oxford health insurance, inc....oxford health insurance, inc. new york small group off‐exchange...
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Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Rate Manual
Rates Effective January 1, 2018
Page 1 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Table of Contents
Section Page(s)
Area Factors 3
Base Medical and Prescription Drug Rates 4 ‐ 7
Ancillary Coverage Rider Rates 8
Medical and Rx Drug Benefits 9 ‐ 10
Pediatric Dental and Vision Benefits 11
Additional Notes 12
Page 2 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Area FactorsArea Factor is "n/a" for counties outside the service area.
County
DFS Rating
Region Area Factor County
DFS Rating
Region Area Factor County
DFS Rating
Region Area Factor
Albany 1 n/a Delaware 3 n/a Broome 6 n/a
Columbia 1 n/a Dutchess 3 1.100 Cayuga 6 n/a
Fulton 1 n/a Orange 3 1.100 Chemung 6 n/a
Greene 1 n/a Putnam 3 1.100 Cortland 6 n/a
Montgomery 1 n/a Sullivan 3 1.100 Onondaga 6 n/a
Rensselaer 1 n/a Ulster 3 1.100 Schuyler 6 n/a
Saratoga 1 n/a Bronx 4 0.999 Steuben 6 n/a
Schenectady 1 n/a Kings 4 0.999 Tioga 6 n/a
Schoharie 1 n/a New York 4 0.999 Tompkins 6 n/a
Warren 1 n/a Queens 4 0.999 Chenango 7 n/a
Washington 1 n/a Richmond 4 0.999 Clinton 7 n/a
Allegany 2 n/a Rockland 4 0.999 Essex 7 n/a
Cattaraugus 2 n/a Westchester 4 0.999 Franklin 7 n/a
Chautauqua 2 n/a Livingston 5 n/a Hamilton 7 n/a
Erie 2 n/a Monroe 5 n/a Herkimer 7 n/a
Genesee 2 n/a Ontario 5 n/a Jefferson 7 n/a
Niagara 2 n/a Seneca 5 n/a Lewis 7 n/a
Orleans 2 n/a Wayne 5 n/a Madison 7 n/a
Wyoming 2 n/a Yates 5 n/a Oneida 7 n/a
Oswego 7 n/a
Otsego 7 n/a
St. Lawrence 7 n/a
Nassau 8 0.999
Suffolk 8 0.999
Page 3 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,226.05$ 2,084.29$ 2,452.11$ 3,494.25$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,222.42$ 2,078.12$ 2,444.85$ 3,483.90$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,226.05$ 2,084.29$ 2,452.11$ 3,494.25$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,222.42$ 2,078.12$ 2,444.85$ 3,483.90$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,241.55$ 2,110.64$ 2,483.11$ 3,538.43$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,241.55$ 2,110.64$ 2,483.11$ 3,538.43$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,237.92$ 2,104.47$ 2,475.85$ 3,528.08$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,237.92$ 2,104.47$ 2,475.85$ 3,528.08$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,152.68$ 1,959.55$ 2,305.35$ 3,285.13$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,149.05$ 1,953.38$ 2,298.09$ 3,274.78$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,152.68$ 1,959.55$ 2,305.35$ 3,285.13$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,149.05$ 1,953.38$ 2,298.09$ 3,274.78$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,168.18$ 1,985.90$ 2,336.35$ 3,329.31$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,168.18$ 1,985.90$ 2,336.35$ 3,329.31$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,164.55$ 1,979.73$ 2,329.09$ 3,318.96$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,164.55$ 1,979.73$ 2,329.09$ 3,318.96$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,204.18$ 2,047.11$ 2,408.37$ 3,431.92$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,200.55$ 2,040.94$ 2,401.11$ 3,421.57$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,204.18$ 2,047.11$ 2,408.37$ 3,431.92$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,200.55$ 2,040.94$ 2,401.11$ 3,421.57$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,219.68$ 2,073.46$ 2,439.37$ 3,476.10$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,219.68$ 2,073.46$ 2,439.37$ 3,476.10$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,216.05$ 2,067.29$ 2,432.11$ 3,465.75$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,216.05$ 2,067.29$ 2,432.11$ 3,465.75$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,135.39$ 1,930.16$ 2,270.78$ 3,235.86$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,131.76$ 1,923.99$ 2,263.52$ 3,225.51$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,135.39$ 1,930.16$ 2,270.78$ 3,235.86$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,131.76$ 1,923.99$ 2,263.52$ 3,225.51$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,150.89$ 1,956.51$ 2,301.78$ 3,280.04$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,150.89$ 1,956.51$ 2,301.78$ 3,280.04$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,147.26$ 1,950.34$ 2,294.52$ 3,269.69$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,147.26$ 1,950.34$ 2,294.52$ 3,269.69$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 1,048.40$ 1,782.28$ 2,096.80$ 2,987.94$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 1,044.77$ 1,776.11$ 2,089.54$ 2,977.59$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 1,048.40$ 1,782.28$ 2,096.80$ 2,987.94$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 1,044.77$ 1,776.11$ 2,089.54$ 2,977.59$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 1,063.90$ 1,808.63$ 2,127.80$ 3,032.12$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 1,063.90$ 1,808.63$ 2,127.80$ 3,032.12$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 1,060.27$ 1,802.46$ 2,120.54$ 3,021.77$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 1,060.27$ 1,802.46$ 2,120.54$ 3,021.77$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 941.98$ 1,601.36$ 1,883.95$ 2,684.63$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 938.35$ 1,595.19$ 1,876.69$ 2,674.28$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 941.98$ 1,601.36$ 1,883.95$ 2,684.63$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 938.35$ 1,595.19$ 1,876.69$ 2,674.28$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 957.48$ 1,627.71$ 1,914.95$ 2,728.81$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 957.48$ 1,627.71$ 1,914.95$ 2,728.81$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 953.85$ 1,621.54$ 1,907.69$ 2,718.46$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 953.85$ 1,621.54$ 1,907.69$ 2,718.46$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 971.01$ 1,650.72$ 1,942.03$ 2,767.39$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 967.38$ 1,644.55$ 1,934.77$ 2,757.04$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 971.01$ 1,650.72$ 1,942.03$ 2,767.39$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 967.38$ 1,644.55$ 1,934.77$ 2,757.04$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 986.51$ 1,677.07$ 1,973.03$ 2,811.57$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 986.51$ 1,677.07$ 1,973.03$ 2,811.57$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 982.88$ 1,670.90$ 1,965.77$ 2,801.22$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 982.88$ 1,670.90$ 1,965.77$ 2,801.22$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 998.76$ 1,697.89$ 1,997.51$ 2,846.46$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 995.13$ 1,691.72$ 1,990.25$ 2,836.11$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 998.76$ 1,697.89$ 1,997.51$ 2,846.46$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 995.13$ 1,691.72$ 1,990.25$ 2,836.11$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 1,014.26$ 1,724.24$ 2,028.51$ 2,890.64$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 1,014.26$ 1,724.24$ 2,028.51$ 2,890.64$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 1,010.63$ 1,718.07$ 2,021.25$ 2,880.29$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 1,010.63$ 1,718.07$ 2,021.25$ 2,880.29$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 937.80$ 1,594.26$ 1,875.60$ 2,672.73$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 934.17$ 1,588.09$ 1,868.34$ 2,662.38$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 937.80$ 1,594.26$ 1,875.60$ 2,672.73$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 934.17$ 1,588.09$ 1,868.34$ 2,662.38$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 953.30$ 1,620.61$ 1,906.60$ 2,716.91$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 953.30$ 1,620.61$ 1,906.60$ 2,716.91$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 949.67$ 1,614.44$ 1,899.34$ 2,706.56$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 949.67$ 1,614.44$ 1,899.34$ 2,706.56$
Region 3
Page 4 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 968.57$ 1,646.56$ 1,937.13$ 2,760.41$
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 964.94$ 1,640.39$ 1,929.87$ 2,750.06$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 968.57$ 1,646.56$ 1,937.13$ 2,760.41$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 964.94$ 1,640.39$ 1,929.87$ 2,750.06$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 984.07$ 1,672.91$ 1,968.13$ 2,804.59$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 984.07$ 1,672.91$ 1,968.13$ 2,804.59$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 980.44$ 1,666.74$ 1,960.87$ 2,794.24$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 980.44$ 1,666.74$ 1,960.87$ 2,794.24$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 907.38$ 1,542.54$ 1,814.75$ 2,586.02$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 903.75$ 1,536.37$ 1,807.49$ 2,575.67$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 907.38$ 1,542.54$ 1,814.75$ 2,586.02$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 903.75$ 1,536.37$ 1,807.49$ 2,575.67$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 922.88$ 1,568.89$ 1,845.75$ 2,630.20$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 922.88$ 1,568.89$ 1,845.75$ 2,630.20$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 919.25$ 1,562.72$ 1,838.49$ 2,619.85$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 919.25$ 1,562.72$ 1,838.49$ 2,619.85$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 880.39$ 1,496.66$ 1,760.78$ 2,509.11$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 876.76$ 1,490.49$ 1,753.52$ 2,498.76$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 880.39$ 1,496.66$ 1,760.78$ 2,509.11$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 876.76$ 1,490.49$ 1,753.52$ 2,498.76$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 895.89$ 1,523.01$ 1,791.78$ 2,553.29$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 895.89$ 1,523.01$ 1,791.78$ 2,553.29$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 892.26$ 1,516.84$ 1,784.52$ 2,542.94$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 892.26$ 1,516.84$ 1,784.52$ 2,542.94$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 749.85$ 1,274.75$ 1,499.71$ 2,137.08$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 746.22$ 1,268.58$ 1,492.45$ 2,126.73$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 749.85$ 1,274.75$ 1,499.71$ 2,137.08$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 746.22$ 1,268.58$ 1,492.45$ 2,126.73$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 765.35$ 1,301.10$ 1,530.71$ 2,181.26$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 765.35$ 1,301.10$ 1,530.71$ 2,181.26$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 761.72$ 1,294.93$ 1,523.45$ 2,170.91$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 761.72$ 1,294.93$ 1,523.45$ 2,170.91$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 791.50$ 1,345.56$ 1,583.01$ 2,255.79$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 787.87$ 1,339.39$ 1,575.75$ 2,245.44$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 791.50$ 1,345.56$ 1,583.01$ 2,255.79$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 787.87$ 1,339.39$ 1,575.75$ 2,245.44$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 807.00$ 1,371.91$ 1,614.01$ 2,299.97$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 807.00$ 1,371.91$ 1,614.01$ 2,299.97$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 803.37$ 1,365.74$ 1,606.75$ 2,289.62$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 803.37$ 1,365.74$ 1,606.75$ 2,289.62$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 880.11$ 1,496.18$ 1,760.22$ 2,508.31$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 876.48$ 1,490.01$ 1,752.96$ 2,497.96$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 880.11$ 1,496.18$ 1,760.22$ 2,508.31$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 876.48$ 1,490.01$ 1,752.96$ 2,497.96$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 895.61$ 1,522.53$ 1,791.22$ 2,552.49$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 895.61$ 1,522.53$ 1,791.22$ 2,552.49$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 891.98$ 1,516.36$ 1,783.96$ 2,542.14$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 891.98$ 1,516.36$ 1,783.96$ 2,542.14$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 814.11$ 1,383.99$ 1,628.22$ 2,320.22$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 810.48$ 1,377.82$ 1,620.96$ 2,309.87$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 814.11$ 1,383.99$ 1,628.22$ 2,320.22$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 810.48$ 1,377.82$ 1,620.96$ 2,309.87$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 829.61$ 1,410.34$ 1,659.22$ 2,364.40$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 829.61$ 1,410.34$ 1,659.22$ 2,364.40$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 825.98$ 1,404.17$ 1,651.96$ 2,354.05$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 825.98$ 1,404.17$ 1,651.96$ 2,354.05$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 777.90$ 1,322.43$ 1,555.80$ 2,217.01$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 774.27$ 1,316.26$ 1,548.54$ 2,206.66$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 777.90$ 1,322.43$ 1,555.80$ 2,217.01$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 774.27$ 1,316.26$ 1,548.54$ 2,206.66$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 793.40$ 1,348.78$ 1,586.80$ 2,261.19$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 793.40$ 1,348.78$ 1,586.80$ 2,261.19$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 789.77$ 1,342.61$ 1,579.54$ 2,250.84$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 789.77$ 1,342.61$ 1,579.54$ 2,250.84$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 819.67$ 1,393.43$ 1,639.33$ 2,336.05$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 816.04$ 1,387.26$ 1,632.07$ 2,325.70$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 819.67$ 1,393.43$ 1,639.33$ 2,336.05$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 816.04$ 1,387.26$ 1,632.07$ 2,325.70$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 835.17$ 1,419.78$ 1,670.33$ 2,380.23$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 835.17$ 1,419.78$ 1,670.33$ 2,380.23$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 831.54$ 1,413.61$ 1,663.07$ 2,369.88$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 831.54$ 1,413.61$ 1,663.07$ 2,369.88$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 783.21$ 1,331.46$ 1,566.42$ 2,232.15$
Page 5 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 779.58$ 1,325.29$ 1,559.16$ 2,221.80$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 783.21$ 1,331.46$ 1,566.42$ 2,232.15$
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 779.58$ 1,325.29$ 1,559.16$ 2,221.80$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 798.71$ 1,357.81$ 1,597.42$ 2,276.33$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 798.71$ 1,357.81$ 1,597.42$ 2,276.33$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 795.08$ 1,351.64$ 1,590.16$ 2,265.98$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 795.08$ 1,351.64$ 1,590.16$ 2,265.98$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 746.49$ 1,269.04$ 1,492.99$ 2,127.51$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 742.86$ 1,262.87$ 1,485.73$ 2,117.16$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 746.49$ 1,269.04$ 1,492.99$ 2,127.51$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 742.86$ 1,262.87$ 1,485.73$ 2,117.16$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 761.99$ 1,295.39$ 1,523.99$ 2,171.69$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 761.99$ 1,295.39$ 1,523.99$ 2,171.69$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 758.36$ 1,289.22$ 1,516.73$ 2,161.34$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 758.36$ 1,289.22$ 1,516.73$ 2,161.34$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 740.63$ 1,259.07$ 1,481.26$ 2,110.79$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 737.00$ 1,252.90$ 1,474.00$ 2,100.44$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 740.63$ 1,259.07$ 1,481.26$ 2,110.79$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 737.00$ 1,252.90$ 1,474.00$ 2,100.44$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 756.13$ 1,285.42$ 1,512.26$ 2,154.97$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 756.13$ 1,285.42$ 1,512.26$ 2,154.97$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 752.50$ 1,279.25$ 1,505.00$ 2,144.62$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 752.50$ 1,279.25$ 1,505.00$ 2,144.62$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,385.48$ 2,355.31$ 2,770.96$ 3,948.61$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,381.85$ 2,349.14$ 2,763.70$ 3,938.26$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,385.48$ 2,355.31$ 2,770.96$ 3,948.61$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,381.85$ 2,349.14$ 2,763.70$ 3,938.26$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,400.98$ 2,381.66$ 2,801.96$ 3,992.79$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,400.98$ 2,381.66$ 2,801.96$ 3,992.79$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,397.35$ 2,375.49$ 2,794.70$ 3,982.44$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,397.35$ 2,375.49$ 2,794.70$ 3,982.44$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 935.10$ 1,589.67$ 1,870.20$ 2,665.04$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 931.47$ 1,583.50$ 1,862.94$ 2,654.69$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 935.10$ 1,589.67$ 1,870.20$ 2,665.04$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 931.47$ 1,583.50$ 1,862.94$ 2,654.69$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 950.60$ 1,616.02$ 1,901.20$ 2,709.22$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 950.60$ 1,616.02$ 1,901.20$ 2,709.22$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 946.97$ 1,609.85$ 1,893.94$ 2,698.87$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 946.97$ 1,609.85$ 1,893.94$ 2,698.87$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 1,049.83$ 1,784.71$ 2,099.65$ 2,992.01$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 1,046.20$ 1,778.54$ 2,092.39$ 2,981.66$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 1,049.83$ 1,784.71$ 2,099.65$ 2,992.01$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 1,046.20$ 1,778.54$ 2,092.39$ 2,981.66$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 1,065.33$ 1,811.06$ 2,130.65$ 3,036.19$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 1,065.33$ 1,811.06$ 2,130.65$ 3,036.19$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 1,061.70$ 1,804.89$ 2,123.39$ 3,025.84$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 1,061.70$ 1,804.89$ 2,123.39$ 3,025.84$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 754.46$ 1,282.58$ 1,508.91$ 2,150.20$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 750.83$ 1,276.41$ 1,501.65$ 2,139.85$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 754.46$ 1,282.58$ 1,508.91$ 2,150.20$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 750.83$ 1,276.41$ 1,501.65$ 2,139.85$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 769.96$ 1,308.93$ 1,539.91$ 2,194.38$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 769.96$ 1,308.93$ 1,539.91$ 2,194.38$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 766.33$ 1,302.76$ 1,532.65$ 2,184.03$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 766.33$ 1,302.76$ 1,532.65$ 2,184.03$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 666.82$ 1,133.59$ 1,333.63$ 1,900.42$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 663.19$ 1,127.42$ 1,326.37$ 1,890.07$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 666.82$ 1,133.59$ 1,333.63$ 1,900.42$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 663.19$ 1,127.42$ 1,326.37$ 1,890.07$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 682.32$ 1,159.94$ 1,364.63$ 1,944.60$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 682.32$ 1,159.94$ 1,364.63$ 1,944.60$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 678.69$ 1,153.77$ 1,357.37$ 1,934.25$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 678.69$ 1,153.77$ 1,357.37$ 1,934.25$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 679.52$ 1,155.18$ 1,359.04$ 1,936.62$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 675.89$ 1,149.01$ 1,351.78$ 1,926.27$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 679.52$ 1,155.18$ 1,359.04$ 1,936.62$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 675.89$ 1,149.01$ 1,351.78$ 1,926.27$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 695.02$ 1,181.53$ 1,390.04$ 1,980.80$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 695.02$ 1,181.53$ 1,390.04$ 1,980.80$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 691.39$ 1,175.36$ 1,382.78$ 1,970.45$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 691.39$ 1,175.36$ 1,382.78$ 1,970.45$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 646.99$ 1,099.88$ 1,293.97$ 1,843.91$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 643.36$ 1,093.71$ 1,286.71$ 1,833.56$
Page 6 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 646.99$ 1,099.88$ 1,293.97$ 1,843.91$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 643.36$ 1,093.71$ 1,286.71$ 1,833.56$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 662.49$ 1,126.23$ 1,324.97$ 1,888.09$
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 662.49$ 1,126.23$ 1,324.97$ 1,888.09$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 658.86$ 1,120.06$ 1,317.71$ 1,877.74$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 658.86$ 1,120.06$ 1,317.71$ 1,877.74$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 676.54$ 1,150.11$ 1,353.07$ 1,928.13$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 672.91$ 1,143.94$ 1,345.81$ 1,917.78$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 676.54$ 1,150.11$ 1,353.07$ 1,928.13$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 672.91$ 1,143.94$ 1,345.81$ 1,917.78$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 692.04$ 1,176.46$ 1,384.07$ 1,972.31$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 692.04$ 1,176.46$ 1,384.07$ 1,972.31$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 688.41$ 1,170.29$ 1,376.81$ 1,961.96$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 688.41$ 1,170.29$ 1,376.81$ 1,961.96$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 646.45$ 1,098.97$ 1,292.90$ 1,842.39$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 642.82$ 1,092.80$ 1,285.64$ 1,832.04$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 646.45$ 1,098.97$ 1,292.90$ 1,842.39$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 642.82$ 1,092.80$ 1,285.64$ 1,832.04$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 661.95$ 1,125.32$ 1,323.90$ 1,886.57$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 661.95$ 1,125.32$ 1,323.90$ 1,886.57$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 658.32$ 1,119.15$ 1,316.64$ 1,876.22$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 658.32$ 1,119.15$ 1,316.64$ 1,876.22$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 685.72$ 1,165.73$ 1,371.45$ 1,954.31$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 682.09$ 1,159.56$ 1,364.19$ 1,943.96$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 685.72$ 1,165.73$ 1,371.45$ 1,954.31$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 682.09$ 1,159.56$ 1,364.19$ 1,943.96$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 701.22$ 1,192.08$ 1,402.45$ 1,998.49$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 701.22$ 1,192.08$ 1,402.45$ 1,998.49$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 697.59$ 1,185.91$ 1,395.19$ 1,988.14$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 697.59$ 1,185.91$ 1,395.19$ 1,988.14$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 551.86$ 938.16$ 1,103.71$ 1,572.79$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 548.23$ 931.99$ 1,096.45$ 1,562.44$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 551.86$ 938.16$ 1,103.71$ 1,572.79$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 548.23$ 931.99$ 1,096.45$ 1,562.44$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 567.36$ 964.51$ 1,134.71$ 1,616.97$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 567.36$ 964.51$ 1,134.71$ 1,616.97$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 563.73$ 958.34$ 1,127.45$ 1,606.62$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 563.73$ 958.34$ 1,127.45$ 1,606.62$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 550.56$ 935.94$ 1,101.11$ 1,569.08$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 546.93$ 929.77$ 1,093.85$ 1,558.73$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 550.56$ 935.94$ 1,101.11$ 1,569.08$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 546.93$ 929.77$ 1,093.85$ 1,558.73$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 566.06$ 962.29$ 1,132.11$ 1,613.26$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 566.06$ 962.29$ 1,132.11$ 1,613.26$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 562.43$ 956.12$ 1,124.85$ 1,602.91$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 562.43$ 956.12$ 1,124.85$ 1,602.91$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 669.14$ 1,137.53$ 1,338.27$ 1,907.04$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 665.51$ 1,131.36$ 1,331.01$ 1,896.69$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 669.14$ 1,137.53$ 1,338.27$ 1,907.04$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 665.51$ 1,131.36$ 1,331.01$ 1,896.69$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 684.64$ 1,163.88$ 1,369.27$ 1,951.22$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 684.64$ 1,163.88$ 1,369.27$ 1,951.22$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 681.01$ 1,157.71$ 1,362.01$ 1,940.87$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 681.01$ 1,157.71$ 1,362.01$ 1,940.87$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 544.52$ 925.69$ 1,089.05$ 1,551.90$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 540.89$ 919.52$ 1,081.79$ 1,541.55$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 544.52$ 925.69$ 1,089.05$ 1,551.90$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 540.89$ 919.52$ 1,081.79$ 1,541.55$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 560.02$ 952.04$ 1,120.05$ 1,596.08$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 560.02$ 952.04$ 1,120.05$ 1,596.08$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 556.39$ 945.87$ 1,112.79$ 1,585.73$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 556.39$ 945.87$ 1,112.79$ 1,585.73$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 689.43$ 1,172.04$ 1,378.86$ 1,964.88$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 685.80$ 1,165.87$ 1,371.60$ 1,954.53$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 689.43$ 1,172.04$ 1,378.86$ 1,964.88$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 685.80$ 1,165.87$ 1,371.60$ 1,954.53$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 704.93$ 1,198.39$ 1,409.86$ 2,009.06$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 704.93$ 1,198.39$ 1,409.86$ 2,009.06$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 701.30$ 1,192.22$ 1,402.60$ 1,998.71$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 701.30$ 1,192.22$ 1,402.60$ 1,998.71$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 798.49$ 1,357.43$ 1,596.97$ 2,275.69$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 794.86$ 1,351.26$ 1,589.71$ 2,265.34$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 798.49$ 1,357.43$ 1,596.97$ 2,275.69$
Page 7 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 794.86$ 1,351.26$ 1,589.71$ 2,265.34$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 813.99$ 1,383.78$ 1,627.97$ 2,319.87$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 813.99$ 1,383.78$ 1,627.97$ 2,319.87$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 810.36$ 1,377.61$ 1,620.71$ 2,309.52$
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 810.36$ 1,377.61$ 1,620.71$ 2,309.52$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 638.26$ 1,085.03$ 1,276.51$ 1,819.03$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 634.63$ 1,078.86$ 1,269.25$ 1,808.68$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 638.26$ 1,085.03$ 1,276.51$ 1,819.03$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 634.63$ 1,078.86$ 1,269.25$ 1,808.68$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 653.76$ 1,111.38$ 1,307.51$ 1,863.21$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 653.76$ 1,111.38$ 1,307.51$ 1,863.21$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 650.13$ 1,105.21$ 1,300.25$ 1,852.86$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 650.13$ 1,105.21$ 1,300.25$ 1,852.86$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 863.93$ 1,468.68$ 1,727.86$ 2,462.20$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 860.30$ 1,462.51$ 1,720.60$ 2,451.85$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 863.93$ 1,468.68$ 1,727.86$ 2,462.20$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 860.30$ 1,462.51$ 1,720.60$ 2,451.85$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 879.43$ 1,495.03$ 1,758.86$ 2,506.38$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 879.43$ 1,495.03$ 1,758.86$ 2,506.38$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 875.80$ 1,488.86$ 1,751.60$ 2,496.03$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 875.80$ 1,488.86$ 1,751.60$ 2,496.03$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 717.57$ 1,219.88$ 1,435.15$ 2,045.09$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 713.94$ 1,213.71$ 1,427.89$ 2,034.74$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 717.57$ 1,219.88$ 1,435.15$ 2,045.09$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 713.94$ 1,213.71$ 1,427.89$ 2,034.74$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 733.07$ 1,246.23$ 1,466.15$ 2,089.27$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 733.07$ 1,246.23$ 1,466.15$ 2,089.27$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 729.44$ 1,240.06$ 1,458.89$ 2,078.92$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 729.44$ 1,240.06$ 1,458.89$ 2,078.92$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 682.66$ 1,160.53$ 1,365.33$ 1,945.59$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 679.03$ 1,154.36$ 1,358.07$ 1,935.24$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 682.66$ 1,160.53$ 1,365.33$ 1,945.59$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 679.03$ 1,154.36$ 1,358.07$ 1,935.24$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 698.16$ 1,186.88$ 1,396.33$ 1,989.77$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 698.16$ 1,186.88$ 1,396.33$ 1,989.77$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 694.53$ 1,180.71$ 1,389.07$ 1,979.42$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 694.53$ 1,180.71$ 1,389.07$ 1,979.42$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,099.41$ 1,869.00$ 2,198.82$ 3,133.32$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,095.78$ 1,862.83$ 2,191.56$ 3,122.97$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,099.41$ 1,869.00$ 2,198.82$ 3,133.32$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,095.78$ 1,862.83$ 2,191.56$ 3,122.97$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,114.91$ 1,895.35$ 2,229.82$ 3,177.50$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,114.91$ 1,895.35$ 2,229.82$ 3,177.50$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,111.28$ 1,889.18$ 2,222.56$ 3,167.15$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,111.28$ 1,889.18$ 2,222.56$ 3,167.15$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 889.57$ 1,512.26$ 1,779.13$ 2,535.26$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 885.94$ 1,506.09$ 1,771.87$ 2,524.91$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 889.57$ 1,512.26$ 1,779.13$ 2,535.26$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 885.94$ 1,506.09$ 1,771.87$ 2,524.91$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 905.07$ 1,538.61$ 1,810.13$ 2,579.44$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 905.07$ 1,538.61$ 1,810.13$ 2,579.44$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 901.44$ 1,532.44$ 1,802.87$ 2,569.09$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 901.44$ 1,532.44$ 1,802.87$ 2,569.09$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 850.00$ 1,445.01$ 1,700.01$ 2,422.51$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 846.37$ 1,438.84$ 1,692.75$ 2,412.16$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 850.00$ 1,445.01$ 1,700.01$ 2,422.51$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 846.37$ 1,438.84$ 1,692.75$ 2,412.16$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 865.50$ 1,471.36$ 1,731.01$ 2,466.69$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 865.50$ 1,471.36$ 1,731.01$ 2,466.69$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 861.87$ 1,465.19$ 1,723.75$ 2,456.34$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 861.87$ 1,465.19$ 1,723.75$ 2,456.34$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 950.77$ 1,616.30$ 1,901.53$ 2,709.68$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 947.14$ 1,610.13$ 1,894.27$ 2,699.33$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 950.77$ 1,616.30$ 1,901.53$ 2,709.68$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 947.14$ 1,610.13$ 1,894.27$ 2,699.33$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 966.27$ 1,642.65$ 1,932.53$ 2,753.86$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 966.27$ 1,642.65$ 1,932.53$ 2,753.86$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 962.64$ 1,636.48$ 1,925.27$ 2,743.51$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 962.64$ 1,636.48$ 1,925.27$ 2,743.51$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 685.49$ 1,165.33$ 1,370.98$ 1,953.65$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 681.86$ 1,159.16$ 1,363.72$ 1,943.30$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 685.49$ 1,165.33$ 1,370.98$ 1,953.65$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 681.86$ 1,159.16$ 1,363.72$ 1,943.30$
Page 8 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 700.99$ 1,191.68$ 1,401.98$ 1,997.83$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 700.99$ 1,191.68$ 1,401.98$ 1,997.83$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 697.36$ 1,185.51$ 1,394.72$ 1,987.48$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 697.36$ 1,185.51$ 1,394.72$ 1,987.48$
Page 9 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,113.47$ 1,892.90$ 2,226.95$ 3,173.40$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,110.17$ 1,887.29$ 2,220.35$ 3,163.99$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,113.47$ 1,892.90$ 2,226.95$ 3,173.40$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,110.17$ 1,887.29$ 2,220.35$ 3,163.99$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,127.55$ 1,916.84$ 2,255.11$ 3,213.53$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,127.55$ 1,916.84$ 2,255.11$ 3,213.53$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,124.25$ 1,911.23$ 2,248.51$ 3,204.12$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,124.25$ 1,911.23$ 2,248.51$ 3,204.12$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,046.84$ 1,779.62$ 2,093.67$ 2,983.48$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,043.54$ 1,774.01$ 2,087.07$ 2,974.07$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,046.84$ 1,779.62$ 2,093.67$ 2,983.48$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,043.54$ 1,774.01$ 2,087.07$ 2,974.07$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,060.92$ 1,803.56$ 2,121.83$ 3,023.61$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,060.92$ 1,803.56$ 2,121.83$ 3,023.61$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,057.62$ 1,797.95$ 2,115.23$ 3,014.20$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,057.62$ 1,797.95$ 2,115.23$ 3,014.20$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,093.61$ 1,859.14$ 2,187.23$ 3,116.80$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,090.31$ 1,853.53$ 2,180.63$ 3,107.39$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,093.61$ 1,859.14$ 2,187.23$ 3,116.80$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,090.31$ 1,853.53$ 2,180.63$ 3,107.39$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,107.69$ 1,883.08$ 2,215.39$ 3,156.93$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,107.69$ 1,883.08$ 2,215.39$ 3,156.93$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,104.39$ 1,877.47$ 2,208.79$ 3,147.52$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,104.39$ 1,877.47$ 2,208.79$ 3,147.52$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,031.14$ 1,752.94$ 2,062.29$ 2,938.76$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,027.84$ 1,747.33$ 2,055.69$ 2,929.35$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,031.14$ 1,752.94$ 2,062.29$ 2,938.76$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,027.84$ 1,747.33$ 2,055.69$ 2,929.35$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,045.22$ 1,776.88$ 2,090.45$ 2,978.89$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,045.22$ 1,776.88$ 2,090.45$ 2,978.89$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,041.92$ 1,771.27$ 2,083.85$ 2,969.48$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,041.92$ 1,771.27$ 2,083.85$ 2,969.48$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 952.13$ 1,618.63$ 1,904.27$ 2,713.58$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 948.83$ 1,613.02$ 1,897.67$ 2,704.17$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 952.13$ 1,618.63$ 1,904.27$ 2,713.58$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 948.83$ 1,613.02$ 1,897.67$ 2,704.17$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 966.21$ 1,642.57$ 1,932.43$ 2,753.71$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 966.21$ 1,642.57$ 1,932.43$ 2,753.71$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 962.91$ 1,636.96$ 1,925.83$ 2,744.30$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 962.91$ 1,636.96$ 1,925.83$ 2,744.30$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 855.49$ 1,454.33$ 1,710.98$ 2,438.15$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 852.19$ 1,448.72$ 1,704.38$ 2,428.74$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 855.49$ 1,454.33$ 1,710.98$ 2,438.15$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 852.19$ 1,448.72$ 1,704.38$ 2,428.74$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 869.57$ 1,478.27$ 1,739.14$ 2,478.28$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 869.57$ 1,478.27$ 1,739.14$ 2,478.28$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 866.27$ 1,472.66$ 1,732.54$ 2,468.87$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 866.27$ 1,472.66$ 1,732.54$ 2,468.87$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 881.86$ 1,499.16$ 1,763.71$ 2,513.29$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 878.56$ 1,493.55$ 1,757.11$ 2,503.88$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 881.86$ 1,499.16$ 1,763.71$ 2,513.29$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 878.56$ 1,493.55$ 1,757.11$ 2,503.88$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 895.94$ 1,523.10$ 1,791.87$ 2,553.42$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 895.94$ 1,523.10$ 1,791.87$ 2,553.42$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 892.64$ 1,517.49$ 1,785.27$ 2,544.01$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 892.64$ 1,517.49$ 1,785.27$ 2,544.01$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 907.06$ 1,542.00$ 1,814.11$ 2,585.11$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 903.76$ 1,536.39$ 1,807.51$ 2,575.70$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 907.06$ 1,542.00$ 1,814.11$ 2,585.11$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 903.76$ 1,536.39$ 1,807.51$ 2,575.70$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 921.14$ 1,565.94$ 1,842.27$ 2,625.24$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 921.14$ 1,565.94$ 1,842.27$ 2,625.24$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 917.84$ 1,560.33$ 1,835.67$ 2,615.83$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 917.84$ 1,560.33$ 1,835.67$ 2,615.83$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 851.69$ 1,447.88$ 1,703.39$ 2,427.33$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 848.39$ 1,442.27$ 1,696.79$ 2,417.92$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 851.69$ 1,447.88$ 1,703.39$ 2,427.33$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 848.39$ 1,442.27$ 1,696.79$ 2,417.92$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 865.77$ 1,471.82$ 1,731.55$ 2,467.46$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 865.77$ 1,471.82$ 1,731.55$ 2,467.46$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 862.47$ 1,466.21$ 1,724.95$ 2,458.05$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 862.47$ 1,466.21$ 1,724.95$ 2,458.05$
Region 4
Page 10 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 879.63$ 1,495.37$ 1,759.26$ 2,506.95$
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 876.33$ 1,489.76$ 1,752.66$ 2,497.54$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 879.63$ 1,495.37$ 1,759.26$ 2,506.95$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 876.33$ 1,489.76$ 1,752.66$ 2,497.54$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 893.71$ 1,519.31$ 1,787.42$ 2,547.08$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 893.71$ 1,519.31$ 1,787.42$ 2,547.08$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 890.41$ 1,513.70$ 1,780.82$ 2,537.67$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 890.41$ 1,513.70$ 1,780.82$ 2,537.67$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 824.07$ 1,400.91$ 1,648.13$ 2,348.59$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 820.77$ 1,395.30$ 1,641.53$ 2,339.18$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 824.07$ 1,400.91$ 1,648.13$ 2,348.59$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 820.77$ 1,395.30$ 1,641.53$ 2,339.18$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 838.15$ 1,424.85$ 1,676.29$ 2,388.72$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 838.15$ 1,424.85$ 1,676.29$ 2,388.72$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 834.85$ 1,419.24$ 1,669.69$ 2,379.31$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 834.85$ 1,419.24$ 1,669.69$ 2,379.31$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 799.56$ 1,359.24$ 1,599.11$ 2,278.73$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 796.26$ 1,353.63$ 1,592.51$ 2,269.32$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 799.56$ 1,359.24$ 1,599.11$ 2,278.73$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 796.26$ 1,353.63$ 1,592.51$ 2,269.32$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 813.64$ 1,383.18$ 1,627.27$ 2,318.86$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 813.64$ 1,383.18$ 1,627.27$ 2,318.86$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 810.34$ 1,377.57$ 1,620.67$ 2,309.45$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 810.34$ 1,377.57$ 1,620.67$ 2,309.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 681.00$ 1,157.71$ 1,362.01$ 1,940.86$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 677.70$ 1,152.10$ 1,355.41$ 1,931.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 681.00$ 1,157.71$ 1,362.01$ 1,940.86$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 677.70$ 1,152.10$ 1,355.41$ 1,931.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 695.08$ 1,181.65$ 1,390.17$ 1,980.99$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 695.08$ 1,181.65$ 1,390.17$ 1,980.99$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 691.78$ 1,176.04$ 1,383.57$ 1,971.58$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 691.78$ 1,176.04$ 1,383.57$ 1,971.58$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 718.83$ 1,222.01$ 1,437.66$ 2,048.66$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 715.53$ 1,216.40$ 1,431.06$ 2,039.25$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 718.83$ 1,222.01$ 1,437.66$ 2,048.66$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 715.53$ 1,216.40$ 1,431.06$ 2,039.25$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 732.91$ 1,245.95$ 1,465.82$ 2,088.79$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 732.91$ 1,245.95$ 1,465.82$ 2,088.79$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 729.61$ 1,240.34$ 1,459.22$ 2,079.38$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 729.61$ 1,240.34$ 1,459.22$ 2,079.38$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 799.30$ 1,358.81$ 1,598.61$ 2,278.01$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 796.00$ 1,353.20$ 1,592.01$ 2,268.60$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 799.30$ 1,358.81$ 1,598.61$ 2,278.01$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 796.00$ 1,353.20$ 1,592.01$ 2,268.60$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 813.38$ 1,382.75$ 1,626.77$ 2,318.14$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 813.38$ 1,382.75$ 1,626.77$ 2,318.14$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 810.08$ 1,377.14$ 1,620.17$ 2,308.73$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 810.08$ 1,377.14$ 1,620.17$ 2,308.73$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 739.37$ 1,256.92$ 1,478.73$ 2,107.19$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 736.07$ 1,251.31$ 1,472.13$ 2,097.78$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 739.37$ 1,256.92$ 1,478.73$ 2,107.19$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 736.07$ 1,251.31$ 1,472.13$ 2,097.78$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 753.45$ 1,280.86$ 1,506.89$ 2,147.32$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 753.45$ 1,280.86$ 1,506.89$ 2,147.32$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 750.15$ 1,275.25$ 1,500.29$ 2,137.91$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 750.15$ 1,275.25$ 1,500.29$ 2,137.91$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 706.48$ 1,201.01$ 1,412.95$ 2,013.45$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 703.18$ 1,195.40$ 1,406.35$ 2,004.04$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 706.48$ 1,201.01$ 1,412.95$ 2,013.45$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 703.18$ 1,195.40$ 1,406.35$ 2,004.04$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 720.56$ 1,224.95$ 1,441.11$ 2,053.58$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 720.56$ 1,224.95$ 1,441.11$ 2,053.58$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 717.26$ 1,219.34$ 1,434.51$ 2,044.17$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 717.26$ 1,219.34$ 1,434.51$ 2,044.17$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 744.41$ 1,265.49$ 1,488.81$ 2,121.56$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 741.11$ 1,259.88$ 1,482.21$ 2,112.15$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 744.41$ 1,265.49$ 1,488.81$ 2,121.56$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 741.11$ 1,259.88$ 1,482.21$ 2,112.15$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 758.49$ 1,289.43$ 1,516.97$ 2,161.69$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 758.49$ 1,289.43$ 1,516.97$ 2,161.69$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 755.19$ 1,283.82$ 1,510.37$ 2,152.28$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 755.19$ 1,283.82$ 1,510.37$ 2,152.28$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 711.30$ 1,209.21$ 1,422.60$ 2,027.21$
Page 11 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 708.00$ 1,203.60$ 1,416.00$ 2,017.80$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 711.30$ 1,209.21$ 1,422.60$ 2,027.21$
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 708.00$ 1,203.60$ 1,416.00$ 2,017.80$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 725.38$ 1,233.15$ 1,450.76$ 2,067.34$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 725.38$ 1,233.15$ 1,450.76$ 2,067.34$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 722.08$ 1,227.54$ 1,444.16$ 2,057.93$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 722.08$ 1,227.54$ 1,444.16$ 2,057.93$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 677.95$ 1,152.52$ 1,355.91$ 1,932.17$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 674.65$ 1,146.91$ 1,349.31$ 1,922.76$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 677.95$ 1,152.52$ 1,355.91$ 1,932.17$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 674.65$ 1,146.91$ 1,349.31$ 1,922.76$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 692.03$ 1,176.46$ 1,384.07$ 1,972.30$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 692.03$ 1,176.46$ 1,384.07$ 1,972.30$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 688.73$ 1,170.85$ 1,377.47$ 1,962.89$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 688.73$ 1,170.85$ 1,377.47$ 1,962.89$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 672.63$ 1,143.48$ 1,345.26$ 1,917.00$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 669.33$ 1,137.87$ 1,338.66$ 1,907.59$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 672.63$ 1,143.48$ 1,345.26$ 1,917.00$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 669.33$ 1,137.87$ 1,338.66$ 1,907.59$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 686.71$ 1,167.42$ 1,373.42$ 1,957.13$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 686.71$ 1,167.42$ 1,373.42$ 1,957.13$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 683.41$ 1,161.81$ 1,366.82$ 1,947.72$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 683.41$ 1,161.81$ 1,366.82$ 1,947.72$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,258.26$ 2,139.05$ 2,516.53$ 3,586.05$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,254.96$ 2,133.44$ 2,509.93$ 3,576.64$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,258.26$ 2,139.05$ 2,516.53$ 3,586.05$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,254.96$ 2,133.44$ 2,509.93$ 3,576.64$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,272.34$ 2,162.99$ 2,544.69$ 3,626.18$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,272.34$ 2,162.99$ 2,544.69$ 3,626.18$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,269.04$ 2,157.38$ 2,538.09$ 3,616.77$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,269.04$ 2,157.38$ 2,538.09$ 3,616.77$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 849.24$ 1,443.70$ 1,698.47$ 2,420.32$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 845.94$ 1,438.09$ 1,691.87$ 2,410.91$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 849.24$ 1,443.70$ 1,698.47$ 2,420.32$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 845.94$ 1,438.09$ 1,691.87$ 2,410.91$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 863.32$ 1,467.64$ 1,726.63$ 2,460.45$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 863.32$ 1,467.64$ 1,726.63$ 2,460.45$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 860.02$ 1,462.03$ 1,720.03$ 2,451.04$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 860.02$ 1,462.03$ 1,720.03$ 2,451.04$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 953.44$ 1,620.84$ 1,906.87$ 2,717.29$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 950.14$ 1,615.23$ 1,900.27$ 2,707.88$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 953.44$ 1,620.84$ 1,906.87$ 2,717.29$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 950.14$ 1,615.23$ 1,900.27$ 2,707.88$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 967.52$ 1,644.78$ 1,935.03$ 2,757.42$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 967.52$ 1,644.78$ 1,935.03$ 2,757.42$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 964.22$ 1,639.17$ 1,928.43$ 2,748.01$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 964.22$ 1,639.17$ 1,928.43$ 2,748.01$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 685.18$ 1,164.80$ 1,370.36$ 1,952.76$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 681.88$ 1,159.19$ 1,363.76$ 1,943.35$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 685.18$ 1,164.80$ 1,370.36$ 1,952.76$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 681.88$ 1,159.19$ 1,363.76$ 1,943.35$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 699.26$ 1,188.74$ 1,398.52$ 1,992.89$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 699.26$ 1,188.74$ 1,398.52$ 1,992.89$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 695.96$ 1,183.13$ 1,391.92$ 1,983.48$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 695.96$ 1,183.13$ 1,391.92$ 1,983.48$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 605.60$ 1,029.52$ 1,211.19$ 1,725.95$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 602.30$ 1,023.91$ 1,204.59$ 1,716.54$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 605.60$ 1,029.52$ 1,211.19$ 1,725.95$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 602.30$ 1,023.91$ 1,204.59$ 1,716.54$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 619.68$ 1,053.46$ 1,239.35$ 1,766.08$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 619.68$ 1,053.46$ 1,239.35$ 1,766.08$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 616.38$ 1,047.85$ 1,232.75$ 1,756.67$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 616.38$ 1,047.85$ 1,232.75$ 1,756.67$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 617.12$ 1,049.11$ 1,234.25$ 1,758.80$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 613.82$ 1,043.50$ 1,227.65$ 1,749.39$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 617.12$ 1,049.11$ 1,234.25$ 1,758.80$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 613.82$ 1,043.50$ 1,227.65$ 1,749.39$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 631.20$ 1,073.05$ 1,262.41$ 1,798.93$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 631.20$ 1,073.05$ 1,262.41$ 1,798.93$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 627.90$ 1,067.44$ 1,255.81$ 1,789.52$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 627.90$ 1,067.44$ 1,255.81$ 1,789.52$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 587.57$ 998.88$ 1,175.15$ 1,674.59$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 584.27$ 993.27$ 1,168.55$ 1,665.18$
Page 12 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 587.57$ 998.88$ 1,175.15$ 1,674.59$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 584.27$ 993.27$ 1,168.55$ 1,665.18$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 601.65$ 1,022.82$ 1,203.31$ 1,714.72$
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 601.65$ 1,022.82$ 1,203.31$ 1,714.72$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 598.35$ 1,017.21$ 1,196.71$ 1,705.31$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 598.35$ 1,017.21$ 1,196.71$ 1,705.31$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 614.42$ 1,044.52$ 1,228.85$ 1,751.11$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 611.12$ 1,038.91$ 1,222.25$ 1,741.70$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 614.42$ 1,044.52$ 1,228.85$ 1,751.11$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 611.12$ 1,038.91$ 1,222.25$ 1,741.70$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 628.50$ 1,068.46$ 1,257.01$ 1,791.24$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 628.50$ 1,068.46$ 1,257.01$ 1,791.24$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 625.20$ 1,062.85$ 1,250.41$ 1,781.83$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 625.20$ 1,062.85$ 1,250.41$ 1,781.83$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 587.09$ 998.05$ 1,174.18$ 1,673.20$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 583.79$ 992.44$ 1,167.58$ 1,663.79$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 587.09$ 998.05$ 1,174.18$ 1,673.20$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 583.79$ 992.44$ 1,167.58$ 1,663.79$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 601.17$ 1,021.99$ 1,202.34$ 1,713.33$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 601.17$ 1,021.99$ 1,202.34$ 1,713.33$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 597.87$ 1,016.38$ 1,195.74$ 1,703.92$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 597.87$ 1,016.38$ 1,195.74$ 1,703.92$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 622.77$ 1,058.70$ 1,245.53$ 1,774.88$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 619.47$ 1,053.09$ 1,238.93$ 1,765.47$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 622.77$ 1,058.70$ 1,245.53$ 1,774.88$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 619.47$ 1,053.09$ 1,238.93$ 1,765.47$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 636.85$ 1,082.64$ 1,273.69$ 1,815.01$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 636.85$ 1,082.64$ 1,273.69$ 1,815.01$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 633.55$ 1,077.03$ 1,267.09$ 1,805.60$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 633.55$ 1,077.03$ 1,267.09$ 1,805.60$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 501.18$ 852.01$ 1,002.37$ 1,428.38$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 497.88$ 846.40$ 995.77$ 1,418.97$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 501.18$ 852.01$ 1,002.37$ 1,428.38$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 497.88$ 846.40$ 995.77$ 1,418.97$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 515.26$ 875.95$ 1,030.53$ 1,468.51$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 515.26$ 875.95$ 1,030.53$ 1,468.51$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 511.96$ 870.34$ 1,023.93$ 1,459.10$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 511.96$ 870.34$ 1,023.93$ 1,459.10$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 500.00$ 850.00$ 1,000.00$ 1,425.00$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 496.70$ 844.39$ 993.40$ 1,415.59$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 500.00$ 850.00$ 1,000.00$ 1,425.00$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 496.70$ 844.39$ 993.40$ 1,415.59$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 514.08$ 873.94$ 1,028.16$ 1,465.13$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 514.08$ 873.94$ 1,028.16$ 1,465.13$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 510.78$ 868.33$ 1,021.56$ 1,455.72$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 510.78$ 868.33$ 1,021.56$ 1,455.72$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 607.69$ 1,033.08$ 1,215.39$ 1,731.93$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 604.39$ 1,027.47$ 1,208.79$ 1,722.52$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 607.69$ 1,033.08$ 1,215.39$ 1,731.93$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 604.39$ 1,027.47$ 1,208.79$ 1,722.52$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 621.77$ 1,057.02$ 1,243.55$ 1,772.06$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 621.77$ 1,057.02$ 1,243.55$ 1,772.06$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 618.47$ 1,051.41$ 1,236.95$ 1,762.65$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 618.47$ 1,051.41$ 1,236.95$ 1,762.65$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 494.52$ 840.69$ 989.05$ 1,409.39$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 491.22$ 835.08$ 982.45$ 1,399.98$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 494.52$ 840.69$ 989.05$ 1,409.39$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 491.22$ 835.08$ 982.45$ 1,399.98$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 508.60$ 864.63$ 1,017.21$ 1,449.52$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 508.60$ 864.63$ 1,017.21$ 1,449.52$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 505.30$ 859.02$ 1,010.61$ 1,440.11$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 505.30$ 859.02$ 1,010.61$ 1,440.11$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 626.13$ 1,064.41$ 1,252.25$ 1,784.46$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 622.83$ 1,058.80$ 1,245.65$ 1,775.05$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 626.13$ 1,064.41$ 1,252.25$ 1,784.46$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 622.83$ 1,058.80$ 1,245.65$ 1,775.05$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 640.21$ 1,088.35$ 1,280.41$ 1,824.59$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 640.21$ 1,088.35$ 1,280.41$ 1,824.59$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 636.91$ 1,082.74$ 1,273.81$ 1,815.18$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 636.91$ 1,082.74$ 1,273.81$ 1,815.18$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 725.17$ 1,232.79$ 1,450.34$ 2,066.73$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 721.87$ 1,227.18$ 1,443.74$ 2,057.32$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 725.17$ 1,232.79$ 1,450.34$ 2,066.73$
Page 13 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 721.87$ 1,227.18$ 1,443.74$ 2,057.32$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 739.25$ 1,256.73$ 1,478.50$ 2,106.86$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 739.25$ 1,256.73$ 1,478.50$ 2,106.86$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 735.95$ 1,251.12$ 1,471.90$ 2,097.45$
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 735.95$ 1,251.12$ 1,471.90$ 2,097.45$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 579.65$ 985.40$ 1,159.30$ 1,652.00$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 576.35$ 979.79$ 1,152.70$ 1,642.59$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 579.65$ 985.40$ 1,159.30$ 1,652.00$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 576.35$ 979.79$ 1,152.70$ 1,642.59$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 593.73$ 1,009.34$ 1,187.46$ 1,692.13$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 593.73$ 1,009.34$ 1,187.46$ 1,692.13$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 590.43$ 1,003.73$ 1,180.86$ 1,682.72$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 590.43$ 1,003.73$ 1,180.86$ 1,682.72$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 784.60$ 1,333.82$ 1,569.20$ 2,236.11$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 781.30$ 1,328.21$ 1,562.60$ 2,226.70$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 784.60$ 1,333.82$ 1,569.20$ 2,236.11$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 781.30$ 1,328.21$ 1,562.60$ 2,226.70$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 798.68$ 1,357.76$ 1,597.36$ 2,276.24$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 798.68$ 1,357.76$ 1,597.36$ 2,276.24$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 795.38$ 1,352.15$ 1,590.76$ 2,266.83$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 795.38$ 1,352.15$ 1,590.76$ 2,266.83$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 651.69$ 1,107.87$ 1,303.37$ 1,857.30$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 648.39$ 1,102.26$ 1,296.77$ 1,847.89$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 651.69$ 1,107.87$ 1,303.37$ 1,857.30$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 648.39$ 1,102.26$ 1,296.77$ 1,847.89$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 665.77$ 1,131.81$ 1,331.53$ 1,897.43$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 665.77$ 1,131.81$ 1,331.53$ 1,897.43$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 662.47$ 1,126.20$ 1,324.93$ 1,888.02$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 662.47$ 1,126.20$ 1,324.93$ 1,888.02$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 619.98$ 1,053.96$ 1,239.96$ 1,766.94$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 616.68$ 1,048.35$ 1,233.36$ 1,757.53$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 619.98$ 1,053.96$ 1,239.96$ 1,766.94$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 616.68$ 1,048.35$ 1,233.36$ 1,757.53$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 634.06$ 1,077.90$ 1,268.12$ 1,807.07$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 634.06$ 1,077.90$ 1,268.12$ 1,807.07$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 630.76$ 1,072.29$ 1,261.52$ 1,797.66$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 630.76$ 1,072.29$ 1,261.52$ 1,797.66$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 998.47$ 1,697.39$ 1,996.93$ 2,845.63$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 995.17$ 1,691.78$ 1,990.33$ 2,836.22$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 998.47$ 1,697.39$ 1,996.93$ 2,845.63$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 995.17$ 1,691.78$ 1,990.33$ 2,836.22$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,012.55$ 1,721.33$ 2,025.09$ 2,885.76$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,012.55$ 1,721.33$ 2,025.09$ 2,885.76$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,009.25$ 1,715.72$ 2,018.49$ 2,876.35$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,009.25$ 1,715.72$ 2,018.49$ 2,876.35$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 807.89$ 1,373.41$ 1,615.77$ 2,302.48$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 804.59$ 1,367.80$ 1,609.17$ 2,293.07$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 807.89$ 1,373.41$ 1,615.77$ 2,302.48$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 804.59$ 1,367.80$ 1,609.17$ 2,293.07$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 821.97$ 1,397.35$ 1,643.93$ 2,342.61$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 821.97$ 1,397.35$ 1,643.93$ 2,342.61$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 818.67$ 1,391.74$ 1,637.33$ 2,333.20$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 818.67$ 1,391.74$ 1,637.33$ 2,333.20$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 771.96$ 1,312.33$ 1,543.91$ 2,200.08$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 768.66$ 1,306.72$ 1,537.31$ 2,190.67$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 771.96$ 1,312.33$ 1,543.91$ 2,200.08$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 768.66$ 1,306.72$ 1,537.31$ 2,190.67$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 786.04$ 1,336.27$ 1,572.07$ 2,240.21$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 786.04$ 1,336.27$ 1,572.07$ 2,240.21$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 782.74$ 1,330.66$ 1,565.47$ 2,230.80$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 782.74$ 1,330.66$ 1,565.47$ 2,230.80$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 863.46$ 1,467.89$ 1,726.93$ 2,460.87$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 860.16$ 1,462.28$ 1,720.33$ 2,451.46$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 863.46$ 1,467.89$ 1,726.93$ 2,460.87$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 860.16$ 1,462.28$ 1,720.33$ 2,451.46$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 877.54$ 1,491.83$ 1,755.09$ 2,501.00$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 877.54$ 1,491.83$ 1,755.09$ 2,501.00$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 874.24$ 1,486.22$ 1,748.49$ 2,491.59$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 874.24$ 1,486.22$ 1,748.49$ 2,491.59$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 622.55$ 1,058.34$ 1,245.11$ 1,774.28$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 619.25$ 1,052.73$ 1,238.51$ 1,764.87$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 622.55$ 1,058.34$ 1,245.11$ 1,774.28$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 619.25$ 1,052.73$ 1,238.51$ 1,764.87$
Page 14 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 636.63$ 1,082.28$ 1,273.27$ 1,814.41$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 636.63$ 1,082.28$ 1,273.27$ 1,814.41$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 633.33$ 1,076.67$ 1,266.67$ 1,805.00$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 633.33$ 1,076.67$ 1,266.67$ 1,805.00$
Page 15 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,113.47$ 1,892.90$ 2,226.95$ 3,173.40$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,110.17$ 1,887.29$ 2,220.35$ 3,163.99$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,113.47$ 1,892.90$ 2,226.95$ 3,173.40$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,110.17$ 1,887.29$ 2,220.35$ 3,163.99$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,127.55$ 1,916.84$ 2,255.11$ 3,213.53$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,127.55$ 1,916.84$ 2,255.11$ 3,213.53$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,124.25$ 1,911.23$ 2,248.51$ 3,204.12$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,124.25$ 1,911.23$ 2,248.51$ 3,204.12$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,046.84$ 1,779.62$ 2,093.67$ 2,983.48$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,043.54$ 1,774.01$ 2,087.07$ 2,974.07$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,046.84$ 1,779.62$ 2,093.67$ 2,983.48$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,043.54$ 1,774.01$ 2,087.07$ 2,974.07$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,060.92$ 1,803.56$ 2,121.83$ 3,023.61$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,060.92$ 1,803.56$ 2,121.83$ 3,023.61$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,057.62$ 1,797.95$ 2,115.23$ 3,014.20$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,057.62$ 1,797.95$ 2,115.23$ 3,014.20$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,093.61$ 1,859.14$ 2,187.23$ 3,116.80$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,090.31$ 1,853.53$ 2,180.63$ 3,107.39$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,093.61$ 1,859.14$ 2,187.23$ 3,116.80$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,090.31$ 1,853.53$ 2,180.63$ 3,107.39$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,107.69$ 1,883.08$ 2,215.39$ 3,156.93$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,107.69$ 1,883.08$ 2,215.39$ 3,156.93$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,104.39$ 1,877.47$ 2,208.79$ 3,147.52$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,104.39$ 1,877.47$ 2,208.79$ 3,147.52$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,031.14$ 1,752.94$ 2,062.29$ 2,938.76$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,027.84$ 1,747.33$ 2,055.69$ 2,929.35$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,031.14$ 1,752.94$ 2,062.29$ 2,938.76$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,027.84$ 1,747.33$ 2,055.69$ 2,929.35$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,045.22$ 1,776.88$ 2,090.45$ 2,978.89$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,045.22$ 1,776.88$ 2,090.45$ 2,978.89$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,041.92$ 1,771.27$ 2,083.85$ 2,969.48$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,041.92$ 1,771.27$ 2,083.85$ 2,969.48$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 952.13$ 1,618.63$ 1,904.27$ 2,713.58$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 948.83$ 1,613.02$ 1,897.67$ 2,704.17$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 952.13$ 1,618.63$ 1,904.27$ 2,713.58$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 948.83$ 1,613.02$ 1,897.67$ 2,704.17$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 966.21$ 1,642.57$ 1,932.43$ 2,753.71$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 966.21$ 1,642.57$ 1,932.43$ 2,753.71$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 962.91$ 1,636.96$ 1,925.83$ 2,744.30$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 962.91$ 1,636.96$ 1,925.83$ 2,744.30$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 855.49$ 1,454.33$ 1,710.98$ 2,438.15$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 852.19$ 1,448.72$ 1,704.38$ 2,428.74$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 855.49$ 1,454.33$ 1,710.98$ 2,438.15$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 852.19$ 1,448.72$ 1,704.38$ 2,428.74$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 869.57$ 1,478.27$ 1,739.14$ 2,478.28$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 869.57$ 1,478.27$ 1,739.14$ 2,478.28$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 866.27$ 1,472.66$ 1,732.54$ 2,468.87$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 866.27$ 1,472.66$ 1,732.54$ 2,468.87$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 881.86$ 1,499.16$ 1,763.71$ 2,513.29$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 878.56$ 1,493.55$ 1,757.11$ 2,503.88$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 881.86$ 1,499.16$ 1,763.71$ 2,513.29$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 878.56$ 1,493.55$ 1,757.11$ 2,503.88$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 895.94$ 1,523.10$ 1,791.87$ 2,553.42$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 895.94$ 1,523.10$ 1,791.87$ 2,553.42$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 892.64$ 1,517.49$ 1,785.27$ 2,544.01$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 892.64$ 1,517.49$ 1,785.27$ 2,544.01$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 907.06$ 1,542.00$ 1,814.11$ 2,585.11$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 903.76$ 1,536.39$ 1,807.51$ 2,575.70$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 907.06$ 1,542.00$ 1,814.11$ 2,585.11$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 903.76$ 1,536.39$ 1,807.51$ 2,575.70$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 921.14$ 1,565.94$ 1,842.27$ 2,625.24$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 921.14$ 1,565.94$ 1,842.27$ 2,625.24$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 917.84$ 1,560.33$ 1,835.67$ 2,615.83$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 917.84$ 1,560.33$ 1,835.67$ 2,615.83$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 851.69$ 1,447.88$ 1,703.39$ 2,427.33$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 848.39$ 1,442.27$ 1,696.79$ 2,417.92$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 851.69$ 1,447.88$ 1,703.39$ 2,427.33$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 848.39$ 1,442.27$ 1,696.79$ 2,417.92$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 865.77$ 1,471.82$ 1,731.55$ 2,467.46$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 865.77$ 1,471.82$ 1,731.55$ 2,467.46$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 862.47$ 1,466.21$ 1,724.95$ 2,458.05$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 862.47$ 1,466.21$ 1,724.95$ 2,458.05$
Region 8
Page 16 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 879.63$ 1,495.37$ 1,759.26$ 2,506.95$
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 876.33$ 1,489.76$ 1,752.66$ 2,497.54$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 879.63$ 1,495.37$ 1,759.26$ 2,506.95$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 876.33$ 1,489.76$ 1,752.66$ 2,497.54$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 893.71$ 1,519.31$ 1,787.42$ 2,547.08$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 893.71$ 1,519.31$ 1,787.42$ 2,547.08$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 890.41$ 1,513.70$ 1,780.82$ 2,537.67$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 890.41$ 1,513.70$ 1,780.82$ 2,537.67$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 824.07$ 1,400.91$ 1,648.13$ 2,348.59$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 820.77$ 1,395.30$ 1,641.53$ 2,339.18$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 824.07$ 1,400.91$ 1,648.13$ 2,348.59$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 820.77$ 1,395.30$ 1,641.53$ 2,339.18$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 838.15$ 1,424.85$ 1,676.29$ 2,388.72$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 838.15$ 1,424.85$ 1,676.29$ 2,388.72$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 834.85$ 1,419.24$ 1,669.69$ 2,379.31$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 834.85$ 1,419.24$ 1,669.69$ 2,379.31$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 799.56$ 1,359.24$ 1,599.11$ 2,278.73$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 796.26$ 1,353.63$ 1,592.51$ 2,269.32$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 799.56$ 1,359.24$ 1,599.11$ 2,278.73$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 796.26$ 1,353.63$ 1,592.51$ 2,269.32$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 813.64$ 1,383.18$ 1,627.27$ 2,318.86$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 813.64$ 1,383.18$ 1,627.27$ 2,318.86$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 810.34$ 1,377.57$ 1,620.67$ 2,309.45$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 810.34$ 1,377.57$ 1,620.67$ 2,309.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 681.00$ 1,157.71$ 1,362.01$ 1,940.86$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 677.70$ 1,152.10$ 1,355.41$ 1,931.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 681.00$ 1,157.71$ 1,362.01$ 1,940.86$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 677.70$ 1,152.10$ 1,355.41$ 1,931.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 695.08$ 1,181.65$ 1,390.17$ 1,980.99$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 695.08$ 1,181.65$ 1,390.17$ 1,980.99$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 691.78$ 1,176.04$ 1,383.57$ 1,971.58$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 691.78$ 1,176.04$ 1,383.57$ 1,971.58$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 718.83$ 1,222.01$ 1,437.66$ 2,048.66$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 715.53$ 1,216.40$ 1,431.06$ 2,039.25$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 718.83$ 1,222.01$ 1,437.66$ 2,048.66$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 715.53$ 1,216.40$ 1,431.06$ 2,039.25$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 732.91$ 1,245.95$ 1,465.82$ 2,088.79$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 732.91$ 1,245.95$ 1,465.82$ 2,088.79$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 729.61$ 1,240.34$ 1,459.22$ 2,079.38$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 729.61$ 1,240.34$ 1,459.22$ 2,079.38$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 799.30$ 1,358.81$ 1,598.61$ 2,278.01$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 796.00$ 1,353.20$ 1,592.01$ 2,268.60$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 799.30$ 1,358.81$ 1,598.61$ 2,278.01$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 796.00$ 1,353.20$ 1,592.01$ 2,268.60$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 813.38$ 1,382.75$ 1,626.77$ 2,318.14$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 813.38$ 1,382.75$ 1,626.77$ 2,318.14$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 810.08$ 1,377.14$ 1,620.17$ 2,308.73$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 810.08$ 1,377.14$ 1,620.17$ 2,308.73$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 739.37$ 1,256.92$ 1,478.73$ 2,107.19$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 736.07$ 1,251.31$ 1,472.13$ 2,097.78$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 739.37$ 1,256.92$ 1,478.73$ 2,107.19$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 736.07$ 1,251.31$ 1,472.13$ 2,097.78$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 753.45$ 1,280.86$ 1,506.89$ 2,147.32$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 753.45$ 1,280.86$ 1,506.89$ 2,147.32$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 750.15$ 1,275.25$ 1,500.29$ 2,137.91$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 750.15$ 1,275.25$ 1,500.29$ 2,137.91$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 706.48$ 1,201.01$ 1,412.95$ 2,013.45$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 703.18$ 1,195.40$ 1,406.35$ 2,004.04$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 706.48$ 1,201.01$ 1,412.95$ 2,013.45$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 703.18$ 1,195.40$ 1,406.35$ 2,004.04$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 720.56$ 1,224.95$ 1,441.11$ 2,053.58$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 720.56$ 1,224.95$ 1,441.11$ 2,053.58$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 717.26$ 1,219.34$ 1,434.51$ 2,044.17$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 717.26$ 1,219.34$ 1,434.51$ 2,044.17$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 744.41$ 1,265.49$ 1,488.81$ 2,121.56$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 741.11$ 1,259.88$ 1,482.21$ 2,112.15$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 744.41$ 1,265.49$ 1,488.81$ 2,121.56$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 741.11$ 1,259.88$ 1,482.21$ 2,112.15$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 758.49$ 1,289.43$ 1,516.97$ 2,161.69$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 758.49$ 1,289.43$ 1,516.97$ 2,161.69$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 755.19$ 1,283.82$ 1,510.37$ 2,152.28$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 755.19$ 1,283.82$ 1,510.37$ 2,152.28$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 711.30$ 1,209.21$ 1,422.60$ 2,027.21$
Page 17 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 708.00$ 1,203.60$ 1,416.00$ 2,017.80$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 711.30$ 1,209.21$ 1,422.60$ 2,027.21$
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 708.00$ 1,203.60$ 1,416.00$ 2,017.80$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 725.38$ 1,233.15$ 1,450.76$ 2,067.34$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 725.38$ 1,233.15$ 1,450.76$ 2,067.34$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 722.08$ 1,227.54$ 1,444.16$ 2,057.93$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 722.08$ 1,227.54$ 1,444.16$ 2,057.93$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 677.95$ 1,152.52$ 1,355.91$ 1,932.17$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 674.65$ 1,146.91$ 1,349.31$ 1,922.76$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 677.95$ 1,152.52$ 1,355.91$ 1,932.17$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 674.65$ 1,146.91$ 1,349.31$ 1,922.76$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 692.03$ 1,176.46$ 1,384.07$ 1,972.30$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 692.03$ 1,176.46$ 1,384.07$ 1,972.30$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 688.73$ 1,170.85$ 1,377.47$ 1,962.89$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 688.73$ 1,170.85$ 1,377.47$ 1,962.89$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 672.63$ 1,143.48$ 1,345.26$ 1,917.00$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 669.33$ 1,137.87$ 1,338.66$ 1,907.59$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 672.63$ 1,143.48$ 1,345.26$ 1,917.00$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 669.33$ 1,137.87$ 1,338.66$ 1,907.59$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 686.71$ 1,167.42$ 1,373.42$ 1,957.13$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 686.71$ 1,167.42$ 1,373.42$ 1,957.13$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 683.41$ 1,161.81$ 1,366.82$ 1,947.72$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 683.41$ 1,161.81$ 1,366.82$ 1,947.72$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,258.26$ 2,139.05$ 2,516.53$ 3,586.05$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,254.96$ 2,133.44$ 2,509.93$ 3,576.64$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,258.26$ 2,139.05$ 2,516.53$ 3,586.05$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,254.96$ 2,133.44$ 2,509.93$ 3,576.64$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,272.34$ 2,162.99$ 2,544.69$ 3,626.18$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,272.34$ 2,162.99$ 2,544.69$ 3,626.18$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,269.04$ 2,157.38$ 2,538.09$ 3,616.77$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,269.04$ 2,157.38$ 2,538.09$ 3,616.77$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 849.24$ 1,443.70$ 1,698.47$ 2,420.32$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 845.94$ 1,438.09$ 1,691.87$ 2,410.91$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 849.24$ 1,443.70$ 1,698.47$ 2,420.32$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 845.94$ 1,438.09$ 1,691.87$ 2,410.91$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 863.32$ 1,467.64$ 1,726.63$ 2,460.45$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 863.32$ 1,467.64$ 1,726.63$ 2,460.45$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 860.02$ 1,462.03$ 1,720.03$ 2,451.04$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 860.02$ 1,462.03$ 1,720.03$ 2,451.04$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 953.44$ 1,620.84$ 1,906.87$ 2,717.29$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 950.14$ 1,615.23$ 1,900.27$ 2,707.88$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 953.44$ 1,620.84$ 1,906.87$ 2,717.29$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 950.14$ 1,615.23$ 1,900.27$ 2,707.88$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 967.52$ 1,644.78$ 1,935.03$ 2,757.42$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 967.52$ 1,644.78$ 1,935.03$ 2,757.42$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 964.22$ 1,639.17$ 1,928.43$ 2,748.01$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 964.22$ 1,639.17$ 1,928.43$ 2,748.01$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 685.18$ 1,164.80$ 1,370.36$ 1,952.76$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 681.88$ 1,159.19$ 1,363.76$ 1,943.35$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 685.18$ 1,164.80$ 1,370.36$ 1,952.76$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 681.88$ 1,159.19$ 1,363.76$ 1,943.35$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 699.26$ 1,188.74$ 1,398.52$ 1,992.89$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 699.26$ 1,188.74$ 1,398.52$ 1,992.89$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 695.96$ 1,183.13$ 1,391.92$ 1,983.48$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 695.96$ 1,183.13$ 1,391.92$ 1,983.48$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 605.60$ 1,029.52$ 1,211.19$ 1,725.95$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 602.30$ 1,023.91$ 1,204.59$ 1,716.54$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 605.60$ 1,029.52$ 1,211.19$ 1,725.95$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 602.30$ 1,023.91$ 1,204.59$ 1,716.54$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 619.68$ 1,053.46$ 1,239.35$ 1,766.08$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 619.68$ 1,053.46$ 1,239.35$ 1,766.08$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 616.38$ 1,047.85$ 1,232.75$ 1,756.67$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 616.38$ 1,047.85$ 1,232.75$ 1,756.67$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 617.12$ 1,049.11$ 1,234.25$ 1,758.80$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 613.82$ 1,043.50$ 1,227.65$ 1,749.39$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 617.12$ 1,049.11$ 1,234.25$ 1,758.80$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 613.82$ 1,043.50$ 1,227.65$ 1,749.39$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 631.20$ 1,073.05$ 1,262.41$ 1,798.93$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 631.20$ 1,073.05$ 1,262.41$ 1,798.93$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 627.90$ 1,067.44$ 1,255.81$ 1,789.52$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 627.90$ 1,067.44$ 1,255.81$ 1,789.52$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 587.57$ 998.88$ 1,175.15$ 1,674.59$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 584.27$ 993.27$ 1,168.55$ 1,665.18$
Page 18 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 587.57$ 998.88$ 1,175.15$ 1,674.59$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 584.27$ 993.27$ 1,168.55$ 1,665.18$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 601.65$ 1,022.82$ 1,203.31$ 1,714.72$
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 601.65$ 1,022.82$ 1,203.31$ 1,714.72$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 598.35$ 1,017.21$ 1,196.71$ 1,705.31$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 598.35$ 1,017.21$ 1,196.71$ 1,705.31$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 614.42$ 1,044.52$ 1,228.85$ 1,751.11$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 611.12$ 1,038.91$ 1,222.25$ 1,741.70$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 614.42$ 1,044.52$ 1,228.85$ 1,751.11$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 611.12$ 1,038.91$ 1,222.25$ 1,741.70$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 628.50$ 1,068.46$ 1,257.01$ 1,791.24$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 628.50$ 1,068.46$ 1,257.01$ 1,791.24$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 625.20$ 1,062.85$ 1,250.41$ 1,781.83$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 625.20$ 1,062.85$ 1,250.41$ 1,781.83$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 587.09$ 998.05$ 1,174.18$ 1,673.20$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 583.79$ 992.44$ 1,167.58$ 1,663.79$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 587.09$ 998.05$ 1,174.18$ 1,673.20$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 583.79$ 992.44$ 1,167.58$ 1,663.79$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 601.17$ 1,021.99$ 1,202.34$ 1,713.33$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 601.17$ 1,021.99$ 1,202.34$ 1,713.33$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 597.87$ 1,016.38$ 1,195.74$ 1,703.92$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 597.87$ 1,016.38$ 1,195.74$ 1,703.92$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 622.77$ 1,058.70$ 1,245.53$ 1,774.88$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 619.47$ 1,053.09$ 1,238.93$ 1,765.47$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 622.77$ 1,058.70$ 1,245.53$ 1,774.88$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 619.47$ 1,053.09$ 1,238.93$ 1,765.47$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 636.85$ 1,082.64$ 1,273.69$ 1,815.01$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 636.85$ 1,082.64$ 1,273.69$ 1,815.01$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 633.55$ 1,077.03$ 1,267.09$ 1,805.60$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 633.55$ 1,077.03$ 1,267.09$ 1,805.60$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 501.18$ 852.01$ 1,002.37$ 1,428.38$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 497.88$ 846.40$ 995.77$ 1,418.97$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 501.18$ 852.01$ 1,002.37$ 1,428.38$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 497.88$ 846.40$ 995.77$ 1,418.97$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 515.26$ 875.95$ 1,030.53$ 1,468.51$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 515.26$ 875.95$ 1,030.53$ 1,468.51$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 511.96$ 870.34$ 1,023.93$ 1,459.10$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 511.96$ 870.34$ 1,023.93$ 1,459.10$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 500.00$ 850.00$ 1,000.00$ 1,425.00$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 496.70$ 844.39$ 993.40$ 1,415.59$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 500.00$ 850.00$ 1,000.00$ 1,425.00$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 496.70$ 844.39$ 993.40$ 1,415.59$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 514.08$ 873.94$ 1,028.16$ 1,465.13$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 514.08$ 873.94$ 1,028.16$ 1,465.13$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 510.78$ 868.33$ 1,021.56$ 1,455.72$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 510.78$ 868.33$ 1,021.56$ 1,455.72$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 607.69$ 1,033.08$ 1,215.39$ 1,731.93$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 604.39$ 1,027.47$ 1,208.79$ 1,722.52$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 607.69$ 1,033.08$ 1,215.39$ 1,731.93$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 604.39$ 1,027.47$ 1,208.79$ 1,722.52$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 621.77$ 1,057.02$ 1,243.55$ 1,772.06$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 621.77$ 1,057.02$ 1,243.55$ 1,772.06$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 618.47$ 1,051.41$ 1,236.95$ 1,762.65$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 618.47$ 1,051.41$ 1,236.95$ 1,762.65$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 494.52$ 840.69$ 989.05$ 1,409.39$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 491.22$ 835.08$ 982.45$ 1,399.98$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 494.52$ 840.69$ 989.05$ 1,409.39$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 491.22$ 835.08$ 982.45$ 1,399.98$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 508.60$ 864.63$ 1,017.21$ 1,449.52$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 508.60$ 864.63$ 1,017.21$ 1,449.52$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 505.30$ 859.02$ 1,010.61$ 1,440.11$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 505.30$ 859.02$ 1,010.61$ 1,440.11$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 626.13$ 1,064.41$ 1,252.25$ 1,784.46$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 622.83$ 1,058.80$ 1,245.65$ 1,775.05$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 626.13$ 1,064.41$ 1,252.25$ 1,784.46$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 622.83$ 1,058.80$ 1,245.65$ 1,775.05$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 640.21$ 1,088.35$ 1,280.41$ 1,824.59$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 640.21$ 1,088.35$ 1,280.41$ 1,824.59$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 636.91$ 1,082.74$ 1,273.81$ 1,815.18$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 636.91$ 1,082.74$ 1,273.81$ 1,815.18$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 725.17$ 1,232.79$ 1,450.34$ 2,066.73$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 721.87$ 1,227.18$ 1,443.74$ 2,057.32$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 725.17$ 1,232.79$ 1,450.34$ 2,066.73$
Page 19 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 721.87$ 1,227.18$ 1,443.74$ 2,057.32$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 739.25$ 1,256.73$ 1,478.50$ 2,106.86$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 739.25$ 1,256.73$ 1,478.50$ 2,106.86$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 735.95$ 1,251.12$ 1,471.90$ 2,097.45$
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 735.95$ 1,251.12$ 1,471.90$ 2,097.45$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 579.65$ 985.40$ 1,159.30$ 1,652.00$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 576.35$ 979.79$ 1,152.70$ 1,642.59$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 579.65$ 985.40$ 1,159.30$ 1,652.00$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 576.35$ 979.79$ 1,152.70$ 1,642.59$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 593.73$ 1,009.34$ 1,187.46$ 1,692.13$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 593.73$ 1,009.34$ 1,187.46$ 1,692.13$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 590.43$ 1,003.73$ 1,180.86$ 1,682.72$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 590.43$ 1,003.73$ 1,180.86$ 1,682.72$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 784.60$ 1,333.82$ 1,569.20$ 2,236.11$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 781.30$ 1,328.21$ 1,562.60$ 2,226.70$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 784.60$ 1,333.82$ 1,569.20$ 2,236.11$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 781.30$ 1,328.21$ 1,562.60$ 2,226.70$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 798.68$ 1,357.76$ 1,597.36$ 2,276.24$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 798.68$ 1,357.76$ 1,597.36$ 2,276.24$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 795.38$ 1,352.15$ 1,590.76$ 2,266.83$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 795.38$ 1,352.15$ 1,590.76$ 2,266.83$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 651.69$ 1,107.87$ 1,303.37$ 1,857.30$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 648.39$ 1,102.26$ 1,296.77$ 1,847.89$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 651.69$ 1,107.87$ 1,303.37$ 1,857.30$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 648.39$ 1,102.26$ 1,296.77$ 1,847.89$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 665.77$ 1,131.81$ 1,331.53$ 1,897.43$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 665.77$ 1,131.81$ 1,331.53$ 1,897.43$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 662.47$ 1,126.20$ 1,324.93$ 1,888.02$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 662.47$ 1,126.20$ 1,324.93$ 1,888.02$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 619.98$ 1,053.96$ 1,239.96$ 1,766.94$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 616.68$ 1,048.35$ 1,233.36$ 1,757.53$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 619.98$ 1,053.96$ 1,239.96$ 1,766.94$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 616.68$ 1,048.35$ 1,233.36$ 1,757.53$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 634.06$ 1,077.90$ 1,268.12$ 1,807.07$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 634.06$ 1,077.90$ 1,268.12$ 1,807.07$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 630.76$ 1,072.29$ 1,261.52$ 1,797.66$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 630.76$ 1,072.29$ 1,261.52$ 1,797.66$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 998.47$ 1,697.39$ 1,996.93$ 2,845.63$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 995.17$ 1,691.78$ 1,990.33$ 2,836.22$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 998.47$ 1,697.39$ 1,996.93$ 2,845.63$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 995.17$ 1,691.78$ 1,990.33$ 2,836.22$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,012.55$ 1,721.33$ 2,025.09$ 2,885.76$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,012.55$ 1,721.33$ 2,025.09$ 2,885.76$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,009.25$ 1,715.72$ 2,018.49$ 2,876.35$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,009.25$ 1,715.72$ 2,018.49$ 2,876.35$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 807.89$ 1,373.41$ 1,615.77$ 2,302.48$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 804.59$ 1,367.80$ 1,609.17$ 2,293.07$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 807.89$ 1,373.41$ 1,615.77$ 2,302.48$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 804.59$ 1,367.80$ 1,609.17$ 2,293.07$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 821.97$ 1,397.35$ 1,643.93$ 2,342.61$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 821.97$ 1,397.35$ 1,643.93$ 2,342.61$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 818.67$ 1,391.74$ 1,637.33$ 2,333.20$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 818.67$ 1,391.74$ 1,637.33$ 2,333.20$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 771.96$ 1,312.33$ 1,543.91$ 2,200.08$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 768.66$ 1,306.72$ 1,537.31$ 2,190.67$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 771.96$ 1,312.33$ 1,543.91$ 2,200.08$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 768.66$ 1,306.72$ 1,537.31$ 2,190.67$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 786.04$ 1,336.27$ 1,572.07$ 2,240.21$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 786.04$ 1,336.27$ 1,572.07$ 2,240.21$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 782.74$ 1,330.66$ 1,565.47$ 2,230.80$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 782.74$ 1,330.66$ 1,565.47$ 2,230.80$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 863.46$ 1,467.89$ 1,726.93$ 2,460.87$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 860.16$ 1,462.28$ 1,720.33$ 2,451.46$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 863.46$ 1,467.89$ 1,726.93$ 2,460.87$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 860.16$ 1,462.28$ 1,720.33$ 2,451.46$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 877.54$ 1,491.83$ 1,755.09$ 2,501.00$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 877.54$ 1,491.83$ 1,755.09$ 2,501.00$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 874.24$ 1,486.22$ 1,748.49$ 2,491.59$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 874.24$ 1,486.22$ 1,748.49$ 2,491.59$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 622.55$ 1,058.34$ 1,245.11$ 1,774.28$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 619.25$ 1,052.73$ 1,238.51$ 1,764.87$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 622.55$ 1,058.34$ 1,245.11$ 1,774.28$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 619.25$ 1,052.73$ 1,238.51$ 1,764.87$
Page 20 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q1
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 636.63$ 1,082.28$ 1,273.27$ 1,814.41$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 636.63$ 1,082.28$ 1,273.27$ 1,814.41$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 633.33$ 1,076.67$ 1,266.67$ 1,805.00$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 633.33$ 1,076.67$ 1,266.67$ 1,805.00$
Page 21 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,254.28$ 2,132.28$ 2,508.56$ 3,574.71$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,250.56$ 2,125.96$ 2,501.12$ 3,564.11$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,254.28$ 2,132.28$ 2,508.56$ 3,574.71$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,250.56$ 2,125.96$ 2,501.12$ 3,564.11$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,270.14$ 2,159.24$ 2,540.28$ 3,619.91$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,270.14$ 2,159.24$ 2,540.28$ 3,619.91$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,266.42$ 2,152.92$ 2,532.84$ 3,609.31$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,266.42$ 2,152.92$ 2,532.84$ 3,609.31$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,179.22$ 2,004.67$ 2,358.43$ 3,360.77$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,175.50$ 1,998.35$ 2,350.99$ 3,350.17$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,179.22$ 2,004.67$ 2,358.43$ 3,360.77$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,175.50$ 1,998.35$ 2,350.99$ 3,350.17$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,195.08$ 2,031.63$ 2,390.15$ 3,405.97$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,195.08$ 2,031.63$ 2,390.15$ 3,405.97$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,191.36$ 2,025.31$ 2,382.71$ 3,395.37$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,191.36$ 2,025.31$ 2,382.71$ 3,395.37$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,231.91$ 2,094.24$ 2,463.82$ 3,510.94$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,228.19$ 2,087.92$ 2,456.38$ 3,500.34$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,231.91$ 2,094.24$ 2,463.82$ 3,510.94$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,228.19$ 2,087.92$ 2,456.38$ 3,500.34$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,247.77$ 2,121.20$ 2,495.54$ 3,556.14$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,247.77$ 2,121.20$ 2,495.54$ 3,556.14$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,244.05$ 2,114.88$ 2,488.10$ 3,545.54$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,244.05$ 2,114.88$ 2,488.10$ 3,545.54$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,161.53$ 1,974.61$ 2,323.07$ 3,310.37$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,157.81$ 1,968.29$ 2,315.63$ 3,299.77$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,161.53$ 1,974.61$ 2,323.07$ 3,310.37$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,157.81$ 1,968.29$ 2,315.63$ 3,299.77$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,177.39$ 2,001.57$ 2,354.79$ 3,355.57$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,177.39$ 2,001.57$ 2,354.79$ 3,355.57$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,173.67$ 1,995.25$ 2,347.35$ 3,344.97$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,173.67$ 1,995.25$ 2,347.35$ 3,344.97$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 1,072.53$ 1,823.30$ 2,145.06$ 3,056.71$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 1,068.81$ 1,816.98$ 2,137.62$ 3,046.11$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 1,072.53$ 1,823.30$ 2,145.06$ 3,056.71$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 1,068.81$ 1,816.98$ 2,137.62$ 3,046.11$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 1,088.39$ 1,850.26$ 2,176.78$ 3,101.91$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 1,088.39$ 1,850.26$ 2,176.78$ 3,101.91$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 1,084.67$ 1,843.94$ 2,169.34$ 3,091.31$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 1,084.67$ 1,843.94$ 2,169.34$ 3,091.31$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 963.67$ 1,638.24$ 1,927.34$ 2,746.46$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 959.95$ 1,631.92$ 1,919.90$ 2,735.86$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 963.67$ 1,638.24$ 1,927.34$ 2,746.46$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 959.95$ 1,631.92$ 1,919.90$ 2,735.86$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 979.53$ 1,665.20$ 1,959.06$ 2,791.66$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 979.53$ 1,665.20$ 1,959.06$ 2,791.66$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 975.81$ 1,658.88$ 1,951.62$ 2,781.06$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 975.81$ 1,658.88$ 1,951.62$ 2,781.06$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 993.38$ 1,688.74$ 1,986.75$ 2,831.12$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 989.66$ 1,682.42$ 1,979.31$ 2,820.52$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 993.38$ 1,688.74$ 1,986.75$ 2,831.12$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 989.66$ 1,682.42$ 1,979.31$ 2,820.52$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 1,009.24$ 1,715.70$ 2,018.47$ 2,876.32$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 1,009.24$ 1,715.70$ 2,018.47$ 2,876.32$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 1,005.52$ 1,709.38$ 2,011.03$ 2,865.72$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 1,005.52$ 1,709.38$ 2,011.03$ 2,865.72$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 1,021.75$ 1,736.98$ 2,043.51$ 2,911.99$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 1,018.03$ 1,730.66$ 2,036.07$ 2,901.39$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 1,021.75$ 1,736.98$ 2,043.51$ 2,911.99$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 1,018.03$ 1,730.66$ 2,036.07$ 2,901.39$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 1,037.61$ 1,763.94$ 2,075.23$ 2,957.19$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 1,037.61$ 1,763.94$ 2,075.23$ 2,957.19$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 1,033.89$ 1,757.62$ 2,067.79$ 2,946.59$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 1,033.89$ 1,757.62$ 2,067.79$ 2,946.59$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 959.40$ 1,630.98$ 1,918.80$ 2,734.28$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 955.68$ 1,624.66$ 1,911.36$ 2,723.68$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 959.40$ 1,630.98$ 1,918.80$ 2,734.28$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 955.68$ 1,624.66$ 1,911.36$ 2,723.68$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 975.26$ 1,657.94$ 1,950.52$ 2,779.48$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 975.26$ 1,657.94$ 1,950.52$ 2,779.48$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 971.54$ 1,651.62$ 1,943.08$ 2,768.88$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 971.54$ 1,651.62$ 1,943.08$ 2,768.88$
Region 3
Page 22 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 990.87$ 1,684.48$ 1,981.74$ 2,823.98$
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 987.15$ 1,678.16$ 1,974.30$ 2,813.38$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 990.87$ 1,684.48$ 1,981.74$ 2,823.98$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 987.15$ 1,678.16$ 1,974.30$ 2,813.38$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 1,006.73$ 1,711.44$ 2,013.46$ 2,869.18$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 1,006.73$ 1,711.44$ 2,013.46$ 2,869.18$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 1,003.01$ 1,705.12$ 2,006.02$ 2,858.58$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 1,003.01$ 1,705.12$ 2,006.02$ 2,858.58$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 928.27$ 1,578.07$ 1,856.55$ 2,645.58$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 924.55$ 1,571.75$ 1,849.11$ 2,634.98$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 928.27$ 1,578.07$ 1,856.55$ 2,645.58$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 924.55$ 1,571.75$ 1,849.11$ 2,634.98$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 944.13$ 1,605.03$ 1,888.27$ 2,690.78$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 944.13$ 1,605.03$ 1,888.27$ 2,690.78$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 940.41$ 1,598.71$ 1,880.83$ 2,680.18$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 940.41$ 1,598.71$ 1,880.83$ 2,680.18$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 900.66$ 1,531.12$ 1,801.31$ 2,566.87$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 896.94$ 1,524.80$ 1,793.87$ 2,556.27$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 900.66$ 1,531.12$ 1,801.31$ 2,566.87$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 896.94$ 1,524.80$ 1,793.87$ 2,556.27$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 916.52$ 1,558.08$ 1,833.03$ 2,612.07$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 916.52$ 1,558.08$ 1,833.03$ 2,612.07$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 912.80$ 1,551.76$ 1,825.59$ 2,601.47$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 912.80$ 1,551.76$ 1,825.59$ 2,601.47$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 767.12$ 1,304.10$ 1,534.24$ 2,186.29$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 763.40$ 1,297.78$ 1,526.80$ 2,175.69$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 767.12$ 1,304.10$ 1,534.24$ 2,186.29$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 763.40$ 1,297.78$ 1,526.80$ 2,175.69$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 782.98$ 1,331.06$ 1,565.96$ 2,231.49$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 782.98$ 1,331.06$ 1,565.96$ 2,231.49$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 779.26$ 1,324.74$ 1,558.52$ 2,220.89$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 779.26$ 1,324.74$ 1,558.52$ 2,220.89$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 809.72$ 1,376.53$ 1,619.45$ 2,307.71$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 806.00$ 1,370.21$ 1,612.01$ 2,297.11$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 809.72$ 1,376.53$ 1,619.45$ 2,307.71$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 806.00$ 1,370.21$ 1,612.01$ 2,297.11$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 825.58$ 1,403.49$ 1,651.17$ 2,352.91$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 825.58$ 1,403.49$ 1,651.17$ 2,352.91$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 821.86$ 1,397.17$ 1,643.73$ 2,342.31$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 821.86$ 1,397.17$ 1,643.73$ 2,342.31$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 900.37$ 1,530.64$ 1,800.75$ 2,566.07$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 896.65$ 1,524.32$ 1,793.31$ 2,555.47$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 900.37$ 1,530.64$ 1,800.75$ 2,566.07$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 896.65$ 1,524.32$ 1,793.31$ 2,555.47$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 916.23$ 1,557.60$ 1,832.47$ 2,611.27$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 916.23$ 1,557.60$ 1,832.47$ 2,611.27$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 912.51$ 1,551.28$ 1,825.03$ 2,600.67$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 912.51$ 1,551.28$ 1,825.03$ 2,600.67$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 832.86$ 1,415.87$ 1,665.73$ 2,373.66$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 829.14$ 1,409.55$ 1,658.29$ 2,363.06$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 832.86$ 1,415.87$ 1,665.73$ 2,373.66$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 829.14$ 1,409.55$ 1,658.29$ 2,363.06$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 848.72$ 1,442.83$ 1,697.45$ 2,418.86$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 848.72$ 1,442.83$ 1,697.45$ 2,418.86$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 845.00$ 1,436.51$ 1,690.01$ 2,408.26$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 845.00$ 1,436.51$ 1,690.01$ 2,408.26$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 795.82$ 1,352.89$ 1,591.63$ 2,268.08$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 792.10$ 1,346.57$ 1,584.19$ 2,257.48$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 795.82$ 1,352.89$ 1,591.63$ 2,268.08$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 792.10$ 1,346.57$ 1,584.19$ 2,257.48$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 811.68$ 1,379.85$ 1,623.35$ 2,313.28$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 811.68$ 1,379.85$ 1,623.35$ 2,313.28$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 807.96$ 1,373.53$ 1,615.91$ 2,302.68$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 807.96$ 1,373.53$ 1,615.91$ 2,302.68$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 838.54$ 1,425.53$ 1,677.09$ 2,389.85$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 834.82$ 1,419.21$ 1,669.65$ 2,379.25$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 838.54$ 1,425.53$ 1,677.09$ 2,389.85$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 834.82$ 1,419.21$ 1,669.65$ 2,379.25$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 854.40$ 1,452.49$ 1,708.81$ 2,435.05$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 854.40$ 1,452.49$ 1,708.81$ 2,435.05$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 850.68$ 1,446.17$ 1,701.37$ 2,424.45$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 850.68$ 1,446.17$ 1,701.37$ 2,424.45$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 801.24$ 1,362.12$ 1,602.49$ 2,283.55$
Page 23 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 797.52$ 1,355.80$ 1,595.05$ 2,272.95$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 801.24$ 1,362.12$ 1,602.49$ 2,283.55$
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 797.52$ 1,355.80$ 1,595.05$ 2,272.95$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 817.10$ 1,389.08$ 1,634.21$ 2,328.75$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 817.10$ 1,389.08$ 1,634.21$ 2,328.75$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 813.38$ 1,382.76$ 1,626.77$ 2,318.15$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 813.38$ 1,382.76$ 1,626.77$ 2,318.15$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 763.68$ 1,298.26$ 1,527.37$ 2,176.50$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 759.96$ 1,291.94$ 1,519.93$ 2,165.90$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 763.68$ 1,298.26$ 1,527.37$ 2,176.50$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 759.96$ 1,291.94$ 1,519.93$ 2,165.90$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 779.54$ 1,325.22$ 1,559.09$ 2,221.70$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 779.54$ 1,325.22$ 1,559.09$ 2,221.70$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 775.82$ 1,318.90$ 1,551.65$ 2,211.10$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 775.82$ 1,318.90$ 1,551.65$ 2,211.10$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 757.69$ 1,288.07$ 1,515.38$ 2,159.42$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 753.97$ 1,281.75$ 1,507.94$ 2,148.82$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 757.69$ 1,288.07$ 1,515.38$ 2,159.42$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 753.97$ 1,281.75$ 1,507.94$ 2,148.82$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 773.55$ 1,315.03$ 1,547.10$ 2,204.62$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 773.55$ 1,315.03$ 1,547.10$ 2,204.62$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 769.83$ 1,308.71$ 1,539.66$ 2,194.02$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 769.83$ 1,308.71$ 1,539.66$ 2,194.02$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,417.38$ 2,409.54$ 2,834.76$ 4,039.53$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,413.66$ 2,403.22$ 2,827.32$ 4,028.93$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,417.38$ 2,409.54$ 2,834.76$ 4,039.53$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,413.66$ 2,403.22$ 2,827.32$ 4,028.93$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,433.24$ 2,436.50$ 2,866.48$ 4,084.73$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,433.24$ 2,436.50$ 2,866.48$ 4,084.73$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,429.52$ 2,430.18$ 2,859.04$ 4,074.13$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,429.52$ 2,430.18$ 2,859.04$ 4,074.13$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 956.63$ 1,626.27$ 1,913.26$ 2,726.40$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 952.91$ 1,619.95$ 1,905.82$ 2,715.80$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 956.63$ 1,626.27$ 1,913.26$ 2,726.40$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 952.91$ 1,619.95$ 1,905.82$ 2,715.80$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 972.49$ 1,653.23$ 1,944.98$ 2,771.60$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 972.49$ 1,653.23$ 1,944.98$ 2,771.60$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 968.77$ 1,646.91$ 1,937.54$ 2,761.00$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 968.77$ 1,646.91$ 1,937.54$ 2,761.00$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 1,074.00$ 1,825.80$ 2,148.00$ 3,060.89$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 1,070.28$ 1,819.48$ 2,140.56$ 3,050.29$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 1,074.00$ 1,825.80$ 2,148.00$ 3,060.89$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 1,070.28$ 1,819.48$ 2,140.56$ 3,050.29$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 1,089.86$ 1,852.76$ 2,179.72$ 3,106.09$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 1,089.86$ 1,852.76$ 2,179.72$ 3,106.09$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 1,086.14$ 1,846.44$ 2,172.28$ 3,095.49$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 1,086.14$ 1,846.44$ 2,172.28$ 3,095.49$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 771.83$ 1,312.11$ 1,543.66$ 2,199.72$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 768.11$ 1,305.79$ 1,536.22$ 2,189.12$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 771.83$ 1,312.11$ 1,543.66$ 2,199.72$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 768.11$ 1,305.79$ 1,536.22$ 2,189.12$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 787.69$ 1,339.07$ 1,575.38$ 2,244.92$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 787.69$ 1,339.07$ 1,575.38$ 2,244.92$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 783.97$ 1,332.75$ 1,567.94$ 2,234.32$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 783.97$ 1,332.75$ 1,567.94$ 2,234.32$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 682.18$ 1,159.70$ 1,364.36$ 1,944.21$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 678.46$ 1,153.38$ 1,356.92$ 1,933.61$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 682.18$ 1,159.70$ 1,364.36$ 1,944.21$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 678.46$ 1,153.38$ 1,356.92$ 1,933.61$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 698.04$ 1,186.66$ 1,396.08$ 1,989.41$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 698.04$ 1,186.66$ 1,396.08$ 1,989.41$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 694.32$ 1,180.34$ 1,388.64$ 1,978.81$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 694.32$ 1,180.34$ 1,388.64$ 1,978.81$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 695.17$ 1,181.79$ 1,390.34$ 1,981.24$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 691.45$ 1,175.47$ 1,382.90$ 1,970.64$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 695.17$ 1,181.79$ 1,390.34$ 1,981.24$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 691.45$ 1,175.47$ 1,382.90$ 1,970.64$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 711.03$ 1,208.75$ 1,422.06$ 2,026.44$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 711.03$ 1,208.75$ 1,422.06$ 2,026.44$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 707.31$ 1,202.43$ 1,414.62$ 2,015.84$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 707.31$ 1,202.43$ 1,414.62$ 2,015.84$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 661.88$ 1,125.20$ 1,323.76$ 1,886.36$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 658.16$ 1,118.88$ 1,316.32$ 1,875.76$
Page 24 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 661.88$ 1,125.20$ 1,323.76$ 1,886.36$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 658.16$ 1,118.88$ 1,316.32$ 1,875.76$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 677.74$ 1,152.16$ 1,355.48$ 1,931.56$
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 677.74$ 1,152.16$ 1,355.48$ 1,931.56$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 674.02$ 1,145.84$ 1,348.04$ 1,920.96$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 674.02$ 1,145.84$ 1,348.04$ 1,920.96$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 692.12$ 1,176.61$ 1,384.24$ 1,972.55$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 688.40$ 1,170.29$ 1,376.80$ 1,961.95$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 692.12$ 1,176.61$ 1,384.24$ 1,972.55$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 688.40$ 1,170.29$ 1,376.80$ 1,961.95$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 707.98$ 1,203.57$ 1,415.96$ 2,017.75$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 707.98$ 1,203.57$ 1,415.96$ 2,017.75$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 704.26$ 1,197.25$ 1,408.52$ 2,007.15$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 704.26$ 1,197.25$ 1,408.52$ 2,007.15$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 661.34$ 1,124.28$ 1,322.68$ 1,884.81$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 657.62$ 1,117.96$ 1,315.24$ 1,874.21$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 661.34$ 1,124.28$ 1,322.68$ 1,884.81$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 657.62$ 1,117.96$ 1,315.24$ 1,874.21$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 677.20$ 1,151.24$ 1,354.40$ 1,930.01$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 677.20$ 1,151.24$ 1,354.40$ 1,930.01$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 673.48$ 1,144.92$ 1,346.96$ 1,919.41$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 673.48$ 1,144.92$ 1,346.96$ 1,919.41$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 701.51$ 1,192.57$ 1,403.03$ 1,999.31$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 697.79$ 1,186.25$ 1,395.59$ 1,988.71$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 701.51$ 1,192.57$ 1,403.03$ 1,999.31$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 697.79$ 1,186.25$ 1,395.59$ 1,988.71$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 717.37$ 1,219.53$ 1,434.75$ 2,044.51$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 717.37$ 1,219.53$ 1,434.75$ 2,044.51$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 713.65$ 1,213.21$ 1,427.31$ 2,033.91$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 713.65$ 1,213.21$ 1,427.31$ 2,033.91$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 564.57$ 959.77$ 1,129.14$ 1,609.02$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 560.85$ 953.45$ 1,121.70$ 1,598.42$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 564.57$ 959.77$ 1,129.14$ 1,609.02$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 560.85$ 953.45$ 1,121.70$ 1,598.42$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 580.43$ 986.73$ 1,160.86$ 1,654.22$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 580.43$ 986.73$ 1,160.86$ 1,654.22$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 576.71$ 980.41$ 1,153.42$ 1,643.62$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 576.71$ 980.41$ 1,153.42$ 1,643.62$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 563.23$ 957.49$ 1,126.46$ 1,605.20$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 559.51$ 951.17$ 1,119.02$ 1,594.60$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 563.23$ 957.49$ 1,126.46$ 1,605.20$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 559.51$ 951.17$ 1,119.02$ 1,594.60$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 579.09$ 984.45$ 1,158.18$ 1,650.40$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 579.09$ 984.45$ 1,158.18$ 1,650.40$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 575.37$ 978.13$ 1,150.74$ 1,639.80$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 575.37$ 978.13$ 1,150.74$ 1,639.80$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 684.55$ 1,163.73$ 1,369.10$ 1,950.96$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 680.83$ 1,157.41$ 1,361.66$ 1,940.36$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 684.55$ 1,163.73$ 1,369.10$ 1,950.96$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 680.83$ 1,157.41$ 1,361.66$ 1,940.36$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 700.41$ 1,190.69$ 1,400.82$ 1,996.16$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 700.41$ 1,190.69$ 1,400.82$ 1,996.16$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 696.69$ 1,184.37$ 1,393.38$ 1,985.56$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 696.69$ 1,184.37$ 1,393.38$ 1,985.56$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 557.06$ 947.01$ 1,114.12$ 1,587.63$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 553.34$ 940.69$ 1,106.68$ 1,577.03$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 557.06$ 947.01$ 1,114.12$ 1,587.63$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 553.34$ 940.69$ 1,106.68$ 1,577.03$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 572.92$ 973.97$ 1,145.84$ 1,632.83$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 572.92$ 973.97$ 1,145.84$ 1,632.83$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 569.20$ 967.65$ 1,138.40$ 1,622.23$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 569.20$ 967.65$ 1,138.40$ 1,622.23$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 705.31$ 1,199.03$ 1,410.62$ 2,010.13$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 701.59$ 1,192.71$ 1,403.18$ 1,999.53$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 705.31$ 1,199.03$ 1,410.62$ 2,010.13$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 701.59$ 1,192.71$ 1,403.18$ 1,999.53$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 721.17$ 1,225.99$ 1,442.34$ 2,055.33$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 721.17$ 1,225.99$ 1,442.34$ 2,055.33$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 717.45$ 1,219.67$ 1,434.90$ 2,044.73$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 717.45$ 1,219.67$ 1,434.90$ 2,044.73$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 816.87$ 1,388.68$ 1,633.74$ 2,328.08$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 813.15$ 1,382.36$ 1,626.30$ 2,317.48$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 816.87$ 1,388.68$ 1,633.74$ 2,328.08$
Page 25 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 813.15$ 1,382.36$ 1,626.30$ 2,317.48$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 832.73$ 1,415.64$ 1,665.46$ 2,373.28$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 832.73$ 1,415.64$ 1,665.46$ 2,373.28$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 829.01$ 1,409.32$ 1,658.02$ 2,362.68$
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 829.01$ 1,409.32$ 1,658.02$ 2,362.68$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 652.95$ 1,110.01$ 1,305.90$ 1,860.90$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 649.23$ 1,103.69$ 1,298.46$ 1,850.30$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 652.95$ 1,110.01$ 1,305.90$ 1,860.90$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 649.23$ 1,103.69$ 1,298.46$ 1,850.30$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 668.81$ 1,136.97$ 1,337.62$ 1,906.10$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 668.81$ 1,136.97$ 1,337.62$ 1,906.10$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 665.09$ 1,130.65$ 1,330.18$ 1,895.50$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 665.09$ 1,130.65$ 1,330.18$ 1,895.50$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 883.82$ 1,502.49$ 1,767.64$ 2,518.88$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 880.10$ 1,496.17$ 1,760.20$ 2,508.28$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 883.82$ 1,502.49$ 1,767.64$ 2,518.88$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 880.10$ 1,496.17$ 1,760.20$ 2,508.28$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 899.68$ 1,529.45$ 1,799.36$ 2,564.08$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 899.68$ 1,529.45$ 1,799.36$ 2,564.08$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 895.96$ 1,523.13$ 1,791.92$ 2,553.48$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 895.96$ 1,523.13$ 1,791.92$ 2,553.48$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 734.09$ 1,247.96$ 1,468.19$ 2,092.17$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 730.37$ 1,241.64$ 1,460.75$ 2,081.57$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 734.09$ 1,247.96$ 1,468.19$ 2,092.17$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 730.37$ 1,241.64$ 1,460.75$ 2,081.57$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 749.95$ 1,274.92$ 1,499.91$ 2,137.37$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 749.95$ 1,274.92$ 1,499.91$ 2,137.37$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 746.23$ 1,268.60$ 1,492.47$ 2,126.77$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 746.23$ 1,268.60$ 1,492.47$ 2,126.77$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 698.38$ 1,187.24$ 1,396.75$ 1,990.37$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 694.66$ 1,180.92$ 1,389.31$ 1,979.77$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 698.38$ 1,187.24$ 1,396.75$ 1,990.37$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 694.66$ 1,180.92$ 1,389.31$ 1,979.77$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 714.24$ 1,214.20$ 1,428.47$ 2,035.57$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 714.24$ 1,214.20$ 1,428.47$ 2,035.57$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 710.52$ 1,207.88$ 1,421.03$ 2,024.97$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 710.52$ 1,207.88$ 1,421.03$ 2,024.97$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,124.73$ 1,912.04$ 2,249.46$ 3,205.47$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,121.01$ 1,905.72$ 2,242.02$ 3,194.87$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,124.73$ 1,912.04$ 2,249.46$ 3,205.47$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,121.01$ 1,905.72$ 2,242.02$ 3,194.87$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,140.59$ 1,939.00$ 2,281.18$ 3,250.67$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,140.59$ 1,939.00$ 2,281.18$ 3,250.67$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,136.87$ 1,932.68$ 2,273.74$ 3,240.07$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,136.87$ 1,932.68$ 2,273.74$ 3,240.07$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 910.05$ 1,547.08$ 1,820.09$ 2,593.63$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 906.33$ 1,540.76$ 1,812.65$ 2,583.03$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 910.05$ 1,547.08$ 1,820.09$ 2,593.63$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 906.33$ 1,540.76$ 1,812.65$ 2,583.03$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 925.91$ 1,574.04$ 1,851.81$ 2,638.83$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 925.91$ 1,574.04$ 1,851.81$ 2,638.83$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 922.19$ 1,567.72$ 1,844.37$ 2,628.23$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 922.19$ 1,567.72$ 1,844.37$ 2,628.23$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 869.58$ 1,478.29$ 1,739.16$ 2,478.31$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 865.86$ 1,471.97$ 1,731.72$ 2,467.71$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 869.58$ 1,478.29$ 1,739.16$ 2,478.31$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 865.86$ 1,471.97$ 1,731.72$ 2,467.71$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 885.44$ 1,505.25$ 1,770.88$ 2,523.51$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 885.44$ 1,505.25$ 1,770.88$ 2,523.51$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 881.72$ 1,498.93$ 1,763.44$ 2,512.91$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 881.72$ 1,498.93$ 1,763.44$ 2,512.91$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 972.65$ 1,653.51$ 1,945.31$ 2,772.06$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 968.93$ 1,647.19$ 1,937.87$ 2,761.46$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 972.65$ 1,653.51$ 1,945.31$ 2,772.06$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 968.93$ 1,647.19$ 1,937.87$ 2,761.46$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 988.51$ 1,680.47$ 1,977.03$ 2,817.26$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 988.51$ 1,680.47$ 1,977.03$ 2,817.26$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 984.79$ 1,674.15$ 1,969.59$ 2,806.66$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 984.79$ 1,674.15$ 1,969.59$ 2,806.66$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 701.28$ 1,192.18$ 1,402.56$ 1,998.65$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 697.56$ 1,185.86$ 1,395.12$ 1,988.05$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 701.28$ 1,192.18$ 1,402.56$ 1,998.65$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 697.56$ 1,185.86$ 1,395.12$ 1,988.05$
Page 26 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 717.14$ 1,219.14$ 1,434.28$ 2,043.85$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 717.14$ 1,219.14$ 1,434.28$ 2,043.85$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 713.42$ 1,212.82$ 1,426.84$ 2,033.25$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 713.42$ 1,212.82$ 1,426.84$ 2,033.25$
Page 27 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,139.11$ 1,936.49$ 2,278.22$ 3,246.46$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,135.74$ 1,930.76$ 2,271.48$ 3,236.86$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,139.11$ 1,936.49$ 2,278.22$ 3,246.46$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,135.74$ 1,930.76$ 2,271.48$ 3,236.86$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,153.51$ 1,960.97$ 2,307.02$ 3,287.50$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,153.51$ 1,960.97$ 2,307.02$ 3,287.50$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,150.14$ 1,955.24$ 2,300.28$ 3,277.90$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,150.14$ 1,955.24$ 2,300.28$ 3,277.90$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,070.94$ 1,820.60$ 2,141.88$ 3,052.18$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,067.57$ 1,814.87$ 2,135.14$ 3,042.58$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,070.94$ 1,820.60$ 2,141.88$ 3,052.18$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,067.57$ 1,814.87$ 2,135.14$ 3,042.58$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,085.34$ 1,845.08$ 2,170.68$ 3,093.22$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,085.34$ 1,845.08$ 2,170.68$ 3,093.22$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,081.97$ 1,839.35$ 2,163.94$ 3,083.62$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,081.97$ 1,839.35$ 2,163.94$ 3,083.62$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,118.79$ 1,901.95$ 2,237.59$ 3,188.56$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,115.42$ 1,896.22$ 2,230.85$ 3,178.96$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,118.79$ 1,901.95$ 2,237.59$ 3,188.56$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,115.42$ 1,896.22$ 2,230.85$ 3,178.96$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,133.19$ 1,926.43$ 2,266.39$ 3,229.60$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,133.19$ 1,926.43$ 2,266.39$ 3,229.60$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,129.82$ 1,920.70$ 2,259.65$ 3,220.00$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,129.82$ 1,920.70$ 2,259.65$ 3,220.00$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,054.89$ 1,793.31$ 2,109.77$ 3,006.43$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,051.52$ 1,787.58$ 2,103.03$ 2,996.83$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,054.89$ 1,793.31$ 2,109.77$ 3,006.43$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,051.52$ 1,787.58$ 2,103.03$ 2,996.83$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,069.29$ 1,817.79$ 2,138.57$ 3,047.47$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,069.29$ 1,817.79$ 2,138.57$ 3,047.47$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,065.92$ 1,812.06$ 2,131.83$ 3,037.87$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,065.92$ 1,812.06$ 2,131.83$ 3,037.87$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 974.06$ 1,655.91$ 1,948.12$ 2,776.08$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 970.69$ 1,650.18$ 1,941.38$ 2,766.48$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 974.06$ 1,655.91$ 1,948.12$ 2,776.08$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 970.69$ 1,650.18$ 1,941.38$ 2,766.48$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 988.46$ 1,680.39$ 1,976.92$ 2,817.12$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 988.46$ 1,680.39$ 1,976.92$ 2,817.12$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 985.09$ 1,674.66$ 1,970.18$ 2,807.52$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 985.09$ 1,674.66$ 1,970.18$ 2,807.52$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 875.18$ 1,487.81$ 1,750.37$ 2,494.28$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 871.81$ 1,482.08$ 1,743.63$ 2,484.68$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 875.18$ 1,487.81$ 1,750.37$ 2,494.28$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 871.81$ 1,482.08$ 1,743.63$ 2,484.68$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 889.58$ 1,512.29$ 1,779.17$ 2,535.32$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 889.58$ 1,512.29$ 1,779.17$ 2,535.32$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 886.21$ 1,506.56$ 1,772.43$ 2,525.72$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 886.21$ 1,506.56$ 1,772.43$ 2,525.72$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 902.16$ 1,533.67$ 1,804.32$ 2,571.16$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 898.79$ 1,527.94$ 1,797.58$ 2,561.56$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 902.16$ 1,533.67$ 1,804.32$ 2,571.16$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 898.79$ 1,527.94$ 1,797.58$ 2,561.56$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 916.56$ 1,558.15$ 1,833.12$ 2,612.20$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 916.56$ 1,558.15$ 1,833.12$ 2,612.20$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 913.19$ 1,552.42$ 1,826.38$ 2,602.60$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 913.19$ 1,552.42$ 1,826.38$ 2,602.60$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 927.93$ 1,577.49$ 1,855.87$ 2,644.61$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 924.56$ 1,571.76$ 1,849.13$ 2,635.01$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 927.93$ 1,577.49$ 1,855.87$ 2,644.61$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 924.56$ 1,571.76$ 1,849.13$ 2,635.01$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 942.33$ 1,601.97$ 1,884.67$ 2,685.65$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 942.33$ 1,601.97$ 1,884.67$ 2,685.65$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 938.96$ 1,596.24$ 1,877.93$ 2,676.05$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 938.96$ 1,596.24$ 1,877.93$ 2,676.05$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 871.31$ 1,481.23$ 1,742.62$ 2,483.23$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 867.94$ 1,475.50$ 1,735.88$ 2,473.63$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 871.31$ 1,481.23$ 1,742.62$ 2,483.23$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 867.94$ 1,475.50$ 1,735.88$ 2,473.63$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 885.71$ 1,505.71$ 1,771.42$ 2,524.27$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 885.71$ 1,505.71$ 1,771.42$ 2,524.27$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 882.34$ 1,499.98$ 1,764.68$ 2,514.67$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 882.34$ 1,499.98$ 1,764.68$ 2,514.67$
Region 4
Page 28 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 899.89$ 1,529.81$ 1,799.78$ 2,564.68$
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 896.52$ 1,524.08$ 1,793.04$ 2,555.08$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 899.89$ 1,529.81$ 1,799.78$ 2,564.68$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 896.52$ 1,524.08$ 1,793.04$ 2,555.08$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 914.29$ 1,554.29$ 1,828.58$ 2,605.72$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 914.29$ 1,554.29$ 1,828.58$ 2,605.72$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 910.92$ 1,548.56$ 1,821.84$ 2,596.12$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 910.92$ 1,548.56$ 1,821.84$ 2,596.12$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 843.04$ 1,433.17$ 1,686.08$ 2,402.67$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 839.67$ 1,427.44$ 1,679.34$ 2,393.07$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 843.04$ 1,433.17$ 1,686.08$ 2,402.67$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 839.67$ 1,427.44$ 1,679.34$ 2,393.07$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 857.44$ 1,457.65$ 1,714.88$ 2,443.71$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 857.44$ 1,457.65$ 1,714.88$ 2,443.71$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 854.07$ 1,451.92$ 1,708.14$ 2,434.11$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 854.07$ 1,451.92$ 1,708.14$ 2,434.11$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 817.96$ 1,390.53$ 1,635.92$ 2,331.18$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 814.59$ 1,384.80$ 1,629.18$ 2,321.58$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 817.96$ 1,390.53$ 1,635.92$ 2,331.18$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 814.59$ 1,384.80$ 1,629.18$ 2,321.58$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 832.36$ 1,415.01$ 1,664.72$ 2,372.22$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 832.36$ 1,415.01$ 1,664.72$ 2,372.22$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 828.99$ 1,409.28$ 1,657.98$ 2,362.62$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 828.99$ 1,409.28$ 1,657.98$ 2,362.62$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 696.69$ 1,184.37$ 1,393.37$ 1,985.56$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 693.32$ 1,178.64$ 1,386.63$ 1,975.96$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 696.69$ 1,184.37$ 1,393.37$ 1,985.56$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 693.32$ 1,178.64$ 1,386.63$ 1,975.96$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 711.09$ 1,208.85$ 1,422.17$ 2,026.60$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 711.09$ 1,208.85$ 1,422.17$ 2,026.60$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 707.72$ 1,203.12$ 1,415.43$ 2,017.00$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 707.72$ 1,203.12$ 1,415.43$ 2,017.00$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 735.38$ 1,250.14$ 1,470.75$ 2,095.82$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 732.01$ 1,244.41$ 1,464.01$ 2,086.22$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 735.38$ 1,250.14$ 1,470.75$ 2,095.82$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 732.01$ 1,244.41$ 1,464.01$ 2,086.22$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 749.78$ 1,274.62$ 1,499.55$ 2,136.86$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 749.78$ 1,274.62$ 1,499.55$ 2,136.86$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 746.41$ 1,268.89$ 1,492.81$ 2,127.26$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 746.41$ 1,268.89$ 1,492.81$ 2,127.26$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 817.71$ 1,390.10$ 1,635.41$ 2,330.46$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 814.34$ 1,384.37$ 1,628.67$ 2,320.86$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 817.71$ 1,390.10$ 1,635.41$ 2,330.46$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 814.34$ 1,384.37$ 1,628.67$ 2,320.86$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 832.11$ 1,414.58$ 1,664.21$ 2,371.50$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 832.11$ 1,414.58$ 1,664.21$ 2,371.50$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 828.74$ 1,408.85$ 1,657.47$ 2,361.90$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 828.74$ 1,408.85$ 1,657.47$ 2,361.90$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 756.39$ 1,285.86$ 1,512.78$ 2,155.71$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 753.02$ 1,280.13$ 1,506.04$ 2,146.11$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 756.39$ 1,285.86$ 1,512.78$ 2,155.71$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 753.02$ 1,280.13$ 1,506.04$ 2,146.11$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 770.79$ 1,310.34$ 1,541.58$ 2,196.75$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 770.79$ 1,310.34$ 1,541.58$ 2,196.75$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 767.42$ 1,304.61$ 1,534.84$ 2,187.15$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 767.42$ 1,304.61$ 1,534.84$ 2,187.15$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 722.74$ 1,228.66$ 1,445.48$ 2,059.81$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 719.37$ 1,222.93$ 1,438.74$ 2,050.21$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 722.74$ 1,228.66$ 1,445.48$ 2,059.81$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 719.37$ 1,222.93$ 1,438.74$ 2,050.21$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 737.14$ 1,253.14$ 1,474.28$ 2,100.85$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 737.14$ 1,253.14$ 1,474.28$ 2,100.85$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 733.77$ 1,247.41$ 1,467.54$ 2,091.25$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 733.77$ 1,247.41$ 1,467.54$ 2,091.25$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 761.55$ 1,294.63$ 1,523.09$ 2,170.41$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 758.18$ 1,288.90$ 1,516.35$ 2,160.81$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 761.55$ 1,294.63$ 1,523.09$ 2,170.41$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 758.18$ 1,288.90$ 1,516.35$ 2,160.81$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 775.95$ 1,319.11$ 1,551.89$ 2,211.45$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 775.95$ 1,319.11$ 1,551.89$ 2,211.45$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 772.58$ 1,313.38$ 1,545.15$ 2,201.85$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 772.58$ 1,313.38$ 1,545.15$ 2,201.85$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 727.67$ 1,237.05$ 1,455.35$ 2,073.87$
Page 29 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 724.30$ 1,231.32$ 1,448.61$ 2,064.27$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 727.67$ 1,237.05$ 1,455.35$ 2,073.87$
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 724.30$ 1,231.32$ 1,448.61$ 2,064.27$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 742.07$ 1,261.53$ 1,484.15$ 2,114.91$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 742.07$ 1,261.53$ 1,484.15$ 2,114.91$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 738.70$ 1,255.80$ 1,477.41$ 2,105.31$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 738.70$ 1,255.80$ 1,477.41$ 2,105.31$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 693.57$ 1,179.07$ 1,387.14$ 1,976.67$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 690.20$ 1,173.34$ 1,380.40$ 1,967.07$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 693.57$ 1,179.07$ 1,387.14$ 1,976.67$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 690.20$ 1,173.34$ 1,380.40$ 1,967.07$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 707.97$ 1,203.55$ 1,415.94$ 2,017.71$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 707.97$ 1,203.55$ 1,415.94$ 2,017.71$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 704.60$ 1,197.82$ 1,409.20$ 2,008.11$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 704.60$ 1,197.82$ 1,409.20$ 2,008.11$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 688.12$ 1,169.81$ 1,376.24$ 1,961.15$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 684.75$ 1,164.08$ 1,369.50$ 1,951.55$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 688.12$ 1,169.81$ 1,376.24$ 1,961.15$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 684.75$ 1,164.08$ 1,369.50$ 1,951.55$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 702.52$ 1,194.29$ 1,405.04$ 2,002.19$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 702.52$ 1,194.29$ 1,405.04$ 2,002.19$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 699.15$ 1,188.56$ 1,398.30$ 1,992.59$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 699.15$ 1,188.56$ 1,398.30$ 1,992.59$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,287.24$ 2,188.31$ 2,574.48$ 3,668.64$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,283.87$ 2,182.58$ 2,567.74$ 3,659.04$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,287.24$ 2,188.31$ 2,574.48$ 3,668.64$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,283.87$ 2,182.58$ 2,567.74$ 3,659.04$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,301.64$ 2,212.79$ 2,603.28$ 3,709.68$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,301.64$ 2,212.79$ 2,603.28$ 3,709.68$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,298.27$ 2,207.06$ 2,596.54$ 3,700.08$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,298.27$ 2,207.06$ 2,596.54$ 3,700.08$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 868.79$ 1,476.95$ 1,737.59$ 2,476.06$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 865.42$ 1,471.22$ 1,730.85$ 2,466.46$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 868.79$ 1,476.95$ 1,737.59$ 2,476.06$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 865.42$ 1,471.22$ 1,730.85$ 2,466.46$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 883.19$ 1,501.43$ 1,766.39$ 2,517.10$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 883.19$ 1,501.43$ 1,766.39$ 2,517.10$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 879.82$ 1,495.70$ 1,759.65$ 2,507.50$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 879.82$ 1,495.70$ 1,759.65$ 2,507.50$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 975.38$ 1,658.15$ 1,950.77$ 2,779.84$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 972.01$ 1,652.42$ 1,944.03$ 2,770.24$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 975.38$ 1,658.15$ 1,950.77$ 2,779.84$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 972.01$ 1,652.42$ 1,944.03$ 2,770.24$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 989.78$ 1,682.63$ 1,979.57$ 2,820.88$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 989.78$ 1,682.63$ 1,979.57$ 2,820.88$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 986.41$ 1,676.90$ 1,972.83$ 2,811.28$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 986.41$ 1,676.90$ 1,972.83$ 2,811.28$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 700.96$ 1,191.63$ 1,401.92$ 1,997.73$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 697.59$ 1,185.90$ 1,395.18$ 1,988.13$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 700.96$ 1,191.63$ 1,401.92$ 1,997.73$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 697.59$ 1,185.90$ 1,395.18$ 1,988.13$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 715.36$ 1,216.11$ 1,430.72$ 2,038.77$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 715.36$ 1,216.11$ 1,430.72$ 2,038.77$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 711.99$ 1,210.38$ 1,423.98$ 2,029.17$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 711.99$ 1,210.38$ 1,423.98$ 2,029.17$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 619.54$ 1,053.22$ 1,239.08$ 1,765.70$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 616.17$ 1,047.49$ 1,232.34$ 1,756.10$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 619.54$ 1,053.22$ 1,239.08$ 1,765.70$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 616.17$ 1,047.49$ 1,232.34$ 1,756.10$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 633.94$ 1,077.70$ 1,267.88$ 1,806.74$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 633.94$ 1,077.70$ 1,267.88$ 1,806.74$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 630.57$ 1,071.97$ 1,261.14$ 1,797.14$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 630.57$ 1,071.97$ 1,261.14$ 1,797.14$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 631.34$ 1,073.28$ 1,262.68$ 1,799.32$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 627.97$ 1,067.55$ 1,255.94$ 1,789.72$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 631.34$ 1,073.28$ 1,262.68$ 1,799.32$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 627.97$ 1,067.55$ 1,255.94$ 1,789.72$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 645.74$ 1,097.76$ 1,291.48$ 1,840.36$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 645.74$ 1,097.76$ 1,291.48$ 1,840.36$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 642.37$ 1,092.03$ 1,284.74$ 1,830.76$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 642.37$ 1,092.03$ 1,284.74$ 1,830.76$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 601.11$ 1,021.89$ 1,202.22$ 1,713.17$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 597.74$ 1,016.16$ 1,195.48$ 1,703.57$
Page 30 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 601.11$ 1,021.89$ 1,202.22$ 1,713.17$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 597.74$ 1,016.16$ 1,195.48$ 1,703.57$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 615.51$ 1,046.37$ 1,231.02$ 1,754.21$
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 615.51$ 1,046.37$ 1,231.02$ 1,754.21$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 612.14$ 1,040.64$ 1,224.28$ 1,744.61$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 612.14$ 1,040.64$ 1,224.28$ 1,744.61$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 628.57$ 1,068.58$ 1,257.15$ 1,791.43$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 625.20$ 1,062.85$ 1,250.41$ 1,781.83$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 628.57$ 1,068.58$ 1,257.15$ 1,791.43$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 625.20$ 1,062.85$ 1,250.41$ 1,781.83$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 642.97$ 1,093.06$ 1,285.95$ 1,832.47$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 642.97$ 1,093.06$ 1,285.95$ 1,832.47$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 639.60$ 1,087.33$ 1,279.21$ 1,822.87$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 639.60$ 1,087.33$ 1,279.21$ 1,822.87$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 600.62$ 1,021.05$ 1,201.23$ 1,711.75$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 597.25$ 1,015.32$ 1,194.49$ 1,702.15$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 600.62$ 1,021.05$ 1,201.23$ 1,711.75$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 597.25$ 1,015.32$ 1,194.49$ 1,702.15$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 615.02$ 1,045.53$ 1,230.03$ 1,752.79$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 615.02$ 1,045.53$ 1,230.03$ 1,752.79$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 611.65$ 1,039.80$ 1,223.29$ 1,743.19$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 611.65$ 1,039.80$ 1,223.29$ 1,743.19$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 637.10$ 1,083.07$ 1,274.20$ 1,815.73$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 633.73$ 1,077.34$ 1,267.46$ 1,806.13$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 637.10$ 1,083.07$ 1,274.20$ 1,815.73$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 633.73$ 1,077.34$ 1,267.46$ 1,806.13$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 651.50$ 1,107.55$ 1,303.00$ 1,856.77$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 651.50$ 1,107.55$ 1,303.00$ 1,856.77$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 648.13$ 1,101.82$ 1,296.26$ 1,847.17$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 648.13$ 1,101.82$ 1,296.26$ 1,847.17$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 512.73$ 871.64$ 1,025.46$ 1,461.28$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 509.36$ 865.91$ 1,018.72$ 1,451.68$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 512.73$ 871.64$ 1,025.46$ 1,461.28$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 509.36$ 865.91$ 1,018.72$ 1,451.68$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 527.13$ 896.12$ 1,054.26$ 1,502.32$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 527.13$ 896.12$ 1,054.26$ 1,502.32$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 523.76$ 890.39$ 1,047.52$ 1,492.72$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 523.76$ 890.39$ 1,047.52$ 1,492.72$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 511.52$ 869.58$ 1,023.03$ 1,457.82$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 508.15$ 863.85$ 1,016.29$ 1,448.22$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 511.52$ 869.58$ 1,023.03$ 1,457.82$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 508.15$ 863.85$ 1,016.29$ 1,448.22$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 525.92$ 894.06$ 1,051.83$ 1,498.86$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 525.92$ 894.06$ 1,051.83$ 1,498.86$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 522.55$ 888.33$ 1,045.09$ 1,489.26$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 522.55$ 888.33$ 1,045.09$ 1,489.26$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 621.69$ 1,056.87$ 1,243.38$ 1,771.81$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 618.32$ 1,051.14$ 1,236.64$ 1,762.21$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 621.69$ 1,056.87$ 1,243.38$ 1,771.81$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 618.32$ 1,051.14$ 1,236.64$ 1,762.21$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 636.09$ 1,081.35$ 1,272.18$ 1,812.85$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 636.09$ 1,081.35$ 1,272.18$ 1,812.85$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 632.72$ 1,075.62$ 1,265.44$ 1,803.25$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 632.72$ 1,075.62$ 1,265.44$ 1,803.25$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 505.91$ 860.05$ 1,011.83$ 1,441.85$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 502.54$ 854.32$ 1,005.09$ 1,432.25$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 505.91$ 860.05$ 1,011.83$ 1,441.85$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 502.54$ 854.32$ 1,005.09$ 1,432.25$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 520.31$ 884.53$ 1,040.63$ 1,482.89$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 520.31$ 884.53$ 1,040.63$ 1,482.89$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 516.94$ 878.80$ 1,033.89$ 1,473.29$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 516.94$ 878.80$ 1,033.89$ 1,473.29$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 640.55$ 1,088.93$ 1,281.09$ 1,825.56$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 637.18$ 1,083.20$ 1,274.35$ 1,815.96$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 640.55$ 1,088.93$ 1,281.09$ 1,825.56$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 637.18$ 1,083.20$ 1,274.35$ 1,815.96$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 654.95$ 1,113.41$ 1,309.89$ 1,866.60$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 654.95$ 1,113.41$ 1,309.89$ 1,866.60$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 651.58$ 1,107.68$ 1,303.15$ 1,857.00$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 651.58$ 1,107.68$ 1,303.15$ 1,857.00$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 741.87$ 1,261.18$ 1,483.74$ 2,114.33$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 738.50$ 1,255.45$ 1,477.00$ 2,104.73$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 741.87$ 1,261.18$ 1,483.74$ 2,114.33$
Page 31 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 738.50$ 1,255.45$ 1,477.00$ 2,104.73$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 756.27$ 1,285.66$ 1,512.54$ 2,155.37$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 756.27$ 1,285.66$ 1,512.54$ 2,155.37$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 752.90$ 1,279.93$ 1,505.80$ 2,145.77$
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 752.90$ 1,279.93$ 1,505.80$ 2,145.77$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 593.00$ 1,008.10$ 1,186.00$ 1,690.06$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 589.63$ 1,002.37$ 1,179.26$ 1,680.46$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 593.00$ 1,008.10$ 1,186.00$ 1,690.06$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 589.63$ 1,002.37$ 1,179.26$ 1,680.46$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 607.40$ 1,032.58$ 1,214.80$ 1,731.10$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 607.40$ 1,032.58$ 1,214.80$ 1,731.10$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 604.03$ 1,026.85$ 1,208.06$ 1,721.50$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 604.03$ 1,026.85$ 1,208.06$ 1,721.50$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 802.67$ 1,364.54$ 1,605.34$ 2,287.62$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 799.30$ 1,358.81$ 1,598.60$ 2,278.02$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 802.67$ 1,364.54$ 1,605.34$ 2,287.62$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 799.30$ 1,358.81$ 1,598.60$ 2,278.02$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 817.07$ 1,389.02$ 1,634.14$ 2,328.66$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 817.07$ 1,389.02$ 1,634.14$ 2,328.66$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 813.70$ 1,383.29$ 1,627.40$ 2,319.06$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 813.70$ 1,383.29$ 1,627.40$ 2,319.06$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 666.69$ 1,133.37$ 1,333.38$ 1,900.06$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 663.32$ 1,127.64$ 1,326.64$ 1,890.46$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 666.69$ 1,133.37$ 1,333.38$ 1,900.06$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 663.32$ 1,127.64$ 1,326.64$ 1,890.46$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 681.09$ 1,157.85$ 1,362.18$ 1,941.10$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 681.09$ 1,157.85$ 1,362.18$ 1,941.10$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 677.72$ 1,152.12$ 1,355.44$ 1,931.50$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 677.72$ 1,152.12$ 1,355.44$ 1,931.50$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 634.25$ 1,078.23$ 1,268.51$ 1,807.63$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 630.88$ 1,072.50$ 1,261.77$ 1,798.03$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 634.25$ 1,078.23$ 1,268.51$ 1,807.63$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 630.88$ 1,072.50$ 1,261.77$ 1,798.03$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 648.65$ 1,102.71$ 1,297.31$ 1,848.67$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 648.65$ 1,102.71$ 1,297.31$ 1,848.67$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 645.28$ 1,096.98$ 1,290.57$ 1,839.07$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 645.28$ 1,096.98$ 1,290.57$ 1,839.07$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,021.46$ 1,736.48$ 2,042.92$ 2,911.16$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,018.09$ 1,730.75$ 2,036.18$ 2,901.56$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,021.46$ 1,736.48$ 2,042.92$ 2,911.16$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,018.09$ 1,730.75$ 2,036.18$ 2,901.56$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,035.86$ 1,760.96$ 2,071.72$ 2,952.20$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,035.86$ 1,760.96$ 2,071.72$ 2,952.20$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,032.49$ 1,755.23$ 2,064.98$ 2,942.60$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,032.49$ 1,755.23$ 2,064.98$ 2,942.60$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 826.48$ 1,405.02$ 1,652.97$ 2,355.48$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 823.11$ 1,399.29$ 1,646.23$ 2,345.88$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 826.48$ 1,405.02$ 1,652.97$ 2,355.48$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 823.11$ 1,399.29$ 1,646.23$ 2,345.88$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 840.88$ 1,429.50$ 1,681.77$ 2,396.52$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 840.88$ 1,429.50$ 1,681.77$ 2,396.52$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 837.51$ 1,423.77$ 1,675.03$ 2,386.92$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 837.51$ 1,423.77$ 1,675.03$ 2,386.92$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 789.74$ 1,342.55$ 1,579.47$ 2,250.75$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 786.37$ 1,336.82$ 1,572.73$ 2,241.15$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 789.74$ 1,342.55$ 1,579.47$ 2,250.75$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 786.37$ 1,336.82$ 1,572.73$ 2,241.15$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 804.14$ 1,367.03$ 1,608.27$ 2,291.79$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 804.14$ 1,367.03$ 1,608.27$ 2,291.79$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 800.77$ 1,361.30$ 1,601.53$ 2,282.19$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 800.77$ 1,361.30$ 1,601.53$ 2,282.19$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 883.34$ 1,501.68$ 1,766.68$ 2,517.52$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 879.97$ 1,495.95$ 1,759.94$ 2,507.92$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 883.34$ 1,501.68$ 1,766.68$ 2,517.52$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 879.97$ 1,495.95$ 1,759.94$ 2,507.92$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 897.74$ 1,526.16$ 1,795.48$ 2,558.56$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 897.74$ 1,526.16$ 1,795.48$ 2,558.56$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 894.37$ 1,520.43$ 1,788.74$ 2,548.96$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 894.37$ 1,520.43$ 1,788.74$ 2,548.96$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 636.89$ 1,082.71$ 1,273.77$ 1,815.13$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 633.52$ 1,076.98$ 1,267.03$ 1,805.53$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 636.89$ 1,082.71$ 1,273.77$ 1,815.13$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 633.52$ 1,076.98$ 1,267.03$ 1,805.53$
Page 32 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 651.29$ 1,107.19$ 1,302.57$ 1,856.17$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 651.29$ 1,107.19$ 1,302.57$ 1,856.17$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 647.92$ 1,101.46$ 1,295.83$ 1,846.57$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 647.92$ 1,101.46$ 1,295.83$ 1,846.57$
Page 33 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,139.11$ 1,936.49$ 2,278.22$ 3,246.46$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,135.74$ 1,930.76$ 2,271.48$ 3,236.86$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,139.11$ 1,936.49$ 2,278.22$ 3,246.46$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,135.74$ 1,930.76$ 2,271.48$ 3,236.86$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,153.51$ 1,960.97$ 2,307.02$ 3,287.50$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,153.51$ 1,960.97$ 2,307.02$ 3,287.50$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,150.14$ 1,955.24$ 2,300.28$ 3,277.90$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,150.14$ 1,955.24$ 2,300.28$ 3,277.90$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,070.94$ 1,820.60$ 2,141.88$ 3,052.18$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,067.57$ 1,814.87$ 2,135.14$ 3,042.58$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,070.94$ 1,820.60$ 2,141.88$ 3,052.18$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,067.57$ 1,814.87$ 2,135.14$ 3,042.58$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,085.34$ 1,845.08$ 2,170.68$ 3,093.22$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,085.34$ 1,845.08$ 2,170.68$ 3,093.22$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,081.97$ 1,839.35$ 2,163.94$ 3,083.62$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,081.97$ 1,839.35$ 2,163.94$ 3,083.62$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,118.79$ 1,901.95$ 2,237.59$ 3,188.56$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,115.42$ 1,896.22$ 2,230.85$ 3,178.96$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,118.79$ 1,901.95$ 2,237.59$ 3,188.56$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,115.42$ 1,896.22$ 2,230.85$ 3,178.96$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,133.19$ 1,926.43$ 2,266.39$ 3,229.60$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,133.19$ 1,926.43$ 2,266.39$ 3,229.60$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,129.82$ 1,920.70$ 2,259.65$ 3,220.00$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,129.82$ 1,920.70$ 2,259.65$ 3,220.00$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,054.89$ 1,793.31$ 2,109.77$ 3,006.43$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,051.52$ 1,787.58$ 2,103.03$ 2,996.83$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,054.89$ 1,793.31$ 2,109.77$ 3,006.43$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,051.52$ 1,787.58$ 2,103.03$ 2,996.83$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,069.29$ 1,817.79$ 2,138.57$ 3,047.47$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,069.29$ 1,817.79$ 2,138.57$ 3,047.47$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,065.92$ 1,812.06$ 2,131.83$ 3,037.87$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,065.92$ 1,812.06$ 2,131.83$ 3,037.87$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 974.06$ 1,655.91$ 1,948.12$ 2,776.08$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 970.69$ 1,650.18$ 1,941.38$ 2,766.48$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 974.06$ 1,655.91$ 1,948.12$ 2,776.08$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 970.69$ 1,650.18$ 1,941.38$ 2,766.48$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 988.46$ 1,680.39$ 1,976.92$ 2,817.12$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 988.46$ 1,680.39$ 1,976.92$ 2,817.12$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 985.09$ 1,674.66$ 1,970.18$ 2,807.52$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 985.09$ 1,674.66$ 1,970.18$ 2,807.52$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 875.18$ 1,487.81$ 1,750.37$ 2,494.28$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 871.81$ 1,482.08$ 1,743.63$ 2,484.68$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 875.18$ 1,487.81$ 1,750.37$ 2,494.28$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 871.81$ 1,482.08$ 1,743.63$ 2,484.68$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 889.58$ 1,512.29$ 1,779.17$ 2,535.32$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 889.58$ 1,512.29$ 1,779.17$ 2,535.32$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 886.21$ 1,506.56$ 1,772.43$ 2,525.72$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 886.21$ 1,506.56$ 1,772.43$ 2,525.72$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 902.16$ 1,533.67$ 1,804.32$ 2,571.16$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 898.79$ 1,527.94$ 1,797.58$ 2,561.56$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 902.16$ 1,533.67$ 1,804.32$ 2,571.16$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 898.79$ 1,527.94$ 1,797.58$ 2,561.56$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 916.56$ 1,558.15$ 1,833.12$ 2,612.20$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 916.56$ 1,558.15$ 1,833.12$ 2,612.20$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 913.19$ 1,552.42$ 1,826.38$ 2,602.60$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 913.19$ 1,552.42$ 1,826.38$ 2,602.60$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 927.93$ 1,577.49$ 1,855.87$ 2,644.61$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 924.56$ 1,571.76$ 1,849.13$ 2,635.01$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 927.93$ 1,577.49$ 1,855.87$ 2,644.61$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 924.56$ 1,571.76$ 1,849.13$ 2,635.01$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 942.33$ 1,601.97$ 1,884.67$ 2,685.65$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 942.33$ 1,601.97$ 1,884.67$ 2,685.65$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 938.96$ 1,596.24$ 1,877.93$ 2,676.05$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 938.96$ 1,596.24$ 1,877.93$ 2,676.05$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 871.31$ 1,481.23$ 1,742.62$ 2,483.23$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 867.94$ 1,475.50$ 1,735.88$ 2,473.63$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 871.31$ 1,481.23$ 1,742.62$ 2,483.23$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 867.94$ 1,475.50$ 1,735.88$ 2,473.63$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 885.71$ 1,505.71$ 1,771.42$ 2,524.27$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 885.71$ 1,505.71$ 1,771.42$ 2,524.27$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 882.34$ 1,499.98$ 1,764.68$ 2,514.67$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 882.34$ 1,499.98$ 1,764.68$ 2,514.67$
Region 8
Page 34 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 899.89$ 1,529.81$ 1,799.78$ 2,564.68$
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 896.52$ 1,524.08$ 1,793.04$ 2,555.08$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 899.89$ 1,529.81$ 1,799.78$ 2,564.68$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 896.52$ 1,524.08$ 1,793.04$ 2,555.08$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 914.29$ 1,554.29$ 1,828.58$ 2,605.72$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 914.29$ 1,554.29$ 1,828.58$ 2,605.72$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 910.92$ 1,548.56$ 1,821.84$ 2,596.12$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 910.92$ 1,548.56$ 1,821.84$ 2,596.12$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 843.04$ 1,433.17$ 1,686.08$ 2,402.67$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 839.67$ 1,427.44$ 1,679.34$ 2,393.07$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 843.04$ 1,433.17$ 1,686.08$ 2,402.67$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 839.67$ 1,427.44$ 1,679.34$ 2,393.07$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 857.44$ 1,457.65$ 1,714.88$ 2,443.71$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 857.44$ 1,457.65$ 1,714.88$ 2,443.71$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 854.07$ 1,451.92$ 1,708.14$ 2,434.11$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 854.07$ 1,451.92$ 1,708.14$ 2,434.11$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 817.96$ 1,390.53$ 1,635.92$ 2,331.18$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 814.59$ 1,384.80$ 1,629.18$ 2,321.58$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 817.96$ 1,390.53$ 1,635.92$ 2,331.18$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 814.59$ 1,384.80$ 1,629.18$ 2,321.58$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 832.36$ 1,415.01$ 1,664.72$ 2,372.22$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 832.36$ 1,415.01$ 1,664.72$ 2,372.22$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 828.99$ 1,409.28$ 1,657.98$ 2,362.62$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 828.99$ 1,409.28$ 1,657.98$ 2,362.62$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 696.69$ 1,184.37$ 1,393.37$ 1,985.56$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 693.32$ 1,178.64$ 1,386.63$ 1,975.96$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 696.69$ 1,184.37$ 1,393.37$ 1,985.56$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 693.32$ 1,178.64$ 1,386.63$ 1,975.96$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 711.09$ 1,208.85$ 1,422.17$ 2,026.60$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 711.09$ 1,208.85$ 1,422.17$ 2,026.60$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 707.72$ 1,203.12$ 1,415.43$ 2,017.00$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 707.72$ 1,203.12$ 1,415.43$ 2,017.00$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 735.38$ 1,250.14$ 1,470.75$ 2,095.82$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 732.01$ 1,244.41$ 1,464.01$ 2,086.22$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 735.38$ 1,250.14$ 1,470.75$ 2,095.82$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 732.01$ 1,244.41$ 1,464.01$ 2,086.22$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 749.78$ 1,274.62$ 1,499.55$ 2,136.86$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 749.78$ 1,274.62$ 1,499.55$ 2,136.86$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 746.41$ 1,268.89$ 1,492.81$ 2,127.26$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 746.41$ 1,268.89$ 1,492.81$ 2,127.26$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 817.71$ 1,390.10$ 1,635.41$ 2,330.46$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 814.34$ 1,384.37$ 1,628.67$ 2,320.86$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 817.71$ 1,390.10$ 1,635.41$ 2,330.46$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 814.34$ 1,384.37$ 1,628.67$ 2,320.86$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 832.11$ 1,414.58$ 1,664.21$ 2,371.50$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 832.11$ 1,414.58$ 1,664.21$ 2,371.50$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 828.74$ 1,408.85$ 1,657.47$ 2,361.90$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 828.74$ 1,408.85$ 1,657.47$ 2,361.90$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 756.39$ 1,285.86$ 1,512.78$ 2,155.71$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 753.02$ 1,280.13$ 1,506.04$ 2,146.11$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 756.39$ 1,285.86$ 1,512.78$ 2,155.71$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 753.02$ 1,280.13$ 1,506.04$ 2,146.11$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 770.79$ 1,310.34$ 1,541.58$ 2,196.75$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 770.79$ 1,310.34$ 1,541.58$ 2,196.75$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 767.42$ 1,304.61$ 1,534.84$ 2,187.15$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 767.42$ 1,304.61$ 1,534.84$ 2,187.15$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 722.74$ 1,228.66$ 1,445.48$ 2,059.81$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 719.37$ 1,222.93$ 1,438.74$ 2,050.21$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 722.74$ 1,228.66$ 1,445.48$ 2,059.81$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 719.37$ 1,222.93$ 1,438.74$ 2,050.21$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 737.14$ 1,253.14$ 1,474.28$ 2,100.85$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 737.14$ 1,253.14$ 1,474.28$ 2,100.85$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 733.77$ 1,247.41$ 1,467.54$ 2,091.25$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 733.77$ 1,247.41$ 1,467.54$ 2,091.25$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 761.55$ 1,294.63$ 1,523.09$ 2,170.41$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 758.18$ 1,288.90$ 1,516.35$ 2,160.81$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 761.55$ 1,294.63$ 1,523.09$ 2,170.41$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 758.18$ 1,288.90$ 1,516.35$ 2,160.81$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 775.95$ 1,319.11$ 1,551.89$ 2,211.45$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 775.95$ 1,319.11$ 1,551.89$ 2,211.45$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 772.58$ 1,313.38$ 1,545.15$ 2,201.85$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 772.58$ 1,313.38$ 1,545.15$ 2,201.85$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 727.67$ 1,237.05$ 1,455.35$ 2,073.87$
Page 35 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 724.30$ 1,231.32$ 1,448.61$ 2,064.27$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 727.67$ 1,237.05$ 1,455.35$ 2,073.87$
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 724.30$ 1,231.32$ 1,448.61$ 2,064.27$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 742.07$ 1,261.53$ 1,484.15$ 2,114.91$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 742.07$ 1,261.53$ 1,484.15$ 2,114.91$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 738.70$ 1,255.80$ 1,477.41$ 2,105.31$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 738.70$ 1,255.80$ 1,477.41$ 2,105.31$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 693.57$ 1,179.07$ 1,387.14$ 1,976.67$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 690.20$ 1,173.34$ 1,380.40$ 1,967.07$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 693.57$ 1,179.07$ 1,387.14$ 1,976.67$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 690.20$ 1,173.34$ 1,380.40$ 1,967.07$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 707.97$ 1,203.55$ 1,415.94$ 2,017.71$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 707.97$ 1,203.55$ 1,415.94$ 2,017.71$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 704.60$ 1,197.82$ 1,409.20$ 2,008.11$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 704.60$ 1,197.82$ 1,409.20$ 2,008.11$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 688.12$ 1,169.81$ 1,376.24$ 1,961.15$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 684.75$ 1,164.08$ 1,369.50$ 1,951.55$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 688.12$ 1,169.81$ 1,376.24$ 1,961.15$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 684.75$ 1,164.08$ 1,369.50$ 1,951.55$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 702.52$ 1,194.29$ 1,405.04$ 2,002.19$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 702.52$ 1,194.29$ 1,405.04$ 2,002.19$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 699.15$ 1,188.56$ 1,398.30$ 1,992.59$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 699.15$ 1,188.56$ 1,398.30$ 1,992.59$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,287.24$ 2,188.31$ 2,574.48$ 3,668.64$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,283.87$ 2,182.58$ 2,567.74$ 3,659.04$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,287.24$ 2,188.31$ 2,574.48$ 3,668.64$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,283.87$ 2,182.58$ 2,567.74$ 3,659.04$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,301.64$ 2,212.79$ 2,603.28$ 3,709.68$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,301.64$ 2,212.79$ 2,603.28$ 3,709.68$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,298.27$ 2,207.06$ 2,596.54$ 3,700.08$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,298.27$ 2,207.06$ 2,596.54$ 3,700.08$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 868.79$ 1,476.95$ 1,737.59$ 2,476.06$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 865.42$ 1,471.22$ 1,730.85$ 2,466.46$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 868.79$ 1,476.95$ 1,737.59$ 2,476.06$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 865.42$ 1,471.22$ 1,730.85$ 2,466.46$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 883.19$ 1,501.43$ 1,766.39$ 2,517.10$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 883.19$ 1,501.43$ 1,766.39$ 2,517.10$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 879.82$ 1,495.70$ 1,759.65$ 2,507.50$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 879.82$ 1,495.70$ 1,759.65$ 2,507.50$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 975.38$ 1,658.15$ 1,950.77$ 2,779.84$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 972.01$ 1,652.42$ 1,944.03$ 2,770.24$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 975.38$ 1,658.15$ 1,950.77$ 2,779.84$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 972.01$ 1,652.42$ 1,944.03$ 2,770.24$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 989.78$ 1,682.63$ 1,979.57$ 2,820.88$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 989.78$ 1,682.63$ 1,979.57$ 2,820.88$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 986.41$ 1,676.90$ 1,972.83$ 2,811.28$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 986.41$ 1,676.90$ 1,972.83$ 2,811.28$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 700.96$ 1,191.63$ 1,401.92$ 1,997.73$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 697.59$ 1,185.90$ 1,395.18$ 1,988.13$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 700.96$ 1,191.63$ 1,401.92$ 1,997.73$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 697.59$ 1,185.90$ 1,395.18$ 1,988.13$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 715.36$ 1,216.11$ 1,430.72$ 2,038.77$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 715.36$ 1,216.11$ 1,430.72$ 2,038.77$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 711.99$ 1,210.38$ 1,423.98$ 2,029.17$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 711.99$ 1,210.38$ 1,423.98$ 2,029.17$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 619.54$ 1,053.22$ 1,239.08$ 1,765.70$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 616.17$ 1,047.49$ 1,232.34$ 1,756.10$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 619.54$ 1,053.22$ 1,239.08$ 1,765.70$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 616.17$ 1,047.49$ 1,232.34$ 1,756.10$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 633.94$ 1,077.70$ 1,267.88$ 1,806.74$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 633.94$ 1,077.70$ 1,267.88$ 1,806.74$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 630.57$ 1,071.97$ 1,261.14$ 1,797.14$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 630.57$ 1,071.97$ 1,261.14$ 1,797.14$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 631.34$ 1,073.28$ 1,262.68$ 1,799.32$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 627.97$ 1,067.55$ 1,255.94$ 1,789.72$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 631.34$ 1,073.28$ 1,262.68$ 1,799.32$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 627.97$ 1,067.55$ 1,255.94$ 1,789.72$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 645.74$ 1,097.76$ 1,291.48$ 1,840.36$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 645.74$ 1,097.76$ 1,291.48$ 1,840.36$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 642.37$ 1,092.03$ 1,284.74$ 1,830.76$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 642.37$ 1,092.03$ 1,284.74$ 1,830.76$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 601.11$ 1,021.89$ 1,202.22$ 1,713.17$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 597.74$ 1,016.16$ 1,195.48$ 1,703.57$
Page 36 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 601.11$ 1,021.89$ 1,202.22$ 1,713.17$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 597.74$ 1,016.16$ 1,195.48$ 1,703.57$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 615.51$ 1,046.37$ 1,231.02$ 1,754.21$
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 615.51$ 1,046.37$ 1,231.02$ 1,754.21$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 612.14$ 1,040.64$ 1,224.28$ 1,744.61$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 612.14$ 1,040.64$ 1,224.28$ 1,744.61$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 628.57$ 1,068.58$ 1,257.15$ 1,791.43$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 625.20$ 1,062.85$ 1,250.41$ 1,781.83$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 628.57$ 1,068.58$ 1,257.15$ 1,791.43$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 625.20$ 1,062.85$ 1,250.41$ 1,781.83$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 642.97$ 1,093.06$ 1,285.95$ 1,832.47$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 642.97$ 1,093.06$ 1,285.95$ 1,832.47$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 639.60$ 1,087.33$ 1,279.21$ 1,822.87$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 639.60$ 1,087.33$ 1,279.21$ 1,822.87$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 600.62$ 1,021.05$ 1,201.23$ 1,711.75$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 597.25$ 1,015.32$ 1,194.49$ 1,702.15$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 600.62$ 1,021.05$ 1,201.23$ 1,711.75$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 597.25$ 1,015.32$ 1,194.49$ 1,702.15$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 615.02$ 1,045.53$ 1,230.03$ 1,752.79$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 615.02$ 1,045.53$ 1,230.03$ 1,752.79$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 611.65$ 1,039.80$ 1,223.29$ 1,743.19$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 611.65$ 1,039.80$ 1,223.29$ 1,743.19$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 637.10$ 1,083.07$ 1,274.20$ 1,815.73$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 633.73$ 1,077.34$ 1,267.46$ 1,806.13$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 637.10$ 1,083.07$ 1,274.20$ 1,815.73$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 633.73$ 1,077.34$ 1,267.46$ 1,806.13$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 651.50$ 1,107.55$ 1,303.00$ 1,856.77$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 651.50$ 1,107.55$ 1,303.00$ 1,856.77$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 648.13$ 1,101.82$ 1,296.26$ 1,847.17$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 648.13$ 1,101.82$ 1,296.26$ 1,847.17$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 512.73$ 871.64$ 1,025.46$ 1,461.28$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 509.36$ 865.91$ 1,018.72$ 1,451.68$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 512.73$ 871.64$ 1,025.46$ 1,461.28$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 509.36$ 865.91$ 1,018.72$ 1,451.68$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 527.13$ 896.12$ 1,054.26$ 1,502.32$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 527.13$ 896.12$ 1,054.26$ 1,502.32$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 523.76$ 890.39$ 1,047.52$ 1,492.72$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 523.76$ 890.39$ 1,047.52$ 1,492.72$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 511.52$ 869.58$ 1,023.03$ 1,457.82$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 508.15$ 863.85$ 1,016.29$ 1,448.22$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 511.52$ 869.58$ 1,023.03$ 1,457.82$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 508.15$ 863.85$ 1,016.29$ 1,448.22$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 525.92$ 894.06$ 1,051.83$ 1,498.86$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 525.92$ 894.06$ 1,051.83$ 1,498.86$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 522.55$ 888.33$ 1,045.09$ 1,489.26$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 522.55$ 888.33$ 1,045.09$ 1,489.26$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 621.69$ 1,056.87$ 1,243.38$ 1,771.81$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 618.32$ 1,051.14$ 1,236.64$ 1,762.21$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 621.69$ 1,056.87$ 1,243.38$ 1,771.81$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 618.32$ 1,051.14$ 1,236.64$ 1,762.21$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 636.09$ 1,081.35$ 1,272.18$ 1,812.85$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 636.09$ 1,081.35$ 1,272.18$ 1,812.85$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 632.72$ 1,075.62$ 1,265.44$ 1,803.25$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 632.72$ 1,075.62$ 1,265.44$ 1,803.25$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 505.91$ 860.05$ 1,011.83$ 1,441.85$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 502.54$ 854.32$ 1,005.09$ 1,432.25$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 505.91$ 860.05$ 1,011.83$ 1,441.85$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 502.54$ 854.32$ 1,005.09$ 1,432.25$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 520.31$ 884.53$ 1,040.63$ 1,482.89$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 520.31$ 884.53$ 1,040.63$ 1,482.89$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 516.94$ 878.80$ 1,033.89$ 1,473.29$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 516.94$ 878.80$ 1,033.89$ 1,473.29$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 640.55$ 1,088.93$ 1,281.09$ 1,825.56$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 637.18$ 1,083.20$ 1,274.35$ 1,815.96$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 640.55$ 1,088.93$ 1,281.09$ 1,825.56$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 637.18$ 1,083.20$ 1,274.35$ 1,815.96$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 654.95$ 1,113.41$ 1,309.89$ 1,866.60$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 654.95$ 1,113.41$ 1,309.89$ 1,866.60$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 651.58$ 1,107.68$ 1,303.15$ 1,857.00$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 651.58$ 1,107.68$ 1,303.15$ 1,857.00$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 741.87$ 1,261.18$ 1,483.74$ 2,114.33$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 738.50$ 1,255.45$ 1,477.00$ 2,104.73$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 741.87$ 1,261.18$ 1,483.74$ 2,114.33$
Page 37 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 738.50$ 1,255.45$ 1,477.00$ 2,104.73$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 756.27$ 1,285.66$ 1,512.54$ 2,155.37$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 756.27$ 1,285.66$ 1,512.54$ 2,155.37$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 752.90$ 1,279.93$ 1,505.80$ 2,145.77$
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 752.90$ 1,279.93$ 1,505.80$ 2,145.77$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 593.00$ 1,008.10$ 1,186.00$ 1,690.06$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 589.63$ 1,002.37$ 1,179.26$ 1,680.46$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 593.00$ 1,008.10$ 1,186.00$ 1,690.06$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 589.63$ 1,002.37$ 1,179.26$ 1,680.46$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 607.40$ 1,032.58$ 1,214.80$ 1,731.10$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 607.40$ 1,032.58$ 1,214.80$ 1,731.10$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 604.03$ 1,026.85$ 1,208.06$ 1,721.50$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 604.03$ 1,026.85$ 1,208.06$ 1,721.50$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 802.67$ 1,364.54$ 1,605.34$ 2,287.62$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 799.30$ 1,358.81$ 1,598.60$ 2,278.02$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 802.67$ 1,364.54$ 1,605.34$ 2,287.62$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 799.30$ 1,358.81$ 1,598.60$ 2,278.02$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 817.07$ 1,389.02$ 1,634.14$ 2,328.66$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 817.07$ 1,389.02$ 1,634.14$ 2,328.66$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 813.70$ 1,383.29$ 1,627.40$ 2,319.06$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 813.70$ 1,383.29$ 1,627.40$ 2,319.06$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 666.69$ 1,133.37$ 1,333.38$ 1,900.06$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 663.32$ 1,127.64$ 1,326.64$ 1,890.46$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 666.69$ 1,133.37$ 1,333.38$ 1,900.06$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 663.32$ 1,127.64$ 1,326.64$ 1,890.46$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 681.09$ 1,157.85$ 1,362.18$ 1,941.10$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 681.09$ 1,157.85$ 1,362.18$ 1,941.10$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 677.72$ 1,152.12$ 1,355.44$ 1,931.50$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 677.72$ 1,152.12$ 1,355.44$ 1,931.50$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 634.25$ 1,078.23$ 1,268.51$ 1,807.63$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 630.88$ 1,072.50$ 1,261.77$ 1,798.03$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 634.25$ 1,078.23$ 1,268.51$ 1,807.63$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 630.88$ 1,072.50$ 1,261.77$ 1,798.03$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 648.65$ 1,102.71$ 1,297.31$ 1,848.67$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 648.65$ 1,102.71$ 1,297.31$ 1,848.67$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 645.28$ 1,096.98$ 1,290.57$ 1,839.07$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 645.28$ 1,096.98$ 1,290.57$ 1,839.07$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,021.46$ 1,736.48$ 2,042.92$ 2,911.16$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,018.09$ 1,730.75$ 2,036.18$ 2,901.56$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,021.46$ 1,736.48$ 2,042.92$ 2,911.16$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,018.09$ 1,730.75$ 2,036.18$ 2,901.56$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,035.86$ 1,760.96$ 2,071.72$ 2,952.20$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,035.86$ 1,760.96$ 2,071.72$ 2,952.20$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,032.49$ 1,755.23$ 2,064.98$ 2,942.60$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,032.49$ 1,755.23$ 2,064.98$ 2,942.60$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 826.48$ 1,405.02$ 1,652.97$ 2,355.48$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 823.11$ 1,399.29$ 1,646.23$ 2,345.88$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 826.48$ 1,405.02$ 1,652.97$ 2,355.48$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 823.11$ 1,399.29$ 1,646.23$ 2,345.88$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 840.88$ 1,429.50$ 1,681.77$ 2,396.52$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 840.88$ 1,429.50$ 1,681.77$ 2,396.52$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 837.51$ 1,423.77$ 1,675.03$ 2,386.92$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 837.51$ 1,423.77$ 1,675.03$ 2,386.92$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 789.74$ 1,342.55$ 1,579.47$ 2,250.75$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 786.37$ 1,336.82$ 1,572.73$ 2,241.15$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 789.74$ 1,342.55$ 1,579.47$ 2,250.75$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 786.37$ 1,336.82$ 1,572.73$ 2,241.15$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 804.14$ 1,367.03$ 1,608.27$ 2,291.79$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 804.14$ 1,367.03$ 1,608.27$ 2,291.79$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 800.77$ 1,361.30$ 1,601.53$ 2,282.19$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 800.77$ 1,361.30$ 1,601.53$ 2,282.19$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 883.34$ 1,501.68$ 1,766.68$ 2,517.52$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 879.97$ 1,495.95$ 1,759.94$ 2,507.92$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 883.34$ 1,501.68$ 1,766.68$ 2,517.52$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 879.97$ 1,495.95$ 1,759.94$ 2,507.92$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 897.74$ 1,526.16$ 1,795.48$ 2,558.56$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 897.74$ 1,526.16$ 1,795.48$ 2,558.56$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 894.37$ 1,520.43$ 1,788.74$ 2,548.96$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 894.37$ 1,520.43$ 1,788.74$ 2,548.96$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 636.89$ 1,082.71$ 1,273.77$ 1,815.13$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 633.52$ 1,076.98$ 1,267.03$ 1,805.53$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 636.89$ 1,082.71$ 1,273.77$ 1,815.13$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 633.52$ 1,076.98$ 1,267.03$ 1,805.53$
Page 38 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q2
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 651.29$ 1,107.19$ 1,302.57$ 1,856.17$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 651.29$ 1,107.19$ 1,302.57$ 1,856.17$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 647.92$ 1,101.46$ 1,295.83$ 1,846.57$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 647.92$ 1,101.46$ 1,295.83$ 1,846.57$
Page 39 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,283.16$ 2,181.38$ 2,566.33$ 3,657.01$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,279.36$ 2,174.92$ 2,558.73$ 3,646.18$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,283.16$ 2,181.38$ 2,566.33$ 3,657.01$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,279.36$ 2,174.92$ 2,558.73$ 3,646.18$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,299.38$ 2,208.95$ 2,598.77$ 3,703.24$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,299.38$ 2,208.95$ 2,598.77$ 3,703.24$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,295.58$ 2,202.49$ 2,591.17$ 3,692.41$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,295.58$ 2,202.49$ 2,591.17$ 3,692.41$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,206.37$ 2,050.83$ 2,412.74$ 3,438.15$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,202.57$ 2,044.37$ 2,405.14$ 3,427.32$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,206.37$ 2,050.83$ 2,412.74$ 3,438.15$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,202.57$ 2,044.37$ 2,405.14$ 3,427.32$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,222.59$ 2,078.40$ 2,445.18$ 3,484.38$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,222.59$ 2,078.40$ 2,445.18$ 3,484.38$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,218.79$ 2,071.94$ 2,437.58$ 3,473.55$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,218.79$ 2,071.94$ 2,437.58$ 3,473.55$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,260.27$ 2,142.47$ 2,520.55$ 3,591.78$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,256.47$ 2,136.01$ 2,512.95$ 3,580.95$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,260.27$ 2,142.47$ 2,520.55$ 3,591.78$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,256.47$ 2,136.01$ 2,512.95$ 3,580.95$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,276.49$ 2,170.04$ 2,552.99$ 3,638.01$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,276.49$ 2,170.04$ 2,552.99$ 3,638.01$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,272.69$ 2,163.58$ 2,545.39$ 3,627.18$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,272.69$ 2,163.58$ 2,545.39$ 3,627.18$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,188.28$ 2,020.07$ 2,376.55$ 3,386.59$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,184.48$ 2,013.61$ 2,368.95$ 3,375.76$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,188.28$ 2,020.07$ 2,376.55$ 3,386.59$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,184.48$ 2,013.61$ 2,368.95$ 3,375.76$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,204.50$ 2,047.64$ 2,408.99$ 3,432.82$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,204.50$ 2,047.64$ 2,408.99$ 3,432.82$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,200.70$ 2,041.18$ 2,401.39$ 3,421.99$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,200.70$ 2,041.18$ 2,401.39$ 3,421.99$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 1,097.24$ 1,865.30$ 2,194.47$ 3,127.12$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 1,093.44$ 1,858.84$ 2,186.87$ 3,116.29$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 1,097.24$ 1,865.30$ 2,194.47$ 3,127.12$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 1,093.44$ 1,858.84$ 2,186.87$ 3,116.29$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 1,113.46$ 1,892.87$ 2,226.91$ 3,173.35$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 1,113.46$ 1,892.87$ 2,226.91$ 3,173.35$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 1,109.66$ 1,886.41$ 2,219.31$ 3,162.52$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 1,109.66$ 1,886.41$ 2,219.31$ 3,162.52$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 985.86$ 1,675.96$ 1,971.72$ 2,809.70$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 982.06$ 1,669.50$ 1,964.12$ 2,798.87$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 985.86$ 1,675.96$ 1,971.72$ 2,809.70$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 982.06$ 1,669.50$ 1,964.12$ 2,798.87$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 1,002.08$ 1,703.53$ 2,004.16$ 2,855.93$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 1,002.08$ 1,703.53$ 2,004.16$ 2,855.93$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 998.28$ 1,697.07$ 1,996.56$ 2,845.10$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 998.28$ 1,697.07$ 1,996.56$ 2,845.10$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 1,016.25$ 1,727.62$ 2,032.49$ 2,896.30$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 1,012.45$ 1,721.16$ 2,024.89$ 2,885.47$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 1,016.25$ 1,727.62$ 2,032.49$ 2,896.30$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 1,012.45$ 1,721.16$ 2,024.89$ 2,885.47$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 1,032.47$ 1,755.19$ 2,064.93$ 2,942.53$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 1,032.47$ 1,755.19$ 2,064.93$ 2,942.53$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 1,028.67$ 1,748.73$ 2,057.33$ 2,931.70$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 1,028.67$ 1,748.73$ 2,057.33$ 2,931.70$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 1,045.28$ 1,776.98$ 2,090.56$ 2,979.05$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 1,041.48$ 1,770.52$ 2,082.96$ 2,968.22$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 1,045.28$ 1,776.98$ 2,090.56$ 2,979.05$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 1,041.48$ 1,770.52$ 2,082.96$ 2,968.22$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 1,061.50$ 1,804.55$ 2,123.00$ 3,025.28$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 1,061.50$ 1,804.55$ 2,123.00$ 3,025.28$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 1,057.70$ 1,798.09$ 2,115.40$ 3,014.45$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 1,057.70$ 1,798.09$ 2,115.40$ 3,014.45$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 981.49$ 1,668.53$ 1,962.98$ 2,797.25$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 977.69$ 1,662.07$ 1,955.38$ 2,786.42$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 981.49$ 1,668.53$ 1,962.98$ 2,797.25$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 977.69$ 1,662.07$ 1,955.38$ 2,786.42$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 997.71$ 1,696.10$ 1,995.42$ 2,843.48$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 997.71$ 1,696.10$ 1,995.42$ 2,843.48$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 993.91$ 1,689.64$ 1,987.82$ 2,832.65$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 993.91$ 1,689.64$ 1,987.82$ 2,832.65$
Region 3
Page 40 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 1,013.68$ 1,723.26$ 2,027.37$ 2,889.00$
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 1,009.88$ 1,716.80$ 2,019.77$ 2,878.17$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 1,013.68$ 1,723.26$ 2,027.37$ 2,889.00$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 1,009.88$ 1,716.80$ 2,019.77$ 2,878.17$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 1,029.90$ 1,750.83$ 2,059.81$ 2,935.23$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 1,029.90$ 1,750.83$ 2,059.81$ 2,935.23$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 1,026.10$ 1,744.37$ 2,052.21$ 2,924.40$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 1,026.10$ 1,744.37$ 2,052.21$ 2,924.40$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 949.65$ 1,614.40$ 1,899.30$ 2,706.50$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 945.85$ 1,607.94$ 1,891.70$ 2,695.67$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 949.65$ 1,614.40$ 1,899.30$ 2,706.50$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 945.85$ 1,607.94$ 1,891.70$ 2,695.67$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 965.87$ 1,641.97$ 1,931.74$ 2,752.73$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 965.87$ 1,641.97$ 1,931.74$ 2,752.73$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 962.07$ 1,635.51$ 1,924.14$ 2,741.90$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 962.07$ 1,635.51$ 1,924.14$ 2,741.90$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 921.40$ 1,566.38$ 1,842.80$ 2,625.99$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 917.60$ 1,559.92$ 1,835.20$ 2,615.16$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 921.40$ 1,566.38$ 1,842.80$ 2,625.99$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 917.60$ 1,559.92$ 1,835.20$ 2,615.16$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 937.62$ 1,593.95$ 1,875.24$ 2,672.22$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 937.62$ 1,593.95$ 1,875.24$ 2,672.22$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 933.82$ 1,587.49$ 1,867.64$ 2,661.39$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 933.82$ 1,587.49$ 1,867.64$ 2,661.39$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 784.78$ 1,334.13$ 1,569.57$ 2,236.64$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 780.98$ 1,327.67$ 1,561.97$ 2,225.81$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 784.78$ 1,334.13$ 1,569.57$ 2,236.64$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 780.98$ 1,327.67$ 1,561.97$ 2,225.81$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 801.00$ 1,361.70$ 1,602.01$ 2,282.87$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 801.00$ 1,361.70$ 1,602.01$ 2,282.87$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 797.20$ 1,355.24$ 1,594.41$ 2,272.04$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 797.20$ 1,355.24$ 1,594.41$ 2,272.04$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 828.37$ 1,408.23$ 1,656.74$ 2,360.85$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 824.57$ 1,401.77$ 1,649.14$ 2,350.02$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 828.37$ 1,408.23$ 1,656.74$ 2,360.85$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 824.57$ 1,401.77$ 1,649.14$ 2,350.02$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 844.59$ 1,435.80$ 1,689.18$ 2,407.08$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 844.59$ 1,435.80$ 1,689.18$ 2,407.08$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 840.79$ 1,429.34$ 1,681.58$ 2,396.25$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 840.79$ 1,429.34$ 1,681.58$ 2,396.25$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 921.11$ 1,565.88$ 1,842.22$ 2,625.16$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 917.31$ 1,559.42$ 1,834.62$ 2,614.33$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 921.11$ 1,565.88$ 1,842.22$ 2,625.16$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 917.31$ 1,559.42$ 1,834.62$ 2,614.33$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 937.33$ 1,593.45$ 1,874.66$ 2,671.39$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 937.33$ 1,593.45$ 1,874.66$ 2,671.39$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 933.53$ 1,586.99$ 1,867.06$ 2,660.56$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 933.53$ 1,586.99$ 1,867.06$ 2,660.56$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 852.04$ 1,448.47$ 1,704.09$ 2,428.32$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 848.24$ 1,442.01$ 1,696.49$ 2,417.49$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 852.04$ 1,448.47$ 1,704.09$ 2,428.32$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 848.24$ 1,442.01$ 1,696.49$ 2,417.49$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 868.26$ 1,476.04$ 1,736.53$ 2,474.55$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 868.26$ 1,476.04$ 1,736.53$ 2,474.55$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 864.46$ 1,469.58$ 1,728.93$ 2,463.72$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 864.46$ 1,469.58$ 1,728.93$ 2,463.72$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 814.14$ 1,384.04$ 1,628.28$ 2,320.30$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 810.34$ 1,377.58$ 1,620.68$ 2,309.47$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 814.14$ 1,384.04$ 1,628.28$ 2,320.30$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 810.34$ 1,377.58$ 1,620.68$ 2,309.47$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 830.36$ 1,411.61$ 1,660.72$ 2,366.53$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 830.36$ 1,411.61$ 1,660.72$ 2,366.53$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 826.56$ 1,405.15$ 1,653.12$ 2,355.70$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 826.56$ 1,405.15$ 1,653.12$ 2,355.70$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 857.85$ 1,458.35$ 1,715.70$ 2,444.87$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 854.05$ 1,451.89$ 1,708.10$ 2,434.04$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 857.85$ 1,458.35$ 1,715.70$ 2,444.87$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 854.05$ 1,451.89$ 1,708.10$ 2,434.04$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 874.07$ 1,485.92$ 1,748.14$ 2,491.10$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 874.07$ 1,485.92$ 1,748.14$ 2,491.10$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 870.27$ 1,479.46$ 1,740.54$ 2,480.27$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 870.27$ 1,479.46$ 1,740.54$ 2,480.27$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 819.70$ 1,393.48$ 1,639.39$ 2,336.13$
Page 41 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 815.90$ 1,387.02$ 1,631.79$ 2,325.30$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 819.70$ 1,393.48$ 1,639.39$ 2,336.13$
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 815.90$ 1,387.02$ 1,631.79$ 2,325.30$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 835.92$ 1,421.05$ 1,671.83$ 2,382.36$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 835.92$ 1,421.05$ 1,671.83$ 2,382.36$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 832.12$ 1,414.59$ 1,664.23$ 2,371.53$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 832.12$ 1,414.59$ 1,664.23$ 2,371.53$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 781.27$ 1,328.16$ 1,562.54$ 2,226.62$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 777.47$ 1,321.70$ 1,554.94$ 2,215.79$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 781.27$ 1,328.16$ 1,562.54$ 2,226.62$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 777.47$ 1,321.70$ 1,554.94$ 2,215.79$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 797.49$ 1,355.73$ 1,594.98$ 2,272.85$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 797.49$ 1,355.73$ 1,594.98$ 2,272.85$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 793.69$ 1,349.27$ 1,587.38$ 2,262.02$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 793.69$ 1,349.27$ 1,587.38$ 2,262.02$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 775.13$ 1,317.72$ 1,550.26$ 2,209.13$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 771.33$ 1,311.26$ 1,542.66$ 2,198.30$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 775.13$ 1,317.72$ 1,550.26$ 2,209.13$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 771.33$ 1,311.26$ 1,542.66$ 2,198.30$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 791.35$ 1,345.29$ 1,582.70$ 2,255.36$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 791.35$ 1,345.29$ 1,582.70$ 2,255.36$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 787.55$ 1,338.83$ 1,575.10$ 2,244.53$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 787.55$ 1,338.83$ 1,575.10$ 2,244.53$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,450.02$ 2,465.03$ 2,900.03$ 4,132.55$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,446.22$ 2,458.57$ 2,892.43$ 4,121.72$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,450.02$ 2,465.03$ 2,900.03$ 4,132.55$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,446.22$ 2,458.57$ 2,892.43$ 4,121.72$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,466.24$ 2,492.60$ 2,932.47$ 4,178.78$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,466.24$ 2,492.60$ 2,932.47$ 4,178.78$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,462.44$ 2,486.14$ 2,924.87$ 4,167.95$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,462.44$ 2,486.14$ 2,924.87$ 4,167.95$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 978.66$ 1,663.73$ 1,957.33$ 2,789.19$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 974.86$ 1,657.27$ 1,949.73$ 2,778.36$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 978.66$ 1,663.73$ 1,957.33$ 2,789.19$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 974.86$ 1,657.27$ 1,949.73$ 2,778.36$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 994.88$ 1,691.30$ 1,989.77$ 2,835.42$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 994.88$ 1,691.30$ 1,989.77$ 2,835.42$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 991.08$ 1,684.84$ 1,982.17$ 2,824.59$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 991.08$ 1,684.84$ 1,982.17$ 2,824.59$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 1,098.73$ 1,867.84$ 2,197.46$ 3,131.39$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 1,094.93$ 1,861.38$ 2,189.86$ 3,120.56$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 1,098.73$ 1,867.84$ 2,197.46$ 3,131.39$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 1,094.93$ 1,861.38$ 2,189.86$ 3,120.56$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 1,114.95$ 1,895.41$ 2,229.90$ 3,177.62$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 1,114.95$ 1,895.41$ 2,229.90$ 3,177.62$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 1,111.15$ 1,888.95$ 2,222.30$ 3,166.79$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 1,111.15$ 1,888.95$ 2,222.30$ 3,166.79$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 789.60$ 1,342.32$ 1,579.20$ 2,250.36$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 785.80$ 1,335.86$ 1,571.60$ 2,239.53$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 789.60$ 1,342.32$ 1,579.20$ 2,250.36$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 785.80$ 1,335.86$ 1,571.60$ 2,239.53$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 805.82$ 1,369.89$ 1,611.64$ 2,296.59$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 805.82$ 1,369.89$ 1,611.64$ 2,296.59$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 802.02$ 1,363.43$ 1,604.04$ 2,285.76$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 802.02$ 1,363.43$ 1,604.04$ 2,285.76$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 697.88$ 1,186.40$ 1,395.76$ 1,988.96$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 694.08$ 1,179.94$ 1,388.16$ 1,978.13$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 697.88$ 1,186.40$ 1,395.76$ 1,988.96$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 694.08$ 1,179.94$ 1,388.16$ 1,978.13$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 714.10$ 1,213.97$ 1,428.20$ 2,035.19$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 714.10$ 1,213.97$ 1,428.20$ 2,035.19$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 710.30$ 1,207.51$ 1,420.60$ 2,024.36$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 710.30$ 1,207.51$ 1,420.60$ 2,024.36$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 711.18$ 1,209.00$ 1,422.35$ 2,026.85$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 707.38$ 1,202.54$ 1,414.75$ 2,016.02$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 711.18$ 1,209.00$ 1,422.35$ 2,026.85$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 707.38$ 1,202.54$ 1,414.75$ 2,016.02$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 727.40$ 1,236.57$ 1,454.79$ 2,073.08$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 727.40$ 1,236.57$ 1,454.79$ 2,073.08$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 723.60$ 1,230.11$ 1,447.19$ 2,062.25$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 723.60$ 1,230.11$ 1,447.19$ 2,062.25$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 677.12$ 1,151.10$ 1,354.24$ 1,929.79$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 673.32$ 1,144.64$ 1,346.64$ 1,918.96$
Page 42 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 677.12$ 1,151.10$ 1,354.24$ 1,929.79$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 673.32$ 1,144.64$ 1,346.64$ 1,918.96$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 693.34$ 1,178.67$ 1,386.68$ 1,976.02$
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 693.34$ 1,178.67$ 1,386.68$ 1,976.02$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 689.54$ 1,172.21$ 1,379.08$ 1,965.19$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 689.54$ 1,172.21$ 1,379.08$ 1,965.19$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 708.06$ 1,203.70$ 1,416.12$ 2,017.97$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 704.26$ 1,197.24$ 1,408.52$ 2,007.14$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 708.06$ 1,203.70$ 1,416.12$ 2,017.97$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 704.26$ 1,197.24$ 1,408.52$ 2,007.14$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 724.28$ 1,231.27$ 1,448.56$ 2,064.20$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 724.28$ 1,231.27$ 1,448.56$ 2,064.20$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 720.48$ 1,224.81$ 1,440.96$ 2,053.37$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 720.48$ 1,224.81$ 1,440.96$ 2,053.37$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 676.57$ 1,150.16$ 1,353.13$ 1,928.21$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 672.77$ 1,143.70$ 1,345.53$ 1,917.38$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 676.57$ 1,150.16$ 1,353.13$ 1,928.21$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 672.77$ 1,143.70$ 1,345.53$ 1,917.38$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 692.79$ 1,177.73$ 1,385.57$ 1,974.44$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 692.79$ 1,177.73$ 1,385.57$ 1,974.44$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 688.99$ 1,171.27$ 1,377.97$ 1,963.61$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 688.99$ 1,171.27$ 1,377.97$ 1,963.61$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 717.67$ 1,220.04$ 1,435.34$ 2,045.37$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 713.87$ 1,213.58$ 1,427.74$ 2,034.54$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 717.67$ 1,220.04$ 1,435.34$ 2,045.37$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 713.87$ 1,213.58$ 1,427.74$ 2,034.54$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 733.89$ 1,247.61$ 1,467.78$ 2,091.60$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 733.89$ 1,247.61$ 1,467.78$ 2,091.60$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 730.09$ 1,241.15$ 1,460.18$ 2,080.77$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 730.09$ 1,241.15$ 1,460.18$ 2,080.77$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 577.56$ 981.85$ 1,155.12$ 1,646.05$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 573.76$ 975.39$ 1,147.52$ 1,635.22$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 577.56$ 981.85$ 1,155.12$ 1,646.05$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 573.76$ 975.39$ 1,147.52$ 1,635.22$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 593.78$ 1,009.42$ 1,187.56$ 1,692.28$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 593.78$ 1,009.42$ 1,187.56$ 1,692.28$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 589.98$ 1,002.96$ 1,179.96$ 1,681.45$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 589.98$ 1,002.96$ 1,179.96$ 1,681.45$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 576.20$ 979.54$ 1,152.40$ 1,642.18$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 572.40$ 973.08$ 1,144.80$ 1,631.35$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 576.20$ 979.54$ 1,152.40$ 1,642.18$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 572.40$ 973.08$ 1,144.80$ 1,631.35$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 592.42$ 1,007.11$ 1,184.84$ 1,688.41$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 592.42$ 1,007.11$ 1,184.84$ 1,688.41$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 588.62$ 1,000.65$ 1,177.24$ 1,677.58$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 588.62$ 1,000.65$ 1,177.24$ 1,677.58$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 700.31$ 1,190.52$ 1,400.62$ 1,995.88$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 696.51$ 1,184.06$ 1,393.02$ 1,985.05$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 700.31$ 1,190.52$ 1,400.62$ 1,995.88$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 696.51$ 1,184.06$ 1,393.02$ 1,985.05$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 716.53$ 1,218.09$ 1,433.06$ 2,042.11$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 716.53$ 1,218.09$ 1,433.06$ 2,042.11$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 712.73$ 1,211.63$ 1,425.46$ 2,031.28$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 712.73$ 1,211.63$ 1,425.46$ 2,031.28$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 569.89$ 968.81$ 1,139.78$ 1,624.19$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 566.09$ 962.35$ 1,132.18$ 1,613.36$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 569.89$ 968.81$ 1,139.78$ 1,624.19$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 566.09$ 962.35$ 1,132.18$ 1,613.36$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 586.11$ 996.38$ 1,172.22$ 1,670.42$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 586.11$ 996.38$ 1,172.22$ 1,670.42$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 582.31$ 989.92$ 1,164.62$ 1,659.59$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 582.31$ 989.92$ 1,164.62$ 1,659.59$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 721.55$ 1,226.63$ 1,443.09$ 2,056.41$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 717.75$ 1,220.17$ 1,435.49$ 2,045.58$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 721.55$ 1,226.63$ 1,443.09$ 2,056.41$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 717.75$ 1,220.17$ 1,435.49$ 2,045.58$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 737.77$ 1,254.20$ 1,475.53$ 2,102.64$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 737.77$ 1,254.20$ 1,475.53$ 2,102.64$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 733.97$ 1,247.74$ 1,467.93$ 2,091.81$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 733.97$ 1,247.74$ 1,467.93$ 2,091.81$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 835.68$ 1,420.66$ 1,671.36$ 2,381.69$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 831.88$ 1,414.20$ 1,663.76$ 2,370.86$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 835.68$ 1,420.66$ 1,671.36$ 2,381.69$
Page 43 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 831.88$ 1,414.20$ 1,663.76$ 2,370.86$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 851.90$ 1,448.23$ 1,703.80$ 2,427.92$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 851.90$ 1,448.23$ 1,703.80$ 2,427.92$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 848.10$ 1,441.77$ 1,696.20$ 2,417.09$
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 848.10$ 1,441.77$ 1,696.20$ 2,417.09$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 667.99$ 1,135.58$ 1,335.98$ 1,903.77$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 664.19$ 1,129.12$ 1,328.38$ 1,892.94$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 667.99$ 1,135.58$ 1,335.98$ 1,903.77$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 664.19$ 1,129.12$ 1,328.38$ 1,892.94$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 684.21$ 1,163.15$ 1,368.42$ 1,950.00$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 684.21$ 1,163.15$ 1,368.42$ 1,950.00$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 680.41$ 1,156.69$ 1,360.82$ 1,939.17$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 680.41$ 1,156.69$ 1,360.82$ 1,939.17$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 904.17$ 1,537.09$ 1,808.34$ 2,576.89$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 900.37$ 1,530.63$ 1,800.74$ 2,566.06$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 904.17$ 1,537.09$ 1,808.34$ 2,576.89$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 900.37$ 1,530.63$ 1,800.74$ 2,566.06$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 920.39$ 1,564.66$ 1,840.78$ 2,623.12$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 920.39$ 1,564.66$ 1,840.78$ 2,623.12$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 916.59$ 1,558.20$ 1,833.18$ 2,612.29$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 916.59$ 1,558.20$ 1,833.18$ 2,612.29$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 751.00$ 1,276.70$ 1,502.00$ 2,140.35$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 747.20$ 1,270.24$ 1,494.40$ 2,129.52$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 751.00$ 1,276.70$ 1,502.00$ 2,140.35$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 747.20$ 1,270.24$ 1,494.40$ 2,129.52$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 767.22$ 1,304.27$ 1,534.44$ 2,186.58$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 767.22$ 1,304.27$ 1,534.44$ 2,186.58$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 763.42$ 1,297.81$ 1,526.84$ 2,175.75$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 763.42$ 1,297.81$ 1,526.84$ 2,175.75$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 714.46$ 1,214.58$ 1,428.92$ 2,036.20$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 710.66$ 1,208.12$ 1,421.32$ 2,025.37$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 714.46$ 1,214.58$ 1,428.92$ 2,036.20$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 710.66$ 1,208.12$ 1,421.32$ 2,025.37$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 730.68$ 1,242.15$ 1,461.36$ 2,082.43$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 730.68$ 1,242.15$ 1,461.36$ 2,082.43$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 726.88$ 1,235.69$ 1,453.76$ 2,071.60$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 726.88$ 1,235.69$ 1,453.76$ 2,071.60$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,150.63$ 1,956.07$ 2,301.25$ 3,279.29$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,146.83$ 1,949.61$ 2,293.65$ 3,268.46$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,150.63$ 1,956.07$ 2,301.25$ 3,279.29$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,146.83$ 1,949.61$ 2,293.65$ 3,268.46$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,166.85$ 1,983.64$ 2,333.69$ 3,325.52$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,166.85$ 1,983.64$ 2,333.69$ 3,325.52$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,163.05$ 1,977.18$ 2,326.09$ 3,314.69$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,163.05$ 1,977.18$ 2,326.09$ 3,314.69$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 931.00$ 1,582.71$ 1,862.01$ 2,653.36$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 927.20$ 1,576.25$ 1,854.41$ 2,642.53$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 931.00$ 1,582.71$ 1,862.01$ 2,653.36$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 927.20$ 1,576.25$ 1,854.41$ 2,642.53$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 947.22$ 1,610.28$ 1,894.45$ 2,699.59$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 947.22$ 1,610.28$ 1,894.45$ 2,699.59$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 943.42$ 1,603.82$ 1,886.85$ 2,688.76$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 943.42$ 1,603.82$ 1,886.85$ 2,688.76$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 889.61$ 1,512.33$ 1,779.21$ 2,535.38$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 885.81$ 1,505.87$ 1,771.61$ 2,524.55$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 889.61$ 1,512.33$ 1,779.21$ 2,535.38$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 885.81$ 1,505.87$ 1,771.61$ 2,524.55$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 905.83$ 1,539.90$ 1,811.65$ 2,581.61$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 905.83$ 1,539.90$ 1,811.65$ 2,581.61$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 902.03$ 1,533.44$ 1,804.05$ 2,570.78$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 902.03$ 1,533.44$ 1,804.05$ 2,570.78$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 995.05$ 1,691.58$ 1,990.09$ 2,835.88$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 991.25$ 1,685.12$ 1,982.49$ 2,825.05$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 995.05$ 1,691.58$ 1,990.09$ 2,835.88$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 991.25$ 1,685.12$ 1,982.49$ 2,825.05$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 1,011.27$ 1,719.15$ 2,022.53$ 2,882.11$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 1,011.27$ 1,719.15$ 2,022.53$ 2,882.11$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 1,007.47$ 1,712.69$ 2,014.93$ 2,871.28$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 1,007.47$ 1,712.69$ 2,014.93$ 2,871.28$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 717.42$ 1,219.61$ 1,434.84$ 2,044.65$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 713.62$ 1,213.15$ 1,427.24$ 2,033.82$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 717.42$ 1,219.61$ 1,434.84$ 2,044.65$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 713.62$ 1,213.15$ 1,427.24$ 2,033.82$
Page 44 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 3
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 733.64$ 1,247.18$ 1,467.28$ 2,090.88$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 733.64$ 1,247.18$ 1,467.28$ 2,090.88$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 729.84$ 1,240.72$ 1,459.68$ 2,080.05$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 729.84$ 1,240.72$ 1,459.68$ 2,080.05$
Page 45 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,165.35$ 1,981.09$ 2,330.70$ 3,321.25$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,161.90$ 1,975.22$ 2,323.80$ 3,311.42$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,165.35$ 1,981.09$ 2,330.70$ 3,321.25$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,161.90$ 1,975.22$ 2,323.80$ 3,311.42$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,180.08$ 2,006.13$ 2,360.16$ 3,363.23$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,180.08$ 2,006.13$ 2,360.16$ 3,363.23$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,176.63$ 2,000.26$ 2,353.26$ 3,353.40$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,176.63$ 2,000.26$ 2,353.26$ 3,353.40$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,095.60$ 1,862.53$ 2,191.21$ 3,122.47$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,092.15$ 1,856.66$ 2,184.31$ 3,112.64$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,095.60$ 1,862.53$ 2,191.21$ 3,122.47$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,092.15$ 1,856.66$ 2,184.31$ 3,112.64$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,110.33$ 1,887.57$ 2,220.67$ 3,164.45$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,110.33$ 1,887.57$ 2,220.67$ 3,164.45$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,106.88$ 1,881.70$ 2,213.77$ 3,154.62$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,106.88$ 1,881.70$ 2,213.77$ 3,154.62$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,144.56$ 1,945.75$ 2,289.12$ 3,261.99$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,141.11$ 1,939.88$ 2,282.22$ 3,252.16$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,144.56$ 1,945.75$ 2,289.12$ 3,261.99$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,141.11$ 1,939.88$ 2,282.22$ 3,252.16$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,159.29$ 1,970.79$ 2,318.58$ 3,303.97$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,159.29$ 1,970.79$ 2,318.58$ 3,303.97$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,155.84$ 1,964.92$ 2,311.68$ 3,294.14$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,155.84$ 1,964.92$ 2,311.68$ 3,294.14$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,079.17$ 1,834.60$ 2,158.35$ 3,075.65$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,075.72$ 1,828.73$ 2,151.45$ 3,065.82$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,079.17$ 1,834.60$ 2,158.35$ 3,075.65$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,075.72$ 1,828.73$ 2,151.45$ 3,065.82$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,093.90$ 1,859.64$ 2,187.81$ 3,117.63$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,093.90$ 1,859.64$ 2,187.81$ 3,117.63$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,090.45$ 1,853.77$ 2,180.91$ 3,107.80$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,090.45$ 1,853.77$ 2,180.91$ 3,107.80$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 996.48$ 1,694.02$ 1,992.97$ 2,839.98$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 993.03$ 1,688.15$ 1,986.07$ 2,830.15$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 996.48$ 1,694.02$ 1,992.97$ 2,839.98$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 993.03$ 1,688.15$ 1,986.07$ 2,830.15$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 1,011.21$ 1,719.06$ 2,022.43$ 2,881.96$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 1,011.21$ 1,719.06$ 2,022.43$ 2,881.96$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 1,007.76$ 1,713.19$ 2,015.53$ 2,872.13$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 1,007.76$ 1,713.19$ 2,015.53$ 2,872.13$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 895.34$ 1,522.09$ 1,790.69$ 2,551.73$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 891.89$ 1,516.22$ 1,783.79$ 2,541.90$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 895.34$ 1,522.09$ 1,790.69$ 2,551.73$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 891.89$ 1,516.22$ 1,783.79$ 2,541.90$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 910.07$ 1,547.13$ 1,820.15$ 2,593.71$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 910.07$ 1,547.13$ 1,820.15$ 2,593.71$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 906.62$ 1,541.26$ 1,813.25$ 2,583.88$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 906.62$ 1,541.26$ 1,813.25$ 2,583.88$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 922.93$ 1,568.99$ 1,845.87$ 2,630.36$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 919.48$ 1,563.12$ 1,838.97$ 2,620.53$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 922.93$ 1,568.99$ 1,845.87$ 2,630.36$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 919.48$ 1,563.12$ 1,838.97$ 2,620.53$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 937.66$ 1,594.03$ 1,875.33$ 2,672.34$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 937.66$ 1,594.03$ 1,875.33$ 2,672.34$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 934.21$ 1,588.16$ 1,868.43$ 2,662.51$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 934.21$ 1,588.16$ 1,868.43$ 2,662.51$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 949.31$ 1,613.82$ 1,898.62$ 2,705.53$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 945.86$ 1,607.95$ 1,891.72$ 2,695.70$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 949.31$ 1,613.82$ 1,898.62$ 2,705.53$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 945.86$ 1,607.95$ 1,891.72$ 2,695.70$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 964.04$ 1,638.86$ 1,928.08$ 2,747.51$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 964.04$ 1,638.86$ 1,928.08$ 2,747.51$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 960.59$ 1,632.99$ 1,921.18$ 2,737.68$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 960.59$ 1,632.99$ 1,921.18$ 2,737.68$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 891.37$ 1,515.33$ 1,782.75$ 2,540.41$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 887.92$ 1,509.46$ 1,775.85$ 2,530.58$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 891.37$ 1,515.33$ 1,782.75$ 2,540.41$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 887.92$ 1,509.46$ 1,775.85$ 2,530.58$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 906.10$ 1,540.37$ 1,812.21$ 2,582.39$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 906.10$ 1,540.37$ 1,812.21$ 2,582.39$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 902.65$ 1,534.50$ 1,805.31$ 2,572.56$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 902.65$ 1,534.50$ 1,805.31$ 2,572.56$
Region 4
Page 46 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 920.61$ 1,565.04$ 1,841.23$ 2,623.75$
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 917.16$ 1,559.17$ 1,834.33$ 2,613.92$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 920.61$ 1,565.04$ 1,841.23$ 2,623.75$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 917.16$ 1,559.17$ 1,834.33$ 2,613.92$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 935.34$ 1,590.08$ 1,870.69$ 2,665.73$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 935.34$ 1,590.08$ 1,870.69$ 2,665.73$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 931.89$ 1,584.21$ 1,863.79$ 2,655.90$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 931.89$ 1,584.21$ 1,863.79$ 2,655.90$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 862.45$ 1,466.17$ 1,724.91$ 2,457.99$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 859.00$ 1,460.30$ 1,718.01$ 2,448.16$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 862.45$ 1,466.17$ 1,724.91$ 2,457.99$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 859.00$ 1,460.30$ 1,718.01$ 2,448.16$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 877.18$ 1,491.21$ 1,754.37$ 2,499.97$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 877.18$ 1,491.21$ 1,754.37$ 2,499.97$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 873.73$ 1,485.34$ 1,747.47$ 2,490.14$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 873.73$ 1,485.34$ 1,747.47$ 2,490.14$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 836.80$ 1,422.55$ 1,673.59$ 2,384.87$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 833.35$ 1,416.68$ 1,666.69$ 2,375.04$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 836.80$ 1,422.55$ 1,673.59$ 2,384.87$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 833.35$ 1,416.68$ 1,666.69$ 2,375.04$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 851.53$ 1,447.59$ 1,703.05$ 2,426.85$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 851.53$ 1,447.59$ 1,703.05$ 2,426.85$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 848.08$ 1,441.72$ 1,696.15$ 2,417.02$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 848.08$ 1,441.72$ 1,696.15$ 2,417.02$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 712.73$ 1,211.64$ 1,425.46$ 2,031.28$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 709.28$ 1,205.77$ 1,418.56$ 2,021.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 712.73$ 1,211.64$ 1,425.46$ 2,031.28$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 709.28$ 1,205.77$ 1,418.56$ 2,021.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 727.46$ 1,236.68$ 1,454.92$ 2,073.26$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 727.46$ 1,236.68$ 1,454.92$ 2,073.26$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 724.01$ 1,230.81$ 1,448.02$ 2,063.43$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 724.01$ 1,230.81$ 1,448.02$ 2,063.43$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 752.31$ 1,278.93$ 1,504.62$ 2,144.09$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 748.86$ 1,273.06$ 1,497.72$ 2,134.26$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 752.31$ 1,278.93$ 1,504.62$ 2,144.09$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 748.86$ 1,273.06$ 1,497.72$ 2,134.26$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 767.04$ 1,303.97$ 1,534.08$ 2,186.07$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 767.04$ 1,303.97$ 1,534.08$ 2,186.07$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 763.59$ 1,298.10$ 1,527.18$ 2,176.24$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 763.59$ 1,298.10$ 1,527.18$ 2,176.24$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 836.53$ 1,422.11$ 1,673.07$ 2,384.12$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 833.08$ 1,416.24$ 1,666.17$ 2,374.29$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 836.53$ 1,422.11$ 1,673.07$ 2,384.12$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 833.08$ 1,416.24$ 1,666.17$ 2,374.29$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 851.26$ 1,447.15$ 1,702.53$ 2,426.10$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 851.26$ 1,447.15$ 1,702.53$ 2,426.10$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 847.81$ 1,441.28$ 1,695.63$ 2,416.27$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 847.81$ 1,441.28$ 1,695.63$ 2,416.27$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 773.80$ 1,315.46$ 1,547.60$ 2,205.33$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 770.35$ 1,309.59$ 1,540.70$ 2,195.50$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 773.80$ 1,315.46$ 1,547.60$ 2,205.33$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 770.35$ 1,309.59$ 1,540.70$ 2,195.50$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 788.53$ 1,340.50$ 1,577.06$ 2,247.31$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 788.53$ 1,340.50$ 1,577.06$ 2,247.31$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 785.08$ 1,334.63$ 1,570.16$ 2,237.48$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 785.08$ 1,334.63$ 1,570.16$ 2,237.48$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 739.39$ 1,256.96$ 1,478.77$ 2,107.25$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 735.94$ 1,251.09$ 1,471.87$ 2,097.42$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 739.39$ 1,256.96$ 1,478.77$ 2,107.25$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 735.94$ 1,251.09$ 1,471.87$ 2,097.42$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 754.12$ 1,282.00$ 1,508.23$ 2,149.23$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 754.12$ 1,282.00$ 1,508.23$ 2,149.23$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 750.67$ 1,276.13$ 1,501.33$ 2,139.40$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 750.67$ 1,276.13$ 1,501.33$ 2,139.40$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 779.08$ 1,324.44$ 1,558.17$ 2,220.39$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 775.63$ 1,318.57$ 1,551.27$ 2,210.56$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 779.08$ 1,324.44$ 1,558.17$ 2,220.39$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 775.63$ 1,318.57$ 1,551.27$ 2,210.56$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 793.81$ 1,349.48$ 1,587.63$ 2,262.37$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 793.81$ 1,349.48$ 1,587.63$ 2,262.37$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 790.36$ 1,343.61$ 1,580.73$ 2,252.54$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 790.36$ 1,343.61$ 1,580.73$ 2,252.54$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 744.44$ 1,265.54$ 1,488.87$ 2,121.64$
Page 47 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 740.99$ 1,259.67$ 1,481.97$ 2,111.81$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 744.44$ 1,265.54$ 1,488.87$ 2,121.64$
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 740.99$ 1,259.67$ 1,481.97$ 2,111.81$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 759.17$ 1,290.58$ 1,518.33$ 2,163.62$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 759.17$ 1,290.58$ 1,518.33$ 2,163.62$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 755.72$ 1,284.71$ 1,511.43$ 2,153.79$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 755.72$ 1,284.71$ 1,511.43$ 2,153.79$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 709.53$ 1,206.21$ 1,419.07$ 2,022.17$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 706.08$ 1,200.34$ 1,412.17$ 2,012.34$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 709.53$ 1,206.21$ 1,419.07$ 2,022.17$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 706.08$ 1,200.34$ 1,412.17$ 2,012.34$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 724.26$ 1,231.25$ 1,448.53$ 2,064.15$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 724.26$ 1,231.25$ 1,448.53$ 2,064.15$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 720.81$ 1,225.38$ 1,441.63$ 2,054.32$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 720.81$ 1,225.38$ 1,441.63$ 2,054.32$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 703.96$ 1,196.73$ 1,407.92$ 2,006.29$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 700.51$ 1,190.86$ 1,401.02$ 1,996.46$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 703.96$ 1,196.73$ 1,407.92$ 2,006.29$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 700.51$ 1,190.86$ 1,401.02$ 1,996.46$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 718.69$ 1,221.77$ 1,437.38$ 2,048.27$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 718.69$ 1,221.77$ 1,437.38$ 2,048.27$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 715.24$ 1,215.90$ 1,430.48$ 2,038.44$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 715.24$ 1,215.90$ 1,430.48$ 2,038.44$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,316.88$ 2,238.70$ 2,633.76$ 3,753.11$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,313.43$ 2,232.83$ 2,626.86$ 3,743.28$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,316.88$ 2,238.70$ 2,633.76$ 3,753.11$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,313.43$ 2,232.83$ 2,626.86$ 3,743.28$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,331.61$ 2,263.74$ 2,663.22$ 3,795.09$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,331.61$ 2,263.74$ 2,663.22$ 3,795.09$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,328.16$ 2,257.87$ 2,656.32$ 3,785.26$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,328.16$ 2,257.87$ 2,656.32$ 3,785.26$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 888.80$ 1,510.96$ 1,777.60$ 2,533.08$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 885.35$ 1,505.09$ 1,770.70$ 2,523.25$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 888.80$ 1,510.96$ 1,777.60$ 2,533.08$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 885.35$ 1,505.09$ 1,770.70$ 2,523.25$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 903.53$ 1,536.00$ 1,807.06$ 2,575.06$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 903.53$ 1,536.00$ 1,807.06$ 2,575.06$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 900.08$ 1,530.13$ 1,800.16$ 2,565.23$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 900.08$ 1,530.13$ 1,800.16$ 2,565.23$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 997.84$ 1,696.33$ 1,995.69$ 2,843.86$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 994.39$ 1,690.46$ 1,988.79$ 2,834.03$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 997.84$ 1,696.33$ 1,995.69$ 2,843.86$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 994.39$ 1,690.46$ 1,988.79$ 2,834.03$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 1,012.57$ 1,721.37$ 2,025.15$ 2,885.84$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 1,012.57$ 1,721.37$ 2,025.15$ 2,885.84$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 1,009.12$ 1,715.50$ 2,018.25$ 2,876.01$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 1,009.12$ 1,715.50$ 2,018.25$ 2,876.01$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 717.10$ 1,219.07$ 1,434.20$ 2,043.73$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 713.65$ 1,213.20$ 1,427.30$ 2,033.90$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 717.10$ 1,219.07$ 1,434.20$ 2,043.73$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 713.65$ 1,213.20$ 1,427.30$ 2,033.90$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 731.83$ 1,244.11$ 1,463.66$ 2,085.71$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 731.83$ 1,244.11$ 1,463.66$ 2,085.71$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 728.38$ 1,238.24$ 1,456.76$ 2,075.88$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 728.38$ 1,238.24$ 1,456.76$ 2,075.88$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 633.81$ 1,077.47$ 1,267.62$ 1,806.35$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 630.36$ 1,071.60$ 1,260.72$ 1,796.52$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 633.81$ 1,077.47$ 1,267.62$ 1,806.35$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 630.36$ 1,071.60$ 1,260.72$ 1,796.52$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 648.54$ 1,102.51$ 1,297.08$ 1,848.33$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 648.54$ 1,102.51$ 1,297.08$ 1,848.33$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 645.09$ 1,096.64$ 1,290.18$ 1,838.50$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 645.09$ 1,096.64$ 1,290.18$ 1,838.50$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 645.88$ 1,097.99$ 1,291.76$ 1,840.75$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 642.43$ 1,092.12$ 1,284.86$ 1,830.92$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 645.88$ 1,097.99$ 1,291.76$ 1,840.75$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 642.43$ 1,092.12$ 1,284.86$ 1,830.92$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 660.61$ 1,123.03$ 1,321.22$ 1,882.73$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 660.61$ 1,123.03$ 1,321.22$ 1,882.73$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 657.16$ 1,117.16$ 1,314.32$ 1,872.90$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 657.16$ 1,117.16$ 1,314.32$ 1,872.90$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 614.95$ 1,045.41$ 1,229.90$ 1,752.60$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 611.50$ 1,039.54$ 1,223.00$ 1,742.77$
Page 48 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 614.95$ 1,045.41$ 1,229.90$ 1,752.60$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 611.50$ 1,039.54$ 1,223.00$ 1,742.77$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 629.68$ 1,070.45$ 1,259.36$ 1,794.58$
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 629.68$ 1,070.45$ 1,259.36$ 1,794.58$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 626.23$ 1,064.58$ 1,252.46$ 1,784.75$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 626.23$ 1,064.58$ 1,252.46$ 1,784.75$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 643.04$ 1,093.17$ 1,286.09$ 1,832.67$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 639.59$ 1,087.30$ 1,279.19$ 1,822.84$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 643.04$ 1,093.17$ 1,286.09$ 1,832.67$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 639.59$ 1,087.30$ 1,279.19$ 1,822.84$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 657.77$ 1,118.21$ 1,315.55$ 1,874.65$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 657.77$ 1,118.21$ 1,315.55$ 1,874.65$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 654.32$ 1,112.34$ 1,308.65$ 1,864.82$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 654.32$ 1,112.34$ 1,308.65$ 1,864.82$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 614.44$ 1,044.55$ 1,228.89$ 1,751.17$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 610.99$ 1,038.68$ 1,221.99$ 1,741.34$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 614.44$ 1,044.55$ 1,228.89$ 1,751.17$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 610.99$ 1,038.68$ 1,221.99$ 1,741.34$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 629.17$ 1,069.59$ 1,258.35$ 1,793.15$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 629.17$ 1,069.59$ 1,258.35$ 1,793.15$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 625.72$ 1,063.72$ 1,251.45$ 1,783.32$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 625.72$ 1,063.72$ 1,251.45$ 1,783.32$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 651.77$ 1,108.01$ 1,303.55$ 1,857.55$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 648.32$ 1,102.14$ 1,296.65$ 1,847.72$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 651.77$ 1,108.01$ 1,303.55$ 1,857.55$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 648.32$ 1,102.14$ 1,296.65$ 1,847.72$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 666.50$ 1,133.05$ 1,333.01$ 1,899.53$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 666.50$ 1,133.05$ 1,333.01$ 1,899.53$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 663.05$ 1,127.18$ 1,326.11$ 1,889.70$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 663.05$ 1,127.18$ 1,326.11$ 1,889.70$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 524.54$ 891.72$ 1,049.08$ 1,494.94$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 521.09$ 885.85$ 1,042.18$ 1,485.11$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 524.54$ 891.72$ 1,049.08$ 1,494.94$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 521.09$ 885.85$ 1,042.18$ 1,485.11$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 539.27$ 916.76$ 1,078.54$ 1,536.92$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 539.27$ 916.76$ 1,078.54$ 1,536.92$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 535.82$ 910.89$ 1,071.64$ 1,527.09$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 535.82$ 910.89$ 1,071.64$ 1,527.09$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 523.30$ 889.60$ 1,046.59$ 1,491.40$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 519.85$ 883.73$ 1,039.69$ 1,481.57$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 523.30$ 889.60$ 1,046.59$ 1,491.40$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 519.85$ 883.73$ 1,039.69$ 1,481.57$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 538.03$ 914.64$ 1,076.05$ 1,533.38$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 538.03$ 914.64$ 1,076.05$ 1,533.38$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 534.58$ 908.77$ 1,069.15$ 1,523.55$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 534.58$ 908.77$ 1,069.15$ 1,523.55$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 636.00$ 1,081.20$ 1,272.01$ 1,812.61$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 632.55$ 1,075.33$ 1,265.11$ 1,802.78$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 636.00$ 1,081.20$ 1,272.01$ 1,812.61$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 632.55$ 1,075.33$ 1,265.11$ 1,802.78$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 650.73$ 1,106.24$ 1,301.47$ 1,854.59$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 650.73$ 1,106.24$ 1,301.47$ 1,854.59$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 647.28$ 1,100.37$ 1,294.57$ 1,844.76$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 647.28$ 1,100.37$ 1,294.57$ 1,844.76$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 517.56$ 879.85$ 1,035.11$ 1,475.04$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 514.11$ 873.98$ 1,028.21$ 1,465.21$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 517.56$ 879.85$ 1,035.11$ 1,475.04$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 514.11$ 873.98$ 1,028.21$ 1,465.21$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 532.29$ 904.89$ 1,064.57$ 1,517.02$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 532.29$ 904.89$ 1,064.57$ 1,517.02$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 528.84$ 899.02$ 1,057.67$ 1,507.19$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 528.84$ 899.02$ 1,057.67$ 1,507.19$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 655.30$ 1,114.01$ 1,310.60$ 1,867.60$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 651.85$ 1,108.14$ 1,303.70$ 1,857.77$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 655.30$ 1,114.01$ 1,310.60$ 1,867.60$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 651.85$ 1,108.14$ 1,303.70$ 1,857.77$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 670.03$ 1,139.05$ 1,340.06$ 1,909.58$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 670.03$ 1,139.05$ 1,340.06$ 1,909.58$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 666.58$ 1,133.18$ 1,333.16$ 1,899.75$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 666.58$ 1,133.18$ 1,333.16$ 1,899.75$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 758.95$ 1,290.22$ 1,517.91$ 2,163.02$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 755.50$ 1,284.35$ 1,511.01$ 2,153.19$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 758.95$ 1,290.22$ 1,517.91$ 2,163.02$
Page 49 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 755.50$ 1,284.35$ 1,511.01$ 2,153.19$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 773.68$ 1,315.26$ 1,547.37$ 2,205.00$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 773.68$ 1,315.26$ 1,547.37$ 2,205.00$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 770.23$ 1,309.39$ 1,540.47$ 2,195.17$
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 770.23$ 1,309.39$ 1,540.47$ 2,195.17$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 606.66$ 1,031.31$ 1,213.31$ 1,728.97$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 603.21$ 1,025.44$ 1,206.41$ 1,719.14$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 606.66$ 1,031.31$ 1,213.31$ 1,728.97$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 603.21$ 1,025.44$ 1,206.41$ 1,719.14$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 621.39$ 1,056.35$ 1,242.77$ 1,770.95$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 621.39$ 1,056.35$ 1,242.77$ 1,770.95$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 617.94$ 1,050.48$ 1,235.87$ 1,761.12$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 617.94$ 1,050.48$ 1,235.87$ 1,761.12$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 821.15$ 1,395.96$ 1,642.30$ 2,340.28$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 817.70$ 1,390.09$ 1,635.40$ 2,330.45$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 821.15$ 1,395.96$ 1,642.30$ 2,340.28$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 817.70$ 1,390.09$ 1,635.40$ 2,330.45$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 835.88$ 1,421.00$ 1,671.76$ 2,382.26$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 835.88$ 1,421.00$ 1,671.76$ 2,382.26$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 832.43$ 1,415.13$ 1,664.86$ 2,372.43$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 832.43$ 1,415.13$ 1,664.86$ 2,372.43$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 682.04$ 1,159.47$ 1,364.08$ 1,943.82$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 678.59$ 1,153.60$ 1,357.18$ 1,933.99$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 682.04$ 1,159.47$ 1,364.08$ 1,943.82$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 678.59$ 1,153.60$ 1,357.18$ 1,933.99$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 696.77$ 1,184.51$ 1,393.54$ 1,985.80$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 696.77$ 1,184.51$ 1,393.54$ 1,985.80$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 693.32$ 1,178.64$ 1,386.64$ 1,975.97$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 693.32$ 1,178.64$ 1,386.64$ 1,975.97$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 648.86$ 1,103.06$ 1,297.72$ 1,849.25$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 645.41$ 1,097.19$ 1,290.82$ 1,839.42$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 648.86$ 1,103.06$ 1,297.72$ 1,849.25$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 645.41$ 1,097.19$ 1,290.82$ 1,839.42$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 663.59$ 1,128.10$ 1,327.18$ 1,891.23$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 663.59$ 1,128.10$ 1,327.18$ 1,891.23$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 660.14$ 1,122.23$ 1,320.28$ 1,881.40$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 660.14$ 1,122.23$ 1,320.28$ 1,881.40$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,044.98$ 1,776.47$ 2,089.96$ 2,978.20$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,041.53$ 1,770.60$ 2,083.06$ 2,968.37$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,044.98$ 1,776.47$ 2,089.96$ 2,978.20$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,041.53$ 1,770.60$ 2,083.06$ 2,968.37$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,059.71$ 1,801.51$ 2,119.42$ 3,020.18$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,059.71$ 1,801.51$ 2,119.42$ 3,020.18$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,056.26$ 1,795.64$ 2,112.52$ 3,010.35$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,056.26$ 1,795.64$ 2,112.52$ 3,010.35$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 845.52$ 1,437.38$ 1,691.03$ 2,409.72$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 842.07$ 1,431.51$ 1,684.13$ 2,399.89$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 845.52$ 1,437.38$ 1,691.03$ 2,409.72$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 842.07$ 1,431.51$ 1,684.13$ 2,399.89$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 860.25$ 1,462.42$ 1,720.49$ 2,451.70$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 860.25$ 1,462.42$ 1,720.49$ 2,451.70$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 856.80$ 1,456.55$ 1,713.59$ 2,441.87$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 856.80$ 1,456.55$ 1,713.59$ 2,441.87$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 807.92$ 1,373.46$ 1,615.83$ 2,302.56$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 804.47$ 1,367.59$ 1,608.93$ 2,292.73$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 807.92$ 1,373.46$ 1,615.83$ 2,302.56$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 804.47$ 1,367.59$ 1,608.93$ 2,292.73$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 822.65$ 1,398.50$ 1,645.29$ 2,344.54$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 822.65$ 1,398.50$ 1,645.29$ 2,344.54$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 819.20$ 1,392.63$ 1,638.39$ 2,334.71$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 819.20$ 1,392.63$ 1,638.39$ 2,334.71$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 903.69$ 1,536.27$ 1,807.37$ 2,575.51$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 900.24$ 1,530.40$ 1,800.47$ 2,565.68$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 903.69$ 1,536.27$ 1,807.37$ 2,575.51$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 900.24$ 1,530.40$ 1,800.47$ 2,565.68$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 918.42$ 1,561.31$ 1,836.83$ 2,617.49$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 918.42$ 1,561.31$ 1,836.83$ 2,617.49$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 914.97$ 1,555.44$ 1,829.93$ 2,607.66$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 914.97$ 1,555.44$ 1,829.93$ 2,607.66$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 651.55$ 1,107.63$ 1,303.10$ 1,856.92$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 648.10$ 1,101.76$ 1,296.20$ 1,847.09$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 651.55$ 1,107.63$ 1,303.10$ 1,856.92$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 648.10$ 1,101.76$ 1,296.20$ 1,847.09$
Page 50 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 4
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 666.28$ 1,132.67$ 1,332.56$ 1,898.90$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 666.28$ 1,132.67$ 1,332.56$ 1,898.90$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 662.83$ 1,126.80$ 1,325.66$ 1,889.07$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 662.83$ 1,126.80$ 1,325.66$ 1,889.07$
Page 51 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,165.35$ 1,981.09$ 2,330.70$ 3,321.25$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,161.90$ 1,975.22$ 2,323.80$ 3,311.42$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,165.35$ 1,981.09$ 2,330.70$ 3,321.25$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,161.90$ 1,975.22$ 2,323.80$ 3,311.42$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,180.08$ 2,006.13$ 2,360.16$ 3,363.23$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,180.08$ 2,006.13$ 2,360.16$ 3,363.23$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,176.63$ 2,000.26$ 2,353.26$ 3,353.40$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,176.63$ 2,000.26$ 2,353.26$ 3,353.40$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,095.60$ 1,862.53$ 2,191.21$ 3,122.47$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,092.15$ 1,856.66$ 2,184.31$ 3,112.64$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,095.60$ 1,862.53$ 2,191.21$ 3,122.47$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,092.15$ 1,856.66$ 2,184.31$ 3,112.64$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,110.33$ 1,887.57$ 2,220.67$ 3,164.45$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,110.33$ 1,887.57$ 2,220.67$ 3,164.45$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,106.88$ 1,881.70$ 2,213.77$ 3,154.62$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,106.88$ 1,881.70$ 2,213.77$ 3,154.62$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,144.56$ 1,945.75$ 2,289.12$ 3,261.99$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,141.11$ 1,939.88$ 2,282.22$ 3,252.16$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,144.56$ 1,945.75$ 2,289.12$ 3,261.99$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,141.11$ 1,939.88$ 2,282.22$ 3,252.16$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,159.29$ 1,970.79$ 2,318.58$ 3,303.97$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,159.29$ 1,970.79$ 2,318.58$ 3,303.97$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,155.84$ 1,964.92$ 2,311.68$ 3,294.14$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,155.84$ 1,964.92$ 2,311.68$ 3,294.14$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,079.17$ 1,834.60$ 2,158.35$ 3,075.65$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,075.72$ 1,828.73$ 2,151.45$ 3,065.82$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,079.17$ 1,834.60$ 2,158.35$ 3,075.65$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,075.72$ 1,828.73$ 2,151.45$ 3,065.82$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,093.90$ 1,859.64$ 2,187.81$ 3,117.63$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,093.90$ 1,859.64$ 2,187.81$ 3,117.63$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,090.45$ 1,853.77$ 2,180.91$ 3,107.80$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,090.45$ 1,853.77$ 2,180.91$ 3,107.80$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 996.48$ 1,694.02$ 1,992.97$ 2,839.98$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 993.03$ 1,688.15$ 1,986.07$ 2,830.15$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 996.48$ 1,694.02$ 1,992.97$ 2,839.98$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 993.03$ 1,688.15$ 1,986.07$ 2,830.15$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 1,011.21$ 1,719.06$ 2,022.43$ 2,881.96$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 1,011.21$ 1,719.06$ 2,022.43$ 2,881.96$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 1,007.76$ 1,713.19$ 2,015.53$ 2,872.13$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 1,007.76$ 1,713.19$ 2,015.53$ 2,872.13$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 895.34$ 1,522.09$ 1,790.69$ 2,551.73$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 891.89$ 1,516.22$ 1,783.79$ 2,541.90$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 895.34$ 1,522.09$ 1,790.69$ 2,551.73$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 891.89$ 1,516.22$ 1,783.79$ 2,541.90$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 910.07$ 1,547.13$ 1,820.15$ 2,593.71$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 910.07$ 1,547.13$ 1,820.15$ 2,593.71$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 906.62$ 1,541.26$ 1,813.25$ 2,583.88$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 906.62$ 1,541.26$ 1,813.25$ 2,583.88$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 922.93$ 1,568.99$ 1,845.87$ 2,630.36$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 919.48$ 1,563.12$ 1,838.97$ 2,620.53$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 922.93$ 1,568.99$ 1,845.87$ 2,630.36$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 919.48$ 1,563.12$ 1,838.97$ 2,620.53$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 937.66$ 1,594.03$ 1,875.33$ 2,672.34$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 937.66$ 1,594.03$ 1,875.33$ 2,672.34$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 934.21$ 1,588.16$ 1,868.43$ 2,662.51$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 934.21$ 1,588.16$ 1,868.43$ 2,662.51$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 949.31$ 1,613.82$ 1,898.62$ 2,705.53$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 945.86$ 1,607.95$ 1,891.72$ 2,695.70$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 949.31$ 1,613.82$ 1,898.62$ 2,705.53$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 945.86$ 1,607.95$ 1,891.72$ 2,695.70$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 964.04$ 1,638.86$ 1,928.08$ 2,747.51$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 964.04$ 1,638.86$ 1,928.08$ 2,747.51$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 960.59$ 1,632.99$ 1,921.18$ 2,737.68$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 960.59$ 1,632.99$ 1,921.18$ 2,737.68$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 891.37$ 1,515.33$ 1,782.75$ 2,540.41$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 887.92$ 1,509.46$ 1,775.85$ 2,530.58$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 891.37$ 1,515.33$ 1,782.75$ 2,540.41$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 887.92$ 1,509.46$ 1,775.85$ 2,530.58$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 906.10$ 1,540.37$ 1,812.21$ 2,582.39$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 906.10$ 1,540.37$ 1,812.21$ 2,582.39$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 902.65$ 1,534.50$ 1,805.31$ 2,572.56$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 902.65$ 1,534.50$ 1,805.31$ 2,572.56$
Region 8
Page 52 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 920.61$ 1,565.04$ 1,841.23$ 2,623.75$
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 917.16$ 1,559.17$ 1,834.33$ 2,613.92$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 920.61$ 1,565.04$ 1,841.23$ 2,623.75$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 917.16$ 1,559.17$ 1,834.33$ 2,613.92$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 935.34$ 1,590.08$ 1,870.69$ 2,665.73$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 935.34$ 1,590.08$ 1,870.69$ 2,665.73$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 931.89$ 1,584.21$ 1,863.79$ 2,655.90$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 931.89$ 1,584.21$ 1,863.79$ 2,655.90$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 862.45$ 1,466.17$ 1,724.91$ 2,457.99$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 859.00$ 1,460.30$ 1,718.01$ 2,448.16$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 862.45$ 1,466.17$ 1,724.91$ 2,457.99$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 859.00$ 1,460.30$ 1,718.01$ 2,448.16$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 877.18$ 1,491.21$ 1,754.37$ 2,499.97$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 877.18$ 1,491.21$ 1,754.37$ 2,499.97$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 873.73$ 1,485.34$ 1,747.47$ 2,490.14$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 873.73$ 1,485.34$ 1,747.47$ 2,490.14$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 836.80$ 1,422.55$ 1,673.59$ 2,384.87$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 833.35$ 1,416.68$ 1,666.69$ 2,375.04$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 836.80$ 1,422.55$ 1,673.59$ 2,384.87$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 833.35$ 1,416.68$ 1,666.69$ 2,375.04$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 851.53$ 1,447.59$ 1,703.05$ 2,426.85$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 851.53$ 1,447.59$ 1,703.05$ 2,426.85$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 848.08$ 1,441.72$ 1,696.15$ 2,417.02$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 848.08$ 1,441.72$ 1,696.15$ 2,417.02$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 712.73$ 1,211.64$ 1,425.46$ 2,031.28$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 709.28$ 1,205.77$ 1,418.56$ 2,021.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 712.73$ 1,211.64$ 1,425.46$ 2,031.28$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 709.28$ 1,205.77$ 1,418.56$ 2,021.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 727.46$ 1,236.68$ 1,454.92$ 2,073.26$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 727.46$ 1,236.68$ 1,454.92$ 2,073.26$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 724.01$ 1,230.81$ 1,448.02$ 2,063.43$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 724.01$ 1,230.81$ 1,448.02$ 2,063.43$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 752.31$ 1,278.93$ 1,504.62$ 2,144.09$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 748.86$ 1,273.06$ 1,497.72$ 2,134.26$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 752.31$ 1,278.93$ 1,504.62$ 2,144.09$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 748.86$ 1,273.06$ 1,497.72$ 2,134.26$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 767.04$ 1,303.97$ 1,534.08$ 2,186.07$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 767.04$ 1,303.97$ 1,534.08$ 2,186.07$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 763.59$ 1,298.10$ 1,527.18$ 2,176.24$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 763.59$ 1,298.10$ 1,527.18$ 2,176.24$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 836.53$ 1,422.11$ 1,673.07$ 2,384.12$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 833.08$ 1,416.24$ 1,666.17$ 2,374.29$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 836.53$ 1,422.11$ 1,673.07$ 2,384.12$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 833.08$ 1,416.24$ 1,666.17$ 2,374.29$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 851.26$ 1,447.15$ 1,702.53$ 2,426.10$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 851.26$ 1,447.15$ 1,702.53$ 2,426.10$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 847.81$ 1,441.28$ 1,695.63$ 2,416.27$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 847.81$ 1,441.28$ 1,695.63$ 2,416.27$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 773.80$ 1,315.46$ 1,547.60$ 2,205.33$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 770.35$ 1,309.59$ 1,540.70$ 2,195.50$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 773.80$ 1,315.46$ 1,547.60$ 2,205.33$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 770.35$ 1,309.59$ 1,540.70$ 2,195.50$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 788.53$ 1,340.50$ 1,577.06$ 2,247.31$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 788.53$ 1,340.50$ 1,577.06$ 2,247.31$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 785.08$ 1,334.63$ 1,570.16$ 2,237.48$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 785.08$ 1,334.63$ 1,570.16$ 2,237.48$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 739.39$ 1,256.96$ 1,478.77$ 2,107.25$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 735.94$ 1,251.09$ 1,471.87$ 2,097.42$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 739.39$ 1,256.96$ 1,478.77$ 2,107.25$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 735.94$ 1,251.09$ 1,471.87$ 2,097.42$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 754.12$ 1,282.00$ 1,508.23$ 2,149.23$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 754.12$ 1,282.00$ 1,508.23$ 2,149.23$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 750.67$ 1,276.13$ 1,501.33$ 2,139.40$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 750.67$ 1,276.13$ 1,501.33$ 2,139.40$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 779.08$ 1,324.44$ 1,558.17$ 2,220.39$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 775.63$ 1,318.57$ 1,551.27$ 2,210.56$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 779.08$ 1,324.44$ 1,558.17$ 2,220.39$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 775.63$ 1,318.57$ 1,551.27$ 2,210.56$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 793.81$ 1,349.48$ 1,587.63$ 2,262.37$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 793.81$ 1,349.48$ 1,587.63$ 2,262.37$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 790.36$ 1,343.61$ 1,580.73$ 2,252.54$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 790.36$ 1,343.61$ 1,580.73$ 2,252.54$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 744.44$ 1,265.54$ 1,488.87$ 2,121.64$
Page 53 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 740.99$ 1,259.67$ 1,481.97$ 2,111.81$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 744.44$ 1,265.54$ 1,488.87$ 2,121.64$
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 740.99$ 1,259.67$ 1,481.97$ 2,111.81$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 759.17$ 1,290.58$ 1,518.33$ 2,163.62$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 759.17$ 1,290.58$ 1,518.33$ 2,163.62$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 755.72$ 1,284.71$ 1,511.43$ 2,153.79$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 755.72$ 1,284.71$ 1,511.43$ 2,153.79$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 709.53$ 1,206.21$ 1,419.07$ 2,022.17$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 706.08$ 1,200.34$ 1,412.17$ 2,012.34$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 709.53$ 1,206.21$ 1,419.07$ 2,022.17$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 706.08$ 1,200.34$ 1,412.17$ 2,012.34$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 724.26$ 1,231.25$ 1,448.53$ 2,064.15$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 724.26$ 1,231.25$ 1,448.53$ 2,064.15$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 720.81$ 1,225.38$ 1,441.63$ 2,054.32$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 720.81$ 1,225.38$ 1,441.63$ 2,054.32$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 703.96$ 1,196.73$ 1,407.92$ 2,006.29$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 700.51$ 1,190.86$ 1,401.02$ 1,996.46$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 703.96$ 1,196.73$ 1,407.92$ 2,006.29$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 700.51$ 1,190.86$ 1,401.02$ 1,996.46$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 718.69$ 1,221.77$ 1,437.38$ 2,048.27$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 718.69$ 1,221.77$ 1,437.38$ 2,048.27$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 715.24$ 1,215.90$ 1,430.48$ 2,038.44$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 715.24$ 1,215.90$ 1,430.48$ 2,038.44$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,316.88$ 2,238.70$ 2,633.76$ 3,753.11$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,313.43$ 2,232.83$ 2,626.86$ 3,743.28$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,316.88$ 2,238.70$ 2,633.76$ 3,753.11$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,313.43$ 2,232.83$ 2,626.86$ 3,743.28$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,331.61$ 2,263.74$ 2,663.22$ 3,795.09$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,331.61$ 2,263.74$ 2,663.22$ 3,795.09$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,328.16$ 2,257.87$ 2,656.32$ 3,785.26$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,328.16$ 2,257.87$ 2,656.32$ 3,785.26$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 888.80$ 1,510.96$ 1,777.60$ 2,533.08$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 885.35$ 1,505.09$ 1,770.70$ 2,523.25$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 888.80$ 1,510.96$ 1,777.60$ 2,533.08$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 885.35$ 1,505.09$ 1,770.70$ 2,523.25$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 903.53$ 1,536.00$ 1,807.06$ 2,575.06$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 903.53$ 1,536.00$ 1,807.06$ 2,575.06$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 900.08$ 1,530.13$ 1,800.16$ 2,565.23$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 900.08$ 1,530.13$ 1,800.16$ 2,565.23$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 997.84$ 1,696.33$ 1,995.69$ 2,843.86$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 994.39$ 1,690.46$ 1,988.79$ 2,834.03$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 997.84$ 1,696.33$ 1,995.69$ 2,843.86$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 994.39$ 1,690.46$ 1,988.79$ 2,834.03$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 1,012.57$ 1,721.37$ 2,025.15$ 2,885.84$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 1,012.57$ 1,721.37$ 2,025.15$ 2,885.84$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 1,009.12$ 1,715.50$ 2,018.25$ 2,876.01$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 1,009.12$ 1,715.50$ 2,018.25$ 2,876.01$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 717.10$ 1,219.07$ 1,434.20$ 2,043.73$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 713.65$ 1,213.20$ 1,427.30$ 2,033.90$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 717.10$ 1,219.07$ 1,434.20$ 2,043.73$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 713.65$ 1,213.20$ 1,427.30$ 2,033.90$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 731.83$ 1,244.11$ 1,463.66$ 2,085.71$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 731.83$ 1,244.11$ 1,463.66$ 2,085.71$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 728.38$ 1,238.24$ 1,456.76$ 2,075.88$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 728.38$ 1,238.24$ 1,456.76$ 2,075.88$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 633.81$ 1,077.47$ 1,267.62$ 1,806.35$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 630.36$ 1,071.60$ 1,260.72$ 1,796.52$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 633.81$ 1,077.47$ 1,267.62$ 1,806.35$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 630.36$ 1,071.60$ 1,260.72$ 1,796.52$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 648.54$ 1,102.51$ 1,297.08$ 1,848.33$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 648.54$ 1,102.51$ 1,297.08$ 1,848.33$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 645.09$ 1,096.64$ 1,290.18$ 1,838.50$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 645.09$ 1,096.64$ 1,290.18$ 1,838.50$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 645.88$ 1,097.99$ 1,291.76$ 1,840.75$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 642.43$ 1,092.12$ 1,284.86$ 1,830.92$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 645.88$ 1,097.99$ 1,291.76$ 1,840.75$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 642.43$ 1,092.12$ 1,284.86$ 1,830.92$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 660.61$ 1,123.03$ 1,321.22$ 1,882.73$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 660.61$ 1,123.03$ 1,321.22$ 1,882.73$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 657.16$ 1,117.16$ 1,314.32$ 1,872.90$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 657.16$ 1,117.16$ 1,314.32$ 1,872.90$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 614.95$ 1,045.41$ 1,229.90$ 1,752.60$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 611.50$ 1,039.54$ 1,223.00$ 1,742.77$
Page 54 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 614.95$ 1,045.41$ 1,229.90$ 1,752.60$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 611.50$ 1,039.54$ 1,223.00$ 1,742.77$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 629.68$ 1,070.45$ 1,259.36$ 1,794.58$
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 629.68$ 1,070.45$ 1,259.36$ 1,794.58$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 626.23$ 1,064.58$ 1,252.46$ 1,784.75$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 626.23$ 1,064.58$ 1,252.46$ 1,784.75$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 643.04$ 1,093.17$ 1,286.09$ 1,832.67$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 639.59$ 1,087.30$ 1,279.19$ 1,822.84$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 643.04$ 1,093.17$ 1,286.09$ 1,832.67$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 639.59$ 1,087.30$ 1,279.19$ 1,822.84$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 657.77$ 1,118.21$ 1,315.55$ 1,874.65$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 657.77$ 1,118.21$ 1,315.55$ 1,874.65$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 654.32$ 1,112.34$ 1,308.65$ 1,864.82$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 654.32$ 1,112.34$ 1,308.65$ 1,864.82$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 614.44$ 1,044.55$ 1,228.89$ 1,751.17$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 610.99$ 1,038.68$ 1,221.99$ 1,741.34$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 614.44$ 1,044.55$ 1,228.89$ 1,751.17$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 610.99$ 1,038.68$ 1,221.99$ 1,741.34$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 629.17$ 1,069.59$ 1,258.35$ 1,793.15$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 629.17$ 1,069.59$ 1,258.35$ 1,793.15$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 625.72$ 1,063.72$ 1,251.45$ 1,783.32$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 625.72$ 1,063.72$ 1,251.45$ 1,783.32$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 651.77$ 1,108.01$ 1,303.55$ 1,857.55$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 648.32$ 1,102.14$ 1,296.65$ 1,847.72$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 651.77$ 1,108.01$ 1,303.55$ 1,857.55$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 648.32$ 1,102.14$ 1,296.65$ 1,847.72$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 666.50$ 1,133.05$ 1,333.01$ 1,899.53$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 666.50$ 1,133.05$ 1,333.01$ 1,899.53$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 663.05$ 1,127.18$ 1,326.11$ 1,889.70$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 663.05$ 1,127.18$ 1,326.11$ 1,889.70$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 524.54$ 891.72$ 1,049.08$ 1,494.94$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 521.09$ 885.85$ 1,042.18$ 1,485.11$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 524.54$ 891.72$ 1,049.08$ 1,494.94$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 521.09$ 885.85$ 1,042.18$ 1,485.11$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 539.27$ 916.76$ 1,078.54$ 1,536.92$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 539.27$ 916.76$ 1,078.54$ 1,536.92$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 535.82$ 910.89$ 1,071.64$ 1,527.09$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 535.82$ 910.89$ 1,071.64$ 1,527.09$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 523.30$ 889.60$ 1,046.59$ 1,491.40$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 519.85$ 883.73$ 1,039.69$ 1,481.57$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 523.30$ 889.60$ 1,046.59$ 1,491.40$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 519.85$ 883.73$ 1,039.69$ 1,481.57$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 538.03$ 914.64$ 1,076.05$ 1,533.38$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 538.03$ 914.64$ 1,076.05$ 1,533.38$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 534.58$ 908.77$ 1,069.15$ 1,523.55$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 534.58$ 908.77$ 1,069.15$ 1,523.55$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 636.00$ 1,081.20$ 1,272.01$ 1,812.61$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 632.55$ 1,075.33$ 1,265.11$ 1,802.78$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 636.00$ 1,081.20$ 1,272.01$ 1,812.61$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 632.55$ 1,075.33$ 1,265.11$ 1,802.78$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 650.73$ 1,106.24$ 1,301.47$ 1,854.59$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 650.73$ 1,106.24$ 1,301.47$ 1,854.59$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 647.28$ 1,100.37$ 1,294.57$ 1,844.76$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 647.28$ 1,100.37$ 1,294.57$ 1,844.76$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 517.56$ 879.85$ 1,035.11$ 1,475.04$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 514.11$ 873.98$ 1,028.21$ 1,465.21$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 517.56$ 879.85$ 1,035.11$ 1,475.04$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 514.11$ 873.98$ 1,028.21$ 1,465.21$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 532.29$ 904.89$ 1,064.57$ 1,517.02$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 532.29$ 904.89$ 1,064.57$ 1,517.02$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 528.84$ 899.02$ 1,057.67$ 1,507.19$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 528.84$ 899.02$ 1,057.67$ 1,507.19$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 655.30$ 1,114.01$ 1,310.60$ 1,867.60$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 651.85$ 1,108.14$ 1,303.70$ 1,857.77$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 655.30$ 1,114.01$ 1,310.60$ 1,867.60$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 651.85$ 1,108.14$ 1,303.70$ 1,857.77$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 670.03$ 1,139.05$ 1,340.06$ 1,909.58$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 670.03$ 1,139.05$ 1,340.06$ 1,909.58$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 666.58$ 1,133.18$ 1,333.16$ 1,899.75$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 666.58$ 1,133.18$ 1,333.16$ 1,899.75$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 758.95$ 1,290.22$ 1,517.91$ 2,163.02$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 755.50$ 1,284.35$ 1,511.01$ 2,153.19$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 758.95$ 1,290.22$ 1,517.91$ 2,163.02$
Page 55 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 755.50$ 1,284.35$ 1,511.01$ 2,153.19$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 773.68$ 1,315.26$ 1,547.37$ 2,205.00$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 773.68$ 1,315.26$ 1,547.37$ 2,205.00$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 770.23$ 1,309.39$ 1,540.47$ 2,195.17$
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 770.23$ 1,309.39$ 1,540.47$ 2,195.17$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 606.66$ 1,031.31$ 1,213.31$ 1,728.97$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 603.21$ 1,025.44$ 1,206.41$ 1,719.14$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 606.66$ 1,031.31$ 1,213.31$ 1,728.97$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 603.21$ 1,025.44$ 1,206.41$ 1,719.14$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 621.39$ 1,056.35$ 1,242.77$ 1,770.95$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 621.39$ 1,056.35$ 1,242.77$ 1,770.95$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 617.94$ 1,050.48$ 1,235.87$ 1,761.12$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 617.94$ 1,050.48$ 1,235.87$ 1,761.12$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 821.15$ 1,395.96$ 1,642.30$ 2,340.28$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 817.70$ 1,390.09$ 1,635.40$ 2,330.45$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 821.15$ 1,395.96$ 1,642.30$ 2,340.28$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 817.70$ 1,390.09$ 1,635.40$ 2,330.45$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 835.88$ 1,421.00$ 1,671.76$ 2,382.26$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 835.88$ 1,421.00$ 1,671.76$ 2,382.26$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 832.43$ 1,415.13$ 1,664.86$ 2,372.43$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 832.43$ 1,415.13$ 1,664.86$ 2,372.43$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 682.04$ 1,159.47$ 1,364.08$ 1,943.82$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 678.59$ 1,153.60$ 1,357.18$ 1,933.99$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 682.04$ 1,159.47$ 1,364.08$ 1,943.82$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 678.59$ 1,153.60$ 1,357.18$ 1,933.99$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 696.77$ 1,184.51$ 1,393.54$ 1,985.80$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 696.77$ 1,184.51$ 1,393.54$ 1,985.80$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 693.32$ 1,178.64$ 1,386.64$ 1,975.97$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 693.32$ 1,178.64$ 1,386.64$ 1,975.97$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 648.86$ 1,103.06$ 1,297.72$ 1,849.25$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 645.41$ 1,097.19$ 1,290.82$ 1,839.42$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 648.86$ 1,103.06$ 1,297.72$ 1,849.25$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 645.41$ 1,097.19$ 1,290.82$ 1,839.42$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 663.59$ 1,128.10$ 1,327.18$ 1,891.23$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 663.59$ 1,128.10$ 1,327.18$ 1,891.23$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 660.14$ 1,122.23$ 1,320.28$ 1,881.40$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 660.14$ 1,122.23$ 1,320.28$ 1,881.40$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,044.98$ 1,776.47$ 2,089.96$ 2,978.20$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,041.53$ 1,770.60$ 2,083.06$ 2,968.37$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,044.98$ 1,776.47$ 2,089.96$ 2,978.20$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,041.53$ 1,770.60$ 2,083.06$ 2,968.37$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,059.71$ 1,801.51$ 2,119.42$ 3,020.18$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,059.71$ 1,801.51$ 2,119.42$ 3,020.18$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,056.26$ 1,795.64$ 2,112.52$ 3,010.35$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,056.26$ 1,795.64$ 2,112.52$ 3,010.35$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 845.52$ 1,437.38$ 1,691.03$ 2,409.72$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 842.07$ 1,431.51$ 1,684.13$ 2,399.89$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 845.52$ 1,437.38$ 1,691.03$ 2,409.72$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 842.07$ 1,431.51$ 1,684.13$ 2,399.89$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 860.25$ 1,462.42$ 1,720.49$ 2,451.70$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 860.25$ 1,462.42$ 1,720.49$ 2,451.70$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 856.80$ 1,456.55$ 1,713.59$ 2,441.87$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 856.80$ 1,456.55$ 1,713.59$ 2,441.87$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 807.92$ 1,373.46$ 1,615.83$ 2,302.56$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 804.47$ 1,367.59$ 1,608.93$ 2,292.73$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 807.92$ 1,373.46$ 1,615.83$ 2,302.56$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 804.47$ 1,367.59$ 1,608.93$ 2,292.73$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 822.65$ 1,398.50$ 1,645.29$ 2,344.54$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 822.65$ 1,398.50$ 1,645.29$ 2,344.54$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 819.20$ 1,392.63$ 1,638.39$ 2,334.71$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 819.20$ 1,392.63$ 1,638.39$ 2,334.71$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 903.69$ 1,536.27$ 1,807.37$ 2,575.51$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 900.24$ 1,530.40$ 1,800.47$ 2,565.68$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 903.69$ 1,536.27$ 1,807.37$ 2,575.51$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 900.24$ 1,530.40$ 1,800.47$ 2,565.68$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 918.42$ 1,561.31$ 1,836.83$ 2,617.49$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 918.42$ 1,561.31$ 1,836.83$ 2,617.49$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 914.97$ 1,555.44$ 1,829.93$ 2,607.66$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 914.97$ 1,555.44$ 1,829.93$ 2,607.66$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 651.55$ 1,107.63$ 1,303.10$ 1,856.92$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 648.10$ 1,101.76$ 1,296.20$ 1,847.09$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 651.55$ 1,107.63$ 1,303.10$ 1,856.92$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 648.10$ 1,101.76$ 1,296.20$ 1,847.09$
Page 56 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q3
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Region 8
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 666.28$ 1,132.67$ 1,332.56$ 1,898.90$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 666.28$ 1,132.67$ 1,332.56$ 1,898.90$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 662.83$ 1,126.80$ 1,325.66$ 1,889.07$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 662.83$ 1,126.80$ 1,325.66$ 1,889.07$
Page 57 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,312.71$ 2,231.61$ 2,625.43$ 3,741.23$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,308.82$ 2,225.00$ 2,617.65$ 3,730.14$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,312.71$ 2,231.61$ 2,625.43$ 3,741.23$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,308.82$ 2,225.00$ 2,617.65$ 3,730.14$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,329.31$ 2,259.83$ 2,658.63$ 3,788.54$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,329.31$ 2,259.83$ 2,658.63$ 3,788.54$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,325.42$ 2,253.22$ 2,650.85$ 3,777.45$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,325.42$ 2,253.22$ 2,650.85$ 3,777.45$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,234.15$ 2,098.06$ 2,468.30$ 3,517.33$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,230.26$ 2,091.45$ 2,460.52$ 3,506.24$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,234.15$ 2,098.06$ 2,468.30$ 3,517.33$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,230.26$ 2,091.45$ 2,460.52$ 3,506.24$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,250.75$ 2,126.28$ 2,501.50$ 3,564.64$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,250.75$ 2,126.28$ 2,501.50$ 3,564.64$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,246.86$ 2,119.67$ 2,493.72$ 3,553.55$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,246.86$ 2,119.67$ 2,493.72$ 3,553.55$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,289.30$ 2,191.81$ 2,578.60$ 3,674.51$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,285.41$ 2,185.20$ 2,570.82$ 3,663.42$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,289.30$ 2,191.81$ 2,578.60$ 3,674.51$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,285.41$ 2,185.20$ 2,570.82$ 3,663.42$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,305.90$ 2,220.03$ 2,611.80$ 3,721.82$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,305.90$ 2,220.03$ 2,611.80$ 3,721.82$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,302.01$ 2,213.42$ 2,604.02$ 3,710.73$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,302.01$ 2,213.42$ 2,604.02$ 3,710.73$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,215.64$ 2,066.59$ 2,431.28$ 3,464.58$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,211.75$ 2,059.98$ 2,423.50$ 3,453.49$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,215.64$ 2,066.59$ 2,431.28$ 3,464.58$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,211.75$ 2,059.98$ 2,423.50$ 3,453.49$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,232.24$ 2,094.81$ 2,464.48$ 3,511.89$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,232.24$ 2,094.81$ 2,464.48$ 3,511.89$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,228.35$ 2,088.20$ 2,456.70$ 3,500.80$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,228.35$ 2,088.20$ 2,456.70$ 3,500.80$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 1,122.49$ 1,908.24$ 2,244.99$ 3,199.11$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 1,118.60$ 1,901.63$ 2,237.21$ 3,188.02$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 1,122.49$ 1,908.24$ 2,244.99$ 3,199.11$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 1,118.60$ 1,901.63$ 2,237.21$ 3,188.02$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 1,139.09$ 1,936.46$ 2,278.19$ 3,246.42$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 1,139.09$ 1,936.46$ 2,278.19$ 3,246.42$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 1,135.20$ 1,929.85$ 2,270.41$ 3,235.33$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 1,135.20$ 1,929.85$ 2,270.41$ 3,235.33$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 1,008.57$ 1,714.56$ 2,017.13$ 2,874.41$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 1,004.68$ 1,707.95$ 2,009.35$ 2,863.32$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 1,008.57$ 1,714.56$ 2,017.13$ 2,874.41$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 1,004.68$ 1,707.95$ 2,009.35$ 2,863.32$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 1,025.17$ 1,742.78$ 2,050.33$ 2,921.72$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 1,025.17$ 1,742.78$ 2,050.33$ 2,921.72$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 1,021.28$ 1,736.17$ 2,042.55$ 2,910.63$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 1,021.28$ 1,736.17$ 2,042.55$ 2,910.63$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 1,039.65$ 1,767.40$ 2,079.30$ 2,963.00$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 1,035.76$ 1,760.79$ 2,071.52$ 2,951.91$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 1,039.65$ 1,767.40$ 2,079.30$ 2,963.00$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 1,035.76$ 1,760.79$ 2,071.52$ 2,951.91$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 1,056.25$ 1,795.62$ 2,112.50$ 3,010.31$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 1,056.25$ 1,795.62$ 2,112.50$ 3,010.31$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 1,052.36$ 1,789.01$ 2,104.72$ 2,999.22$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 1,052.36$ 1,789.01$ 2,104.72$ 2,999.22$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 1,069.35$ 1,817.89$ 2,138.69$ 3,047.64$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 1,065.46$ 1,811.28$ 2,130.91$ 3,036.55$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 1,069.35$ 1,817.89$ 2,138.69$ 3,047.64$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 1,065.46$ 1,811.28$ 2,130.91$ 3,036.55$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 1,085.95$ 1,846.11$ 2,171.89$ 3,094.95$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 1,085.95$ 1,846.11$ 2,171.89$ 3,094.95$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 1,082.06$ 1,839.50$ 2,164.11$ 3,083.86$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 1,082.06$ 1,839.50$ 2,164.11$ 3,083.86$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 1,004.09$ 1,706.95$ 2,008.18$ 2,861.65$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 1,000.20$ 1,700.34$ 2,000.40$ 2,850.56$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 1,004.09$ 1,706.95$ 2,008.18$ 2,861.65$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 1,000.20$ 1,700.34$ 2,000.40$ 2,850.56$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 1,020.69$ 1,735.17$ 2,041.38$ 2,908.96$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 1,020.69$ 1,735.17$ 2,041.38$ 2,908.96$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 1,016.80$ 1,728.56$ 2,033.60$ 2,897.87$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 1,016.80$ 1,728.56$ 2,033.60$ 2,897.87$
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 1,037.03$ 1,762.95$ 2,074.06$ 2,955.53$
Region 3
Page 58 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 3
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 1,033.14$ 1,756.34$ 2,066.28$ 2,944.44$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 1,037.03$ 1,762.95$ 2,074.06$ 2,955.53$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 1,033.14$ 1,756.34$ 2,066.28$ 2,944.44$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 1,053.63$ 1,791.17$ 2,107.26$ 3,002.84$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 1,053.63$ 1,791.17$ 2,107.26$ 3,002.84$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 1,049.74$ 1,784.56$ 2,099.48$ 2,991.75$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 1,049.74$ 1,784.56$ 2,099.48$ 2,991.75$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 971.52$ 1,651.58$ 1,943.04$ 2,768.83$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 967.63$ 1,644.97$ 1,935.26$ 2,757.74$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 971.52$ 1,651.58$ 1,943.04$ 2,768.83$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 967.63$ 1,644.97$ 1,935.26$ 2,757.74$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 988.12$ 1,679.80$ 1,976.24$ 2,816.14$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 988.12$ 1,679.80$ 1,976.24$ 2,816.14$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 984.23$ 1,673.19$ 1,968.46$ 2,805.05$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 984.23$ 1,673.19$ 1,968.46$ 2,805.05$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 942.62$ 1,602.45$ 1,885.24$ 2,686.46$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 938.73$ 1,595.84$ 1,877.46$ 2,675.37$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 942.62$ 1,602.45$ 1,885.24$ 2,686.46$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 938.73$ 1,595.84$ 1,877.46$ 2,675.37$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 959.22$ 1,630.67$ 1,918.44$ 2,733.77$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 959.22$ 1,630.67$ 1,918.44$ 2,733.77$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 955.33$ 1,624.06$ 1,910.66$ 2,722.68$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 955.33$ 1,624.06$ 1,910.66$ 2,722.68$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 802.86$ 1,364.86$ 1,605.71$ 2,288.14$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 798.97$ 1,358.25$ 1,597.93$ 2,277.05$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 802.86$ 1,364.86$ 1,605.71$ 2,288.14$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 798.97$ 1,358.25$ 1,597.93$ 2,277.05$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 819.46$ 1,393.08$ 1,638.91$ 2,335.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 819.46$ 1,393.08$ 1,638.91$ 2,335.45$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 815.57$ 1,386.47$ 1,631.13$ 2,324.36$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 815.57$ 1,386.47$ 1,631.13$ 2,324.36$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 847.45$ 1,440.66$ 1,694.90$ 2,415.23$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 843.56$ 1,434.05$ 1,687.12$ 2,404.14$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 847.45$ 1,440.66$ 1,694.90$ 2,415.23$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 843.56$ 1,434.05$ 1,687.12$ 2,404.14$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 864.05$ 1,468.88$ 1,728.10$ 2,462.54$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 864.05$ 1,468.88$ 1,728.10$ 2,462.54$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 860.16$ 1,462.27$ 1,720.32$ 2,451.45$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 860.16$ 1,462.27$ 1,720.32$ 2,451.45$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 942.32$ 1,601.94$ 1,884.63$ 2,685.60$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 938.43$ 1,595.33$ 1,876.85$ 2,674.51$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 942.32$ 1,601.94$ 1,884.63$ 2,685.60$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 938.43$ 1,595.33$ 1,876.85$ 2,674.51$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 958.92$ 1,630.16$ 1,917.83$ 2,732.91$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 958.92$ 1,630.16$ 1,917.83$ 2,732.91$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 955.03$ 1,623.55$ 1,910.05$ 2,721.82$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 955.03$ 1,623.55$ 1,910.05$ 2,721.82$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 871.66$ 1,481.82$ 1,743.32$ 2,484.23$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 867.77$ 1,475.21$ 1,735.54$ 2,473.14$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 871.66$ 1,481.82$ 1,743.32$ 2,484.23$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 867.77$ 1,475.21$ 1,735.54$ 2,473.14$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 888.26$ 1,510.04$ 1,776.52$ 2,531.54$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 888.26$ 1,510.04$ 1,776.52$ 2,531.54$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 884.37$ 1,503.43$ 1,768.74$ 2,520.45$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 884.37$ 1,503.43$ 1,768.74$ 2,520.45$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 832.88$ 1,415.90$ 1,665.77$ 2,373.72$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 828.99$ 1,409.29$ 1,657.99$ 2,362.63$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 832.88$ 1,415.90$ 1,665.77$ 2,373.72$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 828.99$ 1,409.29$ 1,657.99$ 2,362.63$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 849.48$ 1,444.12$ 1,698.97$ 2,421.03$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 849.48$ 1,444.12$ 1,698.97$ 2,421.03$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 845.59$ 1,437.51$ 1,691.19$ 2,409.94$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 845.59$ 1,437.51$ 1,691.19$ 2,409.94$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 877.60$ 1,491.92$ 1,755.20$ 2,501.17$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 873.71$ 1,485.31$ 1,747.42$ 2,490.08$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 877.60$ 1,491.92$ 1,755.20$ 2,501.17$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 873.71$ 1,485.31$ 1,747.42$ 2,490.08$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 894.20$ 1,520.14$ 1,788.40$ 2,548.48$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 894.20$ 1,520.14$ 1,788.40$ 2,548.48$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 890.31$ 1,513.53$ 1,780.62$ 2,537.39$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 890.31$ 1,513.53$ 1,780.62$ 2,537.39$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 838.57$ 1,425.58$ 1,677.15$ 2,389.94$
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 834.68$ 1,418.97$ 1,669.37$ 2,378.85$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 838.57$ 1,425.58$ 1,677.15$ 2,389.94$
Page 59 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 3
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 834.68$ 1,418.97$ 1,669.37$ 2,378.85$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 855.17$ 1,453.80$ 1,710.35$ 2,437.25$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 855.17$ 1,453.80$ 1,710.35$ 2,437.25$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 851.28$ 1,447.19$ 1,702.57$ 2,426.16$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 851.28$ 1,447.19$ 1,702.57$ 2,426.16$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 799.26$ 1,358.75$ 1,598.53$ 2,277.90$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 795.37$ 1,352.14$ 1,590.75$ 2,266.81$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 799.26$ 1,358.75$ 1,598.53$ 2,277.90$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 795.37$ 1,352.14$ 1,590.75$ 2,266.81$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 815.86$ 1,386.97$ 1,631.73$ 2,325.21$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 815.86$ 1,386.97$ 1,631.73$ 2,325.21$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 811.97$ 1,380.36$ 1,623.95$ 2,314.12$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 811.97$ 1,380.36$ 1,623.95$ 2,314.12$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 792.98$ 1,348.07$ 1,585.96$ 2,260.00$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 789.09$ 1,341.46$ 1,578.18$ 2,248.91$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 792.98$ 1,348.07$ 1,585.96$ 2,260.00$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 789.09$ 1,341.46$ 1,578.18$ 2,248.91$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 809.58$ 1,376.29$ 1,619.16$ 2,307.31$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 809.58$ 1,376.29$ 1,619.16$ 2,307.31$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 805.69$ 1,369.68$ 1,611.38$ 2,296.22$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 805.69$ 1,369.68$ 1,611.38$ 2,296.22$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,483.40$ 2,521.79$ 2,966.81$ 4,227.70$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,479.51$ 2,515.18$ 2,959.03$ 4,216.61$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,483.40$ 2,521.79$ 2,966.81$ 4,227.70$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,479.51$ 2,515.18$ 2,959.03$ 4,216.61$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,500.00$ 2,550.01$ 3,000.01$ 4,275.01$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,500.00$ 2,550.01$ 3,000.01$ 4,275.01$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,496.11$ 2,543.40$ 2,992.23$ 4,263.92$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,496.11$ 2,543.40$ 2,992.23$ 4,263.92$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 1,001.19$ 1,702.03$ 2,002.39$ 2,853.40$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 997.30$ 1,695.42$ 1,994.61$ 2,842.31$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 1,001.19$ 1,702.03$ 2,002.39$ 2,853.40$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 997.30$ 1,695.42$ 1,994.61$ 2,842.31$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 1,017.79$ 1,730.25$ 2,035.59$ 2,900.71$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 1,017.79$ 1,730.25$ 2,035.59$ 2,900.71$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 1,013.90$ 1,723.64$ 2,027.81$ 2,889.62$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 1,013.90$ 1,723.64$ 2,027.81$ 2,889.62$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 1,124.03$ 1,910.85$ 2,248.06$ 3,203.48$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 1,120.14$ 1,904.24$ 2,240.28$ 3,192.39$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 1,124.03$ 1,910.85$ 2,248.06$ 3,203.48$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 1,120.14$ 1,904.24$ 2,240.28$ 3,192.39$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 1,140.63$ 1,939.07$ 2,281.26$ 3,250.79$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 1,140.63$ 1,939.07$ 2,281.26$ 3,250.79$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 1,136.74$ 1,932.46$ 2,273.48$ 3,239.70$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 1,136.74$ 1,932.46$ 2,273.48$ 3,239.70$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 807.78$ 1,373.23$ 1,615.56$ 2,302.17$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 803.89$ 1,366.62$ 1,607.78$ 2,291.08$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 807.78$ 1,373.23$ 1,615.56$ 2,302.17$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 803.89$ 1,366.62$ 1,607.78$ 2,291.08$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 824.38$ 1,401.45$ 1,648.76$ 2,349.48$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 824.38$ 1,401.45$ 1,648.76$ 2,349.48$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 820.49$ 1,394.84$ 1,640.98$ 2,338.39$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 820.49$ 1,394.84$ 1,640.98$ 2,338.39$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 713.95$ 1,213.72$ 1,427.91$ 2,034.77$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 710.06$ 1,207.11$ 1,420.13$ 2,023.68$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 713.95$ 1,213.72$ 1,427.91$ 2,034.77$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 710.06$ 1,207.11$ 1,420.13$ 2,023.68$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 730.55$ 1,241.94$ 1,461.11$ 2,082.08$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 730.55$ 1,241.94$ 1,461.11$ 2,082.08$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 726.66$ 1,235.33$ 1,453.33$ 2,070.99$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 726.66$ 1,235.33$ 1,453.33$ 2,070.99$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 727.55$ 1,236.83$ 1,455.10$ 2,073.51$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 723.66$ 1,230.22$ 1,447.32$ 2,062.42$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 727.55$ 1,236.83$ 1,455.10$ 2,073.51$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 723.66$ 1,230.22$ 1,447.32$ 2,062.42$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 744.15$ 1,265.05$ 1,488.30$ 2,120.82$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 744.15$ 1,265.05$ 1,488.30$ 2,120.82$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 740.26$ 1,258.44$ 1,480.52$ 2,109.73$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 740.26$ 1,258.44$ 1,480.52$ 2,109.73$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 692.71$ 1,177.62$ 1,385.43$ 1,974.24$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 688.82$ 1,171.01$ 1,377.65$ 1,963.15$
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 692.71$ 1,177.62$ 1,385.43$ 1,974.24$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 688.82$ 1,171.01$ 1,377.65$ 1,963.15$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 709.31$ 1,205.84$ 1,418.63$ 2,021.55$
Page 60 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 3
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 709.31$ 1,205.84$ 1,418.63$ 2,021.55$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 705.42$ 1,199.23$ 1,410.85$ 2,010.46$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 705.42$ 1,199.23$ 1,410.85$ 2,010.46$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 724.36$ 1,231.42$ 1,448.73$ 2,064.43$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 720.47$ 1,224.81$ 1,440.95$ 2,053.34$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 724.36$ 1,231.42$ 1,448.73$ 2,064.43$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 720.47$ 1,224.81$ 1,440.95$ 2,053.34$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 740.96$ 1,259.64$ 1,481.93$ 2,111.74$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 740.96$ 1,259.64$ 1,481.93$ 2,111.74$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 737.07$ 1,253.03$ 1,474.15$ 2,100.65$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 737.07$ 1,253.03$ 1,474.15$ 2,100.65$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 692.14$ 1,176.64$ 1,384.28$ 1,972.60$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 688.25$ 1,170.03$ 1,376.50$ 1,961.51$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 692.14$ 1,176.64$ 1,384.28$ 1,972.60$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 688.25$ 1,170.03$ 1,376.50$ 1,961.51$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 708.74$ 1,204.86$ 1,417.48$ 2,019.91$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 708.74$ 1,204.86$ 1,417.48$ 2,019.91$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 704.85$ 1,198.25$ 1,409.70$ 2,008.82$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 704.85$ 1,198.25$ 1,409.70$ 2,008.82$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 734.20$ 1,248.14$ 1,468.40$ 2,092.47$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 730.31$ 1,241.53$ 1,460.62$ 2,081.38$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 734.20$ 1,248.14$ 1,468.40$ 2,092.47$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 730.31$ 1,241.53$ 1,460.62$ 2,081.38$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 750.80$ 1,276.36$ 1,501.60$ 2,139.78$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 750.80$ 1,276.36$ 1,501.60$ 2,139.78$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 746.91$ 1,269.75$ 1,493.82$ 2,128.69$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 746.91$ 1,269.75$ 1,493.82$ 2,128.69$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 590.87$ 1,004.47$ 1,181.73$ 1,683.97$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 586.98$ 997.86$ 1,173.95$ 1,672.88$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 590.87$ 1,004.47$ 1,181.73$ 1,683.97$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 586.98$ 997.86$ 1,173.95$ 1,672.88$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 607.47$ 1,032.69$ 1,214.93$ 1,731.28$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 607.47$ 1,032.69$ 1,214.93$ 1,731.28$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 603.58$ 1,026.08$ 1,207.15$ 1,720.19$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 603.58$ 1,026.08$ 1,207.15$ 1,720.19$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 589.47$ 1,002.09$ 1,178.93$ 1,679.98$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 585.58$ 995.48$ 1,171.15$ 1,668.89$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 589.47$ 1,002.09$ 1,178.93$ 1,679.98$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 585.58$ 995.48$ 1,171.15$ 1,668.89$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 606.07$ 1,030.31$ 1,212.13$ 1,727.29$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 606.07$ 1,030.31$ 1,212.13$ 1,727.29$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 602.18$ 1,023.70$ 1,204.35$ 1,716.20$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 602.18$ 1,023.70$ 1,204.35$ 1,716.20$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 716.43$ 1,217.93$ 1,432.86$ 2,041.82$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 712.54$ 1,211.32$ 1,425.08$ 2,030.73$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 716.43$ 1,217.93$ 1,432.86$ 2,041.82$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 712.54$ 1,211.32$ 1,425.08$ 2,030.73$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 733.03$ 1,246.15$ 1,466.06$ 2,089.13$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 733.03$ 1,246.15$ 1,466.06$ 2,089.13$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 729.14$ 1,239.54$ 1,458.28$ 2,078.04$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 729.14$ 1,239.54$ 1,458.28$ 2,078.04$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 583.01$ 991.12$ 1,166.02$ 1,661.58$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 579.12$ 984.51$ 1,158.24$ 1,650.49$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 583.01$ 991.12$ 1,166.02$ 1,661.58$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 579.12$ 984.51$ 1,158.24$ 1,650.49$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 599.61$ 1,019.34$ 1,199.22$ 1,708.89$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 599.61$ 1,019.34$ 1,199.22$ 1,708.89$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 595.72$ 1,012.73$ 1,191.44$ 1,697.80$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 595.72$ 1,012.73$ 1,191.44$ 1,697.80$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 738.16$ 1,254.88$ 1,476.32$ 2,103.76$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 734.27$ 1,248.27$ 1,468.54$ 2,092.67$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 738.16$ 1,254.88$ 1,476.32$ 2,103.76$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 734.27$ 1,248.27$ 1,468.54$ 2,092.67$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 754.76$ 1,283.10$ 1,509.52$ 2,151.07$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 754.76$ 1,283.10$ 1,509.52$ 2,151.07$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 750.87$ 1,276.49$ 1,501.74$ 2,139.98$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 750.87$ 1,276.49$ 1,501.74$ 2,139.98$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 854.93$ 1,453.38$ 1,709.85$ 2,436.54$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 851.04$ 1,446.77$ 1,702.07$ 2,425.45$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 854.93$ 1,453.38$ 1,709.85$ 2,436.54$
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 851.04$ 1,446.77$ 1,702.07$ 2,425.45$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 871.53$ 1,481.60$ 1,743.05$ 2,483.85$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 871.53$ 1,481.60$ 1,743.05$ 2,483.85$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 867.64$ 1,474.99$ 1,735.27$ 2,472.76$
Page 61 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 3
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 867.64$ 1,474.99$ 1,735.27$ 2,472.76$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 683.37$ 1,161.73$ 1,366.75$ 1,947.61$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 679.48$ 1,155.12$ 1,358.97$ 1,936.52$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 683.37$ 1,161.73$ 1,366.75$ 1,947.61$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 679.48$ 1,155.12$ 1,358.97$ 1,936.52$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 699.97$ 1,189.95$ 1,399.95$ 1,994.92$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 699.97$ 1,189.95$ 1,399.95$ 1,994.92$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 696.08$ 1,183.34$ 1,392.17$ 1,983.83$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 696.08$ 1,183.34$ 1,392.17$ 1,983.83$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 924.99$ 1,572.49$ 1,849.98$ 2,636.23$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 921.10$ 1,565.88$ 1,842.20$ 2,625.14$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 924.99$ 1,572.49$ 1,849.98$ 2,636.23$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 921.10$ 1,565.88$ 1,842.20$ 2,625.14$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 941.59$ 1,600.71$ 1,883.18$ 2,683.54$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 941.59$ 1,600.71$ 1,883.18$ 2,683.54$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 937.70$ 1,594.10$ 1,875.40$ 2,672.45$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 937.70$ 1,594.10$ 1,875.40$ 2,672.45$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 768.29$ 1,306.09$ 1,536.57$ 2,189.61$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 764.40$ 1,299.48$ 1,528.79$ 2,178.52$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 768.29$ 1,306.09$ 1,536.57$ 2,189.61$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 764.40$ 1,299.48$ 1,528.79$ 2,178.52$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 784.89$ 1,334.31$ 1,569.77$ 2,236.92$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 784.89$ 1,334.31$ 1,569.77$ 2,236.92$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 781.00$ 1,327.70$ 1,561.99$ 2,225.83$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 781.00$ 1,327.70$ 1,561.99$ 2,225.83$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 730.92$ 1,242.56$ 1,461.84$ 2,083.12$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 727.03$ 1,235.95$ 1,454.06$ 2,072.03$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 730.92$ 1,242.56$ 1,461.84$ 2,083.12$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 727.03$ 1,235.95$ 1,454.06$ 2,072.03$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 747.52$ 1,270.78$ 1,495.04$ 2,130.43$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 747.52$ 1,270.78$ 1,495.04$ 2,130.43$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 743.63$ 1,264.17$ 1,487.26$ 2,119.34$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 743.63$ 1,264.17$ 1,487.26$ 2,119.34$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,177.12$ 2,001.10$ 2,354.24$ 3,354.79$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,173.23$ 1,994.49$ 2,346.46$ 3,343.70$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,177.12$ 2,001.10$ 2,354.24$ 3,354.79$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,173.23$ 1,994.49$ 2,346.46$ 3,343.70$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,193.72$ 2,029.32$ 2,387.44$ 3,402.10$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,193.72$ 2,029.32$ 2,387.44$ 3,402.10$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,189.83$ 2,022.71$ 2,379.66$ 3,391.01$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,189.83$ 2,022.71$ 2,379.66$ 3,391.01$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 952.44$ 1,619.14$ 1,904.87$ 2,714.44$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 948.55$ 1,612.53$ 1,897.09$ 2,703.35$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 952.44$ 1,619.14$ 1,904.87$ 2,714.44$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 948.55$ 1,612.53$ 1,897.09$ 2,703.35$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 969.04$ 1,647.36$ 1,938.07$ 2,761.75$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 969.04$ 1,647.36$ 1,938.07$ 2,761.75$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 965.15$ 1,640.75$ 1,930.29$ 2,750.66$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 965.15$ 1,640.75$ 1,930.29$ 2,750.66$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 910.09$ 1,547.15$ 1,820.17$ 2,593.74$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 906.20$ 1,540.54$ 1,812.39$ 2,582.65$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 910.09$ 1,547.15$ 1,820.17$ 2,593.74$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 906.20$ 1,540.54$ 1,812.39$ 2,582.65$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 926.69$ 1,575.37$ 1,853.37$ 2,641.05$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 926.69$ 1,575.37$ 1,853.37$ 2,641.05$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 922.80$ 1,568.76$ 1,845.59$ 2,629.96$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 922.80$ 1,568.76$ 1,845.59$ 2,629.96$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 1,017.97$ 1,730.54$ 2,035.93$ 2,901.20$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 1,014.08$ 1,723.93$ 2,028.15$ 2,890.11$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 1,017.97$ 1,730.54$ 2,035.93$ 2,901.20$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 1,014.08$ 1,723.93$ 2,028.15$ 2,890.11$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 1,034.57$ 1,758.76$ 2,069.13$ 2,948.51$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 1,034.57$ 1,758.76$ 2,069.13$ 2,948.51$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 1,030.68$ 1,752.15$ 2,061.35$ 2,937.42$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 1,030.68$ 1,752.15$ 2,061.35$ 2,937.42$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 733.95$ 1,247.71$ 1,467.90$ 2,091.75$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 730.06$ 1,241.10$ 1,460.12$ 2,080.66$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 733.95$ 1,247.71$ 1,467.90$ 2,091.75$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 730.06$ 1,241.10$ 1,460.12$ 2,080.66$
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 750.55$ 1,275.93$ 1,501.10$ 2,139.06$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 750.55$ 1,275.93$ 1,501.10$ 2,139.06$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 746.66$ 1,269.32$ 1,493.32$ 2,127.97$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 746.66$ 1,269.32$ 1,493.32$ 2,127.97$
Page 62 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,192.18$ 2,026.71$ 2,384.36$ 3,397.71$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,188.65$ 2,020.71$ 2,377.30$ 3,387.65$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,192.18$ 2,026.71$ 2,384.36$ 3,397.71$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,188.65$ 2,020.71$ 2,377.30$ 3,387.65$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,207.25$ 2,052.33$ 2,414.50$ 3,440.66$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,207.25$ 2,052.33$ 2,414.50$ 3,440.66$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,203.72$ 2,046.33$ 2,407.44$ 3,430.60$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,203.72$ 2,046.33$ 2,407.44$ 3,430.60$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,120.83$ 1,905.42$ 2,241.67$ 3,194.38$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,117.30$ 1,899.42$ 2,234.61$ 3,184.32$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,120.83$ 1,905.42$ 2,241.67$ 3,194.38$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,117.30$ 1,899.42$ 2,234.61$ 3,184.32$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,135.90$ 1,931.04$ 2,271.81$ 3,237.33$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,135.90$ 1,931.04$ 2,271.81$ 3,237.33$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,132.37$ 1,925.04$ 2,264.75$ 3,227.27$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,132.37$ 1,925.04$ 2,264.75$ 3,227.27$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,170.91$ 1,990.55$ 2,341.83$ 3,337.10$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,167.38$ 1,984.55$ 2,334.77$ 3,327.04$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,170.91$ 1,990.55$ 2,341.83$ 3,337.10$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,167.38$ 1,984.55$ 2,334.77$ 3,327.04$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,185.98$ 2,016.17$ 2,371.97$ 3,380.05$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,185.98$ 2,016.17$ 2,371.97$ 3,380.05$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,182.45$ 2,010.17$ 2,364.91$ 3,369.99$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,182.45$ 2,010.17$ 2,364.91$ 3,369.99$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,104.02$ 1,876.84$ 2,208.05$ 3,146.47$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,100.49$ 1,870.84$ 2,200.99$ 3,136.41$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,104.02$ 1,876.84$ 2,208.05$ 3,146.47$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,100.49$ 1,870.84$ 2,200.99$ 3,136.41$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,119.09$ 1,902.46$ 2,238.19$ 3,189.42$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,119.09$ 1,902.46$ 2,238.19$ 3,189.42$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,115.56$ 1,896.46$ 2,231.13$ 3,179.36$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,115.56$ 1,896.46$ 2,231.13$ 3,179.36$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 1,019.43$ 1,733.03$ 2,038.86$ 2,905.38$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 1,015.90$ 1,727.03$ 2,031.80$ 2,895.32$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 1,019.43$ 1,733.03$ 2,038.86$ 2,905.38$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 1,015.90$ 1,727.03$ 2,031.80$ 2,895.32$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 1,034.50$ 1,758.65$ 2,069.00$ 2,948.33$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 1,034.50$ 1,758.65$ 2,069.00$ 2,948.33$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 1,030.97$ 1,752.65$ 2,061.94$ 2,938.27$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 1,030.97$ 1,752.65$ 2,061.94$ 2,938.27$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 915.96$ 1,557.13$ 1,831.92$ 2,610.49$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 912.43$ 1,551.13$ 1,824.86$ 2,600.43$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 915.96$ 1,557.13$ 1,831.92$ 2,610.49$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 912.43$ 1,551.13$ 1,824.86$ 2,600.43$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 931.03$ 1,582.75$ 1,862.06$ 2,653.44$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 931.03$ 1,582.75$ 1,862.06$ 2,653.44$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 927.50$ 1,576.75$ 1,855.00$ 2,643.38$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 927.50$ 1,576.75$ 1,855.00$ 2,643.38$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 944.19$ 1,605.12$ 1,888.38$ 2,690.94$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 940.66$ 1,599.12$ 1,881.32$ 2,680.88$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 944.19$ 1,605.12$ 1,888.38$ 2,690.94$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 940.66$ 1,599.12$ 1,881.32$ 2,680.88$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 959.26$ 1,630.74$ 1,918.52$ 2,733.89$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 959.26$ 1,630.74$ 1,918.52$ 2,733.89$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 955.73$ 1,624.74$ 1,911.46$ 2,723.83$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 955.73$ 1,624.74$ 1,911.46$ 2,723.83$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 971.17$ 1,650.99$ 1,942.34$ 2,767.83$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 967.64$ 1,644.99$ 1,935.28$ 2,757.77$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 971.17$ 1,650.99$ 1,942.34$ 2,767.83$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 967.64$ 1,644.99$ 1,935.28$ 2,757.77$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 986.24$ 1,676.61$ 1,972.48$ 2,810.78$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 986.24$ 1,676.61$ 1,972.48$ 2,810.78$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 982.71$ 1,670.61$ 1,965.42$ 2,800.72$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 982.71$ 1,670.61$ 1,965.42$ 2,800.72$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 911.89$ 1,550.22$ 1,823.78$ 2,598.89$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 908.36$ 1,544.22$ 1,816.72$ 2,588.83$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 911.89$ 1,550.22$ 1,823.78$ 2,598.89$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 908.36$ 1,544.22$ 1,816.72$ 2,588.83$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 926.96$ 1,575.84$ 1,853.92$ 2,641.84$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 926.96$ 1,575.84$ 1,853.92$ 2,641.84$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 923.43$ 1,569.84$ 1,846.86$ 2,631.78$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 923.43$ 1,569.84$ 1,846.86$ 2,631.78$
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 941.81$ 1,601.08$ 1,883.62$ 2,684.16$
Region 4
Page 63 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 4
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 938.28$ 1,595.08$ 1,876.56$ 2,674.10$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 941.81$ 1,601.08$ 1,883.62$ 2,684.16$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 938.28$ 1,595.08$ 1,876.56$ 2,674.10$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 956.88$ 1,626.70$ 1,913.76$ 2,727.11$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 956.88$ 1,626.70$ 1,913.76$ 2,727.11$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 953.35$ 1,620.70$ 1,906.70$ 2,717.05$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 953.35$ 1,620.70$ 1,906.70$ 2,717.05$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 882.31$ 1,499.93$ 1,764.62$ 2,514.59$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 878.78$ 1,493.93$ 1,757.56$ 2,504.53$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 882.31$ 1,499.93$ 1,764.62$ 2,514.59$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 878.78$ 1,493.93$ 1,757.56$ 2,504.53$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 897.38$ 1,525.55$ 1,794.76$ 2,557.54$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 897.38$ 1,525.55$ 1,794.76$ 2,557.54$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 893.85$ 1,519.55$ 1,787.70$ 2,547.48$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 893.85$ 1,519.55$ 1,787.70$ 2,547.48$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 856.06$ 1,455.31$ 1,712.13$ 2,439.78$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 852.53$ 1,449.31$ 1,705.07$ 2,429.72$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 856.06$ 1,455.31$ 1,712.13$ 2,439.78$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 852.53$ 1,449.31$ 1,705.07$ 2,429.72$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 871.13$ 1,480.93$ 1,742.27$ 2,482.73$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 871.13$ 1,480.93$ 1,742.27$ 2,482.73$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 867.60$ 1,474.93$ 1,735.21$ 2,472.67$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 867.60$ 1,474.93$ 1,735.21$ 2,472.67$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 729.14$ 1,239.54$ 1,458.28$ 2,078.05$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 725.61$ 1,233.54$ 1,451.22$ 2,067.99$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 729.14$ 1,239.54$ 1,458.28$ 2,078.05$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 725.61$ 1,233.54$ 1,451.22$ 2,067.99$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 744.21$ 1,265.16$ 1,488.42$ 2,121.00$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 744.21$ 1,265.16$ 1,488.42$ 2,121.00$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 740.68$ 1,259.16$ 1,481.36$ 2,110.94$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 740.68$ 1,259.16$ 1,481.36$ 2,110.94$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 769.64$ 1,308.38$ 1,539.27$ 2,193.46$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 766.11$ 1,302.38$ 1,532.21$ 2,183.40$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 769.64$ 1,308.38$ 1,539.27$ 2,193.46$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 766.11$ 1,302.38$ 1,532.21$ 2,183.40$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 784.71$ 1,334.00$ 1,569.41$ 2,236.41$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 784.71$ 1,334.00$ 1,569.41$ 2,236.41$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 781.18$ 1,328.00$ 1,562.35$ 2,226.35$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 781.18$ 1,328.00$ 1,562.35$ 2,226.35$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 855.79$ 1,454.85$ 1,711.58$ 2,439.01$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 852.26$ 1,448.85$ 1,704.52$ 2,428.95$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 855.79$ 1,454.85$ 1,711.58$ 2,439.01$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 852.26$ 1,448.85$ 1,704.52$ 2,428.95$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 870.86$ 1,480.47$ 1,741.72$ 2,481.96$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 870.86$ 1,480.47$ 1,741.72$ 2,481.96$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 867.33$ 1,474.47$ 1,734.66$ 2,471.90$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 867.33$ 1,474.47$ 1,734.66$ 2,471.90$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 791.62$ 1,345.76$ 1,583.24$ 2,256.12$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 788.09$ 1,339.76$ 1,576.18$ 2,246.06$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 791.62$ 1,345.76$ 1,583.24$ 2,256.12$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 788.09$ 1,339.76$ 1,576.18$ 2,246.06$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 806.69$ 1,371.38$ 1,613.38$ 2,299.07$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 806.69$ 1,371.38$ 1,613.38$ 2,299.07$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 803.16$ 1,365.38$ 1,606.32$ 2,289.01$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 803.16$ 1,365.38$ 1,606.32$ 2,289.01$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 756.41$ 1,285.90$ 1,512.82$ 2,155.77$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 752.88$ 1,279.90$ 1,505.76$ 2,145.71$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 756.41$ 1,285.90$ 1,512.82$ 2,155.77$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 752.88$ 1,279.90$ 1,505.76$ 2,145.71$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 771.48$ 1,311.52$ 1,542.96$ 2,198.72$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 771.48$ 1,311.52$ 1,542.96$ 2,198.72$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 767.95$ 1,305.52$ 1,535.90$ 2,188.66$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 767.95$ 1,305.52$ 1,535.90$ 2,188.66$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 797.03$ 1,354.95$ 1,594.06$ 2,271.54$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 793.50$ 1,348.95$ 1,587.00$ 2,261.48$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 797.03$ 1,354.95$ 1,594.06$ 2,271.54$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 793.50$ 1,348.95$ 1,587.00$ 2,261.48$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 812.10$ 1,380.57$ 1,624.20$ 2,314.49$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 812.10$ 1,380.57$ 1,624.20$ 2,314.49$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 808.57$ 1,374.57$ 1,617.14$ 2,304.43$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 808.57$ 1,374.57$ 1,617.14$ 2,304.43$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 761.58$ 1,294.68$ 1,523.15$ 2,170.49$
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 758.05$ 1,288.68$ 1,516.09$ 2,160.43$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 761.58$ 1,294.68$ 1,523.15$ 2,170.49$
Page 64 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 4
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 758.05$ 1,288.68$ 1,516.09$ 2,160.43$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 776.65$ 1,320.30$ 1,553.29$ 2,213.44$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 776.65$ 1,320.30$ 1,553.29$ 2,213.44$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 773.12$ 1,314.30$ 1,546.23$ 2,203.38$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 773.12$ 1,314.30$ 1,546.23$ 2,203.38$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 725.88$ 1,233.99$ 1,451.76$ 2,068.75$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 722.35$ 1,227.99$ 1,444.70$ 2,058.69$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 725.88$ 1,233.99$ 1,451.76$ 2,068.75$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 722.35$ 1,227.99$ 1,444.70$ 2,058.69$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 740.95$ 1,259.61$ 1,481.90$ 2,111.70$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 740.95$ 1,259.61$ 1,481.90$ 2,111.70$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 737.42$ 1,253.61$ 1,474.84$ 2,101.64$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 737.42$ 1,253.61$ 1,474.84$ 2,101.64$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 720.17$ 1,224.29$ 1,440.34$ 2,052.48$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 716.64$ 1,218.29$ 1,433.28$ 2,042.42$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 720.17$ 1,224.29$ 1,440.34$ 2,052.48$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 716.64$ 1,218.29$ 1,433.28$ 2,042.42$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 735.24$ 1,249.91$ 1,470.48$ 2,095.43$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 735.24$ 1,249.91$ 1,470.48$ 2,095.43$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 731.71$ 1,243.91$ 1,463.42$ 2,085.37$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 731.71$ 1,243.91$ 1,463.42$ 2,085.37$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,347.21$ 2,290.25$ 2,694.41$ 3,839.54$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,343.68$ 2,284.25$ 2,687.35$ 3,829.48$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,347.21$ 2,290.25$ 2,694.41$ 3,839.54$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,343.68$ 2,284.25$ 2,687.35$ 3,829.48$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,362.28$ 2,315.87$ 2,724.55$ 3,882.49$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,362.28$ 2,315.87$ 2,724.55$ 3,882.49$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,358.75$ 2,309.87$ 2,717.49$ 3,872.43$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,358.75$ 2,309.87$ 2,717.49$ 3,872.43$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 909.27$ 1,545.76$ 1,818.54$ 2,591.42$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 905.74$ 1,539.76$ 1,811.48$ 2,581.36$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 909.27$ 1,545.76$ 1,818.54$ 2,591.42$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 905.74$ 1,539.76$ 1,811.48$ 2,581.36$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 924.34$ 1,571.38$ 1,848.68$ 2,634.37$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 924.34$ 1,571.38$ 1,848.68$ 2,634.37$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 920.81$ 1,565.38$ 1,841.62$ 2,624.31$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 920.81$ 1,565.38$ 1,841.62$ 2,624.31$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 1,020.82$ 1,735.39$ 2,041.64$ 2,909.34$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 1,017.29$ 1,729.39$ 2,034.58$ 2,899.28$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 1,020.82$ 1,735.39$ 2,041.64$ 2,909.34$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 1,017.29$ 1,729.39$ 2,034.58$ 2,899.28$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 1,035.89$ 1,761.01$ 2,071.78$ 2,952.29$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 1,035.89$ 1,761.01$ 2,071.78$ 2,952.29$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 1,032.36$ 1,755.01$ 2,064.72$ 2,942.23$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 1,032.36$ 1,755.01$ 2,064.72$ 2,942.23$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 733.62$ 1,247.15$ 1,467.23$ 2,090.81$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 730.09$ 1,241.15$ 1,460.17$ 2,080.75$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 733.62$ 1,247.15$ 1,467.23$ 2,090.81$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 730.09$ 1,241.15$ 1,460.17$ 2,080.75$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 748.69$ 1,272.77$ 1,497.37$ 2,133.76$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 748.69$ 1,272.77$ 1,497.37$ 2,133.76$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 745.16$ 1,266.77$ 1,490.31$ 2,123.70$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 745.16$ 1,266.77$ 1,490.31$ 2,123.70$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 648.39$ 1,102.27$ 1,296.79$ 1,847.92$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 644.86$ 1,096.27$ 1,289.73$ 1,837.86$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 648.39$ 1,102.27$ 1,296.79$ 1,847.92$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 644.86$ 1,096.27$ 1,289.73$ 1,837.86$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 663.46$ 1,127.89$ 1,326.93$ 1,890.87$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 663.46$ 1,127.89$ 1,326.93$ 1,890.87$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 659.93$ 1,121.89$ 1,319.87$ 1,880.81$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 659.93$ 1,121.89$ 1,319.87$ 1,880.81$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 660.75$ 1,123.27$ 1,321.49$ 1,883.13$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 657.22$ 1,117.27$ 1,314.43$ 1,873.07$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 660.75$ 1,123.27$ 1,321.49$ 1,883.13$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 657.22$ 1,117.27$ 1,314.43$ 1,873.07$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 675.82$ 1,148.89$ 1,351.63$ 1,926.08$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 675.82$ 1,148.89$ 1,351.63$ 1,926.08$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 672.29$ 1,142.89$ 1,344.57$ 1,916.02$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 672.29$ 1,142.89$ 1,344.57$ 1,916.02$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 629.11$ 1,069.48$ 1,258.22$ 1,792.96$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 625.58$ 1,063.48$ 1,251.16$ 1,782.90$
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 629.11$ 1,069.48$ 1,258.22$ 1,792.96$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 625.58$ 1,063.48$ 1,251.16$ 1,782.90$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 644.18$ 1,095.10$ 1,288.36$ 1,835.91$
Page 65 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 4
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 644.18$ 1,095.10$ 1,288.36$ 1,835.91$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 640.65$ 1,089.10$ 1,281.30$ 1,825.85$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 640.65$ 1,089.10$ 1,281.30$ 1,825.85$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 657.85$ 1,118.35$ 1,315.70$ 1,874.88$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 654.32$ 1,112.35$ 1,308.64$ 1,864.82$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 657.85$ 1,118.35$ 1,315.70$ 1,874.88$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 654.32$ 1,112.35$ 1,308.64$ 1,864.82$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 672.92$ 1,143.97$ 1,345.84$ 1,917.83$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 672.92$ 1,143.97$ 1,345.84$ 1,917.83$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 669.39$ 1,137.97$ 1,338.78$ 1,907.77$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 669.39$ 1,137.97$ 1,338.78$ 1,907.77$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 628.59$ 1,068.61$ 1,257.19$ 1,791.49$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 625.06$ 1,062.61$ 1,250.13$ 1,781.43$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 628.59$ 1,068.61$ 1,257.19$ 1,791.49$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 625.06$ 1,062.61$ 1,250.13$ 1,781.43$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 643.66$ 1,094.23$ 1,287.33$ 1,834.44$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 643.66$ 1,094.23$ 1,287.33$ 1,834.44$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 640.13$ 1,088.23$ 1,280.27$ 1,824.38$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 640.13$ 1,088.23$ 1,280.27$ 1,824.38$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 666.79$ 1,133.54$ 1,333.57$ 1,900.34$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 663.26$ 1,127.54$ 1,326.51$ 1,890.28$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 666.79$ 1,133.54$ 1,333.57$ 1,900.34$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 663.26$ 1,127.54$ 1,326.51$ 1,890.28$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 681.86$ 1,159.16$ 1,363.71$ 1,943.29$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 681.86$ 1,159.16$ 1,363.71$ 1,943.29$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 678.33$ 1,153.16$ 1,356.65$ 1,933.23$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 678.33$ 1,153.16$ 1,356.65$ 1,933.23$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 536.61$ 912.24$ 1,073.22$ 1,529.34$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 533.08$ 906.24$ 1,066.16$ 1,519.28$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 536.61$ 912.24$ 1,073.22$ 1,529.34$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 533.08$ 906.24$ 1,066.16$ 1,519.28$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 551.68$ 937.86$ 1,103.36$ 1,572.29$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 551.68$ 937.86$ 1,103.36$ 1,572.29$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 548.15$ 931.86$ 1,096.30$ 1,562.23$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 548.15$ 931.86$ 1,096.30$ 1,562.23$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 535.35$ 910.09$ 1,070.70$ 1,525.74$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 531.82$ 904.09$ 1,063.64$ 1,515.68$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 535.35$ 910.09$ 1,070.70$ 1,525.74$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 531.82$ 904.09$ 1,063.64$ 1,515.68$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 550.42$ 935.71$ 1,100.84$ 1,568.69$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 550.42$ 935.71$ 1,100.84$ 1,568.69$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 546.89$ 929.71$ 1,093.78$ 1,558.63$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 546.89$ 929.71$ 1,093.78$ 1,558.63$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 650.66$ 1,106.12$ 1,301.31$ 1,854.37$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 647.13$ 1,100.12$ 1,294.25$ 1,844.31$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 650.66$ 1,106.12$ 1,301.31$ 1,854.37$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 647.13$ 1,100.12$ 1,294.25$ 1,844.31$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 665.73$ 1,131.74$ 1,331.45$ 1,897.32$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 665.73$ 1,131.74$ 1,331.45$ 1,897.32$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 662.20$ 1,125.74$ 1,324.39$ 1,887.26$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 662.20$ 1,125.74$ 1,324.39$ 1,887.26$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 529.47$ 900.10$ 1,058.95$ 1,509.00$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 525.94$ 894.10$ 1,051.89$ 1,498.94$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 529.47$ 900.10$ 1,058.95$ 1,509.00$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 525.94$ 894.10$ 1,051.89$ 1,498.94$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 544.54$ 925.72$ 1,089.09$ 1,551.95$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 544.54$ 925.72$ 1,089.09$ 1,551.95$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 541.01$ 919.72$ 1,082.03$ 1,541.89$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 541.01$ 919.72$ 1,082.03$ 1,541.89$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 670.39$ 1,139.66$ 1,340.78$ 1,910.61$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 666.86$ 1,133.66$ 1,333.72$ 1,900.55$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 670.39$ 1,139.66$ 1,340.78$ 1,910.61$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 666.86$ 1,133.66$ 1,333.72$ 1,900.55$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 685.46$ 1,165.28$ 1,370.92$ 1,953.56$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 685.46$ 1,165.28$ 1,370.92$ 1,953.56$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 681.93$ 1,159.28$ 1,363.86$ 1,943.50$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 681.93$ 1,159.28$ 1,363.86$ 1,943.50$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 776.42$ 1,319.92$ 1,552.85$ 2,212.81$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 772.89$ 1,313.92$ 1,545.79$ 2,202.75$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 776.42$ 1,319.92$ 1,552.85$ 2,212.81$
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 772.89$ 1,313.92$ 1,545.79$ 2,202.75$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 791.49$ 1,345.54$ 1,582.99$ 2,255.76$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 791.49$ 1,345.54$ 1,582.99$ 2,255.76$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 787.96$ 1,339.54$ 1,575.93$ 2,245.70$
Page 66 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 4
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 787.96$ 1,339.54$ 1,575.93$ 2,245.70$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 620.62$ 1,055.05$ 1,241.24$ 1,768.77$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 617.09$ 1,049.05$ 1,234.18$ 1,758.71$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 620.62$ 1,055.05$ 1,241.24$ 1,768.77$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 617.09$ 1,049.05$ 1,234.18$ 1,758.71$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 635.69$ 1,080.67$ 1,271.38$ 1,811.72$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 635.69$ 1,080.67$ 1,271.38$ 1,811.72$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 632.16$ 1,074.67$ 1,264.32$ 1,801.66$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 632.16$ 1,074.67$ 1,264.32$ 1,801.66$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 840.06$ 1,428.10$ 1,680.12$ 2,394.17$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 836.53$ 1,422.10$ 1,673.06$ 2,384.11$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 840.06$ 1,428.10$ 1,680.12$ 2,394.17$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 836.53$ 1,422.10$ 1,673.06$ 2,384.11$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 855.13$ 1,453.72$ 1,710.26$ 2,437.12$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 855.13$ 1,453.72$ 1,710.26$ 2,437.12$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 851.60$ 1,447.72$ 1,703.20$ 2,427.06$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 851.60$ 1,447.72$ 1,703.20$ 2,427.06$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 697.75$ 1,186.17$ 1,395.49$ 1,988.57$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 694.22$ 1,180.17$ 1,388.43$ 1,978.51$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 697.75$ 1,186.17$ 1,395.49$ 1,988.57$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 694.22$ 1,180.17$ 1,388.43$ 1,978.51$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 712.82$ 1,211.79$ 1,425.63$ 2,031.52$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 712.82$ 1,211.79$ 1,425.63$ 2,031.52$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 709.29$ 1,205.79$ 1,418.57$ 2,021.46$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 709.29$ 1,205.79$ 1,418.57$ 2,021.46$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 663.81$ 1,128.47$ 1,327.61$ 1,891.84$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 660.28$ 1,122.47$ 1,320.55$ 1,881.78$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 663.81$ 1,128.47$ 1,327.61$ 1,891.84$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 660.28$ 1,122.47$ 1,320.55$ 1,881.78$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 678.88$ 1,154.09$ 1,357.75$ 1,934.79$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 678.88$ 1,154.09$ 1,357.75$ 1,934.79$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 675.35$ 1,148.09$ 1,350.69$ 1,924.73$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 675.35$ 1,148.09$ 1,350.69$ 1,924.73$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,069.05$ 1,817.38$ 2,138.09$ 3,046.78$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,065.52$ 1,811.38$ 2,131.03$ 3,036.72$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,069.05$ 1,817.38$ 2,138.09$ 3,046.78$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,065.52$ 1,811.38$ 2,131.03$ 3,036.72$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,084.12$ 1,843.00$ 2,168.23$ 3,089.73$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,084.12$ 1,843.00$ 2,168.23$ 3,089.73$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,080.59$ 1,837.00$ 2,161.17$ 3,079.67$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,080.59$ 1,837.00$ 2,161.17$ 3,079.67$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 864.99$ 1,470.48$ 1,729.98$ 2,465.22$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 861.46$ 1,464.48$ 1,722.92$ 2,455.16$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 864.99$ 1,470.48$ 1,729.98$ 2,465.22$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 861.46$ 1,464.48$ 1,722.92$ 2,455.16$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 880.06$ 1,496.10$ 1,760.12$ 2,508.17$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 880.06$ 1,496.10$ 1,760.12$ 2,508.17$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 876.53$ 1,490.10$ 1,753.06$ 2,498.11$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 876.53$ 1,490.10$ 1,753.06$ 2,498.11$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 826.52$ 1,405.09$ 1,653.05$ 2,355.59$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 822.99$ 1,399.09$ 1,645.99$ 2,345.53$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 826.52$ 1,405.09$ 1,653.05$ 2,355.59$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 822.99$ 1,399.09$ 1,645.99$ 2,345.53$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 841.59$ 1,430.71$ 1,683.19$ 2,398.54$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 841.59$ 1,430.71$ 1,683.19$ 2,398.54$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 838.06$ 1,424.71$ 1,676.13$ 2,388.48$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 838.06$ 1,424.71$ 1,676.13$ 2,388.48$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 924.50$ 1,571.64$ 1,848.99$ 2,634.82$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 920.97$ 1,565.64$ 1,841.93$ 2,624.76$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 924.50$ 1,571.64$ 1,848.99$ 2,634.82$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 920.97$ 1,565.64$ 1,841.93$ 2,624.76$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 939.57$ 1,597.26$ 1,879.13$ 2,677.77$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 939.57$ 1,597.26$ 1,879.13$ 2,677.77$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 936.04$ 1,591.26$ 1,872.07$ 2,667.71$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 936.04$ 1,591.26$ 1,872.07$ 2,667.71$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 666.55$ 1,133.14$ 1,333.11$ 1,899.68$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 663.02$ 1,127.14$ 1,326.05$ 1,889.62$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 666.55$ 1,133.14$ 1,333.11$ 1,899.68$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 663.02$ 1,127.14$ 1,326.05$ 1,889.62$
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 681.62$ 1,158.76$ 1,363.25$ 1,942.63$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 681.62$ 1,158.76$ 1,363.25$ 1,942.63$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 678.09$ 1,152.76$ 1,356.19$ 1,932.57$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 678.09$ 1,152.76$ 1,356.19$ 1,932.57$
Page 67 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
P PPO 5/15 F NG OHI 85629NY0050012‐00 N N N 1,192.18$ 2,026.71$ 2,384.36$ 3,397.71$
P PPO 5/15 F NG OHI 85629NY0050177‐00 N N Y 1,188.65$ 2,020.71$ 2,377.30$ 3,387.65$
P PPO 5/15 F NG OHI 85629NY0050010‐00 N Y N 1,192.18$ 2,026.71$ 2,384.36$ 3,397.71$
P PPO 5/15 F NG OHI 85629NY0050178‐00 N Y Y 1,188.65$ 2,020.71$ 2,377.30$ 3,387.65$
P PPO 5/15 F NG OHI 85629NY0050011‐00 Y N N 1,207.25$ 2,052.33$ 2,414.50$ 3,440.66$
P PPO 5/15 F NG OHI 85629NY0050009‐00 Y Y N 1,207.25$ 2,052.33$ 2,414.50$ 3,440.66$
P PPO 5/15 F NG OHI 85629NY0050179‐00 Y N Y 1,203.72$ 2,046.33$ 2,407.44$ 3,430.60$
P PPO 5/15 F NG OHI 85629NY0050180‐00 Y Y Y 1,203.72$ 2,046.33$ 2,407.44$ 3,430.60$
P EPO 5/15 F NG OHI 85629NY0010336‐00 N N N 1,120.83$ 1,905.42$ 2,241.67$ 3,194.38$
P EPO 5/15 F NG OHI 85629NY0010213‐00 N N Y 1,117.30$ 1,899.42$ 2,234.61$ 3,184.32$
P EPO 5/15 F NG OHI 85629NY0010341‐00 N Y N 1,120.83$ 1,905.42$ 2,241.67$ 3,194.38$
P EPO 5/15 F NG OHI 85629NY0010214‐00 N Y Y 1,117.30$ 1,899.42$ 2,234.61$ 3,184.32$
P EPO 5/15 F NG OHI 85629NY0010342‐00 Y N N 1,135.90$ 1,931.04$ 2,271.81$ 3,237.33$
P EPO 5/15 F NG OHI 85629NY0010340‐00 Y Y N 1,135.90$ 1,931.04$ 2,271.81$ 3,237.33$
P EPO 5/15 F NG OHI 85629NY0010215‐00 Y N Y 1,132.37$ 1,925.04$ 2,264.75$ 3,227.27$
P EPO 5/15 F NG OHI 85629NY0010216‐00 Y Y Y 1,132.37$ 1,925.04$ 2,264.75$ 3,227.27$
P PPO 20/40 F NG OHI 85629NY0050028‐00 N N N 1,170.91$ 1,990.55$ 2,341.83$ 3,337.10$
P PPO 20/40 F NG OHI 85629NY0050185‐00 N N Y 1,167.38$ 1,984.55$ 2,334.77$ 3,327.04$
P PPO 20/40 F NG OHI 85629NY0050026‐00 N Y N 1,170.91$ 1,990.55$ 2,341.83$ 3,337.10$
P PPO 20/40 F NG OHI 85629NY0050186‐00 N Y Y 1,167.38$ 1,984.55$ 2,334.77$ 3,327.04$
P PPO 20/40 F NG OHI 85629NY0050027‐00 Y N N 1,185.98$ 2,016.17$ 2,371.97$ 3,380.05$
P PPO 20/40 F NG OHI 85629NY0050025‐00 Y Y N 1,185.98$ 2,016.17$ 2,371.97$ 3,380.05$
P PPO 20/40 F NG OHI 85629NY0050187‐00 Y N Y 1,182.45$ 2,010.17$ 2,364.91$ 3,369.99$
P PPO 20/40 F NG OHI 85629NY0050188‐00 Y Y Y 1,182.45$ 2,010.17$ 2,364.91$ 3,369.99$
P EPO 20/40 F NG OHI 85629NY0010036‐00 N N N 1,104.02$ 1,876.84$ 2,208.05$ 3,146.47$
P EPO 20/40 F NG OHI 85629NY0010226‐00 N N Y 1,100.49$ 1,870.84$ 2,200.99$ 3,136.41$
P EPO 20/40 F NG OHI 85629NY0010034‐00 N Y N 1,104.02$ 1,876.84$ 2,208.05$ 3,146.47$
P EPO 20/40 F NG OHI 85629NY0010227‐00 N Y Y 1,100.49$ 1,870.84$ 2,200.99$ 3,136.41$
P EPO 20/40 F NG OHI 85629NY0010035‐00 Y N N 1,119.09$ 1,902.46$ 2,238.19$ 3,189.42$
P EPO 20/40 F NG OHI 85629NY0010033‐00 Y Y N 1,119.09$ 1,902.46$ 2,238.19$ 3,189.42$
P EPO 20/40 F NG OHI 85629NY0010228‐00 Y N Y 1,115.56$ 1,896.46$ 2,231.13$ 3,179.36$
P EPO 20/40 F NG OHI 85629NY0010229‐00 Y Y Y 1,115.56$ 1,896.46$ 2,231.13$ 3,179.36$
G PPO 25/40 F NG OHI 85629NY0050044‐00 N N N 1,019.43$ 1,733.03$ 2,038.86$ 2,905.38$
G PPO 25/40 F NG OHI 85629NY0050193‐00 N N Y 1,015.90$ 1,727.03$ 2,031.80$ 2,895.32$
G PPO 25/40 F NG OHI 85629NY0050042‐00 N Y N 1,019.43$ 1,733.03$ 2,038.86$ 2,905.38$
G PPO 25/40 F NG OHI 85629NY0050194‐00 N Y Y 1,015.90$ 1,727.03$ 2,031.80$ 2,895.32$
G PPO 25/40 F NG OHI 85629NY0050043‐00 Y N N 1,034.50$ 1,758.65$ 2,069.00$ 2,948.33$
G PPO 25/40 F NG OHI 85629NY0050041‐00 Y Y N 1,034.50$ 1,758.65$ 2,069.00$ 2,948.33$
G PPO 25/40 F NG OHI 85629NY0050195‐00 Y N Y 1,030.97$ 1,752.65$ 2,061.94$ 2,938.27$
G PPO 25/40 F NG OHI 85629NY0050196‐00 Y Y Y 1,030.97$ 1,752.65$ 2,061.94$ 2,938.27$
G EPO 25/40 F NG OHI 85629NY0010248‐00 N N N 915.96$ 1,557.13$ 1,831.92$ 2,610.49$
G EPO 25/40 F NG OHI 85629NY0010261‐00 N N Y 912.43$ 1,551.13$ 1,824.86$ 2,600.43$
G EPO 25/40 F NG OHI 85629NY0010246‐00 N Y N 915.96$ 1,557.13$ 1,831.92$ 2,610.49$
G EPO 25/40 F NG OHI 85629NY0010262‐00 N Y Y 912.43$ 1,551.13$ 1,824.86$ 2,600.43$
G EPO 25/40 F NG OHI 85629NY0010247‐00 Y N N 931.03$ 1,582.75$ 1,862.06$ 2,653.44$
G EPO 25/40 F NG OHI 85629NY0010245‐00 Y Y N 931.03$ 1,582.75$ 1,862.06$ 2,653.44$
G EPO 25/40 F NG OHI 85629NY0010263‐00 Y N Y 927.50$ 1,576.75$ 1,855.00$ 2,643.38$
G EPO 25/40 F NG OHI 85629NY0010264‐00 Y Y Y 927.50$ 1,576.75$ 1,855.00$ 2,643.38$
G EPO 15/35 F NG OHI 85629NY0010240‐00 N N N 944.19$ 1,605.12$ 1,888.38$ 2,690.94$
G EPO 15/35 F NG OHI 85629NY0010253‐00 N N Y 940.66$ 1,599.12$ 1,881.32$ 2,680.88$
G EPO 15/35 F NG OHI 85629NY0010238‐00 N Y N 944.19$ 1,605.12$ 1,888.38$ 2,690.94$
G EPO 15/35 F NG OHI 85629NY0010254‐00 N Y Y 940.66$ 1,599.12$ 1,881.32$ 2,680.88$
G EPO 15/35 F NG OHI 85629NY0010239‐00 Y N N 959.26$ 1,630.74$ 1,918.52$ 2,733.89$
G EPO 15/35 F NG OHI 85629NY0010237‐00 Y Y N 959.26$ 1,630.74$ 1,918.52$ 2,733.89$
G EPO 15/35 F NG OHI 85629NY0010255‐00 Y N Y 955.73$ 1,624.74$ 1,911.46$ 2,723.83$
G EPO 15/35 F NG OHI 85629NY0010256‐00 Y Y Y 955.73$ 1,624.74$ 1,911.46$ 2,723.83$
G PPO HSA $1500 F NG OHI 85629NY0050068‐00 N N N 971.17$ 1,650.99$ 1,942.34$ 2,767.83$
G PPO HSA $1500 F NG OHI 85629NY0050001‐00 N N Y 967.64$ 1,644.99$ 1,935.28$ 2,757.77$
G PPO HSA $1500 F NG OHI 85629NY0050066‐00 N Y N 971.17$ 1,650.99$ 1,942.34$ 2,767.83$
G PPO HSA $1500 F NG OHI 85629NY0050002‐00 N Y Y 967.64$ 1,644.99$ 1,935.28$ 2,757.77$
G PPO HSA $1500 F NG OHI 85629NY0050067‐00 Y N N 986.24$ 1,676.61$ 1,972.48$ 2,810.78$
G PPO HSA $1500 F NG OHI 85629NY0050065‐00 Y Y N 986.24$ 1,676.61$ 1,972.48$ 2,810.78$
G PPO HSA $1500 F NG OHI 85629NY0050003‐00 Y N Y 982.71$ 1,670.61$ 1,965.42$ 2,800.72$
G PPO HSA $1500 F NG OHI 85629NY0050004‐00 Y Y Y 982.71$ 1,670.61$ 1,965.42$ 2,800.72$
G EPO HSA $1500 F NG OHI 85629NY0010076‐00 N N N 911.89$ 1,550.22$ 1,823.78$ 2,598.89$
G EPO HSA $1500 F NG OHI 85629NY0010072‐00 N N Y 908.36$ 1,544.22$ 1,816.72$ 2,588.83$
G EPO HSA $1500 F NG OHI 85629NY0010235‐00 N Y N 911.89$ 1,550.22$ 1,823.78$ 2,598.89$
G EPO HSA $1500 F NG OHI 85629NY0010073‐00 N Y Y 908.36$ 1,544.22$ 1,816.72$ 2,588.83$
G EPO HSA $1500 F NG OHI 85629NY0010236‐00 Y N N 926.96$ 1,575.84$ 1,853.92$ 2,641.84$
G EPO HSA $1500 F NG OHI 85629NY0010234‐00 Y Y N 926.96$ 1,575.84$ 1,853.92$ 2,641.84$
G EPO HSA $1500 F NG OHI 85629NY0010074‐00 Y N Y 923.43$ 1,569.84$ 1,846.86$ 2,631.78$
G EPO HSA $1500 F NG OHI 85629NY0010075‐00 Y Y Y 923.43$ 1,569.84$ 1,846.86$ 2,631.78$
G EPO $50 F NG OHI 85629NY0010084‐00 N N N 941.81$ 1,601.08$ 1,883.62$ 2,684.16$
Region 8
Page 68 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 8
G EPO $50 F NG OHI 85629NY0010101‐00 N N Y 938.28$ 1,595.08$ 1,876.56$ 2,674.10$
G EPO $50 F NG OHI 85629NY0010082‐00 N Y N 941.81$ 1,601.08$ 1,883.62$ 2,684.16$
G EPO $50 F NG OHI 85629NY0010102‐00 N Y Y 938.28$ 1,595.08$ 1,876.56$ 2,674.10$
G EPO $50 F NG OHI 85629NY0010083‐00 Y N N 956.88$ 1,626.70$ 1,913.76$ 2,727.11$
G EPO $50 F NG OHI 85629NY0010081‐00 Y Y N 956.88$ 1,626.70$ 1,913.76$ 2,727.11$
G EPO $50 F NG OHI 85629NY0010103‐00 Y N Y 953.35$ 1,620.70$ 1,906.70$ 2,717.05$
G EPO $50 F NG OHI 85629NY0010104‐00 Y Y Y 953.35$ 1,620.70$ 1,906.70$ 2,717.05$
G EPO 30/60 L Gated OHI 85629NY0010429‐00 N N N 882.31$ 1,499.93$ 1,764.62$ 2,514.59$
G EPO 30/60 L Gated OHI 85629NY0010430‐00 N N Y 878.78$ 1,493.93$ 1,757.56$ 2,504.53$
G EPO 30/60 L Gated OHI 85629NY0010431‐00 N Y N 882.31$ 1,499.93$ 1,764.62$ 2,514.59$
G EPO 30/60 L Gated OHI 85629NY0010432‐00 N Y Y 878.78$ 1,493.93$ 1,757.56$ 2,504.53$
G EPO 30/60 L Gated OHI 85629NY0010433‐00 Y N N 897.38$ 1,525.55$ 1,794.76$ 2,557.54$
G EPO 30/60 L Gated OHI 85629NY0010434‐00 Y Y N 897.38$ 1,525.55$ 1,794.76$ 2,557.54$
G EPO 30/60 L Gated OHI 85629NY0010435‐00 Y N Y 893.85$ 1,519.55$ 1,787.70$ 2,547.48$
G EPO 30/60 L Gated OHI 85629NY0010436‐00 Y Y Y 893.85$ 1,519.55$ 1,787.70$ 2,547.48$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050108‐00 N N N 856.06$ 1,455.31$ 1,712.13$ 2,439.78$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050008‐00 N N Y 852.53$ 1,449.31$ 1,705.07$ 2,429.72$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050106‐00 N Y N 856.06$ 1,455.31$ 1,712.13$ 2,439.78$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050018‐00 N Y Y 852.53$ 1,449.31$ 1,705.07$ 2,429.72$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050107‐00 Y N N 871.13$ 1,480.93$ 1,742.27$ 2,482.73$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050105‐00 Y Y N 871.13$ 1,480.93$ 1,742.27$ 2,482.73$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050019‐00 Y N Y 867.60$ 1,474.93$ 1,735.21$ 2,472.67$
S PPO HSA $2000 30/60 F NG OHI 85629NY0050020‐00 Y Y Y 867.60$ 1,474.93$ 1,735.21$ 2,472.67$
S EPO Prim Adv $2000 L NG OHI 85629NY0010116‐00 N N N 729.14$ 1,239.54$ 1,458.28$ 2,078.05$
S EPO Prim Adv $2000 L NG OHI 85629NY0010133‐00 N N Y 725.61$ 1,233.54$ 1,451.22$ 2,067.99$
S EPO Prim Adv $2000 L NG OHI 85629NY0010114‐00 N Y N 729.14$ 1,239.54$ 1,458.28$ 2,078.05$
S EPO Prim Adv $2000 L NG OHI 85629NY0010134‐00 N Y Y 725.61$ 1,233.54$ 1,451.22$ 2,067.99$
S EPO Prim Adv $2000 L NG OHI 85629NY0010115‐00 Y N N 744.21$ 1,265.16$ 1,488.42$ 2,121.00$
S EPO Prim Adv $2000 L NG OHI 85629NY0010113‐00 Y Y N 744.21$ 1,265.16$ 1,488.42$ 2,121.00$
S EPO Prim Adv $2000 L NG OHI 85629NY0010135‐00 Y N Y 740.68$ 1,259.16$ 1,481.36$ 2,110.94$
S EPO Prim Adv $2000 L NG OHI 85629NY0010136‐00 Y Y Y 740.68$ 1,259.16$ 1,481.36$ 2,110.94$
S EPO HSA $2000 F NG OHI 85629NY0010272‐00 N N N 769.64$ 1,308.38$ 1,539.27$ 2,193.46$
S EPO HSA $2000 F NG OHI 85629NY0010277‐00 N N Y 766.11$ 1,302.38$ 1,532.21$ 2,183.40$
S EPO HSA $2000 F NG OHI 85629NY0010270‐00 N Y N 769.64$ 1,308.38$ 1,539.27$ 2,193.46$
S EPO HSA $2000 F NG OHI 85629NY0010278‐00 N Y Y 766.11$ 1,302.38$ 1,532.21$ 2,183.40$
S EPO HSA $2000 F NG OHI 85629NY0010271‐00 Y N N 784.71$ 1,334.00$ 1,569.41$ 2,236.41$
S EPO HSA $2000 F NG OHI 85629NY0010269‐00 Y Y N 784.71$ 1,334.00$ 1,569.41$ 2,236.41$
S EPO HSA $2000 F NG OHI 85629NY0010279‐00 Y N Y 781.18$ 1,328.00$ 1,562.35$ 2,226.35$
S EPO HSA $2000 F NG OHI 85629NY0010280‐00 Y Y Y 781.18$ 1,328.00$ 1,562.35$ 2,226.35$
S PPO 40/70 F NG OHI 85629NY0050132‐00 N N N 855.79$ 1,454.85$ 1,711.58$ 2,439.01$
S PPO 40/70 F NG OHI 85629NY0050033‐00 N N Y 852.26$ 1,448.85$ 1,704.52$ 2,428.95$
S PPO 40/70 F NG OHI 85629NY0050130‐00 N Y N 855.79$ 1,454.85$ 1,711.58$ 2,439.01$
S PPO 40/70 F NG OHI 85629NY0050034‐00 N Y Y 852.26$ 1,448.85$ 1,704.52$ 2,428.95$
S PPO 40/70 F NG OHI 85629NY0050131‐00 Y N N 870.86$ 1,480.47$ 1,741.72$ 2,481.96$
S PPO 40/70 F NG OHI 85629NY0050129‐00 Y Y N 870.86$ 1,480.47$ 1,741.72$ 2,481.96$
S PPO 40/70 F NG OHI 85629NY0050035‐00 Y N Y 867.33$ 1,474.47$ 1,734.66$ 2,471.90$
S PPO 40/70 F NG OHI 85629NY0050036‐00 Y Y Y 867.33$ 1,474.47$ 1,734.66$ 2,471.90$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010288‐00 N N N 791.62$ 1,345.76$ 1,583.24$ 2,256.12$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010296‐00 N N Y 788.09$ 1,339.76$ 1,576.18$ 2,246.06$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010186‐00 N Y N 791.62$ 1,345.76$ 1,583.24$ 2,256.12$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010297‐00 N Y Y 788.09$ 1,339.76$ 1,576.18$ 2,246.06$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010287‐00 Y N N 806.69$ 1,371.38$ 1,613.38$ 2,299.07$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010334‐00 Y Y N 806.69$ 1,371.38$ 1,613.38$ 2,299.07$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010298‐00 Y N Y 803.16$ 1,365.38$ 1,606.32$ 2,289.01$
S EPO HSA $2000 25/50 F NG OHI 85629NY0010299‐00 Y Y Y 803.16$ 1,365.38$ 1,606.32$ 2,289.01$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010140‐00 N N N 756.41$ 1,285.90$ 1,512.82$ 2,155.77$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010181‐00 N N Y 752.88$ 1,279.90$ 1,505.76$ 2,145.71$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010138‐00 N Y N 756.41$ 1,285.90$ 1,512.82$ 2,155.77$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010182‐00 N Y Y 752.88$ 1,279.90$ 1,505.76$ 2,145.71$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010139‐00 Y N N 771.48$ 1,311.52$ 1,542.96$ 2,198.72$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010137‐00 Y Y N 771.48$ 1,311.52$ 1,542.96$ 2,198.72$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010183‐00 Y N Y 767.95$ 1,305.52$ 1,535.90$ 2,188.66$
S EPO HSA $2000 25/50 L NG OHI 85629NY0010184‐00 Y Y Y 767.95$ 1,305.52$ 1,535.90$ 2,188.66$
S EPO 40/70 F NG OHI 85629NY0010300‐00 N N N 797.03$ 1,354.95$ 1,594.06$ 2,271.54$
S EPO 40/70 F NG OHI 85629NY0010312‐00 N N Y 793.50$ 1,348.95$ 1,587.00$ 2,261.48$
S EPO 40/70 F NG OHI 85629NY0010294‐00 N Y N 797.03$ 1,354.95$ 1,594.06$ 2,271.54$
S EPO 40/70 F NG OHI 85629NY0010313‐00 N Y Y 793.50$ 1,348.95$ 1,587.00$ 2,261.48$
S EPO 40/70 F NG OHI 85629NY0010295‐00 Y N N 812.10$ 1,380.57$ 1,624.20$ 2,314.49$
S EPO 40/70 F NG OHI 85629NY0010293‐00 Y Y N 812.10$ 1,380.57$ 1,624.20$ 2,314.49$
S EPO 40/70 F NG OHI 85629NY0010314‐00 Y N Y 808.57$ 1,374.57$ 1,617.14$ 2,304.43$
S EPO 40/70 F NG OHI 85629NY0010315‐00 Y Y Y 808.57$ 1,374.57$ 1,617.14$ 2,304.43$
S EPO 40/70 L NG OHI 85629NY0010437‐00 N N N 761.58$ 1,294.68$ 1,523.15$ 2,170.49$
S EPO 40/70 L NG OHI 85629NY0010438‐00 N N Y 758.05$ 1,288.68$ 1,516.09$ 2,160.43$
S EPO 40/70 L NG OHI 85629NY0010439‐00 N Y N 761.58$ 1,294.68$ 1,523.15$ 2,170.49$
Page 69 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 8
S EPO 40/70 L NG OHI 85629NY0010440‐00 N Y Y 758.05$ 1,288.68$ 1,516.09$ 2,160.43$
S EPO 40/70 L NG OHI 85629NY0010441‐00 Y N N 776.65$ 1,320.30$ 1,553.29$ 2,213.44$
S EPO 40/70 L NG OHI 85629NY0010442‐00 Y Y N 776.65$ 1,320.30$ 1,553.29$ 2,213.44$
S EPO 40/70 L NG OHI 85629NY0010443‐00 Y N Y 773.12$ 1,314.30$ 1,546.23$ 2,203.38$
S EPO 40/70 L NG OHI 85629NY0010444‐00 Y Y Y 773.12$ 1,314.30$ 1,546.23$ 2,203.38$
S EPO 25/50 L Gated OHI 85629NY0010445‐00 N N N 725.88$ 1,233.99$ 1,451.76$ 2,068.75$
S EPO 25/50 L Gated OHI 85629NY0010446‐00 N N Y 722.35$ 1,227.99$ 1,444.70$ 2,058.69$
S EPO 25/50 L Gated OHI 85629NY0010447‐00 N Y N 725.88$ 1,233.99$ 1,451.76$ 2,068.75$
S EPO 25/50 L Gated OHI 85629NY0010448‐00 N Y Y 722.35$ 1,227.99$ 1,444.70$ 2,058.69$
S EPO 25/50 L Gated OHI 85629NY0010449‐00 Y N N 740.95$ 1,259.61$ 1,481.90$ 2,111.70$
S EPO 25/50 L Gated OHI 85629NY0010450‐00 Y Y N 740.95$ 1,259.61$ 1,481.90$ 2,111.70$
S EPO 25/50 L Gated OHI 85629NY0010451‐00 Y N Y 737.42$ 1,253.61$ 1,474.84$ 2,101.64$
S EPO 25/50 L Gated OHI 85629NY0010452‐00 Y Y Y 737.42$ 1,253.61$ 1,474.84$ 2,101.64$
S EPO 30/75 L NG OHI 85629NY0010517‐00 N N N 720.17$ 1,224.29$ 1,440.34$ 2,052.48$
S EPO 30/75 L NG OHI 85629NY0010518‐00 N N Y 716.64$ 1,218.29$ 1,433.28$ 2,042.42$
S EPO 30/75 L NG OHI 85629NY0010519‐00 N Y N 720.17$ 1,224.29$ 1,440.34$ 2,052.48$
S EPO 30/75 L NG OHI 85629NY0010520‐00 N Y Y 716.64$ 1,218.29$ 1,433.28$ 2,042.42$
S EPO 30/75 L NG OHI 85629NY0010521‐00 Y N N 735.24$ 1,249.91$ 1,470.48$ 2,095.43$
S EPO 30/75 L NG OHI 85629NY0010522‐00 Y Y N 735.24$ 1,249.91$ 1,470.48$ 2,095.43$
S EPO 30/75 L NG OHI 85629NY0010523‐00 Y N Y 731.71$ 1,243.91$ 1,463.42$ 2,085.37$
S EPO 30/75 L NG OHI 85629NY0010524‐00 Y Y Y 731.71$ 1,243.91$ 1,463.42$ 2,085.37$
P PPO 20/40 F NG OHI FAIR 85629NY0050233 N N N 1,347.21$ 2,290.25$ 2,694.41$ 3,839.54$
P PPO 20/40 F NG OHI FAIR 85629NY0050234 N N Y 1,343.68$ 2,284.25$ 2,687.35$ 3,829.48$
P PPO 20/40 F NG OHI FAIR 85629NY0050235 N Y N 1,347.21$ 2,290.25$ 2,694.41$ 3,839.54$
P PPO 20/40 F NG OHI FAIR 85629NY0050236 N Y Y 1,343.68$ 2,284.25$ 2,687.35$ 3,829.48$
P PPO 20/40 F NG OHI FAIR 85629NY0050237 Y N N 1,362.28$ 2,315.87$ 2,724.55$ 3,882.49$
P PPO 20/40 F NG OHI FAIR 85629NY0050238 Y Y N 1,362.28$ 2,315.87$ 2,724.55$ 3,882.49$
P PPO 20/40 F NG OHI FAIR 85629NY0050239 Y N Y 1,358.75$ 2,309.87$ 2,717.49$ 3,872.43$
P PPO 20/40 F NG OHI FAIR 85629NY0050240 Y Y Y 1,358.75$ 2,309.87$ 2,717.49$ 3,872.43$
P EPO 15/30 M Gated OHI 85629NY0010453‐00 N N N 909.27$ 1,545.76$ 1,818.54$ 2,591.42$
P EPO 15/30 M Gated OHI 85629NY0010454‐00 N N Y 905.74$ 1,539.76$ 1,811.48$ 2,581.36$
P EPO 15/30 M Gated OHI 85629NY0010455‐00 N Y N 909.27$ 1,545.76$ 1,818.54$ 2,591.42$
P EPO 15/30 M Gated OHI 85629NY0010456‐00 N Y Y 905.74$ 1,539.76$ 1,811.48$ 2,581.36$
P EPO 15/30 M Gated OHI 85629NY0010457‐00 Y N N 924.34$ 1,571.38$ 1,848.68$ 2,634.37$
P EPO 15/30 M Gated OHI 85629NY0010458‐00 Y Y N 924.34$ 1,571.38$ 1,848.68$ 2,634.37$
P EPO 15/30 M Gated OHI 85629NY0010459‐00 Y N Y 920.81$ 1,565.38$ 1,841.62$ 2,624.31$
P EPO 15/30 M Gated OHI 85629NY0010460‐00 Y Y Y 920.81$ 1,565.38$ 1,841.62$ 2,624.31$
P EPO $15/$35 LA G 85629NY0010605‐00 N N N 1,020.82$ 1,735.39$ 2,041.64$ 2,909.34$
P EPO $15/$35 LA G 85629NY0010606‐00 N N Y 1,017.29$ 1,729.39$ 2,034.58$ 2,899.28$
P EPO $15/$35 LA G 85629NY0010607‐00 N Y N 1,020.82$ 1,735.39$ 2,041.64$ 2,909.34$
P EPO $15/$35 LA G 85629NY0010608‐00 N Y Y 1,017.29$ 1,729.39$ 2,034.58$ 2,899.28$
P EPO $15/$35 LA G 85629NY0010609‐00 Y N N 1,035.89$ 1,761.01$ 2,071.78$ 2,952.29$
P EPO $15/$35 LA G 85629NY0010610‐00 Y Y N 1,035.89$ 1,761.01$ 2,071.78$ 2,952.29$
P EPO $15/$35 LA G 85629NY0010611‐00 Y N Y 1,032.36$ 1,755.01$ 2,064.72$ 2,942.23$
P EPO $15/$35 LA G 85629NY0010612‐00 Y Y Y 1,032.36$ 1,755.01$ 2,064.72$ 2,942.23$
G EPO 25/40 M Gated OHI 85629NY0010469‐00 N N N 733.62$ 1,247.15$ 1,467.23$ 2,090.81$
G EPO 25/40 M Gated OHI 85629NY0010470‐00 N N Y 730.09$ 1,241.15$ 1,460.17$ 2,080.75$
G EPO 25/40 M Gated OHI 85629NY0010471‐00 N Y N 733.62$ 1,247.15$ 1,467.23$ 2,090.81$
G EPO 25/40 M Gated OHI 85629NY0010472‐00 N Y Y 730.09$ 1,241.15$ 1,460.17$ 2,080.75$
G EPO 25/40 M Gated OHI 85629NY0010473‐00 Y N N 748.69$ 1,272.77$ 1,497.37$ 2,133.76$
G EPO 25/40 M Gated OHI 85629NY0010474‐00 Y Y N 748.69$ 1,272.77$ 1,497.37$ 2,133.76$
G EPO 25/40 M Gated OHI 85629NY0010475‐00 Y N Y 745.16$ 1,266.77$ 1,490.31$ 2,123.70$
G EPO 25/40 M Gated OHI 85629NY0010476‐00 Y Y Y 745.16$ 1,266.77$ 1,490.31$ 2,123.70$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010477‐00 N N N 648.39$ 1,102.27$ 1,296.79$ 1,847.92$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010478‐00 N N Y 644.86$ 1,096.27$ 1,289.73$ 1,837.86$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010479‐00 N Y N 648.39$ 1,102.27$ 1,296.79$ 1,847.92$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010480‐00 N Y Y 644.86$ 1,096.27$ 1,289.73$ 1,837.86$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010481‐00 Y N N 663.46$ 1,127.89$ 1,326.93$ 1,890.87$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010482‐00 Y Y N 663.46$ 1,127.89$ 1,326.93$ 1,890.87$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010483‐00 Y N Y 659.93$ 1,121.89$ 1,319.87$ 1,880.81$
S EPO Prim Adv $2000 M Gated OHI 85629NY0010484‐00 Y Y Y 659.93$ 1,121.89$ 1,319.87$ 1,880.81$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010485‐00 N N N 660.75$ 1,123.27$ 1,321.49$ 1,883.13$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010486‐00 N N Y 657.22$ 1,117.27$ 1,314.43$ 1,873.07$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010487‐00 N Y N 660.75$ 1,123.27$ 1,321.49$ 1,883.13$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010488‐00 N Y Y 657.22$ 1,117.27$ 1,314.43$ 1,873.07$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010489‐00 Y N N 675.82$ 1,148.89$ 1,351.63$ 1,926.08$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010490‐00 Y Y N 675.82$ 1,148.89$ 1,351.63$ 1,926.08$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010491‐00 Y N Y 672.29$ 1,142.89$ 1,344.57$ 1,916.02$
S EPO HSA $1500 35/50 M Gated OHI 85629NY0010492‐00 Y Y Y 672.29$ 1,142.89$ 1,344.57$ 1,916.02$
S EPO 30/60 M Gated OHI 85629NY0010493‐00 N N N 629.11$ 1,069.48$ 1,258.22$ 1,792.96$
S EPO 30/60 M Gated OHI 85629NY0010494‐00 N N Y 625.58$ 1,063.48$ 1,251.16$ 1,782.90$
S EPO 30/60 M Gated OHI 85629NY0010495‐00 N Y N 629.11$ 1,069.48$ 1,258.22$ 1,792.96$
S EPO 30/60 M Gated OHI 85629NY0010496‐00 N Y Y 625.58$ 1,063.48$ 1,251.16$ 1,782.90$
S EPO 30/60 M Gated OHI 85629NY0010497‐00 Y N N 644.18$ 1,095.10$ 1,288.36$ 1,835.91$
Page 70 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 8
S EPO 30/60 M Gated OHI 85629NY0010498‐00 Y Y N 644.18$ 1,095.10$ 1,288.36$ 1,835.91$
S EPO 30/60 M Gated OHI 85629NY0010499‐00 Y N Y 640.65$ 1,089.10$ 1,281.30$ 1,825.85$
S EPO 30/60 M Gated OHI 85629NY0010500‐00 Y Y Y 640.65$ 1,089.10$ 1,281.30$ 1,825.85$
B EPO HSA $5500 F NG OHI 85629NY0010316‐00 N N N 657.85$ 1,118.35$ 1,315.70$ 1,874.88$
B EPO HSA $5500 F NG OHI 85629NY0010325‐00 N N Y 654.32$ 1,112.35$ 1,308.64$ 1,864.82$
B EPO HSA $5500 F NG OHI 85629NY0010310‐00 N Y N 657.85$ 1,118.35$ 1,315.70$ 1,874.88$
B EPO HSA $5500 F NG OHI 85629NY0010326‐00 N Y Y 654.32$ 1,112.35$ 1,308.64$ 1,864.82$
B EPO HSA $5500 F NG OHI 85629NY0010311‐00 Y N N 672.92$ 1,143.97$ 1,345.84$ 1,917.83$
B EPO HSA $5500 F NG OHI 85629NY0010309‐00 Y Y N 672.92$ 1,143.97$ 1,345.84$ 1,917.83$
B EPO HSA $5500 F NG OHI 85629NY0010327‐00 Y N Y 669.39$ 1,137.97$ 1,338.78$ 1,907.77$
B EPO HSA $5500 F NG OHI 85629NY0010328‐00 Y Y Y 669.39$ 1,137.97$ 1,338.78$ 1,907.77$
B EPO HSA $5500 L NG OHI 85629NY0010156‐00 N N N 628.59$ 1,068.61$ 1,257.19$ 1,791.49$
B EPO HSA $5500 L NG OHI 85629NY0010197‐00 N N Y 625.06$ 1,062.61$ 1,250.13$ 1,781.43$
B EPO HSA $5500 L NG OHI 85629NY0010154‐00 N Y N 628.59$ 1,068.61$ 1,257.19$ 1,791.49$
B EPO HSA $5500 L NG OHI 85629NY0010198‐00 N Y Y 625.06$ 1,062.61$ 1,250.13$ 1,781.43$
B EPO HSA $5500 L NG OHI 85629NY0010155‐00 Y N N 643.66$ 1,094.23$ 1,287.33$ 1,834.44$
B EPO HSA $5500 L NG OHI 85629NY0010153‐00 Y Y N 643.66$ 1,094.23$ 1,287.33$ 1,834.44$
B EPO HSA $5500 L NG OHI 85629NY0010199‐00 Y N Y 640.13$ 1,088.23$ 1,280.27$ 1,824.38$
B EPO HSA $5500 L NG OHI 85629NY0010200‐00 Y Y Y 640.13$ 1,088.23$ 1,280.27$ 1,824.38$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050225 N N N 666.79$ 1,133.54$ 1,333.57$ 1,900.34$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050226 N N Y 663.26$ 1,127.54$ 1,326.51$ 1,890.28$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050227 N Y N 666.79$ 1,133.54$ 1,333.57$ 1,900.34$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050228 N Y Y 663.26$ 1,127.54$ 1,326.51$ 1,890.28$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050229 Y N N 681.86$ 1,159.16$ 1,363.71$ 1,943.29$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050230 Y Y N 681.86$ 1,159.16$ 1,363.71$ 1,943.29$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050231 Y N Y 678.33$ 1,153.16$ 1,356.65$ 1,933.23$
B PPO HSA $6000 30/60 L NG OHI 85629NY0050232 Y Y Y 678.33$ 1,153.16$ 1,356.65$ 1,933.23$
B EPO HSA $5500 M Gated OHI 85629NY0010501‐00 N N N 536.61$ 912.24$ 1,073.22$ 1,529.34$
B EPO HSA $5500 M Gated OHI 85629NY0010502‐00 N N Y 533.08$ 906.24$ 1,066.16$ 1,519.28$
B EPO HSA $5500 M Gated OHI 85629NY0010503‐00 N Y N 536.61$ 912.24$ 1,073.22$ 1,529.34$
B EPO HSA $5500 M Gated OHI 85629NY0010504‐00 N Y Y 533.08$ 906.24$ 1,066.16$ 1,519.28$
B EPO HSA $5500 M Gated OHI 85629NY0010505‐00 Y N N 551.68$ 937.86$ 1,103.36$ 1,572.29$
B EPO HSA $5500 M Gated OHI 85629NY0010506‐00 Y Y N 551.68$ 937.86$ 1,103.36$ 1,572.29$
B EPO HSA $5500 M Gated OHI 85629NY0010507‐00 Y N Y 548.15$ 931.86$ 1,096.30$ 1,562.23$
B EPO HSA $5500 M Gated OHI 85629NY0010508‐00 Y Y Y 548.15$ 931.86$ 1,096.30$ 1,562.23$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010509‐00 N N N 535.35$ 910.09$ 1,070.70$ 1,525.74$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010510‐00 N N Y 531.82$ 904.09$ 1,063.64$ 1,515.68$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010511‐00 N Y N 535.35$ 910.09$ 1,070.70$ 1,525.74$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010512‐00 N Y Y 531.82$ 904.09$ 1,063.64$ 1,515.68$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010513‐00 Y N N 550.42$ 935.71$ 1,100.84$ 1,568.69$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010514‐00 Y Y N 550.42$ 935.71$ 1,100.84$ 1,568.69$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010515‐00 Y N Y 546.89$ 929.71$ 1,093.78$ 1,558.63$
B EPO HSA $5750 40/75 M Gated OHI 85629NY0010516‐00 Y Y Y 546.89$ 929.71$ 1,093.78$ 1,558.63$
G Healthy NY Standard EPO M Gated OHI 85629NY0010581‐00 N N N 650.66$ 1,106.12$ 1,301.31$ 1,854.37$
G Healthy NY Standard EPO M Gated OHI 85629NY0010582‐00 N N Y 647.13$ 1,100.12$ 1,294.25$ 1,844.31$
G Healthy NY Standard EPO M Gated OHI 85629NY0010583‐00 N Y N 650.66$ 1,106.12$ 1,301.31$ 1,854.37$
G Healthy NY Standard EPO M Gated OHI 85629NY0010584‐00 N Y Y 647.13$ 1,100.12$ 1,294.25$ 1,844.31$
G Healthy NY Standard EPO M Gated OHI 85629NY0010585‐00 Y N N 665.73$ 1,131.74$ 1,331.45$ 1,897.32$
G Healthy NY Standard EPO M Gated OHI 85629NY0010586‐00 Y Y N 665.73$ 1,131.74$ 1,331.45$ 1,897.32$
G Healthy NY Standard EPO M Gated OHI 85629NY0010587‐00 Y N Y 662.20$ 1,125.74$ 1,324.39$ 1,887.26$
G Healthy NY Standard EPO M Gated OHI 85629NY0010588‐00 Y Y Y 662.20$ 1,125.74$ 1,324.39$ 1,887.26$
B EPO HSA $6550 100% M Gated OHI 85629NY0010597‐00 N N N 529.47$ 900.10$ 1,058.95$ 1,509.00$
B EPO HSA $6550 100% M Gated OHI 85629NY0010598‐00 N N Y 525.94$ 894.10$ 1,051.89$ 1,498.94$
B EPO HSA $6550 100% M Gated OHI 85629NY0010599‐00 N Y N 529.47$ 900.10$ 1,058.95$ 1,509.00$
B EPO HSA $6550 100% M Gated OHI 85629NY0010600‐00 N Y Y 525.94$ 894.10$ 1,051.89$ 1,498.94$
B EPO HSA $6550 100% M Gated OHI 85629NY0010601‐00 Y N N 544.54$ 925.72$ 1,089.09$ 1,551.95$
B EPO HSA $6550 100% M Gated OHI 85629NY0010602‐00 Y Y N 544.54$ 925.72$ 1,089.09$ 1,551.95$
B EPO HSA $6550 100% M Gated OHI 85629NY0010603‐00 Y N Y 541.01$ 919.72$ 1,082.03$ 1,541.89$
B EPO HSA $6550 100% M Gated OHI 85629NY0010604‐00 Y Y Y 541.01$ 919.72$ 1,082.03$ 1,541.89$
S EPO 30/60 ME NG OHI 85629NY0010565‐00 N N N 670.39$ 1,139.66$ 1,340.78$ 1,910.61$
S EPO 30/60 ME NG OHI 85629NY0010566‐00 N N Y 666.86$ 1,133.66$ 1,333.72$ 1,900.55$
S EPO 30/60 ME NG OHI 85629NY0010567‐00 N Y N 670.39$ 1,139.66$ 1,340.78$ 1,910.61$
S EPO 30/60 ME NG OHI 85629NY0010568‐00 N Y Y 666.86$ 1,133.66$ 1,333.72$ 1,900.55$
S EPO 30/60 ME NG OHI 85629NY0010569‐00 Y N N 685.46$ 1,165.28$ 1,370.92$ 1,953.56$
S EPO 30/60 ME NG OHI 85629NY0010570‐00 Y Y N 685.46$ 1,165.28$ 1,370.92$ 1,953.56$
S EPO 30/60 ME NG OHI 85629NY0010571‐00 Y N Y 681.93$ 1,159.28$ 1,363.86$ 1,943.50$
S EPO 30/60 ME NG OHI 85629NY0010572‐00 Y Y Y 681.93$ 1,159.28$ 1,363.86$ 1,943.50$
G EPO 25/40 ME NG OHI 85629NY0010573‐00 N N N 776.42$ 1,319.92$ 1,552.85$ 2,212.81$
G EPO 25/40 ME NG OHI 85629NY0010574‐00 N N Y 772.89$ 1,313.92$ 1,545.79$ 2,202.75$
G EPO 25/40 ME NG OHI 85629NY0010575‐00 N Y N 776.42$ 1,319.92$ 1,552.85$ 2,212.81$
G EPO 25/40 ME NG OHI 85629NY0010576‐00 N Y Y 772.89$ 1,313.92$ 1,545.79$ 2,202.75$
G EPO 25/40 ME NG OHI 85629NY0010577‐00 Y N N 791.49$ 1,345.54$ 1,582.99$ 2,255.76$
G EPO 25/40 ME NG OHI 85629NY0010578‐00 Y Y N 791.49$ 1,345.54$ 1,582.99$ 2,255.76$
G EPO 25/40 ME NG OHI 85629NY0010579‐00 Y N Y 787.96$ 1,339.54$ 1,575.93$ 2,245.70$
Page 71 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Base Medical and Prescription Drug Monthly Rates 2018 Q4
Plan 16‐digit HIOS ID Dep 29 Rider
Domestic
Partner Rider
Contraceptive
Exclusion Rider Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Spouse +
Child(ren)
Rate
Region 8
G EPO 25/40 ME NG OHI 85629NY0010580‐00 Y Y Y 787.96$ 1,339.54$ 1,575.93$ 2,245.70$
B EPO HSA $6550 100% L NG OHI 85629NY0010557‐00 N N N 620.62$ 1,055.05$ 1,241.24$ 1,768.77$
B EPO HSA $6550 100% L NG OHI 85629NY0010558‐00 N N Y 617.09$ 1,049.05$ 1,234.18$ 1,758.71$
B EPO HSA $6550 100% L NG OHI 85629NY0010559‐00 N Y N 620.62$ 1,055.05$ 1,241.24$ 1,768.77$
B EPO HSA $6550 100% L NG OHI 85629NY0010560‐00 N Y Y 617.09$ 1,049.05$ 1,234.18$ 1,758.71$
B EPO HSA $6550 100% L NG OHI 85629NY0010561‐00 Y N N 635.69$ 1,080.67$ 1,271.38$ 1,811.72$
B EPO HSA $6550 100% L NG OHI 85629NY0010562‐00 Y Y N 635.69$ 1,080.67$ 1,271.38$ 1,811.72$
B EPO HSA $6550 100% L NG OHI 85629NY0010563‐00 Y N Y 632.16$ 1,074.67$ 1,264.32$ 1,801.66$
B EPO HSA $6550 100% L NG OHI 85629NY0010564‐00 Y Y Y 632.16$ 1,074.67$ 1,264.32$ 1,801.66$
G EPO $25/$45 $1,500D LA G 85629NY0010613‐00 N N N 840.06$ 1,428.10$ 1,680.12$ 2,394.17$
G EPO $25/$45 $1,500D LA G 85629NY0010614‐00 N N Y 836.53$ 1,422.10$ 1,673.06$ 2,384.11$
G EPO $25/$45 $1,500D LA G 85629NY0010615‐00 N Y N 840.06$ 1,428.10$ 1,680.12$ 2,394.17$
G EPO $25/$45 $1,500D LA G 85629NY0010616‐00 N Y Y 836.53$ 1,422.10$ 1,673.06$ 2,384.11$
G EPO $25/$45 $1,500D LA G 85629NY0010617‐00 Y N N 855.13$ 1,453.72$ 1,710.26$ 2,437.12$
G EPO $25/$45 $1,500D LA G 85629NY0010618‐00 Y Y N 855.13$ 1,453.72$ 1,710.26$ 2,437.12$
G EPO $25/$45 $1,500D LA G 85629NY0010619‐00 Y N Y 851.60$ 1,447.72$ 1,703.20$ 2,427.06$
G EPO $25/$45 $1,500D LA G 85629NY0010620‐00 Y Y Y 851.60$ 1,447.72$ 1,703.20$ 2,427.06$
S EPO $30/$70 $4,000D LA G 85629NY0010621‐00 N N N 697.75$ 1,186.17$ 1,395.49$ 1,988.57$
S EPO $30/$70 $4,000D LA G 85629NY0010622‐00 N N Y 694.22$ 1,180.17$ 1,388.43$ 1,978.51$
S EPO $30/$70 $4,000D LA G 85629NY0010623‐00 N Y N 697.75$ 1,186.17$ 1,395.49$ 1,988.57$
S EPO $30/$70 $4,000D LA G 85629NY0010624‐00 N Y Y 694.22$ 1,180.17$ 1,388.43$ 1,978.51$
S EPO $30/$70 $4,000D LA G 85629NY0010625‐00 Y N N 712.82$ 1,211.79$ 1,425.63$ 2,031.52$
S EPO $30/$70 $4,000D LA G 85629NY0010626‐00 Y Y N 712.82$ 1,211.79$ 1,425.63$ 2,031.52$
S EPO $30/$70 $4,000D LA G 85629NY0010627‐00 Y N Y 709.29$ 1,205.79$ 1,418.57$ 2,021.46$
S EPO $30/$70 $4,000D LA G 85629NY0010628‐00 Y Y Y 709.29$ 1,205.79$ 1,418.57$ 2,021.46$
B EPO HSA $3,000 25/75 L NG 85629NY0010629‐00 N N N 663.81$ 1,128.47$ 1,327.61$ 1,891.84$
B EPO HSA $3,000 25/75 L NG 85629NY0010630‐00 N N Y 660.28$ 1,122.47$ 1,320.55$ 1,881.78$
B EPO HSA $3,000 25/75 L NG 85629NY0010631‐00 N Y N 663.81$ 1,128.47$ 1,327.61$ 1,891.84$
B EPO HSA $3,000 25/75 L NG 85629NY0010632‐00 N Y Y 660.28$ 1,122.47$ 1,320.55$ 1,881.78$
B EPO HSA $3,000 25/75 L NG 85629NY0010633‐00 Y N N 678.88$ 1,154.09$ 1,357.75$ 1,934.79$
B EPO HSA $3,000 25/75 L NG 85629NY0010634‐00 Y Y N 678.88$ 1,154.09$ 1,357.75$ 1,934.79$
B EPO HSA $3,000 25/75 L NG 85629NY0010635‐00 Y N Y 675.35$ 1,148.09$ 1,350.69$ 1,924.73$
B EPO HSA $3,000 25/75 L NG 85629NY0010636‐00 Y Y Y 675.35$ 1,148.09$ 1,350.69$ 1,924.73$
P EPO 10/30 F NG 85629NY0010637‐00 N N N 1,069.05$ 1,817.38$ 2,138.09$ 3,046.78$
P EPO 10/30 F NG 85629NY0010638‐00 N N Y 1,065.52$ 1,811.38$ 2,131.03$ 3,036.72$
P EPO 10/30 F NG 85629NY0010639‐00 N Y N 1,069.05$ 1,817.38$ 2,138.09$ 3,046.78$
P EPO 10/30 F NG 85629NY0010640‐00 N Y Y 1,065.52$ 1,811.38$ 2,131.03$ 3,036.72$
P EPO 10/30 F NG 85629NY0010641‐00 Y N N 1,084.12$ 1,843.00$ 2,168.23$ 3,089.73$
P EPO 10/30 F NG 85629NY0010642‐00 Y Y N 1,084.12$ 1,843.00$ 2,168.23$ 3,089.73$
P EPO 10/30 F NG 85629NY0010643‐00 Y N Y 1,080.59$ 1,837.00$ 2,161.17$ 3,079.67$
P EPO 10/30 F NG 85629NY0010644‐00 Y Y Y 1,080.59$ 1,837.00$ 2,161.17$ 3,079.67$
G EPO 30/60 F NG 85629NY0010645‐00 N N N 864.99$ 1,470.48$ 1,729.98$ 2,465.22$
G EPO 30/60 F NG 85629NY0010646‐00 N N Y 861.46$ 1,464.48$ 1,722.92$ 2,455.16$
G EPO 30/60 F NG 85629NY0010647‐00 N Y N 864.99$ 1,470.48$ 1,729.98$ 2,465.22$
G EPO 30/60 F NG 85629NY0010648‐00 N Y Y 861.46$ 1,464.48$ 1,722.92$ 2,455.16$
G EPO 30/60 F NG 85629NY0010649‐00 Y N N 880.06$ 1,496.10$ 1,760.12$ 2,508.17$
G EPO 30/60 F NG 85629NY0010650‐00 Y Y N 880.06$ 1,496.10$ 1,760.12$ 2,508.17$
G EPO 30/60 F NG 85629NY0010651‐00 Y N Y 876.53$ 1,490.10$ 1,753.06$ 2,498.11$
G EPO 30/60 F NG 85629NY0010652‐00 Y Y Y 876.53$ 1,490.10$ 1,753.06$ 2,498.11$
G EPO 30/60 L NG 85629NY0010653‐00 N N N 826.52$ 1,405.09$ 1,653.05$ 2,355.59$
G EPO 30/60 L NG 85629NY0010654‐00 N N Y 822.99$ 1,399.09$ 1,645.99$ 2,345.53$
G EPO 30/60 L NG 85629NY0010655‐00 N Y N 826.52$ 1,405.09$ 1,653.05$ 2,355.59$
G EPO 30/60 L NG 85629NY0010656‐00 N Y Y 822.99$ 1,399.09$ 1,645.99$ 2,345.53$
G EPO 30/60 L NG 85629NY0010657‐00 Y N N 841.59$ 1,430.71$ 1,683.19$ 2,398.54$
G EPO 30/60 L NG 85629NY0010658‐00 Y Y N 841.59$ 1,430.71$ 1,683.19$ 2,398.54$
G EPO 30/60 L NG 85629NY0010659‐00 Y N Y 838.06$ 1,424.71$ 1,676.13$ 2,388.48$
G EPO 30/60 L NG 85629NY0010660‐00 Y Y Y 838.06$ 1,424.71$ 1,676.13$ 2,388.48$
G PPO 30/60 F NG 85629NY0050017‐00 N N N 924.50$ 1,571.64$ 1,848.99$ 2,634.82$
G PPO 30/60 F NG 85629NY0050058‐00 N N Y 920.97$ 1,565.64$ 1,841.93$ 2,624.76$
G PPO 30/60 F NG 85629NY0050059‐00 N Y N 924.50$ 1,571.64$ 1,848.99$ 2,634.82$
G PPO 30/60 F NG 85629NY0050060‐00 N Y Y 920.97$ 1,565.64$ 1,841.93$ 2,624.76$
G PPO 30/60 F NG 85629NY0050061‐00 Y N N 939.57$ 1,597.26$ 1,879.13$ 2,677.77$
G PPO 30/60 F NG 85629NY0050062‐00 Y Y N 939.57$ 1,597.26$ 1,879.13$ 2,677.77$
G PPO 30/60 F NG 85629NY0050063‐00 Y N Y 936.04$ 1,591.26$ 1,872.07$ 2,667.71$
G PPO 30/60 F NG 85629NY0050064‐00 Y Y Y 936.04$ 1,591.26$ 1,872.07$ 2,667.71$
S EPO Prim Adv $4,000D L G 85629NY0010661‐00 N N N 666.55$ 1,133.14$ 1,333.11$ 1,899.68$
S EPO Prim Adv $4,000D L G 85629NY0010662‐00 N N Y 663.02$ 1,127.14$ 1,326.05$ 1,889.62$
S EPO Prim Adv $4,000D L G 85629NY0010663‐00 N Y N 666.55$ 1,133.14$ 1,333.11$ 1,899.68$
S EPO Prim Adv $4,000D L G 85629NY0010664‐00 N Y Y 663.02$ 1,127.14$ 1,326.05$ 1,889.62$
S EPO Prim Adv $4,000D L G 85629NY0010665‐00 Y N N 681.62$ 1,158.76$ 1,363.25$ 1,942.63$
S EPO Prim Adv $4,000D L G 85629NY0010666‐00 Y Y N 681.62$ 1,158.76$ 1,363.25$ 1,942.63$
S EPO Prim Adv $4,000D L G 85629NY0010667‐00 Y N Y 678.09$ 1,152.76$ 1,356.19$ 1,932.57$
S EPO Prim Adv $4,000D L G 85629NY0010668‐00 Y Y Y 678.09$ 1,152.76$ 1,356.19$ 1,932.57$
Page 72 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Ancillary Coverage Rider Monthly Rates
2018
Effective Quarter Single Rate
Single +
Child(ren)
Rate
Single +
Spouse Rate
Single +
Spouse +
Child(ren)
Rate
Domestic Partner Q1 ‐$ ‐$ ‐$ ‐$
Q2 ‐$ ‐$ ‐$ ‐$
Q3 ‐$ ‐$ ‐$ ‐$
Q4 ‐$ ‐$ ‐$ ‐$
Dependent Cut‐off Age 29 Q1 15.50$ 26.35$ 31.00$ 44.18$
Q2 15.86$ 26.96$ 31.72$ 45.20$
Q3 16.22$ 27.57$ 32.44$ 46.23$
Q4 16.60$ 28.22$ 33.20$ 47.31$
Remove Family Planning Q1 (3.63)$ (6.17)$ (7.26)$ (10.35)$
Q2 (3.72)$ (6.32)$ (7.44)$ (10.60)$
Q3 (3.80)$ (6.46)$ (7.60)$ (10.83)$
Q4 (3.89)$ (6.61)$ (7.78)$ (11.09)$
Region 3
Page 73 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Medical and Rx Drug Benefits
INN = In‐Network, OON = Out‐of‐network, Ded = Deductible, Coin = Coinsurance, MOOP = Maximum Out‐of‐pocket inc. Deductible,
STD = Subject to Deductible, IP = Inpatient, OP = Outpatient, D&C = Subject to Ded and Coin.
The key to the Prescription Drug plans is on a following page.
Plan Name
P PPO 5/15 F NG OHI
P EPO 5/15 F NG OHI
P PPO 20/40 F NG OHI
P EPO 20/40 F NG OHI
G PPO 25/40 F NG OHI
G EPO 25/40 F NG OHI
G EPO 15/35 F NG OHI
G PPO HSA $1500 F NG OHI
G EPO HSA $1500 F NG OHI
G EPO $50 F NG OHI
Metal Platinum Platinum Platinum Platinum Gold Gold Gold Gold Gold Gold
Preventive 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
INN Ded $0 $0 $0 $0 $1,000 $1,250 $1,000 $1,500 $1,500 $750
INN Coin 0% 0% 0% 0% 20% 20% 10% 10% 10% 10%
INN MOOP $2,500 $2,500 $2,500 $2,500 $4,500 $5,000 $4,000 $4,000 $4,000 $4,000
OON Ded $2,000 $0 $3,000 $0 $3,000 $0 $0 $3,000 $0 $0
OON Coin 30% 0% 30% 0% 40% 0% 0% 40% 0% 0%
OON MOOP $5,000 $0 $7,500 $0 $7,500 $0 $0 $7,500 $0 $0
Family Ded 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
Family MOOP 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
PCP Copay $5 $5 $20 $20 $25 $25 $15 D&C D&C $50
PCP STD? N N N N N N N N N N
Spec Copay $15 $15 $40 $40 $40 $40 $35 D&C D&C $50
Spec STD? N N N N N N N N N N
ER Copay $200 $200 $200 $200 $400 $400 $400 D&C D&C $300
ER STD? N N N N N N N N N N
INN OP Surg Copay ‐ ASC $50 $50 $100 $100 $150 $150 $150 D&C D&C $150
INN OP Surg ‐ ASC STD? N N N N Y Y Y N N Y
INN OP Surg Copay ‐ Hospital $100 $100 $300 $300 $250 $250 $300 D&C D&C $250
INN OP Surg ‐ Hospital STD? N N N N Y Y Y N N Y
INN IP Copay $200 $200 $400 $400 D&C D&C D&C D&C D&C $250
INN IP STD? N N N N N N N N N Y
INN IP Copay Max n/a n/a n/a n/a n/a n/a n/a n/a n/a $2,500
IP Copay per Admit / Day Admit Admit Admit Admit n/a n/a n/a n/a n/a Day
PCP Gated? N N N N N N N N N N
Network Freedom Freedom Freedom Freedom Freedom Freedom Freedom Freedom Freedom Freedom
Prescription Drugs AF AF AF AF T V V J J T
Page 74 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Medical and Rx Drug Benefits
Plan NameMetalPreventiveINN DedINN CoinINN MOOPOON DedOON CoinOON MOOPFamily DedFamily MOOPPCP CopayPCP STD?Spec CopaySpec STD?ER CopayER STD?INN OP Surg Copay ‐ ASCINN OP Surg ‐ ASC STD?INN OP Surg Copay ‐ HospitalINN OP Surg ‐ Hospital STD?INN IP CopayINN IP STD?INN IP Copay MaxIP Copay per Admit / DayPCP Gated?NetworkPrescription Drugs
G EPO 30/60 L Gated OHI
S PPO HSA $2000 30/60 F NG OHI
S EPO Prim Adv $2000 L NG OHI
S EPO HSA $2000 F NG OHI
S PPO 40/70 F NG OHI
S EPO HSA $2000 25/50 F NG OHI
S EPO HSA $2000 25/50 L NG OHI
S EPO 40/70 F NG OHI
S EPO 40/70 L NG OHI
S EPO 25/50 L Gated OHI
Gold Silver Silver Silver Silver Silver Silver Silver Silver Silver
100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
$1,000 $2,000 $2,000 $2,000 $2,500 $2,000 $2,000 $2,500 $2,500 $3,000
0% 20% 30% 30% 30% 20% 20% 30% 30% 50%
$4,000 $5,500 $6,000 $6,550 $7,150 $5,500 $5,500 $7,150 $7,150 $7,150
$0 $4,000 $0 $0 $4,000 $0 $0 $0 $0 $0
0% 50% 0% 0% 50% 0% 0% 0% 0% 0%
$0 $10,000 $0 $0 $10,000 $0 $0 $0 $0 $0
2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
$30 $30 $25 D&C $40 $25 $25 $40 $40 $25
N Y N N N Y Y N N N
$60 $60 $50 D&C $70 $50 $50 $70 $70 $50
N Y Y N N Y Y N N N
$300 D&C D&C D&C $700 $250 $250 $700 $700 $700
N N N N N Y Y N N N
$150 $150 $150 D&C D&C $150 $150 D&C D&C D&C
Y Y Y N N Y Y N N N
$250 $250 $250 D&C D&C $250 $250 D&C D&C D&C
Y Y Y N N Y Y N N N
$500 D&C $250 D&C D&C D&C D&C D&C D&C D&C
Y N Y N N N N N N N
$2,000 n/a $1,250 n/a n/a n/a n/a n/a n/a n/a
Day n/a Day n/a n/a n/a n/a n/a n/a n/a
Y N N N N N N N N Y
Liberty Freedom Liberty Freedom Freedom Freedom Liberty Freedom Liberty Liberty
V M AH M AE M M AE AE X
Page 75 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Medical and Rx Drug Benefits
Plan NameMetalPreventiveINN DedINN CoinINN MOOPOON DedOON CoinOON MOOPFamily DedFamily MOOPPCP CopayPCP STD?Spec CopaySpec STD?ER CopayER STD?INN OP Surg Copay ‐ ASCINN OP Surg ‐ ASC STD?INN OP Surg Copay ‐ HospitalINN OP Surg ‐ Hospital STD?INN IP CopayINN IP STD?INN IP Copay MaxIP Copay per Admit / DayPCP Gated?NetworkPrescription Drugs
S EPO 30/75 L NG OHI
P PPO 20/40 F NG OHI FAIR
P EPO 15/30 M Gated OHI
P EPO $15/$35 LA G
G EPO 25/40 M Gated OHI
S EPO Prim Adv $2000 M Gated
OHI
S EPO HSA $1500 35/50 M Gated
OHI
S EPO 30/60 M Gated OHI
B EPO HSA $5500 F NG OHI
B EPO HSA $5500 L NG OHI
Silver Platinum Platinum Platinum Gold Silver Silver Silver Bronze Bronze
100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
$3,000 $0 $0 $250 $1,250 $2,000 $1,500 $3,000 $5,500 $5,500
40% 0% 0% 10% 20% 30% 30% 30% 30% 30%
$7,150 $2,500 $2,500 $3,000 $5,500 $6,500 $6,550 $7,150 $6,550 $6,550
$0 $3,000 $0 $0 $0 $0 $0 $0 $0 $0
0% 20% 0% 0% 0% 0% 0% 0% 0% 0%
$0 $7,500 $0 $0 $0 $0 $0 $0 $0 $0
2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
$30 $20 $15 $15 $25 $30 $35 $30 D&C D&C
N N N N N N Y N N N
$75 $40 $30 $35 $40 $60 $50 $60 D&C D&C
N N N N N Y Y N N N
$500 $200 $200 D&C $500 $500 $500 D&C D&C D&C
Y N N N N Y Y N N N
D&C $100 $100 D&C $200 $300 $300 D&C D&C D&C
N N N N Y Y Y N N N
D&C $300 $500 D&C $500 $750 $750 D&C D&C D&C
N N N N Y Y Y N N N
D&C $400 $200 D&C D&C $400 D&C D&C D&C D&C
N N N N N Y N N N N
n/a n/a $800 n/a n/a $1,600 n/a n/a n/a n/a
n/a Admit Day n/a n/a Day n/a n/a n/a n/a
N N Y Y Y Y Y Y N N
Liberty Freedom Metro Liberty Metro Metro Metro Metro Freedom Liberty
Y AF E AC C AG L C K K
Page 76 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Medical and Rx Drug Benefits
Plan NameMetalPreventiveINN DedINN CoinINN MOOPOON DedOON CoinOON MOOPFamily DedFamily MOOPPCP CopayPCP STD?Spec CopaySpec STD?ER CopayER STD?INN OP Surg Copay ‐ ASCINN OP Surg ‐ ASC STD?INN OP Surg Copay ‐ HospitalINN OP Surg ‐ Hospital STD?INN IP CopayINN IP STD?INN IP Copay MaxIP Copay per Admit / DayPCP Gated?NetworkPrescription Drugs
B PPO HSA $6000 30/60 L NG OHI
B EPO HSA $5500 M Gated OHI
B EPO HSA $5750 40/75 M Gated
OHI
G Healthy NY Standard EPO M
Gated OHI
B EPO HSA $6550 100% M Gated
OHI
S EPO 30/60 ME NG OHI
G EPO 25/40 ME NG OHI
B EPO HSA $6550 100% L
NG OHI
G EPO $25/$45
$1,500D LA G
S EPO $30/$70 $4,000D LA G
Bronze Bronze Bronze Gold Bronze Silver Gold Bronze Gold Silver
100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
$6,000 $5,500 $5,750 $600 $6,550 $2,500 $1,250 $6,550 $1,500 $4,000
20% 30% 50% 20% 0% 30% 20% 0% 20% 40%
$6,550 $6,550 $6,550 $4,000 $6,550 $7,150 $5,000 $6,550 $6,000 $7,350
$10,000 $0 $0 $0 $0 $0 $0 $0 $0 $0
20% 0% 0% 0% 0% 0% 0% 0% 0% 0%
$25,000 $0 $0 $0 $0 $0 $0 $0 $0 $0
2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
$30 D&C $40 $25 D&C $30 $25 D&C $25 $30
Y N Y Y N N N N N N
$60 D&C $75 $40 D&C $60 $40 D&C $45 $70
Y N Y Y N N N N N N
D&C D&C $500 $150 D&C D&C $400 D&C D&C D&C
N N Y Y N N N N N N
D&C D&C $500 $100 D&C D&C $200 D&C D&C D&C
N N Y Y N N Y N N N
D&C D&C $1,000 $100 D&C D&C $500 D&C D&C D&C
N N Y Y N N Y N N N
D&C D&C D&C $1,000 D&C D&C D&C D&C D&C D&C
N N N Y N N N N N N
n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a
n/a n/a n/a Admit n/a n/a n/a n/a n/a n/a
N Y Y Y Y N N N Y Y
Liberty Metro Metro Metro Metro Metro Metro Liberty Liberty Liberty
M L L B O U U O AD AB
Page 77 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Medical and Rx Drug Benefits
Plan NameMetalPreventiveINN DedINN CoinINN MOOPOON DedOON CoinOON MOOPFamily DedFamily MOOPPCP CopayPCP STD?Spec CopaySpec STD?ER CopayER STD?INN OP Surg Copay ‐ ASCINN OP Surg ‐ ASC STD?INN OP Surg Copay ‐ HospitalINN OP Surg ‐ Hospital STD?INN IP CopayINN IP STD?INN IP Copay MaxIP Copay per Admit / DayPCP Gated?NetworkPrescription Drugs
B EPO HSA $3,000 25/75 L
NG
P EPO 10/30 F NG
G EPO 30/60 F NG
G EPO 30/60 L NG
G PPO 30/60 F NG
S EPO Prim Adv $4,000D L
G
Bronze Platinum Gold Gold Gold Silver
100% 100% 100% 100% 100% 100%
$3,000 $500 $2,000 $2,000 $2,000 $4,000
30% 10% 30% 30% 30% 30%
$6,550 $3,000 $6,850 $6,850 $6,850 $7,350
$0 $0 $0 $0 $4,000 $0
0% 0% 0% 0% 50% 0%
$0 $0 $0 $0 $10,000 $0
2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
2x Single 2x Single 2x Single 2x Single 2x Single 2x Single
$25 $10 $30 $30 $30 $20
Y N N N N N
$75 $30 $60 $60 $60 $60
Y N N N N Y
D&C $200 $500 $500 $500 $500
N N N N N Y
D&C $150 D&C D&C D&C $250
N Y N N N Y
D&C $300 D&C D&C D&C $750
N Y N N N Y
D&C D&C D&C D&C D&C $500
N N N N N Y
n/a n/a n/a n/a n/a $2,000
n/a n/a n/a n/a n/a Day
N N N N N Y
Liberty Freedom Freedom Liberty Freedom Liberty
P AF W W W AG
Page 78 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Prescription Drug Benefit Key
Format is [Generic]/[Brand Formulary]/[Brand Non‐Formulary].
Letter Code Prescription Drug Plan
A $10/$30/$60
B $10/$35/$70
C $10/$65/50%, max $800
D $15/$35/$75
E $5/$65/50%, max $800
F $6/$15/$30
G $9/$20/$40
H Ded Med/Rx then $10/$35/$60
I Ded Med/Rx then $10/$35/$70
J Ded Med/Rx then $10/$35/$75
K Ded Med/Rx then $10/$40/$80
L Ded Med/Rx then $10/$65/50%, max $800
M Ded Med/Rx then $15/$35/$75
N Ded Med/Rx then $20/$40/$80
O Ded Med/Rx then 0%/0%/0%
P Ded Med/Rx then 30%/30%/30%
Q Ded Med/Rx then 50%/50%/50%
R Non‐T1 Ded $100 then $10/$30/$60
S Non‐T1 Ded $100 then $10/$35/$60
T Non‐T1 Ded $100 then $10/$35/$75
U Non‐T1 Ded $100 then $10/$65/$90
V Non‐T1 Ded $100 then $15/$35/$75
W Non‐T1 Ded $100 then $15/$45/$75
X Non‐T1 Ded $100 then $15/$65/$85
Y Non‐T1 Ded $100 then $15/$65/50%, max $800
Z Non‐T1 Ded $100 then $5/$30/$50
AA Non‐T1 Ded $100 then $5/$30/$60
AB Non‐T1 Ded $150 then $15/$50/$90
AC Non‐T1 Ded $150 then $5/$30/$60
AD Non‐T1 Ded $150 then $5/$45/$75
AE Non‐T1 Ded $200 then $15/$45/$75
AF Non‐T1 Ded $50 then $5/$30/$60
AG Non‐T1 Ded Med/Rx then $10/$65/50%, max $800
AH Non‐T1 Ded Med/Rx then $15/$35/$75
Page 79 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Pediatric Dental and Vision Benefits
Benefit Category NY Commercial SG ‐ Oxford
EHB ‐ Prev & Diagnostic ‐Ped Dental (for
children)
* 100% after Med Ded for
traditional plans
* HMO Plans are subject to
Copay
Ped Dental Ded (Applies to ‐ Basic Dental Svcs,
Major Dental Svcs, Orthodontia, or any
combination)
Basic, Major, Preventive &
Diagnostic, Orthodontia
INN Ped Dental Single Ded * $100 if copay
* Ded if D&C
* No ded for HMO
INN Ped Dental Family Ded * $200 if copay
* Ded if D&C
* No ded for HMO
EHB ‐ Basic Dental Svcs (e.g.
Fillings/extractions) for Children
80% after Med or Den Ded
EHB ‐ Major Dental Svcs (e.g. Crowns) for
Children
50% after Med or Den Ded
EHB ‐ Orthodontia (e.g. braces) for Children 50% after Med or Den Ded
Ped Vision Ded ($/N/A/Inc in Med) * N/A if copay/non‐HSA plan
* Ded if HSA
Ped Vision Ded (Applies to ‐ Routine Vision
Exam, Vision Materials, or both)
* No services fall under ded
for non‐HSA plans
* Vision materials for HSA
EHB ‐ Routine Vision Exam for Children * Lesser of PCP copay or $30
for non‐HSA. Does not apply
to ded but does apply to
OOPM
* 100% for HSA (treated like
prev svc) and applies to
OOPMEHB ‐ Prev Lens copay for Children * 50% for copay
* 50% after Ded for HSA
EHB ‐ Prev Frames Tier 1 for Children * 50% for copay
* 50% after Ded for HSA
EHB ‐ Prev Frames Tier 2 for Children * 50% for copay
* 50% after Ded for HSA
EHB ‐ Prev Frames Tier 3 for Children * 50% for copay
* 50% after Ded for HSA
EHB ‐ Prev Frames Tier 4 for Children * 50% for copay
* 50% after Ded for HSA
EHB ‐ Prev Frames Tier 5 for Children * 50% for copay
* 50% after Ded for HSA
EHB ‐ Prev Contacts for Children * 50% for copay
* 50% after Ded for HSA
Page 80 of 81
Oxford Health Insurance, Inc.
New York Small Group
Off‐Exchange
Form # OHINY_SG_COC_2018
Additional Notes
Estimated Commissions as a percent of premium: 3.75%
Expected Requested Loss Ratio (Claims / Premium): 82.0%
To determine the premium rate for a plan design, first look up the rate for that plan design,
demographic tier, area, and effective quarter. Then add the rate for any riders, for the
demographic tier, area, and effective quarter. The total is the final rate.
Sample Calculation of Monthly Rates2018 Q1: Region 4 P EPO 5/15 F NG OHI
Domestic Partner, Dependent Age Cut‐off 29, and Women's Contraceptive riders
Tier:
Medical + Rx
Rate
Domestic
Partner Rider
Dependent
Cut‐off Age 29
Remove
Family
Planning Total Rate
Single Rate 1,046.84$ ‐$ 14.08$ (3.30)$ 1,057.62$
Single + Child(ren) Rate 1,779.62$ ‐$ 23.94$ (5.61)$ 1,797.95$
Single + Spouse Rate 2,093.67$ ‐$ 28.16$ (6.60)$ 2,115.23$
+ Spouse + Child(ren) Rate 2,983.48$ ‐$ 40.13$ (9.41)$ 3,014.20$
Page 81 of 81