Region 3 – 2017 COBRA Health Rates

Monthly Premiums

Plan Option*EmployeeFamilyEmployee + SpouseEmployee + Child(ren)
Plan 1$686$2264$1372$1165
Plan 2$618$2037$1235$1049
Plan 3$487$1607$975$828
Plan 4$473$1559$944$802
* To determine the deductible amounts, out-of-pocket maximums, and coinsurance percentages for each plan option, please consult the detailed chart below.

Rates effective for rate region 3.

PlanPlan 1Plan 2* Plan 3Plan 4
Medical Deductible
Individual
$500$1000$2600$3500
Medical Deductible
Family
$1000$2000$5200$7000
Member Cost Share
(Co-Insurance) for Covered
Medical Expenses After Deductible
10% In-Network
30% Non-Network
15% In-Network
30% Non-Network
20% In-Network
30% Non-Network
20% In-Network
50% Non-Network
Medical Out-of-Pocket Maximum
Individual
$1500$3000$5100$6000
Medical Out-of-Pocket Maximum
Family
$3000$6000$10200$12000
Rx Out-of-Pocket Maximum
Individual
$1000$1000Applied to Medical Deductible;
then Plan pays 100%
$500
Rx Out-of-Pocket Maximum
Family
$2000$2000Applied to Medical Deductible;
then Plan pays 100%
$1000
Total Plan
Out-of-Pocket Maximum
Individual
$2500$4000$5100$6500
Total Plan
Out-of-Pocket Maximum
Family
$5000$8000$10200$13000

* Plan 3 is a Health Savings Account (HSA)-compliant high deductible health plan (HDHP). Benefits and coverage under plan 3 may be different from other plan options. Please consult the Plan 3 Summary Plan Description for additional details or contact the Benefit Plans Office.