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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.

Loss of Insurance
Eligibility Topics