Preferred Bronze and Bronze HSA EPO

049918 (09-01-2019)

Monthly rates for individuals and families Start date: Jan. 1, 2020

Area 6

These rates apply if you live in the

following county: Franklin

If you are eligible for a subsidy, rates will be adjusted.

Determine your monthly rate

Step 1: Choose a plan and a deductible amount

from the chart. The chart shows the deductible for an individual. The deductible for a family is

2 times the individual deductible. A deductible is the amount you pay each year before the

health plan starts to pay for certain services. Copayments do not count toward meeting your

deductible.

Step 2: Find your age and circle the rate that applies to your use or non-use of tobacco.

Tobacco use means use of any tobacco product on average 4 or more times per week

within the past 6 months. Tobacco use does not include religious or ceremonial use. E-

cigarettes are not considered tobacco.

Step 3: Repeat step 2 for each eligible family member you wish to add to your health care

plan. Eligible family members include you, your spouse or domestic partner, and your legal

dependents and children under age 26. Monthly rates are charged for all dependents and

children age 21 and older and for the first 3 oldest dependents and children under age 21.

Additional dependents and children age 20 and younger are not charged.

Step 4: Add up the circled amounts. The total will be the dollar amount of your monthly

health plan bill.

You $

+ Spouse/Domestic partner $

+ Dependent $

+ Dependent $

+ Dependent $

Total monthly rate $

Deductible

Bronze Bronze HSA

$6,350 $5,250 AGE Non-tobacco Tobacco Non-tobacco Tobacco

0-14 226.28 226.28 228.92 228.92

15 246.39 246.39 249.27 249.27

16 254.08 254.08 257.05 257.05

17 261.77 261.77 264.83 264.83

18 270.05 270.05 273.21 273.21

19 278.33 278.33 281.59 281.59

20 286.91 286.91 290.27 290.27

21 295.79 317.97 299.24 321.69

22 295.79 317.97 299.24 321.69

23 295.79 317.97 299.24 321.69

24 295.79 317.97 299.24 321.69

25 296.97 319.24 300.44 322.97

26 302.88 325.60 306.43 329.41

27 309.98 333.23 313.61 337.13

28 321.52 345.63 325.28 349.67

29 330.98 355.81 334.85 359.97

30 335.72 360.90 339.64 365.12

31 342.82 368.53 346.82 372.84

32 349.91 376.16 354.01 380.56

33 354.35 380.93 358.49 385.38

34 359.08 386.02 363.28 390.53

35 361.45 388.56 365.68 393.10

36 363.82 391.10 368.07 395.68

37 366.18 393.65 370.46 398.25

38 368.55 396.19 372.86 400.82

39 373.28 401.28 377.65 405.97

40 378.01 406.37 382.43 411.12

41 385.11 414.00 389.62 418.84

42 391.92 421.31 396.50 426.24

43 401.38 431.49 406.07 436.53

44 413.21 444.20 418.04 449.40

45 427.11 459.15 432.11 464.52

46 443.68 476.95 448.87 482.53

47 462.31 496.99 467.72 502.80

48 483.61 519.88 489.26 525.96

49 504.61 542.46 510.51 548.80

50 528.27 567.89 534.45 574.53

51 551.64 593.01 558.09 599.95

52 577.37 620.68 584.13 627.93

53 603.40 648.66 610.46 656.24

54 631.50 678.87 638.89 686.80

55 659.60 709.07 667.32 717.36

56 690.07 741.82 698.14 750.50

57 720.83 774.89 729.26 783.95

58 753.66 810.19 762.47 819.66

59 769.93 827.68 778.93 837.35

60 802.76 862.97 812.15 873.06

61 831.16 893.50 840.88 903.94

62 849.79 913.53 859.73 924.21

63 873.16 938.65 883.37 949.62

64+ 887.36 953.91 897.72 965.06

Preferred Exclusive Provider Organization

We want to make it simple and easy for you to understand your health plan.

Important notes

• Individual health plans are available to permanent Washington residents who are not enrolled in

Medicare Part A or Part B. • Rates are based on your current age. When your age

changes during the year, your rate will not change until the next time you enroll in a health plan.

• The deductible amount listed for each rate category is the individual deductible. The family deductible is 2

times the individual deductible.

Contact us

For enrollment information or if you have questions about Premera Blue Cross:

• Visit premera.com • Call 877-Premera (877-773-6372).

• Talk to a producer, a licensed professional also known as an agent.