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+ -