LAPRA Retiree 2018-2019 Medical & Dental Premium Rates

2 Anthem Blue Cross PPO and CaliforniaCare HMO Premium Rates The tables on pages 1 and 2 reflect the retiree monthly premium rates under the Anthem Blue Cross PPO and CaliforniaCare HMO plans effective July 1, 2018. Your cost is the monthly premium rate minus the Pension Department subsidy, based on your retirement date, age and years of service. Anthem Blue Cross Monthly Premium Rates (07/01/18 - 06/30/19) Office Use Only Coverage Tier PPO HMO (CA Residents Only) 34a 3 Party: Member A&B; Spouse None; Deps None $2,200.44 $1,952.59 80 3 Party: Member A&B&D; Spouse None; Deps A&B&D $1,789.44 $1,686.59 80a 3 Party: Member A&B&D; Spouse None; Deps A&B $1,827.44 $1,715.59 35 3 Party: Member A&B&D; Spouse A&B&D; Deps None $1,789.44 $1,686.59 35a 3 Party: Member A&B&D; Spouse A&B; Deps None $1,827.44 $1,764.59 35b 3 Party: Member A&B; Spouse A&B&D; Deps None $1,827.44 $1,715.59 35c 3 Party: Member A&B; Spouse A&B; Deps None $1,865.44 $1,744.59 35d 3 Party: Member A&B&D; Spouse A&B&D; Deps A&B&D $1,416.44 $1,449.59 35e 3 Party: Member A&B&D; Spouse A&D; Deps None $1,939.44 $1,715.59 35f 3 Party: Member A&B&D; Spouse A; Deps None $1,977.44 $1,793.59 35g 3 Party: Member A&B; Spouse A&D; Deps None $1,977.44 $1,793.59 35h 3 Party: Member A&B&D; Spouse A&B; Deps A&B&D $1,454.44 $1,478.59 35i 3 Party: Member A&B&D; Spouse A&B&D; Deps A&B $1,454.44 $1,478.59 36 3 Party: Member None; Spouse A&B&D; Deps A&B&D $1,789.44 $1,686.59 36a 3 Party: Member None; Spouse A&B&D; Deps A&B $1,827.44 $1,715.59 36b 3 Party: Member None; Spouse A&B; Deps A&B&D $1,827.44 $1,715.59 36c 3 Party: Member None; Spouse A&B; Deps A&B $1,865.44 $1,744.59 37 Member A&D $747.75 $790.89 37a Member A Only $785.75 $819.89 38 Two Party: Both A&D $1,718.21 $1,526.61 38a Two Party: Member A&D; Spouse A Only $1,756.21 $1,555.61 38b Two Party: Member A Only; Spouse A&D $1,756.21 $1,555.61 38c Two Party: Both A Only $1,794.21 $1,584.61 38d Two Party: Member None; Spouse A Only $1,979.21 $1,714.61 38e Two Party: Member None; Spouse A&D $1,941.21 $1,685.61 38f Two Party: Member A Only; Spouse None $1,979.21 $1,714.61 38g Two Party: Member A&D; Spouse None $1,941.21 $1,685.61 39 3 Party: Member A&D; Spouse A&D; Deps A&D $1,866.44 $1,683.59 39a 3 Party: Member A&D; Spouse None; Deps None $2,312.44 $2,001.59 39b 3 Party: Member A Only; Spouse A Only; Deps None $2,165.44 $1,900.59 39c 3 Party: Member A&D; Spouse A Only; Deps None $2,127.44 $1,871.59 39d 3 Party: Member A Only; Spouse A&D; Deps None $2,127.44 $1,871.59 39e 3 Party: Member A&D; Spouse A&D; Deps None $2,089.44 $1,842.59 39f 3 Party: Member A Only; Spouse None; Deps A Only $2,165.44 $1,900.59 39g 3 Party: Member A&D; Spouse None; Deps A Only $2,127.44 $1,871.59 39h 3 Party: Member A Only; Spouse None; Deps A&D $2,127.44 $1,871.59 39i 3 Party: Member A&D; Spouse None; Deps A&D $2,089.44 $1,842.59 39j 3 Party: Member None; Spouse A Only; Deps None $2,350.44 $2,030.59 39k 3 Party: Member None; Spouse A&D; Deps None $2,312.44 $2,001.59 39l 3 Party: Member None; Spouse A Only; Deps A Only $2,165.44 $1,900.59 39m 3 Party: Member None; Spouse A&D; Deps A Only $2,127.44 $1,871.59 39n 3 Party: Member None; Spouse A Only; Deps A&D $2,127.44 $1,871.59 39o 3 Party: Member None; Spouse A&D; Deps A&D $2,089.44 $1,842.59 39p 3 Party: Member None; Spouse None; Deps A Only $2,350.44 $2,030.59 39q 3 Party: Member None; Spouse None; Deps A&D $2,312.44 $2,001.59 39r 3 Party: Member A Only; Spouse None; Deps None $2,350.44 $2,030.59 39s 3 Party: Member None; Spouse B/D; Deps None $2,347.44 $2,053.59