|
| Individuals and families that don’t currently have BCBSM coverage |
|
|
| Age: |
24 and younger |
25–29 |
30–34 |
35–39 |
40–44 |
45–49 |
50–54 |
55 and older |
| One-Person |
$141.15 |
$176.46 |
$190.73 |
$210.84 |
$239.66 |
$282.71 |
$345.93 |
$504.20 |
| Two-Person |
$282.30 |
$352.92 |
$381.45 |
$421.68 |
$479.31 |
$565.41 |
$691.89 |
$1,008.42 |
| Family |
$296.44 |
$370.58 |
$400.55 |
$442.76 |
$503.28 |
$593.67 |
$726.48 |
$1,058.85 |
| Dependent, 19 and older |
$108.61 |
$108.61 |
$108.61 |
$108.61 |
$108.61 |
$108.61 |
$108.61 |
$108.61 |
|
|
| Individuals and families transferring or converting from a BCBSM employer-sponsored group health plan |
|
|
| Age: |
24 and younger |
25–29 |
30–34 |
35–39 |
40–44 |
45–49 |
50–54 |
55 and older |
| One-Person |
$138.54 |
$173.82 |
$188.61 |
$209.44 |
$238.72 |
$282.33 |
$345.91 |
$503.81 |
| Two-Person |
$277.08 |
$347.64 |
$377.22 |
$418.88 |
$477.44 |
$564.66 |
$691.82 |
$1007.62 |
| Family |
$290.95 |
$365.03 |
$396.10 |
$439.83 |
$501.32 |
$592.90 |
$726.42 |
$1058.02 |
| Dependent, 19 and older |
$107.74 |
$107.74 |
$107.74 |
$107.74 |
$107.74 |
$107.74 |
$107.74 |
$107.74 |
|
|
| |
|
| Individuals and families that don’t currently have BCBSM coverage |
|
|
| |
PPO |
Traditional |
| One-Person |
$171.70 |
$195.14 |
| Two-Person |
$343.39 |
$390.30 |
| Family |
$360.55 |
$409.81 |
| Dependent, 19 and older |
$60.09 |
$68.30 |
|
|
|
| Individuals and families transferring or converting from a BCBSM employer-sponsored group health plan |
|
|
| |
PPO |
Traditional |
| One-Person |
$126.33 |
$144.20 |
| Two-Person |
$252.66 |
$288.40 |
| Family |
$265.29 |
$302.83 |
| Dependent, 19 and older |
$44.22 |
$50.47 |
|
|
|
|
| |
|
| Individuals and families that don’t currently have BCBSM coverage |
|
|
| PPO |
Traditional |
| $47.14 |
$54.00 |
|
|
|
| Individuals and families transferring or converting from a BCBSM employer-sponsored group health plan |
|
|
| PPO |
Traditional |
| $47.14 |
$54.00 |
|
|
|
|
| |
|
| Individuals and families that don’t currently have BCBSM coverage |
|
|
| Age |
One-Person |
Two-Person |
Family |
Dependant Continuation |
| Under 25 |
$102.92 |
$205.83 |
$216.13 |
$89.12 |
| 25-29 |
$132.43 |
$264.85 |
$278.10 |
$89.12 |
| 30-34 |
$147.55 |
$295.10 |
$309.86 |
$89.12 |
| 35-39 |
$175.56 |
$351.13 |
$368.69 |
$89.12 |
| 40-44 |
$202.62 |
$405.23 |
$425.50 |
$89.12 |
| 45-49 |
$242.05 |
$484.11 |
$508.32 |
$89.12 |
| 50-54 |
$305.44 |
$610.89 |
$641.44 |
$89.12 |
| 55+ |
$449.28 |
$898.56 |
$943.50 |
$89.12 |
|
|
|
|
| Individuals and families transferring or converting from a BCBSM
employer-sponsored group health plan* (NOTE: Your group health plan
must meet qualifying criteria.) |
|
|
| Age |
One-Person |
Two-Person |
Family |
Dependant Continuation |
| Under 25 |
$102.37 |
$204.74 |
$214.99 |
$89.69 |
| 25-29 |
$132.32 |
$264.63 |
$277.87 |
$89.69 |
| 30-34 |
$148.18 |
$296.36 |
$311.18 |
$89.69 |
| 35-39 |
$176.89 |
$353.79 |
$371.49 |
$89.69 |
| 40-44 |
$204.79 |
$409.58 |
$430.06 |
$89.69 |
| 45-49 |
$245.38 |
$490.76 |
$515.31 |
$89.69 |
| 50-54 |
$309.70 |
$619.39 |
$650.37 |
$89.69 |
| 55+ |
$454.91 |
$909.82 |
$955.32 |
$89.69 |
|
|
| Optional Benefits - Maternity |
|
|
| |
One-Person |
Two-Person |
Family |
Dependant Continuation |
| Under 25 |
$133.72 |
$133.72 |
$133.72 |
$0.00 |
|
|
* Rates for members who are transferring or who have already transferred from a qualifying BCBSM employer sponsored
health plan will apply for one year and will change in the second year.
NOTE: The rates listed in this section are in effect at the time of printing. |
|
| Individuals and families that don’t currently have BCBSM coverage |
|
|
| Age |
One-Person |
Two-Person |
Family |
Dependant Continuation |
| Under 25 |
$59.83 |
$119.66 |
$125.65 |
$48.01 |
| 25-29 |
$74.85 |
$149.69 |
$157.18 |
$48.01 |
| 30-34 |
$81.38 |
$162.75 |
$170.89 |
$48.01 |
| 35-39 |
$95.19 |
$190.17 |
$199.68 |
$48.01 |
| 40-44 |
$107.83 |
$215.65 |
$226.44 |
$48.01 |
| 45-49 |
$126.70 |
$253.41 |
$266.09 |
$48.01 |
| 50-54 |
$159.05 |
$318.09 |
$334.00 |
$48.01 |
| 55+ |
$233.94 |
$467.89 |
$491.29 |
$48.01 |
|
|
| Individuals and families transferring or converting from a BCBSM
employer-sponsored group health plan* (NOTE: Your group health plan
must meet qualifying criteria.) |
|
|
| Age |
One-Person |
Two-Person |
Family |
Dependant Continuation |
| Under 25 |
$58.53 |
$117.07 |
$122.92 |
$47.22 |
| 25-29 |
$73.37 |
$146.74 |
$154.09 |
$47.22 |
| 30-34 |
$79.99 |
$159.98 |
$167.98 |
$47.22 |
| 35-39 |
$93.64 |
$187.28 |
$196.65 |
$47.22 |
| 40-44 |
$106.35 |
$212.70 |
$223.34 |
$47.22 |
| 45-49 |
$125.18 |
$250.35 |
$262.88 |
$47.22 |
| 50-54 |
$157.11 |
$314.21 |
$329.92 |
$47.22 |
| 55+ |
$230.85 |
$461.69 |
$484.78 |
$47.22 |
|
|
| Optional Benefits - Maternity |
|
|
| |
One-Person |
Two-Person |
Family |
Dependant Continuation |
| Under 25 |
$94.08 |
$94.08 |
$94.08 |
$0.00 |
|
|
| Optional Benefits - Individual Dental |
|
|
| Age |
One-Person |
Two-Person |
Family |
Dependant Continuation |
| Under 25 |
$15.10 |
$30.20 |
$31.71 |
$11.00 |
| 25-29 |
$19.01 |
$38.02 |
$39.92 |
$11.00 |
| 30-34 |
$20.40 |
$40.80 |
$42.84 |
$11.00 |
| 35-39 |
$23.82 |
$47.64 |
$50.02 |
$11.00 |
| 40-44 |
$26.85 |
$53.70 |
$56.39 |
$11.00 |
| 45-49 |
$31.43 |
$62.86 |
$66.00 |
$11.00 |
| 50-54 |
$39.85 |
$79.70 |
$83.69 |
$11.00 |
| 55+ |
$39.85 |
$79.70 |
$83.69 |
$11.00 |
|
|
| |
