Retiree monthly premiums (2024)

2024 PEBB Retiree Monthly Premiums E昀昀ective January 1, 2024 Special requirements for Medicare premiums • To qualify for the Medicare premium, at least one member on the account must be enrolled in Medicare Part A and Part B. • Medicare premiums have been reduced by the state-funded contribution, up to the lesser of $183 or 50 percent of the plan rate per retiree per month. For more information on these requirements, contact your medical plan’s customer service department. Note: These premiums do not include your Medicare Part B premium. • Kaiser Foundation Health Plan of the Northwest (Kaiser Permanente NW) o昀昀ers plans in Clark and Cowlitz counties in Washington and select counties and zip codes in Oregon. Kaiser Permanente NW Medicare plans have a larger service area. • Uniform Medical Plan (UMP) is administered by Regence BlueShield and Washington State Rx Services. • UnitedHealthcare plans are Medicare Advantage Part D (MAPD) plans. If a UnitedHealthcare Medicare plan is selected, non- Medicare eligible members are enrolled in UMP Classic. The rates re昀氀ect the total due, including premiums for both plans. • The term spouse is interchangable with state registered domestic partner (SRDP). Medicare medical plan premiums (for members enrolled in Medicare Part A and Part B) * If a Kaiser Permanente NW member is enrolled in Medicare Part A and Part B, and other enrolled members are not eligible for Medicare, the non-Medicare members will be enrolled in Kaiser Permanente NW Classic. The subscriber will pay the combined Medicare and non-Medicare premium shown for Kaiser Permanente NW Senior Advantage. # If a Kaiser Foundation Health Plan of Washington (KFHPW) member is enrolled in Medicare Part A and Part B, and other enrolled members are not eligible for Medicare, the non-Medicare members must enroll in (KFHPW) Classic, SoundChoice, or Value plan. The subscriber will pay a combined Medicare and non-Medicare premium. Kaiser Foundation Kaiser Foundation Health Uniform Health Plan of Washington Medical UnitedHealthcare Plan of the Plan Northwest Senior Medicare PEBB PEBB Advantage Classic (Original or SoundChoice Value Classic Balance Complete Advantage) Subscriber only 1 eligible $193.95* N/A $188.62 N/A N/A $532.94 $135.65 $160.58 Subscriber and spouse 1 eligible $1,227.17* $1,116.22 N/A $960.07 $1,102.03 $1,358.66 $961.37 $986.30 2 eligible # # # $381.94 N/A $371.29 N/A N/A $1,059.92 $265.34 $315.21 Subscriber and children 1 eligible # $968.87* $884.32 N/A $767.21 $873.67 $1,152.23 $754.94 $779.87 2 eligible # # # $381.94 N/A $371.29 N/A N/A $1,059.92 $265.34 $315.21 Subscriber, spouse, and children 1 eligible $2,002.09* $1,811.92 N/A# $1,538.66 $1,787.08 $1,977.95 $1,580.66 $1,605.59 2 eligible $1,156.86* $1,066.99 N/A# $949.88 $1,056.34 $1,679.21 $884.63 $934.50 3 eligible $569.93 N/A# $553.95 N/A# N/A# $1,586.90 $395.03 $469.83 1 HCA 51-0275 (9/23)

Medicare supplement plan premiums Premera Blue Cross Plan F (closed to new members) Plan G Age 65 or older, Under age Age 65 or older, Under age eligible by age 65, eligible eligible by age 65, eligible by disability by disability Subscriber only 1 Medicare eligible $119.05 $207.45 $101.99 $169.20 Subscriber and spouse 1 Medicare eligible $944.77 $1,033.17 $927.71 $994.92 2 Medicare eligible: 1 $320.54 $320.54 $265.23 $265.23 retired, 1 disabled 2 Medicare eligible $232.14 $408.94 $198.02 $332.44 Subscriber and children 1 Medicare eligible $738.34 $826.74 $721.28 $788.49 Subscriber, spouse,and children 1 Medicare eligible $1,564.06 $1,652.46 $1,547.00 $1,614.21 2 Medicare eligible: 1 $940.58 $940.58 $885.27 $885.27 retired, 1 disabled 2 Medicare eligible $851.43 $1,028.23 $817.31 $951.73 2

Non-Medicare medical plan premiums (for members not enrolled in Medicare) Managed Care Plans Kaiser Foundation Health Kaiser Foundation Health Plan of Washington Plan of the Northwest Classic CDHP Classic CDHP SoundChoice Value Subscriber only $1,039.18 $907.72 $933.56 $738.98 $777.41 $919.37 Subscriber & spouse $2,072.40 $1,808.12 $1,861.16 $1,470.63 $1,548.87 $1,832.77 Subscriber & children $1,814.10 $1,597.60 $1,629.26 $1,302.30 $1,356.00 $1,604.42 Subscriber, spouse, $2,847.32 $2,439.67 $2,556.86 $1,975.63 $2,127.45 $2,517.83 & children Preferred Provider Organization (PPO) Plans Uniform Medical Plan Classic CDHP Select UMP Plus Subscriber only $831.68 $747.79 $766.61 $816.50 Subscriber & spouse $1,657.40 $1,488.26 $1,527.27 $1,627.04 Subscriber & children $1,450.97 $1,317.73 $1,337.10 $1,424.41 Subscriber, spouse, $2,276.69 $1,999.87 $2,097.76 $2,234.95 & children Medical premium surcharges (for non-Medicare subscribers only) Two premium surcharges may apply in addition to your monthly medical premium. You will be charged for them if the conditions described below apply, or if you do not attest to the surcharges when required. • A monthly $25-per-account medical premium surcharge will apply if you or any dependent (age 13 and older) enrolled in PEBB medical uses tobacco products. • A monthly $50 medical premium surcharge will apply if you enroll a spouse or state-registered domestic partner, and they have chosen not to enroll in another employer-based group medical plan that is comparable to PEBB’s Uniform Medical Plan (UMP) Classic. For more guidance on whether these premium surcharges apply to you, see the 2024 PEBB Premium Surcharge Attestation Help Sheet on the HCA website at hca.wa.gov/erb under Forms & publications. 3

Dental plan premiums You must enroll in medical coverage to enroll in dental. Managed Care Plans Preferred Provider Organization (PPO) DeltaCare Willamette Dental Group Uniform Dental Plan Monthly premiums Subscriber only $41.50 $48.87 $48.92 Subscriber & spouse $83.00 $97.74 $97.84 Subscriber & children $83.00 $97.74 $97.84 Subscriber, spouse, $124.50 $146.61 $146.76 & children Retiree term life insurance premiums The table below shows that monthly costs increase as your age increases, but your bene昀椀t coverage amount does not change. Administered by Metropolitan Life Insurance Company. Your age 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90–94 95+ Monthly cost for... $5,000 $0.87 $1.34 $2.50 $3.84 $7.38 $11.97 $19.41 $31.43 $50.90 $82.45 $133.57 coverage $10,000 $1.74 $2.67 $5.00 $7.67 $14.76 $23.94 $38.81 $62.86 $101.79 $164.89 $267.14 coverage $15,000 $2.61 $4.01 $7.50 $11.51 $22.14 $35.91 $58.22 $94.29 $152.69 $247.34 $400.71 coverage $20,000 $3.48 $5.34 $10.00 $15.34 $29.52 $47.88 $77.62 $125.72 $203.58 $329.78 $534.28 coverage Legacy retiree life insurance plan premiums The legacy retiree life insurance plan is only available to retirees enrolled as of December 31, 2016, who didn’t elect to increase their retiree term life insurance amount during MetLife’s open enrollment (November 1–30, 2016). Administered by Metropolitan Life Insurance Company. Age at death Amount of insurance Monthly cost Under 65 $3,000 $7.75 65 through 69 $2,100 $7.75 70 and over $1,800 $7.75 HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call us at 1-800-200-1004 (TRS: 711). 4