Plan

Total   Monthly Benefit Costs

CityCore Medical & VSP Vision

$766.99

$1,444.16

$2,049.57

CityCore Medical & VSP Buy up

$774.91

$1,458.57

$2,068.78

CityHD Medical & VSP Vision

$604.38

$1,127.09

$1,594.27

CityHD Medical & VSP Buy up

$612.30

$1,141.50

$1,613.48

Kaiser NW Medical & Vision

$753.60

$1,418.56

$2,013.52

Delta Core Dental Plan

$61.25

$105.78

$187.94

Delta Buy-up Dental Plan

$78.52

$137.42

$223.79

Kaiser NW Dental

$74.88

$149.74

$224.62

Kaiser NW Medicare Senior Advantage Plan

  One-party   $357.54
  Two-party   $661.44

Retiree Medicare (Sr. Advantage)  & Spouse/Domestic Partner 
(Kaiser Medical)

  Two-party   $ TBD

Retiree (Kaiser Medical)  & Spouse/Domestic Partner Medicare (Sr. Advantage)

  Two-party   $ TBD

Employee Assistance Program (EAP)

$4.50 per month (same for all tiers)

$5.55 per month (for PFFA  retirees, same for all tiers)

Plan

Total Monthly Benefit Costs

One Party

Family

CityNet Medical & VSP Vision

$683.37

$1,323.15

$1,770.45

CityNet Medical & VSP Buy up

$693.59

$1,341.71

$1,795.20

CityHD Medical & VSP Vision

$511.15

$975.74

$1,300.58

CityHD Medical & VSP Buy up

$521.37

$994.30

$1,325.33

Kaiser NW Medical & Vision

$592.84

$1,132.02

$1,671.22

Delta Core Dental Plan

$57.42

$99.20

$176.23

Delta Buy-up Dental Plan

$66.30

$114.57

$203.55

Kaiser NW Dental

$63.70

$127.36

$191.06

Kaiser NW Medicare Senior Advantage Plan

  One-party   $357.54 
  Two-party   $661.44

Retiree Medicare (Sr. Advantage)& Spouse/Domestic Partner 
(Kaiser Medical)

  Two-party   $ TBD

Retiree (Kaiser Medical)  & Spouse/Dependent Medicare
(Sr. Advantage)

  Two-party   $ TBD

Employee Assistance Program (EAP)

$5.55 per month (same for all tiers)

Plan

CityBasic   Retiree Total Monthly Benefit Costs

One Party

Two Party

Family

CityBasic Medical & VSP Vision

$551.83

$1,024.60

$1,447.11

CityBasic Dental Plan

$45.24

$78.11

$138.77