2008 DentalBlue (Dentacare)

Monthly Premiums Effective for Coverage 1/1/08

UW Deduction Codes

Plan

Employee

Employee
+ 1

Employee
+2

467
Group Nos.
00166271 and 00166260

Anthem BCBS HMO — Region 1

(Kenosha, Milwaukee, Ozaukee, Racine, Washington & Waukesha Counties

$23.27

$46.55

$74.47

Anthem BCBS HMO — Region 2

(All other Wisconsin Counties)

$28.78

$57.56

$92.10

478
Group Nos.
00166270 and 00166212

Anthem BCBS PPO

$21.70

$43.38

$71.58

479
Group Nos.
00166272 and 00166261

Anthem BCBS Supplemental

$14.28

$28.56

$42.86