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1 Important information about our rates What determines your rate Your rate is based on the following: n The plan (or plans) you select n The age of the oldest applicant (the subscriber) as of January 1, 2012 n How many family members are covered n Household tobacco use (past or present) Please note that premiums are based on medical history, tobacco use, actual plan effective date, age of applicant(s), and geographic location, and are subject to scheduled rate adjustments. Finding your rate After you ve determined which plans you are interested in, you can use these charts to easily compare the rates. n Scan the following pages to find the category of coverage that you re looking for (Subscriber only, Subscriber + spouse, etc.). n Find your desired plan in the top row. n Then look in the left-hand column to find the age of the subscriber on January 1, (When a couple are enrolling together, the subscriber is the older spouse.) CHILD-ONLY OPEN ENROLLMENT PERIODS Children under the age of 19 can enroll as dependents on a family plan at any time during the year. For applicants under age 19 seeking individual coverage, the state of Colorado has established two child-only open enrollment periods during the months of January and July. Your child may enroll in an individual plan outside the open enrollment periods if he or she has experienced a designated qualifying event. For more information, please see the Getting Coverage for Your Child section of How to Apply. Medicare-eligible subscribers Our Kaiser Permanente for Individuals and Families plans are not available for new members age 65 and over who are eligible for Medicare. If you are 65+ years of age and Medicare eligible or are under age 65 and entitled to Medicare on the basis of Social Security disability, you may be eligible for lower rates under Kaiser Permanente Senior Advantage. Please call for more information. Our service area Please check to see if you reside within the Denver/Boulder service area, based on your home address. All new membership in Kaiser Permanente is limited to individuals who live in those portions of Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson, Larimer, Park, and Weld counties within the following ZIP codes Rates are effective April 1, 2012, and are subject to change. 13

2 Age on January 1, HMO 1000/ 2012 HMO 1500/ HMO 2000/ KAISER PERMANENTE FOR INDIVIDUALS AND FAMILIES RATES: April 2012 Subscriber HMO 3000/ HMO 3500/ 40/Rx HMO 5000/ 40/Rx HMO 6000/50 HMO 7500/50 <1 $ $ $ $ $ $ $ $ $ $ $

3 Subscriber + Spouse Age on 16 $ $ $ $ $ $ $ $ $ $ $

4 Subscriber + Child(ren) Age on 16 $ $ $ $ $ $ $ $ $ $ $

5 Subscriber + spouse + child(ren) Age on 16 $ $ $ $ $ $ $ $ $ $ $