Oklahoma State and Education Employees Group Insurance Board

Monthly Premiums for COBRA Employees and Dependents

Plan Year January 1, 2010 - December 31, 2010

HEALTH PLANS MEMBER *SPOUSE *CHILD *CHILDREN
HealthChoice High $451.66 $638.40 $232.89 $349.29
HealthChoice Basic $391.90 $557.78 $204.37 $306.90
HealthChoice S-Account $373.12 $523.95 $194.13 $289.66
HealthChoice USA $692.14 $692.14 $230.86 $346.10
Aetna Standard HMO $729.71 $970.41 $498.56 $797.68
Aetna Alternative HMO $512.37 $681.38 $350.06 $560.10
CommunityCare Standard HMO $790.58 $1130.51 $395.29 $632.46
CommunityCare Alternative HMO $545.23 $779.67 $272.63 $436.19
GlobalHealth Standard HMO $351.06 $520.91 $188.25 $300.19
GlobalHealth Alternative HMO $319.16 $473.59 $171.18 $272.89
PacifiCare Standard HMO $617.30 $887.56 $308.43 $493.60
PacifiCare Alternative HMO $425.73 $612.10 $212.69 $340.39
DENTAL PLANS MEMBER *SPOUSE *CHILD *CHILDREN
HealthChoice Dental $30.89 $30.89 $25.74 $66.81
Assurant Freedom Preferred $26.86 $26.70 $20.02 $53.85
Assurant Heritage Plus with SBA (Prepaid) $11.97 $9.04 $7.75 $15.50
Assurant Heritage Secure (Prepaid) $7.34 $6.10 $5.30 $10.59
CIGNA Dental Care Plan (Prepaid) $9.45 $6.18 $7.22 $15.63
Delta Dental PPO (POS) $31.09 $31.11 $27.34 $69.58
Delta’s Choice (PPO) $13.67 $31.05 $31.29 $75.95
VISION PLANS MEMBER *SPOUSE *CHILD *CHILDREN
Humana/CompBenefits VisionCare Plan $6.90 $5.16 $3.64 $4.55
Primary Vision Care Services $9.44 $8.16 $8.67 $10.97
Superior Vision Services $7.12 $7.04 $6.73 $6.73
UnitedHealthcare Vision $8.34 $5.91 $4.68 $7.12
Vision Service Plan (VSP) $9.14 $6.12 $5.85 $13.18

*It is the policy of the Oklahoma State and Education Employees Group Insurance Board that for any benefit continued under COBRA, one person must always pay the primary member premium. In cases where a spouse, child, or children are insured under a particular benefit and the member did not retain coverage, one person will always be billed at the primary member rate.