DEDUCTIONS EFFECTIVE DECEMBER 1, NOVEMBER 30, MONTHLY PREMIUM
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1 BAY AREA REGION HEALTH NET SMARTCARE CONTRA COSTA HEALTH PLAN WESTERN HEALTH ADVANTAGE $ $ $ $1, $1, $ $2, $1, $ $1, $ $ $2, $1, $ $2, $2, $ $ $ $ $1, $1, $ $2, $1, $ $ $ $ $1, $1, $ $2, $1, $ $1, $ $ $2, $1, $ $2, $2, $ $ $ $ $1, $1, $ $1, $1, $ $ $ $ $1, $1, $ $2, $1, $ $ $ $28.00 $1, $1, $56.00 $1, $1, $72.79 $1, $ $ $2, $1, $1, $2, $1, $1, $ $ $ $1, $1, $ $1, $1, $ * Blue Shield Access + is no longer available for the following counties: Alameda, Contra Costa, Marin, San Francisco, San Mateo, Santa Clara, Solano, and Sonoma. Alameda, Amador, Contra Costa, Marin, Napa, Nevada, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Sutter and Yuba Counties
2 SACRAMENTO AREA REGION UNITED HEALTH CARE WESTERN HEALTH ADVANTAGE $ $ $ $1, $1, $ $2, $1, $ $1, $ $ $2, $1, $ $3, $2, $1, $ $ $ $1, $1, $ $2, $1, $ $ $ $78.88 $1, $1, $ $1, $1, $ $ $ $ $1, $1, $ $2, $1, $ $ $ $27.74 $1, $ $55.48 $1, $1, $72.12 $1, $ $ $2, $1, $ $2, $1, $1, $ $ $ $1, $1, $ $2, $1, $ $ $ $ $1, $1, $ $1, $1, $ El Dorado, Placer, Sacramento and Yolo Counties
3 OTHER NORTHERN CALIFORNIA REGION ANTHEM EPO DEL NORTE BLUE SHIELD Access+ and EPO WESTERN HEALTH ADVANTAGE $ $ $0.01 $1, $1, $0.01 $1, $1, $0.01 $ $ $ $1, $1, $ $2, $1, $ $1, $ $ $2, $1, $ $3, $2, $1, $ $ $ $1, $1, $ $2, $1, $ $ $ $ $1, $1, $ $2, $1, $ $ $ $ $1, $1, $ $2, $1, $ $ $ $18.37 $1, $ $36.74 $1, $1, $47.75 $1, $ $ $2, $1, $ $2, $1, $1, $ $ $ $1, $1, $ $1, $1, $ Alpine, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Plumas, San Benito, Shasta, Sierra, Siskiyou, Stanislaus, Tehema, Trinity and Toulumne Counties
4 LOS ANGELES AREA REGION HEALTH NET SALUD Y MAS HEALTH NET SMARTCARE UNITED HEALTH CARE $ $ $75.61 $1, $1, $ $1, $1, $ $ $ $ $1, $1, $ $2, $1, $ $ $ $69.51 $1, $1, $ $1, $1, $ $ $ $0.01 $ $ $0.01 $ $ $0.01 $ $ $41.40 $1, $1, $82.80 $1, $1, $ $ $ $58.13 $1, $1, $ $1, $1, $ $ $ $49.16 $1, $1, $98.31 $1, $1, $ $ $ $0.01 $ $ $0.01 $1, $1, $0.01 $ $ $ $1, $1, $ $2, $1, $ $ $ $90.93 $1, $1, $ $1, $1, $ Los Angeles, San Bernadino and Ventura Counties
5 OTHER SOUTHERN CALIFORNIA REGION HEALTH NET SALUD Y MAS HEALTH NET SMARTCARE SHARP UNITED HEALTH CARE $ $ $44.05 $1, $1, $88.09 $1, $1, $ $ $ $ $1, $1, $ $2, $1, $ $ $ $ $1, $1, $ $1, $1, $ $ $ $0.01 $ $ $0.01 $1, $1, $0.01 $ $ $37.11 $1, $1, $74.21 $1, $1, $96.47 $ $ $34.85 $1, $1, $69.69 $1, $1, $90.59 $ $ $94.38 $1, $1, $ $1, $1, $ $ $ $8.12 $ $ $16.23 $1, $1, $21.10 $ $ $ $1, $1, $ $2, $1, $ $ $ $27.54 $1, $1, $55.08 $1, $1, $71.60 $ $ $2.97 $1, $1, $5.93 $1, $1, $7.71 Fresno, Imperial, Inyo, Kern, Kings, Madera, Riverside, Orange, San Diego, San Luis Obispo, Santa Barbara and Tulare Counties
6 OUT OF STATE REGION $ $ $ $1, $1, $ $2, $1, $ $ $ $58.59 $1, $1, $ $1, $1, $ $ $ $ $1, $1, $ $2, $1, $ Kaiser Out-of-State Regions Include: Colorado, Georgia, Hawaii, Mid-Atlantic and Northwest
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> 0 to 1,600 OJT Hours 1,601 to 3,200 OJT Hours 40% 50% 1 Alameda $37.12 $24.13 $2.25 $4.50 $0.00 $6.24 $46.40 $30.16 $2.25 $4.50 $0.50 $8.99 2 Alpine $28.10 $18.27 $2.25 $4.50 $0.00 $3.08 $35.12 $22.83
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