Washington State Health Care Authority SUBSCRIPTION CHARGES AND PAYMENT INFORMATION (Rates effective January 1, 2024) Eligible By Reason Of Age Subscription Charges - Per Month PEBB Retiree PEBB Retiree & Spouse State Resident State Resident & Spouse Plan G $101.99 Plan G $198.02 Plan G $192.06 Plan G $384.12 Eligible By Reason Of Disability Subscription Charges - Per Month PEBB Retiree PEBB Retiree & Spouse State Resident State Resident & Spouse Plan G $169.20 Plan G $332.44 Plan G $326.49 Plan G $652.98 Please Note: The subscription charge amount charged is the same for all plan subscribers with certificates like yours. However, the actual amount a plan subscriber pays can vary depending on if and how much the group contributes toward a particular class of subscribers’ subscription charges. SUBSCRIPTION CHARGE INFORMATION We (Premera) can only raise your subscription charges if we raise the subscription charges for all certificates like yours in this state. DISCLOSURES Use this outline to compare benefits and subscription charges among plans. READ YOUR CERTIFICATE VERY CAREFULLY This is only an outline describing your certificate's most important features. The Group policy is the insurance contract. You must read the certificate itself to understand all of the rights and duties of both you and your Medicare supplement carrier. RIGHT TO RETURN CERTIFICATE If you find that you are not satisfied with your certificate, you may return it to PO Box 327, MS 295, Seattle, Washington 98111. If you send the certificate back to us within 30 days after you receive it, we will treat the certificate as if it had never been issued and all of your payments will be returned. CERTIFICATE REPLACEMENT If you are replacing another health insurance certificate, do NOT cancel it until you have actually received your new certificate and are sure you want to keep it. NOTICE This certificate may not fully cover all of your medical costs. Neither Premera nor its producers are connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security office or consult Medicare and You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT Be sure to answer truthfully and completely all questions. Review the application carefully before you sign it. Be certain that all information has been properly recorded.