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