City Of New York Employee Benefits Program Continuation Of Coverage Application Page 4
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8NON-MEDICARE Monthly COBRA Rates for Effective July 1, 2017
MEDICARE Related Plans Monthly COBRA Rates for Effective July 1, 2017
PLAN
Coverage
COBRA RATE
PLAN
Coverage
COBRA RATE
PLAN
Coverage
COBRA RATE
INDIVIDUAL BASIC
$924.91
INDIVIDUAL BASIC
$719.36
PER PERSON BASIC
$175.87
GHI SENIOR CARE
FAMILY BASIC
$2,771.47
FAMILY BASIC
$1,763.71
PER PERSON with RIDER
$296.48
AETNA EPO
HIP PRIME HMO
INDIVIDUAL with RIDER
$2,005.36
INDIVIDUAL with RIDER
$922.60
FAMILY with RIDER
$5,802.02
FAMILY with RIDER
$2,261.61
PER PERSON BASIC
$545.19
GHI HMO
PER PERSON with RIDER
$620.67
INDIVIDUAL BASIC
$1,466.56
INDIVIDUAL BASIC
$1,692.33
FAMILY BASIC
$3,790.34
FAMILY BASIC
$4,147.48
PER PERSON BASIC
$181.76
CIGNA
HIP PRIME POS
DC37 MED TEAM
INDIVIDUAL with RIDER
$1,735.25
INDIVIDUAL with RIDER
$1,982.45
RIDER NOT AVAILABLE
FAMILY with RIDER
$4,594.82
FAMILY with RIDER
$4,858.26
ONE PERSON BASIC
$266.36
EMPIRE
INDIVIDUAL BASIC
$1,343.07
INDIVIDUAL BASIC
$738.16
MEDICARE
TWO PERSONS BASIC
$526.37
DC 37 MED TEAM
RELATED
FAMILY BASIC
$3,358.17
FAMILY BASIC
$1,809.78
ONE PERSON with RIDER
$471.02
EMPIRE EPO
(no rider available)
INDIVIDUAL with RIDER
$1,561.24
TWO PERSONS w/RIDER
$935.68
FAMILY with RIDER
$3,893.02
PER PERSON BASIC
$298.13
Aetna PPO/ESA
(NY/NJ/PA)
INDIVIDUAL BASIC
$1,021.13
INDIVIDUAL BASIC
$719.36
PER PERSON with RIDER
$482.60
FAMILY BASIC
$2,652.44
FAMILY BASIC
$1,763.71
EMPIRE HMO
METROPLUS
INDIVIDUAL with RIDER
$1,239.30
INDIVIDUAL with RIDER
$911.82
Aetna PPO/ESA
PER PERSON BASIC
$175.87
(All other areas)
FAMILY with RIDER
$3,187.29
FAMILY with RIDER
$2,205.76
PER PERSON with RIDER
$375.93
INDIVIDUAL BASIC
$861.68
INDIVIDUAL BASIC
$820.31
NOTE: If you were enrolled in a Medicare HMO you MUST
FAMILY BASIC
$2,195.96
FAMILY BASIC
$2,157.28
GHI HMO
VYTRA
INDIVIDUAL with RIDER
$1,140.42
INDIVIDUAL with RIDER
$1,061.54
contact your health plan DIRECTLY for benefit and cost
information regarding continuation of coverage.
FAMILY with RIDER
$2,906.62
FAMILY with RIDER
$2,784.61
INDIVIDUAL BASIC
$635.75
FAMILY BASIC
$1,666.33
GHI-CBP/BCBS
INDIVIDUAL with RIDER
$763.99
FAMILY with RIDER
$1,905.38
Return the completed COBRA form to your chosen plan. Addresses are listed on the front of this pamphlet.
Wait for notification from the plan before mailing in your first payment. Checks and/or money orders must be
made payable to the health plan and mailed DIRECTLY to the plan. Enrollees of all plans not listed must contact
the plan DIRECTLY for enrollment options.
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