CalPERS 2022 Health Premiums (State)

1 Updated: September 14, 2021 CalPERS 2022 State Health Premiums (Actives and Annuitants)Effective Date: January 1, 2022 Basic Monthly Premiums (B)Plan Subscriber Plan CodeParty CodeParty Rate Subscriber & 1 Dependent Plan CodeParty CodeParty Rate Subscriber & 2+ Dependents Plan CodeParty CodeParty RateAnthem Blue Cross Del $ 172111, $ 172222, $ 17233 Anthem Blue Cross 181111, 181222, 18133 Anthem Blue Cross Traditional1, 180112, 180223, 18033 Blue Shield Access+ 141111, 141222, 14133 Blue Shield Access+ 191111, 191222, 19133 Blue Shield 471111, 471221, 47133CA Assoc of Highway 230111, 230221, 23033CA Correctional Peace Officers Assoc - BSC 256111, 256222, 25633CA Correctional Peace Officers Assoc - BSC 266111, 266221.

2 26633 Health Net Salud y M 184221, 18433 Health Net SmartCare1, 185112, 185222, 18533 Kaiser 056111, 056222, 05633 PERS 437111, 437221, 43733 PERS 434111, 434222, 43433 Peace Officers Research Assoc of 207111, 207221, 20733 Sharp Performance 189111, 189221, 18933 UnitedHealthcare SignatureValue 187111, 187222, 18733 UnitedHealthcare SignatureValue 319111, 319221, 31933 Western Health 176111, 176221, 17633 Supplement/Managed Medicare Monthly Premiums (M)Plan Subscriber Plan CodeParty CodeParty Rate Subscriber & 1 Dependent Plan CodeParty CodeParty Rate Subscriber & 2+ Dependents Plan CodeParty CodeParty RateAnthem Blue Cross Select Medicare $ $ 473251, $ 47336 Anthem Blue Cross Medicare 258251, 25836 Blue Shield 013251, 01336CA Assoc of Highway Patrolmen Medicare 231251, 23136CA Correctional Peace Officers Assoc Medicare Supplement - BSC 257141, 257251, 25736CA Correctional Peace Officers Assoc Medicare Supplement - BSC 267141, 267251, 26736 Kaiser Permanente Senior 06636 PERS Gold Medicare 438251.

3 43836 PERS Platinum Medicare 435251, 43536 Peace Officers Research Assoc of CA Medicare 208251, 20836 Sharp Direct Advantage 24336 UnitedHealthcare Medicare Advantage 395251, 39536 UnitedHealthcare Medicare 16336 Western Health Advantage Medicare 479361 Updated: September 14, 2021 CalPERS 2022 State Health Premiums (Actives and Annuitants)Effective Date: January 1, 2022 Combination Monthly PremiumsPlan Subscriber in M, & 1 Dependent in B Plan CodeParty CodeParty Rate Subscriber in M, & 2+ Dependents in B Plan CodeParty CodeParty Rate Subscriber in M,1 Dependent in M, & 1+ Dependent in B Plan CodeParty CodeParty RateAnthem Blue Cross Del Norte and Medicare Supplement1, $ 033471, $ 033581, $ 03369 Anthem Blue Cross Select and Medicare Preferred1, 456471, 456581, 45669 Anthem Blue Cross Traditional HMO and Medicare Preferred1, 309472, 309581, 30969 Blue Shield Access+ and Medicare1, 018471, 018581, 01869 Blue Shield Access+ EPO and Medicare1, 028471.

4 028581, 02869 Blue Shield Trio and Medicare1, 030471, 030581, 03069CA Assoc of Highway Patrolmen and Medicare Supplement1, 117471, 117581, 11769CA Correctional Peace Officers Assoc and Medicare Supplement - BSC North1, 118472, 118581, 11869CA Correctional Peace Officers Assoc and Medicare Supplement - BSC South1, 119471, 119581, 11969 Kaiser Permanente and Senior Advantage1, 120471, 120581, 12069 PERS Gold and Medicare Supplement1, 439471, 439581, 43969 PERS Platinum and Medicare Supplement1, 436471, 436581, 43669 Peace Officers Research Assoc of CA and Medicare Supplement1, 158471, 158581, 15869 Sharp Performance and Direct Advantage 244471, 24469 UnitedHealthcare SignatureValue Harmony and Medicare Advantage Edge1, 396471, 396581, 39669 UnitedHealthcare SignatureValue Harmony and Medicare Advantage1, 398471, 398581, 39869 UnitedHealthcare SignatureValue Alliance and Medicare Advantage Edge1, 397471, 397581, 39769 UnitedHealthcare SignatureValue Alliance and Medicare Advantage1, 164471, 164581, 16469 Western Health Advantage and Medicare Advantage1, 480471, 480581, 48069 Combination Monthly Premiums (Continued)

5 Plan Subscriber in B, & 1 Dependent in M Plan CodeParty CodeParty Rate Subscriber in B, & 2+ Dependents in M Plan CodeParty CodeParty Rate Subscriber in B,1 Dependent in M, & 1+ Dependent in B Plan CodeParty CodeParty RateAnthem Blue Cross Del Norte and Medicare Supplement1, $ 0337101, $ 0338111, $ 033912 Anthem Blue Cross Select and Medicare Preferred1, 4567101, 4568111, 456912 Anthem Blue Cross Traditional HMO and Medicare Preferred1, 3097101, 3098112, 309912 Blue Shield Access+ and Medicare1, 0187101, 0188111, 018912 Blue Shield Access+ EPO and Medicare1, 0287101, 0288111, 028912 Blue Shield Trio and Medicare1, 0307101, 0308111, 030912CA Assoc of Highway Patrolmen and Medicare Supplement1, 1177101, 1178111, 117912CA Correctional Peace Officers Assoc and Medicare Supplement - BSC North1, 1187101, 1188112, 118912CA Correctional Peace Officers Assoc and Medicare Supplement - BSC South1, 1197101, 1198111, 119912 Kaiser Permanente and Senior Advantage1, 1207101, 1208111, 120912 PERS Gold and Medicare Supplement1, 4397101, 4398111, 439912 PERS Platinum and Medicare Supplement1, 4367101, 4368111, 436912 Peace Officers Research Assoc of CA and Medicare Supplement1.

6 1587101, 1588111, 158912 Sharp Performance and Direct Advantage 2447101, 2448111, 244912 UnitedHealthcare SignatureValue Harmony and Medicare Advantage Edge1, 3967101, 3968111, 396912 UnitedHealthcare SignatureValue Harmony and Medicare Advantage1, 3987101, 3988111, 398912 UnitedHealthcare SignatureValue Alliance and Medicare Advantage Edge1, 3977101, 3978111, 397912 UnitedHealthcare SignatureValue Alliance and Medicare Advantage1, 1647101, 1648111, 164912 Western Health Advantage and Medicare Advantage1, 4807101, 4808111, 4809122