Rates Orange SD 1 17

small business rate tables Rate Book 11 Rating region 18: Orange County Rating region 19: San Diego Effective January 2...

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small business rate tables Rate Book 11 Rating region 18: Orange County Rating region 19: San Diego

Effective January 2017 Includes rates for standard plans

blueshieldca.com

Blue Shield of California county grouping for Rate Book 11 Region 18 – Orange County: Orange County1,2 Region 19 – San Diego: San Diego1,2

DEL NORTE

SISKIYOU

MODOC

SHASTA HUMBOLDT

LASSEN

TRINITY

TEHAMA

MENDOCINO

PLUMAS BUTTE

GLENN

SIERRA NEVADA

YOLO NAPA

YUBA

PLACER

EL DORADO SACRAMENTO

ALPINE AMADOR OR AMAD

LA VE R A

SOLANO SAN CONTRA- JOAQUIN COSTA

C

MARIN

A

S

SONOMA

COLUSA

SUTTER

LAKE

TUOLUMNE

MONO

SAN FRANCISCO ALAMEDA SAN MATEO SANTA CLARA

MARIPOSA

STANISLAUS MERCED

MADERA

SANTA CRUZ

SAN BENITO

FRESNO

INYO

TULARE MONTEREY

KINGS

SAN LUIS OBISPO

KERN SAN BERNARDINO

SANTA BARBARA VENTURA

LOS ANGELES

ORANGE

RIVERSIDE

SAN DIEGO IMPERIAL

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

Small Business Rate Tables CONTENTS Life Insurance Rates

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2

Regional Groupings

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3

Small Business Rates: Region 18

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Region 19

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Life Insurance Rates for Blue Shield of California Group Plans 2-9 Eligible Employee Rate Table Effective January 2017 Region 1 - 19 Life Insurance Rates Age

Rate/$1,000

0-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69¹ 70-74² 75-79² 80-84² 85+²

$ .19 .20 .21 .33 .46 .74 1.15 2.25 3.75 5.33 8.39 12.05 18.04

*Includes $.05 Accidental Death & Dismemberment Insurance

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

Groups with 10 to 100 eligible employees will be composite rated. Contact your Blue Shield sales representative for a quote. Benefits Allowed for new groups of 2 to 100 eligible employees: Flat, Graded, or Salaried Plans

Basic group term life and AD&D insurance is underwritten by Blue Shield of California Life & Health Insurance Company. 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 Effective January 2017

Rating Region

1

2

3

County

Alpine Amador Butte Calaveras Colusa Del Norte Glenn Humboldt Lake Lassen Mendocino Modoc Nevada Plumas Shasta Sierra Siskiyou Sutter Tehama Trinity Tuolumne Yuba

Access+ HMO® Dental Dental Network HMO INO Availability Availability Availability

Rating Region

County

8

San Mateo

9

Monterey San Benito Santa Cruz

Access+ HMO® Dental Dental Network HMO INO Availability Availability Availability 





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 





























Fresno Kings Madera



















San Luis Obispo Santa Barbara Ventura



















Imperial Inyo Mono





14

Kern



















10

 





Mariposa Merced San Joaquin Stanislaus Tulare





 

11

  



12

 





 

13

 

Marin Napa Solano Sonoma



El Dorado Placer Sacramento Yolo

 





















15

Los Angeles ZIP Codes*







16







Los Angeles - Except ZIP Codes in Region 15













17

Riverside San Bernardino













18

Orange







19

San Diego







4

San Francisco







5

Contra Costa







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, 9071090717, 90723, 90731-90734, 90744-90749, 90755, 90800-90810, 90813-90815, 90822, 90831-90835, 90840, 90842, 90844-90848, 90853, 90888, 90895, 90899, 9100191003, 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.

3

SMALL BUSINESS OFF EXCHANGE LOCAL ACCESS+ HMO® NETWORK RATING REGION DEFINITIONS AND AVAILABILITY Effective January 2017

Rating Region

Rating Region

County

1

None.

2

Marin, Sonoma.

3

Sacramento except zip codes: 95632, 95638-95639, 95641, 95671, 95680, 95683, 95690, 95693, 95798, 95799.

15

Los Angeles zip codes: 90601-90610, 90637-90640, 90650-90652, 90660-90662, 90670-90671, 90701-90703, 90706-90707, 90710-90717, 90723, 90731-90734, 90744-90749, 90755, 90801-90810, 90813-90815, 90822, 90831-90835, 90840, 90842, 90844, 90846-90848, 90853, 90895, 90899, 91001, 91006-91012, 91016-91017, 91020-91021, 91023-91025, 91030-91031, 91040-91043, 91046, 91066, 91077, 91101-91110, 91114-91118, 91121, 91123-91126, 91129, 91182, 91184-91185, 91188-91189, 91199, 91201-91210, 91214, 91221-91222, 91224-91226, 91501-91508, 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, 91801-91804, 91896, 91899, 93563.

16

Los Angeles except zip codes in Rating Region 15 and except zip codes: 90704, 93510, 93532, 93534-93536, 93539, 93543-93544, 93550-93553, 93584, 93586, 93590-93591, 93599.

17

Riverside except zip codes: 92225-92226, 92239, 92275, 92539.

Yolo. 4

San Francisco.

5

Contra Costa except zip codes: 94525, 94530, 94547, 94551, 94564, 94569, 94572, 94801-94808, 94820, 94850.

6

None.

7

Santa Clara.

8

San Mateo except zip codes: 94018-94021, 94028, 94037-94038, 94060, 94074.

9

Santa Cruz.

10

Stanislaus.

11

None.

12

San Luis Obispo.

County

San Bernardino except zip codes: 91759, 92242, 92252, 92256, 92267-92268, 92277-92278, 92280, 92284-92286, 92304-92305, 92309-92310, 92314-92315, 92317, 92321-92323, 92325-92327, 92332-92333, 92338, 92341-92342, 92347, 92352, 92356, 92358, 92363-92366, 92368, 92372, 92378, 92382, 92385-92386, 92391, 92395, 92397-92398, 92407, 93562, 93592. 18

Orange.

19

San Diego except zip codes: 91905-91906, 91934, 91963, 91980, 91987, 92004, 92036, 92066, 92086.

Ventura except zip codes: 00061, 93013. 93225, 93252. 13

None.

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.

4

SMALL BUSINESS OFF EXCHANGE AND MIRROR ACO HMO NETWORK RATING REGION DEFINITIONS AND AVAILABILITY Effective January 2017

Rating Region

Rating Region

County

1

Nevada zip codes: 95712, 95924, 95945-95946, 95949, 95959-95960, 95975, 95986.

2

Solano zip codes: 94503, 94510, 94589, 94592, 95620.

3

El Dorado zip codes: 95664, 95672, 95682, 95762.

14

Kern zip codes: 93203, 93205-93206, 93215-93216, 93220, 93224-93226, 93240-93241, 93250-93252, 93255, 93263, 93268, 93276, 93280, 93283, 93285, 93287, 93301-93309, 93311-93314, 93380, 93383-93390, 93501-93502, 93504-93505, 93516, 93518, 93531, 93560-93561, 93596.

15

Los Angeles zip codes: 90601-90610, 90637-90640, 90650-90652, 90660-90662, 90670, 90701-90703, 90706-90707, 90710-90717, 90723, 90731-90734, 90744-90749, 90755, 90801-90810, 90813-90815, 90822, 90831-90835, 90840, 90842, 90844, 90846-90848, 90853, 90895, 90899, 91001, 91003, 91006-91012, 91016-91017, 91020-91025, 91030-91031, 91040-91043, 91046, 91066, 91077, 91101-91110, 91114-91118, 91121, 91123-91126, 91129, 91182, 91184-91185, 91188-91189, 91199, 91201-90210, 91214, 91221-91222, 91224-91226, 91501-91508, 91510, 91521-91523, 91702, 91706, 91711, 91715-91716, 91722-91724, 91731-91735, 91740-91741, 91744-91750, 91754-91756, 91765-91773, 91775-91776, 91778, 91780, 91788-91793, 91801-91803, 91899, 93510, 93563.

16

Los Angeles zip codes: 90001-90084, 90086-90091, 90093-90096, 90189, 90201-90202, 90209-90213, 90220-90224, 90230-90232, 90239-90242, 90245, 90247-90251, 90254-90255, 90260-90267, 90270, 90272, 90274-90275, 90277-90278, 90280, 90290-90296, 90301-90312, 90401-90411, 90501-90510, 91301-91311, 91313, 91316, 91321-91322, 91324-91331, 91333-91335, 91337, 91340-91346, 91350-91357, 91364-91365, 91367, 91371-91372, 91376, 91380-91381, 91383-91387, 91390, 91392-91396, 91401-91413, 91416, 91423, 91426, 91436, 91470, 91482, 91495-91496, 91499, 91601-91612, 91614-91617.

17

Riverside zip codes: 91752, 92220, 92223, 92230, 92320, 92501-92509, 92513-92514, 92516-92519, 92521-92522, 92530-92532, 92543-92546, 92548, 92551-92557, 92562-92564, 92567, 92570-92572, 92581-92587, 92589-92593, 92595-92596, 92599, 92860, 92877-92883.

Placer zip codes: 95602-95604, 95648, 95650, 95658, 95661, 95663, 95677-95678, 95713, 95746-95747, 95765. Sacramento zip codes: 94203-94206, 92409, 94229-94230, 94232, 94235-94237, 94239-94240, 94244, 94247-94250, 94252, 94254, 94256-94259, 94261-94263, 94267-94269, 94271, 94273-94274, 94277-94280, 94283-94290, 94293, 94298, 95608-95611, 95615, 95621, 95624, 95626, 95628, 95630, 95632, 95638-95639, 95652, 95655, 95660, 95662, 95670-95671, 95673, 95683, 95693, 95741-95742, 95757-95759, 95763, 95812-95838, 95840-95843, 95851-95853, 95860, 95864-95867, 95894, 95899. Yolo zip codes: 95605-95607, 95612, 95616-95618, 95627, 95637, 95645, 95653, 95691, 95694-95695, 95697-95698, 95776, 95798-95799, 95937. 4

San Francisco.

5

Contra Costa zip codes: 94506-94507, 94509, 94511, 94513-94514, 94516-94529, 94531, 94548-94549, 94553, 94556, 94561, 94563-94565, 94570, 94575, 94582-94583, 94595-94598.

6

Alameda zip codes: 94550-94551, 94566, 94568, 94588.

7

Santa Clara.

8

San Mateo.

9

Santa Cruz.

10

San Joaquin.

County

San Bernardino zip codes: 91701, 91708-91710, 91729-91730, 91737, 91739, 91743, 91758, 91761-91764, 91784-91786, 92301, 92305, 92307-92308, 92313-92318, 92321-92322, 92324-92325, 92329, 92331, 92333-92337, 92339-92342, 92344-92346, 92350, 92352, 92354, 92356-92359, 92368-92369, 92371-92378, 92382, 92385-92386, 92391-92395, 92397, 92399, 92401-92408, 92410-92411, 92413, 92415, 92418, 92423, 92427.

Stanislaus zip codes: 95307, 95313, 95316, 95319, 95323, 95326, 95328-95329, 95350-95358, 95361, 95363, 95367-95368, 95380-95382, 95386-95387, 95397. Tulare zip codes: 93219, 93256, 93260.

18

Orange.

11

None.

19

12

Ventura zip codes: 91319-91320, 91358-91362, 91377, 93010-93012, 93015-93016, 93020-93021, 93040, 93062-93066, 93094, 93099.

13

None.

San Diego zip codes: 91901-91903, 91905-91906, 91908-91917, 91921, 91931-91933, 91935, 91941-91946, 91948, 91950-91951, 91962-91963, 91976-91980, 91987, 92003, 92007-92011, 92013-92014, 92018-92030, 92033, 92036-92040, 92046, 92049, 92051-92052, 92054-92061, 92064-92065, 92067-92069, 92071-92072, 92074-92075, 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.

5

Region 18 Blue Shield Bronze 60 PPO 6300/75 + Child Dental Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

163.20 257.00 257.00 257.00 257.00 258.03 263.17 269.34 279.36 287.59 291.70 297.87 304.04 307.89 312.00 314.06 316.12 318.17 320.23 324.34 328.45 334.62 340.53 348.76 359.04 371.11 385.51 401.70 420.20 438.45 459.01 479.31 501.67 524.29 548.71

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 573.12 599.59 626.32 654.85 668.98 697.51 722.18 738.37 758.68 771.01 771.01

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. 08/23/2016

18-1

Region 18 Bronze Full PPO 5100/60 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

180.14 283.69 283.69 283.69 283.69 284.82 290.50 297.31 308.37 317.45 321.99 328.80 335.60 339.86 344.40 346.67 348.94 351.21 353.48 358.02 362.55 369.36 375.89 384.97 396.31 409.65 425.53 443.41 463.83 483.97 506.67 529.08 553.76 578.73 605.68

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 632.63 661.85 691.35 722.84 738.44 769.93 797.17 815.04 837.45 851.07 851.07

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. 08/23/2016

18-2

Region 18 Bronze Full PPO 3750/65 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

176.83 278.47 278.47 278.47 278.47 279.58 285.15 291.83 302.69 311.60 316.06 322.74 329.43 333.60 338.06 340.29 342.51 344.74 346.97 351.43 355.88 362.56 368.97 377.88 389.02 402.11 417.70 435.24 455.29 475.06 497.34 519.34 543.57 568.07 594.53

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 620.98 649.66 678.62 709.53 724.85 755.76 782.49 800.03 822.03 835.40 835.40

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. 08/23/2016

18-3

Region 18 Blue Shield Silver 70 PPO 2000/45 + Child Dental Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

214.90 338.43 338.43 338.43 338.43 339.78 346.55 354.68 367.87 378.70 384.12 392.24 400.36 405.44 410.85 413.56 416.27 418.98 421.68 427.10 432.51 440.64 448.42 459.25 472.79 488.69 507.65 528.97 553.33 577.36 604.44 631.17 660.62 690.40 722.55

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

754.70 789.56 824.76 862.32 880.94 918.50 950.99 972.31 999.05 1015.29 1015.29

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. 08/23/2016

18-4

Region 18 Silver Full PPO 1700/40 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

204.08 321.38 321.38 321.38 321.38 322.67 329.10 336.81 349.34 359.63 364.77 372.48 380.19 385.02 390.16 392.73 395.30 397.87 400.44 405.58 410.73 418.44 425.83 436.12 448.97 464.08 482.07 502.32 525.46 548.28 573.99 599.38 627.34 655.62 686.15

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 716.68 749.78 783.21 818.88 836.56 872.23 903.08 923.33 948.72 964.15 964.15

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. 08/23/2016

18-5

Region 18 Silver Full PPO 1300/45 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

203.24 320.06 320.06 320.06 320.06 321.34 327.74 335.42 347.90 358.14 363.26 370.94 378.63 383.43 388.55 391.11 393.67 396.23 398.79 403.91 409.03 416.71 424.07 434.32 447.12 462.16 480.08 500.25 523.29 546.02 571.62 596.90 624.75 652.91 683.32

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 713.72 746.69 779.98 815.50 833.11 868.63 899.36 919.52 944.80 960.17 960.17

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. 08/23/2016

18-6

Region 18 Gold Full PPO 1000/35 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

225.18 354.61 354.61 354.61 354.61 356.03 363.12 371.63 385.46 396.81 402.48 410.99 419.50 424.82 430.50 433.33 436.17 439.01 441.85 447.52 453.19 461.70 469.86 481.21 495.39 512.06 531.92 554.26 579.79 604.97 633.34 661.35 692.20 723.41 757.09

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

790.78 827.31 864.19 903.55 923.05 962.41 996.46 1018.80 1046.81 1063.83 1063.83

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. 08/23/2016

18-7

Region 18 Gold Full PPO 750/20 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

234.98 370.05 370.05 370.05 370.05 371.53 378.93 387.81 402.24 414.09 420.01 428.89 437.77 443.32 449.24 452.20 455.16 458.12 461.08 467.00 472.92 481.81 490.32 502.16 516.96 534.35 555.07 578.39 605.03 631.31 660.91 690.14 722.34 754.90 790.06

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

825.21 863.33 901.81 942.89 963.24 1004.32 1039.84 1063.15 1092.39 1110.15 1110.15

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. 08/23/2016

18-8

Region 18 Gold Full PPO 250/30 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

244.69 385.34 385.34 385.34 385.34 386.88 394.59 403.83 418.86 431.19 437.36 446.61 455.86 461.64 467.80 470.88 473.97 477.05 480.13 486.30 492.46 501.71 510.57 522.90 538.32 556.43 578.01 602.28 630.03 657.39 688.21 718.66 752.18 786.09 822.70

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

859.31 899.00 939.07 981.84 1003.04 1045.81 1082.80 1107.08 1137.52 1156.02 1156.02

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. 08/23/2016

18-9

Region 18 Blue Shield Gold 80 PPO 0/30 + Child Dental Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

256.66 404.19 404.19 404.19 404.19 405.81 413.89 423.59 439.35 452.29 458.75 468.46 478.16 484.22 490.69 493.92 497.15 500.39 503.62 510.09 516.55 526.25 535.55 548.48 564.65 583.65 606.28 631.75 660.85 689.55 721.88 753.81 788.98 824.55 862.94

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

901.34 942.97 985.01 1029.87 1052.10 1096.97 1135.77 1161.24 1193.17 1212.57 1212.57

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. 08/23/2016

18-10

Region 18 Gold Full PPO 0/20 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

243.78 383.91 383.91 383.91 383.91 385.44 393.12 402.34 417.31 429.59 435.74 444.95 454.16 459.92 466.06 469.14 472.21 475.28 478.35 484.49 490.63 499.85 508.68 520.96 536.32 554.36 575.86 600.05 627.69 654.95 685.66 715.99 749.39 783.17 819.64

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

856.11 895.66 935.58 978.20 999.31 1041.93 1078.78 1102.97 1133.30 1151.72 1151.72

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. 08/23/2016

18-11

Region 18 Platinum Full PPO 150/15 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

279.23 439.74 439.74 439.74 439.74 441.50 450.29 460.85 478.00 492.07 499.10 509.66 520.21 526.81 533.84 537.36 540.88 544.40 547.91 554.95 561.99 572.54 582.65 596.73 614.31 634.98 659.61 687.31 718.97 750.19 785.37 820.11 858.37 897.07 938.84

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

980.62 1025.91 1071.64 1120.45 1144.64 1193.45 1235.67 1263.37 1298.11 1319.22 1319.22

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. 08/23/2016

18-12

Region 18 Blue Shield Platinum 90 PPO 0/15 + Child Dental Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

287.85 453.30 453.30 453.30 453.30 455.12 464.18 475.06 492.74 507.25 514.50 525.38 536.26 543.06 550.31 553.94 557.56 561.19 564.82 572.07 579.32 590.20 600.63 615.13 633.26 654.57 679.95 708.51 741.15 773.33 809.60 845.41 884.85 924.74 967.80

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

1010.87 1057.56 1104.70 1155.02 1179.95 1230.26 1273.78 1302.34 1338.15 1359.91 1359.91

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. 08/23/2016

18-13

Region 18 Platinum Full PPO 0/10 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

290.30 457.17 457.17 457.17 457.17 459.00 468.14 479.11 496.94 511.57 518.89 529.86 540.83 547.69 555.00 558.66 562.32 565.98 569.63 576.95 584.26 595.23 605.75 620.38 638.67 660.15 685.75 714.56 747.47 779.93 816.50 852.62 892.39 932.63 976.06

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

1019.49 1066.58 1114.12 1164.87 1190.01 1240.76 1284.65 1313.45 1349.56 1371.51 1371.51

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. 08/23/2016

18-14

Region 18 Bronze Full PPO Savings 5500/40% OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

179.48 282.64 282.64 282.64 282.64 283.77 289.43 296.21 307.23 316.28 320.80 327.58 334.37 338.61 343.13 345.39 347.65 349.91 352.17 356.69 361.22 368.00 374.50 383.55 394.85 408.14 423.96 441.77 462.12 482.19 504.80 527.13 551.72 576.59 603.44

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 630.29 659.40 688.80 720.17 735.72 767.09 794.22 812.03 834.36 847.93 847.93

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. 08/23/2016

18-15

Region 18 Bronze Full PPO Savings 4700/40% OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

181.48 285.80 285.80 285.80 285.80 286.94 292.66 299.52 310.66 319.81 324.38 331.24 338.10 342.38 346.96 349.24 351.53 353.82 356.10 360.68 365.25 372.11 378.68 387.83 399.26 412.69 428.70 446.70 467.28 487.57 510.43 533.01 557.88 583.03 610.18

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 637.33 666.76 696.49 728.21 743.93 775.65 803.09 821.09 843.67 857.39 857.39

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. 08/23/2016

18-16

Region 18 Silver Full PPO Savings 2000/20% OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

225.95 355.83 355.83 355.83 355.83 357.25 364.37 372.91 386.78 398.17 403.86 412.40 420.94 426.28 431.97 434.82 437.67 440.51 443.36 449.05 454.75 463.29 471.47 482.86 497.09 513.81 533.74 556.16 581.78 607.04 635.51 663.62 694.57 725.89 759.69

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

793.49 830.14 867.15 906.65 926.22 965.71 999.87 1022.29 1050.40 1067.48 1067.48

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. 08/23/2016

18-17

Region 18 Blue Shield Silver 70 HMO 2000/45 + Child Dental INF* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

188.78 297.29 297.29 297.29 297.29 298.48 304.42 311.56 323.15 332.67 337.42 344.56 351.69 356.15 360.91 363.29 365.67 368.04 370.42 375.18 379.94 387.07 393.91 403.42 415.31 429.29 445.93 464.66 486.07 507.17 530.96 554.44 580.31 606.47 634.71

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 662.95 693.57 724.49 757.49 773.84 806.84 835.38 854.11 877.60 891.87 891.87

*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. 08/23/2016

18-18

Region 18 Silver Access+ HMO® 1700/55 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

205.62 323.81 323.81 323.81 323.81 325.11 331.58 339.36 351.99 362.35 367.53 375.30 383.07 387.93 393.11 395.70 398.29 400.88 403.47 408.65 413.83 421.60 429.05 439.41 452.37 467.59 485.72 506.12 529.43 552.43 578.33 603.91 632.08 660.58 691.34

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 722.10 755.46 789.13 825.08 842.89 878.83 909.92 930.32 955.90 971.44 971.44

*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. 08/23/2016

18-19

Region 18 Silver Local Access+ HMO® 1700/55 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

194.46 306.23 306.23 306.23 306.23 307.46 313.58 320.93 332.87 342.67 347.57 354.92 362.27 366.87 371.77 374.22 376.67 379.12 381.57 386.47 391.37 398.72 405.76 415.56 427.81 442.20 459.35 478.64 500.69 522.43 546.93 571.12 597.77 624.71 653.81

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 682.90 714.44 746.29 780.28 797.12 831.12 860.51 879.81 904.00 918.70 918.70

*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. 08/23/2016

18-20

Region 18 Silver Trio ACO HMO 1700/55 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

176.22 277.51 277.51 277.51 277.51 278.62 284.17 290.83 301.65 310.53 314.97 321.63 328.29 332.45 336.89 339.11 341.33 343.55 345.77 350.21 354.65 361.31 367.70 376.58 387.68 400.72 416.26 433.74 453.72 473.43 495.63 517.55 541.69 566.11 592.48

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 618.84 647.42 676.28 707.09 722.35 753.15 779.79 797.28 819.20 832.52 832.52

*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. 08/23/2016

18-21

Region 18 Gold Access+ HMO® 1700/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

217.46 342.46 342.46 342.46 342.46 343.83 350.68 358.90 372.25 383.21 388.69 396.91 405.13 410.27 415.75 418.49 421.23 423.97 426.71 432.18 437.66 445.88 453.76 464.72 478.42 494.51 513.69 535.27 559.92 584.24 611.63 638.69 668.48 698.62 731.15

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

763.69 798.96 834.58 872.59 891.42 929.44 962.31 983.89 1010.94 1027.38 1027.38

*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. 08/23/2016

18-22

Region 18 Gold Local Access+ HMO® 1700/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

205.61 323.80 323.80 323.80 323.80 325.09 331.57 339.34 351.97 362.33 367.51 375.28 383.05 387.91 393.09 395.68 398.27 400.86 403.45 408.63 413.82 421.59 429.03 439.40 452.35 467.57 485.70 506.10 529.41 552.40 578.30 603.88 632.06 660.55 691.31

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 722.07 755.42 789.10 825.04 842.85 878.79 909.87 930.27 955.85 971.40 971.40

*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. 08/23/2016

18-23

Region 18 Gold Trio ACO HMO 1700/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

186.21 293.25 293.25 293.25 293.25 294.42 300.29 307.32 318.76 328.15 332.84 339.88 346.91 351.31 356.00 358.35 360.70 363.04 365.39 370.08 374.77 381.81 388.55 397.94 409.67 423.45 439.87 458.35 479.46 500.28 523.74 546.91 572.42 598.23 626.09

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 653.94 684.15 714.65 747.20 763.33 795.88 824.03 842.50 865.67 879.75 879.75

*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. 08/23/2016

18-24

Region 18 Gold Access+ HMO® 500/35 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

222.95 351.11 351.11 351.11 351.11 352.51 359.53 367.96 381.65 392.89 398.51 406.93 415.36 420.62 426.24 429.05 431.86 434.67 437.48 443.10 448.71 457.14 465.22 476.45 490.50 507.00 526.66 548.78 574.06 598.99 627.08 654.81 685.36 716.26 749.61

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

782.97 819.13 855.65 894.62 913.93 952.90 986.61 1008.73 1036.46 1053.32 1053.32

*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. 08/23/2016

18-25

Region 18 Gold Local Access+ HMO® 500/35 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

210.78 331.94 331.94 331.94 331.94 333.27 339.91 347.88 360.82 371.44 376.76 384.72 392.69 397.67 402.98 405.63 408.29 410.95 413.60 418.91 424.22 432.19 439.83 450.45 463.73 479.33 497.92 518.83 542.73 566.30 592.85 619.07 647.95 677.16 708.70

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 740.23 774.42 808.95 845.79 864.05 900.89 932.76 953.67 979.90 995.83 995.83

*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. 08/23/2016

18-26

Region 18 Gold Trio ACO HMO 500/35 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

190.85 300.55 300.55 300.55 300.55 301.75 307.76 314.97 326.70 336.31 341.12 348.33 355.55 360.06 364.86 367.27 369.67 372.08 374.48 379.29 384.10 391.31 398.23 407.84 419.86 433.99 450.82 469.76 491.40 512.73 536.78 560.52 586.67 613.12 641.67

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 670.22 701.18 732.43 765.79 782.33 815.69 844.54 863.47 887.22 901.64 901.64

*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. 08/23/2016

18-27

Region 18 Blue Shield Gold 80 HMO 0/30 + Child Dental INF* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

191.11 300.97 300.97 300.97 300.97 302.17 308.19 315.41 327.15 336.78 341.60 348.82 356.04 360.56 365.37 367.78 370.19 372.60 375.00 379.82 384.63 391.86 398.78 408.41 420.45 434.59 451.45 470.41 492.08 513.45 537.52 561.30 587.49 613.97 642.56

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 671.15 702.15 733.45 766.86 783.41 816.82 845.71 864.67 888.45 902.90 902.90

*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. 08/23/2016

18-28

Region 18 Platinum Access+ HMO® 0/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

235.97 371.60 371.60 371.60 371.60 373.09 380.52 389.44 403.93 415.82 421.77 430.68 439.60 445.18 451.12 454.09 457.07 460.04 463.01 468.96 474.90 483.82 492.37 504.26 519.12 536.59 557.40 580.81 607.57 633.95 663.68 693.03 725.36 758.06 793.37

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

828.67 866.94 905.59 946.84 967.27 1008.52 1044.20 1067.61 1096.96 1114.80 1114.80

*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. 08/23/2016

18-29

Region 18 Platinum Local Access+ HMO® 0/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

223.04 351.25 351.25 351.25 351.25 352.65 359.68 368.11 381.81 393.05 398.67 407.10 415.53 420.80 426.42 429.23 432.04 434.85 437.66 443.28 448.90 457.33 465.41 476.65 490.70 507.20 526.87 549.00 574.29 599.23 627.33 655.08 685.64 716.55 749.92

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

783.29 819.46 855.99 894.98 914.30 953.29 987.01 1009.14 1036.89 1053.75 1053.75

*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. 08/23/2016

18-30

Region 18 Platinum Trio ACO HMO 0/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

201.83 317.85 317.85 317.85 317.85 319.12 325.48 333.10 345.50 355.67 360.76 368.39 376.01 380.78 385.87 388.41 390.95 393.50 396.04 401.12 406.21 413.84 421.15 431.32 444.03 458.97 476.77 496.80 519.68 542.25 567.68 592.79 620.44 648.41 678.61

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 708.80 741.54 774.60 809.88 827.36 862.64 893.15 913.18 938.29 953.54 953.54

*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. 08/23/2016

18-31

Region 18 Platinum Access+ HMO® 0/25 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

238.03 374.84 374.84 374.84 374.84 376.34 383.84 392.84 407.45 419.45 425.45 434.44 443.44 449.06 455.06 458.06 461.06 464.06 467.05 473.05 479.05 488.05 496.67 508.66 523.66 541.27 562.27 585.88 612.87 639.48 669.47 699.08 731.69 764.68 800.29

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

835.90 874.51 913.49 955.10 975.72 1017.33 1053.31 1076.93 1106.54 1124.53 1124.53

*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. 08/23/2016

18-32

Region 18 Platinum Local Access+ HMO® 0/25 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

224.98 354.30 354.30 354.30 354.30 355.72 362.81 371.31 385.13 396.47 402.14 410.64 419.14 424.46 430.13 432.96 435.80 438.63 441.46 447.13 452.80 461.31 469.45 480.79 494.96 511.62 531.46 553.78 579.29 604.44 632.79 660.78 691.60 722.78 756.44

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

790.10 826.59 863.44 902.77 922.26 961.58 995.60 1017.92 1045.91 1062.91 1062.91

*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. 08/23/2016

18-33

Region 18 Platinum Trio ACO HMO 0/25 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

203.57 320.59 320.59 320.59 320.59 321.87 328.28 335.97 348.48 358.74 363.87 371.56 379.25 384.06 389.19 391.76 394.32 396.89 399.45 404.58 409.71 417.40 424.78 435.04 447.86 462.93 480.88 501.08 524.16 546.92 572.57 597.89 625.78 654.00 684.45

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 714.91 747.93 781.27 816.85 834.49 870.07 900.85 921.05 946.37 961.76 961.76

*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. 08/23/2016

18-34

Region 18 Platinum Access+ HMO® 0/20 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

240.38 378.55 378.55 378.55 378.55 380.07 387.64 396.72 411.48 423.60 429.66 438.74 447.83 453.50 459.56 462.59 465.62 468.65 471.67 477.73 483.79 492.87 501.58 513.69 528.84 546.63 567.83 591.68 618.93 645.81 676.09 706.00 738.93 772.24 808.21

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

844.17 883.16 922.53 964.55 985.37 1027.39 1063.73 1087.58 1117.48 1135.65 1135.65

*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. 08/23/2016

18-35

Region 18 Platinum Local Access+ HMO® 0/20 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

227.20 357.80 357.80 357.80 357.80 359.23 366.38 374.97 388.93 400.38 406.10 414.69 423.27 428.64 434.37 437.23 440.09 442.95 445.82 451.54 457.27 465.85 474.08 485.53 499.84 516.66 536.70 559.24 585.00 610.40 639.03 667.29 698.42 729.91 763.90

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

797.89 834.74 871.95 911.67 931.35 971.06 1005.41 1027.95 1056.22 1073.39 1073.39

*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. 08/23/2016

18-36

Region 18 Platinum Trio ACO HMO 0/20 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

205.56 323.72 323.72 323.72 323.72 325.01 331.49 339.25 351.88 362.24 367.42 375.19 382.96 387.81 392.99 395.58 398.17 400.76 403.35 408.53 413.71 421.48 428.92 439.28 452.23 467.45 485.57 505.97 529.28 552.26 578.16 603.73 631.89 660.38 691.13

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 721.89 755.23 788.90 824.83 842.63 878.57 909.64 930.04 955.61 971.15 971.15

*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. 08/23/2016

18-37

Region 18 Blue Shield Platinum 90 HMO 0/15 + Child Dental INF* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

202.75 319.29 319.29 319.29 319.29 320.56 326.95 334.61 347.06 357.28 362.39 370.05 377.72 382.51 387.61 390.17 392.72 395.28 397.83 402.94 408.05 415.71 423.05 433.27 446.04 461.05 478.93 499.05 522.03 544.70 570.25 595.47 623.25 651.34 681.68

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 712.01 744.90 778.10 813.54 831.10 866.54 897.20 917.31 942.53 957.86 957.86

*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. 08/23/2016

18-38

Region 18 Specialty Benefits Dental Employee

Rates are for groups with 1-50 eligible employees. DENTAL PPO Smile (SM) Basic Voluntary 75/1000/No Ortho/MAC Smile (SM) Basic 75/1000/No Ortho/MAC Smile (SM) Plus Gold 50/1500/Ortho/U85 Smile (SM) Value 50/1500/No Ortho/MAC Smile (SM) Plus 50/1500/Ortho/MAC Smile (SM) 50/1500/No Ortho/MAC Smile (SM) Deluxe Gold 50/1500/Ortho/U85 Smile (SM) Deluxe 50/1500/Ortho/MAC Smile (SM) Deluxe Plus 2000 50/2000/Ortho/MAC Smile (SM) Deluxe 2000 50/2000/No Ortho/MAC

Employee + spouse

Employee + child(ren)

Employee + family

35.30 28.50 65.30 38.10 50.60 45.50 80.30 51.50 66.90 59.70

70.60 57.20 131.40 76.00 101.20 89.80 159.40 103.10 133.70 120.30

89.30 73.50 165.20 97.60 128.00 114.10 200.10 130.70 168.10 151.40

119.50 98.90 222.20 114.00 148.70 133.20 269.80 174.20 226.40 203.40

ULTIMATE DENTAL PPO FOR SMALL BUSINESS Ultimate Dental PPO for Small Business 50/2000 Ultimate Dental Plus PPO for Small Business 50/2000

57.20 65.00

115.30 129.80

145.00 163.30

194.90 220.00

SMILE(SM) IN-NETWORK ONLY DENTAL PLAN* 50/1500/Endo-Perio 80%/No Ortho 50/1500/Endo-Perio 80%/Ortho 50/2500/Endo-Perio 80%/No Ortho 50/2500/Endo-Perio 80%/Ortho

37.50 40.60 59.80 66.90

74.90 80.90 120.40 133.70

96.10 103.90 151.80 168.20

112.40 121.40 204.60 226.90

SMILE(SM) IN-NETWORK ONLY DENTAL VOLUNTARY PLAN* 50/1500/EndoPerio 50%/No Ortho 50/1500/EndoPerio 50%/Ortho 50/2500/Endo-Perio 50%/No Ortho 50/2500/Endo-Perio 50%/Ortho

35.60 43.80 56.80 72.40

71.10 87.50 114.50 144.60

91.30 112.20 144.30 181.80

106.70 131.30 194.20 245.40

DENTAL HMO¹ DHMO Basic DHMO Voluntary DHMO Plus DHMO Deluxe

13.50 18.90 20.40 23.70

28.20 37.70 43.40 47.50

36.20 44.10 51.70 55.40

45.30 56.70 65.20 71.20

*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 located in each region. 08/23/2016

18-39

Region 18 Specialty Benefits Dental Employee

Rates are for groups with 51-100 eligible employees. DENTAL PPO Smile (SM) Basic Voluntary 75/1000/No Ortho/MAC Smile (SM) Basic 75/1000/No Ortho/MAC Smile (SM) Plus Gold 50/1500/Ortho/U85 Smile (SM) Value 50/1500/No Ortho/MAC Smile (SM) Plus 50/1500/Ortho/MAC Smile (SM) 50/1500/No Ortho/MAC Smile (SM) Deluxe Gold 50/1500/Ortho/U85 Smile (SM) Deluxe 50/1500/Ortho/MAC Smile (SM) Deluxe Plus 2000 50/2000/Ortho/MAC Smile (SM) Deluxe 2000 50/2000/No Ortho/MAC

Employee + spouse

Employee + child(ren)

Employee + family

26.50 21.40 48.90 28.60 37.90 34.10 60.20 38.60 50.20 44.80

52.90 42.90 98.60 57.00 75.90 67.40 119.50 77.30 100.20 90.20

67.00 55.10 123.90 73.20 96.00 85.60 150.10 98.00 126.10 113.50

89.60 74.20 166.70 85.50 111.50 99.90 202.40 130.70 169.80 152.60

ULTIMATE DENTAL PPO FOR SMALL BUSINESS Ultimate Dental PPO for Small Business 50/2000 Ultimate Dental Plus PPO for Small Business 50/2000

42.90 48.70

86.50 97.30

108.70 122.40

146.10 165.00

SMILE(SM) IN-NETWORK ONLY DENTAL PLAN* 50/1500/Endo-Perio 80%/No Ortho 50/1500/Endo-Perio 80%/Ortho 50/2500/Endo-Perio 80%/No Ortho 50/2500/Endo-Perio 80%/Ortho

28.10 30.40 44.80 50.20

56.20 60.70 90.30 100.30

72.10 77.90 113.90 126.20

84.30 91.10 153.40 170.20

SMILE(SM) IN-NETWORK ONLY DENTAL VOLUNTARY PLAN* 50/1500/EndoPerio 50%/No Ortho 50/1500/EndoPerio 50%/Ortho 50/2500/Endo-Perio 50%/No Ortho 50/2500/Endo-Perio 50%/Ortho

26.70 32.90 42.60 54.30

53.30 65.60 85.90 108.50

68.40 84.20 108.20 136.40

80.10 98.50 145.70 184.10

DENTAL HMO¹ DHMO Basic DHMO Voluntary DHMO Plus DHMO Deluxe

11.60 16.20 17.50 20.30

24.20 32.30 37.20 40.70

31.10 37.80 44.30 47.50

38.80 48.60 55.90 61.00

*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 located in each region. 08/23/2016

18-40

Region 18 Specialty Benefits Vision and Optional Product Employee

Rates are for groups with 1-50 eligible employees. ENHANCED VISION FOR SMALL BUSINESS* Enhanced Vision Voluntary¹ for Small Business 15/25/120 Enhanced Vision for Small Business 15/25/120 Enhanced Vision for Small Business 0/0/120 Enhanced Vision for Small Business 15/25/150 Enhanced Vision Plus for Small Business 15/25/150/120 Enhanced Vision for Small Business 0/0/150 Enhanced Vision Plus for Small Business 0/0/150/120

Employee + spouse

Employee + child(ren)

Employee + family

9.80 6.90 9.00 8.00 10.60 10.50 13.00

18.60 13.00 17.10 15.10 20.00 19.80 24.70

17.10 12.00 15.80 13.90 18.40 18.20 22.70

24.20 17.00 22.30 19.80 26.00 25.80 32.20

PREFERRED VISION FOR SMALL BUSINESS* Preferred Vision Voluntary¹ for Small Business 15/25/120 Preferred Vision for Small Business 15/25/120 Preferred Vision for Small Business 0/0/120 Preferred Vision for Small Business 15/25/150 Preferred Vision Plus for Small Business 15/25/150/120 Preferred Vision for Small Business 0/0/150 Preferred Vision Plus for Small Business 0/0/150/120

10.60 7.40 9.80 8.70 11.40 11.40 14.00

20.20 14.10 18.60 16.50 21.50 21.50 26.50

18.50 13.00 17.10 15.20 19.80 19.80 24.40

26.20 18.30 24.20 21.50 28.00 28.00 34.50

ULTIMATE VISION FOR SMALL BUSINESS* Ultimate Vision for Small Business 15/25/120 Ultimate Vision for Small Business 0/0/120 Ultimate Vision Voluntary¹ for Small Business 15/25/150 Ultimate Vision for Small Business 15/25/150 Ultimate Vision Plus for Small Business 15/25/150/120 Ultimate Vision for Small Business 0/0/150 Ultimate Vision Plus for Small Business 0/0/150/120

10.60 13.80 17.70 12.40 16.60 16.00 20.20

20.20 26.10 33.40 23.40 31.50 30.30 38.20

18.50 23.90 30.80 21.60 29.00 27.80 35.10

26.20 33.90 43.60 30.60 41.00 39.40 49.70

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

_____________________ OPTIONAL PRODUCT INFERTILITY** PPO and HSA-HDHP Only

All Ages 15.90

*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 Exchange Package 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 located in each region. 08/23/2016

18-41

Region 18 Specialty Benefits Vision and Optional Product Employee

Rates are for groups with 51-100 eligible employees. ENHANCED VISION FOR SMALL BUSINESS* Enhanced Vision Voluntary¹ for Small Business 15/25/120 Enhanced Vision for Small Business 15/25/120 Enhanced Vision for Small Business 0/0/120 Enhanced Vision for Small Business 15/25/150 Enhanced Vision Plus for Small Business 15/25/150/120 Enhanced Vision for Small Business 0/0/150 Enhanced Vision Plus for Small Business 0/0/150/120

Employee + spouse

Employee + child(ren)

Employee + family

7.90 5.50 7.20 6.40 8.40 8.40 10.40

14.90 10.40 13.70 12.10 16.00 15.90 19.80

13.70 9.60 12.60 11.10 14.70 14.60 18.20

19.40 13.60 17.90 15.80 20.80 20.70 25.70

PREFERRED VISION FOR SMALL BUSINESS* Preferred Vision Voluntary¹ for Small Business 15/25/120 Preferred Vision for Small Business 15/25/120 Preferred Vision for Small Business 0/0/120 Preferred Vision for Small Business 15/25/150 Preferred Vision Plus for Small Business 15/25/150/120 Preferred Vision for Small Business 0/0/150 Preferred Vision Plus for Small Business 0/0/150/120

8.50 6.00 7.90 7.00 9.10 9.10 11.20

16.10 11.30 14.90 13.20 17.20 17.20 21.20

14.80 10.40 13.70 12.20 15.80 15.80 19.50

21.00 14.70 19.40 17.20 22.40 22.40 27.60

ULTIMATE VISION FOR SMALL BUSINESS* Ultimate Vision for Small Business 15/25/120 Ultimate Vision for Small Business 0/0/120 Ultimate Vision Voluntary¹ for Small Business 15/25/150 Ultimate Vision for Small Business 15/25/150 Ultimate Vision Plus for Small Business 15/25/150/120 Ultimate Vision for Small Business 0/0/150 Ultimate Vision Plus for Small Business 0/0/150/120

8.50 11.00 14.10 9.90 13.30 12.80 16.10

16.10 20.90 26.80 18.80 25.20 24.30 30.50

14.80 19.10 24.60 17.30 23.20 22.30 28.10

21.00 27.10 34.90 24.40 32.80 31.60 39.70

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

_____________________ OPTIONAL PRODUCT INFERTILITY** PPO and HSA-HDHP Only

All Ages 15.90

*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 Exchange Package 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 located in each region. 08/23/2016

18-42

Region 19 Blue Shield Bronze 60 PPO 6300/75 + Child Dental Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

178.74 281.48 281.48 281.48 281.48 282.61 288.24 295.00 305.97 314.98 319.48 326.24 333.00 337.22 341.72 343.97 346.23 348.48 350.73 355.23 359.74 366.49 372.97 381.97 393.23 406.46 422.23 439.96 460.23 480.21 502.73 524.97 549.46 574.23 600.97

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 627.71 656.70 685.98 717.22 732.70 763.95 790.97 808.70 830.94 844.45 844.45

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. 08/23/2016

19-1

Region 19 Bronze Full PPO 5100/60 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

197.30 310.71 310.71 310.71 310.71 311.95 318.17 325.62 337.74 347.68 352.66 360.11 367.57 372.23 377.20 379.69 382.17 384.66 387.15 392.12 397.09 404.54 411.69 421.63 434.06 448.67 466.07 485.64 508.01 530.07 554.93 579.47 606.51 633.85 663.37

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 692.88 724.89 757.20 791.69 808.78 843.27 873.10 892.67 917.22 932.13 932.13

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. 08/23/2016

19-2

Region 19 Bronze Full PPO 3750/65 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

193.67 304.99 304.99 304.99 304.99 306.21 312.31 319.63 331.52 341.28 346.16 353.48 360.80 365.38 370.26 372.70 375.14 377.58 380.02 384.90 389.78 397.10 404.11 413.87 426.07 440.41 457.49 476.70 498.66 520.31 544.71 568.81 595.34 622.18 651.15

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 680.13 711.54 743.26 777.12 793.89 827.74 857.02 876.24 900.33 914.97 914.97

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. 08/23/2016

19-3

Region 19 Blue Shield Silver 70 PPO 2000/45 + Child Dental Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

235.37 370.67 370.67 370.67 370.67 372.15 379.56 388.46 402.91 414.78 420.71 429.60 438.50 444.06 449.99 452.95 455.92 458.88 461.85 467.78 473.71 482.61 491.13 502.99 517.82 535.24 556.00 579.35 606.04 632.36 662.01 691.29 723.54 756.16 791.37

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

826.59 864.76 903.31 944.46 964.84 1005.99 1041.57 1064.92 1094.21 1112.00 1112.00

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. 08/23/2016

19-4

Region 19 Silver Full PPO 1700/40 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

223.52 351.99 351.99 351.99 351.99 353.40 360.44 368.89 382.62 393.88 399.51 407.96 416.41 421.69 427.32 430.14 432.95 435.77 438.58 444.22 449.85 458.30 466.39 477.65 491.73 508.28 527.99 550.17 575.51 600.50 628.66 656.47 687.09 718.07 751.51

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

784.94 821.20 857.81 896.88 916.24 955.31 989.10 1011.28 1039.08 1055.98 1055.98

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. 08/23/2016

19-5

Region 19 Silver Full PPO 1300/45 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

222.59 350.54 350.54 350.54 350.54 351.94 358.95 367.37 381.04 392.26 397.86 406.28 414.69 419.95 425.56 428.36 431.17 433.97 436.77 442.38 447.99 456.40 464.47 475.68 489.71 506.18 525.81 547.90 573.13 598.02 626.07 653.76 684.26 715.10 748.40

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

781.71 817.81 854.27 893.18 912.46 951.37 985.02 1007.10 1034.80 1051.62 1051.62

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. 08/23/2016

19-6

Region 19 Gold Full PPO 1000/35 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

246.63 388.39 388.39 388.39 388.39 389.94 397.71 407.03 422.18 434.61 440.82 450.14 459.46 465.29 471.50 474.61 477.72 480.82 483.93 490.14 496.36 505.68 514.61 527.04 542.58 560.83 582.58 607.05 635.01 662.59 693.66 724.34 758.13 792.31 829.21

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

866.10 906.11 946.50 989.61 1010.97 1054.08 1091.37 1115.84 1146.52 1165.16 1165.16

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. 08/23/2016

19-7

Region 19 Gold Full PPO 750/20 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

257.36 405.30 405.30 405.30 405.30 406.92 415.02 424.75 440.56 453.53 460.01 469.74 479.47 485.55 492.03 495.27 498.52 501.76 505.00 511.48 517.97 527.70 537.02 549.99 566.20 585.25 607.95 633.48 662.66 691.44 723.86 755.88 791.14 826.81 865.31

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

903.81 945.56 987.71 1032.70 1054.99 1099.98 1138.88 1164.42 1196.44 1215.89 1215.89

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. 08/23/2016

19-8

Region 19 Gold Full PPO 250/30 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

268.00 422.04 422.04 422.04 422.04 423.73 432.17 442.30 458.76 472.26 479.02 489.15 499.28 505.61 512.36 515.74 519.11 522.49 525.86 532.62 539.37 549.50 559.21 572.71 589.59 609.43 633.06 659.65 690.04 720.00 753.77 787.11 823.83 860.97 901.06

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

941.15 984.62 1028.52 1075.36 1098.58 1145.42 1185.94 1212.53 1245.87 1266.13 1266.13

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. 08/23/2016

19-9

Region 19 Blue Shield Gold 80 PPO 0/30 + Child Dental Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

281.11 442.69 442.69 442.69 442.69 444.46 453.31 463.94 481.20 495.37 502.45 513.08 523.70 530.34 537.42 540.96 544.51 548.05 551.59 558.67 565.76 576.38 586.56 600.73 618.44 639.24 664.03 691.92 723.79 755.23 790.64 825.61 864.13 903.08 945.14

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

987.19 1032.79 1078.83 1127.97 1152.32 1201.46 1243.95 1271.84 1306.82 1328.06 1328.06

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. 08/23/2016

19-10

Region 19 Gold Full PPO 0/20 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

267.00 420.47 420.47 420.47 420.47 422.16 430.57 440.66 457.06 470.51 477.24 487.33 497.42 503.73 510.46 513.82 517.18 520.55 523.91 530.64 537.37 547.46 557.13 570.58 587.40 607.17 630.71 657.20 687.48 717.33 750.97 784.19 820.77 857.77 897.71

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

937.66 980.97 1024.70 1071.37 1094.50 1141.17 1181.53 1208.02 1241.24 1261.42 1261.42

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. 08/23/2016

19-11

Region 19 Platinum Full PPO 150/15 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

305.83 481.62 481.62 481.62 481.62 483.55 493.18 504.74 523.52 538.94 546.64 558.20 569.76 576.98 584.69 588.54 592.40 596.25 600.10 607.81 615.51 627.07 638.15 653.56 672.83 695.46 722.44 752.78 787.45 821.65 860.18 898.23 940.13 982.51 1028.27

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

1074.02 1123.63 1173.72 1227.18 1253.67 1307.13 1353.36 1383.70 1421.75 1444.87 1444.87

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. 08/23/2016

19-12

Region 19 Blue Shield Platinum 90 PPO 0/15 + Child Dental Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

315.26 496.48 496.48 496.48 496.48 498.47 508.40 520.31 539.67 555.56 563.50 575.42 587.34 594.78 602.73 606.70 610.67 614.64 618.61 626.56 634.50 646.42 657.84 673.72 693.58 716.92 744.72 776.00 811.74 846.99 886.71 925.93 969.13 1012.82 1059.98

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

1107.15 1158.29 1209.92 1265.03 1292.34 1347.45 1395.11 1426.39 1465.61 1489.44 1489.44

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. 08/23/2016

19-13

Region 19 Platinum Full PPO 0/10 OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

317.95 500.71 500.71 500.71 500.71 502.72 512.73 524.75 544.28 560.30 568.31 580.33 592.35 599.86 607.87 611.87 615.88 619.88 623.89 631.90 639.91 651.93 663.45 679.47 699.50 723.03 751.07 782.62 818.67 854.22 894.28 933.83 977.39 1021.46 1069.03

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

1116.59 1168.17 1220.24 1275.82 1303.36 1358.94 1407.01 1438.55 1478.11 1502.14 1502.14

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. 08/23/2016

19-14

Region 19 Bronze Full PPO Savings 5500/40% OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

196.57 309.56 309.56 309.56 309.56 310.80 316.99 324.42 336.50 346.40 351.35 358.78 366.21 370.86 375.81 378.29 380.76 383.24 385.72 390.67 395.62 403.05 410.17 420.08 432.46 447.01 464.35 483.85 506.14 528.12 552.88 577.34 604.27 631.51 660.92

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 690.33 722.21 754.41 788.77 805.79 840.16 869.87 889.38 913.83 928.69 928.69

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. 08/23/2016

19-15

Region 19 Bronze Full PPO Savings 4700/40% OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

198.77 313.02 313.02 313.02 313.02 314.27 320.53 328.04 340.25 350.27 355.28 362.79 370.30 375.00 380.01 382.51 385.01 387.52 390.02 395.03 400.04 407.55 414.75 424.77 437.29 452.00 469.53 489.25 511.79 534.01 559.05 583.78 611.01 638.56 668.30

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 698.03 730.27 762.83 797.57 814.79 849.53 879.58 899.30 924.03 939.06 939.06

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. 08/23/2016

19-16

Region 19 Silver Full PPO Savings 2000/20% OffEx Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

247.47 389.72 389.72 389.72 389.72 391.28 399.07 408.43 423.62 436.10 442.33 451.68 461.04 466.88 473.12 476.24 479.35 482.47 485.59 491.83 498.06 507.41 516.38 528.85 544.44 562.75 584.58 609.13 637.19 664.86 696.04 726.83 760.73 795.03 832.05

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

869.07 909.22 949.75 993.01 1014.44 1057.70 1095.11 1119.66 1150.45 1169.16 1169.16

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. 08/23/2016

19-17

Region 19 Blue Shield Silver 70 HMO 2000/45 + Child Dental INF* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

219.68 345.95 345.95 345.95 345.95 347.33 354.25 362.55 376.04 387.11 392.65 400.95 409.25 414.44 419.98 422.75 425.51 428.28 431.05 436.58 442.12 450.42 458.38 469.45 483.29 499.55 518.92 540.71 565.62 590.18 617.86 645.19 675.29 705.73 738.60

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

771.46 807.09 843.07 881.47 900.50 938.90 972.11 993.90 1021.23 1037.84 1037.84

*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. 08/23/2016

19-18

Region 19 Silver Access+ HMO® 1700/55 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

231.89 365.17 365.17 365.17 365.17 366.64 373.94 382.70 396.95 408.63 414.47 423.24 432.00 437.48 443.32 446.24 449.17 452.09 455.01 460.85 466.69 475.46 483.86 495.54 510.15 527.31 547.76 570.77 597.06 622.99 652.20 681.05 712.82 744.96 779.65

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

814.34 851.95 889.93 930.47 950.55 991.08 1026.14 1049.15 1078.00 1095.52 1095.52

*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. 08/23/2016

19-19

Region 19 Silver Local Access+ HMO® 1700/55 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

227.90 358.89 358.89 358.89 358.89 360.33 367.51 376.12 390.12 401.60 407.34 415.96 424.57 429.95 435.69 438.57 441.44 444.31 447.18 452.92 458.66 467.28 475.53 487.02 501.37 518.24 538.34 560.95 586.79 612.27 640.98 669.33 700.56 732.14 766.23

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

800.33 837.29 874.62 914.46 934.20 974.03 1008.49 1031.10 1059.45 1076.68 1076.68

*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. 08/23/2016

19-20

Region 19 Silver Trio ACO HMO 1700/55 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

205.06 322.93 322.93 322.93 322.93 324.22 330.68 338.43 351.02 361.36 366.52 374.27 382.02 386.87 392.03 394.62 397.20 399.78 402.37 407.53 412.70 420.45 427.88 438.21 451.13 466.31 484.39 504.73 527.99 550.91 576.75 602.26 630.35 658.77 689.45

Age 55 56 57 58 59 60 61 62 63 64 65 and over

Member Rate 720.13 753.39 786.97 822.82 840.58 876.42 907.42 927.77 953.28 968.78 968.78

*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. 08/23/2016

19-21

Region 19 Gold Access+ HMO® 1700/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

245.24 386.20 386.20 386.20 386.20 387.75 395.47 404.74 419.80 432.16 438.34 447.61 456.88 462.67 468.85 471.94 475.03 478.12 481.21 487.39 493.57 502.84 511.72 524.08 539.53 557.68 579.31 603.64 631.44 658.86 689.76 720.27 753.87 787.86 824.55

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

861.23 901.01 941.18 984.05 1005.29 1048.16 1085.23 1109.56 1140.07 1158.61 1158.61

*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. 08/23/2016

19-22

Region 19 Gold Local Access+ HMO® 1700/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

240.97 379.48 379.48 379.48 379.48 381.00 388.59 397.69 412.49 424.64 430.71 439.82 448.92 454.62 460.69 463.72 466.76 469.79 472.83 478.90 484.97 494.08 502.81 514.95 530.13 547.97 569.22 593.13 620.45 647.39 677.75 707.73 740.74 774.14 810.19

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

846.24 885.32 924.79 966.91 987.78 1029.91 1066.34 1090.24 1120.22 1138.44 1138.44

*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. 08/23/2016

19-23

Region 19 Gold Trio ACO HMO 1700/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

216.69 341.25 341.25 341.25 341.25 342.61 349.44 357.62 370.93 381.85 387.31 395.50 403.69 408.81 414.27 417.00 419.73 422.46 425.19 430.65 436.11 444.30 452.15 463.07 476.72 492.76 511.87 533.37 557.94 582.16 609.46 636.42 666.11 696.14 728.56

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

760.98 796.12 831.61 869.49 888.26 926.14 958.90 980.40 1007.36 1023.74 1023.74

*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. 08/23/2016

19-24

Region 19 Gold Access+ HMO® 500/35 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

251.43 395.95 395.95 395.95 395.95 397.54 405.46 414.96 430.40 443.07 449.41 458.91 468.41 474.35 480.69 483.86 487.02 490.19 493.36 499.69 506.03 515.53 524.64 537.31 553.15 571.76 593.93 618.88 647.38 675.50 707.17 738.45 772.90 807.75 845.36

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

882.98 923.76 964.94 1008.89 1030.67 1074.62 1112.63 1137.58 1168.86 1187.86 1187.86

*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. 08/23/2016

19-25

Region 19 Gold Local Access+ HMO® 500/35 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

247.03 389.02 389.02 389.02 389.02 390.58 398.36 407.70 422.87 435.32 441.54 450.88 460.22 466.05 472.27 475.39 478.50 481.61 484.72 490.95 497.17 506.51 515.46 527.91 543.47 561.75 583.54 608.04 636.05 663.67 694.80 725.53 759.37 793.61 830.57

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

867.52 907.59 948.05 991.23 1012.63 1055.81 1093.16 1117.67 1148.40 1167.07 1167.07

*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. 08/23/2016

19-26

Region 19 Gold Trio ACO HMO 500/35 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

222.08 349.74 349.74 349.74 349.74 351.14 358.13 366.53 380.17 391.36 396.95 405.35 413.74 418.99 424.58 427.38 430.18 432.98 435.77 441.37 446.97 455.36 463.40 474.59 488.58 505.02 524.61 546.64 571.82 596.65 624.63 652.26 682.69 713.47 746.69

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

779.92 815.94 852.31 891.13 910.37 949.19 982.76 1004.80 1032.43 1049.22 1049.22

*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. 08/23/2016

19-27

Region 19 Blue Shield Gold 80 HMO 0/30 + Child Dental INF* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

222.39 350.23 350.23 350.23 350.23 351.63 358.63 367.04 380.69 391.90 397.51 405.91 414.32 419.57 425.17 427.98 430.78 433.58 436.38 441.98 447.59 455.99 464.05 475.26 489.26 505.73 525.34 547.40 572.62 597.48 625.50 653.17 683.64 714.46 747.73

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

781.00 817.08 853.50 892.37 911.64 950.51 984.13 1006.20 1033.86 1050.68 1050.68

*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. 08/23/2016

19-28

Region 19 Platinum Access+ HMO® 0/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

266.11 419.07 419.07 419.07 419.07 420.74 429.12 439.18 455.52 468.93 475.64 485.70 495.75 502.04 508.75 512.10 515.45 518.80 522.16 528.86 535.57 545.62 555.26 568.67 585.43 605.13 628.60 655.00 685.17 714.93 748.45 781.56 818.02 854.89 894.70

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

934.52 977.68 1021.26 1067.78 1090.83 1137.34 1177.57 1203.97 1237.08 1257.20 1257.20

*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. 08/23/2016

19-29

Region 19 Platinum Local Access+ HMO® 0/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

261.40 411.65 411.65 411.65 411.65 413.30 421.53 431.41 447.46 460.64 467.22 477.10 486.98 493.16 499.74 503.04 506.33 509.62 512.92 519.50 526.09 535.97 545.44 558.61 575.07 594.42 617.47 643.41 673.05 702.27 735.21 767.73 803.54 839.76 878.87

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

917.98 960.38 1003.19 1048.88 1071.52 1117.22 1156.73 1182.67 1215.19 1234.95 1234.95

*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. 08/23/2016

19-30

Region 19 Platinum Trio ACO HMO 0/30 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

234.87 369.87 369.87 369.87 369.87 371.35 378.75 387.62 402.05 413.89 419.80 428.68 437.56 443.11 449.02 451.98 454.94 457.90 460.86 466.78 472.69 481.57 490.08 501.91 516.71 534.09 554.81 578.11 604.74 631.00 660.59 689.81 721.99 754.54 789.67

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

824.81 862.91 901.37 942.43 962.77 1003.83 1039.34 1062.64 1091.86 1109.61 1109.61

*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. 08/23/2016

19-31

Region 19 Platinum Access+ HMO® 0/25 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

268.43 422.72 422.72 422.72 422.72 424.41 432.87 443.01 459.50 473.03 479.79 489.94 500.08 506.42 513.19 516.57 519.95 523.33 526.71 533.48 540.24 550.39 560.11 573.64 590.54 610.41 634.08 660.72 691.15 721.17 754.98 788.38 825.16 862.36 902.51

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

942.67 986.21 1030.18 1077.10 1100.35 1147.27 1187.85 1214.48 1247.88 1268.17 1268.17

*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. 08/23/2016

19-32

Region 19 Platinum Local Access+ HMO® 0/25 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

263.67 415.23 415.23 415.23 415.23 416.89 425.20 435.16 451.36 464.64 471.29 481.25 491.22 497.45 504.09 507.41 510.73 514.06 517.38 524.02 530.66 540.63 550.18 563.47 580.08 599.59 622.85 649.01 678.90 708.38 741.60 774.40 810.53 847.07 886.52

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

925.96 968.73 1011.92 1058.01 1080.85 1126.94 1166.80 1192.96 1225.76 1245.69 1245.69

*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. 08/23/2016

19-33

Region 19 Platinum Trio ACO HMO 0/25 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

236.89 373.06 373.06 373.06 373.06 374.55 382.01 390.96 405.51 417.45 423.42 432.37 441.33 446.92 452.89 455.88 458.86 461.84 464.83 470.80 476.77 485.72 494.30 506.24 521.16 538.69 559.59 583.09 609.95 636.44 666.28 695.75 728.21 761.04 796.48

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

831.92 870.34 909.14 950.55 971.07 1012.48 1048.29 1071.79 1101.27 1119.17 1119.17

*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. 08/23/2016

19-34

Region 19 Platinum Access+ HMO® 0/20 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

271.08 426.90 426.90 426.90 426.90 428.61 437.15 447.40 464.05 477.71 484.54 494.78 505.03 511.43 518.26 521.68 525.09 528.51 531.92 538.75 545.58 555.83 565.65 579.31 596.39 616.45 640.36 667.25 697.99 728.30 762.45 796.18 833.32 870.88 911.44

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

952.00 995.97 1040.37 1087.75 1111.23 1158.62 1199.60 1226.50 1260.22 1280.71 1280.71

*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. 08/23/2016

19-35

Region 19 Platinum Local Access+ HMO® 0/20 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

266.27 419.32 419.32 419.32 419.32 421.00 429.39 439.45 455.80 469.22 475.93 486.00 496.06 502.35 509.06 512.41 515.77 519.12 522.48 529.19 535.90 545.96 555.60 569.02 585.80 605.50 628.99 655.40 685.59 715.37 748.91 782.04 818.52 855.42 895.26

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

935.09 978.28 1021.89 1068.44 1091.50 1138.04 1178.30 1204.72 1237.84 1257.97 1257.97

*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. 08/23/2016

19-36

Region 19 Platinum Trio ACO HMO 0/20 OffEx* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

239.20 376.70 376.70 376.70 376.70 378.21 385.74 394.78 409.47 421.53 427.55 436.59 445.64 451.29 457.31 460.33 463.34 466.35 469.37 475.39 481.42 490.46 499.13 511.18 526.25 543.95 565.05 588.78 615.90 642.65 672.79 702.54 735.32 768.47 804.25

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

840.04 878.84 918.02 959.83 980.55 1022.36 1058.53 1082.26 1112.02 1130.10 1130.10

*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. 08/23/2016

19-37

Region 19 Blue Shield Platinum 90 HMO 0/15 + Child Dental INF* Age

Member Rate

0-20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54

235.93 371.54 371.54 371.54 371.54 373.03 380.46 389.38 403.87 415.76 421.70 430.62 439.54 445.11 451.06 454.03 457.00 459.97 462.94 468.89 474.83 483.75 492.30 504.19 519.05 536.51 557.32 580.72 607.48 633.86 663.58 692.93 725.26 757.95 793.25

Age

Member Rate

55 56 57 58 59 60 61 62 63 64 65 and over

828.54 866.81 905.45 946.70 967.13 1008.37 1044.04 1067.45 1096.80 1114.63 1114.63

*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. 08/23/2016

19-38

Region 19 Specialty Benefits Dental Employee

Rates are for groups with 1-50 eligible employees. DENTAL PPO Smile (SM) Basic Voluntary 75/1000/No Ortho/MAC Smile (SM) Basic 75/1000/No Ortho/MAC Smile (SM) Plus Gold 50/1500/Ortho/U85 Smile (SM) Value 50/1500/No Ortho/MAC Smile (SM) Plus 50/1500/Ortho/MAC Smile (SM) 50/1500/No Ortho/MAC Smile (SM) Deluxe Gold 50/1500/Ortho/U85 Smile (SM) Deluxe 50/1500/Ortho/MAC Smile (SM) Deluxe Plus 2000 50/2000/Ortho/MAC Smile (SM) Deluxe 2000 50/2000/No Ortho/MAC

Employee + spouse

Employee + child(ren)

Employee + family

35.30 28.50 65.30 38.10 50.60 45.50 80.30 51.50 66.90 59.70

70.60 57.20 131.40 76.00 101.20 89.80 159.40 103.10 133.70 120.30

89.30 73.50 165.20 97.60 128.00 114.10 200.10 130.70 168.10 151.40

119.50 98.90 222.20 114.00 148.70 133.20 269.80 174.20 226.40 203.40

ULTIMATE DENTAL PPO FOR SMALL BUSINESS Ultimate Dental PPO for Small Business 50/2000 Ultimate Dental Plus PPO for Small Business 50/2000

57.20 65.00

115.30 129.80

145.00 163.30

194.90 220.00

SMILE(SM) IN-NETWORK ONLY DENTAL PLAN* 50/1500/Endo-Perio 80%/No Ortho 50/1500/Endo-Perio 80%/Ortho 50/2500/Endo-Perio 80%/No Ortho 50/2500/Endo-Perio 80%/Ortho

37.50 40.60 59.80 66.90

74.90 80.90 120.40 133.70

96.10 103.90 151.80 168.20

112.40 121.40 204.60 226.90

SMILE(SM) IN-NETWORK ONLY DENTAL VOLUNTARY PLAN* 50/1500/EndoPerio 50%/No Ortho 50/1500/EndoPerio 50%/Ortho 50/2500/Endo-Perio 50%/No Ortho 50/2500/Endo-Perio 50%/Ortho

35.60 43.80 56.80 72.40

71.10 87.50 114.50 144.60

91.30 112.20 144.30 181.80

106.70 131.30 194.20 245.40

DENTAL HMO¹ DHMO Basic DHMO Voluntary DHMO Plus DHMO Deluxe

13.50 18.90 20.40 23.70

28.20 37.70 43.40 47.50

36.20 44.10 51.70 55.40

45.30 56.70 65.20 71.20

*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 located in each region. 08/23/2016

19-39

Region 19 Specialty Benefits Dental Employee

Rates are for groups with 51-100 eligible employees. DENTAL PPO Smile (SM) Basic Voluntary 75/1000/No Ortho/MAC Smile (SM) Basic 75/1000/No Ortho/MAC Smile (SM) Plus Gold 50/1500/Ortho/U85 Smile (SM) Value 50/1500/No Ortho/MAC Smile (SM) Plus 50/1500/Ortho/MAC Smile (SM) 50/1500/No Ortho/MAC Smile (SM) Deluxe Gold 50/1500/Ortho/U85 Smile (SM) Deluxe 50/1500/Ortho/MAC Smile (SM) Deluxe Plus 2000 50/2000/Ortho/MAC Smile (SM) Deluxe 2000 50/2000/No Ortho/MAC

Employee + spouse

Employee + child(ren)

Employee + family

26.50 21.40 48.90 28.60 37.90 34.10 60.20 38.60 50.20 44.80

52.90 42.90 98.60 57.00 75.90 67.40 119.50 77.30 100.20 90.20

67.00 55.10 123.90 73.20 96.00 85.60 150.10 98.00 126.10 113.50

89.60 74.20 166.70 85.50 111.50 99.90 202.40 130.70 169.80 152.60

ULTIMATE DENTAL PPO FOR SMALL BUSINESS Ultimate Dental PPO for Small Business 50/2000 Ultimate Dental Plus PPO for Small Business 50/2000

42.90 48.70

86.50 97.30

108.70 122.40

146.10 165.00

SMILE(SM) IN-NETWORK ONLY DENTAL PLAN* 50/1500/Endo-Perio 80%/No Ortho 50/1500/Endo-Perio 80%/Ortho 50/2500/Endo-Perio 80%/No Ortho 50/2500/Endo-Perio 80%/Ortho

28.10 30.40 44.80 50.20

56.20 60.70 90.30 100.30

72.10 77.90 113.90 126.20

84.30 91.10 153.40 170.20

SMILE(SM) IN-NETWORK ONLY DENTAL VOLUNTARY PLAN* 50/1500/EndoPerio 50%/No Ortho 50/1500/EndoPerio 50%/Ortho 50/2500/Endo-Perio 50%/No Ortho 50/2500/Endo-Perio 50%/Ortho

26.70 32.90 42.60 54.30

53.30 65.60 85.90 108.50

68.40 84.20 108.20 136.40

80.10 98.50 145.70 184.10

DENTAL HMO¹ DHMO Basic DHMO Voluntary DHMO Plus DHMO Deluxe

11.60 16.20 17.50 20.30

24.20 32.30 37.20 40.70

31.10 37.80 44.30 47.50

38.80 48.60 55.90 61.00

*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 located in each region. 08/23/2016

19-40

Region 19 Specialty Benefits Vision and Optional Product Employee

Rates are for groups with 1-50 eligible employees. ENHANCED VISION FOR SMALL BUSINESS* Enhanced Vision Voluntary¹ for Small Business 15/25/120 Enhanced Vision for Small Business 15/25/120 Enhanced Vision for Small Business 0/0/120 Enhanced Vision for Small Business 15/25/150 Enhanced Vision Plus for Small Business 15/25/150/120 Enhanced Vision for Small Business 0/0/150 Enhanced Vision Plus for Small Business 0/0/150/120

Employee + spouse

Employee + child(ren)

Employee + family

9.80 6.90 9.00 8.00 10.60 10.50 13.00

18.60 13.00 17.10 15.10 20.00 19.80 24.70

17.10 12.00 15.80 13.90 18.40 18.20 22.70

24.20 17.00 22.30 19.80 26.00 25.80 32.20

PREFERRED VISION FOR SMALL BUSINESS* Preferred Vision Voluntary¹ for Small Business 15/25/120 Preferred Vision for Small Business 15/25/120 Preferred Vision for Small Business 0/0/120 Preferred Vision for Small Business 15/25/150 Preferred Vision Plus for Small Business 15/25/150/120 Preferred Vision for Small Business 0/0/150 Preferred Vision Plus for Small Business 0/0/150/120

10.60 7.40 9.80 8.70 11.40 11.40 14.00

20.20 14.10 18.60 16.50 21.50 21.50 26.50

18.50 13.00 17.10 15.20 19.80 19.80 24.40

26.20 18.30 24.20 21.50 28.00 28.00 34.50

ULTIMATE VISION FOR SMALL BUSINESS* Ultimate Vision for Small Business 15/25/120 Ultimate Vision for Small Business 0/0/120 Ultimate Vision Voluntary¹ for Small Business 15/25/150 Ultimate Vision for Small Business 15/25/150 Ultimate Vision Plus for Small Business 15/25/150/120 Ultimate Vision for Small Business 0/0/150 Ultimate Vision Plus for Small Business 0/0/150/120

10.60 13.80 17.70 12.40 16.60 16.00 20.20

20.20 26.10 33.40 23.40 31.50 30.30 38.20

18.50 23.90 30.80 21.60 29.00 27.80 35.10

26.20 33.90 43.60 30.60 41.00 39.40 49.70

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

_____________________ OPTIONAL PRODUCT INFERTILITY** PPO and HSA-HDHP Only

All Ages 15.90

*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 Exchange Package 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 located in each region. 08/23/2016

19-41

Region 19 Specialty Benefits Vision and Optional Product Employee

Rates are for groups with 51-100 eligible employees. ENHANCED VISION FOR SMALL BUSINESS* Enhanced Vision Voluntary¹ for Small Business 15/25/120 Enhanced Vision for Small Business 15/25/120 Enhanced Vision for Small Business 0/0/120 Enhanced Vision for Small Business 15/25/150 Enhanced Vision Plus for Small Business 15/25/150/120 Enhanced Vision for Small Business 0/0/150 Enhanced Vision Plus for Small Business 0/0/150/120

Employee + spouse

Employee + child(ren)

Employee + family

7.90 5.50 7.20 6.40 8.40 8.40 10.40

14.90 10.40 13.70 12.10 16.00 15.90 19.80

13.70 9.60 12.60 11.10 14.70 14.60 18.20

19.40 13.60 17.90 15.80 20.80 20.70 25.70

PREFERRED VISION FOR SMALL BUSINESS* Preferred Vision Voluntary¹ for Small Business 15/25/120 Preferred Vision for Small Business 15/25/120 Preferred Vision for Small Business 0/0/120 Preferred Vision for Small Business 15/25/150 Preferred Vision Plus for Small Business 15/25/150/120 Preferred Vision for Small Business 0/0/150 Preferred Vision Plus for Small Business 0/0/150/120

8.50 6.00 7.90 7.00 9.10 9.10 11.20

16.10 11.30 14.90 13.20 17.20 17.20 21.20

14.80 10.40 13.70 12.20 15.80 15.80 19.50

21.00 14.70 19.40 17.20 22.40 22.40 27.60

ULTIMATE VISION FOR SMALL BUSINESS* Ultimate Vision for Small Business 15/25/120 Ultimate Vision for Small Business 0/0/120 Ultimate Vision Voluntary¹ for Small Business 15/25/150 Ultimate Vision for Small Business 15/25/150 Ultimate Vision Plus for Small Business 15/25/150/120 Ultimate Vision for Small Business 0/0/150 Ultimate Vision Plus for Small Business 0/0/150/120

8.50 11.00 14.10 9.90 13.30 12.80 16.10

16.10 20.90 26.80 18.80 25.20 24.30 30.50

14.80 19.10 24.60 17.30 23.20 22.30 28.10

21.00 27.10 34.90 24.40 32.80 31.60 39.70

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

_____________________ OPTIONAL PRODUCT INFERTILITY** PPO and HSA-HDHP Only

All Ages 15.90

*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 Exchange Package 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 located in each region. 08/23/2016

19-42

Blue Shield of California is an independent member of the Blue Shield Association

Blue Shield of California 50 Beale Street, San Francisco, CA 94105 A46124-R11 (1/17)