Loss of Insurance Eligibility for
Faculty, Staff & Librarians — 2012 COBRA PEBB Monthly Rates

Medical Rates

For subscribers not eligible for Medicare (or enrolled in Part A only):

	Uniform Medical Plan Classic	Uniform Medical Plan CDHP w/HSA	Group Health Classic	Group Health Value	Group Health CDHP w/HSA	Kaiser Permanente Classic	Kaiser Permanente CDHP w/HSA
Subscriber	$531.11	$485.22	$550.48	$501.58	$482.92	$538.18	$481.27
Subscriber & Spouse/QDP	1,056.69	961.45	1,095.43	997.63	957.35	1,070.83	953.55
Subscriber & Child(ren)	925.30	856.97	959.19	873.62	853.32	937.67	850.06
Full Family	1,450.88	1,274.87	1,504.14	1,369.67	1,269.42	1,470.32	1,264.01

Medical Rates

For subscribers enrolled in Part A & Part B of Medicare:

Members enrolled in Part A & B of Medicare:	# Eligible	Uniform Medical Plan Classic	Group Health Medicare Plan	Group Health Classic	Group Health Value	Kaiser Permanente Classic
Subscriber Only		$363.87	$258.19	N/A ‡	N/A ‡	$292.94
Subscriber & Spouse/QDP	1	889.45	N/A ‡	$803.14	$754.24	825.59
Subscriber & Spouse/QDP	2	722.21	510.85	N/A ‡	N/A ‡	580.35
Subscriber & Child(ren)	1	758.06	N/A ‡	666.90	630.23	692.43
Subscriber & Child(ren)	2	722.21	510.85	N/A ‡	N/A ‡	580.35
Full Family	1	1,283.64	N/A ‡	1,211.85	1,126.28	1,225.08
Full Family	2	1,116.40	N/A ‡	919.56	882.89	979.84
Full Family	3	1,080.55	763.51	N/A ‡	N/A ‡	867.76

‡ If a Group Health subscriber is enrolled in Medicare Part A and Part B but covers a family member not eligible for Medicare, the family member must enroll in a Group Health Classic or Value plan and the subscriber pays a combined Medicare and non-Medicare rate.

Dental Plan Rates**

With Medical Plan

	Uniform Dental Plan, administered by WDS	DeltaCare, administered by WDS	Willamette Dental
Subscriber Only	$45.20	$39.53	$42.68
Subscriber & Spouse/QDP	90.40	79.06	85.36
Subscriber & Child(ren)	90.40	79.06	85.36
Full Family	135.60	118.59	128.04

Dental Plan Rates**

Without Medical Plan (Dental Only)

	Uniform Dental Plan, administered by WDS	DeltaCare, administered by WDS	Willamette Dental
Subscriber Only	$50.73	$45.06	$48.21
Subscriber & Spouse/QDP	95.93	84.59	90.89
Subscriber & Child(ren)	95.93	84.59	90.89
Full Family	141.13	124.12	133.57

*QDP = Qualified Domestic Partner (i.e. Washington State-registered domestic partner)

** Rates are subject to change.

Loss of Insurance
Eligibility Topics

Loss of Insurance Eligibility for Faculty, Staff & Librarians — 2012 COBRA PEBB Monthly Rates

Medical Rates

For subscribers not eligible for Medicare (or enrolled in Part A only):

Medical Rates

For subscribers enrolled in Part A & Part B of Medicare:

Dental Plan Rates**

With Medical Plan

Dental Plan Rates**

Without Medical Plan (Dental Only)

Loss of Insurance Eligibility for
Faculty, Staff & Librarians — 2012 COBRA PEBB Monthly Rates