2018 Medical Premiums: Retiree or Survivor of Retiree Without Medicare Residing in California

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1 2018 : Retiree or Survivor of Retiree Without Medicare Residing in California Blue Shield of California Trio Access+ UHC Plan PPO Survivor Only $1, $29.44 $1, $70.44 $1, $0 $1, $ Survivor Survivor +2 or More with Survivor Survivor B $1, $ $2, $ $1, $ $1, $ $1, $ $2, $1, $1, $ $1, $1, $1, $ $1, $ $1, $ $1, $ $1, $ $1, $ $1, $ $1, $1, Blue Shield of California Trio Access+ UHC Plan PPO Survivor Only $0 $1, $0 $1, $0 $1, $0 $1, Survivor Survivor +2 or More with Survivor Survivor B $0 $2, $0 $2, $0 $1, $0 $2, $0 $2, $0 $3, $0 $2, $0 $3, $0 $2, $0 $2, $0 $1, $0 $1, $0 $2, $0 $2, $0 $2, $0 $2, Required Survivor premium contributions, if any, will be deducted from the member s monthly pension check. If the pension check does not fully cover premium payments, the member must contact SFHSS to make payment arrangements.

2 2018 : Retiree or Survivor of Retiree With Medicare Part A & Residing in California RETIREES HIRED BEFORE JANUARY 9, 2009 Advantage in Blue Shield of California Trio Advantage in Blue Shield of California Access+ Survivor Only $ $0 $ $0 $ $0 $ $0 Survivor $ $ $ $ $ $ $ $ Survivor +2 or More with $ $ $ $1, $ $ $ $1, Survivor $ $ $ $ Survivor B $ $ $ $1, $ $ $ $ RETIREES HIRED AFTER JANUARY 9, 2009 Advantage in Blue Shield of California Trio Advantage in Blue Shield of California Access+ Survivor Only $0 $ $0 $ $0 $ $0 $ Survivor $0 $ $0 $1, $0 $1, $0 $1, Survivor +2 or More with $0 $1, $0 $2, $0 $1, $0 $1, Survivor $0 $ $0 $ Survivor B $0 $1, $0 $1, $0 $1, $0 $1,412.73

3 2018 : Retiree or Survivor of Retiree Without Medicare Residing Outside of California UHC Plan PPO Survivor Only $1, $0 $1, $0 $ $0 $1, $ Survivor Survivor +2 or More with Survivor Survivor B $2, $ $1, $ $1, $ $1, $ $2, $1, $1, $1, $1, $1, $1, $1, $1, $ $1, $ $1, $ $1, $ $1, $1, $1, $1, $1, $ $1, $1, UHC Plan PPO Survivor Only $0 $1, $0 $1, $0 $ $0 $1, Survivor Survivor +2 or More with Survivor Survivor B $0 $2, $0 $2, $0 $1, $0 $2, $0 $3, $0 $3, $0 $2, $0 $3, $0 $1, $0 $1, $0 $1, $0 $1, $0 $3, $0 $2, $0 $1, $0 $2,416.38

4 2018 : Retiree or Survivor of Retiree With Residing Outside of California Senior Advantage Survivor Only $ $0 $ $0 $ $0 $ $0 Survivor Survivor +2 or More with Survivor Survivor B $1, $ $1, $ $ $ $ $ $1, $1, $1, $1, $ $1, $ $1, $ $ $ $ $ $ $ $ $ $1, $ $1, $ $1, $ $1, Senior Advantage Survivor Only $0 $ $0 $ $0 $ $0 $ Survivor Survivor +2 or More with Survivor Survivor B $0 $1, $0 $1, $0 $1, $0 $1, $0 $2, $0 $2, $0 $1, $0 $2, $0 $ $0 $ $0 $ $0 $ $0 $2, $0 $1, $0 $1, $0 $1,608.82

5 Retirees 2018 Dental Premiums: All Retirees / Survivors Dental Premiums Delta Dental PPO DeltaCare USA DMO UnitedHealthcare Dental DMO Survivor Only $0 $45.77 $0 $32.85 $0 $16.47 Survivor +1 Dependent $0 $91.04 $0 $54.21 $0 $27.20 Survivor +2 or More $0 $ $0 $80.19 $0 $ VSP Premier Premiums: All Retirees / Survivors Vision Premiums Survivor Only $10.86 Survivor +1 Dependent $15.54 Survivor +2 or More $30.82