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ATTACHMENT D <br /> MONTHLY PLAN RATES <br /> Page 1 <br /> Basic & Supplement To Medicare Plans <br /> The following monthly rates do not reflect any employer contributions.To find out what your coverage will cost,subtract your <br /> employer's contribution from the applicable monthly rates shown below. <br /> B = Basic Plan SM =Supplement To Medicare Plan dep= Dependent <br /> BLUE SHIELD BRIDGEWAY <br /> AETNA NORTH* AETNA SOUTH** HMO PLAN FOR HEALTH <br /> (ANC) (ASC) (BS) (BR) <br /> Plan Monthly Plan Monthly Plan Monthly Plan Monthly <br /> Code Rate Code Rate Code Rate Code Rate <br /> Basic(B) <br /> Emp.only 221 $156.00 2011 $156.00 2051 $157.00 781 $159.90 <br /> Emp. & 1 dep. 222 312.00 2012 312.00 2052 311.00 782 319.80 <br /> Emp. &2+deps. 223 395.00 2013 417.00 2053 409.00 783 414.14 <br /> Supplement To Medicare(SM) <br /> Emp.only 231 85.00 2021 116.57 2061 126.00 791 80.00 <br /> Emp. & 1 dep. 232 170.00 2022 233.14 2062 251.00 792 160.00 <br /> Emp. & 2+deps. 233 234.00 2023 349.71 2063 377.00 793 240.00 <br /> Combination (B&SM) <br /> Emp.(SM), 1 dep. (B) 234 241.00 2024 272.57 2064 280.00 794 239.90 <br /> Emp.(SM), 2+deps. (B) 235 324.00 2025 377.57 2065 378.00 795 334.24 <br /> Emp. & 1 dep. (SM), 1+deps. (B) 236 253.00 2026 338.14 2066 349.00 796 254.34 <br /> Emp. (B), 1 dep.(SM) 237 241.00 2027 272.57 2067 282.00 797 239.90 <br /> Emp. (B), 2+ deps. (SM) 238 305.00 2028 389.14 2068 408.00 798 319.90 <br /> Emp. & 1+dep. (B), 1 dep. (SM) 239 324.00 2029 377.57 2069 380.00 799 334.24 <br /> CALIFORNIA <br /> CAHP CCPOA FIREFIGHTERS CIGNA <br /> (CAHP-PBP) (CCPOA) (CPFA) (CIG) <br /> Plan Monthly Plan Monthly Plan Monthly Plan Monthly <br /> Code Rate Code Rate Code Rate Code Rate <br /> Basic(B) <br /> Emp.only 2301 $193.00 2741 $191.43 2891 $175.00 581 $157.00 <br /> Emp. & 1 dep. 2302 359.00 2742 364.11 2892 325.00 582 297.26 <br /> Emp. & 2+deps. 2303 470.00 2743 489.47 2893 410.00 583 394.07 <br /> Supplement To Medicare (SM) <br /> Emp.only 2311 173.00 2751 144.56 2901 132.00 681 127.03 <br /> Emp. & 1 dep. 2312 317.00 2752 289.09 2902 232.00 682 264.50 <br /> Emp. & 2 deps. 2313 401.00 2753 416.10 2903 356.00 683 436.63 <br /> Combination (B&SM) <br /> Emp. (SM), 1 dep. (B) 2314 339.00 2754 317.24 2904 282.00 684 267.29 <br /> Emp. (SM), 2+deps. (B) 2315 450.00 2755 442.60 2905 367.00 685 364.10 <br /> Emp. & 1 dep.(SM), 1+deps. (B) 2316 428.00 2756 414.45 2906 317.00 686 361.31 <br /> Emp. (B), 1 dep.(SM) 2317 337.00 2757 335.96 2907 275.00 687 294.47 <br /> Emp. (B), 2+deps. (SM) 2318 421.00 2758 462.97 2908 399.00 688 466.60 <br /> Emp. & 1+ dep. (B), 1 dep. (SM) 2319 448.00 2759 461.32 2909 360.00 689 391.28 <br /> • Formerly Bay Pacific Health Plan <br /> "Formerly PARTNERS Health Plan <br />