small business rate tables Rate Book 10 Rating region 17: San Bernardino, Riverside
Effective October 2016 Includes rates for standard plans
blueshieldca.com
Blue Shield of California county grouping for Rate Book 10 Region 17 – Inland Empire: San Bernardino,1,2 Riverside1,2
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
Counties where Full network HMO is available. Counties where Dental HMO is available.
1
2
Small Business Rate Tables CONTENTS Life Insurance Rates
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2
Regional Groupings
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3
Small Business Rates: Region 17
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Life Insurance Rates for Blue Shield of California Group Plans 2-9 Eligible Employee Rate Table Effective October 2016 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 October 2016
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
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 AND MIRROR LOCAL ACCESS+ HMO® NETWORK RATING REGION DEFINITIONS AND AVAILABILITY Effective October 2016
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 MIRROR PLANS RATING REGION DEFINITIONS AND AVAILABILITY Effective October 2016
Rating Region
1
County
Access+ HMO® Network Availability
Local Access+ HMO® Network Availability
Select PPO Network Availability
Rating Region
Alpine
County
8
San Mateo4
9
Monterey
Access+ HMO® Network Availability
Local Access+ HMO® Network Availability
Select PPO Network Availability
Amador Butte
Calaveras
San Benito
Colusa
Santa Cruz
Del Norte 10
Glenn
Mariposa
Humboldt
Merced
Lake
San Joaquin
Lassen
Stanislaus
Mendocino
Tulare
Modoc Nevada1
11
Plumas Shasta
Fresno5
Kings Madera6
Sierra 12
Siskiyou Sutter Tehama
San Luis Obispo7
Santa Barbara Ventura8
Trinity 13
Tuolumne Yuba
Imperial
Inyo Mono
2
Marin
Napa
14
Kern9
15
Los Angeles ZIP Codes10
16
Los Angeles - Except ZIP Codes in Region 1511
17
Riverside12
San Bernardino13
18
Orange
19
San Diego14
Solano
Sonoma
3
El Dorado Placer Sacramento2
Yolo
4
San Francisco
5
Contra Costa 3
6
Alameda
7
Santa Clara
1
Access+ HMO® and Select PPO Network ZIP Code Exceptions: 95724, 95728, 95977, 96111, 96160-96162.
2
Local Access+ HMO® and Select PPO Network ZIP Code Exceptions: 95632, 95638-95639, 95641, 95671, 95680, 95683, 95690, 95693.
3
Local Access+ HMO® and Select PPO Network ZIP Code Exceptions: 94525, 94530, 94547, 94564, 94569, 94572, 94801-94808, 94820, 94850.
4
Local Access+ HMO® and Select PPO Network ZIP Code Exceptions: 94018-94021, 94028, 94037-94038, 94060, 94074, 94128.
5
Select PPO Network ZIP Code Exceptions: 00017.
6
Select PPO Network ZIP Code Exceptions: 00020.
7
Select PPO Network ZIP Code Exceptions: 00032.
8
Local Access+ HMO® and Select PPO Network ZIP Code Exceptions: 91358-91360, 91362, 91377, 93020-93021, 93040, 93042, 93062-93065, 93094, 93099. Local Access+ HMO® and Select PPO Network ZIP Code Exceptions: 93205-93206, 93220, 93222, 93224-93226, 93238, 93240, 93243, 93249, 93251-93252, 93255, 93268, 93283, 93285, 93287, 93501-93502, 93504-93505, 93516, 93518-93519, 93523-93524, 93527-93528, 93554-93556, 93558, 93560, 93596. 9
10
Los Angeles Region 15 Local Access+ HMO® and Select PPO Network ZIP Codes: 90601-90610, 90612, 90637-90639, 90640, 90650-90652, 90659-90662, 90665, 90670-90671, 9070190703, 90706-90707, 90710-90717, 90723, 90731-90734, 90744-90749, 90755, 90800-90810, 90813-90815, 90822, 90831-90835, 90840, 90842, 90844-90848, 90853, 90888, 90895, 90899, 91001-91003, 91006-91012, 91016-91017, 91020-91021, 91023-91025, 91030-91031, 91040-91043, 91046, 91050-91051, 91066, 91077, 91100-91110, 91114-91118, 91121, 91123-91126, 91129, 91131, 91175, 91182, 91184-91189, 91191, 91199-91210, 91214, 91221-91222, 91224-91226, 91500-91508, 91510, 91521-91523, 91526, 91702, 91706, 91711, 91714-91716, 9172291724, 91731-91735, 91740-91741, 91744-91750, 91754-91756, 91765-91773, 91775-91776, 91778, 91780, 91788-91793, 91795, 91797, 91799-91804, 91841, 91896, 91899, 93563.
11 12
Local Access+ HMO® and Select PPO Network ZIP Code Exceptions: 90704, 93510, 93532, 93534-93536, 93539, 93543-93544, 93550-93553, 93584, 93586, 93590-93591, 93599. Local Access+ HMO® and Select PPO Network ZIP Code Exceptions: 92225-92226, 92239, 92539.
13 Local Access+ HMO® and Select PPO Network ZIP Code Exceptions: 91759, 92242, 92252, 92256, 92267-92268, 92277-92278, 92280, 92284-92286, 92304-92305, 92309-92310, 9231492315, 92317, 92321-92323, 92325-92327, 92332-92333, 92338, 92341-92342, 92347, 92352, 92356, 92358, 92363-92366, 92368, 92372, 92378, 92382, 92385-92386, 92391, 92395, 9239792398, 92407, 93562, 93592. 14
Local Access+ HMO® and Select PPO Network ZIP Code Exceptions: 91905-91906, 91934, 91963, 91980, 91987, 92004, 92036, 92066, 92086.
5
SMALL BUSINESS OFF EXCHANGE ACO HMO NETWORK RATING REGION DEFINITIONS AND AVAILABILITY Effective October 2016
Rating Region
Rating Region
County
1
None.
2
Solano zip codes: 94503, 94510, 94589, 94592, 95620.
3
El Dorado zip codes: 95664, 95672, 95682, 95762. Placer zip codes: 95602-95604, 95648, 95650, 95658, 95661, 95663, 95677-95678, 95713, 95746-95747, 95765.
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, 90670-90671, 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, 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, 91526, 91702, 91706, 91711, 91714-91716, 91722-91724, 91731-91735, 91740-91741, 91744-91750, 91754-91756, 91765-91773, 91775-91776, 91778, 91780, 91788-91793, 91801-91804, 91896, 91899, 93510, 93563.
16
Los Angeles zip codes: 90001-90084, 90086-90091, 90093-90096, 90099, 90189, 90201-90202, 90209-90213, 90220-90224, 90230-90233, 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, 91380-91387, 91390, 91392-91396, 91401-91413, 91416, 91423, 91426, 91436, 91470, 91482, 91495-91496, 91499, 91601-91612, 91614-91618.
17
Riverside zip codes: 91752, 92220, 92223, 92230, 92320, 92501-92509, 92513-92519, 92521-92522, 92530-92532, 92543-92546, 92548, 92551-92557, 92562-92564, 92567, 92570-92572, 92581-92587, 92589-92593, 92595-92596, 92599, 92860, 92877-92882.
Sacramento zip codes: 94203-94209, 94211, 94229-94230, 94232, 94234-94237, 94239-94240, 94244-94245, 94247-94250, 94252, 94254, 94256-94259, 94261-94263, 94267-94269, 94271, 94273-94274, 94277-94280, 94282-94291, 94293-94299, 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, 95811-95838, 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 zip codes: 94002, 94005, 94010, 94011, 94014, 94015, 94016, 94017, 94018, 94019, 94025, 94026, 94027, 94030, 94037, 94038, 94044, 94061, 94062, 94063, 94064, 94065, 94066, 94070, 94080, 94083, 94128, 94401, 94402, 94403, 94404, 94497.
9
Santa Cruz.
10
San Joaquin.
County
San Bernardino zip codes: 91701, 91708-91710, 91729-91730, 91737, 91739, 91743, 91758-91759, 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.
18
Orange.
Tulare zip codes: 93219, 93256, 93260.
19
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, 92018-92027, 92029-92030, 92033, 92036-92040, 92046, 92049, 92051-92052, 92054-92058, 92060-92061, 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.
11
None.
12
Ventura zip codes: 91319-91320, 91358-91362, 91377, 93010-93012, 93015-93016, 93020-93021, 93040, 93062-93066, 93094, 93099.
13
None.
6
Region 17 Blue Shield Bronze 60 PPO 6000/70 Network 1 Mirror w/ 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
137.92 217.19 217.19 217.19 217.19 218.06 222.41 227.62 236.09 243.04 246.51 251.73 256.94 260.20 263.67 265.41 267.15 268.88 270.62 274.10 277.57 282.78 287.78 294.73 303.42 313.63 325.79 339.47 355.11 370.53 387.91 405.06 423.96 443.07 463.71
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 484.34 506.71 529.30 553.41 565.35 589.46 610.31 623.99 641.15 651.58 651.58
*The Bronze 60 PPO Mirror Plan uses the Select PPO Network. The Bronze 60 PPO Mirror Plan is available in certain California counties and cities (the "service area"). To purchase the plan, the employer must be located and their eligible employees must live or work in the Select PPO Network. The Select PPO Network is only available in designated counties: portions of Contra Costa, Fresno, Kern, Los Angeles, Madera, Nevada, Riverside, Sacramento, San Bernardino, San Diego, San Luis Obispo, San Mateo, and Ventura counties, as well as in all of Alameda, Butte, Imperial, Kings, Marin, Orange, San Francisco, Santa Clara, Santa Cruz, Sonoma, Stanislaus, and Yolo counties. Please review the Benefit Summary Guide (A16609) for detailed information regarding the PPO 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. 06/21/2016
17-1
Region 17 Bronze Full PPO 4500/45 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
160.22 252.32 252.32 252.32 252.32 253.32 258.37 264.43 274.27 282.34 286.38 292.43 298.49 302.27 306.31 308.33 310.35 312.37 314.38 318.42 322.46 328.51 334.32 342.39 352.48 364.34 378.47 394.37 412.54 430.45 450.63 470.57 492.52 514.72 538.69
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 562.66 588.65 614.89 642.90 656.78 684.78 709.01 724.90 744.83 756.95 756.95
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. 06/21/2016
17-2
Region 17 Bronze Full PPO 3500/60 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
157.30 247.72 247.72 247.72 247.72 248.71 253.66 259.61 269.27 277.20 281.16 287.11 293.05 296.77 300.73 302.71 304.69 306.68 308.66 312.62 316.58 322.53 328.23 336.15 346.06 357.71 371.58 387.18 405.02 422.61 442.43 462.00 483.55 505.35 528.88
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 552.41 577.93 603.69 631.19 644.81 672.31 696.09 711.70 731.27 743.16 743.16
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. 06/21/2016
17-3
Region 17 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
182.32 287.11 287.11 287.11 287.11 288.26 294.00 300.89 312.09 321.28 325.87 332.76 339.65 343.96 348.55 350.85 353.15 355.45 357.74 362.34 366.93 373.82 380.42 389.61 401.10 414.59 430.67 448.76 469.43 489.81 512.78 535.47 560.44 585.71 612.99
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 640.26 669.83 699.69 731.56 747.35 779.22 806.79 824.88 847.56 861.34 861.34
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. 06/21/2016
17-4
Region 17 Silver Full PPO 1250/40 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
182.77 287.82 287.82 287.82 287.82 288.97 294.73 301.64 312.86 322.07 326.68 333.59 340.49 344.81 349.42 351.72 354.02 356.32 358.63 363.23 367.84 374.75 381.37 390.58 402.09 415.62 431.73 449.87 470.59 491.03 514.05 536.79 561.83 587.16 614.50
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 641.84 671.49 701.42 733.37 749.20 781.15 808.78 826.91 849.65 863.47 863.47
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. 06/21/2016
17-5
Region 17 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
200.16 315.21 315.21 315.21 315.21 316.48 322.78 330.34 342.64 352.73 357.77 365.33 372.90 377.63 382.67 385.19 387.71 390.24 392.76 397.80 402.84 410.41 417.66 427.75 440.35 455.17 472.82 492.68 515.38 537.76 562.97 587.88 615.30 643.04 672.98
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 702.93 735.40 768.18 803.17 820.50 855.49 885.75 905.61 930.51 945.64 945.64
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. 06/21/2016
17-6
Region 17 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
209.36 329.70 329.70 329.70 329.70 331.02 337.62 345.53 358.39 368.94 374.21 382.13 390.04 394.98 400.26 402.90 405.53 408.17 410.81 416.08 421.36 429.27 436.86 447.41 460.59 476.09 494.55 515.33 539.06 562.47 588.85 614.90 643.58 672.59 703.92
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 735.24 769.20 803.49 840.08 858.22 894.81 926.46 947.24 973.28 989.11 989.11
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. 06/21/2016
17-7
Region 17 Gold Full PPO 250/20 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
222.86 350.96 350.96 350.96 350.96 352.37 359.38 367.81 381.50 392.73 398.34 406.76 415.19 420.45 426.07 428.87 431.68 434.49 437.30 442.91 448.53 456.95 465.02 476.25 490.29 506.79 526.44 548.55 573.82 598.74 626.82 654.54 685.08 715.96 749.30
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
782.64 818.79 855.29 894.25 913.55 952.51 986.20 1008.31 1036.04 1052.88 1052.88
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. 06/21/2016
17-8
Region 17 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
219.87 346.26 346.26 346.26 346.26 347.64 354.57 362.88 376.38 387.46 393.00 401.31 409.62 414.82 420.36 423.13 425.90 428.67 431.44 436.98 442.52 450.83 458.79 469.87 483.72 500.00 519.39 541.20 566.13 590.72 618.42 645.77 675.89 706.37 739.26
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
772.15 807.82 843.83 882.26 901.31 939.74 972.98 994.80 1022.15 1038.77 1038.77
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. 06/21/2016
17-9
Region 17 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
250.73 394.86 394.86 394.86 394.86 396.44 404.33 413.81 429.21 441.85 448.16 457.64 467.12 473.04 479.36 482.52 485.68 488.83 491.99 498.31 504.63 514.11 523.19 535.82 551.62 570.17 592.29 617.16 645.59 673.63 705.22 736.41 770.76 805.51 843.02
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
880.53 921.20 962.27 1006.10 1027.82 1071.64 1109.55 1134.43 1165.62 1184.57 1184.57
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. 06/21/2016
17-10
Region 17 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
261.24 411.40 411.40 411.40 411.40 413.04 421.27 431.14 447.19 460.35 466.94 476.81 486.68 492.85 499.44 502.73 506.02 509.31 512.60 519.18 525.76 535.64 545.10 558.27 574.72 594.06 617.09 643.01 672.63 701.84 734.75 767.25 803.05 839.25 878.33
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
917.41 959.79 1002.57 1048.24 1070.87 1116.53 1156.02 1181.94 1214.44 1234.19 1234.19
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. 06/21/2016
17-11
Region 17 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
159.01 250.42 250.42 250.42 250.42 251.42 256.42 262.43 272.20 280.21 284.22 290.23 296.24 300.00 304.00 306.01 308.01 310.01 312.02 316.02 320.03 326.04 331.80 339.81 349.83 361.60 375.62 391.40 409.43 427.21 447.24 467.02 488.81 510.85 534.64
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 558.43 584.22 610.26 638.06 651.83 679.63 703.67 719.44 739.23 751.25 751.25
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. 06/21/2016
17-12
Region 17 Bronze Full PPO Savings 4500/30% 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
163.03 256.75 256.75 256.75 256.75 257.77 262.91 269.07 279.08 287.30 291.41 297.57 303.73 307.58 311.69 313.74 315.80 317.85 319.91 324.01 328.12 334.28 340.19 348.41 358.68 370.74 385.12 401.30 419.78 438.01 458.55 478.83 501.17 523.76 548.15
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 572.55 598.99 625.69 654.19 668.31 696.81 721.46 737.63 757.92 770.24 770.24
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. 06/21/2016
17-13
Region 17 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
205.01 322.85 322.85 322.85 322.85 324.15 330.60 338.35 350.94 361.27 366.44 374.19 381.94 386.78 391.95 394.53 397.11 399.69 402.28 407.44 412.61 420.36 427.78 438.11 451.03 466.20 484.28 504.62 527.87 550.79 576.62 602.12 630.21 658.62 689.29
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 719.97 753.22 786.80 822.63 840.39 876.23 907.22 927.56 953.07 968.56 968.56
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. 06/21/2016
17-14
Region 17 Blue Shield Silver 70 HMO 1500/45 Network 1 Mirror w/ 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
193.27 304.36 304.36 304.36 304.36 305.58 311.67 318.97 330.84 340.58 345.45 352.75 360.06 364.62 369.49 371.93 374.36 376.80 379.23 384.10 388.97 396.28 403.28 413.02 425.19 439.50 456.54 475.72 497.63 519.24 543.59 567.63 594.11 620.90 649.81
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 678.73 710.07 741.73 775.51 792.25 826.04 855.26 874.43 898.47 913.08 913.08
*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. 06/21/2016
17-15
Region 17 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
159.80 251.66 251.66 251.66 251.66 252.66 257.70 263.74 273.55 281.60 285.63 291.67 297.71 301.49 305.51 307.52 309.54 311.55 313.56 317.59 321.62 327.66 333.45 341.50 351.56 363.39 377.49 393.34 411.46 429.33 449.46 469.34 491.23 513.38 537.29
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 561.20 587.12 613.29 641.22 655.06 683.00 707.16 723.01 742.89 754.97 754.97
*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. 06/21/2016
17-16
Region 17 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
185.10 291.50 291.50 291.50 291.50 292.67 298.50 305.50 316.86 326.19 330.86 337.85 344.85 349.22 353.89 356.22 358.55 360.88 363.21 367.88 372.54 379.54 386.24 395.57 407.23 420.93 437.26 455.62 476.61 497.31 520.63 543.65 569.02 594.67 622.36
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 650.05 680.08 710.39 742.75 758.78 791.14 819.13 837.49 860.52 874.51 874.51
*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. 06/21/2016
17-17
Region 17 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
189.76 298.83 298.83 298.83 298.83 300.03 306.01 313.18 324.83 334.40 339.18 346.35 353.52 358.00 362.78 365.18 367.57 369.96 372.35 377.13 381.91 389.08 395.96 405.52 417.47 431.52 448.25 467.08 488.59 509.81 533.72 557.33 583.32 609.62 638.01
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 666.40 697.18 728.26 761.43 777.87 811.04 839.72 858.55 882.16 896.50 896.50
*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. 06/21/2016
17-18
Region 17 Blue Shield Gold 80 HMO 0/35 Network 1 Mirror w/ 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
203.66 320.72 320.72 320.72 320.72 322.00 328.42 336.11 348.62 358.89 364.02 371.71 379.41 384.22 389.35 391.92 394.49 397.05 399.62 404.75 409.88 417.58 424.95 435.22 448.05 463.12 481.08 501.29 524.38 547.15 572.81 598.14 626.05 654.27 684.74
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 715.21 748.24 781.60 817.20 834.83 870.43 901.22 921.43 946.77 962.16 962.16
*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. 06/21/2016
17-19
Region 17 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
169.85 267.48 267.48 267.48 267.48 268.55 273.90 280.32 290.75 299.31 303.59 310.01 316.43 320.44 324.72 326.86 329.00 331.14 333.28 337.56 341.84 348.26 354.41 362.97 373.67 386.24 401.22 418.07 437.33 456.32 477.72 498.85 522.12 545.66 571.07
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 596.48 624.03 651.85 681.54 696.25 725.94 751.62 768.47 789.61 802.44 802.44
*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. 06/21/2016
17-20
Region 17 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
196.88 310.04 310.04 310.04 310.04 311.28 317.48 324.92 337.02 346.94 351.90 359.34 366.78 371.43 376.39 378.87 381.35 383.83 386.31 391.27 396.23 403.68 410.81 420.73 433.13 447.70 465.06 484.60 506.92 528.93 553.74 578.23 605.20 632.49 661.94
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 691.39 723.33 755.57 789.99 807.04 841.45 871.22 890.75 915.24 930.13 930.13
*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. 06/21/2016
17-21
Region 17 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
201.88 317.91 317.91 317.91 317.91 319.19 325.54 333.17 345.57 355.75 360.83 368.46 376.09 380.86 385.95 388.49 391.03 393.58 396.12 401.21 406.29 413.92 421.24 431.41 444.13 459.07 476.87 496.90 519.79 542.36 567.79 592.91 620.57 648.55 678.75
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 708.95 741.69 774.76 810.05 827.53 862.82 893.34 913.37 938.48 953.74 953.74
*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. 06/21/2016
17-22
Region 17 Gold Trio ACO HMO 750/30 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
174.51 274.82 274.82 274.82 274.82 275.92 281.41 288.01 298.73 307.52 311.92 318.51 325.11 329.23 333.63 335.83 338.03 340.22 342.42 346.82 351.22 357.81 364.13 372.93 383.92 396.84 412.23 429.54 449.33 468.84 490.82 512.54 536.44 560.63 586.74
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 612.84 641.15 669.73 700.24 715.35 745.86 772.24 789.55 811.26 824.45 824.45
*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. 06/21/2016
17-23
Region 17 Gold Local Access+ HMO® 750/30 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
202.33 318.64 318.64 318.64 318.64 319.91 326.28 333.93 346.36 356.56 361.65 369.30 376.95 381.73 386.83 389.37 391.92 394.47 397.02 402.12 407.22 414.87 422.19 432.39 445.14 460.11 477.96 498.03 520.97 543.60 569.09 594.26 621.98 650.02 680.29
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 710.56 743.38 776.52 811.89 829.41 864.78 895.37 915.44 940.62 955.91 955.91
*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. 06/21/2016
17-24
Region 17 Gold Access+ HMO® 750/30 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
207.49 326.76 326.76 326.76 326.76 328.07 334.60 342.44 355.19 365.64 370.87 378.71 386.56 391.46 396.69 399.30 401.91 404.53 407.14 412.37 417.60 425.44 432.96 443.41 456.48 471.84 490.14 510.73 534.25 557.45 583.59 609.41 637.84 666.59 697.63
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 728.68 762.33 796.31 832.58 850.56 886.83 918.20 938.78 964.60 980.28 980.28
*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. 06/21/2016
17-25
Region 17 Blue Shield Platinum 90 HMO 0/20 Network 1 Mirror w/ 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
214.61 337.97 337.97 337.97 337.97 339.32 346.08 354.19 367.38 378.19 383.60 391.71 399.82 404.89 410.30 413.00 415.71 418.41 421.11 426.52 431.93 440.04 447.81 458.63 472.15 488.03 506.96 528.25 552.58 576.58 603.62 630.32 659.72 689.46 721.57
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
753.68 788.49 823.64 861.15 879.74 917.26 949.70 970.99 997.69 1013.92 1013.92
*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. 06/21/2016
17-26
Region 17 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
183.52 289.01 289.01 289.01 289.01 290.16 295.94 302.88 314.15 323.40 328.02 334.96 341.90 346.23 350.86 353.17 355.48 357.79 360.10 364.73 369.35 376.29 382.94 392.18 403.74 417.33 433.51 451.72 472.53 493.05 516.17 539.00 564.14 589.58 617.03
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 644.49 674.26 704.31 736.39 752.29 784.37 812.11 830.32 853.15 867.02 867.02
*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. 06/21/2016
17-27
Region 17 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
212.89 335.26 335.26 335.26 335.26 336.60 343.31 351.35 364.43 375.16 380.52 388.57 396.61 401.64 407.01 409.69 412.37 415.05 417.74 423.10 428.46 436.51 444.22 454.95 468.36 484.12 502.89 524.01 548.15 571.96 598.78 625.26 654.43 683.93 715.78
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
747.63 782.16 817.03 854.25 872.68 909.90 942.08 963.20 989.69 1005.78 1005.78
*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. 06/21/2016
17-28
Region 17 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
218.36 343.87 343.87 343.87 343.87 345.24 352.12 360.38 373.79 384.79 390.29 398.54 406.80 411.96 417.46 420.21 422.96 425.71 428.46 433.96 439.47 447.72 455.63 466.63 480.39 496.55 515.80 537.47 562.23 586.64 614.15 641.32 671.23 701.49 734.16
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
766.83 802.25 838.01 876.18 895.09 933.26 966.27 987.94 1015.10 1031.61 1031.61
*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. 06/21/2016
17-29
Region 17 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
187.96 296.00 296.00 296.00 296.00 297.19 303.11 310.21 321.75 331.23 335.96 343.07 350.17 354.61 359.35 361.71 364.08 366.45 368.82 373.55 378.29 385.39 392.20 401.67 413.51 427.43 444.00 462.65 483.96 504.98 528.66 552.04 577.79 603.84 631.96
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 660.08 690.57 721.36 754.21 770.49 803.35 831.76 850.41 873.80 888.00 888.00
*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. 06/21/2016
17-30
Region 17 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
218.09 343.45 343.45 343.45 343.45 344.83 351.70 359.94 373.33 384.32 389.82 398.06 406.31 411.46 416.95 419.70 422.45 425.20 427.94 433.44 438.93 447.18 455.08 466.07 479.81 495.95 515.18 536.82 561.55 585.93 613.41 640.54 670.42 700.65 733.27
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
765.90 801.28 837.00 875.12 894.01 932.13 965.11 986.74 1013.88 1030.36 1030.36
*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. 06/21/2016
17-31
Region 17 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
223.71 352.30 352.30 352.30 352.30 353.71 360.76 369.21 382.95 394.23 399.86 408.32 416.77 422.06 427.69 430.51 433.33 436.15 438.97 444.60 450.24 458.70 466.80 478.07 492.17 508.72 528.45 550.65 576.01 601.03 629.21 657.04 687.69 718.70 752.16
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
785.63 821.92 858.56 897.66 917.04 956.15 989.97 1012.16 1039.99 1056.90 1056.90
*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. 06/21/2016
17-32
Region 17 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
185.60 292.29 292.29 292.29 292.29 293.46 299.30 306.32 317.72 327.07 331.75 338.76 345.78 350.16 354.84 357.18 359.51 361.85 364.19 368.87 373.54 380.56 387.28 396.64 408.33 422.06 438.43 456.85 477.89 498.64 522.03 545.12 570.55 596.27 624.04
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 651.80 681.91 712.31 744.75 760.83 793.27 821.33 839.74 862.84 876.87 876.87
*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. 06/21/2016
17-33
Region 17 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
215.33 339.10 339.10 339.10 339.10 340.46 347.24 355.38 368.61 379.46 384.88 393.02 401.16 406.25 411.67 414.39 417.10 419.81 422.52 427.95 433.38 441.51 449.31 460.16 473.73 489.67 508.66 530.02 554.44 578.51 605.64 632.43 661.93 691.77 723.99
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
756.20 791.13 826.40 864.04 882.69 920.33 952.88 974.25 1001.04 1017.31 1017.31
*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. 06/21/2016
17-34
Region 17 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
220.87 347.82 347.82 347.82 347.82 349.22 356.17 364.52 378.09 389.22 394.78 403.13 411.48 416.69 422.26 425.04 427.82 430.61 433.39 438.95 444.52 452.87 460.87 472.00 485.91 502.26 521.74 543.65 568.69 593.39 621.21 648.69 678.95 709.56 742.61
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
775.65 811.48 847.65 886.26 905.39 944.00 977.39 999.30 1026.78 1043.47 1043.47
*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. 06/21/2016
17-35
Region 17 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
12.90 18.00 19.40 22.60
26.90 35.90 41.30 45.20
34.50 42.00 49.20 52.80
43.10 54.00 62.10 67.80
*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. 06/21/2016
17-36
Region 17 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. 06/21/2016
17-37
Region 17 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. 06/21/2016
17-38
Region 17 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. 06/21/2016
17-39
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-R10 (10/16)
