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P. 21
Benefit Amount: $10,000
Employee (EE) Employee + Spouse Employee + Children Employee + Family (EE+F)
(EE+SP)
(EE+CH)
Age Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco
<25 $3.75 $3.93 $5.51 $5.81 $3.75 $3.93 $5.51 $5.81
25 to 29 $3.92 $4.26 $5.72 $6.23 $3.92 $4.26 $5.72 $6.23
30 to 34 $4.39 $5.06 $6.32 $7.29 $4.39 $5.06 $6.32 $7.29
35 to 39 $5.04 $6.46 $7.23 $9.29 $5.04 $6.46 $7.32 $9.29
40 to 44 $5.65 $7.72 $8.15 $11.20 $5.65 $7.72 $8.15 $11.20
45 to 49 $6.80 $10.18 $9.91 $15.00 $6.80 $10.18 $9.91 $15.00
50 to 54 $8.02 $12.70 $12.23 $19.42 $8.02 $12.70 $12.23 $19.42
55 to 59 $9.58 $15.47 $15.27 $24.77 $9.58 $15.47 $15.27 $24.77
60 to 64 $11.30 $18.14 $18.31 $29.46 $11.30 $18.14 $18.31 $29.46
65 to 69 $13.44 $21.47 $21.65 $33.82 $13.44 $21.47 $21.65 $33.82
70 to 74 $18.23 $27.86 $28.83 $43.73 $18.23 $27.86 $28.83 $43.73
75 to 79 $24.17 $33.50 $37.47 $52.35 $24.17 $33.50 $37.47 $52.35
80 to 84 $29.07 $40.28 $45.10 $63.04 $29.07 $40.28 $45.10 $63.04
85 to 89 $40.05 $47.91 $62.21 $74.67 $40.05 $47.91 $62.21 $74.67
90 to 94 $40.05 $47.91 $62.21 $74.67 $40.05 $47.91 $62.21 $74.67
95+ $40.05 $47.91 $62.21 $74.67 $40.05 $47.91 $62.21 $74.67
Benefit Amount: $20,000
Employee (EE) Employee + Spouse Employee + Children Employee + Family (EE+F)
(EE+CH)
(EE+SP)
Age Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco
<25 $5.39 $5.76 $7.64 $8.23 $5.39 $5.76 $7.64 $8.23
25 to 29 $5.73 $6.40 $8.05 $9.08 $5.73 $6.40 $8.05 $9.08
30 to 34 $6.68 $8.01 $9.25 $11.20 $6.68 $8.01 $9.25 $11.20
35 to 39 $7.97 $10.80 $11.08 $15.20 $7.97 $10.80 $11.08 $15.20
40 to 44 $9.18 $13.33 $12.92 $19.01 $9.18 $13.33 $12.92 $19.01
45 to 49 $11.48 $18.24 $16.43 $26.62 $11.48 $18.24 $16.43 $26.62
50 to 54 $13.93 $23.29 $21.07 $35.45 $13.93 $23.29 $21.07 $35.45
55 to 59 $17.05 $28.83 $27.16 $46.16 $17.05 $28.83 $27.16 $46.16
60 to 64 $20.49 $34.17 $33.24 $55.52 $20.49 $34.17 $33.24 $55.52
65 to 69 $24.76 $40.83 $39.92 $64.25 $24.76 $40.83 $39.92 $64.25
70 to 74 $34.35 $53.61 $54.26 $84.07 $34.35 $53.61 $54.26 $84.07
75 to 79 $46.22 $64.88 $71.55 $101.32 $46.22 $64.88 $71.55 $101.32
80 to 84 $56.04 $78.45 $86.80 $122.70 $56.04 $78.45 $86.60 $122.70
85 to 89 $77.98 $93.70 $121.03 $145.95 $77.98 $93.70 $121.03 $145.95
90 to 94 $77.98 $93.70 $121.03 $145.95 $77.98 $93.70 $121.03 $145.95
95+ $77.98 $93.70 $121.03 $145.95 $77.98 $93.70 $121.03 $145.95
Costs are subject to change. Actual per pay period premiums may differ slightly due to rounding.
American Oncology Network 21
Employee (EE) Employee + Spouse Employee + Children Employee + Family (EE+F)
(EE+SP)
(EE+CH)
Age Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco
<25 $3.75 $3.93 $5.51 $5.81 $3.75 $3.93 $5.51 $5.81
25 to 29 $3.92 $4.26 $5.72 $6.23 $3.92 $4.26 $5.72 $6.23
30 to 34 $4.39 $5.06 $6.32 $7.29 $4.39 $5.06 $6.32 $7.29
35 to 39 $5.04 $6.46 $7.23 $9.29 $5.04 $6.46 $7.32 $9.29
40 to 44 $5.65 $7.72 $8.15 $11.20 $5.65 $7.72 $8.15 $11.20
45 to 49 $6.80 $10.18 $9.91 $15.00 $6.80 $10.18 $9.91 $15.00
50 to 54 $8.02 $12.70 $12.23 $19.42 $8.02 $12.70 $12.23 $19.42
55 to 59 $9.58 $15.47 $15.27 $24.77 $9.58 $15.47 $15.27 $24.77
60 to 64 $11.30 $18.14 $18.31 $29.46 $11.30 $18.14 $18.31 $29.46
65 to 69 $13.44 $21.47 $21.65 $33.82 $13.44 $21.47 $21.65 $33.82
70 to 74 $18.23 $27.86 $28.83 $43.73 $18.23 $27.86 $28.83 $43.73
75 to 79 $24.17 $33.50 $37.47 $52.35 $24.17 $33.50 $37.47 $52.35
80 to 84 $29.07 $40.28 $45.10 $63.04 $29.07 $40.28 $45.10 $63.04
85 to 89 $40.05 $47.91 $62.21 $74.67 $40.05 $47.91 $62.21 $74.67
90 to 94 $40.05 $47.91 $62.21 $74.67 $40.05 $47.91 $62.21 $74.67
95+ $40.05 $47.91 $62.21 $74.67 $40.05 $47.91 $62.21 $74.67
Benefit Amount: $20,000
Employee (EE) Employee + Spouse Employee + Children Employee + Family (EE+F)
(EE+CH)
(EE+SP)
Age Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco
<25 $5.39 $5.76 $7.64 $8.23 $5.39 $5.76 $7.64 $8.23
25 to 29 $5.73 $6.40 $8.05 $9.08 $5.73 $6.40 $8.05 $9.08
30 to 34 $6.68 $8.01 $9.25 $11.20 $6.68 $8.01 $9.25 $11.20
35 to 39 $7.97 $10.80 $11.08 $15.20 $7.97 $10.80 $11.08 $15.20
40 to 44 $9.18 $13.33 $12.92 $19.01 $9.18 $13.33 $12.92 $19.01
45 to 49 $11.48 $18.24 $16.43 $26.62 $11.48 $18.24 $16.43 $26.62
50 to 54 $13.93 $23.29 $21.07 $35.45 $13.93 $23.29 $21.07 $35.45
55 to 59 $17.05 $28.83 $27.16 $46.16 $17.05 $28.83 $27.16 $46.16
60 to 64 $20.49 $34.17 $33.24 $55.52 $20.49 $34.17 $33.24 $55.52
65 to 69 $24.76 $40.83 $39.92 $64.25 $24.76 $40.83 $39.92 $64.25
70 to 74 $34.35 $53.61 $54.26 $84.07 $34.35 $53.61 $54.26 $84.07
75 to 79 $46.22 $64.88 $71.55 $101.32 $46.22 $64.88 $71.55 $101.32
80 to 84 $56.04 $78.45 $86.80 $122.70 $56.04 $78.45 $86.60 $122.70
85 to 89 $77.98 $93.70 $121.03 $145.95 $77.98 $93.70 $121.03 $145.95
90 to 94 $77.98 $93.70 $121.03 $145.95 $77.98 $93.70 $121.03 $145.95
95+ $77.98 $93.70 $121.03 $145.95 $77.98 $93.70 $121.03 $145.95
Costs are subject to change. Actual per pay period premiums may differ slightly due to rounding.
American Oncology Network 21
