| Active Employees - Medical and $10,000 Life/AD&D Insurance ONLY |
| Medical Plan |
Employee
Only |
Employee
+1 Dep |
Family |
Employee
Only |
Employee
+1 Dep |
Family |
Total |
| Blue Shield - $1,700 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield HMO Plan |
|
|
|
$- |
$- |
$- |
$- |
Blue Shield - High Option PPO |
|
|
|
$- |
$- |
$- |
$- |
| Southern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Northern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Southern California Kaiser - $1,500 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Northern California Kaiser - $1,500 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Sub-Total Medical & Life/AD & D |
0 |
0 |
0 |
$- |
$- |
$- |
$- |
| |
| 1) Would you like to add dental coverage? |
yes
no
|
|
$- |
|
$67.21 per single employee, $119.48 per 2-party employee, $197.88 per family employee.
|
| |
| 2) Would you like to add vision coverage? |
yes
no
|
|
$- |
|
$8.96 per single employee, $13.92 per 2-party employee, $22.08 per family employee. |
| |
| Monthly Billing Rate for Active Employees |
$- |
|
| |
| Early Retirees - Medical ONLY |
| Medical Plan |
Employee
Only |
Employee
+1 Dep |
Family |
Employee
Only |
Employee
+1 Dep |
Family |
Total |
| Blue Shield - $1,700 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield - HMO Plan |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield - High Option PPO |
|
|
|
$- |
$- |
$- |
$- |
| Southern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Northern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Southern California Kaiser - $1,500 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Northern California Kaiser - $1,500 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Sub-Total Medical ONLY |
0 |
0 |
0 |
$- |
$- |
$- |
$- |
| |
| 1) Would you like to add dental coverage? |
yes
no
|
|
$- |
|
$67.21 per single employee, $119.48 per 2-party employee, $197.88 per family employee. |
| |
| 2) Would you like to add vision coverage? |
yes
no
|
|
$- |
|
$8.96 per single employee, $13.92 per 2-party employee, $22.08 per family employee. |
| |
| Monthly Billing Rate for Early Retirees |
$- |
|
| |
| Cobra - Medical ONLY |
| Medical Plan |
Employee
Only |
Employee
+1 Dep |
Family |
Employee
Only |
Employee
+1 Dep |
Family |
Total |
| Blue Shield - $1,700 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield HMO Plan |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield - Hi Option PPO |
|
|
|
$- |
$- |
$- |
$- |
| Southern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Northern California Kaiser |
|
|
|
$- |
$- |
$- |
$- |
| Southern California Kaiser - $1,500 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Northern California Kaiser - $1,500 Deductible |
|
|
|
$- |
$- |
$- |
$- |
| Sub-Total Medical &Life/AD & D |
0 |
0 |
0 |
$- |
$- |
$- |
$- |
| |
| 1) Would you like to add dental coverage? |
yes
no
|
|
$- |
|
$68.55 per single employee, $121.87 per 2-party employee, $201.83 per family employee. |
| |
| 2) Would you like to add vision coverage? |
yes
no
|
|
$- |
|
$9.15 per single employee, $14.20 per 2-party employee, $22.52 per family employee. |
| |
| Monthly Billing Rate for Retirees |
$- |
|
| |
| Medicare - Medical ONLY |
| Medical Plan |
Employee
Only |
Employee
+1 Dep |
Family |
Employee
Only |
Employee
+1 Dep |
Family |
Total |
| Blue Shield - Plan A (Hi Option) |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield - HMO Plan |
|
|
|
$- |
$- |
$- |
$- |
| Blue Shield - Medicare Prime Plan |
|
|
|
$- |
$- |
$- |
$- |
| Kaiser - Northern California - Medicare Risk Plan |
|
|
|
$- |
$- |
$- |
$- |
| Kaiser - Southern California - Medicare Risk Plan |
|
|
|
$- |
$- |
$- |
$- |
| Sub-Total Medical &Life/AD & D |
0 |
0 |
0 |
$- |
$- |
$- |
$- |
| |
| 1) Would you like to add dental coverage? |
yes
no
|
|
$- |
|
$67.21 per single employee, $119.48 per 2-party employee, $197.88 per family employee. |
| |
| 2) Would you like to add vision coverage? |
yes
no
|
|
$- |
|
$8.96 per single employee, $13.92 per 2-party employee, $22.08 per family employee. |
| |
| Monthly Billing Rate for Retirees |
$- |
|
| |
| Total Employees |
0 |
| Total Monthly Billing |
$- |
