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Regence BlueCross BlueShield - Online Application

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Benefit Schedule
Evolve HSA 50 | Evolve HSA 80 | Evolve HSA 100 | Optional Dental Coverage
Rate Schedule
Evolve HSA 50 | Evolve HSA 80 | Evolve HSA 100


Evolve HSA 80 Rates
Effective date : 3/1/2010
Valid thru : 2/28/2011
Counties : Clark
Family Status : Applicant
Non-Smoker		 Applicant
Smoker		 Family
Non-Smoker		 Family
Smoker
Age Deductible : 2000
0-24 154.00 177.00 N/A N/A
25-29 177.00 203.00 N/A N/A
30-34 205.00 236.00 N/A N/A
35-39 242.00 278.00 N/A N/A
40-44 285.00 328.00 N/A N/A
45-49 345.00 396.00 N/A N/A
50-54 410.00 472.00 N/A N/A
55-59 481.00 554.00 N/A N/A
60+ 564.00 649.00 N/A N/A
Child 154.00 177.00 N/A N/A
Age Deductible : 3500
0-24 123.00 141.00 N/A N/A
25-29 141.00 162.00 N/A N/A
30-34 164.00 188.00 N/A N/A
35-39 193.00 222.00 N/A N/A
40-44 227.00 261.00 N/A N/A
45-49 275.00 316.00 N/A N/A
50-54 327.00 376.00 N/A N/A
55-59 384.00 441.00 N/A N/A
60+ 450.00 517.00 N/A N/A
Child 123.00 141.00 N/A N/A
Age Deductible : 4000
0-24 N/A N/A 154.00 177.00
25-29 N/A N/A 177.00 203.00
30-34 N/A N/A 205.00 236.00
35-39 N/A N/A 242.00 278.00
40-44 N/A N/A 285.00 328.00
45-49 N/A N/A 345.00 396.00
50-54 N/A N/A 410.00 472.00
55-59 N/A N/A 481.00 554.00
60+ N/A N/A 564.00 649.00
Child N/A N/A 154.00 177.00
Age Deductible : 7000
0-24 N/A N/A 123.00 141.00
25-29 N/A N/A 141.00 162.00
30-34 N/A N/A 164.00 188.00
35-39 N/A N/A 193.00 222.00
40-44 N/A N/A 227.00 261.00
45-49 N/A N/A 275.00 316.00
50-54 N/A N/A 327.00 376.00
55-59 N/A N/A 384.00 441.00
60+ N/A N/A 450.00 517.00
Child N/A N/A 123.00 141.00



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