INPATIENT RATES

1 2 3 4 5 6 1
Inpatient Premium Per Shared Limit Per Family
Limit M (Per Person Rate) M+1 M+2 M+3 M+4 M+5 Extra
5,000,000 136,650 233,860 323,182 412,504 501,826 591,148 89,322
7,500,000 150,856 255,168 350,172 445,176 540,180 635,185 95,004
10,000,000 160,934 270,286 369,322 468,358 567,393 666,429 99,036
15,000,000 175,140 291,594 396,312 501,030 605,747 710,465 104,718
20,000,000 185,218 306,712 415,461 524,211 632,960 741,709 108,749
30,000,000 204,966 336,333 452,982 569,630 686,278 802,926 116,648
50,000,000 231,401 375,986 503,208 630,430 757,652 884,874 127,222
60,000,000 238,363 386,429 516,436 646,443 776,451 906,458 130,007
75,000,000 252,857 408,171 543,976 679,780 815,585 951,390 135,805
100,000,000 264,196 425,179 565,519 705,859 846,199 986,540 140,340
150,000,000 280,177 449,150 595,883 742,615 889,348 1,036,080 146,733
200,000,000 291,515 466,158 617,426 768,694 919,962 1,071,230 151,268
56,916 113,832 170,748 227,664 284,580 341,496 56,916
INPATIENT NOTE 1 For only Inpatient Low Cost Providers Discount above rates by 8.5%

OUTPATIENT RATES
Outpatient Premium Per Shared Limit Per Family
Limit M (Per Person Rate) M+1 M+2 M+3 M+4 M+5 Extra
900,000 251,791 0 0 0 0 0 0
1,050,000 268,170 0 0 0 0 0 0
1,250,000 286,696 430,044 544,723 659,401 774,080 888,758 114,678
1,500,000 306,069 459,103 581,531 703,958 826,385 948,813 122,427
2,000,000 336,636 504,954 639,609 774,263 908,918 1,043,572 134,654
 2,500,000 372,958 559,437 708,621 857,804 1,006,987 1,156,171 149,183
3,000,000 393,009 589,513 746,717 903,920 1,061,124 1,218,327 157,204
4,000,000 475,303 712,954 903,075 1,093,196 1,283,317 1,473,438 190,121
5,000,000 502,770 754,155 955,263 1,156,371 1,357,479 1,558,587 201,108
6,000,000 525,212 787,818 997,903 1,207,988 1,418,073 1,628,158 210,085

OUTPATIENT NOTE 1 Above rates are for the Enhanced Provider panel
OUTPATIENT NOTE 2 To have co-pay at high cost providers, discount Outpatient rates by 3.5%
OUTPATIENT NOTE 3 For Only outpatient low cost providers discount above rates by 6.5%
 DENTAL RATES

Dental Premium Per Shared Limit Per Family

Limit M (Per Person Rate) M+1 M+2 M+3 M+4 M+5 Extra Dependant
150,000 26,463 0 0 0 0 0 0
180,000 31,756 47,634 60,336 73,038 85,741 98,443 12,702
200,000 35,284 52,926 67,040 81,154 95,268 109,381 14,114
250,000 44,105 66,158 83,800 101,442 119,084 136,727 17,642
300,000 52,926 79,390 100,560 121,731 142,901 164,072 21,171
350,000 61,747 92,621 117,320 142,019 166,718 191,417 24,699
400,000 70,569 105,853 134,080 162,308 190,535 218,762 28,227
450,000 79,390 119,084 150,840 182,596 214,352 246,108 31,756
500,000 88,211 132,316 167,600 202,885 238,169 273,453 35,284
600,000 105,853 158,779 201,120 243,461 285,803 328,144 42,341
750,000 132,316 198,474 251,400 304,327 357,253 410,180 52,926

OPTICAL RATES
Optical Premium Per Shared Limit Per Family
Limit M (Per Person Rate) M+1 M+2 M+3 M+4 M+5 Extra Dependant
150,000 37,413 0 0 0 0 0 0
180,000 44,895 67,343 85,301 103,260 121,218 139,176 17,958
200,000 49,884 74,826 94,779 114,733 134,686 154,640 19,954
250,000 62,355 93,532 118,474 143,416 168,358 193,300 24,942
300,000 74,826 112,239 142,169 172,099 202,030 231,960 29,930
350,000 87,297 130,945 165,864 200,783 235,701 270,620 34,919
400,000 99,768 149,652 189,559 229,466 269,373 309,280 39,907
450,000 112,239 168,358 213,254 258,149 303,044 347,940 44,895
500,000 124,710 187,065 236,948 286,832 336,716 386,600 49,884
600,000 149,652 224,477 284,338 344,199 404,059 463,920 59,861
750,000 187,065 280,597 355,423 430,248 505,074 579,900 74,826
 MATERNITY RATES
Maternity (Principal Member Premium
Limit Per Family
1,000,000 93,786
1,500,000 140,679
2,000,000 187,572
2,500,000 234,465
3,000,000 281,358
4,000,000 375,144
4,500,000 422,037
5,000,000 468,930

LAST EXPENSE RATES

Last Expense Premium
Limit per person
600,000 12,228
1,000,000 15,677
1,500,000 18,089
2,250,000 22,611
3,000,000 30,149
4,500,000 45,223
6,000,000 60,297