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PDF Pipeline for SERFF Tracking Number HPHP-127306444 Generated 11/03/2011 08:26 AM

SERFF Tracking Number: HPHP-127306444 State: New York

Filing Company: HIP Insurance Company of New York State Tracking Number: 2011070114

Company Tracking Number: 2011 0715 HIPIC LG 2012 RATE FILING

TOI: H21 Health - Other Sub-TOI: H21.000 Health - Other

Product Name: 2012 HIPIC LG Prior Approval Rate Filing

Project Name/Number: /

Filing at a Glance

Company: HIP Insurance Company of New YorkProduct Name: 2012 HIPIC LG Prior ApprovalRate Filing

SERFF Tr Num: HPHP-127306444 State: New York

TOI: H21 Health - Other SERFF Status: Closed-APPRApproved

State Tr Num: 2011070114

Sub-TOI: H21.000 Health - Other Co Tr Num: 2011 0715 HIPIC LG2012 RATE FILING

State Status:

Filing Type: Rate Adjustment pursuant toSection 3231(e)(1)

Reviewer(s):

Authors: ,Disposition Date: 10/17/2011

Date Submitted: 07/18/2011 Disposition Status: APPR ApprovedImplementation Date Requested: 01/01/2012 Implementation Date: 01/01/2012State Filing Description:

General Information

Project Name: Status of Filing in Domicile: Project Number: Date Approved in Domicile: Requested Filing Mode: Review & Approval Domicile Status Comments: Explanation for Combination/Other: Market Type: GroupSubmission Type: New Submission Group Market Size: LargeGroup Market Type: Overall Rate Impact: Filing Status Changed: 10/17/2011State Status Changed: Deemer Date: Created By: Submitted By: Corresponding Filing Tracking Number: PPACA: Not PPACA-RelatedPPACA Notes: nullFiling Description:This is the 2012 HIPIC Large Group community rated rate filing.

Company and Contact








Filing Contact Information

55 Water Street New York, NY 10041Filing Company InformationHIP Insurance Company of New York CoCode: 60094 State of Domicile: New York55 Water Street Group Code: -99 Company Type: HEALTHNew York, NY 10041 Group Name: State ID Number: (646) 447-5000 ext. [Phone] FEIN Number: 13-3802010---------

Filing Fees

Fee Required? NoRetaliatory? NoFee Explanation:Per Company: No

State Specific

1. Is a parallel product being submitted for another entity of the same parent organization? Yes/No (If Yes, entername of other entity, submission date, and SERFF Tracking Number of the parallel file.): No2. Type of insurer? Article 43, HMO, Commercial, Municipal Coop, or Fraternal Benefit Society: Article 433. Is this filing for Group Remittance, Statutory Individual HMO, Statutory Individual POS, Blanket, or Healthy NewYork? Yes/No (If Yes, enter which one.): Group Remittance4. Type of filing? Enter Form and Rate, Form only, Rate only (Form only should be used ONLY when the filing onlycontains an application, advertisement, administrative form, or is an out-of-state filing. Form submissions with noproposed rate impact are considered form and rate filings and require an actuarial memorandum.): Rate only5. Is this a Rate only filing? Yes/No [If Yes, enter one: Commission/Fee Schedule, "File and Use" Rate Adjustment,Prior Approval Rate Adjustment, DBL Loss Ratio Monitoring, Loss Ratio Experience Monitoring/Reporting, MedicareSupplement Annual Filing (other than rate adjustment), Medicare Supplement Refund Calculation Filing, Timothy's LawSubsidy Filing, Sole Proprietor Rating, 4308(h) Loss Ratio Report, 3231(e) Loss Ratio Report, Experience RatingFormula, or Other with brief explanation).]: Yes. Prior Approval Rate Adjustment6. Does this submission contain a form subject to Regulation 123? Yes/No (If Yes, provide a full explanation in theFiling Description field.: No7. Did this insurer prefile group coverage for this group under Section 52.32 prior to this filing? Yes/No (If Yes, enter








the state tracking number assigned and the effective date of coverage.): No8. Does this submission contain any form which is subject to review by the Life Bureau, the Property Bureau or both?Yes/No (If Yes, identify the forms, the Bureau, the date submitted, and the SERFF file number.): No9. Does this filing contain forms that replace any other previously approved forms? Yes/No (If Yes, identify the formnumbers, the file number, and the date of approval of the forms being replaced in the Filing Description field.): No








Rate InformationRate data applies to filing.

Filing Method: Prior ApprovalRate Change Type: IncreaseOverall Percentage of Last Rate Revision: 9.700%Effective Date of Last Rate Revision: 10/01/2011Filing Method of Last Filing: Prior Approval

Company Rate InformationCompany Name: Company

RateChange:

Overall %IndicatedChange:

Overall % RateImpact:

WrittenPremiumChange forthisProgram:

# of PolicyHoldersAffected forthis Program:

WrittenPremium forthis Program:

Maximum %Change(whererequired):

Minimum %Change(whererequired):

HIP InsuranceCompany of New York

Increase 34.000% 34.000% $1,217,269 64 $3,577,797 34.000% 34.000%

Product Type: HMO PPO EPO POS HSA HDHP FFS OtherCovered Lives: 37 507Policy Holders: 5 59








Rate Review DetailsCOMPANY: Company Name: HIP Insurance Company of New YorkHHS Issuer Id: 20984Product Names: HIP Prime EPO, HIP Prime PPO, HIP Select EPO, HIP Select PPO, CompreHealth EPOTrend Factors: FORMS: New Policy Forms: Affected Forms: Other Affected Forms: 151-23-EPOPOL (05/02), 151-23-EPOPOL (06/03), 151-23-PPOPOL (05/02), 151-23-PPOPOL (06/03), 151-23-

EMEPOPOL (05/08)REQUESTED RATE CHANGEINFORMATION: Change Period: AnnualMember Months: 7,574Benefit Change: NonePercent Change Requested: Min: 34.0 Max: 34.0 Avg: 34.0PRIOR RATE: Total Earned Premium: 3,577,797.00Total Incurred Claims: 3,530,594.00Annual $: Min: 165.51 Max: 1,004.28 Avg: 472.38REQUESTED RATE: Projected Earned Premium: 7,203,801.00Projected Incurred Claims: 12,427,344.00








Annual $: Min: 195.02 Max: 1,183.29 Avg: 556.58








Rate/Rule Schedule

ScheduleItemStatus:

Document Name: Affected FormNumbers:(Separated withcommas)

RateAction:*

Rate Action Information: Attachments

2012 HIPIC LG RateManual

151-23-EPOPOL(05/02), 151-23-EPOPOL (06/03),151-23-PPOPOL(05/02), 151-23-PPOPOL (06/03),151-23-EMEPOPOL(05/08)

New 2012 HIPIC LG1Q Rate Manual071411.pdf2012 HIPIC LG2Q Rate Manual071411.pdf2012 HIPIC LG3Q Rate Manual071411.pdf2012 HIPIC LG4Q Rate Manual071411.pdf2012 HIPIC LG1Q Rate ManualRate Change071411.pdf2012 HIPIC LG2Q Rate ManualRate Change071411.pdf2012 HIPIC LG3Q Rate ManualRate Change071411.pdf2012 HIPIC LG4Q Rate ManualRate Change071411.pdf

HIP INSURANCE COMPANY OF NEW YORKSample Rate Calculation

Prime /Comprehealth Rate Formula

Large groups= (Base Rate+ Optional Base Benefit Variables (excluding Mental Health)+ Inpatient Mental Health Care with unlimited BIO and CSED coverage+ Outpatient Mental Health Care with unlimited BIO and CSED coverage+ Optional Benefit Rider Coverage)x Optional Dependent Care Coveragex Network Area Factor

Example: Large Group Prime EPO Individual Employee Rate Example= 946.36 1st QUARTER (Base Rate+ (10.08) $10 Specialist visit copay Optional Base Benefit Variables (exlcuding Mental Health)+ 15.25 30 Days Inpatient Mental Health Care with unlimited BIO and CSED coverage+ 15.00 $10 copay, 20 visits Outpatient Mental Health Care with unlimited BIO and CSED coverage+ - Not covered Optional Benefit Rider Coverage)x 1.020 Standard Coverage Dependents to Age 26 end-of-monthx 1.00 Standard Coverage Network Area Factor

985.86

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1

HIP INSURANCE COMPANY OF NEW YORK

EMBLEMHEALTH COMPREHEALTH EPO - BASE BENEFITS

ALL TIERS TWO TIER THREE TIER FOUR TIERTwo Employee Employee

Plan Individual Family Persons Family & Child(ren) & Spouse Family

Large Group* 462.84 1,194.13 925.68 1,346.86 879.40 971.96 1,388.52

* Base rates exclude premium component for mandatory mental health coverage

1st QUARTER 2012 LARGE GROUP RATE MANUAL

JANUARY 1, 2012 - MARCH 31, 2012 MONTHLY PREMIUMS

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EMBLEMHEALTH COMPREHEALTH EPO - BASE BENEFIT VARIABLES


Rider Individual Family Persons Family & Child(ren) & Spouse Family2%

Copay PCP Office Visit Copay [inc. Urgent Care facility visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (3.36) (8.67) (6.72) (9.78) (6.38) (7.06) (10.08)$10 (7.07) (18.24) (14.14) (20.57) (13.43) (14.85) (21.21)$15 (10.92) (28.17) (21.84) (31.78) (20.75) (22.93) (32.76)$20 (15.78) (40.71) (31.56) (45.92) (29.98) (33.14) (47.34)$25 (19.50) (50.31) (39.00) (56.75) (37.05) (40.95) (58.50)$30 (23.24) (59.96) (46.48) (67.63) (44.16) (48.80) (69.72)$35 (26.93) (69.48) (53.86) (78.37) (51.17) (56.55) (80.79)$40 (30.68) (79.15) (61.36) (89.28) (58.29) (64.43) (92.04)

Copay PCP Office Visit Copay with $0 Child Copay [inc. Urgent Care facility visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (1.91) (4.93) (3.82) (5.56) (3.63) (4.01) (5.73)$10 (4.05) (10.45) (8.10) (11.79) (7.70) (8.51) (12.15)$15 (6.24) (16.10) (12.48) (18.16) (11.86) (13.10) (18.72)$20 (9.03) (23.30) (18.06) (26.28) (17.16) (18.96) (27.09)$25 (11.18) (28.84) (22.36) (32.53) (21.24) (23.48) (33.54)$30 (13.30) (34.31) (26.60) (38.70) (25.27) (27.93) (39.90)$35 (15.45) (39.86) (30.90) (44.96) (29.36) (32.45) (46.35)$40 (17.59) (45.38) (35.18) (51.19) (33.42) (36.94) (52.77)

Copay Specialist Office Visit Copay [incl. Chiropractic visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (2.48) (6.40) (4.96) (7.22) (4.71) (5.21) (7.44)$10 (5.18) (13.36) (10.36) (15.07) (9.84) (10.88) (15.54)$15 (7.94) (20.49) (15.88) (23.11) (15.09) (16.67) (23.82)$20 (10.83) (27.94) (21.66) (31.52) (20.58) (22.74) (32.49)$25 (13.86) (35.76) (27.72) (40.33) (26.33) (29.11) (41.58)$30 (16.96) (43.76) (33.92) (49.35) (32.22) (35.62) (50.88)$35 (19.66) (50.72) (39.32) (57.21) (37.35) (41.29) (58.98)$40 (22.29) (57.51) (44.58) (64.86) (42.35) (46.81) (66.87)$45 (24.95) (64.37) (49.90) (72.60) (47.41) (52.40) (74.85)$50 (27.58) (71.16) (55.16) (80.26) (52.40) (57.92) (82.74)










Copay Specialist Office Visit Copay with $0 Child copay [incl. Chiropractic visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (1.42) (3.66) (2.84) (4.13) (2.70) (2.98) (4.26)$10 (2.94) (7.59) (5.88) (8.56) (5.59) (6.17) (8.82)$15 (4.54) (11.71) (9.08) (13.21) (8.63) (9.53) (13.62)$20 (6.20) (16.00) (12.40) (18.04) (11.78) (13.02) (18.60)$25 (7.95) (20.51) (15.90) (23.13) (15.11) (16.70) (23.85)$30 (9.72) (25.08) (19.44) (28.29) (18.47) (20.41) (29.16)$35 (11.26) (29.05) (22.52) (32.77) (21.39) (23.65) (33.78)$40 (12.78) (32.97) (25.56) (37.19) (24.28) (26.84) (38.34)$45 (14.29) (36.87) (28.58) (41.58) (27.15) (30.01) (42.87)$50 (15.83) (40.84) (31.66) (46.07) (30.08) (33.24) (47.49)

* $0 child copay also applies to home health, x-rays, diag. & lab tests, outp. mh, outp. s/a rehab, outp. therapies

Copay/Admit Inpatient Facility Copay [std: $0]

$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$100 (1.22) (3.15) (2.44) (3.55) (2.32) (2.56) (3.66)$150 (2.04) (5.26) (4.08) (5.94) (3.88) (4.28) (6.12)$200 (2.83) (7.30) (5.66) (8.24) (5.38) (5.94) (8.49)$250 (3.98) (10.27) (7.96) (11.58) (7.56) (8.36) (11.94)$500 (8.84) (22.81) (17.68) (25.72) (16.80) (18.56) (26.52)$750 (14.09) (36.35) (28.18) (41.00) (26.77) (29.59) (42.27)

$1,000 (19.69) (50.80) (39.38) (57.30) (37.41) (41.35) (59.07)

Copay/Day$50 w/3 Day Max (1.74) (4.49) (3.48) (5.06) (3.31) (3.65) (5.22)$50 w/5 Day Max (2.24) (5.78) (4.48) (6.52) (4.26) (4.70) (6.72)$100 w/3 Day Max (3.53) (9.11) (7.06) (10.27) (6.71) (7.41) (10.59)$100 w/5 Day Max (5.40) (13.93) (10.80) (15.71) (10.26) (11.34) (16.20)$250 w/3 Day Max (9.52) (24.56) (19.04) (27.70) (18.09) (19.99) (28.56)

Copay Ambulatory Surgery Facility Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$50 (0.59) (1.52) (1.18) (1.72) (1.12) (1.24) (1.77)$75 (0.94) (2.43) (1.88) (2.74) (1.79) (1.97) (2.82)$100 (1.35) (3.48) (2.70) (3.93) (2.57) (2.84) (4.05)$125 (1.79) (4.62) (3.58) (5.21) (3.40) (3.76) (5.37)$150 (2.23) (5.75) (4.46) (6.49) (4.24) (4.68) (6.69)$250 (4.03) (10.40) (8.06) (11.73) (7.66) (8.46) (12.09)$500 (8.49) (21.90) (16.98) (24.71) (16.13) (17.83) (25.47)

$1,000 (17.45) (45.02) (34.90) (50.78) (33.16) (36.65) (52.35)








Copay Hospital Emergency Room Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$15 (0.28) (0.72) (0.56) (0.81) (0.53) (0.59) (0.84)$25 (0.52) (1.34) (1.04) (1.51) (0.99) (1.09) (1.56)$35 (0.81) (2.09) (1.62) (2.36) (1.54) (1.70) (2.43)$50 (1.28) (3.30) (2.56) (3.72) (2.43) (2.69) (3.84)$60 (1.56) (4.02) (3.12) (4.54) (2.96) (3.28) (4.68)$75 (1.98) (5.11) (3.96) (5.76) (3.76) (4.16) (5.94)$100 (2.58) (6.66) (5.16) (7.51) (4.90) (5.42) (7.74)$125 (3.18) (8.20) (6.36) (9.25) (6.04) (6.68) (9.54)$150 (3.79) (9.78) (7.58) (11.03) (7.20) (7.96) (11.37)

# Days Skilled Nursing Facility Care Limit [std: 30 days]30 0.00 0.00 0.00 0.00 0.00 0.00 0.0045 0.58 1.50 1.16 1.69 1.10 1.22 1.7460 1.11 2.86 2.22 3.23 2.11 2.33 3.3390 1.66 4.28 3.32 4.83 3.15 3.49 4.98120 1.95 5.03 3.90 5.67 3.71 4.10 5.85

Unlimited 2.50 6.45 5.00 7.28 4.75 5.25 7.50

# Visits Home Health Care Limit [std: 40 visits, $0 copay]40/$0 copay 0.00 0.00 0.00 0.00 0.00 0.00 0.0040/$5 copay (0.14) (0.36) (0.28) (0.41) (0.27) (0.29) (0.42)40/$10 copay (0.28) (0.72) (0.56) (0.81) (0.53) (0.59) (0.84)40/$15 copay (0.45) (1.16) (0.90) (1.31) (0.86) (0.95) (1.35)40/$20 copay (0.64) (1.65) (1.28) (1.86) (1.22) (1.34) (1.92)40/$25 copay (0.82) (2.12) (1.64) (2.39) (1.56) (1.72) (2.46)

60 0.28 0.72 0.56 0.81 0.53 0.59 0.84100 0.72 1.86 1.44 2.10 1.37 1.51 2.16200 1.96 5.06 3.92 5.70 3.72 4.12 5.88

# Days Inpatient Therapies Limit [std: 30 days]0 (1.18) (3.04) (2.36) (3.43) (2.24) (2.48) (3.54)30 0.00 0.00 0.00 0.00 0.00 0.00 0.0060 0.77 1.99 1.54 2.24 1.46 1.62 2.3190 1.59 4.10 3.18 4.63 3.02 3.34 4.77








Outpatient Therapies Limit [std: 30 visits]# Visits [Copay same as Specialist Physician Office Visit]

30 0.00 0.00 0.00 0.00 0.00 0.00 0.0060 0.68 1.75 1.36 1.98 1.29 1.43 2.0490 1.25 3.23 2.50 3.64 2.38 2.63 3.75120 2.01 5.19 4.02 5.85 3.82 4.22 6.03

Inpatient Alcohol/Substance Abuse Detoxification Limit [std: 7 days]# Days [Copay same as Inpatient Facility]

0 (0.94) (2.43) (1.88) (2.74) (1.79) (1.97) (2.82)7 0.00 0.00 0.00 0.00 0.00 0.00 0.0021 0.26 0.67 0.52 0.76 0.49 0.55 0.7830 0.47 1.21 0.94 1.37 0.89 0.99 1.41

Unlimited 0.68 1.75 1.36 1.98 1.29 1.43 2.04

Inpatient Alcohol/Substance Abuse Rehabilitation Limit [std: 0 days]# Days [Copay same as Inpatient Facility]

0 0.00 0.00 0.00 0.00 0.00 0.00 0.0030 3.43 8.85 6.86 9.98 6.52 7.20 10.2960 4.01 10.35 8.02 11.67 7.62 8.42 12.0390 4.79 12.36 9.58 13.94 9.10 10.06 14.37

Unlimited 4.88 12.59 9.76 14.20 9.27 10.25 14.64

Outpatient Alcoholism/Substance Abuse Rehab Limit [std: 60 visits]# Visits [Copay same as Specialist Physician Office Visit, Not to Exceed $25 Copay]

60/$0 copay 0.00 0.00 0.00 0.00 0.00 0.00 0.00120 days 0.62 1.60 1.24 1.80 1.18 1.30 1.86Unlimited 0.70 1.81 1.40 2.04 1.33 1.47 2.10

Copay Dialysis Treatment Copay [std: $10]$0 0.16 0.41 0.32 0.47 0.30 0.34 0.48$5 0.08 0.21 0.16 0.23 0.15 0.17 0.24$10 0.00 0.00 0.00 0.00 0.00 0.00 0.00$15 (0.09) (0.23) (0.18) (0.26) (0.17) (0.19) (0.27)$20 (0.21) (0.54) (0.42) (0.61) (0.40) (0.44) (0.63)$25 (0.26) (0.67) (0.52) (0.76) (0.49) (0.55) (0.78)








Copay Refractive Eye Exam Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (0.11) (0.28) (0.22) (0.32) (0.21) (0.23) (0.33)$10 (0.26) (0.67) (0.52) (0.76) (0.49) (0.55) (0.78)$15 (0.42) (1.08) (0.84) (1.22) (0.80) (0.88) (1.26)$20 (0.60) (1.55) (1.20) (1.75) (1.14) (1.26) (1.80)$25 (0.78) (2.01) (1.56) (2.27) (1.48) (1.64) (2.34)$30 (0.94) (2.43) (1.88) (2.74) (1.79) (1.97) (2.82)$35 (1.14) (2.94) (2.28) (3.32) (2.17) (2.39) (3.42)$40 (1.30) (3.35) (2.60) (3.78) (2.47) (2.73) (3.90)$45 (1.47) (3.79) (2.94) (4.28) (2.79) (3.09) (4.41)$50 (1.65) (4.26) (3.30) (4.80) (3.14) (3.47) (4.95)

Copay Diabetic Supplies Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (0.14) (0.36) (0.28) (0.41) (0.27) (0.29) (0.42)$10 (0.30) (0.77) (0.60) (0.87) (0.57) (0.63) (0.90)$15 (0.48) (1.24) (0.96) (1.40) (0.91) (1.01) (1.44)$20 (0.67) (1.73) (1.34) (1.95) (1.27) (1.41) (2.01)$25 (0.91) (2.35) (1.82) (2.65) (1.73) (1.91) (2.73)

Copay Pre Hospital Emergency Services$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$15 (0.09) (0.23) (0.18) (0.26) (0.17) (0.19) (0.27)$25 (0.14) (0.36) (0.28) (0.41) (0.27) (0.29) (0.42)$35 (0.20) (0.52) (0.40) (0.58) (0.38) (0.42) (0.60)$50 (0.29) (0.75) (0.58) (0.84) (0.55) (0.61) (0.87)$60 (0.39) (1.01) (0.78) (1.13) (0.74) (0.82) (1.17)$75 (0.52) (1.34) (1.04) (1.51) (0.99) (1.09) (1.56)$100 (0.67) (1.73) (1.34) (1.95) (1.27) (1.41) (2.01)

Ambulance Copay [std: $0]Copay [Copay same or less than Emergency Room Copay]

$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$15 (0.06) (0.15) (0.12) (0.17) (0.11) (0.13) (0.18)$25 (0.09) (0.23) (0.18) (0.26) (0.17) (0.19) (0.27)$35 (0.14) (0.36) (0.28) (0.41) (0.27) (0.29) (0.42)$50 (0.21) (0.54) (0.42) (0.61) (0.40) (0.44) (0.63)$60 (0.26) (0.67) (0.52) (0.76) (0.49) (0.55) (0.78)$75 (0.35) (0.90) (0.70) (1.02) (0.67) (0.74) (1.05)$100 (0.48) (1.24) (0.96) (1.40) (0.91) (1.01) (1.44)








Surgery [std: $0 copay]Copay per procedure of minimum of [20%, $300]

(2.84) (7.33) (5.68) (8.26) (5.40) (5.96) (8.52)

Diagnostic and Therapeutic Radiology [std: $0]Copay per procedure of minimum (20%, $100); $500 annual maximum

(4.42) (11.40) (8.84) (12.86) (8.40) (9.28) (13.26)

Diagnostic Testing [std: $0]Copay per procedure minimum of [20%, $500], $500 annual maximum

(0.38) (0.98) (0.76) (1.11) (0.72) (0.80) (1.14)



EMBLEMHEALTH COMPREHEALTH EPO - MENTAL HEALTH



Inpatient Mental Health Care with Unlimited Bio and CSED CoverageLARGE GROUP [minimum mandatory coverage: 30 days with unlimited BIO and CSED]

# Days [Copay same as Inpatient Facility]30 7.28 18.78 14.56 21.18 13.83 15.29 21.8460 7.64 19.71 15.28 22.23 14.52 16.04 22.9290 7.95 20.51 15.90 23.13 15.11 16.70 23.85

Unlimited 8.04 20.74 16.08 23.40 15.28 16.88 24.12

Outpatient Mental Health Care with Unlimited Bio and CSED Coverage# Visits [minimum mandatory coverage: 20 visits with unlimited Bio and CSED]

[Copay same or less than Specialist Physician Office Visit]LARGE GROUP $0 Copay

20 8.14 21.00 16.28 23.69 15.47 17.09 24.4230 8.83 22.78 17.66 25.70 16.78 18.54 26.4940 9.28 23.94 18.56 27.00 17.63 19.49 27.8460 9.72 25.08 19.44 28.29 18.47 20.41 29.16

Unlimited 9.82 25.34 19.64 28.58 18.66 20.62 29.46

LARGE GROUP $5 Copay20 7.62 19.66 15.24 22.17 14.48 16.00 22.8630 8.29 21.39 16.58 24.12 15.75 17.41 24.8740 8.74 22.55 17.48 25.43 16.61 18.35 26.2260 9.12 23.53 18.24 26.54 17.33 19.15 27.36

Unlimited 9.21 23.76 18.42 26.80 17.50 19.34 27.63


Unlimited 8.63 22.27 17.26 25.11 16.40 18.12 25.89











Unlimited 8.11 20.92 16.22 23.60 15.41 17.03 24.33


Unlimited 7.59 19.58 15.18 22.09 14.42 15.94 22.77


Unlimited 7.06 18.21 14.12 20.54 13.41 14.83 21.18


Unlimited 6.62 17.08 13.24 19.26 12.58 13.90 19.86


Unlimited 6.20 16.00 12.40 18.04 11.78 13.02 18.60


Unlimited 6.09 15.71 12.18 17.72 11.57 12.79 18.27









Unlimited 5.90 15.22 11.80 17.17 11.21 12.39 17.70


Unlimited 5.74 14.81 11.48 16.70 10.91 12.05 17.22

Bio = Biologically BasedCSED = Childhood Serious Emotional Disturbances



EMBLEMHEALTH COMPREHEALTH EPO LARGE GROUP CONTRACTDEPENDENT VARIABLES - APPLIED TO TOTAL PREMIUM


Rider Individual Family Persons Family & Child(ren) & Spouse Family

Dependent Coverage

Dependent Children [std: covered to 19 end of month]Age End of Month19 na na na na na na na20 na na na na na na na21 na na na na na na na22 na na na na na na na23 na na na na na na na24 na na na na na na na25 na na na na na na na26 2.0% 2.0% 2.0% 2.0% 2.0% 2.0% 2.0%30 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0%

End of Year19 na na na na na na na20 na na na na na na na21 na na na na na na na22 na na na na na na na23 na na na na na na na24 na na na na na na na25 na na na na na na na26 4.4% 4.4% 4.4% 4.4% 4.4% 4.4% 4.4%



Expressed as % add-on to each premium rate otherwise computedMinimum Mandatory Coverage = Dependent Children to Age 26 EOM



EMBLEMHEALTH COMPREHEALTH EPO LARGE GROUP CONTRACTDEPENDENT VARIABLES - APPLIED TO TOTAL PREMIUM





Full-time Students [std: covered to 23 end of year]Age End of Year23 na na na na na na na24 na na na na na na na25 na na na na na na na26 1.2% 1.2% 1.2% 1.2% 1.2% 1.2% 1.2%

End of Month23 na na na na na na na24 na na na na na na na25 na na na na na na na26 na na na na na na na

Dependent CoverageGrandchildren

0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2%



EMBLEMHEALTH COMPREHEALTH EPO - RIDERS



Durable Medical Equipment RidersDeductible

$0 4.45 11.48 8.90 12.95 8.46 9.35 13.35$25 4.20 10.84 8.40 12.22 7.98 8.82 12.60$50 3.94 10.17 7.88 11.47 7.49 8.27 11.82$100 3.61 9.31 7.22 10.51 6.86 7.58 10.83$500 1.72 4.44 3.44 5.01 3.27 3.61 5.16

Coinsurance20% 3.56 9.18 7.12 10.36 6.76 7.48 10.6825% 3.33 8.59 6.66 9.69 6.33 6.99 9.9930% 3.12 8.05 6.24 9.08 5.93 6.55 9.36

Deductible Orthotics Riders$0 0.75 1.94 1.50 2.18 1.43 1.58 2.25$25 0.73 1.88 1.46 2.12 1.39 1.53 2.19$50 0.68 1.75 1.36 1.98 1.29 1.43 2.04$100 0.62 1.60 1.24 1.80 1.18 1.30 1.86$500 0.28 0.72 0.56 0.81 0.53 0.59 0.84

Coinsurance20% 0.62 1.60 1.24 1.80 1.18 1.30 1.8625% 0.59 1.52 1.18 1.72 1.12 1.24 1.7730% 0.57 1.47 1.14 1.66 1.08 1.20 1.71

Optical RidersEyeglasses Only with $45 copay

24 Months 0.00 0.00 0.00 0.00 0.00 0.00 0.00Eyeglasses with $0 copay and Contacts with $70 copay

24 Months 1.40 3.61 2.80 4.07 2.66 2.94 4.2012 Months 2.25 5.81 4.50 6.55 4.28 4.73 6.75

Eyeglasses with $0 copay and Contacts with $25 copay24 Months 2.19 5.65 4.38 6.37 4.16 4.60 6.5712 Months 3.50 9.03 7.00 10.19 6.65 7.35 10.50

Private Duty Nursing RidersIn Full 0.59 1.52 1.18 1.72 1.12 1.24 1.77

80% hrs 73-504 0.09 0.23 0.18 0.26 0.17 0.19 0.27100% hrs 73-504 0.16 0.41 0.32 0.47 0.30 0.34 0.48





EMBLEMHEALTH COMPREHEALTH EPO - RIDERS





Dental Network Access0.45 1.16 0.90 1.31 0.86 0.95 1.35

Limit Infertility Rider2 IVF 9.37 24.17 18.74 27.27 17.80 19.68 28.113 IVF 11.33 29.23 22.66 32.97 21.53 23.79 33.99

Complementary Alternative Medicine (CAM)$20 Copay 4.69 12.10 9.38 13.65 8.91 9.85 14.07

Health Club Reimbursement$200 per year 1.36 3.51 2.72 3.96 2.58 2.86 4.08

Wellness RiderInclusion 1.12 1.12 1.12 1.12 1.12 1.12 1.12

0.36 0.93 0.72 1.05 0.68 0.76 1.08Nurse Advice Line Rider



PRIME EPO LARGE GROUP CONTRACT - BASE BENEFITS


Plan Individual Family Persons Family & Child(ren) & Spouse Family

Effective January 1, 2011 - March 31, 2011

Large Group* 946.36 2,318.58 1,728.05 2,751.07 1,760.23 1,892.72 2,894.92

* Base rates exclude premium component for mandatory mental health coverage





PRIME EPO LARGE GROUP CONTRACT - BASE BENEFIT VARIABLES



Copay PCP Office Visit Copay [inc. Urgent Care facility visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (6.33) (15.51) (11.56) (18.40) (11.77) (12.66) (19.36)$10 (13.31) (32.61) (24.30) (38.69) (24.76) (26.62) (40.72)$15 (22.14) (54.24) (40.43) (64.36) (41.18) (44.28) (67.73)$20 (34.17) (83.72) (62.39) (99.33) (63.56) (68.34) (104.53)$25 (44.99) (110.23) (82.15) (130.79) (83.68) (89.98) (137.62)$30 (56.91) (139.43) (103.92) (165.44) (105.85) (113.82) (174.09)

Copay PCP Office Visit Copay with $0 Child Copay [inc. Urgent Care facility visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (3.62) (8.87) (6.61) (10.52) (6.73) (7.24) (11.07)$10 (7.62) (18.67) (13.91) (22.15) (14.17) (15.24) (23.31)$15 (12.68) (31.07) (23.15) (36.86) (23.58) (25.36) (38.79)$20 (19.56) (47.92) (35.72) (56.86) (36.38) (39.12) (59.83)$25 (25.78) (63.16) (47.07) (74.94) (47.95) (51.56) (78.86)$30 (32.63) (79.94) (59.58) (94.86) (60.69) (65.26) (99.82)

Copay Specialist Office Visit Copay [incl. Chiropractic visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (4.82) (11.81) (8.80) (14.01) (8.97) (9.64) (14.74)$10 (10.08) (24.70) (18.41) (29.30) (18.75) (20.16) (30.83)$15 (15.83) (38.78) (28.91) (46.02) (29.44) (31.66) (48.42)$20 (22.27) (54.56) (40.67) (64.74) (41.42) (44.54) (68.12)$25 (29.27) (71.71) (53.45) (85.09) (54.44) (58.54) (89.54)$30 (36.93) (90.48) (67.43) (107.36) (68.69) (73.86) (112.97)$35 (44.09) (108.02) (80.51) (128.17) (82.01) (88.18) (134.87)$40 (51.53) (126.25) (94.09) (149.80) (95.85) (103.06) (157.63)$45 (59.38) (145.48) (108.43) (172.62) (110.45) (118.76) (181.64)$50 (67.58) (165.57) (123.40) (196.46) (125.70) (135.16) (206.73)











Copay/Admit Inpatient Facility Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00

$100 (2.31) (5.66) (4.22) (6.72) (4.30) (4.62) (7.07)$150 (3.82) (9.36) (6.98) (11.10) (7.11) (7.64) (11.69)$200 (5.43) (13.30) (9.92) (15.79) (10.10) (10.86) (16.61)$250 (7.79) (19.09) (14.22) (22.65) (14.49) (15.58) (23.83)$500 (18.68) (45.77) (34.11) (54.30) (34.74) (37.36) (57.14)$750 (32.07) (78.57) (58.56) (93.23) (59.65) (64.14) (98.10)

$1,000 (48.23) (118.16) (88.07) (140.20) (89.71) (96.46) (147.54)


Copay Ambulatory Surgery Facility Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$50 (1.22) (2.99) (2.23) (3.55) (2.27) (2.44) (3.73)$75 (1.98) (4.85) (3.62) (5.76) (3.68) (3.96) (6.06)$100 (2.82) (6.91) (5.15) (8.20) (5.25) (5.64) (8.63)$125 (3.66) (8.97) (6.68) (10.64) (6.81) (7.32) (11.20)$150 (4.60) (11.27) (8.40) (13.37) (8.56) (9.20) (14.07)



Unlimited 4.79 11.74 8.75 13.92 8.91 9.58 14.65









60 0.57 1.40 1.04 1.66 1.06 1.14 1.74100 1.42 3.48 2.59 4.13 2.64 2.84 4.34200 3.72 9.11 6.79 10.81 6.92 7.44 11.38

* no longer offered, benefit must be switched to 40 visits/$25 copay# Days Inpatient Therapies Limit [std: 30 days]

0 (2.20) (5.39) (4.02) (6.40) (4.09) (4.40) (6.73)30 0.00 0.00 0.00 0.00 0.00 0.00 0.0060 1.47 3.60 2.68 4.27 2.73 2.94 4.5090 3.03 7.42 5.53 8.81 5.64 6.06 9.27

Outpatient Therapies Limit [std: 30 visits]# Visits [Copay same as Specialist Physician Office Visit]

30 0.00 0.00 0.00 0.00 0.00 0.00 0.0060 1.31 3.21 2.39 3.81 2.44 2.62 4.0190 2.42 5.93 4.42 7.03 4.50 4.84 7.40120 3.86 9.46 7.05 11.22 7.18 7.72 11.81


0 (1.85) (4.53) (3.38) (5.38) (3.44) (3.70) (5.66)7 0.00 0.00 0.00 0.00 0.00 0.00 0.0021 0.54 1.32 0.99 1.57 1.00 1.08 1.6530 0.88 2.16 1.61 2.56 1.64 1.76 2.69

Unlimited 1.31 3.21 2.39 3.81 2.44 2.62 4.01


0 0.00 0.00 0.00 0.00 0.00 0.00 0.0030 6.55 16.05 11.96 19.04 12.18 13.10 20.0460 7.66 18.77 13.99 22.27 14.25 15.32 23.4390 9.15 22.42 16.71 26.60 17.02 18.30 27.99

Unlimited 9.30 22.79 16.98 27.04 17.30 18.60 28.45

Outpatient Alcoholism/Substance Abuse Rehab Limit [std: 60 visits]# Visits [Copay same as Specialist Physician Office Visit, Not to Exceed $25 Copay]60 days 0.00 0.00 0.00 0.00 0.00 0.00 0.00120 days 1.16 2.84 2.12 3.37 2.16 2.32 3.55Unlimited 1.35 3.31 2.47 3.92 2.51 2.70 4.13









Copay Refractive Eye Exam Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (0.28) (0.69) (0.51) (0.81) (0.52) (0.56) (0.86)$10 (0.57) (1.40) (1.04) (1.66) (1.06) (1.14) (1.74)$15 (0.88) (2.16) (1.61) (2.56) (1.64) (1.76) (2.69)$20 (1.27) (3.11) (2.32) (3.69) (2.36) (2.54) (3.88)$25 (1.61) (3.94) (2.94) (4.68) (2.99) (3.22) (4.92)$30 (1.98) (4.85) (3.62) (5.76) (3.68) (3.96) (6.06)$35 (2.33) (5.71) (4.25) (6.77) (4.33) (4.66) (7.13)$40 (2.69) (6.59) (4.91) (7.82) (5.00) (5.38) (8.23)$45 (3.06) (7.50) (5.59) (8.90) (5.69) (6.12) (9.36)$50 (3.41) (8.35) (6.23) (9.91) (6.34) (6.82) (10.43)


Copay Pre-Hospital Emergency Services [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$15 (0.19) (0.47) (0.35) (0.55) (0.35) (0.38) (0.58)$25 (0.30) (0.74) (0.55) (0.87) (0.56) (0.60) (0.92)$35 (0.42) (1.03) (0.77) (1.22) (0.78) (0.84) (1.28)$50 (0.62) (1.52) (1.13) (1.80) (1.15) (1.24) (1.90)$60 (0.81) (1.98) (1.48) (2.35) (1.51) (1.62) (2.48)$75 (1.07) (2.62) (1.95) (3.11) (1.99) (2.14) (3.27)$100 (1.42) (3.48) (2.59) (4.13) (2.64) (2.84) (4.34)


$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$15 (0.11) (0.27) (0.20) (0.32) (0.20) (0.22) (0.34)$25 (0.23) (0.56) (0.42) (0.67) (0.43) (0.46) (0.70)$35 (0.30) (0.74) (0.55) (0.87) (0.56) (0.60) (0.92)$50 (0.47) (1.15) (0.86) (1.37) (0.87) (0.94) (1.44)$60 (0.57) (1.40) (1.04) (1.66) (1.06) (1.14) (1.74)$75 (0.69) (1.69) (1.26) (2.01) (1.28) (1.38) (2.11)$100 (0.93) (2.28) (1.70) (2.70) (1.73) (1.86) (2.84)


(5.90) (14.46) (10.77) (17.15) (10.97) (11.80) (18.05)

Diagnostic and Therapeutic Radiology [std: $0]Copay per procedure of minimum (20%, $100); $500 annual maximum

(9.13) (22.37) (16.67) (26.54) (16.98) (18.26) (27.93)

Diagnostic Testing [std: $0]Copay per procedure minimum of [20%, $500], $500 annual maximum

(0.78) (1.91) (1.42) (2.27) (1.45) (1.56) (2.39)



PRIME PPO LARGE GROUP CONTRACTDEPENDENT VARIABLES - APPLIED TO TOTAL PREMIUM



Dependent Coverage






0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2%

Class II Dependents2.0% 2.0% 2.0% 2.0% 2.0% 2.0% 2.0%






PRIME EPO LARGE GROUP CONTRACT - MENTAL HEALTH


Rider Individual Family Persons Family & Child(ren) & Spouse Family2%Inpatient Mental Health Care with Unlimited Bio and CSED Coverage

LARGE GROUP [minimum mandatory coverage: 30 days with unlimited BIO and CSED]# Days [Copay same as Inpatient Facility]

30 15.25 37.36 27.85 44.33 28.37 30.50 46.6560 16.06 39.35 29.33 46.69 29.87 32.12 49.1390 16.64 40.77 30.38 48.37 30.95 33.28 50.90

Unlimited 16.84 41.26 30.75 48.95 31.32 33.68 51.51



20 17.02 41.70 31.08 49.48 31.66 34.04 52.0630 18.73 45.89 34.20 54.45 34.84 37.46 57.3040 19.80 48.51 36.15 57.56 36.83 39.60 60.5760 20.87 51.13 38.11 60.67 38.82 41.74 63.84

Unlimited 21.02 51.50 38.38 61.11 39.10 42.04 64.30


Unlimited 19.78 48.46 36.12 57.50 36.79 39.56 60.51


Unlimited 18.54 45.42 33.85 53.90 34.48 37.08 56.71











Unlimited 17.51 42.90 31.97 50.90 32.57 35.02 53.56

LARGE GROUP20 13.25 32.46 24.19 38.52 24.65 26.50 40.5330 14.52 35.57 26.51 42.21 27.01 29.04 44.4240 15.32 37.53 27.97 44.54 28.50 30.64 46.8660 16.28 39.89 29.73 47.33 30.28 32.56 49.80

Unlimited 16.40 40.18 29.95 47.67 30.50 32.80 50.17


Unlimited 15.30 37.49 27.94 44.48 28.46 30.60 46.80


Unlimited 14.30 35.04 26.11 41.57 26.60 28.60 43.74


Unlimited 13.41 32.85 24.49 38.98 24.94 26.82 41.02


Unlimited 13.11 32.12 23.94 38.11 24.38 26.22 40.10









Unlimited 12.78 31.31 23.34 37.15 23.77 25.56 39.09


Unlimited 12.47 30.55 22.77 36.25 23.19 24.94 38.15



PRIME EPO LARGE GROUP CONTRACT - RIDERS




$0 8.48 20.78 15.48 24.65 15.77 16.96 25.94$25 8.04 19.70 14.68 23.37 14.95 16.08 24.59$50 7.52 18.42 13.73 21.86 13.99 15.04 23.00$100 6.91 16.93 12.62 20.09 12.85 13.82 21.14$500 3.32 8.13 6.06 9.65 6.18 6.64 10.16

Coinsurance80% 6.81 16.68 12.44 19.80 12.67 13.62 20.8375% 6.39 15.66 11.67 18.58 11.89 12.78 19.5570% 5.95 14.58 10.86 17.30 11.07 11.90 18.20


Coinsurance80% 1.18 2.89 2.15 3.43 2.19 2.36 3.6175% 1.12 2.74 2.05 3.26 2.08 2.24 3.4370% 1.07 2.62 1.95 3.11 1.99 2.14 3.27



24 Months 1.77 4.34 3.23 5.15 3.29 3.54 5.4112 Months 2.83 6.93 5.17 8.23 5.26 5.66 8.66






PRIME EPO LARGE GROUP CONTRACT - RIDERS






80% hrs 73-504 0.16 0.39 0.29 0.47 0.30 0.32 0.49100% hrs 73-504 0.30 0.74 0.55 0.87 0.56 0.60 0.92

Dental Network Access0.55 1.35 1.00 1.60 1.02 1.10 1.68

Limit Infertility Rider2 IVF 17.93 43.93 32.74 52.12 33.35 35.86 54.853 IVF 21.68 53.12 39.59 63.02 40.32 43.36 66.32



PRIME PPO LARGE GROUP CONTRACT - BASE BENEFITS *


Individual Family Persons Family & Child(ren) & Spouse Family

Effective January 1, 2011 - March 31, 2011Large Group**80% Coinsurance

1,722.13 4,219.22 3,144.61 5,006.23 3,203.16 3,444.26 5,268.0075% Coinsurance

1,637.98 4,013.05 2,990.95 4,761.61 3,046.64 3,275.96 5,010.5870% Coinsurance

1,555.86 3,811.86 2,841.00 4,522.89 2,893.90 3,111.72 4,759.3850% Coinsurance

1,471.72 3,605.71 2,687.36 4,278.29 2,737.40 2,943.44 4,501.99

*Base Benefits = In-network: HMO base benefits, Standard Out-of-network coverage = $250 ded and $1,000 coins max ** Base rates excludes ded. and coins. max premium credit and mandatory mental health coverage premium component





PRIME PPO LARGE GROUP CONTRACT - BASE BENEFIT VARIABLES

OUT-OF-NETWORK BENEFIT VARIABLES


Rider Individual Family Persons Family & Child(ren) & Spouse FamilyFamily = 2.002%

LARGE GROUP

Deductible Deductible Credits - 80% Coinsurance$200 (105.47) (258.40) (192.59) (306.60) (196.17) (210.94) (322.63)$250 (125.85) (308.33) (229.80) (365.85) (234.08) (251.70) (384.98)$300 (146.24) (358.29) (267.03) (425.12) (272.01) (292.48) (447.35)$350 (166.66) (408.32) (304.32) (484.48) (309.99) (333.32) (509.81)$400 (182.69) (447.59) (333.59) (531.08) (339.80) (365.38) (558.85)$500 (214.73) (526.09) (392.10) (624.22) (399.40) (429.46) (656.86)$750 (278.87) (683.23) (509.22) (810.68) (518.70) (557.74) (853.06)

$1,000 (328.25) (804.21) (599.38) (954.22) (610.55) (656.50) (1,004.12)$1,500 (403.79) (989.29) (737.32) (1,173.82) (751.05) (807.58) (1,235.19)$2,000 (434.68) (1,064.97) (793.73) (1,263.61) (808.50) (869.36) (1,329.69)$2,500 (465.67) (1,140.89) (850.31) (1,353.70) (866.15) (931.34) (1,424.48)$5,000 (547.46) (1,341.28) (999.66) (1,591.47) (1,018.28) (1,094.92) (1,674.68)$10,000 (614.97) (1,506.68) (1,122.94) (1,787.72) (1,143.84) (1,229.94) (1,881.19)


$1,000 (271.41) (664.95) (495.59) (788.99) (504.82) (542.82) (830.24)$1,500 (334.16) (818.69) (610.18) (971.40) (621.54) (668.32) (1,022.20)$2,000 (362.61) (888.39) (662.13) (1,054.11) (674.45) (725.22) (1,109.22)$2,500 (391.05) (958.07) (714.06) (1,136.78) (727.35) (782.10) (1,196.22)$5,000 (472.44) (1,157.48) (862.68) (1,373.38) (878.74) (944.88) (1,445.19)$10,000 (539.61) (1,322.04) (985.33) (1,568.65) (1,003.67) (1,079.22) (1,650.67)








Rider Individual Family Persons Family & Child(ren) & Spouse FamilyFamily = 2.00




$1,000 (214.45) (525.40) (391.59) (623.41) (398.88) (428.90) (656.00)$1,500 (264.57) (648.20) (483.10) (769.10) (492.10) (529.14) (809.32)$2,000 (290.52) (711.77) (530.49) (844.54) (540.37) (581.04) (888.70)$2,500 (316.50) (775.43) (577.93) (920.07) (588.69) (633.00) (968.17)$5,000 (397.48) (973.83) (725.80) (1,155.47) (739.31) (794.96) (1,215.89)$10,000 (464.35) (1,137.66) (847.90) (1,349.87) (863.69) (928.70) (1,420.45)


$1,000 (153.25) (375.46) (279.83) (445.50) (285.05) (306.50) (468.79)$1,500 (191.48) (469.13) (349.64) (556.63) (356.15) (382.96) (585.74)$2,000 (211.86) (519.06) (386.86) (615.88) (394.06) (423.72) (648.08)$2,500 (232.29) (569.11) (424.16) (675.27) (432.06) (464.58) (710.58)$5,000 (312.17) (764.82) (570.02) (907.48) (580.64) (624.34) (954.93)$10,000 (378.04) (926.20) (690.30) (1,098.96) (703.15) (756.08) (1,156.42)









LARGE GROUP

Maximum Coinsurance Maximum Credits - 80% Coinsurance$1,000 (97.68) (239.32) (178.36) (283.96) (181.68) (195.36) (298.80)$1,500 (106.54) (261.02) (194.54) (309.71) (198.16) (213.08) (325.91)$2,000 (111.11) (272.22) (202.89) (323.00) (206.66) (222.22) (339.89)$3,000 (115.35) (282.61) (210.63) (335.32) (214.55) (230.70) (352.86)$4,000 (117.11) (286.92) (213.84) (340.44) (217.82) (234.22) (358.24)$5,000 (118.06) (289.25) (215.58) (343.20) (219.59) (236.12) (361.15)$7,000 (119.20) (292.04) (217.66) (346.51) (221.71) (238.40) (364.63)$7,500 (120.16) (294.39) (219.41) (349.31) (223.50) (240.32) (367.57)$10,000 (123.69) (303.04) (225.86) (359.57) (230.06) (247.38) (378.37)$20,000 (128.69) (315.29) (234.99) (374.10) (239.36) (257.38) (393.66)












Maximum Annual Benefit Maximum [ $5,000,000 standard ]Unlimited 0.77 1.89 1.41 2.24 1.43 1.54 2.36

$1,000,000 (0.62) (1.52) (1.13) (1.80) (1.15) (1.24) (1.90)$50,000 (10.11) (24.77) (18.46) (29.39) (18.80) (20.22) (30.93)

OON Coins Out Of Network Outpatient Therapies - 50% Coinsurance, 30 Day Maximum80% (0.77) (1.89) (1.41) (2.24) (1.43) (1.54) (2.36)75% (0.64) (1.57) (1.17) (1.86) (1.19) (1.28) (1.96)70% (0.57) (1.40) (1.04) (1.66) (1.06) (1.14) (1.74)



PRIME PPO GROUP GROUP CONTRACT - BASE BENEFIT VARIABLESOUT-OF-NETWORK BENEFIT VARIABLES

Family Deductible Factors [std: 2x Individual Ded]Expressed as a % add on to each deductible credit rate

Individual Deductible Fam. Ded= 2.25 x Ind. Dam. Ded= 2.5 x Ind. Dem. Ded= 3.0. x Ind. D $200 1.039 1.077 1.148 $250 1.038 1.075 1.144 $300 1.037 1.073 1.140 $350 1.036 1.071 1.136 $400 1.036 1.070 1.134 $500 1.035 1.067 1.129 $750 1.034 1.062 1.116

$1,000 1.032 1.057 1.106 $1,500 1.031 1.051 1.087 $2,000 1.027 1.048 1.082 $2,500 1.022 1.044 1.077 $5,000 1.019 1.036 1.060 $10,000 1.017 1.032 1.052

Family Coinsurance Maximum Factors [std: 2x Individual Ded]

Expressed as a % add on to each deductible credit rate Fam. Co. Max.= 2.25 x Ind. Co. Max.= 2.5 x Ind. Coo. Max.= 3.0. x Ind. C

$1,000 1.017 1.034 1.069 $1,500 1.014 1.024 1.047 $2,000 1.012 1.021 1.040 $3,000 1.009 1.017 1.031 $4,000 1.008 1.015 1.027 $5,000 1.007 1.014 1.024 $7,000 1.006 1.011 1.019 $7,500 1.006 1.011 1.019 $10,000 1.005 1.009 1.015 $20,000 1.002 1.004 1.007

Out Of Network Fee Schedule Reimbursement [std: 80th percentile of HIAA]

Expressed as a % add on to each premium rate otherwise computedSchedule

70th Percentile of HIAA 0.964 90th Percentile of HIAA 1.036





PRIME PPO LARGE GROUP CONTRACTIN-NETWORK BENEFIT VARIABLES



Copay PCP Office Visit Copay [inc. Urgent Care facility visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (4.25) (10.41) (7.76) (12.35) (7.91) (8.50) (13.00)$10 (8.92) (21.85) (16.29) (25.93) (16.59) (17.84) (27.29)$15 (14.84) (36.36) (27.10) (43.14) (27.60) (29.68) (45.40)$20 (22.92) (56.15) (41.85) (66.63) (42.63) (45.84) (70.11)$25 (30.17) (73.92) (55.09) (87.70) (56.12) (60.34) (92.29)$30 (38.14) (93.44) (69.64) (110.87) (70.94) (76.28) (116.67)

Copay PCP Office Visit Copay with $0 Child Copay [inc. Urgent Care facility visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (2.43) (5.95) (4.44) (7.06) (4.52) (4.86) (7.43)$10 (5.11) (12.52) (9.33) (14.85) (9.50) (10.22) (15.63)$15 (8.52) (20.87) (15.56) (24.77) (15.85) (17.04) (26.06)$20 (13.11) (32.12) (23.94) (38.11) (24.38) (26.22) (40.10)$25 (17.30) (42.39) (31.59) (50.29) (32.18) (34.60) (52.92)$30 (21.85) (53.53) (39.90) (63.52) (40.64) (43.70) (66.84)

Copay Specialist Physician Office Visit Copay [incl. Chiropractic visits] [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$5 (3.27) (8.01) (5.97) (9.51) (6.08) (6.54) (10.00)$10 (6.81) (16.68) (12.44) (19.80) (12.67) (13.62) (20.83)$15 (10.66) (26.12) (19.47) (30.99) (19.83) (21.32) (32.61)$20 (15.01) (36.77) (27.41) (43.63) (27.92) (30.02) (45.92)$25 (19.75) (48.39) (36.06) (57.41) (36.74) (39.50) (60.42)$30 (24.87) (60.93) (45.41) (72.30) (46.26) (49.74) (76.08)$35 (29.66) (72.67) (54.16) (86.22) (55.17) (59.32) (90.73)$40 (34.66) (84.92) (63.29) (100.76) (64.47) (69.32) (106.02)$45 (39.90) (97.76) (72.86) (115.99) (74.21) (79.80) (122.05)$50 (45.40) (111.23) (82.90) (131.98) (84.44) (90.80) (138.88)











Copay/Admit Inpatient Facility Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00

$100 (1.55) (3.80) (2.83) (4.51) (2.88) (3.10) (4.74)$150 (2.55) (6.25) (4.66) (7.41) (4.74) (5.10) (7.80)$200 (3.62) (8.87) (6.61) (10.52) (6.73) (7.24) (11.07)$250 (5.21) (12.76) (9.51) (15.15) (9.69) (10.42) (15.94)$500 (12.50) (30.63) (22.83) (36.34) (23.25) (25.00) (38.24)$750 (21.47) (52.60) (39.20) (62.41) (39.93) (42.94) (65.68)

$1,000 (32.29) (79.11) (58.96) (93.87) (60.06) (64.58) (98.78)


Copay Ambulatory Surgery Facility Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$50 (0.84) (2.06) (1.53) (2.44) (1.56) (1.68) (2.57)$75 (1.35) (3.31) (2.47) (3.92) (2.51) (2.70) (4.13)$100 (1.89) (4.63) (3.45) (5.49) (3.52) (3.78) (5.78)$125 (2.47) (6.05) (4.51) (7.18) (4.59) (4.94) (7.56)$150 (3.08) (7.55) (5.62) (8.95) (5.73) (6.16) (9.42)










Unlimited 3.66 8.97 6.68 10.64 6.81 7.32 11.20


60 0.40 0.98 0.73 1.16 0.74 0.80 1.22100 0.93 2.28 1.70 2.70 1.73 1.86 2.84200 2.50 6.13 4.57 7.27 4.65 5.00 7.65

* 40 visits/$30 copay no longer offered, benefit must be switched to 40 visits/$25 copay# Days Inpatient Therapies Limit [std: 30 days]

0 (1.72) (4.21) (3.14) (5.00) (3.20) (3.44) (5.26)30 0.00 0.00 0.00 0.00 0.00 0.00 0.0060 1.14 2.79 2.08 3.31 2.12 2.28 3.4990 2.31 5.66 4.22 6.72 4.30 4.62 7.07

Outpatient Therapies Limit [std: 30 visits]








# Visits [Copay same as Specialist Physician Office Visit]30 0.00 0.00 0.00 0.00 0.00 0.00 0.0060 0.97 2.38 1.77 2.82 1.80 1.94 2.9790 1.84 4.51 3.36 5.35 3.42 3.68 5.63120 2.94 7.20 5.37 8.55 5.47 5.88 8.99


0 (1.42) (3.48) (2.59) (4.13) (2.64) (2.84) (4.34)7 0.00 0.00 0.00 0.00 0.00 0.00 0.0021 0.42 1.03 0.77 1.22 0.78 0.84 1.2830 0.65 1.59 1.19 1.89 1.21 1.30 1.99

Unlimited 0.97 2.38 1.77 2.82 1.80 1.94 2.97


0 0.00 0.00 0.00 0.00 0.00 0.00 0.0030 4.39 10.76 8.02 12.76 8.17 8.78 13.4360 5.16 12.64 9.42 15.00 9.60 10.32 15.7890 6.14 15.04 11.21 17.85 11.42 12.28 18.78

Unlimited 6.23 15.26 11.38 18.11 11.59 12.46 19.06

Outpatient Alcoholism/Substance Abuse Rehab Limit [std: 60 visits]# Visits [Copay same as Specialist Physician Office Visit, Not to Exceed $25 Copay]60 Days 0.00 0.00 0.00 0.00 0.00 0.00 0.00120 days 0.88 2.16 1.61 2.56 1.64 1.76 2.69Unlimited 1.04 2.55 1.90 3.02 1.93 2.08 3.18


Copay Refractive Eye Exam Copay [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00








$5 (0.16) (0.39) (0.29) (0.47) (0.30) (0.32) (0.49)$10 (0.40) (0.98) (0.73) (1.16) (0.74) (0.80) (1.22)$15 (0.58) (1.42) (1.06) (1.69) (1.08) (1.16) (1.77)$20 (0.86) (2.11) (1.57) (2.50) (1.60) (1.72) (2.63)$25 (1.11) (2.72) (2.03) (3.23) (2.06) (2.22) (3.40)$30 (1.35) (3.31) (2.47) (3.92) (2.51) (2.70) (4.13)$35 (1.55) (3.80) (2.83) (4.51) (2.88) (3.10) (4.74)$40 (1.81) (4.43) (3.31) (5.26) (3.37) (3.62) (5.54)$45 (2.05) (5.02) (3.74) (5.96) (3.81) (4.10) (6.27)$50 (2.28) (5.59) (4.16) (6.63) (4.24) (4.56) (6.97)


Copay Pre-Hospital Emergency Services [std: $0]$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$15 (0.11) (0.27) (0.20) (0.32) (0.20) (0.22) (0.34)$25 (0.19) (0.47) (0.35) (0.55) (0.35) (0.38) (0.58)$35 (0.28) (0.69) (0.51) (0.81) (0.52) (0.56) (0.86)$50 (0.45) (1.10) (0.82) (1.31) (0.84) (0.90) (1.38)$60 (0.54) (1.32) (0.99) (1.57) (1.00) (1.08) (1.65)$75 (0.69) (1.69) (1.26) (2.01) (1.28) (1.38) (2.11)$100 (0.93) (2.28) (1.70) (2.70) (1.73) (1.86) (2.84)









$0 0.00 0.00 0.00 0.00 0.00 0.00 0.00$15 (0.08) (0.20) (0.15) (0.23) (0.15) (0.16) (0.24)$25 (0.14) (0.34) (0.26) (0.41) (0.26) (0.28) (0.43)$35 (0.19) (0.47) (0.35) (0.55) (0.35) (0.38) (0.58)$50 (0.30) (0.74) (0.55) (0.87) (0.56) (0.60) (0.92)$60 (0.40) (0.98) (0.73) (1.16) (0.74) (0.80) (1.22)$75 (0.49) (1.20) (0.89) (1.42) (0.91) (0.98) (1.50)$100 (0.62) (1.52) (1.13) (1.80) (1.15) (1.24) (1.90)


(3.94) (9.65) (7.19) (11.45) (7.33) (7.88) (12.05)

Diagnostic and Therapeutic Radiology [std: $0]Copay per procedure of minimum (20%, $100); $500 annual maximum(6.14) (15.04) (11.21) (17.85) (11.42) (12.28) (18.78)

Diagnostic Testing [std: $0]Copay per procedure minimum of [20%, $500], $500 annual maximum(0.54) (1.32) (0.99) (1.57) (1.00) (1.08) (1.65)



PRIME PPO LARGE GROUP CONTRACTMENTAL HEALTH



Inpatient Mental Health Care with Unlimited Bio and CSED CoverageLARGE GROUP [minimum mandatory coverage: 30 days with unlimited BIO and CSED]

# Days [Copay same as Inpatient Facility]30 15.99 39.18 29.20 46.48 29.74 31.98 48.9160 16.88 41.36 30.82 49.07 31.40 33.76 51.6490 17.50 42.88 31.96 50.87 32.55 35.00 53.53

Unlimited 17.67 43.29 32.27 51.37 32.87 35.34 54.05



20 17.89 43.83 32.67 52.01 33.28 35.78 54.7330 19.69 48.24 35.95 57.24 36.62 39.38 60.2340 20.77 50.89 37.93 60.38 38.63 41.54 63.5460 21.90 53.66 39.99 63.66 40.73 43.80 66.99

Unlimited 22.07 54.07 40.30 64.16 41.05 44.14 67.51


Unlimited 20.74 50.81 37.87 60.29 38.58 41.48 63.44


Unlimited 19.46 47.68 35.53 56.57 36.20 38.92 59.53











Unlimited 18.39 45.06 33.58 53.46 34.21 36.78 56.26


Unlimited 17.22 42.19 31.44 50.06 32.03 34.44 52.68


Unlimited 16.06 39.35 29.33 46.69 29.87 32.12 49.13


Unlimited 15.01 36.77 27.41 43.63 27.92 30.02 45.92


Unlimited 14.08 34.50 25.71 40.93 26.19 28.16 43.07


Unlimited 13.79 33.79 25.18 40.09 25.65 27.58 42.18









Unlimited 13.41 32.85 24.49 38.98 24.94 26.82 41.02


Unlimited 13.08 32.05 23.88 38.02 24.33 26.16 40.01



PRIME PPO LARGE GROUP CONTRACTDEPENDENT VARIABLES - APPLIED TO TOTAL PREMIUM



Dependent Coverage






0.2% 0.2% 0.2% 0.2% 0.2% 0.2% 0.2%

Class II Dependents2.0% 2.0% 2.0% 2.0% 2.0% 2.0% 2.0%






PRIME PPO LARGE GROUP CONTRACT - RIDERS




$0 12.68 31.07 23.15 36.86 23.58 25.36 38.79$25 11.89 29.13 21.71 34.56 22.12 23.78 36.37$50 11.22 27.49 20.49 32.62 20.87 22.44 34.32$100 10.05 24.62 18.35 29.22 18.69 20.10 30.74$500 4.94 12.10 9.02 14.36 9.19 9.88 15.11

Coinsurance80% 10.08 24.70 18.41 29.30 18.75 20.16 30.8375% 9.50 23.28 17.35 27.62 17.67 19.00 29.0670% 8.84 21.66 16.14 25.70 16.44 17.68 27.04


Coinsurance80% 1.80 4.41 3.29 5.23 3.35 3.60 5.5175% 1.64 4.02 2.99 4.77 3.05 3.28 5.0270% 1.53 3.75 2.79 4.45 2.85 3.06 4.68



24 Months 1.77 4.34 3.23 5.15 3.29 3.54 5.4112 Months 2.83 6.93 5.17 8.23 5.26 5.66 8.66



80% hrs 73-504 0.26 0.64 0.47 0.76 0.48 0.52 0.80100% hrs 73-504 0.47 1.15 0.86 1.37 0.87 0.94 1.44

Dental Network Rider0.55 1.35 1.00 1.60 1.02 1.10 1.68

Limit Infertility Riders2 IVF 27.71 67.89 50.60 80.55 51.54 55.42 84.763 IVF 33.30 81.59 60.81 96.80 61.94 66.60 101.86

0.36 0.88 0.66 1.05 0.67 0.72 1.10



Nurse Advice Line Rider



PRIME EPO & PPO NETWORK AREA FACTORS

Network

HIP VYTRAArea*/Plan Prime Premium

Long Island

Prime EPO 1.000 1.074

Prime PPO 1.000 1.044

New York City, Westchester, Rockland and Orange Counties

Prime EPO 1.000 1.028

Prime PPO 1.000 1.017

Upstate New York 1.023 1.023

New Jersey 0.954 0.954

Connecticut 1.148 1.148

All Other States 1.200 1.200



Manual Rate = ([(Par Claim Cost + Non-Par Claim Cost) * (100% + 37%*HCRA Surcharge Percentage) + HCRA Covered Lives Assessment]/ (100% - Retention Percentage)+ Mental Health + Rider Premium)* Network/Area Factor* Sole Proprietor Factor

Par Claim Cost: EPO = [ (1) + (2) ] * (4) * (5) PPO = [ (1) + (2) ] * (4) * (5) * 116%

note: use Par Benefits, Par Deductible, Par Coinsurance %, Par Coinsurance Max., and Par Calendar Year Max.

Non-Par Claim Cost: EPO = 0 PPO = [ (1) + (3) ] * (4) * (6) * 53%

note: use Non-Par Deductible, Non-Par Coinsurance %, Non-Par Coinsurance Max., and Non-Par Calendar Year Max.

where: (1) = Base Benefits Claim Cost {Table 1}(2) = Par Benefit Dollar Variable adjustments {Table 2}(3) = Non-Par Benefit Dollar Variable adjustments {Table 3}(4) = Dependent Coverge percentage {Table 4}(5) = Par Benefit Percentage Variable adjustments {Table 5}(6) = Non-Par Benefit Percentage Variable adjustments {Table 6}

Note: The minimum [PPO Par Claim Cost plus PPO Non-Par ClaimCost] is 104% of the EPO Par Claim Cost for the Par plan design.

HCRA Surcharge = currently 9.63% (subject to changes as amended by law)

HCRA CLA = Covered Lives Assessment {Table 7}(subject to changes as amended by law)

Retention Percentage = Retention Percenta

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