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