Print this pagePart A Basic
| Employees |
| $5.23 (employer-paid) |
Part B Basic (for Dependents)
An employee pays $0.52 per family, regardless of the number of dependents.
Part B Supplemental, Part C Optional, and Part D Supplemental Insurance
Your premium rate changes to the next higher rate as you reach each new age bracket.| Employee's age | Monthly cost for each $1,000 of coverage |
|
| Non-smoker | Smoker | |
| Under 25 | $0.030 | $0.038 |
| 25-29 | 0.032 | 0.046 |
| 30-34 | 0.036 | 0.060 |
| 35-39 | 0.042 | 0.070 |
| 40-44 | 0.066 | 0.078 |
| 45-49 | 0.096 | 0.116 |
| 50-54 | 0.148 | 0.176 |
| 55-59 | 0.276 | 0.328 |
| 60-64 | 0.424 | 0.502 |
| 65-69 | 0.782 | 0.966 |
| 70+ | 1.164 | 1.566 |
Part E - Accidental Death and Dismemberment (Voluntary)
| Employee AD&D benefit | Cost to cover employee only | Cost to cover employee & dependents |
Coverage for spouse/Qualified Domestic Partner: | Coverage for children: | ||
| With no children | With children | With spouse/ Qualified Domestic Partner |
With no spouse/ Qualified Domestic Partner |
|||
| $ 25,000 | $0.25 | $0.35 | $ 12,500 | $ 10,000 | $ 1,250 | $ 2,500 |
| 50,000 | 0.50 | 0.70 | 25,000 | 20,000 | 2,500 | 5,000 |
| 75,000 | 0.75 | 1.05 | 37,500 | 30,000 | 3,750 | 7,500 |
| 100,000 | 1.00 | 1.40 | 50,000 | 40,000 | 5,000 | 10,000 |
| 125,000 | 1.25 | 1.75 | 62,500 | 50,000 | 6,250 | 12,500 |
| 150,000 | 1.50 | 2.10 | 75,000 | 60,000 | 7,500 | 15,000 |
| 175,000 | 1.75 | 2.45 | 87,500 | 70,000 | 8,750 | 17,500 |
| 200,000 | 2.00 | 2.80 | 100,000 | 80,000 | 10,000 | 20,000 |
| 225,000 | 2.25 | 3.15 | 112,500 | 90,000 | 11,250 | 22,500 |
| 250,000 | 2.50 | 3.50 | 125,000 | 100,000 | 12,500 | 25,000 |
