HEALTH CARE PLUS, New Association Rates

Health Care Plus - Monthly Premium Rates* - Eff. April 1998
 

 SINGLE

COUPLE

FAMILY

 AGE

0-64

65+

0-64

65+

0-64

65+
 PLAN A
 Extended Helth Care

 $14.00

$24.50

$27.50

$48.50

$36.00

$54.00
 PLAN B
 Extended Health Care &
 Dental

$47.50

$57.00

$92.00

$111.00

$118.50

$125.50

 Select Plan A or B, then add any options you wish below.
 OPTION 1
 Prescription Drugs**

$35.00

NA

$68.50

NA

$88.50

NA
 OPTION 2
 Preferred Hospital**

$7.50

$33.00

$14.00

$64.50

$17.00

$73.00
 OPTION 3
 Hospital Cash

$4.50

$22.00

$8.50

$42.50

$10.50

$48.50
 OPTION 4
 Travel Health

$4.50

$11.50

$8.50

$21.50

$9.50

$23.50
To calculate your monthly premium, select Pan A or Plan B. Then add the Optional benefits you would like and sinsert the total below. For example, to calculate Plan B + Option 1 for a single person under age 65: $50 + $37 = $87 per month. 
 TOTAL
 You may have to print this form.		            

 General Notes:
 * Rates are subject to change without notice.
   Plans A and B are guaranteed issue.
  Rates are monthly.
  Optional Benefits can only be purchased in addtion to Plan A or B.
  When calculating Couple or Family use the eldest member.
** Options 1 & 2 require you to complete a medical questionnaire.
   You may be declined or accepted for these benefits based on your
   health history.

Use Association Rates when three or more individuals wish to purchase atthe same time.

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