Loss of Insurance Eligibility for
Faculty, Staff & Librarians — 2013 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 Only	$545.83	$499.95	$584.66	$535.22	$513.77	$567.06	$498.95
Subscriber & Spouse/QDP	1,085.48	990.26	1,163.14	1,064.26	1,018.40	1,127.94	988.26
Subscriber & Child(ren)	950.57	882.27	1,018.52	932.00	906.83	987.72	880.52
Full Family	1,490.22	1,314.25	1,597.00	1,461.04	1,353.13	1,548.60	1,311.50

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		$369.24	$265.03	N/A ‡	N/A ‡	$297.16
Subscriber & Spouse/QDP	1	908.89	N/A ‡	$843.51	$794.07	858.04
Subscriber & Spouse/QDP	2	732.30	523.88	N/A ‡	N/A ‡	588.14
Subscriber & Child(ren)	1	773.98	N/A ‡	698.89	661.81	717.82
Subscriber & Child(ren)	2	732.30	523.88	N/A ‡	N/A ‡	588.14
Full Family	1	1,313.63	N/A ‡	1,277.37	1,190.85	1,278.70
Full Family	2	1,137.04	N/A ‡	957.74	920.66	1,008.80
Full Family	3	1,095.36	782.73	N/A ‡	N/A ‡	879.12

‡ 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	$46.34	$39.53	$40.20
Subscriber & Spouse/QDP	92.68	79.06	80.40
Subscriber & Child(ren)	92.68	79.06	80.40
Full Family	139.02	118.59	120.60

Dental Plan Rates**

Without Medical Plan (Dental Only)

	Uniform Dental Plan, administered by WDS	DeltaCare, administered by WDS	Willamette Dental
Subscriber Only	$52.52	$45.71	$46.38
Subscriber & Spouse/QDP	98.86	85.24	86.58
Subscriber & Child(ren)	98.86	85.24	86.58
Full Family	145.20	124.77	126.78

*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 — 2013 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 — 2013 COBRA PEBB Monthly Rates