MEDICAL PREMIUM RATES - San Diego City Schools

SAN DIEGO UNIFIED SCHOOL DISTRICT
Employee Benefits Department
MEDICAL/DENTAL/VISION GROUP RATES
Plan Year: January 1, 2015 thru December 31, 2015
MEDICAL PREMIUM RATES
ACTIVE AND LOA EMPLOYEE MEDICAL RATES
PLAN
Kaiser
UHC Network 1
UHC Network 2
UHC Network 3
UHC PPO
$
$
$
$
$
TIER 1 (12THLY)
502.42
574.91
746.32
861.87
705.96
Tier 1
602.90
689.89
895.58
1,034.24
847.15
$
$
$
$
$
TIER 2 (12THLY)
$
992.39
$
1,136.27
$
1,478.83
$
1,709.83
$
1,378.93
TIER 2 (10THLY)
$
1,190.87
$
1,363.52
$
1,774.60
$
2,051.80
$
1,654.72
Tier3 (12THLY)
$
1,399.05
$
1,595.25
$
2,078.00
$
2,403.61
$
1,927.35
TIER 3 (10THLY)
$
1,678.86
$
1,914.30
$
2,493.60
$
2,884.33
$
2,312.82
VISITING TCHR MEDICAL RATES
Tier2
Tier3
1,190.87 $
1,678.86
1,363.52 $
1,914.30 VT RATES ARE 10THLY RATES
1,774.60 $
2,493.60
2,051.80 $
2,884.33
1,654.72 $
2,312.82
KAISER
UHC Network 1
UHC Network 2
UHC Network 3
PPO 2
$
$
$
$
$
PLAN
KAISER
UHC Network 1
UHC Network 2
UHC Network 3
PPO 2
COBRA MEDICAL RATES
Tier 1
Tier 2
$
512.47 $
1,012.24
$
586.41 $
1,159.00
$
761.25 $
1,508.41
$
879.11 $
1,744.03
$
720.08 $
1,406.51
SUMMARY-Active Cobra-LOA-Y Fund Rates 2015
12/18/2014
$
$
$
$
$
TIER 1 (10THLY)
602.90
689.89
895.58
1,034.24
847.15
$
$
$
$
$
Tier 3
1,427.03
1,627.16
2,119.56
2,451.68
1,965.90
PAGE 1
COBRA RATES INCLUDE A 2% FEE ON TOP OF
PREMIUM
SAN DIEGO UNIFIED SCHOOL DISTRICT
Employee Benefits Department
MEDICAL/DENTAL/VISION GROUP RATES
Plan Year: January 1, 2015 thru December 31, 2015
DENTAL/VISION PREMIUM RATES
PLAN
DELTACARE
DELTA PPO
WESTERN
PLAN
DELTACARE
DELTA PPO
WESTERN
ACTIVE/LOA/COBRA DENTAL RATES
ACTIVE 10THLY
ACTIVE 12THLY
$
39.52 $
32.93 $
$
103.93 $
86.61 $
$
37.16 $
30.97 $
LOA
RETIREE DENTAL RATES (TIERED 1/2 PARTY)
RETIREE
RETIREE +
ONLY
SPOUSE
$
22.52 $
35.17
$
46.91 $
79.75
$
17.75 $
35.91
RETIREE MEDICAL TRUST CONTRIBUTIONS TO PREMIUM COST
Bargaining Unit
Single
with Spouse
01 Certificated
$
310.00
02 OSS
$
70.00
03 OTBS
$
105.00 $
115.00
04 POA
$
250.00
05 PARA
$
50.00
L6, 06, L7, 07, & 08
SUPV/MANAGERS
$
150.00
C7 Certificated Management
$
135.00
08 Confidential
$
135.00 $
135.00
06, 07 Non Representative
Management
$
135.00 $
135.00
SUMMARY-Active Cobra-LOA-Y Fund Rates 2015
12/18/2014
COBRA
32.93 $
86.61 $
30.97 $
33.59
88.34
31.59
PLAN
VSP
ACTIVE/LOA/COBRA VISION RATES
12THLY
10THLY
COBRA
$
8.50 $
10.20 $
8.67
PLAN
VSP
RETIREE VISION RATES
12THLY
$
10.72 $
10THLY
12.86
*ADMINISTRATIVE FEE HAS BEEN SUSPENDED AS OF 09/01/2014
PAGE 2

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