Page 5 - Benefit Guide - Heritage School 2021
P. 5
Medical Option Rates
Blue Cross Blue Shield
2021 Rate Information - Cost is per Employee and each additional family Member.
Simply add the cost of each family member to be covered and
subtract $550 from the Employee Only Amount.
MEDICAL - BCBS B661CHC High Deductible Health Plan HSA
Age Monthly Cost Age Monthly Cost Age Monthly Cost Age Monthly Cost Age Monthly Cost Age Monthly Cost
<15 $293.75 23 $383.99 32 $454.26 41 $499.96 50 $685.81 59 $999.53
15 $319.87 24 $383.99 33 $460.02 42 $508.79 51 $716.15 60 $1,042.16
16 $329.85 25 $385.53 34 $466.17 43 $521.08 52 $749.55 61 $1,079.02
17 $339.83 26 $393.21 35 $469.24 44 $536.44 53 $783.34 62 $1,103.21
18 $350.59 27 $402.42 36 $472.31 45 $554.49 54 $819.82 63 $1,133.55
19 $361.34 28 $417.40 37 $475.38 46 $575.99 55 $856.30 64+ $1,151.97
20 $372.47 29 $429.69 38 $478.45 47 $600.18 56 $895.85
21 $383.99 30 $435.83 39 $484.60 48 $627.83 57 $935.79
22 $383.99 31 $445.05 40 $490.74 49 $655.09 58 $978.41
MEDICAL - BCBS S663CHC Core Plan
Age Monthly Cost Age Monthly Cost Age Monthly Cost Age Monthly Cost Age Monthly Cost Age Monthly Cost
<15 $332.18 23 $434.22 32 $513.69 41 $565.36 50 $775.52 59 $1,130.29
15 $361.71 24 $434.22 33 $520.20 42 $575.35 51 $809.83 60 $1,178.49
16 $373.00 25 $435.96 34 $527.15 43 $589.24 52 $847.61 61 $1,220.17
17 $384.29 26 $444.65 35 $530.62 44 $606.61 53 $885.82 62 $1,247.53
18 $396.45 27 $455.07 36 $534.10 45 $627.02 54 $927.07 63 $1,281.83
19 $408.61 28 $472.00 37 $537.57 46 $651.34 55 $968.32 64+ $1,302.66
20 $421.20 29 $485.90 38 $541.04 47 $678.69 56 $1,013.05
21 $434.22 30 $492.84 39 $547.99 48 $709.96 57 $1,058.20
22 $434.22 31 $503.27 40 $554.94 49 $740.79 58 $1,106.40
MEDICAL - BCBS G652CHC Buy-Up Plan
Age Monthly Cost Age Monthly Cost Age Monthly Cost Age Monthly Cost Age Monthly Cost Age Monthly Cost
<15 $381.55 23 $498.76 32 $590.04 41 $649.39 50 $890.79 59 $1,298.28
15 $415.47 24 $498.76 33 $597.52 42 $660.86 51 $930.20 60 $1,353.65
16 $428.44 25 $500.76 34 $605.50 43 $676.82 52 $973.59 61 $1,401.53
17 $441.41 26 $510.73 35 $609.49 44 $696.77 53 $1,017.48 62 $1,432.95
18 $455.37 27 $522.71 36 $613.48 45 $720.22 54 $1,064.86 63 $1,472.35
19 $469.34 28 $542.16 37 $617.47 46 $748.15 55 $1,112.24 64+ $1,496.28
20 $483.80 29 $558.12 38 $621.46 47 $779.57 56 $1,163.62
21 $498.76 30 $566.10 39 $629.44 48 $815.48 57 $1,215.49
22 $498.76 31 $578.07 40 $637.42 49 $850.89 58 $1,270.85
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