Finance Committee
September 6, 2022

CalPERS 2023 Regional Health Premiums (Actives and Annuitants) Effective Date: January 1, 2023
Region 1
Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, El Dorado, Glenn, Humboldt, Lake, Lassen, Marin, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Napa, Nevada, Placer, Plumas, Sacramento, San Benito, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Shasta, Sierra, Siskiyou, Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, Yuba Basic Monthly Premiums (B)
Plan Subscriber
Plan
Code
Party
Code
Party
Rate
Subscriber &
1 Dependent
Plan
Code
Party
Code
Party
Rate
Subscriber &
2+ Dependents
Plan
Code
Party
Code
Party
Rate
Anthem Blue Cross Del Norte EPO $1,200.12 504 1 1 $2,400.24 504 2 2 $3,120.31 504 3 3 Anthem Blue Cross Select HMO 1,128.83 506 1 1 2,257.66 506 2 2 2,934.96 506 3 3 Anthem Blue Cross Traditional HMO 1,210.71 509 1 1 2,421.42 509 2 2 3,147.85 509 3 3 Blue Shield Access+ HMO 1,035.21 525 1 1 2,070.42 525 2 2 2,691.55 525 3 3 Blue Shield Access+ EPO 1,035.21 524 1 1 2,070.42 524 2 2 2,691.55 524 3 3 Blue Shield Trio HMO* 888.94 451 1 1 1,777.88 451 2 2 2,311.24 451 3 3 Health Net SmartCare 1,174.50 528 1 1 2,349.00 528 2 2 3,053.70 528 3 3 Kaiser Permanente 913.74 533 1 1 1,827.48 533 2 2 2,375.72 533 3 3 Peace Officers Research Assoc of CA 825.00 592 1 1 1,875.00 592 2 2 2,300.00 592 3 3 PERS Gold 825.61 613 1 1 1,651.22 613 2 2 2,146.59 613 3 3 PERS Platinum 1,200.12 601 1 1 2,400.24 601 2 2 3,120.31 601 3 3 UnitedHealthcare SignatureValue Alliance 1,044.07 576 1 1 2,088.14 576 2 2 2,714.58 576 3 3 Western Health Advantage HMO 760.17 591 1 1 1,520.34 591 2 2 1,976.44 591 3 3 Supplement/Managed Medicare Monthly Premiums (M)
Plan Subscriber
Plan
Code
Party
Code
Party
Rate
Subscriber &
1 Dependent
Plan
Code
Party
Code
Party
Rate
Subscriber &
2+ Dependents
Plan
Code
Party
Code
Party
Rate
Anthem Medicare Preferred PPO $413.59 515 1 4 $827.18 515 2 5 $1,240.77 515 3 6 Anthem Medicare Preferred PPO with
Dental/Vision1 413.59 512 1 4 827.18 512 2 5 1,240.77 512 3 6 Anthem Medicare Preferred PPO 413.59 455 1 4 827.18 455 2 5 1,240.77 455 3 6 Anthem Medicare Preferred PPO with Dental1 413.59 459 1 4 827.18 459 2 5 1,240.77 459 3 6 Blue Shield Medicare PPO 361.90 011 1 4 723.80 011 2 5 1,085.70 011 3 6 Blue Shield Medicare PPO with Dental/Vision2 361.90 016 1 4 723.80 016 2 5 1,085.70 016 3 6 Kaiser Permanente Senior Advantage 283.25 536 1 4 566.50 536 2 5 849.75 536 3 6 Kaiser Permanente Senior Advantage with
Dental
3 283.25 542 1 4 566.50 542 2 5 849.75 542 3 6
Kaiser Permanente Senior Advantage Summit 336.29 630 1 4 672.58 630 2 5 1,008.87 630 3 6 Kaiser Permanente Senior Advantage Summit
with Dental
3 336.29 636 1 4 672.58 636 2 5 1,008.87 636 3 6
Peace Officers Research Assoc of CA Medicare
Supplement 465.00 595 1 4 1,030.00 595 2 5 1,395.00 595 3 6 PERS Gold Medicare Supplement 392.71 616 1 4 785.42 616 2 5 1,178.13 616 3 6 PERS Platinum Medicare Supplement 420.02 605 1 4 840.04 605 2 5 1,260.06 605 3 6 UnitedHealthcare Group Medicare Advantage
PPO
299.68 579 1 4 599.36 579 2 5 899.04 579 3 6
UnitedHealthcare Group Medicare Advantage
Edge PPO
357.70 476 1 4 715.40 476 2 5 1,073.10 476 3 6
UnitedHealthcare Group Medicare Advantage
PPO with Dental/Vision4 299.68 585 1 4 599.36 585 2 5 899.04 585 3 6 Western Health Advantage MyCare Select HMO 331.11 035 1 4 662.22 035 2 5 993.33 035 3 6 *Blue Shield Trio is only available in Butte (pending DMHC approval), El Dorado, Monterey, Nevada, Placer, Sacramento, Santa Cruz, Stanislaus, and Yolo (partial counties served). 1Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 2Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 3Dental benefit is an additional $15.35 per member per month premium. You will be billed directly for this amount. 4Dental and Vision coverage is an additional $26.03 per member per month premium. You will be billed directly for this amount. 1 CalPERS 2023 Regional Health Premiums (Actives and Annuitants) Effective Date: January 1, 2023
Region 1
Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, El Dorado, Glenn, Humboldt, Lake, Lassen, Marin, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Napa, Nevada, Placer, Plumas, Sacramento, San Benito, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Shasta, Sierra, Siskiyou, Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, Yuba Combination Monthly Premiums
Plan
Subscriber in M, &
1 Dependent in B
Plan
Code
Party
Code
Party
Rate
Subscriber in M, &
2+ Dependents in B
Plan
Code
Party
Code
Party
Rate
Subscriber in M,
1 Dependent in M, &
1+ Dependent in B
Plan
Code
Party
Code
Party
Rate
Anthem Blue Cross Del Norte EPO and
Medicare Supplement $1,620.14 021 4 7 $2,340.21 021 5 8 $1,560.11 021 6 9 Anthem Blue Cross Select HMO and Medicare
Preferred
1,542.42 457 4 7 2,219.72 457 5 8 1,504.48 457 6 9
Anthem Blue Cross Select HMO and Medicare
Preferred with Dental/Vision1 1,542.42 460 4 7 2,219.72 460 5 8 1,504.48 460 6 9 Anthem Blue Cross Traditional HMO and
Medicare Preferred 1,624.30 518 4 7 2,350.73 518 5 8 1,553.61 518 6 9 Anthem Blue Cross Traditional HMO and
Medicare Preferred with Dental/Vision1 1,624.30 521 4 7 2,350.73 521 5 8 1,553.61 521 6 9 Blue Shield Access+ HMO and Medicare 1,397.11 049 4 7 2,018.24 049 5 8 1,344.93 049 6 9 Blue Shield Access+ HMO and Medicare with
Dental/Vision
2 1,397.11 089 4 7 2,018.24 089 5 8 1,344.93 089 6 9
Blue Shield Access+ EPO and Medicare 1,397.11 092 4 7 2,018.24 092 5 8 1,344.93 092 6 9 Blue Shield Access+ EPO and Medicare with
Dental/Vision
3 1,397.11 093 4 7 2,018.24 093 5 8 1,344.93 093 6 9
Blue Shield Trio HMO and Medicare 1,250.84 094 4 7 1,784.20 094 5 8 1,257.16 094 6 9 Blue Shield Trio HMO and Medicare with
Dental/Vision
4 1,250.84 097 4 7 1,784.20 097 5 8 1,257.16 097 6 9
Kaiser Permanente and Senior Advantage 1,196.99 539 4 7 1,745.23 539 5 8 1,114.74 539 6 9 Kaiser Permanente and Senior Advantage with
Dental
5 1,196.99 545 4 7 1,745.23 545 5 8 1,114.74 545 6 9
Kaiser Permanente and Senior Advantage
Summit 1,250.03 633 4 7 1,798.27 633 5 8 1,220.82 633 6 9 Kaiser Permanente and Senior Advantage
Summit with Dental5 1,250.03 639 4 7 1,798.27 639 5 8 1,220.82 639 6 9 Peace Officers Research Assoc of CA and
Medicare Supplement 1,525.00 598 4 7 1,999.00 598 5 8 1,582.00 598 6 9 PERS Gold and Medicare Supplement 1,218.32 619 4 7 1,713.69 619 5 8 1,280.79 619 6 9 PERS Platinum and Medicare Supplement 1,620.14 609 4 7 2,340.21 609 5 8 1,560.11 609 6 9 UnitedHealthcare SignatureValue Alliance and
Group Medicare Advantage PPO
1,343.75 582 4 7 1,970.19 582 5 8 1,225.80 582 6 9
UnitedHealthcare SignatureValue Alliance and
Group Medicare Advantage Edge PPO
1,401.77 627 4 7 2,028.21 627 5 8 1,341.84 627 6 9
UnitedHealthcare SignatureValue Alliance and
Group Medicare Advantage PPO with
Dental/Vision
6 1,343.75 588 4 7 1,970.19 588 5 8 1,225.80 588 6 9
Western Health Advantage HMO and MyCare
Select HMO 1,091.28 036 4 7 1,547.38 036 5 8 1,118.32 036 6 9 1Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 2Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 3Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 4Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 5Dental benefit is an additional $15.35 per member per month premium. You will be billed directly for this amount. 6Dental and Vision coverage is an additional $26.03 per member per month premium. You will be billed directly for this amount. 2 CalPERS 2023 Regional Health Premiums (Actives and Annuitants) Effective Date: January 1, 2023
Region 1
Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, El Dorado, Glenn, Humboldt, Lake, Lassen, Marin, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Napa, Nevada, Placer, Plumas, Sacramento, San Benito, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Shasta, Sierra, Siskiyou, Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, Yuba Combination Monthly Premiums (Continued)
Plan
Subscriber in B, &
1 Dependent in M
Plan
Code
Party
Code
Party
Rate
Subscriber in B, &
2+ Dependents in M
Plan
Code
Party
Code
Party
Rate
Subscriber in B,
1 Dependent in M, &
1+ Dependent in B
Plan
Code
Party
Code
Party
Rate
Anthem Blue Cross Del Norte EPO and
Medicare Supplement $1,620.14 021 7 10 $2,040.16 021 8 11 $2,340.21 021 9 12 Anthem Blue Cross Select HMO and Medicare
Preferred
1,542.42 457 7 10 1,956.01 457 8 11 2,219.72 457 9 12
Anthem Blue Cross Select HMO and Medicare
Preferred with Dental/Vision1 1,542.42 460 7 10 1,956.01 460 8 11 2,219.72 460 9 12 Anthem Blue Cross Traditional HMO and
Medicare Preferred 1,624.30 518 7 10 2,037.89 518 8 11 2,350.73 518 9 12 Anthem Blue Cross Traditional HMO and
Medicare Preferred with Dental/Vision1 1,624.30 521 7 10 2,037.89 521 8 11 2,350.73 521 9 12 Blue Shield Access+ HMO and Medicare 1,397.11 049 7 10 1,759.01 049 8 11 2,018.24 049 9 12 Blue Shield Access+ HMO and Medicare with
Dental/Vision
2 1,397.11 089 7 10 1,759.01 089 8 11 2,018.24 089 9 12 Blue Shield Access+ EPO and Medicare 1,397.11 092 7 10 1,759.01 092 8 11 2,018.24 092 9 12 Blue Shield Access+ EPO and Medicare with
Dental/Vision
3 1,397.11 093 7 10 1,759.01 093 8 11 2,018.24 093 9 12 Blue Shield Trio HMO and Medicare 1,250.84 094 7 10 1,612.74 094 8 11 1,784.20 094 9 12 Blue Shield Trio HMO and Medicare with
Dental/Vision
4 1,250.84 097 7 10 1,612.74 097 8 11 1,784.20 097 9 12 Kaiser Permanente and Senior Advantage 1,196.99 539 7 10 1,480.24 539 8 11 1,745.23 539 9 12 Kaiser Permanente and Senior Advantage with
Dental
5 1,196.99 545 7 10 1,480.24 545 8 11 1,745.23 545 9 12 Kaiser Permanente and Senior Advantage
Summit 1,250.03 633 7 10 1,586.32 633 8 11 1,798.27 633 9 12 Kaiser Permanente and Senior Advantage
Summit with Dental5 1,250.03 639 7 10 1,586.32 639 8 11 1,798.27 639 9 12 Peace Officers Research Assoc of CA and
Medicare Supplement 1,392.00 598 7 10 1,854.00 598 8 11 1,868.00 598 9 12 PERS Gold and Medicare Supplement 1,218.32 619 7 10 1,611.03 619 8 11 1,713.69 619 9 12 PERS Platinum and Medicare Supplement 1,620.14 609 7 10 2,040.16 609 8 11 2,340.21 609 9 12 UnitedHealthcare SignatureValue Alliance and
Group Medicare Advantage PPO 1,343.75 582 7 10 1,643.43 582 8 11 1,970.19 582 9 12 UnitedHealthcare SignatureValue Alliance and
Group Medicare Advantage Edge PPO
1,401.77 627 7 10 1,759.47 627 8 11 2,028.21 627 9 12
UnitedHealthcare SignatureValue Alliance and
Group Medicare Advantage PPO with
Dental/Vision
6 1,343.75 588 7 10 1,643.43 588 8 11 1,970.19 588 9 12 Western Health Advantage HMO and MyCare
Select HMO 1,091.28 036 7 10 1,422.39 036 8 11 1,547.38 036 9 12 1Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 2Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 3Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 4Dental and Vision coverage is an additional $38.00 per member per month premium. You will be billed directly for this amount. 5Dental benefit is an additional $15.35 per member per month premium. You will be billed directly for this amount. 6Dental and Vision coverage is an additional $26.03 per member per month premium. You will be billed directly for this amount. 3