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Loss of Insurance Eligibility for
Faculty, Staff & Librarians — 2008 COBRA PEBB Monthly Rates

Medical Rates Without Medicare

  Subscriber Subscriber &
Spouse/QDP*		 Subscriber &
Child(ren)		 Full Family
Aetna Public Employees Plan $494.01 $976.34 $855.76 $1,338.10
Group Health Classic 463.99 916.31 803.23 1,255.55
Group Health Value 408.19 804.72 705.59 1,102.11
Kaiser Permanente Classic 491.51 971.35 851.38 1,331.22
Kaiser Permanente Value 447.93 884.20 775.13 1,211.39
Uniform Medical Plan 416.94 822.20 720.89 1,126.15

Medical Rates (With Medicare)

  Subscriber
Only 		Subscriber & Spouse/
QDP*
(1 elig)		 Subscriber &
Spouse/QDP*
(2 elig)		 Subscriber &
Child(ren)
(1 elig) 		Subscriber &
Child(ren)
(2 elig)		 Full Family
(1 elig)		 Full Family
(2 elig)		 Full Family
(3 elig)
Aetna Public Employees Plan $404.63 $866.97 $797.60 $766.39 $797.60 $1,248.72 $1,159.35 $1,190.56
Group Health Classic 317.34 769.66 623.02 656.58 623.02 1,108.90 962.26 928.69
Group Health Value 280.70 677.23 549.74 578.10 549.74 974.62 847.13 818.77
Kaiser Permanente Classic 341.84 821.68 672.02 701.72 672.02 1,181.56 1,031.89 1,002.19
Kaiser Permanente Value 273.60 709.87 535.54 600.80 535.54 1,037.06 862.74 797.48
Secure Horizons Classic * 371.34 N.A. 731.01 N.A. 731.01 N.A. N.A. 1,090.69
Secure Horizons Value* 288.66 N.A. 565.65 N.A. 565.65 N.A. N.A. 842.64
Uniform Medical Plan 342.55 747.81 673.42 646.50 673.42 1,051.76 977.37 1,004.30

*The retiree and his or her enrolled dependents must be enrolled in Medicare Parts A and B to enroll in Secure Horizons.

Dental Rates (With Medical)

  Subscriber Only Subscriber &
Spouse/QDP*		 Subscriber &
Child(ren)		 Full Family
DeltaCare, administered by Washington Dental Service $35.89 $71.79 $71.79 $107.68
Willamette Dental of Washington 35.90 71.81 71.81 107.71
Uniform Dental Plan 40.81 81.62 81.62 122.43

Dental Rates (Dental Only)

  Subscriber Only Subscriber &
Spouse/QDP*		 Subscriber &
Child(ren)		 Full Family
DeltaCare, administered by Washington Dental Service $47.56 $83.46 $83.46 $119.35
Willamette Dental of Washington 47.57 83.48 83.48 119.38
Uniform Dental Plan 52.48 93.29 93.29 134.10

*QDP = Qualified Domestic Partner

Loss of Insurance
Eligibility Topics