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5
Kaiser HMO Premium Rates
The tables on pages 3, 4 and 5 reflect the retiree monthly premium rates under the Kaiser HMO plan 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.
Kaiser HMO Monthly Premium Rates (07/01/17 - 06/30/18)
Office Use Only
Coverage Tier
HMO
(CA Residents
Only)
Member (over 65) A&B unknown or unassigned with KP (“Medicare” - assigned to Kaiser).
A1
Member (over 65) A/B unknown with KP
$1,270.62
A2
2 Party: Member (over 65) A/B unknown; Spouse Medicare A/B/D
$1,470.86
A3
2 Party: Member (over 65) A/B unknown; Spouse Medicare B/D
$1,782.86
A4
2 Party: Member (over 65) A/B unknown; Spouse None (under 65)
$1,839.58
A5
2 Party: Member (over 65) A/B unknown; Spouse (over 65) A .
$2,223.22
A6
2 Party: Member (over 65) A/B unknown; Spouse (over 65) B
$2,536.24
A7
2 Party: Member (over 65) A/B unknown; Spouse A/B unknown
$2,536.24
A8
2 Party: Member Medicare A/B/D; Spouse (over 65) A/B unknown
$1,470.88
A9
2 Party: Member Medicare B/D; Spouse (over 65) A/B unknown
$1,782.88
B1
2 Party: Member None (under 65); Spouse (over 65) A/B unknown
$1,845.32
B2
2 Party: Member (over 65) A ; Spouse (over 65) A/B unknown
$2,223.22
B3
3 Party: Member (over 65) A/B unknown; Spouse Medicare A/B/D; Deps (under 65)
$1,672.02
B4
3 Party: Member (over 65) A/B unknown; Spouse Medicare B/D; Deps (under 65)
$1,984.02
B5
3 Party: Member (over 65) A/B unknown; Spouse None (under 65); Deps (under 65)
$2,040.74
B6
3 Party: Member (over 65) A/B unknown; Spouse (over 65) A ; Deps (under 65)
$2,424.38
B7
3 Party: Member (over 65) A/B unknown; Spouse (over 65) B ; Deps (under 65)
$2,737.40
B8
3 Party: Member Medicare A/B/D; Spouse (over 65) A/B unknown; Deps (under 65)
$1,672.04
B9
3 Party: Member Medicare B/D; Spouse (over 65) A/B unknown; Deps (under 65)
$1,984.04
C1
3 Party: Member None (under 65); Spouse (over 65) A/B unknown; Deps (under 65)
$2,046.48
C2
3 Party: member (over 65) A ; Spouse (over 65) A/B unknown, Deps (under 65)
$2,424.38
C3
3 Party: Member (over 65) B ; Spouse (over 65) A/B unknown; Deps (under 65)
$2,737.40
C4
3 Party: Member (over 65) A/B unknown; Spouse A/B unknown; Deps (under 65)
$2,737.40
C5
3 Party: Member (over 65) A/B unknown; Spouse (over 65) A/B Unassigned; Deps (under 65)
$2,424.38
C6
3 Party: Member (over 65) A/B Unassigned; Spouse (over 65) A/B unknown; Deps (under 65)
$2,424.38
C7
2 Party: Member (overs 65) A/B unknown; Spouse (over 65) A/B unassigned
$2,223.22
C8
2 Party: Member (over 65) A/B Unassigned; Spouse (over 65) A/B unknown
$2,223.22