• Applicant-only cost applies if only one person, either you or a dependent, wishes to continue coverage.
• When two or more persons wish to continue coverage, the cost that applies depends on the relationship of persons continuing coverage. Examples:
  • Employee and spouse: Applicant and spouse/same-sex domestic partner rates apply.
  • Same-sex domestic partner and children: Applicant and child/children rates apply.
  • Two or more children: Applicant and child/children rates apply. The oldest child is considered the applicant.
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• Your cost is based on the plan and the zone you had in effect when the qualifying event occurred.
• If you, your spouse/registered same-sex domestic partner or dependent receive an extension due to a disability, the cost for that coverage is 150 percent of the cost shown below. (Contact Employee Benefits for these rates.)

A non-refundable administrative fee of 2% is included in the rates below.

Applicant-only coverage

Applicant and Spouse/Same-sex Domestic Partner

Applicant and Child/Children

Applicant and Spouse/Same-sex Domestic Partner and Child/Children