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Loss of Insurance Eligibility for
Faculty, Staff & Librarians — 2009 COBRA PEBB Monthly Rates

Medical Rates Without Medicare

  Subscriber Subscriber &
Spouse/QDP*		 Subscriber &
Child(ren)		 Full Family
Aetna Public Employees Plan $513.44 $1,020.79 $893.95 $1,401.30
Group Health Classic 508.50 1,010.91 885.31 1,387.72
Group Health Value 426.16 846.23 741.21 1,161.28
Kaiser Permanente Classic 476.60 947.11 829.48 1,299.99
Kaiser Permanente Value 433.88 861.67 754.72 1,182.51
Uniform Medical Plan 427.25 848.41 743.12 1,164.28

Medical Rates (With Medicare)

  Subscriber
Only 		Subscriber & Spouse/
QDP*
(1 elig)		 Subscriber &
Spouse/QDP*
(2 elig)		 Subscriber &
Child(ren)
(2 elig) 		Subscriber &
Child(ren)		 Full Family
(1 elig)		 Full Family
(2 elig)		 Full Family
(3 elig)
Aetna Public Employees Plan $385.17 $892.52 $764.25 $764.25 $765.68 $1,273.03 $1,144.76 $1,143.33
Group Health Classic 278.53 780.94 550.97 550.97 655.34 1,157.75 927.78 823.41
Group Health Value 247.54 667.61 488.99 488.99 562.59 982.66 804.04 730.44
Kaiser Permanente Classic 336.54 807.05 666.99 666.99 689.42 1,159.93 1,019.87 997.44
Kaiser Permanente Value 271.99 699.78 537.89 537.89 592.83 1,020.62 858.73 803.79
Secure Horizons Classic * 366.23 N.A. 726.37 726.37 N.A. N.A. N.A. 1,086.51
Secure Horizons Value* 283.08 N.A. 560.07 560.07 N.A. N.A. N.A. 837.06
Uniform Medical Plan 333.96 755.12 661.83 661.83 649.83 1,070.99 977.70 989.70

*The retiree and his or her enrolled dependents must be enrolled in Medicare Parts A and B to enroll in Secure Horizons.

Dental Rates (With Medical)

  Subscriber Only Subscriber &
Spouse/QDP*		 Subscriber &
Child(ren)		 Full Family
DeltaCare, administered by Washington Dental Service $37.19 $74.38 $74.38 $111.57
Willamette Dental of Washington 37.03 74.06 74.06 111.09
Uniform Dental Plan 41.69 83.38 83.38 125.07

Dental Rates (Dental Only)

  Subscriber Only Subscriber &
Spouse/QDP*		 Subscriber &
Child(ren)		 Full Family
DeltaCare, administered by Washington Dental Service $43.28 $80.47 $80.47 $117.66
Willamette Dental of Washington 43.12 80.15 80.15 117.18
Uniform Dental Plan 47.78 89.47 89.47 131.16

*QDP = Qualified Domestic Partner

Loss of Insurance
Eligibility Topics