WHA WHA WHA
  GATEWAY 20 GATEWAY 70 GATEWAY 2000 HSA
Annual Deductible $0 $0 $2,000
Annual Out of Pocket Limit $4,000 $4,000 $2,000
Office Visit $20 $20 $0 after deductible
Inpatient Hospital Copay $0 30% $0 after deductible
Outpatient Hospital Copay $100 $100 $0 after deductible
Rx Generic $5 $5 $0 after deductible
Rx Brand Name $25 $25 $0 after deductible
Rx Non-Preferred $45 $45 $0 after deductible
       
  Rates effective 12/1/16    
  WHA WHA WHA
Age GATEWAY 20 GATEWAY 70 GATEWAY 2000 HSA
0 -20 $202.37 $188.43 $160.54
21 -21 $318.70 $296.75 $252.82
22 -22 $318.70 $296.75 $252.82
23 -23 $318.70 $296.75 $252.82
24 -24 $318.70 $296.75 $252.82
25 -25 $319.97 $297.93 $253.83
26 -26 $326.34 $303.87 $258.88
27 -27 $333.99 $310.99 $264.95
28 -28 $346.42 $322.56 $274.81
29 -29 $356.62 $332.06 $282.90
30 -30 $361.72 $336.81 $286.95
31 -31 $369.37 $343.93 $293.01
32 -32 $377.02 $351.05 $299.08
33 -33 $381.80 $355.50 $302.87
34 -34 $386.90 $360.25 $306.92
35 -35 $389.45 $362.62 $308.94
36 -36 $392.00 $365.00 $310.96
37 -37 $394.55 $367.37 $312.99
38 -38 $397.10 $369.75 $315.01
39 -39 $402.19 $374.49 $319.05
40 -40 $407.29 $379.24 $323.10
41 -41 $414.94 $386.36 $329.17
42 -42 $422.27 $393.19 $334.98
43 -43 $432.47 $402.68 $343.07
44 -44 $445.22 $414.55 $353.18
45 -45 $460.20 $428.50 $365.07
46 -46 $478.05 $445.12 $379.23
47 -47 $498.12 $463.82 $395.15
48 -48 $521.07 $485.18 $413.36
49 -49 $543.70 $506.25 $431.31
50 -50 $569.19 $529.99 $451.53
51 -51 $594.37 $553.43 $471.50
52 -52 $622.10 $579.25 $493.50
53 -53 $650.14 $605.37 $515.75
54 -54 $680.42 $633.56 $539.77
55 -55 $710.70 $661.75 $563.78
56 -56 $743.52 $692.31 $589.82
57 -57 $776.67 $723.17 $616.12
58 -58 $812.04 $756.11 $644.18
59 -59 $829.57 $772.44 $658.09
60 -60 $864.95 $805.37 $686.15
61 -61 $895.54 $833.86 $710.42
62 -62 $915.62 $852.56 $726.35
63 -63 $940.80 $876.00 $746.32
64 -99 $956.10 $890.25 $758.46