|
2009 Retiree Medical
Plan Rate Chart - Biweekly Deduction
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)
|
114.12
|
138.42
|
173.96
|
176.83
|
127.43
|
|
P |
Retiree Plus
Dependent Child (Non Medicare)
|
222.54
|
267.38
|
322.85
|
306.80
|
236.42
|
|
H |
Retiree Plus
Spouse/Domestic Partner (Non Medicare) |
255.99 |
308.58 |
349.29 |
322.99 |
251.29 |
|
F |
Retiree Plus
Two or More Dependents (Family All Non Medicare) |
280.69 |
332.17 |
576.02 |
533.41 |
443.95 |
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 |
45.23 |
97.44 |
92.25 |
24.70 |
|
2 3 4 |
Two or more
with Medicare A & B |
N/A |
90.46 |
199.00 |
184.50 |
49.40 |
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 |
159.35 |
159.35 |
186.64 |
198.85 |
19.77 |
|
I2 I3 F2 N2
P2 H2 |
Two or more
with Medicare A & B and One or more Non Medicare |
204.58 |
228.87 |
276.52 |
217.69 |
44.47 |
|
F1 N1 |
One with
Medicare A & B and One or more Non Medicare |
300.37 |
300.37 |
261.94 |
68.28 |
1.00 |
|
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 |
104.02 |
339.07 |
171.25 |
171.73 |
|
SS |
Two with
Medicare B Only |
N/A |
208.05 |
678.15 |
281.55 |
343.47 |
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 |
218.15
N/A |
242.44 |
603.95 |
310.41 |
85.24 |
Express-Scripts
Retail 30 Day Prescriptions & 90 Day Mail Order
Generic
Name Brand Preferred
30 Day
Retail $10.00 $20.00 $30.00
Mail Order
90 Day $20.00 $40.00 $60.00
| 
