|
2008 Retiree Medical Plan Rate Chart
Biweekly Deduction
NON-MEDICARE
Non Medicare |
CareFirst
BCBS Preferred Provider Network
|
CareFirst BCBS
Traditional
|
UnitedHealth-care
|
Optimum Choice
|
Kaiser
Permanente
|
Level Code
|
Coverage
Level Description
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
I
|
Retiree Only
(Non Medicare)
|
107.43
|
130.04
|
159.12
|
159.63
|
141.49
|
|
P |
Retiree Plus
Dependent Child (Non Medicare)
|
209.48
|
251.19
|
295.24
|
276.40
|
263.47
|
|
H |
Retiree Plus
Spouse/Domestic Partner (Non Medicare) |
240.94 |
289.92 |
319.14 |
290.48 |
281.80 |
|
F |
Retiree Plus
Two or More Dependents (Family All Non Medicare) |
264.36 |
311.93 |
528.40 |
482.92 |
482.42 |
MEDICARE PARTS A&B ONLY
Medicare Parts A & B Only |
CareFirst
BCBS Preferred Provider Network
|
CareFirst BCBS
Traditional
|
UnitedHealth-care
|
Optimum Choice
|
Kaiser
Permanente
|
Level Code
|
Coverage
Level Description
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
|
1 |
Retiree with
Medicare A & B |
N/A |
42.47 |
89.29 |
83.76 |
29.25 |
|
2 3 4 |
Two or more
with Medicare A & B |
N/A |
84.95 |
182.01 |
167.62 |
58.50 |
MEDICARE
PARTS A&B PLUS NON-MEDICARE
|
Medicare Parts A & B Plus Non
Medicare |
CareFirst
BCBS Preferred Provider Network
|
CareFirst BCBS
Traditional
|
UnitedHealth-care
|
Optimum Choice
|
Kaiser
Permanente
|
Level Code
|
Coverage
Level Description
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
I1
P1
H1
|
One Non Medicare and One with
Medicare A & B
Parent &
Child Non Medicare & One Medicare A & B
Husband &
Wife Non Medicare & One Medicare A & B |
149.90 |
149.90 |
169.84 |
178.94 |
33.81 |
|
I2 I3 F2 N2
P2 H2 |
Two or more
with Medicare A & B and One or more Non Medicare |
192.37 |
214.98 |
252.22 |
195.36 |
63.06 |
|
F1 N1 |
One with
Medicare A & B and One or more Non Medicare |
282.57 |
282.57 |
237.30 |
55.97 |
1.93 |
MEDICARE PART B ONLY
|
Medicare Part B Only |
CareFirst
BCBS Preferred Provider Network
|
CareFirst BCBS
Traditional
|
UnitedHealth-care
|
Optimum Choice
|
Kaiser
Permanente
|
Level Code
|
Coverage
Level Description
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
|
S |
Retiree with
Medicare B Only |
N/A |
97.68 |
312.54 |
154.98 |
185.14 |
|
SS |
Two with
Medicare B Only |
N/A |
195.37 |
625.10 |
254.04 |
370.29 |
MEDICARE
PART B ONLY PLUS NON-MEDICARE
MEDICARE PART B ONLY PLUS MEDICARE PARTS
A&B
|
Medicare B Only Plus Non Medicare
/ Medicare Part B Only Plus Medicare Parts A & B |
CareFirst
BCBS Preferred Provider Network
|
CareFirst BCBS
Traditional
|
UnitedHealth-care
|
Optimum Choice
|
Kaiser
Permanente
|
Level Code
|
Coverage
Level Description
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
Your
Cost
|
IS
PS
FS
IZ
S1
|
One with Medicare B Only and One
or more Non Medicare
Two with
Medicare B Only and One Non Medicare
One Medicare
B Only & One Medicare A & B |
205.12
N/A |
227.73 |
555.56 |
280.15 |
106.05 |
Express-Scripts
Retail 30 Day Prescriptions & 100 Day Mail Order
Generic
Name Brand Preferred
30 Day
Retail $10.00 $20.00 $30.00
Mail Order 100 Day $20.00 $40.00 $60.00
| 
