Page 24 - MedigapFreedom Plan Information

MONTHLY TOBACCO PREMIUMS
MALE
Plan G-HD
Plan A
Plan B
Plan F
Plan F-HD
Plan G
Plan N
Attained Age
Under 65*
$144.19 $174.97 $220.88 $82.91 $199.71 $74.96 $153.97 $131.08 $159.06 $200.80 $75.37 $181.55 $68.15 $139.97
$150.75 $182.93 $230.75 $86.68 $208.63 $78.37 $161.35 $137.04 $166.30 $209.77 $78.80 $189.66 $71.25 $146.69
$163.47 $198.37 $250.68 $94.00 $226.65 $84.99 $176.68 $148.61 $180.33 $227.89 $85.45 $206.04 $77.26 $160.62
$176.46 $214.13 $271.22 $101.47 $245.23 $91.74 $192.43 $160.42 $194.66 $246.57 $92.24 $222.93 $83.40 $174.93
$186.43 $226.23 $290.33 $107.20 $262.50 $96.92 $207.61 $169.48 $205.66 $263.94 $97.46 $238.64 $88.11 $188.74
$195.35 $237.05 $308.62 $112.33 $279.04 $101.56 $222.25 $177.60 $215.50 $280.56 $102.12 $253.67 $92.33 $202.04
$204.28 $247.88 $330.20 $117.46 $298.54 $106.20 $239.80 $185.71 $225.35 $300.18 $106.78 $271.40 $96.55 $218.00
$208.34 $252.82 $344.78 $119.80 $311.73 $108.32 $251.65 $189.40 $229.83 $313.44 $108.91 $283.39 $98.47 $228.77
(continued)
*This includes people under 65 on Medicare due to disability.
Non-Tobacco rates apply to applications submitted during the six-month open enrollment or in a guaranteed issue situation. Applicants NOT enrolling during the six- month open enrollment period or in a guaranteed issue situation will be evaluated for tobacco usage and charged the corresponding tobacco or non-tobacco rates.
Plan A
Plan B
Plan F
Plan F-HD
FEMALE
Plan G
Plan G-HD
Plan N
$131.08
$159.06
$200.80
$75.37
$181.55
$68.15
$139.97
$144.19
$174.97
$220.88
$82.91
$199.71
$74.96
$153.97
65-67
68
$142.65
$173.10
$217.99
$82.02
$197.09
$74.16
$153.02
$156.91
$190.41
$239.79
$90.23
$216.80
$81.58
$168.32
69
70
$154.93
$188.01
$237.79
$89.09
$214.99
$80.55
$168.22
$170.43
$206.81
$261.57
$98.00
$236.49
$88.60
$185.04
71
72
$165.31
$200.60
$255.91
$95.06
$231.38
$85.94
$182.41
$181.84
$220.66
$281.50
$104.56
$254.51
$94.54
$200.65
73
74
$174.02
$211.16
$272.72
$100.06
$246.58
$90.47
$195.83
$191.42
$232.28
$299.99
$110.07
$271.23
$99.52
$215.42
75
76
$181.29
$219.99
$289.72
$104.25
$261.95
$94.25
$209.39
$199.42
$241.99
$318.69
$114.67
$288.14
$103.68
$230.33
77
78
$188.21
$228.39
$307.09
$108.22
$277.65
$97.85
$223.58
$207.03
$251.22
$337.80
$119.05
$305.42
$107.63
$245.93
79
80
FORM #18803 Page 4