Page 5 - Benefit Guide_Heritage School 2020_Revised 9-25-2020

Medical Option Rates

Blue Cross Blue Shield

2020 Rate Information—Cost is per Employee and each additional family Member.
Simply add the cost of each family member to be covered and
subtract $500 from the Employee Only Amount.

MEDICAL - BCBS B661CHC High Deductible Health Plan HSA

Monthly Monthly Monthly Monthly Monthly Monthly
Age Age Age Age Age Age
Cost Cost Cost Cost Cost Cost
<15 $273.53 23 $357.56 32 $422.99 41 $465.54 50 $638.60 59 $930.72
15 $297.85 24 $357.56 33 $428.35 42 $473.76 51 $666.84 60 $970.41
16 $307.14 25 $358.99 34 $434.07 43 $485.21 52 $697.95 61 $1,004.74
17 $316.44 26 $366.14 35 $436.94 44 $499.51 53 $729.42 62 $1,027.26
18 $326.45 27 $374.72 36 $439.80 45 $516.31 54 $763.38 63 $1,055.51
19 $336.46 28 $388.66 37 $442.66 46 $536.34 55 $797.35 64+ $1,072.68
20 $346.83 29 $400.11 38 $445.52 47 $558.86 56 $834.18
21 $357.56 30 $405.83 39 $451.24 48 $584.61 57 $871.37
22 $357.56 31 $414.41 40 $456.96 49 $609.99 58 $911.06
MEDICAL - BCBS S663CHC Core Plan

Monthly Monthly Monthly Monthly Monthly Monthly
Age Age Age Age Age Age
Cost Cost Cost Cost Cost Cost
<15 $311.91 23 $407.72 32 $482.34 41 $530.85 50 $728.19 59 $1,061.30
15 $339.63 24 $407.72 33 $488.45 42 $540.23 51 $760.40 60 $1,106.56
16 $350.23 25 $409.35 34 $494.97 43 $553.28 52 $795.87 61 $1,145.70
17 $360.83 26 $417.51 35 $498.24 44 $569.59 53 $831.75 62 $1,171.39
18 $372.25 27 $427.29 36 $501.50 45 $588.75 54 $870.49 63 $1,203.60
19 $383.67 28 $443.19 37 $504.76 46 $611.58 55 $909.22 64+ $1,223.16
20 $395.49 29 $456.24 38 $508.02 47 $637.27 56 $951.22
21 $407.72 30 $462.76 39 $514.55 48 $666.63 57 $993.62
22 $407.72 31 $472.55 40 $521.07 49 $695.57 58 $1,038.88
MEDICAL - BCBS G652CHC Buy-Up Plan

Monthly Monthly Monthly Monthly Monthly Monthly
Age Age Age Age Age Age
Cost Cost Cost Cost Cost Cost
<15 $362.87 23 $474.34 32 $561.15 41 $617.60 50 $847.18 59 $1,234.72
15 $395.13 24 $474.34 33 $568.26 42 $628.51 51 $884.65 60 $1,287.37
16 $407.46 25 $476.24 34 $575.85 43 $643.69 52 $925.92 61 $1,332.91
17 $419.79 26 $485.73 35 $579.65 44 $662.66 53 $967.66 62 $1,362.79
18 $433.08 27 $497.11 36 $583.44 45 $684.95 54 $1,012.73 63 $1,400.27
19 $446.36 28 $515.61 37 $587.24 46 $711.52 55 $1,057.79 64+ $1,423.02
20 $460.11 29 $530.79 38 $591.03 47 $741.40 56 $1,106.65
21 $474.34 30 $538.38 39 $598.62 48 $775.55 57 $1,155.98
22 $474.34 31 $549.77 40 $606.21 49 $809.23 58 $1,208.63

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