BlueChoice Underwritten -- Maryland

"High Option"

In Network: $10/$20 Copays, $250 Hospital Copay, $2000/$4000/$6000 Out Of Pocket
Prescription: $10/$25/$40 Copays, $50 Deductible, $1,000 Annual Max

Monthly Premium Rates Effective: January 1, 2007

AGE Ind. Ind. & Child(ren) Ind. & Adult Family
1-5 $200      
6-17 $178 $339 $373 $482
18-20 $251 $476 $528 $678
21 $255 $485 $536 $687
22 $259 $493 $545 $701
23 $264 $502 $553 $713
24 $268 $511 $562 $722
25 $273 $519 $571 $734
26 $277 $528 $579 $748
27 $281 $536 $592 $760
28 $285 $541 $600 $769
29 $290 $549 $609 $782
30 $298 $567 $626 $804
31 $306 $583 $644 $829
32 $315 $600 $661 $851
33 $324 $618 $682 $876
34 $332 $630 $700 $898
35 $341 $648 $717 $919
36 $350 $665 $733 $945
37 $359 $682 $751 $967
38 $367 $700 $772 $993
39 $376 $712 $789 $1,014
40 $385 $730 $807 $1,035
41 $401 $764 $841 $1,082
42 $423 $803 $889 $1,143
43 $439 $836 $922 $1,185
44 $462 $875 $969 $1,246
45 $483 $918 $1,013 $1,302
46 $504 $957 $1,060 $1,362
47 $526 $1,000 $1,103 $1,418
48 $551 $1,047 $1,158 $1,491
49 $577 $1,099 $1,210 $1,559
50 $603 $1,146 $1,266 $1,628
51 $628 $1,193 $1,322 $1,696
52 $659 $1,253 $1,382 $1,778
53 $689 $1,309 $1,446 $1,860
54 $719 $1,364 $1,511 $1,941
55 $754 $1,434 $1,584 $2,035
56 $787 $1,497 $1,653 $2,126
57 $826 $1,571 $1,733 $2,229
58 $860 $1,635 $1,807 $2,323
59 $904 $1,717 $1,897 $2,439
60 $942 $1,789 $1,978 $2,542
61 $985 $1,871 $2,069 $2,658
62 $1,032 $1,962 $2,167 $2,787
63 $1,079 $2,051 $2,266 $2,916
64 $1,126 $2,142 $2,365 $3,040
65 $1,178 $2,240 $2,473 $3,182
66+ $1,234 $2,343 $2,593 $3,332
OPTIONAL DENTAL $10 $20 $20 $30