Public Agencies
| |
EmployeeOnly |
Employee+1 Dependent |
Employee2+ Dependents |
| Region 1 |
$975.00 |
$2,218.00 |
$2,777.00 |
| Region 2 |
$970.00 |
$1,951.00 |
$2,484.00 |
| Region 3 |
$970.00 |
$1,951.00 |
$2,484.00 |
| Out of State |
$1,106.00 |
$2,246.00 |
$2,661.00 |
| Supplemental Plan to Medicare |
$507.00 |
$1,123.00 |
$1,521.00 |
Region 1: Northern California
Region 2: Central California
Region 3: LA, Riverside & San Bernardino
State Agencies
| |
Employee Only |
Employee+1 Dependent |
Employee2+ Dependents |
| California |
$894.00 |
$1,789.00 |
$2,325.00 |
| Out of State |
$1,106.00 |
$2,246.00 |
$2,661.00 |
| Supplemental Plan to Medicare |
$507.00 |
$1,123.00 |
$1,521.00 |
Maximum Out-of-Pocket Expense is $2,000 per person / $4,000 per a family.
Prescription Drugs
| Retail |
| Generic |
$10.00 copay |
| Brand Formulary |
$25.00 copay |
| Brand Non-Formulary |
$45.00 copay |
| Mail Order |
| Generic |
$20.00 copay |
| Brand Formulary |
$40.00 copay |
| Brand Non-Formulary |
$75.00 copay |
Body Scans are subject to a maximum $1,000 coverage limit every 36 months.
Public Agencies
| |
EmployeeOnly |
Employee+1 Dependent |
Employee2+ Dependents |
| Region 1 |
$931.00 |
$2,117.00 |
$2,651.00 |
| Region 2 |
$926.00 |
$1,863.00 |
$2,371.00 |
| Region 3 |
$926.00 |
$1,863.00 |
$2,371.00 |
| Out of State |
$1,056.00 |
$2,144.00 |
$2,540.00 |
| Supplemental Plan to Medicare |
$465.00 |
$1,030.00 |
$1,395.00 |
Region 1: Northern California
Region 2: Central California
Region 3: LA, Riverside & San Bernardino
State Agencies
| |
Employee Only |
Employee+1 Dependent |
Employee2+ Dependents |
| California |
$853.00 |
$1,708.00 |
$2,220.00 |
| Out of State |
$1,056.00 |
$2,144.00 |
$2,540.00 |
| Supplemental Plan to Medicare |
$465.00 |
$1,030.00 |
$1,395.00 |
Maximum Out-of-Pocket Expense is $2,000 per person / $4,000 per a family.
Prescription Drugs
| Retail |
| Generic |
$10.00 copay |
| Brand Formulary |
$25.00 copay |
| Brand Non-Formulary |
$45.00 copay |
| Mail Order |
| Generic |
$20.00 copay |
| Brand Formulary |
$40.00 copay |
| Brand Non-Formulary |
$75.00 copay |
Body Scans are subject to a maximum $1,000 coverage limit every 36 months.
Public Agencies
| |
EmployeeOnly |
Employee+1 Dependent |
Employee2+ Dependents |
| Region 1 |
$825.00 |
$1,875.00 |
$2,300.00 |
| Region 2 |
$820.00 |
$1,650.00 |
$2,100.00 |
| Region 3 |
$820.00 |
$1,600.00 |
$2,100.00 |
| Out of State |
$935.00 |
$1,899.00 |
$2,250.00 |
| Supplemental Plan to Medicare |
$465.00 |
$1,030.00 |
$1,395.00 |
Region 1: Northern California
Region 2: Central California
Region 3: LA, Riverside & San Bernardino
State Agencies
| |
Employee Only |
Employee+1 Dependent |
Employee2+ Dependents |
| California |
$775.00 |
$1,525.00 |
$2,000.00 |
| Out of State |
$935.00 |
$1,899.00 |
$2,250.00 |
| Supplemental Plan to Medicare |
$465.00 |
$1,030.00 |
$1,395.00 |
Maximum Out-of-Pocket Expense is $2,000 per person / $4,000 per a family.
Prescription Drugs
| Retail |
| Generic |
$10.00 copay |
| Brand Formulary |
$25.00 copay |
| Brand Non-Formulary |
$45.00 copay |
| Mail Order |
| Generic |
$20.00 copay |
| Brand Formulary |
$40.00 copay |
| Brand Non-Formulary |
$75.00 copay |
Body Scans are subject to a maximum $1,000 coverage limit every 36 months.
Public Agencies
| |
Employee Only |
Employee and 1 Dependent |
Employee and 2 or more Dependents |
| Region 1 |
$799.00 |
$1,725.00 |
$2,219.00 |
| Region 2 |
$775.00 |
$1,550.00 |
$2,010.00 |
| Region 3 |
$775.00 |
$1,475.00 |
$1,894.00 |
| Out of State |
$899.00 |
$1,899.00 |
$2,223.00 |
| Supplemental Plan to Medicare |
$461.00 |
$919.00 |
$1,471.00 |
Region 1: Northern California
Region 2: Central California
Region 3: LA, Riverside & San Bernardino
State Agencies
| |
Employee Only |
Employee and 1 Dependent |
Employee and 2 or more Dependents |
| California |
$750.00 |
$1,499.00 |
$1,927.00 |
| Out of State |
$899.00 |
$1,899.00 |
$2,223.00 |
| Supplemental Plan to Medicare |
$461.00 |
$919.00 |
$1,471.00 |
Maximum Out-of-Pocket Expense is $2,000 per person / $4,000 per a family.
Prescription Drugs
| Retail |
| Generic |
$10.00 copay |
| Brand Formulary |
$25.00 copay |
| Brand Non-Formulary |
$45.00 copay |
| Mail Order |
| Generic |
$20.00 copay |
| Brand Formulary |
$40.00 copay |
| Brand Non-Formulary |
$75.00 copay |
Body Scans are subject to a maximum $1,000 coverage limit every 36 months.
| Public Agencies |
Region 1 Northern CA |
Region 2 Central CA |
Region 3 LA/ Riverside/ San Bernardino |
Out of State |
Supplemental Plan to Medicare |
| Employee Only |
$ 799.00 |
$ 749.00 |
$ 725.00 |
$ 899.00 |
$ 513.00 |
| Employee and One Dependent |
$1,725.00 |
$1,499.00 |
$1,450.00 |
$1,850.00 |
$1,022.00 |
| Employee and Two or more Dependents |
$2,199.00 |
$1,960.00 |
$1,894.00 |
$2,223.00 |
$1,635.00 |
| State |
California |
Out of State |
Supplemental Plan to Medicare |
| Employee Only |
$ 750.00 |
$ 899.00 |
$ 513.00 |
| Employee and One Dependent |
$1449.00 |
$1850.00 |
$1022.00 |
| Employee and Two or more Dependents |
$1,927.00 |
$2,223.00 |
$1,635.00 |
Maximum Out-of-Pocket Expense $2,000 per person/ $4,000 for a family.
Prescription Drugs
| Retail |
| Generic |
$10.00 copay |
| Brand Formulary |
$25.00 copay |
| Brand Non-Formulary |
$45.00 copay |
| Mail Order |
| Generic |
$20.00 copay |
| Brand Formulary |
$40.00 copay |
| Brand Non-Formulary |
$75.00 copay |
Body Scans are subject to a maximum $1,000 coverage limit every 36 months.
Anthem Blue Cross Rates older than five years are available upon written request from the IBT Chief Operations Officer.
