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Continuation of Coverage Election Notice

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You are receiving this booklet because your Public Employees Benefits Board (PEBB) health coverage recently ended. This booklet explains how you can continue your PEBB health coverage. To continue PEBB health coverage, you must complete the enclosed form(s) and follow the instructions. You have 60 days after the postmark to elect to continue your PEBB health coverage and submit your form to the PEBB Program.

HCA 50-801 (12/11)

PEBB contact information

You may obtain information about PEBB eligibility and continuation coverage from: Mailing address Health Care Authority PEBB Program P Box 42684 .O. Olympia, WA 98504-2684 Street address Health Care Authority PEBB Program 676 Woodland Square Loop SE Lacey, WA 98503

In 2012, our new street address will be: Health Care Authority PEBB Program 626 8th Avenue SE Olympia, WA 98501 Phone: 1-800-200-1004 or 360-412-4200 (after January 1, 2012, call 360-725-0440) PEBB website: www.pebb.hca.wa.gov

You may find the Public Employees Benefits Board's existing laws in chapter 41.05 of the Revised Code of Washington (RCW), and rules in chapters 182-04, 182-08, 182-12, 182-13, and 182-16 of the Washington Administrative Code (WAC). These are available on the Office of the Code Reviser's website at slc.leg.wa.gov.

To obtain this document in another format (such as Braille or audio), call our Americans with Disabilities Act (ADA) Coordinator at 360-923-2714. TTY users may call this number through the Washington Relay Service by dialing 711.

Table of Contents

Introduction ..........................................................................5 Important information about your continuation coverage rights ......................................................................6 What continuation coverage options are available? .......6 How to elect continuation coverage ...............................7 Electing COBRA or PEBB Extension of Coverage.....7 Special considerations in deciding whether to elect COBRA .......................................................7 Electing LWOP coverage .........................................8 How long can I remain on continuation coverage? ........8 Termination of continuation coverage before the end of the maximum coverage period ....................10 How much does continuation coverage cost? ..............11 When and how do I make payments? ..........................11 For more information...................................................12 Appendix A (COBRA and PEBB Extension of Coverage) ..........................13 Appendix B (LWOP Coverage) .................................................................25

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Introduction

This notice contains important information about the right you and your dependents have to continue your health care coverage in the Public Employees Benefits Board (PEBB) Program. Please read the information carefully. We use "you" in this notice to refer to each person who will lose PEBB coverage. This notice contains information about and election forms for temporary continuation of coverage, not retiree coverage or coverage for survivors. (See page 6.) To elect continuation coverage, you must complete the appropriate enclosed election form(s) and submit them to the PEBB Program following the instructions in this notice. If you do not elect to continue coverage within the required timeframe, PEBB coverage will end on the last day of the month you and your dependent(s) stop being eligibile. Continuation coverage begins the first day of the month after the date your coverage ended. You must pay for all months of coverage, even if you wait up to 60 days to elect coverage. You do not have to send payment with your election form; however, we will not enroll you until we receive your first payment. (See page 11.) If you do not pay your premiums by the deadline, you will forfeit your rights to PEBB continuation coverage unless you regain eligibility for PEBB coverage. Thinking of retiring? If you are eligible for PEBB retiree coverage, you can find information on PEBB retiree health coverage: · · At www.pebb.hca.wa.gov by selecting the New Retiree link under Enroll for 2012; or By calling the PEBB Program toll-free at 1-800-200-1004 to request a Retiree Enrollment Guide.

To enroll in or defer your PEBB retiree coverage, you must submit your completed forms to the PEBB Program no later than 60 days after your employer-paid or COBRA coverage ends.

If you are enrolled in a PEBB flexible spending account (FSA) and your employment ends, you can elect to continue your FSA coverage through ASIFlex. You must contact ASIFlex at 1-800-659-3035 or via email to [email protected] no later than 60 days after the date ASIFlex provides notice of your continuation right. You can also find more information in ASIFlex's 2012 FSA Enrollment Guide online at http://pebb.asiflex.com/.

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Important information about your continuation coverage rights

Continuation coverage provides the same medical and dental benefits and cost-sharing available to other PEBB enrollees, including (for example) copayments, deductibles, and choice of health plans. Each qualified person who elects COBRA or PEBB Extension of Coverage will have the same rights as other PEBB enrollees, including open enrollment and special open enrollment rights. For detailed information on retiree eligibility, enrollment, premiums, and available plan options, refer to the PEBB Retiree Enrollment Guide. You can find this at www.pebb.hca.wa.gov by selecting the New Retiree link under Enroll for 2012 or by calling the PEBB Program at 1-800-200-1004 to request a guide. The event that caused you to lose PEBB coverage is called a "qualifying event," and the date of that event is the date of your qualifying event. Each "qualified beneficiary" (each individual who lost PEBB coverage due to the qualifying event) is entitled to elect to continue PEBB coverage. The reason for the qualifying event determines the maximum coverage period available. A summary of the eligibility requirements for each continuation coverage option follows: COBRA lndividuals who are enrolled in PEBB health coverage, are qualified beneficiaries under COBRA, and have a qualifying event may be eligible to continue PEBB coverage under COBRA. (See Appendix A.) PEBB Extension of Coverage lndividuals who are enrolled in PEBB health coverage and have a qualifying event, but are not qualified beneficiaries under COBRA, may be eligible to continue PEBB coverage under PEBB Extension of Coverage. People who are not qualified beneficiaries under COBRA law include dependents who are registered domestic partners, children of registered domestic partners, COBRA beneficiaries who become entitled to Medicare, and retirees and their dependents who stop being eligible for PEBB retiree coverage. (See Appendix A.) Independent election rights Each individual who was enrolled in and will lose PEBB coverage will have an independent right to elect COBRA or PEBB Extension of Coverage. For example:

· The employee's spouse or state-registered domestic partner may elect continuation coverage, even if the employee does not. You may elect continuation coverage for only one, several, or all eligible dependent children. Parents may elect continuation coverage on behalf of their eligible children.

What continuation coverage options are available?

You and your covered dependents may be eligible for one or more of the following temporary continuation of coverage options: 1. Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA)--Governed by federal law and regulations. 2. PEBB Extension of Coverage--An alternative created for PEBB enrollees who are not eligible for COBRA. 3. Leave Without Pay (LWOP) coverage--An alternative to COBRA or PEBB Extension of Coverage that may provide extended coverage in specific situations. The details of the types of coverage available (medical, dental, life insurance, long-term disability coverage) and who qualifies follows. In addition, PEBB retiree insurance is available to employees and survivors who meet eligibility and procedural requirements as described in Washington Administrative Code (WAC): · Retiringemployeesandemployeeswitha disability, as defined in WAC 182-12-171. · Survivingdependentsofemergencyservice personnel killed in the line of duty, as defined in WAC 182-12-250. · Survivingdependentsofemployeesandretirees,as defined in WAC 182-12-265. You can find these rules at www.pebb.hca.wa.gov in the PEBB Rules and Policies section.

· ·

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Leave Without Pay (LWOP) Employees who are in one of the following circumstances may be eligible to continue PEBB coverage for themselves and their dependents under the Leave Without Pay (LWOP) option. (See Appendix B.) · Youareonauthorizedleavewithoutpay. · Youareonapprovededucationalleave. · Youarereceivingtime-lossbenefitsunderworkers' compensation. · Youarecalledtoactivedutyintheuniformed services, as defined under the Uniformed Services Employment and Reemployment Rights Act (USERRA). · Youremploymentendsduetoalayoff. · Youareapplyingfordisabilityretirement. · Youarerevertingfromaneligiblepositionandyou are no longer eligible for the employer contribution toward insurance coverage. · Youareafacultymemberwhoisbetweenperiods of eligibility. · Youareaseasonalemployeeduringanoffseason. · Youareawaitinghearingofadismissalaction.

qualifying event, you may elect COBRA for dental coverage only, medical coverage only, or both medical and dental.) You may elect COBRA or PEBB Extension of Coverage even if you have other group health coverage or are entitled to Medicare on or before the date you elect COBRA or PEBB Extension of Coverage.

Special considerations in deciding whether to elect COBRA

ln considering whether to elect COBRA, you should take into account that choosing not to elect COBRA will affect your future rights under federal law. Here are some examples of how you could be affected: · Youcouldlosetherighttoavoidhaving preexisting-condition exclusions applied to you by other group health plans if you have more than a 63-day gap in health coverage. Election of COBRA may help you avoid such a gap. · Youlosetheguaranteedrighttopurchasean individual health insurance policy that does not impose preexisting-condition exclusions if you do not get COBRA coverage for the maximum time available to you. · Youcouldlosethespecialenrollmentrights granted to you by federal law. These rights include the right to request special enrollment in another group health plan you are eligible for (such as a plansponsoredbyyourspouse'semployer)within 30 days after your PEBB coverage ends because of a qualifying event. lf you enroll in COBRA for the maximum time available to you, you will also have the same special enrollment right at the end of your COBRA coverage. More information about COBRA and other continuation coverage is available in the Initial Notice of COBRA and Continuation Coverage Rights. This document is available at www.pebb.hca.wa.gov and from the PEBB Program.

How to elect continuation coverage

You must follow the procedures included in this packet, and mail or hand-deliver the election form(s) to the PEBB Program within 60 days of the postmark on this booklet. If you do not elect continuation coverage within 60 days of the postmark on this notice, you will lose your right to elect any continuation coverage. Oral communications (in person or by telephone) and electronic communications (fax or email) are not acceptable methods of election, and will not preserve your continuation coverage rights.

Electing COBRA or PEBB Extension of Coverage

To elect COBRA or PEBB Extension of Coverage, you must complete the COBRA Continuation or Extension of Coverage form in Appendix A. lf you are eligible for COBRA or PEBB Extension of Coverage due to a qualifying event, you may elect medical and/or dental coverage from the type of plan(s) you were covered under on the day before the qualifying event. (For example, even if you had medical and dental coverage on the day before a

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Electing LWOP coverage

To elect LWOP coverage, you must complete the Leave Without Pay (LWOP) Continuation Coverage Election form in Appendix B. lf you qualify for LWOP coverage due to a qualifying event, you may elect medical, dental, and/or life insurance coverage from the type of plan(s) you were covered under on the day before the qualifying event. lf you were not enrolled in PEBB life insurance on the day before the qualifying event, you may not enroll in life insurance when electing LWOP coverage. Note: lf you are on an approved educational leave or called to active duty in the uniformed services as defined in the Uniformed Services Employment and Reemployment Rights Act (USERRA), you may also elect to continue your long-term disability (LTD) coverage for up to 24 months. You may elect LWOP coverage even if you have other group health coverage or are entitled to Medicare on or before the date you elect LWOP continuation coverage.

For example, if a covered employee becomes entitled to Medicare eight months before the date employment terminates, continuation of PEBB medical and dental coverage for the spouse or state-registered domestic partner and children can last up to 36 months after the date of the employee'sMedicareentitlement.Thisequals28 months after the date of the qualifying event (36 months minus eight months). This continuation coverage period is available only if the covered employee becomes entitled to Medicare 18 months or less before termination of employment or reduction of hours. (3) Limited right to a maximum of 12 to 29 months for employees on approved LWOP (a) When PEBB coverage is lost because of one of the following events, continuation coverage generally can last for a maximum of 29 months as described in WAC 182-12-133(1) and described below: · Theemployeeisonauthorizedleave without pay from his or her agency. · Theemployeeisonapprovededucational leave. (Employees on educational leave may continue their PEBB medical and/or dental coverage for up to 29 months, and PEBB long-term disability for a maximum of 24 months.) · Theemployeeisreceivingtime-loss benefitsunderworkers'compensation. · Theemployeeiscalledtoactivedutyin the uniformed services, as defined under USERRA. (Employees called to active duty may continue their PEBB medical and/or dental coverage for up to 29 months, and PEBB long-term disability for a maximum of 24 months.) · Theemployeeisapplyingfordisability retirement. · Theemployee'semploymentendsdueto layoff (as defined in WAC 182-12-109). (b) When PEBB coverage is lost because the employee is a faculty who is between periods of eligibility, LWOP coverage generally can last for a maximum of 12 months as described in WAC 182-12-142. (Faculty who use up the months of continuation coverage under LWOP may continue medical and dental for the remaining difference in months allowed under COBRA.)

How long can I remain on continuation coverage?

COBRA, PEBB Extension of Coverage, and LWOP coverage provide temporary continuation of coverage. The periods described below are maximum coverage periods. Coverage can end before the end of the maximum coverage period for any of the reasons described under "Termination of continuation coverage before the end of the maximum coverage period" beginning on page 10. (1) When the qualifying event is a termination of employment or reduction in hours When PEBB coverage is lost due to the end of employmentorareductionoftheemployee's hours, continuation coverage generally can last up to 18 months subject to other provisions in this booklet. Additional coverage may be available under LWOP as described in (3). (2) When the covered employee becomes entitled to Medicare within 18 months before his or her termination of employment or reduction in hours When PEBB coverage is lost due to the end of employmentorareductionintheemployee's hours, and the employee became entitled to Medicare benefits 18 months or less before the qualifying event, continuation coverage for qualified beneficiaries (other than the employee) who lose coverage as a result of the qualifying event can last up to 36 months after the date of Medicare entitlement.

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(c) When PEBB coverage is lost because the employee is a seasonal employee who is between seasons of eligibility, LWOP coverage generally can last through the off-season as described in WAC 182-12142. (Seasonal employees who use up the months of continuation coverage under LWOP may continue medical and dental for the remaining difference in months allowed under COBRA.) (d) Employee reverts for reasons other than a layoff and is not eligible for the employer contribution toward insurance coverage, he or she may continue PEBB insurance coverage by self-paying the premium for up to 18 months as described in WAC 182-12141. (e) When PEBB coverage is lost because the employee is awaiting hearing of a dismissal action, LWOP continuation coverage generally can last until the dismissal is upheld or overturned for up to 29 months as described in WAC 182-12-148. (4) When the qualifying event is death, divorce, legal separation, termination of a domestic partnership, or child's loss of eligibility (a) When PEBB coverage is lost due to the death oftheemployee,thecoveredemployee's divorce or legal separation, or when a dependent child is no longer eligible (as described in WAC 182-12-260), COBRA coverage can last up to 36 months. (b) When PEBB coverage is lost due to the death oftheemployee,thecoveredemployee's termination of a domestic partnership, or a dependent child of a domestic partnership is no longer eligible (as described in WAC 18212-260), PEBB Extension of Coverage can last up to 36 months. (5) Extending the length of the COBRA, PEBB Extension of Coverage, or LWOP coverage period An extension of the maximum 18-month period of continuation coverage available under COBRA, PEBB Extension of Coverage, or LWOP coverage may be available if you or a qualified dependent becomes disabled or a second qualifying event occurs. You must notify the PEBB Program no later than 60 days after a disability or a second qualifying event to extend the continuation coverage period. lfyoudon't,youwilllosetherighttoextend continuation coverage.

(a) Disability lf the Social Security Administration determines that any qualified beneficiary is disabled, you and all of the qualified beneficiaries in your family may be entitled to receive up to 11 months of additional continuation coverage (for a total of 29 months). This extension is available only to those individuals who are receiving continuation coverage because of a qualifying event(thecoveredemployee'sterminationof employment or reduction of hours). The disability must have started before the61stdayafterthecoveredemployee's termination of employment or reduction in hours, and must last at least until the end of the continuation coverage period available without the disability extension (generally 18 months, as described above). You and each qualified beneficiary will be entitled to the disability extension if one of you qualifies. The disability extension is available only if you notify the PEBB Program in writing no later than 60 days after the last of the following events: ·ThedateoftheSocialSecurity Administration'sdisabilitydetermination. ·Thedateofthecoveredemployee's termination of employment or reduction of hours. ·Thedatethequalifiedbeneficiaryloses (or would lose) coverage under PEBB rulesasaresultofthecoveredemployee's termination of employment or reduction of hours. To request a disability extension, you must send written notice and a copy of your disability award letter from the Social Security Administration to the PEBB Program. (b) Second qualifying-event extension An extension of COBRA, PEBB Extension of Coverage, or LWOP coverage may be available to spouses, state-registered domestic partners, and dependent children who are receiving continuation coverage if a second qualifying event occurs during the 18 months (or, in the case of a disability extension or for some LWOP coverage enrollees, 29 months) followingthecoveredemployee'stermination of employment or reduction in hours. The

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maximum amount of continuation coverage available when a second qualifying event occurs is 36 months. For example, if a second qualifying event occurs after eight months of continuation coverage and the PEBB Program is notified in writing no later than 60 days after: ·Thedateofthesecondqualifyingevent,or ·Thedatethequalifiedbeneficiarywould lose coverage as a result of the second qualifying event thentheemployee'scoveragecanlastupto 28 months beyond the date of the second qualifying event. Second qualifying events may include the death of a covered employee, divorce or legal separation, termination of a qualified or state-registered domestic partnership, or when a dependent child stops being eligible for coverage under PEBB rules. These events can be a second qualifying event only if they would have caused a qualified beneficiary to lose coverage under PEBB rules if the first qualifying event had not occurred. Extension of coverage due to a second qualifying event is available only if you notify the PEBB Program in writing of the second qualifying event no later than 60 days after the later of the following events: ·Thedateofthesecondqualifyingevent,or ·Thedatethequalifiedbeneficiarywould lose coverage under PEBB rules as a result of the second qualifying event. You may also need to send appropriate forms or supporting documentation when you notify the PEBB Program. Call us to ask what information to provide. lf you are eligible for and elect to continue coverage under LWOP the maximum number , of months allowed under COBRA are included in the maximum number of months allowed under LWOP (For example, if you are eligible . for 29 months of LWOP coverage under PEBB rules, and eligible for 18 months of COBRA coverage because of your qualifying event, the first 18 months of LWOP coverage will satisfy the 18-month COBRA period. Likewise, if you are eligible for 12 months of LWOP coverage under PEBB rules and eligible for 18 months of COBRA because of

your qualifying event, you may switch to COBRA continuation coverage for six months after the 12 months of LWOP for a total of 18 , months of medical and/or dental continuation coverage.)

Termination of continuation coverage before the end of the maximum coverage period

(1) Automatic termination before the end of the maximum coverage period Continuation coverage will automatically terminate before the end of the maximum period if: (a) Any required premium is not paid in full on time. (This will terminate your rights to all PEBB continuation coverage.) (b) The employer stops providing any group health plan for its employees (this is particularly important for people eligible through an employer group such as a political subdivision). (c) Continuation coverage may also terminate for any reason coverage would terminate for any other PEBB enrollee (such as fraud). If you do not pay the full amount due within 45 days after the date you elect coverage, you will lose all rights to PEBB continuation coverage. (2) Medicare entitlement or other group health coverage Your COBRA coverage will terminate automatically if you become entitled to Medicare after you enroll. However, you may continue your health coverage for the remainder of your COBRA period through PEBB Extension of Coverage. lf you elect COBRA or PEBB Extension of Coverage, your coverage will also end early if you enroll in other group health coverage (but only after any applicable preexisting condition exclusions of that other plan have been exhausted or satisfied). You must notify the PEBB Program in writing no later than 60 days after electing COBRA or PEBB Extension of Coverage, if you or a qualified dependent becomes entitled to Medicare (Part A, Part B, or both) or becomes covered under

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other group health coverage (but only after any preexisting condition exclusions of that other plan have been exhausted or satisfied). (3) A qualified beneficiary stops being disabled lf the Social Security Administration determines that a qualified beneficiary is no longer disabled, you must notify the PEBB Program in writing within 60 days. COBRA, PEBB Extension of Coverage, or LWOP coverage for all qualified beneficiaries will end on the last day of the month that the Social Security Administration'sdeterminationwasmade,oras allowed by law.

You must make sure the amount of your first payment is correct. You may contact the PEBB Program to confirm the amount due. We will not enroll you until you have elected to continue your PEBB coverage and made the first payment. (2) How to make premium payments You must mail or hand-deliver your first payment to: Mailing address Health Care Authority PEBB Program P Box 42691 .O. Olympia, WA 98504-2691 Street address (for hand deliveries) Health Care Authority PEBB Program 676 Woodland Square Loop SE Lacey, WA 98503 In 2012, our new street address will be: Health Care Authority PEBB Program 626 8th Avenue SE Olympia, WA 98501 Make checks payable to the Washington State Treasurer. To request electronic funds transfer, contact the PEBB Program. After the Health Care Authority receives your first payment, you must pay all continuation coverage premiums by check or electronic funds transfer. You may also pay in cash at the Health Care Authority'soffice.Sendsubsequent payments for continuation coverage to: Mailing address Health Care Authority PEBB Program P Box 34270 .O. Seattle, WA 98124-1270 Street address (for hand deliveries) Health Care Authority PEBB Program 676 Woodland Square Loop SE Lacey, WA 98503

How much does continuation coverage cost?

The cost you pay for your coverage is similar to the total cost paid by both the employer and employee. COBRA or PEBB Extension of Coverage (See rates on pages 19-20.) The monthly premiums for PEBB medical and dental plans are in Appendix A. LWOP coverage (See rates on pages 31-32.) The monthly premiums for medical, dental, life, and LTD coverage are in Appendix B.

When and how do I make payments?

(1) First payment for continuation coverage lf you elect to continue PEBB coverage, you do not have to send payment with the election form. However, you must make your first payment no later than 45 days after the date you elect continuation coverage. This is the date PEBB receives your PEBB election form. Your first payment must cover the cost of continuation coverage from the time your PEBB coverage ends through the end of the previous month. Forexample:Sue'semployment ends on September 30, and she loses coverage on September 30. Sue elects COBRA on November 15. Her first premium payment must cover the premiums for October and November and is due by December 30, the 45th day after the date of her COBRA election.

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In 2012, the Health Care Authority's Lacey office will move to the Cherry Street Plaza in downtown Olympia. The new street address will be: Health Care Authority PEBB Program 626 8th Avenue SE Olympia, WA 98501 (3) When premium payments are considered made We consider your payment made when it is received by the Health Care Authority at one of the addresses above. Payment will not be considered made if your check is returned due to insufficient funds or for any other reason. (4) Monthly payments for continuation coverage After you make your first payment for continuation coverage, you make regular monthly payments to continue your coverage. The amount due each month is shown in this booklet and is subject to change at the beginning of each calendar year. We will inform you before the beginning of each calendar year of changes to premium rates and benefits. Payment for continuation coverage is due on the 15th day of themonthforthatmonth'scoverage.lfyoumake a monthly payment on or before the 15th day of the current month, your PEBB coverage will continue for that month without any break. You may not be billed for your continuation coverage premium. Depending on your payment method, we may send you periodic statements as a reminder of your responsibility to pay your premiums on time. You must pay your premiums on time, even if we do not send you a periodic statement. (5) Grace periods for monthly premium payments Although monthly payments are due on the 15th day of each month of continuous coverage, we will give you a 30-day grace period to make each monthly payment. Your PEBB continuation coverage will continue as long as you send payment for the current month before the end of thegraceperiod.Forexample:Suedoesn'tmake her payment for May coverage by June 15. Her coverage is terminated effective May 1.

Notify the PEBB Program of address changes To protect your rights and the rights of your family, you should keep the PEBB Program informed of address changes for all family members. You can do this by calling us at 1-800-200-1004, or notifying us in writing. You should also keep a copy of any notices you send to the PEBB Program for your records.

For more information

This notice does not fully describe your rights for continuation coverage. You can find more information in the PEBB Initial Notice of COBRA and Continuation of Coverage Rights, on the PEBB website at www.pebb.hca.wa.gov, or from the PEBB Program. Contact the PEBB Program for questions about your eligibility. For more information about your COBRA rights, the Health lnsurance Portability and Accountability Act (HIPAA), and other federal laws affecting group health plans, contact the nearest office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) or visit www.dol.gov/ebsa. (Addresses and phone numbers of regional and district EBSA offices are available through EBSA's website.)

If you fail to follow the payment instructions or make a monthly payment before the end of the grace period, you will lose all rights to PEBB continuation coverage unless you regain eligibility for PEBB coverage.

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Appendix A (COBRA and PEBB Extension of Coverage)

Complete this COBRA Continuation or Extension of Coverage form if the qualifying event is one of the following:

Employee: · Youremploymentendedforanyreasonotherthangrossmisconduct. · Yourhoursofemploymentwerereduced. Note: If you are being laid off, reverting to a position that is not eligible for benefits, or appealing a dismissal, you may qualify to continue coverage under the Leave Without Pay (LWOP) option. See page 25 for other examples. Spouse: · Yourspouse(theemployeeorretiree)died.Note: You may qualify to continue coverage under PEBB retiree coverage. · Yourspouse's(theemployee's)hoursofemploymentwerereduced. · Yourspouse's(theemployee's)employmentendedforanyreasonotherthangrossmisconduct. · Youbecomedivorcedorlegallyseparatedfromyourspouse. Qualified/state-registered domestic partner: · Yourqualified/state-registered domestic partner (the employee or retiree) died. Note: You may qualify to continue coverage under PEBB retiree coverage. · Yourqualified/state-registereddomesticpartner's(theemployee's)hoursofemploymentwerereduced. · Yourqualified/state-registereddomesticpartner's(theemployee's)employmentendedforanyreasonother than gross misconduct. · Yourdomesticpartnershipterminated. Dependent child: · Yourparent(theemployeeorretiree)died.Note: You may qualify to continue coverage under PEBB retiree coverage. · Yourparent's(theemployee's)hoursofemploymentwerereduced. · Yourparent's(theemployee's)employmentendedforanyreasonotherthanhisorhergrossmisconduct. · YoureligibilityforPEBBcoverageasadependentchildended.(SeeWAC182-12-260(3).) Retiree: · Youarearetireeandyouremployergroupterminatedplanparticipation. · YouarearetireeandtheDepartmentofRetirementSystemshasdeterminedthatyouarenolongerdisabled, so your pension has stopped.

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Instructions

To elect COBRA or PEBB Extension of Coverage, you must complete this COBRA Continuation or Extension of Coverage form and mail or hand-deliver it to the PEBB Program no later than 60 days after the postmarked date of this Continuation of Coverage Election Notice. Mail to (if no payment enclosed): Health Care Authority PEBB Program P Box 42684 .O. Olympia, WA 98504-2684 Hand-deliver to: Health Care Authority PEBB Program 676 Woodland Square Loop SE Lacey, WA 98503 Mail to (if payment enclosed): Health Care Authority P Box 42691 .O. Olympia, WA 98504-2691 In 2012, our new street address will be: Health Care Authority PEBB Program 626 8th Avenue SE Olympia, WA 98501

Oral communications (in person or by telephone) and electronic communications (fax or e-mail) are not acceptable methods of election, and will not preserve your COBRA rights. If you do not submit a completed COBRA Continuation or Extension of Coverage form within the 60-day timeframe, you will lose your right to elect COBRA or PEBB Extension of Coverage. Read the important information about your rights in the Continuation of Coverage Election Notice.

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2012 COBRA Continuation or Extension of Coverage

· Type or print clearly in black ink. Inaccurate, incomplete, or illegible information may delay coverage. · We must receive your first payment before you can be enrolled. (Make checks payable to the Washington State Treasurer.) · List eligible family members you wish to cover or disenroll. · If enrolling a dependent with a disability age 26 or older, or an extended dependent, you must attach the appropriate dependent certification form. Forms are available at www.pebb.hca.wa.gov or by calling 1-800-200-1004.

Employee/retiree name

Employee or Retiree Information ONLY

Employee/retiree social security number

Date employer coverage ended (mm/dd/yyyy)

Are you making changes to an existing account?

Yes

No If no, go to Section 1.

If yes, what changes? (Check all that apply in the sections below.) Changes you can make anytime Give date of event/change ____________________ Name change Address change Disenroll from medical coverage Disenroll from dental coverage Disenroll dependent(s). If disenrolling due to loss of eligibility (divorce, legal separation documented by a court order, dissolution of domestic partnership, death, or other loss of eligibility under PEBB rules), you must submit this form no later than 60 days after the event. If applicable, provide dependent's new address: _____________________________________________________________________________________

Additional changes you can make during annual open enrollment All changes become effective January 1 of the following year. Check the box(es) next to the change requested. Add dependent(s) Change medical plan Change dental plan

Additional changes you can make if a qualifying event occurs (special open enrollment) The PEBB Program will only allow changes outside of an annual open enrollment when allowed under PEBB rules (see WACs 182-12-262 and 182-08-198). You must submit this form no later than 60 days after the event. However, if adding a newborn or newly adopted child, and adding the child increases your premium, you must submit this form no later than 12 months after the birth or adoption. You must provide proof of the event that created the special open enrollment. Check the box(es) next to the change requested, and indicate the event(s) below. Give date of event __________________ Add dependent(s) Change medical plan Change dental plan Other--explain: ___________________________________ New spouse, Washington State-registered domestic partner, or child added to family due to marriage, Washington State-registered domestic partnership, birth, adoption, court order, or medical support order. Child becoming eligible as an extended dependent through legal custody or legal guardianship. Also complete Extended Dependent Certification form. Form available at www.pebb.hca.wa.gov. Child becoming eligible as a dependent with a disability. Also complete Certification of Dependents With Disabilities form. Form available at www.pebb.hca.wa.gov. Dependent losing other coverage under a group health plan or through health insurance, as defined by the Health Insurance Portability and Accountability Act (HIPAA). Dependent having a change in employment status that affects the dependent's eligibility for the employer contribution toward group health coverage. Dependent becoming eligible or losing eligibility for premium assistance through Medicaid or a state Children's Health Insurance Program (CHIP). The following events also allow a health plan change: Subscriber or dependent having a change in residence that affects health plan availability. Subscriber or dependent becomes entitled to Medicare, or enrolls in or disenrolls from a Medicare Part D plan. Subscriber or dependent's current health plan becoming unavailable because the subscriber or dependent is no longer eligible for a health savings account (HSA).

Are you or any eligible dependents enrolled in PEBB coverage under another account?

Yes

No

HCA 50-245F (10/11)

(continued)

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2012 COBRA Continuation or Extension of Coverage

Subscriber's last name First name

(continued) Middle initial Social security number

Section 1: Subscriber Information (COBRA Enrollee)

Social security number Street address Mailing address (if different from above) County of residence Date of birth (mm/dd/yyyy) Last name First name Apt./unit number Apt./unit number City City Middle initial Sex M State State ZIP Code ZIP Code F

Daytime phone number (including area code) Home phone number (including area code)

(

)

(

)

Select coverage you wish to continue: Medical and dental

Medical only

Dental only

If you have optional life insurance and wish to continue it, complete and submit the Group Life Portability Application no later than 31 days after your coverage ends. Disenrollment date _____________________ If yes, effective date _____________________ If yes, effective date _____________________ If yes, effective date _____________________ If yes, effective date _____________________

Disenroll

Reason _________________________________________________________ Yes Yes Yes Yes No No No No

Are you covered by another group medical plan? Are you covered by another group dental plan? Are you disabled under Title II (OASDI) of the Social Security Act? Are you disabled under Title XVI (SSI) of the Social Security Act?

If yes, you must send a copy of your Social Security Disability Award letter. You and your enrolled dependents may be eligible for additional months of coverage. Are you enrolled in Part(s) A and/or B of Medicare? Part A (hospital) Part B (medical) Yes Yes No No If yes, effective date _____________________ If yes, effective date _____________________

If you are enrolled in Medicare Part(s) A and/or B, attach a copy of your Medicare card to this form.

Section 2: Spouse or Qualified/Washington State-Registered Domestic Partner Information

Relationship to subscriber: If adding a Washington State-registered domestic partner, please complete and attach a Declaration of Tax Status form. Spouse: date of marriage___________________________ Social security number Last name

List eligible family members you wish to cover or disenroll. Family members cannot be enrolled in two PEBB medical or dental accounts at the same time.

Domestic partner: date qualified or registered ______________________ First name Middle initial Sex Date of birth (mm/dd/yyyy) M F State ZIP Code Dental only Date of event __________________________ If yes, effective date _____________________ If yes, effective date _____________________ If yes, effective date _____________________ If yes, effective date _____________________ No No No No

Street address (if different from subscriber) Select coverage to continue: Disenroll Medical and dental

Apt./unit number

City

Medical only Yes Yes Yes Yes

Reason __________________________________________________________

Covered by another group medical plan? Covered by another group dental plan? Disabled under Title II (OASDI) of the Social Security Act? Disabled under Title XVI (SSI) of the Social Security Act?

If yes, you must send a copy of the Social Security Disability Award letter. You and your enrolled dependents may be eligible for additional months of coverage. Enrolled in Part(s) A and/or B of Medicare? Part A (hospital) Part B (medical) Yes Yes No No If yes, effective date _____________________ If yes, effective date _____________________

If enrolled in Medicare Part(s) A and/or B, attach a copy of the Medicare card to this form.

16

(continued)

2012 COBRA Continuation or Extension of Coverage

Subscriber's last name First name

(continued) Middle initial Social security number

List eligible family members you wish to cover or disenroll. Family members cannot be enrolled in two PEBB medical or dental accounts at the same time. If adding a child of your qualified/Washington State-registered domestic partner, attach a Declaration of Tax Status form. Also attach appropriate certification form(s) if enrolling a dependent with a disability age 26 or older, or an extended dependent. Relationship to subscriber Social security number Disabled? (Check only if age 26 or older.) Sex A Yes No M F Last name Street address (if different from subscriber) Select coverage to continue: Disenroll Medical and dental First name Apt./unit number City Dental only Date of event __________________________ If yes, effective date _____________________ If yes, effective date _____________________ If yes, effective date _____________________ If yes, effective date _____________________ No No No No Middle initial Date of birth (mm/dd/yyyy) State ZIP Code

Section 3: Family Member Information (such as child, etc.) Use additional forms for more members.

Medical only Yes Yes Yes Yes

Reason __________________________________________________________

Covered by another group medical plan? Covered by another group dental plan? Disabled under Title II (OASDI) of the Social Security Act? Disabled under Title XVI (SSI) of the Social Security Act? Enrolled in Part(s) A and/or B of Medicare? Part A (hospital) Part B (medical)

If yes, you must send a copy of the Social Security Disability Award letter. You and your enrolled dependents may be eligible for additional months of coverage. Yes Yes No No If yes, effective date _____________________ If yes, effective date _____________________

If enrolled in Medicare Part(s) A and/or B, attach a copy of the Medicare card to this form.

Section 4: Medical Plan Selection Check only one.

Contact plans for benefits information; their contact information is at the end of this form. Group Health Cooperative 1 Group Health Classic Group Health Consumer-Directed Health Plan 2 Group Health Medicare Plan 3 Group Health Value Kaiser Foundation Health Plan of the Northwest 1 Kaiser Permanente Classic Kaiser Permanente Consumer-Directed Health Plan 2 Medicare Supplement Plan F, administered by Premera Blue Cross 4 Uniform Medical Plan, administered by Regence BlueShield of Washington UMP Classic UMP Consumer-Directed Health Plan 2

1 These plans offer Medicare Advantage plans to Medicare enrollees in certain counties. Complete and attach the Medicare Advantage Plan 2 These plans are available only to retirees not enrolled in Medicare. If you cover a dependent enrolled in Medicare you must cancel your 3 If you cover family members not enrolled in Medicare, also check Group Health Classic or Group Health Value for your family members' 4 Complete and return form B to enroll in Medicare Supplement Plan F.

Election Form (form C) if you live in a county where Medicare Advantage is available.

dependent's PEBB coverage before you can enroll in this plan. non-Medicare coverage.

Section 5: Dental Plan Selection Check only one.

Contact plans for benefits information; their contact information is at the end of this form. Preferred Provider Organization Uniform Dental Plan, administered by Washington Dental Service (Group #3000) (may receive services from any provider) Managed-Care Plans DeltaCare, administered by Washington Dental Service (Group #3100) Dentist name or clinic code _________________________________ (must receive services from a DeltaCare provider) Willamette Dental of Washington, Inc. Clinic location ____________________________________________ (must receive services from a Willamette Dental Group provider)

Please sign and date this form on the next page.

17 (continued)

2012 COBRA Continuation or Extension of Coverage

Subscriber's last name First name

(continued) Middle initial Social security number

Section 6: Signature Required

I have received and read the Continuation of Coverage Election Notice including any appendices. By signing this form, I declare that the information I have provided is true, complete, and correct. If it isn't, or if I do not update this information within the timelines in PEBB rules, to the extent permitted by federal and state law, I must repay any claims paid by my health plan(s). My family members and I may also lose PEBB benefits as of the last day of the month we were eligible. To the extent permitted by law, PEBB may retroactively terminate coverage for me and my dependents if I intentionally misrepresent eligibility, or do not fully pay premiums when due. In addition, I understand that knowingly providing false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company is a crime, and can result in imprisonment, fines, and denial of PEBB benefits. If adding a domestic partner to my account, I declare that my partner and I have registered through the Washington Secretary of State's Office. If I send payment, this does not mean that I will be automatically enrolled in PEBB insurance coverage. The PEBB Program will verify eligibility for me and my family members. If we do not qualify, I will receive a refund. If I am enrolling in a consumer-directed health plan with a health savings account (HSA), I must meet HSA eligibility conditions. I understand that the PEBB Program will direct a portion of my monthly premium to an HSA on my behalf based on the information I have provided, and that there are limits to these contributions and my HSA contributions (if any) under federal tax law. This form replaces all COBRA Continuation or Extension of Coverage forms previously submitted to PEBB. HCA's Privacy Notice: We will keep your information private as allowed by law. To receive our Privacy Notice, call 360-923-2822 (effective January 1, 2012, call 360-725-0442) or go to www.hca.wa.gov. Subscriber's signature ______________________________________________________ Date ___________________________________

Please sign and date this form.

Washington State Health Care Authority, P.O. Box 42684, Olympia, WA 98504-2684 Washington State Health Care Authority, P.O. Box 42695, Olympia, WA 98504-2695

Return to:

If payment is enclosed, return to:

2012 PEBB MEDICAL CONTRACTORS

Group Health Cooperative, 320 Westlake Ave. N., Suite 100, Seattle, WA 98109-5233 1-888-901-4636 or TTY 1-800-833-6388 Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St., Suite 100, Portland, OR 97232-2099 1-800-813-2000 or TTY 1-800-735-2900 Premera Blue Cross, P.O. Box 327, Seattle, WA 98111-0327 1-800-817-3049 or TTY 1-800-842-5357 Uniform Medical Plan, administered by Regence BlueShield of Washington, P.O. Box 91015, MS BU248, Seattle, WA 98111-9115 1-888-849-3681 or TTY 711

2012 PEBB DENTAL CONTRACTORS

DeltaCare, administered by Washington Dental Service, 9706 Fourth Avenue NE, Seattle, WA 98115-2157 1-800-650-1583 Uniform Dental Plan, administered by Washington Dental Service, 9706 Fourth Avenue NE, Seattle, WA 98115-2157 1-800-537-3406 Willamette Dental of Washington, Inc., 6950 NE Campus Way, Hillsboro, OR 97124-5611 1-855-433-6825

18

2012 PEBB COBRA, Leave Without Pay, and Extension of Coverage Monthly Rates

Effective January 1, 2012 Special Requirements 1. To qualify for the Medicare rate, at least one covered family member must be enrolled in both Part A and Part B of Medicare. (Medicare rates are not available to Leave Without Pay members.) 2. Medicare-enrolled subscribers in Group Health Cooperative's Medicare Advantage plan or Kaiser Permanente Senior Advantage must complete and sign the Medicare Advantage Plan Election Form to enroll in one of these plans. For more information on these requirements, please contact your health plan's customer service department.

Medical Plans

Membersnoteligible forMedicare (or

enrolled in Part A only): Group Health Classic $ 550.48 1,095.43 959.19 1,504.14 Group Health Value $ 501.58 997.63 873.62 1,369.67 Group Health CDHP $ 482.92 957.35 853.32 1,269.42 Kaiser Permanente Classic $ 538.18 1,070.83 937.67 1,470.32 GroupHealth Value N/A $ 754.24 N/A 630.23 N/A 1,126.28 882.89 N/A Kaiser Permanente CDHP $ 481.27 953.55 850.06 1,264.01 UMP Classic $ 531.11 1,056.69 925.30 1,450.88 UMP CDHP $ 485.22 961.45 856.97 1,274.87

SubscriberOnly Subscriber&Spouse* Subscriber&Child(ren) FullFamily Members enrolled in Part A & Part B of Medicare: SubscriberOnly Subscriber&Spouse* (1Medicareeligible) Subscriber&Spouse* (2Medicareeligible) Subscriber&Child(ren) (1Medicareeligible) Subscriber&Child(ren) (2Medicareeligible) FullFamily (1Medicareeligible) FullFamily (2Medicareeligible) FullFamily (3Medicareeligible)

GroupHealth MedicarePlan $258.19 N/A 510.85 N/A 510.85 N/A N/A 763.51

GroupHealth Classic N/A $ 803.14 N/A 666.90 N/A 1,211.85 919.56 N/A

Kaiser Permanente Classic $ 292.94 825.59 580.35 692.43 580.35 1,225.08 979.84 867.76

UMPClassic $ 363.87 889.45 722.21 758.06 722.21 1,283.64 1,116.40 1,080.55

(continued) *orqualified/WashingtonState-registereddomesticpartner IfaGroupHealthsubscriberisenrolledinMedicarePartAandPartBbutcoversafamilymembernoteligiblefor Medicare,thefamilymembermustenrollinaGroupHealthClassicorValueplanandthesubscriberpaysacombined Medicareandnon-Medicarerate.

19

HCA 50-300R (9/11)

For rate information, contact the Health Care Authority at 1-800-200-1004.

Medicare Supplement Plans

Premera Blue Cross

Plan F

(age 65 or older, eligible by age)

Plan F

(under age 65, eligible by disability)

SubscriberOnly Subscriber&Spouse* (1Medicareeligible)** Subscriber&Spouse* (2Medicareeligible-1retired,1disabled) Subscriber&Spouse* (2Medicareeligible) Subscriber&Child(ren) (1Medicareeligible)** FullFamily (1Medicareeligible)** FullFamily (2Medicareeligible-1retired,1disabled)** FullFamily (2Medicareeligible)** *orqualified/WashingtonState-registereddomesticpartner

$ 188.48

$ 320.40

719.59 508.88 376.96 588.20 1,113.78 908.60 776.68

851.51 508.88 640.80 720.12 1,245.70 908.60 1,040.52

**IfaMedicaresupplementplanisselected,non-MedicareeligibledependentsareenrolledinUniformMedicalPlan (UMP)Classic.Theratesshownreflectthetotaldue,includingpremiumsforbothplans.

Dental Plans

with Medical Plan

SubscriberOnly Subscriber& Spouse* Subscriber& Child(ren) FullFamily

DeltaCare, administered by Washington Dental Service

Uniform Dental Plan, administered by Washington Dental Service

Willamette Dental

Dental Plans

Dental Only

DeltaCare, administered by Washington Dental Service

Uniform Dental Plan, administered by Washington Dental Service

Willamette Dental

$ 39.53

$ 45.20

$ 42.68

SubscriberOnly Subscriber& Spouse* Subscriber& Child(ren) FullFamily

$ 45.06

$ 50.73

$ 48.21

79.06 79.06 118.59

90.40 90.40 135.60

85.36 85.36 128.04

84.59 84.59 124.12

95.93 95.93 141.13

90.89 90.89 133.57

*orqualified/WashingtonState-registereddomesticpartner

20

Group Life Portability Application

ReliaStar Life Insurance Company Home Office: Minneapolis, Minnesota

Employer / Administrator: Read the certificate to determine eligibility for portability. Complete and sign the Employer/Administrator section of this form. Send this form to the employee to complete, along with copies of initial and all subsequent enrollment/application form(s), beneficiary designations, and assignments. Employee: Complete the Employee section and return the form to the address shown at the end of the form. Be sure to include copies of enrollment/application form(s), beneficiary designations and assignments. Coverage can not be ported without this information. The insurer must receive this completed form within 31 days of the coverage termination date. If you do not want to apply for portability and only want to receive information about conversion, please refer to the section TO RECEIVE CONVERSION INFORMATION ONLY (top of page two). ___________________________________________________________________________________________________________________________

THIS SECTION TO BE COMPLETED BY EMPLOYER/ADMINISTRATOR

Employer or Group name State of Washington Group Policy number(s) 12373-1 Account number

Employee name

Social Security Number

Account 10 State Higher Education Account 20 State Employees Account 30 K-12 Employees Account 40 Political Subdivision Employees

Date of birth

Date of hire

Annual Salary at Termination

Date last worked

Coverage termination date

Coverage Type Employee Basic Life Insurance Employee Supplemental Life Insurance Dependent Spouse/Domestic Partner Basic Life Insurance Dependent Spouse/Domestic Partner Supplemental Life Insurance Dependent Child(ren) Basic Life Insurance

Coverage Effective Date (mm/dd/yyyy)

Coverage Amount at Termination $25,000 $ $ $ $

I certify that the above information is true and correct according to the employer's records. Please note: Signature, name, title, agency, and telephone number must be included on the application or it will not be processed.

Authorized Signature of Payroll or Benefits Office Staff Print Name and Title

This form will be

handed

mailed

to employee on ______________________________(date) ( )

Agency phone number Agency number

___________________________________________________________________________________________________________________________

THIS SECTION TO BE COMPLETED BY EMPLOYEE

Employee billing address (street, city, state, zip)

Phone Number

Insured dependent spouse/Washington State-Registered domestic partner name Insured dependent child(ren) name(s)

________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

Date of birth Date(s) of Birth

________________________________________ ________________________________________ ________________________________________

Employee continue on page 2

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21

Employee name

Date of birth

To be eligible for portability, you must be able to answer "no" to all of the health questions below. To port dependent spouse or Washington State registered domestic partner coverage, your spouse or Washington State registered domestic partner must also be able to answer "no" to all of the health questions below. You must port Employee coverage in order to port coverage on your Spouse/Washington State-registered domestic partner and your children. For any Life Insurance not eligible for portability, or if portability is not approved by ReliaStar Life Insurance Company, conversion to an individual life insurance policy may be an option. Please read the Conversion Rights in your group certificate to determine eligibility for conversion. ReliaStar Life Insurance Company will send you a description of the conversion plan, premium rates, and an application form.

TO RECEIVE CONSERION INFORMATION ONLY:

If you do not want to apply for portability and only want to receive information about conversion, you can request a copy of the conversion form from your No Portability personnel, payroll or benefits staff or please check the box at the right to receive conversion information from ReliaStar Life. You may then skip the next two sections of this form. Please sign and date the form and return it as directed below.

PORTABILITY ELECTIONS

Read your group certificate carefully to determine which coverage(s) are eligible for portability. You may only elect to port coverage that is terminating on your coverage termination date. You will not be able to elect or increase ported coverage in the future. Please refer to the attached sheet for portability premium rate information.

Employee Basic and Supplemental Life Insurance Dependent Spouse/Washington State Registered Domestic Partner Basic & Supplemental Life Insurance Dependent Child(ren) Basic Life Insurance · · · · · · Minimum $5,000 Will not exceed the lesser of $750,000 or 5 times Basic Yearly Earnings Same percent elected for Employee Life Will not exceed Employee Life amount ported Same percent elected for Employee Life Will not exceed the lesser of Employee Life amount ported or $2,500 100% of terminated amount 75% of terminated amount 50% of terminated amount 25% of terminated amount Elect to Port Waive Elect to Port Waive

If you elect to port less than 100% of all Life coverage(s) and you also want conversion information, you can request a copy of the conversion form from Send conversion your personnel, payroll or benefits staff or please check the box at the right to receive conversion information from ReliaStar Life.

information

ANSWER THESE QUESTIONS FOR PORTABILITY

Are you terminating active employment due to a disability that has, or is expected to result in your inability to perform the regular duties of your occupation? In the past 2 years, have you been diagnosed or treated (including taking prescribed medications) by a medical professional for any of the following: cardiovascular or liver disorder, kidney or neurological disease, drug or alcohol abuse, emphysema, cancer, stroke or diabetes? Have you ever been diagnosed or treated (including taking prescribed medications) by a medical professional for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or disorders of the immune system, or ever tested positive for antibodies to the Human Immunodeficiency Virus (HIV)?

Employee

Yes Yes No No

Spouse/Washington State-registered domestic partner

Yes No

Yes

No

Yes

No

· To the best of my knowledge and belief, the information I have provided on this form is correct. · I understand that portability is subject to the approval of ReliaStar Life Insurance Company. · I have received ReliaStar Life Insurance Company's Consumer Privacy Notice and Insurance Information Practices Notice. Any person who, knowingly with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and may subject such person to criminal and civil penalties, and denial of insurance benefits. Signature of insured employee Date Signature of insured spouse/Washington State registered domestic partner Date

READ THIS INFORMATION AND THEN SIGN AND DATE BELOW

Mail this form and all other documentation within 31 days of coverage termination to:

ReliaStar Life Insurance Company Route 7325 20 Washington Avenue South Minneapolis, MN 55401

Questions? Call Customer Service at 1-866-869-6990

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22

Group Life Portability Premium Rates

Monthly Rates per $1,000 of coverage Life Insurance ­ Employee, Spouse or Washington State Registered Domestic Partner Age Rate through 24 $ .08 25-29 $ .08 30-34 $ .10 35-39 $ .13 40-44 $ .23 45-49 $ .39 50-54 $ .64 55-59 $1.00 60-64 $1.56 65-69 $2.80 Child(ren) Life Insurance $.25 Premiums are billed on a quarterly basis. Each quarterly bill will include a $3.50 billing charge.

Rates shown are guaranteed until December 31 of the current year in which you are eligible to apply for portability. Underwritten by ReliaStar Life Insurance Company. Policy form LP00GP.

(4/06)

23

ReliaStar Life Insurance Company and ReliaStar Life Insurance Company of New York Consumer Privacy Notice and Insurance Information Practices Notice

We are pleased to provide you with information regarding your application or claim. This information is provided to you in accordance with legislation enacted in your state. You may also receive other privacy notices from us or from our affiliated companies. Please keep this notice and a copy of the completed application or claim form for your records.

Our Underwriting Procedures

For certain types of coverage, we underwrite your request to determine if you are eligible for the coverage you requested. We review all of the information in the application, and, if necessary, confirm or add to this information in the ways described in this notice. In the event of an adverse underwriting decision, we will provide you with the specific reason for the decision in writing. Collecting Information Your application or claim form is our main source of information. But we may: · Ask you to have a physical exam, an EKG and/or a blood profile, etc. · Ask physicians, hospitals, or other health care providers to confirm or add to the information you have given us. The types of information we may ask for are described on the authorization form you will be asked to sign. If you want a copy of this form, it will be given to you for your records. · Obtain information from MIB, Inc., formerly known as the Medical Information Bureau. See "Notice Regarding MIB, Inc." below. · Seek information from other companies you have applied to for insurance. · Ask you for additional information through use of a written request. Notice Regarding Consumer Reports Insurance companies commonly ask an outside source to verify and add to the information given in an application. Consumer reports are used to help us decide if you are eligible for the insurance you have applied for. The report deals with your mode of living, character, general reputation, and such personal items as your health, job, and finances. It may include information on the following: your marital status, past and present employment record, job duties, driving record, avocation, health history, use of alcohol and drugs, and hazardous sports activities. The agency may get information in these ways: from public records, and by contacting you, members of your family, business associates and employers, financial sources, friends, or others you know. This information will not be used to determine your sexual orientation. You can request that the agency interview you in connection with the preparation of the report. If the report affects your application as requested, we will notify you and provide you with the name and address of the reporting firm. We use the report only to be sure that each application is evaluated on a fair basis. We will not reveal any of the information we obtain to your friends or associates. We may reveal the information we obtain to other companies or entities affiliated with us. The information may be kept by the consumer reporting agency; it may also later be given to others who have a legitimate need for these reports. It will be given only to the extent permitted by these laws: the Federal Fair Credit Reporting Act as amended by the Consumer Credit Reporting Reform Act of 1996; your state's Fair Credit Reporting Act, if any; or your state's Insurance Information and Privacy Protection Act, if any. If you wish, we will send you the name, address and phone number of any agency we ask to prepare a consumer report about you. The agency will give you a copy of the report if you ask for one and give proper identification. Information Use We will use the information only for business purposes arising from the relationship you have with us. Information Maintenance and Disclosure We treat the information we have about you as confidential. The authorization form that you have been asked to complete will permit us to send the information to our affiliates and to MIB, our reinsurers, employees, contractors, or other organizations that process transactions concerning coverage you have with us or our affiliates, and to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted. In certain circumstances, the information we have about you may be disclosed to third parties without your specific permission. Access to Information If you request it in writing, we will send you a copy of the relevant information we obtain about you in connection with your request for coverage or an adverse underwriting decision. Medical information, however, will only be disclosed through the attending licensed physician unless state law provides otherwise. If you feel that any of the information in our file is not correct or is incomplete, we will review it. If we agree with you, we will make the corrections. If we do not agree with you, you may file a short statement of dispute with us. Your statement will be included any time we disclose this information to anyone. We will not send you information we collect in expectation of or in connection with any claim or civil or criminal proceeding. Notice Regarding MIB, Inc. We or our reinsurers may make brief reports to MIB. The reports will include the factors that affect the insurability of any person for whom coverage is being requested. MIB is a nonprofit organization of life insurance companies. It operates an information exchange for its members. If you apply to some other member company for life or health coverage, or send in a claim for benefits, MIB may supply that company with any information in its file. If you ask, MIB will arrange to disclose to you the information it has about you in its file. If you question the accuracy of the information in MIB's file, you may contact MIB and ask them to correct it as provided in the Fair Credit Reporting Act. The address of MIB's information office is 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734. MIB's phone number is 866-692-6901 (TTY 866 346-3642). We may also release information in our files to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted. 47316c 116249 (5/09)

Privacy and Information Practices

24

Appendix B (LWOP Coverage)

Complete this Leave Without Pay (LWOP) Continuation Coverage Election form if you are an employee or the eligible dependent of an employee who will lose your PEBB coverage because of one of the following events:

Employee: · Youareonauthorizedleavewithoutpayfromyouragency. · Youremploymentendsduetoalayoff. · Youareanemployeewhorevertedtoapositionthatisnoteligiblefortheemployercontribution toward insurance coverage. · Youareanemployeeappealingadismissalaction. · Youarereceivingtime-lossbenefitsunderworkers'compensation. · Youareapplyingfordisabilityretirement. · Youarecalledtoactivedutyintheuniformedservices,asdefinedundertheUniformedServices Employment and Reemployment Rights Act (USERRA).* · Youareonapprovededucationalleave.* · Youareafacultywhoisbetweenperiodsofeligibility. · Youareaseasonalemployeeduringanoffseason. *You may also be entitled to continue long-term disability coverage.

Instructions

To elect LWOP coverage, you must complete this Leave Without Pay (LWOP) Continuation Coverage Election form and either mail or hand-deliver it to the PEBB Program no later than 60 days after the postmarked date of this Continuation of Coverage Election Notice. Mail to: (if no payment enclosed): Health Care Authority PEBB Program P Box 42684 .O. Olympia, WA 98504-2684 Hand-deliver to: . Health Care Authority PEBB Program 676 Woodland Square Loop SE Lacey, WA 98503 Mail to: (if payment enclosed): Health Care Authority P Box 42691 .O. Olympia, WA 98504-2691 In 2012, our new street address will be: Health Care Authority PEBB Program 626 8th Avenue SE Olympia, WA 98501

Oral communications (in person or by telephone) and electronic communications (fax or e-mail) are not acceptable methods of election, and will not preserve your LWOP continuation coverage rights. If you do not submit a completed Leave Without Pay (LWOP) Continuation Coverage Election form within the 60-day timeframe, you will lose your right to elect LWOP continuation coverage. Read the important information about your rights in the Continuation of Coverage Election Notice.

25

Read the following information carefully before completing the form. Medical and dental benefits

You and your dependents may make a separate election. You may continue medical coverage only, both medical and dental, or dental coverage only on a self-pay basis. You will be allowed to change health plans during an open enrollment period, or after a qualifying event. continued Basic Dependent Life Insurance and any supplemental life insurance. Supplemental AD&D Insurance coverage cannot be continued. · Youcanself-payyourlifeinsurancecoverage by completing the life insurance section of the Leave Without Pay (LWOP) Continuation Coverage Election form. If you return to full-time employment status before the end of the 29th calendar month in which you began active duty, you may reinstate your original coverage without proof of insurability. lf you return to full-time employment status after the end of the 29th month in which you began active duty, you may be required to provide proof of insurability for Basic Dependent Life Insurance and any supplemental life insurance. Any increase to the amount of life insurance you had in place when you were called to active duty will require proof of insurability. Reinstating coverage when you return to work When you return to work, you will need to complete and submit the appropriate form within 31 days in both situations to reinstate your employer-sponsored and supplemental coverages: · lfyouchoosetoself-paysupplementalcoverage during LWOP complete the Life and AD&D , Insurance Enrollment/Change Form. Your employee coverage will be reinstated when you return to work without evidence of insurability. · lfyouchoosenottopayforsupplementalcoverage or if you reduced your coverage during LWOP , complete the Life and AD&D Insurance Enrollment/ Change Form. You must provide evidence of insurability when you return to work.

Life insurance benefits

You may choose to continue all or part of your life insurance coverage while on Leave Without Pay (LWOP), or apply to reinstate coverage when you return to work. lf you choose to continue any part of your supplemental life coverage, you must also continue the $25,000 Basic Life and Accidental Death & Dismemberment (AD&D) Insurance at a cost of $4.08 per month. lf you self-pay for a reduced amount of supplemental life coverage, you must reapply to increase your life insurance coverage when you return to active employment. Please note the following: If you wish to continue spouse coverage lf you continue Supplemental Spouse Life Insurance, you must also continue Basic Dependent Life Insurance. The amount of Supplemental Spouse Life Insurance continued during LWOP cannot exceed the coverage you had as an active employee. If you continue coverage while on active military duty lf you are called to active military duty in the uniformed services as defined under the Uniformed Services Employment and Reemployment Rights Act (USERRA), you may extend life insurance to the end of the 29th calendar month in which your active duty began. You cannot continue Supplemental AD&D insurance. lf you do not choose to continue your life insurance under one of the following options, all life insurance, including Basic Life and AD&D Insurance paid by your employer, will end at the end of the month in which you begin active duty. There are two options for extending insurance benefits: · You can use agency-approved annual or military leave to maintain a minimum of eight hours pay status each month. Employer-sponsored Basic Life and AD&D Insurance will be continued. You are responsible for paying the premium for

Long-term disability benefits

You cannot self-pay basic or optional long-term disability (LTD) coverage unless you are on approved educational leave or called to active duty in the uniformed services as defined under USERRA. Your personnel, payroll, or benefits office has a definition of educational leave. lf you qualify for continuation of LTD coverage and choose to do so, you must pay the $2.00 monthly premium for basic LTD coverage if you want to continue under the optional LTD plan. Optional LTD coverage dropped during LWOP will be reinstated when you return to work without providing evidence of insurability.

26

2012 Leave Without Pay (LWOP) Continuation Coverage Election

· Type or print clearly in black ink. Inaccurate, incomplete, or illegible information may delay coverage. · We must receive your first payment before you can be enrolled. (Make checks payable to the Washington State Treasurer.) · List eligible family members you wish to cover or disenroll. · If enrolling a dependent with a disability age 26 or older, or an extended dependent, you must attach the appropriate dependent certification form. Forms are available at www.pebb.hca.wa.gov or by calling 1-800-200-1004.

Qualifying event

Layoff

Check only one.

Reversion employee Approved leave without pay (LWOP) Workers' compensation Approved educational leave Faculty between periods of eligibility Seasonal employee off-season Employee awaiting hearing of a dismissal

Applying for disability retirement USERRA (military) leave Date called to duty in the uniformed services ______________________

Section 1: Subscriber Information

Social security number Street address Mailing address (if different from above) County of residence Date of birth (mm/dd/yyyy) Last name Apt./unit number Apt./unit number First name City City

Date employer coverage ended Middle initial State State Sex M ZIP Code ZIP Code F

Daytime phone number (including area code) Home phone number (including area code)

(

Select coverage you wish to continue: Medical and dental Life insurance Disenroll

)

Medical only Dental only

(

)

Long-term disability (only if on educational or military leave) Disenrollment date _____________________

Reason _________________________________________________________

If you are enrolled in Medicare Part(s) A and/or B, attach a copy of your Medicare card to this form.

Section 2: Spouse or Qualified/Washington State-Registered Domestic Partner Information

List eligible family members you wish to cover or disenroll. Family members cannot be enrolled in two PEBB medical or dental accounts at the same time.

Relationship to subscriber: (If adding a Washington State-registered domestic partner, please attach a completed Declaration of Tax Status form.) Spouse: date of marriage___________________________ Social security number Last name Domestic partner: date qualified or registered _______________________ First name Middle initial City Sex Date of birth (mm/dd/yyyy) M F State ZIP Code

Street address (if different from subscriber)

Apt./unit number

Select coverage to continue: Disenroll

Medical and dental

Medical only

Dental only Disenrollment date ______________________

Reason __________________________________________________________

If enrolled in Medicare Part(s) A and/or B, attach a copy of the Medicare card to this form.

Visit our website at www.pebb.hca.wa.gov

HCA 50-135F (10/11)

(continued)

27

2012 LWOP Continuation Coverage Election

Subscriber's last name First name

(continued) Middle initial Social security number

Section 3: Family Member Information (Such as child, etc.) Use additional forms for more members.

List eligible family members you wish to cover or disenroll. Family members cannot be enrolled in two PEBB medical or dental accounts at the same time.

A

Relationship to subscriber

Social security number First name

Disabled?(Check only if age 26 or older.) Yes No Middle initial

Sex M F Date of birth (mm/dd/yyyy) State ZIP Code

Last name Street address (if different from subscriber) Select coverage to continue: Disenroll Medical and dental

Apt./unit number City Medical only Dental only

Reason ____________________________________________________________ Social security number First name Apt./unit number City Medical only Dental only

Date of event ________________________ Sex M F Date of birth (mm/dd/yyyy) State ZIP Code

If enrolled in Medicare Part(s) A and/or B, attach a copy of the Medicare card to this form.

B

Relationship to subscriber

Disabled?(Check only if age 26 or older.) Yes No Middle initial

Last name Street address (if different from subscriber) Select coverage to continue: Disenroll Medical and dental

Reason _____________________________________________________________

Date of event ________________________

If enrolled in Medicare Part(s) A and/or B, attach a copy of the Medicare card to this form.

Section 4: Changes

Are you making changes to an existing account? Yes No If no, go to Section 5. If yes, what changes? (Check all that apply in the sections below.) Changes you can make anytime Give date of event/change ____________________ Name change Address change Disenroll from medical coverage Disenroll from dental coverage Disenroll dependent(s). If disenrolling due to loss of eligibility (divorce, legal separation documented by a court order, dissolution of domestic partnership, death, or other loss of eligibility under PEBB rules), you must submit this form no later than 60 days after the event. If applicable, provide dependent's new address: _____________________________________________________________________________________

Additional changes you can make during annual open enrollment All changes become effective January 1 of the following year. Check the box(es) next to the change requested. Add dependent(s) Change medical plan Change dental plan Additional changes you can make if a qualifying event occurs (special open enrollment) The PEBB Program will only allow changes outside of an annual open enrollment when allowed under PEBB rules (see WACs 182-12-262 and 182-08-198). You must submit this form no later than 60 days after the event. However, if adding a newborn or newly adopted child, and adding the child increases your premium, you must submit this form no later than 12 months after the birth or adoption. You must provide proof of the event that created the special open enrollment. Check the box(es) next to the change requested, and indicate the event(s) below. Give date of event __________________ Add dependent(s) Change medical plan Change dental plan Other--explain: ___________________________________ New spouse, Washington State-registered domestic partner, or child added to family due to marriage, Washington State-registered domestic partnership, birth, adoption, court order, or medical support order. Child becoming eligible as an extended dependent through legal custody or legal guardianship. Also complete Extended Dependent Certification form. Form available at www.pebb.hca.wa.gov. Child becoming eligible as a dependent with a disability. Also complete Certification of Dependents With Disabilities form. Form available at www.pebb.hca.wa.gov. Dependent losing other coverage under a group health plan or through health insurance, as defined by the Health Insurance Portability and Accountability Act (HIPAA). Dependent having a change in employment status that affects the dependent's eligibility for the employer contribution toward group health coverage. Dependent becoming eligible or losing eligibility for premium assistance through Medicaid or a state Children's Health Insurance Program (CHIP). The following events also allow a health plan change: Subscriber or dependent having a change in residence that affects health plan availability. Subscriber or dependent becomes entitled to Medicare, or enrolls in or disenrolls from a Medicare Part D plan. Subscriber or dependent's current health plan becoming unavailable because the subscriber or dependent is no longer eligible for a health savings account (HSA). Are you or any eligible dependents enrolled in PEBB coverage under another account? Yes No

28

2012 LWOP Continuation Coverage Election

Subscriber's last name First name

(continued) Middle initial Social security number

Section 5: Medical Plan Selection

Check only one.

Section 6: Dental Plan Selection

Check only one.

Group Health Cooperative Group Health Classic Group Health Consumer-Directed Health Plan Group Health Value Kaiser Foundation Health Plan of the Northwest Kaiser Permanente Classic Kaiser Permanente Consumer-Directed Health Plan Uniform Medical Plan, administered by Regence BlueShield of Washington UMP Classic UMP Consumer-Directed Health Plan

Preferred Provider Organization Uniform Dental Plan, administered by Washington Dental Service (Group #3000), (may receive services from any provider) Managed-Care Plans DeltaCare, administered by Washington Dental Service (Group #3100) Dentist name or clinic code ________________________________ (must receive services from a DeltaCare provider) Willamette Dental of Washington, Inc. Clinic location ___________________________________________ (must receive services from a Willamette Dental Group provider)

Contact plans for benefits information; their contact information is shown at the end of this form.

Section 7: Life and Accidental Death & Dismemberment (AD&D) Insurance

Current Enrollment With Agency Basic Employee Life and AD&D ($4.08/month) Supplemental Employee Life Basic Spouse/Washington State-Registered Domestic Partner Life Basic Children Life Supplemental Spouse/Washington State-Registered Domestic Partner Life Supplemental Employee AD&D Include Supplemental AD&D for dependents Do not include Supplemental AD&D for dependents Desired Enrollment While Self-Paying I wish to maintain the same coverage I had as an active employee. _____________ (initials) I do not wish to continue the life coverage while eligible for self-pay; I understand that I must reapply and submit evidence of insurability to reinstate optional life insurance when I return to work. _____________ (initials) Coverage Amount $ 25,000 Life / $ 5,000 AD&D $ ____________________ $ 2,500 $ 2,500 per child $ ____________________ $ ____________________

Section 8: Long-Term Disability

This section applies ONLY to employees on educational leave or called to active duty in the uniformed services as defined under the Uniformed Services Employment and Reemployment Rights Act (USERRA). Current Enrollment With Agency Basic ($2.00/month) 30­Day 60­Day Desired Enrollment While Self-Paying I wish to maintain the same coverage I had as an active employee. _____________ (initials) I do not wish to maintain the same coverage I had as an active employee. ______________ (initials) 90­Day 120­Day 180­Day 240­Day 300­Day 360­Day

Please sign and date this form on the next page.

29

2012 LWOP Continuation Coverage Election

Subscriber's last name First name

(continued) Middle initial Social security number

Section 9: Signature

Required

I have received and read the Continuation of Coverage Election Notice including any appendices. By signing this form, I declare that the information I have provided is true, complete, and correct. If it isn't, or if I do not update this information within the timelines in PEBB rules, to the extent permitted by federal and state law, I must repay any claims paid by my health plan(s). My family members and I may also lose PEBB benefits as of the last day of the month we were eligible. To the extent permitted by law, PEBB may retroactively terminate coverage for me and my dependents if I intentionally misrepresent eligibility, or do not fully pay premiums when due. In addition, I understand that knowingly providing false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company is a crime, and can result in imprisonment, fines, and denial of PEBB benefits. If adding a domestic partner to my account, I declare that my partner and I have registered through the Washington Secretary of State's Office. If I send payment, this does not mean that I will be automatically enrolled in PEBB insurance coverage. The PEBB Program will verify eligibility for me and my family members. If we do not qualify, I will receive a refund. If I am enrolling in a consumer-directed health plan with a health savings account (HSA), I must meet HSA eligibility conditions. I understand that the PEBB Program will direct a portion of my monthly premium to an HSA on my behalf based on the information I have provided, and that there are limits to these contributions and my HSA contributions (if any) under federal tax law. This form replaces all Leave Without Pay Continuation Coverage Election forms I have previously submitted to PEBB. HCA's Privacy Notice: We will keep your information private as allowed by law. To receive our Privacy Notice, call 360-923-2822 (effective January 1, 2012, call 360-725-0442) or go to www.hca.wa.gov. Subscriber's signature _________________________________________________________ Date ________________________________

Please sign and date this form.

Washington State Health Care Authority, P.O. Box 42684, Olympia, WA 98504-2684

Return to:

Washington State Health Care Authority, P.O. Box 42695, Olympia, WA 98504-2695

If payment is enclosed, return to:

2012 PEBB MEDICAL CONTRACTORS

Group Health Cooperative, 320 Westlake Ave. N, Suite 100, Seattle, WA 98109-5233 1-888-901-4636 or TTY 1-800-833-6388 Kaiser Foundation Health Plan of the Northwest, 500 NE Multnomah St., Suite 100, Portland, OR 97232-2099 1-800-813-2000 or TTY 1-800-735-2900 Uniform Medical Plan, administered by Regence BlueShield of Washington, P.O. Box 91015, MS BU248, Seattle, WA 98111-9115 1-888-849-3681 or TTY 711

2012 PEBB DENTAL CONTRACTORS

DeltaCare, administered by Washington Dental Service, 9706 Fourth Avenue NE, Seattle, WA 98115-2157 1-800-650-1583 Uniform Dental Plan, administered by Washington Dental Service, 9706 Fourth Avenue NE, Seattle, WA 98115-2157 1-800-537-3406 Willamette Dental of Washington, Inc., 6950 NE Campus Way, Hillsboro, OR 97124-5611 1-855-433-6825

2012 PEBB LIFE INSURANCE CONTRACTOR

ReliaStar Life Insurance Company, P.O. Box 20, Route 7325, Minneapolis, MN 55440-0020 1-866-689-6990

2012 PEBB LONG TERM DISABILITY INSURANCE CONTRACTOR

Standard Insurance Company, Attn: Medical Underwriting Department, 900 SW 5th, Portland, OR 97204-1282 1-800-399-7271

30

2012 PEBB COBRA, Leave Without Pay, and Extension of Coverage Monthly Rates

Effective January 1, 2012 Special Requirements 1. To qualify for the Medicare rate, at least one covered family member must be enrolled in both Part A and Part B of Medicare. (Medicare rates are not available to Leave Without Pay members.) 2. Medicare-enrolled subscribers in Group Health Cooperative's Medicare Advantage plan or Kaiser Permanente Senior Advantage must complete and sign the Medicare Advantage Plan Election Form to enroll in one of these plans. For more information on these requirements, please contact your health plan's customer service department.

Medical Plans

Membersnoteligible forMedicare (or

enrolled in Part A only): Group Health Classic $ 550.48 1,095.43 959.19 1,504.14 Group Health Value $ 501.58 997.63 873.62 1,369.67 Group Health CDHP $ 482.92 957.35 853.32 1,269.42 Kaiser Permanente Classic $ 538.18 1,070.83 937.67 1,470.32 GroupHealth Value N/A $ 754.24 N/A 630.23 N/A 1,126.28 882.89 N/A Kaiser Permanente CDHP $ 481.27 953.55 850.06 1,264.01 UMP Classic $ 531.11 1,056.69 925.30 1,450.88 UMP CDHP $ 485.22 961.45 856.97 1,274.87

SubscriberOnly Subscriber&Spouse* Subscriber&Child(ren) FullFamily Members enrolled in Part A & Part B of Medicare: SubscriberOnly Subscriber&Spouse* (1Medicareeligible) Subscriber&Spouse* (2Medicareeligible) Subscriber&Child(ren) (1Medicareeligible) Subscriber&Child(ren) (2Medicareeligible) FullFamily (1Medicareeligible) FullFamily (2Medicareeligible) FullFamily (3Medicareeligible)

GroupHealth MedicarePlan $258.19 N/A 510.85 N/A 510.85 N/A N/A 763.51

GroupHealth Classic N/A $ 803.14 N/A 666.90 N/A 1,211.85 919.56 N/A

Kaiser Permanente Classic $ 292.94 825.59 580.35 692.43 580.35 1,225.08 979.84 867.76

UMPClassic $ 363.87 889.45 722.21 758.06 722.21 1,283.64 1,116.40 1,080.55

(continued) *orqualified/WashingtonState-registereddomesticpartner IfaGroupHealthsubscriberisenrolledinMedicarePartAandPartBbutcoversafamilymembernoteligiblefor Medicare,thefamilymembermustenrollinaGroupHealthClassicorValueplanandthesubscriberpaysacombined Medicareandnon-Medicarerate.

31

HCA 50-300R (9/11)

For rate information, contact the Health Care Authority at 1-800-200-1004.

Medicare Supplement Plans

Premera Blue Cross

Plan F

(age 65 or older, eligible by age)

Plan F

(under age 65, eligible by disability)

SubscriberOnly Subscriber&Spouse* (1Medicareeligible)** Subscriber&Spouse* (2Medicareeligible-1retired,1disabled) Subscriber&Spouse* (2Medicareeligible) Subscriber&Child(ren) (1Medicareeligible)** FullFamily (1Medicareeligible)** FullFamily (2Medicareeligible-1retired,1disabled)** FullFamily (2Medicareeligible)** *orqualified/WashingtonState-registereddomesticpartner

$ 188.48

$ 320.40

719.59 508.88 376.96 588.20 1,113.78 908.60 776.68

851.51 508.88 640.80 720.12 1,245.70 908.60 1,040.52

**IfaMedicaresupplementplanisselected,non-MedicareeligibledependentsareenrolledinUniformMedicalPlan (UMP)Classic.Theratesshownreflectthetotaldue,includingpremiumsforbothplans.

Dental Plans

with Medical Plan

SubscriberOnly Subscriber& Spouse* Subscriber& Child(ren) FullFamily

DeltaCare, administered by Washington Dental Service

Uniform Dental Plan, administered by Washington Dental Service

Willamette Dental

Dental Plans

Dental Only

DeltaCare, administered by Washington Dental Service

Uniform Dental Plan, administered by Washington Dental Service

Willamette Dental

$ 39.53

$ 45.20

$ 42.68

SubscriberOnly Subscriber& Spouse* Subscriber& Child(ren) FullFamily

$ 45.06

$ 50.73

$ 48.21

79.06 79.06 118.59

90.40 90.40 135.60

85.36 85.36 128.04

84.59 84.59 124.12

95.93 95.93 141.13

90.89 90.89 133.57

*orqualified/WashingtonState-registereddomesticpartner

32

P.O. Box 42684 Olympia, WA 98504

HCA 50-801 (12/11)

READ NOW

You have 60 days after the postmark to elect to continue your PEBB health coverage.

Information

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