BlueChoice DC RATES FOR INDIVIDUAL
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 | $107 | $97 | $86 |
| 6-17 | $97 | $87 | $77 |
| 18-20 | $140 | $127 | $111 |
| 21 | $142 | $128 | $113 |
| 22 | $145 | $130 | $115 |
| 23 | $149 | $134 | $118 |
| 24 | $151 | $137 | $121 |
| 25 | $154 | $138 | $123 |
| 26 | $158 | $143 | $126 |
| 27 | $160 | $145 | $128 |
| 28 | $163 | $147 | $130 |
| 29 | $167 | $151 | $134 |
| 30 | $169 | $153 | $135 |
| 31 | $174 | $157 | $138 |
| 32 | $177 | $160 | $141 |
| 33 | $181 | $164 | $144 |
| 34 | $184 | $166 | $147 |
| 35 | $188 | $170 | $150 |
| 36 | $190 | $171 | $151 |
| 37 | $195 | $176 | $155 |
| 38 | $199 | $180 | $159 |
| 39 | $202 | $183 | $161 |
| 40 | $207 | $186 | $164 |
| 41 | $216 | $194 | $172 |
| 42 | $226 | $204 | $181 |
| 43 | $237 | $213 | $188 |
| 44 | $247 | $223 | $198 |
| 45 | $259 | $234 | $206 |
| 46 | $270 | $244 | $215 |
| 47 | $282 | $255 | $225 |
| 48 | $296 | $267 | $236 |
| 49 | $309 | $279 | $246 |
| 50 | $324 | $292 | $257 |
| 51 | $337 | $305 | $269 |
| 52 | $353 | $319 | $281 |
| 53 | $369 | $333 | $294 |
| 54 | $386 | $348 | $307 |
| 55 | $404 | $364 | $321 |
| 56 | $422 | $381 | $335 |
| 57 | $443 | $399 | $352 |
| 58 | $461 | $416 | $367 |
| 59 | $484 | $437 | $385 |
| 60 | $505 | $455 | $401 |
| 61 | $527 | $476 | $419 |
| 62 | $553 | $499 | $439 |
| 63 | $578 | $521 | $460 |
| 64 | $604 | $544 | $480 |
| 65 | $631 | $569 | $501 |
| 65+ | $661 | $596 | $525 |
* To include Dental Benefit, add $10 to the monthly premium rate.
** To include Maternity Benefit, add $126 to the monthly premium rate.