| 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.
| 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 Chief Operations Officer.
