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Benefit Amount: $10,000
Employee (EE) Employee + Spouse Employee + Children Employee + Family
(EE+SP) (EE+CH) (EE+F)
Age Non- Tobacco Non- Tobacco Non- Tobacco Non- Tobacco
Tobacco Tobacco 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+SP) (EE+CH) (EE+F)
Age Non- Tobacco Non- Tobacco Non- Tobacco Non- Tobacco
Tobacco Tobacco 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 17
Employee (EE) Employee + Spouse Employee + Children Employee + Family
(EE+SP) (EE+CH) (EE+F)
Age Non- Tobacco Non- Tobacco Non- Tobacco Non- Tobacco
Tobacco Tobacco 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+SP) (EE+CH) (EE+F)
Age Non- Tobacco Non- Tobacco Non- Tobacco Non- Tobacco
Tobacco Tobacco 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 17
