Page 7 - Caltech

2021 Monthly Plan Premium Rates At-A-Glance
Medical Plans for Medicare Eligible Retirees
1 Person Rate
$640.96
$1,281.92
$292.57
$585.14
$250.27
$500.54
$63.76
$127.52
$322.52
$645.04
$215.98
$431.96
Plan Option
Aetna Traditional Choice with Rx 1505 Aetna Medicare PPO – Premier Plan Aetna Medicare PPO – Medium Plan Aetna Medicare PPO – Value Plan Aetna Medicare HMO Plan
Kaiser Permanente Senior Advantage HMO Plan (includes medical, dental and vision)
Plan Option
Aetna Choice PPO – High Option
Aetna Choice PPO – Medium Option Aetna Choice PPO – Low Option
Aetna HMO
Kaiser HMO (includes medical and vision)
Plan Option
Aetna Dental PPO Plan
Plan Option
Aetna Vision Preferred Plan
2 Person Rate*
Medical Plans for Non-Medicare Eligible Retirees
1 Person Rate
$1,581.81
$3,163.62
$1,119.78
$2,239.56
$714.92
$1,429.84
$1,057.08
$2,114.16
$828.24
$1,656.46
2 Person Rate*
Dental Plans for Medicare and Non-Medicare Eligible Retirees
1 Person Rate
$42.14
$84.28
2 Person Rate*
2 Person Rate*
Vision Plans for Medicare and Non-Medicare Eligible Retirees
1 Person Rate
$7.32
$14.46
*2 person rate assumes Retiree & Spouse. For Retiree & Child rates for the medical plan, please contact the Retiree Service Center.
Dental and Vision Retiree & Child rates are listed beginning on page 12.
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