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Loss of Insurance Eligibility for
Faculty, Staff & Librarians — 2010 COBRA PEBB Monthly Rates

Medical Rates

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

  Subscriber Subscriber &
Spouse/QDP*		 Subscriber &
Child(ren)		 Full Family
Aetna Public Employees Plan $531.44 $1,056.44 $925.19 $1,450.19
Group Health Classic 470.73 935.02 818.95 1,283.24
Group Health Value 421.44 836.44 732.69 1,147.69
Kaiser Permanente Classic 471.51 936.58 820.31 1,285.38
Kaiser Permanente Value 441.08 875.72 767.06 1,201.70
Uniform Medical Plan 440.20 873.96 765.52 1,199.28

Medical Rates

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

  Subscriber
Only 		Subscriber & Spouse/
QDP*
(1 Medicare eligible)		 Subscriber &
Spouse/QDP*
(2 Medicare eligible)		 Subscriber &
Child(ren)
(1 Medicare eligible)

Subscriber &
Child(ren)
(2 Medicare eligible)

 Full Family
(1 Medicare eligible)		 Full Family
(2 Medicare eligible)		 Full Family
(3 Medicare eligible)
Aetna Public Employees Plan $460.27 $985.27 $914.10 $854.02 $914.10 $1,379.02 $1,307.85 $1,367.93
Group Health Classic** 258.28 722.57 510.12 606.50 510.12 1,070.79 858.34 761.96
Group Health Value ** 242.45 657.45 478.46 553.70 478.46 968.70 789.71 714.47
Kaiser Permanente Classic ** 326.37 791.44 646.30 675.17 646.30 1,140.24 995.10 966.23
Kaiser Permanente Value ** 264.45 699.09 522.46 590.43 522.46 1,025.07 848.44 780.47
Secure Horizons Classic ** 393.59 n/a 780.74 n/a 780.74 n/a n/a 1,167.89
Secure Horizons Value ** 247.60 n/a 488.76 n/a 488.76 n/a n/a 729.92
Uniform Medical Plan 319.29 753.05 632.14 644.61 632.14 1,078.37 957.46 944.99

**Medicare-enrolled subscribers must complete and sign a Medicare Advantage Plan Election form to enroll in one of the plans. To obtain a form, contact your health plan's customer service department.

Dental Plan Rates

With Medical Plan

  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 40.18 80.36 80.36 120.54
Uniform Dental Plan 44.53 89.06 89.06 133.59

Dental Plan Rates

Without Medical Plan (Dental Only)

  Subscriber Only Subscriber &
Spouse/QDP*		 Subscriber &
Child(ren)		 Full Family
DeltaCare, administered by Washington Dental Service $43.63 $80.82 $80.82 $118.01
Willamette Dental of Washington 46.62 86.80 86.80 126.98
Uniform Dental Plan 50.97 95.50 95.50 140.03

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

Loss of Insurance
Eligibility Topics