E F F E C T I V E J A N U A R Y 1 , 2 0 2 1

Employee and Retiree Service Center ¡ 45 W. Gude Drive, Suite 1200, Rockville, MD 20850301-517-8100 ¡ www.montgomeryschoolsmd.org/departments/ersc

Retiree Benefit Rate Schedules

2 0 2 1

MONTHLY BENEF IT RATES FOR :

¡ Non-Medicare-eligible retirees and their non-Medicare-eligible spouses/dependents

¡ Medicare-eligible retirees and their Medicare-eligible spouses/dependents

¡ Non-Medicare-eligible retirees and their Medicare-eligible spouses/dependents

¡ Medicare-eligible retirees and their non-Medicare-eligible spouses/dependents

VISIONWe inspire learning by providing the greatest public education to each and every student.

MISSIONEvery student will have the academic, creative problem solving, and social emotional skills to be successful in college and career.

CORE PURPOSEPrepare all students to thrive in their future.

CORE VALUESLearningRelationshipsRespectExcellenceEquity

Board of Education

Mrs. Shebra L. EvansPresident

Ms. Brenda WolffVice President

Ms. Jeanette E. Dixon

Dr. Judith R. Docca

Mrs. Patricia B. O’Neill

Ms. Karla Silvestre

Mrs. Rebecca K. Smondrowski

Mr. Nicholas W. AsanteStudent Member

Montgomery County Public Schools (MCPS) AdministrationJack R. Smith, Ph.D.Superintendent of Schools

Monifa B. McKnight, Ed.D.Deputy Superintendent

Henry R. Johnson, Jr., Ed.D.Chief of Staff

Derek G. TurnerChief of Engagement, Innovation, and Operations

Janet S. Wilson, Ph.D.Chief of Teaching, Learning, and Schools

850 Hungerford Drive Rockville, Maryland 20850 www.montgomeryschoolsmd.org

M C P S N O N D I S C R I M I N A T I O N S T A T E M E N TMontgomery County Public Schools (MCPS) prohibits illegal discrimination based on race, ethnicity, color, ancestry, national

origin, religion, immigration status, sex, gender, gender identity, gender expression, sexual orientation, family/parental

status, marital status, age, physical or mental disability, poverty and socioeconomic status, language, or other legally or

constitutionally protected attributes or affiliations. Discrimination undermines our community’s long-standing efforts to create,

foster, and promote equity, inclusion, and acceptance for all. Some examples of discrimination include acts of hate, violence,

insensitivity, harassment, bullying, disrespect, or retaliation. For more information, please review Montgomery County Board

of Education Policy ACA, Nondiscrimination, Equity, and Cultural Proficiency. This Policy affirms the Board’s belief that each

and every student matters, and in particular, that educational outcomes should never be predictable by any individual’s actual

or perceived personal characteristics. The Policy also recognizes that equity requires proactive steps to identify and redress

implicit biases, practices that have an unjustified disparate impact, and structural and institutional barriers that impede

equality of educational or employment opportunities.

For inquiries or complaints about discrimination against MCPS staff *

For inquiries or complaints about discrimination against MCPS students *

Office of Employee Engagement and Labor RelationsDepartment of Compliance and Investigations850 Hungerford Drive, Room 55, Rockville, MD 20850240-740-2888OEELR-EmployeeEngagement@mcpsmd.org

Office of the Chief of StaffStudent Welfare and Compliance850 Hungerford Drive, Room 162, Rockville, MD 20850240-740-3215 COS-StudentWelfare@mcpsmd.org

For inquiries or complaints about sex discrimination under Title IX, including sexual harassment, against students or staff*

Title IX CoordinatorOffice of the Chief of StaffStudent Welfare and Compliance850 Hungerford Drive, Room 162, Rockville, MD 20850240-740-3215COS-TitleIX@mcpsmd.org

* Inquiries, complaints, or requests for accommodations for students with disabilities also may be directed to the supervisor of the Office of Special Education, Resolution and Compliance Unit, at 240-740-3230. Inquiries regarding accommodations or modifications for staff may be directed to the Office of Employee Engagement and Labor Relations, Department of Compliance and Investigations, at 240-740-2888. In addition, discrimination complaints may be filed with other agencies, such as: the U.S. Equal Employment Opportunity Commission, Baltimore Field Office, City Crescent Bldg., 10 S. Howard Street, Third Floor, Baltimore, MD 21201, 1-800-669-4000, 1-800-669-6820 (TTY); or U.S. Department of Education, Office for Civil Rights, Lyndon Baines Johnson Dept. of Education Bldg., 400 Maryland Avenue, SW, Washington, DC 20202-1100, 1-800-421-3481, 1-800-877-8339 (TDD), OCR@ed.gov, or www2.ed.gov/about/offices/list/ocr/complaintintro.html.

This document is available, upon request, in languages other than English and in an alternate format under the Americans

with Disabilities Act, by contacting the MCPS Office of Communications at 240-740-2837, 1-800-735-2258 (Maryland Relay),

or PIO@mcpsmd.org. Individuals who need sign language interpretation or cued speech transliteration may contact the MCPS

Office of Interpreting Services at 240-740-1800, 301-637-2958 (VP) or MCPSInterpretingServices@mcpsmd.org. MCPS also

provides equal access to the Boy/Girl Scouts and other designated youth groups.

June 2020

2021 Retiree Benefit Rate Schedules

Effective January 1, 2021

Table of Contents Monthly Rates for— Non-Medicare-Eligible Retirees and their Non-Medicare-Eligible Spouses/Dependents ……………...3 Medicare-Eligible Retirees and their Medicare-Eligible Spouses/Dependents ………………………..11 Medicare-Eligible Retirees and their Non-Medicare-Eligible Spouses/Dependents and Non-Medicare-Eligible Retirees and their Medicare-Eligible Spouses/Dependents …………………..17

Monthly Rates for

Non-Medicare-Eligible Retirees and their

Non-Medicare-Eligible Spouses/Dependents

Non-

Med

icar

e-El

igib

le In

divi

dual

s M

onth

ly R

ate

Sche

dule

100%

Cos

t for

Med

ical

, Pre

scrip

tion,

Den

tal,

and

Visi

on C

over

age

Retir

ee C

ost =

100

%Ef

fect

ive

Janu

ary

1, 2

021

Com

plet

ed N

eith

er H

ealth

Ris

k As

sess

men

t nor

Bio

met

ric H

ealth

Scr

eeni

ng

Car

eFirs

t BC

Ad

v In

dem

nity

Car

eFirs

t B

lueC

hoic

e Ad

v PO

S

Car

eFirs

t B

lueC

hoic

e H

MO

/EPO

Kai

ser

Perm

anen

te

HM

O

Car

emar

k Pr

escr

iptio

n O

ptio

n A

Car

emar

k Pr

escr

iptio

n O

ptio

n B

Kai

ser

Perm

anen

te

Pres

crip

tion

Car

eFirs

t D

enta

l PP

O

Aetn

a D

enta

l D

MO

Dav

is

Visi

onIn

divi

dual

802.

6773

5.39

516.

7058

1.28

478.

9425

3.13

74.2

333

.67

21.5

50.

782-

PAR

TY1,

605.

371,

470.

8097

1.18

1,16

0.07

957.

8850

6.23

148.

1467

.35

43.1

21.

44FA

MIL

Y2,

184.

162,

001.

001,

591.

071,

680.

961,

197.

3663

2.81

214.

6599

.04

63.3

81.

83

Med

ical

Pres

crip

tion

Den

tal/

Visi

on

3

Non-

Med

icar

e-El

igib

le In

divi

dual

s M

onth

ly R

ate

Sche

dule

100%

Cos

t for

Med

ical

, Pre

scrip

tion,

Den

tal,

and

Visi

on C

over

age

COBR

A Re

tiree

Cos

t = 1

02%

Effe

ctiv

e Ja

nuar

y 1,

202

1

Car

eFirs

t BC

Ad

v In

dem

nity

Car

eFirs

t B

lueC

hoic

e Ad

v PO

S

Car

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t B

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e H

MO

/EPO

Kai

ser

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te

HM

O

Car

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k Pr

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iptio

n O

ptio

n A

Car

emar

k Pr

escr

iptio

n O

ptio

n B

Kai

ser

Perm

anen

te

Pres

crip

tion

Car

eFirs

t D

enta

l PP

O

Aetn

a D

enta

l D

MO

Dav

is

Visi

onIn

divi

dual

818.

7275

0.10

527.

0359

2.91

488.

5225

8.19

75.7

134

.34

21.9

80.

802-

PAR

TY1,

637.

481,

500.

2299

0.60

1,18

3.27

977.

0451

6.35

151.

1068

.70

43.9

81.

47FA

MIL

Y2,

227.

842,

041.

021,

622.

891,

714.

581,

221.

3164

5.47

218.

9410

1.02

64.6

51.

87

Med

ical

Pres

crip

tion

Den

tal/

Visi

on

4

Non

-Med

icar

e-El

igib

le In

divi

dual

s M

onth

ly R

ate

Sche

dule

Ret

iree

Cont

ribut

ion

for M

edic

al, P

resc

riptio

n, D

enta

l, Vi

sion

, and

Life

Cov

erag

eEf

fect

ive

Janu

ary

1, 2

021

Com

plet

ed N

eith

er H

ealth

Ris

k As

sess

men

t nor

Bio

met

ric H

ealth

Scr

eeni

ng

Ret

iree

Cost

Sha

ring

= 60

% (

Ten

up to

Fift

een

Year

s of

Act

ive

Empl

oym

ent)

Care

Firs

t BC

Adv

Inde

mni

ty

Care

Firs

t Bl

ueCh

oice

Adv

PO

S

Care

Firs

t Bl

ueCh

oice

HM

O/E

PO

Kais

er

Perm

anen

te

HMO

Care

mar

kPr

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iptio

n O

ptio

n A

Care

mar

kPr

escr

iptio

n O

ptio

n B

Kais

er

Perm

anen

te

Pres

crip

tion

Care

Firs

t De

ntal

PP

O

Aetn

a De

ntal

DM

ODa

vis

Visi

onIn

divi

dual

481.

6044

1.23

310.

0234

8.77

287.

3615

1.88

44.5

420

.20

12.9

30.

472-

PART

Y96

3.22

882.

4858

2.71

696.

0457

4.72

303.

7488

.89

40.4

125

.87

0.87

FAM

ILY

1,31

0.49

1,20

0.60

954.

641,

008.

5771

8.41

379.

6912

8.80

59.4

238

.03

1.10

Life

Insu

ranc

eCo

st P

er $

1,00

0Re

tiree

s w

ith 1

0 up

to 1

5 ye

ars

of s

ervi

ce

Ret

iree

Cost

Sha

ring

= 50

% (

Fifte

en u

p to

Tw

enty

Yea

rs o

f Act

ive

Empl

oym

ent)

Care

Firs

t BC

Adv

Inde

mni

ty

Care

Firs

t Bl

ueCh

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Adv

PO

S

Care

Firs

t Bl

ueCh

oice

HM

O/E

PO

Kais

er

Perm

anen

te

HMO

Care

mar

kPr

escr

iptio

n O

ptio

n A

Care

mar

kPr

escr

iptio

n O

ptio

n B

Kais

er

Perm

anen

te

Pres

crip

tion

Care

Firs

t De

ntal

PP

O

Aetn

a De

ntal

DM

ODa

vis

Visi

onIn

divi

dual

401.

3436

7.70

258.

3529

0.64

239.

4712

6.57

37.1

216

.84

10.7

80.

392-

PART

Y80

2.69

735.

4148

5.59

580.

0447

8.94

253.

1274

.08

33.6

821

.57

0.72

FAM

ILY

1,09

2.09

1,00

0.51

795.

5484

0.49

598.

6831

6.41

107.

3449

.53

31.7

00.

92

Life

Insu

ranc

eCo

st P

er $

1,00

0Re

tiree

s w

ith 1

5 up

to 2

0 ye

ars

of s

ervi

ce

Ret

iree

Cost

Sha

ring

= 36

% (

Twen

ty o

r Mor

e Ye

ars

of A

ctiv

e Em

ploy

men

t)

Care

Firs

t BC

Adv

Inde

mni

ty

Care

Firs

t Bl

ueCh

oice

Adv

PO

S

Care

Firs

t Bl

ueCh

oice

HM

O/E

PO

Kais

er

Perm

anen

te

HMO

Care

mar

kPr

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iptio

n O

ptio

n A

Care

mar

kPr

escr

iptio

n O

ptio

n B

Kais

er

Perm

anen

te

Pres

crip

tion

Care

Firs

t De

ntal

PP

O

Aetn

a De

ntal

DM

ODa

vis

Visi

onIn

divi

dual

288.

9626

4.74

186.

0120

9.26

172.

4291

.13

26.7

212

.12

7.76

0.28

2-PA

RTY

577.

9352

9.49

349.

6241

7.62

344.

8418

2.25

53.3

324

.24

15.5

30.

52FA

MIL

Y78

6.29

720.

3657

2.78

605.

1443

1.05

227.

8277

.27

35.6

522

.82

0.66

Life

Insu

ranc

eCo

st P

er $

1,00

0Re

tiree

s w

ith 2

0 or

mor

e ye

ars

of s

ervi

ce0.

58

Mon

thly

per

$1,

000

0.80

Med

ical

Pres

crip

tion

Dent

al/ V

ision

Mon

thly

per

$1,

000

Med

ical

Pres

crip

tion

Dent

al/ V

ision

Mon

thly

per

$1,

000

0.96

Med

ical

Pres

crip

tion

Dent

al/ V

ision

5

Non

-Med

icar

e-El

igib

le In

divi

dual

s M

onth

ly R

ate

Sche

dule

Ret

iree

Cont

ribut

ion

for M

edic

al, P

resc

riptio

n, D

enta

l, Vi

sion

, and

Life

Cov

erag

eEf

fect

ive

Janu

ary

1, 2

021

Com

plet

ed B

oth

Hea

lth R

isk

Asse

ssm

ent a

nd B

iom

etric

Hea

lth S

cree

ning

Ret

iree

Cost

Sha

ring

= 58

% (

Ten

up to

Fift

een

Year

s of

Act

ive

Empl

oym

ent)

Care

Firs

t BC

Adv

Inde

mni

ty

Care

Firs

t Bl

ueCh

oice

Adv

PO

S

Care

Firs

t Bl

ueCh

oice

HM

O/E

PO

Kais

er

Perm

anen

te

HMO

Care

mar

kPr

escr

iptio

n O

ptio

n A

Care

mar

kPr

escr

iptio

n O

ptio

n B

Kais

er

Perm

anen

te

Pres

crip

tion

Care

Firs

t De

ntal

PP

O

Aetn

a De

ntal

DM

ODa

vis

Visi

onIn

divi

dual

465.

5542

6.53

299.

6933

7.14

277.

7914

6.82

43.0

519

.53

12.5

00.

452-

PART

Y93

1.12

853.

0756

3.29

672.

8455

5.58

293.

6285

.92

39.0

625

.01

0.83

FAM

ILY

1,26

6.82

1,16

0.59

922.

8397

4.96

694.

4836

7.04

124.

5057

.44

36.7

61.

06

Life

Insu

ranc

eCo

st P

er $

1,00

0Re

tiree

s w

ith 1

0 up

to 1

5 ye

ars

of s

ervi

ce

Ret

iree

Cost

Sha

ring

= 48

% (

Fifte

en u

p to

Tw

enty

Yea

rs o

f Act

ive

Empl

oym

ent)

Care

Firs

t BC

Adv

Inde

mni

ty

Care

Firs

t Bl

ueCh

oice

Adv

PO

S

Care

Firs

t Bl

ueCh

oice

HM

O/E

PO

Kais

er

Perm

anen

te

HMO

Care

mar

kPr

escr

iptio

n O

ptio

n A

Care

mar

kPr

escr

iptio

n O

ptio

n B

Kais

er

Perm

anen

te

Pres

crip

tion

Care

Firs

t De

ntal

PP

O

Aetn

a De

ntal

DM

ODa

vis

Visi

onIn

divi

dual

385.

2835

2.99

248.

0227

9.01

229.

8912

1.50

35.6

316

.16

10.3

40.

372-

PART

Y77

0.58

705.

9946

6.17

556.

8345

9.78

242.

9971

.11

32.3

320

.69

0.69

FAM

ILY

1,04

8.40

960.

4976

3.72

806.

8657

4.73

303.

7510

3.03

47.5

430

.41

0.88

Life

Insu

ranc

eCo

st P

er $

1,00

0Re

tiree

s w

ith 1

5 up

to 2

0 ye

ars

of s

ervi

ce

Ret

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Cost

Sha

ring

= 34

% (

Twen

ty o

r Mor

e Ye

ars

of A

ctiv

e Em

ploy

men

t)

Care

Firs

t BC

Adv

Inde

mni

ty

Care

Firs

t Bl

ueCh

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Adv

PO

S

Care

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HM

O/E

PO

Kais

er

Perm

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te

HMO

Care

mar

kPr

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iptio

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n A

Care

mar

kPr

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ptio

n B

Kais

er

Perm

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te

Pres

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tion

Care

Firs

t De

ntal

PP

O

Aetn

a De

ntal

DM

ODa

vis

Visi

onIn

divi

dual

272.

9125

0.03

175.

6819

7.64

162.

8486

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25.2

411

.45

7.33

0.27

2-PA

RTY

545.

8350

0.07

330.

2039

4.43

325.

6817

2.11

50.3

722

.90

14.6

60.

49FA

MIL

Y74

2.62

680.

3454

0.96

571.

5340

7.10

215.

1572

.98

33.6

721

.55

0.62

Life

Insu

ranc

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st P

er $

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s w

ith 2

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mor

e ye

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58

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0.80

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ical

Pres

crip

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Dent

al/ V

ision

Mon

thly

per

$1,

000

Med

ical

Pres

crip

tion

Dent

al/ V

ision

Mon

thly

per

$1,

000

0.96

Med

ical

Pres

crip

tion

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al/ V

ision

6

Non

-Med

icar

e-El

igib

le In

divi

dual

s M

onth

ly R

ate

Sche

dule

Ret

iree

Cont

ribut

ion

for M

edic

al, P

resc

riptio

n, D

enta

l, Vi

sion

, and

Life

Cov

erag

eEf

fect

ive

Janu

ary

1, 2

021

Com

plet

ed E

ither

Hea

lth R

isk

Asse

ssm

ent o

r Bio

met

ric H

ealth

Scr

eeni

ng

Ret

iree

Cost

Sha

ring

= 59

% (

Ten

up to

Fift

een

Year

s of

Act

ive

Empl

oym

ent)

Care

Firs

t BC

Adv

Inde

mni

ty

Care

Firs

t Bl

ueCh

oice

Adv

PO

S

Care

Firs

t Bl

ueCh

oice

HM

O/E

PO

Kais

er

Perm

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te

HMO

Care

mar

kPr

escr

iptio

n O

ptio

n A

Care

mar

kPr

escr

iptio

n O

ptio

n B

Kais

er

Perm

anen

te

Pres

crip

tion

Care

Firs

t De

ntal

PP

O

Aetn

a De

ntal

DM

ODa

vis

Visi

onIn

divi

dual

473.

5843

3.88

304.

8534

2.96

282.

5714

9.35

43.8

019

.87

12.7

10.

462-

PART

Y94

7.17

867.

7757

2.99

684.

4556

5.14

298.

6887

.41

39.7

425

.44

0.85

FAM

ILY

1,28

8.66

1,18

0.59

938.

7399

1.78

706.

4337

3.36

126.

6558

.44

37.3

91.

08

Life

Insu

ranc

eCo

st P

er $

1,00

0Re

tiree

s w

ith 1

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ars

of s

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ce

Ret

iree

Cost

Sha

ring

= 49

% (

Fifte

en u

p to

Tw

enty

Yea

rs o

f Act

ive

Empl

oym

ent)

Care

Firs

t BC

Adv

Inde

mni

ty

Care

Firs

t Bl

ueCh

oice

Adv

PO

S

Care

Firs

t Bl

ueCh

oice

HM

O/E

PO

Kais

er

Perm

anen

te

HMO

Care

mar

kPr

escr

iptio

n O

ptio

n A

Care

mar

kPr

escr

iptio

n O

ptio

n B

Kais

er

Perm

anen

te

Pres

crip

tion

Care

Firs

t De

ntal

PP

O

Aetn

a De

ntal

DM

ODa

vis

Visi

onIn

divi

dual

393.

3136

0.34

253.

1828

4.83

234.

6812

4.03

36.3

716

.50

10.5

60.

382-

PART

Y78

6.63

720.

6947

5.88

568.

4446

9.36

248.

0572

.59

33.0

021

.13

0.70

FAM

ILY

1,07

0.24

980.

4977

9.63

823.

6858

6.71

310.

0710

5.18

48.5

331

.06

0.89

Life

Insu

ranc

eCo

st P

er $

1,00

0Re

tiree

s w

ith 1

5 up

to 2

0 ye

ars

of s

ervi

ce

Ret

iree

Cost

Sha

ring

= 35

% (

Twen

ty o

r Mor

e Ye

ars

of A

ctiv

e Em

ploy

men

t)

Care

Firs

t BC

Adv

Inde

mni

ty

Care

Firs

t Bl

ueCh

oice

Adv

PO

S

Care

Firs

t Bl

ueCh

oice

HM

O/E

PO

Kais

er

Perm

anen

te

HMO

Care

mar

kPr

escr

iptio

n O

ptio

n A

Care

mar

kPr

escr

iptio

n O

ptio

n B

Kais

er

Perm

anen

te

Pres

crip

tion

Care

Firs

t De

ntal

PP

O

Aetn

a De

ntal

DM

ODa

vis

Visi

onIn

divi

dual

280.

9325

7.39

180.

8520

3.45

167.

6388

.60

25.9

811

.78

7.54

0.27

2-PA

RTY

561.

8851

4.78

339.

9240

6.03

335.

2617

7.19

51.8

523

.57

15.0

90.

50FA

MIL

Y76

4.46

700.

3555

6.88

588.

3441

9.08

221.

4975

.13

34.6

622

.18

0.64

Life

Insu

ranc

eCo

st P

er $

1,00

0Re

tiree

s w

ith 2

0 or

mor

e ye

ars

of s

ervi

ce0.

58

Mon

thly

per

$1,

000

0.80

Med

ical

Pres

crip

tion

Dent

al/ V

ision

Mon

thly

per

$1,

000

Med

ical

Pres

crip

tion

Dent

al/ V

ision

Mon

thly

per

$1,

000

0.96

Med

ical

Pres

crip

tion

Dent

al/ V

ision

7

Monthly Rates for

Medicare-Eligible Retirees and their

Medicare-Eligible Spouses/Dependents

Med

icar

e-El

igib

le In

divi

dual

s M

onth

ly R

ate

Sche

dule

100%

Cos

t for

Med

ical

, Pre

scrip

tion,

Den

tal,

and

Visi

on C

over

age

Retir

ee C

ost =

100

%Ef

fect

ive

Janu

ary

1, 2

021

Car

eFirs

t BC

Ad

v M

edic

are

Supp

Car

eFirs

t B

lueC

hoic

e Ad

v PO

S

Car

eFirs

t B

lueC

hoic

e H

MO

/EPO

Kai

ser

Perm

anen

te

HM

O

Silv

erSc

ript

Pres

crip

tion

Opt

ion

A

Silv

erSc

ript

Pres

crip

tion

Opt

ion

B

Kai

ser

Perm

anen

te

Pres

crip

tion

Car

eFirs

t D

enta

l PP

O

Aetn

a D

enta

l D

MO

Dav

is

Visi

onIN

DIV

IDU

AL M

edic

are

241.

94N

/A28

3.49

347.

4147

8.94

253.

1333

.67

21.5

50.

782-

PAR

TY M

edic

are

483.

88N

/A56

6.98

694.

8295

7.88

506.

2367

.35

43.1

21.

44FA

MIL

Y M

edic

are

725.

82N

/A85

0.47

1,04

2.23

1,19

7.36

632.

8199

.04

63.3

81.

83

Med

ical

Pres

crip

tion

Den

tal/

Visi

on

incl

uded

in

med

ical

11

Med

icar

e-El

igib

le In

divi

dual

s M

onth

ly R

ate

Sche

dule

100%

Cos

t for

Med

ical

, Pre

scrip

tion,

Den

tal,

and

Visi

on C

over

age

COBR

A Re

tiree

Cos

t = 1

02%

Effe

ctiv

e Ja

nuar

y 1,

202

1

Car

eFirs

t BC

Ad

v M

edic

are

Supp

Car

eFirs

t B

lueC

hoic

e Ad

v PO

S

Car

eFirs

t B

lueC

hoic

e H

MO

/EPO

Kai

ser

Perm

anen

te

HM

O

Silv

erSc

ript

Pres

crip

tion

Opt

ion

A

Silv

erSc

ript

Pres

crip

tion

Opt

ion

B

Kai

ser

Perm

anen

te

Pres

crip

tion

Car

eFirs

t D

enta

l PP

O

Aetn

a D

enta

l D

MO

Dav

is

Visi

onIN

DIV

IDU

AL M

edic

are

246.

78N

/A28

9.16

354.

3648

8.52

258.

1934

.34

21.9

80.

802-

PAR

TY M

edic

are

493.

56N

/A57

8.32

708.

7297

7.04

516.

3568

.70

43.9

81.

47FA

MIL

Y M

edic

are

740.

34N

/A86

7.48

1,06

3.07

1,22

1.31

645.

4710

1.02

64.6

51.

87

Med

ical

Pres

crip

tion

Den

tal/

Visi

on

incl

uded

in

med

ical

12

Med

icar

e-El

igib

le In

divi

dual

s M

onth

ly R

ate

Sche

dule

Retir

ee C

ontr

ibut

ion

for M

edic

al, P

resc

riptio

n, D

enta

l, Vi

sion

, and

Life

Cov

erag

eEf

fect

ive

Janu

ary

1, 2

021

Retir

ee C

ost S

harin

g =

60%

(Te

n up

to F

iftee

n Ye

ars

of A

ctiv

e Em

ploy

men

t)

Car

eFirs

t BC

Ad

v M

edic

are

Supp

Car

eFirs

t B

lueC

hoic

e Ad

v PO

S

Car

eFirs

t B

lueC

hoic

e H

MO

/EPO

Kai

ser

Perm

anen

te

HM

O

Silv

erSc

ript

Pres

crip

tion

Opt

ion

A

Silv

erSc

ript

Pres

crip

tion

Opt

ion

B

Kai

ser

Perm

anen

te

Pres

crip

tion

Car

eFirs

t D

enta

l PP

O

Aetn

a D

enta

l D

MO

Dav

is

Visi

onIN

DIV

IDU

AL M

edic

are

145.

16N

/A17

0.09

208.

4528

7.36

151.

8820

.20

12.9

30.

472-

PAR

TY M

edic

are

290.

32N

/A34

0.18

416.

9057

4.72

303.

7440

.41

25.8

70.

87FA

MIL

Y M

edic

are

435.

48N

/A51

0.27

625.

3571

8.41

379.

6959

.42

38.0

31.

10

Life

Insu

ranc

eC

ost P

er $

1,00

0R

etire

es w

ith 1

0 up

to 1

5 ye

ars

of s

ervi

ce

Retir

ee C

ost S

harin

g =

50%

(Fi

fteen

up

to T

wen

ty Y

ears

of A

ctiv

e Em

ploy

men

t)

Car

eFirs

t BC

Ad

v M

edic

are

Supp

Car

eFirs

t B

lueC

hoic

e Ad

v PO

S

Car

eFirs

t B

lueC

hoic

e H

MO

/EPO

Kai

ser

Perm

anen

te

HM

O

Silv

erSc

ript

Pres

crip

tion

Opt

ion

A

Silv

erSc

ript

Pres

crip

tion

Opt

ion

B

Kai

ser

Perm

anen

te

Pres

crip

tion

Car

eFirs

t D

enta

l PP

O

Aetn

a D

enta

l D

MO

Dav

is

Visi

onIN

DIV

IDU

AL12

0.97

N/A

141.

7517

3.71

239.

4712

6.57

16.8

410

.78

0.39

2- P

ARTY

241.

94N

/A28

3.50

347.

4247

8.94

253.

1233

.68

21.5

70.

72FA

MIL

Y36

2.91

N/A

425.

2552

1.13

598.

6831

6.41

49.5

331

.70

0.92

Life

Insu

ranc

eC

ost P

er $

1,00

0R

etire

es w

ith 1

5 up

to 2

0 ye

ars

of s

ervi

ce

Retir

ee C

ost S

harin

g =

36%

(Tw

enty

or M

ore

Year

s of

Act

ive

Empl

oym

ent)

Car

eFirs

t BC

Ad

v M

edic

are

Supp

Car

eFirs

t B

lueC

hoic

e Ad

v PO

S

Car

eFirs

t B

lueC

hoic

e H

MO

/EPO

Kai

ser

Perm

anen

te

HM

O

Silv

erSc

ript

Pres

crip

tion

Opt

ion

A

Silv

erSc

ript

Pres

crip

tion

Opt

ion

B

Kai

ser

Perm

anen

te

Pres

crip

tion

Car

eFirs

t D

enta

l PP

O

Aetn

a D

enta

l D

MO

Dav

is

Visi

onIN

DIV

IDU

AL87

.10

N/A

102.

0612

5.07

172.

4291

.13

12.1

27.

760.

282-

PAR

TY17

4.20

N/A

204.

1225

0.14

344.

8418

2.25

24.2

415

.53

0.52

FAM

ILY

261.

30N

/A30

6.18

375.

2143

1.05

227.

8235

.65

22.8

20.

66

Life

Insu

ranc

eC

ost P

er $

1,00

0R

etire

es w

ith 2

0 or

mor

e ye

ars

of s

ervi

ce

Med

ical

Pres

crip

tion

Den

tal/

Visi

on

incl

uded

in

med

ical

Mon

thly

per

$1,

000

0.58

Med

ical

Pres

crip

tion

Den

tal/

Visi

on

incl

uded

in

med

ical

Mon

thly

per

$1,

000

0.80

Med

ical

Pres

crip

tion

Den

tal/

Visi

on

incl

uded

in

med

ical

Mon

thly

per

$1,

000

0.96

13

 

Monthly Rates for

Medicare-Eligible Retirees and their Non-Medicare-Eligible Spouses/Dependents

and

Non-Medicare-Eligible Retirees and their Medicare-Eligible Spouses/Dependents

Split

-Fam

ily M

onth

ly R

ate

Sche

dule

100%

Cos

t for

Med

ical

, Pre

scrip

tion,

Den

tal,

and

Visi

on C

over

age

Ret

iree

Cos

t = 1

00%

Effe

ctiv

e Ja

nuar

y 1,

202

1C

ompl

eted

Nei

ther

Hea

lth R

isk

Asse

ssm

ent n

or B

iom

etric

Hea

lth S

cree

ning

67

1012

1318

1911

89

Med

ical

2- P

ARTY

Ret

iree

Med

icar

eSp

ouse

Non

-M

edic

are

2- P

ARTY

Ret

iree

Non

-M

edic

are

Spou

se/C

hild

M

edic

are

2- P

ARTY

Ret

iree

Med

icar

eD

epen

dent

Non

-M

edic

are

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se N

on-

Med

icar

e,

Dep

ende

nt

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Dep

ende

nt

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se N

on-

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Non

-M

edic

are,

Sp

ouse

Non

-M

edic

are,

D

epen

dent

M

edic

are

FAM

ILY

Ret

iree

Non

-M

edic

are,

Sp

ouse

M

edic

are,

D

epen

dent

Non

-M

edic

are

Car

eFirs

t BC

Adv

Inde

mni

ty/M

edic

are

Supp

1,04

4.61

1,04

4.61

1,04

4.61

1,28

6.55

1,28

6.55

1,28

6.55

1,84

7.31

1,84

7.31

1,84

7.31

1,84

7.31

Car

eFirs

t Blu

eCho

ice

Adv

POS

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Car

eFirs

t Blu

eCho

ice

HM

O/E

PO80

0.19

800.

1980

0.19

1,08

3.68

1,08

3.68

1,08

3.68

1,25

4.67

1,25

4.67

1,25

4.67

1,25

4.67

Kai

ser P

erm

anen

te H

MO

928.

6992

8.69

928.

691,

276.

101,

276.

101,

276.

101,

507.

481,

507.

481,

507.

481,

507.

48

Pres

crip

tion

Dru

gs, D

enta

l, an

d Vi

sion

Car

emar

k/Si

lver

Scrip

t Opt

ion

A95

7.88

957.

8895

7.88

1,19

7.36

1,19

7.36

1,19

7.36

1,19

7.36

1,19

7.36

1,19

7.36

1,19

7.36

Car

emar

k/Si

lver

Scrip

t Opt

ion

B50

6.23

506.

2350

6.23

632.

8163

2.81

632.

8163

2.81

632.

8163

2.81

632.

81K

aise

r Per

man

ente

Pre

scrip

tion

74.2

374

.23

74.2

374

.23

74.2

374

.23

148.

1414

8.14

148.

1414

8.14

Car

eFirs

t Den

tal P

PO67

.35

67.3

567

.35

99.0

499

.04

99.0

499

.04

99.0

499

.04

99.0

4Ae

tna

Den

tal D

MO

43.1

243

.12

43.1

263

.38

63.3

863

.38

63.3

863

.38

63.3

863

.38

Dav

is V

isio

n1.

441.

441.

441.

831.

831.

831.

831.

831.

831.

83

17

Split

-Fam

ily M

onth

ly R

ate

Sche

dule

100%

Cos

t for

Med

ical

, Pre

scrip

tion,

Den

tal,

and

Visi

on C

over

age

CO

BR

A R

etire

e C

ost =

102

%Ef

fect

ive

Janu

ary

1, 2

021

Med

ical

2- P

ARTY

Ret

iree

Med

icar

eSp

ouse

Non

-M

edic

are

2- P

ARTY

Ret

iree

Non

-M

edic

are

Spou

se/C

hild

M

edic

are

2- P

ARTY

Ret

iree

Med

icar

eD

epen

dent

Non

-M

edic

are

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se N

on-

Med

icar

e,

Dep

ende

nt

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Dep

ende

nt

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se N

on-

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Non

-M

edic

are,

Sp

ouse

Non

-M

edic

are,

D

epen

dent

M

edic

are

FAM

ILY

Ret

iree

Non

-M

edic

are,

Sp

ouse

M

edic

are,

D

epen

dent

Non

-M

edic

are

Car

eFirs

t BC

Adv

Inde

mni

ty/M

edic

are

Supp

1,06

5.50

1,06

5.50

1,06

5.50

1,31

2.28

1,31

2.28

1,31

2.28

1,88

4.26

1,88

4.26

1,88

4.26

1,88

4.26

Car

eFirs

t Blu

eCho

ice

Adv

POS

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Car

eFirs

t Blu

eCho

ice

HM

O/E

PO81

6.19

816.

1981

6.19

1,10

5.35

1,10

5.35

1,10

5.35

1,27

9.76

1,27

9.76

1,27

9.76

1,27

9.76

Kai

ser P

erm

anen

te H

MO

947.

2694

7.26

947.

261,

301.

621,

301.

621,

301.

621,

537.

631,

537.

631,

537.

631,

537.

63

Pres

crip

tion

Dru

gs, D

enta

l, an

d Vi

sion

Car

emar

k/Si

lver

Scrip

t Opt

ion

A97

7.04

977.

0497

7.04

1,22

1.31

1,22

1.31

1,22

1.31

1,22

1.31

1,22

1.31

1,22

1.31

1,22

1.31

Car

emar

k/Si

lver

Scrip

t Opt

ion

B51

6.35

516.

3551

6.35

645.

4764

5.47

645.

4764

5.47

645.

4764

5.47

645.

47K

aise

r Per

man

ente

Pre

scrip

tion

75.7

175

.71

75.7

175

.71

75.7

175

.71

151.

1015

1.10

151.

1015

1.10

Car

eFirs

t Den

tal P

PO68

.70

68.7

068

.70

101.

0210

1.02

101.

0210

1.02

101.

0210

1.02

101.

02Ae

tna

Den

tal D

MO

43.9

843

.98

43.9

864

.65

64.6

564

.65

64.6

564

.65

64.6

564

.65

Dav

is V

isio

n1.

471.

471.

471.

871.

871.

871.

871.

871.

871.

87

18

Split

-Fam

ily M

onth

ly R

ate

Sche

dule

Ret

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Con

trib

utio

n fo

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ical

, Pre

scrip

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Den

tal,

Visi

on, a

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ife C

over

age

67

1012

1318

1911

89

Med

ical

2- P

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Ret

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Med

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Non

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are

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Dep

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Non

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Non

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Sp

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M

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are,

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Non

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are

Car

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Adv

Inde

mni

ty/M

edic

are

Supp

626.

7662

6.76

626.

7677

1.92

771.

9277

1.92

1,10

8.38

1,10

8.38

1,10

8.38

1,10

8.38

Car

eFirs

t Blu

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ice

Adv

POS

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Car

eFirs

t Blu

eCho

ice

HM

O/E

PO48

0.11

480.

1148

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2.80

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8075

2.80

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man

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HM

O55

7.22

557.

2255

7.22

765.

6776

5.67

765.

6790

4.49

904.

4990

4.49

904.

49

Pres

crip

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gs, D

enta

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Car

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Scrip

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A57

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574.

7257

4.72

718.

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8.41

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8.41

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8.41

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41C

arem

ark/

Silv

erSc

ript O

ptio

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303.

7430

3.74

303.

7437

9.69

379.

6937

9.69

379.

6937

9.69

379.

6937

9.69

Kai

ser P

erm

anen

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resc

riptio

n44

.54

44.5

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.54

44.5

444

.54

44.5

488

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88.8

988

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88.8

9

Car

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PO40

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40.4

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59.4

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59.4

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59.4

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59.4

2Ae

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MO

25.8

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25.8

738

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338

.03

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338

.03

38.0

338

.03

Dav

is V

isio

n0.

870.

870.

871.

101.

101.

101.

101.

101.

101.

10*H

ealth

Risk

Ass

essm

ent a

nd B

iom

etric

Hea

lth S

cree

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ply

to n

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Life

Insu

ranc

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0R

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es w

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up

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Cos

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Cos

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Janu

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Ret

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plet

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Split

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Ret

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Con

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1911

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Med

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are

Car

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Adv

Inde

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are

Supp

626.

7661

0.71

626.

7677

1.92

771.

9277

1.92

1,10

8.38

1,10

8.38

1,07

6.28

1,07

6.28

Car

eFirs

t Blu

eCho

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Adv

POS

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Car

eFirs

t Blu

eCho

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HM

O/E

PO48

0.11

469.

7848

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650.

2065

0.20

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2.80

752.

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3.38

733.

38K

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man

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HM

O55

7.22

545.

5955

7.22

765.

6776

5.67

765.

6790

4.49

904.

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1.29

881.

29

Pres

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Car

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1557

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8.41

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8.41

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4169

9.27

699.

27C

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ptio

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303.

7429

8.68

303.

7437

9.69

379.

6937

9.69

379.

6937

9.69

369.

5736

9.57

Kai

ser P

erm

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.54

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544

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444

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44.5

488

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88.8

985

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2

Car

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PO40

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39.7

440

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59.4

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59.4

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MO

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25.8

738

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338

.03

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338

.03

37.1

737

.17

Dav

is V

isio

n0.

870.

850.

871.

101.

101.

101.

101.

101.

061.

06*H

ealth

Risk

Ass

essm

ent a

nd B

iom

etric

Hea

lth S

cree

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y ap

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Life

Insu

ranc

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ost P

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1,00

0R

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es w

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of s

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96Ten

up

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are-

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Cos

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Cos

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fect

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Janu

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plet

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*

20

Split

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Ret

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Den

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1911

89

Med

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Car

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Adv

POS

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Car

eFirs

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HM

O/E

PO48

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HM

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551.

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7.22

765.

6776

5.67

765.

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4.49

904.

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90

Pres

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569.

9357

4.72

718.

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8.83

708.

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Silv

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ptio

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303.

7430

1.21

303.

7437

9.69

379.

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9.69

374.

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4.63

Kai

ser P

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.54

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Car

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58.7

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MO

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338

.03

37.6

037

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Dav

is V

isio

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870.

860.

871.

101.

101.

101.

101.

101.

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08*H

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Risk

Ass

essm

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Hea

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cree

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Life

Insu

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es w

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to 1

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of s

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up

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ars

of A

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ploy

men

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are-

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Cos

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Cos

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Janu

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Ret

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Com

plet

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Split

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1911

89

Med

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Non

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3.66

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3.66

Car

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Adv

POS

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Car

eFirs

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HM

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PO40

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7.34

627.

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7.34

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HM

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464.

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4.35

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8.06

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3.75

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7575

3.75

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75

Pres

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Scrip

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478.

9447

8.94

598.

6859

8.68

598.

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8.68

598.

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8.68

598.

68C

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Silv

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ptio

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253.

1225

3.12

253.

1231

6.41

316.

4131

6.41

316.

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6.41

316.

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6.41

Kai

ser P

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resc

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37.1

237

.12

37.1

237

.12

37.1

274

.08

74.0

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8

Car

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PO33

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49.5

349

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349

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49.5

349

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49.5

3Ae

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Den

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21.5

731

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Dav

is V

isio

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720.

720.

720.

920.

920.

920.

920.

920.

920.

92*H

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Risk

Ass

essm

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Hea

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cree

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Life

Insu

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harin

g =

50%

Effe

ctiv

e Ja

nuar

y 1,

202

1R

etire

e C

ompl

eted

Nei

ther

Hea

lth R

isk

Asse

ssm

ent n

or B

iom

etric

Hea

lth S

cree

ning

*

22

Split

-Fam

ily M

onth

ly R

ate

Sche

dule

Ret

iree

Con

trib

utio

n fo

r Med

ical

, Pre

scrip

tion,

Den

tal,

Visi

on, a

nd L

ife C

over

age

67

1012

1318

1911

89

Med

ical

2- P

ARTY

Ret

iree

Med

icar

eSp

ouse

Non

-M

edic

are

2- P

ARTY

Ret

iree

Non

-M

edic

are

Spou

se/C

hild

M

edic

are

2- P

ARTY

Ret

iree

Med

icar

eD

epen

dent

Non

-M

edic

are

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se N

on-

Med

icar

e,

Dep

ende

nt

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Dep

ende

nt

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se N

on-

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

Ret

iree

Non

-M

edic

are,

Sp

ouse

Non

-M

edic

are,

D

epen

dent

M

edic

are

FAM

ILY

Ret

iree

Non

-M

edic

are,

Sp

ouse

M

edic

are,

D

epen

dent

Non

-M

edic

are

Car

eFirs

t BC

Adv

Inde

mni

ty/M

edic

are

Supp

522.

3150

6.25

522.

3164

3.28

643.

2864

3.28

923.

6692

3.66

891.

5589

1.55

Car

eFirs

t Blu

eCho

ice

Adv

POS

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Car

eFirs

t Blu

eCho

ice

HM

O/E

PO40

0.10

389.

7740

0.10

541.

8554

1.85

541.

8562

7.34

627.

3460

7.92

607.

92K

aise

r Per

man

ente

HM

O46

4.35

452.

7246

4.35

638.

0663

8.06

638.

0675

3.75

753.

7573

0.54

730.

54

Pres

crip

tion

Dru

gs, D

enta

l, an

d Vi

sion

Car

emar

k/Si

lver

Scrip

t Opt

ion

A47

8.94

469.

3647

8.94

598.

6859

8.68

598.

6859

8.68

598.

6857

9.52

579.

52C

arem

ark/

Silv

erSc

ript O

ptio

n B

253.

1224

8.05

253.

1231

6.41

316.

4131

6.41

316.

4131

6.41

306.

2830

6.28

Kai

ser P

erm

anen

te P

resc

riptio

n37

.12

35.6

337

.12

37.1

237

.12

37.1

274

.08

74.0

871

.11

71.1

1

Car

eFirs

t Den

tal P

PO33

.68

33.0

033

.68

49.5

349

.53

49.5

349

.53

49.5

348

.18

48.1

8Ae

tna

Den

tal D

MO

21.5

721

.13

21.5

731

.70

31.7

031

.70

31.7

031

.70

30.8

230

.82

Dav

is V

isio

n0.

720.

700.

720.

920.

920.

920.

920.

920.

890.

89*H

ealth

Risk

Ass

essm

ent a

nd B

iom

etric

Hea

lth S

cree

ning

cre

dits

onl

y ap

ply

to n

on-M

edica

re re

tiree

.

Life

Insu

ranc

eC

ost P

er $

1,00

0R

etire

es w

ith 1

5 up

to 2

0 ye

ars

of s

ervi

ceM

onth

ly p

er $

1,00

00.

80Fifte

en u

p to

Tw

enty

Yea

rs o

f Act

ive

Empl

oym

ent

Med

icar

e-El

igib

le In

divi

dual

s C

ost S

harin

g =

50%

Non

-Med

icar

e-El

igib

le In

divi

dual

s C

ost S

harin

g =

48%

Effe

ctiv

e Ja

nuar

y 1,

202

1R

etire

e C

ompl

eted

Bot

h H

ealth

Ris

k As

sess

men

t and

Bio

met

ric H

ealth

Scr

eeni

ng*

23

Split

-Fam

ily M

onth

ly R

ate

Sche

dule

Ret

iree

Con

trib

utio

n fo

r Med

ical

, Pre

scrip

tion,

Den

tal,

Visi

on, a

nd L

ife C

over

age

67

1012

1318

1911

89

Med

ical

2- P

ARTY

Ret

iree

Med

icar

eSp

ouse

Non

-M

edic

are

2- P

ARTY

Ret

iree

Non

-M

edic

are

Spou

se/C

hild

M

edic

are

2- P

ARTY

Ret

iree

Med

icar

eD

epen

dent

Non

-M

edic

are

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

FAM

ILY

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iree

Med

icar

e,

Spou

se N

on-

Med

icar

e,

Dep

ende

nt

Med

icar

e

FAM

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icar

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Dep

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ende

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icar

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FAM

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Ret

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ende

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icar

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FAM

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icar

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Spou

se N

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Dep

ende

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on-

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icar

e

FAM

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Ret

iree

Non

-M

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are,

Sp

ouse

Non

-M

edic

are,

D

epen

dent

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edic

are

FAM

ILY

Ret

iree

Non

-M

edic

are,

Sp

ouse

M

edic

are,

D

epen

dent

Non

-M

edic

are

Car

eFirs

t BC

Adv

Inde

mni

ty/M

edic

are

Supp

522.

3151

4.28

522.

3164

3.28

643.

2864

3.28

923.

6692

3.66

907.

6090

7.60

Car

eFirs

t Blu

eCho

ice

Adv

POS

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Car

eFirs

t Blu

eCho

ice

HM

O/E

PO40

0.10

394.

9340

0.10

541.

8554

1.85

541.

8562

7.34

627.

3461

7.63

617.

63K

aise

r Per

man

ente

HM

O46

4.35

458.

5446

4.35

638.

0663

8.06

638.

0675

3.75

753.

7574

2.15

742.

15

Pres

crip

tion

Dru

gs, D

enta

l, an

d Vi

sion

Car

emar

k/Si

lver

Scrip

t Opt

ion

A47

8.94

474.

1547

8.94

598.

6859

8.68

598.

6859

8.68

598.

6858

9.10

589.

10C

arem

ark/

Silv

erSc

ript O

ptio

n B

253.

1225

0.58

253.

1231

6.41

316.

4131

6.41

316.

4131

6.41

311.

3431

1.34

Kai

ser P

erm

anen

te P

resc

riptio

n37

.12

36.3

737

.12

37.1

237

.12

37.1

274

.08

74.0

872

.59

72.5

9

Car

eFirs

t Den

tal P

PO33

.68

33.3

433

.68

49.5

349

.53

49.5

349

.53

49.5

348

.85

48.8

5Ae

tna

Den

tal D

MO

21.5

721

.35

21.5

731

.70

31.7

031

.70

31.7

031

.70

31.2

631

.26

Dav

is V

isio

n0.

720.

710.

720.

920.

920.

920.

920.

920.

900.

90*H

ealth

Risk

Ass

essm

ent a

nd B

iom

etric

Hea

lth S

cree

ning

cre

dits

onl

y ap

ply

to n

on-M

edica

re re

tiree

.

Life

Insu

ranc

eC

ost P

er $

1,00

0R

etire

es w

ith 1

5 up

to 2

0 ye

ars

of s

ervi

ceM

onth

ly p

er $

1,00

00.

80Fifte

en u

p to

Tw

enty

Yea

rs o

f Act

ive

Empl

oym

ent

Med

icar

e-El

igib

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s C

ost S

harin

g =

50%

Non

-Med

icar

e-El

igib

le In

divi

dual

s C

ost S

harin

g =

49%

Effe

ctiv

e Ja

nuar

y 1,

202

1R

etire

e C

ompl

eted

Eith

er H

ealth

Ris

k As

sess

men

t or B

iom

etric

Hea

lth S

cree

ning

*

24

Split

-Fam

ily M

onth

ly R

ate

Sche

dule

Ret

iree

Con

trib

utio

n fo

r Med

ical

, Pre

scrip

tion,

Den

tal,

Visi

on, a

nd L

ife C

over

age

67

1012

1318

1911

89

Med

ical

2- P

ARTY

Ret

iree

Med

icar

eSp

ouse

Non

-M

edic

are

2- P

ARTY

Ret

iree

Non

-M

edic

are

Spou

se/C

hild

M

edic

are

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ARTY

Ret

iree

Med

icar

eD

epen

dent

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-M

edic

are

FAM

ILY

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iree

Med

icar

e,

Spou

se

Med

icar

e,

Dep

ende

nt N

on-

Med

icar

e

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ILY

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icar

e,

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se N

on-

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icar

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ende

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icar

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are

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are,

Sp

ouse

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are,

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epen

dent

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edic

are

Car

eFirs

t BC

Adv

Inde

mni

ty/M

edic

are

Supp

376.

0637

6.06

376.

0646

3.16

463.

1646

3.16

665.

0366

5.03

665.

0366

5.03

Car

eFirs

t Blu

eCho

ice

Adv

POS

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Car

eFirs

t Blu

eCho

ice

HM

O/E

PO28

8.07

288.

0728

8.07

390.

1339

0.13

390.

1345

1.68

451.

6845

1.68

451.

68K

aise

r Per

man

ente

HM

O33

4.33

334.

3333

4.33

459.

4045

9.40

459.

4054

2.69

542.

6954

2.69

542.

69

Pres

crip

tion

Dru

gs, D

enta

l, an

d Vi

sion

Car

emar

k/Si

lver

Scrip

t Opt

ion

A34

4.84

344.

8434

4.84

431.

0543

1.05

431.

0543

1.05

431.

0543

1.05

431.

05C

arem

ark/

Silv

erSc

ript O

ptio

n B

182.

2518

2.25

182.

2522

7.82

227.

8222

7.82

227.

8222

7.82

227.

8222

7.82

Kai

ser P

erm

anen

te P

resc

riptio

n26

.72

26.7

226

.72

26.7

226

.72

26.7

253

.33

53.3

353

.33

53.3

3

Car

eFirs

t Den

tal P

PO24

.24

24.2

424

.24

35.6

535

.65

35.6

535

.65

35.6

535

.65

35.6

5Ae

tna

Den

tal D

MO

15.5

315

.53

15.5

322

.82

22.8

222

.82

22.8

222

.82

22.8

222

.82

Dav

is V

isio

n0.

520.

520.

520.

660.

660.

660.

660.

660.

660.

66*H

ealth

Risk

Ass

essm

ent a

nd B

iom

etric

Hea

lth S

cree

ning

cre

dits

onl

y ap

ply

to n

on-M

edica

re re

tiree

.

Life

Insu

ranc

eC

ost P

er $

1,00

0R

etire

es w

ith 2

0 or

mor

e ye

ars

of s

ervi

ceM

onth

ly p

er $

1,00

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58Tw

enty

or M

ore

Year

s of

Act

ive

Empl

oym

ent

Med

icar

e-El

igib

le In

divi

dual

s C

ost S

harin

g =

36%

Non

-Med

icar

e-El

igib

le In

divi

dual

s C

ost S

harin

g =

36%

Effe

ctiv

e Ja

nuar

y 1,

202

1R

etire

e C

ompl

eted

Neither

Hea

lth R

isk

Ass

essm

ent n

or B

iom

etric

Hea

lth S

cree

ning

*

25

Split

-Fam

ily M

onth

ly R

ate

Sche

dule

Ret

iree

Con

trib

utio

n fo

r Med

ical

, Pre

scrip

tion,

Den

tal,

Visi

on, a

nd L

ife C

over

age

67

1012

1318

1911

89

Med

ical

2- P

ARTY

Ret

iree

Med

icar

eSp

ouse

Non

-M

edic

are

2- P

ARTY

Ret

iree

Non

-M

edic

are

Spou

se/C

hild

M

edic

are

2- P

ARTY

Ret

iree

Med

icar

eD

epen

dent

Non

-M

edic

are

FAM

ILY

Ret

iree

Med

icar

e,

Spou

se

Med

icar

e,

Dep

ende