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Retiree/Direct Bill Health Plan Rates (Chart 1)
Retiree/Direct Bill Medicare Plan Rates (Chart 2)
Retiree/Direct Bill Health Plan Rates (Chart 1)
| Monthly Premiums (Plan A, Superior Vision and Delta Dental Services) | |||||||
|---|---|---|---|---|---|---|---|
| Coverage Choice | Monthly Medical Plan A Premiums | Monthly Superior Vision Premiums | Monthly Delta Dental Premiums | ||||
| Blue Cross and Blue Shield Plan A | Coventry Plan A | Preferred Health Systems Plan A | UMR, A United Healthcare Company Plan A | Superior Vision Services: Basic Plan | Superior Vision Services: Enhanced Plan | ||
| 1 | $497.52 | $474.60 | $487.68 | $453.68 | $4.36 | $7.26 | $30.64 |
| 2 | $955.04 | $909.20 | $935.34 | $867.34 | $8.72 | $14.52 | $61.28 |
| 3 | $863.54 | $822.28 | $845.82 | $784.62 | $7.85 | $13.07 | $55.16 |
| 4 | $1,321.06 | $1,256.88 | $1,293.48 | $1,198.52 | $12.21 | $20.33 | $85.80 |
| B | $458.94 | $479.34 | $487.18 | $415.14 | $6.54 | $10.89 | $30.64 |
| Monthly Premiums (Plan B, Superior Vision and Delta Dental Services) | |||||||
|---|---|---|---|---|---|---|---|
| Coverage Choice | Monthly Medical Plan B Premiums | Monthly Superior Vision Premiums | Monthly Delta Dental Premiums | ||||
| Blue Cross and Blue Shield Plan B | Coventry Plan B | Preferred Health Systems Plan B | UMR, A United Healthcare Company Plan B | Superior Vision Services: Basic Plan | Superior Vision Services: Enhanced Plan | ||
| 1 | $477.42 | $455.64 | $468.06 | $435.76 | $4.36 | $7.26 | $30.64 |
| 2 | $914.86 | $871.28 | $896.12 | $831.54 | $8.72 | $14.52 | $61.28 |
| 3 | $827.36 | $788.16 | $810.52 | $752.38 | $7.85 | $13.07 | $55.16 |
| 4 | $1,264.80 | $1,203.80 | $1,238.58 | $1,148.36 | $12.21 | $20.33 | $85.80 |
| B | $425.82 | $467.98 | $475.38 | $407.10 | $6.54 | $10.89 | $30.64 |
| Coverage Choice Codes Key | ||||
| 1 - Member only | 2 - Member and spouse only | 3 - Member and child(ren) only | 4 - Member, spouse and child(ren) | B - Medicare member only |
Important Reminders:
The premiums provided for vision and dental coverage above are separate from the premiums provided for the medical plans. Therefore, when calculating your total monthly premium, please be sure to add all three premium amounts, as applicable. In addition, remember, you can receive a $40 discount each month on the medical premiums listed above if you are a Non-Tobacco User. Tobacco Users that complete the Tobacco Cessation Program (offered through HealthQuest) will receive this $40 discount as well! Please subtract $40 from the medical rates above to determine the amount of your discounted premium.
Retiree/Direct Bill Medicare Plan Rates (Chart 2)
| Monthly Premiums (Medicare Plans with or without Part D, Superior Vision Services and Delta Dental): Member Only | ||||
|---|---|---|---|---|
| Medical Plan (with or without Part D) | Monthly Premium for Medical Plan (with or without Part D) |
Superior Vision Services: Basic Plan |
Superior Vision Services: Enhanced Plan |
Delta Dental |
| Coventry Advantra Freedom PPO with Coventry Part D | $87.50 | $6.54 | $10.89 | $30.64 |
| Coventry Advantra Freedom PPO with SilverScript | $188.50 | $6.54 | $10.89 | $30.64 |
| Humana PPO with Humana Part D | $145.50 | $6.54 | $10.89 | $30.64 |
| Humana PPO with SilverScript | $240.50 | $6.54 | $10.89 | $30.64 |
| Kansas Senior Plan C with SilverScript | $343.31 | $6.54 | $10.89 | $30.64 |
| Kansas Senior Plan C without SilverScript | $188.31 | $6.54 | $10.89 | $30.64 |
Important Reminders:
The premiums provided for vision and dental coverage above are separate from the premiums provided for the medical plans. Therefore, when calculating your total monthly premium, please be sure to add all three premium amounts, as applicable.
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