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Personal Health Coverage - H Plans
TM
Monthly Premiums Effective 8/1/08
H01 H02
$250 deductible, 80% Coinsurance, $1,250 Out-of-Pocket Max $500 deductible, 80% Coinsurance, $1,500 Out-of-Pocket Max
$20 Office Visit $20 Office Visit
Maternity $310.10 Maternity $288.65
Preferred Non-Tobacco Tobacco Preferred Non-Tobacco Tobacco
Male Female Male Female Male Female Male Female
0-17 $239.11 $239.11 $239.11 $239.11 0-17 $203.67 $203.67 $203.67 $203.67
18-24 $289.11 $338.20 $361.39 $422.76 18-24 $246.25 $288.07 $307.81 $360.09
25-29 $302.59 $372.84 $378.24 $466.05 25-29 $257.73 $317.57 $322.17 $396.96
30-34 $322.41 $421.02 $419.13 $547.33 30-34 $274.61 $358.61 $357.00 $466.19
35-39 $370.69 $479.99 $500.44 $647.98 35-39 $315.74 $408.83 $426.25 $551.92
40-44 $440.86 $539.79 $617.20 $755.71 40-44 $375.50 $459.77 $525.71 $643.68
45-49 $562.36 $623.11 $815.41 $903.50 45-49 $478.99 $530.74 $694.53 $769.56
50-54 $685.66 $678.61 $1,028.49 $1,017.91 50-54 $584.02 $578.01 $876.03 $867.01
55-59 $805.45 $735.45 $1,208.18 $1,103.18 55-59 $686.05 $626.42 $1,029.08 $939.64
60-64 $915.10 $803.99 $1,372.65 $1,205.98 60-64 $779.45 $684.80 $1,169.16 $1,027.20
65+ $1,238.31 $1,136.69 $1,857.46 $1,705.03 65+ $1,054.73 $968.18 $1,582.11 $1,452.27
H03 H05
$1,000 deductible, 80% Coinsurance, $2,000 Out-of-Pocket Max $2,500 deductible, 80% Coinsurance, $3,500 Out-of-Pocket Max
$20 Office Visit $20 Office Visit
Maternity $260.34 Maternity $205.14
Preferred Non-Tobacco Tobacco Preferred Non-Tobacco Tobacco
Male Female Male Female Male Female Male Female
0-17 $163.23 $163.23 $163.23 $163.23 0-17 $127.48 $127.48 $127.48 $127.48
18-24 $197.37 $230.89 $246.71 $288.60 18-24 $154.13 $180.31 $192.67 $225.39
25-29 $206.57 $254.52 $258.22 $318.16 25-29 $161.32 $198.77 $201.66 $248.47
30-34 $220.09 $287.41 $286.12 $373.64 30-34 $171.89 $224.46 $223.45 $291.80
35-39 $253.06 $327.66 $341.63 $442.35 35-39 $197.63 $255.89 $266.80 $345.46
40-44 $300.96 $368.49 $421.35 $515.89 40-44 $235.04 $287.78 $329.06 $402.89
45-49 $383.90 $425.37 $556.65 $616.79 45-49 $299.81 $332.20 $434.73 $481.68
50-54 $468.08 $463.26 $702.12 $694.89 50-54 $365.55 $361.78 $548.32 $542.68
55-59 $549.85 $502.07 $824.79 $753.10 55-59 $429.41 $392.09 $644.12 $588.14
60-64 $624.71 $548.85 $937.05 $823.28 60-64 $487.87 $428.63 $731.81 $642.95
65+ $845.35 $775.97 $1,268.02 $1,163.96 65+ $660.18 $606.01 $990.28 $909.01
H11 H13
$1,000 deductible, 80% Coinsurance, $2,000 Out-of-Pocket Max $2,500 deductible, 80% Coinsurance, $3,500 Out-of-Pocket Max
$30 Office Visit $30 Office Visit
Maternity $260.34 Maternity $205.14
Preferred Non-Tobacco Tobacco Preferred Non-Tobacco Tobacco
Male Female Male Female Male Female Male Female
0-17 $153.18 $153.18 $153.18 $153.18 0-17 $119.00 $119.00 $119.00 $119.00
18-24 $185.20 $216.65 $231.50 $270.82 18-24 $143.88 $168.31 $179.85 $210.39
25-29 $193.83 $238.84 $242.30 $298.54 25-29 $150.59 $185.55 $188.24 $231.93
30-34 $206.53 $269.70 $268.49 $350.61 30-34 $160.45 $209.53 $208.58 $272.38
35-39 $237.46 $307.47 $320.57 $415.09 35-39 $184.48 $238.87 $249.05 $322.47
40-44 $282.41 $345.78 $395.37 $484.10 40-44 $219.40 $268.63 $307.16 $376.09
45-49 $360.23 $399.15 $522.34 $578.77 45-49 $279.86 $310.09 $405.80 $449.63
50-54 $439.23 $434.71 $658.84 $652.06 50-54 $341.23 $337.71 $511.84 $506.57
55-59 $515.96 $471.12 $773.95 $706.67 55-59 $400.84 $366.01 $601.27 $549.01
60-64 $586.20 $515.02 $879.30 $772.53 60-64 $455.41 $400.11 $683.11 $600.17
65+ $793.23 $728.14 $1,189.85 $1,092.21 65+ $616.25 $565.68 $924.38 $848.53
H18 H20
$5,000 deductible, 100% Coinsurance, $5,000 Out-of-Pocket Max $500 deductible, 80% Coinsurance, $1,500 Out-of-Pocket Max
$30 Office Visit
Maternity $166.77 Maternity $288.65
Preferred Non-Tobacco Tobacco Preferred Non-Tobacco Tobacco
Male Female Male Female Male Female Male Female
0-17 $94.24 $94.24 $94.24 $94.24 0-17 $165.79 $165.79 $165.79 $165.79
18-24 $113.95 $133.29 $142.43 $166.62 18-24 $200.46 $234.50 $250.58 $293.12
25-29 $119.25 $146.94 $149.07 $183.67 25-29 $209.80 $258.52 $262.26 $323.14
30-34 $127.07 $165.93 $165.19 $215.71 30-34 $223.54 $291.92 $290.61 $379.49
35-39 $146.10 $189.17 $197.23 $255.37 35-39 $257.02 $332.80 $346.98 $449.29
40-44 $173.75 $212.74 $243.25 $297.84 40-44 $305.67 $374.27 $427.94 $523.98
45-49 $221.63 $245.57 $321.37 $356.08 45-49 $389.91 $432.04 $565.37 $626.44
50-54 $270.23 $267.45 $405.34 $401.17 50-54 $475.41 $470.52 $713.12 $705.78
55-59 $317.44 $289.85 $476.16 $434.78 55-59 $558.47 $509.93 $837.71 $764.90
60-64 $360.66 $316.86 $540.98 $475.29 60-64 $634.49 $557.46 $951.74 $836.18
65+ $488.03 $447.99 $732.05 $671.97 65+ $858.59 $788.12 $1,287.88 $1,182.20
Personal Health Coverage - H Plans
TM
Monthly Premiums Effective 8/1/08
H21 H25
$1,000 deductible, 80% Coinsurance, $2,000 Out-of-Pocket Max $2,500 deductible, 100% Coinsurance, $2,500 Out-of-Pocket Max
Maternity $260.34 Maternity $223.16
Preferred Non-Tobacco Tobacco Preferred Non-Tobacco Tobacco
Male Female Male Female Male Female Male Female
0-17 $126.20 $126.20 $126.20 $126.20 0-17 $96.21 $96.21 $96.21 $96.21
18-24 $152.60 $178.51 $190.75 $223.14 18-24 $116.33 $136.09 $145.42 $170.11
25-29 $159.71 $196.79 $199.64 $245.99 25-29 $121.76 $150.02 $152.20 $187.53
30-34 $170.17 $222.22 $221.22 $288.88 30-34 $129.73 $169.41 $168.65 $220.23
35-39 $195.66 $253.35 $264.14 $342.01 35-39 $149.16 $193.14 $201.37 $260.74
40-44 $232.69 $284.91 $325.77 $398.87 40-44 $177.40 $217.20 $248.35 $304.09
45-49 $296.82 $328.88 $430.39 $476.88 45-49 $226.28 $250.73 $328.11 $363.56
50-54 $361.91 $358.18 $542.85 $537.27 50-54 $275.90 $273.06 $413.85 $409.59
55-59 $425.13 $388.18 $637.70 $582.28 55-59 $324.11 $295.94 $486.16 $443.90
60-64 $483.00 $424.36 $724.51 $636.54 60-64 $368.22 $323.51 $552.34 $485.27
65+ $653.60 $599.97 $980.40 $899.94 65+ $498.27 $457.39 $747.41 $686.08
H26 H28
$5,000 deductible, 80% Coinsurance, $6,000 Out-of-Pocket Max $5,000 deductible, 100% Coinsurance, $5,000 Out-of-Pocket Max
Maternity $155.55 Maternity $166.77
Preferred Non-Tobacco Tobacco Preferred Non-Tobacco Tobacco
Male Female Male Female Male Female Male Female
0-17 $59.73 $59.73 $59.73 $59.73 0-17 $62.12 $62.12 $62.12 $62.12
18-24 $72.22 $84.49 $90.28 $105.60 18-24 $75.11 $87.87 $93.89 $109.84
25-29 $75.59 $93.14 $94.49 $116.42 25-29 $78.62 $96.87 $98.27 $121.08
30-34 $80.54 $105.18 $104.70 $136.72 30-34 $83.76 $109.38 $108.89 $142.20
35-39 $92.60 $119.90 $125.01 $161.86 35-39 $96.31 $124.71 $130.01 $168.34
40-44 $110.13 $134.84 $154.18 $188.78 40-44 $114.53 $140.24 $160.35 $196.33
45-49 $140.48 $155.65 $203.69 $225.70 45-49 $146.10 $161.89 $211.84 $234.73
50-54 $171.28 $169.52 $256.93 $254.28 50-54 $178.14 $176.31 $267.20 $264.45
55-59 $201.21 $183.72 $301.81 $275.58 55-59 $209.26 $191.07 $313.89 $286.61
60-64 $228.60 $200.84 $342.89 $301.26 60-64 $237.74 $208.87 $356.62 $313.31
65+ $309.33 $283.95 $464.00 $425.93 65+ $321.71 $295.32 $482.57 $442.97
H29 H30
$20 Office Visit Copay Plan $30 Office Visit Copay Plan
Maternity $349.84 Maternity $316.81
Preferred Non-Tobacco Tobacco Preferred Non-Tobacco Tobacco
Male Female Male Female Male Female Male Female
0-17 $269.32 $269.32 $269.32 $269.32 0-17 $244.15 $244.15 $244.15 $244.15
18-24 $325.64 $380.93 $407.04 $476.17 18-24 $295.20 $345.33 $369.00 $431.67
25-29 $340.83 $419.94 $426.03 $524.93 25-29 $308.98 $380.69 $386.21 $475.87
30-34 $363.14 $474.21 $472.08 $616.48 30-34 $329.21 $429.90 $427.96 $558.86
35-39 $417.53 $540.62 $563.66 $729.84 35-39 $378.50 $490.09 $510.98 $661.63
40-44 $496.56 $607.99 $695.18 $851.18 40-44 $450.15 $551.16 $630.21 $771.63
45-49 $633.40 $701.82 $918.43 $1,017.64 45-49 $574.20 $636.23 $832.59 $922.53
50-54 $772.29 $764.34 $1,158.42 $1,146.51 50-54 $700.10 $692.90 $1,050.16 $1,039.36
55-59 $907.21 $828.37 $1,360.82 $1,242.54 55-59 $822.43 $750.94 $1,233.64 $1,126.42
60-64 $1,030.71 $905.56 $1,546.06 $1,358.34 60-64 $934.38 $820.93 $1,401.57 $1,231.39
65+ $1,394.74 $1,280.29 $2,092.12 $1,920.43 65+ $1,264.40 $1,160.63 $1,896.59 $1,740.94
Estimating Your Personal Health Optional Dental Coverage Available
Coverage Monthly Premium Monthly premiums are $26.50 for each adult and
The premium tables can be used to estimate your $14.60 for each dependent from age 2 through age
Personal Health Coverage plan’s monthly premium. 17. Your dental premiums will be billed with your
The premiums listed are for a preferred risk. Your individual health coverage.
actual rate may vary based on your health status.
Your rates will be calculated by our automated
system and your final rate may vary due to rounding.
BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association
® Registered marks of the BlueCross BlueShield Association, an Association of Independent BlueCross BlueShield Plans
This document has been classified as public information
COMM-555 (6/08)
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