Please read this information carefully and contact us at if you have any questions.

Transcription

1 PO Box 1090 Great Bend, KS Fax: (620) Questions? Call Preguntas? Teléfono November 2018 IMPORTANT NOTICE Re: - Premium Rate Change - Eligibility Verification Form Due December 15, How to Renew or Enroll in New Coverage for 2019 Your Current Plan is: Dear «First», «Plan» This letter contains important information about your premium rate change effective January 1, 2019 and Eligibility Verification Form that must be returned to us by December 15 to renew WSHIP coverage. We have also included information about how to buy new coverage from the Washington Healthplanfinder or directly from an insurance company. You cannot be turned down or charged more due to pre-existing conditions, and premiums may be less than WSHIP. Your savings may be even greater if you qualify for federal tax credits for coverage purchased from the Washington Healthplanfinder. Please read this information carefully and contact us at if you have any questions WSHIP Premium Rates Your WSHIP monthly premium rate will be changing effective January 1, The following is important information about our 2019 rates: All rates have been calculated in accordance with Washington State law (RCW ). Rates for WSHIP Preferred Provider Plans continue to be set as low as the law will allow. Rates are segmented into nine geographic regions within the State of Washington. Please consult the enclosed rate chart to locate the rates for WSHIP plans available in Your rate will be based on plan selection, geographic location, age, and tobacco-use status. Eligibility Verification Form Due December 15, 2018 WSHIP is required to verify continued eligibility of all enrollees. This eligibility verification requirement is combined with our yearly rate notice to simplify the process of returning this information to us. Please return the enclosed purple form by December 15. Page 1 of 3

2 [Type here] How to Renew or Buy New Coverage for 2019 You have the option to renew your current WSHIP plan, change to a new WSHIP plan (some restrictions apply) or buy new coverage from the Washington Healthplanfinder or private market. In making your choice, please consider the following information: WSHIP premiums are higher o o By law, WSHIP premiums are generally higher than premiums in the market so we encourage you to explore all of your coverage options. You can t be turned down or charged more because you have a pre-existing condition. Your savings may be even greater if you qualify for federal tax credits available for coverage purchased through the Washington Healthplanfinder. December 15 is the deadline for January 1, 2019 coverage o o You must renew or enroll in new coverage by December 15 for a January 1 effective date. Open enrollment for the Washington Healthplanfinder or when buying from an insurance company begins November 1. If you cancel your WSHIP coverage or it is terminated, you may not be able to re-enroll in WSHIP o You can only re-enroll in WSHIP if an individual health plan is not offered in your county during defined open enrollment or special enrollment periods or you become eligible for WSHIP s Medicare plan. Generally, you must also wait until 12 months have elapsed since your WSHIP termination to re-enroll. Check to see if you are eligible for Medicaid (also called Apple Health ) o o o Medicaid is the joint state-federal government health insurance program for lower-income individuals. It was expanded in our state as part of the Affordable Care Act. If you are eligible for Medicaid, you are no longer eligible for WSHIP coverage. To avoid a retroactive cancellation of your WSHIP coverage, please be sure to check your eligibility for Medicaid if you think you may qualify. There is no open enrollment period for Medicaid, so you can apply throughout the year. You can submit a single application through Washington Healthplanfinder to find out if you are eligible for Medicaid or federal tax credits. For more information about Medicaid, please visit or Page 2 of 3

3 [Type here] Steps for Renewing, Changing, or Buying New Coverage For 2019 Step 1 Step 2 Step 3 Step 4 Review the enclosed WSHIP 2019 Monthly Premium Rates. Find out if you are eligible for Medicaid or federal tax credits for plans offered through Washington Healthplanfinder. Call or visit Compare your options. Compare your WSHIP coverage and premium to coverage options available through Washington Healthplanfinder or directly from insurance companies. When comparing plans, be sure to also look at their provider network and prescription drug formulary. Out-of-pocket costs can be substantially higher if you use out-of-network providers or non-formulary prescription drugs. If you have questions, please contact your insurance agent or broker, or call the Washington Healthplanfinder at or WSHIP Customer Service at To renew WSHIP coverage or change WSHIP plans: 1. Fill out and return the enclosed (purple) Eligibility Verification Form by December If you want to change to a different WSHIP plan, also fill out and return the enclosed (pink) Plan Change Form by December 15. OR To cancel your WSHIP coverage and buy new coverage: Please use the enclosed postage-paid return envelope to let us know you are cancelling your WSHIP coverage. If we do not receive notice of cancellation, your coverage will be renewed pending receipt of your Eligibility Verification Form. Questions? If you have questions or need assistance during this year s WSHIP open enrollment, please call WSHIP Customer Service at or visit our website at Information for Washington Healthplanfinder is available at or by calling Enclosures: 2019 WSHIP Premium Rates Eligibility Verification Form (Purple Paper) RETURN by December 15 Plan Change Form (Pink Paper) RETURN by December 15 along with your Eligibility Verification Form if you would like to change WSHIP plans. This form may also be used to report any changes to your address or telephone number; simply draw a line through any incorrect information and write the correct information next to it. Personalized Schedule of Benefits 2019 Benefit Plans Summary and Comparison Chart Return Envelope IMPORTANT REMINDERS! December 15 is the deadline to return WSHIP Eligibility Verification Form and Plan Change Form. Page 3 of 3

4 2019 Monthly Premium Rates PREFERRED PROVIDER PLANS (PPO Plans) Area 1: King County Non-Smoker Rates Smoker Rates Age $500 $1,000 $2,500 $5,000 $3,000 $500 $1,000 $2,500 $5,000 $ $864 $768 $436 $373 $394 $864 $768 $436 $373 $ $941 $836 $475 $406 $429 $941 $836 $475 $406 $ $970 $862 $490 $419 $442 $970 $862 $490 $419 $ $999 $888 $504 $432 $456 $999 $888 $504 $432 $ $1,031 $916 $520 $445 $470 $1,031 $916 $520 $445 $ $1,062 $944 $536 $459 $484 $1,062 $944 $536 $459 $ $1,095 $973 $553 $473 $499 $1,095 $973 $553 $473 $ $1,129 $1,003 $570 $488 $515 $1,278 $1,136 $645 $553 $ $1,129 $1,003 $570 $488 $515 $1,278 $1,136 $645 $553 $ $1,129 $1,003 $570 $488 $515 $1,278 $1,136 $645 $553 $ $1,129 $1,003 $570 $488 $515 $1,278 $1,136 $645 $553 $ $1,134 $1,007 $572 $490 $517 $1,284 $1,140 $648 $555 $ $1,156 $1,028 $584 $500 $527 $1,309 $1,164 $661 $566 $ $1,183 $1,052 $597 $511 $539 $1,340 $1,191 $676 $579 $ $1,227 $1,091 $620 $530 $560 $1,389 $1,235 $702 $600 $ $1,263 $1,123 $638 $546 $576 $1,430 $1,272 $722 $618 $ $1,282 $1,139 $647 $554 $584 $1,452 $1,290 $733 $627 $ $1,309 $1,163 $661 $565 $597 $1,482 $1,317 $748 $640 $ $1,336 $1,187 $674 $577 $609 $1,513 $1,344 $763 $653 $ $1,353 $1,202 $683 $584 $617 $1,532 $1,361 $773 $661 $ $1,371 $1,218 $692 $592 $625 $1,552 $1,379 $784 $670 $ $1,380 $1,226 $697 $596 $629 $1,563 $1,388 $789 $675 $ $1,389 $1,234 $701 $600 $633 $1,573 $1,397 $794 $679 $ $1,398 $1,242 $706 $604 $637 $1,583 $1,406 $799 $684 $ $1,407 $1,250 $710 $608 $641 $1,593 $1,415 $804 $688 $ $1,425 $1,266 $719 $616 $650 $1,614 $1,434 $814 $698 $ $1,443 $1,282 $729 $623 $658 $1,634 $1,452 $825 $705 $ $1,470 $1,307 $742 $635 $670 $1,665 $1,480 $840 $719 $ $1,496 $1,330 $755 $646 $682 $1,694 $1,506 $855 $731 $ $1,532 $1,362 $774 $662 $699 $1,735 $1,542 $876 $750 $ $1,577 $1,402 $796 $682 $719 $1,786 $1,588 $901 $772 $ $1,630 $1,449 $823 $704 $743 $1,846 $1,641 $932 $797 $ $1,694 $1,505 $855 $732 $772 $1,918 $1,704 $968 $829 $ $1,765 $1,568 $891 $763 $805 $1,999 $1,776 $1,009 $864 $ $1,846 $1,641 $932 $798 $842 $2,090 $1,858 $1,055 $904 $ $1,926 $1,712 $972 $832 $878 $2,181 $1,939 $1,101 $942 $ $2,017 $1,792 $1,018 $871 $919 $2,284 $2,029 $1,153 $986 $1, $2,106 $1,871 $1,063 $910 $960 $2,385 $2,119 $1,204 $1,030 $1, $2,204 $1,959 $1,113 $952 $1,005 $2,496 $2,218 $1,260 $1,078 $1, $2,303 $2,047 $1,163 $995 $1,050 $2,608 $2,318 $1,317 $1,127 $1, $2,411 $2,142 $1,217 $1,042 $1,099 $2,730 $2,425 $1,378 $1,180 $1, $2,518 $2,238 $1,271 $1,088 $1,148 $2,851 $2,534 $1,439 $1,232 $1, $2,634 $2,341 $1,330 $1,138 $1,201 $2,983 $2,651 $1,506 $1,289 $1, $2,752 $2,445 $1,389 $1,189 $1,254 $3,116 $2,769 $1,573 $1,346 $1, $2,877 $2,557 $1,452 $1,243 $1,312 $3,258 $2,895 $1,644 $1,408 $1, $2,939 $2,612 $1,484 $1,270 $1,340 $3,328 $2,958 $1,680 $1,438 $1, $3,064 $2,723 $1,547 $1,324 $1,397 $3,470 $3,083 $1,752 $1,499 $1, $3,173 $2,820 $1,602 $1,371 $1,446 $3,593 $3,193 $1,814 $1,552 $1, $3,244 $2,883 $1,638 $1,402 $1,479 $3,673 $3,265 $1,855 $1,588 $1, $3,333 $2,962 $1,683 $1,440 $1,520 $3,774 $3,354 $1,906 $1,631 $1, $3,387 $3,010 $1,710 $1,464 $1,544 $3,835 $3,408 $1,936 $1,658 $1, $3,387 $3,010 $1,710 $1,464 $1,544 $3,835 $3,408 $1,936 $1,658 $1,748

5 Area 2: 2019 Monthly Premium Rates PREFERRED PROVIDER PLANS (PPO Plans) Clallam, Cowlitz, Grays Harbor, Jefferson, Kitsap, Lewis, Pacific, and Wahkiakum Counties Non-Smoker Rates Smoker Rates Age $500 $1,000 $2,500 $5,000 $3,000 $500 $1,000 $2,500 $5,000 $ $916 $814 $462 $396 $418 $916 $814 $462 $396 $ $998 $887 $504 $431 $455 $998 $887 $504 $431 $ $1,029 $914 $520 $444 $469 $1,029 $914 $520 $444 $ $1,059 $942 $534 $458 $484 $1,059 $942 $534 $458 $ $1,093 $971 $551 $472 $498 $1,093 $971 $551 $472 $ $1,126 $1,001 $568 $487 $513 $1,126 $1,001 $568 $487 $ $1,161 $1,032 $586 $502 $529 $1,161 $1,032 $586 $502 $ $1,197 $1,064 $604 $518 $546 $1,355 $1,205 $684 $587 $ $1,197 $1,064 $604 $518 $546 $1,355 $1,205 $684 $587 $ $1,197 $1,064 $604 $518 $546 $1,355 $1,205 $684 $587 $ $1,197 $1,064 $604 $518 $546 $1,355 $1,205 $684 $587 $ $1,203 $1,068 $607 $520 $548 $1,362 $1,209 $687 $589 $ $1,226 $1,090 $619 $530 $559 $1,388 $1,234 $701 $600 $ $1,255 $1,116 $633 $542 $572 $1,421 $1,264 $717 $614 $ $1,301 $1,157 $657 $562 $594 $1,473 $1,310 $744 $636 $ $1,339 $1,191 $677 $579 $611 $1,516 $1,349 $767 $656 $ $1,360 $1,208 $686 $588 $619 $1,540 $1,368 $777 $666 $ $1,388 $1,233 $701 $599 $633 $1,572 $1,396 $794 $678 $ $1,417 $1,259 $715 $612 $646 $1,605 $1,426 $810 $693 $ $1,435 $1,275 $724 $619 $654 $1,625 $1,444 $820 $701 $ $1,454 $1,292 $734 $628 $663 $1,646 $1,463 $831 $711 $ $1,463 $1,300 $739 $632 $667 $1,657 $1,472 $837 $716 $ $1,473 $1,309 $743 $636 $671 $1,668 $1,482 $841 $720 $ $1,483 $1,317 $749 $641 $676 $1,679 $1,491 $848 $726 $ $1,492 $1,326 $753 $645 $680 $1,689 $1,501 $853 $730 $ $1,511 $1,343 $762 $653 $689 $1,711 $1,521 $863 $739 $ $1,530 $1,360 $773 $661 $698 $1,732 $1,540 $875 $748 $ $1,559 $1,386 $787 $673 $711 $1,765 $1,569 $891 $762 $ $1,586 $1,410 $801 $685 $723 $1,796 $1,597 $907 $776 $ $1,625 $1,444 $821 $702 $741 $1,840 $1,635 $930 $795 $ $1,672 $1,487 $844 $723 $762 $1,893 $1,684 $956 $819 $ $1,729 $1,537 $873 $747 $788 $1,958 $1,740 $989 $846 $ $1,796 $1,596 $907 $776 $819 $2,034 $1,807 $1,027 $879 $ $1,872 $1,663 $945 $809 $854 $2,120 $1,883 $1,070 $916 $ $1,958 $1,740 $988 $846 $893 $2,217 $1,970 $1,119 $958 $1, $2,042 $1,816 $1,031 $882 $931 $2,312 $2,056 $1,167 $999 $1, $2,139 $1,900 $1,080 $924 $975 $2,422 $2,151 $1,223 $1,046 $1, $2,233 $1,984 $1,127 $965 $1,018 $2,529 $2,247 $1,276 $1,093 $1, $2,337 $2,077 $1,180 $1,010 $1,066 $2,646 $2,352 $1,336 $1,144 $1, $2,442 $2,171 $1,233 $1,055 $1,114 $2,765 $2,458 $1,396 $1,195 $1, $2,557 $2,272 $1,291 $1,105 $1,165 $2,895 $2,573 $1,462 $1,251 $1, $2,670 $2,373 $1,348 $1,154 $1,217 $3,023 $2,687 $1,526 $1,307 $1, $2,793 $2,483 $1,410 $1,207 $1,274 $3,163 $2,812 $1,597 $1,367 $1, $2,918 $2,593 $1,473 $1,261 $1,330 $3,304 $2,936 $1,668 $1,428 $1, $3,051 $2,712 $1,540 $1,318 $1,391 $3,455 $3,071 $1,744 $1,492 $1, $3,117 $2,770 $1,574 $1,347 $1,421 $3,530 $3,137 $1,782 $1,525 $1, $3,249 $2,888 $1,641 $1,404 $1,481 $3,679 $3,270 $1,858 $1,590 $1, $3,365 $2,991 $1,699 $1,454 $1,533 $3,810 $3,387 $1,924 $1,646 $1, $3,440 $3,057 $1,737 $1,487 $1,568 $3,895 $3,462 $1,967 $1,684 $1, $3,535 $3,141 $1,785 $1,527 $1,612 $4,003 $3,557 $2,021 $1,729 $1, $3,592 $3,192 $1,813 $1,553 $1,637 $4,067 $3,614 $2,053 $1,759 $1, $3,592 $3,192 $1,813 $1,553 $1,637 $4,067 $3,614 $2,053 $1,759 $1,854

6 Area 3: 2019 Monthly Premium Rates PREFERRED PROVIDER PLANS (PPO Plans) Clark, Klickitat, Skamania Counties Non-Smoker Rates Smoker Rates Age $500 $1,000 $2,500 $5,000 $3,000 $500 $1,000 $2,500 $5,000 $ $950 $844 $479 $410 $433 $950 $844 $479 $410 $ $1,034 $919 $522 $446 $472 $1,034 $919 $522 $446 $ $1,066 $947 $539 $461 $486 $1,066 $947 $539 $461 $ $1,098 $976 $554 $475 $501 $1,098 $976 $554 $475 $ $1,133 $1,007 $572 $489 $517 $1,133 $1,007 $572 $489 $ $1,167 $1,038 $589 $505 $532 $1,167 $1,038 $589 $505 $ $1,204 $1,069 $608 $520 $548 $1,204 $1,069 $608 $520 $ $1,241 $1,102 $627 $536 $566 $1,405 $1,248 $710 $607 $ $1,241 $1,102 $627 $536 $566 $1,405 $1,248 $710 $607 $ $1,241 $1,102 $627 $536 $566 $1,405 $1,248 $710 $607 $ $1,241 $1,102 $627 $536 $566 $1,405 $1,248 $710 $607 $ $1,246 $1,107 $629 $539 $568 $1,411 $1,254 $712 $610 $ $1,271 $1,130 $642 $550 $579 $1,439 $1,280 $727 $623 $ $1,300 $1,156 $656 $562 $592 $1,472 $1,309 $743 $636 $ $1,349 $1,199 $681 $583 $616 $1,528 $1,358 $771 $660 $ $1,388 $1,234 $701 $600 $633 $1,572 $1,397 $794 $679 $ $1,409 $1,252 $711 $609 $642 $1,595 $1,418 $805 $690 $ $1,439 $1,278 $727 $621 $656 $1,629 $1,447 $823 $703 $ $1,468 $1,305 $741 $634 $669 $1,662 $1,478 $839 $718 $ $1,487 $1,321 $751 $642 $678 $1,684 $1,496 $850 $727 $ $1,507 $1,339 $761 $651 $687 $1,706 $1,516 $862 $737 $ $1,517 $1,348 $766 $655 $691 $1,718 $1,526 $867 $742 $ $1,527 $1,356 $771 $659 $696 $1,729 $1,535 $873 $746 $ $1,537 $1,365 $776 $664 $700 $1,740 $1,546 $879 $752 $ $1,547 $1,374 $780 $668 $705 $1,752 $1,556 $883 $756 $ $1,566 $1,392 $790 $677 $714 $1,773 $1,576 $895 $767 $ $1,586 $1,409 $801 $685 $723 $1,796 $1,595 $907 $776 $ $1,616 $1,437 $816 $698 $736 $1,830 $1,627 $924 $790 $ $1,644 $1,462 $830 $710 $750 $1,862 $1,655 $940 $804 $ $1,684 $1,497 $851 $728 $768 $1,907 $1,695 $964 $824 $ $1,733 $1,541 $875 $750 $790 $1,962 $1,745 $991 $849 $ $1,792 $1,593 $905 $774 $817 $2,029 $1,804 $1,025 $876 $ $1,862 $1,654 $940 $805 $849 $2,108 $1,873 $1,064 $912 $ $1,940 $1,723 $979 $839 $885 $2,197 $1,951 $1,109 $950 $1, $2,029 $1,804 $1,024 $877 $925 $2,298 $2,043 $1,160 $993 $1, $2,117 $1,882 $1,068 $914 $965 $2,397 $2,131 $1,209 $1,035 $1, $2,217 $1,970 $1,119 $957 $1,010 $2,510 $2,231 $1,267 $1,084 $1, $2,315 $2,057 $1,168 $1,000 $1,055 $2,621 $2,329 $1,323 $1,132 $1, $2,423 $2,153 $1,223 $1,046 $1,105 $2,744 $2,438 $1,385 $1,184 $1, $2,531 $2,250 $1,278 $1,094 $1,154 $2,866 $2,548 $1,447 $1,239 $1, $2,650 $2,354 $1,338 $1,145 $1,208 $3,001 $2,666 $1,515 $1,297 $1, $2,768 $2,460 $1,397 $1,196 $1,262 $3,134 $2,786 $1,582 $1,354 $1, $2,895 $2,573 $1,462 $1,251 $1,320 $3,278 $2,914 $1,655 $1,417 $1, $3,025 $2,687 $1,527 $1,307 $1,378 $3,425 $3,043 $1,729 $1,480 $1, $3,162 $2,811 $1,596 $1,366 $1,442 $3,580 $3,183 $1,807 $1,547 $1, $3,230 $2,871 $1,631 $1,396 $1,473 $3,657 $3,251 $1,847 $1,581 $1, $3,368 $2,993 $1,700 $1,455 $1,536 $3,814 $3,389 $1,925 $1,648 $1, $3,488 $3,100 $1,761 $1,507 $1,589 $3,950 $3,510 $1,994 $1,706 $1, $3,566 $3,169 $1,800 $1,541 $1,626 $4,038 $3,588 $2,038 $1,745 $1, $3,663 $3,256 $1,850 $1,583 $1,671 $4,148 $3,687 $2,095 $1,793 $1, $3,723 $3,308 $1,880 $1,609 $1,697 $4,216 $3,746 $2,129 $1,822 $1, $3,723 $3,308 $1,880 $1,609 $1,697 $4,216 $3,746 $2,129 $1,822 $1,922

7 2019 Monthly Premium Rates PREFERRED PROVIDER PLANS (PPO Plans) Area 4: Ferry, Lincoln, Pend Oreille, Spokane, Stevens Counties Non-Smoker Rates Smoker Rates Age $500 $1,000 $2,500 $5,000 $3,000 $500 $1,000 $2,500 $5,000 $ $854 $759 $431 $368 $389 $854 $759 $431 $368 $ $930 $826 $469 $401 $424 $930 $826 $469 $401 $ $958 $852 $484 $414 $437 $958 $852 $484 $414 $ $987 $877 $498 $427 $450 $987 $877 $498 $427 $ $1,019 $905 $514 $440 $464 $1,019 $905 $514 $440 $ $1,049 $933 $530 $453 $478 $1,049 $933 $530 $453 $ $1,082 $961 $546 $467 $493 $1,082 $961 $546 $467 $ $1,115 $991 $563 $482 $509 $1,263 $1,122 $638 $546 $ $1,115 $991 $563 $482 $509 $1,263 $1,122 $638 $546 $ $1,115 $991 $563 $482 $509 $1,263 $1,122 $638 $546 $ $1,115 $991 $563 $482 $509 $1,263 $1,122 $638 $546 $ $1,120 $995 $565 $484 $511 $1,268 $1,127 $640 $548 $ $1,142 $1,016 $577 $494 $521 $1,293 $1,150 $653 $559 $ $1,169 $1,039 $590 $505 $532 $1,324 $1,177 $668 $572 $ $1,212 $1,078 $613 $524 $553 $1,372 $1,221 $694 $593 $ $1,248 $1,109 $630 $539 $569 $1,413 $1,256 $713 $610 $ $1,267 $1,125 $639 $547 $577 $1,435 $1,274 $724 $619 $ $1,293 $1,149 $653 $558 $590 $1,464 $1,301 $739 $632 $ $1,320 $1,173 $666 $570 $602 $1,495 $1,328 $754 $645 $ $1,337 $1,187 $675 $577 $610 $1,514 $1,344 $764 $653 $ $1,354 $1,203 $684 $585 $617 $1,533 $1,362 $775 $662 $ $1,363 $1,211 $689 $589 $621 $1,543 $1,371 $780 $667 $ $1,372 $1,219 $693 $593 $625 $1,554 $1,380 $785 $671 $ $1,381 $1,227 $697 $597 $629 $1,564 $1,389 $789 $676 $ $1,390 $1,235 $701 $601 $633 $1,574 $1,398 $794 $681 $ $1,408 $1,251 $710 $609 $642 $1,594 $1,417 $804 $690 $ $1,426 $1,267 $720 $615 $650 $1,615 $1,435 $815 $696 $ $1,452 $1,291 $733 $627 $662 $1,644 $1,462 $830 $710 $ $1,478 $1,314 $746 $638 $674 $1,674 $1,488 $845 $722 $ $1,513 $1,346 $765 $654 $691 $1,713 $1,524 $866 $741 $ $1,558 $1,385 $786 $674 $710 $1,764 $1,568 $890 $763 $ $1,610 $1,431 $813 $695 $734 $1,823 $1,620 $921 $787 $ $1,674 $1,487 $845 $723 $763 $1,896 $1,684 $957 $819 $ $1,744 $1,549 $880 $754 $795 $1,975 $1,754 $996 $854 $ $1,824 $1,621 $921 $788 $832 $2,065 $1,836 $1,043 $892 $ $1,903 $1,691 $960 $822 $867 $2,155 $1,915 $1,087 $931 $ $1,993 $1,770 $1,006 $860 $908 $2,257 $2,004 $1,139 $974 $1, $2,081 $1,848 $1,050 $899 $948 $2,356 $2,093 $1,189 $1,018 $1, $2,177 $1,935 $1,100 $940 $993 $2,465 $2,191 $1,246 $1,064 $1, $2,275 $2,022 $1,149 $983 $1,037 $2,576 $2,290 $1,301 $1,113 $1, $2,382 $2,116 $1,202 $1,029 $1,086 $2,697 $2,396 $1,361 $1,165 $1, $2,488 $2,211 $1,256 $1,075 $1,134 $2,817 $2,504 $1,422 $1,217 $1, $2,602 $2,313 $1,314 $1,124 $1,186 $2,946 $2,619 $1,488 $1,273 $1, $2,719 $2,415 $1,372 $1,175 $1,239 $3,079 $2,735 $1,554 $1,331 $1, $2,842 $2,526 $1,434 $1,228 $1,296 $3,218 $2,860 $1,624 $1,391 $1, $2,903 $2,580 $1,466 $1,255 $1,324 $3,287 $2,921 $1,660 $1,421 $1, $3,027 $2,690 $1,528 $1,308 $1,380 $3,428 $3,046 $1,730 $1,481 $1, $3,135 $2,786 $1,583 $1,354 $1,429 $3,550 $3,155 $1,793 $1,533 $1, $3,205 $2,848 $1,618 $1,385 $1,461 $3,629 $3,225 $1,832 $1,568 $1, $3,293 $2,926 $1,663 $1,423 $1,502 $3,729 $3,313 $1,883 $1,611 $1, $3,346 $2,974 $1,689 $1,446 $1,525 $3,789 $3,368 $1,913 $1,637 $1, $3,346 $2,974 $1,689 $1,446 $1,525 $3,789 $3,368 $1,913 $1,637 $1,727

8 2019 Monthly Premium Rates PREFERRED PROVIDER PLANS (PPO Plans) Area 5: Mason, Pierce, and Thurston Counties Non-Smoker Rates Smoker Rates Age $500 $1,000 $2,500 $5,000 $3,000 $500 $1,000 $2,500 $5,000 $ $922 $820 $466 $398 $421 $922 $820 $466 $398 $ $1,005 $893 $507 $433 $458 $1,005 $893 $507 $433 $ $1,036 $920 $523 $447 $472 $1,036 $920 $523 $447 $ $1,067 $948 $538 $461 $487 $1,067 $948 $538 $461 $ $1,101 $978 $555 $475 $502 $1,101 $978 $555 $475 $ $1,134 $1,008 $572 $490 $517 $1,134 $1,008 $572 $490 $ $1,169 $1,039 $590 $505 $533 $1,169 $1,039 $590 $505 $ $1,205 $1,071 $609 $521 $550 $1,364 $1,213 $690 $590 $ $1,205 $1,071 $609 $521 $550 $1,364 $1,213 $690 $590 $ $1,205 $1,071 $609 $521 $550 $1,364 $1,213 $690 $590 $ $1,205 $1,071 $609 $521 $550 $1,364 $1,213 $690 $590 $ $1,211 $1,075 $611 $523 $552 $1,371 $1,217 $692 $592 $ $1,234 $1,098 $624 $534 $563 $1,397 $1,243 $707 $605 $ $1,263 $1,123 $637 $546 $575 $1,430 $1,272 $721 $618 $ $1,310 $1,165 $662 $566 $598 $1,483 $1,319 $750 $641 $ $1,349 $1,199 $681 $583 $615 $1,528 $1,358 $771 $660 $ $1,369 $1,216 $691 $592 $624 $1,550 $1,377 $782 $670 $ $1,398 $1,242 $706 $603 $637 $1,583 $1,406 $799 $683 $ $1,426 $1,267 $720 $616 $650 $1,615 $1,435 $815 $698 $ $1,445 $1,283 $729 $624 $659 $1,636 $1,453 $825 $707 $ $1,464 $1,300 $739 $632 $667 $1,658 $1,472 $837 $716 $ $1,473 $1,309 $744 $636 $672 $1,668 $1,482 $842 $720 $ $1,483 $1,318 $748 $641 $676 $1,679 $1,492 $847 $726 $ $1,493 $1,326 $754 $645 $680 $1,691 $1,501 $854 $730 $ $1,502 $1,335 $758 $649 $684 $1,701 $1,512 $858 $735 $ $1,521 $1,352 $768 $658 $694 $1,722 $1,531 $870 $745 $ $1,541 $1,369 $778 $665 $703 $1,745 $1,550 $881 $753 $ $1,570 $1,395 $792 $678 $715 $1,778 $1,580 $897 $768 $ $1,597 $1,420 $806 $690 $728 $1,808 $1,608 $913 $781 $ $1,636 $1,454 $826 $707 $746 $1,853 $1,646 $935 $801 $ $1,684 $1,497 $850 $728 $768 $1,907 $1,695 $962 $824 $ $1,740 $1,547 $879 $752 $793 $1,970 $1,752 $995 $852 $ $1,809 $1,607 $913 $782 $824 $2,048 $1,820 $1,034 $885 $ $1,884 $1,674 $951 $815 $859 $2,133 $1,896 $1,077 $923 $ $1,971 $1,752 $995 $852 $899 $2,232 $1,984 $1,127 $965 $1, $2,056 $1,828 $1,038 $888 $937 $2,328 $2,070 $1,175 $1,006 $1, $2,154 $1,913 $1,087 $930 $981 $2,439 $2,166 $1,231 $1,053 $1, $2,249 $1,998 $1,135 $972 $1,025 $2,547 $2,262 $1,285 $1,101 $1, $2,353 $2,092 $1,188 $1,016 $1,073 $2,664 $2,369 $1,345 $1,150 $1, $2,459 $2,186 $1,242 $1,062 $1,121 $2,784 $2,475 $1,406 $1,203 $1, $2,574 $2,287 $1,299 $1,113 $1,173 $2,915 $2,590 $1,471 $1,260 $1, $2,688 $2,390 $1,357 $1,162 $1,226 $3,044 $2,706 $1,537 $1,316 $1, $2,812 $2,499 $1,420 $1,215 $1,282 $3,184 $2,830 $1,608 $1,376 $1, $2,938 $2,611 $1,483 $1,269 $1,339 $3,327 $2,957 $1,679 $1,437 $1, $3,072 $2,730 $1,550 $1,327 $1,401 $3,479 $3,091 $1,755 $1,503 $1, $3,138 $2,789 $1,584 $1,356 $1,431 $3,553 $3,158 $1,794 $1,535 $1, $3,271 $2,907 $1,652 $1,414 $1,492 $3,704 $3,292 $1,871 $1,601 $1, $3,388 $3,011 $1,710 $1,464 $1,544 $3,836 $3,410 $1,936 $1,658 $1, $3,464 $3,078 $1,749 $1,497 $1,579 $3,922 $3,485 $1,980 $1,695 $1, $3,559 $3,163 $1,797 $1,537 $1,623 $4,030 $3,582 $2,035 $1,740 $1, $3,616 $3,214 $1,826 $1,563 $1,649 $4,095 $3,639 $2,068 $1,770 $1, $3,616 $3,214 $1,826 $1,563 $1,649 $4,095 $3,639 $2,068 $1,770 $1,867

9 2019 Monthly Premium Rates PREFERRED PROVIDER PLANS (PPO Plans) Area 6: Benton, Franklin, Kittitas, and Yakima Counties Non-Smoker Rates Smoker Rates Age $500 $1,000 $2,500 $5,000 $3,000 $500 $1,000 $2,500 $5,000 $ $969 $862 $489 $418 $442 $969 $862 $489 $418 $ $1,056 $938 $533 $455 $481 $1,056 $938 $533 $455 $ $1,088 $967 $550 $470 $496 $1,088 $967 $550 $470 $ $1,121 $996 $565 $485 $512 $1,121 $996 $565 $485 $ $1,157 $1,028 $583 $499 $527 $1,157 $1,028 $583 $499 $ $1,191 $1,059 $601 $515 $543 $1,191 $1,059 $601 $515 $ $1,228 $1,091 $620 $531 $560 $1,228 $1,091 $620 $531 $ $1,266 $1,125 $639 $547 $578 $1,434 $1,274 $724 $619 $ $1,266 $1,125 $639 $547 $578 $1,434 $1,274 $724 $619 $ $1,266 $1,125 $639 $547 $578 $1,434 $1,274 $724 $619 $ $1,266 $1,125 $639 $547 $578 $1,434 $1,274 $724 $619 $ $1,272 $1,130 $642 $550 $580 $1,440 $1,280 $727 $623 $ $1,297 $1,153 $655 $561 $591 $1,469 $1,306 $742 $635 $ $1,327 $1,180 $670 $573 $605 $1,503 $1,336 $759 $649 $ $1,376 $1,224 $695 $595 $628 $1,558 $1,386 $787 $674 $ $1,417 $1,260 $716 $612 $646 $1,605 $1,427 $811 $693 $ $1,438 $1,278 $726 $621 $655 $1,628 $1,447 $822 $703 $ $1,468 $1,305 $741 $634 $670 $1,662 $1,478 $839 $718 $ $1,499 $1,332 $756 $647 $683 $1,697 $1,508 $856 $733 $ $1,518 $1,348 $766 $655 $692 $1,719 $1,526 $867 $742 $ $1,538 $1,366 $776 $664 $701 $1,742 $1,547 $879 $752 $ $1,548 $1,375 $782 $669 $706 $1,753 $1,557 $885 $758 $ $1,558 $1,384 $786 $673 $710 $1,764 $1,567 $890 $762 $ $1,568 $1,393 $792 $678 $715 $1,776 $1,577 $897 $768 $ $1,578 $1,402 $796 $682 $719 $1,787 $1,588 $901 $772 $ $1,598 $1,420 $807 $691 $729 $1,809 $1,608 $914 $782 $ $1,619 $1,438 $818 $699 $738 $1,833 $1,628 $926 $792 $ $1,649 $1,466 $832 $712 $752 $1,867 $1,660 $942 $806 $ $1,678 $1,492 $847 $725 $765 $1,900 $1,689 $959 $821 $ $1,719 $1,528 $868 $743 $784 $1,947 $1,730 $983 $841 $ $1,769 $1,573 $893 $765 $807 $2,003 $1,781 $1,011 $866 $ $1,828 $1,625 $923 $790 $833 $2,070 $1,840 $1,045 $895 $ $1,900 $1,688 $959 $821 $866 $2,151 $1,911 $1,086 $930 $ $1,980 $1,759 $999 $856 $903 $2,242 $1,992 $1,131 $969 $1, $2,071 $1,841 $1,045 $895 $945 $2,345 $2,085 $1,183 $1,013 $1, $2,160 $1,920 $1,090 $933 $985 $2,446 $2,174 $1,234 $1,056 $1, $2,263 $2,010 $1,142 $977 $1,031 $2,563 $2,276 $1,293 $1,106 $1, $2,362 $2,099 $1,192 $1,021 $1,077 $2,675 $2,377 $1,350 $1,156 $1, $2,472 $2,198 $1,249 $1,068 $1,127 $2,799 $2,489 $1,414 $1,209 $1, $2,583 $2,296 $1,305 $1,116 $1,178 $2,925 $2,600 $1,478 $1,264 $1, $2,705 $2,403 $1,365 $1,169 $1,233 $3,063 $2,721 $1,546 $1,324 $1, $2,825 $2,510 $1,426 $1,220 $1,288 $3,199 $2,842 $1,615 $1,381 $1, $2,955 $2,626 $1,492 $1,277 $1,347 $3,346 $2,974 $1,689 $1,446 $1, $3,087 $2,743 $1,558 $1,334 $1,407 $3,496 $3,106 $1,764 $1,511 $1, $3,227 $2,868 $1,629 $1,394 $1,472 $3,654 $3,248 $1,845 $1,578 $1, $3,297 $2,930 $1,665 $1,425 $1,503 $3,733 $3,318 $1,885 $1,614 $1, $3,437 $3,055 $1,735 $1,485 $1,567 $3,892 $3,459 $1,965 $1,682 $1, $3,559 $3,163 $1,797 $1,538 $1,622 $4,030 $3,582 $2,035 $1,742 $1, $3,639 $3,234 $1,837 $1,573 $1,659 $4,121 $3,662 $2,080 $1,781 $1, $3,739 $3,323 $1,888 $1,615 $1,705 $4,234 $3,763 $2,138 $1,829 $1, $3,799 $3,376 $1,918 $1,642 $1,732 $4,302 $3,823 $2,172 $1,859 $1, $3,799 $3,376 $1,918 $1,642 $1,732 $4,302 $3,823 $2,172 $1,859 $1,961

10 2019 Monthly Premium Rates PREFERRED PROVIDER PLANS (PPO Plans) Area 7: Adams, Chelan, Douglas, Grant, and Okanogan Counties Non-Smoker Rates Smoker Rates Age $500 $1,000 $2,500 $5,000 $3,000 $500 $1,000 $2,500 $5,000 $ $871 $774 $440 $376 $397 $871 $774 $440 $376 $ $949 $843 $479 $409 $432 $949 $843 $479 $409 $ $978 $869 $494 $422 $446 $978 $869 $494 $422 $ $1,007 $895 $508 $436 $460 $1,007 $895 $508 $436 $ $1,039 $923 $524 $449 $474 $1,039 $923 $524 $449 $ $1,071 $952 $540 $463 $488 $1,071 $952 $540 $463 $ $1,104 $981 $558 $477 $503 $1,104 $981 $558 $477 $ $1,138 $1,011 $575 $492 $519 $1,289 $1,145 $651 $557 $ $1,138 $1,011 $575 $492 $519 $1,289 $1,145 $651 $557 $ $1,138 $1,011 $575 $492 $519 $1,289 $1,145 $651 $557 $ $1,138 $1,011 $575 $492 $519 $1,289 $1,145 $651 $557 $ $1,143 $1,015 $577 $494 $521 $1,294 $1,149 $653 $559 $ $1,165 $1,036 $589 $504 $531 $1,319 $1,173 $667 $571 $ $1,193 $1,061 $602 $515 $543 $1,351 $1,201 $682 $583 $ $1,237 $1,100 $625 $534 $565 $1,401 $1,246 $708 $605 $ $1,273 $1,132 $643 $550 $581 $1,441 $1,282 $728 $623 $ $1,292 $1,148 $652 $559 $589 $1,463 $1,300 $738 $633 $ $1,320 $1,172 $666 $570 $602 $1,495 $1,327 $754 $645 $ $1,347 $1,197 $679 $582 $614 $1,525 $1,355 $769 $659 $ $1,364 $1,212 $689 $589 $622 $1,545 $1,372 $780 $667 $ $1,382 $1,228 $698 $597 $630 $1,565 $1,391 $790 $676 $ $1,391 $1,236 $703 $601 $634 $1,575 $1,400 $796 $681 $ $1,400 $1,244 $707 $605 $638 $1,585 $1,409 $801 $685 $ $1,409 $1,252 $712 $609 $642 $1,595 $1,418 $806 $690 $ $1,418 $1,260 $716 $613 $646 $1,606 $1,427 $811 $694 $ $1,437 $1,276 $725 $621 $655 $1,627 $1,445 $821 $703 $ $1,455 $1,292 $735 $628 $663 $1,648 $1,463 $832 $711 $ $1,482 $1,318 $748 $640 $675 $1,678 $1,492 $847 $725 $ $1,508 $1,341 $761 $651 $688 $1,708 $1,518 $862 $737 $ $1,544 $1,373 $780 $667 $705 $1,748 $1,555 $883 $755 $ $1,590 $1,413 $802 $688 $725 $1,800 $1,600 $908 $779 $ $1,643 $1,461 $830 $710 $749 $1,860 $1,654 $940 $804 $ $1,708 $1,517 $862 $738 $778 $1,934 $1,718 $976 $836 $ $1,779 $1,581 $898 $769 $812 $2,014 $1,790 $1,017 $871 $ $1,861 $1,654 $940 $805 $849 $2,107 $1,873 $1,064 $912 $ $1,942 $1,726 $980 $839 $885 $2,199 $1,954 $1,110 $950 $1, $2,033 $1,807 $1,026 $878 $926 $2,302 $2,046 $1,162 $994 $1, $2,123 $1,886 $1,072 $917 $968 $2,404 $2,136 $1,214 $1,038 $1, $2,222 $1,975 $1,122 $960 $1,013 $2,516 $2,236 $1,270 $1,087 $1, $2,322 $2,064 $1,172 $1,003 $1,059 $2,629 $2,337 $1,327 $1,136 $1, $2,431 $2,159 $1,227 $1,051 $1,108 $2,753 $2,445 $1,389 $1,190 $1, $2,539 $2,256 $1,281 $1,097 $1,157 $2,875 $2,555 $1,451 $1,242 $1, $2,655 $2,360 $1,341 $1,147 $1,211 $3,006 $2,672 $1,518 $1,299 $1, $2,774 $2,465 $1,400 $1,199 $1,264 $3,141 $2,791 $1,585 $1,358 $1, $2,900 $2,578 $1,464 $1,253 $1,323 $3,284 $2,919 $1,658 $1,419 $1, $2,963 $2,633 $1,496 $1,280 $1,351 $3,355 $2,981 $1,694 $1,449 $1, $3,089 $2,745 $1,560 $1,335 $1,408 $3,498 $3,108 $1,766 $1,512 $1, $3,199 $2,843 $1,615 $1,382 $1,458 $3,622 $3,219 $1,829 $1,565 $1, $3,270 $2,907 $1,651 $1,413 $1,491 $3,703 $3,292 $1,870 $1,600 $1, $3,360 $2,986 $1,697 $1,452 $1,532 $3,805 $3,381 $1,922 $1,644 $1, $3,415 $3,035 $1,724 $1,476 $1,557 $3,867 $3,437 $1,952 $1,671 $1, $3,415 $3,035 $1,724 $1,476 $1,557 $3,867 $3,437 $1,952 $1,671 $1,763

11 2019 Monthly Premium Rates PREFERRED PROVIDER PLANS (PPO Plans) Area 8: Island, San Juan, Skagit, Snohomish, and Whatcom Counties Non-Smoker Rates Smoker Rates Age $500 $1,000 $2,500 $5,000 $3,000 $500 $1,000 $2,500 $5,000 $ $952 $846 $480 $411 $434 $952 $846 $480 $411 $ $1,037 $921 $523 $447 $473 $1,037 $921 $523 $447 $ $1,069 $950 $540 $462 $487 $1,069 $950 $540 $462 $ $1,101 $978 $555 $476 $502 $1,101 $978 $555 $476 $ $1,136 $1,009 $573 $490 $518 $1,136 $1,009 $573 $490 $ $1,170 $1,040 $591 $506 $533 $1,170 $1,040 $591 $506 $ $1,207 $1,072 $609 $521 $550 $1,207 $1,072 $609 $521 $ $1,244 $1,105 $628 $538 $567 $1,409 $1,251 $711 $609 $ $1,244 $1,105 $628 $538 $567 $1,409 $1,251 $711 $609 $ $1,244 $1,105 $628 $538 $567 $1,409 $1,251 $711 $609 $ $1,244 $1,105 $628 $538 $567 $1,409 $1,251 $711 $609 $ $1,249 $1,110 $630 $540 $570 $1,414 $1,257 $713 $611 $ $1,274 $1,133 $643 $551 $581 $1,443 $1,283 $728 $624 $ $1,303 $1,159 $658 $563 $594 $1,475 $1,312 $745 $638 $ $1,352 $1,202 $683 $584 $617 $1,531 $1,361 $773 $661 $ $1,392 $1,237 $703 $602 $635 $1,576 $1,401 $796 $682 $ $1,413 $1,255 $713 $610 $643 $1,600 $1,421 $807 $691 $ $1,442 $1,281 $728 $623 $658 $1,633 $1,451 $824 $705 $ $1,472 $1,308 $743 $636 $671 $1,667 $1,481 $841 $720 $ $1,491 $1,324 $753 $643 $680 $1,688 $1,499 $853 $728 $ $1,511 $1,342 $762 $652 $689 $1,711 $1,520 $863 $738 $ $1,521 $1,351 $768 $657 $693 $1,722 $1,530 $870 $744 $ $1,530 $1,360 $772 $661 $697 $1,732 $1,540 $874 $748 $ $1,540 $1,368 $778 $666 $702 $1,744 $1,549 $881 $754 $ $1,550 $1,377 $782 $670 $706 $1,755 $1,559 $885 $759 $ $1,570 $1,395 $792 $679 $716 $1,778 $1,580 $897 $769 $ $1,590 $1,413 $803 $686 $725 $1,800 $1,600 $909 $777 $ $1,620 $1,440 $818 $700 $738 $1,834 $1,631 $926 $793 $ $1,648 $1,465 $832 $712 $751 $1,866 $1,659 $942 $806 $ $1,688 $1,501 $853 $729 $770 $1,911 $1,700 $966 $825 $ $1,738 $1,545 $877 $751 $792 $1,968 $1,749 $993 $850 $ $1,796 $1,597 $907 $776 $819 $2,034 $1,808 $1,027 $879 $ $1,867 $1,658 $942 $807 $851 $2,114 $1,877 $1,067 $914 $ $1,945 $1,728 $982 $841 $887 $2,202 $1,957 $1,112 $952 $1, $2,034 $1,808 $1,027 $879 $928 $2,303 $2,047 $1,163 $995 $1, $2,122 $1,886 $1,071 $917 $967 $2,403 $2,136 $1,213 $1,038 $1, $2,222 $1,974 $1,122 $960 $1,013 $2,516 $2,235 $1,270 $1,087 $1, $2,320 $2,062 $1,171 $1,003 $1,058 $2,627 $2,335 $1,326 $1,136 $1, $2,428 $2,159 $1,226 $1,049 $1,107 $2,749 $2,445 $1,388 $1,188 $1, $2,538 $2,255 $1,281 $1,096 $1,157 $2,874 $2,553 $1,451 $1,241 $1, $2,657 $2,360 $1,341 $1,148 $1,211 $3,009 $2,672 $1,518 $1,300 $1, $2,774 $2,466 $1,400 $1,199 $1,265 $3,141 $2,792 $1,585 $1,358 $1, $2,902 $2,579 $1,465 $1,254 $1,323 $3,286 $2,920 $1,659 $1,420 $1, $3,032 $2,694 $1,530 $1,310 $1,382 $3,433 $3,051 $1,732 $1,483 $1, $3,170 $2,817 $1,600 $1,370 $1,446 $3,590 $3,190 $1,812 $1,551 $1, $3,238 $2,878 $1,635 $1,399 $1,476 $3,667 $3,259 $1,851 $1,584 $1, $3,376 $3,000 $1,705 $1,459 $1,539 $3,823 $3,397 $1,931 $1,652 $1, $3,496 $3,107 $1,765 $1,511 $1,593 $3,959 $3,518 $1,999 $1,711 $1, $3,574 $3,177 $1,805 $1,545 $1,630 $4,047 $3,597 $2,044 $1,749 $1, $3,672 $3,264 $1,854 $1,587 $1,675 $4,158 $3,696 $2,099 $1,797 $1, $3,732 $3,317 $1,884 $1,613 $1,701 $4,226 $3,756 $2,133 $1,826 $1, $3,732 $3,317 $1,884 $1,613 $1,701 $4,226 $3,756 $2,133 $1,826 $1,926

12 2019 Monthly Premium Rates PREFERRED PROVIDER PLANS (PPO Plans) Area 9: Asotin, Columbia, Garfield, Walla Walla, and Whitman Counties Non-Smoker Rates Smoker Rates Age $500 $1,000 $2,500 $5,000 $3,000 $500 $1,000 $2,500 $5,000 $ $939 $835 $474 $405 $428 $939 $835 $474 $405 $ $1,023 $909 $516 $441 $466 $1,023 $909 $516 $441 $ $1,054 $937 $533 $455 $480 $1,054 $937 $533 $455 $ $1,086 $965 $548 $469 $496 $1,086 $965 $548 $469 $ $1,120 $995 $565 $484 $511 $1,120 $995 $565 $484 $ $1,154 $1,026 $583 $499 $526 $1,154 $1,026 $583 $499 $ $1,190 $1,057 $601 $514 $542 $1,190 $1,057 $601 $514 $ $1,227 $1,090 $619 $530 $560 $1,389 $1,234 $701 $600 $ $1,227 $1,090 $619 $530 $560 $1,389 $1,234 $701 $600 $ $1,227 $1,090 $619 $530 $560 $1,389 $1,234 $701 $600 $ $1,227 $1,090 $619 $530 $560 $1,389 $1,234 $701 $600 $ $1,232 $1,094 $622 $533 $562 $1,395 $1,239 $704 $604 $ $1,256 $1,117 $635 $543 $573 $1,422 $1,265 $719 $615 $ $1,286 $1,143 $649 $555 $586 $1,456 $1,294 $735 $628 $ $1,333 $1,186 $674 $576 $609 $1,509 $1,343 $763 $652 $ $1,373 $1,220 $693 $593 $626 $1,555 $1,381 $785 $671 $ $1,393 $1,238 $703 $602 $635 $1,577 $1,402 $796 $682 $ $1,423 $1,264 $718 $614 $649 $1,611 $1,431 $813 $695 $ $1,452 $1,290 $732 $627 $662 $1,644 $1,461 $829 $710 $ $1,470 $1,306 $742 $635 $671 $1,665 $1,479 $840 $719 $ $1,490 $1,324 $752 $643 $679 $1,687 $1,499 $852 $728 $ $1,500 $1,332 $757 $648 $684 $1,699 $1,508 $857 $734 $ $1,510 $1,341 $762 $652 $688 $1,710 $1,518 $863 $738 $ $1,519 $1,350 $767 $656 $692 $1,720 $1,529 $869 $743 $ $1,529 $1,358 $772 $661 $697 $1,731 $1,538 $874 $748 $ $1,549 $1,376 $781 $669 $706 $1,754 $1,558 $884 $758 $ $1,568 $1,393 $792 $677 $715 $1,776 $1,577 $897 $767 $ $1,598 $1,420 $806 $690 $728 $1,809 $1,608 $913 $781 $ $1,626 $1,445 $821 $702 $741 $1,841 $1,636 $930 $795 $ $1,665 $1,480 $841 $719 $760 $1,885 $1,676 $952 $814 $ $1,714 $1,524 $865 $741 $781 $1,941 $1,726 $979 $839 $ $1,771 $1,575 $894 $765 $807 $2,005 $1,783 $1,012 $866 $ $1,841 $1,636 $929 $796 $839 $2,085 $1,853 $1,052 $901 $ $1,918 $1,704 $968 $829 $875 $2,172 $1,930 $1,096 $939 $ $2,006 $1,783 $1,013 $867 $915 $2,271 $2,019 $1,147 $982 $1, $2,093 $1,861 $1,056 $904 $954 $2,370 $2,107 $1,196 $1,024 $1, $2,192 $1,947 $1,106 $947 $999 $2,482 $2,205 $1,252 $1,072 $1, $2,289 $2,033 $1,155 $989 $1,043 $2,592 $2,302 $1,308 $1,120 $1, $2,395 $2,129 $1,210 $1,035 $1,092 $2,712 $2,411 $1,370 $1,172 $1, $2,503 $2,225 $1,264 $1,081 $1,141 $2,834 $2,519 $1,431 $1,224 $1, $2,620 $2,328 $1,323 $1,132 $1,194 $2,967 $2,636 $1,498 $1,282 $1, $2,736 $2,432 $1,381 $1,182 $1,248 $3,098 $2,754 $1,564 $1,338 $1, $2,863 $2,544 $1,445 $1,237 $1,305 $3,242 $2,881 $1,636 $1,401 $1, $2,991 $2,657 $1,510 $1,292 $1,363 $3,387 $3,009 $1,710 $1,463 $1, $3,127 $2,779 $1,578 $1,351 $1,426 $3,541 $3,147 $1,787 $1,530 $1, $3,194 $2,839 $1,613 $1,380 $1,456 $3,617 $3,215 $1,826 $1,563 $1, $3,330 $2,959 $1,681 $1,439 $1,518 $3,771 $3,351 $1,903 $1,629 $1, $3,448 $3,065 $1,741 $1,490 $1,571 $3,904 $3,471 $1,971 $1,687 $1, $3,525 $3,133 $1,780 $1,524 $1,607 $3,992 $3,548 $2,016 $1,726 $1, $3,622 $3,219 $1,829 $1,565 $1,652 $4,101 $3,645 $2,071 $1,772 $1, $3,681 $3,271 $1,858 $1,591 $1,678 $4,168 $3,704 $2,104 $1,802 $1, $3,681 $3,271 $1,858 $1,591 $1,678 $4,168 $3,704 $2,104 $1,802 $1,900

13 Tray Enrollee Name Address 1, Address 2 City, State zip Bar code PO Box 1090 Great Bend, KS Fax # WSHIP ELIGIBILITY VERIFICATION FORM (Non-Medicare Plans) WSHIP must confirm that you continue to meet eligibility requirements. Your prompt response is appreciated. Failure to respond may lead to termination of your coverage. If you have questions, please call WSHIP at WASHINGTON STATE RESIDENCY: Please provide your physical address and information below. Physical Address of your current residence - Required Mailing Address if different than physical address Name Name Name Address Address Address City City City State & Zip COUNTY OF RESIDENCE: State & Zip Important! The premium you pay is based in part on the county you live in. Telephone Number: ( ) Cell Number: ( ) (Optional) Secondary Contact: Address: Billing Address of 3 rd party paying premiums (if applicable) State & Zip Contact s Telephone Number: Secondary contact is a person who will know how to contact if we are unable to do so. We are not authorized to discuss your protected health information with a secondary contact unless you submit appropriate documentation. ARE YOU ELIGIBLE FOR MEDICARE? Yes No If you do not know or are unsure please call: ; or visit or go to your local Social Security office. If you have End Stage Renal Disease OR you are 65 or older but not eligible for Medicare, enclose proof of ineligibility. ARE YOU ELIGIBLE FOR MEDICAID? (Washington Apple Health)? Yes No Note: This includes expanded Medicaid that was implemented in 2014 as part of the Affordable Care Act. If you don t know or are unsure please call: or visit DO YOU HAVE COVERAGE OTHER THAN WSHIP? Yes No If Yes, in order to coordinate benefits, please provide the following: Insurer Effective Date If you have other coverage and will CANCEL YOUR WSHIP POLICY, what is the effective date for cancellation?: PLEASE SIGN BELOW: I attest that my responses on this form are true and complete. IMPORTANT This form must be SIGNED and RETURNED by DUE DATE: DECEMBER 15, 2018 X Signature Printed Name: / / Date Signed Enrollee ID # <<participant>> WSHIP Non-Medicare Verification Form Rev 8/15/2018 SIGNATURE REQUIRED For your convenience we have enclosed a stamped addressed envelope.

14 PO Box 1090 Great Bend, KS Fax: (620) Questions? Call October 2018 «First» «Last» «Addr» «Addr2» «City», «ST» «Zip» Member ID: «Partic» Current Plan: «Plan» Current : Date of Birth: «DOB» Plan Change Form Return by December 15, 2018 This form is used to change plans during open enrollment for coverage that will begin January 1st of the following year. To change plans, you must select a plan that has the same or higher deductible as your current plan. (Your current plan and deductible are displayed above for quick reference.) Check the box below for the plan you want to change to effective January 1, 2019: I DO NOT want to change my plan for 2019 (Returning this form is optional if you do not want to change plans. If the form is not returned, your coverage will remain under your current plan.) Preferred Provider Plan $500 deductible Preferred Provider Plan $1,000 deductible Preferred Provider Plan $2,500 deductible Preferred Provider Plan $5,000 deductible HSA Qualified Preferred Provider Plan $3,000 combined medical / pharmacy deductible If you have any questions concerning changes you might be considering, please call WSHIP customer service at If you do not return this form, you will remain enrolled in your current plan and cannot elect to change plans until the next open enrollment period. To change plans, this form must be SIGNED and RETURNED PRIOR TO DECEMBER 15, For your convenience we have enclosed a pre-addressed envelope, or you may fax this form to us at (620) By signing this form, I certify the following: I understand that I may only change to a plan that has the same or higher deductible as my current plan and that I will not be able to decrease my deductible in the future. X Signature Date Signed «Phone» Printed Name Telephone # 2019 WSHIP Non-Medicare Plan Change rev

15 WASHINGTON STATE HEALTH INSURANCE POOL (WSHIP) SCHEDULE OF BENEFITS Preferred Provider Plan - $5,000 Please Read This Schedule Carefully. Your Benefits Are Based On The Information Provided On This Schedule. If You Believe There Could Be An Error, Notify Our Administrator Immediately at or write to us at PO Box 1090, Great Bend, KS You Must Include Your Name and Policy Number In Any Communication. Enrollee Name: «FNAME» «LNAME» Policy Number: «POLICY_» Coverage Effective Date: «EFFECTIVE_DATE» : $5,000 Individual $10,000 Family Coinsurance and Out-of-Pocket Expense Limits: Your Policy s coinsurance and out-of-pocket limits are contained in the table below. Plan Medical Coinsurance* Medical Out-of-Pocket Expense Limit Prescription Drug and Coinsurance Prescription Drug Out-of-Pocket Expense Limit $5,000 20% Network 40% Non-Network Individual: $10,000 Network $15,000 Non-Network Family: $20,000 Network $30,000 Non-Network $500 Individual $1,000 Family 50% Non-Preferred Brand 30% Preferred Brand Individual: $ 5,000 Family: $10,000 20% Generic This Policy has separate deductibles for Medical Services and Prescription Drugs. Covered medical expenses apply only to the Medical Services deductible, and covered Prescription Drug expenses apply only to the Prescription Drug deductible. Covered expenses are applied toward the individual deductible in the year in which they are incurred. Covered expenses incurred in the last three months of the year which were applied to meet the deductible are also applied in an equal amount toward the individual deductible required for the next year. This Policy has separate out-of-pocket expense limits for Medical Services and Prescription Drugs. Once Your out-of-pocket expense limit has been reached, we will pay Covered Services at a rate of 100% for the remainder of the Calendar Year. *There is no medical coinsurance; and deductible is waived on preventive care services, diabetes education (certified providers only), and mammography (network providers only). WSHIP 19 Preferred Provider Plan Schedule-$5,000 January 1, 2019

16 2019 WSHIP Benefit Plans Summary and Comparison Chart (Non-Medicare Plans) DEDUCTIBLES, COINSURANCE, OUT-OF-POCKET Preferred Provider HSA Qualified Preferred Provider Annual (Individual) Coinsurance Annual Out-of-Pocket Expense Limits (Individual) The maximum amount you pay yearly including deductible and coinsurance PRESCRIPTION DRUGS Choices: $500, $1,000, $2,500 or $5,000 ($2,500 and $5,000 plans have a separate $500 Prescription Drug deductible) 20% Network 40% Non-Network $500 Plan: $1,000 Network $2,000 Non-Network $ 500 Prescription Drug $1,000 Plan: $1,650 Network $3,300 Non-Network $ 850 Prescription Drug $2,500 Plan: $5,000 Network $7,500 Non-Network $5,000 Prescription Drug $5,000 Plan: $10,000 Network $15,000 Non-Network $ 5,000 Prescription Drug $500 Plan: Generic: $2 copay Preferred Brand: 10% up to $50 Non-Preferred: 15% up to $100 $1,000 Plan: Generic: $5 copay Preferred Brand: 15% up to $50 Non-Preferred: 20% up to $100 $2,500 and $5,000 Plans: Drug : $500 Generic: 20% Preferred Brand: 30% Non-Preferred: 50% $3,000 (Combined Medical and Prescription Drug deductible) 20% Network 40% Non-Network $ 5,250 Network $10,500 Non-Network (Combined Medical and Prescription Drug out-of-pocket limit) 20% (After annual combined Medical & Prescription Drug deductible is met) NOTE: All coinsurance amounts are based on allowable charges. Balance billing may apply if provider is not in network. WSHIP 19 Non-Medicare Plan Comparison

17 2019 WSHIP Benefit Plans Summary and Comparison Chart (continued) MEDICAL BENEFITS Preferred Provider HSA Qualified Preferred Provider COINSURANCE (% You Pay) AND LIMITS PCY (1) Network Non-Network Network Non-Network PREVENTIVE CARE Preventive care exams and immunizations 0% / 40% 0% / 40% (deductible waived) PROFESSIONAL SERVICES Office, inpatient, and outpatient professional services DIAGNOSTIC SERVICES Diagnostic x-ray & laboratory services Mammography (deductible waived) 0% / 40% 0% / 40% HOSPITAL SERVICES Inpatient (2) and outpatient facility services EMERGENCY CARE Emergency room 20% / 20% 20% / 20% OTHER SERVICES Acupuncture 12 visits PCY 12 visits PCY Ambulance Chemical Dependency Diabetes Education (certified only; deductible waived) 0% 0% Habilitative Services 30 Inpatient days PCY 25 Outpatient visits PCY 30 Inpatient days PCY 25 Outpatient visits PCY Home Health Care (2) 130 visits PCY 130 visits PCY Hospice and Respite Care Massage Therapy (when prescribed by a physician) 12 visits PCY 12 visits PCY Maternity Services Medical Supplies and Equipment (3) Mental Health Services (2) Oral Surgery Rehabilitation Therapy Services (Physical, Speech, Occupational, and Respiratory) (2) Skilled Nursing Facility (2) 30 Inpatient days PCY 25 Outpatient visits PCY 100 days PCY 30 Inpatient days PCY 25 Outpatient visits PCY 100 days PCY Spinal Manipulations Tobacco Cessation (WSHIP s program only) 0% 0% Temporomandibular Joint (TMJ) Disorders Transplant Surgery (3) NOTES: (1) PCY = Per Calendar Year; (2) A prior review for Medical Necessity is recommended; (3) Pre-approval is required. WSHIP 19 Non-Medicare Plan Comparison

18 2019 WSHIP Benefit Plans Summary and Comparison Chart (continued) COVERED PRESCRIPTION DRUGS Prescription drug services are administered by Express Scripts; Prescriptions must be obtained from WSHIP s network of pharmacies. For your long-term prescriptions, you can often save time and money by filling your prescriptions through our mail order pharmacy program. Most plans have different copays or coinsurance for generics, preferred brands and non-preferred brand-name drugs; and some drugs require a coverage review (priorauthorization). A copy of our prescription drug formulary and information about coverage reviews and the mail order program is available at or by calling LIMITED COVERED SERVICES The following are limited covered services: Acupuncture Habilitative Services Home Health Care Massage Therapy Rehabilitation Services Skilled Nursing Facility Investigational and Experimental Services EXCLUSIONS TO COVERED SERVICES Benefits are not provided for treatment, surgery, services, drugs or supplies for any of the following: Cosmetic and Reconstructive Services (with some exceptions) Counseling, Educational or Training Services (except Diabetes Education) Custodial Care Dental Care Fertility or Infertility; and Sterilization Reversal Foot Care (routine care) Governmental Medical Facilities Military and War-Related Conditions; and Illegal Acts Not Medically Necessary Care Obesity and Weight Control Services For Which You Do Not Have to Pay Sexual Dysfunction Transportation or Travel Vision and Hearing Services Work-Related Conditions Services or supplies not specifically listed as covered in the Plan Policy ELIGIBILITY To be eligible for WSHIP, you must meet all of the following requirements: You are a resident of Washington State; You were enrolled in WSHIP prior to December 31, 2013 and have not had a termination of WSHIP coverage since then or you live in a Washington State county where an individual benefit plan is not offered during defined open enrollment or special enrollment periods; and You are not eligible for Medicaid or Medicare coverage. CHANGING PLANS AFTER YOU ENROLL Once you enroll in a plan, you may only switch plans every January 1 st and you may only change to a plan that has the same or higher deductible and is not more comprehensive than your current plan. PROVIDER NETWORKS Provider network services are provided by First Choice Health for medical services. Visit or call for network information. The retail and mail order pharmacy network is provided by Express Scripts; visit or call for pharmacy network information. CARE MANAGEMENT For Care Management services, call Services include medical necessity reviews and case and disease management programs. PRIOR REVIEWS FOR MEDICAL NECESSITY A medical necessity review should be requested by you or your provider before all admissions to a hospital, skilled nursing facility or other covered facility, and for outpatient services listed on your ID card. This review lets you and your provider know ahead of time if the service is Medically Necessary. We do not pay for any services that are determined by WSHIP to be not Medically Necessary. To request a review, call MINIMUM ESSENTIAL COVERAGE DESIGNATION Minimum essential coverage is designated by federal regulations to include state high risk pool coverage established before November 26, 2014 in any state. This includes WSHIP and means that WSHIP plans are designated as minimum essential coverage and satisfy the individual responsibility requirement of the Affordable Care Act and Internal Revenue Code. WSHIP benefits may not be the same as health plans in the individual market. HOW TO CONTACT US Customer Service: Mail: PO Box 1090, Great Bend, KS NOTE: This information is not a contract, nor does it cover all exclusions or limitations. Once you enroll, you will receive a copy of your Plan Policy which will outline your coverage in detail. For a sample copy of the Plan Policy, contact Customer Service or go to WSHIP 19 Non-Medicare Plan Comparison