CalPERS 2022 Regional Health Premiums (Region 1)

1 Updated: September 14, 2021 CalPERS 2022 Regional Health Premiums (Actives and Annuitants)Effective Date: January 1, 2022 Region 1 Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, YubaBasic 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 Norte1, $ 504112, $ 504222, $ 50433 Anthem Blue Cross Select1, 506112, 506222, 50633 Anthem Blue Cross Traditional1, 509112, 509223, 50933 Blue Shield Access+1, 525112, 525222, 52533 Blue Shield Access+ EPO1, 524112, 524222, 52433 Blue Shield Trio* 451111, 451222, 45133 Health Net SmartCare1, 528112, 528222, 52833 Kaiser 533111, 533222, 53333 PERS 613111, 613221, 61333 PERS Platinum1, 601112, 601222, 60133 Peace Officers Research Assoc of 592111, 592222, 59233 UnitedHealthcare SignatureValue Alliance1, 576112, 576222, 57633 Western Health 591111, 591221, 59133 Supplement/Managed Medicare Monthly Premiums (M)

2 Plan Subscriber Plan CodeParty CodeParty Rate Subscriber & 1 Dependent Plan CodeParty CodeParty Rate Subscriber & 2+ Dependents Plan CodeParty CodeParty RateAnthem Blue Cross Select Medicare $ $ 455251, $ 45536 Anthem Blue Cross Select Medicare Preferred with 459251, 45936 Anthem Blue Cross Medicare 515251, 51536 Anthem Blue Cross Medicare Preferred with 512251, 51236 Blue Shield 011251, 01136 Blue Shield Medicare with 016251, 01636 Kaiser Permanente Senior 53636 Kaiser Permanente Senior Advantage with 54236 PERS Gold Medicare 616251, 61636 PERS Platinum Medicare 605251, 60536 Peace Officers Research Assoc of CA Medicare 595251, 59536 UnitedHealthcare Medicare Advantage 476251, 47636 UnitedHealthcare Medicare 57936 UnitedHealthcare Medicare Advantage with 58536 Western Health Advantage Medicare 035362 Dental and Vision coverage is an additional $ per member per month premium.

3 You will be billed directly for this amount. 3 Dental benefit is an additional $ per member per month premium. You will be billed directly for this , 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, *Blue Shield Trio is only available in El Dorado, Nevada, Placer, Sacramento, Santa Cruz, Stanislaus, and Yolo (partial county served)1 Dental and Vision coverage is an additional $ per member per month premium. You will be billed directly for this and Vision coverage is an additional $ per member per month premium. You will be billed directly for this : September 14, 2021 CalPERS 2022 Regional Health Premiums (Actives and Annuitants)Effective Date.

4 January 1, 2022 Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, YubaPlan 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, $ 021472, $ 21581, $ 02169 Anthem Blue Cross Select and Medicare Preferred1, 457471, 457581, 45769 Anthem Blue Cross Select and Medicare Preferred with Dental/Vision11, 460471, 460581, 46069 Anthem Blue Cross Traditional HMO and Medicare Preferred1, 518472, 518581, 51869 Anthem Blue Cross Traditional HMO and Medicare Preferred Dental/Vision11, 521472, 521581, 52169 Blue Shield Access+ and Medicare1, 049472, 49581, 04969 Blue Shield Access+ and Medicare with Dental/Vision21, 089472, 89581, 08969 Blue Shield Access+ EPO and Medicare1, 092472, 92581, 09269 Blue Shield Access+ EPO and Medicare with Dental/Vision31, 093472, 93581, 09369 Blue Shield Trio and Medicare1, 094471, 94581, 09469 Blue Shield Trio and Medicare with Dental/Vision41, 097471, 97581, 09769 Kaiser Permanente and Senior Advantage1, 539471, 539581, 53969 Kaiser Permanente Senior Advantage with Dental51, 545471, 545581, 54569 PERS Gold and Medicare Supplement1, 619471, 619581, 61969 PERS Platinum and Medicare Supplement1, 609472, 609581, 60969 Peace Officers Research Assoc of CA and Medicare Supplement1, 598471, 598581, 59869 UnitedHealthcare SignatureValue Alliance and Medicare Advantage Edge1, 627471, 627581, 62769 UnitedHealthcare SignatureValue Alliance and Medicare Advantage1, 582471, 582581.

5 58269 UnitedHealthcare SignatureValue Alliance and Medicare Advantage with Dental/Vision61, 588471, 588581, 58869 Western Health Advantage and Medicare Advantage1, 036471, 36581, 03669 Combination Monthly Premiums (Continued)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, $ 0217101, $ 218112, $ 021912 Anthem Blue Cross Select and Medicare Preferred1, 4577101, 4578111, 457912 Anthem Blue Cross Select and Medicare Preferred with Dental/Vision11, 4607101, 4608111, 460912 Anthem Blue Cross Traditional HMO and Medicare Preferred1, 5187102, 5188112, 518912 Anthem Blue Cross Traditional HMO and Medicare Preferred Dental/Vision11, 5217102, 5218112, 521912 Blue Shield Access+ and Medicare1, 0497101, 498112, 049912 Blue Shield Access+ and Medicare with Dental/Vision21, 0897101, 898112, 089912 Region 1 Alameda, Alpine, Amador, Butte, Calaveras.

6 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, Combination Monthly Premiums2 Updated: September 14, 2021 CalPERS 2022 Regional Health Premiums (Actives and Annuitants)Effective Date: January 1, 2022 Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, YubaCombination Monthly Premiums (Continued)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 RateBlue Shield Access+ EPO and Medicare1, $ 0927101, $ 0928112, $ 092912 Blue Shield Access+ EPO and Medicare with Dental/Vision31, 0937101, 0938112, 093912 Blue Shield Trio and Medicare1, 0947101, 0948111, 094912 Blue Shield Trio and Medicare withDental/Vision41, 0977101, 0978111, 097912 Kaiser Permanente and Senior Advantage1, 5397101, 5398111, 539912 Kaiser Permanente and Senior Advantage with Dental51, 5457101, 5458111, 545912 PERS Gold and Medicare Supplement1, 6197101, 6198111, 619912 PERS Platinum and Medicare Supplement1, 6097101, 6098112, 609912 Peace Officers Research Assoc of CA and Medicare Supplement1.

7 5987101, 5988111, 598912 UnitedHealthcare SignatureValue Alliance and Medicare Advantage Edge1, 6277101, 6278111, 627912 UnitedHealthcare SignatureValue Alliance and Medicare Advantage1, 5827101, 5828111, 582912 UnitedHealthcare SignatureValue Alliance and Medicare Advantage with Dental/Vision61, 5887101, 5888111, 588912 Western Health Advantage and Medicare Advantage1, 0367101, 0368111, 0369121 Dental and Vision coverage is an additional $ per member per month premium. You will be billed directly for this amount. Mono, Monterey, Napa, Nevada, Placer, Plumas, Sacramento, San Benito, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Shasta, Sierra, Siskiyou, Region 1 Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, El Dorado, Glenn, Humboldt, Lake, Lassen, Marin, Mariposa, Mendocino, Merced, Modoc, 2 Dental and Vision coverage is an additional $ per member per month premium.

8 You will be billed directly for this amount. 3 Dental and Vision coverage is an additional $ per member per month premium. You will be billed directly for this amount. 4 Dental and Vision coverage is an additional $ per member per month premium. You will be billed directly for this amount. 5 Dental benefit is an additional $ per member per month premium. You will be billed directly for this and Vision coverage is an additional $ per member per month premium. You will be billed directly for this