Blue Choice Rates

To be completed and returned with application

Plan rates are valid for coverage effective July 1, 2014 to June 1, 2015. Blue Choice Core Health Benefits and Options are separately priced. To calculate the total premium for the coverage you desire, find the monthly or annual.
premiums that apply to you and add them together. The oldest person on the application determines the age band and rate. Single rate is for one person, couple rate is for two persons and family rate is for three or more persons.

Core Extended
Health Care Benefits
Age Group

Prescription Drug Options

Essential
Enhanced

Monthly $

Annual $

Monthly $

single
couple
family

11
18
25

126
206
285

3544

single
couple
family

15
23
31

4554

single
couple
family

5564

65+

1834

Dental Options
Essential
Enhanced

Annual $

Monthly $

Annual $

Monthly $

Annual $

Monthly $

Annual $

10
19
26

114
217
297

19
36
46

217
411
525

21
40
61

239
455
694

41
76
119

468
867
1,357

171
263
354

15
24
31

171
274
354

28
44
57

320
502
650

27
51
77

308
580
876

56
104
162

639
1,186
1,847

20
32
44

228
365
502

18
32
42

206
365
479

33
60
77

377
684
878

30
59
90

342
672
1,026

64
127
198

730
1,448
2,258

single
couple
family

22
42
56

251
479
639

21
43
57

240
491
650

38
80
103

434
912
1,175

31
65
99

353
742
1,131

67
140
219

764
1,596
2,497

single
couple
family

24
43
56

274
491
639

25
52
68

285
589
776

46
96
124

525
1,095
1,414

33
67
102

376
764
1,164

70
145
226

798
1,653
2,577

Total $

Annual Travel Plan Options

Age Group

Age Group

Essential

Dental Options

single
couple
family

56
112
112

76
152
152

189
n/a
n/a

35-60

single
couple
family

64
128
128

88
176
176

189
n/a
n/a

Applicants must be actively covered under a

recognized Blue Cross Group Health Plan.

Essential
Monthly $

Enhanced

Monthly $

Annual $

Monthly $

Annual $

Monthly $

Annual $

Monthly $

Annual $

1834

single
couple
family

32
51
69

360
575
791

55
99
129

627
1,132
1,468

21
40
61

239
455
694

41
76
119

468
867
1,257

3544

single
couple
family

34
55
75

392
629
864

60
108
139

684
1,231
1,581

27
51
77

308
580
876

56
104
162

639
1,186
1,847

4554

single
couple
family

38
61
84

436
699
961

67
121
155

764
1,375
1,772

30
59
90

342
672
1,026

64
127
198

730
1,448
2,258

5564

single
couple
family

42
80
107

481
917
1,222

76
160
207

866
1,824
2,356

31
65
99

353
742
1,131

67
140
219

764
1,596
2,497

65+

single
couple
family

46
83
107

524
945
1,222

92
192
248

1,049
2,189
2,827

33
67
102

376
764
1,164

70
145
226

798
1,653
2,577

60 Days $

Group Dental Add-On Rates

For conversion plan rates, applicants must have been covered under a recognized group health plan. Once options are selected, they cannot be altered.

Prescription Drug
Option Enhanced

30 Days $

If you are 61 and over you may be eligible for Annual Travel,
based on your responses to our health questionnaire, please
contact us at 604 419-2200 or toll free at 1 800 USE-BLUE
(1 800 873-2583) or visit our website at www.pac.bluecross.ca.

Conversion Plan Rates

Core Extended
Health Care Benefits

15 Days $

0-34

Total $

Enhanced

Annual $

Monthly $

Annual $

single

32

365

65

741

couple

66

752

129

1,469

family

101

1,147

199

2,269

Stand Alone Dental Plan Rates

Monthly $

Annual $

single

27

308

couple

56

641

family

91

1,036

0200.002.05 34-70-210 RATES 01/15

CUPE 1816