*In Network: $100 Deductible, 90%/10% Coinsurance, $2,500 Out of Pocket*
*Out of Network: $300 Deductible, 70%/30% Coinsurance, $5,000 Out of Pocket*
*Prescription: $10/$25/$45 Copays, $100 Deductible, $1,500 Annual Max*
AGE AT EFFECTIVE DATE	INDIVIDUAL	INDIVIDUAL & CHILDREN	INDIVIDUAL & ADULT	FAMILY
1-5	$130
6-17	$116	$221	$232	$313
18-20	$168	$320	$337	$454
21	$171	$326	$343	$463
22	$174	$331	$348	$468
23	$180	$343	$360	$485
24	$182	$348	$364	$493
25	$186	$351	$370	$499
26	$190	$362	$381	$516
27	$194	$368	$387	$521
28	$196	$373	$393	$529
29	$202	$384	$403	$543
30	$205	$389	$409	$551
31	$211	$401	$420	$568
32	$213	$403	$426	$574
33	$219	$414	$437	$591
34	$221	$420	$443	$596
35	$227	$432	$453	$613
36	$230	$437	$459	$618
37	$235	$448	$470	$634
38	$240	$457	$482	$649
39	$244	$462	$486	$657
40	$249	$473	$498	$671
41	$260	$495	$520	$702
42	$274	$520	$548	$740
43	$285	$542	$570	$768
44	$298	$567	$598	$807
45	$313	$595	$625	$843
46	$327	$620	$654	$882
47	$341	$648	$681	$918
48	$358	$678	$714	$965
49	$374	$712	$747	$1,009
50	$391	$742	$781	$1,054
51	$407	$772	$815	$1,098
52	$426	$811	$853	$1,151
53	$446	$848	$892	$1,203
54	$465	$884	$931	$1,257
55	$488	$928	$975	$1,317
56	$509	$970	$1,020	$1,376
57	$534	$1,017	$1,070	$1,443
58	$557	$1,059	$1,114	$1,503
59	$585	$1,111	$1,169	$1,578
60	$610	$1,158	$1,219	$1,645
61	$637	$1,211	$1,275	$1,720
62	$668	$1,270	$1,336	$1,803
63	$699	$1,328	$1,397	$1,886
64	$729	$1,386	$1,458	$1,967
65	$762	$1,450	$1,525	$2,058
66 and over	$799	$1,516	$1,597	$2,155
* To Include a Maternity Benefit Add $126 To the Monthly Premium Rate

*In Network: $300 Deductible, 80%/20% Coinsurance, $2,500 Out of Pocket*
*Out of Network: $600 Deductible, 60%/40% Coinsurance, $5,000 Out of Pocket*
*Prescription: $10/$25/$45 Copays, $100 Deductible, $1,500 Annual Max*
AGE AT EFFECTIVE DATE	INDIVIDUAL	INDIVIDUAL & CHILDREN	INDIVIDUAL & ADULT	FAMILY
1-5	$96
6-17	$85	$162	$170	$230
18-20	$123	$235	$247	$333
21	$126	$239	$252	$339
22	$127	$243	$255	$343
23	$132	$252	$264	$356
24	$134	$255	$267	$362
25	$136	$258	$271	$366
26	$140	$265	$279	$378
27	$142	$270	$284	$381
28	$144	$273	$288	$387
29	$148	$282	$296	$398
30	$150	$285	$300	$404
31	$154	$294	$308	$416
32	$156	$296	$312	$420
33	$160	$303	$320	$433
34	$162	$308	$324	$437
35	$166	$316	$332	$449
36	$168	$320	$336	$452
37	$173	$329	$344	$464
38	$176	$335	$353	$475
39	$179	$338	$356	$481
40	$182	$347	$365	$491
41	$191	$362	$380	$514
42	$200	$380	$401	$542
43	$209	$397	$418	$562
44	$218	$415	$438	$591
45	$229	$436	$457	$617
46	$239	$454	$478	$645
47	$250	$474	$498	$671
48	$262	$496	$522	$706
49	$274	$521	$547	$738
50	$286	$543	$572	$771
51	$298	$565	$596	$803
52	$312	$593	$624	$842
53	$327	$620	$652	$880
54	$340	$646	$681	$919
55	$357	$679	$713	$963
56	$372	$709	$746	$1,006
57	$391	$744	$782	$1,055
58	$407	$774	$814	$1,099
59	$428	$812	$855	$1,153
60	$446	$847	$891	$1,203
61	$466	$885	$932	$1,257
62	$488	$928	$977	$1,318
63	$511	$971	$1,021	$1,378
64	$532	$1,013	$1,066	$1,437
65	$557	$1,060	$1,114	$1,504
66 and over	$584	$1,108	$1,167	$1,575
* To Include a Maternity Benefit Add $126 To the Monthly Premium Rate

*In Network: $500 Deductible, 80%/20% Coinsurance, $2,500 Out of Pocket*
*Out of Network: $1,000 Deductible, 60%/40% Coinsurance, $5,000 Out of Pocket*
*Prescription: $10/$25/$45 Copays, $100 Deductible, $1,500 Annual Max*
AGE AT EFFECTIVE DATE	INDIVIDUAL	INDIVIDUAL & CHILDREN	INDIVIDUAL & ADULT	FAMILY
1-5	$89	-	-	-
6-17	$80	$152	$159	$215
18-20	$115	$220	$231	$312
21	$118	$224	$235	$317
22	$119	$227	$239	$321
23	$123	$235	$247	$333
24	$125	$239	$250	$338
25	$127	$241	$254	$342
26	$131	$248	$261	$354
27	$133	$252	$265	$357
28	$135	$256	$269	$363
29	$139	$264	$277	$372
30	$140	$267	$281	$378
31	$144	$275	$288	$389
32	$146	$277	$292	$393
33	$150	$284	$299	$405
34	$152	$288	$303	$409
35	$156	$296	$311	$420
36	$157	$299	$315	$423
37	$161	$307	$322	$435
38	$165	$313	$330	$444
39	$167	$316	$333	$450
40	$170	$324	$341	$460
41	$178	$339	$356	$481
42	$187	$356	$375	$507
43	$195	$371	$391	$526
44	$204	$388	$409	$553
45	$214	$408	$428	$577
46	$224	$425	$447	$604
47	$233	$443	$466	$628
48	$245	$464	$489	$660
49	$256	$487	$511	$690
50	$267	$508	$535	$721
51	$279	$528	$557	$751
52	$292	$555	$583	$787
53	$305	$580	$610	$823
54	$318	$604	$637	$859
55	$334	$635	$667	$901
56	$348	$663	$697	$941
57	$365	$696	$731	$986
58	$381	$724	$761	$1,028
59	$400	$760	$799	$1,079
60	$417	$792	$833	$1,125
61	$436	$828	$871	$1,176
62	$457	$868	$913	$1,232
63	$478	$908	$955	$1,289
64	$498	$947	$997	$1,344
65	$521	$991	$1,042	$1,406
66 and over	$546	$1,036	$1,091	$1,473
* To Include a Maternity Benefit Add $126 To the Monthly Premium Rate

*In Network: $750 Deductible, 80%/20% Coinsurance, $3,500 Out of Pocket*
*Out of Network: $1,500 Deductible, 60%/40% Coinsurance, $7,000 Out of Pocket*
*Prescription: $10/$25/$45 Copays, $100 Deductible, $1,500 Annual Max*
AGE AT EFFECTIVE DATE	INDIVIDUAL	INDIVIDUAL & CHILDREN	INDIVIDUAL & ADULT	FAMILY
1-5	$82
6-17	$73	$140	$147	$198
18-20	$106	$202	$213	$286
21	$108	$206	$216	$291
22	$110	$209	$219	$295
23	$113	$216	$227	$306
24	$115	$219	$230	$311
25	$117	$222	$233	$315
26	$120	$228	$240	$325
27	$122	$232	$244	$328
28	$124	$235	$248	$333
29	$128	$242	$254	$342
30	$129	$245	$258	$347
31	$133	$253	$265	$358
32	$134	$254	$268	$361
33	$138	$261	$275	$372
34	$139	$265	$279	$376
35	$143	$272	$285	$386
36	$145	$275	$289	$389
37	$148	$282	$296	$399
38	$151	$288	$303	$408
39	$154	$290	$306	$413
40	$156	$298	$314	$422
41	$164	$311	$327	$442
42	$172	$327	$345	$465
43	$179	$341	$359	$483
44	$187	$357	$376	$508
45	$196	$375	$393	$530
46	$205	$390	$411	$554
47	$214	$407	$428	$577
48	$225	$426	$449	$606
49	$235	$447	$469	$634
50	$246	$467	$491	$662
51	$256	$485	$512	$689
52	$268	$509	$535	$723
53	$280	$533	$560	$755
54	$292	$555	$585	$789
55	$306	$583	$612	$827
56	$320	$609	$640	$864
57	$335	$639	$671	$906
58	$349	$665	$699	$943
59	$367	$697	$734	$990
60	$383	$727	$765	$1,033
61	$400	$760	$800	$1,079
62	$419	$797	$838	$1,131
63	$439	$833	$876	$1,183
64	$457	$870	$915	$1,234
65	$478	$910	$956	$1,291
66 and over	$501	$951	$1,002	$1,352
* To Include a Maternity Benefit Add $126 To the Monthly Premium Rate