small business rate tables Rate Book 10 Rating region 17: San Bernardino, Riverside
Effective January 2017 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.
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2
Small Business Rate Tables CONTENTS Life Insurance Rates
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2
Regional Groupings
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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 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
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 17 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
145.90 229.77 229.77 229.77 229.77 230.69 235.28 240.80 249.76 257.11 260.79 266.30 271.82 275.26 278.94 280.78 282.61 284.45 286.29 289.97 293.64 299.16 304.44 311.80 320.99 331.79 344.65 359.13 375.67 391.98 410.37 428.52 448.51 468.73 490.56
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 512.38 536.05 559.95 585.45 598.09 623.59 645.65 660.12 678.28 689.30 689.30
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
17-1
Region 17 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
161.05 253.62 253.62 253.62 253.62 254.64 259.71 265.80 275.69 283.81 287.86 293.95 300.04 303.84 307.90 309.93 311.96 313.99 316.02 320.07 324.13 330.22 336.05 344.17 354.31 366.23 380.44 396.42 414.68 432.68 452.97 473.01 495.08 517.39 541.49
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 565.58 591.71 618.08 646.24 660.19 688.34 712.69 728.66 748.70 760.87 760.87
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
17-2
Region 17 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
158.09 248.96 248.96 248.96 248.96 249.95 254.93 260.91 270.61 278.58 282.56 288.54 294.51 298.25 302.23 304.22 306.22 308.21 310.20 314.18 318.17 324.14 329.87 337.83 347.79 359.49 373.43 389.12 407.04 424.72 444.64 464.30 485.96 507.87 531.52
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 555.17 580.81 606.71 634.34 648.03 675.67 699.57 715.25 734.92 746.87 746.87
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
17-3
Region 17 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
192.13 302.57 302.57 302.57 302.57 303.78 309.83 317.09 328.89 338.57 343.41 350.67 357.93 362.47 367.31 369.73 372.16 374.58 377.00 381.84 386.68 393.94 400.90 410.58 422.68 436.90 453.85 472.91 494.69 516.18 540.38 564.28 590.61 617.23 645.98
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 674.72 705.88 737.35 770.94 787.58 821.16 850.21 869.27 893.17 907.70 907.70
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
17-4
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
182.45 287.32 287.32 287.32 287.32 288.47 294.22 301.11 312.32 321.51 326.11 333.01 339.90 344.21 348.81 351.11 353.41 355.71 358.00 362.60 367.20 374.09 380.70 389.90 401.39 414.89 430.98 449.09 469.77 490.17 513.16 535.86 560.85 586.14 613.43
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 640.73 670.32 700.21 732.10 747.90 779.79 807.38 825.48 848.18 861.97 861.97
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
17-5
Region 17 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
181.70 286.14 286.14 286.14 286.14 287.28 293.00 299.87 311.03 320.19 324.77 331.63 338.50 342.79 347.37 349.66 351.95 354.24 356.53 361.11 365.68 372.55 379.13 388.29 399.73 413.18 429.21 447.23 467.83 488.15 511.04 533.65 558.54 583.72 610.90
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 638.09 667.56 697.32 729.08 744.82 776.58 804.05 822.07 844.68 858.41 858.41
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
17-6
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
201.31 317.03 317.03 317.03 317.03 318.30 324.64 332.25 344.61 354.76 359.83 367.44 375.05 379.80 384.88 387.41 389.95 392.48 395.02 400.09 405.17 412.77 420.07 430.21 442.89 457.79 475.55 495.52 518.34 540.85 566.22 591.26 618.84 646.74 676.86
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 706.98 739.63 772.60 807.79 825.23 860.42 890.86 910.83 935.87 951.09 951.09
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
17-7
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
210.08 330.83 330.83 330.83 330.83 332.16 338.77 346.71 359.62 370.20 375.50 383.44 391.38 396.34 401.63 404.28 406.93 409.57 412.22 417.51 422.81 430.75 438.35 448.94 462.17 477.72 496.25 517.09 540.91 564.40 590.87 617.00 645.79 674.90 706.33
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 737.76 771.83 806.24 842.96 861.16 897.88 929.64 950.48 976.62 992.50 992.50
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
17-8
Region 17 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
218.76 344.50 344.50 344.50 344.50 345.88 352.77 361.04 374.47 385.50 391.01 399.28 407.55 412.71 418.23 420.98 423.74 426.49 429.25 434.76 440.27 448.54 456.47 467.49 481.27 497.46 516.75 538.46 563.26 587.72 615.28 642.50 672.47 702.78 735.51
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
768.24 803.72 839.55 877.79 896.74 934.98 968.05 989.75 1016.97 1033.51 1033.51
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
17-9
Region 17 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
229.46 361.35 361.35 361.35 361.35 362.80 370.03 378.70 392.79 404.36 410.14 418.81 427.48 432.90 438.68 441.58 444.47 447.36 450.25 456.03 461.81 470.48 478.80 490.36 504.81 521.80 542.03 564.80 590.82 616.47 645.38 673.93 705.36 737.16 771.49
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
805.82 843.04 880.62 920.73 940.61 980.72 1015.41 1038.17 1066.72 1084.06 1084.06
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
17-10
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
217.95 343.22 343.22 343.22 343.22 344.60 351.46 359.70 373.08 384.07 389.56 397.79 406.03 411.18 416.67 419.42 422.16 424.91 427.66 433.15 438.64 446.88 454.77 465.75 479.48 495.61 514.83 536.46 561.17 585.54 613.00 640.11 669.97 700.17 732.78
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
765.39 800.74 836.43 874.53 893.41 931.51 964.46 986.08 1013.19 1029.67 1029.67
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
17-11
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
249.64 393.14 393.14 393.14 393.14 394.71 402.57 412.01 427.34 439.92 446.21 455.65 465.08 470.98 477.27 480.41 483.56 486.70 489.85 496.14 502.43 511.86 520.91 533.49 549.21 567.69 589.70 614.47 642.78 670.69 702.14 733.20 767.40 802.00 839.35
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
876.69 917.19 958.07 1001.71 1023.33 1066.97 1104.71 1129.48 1160.54 1179.41 1179.41
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
17-12
Region 17 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
257.34 405.26 405.26 405.26 405.26 406.88 414.99 424.72 440.52 453.49 459.97 469.70 479.43 485.51 491.99 495.23 498.47 501.72 504.96 511.44 517.93 527.65 536.97 549.94 566.15 585.20 607.90 633.43 662.61 691.38 723.80 755.82 791.07 826.74 865.24
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
903.74 945.48 987.63 1032.61 1054.90 1099.89 1138.79 1164.32 1196.34 1215.79 1215.79
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
17-13
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
259.54 408.72 408.72 408.72 408.72 410.36 418.53 428.34 444.28 457.36 463.90 473.71 483.52 489.65 496.19 499.46 502.73 506.00 509.27 515.81 522.34 532.15 541.55 554.63 570.98 590.19 613.08 638.83 668.26 697.28 729.97 762.26 797.82 833.79 872.62
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
911.45 953.54 996.05 1041.42 1063.90 1109.27 1148.50 1174.25 1206.54 1226.16 1226.16
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
17-14
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
160.46 252.69 252.69 252.69 252.69 253.70 258.75 264.82 274.67 282.76 286.80 292.87 298.93 302.72 306.76 308.79 310.81 312.83 314.85 318.89 322.94 329.00 334.81 342.90 353.01 364.88 379.03 394.95 413.15 431.09 451.30 471.26 493.25 515.48 539.49
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 563.50 589.52 615.80 643.85 657.75 685.80 710.05 725.97 745.94 758.07 758.07
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
17-15
Region 17 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
162.25 255.51 255.51 255.51 255.51 256.53 261.64 267.77 277.74 285.91 290.00 296.14 302.27 306.10 310.19 312.23 314.28 316.32 318.36 322.45 326.54 332.67 338.55 346.73 356.95 368.96 383.26 399.36 417.76 435.90 456.34 476.52 498.75 521.24 545.51
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 569.79 596.10 622.68 651.04 665.09 693.45 717.98 734.08 754.26 766.53 766.53
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
17-16
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
202.00 318.12 318.12 318.12 318.12 319.39 325.75 333.39 345.79 355.97 361.06 368.70 376.33 381.11 386.20 388.74 391.28 393.83 396.37 401.46 406.55 414.19 421.51 431.69 444.41 459.36 477.18 497.22 520.12 542.71 568.16 593.29 620.97 648.96 679.18
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 709.40 742.17 775.25 810.56 828.06 863.37 893.91 913.95 939.08 954.35 954.35
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
17-17
Region 17 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
172.07 270.98 270.98 270.98 270.98 272.07 277.49 283.99 294.56 303.23 307.57 314.07 320.57 324.64 328.97 331.14 333.31 335.48 337.64 341.98 346.32 352.82 359.05 367.72 378.56 391.30 406.47 423.55 443.06 462.30 483.97 505.38 528.96 552.80 578.55
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 604.29 632.20 660.38 690.46 705.37 735.45 761.46 778.53 799.94 812.95 812.95
*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
17-18
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
190.78 300.44 300.44 300.44 300.44 301.64 307.65 314.86 326.57 336.19 341.00 348.21 355.42 359.92 364.73 367.13 369.54 371.94 374.34 379.15 383.96 391.17 398.08 407.69 419.71 433.83 450.65 469.58 491.21 512.54 536.58 560.31 586.45 612.89 641.43
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 669.97 700.92 732.16 765.51 782.04 815.38 844.23 863.15 886.89 901.31 901.31
*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
17-19
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
186.09 293.05 293.05 293.05 293.05 294.22 300.08 307.12 318.55 327.92 332.61 339.64 346.68 351.07 355.76 358.11 360.45 362.80 365.14 369.83 374.52 381.55 388.29 397.67 409.39 423.16 439.57 458.04 479.14 499.94 523.39 546.54 572.03 597.82 625.66
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 653.50 683.69 714.16 746.69 762.81 795.34 823.47 841.93 865.08 879.15 879.15
*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
17-20
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
160.62 252.95 252.95 252.95 252.95 253.96 259.02 265.09 274.96 283.05 287.10 293.17 299.24 303.04 307.08 309.11 311.13 313.15 315.18 319.22 323.27 329.34 335.16 343.25 353.37 365.26 379.43 395.36 413.58 431.53 451.77 471.75 493.76 516.02 540.05
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 564.08 590.14 616.44 644.52 658.43 686.51 710.79 726.73 746.71 758.85 758.85
*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
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
201.76 317.74 317.74 317.74 317.74 319.01 325.36 332.99 345.38 355.55 360.63 368.26 375.88 380.65 385.73 388.27 390.82 393.36 395.90 400.98 406.07 413.69 421.00 431.17 443.88 458.81 476.61 496.62 519.50 542.06 567.48 592.58 620.22 648.18 678.37
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 708.55 741.28 774.32 809.59 827.07 862.34 892.84 912.86 937.96 953.21 953.21
*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
17-22
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
196.76 309.86 309.86 309.86 309.86 311.10 317.30 324.73 336.82 346.73 351.69 359.13 366.56 371.21 376.17 378.65 381.13 383.61 386.09 391.04 396.00 403.44 410.56 420.48 432.87 447.44 464.79 484.31 506.62 528.62 553.41 577.89 604.85 632.11 661.55
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 690.99 722.90 755.13 789.52 806.56 840.96 870.71 890.23 914.71 929.58 929.58
*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
17-23
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
169.74 267.30 267.30 267.30 267.30 268.37 273.72 280.13 290.56 299.11 303.39 309.80 316.22 320.23 324.50 326.64 328.78 330.92 333.06 337.33 341.61 348.02 354.17 362.73 373.42 385.98 400.95 417.79 437.04 456.01 477.40 498.51 521.77 545.29 570.69
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 596.08 623.61 651.41 681.08 695.78 725.45 751.11 767.95 789.07 801.90 801.90
*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
17-24
Region 17 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
206.86 325.76 325.76 325.76 325.76 327.06 333.58 341.39 354.10 364.52 369.74 377.55 385.37 390.26 395.47 398.08 400.68 403.29 405.90 411.11 416.32 424.14 431.63 442.05 455.08 470.40 488.64 509.16 532.62 555.74 581.80 607.54 635.88 664.55 695.49
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 726.44 759.99 793.87 830.03 847.95 884.11 915.38 935.90 961.64 977.28 977.28
*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. 08/23/2016
17-25
Region 17 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
201.71 317.65 317.65 317.65 317.65 318.92 325.28 332.90 345.29 355.45 360.54 368.16 375.78 380.55 385.63 388.17 390.71 393.26 395.80 400.88 405.96 413.59 420.89 431.06 443.76 458.69 476.48 496.49 519.36 541.92 567.33 592.42 620.06 648.01 678.19
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 708.37 741.09 774.12 809.38 826.85 862.11 892.61 912.62 937.71 952.96 952.96
*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
17-26
Region 17 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
173.96 273.95 273.95 273.95 273.95 275.05 280.53 287.10 297.79 306.55 310.94 317.51 324.09 328.20 332.58 334.77 336.96 339.15 341.35 345.73 350.11 356.69 362.99 371.75 382.71 395.59 410.93 428.19 447.91 467.36 489.28 510.92 534.76 558.86 584.89
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 610.91 639.13 667.62 698.03 713.10 743.51 769.81 787.07 808.71 821.86 821.86
*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
17-27
Region 17 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
174.20 274.33 274.33 274.33 274.33 275.43 280.92 287.50 298.20 306.98 311.37 317.95 324.54 328.65 333.04 335.24 337.43 339.63 341.82 346.21 350.60 357.18 363.49 372.27 383.24 396.14 411.50 428.78 448.54 468.01 489.96 511.63 535.50 559.64 585.70
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 611.77 640.02 668.55 699.00 714.09 744.54 770.88 788.16 809.83 823.00 823.00
*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. 08/23/2016
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
218.93 344.77 344.77 344.77 344.77 346.15 353.05 361.32 374.77 385.80 391.32 399.59 407.87 413.04 418.55 421.31 424.07 426.83 429.59 435.10 440.62 448.89 456.82 467.86 481.65 497.85 517.16 538.88 563.70 588.18 615.76 643.00 673.00 703.34 736.09
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
768.84 804.35 840.21 878.48 897.44 935.71 968.81 990.53 1017.77 1034.32 1034.32
*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
17-29
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
213.44 336.13 336.13 336.13 336.13 337.47 344.20 352.26 365.37 376.13 381.51 389.57 397.64 402.68 408.06 410.75 413.44 416.13 418.82 424.19 429.57 437.64 445.37 456.13 469.57 485.37 504.19 525.37 549.57 573.44 600.33 626.88 656.12 685.70 717.63
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
749.57 784.19 819.14 856.46 874.94 912.25 944.52 965.70 992.25 1008.39 1008.39
*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
17-30
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
183.97 289.72 289.72 289.72 289.72 290.88 296.68 303.63 314.93 324.20 328.84 335.79 342.74 347.09 351.72 354.04 356.36 358.68 360.99 365.63 370.27 377.22 383.88 393.15 404.74 418.36 434.58 452.84 473.70 494.27 517.44 540.33 565.54 591.03 618.56
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 646.08 675.92 706.05 738.21 754.15 786.31 814.12 832.37 855.26 869.17 869.17
*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
17-31
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
220.84 347.78 347.78 347.78 347.78 349.17 356.13 364.48 378.04 389.17 394.73 403.08 411.43 416.64 422.21 424.99 427.77 430.55 433.34 438.90 444.47 452.81 460.81 471.94 485.85 502.20 521.67 543.58 568.62 593.32 621.14 648.61 678.87 709.48 742.52
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
775.55 811.38 847.55 886.15 905.28 943.88 977.27 999.18 1026.65 1043.35 1043.35
*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
17-32
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
215.30 339.05 339.05 339.05 339.05 340.41 347.19 355.33 368.55 379.40 384.82 392.96 401.10 406.18 411.61 414.32 417.03 419.75 422.46 427.88 433.31 441.45 449.24 460.09 473.66 489.59 508.58 529.94 554.35 578.42 605.55 632.33 661.83 691.67 723.88
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
756.09 791.01 826.27 863.91 882.55 920.19 952.74 974.10 1000.88 1017.16 1017.16
*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. 08/23/2016
17-33
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
185.56 292.22 292.22 292.22 292.22 293.39 299.23 306.25 317.64 326.99 331.67 338.68 345.69 350.08 354.75 357.09 359.43 361.77 364.10 368.78 373.46 380.47 387.19 396.54 408.23 421.96 438.33 456.74 477.78 498.53 521.90 544.99 570.41 596.13 623.89
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 651.65 681.75 712.14 744.57 760.65 793.08 821.13 839.54 862.63 876.66 876.66
*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
17-34
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
223.03 351.22 351.22 351.22 351.22 352.63 359.65 368.08 381.78 393.02 398.64 407.07 415.50 420.76 426.38 429.19 432.00 434.81 437.62 443.24 448.86 457.29 465.37 476.61 490.66 507.16 526.83 548.96 574.25 599.18 627.28 655.03 685.59 716.49 749.86
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
783.23 819.40 855.93 894.91 914.23 953.22 986.93 1009.06 1036.81 1053.67 1053.67
*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
17-35
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
217.42 342.39 342.39 342.39 342.39 343.76 350.61 358.83 372.18 383.14 388.62 396.84 405.05 410.19 415.67 418.41 421.15 423.88 426.62 432.10 437.58 445.80 453.67 464.63 478.33 494.42 513.59 535.16 559.82 584.13 611.52 638.57 668.35 698.49 731.01
Age
Member Rate
55 56 57 58 59 60 61 62 63 64 65 and over
763.54 798.81 834.42 872.42 891.25 929.26 962.13 983.70 1010.75 1027.18 1027.18
*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
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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
187.37 295.07 295.07 295.07 295.07 296.25 302.15 309.24 320.74 330.19 334.91 341.99 349.07 353.50 358.22 360.58 362.94 365.30 367.66 372.38 377.10 384.18 390.97 400.41 412.22 426.08 442.61 461.20 482.44 503.39 527.00 550.31 575.98 601.95 629.98
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 658.01 688.40 719.09 751.84 768.07 800.82 829.15 847.74 871.05 885.22 885.22
*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
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Region 17 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
184.81 291.03 291.03 291.03 291.03 292.20 298.02 305.00 316.35 325.67 330.32 337.31 344.29 348.66 353.32 355.64 357.97 360.30 362.63 367.28 371.94 378.93 385.62 394.93 406.57 420.25 436.55 454.89 475.84 496.50 519.79 542.78 568.10 593.71 621.36
Age 55 56 57 58 59 60 61 62 63 64 65 and over
Member Rate 649.01 678.98 709.25 741.55 757.56 789.87 817.81 836.14 859.13 873.10 873.10
*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
17-38
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
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
17-39
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. 08/23/2016
17-40
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. 08/23/2016
17-41
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. 08/23/2016
17-42
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-R10 (1/17)
