Rates For Effective dates October, November & December  2008

BCBSMT 2500/5000

• Age 0-24 -        $111.89
• Age 25-29 -      $120.27
• Age 30-34 -      $127.60
• Age 35-39 -      $150.62
• Age 40-44 -      $183.08
• Age 45-49 -      $228.11
• Age 50-54 -      $274.17
• Age 55-59 -      $329.60
• Age 60+ -          $387.39
• One Child -         $32.53
• Two Children+ - $65.06

HDHP Description of Benefits 

BCBSMT 5000-10000 

• Age 0-24 -           $96.65
• Age 25-29 -       $103.88
• Age 30-34 -       $110.21
• Age 35-39 -       $130.10
• Age 40-44 -       $158.13
• Age 45-49 -       $197.02
• Age 50 - 54 -     $236.81
• Age 55 - 59 -     $279.15
• Age 60+ -           $328.21
• One Child -          $28.10
• Two Children+  - $56.20

 $1,000 Calendar Year Deductible
Includes Prescription Drugs after $100 deductible
75/25 copayment feature
$2,500 Maximum Member Liability

Primary Care benefit - $400 per benefit year (Deductible does not apply)

• Office Calls
• Routine Physicals
• One Vision Exam
• Gynecological Exam
  

Montana Youth Care Description of Benefits

Rates for October, November & December 2008

Monthly Dues Per Person

• 3 Months - 5 Years -     $124.08
• 6 Years - 14 Years -       $96.84
• 15 Years to 18 Years - $141.24

 

  Description of Benefits and Application

Premier Rates:

Area                               Member                               Plus One                               Family

1                                      $36.64                                    $66.70                                $96.76

2                                      $40.12                                    $73.48                              $106.85

 590-591, 599   -  1
All Others  -  2

PPO Rates:

Area                               Member                                Plus One                               Family

1                                      $29.68                                   $53.12                                   $76.57

2                                      $32.39                                   $58.42                                   $84.44

 590-591, 599  -  1
All Others  -  2