Retiree Plans | Benefit Summary

AREA 1:

IA, NE, NC, SC, SD

             

Effective July 1, 2003

                     

Plan I

Basic

With Generic Drug

 

Plan II

Basic

 

With Drug Card

 

(A)

MALE

FEMALE

MALE

FEMALE

 

(C )

MALE

FEMALE

MALE

FEMALE

65-69

$       77.23

$       68.65

$     113.63

$     105.05

 

65-69

$     119.57

$     106.82

$     246.57

$     233.82

70-74

$       90.10

$       77.23

$     126.50

$     113.63

 

70-74

$     139.49

$     120.38

$     266.49

$     247.38

75-79

$     102.97

$       88.39

$     139.37

$     124.79

 

75-79

$     159.41

$     137.76

$     286.41

$     264.76

80-84

$     109.83

$       96.10

$     146.23

$     132.50

 

80-84

$     170.04

$     149.66

$     297.04

$     276.66

85+

$     120.13

$     102.97

$     156.53

$     139.37

 

85+

$     185.98

$     160.52

$     312.98

$     287.52

                     

Plan III

Basic

With Drug Card

 

Plan IV

Basic

With Drug Card

(D)

MALE

FEMALE

MALE

FEMALE

 

(F)

MALE

FEMALE

MALE

FEMALE

65-69

$     113.62

$     101.00

$     240.62

$     228.00

 

65-69

$     127.72

$     113.52

$     254.72

$     240.52

70-74

$     132.55

$     113.62

$     259.55

$     240.62

 

70-74

$     149.00

$     127.72

$     276.00

$     254.72

75-79

$     151.49

$     130.03

$     278.49

$     257.03

 

75-79

$     170.33

$     146.16

$     297.33

$     273.16

80-84

$     161.58

$     141.38

$     288.58

$     268.38

 

80-84

$     181.63

$     158.94

$     308.63

$     285.94

85+

$     176.72

$     151.49

$     303.72

$     278.49

 

85+

$     198.68

$     177.26

$     325.68

$     304.26




AREA 2:

AL, AR, CO, CT, HI, ID, IN, KS, KY, MS, MO, MT, NH, ND, OK, OR, RI, TN, UT, VA, WY

Plan I

Basic

With Generic Drug

Plan II

Basic

With Drug Card

(A)

MALE

FEMALE

MALE

FEMALE

(C )

MALE

FEMALE

MALE

FEMALE

65-69

$       81.52

$       72.46

$     117.92

$     108.86

65-69

$     126.19

$     112.76

$     253.19

$     239.76

70-74

$       95.10

$       81.52

$     131.50

$     117.92

70-74

$     147.23

$     127.07

$     274.23

$     254.07

75-79

$     108.69

$       93.29

$     145.09

$     129.69

75-79

$     168.27

$     145.41

$     295.27

$     272.41

80-84

$     115.93

$     101.44

$     152.33

$     137.84

80-84

$     179.48

$     157.97

$     306.48

$     284.97

85+

$     126.79

$     108.69

$     163.19

$     145.09

85+

$     196.31

$     169.43

$     323.31

$     296.43

Plan III

Basic

With Drug Card

Plan IV

Basic

With Drug Card

(D)

MALE

FEMALE

MALE

FEMALE

(F)

MALE

FEMALE

MALE

FEMALE

65-69

$     119.93

$     106.59

$     246.93

$     233.59

65-69

$     134.81

$     119.82

$     261.81

$     246.82

70-74

$     139.91

$     119.93

$     266.91

$     246.93

70-74

$     157.27

$     134.81

$     284.27

$     261.81

75-79

$     159.91

$     137.24

$     286.91

$     264.24

75-79

$     179.75

$     154.29

$     306.75

$     281.29

80-84

$     170.56

$     149.24

$     297.56

$     276.24

80-84

$     191.74

$     167.76

$     318.74

$     294.76

85+

$     186.55

$     159.91

$     313.55

$     286.91

85+

$     209.71

$     179.75

$     336.71

$     306.75




AREA 3:

DE, GA, IL, LA, MD, MA, NJ, OH, TX, WV

Plan I

Basic

With Generic Drug

Plan II

Basic

With Drug Card

(A)

MALE

FEMALE

MALE

FEMALE

(C )

MALE

FEMALE

MALE

FEMALE

65-69

$       85.81

$       76.26

$     122.21

$     112.66

65-69

$     132.84

$     118.69

$     259.84

$     245.69

70-74

$     100.11

$       85.81

$     136.51

$     122.21

70-74

$     154.99

$     133.76

$     281.99

$     260.76

75-79

$     114.41

$       98.19

$     150.81

$     134.59

75-79

$     177.12

$     153.07

$     304.12

$     280.07

80-84

$     122.04

$     106.78

$     158.44

$     143.18

80-84

$     188.94

$     166.30

$     315.94

$     293.30

85+

$     133.46

$     114.41

$     169.86

$     150.81

85+

$     206.65

$     178.35

$     333.65

$     305.35

Plan III

Basic

With Drug Card

Plan IV

Basic

With Drug Card

(D)

MALE

FEMALE

MALE

FEMALE

(F)

MALE

FEMALE

MALE

FEMALE

65-69

$     126.24

$     112.21

$     253.24

$     239.21

65-69

$     141.91

$     126.14

$     268.91

$     253.14

70-74

$     147.28

$     126.24

$     274.28

$     253.24

70-74

$     165.55

$     141.91

$     292.55

$     268.91

75-79

$     168.31

$     144.47

$     295.31

$     271.47

75-79

$     189.21

$     162.41

$     316.21

$     289.41

80-84

$     179.53

$     157.10

$     306.53

$     284.10

80-84