BlueChoice DC RATES FOR FAMILY
Prescription: $10/$25/$40 Copays, $100 Deductible, $1000 Annual Max
Monthly Premium Rates Effective: AUGUST 1, 2007
| AGE | HIGH OPTION $10/$20 copay |
MEDIUM OPTION $15/ $25 Copay |
LOW OPTION $20/$30 Copay |
| 1-5 | |||
| 6-17 | $260 | $235 | $208 |
| 18-20 | $337 | $341 | $300 |
| 21 | $384 | $347 | $306 |
| 22 | $389 | $351 | $310 |
| 23 | $402 | $364 | $320 |
| 24 | $409 | $369 | $326 |
| 25 | $414 | $374 | $330 |
| 26 | $428 | $385 | $340 |
| 27 | $432 | $390 | $344 |
| 28 | $439 | $397 | $350 |
| 29 | $450 | $407 | $358 |
| 30 | $458 | $413 | $364 |
| 31 | $471 | $425 | $375 |
| 32 | $476 | $430 | $378 |
| 33 | $490 | $441 | $390 |
| 34 | $494 | $446 | $394 |
| 35 | $508 | $458 | $404 |
| 36 | $512 | $463 | $408 |
| 37 | $526 | $474 | $419 |
| 38 | $538 | $486 | $428 |
| 39 | $544 | $491 | $433 |
| 40 | $556 | $502 | $442 |
| 41 | $581 | $524 | $463 |
| 42 | $613 | $553 | $489 |
| 43 | $636 | $575 | $506 |
| 44 | $669 | $603 | $531 |
| 45 | $699 | $630 | $555 |
| 46 | $730 | $659 | $581 |
| 47 | $760 | $686 | $605 |
| 48 | $800 | $721 | $636 |
| 49 | $838 | $754 | $665 |
| 50 | $873 | $787 | $694 |
| 51 | $910 | $820 | $723 |
| 52 | $953 | $860 | $758 |
| 53 | $997 | $899 | $792 |
| 54 | $1,040 | $939 | $828 |
| 55 | $1,091 | $984 | $867 |
| 56 | $1,140 | $1,028 | $906 |
| 57 | $1,194 | $1,077 | $950 |
| 58 | $1,245 | $1,123 | $990 |
| 59 | $1,307 | $1,179 | $1,039 |
| 60 | $1,362 | $1,229 | $1,083 |
| 61 | $1,424 | $1,285 | $1,131 |
| 62 | $1,492 | $1,347 | $1,187 |
| 63 | $1,561 | $1,408 | $1,241 |
| 64 | $1,628 | $1,469 | $1,294 |
| 65 | $1,704 | $1,537 | $1,354 |
| 65+ | $1,784 | $1,609 | $1,418 |
* To include Dental Benefit, add $30 to the monthly premium rate.
** To include Maternity Benefit, add $126 to the monthly premium rate.