In Network: $100 Deductible, 90%/10% Coinsurance, $2,500 Out of Pocket

Out of Network: $300 Deductible, 70%/30% Coinsurance, $5,000 Out of Pocket

Prescription: $10/$25/$45 Copays, $100 Deductible, $1,500 Annual Max

AGE AT EFFECTIVE DATE

INDIVIDUAL

SUBSCRIBER + CHILD

SUBSCRIBER + SPOUSE

FAMILY

<21

$150

$240

$300

$435

21

$153

$245

$305

$443

22

$155

$248

$311

$450

23

$160

$255

$320

$465

24

$162

$260

$325

$473

25

$165

$265

$330

$478

26

$170

$272

$340

$493

27

$173

$275

$346

$500

28

$175

$280

$350

$508

29

$180

$287

$360

$523

30

$182

$293

$365

$530

31

$188

$300

$375

$545

32

$190

$305

$381

$550

33

$195

$313

$390

$565

34

$197

$315

$395

$572

35

$202

$325

$405

$587

36

$205

$328

$410

$595

37

$210

$335

$420

$611

38

$215

$346

$430

$622

39

$217

$348

$435

$630

40

$223

$355

$445

$646

41

$232

$372

$465

$675

42

$245

$392

$490

$710

43

$255

$408

$510

$740

44

$267

$427

$535

$775

45

$280

$447

$560

$813

46

$293

$467

$585

$848

47

$305

$488

$611

$885

48

$320

$513

$640

$927

49

$335

$535

$670

$973

50

$350

$560

$701

$1,015

51

$365

$585

$730

$1,058

52

$383

$613

$765

$1,110

53

$400

$640

$800

$1,161

54

$418

$668

$835

$1,210

55

$438

$701

$876

$1,270

56

$458

$732

$915

$1,328

57

$480

$767

$960

$1,393

58

$500

$800

$1,001

$1,450

59

$525

$841

$1,050

$1,523

60

$548

$876

$1,095

$1,588

61

$572

$915

$1,145

$1,660

62

$600

$960

$1,200

$1,740

63

$628

$1,005

$1,255

$1,820

64

$655

$1,047

$1,310

$1,901

65

$685

$1,095

$1,371

$1,987

>65

$718

$1,148

$1,435

$2,081

* To Include a Maternity Benefit Add $126 To the Monthly Premium Rate

In Network: $300 Deductible, 90%/10% Coinsurance, $2,500 Out of Pocket

Out of Network: $600 Deductible, 70%/30% Coinsurance, $5,000 Out of Pocket

Prescription: $10/$25/$45 Copays, $100 Deductible, $1,500 Annual Max

AGE AT EFFECTIVE DATE

INDIVIDUAL

SUBSCRIBER + CHILD

SUBSCRIBER + SPOUSE

FAMILY

<21

$139

$221

$277

$401

21

$141

$226

$282

$409

22

$143

$229

$286

$415

23

$148

$236

$295

$429

24

$150

$239

$300

$436

25

$152

$244

$304

$441

26

$156

$251

$314

$455

27

$159

$253

$319

$461

28

$161

$258

$323

$468

29

$166

$265

$332

$482

30

$168

$270

$336

$489

31

$173

$277

$346

$502

32

$175

$282

$351

$507

33

$180

$288

$360

$521

34

$182

$290

$365

$528

35

$187

$300

$373

$541

36

$189

$302

$378

$548

37

$194

$309

$387

$563

38

$198

$319

$397

$574

39

$200

$321

$401

$581

40

$205

$327

$411

$595

41

$214

$343

$429

$623

42

$226

$362

$452

$655

43

$236

$376

$470

$682

44

$246

$394

$494

$715

45

$258

$412

$516

$750

46

$270

$431

$540

$782

47

$282

$450

$563

$816

48

$295

$473

$590

$855

49

$309

$494

$618

$897

50

$323

$516

$646

$936

51

$336

$540

$673

$975

52

$353

$565

$706

$1,023

53

$368

$590

$738

$1,070

54

$385

$616

$770

$1,116

55

$404

$646

$807

$1,171

56

$422

$675

$844

$1,225

57

$443

$708

$886

$1,284

58

$461

$738

$923

$1,337

59

$484

$775

$969

$1,405

60

$505

$807

$1,010

$1,464

61

$528

$844

$1,056

$1,531

62

$553

$886

$1,106

$1,605

63

$579

$927

$1,157

$1,678

64

$604

$966

$1,208

$1,753

65

$631

$1,010

$1,264

$1,833

>65

$662

$1,059

$1,323

$1,919

In Network: $300 Deductible, 80%/20% Coinsurance, $2,500 Out of Pocket

Out of Network: $600 Deductible, 60%/40% Coinsurance, $5,000 Out of Pocket

Prescription: $10/$25/$45 Copays, $100 Deductible, $1,500 Annual Max

AGE AT EFFECTIVE DATE

INDIVIDUAL

SUBSCRIBER + CHILD

SUBSCRIBER + SPOUSE

FAMILY

<21

$130

$208

$260

$377

21

$132

$212

$265

$384

22

$134

$215

$269

$390

23

$139

$221

$277

$403

24

$141

$225

$282

$410

25

$143

$230

$286

$414

26

$147

$236

$295

$427

27

$150

$238

$299

$434

28

$152

$242

$303

$440

29

$156

$249

$312

$453

30

$158

$254

$316

$459

31

$163

$260

$325

$472

32

$164

$265

$330

$477

33

$169

$271

$338

$490

34

$171

$273

$343

$496

35

$175

$282

$351

$509

36

$177

$284

$355

$515

37

$182

$290

$364

$529

38

$186

$299

$373

$539

39

$188

$301

$377

$546

40

$193

$308

$386

$559

41

$201

$322

$403

$585

42

$212

$340

$424

$615

43

$221

$354

$442

$641

44

$231

$370

$464

$671

45

$242

$388

$485

$705

46

$254

$405

$507

$735

47

$265

$423

$529

$767

48

$277

$445

$555

$804

49

$290

$464

$580

$843

50

$303

$485

$607

$880

51

$316

$507

$633

$917

52

$332

$531

$663

$962

53

$346

$555

$693

$1,006

54

$362

$579

$724

$1,049

55

$379

$607

$759

$1,100

56

$397

$635

$793

$1,151

57

$416

$665

$832

$1,207

58

$434

$693

$867

$1,257

59

$455

$728

$910

$1,320

60

$475

$759

$949

$1,376

61

$496

$793

$992

$1,438

62

$520

$832

$1,040

$1,508

63

$544

$871

$1,088

$1,577

64

$568

$907

$1,135

$1,647

65

$593

$949

$1,188

$1,722

>65

$622

$995

$1,244

$1,803

* To Include a Maternity Benefit Add $126 To the Monthly Premium Rate

In Network: $500 Deductible, 80%/20% Coinsurance, $2,500 Out of Pocket

Out of Network: $1,000 Deductible, 60%/40% Coinsurance, $5,000 Out of Pocket

Prescription: $10/$25/$45 Copays, $100 Deductible, $1,500 Annual Max

AGE AT EFFECTIVE DATE

INDIVIDUAL

SUBSCRIBER + CHILD

SUBSCRIBER + SPOUSE

FAMILY

<21

$122

$194

$243

$352

21

$124

$198

$247

$359

22

$125

$201

$252

$365

23

$130

$207

$259

$377

24

$131

$210

$264

$383

25

$134

$215

$267

$387

26

$137

$221

$276

$399

27

$140

$222

$280

$405

28

$142

$227

$283

$411

29

$146

$233

$292

$423

30

$148

$237

$295

$429

31

$152

$243

$304

$441

32

$154

$247

$308

$446

33

$158

$253

$316

$458

34

$160

$255

$320

$464

35

$164

$264

$328

$476

36

$166

$265

$332

$482

37

$170

$271

$340

$495

38

$174

$280

$349

$504

39

$176

$282

$352

$510

40

$180

$288

$361

$523

41

$188

$301

$377

$547

42

$198

$318

$397

$575

43

$207

$331

$413

$599

44

$216

$346

$434

$627

45

$227

$362

$453

$658

46

$237

$379

$474

$687

47

$247

$395

$495

$717

48

$259

$416

$519

$751

49

$271

$434

$543

$788

50

$283

$453

$568

$822

51

$295

$474

$592

$857

52

$310

$496

$620

$899

53

$324

$519

$648

$940

54

$338

$541

$676

$980

55

$355

$568

$709

$1,028

56

$371

$593

$741

$1,076

57

$389

$621

$778

$1,128

58

$405

$648

$810

$1,174

59

$425

$681

$851

$1,234

60

$444

$709

$887

$1,286

61

$464

$741

$927

$1,344

62

$486

$778

$972

$1,410

63

$508

$814

$1,016

$1,474

64

$531

$848

$1,061

$1,539

65

$555

$887

$1,110

$1,610

>65

$581

$930

$1,162

$1,685

* To Include a Maternity Benefit Add $126 To the Monthly Premium Rate

In Network: $750 Deductible, 80%/20% Coinsurance, $3,500 Out of Pocket

Out of Network: $1,500 Deductible, 60%/40% Coinsurance, $7,000 Out of Pocket

Prescription: $10/$25/$45 Copays, $100 Deductible, $1,500 Annual Max

AGE AT EFFECTIVE DATE

INDIVIDUAL

SUBSCRIBER + CHILD

SUBSCRIBER + SPOUSE

FAMILY

<21

$112

$178

$223

$323

21

$113

$182

$227

$329

22

$115

$184

$231

$335

23

$119

$190

$238

$346

24

$120

$193

$242

$351

25

$123

$197

$245

$355

26

$126

$202

$253

$366

27

$128

$204

$257

$372

28

$130

$208

$260

$377

29

$134

$213

$268

$388

30

$135

$217

$271

$394

31

$139

$223

$279

$405

32

$141

$227

$283

$409

33

$145

$232

$290

$420

34

$146

$234

$294

$425

35

$150

$242

$301

$436

36

$152

$243

$305

$442

37