Plan & Coverage Level Code Monthly Rate WSSC Monthly Contribution Retiree Monthly* Deduction United Healthcare ChoicePlus POS Individual 171 1,118.00 $ 849.68 $ 268.32 $ 2-Person 172 2,208.00 $ 1,678.08 $ 529.92 $ Family 173 2,792.00 $ 2,121.92 $ 670.08 $ United Healthcare Select EPO Individual 161 768.00 $ 606.72 $ 161.28 $ 2-Person 162 1,536.00 $ 1,213.44 $ 322.56 $ Family 163 2,235.00 $ 1,765.65 $ 469.35 $ Kaiser Permanente HMO Individual 167 537.00 $ 424.23 $ 112.77 $ 2-Person 184 1,073.00 $ 847.67 $ 225.33 $ Family 168 1,626.00 $ 1,284.54 $ 341.46 $ United Healthcare Medicare Supplement Individual Medicare** 165 615.00 $ 485.85 $ 129.15 $ 2-Person Medicare** 164 1,234.00 $ 974.86 $ 259.14 $ Kaiser Permanente Medicare Plus Individual Medicare** 169 249.00 $ 196.71 $ 52.29 $ 2-Person Medicare** 170 497.00 $ 392.63 $ 104.37 $ Delta Dental PPO Individual 143 40.00 $ - $ 40.00 $ 2-Person 156 67.00 $ - $ 67.00 $ Family 142 99.00 $ - $ 99.00 $ Delta Dental HMO Individual 174 21.00 $ - $ 21.00 $ 2-Person 175 34.00 $ - $ 34.00 $ Family 176 50.00 $ - $ 50.00 $ National Vision Administrators Individual 157 3.49 $ - $ 3.49 $ Family 158 12.23 $ - $ 12.23 $ NOTE: Must be enrolled in Retiree medical to participate in the vision plan. NOTES: For the 2018 plan year, WSSC contributes 76% of the monthly premium towards the United Healthcare Choice Plus POS plan and 79% of the monthly premium for all other health plans. 2018 Medical, Dental & Vision Plan Rates for WSSC Retirees **Once you become eligible for Medicare Part B, you must enroll. Your plan with WSSC will coordinate with Medicare to pay your medical bills. Please see pages ______ in this booklet for more information. There is no contribution to the dental or Vision plans. *Rates may vary based on years of service and/or retirement status. If you were hired after April 1, 1994 and have less than 20 years of service, or you are a deferred retiree with less than 20 years of service, you are subject to a higher perceptage of cost sharing than what is shown in this chart. Please contact HR for more details. Plan & Coverage Level Code Monthly Rate WSSC Monthly Contribution Retiree Monthly* Deduction United Healthcare ChoicePlus POS Individual 171 1,118.00 $ 849.68 $ 268.32 $ 2-Person 172 2,208.00 $ 1,678.08 $ 529.92 $ Family 173 2,792.00 $ 2,121.92 $ 670.08 $ United Healthcare Select EPO Individual 161 768.00 $ 606.72 $ 161.28 $ 2-Person 162 1,536.00 $ 1,213.44 $ 322.56 $ Family 163 2,235.00 $ 1,765.65 $ 469.35 $ Kaiser Permanente HMO Individual 167 537.00 $ 424.23 $ 112.77 $ 2-Person 184 1,073.00 $ 847.67 $ 225.33 $ Family 168 1,626.00 $ 1,284.54 $ 341.46 $ United Healthcare Medicare Supplement Individual Medicare** 165 615.00 $ 485.85 $ 129.15 $ 2-Person Medicare** 164 1,234.00 $ 974.86 $ 259.14 $ Kaiser Permanente Medicare Plus Individual Medicare** 169 249.00 $ 196.71 $ 52.29 $ 2-Person Medicare** 170 497.00 $ 392.63 $ 104.37 $ Delta Dental PPO Individual 143 40.00 $ - $ 40.00 $ 2-Person 156 67.00 $ - $ 67.00 $ Family 142 99.00 $ - $ 99.00 $ Delta Dental HMO Individual 174 21.00 $ - $ 21.00 $ 2-Person 175 34.00 $ - $ 34.00 $ Family 176 50.00 $ - $ 50.00 $ National Vision Administrators Individual 157 3.49 $ - $ 3.49 $ Family 158 12.23 $ - $ 12.23 $ NOTE: Must be enrolled in Retiree medical to participate in the vision plan. NOTES: For the 2018 plan year, WSSC contributes 76% of the monthly premium towards the United Healthcare Choice Plus POS plan and 79% of the monthly premium for all other health plans. 2018 Medical, Dental & Vision Plan Rates for WSSC Retirees **Once you become eligible for Medicare Part B, you must enroll. Your plan with WSSC will coordinate with Medicare to pay your medical bills. Please see pages ______ in this booklet for more information. There is no contribution to the dental or Vision plans. *Rates may vary based on years of service and/or retirement status. If you were hired after April 1, 1994 and have less than 20 years of service, or you are a deferred retiree with less than 20 years of service, you are subject to a higher perceptage of cost sharing than what is shown in this chart. Please contact HR for more details. 4 •  For the 2018 plan year, WSSC contributes 76% of the monthly premium towards the United Healthcare Choice Plus POS plan and 79% of the monthly premium for all other health plans. •  There is no WSSC contribution to the Dental or Vision plans. *  Rates may vary based on years of service and/or retirement status. If you were hired after April 1, 1994 and have less than 20 years of service, or you are a deferred retiree with less than 20 years of service, you are subject to a higher perceptage of cost sharing than what is shown in this chart. Please contact HR for more details. **  Once you become eligible for Medicare Part B, you must enroll. Your plan with WSSC will coordinate with Medicare to pay your medical bills. Please see pages 19–23 in this booklet for more information. 2018 Medical, Dental & Vision Plan Rates for Retirees