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Index | Optional Dental Coverage | Exclusions
& Limitations | Locate Providers &
Pharmacy | Application
Plan Benefits:
Maximizer | Beneficial Value (PPO)
| Beneficial Rx (PPO) | HSA Value | HSA
3000
Plan Rates:
Maximizer | Beneficial Value (PPO) | Beneficial Value w/ Rx Option | Beneficial
Rx (PPO) | HSA Value | HSA
3000
Maximizer Rates
Effective date : 11/1/2009
Valid thru : 10/30/2010
Counties :
Available in all counties
| Family Status : |
Applicant |
Applicant and Spouse |
Applicant and Child(ren) |
Applicant and Family |
| Age |
Deductible : 1000 |
| 0-19 |
100.00 |
199.00 |
172.00 |
277.00 |
| 20-24 |
146.00 |
290.00 |
250.00 |
404.00 |
| 25-29 |
159.00 |
336.00 |
293.00 |
473.00 |
| 30-34 |
185.00 |
392.00 |
337.00 |
541.00 |
| 35-39 |
201.00 |
425.00 |
363.00 |
564.00 |
| 40-44 |
249.00 |
495.00 |
411.00 |
660.00 |
| 45-49 |
295.00 |
586.00 |
424.00 |
720.00 |
| 50-54 |
350.00 |
693.00 |
478.00 |
832.00 |
| 55-59 |
414.00 |
821.00 |
538.00 |
960.00 |
| 60-64 |
483.00 |
964.00 |
579.00 |
1033.00 |
| Age |
Deductible : 2500 |
| 0-19 |
82.00 |
161.00 |
140.00 |
226.00 |
| 20-24 |
119.00 |
237.00 |
205.00 |
329.00 |
| 25-29 |
129.00 |
274.00 |
240.00 |
387.00 |
| 30-34 |
151.00 |
320.00 |
276.00 |
442.00 |
| 35-39 |
164.00 |
349.00 |
296.00 |
461.00 |
| 40-44 |
204.00 |
405.00 |
336.00 |
539.00 |
| 45-49 |
241.00 |
479.00 |
346.00 |
588.00 |
| 50-54 |
286.00 |
568.00 |
391.00 |
679.00 |
| 55-59 |
338.00 |
671.00 |
440.00 |
784.00 |
| 60-64 |
395.00 |
788.00 |
474.00 |
844.00 |
| Age |
Deductible : 5000 |
| 0-19 |
65.00 |
129.00 |
113.00 |
181.00 |
| 20-24 |
96.00 |
190.00 |
164.00 |
264.00 |
| 25-29 |
104.00 |
220.00 |
192.00 |
310.00 |
| 30-34 |
120.00 |
258.00 |
222.00 |
355.00 |
| 35-39 |
132.00 |
279.00 |
237.00 |
369.00 |
| 40-44 |
164.00 |
324.00 |
269.00 |
433.00 |
| 45-49 |
194.00 |
384.00 |
278.00 |
472.00 |
| 50-54 |
229.00 |
455.00 |
314.00 |
545.00 |
| 55-59 |
272.00 |
539.00 |
352.00 |
629.00 |
| 60-64 |
317.00 |
632.00 |
379.00 |
678.00 |
* - not all of the zip codes are eligible in this county
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