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Loss of Insurance Eligibility for
Faculty, Staff & Librarians — 2015 COBRA PEBB Monthly Rates

Special Requirements

To qualify for the Medicare rate, at least one covered famiy member must be enrolled in both Part A and Part B of Medicare. (Medicare rates are not available to Leave Without Pay members.)

Medicare-enrolled subscribers in Group Health Cooperative's Medicare Advantage plan or Kaiser Permanente Senior Advantage must complete and sign the Medicare Advantage Plan Election Form C to enroll in one of these plans.

Note: Medical premium surcharges do not apply to COBRA and PEBB Extension of Coverage subscribers enrolled in Medicare Part A and B.

Base Monthly Premium Rates for Medical

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
$578.51
$535.82
$600.80
$569.38
$530.10
$619.65
$540.35
Subscriber & Spouse/QDP*
1,150.77
1,056.18
1,195.35
1,132.51
1,044.74
1,233.05
1,064.74
Subscriber & Child(ren)
1,007.71
940.67
1,046.71
991.73
930.66
1,079.70
948.23
Full Family
1,579.97
1,402.70
1,641.26
1,554.86
1,386.97
1,693.10
1,414.29

Base Monthly Premium Rates for Medical

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
$384.69
$290.04
N/A ‡
N/A ‡
$299.79
Subscriber & Spouse/QDP*
1
956.95
N/A ‡
$884.59
$853.17
913.19
Subscriber & Spouse/QDP*
2
763.13
573.83
N/A ‡
N/A ‡
593.33
Subscriber & Child(ren)
1
813.89
N/A ‡
735.95
712.39
759.84
Subscriber & Child(ren)
2
763.13
573.83
N/A ‡
N/A ‡
593.33
Full Family
1
1,386.15
N/A ‡
1,330.50
1,275.52
1,373.24
Full Family
2
1,192.33
N/A ‡
1,019.74
996.18
1,053.38
Full Family
3
1,141.57
857.62
N/A ‡
N/A ‡
886.87

‡ 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
$207.66
$353.01

Subscriber & Spouse/QDP*

1 Medicare eligible

786.17
931.52

Subscriber & Spouse/QDP*

2 Medicare eligible - 1 retired, 1 disabled

560.67
560.67

Subscriber & Spouse/QDP*

2 Medicare eligible

415.32
706.02

Subscriber & Child(ren)

1 Medicare eligible

643.11
788.46

Full Family

1 Medicare eligible

1,215.37
1,360.72

Full Family

2 Medicare eligible - 1 retired, 1 disabled

996.12
996.12

Full Family

2 Medicare eligible

850.77
1,141.47

Note: 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
$45.22
$39.53
$42.37
Subscriber & Spouse/QDP*
90.44
79.06
84.74
Subscriber & Child(ren)
90.44
79.06
84.74
Full Family
135.66
118.59
127.11

Dental Plan Rates

Without Medical Plan (Dental Only)

  Uniform Dental Plan, administered by WDS DeltaCare,
administered by WDS
Willamette Dental
Subscriber Only
$51.47
$45.78
$48.62
Subscriber & Spouse/QDP*
96.69
85.31
90.99
Subscriber & Child(ren)
96.69
85.31
90.99
Full Family
141.91
124.84
133.36

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

All 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