Providence Value Plan |
| Effective Date: 11/01/2012 |
| Expiration Date: 10/31/2013 |
|
Available in: 97324, 97330, 97331, 97333, 97339, 97370, 97456, 97004, 97009, 97011, 97013, 97015, 97017, 97022, 97023, 97027, 97028, 97034, 97035, 97036, 97038, 97042, 97045, 97049, 97055, 97067, 97068, 97070, 97086, 97089, 97222, 97267, 97268, 97269, 97102, 97103, 97110, 97121, 97138, 97145, 97146, 97016, 97018, 97048, 97051, 97053, 97054, 97056, 97064, 97751, 97752, 97753, 97754, 97701, 97702, 97707, 97708, 97709, 97712, 97739, 97756, 97759, 97410, 97416, 97417, 97429, 97432, 97435, 97436, 97441, 97442, 97443, 97447, 97457, 97462, 97467, 97469, 97470, 97471, 97473, 97479, 97481, 97484, 97486, 97494, 97495, 97496, 97499, 97812, 97823, 97861, 97817, 97820, 97825, 97845, 97848, 97856, 97864, 97865, 97869, 97873, 97710, 97720, 97721, 97722, 97732, 97736, 97738, 97758, 97904, 97031, 97041, 97044, 97501, 97502, 97503, 97504, 97520, 97522, 97524, 97525, 97530, 97535, 97536, 97537, 97539, 97540, 97541, 97711, 97730, 97734, 97741, 97760, 97761, 97497, 97523, 97526, 97527, 97528, 97531, 97532, 97533, 97534, 97538, 97543, 97544, 97321, 97322, 97327, 97329, 97335, 97336, 97345, 97348, 97355, 97358, 97360, 97374, 97377, 97386, 97389, 97446, 97002, 97020, 97026, 97032, 97071, 97137, 97301, 97302, 97303, 97305, 97306, 97307, 97308, 97309, 97310, 97311, 97312, 97314, 97317, 97325, 97342, 97346, 97350, 97352, 97362, 97373, 97375, 97381, 97383, 97384, 97385, 97392, 97010, 97014, 97019, 97024, 97030, 97060, 97080, 97201, 97202, 97203, 97204, 97205, 97206, 97207, 97208, 97209, 97210, 97211, 97212, 97213, 97214, 97215, 97216, 97217, 97218, 97219, 97220, 97221, 97227, 97228, 97230, 97231, 97232, 97233, 97236, 97238, 97239, 97240, 97242, 97256, 97258, 97266, 97280, 97282, 97283, 97286, 97290, 97292, 97293, 97294, 97296, 97304, 97338, 97344, 97347, 97351, 97361, 97371, 97029, 97033, 97039, 97050, 97065, 97107, 97108, 97112, 97118, 97122, 97130, 97131, 97134, 97135, 97136, 97141, 97143, 97147, 97149, 97001, 97021, 97037, 97040, 97057, 97058, 97063, 97005, 97006, 97007, 97008, 97062, 97075, 97076, 97077, 97106, 97109, 97113, 97116, 97117, 97119, 97123, 97124, 97125, 97133, 97140, 97144, 97223, 97224, 97225, 97229, 97281, 97291, 97298, 97750, 97830, 97874, 97101, 97111, 97114, 97115, 97127, 97128, 97132, 97148, 97378, 97396, 97401, 97402, 97403, 97404, 97405, 97408, 97409, 97412, 97413, 97419, 97424, 97426, 97431, 97434, 97437, 97438, 97440, 97451, 97452, 97454, 97455, 97461, 97463, 97477, 97478, 97487, 97488, 97489, 97490, 97492, 97733, 97737, 97427, 97482, 97472, 97425
|
| Deductible: $1,000 |
|
Age
|
Applicant Alone
|
Applicant and Spouse
|
Applicant and Child
|
Applicant and Family
|
|
1-17
|
$127.00
|
— |
— |
— |
|
18-20
|
$165.00
|
$329.00
|
$247.00
|
$462.00
|
|
21-24
|
$196.00
|
$395.00
|
$297.00
|
$552.00
|
|
25-29
|
$213.00
|
$426.00
|
$320.00
|
$629.00
|
|
30-34
|
$242.00
|
$486.00
|
$363.00
|
$726.00
|
|
35-39
|
$260.00
|
$519.00
|
$388.00
|
$764.00
|
|
40-44
|
$330.00
|
$661.00
|
$496.00
|
$959.00
|
|
45-49
|
$390.00
|
$781.00
|
$585.00
|
$975.00
|
|
50-54
|
$453.00
|
$906.00
|
$680.00
|
$1,042.00
|
|
55-59
|
$545.00
|
$1,090.00
|
$819.00
|
$1,253.00
|
|
60-64
|
$625.00
|
$1,251.00
|
$938.00
|
$1,375.00
|
| |
| Deductible: $2,500 |
|
Age
|
Applicant Alone
|
Applicant and Spouse
|
Applicant and Child
|
Applicant and Family
|
|
1-17
|
$110.00
|
— |
— |
— |
|
18-20
|
$141.00
|
$282.00
|
$211.00
|
$395.00
|
|
21-24
|
$169.00
|
$338.00
|
$254.00
|
$474.00
|
|
25-29
|
$182.00
|
$365.00
|
$274.00
|
$538.00
|
|
30-34
|
$207.00
|
$414.00
|
$311.00
|
$623.00
|
|
35-39
|
$222.00
|
$445.00
|
$333.00
|
$655.00
|
|
40-44
|
$283.00
|
$566.00
|
$424.00
|
$821.00
|
|
45-49
|
$333.00
|
$668.00
|
$502.00
|
$834.00
|
|
50-54
|
$387.00
|
$777.00
|
$582.00
|
$891.00
|
|
55-59
|
$467.00
|
$932.00
|
$699.00
|
$1,073.00
|
|
60-64
|
$534.00
|
$1,070.00
|
$804.00
|
$1,177.00
|
| |
| Deductible: $5,000 |
|
Age
|
Applicant Alone
|
Applicant and Spouse
|
Applicant and Child
|
Applicant and Family
|
|
1-17
|
$92.00
|
— |
— |
— |
|
18-20
|
$120.00
|
$238.00
|
$179.00
|
$335.00
|
|
21-24
|
$144.00
|
$286.00
|
$215.00
|
$401.00
|
|
25-29
|
$154.00
|
$309.00
|
$231.00
|
$456.00
|
|
30-34
|
$176.00
|
$351.00
|
$264.00
|
$526.00
|
|
35-39
|
$188.00
|
$375.00
|
$282.00
|
$553.00
|
|
40-44
|
$239.00
|
$480.00
|
$360.00
|
$694.00
|
|
45-49
|
$282.00
|
$565.00
|
$423.00
|
$705.00
|
|
50-54
|
$328.00
|
$657.00
|
$492.00
|
$754.00
|
|
55-59
|
$395.00
|
$789.00
|
$592.00
|
$907.00
|
|
60-64
|
$453.00
|
$905.00
|
$678.00
|
$996.00
|
| |
| Deductible: $7,500 |
|
Age
|
Applicant Alone
|
Applicant and Spouse
|
Applicant and Child
|
Applicant and Family
|
|
1-17
|
$78.00
|
— |
— |
— |
|
18-20
|
$102.00
|
$202.00
|
$152.00
|
$284.00
|
|
21-24
|
$122.00
|
$242.00
|
$183.00
|
$339.00
|
|
25-29
|
$131.00
|
$263.00
|
$197.00
|
$387.00
|
|
30-34
|
$149.00
|
$298.00
|
$223.00
|
$447.00
|
|
35-39
|
$159.00
|
$319.00
|
$238.00
|
$471.00
|
|
40-44
|
$204.00
|
$406.00
|
$306.00
|
$589.00
|
|
45-49
|
$239.00
|
$480.00
|
$361.00
|
$600.00
|
|
50-54
|
$279.00
|
$557.00
|
$418.00
|
$641.00
|
|
55-59
|
$335.00
|
$671.00
|
$503.00
|
$771.00
|
|
60-64
|
$384.00
|
$769.00
|
$576.00
|
$847.00
|
| |
|