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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 3000 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 : 3000 |
| 0-19 |
81.00 |
N/A |
N/A |
N/A |
| 20-24 |
118.00 |
N/A |
N/A |
N/A |
| 25-29 |
129.00 |
N/A |
N/A |
N/A |
| 30-34 |
150.00 |
N/A |
N/A |
N/A |
| 35-39 |
164.00 |
N/A |
N/A |
N/A |
| 40-44 |
202.00 |
N/A |
N/A |
N/A |
| 45-49 |
240.00 |
N/A |
N/A |
N/A |
| 50-54 |
283.00 |
N/A |
N/A |
N/A |
| 55-59 |
335.00 |
N/A |
N/A |
N/A |
| 60-64 |
392.00 |
N/A |
N/A |
N/A |
| Age |
Deductible : 6000 |
| 0-19 |
N/A |
161.00 |
140.00 |
225.00 |
| 20-24 |
N/A |
235.00 |
203.00 |
327.00 |
| 25-29 |
N/A |
273.00 |
239.00 |
383.00 |
| 30-34 |
N/A |
319.00 |
274.00 |
439.00 |
| 35-39 |
N/A |
345.00 |
294.00 |
457.00 |
| 40-44 |
N/A |
402.00 |
334.00 |
536.00 |
| 45-49 |
N/A |
476.00 |
344.00 |
584.00 |
| 50-54 |
N/A |
564.00 |
388.00 |
674.00 |
| 55-59 |
N/A |
666.00 |
437.00 |
779.00 |
| 60-64 |
N/A |
782.00 |
470.00 |
838.00 |
* - not all of the zip codes are eligible in this county
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