PETALUMA CITY SCHOOLS

2017/2018 Active Employee Monthly Premiums

Effective 10/1/17 - 9/30/18

KAISER - Composite Rates

HIGH PACKAGE 1 / HIGH PACKAGE 2 / MID / LOW
Single / $1,650.00 / $1,614.00 / $1,380.00 / $1,010.00
Cost to FT Employee / ($579.87 over Cap) / ($543.87 over Cap) / ($309.87 over Cap) / ($0 over Cap)
Double / $1,650.00 / $1,614.00 / $1,380.00 / $1,010.00
Cost to FT Employee / ($579.87 over Cap) / ($543.87 over Cap) / ($309.87 over Cap) / ($0 over Cap)
Family / $1,650.00 / $1,614.00 / $1,380.00 / $1,010.00
Cost to FT Employee / ($579.87 over Cap) / ($543.87 over Cap) / ($309.87 over Cap) / ($0 over Cap)

Kaiser High Package 1, Kaiser High Package 2, Kaiser Mid - Includes Chiro and Vision

Kaiser Low - No Chiro or Vision (Vision available through Vision Service Plan)

BLUE SHIELD - Composite Rates

100% / 90% / 80% / HIGH DEDUCTIBLE
Single / $1,735.00 / $1,578.00 / $1,394.00 / $1,116.00
Cost to FT Employee / ($664.87 over Cap) / ($507.87 over Cap) / ($323.87 over Cap) / ($45.87 over Cap)
Double / $1,735.00 / $1,578.00 / $1,394.00 / $1,116.00
Cost to FT Employee / ($664.87 over Cap) / ($507.87 over Cap) / ($323.87 over Cap) / ($45.87 over Cap)
Family / $1,735.00 / $1,578.00 / $1,394.00 / $1,116.00
Cost to FT Employee / ($664.87 over Cap) / ($507.87 over Cap) / ($323.87 over Cap) / ($45.87 over Cap)

BLUE SHIELD ANCHOR BRONZE (MINIMUM VALUE PLAN) - Tiered Rates

·  Coverage available for Employee OR Employee + Child(ren) only

·  Spouses / Domestic Partners are not eligible for this plan

ANCHOR BRONZE
Single (Employee Only) / $630.00
Cost to FT Employee / ($0 over Cap)
Double (Employee + Child) / $989.00
Cost to FT Employee / ($0 over Cap)
Family (Employee + Children) / $989.00
Cost to FT Employee / ($0 over Cap)

OVER

DELTA DENTAL - Composite Rates VISION SERVICE PLAN - Composite Rates

Single / $121.00 / Single / $29.00
Double / $121.00 / Double / $29.00
Family / $121.00 / Family / $29.00
Cost to FT Employee / ($0 over Cap) / Cost to FT Employee / ($0 over Cap)

LIFE INSURANCE

$5.55 per Month**

**100% of premium paid in full for the following: Classified - 6 hours per day / Certificated - .75 FTE to 1.0 FTE

DISTRICT CAP FOR FULL-TIME EMPLOYEES (PRO-RATED FOR PART-TIME EMPLOYEES)

$1,070.13 per Month

6/20/17