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