Member Benefits Program - sacrealtor.org · Gold 80 500/30 BENEFIT HMO Lifetime Maximum Unlimited...

Sacramento, CA 95864

Lic #0787081www.amesgrenz.com

Phone (916) 486-2900

3435 American River Drive, Suite C

Contact Robyn Caspary for Benefit information

Member Benefits Program

Ames‐Grenz Insurance Services, Inc.

BENEFIT

Lifetime Maximum

Calendar Year Deductible :

Individual / Family

Calendar Year Max Out‐of‐Pocket:

Individual / Family

Office Visit

Most Laboratory Tests

Most X‐rays & Diagnostics

MRI/CT/PET

Preventive Care Exam

Hospitalization

Outpatient Surgery

Emergency Room

Urgent Care Center

Maternity:

Inpatient

Prenatal/First Postpartum Visit

Mental Health:

Inpatient

Outpatient

Substance Abuse:

Inpatient Detox Only

Prescriptions:

Generic

Deductible (Brand Name)

Brand

Pediatric Dental & Vision (Up to age 19)

Deductible / Waiting Period

Annual Out‐of‐Pocket Maximum

Office Visit

Cleaning & Exam

Periodontics

Restorative

Endodontics

Prosthodontics

Orthodontics (Medically Necessary)

Pediatric Vision (Up to age 19)

Includes Exam and Eyewear

Adult Vision Exam

Adult Optical (Eyewear)

Provider Restrictions

Kaiser Members & Dependents

Open Enrollment

One standard pair of frames & lenses or contact lenses per calendar year

$85 ‐ $350 Copay Depending on Procedure



New Members: May join the 1st of the month following 30 days of membership.

Qualifying Events: you may join within 30 days after you have a loss of coverage,

marriage, birth or adoption. Over

Age Dependents: may remain on coverage up to age 26.

November 1st ‐ November 30th

$0 Copay

$175 allowance

Kaiser

Eligibility Guidelines ‐ GUARANTEED ISSUE

$0 Copay

$15 Copay

$0 Deductible & No Waiting Periods


$350 Copay

None

$20 Copay

$290 per Day (Days 1‐5) per Admission

$350 per Child / $700 Multichild

$0 Copay


$20 Copay


(Up to a 30‐Day Supply)

$5 Copay

$150 Copay (waived if admitted directly to hospital)

$40 Copay

$150 Copay

$0 Copay

$0 Copay

$20 Copay

Unlimited

None


$290 Copay per Procedure

KAISER PERMANENTE

Platinum 90 0/20HMO

$4,000 / $8,000 (Embedded)

$20 (Primary) $40 (Specialty)

December 1, 2016 ‐ November 30, 2017

Gold 80 500/30BENEFIT HMO

Lifetime Maximum Unlimited

Calendar Year Deductible :

Individual / Family $500 / $1,000 (1)


Individual / Family $6,250 / $12,500

Office Visit $30 Copay

Most Laboratory Tests $20 Copay

Most X‐rays & Diagnostics $20 Copay

MRI/CT/PET $250 Copay

Preventive Care Exam $0 Copay

Hospitalization $600 per Day (Days 1‐5) per Admission After Deductible

Outpatient Surgery $600 Copay per Procedure After Deductible

Emergency Room

$250 Copay After Deductible

(waived if admitted directly to hospital)

Urgent Care Center $30 Copay

Maternity:

Inpatient $600 per Day (Days 1‐5) per Admission After Deductible

Prenatal/First Postpartum Visit $0 Copay

Mental Health:

Inpatient $600 per Day (Days 1‐5) per Admission After Deductible

Outpatient $30 copay

Substance Abuse:

Inpatient Detox Only $600 per Day (Days 1‐5) per Admission After Deductible

Prescriptions: (Up to a 30‐Day Supply)

Generic $15 Copay

Deductible (Brand Name) None

Brand $50 Copay


Deductible / Waiting Period $0 Deductible & No Waiting Periods

Annual Out‐of‐Pocket Maximum $350 per Child / $700 Multichild

Office Visit $0 Copay

Cleaning & Exam $0 Copay

Periodontics $85 ‐ $350 Copay Depending on Procedure

Restorative $25 ‐ $350 Copay Depending on Procedure

Endodontics $85 ‐ $300 Copay Depending on Procedure

Prosthodontics $65 ‐ $350 Copay Depending on Procedure

Orthodontics (Medically Necessary) $350 Copay



Adult Vision Exam $0 Copay

Adult Optical (Eyewear) Not Covered



Open Enrollment

Kaiser



Qualifying Events: you may join within 30 days after you have a loss of coverage, marriage, birth or adoption.

Over Age Dependents: may remain on coverage up to age 26.

$50 Copay

$0 Deductible & No Waiting Periods

One standard pair of frames & lenses or

contact lenses per calendar year




$35 Copay


November 1st ‐ November 30th


$350 Copay

Not Covered

$0 Copay

$15 Copay

$350 per Child / $700 Multichild

Unlimited

None


$655 Copay per Procedure

$250 Copay

(waived if admitted directly to hospital)

$50 Copay

$250 Copay

$0 Copay


(Up to a 30‐Day Supply)

HMO

KAISER PERMANENTE

Gold 80 0/35

$0 Copay

$6,200 / $12,400

$35 (Primary) $55 (Specialty)

$35 Copay


(1) This plan has an embedded deductible and out‐of‐pocket maximum. Each family member will begin paying copayments or coinsurance after meeting his or her individual

deductible, or whenthe family deductible is satisfied. Individual family members are no longer subject to cost sharing when they reach their individual out‐of‐pocket maximum, or

when the family out‐of pocket maximum is met.

None


$35 copay


$0 Copay

$0 Copay


For illustrative purposes only Ames-Grenz Insurance Services, Inc. Lic. 0787081

Silver 70 1000/50 Silver 70 1500/45BENEFITS HMO HMO

Lifetime Maximum Unlimited Unlimited

Calendar Year Deductible:

Individual/family $1,000 / $2,000 (1) $1,500 / $3,000 (1)



Office Visit $50 Copay $45 Primary / $70 Specialty Copay

Most Laboratory Tests $40 Copay $35 Copay

Most X‐rays & Diagnostics $40 Copay $65 Copay

MRI/CT/PET 30% After Deductible $250 Copay

Preventive Care Exam $0 Copay $0 Copay

Hospitalization 30% After Deductible 20% After Deductible

Outpatient Surgery 30% After Deductible 20 % (Deductible Waived)

Emergency Room 30% After Deductible

$300 Copay After Deductible

(waived if admitted directily to hospital)

Urgent Care Center $50 Copay $45 Copay

Maternity:

Inpatient 30% After Deductible 20% After Deductible

Prenatal/Prenatal Care $0 Copay $0 Copay

Mental Health:

Inpatient 30% After Deductible 20% After Deductible

Outpatient $50 Copay $45 Copay

Substance Abuse:

Inpatient Detox Only 30% After Deductible 20% After Deductible

Prescriptions: (Up to a 30‐Day Supply) (Up to a 30‐Day Supply)

Generic $25 Copay $15 Copay

Deductible (Brand Name) None $250 Brand Name Deductible Brand $50 Copay $55 Copay (After $250 drug deductible)


Deductible / Waiting Period $0 Deductible & No Waiting Periods $0 Deductible & No Waiting Periods

Annual Out‐of‐Pocket Maximum $350 per Child / $700 Multichild $350 per Child / $700 Multichild

Office visits $20 Copay $0 Copay

Cleaning & Exam $0 Copay $0 Copay

Periodontics $85 ‐ $350 Copay Depending on Procedure $85 ‐ $350 Copay Depending on Procedure

Restorative $25 ‐ $350 Copay Depending on Procedure $25 ‐ $350 Copay Depending on Procedure

Endodontics $85 ‐ $300 Copay Depending on Procedure $85 ‐ $300 Copay Depending on Procedure

Prosthodontics $65 ‐ $350 Copay Depending on Procedure $65 ‐ $350 Copay Depending on Procedure

Orthodontics (medically necessary) $350 Copay $350 Copay



Adult Vision Exam $0 Copay $0 Copay

Adult Optical (Eyewear) Not Covered Not Covered



Open Enrollment November 1st ‐ November 30th(1) This plan has an embedded deductible and out‐of‐pocket maximum. Each family member will begin paying copayments or coinsurance after meeting his or her individual

deductible, or whenthe family deductible is satisfied. Individual family members are no longer subject to cost sharing when they reach their individual out‐of‐pocket

maximum, or when the family out‐of pocket maximum is met.

Kaiser


KAISER PERMANENTE






One standard pair of frames & lenses or contact

lenses per calendar year



MAPPED FROM Silver 70 HSA 1500/20 OR Bronze 60 HSA 3500/30

Bronze 60 6000/70 Bronze 60 HSA 4500/40%BENEFITS HMO HMO

Lifetime Maximum Unlimited Unlimited

Calendar Year Deductible:




Office Visit 40% After Deductible

Most Laboratory Tests 40% After Deductible

Most X‐rays & Diagnostics 40% After Deductible

MRI/CT/PET 40% After Deductible

Preventive Care Exam

$70 Primary (2) ‐ After Deductible$90 Specialist (2) ‐ After deductible

$40

100% (up to out‐of‐pocket maximum) 100% (up to out‐of‐pocket maximum)

$0 Copay $0 Copay

Hospitalization 100% (up to out‐of‐pocket maximum) 40% After Deductible

Outpatient Surgery 100% (up to out‐of‐pocket maximum) 40% After Deductible

Emergency Room 40% After Deductible

Urgent Care Center

100% (up to out‐of‐pocket maximum)

$70 (2) After Deductible 40% After Deductible

Maternity:

Inpatient 100% (up to out‐of‐pocket maximum) 40% After Deductible

Prenatal/Prenatal Care $0 $0

Mental Health:

Inpatient 40% After Deductible

Outpatient

100% (up to out‐of‐pocket maximum) $70 (2) After Deductible 40% After Deductible

Substance Abuse:

Inpatient Detox Only 100% (up to out‐of‐pocket maximum) 40% After Deductible

Prescriptions: (Up to a 30‐Day Supply) (Up to a 100‐Day Supply)

Generic 100% per prescription up to $500 maximum After

$500 drug deductible

40% After Plan Deductible

Deductible $500 Subject to Plan Deductible (1)

Brand 100% per prescription up to $500 maximum

After $500 drug deductible

40% After Plan Deductible


Deductible / Waiting Period $0 Deductible & No Waiting Periods $0 Deductible & No Waiting Periods

Annual Out‐of‐Pocket Maximum $350 per Child / $700 Multichild $350 per Child / $700 Multichild

Office visits $0 Copay $20 Copay

Cleaning & Exam $0 Copay $0 Copay

Periodontics $85 ‐ $350 Copay Depending on Procedure $85 ‐ $350 Copay Depending on Procedure

Restorative $25 ‐ $350 Copay Depending on Procedure $25 ‐ $350 Copay Depending on Procedure

Endodontics $85 ‐ $300 Copay Depending on Procedure $85 ‐ $300 Copay Depending on Procedure

Prosthodontics $65 ‐ $350 Copay Depending on Procedure $65 ‐ $350 Copay Depending on Procedure

Orthodontics (medically necessary) $350 Copay $350 Copay



Adult Vision Exam $0 Copay $0 Copay

Adult Optical (Eyewear) Not Covered Not Covered



Open Enrollment

KAISER PERMANENTE




November 1st ‐ November 30th(1) This plan has an embedded deductible and out‐of‐pocket maximum. Each family member will begin paying co-payments or coinsurance after meeting his or her individual

deductible, or when the family deductible is satisfied. Individual family members are no longer subject to cost sharing when they reach their individual out‐of‐pocket

maximum, or when the family out‐of pocket maximum is met.

(2) Deductible is waived for first three visits combined for non-preventive primary care, specialty care, urgent care, and individual mental/behavioral health and substance use disorder services.


Kaiser

One standard pair of frames & lenses

or contact lenses per calendar year

One standard pair of frames & lenses




Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $19.99 $19.99 $19.99 $19.99 $19.99 $19.99 $19.99

0–18 Medical $126.96 $123.55 $166.47 $169.86 $195.43 $194.79 $215.42

0–18 Total $146.95 $143.54 $186.46 $189.85 $215.42 $214.78 $235.41

19–20 $126.96 $123.55 $166.47 $169.86 $195.43 $194.79 $215.42

21 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

22 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

23 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

24 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

25 $200.74 $195.34 $263.21 $268.57 $309.00 $307.99 $340.60

26 $204.74 $199.23 $268.45 $273.92 $315.15 $314.12 $347.39

27 $209.53 $203.90 $274.74 $280.34 $322.54 $321.48 $355.53

28 $217.33 $211.49 $284.96 $290.77 $334.54 $333.45 $368.76

29 $223.73 $217.71 $293.35 $299.34 $344.39 $343.26 $379.62

30 $226.93 $220.83 $297.55 $303.62 $349.31 $348.17 $385.05

31 $231.73 $225.50 $303.84 $310.04 $356.70 $355.53 $393.19

32 $236.53 $230.17 $310.13 $316.46 $364.09 $362.90 $401.33

33 $239.52 $233.08 $314.06 $320.47 $368.70 $367.50 $406.42

34 $242.72 $236.20 $318.26 $324.75 $373.63 $372.41 $411.85

35 $244.32 $237.75 $320.36 $326.89 $376.09 $374.86 $414.56

36 $245.92 $239.31 $322.45 $329.03 $378.55 $377.31 $417.28

37 $247.52 $240.87 $324.55 $331.17 $381.01 $379.77 $419.99

38 $249.12 $242.42 $326.65 $333.31 $383.48 $382.22 $422.70

39 $252.32 $245.54 $330.84 $337.59 $388.40 $387.13 $428.13

40 $255.52 $248.65 $335.04 $341.87 $393.32 $392.04 $433.56

41 $260.32 $253.32 $341.33 $348.29 $400.71 $399.40 $441.70

42 $264.92 $257.79 $347.36 $354.44 $407.79 $406.46 $449.50

43 $271.31 $264.02 $355.75 $363.00 $417.64 $416.27 $460.36

44 $279.31 $271.80 $366.23 $373.70 $429.95 $428.54 $473.93

45 $288.71 $280.95 $378.55 $386.27 $444.41 $442.96 $489.87

46 $299.91 $291.84 $393.24 $401.25 $461.65 $460.14 $508.87

47 $312.50 $304.10 $409.75 $418.11 $481.04 $479.47 $530.24

48 $326.90 $318.11 $428.63 $437.37 $503.20 $501.55 $554.67

49 $341.09 $331.92 $447.24 $456.36 $525.05 $523.33 $578.76

50 $357.09 $347.49 $468.21 $477.76 $549.67 $547.87 $605.90

51 $372.88 $362.86 $488.92 $498.89 $573.98 $572.11 $632.70

52 $390.28 $379.78 $511.73 $522.16 $600.76 $598.79 $662.21

53 $407.87 $396.91 $534.80 $545.70 $627.84 $625.79 $692.07

54 $426.87 $415.39 $559.71 $571.12 $657.08 $654.93 $724.29

55 $445.86 $433.87 $584.61 $596.53 $686.32 $684.07 $756.52

56 $466.45 $453.91 $611.61 $624.08 $718.02 $715.67 $791.47

57 $487.25 $474.15 $638.88 $651.90 $750.02 $747.57 $826.75

58 $509.44 $495.74 $667.98 $681.60 $784.19 $781.62 $864.40

59 $520.44 $506.44 $682.39 $696.31 $801.11 $798.50 $883.06

60 $542.63 $528.04 $711.49 $726.00 $835.28 $832.55 $920.72

61 $561.82 $546.72 $736.66 $751.68 $864.82 $861.99 $953.29

62 $574.42 $558.98 $753.18 $768.53 $884.21 $881.32 $974.66

63 $590.21 $574.35 $773.89 $789.67 $908.52 $905.55 $1,001.46

64+ $599.82 $583.68 $786.48 $802.50 $923.31 $920.28 $1,017.75

Counties: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra,

Siskiyou, Sutter, Tehama, Trinity, Tuolumne, and Yuba

KAISER MEDICAL PLANS

EFFECTIVE DATE: DECEMBER 01, 2016 ‐ NOVEMBER 30, 2017

KAISER MEDICAL PLAN RATES

Rate Region 1

A SEPERATE $20.00 MONTHLY ADMINISTRATION FEE WILL BE ADDED TO CALCULATE YOUR TOTAL MONTHLY RATE


Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $15.99 $15.99 $15.99 $15.99 $15.99 $15.99 $15.99

0–18 Medical $133.64 $130.05 $175.23 $178.80 $205.72 $205.04 $226.76

0–18 Total $149.63 $146.04 $191.22 $194.79 $221.71 $221.03 $242.75

19–20 $133.64 $130.05 $175.23 $178.80 $205.72 $205.04 $226.76

21 $210.46 $204.80 $275.95 $281.58 $323.96 $322.90 $357.10

22 $210.46 $204.80 $275.95 $281.58 $323.96 $322.90 $357.10

23 $210.46 $204.80 $275.95 $281.58 $323.96 $322.90 $357.10

24 $210.46 $204.80 $275.95 $281.58 $323.96 $322.90 $357.10

25 $211.30 $205.62 $277.06 $282.71 $325.26 $324.20 $358.53

26 $215.51 $209.72 $282.58 $288.34 $331.74 $330.65 $365.67

27 $220.56 $214.63 $289.20 $295.10 $339.51 $338.40 $374.24

28 $228.77 $222.62 $299.96 $306.08 $352.15 $351.00 $388.17

29 $235.51 $229.17 $308.79 $315.09 $362.52 $361.33 $399.60

30 $238.87 $232.45 $313.21 $319.59 $367.70 $366.50 $405.31

31 $243.92 $237.37 $319.83 $326.35 $375.47 $374.25 $413.88

32 $248.97 $242.28 $326.45 $333.11 $383.25 $382.00 $422.45

33 $252.13 $245.35 $330.59 $337.33 $388.11 $386.84 $427.81

34 $255.50 $248.63 $335.01 $341.84 $393.29 $392.01 $433.52

35 $257.18 $250.27 $337.22 $344.09 $395.88 $394.59 $436.38

36 $258.87 $251.91 $339.42 $346.35 $398.48 $397.17 $439.24

37 $260.55 $253.54 $341.63 $348.60 $401.07 $399.76 $442.09

38 $262.23 $255.18 $343.84 $350.85 $403.66 $402.34 $444.95

39 $265.60 $258.46 $348.25 $355.36 $408.84 $407.51 $450.66

40 $268.97 $261.74 $352.67 $359.86 $414.03 $412.67 $456.38

41 $274.02 $266.65 $359.29 $366.62 $421.80 $420.42 $464.95

42 $278.86 $271.36 $365.64 $373.10 $429.25 $427.85 $473.16

43 $285.59 $277.92 $374.47 $382.11 $439.62 $438.18 $484.59

44 $294.01 $286.11 $385.51 $393.37 $452.58 $451.10 $498.87

45 $303.90 $295.73 $398.48 $406.60 $467.80 $466.27 $515.66

46 $315.69 $307.20 $413.93 $422.37 $485.95 $484.36 $535.65

47 $328.95 $320.11 $431.32 $440.11 $506.36 $504.70 $558.15

48 $344.10 $334.85 $451.19 $460.39 $529.68 $527.95 $583.86

49 $359.05 $349.39 $470.78 $480.38 $552.68 $550.88 $609.22

50 $375.88 $365.78 $492.86 $502.90 $578.60 $576.71 $637.79

51 $392.51 $381.96 $514.66 $525.15 $604.19 $602.22 $666.00

52 $410.82 $399.77 $538.66 $549.65 $632.38 $630.31 $697.07

53 $429.34 $417.80 $562.95 $574.43 $660.89 $658.73 $728.49

54 $449.33 $437.25 $589.16 $601.18 $691.66 $689.40 $762.42

55 $469.33 $456.71 $615.38 $627.93 $722.44 $720.08 $796.34

56 $491.00 $477.80 $643.80 $656.93 $755.81 $753.34 $833.12

57 $512.89 $499.10 $672.50 $686.21 $789.50 $786.92 $870.26

58 $536.25 $521.83 $703.13 $717.47 $825.46 $822.76 $909.90

59 $547.83 $533.10 $718.31 $732.96 $843.28 $840.52 $929.54

60 $571.19 $555.83 $748.94 $764.21 $879.24 $876.36 $969.18

61 $591.39 $575.49 $775.43 $791.24 $910.34 $907.36 $1,003.46

62 $604.65 $588.40 $792.82 $808.98 $930.75 $927.71 $1,025.96

63 $621.28 $604.57 $814.62 $831.23 $956.34 $953.22 $1,054.17

64+ $631.38 $614.40 $827.85 $844.74 $971.88 $968.70 $1,071.30

Counties: Marin, Napa, Solano, and Sonoma




Rate Region 2



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $15.99 $15.99 $15.99 $15.99 $15.99 $15.99 $15.99

0–18 Medical $126.96 $123.55 $166.47 $169.86 $195.43 $194.79 $215.42

0–18 Total $142.95 $139.54 $182.46 $185.85 $211.42 $210.78 $231.41

19–20 $126.96 $123.55 $166.47 $169.86 $195.43 $194.79 $215.42

21 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

22 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

23 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

24 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

25 $200.74 $195.34 $263.21 $268.57 $309.00 $307.99 $340.60

26 $204.74 $199.23 $268.45 $273.92 $315.15 $314.12 $347.39

27 $209.53 $203.90 $274.74 $280.34 $322.54 $321.48 $355.53

28 $217.33 $211.49 $284.96 $290.77 $334.54 $333.45 $368.76

29 $223.73 $217.71 $293.35 $299.34 $344.39 $343.26 $379.62

30 $226.93 $220.83 $297.55 $303.62 $349.31 $348.17 $385.05

31 $231.73 $225.50 $303.84 $310.04 $356.70 $355.53 $393.19

32 $236.53 $230.17 $310.13 $316.46 $364.09 $362.90 $401.33

33 $239.52 $233.08 $314.06 $320.47 $368.70 $367.50 $406.42

34 $242.72 $236.20 $318.26 $324.75 $373.63 $372.41 $411.85

35 $244.32 $237.75 $320.36 $326.89 $376.09 $374.86 $414.56

36 $245.92 $239.31 $322.45 $329.03 $378.55 $377.31 $417.28

37 $247.52 $240.87 $324.55 $331.17 $381.01 $379.77 $419.99

38 $249.12 $242.42 $326.65 $333.31 $383.48 $382.22 $422.70

39 $252.32 $245.54 $330.84 $337.59 $388.40 $387.13 $428.13

40 $255.52 $248.65 $335.04 $341.87 $393.32 $392.04 $433.56

41 $260.32 $253.32 $341.33 $348.29 $400.71 $399.40 $441.70

42 $264.92 $257.79 $347.36 $354.44 $407.79 $406.46 $449.50

43 $271.31 $264.02 $355.75 $363.00 $417.64 $416.27 $460.36

44 $279.31 $271.80 $366.23 $373.70 $429.95 $428.54 $473.93

45 $288.71 $280.95 $378.55 $386.27 $444.41 $442.96 $489.87

46 $299.91 $291.84 $393.24 $401.25 $461.65 $460.14 $508.87

47 $312.50 $304.10 $409.75 $418.11 $481.04 $479.47 $530.24

48 $326.90 $318.11 $428.63 $437.37 $503.20 $501.55 $554.67

49 $341.09 $331.92 $447.24 $456.36 $525.05 $523.33 $578.76

50 $357.09 $347.49 $468.21 $477.76 $549.67 $547.87 $605.90

51 $372.88 $362.86 $488.92 $498.89 $573.98 $572.11 $632.70

52 $390.28 $379.78 $511.73 $522.16 $600.76 $598.79 $662.21

53 $407.87 $396.91 $534.80 $545.70 $627.84 $625.79 $692.07

54 $426.87 $415.39 $559.71 $571.12 $657.08 $654.93 $724.29

55 $445.86 $433.87 $584.61 $596.53 $686.32 $684.07 $756.52

56 $466.45 $453.91 $611.61 $624.08 $718.02 $715.67 $791.47

57 $487.25 $474.15 $638.88 $651.90 $750.02 $747.57 $826.75

58 $509.44 $495.74 $667.98 $681.60 $784.19 $781.62 $864.40

59 $520.44 $506.44 $682.39 $696.31 $801.11 $798.50 $883.06

60 $542.63 $528.04 $711.49 $726.00 $835.28 $832.55 $920.72

61 $561.82 $546.72 $736.66 $751.68 $864.82 $861.99 $953.29

62 $574.42 $558.98 $753.18 $768.53 $884.21 $881.32 $974.66

63 $590.21 $574.35 $773.89 $789.67 $908.52 $905.55 $1,001.46

64+ $599.82 $583.68 $786.48 $802.50 $923.31 $920.28 $1,017.75

Counties: El Dorado, Placer, Sacramento, and Yolo




Rate Region 3



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $14.99 $14.99 $14.99 $14.99 $14.99 $14.99 $14.99

0–18 Medical $140.32 $136.55 $183.99 $187.74 $216.00 $215.30 $238.10

0–18 Total $155.31 $151.54 $198.98 $202.73 $230.99 $230.29 $253.09

19–20 $140.32 $136.55 $183.99 $187.74 $216.00 $215.30 $238.10

21 $220.98 $215.04 $289.75 $295.66 $340.16 $339.05 $374.96

22 $220.98 $215.04 $289.75 $295.66 $340.16 $339.05 $374.96

23 $220.98 $215.04 $289.75 $295.66 $340.16 $339.05 $374.96

24 $220.98 $215.04 $289.75 $295.66 $340.16 $339.05 $374.96

25 $221.87 $215.90 $290.91 $296.84 $341.52 $340.41 $376.46

26 $226.29 $220.20 $296.71 $302.76 $348.33 $347.19 $383.96

27 $231.59 $225.36 $303.66 $309.85 $356.49 $355.32 $392.96

28 $240.21 $233.75 $314.96 $321.38 $369.76 $368.55 $407.58

29 $247.28 $240.63 $324.23 $330.84 $380.64 $379.40 $419.58

30 $250.82 $244.07 $328.87 $335.57 $386.08 $384.82 $425.58

31 $256.12 $249.23 $335.82 $342.67 $394.25 $392.96 $434.58

32 $261.42 $254.39 $342.78 $349.77 $402.41 $401.10 $443.58

33 $264.74 $257.62 $347.12 $354.20 $407.51 $406.18 $449.20

34 $268.27 $261.06 $351.76 $358.93 $412.96 $411.61 $455.20

35 $270.04 $262.78 $354.08 $361.30 $415.68 $414.32 $458.20

36 $271.81 $264.50 $356.40 $363.66 $418.40 $417.03 $461.20

37 $273.58 $266.22 $358.71 $366.03 $421.12 $419.74 $464.20

38 $275.35 $267.94 $361.03 $368.39 $423.84 $422.46 $467.20

39 $278.88 $271.38 $365.67 $373.12 $429.28 $427.88 $473.20

40 $282.42 $274.82 $370.30 $377.85 $434.73 $433.31 $479.20

41 $287.72 $279.98 $377.26 $384.95 $442.89 $441.44 $488.20

42 $292.80 $284.93 $383.92 $391.75 $450.71 $449.24 $496.82

43 $299.87 $291.81 $393.19 $401.21 $461.60 $460.09 $508.82

44 $308.71 $300.41 $404.78 $413.04 $475.21 $473.65 $523.82

45 $319.10 $310.52 $418.40 $426.93 $491.19 $489.59 $541.44

46 $331.47 $322.56 $434.63 $443.49 $510.24 $508.58 $562.44

47 $345.40 $336.11 $452.88 $462.12 $531.67 $529.94 $586.06

48 $361.31 $351.59 $473.75 $483.40 $556.16 $554.35 $613.06

49 $377.00 $366.86 $494.32 $504.40 $580.32 $578.42 $639.68

50 $394.68 $384.06 $517.50 $528.05 $607.53 $605.54 $669.68

51 $412.13 $401.05 $540.39 $551.41 $634.40 $632.33 $699.30

52 $431.36 $419.76 $565.60 $577.13 $664.00 $661.83 $731.92

53 $450.81 $438.69 $591.09 $603.15 $693.93 $691.66 $764.91

54 $471.80 $459.11 $618.62 $631.23 $726.25 $723.87 $800.54

55 $492.79 $479.54 $646.15 $659.32 $758.56 $756.08 $836.16

56 $515.55 $501.69 $675.99 $689.78 $793.60 $791.00 $874.78

57 $538.54 $524.06 $706.13 $720.52 $828.97 $826.27 $913.77

58 $563.07 $547.93 $738.29 $753.34 $866.73 $863.90 $955.39

59 $575.22 $559.75 $754.23 $769.60 $885.44 $882.55 $976.02

60 $599.75 $583.62 $786.39 $802.42 $923.20 $920.18 $1,017.64

61 $620.96 $604.27 $814.20 $830.81 $955.85 $952.73 $1,053.63

62 $634.88 $617.82 $832.46 $849.43 $977.29 $974.09 $1,077.26

63 $652.34 $634.80 $855.35 $872.79 $1,004.16 $1,000.88 $1,106.88

64+ $662.94 $645.12 $869.25 $886.98 $1,020.48 $1,017.15 $1,124.88

Counties: San Francisco and San Mateo




Rate Region 4 & 8



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $14.99 $14.99 $14.99 $14.99 $14.99 $14.99 $14.99

0–18 Medical $126.96 $123.55 $166.47 $169.86 $195.43 $194.79 $215.42

0–18 Total $141.95 $138.54 $181.46 $184.85 $210.42 $209.78 $230.41

19–20 $126.96 $123.55 $166.47 $169.86 $195.43 $194.79 $215.42

21 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

22 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

23 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

24 $199.94 $194.56 $262.16 $267.50 $307.77 $306.76 $339.25

25 $200.74 $195.34 $263.21 $268.57 $309.00 $307.99 $340.60

26 $204.74 $199.23 $268.45 $273.92 $315.15 $314.12 $347.39

27 $209.53 $203.90 $274.74 $280.34 $322.54 $321.48 $355.53

28 $217.33 $211.49 $284.96 $290.77 $334.54 $333.45 $368.76

29 $223.73 $217.71 $293.35 $299.34 $344.39 $343.26 $379.62

30 $226.93 $220.83 $297.55 $303.62 $349.31 $348.17 $385.05

31 $231.73 $225.50 $303.84 $310.04 $356.70 $355.53 $393.19

32 $236.53 $230.17 $310.13 $316.46 $364.09 $362.90 $401.33

33 $239.52 $233.08 $314.06 $320.47 $368.70 $367.50 $406.42

34 $242.72 $236.20 $318.26 $324.75 $373.63 $372.41 $411.85

35 $244.32 $237.75 $320.36 $326.89 $376.09 $374.86 $414.56

36 $245.92 $239.31 $322.45 $329.03 $378.55 $377.31 $417.28

37 $247.52 $240.87 $324.55 $331.17 $381.01 $379.77 $419.99

38 $249.12 $242.42 $326.65 $333.31 $383.48 $382.22 $422.70

39 $252.32 $245.54 $330.84 $337.59 $388.40 $387.13 $428.13

40 $255.52 $248.65 $335.04 $341.87 $393.32 $392.04 $433.56

41 $260.32 $253.32 $341.33 $348.29 $400.71 $399.40 $441.70

42 $264.92 $257.79 $347.36 $354.44 $407.79 $406.46 $449.50

43 $271.31 $264.02 $355.75 $363.00 $417.64 $416.27 $460.36

44 $279.31 $271.80 $366.23 $373.70 $429.95 $428.54 $473.93

45 $288.71 $280.95 $378.55 $386.27 $444.41 $442.96 $489.87

46 $299.91 $291.84 $393.24 $401.25 $461.65 $460.14 $508.87

47 $312.50 $304.10 $409.75 $418.11 $481.04 $479.47 $530.24

48 $326.90 $318.11 $428.63 $437.37 $503.20 $501.55 $554.67

49 $341.09 $331.92 $447.24 $456.36 $525.05 $523.33 $578.76

50 $357.09 $347.49 $468.21 $477.76 $549.67 $547.87 $605.90

51 $372.88 $362.86 $488.92 $498.89 $573.98 $572.11 $632.70

52 $390.28 $379.78 $511.73 $522.16 $600.76 $598.79 $662.21

53 $407.87 $396.91 $534.80 $545.70 $627.84 $625.79 $692.07

54 $426.87 $415.39 $559.71 $571.12 $657.08 $654.93 $724.29

55 $445.86 $433.87 $584.61 $596.53 $686.32 $684.07 $756.52

56 $466.45 $453.91 $611.61 $624.08 $718.02 $715.67 $791.47

57 $487.25 $474.15 $638.88 $651.90 $750.02 $747.57 $826.75

58 $509.44 $495.74 $667.98 $681.60 $784.19 $781.62 $864.40

59 $520.44 $506.44 $682.39 $696.31 $801.11 $798.50 $883.06

60 $542.63 $528.04 $711.49 $726.00 $835.28 $832.55 $920.72

61 $561.82 $546.72 $736.66 $751.68 $864.82 $861.99 $953.29

62 $574.42 $558.98 $753.18 $768.53 $884.21 $881.32 $974.66

63 $590.21 $574.35 $773.89 $789.67 $908.52 $905.55 $1,001.46

64+ $599.82 $583.68 $786.48 $802.50 $923.31 $920.28 $1,017.75

Counties: Contra Costa




Rate Region 5



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $14.99 $14.99 $14.99 $14.99 $14.99 $14.99 $14.99

0–18 Medical $133.64 $130.05 $175.23 $178.80 $205.72 $205.04 $226.76

0–18 Total $148.63 $145.04 $190.22 $193.79 $220.71 $220.03 $241.75

19–20 $133.64 $130.05 $175.23 $178.80 $205.72 $205.04 $226.76

21 $210.46 $204.80 $275.95 $281.58 $323.96 $322.90 $357.10

22 $210.46 $204.80 $275.95 $281.58 $323.96 $322.90 $357.10

23 $210.46 $204.80 $275.95 $281.58 $323.96 $322.90 $357.10

24 $210.46 $204.80 $275.95 $281.58 $323.96 $322.90 $357.10

25 $211.30 $205.62 $277.06 $282.71 $325.26 $324.20 $358.53

26 $215.51 $209.72 $282.58 $288.34 $331.74 $330.65 $365.67

27 $220.56 $214.63 $289.20 $295.10 $339.51 $338.40 $374.24

28 $228.77 $222.62 $299.96 $306.08 $352.15 $351.00 $388.17

29 $235.51 $229.17 $308.79 $315.09 $362.52 $361.33 $399.60

30 $238.87 $232.45 $313.21 $319.59 $367.70 $366.50 $405.31

31 $243.92 $237.37 $319.83 $326.35 $375.47 $374.25 $413.88

32 $248.97 $242.28 $326.45 $333.11 $383.25 $382.00 $422.45

33 $252.13 $245.35 $330.59 $337.33 $388.11 $386.84 $427.81

34 $255.50 $248.63 $335.01 $341.84 $393.29 $392.01 $433.52

35 $257.18 $250.27 $337.22 $344.09 $395.88 $394.59 $436.38

36 $258.87 $251.91 $339.42 $346.35 $398.48 $397.17 $439.24

37 $260.55 $253.54 $341.63 $348.60 $401.07 $399.76 $442.09

38 $262.23 $255.18 $343.84 $350.85 $403.66 $402.34 $444.95

39 $265.60 $258.46 $348.25 $355.36 $408.84 $407.51 $450.66

40 $268.97 $261.74 $352.67 $359.86 $414.03 $412.67 $456.38

41 $274.02 $266.65 $359.29 $366.62 $421.80 $420.42 $464.95

42 $278.86 $271.36 $365.64 $373.10 $429.25 $427.85 $473.16

43 $285.59 $277.92 $374.47 $382.11 $439.62 $438.18 $484.59

44 $294.01 $286.11 $385.51 $393.37 $452.58 $451.10 $498.87

45 $303.90 $295.73 $398.48 $406.60 $467.80 $466.27 $515.66

46 $315.69 $307.20 $413.93 $422.37 $485.95 $484.36 $535.65

47 $328.95 $320.11 $431.32 $440.11 $506.36 $504.70 $558.15

48 $344.10 $334.85 $451.19 $460.39 $529.68 $527.95 $583.86

49 $359.05 $349.39 $470.78 $480.38 $552.68 $550.88 $609.22

50 $375.88 $365.78 $492.86 $502.90 $578.60 $576.71 $637.79

51 $392.51 $381.96 $514.66 $525.15 $604.19 $602.22 $666.00

52 $410.82 $399.77 $538.66 $549.65 $632.38 $630.31 $697.07

53 $429.34 $417.80 $562.95 $574.43 $660.89 $658.73 $728.49

54 $449.33 $437.25 $589.16 $601.18 $691.66 $689.40 $762.42

55 $469.33 $456.71 $615.38 $627.93 $722.44 $720.08 $796.34

56 $491.00 $477.80 $643.80 $656.93 $755.81 $753.34 $833.12

57 $512.89 $499.10 $672.50 $686.21 $789.50 $786.92 $870.26

58 $536.25 $521.83 $703.13 $717.47 $825.46 $822.76 $909.90

59 $547.83 $533.10 $718.31 $732.96 $843.28 $840.52 $929.54

60 $571.19 $555.83 $748.94 $764.21 $879.24 $876.36 $969.18

61 $591.39 $575.49 $775.43 $791.24 $910.34 $907.36 $1,003.46

62 $604.65 $588.40 $792.82 $808.98 $930.75 $927.71 $1,025.96

63 $621.28 $604.57 $814.62 $831.23 $956.34 $953.22 $1,054.17

64+ $631.38 $614.40 $827.85 $844.74 $971.88 $968.70 $1,071.30

Counties: Alameda




Rate Region 6



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $14.99 $14.99 $14.99 $14.99 $14.99 $14.99 $14.99

0–18 Medical $137.65 $133.95 $180.49 $184.17 $211.89 $211.20 $233.56

0–18 Total $152.64 $148.94 $195.48 $199.16 $226.88 $226.19 $248.55

19–20 $137.65 $133.95 $180.49 $184.17 $211.89 $211.20 $233.56

21 $216.77 $210.95 $284.23 $290.03 $333.68 $332.59 $367.82

22 $216.77 $210.95 $284.23 $290.03 $333.68 $332.59 $367.82

23 $216.77 $210.95 $284.23 $290.03 $333.68 $332.59 $367.82

24 $216.77 $210.95 $284.23 $290.03 $333.68 $332.59 $367.82

25 $217.64 $211.79 $285.37 $291.19 $335.02 $333.92 $369.29

26 $221.98 $216.01 $291.05 $296.99 $341.69 $340.57 $376.64

27 $227.18 $221.07 $297.88 $303.95 $349.70 $348.56 $385.47

28 $235.63 $229.30 $308.96 $315.26 $362.71 $361.53 $399.82

29 $242.57 $236.05 $318.06 $324.54 $373.39 $372.17 $411.59

30 $246.04 $239.42 $322.60 $329.18 $378.73 $377.49 $417.47

31 $251.24 $244.49 $329.43 $336.14 $386.74 $385.47 $426.30

32 $256.44 $249.55 $336.25 $343.10 $394.75 $393.46 $435.13

33 $259.70 $252.71 $340.51 $347.45 $399.75 $398.45 $440.64

34 $263.16 $256.09 $345.06 $352.09 $405.09 $403.77 $446.53

35 $264.90 $257.78 $347.33 $354.42 $407.76 $406.43 $449.47

36 $266.63 $259.46 $349.61 $356.74 $410.43 $409.09 $452.41

37 $268.37 $261.15 $351.88 $359.06 $413.10 $411.75 $455.36

38 $270.10 $262.84 $354.15 $361.38 $415.77 $414.41 $458.30

39 $273.57 $266.21 $358.70 $366.02 $421.11 $419.73 $464.18

40 $277.04 $269.59 $363.25 $370.66 $426.45 $425.05 $470.07

41 $282.24 $274.65 $370.07 $377.62 $434.45 $433.03 $478.90

42 $287.23 $279.50 $376.61 $384.29 $442.13 $440.68 $487.36

43 $294.16 $286.25 $385.70 $393.57 $452.81 $451.33 $499.13

44 $302.83 $294.69 $397.07 $405.17 $466.15 $464.63 $513.84

45 $313.02 $304.61 $410.43 $418.80 $481.84 $480.26 $531.13

46 $325.16 $316.42 $426.35 $435.04 $500.52 $498.89 $551.72

47 $338.82 $329.71 $444.26 $453.31 $521.55 $519.84 $574.90

48 $354.43 $344.90 $464.72 $474.20 $545.57 $543.79 $601.38

49 $369.82 $359.87 $484.90 $494.79 $569.26 $567.40 $627.49

50 $387.16 $376.75 $507.64 $517.99 $595.96 $594.01 $656.92

51 $404.28 $393.41 $530.10 $540.90 $622.32 $620.28 $685.98

52 $423.14 $411.77 $554.82 $566.14 $651.35 $649.22 $717.98

53 $442.22 $430.33 $579.84 $591.66 $680.71 $678.49 $750.35

54 $462.81 $450.37 $606.84 $619.21 $712.41 $710.08 $785.29

55 $483.41 $470.41 $633.84 $646.76 $744.11 $741.68 $820.23

56 $505.73 $492.14 $663.12 $676.64 $778.48 $775.94 $858.12

57 $528.28 $514.07 $692.68 $706.80 $813.18 $810.53 $896.37

58 $552.34 $537.49 $724.23 $738.99 $850.22 $847.44 $937.20

59 $564.26 $549.09 $739.86 $754.94 $868.58 $865.74 $957.43

60 $588.32 $572.51 $771.41 $787.14 $905.61 $902.65 $998.25

61 $609.14 $592.76 $798.70 $814.98 $937.65 $934.58 $1,033.56

62 $622.79 $606.05 $816.60 $833.25 $958.67 $955.54 $1,056.74

63 $639.92 $622.71 $839.06 $856.16 $985.03 $981.81 $1,085.79

64+ $650.31 $632.85 $852.69 $870.09 $1,001.04 $997.77 $1,103.46

Counties: Santa Clara, Monterey, San Benito, and Santa Cruz




Rate Region 7 & 9



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $15.99 $15.99 $15.99 $15.99 $15.99 $15.99 $15.99

0–18 Medical $120.28 $117.04 $157.71 $160.92 $185.15 $184.54 $204.08

0–18 Total $136.27 $133.03 $173.70 $176.91 $201.14 $200.53 $220.07

19–20 $120.28 $117.04 $157.71 $160.92 $185.15 $184.54 $204.08

21 $189.41 $184.32 $248.36 $253.42 $291.57 $290.61 $321.39

22 $189.41 $184.32 $248.36 $253.42 $291.57 $290.61 $321.39

23 $189.41 $184.32 $248.36 $253.42 $291.57 $290.61 $321.39

24 $189.41 $184.32 $248.36 $253.42 $291.57 $290.61 $321.39

25 $190.17 $185.06 $249.35 $254.44 $292.73 $291.78 $322.68

26 $193.96 $188.75 $254.32 $259.51 $298.56 $297.59 $329.11

27 $198.51 $193.17 $260.28 $265.59 $305.56 $304.56 $336.82

28 $205.89 $200.36 $269.97 $275.47 $316.93 $315.90 $349.35

29 $211.95 $206.26 $277.91 $283.58 $326.26 $325.20 $359.64

30 $214.99 $209.21 $281.89 $287.64 $330.93 $329.85 $364.78

31 $219.53 $213.63 $287.85 $293.72 $337.93 $336.82 $372.49

32 $224.08 $218.05 $293.81 $299.80 $344.92 $343.80 $380.21

33 $226.92 $220.82 $297.53 $303.60 $349.30 $348.16 $385.03

34 $229.95 $223.77 $301.51 $307.66 $353.96 $352.81 $390.17

35 $231.46 $225.24 $303.49 $309.68 $356.30 $355.13 $392.74

36 $232.98 $226.72 $305.48 $311.71 $358.63 $357.46 $395.31

37 $234.49 $228.19 $307.47 $313.74 $360.96 $359.78 $397.88

38 $236.01 $229.66 $309.46 $315.77 $363.29 $362.11 $400.46

39 $239.04 $232.61 $313.43 $319.82 $367.96 $366.76 $405.60

40 $242.07 $235.56 $317.40 $323.87 $372.62 $371.41 $410.74

41 $246.62 $239.99 $323.36 $329.96 $379.62 $378.38 $418.45

42 $250.97 $244.23 $329.08 $335.79 $386.33 $385.06 $425.85

43 $257.04 $250.12 $337.02 $343.90 $395.66 $394.36 $436.13

44 $264.61 $257.50 $346.96 $354.03 $407.32 $405.99 $448.99

45 $273.51 $266.16 $358.63 $365.94 $421.02 $419.65 $464.09

46 $284.12 $276.48 $372.54 $380.13 $437.35 $435.92 $482.09

47 $296.05 $288.09 $388.19 $396.10 $455.72 $454.23 $502.34

48 $309.69 $301.37 $406.07 $414.35 $476.71 $475.15 $525.48

49 $323.14 $314.45 $423.70 $432.34 $497.41 $495.79 $548.30

50 $338.29 $329.20 $443.57 $452.61 $520.74 $519.04 $574.01

51 $353.26 $343.76 $463.19 $472.63 $543.77 $542.00 $599.40

52 $369.74 $359.80 $484.80 $494.68 $569.14 $567.28 $627.36

53 $386.40 $376.02 $506.65 $516.98 $594.80 $592.85 $655.64

54 $404.40 $393.53 $530.25 $541.06 $622.50 $620.46 $686.17

55 $422.39 $411.04 $553.84 $565.13 $650.20 $648.07 $716.71

56 $441.90 $430.02 $579.42 $591.24 $680.23 $678.00 $749.81

57 $461.60 $449.19 $605.25 $617.59 $710.55 $708.23 $783.23

58 $482.63 $469.65 $632.82 $645.72 $742.91 $740.49 $818.91

59 $493.05 $479.79 $646.48 $659.66 $758.95 $756.47 $836.59

60 $514.07 $500.25 $674.05 $687.79 $791.31 $788.73 $872.26

61 $532.25 $517.94 $697.89 $712.12 $819.30 $816.63 $903.11

62 $544.19 $529.56 $713.54 $728.08 $837.67 $834.94 $923.36

63 $559.15 $544.12 $733.16 $748.11 $860.71 $857.89 $948.75

64+ $568.23 $552.96 $745.08 $760.26 $874.71 $871.83 $964.17

Counties: Mariposa, Merced, San Joaquin, Stanislaus, and Tulare




Rate Region 10



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $15.99 $15.99 $15.99 $15.99 $15.99 $15.99 $15.99

0–18 Medical $116.67 $113.53 $152.98 $156.10 $179.59 $179.00 $197.96

0–18 Total $132.66 $129.52 $168.97 $172.09 $195.58 $194.99 $213.95

19–20 $116.67 $113.53 $152.98 $156.10 $179.59 $179.00 $197.96

21 $183.73 $178.79 $240.91 $245.82 $282.82 $281.90 $311.75

22 $183.73 $178.79 $240.91 $245.82 $282.82 $281.90 $311.75

23 $183.73 $178.79 $240.91 $245.82 $282.82 $281.90 $311.75

24 $183.73 $178.79 $240.91 $245.82 $282.82 $281.90 $311.75

25 $184.47 $179.51 $241.87 $246.80 $283.95 $283.02 $313.00

26 $188.14 $183.08 $246.69 $251.72 $289.61 $288.66 $319.23

27 $192.55 $187.37 $252.47 $257.62 $296.40 $295.43 $326.72

28 $199.72 $194.35 $261.87 $267.21 $307.43 $306.42 $338.87

29 $205.60 $200.07 $269.58 $275.07 $316.48 $315.44 $348.85

30 $208.54 $202.93 $273.43 $279.01 $321.00 $319.95 $353.84

31 $212.95 $207.22 $279.21 $284.91 $327.79 $326.72 $361.32

32 $217.35 $211.51 $284.99 $290.81 $334.58 $333.48 $368.80

33 $220.11 $214.19 $288.61 $294.49 $338.82 $337.71 $373.48

34 $223.05 $217.05 $292.46 $298.43 $343.34 $342.22 $378.47

35 $224.52 $218.48 $294.39 $300.39 $345.61 $344.48 $380.96

36 $225.99 $219.91 $296.32 $302.36 $347.87 $346.73 $383.45

37 $227.46 $221.34 $298.24 $304.33 $350.13 $348.99 $385.95

38 $228.93 $222.77 $300.17 $306.29 $352.39 $351.24 $388.44

39 $231.87 $225.64 $304.03 $310.23 $356.92 $355.75 $393.43

40 $234.81 $228.50 $307.88 $314.16 $361.44 $360.26 $398.42

41 $239.22 $232.79 $313.66 $320.06 $368.23 $367.03 $405.90

42 $243.44 $236.90 $319.20 $325.71 $374.74 $373.51 $413.07

43 $249.32 $242.62 $326.91 $333.58 $383.79 $382.53 $423.05

44 $256.67 $249.77 $336.55 $343.41 $395.10 $393.81 $435.52

45 $265.31 $258.18 $347.87 $354.96 $408.39 $407.06 $450.17

46 $275.60 $268.19 $361.36 $368.73 $424.23 $422.84 $467.63

47 $287.17 $279.45 $376.54 $384.22 $442.05 $440.60 $487.27

48 $300.40 $292.32 $393.89 $401.92 $462.41 $460.90 $509.71

49 $313.45 $305.02 $410.99 $419.37 $482.49 $480.91 $531.85

50 $328.14 $319.32 $430.26 $439.04 $505.12 $503.47 $556.79

51 $342.66 $333.45 $449.29 $458.46 $527.46 $525.74 $581.42

52 $358.64 $349.00 $470.25 $479.84 $552.07 $550.26 $608.54

53 $374.81 $364.74 $491.45 $501.47 $576.95 $575.07 $635.97

54 $392.27 $381.72 $514.34 $524.83 $603.82 $601.85 $665.59

55 $409.72 $398.71 $537.23 $548.18 $630.69 $628.63 $695.20

56 $428.65 $417.12 $562.04 $573.50 $659.82 $657.66 $727.32

57 $447.75 $435.72 $587.09 $599.06 $689.23 $686.98 $759.74

58 $468.15 $455.56 $613.83 $626.35 $720.63 $718.27 $794.34

59 $478.25 $465.40 $627.08 $639.87 $736.18 $733.78 $811.49

60 $498.65 $485.24 $653.83 $667.16 $767.57 $765.07 $846.09

61 $516.29 $502.41 $676.95 $690.76 $794.73 $792.13 $876.02

62 $527.86 $513.67 $692.13 $706.24 $812.54 $809.89 $895.66

63 $542.38 $527.79 $711.16 $725.66 $834.89 $832.16 $920.29

64+ $551.19 $536.37 $722.73 $737.46 $848.46 $845.70 $935.25

Counties: Fresno, Kings, and Madera




Rate Region 11



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $15.99 $15.99 $15.99 $15.99 $15.99 $15.99 $15.99

0–18 Medical $119.36 $116.15 $156.51 $159.70 $183.73 $183.13 $202.53

0–18 Total $135.35 $132.14 $172.50 $175.69 $199.72 $199.12 $218.52

19–20 $119.36 $116.15 $156.51 $159.70 $183.73 $183.13 $202.53

21 $187.97 $182.92 $246.46 $251.49 $289.34 $288.40 $318.94

22 $187.97 $182.92 $246.46 $251.49 $289.34 $288.40 $318.94

23 $187.97 $182.92 $246.46 $251.49 $289.34 $288.40 $318.94

24 $187.97 $182.92 $246.46 $251.49 $289.34 $288.40 $318.94

25 $188.72 $183.65 $247.45 $252.50 $290.50 $289.55 $320.22

26 $192.48 $187.31 $252.38 $257.53 $296.29 $295.32 $326.60

27 $196.99 $191.70 $258.30 $263.56 $303.23 $302.24 $334.25

28 $204.32 $198.83 $267.91 $273.37 $314.52 $313.49 $346.69

29 $210.34 $204.68 $275.79 $281.42 $323.78 $322.72 $356.90

30 $213.35 $207.61 $279.74 $285.44 $328.40 $327.33 $362.00

31 $217.86 $212.00 $285.65 $291.48 $335.35 $334.25 $369.65

32 $222.37 $216.39 $291.57 $297.51 $342.29 $341.17 $377.31

33 $225.19 $219.13 $295.26 $301.29 $346.63 $345.50 $382.09

34 $228.19 $222.06 $299.21 $305.31 $351.26 $350.11 $387.19

35 $229.70 $223.52 $301.18 $307.32 $353.58 $352.42 $389.75

36 $231.20 $224.99 $303.15 $309.33 $355.89 $354.73 $392.30

37 $232.71 $226.45 $305.12 $311.34 $358.21 $357.04 $394.85

38 $234.21 $227.91 $307.10 $313.36 $360.52 $359.34 $397.40

39 $237.22 $230.84 $311.04 $317.38 $365.15 $363.96 $402.50

40 $240.23 $233.77 $314.98 $321.40 $369.78 $368.57 $407.61

41 $244.74 $238.16 $320.90 $327.44 $376.73 $375.49 $415.26

42 $249.06 $242.36 $326.57 $333.22 $383.38 $382.13 $422.60

43 $255.07 $248.22 $334.45 $341.27 $392.64 $391.36 $432.80

44 $262.59 $255.53 $344.31 $351.33 $404.21 $402.89 $445.56

45 $271.43 $264.13 $355.90 $363.15 $417.81 $416.45 $460.55

46 $281.95 $274.37 $369.70 $377.24 $434.02 $432.60 $478.41

47 $293.80 $285.90 $385.22 $393.08 $452.24 $450.77 $498.51

48 $307.33 $299.07 $402.97 $411.19 $473.08 $471.53 $521.47

49 $320.68 $312.05 $420.47 $429.04 $493.62 $492.01 $544.11

50 $335.71 $326.69 $440.19 $449.16 $516.77 $515.08 $569.63

51 $350.56 $341.14 $459.66 $469.03 $539.63 $537.86 $594.83

52 $366.92 $357.05 $481.10 $490.91 $564.80 $562.95 $622.57

53 $383.46 $373.15 $502.79 $513.04 $590.26 $588.33 $650.64

54 $401.31 $390.53 $526.20 $536.93 $617.75 $615.73 $680.94

55 $419.17 $407.90 $549.62 $560.82 $645.24 $643.13 $711.24

56 $438.53 $426.74 $575.00 $586.73 $675.04 $672.83 $744.09

57 $458.08 $445.77 $600.63 $612.88 $705.13 $702.83 $777.26

58 $478.95 $466.07 $627.99 $640.80 $737.25 $734.84 $812.66

59 $489.28 $476.13 $641.55 $654.63 $753.16 $750.70 $830.20

60 $510.15 $496.43 $668.91 $682.54 $785.28 $782.71 $865.61

61 $528.19 $513.99 $692.57 $706.69 $813.06 $810.40 $896.23

62 $540.04 $525.52 $708.09 $722.53 $831.28 $828.57 $916.32

63 $554.89 $539.97 $727.56 $742.40 $854.14 $851.35 $941.52

64+ $563.91 $548.76 $739.38 $754.47 $868.02 $865.20 $956.82

Counties: San Luis Obispo, Santa Barbara, and Ventura




Rate Region 12



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $15.99 $15.99 $15.99 $15.99 $15.99 $15.99 $15.99

0–18 Medical $113.39 $110.34 $148.68 $151.71 $174.55 $173.98 $192.40

0–18 Total $129.38 $126.33 $164.67 $167.70 $190.54 $189.97 $208.39

19–20 $113.39 $110.34 $148.68 $151.71 $174.55 $173.98 $192.40

21 $178.57 $173.77 $234.14 $238.92 $274.88 $273.98 $302.99

22 $178.57 $173.77 $234.14 $238.92 $274.88 $273.98 $302.99

23 $178.57 $173.77 $234.14 $238.92 $274.88 $273.98 $302.99

24 $178.57 $173.77 $234.14 $238.92 $274.88 $273.98 $302.99

25 $179.29 $174.47 $235.08 $239.87 $275.98 $275.07 $304.21

26 $182.86 $177.94 $239.76 $244.65 $281.47 $280.55 $310.27

27 $187.14 $182.11 $245.38 $250.38 $288.07 $287.13 $317.54

28 $194.11 $188.89 $254.51 $259.70 $298.79 $297.81 $329.35

29 $199.82 $194.45 $262.00 $267.35 $307.59 $306.58 $339.05

30 $202.68 $197.23 $265.75 $271.17 $311.98 $310.96 $343.90

31 $206.96 $201.40 $271.37 $276.90 $318.58 $317.54 $351.17

32 $211.25 $205.57 $276.99 $282.64 $325.18 $324.12 $358.44

33 $213.93 $208.18 $280.50 $286.22 $329.30 $328.23 $362.99

34 $216.79 $210.96 $284.25 $290.04 $333.70 $332.61 $367.84

35 $218.21 $212.35 $286.12 $291.96 $335.90 $334.80 $370.26

36 $219.64 $213.74 $287.99 $293.87 $338.10 $336.99 $372.68

37 $221.07 $215.13 $289.87 $295.78 $340.30 $339.18 $375.11

38 $222.50 $216.52 $291.74 $297.69 $342.50 $341.38 $377.53

39 $225.36 $219.30 $295.49 $301.51 $346.89 $345.76 $382.38

40 $228.21 $222.08 $299.23 $305.33 $351.29 $350.14 $387.23

41 $232.50 $226.25 $304.85 $311.07 $357.89 $356.72 $394.50

42 $236.61 $230.25 $310.24 $316.56 $364.21 $363.02 $401.47

43 $242.32 $235.81 $317.73 $324.21 $373.01 $371.79 $411.16

44 $249.46 $242.76 $327.10 $333.77 $384.00 $382.75 $423.28

45 $257.86 $250.92 $338.10 $344.99 $396.92 $395.62 $437.52

46 $267.86 $260.65 $351.21 $358.37 $412.31 $410.97 $454.49

47 $279.11 $271.60 $365.96 $373.43 $429.63 $428.23 $473.58

48 $291.96 $284.11 $382.82 $390.63 $449.42 $447.95 $495.40

49 $304.64 $296.45 $399.45 $407.59 $468.94 $467.41 $516.91

50 $318.93 $310.35 $418.18 $426.70 $490.93 $489.32 $541.15

51 $333.03 $324.08 $436.67 $445.58 $512.64 $510.97 $565.08

52 $348.57 $339.20 $457.04 $466.36 $536.56 $534.80 $591.45

53 $364.28 $354.49 $477.65 $487.39 $560.75 $558.91 $618.11

54 $381.25 $371.00 $499.89 $510.09 $586.86 $584.94 $646.89

55 $398.21 $387.51 $522.14 $532.78 $612.97 $610.97 $675.68

56 $416.61 $405.41 $546.25 $557.39 $641.29 $639.19 $706.89

57 $435.18 $423.48 $570.60 $582.24 $669.87 $667.68 $738.40

58 $455.00 $442.77 $596.59 $608.76 $700.38 $698.10 $772.03

59 $464.82 $452.32 $609.47 $621.90 $715.50 $713.16 $788.69

60 $484.64 $471.61 $635.46 $648.42 $746.01 $743.58 $822.33

61 $501.78 $488.29 $657.94 $671.35 $772.40 $769.88 $851.41

62 $513.03 $499.24 $672.69 $686.41 $789.72 $787.14 $870.50

63 $527.14 $512.97 $691.19 $705.28 $811.43 $808.78 $894.44

64+ $535.71 $521.31 $702.42 $716.76 $824.64 $821.94 $908.97

Counties: Imperial, Inyo, and Mono




Rate Region 13



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $14.99 $14.99 $14.99 $14.99 $14.99 $14.99 $14.99

0–18 Medical $113.39 $110.34 $148.68 $151.71 $174.55 $173.98 $192.40

0–18 Total $128.38 $125.33 $163.67 $166.70 $189.54 $188.97 $207.39

19–20 $113.39 $110.34 $148.68 $151.71 $174.55 $173.98 $192.40

21 $178.57 $173.77 $234.14 $238.92 $274.88 $273.98 $302.99

22 $178.57 $173.77 $234.14 $238.92 $274.88 $273.98 $302.99

23 $178.57 $173.77 $234.14 $238.92 $274.88 $273.98 $302.99

24 $178.57 $173.77 $234.14 $238.92 $274.88 $273.98 $302.99

25 $179.29 $174.47 $235.08 $239.87 $275.98 $275.07 $304.21

26 $182.86 $177.94 $239.76 $244.65 $281.47 $280.55 $310.27

27 $187.14 $182.11 $245.38 $250.38 $288.07 $287.13 $317.54

28 $194.11 $188.89 $254.51 $259.70 $298.79 $297.81 $329.35

29 $199.82 $194.45 $262.00 $267.35 $307.59 $306.58 $339.05

30 $202.68 $197.23 $265.75 $271.17 $311.98 $310.96 $343.90

31 $206.96 $201.40 $271.37 $276.90 $318.58 $317.54 $351.17

32 $211.25 $205.57 $276.99 $282.64 $325.18 $324.12 $358.44

33 $213.93 $208.18 $280.50 $286.22 $329.30 $328.23 $362.99

34 $216.79 $210.96 $284.25 $290.04 $333.70 $332.61 $367.84

35 $218.21 $212.35 $286.12 $291.96 $335.90 $334.80 $370.26

36 $219.64 $213.74 $287.99 $293.87 $338.10 $336.99 $372.68

37 $221.07 $215.13 $289.87 $295.78 $340.30 $339.18 $375.11

38 $222.50 $216.52 $291.74 $297.69 $342.50 $341.38 $377.53

39 $225.36 $219.30 $295.49 $301.51 $346.89 $345.76 $382.38

40 $228.21 $222.08 $299.23 $305.33 $351.29 $350.14 $387.23

41 $232.50 $226.25 $304.85 $311.07 $357.89 $356.72 $394.50

42 $236.61 $230.25 $310.24 $316.56 $364.21 $363.02 $401.47

43 $242.32 $235.81 $317.73 $324.21 $373.01 $371.79 $411.16

44 $249.46 $242.76 $327.10 $333.77 $384.00 $382.75 $423.28

45 $257.86 $250.92 $338.10 $344.99 $396.92 $395.62 $437.52

46 $267.86 $260.65 $351.21 $358.37 $412.31 $410.97 $454.49

47 $279.11 $271.60 $365.96 $373.43 $429.63 $428.23 $473.58

48 $291.96 $284.11 $382.82 $390.63 $449.42 $447.95 $495.40

49 $304.64 $296.45 $399.45 $407.59 $468.94 $467.41 $516.91

50 $318.93 $310.35 $418.18 $426.70 $490.93 $489.32 $541.15

51 $333.03 $324.08 $436.67 $445.58 $512.64 $510.97 $565.08

52 $348.57 $339.20 $457.04 $466.36 $536.56 $534.80 $591.45

53 $364.28 $354.49 $477.65 $487.39 $560.75 $558.91 $618.11

54 $381.25 $371.00 $499.89 $510.09 $586.86 $584.94 $646.89

55 $398.21 $387.51 $522.14 $532.78 $612.97 $610.97 $675.68

56 $416.61 $405.41 $546.25 $557.39 $641.29 $639.19 $706.89

57 $435.18 $423.48 $570.60 $582.24 $669.87 $667.68 $738.40

58 $455.00 $442.77 $596.59 $608.76 $700.38 $698.10 $772.03

59 $464.82 $452.32 $609.47 $621.90 $715.50 $713.16 $788.69

60 $484.64 $471.61 $635.46 $648.42 $746.01 $743.58 $822.33

61 $501.78 $488.29 $657.94 $671.35 $772.40 $769.88 $851.41

62 $513.03 $499.24 $672.69 $686.41 $789.72 $787.14 $870.50

63 $527.14 $512.97 $691.19 $705.28 $811.43 $808.78 $894.44

64+ $535.71 $521.31 $702.42 $716.76 $824.64 $821.94 $908.97

Counties: Kern, Riverside, San Bernardino, and SanDiego




Rate Region 14, 17 & 19



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $14.99 $14.99 $14.99 $14.99 $14.99 $14.99 $14.99

0–18 Medical $110.09 $107.13 $144.35 $147.29 $169.46 $168.91 $186.80

0–18 Total $125.08 $122.12 $159.34 $162.28 $184.45 $183.90 $201.79

19–20 $110.09 $107.13 $144.35 $147.29 $169.46 $168.91 $186.80

21 $173.37 $168.71 $227.32 $231.96 $266.87 $266.00 $294.17

22 $173.37 $168.71 $227.32 $231.96 $266.87 $266.00 $294.17

23 $173.37 $168.71 $227.32 $231.96 $266.87 $266.00 $294.17

24 $173.37 $168.71 $227.32 $231.96 $266.87 $266.00 $294.17

25 $174.06 $169.38 $228.23 $232.88 $267.94 $267.06 $295.35

26 $177.53 $172.76 $232.78 $237.52 $273.28 $272.38 $301.23

27 $181.69 $176.81 $238.23 $243.09 $279.68 $278.77 $308.29

28 $188.45 $183.39 $247.10 $252.14 $290.09 $289.14 $319.76

29 $194.00 $188.79 $254.37 $259.56 $298.63 $297.65 $329.18

30 $196.77 $191.48 $258.01 $263.27 $302.90 $301.91 $333.88

31 $200.94 $195.53 $263.47 $268.84 $309.30 $308.29 $340.94

32 $205.10 $199.58 $268.92 $274.41 $315.71 $314.68 $348.00

33 $207.70 $202.11 $272.33 $277.88 $319.71 $318.67 $352.41

34 $210.47 $204.81 $275.97 $281.60 $323.98 $322.92 $357.12

35 $211.86 $206.16 $277.79 $283.45 $326.12 $325.05 $359.47

36 $213.25 $207.51 $279.61 $285.31 $328.25 $327.18 $361.83

37 $214.63 $208.86 $281.42 $287.16 $330.39 $329.31 $364.18

38 $216.02 $210.21 $283.24 $289.02 $332.52 $331.43 $366.53

39 $218.79 $212.91 $286.88 $292.73 $336.79 $335.69 $371.24

40 $221.57 $215.61 $290.52 $296.44 $341.06 $339.95 $375.95

41 $225.73 $219.66 $295.97 $302.01 $347.46 $346.33 $383.01

42 $229.72 $223.54 $301.20 $307.34 $353.60 $352.45 $389.77

43 $235.26 $228.94 $308.48 $314.77 $362.14 $360.96 $399.19

44 $242.20 $235.69 $317.57 $324.04 $372.82 $371.60 $410.95

45 $250.35 $243.62 $328.25 $334.95 $385.36 $384.10 $424.78

46 $260.05 $253.06 $340.98 $347.94 $400.31 $399.00 $441.25

47 $270.98 $263.69 $355.30 $362.55 $417.12 $415.75 $459.79

48 $283.46 $275.84 $371.67 $379.25 $436.33 $434.91 $480.97

49 $295.77 $287.82 $387.81 $395.72 $455.28 $453.79 $501.85

50 $309.64 $301.31 $406.00 $414.28 $476.63 $475.07 $525.39

51 $323.33 $314.64 $423.96 $432.60 $497.71 $496.09 $548.63

52 $338.42 $329.32 $443.73 $452.78 $520.93 $519.23 $574.22

53 $353.67 $344.17 $463.74 $473.19 $544.42 $542.64 $600.11

54 $370.14 $360.19 $485.33 $495.23 $569.77 $567.91 $628.05

55 $386.61 $376.22 $506.93 $517.26 $595.12 $593.18 $656.00

56 $404.47 $393.60 $530.34 $541.16 $622.61 $620.57 $686.30

57 $422.50 $411.14 $553.98 $565.28 $650.36 $648.24 $716.89

58 $441.75 $429.87 $579.22 $591.03 $679.99 $677.76 $749.54

59 $451.28 $439.15 $591.72 $603.78 $694.66 $692.39 $765.72

60 $470.53 $457.88 $616.95 $629.53 $724.29 $721.92 $798.38

61 $487.17 $474.07 $638.77 $651.80 $749.91 $747.45 $826.62

62 $498.09 $484.70 $653.10 $666.41 $766.72 $764.21 $845.15

63 $511.79 $498.03 $671.05 $684.74 $787.80 $785.23 $868.39

64+ $520.11 $506.13 $681.96 $695.88 $800.61 $798.00 $882.51

Counties: Los Angeles 906‐912, 915, 917, 918, and 935




Rate Region 15



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $14.99 $14.99 $14.99 $14.99 $14.99 $14.99 $14.99

0–18 Medical $115.59 $112.49 $151.57 $154.66 $177.94 $177.35 $196.14

0–18 Total $130.58 $127.48 $166.56 $169.65 $192.93 $192.34 $211.13

19–20 $115.59 $112.49 $151.57 $154.66 $177.94 $177.35 $196.14

21 $182.04 $177.14 $238.69 $243.55 $280.21 $279.30 $308.88

22 $182.04 $177.14 $238.69 $243.55 $280.21 $279.30 $308.88

23 $182.04 $177.14 $238.69 $243.55 $280.21 $279.30 $308.88

24 $182.04 $177.14 $238.69 $243.55 $280.21 $279.30 $308.88

25 $182.77 $177.85 $239.64 $244.53 $281.33 $280.42 $310.11

26 $186.41 $181.40 $244.42 $249.40 $286.94 $286.00 $316.29

27 $190.78 $185.65 $250.15 $255.25 $293.66 $292.70 $323.70

28 $197.88 $192.56 $259.45 $264.74 $304.59 $303.60 $335.75

29 $203.70 $198.22 $267.09 $272.54 $313.56 $312.53 $345.63

30 $206.61 $201.06 $270.91 $276.43 $318.04 $317.00 $350.58

31 $210.98 $205.31 $276.64 $282.28 $324.77 $323.71 $357.99

32 $215.35 $209.56 $282.37 $288.13 $331.49 $330.41 $365.40

33 $218.08 $212.22 $285.95 $291.78 $335.70 $334.60 $370.04

34 $220.99 $215.05 $289.77 $295.68 $340.18 $339.07 $374.98

35 $222.45 $216.47 $291.68 $297.62 $342.42 $341.30 $377.45

36 $223.91 $217.89 $293.59 $299.57 $344.66 $343.54 $379.92

37 $225.36 $219.30 $295.50 $301.52 $346.90 $345.77 $382.39

38 $226.82 $220.72 $297.41 $303.47 $349.15 $348.01 $384.86

39 $229.73 $223.56 $301.22 $307.37 $353.63 $352.47 $389.80

40 $232.65 $226.39 $305.04 $311.26 $358.11 $356.94 $394.75

41 $237.01 $230.64 $310.77 $317.11 $364.84 $363.65 $402.16

42 $241.20 $234.72 $316.26 $322.71 $371.28 $370.07 $409.26

43 $247.03 $240.38 $323.90 $330.50 $380.25 $379.01 $419.15

44 $254.31 $247.47 $333.45 $340.25 $391.46 $390.18 $431.50

45 $262.86 $255.80 $344.67 $351.69 $404.63 $403.31 $446.02

46 $273.06 $265.72 $358.03 $365.33 $420.32 $418.95 $463.32

47 $284.53 $276.88 $373.07 $380.68 $437.97 $436.54 $482.78

48 $297.63 $289.63 $390.26 $398.21 $458.15 $456.65 $505.02

49 $310.56 $302.21 $407.20 $415.50 $478.04 $476.48 $526.95

50 $325.12 $316.38 $426.30 $434.99 $500.46 $498.83 $551.66

51 $339.50 $330.37 $445.15 $454.23 $522.60 $520.89 $576.06

52 $355.34 $345.79 $465.92 $475.42 $546.98 $545.19 $602.93

53 $371.36 $361.37 $486.92 $496.85 $571.64 $569.77 $630.11

54 $388.65 $378.20 $509.60 $519.99 $598.26 $596.30 $659.45

55 $405.95 $395.03 $532.27 $543.13 $624.88 $622.83 $688.80

56 $424.70 $413.28 $556.86 $568.21 $653.74 $651.60 $720.61

57 $443.63 $431.70 $581.68 $593.54 $682.88 $680.65 $752.74

58 $463.83 $451.36 $608.18 $620.58 $713.98 $711.65 $787.02

59 $473.85 $461.11 $621.31 $633.97 $729.40 $727.01 $804.01

60 $494.05 $480.77 $647.80 $661.01 $760.50 $758.01 $838.29

61 $511.53 $497.77 $670.71 $684.39 $787.40 $784.83 $867.95

62 $523.00 $508.94 $685.75 $699.73 $805.05 $802.42 $887.41

63 $537.38 $522.93 $704.61 $718.97 $827.19 $824.49 $911.81

64+ $546.12 $531.42 $716.07 $730.65 $840.63 $837.90 $926.64

Counties: Los Angeles other




Rate Region 16



Age on 2016

effective date

Bronze 60

HMO 6000/70

w/ Child Dental*

Bronze 60 HSA

HMO 4500/40%

w/ Child Dental*

Silver 70

HMO 1000/50

w/ Child Dental*

Silver 70

HMO 1500/45

w/ Child Dental*

Gold 80

HMO 0/35

w/ Child Dental*

Gold 80

HMO 500/30

w/ Child Dental*

Platinum 90

HMO 0/20

w/ Child Dental*

0–18 CD $14.99 $14.99 $14.99 $14.99 $14.99 $14.99 $14.99

0–18 Medical $121.68 $118.41 $159.54 $162.80 $187.30 $186.69 $206.46

0–18 Total $136.67 $133.40 $174.53 $177.79 $202.29 $201.68 $221.45

19–20 $121.68 $118.41 $159.54 $162.80 $187.30 $186.69 $206.46

21 $191.62 $186.47 $251.25 $256.37 $294.96 $294.00 $325.13

22 $191.62 $186.47 $251.25 $256.37 $294.96 $294.00 $325.13

23 $191.62 $186.47 $251.25 $256.37 $294.96 $294.00 $325.13

24 $191.62 $186.47 $251.25 $256.37 $294.96 $294.00 $325.13

25 $192.39 $187.21 $252.26 $257.40 $296.14 $295.17 $326.44

26 $196.22 $190.94 $257.28 $262.53 $302.04 $301.05 $332.94

27 $200.82 $195.42 $263.31 $268.68 $309.12 $308.11 $340.74

28 $208.29 $202.69 $273.11 $278.68 $320.62 $319.58 $353.42

29 $214.42 $208.66 $281.15 $286.88 $330.06 $328.98 $363.83

30 $217.49 $211.64 $285.17 $290.98 $334.78 $333.69 $369.03

31 $222.09 $216.12 $291.20 $297.14 $341.86 $340.74 $376.83

32 $226.69 $220.59 $297.23 $303.29 $348.94 $347.80 $384.63

33 $229.56 $223.39 $301.00 $307.14 $353.36 $352.21 $389.51

34 $232.63 $226.37 $305.02 $311.24 $358.08 $356.91 $394.71

35 $234.16 $227.86 $307.03 $313.29 $360.44 $359.27 $397.31

36 $235.69 $229.36 $309.04 $315.34 $362.80 $361.62 $399.92

37 $237.22 $230.85 $311.05 $317.39 $365.16 $363.97 $402.52

38 $238.76 $232.34 $313.06 $319.44 $367.52 $366.32 $405.12

39 $241.82 $235.32 $317.08 $323.54 $372.24 $371.03 $410.32

40 $244.89 $238.31 $321.10 $327.65 $376.96 $375.73 $415.52

41 $249.49 $242.78 $327.13 $333.80 $384.04 $382.79 $423.33

42 $253.90 $247.07 $332.91 $339.70 $390.82 $389.55 $430.80

43 $260.03 $253.04 $340.95 $347.90 $400.26 $398.95 $441.21

44 $267.69 $260.50 $351.00 $358.15 $412.06 $410.71 $454.21

45 $276.70 $269.26 $362.81 $370.20 $425.92 $424.53 $469.49

46 $287.43 $279.70 $376.88 $384.56 $442.44 $441.00 $487.70

47 $299.50 $291.45 $392.70 $400.71 $461.03 $459.52 $508.19

48 $313.30 $304.87 $410.79 $419.17 $482.26 $480.69 $531.59

49 $326.90 $318.11 $428.63 $437.37 $503.20 $501.56 $554.68

50 $342.23 $333.03 $448.73 $457.88 $526.80 $525.08 $580.69

51 $357.37 $347.76 $468.58 $478.14 $550.10 $548.31 $606.38

52 $374.04 $363.98 $490.44 $500.44 $575.77 $573.88 $634.66

53 $390.90 $380.39 $512.55 $523.00 $601.72 $599.76 $663.27

54 $409.11 $398.11 $536.42 $547.36 $629.74 $627.69 $694.16

55 $427.31 $415.82 $560.29 $571.71 $657.76 $655.62 $725.05

56 $447.05 $435.03 $586.17 $598.12 $688.15 $685.90 $758.54

57 $466.98 $454.42 $612.30 $624.78 $718.82 $716.47 $792.35

58 $488.25 $475.12 $640.19 $653.24 $751.56 $749.11 $828.44

59 $498.79 $485.37 $654.01 $667.34 $767.79 $765.28 $846.33

60 $520.06 $506.07 $681.89 $695.80 $800.53 $797.91 $882.42

61 $538.45 $523.97 $706.01 $720.41 $828.84 $826.13 $913.63

62 $550.52 $535.72 $721.84 $736.56 $847.43 $844.66 $934.11

63 $565.66 $550.45 $741.69 $756.81 $870.73 $867.88 $959.80

64+ $574.86 $559.41 $753.75 $769.11 $884.88 $882.00 $975.39

Counties: Orange




Rate Region 18



Mapped From Gateway 1800 HSA Gold HMO

Gateway 30 Gateway 70 Gateway 2000 HSA BENEFITS Platinum HMO Platinum HMO Gold HMOLifetime Maximum Unlimited Unlimited Unlimited

$2,000 Single Coverage

Calendar Year Deductible: None None $2,600 Single w/ Family

$4,000 Family Coverage

$2,000 Single Coverage

Calendar Year Max Out‐of‐Pocket: $4,000 / $8,000 $4,000 / $8,000 $2,600 Single w/ Family

$4,000 Family Coverage

Office Visit $30 per Visit $20 per Visit Covered in Full After Deductible

Preventive Services Covered in Full Covered in Full Covered In Full

Diagnostic X‐Ray & Lab Covered in Full Covered in Full Covered in Full After Deductible

Imaging (CT/PET Scans & MRIs) $100 per Visit $100 per Visit Covered in Full After Deductible

Hospitalization $300 per Day, Days 1‐3 30% Covered in Full After Deductible

Outpatient Surgery Facility $100 per Visit $100 per Visit Covered in Full After Deductible

Outpatient Surgery Professional Covered in Full Covered in Full Covered in Full After Deductible

Emergency Room $150 per Visit $150 per Visit Covered in Full After Deductible

Urgent Care Center $50 per Visit $50 per Visit Covered in Full After Deductible

Maternity: Inpatient $300 per Day, Days 1‐3 30% Covered in Full After Deductible

Prenatal/First Postpartum Visit Covered in Full Covered in Full Covered in Full

Mental Health: Inpatient $300 per Day, Days 1‐3 30% Covered in Full After Deductible

Outpatient $30 per Visit $20 per Visit Covered in Full After Deductible

Substance Abuse: Inpatient Detox Only $300 per Day, Days 1‐3 30% Covered in Full After Deductible

Prescriptions: (Up to a 30‐Day Supply) (Up to a 30‐Day Supply) (Up to a 30‐Day Supply)

Generic $10 Copay $10 Copay Covered in Full After Deductible

Deductible (Brand Name) None None Medical Deductible Applies

Brand $30 copay $30 copay Covered in Full After Deductible

Non Formulary $50 copay $50 copay Covered in Full After Deductible


Annual Out‐of‐Pocket Maximum None None None

Deductible / Waiting Period $0 Deductible / No Waiting Period $0 Deductible / No Waiting Period $0 Deductible / No Waiting Period

Annual Maximum N/A N/A N/A

Office Visit $0 Copay $0 Copay $0 Copay

Diagnostic & Preventive: X‐Ray, Exam, Cleanings $0 Copay $0 Copay $0 Copay

Basic Services: $40 ‐ $365 Copay $40 ‐ $365 Copay $40 ‐ $365 Copay

Basic restorative Depending on Procedure Depending on Procedure Depending on Procedure

Major Services: Crown, Cast, Prothodontists, $40 ‐ $365 Copay $40 ‐ $365 Copay $40 ‐ $365 Copay

Endodontics, Periodontics, Oral Surgery Depending on Procedure Depending on Procedure Depending on Procedure

Orthodontics (Medically Necessary) $1,000 Maximum $1,000 Maximum $1,000 Maximum



Adult Vision Exam $0 Copay $0 Copay $0 Copay

Adult Optical (Eyewear) Not Covered Not Covered Not Covered


WHA Members & Dependents

Open Enrollment November 1st ‐ November 30th.


WESTERN HEALTH ADVANTAGE

One pair of standard frames & lenses






Western Health Advantage HMO


Members may apply at anytime except if you are a new member, then it is the 1st of the month following new membership.




Mapped From Gateway 5500B HSA Bronze HMO

Gateway 1500 HSA Gateway 4010 Gateway 6000 HSA

BENEFITS Silver HMO Gold HMO Bronze HMO

Lifetime Maximum Unlimited Unlimited Unlimited$1,500 Single Coverage $1,000 Single Coverage $6,000 Single Coverage

Calendar Year Deductible: $2,600 Single w/ Family $1,000 Single w/Family $6,000 Single w/Family

$3,000 Family Coverage $2,000 Family Coverage $12,000 Family Coverage

$6,350 Single Coverage $6,350 Single Coverage $6,000 Single Coverage

Calendar Year Max Out‐of‐Pocket: $6,350 Single w/ Family $6,350 Single w/Family $6,000 Single w/Family

$12,700 Family Coverage $12,700 Family Coverage $12,000 Family Coverage

Office Visit $20 per Visit After Deductible $40 per Visit Covered in Full After Deductible

Preventive Services Covered in Full Covered in Full Covered In Full

Diagnostic X‐Ray & Lab Covered in Full After Deductible Covered in Full Covered in Full After Deductible

Imaging (CT/PET Scans & MRIs) 30% After Deductible $250 per Visit Covered in Full After Deductible

Hospitalization 30% After Deductible $500 per Day, Days 1‐5 After Deductible Covered in Full After Deductible

Outpatient Surgery Facility 30% After Deductible $500 per Visit After Deductible Covered in Full After Deductible

Outpatient Surgery Professional Covered in Full Covered in Full Covered in Full After Deductible

Emergency Room 30% After Deductible $275 per Visit After Deductible Covered in Full After Deductible

Urgent Care Center $50 per Visit After Deductible $50 per Visit Covered in Full After Deductible

Maternity:

Inpatient 30% After Deductible $500 per Day, Days 1‐5 After Deductible Covered in Full After Deductible

Prenatal/First Postpartum Visit Covered in Full Covered in Full Covered in Full

Mental Health:

Inpatient 30% After Deductible $500 per Day, Days 1‐5 After Deductible Covered in Full After Deductible

Outpatient $20 per Visit After Deductible $40 per Visit Covered in Full After Deductible

Substance Abuse:

Inpatient Detox Only 30% After Deductible $500 per Day, Days 1‐5 After Deductible Covered in Full After Deductible

Prescriptions: (Up to a 30‐Day Supply) (Up to a 30‐Day Supply) (Up to a 30‐Day Supply)

Generic $25 After Deductible $10 copay Covered in Full After Deductible

Deductible (Brand Name) Medical Deductible Applies $250/$250 / $500 Medical Deductible Applies

Brand $50 After Deductible $30 Copay Covered in Full After Deductible

Non Formulary $75 After Deductible $50 Copay Covered in Full After Deductible


Annual Out‐of‐Pocket Maximum None None None

Deductible / Waiting Period $0 Deductible / No Waiting Period $0 Deductible / No Waiting Period $0 Deductible / No Waiting Period

Annual Maximum N/A N/A N/A

Office Visit $20 Copay $0 Copay $0 Copay

Diagnostic & Preventive:

X‐Ray, Exam, Cleanings $0 Copay $0 Copay $0 Copay

Basic Services: $55 ‐ $365 Copay $40 ‐ $365 Copay $40 ‐ $365 Copay

Basic restorative Depending on Procedure Depending on Procedure Depending on Procedure

Major Services:

Crown, Cast, Prothodontists, $55 ‐ $365 Copay $40 ‐ $365 Copay $40 ‐ $365 Copay

Endodontics, Periodontics, Oral Surgery Depending on Procedure Depending on Procedure Depending on Procedure

Orthodontics (Medically Necessary) $1,000 Maximum $1,000 Maximum $1,000 Maximum



Adult Vision Exam $0 Copay $0 Copay $0 Copay

Adult Optical (Eyewear) Not Covered Not Covered Not Covered


WHA Members & Dependents

Open Enrollment November 1st ‐ November 30th.

Western Health Advantage HMO


Members may apply at anytime except if you are a new member, then it is the 1st of the month following new membership.





One pair of standard frames & lenses or




One pair of standard frames & lenses or



Mapped From Gateway 1800 Gateway 5500B

New Plan Name Gateway 30 Gateway 70 Gateway 2000 Gateway 1500 Gateway 4010 Gateway 6000

0‐20 $198.27 $188.43 $160.54 $163.20 $167.18 $120.50

21 $312.25 $296.75 $252.82 $257.02 $263.28 $189.77

22 $312.25 $296.75 $252.82 $257.02 $263.28 $189.77

23 $312.25 $296.75 $252.82 $257.02 $263.28 $189.77

24 $312.25 $296.75 $252.82 $257.02 $263.28 $189.77

25 $313.49 $297.93 $253.83 $258.04 $264.33 $190.52

26 $319.74 $303.87 $258.88 $263.18 $269.59 $194.32

27 $327.23 $310.99 $264.95 $269.35 $275.91 $198.87

28 $339.41 $322.56 $274.81 $279.38 $286.18 $206.27

29 $349.40 $332.06 $282.90 $287.60 $294.61 $212.35

30 $354.40 $336.81 $286.95 $291.71 $298.82 $215.38

31 $361.89 $343.93 $293.01 $297.88 $305.14 $219.94

32 $369.39 $351.05 $299.08 $304.05 $311.46 $224.49

33 $374.07 $355.50 $302.87 $307.90 $315.40 $227.34

34 $379.07 $360.25 $306.92 $312.02 $319.62 $230.38

35 $381.56 $362.62 $308.94 $314.07 $321.72 $231.89

36 $384.06 $365.00 $310.96 $316.13 $323.83 $233.41

37 $386.56 $367.37 $312.99 $318.19 $325.94 $234.93

38 $389.06 $369.75 $315.01 $320.24 $328.04 $236.45

39 $394.05 $374.49 $319.05 $324.35 $332.25 $239.48

40 $399.05 $379.24 $323.10 $328.47 $336.47 $242.52

41 $406.54 $386.36 $329.17 $334.64 $342.79 $247.08

42 $413.73 $393.19 $334.98 $340.55 $348.84 $251.44

43 $423.72 $402.68 $343.07 $348.77 $357.27 $257.51

44 $436.21 $414.55 $353.18 $359.05 $367.80 $265.10

45 $450.88 $428.50 $365.07 $371.13 $380.17 $274.02

46 $468.37 $445.12 $379.23 $385.53 $394.92 $284.65

47 $488.04 $463.82 $395.15 $401.72 $411.50 $296.61

48 $510.52 $485.18 $413.36 $420.22 $430.46 $310.27

49 $532.69 $506.25 $431.31 $438.47 $449.15 $323.74

50 $557.67 $529.99 $451.53 $459.03 $470.21 $338.92

51 $582.34 $553.43 $471.50 $479.34 $491.01 $353.92

52 $609.51 $579.25 $493.50 $501.70 $513.92 $370.43

53 $636.99 $605.37 $515.75 $524.32 $537.09 $387.13

54 $666.65 $633.56 $539.77 $548.73 $562.10 $405.15

55 $696.31 $661.75 $563.78 $573.15 $587.11 $423.18

56 $728.47 $692.31 $589.82 $599.62 $614.23 $442.73

57 $760.95 $723.17 $616.12 $626.35 $641.61 $462.46

58 $795.61 $756.11 $644.18 $654.88 $670.83 $483.53

59 $812.78 $772.44 $658.09 $669.02 $685.31 $493.97

60 $847.44 $805.37 $686.15 $697.55 $714.54 $515.03

61 $877.42 $833.86 $710.42 $722.22 $739.81 $533.25

62 $897.09 $852.56 $726.35 $738.41 $756.40 $545.20

63 $921.76 $876.00 $746.32 $758.72 $777.20 $560.20

64+ $936.75 $890.25 $758.46 $771.06 $789.84 $569.31


High Deductible PlanCopay Plans HSA Qualified Plans

WESTERN HEALTH ADVANTAGE MEDICAL PLANSEFFECTIVE DATE: DECEMBER 01, 2016 ‐ NOVEMBER 30, 2017

The following counties are entirely within Rate Regions 1 and 3: Sacramento, Yolo and parts of Colusa, El Dorado and Placer.


Mapped From Gateway 1800 Gateway 5500B

New Plan Name Gateway 30 Gateway 70 Gateway 2000 Gateway 1500 Gateway 4010 Gateway 6000

0‐20 $206.27 $196.03 $167.01 $169.78 $173.92 $125.36

21 $324.84 $308.71 $263.02 $267.38 $273.89 $197.42

22 $324.84 $308.71 $263.02 $267.38 $273.89 $197.42

23 $324.84 $308.71 $263.02 $267.38 $273.89 $197.42

24 $324.84 $308.71 $263.02 $267.38 $273.89 $197.42

25 $326.13 $309.94 $264.07 $268.44 $274.98 $198.20

26 $332.63 $316.11 $269.33 $273.79 $280.46 $202.15

27 $340.43 $323.52 $275.64 $280.21 $287.03 $206.89

28 $353.10 $335.56 $285.90 $290.64 $297.71 $214.59

29 $363.49 $345.44 $294.31 $299.19 $306.48 $220.91

30 $368.69 $350.38 $298.52 $303.47 $310.86 $224.07

31 $376.48 $357.79 $304.84 $309.89 $317.43 $228.80

32 $384.28 $365.20 $311.15 $316.31 $324.01 $233.54

33 $389.15 $369.83 $315.09 $320.32 $328.12 $236.50

34 $394.35 $374.77 $319.30 $324.59 $332.50 $239.66

35 $396.95 $377.24 $321.41 $326.73 $334.69 $241.24

36 $399.55 $379.71 $323.51 $328.87 $336.88 $242.82

37 $402.15 $382.18 $325.61 $331.01 $339.07 $244.40

38 $404.75 $384.65 $327.72 $333.15 $341.26 $245.98

39 $409.94 $389.59 $331.93 $337.43 $345.64 $249.14

40 $415.14 $394.53 $336.13 $341.71 $350.03 $252.30

41 $422.94 $401.94 $342.45 $348.12 $356.60 $257.04

42 $430.41 $409.04 $348.50 $354.27 $362.90 $261.58

43 $440.80 $418.91 $356.91 $362.83 $371.66 $267.89

44 $453.80 $431.26 $367.43 $373.52 $382.62 $275.79

45 $469.06 $445.77 $379.80 $386.09 $395.49 $285.07

46 $487.26 $463.06 $394.53 $401.07 $410.83 $296.13

47 $507.72 $482.51 $411.10 $417.91 $428.09 $308.56

48 $531.11 $504.74 $430.03 $437.16 $447.81 $322.78

49 $554.17 $526.65 $448.71 $456.15 $467.25 $336.79

50 $580.16 $551.35 $469.75 $477.54 $489.16 $352.59

51 $605.82 $575.74 $490.53 $498.66 $510.80 $368.18

52 $634.08 $602.60 $513.41 $521.92 $534.63 $385.36

53 $662.67 $629.76 $536.56 $545.45 $558.73 $402.73

54 $693.53 $659.09 $561.54 $570.85 $584.75 $421.49

55 $724.39 $688.42 $586.53 $596.25 $610.77 $440.24

56 $757.85 $720.22 $613.62 $623.79 $638.98 $460.58

57 $791.63 $752.32 $640.97 $651.60 $667.46 $481.11

58 $827.69 $786.59 $670.17 $681.28 $697.87 $503.02

59 $845.55 $803.57 $684.64 $695.99 $712.93 $513.88

60 $881.61 $837.83 $713.83 $725.66 $743.33 $535.79

61 $912.80 $867.47 $739.08 $751.33 $769.63 $554.75

62 $933.26 $886.92 $755.65 $768.18 $786.88 $567.18

63 $958.92 $911.31 $776.43 $789.30 $808.52 $582.78

64+ $974.52 $926.13 $789.06 $802.14 $821.67 $592.26


Copay Plans HSA Qualified Plans

WESTERN HEALTH ADVANTAGE MEDICAL PLANSEFFECTIVE DATE: DECEMBER 01, 2016 ‐ NOVEMBER 30, 2017

The following counties are entirely within Rate Regions 2: Marin, Napa, Sonoma and part of Solano.

High Deductible Plan


LUD: 3-26-16

Bronze PPO6000/0%/6000 HSA

1ZK8

Bronze PPO4500/30%/6350 HSA

1ZMR

Silver PPO2000/20%/4600 HSA - RxC

1ZG7

HSA COMPATIBLE PLAN HSA COMPATIBLE PLAN HSA COMPATIBLE PLAN

Calendar Year Deductible$6,000/member $12,000/family(Embedded)(4)

$4500/member $9,000/family(Embedded)(4)

$5,000/member $10,000/family (Embedded)(4)

$6,000/member $12,000/family (Embedded)(4)

$2,000/member$4,000/family

(Non-Embedded)(5)

$2,000/member $4,000/family(Embedded)(4)

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Annual Out of Pocket Maximum (2)

(Includes annual deductible) $6,000/member$12,000/family

$6,350/member $12,700/family





Office Visits (Primary Care/Specialist) 0% of covered expense after deductible

30% of covered expense after deductible

$30 for first 3 visits(3), then ded. + 30% of covered expense after

deductible

$70 for first 3 visits(3), then ded. + 35% of covered expense

20% of covered expense after deductible $25/$45(3)

Preventive Care Services including physical exams and covered preventive screenings No copay (ded. waived) No copay (ded. waived) No copay

(ded. waived) No copay (ded. waived) No copay (ded. waived) No copay (ded. waived)

Diagnostic Services(Includes lab, X-Ray and Advanced imaging) 0% of covd. exp. after ded. 30% of covd. exp. after ded. 30% of covd. exp. after ded. 35% of covd. exp. after ded. 20% of covd. exp. after ded. 35% of covd. exp. after ded.

Emergency Care 0% of covd. exp. after ded. 30% of covd. exp. after ded. $300 copay + 30% of cov. exp. after ded. 35% of covd. exp. after ded. 20% of covd. exp. after ded. $300 Copay + 35% of

covd. exp. after ded.Ambulance 0% of covd. exp. after ded. 30% of covd. exp. after ded. 30% of covd. exp. after ded. 35% of covd. exp. after ded. 20% of covd. exp. after ded. 35% of covd. exp. after ded.

Hospital Stay Inpatient Facility Fees (Room & Board) Doctor and other services

0% of covd. exp. after ded.0% of covd. exp. after ded.

30% of covd. exp. after ded.30% of covd. exp. after ded. $500 copay after ded. 35% of covd. exp. after ded.

35% of covd. exp. after ded.20% of covd. exp. after ded.20% of covd. exp. after ded.


Outpatient Surgery Facility Fee Doctor Services

0% of covd. exp. after ded. 30% of covd. exp. after ded. 30% of covd. exp. after ded. 35% of covd. exp. after ded. 20% of covd. exp. after ded.20% of covd. exp. after ded.


Prescription Drug Deductible Combined with Medical Ded. Combined with Medical Ded. $500/member $1,000/Family $250 ind./$500/family

annual pharmacy ded. (waived for Tier 1 drugs)

Combined with Medical Ded. None

Prescription Drug BenefitsRetail Participating Pharmacy (30 day supply)Copay is determined by tier as listed on the Anthem Select Drug list.

All Tiers: 0% of covered expense (medical deductible applies)

All Tiers: 30% of covered expense (medical deductible

applies)

Tier 1: $15 copayTier 2: $40 copayTier 3: $80 copayTier 4: See Below


Tier 1 : $15 copay after med. ded.Tier 2 : $40 copay after med. ded. Tier 3 : $80 copay after med. ded.

Tier 4 : See Below


Specialty Pharmacy Drugs (30 day supply)May only be obtained through the specialty pharmacy program.

0% of covered expense (medical deductible applies)

30% of covered expense (medical deductible applies)

Tier 4: 30% of prescription drug maximum allowed amount up to a

maximum $500 copay per prescription



25% of covered expense after medical deductible



California Association of REALTORS®

June - December 2016 Anthem Blue Cross of CaliforniaSilver & Bronze PPO Medical Plans Benefit Summary (1)

Benefits shown are what YOU WILL PAY for Preferred Providers ONLY. Benefits shown are always based on the Blue Cross covered expense.

Benefits for Non Preferred Providers are significantly reduced.

(4) The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family member will be applied to the individual deductible and individual out-of-pocket maximum; in addition, amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one member will pay more than the individual deductible and individual out-of-pocket maximum.(5) The family deductible and out-of-pocket maximum are non-embedded meaning the cost shares of all family members apply to one shared family deductible and one shared family out-of-pocket maximum. The individual deductible and individual out-of-pocket maximum only apply to individuals enrolled under single coverage.

ALL BENEFITS LISTED ARE AFTER ANNUAL DEDUCTIBLE UNLESS OTHERWISE NOTED

Anthem Select Drug List

Bronze PPO5000/30%/6850

1KBD

Plans offered byAnthem Blue Cross of California

Small Group Prudent Buyer PPO Network

Silver PPO 2000/35%/6850

1ZM3

Bronze PPO 6000/35%/66001ZJJ

(3) Not subject to plan deductible.

(2) When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of your benefit period. Your copays, coinsurance and deductibles count toward your out-of-pocket limit. If Pediatric Vision and/or Dental services are covered under this plan, these services count towards your out of pocket limit. For prescription drug, all cost shares count towards your plan's annual out-of-pocket limit.

(1) This document is a summary of benefits only. Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits valid for plan year 6/1/16 to 12/31/16 and subject to change without notice. For a detailed listing of plan benefits and a copy of the Evidence of Coverage please visit: www.RealcareCAR.com/notices

Authorized Independent Agent for Anthem Blue Cross of California and Anthem BC Life & Health Insurance Company

LUD 3-26-16

Gold PPO 2000/0%/2500 HSA- RxC

1ZGF

HSA COMPATIBLE PLAN

Calendar Year Deductible$2,000/member

$4,000/family(Non-Embedded)(5)

$1,000/member $3,000/family(Embedded)(4)

$500/member $1,500/family(Embedded)(4)

$0/member$0/family

$200/member$600/family

(Embedded)(4)

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited UnlimitedAnnual Out of Pocket Maximum (2)

(Includes annual deductible) $2,500/member

$5,000/family$4,000/member

$8,000/family$4,500/member

$9,000/family$5,500/member$11,000/family


Office Visits (Primary Care/Specialist) $0 of covered expense after deductible $20/$40 Copay (3) $30/$60 Copay (3) $20/$40 Copay (3) $10/$30 Copay (3)

Preventive Care Services including physical exams and covered preventive screenings No copay (deductible waived) No copay (deductible waived) No copay (deductible waived) No copay (deductible waived) No copay (deductible waived)

Diagnostic Services(Includes lab, X-Ray and Advanced imaging) $0 of covered expense after ded. 20% of covered expense after ded. 20% of covered expense after

deductible 30% of covered expense after ded. 10% of covered expense after ded.

Emergency Care $0 of covered expense after ded. $200 Copay + 20% of covered expense after ded.

$200 Copay + 20% of covered expense after deductible

$200 Copay + 30% of covered expense after deductible

$200 Copay and then 10% of covered expenses after deductible

Ambulance $0 of covered expense after ded. 20% of covered expense after ded. 20% of covered expense after deductible 30% of covered expense after ded. 10% of covered expense after ded.

Hospital Stay Inpatient Facility Fees (Room & Board) Doctor and other services

0% of covered expense after ded.0% of covered expense after ded.











Prescription Drug Deductible Combined with medical deductible$250 annual pharmacy deductible

$500/family(waived for Tier 1 drugs)

$250 annual pharmacy deductible $500/family

(waived for Tier 1 drugs)

$250 annual pharmacy deductible$500/family

(waived for Tier 1 drugs) None

Prescription Drug BenefitsRetail Participating Pharmacy (30 day supply)Copay is determined by tier as listed on the tiered drug formulary list. For more information consult your physician or visit www.anthem.com/ca, click on Customer Care

Tier 1 : $15 copayTier 2 : $40 copayTier 3 : $80 copay Tier 4 : See Below

Tier 1: $15 copayTier 2: $40 copay Tier 3: $80 copayTier 4: See Below

Tier 1: $15 copayTier 2: $40 copay Tier 3: $80 copay Tier 4: See Below

Tier 1 : $15 copayTier 2 : $40 copay Tier 3 : $80 copayTier 4 : See Below

Tier 1 : $10 copayTier 2 : $35 copayTier 3 : $70 copay Tier 4 : See Below


25% of covered expense after medical deductible

Tier 4: 25% of prescription drug maximum allowed amount up to a maximum $250

copay per prescription



Tier 4 : 25%of prescription drug maximum allowed amount up to a


Tier 4 : 25% of prescription drug maximum allowed amount up to a


Platinum PPO 200/10%/30001ZH1

Gold PPO 20/30%/55001ZF9

Gold PPO 500/20%/45001ZHT

Gold PPO 1000/20%/40001ZH9

California Association of REALTORS® June - December 2016 Anthem Blue Cross of California

Platinum and Gold PPO Medical Plans Benefit Summary (1)

Benefits shown are what YOU WILL PAY for Preferred Providers ONLY. Benefits shown are always based on the Blue Cross covered expense.

Benefits for Non Preferred Providers are significantly reduced.

Plans offered by Anthem Blue Cross of California

Small Group Prudent Buyer PPO Network



(5) The family deductible and out-of-pocket maximum are non-embedded meaning the cost shares of all



(3) Not subject to plan deductible.

(4) The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family member will be applied to the individual deductible and individual out-of-pocket maximum; in addition, amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one member will pay more than the individual deductible and individual out-of-pocket maximum.

Authorized Independent Agent for Anthem Blue Cross of California and Anthem BC Life & Health Insurance Company

LUD: 3-26-16

Plans offered by Anthem Blue Cross of CaliforniaCaliforniaCare Network

Gold HMO 50/30%/68501ZHR

Gold HMO 500/20%/50001ZFD

Calendar Year Deductible (3) None $500/member$1,500/family(Embedded)(4)

Lifetime Maximum Benefit Unlimited UmlimitedAnnual Out of Pocket Maximum (2)

(Includes annual deductible) $6,850/member$13,700/family


Office Visits (Primary Care/Specialist) $50/$100 Copay $30/$60 Copay

Preventive Care Services including physical exams, preventive screenings, flu vaccine, immunizations, health education, intervention services, and HIV testing (including screenings for cancer, HPV, diabetes, cholesterol, blood pressure, hearing and vision)

No copay (deductible waived) No copay (deductible waived)

Diagnostic Services(Includes lab, X-Ray) 0% 20% of covered expense after deductible

Emergency Care $350 Copay + 30% of covered expense $200 Copay + 20% of covered expense after deductible

Ambulance 30% of covered expense 20% of covered expense after deductibleHospital Stay Inpatient Facility Fees (Room & Board) Doctor and other services

$750 copay per day up to 4 daysCovered in full

20% of covered expense after deductibleCovered in full


Outpatient facility fee: $500 CopayCovered in full

20% of covered expense after deductibleCovered in full

Prescription Drug Deductible$250 annual pharmacy deductible

$500/family (waived for Tier 1 drugs)

$250 annual pharmacy deductible$500/family

(waived for Tier 1 drugs)

Prescription Drug Benefits

Retail Participating Pharmacy (30 day supply)Copay is determined by tier as listed on the tiered drug formulary list. For more information consult your physician or visit www.anthem.com/ca, click on Customer Care

Tier 1: $15 copayTier 2: $50 copay Tier 3: $90 copay Tier 4: See Below

Tier 1 : $15 copayTier 2 : $40 copayTier 3 : $80 copayTier 4 : See Below


Tier 4: 25% of prescription drug maximum allowed amount up to a maximum $250 copay per prescription

Tier 4 : 25% of prescription drug maximum allowed amount up to a maximum $250 copay per prescription

(4) The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family member will be applied to the individual deductible and individual out-of-pocket maximum; in addition, amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one member will pay more than the individual deductible and individual out-of-pocket maximum.



California Association of REALTORS®

June - December 2016 Anthem Blue Cross of CaliforniaHMO Medical Plans Benefit Summary (1)

Benefits shown are what YOU WILL PAY for Contracted Providers ONLY. Benefits for Non Contracted Providers are not covered.

Benefits shown are always based on the Blue Cross covered expense.



(3) The annual medical deductible applies to all facility services, home dialysis, and home infusion therapy services, ambulance, DME and hospice services.

Authorized Independent Agent for Anthem Blue Cross of California and Anthem BC Life & Health Insurance

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $184.45 $180.08 $189.18 $184.29 $210.41 $224.3021 $290.47 $283.59 $297.92 $290.22 $331.35 $353.2322 $290.47 $283.59 $297.92 $290.22 $331.35 $353.2323 $290.47 $283.59 $297.92 $290.22 $331.35 $353.2324 $290.47 $283.59 $297.92 $290.22 $331.35 $353.2325 $291.63 $284.72 $299.11 $291.38 $332.68 $354.6426 $297.44 $290.40 $305.07 $297.19 $339.30 $361.7127 $304.41 $297.20 $312.22 $304.15 $347.25 $370.1928 $315.74 $308.26 $323.84 $315.47 $360.18 $383.9629 $325.04 $317.34 $333.37 $324.76 $370.78 $395.2630 $329.68 $321.87 $338.14 $329.40 $376.08 $400.9231 $336.65 $328.68 $345.29 $336.36 $384.03 $409.3932 $343.63 $335.49 $352.44 $343.33 $391.99 $417.8733 $347.98 $339.74 $356.91 $347.68 $396.96 $423.1734 $352.63 $344.28 $361.67 $352.33 $402.26 $428.8235 $354.95 $346.55 $364.06 $354.65 $404.91 $431.6536 $357.28 $348.82 $366.44 $356.97 $407.56 $434.4737 $359.60 $351.08 $368.82 $359.29 $410.21 $437.3038 $361.93 $353.35 $371.21 $361.61 $412.86 $440.1239 $366.57 $357.89 $375.98 $366.26 $418.16 $445.7840 $371.22 $362.43 $380.74 $370.90 $423.47 $451.4341 $378.19 $369.23 $387.89 $377.87 $431.42 $459.9142 $384.87 $375.76 $394.74 $384.54 $439.04 $468.0343 $394.17 $384.83 $404.28 $393.83 $449.64 $479.3344 $405.79 $396.18 $416.19 $405.44 $462.90 $493.4645 $419.44 $409.50 $430.20 $419.08 $478.47 $510.0646 $435.71 $425.39 $446.88 $435.33 $497.03 $529.8547 $454.00 $443.25 $465.65 $453.61 $517.90 $552.1048 $474.92 $463.67 $487.10 $474.51 $541.76 $577.5349 $495.54 $483.80 $508.25 $495.12 $565.28 $602.6150 $518.78 $506.49 $532.09 $518.33 $591.79 $630.8751 $541.73 $528.90 $555.62 $541.26 $617.97 $658.7752 $567.00 $553.57 $581.54 $566.51 $646.80 $689.5053 $592.56 $578.52 $607.76 $592.05 $675.95 $720.5954 $620.15 $605.46 $636.06 $619.62 $707.43 $754.1555 $647.75 $632.41 $664.36 $647.19 $738.91 $787.7056 $677.67 $661.62 $695.05 $677.08 $773.04 $824.0957 $707.88 $691.11 $726.03 $707.27 $807.50 $860.8258 $740.12 $722.59 $759.10 $739.48 $844.28 $900.0359 $756.09 $738.18 $775.49 $755.44 $862.50 $919.4660 $788.34 $769.66 $808.55 $787.66 $899.28 $958.6761 $816.22 $796.89 $837.16 $815.52 $931.09 $992.5862 $834.52 $814.75 $855.92 $833.80 $951.97 $1,014.8363 $857.47 $837.16 $879.46 $856.73 $978.15 $1,042.73

64+ $871.41 $850.77 $893.76 $870.66 $994.05 $1,059.69Rates will change again on January 1, 2017 when the plan renews.

Age on member's effective

date

SILVER PPO PLANS

Monthly rates shown below are for Anthem medical and pediatric dental. By law, all ACA plans must include coverage for pediatric dental benefits.

A separate $20 monthly administration fee will be added to total premium to calculate your total monthly rate.

Region 1

Region 1 includes the counties of: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, and Yuba

Rates Effective 6/1/16 through 12/31/16

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9

Platinum PPO 200/10%/3000

1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $247.14 $254.36 $259.18 $261.39 $296.77 $323.53 $324.9921 $389.19 $400.56 $408.15 $411.64 $467.35 $509.50 $511.8022 $389.19 $400.56 $408.15 $411.64 $467.35 $509.50 $511.8023 $389.19 $400.56 $408.15 $411.64 $467.35 $509.50 $511.8024 $389.19 $400.56 $408.15 $411.64 $467.35 $509.50 $511.8025 $390.75 $402.16 $409.78 $413.29 $469.22 $511.54 $513.8526 $398.53 $410.17 $417.95 $421.52 $478.57 $521.73 $524.0827 $407.87 $419.79 $427.74 $431.40 $489.78 $533.96 $536.3728 $423.05 $435.41 $443.66 $447.45 $508.01 $553.83 $556.3329 $435.50 $448.23 $456.72 $460.63 $522.96 $570.13 $572.7030 $441.73 $454.64 $463.25 $467.21 $530.44 $578.28 $580.8931 $451.07 $464.25 $473.05 $477.09 $541.66 $590.51 $593.1832 $460.41 $473.86 $482.84 $486.97 $552.88 $602.74 $605.4633 $466.25 $479.87 $488.96 $493.14 $559.89 $610.38 $613.1434 $472.48 $486.28 $495.49 $499.73 $567.36 $618.53 $621.3335 $475.59 $489.48 $498.76 $503.02 $571.10 $622.61 $625.4236 $478.70 $492.69 $502.02 $506.32 $574.84 $626.69 $629.5137 $481.82 $495.89 $505.29 $509.61 $578.58 $630.76 $633.6138 $484.93 $499.10 $508.55 $512.90 $582.32 $634.84 $637.7039 $491.16 $505.51 $515.09 $519.49 $589.80 $642.99 $645.8940 $497.38 $511.92 $521.62 $526.08 $597.27 $651.14 $654.0841 $506.73 $521.53 $531.41 $535.96 $608.49 $663.37 $666.3642 $515.68 $530.74 $540.80 $545.42 $619.24 $675.09 $678.1443 $528.13 $543.56 $553.86 $558.60 $634.19 $691.39 $694.5144 $543.70 $559.58 $570.19 $575.06 $652.89 $711.77 $714.9845 $561.99 $578.41 $589.37 $594.41 $674.85 $735.72 $739.0446 $583.79 $600.84 $612.23 $617.46 $701.03 $764.25 $767.7047 $608.30 $626.08 $637.94 $643.39 $730.47 $796.35 $799.9448 $636.33 $654.92 $667.33 $673.03 $764.12 $833.03 $836.7949 $663.96 $683.36 $696.30 $702.26 $797.30 $869.21 $873.1350 $695.09 $715.40 $728.96 $735.19 $834.69 $909.97 $914.0751 $725.84 $747.04 $761.20 $767.71 $871.61 $950.22 $954.5152 $759.70 $781.89 $796.71 $803.52 $912.27 $994.54 $999.0353 $793.95 $817.14 $832.63 $839.75 $953.39 $1,039.38 $1,044.0754 $830.92 $855.20 $871.40 $878.85 $997.79 $1,087.78 $1,092.6955 $867.89 $893.25 $910.17 $917.96 $1,042.19 $1,136.19 $1,141.3156 $907.98 $934.51 $952.21 $960.36 $1,090.33 $1,188.66 $1,194.0357 $948.46 $976.16 $994.66 $1,003.17 $1,138.93 $1,241.65 $1,247.2658 $991.66 $1,020.63 $1,039.97 $1,048.86 $1,190.81 $1,298.21 $1,304.0759 $1,013.06 $1,042.66 $1,062.41 $1,071.50 $1,216.51 $1,326.23 $1,332.2260 $1,056.26 $1,087.12 $1,107.72 $1,117.19 $1,268.39 $1,382.78 $1,389.0361 $1,093.62 $1,125.57 $1,146.90 $1,156.71 $1,313.25 $1,431.70 $1,438.1662 $1,118.14 $1,150.81 $1,172.61 $1,182.64 $1,342.70 $1,463.79 $1,470.4063 $1,148.89 $1,182.45 $1,204.86 $1,215.16 $1,379.62 $1,504.04 $1,510.83

64+ $1,167.57 $1,201.68 $1,224.45 $1,234.92 $1,402.05 $1,528.50 $1,535.40Rates will change again on January 1, 2017 when the plan renews.


date

HMO PLANS

Monthly rates shown are for Anthem medical and pediatric dental. By law, all ACA plans must include coverage for pediatric dental benefits.


Region 1Rates Effective 6/1/16 through 12/31/16

Region 1 includes the counties of: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, and Yuba

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $205.91 $201.02 $211.20 $205.71 $234.88 $250.4021 $324.27 $316.57 $332.60 $323.96 $369.89 $394.3322 $324.27 $316.57 $332.60 $323.96 $369.89 $394.3323 $324.27 $316.57 $332.60 $323.96 $369.89 $394.3324 $324.27 $316.57 $332.60 $323.96 $369.89 $394.3325 $325.57 $317.84 $333.93 $325.26 $371.37 $395.9126 $332.05 $324.17 $340.58 $331.74 $378.77 $403.7927 $339.83 $331.77 $348.56 $339.51 $387.64 $413.2628 $352.48 $344.11 $361.54 $352.14 $402.07 $428.6429 $362.86 $354.24 $372.18 $362.51 $413.91 $441.2630 $368.05 $359.31 $377.50 $367.69 $419.83 $447.5631 $375.83 $366.90 $385.48 $375.47 $428.70 $457.0332 $383.61 $374.50 $393.47 $383.24 $437.58 $466.4933 $388.48 $379.25 $398.45 $388.10 $443.13 $472.4134 $393.66 $384.32 $403.78 $393.29 $449.05 $478.7235 $396.26 $386.85 $406.44 $395.88 $452.01 $481.8736 $398.85 $389.38 $409.10 $398.47 $454.96 $485.0337 $401.45 $391.91 $411.76 $401.06 $457.92 $488.1838 $404.04 $394.45 $414.42 $403.65 $460.88 $491.3439 $409.23 $399.51 $419.74 $408.84 $466.80 $497.6440 $414.42 $404.58 $425.06 $414.02 $472.72 $503.9541 $422.20 $412.17 $433.05 $421.80 $481.60 $513.4242 $429.66 $419.46 $440.70 $429.25 $490.10 $522.4943 $440.03 $429.59 $451.34 $439.61 $501.94 $535.1144 $453.01 $442.25 $464.64 $452.57 $516.74 $550.8845 $468.25 $457.13 $480.27 $467.80 $534.12 $569.4146 $486.41 $474.86 $498.90 $485.94 $554.84 $591.5047 $506.83 $494.80 $519.85 $506.35 $578.14 $616.3448 $530.18 $517.59 $543.80 $529.67 $604.77 $644.7349 $553.20 $540.07 $567.42 $552.68 $631.03 $672.7350 $579.15 $565.39 $594.02 $578.59 $660.62 $704.2751 $604.76 $590.40 $620.30 $604.19 $689.84 $735.4352 $632.98 $617.94 $649.24 $632.37 $722.03 $769.7353 $661.51 $645.80 $678.50 $660.88 $754.58 $804.4354 $692.32 $675.88 $710.10 $691.65 $789.72 $841.8955 $723.12 $705.95 $741.70 $722.43 $824.85 $879.3656 $756.52 $738.56 $775.96 $755.80 $862.95 $919.9757 $790.25 $771.48 $810.55 $789.49 $901.42 $960.9858 $826.24 $806.62 $847.46 $825.45 $942.48 $1,004.7559 $844.07 $824.03 $865.76 $843.27 $962.82 $1,026.4460 $880.07 $859.17 $902.68 $879.23 $1,003.88 $1,070.2161 $911.20 $889.56 $934.61 $910.33 $1,039.39 $1,108.0762 $931.63 $909.51 $955.56 $930.74 $1,062.69 $1,132.9163 $957.25 $934.51 $981.84 $956.33 $1,091.92 $1,164.06

64+ $972.81 $949.71 $997.80 $971.88 $1,109.67 $1,182.99Rates will change again on January 1, 2017 when the plan renews.

SILVER PPO PLANS




Region 2 includes the counties of: Marin, Napa, Solano, and Sonoma


date

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $275.86 $283.93 $289.34 $291.80 $331.30 $356.59 $358.2021 $434.43 $447.14 $455.66 $459.53 $521.73 $561.56 $564.1022 $434.43 $447.14 $455.66 $459.53 $521.73 $561.56 $564.1023 $434.43 $447.14 $455.66 $459.53 $521.73 $561.56 $564.1024 $434.43 $447.14 $455.66 $459.53 $521.73 $561.56 $564.1025 $436.17 $448.93 $457.48 $461.37 $523.82 $563.81 $566.3626 $444.86 $457.87 $466.60 $470.56 $534.25 $575.04 $577.6427 $455.28 $468.60 $477.53 $481.59 $546.77 $588.51 $591.1828 $472.23 $486.04 $495.30 $499.51 $567.12 $610.42 $613.1829 $486.13 $500.35 $509.88 $514.21 $583.82 $628.39 $631.2330 $493.08 $507.50 $517.17 $521.57 $592.16 $637.37 $640.2531 $503.50 $518.24 $528.11 $532.60 $604.69 $650.85 $653.7932 $513.93 $528.97 $539.05 $543.62 $617.21 $664.33 $667.3333 $520.45 $535.67 $545.88 $550.52 $625.03 $672.75 $675.7934 $527.40 $542.83 $553.17 $557.87 $633.38 $681.73 $684.8235 $530.87 $546.41 $556.82 $561.55 $637.55 $686.23 $689.3336 $534.35 $549.98 $560.46 $565.22 $641.73 $690.72 $693.8437 $537.82 $553.56 $564.11 $568.90 $645.90 $695.21 $698.3638 $541.30 $557.14 $567.75 $572.57 $650.08 $699.70 $702.8739 $548.25 $564.29 $575.04 $579.93 $658.42 $708.69 $711.8940 $555.20 $571.44 $582.33 $587.28 $666.77 $717.67 $720.9241 $565.63 $582.18 $593.27 $598.31 $679.29 $731.15 $734.4642 $575.62 $592.46 $603.75 $608.88 $691.29 $744.07 $747.4343 $589.52 $606.77 $618.33 $623.58 $707.99 $762.04 $765.4844 $606.90 $624.65 $636.56 $641.96 $728.86 $784.50 $788.0545 $627.32 $645.67 $657.97 $663.56 $753.38 $810.89 $814.5646 $651.65 $670.71 $683.49 $689.30 $782.60 $842.34 $846.1547 $679.01 $698.88 $712.20 $718.25 $815.46 $877.72 $881.6948 $710.29 $731.07 $745.00 $751.33 $853.03 $918.15 $922.3049 $741.14 $762.82 $777.36 $783.96 $890.07 $958.02 $962.3550 $775.89 $798.59 $813.81 $820.72 $931.81 $1,002.95 $1,007.4851 $810.21 $833.92 $849.81 $857.02 $973.03 $1,047.31 $1,052.0552 $848.01 $872.82 $889.45 $897.00 $1,018.42 $1,096.17 $1,101.1253 $886.24 $912.17 $929.55 $937.44 $1,064.33 $1,145.58 $1,150.7654 $927.51 $954.64 $972.83 $981.10 $1,113.89 $1,198.93 $1,204.3555 $968.78 $997.12 $1,016.12 $1,024.75 $1,163.46 $1,252.28 $1,257.9456 $1,013.53 $1,043.18 $1,063.05 $1,072.08 $1,217.20 $1,310.12 $1,316.0557 $1,058.71 $1,089.68 $1,110.44 $1,119.87 $1,271.46 $1,368.52 $1,374.7158 $1,106.93 $1,139.31 $1,161.02 $1,170.88 $1,329.37 $1,430.85 $1,437.3359 $1,130.82 $1,163.91 $1,186.08 $1,196.16 $1,358.06 $1,461.74 $1,468.3560 $1,179.04 $1,213.54 $1,236.66 $1,247.16 $1,415.98 $1,524.07 $1,530.9761 $1,220.75 $1,256.46 $1,280.40 $1,291.28 $1,466.06 $1,577.98 $1,585.1262 $1,248.12 $1,284.63 $1,309.11 $1,320.23 $1,498.93 $1,613.36 $1,620.6663 $1,282.44 $1,319.96 $1,345.11 $1,356.53 $1,540.15 $1,657.73 $1,665.22


HMO PLANS




Region 2 includes the counties of: Marin, Napa, Solano, and Sonoma

GOLD PPO PLANSAge on

member's effective

date

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $206.98 $202.08 $212.29 $206.81 $236.12 $251.6921 $325.95 $318.23 $334.31 $325.68 $371.85 $396.3622 $325.95 $318.23 $334.31 $325.68 $371.85 $396.3623 $325.95 $318.23 $334.31 $325.68 $371.85 $396.3624 $325.95 $318.23 $334.31 $325.68 $371.85 $396.3625 $327.25 $319.50 $335.65 $326.98 $373.34 $397.9526 $333.77 $325.87 $342.33 $333.50 $380.77 $405.8727 $341.60 $333.51 $350.36 $341.31 $389.70 $415.3928 $354.31 $345.92 $363.39 $354.01 $404.20 $430.8429 $364.74 $356.10 $374.09 $364.44 $416.10 $443.5330 $369.95 $361.19 $379.44 $369.65 $422.05 $449.8731 $377.78 $368.83 $387.47 $377.46 $430.97 $459.3832 $385.60 $376.47 $395.49 $385.28 $439.90 $468.8933 $390.49 $381.24 $400.50 $390.16 $445.48 $474.8434 $395.70 $386.33 $405.85 $395.38 $451.43 $481.1835 $398.31 $388.88 $408.53 $397.98 $454.40 $484.3536 $400.92 $391.42 $411.20 $400.59 $457.38 $487.5237 $403.53 $393.97 $413.88 $403.19 $460.35 $490.6938 $406.13 $396.51 $416.55 $405.80 $463.33 $493.8639 $411.35 $401.61 $421.90 $411.01 $469.27 $500.2140 $416.56 $406.70 $427.25 $416.22 $475.22 $506.5541 $424.39 $414.34 $435.27 $424.04 $484.15 $516.0642 $431.88 $421.65 $442.96 $431.53 $492.70 $525.1843 $442.31 $431.84 $453.66 $441.95 $504.60 $537.8644 $455.35 $444.57 $467.03 $454.97 $519.47 $553.7145 $470.67 $459.52 $482.74 $470.28 $536.95 $572.3446 $488.93 $477.35 $501.47 $488.52 $557.78 $594.5447 $509.46 $497.39 $522.53 $509.04 $581.20 $619.5148 $532.93 $520.31 $546.60 $532.49 $607.97 $648.0549 $556.07 $542.90 $570.33 $555.61 $634.38 $676.1950 $582.15 $568.36 $597.08 $581.66 $664.12 $707.9051 $607.90 $593.50 $623.49 $607.39 $693.50 $739.2152 $636.25 $621.18 $652.57 $635.73 $725.85 $773.6953 $664.94 $649.19 $681.99 $664.39 $758.57 $808.5754 $695.90 $679.42 $713.75 $695.33 $793.90 $846.2355 $726.87 $709.65 $745.51 $726.27 $829.23 $883.8856 $760.44 $742.43 $779.95 $759.81 $867.53 $924.7157 $794.34 $775.53 $814.71 $793.68 $906.20 $965.9358 $830.52 $810.85 $851.82 $829.83 $947.47 $1,009.9359 $848.45 $828.35 $870.21 $847.75 $967.93 $1,031.7360 $884.63 $863.68 $907.32 $883.90 $1,009.20 $1,075.7261 $915.92 $894.23 $939.41 $915.16 $1,044.90 $1,113.7762 $936.45 $914.27 $960.47 $935.68 $1,068.33 $1,138.7463 $962.20 $939.41 $986.88 $961.41 $1,097.70 $1,170.05

64+ $977.85 $954.69 $1,002.93 $977.04 $1,115.55 $1,189.08Rates will change again on January 1, 2017 when the plan renews.

SILVER PPO PLANS




Region 3 includes the counties of: El Dorado, Placer, Sacramento, and Yolo


date

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $277.31 $285.41 $290.84 $293.32 $333.02 $327.87 $329.3321 $436.71 $449.47 $458.02 $461.92 $524.44 $516.33 $518.6322 $436.71 $449.47 $458.02 $461.92 $524.44 $516.33 $518.6323 $436.71 $449.47 $458.02 $461.92 $524.44 $516.33 $518.6324 $436.71 $449.47 $458.02 $461.92 $524.44 $516.33 $518.6325 $438.46 $451.27 $459.85 $463.77 $526.54 $518.40 $520.7026 $447.19 $460.26 $469.01 $473.01 $537.03 $528.72 $531.0827 $457.67 $471.04 $480.00 $484.09 $549.61 $541.11 $543.5228 $474.70 $488.57 $497.87 $502.11 $570.07 $561.25 $563.7529 $488.68 $502.96 $512.52 $516.89 $586.85 $577.77 $580.3530 $495.67 $510.15 $519.85 $524.28 $595.24 $586.03 $588.6531 $506.15 $520.94 $530.85 $535.37 $607.83 $598.43 $601.0932 $516.63 $531.72 $541.84 $546.45 $620.41 $610.82 $613.5433 $523.18 $538.47 $548.71 $553.38 $628.28 $618.56 $621.3234 $530.17 $545.66 $556.04 $560.77 $636.67 $626.82 $629.6235 $533.66 $549.25 $559.70 $564.47 $640.87 $630.96 $633.7736 $537.15 $552.85 $563.36 $568.16 $645.06 $635.09 $637.9137 $540.65 $556.44 $567.03 $571.86 $649.26 $639.22 $642.0638 $544.14 $560.04 $570.69 $575.55 $653.45 $643.35 $646.2139 $551.13 $567.23 $578.02 $582.94 $661.84 $651.61 $654.5140 $558.12 $574.42 $585.35 $590.33 $670.23 $659.87 $662.8141 $568.60 $585.21 $596.34 $601.42 $682.82 $672.26 $675.2642 $578.64 $595.55 $606.88 $612.04 $694.88 $684.14 $687.1843 $592.62 $609.93 $621.53 $626.83 $711.67 $700.66 $703.7844 $610.08 $627.91 $639.85 $645.30 $732.64 $721.31 $724.5345 $630.61 $649.03 $661.38 $667.01 $757.29 $745.58 $748.9046 $655.07 $674.21 $687.03 $692.88 $786.66 $774.50 $777.9547 $682.58 $702.52 $715.89 $721.98 $819.70 $807.02 $810.6248 $714.02 $734.88 $748.86 $755.24 $857.46 $844.20 $847.9649 $745.03 $766.80 $781.38 $788.04 $894.69 $880.86 $884.7850 $779.96 $802.75 $818.02 $824.99 $936.65 $922.17 $926.2751 $814.46 $838.26 $854.21 $861.48 $978.08 $962.96 $967.2452 $852.46 $877.37 $894.06 $901.67 $1,023.71 $1,007.88 $1,012.3753 $890.89 $916.92 $934.36 $942.32 $1,069.86 $1,053.31 $1,058.0154 $932.38 $959.62 $977.87 $986.20 $1,119.68 $1,102.36 $1,107.2855 $973.86 $1,002.32 $1,021.38 $1,030.08 $1,169.50 $1,151.42 $1,156.5456 $1,018.84 $1,048.61 $1,068.56 $1,077.66 $1,223.52 $1,204.60 $1,209.9657 $1,064.26 $1,095.36 $1,116.19 $1,125.70 $1,278.06 $1,258.30 $1,263.9058 $1,112.74 $1,145.25 $1,167.03 $1,176.97 $1,336.27 $1,315.61 $1,321.4759 $1,136.76 $1,169.97 $1,192.23 $1,202.38 $1,365.12 $1,344.01 $1,349.9960 $1,185.23 $1,219.86 $1,243.07 $1,253.65 $1,423.33 $1,401.32 $1,407.5661 $1,227.16 $1,263.01 $1,287.04 $1,298.00 $1,473.68 $1,450.89 $1,457.3562 $1,254.67 $1,291.33 $1,315.89 $1,327.10 $1,506.72 $1,483.42 $1,490.0263 $1,289.17 $1,326.84 $1,352.08 $1,363.59 $1,548.15 $1,524.21 $1,531.00

64+ $1,310.13 $1,348.41 $1,374.06 $1,385.76 $1,573.32 $1,548.99 $1,555.89

HMO PLANS


Rates will change again on January 1, 2017 when the plan renews.



Region 3

Region 3 includes the counties of: El Dorado, Placer, Sacramento, and Yolo


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $213.45 $208.36 $218.91 $213.25 $243.46 $259.5321 $336.14 $328.13 $344.74 $335.82 $383.40 $408.7122 $336.14 $328.13 $344.74 $335.82 $383.40 $408.7123 $336.14 $328.13 $344.74 $335.82 $383.40 $408.7124 $336.14 $328.13 $344.74 $335.82 $383.40 $408.7125 $337.48 $329.44 $346.12 $337.16 $384.93 $410.3426 $344.21 $336.01 $353.01 $343.88 $392.60 $418.5227 $352.27 $343.88 $361.29 $351.94 $401.80 $428.3328 $365.38 $356.68 $374.73 $365.04 $416.76 $444.2729 $376.14 $367.18 $385.76 $375.78 $429.02 $457.3530 $381.52 $372.43 $391.28 $381.16 $435.16 $463.8931 $389.59 $380.30 $399.55 $389.22 $444.36 $473.6932 $397.65 $388.18 $407.83 $397.28 $453.56 $483.5033 $402.70 $393.10 $413.00 $402.31 $459.31 $489.6334 $408.07 $398.35 $418.51 $407.69 $465.45 $496.1735 $410.76 $400.97 $421.27 $410.37 $468.51 $499.4436 $413.45 $403.60 $424.03 $413.06 $471.58 $502.7137 $416.14 $406.22 $426.79 $415.75 $474.65 $505.9838 $418.83 $408.85 $429.55 $418.43 $477.72 $509.2539 $424.21 $414.10 $435.06 $423.80 $483.85 $515.7940 $429.59 $419.35 $440.58 $429.18 $489.99 $522.3341 $437.65 $427.23 $448.85 $437.24 $499.19 $532.1442 $445.39 $434.77 $456.78 $444.96 $508.01 $541.5443 $456.14 $445.27 $467.81 $455.71 $520.27 $554.6244 $469.59 $458.40 $481.60 $469.14 $535.61 $570.9745 $485.39 $473.82 $497.80 $484.92 $553.63 $590.1846 $504.21 $492.20 $517.11 $503.73 $575.10 $613.0747 $525.39 $512.87 $538.83 $524.89 $599.25 $638.8148 $549.59 $536.49 $563.65 $549.07 $626.86 $668.2449 $573.45 $559.79 $588.13 $572.91 $654.08 $697.2650 $600.35 $586.04 $615.71 $599.77 $684.75 $729.9651 $626.90 $611.96 $642.94 $626.30 $715.04 $762.2452 $656.15 $640.51 $672.93 $655.52 $748.40 $797.8053 $685.73 $669.39 $703.27 $685.07 $782.14 $833.7754 $717.66 $700.56 $736.02 $716.98 $818.56 $872.6055 $749.59 $731.73 $768.77 $748.88 $854.98 $911.4256 $784.21 $765.53 $804.28 $783.47 $894.47 $953.5257 $819.17 $799.65 $840.13 $818.39 $934.35 $996.0358 $856.48 $836.08 $878.40 $855.67 $976.90 $1,041.3959 $874.97 $854.12 $897.36 $874.14 $997.99 $1,063.8760 $912.28 $890.54 $935.62 $911.42 $1,040.55 $1,109.2461 $944.55 $922.05 $968.72 $943.65 $1,077.35 $1,148.4862 $965.73 $942.72 $990.44 $964.81 $1,101.51 $1,174.2263 $992.29 $968.64 $1,017.67 $991.34 $1,131.80 $1,206.51

64+ $1,008.42 $984.39 $1,034.22 $1,007.46 $1,150.20 $1,226.13

SILVER PPO PLANS




date



Region 4

Region 4 includes the county of: San Francisco

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $285.94 $294.28 $299.89 $302.44 $343.36 $320.37 $321.8221 $450.30 $463.43 $472.26 $476.29 $540.72 $504.52 $506.8122 $450.30 $463.43 $472.26 $476.29 $540.72 $504.52 $506.8123 $450.30 $463.43 $472.26 $476.29 $540.72 $504.52 $506.8124 $450.30 $463.43 $472.26 $476.29 $540.72 $504.52 $506.8125 $452.10 $465.28 $474.15 $478.20 $542.88 $506.54 $508.8426 $461.11 $474.55 $483.59 $487.72 $553.70 $516.63 $518.9727 $471.91 $485.67 $494.93 $499.15 $566.67 $528.74 $531.1428 $489.48 $503.75 $513.35 $517.73 $587.76 $548.41 $550.9029 $503.89 $518.58 $528.46 $532.97 $605.07 $564.56 $567.1230 $511.09 $525.99 $536.02 $540.59 $613.72 $572.63 $575.2331 $521.90 $537.12 $547.35 $552.02 $626.69 $584.74 $587.3932 $532.70 $548.24 $558.68 $563.45 $639.67 $596.85 $599.5633 $539.46 $555.19 $565.77 $570.60 $647.78 $604.41 $607.1634 $546.66 $562.60 $573.32 $578.22 $656.43 $612.49 $615.2735 $550.27 $566.31 $577.10 $582.03 $660.76 $616.52 $619.3236 $553.87 $570.02 $580.88 $585.84 $665.09 $620.56 $623.3837 $557.47 $573.73 $584.66 $589.65 $669.41 $624.60 $627.4338 $561.07 $577.43 $588.44 $593.46 $673.74 $628.63 $631.4939 $568.28 $584.85 $595.99 $601.08 $682.39 $636.70 $639.5940 $575.48 $592.26 $603.55 $608.70 $691.04 $644.78 $647.7041 $586.29 $603.39 $614.88 $620.13 $704.02 $656.89 $659.8742 $596.65 $614.04 $625.74 $631.08 $716.45 $668.49 $671.5243 $611.06 $628.87 $640.86 $646.33 $733.76 $684.63 $687.7444 $629.07 $647.41 $659.75 $665.38 $755.39 $704.81 $708.0145 $650.23 $669.19 $681.94 $687.76 $780.80 $728.53 $731.8346 $675.45 $695.15 $708.39 $714.44 $811.08 $756.78 $760.2247 $703.82 $724.34 $738.14 $744.44 $845.15 $788.56 $792.1448 $736.24 $757.71 $772.15 $778.73 $884.08 $824.89 $828.6349 $768.21 $790.61 $805.68 $812.55 $922.47 $860.71 $864.6250 $804.24 $827.69 $843.46 $850.65 $965.73 $901.07 $905.1651 $839.81 $864.30 $880.76 $888.28 $1,008.44 $940.93 $945.2052 $878.99 $904.62 $921.85 $929.72 $1,055.49 $984.82 $989.2953 $918.61 $945.40 $963.41 $971.63 $1,103.07 $1,029.22 $1,033.8954 $961.39 $989.42 $1,008.28 $1,016.88 $1,154.44 $1,077.15 $1,082.0455 $1,004.17 $1,033.45 $1,053.14 $1,062.13 $1,205.81 $1,125.08 $1,130.1956 $1,050.55 $1,081.18 $1,101.78 $1,111.18 $1,261.50 $1,177.05 $1,182.3957 $1,097.38 $1,129.38 $1,150.90 $1,160.72 $1,317.73 $1,229.52 $1,235.1058 $1,147.36 $1,180.82 $1,203.32 $1,213.59 $1,377.75 $1,285.52 $1,291.3559 $1,172.13 $1,206.31 $1,229.29 $1,239.78 $1,407.49 $1,313.27 $1,319.2360 $1,222.11 $1,257.75 $1,281.71 $1,292.65 $1,467.51 $1,369.27 $1,375.4861 $1,265.34 $1,302.24 $1,327.05 $1,338.37 $1,519.42 $1,417.70 $1,424.1462 $1,293.71 $1,331.43 $1,356.80 $1,368.38 $1,553.49 $1,449.49 $1,456.0763 $1,329.29 $1,368.05 $1,394.11 $1,406.01 $1,596.21 $1,489.34 $1,496.10

64+ $1,350.90 $1,390.29 $1,416.78 $1,428.87 $1,622.16 $1,513.56 $1,520.43

HMO PLANS





Region 4

Region 4 includes the county of: San Francisco


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $203.48 $198.65 $208.71 $203.30 $232.12 $247.4521 $320.44 $312.84 $328.67 $320.16 $365.54 $389.6922 $320.44 $312.84 $328.67 $320.16 $365.54 $389.6923 $320.44 $312.84 $328.67 $320.16 $365.54 $389.6924 $320.44 $312.84 $328.67 $320.16 $365.54 $389.6925 $321.72 $314.09 $329.98 $321.44 $367.00 $391.2526 $328.13 $320.35 $336.56 $327.84 $374.31 $399.0427 $335.82 $327.86 $344.45 $335.53 $383.09 $408.4028 $348.32 $340.06 $357.26 $348.01 $397.34 $423.5929 $358.57 $350.07 $367.78 $358.26 $409.04 $436.0630 $363.70 $355.07 $373.04 $363.38 $414.89 $442.3031 $371.39 $362.58 $380.93 $371.07 $423.66 $451.6532 $379.08 $370.09 $388.82 $378.75 $432.43 $461.0033 $383.89 $374.78 $393.75 $383.55 $437.92 $466.8534 $389.01 $379.79 $399.01 $388.67 $443.77 $473.0835 $391.58 $382.29 $401.63 $391.24 $446.69 $476.2036 $394.14 $384.79 $404.26 $393.80 $449.61 $479.3237 $396.70 $387.30 $406.89 $396.36 $452.54 $482.4438 $399.27 $389.80 $409.52 $398.92 $455.46 $485.5539 $404.40 $394.80 $414.78 $404.04 $461.31 $491.7940 $409.52 $399.81 $420.04 $409.16 $467.16 $498.0241 $417.21 $407.32 $427.93 $416.85 $475.93 $507.3842 $424.58 $414.51 $435.49 $424.21 $484.34 $516.3443 $434.84 $424.52 $446.01 $434.46 $496.04 $528.8144 $447.65 $437.04 $459.15 $447.26 $510.66 $544.4045 $462.72 $451.74 $474.60 $462.31 $527.84 $562.7146 $480.66 $469.26 $493.01 $480.24 $548.31 $584.5447 $500.85 $488.97 $513.71 $500.41 $571.34 $609.0948 $523.92 $511.49 $537.38 $523.46 $597.66 $637.1449 $546.67 $533.71 $560.71 $546.19 $623.61 $664.8150 $572.31 $558.73 $587.00 $571.81 $652.85 $695.9951 $597.62 $583.45 $612.97 $597.10 $681.73 $726.7752 $625.50 $610.66 $641.56 $624.95 $713.53 $760.6753 $653.70 $638.19 $670.49 $653.13 $745.70 $794.9754 $684.14 $667.91 $701.71 $683.54 $780.43 $831.9955 $714.58 $697.63 $732.93 $713.96 $815.15 $869.0156 $747.59 $729.86 $766.79 $746.93 $852.80 $909.1557 $780.91 $762.39 $800.97 $780.23 $890.82 $949.6758 $816.48 $797.12 $837.45 $815.77 $931.40 $992.9359 $834.11 $814.32 $855.53 $833.38 $951.50 $1,014.3660 $869.67 $849.05 $892.01 $868.91 $992.08 $1,057.6261 $900.44 $879.08 $923.56 $899.65 $1,027.17 $1,095.0362 $920.62 $898.79 $944.27 $919.82 $1,050.20 $1,119.5863 $945.94 $923.50 $970.23 $945.11 $1,079.07 $1,150.36

64+ $961.32 $938.52 $986.01 $960.48 $1,096.62 $1,169.07

SILVER PPO PLANS




date



Region 5

Region 5 includes the county of: Contra Costa

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $272.62 $280.59 $285.92 $288.36 $327.38 $320.27 $321.7221 $429.32 $441.87 $450.27 $454.11 $515.56 $504.36 $506.6522 $429.32 $441.87 $450.27 $454.11 $515.56 $504.36 $506.6523 $429.32 $441.87 $450.27 $454.11 $515.56 $504.36 $506.6524 $429.32 $441.87 $450.27 $454.11 $515.56 $504.36 $506.6525 $431.04 $443.64 $452.07 $455.93 $517.62 $506.38 $508.6826 $439.62 $452.47 $461.08 $465.01 $527.93 $516.46 $518.8127 $449.93 $463.08 $471.88 $475.91 $540.31 $528.57 $530.9728 $466.67 $480.31 $489.44 $493.62 $560.41 $548.24 $550.7329 $480.41 $494.45 $503.85 $508.15 $576.91 $564.38 $566.9430 $487.28 $501.52 $511.06 $515.41 $585.16 $572.45 $575.0531 $497.58 $512.13 $521.86 $526.31 $597.53 $584.55 $587.2132 $507.89 $522.73 $532.67 $537.21 $609.91 $596.66 $599.3733 $514.33 $529.36 $539.42 $544.02 $617.64 $604.22 $606.9734 $521.19 $536.43 $546.63 $551.29 $625.89 $612.29 $615.0735 $524.63 $539.97 $550.23 $554.92 $630.01 $616.33 $619.1336 $528.06 $543.50 $553.83 $558.56 $634.14 $620.36 $623.1837 $531.50 $547.04 $557.43 $562.19 $638.26 $624.40 $627.2338 $534.93 $550.57 $561.04 $565.82 $642.39 $628.43 $631.2939 $541.80 $557.64 $568.24 $573.09 $650.64 $636.50 $639.3940 $548.67 $564.71 $575.45 $580.35 $658.89 $644.57 $647.5041 $558.97 $575.31 $586.25 $591.25 $671.26 $656.68 $659.6642 $568.85 $585.48 $596.61 $601.70 $683.12 $668.28 $671.3143 $582.59 $599.62 $611.02 $616.23 $699.61 $684.42 $687.5244 $599.76 $617.29 $629.03 $634.39 $720.24 $704.59 $707.7945 $619.94 $638.06 $650.19 $655.73 $744.47 $728.30 $731.6046 $643.98 $662.81 $675.41 $681.17 $773.34 $756.54 $759.9847 $671.03 $690.64 $703.77 $709.77 $805.82 $788.31 $791.8948 $701.94 $722.46 $736.19 $742.47 $842.94 $824.63 $828.3749 $732.42 $753.83 $768.16 $774.71 $879.55 $860.44 $864.3450 $766.77 $789.18 $804.18 $811.04 $920.79 $900.79 $904.8851 $800.68 $824.09 $839.75 $846.92 $961.52 $940.63 $944.9052 $838.03 $862.53 $878.93 $886.42 $1,006.37 $984.51 $988.9853 $875.81 $901.41 $918.55 $926.38 $1,051.74 $1,028.89 $1,033.5754 $916.60 $943.39 $961.33 $969.52 $1,100.72 $1,076.81 $1,081.7055 $957.38 $985.37 $1,004.10 $1,012.67 $1,149.70 $1,124.72 $1,129.8356 $1,001.60 $1,030.88 $1,050.48 $1,059.44 $1,202.80 $1,176.67 $1,182.0157 $1,046.25 $1,076.84 $1,097.31 $1,106.67 $1,256.42 $1,229.13 $1,234.7158 $1,093.91 $1,125.88 $1,147.29 $1,157.07 $1,313.65 $1,285.11 $1,290.9459 $1,117.52 $1,150.19 $1,172.05 $1,182.05 $1,342.00 $1,312.85 $1,318.8160 $1,165.17 $1,199.24 $1,222.03 $1,232.45 $1,399.23 $1,368.83 $1,375.0561 $1,206.39 $1,241.65 $1,265.26 $1,276.05 $1,448.72 $1,417.25 $1,423.6962 $1,233.44 $1,269.49 $1,293.63 $1,304.66 $1,481.20 $1,449.03 $1,455.6163 $1,267.35 $1,304.40 $1,329.20 $1,340.53 $1,521.93 $1,488.87 $1,495.63

64+ $1,287.96 $1,325.61 $1,350.81 $1,362.33 $1,546.68 $1,513.08 $1,519.95

HMO PLANS





Region 5

Region 5 includes the county of: Contra Costa


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $214.34 $209.25 $219.82 $214.13 $244.49 $260.6321 $337.54 $329.53 $346.17 $337.22 $385.02 $410.4422 $337.54 $329.53 $346.17 $337.22 $385.02 $410.4423 $337.54 $329.53 $346.17 $337.22 $385.02 $410.4424 $337.54 $329.53 $346.17 $337.22 $385.02 $410.4425 $338.89 $330.85 $347.55 $338.57 $386.56 $412.0826 $345.64 $337.44 $354.48 $345.31 $394.26 $420.2927 $353.74 $345.35 $362.79 $353.41 $403.50 $430.1428 $366.91 $358.20 $376.29 $366.56 $418.52 $446.1529 $377.71 $368.74 $387.36 $377.35 $430.84 $459.2830 $383.11 $374.02 $392.90 $382.74 $437.00 $465.8531 $391.21 $381.93 $401.21 $390.84 $446.24 $475.7032 $399.31 $389.83 $409.52 $398.93 $455.48 $485.5533 $404.37 $394.78 $414.71 $403.99 $461.25 $491.7134 $409.77 $400.05 $420.25 $409.39 $467.41 $498.2735 $412.47 $402.69 $423.02 $412.08 $470.49 $501.5636 $415.17 $405.32 $425.79 $414.78 $473.57 $504.8437 $417.87 $407.96 $428.56 $417.48 $476.65 $508.1238 $420.57 $410.59 $431.33 $420.18 $479.73 $511.4139 $425.98 $415.87 $436.87 $425.57 $485.90 $517.9840 $431.38 $421.14 $442.41 $430.97 $492.06 $524.5441 $439.48 $429.05 $450.71 $439.06 $501.30 $534.3942 $447.24 $436.63 $458.68 $446.82 $510.15 $543.8343 $458.04 $447.17 $469.75 $457.61 $522.47 $556.9744 $471.54 $460.35 $483.60 $471.10 $537.87 $573.3845 $487.41 $475.84 $499.87 $486.95 $555.97 $592.6846 $506.31 $494.30 $519.26 $505.83 $577.53 $615.6647 $527.58 $515.06 $541.06 $527.07 $601.79 $641.5248 $551.88 $538.78 $565.99 $551.35 $629.51 $671.0749 $575.84 $562.18 $590.57 $575.30 $656.84 $700.2150 $602.85 $588.54 $618.26 $602.27 $687.65 $733.0551 $629.51 $614.57 $645.61 $628.92 $718.06 $765.4752 $658.88 $643.24 $675.72 $658.25 $751.56 $801.1853 $688.58 $672.24 $706.19 $687.93 $785.44 $837.3054 $720.65 $703.55 $739.07 $719.96 $822.02 $876.2955 $752.71 $734.85 $771.96 $752.00 $858.59 $915.2856 $787.48 $768.79 $807.61 $786.73 $898.25 $957.5657 $822.58 $803.06 $843.62 $821.81 $938.29 $1,000.2458 $860.05 $839.64 $882.04 $859.24 $981.03 $1,045.8059 $878.62 $857.77 $901.08 $877.78 $1,002.21 $1,068.3860 $916.08 $894.34 $939.51 $915.22 $1,044.94 $1,113.9361 $948.49 $925.98 $972.74 $947.59 $1,081.91 $1,153.3462 $969.75 $946.74 $994.55 $968.83 $1,106.16 $1,179.1963 $996.42 $972.77 $1,021.89 $995.47 $1,136.58 $1,211.62

64+ $1,012.62 $988.59 $1,038.51 $1,011.66 $1,155.06 $1,231.32

SILVER PPO PLANS




date



Region 6

Region 6 includes the couny of: Alameda

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $287.17 $295.54 $301.16 $303.75 $344.85 $320.31 $321.7321 $452.23 $465.41 $474.27 $478.34 $543.07 $504.42 $506.6622 $452.23 $465.41 $474.27 $478.34 $543.07 $504.42 $506.6623 $452.23 $465.41 $474.27 $478.34 $543.07 $504.42 $506.6624 $452.23 $465.41 $474.27 $478.34 $543.07 $504.42 $506.6625 $454.04 $467.27 $476.17 $480.25 $545.24 $506.44 $508.6926 $463.08 $476.58 $485.65 $489.82 $556.10 $516.53 $518.8227 $473.94 $487.75 $497.03 $501.30 $569.14 $528.63 $530.9828 $491.57 $505.90 $515.53 $519.96 $590.32 $548.30 $550.7429 $506.05 $520.79 $530.71 $535.26 $607.70 $564.45 $566.9530 $513.28 $528.24 $538.30 $542.92 $616.38 $572.52 $575.0631 $524.13 $539.41 $549.68 $554.40 $629.42 $584.62 $587.2232 $534.99 $550.58 $561.06 $565.88 $642.45 $596.73 $599.3833 $541.77 $557.56 $568.18 $573.05 $650.60 $604.30 $606.9834 $549.01 $565.01 $575.76 $580.70 $659.29 $612.37 $615.0935 $552.63 $568.73 $579.56 $584.53 $663.63 $616.40 $619.1436 $556.24 $572.45 $583.35 $588.36 $667.98 $620.44 $623.1937 $559.86 $576.18 $587.15 $592.18 $672.32 $624.47 $627.2538 $563.48 $579.90 $590.94 $596.01 $676.67 $628.51 $631.3039 $570.71 $587.35 $598.53 $603.67 $685.35 $636.58 $639.4040 $577.95 $594.79 $606.12 $611.32 $694.04 $644.65 $647.5141 $588.80 $605.96 $617.50 $622.80 $707.08 $656.75 $659.6742 $599.20 $616.67 $628.41 $633.80 $719.57 $668.36 $671.3243 $613.68 $631.56 $643.58 $649.11 $736.95 $684.50 $687.5444 $631.77 $650.18 $662.56 $668.24 $758.67 $704.67 $707.8045 $653.02 $672.05 $684.85 $690.72 $784.19 $728.38 $731.6246 $678.35 $698.12 $711.41 $717.51 $814.61 $756.63 $759.9947 $706.84 $727.44 $741.28 $747.65 $848.82 $788.41 $791.9148 $739.40 $760.95 $775.43 $782.09 $887.92 $824.73 $828.3949 $771.50 $793.99 $809.10 $816.05 $926.48 $860.54 $864.3650 $807.68 $831.22 $847.05 $854.32 $969.92 $900.89 $904.8951 $843.41 $867.99 $884.51 $892.10 $1,012.83 $940.74 $944.9252 $882.75 $908.48 $925.78 $933.72 $1,060.07 $984.63 $989.0053 $922.55 $949.44 $967.51 $975.81 $1,107.86 $1,029.02 $1,033.5954 $965.51 $993.65 $1,012.57 $1,021.26 $1,159.45 $1,076.94 $1,081.7255 $1,008.47 $1,037.86 $1,057.62 $1,066.70 $1,211.05 $1,124.86 $1,129.8556 $1,055.05 $1,085.80 $1,106.47 $1,115.97 $1,266.98 $1,176.81 $1,182.0457 $1,102.08 $1,134.20 $1,155.80 $1,165.71 $1,323.46 $1,229.27 $1,234.7358 $1,152.28 $1,185.86 $1,208.44 $1,218.81 $1,383.74 $1,285.26 $1,290.9759 $1,177.15 $1,211.46 $1,234.52 $1,245.12 $1,413.61 $1,313.01 $1,318.8460 $1,227.35 $1,263.12 $1,287.17 $1,298.21 $1,473.89 $1,369.00 $1,375.0861 $1,270.77 $1,307.80 $1,332.70 $1,344.14 $1,526.03 $1,417.42 $1,423.7162 $1,299.26 $1,337.12 $1,362.58 $1,374.27 $1,560.24 $1,449.20 $1,455.6363 $1,334.98 $1,373.89 $1,400.05 $1,412.06 $1,603.14 $1,489.05 $1,495.66



date

GOLD PPO PLANS



Region 6

Region 6 includes the couny of: Alameda

HMO PLANS


Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $186.68 $182.26 $191.47 $186.52 $212.98 $227.0321 $293.99 $287.02 $301.53 $293.74 $335.40 $357.5222 $293.99 $287.02 $301.53 $293.74 $335.40 $357.5223 $293.99 $287.02 $301.53 $293.74 $335.40 $357.5224 $293.99 $287.02 $301.53 $293.74 $335.40 $357.5225 $295.17 $288.17 $302.74 $294.91 $336.74 $358.9526 $301.05 $293.91 $308.77 $300.79 $343.45 $366.1027 $308.10 $300.80 $316.00 $307.84 $351.50 $374.6828 $319.57 $311.99 $327.76 $319.30 $364.58 $388.6229 $328.97 $321.18 $337.41 $328.70 $375.31 $400.0630 $333.68 $325.77 $342.24 $333.39 $380.68 $405.7931 $340.73 $332.66 $349.47 $340.44 $388.73 $414.3732 $347.79 $339.54 $356.71 $347.49 $396.78 $422.9533 $352.20 $343.85 $361.23 $351.90 $401.81 $428.3134 $356.90 $348.44 $366.06 $356.60 $407.18 $434.0335 $359.26 $350.74 $368.47 $358.95 $409.86 $436.8936 $361.61 $353.03 $370.88 $361.30 $412.54 $439.7537 $363.96 $355.33 $373.29 $363.65 $415.23 $442.6138 $366.31 $357.63 $375.71 $366.00 $417.91 $445.4739 $371.02 $362.22 $380.53 $370.70 $423.27 $451.1940 $375.72 $366.81 $385.36 $375.40 $428.64 $456.9141 $382.77 $373.70 $392.59 $382.45 $436.69 $465.4942 $389.54 $380.30 $399.53 $389.21 $444.41 $473.7143 $398.94 $389.49 $409.18 $398.61 $455.14 $485.1544 $410.70 $400.97 $421.24 $410.35 $468.55 $499.4645 $424.52 $414.46 $435.41 $424.16 $484.32 $516.2646 $440.99 $430.53 $452.30 $440.61 $503.10 $536.2847 $459.51 $448.61 $471.29 $459.12 $524.23 $558.8048 $480.67 $469.28 $493.00 $480.26 $548.38 $584.5549 $501.55 $489.66 $514.41 $501.12 $572.19 $609.9350 $525.07 $512.62 $538.53 $524.62 $599.02 $638.5351 $548.29 $535.29 $562.35 $547.83 $625.52 $666.7752 $573.87 $560.26 $588.59 $573.38 $654.70 $697.8853 $599.74 $585.52 $615.12 $599.23 $684.22 $729.3454 $627.67 $612.79 $643.77 $627.13 $716.08 $763.3155 $655.60 $640.05 $672.41 $655.04 $747.94 $797.2756 $685.88 $669.62 $703.47 $685.30 $782.49 $834.0957 $716.45 $699.47 $734.83 $715.84 $817.37 $871.2858 $749.09 $731.33 $768.30 $748.45 $854.60 $910.9659 $765.26 $747.11 $784.88 $764.61 $873.05 $930.6260 $797.89 $778.97 $818.35 $797.21 $910.28 $970.3161 $826.11 $806.53 $847.30 $825.41 $942.47 $1,004.6362 $844.63 $824.61 $866.30 $843.92 $963.60 $1,027.1563 $867.86 $847.28 $890.12 $867.12 $990.10 $1,055.40

64+ $881.97 $861.06 $904.59 $881.22 $1,006.20 $1,072.56

SILVER PPO PLANS



date




Region 7 includes the county of: Santa Clara

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $250.13 $257.43 $262.33 $264.57 $300.37 $320.20 $321.6521 $393.91 $405.40 $413.12 $416.64 $473.02 $504.25 $506.5322 $393.91 $405.40 $413.12 $416.64 $473.02 $504.25 $506.5323 $393.91 $405.40 $413.12 $416.64 $473.02 $504.25 $506.5324 $393.91 $405.40 $413.12 $416.64 $473.02 $504.25 $506.5325 $395.49 $407.02 $414.77 $418.31 $474.91 $506.27 $508.5626 $403.36 $415.13 $423.03 $426.64 $484.37 $516.35 $518.6927 $412.82 $424.86 $432.95 $436.64 $495.72 $528.45 $530.8428 $428.18 $440.67 $449.06 $452.89 $514.17 $548.12 $550.6029 $440.79 $453.64 $462.28 $466.22 $529.31 $564.26 $566.8130 $447.09 $460.13 $468.89 $472.89 $536.88 $572.32 $574.9131 $456.54 $469.86 $478.81 $482.89 $548.23 $584.43 $587.0732 $466.00 $479.59 $488.72 $492.89 $559.58 $596.53 $599.2233 $471.90 $485.67 $494.92 $499.13 $566.68 $604.09 $606.8234 $478.21 $492.16 $501.53 $505.80 $574.25 $612.16 $614.9335 $481.36 $495.40 $504.83 $509.13 $578.03 $616.19 $618.9836 $484.51 $498.64 $508.14 $512.47 $581.81 $620.23 $623.0337 $487.66 $501.89 $511.44 $515.80 $585.60 $624.26 $627.0838 $490.81 $505.13 $514.75 $519.13 $589.38 $628.30 $631.1439 $497.11 $511.61 $521.36 $525.80 $596.95 $636.36 $639.2440 $503.42 $518.10 $527.97 $532.47 $604.52 $644.43 $647.3541 $512.87 $527.83 $537.88 $542.47 $615.87 $656.53 $659.5042 $521.93 $537.16 $547.38 $552.05 $626.75 $668.13 $671.1543 $534.54 $550.13 $560.60 $565.38 $641.89 $684.27 $687.3644 $550.29 $566.34 $577.13 $582.05 $660.81 $704.44 $707.6245 $568.81 $585.40 $596.55 $601.63 $683.04 $728.14 $731.4346 $590.87 $608.10 $619.68 $624.96 $709.53 $756.38 $759.8047 $615.68 $633.64 $645.71 $651.21 $739.33 $788.14 $791.7148 $644.04 $662.83 $675.45 $681.21 $773.39 $824.45 $828.1849 $672.01 $691.61 $704.78 $710.79 $806.97 $860.25 $864.1450 $703.52 $724.04 $737.83 $744.12 $844.81 $900.59 $904.6651 $734.64 $756.07 $770.47 $777.03 $882.18 $940.43 $944.6852 $768.91 $791.34 $806.41 $813.28 $923.34 $984.30 $988.7553 $803.58 $827.02 $842.76 $849.95 $964.96 $1,028.67 $1,033.3254 $841.00 $865.53 $882.01 $889.53 $1,009.90 $1,076.57 $1,081.4455 $878.42 $904.04 $921.26 $929.11 $1,054.83 $1,124.48 $1,129.5656 $918.99 $945.80 $963.81 $972.02 $1,103.56 $1,176.42 $1,181.7357 $959.96 $987.96 $1,006.77 $1,015.35 $1,152.75 $1,228.86 $1,234.4158 $1,003.68 $1,032.96 $1,052.63 $1,061.60 $1,205.25 $1,284.83 $1,290.6459 $1,025.35 $1,055.26 $1,075.35 $1,084.51 $1,231.27 $1,312.56 $1,318.5060 $1,069.07 $1,100.26 $1,121.21 $1,130.76 $1,283.78 $1,368.53 $1,374.7261 $1,106.89 $1,139.17 $1,160.87 $1,170.76 $1,329.19 $1,416.94 $1,423.3562 $1,131.70 $1,164.71 $1,186.89 $1,197.01 $1,358.99 $1,448.71 $1,455.2663 $1,162.82 $1,196.74 $1,219.53 $1,229.92 $1,396.36 $1,488.55 $1,495.28

64+ $1,181.73 $1,216.20 $1,239.36 $1,249.92 $1,419.06 $1,512.75 $1,519.59

HMO PLANS





Region 7

Region 7 includes the county of: Santa Clara


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $228.30 $222.87 $234.13 $228.07 $260.42 $277.5921 $359.53 $350.98 $368.71 $359.17 $410.11 $437.1522 $359.53 $350.98 $368.71 $359.17 $410.11 $437.1523 $359.53 $350.98 $368.71 $359.17 $410.11 $437.1524 $359.53 $350.98 $368.71 $359.17 $410.11 $437.1525 $360.97 $352.38 $370.18 $360.61 $411.75 $438.9026 $368.16 $359.40 $377.56 $367.79 $419.95 $447.6427 $376.79 $367.83 $386.41 $376.41 $429.80 $458.1328 $390.81 $381.52 $400.79 $390.42 $445.79 $475.1829 $402.31 $392.75 $412.59 $401.91 $458.91 $489.1730 $408.07 $398.36 $418.49 $407.66 $465.47 $496.1731 $416.70 $406.79 $427.33 $416.28 $475.32 $506.6632 $425.32 $415.21 $436.18 $424.90 $485.16 $517.1533 $430.72 $420.47 $441.71 $430.29 $491.31 $523.7134 $436.47 $426.09 $447.61 $436.03 $497.87 $530.7035 $439.35 $428.90 $450.56 $438.91 $501.15 $534.2036 $442.22 $431.71 $453.51 $441.78 $504.44 $537.6937 $445.10 $434.51 $456.46 $444.65 $507.72 $541.1938 $447.97 $437.32 $459.41 $447.53 $511.00 $544.6939 $453.73 $442.94 $465.31 $453.27 $517.56 $551.6840 $459.48 $448.55 $471.21 $459.02 $524.12 $558.6841 $468.11 $456.98 $480.06 $467.64 $533.96 $569.1742 $476.38 $465.05 $488.54 $475.90 $543.40 $579.2243 $487.88 $476.28 $500.34 $487.39 $556.52 $593.2144 $502.26 $490.32 $515.09 $501.76 $572.92 $610.7045 $519.16 $506.82 $532.42 $518.64 $592.20 $631.2446 $539.30 $526.47 $553.07 $538.76 $615.17 $655.7347 $561.95 $548.58 $576.29 $561.38 $641.00 $683.2748 $587.83 $573.85 $602.84 $587.24 $670.53 $714.7449 $613.36 $598.77 $629.02 $612.74 $699.65 $745.7850 $642.12 $626.85 $658.52 $641.48 $732.46 $780.7551 $670.52 $654.58 $687.64 $669.85 $764.86 $815.2852 $701.80 $685.11 $719.72 $701.10 $800.53 $853.3253 $733.44 $716.00 $752.17 $732.71 $836.62 $891.7954 $767.60 $749.34 $787.20 $766.83 $875.58 $933.3255 $801.75 $782.69 $822.22 $800.95 $914.55 $974.8456 $838.78 $818.84 $860.20 $837.94 $956.79 $1,019.8757 $876.17 $855.34 $898.55 $875.30 $999.44 $1,065.3358 $916.08 $894.30 $939.47 $915.17 $1,044.96 $1,113.8659 $935.86 $913.60 $959.75 $934.92 $1,067.52 $1,137.9060 $975.76 $952.56 $1,000.68 $974.79 $1,113.04 $1,186.4361 $1,010.28 $986.25 $1,036.08 $1,009.27 $1,152.41 $1,228.3962 $1,032.93 $1,008.37 $1,059.30 $1,031.90 $1,178.25 $1,255.9363 $1,061.33 $1,036.09 $1,088.43 $1,060.27 $1,210.64 $1,290.47

64+ $1,078.59 $1,052.94 $1,106.13 $1,077.51 $1,230.33 $1,311.45

SILVER PPO PLANS




date



Region 8

Region 8 includes the county of: San Mateo

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $305.85 $314.79 $320.76 $323.51 $367.28 $361.88 $363.5121 $481.65 $495.73 $505.14 $509.46 $578.39 $569.89 $572.4622 $481.65 $495.73 $505.14 $509.46 $578.39 $569.89 $572.4623 $481.65 $495.73 $505.14 $509.46 $578.39 $569.89 $572.4624 $481.65 $495.73 $505.14 $509.46 $578.39 $569.89 $572.4625 $483.58 $497.71 $507.16 $511.50 $580.70 $572.17 $574.7526 $493.21 $507.63 $517.26 $521.69 $592.27 $583.57 $586.2027 $504.77 $519.53 $529.39 $533.91 $606.15 $597.24 $599.9428 $523.55 $538.86 $549.09 $553.78 $628.71 $619.47 $622.2629 $538.97 $554.72 $565.25 $570.09 $647.22 $637.71 $640.5830 $546.67 $562.65 $573.33 $578.24 $656.47 $646.83 $649.7431 $558.23 $574.55 $585.46 $590.46 $670.35 $660.50 $663.4832 $569.79 $586.45 $597.58 $602.69 $684.24 $674.18 $677.2233 $577.02 $593.88 $605.16 $610.33 $692.91 $682.73 $685.8134 $584.72 $601.82 $613.24 $618.48 $702.17 $691.85 $694.9735 $588.58 $605.78 $617.28 $622.56 $706.79 $696.41 $699.5536 $592.43 $609.75 $621.32 $626.64 $711.42 $700.96 $704.1337 $596.28 $613.71 $625.36 $630.71 $716.05 $705.52 $708.7138 $600.14 $617.68 $629.40 $634.79 $720.67 $710.08 $713.2939 $607.84 $625.61 $637.49 $642.94 $729.93 $719.20 $722.4440 $615.55 $633.54 $645.57 $651.09 $739.18 $728.32 $731.6041 $627.11 $645.44 $657.69 $663.32 $753.06 $742.00 $745.3442 $638.19 $656.84 $669.31 $675.03 $766.37 $755.10 $758.5143 $653.60 $672.71 $685.47 $691.34 $784.88 $773.34 $776.8344 $672.87 $692.53 $705.68 $711.72 $808.01 $796.14 $799.7345 $695.50 $715.83 $729.42 $735.66 $835.20 $822.92 $826.6346 $722.48 $743.60 $757.71 $764.19 $867.59 $854.84 $858.6947 $752.82 $774.83 $789.53 $796.29 $904.02 $890.74 $894.7548 $787.50 $810.52 $825.90 $832.97 $945.67 $931.77 $935.9749 $821.69 $845.72 $861.77 $869.14 $986.73 $972.23 $976.6250 $860.23 $885.37 $902.18 $909.90 $1,033.00 $1,017.82 $1,022.4151 $898.28 $924.54 $942.09 $950.14 $1,078.70 $1,062.84 $1,067.6452 $940.18 $967.66 $986.03 $994.47 $1,129.02 $1,112.43 $1,117.4453 $982.57 $1,011.29 $1,030.49 $1,039.30 $1,179.92 $1,162.58 $1,167.8254 $1,028.32 $1,058.38 $1,078.47 $1,087.70 $1,234.86 $1,216.72 $1,222.2055 $1,074.08 $1,105.48 $1,126.46 $1,136.10 $1,289.81 $1,270.85 $1,276.5956 $1,123.69 $1,156.54 $1,178.49 $1,188.57 $1,349.38 $1,329.55 $1,335.5557 $1,173.78 $1,208.09 $1,231.03 $1,241.55 $1,409.54 $1,388.82 $1,395.0958 $1,227.24 $1,263.12 $1,287.10 $1,298.10 $1,473.74 $1,452.08 $1,458.6359 $1,253.73 $1,290.39 $1,314.88 $1,326.12 $1,505.55 $1,483.42 $1,490.1160 $1,307.20 $1,345.41 $1,370.95 $1,382.67 $1,569.75 $1,546.68 $1,553.6661 $1,353.44 $1,393.00 $1,419.44 $1,431.58 $1,625.28 $1,601.39 $1,608.6162 $1,383.78 $1,424.23 $1,451.27 $1,463.68 $1,661.71 $1,637.29 $1,644.6863 $1,421.83 $1,463.39 $1,491.17 $1,503.93 $1,707.41 $1,682.32 $1,689.90

64+ $1,444.95 $1,487.19 $1,515.42 $1,528.38 $1,735.17 $1,709.67 $1,717.38

HMO PLANS





Region 8

Region 8 includes the county of: San Mateo


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $211.56 $206.54 $217.00 $211.37 $241.34 $257.2621 $333.16 $325.26 $341.73 $332.87 $380.07 $405.1422 $333.16 $325.26 $341.73 $332.87 $380.07 $405.1423 $333.16 $325.26 $341.73 $332.87 $380.07 $405.1424 $333.16 $325.26 $341.73 $332.87 $380.07 $405.1425 $334.49 $326.56 $343.10 $334.20 $381.59 $406.7626 $341.16 $333.07 $349.93 $340.86 $389.19 $414.8627 $349.15 $340.87 $358.13 $348.85 $398.31 $424.5928 $362.14 $353.56 $371.46 $361.83 $413.14 $440.3929 $372.81 $363.97 $382.40 $372.48 $425.30 $453.3530 $378.14 $369.17 $387.86 $377.81 $431.38 $459.8331 $386.13 $376.98 $396.07 $385.80 $440.50 $469.5632 $394.13 $384.78 $404.27 $393.79 $449.62 $479.2833 $399.13 $389.66 $409.39 $398.78 $455.32 $485.3634 $404.46 $394.87 $414.86 $404.10 $461.40 $491.8435 $407.12 $397.47 $417.59 $406.77 $464.45 $495.0836 $409.79 $400.07 $420.33 $409.43 $467.49 $498.3237 $412.45 $402.67 $423.06 $412.09 $470.53 $501.5638 $415.12 $405.27 $425.80 $414.76 $473.57 $504.8039 $420.45 $410.48 $431.26 $420.08 $479.65 $511.2940 $425.78 $415.68 $436.73 $425.41 $485.73 $517.7741 $433.77 $423.49 $444.93 $433.40 $494.85 $527.4942 $441.44 $430.97 $452.79 $441.05 $503.59 $536.8143 $452.10 $441.38 $463.73 $451.70 $515.75 $549.7744 $465.42 $454.39 $477.40 $465.02 $530.96 $565.9845 $481.08 $469.68 $493.46 $480.66 $548.82 $585.0246 $499.74 $487.89 $512.60 $499.31 $570.11 $607.7147 $520.73 $508.38 $534.12 $520.28 $594.05 $633.2348 $544.72 $531.80 $558.73 $544.24 $621.41 $662.4049 $568.37 $554.89 $582.99 $567.88 $648.40 $691.1750 $595.02 $580.91 $610.33 $594.51 $678.81 $723.5851 $621.34 $606.61 $637.33 $620.80 $708.83 $755.5952 $650.33 $634.91 $667.06 $649.76 $741.90 $790.8353 $679.65 $663.53 $697.13 $679.05 $775.34 $826.4954 $711.30 $694.43 $729.59 $710.68 $811.45 $864.9755 $742.95 $725.33 $762.06 $742.30 $847.56 $903.4656 $777.26 $758.83 $797.26 $776.59 $886.70 $945.1957 $811.91 $792.66 $832.80 $811.20 $926.23 $987.3358 $848.89 $828.76 $870.73 $848.15 $968.42 $1,032.3059 $867.22 $846.65 $889.52 $866.46 $989.32 $1,054.5860 $904.20 $882.76 $927.46 $903.41 $1,031.51 $1,099.5561 $936.18 $913.98 $960.26 $935.36 $1,068.00 $1,138.4462 $957.17 $934.47 $981.79 $956.34 $1,091.94 $1,163.9763 $983.49 $960.17 $1,008.79 $982.63 $1,121.97 $1,195.97

64+ $999.48 $975.78 $1,025.19 $998.61 $1,140.21 $1,215.42

SILVER PPO PLANS




date



Region 9

Region 9 includes the counties of: Santa Cruz, Monterey, and San Benito

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $283.45 $291.73 $297.27 $299.82 $340.37 $323.12 $324.5621 $446.38 $459.41 $468.14 $472.16 $536.02 $508.85 $511.1222 $446.38 $459.41 $468.14 $472.16 $536.02 $508.85 $511.1223 $446.38 $459.41 $468.14 $472.16 $536.02 $508.85 $511.1224 $446.38 $459.41 $468.14 $472.16 $536.02 $508.85 $511.1225 $448.17 $461.25 $470.01 $474.05 $538.16 $510.89 $513.1626 $457.09 $470.44 $479.38 $483.49 $548.88 $521.06 $523.3927 $467.81 $481.46 $490.61 $494.82 $561.75 $533.27 $535.6528 $485.22 $499.38 $508.87 $513.24 $582.65 $553.12 $555.5929 $499.50 $514.08 $523.85 $528.35 $599.81 $569.40 $571.9430 $506.64 $521.43 $531.34 $535.90 $608.38 $577.54 $580.1231 $517.35 $532.46 $542.57 $547.23 $621.25 $589.76 $592.3932 $528.07 $543.48 $553.81 $558.57 $634.11 $601.97 $604.6533 $534.76 $550.37 $560.83 $565.65 $642.15 $609.60 $612.3234 $541.91 $557.72 $568.32 $573.20 $650.73 $617.74 $620.5035 $545.48 $561.40 $572.07 $576.98 $655.02 $621.81 $624.5936 $549.05 $565.07 $575.81 $580.76 $659.30 $625.89 $628.6837 $552.62 $568.75 $579.56 $584.53 $663.59 $629.96 $632.7738 $556.19 $572.42 $583.30 $588.31 $667.88 $634.03 $636.8639 $563.33 $579.78 $590.79 $595.87 $676.46 $642.17 $645.0340 $570.47 $587.13 $598.28 $603.42 $685.03 $650.31 $653.2141 $581.19 $598.15 $609.52 $614.75 $697.90 $662.52 $665.4842 $591.45 $608.72 $620.29 $625.61 $710.23 $674.23 $677.2343 $605.74 $623.42 $635.27 $640.72 $727.38 $690.51 $693.5944 $623.59 $641.80 $653.99 $659.61 $748.82 $710.86 $714.0345 $644.57 $663.39 $675.99 $681.80 $774.01 $734.78 $738.0646 $669.57 $689.12 $702.21 $708.24 $804.03 $763.28 $766.6847 $697.69 $718.06 $731.70 $737.99 $837.80 $795.33 $798.8848 $729.83 $751.14 $765.41 $771.98 $876.39 $831.97 $835.6849 $761.52 $783.75 $798.65 $805.50 $914.45 $868.10 $871.9750 $797.23 $820.51 $836.10 $843.28 $957.33 $908.81 $912.8651 $832.50 $856.80 $873.08 $880.58 $999.68 $949.01 $953.2452 $871.33 $896.77 $913.81 $921.66 $1,046.31 $993.28 $997.7153 $910.62 $937.20 $955.01 $963.21 $1,093.48 $1,038.05 $1,042.6854 $953.02 $980.84 $999.48 $1,008.06 $1,144.40 $1,086.39 $1,091.2455 $995.43 $1,024.48 $1,043.95 $1,052.92 $1,195.32 $1,134.74 $1,139.8056 $1,041.40 $1,071.80 $1,092.17 $1,101.55 $1,250.53 $1,187.15 $1,192.4457 $1,087.83 $1,119.58 $1,140.86 $1,150.65 $1,306.28 $1,240.07 $1,245.6058 $1,137.38 $1,170.58 $1,192.82 $1,203.06 $1,365.78 $1,296.55 $1,302.3359 $1,161.93 $1,195.84 $1,218.57 $1,229.03 $1,395.26 $1,324.54 $1,330.4560 $1,211.48 $1,246.84 $1,270.53 $1,281.44 $1,454.76 $1,381.02 $1,387.1861 $1,254.33 $1,290.94 $1,315.47 $1,326.77 $1,506.22 $1,429.87 $1,436.2562 $1,282.45 $1,319.88 $1,344.97 $1,356.52 $1,539.99 $1,461.93 $1,468.4563 $1,317.71 $1,356.18 $1,381.95 $1,393.82 $1,582.33 $1,502.13 $1,508.83




Region 9

Region 9 includes the counties of: Santa Cruz, Monterey, and San Benito


date

GOLD PPO PLANS HMO PLANS


Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $169.46 $165.44 $173.82 $169.32 $193.33 $206.0921 $266.87 $260.53 $273.74 $266.64 $304.45 $324.5522 $266.87 $260.53 $273.74 $266.64 $304.45 $324.5523 $266.87 $260.53 $273.74 $266.64 $304.45 $324.5524 $266.87 $260.53 $273.74 $266.64 $304.45 $324.5525 $267.94 $261.57 $274.83 $267.71 $305.67 $325.8526 $273.27 $266.78 $280.31 $273.04 $311.76 $332.3427 $279.68 $273.04 $286.88 $279.44 $319.06 $340.1328 $290.09 $283.20 $297.56 $289.84 $330.94 $352.7929 $298.63 $291.53 $306.32 $298.37 $340.68 $363.1730 $302.90 $295.70 $310.69 $302.64 $345.55 $368.3631 $309.30 $301.95 $317.26 $309.04 $352.86 $376.1532 $315.71 $308.21 $323.83 $315.44 $360.16 $383.9433 $319.71 $312.11 $327.94 $319.43 $364.73 $388.8134 $323.98 $316.28 $332.32 $323.70 $369.60 $394.0035 $326.12 $318.37 $334.51 $325.83 $372.04 $396.6036 $328.25 $320.45 $336.70 $327.97 $374.47 $399.2037 $330.39 $322.54 $338.89 $330.10 $376.91 $401.7938 $332.52 $324.62 $341.08 $332.23 $379.34 $404.3939 $336.79 $328.79 $345.46 $336.50 $384.22 $409.5840 $341.06 $332.96 $349.84 $340.77 $389.09 $414.7741 $347.46 $339.21 $356.41 $347.17 $396.39 $422.5642 $353.60 $345.20 $362.71 $353.30 $403.40 $430.0343 $362.14 $353.54 $371.47 $361.83 $413.14 $440.4144 $372.82 $363.96 $382.41 $372.50 $425.32 $453.4045 $385.36 $376.21 $395.28 $385.03 $439.63 $468.6546 $400.31 $390.80 $410.61 $399.96 $456.68 $486.8347 $417.12 $407.21 $427.86 $416.76 $475.86 $507.2748 $436.33 $425.97 $447.56 $435.96 $497.78 $530.6449 $455.28 $444.46 $467.00 $454.89 $519.39 $553.6850 $476.63 $465.31 $488.90 $476.22 $543.75 $579.6551 $497.71 $485.89 $510.53 $497.28 $567.80 $605.2952 $520.93 $508.55 $534.34 $520.48 $594.29 $633.5253 $544.41 $531.48 $558.43 $543.95 $621.08 $662.0854 $569.77 $556.23 $584.43 $569.28 $650.00 $692.9155 $595.12 $580.98 $610.44 $594.61 $678.92 $723.7556 $622.61 $607.82 $638.64 $622.07 $710.28 $757.1857 $650.36 $634.91 $667.10 $649.80 $741.94 $790.9358 $679.98 $663.83 $697.49 $679.40 $775.74 $826.9559 $694.66 $678.16 $712.55 $694.06 $792.48 $844.8060 $724.29 $707.08 $742.93 $723.66 $826.28 $880.8361 $749.90 $732.09 $769.21 $749.26 $855.50 $911.9962 $766.72 $748.50 $786.46 $766.06 $874.68 $932.4363 $787.80 $769.08 $808.08 $787.12 $898.74 $958.07

64+ $800.61 $781.59 $821.22 $799.92 $913.35 $973.65

SILVER PPO PLANS




date



Region 10

Region 10 includes the counties of: San Joaquin, Stanislaus, Merced, Mariposa, and Tulare

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $227.05 $233.68 $238.13 $240.17 $272.66 $347.02 $348.5821 $357.56 $368.00 $375.00 $378.22 $429.39 $546.49 $548.9522 $357.56 $368.00 $375.00 $378.22 $429.39 $546.49 $548.9523 $357.56 $368.00 $375.00 $378.22 $429.39 $546.49 $548.9524 $357.56 $368.00 $375.00 $378.22 $429.39 $546.49 $548.9525 $358.99 $369.47 $376.50 $379.73 $431.11 $548.68 $551.1526 $366.14 $376.83 $384.00 $387.30 $439.70 $559.61 $562.1227 $374.72 $385.66 $393.00 $396.37 $450.00 $572.72 $575.3028 $388.67 $400.02 $407.63 $411.13 $466.75 $594.03 $596.7129 $400.11 $411.79 $419.63 $423.23 $480.49 $611.52 $614.2830 $405.83 $417.68 $425.63 $429.28 $487.36 $620.27 $623.0631 $414.41 $426.51 $434.63 $438.36 $497.66 $633.38 $636.2332 $422.99 $435.34 $443.63 $447.43 $507.97 $646.50 $649.4133 $428.36 $440.86 $449.25 $453.11 $514.41 $654.70 $657.6434 $434.08 $446.75 $455.25 $459.16 $521.28 $663.44 $666.4335 $436.94 $449.70 $458.25 $462.18 $524.71 $667.81 $670.8236 $439.80 $452.64 $461.25 $465.21 $528.15 $672.18 $675.2137 $442.66 $455.58 $464.25 $468.24 $531.58 $676.55 $679.6038 $445.52 $458.53 $467.25 $471.26 $535.02 $680.93 $683.9939 $451.24 $464.42 $473.25 $477.31 $541.89 $689.67 $692.7740 $456.96 $470.30 $479.25 $483.37 $548.76 $698.41 $701.5641 $465.54 $479.14 $488.25 $492.44 $559.07 $711.53 $714.7342 $473.77 $487.60 $496.88 $501.14 $568.94 $724.10 $727.3643 $485.21 $499.38 $508.88 $513.24 $582.68 $741.59 $744.9344 $499.51 $514.10 $523.88 $528.37 $599.86 $763.45 $766.8845 $516.32 $531.39 $541.50 $546.15 $620.04 $789.13 $792.6846 $536.34 $552.00 $562.50 $567.33 $644.09 $819.74 $823.4347 $558.87 $575.18 $586.13 $591.16 $671.14 $854.16 $858.0148 $584.61 $601.68 $613.13 $618.39 $702.05 $893.51 $897.5349 $610.00 $627.81 $639.75 $645.24 $732.54 $932.31 $936.5150 $638.60 $657.25 $669.75 $675.50 $766.89 $976.03 $980.4251 $666.85 $686.32 $699.38 $705.38 $800.81 $1,019.20 $1,023.7952 $697.96 $718.34 $732.00 $738.29 $838.17 $1,066.75 $1,071.5553 $729.42 $750.72 $765.00 $771.57 $875.96 $1,114.84 $1,119.8654 $763.39 $785.68 $800.63 $807.50 $916.75 $1,166.76 $1,172.0155 $797.36 $820.64 $836.25 $843.43 $957.54 $1,218.67 $1,224.1656 $834.19 $858.54 $874.88 $882.39 $1,001.77 $1,274.96 $1,280.7057 $871.37 $896.82 $913.88 $921.72 $1,046.42 $1,331.80 $1,337.7958 $911.06 $937.66 $955.50 $963.70 $1,094.09 $1,392.46 $1,398.7259 $930.73 $957.90 $976.13 $984.51 $1,117.70 $1,422.51 $1,428.9260 $970.42 $998.75 $1,017.75 $1,026.49 $1,165.36 $1,483.17 $1,489.8561 $1,004.74 $1,034.08 $1,053.75 $1,062.80 $1,206.59 $1,535.64 $1,542.5562 $1,027.27 $1,057.26 $1,077.38 $1,086.63 $1,233.64 $1,570.07 $1,577.1363 $1,055.52 $1,086.34 $1,107.00 $1,116.51 $1,267.56 $1,613.24 $1,620.50

64+ $1,072.68 $1,104.00 $1,125.00 $1,134.66 $1,288.17 $1,639.47 $1,646.85

HMO PLANS





Region 10

Region 10 includes the counties of: San Joaquin, Stanislaus, Merced, Mariposa, and Tulare


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $151.76 $148.14 $155.65 $151.62 $173.11 $184.5421 $238.99 $233.29 $245.12 $238.77 $272.62 $290.6122 $238.99 $233.29 $245.12 $238.77 $272.62 $290.6123 $238.99 $233.29 $245.12 $238.77 $272.62 $290.6124 $238.99 $233.29 $245.12 $238.77 $272.62 $290.6125 $239.95 $234.22 $246.10 $239.73 $273.71 $291.7726 $244.73 $238.89 $251.00 $244.50 $279.16 $297.5827 $250.46 $244.49 $256.89 $250.23 $285.71 $304.5628 $259.78 $253.59 $266.45 $259.54 $296.34 $315.8929 $267.43 $261.05 $274.29 $267.18 $305.06 $325.1930 $271.25 $264.78 $278.21 $271.00 $309.42 $329.8431 $276.99 $270.38 $284.09 $276.73 $315.97 $336.8232 $282.73 $275.98 $289.98 $282.46 $322.51 $343.7933 $286.31 $279.48 $293.65 $286.05 $326.60 $348.1534 $290.13 $283.21 $297.58 $289.87 $330.96 $352.8035 $292.05 $285.08 $299.54 $291.78 $333.14 $355.1336 $293.96 $286.95 $301.50 $293.69 $335.32 $357.4537 $295.87 $288.81 $303.46 $295.60 $337.50 $359.7838 $297.78 $290.68 $305.42 $297.51 $339.68 $362.1039 $301.61 $294.41 $309.34 $301.33 $344.05 $366.7540 $305.43 $298.14 $313.26 $305.15 $348.41 $371.4041 $311.16 $303.74 $319.15 $310.88 $354.95 $378.3742 $316.66 $309.11 $324.78 $316.37 $361.22 $385.0643 $324.31 $316.57 $332.63 $324.01 $369.95 $394.3644 $333.87 $325.91 $342.43 $333.56 $380.85 $405.9845 $345.10 $336.87 $353.95 $344.78 $393.66 $419.6446 $358.49 $349.94 $367.68 $358.16 $408.93 $435.9247 $373.54 $364.63 $383.12 $373.20 $426.11 $454.2248 $390.75 $381.43 $400.77 $390.39 $445.73 $475.1549 $407.72 $397.99 $418.17 $407.34 $465.09 $495.7850 $426.84 $416.66 $437.78 $426.44 $486.90 $519.0351 $445.72 $435.09 $457.15 $445.31 $508.44 $541.9952 $466.51 $455.38 $478.47 $466.08 $532.15 $567.2753 $487.54 $475.91 $500.04 $487.09 $556.14 $592.8454 $510.24 $498.07 $523.33 $509.77 $582.04 $620.4555 $532.95 $520.24 $546.62 $532.46 $607.94 $648.0656 $557.56 $544.27 $571.86 $557.05 $636.02 $677.9957 $582.42 $568.53 $597.36 $581.88 $664.37 $708.2258 $608.95 $594.42 $624.57 $608.39 $694.64 $740.4759 $622.09 $607.25 $638.05 $621.52 $709.63 $756.4660 $648.62 $633.15 $665.26 $648.02 $739.89 $788.7261 $671.56 $655.54 $688.79 $670.94 $766.06 $816.6162 $686.62 $670.24 $704.23 $685.99 $783.24 $834.9263 $705.50 $688.67 $723.59 $704.85 $804.77 $857.88

64+ $716.97 $699.87 $735.36 $716.31 $817.86 $871.83

SILVER PPO PLANS




date



Region 11

Region 11 includes the counties of: Madera, Fresno, and Kings.

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $203.31 $209.25 $213.22 $215.05 $244.13 $252.22 $253.3521 $320.17 $329.52 $335.78 $338.66 $384.46 $397.19 $398.9822 $320.17 $329.52 $335.78 $338.66 $384.46 $397.19 $398.9823 $320.17 $329.52 $335.78 $338.66 $384.46 $397.19 $398.9824 $320.17 $329.52 $335.78 $338.66 $384.46 $397.19 $398.9825 $321.45 $330.84 $337.12 $340.01 $386.00 $398.78 $400.5826 $327.85 $337.43 $343.84 $346.79 $393.69 $406.72 $408.5627 $335.54 $345.34 $351.90 $354.92 $402.91 $416.26 $418.1328 $348.02 $358.19 $364.99 $368.12 $417.91 $431.75 $433.6929 $358.27 $368.73 $375.74 $378.96 $430.21 $444.46 $446.4630 $363.39 $374.01 $381.11 $384.38 $436.36 $450.81 $452.8431 $371.08 $381.91 $389.17 $392.51 $445.59 $460.34 $462.4232 $378.76 $389.82 $397.23 $400.63 $454.82 $469.88 $471.9933 $383.56 $394.76 $402.26 $405.71 $460.58 $475.83 $477.9834 $388.69 $400.04 $407.64 $411.13 $466.73 $482.19 $484.3635 $391.25 $402.67 $410.32 $413.84 $469.81 $485.37 $487.5536 $393.81 $405.31 $413.01 $416.55 $472.89 $488.54 $490.7537 $396.37 $407.95 $415.70 $419.26 $475.96 $491.72 $493.9438 $398.93 $410.58 $418.38 $421.97 $479.04 $494.90 $497.1339 $404.05 $415.85 $423.75 $427.39 $485.19 $501.25 $503.5140 $409.18 $421.13 $429.13 $432.81 $491.34 $507.61 $509.9041 $416.86 $429.04 $437.19 $440.94 $500.57 $517.14 $519.4742 $424.23 $436.61 $444.91 $448.72 $509.41 $526.28 $528.6543 $434.47 $447.16 $455.65 $459.56 $521.71 $538.99 $541.4244 $447.28 $460.34 $469.08 $473.11 $537.09 $554.87 $557.3845 $462.33 $475.83 $484.87 $489.03 $555.16 $573.54 $576.1346 $480.26 $494.28 $503.67 $507.99 $576.69 $595.79 $598.4747 $500.43 $515.04 $524.82 $529.33 $600.91 $620.81 $623.6148 $523.48 $538.77 $549.00 $553.71 $628.59 $649.41 $652.3349 $546.21 $562.16 $572.84 $577.75 $655.89 $677.61 $680.6650 $571.82 $588.52 $599.70 $604.85 $686.65 $709.38 $712.5851 $597.12 $614.55 $626.23 $631.60 $717.02 $740.76 $744.1052 $624.97 $643.22 $655.44 $661.06 $750.47 $775.31 $778.8153 $653.15 $672.22 $684.99 $690.87 $784.30 $810.27 $813.9254 $683.56 $703.53 $716.89 $723.04 $820.82 $848.00 $851.8255 $713.98 $734.83 $748.79 $755.21 $857.35 $885.73 $889.7356 $746.96 $768.77 $783.37 $790.09 $896.95 $926.64 $930.8257 $780.25 $803.04 $818.30 $825.31 $936.93 $967.95 $972.3158 $815.79 $839.62 $855.57 $862.91 $979.60 $1,012.04 $1,016.6059 $833.40 $857.74 $874.04 $881.53 $1,000.75 $1,033.89 $1,038.5460 $868.94 $894.32 $911.31 $919.12 $1,043.42 $1,077.97 $1,082.8361 $899.68 $925.95 $943.54 $951.63 $1,080.33 $1,116.10 $1,121.1362 $919.85 $946.71 $964.70 $972.97 $1,104.55 $1,141.13 $1,146.2763 $945.14 $972.74 $991.22 $999.72 $1,134.93 $1,172.50 $1,177.79

64+ $960.51 $988.56 $1,007.34 $1,015.98 $1,153.38 $1,191.57 $1,196.94

HMO PLANS





Region 11

Region 11 includes the counties of: Madera, Fresno, and Kings.


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $179.76 $175.49 $184.38 $179.60 $205.05 $218.5921 $283.09 $276.37 $290.37 $282.83 $322.92 $344.2322 $283.09 $276.37 $290.37 $282.83 $322.92 $344.2323 $283.09 $276.37 $290.37 $282.83 $322.92 $344.2324 $283.09 $276.37 $290.37 $282.83 $322.92 $344.2325 $284.22 $277.48 $291.53 $283.96 $324.21 $345.6126 $289.88 $283.00 $297.34 $289.62 $330.67 $352.4927 $296.68 $289.64 $304.31 $296.41 $338.42 $360.7528 $307.72 $300.41 $315.63 $307.44 $351.01 $374.1829 $316.78 $309.26 $324.92 $316.49 $361.35 $385.1930 $321.31 $313.68 $329.57 $321.01 $366.51 $390.7031 $328.10 $320.31 $336.54 $327.80 $374.26 $398.9632 $334.90 $326.95 $343.51 $334.59 $382.01 $407.2233 $339.14 $331.09 $347.86 $338.83 $386.86 $412.3934 $343.67 $335.51 $352.51 $343.36 $392.02 $417.9035 $345.94 $337.72 $354.83 $345.62 $394.61 $420.6536 $348.20 $339.94 $357.16 $347.88 $397.19 $423.4037 $350.47 $342.15 $359.48 $350.14 $399.77 $426.1638 $352.73 $344.36 $361.80 $352.41 $402.36 $428.9139 $357.26 $348.78 $366.45 $356.93 $407.53 $434.4240 $361.79 $353.20 $371.09 $361.46 $412.69 $439.9341 $368.58 $359.83 $378.06 $368.24 $420.44 $448.1942 $375.09 $366.19 $384.74 $374.75 $427.87 $456.1043 $384.15 $375.03 $394.03 $383.80 $438.20 $467.1244 $395.48 $386.09 $405.65 $395.11 $451.12 $480.8945 $408.78 $399.08 $419.29 $408.41 $466.30 $497.0746 $424.64 $414.56 $435.56 $424.25 $484.38 $516.3547 $442.47 $431.97 $453.85 $442.06 $504.72 $538.0348 $462.85 $451.86 $474.75 $462.43 $527.97 $562.8249 $482.95 $471.49 $495.37 $482.51 $550.90 $587.2650 $505.60 $493.60 $518.60 $505.13 $576.74 $614.7951 $527.96 $515.43 $541.54 $527.48 $602.25 $641.9952 $552.59 $539.47 $566.80 $552.08 $630.34 $671.9453 $577.50 $563.79 $592.35 $576.97 $658.76 $702.2354 $604.40 $590.05 $619.94 $603.84 $689.43 $734.9355 $631.29 $616.31 $647.53 $630.71 $720.11 $767.6356 $660.45 $644.77 $677.43 $659.84 $753.37 $803.0957 $689.89 $673.51 $707.63 $689.26 $786.96 $838.8958 $721.31 $704.19 $739.86 $720.65 $822.80 $877.1059 $736.88 $719.39 $755.83 $736.21 $840.56 $896.0360 $768.31 $750.07 $788.06 $767.60 $876.40 $934.2461 $795.48 $776.60 $815.94 $794.75 $907.41 $967.2962 $813.32 $794.01 $834.23 $812.57 $927.75 $988.9763 $835.68 $815.84 $857.17 $834.91 $953.26 $1,016.17

64+ $849.27 $829.11 $871.11 $848.49 $968.76 $1,032.69

SILVER PPO PLANS




date



Region 12

Region 12 includes the counties of: San Luis Obispo, Santa Barbara, and Ventura

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $240.82 $247.87 $252.58 $254.73 $289.20 $299.49 $300.8221 $379.25 $390.35 $397.77 $401.15 $455.43 $471.63 $473.7322 $379.25 $390.35 $397.77 $401.15 $455.43 $471.63 $473.7323 $379.25 $390.35 $397.77 $401.15 $455.43 $471.63 $473.7324 $379.25 $390.35 $397.77 $401.15 $455.43 $471.63 $473.7325 $380.77 $391.91 $399.36 $402.75 $457.25 $473.52 $475.6226 $388.35 $399.72 $407.32 $410.78 $466.36 $482.95 $485.1027 $397.45 $409.09 $416.86 $420.41 $477.29 $494.27 $496.4728 $412.24 $424.31 $432.38 $436.05 $495.05 $512.66 $514.9429 $424.38 $436.80 $445.10 $448.89 $509.63 $527.75 $530.1030 $430.45 $443.05 $451.47 $455.31 $516.91 $535.30 $537.6831 $439.55 $452.42 $461.02 $464.93 $527.84 $546.62 $549.0532 $448.65 $461.78 $470.56 $474.56 $538.77 $557.94 $560.4233 $454.34 $467.64 $476.53 $480.58 $545.61 $565.01 $567.5334 $460.41 $473.88 $482.89 $487.00 $552.89 $572.56 $575.1135 $463.44 $477.01 $486.07 $490.21 $556.54 $576.33 $578.9036 $466.48 $480.13 $489.26 $493.41 $560.18 $580.10 $582.6937 $469.51 $483.25 $492.44 $496.62 $563.82 $583.88 $586.4838 $472.55 $486.38 $495.62 $499.83 $567.47 $587.65 $590.2739 $478.61 $492.62 $501.99 $506.25 $574.75 $595.20 $597.8540 $484.68 $498.87 $508.35 $512.67 $582.04 $602.74 $605.4341 $493.78 $508.24 $517.90 $522.30 $592.97 $614.06 $616.8042 $502.51 $517.21 $527.05 $531.52 $603.44 $624.91 $627.6943 $514.64 $529.70 $539.77 $544.36 $618.02 $640.00 $642.8544 $529.81 $545.32 $555.68 $560.41 $636.24 $658.87 $661.8045 $547.64 $563.67 $574.38 $579.26 $657.64 $681.03 $684.0746 $568.88 $585.53 $596.66 $601.73 $683.15 $707.45 $710.6047 $592.77 $610.12 $621.71 $627.00 $711.84 $737.16 $740.4448 $620.07 $638.22 $650.35 $655.88 $744.63 $771.12 $774.5549 $647.00 $665.94 $678.60 $684.36 $776.96 $804.60 $808.1850 $677.34 $697.17 $710.42 $716.45 $813.40 $842.33 $846.0851 $707.30 $728.00 $741.84 $748.14 $849.38 $879.59 $883.5152 $740.30 $761.96 $776.45 $783.04 $889.00 $920.62 $924.7253 $773.67 $796.31 $811.45 $818.35 $929.08 $962.13 $966.4154 $809.70 $833.40 $849.24 $856.46 $972.34 $1,006.93 $1,011.4155 $845.73 $870.48 $887.03 $894.56 $1,015.61 $1,051.73 $1,056.4256 $884.79 $910.69 $928.00 $935.88 $1,062.52 $1,100.31 $1,105.2157 $924.23 $951.28 $969.37 $977.60 $1,109.88 $1,149.36 $1,154.4858 $966.33 $994.61 $1,013.52 $1,022.13 $1,160.44 $1,201.71 $1,207.0659 $987.19 $1,016.08 $1,035.40 $1,044.19 $1,185.48 $1,227.65 $1,233.1260 $1,029.28 $1,059.41 $1,079.55 $1,088.72 $1,236.04 $1,280.00 $1,285.7061 $1,065.69 $1,096.88 $1,117.73 $1,127.23 $1,279.76 $1,325.28 $1,331.1862 $1,089.59 $1,121.48 $1,142.79 $1,152.50 $1,308.45 $1,354.99 $1,361.0363 $1,119.55 $1,152.31 $1,174.22 $1,184.19 $1,344.43 $1,392.25 $1,398.45

64+ $1,137.75 $1,171.05 $1,193.31 $1,203.45 $1,366.29 $1,414.89 $1,421.19

HMO PLANS





Region 12

Region 12 includes the counties of: San Luis Obispo, Santa Barbara, and Ventura


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $180.95 $176.65 $185.60 $180.79 $206.43 $220.0521 $284.96 $278.19 $292.28 $284.71 $325.08 $346.5322 $284.96 $278.19 $292.28 $284.71 $325.08 $346.5323 $284.96 $278.19 $292.28 $284.71 $325.08 $346.5324 $284.96 $278.19 $292.28 $284.71 $325.08 $346.5325 $286.10 $279.30 $293.45 $285.85 $326.38 $347.9226 $291.80 $284.87 $299.29 $291.54 $332.88 $354.8527 $298.64 $291.54 $306.31 $298.38 $340.68 $363.1628 $309.75 $302.39 $317.71 $309.48 $353.36 $376.6829 $318.87 $311.29 $327.06 $318.59 $363.76 $387.7730 $323.43 $315.75 $331.74 $323.15 $368.97 $393.3131 $330.27 $322.42 $338.75 $329.98 $376.77 $401.6332 $337.11 $329.10 $345.77 $336.81 $384.57 $409.9433 $341.38 $333.27 $350.15 $341.08 $389.45 $415.1434 $345.94 $337.72 $354.83 $345.64 $394.65 $420.6935 $348.22 $339.95 $357.17 $347.92 $397.25 $423.4636 $350.50 $342.17 $359.50 $350.19 $399.85 $426.2337 $352.78 $344.40 $361.84 $352.47 $402.45 $429.0038 $355.06 $346.62 $364.18 $354.75 $405.05 $431.7839 $359.62 $351.08 $368.86 $359.30 $410.25 $437.3240 $364.18 $355.53 $373.53 $363.86 $415.45 $442.8741 $371.02 $362.20 $380.55 $370.69 $423.25 $451.1842 $377.57 $368.60 $387.27 $377.24 $430.73 $459.1543 $386.69 $377.50 $396.62 $386.35 $441.13 $470.2444 $398.09 $388.63 $408.32 $397.74 $454.14 $484.1045 $411.48 $401.71 $422.05 $411.12 $469.42 $500.3946 $427.44 $417.29 $438.42 $427.07 $487.62 $519.8047 $445.39 $434.81 $456.83 $445.00 $508.10 $541.6348 $465.91 $454.84 $477.88 $465.50 $531.51 $566.5849 $486.14 $474.59 $498.63 $485.72 $554.59 $591.1850 $508.94 $496.85 $522.01 $508.49 $580.59 $618.9051 $531.45 $518.82 $545.10 $530.98 $606.27 $646.2852 $556.24 $543.03 $570.53 $555.75 $634.56 $676.4353 $581.32 $567.51 $596.25 $580.81 $663.16 $706.9254 $608.39 $593.94 $624.02 $607.86 $694.05 $739.8455 $635.46 $620.36 $651.78 $634.90 $724.93 $772.7656 $664.81 $649.02 $681.89 $664.23 $758.41 $808.4557 $694.45 $677.95 $712.29 $693.84 $792.22 $844.4958 $726.08 $708.83 $744.73 $725.44 $828.30 $882.9659 $741.75 $724.13 $760.80 $741.10 $846.18 $902.0260 $773.38 $755.01 $793.25 $772.70 $882.27 $940.4861 $800.74 $781.71 $821.31 $800.04 $913.47 $973.7562 $818.69 $799.24 $839.72 $817.97 $933.95 $995.5863 $841.20 $821.22 $862.81 $840.46 $959.64 $1,022.96

64+ $854.88 $834.57 $876.84 $854.13 $975.24 $1,039.59

SILVER PPO PLANS




date



Region 13

Region 13 includes the counties of: Mono, Inyo, and Imperial

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $242.43 $249.52 $254.26 $256.42 $291.12 $269.81 $271.0221 $381.78 $392.94 $400.41 $403.81 $458.46 $424.90 $426.8022 $381.78 $392.94 $400.41 $403.81 $458.46 $424.90 $426.8023 $381.78 $392.94 $400.41 $403.81 $458.46 $424.90 $426.8024 $381.78 $392.94 $400.41 $403.81 $458.46 $424.90 $426.8025 $383.31 $394.51 $402.01 $405.43 $460.29 $426.60 $428.5126 $390.94 $402.37 $410.02 $413.50 $469.46 $435.10 $437.0427 $400.11 $411.80 $419.63 $423.19 $480.47 $445.30 $447.2928 $414.99 $427.13 $435.25 $438.94 $498.35 $461.87 $463.9329 $427.21 $439.70 $448.06 $451.86 $513.02 $475.46 $477.5930 $433.32 $445.99 $454.47 $458.32 $520.35 $482.26 $484.4231 $442.48 $455.42 $464.08 $468.02 $531.36 $492.46 $494.6632 $451.65 $464.85 $473.69 $477.71 $542.36 $502.66 $504.9033 $457.37 $470.74 $479.69 $483.76 $549.24 $509.03 $511.3134 $463.48 $477.03 $486.10 $490.23 $556.57 $515.83 $518.1435 $466.54 $480.17 $489.30 $493.46 $560.24 $519.23 $521.5536 $469.59 $483.32 $492.50 $496.69 $563.91 $522.63 $524.9637 $472.64 $486.46 $495.71 $499.92 $567.57 $526.03 $528.3838 $475.70 $489.60 $498.91 $503.15 $571.24 $529.43 $531.7939 $481.81 $495.89 $505.32 $509.61 $578.58 $536.22 $538.6240 $487.91 $502.18 $511.72 $516.07 $585.91 $543.02 $545.4541 $497.08 $511.61 $521.33 $525.76 $596.91 $553.22 $555.6942 $505.86 $520.65 $530.54 $535.05 $607.46 $562.99 $565.5143 $518.08 $533.22 $543.36 $547.97 $622.13 $576.59 $579.1744 $533.35 $548.94 $559.37 $564.12 $640.47 $593.59 $596.2445 $551.29 $567.41 $578.19 $583.10 $662.02 $613.56 $616.3046 $572.67 $589.41 $600.62 $605.72 $687.69 $637.35 $640.2047 $596.72 $614.17 $625.84 $631.16 $716.57 $664.12 $667.0948 $624.21 $642.46 $654.67 $660.23 $749.58 $694.71 $697.8249 $651.32 $670.36 $683.10 $688.90 $782.13 $724.88 $728.1250 $681.86 $701.79 $715.13 $721.20 $818.81 $758.87 $762.2651 $712.02 $732.83 $746.76 $753.11 $855.03 $792.44 $795.9852 $745.23 $767.02 $781.60 $788.24 $894.91 $829.40 $833.1153 $778.83 $801.60 $816.84 $823.77 $935.26 $866.80 $870.6754 $815.10 $838.93 $854.88 $862.13 $978.81 $907.16 $911.2255 $851.37 $876.26 $892.91 $900.50 $1,022.37 $947.53 $951.7656 $890.69 $916.73 $934.16 $942.09 $1,069.59 $991.29 $995.7257 $930.40 $957.59 $975.80 $984.08 $1,117.27 $1,035.48 $1,040.1158 $972.78 $1,001.21 $1,020.24 $1,028.91 $1,168.16 $1,082.65 $1,087.4959 $993.77 $1,022.82 $1,042.27 $1,051.12 $1,193.37 $1,106.01 $1,110.9660 $1,036.15 $1,066.44 $1,086.71 $1,095.94 $1,244.26 $1,153.18 $1,158.3461 $1,072.80 $1,104.16 $1,125.15 $1,134.71 $1,288.27 $1,193.97 $1,199.3162 $1,096.85 $1,128.92 $1,150.38 $1,160.15 $1,317.16 $1,220.74 $1,226.2063 $1,127.01 $1,159.96 $1,182.01 $1,192.05 $1,353.37 $1,254.30 $1,259.91

64+ $1,145.34 $1,178.82 $1,201.23 $1,211.43 $1,375.38 $1,274.70 $1,280.40

HMO PLANS





Region 13

Region 13 includes the counties of: Mono, Inyo, and Imperial


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $150.51 $146.94 $154.38 $150.37 $171.69 $183.0321 $237.03 $231.40 $243.12 $236.81 $270.38 $288.2422 $237.03 $231.40 $243.12 $236.81 $270.38 $288.2423 $237.03 $231.40 $243.12 $236.81 $270.38 $288.2424 $237.03 $231.40 $243.12 $236.81 $270.38 $288.2425 $237.98 $232.33 $244.09 $237.76 $271.46 $289.3926 $242.72 $236.95 $248.95 $242.49 $276.87 $295.1627 $248.41 $242.51 $254.79 $248.18 $283.36 $302.0828 $257.65 $251.53 $264.27 $257.41 $293.90 $313.3229 $265.24 $258.94 $272.05 $264.99 $302.56 $322.5430 $269.03 $262.64 $275.94 $268.78 $306.88 $327.1531 $274.72 $268.19 $281.78 $274.46 $313.37 $334.0732 $280.41 $273.75 $287.61 $280.15 $319.86 $340.9933 $283.96 $277.22 $291.26 $283.70 $323.92 $345.3134 $287.75 $280.92 $295.15 $287.49 $328.24 $349.9235 $289.65 $282.77 $297.09 $289.38 $330.40 $352.2336 $291.55 $284.62 $299.04 $291.28 $332.57 $354.5437 $293.44 $286.47 $300.98 $293.17 $334.73 $356.8438 $295.34 $288.32 $302.93 $295.07 $336.89 $359.1539 $299.13 $292.03 $306.82 $298.85 $341.22 $363.7640 $302.92 $295.73 $310.71 $302.64 $345.55 $368.3741 $308.61 $301.28 $316.54 $308.33 $352.03 $375.2942 $314.06 $306.61 $322.13 $313.77 $358.25 $381.9243 $321.65 $314.01 $329.91 $321.35 $366.91 $391.1444 $331.13 $323.27 $339.64 $330.82 $377.72 $402.6745 $342.27 $334.14 $351.07 $341.95 $390.43 $416.2246 $355.55 $347.10 $364.68 $355.22 $405.57 $432.3647 $370.48 $361.68 $380.00 $370.13 $422.60 $450.5248 $387.54 $378.34 $397.50 $387.18 $442.07 $471.2749 $404.37 $394.77 $414.76 $404.00 $461.27 $491.7450 $423.34 $413.28 $434.21 $422.94 $482.90 $514.8051 $442.06 $431.56 $453.42 $441.65 $504.26 $537.5752 $462.68 $451.69 $474.57 $462.25 $527.78 $562.6453 $483.54 $472.06 $495.96 $483.09 $551.58 $588.0154 $506.06 $494.04 $519.06 $505.59 $577.26 $615.3955 $528.58 $516.02 $542.16 $528.09 $602.95 $642.7856 $552.99 $539.86 $567.20 $552.48 $630.80 $672.4657 $577.64 $563.92 $592.48 $577.11 $658.92 $702.4458 $603.95 $589.61 $619.47 $603.39 $688.93 $734.4459 $616.99 $602.33 $632.84 $616.42 $703.80 $750.2960 $643.30 $628.02 $659.83 $642.70 $733.81 $782.2861 $666.05 $650.23 $683.17 $665.44 $759.77 $809.9562 $680.99 $664.81 $698.48 $680.36 $776.80 $828.1163 $699.71 $683.09 $717.69 $699.06 $798.16 $850.88

64+ $711.09 $694.20 $729.36 $710.43 $811.14 $864.72

SILVER PPO PLANS




date



Region 14

Region 14 includes the county of: Kern

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $201.66 $207.55 $211.49 $213.29 $242.16 $299.35 $300.7021 $317.57 $326.85 $333.06 $335.89 $381.35 $471.42 $473.5422 $317.57 $326.85 $333.06 $335.89 $381.35 $471.42 $473.5423 $317.57 $326.85 $333.06 $335.89 $381.35 $471.42 $473.5424 $317.57 $326.85 $333.06 $335.89 $381.35 $471.42 $473.5425 $318.84 $328.16 $334.39 $337.23 $382.88 $473.31 $475.4326 $325.19 $334.69 $341.05 $343.95 $390.50 $482.73 $484.9027 $332.81 $342.54 $349.05 $352.01 $399.65 $494.05 $496.2728 $345.20 $355.29 $362.04 $365.11 $414.53 $512.43 $514.7429 $355.36 $365.75 $372.69 $375.86 $426.73 $527.52 $529.8930 $360.44 $370.97 $378.02 $381.24 $432.83 $535.06 $537.4731 $368.06 $378.82 $386.02 $389.30 $441.98 $546.38 $548.8332 $375.69 $386.66 $394.01 $397.36 $451.14 $557.69 $560.2033 $380.45 $391.57 $399.01 $402.40 $456.86 $564.76 $567.3034 $385.53 $396.80 $404.33 $407.77 $462.96 $572.30 $574.8835 $388.07 $399.41 $407.00 $410.46 $466.01 $576.08 $578.6736 $390.61 $402.03 $409.66 $413.14 $469.06 $579.85 $582.4537 $393.15 $404.64 $412.33 $415.83 $472.11 $583.62 $586.2438 $395.69 $407.26 $414.99 $418.52 $475.16 $587.39 $590.0339 $400.77 $412.48 $420.32 $423.89 $481.26 $594.93 $597.6140 $405.85 $417.71 $425.65 $429.27 $487.37 $602.47 $605.1841 $413.48 $425.56 $433.64 $437.33 $496.52 $613.79 $616.5542 $420.78 $433.08 $441.30 $445.05 $505.29 $624.63 $627.4443 $430.94 $443.54 $451.96 $455.80 $517.49 $639.72 $642.5944 $443.65 $456.61 $465.28 $469.24 $532.75 $658.57 $661.5445 $458.57 $471.97 $480.94 $485.03 $550.67 $680.73 $683.7946 $476.36 $490.28 $499.59 $503.84 $572.03 $707.13 $710.3147 $496.36 $510.87 $520.57 $525.00 $596.05 $736.83 $740.1448 $519.23 $534.40 $544.55 $549.18 $623.51 $770.77 $774.2449 $541.77 $557.61 $568.20 $573.03 $650.58 $804.24 $807.8650 $567.18 $583.75 $594.85 $599.90 $681.09 $841.96 $845.7451 $592.27 $609.58 $621.16 $626.43 $711.22 $879.20 $883.1552 $619.90 $638.01 $650.13 $655.66 $744.40 $920.21 $924.3553 $647.84 $666.77 $679.44 $685.22 $777.95 $961.70 $966.0254 $678.01 $697.82 $711.08 $717.13 $814.18 $1,006.48 $1,011.0155 $708.18 $728.88 $742.72 $749.03 $850.41 $1,051.27 $1,055.9956 $740.89 $762.54 $777.03 $783.63 $889.69 $1,099.82 $1,104.7757 $773.92 $796.53 $811.67 $818.56 $929.35 $1,148.85 $1,154.0258 $809.17 $832.81 $848.64 $855.85 $971.68 $1,201.18 $1,206.5859 $826.63 $850.79 $866.96 $874.32 $992.65 $1,227.11 $1,232.6260 $861.88 $887.07 $903.92 $911.61 $1,034.98 $1,279.43 $1,285.1961 $892.37 $918.45 $935.90 $943.85 $1,071.59 $1,324.69 $1,330.6562 $912.38 $939.04 $956.88 $965.01 $1,095.62 $1,354.39 $1,360.4863 $937.47 $964.86 $983.19 $991.55 $1,125.75 $1,391.63 $1,397.89

64+ $952.71 $980.55 $999.18 $1,007.67 $1,144.05 $1,414.26 $1,420.62

HMO PLANS





Region 14

Region 14 includes the county of: Kern


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $148.54 $145.02 $152.34 $148.41 $169.44 $180.6321 $233.92 $228.38 $239.91 $233.71 $266.83 $284.4622 $233.92 $228.38 $239.91 $233.71 $266.83 $284.4623 $233.92 $228.38 $239.91 $233.71 $266.83 $284.4624 $233.92 $228.38 $239.91 $233.71 $266.83 $284.4625 $234.86 $229.29 $240.87 $234.64 $267.90 $285.6026 $239.53 $233.86 $245.67 $239.32 $273.23 $291.2927 $245.15 $239.34 $251.43 $244.93 $279.64 $298.1128 $254.27 $248.25 $260.78 $254.04 $290.04 $309.2129 $261.76 $255.56 $268.46 $261.52 $298.58 $318.3130 $265.50 $259.21 $272.30 $265.26 $302.85 $322.8631 $271.11 $264.69 $278.06 $270.87 $309.26 $329.6932 $276.73 $270.17 $283.81 $276.48 $315.66 $336.5233 $280.24 $273.60 $287.41 $279.98 $319.66 $340.7834 $283.98 $277.25 $291.25 $283.72 $323.93 $345.3335 $285.85 $279.08 $293.17 $285.59 $326.07 $347.6136 $287.72 $280.91 $295.09 $287.46 $328.20 $349.8937 $289.59 $282.73 $297.01 $289.33 $330.34 $352.1638 $291.46 $284.56 $298.93 $291.20 $332.47 $354.4439 $295.21 $288.22 $302.77 $294.94 $336.74 $358.9940 $298.95 $291.87 $306.60 $298.68 $341.01 $363.5441 $304.56 $297.35 $312.36 $304.29 $347.41 $370.3742 $309.94 $302.60 $317.88 $309.67 $353.55 $376.9143 $317.43 $309.91 $325.56 $317.14 $362.09 $386.0144 $326.79 $319.05 $335.15 $326.49 $372.76 $397.3945 $337.78 $329.78 $346.43 $337.48 $385.30 $410.7646 $350.88 $342.57 $359.87 $350.57 $400.25 $426.6947 $365.62 $356.96 $374.98 $365.29 $417.06 $444.6148 $382.46 $373.40 $392.25 $382.12 $436.27 $465.0949 $399.07 $389.62 $409.29 $398.71 $455.21 $485.2950 $417.78 $407.89 $428.48 $417.41 $476.56 $508.0551 $436.26 $425.93 $447.43 $435.87 $497.64 $530.5252 $456.61 $445.80 $468.30 $456.20 $520.85 $555.2753 $477.20 $465.90 $489.42 $476.77 $544.33 $580.3054 $499.42 $487.59 $512.21 $498.97 $569.68 $607.3255 $521.64 $509.29 $535.00 $521.17 $595.03 $634.3556 $545.74 $532.81 $559.71 $545.25 $622.51 $663.6557 $570.06 $556.56 $584.66 $569.55 $650.26 $693.2358 $596.03 $581.91 $611.29 $595.49 $679.88 $724.8059 $608.89 $594.47 $624.49 $608.35 $694.56 $740.4560 $634.86 $619.82 $651.12 $634.29 $724.18 $772.0261 $657.32 $641.75 $674.15 $656.73 $749.79 $799.3362 $672.05 $656.14 $689.26 $671.45 $766.60 $817.2563 $690.53 $674.18 $708.21 $689.91 $787.68 $839.73

64+ $701.76 $685.14 $719.73 $701.13 $800.49 $853.38

SILVER PPO PLANS




date



Region 15

Region 15 includes: The zip codes in Los Angeles County starting with 906 to 912, inclusive, 915, 917, 918, and 935.

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $199.01 $204.83 $208.72 $210.49 $238.97 $212.50 $213.4621 $313.40 $322.56 $328.69 $331.48 $376.33 $334.65 $336.1622 $313.40 $322.56 $328.69 $331.48 $376.33 $334.65 $336.1623 $313.40 $322.56 $328.69 $331.48 $376.33 $334.65 $336.1624 $313.40 $322.56 $328.69 $331.48 $376.33 $334.65 $336.1625 $314.65 $323.85 $330.00 $332.81 $377.84 $335.99 $337.5026 $320.92 $330.30 $336.58 $339.44 $385.36 $342.68 $344.2327 $328.44 $338.04 $344.47 $347.39 $394.39 $350.71 $352.3028 $340.67 $350.62 $357.29 $360.32 $409.07 $363.76 $365.4129 $350.69 $360.94 $367.80 $370.93 $421.11 $374.47 $376.1630 $355.71 $366.11 $373.06 $376.23 $427.13 $379.83 $381.5431 $363.23 $373.85 $380.95 $384.19 $436.17 $387.86 $389.6132 $370.75 $381.59 $388.84 $392.14 $445.20 $395.89 $397.6833 $375.45 $386.43 $393.77 $397.11 $450.84 $400.91 $402.7234 $380.47 $391.59 $399.03 $402.42 $456.86 $406.27 $408.1035 $382.97 $394.17 $401.66 $405.07 $459.88 $408.94 $410.7936 $385.48 $396.75 $404.29 $407.72 $462.89 $411.62 $413.4837 $387.99 $399.33 $406.92 $410.37 $465.90 $414.30 $416.1738 $390.50 $401.91 $409.55 $413.02 $468.91 $416.97 $418.8639 $395.51 $407.07 $414.81 $418.33 $474.93 $422.33 $424.2340 $400.53 $412.23 $420.07 $423.63 $480.95 $427.68 $429.6141 $408.05 $419.97 $427.95 $431.59 $489.98 $435.71 $437.6842 $415.26 $427.39 $435.51 $439.21 $498.64 $443.41 $445.4143 $425.28 $437.71 $446.03 $449.82 $510.68 $454.12 $456.1744 $437.82 $450.62 $459.18 $463.08 $525.73 $467.51 $469.6245 $452.55 $465.78 $474.63 $478.66 $543.42 $483.23 $485.4246 $470.10 $483.84 $493.04 $497.22 $564.50 $501.98 $504.2447 $489.84 $504.16 $513.74 $518.10 $588.20 $523.06 $525.4248 $512.41 $527.39 $537.41 $541.97 $615.30 $547.15 $549.6249 $534.66 $550.29 $560.75 $565.50 $642.02 $570.91 $573.4950 $559.73 $576.09 $587.04 $592.02 $672.13 $597.68 $600.3851 $584.49 $601.57 $613.01 $618.21 $701.86 $624.12 $626.9452 $611.76 $629.64 $641.60 $647.05 $734.60 $653.24 $656.1853 $639.34 $658.02 $670.53 $676.22 $767.71 $682.69 $685.7754 $669.11 $688.67 $701.75 $707.71 $803.46 $714.48 $717.7055 $698.88 $719.31 $732.98 $739.20 $839.22 $746.27 $749.6456 $731.16 $752.53 $766.83 $773.34 $877.98 $780.74 $784.2657 $763.76 $786.08 $801.02 $807.82 $917.12 $815.54 $819.2258 $798.54 $821.88 $837.50 $844.61 $958.89 $852.69 $856.5459 $815.78 $839.62 $855.58 $862.84 $979.59 $871.09 $875.0260 $850.57 $875.43 $892.06 $899.64 $1,021.36 $908.24 $912.3461 $880.65 $906.39 $923.62 $931.46 $1,057.49 $940.37 $944.6162 $900.40 $926.71 $944.33 $952.34 $1,081.20 $961.45 $965.7963 $925.16 $952.20 $970.29 $978.53 $1,110.93 $987.89 $992.34

64+ $940.20 $967.68 $986.07 $994.44 $1,128.99 $1,003.95 $1,008.48

HMO PLANS





Region 15

Region 15 includes: The zip codes in Los Angeles County starting with 906 to 912, inclusive, 915, 917, 918, and 935.


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $181.63 $177.31 $186.28 $181.46 $207.17 $220.8521 $286.03 $279.23 $293.35 $285.77 $326.25 $347.8022 $286.03 $279.23 $293.35 $285.77 $326.25 $347.8023 $286.03 $279.23 $293.35 $285.77 $326.25 $347.8024 $286.03 $279.23 $293.35 $285.77 $326.25 $347.8025 $287.17 $280.35 $294.52 $286.91 $327.56 $349.1926 $292.89 $285.93 $300.39 $292.63 $334.08 $356.1527 $299.76 $292.63 $307.43 $299.49 $341.91 $364.4928 $310.91 $303.52 $318.87 $310.63 $354.63 $378.0629 $320.07 $312.46 $328.26 $319.78 $365.07 $389.1930 $324.64 $316.93 $332.95 $324.35 $370.29 $394.7531 $331.51 $323.63 $339.99 $331.21 $378.12 $403.1032 $338.37 $330.33 $347.03 $338.07 $385.95 $411.4533 $342.66 $334.52 $351.43 $342.35 $390.85 $416.6634 $347.24 $338.99 $356.13 $346.92 $396.07 $422.2335 $349.53 $341.22 $358.47 $349.21 $398.68 $425.0136 $351.82 $343.45 $360.82 $351.50 $401.29 $427.7937 $354.11 $345.69 $363.17 $353.78 $403.90 $430.5838 $356.39 $347.92 $365.51 $356.07 $406.51 $433.3639 $360.97 $352.39 $370.21 $360.64 $411.73 $438.9240 $365.55 $356.86 $374.90 $365.21 $416.95 $444.4941 $372.41 $363.56 $381.94 $372.07 $424.78 $452.8442 $378.99 $369.98 $388.69 $378.65 $432.28 $460.8443 $388.14 $378.92 $398.08 $387.79 $442.72 $471.9644 $399.58 $390.08 $409.81 $399.22 $455.77 $485.8845 $413.03 $403.21 $423.60 $412.65 $471.11 $502.2246 $429.05 $418.85 $440.03 $428.66 $489.38 $521.7047 $447.06 $436.44 $458.51 $446.66 $509.93 $543.6148 $467.66 $456.54 $479.63 $467.23 $533.42 $568.6549 $487.97 $476.37 $500.46 $487.52 $556.58 $593.3550 $510.85 $498.70 $523.92 $510.39 $582.68 $621.1751 $533.45 $520.76 $547.10 $532.96 $608.46 $648.6552 $558.33 $545.06 $572.62 $557.82 $636.84 $678.9153 $583.50 $569.63 $598.43 $582.97 $665.55 $709.5154 $610.67 $596.16 $626.30 $610.12 $696.54 $742.5555 $637.85 $622.68 $654.17 $637.27 $727.54 $775.5956 $667.31 $651.44 $684.39 $666.70 $761.14 $811.4257 $697.06 $680.48 $714.89 $696.42 $795.07 $847.5958 $728.80 $711.48 $747.46 $728.14 $831.29 $886.1959 $744.54 $726.84 $763.59 $743.86 $849.23 $905.3260 $776.29 $757.83 $796.15 $775.58 $885.44 $943.9361 $803.74 $784.64 $824.31 $803.01 $916.76 $977.3262 $821.76 $802.23 $842.79 $821.02 $937.32 $999.2363 $844.36 $824.29 $865.97 $843.59 $963.09 $1,026.71

64+ $858.09 $837.69 $880.05 $857.31 $978.75 $1,043.40

SILVER PPO PLANS




date



Region 16

Region 16 includes: The zip codes in Los Angeles County other than those identified in Region 15.

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $243.31 $250.42 $255.19 $257.37 $292.18 $220.76 $221.7721 $383.17 $394.37 $401.87 $405.31 $460.13 $347.65 $349.2422 $383.17 $394.37 $401.87 $405.31 $460.13 $347.65 $349.2423 $383.17 $394.37 $401.87 $405.31 $460.13 $347.65 $349.2424 $383.17 $394.37 $401.87 $405.31 $460.13 $347.65 $349.2425 $384.70 $395.95 $403.48 $406.93 $461.97 $349.04 $350.6426 $392.37 $403.83 $411.51 $415.04 $471.17 $355.99 $357.6227 $401.56 $413.30 $421.16 $424.76 $482.22 $364.34 $366.0028 $416.51 $428.68 $436.83 $440.57 $500.16 $377.90 $379.6229 $428.77 $441.30 $449.69 $453.54 $514.89 $389.02 $390.8030 $434.90 $447.61 $456.12 $460.03 $522.25 $394.58 $396.3931 $444.09 $457.07 $465.77 $469.75 $533.29 $402.93 $404.7732 $453.29 $466.54 $475.41 $479.48 $544.33 $411.27 $413.1533 $459.04 $472.46 $481.44 $485.56 $551.24 $416.48 $418.3934 $465.17 $478.77 $487.87 $492.05 $558.60 $422.05 $423.9835 $468.23 $481.92 $491.09 $495.29 $562.28 $424.83 $426.7736 $471.30 $485.08 $494.30 $498.53 $565.96 $427.61 $429.5737 $474.36 $488.23 $497.52 $501.77 $569.64 $430.39 $432.3638 $477.43 $491.39 $500.73 $505.02 $573.32 $433.17 $435.1539 $483.56 $497.69 $507.16 $511.50 $580.68 $438.73 $440.7440 $489.69 $504.00 $513.59 $517.99 $588.05 $444.30 $446.3341 $498.89 $513.47 $523.23 $527.71 $599.09 $452.64 $454.7142 $507.70 $522.54 $532.48 $537.04 $609.67 $460.64 $462.7443 $519.96 $535.16 $545.34 $550.01 $624.40 $471.76 $473.9244 $535.29 $550.93 $561.41 $566.22 $642.80 $485.67 $487.8945 $553.30 $569.47 $580.30 $585.27 $664.43 $502.01 $504.3046 $574.76 $591.56 $602.81 $607.97 $690.20 $521.48 $523.8647 $598.89 $616.40 $628.12 $633.50 $719.18 $543.38 $545.8648 $626.48 $644.79 $657.06 $662.68 $752.31 $568.41 $571.0149 $653.69 $672.80 $685.59 $691.46 $784.98 $593.09 $595.8050 $684.34 $704.34 $717.74 $723.88 $821.79 $620.90 $623.7451 $714.61 $735.50 $749.49 $755.90 $858.14 $648.37 $651.3352 $747.95 $769.81 $784.45 $791.17 $898.17 $678.61 $681.7253 $781.67 $804.51 $819.81 $826.83 $938.67 $709.21 $712.4554 $818.07 $841.98 $857.99 $865.34 $982.38 $742.23 $745.6355 $854.47 $879.45 $896.17 $903.84 $1,026.09 $775.26 $778.8156 $893.94 $920.07 $937.56 $945.59 $1,073.48 $811.07 $814.7857 $933.79 $961.08 $979.36 $987.74 $1,121.34 $847.22 $851.1058 $976.32 $1,004.85 $1,023.96 $1,032.73 $1,172.41 $885.81 $889.8659 $997.39 $1,026.55 $1,046.07 $1,055.02 $1,197.72 $904.93 $909.0760 $1,039.92 $1,070.32 $1,090.68 $1,100.01 $1,248.79 $943.52 $947.8461 $1,076.71 $1,108.18 $1,129.25 $1,138.92 $1,292.97 $976.90 $981.3662 $1,100.85 $1,133.03 $1,154.57 $1,164.46 $1,321.95 $998.80 $1,003.3763 $1,131.12 $1,164.18 $1,186.32 $1,196.48 $1,358.30 $1,026.26 $1,030.96

64+ $1,149.51 $1,183.11 $1,205.61 $1,215.93 $1,380.39 $1,042.95 $1,047.72

HMO PLANS





Region 16

Region 16 includes: The zip codes in Los Angeles County other than those identified in Region 15.


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $168.94 $164.93 $173.26 $168.79 $192.70 $205.4221 $266.05 $259.73 $272.85 $265.81 $303.46 $323.4922 $266.05 $259.73 $272.85 $265.81 $303.46 $323.4923 $266.05 $259.73 $272.85 $265.81 $303.46 $323.4924 $266.05 $259.73 $272.85 $265.81 $303.46 $323.4925 $267.11 $260.77 $273.94 $266.87 $304.67 $324.7826 $272.44 $265.96 $279.40 $272.19 $310.74 $331.2527 $278.82 $272.20 $285.95 $278.57 $318.03 $339.0228 $289.20 $282.33 $296.59 $288.94 $329.86 $351.6329 $297.71 $290.64 $305.32 $297.44 $339.57 $361.9930 $301.97 $294.79 $309.68 $301.69 $344.43 $367.1631 $308.35 $301.03 $316.23 $308.07 $351.71 $374.9232 $314.74 $307.26 $322.78 $314.45 $358.99 $382.6933 $318.73 $311.16 $326.87 $318.44 $363.55 $387.5434 $322.98 $315.31 $331.24 $322.69 $368.40 $392.7235 $325.11 $317.39 $333.42 $324.82 $370.83 $395.3036 $327.24 $319.47 $335.61 $326.95 $373.26 $397.8937 $329.37 $321.55 $337.79 $329.07 $375.68 $400.4838 $331.50 $323.62 $339.97 $331.20 $378.11 $403.0739 $335.76 $327.78 $344.34 $335.45 $382.97 $408.2440 $340.01 $331.93 $348.70 $339.71 $387.82 $413.4241 $346.40 $338.17 $355.25 $346.08 $395.10 $421.1842 $352.52 $344.14 $361.53 $352.20 $402.08 $428.6243 $361.03 $352.45 $370.26 $360.70 $411.80 $438.9844 $371.67 $362.84 $381.17 $371.34 $423.93 $451.9245 $384.18 $375.05 $394.00 $383.83 $438.20 $467.1246 $399.08 $389.60 $409.28 $398.72 $455.19 $485.2447 $415.84 $405.96 $426.46 $415.46 $474.31 $505.6148 $434.99 $424.66 $446.11 $434.60 $496.16 $528.9149 $453.88 $443.10 $465.48 $453.47 $517.70 $551.8750 $475.17 $463.88 $487.31 $474.74 $541.98 $577.7551 $496.18 $484.40 $508.87 $495.74 $565.95 $603.3152 $519.33 $506.99 $532.60 $518.86 $592.35 $631.4553 $542.74 $529.85 $556.61 $542.25 $619.06 $659.9254 $568.02 $554.52 $582.53 $567.50 $647.89 $690.6555 $593.29 $579.20 $608.46 $592.76 $676.72 $721.3856 $620.69 $605.95 $636.56 $620.13 $707.97 $754.7057 $648.36 $632.96 $664.94 $647.78 $739.53 $788.3558 $677.90 $661.79 $695.22 $677.28 $773.22 $824.2559 $692.53 $676.08 $710.23 $691.90 $789.91 $842.0460 $722.06 $704.91 $740.51 $721.41 $823.59 $877.9561 $747.60 $729.84 $766.71 $746.93 $852.72 $909.0162 $764.36 $746.20 $783.90 $763.67 $871.84 $929.3963 $785.38 $766.72 $805.45 $784.67 $895.81 $954.94

64+ $798.15 $779.19 $818.55 $797.43 $910.38 $970.47

SILVER PPO PLANS




date



Region 17

Region 17 includes the counties of: San Bernardino and Riverside

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $226.31 $232.95 $237.38 $239.38 $271.78 $224.07 $225.0921 $356.40 $366.85 $373.82 $376.98 $428.00 $352.87 $354.4822 $356.40 $366.85 $373.82 $376.98 $428.00 $352.87 $354.4823 $356.40 $366.85 $373.82 $376.98 $428.00 $352.87 $354.4824 $356.40 $366.85 $373.82 $376.98 $428.00 $352.87 $354.4825 $357.83 $368.32 $375.32 $378.49 $429.71 $354.28 $355.9026 $364.95 $375.65 $382.79 $386.03 $438.27 $361.34 $362.9927 $373.51 $384.46 $391.76 $395.08 $448.54 $369.81 $371.5028 $387.41 $398.77 $406.34 $409.78 $465.24 $383.57 $385.3229 $398.81 $410.51 $418.30 $421.84 $478.93 $394.86 $396.6630 $404.51 $416.37 $424.29 $427.87 $485.78 $400.51 $402.3331 $413.07 $425.18 $433.26 $436.92 $496.05 $408.98 $410.8432 $421.62 $433.98 $442.23 $445.97 $506.32 $417.45 $419.3533 $426.97 $439.49 $447.84 $451.62 $512.74 $422.74 $424.6734 $432.67 $445.36 $453.82 $457.65 $519.59 $428.38 $430.3435 $435.52 $448.29 $456.81 $460.67 $523.02 $431.21 $433.1736 $438.37 $451.23 $459.80 $463.69 $526.44 $434.03 $436.0137 $441.22 $454.16 $462.79 $466.70 $529.86 $436.85 $438.8538 $444.07 $457.10 $465.78 $469.72 $533.29 $439.68 $441.6839 $449.78 $462.96 $471.76 $475.75 $540.14 $445.32 $447.3540 $455.48 $468.83 $477.74 $481.78 $546.98 $450.97 $453.0341 $464.03 $477.64 $486.71 $490.83 $557.26 $459.44 $461.5342 $472.23 $486.08 $495.31 $499.50 $567.10 $467.55 $469.6943 $483.63 $497.82 $507.27 $511.56 $580.80 $478.84 $481.0344 $497.89 $512.49 $522.23 $526.64 $597.92 $492.96 $495.2145 $514.64 $529.73 $539.80 $544.36 $618.03 $509.54 $511.8746 $534.60 $550.28 $560.73 $565.47 $642.00 $529.31 $531.7247 $557.05 $573.39 $584.28 $589.22 $668.96 $551.54 $554.0548 $582.71 $599.80 $611.20 $616.36 $699.78 $576.94 $579.5749 $608.02 $625.85 $637.74 $643.13 $730.17 $602.00 $604.7450 $636.53 $655.19 $667.64 $673.29 $764.41 $630.23 $633.1051 $664.69 $684.18 $697.17 $703.07 $798.22 $658.10 $661.1152 $695.69 $716.09 $729.70 $735.86 $835.46 $688.80 $691.9453 $727.06 $748.37 $762.59 $769.04 $873.12 $719.85 $723.1454 $760.91 $783.22 $798.11 $804.85 $913.78 $753.38 $756.8155 $794.77 $818.08 $833.62 $840.67 $954.44 $786.90 $790.4956 $831.48 $855.86 $872.12 $879.49 $998.52 $823.25 $827.0057 $868.55 $894.01 $911.00 $918.70 $1,043.04 $859.94 $863.8758 $908.11 $934.73 $952.49 $960.55 $1,090.54 $899.11 $903.2259 $927.71 $954.91 $973.05 $981.28 $1,114.08 $918.52 $922.7160 $967.27 $995.63 $1,014.55 $1,023.12 $1,161.59 $957.69 $962.0661 $1,001.48 $1,030.85 $1,050.43 $1,059.31 $1,202.68 $991.56 $996.0962 $1,023.94 $1,053.96 $1,073.98 $1,083.06 $1,229.64 $1,013.80 $1,018.4263 $1,052.09 $1,082.94 $1,103.52 $1,112.84 $1,263.46 $1,041.67 $1,046.42

64+ $1,069.20 $1,100.55 $1,121.46 $1,130.94 $1,284.00 $1,058.61 $1,063.44

HMO PLANS





Region 17

Region 17 includes the counties of: San Bernardino and Riverside


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $177.14 $172.93 $181.69 $176.98 $202.07 $215.4121 $278.96 $272.33 $286.12 $278.71 $318.22 $339.2322 $278.96 $272.33 $286.12 $278.71 $318.22 $339.2323 $278.96 $272.33 $286.12 $278.71 $318.22 $339.2324 $278.96 $272.33 $286.12 $278.71 $318.22 $339.2325 $280.08 $273.42 $287.26 $279.82 $319.49 $340.5926 $285.66 $278.87 $292.99 $285.40 $325.86 $347.3727 $292.35 $285.40 $299.85 $292.09 $333.49 $355.5128 $303.23 $296.02 $311.01 $302.96 $345.91 $368.7429 $312.16 $304.74 $320.17 $311.88 $356.09 $379.6030 $316.62 $309.09 $324.75 $316.34 $361.18 $385.0331 $323.31 $315.63 $331.61 $323.02 $368.82 $393.1732 $330.01 $322.17 $338.48 $329.71 $376.45 $401.3133 $334.19 $326.25 $342.77 $333.89 $381.23 $406.4034 $338.66 $330.61 $347.35 $338.35 $386.32 $411.8335 $340.89 $332.79 $349.64 $340.58 $388.86 $414.5436 $343.12 $334.97 $351.93 $342.81 $391.41 $417.2537 $345.35 $337.14 $354.22 $345.04 $393.96 $419.9738 $347.58 $339.32 $356.51 $347.27 $396.50 $422.6839 $352.05 $343.68 $361.08 $351.73 $401.59 $428.1140 $356.51 $348.04 $365.66 $356.19 $406.69 $433.5441 $363.21 $354.57 $372.53 $362.88 $414.32 $441.6842 $369.62 $360.84 $379.11 $369.29 $421.64 $449.4843 $378.55 $369.55 $388.26 $378.21 $431.82 $460.3444 $389.71 $380.45 $399.71 $389.36 $444.55 $473.9045 $402.82 $393.24 $413.16 $402.46 $459.51 $489.8546 $418.44 $408.50 $429.18 $418.07 $477.33 $508.8547 $436.01 $425.65 $447.21 $435.62 $497.38 $530.2248 $456.10 $445.26 $467.81 $455.69 $520.29 $554.6449 $475.91 $464.59 $488.12 $475.48 $542.88 $578.7350 $498.22 $486.38 $511.01 $497.78 $568.34 $605.8651 $520.26 $507.90 $533.61 $519.79 $593.48 $632.6652 $544.53 $531.59 $558.51 $544.04 $621.17 $662.1853 $569.08 $555.55 $583.68 $568.57 $649.17 $692.0354 $595.58 $581.42 $610.87 $595.05 $679.40 $724.2655 $622.08 $607.30 $638.05 $621.52 $709.63 $756.4856 $650.81 $635.35 $667.52 $650.23 $742.41 $791.4257 $679.83 $663.67 $697.27 $679.22 $775.50 $826.7058 $710.79 $693.90 $729.03 $710.15 $810.82 $864.3659 $726.13 $708.87 $744.77 $725.48 $828.33 $883.0260 $757.10 $739.10 $776.53 $756.42 $863.65 $920.6761 $783.88 $765.25 $804.00 $783.18 $894.20 $953.2462 $801.45 $782.40 $822.02 $800.73 $914.25 $974.6163 $823.49 $803.92 $844.63 $822.75 $939.39 $1,001.41

64+ $836.88 $816.99 $858.36 $836.13 $954.66 $1,017.69



Region 18

SILVER PPO PLANS




date

Region 18 includes the county of: Orange

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $237.32 $244.25 $248.91 $251.03 $284.98 $218.83 $219.8221 $373.74 $384.65 $391.99 $395.32 $448.79 $344.62 $346.1722 $373.74 $384.65 $391.99 $395.32 $448.79 $344.62 $346.1723 $373.74 $384.65 $391.99 $395.32 $448.79 $344.62 $346.1724 $373.74 $384.65 $391.99 $395.32 $448.79 $344.62 $346.1725 $375.23 $386.19 $393.56 $396.90 $450.59 $346.00 $347.5526 $382.71 $393.88 $401.40 $404.81 $459.56 $352.89 $354.4827 $391.68 $403.11 $410.81 $414.30 $470.33 $361.16 $362.7928 $406.26 $418.11 $426.09 $429.71 $487.83 $374.60 $376.2929 $418.22 $430.42 $438.64 $442.36 $502.20 $385.63 $387.3630 $424.19 $436.58 $444.91 $448.69 $509.38 $391.14 $392.9031 $433.16 $445.81 $454.32 $458.18 $520.15 $399.41 $401.2132 $442.13 $455.04 $463.72 $467.66 $530.92 $407.69 $409.5233 $447.74 $460.81 $469.60 $473.59 $537.65 $412.85 $414.7134 $453.72 $466.97 $475.88 $479.92 $544.83 $418.37 $420.2535 $456.71 $470.04 $479.01 $483.08 $548.42 $421.13 $423.0236 $459.70 $473.12 $482.15 $486.24 $552.01 $423.88 $425.7937 $462.69 $476.20 $485.28 $489.41 $555.60 $426.64 $428.5638 $465.68 $479.27 $488.42 $492.57 $559.19 $429.40 $431.3339 $471.66 $485.43 $494.69 $498.89 $566.37 $434.91 $436.8740 $477.64 $491.58 $500.96 $505.22 $573.55 $440.42 $442.4141 $486.61 $500.81 $510.37 $514.71 $584.32 $448.70 $450.7142 $495.21 $509.66 $519.39 $523.80 $594.65 $456.62 $458.6843 $507.17 $521.97 $531.93 $536.45 $609.01 $467.65 $469.7544 $522.11 $537.36 $547.61 $552.26 $626.96 $481.43 $483.6045 $539.68 $555.43 $566.03 $570.84 $648.05 $497.63 $499.8746 $560.61 $576.98 $587.99 $592.98 $673.19 $516.93 $519.2647 $584.16 $601.21 $612.68 $617.89 $701.46 $538.64 $541.0648 $611.06 $628.90 $640.90 $646.35 $733.77 $563.45 $565.9949 $637.60 $656.21 $668.73 $674.42 $765.64 $587.92 $590.5750 $667.50 $686.98 $700.09 $706.04 $801.54 $615.49 $618.2651 $697.03 $717.37 $731.06 $737.27 $836.99 $642.72 $645.6152 $729.54 $750.84 $765.16 $771.66 $876.04 $672.70 $675.7253 $762.43 $784.69 $799.66 $806.45 $915.53 $703.02 $706.1954 $797.93 $821.23 $836.90 $844.01 $958.17 $735.76 $739.0755 $833.44 $857.77 $874.14 $881.56 $1,000.80 $768.50 $771.9656 $871.94 $897.39 $914.51 $922.28 $1,047.03 $804.00 $807.6157 $910.80 $937.39 $955.28 $963.39 $1,093.70 $839.84 $843.6258 $952.29 $980.09 $998.79 $1,007.28 $1,143.52 $878.09 $882.0459 $972.85 $1,001.24 $1,020.35 $1,029.02 $1,168.20 $897.05 $901.0860 $1,014.33 $1,043.94 $1,063.86 $1,072.90 $1,218.02 $935.30 $939.5161 $1,050.21 $1,080.87 $1,101.49 $1,110.85 $1,261.10 $968.38 $972.7462 $1,073.76 $1,105.10 $1,126.19 $1,135.75 $1,289.37 $990.09 $994.5563 $1,103.28 $1,135.49 $1,157.15 $1,166.98 $1,324.83 $1,017.32 $1,021.89

64+ $1,121.22 $1,153.95 $1,175.97 $1,185.96 $1,346.37 $1,033.86 $1,038.51

HMO PLANS





Region 18

Region 18 includes the county of: Orange


date

GOLD PPO PLANS

Bronze PPO 6000/0%/6000

HSA1ZK5

Bronze 4500/30%/6350

HSA1ZMR

Bronze PPO 5000/30%/6850

1KBD

Bronze PPO 6000/35%/6600

1ZJJ

Silver PPO 2000/20%/4600

HSA - RxC1ZG7

Silver PPO 2000/35%/6850

1ZM3

0-20 $192.65 $188.08 $197.61 $192.49 $219.77 $234.2821 $303.38 $296.19 $311.19 $303.13 $346.10 $368.9422 $303.38 $296.19 $311.19 $303.13 $346.10 $368.9423 $303.38 $296.19 $311.19 $303.13 $346.10 $368.9424 $303.38 $296.19 $311.19 $303.13 $346.10 $368.9425 $304.59 $297.37 $312.43 $304.34 $347.48 $370.4226 $310.66 $303.30 $318.66 $310.41 $354.41 $377.7927 $317.94 $310.41 $326.13 $317.68 $362.71 $386.6528 $329.77 $321.96 $338.26 $329.50 $376.21 $401.0429 $339.48 $331.44 $348.22 $339.20 $387.29 $412.8430 $344.34 $336.18 $353.20 $344.05 $392.82 $418.7531 $351.62 $343.28 $360.67 $351.33 $401.13 $427.6032 $358.90 $350.39 $368.14 $358.60 $409.44 $436.4633 $363.45 $354.84 $372.81 $363.15 $414.63 $441.9934 $368.30 $359.57 $377.78 $368.00 $420.17 $447.8935 $370.73 $361.94 $380.27 $370.42 $422.93 $450.8436 $373.16 $364.31 $382.76 $372.85 $425.70 $453.8037 $375.58 $366.68 $385.25 $375.27 $428.47 $456.7538 $378.01 $369.05 $387.74 $377.70 $431.24 $459.7039 $382.87 $373.79 $392.72 $382.55 $436.78 $465.6040 $387.72 $378.53 $397.70 $387.40 $442.32 $471.5141 $395.00 $385.64 $405.17 $394.68 $450.62 $480.3642 $401.98 $392.45 $412.33 $401.65 $458.58 $488.8543 $411.69 $401.93 $422.28 $411.35 $469.66 $500.6544 $423.82 $413.78 $434.73 $423.47 $483.50 $515.4145 $438.08 $427.70 $449.36 $437.72 $499.77 $532.7546 $455.07 $444.29 $466.79 $454.70 $519.15 $553.4147 $474.18 $462.94 $486.39 $473.79 $540.95 $576.6548 $496.03 $484.27 $508.80 $495.62 $565.87 $603.2249 $517.57 $505.30 $530.89 $517.14 $590.45 $629.4150 $541.84 $529.00 $555.79 $541.39 $618.13 $658.9351 $565.80 $552.39 $580.37 $565.34 $645.48 $688.0752 $592.20 $578.16 $607.44 $591.71 $675.59 $720.1753 $618.90 $604.23 $634.83 $618.39 $706.04 $752.6454 $647.72 $632.37 $664.39 $647.18 $738.92 $787.6955 $676.54 $660.50 $693.95 $675.98 $771.80 $822.7456 $707.79 $691.01 $726.01 $707.20 $807.45 $860.7457 $739.34 $721.82 $758.37 $738.73 $843.45 $899.1158 $773.01 $754.69 $792.91 $772.38 $881.86 $940.0659 $789.70 $770.98 $810.03 $789.05 $900.90 $960.3560 $823.37 $803.86 $844.57 $822.69 $939.32 $1,001.3061 $852.50 $832.29 $874.44 $851.80 $972.54 $1,036.7262 $871.61 $850.95 $894.05 $870.89 $994.35 $1,059.9663 $895.58 $874.35 $918.63 $894.84 $1,021.69 $1,089.11

64+ $910.14 $888.57 $933.57 $909.39 $1,038.30 $1,106.82

SILVER PPO PLANS




date



Region 19

Region 19 includes the county of: San Diego

BRONZE PPO PLANS

PLATINUM PPO PLANS

Gold PPO 2000/0%/2500

HSA- RxC1ZGF

Gold PPO 1000/20%/4000

1ZH9

Gold PPO 500/20%/4500

1ZHT

Gold PPO 20/30%/5500

1ZF9


1ZH1

Gold HMO 50/30%/6850

1ZHR

Gold HMO 500/20%/5000

1ZFD

0-20 $258.11 $265.66 $270.71 $273.01 $309.96 $286.71 $287.9921 $406.48 $418.37 $426.32 $429.94 $488.12 $451.51 $453.5322 $406.48 $418.37 $426.32 $429.94 $488.12 $451.51 $453.5323 $406.48 $418.37 $426.32 $429.94 $488.12 $451.51 $453.5324 $406.48 $418.37 $426.32 $429.94 $488.12 $451.51 $453.5325 $408.11 $420.04 $428.03 $431.66 $490.07 $453.32 $455.3426 $416.24 $428.41 $436.55 $440.26 $499.83 $462.35 $464.4127 $425.99 $438.45 $446.78 $450.58 $511.55 $473.18 $475.3028 $441.84 $454.77 $463.41 $467.34 $530.59 $490.79 $492.9929 $454.85 $468.16 $477.05 $481.10 $546.21 $505.24 $507.5030 $461.35 $474.85 $483.87 $487.98 $554.02 $512.46 $514.7631 $471.11 $484.89 $494.10 $498.30 $565.73 $523.30 $525.6432 $480.87 $494.93 $504.34 $508.62 $577.45 $534.14 $536.5333 $486.96 $501.21 $510.73 $515.07 $584.77 $540.91 $543.3334 $493.47 $507.90 $517.55 $521.95 $592.58 $548.13 $550.5935 $496.72 $511.25 $520.96 $525.39 $596.48 $551.75 $554.2136 $499.97 $514.60 $524.37 $528.83 $600.39 $555.36 $557.8437 $503.22 $517.94 $527.78 $532.27 $604.29 $558.97 $561.4738 $506.47 $521.29 $531.19 $535.71 $608.20 $562.58 $565.1039 $512.98 $527.98 $538.02 $542.58 $616.01 $569.81 $572.3540 $519.48 $534.68 $544.84 $549.46 $623.82 $577.03 $579.6141 $529.24 $544.72 $555.07 $559.78 $635.53 $587.87 $590.5042 $538.59 $554.34 $564.87 $569.67 $646.76 $598.25 $600.9343 $551.59 $567.73 $578.52 $583.43 $662.38 $612.70 $615.4444 $567.85 $584.46 $595.57 $600.63 $681.90 $630.76 $633.5845 $586.96 $604.13 $615.61 $620.83 $704.85 $651.98 $654.9046 $609.72 $627.56 $639.48 $644.91 $732.18 $677.27 $680.3047 $635.33 $653.91 $666.34 $672.00 $762.93 $705.71 $708.8748 $664.59 $684.03 $697.03 $702.95 $798.08 $738.22 $741.5249 $693.45 $713.74 $727.30 $733.48 $832.73 $770.28 $773.7250 $725.97 $747.21 $761.41 $767.87 $871.78 $806.40 $810.0051 $758.09 $780.26 $795.09 $801.84 $910.34 $842.07 $845.8352 $793.45 $816.66 $832.18 $839.24 $952.81 $881.35 $885.2953 $829.22 $853.47 $869.69 $877.08 $995.76 $921.08 $925.2054 $867.83 $893.22 $910.19 $917.92 $1,042.14 $963.97 $968.2955 $906.45 $932.97 $950.69 $958.77 $1,088.51 $1,006.87 $1,011.3756 $948.32 $976.06 $994.60 $1,003.05 $1,138.78 $1,053.37 $1,058.0957 $990.59 $1,019.57 $1,038.94 $1,047.76 $1,189.55 $1,100.33 $1,105.2558 $1,035.71 $1,066.01 $1,086.26 $1,095.49 $1,243.73 $1,150.45 $1,155.5959 $1,058.07 $1,089.02 $1,109.71 $1,119.13 $1,270.58 $1,175.28 $1,180.5460 $1,103.19 $1,135.46 $1,157.03 $1,166.86 $1,324.76 $1,225.40 $1,230.8861 $1,142.21 $1,175.62 $1,197.96 $1,208.13 $1,371.62 $1,268.74 $1,274.4262 $1,167.82 $1,201.98 $1,224.82 $1,235.22 $1,402.37 $1,297.19 $1,302.9963 $1,199.93 $1,235.03 $1,258.50 $1,269.18 $1,440.93 $1,332.86 $1,338.82

64+ $1,219.44 $1,255.11 $1,278.96 $1,289.82 $1,464.36 $1,354.53 $1,360.59

HMO PLANS





Region 19

Region 19 includes the county of: San Diego


date

GOLD PPO PLANS

Insurance Carrier DeltaCare USA Delta DentalPlan Name Plan 11B Fee For ServicePlan Type HMO DPOProvider Network DeltaCare USA Network ONLY PPO or Premier NetworkCalendar Year Maximum Unlimited $1,000Deductible: None Single $50/Family $ 150Waived for Preventive Not Applicable Yes

Diagnostic "Delta Pays" (A) Office Visit $20 copay $26.00 Periodic Oral Evaluation No Charge $17.00 Comprehensive Oral Evaluation No Charge $22.00 Bitewing X‐rays No Charge $12.00 ‐ $26.00 Other X‐rays No Charge $5.00 ‐ $50.00

Preventive "Delta Pays" (A) Cleanings Adult No Charge $40.00

Additional Cleanings: $45.00 Not Applicable Child through Age 13 No Charge $32.00

Additional Cleanings: $35.00 Not Applicable

"Delta Pays" (A) Restorative No Charge ‐ $240 copay $53.00 ‐ $148.00 Oral Surgery No Charge ‐ $110 copay $26.00 ‐ $175.00 Endodontics (Root Canals) No Charge ‐ $250 copay $50.00 ‐ $402.00 Periodontics (Deep Cleaning) $80 copay ‐ $280 copay $39.00 ‐ $448.00

"Delta Pays" (A) Waiting Period None None Crowns $55 copay ‐ $240 copay $343.00 ‐ $391.00 Prosthodontics, Removable $20 copay ‐ $210 copay $255.00 ‐ $676.00 Prosthodontics, Fixed $40 copay ‐ $240 copay $191.00 ‐ $605.00

Orthodontia

Pretreatment/Post Treatment $200 copay / $70 copay Limited Treatment Child to 19 $950 copay Limited Treatment 19 to Adult $1,150 copay Comprehensive Treatment Child to 19 $1,700 copay Comprehensive Treatment 19 to Adult $1,900 copay

Subscriber Only $38.80 $55.84Subscriber+1 $58.47 $98.45Subscriber+2 or more $82.42 $129.24

NOT COVERED

Monthly Premium Rate

(A) For each procedure, you are responsible for the portion of the dentist's fee that is more than the amount listed in the "Delta Dental Pays" column.

Delta Dental Plan Options through the AssociationsEffective Date: December 01, 2016 ‐ November 30, 2017


Vision BenefitsDeductible:

Exams

Material

Exam

Comprehensive Exam

Follow‐Up Exam

Lenses (per pair)

Frames

Contact Lenses

Cosmetic/Convenience

Medically Necessary

Subscriber Subscriber

&

Family

Monthly Rates $7.95 $20.10

Annual Rates $95.40 $241.20

Other Services:

Long Term Care Plans Life Insurance Options Prescription Drug PlansLong Term Disability Plans Medicare Supplements

No Charge

Up to $20

One comprehensive exam in any 24 consecutive months, with a follow‐up

exam at a 12 month interval.

No Charge

1 pair of standard lenses in any 24 consecutive months, or at a 12 month

interval if the prescription changes.

Up to $40

Application Requirements

Up to $105

Subscriber & (1) Child

OR

Up to $100

Subscriber & Spouse

Member/Employer group applications may be submitted at any time. Applications for new hires should

be enrolled within 30 days following the date of eligibility. Dependents must be enrolled during initial

enrollment period. If a member enrolls at any other time than December, the annual rate will be pro‐

rated.

Vision Plan through Associations Effective Date December 01, 2016 ‐ November 30, 2017

In‐Network

$15 deductible $15 deductible

Premium Rates

1 pair of standard lenses in any 24 consecutive months, or at a 12 month

interval if the prescription changes.

MEDICAL EYE SERVICES (MES)Out‐of‐Network

$179.40

Monthly rates available for groups with medical coverage upon request.

$10 deductible$10 deductible

Up to $40

1 standard frame in any 24 consecutive months.

Up to retail cost of $100

$14.95

No Charge Up to $250


NEED HELP FINDING A PROVIDER?


https://www.westernhealth.com/search-for-providers/?sp=home

ANTHEM BLUE CROSS

DELTA DENTAL

PREMIER ACCESS

MEDICAL EYE SERVICES

https://www.mesvision.com/homepage.htm

https://www.deltadentalins.com/find-a-

https://mydental.guardianlife.com/secure/PAWEBSITE.PROVIDER.UI/WBSPrvNewSearch.as

https://www.anthem.com/health-insurance/provider-directory/searchcriteria?qs=*dmobYvnDkpRF9B5i7bq78aM6zsOJDillMrp75xf57aA=&brand=abcbs


Member Benefits Program - sacrealtor.org · Gold 80 500/30 BENEFIT HMO Lifetime Maximum Unlimited...

Documents

Transcript of Member Benefits Program - sacrealtor.org · Gold 80 500/30 BENEFIT HMO Lifetime Maximum Unlimited...