University of California Human Resources and Benefits

2013 Medical Plan Costs - $50,000 or Less

Plan		Self	Self + Child(ren)	Self + Adult	Self + Adult + Child(ren)
Anthem Blue Cross PLUS	Employee Cost	$75.43	$135.77	$206.61	$266.94
Anthem Blue Cross PLUS	UC Contribution	558.21	1,004.78	1,124.04	1,570.61
Anthem Blue Cross PPO	Employee Cost	$106.76	$192.17	$272.40	$357.80
Anthem Blue Cross PPO	UC Contribution	558.21	1,004.78	1,124.04	1,570.61
Anthem Lumenos PPO with HRA	Employee Cost	$9.67	$17.41	$20.31	$28.04
Anthem Lumenos PPO with HRA	UC Contribution	478.51	861.31	1,004.87	1,387.68
Core	Employee Cost	$0.00	$0.00	$0.00	$0.00
Core	UC Contribution	112.21	201.98	235.64	325.41
Health Net Blue & Gold	Employee Cost	$25.26	$45.47	$101.25	$121.45
Health Net Blue & Gold	UC Contribution	558.21	1,004.78	1,124.04	1,570.61
Health Net HMO	Employee Cost	$108.28	$194.91	$275.59	$362.21
Health Net HMO	UC Contribution	558.21	1,004.78	1,124.04	1,570.61
Kaiser Permanente--California	Employee Cost	$9.67	$17.41	$20.31	$28.04
Kaiser Permanente--California	UC Contribution	503.23	905.81	1,056.79	1,459.38
Kaiser Permanente--Umbrella	Employee Cost	$137.54	$247.57	$337.04	$447.07
Kaiser Permanente--Umbrella	UC Contribution	558.21	1,004.78	1,124.04	1,570.61
Western Health Advantage	Employee Cost	$9.67	$17.41	$20.31	$28.04
Western Health Advantage	UC Contribution	523.36	942.05	1,099.06	1,517.74

Rates for union-represented employees are subject to ongoing collective bargaining as appropriate.

Medical Plan Costs - $50,001 to $98,000

Plan		Self	Self + Child(ren)	Self + Adult	Self + Adult + Child(ren)
Anthem Blue Cross PLUS	Employee Cost	$111.48	$200.66	$288.91	$378.08
Anthem Blue Cross PLUS	UC Contribution	522.16	939.89	1,041.74	1,459.47
Anthem Blue Cross PPO	Employee Cost	$142.81	$257.06	$354.70	$468.94
Anthem Blue Cross PPO	UC Contribution	522.16	939.89	1,041.74	1,459.47
Anthem Lumenos PPO with HRA	Employee Cost	$45.72	$82.30	$102.61	$139.18
Anthem Lumenos PPO with HRA	UC Contribution	442.46	796.42	922.57	1,276.54
Core	Employee Cost	$0.00	$0.00	$0.00	$0.00
Core	UC Contribution	112.21	201.98	235.64	325.41
Health Net Blue & Gold	Employee Cost	$61.31	$110.36	$183.55	$232.59
Health Net Blue & Gold	UC Contribution	522.16	939.89	1,041.74	1,459.47
Health Net HMO	Employee Cost	$144.33	$259.80	$357.89	$473.35
Health Net HMO	UC Contribution	522.16	939.89	1,041.74	1,459.47
Kaiser Permanente--California	Employee Cost	$45.72	$82.30	$102.61	$139.18
Kaiser Permanente--California	UC Contribution	467.18	840.92	974.49	1,348.24
Kaiser Permanente--Umbrella	Employee Cost	$173.59	$312.46	$419.34	$558.21
Kaiser Permanente--Umbrella	UC Contribution	522.16	939.89	1,041.74	1,459.47
Western Health Advantage	Employee Cost	$45.72	$82.30	$102.61	$139.18
Western Health Advantage	UC Contribution	487.31	877.16	1,016.76	1,406.60

Rates for union-represented employees are subject to ongoing collective bargaining as appropriate.

Medical Plan Costs - $98,001 to $147,000

Plan		Self	Self + Child(ren)	Self + Adult	Self + Adult + Child(ren)
Anthem Blue Cross PLUS	Employee Cost	$148.48	$267.26	$362.67	$481.44
Anthem Blue Cross PLUS	UC Contribution	485.16	873.29	967.98	1,356.11
Anthem Blue Cross PPO	Employee Cost	$179.81	$323.66	$428.46	$572.30
Anthem Blue Cross PPO	UC Contribution	485.16	873.29	967.98	1,356.11
Anthem Lumenos PPO with HRA	Employee Cost	$82.72	$148.90	$176.37	$242.54
Anthem Lumenos PPO with HRA	UC Contribution	405.46	729.82	848.81	1,173.18
Core	Employee Cost	$0.00	$0.00	$0.00	$0.00
Core	UC Contribution	112.21	201.98	235.64	325.41
Health Net Blue & Gold	Employee Cost	$98.31	$176.96	$257.31	$335.95
Health Net Blue & Gold	UC Contribution	485.16	873.29	967.98	1,356.11
Health Net HMO	Employee Cost	$181.33	$326.40	$431.65	$576.71
Health Net HMO	UC Contribution	485.16	873.29	967.98	1,356.11
Kaiser Permanente--California	Employee Cost	$82.72	$148.90	$176.37	$242.54
Kaiser Permanente--California	UC Contribution	430.18	774.32	900.73	1,244.88
Kaiser Permanente--Umbrella	Employee Cost	$210.59	$379.06	$493.10	$661.57
Kaiser Permanente--Umbrella	UC Contribution	485.16	873.29	967.98	1,356.11
Western Health Advantage	Employee Cost	$82.72	$148.90	$176.37	$242.54
Western Health Advantage	UC Contribution	450.31	810.56	943.00	1,303.24

Rates for union-represented employees are subject to ongoing collective bargaining as appropriate.

Medical Plan Costs - $147,001 or More

Plan		Self	Self + Child(ren)	Self + Adult	Self + Adult + Child(ren)
Anthem Blue Cross PLUS	Employee Cost	$186.79	$336.22	$439.09	$588.51
Anthem Blue Cross PLUS	UC Contribution	446.85	804.33	891.56	1,249.04
Anthem Blue Cross PPO	Employee Cost	$218.12	$392.62	$504.88	$679.37
Anthem Blue Cross PPO	UC Contribution	446.85	804.33	891.56	1,249.04
Anthem Lumenos PPO with HRA	Employee Cost	$121.03	$217.86	$252.79	$349.61
Anthem Lumenos PPO with HRA	UC Contribution	367.15	660.86	772.39	1,066.11
Core	Employee Cost	$0.00	$0.00	$0.00	$0.00
Core	UC Contribution	112.21	201.98	235.64	325.41
Health Net Blue & Gold	Employee Cost	$136.62	$245.92	$333.73	$443.02
Health Net Blue & Gold	UC Contribution	446.85	804.33	891.56	1,249.04
Health Net HMO	Employee Cost	$219.64	$395.36	$508.07	$683.78
Health Net HMO	UC Contribution	446.85	804.33	891.56	1,249.04
Kaiser Permanente--California	Employee Cost	$121.03	$217.86	$252.79	$349.61
Kaiser Permanente--California	UC Contribution	391.87	705.36	824.31	1,137.81
Kaiser Permanente--Umbrella	Employee Cost	$248.90	$448.02	$569.52	$768.64
Kaiser Permanente--Umbrella	UC Contribution	446.85	804.33	891.56	1,249.04
Western Health Advantage	Employee Cost	$121.03	$217.86	$252.79	$349.61
Western Health Advantage	UC Contribution	412.00	741.60	866.58	1,196.17

Rates for union-represented employees are subject to ongoing collective bargaining as appropriate.

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