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<br />Type of <br />Co\"e:--a::-e <br /> <br />KAISER <br /> <br />Retiree under age 65 <br />Retiree with one family <br />dependent <br />Retiree with two or more <br />family dependents <br />Retiree age 65 or older <br />who is (a) not entitled to <br />benefits under Part B of <br />~edicare or (b) entitled to <br />benefits under Part B of <br />Medicare but has not <br />assigned such benefits to <br />Health Plan <br />Retiree <br />Retiree with 1 dependent <br />Retiree with 2 or more <br />dependents <br />Retiree (up to 3 per Family <br />Unit) entitled to benefits <br />unde~ both Parts A & B of <br />r-:edicare who has assigned <br />Part B benefits to Health <br />Plan <br />Re tiree <br />Retiree with one family <br />dependent <br />Retiree with two or three <br />family dependents <br /> <br />I Kat in the contract <br /> <br />*Retiree or Retiree and <br />spouse age 65 or older who <br />are entitled to benefits <br />under both Parts A & B of <br />Medicare who have assigned <br />Part B to Health Plan: <br />Retiree <br />Retiree with one family <br />dependent <br /> <br />Ra te in <br />Effect <br />3-1-85 <br /> <br />61. 54 <br />123.08 <br /> <br />177 .50 <br /> <br />61 .54 <br />123.08 <br /> <br />177 . 50 <br /> <br />36.80 <br />98.34 <br />152.76 <br /> <br />36.80 <br />13.60 <br /> <br />City <br />Pays <br /> <br />Retired <br />Employee <br />Pays <br /> <br />61. 54 <br />61. 54 <br /> <br />-0- <br /> <br />61. 54 <br />115.96 <br /> <br />61. 54 <br /> <br />61. 54 <br />61. 54 <br /> <br />61. 54 <br /> <br />-0- <br />61. 54 <br /> <br />115.96 <br /> <br />36.80 <br />36.80 <br />36.80 <br /> <br />-0- <br /> <br />61. 54 <br />115.96 <br /> <br />36.80 <br />36.80 <br /> <br />-0- <br /> <br />36.80 <br /> <br />Page 2 of 6 <br />