Health Insurance

2013 Premiums

Monthly contributions are subject to each employee group's compensation plan.

All Health Maintenance Organization (HMO) plans are offered at Tier 1 Rates. The Standard Plan is offered at Tier 3 rates. Out-of-state residents whose jobs require them to live out of state are offered the Standard Plan at Tier 2 rates.

Additional Premiums Information

• Employee Contribution for the 2013 Plan Year
• Employer Contribution for Less than Full-Time Appointments

• Combined Premiums Document 2013 (all employee categories below, except Retirees)
• Classified and Unclassified Employees 2013
• Employees Employed Less Than Half-Time (Classified, Unclassified) 2013
• Craftsworkers 2013
• Graduate Assistants 2013
• COBRA 2013
• Retirees 2013

Historical Premiums

EPIC Benefits+

Premiums are deducted one month in advance of the month of coverage.

2013 EPIC Benefits+ Insurance (Group #3180) — Active Employees

Deduction Code	Coverage Type	Employee	Employee + Spouse / Domestic Partner	Employee + Child	Family
404	Active Employee Monthly Premium Without Vision Coverage	$19.77	$39.54	$39.54	$59.31
	Active Employee Monthly Premium With Vision Coverage	$24.02	$47.04	$47.04	$70.34

New State of Wisconsin retirees (annuitants), may continue EPIC Benefits+ coverage at annuitant group rates. Before you retire, contact your payroll office to complete the employee and employer sections of the Continuation Form and submit this form to EPIC to continue your coverage.

2013 and 2014 Monthly Rates for Annuitants

Deduction Code	Coverage Type	Employee	Employee + Spouse / Domestic Partner	Employee + Child	Family
N/A	Annuitant Monthly Premium Without Vision Coverage	$26.69	$53.27	$61.90	$73.53
	Annuitant Monthly Premium With Vision Coverage	$31.26	$61.51	$69.68	$85.43

Historical Premiums

Dental Wisconsin | Union Dental Plans

Dental Wisconsin

2013 Dental Wisconsin Insurance (Group #31800D) — Monthly Premiums Effective for Coverage 1/1/2013

UW Deduction Codes	Plan	Employee	Employee + Spouse/Domestic Partner	Employee + Child(ren)	Family
487	Preferred Provider Plan (PPO)	$28.32	$59.96	$67.04	$101.34
488	Select Plan	$20.52	$42.19	$48.68	$71.59

Historical Premiums

Union Dental Plans

Note: For biweekly payrolls ending July 16, 2011 (check dated July 28, 2011) and monthly payrolls ending July 31, 2011 (check dated August 1, 2011), deductions for union-sponsored insurance plans will be discontinued due to recent legislation. You will need to pay these premiums separately. Please contact your union to coordinate payment for these insurance plans. You can find the last known union dental plan premiums below.

Historical Premiums

Vision Insurance

Premiums are deducted one month in advance of the month of coverage.

2010/2011/2012/2013 VSP Vision Plan Monthly Premiums — Coverage Effective 1/1/2010

UW Deduction Code	Employee	Employee + Spouse/Domestic Partner	Employee + Child(ren)	Employee + Family
411	$5.24	$10.49	$11.23	$17.93

Historical Premiums

Income Continuation Insurance

For Coverage Effective 2/1/2013

• Classified Standard Plan
• Classified Supplemental Plan
• Unclassified Standard Plan
• Unclassified Supplemental Plan

Historical Premiums

Accidental Death & Dismemberment | Individual and Family Group Life | State Group Life | University Insurance Association (UIA) | UW Employees, Inc. Life

Life Insurance

Life Insurance Premium Comparison Chart

Accidental Death & Dismemberment

Premiums are paid one month in advance of the month of coverage.

AD&D Monthly Premium per Principal Sum Elected (Group #GTU 83-64-005)

Principal Sum Elected	Employee Only Premium	Family Plan Premium
$25,000	$.73	$1.10
$50,000	$1.45	$2.20
$100,000	$2.90	$4.40
$150,000	$4.35	$6.60
$200,000	$5.80	$8.80
$250,000	$7.25	$11.00
$300,000	$8.70	$13.20
$350,000	$10.15	$15.40
$400,000	$11.60	$17.60
$450,000	$13.05	$19.80
$500,000	$14.50	$22.00

Individual and Family Group Life Insurance

• Initial Premium Determination: The premium for employee and spouse/domestic partner coverage is determined by the employee's age as of January 1st of the current year (year in which coverage is effective).
• Annual Premium Review: Premiums are reviewed each year and may change based on the employee's age and coverage amount. The premium for employee and spouse/domestic partner coverage is determined by the employee's age as of January 1st of the plan year. Premium changes, if any, are effective for January coverage. Premiums are deducted one month in advance of coverage.

Premiums are based on the cost per $1,000 of coverage. A premium calculator is available to help you determine your exact premium. Child coverage insures all children with the same coverage amount for one monthly premium.

Cost per $1,000 of Coverage for Employee and Spouse/Domestic Partner

Employee Attained Age	Employee	Spouse / Domestic Partner
27 or less	$0.023	$0.036
28-30	0.025	0.040
31-33	0.032	0.050
34-36	0.037	0.059
37-39	0.045	0.072
40-42	0.068	0.108
43-45	0.108	0.171
46-48	0.130	0.207
49-51	0.181	0.288
52-54	0.232	0.369
55-57	0.323	0.513
58-60	0.403	0.621
61-63	0.556	0.774
64-66	0.799	1.080
67-69	1.117	1.503
70-72	1.724	2.331
73+	2.466	3.330

Monthly Premium Table for Employee and Spouse / Domestic Partner Coverage (Deduction Code 428)

Employee Attained Age	Employee				Spouse / Domestic Partner
	$5,000	$10,000	$15,000	$20,000	$5,000	$10,000
27 or less	$0.12	$0.23	$0.35	$0.46	$0.18	$0.36
28-30	0.13	0.25	0.38	0.50	0.20	0.40
31-33	0.16	0.32	0.48	0.64	0.25	0.50
34-36	0.19	0.37	0.56	0.74	0.30	0.59
37-39	0.23	0.45	0.68	0.90	0.36	0.72
40-42	0.34	0.68	1.02	1.36	0.54	1.08
43-45	0.54	1.08	1.62	2.16	0.86	1.71
46-48	0.65	1.30	1.95	2.60	1.04	2.07
49-51	0.91	1.81	2.72	3.62	1.44	2.88
52-54	1.16	2.32	3.48	4.64	1.85	3.69
55-57	1.62	3.23	4.85	6.46	2.57	5.13
58-60	2.02	4.03	6.05	8.06	3.11	6.21
61-63	2.78	5.56	8.34	11.12	3.87	7.74
64-66	4.00	7.99	11.99	15.98	5.40	10.80
67-69	5.59	11.17	16.76	22.34	7.52	15.03
70-72	8.62	17.24	25.86	34.48	11.66	23.31
73+	12.33	24.66	36.99	49.32	16.65	33.30

Monthly Premium Table for Child Coverage

Amount of Insurance	Monthly Premium
$2,500 (Code Y)	$0.18
$5,000 (Code A)	0.35
$7,500 (Code B)	0.53
$10,000 (Code C)	0.70

State Group Life Insurance

Premiums are deducted one month in advance of the month of coverage. Employee premium rates are based on the employee's age as of April 1 for initial enrollment. The employee's age on April 1 is also used for the annual update. When an active employee reaches age 70, Basic coverage continues at a reduced level without premium, Supplemental coverage ceases and the Additional coverage continues.

Basic/Supplemental/Additional Coverage Monthly Premium Rates
(Deduction Codes: Basic=412, Basic Supplemental=414, Additional 1 Unit=419, Additional 2 Units=416, Additional 3 Units=417, Spouse & Dependent=420)

Age As of April 1	Basic and Supplemental	Additional	Spouse & Dependent
	2013 Rate per $1,000	2013 Rate per $1,000
Under age 30	$.04	$.06	One Unit of Coverage: $2.50 per $10,000 Spouse and $5,000 for each dependent Two Units of Coverage: $5.00 per $20,000 Spouse and $10,000 for each dependent
30-34	.04	.06
35-39	.04	.06
40-44	.06	.09
45-49	.10	.15
50-54	.16	.24
55-59	.22	.33
60-64	.30	.45
65-69	.39	.59

Over Age 70 Additional Coverage (Deduction Code: 418)

Age as of April 1	Rate per $1,000
70	$1.00
71	1.15
72	1.25
73	1.45
74	1.60
75	1.80
76	1.95
77–89	2.06
90+	Available upon request

Historical Premiums

University Insurance Association (UIA) Life Insurance

The annual premium is deducted from your October earnings. If you initially qualify for coverage on April 1, a premium will be deducted from your March earnings.

University Insurance Association Schedule of Benefits/Coverage Amounts (Group #32872-G)

Age as of Oct 1	Benefit Amount
Under 28	$101,000
28-30	$98,100
31-33	$90,900
34-36	$78,900
37-39	$65,000
40-42	$50,900
43-45	$39,100
46-48	$30,000
49-51	$22,600
52-54	$17,200
55-57	$13,100
58-60	$10,300
61-63	$8,200
64-66	$6,100
67-69	$4,500
70+	$3,400

UW Employees, Inc. Life Insurance

Rates for employees are based on the employee's age as of January 1 of the current calendar year. Premium changes based on the employee's calendar year age will take effect on December payrolls for January coverage.

UW Employees, Inc. Monthly Premium Table — Premium and Coverage Amounts Effective October 1, 2011

Employee Age	Coverage Amount	Premium
under 35	$30,000	$1.00
35 - 39	25,000	1.25
40 - 44	22,000	1.60
45 - 49	15,000	2.00
50 - 54	12,000	2.40
55 - 59	10,000	3.80
60 - 64	9,000	4.35
65 and over	4,000	3.00

Historical Premiums