntary¹ for Small Business 15/25/120 8.50 16.10 14.80 21.00Preferred Vision for Small Business 15/25/120 6.00 11.30 10.40 14.70Preferred Vision for Small Business 0/0/120 7.90 14.90 13.70 19.40Preferred Vision for Small Business 15/25/150 7.00 13.20 12.20 17.20Preferred Vision Plus for Small Business 15/25/150/120 9.10 17.20 15.80 22.40Preferred Vision for Small Business 0/0/150 9.10 17.20 15.80 22.40Preferred Vision Plus for Small Business 0/0/150/120 11.20 21.20 19.50 27.60ULTIMATE VISION FOR SMALL BUSINESS*Ultimate Vision for Small Business 15/25/120 8.50 16.10 14.80 21.00Ultimate Vision for Small Business 0/0/120 11.00 20.90 19.10 27.10Ultimate Vision Voluntary¹ for Small Business 15/25/150 14.10 26.80 24.60 34.90Ultimate Vision for Small Business 15/25/150 9.90 18.80 17.30 24.40Ultimate Vision Plus for Small Business 15/25/150/120 13.30 25.20 23.20 32.80Ultimate Vision for Small Business 0/0/150 12.80 24.30 22.30 31.60Ultimate Vision Plus for Small Business 0/0/150/120 16.10 30.50 28.10 39.70

LIFE INSURANCE RATESSee page 2.Dental, life insurance, and vision plans are available alongside medical coverage or on a standalone basis.

OPTIONAL PRODUCT All Ages_____________________INFERTILITY**PPO and HSA-HDHP Only 15.90

08/23/2016 9-42

*Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).**Additional Infertility Treatment Benefits are available as supplemental coverage to the PPO and HSA-HDHP plans from the Blue Shield of California Off ExchangePackage for Small Business and the Select PPO Network from the Blue Shield of California Mirror Package for Small Business.¹Voluntary vision plans require a minimum of 3 enrolled employees.Regions may vary by product. The "Small Business Off Exchange Rating Region Definitions" chart located near the front of this booklet identifies the counties locatedin each region.

08/23/2016 47

Blue Shield of California50 Beale Street, San Francisco, CA 94105

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Small Business Rate Tables - Blue Shield of California · 0-29 $ .19 30-34 .20 35-39 .21 60-64 2.25...

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Transcript of Small Business Rate Tables - Blue Shield of California · 0-29 $ .19 30-34 .20 35-39 .21 60-64 2.25...