2020 rates for idaho individuals and families...voyager | rate area 2 clearwater, idaho, latah,...
TRANSCRIPT
Email coverageadvisors@ pacificsource.com
Phone Toll-free: (855) 330-2792
PacificSource.com
IFP64_0919
2020 Rates for Idaho Individuals and FamiliesPlan availability varies depending on geographic locationAll medical plans are available through Your Health Idaho and direct with PacificSource.
Calculating Medical and Dental Rates for FamiliesRates are based on the age of each family member on the date that the plan becomes effective. Premiums will be charged for the following members of your family:
• Subscriber
• Spouse or qualified domestic partner
• Adult children age 21 and over
• Up to three children under the age of 21
• Up to three children under the age of 19 for a pediatric dental plan
Choose a Product Based on Where You Live
Navigator If you live in one of the following counties, you can choose plans on the Navigator Network:
• Ada• Adams• Blaine• Boise• Camas
• Canyon• Cassia• Custer• Elmore• Gem
• Gooding• Jerome• Lemhi• Lincoln• Minidoka
• Owyhee• Payette• Twin Falls• Valley• Washington
Voyager If you live in one of the following counties, you can choose plans on the Voyager Network:
• Bannock• Bear Lake• Benewah• Bingham• Bonner• Bonneville
• Boundary• Butte• Caribou• Clark• Clearwater• Franklin
• Fremont• Idaho• Jefferson• Kootenai• Latah• Lewis
• Madison• Nez Perce• Oneida• Power• Shoshone• Teton
Voyager | Rate Area 1
Gold 1500 Silver HSA 3500 AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $392 $392 $364 $364
15 $427 $427 $396 $396
16 $440 $440 $409 $409
17 $454 $454 $421 $421
18 $468 $562 $434 $521
19 $482 $579 $448 $537
20 $497 $597 $461 $554
21 $513 $615 $476 $571
22 $513 $615 $476 $571
23 $513 $615 $476 $571
24 $513 $615 $476 $571
25 $515 $618 $477 $573
26 $525 $630 $487 $584
27 $537 $645 $498 $598
28 $557 $669 $517 $620
29 $574 $688 $532 $639
30 $582 $698 $540 $648
31 $594 $713 $551 $661
32 $606 $728 $563 $675
33 $614 $737 $570 $684
34 $622 $747 $577 $693
35 $626 $752 $581 $697
36 $630 $757 $585 $702
37 $635 $761 $589 $706
38 $639 $766 $593 $711
39 $647 $776 $600 $720
40 $655 $786 $608 $729
41 $667 $801 $619 $743
42 $679 $815 $630 $756
43 $696 $835 $645 $774
44 $716 $859 $664 $797
45 $740 $888 $687 $824
46 $769 $923 $713 $856
47 $801 $961 $743 $892
48 $838 $1,006 $778 $933
49 $874 $1,049 $811 $974
50 $915 $1,099 $849 $1,019
51 $956 $1,147 $887 $1,064
52 $1,001 $1,201 $928 $1,114
53 $1,046 $1,255 $970 $1,164
54 $1,094 $1,313 $1,015 $1,218
55 $1,143 $1,372 $1,061 $1,273
56 $1,196 $1,435 $1,109 $1,331
57 $1,249 $1,499 $1,159 $1,391
58 $1,306 $1,567 $1,212 $1,454
59 $1,334 $1,601 $1,238 $1,48560 $1,391 $1,669 $1,291 $1,549
61 $1,440 $1,728 $1,336 $1,60462 $1,473 $1,767 $1,366 $1,640
63 $1,513 $1,816 $1,404 $1,68564 and over $1,538 $1,845 $1,427 $1,712
Benewah, Bonner, Boundary, Kootenai, and Shoshone counties
Voyager | Rate Area 2 Clearwater, Idaho, Latah, Lewis, and Nez Perce counties
Gold 1500 Silver HSA 3500 AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $472 $472 $438 $438
15 $514 $514 $477 $477
16 $530 $530 $492 $492
17 $546 $546 $507 $507
18 $564 $676 $523 $628
19 $581 $697 $539 $647
20 $599 $719 $556 $667
21 $617 $741 $573 $687
22 $617 $741 $573 $687
23 $617 $741 $573 $687
24 $617 $741 $573 $687
25 $620 $744 $575 $690
26 $632 $759 $587 $704
27 $647 $776 $600 $720
28 $671 $805 $623 $747
29 $691 $829 $641 $769
30 $701 $841 $650 $780
31 $716 $859 $664 $797
32 $730 $876 $678 $813
33 $740 $888 $686 $824
34 $750 $899 $695 $835
35 $754 $905 $700 $840
36 $759 $911 $705 $846
37 $764 $917 $709 $851
38 $769 $923 $714 $857
39 $779 $935 $723 $868
40 $789 $947 $732 $879
41 $804 $965 $746 $895
42 $818 $982 $759 $911
43 $838 $1,005 $777 $933
44 $863 $1,035 $800 $960
45 $892 $1,070 $827 $993
46 $926 $1,111 $859 $1,031
47 $965 $1,158 $895 $1,074
48 $1,009 $1,211 $937 $1,124
49 $1,053 $1,264 $977 $1,173
50 $1,103 $1,323 $1,023 $1,228
51 $1,151 $1,382 $1,068 $1,282
52 $1,205 $1,446 $1,118 $1,342
53 $1,259 $1,511 $1,169 $1,402
54 $1,318 $1,582 $1,223 $1,468
55 $1,377 $1,652 $1,277 $1,533
56 $1,440 $1,728 $1,336 $1,604
57 $1,505 $1,806 $1,396 $1,675
58 $1,573 $1,888 $1,460 $1,752
59 $1,607 $1,929 $1,491 $1,78960 $1,676 $2,011 $1,555 $1,866
61 $1,735 $2,082 $1,610 $1,93262 $1,774 $2,129 $1,646 $1,975
63 $1,823 $2,187 $1,691 $2,02964 and over $1,851 $2,223 $1,719 $2,061
Navigator | Rate Areas 3 and 5 Ada, Adams, Blaine, Boise, Camas, Canyon, Cassia, Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka, Owyhee, Payette, Twin Falls, Valley, and Washington counties
Gold 1500 Gold 2000 Silver 3000 AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $371 $371 $354 $354 $370 $370
15 $404 $404 $385 $385 $403 $403
16 $417 $417 $397 $397 $416 $416
17 $429 $429 $409 $409 $428 $428
18 $443 $532 $422 $507 $442 $530
19 $457 $548 $435 $522 $455 $547
20 $471 $565 $449 $538 $470 $563
21 $485 $582 $462 $555 $484 $581
22 $485 $582 $462 $555 $484 $581
23 $485 $582 $462 $555 $484 $581
24 $485 $582 $462 $555 $484 $581
25 $487 $585 $464 $557 $486 $583
26 $497 $596 $474 $568 $496 $595
27 $508 $610 $485 $582 $507 $609
28 $527 $633 $503 $603 $526 $631
29 $543 $652 $517 $621 $542 $650
30 $551 $661 $525 $630 $549 $659
31 $562 $675 $536 $643 $561 $673
32 $574 $689 $547 $656 $573 $687
33 $581 $697 $554 $665 $580 $696
34 $589 $707 $561 $674 $588 $705
35 $593 $711 $565 $678 $592 $710
36 $597 $716 $569 $683 $595 $714
37 $601 $721 $572 $687 $599 $719
38 $605 $725 $576 $691 $603 $724
39 $612 $735 $584 $700 $611 $733
40 $620 $744 $591 $709 $619 $742
41 $632 $758 $602 $722 $630 $756
42 $643 $771 $613 $735 $641 $770
43 $658 $790 $627 $753 $657 $788
44 $678 $813 $646 $775 $676 $811
45 $701 $841 $668 $801 $699 $839
46 $728 $873 $694 $832 $726 $871
47 $758 $910 $723 $867 $757 $908
48 $793 $952 $756 $907 $791 $950
49 $828 $993 $789 $947 $826 $991
50 $867 $1,040 $826 $991 $865 $1,037
51 $905 $1,086 $862 $1,035 $903 $1,083
52 $947 $1,136 $903 $1,083 $945 $1,134
53 $990 $1,188 $943 $1,132 $987 $1,185
54 $1,036 $1,243 $987 $1,185 $1,033 $1,240
55 $1,082 $1,298 $1,031 $1,237 $1,079 $1,295
56 $1,132 $1,358 $1,079 $1,295 $1,129 $1,355
57 $1,182 $1,419 $1,127 $1,352 $1,180 $1,416
58 $1,236 $1,483 $1,178 $1,414 $1,233 $1,480
59 $1,263 $1,516 $1,204 $1,444 $1,260 $1,512
60 $1,317 $1,580 $1,255 $1,506 $1,314 $1,576
61 $1,363 $1,636 $1,299 $1,559 $1,360 $1,632
62 $1,394 $1,673 $1,328 $1,594 $1,391 $1,669
63 $1,432 $1,719 $1,365 $1,638 $1,429 $1,715
64 and over $1,455 $1,746 $1,386 $1,665 $1,452 $1,743
Continued on the next page.
Navigator | Rate Areas 3 and 5 Ada, Adams, Blaine, Boise, Camas, Canyon, Cassia, Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka, Owyhee, Payette, Twin Falls, Valley, and Washington counties
Silver 4000 Bronze 5500 Bronze 7000AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $354 $354 $252 $252 $246 $246
15 $385 $385 $275 $275 $268 $268
16 $397 $397 $284 $284 $276 $276
17 $410 $410 $292 $292 $285 $285
18 $422 $507 $301 $362 $294 $353
19 $435 $523 $311 $373 $303 $363
20 $449 $539 $320 $384 $312 $375
21 $463 $555 $330 $396 $322 $386
22 $463 $555 $330 $396 $322 $386
23 $463 $555 $330 $396 $322 $386
24 $463 $555 $330 $396 $322 $386
25 $465 $558 $331 $398 $323 $388
26 $474 $569 $338 $406 $330 $395
27 $485 $582 $346 $415 $337 $405
28 $503 $604 $359 $431 $350 $420
29 $518 $621 $369 $443 $360 $432
30 $525 $630 $375 $450 $365 $438
31 $536 $644 $383 $459 $373 $448
32 $547 $657 $390 $469 $381 $457
33 $554 $665 $395 $474 $386 $463
34 $562 $674 $401 $481 $391 $469
35 $565 $679 $403 $484 $393 $472
36 $569 $683 $406 $487 $396 $475
37 $573 $687 $409 $490 $398 $478
38 $577 $692 $411 $494 $401 $481
39 $584 $701 $417 $500 $406 $487
40 $591 $710 $422 $506 $411 $494
41 $602 $723 $430 $516 $419 $503
42 $613 $736 $437 $525 $426 $512
43 $628 $754 $448 $537 $437 $524
44 $646 $776 $461 $553 $450 $540
45 $668 $802 $477 $572 $465 $558
46 $694 $833 $495 $594 $483 $579
47 $723 $868 $516 $619 $503 $604
48 $757 $908 $540 $648 $526 $631
49 $789 $947 $563 $676 $549 $659
50 $826 $992 $589 $707 $575 $690
51 $863 $1,036 $616 $739 $600 $720
52 $903 $1,084 $644 $773 $628 $754
53 $944 $1,133 $673 $808 $657 $788
54 $988 $1,186 $705 $846 $687 $825
55 $1,032 $1,238 $736 $883 $718 $861
56 $1,080 $1,295 $770 $924 $751 $901
57 $1,128 $1,353 $804 $965 $784 $941
58 $1,179 $1,415 $841 $1,009 $820 $984
59 $1,204 $1,445 $859 $1,031 $838 $1,005
60 $1,256 $1,507 $896 $1,075 $873 $1,048
61 $1,300 $1,560 $927 $1,113 $904 $1,085
62 $1,329 $1,595 $948 $1,138 $925 $1,110
63 $1,366 $1,639 $974 $1,169 $950 $1,140
64 and over $1,388 $1,665 $990 $1,188 $965 $1,158
Continued on the next page.
Navigator | Rate Areas 3 and 5 Ada, Adams, Blaine, Boise, Camas, Canyon, Cassia, Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka, Owyhee, Payette, Twin Falls, Valley, and Washington counties
Catastrophic Silver HSA 3500 Bronze HSA 6750AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $194 $194 $344 $344 $243 $243
15 $211 $211 $375 $375 $264 $264
16 $218 $218 $387 $387 $273 $273
17 $225 $225 $398 $398 $281 $281
18 $232 $278 $411 $493 $290 $348
19 $239 $287 $424 $508 $299 $358
20 $246 $295 $437 $524 $308 $369
21 $254 $305 $450 $540 $317 $381
22 $254 $305 $450 $540 $317 $381
23 $254 $305 $450 $540 $317 $381
24 $254 $305 $450 $540 $317 $381
25 $255 $306 $452 $542 $319 $382
26 $260 $312 $461 $553 $325 $390
27 $266 $319 $472 $566 $333 $399
28 $276 $331 $489 $587 $345 $414
29 $284 $341 $504 $604 $355 $426
30 $288 $346 $511 $613 $360 $432
31 $294 $353 $522 $626 $368 $441
32 $300 $360 $533 $639 $375 $451
33 $304 $365 $539 $647 $380 $456
34 $308 $370 $547 $656 $385 $462
35 $310 $372 $550 $660 $388 $465
36 $312 $375 $554 $664 $390 $468
37 $314 $377 $557 $669 $393 $471
38 $316 $380 $561 $673 $395 $475
39 $320 $384 $568 $682 $400 $481
40 $324 $389 $575 $690 $406 $487
41 $331 $397 $586 $703 $413 $496
42 $336 $404 $596 $716 $420 $505
43 $344 $413 $611 $733 $431 $517
44 $355 $426 $629 $755 $443 $532
45 $367 $440 $650 $780 $458 $550
46 $381 $457 $675 $810 $476 $571
47 $397 $476 $704 $844 $496 $595
48 $415 $498 $736 $883 $519 $623
49 $433 $520 $768 $922 $541 $650
50 $453 $544 $804 $965 $567 $680
51 $473 $568 $840 $1,007 $592 $710
52 $496 $595 $879 $1,054 $619 $743
53 $518 $621 $918 $1,102 $647 $777
54 $542 $650 $961 $1,153 $678 $813
55 $566 $679 $1,004 $1,205 $708 $849
56 $592 $711 $1,050 $1,260 $740 $888
57 $619 $742 $1,097 $1,316 $773 $928
58 $647 $776 $1,147 $1,376 $809 $970
59 $661 $793 $1,172 $1,406 $826 $991
60 $689 $827 $1,222 $1,466 $861 $1,034
61 $713 $856 $1,265 $1,518 $892 $1,070
62 $729 $875 $1,293 $1,552 $912 $1,094
63 $749 $899 $1,329 $1,595 $937 $1,124
64 and over $762 $914 $1,350 $1,620 $951 $1,142
Navigator | Rate Area 4 Custer and Lemhi counties
Gold 1500 Gold 2000 Silver 3000 AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $386 $386 $368 $368 $385 $385
15 $421 $421 $401 $401 $420 $420
16 $434 $434 $413 $413 $433 $433
17 $447 $447 $426 $426 $446 $446
18 $461 $553 $439 $527 $460 $552
19 $475 $570 $453 $543 $474 $569
20 $490 $588 $467 $560 $489 $586
21 $505 $606 $481 $578 $504 $605
22 $505 $606 $481 $578 $504 $605
23 $505 $606 $481 $578 $504 $605
24 $505 $606 $481 $578 $504 $605
25 $507 $608 $483 $580 $506 $607
26 $517 $621 $493 $591 $516 $619
27 $529 $635 $504 $605 $528 $634
28 $549 $659 $523 $628 $548 $657
29 $565 $678 $539 $646 $564 $677
30 $573 $688 $546 $656 $572 $686
31 $585 $702 $558 $669 $584 $701
32 $597 $717 $569 $683 $596 $715
33 $605 $726 $577 $692 $604 $724
34 $613 $736 $584 $701 $612 $734
35 $617 $741 $588 $706 $616 $739
36 $621 $745 $592 $710 $620 $744
37 $625 $750 $596 $715 $624 $748
38 $629 $755 $600 $720 $628 $753
39 $637 $765 $607 $729 $636 $763
40 $645 $774 $615 $738 $644 $773
41 $657 $789 $627 $752 $656 $787
42 $669 $803 $638 $765 $668 $801
43 $685 $822 $653 $784 $684 $820
44 $705 $847 $672 $807 $704 $845
45 $729 $875 $695 $834 $728 $873
46 $757 $909 $722 $866 $756 $907
47 $789 $947 $752 $903 $787 $945
48 $826 $991 $787 $944 $824 $988
49 $862 $1,034 $821 $985 $860 $1,031
50 $902 $1,082 $860 $1,031 $900 $1,080
51 $942 $1,130 $898 $1,077 $940 $1,128
52 $986 $1,183 $939 $1,127 $983 $1,180
53 $1,030 $1,236 $982 $1,178 $1,028 $1,233
54 $1,078 $1,294 $1,028 $1,233 $1,076 $1,291
55 $1,126 $1,351 $1,073 $1,288 $1,123 $1,348
56 $1,178 $1,414 $1,123 $1,347 $1,175 $1,410
57 $1,231 $1,477 $1,173 $1,407 $1,228 $1,473
58 $1,287 $1,544 $1,226 $1,472 $1,284 $1,540
59 $1,314 $1,577 $1,253 $1,503 $1,311 $1,574
60 $1,371 $1,645 $1,306 $1,567 $1,367 $1,641
61 $1,419 $1,703 $1,352 $1,623 $1,416 $1,699
62 $1,451 $1,741 $1,383 $1,659 $1,447 $1,737
63 $1,491 $1,789 $1,421 $1,705 $1,487 $1,785
64 and over $1,515 $1,818 $1,443 $1,733 $1,511 $1,814
Continued on the next page.
Navigator | Rate Area 4 Custer and Lemhi counties
Silver 4000 Bronze 5500 Bronze 7000AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $368 $368 $263 $263 $256 $256
15 $401 $401 $286 $286 $279 $279
16 $414 $414 $295 $295 $288 $288
17 $426 $426 $304 $304 $296 $296
18 $440 $528 $314 $376 $306 $367
19 $453 $544 $323 $388 $315 $378
20 $467 $561 $333 $400 $325 $390
21 $482 $578 $344 $412 $335 $402
22 $482 $578 $344 $412 $335 $402
23 $482 $578 $344 $412 $335 $402
24 $482 $578 $344 $412 $335 $402
25 $484 $580 $345 $414 $336 $404
26 $493 $592 $352 $422 $343 $412
27 $505 $606 $360 $432 $351 $421
28 $524 $628 $373 $448 $364 $437
29 $539 $647 $384 $461 $375 $450
30 $547 $656 $390 $468 $380 $456
31 $558 $670 $398 $478 $388 $466
32 $570 $684 $406 $488 $396 $476
33 $577 $692 $412 $494 $401 $482
34 $585 $702 $417 $500 $407 $488
35 $589 $706 $420 $504 $409 $491
36 $592 $711 $423 $507 $412 $494
37 $596 $715 $425 $510 $415 $498
38 $600 $720 $428 $514 $417 $501
39 $608 $729 $434 $520 $423 $507
40 $616 $739 $439 $527 $428 $514
41 $627 $752 $447 $537 $436 $523
42 $638 $766 $455 $546 $444 $533
43 $654 $784 $466 $559 $455 $545
44 $673 $807 $480 $576 $468 $562
45 $695 $835 $496 $595 $484 $580
46 $722 $867 $515 $618 $502 $603
47 $753 $903 $537 $644 $524 $628
48 $787 $945 $562 $674 $548 $657
49 $822 $986 $586 $703 $571 $686
50 $860 $1,032 $614 $736 $598 $718
51 $898 $1,078 $641 $769 $625 $750
52 $940 $1,128 $671 $805 $654 $785
53 $983 $1,179 $701 $841 $683 $820
54 $1,028 $1,234 $733 $880 $715 $858
55 $1,074 $1,289 $766 $919 $747 $896
56 $1,124 $1,348 $801 $962 $781 $938
57 $1,174 $1,408 $837 $1,005 $816 $980
58 $1,227 $1,473 $875 $1,050 $853 $1,024
59 $1,254 $1,504 $894 $1,073 $872 $1,046
60 $1,307 $1,569 $932 $1,119 $909 $1,091
61 $1,353 $1,624 $965 $1,158 $941 $1,129
62 $1,384 $1,660 $987 $1,184 $962 $1,155
63 $1,422 $1,706 $1,014 $1,217 $989 $1,187
64 and over $1,445 $1,734 $1,031 $1,236 $1,005 $1,206
Continued on the next page.
Navigator | Rate Area 4 Custer and Lemhi counties
Catastrophic Silver HSA 3500 Bronze HSA 6750AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $202 $202 $358 $358 $253 $253
15 $220 $220 $390 $390 $275 $275
16 $227 $227 $402 $402 $284 $284
17 $234 $234 $415 $415 $292 $292
18 $241 $289 $428 $513 $302 $362
19 $249 $298 $441 $529 $311 $373
20 $256 $308 $454 $545 $320 $384
21 $264 $317 $469 $562 $330 $396
22 $264 $317 $469 $562 $330 $396
23 $264 $317 $469 $562 $330 $396
24 $264 $317 $469 $562 $330 $396
25 $265 $318 $470 $564 $332 $398
26 $271 $325 $480 $576 $338 $406
27 $277 $332 $491 $589 $346 $415
28 $287 $345 $509 $611 $359 $431
29 $296 $355 $524 $629 $370 $444
30 $300 $360 $532 $638 $375 $450
31 $306 $367 $543 $652 $383 $459
32 $313 $375 $554 $665 $391 $469
33 $317 $380 $561 $674 $396 $475
34 $321 $385 $569 $683 $401 $481
35 $323 $387 $573 $687 $404 $484
36 $325 $390 $576 $692 $406 $488
37 $327 $393 $580 $696 $409 $491
38 $329 $395 $584 $701 $412 $494
39 $333 $400 $591 $710 $417 $500
40 $338 $405 $599 $719 $422 $507
41 $344 $413 $610 $732 $430 $516
42 $350 $420 $621 $745 $438 $525
43 $359 $430 $636 $763 $448 $538
44 $369 $443 $655 $785 $461 $554
45 $382 $458 $677 $812 $477 $572
46 $396 $476 $703 $843 $495 $595
47 $413 $496 $732 $879 $516 $620
48 $432 $518 $766 $919 $540 $648
49 $451 $541 $799 $959 $564 $676
50 $472 $566 $837 $1,004 $590 $708
51 $493 $591 $874 $1,049 $616 $739
52 $516 $619 $915 $1,098 $645 $774
53 $539 $647 $956 $1,147 $674 $809
54 $564 $677 $1,000 $1,200 $705 $846
55 $589 $707 $1,045 $1,254 $737 $884
56 $616 $740 $1,093 $1,312 $771 $925
57 $644 $773 $1,142 $1,370 $805 $966
58 $673 $808 $1,194 $1,433 $842 $1,010
59 $688 $825 $1,220 $1,464 $860 $1,032
60 $717 $861 $1,272 $1,526 $896 $1,076
61 $742 $891 $1,317 $1,580 $928 $1,114
62 $759 $911 $1,346 $1,615 $949 $1,139
63 $780 $936 $1,383 $1,660 $975 $1,170
64 and over $792 $951 $1,406 $1,686 $990 $1,188
Voyager | Rate Area 4 Bonneville, Butte, Clark, Freemont, Jefferson, Madison, and Teton counties
Gold 1500 Silver HSA 3500AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $454 454 $422 $422
15 $495 495 $459 $459
16 $510 510 $474 $474
17 $526 526 $488 $488
18 $542 651 $503 $604
19 $559 671 $519 $622
20 $576 692 $535 $642
21 $594 713 $551 $661
22 $594 713 $551 $661
23 $594 713 $551 $661
24 $594 713 $551 $661
25 $596 716 $553 $664
26 $608 730 $564 $677
27 $623 747 $578 $693
28 $646 775 $599 $719
29 $665 798 $617 $740
30 $674 809 $626 $751
31 $689 826 $639 $767
32 $703 843 $652 $783
33 $712 854 $660 $792
34 $721 865 $669 $803
35 $726 871 $674 $808
36 $731 877 $678 $814
37 $735 883 $682 $819
38 $740 888 $687 $824
39 $750 900 $696 $835
40 $759 911 $704 $845
41 $774 928 $718 $861
42 $787 945 $730 $876
43 $806 967 $748 $898
44 $830 996 $770 $924
45 $858 1029 $796 $955
46 $891 1069 $827 $992
47 $929 1114 $862 $1,034
48 $971 1166 $901 $1,081
49 $1,014 1216 $940 $1,128
50 $1,061 1273 $984 $1,181
51 $1,108 1330 $1,028 $1,234
52 $1,160 1392 $1,076 $1,291
53 $1,212 1454 $1,124 $1,349
54 $1,268 1522 $1,177 $1,412
55 $1,325 1590 $1,229 $1,475
56 $1,386 1663 $1,286 $1,543
57 $1,448 1737 $1,343 $1,612
58 $1,514 1817 $1,405 $1,685
59 $1,546 1856 $1,435 $1,722
60 $1,612 1935 $1,496 $1,795
61 $1,669 2003 $1,549 $1,859
62 $1,707 2048 $1,584 $1,900
63 $1,754 2105 $1,627 $1,953
64 and over $1,782 2139 $1,653 $1,983
Voyager | Rate Area 6 Bannock, Bear Lake, Bingham, Caribou, Franklin, Oneida, and Power counties
Gold 1500 Silver HSA 3500AGE NONTOBACCO USER TOBACCO USER NONTOBACCO USER TOBACCO USER
0-14 $454 $454 $422 $422
15 $495 $495 $459 $459
16 $510 $510 $474 $474
17 $526 $526 $488 $488
18 $542 $651 $503 $604
19 $559 $671 $519 $622
20 $576 $692 $535 $642
21 $594 $713 $551 $661
22 $594 $713 $551 $661
23 $594 $713 $551 $661
24 $594 $713 $551 $661
25 $596 $716 $553 $664
26 $608 $730 $564 $677
27 $623 $747 $578 $693
28 $646 $775 $599 $719
29 $665 $798 $617 $740
30 $674 $809 $626 $751
31 $689 $826 $639 $767
32 $703 $843 $652 $783
33 $712 $854 $660 $792
34 $721 $865 $669 $803
35 $726 $871 $674 $808
36 $731 $877 $678 $814
37 $735 $883 $682 $819
38 $740 $888 $687 $824
39 $750 $900 $696 $835
40 $759 $911 $704 $845
41 $774 $928 $718 $861
42 $787 $945 $730 $876
43 $806 $967 $748 $898
44 $830 $996 $770 $924
45 $858 $1,029 $796 $955
46 $891 $1,069 $827 $992
47 $929 $1,114 $862 $1,034
48 $971 $1,166 $901 $1,081
49 $1,014 $1,216 $940 $1,128
50 $1,061 $1,273 $984 $1,181
51 $1,108 $1,330 $1,028 $1,234
52 $1,160 $1,392 $1,076 $1,291
53 $1,212 $1,454 $1,124 $1,349
54 $1,268 $1,522 $1,177 $1,412
55 $1,325 $1,590 $1,229 $1,475
56 $1,386 $1,663 $1,286 $1,543
57 $1,448 $1,737 $1,343 $1,612
58 $1,514 $1,817 $1,405 $1,685
59 $1,546 $1,856 $1,435 $1,722
60 $1,612 $1,935 $1,496 $1,795
61 $1,669 $2,003 $1,549 $1,859
62 $1,707 $2,048 $1,584 $1,900
63 $1,754 $2,105 $1,627 $1,953
64 and over $1,782 $2,139 $1,653 $1,983
Dental Rates Plans are available statewide through the Health Insurance Marketplace and direct with PacificSource.
Dental Advantage 0-20-50 1000
Dental Advantage 0-20-50 1500
Kids Dental Advantage 0-20-50
(coverage for members age 18 and under)
AGE PREMIUM AGE PREMIUM AGE PREMIUM
0 to 18 $46 0 to 18 $46 0 to 18 $44
19 to 20 $45 19 to 20 $51 19 to 20 -
21 to 24 $45 21 to 24 $51 21 to 24 -
25 to 29 $47 25 to 29 $53 25 to 29 -
30 to 34 $51 30 to 34 $58 30 to 34 -
35 to 39 $56 35 to 39 $63 35 to 39 -
40 to 44 $61 40 to 44 $69 40 to 44 -
45 to 49 $66 45 to 49 $74 45 to 49 -
50 to 54 $68 50 to 54 $77 50 to 54 -
55 to 59 $71 55 to 59 $80 55 to 59 -
60 to 64 $73 60 to 64 $82 60 to 64 -
65+ $73 65+ $82 65+ -