Your Costs

MEDICAL
CALCULATING YOUR COSTS: BLUE SHIELD - Find the rate for yourself and EACH dependent based on the age of each person ON THE EMPLOYEE'S INITIAL ENROLLMENT DATE. KAISER - Find the rate
for yourself and EACH dependent based on the age of each person AT THE BEGINNING OF THE PLAN YEAR.
Each covered person (employee, spouse, child) has a separate premium, including each child. However, there are no additional premiums charged if you have more than 3 children under the age
of 21.

Blue Shield - Platinum Access+ HMO® 0/25 Blue Shield - Platinum Full PPO 250/15 Blue Shield - Silver Full PPO Savings Kaiser - Platinum 90 HMO 0/15 + Child
OffEx (Broad Network) OffEx (Broad Network) 2000/20% OffEx (Broad Network) Dental (Broad Network)
Employee Cost Per Month Employee Cost Per Month Employee Cost Per Month Employee Cost Per Month
Age Employee Spouse Per Child Employee Spouse Per Child Employee Spouse Per Child Employee Spouse Per Child
0-14 $34.02 $85.06 $85.06 $40.13 $100.32 $100.32 $31.92 $79.80 $79.80 $32.89 $82.23 $82.23
15 $37.05 $92.62 $92.62 $43.69 $109.23 $109.23 $34.76 $86.90 $86.90 $35.69 $89.23 $89.23
16 $38.20 $95.51 $95.51 $45.06 $112.64 $112.64 $35.84 $89.61 $89.61 $36.76 $91.91 $91.91
17 $39.36 $98.40 $98.40 $46.42 $116.05 $116.05 $36.93 $92.32 $92.32 $37.83 $94.58 $94.58
18 $40.61 $101.52 $101.52 $47.89 $119.73 $119.73 $38.10 $95.24 $95.24 $38.99 $97.46 $97.46
19 $41.85 $104.63 $104.63 $49.36 $123.40 $123.40 $39.27 $98.16 $98.16 $38.74 $96.85 $96.85
20 $43.14 $107.85 $107.85 $50.88 $127.20 $127.20 $40.48 $101.19 $101.19 $39.93 $99.83 $99.83
21 $44.48 $111.19 $111.19 $52.45 $131.13 $131.13 $41.73 $104.32 $104.32 $41.17 $102.92 $102.92
22 $44.48 $111.19 $111.19 $52.45 $131.13 $131.13 $41.73 $104.32 $104.32 $41.17 $102.92 $102.92
23 $44.48 $111.19 $111.19 $52.45 $131.13 $131.13 $41.73 $104.32 $104.32 $41.17 $102.92 $102.92
24 $44.48 $111.19 $111.19 $52.45 $131.13 $131.13 $41.73 $104.32 $104.32 $41.17 $102.92 $102.92
25 $44.65 $111.63 $111.63 $52.66 $131.66 $131.66 $41.89 $104.73 $104.73 $41.33 $103.33 $103.33
26 $45.54 $113.86 N/A $53.71 $134.28 N/A $42.73 $106.82 N/A $42.16 $105.39 N/A
27 $46.61 $116.53 N/A $54.97 $137.43 N/A $43.73 $109.32 N/A $43.14 $107.86 N/A
28 $48.34 $120.86 N/A $57.02 $142.54 N/A $45.36 $113.39 N/A $44.75 $111.87 N/A
29 $49.77 $124.42 N/A $58.70 $146.74 N/A $46.69 $116.73 N/A $46.07 $115.17 N/A
30 $50.48 $126.20 N/A $59.53 $148.84 N/A $47.36 $118.40 N/A $46.73 $116.81 N/A
31 $51.55 $128.87 N/A $60.79 $151.98 N/A $48.36 $120.90 N/A $47.71 $119.28 N/A
32 $52.61 $131.54 N/A $62.05 $155.13 N/A $49.36 $123.41 N/A $48.70 $121.75 N/A
33 $53.28 $133.20 N/A $62.84 $157.10 N/A $49.99 $124.97 N/A $49.32 $123.30 N/A
34 $53.99 $134.98 N/A $63.68 $159.20 N/A $50.66 $126.64 N/A $49.98 $124.95 N/A
35 $54.35 $135.87 N/A $64.10 $160.24 N/A $50.99 $127.48 N/A $50.31 $125.77 N/A
36 $54.70 $136.76 N/A $64.52 $161.29 N/A $51.32 $128.31 N/A $50.64 $126.59 N/A
37 $55.06 $137.65 N/A $64.94 $162.34 N/A $51.66 $129.15 N/A $50.97 $127.42 N/A
38 $55.42 $138.54 N/A $65.36 $163.39 N/A $51.99 $129.98 N/A $51.30 $128.24 N/A
39 $56.13 $140.32 N/A $66.20 $165.49 N/A $52.66 $131.65 N/A $51.95 $129.89 N/A
40 $56.84 $142.10 N/A $67.04 $167.59 N/A $53.33 $133.32 N/A $52.61 $131.53 N/A
41 $57.91 $144.77 N/A $68.29 $170.74 N/A $54.33 $135.82 N/A $53.60 $134.00 N/A
42 $58.93 $147.33 N/A $69.50 $173.75 N/A $55.29 $138.22 N/A $54.55 $136.37 N/A
43 $60.35 $150.88 N/A $71.18 $177.95 N/A $56.62 $141.56 N/A $55.87 $139.66 N/A
44 $62.13 $155.33 N/A $73.28 $183.19 N/A $58.29 $145.73 N/A $57.51 $143.78 N/A
45 $64.22 $160.56 N/A $75.74 $189.36 N/A $60.25 $150.63 N/A $59.45 $148.62 N/A
46 $66.71 $166.78 N/A $78.68 $196.70 N/A $62.59 $156.48 N/A $61.75 $154.38 N/A
47 $69.52 $173.79 N/A $81.98 $204.96 N/A $65.22 $163.05 N/A $64.35 $160.86 N/A
48 $72.72 $181.79 N/A $85.76 $214.40 N/A $68.22 $170.56 N/A $67.31 $168.27 N/A
49 $75.88 $189.69 N/A $89.49 $223.71 N/A $71.19 $177.97 N/A $70.23 $175.58 N/A
50 $79.43 $198.58 N/A $93.68 $234.20 N/A $74.52 $186.31 N/A $73.53 $183.82 N/A
51 $82.95 $207.37 N/A $97.83 $244.56 N/A $77.82 $194.55 N/A $76.78 $191.95 N/A
52 $86.82 $217.04 N/A $102.39 $255.97 N/A $81.45 $203.63 N/A $80.36 $200.90 N/A
53 $90.73 $226.82 N/A $107.00 $267.51 N/A $85.12 $212.81 N/A $83.98 $209.96 N/A
54 $94.95 $237.39 N/A $111.99 $279.97 N/A $89.09 $222.72 N/A $87.89 $219.73 N/A
55 $99.18 $247.95 N/A $116.97 $292.43 N/A $93.05 $232.63 N/A $91.80 $229.51 N/A
56 $103.76 $259.40 N/A $122.37 $305.93 N/A $97.35 $243.37 N/A $96.04 $240.11 N/A
57 $108.39 $270.97 N/A $127.83 $319.57 N/A $101.69 $254.22 N/A $100.33 $250.82 N/A
58 $113.32 $283.31 N/A $133.65 $334.13 N/A $106.32 $265.80 N/A $104.90 $262.24 N/A
59 $115.77 $289.42 N/A $136.54 $341.34 N/A $108.61 $271.54 N/A $107.16 $267.90 N/A
60 $120.71 $301.77 N/A $142.36 $355.89 N/A $113.25 $283.12 N/A $111.73 $279.32 N/A
61 $124.98 $312.44 N/A $147.39 $368.48 N/A $117.25 $293.13 N/A $115.68 $289.20 N/A
62 $127.78 $319.44 N/A $150.70 $376.74 N/A $119.88 $299.70 N/A $118.28 $295.69 N/A
63 $131.29 $328.23 N/A $154.84 $387.10 N/A $123.18 $307.94 N/A $121.53 $303.82 N/A
64 $133.43 $333.56 N/A $157.36 $393.40 N/A $125.18 $312.95 N/A $123.50 $308.76 N/A
65+ $133.43 $333.56 N/A $157.36 $393.40 N/A $125.18 $312.95 N/A $123.50 $308.76 N/A

DENTAL/VISION

Delta Dental - PPO Plan 3

VSP - VSP Vision
$40/$120 ($2000 max)
Employee Cost Per Month Employee Cost Per Month
Employee Only $6.05 Employee Only $1.14
EE + SP $20.55 EE + 1 $3.19
EE + Child(ren) $23.49 EE + Children $3.29
EE + Family $37.50 EE + Family $6.35

LIFE & DISABILITY INSURANCE

Life & Disability Insurance 100% Employer Paid

Tax-free disability benefit: N/A