| Monthly Premium for $5,000 of Coverage | ||||
| Attained Age | Member Only | Member + Spouse/ Domestic Partner | Member + Children | Member + Spouse/Domestic Partner + Children |
| <25 | $2.65 | $5.20 | $4.00 | $6.55 |
| 25–29 | $2.80 | $5.55 | $4.10 | $6.90 |
| 30–34 | $3.45 | $6.75 | $4.75 | $8.10 |
| 35–39 | $3.75 | $7.55 | $5.10 | $8.90 |
| 40–44 | $4.50 | $9.20 | $5.85 | $10.55 |
| 45–49 | $6.50 | $13.55 | $7.85 | $14.85 |
| 50–54 | $9.20 | $19.60 | $10.50 | $20.90 |
| 55–59 | $12.75 | $27.60 | $14.10 | $28.90 |
| 60–64 | $17.05 | $37.30 | $18.35 | $38.55 |
| 65–69 | $22.90 | $51.00 | $24.25 | $52.35 |