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Retiree Insurance
2009 Insurance Rates

CONTENTS

Life Insurance Self-Pay Rate for subscribers is $2.19 per month.

Premiums may be automatically deducted from the PERS, TRS, or LEOFF Subscriber benefit checks.
UW Retirement Plan (UWRP) subscribers may make arrangements for automatic deduction from a bank account.

Medical Rates (without Medicare)

Members not eligible for Medicare
(or enrolled in Part A only):
 Subscriber Subscriber+
Spouse/QDP		 Subscriber +
Child(ren)		 Full Family
$513.44 $1,020.79 $893.95 $1,401.30
508.50 1,010.91 885.31 1,387.72
426.16 846.23 741.21 1,161.28
476.60 947.11 829.48 1,299.99
433.88 861.67 754.72 1,182.51
427.25 848.41 743.12 1,164.28

Medical Rates (with Medicare)

Members enrolled in Part A & B of 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)
$202.28 $709.63 $398.47 $398.47 $582.79 $1,090.14 $778.98 $594.66
142.31 644.72 278.53 278.53 519.12 1,021.53 655.34 414.75
126.81 546.88 247.53 247.53 441.86 861.93 562.58 368.25
171.31 641.82 336.53 336.53 524.19 994.70 689.41 501.75
139.04 566.83 271.99 271.99 459.88 887.67 592.83 404.94
186.16 n/a 366.23 366.23 n/a n/a n/a 546.30
144.58 n/a 283.07 283.07 n/a n/a n/a 421.56
170.02 591.18 333.95 333.95 485.89 907.05 649.82 497.88

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
37.03 74.06 74.06 111.09
41.69 83.38 83.38 125.07

Medicare Supplement Plans (administered by Premera Blue Cross)

 Subscriber
Only 		*Subscriber+ Spouse
/QDP
(1 elig)		 Subscriber+ Spouse
/QDP
(2 elig, 1 dis)		 Subscriber+ Spouse
/QDP
(2 elig)		 *Subscriber+ Child(ren)
 *Full Family
(1 elig)		 *Full Family (2 elig, 1 dis) *Full Family
(2 elig)
Plan E Retired
 $72.21 $493.37 $184.61 $138.33 $388.08 $809.24 $500.48 $454.20
Plan E Disabled
 118.49 539.65 184.61 230.89 434.36 855.52 500.48 546.76
Plan J Retired without Rx
 101.62 522.78 264.02 197.15 417.49 838.65 579.89 513.02
Plan J Disabled without Rx
 168.49 589.65 264.02 330.89 484.36 905.52 579.89 646.76
Plan J Retired with Rx**
141.52 562.68 419.11 276.95 457.39 878.55 734.98 592.82
Plan J Disabled with Rx**
 283.68 704.84 419.11 561.27 599.55 1,020.71 734.98 877.14

*If a Medicare supplement plan is selected, non-Medicare eligible dependents are enrolled in the Uniform Medical Plan Preferred Provider Organization (UMP PPO). The rates shown reflect the total rate due, including both the Medicare supplement and UMP PPO premiums.

**Plan J with Rx is no longer offered to new subscribers.

QDP = Qualified Domestic Partner

Retiree Insurance Topics