United eServices

1

Bob Employer

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Plan & Rate Information

ABC Company View Group Information
GROUP NUMBER : 123456 Change Group

Medical Plans

Rates Effective 12/01/2021

Plan: 17633947 CT LIBERTY HMO GATED BUY DOWN PLAN \| CT 25/65/3000/100 HMO

Employee Tier	Premium / Month
Employee Only	$717.35
Employee & Spouse	$1,466.25
Employee & Child	$1,190.07
Employee & Family	$2,078.14

Plan: 17633948 CT LIBERTY HMO GATED BASE PLAN \| CT 25/65/3000/100 HMO

Employee Tier	Premium / Month
Employee Only	$754.26
Employee & Spouse	$1,541.70
Employee & Child	$1,251.32
Employee & Family	$2,185.08

Plan: 12719897 CT FREEDOM 15/30/0/100 ACCESS \| CT 15/30/0/100 CLASSIC/ACCESS

Employee Tier	Premium / Month
Employee Only	$972.21
Employee & Spouse	$1,987.21
Employee & Child	$1,612.91
Employee & Family	$2,816.52