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4R Retiree Under Age 65
Health Care Premium Worksheet

4R = Most recent date of hire is before January 1, 1996, but were not eligible to retire as of July 1, 1996

To calculate your monthly premium:

  1. Refer to the Point System for Post-Retirement Health Care Benefits (bottom of table) to determine your number of applicable points at retirement
  2. Based on your “Points at Retirement” you will find the Monthly University Contribution amount
  3. Calculate your monthly premium by subtracting:
    Total Monthly Premium – Monthly University Contribution = Retiree’s Monthly Premium (payment)
PICK YOUR PLAN CALCULATE YOUR MONTHLY PREMIUM
SINGLE TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
YOUR PPO Plan $545.76    
YOUR PPO Plan - Lower OOPM (for salary bands less than $49,000 only) $550.32    
YOUR HSA Eligible Plan $456.40    
YOUR HSA Eligible Plan - Lower OOPM (for salary bands less than $49,000 only) $461.44    
 
FAMILY TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
YOUR PPO Plan $1,637.20    
YOUR PPO Plan - Lower OOPM (for salary bands less than $49,000 only) $1,650.88    
YOUR HSA Eligible Plan $1,369.20    
YOUR HSA Eligible Plan - Lower OOPM (for salary bands less than $49,000 only) $1,384.32    
 
EMPLOYEE and CHILD(REN) TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
YOUR PPO Plan $982.34    
YOUR PPO Plan - Lower OOPM (for salary bands less than $49,000 only) $990.54    
YOUR HSA Eligible Plan $821.54    
YOUR HSA Eligible Plan - Lower OOPM (for salary bands less than $49,000 only) $830.60    
 
EMPLOYEE and SPOUSE/DOMESTIC PARTNER TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
YOUR PPO Plan $1,200.66    
YOUR PPO Plan - Lower OOPM (for salary bands less than $49,000 only) $1,210.68    
YOUR HSA Eligible Plan $1,004.12    
YOUR HSA Eligible Plan - Lower OOPM (for salary bands less than $49,000 only) $1,015.18    

*The University offers access only to medical plans for retiree surviving spouses and dependents


4R Point System for Post-Retirement Health Care Benefits

How to Calculate Points at Retirement:

  1. Add your age (years and months) to your service (completed years and months) at retirement.
  2. After adding these two factors (age and service), if your combined months are 12 or more, round up to the next higher year to determine your total “Points at Retirement”.

Points at Retirement

Monthly University Contribution for Retirees Age 55-64

 

Single Contracts**

Family Contracts**

85 pts. (max.)

$ 83.33

$ 166.67

84 pts.

$ 81.25

$ 162.50

83 pts.

$ 79.17

$ 158.33

82 pts.

$ 77.08

$ 154.17

81 pts.

$ 75.00

$ 150.00

80 pts.

$ 72.92

$ 145.83

79 pts.

$ 70.83

$ 141.67

78 pts.

$ 68.75

$ 137.50

77 pts.

$ 66.67

$ 133.33

76 pts.

$ 64.58

$ 129.17

75 pts.

$ 62.50

$ 125.00

74 pts.

$ 60.42

$ 120.83

73 pts.

$ 58.33

$ 116.67

72 pts.

$ 56.25

$ 112.50

71 pts.

$ 54.17

$ 108.33

70 pts.

$ 52.08

$ 104.17

69 pts.

$ 50.00

$ 100.00

68 pts.

$ 47.92

$ 95.83

67 pts.

$ 45.83

$ 91.67

66 pts.

$ 43.75

$ 87.50

65 pts. (min.)

$ 41.67

$ 83.33

** For part-time employees, the University contribution will be reduced to one-half that for full-time employees.

Please note: Retirees are billed quarterly for their share of the premium

For questions on additional rate structures please contact retiree benefits.

4R Retiree Age 65 +
Health Care Premium Worksheet

4R = Most recent date of hire is before January 1, 1996, but were not eligible to retire as of July 1, 1996

To calculate your monthly premium:

  1. Refer to the Point System for Post-Retirement Health Care Benefits (bottom of table) to determine your number of applicable points at retirement
  2. Based on your “Points at Retirement” you will find the Monthly University Contribution amount
  3. Calculate your monthly premium by subtracting:
    Total Monthly Premium – Monthly University Contribution = Retiree’s Monthly Premium (payment)
PICK YOUR PLAN CALCULATE YOUR MONTHLY PREMIUM
SINGLE - MEDICARE ELIGIBLE TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
Preferred Gold Standard HMO-POS† (with drug) $260.80    
Preferred Gold HMO-POS with University Major Medical $434.24    
USA Care PPO† (with drug) $334.20    
GoldAnywhere PPO† (with drug) $357.00    
University Complementary Care Plan with Major Medical $463.59    
 
COUPLE - BOTH SPOUSES MEDICARE ELIGIBLE TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
Preferred Gold Standard HMO-POS† (with drug) $521.60    
Preferred Gold HMO-POS with University Major Medical $868.48    
USA Care PPO† (with drug) $668.40    
GoldAnywhere PPO† (with drug) $714.00    
University Complementary Care Plan with Major Medical $927.18    
       
COUPLE - ONE SPOUSE MEDICARE ELIGIBLE TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
YOUR PPO Plan/Preferred Gold Standard HMO-POS† (with drug) $806.56    
YOUR PPO Plan/Preferred Gold HMO-POS with University Major Medical $980.00    
YOUR PPO Plan/USA Care PPO† (with drug) $879.96    
YOUR PPO Plan/GoldAnywhere PPO† (with drug) $902.76    
YOUR PPO Plan/University Complementary Care Plan with Major Medical $1,009.35    
YOUR HSA Eligible Plan/Preferred Gold Standard HMO-POS† (with drug) $717.20    
YOUR HSA Eligible Plan/Preferred Gold HMO-POS with University Major Medical $890.64    
YOUR HSA Eligible Plan/USA Care PPO† (with drug) $790.60    
YOUR HSA Eligible Plan/GoldAnywhere PPO† (with drug) $813.40    
YOUR HSA Eligible Plan/University Complementary Care Plan with Major Medical $919.99    
       
COUPLE - ONE SPOUSE MEDICARE ELIGIBLE
(Lower OOPM & Full Time Salary Less than $49,000) ◊
TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM</td>
YOUR PPO Plan-Lower OOPM/Preferred Gold Standard HMO-POS† (with drug) $811.12    
YOUR PPO Plan-Lower OOPM/Preferred Gold HMO-POS with University Major Medical $984.56    
YOUR PPO Plan-Lower OOPM/USA Care PPO† (with drug) $884.52    
YOUR PPO Plan-Lower OOPM/GoldAnywhere PPO† (with drug) $907.32    
YOUR PPO Plan-Lower OOPM/University Complementary Care Plan with Major Medical $1,013.91    
YOUR HSA Eligible Plan/Preferred Gold Standard HMO-POS† (with drug) $722.24    
YOUR HSA Eligible Plan/Preferred Gold HMO-POS with University Major Medical $895.68    
YOUR HSA Eligible Plan/USA Care PPO† (with drug) $795.64    
YOUR HSA Eligible Plan/GoldAnywhere PPO† (with drug) $818.44    
YOUR HSA Eligible Plan/University Complementary Care Plan with Major Medical $925.03    

*The University offers access only to medical plans for retiree surviving spouses and dependents
†If you are eligible for special assistance through Social Security, you may receive a lower premium
◊Based on salary at time of retirement


4R Point System for Post-Retirement Health Care Benefits

How to Calculate Points at Retirement:

  1. Add your age (years and months) to your service (completed years and months) at retirement.
  2. After adding these two factors (age and service), if your combined months are 12 or more, round up to the next higher year to determine your total “Points at Retirement”.

Points at Retirement

Monthly University Contribution
For Retirees Age 65 and Older

 

Single**

Couple – Both Spouses Medicare Eligible**

Couple – One Spouse Non-Medicare Eligible/One Spouse Medicare Eligible**

85 pts. (max.)

$207.52

$415.04

$290.85

84 pts.

$202.33

$404.66

$283.58

83 pts.

$197.14

$394.29

$276.31

82 pts.

$191.96

$383.91

$269.04

81 pts.

$186.77

$373.54

$261.77

80 pts.

$181.58

$363.16

$254.50

79 pts.

$176.39

$352.78

$247.23

78 pts.

$171.20

$342.41

$239.95

77 pts.

$166.02

$332.03

$232.68

76 pts.

$160.83

$321.66

$225.41

75 pts.

$155.64

$311.28

$218.14

74 pts.

$150.45

$300.90

$210.87

73 pts.

$145.26

$290.53

$203.60

72 pts.

$140.08

$280.15

$196.33

71 pts.

$134.89

$269.78

$189.05

70 pts.

$129.70

$259.40

$181.78

69 pts.

$124.51

$249.02

$174.51

68 pts.

$119.32

$238.65

$167.24

67 pts.

$114.14

$228.27

$159.97

66 pts.

$108.95

$217.90

$152.70

65 pts. (min.)

$103.76

$207.52

$145.43

** For part-time employees, the University contribution will be reduced to one-half that for full-time employees.

As announced in 1996, the University’s share of premiums will be capped at two times the 1/1/96 level, pro-rated based on Points at Retirement. (The Monthly University Contribution for a retiree with 85 points will be capped at $207.52 for single coverage).

Please note: Retirees are billed quarterly for their share of the premium

For questions on additional rate structures please contact retiree benefits.

5R Retiree Under Age 65
Health Care Premium Worksheet

5R = most recent date of hire or rehire is January 1, 1996 and thereafter

To calculate your monthly premium:

  1. Use the Monthly University Contribution Chart (bottom of table) to determine the UR Monthly Contribution
  2. Calculate your monthly premium by subtracting:
    Total Monthly Premium – UR Monthly Contribution = Retiree’s Monthly Premium (payment)
PICK YOUR PLAN CALCULATE YOUR MONTHLY PREMIUM
SINGLE TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
YOUR PPO Plan $545.76    
YOUR PPO Plan - Lower OOPM (for salary bands less than $49,000 only) $550.32    
YOUR HSA Eligible Plan $456.40    
YOUR HSA Eligible Plan - Lower OOPM (for salary bands less than $49,000 only) $461.44    
 
FAMILY TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
YOUR PPO Plan $1,637.20    
YOUR PPO Plan - Lower OOPM (for salary bands less than $49,000 only) $1,650.88    
YOUR HSA Eligible Plan $1,369.20    
YOUR HSA Eligible Plan - Lower OOPM (for salary bands less than $49,000 only) $1,384.32    
 
EMPLOYEE and CHILD(REN) TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
YOUR PPO Plan $982.34    
YOUR PPO Plan - Lower OOPM (for salary bands less than $49,000 only) $990.54    
YOUR HSA Eligible Plan $821.54    
YOUR HSA Eligible Plan - Lower OOPM (for salary bands less than $49,000 only) $830.60    
 
EMPLOYEE and SPOUSE/DOMESTIC PARTNER TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY PREMIUM
YOUR PPO Plan $1,200.66    
YOUR PPO Plan - Lower OOPM (for salary bands less than $49,000 only) $1,210.68    
YOUR HSA Eligible Plan $1,004.12    
YOUR HSA Eligible Plan - Lower OOPM (for salary bands less than $49,000 only) $1,015.18    

*The University offers access only to medical plans for retiree surviving spouses and dependents

effective 1/1/18


5R Monthly University Contribution Chart

Years of UR Service at Retirement

% of Max UR Contribution

Monthly University Contribution** for Retirees Age 60 - 64

25 or more years

100%

$115.90

24 years

95%

$110.10

23 years

90%

$104.31

22 years

85%

$98.51

21 years

80%

$92.72

20 years

75%

$86.92

19 years

70%

$81.13

18 years

65%

$75.33

17 years

60%

$69.54

16 years

55%

$63.74

15 years

50%

$57.95

14 years

45%

$52.15

13 years

40%

$46.36

12 years

35%

$40.56

11 years

30%

$34.77

10 years

25%

$28.97

** For part-time employees, the University contribution will be reduced to one-half that for full-time employees.

The monthly UR contribution is the same regardless of the level of coverage (single, family, one-parent family or sponsored). Contribution amounts will be locked in at the age you retire, and always stay the same.

Please note: Retirees are billed quarterly for their share of the premium

For questions on additional rate structures please contact retiree benefits.

If you already retired, please contact the benefits office for your contribution amount

5R Retiree Age 65+
Health Care Premium Worksheet

5R = most recent date of hire or rehire is January 1, 1996 and thereafter

To calculate your monthly premium:

  1. Use the Monthly University Contribution Chart (bottom of table) to determine the UR Monthly Contribution
  2. Calculate your monthly premium by subtracting:
    Total Monthly Premium – UR Monthly Contribution = Retiree’s Monthly Premium (payment)
PICK YOUR PLAN CALCULATE YOUR MONTHLY PREMIUM
SINGLE - MEDICARE ELIGIBLE TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY SHARE
Preferred Gold Standard HMO-POS† (with drug) $260.80    
Preferred Gold HMO-POS with University Major Medical $434.24    
USA Care PPO† (with drug) $334.20    
GoldAnywhere PPO† (with drug) $357.00    
University Complementary Care Plan with Major Medical $463.59    
 
COUPLE - BOTH SPOUSES MEDICARE ELIGIBLE TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY SHARE
Preferred Gold Standard HMO-POS† (with drug) $521.60    
Preferred Gold HMO-POS with University Major Medical $868.48    
USA Care PPO† (with drug) $668.40    
GoldAnywhere PPO† (with drug) $714.00    
University Complementary Care Plan with Major Medical $927.18    
 
COUPLE - ONE SPOUSE MEDICARE ELIGIBLE TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY SHARE
YOUR PPO Plan/Preferred Gold Standard HMO-POS† (with drug) $806.56    
YOUR PPO Plan/Preferred Gold HMO-POS with University Major Medical $980.00    
YOUR PPO Plan/USA Care PPO† (with drug) $879.96    
YOUR PPO Plan/GoldAnywhere PPO† (with drug) $902.76    
YOUR PPO Plan/University Complementary Care Plan with Major Medical $1,009.35    
YOUR HSA Eligible Plan/Preferred Gold Standard HMO-POS† (with drug) $717.20    
YOUR HSA Eligible Plan/Preferred Gold HMO-POS with University Major Medical $890.64    
YOUR HSA Eligible Plan/USA Care PPO† (with drug) $790.60    
YOUR HSA Eligible Plan/GoldAnywhere PPO† (with drug) $813.40    
YOUR HSA Eligible Plan/University Complementary Care Plan with Major Medical $919.99    
 
COUPLE - ONE SPOUSE MEDICARE ELIGIBLE (Lower OOPM & Full Time Salary Less than $49,000) ◊ TOTAL MONTHLY PREMIUM LESS UR MONTHLY CONTRIBUTION* RETIREE MONTHLY SHARE
YOUR PPO Plan-Lower OOPM/Preferred Gold Standard HMO-POS† (with drug) $811.12    
YOUR PPO Plan-Lower OOPM/Preferred Gold HMO-POS with University Major Medical $984.56    
YOUR PPO Plan-Lower OOPM/vUSA Care PPO† (with drug) $884.52    
YOUR PPO Plan-Lower OOPM/GoldAnywhere PPO† (with drug) $907.32    
YOUR PPO Plan-Lower OOPM/University Complementary Care Plan with Major Medical $1,013.91    
YOUR HSA Eligible Plan/Preferred Gold Standard HMO-POS† (with drug) $722.24    
YOUR HSA Eligible Plan/Preferred Gold HMO-POS with University Major Medical $895.68    
YOUR HSA Eligible Plan/USA Care PPO† (with drug) $795.64    
YOUR HSA Eligible Plan/GoldAnywhere PPO† (with drug) $818.44    
YOUR HSA Eligible Plan/University Complementary Care Plan with Major Medical $925.03    

*The University offers access only to medical plans for retiree surviving spouses and dependents
†If you are eligible for special assistance through Social Security, you may receive a lower premium
◊Based on salary at time of retirement

effective 1/1/18


5R Monthly University Contribution Chart

Years of UR Service at Retirement

% of Max UR Contribution

Monthly University Contribution** for Retirees Age 65+

25 or more years

100%

$231.80

24 years

95%

$220.21

23 years

90%

$208.62

22 years

85%

$197.03

21 years

80%

$185.44

20 years

75%

$173.85

19 years

70%

$162.26

18 years

65%

$150.67

17 years

60%

$139.08

16 years

55%

$127.49

15 years

50%

$115.90

14 years

45%

$104.31

13 years

40%

$92.72

12 years

35%

$81.13

11 years

30%

$69.54

10 years

25%

$57.95

** For part-time employees, the University contribution will be reduced to one-half that for full-time employees.

The monthly UR contribution is the same regardless of the level of coverage (single, family, one-parent family or sponsored). Contribution amounts will be locked in at the age you retire, and always stay the same.

Please note: Retirees are billed quarterly for their share of the premium

For questions on additional rate structures please contact retiree benefits.

If you already retired, please contact the benefits office for your contribution amount