BlueChoice DC RATES FOR INDIVIDUAL AND CHILD
Prescription: $10/$25/$40 Copays, $100 Deductible, $1000 Annual Max
Monthly Premium Rates Effective: AUGUST 1, 2007
| AGE |
HIGH OPTION |
MEDIUM OPTION |
LOW OPTION |
| 1-5 | |||
| 6-17 | $183 | $166 | $146 |
| 18-20 | $266 | $240 | $212 |
| 21 | $270 | $244 | $215 |
| 22 | $275 | $248 | $219 |
| 23 | $284 | $257 | $227 |
| 24 | $289 | $261 | $230 |
| 25 | $291 | $262 | $232 |
| 26 | $300 | $271 | $239 |
| 27 | $305 | $275 | $242 |
| 28 | $309 | $279 | $247 |
| 29 | $319 | $288 | $254 |
| 30 | $323 | $292 | $258 |
| 31 | $332 | $300 | $265 |
| 32 | $335 | $302 | $266 |
| 33 | $344 | $311 | $274 |
| 34 | $349 | $314 | $278 |
| 35 | $358 | $323 | $285 |
| 36 | $362 | $327 | $288 |
| 37 | $371 | $335 | $296 |
| 38 | $379 | $341 | $301 |
| 39 | $383 | $346 | $305 |
| 40 | $392 | $354 | $312 |
| 41 | $410 | $370 | $326 |
| 42 | $431 | $389 | $343 |
| 43 | $449 | $406 | $357 |
| 44 | $470 | $424 | $374 |
| 45 | $493 | $445 | $393 |
| 46 | $514 | $463 | $408 |
| 47 | $537 | $485 | $427 |
| 48 | $562 | $507 | $447 |
| 49 | $589 | $532 | $469 |
| 50 | $615 | $555 | $489 |
| 51 | $640 | $578 | $509 |
| 52 | $672 | $607 | $535 |
| 53 | $702 | $634 | $559 |
| 54 | $732 | $660 | $582 |
| 55 | $769 | $693 | $611 |
| 56 | $803 | $724 | $638 |
| 57 | $842 | $760 | $669 |
| 58 | $877 | $790 | $696 |
| 59 | $920 | $830 | $732 |
| 60 | $959 | $865 | $763 |
| 61 | $1,003 | $905 | $797 |
| 62 | $1,051 | $948 | $835 |
| 63 | $1,099 | $991 | $874 |
| 64 | $1,148 | $1,034 | $912 |
| 65 | $1,200 | $1,083 | $954 |
| 65+ | $1,255 | $1,132 | $997 |
* To include Dental Benefit, add $20 to the monthly premium rate.
** To include Maternity Benefit, add $126 to the monthly premium rate.