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!flue Shield Net Value 3+ 51.306.44 5204.78 I'IiRScare 3+ 51,484.94 S839.33 Kaiser CA 1 5530.78 538.21 PERSchoice 1 $ 504.26 $ 59.14 Kaiser CA 2 51, 061.55 576.43 PERSchoice 2 S 1008.52 $ 118.28 Kaiser CA 3+ 51352.112 5127.35 PERSchoice 3+ 5 1.283.07 $ 181.77 PORAC 1 5 485.50 $ 41.50 PORAC 2 $ 906.50 5 80.50 PORAC 3 $ 1,122.50 $ 131.50 2011 Other Northern CA Rates Benefit & Level City Employee, Benefit & Citv E nlovice bevel Blue Shield 1 5545.57 5140.10 I'ERSselecl 1 5434.78 545.12 I31tie Shield 2 51,091.15 5280.19 PERSselect 2 5869.57 590.23 Blue Shield 3+ $1,390.49 5392.25 PERSselect 3+ 1. 102.43 5145.31 PERSchoice 1 5469.67 579.11 PERSearc I 5526.67 S344.09_ PERSchoice 2 5939,35 5158.21 PRRScarc 2 51.05335 5688.17_ PERSchoice 3+ 51,193.16 5233.67 I'ERScare 3 $1,341.35 5922.63 Kaiser I 5526.43 547.89 PORAC 1 $40.09 ,541.50 Kaiser 2 51,052.87 595.77_ PORAC 2 $886,11 580.50_ Kaiser 3+ 51.340.73 5152.50 l'ORAC 3 51,152.02 5 2011 Out -of -State Rates Benefit & Level City ®EM Benefit & Level City Em tloycc Kaiser 1 527.82 lira PERSchoice 1 5553.47 583.50 • Kaiser2 Inringri PERSchoice 2 SI 106.95 166.99 Kaiser 3+ ® 5697.38 PERSchoice 3+ 51,439.03 5217.09 • In 2044 -2012, the 2010 201lmedical and dental rates listed above will be further adjusted by 50% of the change, respectively, between the 2010/112011/12 dental rates and the CaIPERS 1 010/11 7 011/12 Bay Area rates in each individual plan. Employees electing not to enroll in the core flex benefit plan (i.e., who wish to waive enrollment in the medical and dental plans) and demonstrate to the satisfaction of the City their enrollment in another medical and dental plan, shall receive two- hundred dollars ($200.00) per month for their non- election of medical and dental benefits. In the event both spouses are employed by the City and eligible to enroll in the City's flex benefits plan, one employee may elect not to enroll in the medical and dental plans and will receive the emplovec opt -out rate of up to two- hundred dollars ($200.00) per month payment if enrolled under spouse's medical and dental coverage. n- e +nployae may elect to waive t s one hundred -aed- fifty- dollars ($150.00) per tnetnh for their non elect-ion, An employee may elect to waive the dental plan only and enroll only in the medical plan and receive fifty dollars ($50.00) per month for their non- election. Re- enrollment in the medical and /or dental plan shall be allowed only based upon a qualifying event as defined by the IRS codes or during an open enrollment period. fn- Effective 2011, the above opt -out premiums will he increased as follows, based on the employee's status and eligibility during the 2011 active benefit year, in accordance with Internal Revenue Code (IRC) timelines and qualifying events: Employee rate: Medical $200 + /or dental $50 = $250 /month maximum Two -party rate: Medical $350 + /or dental $50 = $400 /month maximum 24