BlueChoice Underwritten -- Maryland

"Medium Option"

In Network: $15/$25 Copays, $500 Hospital Copay, $3,000/$6000/$9000 Out of Pocket
Prescription: $10/$25/$40 Copays, $100 Deductible, $1,000 Annual Max

Monthly Premium Rates Effective: January 1, 2007

AGE Ind. Ind. & Child(ren) Ind. & Adult Family
1-5 $174      
6-17 $155 $295 $324 $419
18-20 $218 $413 $459 $589
21 $222 $421 $466 $597
22 $225 $429 $473 $608
23 $229 $436 $481 $619
24 $233 $443 $488 $627
25 $236 $451 $496 $638
26 $241 $459 $504 $650
27 $244 $466 $515 $661
28 $247 $470 $521 $668
29 $252 $477 $529 $680
30 $259 $492 $544 $698
31 $266 $507 $559 $720
32 $274 $521 $574 $739
33 $282 $537 $593 $761
34 $289 $548 $607 $780
35 $296 $563 $623 $799
36 $304 $577 $637 $821
37 $311 $593 $652 $839
38 $319 $607 $671 $861
39 $326 $618 $685 $880
40 $333 $634 $701 $899
41 $349 $663 $730 $940
42 $367 $697 $771 $992
43 $382 $727 $801 $1,030
44 $400 $760 $843 $1,081
45 $419 $798 $879 $1,130
46 $438 $831 $921 $1,183
47 $457 $868 $957 $1,231
48 $479 $909 $1,006 $1,294
49 $502 $954 $1,051 $1,353
50 $524 $995 $1,099 $1,413
51 $546 $1,036 $1,148 $1,472
52 $572 $1,088 $1,199 $1,544
53 $598 $1,136 $1,255 $1,614
54 $624 $1,185 $1,311 $1,685
55 $654 $1,244 $1,374 $1,767
56 $683 $1,300 $1,435 $1,845
57 $717 $1,363 $1,505 $1,934
58 $747 $1,419 $1,568 $2,017
59 $784 $1,490 $1,647 $2,117
60 $818 $1,554 $1,718 $2,206
61 $855 $1,624 $1,796 $2,307
62 $896 $1,702 $1,882 $2,419
63 $937 $1,780 $1,967 $2,531
64 $978 $1,859 $2,052 $2,639
65 $1,022 $1,944 $2,146 $2,762
65+ $1,071 $2,035 $2,250 $2,892
OPTIONAL DENTAL $10 $20 $20 $30