RATES FOR PLANS A - D Premiums must be calculated on the basis of mode of payment selected. Plan A Bankdraft Individual 1 Parent Family 2 Parent Family Ages 18 - 44 $2347 $2574 $3745 Ages 45 - 54 $2988 $3215 $4739 Ages 55 - 64 $4083 $4325 $6419 Ages 65 - 69* $4444 $4444 $6666
Plan A Payroll
Individual
1 Parent Family
2 Parent Family
Ages 18 - 64
$2130
$2357
$3417
Individual
1 Parent Family
2 Parent Family
Plan B Bankdraft
$5000 $3371 $4292 $5895 $6116
$10000 $3701 $4622 $6225 $6776
$5000 $3712 $4633 $6273 $6116
$10000 $4072 $4993 $6633 $6776
$5000 $5391 $6854 $9352 $9174
$10000 $5917 $7380 $9878 $10164
Ages 18 - 44 Ages 45 - 54 Ages 55 - 64 Ages 65 - 69*
Individual
1 Parent Family
2 Parent Family
Plan B Payroll
$5000 $3055
$10000 $3355
$5000 $3396
$10000 $3726
$5000 $4911
$10000 $5391
Ages 18 - 64
Plan C Bankdraft
Individual
1 Parent Family
2 Parent Family
Ages 18 - 44 Ages 45 - 54 Ages 55 - 64 Ages 65 - 69*
$5267 $6618 $9003 $9284
$5814 $7165 $9625 $9284
$8440 $10625 $14393 $13926
Plan C Payroll
Individual
1 Parent Family
2 Parent Family
Ages 18 - 64
$4770
$5317
$7677
Plan D Bankdraft
Individual
1 Parent Family
2 Parent Family
Ages 18 - 44 Ages 45 - 54 Ages 55 - 64 Ages 65 - 69*
$4682 $5878 $8138 $6864
$5244 $6440 $8850 $6864
$7562 $9680 $13446 $10296
Plan D Payroll
Individual
1 Parent Family
2 Parent Family
Ages 18 - 64
$4220
$4782
$6842
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FOR AGENT USE ONLY
AGT-CP4000 0216
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