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Apply Online For ODS Insurance
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
HSA Value 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 : 2800 |
| 0-19 |
53.00 |
N/A |
N/A |
N/A |
| 20-24 |
77.00 |
N/A |
N/A |
N/A |
| 25-29 |
85.00 |
N/A |
N/A |
N/A |
| 30-34 |
97.00 |
N/A |
N/A |
N/A |
| 35-39 |
106.00 |
N/A |
N/A |
N/A |
| 40-44 |
132.00 |
N/A |
N/A |
N/A |
| 45-49 |
156.00 |
N/A |
N/A |
N/A |
| 50-54 |
185.00 |
N/A |
N/A |
N/A |
| 55-59 |
219.00 |
N/A |
N/A |
N/A |
| 60-64 |
255.00 |
N/A |
N/A |
N/A |
| Age |
Deductible : 5600 |
| 0-19 |
N/A |
105.00 |
91.00 |
146.00 |
| 20-24 |
N/A |
152.00 |
132.00 |
213.00 |
| 25-29 |
N/A |
178.00 |
155.00 |
250.00 |
| 30-34 |
N/A |
208.00 |
178.00 |
286.00 |
| 35-39 |
N/A |
226.00 |
192.00 |
299.00 |
| 40-44 |
N/A |
261.00 |
218.00 |
350.00 |
| 45-49 |
N/A |
310.00 |
224.00 |
381.00 |
| 50-54 |
N/A |
366.00 |
254.00 |
440.00 |
| 55-59 |
N/A |
434.00 |
284.00 |
507.00 |
| 60-64 |
N/A |
510.00 |
306.00 |
546.00 |
* - not all of the zip codes are eligible in this county
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