Network Choice Individual Rates (Monthly)
Outside Dane County Tobacco User
Effective January 1, 2015 – December 31, 2015
Age
Brackets
0-17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64+
PLATINUM
Copay A
Co: $25/$50
D: $0
Includes Rx
PLATINUM
Copay B
Co: $25/$50
D: $100/$200
Includes Rx
PLATINUM
Copay C
Co: $25/$50
D: $250/$500
Includes Rx
GOLD
Copay A
Co: $25/$50
D: $1500/
$3000
Includes Rx
SILVER
Copay A
Co: $25/$50
D: $2000/
$4000
Includes Rx
SILVER
Copay B
Co: $25/$50
D: $2500/
$5000
Includes Rx
$ 326.27
326.27
326.27
326.27
554.41
554.41
554.41
554.41
561.78
572.97
586.40
608.22
626.13
671.82
686.03
699.62
708.50
718.58
722.69
726.79
731.52
736.24
746.34
756.46
770.67
784.28
803.23
826.90
875.50
909.45
947.65
991.30
1,034.35
1,081.93
1,129.79
1,182.49
1,235.80
1,293.35
1,349.76
1,412.10
1,475.05
1,543.54
1,576.86
1,642.71
1,700.81
1,738.94
1,786.76
1,809.65
$ 321.45
321.45
321.45
321.45
546.21
546.21
546.21
546.21
553.47
564.50
577.73
599.23
616.87
661.88
675.88
689.28
698.02
707.95
712.00
716.04
720.70
725.35
735.31
745.28
759.27
772.68
791.34
814.67
862.55
896.00
933.63
976.64
1,019.05
1,065.93
1,113.08
1,165.00
1,217.52
1,274.22
1,329.79
1,391.21
1,453.23
1,520.71
1,553.54
1,618.41
1,675.66
1,713.22
1,760.33
1,782.88
$ 327.71
327.71
327.71
327.71
556.85
556.85
556.85
556.85
564.25
575.49
588.98
610.90
628.88
674.78
689.04
702.70
711.61
721.74
725.87
729.99
734.73
739.48
749.63
759.79
774.06
787.73
806.76
830.54
879.35
913.45
951.81
995.66
1,038.90
1,086.69
1,134.76
1,187.70
1,241.24
1,299.04
1,355.69
1,418.31
1,481.54
1,550.33
1,583.80
1,649.93
1,708.30
1,746.60
1,794.62
1,817.61
$ 277.23
277.23
277.23
277.23
471.09
471.09
471.09
471.09
477.35
486.85
498.27
516.81
532.02
570.85
582.92
594.47
602.01
610.58
614.07
617.55
621.57
625.59
634.17
642.77
654.84
666.41
682.50
702.62
743.91
772.76
805.22
842.31
878.89
919.32
959.98
1,004.77
1,050.06
1,098.96
1,146.89
1,199.86
1,253.35
1,311.55
1,339.86
1,395.81
1,445.18
1,477.58
1,518.21
1,537.66
$ 225.87
225.87
225.87
225.87
383.80
383.80
383.80
383.80
388.90
396.65
405.94
421.05
433.44
465.08
474.91
484.32
490.46
497.45
500.29
503.13
506.40
509.67
516.67
523.67
533.51
542.93
556.04
572.43
606.07
629.58
656.02
686.24
716.04
748.98
782.11
818.59
855.50
895.34
934.38
977.54
1,021.12
1,068.53
1,091.60
1,137.18
1,177.41
1,203.81
1,236.91
1,252.75
$ 222.47
222.47
222.47
222.47
378.03
378.03
378.03
378.03
383.05
390.68
399.84
414.72
426.92
458.08
467.77
477.04
483.09
489.96
492.76
495.56
498.78
502.01
508.89
515.79
525.48
534.76
547.68
563.82
596.96
620.11
646.15
675.92
705.27
737.71
770.35
806.28
842.63
881.87
920.33
962.84
1,005.76
1,052.46
1,075.18
1,120.08
1,159.70
1,185.70
1,218.30
1,233.91
Network Choice Individual Rates (Monthly)
Outside Dane County Tobacco User
Effective January 1, 2015 – December 31, 2015
Age
Brackets
$ 337.19
337.19
337.19
337.19
572.97
572.97
572.97
572.97
580.58
592.15
606.03
628.58
647.09
694.31
708.99
723.04
732.21
742.63
746.88
751.12
756.00
760.89
771.33
781.79
796.47
810.54
830.11
854.58
904.80
939.89
979.37
1,024.48
1,068.97
1,118.15
1,167.61
1,222.07
1,277.17
1,336.64
1,394.94
1,459.37
1,524.42
1,595.21
1,629.64
1,697.69
1,757.74
1,797.15
1,846.57
1,870.22
$ 289.40
289.40
289.40
289.40
491.77
491.77
491.77
491.77
498.30
508.23
520.14
539.49
555.38
595.90
608.51
620.57
628.44
637.38
641.02
644.66
648.85
653.05
662.01
670.98
683.58
695.66
712.46
733.46
776.56
806.68
840.56
879.28
917.46
959.67
1,002.12
1,048.87
1,096.16
1,147.20
1,197.23
1,252.53
1,308.37
1,369.12
1,398.67
1,457.08
1,508.62
1,542.44
1,584.86
1,605.16
SILVER
Simple
D: $3500/
$7000
Includes Rx
$ 245.20
245.20
245.20
245.20
416.65
416.65
416.65
416.65
422.19
430.60
440.69
457.09
470.54
504.88
515.56
525.78
532.44
540.02
543.11
546.19
549.74
553.30
560.89
568.49
579.17
589.40
603.64
621.43
657.95
683.46
712.17
744.98
777.33
813.09
849.05
888.66
928.72
971.97
1,014.36
1,061.21
1,108.52
1,159.99
1,185.03
1,234.52
1,278.19
1,306.84
1,342.78
1,359.98
BRONZE PLATINUM
GOLD
SILVER
BRONZE
Simple
Deductible Deductible Deductible Deductible
D: $5000/
HDHP
HDHP
HDHP
HDHP
$10000
D: $750/
D: $2000/
D: $3000/
D: $4000/
Includes Rx
$1500
$4000
$6000
$8000
Includes Rx Includes Rx Includes Rx Includes Rx
$ 201.71
201.71
201.71
201.71
342.75
342.75
342.75
342.75
347.30
354.22
362.52
376.01
387.08
415.33
424.11
432.52
438.00
444.24
446.78
449.31
452.24
455.16
461.40
467.66
476.44
484.86
496.57
511.21
541.25
562.24
585.85
612.84
639.45
668.87
698.46
731.04
764.00
799.57
834.44
872.98
911.90
954.24
974.84
1,015.55
1,051.47
1,075.05
1,104.61
1,118.76
$ 344.35
344.35
344.35
344.35
585.13
585.13
585.13
585.13
592.91
604.72
618.89
641.92
660.82
709.04
724.04
738.39
747.75
758.40
762.73
767.06
772.05
777.03
787.70
798.38
813.37
827.74
847.73
872.72
924.00
959.84
1,000.15
1,046.22
1,091.65
1,141.88
1,192.39
1,248.01
1,304.27
1,365.01
1,424.54
1,490.34
1,556.77
1,629.06
1,664.23
1,733.72
1,795.05
1,835.29
1,885.76
1,909.91
$ 285.29
285.29
285.29
285.29
484.78
484.78
484.78
484.78
491.22
501.00
512.75
531.83
547.48
587.44
599.86
611.75
619.51
628.33
631.92
635.50
639.64
643.77
652.60
661.45
673.87
685.78
702.34
723.04
765.53
795.22
828.62
866.79
904.43
946.04
987.89
1,033.97
1,080.58
1,130.90
1,180.22
1,234.74
1,289.78
1,349.67
1,378.80
1,436.38
1,487.19
1,520.53
1,562.34
1,582.35
$ 251.29
251.29
251.29
251.29
427.00
427.00
427.00
427.00
432.67
441.29
451.63
468.44
482.23
517.42
528.36
538.83
545.67
553.43
556.60
559.75
563.39
567.04
574.82
582.61
593.55
604.04
618.62
636.86
674.28
700.43
729.85
763.47
796.63
833.28
870.14
910.73
951.78
996.11
1,039.55
1,087.56
1,136.04
1,188.80
1,214.46
1,265.17
1,309.92
1,339.29
1,376.12
1,393.75
$ 189.36
189.36
189.36
189.36
321.77
321.77
321.77
321.77
326.04
332.53
340.33
352.99
363.38
389.90
398.15
406.04
411.19
417.04
419.42
421.80
424.55
427.29
433.15
439.03
447.27
455.17
466.17
479.91
508.11
527.81
549.98
575.32
600.30
627.92
655.69
686.28
717.22
750.62
783.35
819.54
856.07
895.82
915.16
953.37
987.10
1,009.23
1,036.98
1,050.26
P+6216-1501
0-17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64+
PLATINUM
GOLD
Simple
Simple
D: $600/
D: $1800/
$1200
$3600
Includes Rx Includes Rx