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Loss of Insurance Eligibility for
Faculty, Staff & Librarians — 2014 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
$551.03
$504.56
$589.19
$537.04
$500.69
$588.43
$503.93
Subscriber & Spouse/QDP
1,095.84
999.94
1,172.16
1,067.86
992.20
1,170.64
998.18
Subscriber & Child(ren)
959.64
890.68
1,026.42
935.16
883.91
1,025.09
889.20
Full Family
1,504.45
1,327.73
1,609.39
1,465.98
1,317.09
1,607.30
1,325.12

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
$373.87
$283.37
N/A ‡
N/A ‡
$299.76
Subscriber & Spouse/QDP
1
918.68
N/A ‡
$866.34
$814.19
881.97
Subscriber & Spouse/QDP
2
741.52
560.52
N/A ‡
N/A ‡
593.30
Subscriber & Child(ren)
1
782.48
N/A ‡
720.60
661.49
736.42
Subscriber & Child(ren)
2
741.52
560.52
N/A ‡
N/A ‡
593.30
Full Family
1
1,327.29
N/A ‡
1,303.57
1,212.31
1,318.63
Full Family
2
1,150.13
N/A ‡
997.75
958.64
1,029.96
Full Family
3
1,109.17
837.67
N/A ‡
N/A ‡
886.84

‡ 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.

Medicare Supplement Part F

Administered by Premera Blue Cross

 

Plan F

Age 65 or older

eligible by age

Plan F

Under age 65

eligible by disability

Subscriber Only
$200.31
$340.52

Subscriber & Spouse/QDP*

1 Medicare eligible

751.34
891.55

Subscriber & Spouse/QDP*

2 Medicare eligible - 1 retired, 1 disabled

540.83
540.83

Subscriber & Spouse/QDP*

2 Medicare eligible

400.62
681.04

Subscriber & Child(ren)

1 Medicare eligible

615.14
755.35

Full Family

1 Medicare eligible

1,159.95
1,300.16

Full Family

2 Medicare eligible - 1 retired, 1 disabled

955.66
955.66

Full Family

2 Medicare eligible

815.45
1,095.87

*If a subscriber selects a Medicare supplement plan, non-Medicare eligible dependents are enrolled in Uniform Medical Plan (UMP) Classic. The rates shown reflect the total due, including premiums for both plans.

Dental Plan Rates**

With Medical Plan

  Uniform Dental Plan, administered by WDS DeltaCare,
administered by WDS
Willamette Dental
Subscriber Only
$44.72
$39.53
$43.23
Subscriber & Spouse/QDP
89.44
79.06
86.46
Subscriber & Child(ren)
89.44
79.06
86.46
Full Family
134.16
118.59
129.69

Dental Plan Rates**

Without Medical Plan (Dental Only)

  Uniform Dental Plan, administered by WDS DeltaCare,
administered by WDS
Willamette Dental
Subscriber Only
$50.94
$45.75
$49.45
Subscriber & Spouse/QDP
95.66
85.28
92.68
Subscriber & Child(ren)
95.66
85.28
92.68
Full Family
140.38
124.81
135.91

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

** Rates are subject to change.


Disclaimer: The information on this page does not substitute for official plan documents. If there is a conflict between the information on this site and an official plan document, the official plan document will govern. Refer to the Benefits Forms & Publications page.

Plan availability and eligibility may change depending on your employment status and/or actions of the Washington State Health Care Authority (HCA), the agency that purchases and coordinates health insurance benefits for public employees, including employees of the University of Washington, through the Public Employees Benefits Board (PEBB) program.

Loss of Insurance
Eligibility Topics