Page 63 - SMS WV Overview.pdf

Plan A Plan B
MAC $1000 100/80/50 MAC/MAB MAC $1500 100/80/50 MAC/MAB
Area EE ES EC EF Area EE ES EC EF
1 $24.16 $48.36 $55.88 $80.04 1 $25.84 $51.68 $58.60 $84.44
2 $25.40 $50.84 $58.96 $84.36 2 $27.28 $54.52 $62.16 $89.36
3 $26.56 $53.16 $62.20 $88.80 3 $28.60 $57.20 $65.68 $94.24
4 $27.20 $54.40 $63.72 $90.88 4 $29.28 $58.56 $67.28 $96.52
5 $27.88 $55.80 $65.76 $93.64 5 $30.12 $60.24 $69.56 $99.64
6 $29.20 $58.44 $69.52 $98.72 6 $31.60 $63.20 $73.64 $105.20
7 $30.76 $61.60 $73.96 $104.76 7 $33.32 $66.68 $78.48 $111.84
8 $31.72 $63.48 $76.32 $108.04 8 $34.48 $68.96 $81.20 $115.68
9 $33.72 $67.56 $81.80 $115.60 9 $36.88 $73.76 $87.36 $124.20
10 $36.12 $72.36 $86.36 $122.56 10 $39.44 $78.92 $92.20 $131.68

Plan C Plan D
MAC $2000 100/80/50 MAC/MAB 90TH $1000 100/80/50 MAC/90th
Area EE ES EC EF Area EE ES EC EF
1 $26.56 $53.08 $60.04 $86.56 1 $29.08 $58.28 $68.32 $97.48
2 $28.12 $56.20 $63.80 $91.88 2 $31.60 $63.28 $75.00 $106.64
3 $29.52 $59.00 $67.48 $96.92 3 $33.36 $66.84 $80.12 $113.60
4 $30.28 $60.56 $69.24 $99.52 4 $34.72 $69.56 $83.72 $118.56
5 $31.16 $62.28 $71.60 $102.72 5 $35.84 $71.84 $87.16 $123.16
6 $32.72 $65.40 $76.00 $108.64 6 $37.36 $74.88 $91.92 $129.40
7 $34.64 $69.28 $81.12 $115.72 7 $38.88 $78.00 $96.60 $135.72
8 $35.92 $71.80 $84.08 $119.96 8 $40.24 $80.72 $100.52 $141.00
9 $38.48 $76.92 $90.56 $128.96 9 $42.56 $85.32 $107.24 $149.96
10 $41.08 $82.16 $95.52 $136.60 10 $46.64 $93.64 $116.84 $163.80

Plan E Plan F
90TH $1500 100/80/50 MAC/90th 90th $2000 100/80/50 MAC/90th
Area EE ES EC EF Area EE ES EC EF
1 $31.80 $63.64 $72.96 $104.80 1 $33.20 $66.44 $75.72 $108.92
2 $34.88 $69.84 $80.76 $115.72 2 $36.72 $73.44 $84.40 $121.08
3 $37.08 $74.20 $86.64 $123.72 3 $39.20 $78.40 $90.88 $130.04
4 $38.72 $77.52 $90.80 $129.60 4 $41.12 $82.28 $95.56 $136.72
5 $40.16 $80.40 $94.92 $135.12 5 $42.84 $85.68 $100.20 $143.04
6 $42.00 $84.08 $100.28 $142.36 6 $44.92 $89.84 $106.04 $150.96
7 $43.84 $87.76 $105.56 $149.44 7 $46.92 $93.84 $111.68 $158.56
8 $45.68 $91.52 $110.56 $156.40 8 $49.28 $98.60 $117.64 $166.92
9 $48.52 $97.20 $118.20 $166.88 9 $52.48 $105.00 $126.20 $178.68
10 $53.60 $107.44 $129.68 $183.48 10 $58.36 $116.80 $139.12 $197.52

* Rates are valid for groups with effective dates of 9/1/2021 through 12/31/2022, and are guaranteed for 24 months.
Rates are guaranteed for 12 months for groups sitused in Florida with fewer than 51 enrolled lives.
** Child Orthodontia is available for $9.56 expense load on employee child and employee family.

Ameritas Life Insurance Corp.

This is not a certificate of insurance or guarantee of coverage. Plan designs may not be available in all areas and are subject to individual state regulations. This piece is not for use in New Mexico.
This information is provided by Ameritas Life Insurance Corp. (Ameritas Life). Dental, vision and hearing care products (9000 Rev. 03-16 for Group and 9000 Rev. 02-19 for Individual, dates may vary
by state) are issued by Ameritas Life. The Dental and Vision Networks are not available in RI. In Texas, our dental network and plans are referred to as the Ameritas Dental Network. Ameritas, the
bison design, “fulfilling life” are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. © 2021 Ameritas Mutual
Holding Company.
800-776-9446 ameritas.com
For producers only