Year:
Conference:
Zip Code:
Age*:
Quarterly Rates
Non-Medicare Rates: Plan A Plan B Plan C Dental Plan 1800 Annual Vision Rates
Single$$
Two Adults$$
Single w/Child(ren)$$
Two Adults w/Child(ren)$$

ALL RATES ARE QUARTERLY!

* The correct age-rate is based on the employee's age as of January 1 of the current Plan Year.
* If an employee will age into a different age band during the current Plan Year, their rate will not change until January 1 of the following Plan Year.
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475 Riverside Drive, Room 1020, New York, NY 10115  •  Phone: 800.642.6543  •  Fax: 212.729.2701 •  E-mail: info@pbucc.org