small business rate tables - blue shield of california...napa alpine solano contra-costa san joaquin...

blueshieldca.com

Small Business Rate TablesIncludes rates for standard plans

Effective October 2017

Rate Book 5Rating region 12: San Luis Obispo, Santa Barbara, Ventura

AMADOR

DELNORTE

TRINITYHUMBOLDT

PLUMAS

SIERRA

NEVADA

PLACER

TEHAMA

COLUSA

SUTTER

YUBA

SACRA-MENTO

YOLO

LAKE

BUTTEGLENN

MENDOCINO

SONOMA

MARIN

EL DORADO

ALPINENAPA

SOLANO

CONTRA-COSTA

SAN JOAQUIN

STANISLAUS

MERCED

FRESNO

MADERA

MARIPOSA

MONO

INYO

TULARE

KINGS

SAN BERNARDINO

KERN

LOS ANGELESVENTURA

SANTA BARBARA

SAN LUIS OBISPO

MONTEREY

SAN BENITO

ORANGE RIVERSIDE

SAN DIEGO

IMPERIAL

TUOLUMNE

ALAMEDA

MODOCSISKIYOU

SHASTA LASSEN

AMADOR

CALAVER

AS

SANTACLARA

SAN FRANCISCO

SAN MATEO

SANTA CRUZ

1 Counties where Full network HMO is available. 2 Counties where Dental HMO is available.

Blue Shield of California county grouping for Rate Book 5Region 12 – South Coast: San Luis Obispo,1 Santa Barbara,1,2 Ventura1,2

CONTENTSLife Insurance Rates

Small Business Rate Tables

Small Business Rates:

Regional Groupings

Region 12

..................................................................

..................................................................23

.................................................................. 6

Region 1 - 19Life Insurance Rates

Age Rate/$1,000

*Includes $.05 Accidental Death & Dismemberment Insurance

Dependent Life Insurance Rates for 2-9 eligible employees are $.45/$1,000.

Benefits Allowed for new groups of 2 to 100 eligible employees:Flat, Graded, or Salaried Plans

2

40-44 .3345-49 .4650-54 .7455-59 1.15

0-29 $ .1930-34 .2035-39 .21

60-64 2.2565-69¹ 3.7570-74² 5.3375-79² 8.3980-84² 12.0585+² 18.04

Life Insurance Rates forBlue Shield of California Group Plans

2-9 Eligible Employee Rate TableEffective October 2017

Basic group term life and AD&D insurance is underwritten by Blue Shield of CaliforniaLife & Health Insurance Company.

Groups with 10 to 100 eligible employees will be composite rated.Contact your Blue Shield sales representative for a quote.

¹Benefit amount is reduced by 35% of the original amount at age 65.²Benefit amount is reduced by 50% of the original amount at age 70.

2

SMALL BUSINESS OFF EXCHANGE RATING REGION DEFINITIONS AND ACCESS+ HMO® & INO AVAILABILITY


RatingRegion County

Access+HMO®Network

Availability

DentalHMO

Availability

DentalINO

Availability

RatingRegion County

Access+HMO®Network

Availability

DentalHMO

Availability

DentalINO

Availability

1 Alpine 8 San Mateo

Amador

Butte 9 Monterey

Calaveras San Benito

Colusa Santa Cruz

Del NorteGlenn 10 Mariposa

Humboldt Merced

Lake San Joaquin

Lassen Stanislaus

Mendocino Tulare

Modoc

Nevada 11 Fresno

Plumas Kings

Shasta Madera

SierraSiskiyou 12 San Luis Obispo

Sutter Santa Barbara

Tehama Ventura

Trinity

Tuolumne 13 Imperial

Yuba Inyo

Mono2 Marin

Napa 14 Kern

Solano

Sonoma 15 Los Angeles ZIP Codes*

3 El Dorado 16 Los Angeles - Except

Placer ZIP Codes in Region 15Sacramento

Yolo 17 Riverside

San Bernardino

4 San Francisco

18 Orange

5 Contra Costa

19 San Diego

6 Alameda

7 Santa Clara

* Los Angeles Region 15 ZIP Codes: 90601-90610, 90612, 90637-90639, 90640, 90650-90652, 90659-90662, 90665, 90670-90671, 90701-90704, 90706-90707, 90710-90717, 90723, 90731-90734, 90744-90749, 90755, 90800-90810, 90813-90815, 90822, 90831-90835, 90840, 90842, 90844-90848, 90853, 90888, 90895, 90899, 91001-91003, 91006-91012, 91016-91017, 91020-91021, 91023-91025, 91030-91031, 91040-91043, 91046, 91050-91051, 91066, 91077, 91100-91110, 91114-91118, 91121, 91123-91126, 91129, 91131, 91175, 91182, 91184-91189, 91191, 91199-91210, 91214, 91221-91222, 91224-91226, 91500-91508, 91510, 91521-91523, 91526, 91702, 91706, 91711, 91714-91716, 91722-91724, 91731-91735, 91740-91741, 91744-91750, 91754-91756, 91765-91773, 91775-91776, 91778, 91780, 91788-91793, 91795, 91797, 91799-91804, 91841, 91896, 91899, 93510, 93532, 93534-93536, 93539, 93543-93544, 93550-93553, 93563, 93584, 93586, 93590-93591, 93599.

33

SMALL BUSINESS OFF EXCHANGE LOCAL ACCESS+ HMO® NETWORK RATING REGION DEFINITIONS AND AVAILABILITY


RatingRegion County Rating

Region County

1 None. 15 Los Angeles zip codes: 90601-90610, 90637-90640,90650-90652, 90660-90662, 90670-90671, 90701-90703,

2 Marin, Sonoma. 90706-90707, 90710-90717, 90723, 90731-90734, 90744-90749, 90755, 90801-90810, 90813-90815, 90822, 90831-90835, 90840,

3 Sacramento except zip codes: 95632, 95638-95639, 95641, 90842, 90844, 90846-90848, 90853, 90895, 90899, 91001, 95671, 95680, 95683, 95690, 95693, 95798, 95799. 91006-91012, 91016-91017, 91020-91021, 91023-91025,

91030-91031, 91040-91043, 91046, 91066, 91077, 91101-91110, Yolo. 91114-91118, 91121, 91123-91126, 91129, 91182, 91184-91185,

91188-91189, 91199, 91201-91210, 91214, 91221-91222, 4 San Francisco. 91224-91226, 91501-91508, 91510, 91521-91523, 91526, 91702,

91706, 91711, 91714-91716, 91722-91724, 91731-91735, 5 Contra Costa except zip codes: 94525, 94530, 94547, 94551, 91740-91741, 91744-91750, 91754-91756, 91765-91773,

94564, 94569, 94572, 94801-94808, 94820, 94850. 91775-91776, 91778, 91780, 91788-91793, 91795, 91797, 91801-91804, 91896, 91899, 93563.

6 None.16 Los Angeles except zip codes in Rating Region 15 and except

7 Santa Clara. zip codes: 90704, 93510, 93532, 93534-93536, 93539, 93543-93544, 93550-93553, 93584, 93586, 93590-93591, 93599.

8 San Mateo except zip codes: 94018-94021, 94028, 94037-94038,94060, 94074. 17 Riverside except zip codes: 92225-92226, 92239, 92275, 92539.

9 Santa Cruz. San Bernardino except zip codes: 91759, 92242, 92252, 92256,92267-92268, 92277-92278, 92280, 92284-92286, 92304-92305,

10 Stanislaus. 92309-92310, 92314-92315, 92317, 92321-92323, 92325-92327, 92332-92333, 92338, 92341-92342, 92347, 92352, 92356, 92358,

11 None. 92363-92366, 92368, 92372, 92378, 92382, 92385-92386, 92391, 92395, 92397-92398, 92407, 93562, 93592.

12 San Luis Obispo. 18 Orange.

Ventura except zip codes: 00061, 93013. 93225, 93252.19 San Diego except zip codes: 91905-91906, 91934, 91963, 91980,

13 None. 91987, 92004, 92036, 92066, 92086.

14 Kern except zip codes: 93205-93206, 93220, 93222,93224-93226, 93238, 93240, 93243, 93249, 93251-93252, 93255, 93268, 93283, 93285, 93287, 93501-93502, 93504-93505, 93516, 93518-93519, 93524, 93555, 93558, 93560, 93596.

44

SMALL BUSINESS OFF EXCHANGE AND MIRROR ACO HMO NETWORK RATING REGION DEFINITIONS AND AVAILABILITY


RatingRegion County Rating

Region County

1 Nevada zip codes: 95712, 95924, 95945-95946, 95949, 95959-95960, 14 Kern zip codes: 93203, 93205-93206, 93215-93216, 93220, 93224-93226, 95975, 95986. 93240-93241, 93250-93252, 93255, 93263, 93268, 93276, 93280, 93283,

93285, 93287, 93301-93309, 93311-93314, 93380, 93383-93390,2 Solano zip codes: 94503, 94510, 94589, 94592, 95620. 93501-93502, 93504-93505, 93516, 93518, 93531, 93560-93561, 93596.

3 El Dorado zip codes: 95664, 95672, 95682, 95762.15 Los Angeles zip codes: 90601-90610, 90637-90640, 90650-90652,

Placer zip codes: 95602-95604, 95648, 95650, 95658, 95661, 95663, 90660-90662, 90670, 90701-90703, 90706-90707, 90710-90717,95677-95678, 95713, 95746-95747, 95765. 90723, 90731-90734, 90744-90749, 90755, 90801-90810, 90813-90815,

90822, 90831-90835, 90840, 90842, 90844, 90846-90848, 90853, 90895,Sacramento zip codes: 94203-94206, 92409, 94229-94230, 94232, 90899, 91001, 91003, 91006-91012, 91016-91017, 91020-91025, 94235-94237, 94239-94240, 94244, 94247-94250, 94252, 94254, 91030-91031, 91040-91043, 91046, 91066, 91077, 91101-91110,94256-94259, 94261-94263, 94267-94269, 94271, 94273-94274, 91114-91118, 91121, 91123-91126, 91129, 91182, 91184-91185,94277-94280, 94283-94290, 94293, 94298, 95608-95611, 95615, 95621, 91188-91189, 91199, 91201-90210, 91214, 91221-91222, 91224-91226,95624, 95626, 95628, 95630, 95632, 95638-95639, 95652, 95655, 95660, 91501-91508, 91510, 91521-91523, 91702, 91706, 91711, 91715-91716, 95662, 95670-95671, 95673, 95683, 95693, 95741-95742, 95757-95759, 91722-91724, 91731-91735, 91740-91741, 91744-91750, 91754-91756, 95763, 95812-95838, 95840-95843, 95851-95853, 95860, 95864-95867, 91765-91773, 91775-91776, 91778, 91780, 91788-91793, 91801-91803, 95894, 95899. 91899, 93510, 93563.

Yolo zip codes: 95605-95607, 95612, 95616-95618, 95627, 95637, 95645, 16 Los Angeles zip codes: 90001-90084, 90086-90091, 90093-90096, 95653, 95691, 95694-95695, 95697-95698, 95776, 95798-95799, 95937. 90189, 90201-90202, 90209-90213, 90220-90224, 90230-90232,

90239-90242, 90245, 90247-90251, 90254-90255, 90260-90267, 90270, 4 San Francisco. 90272, 90274-90275, 90277-90278, 90280, 90290-90296, 90301-90312,

90401-90411, 90501-90510, 91301-91311, 91313, 91316, 91321-91322,5 Contra Costa zip codes: 94506-94507, 94509, 94511, 94513-94514, 91324-91331, 91333-91335, 91337, 91340-91346, 91350-91357,

94516-94529, 94531, 94548-94549, 94553, 94556, 94561, 94563-94565, 91364-91365, 91367, 91371-91372, 91376, 91380-91381, 91383-91387,94570, 94575, 94582-94583, 94595-94598. 91390, 91392-91396, 91401-91413, 91416, 91423, 91426, 91436, 91470,

91482, 91495-91496, 91499, 91601-91612, 91614-91617.6 Alameda zip codes: 94550-94551, 94566, 94568, 94588.

17 Riverside zip codes: 91752, 92220, 92223, 92230, 92320, 92501-92509, 7 Santa Clara. 92513-92514, 92516-92519, 92521-92522, 92530-92532, 92543-92546,

92548, 92551-92557, 92562-92564, 92567, 92570-92572, 92581-92587, 8 San Mateo. 92589-92593, 92595-92596, 92599, 92860, 92877-92883.

9 Santa Cruz. San Bernardino zip codes: 91701, 91708-91710, 91729-91730, 91737,91739, 91743, 91758, 91761-91764, 91784-91786, 92301, 92305,

10 San Joaquin. 92307-92308, 92313-92318, 92321-92322, 92324-92325, 92329,92331, 92333-92337, 92339-92342, 92344-92346, 92350, 92352,

Stanislaus zip codes: 95307, 95313, 95316, 95319, 95323, 95326, 92354, 92356-92359, 92368-92369, 92371-92378, 92382, 92385-92386, 95328-95329, 95350-95358, 95361, 95363, 95367-95368, 95380-95382, 92391-92395, 92397, 92399, 92401-92408, 92410-92411, 92413, 92415, 95386-95387, 95397. 92418, 92423, 92427.

Tulare zip codes: 93219, 93256, 93260. 18 Orange.

11 None. 19 San Diego zip codes: 91901-91903, 91905-91906, 91908-91917,91921, 91931-91933, 91935, 91941-91946, 91948, 91950-91951,

12 Ventura zip codes: 91319-91320, 91358-91362, 91377, 93010-93012, 91962-91963, 91976-91980, 91987, 92003, 92007-92011, 92013-92014, 93015-93016, 93020-93021, 93040, 93062-93066, 93094, 93099. 92018-92030, 92033, 92036-92040, 92046, 92049, 92051-92052,

92054-92061, 92064-92065, 92067-92069, 92071-92072, 92074-92075,13 None. 92078-92079, 92081-92085, 92088, 92091-92093, 92096, 92101-92124,

92126-92132, 92134-92140, 92142-92143, 92145, 92147, 92149-92150,92152-92155, 92158-92161, 92163, 92165-92179, 92182, 92186-92187, 92190-92193, 92195-92199.

55

Blue Shield Bronze 60 PPO 6300/75 + Child DentalRegion-12

AgeMember

RateAge

Member

Rate

169.410-20

266.7921

266.7922

266.7923

266.7924

267.8625

273.1926

279.6027

290.0028

298.5429

302.8130

309.2131

315.6132

319.6133

323.8834

326.0235

328.1536

330.2937

332.4238

336.6939

340.9640

347.3641

353.5042

362.0343

372.7044

385.2445

400.1846

416.9947

436.2048

455.1449

476.4950

497.5651

520.7752

544.2553

569.6054

594.9455

622.4256

650.1757

679.7858

694.4559

724.0760

749.6861

766.4962

787.5663

800.3764

800.3765 & over

12-205/16/2017

Regions may vary by product. The Small Business Off Exchange Rating Region Definitions chart located near the front of this booklet identifies the counties

located in each region.

05/16/2017 6

Bronze Full PPO 5100/60 OffExRegion-12

AgeMember

RateAge

Member

Rate

193.150-20

304.1721

304.1722

304.1723

304.1724

305.3825

311.4726

318.7727

330.6328

340.3629

345.2330

352.5331

359.8332

364.3933

369.2634

371.6935

374.1336

376.5637

378.9938

383.8639

388.7340

396.0341

403.0242

412.7643

424.9244

439.2245

456.2546

475.4147

497.3148

518.9149

543.2450

567.2751

593.7452

620.5053

649.4054

678.2955

709.6256

741.2657

775.0258

791.7559

825.5160

854.7161

873.8762

897.9063

912.5064

912.5065 & over

12-305/16/2017



05/16/2017 7

Bronze Full PPO 3750/65 OffExRegion-12

AgeMember

RateAge

Member

Rate

191.260-20

301.2021

301.2022

301.2023

301.2024

302.4025

308.4326

315.6527

327.4028

337.0429

341.8630

349.0931

356.3232

360.8333

365.6534

368.0635

370.4736

372.8837

375.2938

380.1139

384.9340

392.1641

399.0942

408.7243

420.7744

434.9345

451.8046

470.7747

492.4648

513.8449

537.9450

561.7351

587.9452

614.4453

643.0654

671.6755

702.6956

734.0257

767.4558

784.0259

817.4560

846.3661

865.3462

889.1363

903.5964

903.5965 & over

12-405/16/2017



05/16/2017 8

Blue Shield Silver 70 PPO 2000/45 + Child DentalRegion-12

AgeMember

RateAge

Member

Rate

221.540-20

348.8921

348.8922

348.8923

348.8924

350.2825

357.2626

365.6327

379.2428

390.4129

395.9930

404.3631

412.7332

417.9733

423.5534

426.3435

429.1336

431.9237

434.7138

440.3039

445.8840

454.2541

462.2842

473.4443

487.4044

503.7945

523.3346

545.3147

570.4348

595.2049

623.1150

650.6851

681.0352

711.7353

744.8854

778.0255

813.9656

850.2457

888.9758

908.1659

946.8860

980.3761

1,002.3562

1,029.9263

1,046.6664

1,046.6665 & over

12-605/16/2017



05/16/2017 9

Silver Full PPO 1700/40 OffExRegion-12

AgeMember

RateAge

Member

Rate

211.800-20

333.5421

333.5422

333.5423

333.5424

334.8725

341.5426

349.5527

362.5528

373.2329

378.5630

386.5731

394.5732

399.5833

404.9134

407.5835

410.2536

412.9237

415.5938

420.9239

426.2640

434.2641

441.9342

452.6143

465.9544

481.6345

500.3046

521.3247

545.3348

569.0149

595.6950

622.0451

651.0652

680.4153

712.1054

743.7855

778.1456

812.8357

849.8558

868.1959

905.2260

937.2361

958.2562

984.6063

1,000.6164

1,000.6165 & over

12-705/16/2017



05/16/2017 10

Silver Full PPO 1300/45 OffExRegion-12

AgeMember

RateAge

Member

Rate

211.300-20

332.7621

332.7622

332.7623

332.7624

334.0925

340.7426

348.7327

361.7128

372.3629

377.6830

385.6731

393.6532

398.6433

403.9734

406.6335

409.2936

411.9537

414.6238

419.9439

425.2640

433.2541

440.9042

451.5543

464.8644

480.5045

499.1446

520.1047

544.0648

567.6849

594.3150

620.5951

649.5452

678.8353

710.4454

742.0555

776.3256

810.9357

847.8758

866.1759

903.1060

935.0561

956.0162

982.3063

998.2764

998.2765 & over

12-805/16/2017



05/16/2017 11

Gold Full PPO 1000/35 OffExRegion-12

AgeMember

RateAge

Member

Rate

232.820-20

366.6421

366.6422

366.6423

366.6424

368.1125

375.4426

384.2427

398.5428

410.2729

416.1430

424.9431

433.7432

439.2433

445.1134

448.0435

450.9736

453.9137

456.8438

462.7039

468.5740

477.3741

485.8042

497.5443

512.2044

529.4345

549.9746

573.0647

599.4648

625.4949

654.8350

683.7951

715.6952

747.9553

782.7854

817.6255

855.3856

893.5157

934.2158

954.3759

995.0760

1,030.2761

1,053.3762

1,082.3363

1,099.9364

1,099.9365 & over

12-905/16/2017



05/16/2017 12


AgeMember

RateAge

Member

Rate

241.460-20

380.2521

380.2522

380.2523

380.2524

381.7725

389.3826

398.5027

413.3328

425.5029

431.5830

440.7131

449.8432

455.5433

461.6234

464.6735

467.7136

470.7537

473.7938

479.8839

485.9640

495.0941

503.8342

516.0043

531.2144

549.0845

570.3746

594.3347

621.7148

648.7149

679.1350

709.1751

742.2552

775.7153

811.8354

847.9655

887.1256

926.6757

968.8858

989.7959

1,032.0060

1,068.5061

1,092.4662

1,122.5063

1,140.7564

1,140.7565 & over

12-1005/16/2017



05/16/2017 13


AgeMember

RateAge

Member

Rate

248.730-20

391.6921

391.6922

391.6923

391.6924

393.2625

401.1026

410.5027

425.7728

438.3129

444.5730

453.9731

463.3732

469.2533

475.5234

478.6535

481.7836

484.9237

488.0538

494.3239

500.5940

509.9941

519.0042

531.5343

547.2044

565.6145

587.5446

612.2247

640.4248

668.2349

699.5750

730.5151

764.5952

799.0653

836.2754

873.4855

913.8256

954.5657

998.0458

1,019.5859

1,063.0660

1,100.6661

1,125.3462

1,156.2863

1,175.0864

1,175.0865 & over

12-1105/16/2017



05/16/2017 14

Blue Shield Gold 80 PPO 0/30 + Child DentalRegion-12

AgeMember

RateAge

Member

Rate

258.090-20

406.4521

406.4522

406.4523

406.4524

408.0725

416.2026

425.9527

441.8128

454.8129

461.3230

471.0731

480.8232

486.9233

493.4234

496.6835

499.9336

503.1837

506.4338

512.9339

519.4440

529.1941

538.5442

551.5543

567.8044

586.9145

609.6746

635.2747

664.5448

693.4049

725.9150

758.0251

793.3852

829.1553

867.7654

906.3755

948.2456

990.5157

1,035.6258

1,057.9859

1,103.0960

1,142.1161

1,167.7262

1,199.8363

1,219.3464

1,219.3465 & over

12-1205/16/2017



05/16/2017 15


AgeMember

RateAge

Member

Rate

246.480-20

388.1621

388.1622

388.1623

388.1624

389.7225

397.4826

406.7927

421.9328

434.3529

440.5730

449.8831

459.2032

465.0233

471.2334

474.3435

477.4436

480.5537

483.6538

489.8639

496.0740

505.3941

514.3242

526.7443

542.2644

560.5145

582.2446

606.7047

634.6548

662.2149

693.2650

723.9251

757.6952

791.8553

828.7354

865.6055

905.5856

945.9557

989.0458

1,010.3959

1,053.4760

1,090.7461

1,115.1962

1,145.8663

1,164.4964

1,164.4965 & over

12-1405/16/2017



05/16/2017 16

Platinum Full PPO 150/15 OffExRegion-12

AgeMember

RateAge

Member

Rate

285.300-20

449.3021

449.3022

449.3023

449.3024

451.0925

460.0826

470.8627

488.3828

502.7629

509.9530

520.7331

531.5232

538.2633

545.4534

549.0435

552.6336

556.2337

559.8238

567.0139

574.2040

584.9841

595.3242

609.6943

627.6744

648.7845

673.9446

702.2547

734.6048

766.5049

802.4450

837.9451

877.0352

916.5653

959.2554

1,001.9355

1,048.2156

1,094.9357

1,144.8158

1,169.5259

1,219.3960

1,262.5261

1,290.8362

1,326.3263

1,347.8964

1,347.8965 & over

12-1505/16/2017



05/16/2017 17

Blue Shield Platinum 90 PPO 0/15 + Child DentalRegion-12

AgeMember

RateAge

Member

Rate

289.080-20

455.2521

455.2522

455.2523

455.2524

457.0725

466.1726

477.1027

494.8528

509.4229

516.7130

527.6331

538.5632

545.3933

552.6734

556.3135

559.9636

563.6037

567.2438

574.5239

581.8140

592.7341

603.2042

617.7743

635.9844

657.3845

682.8746

711.5547

744.3348

776.6549

813.0750

849.0451

888.6452

928.7153

971.9654

1,015.2055

1,062.0956

1,109.4457

1,159.9758

1,185.0159

1,235.5460

1,279.2561

1,307.9362

1,343.8963

1,365.7464

1,365.7465 & over

12-1605/16/2017



05/16/2017 18

Platinum Full PPO 0/10 OffExRegion-12

AgeMember

RateAge

Member

Rate

296.270-20

466.5721

466.5722

466.5723

466.5724

468.4425

477.7726

488.9727

507.1628

522.0929

529.5630

540.7631

551.9532

558.9533

566.4234

570.1535

573.8836

577.6237

581.3538

588.8139

596.2840

607.4841

618.2142

633.1443

651.8044

673.7345

699.8646

729.2547

762.8548

795.9749

833.3050

870.1651

910.7552

951.8153

996.1354

1,040.4655

1,088.5156

1,137.0457

1,188.8358

1,214.4959

1,266.2860

1,311.0761

1,340.4662

1,377.3263

1,399.7264

1,399.7265 & over

12-1805/16/2017



05/16/2017 19

Bronze Full PPO Savings 5500/40% OffExRegion-12

AgeMember

RateAge

Member

Rate

179.940-20

283.3721

283.3722

283.3723

283.3724

284.5025

290.1726

296.9727

308.0228

317.0929

321.6230

328.4331

335.2332

339.4833

344.0134

346.2835

348.5436

350.8137

353.0838

357.6139

362.1540

368.9541

375.4642

384.5343

395.8744

409.1945

425.0546

442.9147

463.3148

483.4349

506.1050

528.4851

553.1452

578.0753

604.9954

631.9155

661.1056

690.5757

722.0358

737.6159

769.0760

796.2761

814.1262

836.5163

850.1164

850.1165 & over

12-1905/16/2017



05/16/2017 20

Bronze Full PPO Savings 4700/40% OffExRegion-12

AgeMember

RateAge

Member

Rate

181.910-20

286.4821

286.4822

286.4823

286.4824

287.6225

293.3526

300.2327

311.4028

320.5729

325.1530

332.0331

338.9032

343.2033

347.7834

350.0735

352.3736

354.6637

356.9538

361.5339

366.1240

372.9941

379.5842

388.7543

400.2144

413.6745

429.7146

447.7647

468.3948

488.7349

511.6550

534.2851

559.2052

584.4153

611.6354

638.8455

668.3556

698.1457

729.9458

745.7059

777.5060

805.0061

823.0562

845.6863

859.4364

859.4365 & over

12-2005/16/2017



05/16/2017 21

Region-12Silver Full PPO Savings 2000/20% OffEx

AgeMember

RateAge

Member

Rate

225.570-20

355.2221

355.2222

355.2223

355.2224

356.6525

363.7526

372.2827

386.1328

397.5029

403.1830

411.7131

420.2332

425.5633

431.2434

434.0835

436.9336

439.7737

442.6138

448.2939

453.9840

462.5041

470.6742

482.0443

496.2544

512.9445

532.8446

555.2247

580.7948

606.0149

634.4350

662.4951

693.4052

724.6653

758.4054

792.1555

828.7456

865.6857

905.1158

924.6559

964.0860

998.1861

1,020.5662

1,048.6263

1,065.6764

1,065.6765 & over

12-2105/16/2017



05/16/2017 22

Blue Shield Silver 70 HMO 2000/45 + Child Dental INF*Region-12

AgeMember

RateAge

Member

Rate

166.590-20

262.3421

262.3422

262.3423

262.3424

263.3925

268.6426

274.9427

285.1728

293.5629

297.7630

304.0631

310.3532

314.2933

318.4934

320.5935

322.6836

324.7837

326.8838

331.0839

335.2840

341.5741

347.6142

356.0043

366.5044

378.8345

393.5246

410.0547

428.9348

447.5649

468.5550

489.2751

512.1052

535.1853

560.1154

585.0355

612.0556

639.3357

668.4658

682.8859

712.0060

737.1961

753.7262

774.4463

787.0364

787.0365 & over

12-2205/16/2017

*Enrolled employees and their dependents must live or work in the Trio ACO HMO plan service area to be eligible for coverage. Regions may vary by product.

The Small Business Off Exchange Rating Region Definitions chart located near the front of this booklet identifies the counties located in each region.

05/16/2017 23

Silver Access+ HMO® 1700/55 OffEx*Region-12

AgeMember

RateAge

Member

Rate

193.980-20

305.4921

305.4922

305.4923

305.4924

306.7125

312.8226

320.1527

332.0628

341.8429

346.7330

354.0631

361.3932

365.9733

370.8634

373.3035

375.7536

378.1937

380.6438

385.5239

390.4140

397.7441

404.7742

414.5443

426.7644

441.1245

458.2346

477.4747

499.4748

521.1649

545.6050

569.7351

596.3152

623.1953

652.2154

681.2355

712.7056

744.4757

778.3858

795.1859

829.0960

858.4261

877.6662

901.7963

916.4664

916.4665 & over

12-2405/16/2017

*The employer must be located in, and all enrolled employees and family members must live or work in, the Blue Shield of California Access+ HMO® service

area in order to be eligible to purchase. Regions may vary by product. The Small Business Off Exchange Rating Region Definitions chart located near the front

of this booklet identifies the counties located in each region.

05/16/2017 2405/16/2017 24

Silver Local Access+ HMO® 1700/55 OffEx*Region-12

AgeMember

RateAge

Member

Rate

190.610-20

300.1821

300.1822

300.1823

300.1824

301.3825

307.3826

314.5927

326.2928

335.9029

340.7030

347.9131

355.1132

359.6133

364.4234

366.8235

369.2236

371.6237

374.0238

378.8239

383.6340

390.8341

397.7442

407.3443

419.3544

433.4645

450.2746

469.1847

490.7948

512.1049

536.1250

559.8351

585.9552

612.3653

640.8854

669.4055

700.3156

731.5357

764.8558

781.3659

814.6860

843.5061

862.4162

886.1363

900.5364

900.5365 & over

12-2505/16/2017

*Local Access+ HMO plans are only available to employers that are located in a Local Access+ HMO service area. Employees and their dependents must live or work in the service area to be eligible for coverage. Local Access+ HMO products are only available in designated counties: portions of Contra Costa, Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Mateo, and Ventura counties, as well as in all of Marin, Orange, San Francisco, San Luis Obispo, Santa Clara, Santa Cruz, Sonoma, Stanislaus, and Yolo counties. Please review the Benefit Summary Guide (A16609) for detailed information regarding the Local Access+HMO service area. Regions may vary by product. The Small Business Off Exchange Rating Region Definitions chart located near the front of this booklet identifies the counties located in each region.

05/16/2017 25

Silver Trio ACO HMO 1700/55 OffEx*Region-12

AgeMember

RateAge

Member

Rate

157.510-20

248.0421

248.0422

248.0423

248.0424

249.0325

253.9926

259.9527

269.6228

277.5629

281.5330

287.4831

293.4332

297.1533

301.1234

303.1135

305.0936

307.0837

309.0638

313.0339

317.0040

322.9541

328.6642

336.5943

346.5144

358.1745

372.0646

387.6947

405.5548

423.1649

443.0050

462.6051

484.1852

506.0053

529.5754

553.1355

578.6856

604.4857

632.0158

645.6559

673.1860

697.0061

712.6262

732.2263

744.1264

744.1265 & over

12-2605/16/2017



05/16/2017 26

Gold Access+ HMO® 1700/30 OffEx*Region-12

AgeMember

RateAge

Member

Rate

215.860-20

339.9421

339.9422

339.9423

339.9424

341.3025

348.1026

356.2627

369.5228

380.4029

385.8430

394.0031

402.1532

407.2533

412.6934

415.4135

418.1336

420.8537

423.5738

429.0139

434.4540

442.6141

450.4342

461.3043

474.9044

490.8845

509.9246

531.3347

555.8148

579.9449

607.1450

634.0051

663.5752

693.4953

725.7854

758.0855

793.0956

828.4457

866.1858

884.8759

922.6160

955.2461

976.6662

1,003.5263

1,019.8364

1,019.8365 & over

12-2705/16/2017




05/16/2017 27

Gold Local Access+ HMO® 1700/30 OffEx*Region-12

AgeMember

RateAge

Member

Rate

212.050-20

333.9421

333.9422

333.9423

333.9424

335.2725

341.9526

349.9727

362.9928

373.6829

379.0230

387.0431

395.0532

400.0633

405.4034

408.0735

410.7436

413.4237

416.0938

421.4339

426.7740

434.7941

442.4742

453.1643

466.5144

482.2145

500.9146

521.9547

545.9948

569.7049

596.4150

622.8051

651.8552

681.2453

712.9654

744.6855

779.0856

813.8157

850.8858

869.2459

906.3160

938.3761

959.4162

985.7963

1,001.8264

1,001.8265 & over

12-2805/16/2017


05/16/2017 28

Gold Trio ACO HMO 1700/30 OffEx*Region-12

AgeMember

RateAge

Member

Rate

174.810-20

275.2921

275.2922

275.2923

275.2924

276.3925

281.9026

288.5127

299.2428

308.0529

312.4630

319.0731

325.6732

329.8033

334.2134

336.4135

338.6136

340.8137

343.0238

347.4239

351.8340

358.4341

364.7642

373.5743

384.5944

397.5245

412.9446

430.2847

450.1148

469.6549

491.6750

513.4251

537.3752

561.6053

587.7554

613.9055

642.2656

670.8957

701.4558

716.5959

747.1560

773.5861

790.9262

812.6763

825.8864

825.8865 & over

12-2905/16/2017



05/16/2017 29

Gold Access+ HMO® 500/35 OffEx*Region-12

AgeMember

RateAge

Member

Rate

222.980-20

351.1521

351.1522

351.1523

351.1524

352.5525

359.5826

368.0127

381.7028

392.9429

398.5630

406.9831

415.4132

420.6833

426.3034

429.1135

431.9136

434.7237

437.5338

443.1539

448.7740

457.2041

465.2742

476.5143

490.5644

507.0645

526.7246

548.8547

574.1348

599.0649

627.1550

654.8951

685.4452

716.3553

749.7154

783.0655

819.2356

855.7557

894.7358

914.0459

953.0260

986.7361

1,008.8562

1,036.5963

1,053.4564

1,053.4565 & over

12-3005/16/2017




05/16/2017 30

Gold Local Access+ HMO® 500/35 OffEx*Region-12

AgeMember

RateAge

Member

Rate

219.020-20

344.9221

344.9222

344.9223

344.9224

346.3025

353.2026

361.4727

374.9328

385.9629

391.4830

399.7631

408.0432

413.2133

418.7334

421.4935

424.2536

427.0137

429.7738

435.2939

440.8140

449.0841

457.0242

468.0543

481.8544

498.0645

517.3846

539.1147

563.9448

588.4349

616.0250

643.2751

673.2852

703.6353

736.4054

769.1755

804.6956

840.5657

878.8558

897.8259

936.1160

969.2261

990.9562

1,018.2063

1,034.7564

1,034.7565 & over

12-3105/16/2017


05/16/2017 31

Gold Trio ACO HMO 500/35 OffEx*Region-12

AgeMember

RateAge

Member

Rate

180.440-20

284.1621

284.1622

284.1623

284.1624

285.2925

290.9826

297.8027

308.8828

317.9729

322.5230

329.3431

336.1632

340.4233

344.9734

347.2435

349.5136

351.7937

354.0638

358.6039

363.1540

369.9741

376.5142

385.6043

396.9744

410.3245

426.2346

444.1447

464.5948

484.7749

507.5050

529.9551

554.6752

579.6853

606.6754

633.6755

662.9456

692.4957

724.0358

739.6659

771.2060

798.4861

816.3862

838.8363

852.4764

852.4765 & over

12-3205/16/2017



05/16/2017 32

Blue Shield Gold 80 HMO 0/30 + Child Dental INF*Region-12

AgeMember

RateAge

Member

Rate

179.570-20

282.7821

282.7822

282.7823

282.7824

283.9125

289.5726

296.3627

307.3828

316.4329

320.9630

327.7531

334.5332

338.7733

343.3034

345.5635

347.8236

350.0937

352.3538

356.8739

361.4040

368.1841

374.6942

383.7443

395.0544

408.3445

424.1746

441.9947

462.3548

482.4349

505.0550

527.3951

551.9952

576.8853

603.7454

630.6155

659.7356

689.1457

720.5358

736.0859

767.4760

794.6261

812.4462

834.7763

848.3564

848.3565 & over

12-3305/16/2017



05/16/2017 33

Platinum Access+ HMO® 0/30 OffEx*Region-12

AgeMember

RateAge

Member

Rate

243.400-20

383.3121

383.3122

383.3123

383.3124

384.8425

392.5126

401.7127

416.6628

428.9329

435.0630

444.2631

453.4632

459.2133

465.3434

468.4135

471.4736

474.5437

477.6138

483.7439

489.8740

499.0741

507.8942

520.1543

535.4944

553.5045

574.9746

599.1247

626.7148

653.9349

684.5950

714.8851

748.2252

781.9553

818.3754

854.7855

894.2656

934.1357

976.6858

997.7659

1,040.3160

1,077.1061

1,101.2562

1,131.5363

1,149.9364

1,149.9365 & over

12-3505/16/2017




05/16/2017 34

Platinum Local Access+ HMO® 0/30 OffEx*Region-12

AgeMember

RateAge

Member

Rate

239.030-20

376.4321

376.4322

376.4323

376.4324

377.9325

385.4626

394.5027

409.1828

421.2229

427.2530

436.2831

445.3132

450.9633

456.9834

460.0035

463.0136

466.0237

469.0338

475.0539

481.0840

490.1141

498.7742

510.8143

525.8744

543.5645

564.6446

588.3647

615.4648

642.1949

672.3050

702.0451

734.7952

767.9153

803.6754

839.4455

878.2156

917.3657

959.1458

979.8459

1,021.6360

1,057.7661

1,081.4862

1,111.2263

1,129.2964

1,129.2965 & over

12-3605/16/2017


05/16/2017 35

Platinum Trio ACO HMO 0/30 OffEx*Region-12

AgeMember

RateAge

Member

Rate

196.590-20

309.5921

309.5922

309.5923

309.5924

310.8325

317.0226

324.4527

336.5328

346.4329

351.3930

358.8231

366.2532

370.8933

375.8434

378.3235

380.8036

383.2737

385.7538

390.7039

395.6640

403.0941

410.2142

420.1243

432.5044

447.0545

464.3946

483.8947

506.1848

528.1649

552.9350

577.3951

604.3252

631.5753

660.9854

690.3955

722.2856

754.4757

788.8458

805.8759

840.2360

869.9561

889.4662

913.9163

928.7764

928.7765 & over

12-3705/16/2017



05/16/2017 36


AgeMember

RateAge

Member

Rate

246.430-20

388.0721

388.0722

388.0723

388.0724

389.6325

397.3926

406.7027

421.8428

434.2629

440.4630

449.7831

459.0932

464.9133

471.1234

474.2335

477.3336

480.4437

483.5438

489.7539

495.9640

505.2741

514.2042

526.6243

542.1444

560.3845

582.1146

606.5647

634.5048

662.0649

693.1050

723.7651

757.5252

791.6753

828.5454

865.4155

905.3856

945.7457

988.8158

1,010.1659

1,053.2460

1,090.4961

1,114.9462

1,145.6063

1,164.2264

1,164.2265 & over

12-3805/16/2017




05/16/2017 37


AgeMember

RateAge

Member

Rate

242.000-20

381.1021

381.1022

381.1023

381.1024

382.6225

390.2426

399.3927

414.2528

426.4529

432.5430

441.6931

450.8432

456.5533

462.6534

465.7035

468.7536

471.8037

474.8538

480.9439

487.0440

496.1941

504.9542

517.1543

532.3944

550.3045

571.6446

595.6547

623.0948

650.1549

680.6450

710.7451

743.9052

777.4453

813.6454

849.8455

889.1056

928.7357

971.0358

991.9959

1,034.2960

1,070.8861

1,094.8962

1,124.9963

1,143.2964

1,143.2965 & over

12-3905/16/2017


05/16/2017 38


AgeMember

RateAge

Member

Rate

198.980-20

313.3621

313.3622

313.3623

313.3624

314.6125

320.8826

328.4027

340.6228

350.6529

355.6630

363.1831

370.7032

375.4033

380.4234

382.9235

385.4336

387.9437

390.4538

395.4639

400.4740

407.9941

415.2042

425.2343

437.7644

452.4945

470.0446

489.7847

512.3448

534.5949

559.6650

584.4151

611.6852

639.2553

669.0254

698.7955

731.0756

763.6657

798.4458

815.6759

850.4660

880.5461

900.2862

925.0463

940.0864

940.0865 & over

12-4005/16/2017



05/16/2017 39


AgeMember

RateAge

Member

Rate

251.820-20

396.5621

396.5622

396.5623

396.5624

398.1525

406.0826

415.6027

431.0628

443.7529

450.1030

459.6131

469.1332

475.0833

481.4334

484.6035

487.7736

490.9437

494.1238

500.4639

506.8140

516.3241

525.4442

538.1343

554.0044

572.6345

594.8446

619.8347

648.3848

676.5349

708.2650

739.5951

774.0952

808.9953

846.6654

884.3355

925.1856

966.4257

1,010.4458

1,032.2559

1,076.2760

1,114.3461

1,139.3262

1,170.6563

1,189.6864

1,189.6865 & over

12-4105/16/2017




05/16/2017 40


AgeMember

RateAge

Member

Rate

247.280-20

389.4121

389.4122

389.4123

389.4124

390.9725

398.7626

408.1027

423.2928

435.7529

441.9830

451.3331

460.6732

466.5133

472.7434

475.8635

478.9836

482.0937

485.2138

491.4439

497.6740

507.0141

515.9742

528.4343

544.0144

562.3145

584.1246

608.6547

636.6948

664.3349

695.4950

726.2551

760.1352

794.4053

831.3954

868.3955

908.5056

948.9957

992.2258

1,013.6459

1,056.8660

1,094.2461

1,118.7862

1,149.5463

1,168.2364

1,168.2365 & over

12-4205/16/2017


05/16/2017 41


AgeMember

RateAge

Member

Rate

203.240-20

320.0721

320.0722

320.0723

320.0724

321.3525

327.7526

335.4327

347.9228

358.1629

363.2830

370.9631

378.6432

383.4433

388.5734

391.1335

393.6936

396.2537

398.8138

403.9339

409.0540

416.7341

424.0942

434.3443

447.1444

462.1845

480.1146

500.2747

523.3248

546.0449

571.6550

596.9351

624.7852

652.9453

683.3554

713.7655

746.7356

780.0157

815.5458

833.1459

868.6760

899.4061

919.5662

944.8563

960.2164

960.2165 & over

12-4305/16/2017



05/16/2017 42

Blue Shield Platinum 90 HMO 0/15 + Child Dental INF*Region-12

AgeMember

RateAge

Member

Rate

197.130-20

310.4421

310.4422

310.4423

310.4424

311.6825

317.8926

325.3427

337.4528

347.3829

352.3530

359.8031

367.2532

371.9133

376.8834

379.3635

381.8436

384.3337

386.8138

391.7839

396.7540

404.2041

411.3442

421.2743

433.6944

448.2845

465.6646

485.2247

507.5748

529.6149

554.4550

578.9751

605.9852

633.3053

662.7954

692.2955

724.2656

756.5557

791.0158

808.0859

842.5460

872.3461

891.9062

916.4363

931.3364

931.3365 & over

12-4405/16/2017



05/16/2017 43

Employee

Specialty Benefits Dental Region 12

Employee+ spouse

Employee+ child(ren)

Employee+ familyRates are for groups with 1-50 eligible employees.

DENTAL PPOSmile (SM) Basic Voluntary 75/1000/No Ortho/MAC 35.30 70.60 89.30 119.50Smile (SM) Basic 75/1000/No Ortho/MAC 28.50 57.20 73.50 98.90Smile (SM) Plus Gold 50/1500/Ortho/U85 65.30 131.40 165.20 222.20Smile (SM) Value 50/1500/No Ortho/MAC 38.10 76.00 97.60 114.00Smile (SM) Plus 50/1500/Ortho/MAC 50.60 101.20 128.00 148.70Smile (SM) 50/1500/No Ortho/MAC 45.50 89.80 114.10 133.20Smile (SM) Deluxe Gold 50/1500/Ortho/U85 80.30 159.40 200.10 269.80Smile (SM) Deluxe 50/1500/Ortho/MAC 51.50 103.10 130.70 174.20Smile (SM) Deluxe Plus 2000 50/2000/Ortho/MAC 66.90 133.70 168.10 226.40Smile (SM) Deluxe 2000 50/2000/No Ortho/MAC 59.70 120.30 151.40 203.40ULTIMATE DENTAL PPO FOR SMALL BUSINESSUltimate Dental PPO for Small Business 50/2000 57.20 115.30 145.00 194.90Ultimate Dental Plus PPO for Small Business 50/2000 65.00 129.80 163.30 220.00SMILE(SM) IN-NETWORK ONLY DENTAL PLAN*50/1500/Endo-Perio 80%/No Ortho 37.50 74.90 96.10 112.4050/1500/Endo-Perio 80%/Ortho 40.60 80.90 103.90 121.4050/2500/Endo-Perio 80%/No Ortho 59.80 120.40 151.80 204.6050/2500/Endo-Perio 80%/Ortho 66.90 133.70 168.20 226.90SMILE(SM) IN-NETWORK ONLY DENTAL VOLUNTARY PLAN*50/1500/EndoPerio 50%/No Ortho 35.60 71.10 91.30 106.7050/1500/EndoPerio 50%/Ortho 43.80 87.50 112.20 131.3050/2500/Endo-Perio 50%/No Ortho 56.80 114.50 144.30 194.2050/2500/Endo-Perio 50%/Ortho 72.40 144.60 181.80 245.40DENTAL HMO¹DHMO Basic 13.50 28.20 36.20 45.30DHMO Voluntary 18.90 37.70 44.10 56.70DHMO Plus 20.40 43.40 51.70 65.20DHMO Deluxe 23.70 47.50 55.40 71.20

08/23/2016 12-39

*Underwritten by Blue Shield of California Life & Health Insurance Company.¹Plan not available in all regions. See page 3 for product availability.Regions may vary by product. The "Small Business Off Exchange Rating Region Definitions" chart located near the front of this booklet identifies the counties locatedin each region.

08/23/2016 44

Employee

Specialty Benefits Dental Region 12

Employee+ spouse



DENTAL PPOSmile (SM) Basic Voluntary 75/1000/No Ortho/MAC 26.50 52.90 67.00 89.60Smile (SM) Basic 75/1000/No Ortho/MAC 21.40 42.90 55.10 74.20Smile (SM) Plus Gold 50/1500/Ortho/U85 48.90 98.60 123.90 166.70Smile (SM) Value 50/1500/No Ortho/MAC 28.60 57.00 73.20 85.50Smile (SM) Plus 50/1500/Ortho/MAC 37.90 75.90 96.00 111.50Smile (SM) 50/1500/No Ortho/MAC 34.10 67.40 85.60 99.90Smile (SM) Deluxe Gold 50/1500/Ortho/U85 60.20 119.50 150.10 202.40Smile (SM) Deluxe 50/1500/Ortho/MAC 38.60 77.30 98.00 130.70Smile (SM) Deluxe Plus 2000 50/2000/Ortho/MAC 50.20 100.20 126.10 169.80Smile (SM) Deluxe 2000 50/2000/No Ortho/MAC 44.80 90.20 113.50 152.60ULTIMATE DENTAL PPO FOR SMALL BUSINESSUltimate Dental PPO for Small Business 50/2000 42.90 86.50 108.70 146.10Ultimate Dental Plus PPO for Small Business 50/2000 48.70 97.30 122.40 165.00SMILE(SM) IN-NETWORK ONLY DENTAL PLAN*50/1500/Endo-Perio 80%/No Ortho 28.10 56.20 72.10 84.3050/1500/Endo-Perio 80%/Ortho 30.40 60.70 77.90 91.1050/2500/Endo-Perio 80%/No Ortho 44.80 90.30 113.90 153.4050/2500/Endo-Perio 80%/Ortho 50.20 100.30 126.20 170.20SMILE(SM) IN-NETWORK ONLY DENTAL VOLUNTARY PLAN*50/1500/EndoPerio 50%/No Ortho 26.70 53.30 68.40 80.1050/1500/EndoPerio 50%/Ortho 32.90 65.60 84.20 98.5050/2500/Endo-Perio 50%/No Ortho 42.60 85.90 108.20 145.7050/2500/Endo-Perio 50%/Ortho 54.30 108.50 136.40 184.10DENTAL HMO¹DHMO Basic 11.60 24.20 31.10 38.80DHMO Voluntary 16.20 32.30 37.80 48.60DHMO Plus 17.50 37.20 44.30 55.90DHMO Deluxe 20.30 40.70 47.50 61.00

08/23/2016 12-40

*Underwritten by Blue Shield of California Life & Health Insurance Company.¹Plan not available in all regions. See page 3 for product availability.Regions may vary by product. The "Small Business Off Exchange Rating Region Definitions" chart located near the front of this booklet identifies the counties locatedin each region.

08/23/2016 45

Employee

Specialty Benefits Vision and Optional Product Region 12

Employee+ spouse



ENHANCED VISION FOR SMALL BUSINESS*Enhanced Vision Voluntary¹ for Small Business 15/25/120 9.80 18.60 17.10 24.20Enhanced Vision for Small Business 15/25/120 6.90 13.00 12.00 17.00Enhanced Vision for Small Business 0/0/120 9.00 17.10 15.80 22.30Enhanced Vision for Small Business 15/25/150 8.00 15.10 13.90 19.80Enhanced Vision Plus for Small Business 15/25/150/120 10.60 20.00 18.40 26.00Enhanced Vision for Small Business 0/0/150 10.50 19.80 18.20 25.80Enhanced Vision Plus for Small Business 0/0/150/120 13.00 24.70 22.70 32.20PREFERRED VISION FOR SMALL BUSINESS*Preferred Vision Voluntary¹ for Small Business 15/25/120 10.60 20.20 18.50 26.20Preferred Vision for Small Business 15/25/120 7.40 14.10 13.00 18.30Preferred Vision for Small Business 0/0/120 9.80 18.60 17.10 24.20Preferred Vision for Small Business 15/25/150 8.70 16.50 15.20 21.50Preferred Vision Plus for Small Business 15/25/150/120 11.40 21.50 19.80 28.00Preferred Vision for Small Business 0/0/150 11.40 21.50 19.80 28.00Preferred Vision Plus for Small Business 0/0/150/120 14.00 26.50 24.40 34.50ULTIMATE VISION FOR SMALL BUSINESS*Ultimate Vision for Small Business 15/25/120 10.60 20.20 18.50 26.20Ultimate Vision for Small Business 0/0/120 13.80 26.10 23.90 33.90Ultimate Vision Voluntary¹ for Small Business 15/25/150 17.70 33.40 30.80 43.60Ultimate Vision for Small Business 15/25/150 12.40 23.40 21.60 30.60Ultimate Vision Plus for Small Business 15/25/150/120 16.60 31.50 29.00 41.00Ultimate Vision for Small Business 0/0/150 16.00 30.30 27.80 39.40Ultimate Vision Plus for Small Business 0/0/150/120 20.20 38.20 35.10 49.70

LIFE INSURANCE RATESSee page 2.Dental, life insurance, and vision plans are available alongside medical coverage or on a standalone basis.

OPTIONAL PRODUCT All Ages_____________________INFERTILITY**PPO and HSA-HDHP Only 15.90

08/23/2016 12-41

*Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).**Additional Infertility Treatment Benefits are available as supplemental coverage to the PPO and HSA-HDHP plans from the Blue Shield of California Off ExchangePackage for Small Business and the Select PPO Network from the Blue Shield of California Mirror Package for Small Business.¹Voluntary vision plans require a minimum of 3 enrolled employees.Regions may vary by product. The "Small Business Off Exchange Rating Region Definitions" chart located near the front of this booklet identifies the counties locatedin each region.

08/23/2016 46

Employee

Specialty Benefits Vision and Optional Product Region 12

Employee+ spouse



ENHANCED VISION FOR SMALL BUSINESS*Enhanced Vision Voluntary¹ for Small Business 15/25/120 7.90 14.90 13.70 19.40Enhanced Vision for Small Business 15/25/120 5.50 10.40 9.60 13.60Enhanced Vision for Small Business 0/0/120 7.20 13.70 12.60 17.90Enhanced Vision for Small Business 15/25/150 6.40 12.10 11.10 15.80Enhanced Vision Plus for Small Business 15/25/150/120 8.40 16.00 14.70 20.80Enhanced Vision for Small Business 0/0/150 8.40 15.90 14.60 20.70Enhanced Vision Plus for Small Business 0/0/150/120 10.40 19.80 18.20 25.70PREFERRED VISION FOR SMALL BUSINESS*Preferred Vision Voluntary¹ for Small Business 15/25/120 8.50 16.10 14.80 21.00Preferred Vision for Small Business 15/25/120 6.00 11.30 10.40 14.70Preferred Vision for Small Business 0/0/120 7.90 14.90 13.70 19.40Preferred Vision for Small Business 15/25/150 7.00 13.20 12.20 17.20Preferred Vision Plus for Small Business 15/25/150/120 9.10 17.20 15.80 22.40Preferred Vision for Small Business 0/0/150 9.10 17.20 15.80 22.40Preferred Vision Plus for Small Business 0/0/150/120 11.20 21.20 19.50 27.60ULTIMATE VISION FOR SMALL BUSINESS*Ultimate Vision for Small Business 15/25/120 8.50 16.10 14.80 21.00Ultimate Vision for Small Business 0/0/120 11.00 20.90 19.10 27.10Ultimate Vision Voluntary¹ for Small Business 15/25/150 14.10 26.80 24.60 34.90Ultimate Vision for Small Business 15/25/150 9.90 18.80 17.30 24.40Ultimate Vision Plus for Small Business 15/25/150/120 13.30 25.20 23.20 32.80Ultimate Vision for Small Business 0/0/150 12.80 24.30 22.30 31.60Ultimate Vision Plus for Small Business 0/0/150/120 16.10 30.50 28.10 39.70

LIFE INSURANCE RATESSee page 2.Dental, life insurance, and vision plans are available alongside medical coverage or on a standalone basis.

OPTIONAL PRODUCT All Ages_____________________INFERTILITY**PPO and HSA-HDHP Only 15.90

08/23/2016 12-42

*Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).**Additional Infertility Treatment Benefits are available as supplemental coverage to the PPO and HSA-HDHP plans from the Blue Shield of California Off ExchangePackage for Small Business and the Select PPO Network from the Blue Shield of California Mirror Package for Small Business.¹Voluntary vision plans require a minimum of 3 enrolled employees.Regions may vary by product. The "Small Business Off Exchange Rating Region Definitions" chart located near the front of this booklet identifies the counties locatedin each region.

08/23/2016 47

Blue Shield of California50 Beale Street, San Francisco, CA 94105

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small business rate tables - blue shield of california...napa alpine solano contra-costa san joaquin...

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