2 / 7
2
Anthem Blue Cross PPO and CaliforniaCare HMO Premium Rates
The tables on pages 1 and 2 reflect the retiree monthly premium rates under the Anthem Blue Cross PPO
and CaliforniaCare HMO plans effective July 1, 2017. Your cost is the monthly premium rate minus the Pension
Department subsidy, based on your retirement date, age and years of service.
Anthem Blue Cross Monthly Premium Rates (07/01/17 - 06/30/18)
Office Use Only
Coverage Tier
PPO
HMO
(CA Residents Only)
34a
3 Party: Member A&B; Spouse None; Deps None
$2,017.34
$1,745.90
80
3 Party: Member A&B&D; Spouse None; Deps A&B&D
$1,626.79
$1,611.85
80a
3 Party: Member A&B&D; Spouse None; Deps A&B
$1,644.34
$1,625.15
35
3 Party: Member A&B&D; Spouse A&B&D; Deps None
$1,600.85
$1,594.41
35a
3 Party: Member A&B&D; Spouse A&B; Deps None
$1,621.34
$1,631.85
35b
3 Party: Member A&B; Spouse A&B&D; Deps None
$1,641.85
$1,623.41
35c
3 Party: Member A&B; Spouse A&B; Deps None
$1,662.34
$1,638.92
35d
3 Party: Member A&B&D; Spouse A&B&D; Deps A&B&D
$1,251.30
$1,489.36
35e
3 Party: Member A&B&D; Spouse A&D; Deps None
$1,760.85
$1,609.92
35f
3 Party: Member A&B&D; Spouse A; Deps None
$1,781.34
$1,647.36
35g
3 Party: Member A&B; Spouse A&D; Deps None
$1,814.79
$1,660.85
35h
3 Party: Member A&B&D; Spouse A&B; Deps A&B&D
$1,271.79
$1,504.87
35i
3 Party: Member A&B&D; Spouse A&B&D; Deps A&B
$1,268.85
$1,502.66
36
3 Party: Member None; Spouse A&B&D; Deps A&B&D
$1,620.30
$1,718.36
36a
3 Party: Member None; Spouse A&B&D; Deps A&B
$1,637.85
$1,731.66
36b
3 Party: Member None; Spouse A&B; Deps A&B&D
$1,640.79
$1,733.87
36c
3 Party: Member None; Spouse A&B; Deps A&B
$1,658.34
$1,747.17
37
Member A&D
$723.70
$735.03
37a
Member A Only
$764.70
$764.03
38
Two Party: Both A&D
$1,564.89
$1,418.18
38a
Two Party: Member A&D; Spouse A Only
$1,585.38
$1,433.69
38b
Two Party: Member A Only; Spouse A&D
$1,605.89
$1,447.18
38c
Two Party: Both A Only
$1,626.38
$1,462.69
38d
Two Party: Member None; Spouse A Only
$1,807.38
$1,592.69
38e
Two Party: Member None; Spouse A&D
$1,786.89
$1,577.18
38f
Two Party: Member A Only; Spouse None
$1,821.38
$1,532.23
38g
Two Party: Member A&D; Spouse None
$1,780.38
$1,503.23
39
3 Party: Member A&D; Spouse A&D; Deps A&D
$1,705.30
$1,628.91
39a
3 Party: Member A&D; Spouse None; Deps None
$2,123.34
$1,786.90
39b
3 Party: Member A Only; Spouse A Only; Deps None
$1,969.34
$1,746.36
39c
3 Party: Member A&D; Spouse A Only; Deps None
$1,928.34
$1,717.36
39d
3 Party: Member A Only; Spouse A&D; Deps None
$1,948.85
$1,730.85
39e
3 Party: Member A&D; Spouse A&D; Deps None
$1,907.85
$1,701.85
39f
3 Party: Member A Only; Spouse None; Deps A Only
$1,979.34
$1,756.26
39g
3 Party: Member A&D; Spouse None; Deps A Only
$1,938.34
$1,727.26
39h
3 Party: Member A Only; Spouse None; Deps A&D
$1,961.79
$1,742.96
39i
3 Party: Member A&D; Spouse None; Deps A&D
$1,920.79
$1,713.96
39j
3 Party: Member None; Spouse A Only; Deps None
$2,150.34
$1,876.36
39k
3 Party: Member None; Spouse A&D; Deps None
$2,129.85
$1,860.85
39l
3 Party: Member None; Spouse A Only; Deps A Only
$1,965.34
$1,816.72
39m
3 Party: Member None; Spouse A&D; Deps A Only
$1,944.85
$1,801.21
39n
3 Party: Member None; Spouse A Only; Deps A&D
$1,947.79
$1,803.42
39o
3 Party: Member None; Spouse A&D; Deps A&D
$1,927.30
$1,787.91
39p
3 Party: Member None; Spouse None; Deps A Only
$2,160.34
$1,886.26
39q
3 Party: Member None; Spouse None; Deps A&D
$2,142.79
$1,872.96
39r
3 Party: Member A Only; Spouse None; Deps None
$2,164.34
$1,815.90
39s
3 Party: Member None; Spouse B/D; Deps None
$2,164.85
$1,892.95