Employer Group Ended Participation (2024)

2024 PEBB Continuation Coverage (Employer Groups Ended Participation) Monthly Premiums E昀昀ective January 1, 2024 • 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 in Oregon. Kaiser Permanente NW Medicare plans have a larger service area. • UMP is administered by Regence BlueShield and Washington State Rx Services. • The term spouse is interchangable with State Registered Domestic Partner (SRDP). Non-Medicare medical plan premiums (for members not enrolled in Medicare) Managed Care Plans Preferred Provider Organization (PPO) Plans Kaiser Foundation Kaiser Foundation Health Uniform Medical Plan Health Plan of Plan of Washington the Northwest Classic CDHP Classic CDHP SoundChoice Value Classic CDHP Select UMP Plus Monthly premiums Subscriber $1,039.18 $907.72 $933.56 $738.98 $777.41 $919.37 $831.68 $747.74 $766.61 $816.50 only Subscriber $2,072.40 $1,808.12 $1,861.16 $1,470.63 $1,548.87 $1,832.77 $1,657.40 $1,488.26 $1,527.27 $1,627.04 & spouse Subscriber $1,814.10 $1,597.60 $1,629.26 $1,302.30 $1,356.00 $1,604.42 $1,450.97 $1,317.73 $1,337.10 $1,424.41 & children Subscriber, spouse, & $2,847.32 $2,439.67 $2,556.86 $1,975.63 $2,127.45 $2,517.83 $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 (if you, the subscriber, are not enrolled in Medicare Part A and Part B). You will be charged for them if the conditions described below apply, or if you do not attest to the surcharges when required. Visit Surcharges on HCA’s website at hca.wa.gov/pebb-continuation for more information. • A monthly $25-per-account medical premium surcharge will apply if you or any dependent (age 13 and older) enrolled in PEBB medical coverage uses tobacco products. • A monthly $50 medical premium surcharge will apply if you enroll a spouse or state-registered domestic partner in PEBB medical coverage, and they have chosen not to enroll in another employer-based group medical plan that is comparable to PEBB’s UMP Classic. HCA 51-0035 (9/23) 1

Dental plan premiums With medical coverage Managed Care Plans Preferred Provider Organization (PPO) Plans DeltaCare Willamette Uniform Dental Plan Dental Group 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, & children $124.50 $146.61 $146.76 Dental plan premiums Dental coverage only Managed Care Plans Preferred Provider Organization (PPO) Plans DeltaCare Willamette Uniform Dental Plan Dental Group Monthly premiums Subscriber only $47.46 $54.83 $54.88 Subscriber & spouse $88.96 $103.70 2

Medicare medical plan premiums Special requirements for Medicare premiums • At least one member on your account must be enrolled in Medicare Part A and Part B. • 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. For more information on this requirement, contact your medical plan’s customer service department. Note: These Medicare premiums do not include your Medicare Part B premium. * If a Kaiser Permanente Washington member is enrolled in Medicare Part A and Part B, and other enrolled members are not eligiblefor Medicare, the non-Medicare members must enroll in Kaiser Permanente Washington Classic, SoundChoice, or Value plan. Thesubscriber will pay a combined Medicare and non-Medicare premium. # If a Kaiser Permanente Washington 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 Kaiser Permanente Washington Classic, SoundChoice, or Value plan. The subscriber will pay a combined Medicare and non-Medicare premium 3

Medicare supplement plan premiums If a Medicare supplement plan is selected, non-Medicare members are enrolled in UMP Classic. The rates shown re昀氀ect the total due, including premiums for both plans. Note: These Medicare premiums do not include your Medicare Part B premium. Premera Blue Cross Plan F (closed to new members) Plan G Age 65 or older, Under age 65, Age 65 or older, Under age 65, eligible by age eligible by disability eligible by age eligible by disability Subscriber only 1 Medicare eligible $232.14 $390.45 $198.02 $332.45 Subscriber and spouse 1 Medicare eligible $1,057.86 $1,216.17 $1,023.74 $1,158.17 2 Medicare eligible: 1 retired, 1 disabled $616.63 $616.63 $524.51 $524.51 2 Medicare eligible $458.32 $774.94 $390.08 $658.94 Subscriber and children 1 Medicare eligible $851.43 $1,009.74 $817.31 $951.74 Subscriber, spouse, and children 1 Medicare eligible $1,677.15 $1,835.46 $1,643.03 4