correspondence summary...pdf pipeline for serff tracking number aetn-130533528 generated 08/08/2016...

Correspondence Summary Objection Letters and Response LettersObjection Letters Response Letters

Status Created By Created On Date Submitted Responded By Created On Date SubmittedPendingIndustryResponse

Donna Novak 07/25/2016 07/25/2016 Peter Satagaj 07/28/2016 07/28/2016

PendingIndustryResponse

Michael Gurgiolo 07/18/2016 07/18/2016 Peter Satagaj 07/19/2016 07/19/2016






Donna Novak 05/31/2016 05/31/2016 Peter Satagaj 06/13/2016 06/13/2016

SERFF Tracking #: AETN-130533528 State Tracking #: Company Tracking #:

State: Pennsylvania Filing Company: Aetna HealthAssurance Pennsylvania, Inc.

TOI/Sub-TOI: H15G Group Health - Hospital/Surgical/Medical Expense/H15G.003 Small Group Only

Product Name: 2017 PA SG AHASPA filing

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number AETN-130533528 Generated 08/08/2016 02:29 PM

Objection Letter Objection Letter Status Pending Industry Response

Objection Letter Date 07/25/2016

Submitted Date 07/25/2016

Respond By Date 07/29/2016

Dear Andrew Adams,

Introduction: Please see the attached questions.

Conclusion:

Sincerely,

Donna Novak







1. Induced Utilization a. Please complete the table below for all plans, and confirm that the ratio in column

(8) represents the induced utilization for each plan.

Projected Projected Paid-To- AV & Cost Induced

DemD Projected Allowed Paid Allowed Sharing Demand

Plan ID Metal Level Membership Claims Claims Factor Factor (7)/(6)

(1) (2) (3) (4) (5) (6) (7) (8)

xxxxxx

xxxxxx

xxxxxx

Total

b. Please show quantitatively, including an Excel spreadsheet with formulas, the derivation of the AV and cost sharing factors for each plan.

c. Please provide any additional justification for induced utilization assumptions in the Company’s pricing.

d. Please confirm that each plan’s induced utilization factor was normalized by an aggregate factor, and that the resulting sumproduct (against projected

membership) produces a factor of 1.000. Please show the steps that demonstrate

this.





Dear Andrew Adams,

Introduction: As you know, on 7/15/18, the Department advised insurers that they could revise the projected risk adjustment transfer amountin small group filings, and that this revision is due Thursday 7/21. If you are going to or have filed a revised risk adjustment transferestimate, you may ignore the following objection.

Given the difference between the Company’s estimated risk adjustment for 2015 and actual 2015 amount, please provide narrativeand quantitatively show the development of the pmpm impact this will have on the projected 2017 risk adjustment pmpm amount andthe rate impact. Do not revise your filing because of this request; just provide the information requested by Monday, July 25.

Conclusion:

Sincerely,

Michael Gurgiolo











Dear Andrew Adams,

Introduction: Please see the attached and respond by Tuesday, July 19.

Conclusion:

Sincerely,

Michael Gurgiolo







1. Induced Utilization a. Please complete the table below for all plans, and confirm that the ratio in column

(8) represents the AV and Cost Sharing for each plan in your filing.1

Projected Projected Company

AV & Cost Projected Allowed Paid Determined Induced

zation

Sharing

Plan ID Metal Level Membership Claims Claims AV Factor Utilization2 (6)*(7)

(1) (2) (3) (4) (5) (6) (7) (8)

xxxxxx

xxxxxx

xxxxxx

Total

b. Please show quantitatively, including an Excel spreadsheet with formulas, the derivation of each, the AV and the cost sharing factors for each plan. Also,

provide narrative that explains the derivation.

c. Please provide justification for relative induced utilization assumptions in the Company’s pricing that exceed the federal factors used in the risk adjustment

model proving that morbidity is not reflected.3

d. Please confirm that each plan’s induced utilization factor was normalized by an aggregate factor, and that the resulting sumproduct (against projected

membership) produces a factor of 1.000. Please show the steps that demonstrate

this.

2. Please show quantitatively that plan premiums are in proportion to the plan AV Pricing Values.

1 If a tobacco factor is used in the AV and Cost Sharing please add a column for that amount and modify the formula. 2 The Induced Demand is the amount used by the company to reflect increased demand. This may be called by another name in the filing 3 The federal factors relative to the Bronze factors are Silver 1.03, Gold 1.08 and Platinum 1.15.





Dear Andrew Adams,

Introduction: The Pennsylvania Insurance Department has received and conducted a review of the above captioned filing. In order tocomplete the review, we are requesting the following information. To facilitate a timely review, we request this information beprovided within 7 days of the date of this letter and be provided in pdf. If you have any questions or difficulties in providing theinformation within this time frame, please call me.

1.Please provide all tables, exhibits, etc. supporting actuarial memorandum in Excel format with formulas for each entry.

2.Please be advised that each time the URRT is changed in SERFF, the URRT in HIOS must also be updated. Please acknowledgeyour understanding and certify that you are in compliance.

3.Please provide the 2015 Statutory Annual Statement Five-Year Historical Data Exhibit.

4.Please provide a copy of the Supplemental Health Care Exhibit (SHCE), and describe the reason(s) for any differences betweenthe SHCE and Worksheet 1, Section 1 of the Uniform Rate Review Template.

5.Please provide the January 1, 2016 through April 30, 2016 emerging experience in an Excel worksheet formatted similar to Table 2.

6.Please show quantitatively, including an Excel spreadsheet with formulas, the derivation of the Projected Risk Adjustments PMPMamount found in Section III, Worksheet 1 of the URRT. Please provide a detailed narrative that describers the development of theestimated risk adjustment transfer payment. In demonstrating the development of the transfer payment, please show all risk transferformula components, the estimated market-wide average risk assumptions as well as support for those assumptions. Whenresponding to this data call, you may redact this response as it will contain proprietary information. Since this response shouldinclude detailed insight into the risk adjustment transfer methodology, you may redact this response.

7.Regarding broker commissions:•Under what circumstances and in what geographic locations will commissions be paid?•Are commissions paid for SEP?•Provide a copy of the broker agreement - current and 2017.•Show the calculation of the average commission - current and 2017.Since this response should include detailed insight into the broker commission, you may redact this response.

Please be advised that there may be additional questions based on the responses to the above. Data and exhibits in response to thisrequest should be provided via SERFF in Microsoft Excel spreadsheets (version 2013 or less). Please retain all formulas. Shouldyou have any questions regarding this correspondence, please contact me at (717) 783-2115.Sincerely,

Michael GurgioloActuarial Review DivisionBureau of Accident & Health Insurance

Conclusion:







Sincerely,

Michael Gurgiolo











Dear Andrew Adams,

Introduction: Please see the attached questions with regard to this filing. Thank you.

Conclusion:

Sincerely,

Donna Novak







[Type text]

156 West Calle Guija, Suite 200, Sahuarita, AZ 85629 tel: 520-908-7246 - fax: 772-673-0318 NovaRest.com

MEMORANDUM

May 31, 2016

Subject: Aetna Health Assurance of PA Small Group Market January 1, 2017 Rate

Filing

Rate Filing: AETN-130533528

Objections:

1. Please explain the combination of Coventry data with Aetna’s to develop the manual

rate. Was Coventry still active as a separate entity in 2015? Is Coventry membership

moved to Aetna for 2017? Which Aetna entity was used since Aetna’s Health

Assurance of PA did not exist in 2015?

2. Please provide a complete quantitative development in an Excel sheet of the projected

allowed claims PMPM of $551.58 (included in WS 1 of the URRT), starting with the

Aetna and Coventry base claims and showing the applied factor for each adjustment

including all of the adjustments found in the URRT (do not combine adjustments) and

explaining the development of each or refer to the Actuarial Memorandum if

discussed there.

3. Please explain why the index rates on Table 5 (C16 - $552.11 and C17 - $578.69) do

not match the URRT ($551.58).

4. Please breakout the AV and induced utilization factors before and after normalization

from the cost sharing adjustment made to the Market Adjusted Index rate for all

plans.

5. Please confirm that Network and UM adjustments are normalized.

6. Please explain the differences in in Distribution & Admin per plan in Exhibit E-2.

7. Please describe the development of the geographic factors and confirm that they do

not reflect morbidity.

Response Letter Response Letter Status Submitted to State

Response Letter Date 07/28/2016


Dear Donna Novak,

Introduction:

Response 1

Comments: Responses are attached in the supporting documentation.

Changed Items:

Supporting Document Schedule Item ChangesSatisfied - Item: Objection Response 07-25-16Comments:

Attachment(s): Objection Responses AHASPA 07-25-16.pdfObjection Responses AHASPA 07-25-16.xlsx

No Form Schedule items changed.

No Rate/Rule Schedule items changed.

Conclusion:

Sincerely,

Peter Satagaj










Dear Donna Novak,

Introduction: We will not be proposing changes to our filed 2017 rates at this time. The actual risk adjustment PMPM came in as a smaller payable than expected. This impact isestimated to be worth -2.7%.

Response 1

Comments: A quantitative build up for the risk adjustment PMPM change as well as version with risk adjustment assumptions redacted are attached in the supportingdocumentation section

Changed Items:

Supporting Document Schedule Item ChangesSatisfied - Item: Objection Response 07-18-2016Comments:Attachment(s): Objection Responses AHASPA 07-18-16 redacted.xlsx

Supporting Document Schedule Item ChangesSatisfied - Item: Objection Response 07-18-2016Comments:Attachment(s): Objection Responses AHASPA 07-18-16 redacted.xlsx

Satisfied - Item: Objection Response 07-18-2016 UnredactedComments:Attachment(s): Objection Responses AHASPA 07-18-16.xlsx



Conclusion:







Sincerely,

Peter Satagaj










Dear Donna Novak,

Introduction:

Response 1

Comments: Objection Responses are attached in the supplemental documentation.

Changed Items:

Supporting Document Schedule Item ChangesSatisfied - Item: Objection Response 07-13-2016Comments:

Attachment(s): Objection Responses AHASPA 07-13-16.xlsxObjection Responses AHASPA 07-13-16.pdf



Conclusion:

Sincerely,

Peter Satagaj










Dear Donna Novak,

Introduction:

Response 1

Comments: Objection responses are included on the supporting documentation tab. Supporting exhibits have also been updated on the supporting documentation tab to includeformulas.

Changed Items:

Supporting Document Schedule Item ChangesSatisfied - Item: Supporting ExhibitsComments:Attachment(s): 2017 PA SG AHASPA Exhibits formulas.xlsxPrevious VersionSatisfied - Item: Supporting ExhibitsComments:Attachment(s): 2017 PA SG AHASPA Exhibits.xlsx








Satisfied - Item: Objection Response 06-17-2016Comments:

Attachment(s):Objection Responses AHASPA 06-17-16.pdfHASPA 5 year for RBC tax note.pdfHASPA 2015 SHCE.pdfObjection Responses AHASPA 06-17-16 Redacted.xlsx








Satisfied - Item: Objection Response 06-17-2016Comments:

Attachment(s):Objection Responses AHASPA 06-17-16.pdfHASPA 5 year for RBC tax note.pdfHASPA 2015 SHCE.pdfObjection Responses AHASPA 06-17-16 Redacted.xlsx

Satisfied - Item: Objection Response 06-17-2016 UnredactedComments:

Attachment(s): aetna_producer_agreement.pdfObjection Responses AHASPA 06-17-16.xlsx



Conclusion:

Sincerely,

Peter Satagaj










Dear Donna Novak,

Introduction:

Response 1

Comments: Objection Responses are included in supporting documents. Also included is an updated PA Actuarial Memo Rate Exhibit.

Changed Items:







Supporting Document Schedule Item ChangesSatisfied - Item: PA-Specific DocumentsComments:

Attachment(s):

Completeness and Redaction Justification Checklist 4-22-16 SG AHASPA_v2.pdf2017 PA Actuarial Memorandum SG AHASPA_v2.pdfconfidentiality request AHASPA.pdf2017 PA Actuarial Memorandum SG AHASPA Redacted_v2.pdf2017 PA Bulletin Information SG AHASPA v3.pdfAttachment 1 - Rate Chg Request Summary - SG AHASPA v3.pdfFINAL 2017 PA ActMemo Rate Exhibits - SG AHASPA v3.xlsx

Previous VersionSatisfied - Item: PA-Specific DocumentsComments:

Attachment(s):



Attachment(s):

2017 PA Bulletin Information SG AHASPA.pdfAttachment 1 - Rate Chg Request Summary - SG AHASPA.pdfFINAL 2017 PA ActMemo Rate Exhibits - SG AHASPA.xlsxCompleteness and Redaction Justification Checklist 4-22-16 SG AHASPA_v2.pdf2017 PA Actuarial Memorandum SG AHASPA_v2.pdfconfidentiality request AHASPA.pdf2017 PA Actuarial Memorandum SG AHASPA Redacted_v2.pdf







Supporting Document Schedule Item ChangesSatisfied - Item: PA-Specific DocumentsComments:

Attachment(s):



Attachment(s):



Attachment(s):

2017 PA Bulletin Information SG AHASPA.pdfAttachment 1 - Rate Chg Request Summary - SG AHASPA.pdfFINAL 2017 PA ActMemo Rate Exhibits - SG AHASPA.xlsxCompleteness and Redaction Justification Checklist 4-22-16 SG AHASPA_v2.pdf2017 PA Actuarial Memorandum SG AHASPA_v2.pdfconfidentiality request AHASPA.pdf2017 PA Actuarial Memorandum SG AHASPA Redacted_v2.pdf

Satisfied - Item: Objection Responses 05-31-16Comments:

Attachment(s): Objection Responses AHASPA 05-31-16.xlsxObjection Responses AHASPA 05-31-16.pdf









Conclusion:

Sincerely,

Peter Satagaj







Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Premium Rate Manual New 1Q17 PA SG PremiumRate ManualAHASPA.pdf,

2 PA Rate Template New Rate Page FilingFormat 1Q17-AHASPA SG.pdf, RatePage Filing Format2Q17- AHASPASG.pdf, Rate PageFiling Format 3Q17-AHASPA SG.pdf, RatePage Filing Format4Q17- AHASPASG.pdf, Rate PageFiling Format 1Q17-AHASPA SGvalues_v2.xlsx, RatePage Filing Format2Q17- AHASPA SGvalues_v2.xlsx, RatePage Filing Format3Q17- AHASPA SGvalues_v2.xlsx, RatePage Filing Format4Q17- AHASPA SGvalues_v2.xlsx,

3 CMS Rate Template New PA_SG_18939_Rates_OFF_2017_v3.xlsm,PA_SG_18939_Rates_OFF_2017_Q1_v3.pdf,PA_SG_18939_Rates_OFF_2017_Q2_v3.pdf,PA_SG_18939_Rates_OFF_2017_Q3_v3.pdf,PA_SG_18939_Rates_OFF_2017_Q4_v3.pdf,







Attachment Rate Page Filing Format 1Q17- AHASPA SG values_v2.xlsx is not a PDF document andcannot be reproduced here.




Attachment PA_SG_18939_Rates_OFF_2017_v3.xlsm is not a PDF document and cannot be reproducedhere.







Market Index Rate

Product Rate

HMO/QPOS $439.41

Effective Date Factor Table

Effective Date Factor

1st Quarter 2016 1.0000

2nd Quarter 2016 1.0360

3rd Quarter 2016 1.0733

4th Quarter 2016 1.1121

Member Age Table

Age Factor

0-20 0.635

21 1.000

22 1.000

23 1.000

24 1.000

25 1.004

26 1.024

27 1.048

28 1.087

29 1.119

30 1.135

31 1.159

32 1.183

33 1.198

34 1.214

35 1.222

36 1.230

37 1.238

38 1.246

39 1.262

40 1.278

41 1.302

42 1.325

43 1.357

44 1.397

45 1.444

46 1.500

47 1.563

48 1.635

49 1.706

50 1.786

51 1.865

52 1.952

53 2.040

54 2.135

55 2.230

56 2.333

57 2.437

58 2.548

59 2.603

60 2.714

61 2.810

62 2.873

63 2.952

64 and Older 2.999

Area Factor Table

Region Factor

Region 1 0.7850

Region 2 0.7918

Region 3 0.9982

Region 4 0.8102

Region 5 0.7800

Region 6 0.9830

Region 7 0.9838

Region 8 1.0100

Region 9 0.9332

Region County

Region 1: Erie Mercer Clarion Warren

Crawford Venango Forest McKean

Region 2: Elk Cameron Potter

Region 3: Tioga Bradford Lackawanna Monroe

Clinton Susquehanna Wayne Carbon

Lycoming Wyoming Pike Luzerne

Sullivan

Region 4: Lawrence Greene Westmoreland Indiana

Beaver Butler Armstrong Fayette

Washington Allegheny

Region 5: Jefferson Cambria Bedford Huntingdon

Clearfield Somerset Blair

Region 6: Centre Snyder Columbia Lehigh

Mifflin Montour Schuylkill Northampton

Union Northumberland

Region 7: Adams York Lancaster Berks

Region 8: Chester Montgomery Bucks Philadelphia

Delaware

Region 9: Fulton Cumberland Juniata Lebanon

Franklin Perry Dauphin

Plan Relativity Factors

HIOS Plan ID New Plan Name

Plan

Relativity

Factor

18939PA0010012 PA Gold PPO 1000 80/50 0.9683

18939PA0010013 PA Gold PPO 2000 80/50 0.9869

18939PA0010020 PA Gold PPO 2000 100/50 1.0344

18939PA0030002 PA Gold PPO AP 2000 100/50 1.0073

18939PA0010014 PA Silver PPO 3000 80/50 0.8577

18939PA0010025 PA Silver PPO 5000 100/50 0.8691

18939PA0010015 PA Platinum PPO 100/50 200D 1.1975

18939PA0010048 PA Gold PPO 100/50 600D 1.0510

18939PA0010018 PA Gold PPO 1000 100/50 1.1013

18939PA0030001 PA Gold PPO AP 1000 100/50 25 1.0725

18939PA0010003 PA Gold PPO 2000 100/50 HSA T 1.0764

18939PA0010049 PA Silver PPO 3000 100/50 0.9341

18939PA0030004 PA Silver PPO AP 3000 100/50 250A 0.9092

18939PA0010050 PA Silver PPO 3000 100/50 HSA E 0.8869

18939PA0010031 PA Silver PPO 4000 100/50 0.8886

18939PA0030005 PA Silver PPO AP 4000 100/50 30 0.8654

18939PA0010046 PA Bronze PPO 6550 100/50 HSA E 0.7499

18939PA0030003 PA Bronze PPO AP 6550 100/50 HSA E 0.7302

18939PA0010047 PA Bronze PPO 7000 100/50 Int 0.7301

18939PA0020001 PA Silver Indemnity 2000 80% 1.1089

HIOS Plan IDOn/Off

ExchangeProduct Metal Level Plan Design Marketing Name Network Rating Area Counties Excluded

18939PA0010012 Off PPO Gold PA Gold PPO 1000 80/50 Full All None



18939PA0030002 Off PPO Gold PA Gold PPO AP 2000 100/50 Full All None

18939PA0010014 Off PPO Silver PA Silver PPO 3000 80/50 Full All None


18939PA0010015 Off PPO Platinum PA Platinum PPO 100/50 200D Full All None

18939PA0010048 Off PPO Gold PA Gold PPO 100/50 600D Full All None


18939PA0030001 Off PPO Gold PA Gold PPO AP 1000 100/50 25 Full All None

18939PA0010003 Off PPO Gold PA Gold PPO 2000 100/50 HSA T Full All None


18939PA0030004 Off PPO Silver PA Silver PPO AP 3000 100/50 250A Full All None

18939PA0010050 Off PPO Silver PA Silver PPO 3000 100/50 HSA E Full All None


18939PA0030005 Off PPO Silver PA Silver PPO AP 4000 100/50 30 Full All None

18939PA0010046 Off PPO Bronze PA Bronze PPO 6550 100/50 HSA E Full All None

18939PA0030003 Off PPO Bronze PA Bronze PPO AP 6550 100/50 HSA E Full All None

18939PA0010047 Off PPO Bronze PA Bronze PPO 7000 100/50 Int Full All None

18939PA0020001 Off Indemnity Silver PA Silver Indemnity 2000 80% Full All None

Aetna HealthAssurance of Pennsylvania, Inc.Small Group off-SHOPPlan Design Summary

12/24/2014

RATE PAGES

Company Name: AHASPA Aetna HealthAssurance of Pennsylvania, Inc.Market: Small Group Off-SHOP

Product: PPO PPOEffective Date of Rates: Ending date of Rates:

Plan ID (On Exchange)=>

Plan ID (Off Exchange)=> 18939PA0010012 18939PA0010013 18939PA0010020 18939PA0030002 18939PA0010014 18939PA0010025

Form # => AL GR-9N AL GR-9N AL GR-9N AL GR-9N AL GR-9N AL GR-9N

Rating Area => Rating Area 1 Rating Area 1 Rating Area 1 Rating Area 1 Rating Area 1 Rating Area 1

Counties Excluded in Rating Area =>

Network => Full Full Full Full Full Full

Metal => Gold Gold Gold Gold Silver Silver

Plan Name => PA Gold PPO 1000 80/50 PA Gold PPO 2000 80/50 PA Gold PPO 2000 100/50 PA Gold PPO AP 2000 100/50 PA Silver PPO 3000 80/50 PA Silver PPO 5000 100/50

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) No No No No No No

Age Band Tobacco/Non-Tobacco Tobacco/Non-Tobacco Tobacco/Non-Tobacco Tobacco/Non-Tobacco Tobacco/Non-Tobacco Tobacco/Non-Tobacco

0-20 $212.11 $216.18 $226.58 $220.64 $187.88 $190.37

21 $334.03 $340.44 $356.81 $347.47 $295.87 $299.80

22 $334.03 $340.44 $356.81 $347.47 $295.87 $299.80

23 $334.03 $340.44 $356.81 $347.47 $295.87 $299.80

24 $334.03 $340.44 $356.81 $347.47 $295.87 $299.80

25 $335.36 $341.80 $358.24 $348.86 $297.05 $301.00

26 $342.04 $348.61 $365.38 $355.81 $302.97 $306.99

27 $350.06 $356.78 $373.94 $364.15 $310.07 $314.19

28 $363.09 $370.06 $387.85 $377.70 $321.61 $325.88

29 $373.77 $380.96 $399.27 $388.82 $331.08 $335.48

30 $379.12 $386.40 $404.98 $394.38 $335.81 $340.27

31 $387.14 $394.57 $413.54 $402.72 $342.91 $347.47

32 $395.15 $402.74 $422.11 $411.06 $350.01 $354.66

33 $400.16 $407.85 $427.46 $416.27 $354.45 $359.16

34 $405.51 $413.30 $433.17 $421.83 $359.18 $363.96

35 $408.18 $416.02 $436.02 $424.61 $361.55 $366.36

36 $410.85 $418.74 $438.88 $427.39 $363.92 $368.75

37 $413.52 $421.47 $441.73 $430.17 $366.28 $371.15

38 $416.20 $424.19 $444.59 $432.95 $368.65 $373.55

39 $421.54 $429.64 $450.30 $438.51 $373.38 $378.35

40 $426.89 $435.09 $456.01 $444.07 $378.12 $383.14

41 $434.90 $443.26 $464.57 $452.41 $385.22 $390.34

42 $442.58 $451.09 $472.78 $460.40 $392.02 $397.23

43 $453.27 $461.98 $484.19 $471.52 $401.49 $406.83

44 $466.63 $475.60 $498.47 $485.42 $413.33 $418.82

45 $482.33 $491.60 $515.24 $501.75 $427.23 $432.91

46 $501.04 $510.66 $535.22 $521.21 $443.80 $449.70

47 $522.08 $532.11 $557.70 $543.10 $462.44 $468.59

48 $546.13 $556.62 $583.39 $568.12 $483.74 $490.17

49 $569.85 $580.79 $608.72 $592.79 $504.75 $511.46

50 $596.57 $608.03 $637.27 $620.58 $528.42 $535.44

51 $622.96 $634.93 $665.45 $648.03 $551.79 $559.13

52 $652.02 $664.54 $696.50 $678.26 $577.53 $585.21

53 $681.41 $694.50 $727.90 $708.84 $603.57 $611.59

54 $713.15 $726.84 $761.79 $741.85 $631.68 $640.07

55 $744.88 $759.19 $795.69 $774.86 $659.78 $668.55

56 $779.28 $794.25 $832.44 $810.65 $690.26 $699.43

57 $814.02 $829.66 $869.55 $846.79 $721.03 $730.61

58 $851.10 $867.45 $909.16 $885.36 $753.87 $763.89

59 $869.47 $886.17 $928.78 $904.47 $770.14 $780.38

60 $906.55 $923.96 $968.39 $943.04 $802.98 $813.66

61 $938.61 $956.64 $1,002.64 $976.40 $831.39 $842.44

62 $959.66 $978.09 $1,025.12 $998.29 $850.03 $861.32

63 $986.04 $1,004.99 $1,053.31 $1,025.74 $873.40 $885.01

64 $1,001.74 $1,020.99 $1,070.08 $1,042.07 $887.31 $899.10

65 and over $1,001.74 $1,020.99 $1,070.08 $1,042.07 $887.31 $899.10

January 1, 2017 March 31, 2017

Page Number: 2 12/24/2014

RATE PAGES

Company Name: AHASPAMarket: Small Group Off-SHOP

Product: PPOEffective Date of Rates:


Plan ID (Off Exchange)=>

Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65 and over



18939PA0010015 18939PA0010048 18939PA0010018 18939PA0030001 18939PA0010003 18939PA0010049 18939PA0030004

AL GR-9N AL GR-9N AL GR-9N AL GR-9N AL GR-9N AL GR-9N AL GR-9N

Rating Area 1 Rating Area 1 Rating Area 1 Rating Area 1 Rating Area 1 Rating Area 1 Rating Area 1

Full Full Full Full Full Full Full

Platinum Gold Gold Gold Gold Silver Silver

PA Platinum PPO 100/50 200D PA Gold PPO 100/50 600D PA Gold PPO 1000 100/50 PA Gold PPO AP 1000 100/50 25 PA Gold PPO 2000 100/50 HSA T PA Silver PPO 3000 100/50

PA Silver PPO AP 3000 100/50

250A

No No No No No No No

Tobacco/Non-Tobacco Tobacco/Non-Tobacco Tobacco/Non-Tobacco Tobacco/Non-Tobacco Tobacco/Non-Tobacco Tobacco/Non-Tobacco Tobacco/Non-Tobacco

$262.30 $230.22 $241.23 $234.92 $235.79 $204.61 $199.15

$413.08 $362.55 $379.89 $369.95 $371.32 $322.21 $313.63

$413.08 $362.55 $379.89 $369.95 $371.32 $322.21 $313.63

$413.08 $362.55 $379.89 $369.95 $371.32 $322.21 $313.63

$413.08 $362.55 $379.89 $369.95 $371.32 $322.21 $313.63

$414.73 $364.00 $381.41 $371.43 $372.80 $323.50 $314.88

$422.99 $371.25 $389.01 $378.83 $380.23 $329.95 $321.15

$432.91 $379.95 $398.13 $387.70 $389.14 $337.68 $328.68

$449.02 $394.09 $412.94 $402.13 $403.62 $350.25 $340.91

$462.23 $405.70 $425.10 $413.97 $415.50 $360.56 $350.95

$468.84 $411.50 $431.18 $419.89 $421.45 $365.71 $355.97

$478.76 $420.20 $440.29 $428.77 $430.36 $373.44 $363.49

$488.67 $428.90 $449.41 $437.65 $439.27 $381.18 $371.02

$494.87 $434.34 $455.11 $443.20 $444.84 $386.01 $375.73

$501.48 $440.14 $461.19 $449.12 $450.78 $391.17 $380.74

$504.78 $443.04 $464.23 $452.08 $453.75 $393.74 $383.25

$508.09 $445.94 $467.27 $455.03 $456.72 $396.32 $385.76

$511.39 $448.84 $470.31 $457.99 $459.69 $398.90 $388.27

$514.69 $451.74 $473.34 $460.95 $462.66 $401.48 $390.78

$521.30 $457.54 $479.42 $466.87 $468.60 $406.63 $395.80

$527.91 $463.34 $485.50 $472.79 $474.54 $411.79 $400.82

$537.83 $472.04 $494.62 $481.67 $483.46 $419.52 $408.34

$547.33 $480.38 $503.36 $490.18 $492.00 $426.93 $415.56

$560.55 $491.98 $515.51 $502.02 $503.88 $437.24 $425.59

$577.07 $506.48 $530.71 $516.82 $518.73 $450.13 $438.14

$596.48 $523.52 $548.56 $534.20 $536.18 $465.28 $452.88

$619.62 $543.83 $569.84 $554.92 $556.98 $483.32 $470.44

$645.64 $566.67 $593.77 $578.23 $580.37 $503.62 $490.20

$675.38 $592.77 $621.12 $604.86 $607.10 $526.82 $512.78

$704.71 $618.51 $648.09 $631.13 $633.47 $549.70 $535.05

$737.76 $647.52 $678.49 $660.73 $663.17 $575.47 $560.14

$770.39 $676.16 $708.50 $689.95 $692.51 $600.93 $584.92

$806.33 $707.70 $741.55 $722.14 $724.81 $628.96 $612.20

$842.68 $739.61 $774.98 $754.69 $757.49 $657.31 $639.80

$881.92 $774.05 $811.07 $789.84 $792.76 $687.92 $669.59

$921.16 $808.49 $847.16 $824.98 $828.04 $718.53 $699.39

$963.71 $845.83 $886.29 $863.09 $866.28 $751.72 $731.69

$1,006.67 $883.54 $925.80 $901.56 $904.90 $785.23 $764.31

$1,052.52 $923.78 $967.96 $942.63 $946.12 $821.00 $799.12

$1,075.24 $943.72 $988.86 $962.97 $966.54 $838.72 $816.37

$1,121.09 $983.96 $1,031.03 $1,004.04 $1,007.76 $874.49 $851.18

$1,160.75 $1,018.77 $1,067.50 $1,039.55 $1,043.40 $905.42 $881.29

$1,186.77 $1,041.61 $1,091.43 $1,062.86 $1,066.80 $925.72 $901.05

$1,219.41 $1,070.25 $1,121.44 $1,092.08 $1,096.13 $951.17 $925.83

$1,238.82 $1,087.29 $1,139.29 $1,109.47 $1,113.58 $966.32 $940.57

$1,238.82 $1,087.29 $1,139.29 $1,109.47 $1,113.58 $966.32 $940.57



RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65 and over



18939PA0010050 18939PA0010031 18939PA0030005 18939PA0010046 18939PA0030003 18939PA0010047 18939PA0020001




Silver Silver Silver Bronze Bronze Bronze Silver

PA Silver PPO 3000 100/50 HSA E PA Silver PPO 4000 100/50 PA Silver PPO AP 4000 100/50 30 PA Bronze PPO 6550 100/50 HSA E

PA Bronze PPO AP 6550 100/50

HSA E PA Bronze PPO 7000 100/50 Int PA Silver Indemnity 2000 80%



$194.27 $194.64 $189.55 $164.25 $159.95 $159.91 $242.89

$305.94 $306.53 $298.50 $258.66 $251.89 $251.83 $382.50

$305.94 $306.53 $298.50 $258.66 $251.89 $251.83 $382.50

$305.94 $306.53 $298.50 $258.66 $251.89 $251.83 $382.50

$305.94 $306.53 $298.50 $258.66 $251.89 $251.83 $382.50

$307.17 $307.75 $299.70 $259.70 $252.90 $252.84 $384.03

$313.28 $313.88 $305.67 $264.87 $257.94 $257.88 $391.68

$320.63 $321.24 $312.83 $271.08 $263.98 $263.92 $400.86

$332.56 $333.20 $324.47 $281.17 $273.81 $273.74 $415.78

$342.35 $343.00 $334.03 $289.45 $281.87 $281.80 $428.02

$347.24 $347.91 $338.80 $293.58 $285.90 $285.83 $434.13

$354.59 $355.27 $345.97 $299.79 $291.94 $291.87 $443.31

$361.93 $362.62 $353.13 $306.00 $297.99 $297.92 $452.49

$366.52 $367.22 $357.61 $309.88 $301.77 $301.69 $458.23

$371.41 $372.12 $362.38 $314.02 $305.80 $305.72 $464.35

$373.86 $374.58 $364.77 $316.09 $307.81 $307.74 $467.41

$376.31 $377.03 $367.16 $318.16 $309.83 $309.75 $470.47

$378.76 $379.48 $369.55 $320.23 $311.84 $311.77 $473.53

$381.20 $381.93 $371.94 $322.30 $313.86 $313.78 $476.59

$386.10 $386.84 $376.71 $326.43 $317.89 $317.81 $482.71

$390.99 $391.74 $381.49 $330.57 $321.92 $321.84 $488.83

$398.34 $399.10 $388.65 $336.78 $327.97 $327.88 $498.01

$405.37 $406.15 $395.52 $342.73 $333.76 $333.68 $506.81

$415.16 $415.96 $405.07 $351.01 $341.82 $341.74 $519.05

$427.40 $428.22 $417.01 $361.35 $351.90 $351.81 $534.35

$441.78 $442.63 $431.04 $373.51 $363.73 $363.64 $552.33

$458.91 $459.79 $447.76 $388.00 $377.84 $377.75 $573.75

$478.19 $479.10 $466.56 $404.29 $393.71 $393.61 $597.84

$500.21 $501.17 $488.05 $422.92 $411.85 $411.74 $625.38

$521.94 $522.94 $509.25 $441.28 $429.73 $429.62 $652.54

$546.41 $547.46 $533.13 $461.98 $449.88 $449.77 $683.14

$570.58 $571.67 $556.71 $482.41 $469.78 $469.67 $713.36

$597.20 $598.34 $582.68 $504.91 $491.70 $491.57 $746.64

$624.12 $625.32 $608.95 $527.68 $513.86 $513.74 $780.30

$653.19 $654.44 $637.30 $552.25 $537.79 $537.66 $816.63

$682.25 $683.56 $665.66 $576.82 $561.72 $561.58 $852.97

$713.76 $715.13 $696.41 $603.46 $587.67 $587.52 $892.37

$745.58 $747.01 $727.45 $630.37 $613.86 $613.71 $932.15

$779.54 $781.03 $760.59 $659.08 $641.83 $641.67 $974.60

$796.37 $797.89 $777.00 $673.30 $655.68 $655.52 $995.64

$830.33 $831.92 $810.14 $702.02 $683.64 $683.47 $1,038.10

$859.70 $861.34 $838.79 $726.85 $707.82 $707.65 $1,074.82

$878.97 $880.65 $857.60 $743.14 $723.69 $723.51 $1,098.92

$903.14 $904.87 $881.18 $763.58 $743.59 $743.41 $1,129.13

$917.52 $919.28 $895.21 $775.74 $755.43 $755.24 $1,147.11

$917.52 $919.28 $895.21 $775.74 $755.43 $755.24 $1,147.11

March 31, 2017January 1, 2017


RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

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45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65 and over



18939PA0010012 18939PA0010013 18939PA0010020 18939PA0030002 18939PA0010014 18939PA0010025 18939PA0010015




Gold Gold Gold Gold Silver Silver Platinum

PA Gold PPO 1000 80/50 PA Gold PPO 2000 80/50 PA Gold PPO 2000 100/50 PA Gold PPO AP 2000 100/50 PA Silver PPO 3000 80/50 PA Silver PPO 5000 100/50 PA Platinum PPO 100/50 200D



$213.94 $218.05 $228.54 $222.55 $189.50 $192.02 $264.57

$336.92 $343.39 $359.90 $350.48 $298.43 $302.39 $416.65

$336.92 $343.39 $359.90 $350.48 $298.43 $302.39 $416.65

$336.92 $343.39 $359.90 $350.48 $298.43 $302.39 $416.65

$336.92 $343.39 $359.90 $350.48 $298.43 $302.39 $416.65

$338.26 $344.76 $361.34 $351.88 $299.62 $303.60 $418.32

$345.00 $351.63 $368.54 $358.89 $305.59 $309.65 $426.65

$353.09 $359.87 $377.17 $367.30 $312.75 $316.91 $436.65

$366.23 $373.26 $391.21 $380.97 $324.39 $328.70 $452.90

$377.01 $384.25 $402.73 $392.19 $333.94 $338.38 $466.23

$382.40 $389.75 $408.49 $397.79 $338.71 $343.22 $472.90

$390.49 $397.99 $417.12 $406.20 $345.88 $350.47 $482.90

$398.57 $406.23 $425.76 $414.62 $353.04 $357.73 $492.90

$403.63 $411.38 $431.16 $419.87 $357.52 $362.27 $499.15

$409.02 $416.87 $436.92 $425.48 $362.29 $367.11 $505.82

$411.71 $419.62 $439.80 $428.28 $364.68 $369.53 $509.15

$414.41 $422.37 $442.68 $431.09 $367.07 $371.94 $512.48

$417.10 $425.11 $445.56 $433.89 $369.45 $374.36 $515.82

$419.80 $427.86 $448.43 $436.70 $371.84 $376.78 $519.15

$425.19 $433.36 $454.19 $442.30 $376.62 $381.62 $525.81

$430.58 $438.85 $459.95 $447.91 $381.39 $386.46 $532.48

$438.67 $447.09 $468.59 $456.32 $388.55 $393.72 $542.48

$446.41 $454.99 $476.87 $464.38 $395.42 $400.67 $552.06

$457.20 $465.98 $488.38 $475.60 $404.97 $410.35 $565.40

$470.67 $479.71 $502.78 $489.62 $416.90 $422.44 $582.06

$486.51 $495.85 $519.69 $506.09 $430.93 $436.66 $601.65

$505.37 $515.08 $539.85 $525.72 $447.64 $453.59 $624.98

$526.60 $536.72 $562.52 $547.80 $466.44 $472.64 $651.23

$550.86 $561.44 $588.44 $573.03 $487.93 $494.41 $681.23

$574.78 $585.82 $613.99 $597.92 $509.12 $515.88 $710.81

$601.73 $613.29 $642.78 $625.95 $532.99 $540.08 $744.14

$628.35 $640.42 $671.21 $653.64 $556.57 $563.96 $777.06

$657.66 $670.29 $702.52 $684.13 $582.53 $590.27 $813.30

$687.31 $700.51 $734.19 $714.98 $608.79 $616.88 $849.97

$719.32 $733.13 $768.38 $748.27 $637.14 $645.61 $889.55

$751.32 $765.76 $802.58 $781.57 $665.49 $674.34 $929.13

$786.03 $801.13 $839.65 $817.67 $696.23 $705.48 $972.05

$821.07 $836.84 $877.07 $854.12 $727.27 $736.93 $1,015.38

$858.46 $874.95 $917.02 $893.02 $760.39 $770.50 $1,061.63

$876.99 $893.84 $936.82 $912.30 $776.81 $787.13 $1,084.55

$914.39 $931.96 $976.77 $951.20 $809.93 $820.70 $1,130.79

$946.73 $964.92 $1,011.32 $984.84 $838.58 $849.73 $1,170.79

$967.96 $986.55 $1,033.99 $1,006.92 $857.38 $868.78 $1,197.04

$994.58 $1,013.68 $1,062.42 $1,034.61 $880.96 $892.67 $1,229.96

$1,010.41 $1,029.82 $1,079.34 $1,051.08 $894.98 $906.88 $1,249.54

$1,010.41 $1,029.82 $1,079.34 $1,051.08 $894.98 $906.88 $1,249.54



RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

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45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65 and over



18939PA0010048 18939PA0010018 18939PA0030001 18939PA0010003 18939PA0010049 18939PA0030004 18939PA0010050




Gold Gold Gold Gold Silver Silver Silver

PA Gold PPO 100/50 600D PA Gold PPO 1000 100/50 PA Gold PPO AP 1000 100/50 25 PA Gold PPO 2000 100/50 HSA T PA Silver PPO 3000 100/50


250A PA Silver PPO 3000 100/50 HSA E



$232.21 $243.32 $236.95 $237.83 $206.38 $200.88 $195.95

$365.69 $383.18 $373.15 $374.53 $325.00 $316.34 $308.59

$365.69 $383.18 $373.15 $374.53 $325.00 $316.34 $308.59

$365.69 $383.18 $373.15 $374.53 $325.00 $316.34 $308.59

$365.69 $383.18 $373.15 $374.53 $325.00 $316.34 $308.59

$367.15 $384.71 $374.64 $376.03 $326.30 $317.61 $309.82

$374.47 $392.38 $382.10 $383.52 $332.80 $323.93 $315.99

$383.24 $401.57 $391.06 $392.51 $340.60 $331.53 $323.40

$397.50 $416.52 $405.61 $407.11 $353.28 $343.86 $335.44

$409.21 $428.78 $417.55 $419.10 $363.68 $353.99 $345.31

$415.06 $434.91 $423.52 $425.09 $368.88 $359.05 $350.25

$423.83 $444.10 $432.48 $434.08 $376.68 $366.64 $357.65

$432.61 $453.30 $441.43 $443.07 $384.48 $374.23 $365.06

$438.10 $459.05 $447.03 $448.69 $389.35 $378.98 $369.69

$443.95 $465.18 $453.00 $454.68 $394.55 $384.04 $374.63

$446.87 $468.24 $455.99 $457.68 $397.15 $386.57 $377.10

$449.80 $471.31 $458.97 $460.67 $399.75 $389.10 $379.56

$452.72 $474.38 $461.96 $463.67 $402.35 $391.63 $382.03

$455.65 $477.44 $464.94 $466.67 $404.95 $394.16 $384.50

$461.50 $483.57 $470.91 $472.66 $410.15 $399.22 $389.44

$467.35 $489.70 $476.88 $478.65 $415.35 $404.28 $394.38

$476.13 $498.90 $485.84 $487.64 $423.15 $411.88 $401.78

$484.54 $507.71 $494.42 $496.25 $430.63 $419.15 $408.88

$496.24 $519.97 $506.36 $508.24 $441.03 $429.28 $418.76

$510.87 $535.30 $521.29 $523.22 $454.03 $441.93 $431.10

$528.05 $553.31 $538.83 $540.82 $469.30 $456.80 $445.60

$548.53 $574.77 $559.72 $561.80 $487.50 $474.51 $462.88

$571.57 $598.91 $583.23 $585.39 $507.98 $494.44 $482.32

$597.90 $626.50 $610.10 $612.36 $531.38 $517.22 $504.54

$623.86 $653.70 $636.59 $638.95 $554.45 $539.68 $526.45

$653.12 $684.36 $666.44 $668.91 $580.45 $564.99 $551.14

$682.01 $714.63 $695.92 $698.50 $606.13 $589.98 $575.52

$713.82 $747.97 $728.39 $731.08 $634.40 $617.50 $602.37

$746.00 $781.68 $761.22 $764.04 $663.00 $645.34 $629.52

$780.75 $818.09 $796.67 $799.62 $693.88 $675.39 $658.84

$815.49 $854.49 $832.12 $835.20 $724.75 $705.44 $688.15

$853.15 $893.96 $870.56 $873.78 $758.23 $738.02 $719.94

$891.18 $933.81 $909.36 $912.73 $792.03 $770.92 $752.03

$931.77 $976.34 $950.78 $954.30 $828.10 $806.04 $786.28

$951.89 $997.41 $971.31 $974.90 $845.98 $823.44 $803.26

$992.48 $1,039.95 $1,012.72 $1,016.48 $882.05 $858.55 $837.51

$1,027.59 $1,076.73 $1,048.55 $1,052.43 $913.25 $888.92 $867.13

$1,050.62 $1,100.87 $1,072.06 $1,076.03 $933.73 $908.85 $886.58

$1,079.51 $1,131.14 $1,101.53 $1,105.61 $959.40 $933.84 $910.95

$1,096.70 $1,149.15 $1,119.07 $1,123.22 $974.68 $948.71 $925.46

$1,096.70 $1,149.15 $1,119.07 $1,123.22 $974.68 $948.71 $925.46



RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

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40

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57

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59

60

61

62

63

64

65 and over



18939PA0010031 18939PA0030005 18939PA0010046 18939PA0030003 18939PA0010047 18939PA0020001 18939PA0010012




Silver Silver Bronze Bronze Bronze Silver Gold

PA Silver PPO 4000 100/50 PA Silver PPO AP 4000 100/50 30 PA Bronze PPO 6550 100/50 HSA E


HSA E PA Bronze PPO 7000 100/50 Int PA Silver Indemnity 2000 80% PA Gold PPO 1000 80/50



$196.33 $191.19 $165.67 $161.34 $161.30 $244.99 $269.70

$309.18 $301.09 $260.90 $254.07 $254.01 $385.81 $424.73

$309.18 $301.09 $260.90 $254.07 $254.01 $385.81 $424.73

$309.18 $301.09 $260.90 $254.07 $254.01 $385.81 $424.73

$309.18 $301.09 $260.90 $254.07 $254.01 $385.81 $424.73

$310.42 $302.29 $261.95 $255.09 $255.03 $387.35 $426.42

$316.60 $308.31 $267.16 $260.17 $260.11 $395.07 $434.92

$324.02 $315.54 $273.43 $266.27 $266.20 $404.33 $445.11

$336.08 $327.28 $283.60 $276.18 $276.11 $419.37 $461.68

$345.97 $336.92 $291.95 $284.31 $284.24 $431.72 $475.27

$350.92 $341.73 $296.12 $288.37 $288.30 $437.89 $482.06

$358.34 $348.96 $302.39 $294.47 $294.40 $447.15 $492.26

$365.76 $356.19 $308.65 $300.57 $300.49 $456.41 $502.45

$370.40 $360.70 $312.56 $304.38 $304.30 $462.20 $508.82

$375.34 $365.52 $316.74 $308.45 $308.37 $468.37 $515.62

$377.82 $367.93 $318.82 $310.48 $310.40 $471.46 $519.01

$380.29 $370.34 $320.91 $312.51 $312.43 $474.54 $522.41

$382.76 $372.75 $323.00 $314.54 $314.46 $477.63 $525.81

$385.24 $375.15 $325.09 $316.58 $316.50 $480.72 $529.21

$390.18 $379.97 $329.26 $320.64 $320.56 $486.89 $536.00

$395.13 $384.79 $333.43 $324.71 $324.63 $493.06 $542.80

$402.55 $392.01 $339.70 $330.80 $330.72 $502.32 $552.99

$409.66 $398.94 $345.70 $336.65 $336.56 $511.20 $562.76

$419.56 $408.57 $354.05 $344.78 $344.69 $523.54 $576.35

$431.92 $420.62 $364.48 $354.94 $354.85 $538.97 $593.34

$446.46 $434.77 $376.74 $366.88 $366.79 $557.11 $613.30

$463.77 $451.63 $391.35 $381.11 $381.02 $578.71 $637.09

$483.25 $470.60 $407.79 $397.12 $397.02 $603.02 $663.85

$505.51 $492.28 $426.58 $415.41 $415.31 $630.80 $694.43

$527.46 $513.65 $445.10 $433.45 $433.34 $658.19 $724.58

$552.20 $537.74 $465.97 $453.78 $453.66 $689.05 $758.56

$576.62 $561.53 $486.58 $473.85 $473.73 $719.53 $792.11

$603.52 $587.72 $509.28 $495.95 $495.83 $753.10 $829.06

$630.73 $614.22 $532.24 $518.31 $518.18 $787.05 $866.44

$660.10 $642.82 $557.03 $542.45 $542.31 $823.70 $906.79

$689.47 $671.42 $581.81 $566.58 $566.44 $860.35 $947.14

$721.32 $702.43 $608.69 $592.75 $592.61 $900.09 $990.89

$753.47 $733.75 $635.82 $619.18 $619.02 $940.21 $1,035.06

$787.79 $767.17 $664.78 $647.38 $647.22 $983.04 $1,082.20

$804.80 $783.73 $679.13 $661.35 $661.19 $1,004.26 $1,105.56

$839.11 $817.15 $708.09 $689.56 $689.38 $1,047.08 $1,152.71

$868.80 $846.05 $733.14 $713.95 $713.77 $1,084.12 $1,193.48

$888.27 $865.02 $749.57 $729.95 $729.77 $1,108.43 $1,220.24

$912.70 $888.81 $770.19 $750.02 $749.84 $1,138.90 $1,253.79

$927.23 $902.96 $782.45 $761.97 $761.78 $1,157.04 $1,273.75

$927.23 $902.96 $782.45 $761.97 $761.78 $1,157.04 $1,273.75



RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

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35

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65 and over



18939PA0010013 18939PA0010020 18939PA0030002 18939PA0010014 18939PA0010025 18939PA0010015 18939PA0010048




Gold Gold Gold Silver Silver Platinum Gold

PA Gold PPO 2000 80/50 PA Gold PPO 2000 100/50 PA Gold PPO AP 2000 100/50 PA Silver PPO 3000 80/50 PA Silver PPO 5000 100/50 PA Platinum PPO 100/50 200D PA Gold PPO 100/50 600D



$274.88 $288.10 $280.56 $238.89 $242.07 $333.53 $292.73

$432.88 $453.70 $441.82 $376.21 $381.21 $525.24 $461.00

$432.88 $453.70 $441.82 $376.21 $381.21 $525.24 $461.00

$432.88 $453.70 $441.82 $376.21 $381.21 $525.24 $461.00

$432.88 $453.70 $441.82 $376.21 $381.21 $525.24 $461.00

$434.62 $455.51 $443.59 $377.71 $382.73 $527.34 $462.84

$443.27 $464.59 $452.43 $385.23 $390.35 $537.85 $472.06

$453.66 $475.48 $463.03 $394.26 $399.50 $550.45 $483.12

$470.55 $493.17 $480.26 $408.94 $414.37 $570.94 $501.10

$484.40 $507.69 $494.40 $420.97 $426.57 $587.75 $515.86

$491.32 $514.95 $501.47 $426.99 $432.67 $596.15 $523.23

$501.71 $525.84 $512.07 $436.02 $441.82 $608.76 $534.30

$512.10 $536.73 $522.68 $445.05 $450.97 $621.36 $545.36

$518.60 $543.53 $529.30 $450.69 $456.68 $629.24 $552.27

$525.52 $550.79 $536.37 $456.71 $462.78 $637.64 $559.65

$528.99 $554.42 $539.91 $459.72 $465.83 $641.85 $563.34

$532.45 $558.05 $543.44 $462.73 $468.88 $646.05 $567.03

$535.91 $561.68 $546.98 $465.74 $471.93 $650.25 $570.71

$539.37 $565.31 $550.51 $468.75 $474.98 $654.45 $574.40

$546.30 $572.57 $557.58 $474.77 $481.08 $662.86 $581.78

$553.23 $579.83 $564.65 $480.79 $487.18 $671.26 $589.15

$563.62 $590.72 $575.25 $489.82 $496.33 $683.87 $600.22

$573.57 $601.15 $585.41 $498.47 $505.10 $695.95 $610.82

$587.42 $615.67 $599.55 $510.51 $517.30 $712.75 $625.57

$604.74 $633.82 $617.23 $525.56 $532.54 $733.76 $644.01

$625.09 $655.14 $637.99 $543.24 $550.46 $758.45 $665.68

$649.33 $680.55 $662.73 $564.31 $571.81 $787.86 $691.50

$676.60 $709.13 $690.57 $588.01 $595.82 $820.95 $720.54

$707.77 $741.80 $722.38 $615.10 $623.27 $858.77 $753.73

$738.50 $774.01 $753.75 $641.81 $650.34 $896.06 $786.46

$773.13 $810.31 $789.09 $671.90 $680.83 $938.08 $823.34

$807.33 $846.15 $824.00 $701.62 $710.95 $979.58 $859.76

$844.99 $885.62 $862.44 $734.35 $744.11 $1,025.27 $899.87

$883.08 $925.55 $901.32 $767.46 $777.66 $1,071.50 $940.43

$924.21 $968.65 $943.29 $803.20 $813.87 $1,121.39 $984.23

$965.33 $1,011.75 $985.26 $838.94 $850.09 $1,171.29 $1,028.02

$1,009.92 $1,058.48 $1,030.77 $877.69 $889.35 $1,225.39 $1,075.51

$1,054.94 $1,105.66 $1,076.72 $916.81 $929.00 $1,280.02 $1,123.45

$1,102.99 $1,156.02 $1,125.76 $958.57 $971.31 $1,338.32 $1,174.62

$1,126.80 $1,180.98 $1,150.06 $979.26 $992.28 $1,367.21 $1,199.98

$1,174.85 $1,231.34 $1,199.11 $1,021.02 $1,034.59 $1,425.51 $1,251.15

$1,216.41 $1,274.89 $1,241.52 $1,057.14 $1,071.19 $1,475.93 $1,295.40

$1,243.68 $1,303.48 $1,269.36 $1,080.84 $1,095.20 $1,509.02 $1,324.44

$1,277.88 $1,339.32 $1,304.26 $1,110.56 $1,125.32 $1,550.52 $1,360.86

$1,298.22 $1,360.64 $1,325.03 $1,128.24 $1,143.24 $1,575.20 $1,382.53

$1,298.22 $1,360.64 $1,325.03 $1,128.24 $1,143.24 $1,575.20 $1,382.53



RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

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65 and over



18939PA0010018 18939PA0030001 18939PA0010003 18939PA0010049 18939PA0030004 18939PA0010050 18939PA0010031




Gold Gold Gold Silver Silver Silver Silver

PA Gold PPO 1000 100/50 PA Gold PPO AP 1000 100/50 25 PA Gold PPO 2000 100/50 HSA T PA Silver PPO 3000 100/50


250A PA Silver PPO 3000 100/50 HSA E PA Silver PPO 4000 100/50



$306.73 $298.70 $299.81 $260.16 $253.23 $247.02 $247.50

$483.05 $470.40 $472.14 $409.71 $398.79 $389.02 $389.76

$483.05 $470.40 $472.14 $409.71 $398.79 $389.02 $389.76

$483.05 $470.40 $472.14 $409.71 $398.79 $389.02 $389.76

$483.05 $470.40 $472.14 $409.71 $398.79 $389.02 $389.76

$484.98 $472.28 $474.03 $411.34 $400.38 $390.57 $391.32

$494.64 $481.69 $483.47 $419.54 $408.36 $398.35 $399.11

$506.23 $492.98 $494.81 $429.37 $417.93 $407.69 $408.47

$525.07 $511.33 $513.22 $445.35 $433.48 $422.86 $423.67

$540.53 $526.38 $528.33 $458.46 $446.24 $435.31 $436.14

$548.26 $533.91 $535.88 $465.02 $452.62 $441.53 $442.38

$559.85 $545.19 $547.21 $474.85 $462.20 $450.87 $451.73

$571.44 $556.48 $558.55 $484.68 $471.77 $460.21 $461.09

$578.69 $563.54 $565.63 $490.83 $477.75 $466.04 $466.93

$586.42 $571.07 $573.18 $497.38 $484.13 $472.26 $473.17

$590.28 $574.83 $576.96 $500.66 $487.32 $475.38 $476.29

$594.15 $578.59 $580.74 $503.94 $490.51 $478.49 $479.41

$598.01 $582.36 $584.51 $507.21 $493.70 $481.60 $482.52

$601.87 $586.12 $588.29 $510.49 $496.89 $484.71 $485.64

$609.60 $593.65 $595.85 $517.05 $503.27 $490.94 $491.88

$617.33 $601.17 $603.40 $523.60 $509.65 $497.16 $498.11

$628.93 $612.46 $614.73 $533.44 $519.22 $506.50 $507.47

$640.04 $623.28 $625.59 $542.86 $528.39 $515.45 $516.43

$655.49 $638.33 $640.70 $555.97 $541.16 $527.89 $528.91

$674.81 $657.15 $659.58 $572.36 $557.11 $543.45 $544.50

$697.52 $679.26 $681.78 $591.61 $575.85 $561.74 $562.81

$724.57 $705.60 $708.22 $614.56 $598.18 $583.52 $584.64

$755.00 $735.24 $737.96 $640.37 $623.31 $608.03 $609.20

$789.78 $769.11 $771.95 $669.87 $652.02 $636.04 $637.26

$824.08 $802.50 $805.48 $698.96 $680.33 $663.66 $664.93

$862.72 $840.14 $843.25 $731.73 $712.24 $694.78 $696.11

$900.88 $877.30 $880.55 $764.10 $743.74 $725.51 $726.90

$942.90 $918.22 $921.62 $799.74 $778.43 $759.36 $760.81

$985.41 $959.62 $963.17 $835.80 $813.53 $793.59 $795.11

$1,031.30 $1,004.31 $1,008.03 $874.72 $851.41 $830.55 $832.14

$1,077.19 $1,048.99 $1,052.88 $913.64 $889.30 $867.50 $869.17

$1,126.95 $1,097.45 $1,101.51 $955.84 $930.37 $907.57 $909.31

$1,177.18 $1,146.37 $1,150.61 $998.45 $971.85 $948.03 $949.85

$1,230.80 $1,198.58 $1,203.02 $1,043.93 $1,016.11 $991.21 $993.11

$1,257.37 $1,224.45 $1,228.99 $1,066.46 $1,038.05 $1,012.61 $1,014.55

$1,310.99 $1,276.67 $1,281.40 $1,111.94 $1,082.31 $1,055.79 $1,057.81

$1,357.36 $1,321.83 $1,326.72 $1,151.27 $1,120.60 $1,093.13 $1,095.23

$1,387.79 $1,351.46 $1,356.47 $1,177.08 $1,145.72 $1,117.64 $1,119.78

$1,425.95 $1,388.62 $1,393.77 $1,209.45 $1,177.22 $1,148.37 $1,150.57

$1,448.65 $1,410.73 $1,415.96 $1,228.71 $1,195.97 $1,166.66 $1,168.89

$1,448.65 $1,410.73 $1,415.96 $1,228.71 $1,195.97 $1,166.66 $1,168.89



RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

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25

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65 and over



18939PA0030005 18939PA0010046 18939PA0030003 18939PA0010047 18939PA0020001 18939PA0010012 18939PA0010013




Silver Bronze Bronze Bronze Silver Gold Gold

PA Silver PPO AP 4000 100/50 30 PA Bronze PPO 6550 100/50 HSA E


HSA E PA Bronze PPO 7000 100/50 Int PA Silver Indemnity 2000 80% PA Gold PPO 1000 80/50 PA Gold PPO 2000 80/50



$241.02 $208.85 $203.39 $203.33 $308.84 $218.91 $223.11

$379.56 $328.90 $320.29 $320.21 $486.36 $344.74 $351.36

$379.56 $328.90 $320.29 $320.21 $486.36 $344.74 $351.36

$379.56 $328.90 $320.29 $320.21 $486.36 $344.74 $351.36

$379.56 $328.90 $320.29 $320.21 $486.36 $344.74 $351.36

$381.08 $330.22 $321.57 $321.49 $488.31 $346.12 $352.76

$388.67 $336.79 $327.98 $327.90 $498.03 $353.01 $359.79

$397.78 $344.69 $335.67 $335.58 $509.70 $361.28 $368.22

$412.58 $357.52 $348.16 $348.07 $528.67 $374.73 $381.93

$424.73 $368.04 $358.41 $358.32 $544.24 $385.76 $393.17

$430.80 $373.30 $363.53 $363.44 $552.02 $391.28 $398.79

$439.91 $381.20 $371.22 $371.13 $563.69 $399.55 $407.23

$449.02 $389.09 $378.91 $378.81 $575.36 $407.82 $415.66

$454.71 $394.02 $383.71 $383.61 $582.66 $412.99 $420.93

$460.78 $399.29 $388.83 $388.74 $590.44 $418.51 $426.55

$463.82 $401.92 $391.40 $391.30 $594.33 $421.27 $429.36

$466.86 $404.55 $393.96 $393.86 $598.22 $424.03 $432.17

$469.89 $407.18 $396.52 $396.42 $602.11 $426.78 $434.98

$472.93 $409.81 $399.08 $398.98 $606.00 $429.54 $437.79

$479.00 $415.07 $404.21 $404.11 $613.79 $435.06 $443.42

$485.07 $420.34 $409.33 $409.23 $621.57 $440.57 $449.04

$494.18 $428.23 $417.02 $416.92 $633.24 $448.85 $457.47

$502.91 $435.79 $424.39 $424.28 $644.43 $456.78 $465.55

$515.06 $446.32 $434.64 $434.53 $659.99 $467.81 $476.79

$530.24 $459.48 $447.45 $447.34 $679.44 $481.60 $490.85

$548.08 $474.93 $462.50 $462.39 $702.30 $497.80 $507.36

$569.34 $493.35 $480.44 $480.32 $729.54 $517.11 $527.04

$593.25 $514.07 $500.62 $500.49 $760.18 $538.82 $549.17

$620.58 $537.75 $523.68 $523.55 $795.20 $563.64 $574.47

$647.53 $561.11 $546.42 $546.28 $829.73 $588.12 $599.42

$677.89 $587.42 $572.04 $571.90 $868.64 $615.70 $627.53

$707.88 $613.40 $597.34 $597.20 $907.06 $642.93 $655.29

$740.90 $642.02 $625.21 $625.05 $949.37 $672.93 $685.85

$774.30 $670.96 $653.40 $653.23 $992.17 $703.26 $716.77

$810.36 $702.20 $683.82 $683.65 $1,038.38 $736.01 $750.15

$846.41 $733.45 $714.25 $714.07 $1,084.58 $768.76 $783.53

$885.51 $767.33 $747.24 $747.06 $1,134.68 $804.27 $819.72

$924.98 $801.53 $780.55 $780.36 $1,185.26 $840.12 $856.26

$967.11 $838.04 $816.10 $815.90 $1,239.24 $878.39 $895.26

$987.99 $856.13 $833.72 $833.51 $1,265.99 $897.35 $914.59

$1,030.12 $892.64 $869.27 $869.06 $1,319.98 $935.62 $953.59

$1,066.56 $924.21 $900.02 $899.80 $1,366.67 $968.71 $987.32

$1,090.47 $944.93 $920.20 $919.97 $1,397.31 $990.43 $1,009.46

$1,120.45 $970.92 $945.50 $945.27 $1,435.73 $1,017.66 $1,037.21

$1,138.29 $986.38 $960.56 $960.32 $1,458.59 $1,033.87 $1,053.73

$1,138.29 $986.38 $960.56 $960.32 $1,458.59 $1,033.87 $1,053.73

March 31, 2017January 1, 2017

Page Number: 10 12/24/2014

RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

22

23

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25

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65 and over



18939PA0010020 18939PA0030002 18939PA0010014 18939PA0010025 18939PA0010015 18939PA0010048 18939PA0010018




Gold Gold Silver Silver Platinum Gold Gold

PA Gold PPO 2000 100/50 PA Gold PPO AP 2000 100/50 PA Silver PPO 3000 80/50 PA Silver PPO 5000 100/50 PA Platinum PPO 100/50 200D PA Gold PPO 100/50 600D PA Gold PPO 1000 100/50



$233.84 $227.72 $193.90 $196.48 $270.72 $237.60 $248.97

$368.25 $358.61 $305.35 $309.41 $426.32 $374.18 $392.07

$368.25 $358.61 $305.35 $309.41 $426.32 $374.18 $392.07

$368.25 $358.61 $305.35 $309.41 $426.32 $374.18 $392.07

$368.25 $358.61 $305.35 $309.41 $426.32 $374.18 $392.07

$369.73 $360.05 $306.58 $310.65 $428.03 $375.67 $393.64

$377.09 $367.22 $312.68 $316.84 $436.56 $383.16 $401.48

$385.93 $375.83 $320.01 $324.27 $446.79 $392.14 $410.89

$400.29 $389.81 $331.92 $336.33 $463.41 $406.73 $426.18

$412.08 $401.29 $341.69 $346.23 $477.06 $418.70 $438.73

$417.97 $407.03 $346.58 $351.18 $483.88 $424.69 $445.00

$426.81 $415.63 $353.91 $358.61 $494.11 $433.67 $454.41

$435.64 $424.24 $361.23 $366.04 $504.34 $442.65 $463.82

$441.17 $429.62 $365.81 $370.68 $510.74 $448.26 $469.70

$447.06 $435.36 $370.70 $375.63 $517.56 $454.25 $475.98

$450.01 $438.23 $373.14 $378.10 $520.97 $457.24 $479.11

$452.95 $441.09 $375.59 $380.58 $524.38 $460.24 $482.25

$455.90 $443.96 $378.03 $383.05 $527.79 $463.23 $485.39

$458.84 $446.83 $380.47 $385.53 $531.20 $466.22 $488.52

$464.74 $452.57 $385.36 $390.48 $538.02 $472.21 $494.80

$470.63 $458.31 $390.24 $395.43 $544.84 $478.20 $501.07

$479.47 $466.92 $397.57 $402.86 $555.07 $487.18 $510.48

$487.94 $475.16 $404.59 $409.97 $564.88 $495.78 $519.50

$499.72 $486.64 $414.37 $419.87 $578.52 $507.76 $532.04

$514.45 $500.98 $426.58 $432.25 $595.57 $522.73 $547.73

$531.76 $517.84 $440.93 $446.79 $615.61 $540.31 $566.15

$552.38 $537.92 $458.03 $464.12 $639.49 $561.27 $588.11

$575.58 $560.51 $477.27 $483.61 $666.34 $584.84 $612.81

$602.09 $586.33 $499.25 $505.89 $697.04 $611.78 $641.04

$628.24 $611.80 $520.93 $527.86 $727.31 $638.35 $668.88

$657.70 $640.48 $545.36 $552.61 $761.41 $668.28 $700.24

$686.79 $668.81 $569.49 $577.06 $795.09 $697.84 $731.22

$718.83 $700.01 $596.05 $603.97 $832.18 $730.39 $765.33

$751.24 $731.57 $622.92 $631.20 $869.70 $763.32 $799.83

$786.22 $765.64 $651.93 $660.60 $910.20 $798.87 $837.08

$821.21 $799.71 $680.94 $689.99 $950.70 $834.42 $874.32

$859.14 $836.65 $712.39 $721.86 $994.61 $872.96 $914.71

$897.43 $873.94 $744.15 $754.04 $1,038.95 $911.87 $955.48

$938.31 $913.75 $778.04 $788.38 $1,086.27 $953.40 $999.00

$958.56 $933.47 $794.84 $805.40 $1,109.72 $973.98 $1,020.57

$999.44 $973.28 $828.73 $839.75 $1,157.04 $1,015.52 $1,064.09

$1,034.79 $1,007.70 $858.05 $869.45 $1,197.97 $1,051.44 $1,101.73

$1,057.99 $1,030.30 $877.28 $888.94 $1,224.83 $1,075.01 $1,126.43

$1,087.08 $1,058.63 $901.41 $913.39 $1,258.51 $1,104.57 $1,157.40

$1,104.39 $1,075.48 $915.76 $927.93 $1,278.54 $1,122.16 $1,175.83

$1,104.39 $1,075.48 $915.76 $927.93 $1,278.54 $1,122.16 $1,175.83


Page Number: 11 12/24/2014

RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

22

23

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25

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64

65 and over



18939PA0030001 18939PA0010003 18939PA0010049 18939PA0030004 18939PA0010050 18939PA0010031 18939PA0030005




Gold Gold Silver Silver Silver Silver Silver

PA Gold PPO AP 1000 100/50 25 PA Gold PPO 2000 100/50 HSA T PA Silver PPO 3000 100/50


250A PA Silver PPO 3000 100/50 HSA E PA Silver PPO 4000 100/50 PA Silver PPO AP 4000 100/50 30



$242.45 $243.35 $211.17 $205.54 $200.50 $200.89 $195.63

$381.81 $383.22 $332.55 $323.68 $315.75 $316.36 $308.08

$381.81 $383.22 $332.55 $323.68 $315.75 $316.36 $308.08

$381.81 $383.22 $332.55 $323.68 $315.75 $316.36 $308.08

$381.81 $383.22 $332.55 $323.68 $315.75 $316.36 $308.08

$383.34 $384.76 $333.88 $324.98 $317.01 $317.62 $309.31

$390.97 $392.42 $340.53 $331.45 $323.33 $323.95 $315.47

$400.14 $401.62 $348.51 $339.22 $330.91 $331.54 $322.86

$415.03 $416.56 $361.48 $351.84 $343.22 $343.88 $334.88

$427.25 $428.83 $372.12 $362.20 $353.33 $354.00 $344.74

$433.35 $434.96 $377.44 $367.38 $358.38 $359.06 $349.67

$442.52 $444.16 $385.42 $375.15 $365.96 $366.66 $357.06

$451.68 $453.35 $393.40 $382.92 $373.53 $374.25 $364.45

$457.41 $459.10 $398.39 $387.77 $378.27 $379.00 $369.07

$463.52 $465.23 $403.71 $392.95 $383.32 $384.06 $374.00

$466.57 $468.30 $406.37 $395.54 $385.85 $386.59 $376.47

$469.63 $471.37 $409.03 $398.13 $388.37 $389.12 $378.93

$472.68 $474.43 $411.69 $400.72 $390.90 $391.65 $381.40

$475.74 $477.50 $414.35 $403.31 $393.43 $394.18 $383.86

$481.84 $483.63 $419.67 $408.49 $398.48 $399.24 $388.79

$487.95 $489.76 $424.99 $413.67 $403.53 $404.30 $393.72

$497.12 $498.96 $432.97 $421.44 $411.11 $411.90 $401.11

$505.90 $507.77 $440.62 $428.88 $418.37 $419.17 $408.20

$518.12 $520.04 $451.26 $439.24 $428.48 $429.30 $418.06

$533.39 $535.36 $464.57 $452.19 $441.11 $441.95 $430.38

$551.33 $553.38 $480.20 $467.40 $455.95 $456.82 $444.86

$572.72 $574.84 $498.82 $485.53 $473.63 $474.53 $462.11

$596.77 $598.98 $519.77 $505.92 $493.52 $494.47 $481.52

$624.26 $626.57 $543.71 $529.22 $516.25 $517.24 $503.70

$651.37 $653.78 $567.32 $552.21 $538.67 $539.70 $525.58

$681.91 $684.44 $593.93 $578.10 $563.93 $565.01 $550.22

$712.08 $714.71 $620.20 $603.67 $588.88 $590.01 $574.56

$745.29 $748.05 $649.13 $631.83 $616.35 $617.53 $601.36

$778.89 $781.78 $678.39 $660.32 $644.13 $645.37 $628.47

$815.16 $818.18 $709.98 $691.07 $674.13 $675.42 $657.74

$851.44 $854.59 $741.58 $721.82 $704.13 $705.48 $687.01

$890.76 $894.06 $775.83 $755.16 $736.65 $738.06 $718.74

$930.47 $933.92 $810.41 $788.82 $769.49 $770.96 $750.78

$972.85 $976.46 $847.32 $824.75 $804.54 $806.08 $784.98

$993.85 $997.53 $865.61 $842.55 $821.90 $823.48 $801.92

$1,036.23 $1,040.07 $902.53 $878.48 $856.95 $858.59 $836.12

$1,072.89 $1,076.86 $934.45 $909.55 $887.26 $888.96 $865.69

$1,096.94 $1,101.00 $955.40 $929.95 $907.16 $908.89 $885.10

$1,127.10 $1,131.28 $981.67 $955.52 $932.10 $933.88 $909.44

$1,145.05 $1,149.29 $997.30 $970.73 $946.94 $948.75 $923.92

$1,145.05 $1,149.29 $997.30 $970.73 $946.94 $948.75 $923.92


Page Number: 12 12/24/2014

RATE PAGES





Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No)

Age Band

0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65 and over



18939PA0010046 18939PA0030003 18939PA0010047 18939PA0020001 18939PA0010012 18939PA0010013 18939PA0010020




Bronze Bronze Bronze Silver Gold Gold Gold

PA Bronze PPO 6550 100/50 HSA E


HSA E PA Bronze PPO 7000 100/50 Int PA Silver Indemnity 2000 80% PA Gold PPO 1000 80/50 PA Gold PPO 2000 80/50 PA Gold PPO 2000 100/50



$169.52 $165.08 $165.04 $250.67 $210.75 $214.79 $225.12

$266.96 $259.97 $259.91 $394.76 $331.88 $338.26 $354.52

$266.96 $259.97 $259.91 $394.76 $331.88 $338.26 $354.52

$266.96 $259.97 $259.91 $394.76 $331.88 $338.26 $354.52

$266.96 $259.97 $259.91 $394.76 $331.88 $338.26 $354.52

$268.03 $261.01 $260.95 $396.34 $333.21 $339.61 $355.94

$273.37 $266.21 $266.14 $404.24 $339.85 $346.38 $363.03

$279.77 $272.45 $272.38 $413.71 $347.81 $354.49 $371.54

$290.18 $282.59 $282.52 $429.11 $360.76 $367.69 $385.37

$298.73 $290.91 $290.84 $441.74 $371.38 $378.51 $396.71

$303.00 $295.07 $294.99 $448.06 $376.69 $383.92 $402.38

$309.41 $301.31 $301.23 $457.53 $384.65 $392.04 $410.89

$315.81 $307.55 $307.47 $467.00 $392.62 $400.16 $419.40

$319.82 $311.45 $311.37 $472.93 $397.59 $405.23 $424.72

$324.09 $315.60 $315.53 $479.24 $402.91 $410.64 $430.39

$326.22 $317.68 $317.61 $482.40 $405.56 $413.35 $433.23

$328.36 $319.76 $319.69 $485.56 $408.22 $416.06 $436.06

$330.50 $321.84 $321.76 $488.72 $410.87 $418.76 $438.90

$332.63 $323.92 $323.84 $491.87 $413.53 $421.47 $441.73

$336.90 $328.08 $328.00 $498.19 $418.84 $426.88 $447.41

$341.17 $332.24 $332.16 $504.51 $424.15 $432.29 $453.08

$347.58 $338.48 $338.40 $513.98 $432.11 $440.41 $461.59

$353.72 $344.46 $344.38 $523.06 $439.74 $448.19 $469.74

$362.26 $352.78 $352.69 $535.69 $450.36 $459.02 $481.09

$372.94 $363.18 $363.09 $551.48 $463.64 $472.55 $495.27

$385.49 $375.40 $375.31 $570.04 $479.24 $488.44 $511.93

$400.44 $389.96 $389.86 $592.14 $497.82 $507.39 $531.78

$417.26 $406.33 $406.23 $617.01