| HEALTH PLAN | TIER | SINGLE | FAMILY | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| STATE SHARE | REG CODE | EMPLOYEE SHARE | TOTAL PREMIUM | STATE SHARE | REG CODE | EMPLOYEE SHARE | TOTAL PREMIUM | |||
| STANDARD PLAN | 3 | 529.30 | 4AV | 50.00 | 579.30 | 1279.20 | 4AV | 125.00 | 1404.20 | |
| STANDARD PLAN OUT-OF-STATE | 2 | 554.30 | 4AV | 25.00 | 579.30 | 1341.70 | 4AV | 62.50 | 1404.20 | |
| STATE MAINTENANCE PLAN* | 1 | 361.70 | 4AT | 11.00 | 372.70 | 904.40 | 4AT | 27.50 | 931.90 | |
| ATRIUM HEALTH PLAN | 1 | 328.80 | 4CF | 11.00 | 339.80 | 818.50 | 4CF | 27.50 | 846.00 | |
| COMPCAREBLUE - AURORA/FAMILY | 1 | 274.00 | 4HL | 11.00 | 285.00 | 681.60 | 4HL | 27.50 | 709.10 | |
| COMPCAREBLUE NORTHEAST | 2 | 340.00 | 4HP | 25.00 | 365.00 | 846.60 | 4HP | 62.50 | 909.10 | |
| COMPCAREBLUE NORTHWEST | 1 | 353.10 | 4DF | 11.00 | 364.10 | 879.30 | 4DF | 27.50 | 906.80 | |
| COMPCAREBLUE SOUTHEAST | 1 | 345.50 | 4EO | 11.00 | 356.50 | 860.30 | 4EO | 27.50 | 887.80 | |
| DEAN HEALTH PLAN | 1 | 294.60 | 4CQ | 11.00 | 305.60 | 733.10 | 4CQ | 27.50 | 760.60 | |
| GHC-EAU CLAIRE | 1 | 370.20 | 4DO | 11.00 | 381.20 | 922.10 | 4DO | 27.50 | 949.60 | |
| GHC-SOUTH CENTRAL | 1 | 282.90 | 4DC | 11.00 | 293.90 | 703.80 | 4DC | 27.50 | 731.30 | |
| GUNDERSEN LUTHERAN | 1 | 344.50 | 4BO | 11.00 | 355.50 | 857.90 | 4BO | 27.50 | 885.40 | |
| HEALTH TRADITION | 1 | 361.80 | 4CX | 11.00 | 372.80 | 901.10 | 4CX | 27.50 | 928.60 | |
| HUMANA-EASTERN | 2 | 373.60 | 4ER | 25.00 | 398.60 | 930.60 | 4ER | 62.50 | 993.10 | |
| HUMANA-WESTERN | 1 | 363.30 | 4BX | 11.00 | 374.30 | 904.80 | 4BX | 27.50 | 932.30 | |
| MEDICAL ASSOCIATES HMO | 1 | 307.90 | 4DR | 11.00 | 318.90 | 766.30 | 4DR | 27.50 | 793.80 | |
| MERCYCARE HEALTH PLAN | 1 | 268.80 | 4GO | 11.00 | 279.80 | 668.60 | 4GO | 27.50 | 696.10 | |
| NETWORK-FOX VALLEY | 1 | 319.10 | 4GC | 11.00 | 330.10 | 794.30 | 4GC | 27.50 | 821.80 | |
| PHYSICIANS PLUS | 1 | 297.90 | 4CN | 11.00 | 308.90 | 741.30 | 4CN | 27.50 | 768.80 | |
| PREVEA HEALTH PLAN | 1 | 343.20 | 4BI | 11.00 | 354.20 | 854.60 | 4BI | 27.50 | 882.10 | |
| UNITEDHEALTHCARE (formerly TOUCHPOINT) | 1 | 298.60 | 4DI | 11.00 | 309.60 | 743.10 | 4DI | 27.50 | 770.60 | |
| UNITY-COMMUNITY | 1 | 350.60 | 4CK | 11.00 | 361.60 | 873.10 | 4CK | 27.50 | 900.60 | |
| UNITY-UW HEALTH | 1 | 282.90 | 4BF | 11.00 | 293.90 | 703.80 | 4BF | 27.50 | 731.30 | |
*Only available to employees living in SMP counties
File last updated: March 19, 2007
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UW1334-01 10/04