PEBB Continuation Coverage Monthly Premiums 2024

2024 PEBB Continuation Coverage Monthly Premiums E昀昀ective January 1, 2024 Kaiser Foundation Health Plan of the Northwest o昀昀ers plans in Clark and Cowlitz counties in Washington and select counties in Oregon. UMP is administered by Regence BlueShield and Washington State Rx Services. The term "spouse" is interchangeable with state regisetered domestic partner (SRDP). Non-Medicare medical plan premiums (for members not enrolled in Medicare) Managed Care Plans Preferred Provider Organization (PPO) Plans What you Kaiser Foundation Kaiser Foundation Health pay Health Plan of Plan of Washington Uniform Medical Plan ̸̣ the Northwest Classic CDHP Classic CDHP SoundChoice Value Classic CDHP Select UMP Plus Monthly premiums Subscriber only $1,039.18 $907.72 $933.56 $738.98 $777.41 $919.37 $831.68 $747.79 $766.61 $816.50 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, $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 spouse, & 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. Dental plan premiums Managed Care Plans Preferred Provider What you Organization (PPO) Plans pay 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, & children $124.50 $146.61 $146.76 HCA 50-0300 (9/23) 1

Medicare medical plan premiums • UnitedHealthcare (UHC) plans are Medicare Advantage plus Part D (MAPD) plans. If a UHC 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. • If a Kaiser Permanente Northwesrt 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 Northwest Classic. The subscriber 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. Special requirements for Medicare premiums • At least one member on your account must be enrolled in Medicare Part A and Part B. • Medicare plans are not available to PEBB Continuation Coverage (Unpaid Leave) members. 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. Plans Kaiser Uniform What Foundation Kaiser Foundation Health Plan of Washington Medical UnitedHealthcare you Health Plan of Plan pay the Northwest ̸̣ Senior Medicare PEBB Advantage Classic Advantage SoundChoice Value Classic PEBB Balance Complete Subscriber only 1 eligible $376.95 N/A $371.29 N/A N/A $715.94 $265.34 $315.21 Subscriber and spouse 1 eligible $1,410.17 $1,298.89 N/A $1,142.74 $1,284.70 $1,541.66 $1,091.06 $1,140.93 2 eligible $747.94 N/A $736.62 N/A N/A $1,425.92 $524.72 $624.46 Subscriber and children 1 eligible $1,151.87 $1.066.99 N/A $949.88 $1,056.34 $1,335.23 $884.63 $934.50 2 eligible $747.94 N/A $736.62 N/A N/A $1,425.92 $524.72 $624.46 Subscriber, spouse, and children 1 eligible $2,185.09 $1,994.59 N/A $1,721.33 $1,969.75 $2,160.95 $1,710.35 $1,760.22 2 eligible $1,522.86 $1,432.32 N/A $1,315.21 $1,421.67 $2,045.21 $1,144.01 $1,243.75 3 eligible $1,118.93 N/A $1,101.95 N/A N/A $2,135.90 $784.10 $933.71 2

Medicare supplement plan premiums If a Medicare supplement plan is elected, 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 What you Plan F (closed to new members) Plan G pay 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 $226.18 $384.49 $192.06 $326.49 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 $610.67 $610.67 $518.55 $518.55 2 Medicare eligible $452.36 $768.98 $384.12 $652.98 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 $1,777.46 2 Medicare eligible: 1 retired, 1 disabled $1,235.92 $1,235.92 $1,143.80 $1,143.80 2 Medicare eligible $1,077.61 $1,394.23 $1,009.37 $1,278.23 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). 3