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    Tribal Premium Rates for the Federal Employees Health Benefits Program 
    FFS (Fee-for-Service/Nationwide Plans) 
    
        
            
                
                
                    
                    
                    
                    
                    
             
         
        
                    
                        Nationwide APWU Health Plan  - CDHP Self 
                        474 
                                597.68 
                                597.68 
                                448.26 
                                149.42 
                                0.00 
                     
                    
                        Nationwide APWU Health Plan  - CDHP Self & Family 
                        475 
                                1417.09 
                                1417.09 
                                1062.82 
                                354.27 
                                0.00 
                     
                    
                        Nationwide APWU Health Plan  - CDHP Self Plus One 
                        476 
                                1299.00 
                                1299.00 
                                974.25 
                                324.75 
                                0.00 
                     
                    
                        Nationwide APWU Health Plan  - High Self 
                        471 
                                726.22 
                                726.22 
                                510.84 
                                215.38 
                                -12.12 
                     
                    
                        Nationwide APWU Health Plan  - High Self & Family 
                        472 
                                1742.91 
                                1742.91 
                                1184.02 
                                558.89 
                                -45.83 
                     
                    
                        Nationwide APWU Health Plan  - High Self Plus One 
                        473 
                                1525.03 
                                1525.03 
                                1092.26 
                                432.77 
                                -25.67 
                     
                    
                        Nationwide Blue Cross and Blue Shield Service Benefit Plan Basic Option - Basic Self 
                        111 
                                638.95 
                                658.19 
                                493.64 
                                164.55 
                                4.81 
                     
                    
                        Nationwide Blue Cross and Blue Shield Service Benefit Plan Basic Option - Basic Self & Family 
                        112 
                                1522.21 
                                1598.33 
                                1184.02 
                                414.31 
                                30.29 
                     
                    
                        Nationwide Blue Cross and Blue Shield Service Benefit Plan Basic Option - Basic Self Plus One 
                        113 
                                1436.15 
                                1479.25 
                                1092.26 
                                386.99 
                                17.43 
                     
                    
                        Nationwide Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus - FEP Blue Focus Self 
                        131 
                                460.59 
                                460.59 
                                345.44 
                                115.15 
                                0.00 
                     
                    
                        Nationwide Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus - FEP Blue Focus Self & Family 
                        132 
                                1089.18 
                                1089.18 
                                816.89 
                                272.29 
                                0.00 
                     
                    
                        Nationwide Blue Cross and Blue Shield Service Benefit Plan FEP Blue Focus - FEP Blue Focus Self Plus One 
                        133 
                                990.21 
                                990.21 
                                742.66 
                                247.55 
                                0.00 
                     
                    
                        Nationwide Blue Cross and Blue Shield Service Benefit Plan Standard Option - Standard Self 
                        104 
                                741.89 
                                764.14 
                                510.84 
                                253.30 
                                10.13 
                     
                    
                        Nationwide Blue Cross and Blue Shield Service Benefit Plan Standard Option - Standard Self & Family 
                        105 
                                1719.32 
                                1805.29 
                                1184.02 
                                621.27 
                                40.14 
                     
                    
                        Nationwide Blue Cross and Blue Shield Service Benefit Plan Standard Option - Standard Self Plus One 
                        106 
                                1622.42 
                                1671.09 
                                1092.26 
                                578.83 
                                23.00 
                     
                    
                        Nationwide Compass Rose Health Plan - High Self 
                        421 
                                696.28 
                                731.10 
                                510.84 
                                220.26 
                                22.70 
                     
                    
                        Nationwide Compass Rose Health Plan - High Self & Family 
                        422 
                                1671.09 
                                1754.65 
                                1184.02 
                                570.63 
                                37.73 
                     
                    
                        Nationwide Compass Rose Health Plan - High Self Plus One 
                        423 
                                1531.83 
                                1608.43 
                                1092.26 
                                516.17 
                                50.93 
                     
                    
                        Nationwide GEHA Benefit Plan - High Self 
                        311 
                                728.33 
                                739.25 
                                510.84 
                                228.41 
                                -1.20 
                     
                    
                        Nationwide GEHA Benefit Plan - High Self & Family 
                        312 
                                1816.25 
                                1843.53 
                                1184.02 
                                659.51 
                                -18.55 
                     
                    
                        Nationwide GEHA Benefit Plan - High Self Plus One 
                        313 
                                1602.32 
                                1626.37 
                                1092.26 
                                534.11 
                                -1.62 
                     
                    
                        Nationwide GEHA Benefit Plan - Standard Self 
                        314 
                                509.45 
                                524.72 
                                393.54 
                                131.18 
                                3.82 
                     
                    
                        Nationwide GEHA Benefit Plan - Standard Self & Family 
                        315 
                                1283.66 
                                1347.84 
                                1010.88 
                                336.96 
                                16.05 
                     
                    
                        Nationwide GEHA Benefit Plan - Standard Self Plus One 
                        316 
                                1095.34 
                                1128.21 
                                846.16 
                                282.05 
                                8.22 
                     
                    
                        Nationwide GEHA HDHP - HDHP Self 
                        341 
                                508.78 
                                513.85 
                                385.39 
                                128.46 
                                1.27 
                     
                    
                        Nationwide GEHA HDHP - HDHP Self & Family 
                        342 
                                1262.50 
                                1300.35 
                                975.26 
                                325.09 
                                9.47 
                     
                    
                        Nationwide GEHA HDHP - HDHP Self Plus One 
                        343 
                                1093.86 
                                1104.81 
                                828.61 
                                276.20 
                                2.74 
                     
                    
                        Nationwide GEHA Indemnity Benefit Plan - Elevate Plus Self 
                        251 
                                New Plan 
                                629.83 
                                472.37 
                                157.46 
                                New Plan 
                     
                    
                        Nationwide GEHA Indemnity Benefit Plan - Elevate Plus Self & Family 
                        252 
                                New Plan 
                                1561.97 
                                1171.48 
                                390.49 
                                New Plan 
                     
                    
                        Nationwide GEHA Indemnity Benefit Plan - Elevate Plus Self Plus One 
                        253 
                                New Plan 
                                1461.18 
                                1092.26 
                                368.92 
                                New Plan 
                     
                    
                        Nationwide GEHA Indemnity Benefit Plan - Elevate Self 
                        254 
                                New Plan 
                                410.13 
                                307.60 
                                102.53 
                                New Plan 
                     
                    
                        Nationwide GEHA Indemnity Benefit Plan - Elevate Self & Family 
                        255 
                                New Plan 
                                1148.40 
                                861.30 
                                287.10 
                                New Plan 
                     
                    
                        Nationwide GEHA Indemnity Benefit Plan - Elevate Self Plus One 
                        256 
                                New Plan 
                                943.32 
                                707.49 
                                235.83 
                                New Plan 
                     
                    
                        Nationwide MHBP Consumer Option - HDHP Self 
                        481 
                                562.03 
                                573.28 
                                429.96 
                                143.32 
                                2.81 
                     
                    
                        Nationwide MHBP Consumer Option - HDHP Self & Family 
                        482 
                                1305.94 
                                1332.07 
                                999.05 
                                333.02 
                                6.54 
                     
                    
                        Nationwide MHBP Consumer Option - HDHP Self Plus One 
                        483 
                                1243.78 
                                1268.65 
                                951.49 
                                317.16 
                                6.22 
                     
                    
                        Nationwide MHBP Standard Option - Standard Self 
                        454 
                                576.64 
                                570.85 
                                428.14 
                                142.71 
                                -1.45 
                     
                    
                        Nationwide MHBP Standard Option - Standard Self & Family 
                        455 
                                1340.04 
                                1326.65 
                                994.99 
                                331.66 
                                -3.35 
                     
                    
                        Nationwide MHBP Standard Option - Standard Self Plus One 
                        456 
                                1327.28 
                                1314.02 
                                985.52 
                                328.50 
                                -3.32 
                     
                    
                        Nationwide MHBP Value Plan - Value Self 
                        414 
                                477.17 
                                453.31 
                                339.98 
                                113.33 
                                -5.96 
                     
                    
                        Nationwide MHBP Value Plan - Value Self & Family 
                        415 
                                1153.19 
                                1095.53 
                                821.65 
                                273.88 
                                -14.42 
                     
                    
                        Nationwide MHBP Value Plan - Value Self Plus One 
                        416 
                                1130.61 
                                1074.08 
                                805.56 
                                268.52 
                                -14.13 
                     
                    
                        Nationwide NALC Health Benefit Plan  - CDHP Self 
                        324 
                                473.53 
                                473.53 
                                355.15 
                                118.38 
                                0.00 
                     
                    
                        Nationwide NALC Health Benefit Plan  - CDHP Self & Family 
                        325 
                                1067.67 
                                1089.03 
                                816.77 
                                272.26 
                                5.34 
                     
                    
                        Nationwide NALC Health Benefit Plan  - CDHP Self Plus One 
                        326 
                                1034.35 
                                1044.68 
                                783.51 
                                261.17 
                                2.58 
                     
                    
                        Nationwide NALC Health Benefit Plan  - High Self 
                        321 
                                682.09 
                                707.66 
                                510.84 
                                196.82 
                                13.45 
                     
                    
                        Nationwide NALC Health Benefit Plan  - High Self & Family 
                        322 
                                1531.68 
                                1592.96 
                                1184.02 
                                408.94 
                                15.45 
                     
                    
                        Nationwide NALC Health Benefit Plan  - High Self Plus One 
                        323 
                                1501.44 
                                1565.27 
                                1092.26 
                                473.01 
                                38.16 
                     
                    
                        Nationwide NALC Health Benefit Plan  - Value Self 
                        KM1 
                                388.64 
                                388.64 
                                291.48 
                                97.16 
                                0.00 
                     
                    
                        Nationwide NALC Health Benefit Plan  - Value Self & Family 
                        KM2 
                                876.63 
                                894.16 
                                670.62 
                                223.54 
                                4.38 
                     
                    
                        Nationwide NALC Health Benefit Plan  - Value Self Plus One 
                        KM3 
                                848.86 
                                857.35 
                                643.01 
                                214.34 
                                2.13 
                     
                    
                        Nationwide SAMBA Health Benefit Plan - High Self 
                        441 
                                912.69 
                                901.75 
                                510.84 
                                390.91 
                                -23.06 
                     
                    
                        Nationwide SAMBA Health Benefit Plan - High Self & Family 
                        442 
                                2190.44 
                                2164.15 
                                1184.02 
                                980.13 
                                -72.12 
                     
                    
                        Nationwide SAMBA Health Benefit Plan - High Self Plus One 
                        443 
                                2007.89 
                                1983.82 
                                1092.26 
                                891.56 
                                -49.74 
                     
                    
                        Nationwide SAMBA Health Benefit Plan - Standard Self 
                        444 
                                686.90 
                                680.51 
                                510.38 
                                170.13 
                                -18.05 
                     
                    
                        Nationwide SAMBA Health Benefit Plan - Standard Self & Family 
                        445 
                                1579.93 
                                1552.55 
                                1164.41 
                                388.14 
                                -53.60 
                     
                    
                        Nationwide SAMBA Health Benefit Plan - Standard Self Plus One 
                        446 
                                1511.23 
                                1464.67 
                                1092.26 
                                372.41 
                                -72.23 
                     
         
    
 
    
				 
			 
		 
		
		
			
				
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					1900 E Street, NW, Washington, DC 20415
					202-606-1800
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