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Application
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%
Pearl 25 HMO Rates
Effective date : 10/1/2009
Valid thru : 9/30/2010
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 : None |
| 0-2 |
253.00 |
N/A |
N/A |
N/A |
| 3-18 |
195.00 |
N/A |
N/A |
N/A |
| 19-24 |
247.00 |
494.00 |
371.00 |
692.00 |
| 25-29 |
267.00 |
534.00 |
401.00 |
801.00 |
| 30-34 |
305.00 |
610.00 |
458.00 |
870.00 |
| 35-39 |
325.00 |
650.00 |
488.00 |
927.00 |
| 40-44 |
419.00 |
838.00 |
629.00 |
1006.00 |
| 45-49 |
504.00 |
1008.00 |
756.00 |
1210.00 |
| 50-54 |
583.00 |
1166.00 |
863.00 |
1341.00 |
| 55-59 |
707.00 |
1414.00 |
955.00 |
1556.00 |
| 60-64 |
812.00 |
1624.00 |
1056.00 |
1787.00 |
| 65+ |
908.00 |
1816.00 |
1163.00 |
1998.00 |
* - not all of the zip codes are eligible in this county
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