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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
Beneficial Value Rx 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 |
82.00 |
164.00 |
143.00 |
228.00 |
| 20-24 |
120.00 |
238.00 |
206.00 |
333.00 |
| 25-29 |
130.00 |
277.00 |
242.00 |
391.00 |
| 30-34 |
153.00 |
324.00 |
280.00 |
446.00 |
| 35-39 |
167.00 |
351.00 |
299.00 |
465.00 |
| 40-44 |
206.00 |
409.00 |
340.00 |
546.00 |
| 45-49 |
244.00 |
485.00 |
350.00 |
595.00 |
| 50-54 |
289.00 |
573.00 |
394.00 |
687.00 |
| 55-59 |
342.00 |
679.00 |
445.00 |
792.00 |
| 60-64 |
398.00 |
796.00 |
478.00 |
854.00 |
| Age |
Deductible : 2500 |
| 0-19 |
65.00 |
131.00 |
113.00 |
182.00 |
| 20-24 |
96.00 |
191.00 |
165.00 |
266.00 |
| 25-29 |
105.00 |
222.00 |
193.00 |
313.00 |
| 30-34 |
122.00 |
259.00 |
223.00 |
357.00 |
| 35-39 |
133.00 |
281.00 |
240.00 |
372.00 |
| 40-44 |
164.00 |
327.00 |
272.00 |
436.00 |
| 45-49 |
195.00 |
387.00 |
280.00 |
476.00 |
| 50-54 |
231.00 |
459.00 |
316.00 |
549.00 |
| 55-59 |
273.00 |
544.00 |
355.00 |
634.00 |
| 60-64 |
319.00 |
637.00 |
383.00 |
682.00 |
| Age |
Deductible : 5000 |
| 0-19 |
51.00 |
101.00 |
88.00 |
141.00 |
| 20-24 |
74.00 |
147.00 |
126.00 |
205.00 |
| 25-29 |
80.00 |
171.00 |
150.00 |
241.00 |
| 30-34 |
94.00 |
200.00 |
172.00 |
275.00 |
| 35-39 |
103.00 |
217.00 |
184.00 |
287.00 |
| 40-44 |
126.00 |
253.00 |
209.00 |
336.00 |
| 45-49 |
150.00 |
299.00 |
216.00 |
367.00 |
| 50-54 |
179.00 |
352.00 |
243.00 |
423.00 |
| 55-59 |
210.00 |
418.00 |
273.00 |
488.00 |
| 60-64 |
246.00 |
491.00 |
295.00 |
526.00 |
| Age |
Deductible : 7500 |
| 0-19 |
39.00 |
78.00 |
68.00 |
109.00 |
| 20-24 |
58.00 |
114.00 |
98.00 |
160.00 |
| 25-29 |
63.00 |
133.00 |
116.00 |
187.00 |
| 30-34 |
74.00 |
155.00 |
134.00 |
214.00 |
| 35-39 |
80.00 |
169.00 |
143.00 |
223.00 |
| 40-44 |
98.00 |
196.00 |
163.00 |
261.00 |
| 45-49 |
117.00 |
232.00 |
168.00 |
286.00 |
| 50-54 |
139.00 |
274.00 |
189.00 |
330.00 |
| 55-59 |
164.00 |
326.00 |
213.00 |
380.00 |
| 60-64 |
190.00 |
382.00 |
230.00 |
409.00 |
* - not all of the zip codes are eligible in this county
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