Medicare Health Plan Premium Rates

How much you will pay each month for your health care premium.
Plan Year
    2025
Program Option
    Local Deductible Health Plan (PO14) & Supplemental Benefits

Medicare Health Plan Premium Rates

How much you will pay each month for your health care premium.
Plan Year
    2025
Program Option
    Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits

Medicare Health Plan Premium Rates

How much you will pay each month for your health care premium.
Plan Year
    2025
Program Option
    Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits

Medicare Health Plan Premium Rates

How much you will pay each month for your health care premium.
Plan Year
    2025
Program Option
    Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
ET-2305
Form Active Employee / Local Employer / State Employer

Evidence of Insurability

Employees who did not enroll for group life insurance coverage during their initial enrollment period, or insured employees who wish to apply for more insurance for themselves or their spouse or dependents, may apply using this form.