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Index | Exclusions & Limitations | Locate Providers | Dental Plan Info | Brochure & Application
Plan Benefits:
Pearl 25 HMO | Diamond 15 | Emerald 40 | Crystal HDHP 80% | Crystal HDHP 100%
Plan Rates:
Pearl 25 HMO | Diamond 15 | Emerald 40 | Crystal HDHP 80% | Crystal HDHP 100%


Emerald 40 Rates
Effective date : 10/1/2009
Valid thru : 1/1/2011
Counties : Baker, Clatsop, Columbia, Coos, Crook, Curry, Douglas, Gilliam, Grant, Harney, Hood River, Jackson, Jefferson, Josephine, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Wheeler
Family Status : Applicant Applicant and Spouse Applicant and Child(ren) Applicant and Family
Age Deductible : 1000
0-2 213.00 N/A N/A N/A
3-18 164.00 N/A N/A N/A
19-24 207.00 414.00 311.00 580.00
25-29 224.00 448.00 336.00 672.00
30-34 256.00 512.00 384.00 730.00
35-39 273.00 546.00 410.00 779.00
40-44 352.00 704.00 528.00 845.00
45-49 423.00 846.00 635.00 1016.00
50-54 489.00 978.00 724.00 1125.00
55-59 593.00 1186.00 801.00 1305.00
60-64 681.00 1362.00 886.00 1499.00
65+ 762.00 1524.00 976.00 1677.00
Age Deductible : 2500
0-2 179.00 N/A N/A N/A
3-18 138.00 N/A N/A N/A
19-24 174.00 348.00 261.00 488.00
25-29 188.00 376.00 282.00 564.00
30-34 215.00 430.00 323.00 613.00
35-39 229.00 458.00 344.00 653.00
40-44 296.00 592.00 444.00 711.00
45-49 355.00 710.00 533.00 852.00
50-54 411.00 822.00 609.00 946.00
55-59 498.00 996.00 673.00 1096.00
60-64 573.00 1146.00 745.00 1261.00
65+ 640.00 1280.00 820.00 1408.00
Age Deductible : 5000
0-2 147.00 N/A N/A N/A
3-18 113.00 N/A N/A N/A
19-24 143.00 286.00 215.00 401.00
25-29 154.00 308.00 231.00 462.00
30-34 177.00 354.00 266.00 505.00
35-39 188.00 376.00 282.00 536.00
40-44 233.00 466.00 350.00 560.00
45-49 274.00 548.00 411.00 658.00
50-54 334.00 668.00 495.00 769.00
55-59 394.00 788.00 532.00 867.00
60-64 450.00 900.00 585.00 990.00
65+ 525.00 1050.00 672.00 1155.00
Age Deductible : 7500
0-2 119.00 N/A N/A N/A
3-18 99.00 N/A N/A N/A
19-24 116.00 232.00 174.00 325.00
25-29 125.00 250.00 188.00 375.00
30-34 142.00 284.00 213.00 405.00
35-39 149.00 298.00 224.00 425.00
40-44 180.00 360.00 270.00 432.00
45-49 213.00 426.00 320.00 512.00
50-54 261.00 522.00 387.00 601.00
55-59 305.00 610.00 412.00 671.00
60-64 350.00 700.00 455.00 770.00
65+ 416.00 832.00 533.00 916.00
Age Deductible : 10000
0-2 103.00 N/A N/A N/A
3-18 80.00 N/A N/A N/A
19-24 81.00 162.00 122.00 227.00
25-29 99.00 198.00 149.00 297.00
30-34 113.00 226.00 170.00 323.00
35-39 128.00 256.00 192.00 365.00
40-44 154.00 308.00 231.00 370.00
45-49 183.00 366.00 275.00 440.00
50-54 227.00 454.00 336.00 523.00
55-59 262.00 524.00 354.00 577.00
60-64 301.00 602.00 392.00 663.00
65+ 326.00 652.00 418.00 718.00



Counties : Deschutes, Klamath, Lake
Family Status : Applicant Applicant and Spouse Applicant and Child(ren) Applicant and Family
Age Deductible : 1000
0-2 213.00 N/A N/A N/A
3-18 164.00 N/A N/A N/A
19-24 207.00 414.00 311.00 580.00
25-29 224.00 448.00 336.00 672.00
30-34 256.00 512.00 384.00 730.00
35-39 273.00 546.00 410.00 779.00
40-44 352.00 704.00 528.00 845.00
45-49 423.00 846.00 635.00 1016.00
50-54 489.00 978.00 724.00 1125.00
55-59 593.00 1186.00 801.00 1305.00
60-64 681.00 1362.00 886.00 1499.00
65+ 762.00 1524.00 976.00 1677.00
Age Deductible : 2500
0-2 179.00 N/A N/A N/A
3-18 138.00 N/A N/A N/A
19-24 174.00 348.00 261.00 488.00
25-29 188.00 376.00 282.00 564.00
30-34 215.00 430.00 323.00 613.00
35-39 229.00 458.00 344.00 653.00
40-44 296.00 592.00 444.00 711.00
45-49 355.00 710.00 533.00 852.00
50-54 411.00 822.00 609.00 946.00
55-59 498.00 996.00 673.00 1096.00
60-64 573.00 1146.00 745.00 1261.00
65+ 640.00 1280.00 820.00 1408.00
Age Deductible : 5000
0-2 147.00 N/A N/A N/A
3-18 113.00 N/A N/A N/A
19-24 143.00 286.00 215.00 401.00
25-29 154.00 308.00 231.00 462.00
30-34 177.00 354.00 266.00 505.00
35-39 188.00 376.00 282.00 536.00
40-44 233.00 466.00 350.00 560.00
45-49 274.00 548.00 411.00 658.00
50-54 334.00 668.00 495.00 769.00
55-59 394.00 788.00 532.00 867.00
60-64 450.00 900.00 585.00 990.00
65+ 525.00 1050.00 672.00 1155.00
Age Deductible : 7500
0-2 119.00 N/A N/A N/A
3-18 99.00 N/A N/A N/A
19-24 116.00 232.00 174.00 325.00
25-29 125.00 250.00 188.00 375.00
30-34 142.00 284.00 213.00 405.00
35-39 149.00 298.00 224.00 425.00
40-44 180.00 360.00 270.00 432.00
45-49 213.00 426.00 320.00 512.00
50-54 261.00 522.00 387.00 601.00
55-59 305.00 610.00 412.00 671.00
60-64 350.00 700.00 455.00 770.00
65+ 416.00 832.00 533.00 916.00
Age Deductible : 10000
0-2 103.00 N/A N/A N/A
3-18 80.00 N/A N/A N/A
19-24 81.00 162.00 122.00 227.00
25-29 99.00 198.00 149.00 297.00
30-34 113.00 226.00 170.00 323.00
35-39 128.00 256.00 192.00 365.00
40-44 154.00 308.00 231.00 370.00
45-49 183.00 366.00 275.00 440.00
50-54 227.00 454.00 336.00 523.00
55-59 262.00 524.00 354.00 577.00
60-64 301.00 602.00 392.00 663.00
65+ 326.00 652.00 418.00 718.00



Counties : Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill
Family Status : Applicant Applicant and Spouse Applicant and Child(ren) Applicant and Family
Age Deductible : 1000
0-2 193.00 N/A N/A N/A
3-18 149.00 N/A N/A N/A
19-24 188.00 376.00 282.00 527.00
25-29 203.00 406.00 305.00 609.00
30-34 233.00 466.00 350.00 665.00
35-39 248.00 496.00 372.00 707.00
40-44 320.00 640.00 480.00 768.00
45-49 384.00 768.00 576.00 922.00
50-54 445.00 890.00 659.00 1024.00
55-59 539.00 1078.00 728.00 1186.00
60-64 619.00 1238.00 805.00 1362.00
65+ 693.00 1386.00 888.00 1525.00
Age Deductible : 2500
0-2 163.00 N/A N/A N/A
3-18 125.00 N/A N/A N/A
19-24 158.00 316.00 237.00 443.00
25-29 171.00 342.00 257.00 513.00
30-34 196.00 392.00 294.00 559.00
35-39 209.00 418.00 314.00 596.00
40-44 269.00 538.00 404.00 646.00
45-49 323.00 646.00 485.00 776.00
50-54 374.00 748.00 554.00 861.00
55-59 453.00 906.00 612.00 997.00
60-64 521.00 1042.00 678.00 1147.00
65+ 582.00 1164.00 745.00 1281.00
Age Deductible : 5000
0-2 133.00 N/A N/A N/A
3-18 103.00 N/A N/A N/A
19-24 130.00 260.00 195.00 364.00
25-29 140.00 280.00 210.00 420.00
30-34 161.00 322.00 242.00 459.00
35-39 171.00 342.00 257.00 488.00
40-44 212.00 424.00 318.00 509.00
45-49 249.00 498.00 374.00 598.00
50-54 304.00 608.00 450.00 700.00
55-59 358.00 716.00 484.00 788.00
60-64 410.00 820.00 533.00 902.00
65+ 477.00 954.00 611.00 1050.00
Age Deductible : 7500
0-2 109.00 N/A N/A N/A
3-18 90.00 N/A N/A N/A
19-24 106.00 212.00 159.00 297.00
25-29 114.00 228.00 171.00 342.00
30-34 129.00 258.00 194.00 368.00
35-39 136.00 272.00 204.00 388.00
40-44 164.00 328.00 246.00 394.00
45-49 194.00 388.00 291.00 466.00
50-54 237.00 474.00 351.00 546.00
55-59 277.00 554.00 374.00 610.00
60-64 318.00 636.00 414.00 700.00
65+ 378.00 756.00 484.00 832.00
Age Deductible : 10000
0-2 93.00 N/A N/A N/A
3-18 73.00 N/A N/A N/A
19-24 74.00 148.00 111.00 208.00
25-29 90.00 180.00 135.00 270.00
30-34 103.00 206.00 155.00 294.00
35-39 117.00 234.00 176.00 334.00
40-44 140.00 280.00 210.00 336.00
45-49 167.00 334.00 251.00 401.00
50-54 206.00 412.00 305.00 474.00
55-59 239.00 478.00 323.00 526.00
60-64 273.00 546.00 355.00 601.00
65+ 297.00 594.00 381.00 654.00



* - not all of the zip codes are eligible in this county

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