2017

COLORADO SCHOOL OF MINES
R Health Insurance
TOTAL COST
YOUR
Anthem Blue Cross and Blue Shield
MONTHLY COST
BlueAdvantage Point of Service Plan (HMO/POS) & Blue Prime PPO Plan and Custom Plus Health Plan
Employee Only
$637.52
$00.00
Employee + Spouse
$1,528.84
$00.00
Employee + Child(ren)
$1,401.84
$00.00
A Employee and Family
$1,759.13
$00.00
Blue Priority HMO Plan


Employee Only
$586.52
$00.00
Employee + Spouse
$1,406.84
$00.00
Employee + Child(ren)
$1,289.84
$00.00
Employee and Family
$1,619.13
$00.00
Lumenos 2500 HDHP Plan


T Employee Only
$573.52
$00.00
Employee + Spouse
$1,376.84
$00.00
Employee + Child(ren)
$1,261.84
$00.00
Employee and Family
$1,584.13
$00.00
Health rates include Blue View Vision Exam Only plan.

Dental Insurance (same rates for al choices)


Anthem Blue Cross and Blue Shield


E Anthem Blue Dental PPO Plus or Anthem Blue Dental PPO
Employee Only
$41.00
$00.00
Employee + Spouse
$94.00
$00.00
Employee + Child(ren)
$90.00
$00.00
Employee and Family
$107.00
$00.00

Vision Insurance
S Anthem Blue Cross and Blue Shield


Blue View Vision Materials Only Voluntary Vision Plan


Employee Only
$6.36
$6.36
Employee + Spouse
$11.92
$11.92
Employee + Child(ren)
$11.92
$11.92
Employee and Family
$17.31
$17.31
Blue View Vision Exam & Materials Voluntary Vision Plan
Employee Only
$8.80
$8.80
Employee + Spouse
$16.49
$16.49
Employee + Child(ren)
$16.49
$16.49
Employee and Family
$23.95
$23.95

Colorado Higher Education Insurance Benefits Al iance (CHEIBA) Trust



201

7
Flexible Spending Benefit Plan Administrative Fee
24HourFlex
Employer Paid
R One or Both Spending Accounts
$3.75
Voluntary Term Life Insurance (Employee and/or Spouse)
Anthem Life (premium per $10,000 death benefit)

Attained Age
Smoker
Non-Smoker
A less than 35
$ 1.40
$ .90
35-39
$ 2.00
$ 1.20
40-44
$ 3.10
$ 1.70
45-49
$ 5.70
$ 3.00
50-54
$ 9.20
$ 4.70
55-59
$ 16.40
$ 8.60
60-64
$ 20.00
$ 11.20
65-69
$ 32.20
$ 19.40
T 70-74
$ 51.00
$ 33.70
75-79
$ 94.40
$ 68.90
80-84
$126.40
$101.20
85-99
$201.40
$181.50
Voluntary Dependent Child Term Life ($5,000 per child)
$1.50 total per month

E Voluntary Accidental Death & Dismemberment
Mutual of Omaha

Employee
Employee Only
Employee and Family
Principal Sum

$ 10,000.00
$ .36
$ .52

$ 30,000.00
$ 1.08
$ 1.56
S $ 50,000.00 $ 1.80
$ 2.60

$ 80,000.00
$ 2.88
$ 4.16

$100,000.00
$ 3.60
$ 5.20

$150,000.00
$ 5.40
$ 7.80

$200,000.00
$ 7.20
$10.40

$250,000.00
$ 9.00
$13.00

$300,000.00
$10.80
$15.60

$500,000.00
$18.00
$26.00
The amount of insurance you select is caled the “Principal Sum”. You may select a Principal Sum between a
minimum of $10,000 and a maximum of $500,000 in increments of $10,000. Amounts over $250,000 are subject
to ten (10) times your annual salary. Employee and Family includes coverage for you, your Spouse/Domestic
Partner and eligible children. If you elect a Family Plan, your spouse’s benefit wil be 50% of your Principal Sum
and the benefit for each child (no matter how many), wil be 10% of your Principal Sum.
Colorado Higher Education Insurance Benefits Al iance (CHEIBA) Trust


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