Moda Health. Healthcare from your head to your toes. Delta Dental | Moda Health

Managed Care Plan

Area 1 (Portland)

Prevailing Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $424 $890 $1,250 $733
25 - 29 $476 $1,000 $1,405 $824
30 - 34 $476 $1,001 $1,406 $824
35 - 39 $503 $1,056 $1,484 $870
40 - 44 $557 $1,170 $1,643 $964
45 - 49 $659 $1,383 $1,943 $1,140
50 - 54 $764 $1,604 $2,253 $1,321
55 - 59 $813 $1,708 $2,399 $1,407
60 - 64 $838 $1,759 $2,471 $1,449
65 and older $843 $1,771 $2,487 $1,459
Low Cost Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $359 $754 $1,060 $621
25 - 29 $404 $848 $1,191 $698
30 - 34 $404 $848 $1,192 $699
35 - 39 $426 $896 $1,258 $738
40 - 44 $472 $991 $1,393 $817
45 - 49 $558 $1,173 $1,647 $966
50 - 54 $647 $1,359 $1,910 $1,120
55 - 59 $689 $1,447 $2,033 $1,192
60 - 64 $710 $1,491 $2,095 $1,229
65 and older $715 $1,501 $2,109 $1,237

Area 2 (Eugene)

Prevailing Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $413 $867 $1,218 $714
25 - 29 $464 $975 $1,369 $803
30 - 34 $464 $975 $1,370 $803
35 - 39 $490 $1,029 $1,446 $848
40 - 44 $543 $1,140 $1,601 $939
45 - 49 $642 $1,348 $1,893 $1,110
50 - 54 $744 $1,563 $2,195 $1,287
55 - 59 $792 $1,664 $2,337 $1,371
60 - 64 $816 $1,714 $2,408 $1,412
65 and older $822 $1,725 $2,424 $1,421
Low Cost Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $350 $735 $1,032 $605
25 - 29 $393 $826 $1,161 $681
30 - 34 $394 $827 $1,161 $681
35 - 39 $416 $873 $1,226 $719
40 - 44 $460 $966 $1,357 $796
45 - 49 $544 $1,143 $1,605 $941
50 - 54 $631 $1,325 $1,861 $1,091
55 - 59 $672 $1,410 $1,981 $1,162
60 - 64 $692 $1,453 $2,041 $1,197
65 and older $696 $1,463 $2,055 $1,205

Area 3 (Salem)

Prevailing Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $394 $828 $1,162 $682
25 - 29 $443 $930 $1,307 $766
30 - 34 $443 $931 $1,307 $767
35 - 39 $468 $983 $1,380 $809
40 - 44 $518 $1,088 $1,528 $896
45 - 49 $613 $1,286 $1,807 $1,060
50 - 54 $710 $1,491 $2,095 $1,229
55 - 59 $756 $1,588 $2,231 $1,308
60 - 64 $779 $1,636 $2,298 $1,348
65 and older $784 $1,647 $2,313 $1,357
Low Cost Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $334 $701 $985 $578
25 - 29 $375 $789 $1,108 $650
30 - 34 $376 $789 $1,108 $650
35 - 39 $397 $833 $1,170 $686
40 - 44 $439 $922 $1,295 $760
45 - 49 $519 $1,090 $1,532 $898
50 - 54 $602 $1,264 $1,776 $1,042
55 - 59 $641 $1,346 $1,891 $1,109
60 - 64 $660 $1,387 $1,948 $1,143
65 and older $665 $1,396 $1,961 $1,150

Area 4 (Bend/Klamath Falls)

Prevailing Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $441 $925 $1,300 $762
25 - 29 $495 $1,040 $1,461 $857
30 - 34 $496 $1,041 $1,462 $857
35 - 39 $523 $1,099 $1,543 $905
40 - 44 $579 $1,216 $1,709 $1,002
45 - 49 $685 $1,439 $2,021 $1,185
50 - 54 $794 $1,668 $2,343 $1,374
55 - 59 $846 $1,776 $2,495 $1,463
60 - 64 $871 $1,830 $2,570 $1,507
65 and older $877 $1,842 $2,587 $1,517
Low Cost Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $374 $784 $1,102 $646
25 - 29 $420 $882 $1,239 $726
30 - 34 $420 $882 $1,239 $727
35 - 39 $444 $931 $1,308 $767
40 - 44 $491 $1,031 $1,449 $849
45 - 49 $581 $1,219 $1,713 $1,005
50 - 54 $673 $1,414 $1,986 $1,165
55 - 59 $717 $1,505 $2,115 $1,240
60 - 64 $739 $1,551 $2,179 $1,278
65 and older $743 $1,561 $2,193 $1,286

Area 5 (Coastal Areas)

Prevailing Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $411 $863 $1,212 $711
25 - 29 $462 $970 $1,363 $799
30 - 34 $462 $971 $1,363 $800
35 - 39 $488 $1,025 $1,440 $844
40 - 44 $540 $1,135 $1,594 $935
45 - 49 $639 $1,342 $1,885 $1,105
50 - 54 $741 $1,556 $2,185 $1,282
55 - 59 $789 $1,656 $2,327 $1,364
60 - 64 $813 $1,706 $2,397 $1,406
65 and older $818 $1,718 $2,413 $1,415
Low Cost Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $348 $732 $1,028 $603
25 - 29 $392 $822 $1,155 $678
30 - 34 $392 $823 $1,156 $678
35 - 39 $414 $869 $1,220 $716
40 - 44 $458 $962 $1,351 $792
45 - 49 $542 $1,137 $1,598 $937
50 - 54 $628 $1,319 $1,852 $1,086
55 - 59 $669 $1,404 $1,972 $1,157
60 - 64 $689 $1,447 $2,032 $1,192
65 and older $693 $1,456 $2,045 $1,199

Area 6 (Eastern Oregon)

Prevailing Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $428 $899 $1,262 $740
25 - 29 $481 $1,010 $1,419 $832
30 - 34 $481 $1,011 $1,420 $833
35 - 39 $508 $1,067 $1,499 $879
40 - 44 $563 $1,181 $1,660 $973
45 - 49 $665 $1,397 $1,963 $1,151
50 - 54 $771 $1,620 $2,275 $1,334
55 - 59 $821 $1,725 $2,423 $1,421
60 - 64 $846 $1,777 $2,496 $1,464
65 and older $852 $1,788 $2,512 $1,473
Low Cost Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $363 $762 $1,070 $628
25 - 29 $408 $856 $1,203 $705
30 - 34 $408 $857 $1,203 $706
35 - 39 $431 $904 $1,271 $745
40 - 44 $477 $1,001 $1,407 $825
45 - 49 $564 $1,184 $1,664 $976
50 - 54 $654 $1,373 $1,929 $1,131
55 - 59 $696 $1,462 $2,054 $1,204
60 - 64 $717 $1,506 $2,116 $1,241
65 and older $722 $1,516 $2,130 $1,249

Area 7 (Medford)

Prevailing Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $449 $943 $1,325 $777
25 - 29 $505 $1,060 $1,489 $873
30 - 34 $505 $1,061 $1,490 $874
35 - 39 $533 $1,120 $1,573 $923
40 - 44 $590 $1,240 $1,742 $1,021
45 - 49 $698 $1,466 $2,060 $1,208
50 - 54 $810 $1,700 $2,388 $1,400
55 - 59 $862 $1,810 $2,543 $1,491
60 - 64 $888 $1,865 $2,620 $1,536
65 and older $894 $1,877 $2,637 $1,546
Low Cost Benefits
Age Insured
Only		 Insured &
Spouse		 Insured & Spouse & Child (ren) Insured & Child (ren)

Monthly rates effective June 1, 2012
Monthly family rates are based on the age of primary applicant
Under 25 $381 $800 $1,123 $659
25 - 29 $428 $899 $1,262 $740
30 - 34 $428 $899 $1,263 $741
35 - 39 $452 $949 $1,333 $782
40 - 44 $500 $1,051 $1,476 $866
45 - 49 $592 $1,243 $1,746 $1,024
50 - 54 $686 $1,441 $2,024 $1,187
55 - 59 $731 $1,534 $2,155 $1,264
60 - 64 $753 $1,581 $2,221 $1,302
65 and older $758 $1,591 $2,235 $1,311

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