Individual and Family Health Insurance Rates New Business Rates Effective January 1, 2016*
*rates subject to change A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
350137.1115
How to Calculate Family Rates* Family rates are simply calculated by adding the costs of the covered individuals together. Start by finding your rates from the following pages. Then, if applicable, add in your spouse’s rate. Finally, add any children – you only pay for a maximum of 3 children, any more than 3 are covered for no additional cost.
*rates subject to change
Montana County Mapping
County Beaverhead Big Horn Blaine Broadwater Carbon Carter Cascade Chouteau Custer Daniels Dawson Deer Lodge Fallon Fergus Flathead Gallatin Garfield Glacier Golden Valley Granite Hill Jefferson Judith Basin Lake Lewis and Clark Liberty Lincoln Madison
Rating Area 1 2 3 4
Rating Area Description Billings, MT Great Falls, MT Missoula, MT Non MSA
Rating Area 4 4 4 2 1 4 2 2 4 4 4 2 4 4 3 2 4 4 4 4 4 2 2 3 2 4 4 4
County McCone Meagher Mineral Missoula Musselshell Park Petroleum Phillips Pondera Powder River Powell Prairie Ravalli Richland Roosevelt Rosebud Sanders Sheridan Silver Bow Stillwater Sweet Grass Teton Toole Treasure Valley Wheatland Wibaux Yellowstone
*Rates effective January 1, 2016.
Page 1 of 14
Rating Area 4 4 4 3 1 4 4 4 4 4 4 4 4 4 4 4 4 4 2 1 1 2 4 4 4 4 4 1
Montana Off Exchange (Gold) Individual Coverage Billings, MT Plan
Blue Focus POS 101
Blue Preferred PPO 104
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
Non Tobacco
Tobacco
203.53 320.53 320.53 320.53 320.53
203.53 320.53 320.53 320.53 320.53
216.48 340.92 340.92 340.92 340.92
216.48 340.92 340.92 340.92 340.92
25 26 27 28 29
321.81 328.22 335.91 348.41 358.67
321.81 328.22 335.91 348.41 358.67
342.28 349.10 357.28 370.58 381.49
342.28 349.10 357.28 370.58 381.49
30 31 32 33 34
363.80 371.49 379.18 383.99 389.12
412.62 421.35 430.07 435.52 441.34
386.94 395.12 403.31 408.42 413.87
438.87 448.15 457.43 463.23 469.42
35 36 37 38 39
391.68 394.25 396.81 399.38 404.51
480.91 484.06 487.21 490.36 496.65
416.60 419.33 422.06 424.78 430.24
511.50 514.85 518.20 521.55 528.24
40 41 42 43 44
409.63 417.33 424.70 434.96 447.78
528.18 538.10 547.61 560.83 577.36
435.69 443.87 451.72 462.63 476.26
561.78 572.33 582.44 596.51 614.09
45 46 47 48 49
462.84 480.79 500.98 524.06 546.82
610.30 633.97 660.60 691.03 721.04
492.28 511.38 532.85 557.40 581.61
649.13 674.30 702.62 734.99 766.90
50 51 52 53 54
572.46 597.78 625.67 653.88 684.33
756.91 790.39 827.26 864.56 904.82
608.88 635.81 665.47 695.47 727.86
805.06 840.67 879.88 919.55 962.38
55 56 57 58 59
714.78 747.79 781.13 816.70 834.33
935.07 978.26 1021.87 1068.41 1091.47
760.25 795.36 830.82 868.66 887.41
994.56 1040.49 1086.87 1136.38 1160.91
60 61 62 63 64
869.91 900.68 920.88 946.20 961.59
1117.66 1157.20 1183.14 1215.67 1235.44
925.25 957.98 979.46 1006.39 1022.76
1188.76 1230.81 1258.40 1293.01 1314.03
65+ 961.59 1235.44 *Rates effective January 1, 2016.
1022.76
1314.03
Page 2 of 14
Montana Off Exchange (Gold) Individual Coverage Great Falls, MT Plan
Blue Preferred PPO 104
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
203.39 320.30 320.30 320.30 320.30
203.39 320.30 320.30 320.30 320.30
25 26 27 28 29
321.58 327.98 335.67 348.16 358.41
321.58 327.98 335.67 348.16 358.41
30 31 32 33 34
363.54 371.22 378.91 383.72 388.84
412.32 421.04 429.76 435.21 441.02
35 36 37 38 39
391.40 393.96 396.53 399.09 404.21
480.56 483.71 486.86 490.00 496.29
40 41 42 43 44
409.34 417.03 424.39 434.64 447.45
527.80 537.71 547.21 560.43 576.95
45 46 47 48 49
462.51 480.44 500.62 523.68 546.43
609.86 633.51 660.12 690.53 720.52
50 51 52 53 54
572.05 597.35 625.22 653.40 683.83
756.36 789.82 826.66 863.93 904.16
55 56 57 58 59
714.26 747.25 780.56 816.12 833.73
934.40 977.55 1021.13 1067.64 1090.69
60 61 62 63 64
869.28 900.03 920.21 945.52 960.90
1116.86 1156.36 1182.29 1214.80 1234.55
65+ 960.90 1234.55 *Rates effective January 1, 2016.
Page 3 of 14
Montana Off Exchange (Gold) Individual Coverage Missoula, MT Plan
Blue Focus POS 101
Blue Preferred PPO 104
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
Non Tobacco
Tobacco
197.55 311.10 311.10 311.10 311.10
197.55 311.10 311.10 311.10 311.10
214.91 338.44 338.44 338.44 338.44
214.91 338.44 338.44 338.44 338.44
25 26 27 28 29
312.34 318.57 326.03 338.17 348.12
312.34 318.57 326.03 338.17 348.12
339.79 346.56 354.68 367.88 378.71
339.79 346.56 354.68 367.88 378.71
30 31 32 33 34
353.10 360.56 368.03 372.70 377.67
400.48 408.95 417.42 422.71 428.36
384.12 392.25 400.37 405.45 410.86
435.68 444.89 454.10 459.86 466.00
35 36 37 38 39
380.16 382.65 385.14 387.63 392.61
466.76 469.82 472.88 475.93 482.04
413.57 416.28 418.98 421.69 427.11
507.78 511.10 514.43 517.75 524.40
40 41 42 43 44
397.59 405.05 412.21 422.16 434.61
512.65 522.27 531.50 544.34 560.38
432.52 440.64 448.43 459.26 472.79
557.69 568.17 578.20 592.17 609.62
45 46 47 48 49
449.23 466.65 486.25 508.65 530.74
592.35 615.32 641.17 670.70 699.83
488.70 507.65 528.98 553.34 577.37
644.40 669.39 697.51 729.64 761.32
50 51 52 53 54
555.62 580.20 607.27 634.64 664.20
734.65 767.14 802.93 839.13 878.20
604.45 631.18 660.63 690.41 722.56
799.20 834.55 873.48 912.86 955.37
55 56 57 58 59
693.75 725.80 758.15 792.68 809.79
907.57 949.49 991.81 1036.99 1059.37
754.71 789.57 824.77 862.33 880.95
987.32 1032.92 1078.96 1128.10 1152.46
60 61 62 63 64
844.32 874.19 893.79 918.37 933.30
1084.79 1123.16 1148.34 1179.92 1199.10
918.51 951.00 972.33 999.06 1015.32
1180.11 1221.85 1249.24 1283.60 1304.47
65+ 933.30 1199.10 *Rates effective January 1, 2016.
1015.32
1304.47
Page 4 of 14
Montana Off Exchange (Gold) Individual Coverage Non MSA Plan
Blue Preferred PPO 104
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
207.26 326.39 326.39 326.39 326.39
207.26 326.39 326.39 326.39 326.39
25 26 27 28 29
327.69 334.22 342.05 354.78 365.23
327.69 334.22 342.05 354.78 365.23
30 31 32 33 34
370.45 378.28 386.11 391.01 396.23
420.16 429.05 437.93 443.48 449.41
35 36 37 38 39
398.84 401.45 404.07 406.68 411.90
489.70 492.90 496.11 499.32 505.73
40 41 42 43 44
417.12 424.95 432.46 442.91 455.96
537.84 547.94 557.62 571.08 587.92
45 46 47 48 49
471.30 489.58 510.14 533.64 556.81
621.46 645.56 672.67 703.66 734.22
50 51 52 53 54
582.93 608.71 637.11 665.83 696.83
770.74 804.84 842.38 880.36 921.36
55 56 57 58 59
727.84 761.46 795.40 831.63 849.58
952.16 996.14 1040.54 1087.94 1111.42
60 61 62 63 64
885.81 917.14 937.71 963.49 979.17
1138.09 1178.35 1204.77 1237.89 1258.02
65+ 979.17 1258.02 *Rates effective January 1, 2016.
Page 5 of 14
Montana Off Exchange (Silver) Individual Coverage Billings, MT Blue Focus POS 102
Plan
Blue Preferred PPO 101
103
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
171.08 269.41 269.41 269.41 269.41
171.08 269.41 269.41 269.41 269.41
165.92 261.29 261.29 261.29 261.29
165.92 261.29 261.29 261.29 261.29
174.88 275.40 275.40 275.40 275.40
174.88 275.40 275.40 275.40 275.40
25 26 27 28 29
270.49 275.88 282.35 292.85 301.47
270.49 275.88 282.35 292.85 301.47
262.34 267.56 273.83 284.02 292.38
262.34 267.56 273.83 284.02 292.38
276.50 282.01 288.62 299.36 308.17
276.50 282.01 288.62 299.36 308.17
30 31 32 33 34
305.78 312.25 318.72 322.76 327.07
346.82 354.16 361.49 366.07 370.96
296.56 302.84 309.11 313.03 317.21
336.36 343.48 350.59 355.03 359.78
312.58 319.19 325.80 329.93 334.34
354.53 362.03 369.52 374.21 379.20
35 36 37 38 39
329.22 331.38 333.53 335.69 340.00
404.22 406.87 409.51 412.16 417.45
319.30 321.39 323.48 325.57 329.75
392.03 394.60 397.17 399.73 404.86
336.54 338.74 340.95 343.15 347.56
413.20 415.91 418.61 421.32 426.73
40 41 42 43 44
344.31 350.78 356.97 365.59 376.37
443.95 452.29 460.28 471.40 485.29
333.93 340.20 346.21 354.57 365.02
430.57 438.65 446.40 457.18 470.66
351.96 358.57 364.91 373.72 384.73
453.82 462.34 470.51 481.87 496.08
45 46 47 48 49
389.03 404.12 421.09 440.49 459.62
512.98 532.87 555.25 580.83 606.05
377.30 391.94 408.40 427.21 445.76
497.51 516.81 538.51 563.32 587.78
397.68 413.10 430.45 450.28 469.83
524.38 544.71 567.59 593.74 619.52
50 51 52 53 54
481.17 502.46 525.90 549.60 575.20
636.21 664.35 695.34 726.69 760.53
466.66 487.31 510.04 533.03 557.85
617.02 644.32 674.37 704.78 737.60
491.87 513.62 537.58 561.82 587.98
650.34 679.11 710.79 742.84 777.43
55 56 57 58 59
600.79 628.54 656.56 686.47 701.28
785.96 822.26 858.91 898.03 917.42
582.68 609.59 636.76 665.77 680.14
762.26 797.47 833.01 870.96 889.76
614.14 642.51 671.15 701.72 716.87
803.42 840.53 878.00 917.99 937.81
60 61 62 63 64
731.19 757.05 774.03 795.31 808.23
939.43 972.66 994.47 1021.81 1038.43
709.14 734.23 750.69 771.33 783.87
911.11 943.33 964.48 991.00 1007.12
747.44 773.88 791.23 812.98 826.20
960.31 994.28 1016.57 1044.52 1061.50
65+ 808.23 1038.43 *Rates effective January 1, 2016.
783.87
1007.12
826.20
1061.50
Page 6 of 14
Montana Off Exchange (Silver) Individual Coverage Great Falls, MT Plan
Blue Preferred PPO 101
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
164.30 258.74 258.74 258.74 258.74
164.30 258.74 258.74 258.74 258.74
25 26 27 28 29
259.78 264.95 271.16 281.25 289.53
259.78 264.95 271.16 281.25 289.53
30 31 32 33 34
293.67 299.88 306.09 309.97 314.11
333.08 340.13 347.17 351.57 356.27
35 36 37 38 39
316.18 318.25 320.32 322.39 326.53
388.21 390.75 393.29 395.83 400.92
40 41 42 43 44
330.67 336.88 342.83 351.11 361.46
426.37 434.38 442.05 452.73 466.07
45 46 47 48 49
373.62 388.11 404.41 423.04 441.41
492.66 511.77 533.26 557.83 582.05
50 51 52 53 54
462.11 482.55 505.07 527.83 552.42
611.01 638.03 667.80 697.90 730.40
55 56 57 58 59
577.00 603.65 630.56 659.28 673.51
754.83 789.69 824.89 862.46 881.08
60 61 62 63 64
702.23 727.07 743.37 763.81 776.22
902.22 934.14 955.08 981.34 997.30
65+ 776.22 997.30 *Rates effective January 1, 2016.
Page 7 of 14
Montana Off Exchange (Silver) Individual Coverage Missoula, MT Blue Focus POS 102
Plan
Blue Preferred PPO 101
103
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
166.05 261.49 261.49 261.49 261.49
166.05 261.49 261.49 261.49 261.49
161.04 253.61 253.61 253.61 253.61
161.04 253.61 253.61 253.61 253.61
173.61 273.40 273.40 273.40 273.40
173.61 273.40 273.40 273.40 273.40
25 26 27 28 29
262.54 267.77 274.04 284.24 292.61
262.54 267.77 274.04 284.24 292.61
254.62 259.69 265.78 275.67 283.78
254.62 259.69 265.78 275.67 283.78
274.49 279.96 286.52 297.18 305.93
274.49 279.96 286.52 297.18 305.93
30 31 32 33 34
296.79 303.07 309.35 313.27 317.45
336.63 343.74 350.86 355.31 360.05
287.84 293.93 300.02 303.82 307.88
326.47 333.37 340.28 344.59 349.19
310.30 316.87 323.43 327.53 331.90
351.95 359.39 366.83 371.48 376.44
35 36 37 38 39
319.54 321.64 323.73 325.82 330.00
392.34 394.90 397.47 400.04 405.18
309.91 311.93 313.96 315.99 320.05
380.50 382.99 385.49 387.98 392.96
334.09 336.28 338.46 340.65 345.03
410.19 412.88 415.57 418.25 423.62
40 41 42 43 44
334.19 340.46 346.48 354.85 365.31
430.90 438.99 446.75 457.54 471.02
324.11 330.19 336.03 344.14 354.29
417.90 425.75 433.27 443.74 456.82
349.40 355.96 362.25 371.00 381.93
450.52 458.98 467.09 478.37 492.47
45 46 47 48 49
377.60 392.24 408.71 427.54 446.11
497.90 517.21 538.93 563.76 588.24
366.21 380.41 396.39 414.64 432.65
482.88 501.61 522.67 546.75 570.49
394.78 410.09 427.32 447.00 466.41
520.56 540.75 563.46 589.42 615.01
50 51 52 53 54
467.03 487.68 510.43 533.45 558.29
617.50 644.82 674.89 705.32 738.17
452.94 472.97 495.04 517.36 541.45
598.88 625.37 654.54 684.05 715.90
488.28 509.88 533.67 557.73 583.70
645.61 674.17 705.62 737.43 771.77
55 56 57 58 59
583.13 610.06 637.26 666.28 680.67
762.85 798.08 833.66 871.63 890.45
565.54 591.66 618.04 646.19 660.13
739.84 774.01 808.51 845.34 863.59
609.67 637.83 666.27 696.61 711.65
797.57 834.41 871.61 911.31 930.98
60 61 62 63 64
709.69 734.80 751.27 771.93 784.47
911.81 944.07 965.23 991.77 1007.90
688.29 712.63 728.61 748.64 760.83
884.31 915.59 936.12 961.86 977.50
742.00 768.24 785.47 807.06 820.20
953.32 987.04 1009.17 1036.92 1053.78
65+ 784.47 1007.90 *Rates effective January 1, 2016.
760.83
977.50
820.20
1053.78
Page 8 of 14
Montana Off Exchange (Silver) Individual Coverage Non MSA Plan
Blue Preferred PPO 101
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
167.43 263.66 263.66 263.66 263.66
167.43 263.66 263.66 263.66 263.66
25 26 27 28 29
264.72 269.99 276.32 286.60 295.04
264.72 269.99 276.32 286.60 295.04
30 31 32 33 34
299.26 305.58 311.91 315.87 320.09
339.42 346.59 353.77 358.26 363.04
35 36 37 38 39
322.19 324.30 326.41 328.52 332.74
395.59 398.18 400.77 403.36 408.54
40 41 42 43 44
336.96 343.29 349.35 357.79 368.34
434.48 442.64 450.46 461.33 474.93
45 46 47 48 49
380.73 395.49 412.10 431.09 449.81
502.03 521.50 543.40 568.43 593.12
50 51 52 53 54
470.90 491.73 514.67 537.87 562.92
622.62 650.16 680.49 711.17 744.29
55 56 57 58 59
587.97 615.12 642.54 671.81 686.31
769.18 804.70 840.57 878.86 897.83
60 61 62 63 64
715.58 740.89 757.50 778.33 790.98
919.38 951.90 973.24 1000.00 1016.26
65+ 790.98 1016.26 *Rates effective January 1, 2016.
Page 9 of 14
Montana Off Exchange (Bronze) Individual Coverage Billings, MT Plan
Blue Focus POS 104
Blue Preferred PPO 102
006
103
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
123.67 194.75 194.75 194.75 194.75
123.67 194.75 194.75 194.75 194.75
135.63 213.58 213.58 213.58 213.58
135.63 213.58 213.58 213.58 213.58
135.88 213.99 213.99 213.99 213.99
135.88 213.99 213.99 213.99 213.99
151.41 238.44 238.44 238.44 238.44
151.41 238.44 238.44 238.44 238.44
25 26 27 28 29
195.53 199.42 204.10 211.69 217.92
195.53 199.42 204.10 211.69 217.92
214.44 218.71 223.84 232.17 239.00
214.44 218.71 223.84 232.17 239.00
214.84 219.12 224.26 232.60 239.45
214.84 219.12 224.26 232.60 239.45
239.39 244.16 249.88 259.18 266.81
239.39 244.16 249.88 259.18 266.81
30 31 32 33 34
221.04 225.71 230.39 233.31 236.43
250.70 256.01 261.31 264.62 268.15
242.42 247.54 252.67 255.87 259.29
274.95 280.77 286.58 290.21 294.09
242.88 248.01 253.15 256.36 259.78
275.47 281.30 287.12 290.76 294.64
270.62 276.35 282.07 285.65 289.46
306.94 313.43 319.92 323.98 328.31
35 36 37 38 39
237.98 239.54 241.10 242.66 245.77
292.20 294.11 296.02 297.94 301.76
261.00 262.71 264.42 266.13 269.54
320.46 322.55 324.65 326.75 330.94
261.49 263.21 264.92 266.63 270.05
321.06 323.16 325.27 327.37 331.57
291.37 293.28 295.18 297.09 300.91
357.74 360.08 362.43 364.77 369.45
40 41 42 43 44
248.89 253.56 258.04 264.27 272.06
320.92 326.95 332.72 340.76 350.80
272.96 278.09 283.00 289.83 298.38
351.96 358.57 364.90 373.71 384.73
273.48 278.61 283.53 290.38 298.94
352.62 359.24 365.59 374.42 385.45
304.72 310.44 315.93 323.56 333.09
392.91 400.29 407.36 417.20 429.49
45 46 47 48 49
281.22 292.12 304.39 318.42 332.24
370.81 385.19 401.37 419.86 438.09
308.42 320.38 333.83 349.21 364.37
406.68 422.45 440.19 460.47 480.46
309.00 320.98 334.46 349.87 365.06
407.45 423.25 441.02 461.34 481.37
344.30 357.65 372.68 389.84 406.77
454.00 471.60 491.41 514.05 536.37
50 51 52 53 54
347.82 363.21 380.15 397.29 415.79
459.89 480.23 502.63 525.30 549.76
381.46 398.33 416.92 435.71 456.00
504.37 526.68 551.25 576.10 602.93
382.18 399.09 417.70 436.54 456.86
505.32 527.67 552.29 577.19 604.07
425.85 444.68 465.43 486.41 509.06
563.05 587.96 615.39 643.13 673.08
55 56 57 58 59
434.29 454.35 474.60 496.22 506.93
568.14 594.38 620.88 649.16 663.17
476.29 498.29 520.51 544.21 555.96
623.09 651.87 680.92 711.94 727.31
477.19 499.23 521.49 545.24 557.01
624.27 653.10 682.21 713.28 728.68
531.71 556.27 581.07 607.53 620.65
695.59 727.71 760.15 794.78 811.93
60 61 62 63 64
528.55 547.25 559.51 574.90 584.25
679.08 703.10 718.86 738.63 750.64
579.67 600.17 613.63 630.50 640.74
744.76 771.10 788.39 810.07 823.24
580.76 601.31 614.79 631.69 641.97
746.17 772.56 789.88 811.60 824.80
647.11 670.00 685.03 703.86 715.32
831.41 860.82 880.12 904.32 919.03
640.74
823.24
641.97
824.80
715.32
919.03
65+ 584.25 750.64 *Rates effective January 1, 2016.
Page 10 of 14
Montana Off Exchange (Bronze) Individual Coverage Great Falls, MT Blue Preferred PPO 102
006
Plan
103
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
127.42 200.67 200.67 200.67 200.67
127.42 200.67 200.67 200.67 200.67
127.66 201.04 201.04 201.04 201.04
127.66 201.04 201.04 201.04 201.04
142.25 224.01 224.01 224.01 224.01
142.25 224.01 224.01 224.01 224.01
25 26 27 28 29
201.47 205.48 210.30 218.12 224.54
201.47 205.48 210.30 218.12 224.54
201.85 205.87 210.69 218.54 224.97
201.85 205.87 210.69 218.54 224.97
224.91 229.39 234.77 243.50 250.67
224.91 229.39 234.77 243.50 250.67
30 31 32 33 34
227.76 232.57 237.39 240.40 243.61
258.32 263.78 269.24 272.66 276.30
228.19 233.01 237.84 240.85 244.07
258.81 264.28 269.75 273.17 276.82
254.26 259.63 265.01 268.37 271.95
288.38 294.47 300.57 304.38 308.45
35 36 37 38 39
245.21 246.82 248.42 250.03 253.24
301.07 303.04 305.02 306.99 310.93
245.68 247.28 248.89 250.50 253.72
301.64 303.62 305.59 307.57 311.51
273.74 275.54 277.33 279.12 282.71
336.10 338.30 340.50 342.70 347.10
40 41 42 43 44
256.45 261.27 265.88 272.30 280.33
330.67 336.88 342.83 351.11 361.46
256.93 261.76 266.38 272.82 280.86
331.29 337.51 343.48 351.77 362.14
286.29 291.67 296.82 303.99 312.95
369.14 376.07 382.72 391.96 403.51
45 46 47 48 49
289.76 301.00 313.64 328.09 342.33
382.08 396.90 413.57 432.62 451.40
290.31 301.57 314.23 328.71 342.98
382.80 397.65 414.35 433.43 452.26
323.48 336.02 350.13 366.26 382.17
426.54 443.08 461.69 482.95 503.93
50 51 52 53 54
358.39 374.24 391.70 409.36 428.42
473.86 494.82 517.90 541.25 566.46
359.07 374.95 392.44 410.13 429.23
474.76 495.76 518.88 542.28 567.53
400.09 417.79 437.27 456.99 478.27
529.00 552.39 578.16 604.23 632.37
55 56 57 58 59
447.48 468.15 489.02 511.30 522.33
585.40 612.44 639.74 668.88 683.31
448.33 469.04 489.95 512.26 523.32
586.51 613.59 640.95 670.14 684.60
499.55 522.62 545.92 570.79 583.11
653.51 683.70 714.17 746.70 762.82
60 61 62 63 64
544.61 563.87 576.51 592.36 602.01
699.71 724.46 740.70 761.07 773.44
545.63 564.94 577.60 593.48 603.12
701.03 725.83 742.10 762.51 774.91
607.97 629.48 643.59 661.29 672.03
781.12 808.75 826.89 849.62 863.44
603.12
774.91
672.03
863.44
65+ 602.01 773.44 *Rates effective January 1, 2016.
Page 11 of 14
Montana Off Exchange (Bronze) Individual Coverage Missoula, MT Plan
Blue Focus POS 104
Blue Preferred PPO 102
006
103
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
120.03 189.02 189.02 189.02 189.02
120.03 189.02 189.02 189.02 189.02
134.64 212.03 212.03 212.03 212.03
134.64 212.03 212.03 212.03 212.03
134.89 212.43 212.43 212.43 212.43
134.89 212.43 212.43 212.43 212.43
150.30 236.70 236.70 236.70 236.70
150.30 236.70 236.70 236.70 236.70
25 26 27 28 29
189.78 193.56 198.09 205.47 211.51
189.78 193.56 198.09 205.47 211.51
212.88 217.12 222.21 230.48 237.26
212.88 217.12 222.21 230.48 237.26
213.28 217.53 222.63 230.91 237.71
213.28 217.53 222.63 230.91 237.71
237.65 242.38 248.06 257.29 264.87
237.65 242.38 248.06 257.29 264.87
30 31 32 33 34
214.54 219.08 223.61 226.45 229.47
243.33 248.48 253.62 256.84 260.27
240.65 245.74 250.83 254.01 257.40
272.95 278.72 284.49 288.10 291.95
241.11 246.21 251.31 254.49 257.89
273.47 279.25 285.03 288.64 292.50
268.65 274.34 280.02 283.57 287.35
304.71 311.15 317.59 321.62 325.92
35 36 37 38 39
230.98 232.50 234.01 235.52 238.54
283.60 285.46 287.32 289.17 292.88
259.10 260.80 262.49 264.19 267.58
318.12 320.20 322.29 324.37 328.54
259.59 261.29 262.99 264.69 268.09
318.72 320.81 322.90 324.98 329.16
289.25 291.14 293.03 294.93 298.72
355.14 357.46 359.79 362.11 366.76
40 41 42 43 44
241.57 246.11 250.45 256.50 264.06
311.48 317.33 322.93 330.73 340.48
270.97 276.06 280.94 287.72 296.21
349.39 355.96 362.24 370.99 381.93
271.49 276.58 281.47 288.27 296.77
350.05 356.63 362.93 371.69 382.65
302.50 308.18 313.63 321.20 330.67
390.05 397.37 404.39 414.16 426.37
45 46 47 48 49
272.95 283.53 295.44 309.05 322.47
359.91 373.86 389.57 407.51 425.21
306.17 318.04 331.40 346.67 361.72
403.72 419.37 436.99 457.12 476.97
306.75 318.65 332.03 347.32 362.41
404.48 420.17 437.81 457.98 477.87
341.79 355.05 369.96 387.00 403.81
450.69 468.17 487.83 510.30 532.46
50 51 52 53 54
337.59 352.52 368.97 385.60 403.56
446.36 466.11 487.85 509.84 533.59
378.68 395.44 413.88 432.54 452.68
500.70 522.84 547.23 571.91 598.54
379.40 396.18 414.66 433.36 453.54
501.64 523.83 548.27 572.99 599.67
422.75 441.45 462.04 482.87 505.35
558.96 583.68 610.91 638.45 668.18
55 56 57 58 59
421.52 440.99 460.64 481.63 492.02
551.43 576.90 602.61 630.06 643.66
472.83 494.67 516.72 540.25 551.91
618.55 647.12 675.97 706.76 722.01
473.72 495.60 517.69 541.27 552.96
619.72 648.34 677.24 708.09 723.38
527.84 552.22 576.84 603.11 616.13
690.52 722.42 754.62 788.99 806.02
60 61 62 63 64
513.00 531.15 543.06 557.99 567.06
659.11 682.42 697.72 716.91 728.56
575.45 595.80 609.16 625.91 636.09
739.34 765.49 782.65 804.17 817.25
576.54 596.93 610.31 627.09 637.29
740.73 766.93 784.13 805.69 818.79
642.40 665.13 680.04 698.74 710.10
825.36 854.56 873.71 897.74 912.34
636.09
817.25
637.29
818.79
710.10
912.34
65+ 567.06 728.56 *Rates effective January 1, 2016.
Page 12 of 14
Montana Off Exchange (Bronze) Individual Coverage Non MSA Blue Preferred PPO 102
006
Plan
103
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
129.85 204.48 204.48 204.48 204.48
129.85 204.48 204.48 204.48 204.48
130.09 204.87 204.87 204.87 204.87
130.09 204.87 204.87 204.87 204.87
144.95 228.27 228.27 228.27 228.27
144.95 228.27 228.27 228.27 228.27
25 26 27 28 29
205.30 209.39 214.30 222.27 228.81
205.30 209.39 214.30 222.27 228.81
205.69 209.78 214.70 222.69 229.25
205.69 209.78 214.70 222.69 229.25
229.19 233.75 239.23 248.13 255.44
229.19 233.75 239.23 248.13 255.44
30 31 32 33 34
232.09 236.99 241.90 244.97 248.24
263.23 268.80 274.36 277.84 281.55
232.52 237.44 242.36 245.43 248.71
263.73 269.31 274.88 278.37 282.09
259.09 264.57 270.05 273.47 277.12
293.86 300.07 306.29 310.17 314.31
35 36 37 38 39
249.88 251.51 253.15 254.78 258.05
306.80 308.80 310.81 312.82 316.84
250.35 251.99 253.63 255.26 258.54
307.38 309.39 311.40 313.41 317.44
278.95 280.78 282.60 284.43 288.08
342.49 344.73 346.98 349.22 353.70
40 41 42 43 44
261.33 266.23 270.94 277.48 285.66
336.95 343.28 349.35 357.78 368.33
261.82 266.74 271.45 278.00 286.20
337.59 343.93 350.01 358.46 369.02
291.73 297.21 302.46 309.77 318.90
376.16 383.22 389.99 399.41 411.19
45 46 47 48 49
295.27 306.72 319.60 334.33 348.84
389.34 404.44 421.43 440.84 459.98
295.83 307.30 320.21 334.96 349.50
390.08 405.21 422.22 441.67 460.85
329.63 342.41 356.79 373.23 389.43
434.64 451.50 470.46 492.14 513.51
50 51 52 53 54
365.20 381.36 399.15 417.14 436.57
482.87 504.23 527.75 551.54 577.23
365.89 382.08 399.90 417.93 437.39
483.78 505.18 528.75 552.59 578.32
407.69 425.73 445.59 465.68 487.36
539.05 562.90 589.16 615.72 644.39
55 56 57 58 59
455.99 477.05 498.32 521.02 532.26
596.53 624.08 651.90 681.59 696.30
456.85 477.95 499.26 522.00 533.27
597.66 625.26 653.13 682.88 697.62
509.05 532.56 556.30 581.64 594.19
665.94 696.69 727.75 760.90 777.32
60 61 62 63 64
554.96 574.59 587.47 603.63 613.44
713.01 738.23 754.78 775.54 788.15
556.01 575.68 588.58 604.77 614.61
714.36 739.63 756.21 777.00 789.64
619.53 641.45 655.83 673.86 684.81
795.98 824.13 842.61 865.78 879.85
614.61
789.64
684.81
879.85
65+ 613.44 788.15 *Rates effective January 1, 2016.
Page 13 of 14
Montana Off Exchange (Catastrophic)
Individual Coverage
Blue Preferred PPO 100 Rating Area
Billings, MT
Great Falls, MT
Missoula, MT
Non MSA
Age 0-20 21 22 23 24
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
Non Tobacco
Tobacco
109.49 172.43 172.43 172.43 172.43
109.49 172.43 172.43 172.43 172.43
102.87 162.00 162.00 162.00 162.00
102.87 162.00 162.00 162.00 162.00
108.70 171.18 171.18 171.18 171.18
108.70 171.18 171.18 171.18 171.18
104.83 165.08 165.08 165.08 165.08
104.83 165.08 165.08 165.08 165.08
25 26 27 28 29
173.12 176.57 180.71 187.43 192.95
173.12 176.57 180.71 187.43 192.95
162.65 165.89 169.78 176.09 181.28
162.65 165.89 169.78 176.09 181.28
171.86 175.28 179.39 186.07 191.54
171.86 175.28 179.39 186.07 191.54
165.74 169.04 173.00 179.44 184.73
165.74 169.04 173.00 179.44 184.73
30 31 32 33 34
195.71 199.85 203.98 206.57 209.33
221.97 226.67 231.36 234.29 237.42
183.87 187.76 191.65 194.08 196.67
208.55 212.96 217.37 220.12 223.06
194.28 198.39 202.50 205.07 207.81
220.36 225.02 229.68 232.59 235.69
187.37 191.33 195.29 197.77 200.41
212.51 217.00 221.50 224.31 227.30
35 36 37 38 39
210.71 212.09 213.47 214.85 217.61
258.71 260.40 262.10 263.79 267.18
197.96 199.26 200.56 201.85 204.44
243.06 244.65 246.24 247.83 251.02
209.18 210.55 211.91 213.28 216.02
256.83 258.51 260.19 261.87 265.23
201.73 203.05 204.37 205.69 208.33
247.68 249.30 250.93 252.55 255.79
40 41 42 43 44
220.37 224.50 228.47 233.99 240.89
284.14 289.48 294.59 301.70 310.60
207.04 210.92 214.65 219.83 226.31
266.95 271.97 276.77 283.46 291.81
218.76 222.87 226.81 232.28 239.13
282.07 287.37 292.45 299.51 308.34
210.97 214.93 218.73 224.01 230.62
272.03 277.14 282.03 288.84 297.36
45 46 47 48 49
248.99 258.65 269.51 281.92 294.17
328.32 341.05 355.37 371.74 387.89
233.93 243.00 253.21 264.87 276.37
308.46 320.42 333.88 349.26 364.42
247.18 256.76 267.55 279.87 292.02
325.93 338.57 352.79 369.04 385.06
238.38 247.62 258.02 269.91 281.63
314.32 326.51 340.23 355.90 371.35
50 51 52 53 54
307.96 321.58 336.58 351.76 368.14
407.19 425.20 445.03 465.09 486.75
289.33 302.13 316.22 330.48 345.87
382.56 399.48 418.11 436.96 457.31
305.72 319.24 334.13 349.20 365.46
404.22 422.10 441.79 461.71 483.21
294.83 307.88 322.24 336.76 352.45
389.83 407.07 426.06 445.27 466.01
55 56 57 58 59
384.52 402.28 420.21 439.35 448.84
503.03 526.26 549.72 574.76 587.17
361.26 377.95 394.80 412.78 421.69
472.60 494.43 516.47 539.99 551.65
381.72 399.35 417.15 436.15 445.57
499.37 522.43 545.72 570.58 582.89
368.13 385.13 402.30 420.63 429.70
481.59 503.83 526.29 550.26 562.14
60 61 62 63 64
467.98 484.53 495.39 509.01 517.29
601.26 622.52 636.48 653.98 664.62
439.67 455.22 465.43 478.23 486.00
564.89 584.87 597.98 614.42 624.41
464.57 481.00 491.79 505.31 513.54
596.88 617.99 631.85 649.22 659.78
448.03 463.88 474.28 487.32 495.24
575.63 595.99 609.35 626.11 636.29
65+ 517.29 664.62 *Rates effective January 1, 2016.
486.00
624.41
513.54
659.78
495.24
636.29
Page 14 of 14
Blue Cross and Blue Shield of Montana P.O. Box 3236 Naperville, IL 60566-7236 bcbsmt.com
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
