ACTUAL PREMIUM RATE MAY BE EITHER 25% OR 50% HIGHER THAN STATED PREMIUM RATES BASED ON THE MEDICAL UNDERWRITING RESULTS

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	$160
6-17	$143	$273	$286	$388
18-20	$208	$397	$417	$563
21	$213	$404	$424	$573
22	$216	$411	$431	$580
23	$223	$424	$445	$601
24	$226	$431	$452	$611
25	$230	$435	$458	$618
26	$237	$448	$472	$639
27	$240	$455	$479	$646
28	$243	$462	$486	$656
29	$250	$476	$501	$674
30	$254	$482	$507	$684
31	$261	$497	$521	$704
32	$264	$501	$528	$711
33	$271	$514	$542	$732
34	$274	$521	$548	$739
35	$281	$535	$562	$759
36	$284	$542	$569	$767
37	$291	$555	$583	$787
38	$298	$566	$596	$805
39	$302	$572	$603	$815
40	$308	$586	$617	$832
41	$322	$613	$645	$869
42	$339	$645	$679	$918
43	$354	$673	$707	$953
44	$371	$703	$741	$1,000
45	$388	$738	$776	$1,046
46	$405	$769	$810	$1,094
47	$422	$804	$845	$1,138
48	$443	$841	$886	$1,197
49	$463	$882	$928	$1,252
50	$484	$921	$969	$1,307
51	$505	$958	$1,010	$1,363
52	$529	$1,006	$1,059	$1,428
53	$553	$1,052	$1,106	$1,494
54	$577	$1,096	$1,154	$1,559
55	$605	$1,151	$1,210	$1,635
56	$633	$1,203	$1,265	$1,707
57	$664	$1,261	$1,327	$1,790
58	$691	$1,313	$1,382	$1,865
59	$725	$1,379	$1,451	$1,958
60	$756	$1,437	$1,513	$2,041
61	$791	$1,503	$1,581	$2,134
62	$829	$1,575	$1,658	$2,237
63	$866	$1,647	$1,733	$2,341
64	$905	$1,719	$1,809	$2,441
65	$946	$1,799	$1,892	$2,554
66 and over	$991	$1,882	$1,981	$2,675
* To Include a Maternity Benefit Add $126 To the Monthly Premium Rate

In Network: $300 Deductible, 90%/10% Coinsurance, $2,500 Out of Pocket
Out of Network: $500 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	$140
6-17	$125	$239	$250	$339
18-20	$182	$347	$364	$492
21	$186	$353	$370	$500
22	$188	$359	$376	$507
23	$194	$370	$389	$525
24	$197	$376	$395	$534
25	$201	$380	$400	$540
26	$207	$391	$413	$558
27	$209	$398	$419	$564
28	$212	$404	$425	$572
29	$218	$416	$437	$588
30	$222	$421	$442	$597
31	$228	$434	$455	$615
32	$230	$437	$461	$621
33	$237	$449	$473	$639
34	$239	$455	$478	$646
35	$245	$467	$491	$663
36	$248	$473	$497	$669
37	$254	$485	$509	$687
38	$260	$494	$521	$703
39	$264	$499	$527	$711
40	$269	$512	$539	$726
41	$281	$535	$563	$759
42	$296	$563	$593	$801
43	$309	$587	$617	$832
44	$324	$614	$647	$873
45	$338	$645	$677	$913
46	$353	$671	$707	$955
47	$368	$702	$738	$993
48	$387	$734	$774	$1,044
49	$404	$770	$810	$1,093
50	$423	$804	$846	$1,141
51	$440	$836	$882	$1,189
52	$461	$878	$924	$1,246
53	$483	$918	$965	$1,304
54	$504	$956	$1,007	$1,361
55	$528	$1,005	$1,056	$1,427
56	$552	$1,049	$1,104	$1,490
57	$579	$1,100	$1,157	$1,562
58	$603	$1,146	$1,206	$1,628
59	$633	$1,203	$1,267	$1,708
60	$660	$1,254	$1,320	$1,780
61	$690	$1,311	$1,380	$1,862
62	$723	$1,375	$1,447	$1,952
63	$756	$1,437	$1,512	$2,042
64	$789	$1,500	$1,578	$2,129
65	$825	$1,570	$1,650	$2,229
66 and over	$865	$1,642	$1,729	$2,334
* 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: $500Deductible, 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	$122
6-17	$109	$209	$219	$297
18-20	$159	$303	$318	$430
21	$162	$309	$324	$438
22	$165	$314	$329	$443
23	$170	$324	$340	$459
24	$172	$329	$346	$467
25	$175	$333	$350	$472
26	$181	$342	$361	$488
27	$183	$348	$366	$493
28	$185	$353	$372	$501
29	$191	$364	$382	$515
30	$194	$368	$387	$522
31	$199	$379	$398	$537
32	$202	$382	$403	$543
33	$207	$392	$414	$559
34	$209	$398	$418	$564
35	$215	$408	$429	$580
36	$217	$414	$434	$585
37	$222	$424	$445	$600
38	$228	$432	$455	$614
39	$231	$437	$460	$622
40	$235	$447	$471	$635
41	$246	$468	$492	$663
42	$259	$492	$518	$700
43	$270	$514	$540	$727
44	$283	$536	$566	$763
45	$296	$563	$592	$798
46	$309	$586	$618	$834
47	$322	$613	$645	$868
48	$338	$642	$676	$913
49	$353	$673	$708	$955
50	$370	$702	$739	$997
51	$385	$731	$771	$1,039
52	$403	$767	$807	$1,089
53	$422	$802	$843	$1,139
54	$440	$836	$880	$1,189
55	$462	$878	$922	$1,246
56	$482	$917	$965	$1,302
57	$506	$961	$1,011	$1,365
58	$527	$1,002	$1,054	$1,422
59	$553	$1,051	$1,107	$1,493
60	$577	$1,096	$1,153	$1,556
61	$603	$1,146	$1,205	$1,627
62	$632	$1,201	$1,264	$1,705
63	$660	$1,255	$1,321	$1,784
64	$689	$1,311	$1,379	$1,860
65	$721	$1,371	$1,442	$1,947
66 and over	$756	$1,434	$1,510	$2,039
* 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: $750 Deductible, 60%/40% Coinsurance, $4,000 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	$116
6-17	$104	$198	$208	$282
18-20	$151	$288	$302	$408
21	$154	$293	$307	$415
22	$156	$298	$313	$421
23	$161	$307	$323	$436
24	$164	$313	$328	$443
25	$167	$316	$332	$448
26	$172	$325	$342	$463
27	$174	$330	$348	$468
28	$176	$335	$353	$475
29	$181	$346	$363	$488
30	$184	$350	$367	$496
31	$189	$360	$377	$510
32	$191	$363	$383	$515
33	$196	$372	$393	$531
34	$198	$377	$397	$536
35	$204	$388	$407	$550
36	$206	$393	$412	$555
37	$211	$402	$423	$570
38	$216	$410	$432	$583
39	$219	$414	$437	$590
40	$223	$425	$447	$603
41	$233	$444	$467	$629
42	$246	$467	$492	$664
43	$256	$487	$512	$690
44	$268	$509	$537	$724
45	$281	$535	$562	$757
46	$293	$556	$586	$792
47	$305	$582	$612	$824
48	$321	$609	$642	$866
49	$335	$639	$672	$906
50	$351	$666	$701	$946
51	$365	$693	$731	$986
52	$383	$728	$766	$1,034
53	$400	$761	$800	$1,081
54	$418	$793	$835	$1,128
55	$438	$833	$875	$1,183
56	$458	$870	$915	$1,235
57	$480	$912	$960	$1,295
58	$500	$950	$1,000	$1,350
59	$525	$998	$1,050	$1,416
60	$547	$1,040	$1,094	$1,476
61	$572	$1,087	$1,144	$1,544
62	$600	$1,140	$1,199	$1,618
63	$626	$1,191	$1,254	$1,693
64	$654	$1,244	$1,308	$1,765
65	$684	$1,301	$1,368	$1,847
66 and over	$717	$1,361	$1,433	$1,935
* To Include a Maternity Benefit Add $126 To the Monthly Premium Rate