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)