BlueChoice DC RATES FOR INDIVIDUAL AND ADULT
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 | $192 | $173 | $153 |
| 18-20 | $279 | $252 | $223 |
| 21 | $284 | $257 | $227 |
| 22 | $289 | $261 | $230 |
| 23 | $298 | $269 | $238 |
| 24 | $302 | $274 | $241 |
| 25 | $307 | $277 | $245 |
| 26 | $316 | $286 | $252 |
| 27 | $321 | $290 | $255 |
| 28 | $326 | $294 | $259 |
| 29 | $335 | $302 | $266 |
| 30 | $339 | $307 | $271 |
| 31 | $349 | $314 | $278 |
| 32 | $353 | $318 | $281 |
| 33 | $362 | $327 | $288 |
| 34 | $367 | $331 | $292 |
| 35 | $376 | $340 | $299 |
| 36 | $380 | $344 | $303 |
| 37 | $389 | $351 | $310 |
| 38 | $399 | $360 | $318 |
| 39 | $403 | $364 | $322 |
| 40 | $413 | $373 | $329 |
| 41 | $431 | $389 | $343 |
| 42 | $454 | $410 | $361 |
| 43 | $472 | $426 | $376 |
| 44 | $495 | $447 | $394 |
| 45 | $519 | $468 | $413 |
| 46 | $541 | $489 | $431 |
| 47 | $564 | $509 | $449 |
| 48 | $592 | $534 | $471 |
| 49 | $619 | $559 | $492 |
| 50 | $647 | $584 | $515 |
| 51 | $674 | $608 | $536 |
| 52 | $707 | $637 | $562 |
| 53 | $739 | $667 | $587 |
| 54 | $770 | $696 | $613 |
| 55 | $808 | $729 | $642 |
| 56 | $844 | $762 | $671 |
| 57 | $886 | $799 | $705 |
| 58 | $922 | $832 | $733 |
| 59 | $969 | $874 | $770 |
| 60 | $1,009 | $911 | $803 |
| 61 | $1,056 | $952 | $839 |
| 62 | $1,106 | $997 | $879 |
| 63 | $1,157 | $1,043 | $919 |
| 64 | $1,207 | $1,089 | $959 |
| 65 | $1,262 | $1,139 | $1,003 |
| 65+ | $1,322 | $1,182 | $1,051 |
* To include Dental Benefit, add $20 to the monthly premium rate.
** To include Maternity Benefit, add $126 to the monthly premium rate.