Health and Welfare Summary Plan Description

APPENDIX B

Monthly Coverage Payment Schedulesas of February 1, 2022

Early Retirees Ages 55 through 62

Health Plan

Monthly Payment

Kaiser

$ 2,455.00

Blue Shield HMO

$ 2,649.00

Self-Funded PPO

$ 2,582.00

Early Retirees Ages 62 through 64 Who Have Already Satisfied Service Requirements to Qualify as a Regular Retiree at age 62 or Rule of 85 (Section 4.3(d))

Health Plan

Monthly Payment

Kaiser

$ 856.00

Blue Shield HMO

$ 856.00

Self-Funded PPO

$ 856.00

Early Retirees Ages 62 through 64 Who Must Continue Participation as an Early Retire to Qualify as a Regular Retiree at age 62 (Section 4.3(c)

Health Plan

Monthly Payment

Kaiser – Single

$ 982.00

Kaiser – Family

$ 1473.00.00

Blue Shield HMO – Single

$ 1,060.00

Blue Shield HMO - Family

$ 1,589.00

Self-Funded PPO – Single

$ 1,033.00

Self-Funded PPO - Family

$ 1,549.00

Regular Retirees Age 65 and older, Early Retirees Having Reached Age 65 and Older, Disabled Retirees, Surviving Spouses or Domestic Partners -- All Plans

Age

Monthly Payment

Under Age 65

$ 737.00

Ages 65 through 74
and retirees who attain age 75 on or after 1/1/2008;

Single: $ 295.00
Family: $ 590.00

Retirees who attained age 75 before 1/1/2007

$ 0.00