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City & County of San Francisco Employees2022 Medical & VSP Premier Premium Contribution Rates: Employee Only (Biweekly)HEALTH NETCANOPYCARE HMOCITY & COUNTY OF SFBLUE SHIELD OF CALIFORNIATRIO HMOACCESS HMOKAISERPERMANENTEHMOBLUE SHIELD OFCA ay 368.72 27.75 350.64 26.39 399.80 30.09 307.32 23.13 399.80 217.36 368.72 27.75 350.64 26.39 399.80 30.09 307.32 23.13 399.80 217.36Auto Machinists Loc. 1414Building InspectorsConsolidated Crafts1DA Investigators Assoc.Dep. Prob. Ofcrs. Assoc.Dep. Sheriffs Assoc. 12AElec. Workers Local 6Firefighters Local 798IFPTE Local 21Instit. Police Ofcrs. Assoc.Mun. Attys. Assoc. MAAOperating Engineers Loc. 3Phys. and Dentists UAPDPlum. & Pipefitters Loc. 38Police Officers Assoc. POASEIU Local 1021 Para.Sheriff Mgrs. & Sups. 12BStationary Eng. Local 39Sup. Probation OfficersTeam. Loc. 856 Multi-UnitTWU Local 200 SEAMTWU 250-A Auto Svc 7410TWU 250-A Multi-UnitLab. Intl. Union Loc. 261Painters, SFCWU 356.82 39.65 349.53 27.50 386.90 42.99 330.45 0 386.90 230.26SEIU Loc. 1021 Misc. 396.47 0 377.03 0 429.89 0 330.45 0 617.16 0SEIU Loc. 1021 Staff Nurs. 356.82 39.65 349.53 27.50 386.90 42.99 330.45 0 386.90 230.26 0 396.47 0 377.03 0 429.89 0 330.45 0 617.16Teamsters 856, Sup. Nurs. 356.82 39.65 349.53 27.50 386.90 42.99 330.45 0 386.90 230.26MTA SVC CRITICAL aysYouPayEmployerPaysYouPayEmployerPaysYouPay 368.72 27.75 350.64 26.39 399.80 30.90 307.32 23.13 399.80 217.36SEIU Loc. 1021 Svc. Crit. 396.47 0 377.03 0 429.89 0 330.45 0 617.16 uPay 349.53 46.94 349.53 27.50 349.53 80.36 330.45 0 349.53 267.63SEIU Local 1021Per Diem NursesAuto Mach. Loc. 1414Electrical Workers Local 6TWU Local 200TWU 250-A Tran. Op. 9163TWU 250-A Fare Ins. 9132TWU 250-A Aut. Wk. 7410VSP PremierALL MEMBERSYou Pay 4.851Consolidated Crafts includes: Bricklayers Local 3, Hodcarriers Local 166, Carpenters Local 22, Carpet, Linoleum Workers, Local 12,Cement Masons Local 580, Glaziers Local 718, Ironworkers Local 377, Pile Drivers Local 34, Plasterers Local 66, Roofers Local 40,Sheet Metal Workers Local 104, Theatrical Stage Employees Local 16, Teamsters Local 853.10Plan Year 2022

City & County of San Francisco Employees2022 Medical & VSP Premier Premium Contribution Rates: Employee 1 (Biweekly)HEALTH NETCANOPYCARE HMOBLUE SHIELD OF CALIFORNIATRIO HMOACCESS HMOKAISERPERMANENTEHMOBLUE SHIELD OFCA ay 736.16 55.41 699.99 52.69 798.33 60.09 613.35 46.17 798.33 395.42Lab. Intl. Union Loc. 261 736.16 55.41 699.99 52.69 798.33 60.09 613.35 46.17 798.33 395.42Painters, SFCWU 744.63 46.94 725.18 27.50 778.06 80.36 659.52 0 801.18 392.57SEIU Loc. 1021 Misc. 759.91 31.66 722.58 30.10 824.0834.34 633.1426.38 824.08369.67SEIU Loc. 1021 Staff Nurs. 712.41 79.16 677.41 75.27 772.58 85.84 626.54 32.98 637.81 555.94 0 791.57 0 752.68 0 858.42 0 659.52 0 1,193.75Teamsters 856, Sup. Nurs. 712.41 79.16 677.41 75.27 772.58 85.84 626.54 32.98 637.81 555.94MTA SVC CRITICAL aysYouPayEmployerPaysYouPayEmployerPaysYouPay 736.16 55.41 699.99 52.69 798.33 60.09 613.35 46.17 798.33 395.42SEIU Loc. 1021 Svc. Crit. 759.91 31.66 722.58 30.10 824.08 34.34 633.14 26.38 824.08 aysYouPay 349.53 442.04 349.53 403.15 349.53 508.89 330.45 329.07 349.53 844.22CITY & COUNTY OF SFAuto Machinists Loc. 1414Building InspectorsConsolidated Crafts1DA Investigators Assoc.Dep. Prob. Ofcrs. Assoc.Dep. Sheriffs Assoc. 12AElec. Workers Local 6Firefighters Local 798IFPTE Local 21Instit. Police Ofcrs. Assoc.Mun. Attys. Assoc. MAAOperating Engineers Loc. 3Phys. and Dentists UAPDPlum. & Pipefitters Loc. 38Police Officers Assoc. POASEIU Local 1021 Para.Sheriff Mgrs. & Sups. 12BStationary Eng. Local 39Sup. Probation OfficersTeam. Loc. 856 Multi-UnitTWU Local 200 SEAMTWU 250-A Auto Svc 7410TWU 250-A Multi-UnitSEIU Local 1021Per Diem NursesAuto Mach. Loc. 1414Electrical Workers Local 6TWU Local 200TWU 250-A Tran. Op. 9163TWU 250-A Fare Ins. 9132TWU 250-A Aut. Wk. 7410VSP PremierALL MEMBERSYou Pay 7.351Consolidated Crafts includes: Bricklayers Local 3, Hodcarriers Local 166, Carpenters Local 22, Carpet, Linoleum Workers, Local 12,Cement Masons Local 580, Glaziers Local 718, Ironworkers Local 377, Pile Drivers Local 34, Plasterers Local 66, Roofers Local 40,Sheet Metal Workers Local 104, Theatrical Stage Employees Local 16, Teamsters Local 853.Plan Year 202211

City & County of San Francisco Employees2022 Medical & VSP Premier Premium Contribution Rates: Employee 2 or More (Biweekly)HEALTH NETCANOPYCARE HMOBLUE SHIELD OF CALIFORNIATRIO HMOACCESS HMOKAISERPERMANENTEHMOBLUE SHIELD OFCA ay 929.17 190.32 883.51 180.96 1,007.70 206.40 774.10 158.54 1,007.70 677.66Lab. Intl. Union Loc. 261 985.15 134.34 936.73 127.74 1,068.41 145.69 820.72 111.92 1,068.41 616.95Painters, SFCWU 801.18 318.31 801.18 263.29 801.18 412.92 782.10 150.54 801.18 884.18SEIU Loc. 1021 Misc. 929.17 190.32 883.51180.96 1,007.70 206.40 774.10158.54 1,007.70677.66 1,007.54 111.95 958.02 106.45 1,092.69 121.41 886.01 46.63 883.63 801.73CITY & COUNTY OF SFAuto Machinists Loc. 1414Building InspectorsConsolidated Crafts1DA Investigators Assoc.Dep. Prob. Ofcrs. Assoc.Dep. Sheriffs Assoc. 12AElec. Workers Local 6Firefighters Local 798IFPTE Local 21Instit. Police Ofcrs. Assoc.Mun. Attys. Assoc. MAAOperating Engineers Loc. 3Phys. and Dentists UAPDPlum. & Pipefitters Loc. 38Police Officers Assoc. POASEIU Local 1021 Para.Sheriff Mgrs. & Sups. 12BStationary Eng. Local 39Sup. Probation OfficersTeam. Loc. 856 Multi-UnitTWU Local 200 SEAMTWU 250-A Auto Svc 7410TWU 250-A Multi-UnitSEIU Loc. 1021 Staff Nurs.SEIU Local 1021Per Diem Nurses 0 1,119.49 0 1,064.47 0 1,214.10 0 932.64 0 1,685.36 1,007.54 111.95 958.02 106.45 1,092.69 121.41 886.01 46.63 883.63 PaysYouPayEmployerPaysYouPayEmployerPaysYouPay 929.17 190.32 883.51 180.96 1,007.70 206.40 774.10 158.54 1,007.70 677.66SEIU Loc. 1021 Svc. Crit. 929.17 190.32 883.51 180.96 1,007.70 206.40 774.10 158.54 1,007.70 aysYouPay 349.53 769.96 349.53 714.94 349.53 864.57 330.45 602.19 349.53 1,335.83Teamsters 856, Sup. Nurs.MTA SVC CRITICALEMPL.Auto Mach. Loc. 1414Electrical Workers Local 6TWU Local 200TWU 250-A Tran. Op. 9163TWU 250-A Fare Ins. 9132TWU 250-A Aut. Wk. 7410VSP PremierALL MEMBERSYou Pay 15.131Consolidated Crafts includes: Bricklayers Local 3, Hodcarriers Local 166, Carpenters Local 22, Carpet, Linoleum Workers, Local 12,Cement Masons Local 580, Glaziers Local 718, Ironworkers Local 377, Pile Drivers Local 34, Plasterers Local 66, Roofers Local 40,Sheet Metal Workers Local 104, Theatrical Stage Employees Local 16, Teamsters Local 853.12Plan Year 2022

CityCity && CountyCounty ofof SanSan FranciscoFrancisco EmployeesEmployeesVision Plan Benefits-at-a-GlanceCovered ServicesVSP Basic1VSP PremierWell Vision Exam 10 co-pay every calendar year 10 co-pay every calendar yearSingle Vision LensesLined Bifocal LensesLined Trifocal Lenses 25 co-pay every other calendar year2 25 co-pay every other calendar year2 25 co-pay every other calendar year2 0 every calendar year 0 every calendar year 0 every calendar yearStandard Progressive LensesPremium Progressive LensesCustom Progressive Lenses100% coverage every other calendar year 95– 105 co-pay every other calendar year 150– 175 co-pay every other calendar year100% coverage every calendar year 25 co-pay every calendar year 25 co-pay every calendar yearStandard Anti-Reflective CoatingPremium Anti-Reflective CoatingCustom Anti-Reflective Coating 41 co-pay every other calendar year 58– 69 co-pay every other calendar year 85 co-pay every other calendar year 25 co-pay every calendar year 25 co-pay every calendar year 25 co-pay every calendar yearScratch-Resistant CoatingFully covered every other calendar yearFully Covered every calendar yearFrames 150 allowance for a wide selection of frames 170 allowance for featured frames 80 allowance use at Costco 300 allowance for a wide selection of frames 320 allowance for featured frames 165 allowance at Costco 25 co-pay applies; 20% savings on amount overthe allowance; every other calendar yearNo additional co-pay; 20% savings on theamount over your allowance every calendar yearContacts (instead of glasses) 150 allowance every other calendar year2 250 allowance every calendar yearContact Lens ExamUp to 60 co-pay every other calendar year2Primary Eye Care (for thetreatment of urgent or acuteocular conditions) 5 co-pay 5 co-payAverage 15% off regular price or 5% offAverage 15% off regular price or 5% offpromotional price; discounts only available fromcontracted facilitiespromotional price; discounts only available fromcontracted facilitiesUp to 60 co-pay every calendar yearVision Care DiscountsLaser Vision CorrectionVision Care Premium RatesVSP Basic PlanIncluded with your medical premium.VSP Premier Contribution (Biweekly)Employee Only 4.85Employee 1 Dependent 7.35Employee Family 15.13Your Coverage with Out-of-Network ProvidersVisit vsp.com if you plan to see a provider other than a VSP network provider.ExamFrameUp to 50Up to 70Single Vision LensesLined Bifocal LensesUp to 45 Lined Trifocal LensesUp to 65 Progressive LensesUp to 85ContactsUp to 85Up to 105VSP Basic Plan coverage is included with your medical premium.1Under the VSP Basic plan, new lenses may be covered the next year if Rx change is more than .50 diopters.2IFPTE Local 21, SEIU 1021 and miscellaneous unrepresented employees are also eligible for VDT Computer VisionCare benefits.In any instance where information in this chart conflicts with the plan’s Evidence of Coverage (EOC), the plan’s EOC shall prevail.1414Plan Year 2022

City & County of San Francisco EmployeesDental Premium Contribution Rates (Biweekly)DELTA DENTAL PPOCITY AND COUNTY OFSAN FRANCISCO EMPLOYEESDELTACARE USA DHMOUNITEDHEALTHCAREDENTAL DHMOEmployer PaysYou PayEmployer PaysYou PayEmployer PaysYou PayEmployee Only 20.46 2.31 12.22 0 11.53 0Employee 1 Dependent 43.19 4.62 20.16 0 19.05 0Employee 2 or More Dependents 61.38 6.92 29.82 0 28.16 0MTA SVC. CRITICAL EMPLOYEESEmployer PaysYou PayEmployer PaysYou PayEmployer PaysYou PayEmployee Only 20.46 2.31 12.22 0 11.53 0Employee 1 Dependent 43.19 4.62 20.16 0 19.05 0Employee 2 or More Dependents 61.38 6.92 29.82 0 28.16 0Employer PaysYou PayEmployer PaysYou PayEmployer PaysYou PayEmployee Only 0.00 22.77 0.00 12.22 0.00 11.53Employee 1 Dependent 0.00 47.81 0.00 20.16 0.00 19.05Employee 2 or More Dependents 0.00 68.30 0.00 29.82 0.00 28.16COMMISSIONERSAll unions (except SEIU Local 1021 Staff Nurses) pay the employee share of dental premiums. Commissioners appointed orelected after 2002 pay both employer and employee share of dental premiums as indicated.Plan Year 202217

Lab. Intl. Union Loc. 261 736.16 55.41 699.99 52.69 798.33 60.09 613.35 46.17 395.42 . Ironworkers Local 377, Pile Drivers Local 34, Plasterers Local 66, Roofers Local 40, Sheet Metal Workers Local 104, Theatrical Stage Employees Local 16, Teamsters Local 853. HEALTH NET CANOPYCARE HMO BLUE SHIELD OF CALIFORNIA KAISER PERMANENTE HMO .