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Calculate Your Premium for standard HMO Product

 		 

Step 1 of 4:     Select a Benefit Level
Base-level Plan:   Medical deductible applies to all services. Separate deductible applies to prescription drugs.
Mid-level Plan: Medical deductible does not apply to office visits. Separate deductible applies to prescription drugs.
High-level Plan: Medical deductible does not apply to office visits. No deductible for prescription drugs.

Step 2 of 4:   Select Coverage Options
Type of Coverage:
Age of Oldest Family Member:
Coinsurance - Copay:
Supplemental Accident:   First $1000 covered at 100% for accidental injuries.

Estimated Monthly Medical Premium

Step 3 of 4:   Choose a Deductible and Out-of-Pocket Maximum level.
(Deductibles and Out-of-Pocket Maximums are calculated on a Calendar Year basis.)
Medical
Deductibles 		Prescription
Drug Deductibles		 Out-of-Pocket
Maximums

Per Person

Per Family

Per Person

Per Person

Per Family
$250 $750 $150 $2500 $5000
$500 $1500 $250 $3000 $6000
$1000 * $2500 $500 $3500 $7000
$2500 ** $5000 $1000 $4000 $8000
$5000 ** $10000 $2000 $6500 $13000
$7500 ** $15000 $2000 $9000 $18000
* This deductible and out-of-pocket maximum level is not available on the Mid-level Benefit Plan.
* * This deductible and out-of-pocket maximum level is not available on the Mid-level or High-level Benefit Plans.
* * * Prescription Drug Deductible waived when purchasing Tier 1 prescriptions.

Step 4 of 4:   Calculate Premium

Estimated Monthly Premium
Select Value Select Med Plus Select Care Plus
N/A N/A N/A

Estimated Monthly Dental Premium

Estimated Monthly Premium
Annual Max Benefit 750 1000 1500
  $82.00 $90.00 $88.00

Additional Information About Estimated Monthly Premiums
1. These are only estimated monthly premiums and are subject to change based on underwriting review.
2. Premium rates are based on the age of the oldest family member. The enrollment application must
be written with the oldest family member as the applicant.
3. Premiums under these plans are subject to adjustment each January 1, if your original effective date is
January 1 through June 30, or each July 1, if your original effective date is July 1 through December 31.
4. Premiums will increase on the first of the month following the birthday on which the Subscriber (policy
holder) moves from one age category to another.
The age catagories are as follows: 0 to 19 years, 20 to 24 years, 25 to 29 years, 30 to 34 years, 35 to
39 years, 40 to 44 years, 45 to 49 years, 50 to 54 years, 55 to 59 years, 60 to 64 years, 65 to 69 years,
70 to 74 years, 75 to 79 years, 80 to 84 years, and 85 years of age or older.