| 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 | $ 774.00 | $ 749.00 | $ 699.00 | $ 899.00 | $ 513.00 |
| Employee and One Dependent | $1,699.00 | $1,499.00 | $1,399.00 | $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 | $ 724.00 | $ 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.
| Basic |
|---|
| Employee Only | $ 774.00 |
| Employee and One Dependent | $1,623.00 |
| Employee and Two or more Dependent(s) | $2,076.00 |
| Supplement to Medicare |
|---|
| Employee Only | $ 513.00 |
| Employee and One Dependent | $1022.00 |
| Employee and Two or more Dependent(s) | $1,635.00 |
Maximum Out-of-Pocket Expense $3,000 per person/ $6,000 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.
| Basic |
|---|
| Employee Only | $734.00 |
| Employee and One Dependent | $1,540.00 |
| Employee and Two or more Dependent(s) | $1,970.00 |
| Supplement to Medicare |
|---|
| Employee Only | $487.00 |
| Employee and One Dependent | $970.00 |
| Employee and Two or more Dependent(s) | $1,551.00 |
Maximum Out-of-Pocket Expense $3,000 per person/ $6,000 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 |
Benefit Changes effective 2015: Body Scans will be subject to a maximum $1,000 coverage limit every 36 months.
| Basic |
|---|
| Employee Only | $699.00 |
| Employee and One Dependent | $1,467.00 |
| Employee and Two or more Dependent(s) | $1,876.00 |
| Supplement to Medicare |
|---|
| Employee Only | $464.00 |
| Employee and One Dependent | $924.00 |
| Employee and Two or more Dependent(s) | $1,477.00 |
Maximum Out-of-Pocket Expense $4,500 per person/ $9,000 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 |
Benefit Changes effective 2015: Body Scans will be subject to a maximum $1,000 coverage limit every 36 months.
| Basic |
|---|
| Employee Only | $699.00 |
| Employee and One Dependent | $1,399.00 |
| Employee and Two or more Dependent(s) | $1,789.00 |
| Supplement to Medicare |
|---|
| Employee Only | $442.00 |
| Employee and One Dependent | $881.00 |
| Employee and Two or more Dependent(s) | $1,408.00 |
Maximum Out-of-Pocket Expense $4,500 per person/ $9,000 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 |
Benefit Changes effective 2015: Body Scans will be subject to a maximum $1,000 coverage limit every 36 months.
| Basic |
|---|
| Single | $675.00 |
| Two Party | $1,292.00 |
| Family | $1,642.00 |
| Supplement to Medicare |
|---|
| Single | $402.00 |
| Two Party | $802.00 |
| Family | $1,281.00 |
| Basic |
|---|
| Single | $643.00 |
| Two Party | $1,186.00 |
| Family | $1,507.00 |
| Supplement to Medicare |
|---|
| Single | $397.00 |
| Two Party | $791.00 |
| Family | $1,264.00 |
| Basic |
|---|
| Single | $581.00 |
| Two Party | $1,088.00 |
| Family | $1,382.00 |
| Supplement to Medicare |
|---|
| Single | $418.00 |
| Two Party | $833.00 |
| Family | $1,331.00 |
| Basic |
|---|
| Single | $556.00 |
| Two Party | $1,041.00 |
| Family | $1,323.00 |
| Supplement to Medicare |
|---|
| Single | $418.00 |
| Two Party | $833.00 |
| Family | $1,331.00 |
| Basic |
|---|
| Single | $527.00 |
| Two Party | $987.00 |
| Family | $1,254.00 |
| Supplement to Medicare |
|---|
| Single | $418.00 |
| Two Party | $833.00 |
| Family | $1,331.00 |
| Basic |
|---|
| Single | $484.00 |
| Two Party | $906.00 |
| Family | $1,151.00 |
| Supplement to Medicare |
|---|
| Single | $363.00 |
| Two Party | $723.00 |
| Family | $1,157.00 |
Anthem Blue Cross Rates older than five years are available upon written request from the IBT Manager.
