Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Federal Rate Template Revised Previous State Filing Number:BCNP-130071709Percent Rate Change Request:9.5

RatesTablesTempalte_v6_PID OFFERFINAL.pdf,RatesTablesTempalte_v6_PID OFFERFINAL.xls,

2 PID Plan Design Summary andRate Tables

Revised Previous State Filing Number:BCNP-130071709Percent Rate Change Request:9.5

PID Rate Page - FPLICSG ACA - 1-1-17 PIDOffer FINAL REMOVESHOP.pdf, PID RatePage - FPLIC SG ACA- 1-1-17 PID OfferFINAL REMOVESHOP.xlsx,

SERFF Tracking #: HGHM-130536975 State Tracking #: HGHM-130536975 Company Tracking #:

State: Pennsylvania Filing Company: First Priority Life Insurance Compnay

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

Product Name: FPLIC Small Group Rates 2017

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number HGHM-130536975 Generated 10/14/2016 09:46 AM

Attachment RatesTablesTempalte_v6_PID OFFER FINAL.xls is not a PDF document and cannot bereproduced here.

Attachment PID Rate Page - FPLIC SG ACA - 1-1-17 PID Offer FINAL REMOVE SHOP.xlsx is not a PDFdocument and cannot be reproduced here.

SERFF Tracking #: HGHM-130536975 State Tracking #: HGHM-130536975 Company Tracking #:

State: Pennsylvania Filing Company: First Priority Life Insurance Compnay

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

Product Name: FPLIC Small Group Rates 2017

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number HGHM-130536975 Generated 10/14/2016 09:46 AM

2017 Rates Table Template v6.0 All fields with an asterisk ( * ) are required. To validate press Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells B1 through B5.If you are a community rating state, select Family Option under Age and fill in all columns.

If you are not community rating state, select 0-20 under Age and provide an Individual Rate for every age band.

If Tobacco is Tobacco User/Non-Tobacco User, you must give a rate for Tobacco Use and Non-Tobacco Use.

To add a new sheet, press the Add Sheet button, or Ctrl + Shift + H. All plans must have the same dates on a sheet.

HIOS Issuer ID* 55957

Federal TIN* 23-2905083

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

Plan ID* Rating Area ID* Tobacco* Age* Individual Rate*

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a plan

Required:

Select the age of a subscriber eligible for the rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

55957PA0270007 Rating Area 3 No Preference 0-20 276.32

55957PA0270007 Rating Area 3 No Preference 21 435.16

55957PA0270007 Rating Area 3 No Preference 22 435.16

55957PA0270007 Rating Area 3 No Preference 23 435.16

55957PA0270007 Rating Area 3 No Preference 24 435.16

55957PA0270007 Rating Area 3 No Preference 25 436.90

55957PA0270007 Rating Area 3 No Preference 26 445.60

55957PA0270007 Rating Area 3 No Preference 27 456.04

55957PA0270007 Rating Area 3 No Preference 28 473.01

55957PA0270007 Rating Area 3 No Preference 29 486.94

55957PA0270007 Rating Area 3 No Preference 30 493.90

55957PA0270007 Rating Area 3 No Preference 31 504.35

55957PA0270007 Rating Area 3 No Preference 32 514.79

55957PA0270007 Rating Area 3 No Preference 33 521.32

55957PA0270007 Rating Area 3 No Preference 34 528.28

55957PA0270007 Rating Area 3 No Preference 35 531.76

55957PA0270007 Rating Area 3 No Preference 36 535.24

55957PA0270007 Rating Area 3 No Preference 37 538.72

55957PA0270007 Rating Area 3 No Preference 38 542.20

55957PA0270007 Rating Area 3 No Preference 39 549.17

55957PA0270007 Rating Area 3 No Preference 40 556.13

55957PA0270007 Rating Area 3 No Preference 41 566.57

55957PA0270007 Rating Area 3 No Preference 42 576.58

55957PA0270007 Rating Area 3 No Preference 43 590.51

55957PA0270007 Rating Area 3 No Preference 44 607.91

55957PA0270007 Rating Area 3 No Preference 45 628.37

55957PA0270007 Rating Area 3 No Preference 46 652.74

55957PA0270007 Rating Area 3 No Preference 47 680.15

55957PA0270007 Rating Area 3 No Preference 48 711.48

55957PA0270007 Rating Area 3 No Preference 49 742.38

55957PA0270007 Rating Area 3 No Preference 50 777.19

55957PA0270007 Rating Area 3 No Preference 51 811.57

55957PA0270007 Rating Area 3 No Preference 52 849.43

55957PA0270007 Rating Area 3 No Preference 53 887.72

55957PA0270007 Rating Area 3 No Preference 54 929.06

55957PA0270007 Rating Area 3 No Preference 55 970.40

55957PA0270007 Rating Area 3 No Preference 56 1015.22

55957PA0270007 Rating Area 3 No Preference 57 1060.48

55957PA0270007 Rating Area 3 No Preference 58 1108.78

55957PA0270007 Rating Area 3 No Preference 59 1132.72

55957PA0270007 Rating Area 3 No Preference 60 1181.02

55957PA0270007 Rating Area 3 No Preference 61 1222.79

55957PA0270007 Rating Area 3 No Preference 62 1250.21

55957PA0270007 Rating Area 3 No Preference 63 1284.59

55957PA0270007 Rating Area 3 No Preference 64 1305.48

55957PA0270007 Rating Area 3 No Preference 65 and over 1305.48

55957PA0270016 Rating Area 3 No Preference 0-20 278.19

55957PA0270016 Rating Area 3 No Preference 21 438.11

55957PA0270016 Rating Area 3 No Preference 22 438.11

55957PA0270016 Rating Area 3 No Preference 23 438.11

55957PA0270016 Rating Area 3 No Preference 24 438.11

55957PA0270016 Rating Area 3 No Preference 25 439.86

55957PA0270016 Rating Area 3 No Preference 26 448.62

55957PA0270016 Rating Area 3 No Preference 27 459.13

55957PA0270016 Rating Area 3 No Preference 28 476.22

55957PA0270016 Rating Area 3 No Preference 29 490.24

55957PA0270016 Rating Area 3 No Preference 30 497.25

55957PA0270016 Rating Area 3 No Preference 31 507.76

55957PA0270016 Rating Area 3 No Preference 32 518.28

55957PA0270016 Rating Area 3 No Preference 33 524.85

55957PA0270016 Rating Area 3 No Preference 34 531.86

55957PA0270016 Rating Area 3 No Preference 35 535.37

55957PA0270016 Rating Area 3 No Preference 36 538.87

55957PA0270016 Rating Area 3 No Preference 37 542.38

55957PA0270016 Rating Area 3 No Preference 38 545.88

55957PA0270016 Rating Area 3 No Preference 39 552.89

55957PA0270016 Rating Area 3 No Preference 40 559.90

55957PA0270016 Rating Area 3 No Preference 41 570.41

55957PA0270016 Rating Area 3 No Preference 42 580.49

55957PA0270016 Rating Area 3 No Preference 43 594.51

55957PA0270016 Rating Area 3 No Preference 44 612.03

55957PA0270016 Rating Area 3 No Preference 45 632.63

55957PA0270016 Rating Area 3 No Preference 46 657.16

55957PA0270016 Rating Area 3 No Preference 47 684.76

55957PA0270016 Rating Area 3 No Preference 48 716.30

55957PA0270016 Rating Area 3 No Preference 49 747.41

55957PA0270016 Rating Area 3 No Preference 50 782.46

55957PA0270016 Rating Area 3 No Preference 51 817.07

55957PA0270016 Rating Area 3 No Preference 52 855.19

55957PA0270016 Rating Area 3 No Preference 53 893.74

55957PA0270016 Rating Area 3 No Preference 54 935.36

55957PA0270016 Rating Area 3 No Preference 55 976.98

55957PA0270016 Rating Area 3 No Preference 56 1022.11

55957PA0270016 Rating Area 3 No Preference 57 1067.67

55957PA0270016 Rating Area 3 No Preference 58 1116.30

55957PA0270016 Rating Area 3 No Preference 59 1140.40

55957PA0270016 Rating Area 3 No Preference 60 1189.03

55957PA0270016 Rating Area 3 No Preference 61 1231.08

55957PA0270016 Rating Area 3 No Preference 62 1258.69

55957PA0270016 Rating Area 3 No Preference 63 1293.30

55957PA0270016 Rating Area 3 No Preference 64 1314.33

55957PA0270016 Rating Area 3 No Preference 65 and over 1314.33

55957PA0270002 Rating Area 3 No Preference 0-20 276.49

55957PA0270002 Rating Area 3 No Preference 21 435.42

55957PA0270002 Rating Area 3 No Preference 22 435.42

55957PA0270002 Rating Area 3 No Preference 23 435.42

55957PA0270002 Rating Area 3 No Preference 24 435.42

55957PA0270002 Rating Area 3 No Preference 25 437.16

55957PA0270002 Rating Area 3 No Preference 26 445.87

55957PA0270002 Rating Area 3 No Preference 27 456.32

55957PA0270002 Rating Area 3 No Preference 28 473.30

55957PA0270002 Rating Area 3 No Preference 29 487.23

55957PA0270002 Rating Area 3 No Preference 30 494.20

55957PA0270002 Rating Area 3 No Preference 31 504.65

55957PA0270002 Rating Area 3 No Preference 32 515.10

55957PA0270002 Rating Area 3 No Preference 33 521.63

55957PA0270002 Rating Area 3 No Preference 34 528.59

55957PA0270002 Rating Area 3 No Preference 35 532.08

55957PA0270002 Rating Area 3 No Preference 36 535.56

55957PA0270002 Rating Area 3 No Preference 37 539.04

55957PA0270002 Rating Area 3 No Preference 38 542.53

55957PA0270002 Rating Area 3 No Preference 39 549.50

55957PA0270002 Rating Area 3 No Preference 40 556.46

55957PA0270002 Rating Area 3 No Preference 41 566.91

55957PA0270002 Rating Area 3 No Preference 42 576.93

55957PA0270002 Rating Area 3 No Preference 43 590.86

55957PA0270002 Rating Area 3 No Preference 44 608.28

55957PA0270002 Rating Area 3 No Preference 45 628.74

55957PA0270002 Rating Area 3 No Preference 46 653.13

55957PA0270002 Rating Area 3 No Preference 47 680.56

55957PA0270002 Rating Area 3 No Preference 48 711.91

55957PA0270002 Rating Area 3 No Preference 49 742.82

55957PA0270002 Rating Area 3 No Preference 50 777.66

55957PA0270002 Rating Area 3 No Preference 51 812.05

55957PA0270002 Rating Area 3 No Preference 52 849.93

55957PA0270002 Rating Area 3 No Preference 53 888.25

55957PA0270002 Rating Area 3 No Preference 54 929.62

55957PA0270002 Rating Area 3 No Preference 55 970.98

55957PA0270002 Rating Area 3 No Preference 56 1015.83

55957PA0270002 Rating Area 3 No Preference 57 1061.11

55957PA0270002 Rating Area 3 No Preference 58 1109.45

55957PA0270002 Rating Area 3 No Preference 59 1133.39

55957PA0270002 Rating Area 3 No Preference 60 1181.72

55957PA0270002 Rating Area 3 No Preference 61 1223.53

55957PA0270002 Rating Area 3 No Preference 62 1250.96

55957PA0270002 Rating Area 3 No Preference 63 1285.35

55957PA0270002 Rating Area 3 No Preference 64 1306.26

55957PA0270002 Rating Area 3 No Preference 65 and over 1306.26

55957PA0270006 Rating Area 3 No Preference 0-20 273.32

55957PA0270006 Rating Area 3 No Preference 21 430.43

55957PA0270006 Rating Area 3 No Preference 22 430.43

55957PA0270006 Rating Area 3 No Preference 23 430.43

55957PA0270006 Rating Area 3 No Preference 24 430.43

55957PA0270006 Rating Area 3 No Preference 25 432.15

55957PA0270006 Rating Area 3 No Preference 26 440.76

55957PA0270006 Rating Area 3 No Preference 27 451.09

55957PA0270006 Rating Area 3 No Preference 28 467.87

55957PA0270006 Rating Area 3 No Preference 29 481.65

55957PA0270006 Rating Area 3 No Preference 30 488.53

55957PA0270006 Rating Area 3 No Preference 31 498.86

55957PA0270006 Rating Area 3 No Preference 32 509.19

55957PA0270006 Rating Area 3 No Preference 33 515.65

55957PA0270006 Rating Area 3 No Preference 34 522.54

55957PA0270006 Rating Area 3 No Preference 35 525.98

55957PA0270006 Rating Area 3 No Preference 36 529.42

55957PA0270006 Rating Area 3 No Preference 37 532.87

55957PA0270006 Rating Area 3 No Preference 38 536.31

55957PA0270006 Rating Area 3 No Preference 39 543.20

55957PA0270006 Rating Area 3 No Preference 40 550.08

55957PA0270006 Rating Area 3 No Preference 41 560.41

55957PA0270006 Rating Area 3 No Preference 42 570.31

55957PA0270006 Rating Area 3 No Preference 43 584.09

55957PA0270006 Rating Area 3 No Preference 44 601.31

55957PA0270006 Rating Area 3 No Preference 45 621.54

55957PA0270006 Rating Area 3 No Preference 46 645.64

55957PA0270006 Rating Area 3 No Preference 47 672.76

55957PA0270006 Rating Area 3 No Preference 48 703.75

55957PA0270006 Rating Area 3 No Preference 49 734.31

55957PA0270006 Rating Area 3 No Preference 50 768.74

55957PA0270006 Rating Area 3 No Preference 51 802.75

55957PA0270006 Rating Area 3 No Preference 52 840.19

55957PA0270006 Rating Area 3 No Preference 53 878.07

55957PA0270006 Rating Area 3 No Preference 54 918.96

55957PA0270006 Rating Area 3 No Preference 55 959.85

55957PA0270006 Rating Area 3 No Preference 56 1004.19

55957PA0270006 Rating Area 3 No Preference 57 1048.95

55957PA0270006 Rating Area 3 No Preference 58 1096.73

55957PA0270006 Rating Area 3 No Preference 59 1120.40

55957PA0270006 Rating Area 3 No Preference 60 1168.18

55957PA0270006 Rating Area 3 No Preference 61 1209.50

55957PA0270006 Rating Area 3 No Preference 62 1236.62

55957PA0270006 Rating Area 3 No Preference 63 1270.62

55957PA0270006 Rating Area 3 No Preference 64 1291.29

55957PA0270006 Rating Area 3 No Preference 65 and over 1291.29

55957PA0270017 Rating Area 3 No Preference 0-20 249.89

55957PA0270017 Rating Area 3 No Preference 21 393.54

55957PA0270017 Rating Area 3 No Preference 22 393.54

55957PA0270017 Rating Area 3 No Preference 23 393.54

55957PA0270017 Rating Area 3 No Preference 24 393.54

55957PA0270017 Rating Area 3 No Preference 25 395.11

55957PA0270017 Rating Area 3 No Preference 26 402.98

55957PA0270017 Rating Area 3 No Preference 27 412.42

55957PA0270017 Rating Area 3 No Preference 28 427.77

55957PA0270017 Rating Area 3 No Preference 29 440.37

55957PA0270017 Rating Area 3 No Preference 30 446.66

55957PA0270017 Rating Area 3 No Preference 31 456.11

55957PA0270017 Rating Area 3 No Preference 32 465.55

55957PA0270017 Rating Area 3 No Preference 33 471.46

55957PA0270017 Rating Area 3 No Preference 34 477.75

55957PA0270017 Rating Area 3 No Preference 35 480.90

55957PA0270017 Rating Area 3 No Preference 36 484.05

55957PA0270017 Rating Area 3 No Preference 37 487.20

55957PA0270017 Rating Area 3 No Preference 38 490.35

55957PA0270017 Rating Area 3 No Preference 39 496.64

55957PA0270017 Rating Area 3 No Preference 40 502.94

55957PA0270017 Rating Area 3 No Preference 41 512.38

55957PA0270017 Rating Area 3 No Preference 42 521.44

55957PA0270017 Rating Area 3 No Preference 43 534.03

55957PA0270017 Rating Area 3 No Preference 44 549.77

55957PA0270017 Rating Area 3 No Preference 45 568.27

55957PA0270017 Rating Area 3 No Preference 46 590.31

55957PA0270017 Rating Area 3 No Preference 47 615.10

55957PA0270017 Rating Area 3 No Preference 48 643.43

55957PA0270017 Rating Area 3 No Preference 49 671.37

55957PA0270017 Rating Area 3 No Preference 50 702.86

55957PA0270017 Rating Area 3 No Preference 51 733.95

55957PA0270017 Rating Area 3 No Preference 52 768.19

55957PA0270017 Rating Area 3 No Preference 53 802.82

55957PA0270017 Rating Area 3 No Preference 54 840.20

55957PA0270017 Rating Area 3 No Preference 55 877.59

55957PA0270017 Rating Area 3 No Preference 56 918.12

55957PA0270017 Rating Area 3 No Preference 57 959.05

55957PA0270017 Rating Area 3 No Preference 58 1002.73

55957PA0270017 Rating Area 3 No Preference 59 1024.38

55957PA0270017 Rating Area 3 No Preference 60 1068.06

55957PA0270017 Rating Area 3 No Preference 61 1105.84

55957PA0270017 Rating Area 3 No Preference 62 1130.64

55957PA0270017 Rating Area 3 No Preference 63 1161.73

55957PA0270017 Rating Area 3 No Preference 64 1180.62

55957PA0270017 Rating Area 3 No Preference 65 and over 1180.62

55957PA0270018 Rating Area 3 No Preference 0-20 230.09

55957PA0270018 Rating Area 3 No Preference 21 362.36

55957PA0270018 Rating Area 3 No Preference 22 362.36

55957PA0270018 Rating Area 3 No Preference 23 362.36

55957PA0270018 Rating Area 3 No Preference 24 362.36

55957PA0270018 Rating Area 3 No Preference 25 363.80

55957PA0270018 Rating Area 3 No Preference 26 371.05

55957PA0270018 Rating Area 3 No Preference 27 379.75

55957PA0270018 Rating Area 3 No Preference 28 393.88

55957PA0270018 Rating Area 3 No Preference 29 405.48

55957PA0270018 Rating Area 3 No Preference 30 411.27

55957PA0270018 Rating Area 3 No Preference 31 419.97

55957PA0270018 Rating Area 3 No Preference 32 428.67

55957PA0270018 Rating Area 3 No Preference 33 434.10

55957PA0270018 Rating Area 3 No Preference 34 439.90

55957PA0270018 Rating Area 3 No Preference 35 442.80

55957PA0270018 Rating Area 3 No Preference 36 445.70

55957PA0270018 Rating Area 3 No Preference 37 448.60

55957PA0270018 Rating Area 3 No Preference 38 451.50

55957PA0270018 Rating Area 3 No Preference 39 457.29

55957PA0270018 Rating Area 3 No Preference 40 463.09

55957PA0270018 Rating Area 3 No Preference 41 471.79

55957PA0270018 Rating Area 3 No Preference 42 480.12

55957PA0270018 Rating Area 3 No Preference 43 491.72

55957PA0270018 Rating Area 3 No Preference 44 506.21

55957PA0270018 Rating Area 3 No Preference 45 523.24

55957PA0270018 Rating Area 3 No Preference 46 543.54

55957PA0270018 Rating Area 3 No Preference 47 566.36

55957PA0270018 Rating Area 3 No Preference 48 592.45

55957PA0270018 Rating Area 3 No Preference 49 618.18

55957PA0270018 Rating Area 3 No Preference 50 647.17

55957PA0270018 Rating Area 3 No Preference 51 675.80

55957PA0270018 Rating Area 3 No Preference 52 707.32

55957PA0270018 Rating Area 3 No Preference 53 739.21

55957PA0270018 Rating Area 3 No Preference 54 773.63

55957PA0270018 Rating Area 3 No Preference 55 808.06

55957PA0270018 Rating Area 3 No Preference 56 845.38

55957PA0270018 Rating Area 3 No Preference 57 883.07

55957PA0270018 Rating Area 3 No Preference 58 923.29

55957PA0270018 Rating Area 3 No Preference 59 943.22

55957PA0270018 Rating Area 3 No Preference 60 983.44

55957PA0270018 Rating Area 3 No Preference 61 1018.23

55957PA0270018 Rating Area 3 No Preference 62 1041.06

55957PA0270018 Rating Area 3 No Preference 63 1069.68

55957PA0270018 Rating Area 3 No Preference 64 1087.08

55957PA0270018 Rating Area 3 No Preference 65 and over 1087.08

55957PA0270008 Rating Area 3 No Preference 0-20 233.97

55957PA0270008 Rating Area 3 No Preference 21 368.47

55957PA0270008 Rating Area 3 No Preference 22 368.47

55957PA0270008 Rating Area 3 No Preference 23 368.47

55957PA0270008 Rating Area 3 No Preference 24 368.47

55957PA0270008 Rating Area 3 No Preference 25 369.94

55957PA0270008 Rating Area 3 No Preference 26 377.31

55957PA0270008 Rating Area 3 No Preference 27 386.15

55957PA0270008 Rating Area 3 No Preference 28 400.52

55957PA0270008 Rating Area 3 No Preference 29 412.31

55957PA0270008 Rating Area 3 No Preference 30 418.21

55957PA0270008 Rating Area 3 No Preference 31 427.05

55957PA0270008 Rating Area 3 No Preference 32 435.90

55957PA0270008 Rating Area 3 No Preference 33 441.42

55957PA0270008 Rating Area 3 No Preference 34 447.32

55957PA0270008 Rating Area 3 No Preference 35 450.27

55957PA0270008 Rating Area 3 No Preference 36 453.21

55957PA0270008 Rating Area 3 No Preference 37 456.16

55957PA0270008 Rating Area 3 No Preference 38 459.11

55957PA0270008 Rating Area 3 No Preference 39 465.00

55957PA0270008 Rating Area 3 No Preference 40 470.90

55957PA0270008 Rating Area 3 No Preference 41 479.74

55957PA0270008 Rating Area 3 No Preference 42 488.22

55957PA0270008 Rating Area 3 No Preference 43 500.01

55957PA0270008 Rating Area 3 No Preference 44 514.75

55957PA0270008 Rating Area 3 No Preference 45 532.07

55957PA0270008 Rating Area 3 No Preference 46 552.70

55957PA0270008 Rating Area 3 No Preference 47 575.91

55957PA0270008 Rating Area 3 No Preference 48 602.44

55957PA0270008 Rating Area 3 No Preference 49 628.60

55957PA0270008 Rating Area 3 No Preference 50 658.08

55957PA0270008 Rating Area 3 No Preference 51 687.19

55957PA0270008 Rating Area 3 No Preference 52 719.25

55957PA0270008 Rating Area 3 No Preference 53 751.67

55957PA0270008 Rating Area 3 No Preference 54 786.68

55957PA0270008 Rating Area 3 No Preference 55 821.68

55957PA0270008 Rating Area 3 No Preference 56 859.64

55957PA0270008 Rating Area 3 No Preference 57 897.96

55957PA0270008 Rating Area 3 No Preference 58 938.86

55957PA0270008 Rating Area 3 No Preference 59 959.12

55957PA0270008 Rating Area 3 No Preference 60 1000.02

55957PA0270008 Rating Area 3 No Preference 61 1035.40

55957PA0270008 Rating Area 3 No Preference 62 1058.61

55957PA0270008 Rating Area 3 No Preference 63 1087.72

55957PA0270008 Rating Area 3 No Preference 64 1105.41

55957PA0270008 Rating Area 3 No Preference 65 and over 1105.41

55957PA0270009 Rating Area 3 No Preference 0-20 234.20

55957PA0270009 Rating Area 3 No Preference 21 368.82

55957PA0270009 Rating Area 3 No Preference 22 368.82

55957PA0270009 Rating Area 3 No Preference 23 368.82

55957PA0270009 Rating Area 3 No Preference 24 368.82

55957PA0270009 Rating Area 3 No Preference 25 370.29

55957PA0270009 Rating Area 3 No Preference 26 377.67

55957PA0270009 Rating Area 3 No Preference 27 386.52

55957PA0270009 Rating Area 3 No Preference 28 400.90

55957PA0270009 Rating Area 3 No Preference 29 412.70

55957PA0270009 Rating Area 3 No Preference 30 418.61

55957PA0270009 Rating Area 3 No Preference 31 427.46

55957PA0270009 Rating Area 3 No Preference 32 436.31

55957PA0270009 Rating Area 3 No Preference 33 441.84

55957PA0270009 Rating Area 3 No Preference 34 447.74

55957PA0270009 Rating Area 3 No Preference 35 450.69

55957PA0270009 Rating Area 3 No Preference 36 453.64

55957PA0270009 Rating Area 3 No Preference 37 456.59

55957PA0270009 Rating Area 3 No Preference 38 459.54

55957PA0270009 Rating Area 3 No Preference 39 465.45

55957PA0270009 Rating Area 3 No Preference 40 471.35

55957PA0270009 Rating Area 3 No Preference 41 480.20

55957PA0270009 Rating Area 3 No Preference 42 488.68

55957PA0270009 Rating Area 3 No Preference 43 500.48

55957PA0270009 Rating Area 3 No Preference 44 515.24

55957PA0270009 Rating Area 3 No Preference 45 532.57

55957PA0270009 Rating Area 3 No Preference 46 553.23

55957PA0270009 Rating Area 3 No Preference 47 576.46

55957PA0270009 Rating Area 3 No Preference 48 603.02

55957PA0270009 Rating Area 3 No Preference 49 629.20

55957PA0270009 Rating Area 3 No Preference 50 658.71

55957PA0270009 Rating Area 3 No Preference 51 687.84

55957PA0270009 Rating Area 3 No Preference 52 719.93

55957PA0270009 Rating Area 3 No Preference 53 752.39

55957PA0270009 Rating Area 3 No Preference 54 787.43

55957PA0270009 Rating Area 3 No Preference 55 822.46

55957PA0270009 Rating Area 3 No Preference 56 860.45

55957PA0270009 Rating Area 3 No Preference 57 898.81

55957PA0270009 Rating Area 3 No Preference 58 939.75

55957PA0270009 Rating Area 3 No Preference 59 960.03

55957PA0270009 Rating Area 3 No Preference 60 1000.97

55957PA0270009 Rating Area 3 No Preference 61 1036.38

55957PA0270009 Rating Area 3 No Preference 62 1059.61

55957PA0270009 Rating Area 3 No Preference 63 1088.75

55957PA0270009 Rating Area 3 No Preference 64 1106.46

55957PA0270009 Rating Area 3 No Preference 65 and over 1106.46

55957PA0270010 Rating Area 3 No Preference 0-20 238.13

55957PA0270010 Rating Area 3 No Preference 21 375.02

55957PA0270010 Rating Area 3 No Preference 22 375.02

55957PA0270010 Rating Area 3 No Preference 23 375.02

55957PA0270010 Rating Area 3 No Preference 24 375.02

55957PA0270010 Rating Area 3 No Preference 25 376.52

55957PA0270010 Rating Area 3 No Preference 26 384.02

55957PA0270010 Rating Area 3 No Preference 27 393.02

55957PA0270010 Rating Area 3 No Preference 28 407.64

55957PA0270010 Rating Area 3 No Preference 29 419.64

55957PA0270010 Rating Area 3 No Preference 30 425.64

55957PA0270010 Rating Area 3 No Preference 31 434.64

55957PA0270010 Rating Area 3 No Preference 32 443.64

55957PA0270010 Rating Area 3 No Preference 33 449.27

55957PA0270010 Rating Area 3 No Preference 34 455.27

55957PA0270010 Rating Area 3 No Preference 35 458.27

55957PA0270010 Rating Area 3 No Preference 36 461.27

55957PA0270010 Rating Area 3 No Preference 37 464.27

55957PA0270010 Rating Area 3 No Preference 38 467.27

55957PA0270010 Rating Area 3 No Preference 39 473.27

55957PA0270010 Rating Area 3 No Preference 40 479.27

55957PA0270010 Rating Area 3 No Preference 41 488.27

55957PA0270010 Rating Area 3 No Preference 42 496.90

55957PA0270010 Rating Area 3 No Preference 43 508.90

55957PA0270010 Rating Area 3 No Preference 44 523.90

55957PA0270010 Rating Area 3 No Preference 45 541.52

55957PA0270010 Rating Area 3 No Preference 46 562.53

55957PA0270010 Rating Area 3 No Preference 47 586.15

55957PA0270010 Rating Area 3 No Preference 48 613.15

55957PA0270010 Rating Area 3 No Preference 49 639.78

55957PA0270010 Rating Area 3 No Preference 50 669.78

55957PA0270010 Rating Area 3 No Preference 51 699.41

55957PA0270010 Rating Area 3 No Preference 52 732.03

55957PA0270010 Rating Area 3 No Preference 53 765.04

55957PA0270010 Rating Area 3 No Preference 54 800.66

55957PA0270010 Rating Area 3 No Preference 55 836.29

55957PA0270010 Rating Area 3 No Preference 56 874.92

55957PA0270010 Rating Area 3 No Preference 57 913.92

55957PA0270010 Rating Area 3 No Preference 58 955.55

55957PA0270010 Rating Area 3 No Preference 59 976.17

55957PA0270010 Rating Area 3 No Preference 60 1017.80

55957PA0270010 Rating Area 3 No Preference 61 1053.80

55957PA0270010 Rating Area 3 No Preference 62 1077.43

55957PA0270010 Rating Area 3 No Preference 63 1107.05

55957PA0270010 Rating Area 3 No Preference 64 1125.06

55957PA0270010 Rating Area 3 No Preference 65 and over 1125.06

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55957PA0270013 Rating Area 3 No Preference 65 and over 747.42

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55957PA0290007 Rating Area 3 No Preference 21 365.54

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55957PA0290007 Rating Area 3 No Preference 65 and over 1096.62

55957PA0290008 Rating Area 3 No Preference 0-20 233.68

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55957PA0290008 Rating Area 3 No Preference 63 1086.36

55957PA0290008 Rating Area 3 No Preference 64 1104.03

55957PA0290008 Rating Area 3 No Preference 65 and over 1104.03

55957PA0290002 Rating Area 3 No Preference 0-20 232.25

55957PA0290002 Rating Area 3 No Preference 21 365.75

55957PA0290002 Rating Area 3 No Preference 22 365.75

55957PA0290002 Rating Area 3 No Preference 23 365.75

55957PA0290002 Rating Area 3 No Preference 24 365.75

55957PA0290002 Rating Area 3 No Preference 25 367.21

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55957PA0290002 Rating Area 3 No Preference 28 397.57

55957PA0290002 Rating Area 3 No Preference 29 409.27

55957PA0290002 Rating Area 3 No Preference 30 415.12

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55957PA0290002 Rating Area 3 No Preference 65 and over 1097.25

55957PA0290006 Rating Area 3 No Preference 0-20 229.59

55957PA0290006 Rating Area 3 No Preference 21 361.56

55957PA0290006 Rating Area 3 No Preference 22 361.56

55957PA0290006 Rating Area 3 No Preference 23 361.56

55957PA0290006 Rating Area 3 No Preference 24 361.56

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55957PA0290006 Rating Area 3 No Preference 28 393.01

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55957PA0290006 Rating Area 3 No Preference 64 1084.68

55957PA0290006 Rating Area 3 No Preference 65 and over 1084.68

55957PA0290022 Rating Area 3 No Preference 0-20 209.91

55957PA0290022 Rating Area 3 No Preference 21 330.57

55957PA0290022 Rating Area 3 No Preference 22 330.57

55957PA0290022 Rating Area 3 No Preference 23 330.57

55957PA0290022 Rating Area 3 No Preference 24 330.57

55957PA0290022 Rating Area 3 No Preference 25 331.89

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55957PA0290022 Rating Area 3 No Preference 27 346.43

55957PA0290022 Rating Area 3 No Preference 28 359.32

55957PA0290022 Rating Area 3 No Preference 29 369.90

55957PA0290022 Rating Area 3 No Preference 30 375.19

55957PA0290022 Rating Area 3 No Preference 31 383.13

55957PA0290022 Rating Area 3 No Preference 32 391.06

55957PA0290022 Rating Area 3 No Preference 33 396.02

55957PA0290022 Rating Area 3 No Preference 34 401.31

55957PA0290022 Rating Area 3 No Preference 35 403.95

55957PA0290022 Rating Area 3 No Preference 36 406.60

55957PA0290022 Rating Area 3 No Preference 37 409.24

55957PA0290022 Rating Area 3 No Preference 38 411.89

55957PA0290022 Rating Area 3 No Preference 39 417.17

55957PA0290022 Rating Area 3 No Preference 40 422.46

55957PA0290022 Rating Area 3 No Preference 41 430.40

55957PA0290022 Rating Area 3 No Preference 42 438.00

55957PA0290022 Rating Area 3 No Preference 43 448.58

55957PA0290022 Rating Area 3 No Preference 44 461.80

55957PA0290022 Rating Area 3 No Preference 45 477.34

55957PA0290022 Rating Area 3 No Preference 46 495.85

55957PA0290022 Rating Area 3 No Preference 47 516.68

55957PA0290022 Rating Area 3 No Preference 48 540.48

55957PA0290022 Rating Area 3 No Preference 49 563.95

55957PA0290022 Rating Area 3 No Preference 50 590.39

55957PA0290022 Rating Area 3 No Preference 51 616.51

55957PA0290022 Rating Area 3 No Preference 52 645.27

55957PA0290022 Rating Area 3 No Preference 53 674.36

55957PA0290022 Rating Area 3 No Preference 54 705.76

55957PA0290022 Rating Area 3 No Preference 55 737.17

55957PA0290022 Rating Area 3 No Preference 56 771.21

55957PA0290022 Rating Area 3 No Preference 57 805.59

55957PA0290022 Rating Area 3 No Preference 58 842.29

55957PA0290022 Rating Area 3 No Preference 59 860.47

55957PA0290022 Rating Area 3 No Preference 60 897.16

55957PA0290022 Rating Area 3 No Preference 61 928.90

55957PA0290022 Rating Area 3 No Preference 62 949.72

55957PA0290022 Rating Area 3 No Preference 63 975.84

55957PA0290022 Rating Area 3 No Preference 64 991.71

55957PA0290022 Rating Area 3 No Preference 65 and over 991.71

55957PA0290012 Rating Area 3 No Preference 0-20 193.28

55957PA0290012 Rating Area 3 No Preference 21 304.38

55957PA0290012 Rating Area 3 No Preference 22 304.38

55957PA0290012 Rating Area 3 No Preference 23 304.38

55957PA0290012 Rating Area 3 No Preference 24 304.38

55957PA0290012 Rating Area 3 No Preference 25 305.59

55957PA0290012 Rating Area 3 No Preference 26 311.68

55957PA0290012 Rating Area 3 No Preference 27 318.99

55957PA0290012 Rating Area 3 No Preference 28 330.86

55957PA0290012 Rating Area 3 No Preference 29 340.60

55957PA0290012 Rating Area 3 No Preference 30 345.47

55957PA0290012 Rating Area 3 No Preference 31 352.77

55957PA0290012 Rating Area 3 No Preference 32 360.08

55957PA0290012 Rating Area 3 No Preference 33 364.64

55957PA0290012 Rating Area 3 No Preference 34 369.51

55957PA0290012 Rating Area 3 No Preference 35 371.95

55957PA0290012 Rating Area 3 No Preference 36 374.38

55957PA0290012 Rating Area 3 No Preference 37 376.82

55957PA0290012 Rating Area 3 No Preference 38 379.25

55957PA0290012 Rating Area 3 No Preference 39 384.12

55957PA0290012 Rating Area 3 No Preference 40 388.99

55957PA0290012 Rating Area 3 No Preference 41 396.30

55957PA0290012 Rating Area 3 No Preference 42 403.30

55957PA0290012 Rating Area 3 No Preference 43 413.04

55957PA0290012 Rating Area 3 No Preference 44 425.21

55957PA0290012 Rating Area 3 No Preference 45 439.52

55957PA0290012 Rating Area 3 No Preference 46 456.57

55957PA0290012 Rating Area 3 No Preference 47 475.74

55957PA0290012 Rating Area 3 No Preference 48 497.66

55957PA0290012 Rating Area 3 No Preference 49 519.27

55957PA0290012 Rating Area 3 No Preference 50 543.62

55957PA0290012 Rating Area 3 No Preference 51 567.66

55957PA0290012 Rating Area 3 No Preference 52 594.14

55957PA0290012 Rating Area 3 No Preference 53 620.93

55957PA0290012 Rating Area 3 No Preference 54 649.85

55957PA0290012 Rating Area 3 No Preference 55 678.76

55957PA0290012 Rating Area 3 No Preference 56 710.11

55957PA0290012 Rating Area 3 No Preference 57 741.77

55957PA0290012 Rating Area 3 No Preference 58 775.56

55957PA0290012 Rating Area 3 No Preference 59 792.30

55957PA0290012 Rating Area 3 No Preference 60 826.08

55957PA0290012 Rating Area 3 No Preference 61 855.30

55957PA0290012 Rating Area 3 No Preference 62 874.48

55957PA0290012 Rating Area 3 No Preference 63 898.52

55957PA0290012 Rating Area 3 No Preference 64 913.14

55957PA0290012 Rating Area 3 No Preference 65 and over 913.14

55957PA0290011 Rating Area 3 No Preference 0-20 196.53

55957PA0290011 Rating Area 3 No Preference 21 309.51

55957PA0290011 Rating Area 3 No Preference 22 309.51

55957PA0290011 Rating Area 3 No Preference 23 309.51

55957PA0290011 Rating Area 3 No Preference 24 309.51

55957PA0290011 Rating Area 3 No Preference 25 310.74

55957PA0290011 Rating Area 3 No Preference 26 316.93

55957PA0290011 Rating Area 3 No Preference 27 324.36

55957PA0290011 Rating Area 3 No Preference 28 336.43

55957PA0290011 Rating Area 3 No Preference 29 346.34

55957PA0290011 Rating Area 3 No Preference 30 351.29

55957PA0290011 Rating Area 3 No Preference 31 358.72

55957PA0290011 Rating Area 3 No Preference 32 366.15

55957PA0290011 Rating Area 3 No Preference 33 370.79

55957PA0290011 Rating Area 3 No Preference 34 375.74

55957PA0290011 Rating Area 3 No Preference 35 378.22

55957PA0290011 Rating Area 3 No Preference 36 380.69

55957PA0290011 Rating Area 3 No Preference 37 383.17

55957PA0290011 Rating Area 3 No Preference 38 385.64

55957PA0290011 Rating Area 3 No Preference 39 390.60

55957PA0290011 Rating Area 3 No Preference 40 395.55

55957PA0290011 Rating Area 3 No Preference 41 402.98

55957PA0290011 Rating Area 3 No Preference 42 410.10

55957PA0290011 Rating Area 3 No Preference 43 420.00

55957PA0290011 Rating Area 3 No Preference 44 432.38

55957PA0290011 Rating Area 3 No Preference 45 446.93

55957PA0290011 Rating Area 3 No Preference 46 464.26

55957PA0290011 Rating Area 3 No Preference 47 483.76

55957PA0290011 Rating Area 3 No Preference 48 506.04

55957PA0290011 Rating Area 3 No Preference 49 528.02

55957PA0290011 Rating Area 3 No Preference 50 552.78

55957PA0290011 Rating Area 3 No Preference 51 577.23

55957PA0290011 Rating Area 3 No Preference 52 604.16

55957PA0290011 Rating Area 3 No Preference 53 631.40

55957PA0290011 Rating Area 3 No Preference 54 660.80

55957PA0290011 Rating Area 3 No Preference 55 690.20

55957PA0290011 Rating Area 3 No Preference 56 722.08

55957PA0290011 Rating Area 3 No Preference 57 754.27

55957PA0290011 Rating Area 3 No Preference 58 788.63

55957PA0290011 Rating Area 3 No Preference 59 805.65

55957PA0290011 Rating Area 3 No Preference 60 840.01

55957PA0290011 Rating Area 3 No Preference 61 869.72

55957PA0290011 Rating Area 3 No Preference 62 889.22

55957PA0290011 Rating Area 3 No Preference 63 913.67

55957PA0290011 Rating Area 3 No Preference 64 928.53

55957PA0290011 Rating Area 3 No Preference 65 and over 928.53

55957PA0290013 Rating Area 3 No Preference 0-20 196.72

55957PA0290013 Rating Area 3 No Preference 21 309.81

55957PA0290013 Rating Area 3 No Preference 22 309.81

55957PA0290013 Rating Area 3 No Preference 23 309.81

55957PA0290013 Rating Area 3 No Preference 24 309.81

55957PA0290013 Rating Area 3 No Preference 25 311.04

55957PA0290013 Rating Area 3 No Preference 26 317.24

55957PA0290013 Rating Area 3 No Preference 27 324.68

55957PA0290013 Rating Area 3 No Preference 28 336.76

55957PA0290013 Rating Area 3 No Preference 29 346.67

55957PA0290013 Rating Area 3 No Preference 30 351.63

55957PA0290013 Rating Area 3 No Preference 31 359.06

55957PA0290013 Rating Area 3 No Preference 32 366.50

55957PA0290013 Rating Area 3 No Preference 33 371.15

55957PA0290013 Rating Area 3 No Preference 34 376.10

55957PA0290013 Rating Area 3 No Preference 35 378.58

55957PA0290013 Rating Area 3 No Preference 36 381.06

55957PA0290013 Rating Area 3 No Preference 37 383.54

55957PA0290013 Rating Area 3 No Preference 38 386.02

55957PA0290013 Rating Area 3 No Preference 39 390.98

55957PA0290013 Rating Area 3 No Preference 40 395.93

55957PA0290013 Rating Area 3 No Preference 41 403.37

55957PA0290013 Rating Area 3 No Preference 42 410.49

55957PA0290013 Rating Area 3 No Preference 43 420.41

55957PA0290013 Rating Area 3 No Preference 44 432.80

55957PA0290013 Rating Area 3 No Preference 45 447.36

55957PA0290013 Rating Area 3 No Preference 46 464.71

55957PA0290013 Rating Area 3 No Preference 47 484.23

55957PA0290013 Rating Area 3 No Preference 48 506.53

55957PA0290013 Rating Area 3 No Preference 49 528.53

55957PA0290013 Rating Area 3 No Preference 50 553.32

55957PA0290013 Rating Area 3 No Preference 51 577.79

55957PA0290013 Rating Area 3 No Preference 52 604.74

55957PA0290013 Rating Area 3 No Preference 53 632.01

55957PA0290013 Rating Area 3 No Preference 54 661.44

55957PA0290013 Rating Area 3 No Preference 55 690.87

55957PA0290013 Rating Area 3 No Preference 56 722.78

55957PA0290013 Rating Area 3 No Preference 57 755.00

55957PA0290013 Rating Area 3 No Preference 58 789.39

55957PA0290013 Rating Area 3 No Preference 59 806.43

55957PA0290013 Rating Area 3 No Preference 60 840.82

55957PA0290013 Rating Area 3 No Preference 61 870.56

55957PA0290013 Rating Area 3 No Preference 62 890.08

55957PA0290013 Rating Area 3 No Preference 63 914.55

55957PA0290013 Rating Area 3 No Preference 64 929.43

55957PA0290013 Rating Area 3 No Preference 65 and over 929.43

55957PA0290014 Rating Area 3 No Preference 0-20 200.03

55957PA0290014 Rating Area 3 No Preference 21 315.02

55957PA0290014 Rating Area 3 No Preference 22 315.02

55957PA0290014 Rating Area 3 No Preference 23 315.02

55957PA0290014 Rating Area 3 No Preference 24 315.02

55957PA0290014 Rating Area 3 No Preference 25 316.28

55957PA0290014 Rating Area 3 No Preference 26 322.58

55957PA0290014 Rating Area 3 No Preference 27 330.14

55957PA0290014 Rating Area 3 No Preference 28 342.42

55957PA0290014 Rating Area 3 No Preference 29 352.50

55957PA0290014 Rating Area 3 No Preference 30 357.54

55957PA0290014 Rating Area 3 No Preference 31 365.10

55957PA0290014 Rating Area 3 No Preference 32 372.66

55957PA0290014 Rating Area 3 No Preference 33 377.39

55957PA0290014 Rating Area 3 No Preference 34 382.43

55957PA0290014 Rating Area 3 No Preference 35 384.95

55957PA0290014 Rating Area 3 No Preference 36 387.47

55957PA0290014 Rating Area 3 No Preference 37 389.99

55957PA0290014 Rating Area 3 No Preference 38 392.51

55957PA0290014 Rating Area 3 No Preference 39 397.55

55957PA0290014 Rating Area 3 No Preference 40 402.59

55957PA0290014 Rating Area 3 No Preference 41 410.15

55957PA0290014 Rating Area 3 No Preference 42 417.40

55957PA0290014 Rating Area 3 No Preference 43 427.48

55957PA0290014 Rating Area 3 No Preference 44 440.08

55957PA0290014 Rating Area 3 No Preference 45 454.88

55957PA0290014 Rating Area 3 No Preference 46 472.53

55957PA0290014 Rating Area 3 No Preference 47 492.37

55957PA0290014 Rating Area 3 No Preference 48 515.05

55957PA0290014 Rating Area 3 No Preference 49 537.42

55957PA0290014 Rating Area 3 No Preference 50 562.62

55957PA0290014 Rating Area 3 No Preference 51 587.51

55957PA0290014 Rating Area 3 No Preference 52 614.91

55957PA0290014 Rating Area 3 No Preference 53 642.64

55957PA0290014 Rating Area 3 No Preference 54 672.56

55957PA0290014 Rating Area 3 No Preference 55 702.49

55957PA0290014 Rating Area 3 No Preference 56 734.94

55957PA0290014 Rating Area 3 No Preference 57 767.70

55957PA0290014 Rating Area 3 No Preference 58 802.67

55957PA0290014 Rating Area 3 No Preference 59 819.99

55957PA0290014 Rating Area 3 No Preference 60 854.96

55957PA0290014 Rating Area 3 No Preference 61 885.20

55957PA0290014 Rating Area 3 No Preference 62 905.05

55957PA0290014 Rating Area 3 No Preference 63 929.93

55957PA0290014 Rating Area 3 No Preference 64 945.06

55957PA0290014 Rating Area 3 No Preference 65 and over 945.06

55957PA0290016 Rating Area 3 No Preference 0-20 192.03

55957PA0290016 Rating Area 3 No Preference 21 302.42

55957PA0290016 Rating Area 3 No Preference 22 302.42

55957PA0290016 Rating Area 3 No Preference 23 302.42

55957PA0290016 Rating Area 3 No Preference 24 302.42

55957PA0290016 Rating Area 3 No Preference 25 303.62

55957PA0290016 Rating Area 3 No Preference 26 309.67

55957PA0290016 Rating Area 3 No Preference 27 316.93

55957PA0290016 Rating Area 3 No Preference 28 328.73

55957PA0290016 Rating Area 3 No Preference 29 338.40

55957PA0290016 Rating Area 3 No Preference 30 343.24

55957PA0290016 Rating Area 3 No Preference 31 350.50

55957PA0290016 Rating Area 3 No Preference 32 357.76

55957PA0290016 Rating Area 3 No Preference 33 362.29

55957PA0290016 Rating Area 3 No Preference 34 367.13

55957PA0290016 Rating Area 3 No Preference 35 369.55

55957PA0290016 Rating Area 3 No Preference 36 371.97

55957PA0290016 Rating Area 3 No Preference 37 374.39

55957PA0290016 Rating Area 3 No Preference 38 376.81

55957PA0290016 Rating Area 3 No Preference 39 381.65

55957PA0290016 Rating Area 3 No Preference 40 386.49

55957PA0290016 Rating Area 3 No Preference 41 393.75

55957PA0290016 Rating Area 3 No Preference 42 400.70

55957PA0290016 Rating Area 3 No Preference 43 410.38

55957PA0290016 Rating Area 3 No Preference 44 422.48

55957PA0290016 Rating Area 3 No Preference 45 436.69

55957PA0290016 Rating Area 3 No Preference 46 453.63

55957PA0290016 Rating Area 3 No Preference 47 472.68

55957PA0290016 Rating Area 3 No Preference 48 494.45

55957PA0290016 Rating Area 3 No Preference 49 515.92

55957PA0290016 Rating Area 3 No Preference 50 540.12

55957PA0290016 Rating Area 3 No Preference 51 564.01

55957PA0290016 Rating Area 3 No Preference 52 590.32

55957PA0290016 Rating Area 3 No Preference 53 616.93

55957PA0290016 Rating Area 3 No Preference 54 645.66

55957PA0290016 Rating Area 3 No Preference 55 674.39

55957PA0290016 Rating Area 3 No Preference 56 705.54

55957PA0290016 Rating Area 3 No Preference 57 736.99

55957PA0290016 Rating Area 3 No Preference 58 770.56

55957PA0290016 Rating Area 3 No Preference 59 787.19

55957PA0290016 Rating Area 3 No Preference 60 820.76

55957PA0290016 Rating Area 3 No Preference 61 849.80

55957PA0290016 Rating Area 3 No Preference 62 868.85

55957PA0290016 Rating Area 3 No Preference 63 892.74

55957PA0290016 Rating Area 3 No Preference 64 907.26

55957PA0290016 Rating Area 3 No Preference 65 and over 907.26

55957PA0290023 Rating Area 3 No Preference 0-20 164.96

55957PA0290023 Rating Area 3 No Preference 21 259.78

55957PA0290023 Rating Area 3 No Preference 22 259.78

55957PA0290023 Rating Area 3 No Preference 23 259.78

55957PA0290023 Rating Area 3 No Preference 24 259.78

55957PA0290023 Rating Area 3 No Preference 25 260.81

55957PA0290023 Rating Area 3 No Preference 26 266.01

55957PA0290023 Rating Area 3 No Preference 27 272.24

55957PA0290023 Rating Area 3 No Preference 28 282.38

55957PA0290023 Rating Area 3 No Preference 29 290.69

55957PA0290023 Rating Area 3 No Preference 30 294.85

55957PA0290023 Rating Area 3 No Preference 31 301.08

55957PA0290023 Rating Area 3 No Preference 32 307.31

55957PA0290023 Rating Area 3 No Preference 33 311.21

55957PA0290023 Rating Area 3 No Preference 34 315.37

55957PA0290023 Rating Area 3 No Preference 35 317.45

55957PA0290023 Rating Area 3 No Preference 36 319.52

55957PA0290023 Rating Area 3 No Preference 37 321.60

55957PA0290023 Rating Area 3 No Preference 38 323.68

55957PA0290023 Rating Area 3 No Preference 39 327.84

55957PA0290023 Rating Area 3 No Preference 40 331.99

55957PA0290023 Rating Area 3 No Preference 41 338.23

55957PA0290023 Rating Area 3 No Preference 42 344.20

55957PA0290023 Rating Area 3 No Preference 43 352.52

55957PA0290023 Rating Area 3 No Preference 44 362.91

55957PA0290023 Rating Area 3 No Preference 45 375.12

55957PA0290023 Rating Area 3 No Preference 46 389.67

55957PA0290023 Rating Area 3 No Preference 47 406.03

55957PA0290023 Rating Area 3 No Preference 48 424.74

55957PA0290023 Rating Area 3 No Preference 49 443.18

55957PA0290023 Rating Area 3 No Preference 50 463.96

55957PA0290023 Rating Area 3 No Preference 51 484.48

55957PA0290023 Rating Area 3 No Preference 52 507.09

55957PA0290023 Rating Area 3 No Preference 53 529.95

55957PA0290023 Rating Area 3 No Preference 54 554.63

55957PA0290023 Rating Area 3 No Preference 55 579.30

55957PA0290023 Rating Area 3 No Preference 56 606.06

55957PA0290023 Rating Area 3 No Preference 57 633.08

55957PA0290023 Rating Area 3 No Preference 58 661.91

55957PA0290023 Rating Area 3 No Preference 59 676.20

55957PA0290023 Rating Area 3 No Preference 60 705.04

55957PA0290023 Rating Area 3 No Preference 61 729.98

55957PA0290023 Rating Area 3 No Preference 62 746.34

55957PA0290023 Rating Area 3 No Preference 63 766.87

55957PA0290023 Rating Area 3 No Preference 64 779.34

55957PA0290023 Rating Area 3 No Preference 65 and over 779.34

55957PA0290017 Rating Area 3 No Preference 0-20 156.90

55957PA0290017 Rating Area 3 No Preference 21 247.10

55957PA0290017 Rating Area 3 No Preference 22 247.10

55957PA0290017 Rating Area 3 No Preference 23 247.10

55957PA0290017 Rating Area 3 No Preference 24 247.10

55957PA0290017 Rating Area 3 No Preference 25 248.08

55957PA0290017 Rating Area 3 No Preference 26 253.03

55957PA0290017 Rating Area 3 No Preference 27 258.96

55957PA0290017 Rating Area 3 No Preference 28 268.59

55957PA0290017 Rating Area 3 No Preference 29 276.50

55957PA0290017 Rating Area 3 No Preference 30 280.45

55957PA0290017 Rating Area 3 No Preference 31 286.38

55957PA0290017 Rating Area 3 No Preference 32 292.31

55957PA0290017 Rating Area 3 No Preference 33 296.02

55957PA0290017 Rating Area 3 No Preference 34 299.97

55957PA0290017 Rating Area 3 No Preference 35 301.95

55957PA0290017 Rating Area 3 No Preference 36 303.93

55957PA0290017 Rating Area 3 No Preference 37 305.90

55957PA0290017 Rating Area 3 No Preference 38 307.88

55957PA0290017 Rating Area 3 No Preference 39 311.84

55957PA0290017 Rating Area 3 No Preference 40 315.79

55957PA0290017 Rating Area 3 No Preference 41 321.72

55957PA0290017 Rating Area 3 No Preference 42 327.40

55957PA0290017 Rating Area 3 No Preference 43 335.31

55957PA0290017 Rating Area 3 No Preference 44 345.19

55957PA0290017 Rating Area 3 No Preference 45 356.81

55957PA0290017 Rating Area 3 No Preference 46 370.65

55957PA0290017 Rating Area 3 No Preference 47 386.21

55957PA0290017 Rating Area 3 No Preference 48 404.00

55957PA0290017 Rating Area 3 No Preference 49 421.55

55957PA0290017 Rating Area 3 No Preference 50 441.32

55957PA0290017 Rating Area 3 No Preference 51 460.84

55957PA0290017 Rating Area 3 No Preference 52 482.33

55957PA0290017 Rating Area 3 No Preference 53 504.08

55957PA0290017 Rating Area 3 No Preference 54 527.55

55957PA0290017 Rating Area 3 No Preference 55 551.03

55957PA0290017 Rating Area 3 No Preference 56 576.48

55957PA0290017 Rating Area 3 No Preference 57 602.18

55957PA0290017 Rating Area 3 No Preference 58 629.61

55957PA0290017 Rating Area 3 No Preference 59 643.20

55957PA0290017 Rating Area 3 No Preference 60 670.62

55957PA0290017 Rating Area 3 No Preference 61 694.35

55957PA0290017 Rating Area 3 No Preference 62 709.91

55957PA0290017 Rating Area 3 No Preference 63 729.43

55957PA0290017 Rating Area 3 No Preference 64 741.30

55957PA0290017 Rating Area 3 No Preference 65 and over 741.30

55957PA0290018 Rating Area 3 No Preference 0-20 166.74

55957PA0290018 Rating Area 3 No Preference 21 262.59

55957PA0290018 Rating Area 3 No Preference 22 262.59

55957PA0290018 Rating Area 3 No Preference 23 262.59

55957PA0290018 Rating Area 3 No Preference 24 262.59

55957PA0290018 Rating Area 3 No Preference 25 263.64

55957PA0290018 Rating Area 3 No Preference 26 268.89

55957PA0290018 Rating Area 3 No Preference 27 275.19

55957PA0290018 Rating Area 3 No Preference 28 285.43

55957PA0290018 Rating Area 3 No Preference 29 293.83

55957PA0290018 Rating Area 3 No Preference 30 298.03

55957PA0290018 Rating Area 3 No Preference 31 304.34

55957PA0290018 Rating Area 3 No Preference 32 310.64

55957PA0290018 Rating Area 3 No Preference 33 314.58

55957PA0290018 Rating Area 3 No Preference 34 318.78

55957PA0290018 Rating Area 3 No Preference 35 320.88

55957PA0290018 Rating Area 3 No Preference 36 322.98

55957PA0290018 Rating Area 3 No Preference 37 325.08

55957PA0290018 Rating Area 3 No Preference 38 327.18

55957PA0290018 Rating Area 3 No Preference 39 331.38

55957PA0290018 Rating Area 3 No Preference 40 335.59

55957PA0290018 Rating Area 3 No Preference 41 341.89

55957PA0290018 Rating Area 3 No Preference 42 347.93

55957PA0290018 Rating Area 3 No Preference 43 356.33

55957PA0290018 Rating Area 3 No Preference 44 366.83

55957PA0290018 Rating Area 3 No Preference 45 379.17

55957PA0290018 Rating Area 3 No Preference 46 393.88

55957PA0290018 Rating Area 3 No Preference 47 410.42

55957PA0290018 Rating Area 3 No Preference 48 429.33

55957PA0290018 Rating Area 3 No Preference 49 447.97

55957PA0290018 Rating Area 3 No Preference 50 468.98

55957PA0290018 Rating Area 3 No Preference 51 489.73

55957PA0290018 Rating Area 3 No Preference 52 512.57

55957PA0290018 Rating Area 3 No Preference 53 535.68

55957PA0290018 Rating Area 3 No Preference 54 560.62

55957PA0290018 Rating Area 3 No Preference 55 585.57

55957PA0290018 Rating Area 3 No Preference 56 612.62

55957PA0290018 Rating Area 3 No Preference 57 639.93

55957PA0290018 Rating Area 3 No Preference 58 669.07

55957PA0290018 Rating Area 3 No Preference 59 683.52

55957PA0290018 Rating Area 3 No Preference 60 712.66

55957PA0290018 Rating Area 3 No Preference 61 737.87

55957PA0290018 Rating Area 3 No Preference 62 754.42

55957PA0290018 Rating Area 3 No Preference 63 775.16

55957PA0290018 Rating Area 3 No Preference 64 787.77

55957PA0290018 Rating Area 3 No Preference 65 and over 787.77

55957PA0290019 Rating Area 3 No Preference 0-20 164.99

55957PA0290019 Rating Area 3 No Preference 21 259.83

55957PA0290019 Rating Area 3 No Preference 22 259.83

55957PA0290019 Rating Area 3 No Preference 23 259.83

55957PA0290019 Rating Area 3 No Preference 24 259.83

55957PA0290019 Rating Area 3 No Preference 25 260.86

55957PA0290019 Rating Area 3 No Preference 26 266.06

55957PA0290019 Rating Area 3 No Preference 27 272.30

55957PA0290019 Rating Area 3 No Preference 28 282.43

55957PA0290019 Rating Area 3 No Preference 29 290.74

55957PA0290019 Rating Area 3 No Preference 30 294.90

55957PA0290019 Rating Area 3 No Preference 31 301.14

55957PA0290019 Rating Area 3 No Preference 32 307.37

55957PA0290019 Rating Area 3 No Preference 33 311.27

55957PA0290019 Rating Area 3 No Preference 34 315.43

55957PA0290019 Rating Area 3 No Preference 35 317.51

55957PA0290019 Rating Area 3 No Preference 36 319.59

55957PA0290019 Rating Area 3 No Preference 37 321.66

55957PA0290019 Rating Area 3 No Preference 38 323.74

55957PA0290019 Rating Area 3 No Preference 39 327.90

55957PA0290019 Rating Area 3 No Preference 40 332.06

55957PA0290019 Rating Area 3 No Preference 41 338.29

55957PA0290019 Rating Area 3 No Preference 42 344.27

55957PA0290019 Rating Area 3 No Preference 43 352.58

55957PA0290019 Rating Area 3 No Preference 44 362.98

55957PA0290019 Rating Area 3 No Preference 45 375.19

55957PA0290019 Rating Area 3 No Preference 46 389.74

55957PA0290019 Rating Area 3 No Preference 47 406.11

55957PA0290019 Rating Area 3 No Preference 48 424.82

55957PA0290019 Rating Area 3 No Preference 49 443.26

55957PA0290019 Rating Area 3 No Preference 50 464.05

55957PA0290019 Rating Area 3 No Preference 51 484.58

55957PA0290019 Rating Area 3 No Preference 52 507.18

55957PA0290019 Rating Area 3 No Preference 53 530.05

55957PA0290019 Rating Area 3 No Preference 54 554.73

55957PA0290019 Rating Area 3 No Preference 55 579.42

55957PA0290019 Rating Area 3 No Preference 56 606.18

55957PA0290019 Rating Area 3 No Preference 57 633.20

55957PA0290019 Rating Area 3 No Preference 58 662.04

55957PA0290019 Rating Area 3 No Preference 59 676.33

55957PA0290019 Rating Area 3 No Preference 60 705.17

55957PA0290019 Rating Area 3 No Preference 61 730.12

55957PA0290019 Rating Area 3 No Preference 62 746.49

55957PA0290019 Rating Area 3 No Preference 63 767.01

55957PA0290019 Rating Area 3 No Preference 64 779.49

55957PA0290019 Rating Area 3 No Preference 65 and over 779.49

55957PA0290021 Rating Area 3 No Preference 0-20 132.89

55957PA0290021 Rating Area 3 No Preference 21 209.28

55957PA0290021 Rating Area 3 No Preference 22 209.28

55957PA0290021 Rating Area 3 No Preference 23 209.28

55957PA0290021 Rating Area 3 No Preference 24 209.28

55957PA0290021 Rating Area 3 No Preference 25 210.11

55957PA0290021 Rating Area 3 No Preference 26 214.30

55957PA0290021 Rating Area 3 No Preference 27 219.32

55957PA0290021 Rating Area 3 No Preference 28 227.48

55957PA0290021 Rating Area 3 No Preference 29 234.18

55957PA0290021 Rating Area 3 No Preference 30 237.53

55957PA0290021 Rating Area 3 No Preference 31 242.55

55957PA0290021 Rating Area 3 No Preference 32 247.57

55957PA0290021 Rating Area 3 No Preference 33 250.71

55957PA0290021 Rating Area 3 No Preference 34 254.06

55957PA0290021 Rating Area 3 No Preference 35 255.74

55957PA0290021 Rating Area 3 No Preference 36 257.41

55957PA0290021 Rating Area 3 No Preference 37 259.08

55957PA0290021 Rating Area 3 No Preference 38 260.76

55957PA0290021 Rating Area 3 No Preference 39 264.11

55957PA0290021 Rating Area 3 No Preference 40 267.45

55957PA0290021 Rating Area 3 No Preference 41 272.48

55957PA0290021 Rating Area 3 No Preference 42 277.29

55957PA0290021 Rating Area 3 No Preference 43 283.99

55957PA0290021 Rating Area 3 No Preference 44 292.36

55957PA0290021 Rating Area 3 No Preference 45 302.20

55957PA0290021 Rating Area 3 No Preference 46 313.92

55957PA0290021 Rating Area 3 No Preference 47 327.10

55957PA0290021 Rating Area 3 No Preference 48 342.17

55957PA0290021 Rating Area 3 No Preference 49 357.03

55957PA0290021 Rating Area 3 No Preference 50 373.77

55957PA0290021 Rating Area 3 No Preference 51 390.30

55957PA0290021 Rating Area 3 No Preference 52 408.51

55957PA0290021 Rating Area 3 No Preference 53 426.93

55957PA0290021 Rating Area 3 No Preference 54 446.81

55957PA0290021 Rating Area 3 No Preference 55 466.69

55957PA0290021 Rating Area 3 No Preference 56 488.25

55957PA0290021 Rating Area 3 No Preference 57 510.01

55957PA0290021 Rating Area 3 No Preference 58 533.24

55957PA0290021 Rating Area 3 No Preference 59 544.75

55957PA0290021 Rating Area 3 No Preference 60 567.98

55957PA0290021 Rating Area 3 No Preference 61 588.07

55957PA0290021 Rating Area 3 No Preference 62 601.26

55957PA0290021 Rating Area 3 No Preference 63 617.79

55957PA0290021 Rating Area 3 No Preference 64 627.84

55957PA0290021 Rating Area 3 No Preference 65 and over 627.84

55957PA0280001 Rating Area 3 No Preference 0-20 156.22

55957PA0280001 Rating Area 3 No Preference 21 246.02

55957PA0280001 Rating Area 3 No Preference 22 246.02

55957PA0280001 Rating Area 3 No Preference 23 246.02

55957PA0280001 Rating Area 3 No Preference 24 246.02

55957PA0280001 Rating Area 3 No Preference 25 247.00

55957PA0280001 Rating Area 3 No Preference 26 251.92

55957PA0280001 Rating Area 3 No Preference 27 257.82

55957PA0280001 Rating Area 3 No Preference 28 267.42

55957PA0280001 Rating Area 3 No Preference 29 275.29

55957PA0280001 Rating Area 3 No Preference 30 279.23

55957PA0280001 Rating Area 3 No Preference 31 285.13

55957PA0280001 Rating Area 3 No Preference 32 291.04

55957PA0280001 Rating Area 3 No Preference 33 294.73

55957PA0280001 Rating Area 3 No Preference 34 298.66

55957PA0280001 Rating Area 3 No Preference 35 300.63

55957PA0280001 Rating Area 3 No Preference 36 302.60

55957PA0280001 Rating Area 3 No Preference 37 304.57

55957PA0280001 Rating Area 3 No Preference 38 306.54

55957PA0280001 Rating Area 3 No Preference 39 310.47

55957PA0280001 Rating Area 3 No Preference 40 314.41

55957PA0280001 Rating Area 3 No Preference 41 320.31

55957PA0280001 Rating Area 3 No Preference 42 325.97

55957PA0280001 Rating Area 3 No Preference 43 333.84

55957PA0280001 Rating Area 3 No Preference 44 343.68

55957PA0280001 Rating Area 3 No Preference 45 355.25

55957PA0280001 Rating Area 3 No Preference 46 369.03

55957PA0280001 Rating Area 3 No Preference 47 384.52

55957PA0280001 Rating Area 3 No Preference 48 402.24

55957PA0280001 Rating Area 3 No Preference 49 419.71

55957PA0280001 Rating Area 3 No Preference 50 439.39

55957PA0280001 Rating Area 3 No Preference 51 458.82

55957PA0280001 Rating Area 3 No Preference 52 480.23

55957PA0280001 Rating Area 3 No Preference 53 501.88

55957PA0280001 Rating Area 3 No Preference 54 525.25

55957PA0280001 Rating Area 3 No Preference 55 548.62

55957PA0280001 Rating Area 3 No Preference 56 573.96

55957PA0280001 Rating Area 3 No Preference 57 599.55

55957PA0280001 Rating Area 3 No Preference 58 626.85

55957PA0280001 Rating Area 3 No Preference 59 640.39

55957PA0280001 Rating Area 3 No Preference 60 667.69

55957PA0280001 Rating Area 3 No Preference 61 691.31

55957PA0280001 Rating Area 3 No Preference 62 706.81

55957PA0280001 Rating Area 3 No Preference 63 726.25

55957PA0280001 Rating Area 3 No Preference 64 738.06

55957PA0280001 Rating Area 3 No Preference 65 and over 738.06

55957PA0280002 Rating Area 3 No Preference 0-20 156.67

55957PA0280002 Rating Area 3 No Preference 21 246.73

55957PA0280002 Rating Area 3 No Preference 22 246.73

55957PA0280002 Rating Area 3 No Preference 23 246.73

55957PA0280002 Rating Area 3 No Preference 24 246.73

55957PA0280002 Rating Area 3 No Preference 25 247.71

55957PA0280002 Rating Area 3 No Preference 26 252.65

55957PA0280002 Rating Area 3 No Preference 27 258.57

55957PA0280002 Rating Area 3 No Preference 28 268.19

55957PA0280002 Rating Area 3 No Preference 29 276.09

55957PA0280002 Rating Area 3 No Preference 30 280.03

55957PA0280002 Rating Area 3 No Preference 31 285.96

55957PA0280002 Rating Area 3 No Preference 32 291.88

55957PA0280002 Rating Area 3 No Preference 33 295.58

55957PA0280002 Rating Area 3 No Preference 34 299.53

55957PA0280002 Rating Area 3 No Preference 35 301.50

55957PA0280002 Rating Area 3 No Preference 36 303.47

55957PA0280002 Rating Area 3 No Preference 37 305.45

55957PA0280002 Rating Area 3 No Preference 38 307.42

55957PA0280002 Rating Area 3 No Preference 39 311.37

55957PA0280002 Rating Area 3 No Preference 40 315.32

55957PA0280002 Rating Area 3 No Preference 41 321.24

55957PA0280002 Rating Area 3 No Preference 42 326.91

55957PA0280002 Rating Area 3 No Preference 43 334.81

55957PA0280002 Rating Area 3 No Preference 44 344.68

55957PA0280002 Rating Area 3 No Preference 45 356.27

55957PA0280002 Rating Area 3 No Preference 46 370.09

55957PA0280002 Rating Area 3 No Preference 47 385.63

55957PA0280002 Rating Area 3 No Preference 48 403.40

55957PA0280002 Rating Area 3 No Preference 49 420.92

55957PA0280002 Rating Area 3 No Preference 50 440.65

55957PA0280002 Rating Area 3 No Preference 51 460.15

55957PA0280002 Rating Area 3 No Preference 52 481.61

55957PA0280002 Rating Area 3 No Preference 53 503.32

55957PA0280002 Rating Area 3 No Preference 54 526.76

55957PA0280002 Rating Area 3 No Preference 55 550.20

55957PA0280002 Rating Area 3 No Preference 56 575.62

55957PA0280002 Rating Area 3 No Preference 57 601.28

55957PA0280002 Rating Area 3 No Preference 58 628.66

55957PA0280002 Rating Area 3 No Preference 59 642.23

55957PA0280002 Rating Area 3 No Preference 60 669.62

55957PA0280002 Rating Area 3 No Preference 61 693.31

55957PA0280002 Rating Area 3 No Preference 62 708.85

55957PA0280002 Rating Area 3 No Preference 63 728.34

55957PA0280002 Rating Area 3 No Preference 64 740.19

55957PA0280002 Rating Area 3 No Preference 65 and over 740.19

55957PA0280003 Rating Area 3 No Preference 0-20 196.85

55957PA0280003 Rating Area 3 No Preference 21 310.00

55957PA0280003 Rating Area 3 No Preference 22 310.00

55957PA0280003 Rating Area 3 No Preference 23 310.00

55957PA0280003 Rating Area 3 No Preference 24 310.00

55957PA0280003 Rating Area 3 No Preference 25 311.24

55957PA0280003 Rating Area 3 No Preference 26 317.44

55957PA0280003 Rating Area 3 No Preference 27 324.88

55957PA0280003 Rating Area 3 No Preference 28 336.97

55957PA0280003 Rating Area 3 No Preference 29 346.89

55957PA0280003 Rating Area 3 No Preference 30 351.85

55957PA0280003 Rating Area 3 No Preference 31 359.29

55957PA0280003 Rating Area 3 No Preference 32 366.73

55957PA0280003 Rating Area 3 No Preference 33 371.38

55957PA0280003 Rating Area 3 No Preference 34 376.34

55957PA0280003 Rating Area 3 No Preference 35 378.82

55957PA0280003 Rating Area 3 No Preference 36 381.30

55957PA0280003 Rating Area 3 No Preference 37 383.78

55957PA0280003 Rating Area 3 No Preference 38 386.26

55957PA0280003 Rating Area 3 No Preference 39 391.22

55957PA0280003 Rating Area 3 No Preference 40 396.18

55957PA0280003 Rating Area 3 No Preference 41 403.62

55957PA0280003 Rating Area 3 No Preference 42 410.75

55957PA0280003 Rating Area 3 No Preference 43 420.67

55957PA0280003 Rating Area 3 No Preference 44 433.07

55957PA0280003 Rating Area 3 No Preference 45 447.64

55957PA0280003 Rating Area 3 No Preference 46 465.00

55957PA0280003 Rating Area 3 No Preference 47 484.53

55957PA0280003 Rating Area 3 No Preference 48 506.85

55957PA0280003 Rating Area 3 No Preference 49 528.86

55957PA0280003 Rating Area 3 No Preference 50 553.66

55957PA0280003 Rating Area 3 No Preference 51 578.15

55957PA0280003 Rating Area 3 No Preference 52 605.12

55957PA0280003 Rating Area 3 No Preference 53 632.40

55957PA0280003 Rating Area 3 No Preference 54 661.85

55957PA0280003 Rating Area 3 No Preference 55 691.30

55957PA0280003 Rating Area 3 No Preference 56 723.23

55957PA0280003 Rating Area 3 No Preference 57 755.47

55957PA0280003 Rating Area 3 No Preference 58 789.88

55957PA0280003 Rating Area 3 No Preference 59 806.93

55957PA0280003 Rating Area 3 No Preference 60 841.34

55957PA0280003 Rating Area 3 No Preference 61 871.10

55957PA0280003 Rating Area 3 No Preference 62 890.63

55957PA0280003 Rating Area 3 No Preference 63 915.12

55957PA0280003 Rating Area 3 No Preference 64 930.00

55957PA0280003 Rating Area 3 No Preference 65 and over 930.00

55957PA0280004 Rating Area 3 No Preference 0-20 228.40

55957PA0280004 Rating Area 3 No Preference 21 359.69

55957PA0280004 Rating Area 3 No Preference 22 359.69

55957PA0280004 Rating Area 3 No Preference 23 359.69

55957PA0280004 Rating Area 3 No Preference 24 359.69

55957PA0280004 Rating Area 3 No Preference 25 361.12

55957PA0280004 Rating Area 3 No Preference 26 368.32

55957PA0280004 Rating Area 3 No Preference 27 376.95

55957PA0280004 Rating Area 3 No Preference 28 390.98

55957PA0280004 Rating Area 3 No Preference 29 402.49

55957PA0280004 Rating Area 3 No Preference 30 408.24

55957PA0280004 Rating Area 3 No Preference 31 416.88

55957PA0280004 Rating Area 3 No Preference 32 425.51

55957PA0280004 Rating Area 3 No Preference 33 430.90

55957PA0280004 Rating Area 3 No Preference 34 436.66

55957PA0280004 Rating Area 3 No Preference 35 439.54

55957PA0280004 Rating Area 3 No Preference 36 442.41

55957PA0280004 Rating Area 3 No Preference 37 445.29

55957PA0280004 Rating Area 3 No Preference 38 448.17

55957PA0280004 Rating Area 3 No Preference 39 453.92

55957PA0280004 Rating Area 3 No Preference 40 459.68

55957PA0280004 Rating Area 3 No Preference 41 468.31

55957PA0280004 Rating Area 3 No Preference 42 476.58

55957PA0280004 Rating Area 3 No Preference 43 488.09

55957PA0280004 Rating Area 3 No Preference 44 502.48

55957PA0280004 Rating Area 3 No Preference 45 519.39

55957PA0280004 Rating Area 3 No Preference 46 539.53

55957PA0280004 Rating Area 3 No Preference 47 562.19

55957PA0280004 Rating Area 3 No Preference 48 588.09

55957PA0280004 Rating Area 3 No Preference 49 613.63

55957PA0280004 Rating Area 3 No Preference 50 642.40

55957PA0280004 Rating Area 3 No Preference 51 670.82

55957PA0280004 Rating Area 3 No Preference 52 702.11

55957PA0280004 Rating Area 3 No Preference 53 733.76

55957PA0280004 Rating Area 3 No Preference 54 767.93

55957PA0280004 Rating Area 3 No Preference 55 802.10

55957PA0280004 Rating Area 3 No Preference 56 839.15

55957PA0280004 Rating Area 3 No Preference 57 876.56

55957PA0280004 Rating Area 3 No Preference 58 916.49

55957PA0280004 Rating Area 3 No Preference 59 936.27

55957PA0280004 Rating Area 3 No Preference 60 976.19

55957PA0280004 Rating Area 3 No Preference 61 1010.72

55957PA0280004 Rating Area 3 No Preference 62 1033.38

55957PA0280004 Rating Area 3 No Preference 63 1061.80

55957PA0280004 Rating Area 3 No Preference 64 1079.07

55957PA0280004 Rating Area 3 No Preference 65 and over 1079.07

55957PA0300001 Rating Area 3 No Preference 0-20 213.63

55957PA0300001 Rating Area 3 No Preference 21 336.44

55957PA0300001 Rating Area 3 No Preference 22 336.44

55957PA0300001 Rating Area 3 No Preference 23 336.44

55957PA0300001 Rating Area 3 No Preference 24 336.44

55957PA0300001 Rating Area 3 No Preference 25 337.78

55957PA0300001 Rating Area 3 No Preference 26 344.51

55957PA0300001 Rating Area 3 No Preference 27 352.58

55957PA0300001 Rating Area 3 No Preference 28 365.71

55957PA0300001 Rating Area 3 No Preference 29 376.47

55957PA0300001 Rating Area 3 No Preference 30 381.85

55957PA0300001 Rating Area 3 No Preference 31 389.93

55957PA0300001 Rating Area 3 No Preference 32 398.00

55957PA0300001 Rating Area 3 No Preference 33 403.05

55957PA0300001 Rating Area 3 No Preference 34 408.43

55957PA0300001 Rating Area 3 No Preference 35 411.12

55957PA0300001 Rating Area 3 No Preference 36 413.82

55957PA0300001 Rating Area 3 No Preference 37 416.51

55957PA0300001 Rating Area 3 No Preference 38 419.20

55957PA0300001 Rating Area 3 No Preference 39 424.58

55957PA0300001 Rating Area 3 No Preference 40 429.97

55957PA0300001 Rating Area 3 No Preference 41 438.04

55957PA0300001 Rating Area 3 No Preference 42 445.78

55957PA0300001 Rating Area 3 No Preference 43 456.54

55957PA0300001 Rating Area 3 No Preference 44 470.00

55957PA0300001 Rating Area 3 No Preference 45 485.81

55957PA0300001 Rating Area 3 No Preference 46 504.66

55957PA0300001 Rating Area 3 No Preference 47 525.85

55957PA0300001 Rating Area 3 No Preference 48 550.07

55957PA0300001 Rating Area 3 No Preference 49 573.96

55957PA0300001 Rating Area 3 No Preference 50 600.88

55957PA0300001 Rating Area 3 No Preference 51 627.46

55957PA0300001 Rating Area 3 No Preference 52 656.73

55957PA0300001 Rating Area 3 No Preference 53 686.33

55957PA0300001 Rating Area 3 No Preference 54 718.29

55957PA0300001 Rating Area 3 No Preference 55 750.26

55957PA0300001 Rating Area 3 No Preference 56 784.91

55957PA0300001 Rating Area 3 No Preference 57 819.90

55957PA0300001 Rating Area 3 No Preference 58 857.24

55957PA0300001 Rating Area 3 No Preference 59 875.75

55957PA0300001 Rating Area 3 No Preference 60 913.09

55957PA0300001 Rating Area 3 No Preference 61 945.39

55957PA0300001 Rating Area 3 No Preference 62 966.59

55957PA0300001 Rating Area 3 No Preference 63 993.17

55957PA0300001 Rating Area 3 No Preference 64 1009.32

55957PA0300001 Rating Area 3 No Preference 65 and over 1009.32

55957PA0300002 Rating Area 3 No Preference 0-20 182.93

55957PA0300002 Rating Area 3 No Preference 21 288.09

55957PA0300002 Rating Area 3 No Preference 22 288.09

55957PA0300002 Rating Area 3 No Preference 23 288.09

55957PA0300002 Rating Area 3 No Preference 24 288.09

55957PA0300002 Rating Area 3 No Preference 25 289.24

55957PA0300002 Rating Area 3 No Preference 26 295.00

55957PA0300002 Rating Area 3 No Preference 27 301.91

55957PA0300002 Rating Area 3 No Preference 28 313.15

55957PA0300002 Rating Area 3 No Preference 29 322.37

55957PA0300002 Rating Area 3 No Preference 30 326.98

55957PA0300002 Rating Area 3 No Preference 31 333.89

55957PA0300002 Rating Area 3 No Preference 32 340.81

55957PA0300002 Rating Area 3 No Preference 33 345.13

55957PA0300002 Rating Area 3 No Preference 34 349.74

55957PA0300002 Rating Area 3 No Preference 35 352.04

55957PA0300002 Rating Area 3 No Preference 36 354.35

55957PA0300002 Rating Area 3 No Preference 37 356.65

55957PA0300002 Rating Area 3 No Preference 38 358.96

55957PA0300002 Rating Area 3 No Preference 39 363.56

55957PA0300002 Rating Area 3 No Preference 40 368.17

55957PA0300002 Rating Area 3 No Preference 41 375.09

55957PA0300002 Rating Area 3 No Preference 42 381.71

55957PA0300002 Rating Area 3 No Preference 43 390.93

55957PA0300002 Rating Area 3 No Preference 44 402.46

55957PA0300002 Rating Area 3 No Preference 45 416.00

55957PA0300002 Rating Area 3 No Preference 46 432.13

55957PA0300002 Rating Area 3 No Preference 47 450.28

55957PA0300002 Rating Area 3 No Preference 48 471.02

55957PA0300002 Rating Area 3 No Preference 49 491.48

55957PA0300002 Rating Area 3 No Preference 50 514.52

55957PA0300002 Rating Area 3 No Preference 51 537.28

55957PA0300002 Rating Area 3 No Preference 52 562.35

55957PA0300002 Rating Area 3 No Preference 53 587.70

55957PA0300002 Rating Area 3 No Preference 54 615.07

55957PA0300002 Rating Area 3 No Preference 55 642.44

55957PA0300002 Rating Area 3 No Preference 56 672.11

55957PA0300002 Rating Area 3 No Preference 57 702.07

55957PA0300002 Rating Area 3 No Preference 58 734.05

55957PA0300002 Rating Area 3 No Preference 59 749.89

55957PA0300002 Rating Area 3 No Preference 60 781.87

55957PA0300002 Rating Area 3 No Preference 61 809.53

55957PA0300002 Rating Area 3 No Preference 62 827.68

55957PA0300002 Rating Area 3 No Preference 63 850.44

55957PA0300002 Rating Area 3 No Preference 64 864.27

55957PA0300002 Rating Area 3 No Preference 65 and over 864.27

55957PA0370001 Rating Area 3 No Preference 0-20 240.22

55957PA0370001 Rating Area 3 No Preference 21 378.31

55957PA0370001 Rating Area 3 No Preference 22 378.31

55957PA0370001 Rating Area 3 No Preference 23 378.31

55957PA0370001 Rating Area 3 No Preference 24 378.31

55957PA0370001 Rating Area 3 No Preference 25 379.82

55957PA0370001 Rating Area 3 No Preference 26 387.38

55957PA0370001 Rating Area 3 No Preference 27 396.46

55957PA0370001 Rating Area 3 No Preference 28 411.22

55957PA0370001 Rating Area 3 No Preference 29 423.32

55957PA0370001 Rating Area 3 No Preference 30 429.38

55957PA0370001 Rating Area 3 No Preference 31 438.46

55957PA0370001 Rating Area 3 No Preference 32 447.54

55957PA0370001 Rating Area 3 No Preference 33 453.21

55957PA0370001 Rating Area 3 No Preference 34 459.26

55957PA0370001 Rating Area 3 No Preference 35 462.29

55957PA0370001 Rating Area 3 No Preference 36 465.32

55957PA0370001 Rating Area 3 No Preference 37 468.34

55957PA0370001 Rating Area 3 No Preference 38 471.37

55957PA0370001 Rating Area 3 No Preference 39 477.42

55957PA0370001 Rating Area 3 No Preference 40 483.48

55957PA0370001 Rating Area 3 No Preference 41 492.55

55957PA0370001 Rating Area 3 No Preference 42 501.26

55957PA0370001 Rating Area 3 No Preference 43 513.36

55957PA0370001 Rating Area 3 No Preference 44 528.49

55957PA0370001 Rating Area 3 No Preference 45 546.27

55957PA0370001 Rating Area 3 No Preference 46 567.46

55957PA0370001 Rating Area 3 No Preference 47 591.29

55957PA0370001 Rating Area 3 No Preference 48 618.53

55957PA0370001 Rating Area 3 No Preference 49 645.39

55957PA0370001 Rating Area 3 No Preference 50 675.66

55957PA0370001 Rating Area 3 No Preference 51 705.54

55957PA0370001 Rating Area 3 No Preference 52 738.46

55957PA0370001 Rating Area 3 No Preference 53 771.75

55957PA0370001 Rating Area 3 No Preference 54 807.69

55957PA0370001 Rating Area 3 No Preference 55 843.63

55957PA0370001 Rating Area 3 No Preference 56 882.59

55957PA0370001 Rating Area 3 No Preference 57 921.94

55957PA0370001 Rating Area 3 No Preference 58 963.93

55957PA0370001 Rating Area 3 No Preference 59 984.74

55957PA0370001 Rating Area 3 No Preference 60 1026.73

55957PA0370001 Rating Area 3 No Preference 61 1063.05

55957PA0370001 Rating Area 3 No Preference 62 1086.88

55957PA0370001 Rating Area 3 No Preference 63 1116.77

55957PA0370001 Rating Area 3 No Preference 64 1134.93

55957PA0370001 Rating Area 3 No Preference 65 and over 1134.93

55957PA0370002 Rating Area 3 No Preference 0-20 229.60

55957PA0370002 Rating Area 3 No Preference 21 361.58

55957PA0370002 Rating Area 3 No Preference 22 361.58

55957PA0370002 Rating Area 3 No Preference 23 361.58

55957PA0370002 Rating Area 3 No Preference 24 361.58

55957PA0370002 Rating Area 3 No Preference 25 363.02

55957PA0370002 Rating Area 3 No Preference 26 370.25

55957PA0370002 Rating Area 3 No Preference 27 378.93

55957PA0370002 Rating Area 3 No Preference 28 393.03

55957PA0370002 Rating Area 3 No Preference 29 404.60

55957PA0370002 Rating Area 3 No Preference 30 410.39

55957PA0370002 Rating Area 3 No Preference 31 419.07

55957PA0370002 Rating Area 3 No Preference 32 427.74

55957PA0370002 Rating Area 3 No Preference 33 433.17

55957PA0370002 Rating Area 3 No Preference 34 438.95

55957PA0370002 Rating Area 3 No Preference 35 441.85

55957PA0370002 Rating Area 3 No Preference 36 444.74

55957PA0370002 Rating Area 3 No Preference 37 447.63

55957PA0370002 Rating Area 3 No Preference 38 450.52

55957PA0370002 Rating Area 3 No Preference 39 456.31

55957PA0370002 Rating Area 3 No Preference 40 462.09

55957PA0370002 Rating Area 3 No Preference 41 470.77

55957PA0370002 Rating Area 3 No Preference 42 479.09

55957PA0370002 Rating Area 3 No Preference 43 490.66

55957PA0370002 Rating Area 3 No Preference 44 505.12

55957PA0370002 Rating Area 3 No Preference 45 522.12

55957PA0370002 Rating Area 3 No Preference 46 542.37

55957PA0370002 Rating Area 3 No Preference 47 565.14

55957PA0370002 Rating Area 3 No Preference 48 591.18

55957PA0370002 Rating Area 3 No Preference 49 616.85

55957PA0370002 Rating Area 3 No Preference 50 645.78

55957PA0370002 Rating Area 3 No Preference 51 674.34

55957PA0370002 Rating Area 3 No Preference 52 705.80

55957PA0370002 Rating Area 3 No Preference 53 737.62

55957PA0370002 Rating Area 3 No Preference 54 771.97

55957PA0370002 Rating Area 3 No Preference 55 806.32

55957PA0370002 Rating Area 3 No Preference 56 843.56

55957PA0370002 Rating Area 3 No Preference 57 881.17

55957PA0370002 Rating Area 3 No Preference 58 921.30

55957PA0370002 Rating Area 3 No Preference 59 941.19

55957PA0370002 Rating Area 3 No Preference 60 981.32

55957PA0370002 Rating Area 3 No Preference 61 1016.03

55957PA0370002 Rating Area 3 No Preference 62 1038.81

55957PA0370002 Rating Area 3 No Preference 63 1067.38

55957PA0370002 Rating Area 3 No Preference 64 1084.74

55957PA0370002 Rating Area 3 No Preference 65 and over 1084.74

55957PA0380001 Rating Area 3 No Preference 0-20 188.51

55957PA0380001 Rating Area 3 No Preference 21 296.87

55957PA0380001 Rating Area 3 No Preference 22 296.87

55957PA0380001 Rating Area 3 No Preference 23 296.87

55957PA0380001 Rating Area 3 No Preference 24 296.87

55957PA0380001 Rating Area 3 No Preference 25 298.05

55957PA0380001 Rating Area 3 No Preference 26 303.99

55957PA0380001 Rating Area 3 No Preference 27 311.11

55957PA0380001 Rating Area 3 No Preference 28 322.69

55957PA0380001 Rating Area 3 No Preference 29 332.19

55957PA0380001 Rating Area 3 No Preference 30 336.94

55957PA0380001 Rating Area 3 No Preference 31 344.07

55957PA0380001 Rating Area 3 No Preference 32 351.19

55957PA0380001 Rating Area 3 No Preference 33 355.65

55957PA0380001 Rating Area 3 No Preference 34 360.40

55957PA0380001 Rating Area 3 No Preference 35 362.77

55957PA0380001 Rating Area 3 No Preference 36 365.15

55957PA0380001 Rating Area 3 No Preference 37 367.52

55957PA0380001 Rating Area 3 No Preference 38 369.90

55957PA0380001 Rating Area 3 No Preference 39 374.64

55957PA0380001 Rating Area 3 No Preference 40 379.39

55957PA0380001 Rating Area 3 No Preference 41 386.52

55957PA0380001 Rating Area 3 No Preference 42 393.35

55957PA0380001 Rating Area 3 No Preference 43 402.85

55957PA0380001 Rating Area 3 No Preference 44 414.72

55957PA0380001 Rating Area 3 No Preference 45 428.68

55957PA0380001 Rating Area 3 No Preference 46 445.30

55957PA0380001 Rating Area 3 No Preference 47 464.00

55957PA0380001 Rating Area 3 No Preference 48 485.38

55957PA0380001 Rating Area 3 No Preference 49 506.46

55957PA0380001 Rating Area 3 No Preference 50 530.20

55957PA0380001 Rating Area 3 No Preference 51 553.66

55957PA0380001 Rating Area 3 No Preference 52 579.49

55957PA0380001 Rating Area 3 No Preference 53 605.61

55957PA0380001 Rating Area 3 No Preference 54 633.81

55957PA0380001 Rating Area 3 No Preference 55 662.02

55957PA0380001 Rating Area 3 No Preference 56 692.59

55957PA0380001 Rating Area 3 No Preference 57 723.47

55957PA0380001 Rating Area 3 No Preference 58 756.42

55957PA0380001 Rating Area 3 No Preference 59 772.75

55957PA0380001 Rating Area 3 No Preference 60 805.70

55957PA0380001 Rating Area 3 No Preference 61 834.20

55957PA0380001 Rating Area 3 No Preference 62 852.90

55957PA0380001 Rating Area 3 No Preference 63 876.36

55957PA0380001 Rating Area 3 No Preference 64 890.61

55957PA0380001 Rating Area 3 No Preference 65 and over 890.61

2017 Rates Table Template v6.0 All fields with an asterisk ( * ) are required. To validate press Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells B1 through B5.If you are a community rating state, select Family Option under Age and fill in all columns.

If you are not community rating state, select 0-20 under Age and provide an Individual Rate for every age band.

If Tobacco is Tobacco User/Non-Tobacco User, you must give a rate for Tobacco Use and Non-Tobacco Use.

To add a new sheet, press the Add Sheet button, or Ctrl + Shift + H. All plans must have the same dates on a sheet.

HIOS Issuer ID* 55957

Federal TIN* 23-2905083

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

Plan ID* Rating Area ID* Tobacco* Age* Individual Rate*

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a plan

Required:

Select the age of a subscriber eligible for the rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

55957PA0270007 Rating Area 3 No Preference 0-20 284.20

55957PA0270007 Rating Area 3 No Preference 21 447.56

55957PA0270007 Rating Area 3 No Preference 22 447.56

55957PA0270007 Rating Area 3 No Preference 23 447.56

55957PA0270007 Rating Area 3 No Preference 24 447.56

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55957PA0270006 Rating Area 3 No Preference 56 1032.79

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55957PA0270006 Rating Area 3 No Preference 65 and over 1328.07

55957PA0270017 Rating Area 3 No Preference 0-20 257.01

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55957PA0270017 Rating Area 3 No Preference 23 404.75

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55957PA0270017 Rating Area 3 No Preference 65 and over 1214.25

55957PA0270018 Rating Area 3 No Preference 0-20 236.65

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55957PA0270018 Rating Area 3 No Preference 63 1100.15

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55957PA0270018 Rating Area 3 No Preference 65 and over 1118.04

55957PA0270008 Rating Area 3 No Preference 0-20 240.64

55957PA0270008 Rating Area 3 No Preference 21 378.97

55957PA0270008 Rating Area 3 No Preference 22 378.97

55957PA0270008 Rating Area 3 No Preference 23 378.97

55957PA0270008 Rating Area 3 No Preference 24 378.97

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55957PA0270008 Rating Area 3 No Preference 63 1118.71

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55957PA0270008 Rating Area 3 No Preference 65 and over 1136.91

55957PA0270009 Rating Area 3 No Preference 0-20 240.87

55957PA0270009 Rating Area 3 No Preference 21 379.33

55957PA0270009 Rating Area 3 No Preference 22 379.33

55957PA0270009 Rating Area 3 No Preference 23 379.33

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55957PA0270009 Rating Area 3 No Preference 30 430.53

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55957PA0270009 Rating Area 3 No Preference 40 484.78

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55957PA0270009 Rating Area 3 No Preference 63 1119.78

55957PA0270009 Rating Area 3 No Preference 64 1137.99

55957PA0270009 Rating Area 3 No Preference 65 and over 1137.99

55957PA0270010 Rating Area 3 No Preference 0-20 244.91

55957PA0270010 Rating Area 3 No Preference 21 385.70

55957PA0270010 Rating Area 3 No Preference 22 385.70

55957PA0270010 Rating Area 3 No Preference 23 385.70

55957PA0270010 Rating Area 3 No Preference 24 385.70

55957PA0270010 Rating Area 3 No Preference 25 387.24

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55957PA0270010 Rating Area 3 No Preference 65 and over 1157.10

55957PA0270011 Rating Area 3 No Preference 0-20 235.02

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55957PA0270011 Rating Area 3 No Preference 23 370.12

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55957PA0270011 Rating Area 3 No Preference 63 1092.59

55957PA0270011 Rating Area 3 No Preference 64 1110.36

55957PA0270011 Rating Area 3 No Preference 65 and over 1110.36

55957PA0270022 Rating Area 3 No Preference 0-20 201.97

55957PA0270022 Rating Area 3 No Preference 21 318.07

55957PA0270022 Rating Area 3 No Preference 22 318.07

55957PA0270022 Rating Area 3 No Preference 23 318.07

55957PA0270022 Rating Area 3 No Preference 24 318.07

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55957PA0270022 Rating Area 3 No Preference 27 333.33

55957PA0270022 Rating Area 3 No Preference 28 345.74

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55957PA0270021 Rating Area 3 No Preference 56 742.22

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55957PA0270021 Rating Area 3 No Preference 64 954.42

55957PA0270021 Rating Area 3 No Preference 65 and over 954.42

55957PA0270013 Rating Area 3 No Preference 0-20 162.71

55957PA0270013 Rating Area 3 No Preference 21 256.24

55957PA0270013 Rating Area 3 No Preference 22 256.24

55957PA0270013 Rating Area 3 No Preference 23 256.24

55957PA0270013 Rating Area 3 No Preference 24 256.24

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55957PA0270013 Rating Area 3 No Preference 27 268.53

55957PA0270013 Rating Area 3 No Preference 28 278.53

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55957PA0290007 Rating Area 3 No Preference 21 375.95

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55957PA0290007 Rating Area 3 No Preference 25 377.45

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55957PA0290007 Rating Area 3 No Preference 28 408.65

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55957PA0290007 Rating Area 3 No Preference 35 459.41

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55957PA0290007 Rating Area 3 No Preference 65 and over 1127.85

55957PA0290008 Rating Area 3 No Preference 0-20 240.34

55957PA0290008 Rating Area 3 No Preference 21 378.50

55957PA0290008 Rating Area 3 No Preference 22 378.50

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55957PA0290008 Rating Area 3 No Preference 28 411.42

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55957PA0290008 Rating Area 3 No Preference 63 1117.33

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55957PA0290008 Rating Area 3 No Preference 65 and over 1135.50

55957PA0290002 Rating Area 3 No Preference 0-20 238.86

55957PA0290002 Rating Area 3 No Preference 21 376.17

55957PA0290002 Rating Area 3 No Preference 22 376.17

55957PA0290002 Rating Area 3 No Preference 23 376.17

55957PA0290002 Rating Area 3 No Preference 24 376.17

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55957PA0290002 Rating Area 3 No Preference 57 916.72

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55957PA0290002 Rating Area 3 No Preference 63 1110.45

55957PA0290002 Rating Area 3 No Preference 64 1128.51

55957PA0290002 Rating Area 3 No Preference 65 and over 1128.51

55957PA0290006 Rating Area 3 No Preference 0-20 236.13

55957PA0290006 Rating Area 3 No Preference 21 371.86

55957PA0290006 Rating Area 3 No Preference 22 371.86

55957PA0290006 Rating Area 3 No Preference 23 371.86

55957PA0290006 Rating Area 3 No Preference 24 371.86

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55957PA0290006 Rating Area 3 No Preference 28 404.21

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55957PA0290006 Rating Area 3 No Preference 32 439.91

55957PA0290006 Rating Area 3 No Preference 33 445.48

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55957PA0290006 Rating Area 3 No Preference 35 454.41

55957PA0290006 Rating Area 3 No Preference 36 457.38

55957PA0290006 Rating Area 3 No Preference 37 460.36

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55957PA0290006 Rating Area 3 No Preference 40 475.23

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55957PA0290006 Rating Area 3 No Preference 51 693.51

55957PA0290006 Rating Area 3 No Preference 52 725.87

55957PA0290006 Rating Area 3 No Preference 53 758.59

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55957PA0290006 Rating Area 3 No Preference 55 829.24

55957PA0290006 Rating Area 3 No Preference 56 867.54

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55957PA0290006 Rating Area 3 No Preference 63 1097.73

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55957PA0290006 Rating Area 3 No Preference 65 and over 1115.58

55957PA0290022 Rating Area 3 No Preference 0-20 215.89

55957PA0290022 Rating Area 3 No Preference 21 339.99

55957PA0290022 Rating Area 3 No Preference 22 339.99

55957PA0290022 Rating Area 3 No Preference 23 339.99

55957PA0290022 Rating Area 3 No Preference 24 339.99

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55957PA0290022 Rating Area 3 No Preference 48 555.88

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55957PA0290022 Rating Area 3 No Preference 53 693.57

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55957PA0290022 Rating Area 3 No Preference 65 and over 1019.97

55957PA0290012 Rating Area 3 No Preference 0-20 198.79

55957PA0290012 Rating Area 3 No Preference 21 313.06

55957PA0290012 Rating Area 3 No Preference 22 313.06

55957PA0290012 Rating Area 3 No Preference 23 313.06

55957PA0290012 Rating Area 3 No Preference 24 313.06

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55957PA0290012 Rating Area 3 No Preference 38 390.07

55957PA0290012 Rating Area 3 No Preference 39 395.08

55957PA0290012 Rating Area 3 No Preference 40 400.09

55957PA0290012 Rating Area 3 No Preference 41 407.60

55957PA0290012 Rating Area 3 No Preference 42 414.80

55957PA0290012 Rating Area 3 No Preference 43 424.82

55957PA0290012 Rating Area 3 No Preference 44 437.34

55957PA0290012 Rating Area 3 No Preference 45 452.05

55957PA0290012 Rating Area 3 No Preference 46 469.59

55957PA0290012 Rating Area 3 No Preference 47 489.31

55957PA0290012 Rating Area 3 No Preference 48 511.85

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55957PA0290012 Rating Area 3 No Preference 53 638.64

55957PA0290012 Rating Area 3 No Preference 54 668.38

55957PA0290012 Rating Area 3 No Preference 55 698.12

55957PA0290012 Rating Area 3 No Preference 56 730.36

55957PA0290012 Rating Area 3 No Preference 57 762.92

55957PA0290012 Rating Area 3 No Preference 58 797.67

55957PA0290012 Rating Area 3 No Preference 59 814.89

55957PA0290012 Rating Area 3 No Preference 60 849.64

55957PA0290012 Rating Area 3 No Preference 61 879.69

55957PA0290012 Rating Area 3 No Preference 62 899.42

55957PA0290012 Rating Area 3 No Preference 63 924.15

55957PA0290012 Rating Area 3 No Preference 64 939.18

55957PA0290012 Rating Area 3 No Preference 65 and over 939.18

55957PA0290011 Rating Area 3 No Preference 0-20 202.13

55957PA0290011 Rating Area 3 No Preference 21 318.33

55957PA0290011 Rating Area 3 No Preference 22 318.33

55957PA0290011 Rating Area 3 No Preference 23 318.33

55957PA0290011 Rating Area 3 No Preference 24 318.33

55957PA0290011 Rating Area 3 No Preference 25 319.60

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55957PA0290011 Rating Area 3 No Preference 28 346.02

55957PA0290011 Rating Area 3 No Preference 29 356.21

55957PA0290011 Rating Area 3 No Preference 30 361.30

55957PA0290011 Rating Area 3 No Preference 31 368.94

55957PA0290011 Rating Area 3 No Preference 32 376.58

55957PA0290011 Rating Area 3 No Preference 33 381.35

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55957PA0290011 Rating Area 3 No Preference 35 388.99

55957PA0290011 Rating Area 3 No Preference 36 391.54

55957PA0290011 Rating Area 3 No Preference 37 394.09

55957PA0290011 Rating Area 3 No Preference 38 396.63

55957PA0290011 Rating Area 3 No Preference 39 401.73

55957PA0290011 Rating Area 3 No Preference 40 406.82

55957PA0290011 Rating Area 3 No Preference 41 414.46

55957PA0290011 Rating Area 3 No Preference 42 421.78

55957PA0290011 Rating Area 3 No Preference 43 431.97

55957PA0290011 Rating Area 3 No Preference 44 444.70

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55957PA0290011 Rating Area 3 No Preference 46 477.49

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55957PA0290011 Rating Area 3 No Preference 48 520.46

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55957PA0290011 Rating Area 3 No Preference 50 568.53

55957PA0290011 Rating Area 3 No Preference 51 593.68

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55957PA0290011 Rating Area 3 No Preference 53 649.39

55957PA0290011 Rating Area 3 No Preference 54 679.63

55957PA0290011 Rating Area 3 No Preference 55 709.87

55957PA0290011 Rating Area 3 No Preference 56 742.66

55957PA0290011 Rating Area 3 No Preference 57 775.77

55957PA0290011 Rating Area 3 No Preference 58 811.10

55957PA0290011 Rating Area 3 No Preference 59 828.61

55957PA0290011 Rating Area 3 No Preference 60 863.94

55957PA0290011 Rating Area 3 No Preference 61 894.50

55957PA0290011 Rating Area 3 No Preference 62 914.56

55957PA0290011 Rating Area 3 No Preference 63 939.71

55957PA0290011 Rating Area 3 No Preference 64 954.99

55957PA0290011 Rating Area 3 No Preference 65 and over 954.99

55957PA0290013 Rating Area 3 No Preference 0-20 202.33

55957PA0290013 Rating Area 3 No Preference 21 318.64

55957PA0290013 Rating Area 3 No Preference 22 318.64

55957PA0290013 Rating Area 3 No Preference 23 318.64

55957PA0290013 Rating Area 3 No Preference 24 318.64

55957PA0290013 Rating Area 3 No Preference 25 319.91

55957PA0290013 Rating Area 3 No Preference 26 326.28

55957PA0290013 Rating Area 3 No Preference 27 333.93

55957PA0290013 Rating Area 3 No Preference 28 346.36

55957PA0290013 Rating Area 3 No Preference 29 356.55

55957PA0290013 Rating Area 3 No Preference 30 361.65

55957PA0290013 Rating Area 3 No Preference 31 369.30

55957PA0290013 Rating Area 3 No Preference 32 376.95

55957PA0290013 Rating Area 3 No Preference 33 381.73

55957PA0290013 Rating Area 3 No Preference 34 386.82

55957PA0290013 Rating Area 3 No Preference 35 389.37

55957PA0290013 Rating Area 3 No Preference 36 391.92

55957PA0290013 Rating Area 3 No Preference 37 394.47

55957PA0290013 Rating Area 3 No Preference 38 397.02

55957PA0290013 Rating Area 3 No Preference 39 402.12

55957PA0290013 Rating Area 3 No Preference 40 407.22

55957PA0290013 Rating Area 3 No Preference 41 414.86

55957PA0290013 Rating Area 3 No Preference 42 422.19

55957PA0290013 Rating Area 3 No Preference 43 432.39

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55957PA0290013 Rating Area 3 No Preference 46 477.96

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55957PA0290013 Rating Area 3 No Preference 48 520.97

55957PA0290013 Rating Area 3 No Preference 49 543.59

55957PA0290013 Rating Area 3 No Preference 50 569.09

55957PA0290013 Rating Area 3 No Preference 51 594.26

55957PA0290013 Rating Area 3 No Preference 52 621.98

55957PA0290013 Rating Area 3 No Preference 53 650.02

55957PA0290013 Rating Area 3 No Preference 54 680.29

55957PA0290013 Rating Area 3 No Preference 55 710.56

55957PA0290013 Rating Area 3 No Preference 56 743.38

55957PA0290013 Rating Area 3 No Preference 57 776.52

55957PA0290013 Rating Area 3 No Preference 58 811.89

55957PA0290013 Rating Area 3 No Preference 59 829.41

55957PA0290013 Rating Area 3 No Preference 60 864.78

55957PA0290013 Rating Area 3 No Preference 61 895.37

55957PA0290013 Rating Area 3 No Preference 62 915.45

55957PA0290013 Rating Area 3 No Preference 63 940.62

55957PA0290013 Rating Area 3 No Preference 64 955.92

55957PA0290013 Rating Area 3 No Preference 65 and over 955.92

55957PA0290014 Rating Area 3 No Preference 0-20 205.73

55957PA0290014 Rating Area 3 No Preference 21 323.99

55957PA0290014 Rating Area 3 No Preference 22 323.99

55957PA0290014 Rating Area 3 No Preference 23 323.99

55957PA0290014 Rating Area 3 No Preference 24 323.99

55957PA0290014 Rating Area 3 No Preference 25 325.28

55957PA0290014 Rating Area 3 No Preference 26 331.76

55957PA0290014 Rating Area 3 No Preference 27 339.54

55957PA0290014 Rating Area 3 No Preference 28 352.17

55957PA0290014 Rating Area 3 No Preference 29 362.54

55957PA0290014 Rating Area 3 No Preference 30 367.72

55957PA0290014 Rating Area 3 No Preference 31 375.50

55957PA0290014 Rating Area 3 No Preference 32 383.28

55957PA0290014 Rating Area 3 No Preference 33 388.14

55957PA0290014 Rating Area 3 No Preference 34 393.32

55957PA0290014 Rating Area 3 No Preference 35 395.91

55957PA0290014 Rating Area 3 No Preference 36 398.50

55957PA0290014 Rating Area 3 No Preference 37 401.09

55957PA0290014 Rating Area 3 No Preference 38 403.69

55957PA0290014 Rating Area 3 No Preference 39 408.87

55957PA0290014 Rating Area 3 No Preference 40 414.05

55957PA0290014 Rating Area 3 No Preference 41 421.83

55957PA0290014 Rating Area 3 No Preference 42 429.28

55957PA0290014 Rating Area 3 No Preference 43 439.65

55957PA0290014 Rating Area 3 No Preference 44 452.61

55957PA0290014 Rating Area 3 No Preference 45 467.84

55957PA0290014 Rating Area 3 No Preference 46 485.98

55957PA0290014 Rating Area 3 No Preference 47 506.39

55957PA0290014 Rating Area 3 No Preference 48 529.72

55957PA0290014 Rating Area 3 No Preference 49 552.72

55957PA0290014 Rating Area 3 No Preference 50 578.64

55957PA0290014 Rating Area 3 No Preference 51 604.24

55957PA0290014 Rating Area 3 No Preference 52 632.42

55957PA0290014 Rating Area 3 No Preference 53 660.93

55957PA0290014 Rating Area 3 No Preference 54 691.71

55957PA0290014 Rating Area 3 No Preference 55 722.49

55957PA0290014 Rating Area 3 No Preference 56 755.86

55957PA0290014 Rating Area 3 No Preference 57 789.56

55957PA0290014 Rating Area 3 No Preference 58 825.52

55957PA0290014 Rating Area 3 No Preference 59 843.34

55957PA0290014 Rating Area 3 No Preference 60 879.30

55957PA0290014 Rating Area 3 No Preference 61 910.41

55957PA0290014 Rating Area 3 No Preference 62 930.82

55957PA0290014 Rating Area 3 No Preference 63 956.41

55957PA0290014 Rating Area 3 No Preference 64 971.97

55957PA0290014 Rating Area 3 No Preference 65 and over 971.97

55957PA0290016 Rating Area 3 No Preference 0-20 197.50

55957PA0290016 Rating Area 3 No Preference 21 311.03

55957PA0290016 Rating Area 3 No Preference 22 311.03

55957PA0290016 Rating Area 3 No Preference 23 311.03

55957PA0290016 Rating Area 3 No Preference 24 311.03

55957PA0290016 Rating Area 3 No Preference 25 312.27

55957PA0290016 Rating Area 3 No Preference 26 318.49

55957PA0290016 Rating Area 3 No Preference 27 325.95

55957PA0290016 Rating Area 3 No Preference 28 338.08

55957PA0290016 Rating Area 3 No Preference 29 348.04

55957PA0290016 Rating Area 3 No Preference 30 353.01

55957PA0290016 Rating Area 3 No Preference 31 360.48

55957PA0290016 Rating Area 3 No Preference 32 367.94

55957PA0290016 Rating Area 3 No Preference 33 372.61

55957PA0290016 Rating Area 3 No Preference 34 377.59

55957PA0290016 Rating Area 3 No Preference 35 380.07

55957PA0290016 Rating Area 3 No Preference 36 382.56

55957PA0290016 Rating Area 3 No Preference 37 385.05

55957PA0290016 Rating Area 3 No Preference 38 387.54

55957PA0290016 Rating Area 3 No Preference 39 392.51

55957PA0290016 Rating Area 3 No Preference 40 397.49

55957PA0290016 Rating Area 3 No Preference 41 404.96

55957PA0290016 Rating Area 3 No Preference 42 412.11

55957PA0290016 Rating Area 3 No Preference 43 422.06

55957PA0290016 Rating Area 3 No Preference 44 434.50

55957PA0290016 Rating Area 3 No Preference 45 449.12

55957PA0290016 Rating Area 3 No Preference 46 466.54

55957PA0290016 Rating Area 3 No Preference 47 486.13

55957PA0290016 Rating Area 3 No Preference 48 508.53

55957PA0290016 Rating Area 3 No Preference 49 530.61

55957PA0290016 Rating Area 3 No Preference 50 555.49

55957PA0290016 Rating Area 3 No Preference 51 580.07

55957PA0290016 Rating Area 3 No Preference 52 607.13

55957PA0290016 Rating Area 3 No Preference 53 634.50

55957PA0290016 Rating Area 3 No Preference 54 664.04

55957PA0290016 Rating Area 3 No Preference 55 693.59

55957PA0290016 Rating Area 3 No Preference 56 725.63

55957PA0290016 Rating Area 3 No Preference 57 757.98

55957PA0290016 Rating Area 3 No Preference 58 792.50

55957PA0290016 Rating Area 3 No Preference 59 809.61

55957PA0290016 Rating Area 3 No Preference 60 844.13

55957PA0290016 Rating Area 3 No Preference 61 873.99

55957PA0290016 Rating Area 3 No Preference 62 893.58

55957PA0290016 Rating Area 3 No Preference 63 918.16

55957PA0290016 Rating Area 3 No Preference 64 933.09

55957PA0290016 Rating Area 3 No Preference 65 and over 933.09

55957PA0290023 Rating Area 3 No Preference 0-20 169.65

55957PA0290023 Rating Area 3 No Preference 21 267.18

55957PA0290023 Rating Area 3 No Preference 22 267.18

55957PA0290023 Rating Area 3 No Preference 23 267.18

55957PA0290023 Rating Area 3 No Preference 24 267.18

55957PA0290023 Rating Area 3 No Preference 25 268.24

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55957PA0290023 Rating Area 3 No Preference 28 290.42

55957PA0290023 Rating Area 3 No Preference 29 298.97

55957PA0290023 Rating Area 3 No Preference 30 303.24

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55957PA0290023 Rating Area 3 No Preference 32 316.07

55957PA0290023 Rating Area 3 No Preference 33 320.08

55957PA0290023 Rating Area 3 No Preference 34 324.35

55957PA0290023 Rating Area 3 No Preference 35 326.49

55957PA0290023 Rating Area 3 No Preference 36 328.63

55957PA0290023 Rating Area 3 No Preference 37 330.76

55957PA0290023 Rating Area 3 No Preference 38 332.90

55957PA0290023 Rating Area 3 No Preference 39 337.18

55957PA0290023 Rating Area 3 No Preference 40 341.45

55957PA0290023 Rating Area 3 No Preference 41 347.86

55957PA0290023 Rating Area 3 No Preference 42 354.01

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55957PA0290023 Rating Area 3 No Preference 44 373.25

55957PA0290023 Rating Area 3 No Preference 45 385.80

55957PA0290023 Rating Area 3 No Preference 46 400.77

55957PA0290023 Rating Area 3 No Preference 47 417.60

55957PA0290023 Rating Area 3 No Preference 48 436.83

55957PA0290023 Rating Area 3 No Preference 49 455.80

55957PA0290023 Rating Area 3 No Preference 50 477.18

55957PA0290023 Rating Area 3 No Preference 51 498.29

55957PA0290023 Rating Area 3 No Preference 52 521.53

55957PA0290023 Rating Area 3 No Preference 53 545.04

55957PA0290023 Rating Area 3 No Preference 54 570.42

55957PA0290023 Rating Area 3 No Preference 55 595.81

55957PA0290023 Rating Area 3 No Preference 56 623.33

55957PA0290023 Rating Area 3 No Preference 57 651.11

55957PA0290023 Rating Area 3 No Preference 58 680.77

55957PA0290023 Rating Area 3 No Preference 59 695.46

55957PA0290023 Rating Area 3 No Preference 60 725.12

55957PA0290023 Rating Area 3 No Preference 61 750.77

55957PA0290023 Rating Area 3 No Preference 62 767.60

55957PA0290023 Rating Area 3 No Preference 63 788.71

55957PA0290023 Rating Area 3 No Preference 64 801.54

55957PA0290023 Rating Area 3 No Preference 65 and over 801.54

55957PA0290017 Rating Area 3 No Preference 0-20 161.37

55957PA0290017 Rating Area 3 No Preference 21 254.14

55957PA0290017 Rating Area 3 No Preference 22 254.14

55957PA0290017 Rating Area 3 No Preference 23 254.14

55957PA0290017 Rating Area 3 No Preference 24 254.14

55957PA0290017 Rating Area 3 No Preference 25 255.15

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55957PA0290017 Rating Area 3 No Preference 27 266.33

55957PA0290017 Rating Area 3 No Preference 28 276.25

55957PA0290017 Rating Area 3 No Preference 29 284.38

55957PA0290017 Rating Area 3 No Preference 30 288.44

55957PA0290017 Rating Area 3 No Preference 31 294.54

55957PA0290017 Rating Area 3 No Preference 32 300.64

55957PA0290017 Rating Area 3 No Preference 33 304.45

55957PA0290017 Rating Area 3 No Preference 34 308.52

55957PA0290017 Rating Area 3 No Preference 35 310.55

55957PA0290017 Rating Area 3 No Preference 36 312.59

55957PA0290017 Rating Area 3 No Preference 37 314.62

55957PA0290017 Rating Area 3 No Preference 38 316.65

55957PA0290017 Rating Area 3 No Preference 39 320.72

55957PA0290017 Rating Area 3 No Preference 40 324.79

55957PA0290017 Rating Area 3 No Preference 41 330.89

55957PA0290017 Rating Area 3 No Preference 42 336.73

55957PA0290017 Rating Area 3 No Preference 43 344.86

55957PA0290017 Rating Area 3 No Preference 44 355.03

55957PA0290017 Rating Area 3 No Preference 45 366.97

55957PA0290017 Rating Area 3 No Preference 46 381.21

55957PA0290017 Rating Area 3 No Preference 47 397.22

55957PA0290017 Rating Area 3 No Preference 48 415.51

55957PA0290017 Rating Area 3 No Preference 49 433.56

55957PA0290017 Rating Area 3 No Preference 50 453.89

55957PA0290017 Rating Area 3 No Preference 51 473.97

55957PA0290017 Rating Area 3 No Preference 52 496.08

55957PA0290017 Rating Area 3 No Preference 53 518.44

55957PA0290017 Rating Area 3 No Preference 54 542.58

55957PA0290017 Rating Area 3 No Preference 55 566.73

55957PA0290017 Rating Area 3 No Preference 56 592.90

55957PA0290017 Rating Area 3 No Preference 57 619.33

55957PA0290017 Rating Area 3 No Preference 58 647.54

55957PA0290017 Rating Area 3 No Preference 59 661.52

55957PA0290017 Rating Area 3 No Preference 60 689.73

55957PA0290017 Rating Area 3 No Preference 61 714.13

55957PA0290017 Rating Area 3 No Preference 62 730.14

55957PA0290017 Rating Area 3 No Preference 63 750.22

55957PA0290017 Rating Area 3 No Preference 64 762.42

55957PA0290017 Rating Area 3 No Preference 65 and over 762.42

55957PA0290018 Rating Area 3 No Preference 0-20 171.49

55957PA0290018 Rating Area 3 No Preference 21 270.07

55957PA0290018 Rating Area 3 No Preference 22 270.07

55957PA0290018 Rating Area 3 No Preference 23 270.07

55957PA0290018 Rating Area 3 No Preference 24 270.07

55957PA0290018 Rating Area 3 No Preference 25 271.15

55957PA0290018 Rating Area 3 No Preference 26 276.55

55957PA0290018 Rating Area 3 No Preference 27 283.03

55957PA0290018 Rating Area 3 No Preference 28 293.56

55957PA0290018 Rating Area 3 No Preference 29 302.20

55957PA0290018 Rating Area 3 No Preference 30 306.52

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55957PA0290018 Rating Area 3 No Preference 32 319.49

55957PA0290018 Rating Area 3 No Preference 33 323.54

55957PA0290018 Rating Area 3 No Preference 34 327.86

55957PA0290018 Rating Area 3 No Preference 35 330.02

55957PA0290018 Rating Area 3 No Preference 36 332.18

55957PA0290018 Rating Area 3 No Preference 37 334.34

55957PA0290018 Rating Area 3 No Preference 38 336.50

55957PA0290018 Rating Area 3 No Preference 39 340.82

55957PA0290018 Rating Area 3 No Preference 40 345.14

55957PA0290018 Rating Area 3 No Preference 41 351.63

55957PA0290018 Rating Area 3 No Preference 42 357.84

55957PA0290018 Rating Area 3 No Preference 43 366.48

55957PA0290018 Rating Area 3 No Preference 44 377.28

55957PA0290018 Rating Area 3 No Preference 45 389.98

55957PA0290018 Rating Area 3 No Preference 46 405.10

55957PA0290018 Rating Area 3 No Preference 47 422.11

55957PA0290018 Rating Area 3 No Preference 48 441.56

55957PA0290018 Rating Area 3 No Preference 49 460.73

55957PA0290018 Rating Area 3 No Preference 50 482.34

55957PA0290018 Rating Area 3 No Preference 51 503.68

55957PA0290018 Rating Area 3 No Preference 52 527.17

55957PA0290018 Rating Area 3 No Preference 53 550.94

55957PA0290018 Rating Area 3 No Preference 54 576.59

55957PA0290018 Rating Area 3 No Preference 55 602.25

55957PA0290018 Rating Area 3 No Preference 56 630.07

55957PA0290018 Rating Area 3 No Preference 57 658.16

55957PA0290018 Rating Area 3 No Preference 58 688.13

55957PA0290018 Rating Area 3 No Preference 59 702.99

55957PA0290018 Rating Area 3 No Preference 60 732.96

55957PA0290018 Rating Area 3 No Preference 61 758.89

55957PA0290018 Rating Area 3 No Preference 62 775.91

55957PA0290018 Rating Area 3 No Preference 63 797.24

55957PA0290018 Rating Area 3 No Preference 64 810.21

55957PA0290018 Rating Area 3 No Preference 65 and over 810.21

55957PA0290019 Rating Area 3 No Preference 0-20 169.69

55957PA0290019 Rating Area 3 No Preference 21 267.23

55957PA0290019 Rating Area 3 No Preference 22 267.23

55957PA0290019 Rating Area 3 No Preference 23 267.23

55957PA0290019 Rating Area 3 No Preference 24 267.23

55957PA0290019 Rating Area 3 No Preference 25 268.29

55957PA0290019 Rating Area 3 No Preference 26 273.64

55957PA0290019 Rating Area 3 No Preference 27 280.05

55957PA0290019 Rating Area 3 No Preference 28 290.47

55957PA0290019 Rating Area 3 No Preference 29 299.03

55957PA0290019 Rating Area 3 No Preference 30 303.30

55957PA0290019 Rating Area 3 No Preference 31 309.71

55957PA0290019 Rating Area 3 No Preference 32 316.13

55957PA0290019 Rating Area 3 No Preference 33 320.14

55957PA0290019 Rating Area 3 No Preference 34 324.41

55957PA0290019 Rating Area 3 No Preference 35 326.55

55957PA0290019 Rating Area 3 No Preference 36 328.69

55957PA0290019 Rating Area 3 No Preference 37 330.83

55957PA0290019 Rating Area 3 No Preference 38 332.96

55957PA0290019 Rating Area 3 No Preference 39 337.24

55957PA0290019 Rating Area 3 No Preference 40 341.51

55957PA0290019 Rating Area 3 No Preference 41 347.93

55957PA0290019 Rating Area 3 No Preference 42 354.07

55957PA0290019 Rating Area 3 No Preference 43 362.63

55957PA0290019 Rating Area 3 No Preference 44 373.32

55957PA0290019 Rating Area 3 No Preference 45 385.88

55957PA0290019 Rating Area 3 No Preference 46 400.84

55957PA0290019 Rating Area 3 No Preference 47 417.68

55957PA0290019 Rating Area 3 No Preference 48 436.92

55957PA0290019 Rating Area 3 No Preference 49 455.89

55957PA0290019 Rating Area 3 No Preference 50 477.27

55957PA0290019 Rating Area 3 No Preference 51 498.38

55957PA0290019 Rating Area 3 No Preference 52 521.63

55957PA0290019 Rating Area 3 No Preference 53 545.14

55957PA0290019 Rating Area 3 No Preference 54 570.53

55957PA0290019 Rating Area 3 No Preference 55 595.92

55957PA0290019 Rating Area 3 No Preference 56 623.44

55957PA0290019 Rating Area 3 No Preference 57 651.23

55957PA0290019 Rating Area 3 No Preference 58 680.90

55957PA0290019 Rating Area 3 No Preference 59 695.59

55957PA0290019 Rating Area 3 No Preference 60 725.26

55957PA0290019 Rating Area 3 No Preference 61 750.91

55957PA0290019 Rating Area 3 No Preference 62 767.75

55957PA0290019 Rating Area 3 No Preference 63 788.86

55957PA0290019 Rating Area 3 No Preference 64 801.69

55957PA0290019 Rating Area 3 No Preference 65 and over 801.69

55957PA0290021 Rating Area 3 No Preference 0-20 136.67

55957PA0290021 Rating Area 3 No Preference 21 215.24

55957PA0290021 Rating Area 3 No Preference 22 215.24

55957PA0290021 Rating Area 3 No Preference 23 215.24

55957PA0290021 Rating Area 3 No Preference 24 215.24

55957PA0290021 Rating Area 3 No Preference 25 216.10

55957PA0290021 Rating Area 3 No Preference 26 220.40

55957PA0290021 Rating Area 3 No Preference 27 225.57

55957PA0290021 Rating Area 3 No Preference 28 233.96

55957PA0290021 Rating Area 3 No Preference 29 240.85

55957PA0290021 Rating Area 3 No Preference 30 244.29

55957PA0290021 Rating Area 3 No Preference 31 249.46

55957PA0290021 Rating Area 3 No Preference 32 254.62

55957PA0290021 Rating Area 3 No Preference 33 257.85

55957PA0290021 Rating Area 3 No Preference 34 261.30

55957PA0290021 Rating Area 3 No Preference 35 263.02

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55957PA0290021 Rating Area 3 No Preference 37 266.46

55957PA0290021 Rating Area 3 No Preference 38 268.18

55957PA0290021 Rating Area 3 No Preference 39 271.63

55957PA0290021 Rating Area 3 No Preference 40 275.07

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55957PA0290021 Rating Area 3 No Preference 45 310.80

55957PA0290021 Rating Area 3 No Preference 46 322.86

55957PA0290021 Rating Area 3 No Preference 47 336.42

55957PA0290021 Rating Area 3 No Preference 48 351.91

55957PA0290021 Rating Area 3 No Preference 49 367.19

55957PA0290021 Rating Area 3 No Preference 50 384.41

55957PA0290021 Rating Area 3 No Preference 51 401.42

55957PA0290021 Rating Area 3 No Preference 52 420.14

55957PA0290021 Rating Area 3 No Preference 53 439.08

55957PA0290021 Rating Area 3 No Preference 54 459.53

55957PA0290021 Rating Area 3 No Preference 55 479.98

55957PA0290021 Rating Area 3 No Preference 56 502.15

55957PA0290021 Rating Area 3 No Preference 57 524.53

55957PA0290021 Rating Area 3 No Preference 58 548.43

55957PA0290021 Rating Area 3 No Preference 59 560.26

55957PA0290021 Rating Area 3 No Preference 60 584.16

55957PA0290021 Rating Area 3 No Preference 61 604.82

55957PA0290021 Rating Area 3 No Preference 62 618.38

55957PA0290021 Rating Area 3 No Preference 63 635.38

55957PA0290021 Rating Area 3 No Preference 64 645.72

55957PA0290021 Rating Area 3 No Preference 65 and over 645.72

55957PA0280001 Rating Area 3 No Preference 0-20 160.66

55957PA0280001 Rating Area 3 No Preference 21 253.02

55957PA0280001 Rating Area 3 No Preference 22 253.02

55957PA0280001 Rating Area 3 No Preference 23 253.02

55957PA0280001 Rating Area 3 No Preference 24 253.02

55957PA0280001 Rating Area 3 No Preference 25 254.03

55957PA0280001 Rating Area 3 No Preference 26 259.09

55957PA0280001 Rating Area 3 No Preference 27 265.16

55957PA0280001 Rating Area 3 No Preference 28 275.03

55957PA0280001 Rating Area 3 No Preference 29 283.12

55957PA0280001 Rating Area 3 No Preference 30 287.17

55957PA0280001 Rating Area 3 No Preference 31 293.25

55957PA0280001 Rating Area 3 No Preference 32 299.32

55957PA0280001 Rating Area 3 No Preference 33 303.11

55957PA0280001 Rating Area 3 No Preference 34 307.16

55957PA0280001 Rating Area 3 No Preference 35 309.19

55957PA0280001 Rating Area 3 No Preference 36 311.21

55957PA0280001 Rating Area 3 No Preference 37 313.23

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55957PA0280001 Rating Area 3 No Preference 39 319.31

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55957PA0280001 Rating Area 3 No Preference 42 335.25

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55957PA0280001 Rating Area 3 No Preference 44 353.46

55957PA0280001 Rating Area 3 No Preference 45 365.36

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55957PA0280001 Rating Area 3 No Preference 47 395.47

55957PA0280001 Rating Area 3 No Preference 48 413.68

55957PA0280001 Rating Area 3 No Preference 49 431.65

55957PA0280001 Rating Area 3 No Preference 50 451.89

55957PA0280001 Rating Area 3 No Preference 51 471.88

55957PA0280001 Rating Area 3 No Preference 52 493.89

55957PA0280001 Rating Area 3 No Preference 53 516.16

55957PA0280001 Rating Area 3 No Preference 54 540.19

55957PA0280001 Rating Area 3 No Preference 55 564.23

55957PA0280001 Rating Area 3 No Preference 56 590.29

55957PA0280001 Rating Area 3 No Preference 57 616.60

55957PA0280001 Rating Area 3 No Preference 58 644.69

55957PA0280001 Rating Area 3 No Preference 59 658.61

55957PA0280001 Rating Area 3 No Preference 60 686.69

55957PA0280001 Rating Area 3 No Preference 61 710.98

55957PA0280001 Rating Area 3 No Preference 62 726.92

55957PA0280001 Rating Area 3 No Preference 63 746.91

55957PA0280001 Rating Area 3 No Preference 64 759.06

55957PA0280001 Rating Area 3 No Preference 65 and over 759.06

55957PA0280002 Rating Area 3 No Preference 0-20 161.13

55957PA0280002 Rating Area 3 No Preference 21 253.75

55957PA0280002 Rating Area 3 No Preference 22 253.75

55957PA0280002 Rating Area 3 No Preference 23 253.75

55957PA0280002 Rating Area 3 No Preference 24 253.75

55957PA0280002 Rating Area 3 No Preference 25 254.76

55957PA0280002 Rating Area 3 No Preference 26 259.84

55957PA0280002 Rating Area 3 No Preference 27 265.93

55957PA0280002 Rating Area 3 No Preference 28 275.82

55957PA0280002 Rating Area 3 No Preference 29 283.94

55957PA0280002 Rating Area 3 No Preference 30 288.00

55957PA0280002 Rating Area 3 No Preference 31 294.09

55957PA0280002 Rating Area 3 No Preference 32 300.18

55957PA0280002 Rating Area 3 No Preference 33 303.99

55957PA0280002 Rating Area 3 No Preference 34 308.05

55957PA0280002 Rating Area 3 No Preference 35 310.08

55957PA0280002 Rating Area 3 No Preference 36 312.11

55957PA0280002 Rating Area 3 No Preference 37 314.14

55957PA0280002 Rating Area 3 No Preference 38 316.17

55957PA0280002 Rating Area 3 No Preference 39 320.23

55957PA0280002 Rating Area 3 No Preference 40 324.29

55957PA0280002 Rating Area 3 No Preference 41 330.38

55957PA0280002 Rating Area 3 No Preference 42 336.21

55957PA0280002 Rating Area 3 No Preference 43 344.33

55957PA0280002 Rating Area 3 No Preference 44 354.48

55957PA0280002 Rating Area 3 No Preference 45 366.41

55957PA0280002 Rating Area 3 No Preference 46 380.62

55957PA0280002 Rating Area 3 No Preference 47 396.61

55957PA0280002 Rating Area 3 No Preference 48 414.88

55957PA0280002 Rating Area 3 No Preference 49 432.89

55957PA0280002 Rating Area 3 No Preference 50 453.19

55957PA0280002 Rating Area 3 No Preference 51 473.24

55957PA0280002 Rating Area 3 No Preference 52 495.32

55957PA0280002 Rating Area 3 No Preference 53 517.65

55957PA0280002 Rating Area 3 No Preference 54 541.75

55957PA0280002 Rating Area 3 No Preference 55 565.86

55957PA0280002 Rating Area 3 No Preference 56 591.99

55957PA0280002 Rating Area 3 No Preference 57 618.38

55957PA0280002 Rating Area 3 No Preference 58 646.55

55957PA0280002 Rating Area 3 No Preference 59 660.51

55957PA0280002 Rating Area 3 No Preference 60 688.67

55957PA0280002 Rating Area 3 No Preference 61 713.03

55957PA0280002 Rating Area 3 No Preference 62 729.02

55957PA0280002 Rating Area 3 No Preference 63 749.07

55957PA0280002 Rating Area 3 No Preference 64 761.25

55957PA0280002 Rating Area 3 No Preference 65 and over 761.25

55957PA0280003 Rating Area 3 No Preference 0-20 202.45

55957PA0280003 Rating Area 3 No Preference 21 318.83

55957PA0280003 Rating Area 3 No Preference 22 318.83

55957PA0280003 Rating Area 3 No Preference 23 318.83

55957PA0280003 Rating Area 3 No Preference 24 318.83

55957PA0280003 Rating Area 3 No Preference 25 320.10

55957PA0280003 Rating Area 3 No Preference 26 326.48

55957PA0280003 Rating Area 3 No Preference 27 334.13

55957PA0280003 Rating Area 3 No Preference 28 346.56

55957PA0280003 Rating Area 3 No Preference 29 356.77

55957PA0280003 Rating Area 3 No Preference 30 361.87

55957PA0280003 Rating Area 3 No Preference 31 369.52

55957PA0280003 Rating Area 3 No Preference 32 377.17

55957PA0280003 Rating Area 3 No Preference 33 381.95

55957PA0280003 Rating Area 3 No Preference 34 387.05

55957PA0280003 Rating Area 3 No Preference 35 389.61

55957PA0280003 Rating Area 3 No Preference 36 392.16

55957PA0280003 Rating Area 3 No Preference 37 394.71

55957PA0280003 Rating Area 3 No Preference 38 397.26

55957PA0280003 Rating Area 3 No Preference 39 402.36

55957PA0280003 Rating Area 3 No Preference 40 407.46

55957PA0280003 Rating Area 3 No Preference 41 415.11

55957PA0280003 Rating Area 3 No Preference 42 422.44

55957PA0280003 Rating Area 3 No Preference 43 432.65

55957PA0280003 Rating Area 3 No Preference 44 445.40

55957PA0280003 Rating Area 3 No Preference 45 460.39

55957PA0280003 Rating Area 3 No Preference 46 478.24

55957PA0280003 Rating Area 3 No Preference 47 498.33

55957PA0280003 Rating Area 3 No Preference 48 521.28

55957PA0280003 Rating Area 3 No Preference 49 543.92

55957PA0280003 Rating Area 3 No Preference 50 569.43

55957PA0280003 Rating Area 3 No Preference 51 594.61

55957PA0280003 Rating Area 3 No Preference 52 622.35

55957PA0280003 Rating Area 3 No Preference 53 650.41

55957PA0280003 Rating Area 3 No Preference 54 680.70

55957PA0280003 Rating Area 3 No Preference 55 710.99

55957PA0280003 Rating Area 3 No Preference 56 743.83

55957PA0280003 Rating Area 3 No Preference 57 776.98

55957PA0280003 Rating Area 3 No Preference 58 812.37

55957PA0280003 Rating Area 3 No Preference 59 829.91

55957PA0280003 Rating Area 3 No Preference 60 865.30

55957PA0280003 Rating Area 3 No Preference 61 895.91

55957PA0280003 Rating Area 3 No Preference 62 915.99

55957PA0280003 Rating Area 3 No Preference 63 941.18

55957PA0280003 Rating Area 3 No Preference 64 956.49

55957PA0280003 Rating Area 3 No Preference 65 and over 956.49

55957PA0280004 Rating Area 3 No Preference 0-20 234.90

55957PA0280004 Rating Area 3 No Preference 21 369.93

55957PA0280004 Rating Area 3 No Preference 22 369.93

55957PA0280004 Rating Area 3 No Preference 23 369.93

55957PA0280004 Rating Area 3 No Preference 24 369.93

55957PA0280004 Rating Area 3 No Preference 25 371.40

55957PA0280004 Rating Area 3 No Preference 26 378.80

55957PA0280004 Rating Area 3 No Preference 27 387.68

55957PA0280004 Rating Area 3 No Preference 28 402.11

55957PA0280004 Rating Area 3 No Preference 29 413.95

55957PA0280004 Rating Area 3 No Preference 30 419.87

55957PA0280004 Rating Area 3 No Preference 31 428.74

55957PA0280004 Rating Area 3 No Preference 32 437.62

55957PA0280004 Rating Area 3 No Preference 33 443.17

55957PA0280004 Rating Area 3 No Preference 34 449.09

55957PA0280004 Rating Area 3 No Preference 35 452.05

55957PA0280004 Rating Area 3 No Preference 36 455.01

55957PA0280004 Rating Area 3 No Preference 37 457.97

55957PA0280004 Rating Area 3 No Preference 38 460.93

55957PA0280004 Rating Area 3 No Preference 39 466.85

55957PA0280004 Rating Area 3 No Preference 40 472.77

55957PA0280004 Rating Area 3 No Preference 41 481.64

55957PA0280004 Rating Area 3 No Preference 42 490.15

55957PA0280004 Rating Area 3 No Preference 43 501.99

55957PA0280004 Rating Area 3 No Preference 44 516.79

55957PA0280004 Rating Area 3 No Preference 45 534.17

55957PA0280004 Rating Area 3 No Preference 46 554.89

55957PA0280004 Rating Area 3 No Preference 47 578.20

55957PA0280004 Rating Area 3 No Preference 48 604.83

55957PA0280004 Rating Area 3 No Preference 49 631.10

55957PA0280004 Rating Area 3 No Preference 50 660.69

55957PA0280004 Rating Area 3 No Preference 51 689.91

55957PA0280004 Rating Area 3 No Preference 52 722.10

55957PA0280004 Rating Area 3 No Preference 53 754.65

55957PA0280004 Rating Area 3 No Preference 54 789.80

55957PA0280004 Rating Area 3 No Preference 55 824.94

55957PA0280004 Rating Area 3 No Preference 56 863.04

55957PA0280004 Rating Area 3 No Preference 57 901.51

55957PA0280004 Rating Area 3 No Preference 58 942.58

55957PA0280004 Rating Area 3 No Preference 59 962.92

55957PA0280004 Rating Area 3 No Preference 60 1003.99

55957PA0280004 Rating Area 3 No Preference 61 1039.50

55957PA0280004 Rating Area 3 No Preference 62 1062.80

55957PA0280004 Rating Area 3 No Preference 63 1092.03

55957PA0280004 Rating Area 3 No Preference 64 1109.79

55957PA0280004 Rating Area 3 No Preference 65 and over 1109.79

55957PA0300001 Rating Area 3 No Preference 0-20 219.72

55957PA0300001 Rating Area 3 No Preference 21 346.02

55957PA0300001 Rating Area 3 No Preference 22 346.02

55957PA0300001 Rating Area 3 No Preference 23 346.02

55957PA0300001 Rating Area 3 No Preference 24 346.02

55957PA0300001 Rating Area 3 No Preference 25 347.40

55957PA0300001 Rating Area 3 No Preference 26 354.32

55957PA0300001 Rating Area 3 No Preference 27 362.62

55957PA0300001 Rating Area 3 No Preference 28 376.12

55957PA0300001 Rating Area 3 No Preference 29 387.19

55957PA0300001 Rating Area 3 No Preference 30 392.73

55957PA0300001 Rating Area 3 No Preference 31 401.03

55957PA0300001 Rating Area 3 No Preference 32 409.34

55957PA0300001 Rating Area 3 No Preference 33 414.53

55957PA0300001 Rating Area 3 No Preference 34 420.06

55957PA0300001 Rating Area 3 No Preference 35 422.83

55957PA0300001 Rating Area 3 No Preference 36 425.60

55957PA0300001 Rating Area 3 No Preference 37 428.37

55957PA0300001 Rating Area 3 No Preference 38 431.14

55957PA0300001 Rating Area 3 No Preference 39 436.67

55957PA0300001 Rating Area 3 No Preference 40 442.21

55957PA0300001 Rating Area 3 No Preference 41 450.51

55957PA0300001 Rating Area 3 No Preference 42 458.47

55957PA0300001 Rating Area 3 No Preference 43 469.54

55957PA0300001 Rating Area 3 No Preference 44 483.38

55957PA0300001 Rating Area 3 No Preference 45 499.65

55957PA0300001 Rating Area 3 No Preference 46 519.03

55957PA0300001 Rating Area 3 No Preference 47 540.82

55957PA0300001 Rating Area 3 No Preference 48 565.74

55957PA0300001 Rating Area 3 No Preference 49 590.31

55957PA0300001 Rating Area 3 No Preference 50 617.99

55957PA0300001 Rating Area 3 No Preference 51 645.32

55957PA0300001 Rating Area 3 No Preference 52 675.43

55957PA0300001 Rating Area 3 No Preference 53 705.88

55957PA0300001 Rating Area 3 No Preference 54 738.75

55957PA0300001 Rating Area 3 No Preference 55 771.62

55957PA0300001 Rating Area 3 No Preference 56 807.26

55957PA0300001 Rating Area 3 No Preference 57 843.25

55957PA0300001 Rating Area 3 No Preference 58 881.65

55957PA0300001 Rating Area 3 No Preference 59 900.69

55957PA0300001 Rating Area 3 No Preference 60 939.09

55957PA0300001 Rating Area 3 No Preference 61 972.31

55957PA0300001 Rating Area 3 No Preference 62 994.11

55957PA0300001 Rating Area 3 No Preference 63 1021.45

55957PA0300001 Rating Area 3 No Preference 64 1038.06

55957PA0300001 Rating Area 3 No Preference 65 and over 1038.06

55957PA0300002 Rating Area 3 No Preference 0-20 188.15

55957PA0300002 Rating Area 3 No Preference 21 296.30

55957PA0300002 Rating Area 3 No Preference 22 296.30

55957PA0300002 Rating Area 3 No Preference 23 296.30

55957PA0300002 Rating Area 3 No Preference 24 296.30

55957PA0300002 Rating Area 3 No Preference 25 297.48

55957PA0300002 Rating Area 3 No Preference 26 303.41

55957PA0300002 Rating Area 3 No Preference 27 310.52

55957PA0300002 Rating Area 3 No Preference 28 322.07

55957PA0300002 Rating Area 3 No Preference 29 331.55

55957PA0300002 Rating Area 3 No Preference 30 336.30

55957PA0300002 Rating Area 3 No Preference 31 343.41

55957PA0300002 Rating Area 3 No Preference 32 350.52

55957PA0300002 Rating Area 3 No Preference 33 354.96

55957PA0300002 Rating Area 3 No Preference 34 359.70

55957PA0300002 Rating Area 3 No Preference 35 362.07

55957PA0300002 Rating Area 3 No Preference 36 364.44

55957PA0300002 Rating Area 3 No Preference 37 366.81

55957PA0300002 Rating Area 3 No Preference 38 369.18

55957PA0300002 Rating Area 3 No Preference 39 373.93

55957PA0300002 Rating Area 3 No Preference 40 378.67

55957PA0300002 Rating Area 3 No Preference 41 385.78

55957PA0300002 Rating Area 3 No Preference 42 392.59

55957PA0300002 Rating Area 3 No Preference 43 402.07

55957PA0300002 Rating Area 3 No Preference 44 413.93

55957PA0300002 Rating Area 3 No Preference 45 427.85

55957PA0300002 Rating Area 3 No Preference 46 444.45

55957PA0300002 Rating Area 3 No Preference 47 463.11

55957PA0300002 Rating Area 3 No Preference 48 484.45

55957PA0300002 Rating Area 3 No Preference 49 505.48

55957PA0300002 Rating Area 3 No Preference 50 529.19

55957PA0300002 Rating Area 3 No Preference 51 552.59

55957PA0300002 Rating Area 3 No Preference 52 578.37

55957PA0300002 Rating Area 3 No Preference 53 604.45

55957PA0300002 Rating Area 3 No Preference 54 632.60

55957PA0300002 Rating Area 3 No Preference 55 660.74

55957PA0300002 Rating Area 3 No Preference 56 691.26

55957PA0300002 Rating Area 3 No Preference 57 722.08

55957PA0300002 Rating Area 3 No Preference 58 754.97

55957PA0300002 Rating Area 3 No Preference 59 771.26

55957PA0300002 Rating Area 3 No Preference 60 804.15

55957PA0300002 Rating Area 3 No Preference 61 832.60

55957PA0300002 Rating Area 3 No Preference 62 851.26

55957PA0300002 Rating Area 3 No Preference 63 874.67

55957PA0300002 Rating Area 3 No Preference 64 888.90

55957PA0300002 Rating Area 3 No Preference 65 and over 888.90

55957PA0370001 Rating Area 3 No Preference 0-20 247.07

55957PA0370001 Rating Area 3 No Preference 21 389.09

55957PA0370001 Rating Area 3 No Preference 22 389.09

55957PA0370001 Rating Area 3 No Preference 23 389.09

55957PA0370001 Rating Area 3 No Preference 24 389.09

55957PA0370001 Rating Area 3 No Preference 25 390.64

55957PA0370001 Rating Area 3 No Preference 26 398.42

55957PA0370001 Rating Area 3 No Preference 27 407.76

55957PA0370001 Rating Area 3 No Preference 28 422.94

55957PA0370001 Rating Area 3 No Preference 29 435.39

55957PA0370001 Rating Area 3 No Preference 30 441.61

55957PA0370001 Rating Area 3 No Preference 31 450.95

55957PA0370001 Rating Area 3 No Preference 32 460.29

55957PA0370001 Rating Area 3 No Preference 33 466.12

55957PA0370001 Rating Area 3 No Preference 34 472.35

55957PA0370001 Rating Area 3 No Preference 35 475.46

55957PA0370001 Rating Area 3 No Preference 36 478.58

55957PA0370001 Rating Area 3 No Preference 37 481.69

55957PA0370001 Rating Area 3 No Preference 38 484.80

55957PA0370001 Rating Area 3 No Preference 39 491.03

55957PA0370001 Rating Area 3 No Preference 40 497.25

55957PA0370001 Rating Area 3 No Preference 41 506.59

55957PA0370001 Rating Area 3 No Preference 42 515.54

55957PA0370001 Rating Area 3 No Preference 43 527.99

55957PA0370001 Rating Area 3 No Preference 44 543.55

55957PA0370001 Rating Area 3 No Preference 45 561.84

55957PA0370001 Rating Area 3 No Preference 46 583.63

55957PA0370001 Rating Area 3 No Preference 47 608.14

55957PA0370001 Rating Area 3 No Preference 48 636.16

55957PA0370001 Rating Area 3 No Preference 49 663.78

55957PA0370001 Rating Area 3 No Preference 50 694.91

55957PA0370001 Rating Area 3 No Preference 51 725.65

55957PA0370001 Rating Area 3 No Preference 52 759.50

55957PA0370001 Rating Area 3 No Preference 53 793.74

55957PA0370001 Rating Area 3 No Preference 54 830.70

55957PA0370001 Rating Area 3 No Preference 55 867.67

55957PA0370001 Rating Area 3 No Preference 56 907.74

55957PA0370001 Rating Area 3 No Preference 57 948.21

55957PA0370001 Rating Area 3 No Preference 58 991.40

55957PA0370001 Rating Area 3 No Preference 59 1012.80

55957PA0370001 Rating Area 3 No Preference 60 1055.99

55957PA0370001 Rating Area 3 No Preference 61 1093.34

55957PA0370001 Rating Area 3 No Preference 62 1117.85

55957PA0370001 Rating Area 3 No Preference 63 1148.59

55957PA0370001 Rating Area 3 No Preference 64 1167.27

55957PA0370001 Rating Area 3 No Preference 65 and over 1167.27

55957PA0370002 Rating Area 3 No Preference 0-20 236.14

55957PA0370002 Rating Area 3 No Preference 21 371.88

55957PA0370002 Rating Area 3 No Preference 22 371.88

55957PA0370002 Rating Area 3 No Preference 23 371.88

55957PA0370002 Rating Area 3 No Preference 24 371.88

55957PA0370002 Rating Area 3 No Preference 25 373.36

55957PA0370002 Rating Area 3 No Preference 26 380.80

55957PA0370002 Rating Area 3 No Preference 27 389.73

55957PA0370002 Rating Area 3 No Preference 28 404.23

55957PA0370002 Rating Area 3 No Preference 29 416.13

55957PA0370002 Rating Area 3 No Preference 30 422.08

55957PA0370002 Rating Area 3 No Preference 31 431.00

55957PA0370002 Rating Area 3 No Preference 32 439.93

55957PA0370002 Rating Area 3 No Preference 33 445.51

55957PA0370002 Rating Area 3 No Preference 34 451.46

55957PA0370002 Rating Area 3 No Preference 35 454.43

55957PA0370002 Rating Area 3 No Preference 36 457.41

55957PA0370002 Rating Area 3 No Preference 37 460.38

55957PA0370002 Rating Area 3 No Preference 38 463.36

55957PA0370002 Rating Area 3 No Preference 39 469.31

55957PA0370002 Rating Area 3 No Preference 40 475.26

55957PA0370002 Rating Area 3 No Preference 41 484.18

55957PA0370002 Rating Area 3 No Preference 42 492.74

55957PA0370002 Rating Area 3 No Preference 43 504.64

55957PA0370002 Rating Area 3 No Preference 44 519.51

55957PA0370002 Rating Area 3 No Preference 45 536.99

55957PA0370002 Rating Area 3 No Preference 46 557.82

55957PA0370002 Rating Area 3 No Preference 47 581.24

55957PA0370002 Rating Area 3 No Preference 48 608.02

55957PA0370002 Rating Area 3 No Preference 49 634.42

55957PA0370002 Rating Area 3 No Preference 50 664.17

55957PA0370002 Rating Area 3 No Preference 51 693.55

55957PA0370002 Rating Area 3 No Preference 52 725.90

55957PA0370002 Rating Area 3 No Preference 53 758.63

55957PA0370002 Rating Area 3 No Preference 54 793.96

55957PA0370002 Rating Area 3 No Preference 55 829.29

55957PA0370002 Rating Area 3 No Preference 56 867.59

55957PA0370002 Rating Area 3 No Preference 57 906.27

55957PA0370002 Rating Area 3 No Preference 58 947.55

55957PA0370002 Rating Area 3 No Preference 59 968.00

55957PA0370002 Rating Area 3 No Preference 60 1009.28

55957PA0370002 Rating Area 3 No Preference 61 1044.98

55957PA0370002 Rating Area 3 No Preference 62 1068.41

55957PA0370002 Rating Area 3 No Preference 63 1097.78

55957PA0370002 Rating Area 3 No Preference 64 1115.64

55957PA0370002 Rating Area 3 No Preference 65 and over 1115.64

55957PA0380001 Rating Area 3 No Preference 0-20 193.87

55957PA0380001 Rating Area 3 No Preference 21 305.32

55957PA0380001 Rating Area 3 No Preference 22 305.32

55957PA0380001 Rating Area 3 No Preference 23 305.32

55957PA0380001 Rating Area 3 No Preference 24 305.32

55957PA0380001 Rating Area 3 No Preference 25 306.54

55957PA0380001 Rating Area 3 No Preference 26 312.64

55957PA0380001 Rating Area 3 No Preference 27 319.97

55957PA0380001 Rating Area 3 No Preference 28 331.88

55957PA0380001 Rating Area 3 No Preference 29 341.65

55957PA0380001 Rating Area 3 No Preference 30 346.53

55957PA0380001 Rating Area 3 No Preference 31 353.86

55957PA0380001 Rating Area 3 No Preference 32 361.19

55957PA0380001 Rating Area 3 No Preference 33 365.77

55957PA0380001 Rating Area 3 No Preference 34 370.65

55957PA0380001 Rating Area 3 No Preference 35 373.10

55957PA0380001 Rating Area 3 No Preference 36 375.54

55957PA0380001 Rating Area 3 No Preference 37 377.98

55957PA0380001 Rating Area 3 No Preference 38 380.42

55957PA0380001 Rating Area 3 No Preference 39 385.31

55957PA0380001 Rating Area 3 No Preference 40 390.19

55957PA0380001 Rating Area 3 No Preference 41 397.52

55957PA0380001 Rating Area 3 No Preference 42 404.54

55957PA0380001 Rating Area 3 No Preference 43 414.31

55957PA0380001 Rating Area 3 No Preference 44 426.53

55957PA0380001 Rating Area 3 No Preference 45 440.88

55957PA0380001 Rating Area 3 No Preference 46 457.98

55957PA0380001 Rating Area 3 No Preference 47 477.21

55957PA0380001 Rating Area 3 No Preference 48 499.19

55957PA0380001 Rating Area 3 No Preference 49 520.87

55957PA0380001 Rating Area 3 No Preference 50 545.30

55957PA0380001 Rating Area 3 No Preference 51 569.42

55957PA0380001 Rating Area 3 No Preference 52 595.98

55957PA0380001 Rating Area 3 No Preference 53 622.85

55957PA0380001 Rating Area 3 No Preference 54 651.85

55957PA0380001 Rating Area 3 No Preference 55 680.86

55957PA0380001 Rating Area 3 No Preference 56 712.31

55957PA0380001 Rating Area 3 No Preference 57 744.06

55957PA0380001 Rating Area 3 No Preference 58 777.95

55957PA0380001 Rating Area 3 No Preference 59 794.74

55957PA0380001 Rating Area 3 No Preference 60 828.63

55957PA0380001 Rating Area 3 No Preference 61 857.94

55957PA0380001 Rating Area 3 No Preference 62 877.18

55957PA0380001 Rating Area 3 No Preference 63 901.30

55957PA0380001 Rating Area 3 No Preference 64 915.96

55957PA0380001 Rating Area 3 No Preference 65 and over 915.96

2017 Rates Table Template v6.0 All fields with an asterisk ( * ) are required. To validate press Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells B1 through B5.If you are a community rating state, select Family Option under Age and fill in all columns.

If you are not community rating state, select 0-20 under Age and provide an Individual Rate for every age band.

If Tobacco is Tobacco User/Non-Tobacco User, you must give a rate for Tobacco Use and Non-Tobacco Use.

To add a new sheet, press the Add Sheet button, or Ctrl + Shift + H. All plans must have the same dates on a sheet.

HIOS Issuer ID* 55957

Federal TIN* 23-2905083

Rate Effective Date* 7/1/2017

Rate Expiration Date* 9/30/2017

Plan ID* Rating Area ID* Tobacco* Age* Individual Rate*

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a plan

Required:

Select the age of a subscriber eligible for the rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

55957PA0270007 Rating Area 3 No Preference 0-20 292.31

55957PA0270007 Rating Area 3 No Preference 21 460.34

55957PA0270007 Rating Area 3 No Preference 22 460.34

55957PA0270007 Rating Area 3 No Preference 23 460.34

55957PA0270007 Rating Area 3 No Preference 24 460.34

55957PA0270007 Rating Area 3 No Preference 25 462.18

55957PA0270007 Rating Area 3 No Preference 26 471.38

55957PA0270007 Rating Area 3 No Preference 27 482.43

55957PA0270007 Rating Area 3 No Preference 28 500.38

55957PA0270007 Rating Area 3 No Preference 29 515.12

55957PA0270007 Rating Area 3 No Preference 30 522.48

55957PA0270007 Rating Area 3 No Preference 31 533.53

55957PA0270007 Rating Area 3 No Preference 32 544.58

55957PA0270007 Rating Area 3 No Preference 33 551.48

55957PA0270007 Rating Area 3 No Preference 34 558.85

55957PA0270007 Rating Area 3 No Preference 35 562.53

55957PA0270007 Rating Area 3 No Preference 36 566.21

55957PA0270007 Rating Area 3 No Preference 37 569.90

55957PA0270007 Rating Area 3 No Preference 38 573.58

55957PA0270007 Rating Area 3 No Preference 39 580.94

55957PA0270007 Rating Area 3 No Preference 40 588.31

55957PA0270007 Rating Area 3 No Preference 41 599.36

55957PA0270007 Rating Area 3 No Preference 42 609.95

55957PA0270007 Rating Area 3 No Preference 43 624.68

55957PA0270007 Rating Area 3 No Preference 44 643.09

55957PA0270007 Rating Area 3 No Preference 45 664.73

55957PA0270007 Rating Area 3 No Preference 46 690.51

55957PA0270007 Rating Area 3 No Preference 47 719.51

55957PA0270007 Rating Area 3 No Preference 48 752.65

55957PA0270007 Rating Area 3 No Preference 49 785.34

55957PA0270007 Rating Area 3 No Preference 50 822.16

55957PA0270007 Rating Area 3 No Preference 51 858.53

55957PA0270007 Rating Area 3 No Preference 52 898.58

55957PA0270007 Rating Area 3 No Preference 53 939.09

55957PA0270007 Rating Area 3 No Preference 54 982.82

55957PA0270007 Rating Area 3 No Preference 55 1026.55

55957PA0270007 Rating Area 3 No Preference 56 1073.97

55957PA0270007 Rating Area 3 No Preference 57 1121.84

55957PA0270007 Rating Area 3 No Preference 58 1172.94

55957PA0270007 Rating Area 3 No Preference 59 1198.26

55957PA0270007 Rating Area 3 No Preference 60 1249.36

55957PA0270007 Rating Area 3 No Preference 61 1293.55

55957PA0270007 Rating Area 3 No Preference 62 1322.55

55957PA0270007 Rating Area 3 No Preference 63 1358.92

55957PA0270007 Rating Area 3 No Preference 64 1381.02

55957PA0270007 Rating Area 3 No Preference 65 and over 1381.02

55957PA0270016 Rating Area 3 No Preference 0-20 294.29

55957PA0270016 Rating Area 3 No Preference 21 463.46

55957PA0270016 Rating Area 3 No Preference 22 463.46

55957PA0270016 Rating Area 3 No Preference 23 463.46

55957PA0270016 Rating Area 3 No Preference 24 463.46

55957PA0270016 Rating Area 3 No Preference 25 465.31

55957PA0270016 Rating Area 3 No Preference 26 474.58

55957PA0270016 Rating Area 3 No Preference 27 485.70

55957PA0270016 Rating Area 3 No Preference 28 503.78

55957PA0270016 Rating Area 3 No Preference 29 518.61

55957PA0270016 Rating Area 3 No Preference 30 526.02

55957PA0270016 Rating Area 3 No Preference 31 537.15

55957PA0270016 Rating Area 3 No Preference 32 548.27

55957PA0270016 Rating Area 3 No Preference 33 555.22

55957PA0270016 Rating Area 3 No Preference 34 562.64

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55957PA0270006 Rating Area 3 No Preference 0-20 289.14

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55957PA0270006 Rating Area 3 No Preference 51 849.20

55957PA0270006 Rating Area 3 No Preference 52 888.82

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55957PA0270006 Rating Area 3 No Preference 65 and over 1366.02

55957PA0270017 Rating Area 3 No Preference 0-20 264.35

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55957PA0270017 Rating Area 3 No Preference 22 416.31

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55957PA0270017 Rating Area 3 No Preference 32 492.49

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55957PA0270017 Rating Area 3 No Preference 63 1228.94

55957PA0270017 Rating Area 3 No Preference 64 1248.93

55957PA0270017 Rating Area 3 No Preference 65 and over 1248.93

55957PA0270018 Rating Area 3 No Preference 0-20 243.41

55957PA0270018 Rating Area 3 No Preference 21 383.33

55957PA0270018 Rating Area 3 No Preference 22 383.33

55957PA0270018 Rating Area 3 No Preference 23 383.33

55957PA0270018 Rating Area 3 No Preference 24 383.33

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55957PA0270018 Rating Area 3 No Preference 27 401.72

55957PA0270018 Rating Area 3 No Preference 28 416.67

55957PA0270018 Rating Area 3 No Preference 29 428.94

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55957PA0270018 Rating Area 3 No Preference 35 468.42

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55957PA0270018 Rating Area 3 No Preference 57 934.17

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55957PA0270018 Rating Area 3 No Preference 65 and over 1149.99

55957PA0270008 Rating Area 3 No Preference 0-20 247.51

55957PA0270008 Rating Area 3 No Preference 21 389.79

55957PA0270008 Rating Area 3 No Preference 22 389.79

55957PA0270008 Rating Area 3 No Preference 23 389.79

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55957PA0270008 Rating Area 3 No Preference 28 423.70

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55957PA0270008 Rating Area 3 No Preference 35 476.32

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55957PA0270008 Rating Area 3 No Preference 38 485.67

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55957PA0270008 Rating Area 3 No Preference 42 516.47

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55957PA0270008 Rating Area 3 No Preference 45 562.85

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55957PA0270008 Rating Area 3 No Preference 49 664.98

55957PA0270008 Rating Area 3 No Preference 50 696.16

55957PA0270008 Rating Area 3 No Preference 51 726.95

55957PA0270008 Rating Area 3 No Preference 52 760.87

55957PA0270008 Rating Area 3 No Preference 53 795.17

55957PA0270008 Rating Area 3 No Preference 54 832.20

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55957PA0270008 Rating Area 3 No Preference 56 909.38

55957PA0270008 Rating Area 3 No Preference 57 949.91

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55957PA0270008 Rating Area 3 No Preference 62 1119.86

55957PA0270008 Rating Area 3 No Preference 63 1150.66

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55957PA0270008 Rating Area 3 No Preference 65 and over 1169.37

55957PA0270009 Rating Area 3 No Preference 0-20 247.75

55957PA0270009 Rating Area 3 No Preference 21 390.17

55957PA0270009 Rating Area 3 No Preference 22 390.17

55957PA0270009 Rating Area 3 No Preference 23 390.17

55957PA0270009 Rating Area 3 No Preference 24 390.17

55957PA0270009 Rating Area 3 No Preference 25 391.73

55957PA0270009 Rating Area 3 No Preference 26 399.53

55957PA0270009 Rating Area 3 No Preference 27 408.89

55957PA0270009 Rating Area 3 No Preference 28 424.11

55957PA0270009 Rating Area 3 No Preference 29 436.60

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55957PA0270009 Rating Area 3 No Preference 56 910.26

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55957PA0270009 Rating Area 3 No Preference 62 1120.95

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55957PA0270009 Rating Area 3 No Preference 64 1170.51

55957PA0270009 Rating Area 3 No Preference 65 and over 1170.51

55957PA0270010 Rating Area 3 No Preference 0-20 251.91

55957PA0270010 Rating Area 3 No Preference 21 396.72

55957PA0270010 Rating Area 3 No Preference 22 396.72

55957PA0270010 Rating Area 3 No Preference 23 396.72

55957PA0270010 Rating Area 3 No Preference 24 396.72

55957PA0270010 Rating Area 3 No Preference 25 398.30

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55957PA0270010 Rating Area 3 No Preference 28 431.23

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55957PA0270010 Rating Area 3 No Preference 49 676.80

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55957PA0270010 Rating Area 3 No Preference 51 739.88

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55957PA0270010 Rating Area 3 No Preference 54 846.99

55957PA0270010 Rating Area 3 No Preference 55 884.68

55957PA0270010 Rating Area 3 No Preference 56 925.54

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55957PA0270010 Rating Area 3 No Preference 58 1010.84

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55957PA0270010 Rating Area 3 No Preference 63 1171.11

55957PA0270010 Rating Area 3 No Preference 64 1190.16

55957PA0270010 Rating Area 3 No Preference 65 and over 1190.16

55957PA0270011 Rating Area 3 No Preference 0-20 241.74

55957PA0270011 Rating Area 3 No Preference 21 380.70

55957PA0270011 Rating Area 3 No Preference 22 380.70

55957PA0270011 Rating Area 3 No Preference 23 380.70

55957PA0270011 Rating Area 3 No Preference 24 380.70

55957PA0270011 Rating Area 3 No Preference 25 382.22

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55957PA0270011 Rating Area 3 No Preference 28 413.82

55957PA0270011 Rating Area 3 No Preference 29 426.00

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55957PA0270011 Rating Area 3 No Preference 33 456.07

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55957PA0270011 Rating Area 3 No Preference 35 465.21

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55957PA0270011 Rating Area 3 No Preference 37 471.30

55957PA0270011 Rating Area 3 No Preference 38 474.35

55957PA0270011 Rating Area 3 No Preference 39 480.44

55957PA0270011 Rating Area 3 No Preference 40 486.53

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55957PA0270011 Rating Area 3 No Preference 54 812.79

55957PA0270011 Rating Area 3 No Preference 55 848.96

55957PA0270011 Rating Area 3 No Preference 56 888.17

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55957PA0270011 Rating Area 3 No Preference 62 1093.75

55957PA0270011 Rating Area 3 No Preference 63 1123.82

55957PA0270011 Rating Area 3 No Preference 64 1142.10

55957PA0270011 Rating Area 3 No Preference 65 and over 1142.10

55957PA0270022 Rating Area 3 No Preference 0-20 207.74

55957PA0270022 Rating Area 3 No Preference 21 327.16

55957PA0270022 Rating Area 3 No Preference 22 327.16

55957PA0270022 Rating Area 3 No Preference 23 327.16

55957PA0270022 Rating Area 3 No Preference 24 327.16

55957PA0270022 Rating Area 3 No Preference 25 328.46

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55957PA0270022 Rating Area 3 No Preference 27 342.86

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55957PA0270022 Rating Area 3 No Preference 39 412.87

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55957PA0270022 Rating Area 3 No Preference 51 610.15

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55957PA0270022 Rating Area 3 No Preference 58 833.60

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55957PA0270022 Rating Area 3 No Preference 63 965.77

55957PA0270022 Rating Area 3 No Preference 64 981.48

55957PA0270022 Rating Area 3 No Preference 65 and over 981.48

55957PA0270019 Rating Area 3 No Preference 0-20 197.60

55957PA0270019 Rating Area 3 No Preference 21 311.19

55957PA0270019 Rating Area 3 No Preference 22 311.19

55957PA0270019 Rating Area 3 No Preference 23 311.19

55957PA0270019 Rating Area 3 No Preference 24 311.19

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55957PA0270019 Rating Area 3 No Preference 38 387.74

55957PA0270019 Rating Area 3 No Preference 39 392.72

55957PA0270019 Rating Area 3 No Preference 40 397.70

55957PA0270019 Rating Area 3 No Preference 41 405.16

55957PA0270019 Rating Area 3 No Preference 42 412.32

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55957PA0270019 Rating Area 3 No Preference 56 726.00

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55957PA0270019 Rating Area 3 No Preference 62 894.04

55957PA0270019 Rating Area 3 No Preference 63 918.63

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55957PA0270020 Rating Area 3 No Preference 0-20 209.98

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55957PA0270020 Rating Area 3 No Preference 22 330.69

55957PA0270020 Rating Area 3 No Preference 23 330.69

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55957PA0270020 Rating Area 3 No Preference 25 332.01

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55957PA0270020 Rating Area 3 No Preference 56 771.49

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55957PA0270020 Rating Area 3 No Preference 58 842.59

55957PA0270020 Rating Area 3 No Preference 59 860.78

55957PA0270020 Rating Area 3 No Preference 60 897.49

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55957PA0270020 Rating Area 3 No Preference 62 950.07

55957PA0270020 Rating Area 3 No Preference 63 976.19

55957PA0270020 Rating Area 3 No Preference 64 992.07

55957PA0270020 Rating Area 3 No Preference 65 and over 992.07

55957PA0270021 Rating Area 3 No Preference 0-20 207.78

55957PA0270021 Rating Area 3 No Preference 21 327.22

55957PA0270021 Rating Area 3 No Preference 22 327.22

55957PA0270021 Rating Area 3 No Preference 23 327.22

55957PA0270021 Rating Area 3 No Preference 24 327.22

55957PA0270021 Rating Area 3 No Preference 25 328.52

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55957PA0270021 Rating Area 3 No Preference 28 355.68

55957PA0270021 Rating Area 3 No Preference 29 366.15

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55957PA0270021 Rating Area 3 No Preference 32 387.10

55957PA0270021 Rating Area 3 No Preference 33 392.00

55957PA0270021 Rating Area 3 No Preference 34 397.24

55957PA0270021 Rating Area 3 No Preference 35 399.86

55957PA0270021 Rating Area 3 No Preference 36 402.48

55957PA0270021 Rating Area 3 No Preference 37 405.09

55957PA0270021 Rating Area 3 No Preference 38 407.71

55957PA0270021 Rating Area 3 No Preference 39 412.95

55957PA0270021 Rating Area 3 No Preference 40 418.18

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55957PA0270021 Rating Area 3 No Preference 43 444.03

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55957PA0270021 Rating Area 3 No Preference 45 472.50

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55957PA0270021 Rating Area 3 No Preference 51 610.26

55957PA0270021 Rating Area 3 No Preference 52 638.73

55957PA0270021 Rating Area 3 No Preference 53 667.52

55957PA0270021 Rating Area 3 No Preference 54 698.61

55957PA0270021 Rating Area 3 No Preference 55 729.70

55957PA0270021 Rating Area 3 No Preference 56 763.40

55957PA0270021 Rating Area 3 No Preference 57 797.43

55957PA0270021 Rating Area 3 No Preference 58 833.75

55957PA0270021 Rating Area 3 No Preference 59 851.75

55957PA0270021 Rating Area 3 No Preference 60 888.07

55957PA0270021 Rating Area 3 No Preference 61 919.48

55957PA0270021 Rating Area 3 No Preference 62 940.10

55957PA0270021 Rating Area 3 No Preference 63 965.95

55957PA0270021 Rating Area 3 No Preference 64 981.66

55957PA0270021 Rating Area 3 No Preference 65 and over 981.66

55957PA0270013 Rating Area 3 No Preference 0-20 167.36

55957PA0270013 Rating Area 3 No Preference 21 263.56

55957PA0270013 Rating Area 3 No Preference 22 263.56

55957PA0270013 Rating Area 3 No Preference 23 263.56

55957PA0270013 Rating Area 3 No Preference 24 263.56

55957PA0270013 Rating Area 3 No Preference 25 264.61

55957PA0270013 Rating Area 3 No Preference 26 269.88

55957PA0270013 Rating Area 3 No Preference 27 276.21

55957PA0270013 Rating Area 3 No Preference 28 286.48

55957PA0270013 Rating Area 3 No Preference 29 294.92

55957PA0270013 Rating Area 3 No Preference 30 299.14

55957PA0270013 Rating Area 3 No Preference 31 305.46

55957PA0270013 Rating Area 3 No Preference 32 311.79

55957PA0270013 Rating Area 3 No Preference 33 315.74

55957PA0270013 Rating Area 3 No Preference 34 319.96

55957PA0270013 Rating Area 3 No Preference 35 322.07

55957PA0270013 Rating Area 3 No Preference 36 324.17

55957PA0270013 Rating Area 3 No Preference 37 326.28

55957PA0270013 Rating Area 3 No Preference 38 328.39

55957PA0270013 Rating Area 3 No Preference 39 332.61

55957PA0270013 Rating Area 3 No Preference 40 336.82

55957PA0270013 Rating Area 3 No Preference 41 343.15

55957PA0270013 Rating Area 3 No Preference 42 349.21

55957PA0270013 Rating Area 3 No Preference 43 357.65

55957PA0270013 Rating Area 3 No Preference 44 368.19

55957PA0270013 Rating Area 3 No Preference 45 380.58

55957PA0270013 Rating Area 3 No Preference 46 395.34

55957PA0270013 Rating Area 3 No Preference 47 411.94

55957PA0270013 Rating Area 3 No Preference 48 430.92

55957PA0270013 Rating Area 3 No Preference 49 449.63

55957PA0270013 Rating Area 3 No Preference 50 470.71

55957PA0270013 Rating Area 3 No Preference 51 491.53

55957PA0270013 Rating Area 3 No Preference 52 514.46

55957PA0270013 Rating Area 3 No Preference 53 537.66

55957PA0270013 Rating Area 3 No Preference 54 562.70

55957PA0270013 Rating Area 3 No Preference 55 587.73

55957PA0270013 Rating Area 3 No Preference 56 614.88

55957PA0270013 Rating Area 3 No Preference 57 642.29

55957PA0270013 Rating Area 3 No Preference 58 671.55

55957PA0270013 Rating Area 3 No Preference 59 686.04

55957PA0270013 Rating Area 3 No Preference 60 715.30

55957PA0270013 Rating Area 3 No Preference 61 740.60

55957PA0270013 Rating Area 3 No Preference 62 757.20

55957PA0270013 Rating Area 3 No Preference 63 778.02

55957PA0270013 Rating Area 3 No Preference 64 790.68

55957PA0270013 Rating Area 3 No Preference 65 and over 790.68

55957PA0290007 Rating Area 3 No Preference 0-20 245.54

55957PA0290007 Rating Area 3 No Preference 21 386.69

55957PA0290007 Rating Area 3 No Preference 22 386.69

55957PA0290007 Rating Area 3 No Preference 23 386.69

55957PA0290007 Rating Area 3 No Preference 24 386.69

55957PA0290007 Rating Area 3 No Preference 25 388.23

55957PA0290007 Rating Area 3 No Preference 26 395.97

55957PA0290007 Rating Area 3 No Preference 27 405.25

55957PA0290007 Rating Area 3 No Preference 28 420.33

55957PA0290007 Rating Area 3 No Preference 29 432.70

55957PA0290007 Rating Area 3 No Preference 30 438.89

55957PA0290007 Rating Area 3 No Preference 31 448.17

55957PA0290007 Rating Area 3 No Preference 32 457.45

55957PA0290007 Rating Area 3 No Preference 33 463.25

55957PA0290007 Rating Area 3 No Preference 34 469.44

55957PA0290007 Rating Area 3 No Preference 35 472.53

55957PA0290007 Rating Area 3 No Preference 36 475.62

55957PA0290007 Rating Area 3 No Preference 37 478.72

55957PA0290007 Rating Area 3 No Preference 38 481.81

55957PA0290007 Rating Area 3 No Preference 39 488.00

55957PA0290007 Rating Area 3 No Preference 40 494.18

55957PA0290007 Rating Area 3 No Preference 41 503.47

55957PA0290007 Rating Area 3 No Preference 42 512.36

55957PA0290007 Rating Area 3 No Preference 43 524.73

55957PA0290007 Rating Area 3 No Preference 44 540.20

55957PA0290007 Rating Area 3 No Preference 45 558.38

55957PA0290007 Rating Area 3 No Preference 46 580.03

55957PA0290007 Rating Area 3 No Preference 47 604.39

55957PA0290007 Rating Area 3 No Preference 48 632.23

55957PA0290007 Rating Area 3 No Preference 49 659.69

55957PA0290007 Rating Area 3 No Preference 50 690.62

55957PA0290007 Rating Area 3 No Preference 51 721.17

55957PA0290007 Rating Area 3 No Preference 52 754.81

55957PA0290007 Rating Area 3 No Preference 53 788.84

55957PA0290007 Rating Area 3 No Preference 54 825.58

55957PA0290007 Rating Area 3 No Preference 55 862.31

55957PA0290007 Rating Area 3 No Preference 56 902.14

55957PA0290007 Rating Area 3 No Preference 57 942.36

55957PA0290007 Rating Area 3 No Preference 58 985.28

55957PA0290007 Rating Area 3 No Preference 59 1006.55

55957PA0290007 Rating Area 3 No Preference 60 1049.47

55957PA0290007 Rating Area 3 No Preference 61 1086.59

55957PA0290007 Rating Area 3 No Preference 62 1110.96

55957PA0290007 Rating Area 3 No Preference 63 1141.50

55957PA0290007 Rating Area 3 No Preference 64 1160.07

55957PA0290007 Rating Area 3 No Preference 65 and over 1160.07

55957PA0290008 Rating Area 3 No Preference 0-20 247.21

55957PA0290008 Rating Area 3 No Preference 21 389.31

55957PA0290008 Rating Area 3 No Preference 22 389.31

55957PA0290008 Rating Area 3 No Preference 23 389.31

55957PA0290008 Rating Area 3 No Preference 24 389.31

55957PA0290008 Rating Area 3 No Preference 25 390.86

55957PA0290008 Rating Area 3 No Preference 26 398.65

55957PA0290008 Rating Area 3 No Preference 27 407.99

55957PA0290008 Rating Area 3 No Preference 28 423.17

55957PA0290008 Rating Area 3 No Preference 29 435.63

55957PA0290008 Rating Area 3 No Preference 30 441.86

55957PA0290008 Rating Area 3 No Preference 31 451.21

55957PA0290008 Rating Area 3 No Preference 32 460.55

55957PA0290008 Rating Area 3 No Preference 33 466.39

55957PA0290008 Rating Area 3 No Preference 34 472.62

55957PA0290008 Rating Area 3 No Preference 35 475.73

55957PA0290008 Rating Area 3 No Preference 36 478.85

55957PA0290008 Rating Area 3 No Preference 37 481.96

55957PA0290008 Rating Area 3 No Preference 38 485.08

55957PA0290008 Rating Area 3 No Preference 39 491.30

55957PA0290008 Rating Area 3 No Preference 40 497.53

55957PA0290008 Rating Area 3 No Preference 41 506.88

55957PA0290008 Rating Area 3 No Preference 42 515.83

55957PA0290008 Rating Area 3 No Preference 43 528.29

55957PA0290008 Rating Area 3 No Preference 44 543.86

55957PA0290008 Rating Area 3 No Preference 45 562.16

55957PA0290008 Rating Area 3 No Preference 46 583.96

55957PA0290008 Rating Area 3 No Preference 47 608.49

55957PA0290008 Rating Area 3 No Preference 48 636.52

55957PA0290008 Rating Area 3 No Preference 49 664.16

55957PA0290008 Rating Area 3 No Preference 50 695.30

55957PA0290008 Rating Area 3 No Preference 51 726.06

55957PA0290008 Rating Area 3 No Preference 52 759.93

55957PA0290008 Rating Area 3 No Preference 53 794.19

55957PA0290008 Rating Area 3 No Preference 54 831.17

55957PA0290008 Rating Area 3 No Preference 55 868.16

55957PA0290008 Rating Area 3 No Preference 56 908.26

55957PA0290008 Rating Area 3 No Preference 57 948.74

55957PA0290008 Rating Area 3 No Preference 58 991.96

55957PA0290008 Rating Area 3 No Preference 59 1013.37

55957PA0290008 Rating Area 3 No Preference 60 1056.58

55957PA0290008 Rating Area 3 No Preference 61 1093.96

55957PA0290008 Rating Area 3 No Preference 62 1118.48

55957PA0290008 Rating Area 3 No Preference 63 1149.24

55957PA0290008 Rating Area 3 No Preference 64 1167.93

55957PA0290008 Rating Area 3 No Preference 65 and over 1167.93

55957PA0290002 Rating Area 3 No Preference 0-20 245.69

55957PA0290002 Rating Area 3 No Preference 21 386.92

55957PA0290002 Rating Area 3 No Preference 22 386.92

55957PA0290002 Rating Area 3 No Preference 23 386.92

55957PA0290002 Rating Area 3 No Preference 24 386.92

55957PA0290002 Rating Area 3 No Preference 25 388.46

55957PA0290002 Rating Area 3 No Preference 26 396.20

55957PA0290002 Rating Area 3 No Preference 27 405.49

55957PA0290002 Rating Area 3 No Preference 28 420.58

55957PA0290002 Rating Area 3 No Preference 29 432.96

55957PA0290002 Rating Area 3 No Preference 30 439.15

55957PA0290002 Rating Area 3 No Preference 31 448.44

55957PA0290002 Rating Area 3 No Preference 32 457.72

55957PA0290002 Rating Area 3 No Preference 33 463.53

55957PA0290002 Rating Area 3 No Preference 34 469.72

55957PA0290002 Rating Area 3 No Preference 35 472.81

55957PA0290002 Rating Area 3 No Preference 36 475.91

55957PA0290002 Rating Area 3 No Preference 37 479.00

55957PA0290002 Rating Area 3 No Preference 38 482.10

55957PA0290002 Rating Area 3 No Preference 39 488.29

55957PA0290002 Rating Area 3 No Preference 40 494.48

55957PA0290002 Rating Area 3 No Preference 41 503.76

55957PA0290002 Rating Area 3 No Preference 42 512.66

55957PA0290002 Rating Area 3 No Preference 43 525.05

55957PA0290002 Rating Area 3 No Preference 44 540.52

55957PA0290002 Rating Area 3 No Preference 45 558.71

55957PA0290002 Rating Area 3 No Preference 46 580.38

55957PA0290002 Rating Area 3 No Preference 47 604.75

55957PA0290002 Rating Area 3 No Preference 48 632.61

55957PA0290002 Rating Area 3 No Preference 49 660.08

55957PA0290002 Rating Area 3 No Preference 50 691.03

55957PA0290002 Rating Area 3 No Preference 51 721.60

55957PA0290002 Rating Area 3 No Preference 52 755.26

55957PA0290002 Rating Area 3 No Preference 53 789.31

55957PA0290002 Rating Area 3 No Preference 54 826.07

55957PA0290002 Rating Area 3 No Preference 55 862.83

55957PA0290002 Rating Area 3 No Preference 56 902.68

55957PA0290002 Rating Area 3 No Preference 57 942.92

55957PA0290002 Rating Area 3 No Preference 58 985.87

55957PA0290002 Rating Area 3 No Preference 59 1007.15

55957PA0290002 Rating Area 3 No Preference 60 1050.10

55957PA0290002 Rating Area 3 No Preference 61 1087.24

55957PA0290002 Rating Area 3 No Preference 62 1111.62

55957PA0290002 Rating Area 3 No Preference 63 1142.18

55957PA0290002 Rating Area 3 No Preference 64 1160.76

55957PA0290002 Rating Area 3 No Preference 65 and over 1160.76

55957PA0290006 Rating Area 3 No Preference 0-20 242.87

55957PA0290006 Rating Area 3 No Preference 21 382.48

55957PA0290006 Rating Area 3 No Preference 22 382.48

55957PA0290006 Rating Area 3 No Preference 23 382.48

55957PA0290006 Rating Area 3 No Preference 24 382.48

55957PA0290006 Rating Area 3 No Preference 25 384.00

55957PA0290006 Rating Area 3 No Preference 26 391.65

55957PA0290006 Rating Area 3 No Preference 27 400.83

55957PA0290006 Rating Area 3 No Preference 28 415.75

55957PA0290006 Rating Area 3 No Preference 29 427.99

55957PA0290006 Rating Area 3 No Preference 30 434.11

55957PA0290006 Rating Area 3 No Preference 31 443.29

55957PA0290006 Rating Area 3 No Preference 32 452.47

55957PA0290006 Rating Area 3 No Preference 33 458.21

55957PA0290006 Rating Area 3 No Preference 34 464.33

55957PA0290006 Rating Area 3 No Preference 35 467.39

55957PA0290006 Rating Area 3 No Preference 36 470.45

55957PA0290006 Rating Area 3 No Preference 37 473.51

55957PA0290006 Rating Area 3 No Preference 38 476.57

55957PA0290006 Rating Area 3 No Preference 39 482.68

55957PA0290006 Rating Area 3 No Preference 40 488.80

55957PA0290006 Rating Area 3 No Preference 41 497.98

55957PA0290006 Rating Area 3 No Preference 42 506.78

55957PA0290006 Rating Area 3 No Preference 43 519.02

55957PA0290006 Rating Area 3 No Preference 44 534.32

55957PA0290006 Rating Area 3 No Preference 45 552.30

55957PA0290006 Rating Area 3 No Preference 46 573.72

55957PA0290006 Rating Area 3 No Preference 47 597.81

55957PA0290006 Rating Area 3 No Preference 48 625.35

55957PA0290006 Rating Area 3 No Preference 49 652.51

55957PA0290006 Rating Area 3 No Preference 50 683.10

55957PA0290006 Rating Area 3 No Preference 51 713.32

55957PA0290006 Rating Area 3 No Preference 52 746.60

55957PA0290006 Rating Area 3 No Preference 53 780.25

55957PA0290006 Rating Area 3 No Preference 54 816.59

55957PA0290006 Rating Area 3 No Preference 55 852.93

55957PA0290006 Rating Area 3 No Preference 56 892.32

55957PA0290006 Rating Area 3 No Preference 57 932.10

55957PA0290006 Rating Area 3 No Preference 58 974.55

55957PA0290006 Rating Area 3 No Preference 59 995.59

55957PA0290006 Rating Area 3 No Preference 60 1038.05

55957PA0290006 Rating Area 3 No Preference 61 1074.76

55957PA0290006 Rating Area 3 No Preference 62 1098.86

55957PA0290006 Rating Area 3 No Preference 63 1129.08

55957PA0290006 Rating Area 3 No Preference 64 1147.44

55957PA0290006 Rating Area 3 No Preference 65 and over 1147.44

55957PA0290022 Rating Area 3 No Preference 0-20 222.05

55957PA0290022 Rating Area 3 No Preference 21 349.70

55957PA0290022 Rating Area 3 No Preference 22 349.70

55957PA0290022 Rating Area 3 No Preference 23 349.70

55957PA0290022 Rating Area 3 No Preference 24 349.70

55957PA0290022 Rating Area 3 No Preference 25 351.09

55957PA0290022 Rating Area 3 No Preference 26 358.09

55957PA0290022 Rating Area 3 No Preference 27 366.48

55957PA0290022 Rating Area 3 No Preference 28 380.12

55957PA0290022 Rating Area 3 No Preference 29 391.31

55957PA0290022 Rating Area 3 No Preference 30 396.90

55957PA0290022 Rating Area 3 No Preference 31 405.30

55957PA0290022 Rating Area 3 No Preference 32 413.69

55957PA0290022 Rating Area 3 No Preference 33 418.94

55957PA0290022 Rating Area 3 No Preference 34 424.53

55957PA0290022 Rating Area 3 No Preference 35 427.33

55957PA0290022 Rating Area 3 No Preference 36 430.13

55957PA0290022 Rating Area 3 No Preference 37 432.92

55957PA0290022 Rating Area 3 No Preference 38 435.72

55957PA0290022 Rating Area 3 No Preference 39 441.32

55957PA0290022 Rating Area 3 No Preference 40 446.91

55957PA0290022 Rating Area 3 No Preference 41 455.30

55957PA0290022 Rating Area 3 No Preference 42 463.35

55957PA0290022 Rating Area 3 No Preference 43 474.54

55957PA0290022 Rating Area 3 No Preference 44 488.53

55957PA0290022 Rating Area 3 No Preference 45 504.96

55957PA0290022 Rating Area 3 No Preference 46 524.55

55957PA0290022 Rating Area 3 No Preference 47 546.58

55957PA0290022 Rating Area 3 No Preference 48 571.75

55957PA0290022 Rating Area 3 No Preference 49 596.58

55957PA0290022 Rating Area 3 No Preference 50 624.56

55957PA0290022 Rating Area 3 No Preference 51 652.19

55957PA0290022 Rating Area 3 No Preference 52 682.61

55957PA0290022 Rating Area 3 No Preference 53 713.38

55957PA0290022 Rating Area 3 No Preference 54 746.60

55957PA0290022 Rating Area 3 No Preference 55 779.83

55957PA0290022 Rating Area 3 No Preference 56 815.85

55957PA0290022 Rating Area 3 No Preference 57 852.21

55957PA0290022 Rating Area 3 No Preference 58 891.03

55957PA0290022 Rating Area 3 No Preference 59 910.26

55957PA0290022 Rating Area 3 No Preference 60 949.08

55957PA0290022 Rating Area 3 No Preference 61 982.65

55957PA0290022 Rating Area 3 No Preference 62 1004.68

55957PA0290022 Rating Area 3 No Preference 63 1032.31

55957PA0290022 Rating Area 3 No Preference 64 1049.10

55957PA0290022 Rating Area 3 No Preference 65 and over 1049.10

55957PA0290012 Rating Area 3 No Preference 0-20 204.47

55957PA0290012 Rating Area 3 No Preference 21 322.00

55957PA0290012 Rating Area 3 No Preference 22 322.00

55957PA0290012 Rating Area 3 No Preference 23 322.00

55957PA0290012 Rating Area 3 No Preference 24 322.00

55957PA0290012 Rating Area 3 No Preference 25 323.28

55957PA0290012 Rating Area 3 No Preference 26 329.72

55957PA0290012 Rating Area 3 No Preference 27 337.45

55957PA0290012 Rating Area 3 No Preference 28 350.01

55957PA0290012 Rating Area 3 No Preference 29 360.31

55957PA0290012 Rating Area 3 No Preference 30 365.47

55957PA0290012 Rating Area 3 No Preference 31 373.19

55957PA0290012 Rating Area 3 No Preference 32 380.92

55957PA0290012 Rating Area 3 No Preference 33 385.75

55957PA0290012 Rating Area 3 No Preference 34 390.90

55957PA0290012 Rating Area 3 No Preference 35 393.48

55957PA0290012 Rating Area 3 No Preference 36 396.06

55957PA0290012 Rating Area 3 No Preference 37 398.63

55957PA0290012 Rating Area 3 No Preference 38 401.21

55957PA0290012 Rating Area 3 No Preference 39 406.36

55957PA0290012 Rating Area 3 No Preference 40 411.51

55957PA0290012 Rating Area 3 No Preference 41 419.24

55957PA0290012 Rating Area 3 No Preference 42 426.65

55957PA0290012 Rating Area 3 No Preference 43 436.95

55957PA0290012 Rating Area 3 No Preference 44 449.83

55957PA0290012 Rating Area 3 No Preference 45 464.96

55957PA0290012 Rating Area 3 No Preference 46 483.00

55957PA0290012 Rating Area 3 No Preference 47 503.28

55957PA0290012 Rating Area 3 No Preference 48 526.47

55957PA0290012 Rating Area 3 No Preference 49 549.33

55957PA0290012 Rating Area 3 No Preference 50 575.09

55957PA0290012 Rating Area 3 No Preference 51 600.53

55957PA0290012 Rating Area 3 No Preference 52 628.54

55957PA0290012 Rating Area 3 No Preference 53 656.88

55957PA0290012 Rating Area 3 No Preference 54 687.47

55957PA0290012 Rating Area 3 No Preference 55 718.06

55957PA0290012 Rating Area 3 No Preference 56 751.22

55957PA0290012 Rating Area 3 No Preference 57 784.71

55957PA0290012 Rating Area 3 No Preference 58 820.45

55957PA0290012 Rating Area 3 No Preference 59 838.16

55957PA0290012 Rating Area 3 No Preference 60 873.90

55957PA0290012 Rating Area 3 No Preference 61 904.82

55957PA0290012 Rating Area 3 No Preference 62 925.10

55957PA0290012 Rating Area 3 No Preference 63 950.54

55957PA0290012 Rating Area 3 No Preference 64 966.00

55957PA0290012 Rating Area 3 No Preference 65 and over 966.00

55957PA0290011 Rating Area 3 No Preference 0-20 207.91

55957PA0290011 Rating Area 3 No Preference 21 327.43

55957PA0290011 Rating Area 3 No Preference 22 327.43

55957PA0290011 Rating Area 3 No Preference 23 327.43

55957PA0290011 Rating Area 3 No Preference 24 327.43

55957PA0290011 Rating Area 3 No Preference 25 328.73

55957PA0290011 Rating Area 3 No Preference 26 335.28

55957PA0290011 Rating Area 3 No Preference 27 343.14

55957PA0290011 Rating Area 3 No Preference 28 355.91

55957PA0290011 Rating Area 3 No Preference 29 366.39

55957PA0290011 Rating Area 3 No Preference 30 371.63

55957PA0290011 Rating Area 3 No Preference 31 379.49

55957PA0290011 Rating Area 3 No Preference 32 387.34

55957PA0290011 Rating Area 3 No Preference 33 392.26

55957PA0290011 Rating Area 3 No Preference 34 397.50

55957PA0290011 Rating Area 3 No Preference 35 400.11

55957PA0290011 Rating Area 3 No Preference 36 402.73

55957PA0290011 Rating Area 3 No Preference 37 405.35

55957PA0290011 Rating Area 3 No Preference 38 407.97

55957PA0290011 Rating Area 3 No Preference 39 413.21

55957PA0290011 Rating Area 3 No Preference 40 418.45

55957PA0290011 Rating Area 3 No Preference 41 426.31

55957PA0290011 Rating Area 3 No Preference 42 433.84

55957PA0290011 Rating Area 3 No Preference 43 444.32

55957PA0290011 Rating Area 3 No Preference 44 457.41

55957PA0290011 Rating Area 3 No Preference 45 472.80

55957PA0290011 Rating Area 3 No Preference 46 491.14

55957PA0290011 Rating Area 3 No Preference 47 511.77

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55957PA0290011 Rating Area 3 No Preference 50 584.78

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55957PA0290011 Rating Area 3 No Preference 53 667.95

55957PA0290011 Rating Area 3 No Preference 54 699.06

55957PA0290011 Rating Area 3 No Preference 55 730.16

55957PA0290011 Rating Area 3 No Preference 56 763.89

55957PA0290011 Rating Area 3 No Preference 57 797.94

55957PA0290011 Rating Area 3 No Preference 58 834.29

55957PA0290011 Rating Area 3 No Preference 59 852.30

55957PA0290011 Rating Area 3 No Preference 60 888.64

55957PA0290011 Rating Area 3 No Preference 61 920.07

55957PA0290011 Rating Area 3 No Preference 62 940.70

55957PA0290011 Rating Area 3 No Preference 63 966.57

55957PA0290011 Rating Area 3 No Preference 64 982.29

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55957PA0290013 Rating Area 3 No Preference 0-20 208.11

55957PA0290013 Rating Area 3 No Preference 21 327.74

55957PA0290013 Rating Area 3 No Preference 22 327.74

55957PA0290013 Rating Area 3 No Preference 23 327.74

55957PA0290013 Rating Area 3 No Preference 24 327.74

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55957PA0290013 Rating Area 3 No Preference 56 764.61

55957PA0290013 Rating Area 3 No Preference 57 798.70

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55957PA0290013 Rating Area 3 No Preference 63 967.48

55957PA0290013 Rating Area 3 No Preference 64 983.22

55957PA0290013 Rating Area 3 No Preference 65 and over 983.22

55957PA0290014 Rating Area 3 No Preference 0-20 211.61

55957PA0290014 Rating Area 3 No Preference 21 333.25

55957PA0290014 Rating Area 3 No Preference 22 333.25

55957PA0290014 Rating Area 3 No Preference 23 333.25

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55957PA0290014 Rating Area 3 No Preference 28 362.24

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55957PA0290014 Rating Area 3 No Preference 32 394.23

55957PA0290014 Rating Area 3 No Preference 33 399.23

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55957PA0290014 Rating Area 3 No Preference 35 407.23

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55957PA0290014 Rating Area 3 No Preference 37 412.56

55957PA0290014 Rating Area 3 No Preference 38 415.22

55957PA0290014 Rating Area 3 No Preference 39 420.56

55957PA0290014 Rating Area 3 No Preference 40 425.89

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55957PA0290014 Rating Area 3 No Preference 48 544.86

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55957PA0290014 Rating Area 3 No Preference 52 650.50

55957PA0290014 Rating Area 3 No Preference 53 679.83

55957PA0290014 Rating Area 3 No Preference 54 711.48

55957PA0290014 Rating Area 3 No Preference 55 743.14

55957PA0290014 Rating Area 3 No Preference 56 777.47

55957PA0290014 Rating Area 3 No Preference 57 812.13

55957PA0290014 Rating Area 3 No Preference 58 849.12

55957PA0290014 Rating Area 3 No Preference 59 867.44

55957PA0290014 Rating Area 3 No Preference 60 904.44

55957PA0290014 Rating Area 3 No Preference 61 936.43

55957PA0290014 Rating Area 3 No Preference 62 957.42

55957PA0290014 Rating Area 3 No Preference 63 983.75

55957PA0290014 Rating Area 3 No Preference 64 999.75

55957PA0290014 Rating Area 3 No Preference 65 and over 999.75

55957PA0290016 Rating Area 3 No Preference 0-20 203.14

55957PA0290016 Rating Area 3 No Preference 21 319.92

55957PA0290016 Rating Area 3 No Preference 22 319.92

55957PA0290016 Rating Area 3 No Preference 23 319.92

55957PA0290016 Rating Area 3 No Preference 24 319.92

55957PA0290016 Rating Area 3 No Preference 25 321.19

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55957PA0290016 Rating Area 3 No Preference 28 347.75

55957PA0290016 Rating Area 3 No Preference 29 357.99

55957PA0290016 Rating Area 3 No Preference 30 363.10

55957PA0290016 Rating Area 3 No Preference 31 370.78

55957PA0290016 Rating Area 3 No Preference 32 378.46

55957PA0290016 Rating Area 3 No Preference 33 383.26

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55957PA0290016 Rating Area 3 No Preference 35 390.94

55957PA0290016 Rating Area 3 No Preference 36 393.50

55957PA0290016 Rating Area 3 No Preference 37 396.06

55957PA0290016 Rating Area 3 No Preference 38 398.62

55957PA0290016 Rating Area 3 No Preference 39 403.73

55957PA0290016 Rating Area 3 No Preference 40 408.85

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55957PA0290016 Rating Area 3 No Preference 42 423.89

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55957PA0290016 Rating Area 3 No Preference 44 446.92

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55957PA0290016 Rating Area 3 No Preference 46 479.88

55957PA0290016 Rating Area 3 No Preference 47 500.03

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55957PA0290016 Rating Area 3 No Preference 50 571.37

55957PA0290016 Rating Area 3 No Preference 51 596.65

55957PA0290016 Rating Area 3 No Preference 52 624.48

55957PA0290016 Rating Area 3 No Preference 53 652.63

55957PA0290016 Rating Area 3 No Preference 54 683.02

55957PA0290016 Rating Area 3 No Preference 55 713.42

55957PA0290016 Rating Area 3 No Preference 56 746.37

55957PA0290016 Rating Area 3 No Preference 57 779.64

55957PA0290016 Rating Area 3 No Preference 58 815.15

55957PA0290016 Rating Area 3 No Preference 59 832.75

55957PA0290016 Rating Area 3 No Preference 60 868.26

55957PA0290016 Rating Area 3 No Preference 61 898.97

55957PA0290016 Rating Area 3 No Preference 62 919.13

55957PA0290016 Rating Area 3 No Preference 63 944.40

55957PA0290016 Rating Area 3 No Preference 64 959.76

55957PA0290016 Rating Area 3 No Preference 65 and over 959.76

55957PA0290023 Rating Area 3 No Preference 0-20 174.50

55957PA0290023 Rating Area 3 No Preference 21 274.81

55957PA0290023 Rating Area 3 No Preference 22 274.81

55957PA0290023 Rating Area 3 No Preference 23 274.81

55957PA0290023 Rating Area 3 No Preference 24 274.81

55957PA0290023 Rating Area 3 No Preference 25 275.90

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55957PA0290023 Rating Area 3 No Preference 27 288.00

55957PA0290023 Rating Area 3 No Preference 28 298.71

55957PA0290023 Rating Area 3 No Preference 29 307.51

55957PA0290023 Rating Area 3 No Preference 30 311.90

55957PA0290023 Rating Area 3 No Preference 31 318.50

55957PA0290023 Rating Area 3 No Preference 32 325.10

55957PA0290023 Rating Area 3 No Preference 33 329.22

55957PA0290023 Rating Area 3 No Preference 34 333.61

55957PA0290023 Rating Area 3 No Preference 35 335.81

55957PA0290023 Rating Area 3 No Preference 36 338.01

55957PA0290023 Rating Area 3 No Preference 37 340.21

55957PA0290023 Rating Area 3 No Preference 38 342.41

55957PA0290023 Rating Area 3 No Preference 39 346.81

55957PA0290023 Rating Area 3 No Preference 40 351.20

55957PA0290023 Rating Area 3 No Preference 41 357.80

55957PA0290023 Rating Area 3 No Preference 42 364.12

55957PA0290023 Rating Area 3 No Preference 43 372.91

55957PA0290023 Rating Area 3 No Preference 44 383.90

55957PA0290023 Rating Area 3 No Preference 45 396.82

55957PA0290023 Rating Area 3 No Preference 46 412.21

55957PA0290023 Rating Area 3 No Preference 47 429.52

55957PA0290023 Rating Area 3 No Preference 48 449.31

55957PA0290023 Rating Area 3 No Preference 49 468.82

55957PA0290023 Rating Area 3 No Preference 50 490.81

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55957PA0290023 Rating Area 3 No Preference 52 536.42

55957PA0290023 Rating Area 3 No Preference 53 560.61

55957PA0290023 Rating Area 3 No Preference 54 586.71

55957PA0290023 Rating Area 3 No Preference 55 612.82

55957PA0290023 Rating Area 3 No Preference 56 641.13

55957PA0290023 Rating Area 3 No Preference 57 669.71

55957PA0290023 Rating Area 3 No Preference 58 700.21

55957PA0290023 Rating Area 3 No Preference 59 715.33

55957PA0290023 Rating Area 3 No Preference 60 745.83

55957PA0290023 Rating Area 3 No Preference 61 772.21

55957PA0290023 Rating Area 3 No Preference 62 789.52

55957PA0290023 Rating Area 3 No Preference 63 811.23

55957PA0290023 Rating Area 3 No Preference 64 824.43

55957PA0290023 Rating Area 3 No Preference 65 and over 824.43

55957PA0290017 Rating Area 3 No Preference 0-20 165.98

55957PA0290017 Rating Area 3 No Preference 21 261.40

55957PA0290017 Rating Area 3 No Preference 22 261.40

55957PA0290017 Rating Area 3 No Preference 23 261.40

55957PA0290017 Rating Area 3 No Preference 24 261.40

55957PA0290017 Rating Area 3 No Preference 25 262.44

55957PA0290017 Rating Area 3 No Preference 26 267.67

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55957PA0290017 Rating Area 3 No Preference 28 284.14

55957PA0290017 Rating Area 3 No Preference 29 292.50

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55957PA0290017 Rating Area 3 No Preference 32 309.23

55957PA0290017 Rating Area 3 No Preference 33 313.15

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55957PA0290017 Rating Area 3 No Preference 40 334.06

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55957PA0290017 Rating Area 3 No Preference 47 408.56

55957PA0290017 Rating Area 3 No Preference 48 427.38

55957PA0290017 Rating Area 3 No Preference 49 445.94

55957PA0290017 Rating Area 3 No Preference 50 466.86

55957PA0290017 Rating Area 3 No Preference 51 487.51

55957PA0290017 Rating Area 3 No Preference 52 510.25

55957PA0290017 Rating Area 3 No Preference 53 533.25

55957PA0290017 Rating Area 3 No Preference 54 558.08

55957PA0290017 Rating Area 3 No Preference 55 582.92

55957PA0290017 Rating Area 3 No Preference 56 609.84

55957PA0290017 Rating Area 3 No Preference 57 637.03

55957PA0290017 Rating Area 3 No Preference 58 666.04

55957PA0290017 Rating Area 3 No Preference 59 680.42

55957PA0290017 Rating Area 3 No Preference 60 709.43

55957PA0290017 Rating Area 3 No Preference 61 734.53

55957PA0290017 Rating Area 3 No Preference 62 751.00

55957PA0290017 Rating Area 3 No Preference 63 771.65

55957PA0290017 Rating Area 3 No Preference 64 784.20

55957PA0290017 Rating Area 3 No Preference 65 and over 784.20

55957PA0290018 Rating Area 3 No Preference 0-20 176.39

55957PA0290018 Rating Area 3 No Preference 21 277.78

55957PA0290018 Rating Area 3 No Preference 22 277.78

55957PA0290018 Rating Area 3 No Preference 23 277.78

55957PA0290018 Rating Area 3 No Preference 24 277.78

55957PA0290018 Rating Area 3 No Preference 25 278.89

55957PA0290018 Rating Area 3 No Preference 26 284.44

55957PA0290018 Rating Area 3 No Preference 27 291.11

55957PA0290018 Rating Area 3 No Preference 28 301.94

55957PA0290018 Rating Area 3 No Preference 29 310.83

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55957PA0290018 Rating Area 3 No Preference 32 328.61

55957PA0290018 Rating Area 3 No Preference 33 332.78

55957PA0290018 Rating Area 3 No Preference 34 337.22

55957PA0290018 Rating Area 3 No Preference 35 339.44

55957PA0290018 Rating Area 3 No Preference 36 341.66

55957PA0290018 Rating Area 3 No Preference 37 343.89

55957PA0290018 Rating Area 3 No Preference 38 346.11

55957PA0290018 Rating Area 3 No Preference 39 350.55

55957PA0290018 Rating Area 3 No Preference 40 355.00

55957PA0290018 Rating Area 3 No Preference 41 361.66

55957PA0290018 Rating Area 3 No Preference 42 368.05

55957PA0290018 Rating Area 3 No Preference 43 376.94

55957PA0290018 Rating Area 3 No Preference 44 388.05

55957PA0290018 Rating Area 3 No Preference 45 401.11

55957PA0290018 Rating Area 3 No Preference 46 416.67

55957PA0290018 Rating Area 3 No Preference 47 434.17

55957PA0290018 Rating Area 3 No Preference 48 454.17

55957PA0290018 Rating Area 3 No Preference 49 473.89

55957PA0290018 Rating Area 3 No Preference 50 496.11

55957PA0290018 Rating Area 3 No Preference 51 518.05

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55957PA0290018 Rating Area 3 No Preference 53 566.67

55957PA0290018 Rating Area 3 No Preference 54 593.06

55957PA0290018 Rating Area 3 No Preference 55 619.44

55957PA0290018 Rating Area 3 No Preference 56 648.06

55957PA0290018 Rating Area 3 No Preference 57 676.94

55957PA0290018 Rating Area 3 No Preference 58 707.78

55957PA0290018 Rating Area 3 No Preference 59 723.06

55957PA0290018 Rating Area 3 No Preference 60 753.89

55957PA0290018 Rating Area 3 No Preference 61 780.56

55957PA0290018 Rating Area 3 No Preference 62 798.06

55957PA0290018 Rating Area 3 No Preference 63 820.00

55957PA0290018 Rating Area 3 No Preference 64 833.34

55957PA0290018 Rating Area 3 No Preference 65 and over 833.34

55957PA0290019 Rating Area 3 No Preference 0-20 174.54

55957PA0290019 Rating Area 3 No Preference 21 274.87

55957PA0290019 Rating Area 3 No Preference 22 274.87

55957PA0290019 Rating Area 3 No Preference 23 274.87

55957PA0290019 Rating Area 3 No Preference 24 274.87

55957PA0290019 Rating Area 3 No Preference 25 275.96

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55957PA0290019 Rating Area 3 No Preference 27 288.06

55957PA0290019 Rating Area 3 No Preference 28 298.78

55957PA0290019 Rating Area 3 No Preference 29 307.57

55957PA0290019 Rating Area 3 No Preference 30 311.97

55957PA0290019 Rating Area 3 No Preference 31 318.57

55957PA0290019 Rating Area 3 No Preference 32 325.17

55957PA0290019 Rating Area 3 No Preference 33 329.29

55957PA0290019 Rating Area 3 No Preference 34 333.69

55957PA0290019 Rating Area 3 No Preference 35 335.89

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55957PA0290019 Rating Area 3 No Preference 37 340.28

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55957PA0290019 Rating Area 3 No Preference 40 351.28

55957PA0290019 Rating Area 3 No Preference 41 357.88

55957PA0290019 Rating Area 3 No Preference 42 364.20

55957PA0290019 Rating Area 3 No Preference 43 372.99

55957PA0290019 Rating Area 3 No Preference 44 383.99

55957PA0290019 Rating Area 3 No Preference 45 396.91

55957PA0290019 Rating Area 3 No Preference 46 412.30

55957PA0290019 Rating Area 3 No Preference 47 429.62

55957PA0290019 Rating Area 3 No Preference 48 449.41

55957PA0290019 Rating Area 3 No Preference 49 468.92

55957PA0290019 Rating Area 3 No Preference 50 490.91

55957PA0290019 Rating Area 3 No Preference 51 512.63

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55957PA0290019 Rating Area 3 No Preference 53 560.73

55957PA0290019 Rating Area 3 No Preference 54 586.84

55957PA0290019 Rating Area 3 No Preference 55 612.96

55957PA0290019 Rating Area 3 No Preference 56 641.27

55957PA0290019 Rating Area 3 No Preference 57 669.85

55957PA0290019 Rating Area 3 No Preference 58 700.36

55957PA0290019 Rating Area 3 No Preference 59 715.48

55957PA0290019 Rating Area 3 No Preference 60 745.99

55957PA0290019 Rating Area 3 No Preference 61 772.38

55957PA0290019 Rating Area 3 No Preference 62 789.70

55957PA0290019 Rating Area 3 No Preference 63 811.41

55957PA0290019 Rating Area 3 No Preference 64 824.61

55957PA0290019 Rating Area 3 No Preference 65 and over 824.61

55957PA0290021 Rating Area 3 No Preference 0-20 140.58

55957PA0290021 Rating Area 3 No Preference 21 221.39

55957PA0290021 Rating Area 3 No Preference 22 221.39

55957PA0290021 Rating Area 3 No Preference 23 221.39

55957PA0290021 Rating Area 3 No Preference 24 221.39

55957PA0290021 Rating Area 3 No Preference 25 222.27

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55957PA0290021 Rating Area 3 No Preference 28 240.65

55957PA0290021 Rating Area 3 No Preference 29 247.73

55957PA0290021 Rating Area 3 No Preference 30 251.27

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55957PA0290021 Rating Area 3 No Preference 32 261.90

55957PA0290021 Rating Area 3 No Preference 33 265.22

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55957PA0290021 Rating Area 3 No Preference 35 270.53

55957PA0290021 Rating Area 3 No Preference 36 272.30

55957PA0290021 Rating Area 3 No Preference 37 274.08

55957PA0290021 Rating Area 3 No Preference 38 275.85

55957PA0290021 Rating Area 3 No Preference 39 279.39

55957PA0290021 Rating Area 3 No Preference 40 282.93

55957PA0290021 Rating Area 3 No Preference 41 288.24

55957PA0290021 Rating Area 3 No Preference 42 293.34

55957PA0290021 Rating Area 3 No Preference 43 300.42

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55957PA0290021 Rating Area 3 No Preference 46 332.08

55957PA0290021 Rating Area 3 No Preference 47 346.03

55957PA0290021 Rating Area 3 No Preference 48 361.97

55957PA0290021 Rating Area 3 No Preference 49 377.69

55957PA0290021 Rating Area 3 No Preference 50 395.40

55957PA0290021 Rating Area 3 No Preference 51 412.89

55957PA0290021 Rating Area 3 No Preference 52 432.15

55957PA0290021 Rating Area 3 No Preference 53 451.63

55957PA0290021 Rating Area 3 No Preference 54 472.66

55957PA0290021 Rating Area 3 No Preference 55 493.69

55957PA0290021 Rating Area 3 No Preference 56 516.50

55957PA0290021 Rating Area 3 No Preference 57 539.52

55957PA0290021 Rating Area 3 No Preference 58 564.10

55957PA0290021 Rating Area 3 No Preference 59 576.27

55957PA0290021 Rating Area 3 No Preference 60 600.85

55957PA0290021 Rating Area 3 No Preference 61 622.10

55957PA0290021 Rating Area 3 No Preference 62 636.05

55957PA0290021 Rating Area 3 No Preference 63 653.54

55957PA0290021 Rating Area 3 No Preference 64 664.17

55957PA0290021 Rating Area 3 No Preference 65 and over 664.17

55957PA0280001 Rating Area 3 No Preference 0-20 165.25

55957PA0280001 Rating Area 3 No Preference 21 260.25

55957PA0280001 Rating Area 3 No Preference 22 260.25

55957PA0280001 Rating Area 3 No Preference 23 260.25

55957PA0280001 Rating Area 3 No Preference 24 260.25

55957PA0280001 Rating Area 3 No Preference 25 261.29

55957PA0280001 Rating Area 3 No Preference 26 266.49

55957PA0280001 Rating Area 3 No Preference 27 272.74

55957PA0280001 Rating Area 3 No Preference 28 282.89

55957PA0280001 Rating Area 3 No Preference 29 291.21

55957PA0280001 Rating Area 3 No Preference 30 295.38

55957PA0280001 Rating Area 3 No Preference 31 301.62

55957PA0280001 Rating Area 3 No Preference 32 307.87

55957PA0280001 Rating Area 3 No Preference 33 311.77

55957PA0280001 Rating Area 3 No Preference 34 315.94

55957PA0280001 Rating Area 3 No Preference 35 318.02

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55957PA0280001 Rating Area 3 No Preference 38 324.27

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55957PA0280001 Rating Area 3 No Preference 42 344.83

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55957PA0280001 Rating Area 3 No Preference 45 375.80

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55957PA0280001 Rating Area 3 No Preference 48 425.50

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55957PA0280001 Rating Area 3 No Preference 52 508.00

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55957PA0280001 Rating Area 3 No Preference 54 555.63

55957PA0280001 Rating Area 3 No Preference 55 580.35

55957PA0280001 Rating Area 3 No Preference 56 607.16

55957PA0280001 Rating Area 3 No Preference 57 634.22

55957PA0280001 Rating Area 3 No Preference 58 663.11

55957PA0280001 Rating Area 3 No Preference 59 677.43

55957PA0280001 Rating Area 3 No Preference 60 706.31

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55957PA0280001 Rating Area 3 No Preference 62 747.69

55957PA0280001 Rating Area 3 No Preference 63 768.25

55957PA0280001 Rating Area 3 No Preference 64 780.75

55957PA0280001 Rating Area 3 No Preference 65 and over 780.75

55957PA0280002 Rating Area 3 No Preference 0-20 165.73

55957PA0280002 Rating Area 3 No Preference 21 261.00

55957PA0280002 Rating Area 3 No Preference 22 261.00

55957PA0280002 Rating Area 3 No Preference 23 261.00

55957PA0280002 Rating Area 3 No Preference 24 261.00

55957PA0280002 Rating Area 3 No Preference 25 262.04

55957PA0280002 Rating Area 3 No Preference 26 267.26

55957PA0280002 Rating Area 3 No Preference 27 273.52

55957PA0280002 Rating Area 3 No Preference 28 283.70

55957PA0280002 Rating Area 3 No Preference 29 292.05

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55957PA0280002 Rating Area 3 No Preference 31 302.49

55957PA0280002 Rating Area 3 No Preference 32 308.76

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55957PA0280002 Rating Area 3 No Preference 35 318.94

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55957PA0280002 Rating Area 3 No Preference 40 333.55

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55957PA0280002 Rating Area 3 No Preference 50 466.14

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55957PA0280002 Rating Area 3 No Preference 53 532.44

55957PA0280002 Rating Area 3 No Preference 54 557.23

55957PA0280002 Rating Area 3 No Preference 55 582.03

55957PA0280002 Rating Area 3 No Preference 56 608.91

55957PA0280002 Rating Area 3 No Preference 57 636.05

55957PA0280002 Rating Area 3 No Preference 58 665.02

55957PA0280002 Rating Area 3 No Preference 59 679.38

55957PA0280002 Rating Area 3 No Preference 60 708.35

55957PA0280002 Rating Area 3 No Preference 61 733.41

55957PA0280002 Rating Area 3 No Preference 62 749.85

55957PA0280002 Rating Area 3 No Preference 63 770.47

55957PA0280002 Rating Area 3 No Preference 64 783.00

55957PA0280002 Rating Area 3 No Preference 65 and over 783.00

55957PA0280003 Rating Area 3 No Preference 0-20 208.24

55957PA0280003 Rating Area 3 No Preference 21 327.94

55957PA0280003 Rating Area 3 No Preference 22 327.94

55957PA0280003 Rating Area 3 No Preference 23 327.94

55957PA0280003 Rating Area 3 No Preference 24 327.94

55957PA0280003 Rating Area 3 No Preference 25 329.25

55957PA0280003 Rating Area 3 No Preference 26 335.81

55957PA0280003 Rating Area 3 No Preference 27 343.68

55957PA0280003 Rating Area 3 No Preference 28 356.47

55957PA0280003 Rating Area 3 No Preference 29 366.96

55957PA0280003 Rating Area 3 No Preference 30 372.21

55957PA0280003 Rating Area 3 No Preference 31 380.08

55957PA0280003 Rating Area 3 No Preference 32 387.95

55957PA0280003 Rating Area 3 No Preference 33 392.87

55957PA0280003 Rating Area 3 No Preference 34 398.11

55957PA0280003 Rating Area 3 No Preference 35 400.74

55957PA0280003 Rating Area 3 No Preference 36 403.36

55957PA0280003 Rating Area 3 No Preference 37 405.98

55957PA0280003 Rating Area 3 No Preference 38 408.61

55957PA0280003 Rating Area 3 No Preference 39 413.86

55957PA0280003 Rating Area 3 No Preference 40 419.10

55957PA0280003 Rating Area 3 No Preference 41 426.97

55957PA0280003 Rating Area 3 No Preference 42 434.52

55957PA0280003 Rating Area 3 No Preference 43 445.01

55957PA0280003 Rating Area 3 No Preference 44 458.13

55957PA0280003 Rating Area 3 No Preference 45 473.54

55957PA0280003 Rating Area 3 No Preference 46 491.91

55957PA0280003 Rating Area 3 No Preference 47 512.57

55957PA0280003 Rating Area 3 No Preference 48 536.18

55957PA0280003 Rating Area 3 No Preference 49 559.46

55957PA0280003 Rating Area 3 No Preference 50 585.70

55957PA0280003 Rating Area 3 No Preference 51 611.60

55957PA0280003 Rating Area 3 No Preference 52 640.13

55957PA0280003 Rating Area 3 No Preference 53 668.99

55957PA0280003 Rating Area 3 No Preference 54 700.15

55957PA0280003 Rating Area 3 No Preference 55 731.30

55957PA0280003 Rating Area 3 No Preference 56 765.08

55957PA0280003 Rating Area 3 No Preference 57 799.18

55957PA0280003 Rating Area 3 No Preference 58 835.59

55957PA0280003 Rating Area 3 No Preference 59 853.62

55957PA0280003 Rating Area 3 No Preference 60 890.02

55957PA0280003 Rating Area 3 No Preference 61 921.51

55957PA0280003 Rating Area 3 No Preference 62 942.17

55957PA0280003 Rating Area 3 No Preference 63 968.07

55957PA0280003 Rating Area 3 No Preference 64 983.82

55957PA0280003 Rating Area 3 No Preference 65 and over 983.82

55957PA0280004 Rating Area 3 No Preference 0-20 241.61

55957PA0280004 Rating Area 3 No Preference 21 380.50

55957PA0280004 Rating Area 3 No Preference 22 380.50

55957PA0280004 Rating Area 3 No Preference 23 380.50

55957PA0280004 Rating Area 3 No Preference 24 380.50

55957PA0280004 Rating Area 3 No Preference 25 382.02

55957PA0280004 Rating Area 3 No Preference 26 389.63

55957PA0280004 Rating Area 3 No Preference 27 398.76

55957PA0280004 Rating Area 3 No Preference 28 413.60

55957PA0280004 Rating Area 3 No Preference 29 425.77

55957PA0280004 Rating Area 3 No Preference 30 431.86

55957PA0280004 Rating Area 3 No Preference 31 440.99

55957PA0280004 Rating Area 3 No Preference 32 450.13

55957PA0280004 Rating Area 3 No Preference 33 455.83

55957PA0280004 Rating Area 3 No Preference 34 461.92

55957PA0280004 Rating Area 3 No Preference 35 464.97

55957PA0280004 Rating Area 3 No Preference 36 468.01

55957PA0280004 Rating Area 3 No Preference 37 471.05

55957PA0280004 Rating Area 3 No Preference 38 474.10

55957PA0280004 Rating Area 3 No Preference 39 480.19

55957PA0280004 Rating Area 3 No Preference 40 486.27

55957PA0280004 Rating Area 3 No Preference 41 495.41

55957PA0280004 Rating Area 3 No Preference 42 504.16

55957PA0280004 Rating Area 3 No Preference 43 516.33

55957PA0280004 Rating Area 3 No Preference 44 531.55

55957PA0280004 Rating Area 3 No Preference 45 549.44

55957PA0280004 Rating Area 3 No Preference 46 570.75

55957PA0280004 Rating Area 3 No Preference 47 594.72

55957PA0280004 Rating Area 3 No Preference 48 622.11

55957PA0280004 Rating Area 3 No Preference 49 649.13

55957PA0280004 Rating Area 3 No Preference 50 679.57

55957PA0280004 Rating Area 3 No Preference 51 709.63

55957PA0280004 Rating Area 3 No Preference 52 742.73

55957PA0280004 Rating Area 3 No Preference 53 776.22

55957PA0280004 Rating Area 3 No Preference 54 812.36

55957PA0280004 Rating Area 3 No Preference 55 848.51

55957PA0280004 Rating Area 3 No Preference 56 887.70

55957PA0280004 Rating Area 3 No Preference 57 927.27

55957PA0280004 Rating Area 3 No Preference 58 969.51

55957PA0280004 Rating Area 3 No Preference 59 990.44

55957PA0280004 Rating Area 3 No Preference 60 1032.67

55957PA0280004 Rating Area 3 No Preference 61 1069.20

55957PA0280004 Rating Area 3 No Preference 62 1093.17

55957PA0280004 Rating Area 3 No Preference 63 1123.23

55957PA0280004 Rating Area 3 No Preference 64 1141.50

55957PA0280004 Rating Area 3 No Preference 65 and over 1141.50

55957PA0300001 Rating Area 3 No Preference 0-20 225.99

55957PA0300001 Rating Area 3 No Preference 21 355.90

55957PA0300001 Rating Area 3 No Preference 22 355.90

55957PA0300001 Rating Area 3 No Preference 23 355.90

55957PA0300001 Rating Area 3 No Preference 24 355.90

55957PA0300001 Rating Area 3 No Preference 25 357.32

55957PA0300001 Rating Area 3 No Preference 26 364.44

55957PA0300001 Rating Area 3 No Preference 27 372.98

55957PA0300001 Rating Area 3 No Preference 28 386.86

55957PA0300001 Rating Area 3 No Preference 29 398.25

55957PA0300001 Rating Area 3 No Preference 30 403.94

55957PA0300001 Rating Area 3 No Preference 31 412.48

55957PA0300001 Rating Area 3 No Preference 32 421.02

55957PA0300001 Rating Area 3 No Preference 33 426.36

55957PA0300001 Rating Area 3 No Preference 34 432.06

55957PA0300001 Rating Area 3 No Preference 35 434.90

55957PA0300001 Rating Area 3 No Preference 36 437.75

55957PA0300001 Rating Area 3 No Preference 37 440.60

55957PA0300001 Rating Area 3 No Preference 38 443.45

55957PA0300001 Rating Area 3 No Preference 39 449.14

55957PA0300001 Rating Area 3 No Preference 40 454.84

55957PA0300001 Rating Area 3 No Preference 41 463.38

55957PA0300001 Rating Area 3 No Preference 42 471.56

55957PA0300001 Rating Area 3 No Preference 43 482.95

55957PA0300001 Rating Area 3 No Preference 44 497.19

55957PA0300001 Rating Area 3 No Preference 45 513.91

55957PA0300001 Rating Area 3 No Preference 46 533.85

55957PA0300001 Rating Area 3 No Preference 47 556.27

55957PA0300001 Rating Area 3 No Preference 48 581.89

55957PA0300001 Rating Area 3 No Preference 49 607.16

55957PA0300001 Rating Area 3 No Preference 50 635.63

55957PA0300001 Rating Area 3 No Preference 51 663.75

55957PA0300001 Rating Area 3 No Preference 52 694.71

55957PA0300001 Rating Area 3 No Preference 53 726.03

55957PA0300001 Rating Area 3 No Preference 54 759.84

55957PA0300001 Rating Area 3 No Preference 55 793.65

55957PA0300001 Rating Area 3 No Preference 56 830.31

55957PA0300001 Rating Area 3 No Preference 57 867.32

55957PA0300001 Rating Area 3 No Preference 58 906.83

55957PA0300001 Rating Area 3 No Preference 59 926.40

55957PA0300001 Rating Area 3 No Preference 60 965.91

55957PA0300001 Rating Area 3 No Preference 61 1000.07

55957PA0300001 Rating Area 3 No Preference 62 1022.50

55957PA0300001 Rating Area 3 No Preference 63 1050.61

55957PA0300001 Rating Area 3 No Preference 64 1067.70

55957PA0300001 Rating Area 3 No Preference 65 and over 1067.70

55957PA0300002 Rating Area 3 No Preference 0-20 193.52

55957PA0300002 Rating Area 3 No Preference 21 304.77

55957PA0300002 Rating Area 3 No Preference 22 304.77

55957PA0300002 Rating Area 3 No Preference 23 304.77

55957PA0300002 Rating Area 3 No Preference 24 304.77

55957PA0300002 Rating Area 3 No Preference 25 305.98

55957PA0300002 Rating Area 3 No Preference 26 312.08

55957PA0300002 Rating Area 3 No Preference 27 319.39

55957PA0300002 Rating Area 3 No Preference 28 331.28

55957PA0300002 Rating Area 3 No Preference 29 341.03

55957PA0300002 Rating Area 3 No Preference 30 345.91

55957PA0300002 Rating Area 3 No Preference 31 353.22

55957PA0300002 Rating Area 3 No Preference 32 360.54

55957PA0300002 Rating Area 3 No Preference 33 365.11

55957PA0300002 Rating Area 3 No Preference 34 369.99

55957PA0300002 Rating Area 3 No Preference 35 372.42

55957PA0300002 Rating Area 3 No Preference 36 374.86

55957PA0300002 Rating Area 3 No Preference 37 377.30

55957PA0300002 Rating Area 3 No Preference 38 379.74

55957PA0300002 Rating Area 3 No Preference 39 384.61

55957PA0300002 Rating Area 3 No Preference 40 389.49

55957PA0300002 Rating Area 3 No Preference 41 396.81

55957PA0300002 Rating Area 3 No Preference 42 403.82

55957PA0300002 Rating Area 3 No Preference 43 413.57

55957PA0300002 Rating Area 3 No Preference 44 425.76

55957PA0300002 Rating Area 3 No Preference 45 440.08

55957PA0300002 Rating Area 3 No Preference 46 457.15

55957PA0300002 Rating Area 3 No Preference 47 476.35

55957PA0300002 Rating Area 3 No Preference 48 498.29

55957PA0300002 Rating Area 3 No Preference 49 519.93

55957PA0300002 Rating Area 3 No Preference 50 544.31

55957PA0300002 Rating Area 3 No Preference 51 568.39

55957PA0300002 Rating Area 3 No Preference 52 594.91

55957PA0300002 Rating Area 3 No Preference 53 621.73

55957PA0300002 Rating Area 3 No Preference 54 650.68

55957PA0300002 Rating Area 3 No Preference 55 679.63

55957PA0300002 Rating Area 3 No Preference 56 711.02

55957PA0300002 Rating Area 3 No Preference 57 742.72

55957PA0300002 Rating Area 3 No Preference 58 776.55

55957PA0300002 Rating Area 3 No Preference 59 793.31

55957PA0300002 Rating Area 3 No Preference 60 827.14

55957PA0300002 Rating Area 3 No Preference 61 856.40

55957PA0300002 Rating Area 3 No Preference 62 875.60

55957PA0300002 Rating Area 3 No Preference 63 899.68

55957PA0300002 Rating Area 3 No Preference 64 914.31

55957PA0300002 Rating Area 3 No Preference 65 and over 914.31

55957PA0370001 Rating Area 3 No Preference 0-20 254.13

55957PA0370001 Rating Area 3 No Preference 21 400.21

55957PA0370001 Rating Area 3 No Preference 22 400.21

55957PA0370001 Rating Area 3 No Preference 23 400.21

55957PA0370001 Rating Area 3 No Preference 24 400.21

55957PA0370001 Rating Area 3 No Preference 25 401.81

55957PA0370001 Rating Area 3 No Preference 26 409.81

55957PA0370001 Rating Area 3 No Preference 27 419.42

55957PA0370001 Rating Area 3 No Preference 28 435.02

55957PA0370001 Rating Area 3 No Preference 29 447.83

55957PA0370001 Rating Area 3 No Preference 30 454.23

55957PA0370001 Rating Area 3 No Preference 31 463.84

55957PA0370001 Rating Area 3 No Preference 32 473.44

55957PA0370001 Rating Area 3 No Preference 33 479.45

55957PA0370001 Rating Area 3 No Preference 34 485.85

55957PA0370001 Rating Area 3 No Preference 35 489.05

55957PA0370001 Rating Area 3 No Preference 36 492.25

55957PA0370001 Rating Area 3 No Preference 37 495.45

55957PA0370001 Rating Area 3 No Preference 38 498.66

55957PA0370001 Rating Area 3 No Preference 39 505.06

55957PA0370001 Rating Area 3 No Preference 40 511.46

55957PA0370001 Rating Area 3 No Preference 41 521.07

55957PA0370001 Rating Area 3 No Preference 42 530.27

55957PA0370001 Rating Area 3 No Preference 43 543.08

55957PA0370001 Rating Area 3 No Preference 44 559.09

55957PA0370001 Rating Area 3 No Preference 45 577.90

55957PA0370001 Rating Area 3 No Preference 46 600.31

55957PA0370001 Rating Area 3 No Preference 47 625.52

55957PA0370001 Rating Area 3 No Preference 48 654.34

55957PA0370001 Rating Area 3 No Preference 49 682.75

55957PA0370001 Rating Area 3 No Preference 50 714.77

55957PA0370001 Rating Area 3 No Preference 51 746.39

55957PA0370001 Rating Area 3 No Preference 52 781.20

55957PA0370001 Rating Area 3 No Preference 53 816.42

55957PA0370001 Rating Area 3 No Preference 54 854.44

55957PA0370001 Rating Area 3 No Preference 55 892.46

55957PA0370001 Rating Area 3 No Preference 56 933.68

55957PA0370001 Rating Area 3 No Preference 57 975.31

55957PA0370001 Rating Area 3 No Preference 58 1019.73

55957PA0370001 Rating Area 3 No Preference 59 1041.74

55957PA0370001 Rating Area 3 No Preference 60 1086.16

55957PA0370001 Rating Area 3 No Preference 61 1124.59

55957PA0370001 Rating Area 3 No Preference 62 1149.80

55957PA0370001 Rating Area 3 No Preference 63 1181.41

55957PA0370001 Rating Area 3 No Preference 64 1200.63

55957PA0370001 Rating Area 3 No Preference 65 and over 1200.63

55957PA0370002 Rating Area 3 No Preference 0-20 242.88

55957PA0370002 Rating Area 3 No Preference 21 382.50

55957PA0370002 Rating Area 3 No Preference 22 382.50

55957PA0370002 Rating Area 3 No Preference 23 382.50

55957PA0370002 Rating Area 3 No Preference 24 382.50

55957PA0370002 Rating Area 3 No Preference 25 384.03

55957PA0370002 Rating Area 3 No Preference 26 391.68

55957PA0370002 Rating Area 3 No Preference 27 400.86

55957PA0370002 Rating Area 3 No Preference 28 415.77

55957PA0370002 Rating Area 3 No Preference 29 428.01

55957PA0370002 Rating Area 3 No Preference 30 434.13

55957PA0370002 Rating Area 3 No Preference 31 443.31

55957PA0370002 Rating Area 3 No Preference 32 452.49

55957PA0370002 Rating Area 3 No Preference 33 458.23

55957PA0370002 Rating Area 3 No Preference 34 464.35

55957PA0370002 Rating Area 3 No Preference 35 467.41

55957PA0370002 Rating Area 3 No Preference 36 470.47

55957PA0370002 Rating Area 3 No Preference 37 473.53

55957PA0370002 Rating Area 3 No Preference 38 476.59

55957PA0370002 Rating Area 3 No Preference 39 482.71

55957PA0370002 Rating Area 3 No Preference 40 488.83

55957PA0370002 Rating Area 3 No Preference 41 498.01

55957PA0370002 Rating Area 3 No Preference 42 506.81

55957PA0370002 Rating Area 3 No Preference 43 519.05

55957PA0370002 Rating Area 3 No Preference 44 534.35

55957PA0370002 Rating Area 3 No Preference 45 552.33

55957PA0370002 Rating Area 3 No Preference 46 573.75

55957PA0370002 Rating Area 3 No Preference 47 597.84

55957PA0370002 Rating Area 3 No Preference 48 625.38

55957PA0370002 Rating Area 3 No Preference 49 652.54

55957PA0370002 Rating Area 3 No Preference 50 683.14

55957PA0370002 Rating Area 3 No Preference 51 713.36

55957PA0370002 Rating Area 3 No Preference 52 746.64

55957PA0370002 Rating Area 3 No Preference 53 780.30

55957PA0370002 Rating Area 3 No Preference 54 816.63

55957PA0370002 Rating Area 3 No Preference 55 852.97

55957PA0370002 Rating Area 3 No Preference 56 892.37

55957PA0370002 Rating Area 3 No Preference 57 932.15

55957PA0370002 Rating Area 3 No Preference 58 974.61

55957PA0370002 Rating Area 3 No Preference 59 995.64

55957PA0370002 Rating Area 3 No Preference 60 1038.10

55957PA0370002 Rating Area 3 No Preference 61 1074.82

55957PA0370002 Rating Area 3 No Preference 62 1098.92

55957PA0370002 Rating Area 3 No Preference 63 1129.14

55957PA0370002 Rating Area 3 No Preference 64 1147.50

55957PA0370002 Rating Area 3 No Preference 65 and over 1147.50

55957PA0380001 Rating Area 3 No Preference 0-20 199.41

55957PA0380001 Rating Area 3 No Preference 21 314.04

55957PA0380001 Rating Area 3 No Preference 22 314.04

55957PA0380001 Rating Area 3 No Preference 23 314.04

55957PA0380001 Rating Area 3 No Preference 24 314.04

55957PA0380001 Rating Area 3 No Preference 25 315.29

55957PA0380001 Rating Area 3 No Preference 26 321.57

55957PA0380001 Rating Area 3 No Preference 27 329.11

55957PA0380001 Rating Area 3 No Preference 28 341.36

55957PA0380001 Rating Area 3 No Preference 29 351.41

55957PA0380001 Rating Area 3 No Preference 30 356.43

55957PA0380001 Rating Area 3 No Preference 31 363.97

55957PA0380001 Rating Area 3 No Preference 32 371.50

55957PA0380001 Rating Area 3 No Preference 33 376.21

55957PA0380001 Rating Area 3 No Preference 34 381.24

55957PA0380001 Rating Area 3 No Preference 35 383.75

55957PA0380001 Rating Area 3 No Preference 36 386.26

55957PA0380001 Rating Area 3 No Preference 37 388.78

55957PA0380001 Rating Area 3 No Preference 38 391.29

55957PA0380001 Rating Area 3 No Preference 39 396.31

55957PA0380001 Rating Area 3 No Preference 40 401.34

55957PA0380001 Rating Area 3 No Preference 41 408.88

55957PA0380001 Rating Area 3 No Preference 42 416.10

55957PA0380001 Rating Area 3 No Preference 43 426.15

55957PA0380001 Rating Area 3 No Preference 44 438.71

55957PA0380001 Rating Area 3 No Preference 45 453.47

55957PA0380001 Rating Area 3 No Preference 46 471.06

55957PA0380001 Rating Area 3 No Preference 47 490.84

55957PA0380001 Rating Area 3 No Preference 48 513.45

55957PA0380001 Rating Area 3 No Preference 49 535.75

55957PA0380001 Rating Area 3 No Preference 50 560.87

55957PA0380001 Rating Area 3 No Preference 51 585.68

55957PA0380001 Rating Area 3 No Preference 52 613.00

55957PA0380001 Rating Area 3 No Preference 53 640.64

55957PA0380001 Rating Area 3 No Preference 54 670.47

55957PA0380001 Rating Area 3 No Preference 55 700.30

55957PA0380001 Rating Area 3 No Preference 56 732.65

55957PA0380001 Rating Area 3 No Preference 57 765.31

55957PA0380001 Rating Area 3 No Preference 58 800.17

55957PA0380001 Rating Area 3 No Preference 59 817.44

55957PA0380001 Rating Area 3 No Preference 60 852.30

55957PA0380001 Rating Area 3 No Preference 61 882.45

55957PA0380001 Rating Area 3 No Preference 62 902.23

55957PA0380001 Rating Area 3 No Preference 63 927.04

55957PA0380001 Rating Area 3 No Preference 64 942.12

55957PA0380001 Rating Area 3 No Preference 65 and over 942.12

2017 Rates Table Template v6.0 All fields with an asterisk ( * ) are required. To validate press Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells B1 through B5.If you are a community rating state, select Family Option under Age and fill in all columns.

If you are not community rating state, select 0-20 under Age and provide an Individual Rate for every age band.

If Tobacco is Tobacco User/Non-Tobacco User, you must give a rate for Tobacco Use and Non-Tobacco Use.

To add a new sheet, press the Add Sheet button, or Ctrl + Shift + H. All plans must have the same dates on a sheet.

HIOS Issuer ID* 55957

Federal TIN* 23-2905083

Rate Effective Date* 10/1/2017

Rate Expiration Date* 12/31/2017

Plan ID* Rating Area ID* Tobacco* Age* Individual Rate*

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a plan

Required:

Select the age of a subscriber eligible for the rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

55957PA0270007 Rating Area 3 No Preference 0-20 300.69

55957PA0270007 Rating Area 3 No Preference 21 473.53

55957PA0270007 Rating Area 3 No Preference 22 473.53

55957PA0270007 Rating Area 3 No Preference 23 473.53

55957PA0270007 Rating Area 3 No Preference 24 473.53

55957PA0270007 Rating Area 3 No Preference 25 475.42

55957PA0270007 Rating Area 3 No Preference 26 484.89

55957PA0270007 Rating Area 3 No Preference 27 496.25

55957PA0270007 Rating Area 3 No Preference 28 514.72

55957PA0270007 Rating Area 3 No Preference 29 529.88

55957PA0270007 Rating Area 3 No Preference 30 537.45

55957PA0270007 Rating Area 3 No Preference 31 548.82

55957PA0270007 Rating Area 3 No Preference 32 560.18

55957PA0270007 Rating Area 3 No Preference 33 567.28

55957PA0270007 Rating Area 3 No Preference 34 574.86

55957PA0270007 Rating Area 3 No Preference 35 578.65

55957PA0270007 Rating Area 3 No Preference 36 582.44

55957PA0270007 Rating Area 3 No Preference 37 586.23

55957PA0270007 Rating Area 3 No Preference 38 590.01

55957PA0270007 Rating Area 3 No Preference 39 597.59

55957PA0270007 Rating Area 3 No Preference 40 605.17

55957PA0270007 Rating Area 3 No Preference 41 616.53

55957PA0270007 Rating Area 3 No Preference 42 627.42

55957PA0270007 Rating Area 3 No Preference 43 642.58

55957PA0270007 Rating Area 3 No Preference 44 661.52

55957PA0270007 Rating Area 3 No Preference 45 683.77

55957PA0270007 Rating Area 3 No Preference 46 710.29

55957PA0270007 Rating Area 3 No Preference 47 740.12

55957PA0270007 Rating Area 3 No Preference 48 774.22

55957PA0270007 Rating Area 3 No Preference 49 807.84

55957PA0270007 Rating Area 3 No Preference 50 845.72

55957PA0270007 Rating Area 3 No Preference 51 883.13

55957PA0270007 Rating Area 3 No Preference 52 924.33

55957PA0270007 Rating Area 3 No Preference 53 966.00

55957PA0270007 Rating Area 3 No Preference 54 1010.98

55957PA0270007 Rating Area 3 No Preference 55 1055.97

55957PA0270007 Rating Area 3 No Preference 56 1104.74

55957PA0270007 Rating Area 3 No Preference 57 1153.99

55957PA0270007 Rating Area 3 No Preference 58 1206.55

55957PA0270007 Rating Area 3 No Preference 59 1232.59

55957PA0270007 Rating Area 3 No Preference 60 1285.16

55957PA0270007 Rating Area 3 No Preference 61 1330.61

55957PA0270007 Rating Area 3 No Preference 62 1360.45

55957PA0270007 Rating Area 3 No Preference 63 1397.86

55957PA0270007 Rating Area 3 No Preference 64 1420.59

55957PA0270007 Rating Area 3 No Preference 65 and over 1420.59

55957PA0270016 Rating Area 3 No Preference 0-20 302.72

55957PA0270016 Rating Area 3 No Preference 21 476.74

55957PA0270016 Rating Area 3 No Preference 22 476.74

55957PA0270016 Rating Area 3 No Preference 23 476.74

55957PA0270016 Rating Area 3 No Preference 24 476.74

55957PA0270016 Rating Area 3 No Preference 25 478.64

55957PA0270016 Rating Area 3 No Preference 26 488.18

55957PA0270016 Rating Area 3 No Preference 27 499.62

55957PA0270016 Rating Area 3 No Preference 28 518.21

55957PA0270016 Rating Area 3 No Preference 29 533.47

55957PA0270016 Rating Area 3 No Preference 30 541.09

55957PA0270016 Rating Area 3 No Preference 31 552.54

55957PA0270016 Rating Area 3 No Preference 32 563.98

55957PA0270016 Rating Area 3 No Preference 33 571.13

55957PA0270016 Rating Area 3 No Preference 34 578.76

55957PA0270016 Rating Area 3 No Preference 35 582.57

55957PA0270016 Rating Area 3 No Preference 36 586.39

55957PA0270016 Rating Area 3 No Preference 37 590.20

55957PA0270016 Rating Area 3 No Preference 38 594.01

55957PA0270016 Rating Area 3 No Preference 39 601.64

55957PA0270016 Rating Area 3 No Preference 40 609.27

55957PA0270016 Rating Area 3 No Preference 41 620.71

55957PA0270016 Rating Area 3 No Preference 42 631.68

55957PA0270016 Rating Area 3 No Preference 43 646.93

55957PA0270016 Rating Area 3 No Preference 44 666.00

55957PA0270016 Rating Area 3 No Preference 45 688.41

55957PA0270016 Rating Area 3 No Preference 46 715.11

55957PA0270016 Rating Area 3 No Preference 47 745.14

55957PA0270016 Rating Area 3 No Preference 48 779.46

55957PA0270016 Rating Area 3 No Preference 49 813.31

55957PA0270016 Rating Area 3 No Preference 50 851.45

55957PA0270016 Rating Area 3 No Preference 51 889.12

55957PA0270016 Rating Area 3 No Preference 52 930.59

55957PA0270016 Rating Area 3 No Preference 53 972.54

55957PA0270016 Rating Area 3 No Preference 54 1017.83

55957PA0270016 Rating Area 3 No Preference 55 1063.13

55957PA0270016 Rating Area 3 No Preference 56 1112.23

55957PA0270016 Rating Area 3 No Preference 57 1161.81

55957PA0270016 Rating Area 3 No Preference 58 1214.73

55957PA0270016 Rating Area 3 No Preference 59 1240.95

55957PA0270016 Rating Area 3 No Preference 60 1293.87

55957PA0270016 Rating Area 3 No Preference 61 1339.63

55957PA0270016 Rating Area 3 No Preference 62 1369.67

55957PA0270016 Rating Area 3 No Preference 63 1407.33

55957PA0270016 Rating Area 3 No Preference 64 1430.22

55957PA0270016 Rating Area 3 No Preference 65 and over 1430.22

55957PA0270002 Rating Area 3 No Preference 0-20 300.86

55957PA0270002 Rating Area 3 No Preference 21 473.81

55957PA0270002 Rating Area 3 No Preference 22 473.81

55957PA0270002 Rating Area 3 No Preference 23 473.81

55957PA0270002 Rating Area 3 No Preference 24 473.81

55957PA0270002 Rating Area 3 No Preference 25 475.70

55957PA0270002 Rating Area 3 No Preference 26 485.18

55957PA0270002 Rating Area 3 No Preference 27 496.55

55957PA0270002 Rating Area 3 No Preference 28 515.03

55957PA0270002 Rating Area 3 No Preference 29 530.19

55957PA0270002 Rating Area 3 No Preference 30 537.77

55957PA0270002 Rating Area 3 No Preference 31 549.14

55957PA0270002 Rating Area 3 No Preference 32 560.51

55957PA0270002 Rating Area 3 No Preference 33 567.62

55957PA0270002 Rating Area 3 No Preference 34 575.20

55957PA0270002 Rating Area 3 No Preference 35 578.99

55957PA0270002 Rating Area 3 No Preference 36 582.78

55957PA0270002 Rating Area 3 No Preference 37 586.57

55957PA0270002 Rating Area 3 No Preference 38 590.36

55957PA0270002 Rating Area 3 No Preference 39 597.94

55957PA0270002 Rating Area 3 No Preference 40 605.52

55957PA0270002 Rating Area 3 No Preference 41 616.90

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55957PA0270002 Rating Area 3 No Preference 43 642.96

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55957PA0270002 Rating Area 3 No Preference 62 1361.25

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55957PA0270006 Rating Area 3 No Preference 0-20 297.42

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55957PA0270006 Rating Area 3 No Preference 23 468.38

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55957PA0270006 Rating Area 3 No Preference 63 1382.65

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55957PA0270006 Rating Area 3 No Preference 65 and over 1405.14

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55957PA0270017 Rating Area 3 No Preference 21 428.24

55957PA0270017 Rating Area 3 No Preference 22 428.24

55957PA0270017 Rating Area 3 No Preference 23 428.24

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55957PA0270017 Rating Area 3 No Preference 63 1264.16

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55957PA0270017 Rating Area 3 No Preference 65 and over 1284.72

55957PA0270018 Rating Area 3 No Preference 0-20 250.38

55957PA0270018 Rating Area 3 No Preference 21 394.31

55957PA0270018 Rating Area 3 No Preference 22 394.31

55957PA0270018 Rating Area 3 No Preference 23 394.31

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55957PA0270018 Rating Area 3 No Preference 65 and over 1182.93

55957PA0270008 Rating Area 3 No Preference 0-20 254.60

55957PA0270008 Rating Area 3 No Preference 21 400.96

55957PA0270008 Rating Area 3 No Preference 22 400.96

55957PA0270008 Rating Area 3 No Preference 23 400.96

55957PA0270008 Rating Area 3 No Preference 24 400.96

55957PA0270008 Rating Area 3 No Preference 25 402.56

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55957PA0270008 Rating Area 3 No Preference 28 435.84

55957PA0270008 Rating Area 3 No Preference 29 448.67

55957PA0270008 Rating Area 3 No Preference 30 455.08

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55957PA0270008 Rating Area 3 No Preference 32 474.33

55957PA0270008 Rating Area 3 No Preference 33 480.35

55957PA0270008 Rating Area 3 No Preference 34 486.76

55957PA0270008 Rating Area 3 No Preference 35 489.97

55957PA0270008 Rating Area 3 No Preference 36 493.18

55957PA0270008 Rating Area 3 No Preference 37 496.38

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55957PA0270008 Rating Area 3 No Preference 39 506.01

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55957PA0270008 Rating Area 3 No Preference 53 817.95

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55957PA0270008 Rating Area 3 No Preference 56 935.43

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55957PA0270008 Rating Area 3 No Preference 63 1183.63

55957PA0270008 Rating Area 3 No Preference 64 1202.88

55957PA0270008 Rating Area 3 No Preference 65 and over 1202.88

55957PA0270009 Rating Area 3 No Preference 0-20 254.85

55957PA0270009 Rating Area 3 No Preference 21 401.34

55957PA0270009 Rating Area 3 No Preference 22 401.34

55957PA0270009 Rating Area 3 No Preference 23 401.34

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55957PA0270009 Rating Area 3 No Preference 28 436.25

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55957PA0270009 Rating Area 3 No Preference 34 487.22

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55957PA0270009 Rating Area 3 No Preference 37 496.85

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55957PA0270009 Rating Area 3 No Preference 49 684.68

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55957PA0270009 Rating Area 3 No Preference 51 748.49

55957PA0270009 Rating Area 3 No Preference 52 783.41

55957PA0270009 Rating Area 3 No Preference 53 818.73

55957PA0270009 Rating Area 3 No Preference 54 856.86

55957PA0270009 Rating Area 3 No Preference 55 894.98

55957PA0270009 Rating Area 3 No Preference 56 936.32

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55957PA0270009 Rating Area 3 No Preference 58 1022.61

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55957PA0270009 Rating Area 3 No Preference 65 and over 1204.02

55957PA0270010 Rating Area 3 No Preference 0-20 259.13

55957PA0270010 Rating Area 3 No Preference 21 408.08

55957PA0270010 Rating Area 3 No Preference 22 408.08

55957PA0270010 Rating Area 3 No Preference 23 408.08

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55957PA0270010 Rating Area 3 No Preference 30 463.17

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55957PA0270010 Rating Area 3 No Preference 32 482.75

55957PA0270010 Rating Area 3 No Preference 33 488.87

55957PA0270010 Rating Area 3 No Preference 34 495.40

55957PA0270010 Rating Area 3 No Preference 35 498.67

55957PA0270010 Rating Area 3 No Preference 36 501.93

55957PA0270010 Rating Area 3 No Preference 37 505.20

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55957PA0270010 Rating Area 3 No Preference 53 832.48

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55957PA0270010 Rating Area 3 No Preference 65 and over 1224.24

55957PA0270011 Rating Area 3 No Preference 0-20 248.66

55957PA0270011 Rating Area 3 No Preference 21 391.60

55957PA0270011 Rating Area 3 No Preference 22 391.60

55957PA0270011 Rating Area 3 No Preference 23 391.60

55957PA0270011 Rating Area 3 No Preference 24 391.60

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55957PA0270011 Rating Area 3 No Preference 28 425.66

55957PA0270011 Rating Area 3 No Preference 29 438.20

55957PA0270011 Rating Area 3 No Preference 30 444.46

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55957PA0270011 Rating Area 3 No Preference 34 475.40

55957PA0270011 Rating Area 3 No Preference 35 478.53

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55957PA0270011 Rating Area 3 No Preference 37 484.80

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55957PA0270011 Rating Area 3 No Preference 51 730.33

55957PA0270011 Rating Area 3 No Preference 52 764.40

55957PA0270011 Rating Area 3 No Preference 53 798.86

55957PA0270011 Rating Area 3 No Preference 54 836.06

55957PA0270011 Rating Area 3 No Preference 55 873.26

55957PA0270011 Rating Area 3 No Preference 56 913.60

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55957PA0270011 Rating Area 3 No Preference 58 997.79

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55957PA0270011 Rating Area 3 No Preference 62 1125.06

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55957PA0270011 Rating Area 3 No Preference 64 1174.80

55957PA0270011 Rating Area 3 No Preference 65 and over 1174.80

55957PA0270022 Rating Area 3 No Preference 0-20 213.69

55957PA0270022 Rating Area 3 No Preference 21 336.53

55957PA0270022 Rating Area 3 No Preference 22 336.53

55957PA0270022 Rating Area 3 No Preference 23 336.53

55957PA0270022 Rating Area 3 No Preference 24 336.53

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55957PA0270022 Rating Area 3 No Preference 28 365.80

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55957PA0270022 Rating Area 3 No Preference 30 381.96

55957PA0270022 Rating Area 3 No Preference 31 390.03

55957PA0270022 Rating Area 3 No Preference 32 398.11

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55957PA0270022 Rating Area 3 No Preference 34 408.54

55957PA0270022 Rating Area 3 No Preference 35 411.23

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55957PA0270022 Rating Area 3 No Preference 38 419.31

55957PA0270022 Rating Area 3 No Preference 39 424.70

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55957PA0270022 Rating Area 3 No Preference 45 485.94

55957PA0270022 Rating Area 3 No Preference 46 504.79

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55957PA0270022 Rating Area 3 No Preference 48 550.22

55957PA0270022 Rating Area 3 No Preference 49 574.12

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55957PA0270022 Rating Area 3 No Preference 53 686.52

55957PA0270022 Rating Area 3 No Preference 54 718.49

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55957PA0270022 Rating Area 3 No Preference 56 785.12

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55957PA0270022 Rating Area 3 No Preference 62 966.85

55957PA0270022 Rating Area 3 No Preference 63 993.43

55957PA0270022 Rating Area 3 No Preference 64 1009.59

55957PA0270022 Rating Area 3 No Preference 65 and over 1009.59

55957PA0270019 Rating Area 3 No Preference 0-20 203.26

55957PA0270019 Rating Area 3 No Preference 21 320.11

55957PA0270019 Rating Area 3 No Preference 22 320.11

55957PA0270019 Rating Area 3 No Preference 23 320.11

55957PA0270019 Rating Area 3 No Preference 24 320.11

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55957PA0270019 Rating Area 3 No Preference 28 347.95

55957PA0270019 Rating Area 3 No Preference 29 358.20

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55957PA0270019 Rating Area 3 No Preference 52 624.85

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55957PA0270019 Rating Area 3 No Preference 55 713.84

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55957PA0270019 Rating Area 3 No Preference 63 944.96

55957PA0270019 Rating Area 3 No Preference 64 960.33

55957PA0270019 Rating Area 3 No Preference 65 and over 960.33

55957PA0270020 Rating Area 3 No Preference 0-20 216.00

55957PA0270020 Rating Area 3 No Preference 21 340.17

55957PA0270020 Rating Area 3 No Preference 22 340.17

55957PA0270020 Rating Area 3 No Preference 23 340.17

55957PA0270020 Rating Area 3 No Preference 24 340.17

55957PA0270020 Rating Area 3 No Preference 25 341.53

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55957PA0290007 Rating Area 3 No Preference 22 397.77

55957PA0290007 Rating Area 3 No Preference 23 397.77

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55957PA0290007 Rating Area 3 No Preference 56 927.99

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55957PA0290007 Rating Area 3 No Preference 63 1174.21

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55957PA0290007 Rating Area 3 No Preference 65 and over 1193.31

55957PA0290008 Rating Area 3 No Preference 0-20 254.29

55957PA0290008 Rating Area 3 No Preference 21 400.46

55957PA0290008 Rating Area 3 No Preference 22 400.46

55957PA0290008 Rating Area 3 No Preference 23 400.46

55957PA0290008 Rating Area 3 No Preference 24 400.46

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55957PA0290008 Rating Area 3 No Preference 28 435.30

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55957PA0290008 Rating Area 3 No Preference 35 489.36

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55957PA0290008 Rating Area 3 No Preference 41 521.39

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55957PA0290008 Rating Area 3 No Preference 63 1182.15

55957PA0290008 Rating Area 3 No Preference 64 1201.38

55957PA0290008 Rating Area 3 No Preference 65 and over 1201.38

55957PA0290002 Rating Area 3 No Preference 0-20 252.73

55957PA0290002 Rating Area 3 No Preference 21 398.00

55957PA0290002 Rating Area 3 No Preference 22 398.00

55957PA0290002 Rating Area 3 No Preference 23 398.00

55957PA0290002 Rating Area 3 No Preference 24 398.00

55957PA0290002 Rating Area 3 No Preference 25 399.59

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55957PA0290002 Rating Area 3 No Preference 53 811.92

55957PA0290002 Rating Area 3 No Preference 54 849.73

55957PA0290002 Rating Area 3 No Preference 55 887.54

55957PA0290002 Rating Area 3 No Preference 56 928.53

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55957PA0290002 Rating Area 3 No Preference 62 1143.45

55957PA0290002 Rating Area 3 No Preference 63 1174.89

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55957PA0290002 Rating Area 3 No Preference 65 and over 1194.00

55957PA0290006 Rating Area 3 No Preference 0-20 249.83

55957PA0290006 Rating Area 3 No Preference 21 393.44

55957PA0290006 Rating Area 3 No Preference 22 393.44

55957PA0290006 Rating Area 3 No Preference 23 393.44

55957PA0290006 Rating Area 3 No Preference 24 393.44

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55957PA0290006 Rating Area 3 No Preference 37 487.07

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55957PA0290006 Rating Area 3 No Preference 40 502.81

55957PA0290006 Rating Area 3 No Preference 41 512.25

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55957PA0290006 Rating Area 3 No Preference 43 533.89

55957PA0290006 Rating Area 3 No Preference 44 549.63

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55957PA0290006 Rating Area 3 No Preference 48 643.27

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55957PA0290006 Rating Area 3 No Preference 50 702.68

55957PA0290006 Rating Area 3 No Preference 51 733.76

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55957PA0290006 Rating Area 3 No Preference 53 802.61

55957PA0290006 Rating Area 3 No Preference 54 839.99

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55957PA0290006 Rating Area 3 No Preference 65 and over 1180.32

55957PA0290022 Rating Area 3 No Preference 0-20 228.42

55957PA0290022 Rating Area 3 No Preference 21 359.72

55957PA0290022 Rating Area 3 No Preference 22 359.72

55957PA0290022 Rating Area 3 No Preference 23 359.72

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55957PA0290022 Rating Area 3 No Preference 39 453.96

55957PA0290022 Rating Area 3 No Preference 40 459.72

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55957PA0290022 Rating Area 3 No Preference 55 802.17

55957PA0290022 Rating Area 3 No Preference 56 839.22

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55957PA0290022 Rating Area 3 No Preference 62 1033.47

55957PA0290022 Rating Area 3 No Preference 63 1061.89

55957PA0290022 Rating Area 3 No Preference 64 1079.16

55957PA0290022 Rating Area 3 No Preference 65 and over 1079.16

55957PA0290012 Rating Area 3 No Preference 0-20 210.32

55957PA0290012 Rating Area 3 No Preference 21 331.22

55957PA0290012 Rating Area 3 No Preference 22 331.22

55957PA0290012 Rating Area 3 No Preference 23 331.22

55957PA0290012 Rating Area 3 No Preference 24 331.22

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55957PA0290012 Rating Area 3 No Preference 37 410.05

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55957PA0290012 Rating Area 3 No Preference 44 462.71

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55957PA0290012 Rating Area 3 No Preference 52 646.54

55957PA0290012 Rating Area 3 No Preference 53 675.68

55957PA0290012 Rating Area 3 No Preference 54 707.15

55957PA0290012 Rating Area 3 No Preference 55 738.62

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55957PA0290012 Rating Area 3 No Preference 62 951.59

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55957PA0290012 Rating Area 3 No Preference 64 993.66

55957PA0290012 Rating Area 3 No Preference 65 and over 993.66

55957PA0290011 Rating Area 3 No Preference 0-20 213.87

55957PA0290011 Rating Area 3 No Preference 21 336.81

55957PA0290011 Rating Area 3 No Preference 22 336.81

55957PA0290011 Rating Area 3 No Preference 23 336.81

55957PA0290011 Rating Area 3 No Preference 24 336.81

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55957PA0290011 Rating Area 3 No Preference 32 398.44

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55957PA0290011 Rating Area 3 No Preference 53 687.09

55957PA0290011 Rating Area 3 No Preference 54 719.08

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55957PA0290011 Rating Area 3 No Preference 57 820.80

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55957PA0290011 Rating Area 3 No Preference 63 994.26

55957PA0290011 Rating Area 3 No Preference 64 1010.43

55957PA0290011 Rating Area 3 No Preference 65 and over 1010.43

55957PA0290013 Rating Area 3 No Preference 0-20 214.07

55957PA0290013 Rating Area 3 No Preference 21 337.13

55957PA0290013 Rating Area 3 No Preference 22 337.13

55957PA0290013 Rating Area 3 No Preference 23 337.13

55957PA0290013 Rating Area 3 No Preference 24 337.13

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55957PA0290013 Rating Area 3 No Preference 29 377.24

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55957PA0290013 Rating Area 3 No Preference 53 687.74

55957PA0290013 Rating Area 3 No Preference 54 719.77

55957PA0290013 Rating Area 3 No Preference 55 751.79

55957PA0290013 Rating Area 3 No Preference 56 786.52

55957PA0290013 Rating Area 3 No Preference 57 821.58

55957PA0290013 Rating Area 3 No Preference 58 859.00

55957PA0290013 Rating Area 3 No Preference 59 877.54

55957PA0290013 Rating Area 3 No Preference 60 914.97

55957PA0290013 Rating Area 3 No Preference 61 947.33

55957PA0290013 Rating Area 3 No Preference 62 968.57

55957PA0290013 Rating Area 3 No Preference 63 995.20

55957PA0290013 Rating Area 3 No Preference 64 1011.39

55957PA0290013 Rating Area 3 No Preference 65 and over 1011.39

55957PA0290014 Rating Area 3 No Preference 0-20 217.67

55957PA0290014 Rating Area 3 No Preference 21 342.79

55957PA0290014 Rating Area 3 No Preference 22 342.79

55957PA0290014 Rating Area 3 No Preference 23 342.79

55957PA0290014 Rating Area 3 No Preference 24 342.79

55957PA0290014 Rating Area 3 No Preference 25 344.16

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55957PA0290014 Rating Area 3 No Preference 53 699.29

55957PA0290014 Rating Area 3 No Preference 54 731.85

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55957PA0290014 Rating Area 3 No Preference 56 799.72

55957PA0290014 Rating Area 3 No Preference 57 835.37

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55957PA0290014 Rating Area 3 No Preference 59 892.28

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55957PA0290014 Rating Area 3 No Preference 62 984.83

55957PA0290014 Rating Area 3 No Preference 63 1011.91

55957PA0290014 Rating Area 3 No Preference 64 1028.37

55957PA0290014 Rating Area 3 No Preference 65 and over 1028.37

55957PA0290016 Rating Area 3 No Preference 0-20 208.96

55957PA0290016 Rating Area 3 No Preference 21 329.08

55957PA0290016 Rating Area 3 No Preference 22 329.08

55957PA0290016 Rating Area 3 No Preference 23 329.08

55957PA0290016 Rating Area 3 No Preference 24 329.08

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55957PA0290016 Rating Area 3 No Preference 28 357.70

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55957PA0290016 Rating Area 3 No Preference 32 389.30

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55957PA0290016 Rating Area 3 No Preference 35 402.13

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55957PA0290016 Rating Area 3 No Preference 37 407.40

55957PA0290016 Rating Area 3 No Preference 38 410.03

55957PA0290016 Rating Area 3 No Preference 39 415.29

55957PA0290016 Rating Area 3 No Preference 40 420.56

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55957PA0290016 Rating Area 3 No Preference 43 446.56

55957PA0290016 Rating Area 3 No Preference 44 459.72

55957PA0290016 Rating Area 3 No Preference 45 475.19

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55957PA0290016 Rating Area 3 No Preference 52 642.36

55957PA0290016 Rating Area 3 No Preference 53 671.32

55957PA0290016 Rating Area 3 No Preference 54 702.58

55957PA0290016 Rating Area 3 No Preference 55 733.84

55957PA0290016 Rating Area 3 No Preference 56 767.74

55957PA0290016 Rating Area 3 No Preference 57 801.96

55957PA0290016 Rating Area 3 No Preference 58 838.49

55957PA0290016 Rating Area 3 No Preference 59 856.59

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55957PA0290016 Rating Area 3 No Preference 61 924.71

55957PA0290016 Rating Area 3 No Preference 62 945.44

55957PA0290016 Rating Area 3 No Preference 63 971.44

55957PA0290016 Rating Area 3 No Preference 64 987.24

55957PA0290016 Rating Area 3 No Preference 65 and over 987.24

55957PA0290023 Rating Area 3 No Preference 0-20 179.50

55957PA0290023 Rating Area 3 No Preference 21 282.69

55957PA0290023 Rating Area 3 No Preference 22 282.69

55957PA0290023 Rating Area 3 No Preference 23 282.69

55957PA0290023 Rating Area 3 No Preference 24 282.69

55957PA0290023 Rating Area 3 No Preference 25 283.82

55957PA0290023 Rating Area 3 No Preference 26 289.47

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55957PA0290023 Rating Area 3 No Preference 28 307.28

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55957PA0290023 Rating Area 3 No Preference 35 345.44

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55957PA0290023 Rating Area 3 No Preference 37 349.97

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55957PA0290023 Rating Area 3 No Preference 50 504.88

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55957PA0290023 Rating Area 3 No Preference 53 576.68

55957PA0290023 Rating Area 3 No Preference 54 603.54

55957PA0290023 Rating Area 3 No Preference 55 630.39

55957PA0290023 Rating Area 3 No Preference 56 659.51

55957PA0290023 Rating Area 3 No Preference 57 688.91

55957PA0290023 Rating Area 3 No Preference 58 720.29

55957PA0290023 Rating Area 3 No Preference 59 735.84

55957PA0290023 Rating Area 3 No Preference 60 767.22

55957PA0290023 Rating Area 3 No Preference 61 794.35

55957PA0290023 Rating Area 3 No Preference 62 812.16

55957PA0290023 Rating Area 3 No Preference 63 834.50

55957PA0290023 Rating Area 3 No Preference 64 848.07

55957PA0290023 Rating Area 3 No Preference 65 and over 848.07

55957PA0290017 Rating Area 3 No Preference 0-20 170.74

55957PA0290017 Rating Area 3 No Preference 21 268.89

55957PA0290017 Rating Area 3 No Preference 22 268.89

55957PA0290017 Rating Area 3 No Preference 23 268.89

55957PA0290017 Rating Area 3 No Preference 24 268.89

55957PA0290017 Rating Area 3 No Preference 25 269.96

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55957PA0290017 Rating Area 3 No Preference 28 292.28

55957PA0290017 Rating Area 3 No Preference 29 300.88

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55957PA0290017 Rating Area 3 No Preference 32 318.09

55957PA0290017 Rating Area 3 No Preference 33 322.13

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55957PA0290017 Rating Area 3 No Preference 35 328.58

55957PA0290017 Rating Area 3 No Preference 36 330.73

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55957PA0290017 Rating Area 3 No Preference 38 335.03

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55957PA0290017 Rating Area 3 No Preference 41 350.09

55957PA0290017 Rating Area 3 No Preference 42 356.27

55957PA0290017 Rating Area 3 No Preference 43 364.88

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55957PA0290017 Rating Area 3 No Preference 45 388.27

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55957PA0290017 Rating Area 3 No Preference 47 420.27

55957PA0290017 Rating Area 3 No Preference 48 439.63

55957PA0290017 Rating Area 3 No Preference 49 458.72

55957PA0290017 Rating Area 3 No Preference 50 480.23

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55957PA0290017 Rating Area 3 No Preference 52 524.87

55957PA0290017 Rating Area 3 No Preference 53 548.53

55957PA0290017 Rating Area 3 No Preference 54 574.08

55957PA0290017 Rating Area 3 No Preference 55 599.62

55957PA0290017 Rating Area 3 No Preference 56 627.32

55957PA0290017 Rating Area 3 No Preference 57 655.28

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55957PA0290017 Rating Area 3 No Preference 60 729.76

55957PA0290017 Rating Area 3 No Preference 61 755.58

55957PA0290017 Rating Area 3 No Preference 62 772.52

55957PA0290017 Rating Area 3 No Preference 63 793.76

55957PA0290017 Rating Area 3 No Preference 64 806.67

55957PA0290017 Rating Area 3 No Preference 65 and over 806.67

55957PA0290018 Rating Area 3 No Preference 0-20 181.44

55957PA0290018 Rating Area 3 No Preference 21 285.74

55957PA0290018 Rating Area 3 No Preference 22 285.74

55957PA0290018 Rating Area 3 No Preference 23 285.74

55957PA0290018 Rating Area 3 No Preference 24 285.74

55957PA0290018 Rating Area 3 No Preference 25 286.88

55957PA0290018 Rating Area 3 No Preference 26 292.59

55957PA0290018 Rating Area 3 No Preference 27 299.45

55957PA0290018 Rating Area 3 No Preference 28 310.59

55957PA0290018 Rating Area 3 No Preference 29 319.74

55957PA0290018 Rating Area 3 No Preference 30 324.31

55957PA0290018 Rating Area 3 No Preference 31 331.17

55957PA0290018 Rating Area 3 No Preference 32 338.03

55957PA0290018 Rating Area 3 No Preference 33 342.31

55957PA0290018 Rating Area 3 No Preference 34 346.88

55957PA0290018 Rating Area 3 No Preference 35 349.17

55957PA0290018 Rating Area 3 No Preference 36 351.46

55957PA0290018 Rating Area 3 No Preference 37 353.74

55957PA0290018 Rating Area 3 No Preference 38 356.03

55957PA0290018 Rating Area 3 No Preference 39 360.60

55957PA0290018 Rating Area 3 No Preference 40 365.17

55957PA0290018 Rating Area 3 No Preference 41 372.03

55957PA0290018 Rating Area 3 No Preference 42 378.60

55957PA0290018 Rating Area 3 No Preference 43 387.74

55957PA0290018 Rating Area 3 No Preference 44 399.17

55957PA0290018 Rating Area 3 No Preference 45 412.60

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55957PA0290018 Rating Area 3 No Preference 47 446.61

55957PA0290018 Rating Area 3 No Preference 48 467.18

55957PA0290018 Rating Area 3 No Preference 49 487.47

55957PA0290018 Rating Area 3 No Preference 50 510.33

55957PA0290018 Rating Area 3 No Preference 51 532.90

55957PA0290018 Rating Area 3 No Preference 52 557.76

55957PA0290018 Rating Area 3 No Preference 53 582.90

55957PA0290018 Rating Area 3 No Preference 54 610.05

55957PA0290018 Rating Area 3 No Preference 55 637.20

55957PA0290018 Rating Area 3 No Preference 56 666.63

55957PA0290018 Rating Area 3 No Preference 57 696.34

55957PA0290018 Rating Area 3 No Preference 58 728.06

55957PA0290018 Rating Area 3 No Preference 59 743.78

55957PA0290018 Rating Area 3 No Preference 60 775.49

55957PA0290018 Rating Area 3 No Preference 61 802.92

55957PA0290018 Rating Area 3 No Preference 62 820.93

55957PA0290018 Rating Area 3 No Preference 63 843.50

55957PA0290018 Rating Area 3 No Preference 64 857.22

55957PA0290018 Rating Area 3 No Preference 65 and over 857.22

55957PA0290019 Rating Area 3 No Preference 0-20 179.53

55957PA0290019 Rating Area 3 No Preference 21 282.74

55957PA0290019 Rating Area 3 No Preference 22 282.74

55957PA0290019 Rating Area 3 No Preference 23 282.74

55957PA0290019 Rating Area 3 No Preference 24 282.74

55957PA0290019 Rating Area 3 No Preference 25 283.87

55957PA0290019 Rating Area 3 No Preference 26 289.52

55957PA0290019 Rating Area 3 No Preference 27 296.31

55957PA0290019 Rating Area 3 No Preference 28 307.33

55957PA0290019 Rating Area 3 No Preference 29 316.38

55957PA0290019 Rating Area 3 No Preference 30 320.90

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55957PA0290019 Rating Area 3 No Preference 32 334.48

55957PA0290019 Rating Area 3 No Preference 33 338.72

55957PA0290019 Rating Area 3 No Preference 34 343.24

55957PA0290019 Rating Area 3 No Preference 35 345.50

55957PA0290019 Rating Area 3 No Preference 36 347.77

55957PA0290019 Rating Area 3 No Preference 37 350.03

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55957PA0290019 Rating Area 3 No Preference 39 356.81

55957PA0290019 Rating Area 3 No Preference 40 361.34

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55957PA0290019 Rating Area 3 No Preference 45 408.27

55957PA0290019 Rating Area 3 No Preference 46 424.11

55957PA0290019 Rating Area 3 No Preference 47 441.92

55957PA0290019 Rating Area 3 No Preference 48 462.27

55957PA0290019 Rating Area 3 No Preference 49 482.35

55957PA0290019 Rating Area 3 No Preference 50 504.97

55957PA0290019 Rating Area 3 No Preference 51 527.31

55957PA0290019 Rating Area 3 No Preference 52 551.90

55957PA0290019 Rating Area 3 No Preference 53 576.78

55957PA0290019 Rating Area 3 No Preference 54 603.64

55957PA0290019 Rating Area 3 No Preference 55 630.51

55957PA0290019 Rating Area 3 No Preference 56 659.63

55957PA0290019 Rating Area 3 No Preference 57 689.03

55957PA0290019 Rating Area 3 No Preference 58 720.42

55957PA0290019 Rating Area 3 No Preference 59 735.97

55957PA0290019 Rating Area 3 No Preference 60 767.35

55957PA0290019 Rating Area 3 No Preference 61 794.49

55957PA0290019 Rating Area 3 No Preference 62 812.31

55957PA0290019 Rating Area 3 No Preference 63 834.64

55957PA0290019 Rating Area 3 No Preference 64 848.22

55957PA0290019 Rating Area 3 No Preference 65 and over 848.22

55957PA0290021 Rating Area 3 No Preference 0-20 144.60

55957PA0290021 Rating Area 3 No Preference 21 227.73

55957PA0290021 Rating Area 3 No Preference 22 227.73

55957PA0290021 Rating Area 3 No Preference 23 227.73

55957PA0290021 Rating Area 3 No Preference 24 227.73

55957PA0290021 Rating Area 3 No Preference 25 228.64

55957PA0290021 Rating Area 3 No Preference 26 233.19

55957PA0290021 Rating Area 3 No Preference 27 238.66

55957PA0290021 Rating Area 3 No Preference 28 247.54

55957PA0290021 Rating Area 3 No Preference 29 254.82

55957PA0290021 Rating Area 3 No Preference 30 258.47

55957PA0290021 Rating Area 3 No Preference 31 263.93

55957PA0290021 Rating Area 3 No Preference 32 269.40

55957PA0290021 Rating Area 3 No Preference 33 272.82

55957PA0290021 Rating Area 3 No Preference 34 276.46

55957PA0290021 Rating Area 3 No Preference 35 278.28

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55957PA0290021 Rating Area 3 No Preference 37 281.92

55957PA0290021 Rating Area 3 No Preference 38 283.75

55957PA0290021 Rating Area 3 No Preference 39 287.39

55957PA0290021 Rating Area 3 No Preference 40 291.03

55957PA0290021 Rating Area 3 No Preference 41 296.50

55957PA0290021 Rating Area 3 No Preference 42 301.74

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55957PA0290021 Rating Area 3 No Preference 45 328.84

55957PA0290021 Rating Area 3 No Preference 46 341.59

55957PA0290021 Rating Area 3 No Preference 47 355.94

55957PA0290021 Rating Area 3 No Preference 48 372.33

55957PA0290021 Rating Area 3 No Preference 49 388.50

55957PA0290021 Rating Area 3 No Preference 50 406.72

55957PA0290021 Rating Area 3 No Preference 51 424.71

55957PA0290021 Rating Area 3 No Preference 52 444.52

55957PA0290021 Rating Area 3 No Preference 53 464.56

55957PA0290021 Rating Area 3 No Preference 54 486.20

55957PA0290021 Rating Area 3 No Preference 55 507.83

55957PA0290021 Rating Area 3 No Preference 56 531.29

55957PA0290021 Rating Area 3 No Preference 57 554.97

55957PA0290021 Rating Area 3 No Preference 58 580.25

55957PA0290021 Rating Area 3 No Preference 59 592.78

55957PA0290021 Rating Area 3 No Preference 60 618.05

55957PA0290021 Rating Area 3 No Preference 61 639.92

55957PA0290021 Rating Area 3 No Preference 62 654.26

55957PA0290021 Rating Area 3 No Preference 63 672.25

55957PA0290021 Rating Area 3 No Preference 64 683.19

55957PA0290021 Rating Area 3 No Preference 65 and over 683.19

55957PA0280001 Rating Area 3 No Preference 0-20 169.99

55957PA0280001 Rating Area 3 No Preference 21 267.71

55957PA0280001 Rating Area 3 No Preference 22 267.71

55957PA0280001 Rating Area 3 No Preference 23 267.71

55957PA0280001 Rating Area 3 No Preference 24 267.71

55957PA0280001 Rating Area 3 No Preference 25 268.78

55957PA0280001 Rating Area 3 No Preference 26 274.13

55957PA0280001 Rating Area 3 No Preference 27 280.56

55957PA0280001 Rating Area 3 No Preference 28 291.00

55957PA0280001 Rating Area 3 No Preference 29 299.56

55957PA0280001 Rating Area 3 No Preference 30 303.85

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55957PA0280001 Rating Area 3 No Preference 32 316.70

55957PA0280001 Rating Area 3 No Preference 33 320.71

55957PA0280001 Rating Area 3 No Preference 34 324.99

55957PA0280001 Rating Area 3 No Preference 35 327.14

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55957PA0280001 Rating Area 3 No Preference 37 331.42

55957PA0280001 Rating Area 3 No Preference 38 333.56

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55957PA0280001 Rating Area 3 No Preference 43 363.28

55957PA0280001 Rating Area 3 No Preference 44 373.99

55957PA0280001 Rating Area 3 No Preference 45 386.57

55957PA0280001 Rating Area 3 No Preference 46 401.56

55957PA0280001 Rating Area 3 No Preference 47 418.43

55957PA0280001 Rating Area 3 No Preference 48 437.70

55957PA0280001 Rating Area 3 No Preference 49 456.71

55957PA0280001 Rating Area 3 No Preference 50 478.13

55957PA0280001 Rating Area 3 No Preference 51 499.27

55957PA0280001 Rating Area 3 No Preference 52 522.56

55957PA0280001 Rating Area 3 No Preference 53 546.12

55957PA0280001 Rating Area 3 No Preference 54 571.56

55957PA0280001 Rating Area 3 No Preference 55 596.99

55957PA0280001 Rating Area 3 No Preference 56 624.56

55957PA0280001 Rating Area 3 No Preference 57 652.40

55957PA0280001 Rating Area 3 No Preference 58 682.12

55957PA0280001 Rating Area 3 No Preference 59 696.84

55957PA0280001 Rating Area 3 No Preference 60 726.56

55957PA0280001 Rating Area 3 No Preference 61 752.26

55957PA0280001 Rating Area 3 No Preference 62 769.13

55957PA0280001 Rating Area 3 No Preference 63 790.27

55957PA0280001 Rating Area 3 No Preference 64 803.13

55957PA0280001 Rating Area 3 No Preference 65 and over 803.13

55957PA0280002 Rating Area 3 No Preference 0-20 170.48

55957PA0280002 Rating Area 3 No Preference 21 268.48

55957PA0280002 Rating Area 3 No Preference 22 268.48

55957PA0280002 Rating Area 3 No Preference 23 268.48

55957PA0280002 Rating Area 3 No Preference 24 268.48

55957PA0280002 Rating Area 3 No Preference 25 269.55

55957PA0280002 Rating Area 3 No Preference 26 274.92

55957PA0280002 Rating Area 3 No Preference 27 281.36

55957PA0280002 Rating Area 3 No Preference 28 291.83

55957PA0280002 Rating Area 3 No Preference 29 300.42

55957PA0280002 Rating Area 3 No Preference 30 304.72

55957PA0280002 Rating Area 3 No Preference 31 311.16

55957PA0280002 Rating Area 3 No Preference 32 317.61

55957PA0280002 Rating Area 3 No Preference 33 321.63

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55957PA0280002 Rating Area 3 No Preference 35 328.08

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55957PA0280002 Rating Area 3 No Preference 38 334.52

55957PA0280002 Rating Area 3 No Preference 39 338.82

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55957PA0280002 Rating Area 3 No Preference 41 349.56

55957PA0280002 Rating Area 3 No Preference 42 355.73

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55957PA0280002 Rating Area 3 No Preference 44 375.06

55957PA0280002 Rating Area 3 No Preference 45 387.68

55957PA0280002 Rating Area 3 No Preference 46 402.72

55957PA0280002 Rating Area 3 No Preference 47 419.63

55957PA0280002 Rating Area 3 No Preference 48 438.96

55957PA0280002 Rating Area 3 No Preference 49 458.02

55957PA0280002 Rating Area 3 No Preference 50 479.50

55957PA0280002 Rating Area 3 No Preference 51 500.71

55957PA0280002 Rating Area 3 No Preference 52 524.07

55957PA0280002 Rating Area 3 No Preference 53 547.69

55957PA0280002 Rating Area 3 No Preference 54 573.20

55957PA0280002 Rating Area 3 No Preference 55 598.71

55957PA0280002 Rating Area 3 No Preference 56 626.36

55957PA0280002 Rating Area 3 No Preference 57 654.28

55957PA0280002 Rating Area 3 No Preference 58 684.08

55957PA0280002 Rating Area 3 No Preference 59 698.85

55957PA0280002 Rating Area 3 No Preference 60 728.65

55957PA0280002 Rating Area 3 No Preference 61 754.42

55957PA0280002 Rating Area 3 No Preference 62 771.34

55957PA0280002 Rating Area 3 No Preference 63 792.55

55957PA0280002 Rating Area 3 No Preference 64 805.44

55957PA0280002 Rating Area 3 No Preference 65 and over 805.44

55957PA0280003 Rating Area 3 No Preference 0-20 214.21

55957PA0280003 Rating Area 3 No Preference 21 337.34

55957PA0280003 Rating Area 3 No Preference 22 337.34

55957PA0280003 Rating Area 3 No Preference 23 337.34

55957PA0280003 Rating Area 3 No Preference 24 337.34

55957PA0280003 Rating Area 3 No Preference 25 338.68

55957PA0280003 Rating Area 3 No Preference 26 345.43

55957PA0280003 Rating Area 3 No Preference 27 353.53

55957PA0280003 Rating Area 3 No Preference 28 366.68

55957PA0280003 Rating Area 3 No Preference 29 377.48

55957PA0280003 Rating Area 3 No Preference 30 382.88

55957PA0280003 Rating Area 3 No Preference 31 390.97

55957PA0280003 Rating Area 3 No Preference 32 399.07

55957PA0280003 Rating Area 3 No Preference 33 404.13

55957PA0280003 Rating Area 3 No Preference 34 409.53

55957PA0280003 Rating Area 3 No Preference 35 412.22

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55957PA0280003 Rating Area 3 No Preference 37 417.62

55957PA0280003 Rating Area 3 No Preference 38 420.32

55957PA0280003 Rating Area 3 No Preference 39 425.72

55957PA0280003 Rating Area 3 No Preference 40 431.12

55957PA0280003 Rating Area 3 No Preference 41 439.21

55957PA0280003 Rating Area 3 No Preference 42 446.97

55957PA0280003 Rating Area 3 No Preference 43 457.77

55957PA0280003 Rating Area 3 No Preference 44 471.26

55957PA0280003 Rating Area 3 No Preference 45 487.11

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55957PA0280003 Rating Area 3 No Preference 47 527.26

55957PA0280003 Rating Area 3 No Preference 48 551.55

55957PA0280003 Rating Area 3 No Preference 49 575.50

55957PA0280003 Rating Area 3 No Preference 50 602.48

55957PA0280003 Rating Area 3 No Preference 51 629.13

55957PA0280003 Rating Area 3 No Preference 52 658.48

55957PA0280003 Rating Area 3 No Preference 53 688.17

55957PA0280003 Rating Area 3 No Preference 54 720.22

55957PA0280003 Rating Area 3 No Preference 55 752.26

55957PA0280003 Rating Area 3 No Preference 56 787.01

55957PA0280003 Rating Area 3 No Preference 57 822.09

55957PA0280003 Rating Area 3 No Preference 58 859.54

55957PA0280003 Rating Area 3 No Preference 59 878.09

55957PA0280003 Rating Area 3 No Preference 60 915.54

55957PA0280003 Rating Area 3 No Preference 61 947.92

55957PA0280003 Rating Area 3 No Preference 62 969.17

55957PA0280003 Rating Area 3 No Preference 63 995.82

55957PA0280003 Rating Area 3 No Preference 64 1012.02

55957PA0280003 Rating Area 3 No Preference 65 and over 1012.02

55957PA0280004 Rating Area 3 No Preference 0-20 248.53

55957PA0280004 Rating Area 3 No Preference 21 391.40

55957PA0280004 Rating Area 3 No Preference 22 391.40

55957PA0280004 Rating Area 3 No Preference 23 391.40

55957PA0280004 Rating Area 3 No Preference 24 391.40

55957PA0280004 Rating Area 3 No Preference 25 392.96

55957PA0280004 Rating Area 3 No Preference 26 400.79

55957PA0280004 Rating Area 3 No Preference 27 410.18

55957PA0280004 Rating Area 3 No Preference 28 425.45

55957PA0280004 Rating Area 3 No Preference 29 437.97

55957PA0280004 Rating Area 3 No Preference 30 444.23

55957PA0280004 Rating Area 3 No Preference 31 453.63

55957PA0280004 Rating Area 3 No Preference 32 463.02

55957PA0280004 Rating Area 3 No Preference 33 468.89

55957PA0280004 Rating Area 3 No Preference 34 475.15

55957PA0280004 Rating Area 3 No Preference 35 478.29

55957PA0280004 Rating Area 3 No Preference 36 481.42

55957PA0280004 Rating Area 3 No Preference 37 484.55

55957PA0280004 Rating Area 3 No Preference 38 487.68

55957PA0280004 Rating Area 3 No Preference 39 493.94

55957PA0280004 Rating Area 3 No Preference 40 500.20

55957PA0280004 Rating Area 3 No Preference 41 509.60

55957PA0280004 Rating Area 3 No Preference 42 518.60

55957PA0280004 Rating Area 3 No Preference 43 531.12

55957PA0280004 Rating Area 3 No Preference 44 546.78

55957PA0280004 Rating Area 3 No Preference 45 565.18

55957PA0280004 Rating Area 3 No Preference 46 587.10

55957PA0280004 Rating Area 3 No Preference 47 611.75

55957PA0280004 Rating Area 3 No Preference 48 639.93

55957PA0280004 Rating Area 3 No Preference 49 667.72

55957PA0280004 Rating Area 3 No Preference 50 699.04

55957PA0280004 Rating Area 3 No Preference 51 729.96

55957PA0280004 Rating Area 3 No Preference 52 764.01

55957PA0280004 Rating Area 3 No Preference 53 798.45

55957PA0280004 Rating Area 3 No Preference 54 835.63

55957PA0280004 Rating Area 3 No Preference 55 872.82

55957PA0280004 Rating Area 3 No Preference 56 913.13

55957PA0280004 Rating Area 3 No Preference 57 953.84

55957PA0280004 Rating Area 3 No Preference 58 997.28

55957PA0280004 Rating Area 3 No Preference 59 1018.81

55957PA0280004 Rating Area 3 No Preference 60 1062.25

55957PA0280004 Rating Area 3 No Preference 61 1099.83

55957PA0280004 Rating Area 3 No Preference 62 1124.49

55957PA0280004 Rating Area 3 No Preference 63 1155.41

55957PA0280004 Rating Area 3 No Preference 64 1174.20

55957PA0280004 Rating Area 3 No Preference 65 and over 1174.20

55957PA0300001 Rating Area 3 No Preference 0-20 232.47

55957PA0300001 Rating Area 3 No Preference 21 366.10

55957PA0300001 Rating Area 3 No Preference 22 366.10

55957PA0300001 Rating Area 3 No Preference 23 366.10

55957PA0300001 Rating Area 3 No Preference 24 366.10

55957PA0300001 Rating Area 3 No Preference 25 367.56

55957PA0300001 Rating Area 3 No Preference 26 374.88

55957PA0300001 Rating Area 3 No Preference 27 383.67

55957PA0300001 Rating Area 3 No Preference 28 397.95

55957PA0300001 Rating Area 3 No Preference 29 409.66

55957PA0300001 Rating Area 3 No Preference 30 415.52

55957PA0300001 Rating Area 3 No Preference 31 424.30

55957PA0300001 Rating Area 3 No Preference 32 433.09

55957PA0300001 Rating Area 3 No Preference 33 438.58

55957PA0300001 Rating Area 3 No Preference 34 444.44

55957PA0300001 Rating Area 3 No Preference 35 447.37

55957PA0300001 Rating Area 3 No Preference 36 450.30

55957PA0300001 Rating Area 3 No Preference 37 453.23

55957PA0300001 Rating Area 3 No Preference 38 456.16

55957PA0300001 Rating Area 3 No Preference 39 462.01

55957PA0300001 Rating Area 3 No Preference 40 467.87

55957PA0300001 Rating Area 3 No Preference 41 476.66

55957PA0300001 Rating Area 3 No Preference 42 485.08

55957PA0300001 Rating Area 3 No Preference 43 496.79

55957PA0300001 Rating Area 3 No Preference 44 511.44

55957PA0300001 Rating Area 3 No Preference 45 528.64

55957PA0300001 Rating Area 3 No Preference 46 549.15

55957PA0300001 Rating Area 3 No Preference 47 572.21

55957PA0300001 Rating Area 3 No Preference 48 598.57

55957PA0300001 Rating Area 3 No Preference 49 624.56

55957PA0300001 Rating Area 3 No Preference 50 653.85

55957PA0300001 Rating Area 3 No Preference 51 682.77

55957PA0300001 Rating Area 3 No Preference 52 714.62

55957PA0300001 Rating Area 3 No Preference 53 746.84

55957PA0300001 Rating Area 3 No Preference 54 781.62

55957PA0300001 Rating Area 3 No Preference 55 816.40

55957PA0300001 Rating Area 3 No Preference 56 854.11

55957PA0300001 Rating Area 3 No Preference 57 892.18

55957PA0300001 Rating Area 3 No Preference 58 932.82

55957PA0300001 Rating Area 3 No Preference 59 952.95

55957PA0300001 Rating Area 3 No Preference 60 993.59

55957PA0300001 Rating Area 3 No Preference 61 1028.74

55957PA0300001 Rating Area 3 No Preference 62 1051.80

55957PA0300001 Rating Area 3 No Preference 63 1080.72

55957PA0300001 Rating Area 3 No Preference 64 1098.30

55957PA0300001 Rating Area 3 No Preference 65 and over 1098.30

55957PA0300002 Rating Area 3 No Preference 0-20 199.07

55957PA0300002 Rating Area 3 No Preference 21 313.50

55957PA0300002 Rating Area 3 No Preference 22 313.50

55957PA0300002 Rating Area 3 No Preference 23 313.50

55957PA0300002 Rating Area 3 No Preference 24 313.50

55957PA0300002 Rating Area 3 No Preference 25 314.75

55957PA0300002 Rating Area 3 No Preference 26 321.02

55957PA0300002 Rating Area 3 No Preference 27 328.54

55957PA0300002 Rating Area 3 No Preference 28 340.77

55957PA0300002 Rating Area 3 No Preference 29 350.80

55957PA0300002 Rating Area 3 No Preference 30 355.82

55957PA0300002 Rating Area 3 No Preference 31 363.34

55957PA0300002 Rating Area 3 No Preference 32 370.87

55957PA0300002 Rating Area 3 No Preference 33 375.57

55957PA0300002 Rating Area 3 No Preference 34 380.58

55957PA0300002 Rating Area 3 No Preference 35 383.09

55957PA0300002 Rating Area 3 No Preference 36 385.60

55957PA0300002 Rating Area 3 No Preference 37 388.11

55957PA0300002 Rating Area 3 No Preference 38 390.62

55957PA0300002 Rating Area 3 No Preference 39 395.63

55957PA0300002 Rating Area 3 No Preference 40 400.65

55957PA0300002 Rating Area 3 No Preference 41 408.17

55957PA0300002 Rating Area 3 No Preference 42 415.38

55957PA0300002 Rating Area 3 No Preference 43 425.41

55957PA0300002 Rating Area 3 No Preference 44 437.95

55957PA0300002 Rating Area 3 No Preference 45 452.69

55957PA0300002 Rating Area 3 No Preference 46 470.25

55957PA0300002 Rating Area 3 No Preference 47 490.00

55957PA0300002 Rating Area 3 No Preference 48 512.57

55957PA0300002 Rating Area 3 No Preference 49 534.83

55957PA0300002 Rating Area 3 No Preference 50 559.91

55957PA0300002 Rating Area 3 No Preference 51 584.67

55957PA0300002 Rating Area 3 No Preference 52 611.95

55957PA0300002 Rating Area 3 No Preference 53 639.54

55957PA0300002 Rating Area 3 No Preference 54 669.32

55957PA0300002 Rating Area 3 No Preference 55 699.10

55957PA0300002 Rating Area 3 No Preference 56 731.39

55957PA0300002 Rating Area 3 No Preference 57 763.99

55957PA0300002 Rating Area 3 No Preference 58 798.79

55957PA0300002 Rating Area 3 No Preference 59 816.04

55957PA0300002 Rating Area 3 No Preference 60 850.83

55957PA0300002 Rating Area 3 No Preference 61 880.93

55957PA0300002 Rating Area 3 No Preference 62 900.68

55957PA0300002 Rating Area 3 No Preference 63 925.45

55957PA0300002 Rating Area 3 No Preference 64 940.50

55957PA0300002 Rating Area 3 No Preference 65 and over 940.50

55957PA0370001 Rating Area 3 No Preference 0-20 261.41

55957PA0370001 Rating Area 3 No Preference 21 411.67

55957PA0370001 Rating Area 3 No Preference 22 411.67

55957PA0370001 Rating Area 3 No Preference 23 411.67

55957PA0370001 Rating Area 3 No Preference 24 411.67

55957PA0370001 Rating Area 3 No Preference 25 413.31

55957PA0370001 Rating Area 3 No Preference 26 421.55

55957PA0370001 Rating Area 3 No Preference 27 431.43

55957PA0370001 Rating Area 3 No Preference 28 447.48

55957PA0370001 Rating Area 3 No Preference 29 460.65

55957PA0370001 Rating Area 3 No Preference 30 467.24

55957PA0370001 Rating Area 3 No Preference 31 477.12

55957PA0370001 Rating Area 3 No Preference 32 487.00

55957PA0370001 Rating Area 3 No Preference 33 493.18

55957PA0370001 Rating Area 3 No Preference 34 499.76

55957PA0370001 Rating Area 3 No Preference 35 503.06

55957PA0370001 Rating Area 3 No Preference 36 506.35

55957PA0370001 Rating Area 3 No Preference 37 509.64

55957PA0370001 Rating Area 3 No Preference 38 512.94

55957PA0370001 Rating Area 3 No Preference 39 519.52

55957PA0370001 Rating Area 3 No Preference 40 526.11

55957PA0370001 Rating Area 3 No Preference 41 535.99

55957PA0370001 Rating Area 3 No Preference 42 545.46

55957PA0370001 Rating Area 3 No Preference 43 558.63

55957PA0370001 Rating Area 3 No Preference 44 575.10

55957PA0370001 Rating Area 3 No Preference 45 594.45

55957PA0370001 Rating Area 3 No Preference 46 617.50

55957PA0370001 Rating Area 3 No Preference 47 643.44

55957PA0370001 Rating Area 3 No Preference 48 673.08

55957PA0370001 Rating Area 3 No Preference 49 702.30

55957PA0370001 Rating Area 3 No Preference 50 735.24

55957PA0370001 Rating Area 3 No Preference 51 767.76

55957PA0370001 Rating Area 3 No Preference 52 803.57

55957PA0370001 Rating Area 3 No Preference 53 839.80

55957PA0370001 Rating Area 3 No Preference 54 878.91

55957PA0370001 Rating Area 3 No Preference 55 918.02

55957PA0370001 Rating Area 3 No Preference 56 960.42

55957PA0370001 Rating Area 3 No Preference 57 1003.23

55957PA0370001 Rating Area 3 No Preference 58 1048.93

55957PA0370001 Rating Area 3 No Preference 59 1071.57

55957PA0370001 Rating Area 3 No Preference 60 1117.27

55957PA0370001 Rating Area 3 No Preference 61 1156.79

55957PA0370001 Rating Area 3 No Preference 62 1182.72

55957PA0370001 Rating Area 3 No Preference 63 1215.24

55957PA0370001 Rating Area 3 No Preference 64 1235.01

55957PA0370001 Rating Area 3 No Preference 65 and over 1235.01

55957PA0370002 Rating Area 3 No Preference 0-20 249.84

55957PA0370002 Rating Area 3 No Preference 21 393.46

55957PA0370002 Rating Area 3 No Preference 22 393.46

55957PA0370002 Rating Area 3 No Preference 23 393.46

55957PA0370002 Rating Area 3 No Preference 24 393.46

55957PA0370002 Rating Area 3 No Preference 25 395.03

55957PA0370002 Rating Area 3 No Preference 26 402.90

55957PA0370002 Rating Area 3 No Preference 27 412.34

55957PA0370002 Rating Area 3 No Preference 28 427.69

55957PA0370002 Rating Area 3 No Preference 29 440.28

55957PA0370002 Rating Area 3 No Preference 30 446.57

55957PA0370002 Rating Area 3 No Preference 31 456.02

55957PA0370002 Rating Area 3 No Preference 32 465.46

55957PA0370002 Rating Area 3 No Preference 33 471.36

55957PA0370002 Rating Area 3 No Preference 34 477.66

55957PA0370002 Rating Area 3 No Preference 35 480.80

55957PA0370002 Rating Area 3 No Preference 36 483.95

55957PA0370002 Rating Area 3 No Preference 37 487.10

55957PA0370002 Rating Area 3 No Preference 38 490.25

55957PA0370002 Rating Area 3 No Preference 39 496.54

55957PA0370002 Rating Area 3 No Preference 40 502.84

55957PA0370002 Rating Area 3 No Preference 41 512.28

55957PA0370002 Rating Area 3 No Preference 42 521.33

55957PA0370002 Rating Area 3 No Preference 43 533.92

55957PA0370002 Rating Area 3 No Preference 44 549.66

55957PA0370002 Rating Area 3 No Preference 45 568.15

55957PA0370002 Rating Area 3 No Preference 46 590.19

55957PA0370002 Rating Area 3 No Preference 47 614.97

55957PA0370002 Rating Area 3 No Preference 48 643.30

55957PA0370002 Rating Area 3 No Preference 49 671.24

55957PA0370002 Rating Area 3 No Preference 50 702.71

55957PA0370002 Rating Area 3 No Preference 51 733.80

55957PA0370002 Rating Area 3 No Preference 52 768.03

55957PA0370002 Rating Area 3 No Preference 53 802.65

55957PA0370002 Rating Area 3 No Preference 54 840.03

55957PA0370002 Rating Area 3 No Preference 55 877.41

55957PA0370002 Rating Area 3 No Preference 56 917.94

55957PA0370002 Rating Area 3 No Preference 57 958.86

55957PA0370002 Rating Area 3 No Preference 58 1002.53

55957PA0370002 Rating Area 3 No Preference 59 1024.17

55957PA0370002 Rating Area 3 No Preference 60 1067.85

55957PA0370002 Rating Area 3 No Preference 61 1105.62

55957PA0370002 Rating Area 3 No Preference 62 1130.41

55957PA0370002 Rating Area 3 No Preference 63 1161.49

55957PA0370002 Rating Area 3 No Preference 64 1180.38

55957PA0370002 Rating Area 3 No Preference 65 and over 1180.38

55957PA0380001 Rating Area 3 No Preference 0-20 205.13

55957PA0380001 Rating Area 3 No Preference 21 323.04

55957PA0380001 Rating Area 3 No Preference 22 323.04

55957PA0380001 Rating Area 3 No Preference 23 323.04

55957PA0380001 Rating Area 3 No Preference 24 323.04

55957PA0380001 Rating Area 3 No Preference 25 324.33

55957PA0380001 Rating Area 3 No Preference 26 330.79

55957PA0380001 Rating Area 3 No Preference 27 338.54

55957PA0380001 Rating Area 3 No Preference 28 351.14

55957PA0380001 Rating Area 3 No Preference 29 361.48

55957PA0380001 Rating Area 3 No Preference 30 366.65

55957PA0380001 Rating Area 3 No Preference 31 374.40

55957PA0380001 Rating Area 3 No Preference 32 382.15

55957PA0380001 Rating Area 3 No Preference 33 387.00

55957PA0380001 Rating Area 3 No Preference 34 392.17

55957PA0380001 Rating Area 3 No Preference 35 394.75

55957PA0380001 Rating Area 3 No Preference 36 397.33

55957PA0380001 Rating Area 3 No Preference 37 399.92

55957PA0380001 Rating Area 3 No Preference 38 402.50

55957PA0380001 Rating Area 3 No Preference 39 407.67

55957PA0380001 Rating Area 3 No Preference 40 412.84

55957PA0380001 Rating Area 3 No Preference 41 420.59

55957PA0380001 Rating Area 3 No Preference 42 428.02

55957PA0380001 Rating Area 3 No Preference 43 438.36

55957PA0380001 Rating Area 3 No Preference 44 451.28

55957PA0380001 Rating Area 3 No Preference 45 466.46

55957PA0380001 Rating Area 3 No Preference 46 484.56

55957PA0380001 Rating Area 3 No Preference 47 504.91

55957PA0380001 Rating Area 3 No Preference 48 528.17

55957PA0380001 Rating Area 3 No Preference 49 551.10

55957PA0380001 Rating Area 3 No Preference 50 576.94

55957PA0380001 Rating Area 3 No Preference 51 602.46

55957PA0380001 Rating Area 3 No Preference 52 630.57

55957PA0380001 Rating Area 3 No Preference 53 659.00

55957PA0380001 Rating Area 3 No Preference 54 689.69

55957PA0380001 Rating Area 3 No Preference 55 720.37

55957PA0380001 Rating Area 3 No Preference 56 753.65

55957PA0380001 Rating Area 3 No Preference 57 787.24

55957PA0380001 Rating Area 3 No Preference 58 823.10

55957PA0380001 Rating Area 3 No Preference 59 840.87

55957PA0380001 Rating Area 3 No Preference 60 876.73

55957PA0380001 Rating Area 3 No Preference 61 907.74

55957PA0380001 Rating Area 3 No Preference 62 928.09

55957PA0380001 Rating Area 3 No Preference 63 953.61

55957PA0380001 Rating Area 3 No Preference 64 969.12

55957PA0380001 Rating Area 3 No Preference 65 and over 969.12

HIOS Plan ID On/Off Exchange Product Metal Plan Design Marketing Name Network Rating Area Counties Excluded

55957PA0270007 Off BlueCare PPO Platinum BlueCare PPO Platinum 12 PPO 3 None

55957PA0270016 Off BlueCare PPO Platinum BlueCare PPO Platinum 13 PPO 3 None

55957PA0270002 Off BlueCare PPO Platinum BlueCare PPO Platinum 2 PPO 3 None

55957PA0270006 Off BlueCare PPO Platinum BlueCare PPO Platinum 11 PPO 3 None

55957PA0270017 Off BlueCare PPO Gold BlueCare PPO Gold 27 PPO 3 None

55957PA0270018 Off BlueCare PPO Gold BlueCare PPO Gold 15 PPO 3 None

55957PA0270008 Off BlueCare PPO Gold BlueCare PPO Gold 12 PPO 3 None

55957PA0270009 Off BlueCare PPO Gold BlueCare PPO Gold 18 PPO 3 None

55957PA0270010 Off BlueCare PPO Gold BlueCare PPO Gold 19 PPO 3 None

55957PA0270011 Off BlueCare PPO Gold BlueCare PPO Gold 24 PPO 3 None

55957PA0270022 Off BlueCare PPO Silver BlueCare PPO Silver 10 PPO 3 None

55957PA0270019 Off BlueCare PPO Silver BlueCare PPO Silver 2 PPO 3 None

55957PA0270020 Off BlueCare PPO Silver BlueCare PPO Silver 6 PPO 3 None

55957PA0270021 Off BlueCare PPO Silver BlueCare PPO Silver 9 PPO 3 None

55957PA0270013 Off BlueCare PPO Bronze BlueCare PPO Bronze 4 PPO 3 None

55957PA0290007 Off BlueCare CustomPPO Platinum BlueCare Custom PPO Platinum 12 CustomPPO 3 None

55957PA0290008 Off BlueCare CustomPPO Platinum BlueCare Custom PPO Platinum 13 CustomPPO 3 None

55957PA0290002 Off BlueCare CustomPPO Platinum BlueCare Custom PPO Platinum 2 CustomPPO 3 None

55957PA0290006 Off BlueCare CustomPPO Platinum BlueCare Custom PPO Platinum 11 CustomPPO 3 None

55957PA0290022 Off BlueCare CustomPPO Gold BlueCare Custom PPO Gold 27 CustomPPO 3 None

55957PA0290012 Off BlueCare CustomPPO Gold BlueCare Custom PPO Gold 15 CustomPPO 3 None

55957PA0290011 Off BlueCare CustomPPO Gold BlueCare Custom PPO Gold 12 CustomPPO 3 None

55957PA0290013 Off BlueCare CustomPPO Gold BlueCare Custom PPO Gold 18 CustomPPO 3 None

55957PA0290014 Off BlueCare CustomPPO Gold BlueCare Custom PPO Gold 19 CustomPPO 3 None

55957PA0290016 Off BlueCare CustomPPO Gold BlueCare Custom PPO Gold 24 CustomPPO 3 None

55957PA0290023 Off BlueCare CustomPPO Silver BlueCare Custom PPO Silver 10 CustomPPO 3 None

55957PA0290017 Off BlueCare CustomPPO Silver BlueCare Custom PPO Silver 2 CustomPPO 3 None

55957PA0290018 Off BlueCare CustomPPO Silver BlueCare Custom PPO Silver 6 CustomPPO 3 None

55957PA0290019 Off BlueCare CustomPPO Silver BlueCare Custom PPO Silver 9 CustomPPO 3 None

55957PA0290021 Off BlueCare CustomPPO Bronze BlueCare Custom PPO Bronze 4 CustomPPO 3 None

55957PA0280001 Off BlueCare QHD PPO Bronze BlueCare QHD PPO Bronze 3 PPO 3 None

55957PA0280002 Off BlueCare QHD PPO Bronze BlueCare QHD PPO Bronze 4 PPO 3 None

55957PA0280003 Off BlueCare QHD PPO Silver BlueCare QHD PPO Silver 1 PPO 3 None

55957PA0280004 Off BlueCare QHD PPO Gold BlueCare QHD PPO Gold 1 PPO 3 None

55957PA0300001 Off AffordaBlue Platinum AffordaBlue Platinum1 Tiered CustomPPO 3 None

55957PA0300002 Off AffordaBlue Gold AffordaBlue Gold Option 1 Tiered CustomPPO 3 None

55957PA0370001 Off Lehigh Valley Flex Blue PPO Gold Lehigh Valley Flex Blue PPO 500G PPO 3

Tioga, Bradford, Susquehanna, Wayne, Clinton,

Lycoming, Sullivan, Wyoming, Luzerne,

Lackawanna, Pike, Carbon

55957PA0370002 Off Lehigh Valley Flex Blue PPO Gold Lehigh Valley Flex Blue PPO 1250G PPO 3

Tioga, Bradford, Susquehanna, Wayne, Clinton,

Lycoming, Sullivan, Wyoming, Luzerne,

Lackawanna, Pike, Carbon

55957PA0380001 Off Lehigh Valley Flex Blue PPO Silver Lehigh Valley Flex Blue PPO 3000SQE PPO 3

Tioga, Bradford, Susquehanna, Wayne, Clinton,

Lycoming, Sullivan, Wyoming, Luzerne,

Lackawanna, Pike, Carbon

First Priority Life Insurance Company

Small Group

Plan Design Summary

12/24/2014

RATE PAGES

Company Name: First Priority Life Insurance Compan

Market: Small Group

Product: PPO, CustomPPO, QHD PPO, AffordaBlue, Lehigh Valley Flex Blue

Effective Date of Rates: Ending date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

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

0 - 20 $276.32 $276.32 $278.19 $278.19 $276.49 $276.49 $273.32 $273.32 $249.89 $249.89 $230.09 $230.09

21 $435.16 $435.16 $438.11 $438.11 $435.42 $435.42 $430.43 $430.43 $393.54 $393.54 $362.36 $362.36

22 $435.16 $435.16 $438.11 $438.11 $435.42 $435.42 $430.43 $430.43 $393.54 $393.54 $362.36 $362.36

23 $435.16 $435.16 $438.11 $438.11 $435.42 $435.42 $430.43 $430.43 $393.54 $393.54 $362.36 $362.36

24 $435.16 $435.16 $438.11 $438.11 $435.42 $435.42 $430.43 $430.43 $393.54 $393.54 $362.36 $362.36

25 $436.90 $436.90 $439.86 $439.86 $437.16 $437.16 $432.15 $432.15 $395.11 $395.11 $363.80 $363.80

26 $445.60 $445.60 $448.62 $448.62 $445.87 $445.87 $440.76 $440.76 $402.98 $402.98 $371.05 $371.05

27 $456.04 $456.04 $459.13 $459.13 $456.32 $456.32 $451.09 $451.09 $412.42 $412.42 $379.75 $379.75

28 $473.01 $473.01 $476.22 $476.22 $473.30 $473.30 $467.87 $467.87 $427.77 $427.77 $393.88 $393.88

29 $486.94 $486.94 $490.24 $490.24 $487.23 $487.23 $481.65 $481.65 $440.37 $440.37 $405.48 $405.48

30 $493.90 $493.90 $497.25 $497.25 $494.20 $494.20 $488.53 $488.53 $446.66 $446.66 $411.27 $411.27

31 $504.35 $504.35 $507.76 $507.76 $504.65 $504.65 $498.86 $498.86 $456.11 $456.11 $419.97 $419.97

32 $514.79 $514.79 $518.28 $518.28 $515.10 $515.10 $509.19 $509.19 $465.55 $465.55 $428.67 $428.67

33 $521.32 $521.32 $524.85 $524.85 $521.63 $521.63 $515.65 $515.65 $471.46 $471.46 $434.10 $434.10

34 $528.28 $528.28 $531.86 $531.86 $528.59 $528.59 $522.54 $522.54 $477.75 $477.75 $439.90 $439.90

35 $531.76 $531.76 $535.37 $535.37 $532.08 $532.08 $525.98 $525.98 $480.90 $480.90 $442.80 $442.80

36 $535.24 $535.24 $538.87 $538.87 $535.56 $535.56 $529.42 $529.42 $484.05 $484.05 $445.70 $445.70

37 $538.72 $538.72 $542.38 $542.38 $539.04 $539.04 $532.87 $532.87 $487.20 $487.20 $448.60 $448.60

38 $542.20 $542.20 $545.88 $545.88 $542.53 $542.53 $536.31 $536.31 $490.35 $490.35 $451.50 $451.50

39 $549.17 $549.17 $552.89 $552.89 $549.50 $549.50 $543.20 $543.20 $496.64 $496.64 $457.29 $457.29

40 $556.13 $556.13 $559.90 $559.90 $556.46 $556.46 $550.08 $550.08 $502.94 $502.94 $463.09 $463.09

41 $566.57 $566.57 $570.41 $570.41 $566.91 $566.91 $560.41 $560.41 $512.38 $512.38 $471.79 $471.79

42 $576.58 $576.58 $580.49 $580.49 $576.93 $576.93 $570.31 $570.31 $521.44 $521.44 $480.12 $480.12

43 $590.51 $590.51 $594.51 $594.51 $590.86 $590.86 $584.09 $584.09 $534.03 $534.03 $491.72 $491.72

44 $607.91 $607.91 $612.03 $612.03 $608.28 $608.28 $601.31 $601.31 $549.77 $549.77 $506.21 $506.21

45 $628.37 $628.37 $632.63 $632.63 $628.74 $628.74 $621.54 $621.54 $568.27 $568.27 $523.24 $523.24

46 $652.74 $652.74 $657.16 $657.16 $653.13 $653.13 $645.64 $645.64 $590.31 $590.31 $543.54 $543.54

47 $680.15 $680.15 $684.76 $684.76 $680.56 $680.56 $672.76 $672.76 $615.10 $615.10 $566.36 $566.36

48 $711.48 $711.48 $716.30 $716.30 $711.91 $711.91 $703.75 $703.75 $643.43 $643.43 $592.45 $592.45

49 $742.38 $742.38 $747.41 $747.41 $742.82 $742.82 $734.31 $734.31 $671.37 $671.37 $618.18 $618.18

50 $777.19 $777.19 $782.46 $782.46 $777.66 $777.66 $768.74 $768.74 $702.86 $702.86 $647.17 $647.17

51 $811.57 $811.57 $817.07 $817.07 $812.05 $812.05 $802.75 $802.75 $733.95 $733.95 $675.80 $675.80

52 $849.43 $849.43 $855.19 $855.19 $849.93 $849.93 $840.19 $840.19 $768.19 $768.19 $707.32 $707.32

53 $887.72 $887.72 $893.74 $893.74 $888.25 $888.25 $878.07 $878.07 $802.82 $802.82 $739.21 $739.21

54 $929.06 $929.06 $935.36 $935.36 $929.62 $929.62 $918.96 $918.96 $840.20 $840.20 $773.63 $773.63

55 $970.40 $970.40 $976.98 $976.98 $970.98 $970.98 $959.85 $959.85 $877.59 $877.59 $808.06 $808.06

56 $1,015.22 $1,015.22 $1,022.11 $1,022.11 $1,015.83 $1,015.83 $1,004.19 $1,004.19 $918.12 $918.12 $845.38 $845.38

57 $1,060.48 $1,060.48 $1,067.67 $1,067.67 $1,061.11 $1,061.11 $1,048.95 $1,048.95 $959.05 $959.05 $883.07 $883.07

58 $1,108.78 $1,108.78 $1,116.30 $1,116.30 $1,109.45 $1,109.45 $1,096.73 $1,096.73 $1,002.73 $1,002.73 $923.29 $923.29

59 $1,132.72 $1,132.72 $1,140.40 $1,140.40 $1,133.39 $1,133.39 $1,120.40 $1,120.40 $1,024.38 $1,024.38 $943.22 $943.22

60 $1,181.02 $1,181.02 $1,189.03 $1,189.03 $1,181.72 $1,181.72 $1,168.18 $1,168.18 $1,068.06 $1,068.06 $983.44 $983.44

61 $1,222.79 $1,222.79 $1,231.08 $1,231.08 $1,223.53 $1,223.53 $1,209.50 $1,209.50 $1,105.84 $1,105.84 $1,018.23 $1,018.23

62 $1,250.21 $1,250.21 $1,258.69 $1,258.69 $1,250.96 $1,250.96 $1,236.62 $1,236.62 $1,130.64 $1,130.64 $1,041.06 $1,041.06

63 $1,284.59 $1,284.59 $1,293.30 $1,293.30 $1,285.35 $1,285.35 $1,270.62 $1,270.62 $1,161.73 $1,161.73 $1,069.68 $1,069.68

64+ $1,305.48 $1,305.48 $1,314.33 $1,314.33 $1,306.26 $1,306.26 $1,291.29 $1,291.29 $1,180.62 $1,180.62 $1,087.08 $1,087.08

January 1, 2017 March 31, 2017

55957PA0270007 55957PA0270016 55957PA0270002 55957PA0270006 55957PA0270017 55957PA0270018FP-1-SG-EHB PPO-1/1/16

FP-1-X-SG-PPO-1/1/16FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None

PPO PPO PPO PPO PPO PPO

Platinum Platinum Platinum Platinum Gold GoldBlueCare PPO Platinum 12 BlueCare PPO Platinum 13 BlueCare PPO Platinum 2 BlueCare PPO Platinum 11 BlueCare PPO Gold 27 BlueCare PPO Gold 15

$0 $250 $500 $750 $500 $1,000

100% 100% 100% 100% 100% 80%$25/$50 $10/$20 $10/$20 $10/$20 $20/$40 $20/$40

$2,500 $4,000 $2,000 $1,500 $6,000 $5,000

No No No No No No

Page Number: 2 12/24/2014

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Pediatric Dental (Yes/No) =>

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$233.97 $233.97 $234.20 $234.20 $238.13 $238.13 $228.51 $228.51 $196.38 $196.38 $186.79 $186.79

$368.47 $368.47 $368.82 $368.82 $375.02 $375.02 $359.87 $359.87 $309.26 $309.26 $294.17 $294.17

$368.47 $368.47 $368.82 $368.82 $375.02 $375.02 $359.87 $359.87 $309.26 $309.26 $294.17 $294.17

$368.47 $368.47 $368.82 $368.82 $375.02 $375.02 $359.87 $359.87 $309.26 $309.26 $294.17 $294.17

$368.47 $368.47 $368.82 $368.82 $375.02 $375.02 $359.87 $359.87 $309.26 $309.26 $294.17 $294.17

$369.94 $369.94 $370.29 $370.29 $376.52 $376.52 $361.30 $361.30 $310.49 $310.49 $295.34 $295.34

$377.31 $377.31 $377.67 $377.67 $384.02 $384.02 $368.50 $368.50 $316.68 $316.68 $301.23 $301.23

$386.15 $386.15 $386.52 $386.52 $393.02 $393.02 $377.14 $377.14 $324.10 $324.10 $308.29 $308.29

$400.52 $400.52 $400.90 $400.90 $407.64 $407.64 $391.17 $391.17 $336.16 $336.16 $319.76 $319.76

$412.31 $412.31 $412.70 $412.70 $419.64 $419.64 $402.69 $402.69 $346.06 $346.06 $329.17 $329.17

$418.21 $418.21 $418.61 $418.61 $425.64 $425.64 $408.45 $408.45 $351.01 $351.01 $333.88 $333.88

$427.05 $427.05 $427.46 $427.46 $434.64 $434.64 $417.08 $417.08 $358.43 $358.43 $340.94 $340.94

$435.90 $435.90 $436.31 $436.31 $443.64 $443.64 $425.72 $425.72 $365.85 $365.85 $348.00 $348.00

$441.42 $441.42 $441.84 $441.84 $449.27 $449.27 $431.12 $431.12 $370.49 $370.49 $352.41 $352.41

$447.32 $447.32 $447.74 $447.74 $455.27 $455.27 $436.88 $436.88 $375.44 $375.44 $357.12 $357.12

$450.27 $450.27 $450.69 $450.69 $458.27 $458.27 $439.76 $439.76 $377.91 $377.91 $359.47 $359.47

$453.21 $453.21 $453.64 $453.64 $461.27 $461.27 $442.64 $442.64 $380.38 $380.38 $361.82 $361.82

$456.16 $456.16 $456.59 $456.59 $464.27 $464.27 $445.51 $445.51 $382.86 $382.86 $364.18 $364.18

$459.11 $459.11 $459.54 $459.54 $467.27 $467.27 $448.39 $448.39 $385.33 $385.33 $366.53 $366.53

$465.00 $465.00 $465.45 $465.45 $473.27 $473.27 $454.15 $454.15 $390.28 $390.28 $371.24 $371.24

$470.90 $470.90 $471.35 $471.35 $479.27 $479.27 $459.91 $459.91 $395.23 $395.23 $375.94 $375.94

$479.74 $479.74 $480.20 $480.20 $488.27 $488.27 $468.55 $468.55 $402.65 $402.65 $383.00 $383.00

$488.22 $488.22 $488.68 $488.68 $496.90 $496.90 $476.82 $476.82 $409.76 $409.76 $389.77 $389.77

$500.01 $500.01 $500.48 $500.48 $508.90 $508.90 $488.34 $488.34 $419.66 $419.66 $399.18 $399.18

$514.75 $514.75 $515.24 $515.24 $523.90 $523.90 $502.73 $502.73 $432.03 $432.03 $410.95 $410.95

$532.07 $532.07 $532.57 $532.57 $541.52 $541.52 $519.65 $519.65 $446.57 $446.57 $424.78 $424.78

$552.70 $552.70 $553.23 $553.23 $562.53 $562.53 $539.80 $539.80 $463.89 $463.89 $441.25 $441.25

$575.91 $575.91 $576.46 $576.46 $586.15 $586.15 $562.47 $562.47 $483.37 $483.37 $459.78 $459.78

$602.44 $602.44 $603.02 $603.02 $613.15 $613.15 $588.38 $588.38 $505.64 $505.64 $480.96 $480.96

$628.60 $628.60 $629.20 $629.20 $639.78 $639.78 $613.93 $613.93 $527.59 $527.59 $501.85 $501.85

$658.08 $658.08 $658.71 $658.71 $669.78 $669.78 $642.72 $642.72 $552.33 $552.33 $525.38 $525.38

$687.19 $687.19 $687.84 $687.84 $699.41 $699.41 $671.15 $671.15 $576.76 $576.76 $548.62 $548.62

$719.25 $719.25 $719.93 $719.93 $732.03 $732.03 $702.46 $702.46 $603.67 $603.67 $574.21 $574.21

$751.67 $751.67 $752.39 $752.39 $765.04 $765.04 $734.13 $734.13 $630.89 $630.89 $600.10 $600.10

$786.68 $786.68 $787.43 $787.43 $800.66 $800.66 $768.32 $768.32 $660.27 $660.27 $628.05 $628.05

$821.68 $821.68 $822.46 $822.46 $836.29 $836.29 $802.51 $802.51 $689.64 $689.64 $655.99 $655.99

$859.64 $859.64 $860.45 $860.45 $874.92 $874.92 $839.57 $839.57 $721.50 $721.50 $686.29 $686.29

$897.96 $897.96 $898.81 $898.81 $913.92 $913.92 $877.00 $877.00 $753.66 $753.66 $716.89 $716.89

$938.86 $938.86 $939.75 $939.75 $955.55 $955.55 $916.94 $916.94 $787.99 $787.99 $749.54 $749.54

$959.12 $959.12 $960.03 $960.03 $976.17 $976.17 $936.74 $936.74 $805.00 $805.00 $765.72 $765.72

$1,000.02 $1,000.02 $1,000.97 $1,000.97 $1,017.80 $1,017.80 $976.68 $976.68 $839.33 $839.33 $798.37 $798.37

$1,035.40 $1,035.40 $1,036.38 $1,036.38 $1,053.80 $1,053.80 $1,011.23 $1,011.23 $869.02 $869.02 $826.61 $826.61

$1,058.61 $1,058.61 $1,059.61 $1,059.61 $1,077.43 $1,077.43 $1,033.90 $1,033.90 $888.50 $888.50 $845.15 $845.15

$1,087.72 $1,087.72 $1,088.75 $1,088.75 $1,107.05 $1,107.05 $1,062.33 $1,062.33 $912.93 $912.93 $868.38 $868.38

$1,105.41 $1,105.41 $1,106.46 $1,106.46 $1,125.06 $1,125.06 $1,079.61 $1,079.61 $927.78 $927.78 $882.51 $882.51

55957PA0270008 55957PA0270009 55957PA0270010 55957PA0270011 55957PA0270022

FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

55957PA0270019

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None

PPO PPO PPO PPO PPO PPO

Gold Gold Gold Gold Silver SilverBlueCare PPO Gold 12 BlueCare PPO Gold 24 BlueCare PPO Silver 10 BlueCare PPO Silver 2

$1,250 $1,500

BlueCare PPO Gold 18 BlueCare PPO Gold 19

$1,500 $2,000 - 1 per family $1,400 $1,750

100% 100% 90%100% 100% 90%$35/$60 $20/$40 $25/$50 $15/$30 $45/$75 $45/$65

$7,150 $7,150 $5,000 $6,000 - 1 per family $7,150 $7,150

No No No NoNo No

Page Number: 3 12/24/2014

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Pediatric Dental (Yes/No) =>

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$198.50 $198.50 $196.41 $196.41 $158.20 $158.20 $232.11 $232.11 $233.68 $233.68 $232.25 $232.25

$312.60 $312.60 $309.32 $309.32 $249.14 $249.14 $365.54 $365.54 $368.01 $368.01 $365.75 $365.75

$312.60 $312.60 $309.32 $309.32 $249.14 $249.14 $365.54 $365.54 $368.01 $368.01 $365.75 $365.75

$312.60 $312.60 $309.32 $309.32 $249.14 $249.14 $365.54 $365.54 $368.01 $368.01 $365.75 $365.75

$312.60 $312.60 $309.32 $309.32 $249.14 $249.14 $365.54 $365.54 $368.01 $368.01 $365.75 $365.75

$313.85 $313.85 $310.55 $310.55 $250.13 $250.13 $367.00 $367.00 $369.48 $369.48 $367.21 $367.21

$320.10 $320.10 $316.74 $316.74 $255.11 $255.11 $374.31 $374.31 $376.84 $376.84 $374.52 $374.52

$327.60 $327.60 $324.16 $324.16 $261.09 $261.09 $383.08 $383.08 $385.67 $385.67 $383.30 $383.30

$339.79 $339.79 $336.23 $336.23 $270.81 $270.81 $397.34 $397.34 $400.02 $400.02 $397.57 $397.57

$349.79 $349.79 $346.12 $346.12 $278.78 $278.78 $409.03 $409.03 $411.80 $411.80 $409.27 $409.27

$354.80 $354.80 $351.07 $351.07 $282.77 $282.77 $414.88 $414.88 $417.69 $417.69 $415.12 $415.12

$362.30 $362.30 $358.50 $358.50 $288.75 $288.75 $423.66 $423.66 $426.52 $426.52 $423.90 $423.90

$369.80 $369.80 $365.92 $365.92 $294.73 $294.73 $432.43 $432.43 $435.35 $435.35 $432.68 $432.68

$374.49 $374.49 $370.56 $370.56 $298.46 $298.46 $437.91 $437.91 $440.87 $440.87 $438.16 $438.16

$379.49 $379.49 $375.51 $375.51 $302.45 $302.45 $443.76 $443.76 $446.76 $446.76 $444.02 $444.02

$381.99 $381.99 $377.98 $377.98 $304.44 $304.44 $446.68 $446.68 $449.70 $449.70 $446.94 $446.94

$384.49 $384.49 $380.46 $380.46 $306.44 $306.44 $449.61 $449.61 $452.65 $452.65 $449.87 $449.87

$386.99 $386.99 $382.93 $382.93 $308.43 $308.43 $452.53 $452.53 $455.59 $455.59 $452.79 $452.79

$389.49 $389.49 $385.41 $385.41 $310.42 $310.42 $455.46 $455.46 $458.54 $458.54 $455.72 $455.72

$394.50 $394.50 $390.36 $390.36 $314.41 $314.41 $461.31 $461.31 $464.42 $464.42 $461.57 $461.57

$399.50 $399.50 $395.31 $395.31 $318.40 $318.40 $467.16 $467.16 $470.31 $470.31 $467.42 $467.42

$407.00 $407.00 $402.73 $402.73 $324.38 $324.38 $475.93 $475.93 $479.14 $479.14 $476.20 $476.20

$414.19 $414.19 $409.84 $409.84 $330.11 $330.11 $484.34 $484.34 $487.61 $487.61 $484.61 $484.61

$424.19 $424.19 $419.74 $419.74 $338.08 $338.08 $496.03 $496.03 $499.38 $499.38 $496.32 $496.32

$436.70 $436.70 $432.12 $432.12 $348.04 $348.04 $510.65 $510.65 $514.10 $514.10 $510.95 $510.95

$451.39 $451.39 $446.65 $446.65 $359.75 $359.75 $527.83 $527.83 $531.40 $531.40 $528.14 $528.14

$468.90 $468.90 $463.98 $463.98 $373.71 $373.71 $548.31 $548.31 $552.01 $552.01 $548.62 $548.62

$488.59 $488.59 $483.46 $483.46 $389.40 $389.40 $571.33 $571.33 $575.19 $575.19 $571.66 $571.66

$511.10 $511.10 $505.73 $505.73 $407.34 $407.34 $597.65 $597.65 $601.69 $601.69 $598.00 $598.00

$533.29 $533.29 $527.69 $527.69 $425.03 $425.03 $623.61 $623.61 $627.82 $627.82 $623.96 $623.96

$558.30 $558.30 $552.44 $552.44 $444.96 $444.96 $652.85 $652.85 $657.26 $657.26 $653.22 $653.22

$582.99 $582.99 $576.88 $576.88 $464.64 $464.64 $681.73 $681.73 $686.33 $686.33 $682.12 $682.12

$610.19 $610.19 $603.79 $603.79 $486.32 $486.32 $713.53 $713.53 $718.35 $718.35 $713.94 $713.94

$637.70 $637.70 $631.01 $631.01 $508.24 $508.24 $745.70 $745.70 $750.74 $750.74 $746.13 $746.13

$667.40 $667.40 $660.39 $660.39 $531.91 $531.91 $780.42 $780.42 $785.70 $785.70 $780.87 $780.87

$697.09 $697.09 $689.78 $689.78 $555.58 $555.58 $815.15 $815.15 $820.66 $820.66 $815.62 $815.62

$729.29 $729.29 $721.64 $721.64 $581.24 $581.24 $852.80 $852.80 $858.56 $858.56 $853.29 $853.29

$761.80 $761.80 $753.81 $753.81 $607.15 $607.15 $890.82 $890.82 $896.84 $896.84 $891.33 $891.33

$796.50 $796.50 $788.14 $788.14 $634.80 $634.80 $931.39 $931.39 $937.68 $937.68 $931.93 $931.93

$813.69 $813.69 $805.15 $805.15 $648.51 $648.51 $951.50 $951.50 $957.93 $957.93 $952.04 $952.04

$848.39 $848.39 $839.49 $839.49 $676.16 $676.16 $992.07 $992.07 $998.77 $998.77 $992.64 $992.64

$878.40 $878.40 $869.18 $869.18 $700.08 $700.08 $1,027.16 $1,027.16 $1,034.10 $1,034.10 $1,027.75 $1,027.75

$898.09 $898.09 $888.67 $888.67 $715.77 $715.77 $1,050.19 $1,050.19 $1,057.29 $1,057.29 $1,050.79 $1,050.79

$922.79 $922.79 $913.11 $913.11 $735.46 $735.46 $1,079.07 $1,079.07 $1,086.36 $1,086.36 $1,079.69 $1,079.69

$937.80 $937.80 $927.96 $927.96 $747.42 $747.42 $1,096.62 $1,096.62 $1,104.03 $1,104.03 $1,097.25 $1,097.25

55957PA029000255957PA0270020 55957PA0270021 55957PA0270013 55957PA0290007 55957PA0290008

FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

Rating Area 3

FP-1-SG-EHB-CustomPPO-1/1/16

FP-1-X-SG-CustomPPO-1/1/16FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None NoneNone None

PPO PPO PPO CustomPPO CustomPPO CustomPPO

Silver Silver BronzeBlueCare PPO Silver 9 BlueCare PPO Bronze 4 BlueCare Custom PPO Platinum 12 BlueCare Custom PPO Platinum 13 BlueCare Custom PPO Platinum 2BlueCare PPO Silver 6

Platinum Platinum Platinum

$5,000 $0 $250 $500$2,500 $4,000

90% 100% 50% 100% 100% 100%$25/$50 $25/$50 50%*/50%* $25/$50 $10/$20 $10/$20

$7,000 $7,150 $2,500 $4,000 $2,000$7,150

No No No No No No

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Pediatric Dental (Yes/No) =>

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$229.59 $229.59 $209.91 $209.91 $193.28 $193.28 $196.53 $196.53 $196.72 $196.72 $200.03 $200.03

$361.56 $361.56 $330.57 $330.57 $304.38 $304.38 $309.51 $309.51 $309.81 $309.81 $315.02 $315.02

$361.56 $361.56 $330.57 $330.57 $304.38 $304.38 $309.51 $309.51 $309.81 $309.81 $315.02 $315.02

$361.56 $361.56 $330.57 $330.57 $304.38 $304.38 $309.51 $309.51 $309.81 $309.81 $315.02 $315.02

$361.56 $361.56 $330.57 $330.57 $304.38 $304.38 $309.51 $309.51 $309.81 $309.81 $315.02 $315.02

$363.00 $363.00 $331.89 $331.89 $305.59 $305.59 $310.74 $310.74 $311.04 $311.04 $316.28 $316.28

$370.23 $370.23 $338.50 $338.50 $311.68 $311.68 $316.93 $316.93 $317.24 $317.24 $322.58 $322.58

$378.91 $378.91 $346.43 $346.43 $318.99 $318.99 $324.36 $324.36 $324.68 $324.68 $330.14 $330.14

$393.01 $393.01 $359.32 $359.32 $330.86 $330.86 $336.43 $336.43 $336.76 $336.76 $342.42 $342.42

$404.58 $404.58 $369.90 $369.90 $340.60 $340.60 $346.34 $346.34 $346.67 $346.67 $352.50 $352.50

$410.37 $410.37 $375.19 $375.19 $345.47 $345.47 $351.29 $351.29 $351.63 $351.63 $357.54 $357.54

$419.04 $419.04 $383.13 $383.13 $352.77 $352.77 $358.72 $358.72 $359.06 $359.06 $365.10 $365.10

$427.72 $427.72 $391.06 $391.06 $360.08 $360.08 $366.15 $366.15 $366.50 $366.50 $372.66 $372.66

$433.14 $433.14 $396.02 $396.02 $364.64 $364.64 $370.79 $370.79 $371.15 $371.15 $377.39 $377.39

$438.93 $438.93 $401.31 $401.31 $369.51 $369.51 $375.74 $375.74 $376.10 $376.10 $382.43 $382.43

$441.82 $441.82 $403.95 $403.95 $371.95 $371.95 $378.22 $378.22 $378.58 $378.58 $384.95 $384.95

$444.71 $444.71 $406.60 $406.60 $374.38 $374.38 $380.69 $380.69 $381.06 $381.06 $387.47 $387.47

$447.61 $447.61 $409.24 $409.24 $376.82 $376.82 $383.17 $383.17 $383.54 $383.54 $389.99 $389.99

$450.50 $450.50 $411.89 $411.89 $379.25 $379.25 $385.64 $385.64 $386.02 $386.02 $392.51 $392.51

$456.28 $456.28 $417.17 $417.17 $384.12 $384.12 $390.60 $390.60 $390.98 $390.98 $397.55 $397.55

$462.07 $462.07 $422.46 $422.46 $388.99 $388.99 $395.55 $395.55 $395.93 $395.93 $402.59 $402.59

$470.75 $470.75 $430.40 $430.40 $396.30 $396.30 $402.98 $402.98 $403.37 $403.37 $410.15 $410.15

$479.06 $479.06 $438.00 $438.00 $403.30 $403.30 $410.10 $410.10 $410.49 $410.49 $417.40 $417.40

$490.63 $490.63 $448.58 $448.58 $413.04 $413.04 $420.00 $420.00 $420.41 $420.41 $427.48 $427.48

$505.09 $505.09 $461.80 $461.80 $425.21 $425.21 $432.38 $432.38 $432.80 $432.80 $440.08 $440.08

$522.09 $522.09 $477.34 $477.34 $439.52 $439.52 $446.93 $446.93 $447.36 $447.36 $454.88 $454.88

$542.34 $542.34 $495.85 $495.85 $456.57 $456.57 $464.26 $464.26 $464.71 $464.71 $472.53 $472.53

$565.11 $565.11 $516.68 $516.68 $475.74 $475.74 $483.76 $483.76 $484.23 $484.23 $492.37 $492.37

$591.15 $591.15 $540.48 $540.48 $497.66 $497.66 $506.04 $506.04 $506.53 $506.53 $515.05 $515.05

$616.82 $616.82 $563.95 $563.95 $519.27 $519.27 $528.02 $528.02 $528.53 $528.53 $537.42 $537.42

$645.74 $645.74 $590.39 $590.39 $543.62 $543.62 $552.78 $552.78 $553.32 $553.32 $562.62 $562.62

$674.30 $674.30 $616.51 $616.51 $567.66 $567.66 $577.23 $577.23 $577.79 $577.79 $587.51 $587.51

$705.76 $705.76 $645.27 $645.27 $594.14 $594.14 $604.16 $604.16 $604.74 $604.74 $614.91 $614.91

$737.58 $737.58 $674.36 $674.36 $620.93 $620.93 $631.40 $631.40 $632.01 $632.01 $642.64 $642.64

$771.93 $771.93 $705.76 $705.76 $649.85 $649.85 $660.80 $660.80 $661.44 $661.44 $672.56 $672.56

$806.27 $806.27 $737.17 $737.17 $678.76 $678.76 $690.20 $690.20 $690.87 $690.87 $702.49 $702.49

$843.51 $843.51 $771.21 $771.21 $710.11 $710.11 $722.08 $722.08 $722.78 $722.78 $734.94 $734.94

$881.12 $881.12 $805.59 $805.59 $741.77 $741.77 $754.27 $754.27 $755.00 $755.00 $767.70 $767.70

$921.25 $921.25 $842.29 $842.29 $775.56 $775.56 $788.63 $788.63 $789.39 $789.39 $802.67 $802.67

$941.14 $941.14 $860.47 $860.47 $792.30 $792.30 $805.65 $805.65 $806.43 $806.43 $819.99 $819.99

$981.27 $981.27 $897.16 $897.16 $826.08 $826.08 $840.01 $840.01 $840.82 $840.82 $854.96 $854.96

$1,015.98 $1,015.98 $928.90 $928.90 $855.30 $855.30 $869.72 $869.72 $870.56 $870.56 $885.20 $885.20

$1,038.76 $1,038.76 $949.72 $949.72 $874.48 $874.48 $889.22 $889.22 $890.08 $890.08 $905.05 $905.05

$1,067.32 $1,067.32 $975.84 $975.84 $898.52 $898.52 $913.67 $913.67 $914.55 $914.55 $929.93 $929.93

$1,084.68 $1,084.68 $991.71 $991.71 $913.14 $913.14 $928.53 $928.53 $929.43 $929.43 $945.06 $945.06

55957PA029001455957PA0290006 55957PA0290022 55957PA0290012 55957PA0290011 55957PA0290013

FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3Rating Area 3

None None None None None None

Rating Area 3 Rating Area 3

CustomPPO CustomPPO CustomPPOCustomPPO CustomPPO CustomPPO

BlueCare Custom PPO Gold 12 BlueCare Custom PPO Gold 18 BlueCare Custom PPO Gold 19BlueCare Custom PPO Gold 27 BlueCare Custom PPO Gold 15BlueCare Custom PPO Platinum 11Platinum Gold Gold Gold Gold Gold

$750 $500 $1,000 $1,250 $1,500 $1,500

100% 100% 90%100% 100% 80%$20/$40 $35/$60 $20/$40 $25/$50$10/$20 $20/$40

$1,500 $6,000 $5,000 $7,150 $7,150 $5,000

No No No NoNo No

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$192.03 $192.03 $164.96 $164.96 $156.90 $156.90 $166.74 $166.74 $164.99 $164.99 $132.89 $132.89

$302.42 $302.42 $259.78 $259.78 $247.10 $247.10 $262.59 $262.59 $259.83 $259.83 $209.28 $209.28

$302.42 $302.42 $259.78 $259.78 $247.10 $247.10 $262.59 $262.59 $259.83 $259.83 $209.28 $209.28

$302.42 $302.42 $259.78 $259.78 $247.10 $247.10 $262.59 $262.59 $259.83 $259.83 $209.28 $209.28

$302.42 $302.42 $259.78 $259.78 $247.10 $247.10 $262.59 $262.59 $259.83 $259.83 $209.28 $209.28

$303.62 $303.62 $260.81 $260.81 $248.08 $248.08 $263.64 $263.64 $260.86 $260.86 $210.11 $210.11

$309.67 $309.67 $266.01 $266.01 $253.03 $253.03 $268.89 $268.89 $266.06 $266.06 $214.30 $214.30

$316.93 $316.93 $272.24 $272.24 $258.96 $258.96 $275.19 $275.19 $272.30 $272.30 $219.32 $219.32

$328.73 $328.73 $282.38 $282.38 $268.59 $268.59 $285.43 $285.43 $282.43 $282.43 $227.48 $227.48

$338.40 $338.40 $290.69 $290.69 $276.50 $276.50 $293.83 $293.83 $290.74 $290.74 $234.18 $234.18

$343.24 $343.24 $294.85 $294.85 $280.45 $280.45 $298.03 $298.03 $294.90 $294.90 $237.53 $237.53

$350.50 $350.50 $301.08 $301.08 $286.38 $286.38 $304.34 $304.34 $301.14 $301.14 $242.55 $242.55

$357.76 $357.76 $307.31 $307.31 $292.31 $292.31 $310.64 $310.64 $307.37 $307.37 $247.57 $247.57

$362.29 $362.29 $311.21 $311.21 $296.02 $296.02 $314.58 $314.58 $311.27 $311.27 $250.71 $250.71

$367.13 $367.13 $315.37 $315.37 $299.97 $299.97 $318.78 $318.78 $315.43 $315.43 $254.06 $254.06

$369.55 $369.55 $317.45 $317.45 $301.95 $301.95 $320.88 $320.88 $317.51 $317.51 $255.74 $255.74

$371.97 $371.97 $319.52 $319.52 $303.93 $303.93 $322.98 $322.98 $319.59 $319.59 $257.41 $257.41

$374.39 $374.39 $321.60 $321.60 $305.90 $305.90 $325.08 $325.08 $321.66 $321.66 $259.08 $259.08

$376.81 $376.81 $323.68 $323.68 $307.88 $307.88 $327.18 $327.18 $323.74 $323.74 $260.76 $260.76

$381.65 $381.65 $327.84 $327.84 $311.84 $311.84 $331.38 $331.38 $327.90 $327.90 $264.11 $264.11

$386.49 $386.49 $331.99 $331.99 $315.79 $315.79 $335.59 $335.59 $332.06 $332.06 $267.45 $267.45

$393.75 $393.75 $338.23 $338.23 $321.72 $321.72 $341.89 $341.89 $338.29 $338.29 $272.48 $272.48

$400.70 $400.70 $344.20 $344.20 $327.40 $327.40 $347.93 $347.93 $344.27 $344.27 $277.29 $277.29

$410.38 $410.38 $352.52 $352.52 $335.31 $335.31 $356.33 $356.33 $352.58 $352.58 $283.99 $283.99

$422.48 $422.48 $362.91 $362.91 $345.19 $345.19 $366.83 $366.83 $362.98 $362.98 $292.36 $292.36

$436.69 $436.69 $375.12 $375.12 $356.81 $356.81 $379.17 $379.17 $375.19 $375.19 $302.20 $302.20

$453.63 $453.63 $389.67 $389.67 $370.65 $370.65 $393.88 $393.88 $389.74 $389.74 $313.92 $313.92

$472.68 $472.68 $406.03 $406.03 $386.21 $386.21 $410.42 $410.42 $406.11 $406.11 $327.10 $327.10

$494.45 $494.45 $424.74 $424.74 $404.00 $404.00 $429.33 $429.33 $424.82 $424.82 $342.17 $342.17

$515.92 $515.92 $443.18 $443.18 $421.55 $421.55 $447.97 $447.97 $443.26 $443.26 $357.03 $357.03

$540.12 $540.12 $463.96 $463.96 $441.32 $441.32 $468.98 $468.98 $464.05 $464.05 $373.77 $373.77

$564.01 $564.01 $484.48 $484.48 $460.84 $460.84 $489.73 $489.73 $484.58 $484.58 $390.30 $390.30

$590.32 $590.32 $507.09 $507.09 $482.33 $482.33 $512.57 $512.57 $507.18 $507.18 $408.51 $408.51

$616.93 $616.93 $529.95 $529.95 $504.08 $504.08 $535.68 $535.68 $530.05 $530.05 $426.93 $426.93

$645.66 $645.66 $554.63 $554.63 $527.55 $527.55 $560.62 $560.62 $554.73 $554.73 $446.81 $446.81

$674.39 $674.39 $579.30 $579.30 $551.03 $551.03 $585.57 $585.57 $579.42 $579.42 $466.69 $466.69

$705.54 $705.54 $606.06 $606.06 $576.48 $576.48 $612.62 $612.62 $606.18 $606.18 $488.25 $488.25

$736.99 $736.99 $633.08 $633.08 $602.18 $602.18 $639.93 $639.93 $633.20 $633.20 $510.01 $510.01

$770.56 $770.56 $661.91 $661.91 $629.61 $629.61 $669.07 $669.07 $662.04 $662.04 $533.24 $533.24

$787.19 $787.19 $676.20 $676.20 $643.20 $643.20 $683.52 $683.52 $676.33 $676.33 $544.75 $544.75

$820.76 $820.76 $705.04 $705.04 $670.62 $670.62 $712.66 $712.66 $705.17 $705.17 $567.98 $567.98

$849.80 $849.80 $729.98 $729.98 $694.35 $694.35 $737.87 $737.87 $730.12 $730.12 $588.07 $588.07

$868.85 $868.85 $746.34 $746.34 $709.91 $709.91 $754.42 $754.42 $746.49 $746.49 $601.26 $601.26

$892.74 $892.74 $766.87 $766.87 $729.43 $729.43 $775.16 $775.16 $767.01 $767.01 $617.79 $617.79

$907.26 $907.26 $779.34 $779.34 $741.30 $741.30 $787.77 $787.77 $779.49 $779.49 $627.84 $627.84

55957PA029002155957PA0290016 55957PA0290023 55957PA0290017 55957PA0290018 55957PA0290019

FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None

CustomPPO CustomPPO CustomPPOCustomPPO CustomPPO CustomPPO

BlueCare Custom PPO Gold 24Gold Silver Silver Silver Silver Bronze

BlueCare Custom PPO Silver 10 BlueCare Custom PPO Silver 2 BlueCare Custom PPO Silver 6 BlueCare Custom PPO Silver 9 BlueCare Custom PPO Bronze 4

$4,000 $5,000$2,000 - 1 per family $1,400 $1,750 $2,500

100% 100% 90% 90% 100% 50%$15/$30 $45/$75 $45/$65 $25/$50 $25/$50 50%*/50%*

$7,150 $7,000 $7,150$6,000 - 1 per family $7,150 $7,150

No No No No No No

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$156.22 $156.22 $156.67 $156.67 $196.85 $196.85 $228.40 $228.40 $213.63 $213.63 $182.93 $182.93

$246.02 $246.02 $246.73 $246.73 $310.00 $310.00 $359.69 $359.69 $336.44 $336.44 $288.09 $288.09

$246.02 $246.02 $246.73 $246.73 $310.00 $310.00 $359.69 $359.69 $336.44 $336.44 $288.09 $288.09

$246.02 $246.02 $246.73 $246.73 $310.00 $310.00 $359.69 $359.69 $336.44 $336.44 $288.09 $288.09

$246.02 $246.02 $246.73 $246.73 $310.00 $310.00 $359.69 $359.69 $336.44 $336.44 $288.09 $288.09

$247.00 $247.00 $247.71 $247.71 $311.24 $311.24 $361.12 $361.12 $337.78 $337.78 $289.24 $289.24

$251.92 $251.92 $252.65 $252.65 $317.44 $317.44 $368.32 $368.32 $344.51 $344.51 $295.00 $295.00

$257.82 $257.82 $258.57 $258.57 $324.88 $324.88 $376.95 $376.95 $352.58 $352.58 $301.91 $301.91

$267.42 $267.42 $268.19 $268.19 $336.97 $336.97 $390.98 $390.98 $365.71 $365.71 $313.15 $313.15

$275.29 $275.29 $276.09 $276.09 $346.89 $346.89 $402.49 $402.49 $376.47 $376.47 $322.37 $322.37

$279.23 $279.23 $280.03 $280.03 $351.85 $351.85 $408.24 $408.24 $381.85 $381.85 $326.98 $326.98

$285.13 $285.13 $285.96 $285.96 $359.29 $359.29 $416.88 $416.88 $389.93 $389.93 $333.89 $333.89

$291.04 $291.04 $291.88 $291.88 $366.73 $366.73 $425.51 $425.51 $398.00 $398.00 $340.81 $340.81

$294.73 $294.73 $295.58 $295.58 $371.38 $371.38 $430.90 $430.90 $403.05 $403.05 $345.13 $345.13

$298.66 $298.66 $299.53 $299.53 $376.34 $376.34 $436.66 $436.66 $408.43 $408.43 $349.74 $349.74

$300.63 $300.63 $301.50 $301.50 $378.82 $378.82 $439.54 $439.54 $411.12 $411.12 $352.04 $352.04

$302.60 $302.60 $303.47 $303.47 $381.30 $381.30 $442.41 $442.41 $413.82 $413.82 $354.35 $354.35

$304.57 $304.57 $305.45 $305.45 $383.78 $383.78 $445.29 $445.29 $416.51 $416.51 $356.65 $356.65

$306.54 $306.54 $307.42 $307.42 $386.26 $386.26 $448.17 $448.17 $419.20 $419.20 $358.96 $358.96

$310.47 $310.47 $311.37 $311.37 $391.22 $391.22 $453.92 $453.92 $424.58 $424.58 $363.56 $363.56

$314.41 $314.41 $315.32 $315.32 $396.18 $396.18 $459.68 $459.68 $429.97 $429.97 $368.17 $368.17

$320.31 $320.31 $321.24 $321.24 $403.62 $403.62 $468.31 $468.31 $438.04 $438.04 $375.09 $375.09

$325.97 $325.97 $326.91 $326.91 $410.75 $410.75 $476.58 $476.58 $445.78 $445.78 $381.71 $381.71

$333.84 $333.84 $334.81 $334.81 $420.67 $420.67 $488.09 $488.09 $456.54 $456.54 $390.93 $390.93

$343.68 $343.68 $344.68 $344.68 $433.07 $433.07 $502.48 $502.48 $470.00 $470.00 $402.46 $402.46

$355.25 $355.25 $356.27 $356.27 $447.64 $447.64 $519.39 $519.39 $485.81 $485.81 $416.00 $416.00

$369.03 $369.03 $370.09 $370.09 $465.00 $465.00 $539.53 $539.53 $504.66 $504.66 $432.13 $432.13

$384.52 $384.52 $385.63 $385.63 $484.53 $484.53 $562.19 $562.19 $525.85 $525.85 $450.28 $450.28

$402.24 $402.24 $403.40 $403.40 $506.85 $506.85 $588.09 $588.09 $550.07 $550.07 $471.02 $471.02

$419.71 $419.71 $420.92 $420.92 $528.86 $528.86 $613.63 $613.63 $573.96 $573.96 $491.48 $491.48

$439.39 $439.39 $440.65 $440.65 $553.66 $553.66 $642.40 $642.40 $600.88 $600.88 $514.52 $514.52

$458.82 $458.82 $460.15 $460.15 $578.15 $578.15 $670.82 $670.82 $627.46 $627.46 $537.28 $537.28

$480.23 $480.23 $481.61 $481.61 $605.12 $605.12 $702.11 $702.11 $656.73 $656.73 $562.35 $562.35

$501.88 $501.88 $503.32 $503.32 $632.40 $632.40 $733.76 $733.76 $686.33 $686.33 $587.70 $587.70

$525.25 $525.25 $526.76 $526.76 $661.85 $661.85 $767.93 $767.93 $718.29 $718.29 $615.07 $615.07

$548.62 $548.62 $550.20 $550.20 $691.30 $691.30 $802.10 $802.10 $750.26 $750.26 $642.44 $642.44

$573.96 $573.96 $575.62 $575.62 $723.23 $723.23 $839.15 $839.15 $784.91 $784.91 $672.11 $672.11

$599.55 $599.55 $601.28 $601.28 $755.47 $755.47 $876.56 $876.56 $819.90 $819.90 $702.07 $702.07

$626.85 $626.85 $628.66 $628.66 $789.88 $789.88 $916.49 $916.49 $857.24 $857.24 $734.05 $734.05

$640.39 $640.39 $642.23 $642.23 $806.93 $806.93 $936.27 $936.27 $875.75 $875.75 $749.89 $749.89

$667.69 $667.69 $669.62 $669.62 $841.34 $841.34 $976.19 $976.19 $913.09 $913.09 $781.87 $781.87

$691.31 $691.31 $693.31 $693.31 $871.10 $871.10 $1,010.72 $1,010.72 $945.39 $945.39 $809.53 $809.53

$706.81 $706.81 $708.85 $708.85 $890.63 $890.63 $1,033.38 $1,033.38 $966.59 $966.59 $827.68 $827.68

$726.25 $726.25 $728.34 $728.34 $915.12 $915.12 $1,061.80 $1,061.80 $993.17 $993.17 $850.44 $850.44

$738.06 $738.06 $740.19 $740.19 $930.00 $930.00 $1,079.07 $1,079.07 $1,009.32 $1,009.32 $864.27 $864.27

55957PA0280001 55957PA0280002 55957PA0280003 55957PA0280004 55957PA0300001 55957PA0300002

FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-AffordaBlue-1/1/16

FP-1-SG-X-AffordaBlue-1/1/16FP-1-SG-EHB-AffordaBlue-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3Rating Area 3

None None None None NoneNone

PPO PPO PPO PPO Tiered CustomPPO Tiered CustomPPO

Silver Gold Platinum GoldBronze BronzeBlueCare QHD PPO Bronze 4 BlueCare QHD PPO Silver 1 BlueCare QHD PPO Gold 1 AffordaBlue Platinum1 AffordaBlue Gold Option 1BlueCare QHD PPO Bronze 3

$4,750 $5,500 $2,000 $1,500 $250/ $750 $1,500/$2,000

100% 100%/70% 100%/70%60% 80% 80%60%*/60%* 80%*/80%* 80%*/80%* $20*/$40* $20/70%* / $40 /70%* $25/70%* / $50/70%*

$6,550 $6,550 $6,550 $3,100 $1,000/$5,000 $3,000/$4,000

No No No NoNo No

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51

52

53

54

55

56

57

58

59

60

61

62

63

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$240.22 $240.22 $229.60 $229.60 $188.51 $188.51

$378.31 $378.31 $361.58 $361.58 $296.87 $296.87

$378.31 $378.31 $361.58 $361.58 $296.87 $296.87

$378.31 $378.31 $361.58 $361.58 $296.87 $296.87

$378.31 $378.31 $361.58 $361.58 $296.87 $296.87

$379.82 $379.82 $363.02 $363.02 $298.05 $298.05

$387.38 $387.38 $370.25 $370.25 $303.99 $303.99

$396.46 $396.46 $378.93 $378.93 $311.11 $311.11

$411.22 $411.22 $393.03 $393.03 $322.69 $322.69

$423.32 $423.32 $404.60 $404.60 $332.19 $332.19

$429.38 $429.38 $410.39 $410.39 $336.94 $336.94

$438.46 $438.46 $419.07 $419.07 $344.07 $344.07

$447.54 $447.54 $427.74 $427.74 $351.19 $351.19

$453.21 $453.21 $433.17 $433.17 $355.65 $355.65

$459.26 $459.26 $438.95 $438.95 $360.40 $360.40

$462.29 $462.29 $441.85 $441.85 $362.77 $362.77

$465.32 $465.32 $444.74 $444.74 $365.15 $365.15

$468.34 $468.34 $447.63 $447.63 $367.52 $367.52

$471.37 $471.37 $450.52 $450.52 $369.90 $369.90

$477.42 $477.42 $456.31 $456.31 $374.64 $374.64

$483.48 $483.48 $462.09 $462.09 $379.39 $379.39

$492.55 $492.55 $470.77 $470.77 $386.52 $386.52

$501.26 $501.26 $479.09 $479.09 $393.35 $393.35

$513.36 $513.36 $490.66 $490.66 $402.85 $402.85

$528.49 $528.49 $505.12 $505.12 $414.72 $414.72

$546.27 $546.27 $522.12 $522.12 $428.68 $428.68

$567.46 $567.46 $542.37 $542.37 $445.30 $445.30

$591.29 $591.29 $565.14 $565.14 $464.00 $464.00

$618.53 $618.53 $591.18 $591.18 $485.38 $485.38

$645.39 $645.39 $616.85 $616.85 $506.46 $506.46

$675.66 $675.66 $645.78 $645.78 $530.20 $530.20

$705.54 $705.54 $674.34 $674.34 $553.66 $553.66

$738.46 $738.46 $705.80 $705.80 $579.49 $579.49

$771.75 $771.75 $737.62 $737.62 $605.61 $605.61

$807.69 $807.69 $771.97 $771.97 $633.81 $633.81

$843.63 $843.63 $806.32 $806.32 $662.02 $662.02

$882.59 $882.59 $843.56 $843.56 $692.59 $692.59

$921.94 $921.94 $881.17 $881.17 $723.47 $723.47

$963.93 $963.93 $921.30 $921.30 $756.42 $756.42

$984.74 $984.74 $941.19 $941.19 $772.75 $772.75

$1,026.73 $1,026.73 $981.32 $981.32 $805.70 $805.70

$1,063.05 $1,063.05 $1,016.03 $1,016.03 $834.20 $834.20

$1,086.88 $1,086.88 $1,038.81 $1,038.81 $852.90 $852.90

$1,116.77 $1,116.77 $1,067.38 $1,067.38 $876.36 $876.36

$1,134.93 $1,134.93 $1,084.74 $1,084.74 $890.61 $890.61

55957PA038000155957PA0370001 55957PA0370002

Rating Area 3 Rating Area 3Rating Area 3

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

PPO PPO PPO

Gold Gold SilverLehigh Valley Flex Blue PPO 1250G Lehigh Valley Flex Blue PPO Lehigh Valley Flex Blue PPO 500G

$3,000/$3,000$500/$1,500 $1,250/$3,750

100%/70% 100%/70% 90%/70%$10/$50 / $20/$75 $10/$50 / $20/$75 90%/70%* / 90%/70%*

$7,150/$7,150 $6,550/$6,550$7,150/$7,150

NoNo No

Page Number: 8 12/24/2014

RATE PAGES

Company Name: First Priority Life Insurance Compan

Market: Small Group

Product: PPO, CustomPPO, QHD PPO, AffordaBlue, Lehigh Valley Flex Blue

Effective Date of Rates: Ending date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

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

0 - 20 $284.20 $284.20 $286.12 $286.12 $284.36 $284.36 $281.10 $281.10 $257.01 $257.01 $236.65 $236.65

21 $447.56 $447.56 $450.59 $450.59 $447.82 $447.82 $442.69 $442.69 $404.75 $404.75 $372.68 $372.68

22 $447.56 $447.56 $450.59 $450.59 $447.82 $447.82 $442.69 $442.69 $404.75 $404.75 $372.68 $372.68

23 $447.56 $447.56 $450.59 $450.59 $447.82 $447.82 $442.69 $442.69 $404.75 $404.75 $372.68 $372.68

24 $447.56 $447.56 $450.59 $450.59 $447.82 $447.82 $442.69 $442.69 $404.75 $404.75 $372.68 $372.68

25 $449.35 $449.35 $452.39 $452.39 $449.61 $449.61 $444.46 $444.46 $406.36 $406.36 $374.17 $374.17

26 $458.30 $458.30 $461.40 $461.40 $458.56 $458.56 $453.31 $453.31 $414.46 $414.46 $381.62 $381.62

27 $469.04 $469.04 $472.21 $472.21 $469.31 $469.31 $463.93 $463.93 $424.17 $424.17 $390.56 $390.56

28 $486.49 $486.49 $489.79 $489.79 $486.78 $486.78 $481.20 $481.20 $439.96 $439.96 $405.10 $405.10

29 $500.81 $500.81 $504.21 $504.21 $501.11 $501.11 $495.37 $495.37 $452.91 $452.91 $417.02 $417.02

30 $507.98 $507.98 $511.41 $511.41 $508.27 $508.27 $502.45 $502.45 $459.39 $459.39 $422.99 $422.99

31 $518.72 $518.72 $522.23 $522.23 $519.02 $519.02 $513.07 $513.07 $469.10 $469.10 $431.93 $431.93

32 $529.46 $529.46 $533.04 $533.04 $529.77 $529.77 $523.70 $523.70 $478.81 $478.81 $440.88 $440.88

33 $536.17 $536.17 $539.80 $539.80 $536.48 $536.48 $530.34 $530.34 $484.89 $484.89 $446.47 $446.47

34 $543.33 $543.33 $547.01 $547.01 $543.65 $543.65 $537.42 $537.42 $491.36 $491.36 $452.43 $452.43

35 $546.91 $546.91 $550.62 $550.62 $547.23 $547.23 $540.96 $540.96 $494.60 $494.60 $455.41 $455.41

36 $550.49 $550.49 $554.22 $554.22 $550.81 $550.81 $544.50 $544.50 $497.84 $497.84 $458.39 $458.39

37 $554.07 $554.07 $557.83 $557.83 $554.40 $554.40 $548.05 $548.05 $501.08 $501.08 $461.37 $461.37

38 $557.65 $557.65 $561.43 $561.43 $557.98 $557.98 $551.59 $551.59 $504.31 $504.31 $464.35 $464.35

39 $564.82 $564.82 $568.64 $568.64 $565.14 $565.14 $558.67 $558.67 $510.79 $510.79 $470.32 $470.32

40 $571.98 $571.98 $575.85 $575.85 $572.31 $572.31 $565.75 $565.75 $517.27 $517.27 $476.28 $476.28

41 $582.72 $582.72 $586.66 $586.66 $583.06 $583.06 $576.38 $576.38 $526.98 $526.98 $485.22 $485.22

42 $593.01 $593.01 $597.03 $597.03 $593.36 $593.36 $586.56 $586.56 $536.29 $536.29 $493.80 $493.80

43 $607.33 $607.33 $611.45 $611.45 $607.69 $607.69 $600.73 $600.73 $549.24 $549.24 $505.72 $505.72

44 $625.24 $625.24 $629.47 $629.47 $625.60 $625.60 $618.43 $618.43 $565.43 $565.43 $520.63 $520.63

45 $646.27 $646.27 $650.65 $650.65 $646.65 $646.65 $639.24 $639.24 $584.45 $584.45 $538.14 $538.14

46 $671.34 $671.34 $675.88 $675.88 $671.73 $671.73 $664.03 $664.03 $607.12 $607.12 $559.02 $559.02

47 $699.53 $699.53 $704.27 $704.27 $699.94 $699.94 $691.92 $691.92 $632.62 $632.62 $582.49 $582.49

48 $731.76 $731.76 $736.71 $736.71 $732.18 $732.18 $723.79 $723.79 $661.76 $661.76 $609.33 $609.33

49 $763.53 $763.53 $768.70 $768.70 $763.98 $763.98 $755.22 $755.22 $690.50 $690.50 $635.79 $635.79

50 $799.34 $799.34 $804.75 $804.75 $799.80 $799.80 $790.64 $790.64 $722.88 $722.88 $665.60 $665.60

51 $834.69 $834.69 $840.35 $840.35 $835.18 $835.18 $825.61 $825.61 $754.85 $754.85 $695.04 $695.04

52 $873.63 $873.63 $879.55 $879.55 $874.14 $874.14 $864.13 $864.13 $790.07 $790.07 $727.47 $727.47

53 $913.02 $913.02 $919.20 $919.20 $913.55 $913.55 $903.08 $903.08 $825.69 $825.69 $760.26 $760.26

54 $955.54 $955.54 $962.00 $962.00 $956.09 $956.09 $945.14 $945.14 $864.14 $864.14 $795.67 $795.67

55 $998.05 $998.05 $1,004.81 $1,004.81 $998.63 $998.63 $987.19 $987.19 $902.59 $902.59 $831.07 $831.07

56 $1,044.15 $1,044.15 $1,051.22 $1,051.22 $1,044.76 $1,044.76 $1,032.79 $1,032.79 $944.28 $944.28 $869.46 $869.46

57 $1,090.70 $1,090.70 $1,098.08 $1,098.08 $1,091.33 $1,091.33 $1,078.83 $1,078.83 $986.37 $986.37 $908.22 $908.22

58 $1,140.38 $1,140.38 $1,148.10 $1,148.10 $1,141.04 $1,141.04 $1,127.97 $1,127.97 $1,031.30 $1,031.30 $949.58 $949.58

59 $1,164.99 $1,164.99 $1,172.88 $1,172.88 $1,165.67 $1,165.67 $1,152.32 $1,152.32 $1,053.56 $1,053.56 $970.08 $970.08

60 $1,214.67 $1,214.67 $1,222.90 $1,222.90 $1,215.38 $1,215.38 $1,201.46 $1,201.46 $1,098.49 $1,098.49 $1,011.45 $1,011.45

61 $1,257.64 $1,257.64 $1,266.15 $1,266.15 $1,258.37 $1,258.37 $1,243.95 $1,243.95 $1,137.34 $1,137.34 $1,047.23 $1,047.23

62 $1,285.83 $1,285.83 $1,294.54 $1,294.54 $1,286.58 $1,286.58 $1,271.84 $1,271.84 $1,162.84 $1,162.84 $1,070.70 $1,070.70

63 $1,321.19 $1,321.19 $1,330.14 $1,330.14 $1,321.96 $1,321.96 $1,306.82 $1,306.82 $1,194.82 $1,194.82 $1,100.15 $1,100.15

64+ $1,342.68 $1,342.68 $1,351.77 $1,351.77 $1,343.46 $1,343.46 $1,328.07 $1,328.07 $1,214.25 $1,214.25 $1,118.04 $1,118.04

April 1, 2017 June 30, 2017

55957PA0270007 55957PA0270016 55957PA0270002 55957PA0270006 55957PA0270017 55957PA0270018FP-1-SG-EHB PPO-1/1/16

FP-1-X-SG-PPO-1/1/16FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None

PPO PPO PPO PPO PPO PPO

Platinum Platinum Platinum Platinum Gold GoldBlueCare PPO Platinum 12 BlueCare PPO Platinum 13 BlueCare PPO Platinum 2 BlueCare PPO Platinum 11 BlueCare PPO Gold 27 BlueCare PPO Gold 15

$0 $250 $500 $750 $500 $1,000

100% 100% 100% 100% 100% 80%$25/$50 $10/$20 $10/$20 $10/$20 $20/$40 $20/$40

$2,500 $4,000 $2,000 $1,500 $6,000 $5,000

No No No No No No

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Network =>

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OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

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64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$240.64 $240.64 $240.87 $240.87 $244.91 $244.91 $235.02 $235.02 $201.97 $201.97 $192.11 $192.11

$378.97 $378.97 $379.33 $379.33 $385.70 $385.70 $370.12 $370.12 $318.07 $318.07 $302.55 $302.55

$378.97 $378.97 $379.33 $379.33 $385.70 $385.70 $370.12 $370.12 $318.07 $318.07 $302.55 $302.55

$378.97 $378.97 $379.33 $379.33 $385.70 $385.70 $370.12 $370.12 $318.07 $318.07 $302.55 $302.55

$378.97 $378.97 $379.33 $379.33 $385.70 $385.70 $370.12 $370.12 $318.07 $318.07 $302.55 $302.55

$380.48 $380.48 $380.84 $380.84 $387.24 $387.24 $371.60 $371.60 $319.34 $319.34 $303.76 $303.76

$388.06 $388.06 $388.43 $388.43 $394.95 $394.95 $379.00 $379.00 $325.70 $325.70 $309.81 $309.81

$397.16 $397.16 $397.53 $397.53 $404.21 $404.21 $387.88 $387.88 $333.33 $333.33 $317.07 $317.07

$411.94 $411.94 $412.33 $412.33 $419.25 $419.25 $402.32 $402.32 $345.74 $345.74 $328.87 $328.87

$424.06 $424.06 $424.47 $424.47 $431.59 $431.59 $414.16 $414.16 $355.92 $355.92 $338.55 $338.55

$430.13 $430.13 $430.53 $430.53 $437.76 $437.76 $420.08 $420.08 $361.00 $361.00 $343.39 $343.39

$439.22 $439.22 $439.64 $439.64 $447.02 $447.02 $428.96 $428.96 $368.64 $368.64 $350.65 $350.65

$448.32 $448.32 $448.74 $448.74 $456.28 $456.28 $437.85 $437.85 $376.27 $376.27 $357.91 $357.91

$454.00 $454.00 $454.43 $454.43 $462.06 $462.06 $443.40 $443.40 $381.04 $381.04 $362.45 $362.45

$460.06 $460.06 $460.50 $460.50 $468.23 $468.23 $449.32 $449.32 $386.13 $386.13 $367.29 $367.29

$463.10 $463.10 $463.54 $463.54 $471.32 $471.32 $452.28 $452.28 $388.68 $388.68 $369.71 $369.71

$466.13 $466.13 $466.57 $466.57 $474.41 $474.41 $455.24 $455.24 $391.22 $391.22 $372.13 $372.13

$469.16 $469.16 $469.61 $469.61 $477.49 $477.49 $458.20 $458.20 $393.77 $393.77 $374.55 $374.55

$472.19 $472.19 $472.64 $472.64 $480.58 $480.58 $461.16 $461.16 $396.31 $396.31 $376.97 $376.97

$478.26 $478.26 $478.71 $478.71 $486.75 $486.75 $467.09 $467.09 $401.40 $401.40 $381.81 $381.81

$484.32 $484.32 $484.78 $484.78 $492.92 $492.92 $473.01 $473.01 $406.49 $406.49 $386.65 $386.65

$493.41 $493.41 $493.88 $493.88 $502.18 $502.18 $481.89 $481.89 $414.12 $414.12 $393.92 $393.92

$502.13 $502.13 $502.61 $502.61 $511.05 $511.05 $490.40 $490.40 $421.44 $421.44 $400.87 $400.87

$514.26 $514.26 $514.75 $514.75 $523.39 $523.39 $502.25 $502.25 $431.62 $431.62 $410.56 $410.56

$529.42 $529.42 $529.92 $529.92 $538.82 $538.82 $517.05 $517.05 $444.34 $444.34 $422.66 $422.66

$547.23 $547.23 $547.75 $547.75 $556.95 $556.95 $534.45 $534.45 $459.29 $459.29 $436.88 $436.88

$568.45 $568.45 $568.99 $568.99 $578.55 $578.55 $555.18 $555.18 $477.10 $477.10 $453.82 $453.82

$592.33 $592.33 $592.89 $592.89 $602.84 $602.84 $578.49 $578.49 $497.14 $497.14 $472.88 $472.88

$619.61 $619.61 $620.20 $620.20 $630.61 $630.61 $605.14 $605.14 $520.04 $520.04 $494.66 $494.66

$646.52 $646.52 $647.13 $647.13 $658.00 $658.00 $631.42 $631.42 $542.62 $542.62 $516.15 $516.15

$676.84 $676.84 $677.48 $677.48 $688.86 $688.86 $661.03 $661.03 $568.07 $568.07 $540.35 $540.35

$706.77 $706.77 $707.45 $707.45 $719.33 $719.33 $690.27 $690.27 $593.20 $593.20 $564.25 $564.25

$739.74 $739.74 $740.45 $740.45 $752.88 $752.88 $722.47 $722.47 $620.87 $620.87 $590.57 $590.57

$773.09 $773.09 $773.83 $773.83 $786.82 $786.82 $755.04 $755.04 $648.86 $648.86 $617.20 $617.20

$809.10 $809.10 $809.86 $809.86 $823.46 $823.46 $790.20 $790.20 $679.07 $679.07 $645.94 $645.94

$845.10 $845.10 $845.90 $845.90 $860.11 $860.11 $825.36 $825.36 $709.29 $709.29 $674.68 $674.68

$884.13 $884.13 $884.97 $884.97 $899.83 $899.83 $863.48 $863.48 $742.05 $742.05 $705.84 $705.84

$923.54 $923.54 $924.42 $924.42 $939.95 $939.95 $901.98 $901.98 $775.13 $775.13 $737.31 $737.31

$965.61 $965.61 $966.53 $966.53 $982.76 $982.76 $943.06 $943.06 $810.44 $810.44 $770.89 $770.89

$986.45 $986.45 $987.39 $987.39 $1,003.97 $1,003.97 $963.42 $963.42 $827.93 $827.93 $787.53 $787.53

$1,028.52 $1,028.52 $1,029.50 $1,029.50 $1,046.78 $1,046.78 $1,004.50 $1,004.50 $863.24 $863.24 $821.12 $821.12

$1,064.90 $1,064.90 $1,065.91 $1,065.91 $1,083.81 $1,083.81 $1,040.03 $1,040.03 $893.77 $893.77 $850.16 $850.16

$1,088.78 $1,088.78 $1,089.81 $1,089.81 $1,108.11 $1,108.11 $1,063.35 $1,063.35 $913.81 $913.81 $869.22 $869.22

$1,118.71 $1,118.71 $1,119.78 $1,119.78 $1,138.58 $1,138.58 $1,092.59 $1,092.59 $938.94 $938.94 $893.12 $893.12

$1,136.91 $1,136.91 $1,137.99 $1,137.99 $1,157.10 $1,157.10 $1,110.36 $1,110.36 $954.21 $954.21 $907.65 $907.65

55957PA0270008 55957PA0270009 55957PA0270010 55957PA0270011 55957PA0270022

FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

55957PA0270019

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None

PPO PPO PPO PPO PPO PPO

Gold Gold Gold Gold Silver SilverBlueCare PPO Gold 12 BlueCare PPO Gold 24 BlueCare PPO Silver 10 BlueCare PPO Silver 2

$1,250 $1,500

BlueCare PPO Gold 18 BlueCare PPO Gold 19

$1,500 $2,000 - 1 per family $1,400 $1,750

100% 100% 90%100% 100% 90%$35/$60 $20/$40 $25/$50 $15/$30 $45/$75 $45/$65

$7,150 $7,150 $5,000 $6,000 - 1 per family $7,150 $7,150

No No No NoNo No

Page Number: 10 12/24/2014

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Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

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64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$204.15 $204.15 $202.01 $202.01 $162.71 $162.71 $238.72 $238.72 $240.34 $240.34 $238.86 $238.86

$321.51 $321.51 $318.14 $318.14 $256.24 $256.24 $375.95 $375.95 $378.50 $378.50 $376.17 $376.17

$321.51 $321.51 $318.14 $318.14 $256.24 $256.24 $375.95 $375.95 $378.50 $378.50 $376.17 $376.17

$321.51 $321.51 $318.14 $318.14 $256.24 $256.24 $375.95 $375.95 $378.50 $378.50 $376.17 $376.17

$321.51 $321.51 $318.14 $318.14 $256.24 $256.24 $375.95 $375.95 $378.50 $378.50 $376.17 $376.17

$322.79 $322.79 $319.41 $319.41 $257.26 $257.26 $377.45 $377.45 $380.01 $380.01 $377.67 $377.67

$329.22 $329.22 $325.77 $325.77 $262.38 $262.38 $384.97 $384.97 $387.58 $387.58 $385.19 $385.19

$336.94 $336.94 $333.41 $333.41 $268.53 $268.53 $393.99 $393.99 $396.66 $396.66 $394.22 $394.22

$349.48 $349.48 $345.81 $345.81 $278.53 $278.53 $408.65 $408.65 $411.42 $411.42 $408.89 $408.89

$359.76 $359.76 $355.99 $355.99 $286.73 $286.73 $420.68 $420.68 $423.54 $423.54 $420.93 $420.93

$364.91 $364.91 $361.08 $361.08 $290.83 $290.83 $426.70 $426.70 $429.59 $429.59 $426.95 $426.95

$372.63 $372.63 $368.72 $368.72 $296.98 $296.98 $435.72 $435.72 $438.68 $438.68 $435.98 $435.98

$380.34 $380.34 $376.35 $376.35 $303.13 $303.13 $444.74 $444.74 $447.76 $447.76 $445.00 $445.00

$385.16 $385.16 $381.13 $381.13 $306.97 $306.97 $450.38 $450.38 $453.44 $453.44 $450.65 $450.65

$390.31 $390.31 $386.22 $386.22 $311.07 $311.07 $456.40 $456.40 $459.49 $459.49 $456.67 $456.67

$392.88 $392.88 $388.76 $388.76 $313.12 $313.12 $459.41 $459.41 $462.52 $462.52 $459.67 $459.67

$395.45 $395.45 $391.31 $391.31 $315.17 $315.17 $462.41 $462.41 $465.55 $465.55 $462.68 $462.68

$398.02 $398.02 $393.85 $393.85 $317.22 $317.22 $465.42 $465.42 $468.58 $468.58 $465.69 $465.69

$400.60 $400.60 $396.40 $396.40 $319.27 $319.27 $468.43 $468.43 $471.61 $471.61 $468.70 $468.70

$405.74 $405.74 $401.49 $401.49 $323.37 $323.37 $474.44 $474.44 $477.66 $477.66 $474.72 $474.72

$410.88 $410.88 $406.58 $406.58 $327.47 $327.47 $480.46 $480.46 $483.72 $483.72 $480.74 $480.74

$418.60 $418.60 $414.21 $414.21 $333.62 $333.62 $489.48 $489.48 $492.80 $492.80 $489.77 $489.77

$426.00 $426.00 $421.53 $421.53 $339.51 $339.51 $498.13 $498.13 $501.51 $501.51 $498.42 $498.42

$436.28 $436.28 $431.71 $431.71 $347.71 $347.71 $510.16 $510.16 $513.62 $513.62 $510.46 $510.46

$449.14 $449.14 $444.44 $444.44 $357.96 $357.96 $525.20 $525.20 $528.76 $528.76 $525.50 $525.50

$464.26 $464.26 $459.39 $459.39 $370.01 $370.01 $542.87 $542.87 $546.55 $546.55 $543.18 $543.18

$482.26 $482.26 $477.21 $477.21 $384.36 $384.36 $563.92 $563.92 $567.75 $567.75 $564.25 $564.25

$502.52 $502.52 $497.25 $497.25 $400.50 $400.50 $587.60 $587.60 $591.59 $591.59 $587.95 $587.95

$525.66 $525.66 $520.15 $520.15 $418.95 $418.95 $614.67 $614.67 $618.84 $618.84 $615.03 $615.03

$548.49 $548.49 $542.74 $542.74 $437.14 $437.14 $641.37 $641.37 $645.72 $645.72 $641.74 $641.74

$574.21 $574.21 $568.19 $568.19 $457.64 $457.64 $671.44 $671.44 $676.00 $676.00 $671.83 $671.83

$599.61 $599.61 $593.33 $593.33 $477.88 $477.88 $701.14 $701.14 $705.90 $705.90 $701.55 $701.55

$627.58 $627.58 $621.00 $621.00 $500.18 $500.18 $733.85 $733.85 $738.83 $738.83 $734.28 $734.28

$655.88 $655.88 $649.00 $649.00 $522.72 $522.72 $766.93 $766.93 $772.14 $772.14 $767.38 $767.38

$686.42 $686.42 $679.22 $679.22 $547.07 $547.07 $802.65 $802.65 $808.09 $808.09 $803.12 $803.12

$716.96 $716.96 $709.45 $709.45 $571.41 $571.41 $838.36 $838.36 $844.05 $844.05 $838.85 $838.85

$750.08 $750.08 $742.22 $742.22 $597.80 $597.80 $877.09 $877.09 $883.04 $883.04 $877.60 $877.60

$783.51 $783.51 $775.30 $775.30 $624.45 $624.45 $916.19 $916.19 $922.40 $922.40 $916.72 $916.72

$819.20 $819.20 $810.62 $810.62 $652.89 $652.89 $957.92 $957.92 $964.41 $964.41 $958.48 $958.48

$836.89 $836.89 $828.11 $828.11 $666.99 $666.99 $978.59 $978.59 $985.23 $985.23 $979.17 $979.17

$872.57 $872.57 $863.43 $863.43 $695.43 $695.43 $1,020.32 $1,020.32 $1,027.24 $1,027.24 $1,020.92 $1,020.92

$903.44 $903.44 $893.97 $893.97 $720.03 $720.03 $1,056.41 $1,056.41 $1,063.58 $1,063.58 $1,057.03 $1,057.03

$923.69 $923.69 $914.01 $914.01 $736.17 $736.17 $1,080.10 $1,080.10 $1,087.43 $1,087.43 $1,080.73 $1,080.73

$949.09 $949.09 $939.14 $939.14 $756.42 $756.42 $1,109.80 $1,109.80 $1,117.33 $1,117.33 $1,110.45 $1,110.45

$964.53 $964.53 $954.42 $954.42 $768.72 $768.72 $1,127.85 $1,127.85 $1,135.50 $1,135.50 $1,128.51 $1,128.51

55957PA029000255957PA0270020 55957PA0270021 55957PA0270013 55957PA0290007 55957PA0290008

FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

Rating Area 3

FP-1-SG-EHB-CustomPPO-1/1/16

FP-1-X-SG-CustomPPO-1/1/16FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None NoneNone None

PPO PPO PPO CustomPPO CustomPPO CustomPPO

Silver Silver BronzeBlueCare PPO Silver 9 BlueCare PPO Bronze 4 BlueCare Custom PPO Platinum 12 BlueCare Custom PPO Platinum 13 BlueCare Custom PPO Platinum 2BlueCare PPO Silver 6

Platinum Platinum Platinum

$5,000 $0 $250 $500$2,500 $4,000

90% 100% 50% 100% 100% 100%$25/$50 $25/$50 50%*/50%* $25/$50 $10/$20 $10/$20

$7,000 $7,150 $2,500 $4,000 $2,000$7,150

No No No No No No

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$236.13 $236.13 $215.89 $215.89 $198.79 $198.79 $202.13 $202.13 $202.33 $202.33 $205.73 $205.73

$371.86 $371.86 $339.99 $339.99 $313.06 $313.06 $318.33 $318.33 $318.64 $318.64 $323.99 $323.99

$371.86 $371.86 $339.99 $339.99 $313.06 $313.06 $318.33 $318.33 $318.64 $318.64 $323.99 $323.99

$371.86 $371.86 $339.99 $339.99 $313.06 $313.06 $318.33 $318.33 $318.64 $318.64 $323.99 $323.99

$371.86 $371.86 $339.99 $339.99 $313.06 $313.06 $318.33 $318.33 $318.64 $318.64 $323.99 $323.99

$373.34 $373.34 $341.34 $341.34 $314.31 $314.31 $319.60 $319.60 $319.91 $319.91 $325.28 $325.28

$380.78 $380.78 $348.14 $348.14 $320.57 $320.57 $325.96 $325.96 $326.28 $326.28 $331.76 $331.76

$389.70 $389.70 $356.30 $356.30 $328.08 $328.08 $333.60 $333.60 $333.93 $333.93 $339.54 $339.54

$404.21 $404.21 $369.56 $369.56 $340.29 $340.29 $346.02 $346.02 $346.36 $346.36 $352.17 $352.17

$416.11 $416.11 $380.44 $380.44 $350.31 $350.31 $356.21 $356.21 $356.55 $356.55 $362.54 $362.54

$422.06 $422.06 $385.88 $385.88 $355.32 $355.32 $361.30 $361.30 $361.65 $361.65 $367.72 $367.72

$430.98 $430.98 $394.04 $394.04 $362.83 $362.83 $368.94 $368.94 $369.30 $369.30 $375.50 $375.50

$439.91 $439.91 $402.20 $402.20 $370.34 $370.34 $376.58 $376.58 $376.95 $376.95 $383.28 $383.28

$445.48 $445.48 $407.30 $407.30 $375.04 $375.04 $381.35 $381.35 $381.73 $381.73 $388.14 $388.14

$451.43 $451.43 $412.74 $412.74 $380.05 $380.05 $386.45 $386.45 $386.82 $386.82 $393.32 $393.32

$454.41 $454.41 $415.46 $415.46 $382.55 $382.55 $388.99 $388.99 $389.37 $389.37 $395.91 $395.91

$457.38 $457.38 $418.18 $418.18 $385.06 $385.06 $391.54 $391.54 $391.92 $391.92 $398.50 $398.50

$460.36 $460.36 $420.90 $420.90 $387.56 $387.56 $394.09 $394.09 $394.47 $394.47 $401.09 $401.09

$463.33 $463.33 $423.62 $423.62 $390.07 $390.07 $396.63 $396.63 $397.02 $397.02 $403.69 $403.69

$469.28 $469.28 $429.06 $429.06 $395.08 $395.08 $401.73 $401.73 $402.12 $402.12 $408.87 $408.87

$475.23 $475.23 $434.50 $434.50 $400.09 $400.09 $406.82 $406.82 $407.22 $407.22 $414.05 $414.05

$484.16 $484.16 $442.66 $442.66 $407.60 $407.60 $414.46 $414.46 $414.86 $414.86 $421.83 $421.83

$492.71 $492.71 $450.48 $450.48 $414.80 $414.80 $421.78 $421.78 $422.19 $422.19 $429.28 $429.28

$504.61 $504.61 $461.36 $461.36 $424.82 $424.82 $431.97 $431.97 $432.39 $432.39 $439.65 $439.65

$519.48 $519.48 $474.96 $474.96 $437.34 $437.34 $444.70 $444.70 $445.14 $445.14 $452.61 $452.61

$536.96 $536.96 $490.94 $490.94 $452.05 $452.05 $459.66 $459.66 $460.11 $460.11 $467.84 $467.84

$557.79 $557.79 $509.98 $509.98 $469.59 $469.59 $477.49 $477.49 $477.96 $477.96 $485.98 $485.98

$581.21 $581.21 $531.40 $531.40 $489.31 $489.31 $497.54 $497.54 $498.03 $498.03 $506.39 $506.39

$607.99 $607.99 $555.88 $555.88 $511.85 $511.85 $520.46 $520.46 $520.97 $520.97 $529.72 $529.72

$634.39 $634.39 $580.02 $580.02 $534.08 $534.08 $543.07 $543.07 $543.59 $543.59 $552.72 $552.72

$664.14 $664.14 $607.22 $607.22 $559.12 $559.12 $568.53 $568.53 $569.09 $569.09 $578.64 $578.64

$693.51 $693.51 $634.08 $634.08 $583.85 $583.85 $593.68 $593.68 $594.26 $594.26 $604.24 $604.24

$725.87 $725.87 $663.66 $663.66 $611.09 $611.09 $621.38 $621.38 $621.98 $621.98 $632.42 $632.42

$758.59 $758.59 $693.57 $693.57 $638.64 $638.64 $649.39 $649.39 $650.02 $650.02 $660.93 $660.93

$793.92 $793.92 $725.87 $725.87 $668.38 $668.38 $679.63 $679.63 $680.29 $680.29 $691.71 $691.71

$829.24 $829.24 $758.17 $758.17 $698.12 $698.12 $709.87 $709.87 $710.56 $710.56 $722.49 $722.49

$867.54 $867.54 $793.19 $793.19 $730.36 $730.36 $742.66 $742.66 $743.38 $743.38 $755.86 $755.86

$906.22 $906.22 $828.55 $828.55 $762.92 $762.92 $775.77 $775.77 $776.52 $776.52 $789.56 $789.56

$947.49 $947.49 $866.29 $866.29 $797.67 $797.67 $811.10 $811.10 $811.89 $811.89 $825.52 $825.52

$967.95 $967.95 $884.99 $884.99 $814.89 $814.89 $828.61 $828.61 $829.41 $829.41 $843.34 $843.34

$1,009.22 $1,009.22 $922.73 $922.73 $849.64 $849.64 $863.94 $863.94 $864.78 $864.78 $879.30 $879.30

$1,044.92 $1,044.92 $955.37 $955.37 $879.69 $879.69 $894.50 $894.50 $895.37 $895.37 $910.41 $910.41

$1,068.35 $1,068.35 $976.79 $976.79 $899.42 $899.42 $914.56 $914.56 $915.45 $915.45 $930.82 $930.82

$1,097.73 $1,097.73 $1,003.65 $1,003.65 $924.15 $924.15 $939.71 $939.71 $940.62 $940.62 $956.41 $956.41

$1,115.58 $1,115.58 $1,019.97 $1,019.97 $939.18 $939.18 $954.99 $954.99 $955.92 $955.92 $971.97 $971.97

55957PA029001455957PA0290006 55957PA0290022 55957PA0290012 55957PA0290011 55957PA0290013

FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3Rating Area 3

None None None None None None

Rating Area 3 Rating Area 3

CustomPPO CustomPPO CustomPPOCustomPPO CustomPPO CustomPPO

BlueCare Custom PPO Gold 12 BlueCare Custom PPO Gold 18 BlueCare Custom PPO Gold 19BlueCare Custom PPO Gold 27 BlueCare Custom PPO Gold 15BlueCare Custom PPO Platinum 11Platinum Gold Gold Gold Gold Gold

$750 $500 $1,000 $1,250 $1,500 $1,500

100% 100% 90%100% 100% 80%$20/$40 $35/$60 $20/$40 $25/$50$10/$20 $20/$40

$1,500 $6,000 $5,000 $7,150 $7,150 $5,000

No No No NoNo No

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$197.50 $197.50 $169.65 $169.65 $161.37 $161.37 $171.49 $171.49 $169.69 $169.69 $136.67 $136.67

$311.03 $311.03 $267.18 $267.18 $254.14 $254.14 $270.07 $270.07 $267.23 $267.23 $215.24 $215.24

$311.03 $311.03 $267.18 $267.18 $254.14 $254.14 $270.07 $270.07 $267.23 $267.23 $215.24 $215.24

$311.03 $311.03 $267.18 $267.18 $254.14 $254.14 $270.07 $270.07 $267.23 $267.23 $215.24 $215.24

$311.03 $311.03 $267.18 $267.18 $254.14 $254.14 $270.07 $270.07 $267.23 $267.23 $215.24 $215.24

$312.27 $312.27 $268.24 $268.24 $255.15 $255.15 $271.15 $271.15 $268.29 $268.29 $216.10 $216.10

$318.49 $318.49 $273.59 $273.59 $260.23 $260.23 $276.55 $276.55 $273.64 $273.64 $220.40 $220.40

$325.95 $325.95 $280.00 $280.00 $266.33 $266.33 $283.03 $283.03 $280.05 $280.05 $225.57 $225.57

$338.08 $338.08 $290.42 $290.42 $276.25 $276.25 $293.56 $293.56 $290.47 $290.47 $233.96 $233.96

$348.04 $348.04 $298.97 $298.97 $284.38 $284.38 $302.20 $302.20 $299.03 $299.03 $240.85 $240.85

$353.01 $353.01 $303.24 $303.24 $288.44 $288.44 $306.52 $306.52 $303.30 $303.30 $244.29 $244.29

$360.48 $360.48 $309.66 $309.66 $294.54 $294.54 $313.01 $313.01 $309.71 $309.71 $249.46 $249.46

$367.94 $367.94 $316.07 $316.07 $300.64 $300.64 $319.49 $319.49 $316.13 $316.13 $254.62 $254.62

$372.61 $372.61 $320.08 $320.08 $304.45 $304.45 $323.54 $323.54 $320.14 $320.14 $257.85 $257.85

$377.59 $377.59 $324.35 $324.35 $308.52 $308.52 $327.86 $327.86 $324.41 $324.41 $261.30 $261.30

$380.07 $380.07 $326.49 $326.49 $310.55 $310.55 $330.02 $330.02 $326.55 $326.55 $263.02 $263.02

$382.56 $382.56 $328.63 $328.63 $312.59 $312.59 $332.18 $332.18 $328.69 $328.69 $264.74 $264.74

$385.05 $385.05 $330.76 $330.76 $314.62 $314.62 $334.34 $334.34 $330.83 $330.83 $266.46 $266.46

$387.54 $387.54 $332.90 $332.90 $316.65 $316.65 $336.50 $336.50 $332.96 $332.96 $268.18 $268.18

$392.51 $392.51 $337.18 $337.18 $320.72 $320.72 $340.82 $340.82 $337.24 $337.24 $271.63 $271.63

$397.49 $397.49 $341.45 $341.45 $324.79 $324.79 $345.14 $345.14 $341.51 $341.51 $275.07 $275.07

$404.96 $404.96 $347.86 $347.86 $330.89 $330.89 $351.63 $351.63 $347.93 $347.93 $280.24 $280.24

$412.11 $412.11 $354.01 $354.01 $336.73 $336.73 $357.84 $357.84 $354.07 $354.07 $285.19 $285.19

$422.06 $422.06 $362.56 $362.56 $344.86 $344.86 $366.48 $366.48 $362.63 $362.63 $292.08 $292.08

$434.50 $434.50 $373.25 $373.25 $355.03 $355.03 $377.28 $377.28 $373.32 $373.32 $300.69 $300.69

$449.12 $449.12 $385.80 $385.80 $366.97 $366.97 $389.98 $389.98 $385.88 $385.88 $310.80 $310.80

$466.54 $466.54 $400.77 $400.77 $381.21 $381.21 $405.10 $405.10 $400.84 $400.84 $322.86 $322.86

$486.13 $486.13 $417.60 $417.60 $397.22 $397.22 $422.11 $422.11 $417.68 $417.68 $336.42 $336.42

$508.53 $508.53 $436.83 $436.83 $415.51 $415.51 $441.56 $441.56 $436.92 $436.92 $351.91 $351.91

$530.61 $530.61 $455.80 $455.80 $433.56 $433.56 $460.73 $460.73 $455.89 $455.89 $367.19 $367.19

$555.49 $555.49 $477.18 $477.18 $453.89 $453.89 $482.34 $482.34 $477.27 $477.27 $384.41 $384.41

$580.07 $580.07 $498.29 $498.29 $473.97 $473.97 $503.68 $503.68 $498.38 $498.38 $401.42 $401.42

$607.13 $607.13 $521.53 $521.53 $496.08 $496.08 $527.17 $527.17 $521.63 $521.63 $420.14 $420.14

$634.50 $634.50 $545.04 $545.04 $518.44 $518.44 $550.94 $550.94 $545.14 $545.14 $439.08 $439.08

$664.04 $664.04 $570.42 $570.42 $542.58 $542.58 $576.59 $576.59 $570.53 $570.53 $459.53 $459.53

$693.59 $693.59 $595.81 $595.81 $566.73 $566.73 $602.25 $602.25 $595.92 $595.92 $479.98 $479.98

$725.63 $725.63 $623.33 $623.33 $592.90 $592.90 $630.07 $630.07 $623.44 $623.44 $502.15 $502.15

$757.98 $757.98 $651.11 $651.11 $619.33 $619.33 $658.16 $658.16 $651.23 $651.23 $524.53 $524.53

$792.50 $792.50 $680.77 $680.77 $647.54 $647.54 $688.13 $688.13 $680.90 $680.90 $548.43 $548.43

$809.61 $809.61 $695.46 $695.46 $661.52 $661.52 $702.99 $702.99 $695.59 $695.59 $560.26 $560.26

$844.13 $844.13 $725.12 $725.12 $689.73 $689.73 $732.96 $732.96 $725.26 $725.26 $584.16 $584.16

$873.99 $873.99 $750.77 $750.77 $714.13 $714.13 $758.89 $758.89 $750.91 $750.91 $604.82 $604.82

$893.58 $893.58 $767.60 $767.60 $730.14 $730.14 $775.91 $775.91 $767.75 $767.75 $618.38 $618.38

$918.16 $918.16 $788.71 $788.71 $750.22 $750.22 $797.24 $797.24 $788.86 $788.86 $635.38 $635.38

$933.09 $933.09 $801.54 $801.54 $762.42 $762.42 $810.21 $810.21 $801.69 $801.69 $645.72 $645.72

55957PA029002155957PA0290016 55957PA0290023 55957PA0290017 55957PA0290018 55957PA0290019

FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None

CustomPPO CustomPPO CustomPPOCustomPPO CustomPPO CustomPPO

BlueCare Custom PPO Gold 24Gold Silver Silver Silver Silver Bronze

BlueCare Custom PPO Silver 10 BlueCare Custom PPO Silver 2 BlueCare Custom PPO Silver 6 BlueCare Custom PPO Silver 9 BlueCare Custom PPO Bronze 4

$4,000 $5,000$2,000 - 1 per family $1,400 $1,750 $2,500

100% 100% 90% 90% 100% 50%$15/$30 $45/$75 $45/$65 $25/$50 $25/$50 50%*/50%*

$7,150 $7,000 $7,150$6,000 - 1 per family $7,150 $7,150

No No No No No No

Page Number: 13 12/24/2014

RATE PAGES

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HIOS Plan ID (Off Exchange)=>

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Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

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64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$160.66 $160.66 $161.13 $161.13 $202.45 $202.45 $234.90 $234.90 $219.72 $219.72 $188.15 $188.15

$253.02 $253.02 $253.75 $253.75 $318.83 $318.83 $369.93 $369.93 $346.02 $346.02 $296.30 $296.30

$253.02 $253.02 $253.75 $253.75 $318.83 $318.83 $369.93 $369.93 $346.02 $346.02 $296.30 $296.30

$253.02 $253.02 $253.75 $253.75 $318.83 $318.83 $369.93 $369.93 $346.02 $346.02 $296.30 $296.30

$253.02 $253.02 $253.75 $253.75 $318.83 $318.83 $369.93 $369.93 $346.02 $346.02 $296.30 $296.30

$254.03 $254.03 $254.76 $254.76 $320.10 $320.10 $371.40 $371.40 $347.40 $347.40 $297.48 $297.48

$259.09 $259.09 $259.84 $259.84 $326.48 $326.48 $378.80 $378.80 $354.32 $354.32 $303.41 $303.41

$265.16 $265.16 $265.93 $265.93 $334.13 $334.13 $387.68 $387.68 $362.62 $362.62 $310.52 $310.52

$275.03 $275.03 $275.82 $275.82 $346.56 $346.56 $402.11 $402.11 $376.12 $376.12 $322.07 $322.07

$283.12 $283.12 $283.94 $283.94 $356.77 $356.77 $413.95 $413.95 $387.19 $387.19 $331.55 $331.55

$287.17 $287.17 $288.00 $288.00 $361.87 $361.87 $419.87 $419.87 $392.73 $392.73 $336.30 $336.30

$293.25 $293.25 $294.09 $294.09 $369.52 $369.52 $428.74 $428.74 $401.03 $401.03 $343.41 $343.41

$299.32 $299.32 $300.18 $300.18 $377.17 $377.17 $437.62 $437.62 $409.34 $409.34 $350.52 $350.52

$303.11 $303.11 $303.99 $303.99 $381.95 $381.95 $443.17 $443.17 $414.53 $414.53 $354.96 $354.96

$307.16 $307.16 $308.05 $308.05 $387.05 $387.05 $449.09 $449.09 $420.06 $420.06 $359.70 $359.70

$309.19 $309.19 $310.08 $310.08 $389.61 $389.61 $452.05 $452.05 $422.83 $422.83 $362.07 $362.07

$311.21 $311.21 $312.11 $312.11 $392.16 $392.16 $455.01 $455.01 $425.60 $425.60 $364.44 $364.44

$313.23 $313.23 $314.14 $314.14 $394.71 $394.71 $457.97 $457.97 $428.37 $428.37 $366.81 $366.81

$315.26 $315.26 $316.17 $316.17 $397.26 $397.26 $460.93 $460.93 $431.14 $431.14 $369.18 $369.18

$319.31 $319.31 $320.23 $320.23 $402.36 $402.36 $466.85 $466.85 $436.67 $436.67 $373.93 $373.93

$323.35 $323.35 $324.29 $324.29 $407.46 $407.46 $472.77 $472.77 $442.21 $442.21 $378.67 $378.67

$329.43 $329.43 $330.38 $330.38 $415.11 $415.11 $481.64 $481.64 $450.51 $450.51 $385.78 $385.78

$335.25 $335.25 $336.21 $336.21 $422.44 $422.44 $490.15 $490.15 $458.47 $458.47 $392.59 $392.59

$343.34 $343.34 $344.33 $344.33 $432.65 $432.65 $501.99 $501.99 $469.54 $469.54 $402.07 $402.07

$353.46 $353.46 $354.48 $354.48 $445.40 $445.40 $516.79 $516.79 $483.38 $483.38 $413.93 $413.93

$365.36 $365.36 $366.41 $366.41 $460.39 $460.39 $534.17 $534.17 $499.65 $499.65 $427.85 $427.85

$379.53 $379.53 $380.62 $380.62 $478.24 $478.24 $554.89 $554.89 $519.03 $519.03 $444.45 $444.45

$395.47 $395.47 $396.61 $396.61 $498.33 $498.33 $578.20 $578.20 $540.82 $540.82 $463.11 $463.11

$413.68 $413.68 $414.88 $414.88 $521.28 $521.28 $604.83 $604.83 $565.74 $565.74 $484.45 $484.45

$431.65 $431.65 $432.89 $432.89 $543.92 $543.92 $631.10 $631.10 $590.31 $590.31 $505.48 $505.48

$451.89 $451.89 $453.19 $453.19 $569.43 $569.43 $660.69 $660.69 $617.99 $617.99 $529.19 $529.19

$471.88 $471.88 $473.24 $473.24 $594.61 $594.61 $689.91 $689.91 $645.32 $645.32 $552.59 $552.59

$493.89 $493.89 $495.32 $495.32 $622.35 $622.35 $722.10 $722.10 $675.43 $675.43 $578.37 $578.37

$516.16 $516.16 $517.65 $517.65 $650.41 $650.41 $754.65 $754.65 $705.88 $705.88 $604.45 $604.45

$540.19 $540.19 $541.75 $541.75 $680.70 $680.70 $789.80 $789.80 $738.75 $738.75 $632.60 $632.60

$564.23 $564.23 $565.86 $565.86 $710.99 $710.99 $824.94 $824.94 $771.62 $771.62 $660.74 $660.74

$590.29 $590.29 $591.99 $591.99 $743.83 $743.83 $863.04 $863.04 $807.26 $807.26 $691.26 $691.26

$616.60 $616.60 $618.38 $618.38 $776.98 $776.98 $901.51 $901.51 $843.25 $843.25 $722.08 $722.08

$644.69 $644.69 $646.55 $646.55 $812.37 $812.37 $942.58 $942.58 $881.65 $881.65 $754.97 $754.97

$658.61 $658.61 $660.51 $660.51 $829.91 $829.91 $962.92 $962.92 $900.69 $900.69 $771.26 $771.26

$686.69 $686.69 $688.67 $688.67 $865.30 $865.30 $1,003.99 $1,003.99 $939.09 $939.09 $804.15 $804.15

$710.98 $710.98 $713.03 $713.03 $895.91 $895.91 $1,039.50 $1,039.50 $972.31 $972.31 $832.60 $832.60

$726.92 $726.92 $729.02 $729.02 $915.99 $915.99 $1,062.80 $1,062.80 $994.11 $994.11 $851.26 $851.26

$746.91 $746.91 $749.07 $749.07 $941.18 $941.18 $1,092.03 $1,092.03 $1,021.45 $1,021.45 $874.67 $874.67

$759.06 $759.06 $761.25 $761.25 $956.49 $956.49 $1,109.79 $1,109.79 $1,038.06 $1,038.06 $888.90 $888.90

55957PA0280001 55957PA0280002 55957PA0280003 55957PA0280004 55957PA0300001 55957PA0300002

FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-AffordaBlue-1/1/16

FP-1-SG-X-AffordaBlue-1/1/16FP-1-SG-EHB-AffordaBlue-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3Rating Area 3

None None None None NoneNone

PPO PPO PPO PPO Tiered CustomPPO Tiered CustomPPO

Silver Gold Platinum GoldBronze BronzeBlueCare QHD PPO Bronze 4 BlueCare QHD PPO Silver 1 BlueCare QHD PPO Gold 1 AffordaBlue Platinum1 AffordaBlue Gold Option 1BlueCare QHD PPO Bronze 3

$4,750 $5,500 $2,000 $1,500 $250/ $750 $1,500/$2,000

100% 100%/70% 100%/70%60% 80% 80%60%*/60%* 80%*/80%* 80%*/80%* $20*/$40* $20/70%* / $40 /70%* $25/70%* / $50/70%*

$6,550 $6,550 $6,550 $3,100 $1,000/$5,000 $3,000/$4,000

No No No NoNo No

Page Number: 14 12/24/2014

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Network =>

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OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

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64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$247.07 $247.07 $236.14 $236.14 $193.87 $193.87

$389.09 $389.09 $371.88 $371.88 $305.32 $305.32

$389.09 $389.09 $371.88 $371.88 $305.32 $305.32

$389.09 $389.09 $371.88 $371.88 $305.32 $305.32

$389.09 $389.09 $371.88 $371.88 $305.32 $305.32

$390.64 $390.64 $373.36 $373.36 $306.54 $306.54

$398.42 $398.42 $380.80 $380.80 $312.64 $312.64

$407.76 $407.76 $389.73 $389.73 $319.97 $319.97

$422.94 $422.94 $404.23 $404.23 $331.88 $331.88

$435.39 $435.39 $416.13 $416.13 $341.65 $341.65

$441.61 $441.61 $422.08 $422.08 $346.53 $346.53

$450.95 $450.95 $431.00 $431.00 $353.86 $353.86

$460.29 $460.29 $439.93 $439.93 $361.19 $361.19

$466.12 $466.12 $445.51 $445.51 $365.77 $365.77

$472.35 $472.35 $451.46 $451.46 $370.65 $370.65

$475.46 $475.46 $454.43 $454.43 $373.10 $373.10

$478.58 $478.58 $457.41 $457.41 $375.54 $375.54

$481.69 $481.69 $460.38 $460.38 $377.98 $377.98

$484.80 $484.80 $463.36 $463.36 $380.42 $380.42

$491.03 $491.03 $469.31 $469.31 $385.31 $385.31

$497.25 $497.25 $475.26 $475.26 $390.19 $390.19

$506.59 $506.59 $484.18 $484.18 $397.52 $397.52

$515.54 $515.54 $492.74 $492.74 $404.54 $404.54

$527.99 $527.99 $504.64 $504.64 $414.31 $414.31

$543.55 $543.55 $519.51 $519.51 $426.53 $426.53

$561.84 $561.84 $536.99 $536.99 $440.88 $440.88

$583.63 $583.63 $557.82 $557.82 $457.98 $457.98

$608.14 $608.14 $581.24 $581.24 $477.21 $477.21

$636.16 $636.16 $608.02 $608.02 $499.19 $499.19

$663.78 $663.78 $634.42 $634.42 $520.87 $520.87

$694.91 $694.91 $664.17 $664.17 $545.30 $545.30

$725.65 $725.65 $693.55 $693.55 $569.42 $569.42

$759.50 $759.50 $725.90 $725.90 $595.98 $595.98

$793.74 $793.74 $758.63 $758.63 $622.85 $622.85

$830.70 $830.70 $793.96 $793.96 $651.85 $651.85

$867.67 $867.67 $829.29 $829.29 $680.86 $680.86

$907.74 $907.74 $867.59 $867.59 $712.31 $712.31

$948.21 $948.21 $906.27 $906.27 $744.06 $744.06

$991.40 $991.40 $947.55 $947.55 $777.95 $777.95

$1,012.80 $1,012.80 $968.00 $968.00 $794.74 $794.74

$1,055.99 $1,055.99 $1,009.28 $1,009.28 $828.63 $828.63

$1,093.34 $1,093.34 $1,044.98 $1,044.98 $857.94 $857.94

$1,117.85 $1,117.85 $1,068.41 $1,068.41 $877.18 $877.18

$1,148.59 $1,148.59 $1,097.78 $1,097.78 $901.30 $901.30

$1,167.27 $1,167.27 $1,115.64 $1,115.64 $915.96 $915.96

55957PA038000155957PA0370001 55957PA0370002

Rating Area 3 Rating Area 3Rating Area 3

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

PPO PPO PPO

Gold Gold SilverLehigh Valley Flex Blue PPO 1250G Lehigh Valley Flex Blue PPO Lehigh Valley Flex Blue PPO 500G

$3,000/$3,000$500/$1,500 $1,250/$3,750

100%/70% 100%/70% 90%/70%$10/$50 / $20/$75 $10/$50 / $20/$75 90%/70%* / 90%/70%*

$7,150/$7,150 $6,550/$6,550$7,150/$7,150

NoNo No

Page Number: 15 12/24/2014

RATE PAGES

Company Name: First Priority Life Insurance Compan

Market: Small Group

Product: PPO, CustomPPO, QHD PPO, AffordaBlue, Lehigh Valley Flex Blue

Effective Date of Rates: Ending date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

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Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

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

0 - 20 $292.31 $292.31 $294.29 $294.29 $292.49 $292.49 $289.14 $289.14 $264.35 $264.35 $243.41 $243.41

21 $460.34 $460.34 $463.46 $463.46 $460.62 $460.62 $455.34 $455.34 $416.31 $416.31 $383.33 $383.33

22 $460.34 $460.34 $463.46 $463.46 $460.62 $460.62 $455.34 $455.34 $416.31 $416.31 $383.33 $383.33

23 $460.34 $460.34 $463.46 $463.46 $460.62 $460.62 $455.34 $455.34 $416.31 $416.31 $383.33 $383.33

24 $460.34 $460.34 $463.46 $463.46 $460.62 $460.62 $455.34 $455.34 $416.31 $416.31 $383.33 $383.33

25 $462.18 $462.18 $465.31 $465.31 $462.46 $462.46 $457.16 $457.16 $417.97 $417.97 $384.86 $384.86

26 $471.38 $471.38 $474.58 $474.58 $471.67 $471.67 $466.26 $466.26 $426.30 $426.30 $392.52 $392.52

27 $482.43 $482.43 $485.70 $485.70 $482.72 $482.72 $477.19 $477.19 $436.29 $436.29 $401.72 $401.72

28 $500.38 $500.38 $503.78 $503.78 $500.69 $500.69 $494.95 $494.95 $452.52 $452.52 $416.67 $416.67

29 $515.12 $515.12 $518.61 $518.61 $515.43 $515.43 $509.52 $509.52 $465.85 $465.85 $428.94 $428.94

30 $522.48 $522.48 $526.02 $526.02 $522.80 $522.80 $516.81 $516.81 $472.51 $472.51 $435.07 $435.07

31 $533.53 $533.53 $537.15 $537.15 $533.85 $533.85 $527.73 $527.73 $482.50 $482.50 $444.27 $444.27

32 $544.58 $544.58 $548.27 $548.27 $544.91 $544.91 $538.66 $538.66 $492.49 $492.49 $453.47 $453.47

33 $551.48 $551.48 $555.22 $555.22 $551.82 $551.82 $545.49 $545.49 $498.73 $498.73 $459.22 $459.22

34 $558.85 $558.85 $562.64 $562.64 $559.19 $559.19 $552.78 $552.78 $505.40 $505.40 $465.36 $465.36

35 $562.53 $562.53 $566.34 $566.34 $562.87 $562.87 $556.42 $556.42 $508.73 $508.73 $468.42 $468.42

36 $566.21 $566.21 $570.05 $570.05 $566.56 $566.56 $560.06 $560.06 $512.06 $512.06 $471.49 $471.49

37 $569.90 $569.90 $573.76 $573.76 $570.24 $570.24 $563.71 $563.71 $515.39 $515.39 $474.56 $474.56

38 $573.58 $573.58 $577.47 $577.47 $573.93 $573.93 $567.35 $567.35 $518.72 $518.72 $477.62 $477.62

39 $580.94 $580.94 $584.88 $584.88 $581.30 $581.30 $574.63 $574.63 $525.38 $525.38 $483.76 $483.76

40 $588.31 $588.31 $592.30 $592.30 $588.67 $588.67 $581.92 $581.92 $532.04 $532.04 $489.89 $489.89

41 $599.36 $599.36 $603.42 $603.42 $599.72 $599.72 $592.85 $592.85 $542.03 $542.03 $499.09 $499.09

42 $609.95 $609.95 $614.08 $614.08 $610.32 $610.32 $603.32 $603.32 $551.61 $551.61 $507.91 $507.91

43 $624.68 $624.68 $628.91 $628.91 $625.06 $625.06 $617.89 $617.89 $564.93 $564.93 $520.17 $520.17

44 $643.09 $643.09 $647.45 $647.45 $643.48 $643.48 $636.10 $636.10 $581.58 $581.58 $535.51 $535.51

45 $664.73 $664.73 $669.23 $669.23 $665.13 $665.13 $657.51 $657.51 $601.15 $601.15 $553.52 $553.52

46 $690.51 $690.51 $695.19 $695.19 $690.93 $690.93 $683.01 $683.01 $624.46 $624.46 $574.99 $574.99

47 $719.51 $719.51 $724.38 $724.38 $719.94 $719.94 $711.69 $711.69 $650.69 $650.69 $599.14 $599.14

48 $752.65 $752.65 $757.75 $757.75 $753.11 $753.11 $744.48 $744.48 $680.66 $680.66 $626.74 $626.74

49 $785.34 $785.34 $790.66 $790.66 $785.81 $785.81 $776.81 $776.81 $710.22 $710.22 $653.96 $653.96

50 $822.16 $822.16 $827.73 $827.73 $822.66 $822.66 $813.23 $813.23 $743.52 $743.52 $684.62 $684.62

51 $858.53 $858.53 $864.35 $864.35 $859.05 $859.05 $849.20 $849.20 $776.41 $776.41 $714.91 $714.91

52 $898.58 $898.58 $904.67 $904.67 $899.13 $899.13 $888.82 $888.82 $812.63 $812.63 $748.26 $748.26

53 $939.09 $939.09 $945.45 $945.45 $939.66 $939.66 $928.89 $928.89 $849.27 $849.27 $781.99 $781.99

54 $982.82 $982.82 $989.48 $989.48 $983.42 $983.42 $972.15 $972.15 $888.82 $888.82 $818.40 $818.40

55 $1,026.55 $1,026.55 $1,033.51 $1,033.51 $1,027.18 $1,027.18 $1,015.40 $1,015.40 $928.37 $928.37 $854.82 $854.82

56 $1,073.97 $1,073.97 $1,081.25 $1,081.25 $1,074.62 $1,074.62 $1,062.30 $1,062.30 $971.25 $971.25 $894.30 $894.30

57 $1,121.84 $1,121.84 $1,129.45 $1,129.45 $1,122.53 $1,122.53 $1,109.66 $1,109.66 $1,014.54 $1,014.54 $934.17 $934.17

58 $1,172.94 $1,172.94 $1,180.89 $1,180.89 $1,173.65 $1,173.65 $1,160.20 $1,160.20 $1,060.75 $1,060.75 $976.72 $976.72

59 $1,198.26 $1,198.26 $1,206.38 $1,206.38 $1,198.99 $1,198.99 $1,185.25 $1,185.25 $1,083.65 $1,083.65 $997.80 $997.80

60 $1,249.36 $1,249.36 $1,257.83 $1,257.83 $1,250.12 $1,250.12 $1,235.79 $1,235.79 $1,129.86 $1,129.86 $1,040.35 $1,040.35

61 $1,293.55 $1,293.55 $1,302.32 $1,302.32 $1,294.34 $1,294.34 $1,279.50 $1,279.50 $1,169.83 $1,169.83 $1,077.15 $1,077.15

62 $1,322.55 $1,322.55 $1,331.52 $1,331.52 $1,323.36 $1,323.36 $1,308.19 $1,308.19 $1,196.05 $1,196.05 $1,101.30 $1,101.30

63 $1,358.92 $1,358.92 $1,368.13 $1,368.13 $1,359.75 $1,359.75 $1,344.16 $1,344.16 $1,228.94 $1,228.94 $1,131.59 $1,131.59

64+ $1,381.02 $1,381.02 $1,390.38 $1,390.38 $1,381.86 $1,381.86 $1,366.02 $1,366.02 $1,248.93 $1,248.93 $1,149.99 $1,149.99

July 1, 2017 September 30, 2017

55957PA0270007 55957PA0270016 55957PA0270002 55957PA0270006 55957PA0270017 55957PA0270018FP-1-SG-EHB PPO-1/1/16

FP-1-X-SG-PPO-1/1/16FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None

PPO PPO PPO PPO PPO PPO

Platinum Platinum Platinum Platinum Gold GoldBlueCare PPO Platinum 12 BlueCare PPO Platinum 13 BlueCare PPO Platinum 2 BlueCare PPO Platinum 11 BlueCare PPO Gold 27 BlueCare PPO Gold 15

$0 $250 $500 $750 $500 $1,000

100% 100% 100% 100% 100% 80%$25/$50 $10/$20 $10/$20 $10/$20 $20/$40 $20/$40

$2,500 $4,000 $2,000 $1,500 $6,000 $5,000

No No No No No No

Page Number: 16 12/24/2014

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$247.51 $247.51 $247.75 $247.75 $251.91 $251.91 $241.74 $241.74 $207.74 $207.74 $197.60 $197.60

$389.79 $389.79 $390.17 $390.17 $396.72 $396.72 $380.70 $380.70 $327.16 $327.16 $311.19 $311.19

$389.79 $389.79 $390.17 $390.17 $396.72 $396.72 $380.70 $380.70 $327.16 $327.16 $311.19 $311.19

$389.79 $389.79 $390.17 $390.17 $396.72 $396.72 $380.70 $380.70 $327.16 $327.16 $311.19 $311.19

$389.79 $389.79 $390.17 $390.17 $396.72 $396.72 $380.70 $380.70 $327.16 $327.16 $311.19 $311.19

$391.34 $391.34 $391.73 $391.73 $398.30 $398.30 $382.22 $382.22 $328.46 $328.46 $312.43 $312.43

$399.14 $399.14 $399.53 $399.53 $406.24 $406.24 $389.83 $389.83 $335.01 $335.01 $318.65 $318.65

$408.49 $408.49 $408.89 $408.89 $415.76 $415.76 $398.97 $398.97 $342.86 $342.86 $326.12 $326.12

$423.70 $423.70 $424.11 $424.11 $431.23 $431.23 $413.82 $413.82 $355.62 $355.62 $338.26 $338.26

$436.17 $436.17 $436.60 $436.60 $443.92 $443.92 $426.00 $426.00 $366.09 $366.09 $348.22 $348.22

$442.41 $442.41 $442.84 $442.84 $450.27 $450.27 $432.09 $432.09 $371.32 $371.32 $353.20 $353.20

$451.76 $451.76 $452.20 $452.20 $459.79 $459.79 $441.23 $441.23 $379.17 $379.17 $360.66 $360.66

$461.12 $461.12 $461.57 $461.57 $469.31 $469.31 $450.36 $450.36 $387.03 $387.03 $368.13 $368.13

$466.96 $466.96 $467.42 $467.42 $475.27 $475.27 $456.07 $456.07 $391.93 $391.93 $372.80 $372.80

$473.20 $473.20 $473.66 $473.66 $481.61 $481.61 $462.16 $462.16 $397.17 $397.17 $377.78 $377.78

$476.32 $476.32 $476.78 $476.78 $484.79 $484.79 $465.21 $465.21 $399.78 $399.78 $380.27 $380.27

$479.44 $479.44 $479.90 $479.90 $487.96 $487.96 $468.26 $468.26 $402.40 $402.40 $382.76 $382.76

$482.56 $482.56 $483.03 $483.03 $491.13 $491.13 $471.30 $471.30 $405.02 $405.02 $385.25 $385.25

$485.67 $485.67 $486.15 $486.15 $494.31 $494.31 $474.35 $474.35 $407.64 $407.64 $387.74 $387.74

$491.91 $491.91 $492.39 $492.39 $500.66 $500.66 $480.44 $480.44 $412.87 $412.87 $392.72 $392.72

$498.15 $498.15 $498.63 $498.63 $507.00 $507.00 $486.53 $486.53 $418.11 $418.11 $397.70 $397.70

$507.50 $507.50 $508.00 $508.00 $516.52 $516.52 $495.67 $495.67 $425.96 $425.96 $405.16 $405.16

$516.47 $516.47 $516.97 $516.97 $525.65 $525.65 $504.42 $504.42 $433.48 $433.48 $412.32 $412.32

$528.94 $528.94 $529.46 $529.46 $538.34 $538.34 $516.60 $516.60 $443.95 $443.95 $422.28 $422.28

$544.53 $544.53 $545.06 $545.06 $554.21 $554.21 $531.83 $531.83 $457.04 $457.04 $434.73 $434.73

$562.85 $562.85 $563.40 $563.40 $572.86 $572.86 $549.73 $549.73 $472.41 $472.41 $449.35 $449.35

$584.68 $584.68 $585.25 $585.25 $595.08 $595.08 $571.05 $571.05 $490.74 $490.74 $466.78 $466.78

$609.24 $609.24 $609.83 $609.83 $620.07 $620.07 $595.03 $595.03 $511.35 $511.35 $486.38 $486.38

$637.30 $637.30 $637.92 $637.92 $648.63 $648.63 $622.44 $622.44 $534.90 $534.90 $508.79 $508.79

$664.98 $664.98 $665.63 $665.63 $676.80 $676.80 $649.47 $649.47 $558.13 $558.13 $530.89 $530.89

$696.16 $696.16 $696.84 $696.84 $708.54 $708.54 $679.93 $679.93 $584.30 $584.30 $555.78 $555.78

$726.95 $726.95 $727.66 $727.66 $739.88 $739.88 $710.00 $710.00 $610.15 $610.15 $580.36 $580.36

$760.87 $760.87 $761.61 $761.61 $774.39 $774.39 $743.12 $743.12 $638.61 $638.61 $607.44 $607.44

$795.17 $795.17 $795.94 $795.94 $809.30 $809.30 $776.62 $776.62 $667.40 $667.40 $634.82 $634.82

$832.20 $832.20 $833.01 $833.01 $846.99 $846.99 $812.79 $812.79 $698.48 $698.48 $664.39 $664.39

$869.23 $869.23 $870.07 $870.07 $884.68 $884.68 $848.96 $848.96 $729.56 $729.56 $693.95 $693.95

$909.38 $909.38 $910.26 $910.26 $925.54 $925.54 $888.17 $888.17 $763.26 $763.26 $726.00 $726.00

$949.91 $949.91 $950.84 $950.84 $966.80 $966.80 $927.76 $927.76 $797.28 $797.28 $758.37 $758.37

$993.18 $993.18 $994.15 $994.15 $1,010.84 $1,010.84 $970.02 $970.02 $833.60 $833.60 $792.91 $792.91

$1,014.62 $1,014.62 $1,015.61 $1,015.61 $1,032.66 $1,032.66 $990.96 $990.96 $851.59 $851.59 $810.02 $810.02

$1,057.89 $1,057.89 $1,058.92 $1,058.92 $1,076.69 $1,076.69 $1,033.21 $1,033.21 $887.91 $887.91 $844.56 $844.56

$1,095.30 $1,095.30 $1,096.37 $1,096.37 $1,114.78 $1,114.78 $1,069.76 $1,069.76 $919.31 $919.31 $874.44 $874.44

$1,119.86 $1,119.86 $1,120.95 $1,120.95 $1,139.77 $1,139.77 $1,093.75 $1,093.75 $939.93 $939.93 $894.04 $894.04

$1,150.66 $1,150.66 $1,151.78 $1,151.78 $1,171.11 $1,171.11 $1,123.82 $1,123.82 $965.77 $965.77 $918.63 $918.63

$1,169.37 $1,169.37 $1,170.51 $1,170.51 $1,190.16 $1,190.16 $1,142.10 $1,142.10 $981.48 $981.48 $933.57 $933.57

55957PA0270008 55957PA0270009 55957PA0270010 55957PA0270011 55957PA0270022

FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

55957PA0270019

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None

PPO PPO PPO PPO PPO PPO

Gold Gold Gold Gold Silver SilverBlueCare PPO Gold 12 BlueCare PPO Gold 24 BlueCare PPO Silver 10 BlueCare PPO Silver 2

$1,250 $1,500

BlueCare PPO Gold 18 BlueCare PPO Gold 19

$1,500 $2,000 - 1 per family $1,400 $1,750

100% 100% 90%100% 100% 90%$35/$60 $20/$40 $25/$50 $15/$30 $45/$75 $45/$65

$7,150 $7,150 $5,000 $6,000 - 1 per family $7,150 $7,150

No No No NoNo No

Page Number: 17 12/24/2014

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Pediatric Dental (Yes/No) =>

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$209.98 $209.98 $207.78 $207.78 $167.36 $167.36 $245.54 $245.54 $247.21 $247.21 $245.69 $245.69

$330.69 $330.69 $327.22 $327.22 $263.56 $263.56 $386.69 $386.69 $389.31 $389.31 $386.92 $386.92

$330.69 $330.69 $327.22 $327.22 $263.56 $263.56 $386.69 $386.69 $389.31 $389.31 $386.92 $386.92

$330.69 $330.69 $327.22 $327.22 $263.56 $263.56 $386.69 $386.69 $389.31 $389.31 $386.92 $386.92

$330.69 $330.69 $327.22 $327.22 $263.56 $263.56 $386.69 $386.69 $389.31 $389.31 $386.92 $386.92

$332.01 $332.01 $328.52 $328.52 $264.61 $264.61 $388.23 $388.23 $390.86 $390.86 $388.46 $388.46

$338.62 $338.62 $335.07 $335.07 $269.88 $269.88 $395.97 $395.97 $398.65 $398.65 $396.20 $396.20

$346.56 $346.56 $342.92 $342.92 $276.21 $276.21 $405.25 $405.25 $407.99 $407.99 $405.49 $405.49

$359.46 $359.46 $355.68 $355.68 $286.48 $286.48 $420.33 $420.33 $423.17 $423.17 $420.58 $420.58

$370.04 $370.04 $366.15 $366.15 $294.92 $294.92 $432.70 $432.70 $435.63 $435.63 $432.96 $432.96

$375.33 $375.33 $371.39 $371.39 $299.14 $299.14 $438.89 $438.89 $441.86 $441.86 $439.15 $439.15

$383.26 $383.26 $379.24 $379.24 $305.46 $305.46 $448.17 $448.17 $451.21 $451.21 $448.44 $448.44

$391.20 $391.20 $387.10 $387.10 $311.79 $311.79 $457.45 $457.45 $460.55 $460.55 $457.72 $457.72

$396.16 $396.16 $392.00 $392.00 $315.74 $315.74 $463.25 $463.25 $466.39 $466.39 $463.53 $463.53

$401.45 $401.45 $397.24 $397.24 $319.96 $319.96 $469.44 $469.44 $472.62 $472.62 $469.72 $469.72

$404.10 $404.10 $399.86 $399.86 $322.07 $322.07 $472.53 $472.53 $475.73 $475.73 $472.81 $472.81

$406.74 $406.74 $402.48 $402.48 $324.17 $324.17 $475.62 $475.62 $478.85 $478.85 $475.91 $475.91

$409.39 $409.39 $405.09 $405.09 $326.28 $326.28 $478.72 $478.72 $481.96 $481.96 $479.00 $479.00

$412.03 $412.03 $407.71 $407.71 $328.39 $328.39 $481.81 $481.81 $485.08 $485.08 $482.10 $482.10

$417.33 $417.33 $412.95 $412.95 $332.61 $332.61 $488.00 $488.00 $491.30 $491.30 $488.29 $488.29

$422.62 $422.62 $418.18 $418.18 $336.82 $336.82 $494.18 $494.18 $497.53 $497.53 $494.48 $494.48

$430.55 $430.55 $426.04 $426.04 $343.15 $343.15 $503.47 $503.47 $506.88 $506.88 $503.76 $503.76

$438.16 $438.16 $433.56 $433.56 $349.21 $349.21 $512.36 $512.36 $515.83 $515.83 $512.66 $512.66

$448.74 $448.74 $444.03 $444.03 $357.65 $357.65 $524.73 $524.73 $528.29 $528.29 $525.05 $525.05

$461.97 $461.97 $457.12 $457.12 $368.19 $368.19 $540.20 $540.20 $543.86 $543.86 $540.52 $540.52

$477.51 $477.51 $472.50 $472.50 $380.58 $380.58 $558.38 $558.38 $562.16 $562.16 $558.71 $558.71

$496.03 $496.03 $490.83 $490.83 $395.34 $395.34 $580.03 $580.03 $583.96 $583.96 $580.38 $580.38

$516.86 $516.86 $511.44 $511.44 $411.94 $411.94 $604.39 $604.39 $608.49 $608.49 $604.75 $604.75

$540.67 $540.67 $535.00 $535.00 $430.92 $430.92 $632.23 $632.23 $636.52 $636.52 $632.61 $632.61

$564.15 $564.15 $558.23 $558.23 $449.63 $449.63 $659.69 $659.69 $664.16 $664.16 $660.08 $660.08

$590.61 $590.61 $584.41 $584.41 $470.71 $470.71 $690.62 $690.62 $695.30 $695.30 $691.03 $691.03

$616.73 $616.73 $610.26 $610.26 $491.53 $491.53 $721.17 $721.17 $726.06 $726.06 $721.60 $721.60

$645.50 $645.50 $638.73 $638.73 $514.46 $514.46 $754.81 $754.81 $759.93 $759.93 $755.26 $755.26

$674.60 $674.60 $667.52 $667.52 $537.66 $537.66 $788.84 $788.84 $794.19 $794.19 $789.31 $789.31

$706.02 $706.02 $698.61 $698.61 $562.70 $562.70 $825.58 $825.58 $831.17 $831.17 $826.07 $826.07

$737.43 $737.43 $729.70 $729.70 $587.73 $587.73 $862.31 $862.31 $868.16 $868.16 $862.83 $862.83

$771.49 $771.49 $763.40 $763.40 $614.88 $614.88 $902.14 $902.14 $908.26 $908.26 $902.68 $902.68

$805.89 $805.89 $797.43 $797.43 $642.29 $642.29 $942.36 $942.36 $948.74 $948.74 $942.92 $942.92

$842.59 $842.59 $833.75 $833.75 $671.55 $671.55 $985.28 $985.28 $991.96 $991.96 $985.87 $985.87

$860.78 $860.78 $851.75 $851.75 $686.04 $686.04 $1,006.55 $1,006.55 $1,013.37 $1,013.37 $1,007.15 $1,007.15

$897.49 $897.49 $888.07 $888.07 $715.30 $715.30 $1,049.47 $1,049.47 $1,056.58 $1,056.58 $1,050.10 $1,050.10

$929.23 $929.23 $919.48 $919.48 $740.60 $740.60 $1,086.59 $1,086.59 $1,093.96 $1,093.96 $1,087.24 $1,087.24

$950.07 $950.07 $940.10 $940.10 $757.20 $757.20 $1,110.96 $1,110.96 $1,118.48 $1,118.48 $1,111.62 $1,111.62

$976.19 $976.19 $965.95 $965.95 $778.02 $778.02 $1,141.50 $1,141.50 $1,149.24 $1,149.24 $1,142.18 $1,142.18

$992.07 $992.07 $981.66 $981.66 $790.68 $790.68 $1,160.07 $1,160.07 $1,167.93 $1,167.93 $1,160.76 $1,160.76

55957PA029000255957PA0270020 55957PA0270021 55957PA0270013 55957PA0290007 55957PA0290008

FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

Rating Area 3

FP-1-SG-EHB-CustomPPO-1/1/16

FP-1-X-SG-CustomPPO-1/1/16FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None NoneNone None

PPO PPO PPO CustomPPO CustomPPO CustomPPO

Silver Silver BronzeBlueCare PPO Silver 9 BlueCare PPO Bronze 4 BlueCare Custom PPO Platinum 12 BlueCare Custom PPO Platinum 13 BlueCare Custom PPO Platinum 2BlueCare PPO Silver 6

Platinum Platinum Platinum

$5,000 $0 $250 $500$2,500 $4,000

90% 100% 50% 100% 100% 100%$25/$50 $25/$50 50%*/50%* $25/$50 $10/$20 $10/$20

$7,000 $7,150 $2,500 $4,000 $2,000$7,150

No No No No No No

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$242.87 $242.87 $222.05 $222.05 $204.47 $204.47 $207.91 $207.91 $208.11 $208.11 $211.61 $211.61

$382.48 $382.48 $349.70 $349.70 $322.00 $322.00 $327.43 $327.43 $327.74 $327.74 $333.25 $333.25

$382.48 $382.48 $349.70 $349.70 $322.00 $322.00 $327.43 $327.43 $327.74 $327.74 $333.25 $333.25

$382.48 $382.48 $349.70 $349.70 $322.00 $322.00 $327.43 $327.43 $327.74 $327.74 $333.25 $333.25

$382.48 $382.48 $349.70 $349.70 $322.00 $322.00 $327.43 $327.43 $327.74 $327.74 $333.25 $333.25

$384.00 $384.00 $351.09 $351.09 $323.28 $323.28 $328.73 $328.73 $329.05 $329.05 $334.58 $334.58

$391.65 $391.65 $358.09 $358.09 $329.72 $329.72 $335.28 $335.28 $335.60 $335.60 $341.24 $341.24

$400.83 $400.83 $366.48 $366.48 $337.45 $337.45 $343.14 $343.14 $343.47 $343.47 $349.24 $349.24

$415.75 $415.75 $380.12 $380.12 $350.01 $350.01 $355.91 $355.91 $356.25 $356.25 $362.24 $362.24

$427.99 $427.99 $391.31 $391.31 $360.31 $360.31 $366.39 $366.39 $366.74 $366.74 $372.90 $372.90

$434.11 $434.11 $396.90 $396.90 $365.47 $365.47 $371.63 $371.63 $371.98 $371.98 $378.23 $378.23

$443.29 $443.29 $405.30 $405.30 $373.19 $373.19 $379.49 $379.49 $379.85 $379.85 $386.23 $386.23

$452.47 $452.47 $413.69 $413.69 $380.92 $380.92 $387.34 $387.34 $387.71 $387.71 $394.23 $394.23

$458.21 $458.21 $418.94 $418.94 $385.75 $385.75 $392.26 $392.26 $392.63 $392.63 $399.23 $399.23

$464.33 $464.33 $424.53 $424.53 $390.90 $390.90 $397.50 $397.50 $397.87 $397.87 $404.56 $404.56

$467.39 $467.39 $427.33 $427.33 $393.48 $393.48 $400.11 $400.11 $400.49 $400.49 $407.23 $407.23

$470.45 $470.45 $430.13 $430.13 $396.06 $396.06 $402.73 $402.73 $403.12 $403.12 $409.89 $409.89

$473.51 $473.51 $432.92 $432.92 $398.63 $398.63 $405.35 $405.35 $405.74 $405.74 $412.56 $412.56

$476.57 $476.57 $435.72 $435.72 $401.21 $401.21 $407.97 $407.97 $408.36 $408.36 $415.22 $415.22

$482.68 $482.68 $441.32 $441.32 $406.36 $406.36 $413.21 $413.21 $413.60 $413.60 $420.56 $420.56

$488.80 $488.80 $446.91 $446.91 $411.51 $411.51 $418.45 $418.45 $418.85 $418.85 $425.89 $425.89

$497.98 $497.98 $455.30 $455.30 $419.24 $419.24 $426.31 $426.31 $426.71 $426.71 $433.89 $433.89

$506.78 $506.78 $463.35 $463.35 $426.65 $426.65 $433.84 $433.84 $434.25 $434.25 $441.55 $441.55

$519.02 $519.02 $474.54 $474.54 $436.95 $436.95 $444.32 $444.32 $444.74 $444.74 $452.22 $452.22

$534.32 $534.32 $488.53 $488.53 $449.83 $449.83 $457.41 $457.41 $457.85 $457.85 $465.55 $465.55

$552.30 $552.30 $504.96 $504.96 $464.96 $464.96 $472.80 $472.80 $473.25 $473.25 $481.21 $481.21

$573.72 $573.72 $524.55 $524.55 $483.00 $483.00 $491.14 $491.14 $491.61 $491.61 $499.87 $499.87

$597.81 $597.81 $546.58 $546.58 $503.28 $503.28 $511.77 $511.77 $512.25 $512.25 $520.86 $520.86

$625.35 $625.35 $571.75 $571.75 $526.47 $526.47 $535.34 $535.34 $535.85 $535.85 $544.86 $544.86

$652.51 $652.51 $596.58 $596.58 $549.33 $549.33 $558.59 $558.59 $559.12 $559.12 $568.52 $568.52

$683.10 $683.10 $624.56 $624.56 $575.09 $575.09 $584.78 $584.78 $585.34 $585.34 $595.18 $595.18

$713.32 $713.32 $652.19 $652.19 $600.53 $600.53 $610.65 $610.65 $611.23 $611.23 $621.51 $621.51

$746.60 $746.60 $682.61 $682.61 $628.54 $628.54 $639.14 $639.14 $639.74 $639.74 $650.50 $650.50

$780.25 $780.25 $713.38 $713.38 $656.88 $656.88 $667.95 $667.95 $668.58 $668.58 $679.83 $679.83

$816.59 $816.59 $746.60 $746.60 $687.47 $687.47 $699.06 $699.06 $699.72 $699.72 $711.48 $711.48

$852.93 $852.93 $779.83 $779.83 $718.06 $718.06 $730.16 $730.16 $730.86 $730.86 $743.14 $743.14

$892.32 $892.32 $815.85 $815.85 $751.22 $751.22 $763.89 $763.89 $764.61 $764.61 $777.47 $777.47

$932.10 $932.10 $852.21 $852.21 $784.71 $784.71 $797.94 $797.94 $798.70 $798.70 $812.13 $812.13

$974.55 $974.55 $891.03 $891.03 $820.45 $820.45 $834.29 $834.29 $835.08 $835.08 $849.12 $849.12

$995.59 $995.59 $910.26 $910.26 $838.16 $838.16 $852.30 $852.30 $853.10 $853.10 $867.44 $867.44

$1,038.05 $1,038.05 $949.08 $949.08 $873.90 $873.90 $888.64 $888.64 $889.48 $889.48 $904.44 $904.44

$1,074.76 $1,074.76 $982.65 $982.65 $904.82 $904.82 $920.07 $920.07 $920.94 $920.94 $936.43 $936.43

$1,098.86 $1,098.86 $1,004.68 $1,004.68 $925.10 $925.10 $940.70 $940.70 $941.59 $941.59 $957.42 $957.42

$1,129.08 $1,129.08 $1,032.31 $1,032.31 $950.54 $950.54 $966.57 $966.57 $967.48 $967.48 $983.75 $983.75

$1,147.44 $1,147.44 $1,049.10 $1,049.10 $966.00 $966.00 $982.29 $982.29 $983.22 $983.22 $999.75 $999.75

55957PA029001455957PA0290006 55957PA0290022 55957PA0290012 55957PA0290011 55957PA0290013

FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3Rating Area 3

None None None None None None

Rating Area 3 Rating Area 3

CustomPPO CustomPPO CustomPPOCustomPPO CustomPPO CustomPPO

BlueCare Custom PPO Gold 12 BlueCare Custom PPO Gold 18 BlueCare Custom PPO Gold 19BlueCare Custom PPO Gold 27 BlueCare Custom PPO Gold 15BlueCare Custom PPO Platinum 11Platinum Gold Gold Gold Gold Gold

$750 $500 $1,000 $1,250 $1,500 $1,500

100% 100% 90%100% 100% 80%$20/$40 $35/$60 $20/$40 $25/$50$10/$20 $20/$40

$1,500 $6,000 $5,000 $7,150 $7,150 $5,000

No No No NoNo No

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$203.14 $203.14 $174.50 $174.50 $165.98 $165.98 $176.39 $176.39 $174.54 $174.54 $140.58 $140.58

$319.92 $319.92 $274.81 $274.81 $261.40 $261.40 $277.78 $277.78 $274.87 $274.87 $221.39 $221.39

$319.92 $319.92 $274.81 $274.81 $261.40 $261.40 $277.78 $277.78 $274.87 $274.87 $221.39 $221.39

$319.92 $319.92 $274.81 $274.81 $261.40 $261.40 $277.78 $277.78 $274.87 $274.87 $221.39 $221.39

$319.92 $319.92 $274.81 $274.81 $261.40 $261.40 $277.78 $277.78 $274.87 $274.87 $221.39 $221.39

$321.19 $321.19 $275.90 $275.90 $262.44 $262.44 $278.89 $278.89 $275.96 $275.96 $222.27 $222.27

$327.59 $327.59 $281.40 $281.40 $267.67 $267.67 $284.44 $284.44 $281.46 $281.46 $226.70 $226.70

$335.27 $335.27 $288.00 $288.00 $273.94 $273.94 $291.11 $291.11 $288.06 $288.06 $232.01 $232.01

$347.75 $347.75 $298.71 $298.71 $284.14 $284.14 $301.94 $301.94 $298.78 $298.78 $240.65 $240.65

$357.99 $357.99 $307.51 $307.51 $292.50 $292.50 $310.83 $310.83 $307.57 $307.57 $247.73 $247.73

$363.10 $363.10 $311.90 $311.90 $296.68 $296.68 $315.28 $315.28 $311.97 $311.97 $251.27 $251.27

$370.78 $370.78 $318.50 $318.50 $302.96 $302.96 $321.94 $321.94 $318.57 $318.57 $256.59 $256.59

$378.46 $378.46 $325.10 $325.10 $309.23 $309.23 $328.61 $328.61 $325.17 $325.17 $261.90 $261.90

$383.26 $383.26 $329.22 $329.22 $313.15 $313.15 $332.78 $332.78 $329.29 $329.29 $265.22 $265.22

$388.38 $388.38 $333.61 $333.61 $317.33 $317.33 $337.22 $337.22 $333.69 $333.69 $268.76 $268.76

$390.94 $390.94 $335.81 $335.81 $319.43 $319.43 $339.44 $339.44 $335.89 $335.89 $270.53 $270.53

$393.50 $393.50 $338.01 $338.01 $321.52 $321.52 $341.66 $341.66 $338.09 $338.09 $272.30 $272.30

$396.06 $396.06 $340.21 $340.21 $323.61 $323.61 $343.89 $343.89 $340.28 $340.28 $274.08 $274.08

$398.62 $398.62 $342.41 $342.41 $325.70 $325.70 $346.11 $346.11 $342.48 $342.48 $275.85 $275.85

$403.73 $403.73 $346.81 $346.81 $329.88 $329.88 $350.55 $350.55 $346.88 $346.88 $279.39 $279.39

$408.85 $408.85 $351.20 $351.20 $334.06 $334.06 $355.00 $355.00 $351.28 $351.28 $282.93 $282.93

$416.53 $416.53 $357.80 $357.80 $340.34 $340.34 $361.66 $361.66 $357.88 $357.88 $288.24 $288.24

$423.89 $423.89 $364.12 $364.12 $346.35 $346.35 $368.05 $368.05 $364.20 $364.20 $293.34 $293.34

$434.13 $434.13 $372.91 $372.91 $354.71 $354.71 $376.94 $376.94 $372.99 $372.99 $300.42 $300.42

$446.92 $446.92 $383.90 $383.90 $365.17 $365.17 $388.05 $388.05 $383.99 $383.99 $309.28 $309.28

$461.96 $461.96 $396.82 $396.82 $377.46 $377.46 $401.11 $401.11 $396.91 $396.91 $319.68 $319.68

$479.88 $479.88 $412.21 $412.21 $392.10 $392.10 $416.67 $416.67 $412.30 $412.30 $332.08 $332.08

$500.03 $500.03 $429.52 $429.52 $408.56 $408.56 $434.17 $434.17 $429.62 $429.62 $346.03 $346.03

$523.06 $523.06 $449.31 $449.31 $427.38 $427.38 $454.17 $454.17 $449.41 $449.41 $361.97 $361.97

$545.78 $545.78 $468.82 $468.82 $445.94 $445.94 $473.89 $473.89 $468.92 $468.92 $377.69 $377.69

$571.37 $571.37 $490.81 $490.81 $466.86 $466.86 $496.11 $496.11 $490.91 $490.91 $395.40 $395.40

$596.65 $596.65 $512.52 $512.52 $487.51 $487.51 $518.05 $518.05 $512.63 $512.63 $412.89 $412.89

$624.48 $624.48 $536.42 $536.42 $510.25 $510.25 $542.22 $542.22 $536.54 $536.54 $432.15 $432.15

$652.63 $652.63 $560.61 $560.61 $533.25 $533.25 $566.67 $566.67 $560.73 $560.73 $451.63 $451.63

$683.02 $683.02 $586.71 $586.71 $558.08 $558.08 $593.06 $593.06 $586.84 $586.84 $472.66 $472.66

$713.42 $713.42 $612.82 $612.82 $582.92 $582.92 $619.44 $619.44 $612.96 $612.96 $493.69 $493.69

$746.37 $746.37 $641.13 $641.13 $609.84 $609.84 $648.06 $648.06 $641.27 $641.27 $516.50 $516.50

$779.64 $779.64 $669.71 $669.71 $637.03 $637.03 $676.94 $676.94 $669.85 $669.85 $539.52 $539.52

$815.15 $815.15 $700.21 $700.21 $666.04 $666.04 $707.78 $707.78 $700.36 $700.36 $564.10 $564.10

$832.75 $832.75 $715.33 $715.33 $680.42 $680.42 $723.06 $723.06 $715.48 $715.48 $576.27 $576.27

$868.26 $868.26 $745.83 $745.83 $709.43 $709.43 $753.89 $753.89 $745.99 $745.99 $600.85 $600.85

$898.97 $898.97 $772.21 $772.21 $734.53 $734.53 $780.56 $780.56 $772.38 $772.38 $622.10 $622.10

$919.13 $919.13 $789.52 $789.52 $751.00 $751.00 $798.06 $798.06 $789.70 $789.70 $636.05 $636.05

$944.40 $944.40 $811.23 $811.23 $771.65 $771.65 $820.00 $820.00 $811.41 $811.41 $653.54 $653.54

$959.76 $959.76 $824.43 $824.43 $784.20 $784.20 $833.34 $833.34 $824.61 $824.61 $664.17 $664.17

55957PA029002155957PA0290016 55957PA0290023 55957PA0290017 55957PA0290018 55957PA0290019

FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None

CustomPPO CustomPPO CustomPPOCustomPPO CustomPPO CustomPPO

BlueCare Custom PPO Gold 24Gold Silver Silver Silver Silver Bronze

BlueCare Custom PPO Silver 10 BlueCare Custom PPO Silver 2 BlueCare Custom PPO Silver 6 BlueCare Custom PPO Silver 9 BlueCare Custom PPO Bronze 4

$4,000 $5,000$2,000 - 1 per family $1,400 $1,750 $2,500

100% 100% 90% 90% 100% 50%$15/$30 $45/$75 $45/$65 $25/$50 $25/$50 50%*/50%*

$7,150 $7,000 $7,150$6,000 - 1 per family $7,150 $7,150

No No No No No No

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$165.25 $165.25 $165.73 $165.73 $208.24 $208.24 $241.61 $241.61 $225.99 $225.99 $193.52 $193.52

$260.25 $260.25 $261.00 $261.00 $327.94 $327.94 $380.50 $380.50 $355.90 $355.90 $304.77 $304.77

$260.25 $260.25 $261.00 $261.00 $327.94 $327.94 $380.50 $380.50 $355.90 $355.90 $304.77 $304.77

$260.25 $260.25 $261.00 $261.00 $327.94 $327.94 $380.50 $380.50 $355.90 $355.90 $304.77 $304.77

$260.25 $260.25 $261.00 $261.00 $327.94 $327.94 $380.50 $380.50 $355.90 $355.90 $304.77 $304.77

$261.29 $261.29 $262.04 $262.04 $329.25 $329.25 $382.02 $382.02 $357.32 $357.32 $305.98 $305.98

$266.49 $266.49 $267.26 $267.26 $335.81 $335.81 $389.63 $389.63 $364.44 $364.44 $312.08 $312.08

$272.74 $272.74 $273.52 $273.52 $343.68 $343.68 $398.76 $398.76 $372.98 $372.98 $319.39 $319.39

$282.89 $282.89 $283.70 $283.70 $356.47 $356.47 $413.60 $413.60 $386.86 $386.86 $331.28 $331.28

$291.21 $291.21 $292.05 $292.05 $366.96 $366.96 $425.77 $425.77 $398.25 $398.25 $341.03 $341.03

$295.38 $295.38 $296.23 $296.23 $372.21 $372.21 $431.86 $431.86 $403.94 $403.94 $345.91 $345.91

$301.62 $301.62 $302.49 $302.49 $380.08 $380.08 $440.99 $440.99 $412.48 $412.48 $353.22 $353.22

$307.87 $307.87 $308.76 $308.76 $387.95 $387.95 $450.13 $450.13 $421.02 $421.02 $360.54 $360.54

$311.77 $311.77 $312.67 $312.67 $392.87 $392.87 $455.83 $455.83 $426.36 $426.36 $365.11 $365.11

$315.94 $315.94 $316.85 $316.85 $398.11 $398.11 $461.92 $461.92 $432.06 $432.06 $369.99 $369.99

$318.02 $318.02 $318.94 $318.94 $400.74 $400.74 $464.97 $464.97 $434.90 $434.90 $372.42 $372.42

$320.10 $320.10 $321.03 $321.03 $403.36 $403.36 $468.01 $468.01 $437.75 $437.75 $374.86 $374.86

$322.18 $322.18 $323.11 $323.11 $405.98 $405.98 $471.05 $471.05 $440.60 $440.60 $377.30 $377.30

$324.27 $324.27 $325.20 $325.20 $408.61 $408.61 $474.10 $474.10 $443.45 $443.45 $379.74 $379.74

$328.43 $328.43 $329.38 $329.38 $413.86 $413.86 $480.19 $480.19 $449.14 $449.14 $384.61 $384.61

$332.59 $332.59 $333.55 $333.55 $419.10 $419.10 $486.27 $486.27 $454.84 $454.84 $389.49 $389.49

$338.84 $338.84 $339.82 $339.82 $426.97 $426.97 $495.41 $495.41 $463.38 $463.38 $396.81 $396.81

$344.83 $344.83 $345.82 $345.82 $434.52 $434.52 $504.16 $504.16 $471.56 $471.56 $403.82 $403.82

$353.15 $353.15 $354.17 $354.17 $445.01 $445.01 $516.33 $516.33 $482.95 $482.95 $413.57 $413.57

$363.56 $363.56 $364.61 $364.61 $458.13 $458.13 $531.55 $531.55 $497.19 $497.19 $425.76 $425.76

$375.80 $375.80 $376.88 $376.88 $473.54 $473.54 $549.44 $549.44 $513.91 $513.91 $440.08 $440.08

$390.37 $390.37 $391.50 $391.50 $491.91 $491.91 $570.75 $570.75 $533.85 $533.85 $457.15 $457.15

$406.77 $406.77 $407.94 $407.94 $512.57 $512.57 $594.72 $594.72 $556.27 $556.27 $476.35 $476.35

$425.50 $425.50 $426.73 $426.73 $536.18 $536.18 $622.11 $622.11 $581.89 $581.89 $498.29 $498.29

$443.98 $443.98 $445.26 $445.26 $559.46 $559.46 $649.13 $649.13 $607.16 $607.16 $519.93 $519.93

$464.80 $464.80 $466.14 $466.14 $585.70 $585.70 $679.57 $679.57 $635.63 $635.63 $544.31 $544.31

$485.36 $485.36 $486.76 $486.76 $611.60 $611.60 $709.63 $709.63 $663.75 $663.75 $568.39 $568.39

$508.00 $508.00 $509.47 $509.47 $640.13 $640.13 $742.73 $742.73 $694.71 $694.71 $594.91 $594.91

$530.91 $530.91 $532.44 $532.44 $668.99 $668.99 $776.22 $776.22 $726.03 $726.03 $621.73 $621.73

$555.63 $555.63 $557.23 $557.23 $700.15 $700.15 $812.36 $812.36 $759.84 $759.84 $650.68 $650.68

$580.35 $580.35 $582.03 $582.03 $731.30 $731.30 $848.51 $848.51 $793.65 $793.65 $679.63 $679.63

$607.16 $607.16 $608.91 $608.91 $765.08 $765.08 $887.70 $887.70 $830.31 $830.31 $711.02 $711.02

$634.22 $634.22 $636.05 $636.05 $799.18 $799.18 $927.27 $927.27 $867.32 $867.32 $742.72 $742.72

$663.11 $663.11 $665.02 $665.02 $835.59 $835.59 $969.51 $969.51 $906.83 $906.83 $776.55 $776.55

$677.43 $677.43 $679.38 $679.38 $853.62 $853.62 $990.44 $990.44 $926.40 $926.40 $793.31 $793.31

$706.31 $706.31 $708.35 $708.35 $890.02 $890.02 $1,032.67 $1,032.67 $965.91 $965.91 $827.14 $827.14

$731.30 $731.30 $733.41 $733.41 $921.51 $921.51 $1,069.20 $1,069.20 $1,000.07 $1,000.07 $856.40 $856.40

$747.69 $747.69 $749.85 $749.85 $942.17 $942.17 $1,093.17 $1,093.17 $1,022.50 $1,022.50 $875.60 $875.60

$768.25 $768.25 $770.47 $770.47 $968.07 $968.07 $1,123.23 $1,123.23 $1,050.61 $1,050.61 $899.68 $899.68

$780.75 $780.75 $783.00 $783.00 $983.82 $983.82 $1,141.50 $1,141.50 $1,067.70 $1,067.70 $914.31 $914.31

55957PA0280001 55957PA0280002 55957PA0280003 55957PA0280004 55957PA0300001 55957PA0300002

FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-AffordaBlue-1/1/16

FP-1-SG-X-AffordaBlue-1/1/16FP-1-SG-EHB-AffordaBlue-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3Rating Area 3

None None None None NoneNone

PPO PPO PPO PPO Tiered CustomPPO Tiered CustomPPO

Silver Gold Platinum GoldBronze BronzeBlueCare QHD PPO Bronze 4 BlueCare QHD PPO Silver 1 BlueCare QHD PPO Gold 1 AffordaBlue Platinum1 AffordaBlue Gold Option 1BlueCare QHD PPO Bronze 3

$4,750 $5,500 $2,000 $1,500 $250/ $750 $1,500/$2,000

100% 100%/70% 100%/70%60% 80% 80%60%*/60%* 80%*/80%* 80%*/80%* $20*/$40* $20/70%* / $40 /70%* $25/70%* / $50/70%*

$6,550 $6,550 $6,550 $3,100 $1,000/$5,000 $3,000/$4,000

No No No NoNo No

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$254.13 $254.13 $242.88 $242.88 $199.41 $199.41

$400.21 $400.21 $382.50 $382.50 $314.04 $314.04

$400.21 $400.21 $382.50 $382.50 $314.04 $314.04

$400.21 $400.21 $382.50 $382.50 $314.04 $314.04

$400.21 $400.21 $382.50 $382.50 $314.04 $314.04

$401.81 $401.81 $384.03 $384.03 $315.29 $315.29

$409.81 $409.81 $391.68 $391.68 $321.57 $321.57

$419.42 $419.42 $400.86 $400.86 $329.11 $329.11

$435.02 $435.02 $415.77 $415.77 $341.36 $341.36

$447.83 $447.83 $428.01 $428.01 $351.41 $351.41

$454.23 $454.23 $434.13 $434.13 $356.43 $356.43

$463.84 $463.84 $443.31 $443.31 $363.97 $363.97

$473.44 $473.44 $452.49 $452.49 $371.50 $371.50

$479.45 $479.45 $458.23 $458.23 $376.21 $376.21

$485.85 $485.85 $464.35 $464.35 $381.24 $381.24

$489.05 $489.05 $467.41 $467.41 $383.75 $383.75

$492.25 $492.25 $470.47 $470.47 $386.26 $386.26

$495.45 $495.45 $473.53 $473.53 $388.78 $388.78

$498.66 $498.66 $476.59 $476.59 $391.29 $391.29

$505.06 $505.06 $482.71 $482.71 $396.31 $396.31

$511.46 $511.46 $488.83 $488.83 $401.34 $401.34

$521.07 $521.07 $498.01 $498.01 $408.88 $408.88

$530.27 $530.27 $506.81 $506.81 $416.10 $416.10

$543.08 $543.08 $519.05 $519.05 $426.15 $426.15

$559.09 $559.09 $534.35 $534.35 $438.71 $438.71

$577.90 $577.90 $552.33 $552.33 $453.47 $453.47

$600.31 $600.31 $573.75 $573.75 $471.06 $471.06

$625.52 $625.52 $597.84 $597.84 $490.84 $490.84

$654.34 $654.34 $625.38 $625.38 $513.45 $513.45

$682.75 $682.75 $652.54 $652.54 $535.75 $535.75

$714.77 $714.77 $683.14 $683.14 $560.87 $560.87

$746.39 $746.39 $713.36 $713.36 $585.68 $585.68

$781.20 $781.20 $746.64 $746.64 $613.00 $613.00

$816.42 $816.42 $780.30 $780.30 $640.64 $640.64

$854.44 $854.44 $816.63 $816.63 $670.47 $670.47

$892.46 $892.46 $852.97 $852.97 $700.30 $700.30

$933.68 $933.68 $892.37 $892.37 $732.65 $732.65

$975.31 $975.31 $932.15 $932.15 $765.31 $765.31

$1,019.73 $1,019.73 $974.61 $974.61 $800.17 $800.17

$1,041.74 $1,041.74 $995.64 $995.64 $817.44 $817.44

$1,086.16 $1,086.16 $1,038.10 $1,038.10 $852.30 $852.30

$1,124.59 $1,124.59 $1,074.82 $1,074.82 $882.45 $882.45

$1,149.80 $1,149.80 $1,098.92 $1,098.92 $902.23 $902.23

$1,181.41 $1,181.41 $1,129.14 $1,129.14 $927.04 $927.04

$1,200.63 $1,200.63 $1,147.50 $1,147.50 $942.12 $942.12

55957PA038000155957PA0370001 55957PA0370002

Rating Area 3 Rating Area 3Rating Area 3

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

PPO PPO PPO

Gold Gold SilverLehigh Valley Flex Blue PPO 1250G Lehigh Valley Flex Blue PPO Lehigh Valley Flex Blue PPO 500G

$3,000/$3,000$500/$1,500 $1,250/$3,750

100%/70% 100%/70% 90%/70%$10/$50 / $20/$75 $10/$50 / $20/$75 90%/70%* / 90%/70%*

$7,150/$7,150 $6,550/$6,550$7,150/$7,150

NoNo No

Page Number: 22 12/24/2014

RATE PAGES

Company Name: First Priority Life Insurance Compan

Market: Small Group

Product: PPO, CustomPPO, QHD PPO, AffordaBlue, Lehigh Valley Flex Blue

Effective Date of Rates: Ending date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

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

0 - 20 $300.69 $300.69 $302.72 $302.72 $300.86 $300.86 $297.42 $297.42 $271.93 $271.93 $250.38 $250.38 $254.60

21 $473.53 $473.53 $476.74 $476.74 $473.81 $473.81 $468.38 $468.38 $428.24 $428.24 $394.31 $394.31 $400.96

22 $473.53 $473.53 $476.74 $476.74 $473.81 $473.81 $468.38 $468.38 $428.24 $428.24 $394.31 $394.31 $400.96

23 $473.53 $473.53 $476.74 $476.74 $473.81 $473.81 $468.38 $468.38 $428.24 $428.24 $394.31 $394.31 $400.96

24 $473.53 $473.53 $476.74 $476.74 $473.81 $473.81 $468.38 $468.38 $428.24 $428.24 $394.31 $394.31 $400.96

25 $475.42 $475.42 $478.64 $478.64 $475.70 $475.70 $470.25 $470.25 $429.95 $429.95 $395.88 $395.88 $402.56

26 $484.89 $484.89 $488.18 $488.18 $485.18 $485.18 $479.62 $479.62 $438.51 $438.51 $403.77 $403.77 $410.58

27 $496.25 $496.25 $499.62 $499.62 $496.55 $496.55 $490.86 $490.86 $448.79 $448.79 $413.23 $413.23 $420.20

28 $514.72 $514.72 $518.21 $518.21 $515.03 $515.03 $509.12 $509.12 $465.49 $465.49 $428.61 $428.61 $435.84

29 $529.88 $529.88 $533.47 $533.47 $530.19 $530.19 $524.11 $524.11 $479.20 $479.20 $441.23 $441.23 $448.67

30 $537.45 $537.45 $541.09 $541.09 $537.77 $537.77 $531.61 $531.61 $486.05 $486.05 $447.54 $447.54 $455.08

31 $548.82 $548.82 $552.54 $552.54 $549.14 $549.14 $542.85 $542.85 $496.33 $496.33 $457.00 $457.00 $464.71

32 $560.18 $560.18 $563.98 $563.98 $560.51 $560.51 $554.09 $554.09 $506.60 $506.60 $466.46 $466.46 $474.33

33 $567.28 $567.28 $571.13 $571.13 $567.62 $567.62 $561.11 $561.11 $513.03 $513.03 $472.38 $472.38 $480.35

34 $574.86 $574.86 $578.76 $578.76 $575.20 $575.20 $568.61 $568.61 $519.88 $519.88 $478.69 $478.69 $486.76

35 $578.65 $578.65 $582.57 $582.57 $578.99 $578.99 $572.36 $572.36 $523.30 $523.30 $481.84 $481.84 $489.97

36 $582.44 $582.44 $586.39 $586.39 $582.78 $582.78 $576.10 $576.10 $526.73 $526.73 $485.00 $485.00 $493.18

37 $586.23 $586.23 $590.20 $590.20 $586.57 $586.57 $579.85 $579.85 $530.16 $530.16 $488.15 $488.15 $496.38

38 $590.01 $590.01 $594.01 $594.01 $590.36 $590.36 $583.60 $583.60 $533.58 $533.58 $491.31 $491.31 $499.59

39 $597.59 $597.59 $601.64 $601.64 $597.94 $597.94 $591.09 $591.09 $540.43 $540.43 $497.61 $497.61 $506.01

40 $605.17 $605.17 $609.27 $609.27 $605.52 $605.52 $598.58 $598.58 $547.29 $547.29 $503.92 $503.92 $512.42

41 $616.53 $616.53 $620.71 $620.71 $616.90 $616.90 $609.83 $609.83 $557.56 $557.56 $513.39 $513.39 $522.04

42 $627.42 $627.42 $631.68 $631.68 $627.79 $627.79 $620.60 $620.60 $567.41 $567.41 $522.46 $522.46 $531.27

43 $642.58 $642.58 $646.93 $646.93 $642.96 $642.96 $635.59 $635.59 $581.12 $581.12 $535.07 $535.07 $544.10

44 $661.52 $661.52 $666.00 $666.00 $661.91 $661.91 $654.32 $654.32 $598.25 $598.25 $550.85 $550.85 $560.14

45 $683.77 $683.77 $688.41 $688.41 $684.18 $684.18 $676.34 $676.34 $618.37 $618.37 $569.38 $569.38 $578.98

46 $710.29 $710.29 $715.11 $715.11 $710.71 $710.71 $702.57 $702.57 $642.36 $642.36 $591.46 $591.46 $601.44

47 $740.12 $740.12 $745.14 $745.14 $740.56 $740.56 $732.07 $732.07 $669.33 $669.33 $616.30 $616.30 $626.70

48 $774.22 $774.22 $779.46 $779.46 $774.67 $774.67 $765.80 $765.80 $700.17 $700.17 $644.69 $644.69 $655.56

49 $807.84 $807.84 $813.31 $813.31 $808.31 $808.31 $799.05 $799.05 $730.57 $730.57 $672.69 $672.69 $684.03

50 $845.72 $845.72 $851.45 $851.45 $846.22 $846.22 $836.52 $836.52 $764.83 $764.83 $704.23 $704.23 $716.11

51 $883.13 $883.13 $889.12 $889.12 $883.65 $883.65 $873.52 $873.52 $798.66 $798.66 $735.38 $735.38 $747.79

52 $924.33 $924.33 $930.59 $930.59 $924.87 $924.87 $914.27 $914.27 $835.92 $835.92 $769.69 $769.69 $782.67

53 $966.00 $966.00 $972.54 $972.54 $966.57 $966.57 $955.49 $955.49 $873.60 $873.60 $804.39 $804.39 $817.95

54 $1,010.98 $1,010.98 $1,017.83 $1,017.83 $1,011.58 $1,011.58 $999.99 $999.99 $914.29 $914.29 $841.85 $841.85 $856.04

55 $1,055.97 $1,055.97 $1,063.13 $1,063.13 $1,056.59 $1,056.59 $1,044.48 $1,044.48 $954.97 $954.97 $879.31 $879.31 $894.14

56 $1,104.74 $1,104.74 $1,112.23 $1,112.23 $1,105.39 $1,105.39 $1,092.73 $1,092.73 $999.08 $999.08 $919.92 $919.92 $935.43

57 $1,153.99 $1,153.99 $1,161.81 $1,161.81 $1,154.67 $1,154.67 $1,141.44 $1,141.44 $1,043.62 $1,043.62 $960.93 $960.93 $977.13

58 $1,206.55 $1,206.55 $1,214.73 $1,214.73 $1,207.26 $1,207.26 $1,193.43 $1,193.43 $1,091.15 $1,091.15 $1,004.70 $1,004.70 $1,021.64

59 $1,232.59 $1,232.59 $1,240.95 $1,240.95 $1,233.32 $1,233.32 $1,219.19 $1,219.19 $1,114.70 $1,114.70 $1,026.38 $1,026.38 $1,043.69

60 $1,285.16 $1,285.16 $1,293.87 $1,293.87 $1,285.92 $1,285.92 $1,271.18 $1,271.18 $1,162.24 $1,162.24 $1,070.15 $1,070.15 $1,088.20

61 $1,330.61 $1,330.61 $1,339.63 $1,339.63 $1,331.40 $1,331.40 $1,316.14 $1,316.14 $1,203.35 $1,203.35 $1,108.01 $1,108.01 $1,126.69

62 $1,360.45 $1,360.45 $1,369.67 $1,369.67 $1,361.25 $1,361.25 $1,345.65 $1,345.65 $1,230.33 $1,230.33 $1,132.85 $1,132.85 $1,151.95

63 $1,397.86 $1,397.86 $1,407.33 $1,407.33 $1,398.68 $1,398.68 $1,382.65 $1,382.65 $1,264.16 $1,264.16 $1,164.00 $1,164.00 $1,183.63

64+ $1,420.59 $1,420.59 $1,430.22 $1,430.22 $1,421.43 $1,421.43 $1,405.14 $1,405.14 $1,284.72 $1,284.72 $1,182.93 $1,182.93 $1,202.88

October 1, 2017 December 31, 2017

55957PA0270007 55957PA0270016 55957PA0270002 55957PA0270006 55957PA0270017 55957PA0270018 55957PA0270008FP-1-SG-EHB PPO-1/1/16

FP-1-X-SG-PPO-1/1/16FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None None

PPO PPO PPO PPO PPO PPO PPO

Platinum Platinum Platinum Platinum Gold Gold GoldBlueCare PPO Platinum 12 BlueCare PPO Platinum 13 BlueCare PPO Platinum 2 BlueCare PPO Platinum 11 BlueCare PPO Gold 27 BlueCare PPO Gold 15 BlueCare PPO Gold 12

$0 $250 $500 $750 $500 $1,000 $1,250

100% 100% 100% 100% 100% 80% 100%$35/$60$25/$50 $10/$20 $10/$20 $10/$20 $20/$40 $20/$40

$2,500 $4,000 $2,000 $1,500 $6,000 $5,000 $7,150

No No No No No No No

Page Number: 23 12/24/2014

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Product:

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HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

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Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

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64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$254.60 $254.85 $254.85 $259.13 $259.13 $248.66 $248.66 $213.69 $213.69 $203.26 $203.26 $216.00 $216.00

$400.96 $401.34 $401.34 $408.08 $408.08 $391.60 $391.60 $336.53 $336.53 $320.11 $320.11 $340.17 $340.17

$400.96 $401.34 $401.34 $408.08 $408.08 $391.60 $391.60 $336.53 $336.53 $320.11 $320.11 $340.17 $340.17

$400.96 $401.34 $401.34 $408.08 $408.08 $391.60 $391.60 $336.53 $336.53 $320.11 $320.11 $340.17 $340.17

$400.96 $401.34 $401.34 $408.08 $408.08 $391.60 $391.60 $336.53 $336.53 $320.11 $320.11 $340.17 $340.17

$402.56 $402.94 $402.94 $409.71 $409.71 $393.16 $393.16 $337.87 $337.87 $321.39 $321.39 $341.53 $341.53

$410.58 $410.97 $410.97 $417.87 $417.87 $400.99 $400.99 $344.60 $344.60 $327.79 $327.79 $348.33 $348.33

$420.20 $420.60 $420.60 $427.66 $427.66 $410.39 $410.39 $352.68 $352.68 $335.47 $335.47 $356.49 $356.49

$435.84 $436.25 $436.25 $443.58 $443.58 $425.66 $425.66 $365.80 $365.80 $347.95 $347.95 $369.76 $369.76

$448.67 $449.09 $449.09 $456.64 $456.64 $438.20 $438.20 $376.57 $376.57 $358.20 $358.20 $380.65 $380.65

$455.08 $455.52 $455.52 $463.17 $463.17 $444.46 $444.46 $381.96 $381.96 $363.32 $363.32 $386.09 $386.09

$464.71 $465.15 $465.15 $472.96 $472.96 $453.86 $453.86 $390.03 $390.03 $371.00 $371.00 $394.25 $394.25

$474.33 $474.78 $474.78 $482.75 $482.75 $463.26 $463.26 $398.11 $398.11 $378.69 $378.69 $402.42 $402.42

$480.35 $480.80 $480.80 $488.87 $488.87 $469.13 $469.13 $403.16 $403.16 $383.49 $383.49 $407.52 $407.52

$486.76 $487.22 $487.22 $495.40 $495.40 $475.40 $475.40 $408.54 $408.54 $388.61 $388.61 $412.96 $412.96

$489.97 $490.43 $490.43 $498.67 $498.67 $478.53 $478.53 $411.23 $411.23 $391.17 $391.17 $415.68 $415.68

$493.18 $493.64 $493.64 $501.93 $501.93 $481.66 $481.66 $413.93 $413.93 $393.73 $393.73 $418.40 $418.40

$496.38 $496.85 $496.85 $505.20 $505.20 $484.80 $484.80 $416.62 $416.62 $396.29 $396.29 $421.13 $421.13

$499.59 $500.06 $500.06 $508.46 $508.46 $487.93 $487.93 $419.31 $419.31 $398.85 $398.85 $423.85 $423.85

$506.01 $506.49 $506.49 $514.99 $514.99 $494.19 $494.19 $424.70 $424.70 $403.97 $403.97 $429.29 $429.29

$512.42 $512.91 $512.91 $521.52 $521.52 $500.46 $500.46 $430.08 $430.08 $409.10 $409.10 $434.73 $434.73

$522.04 $522.54 $522.54 $531.32 $531.32 $509.86 $509.86 $438.16 $438.16 $416.78 $416.78 $442.90 $442.90

$531.27 $531.77 $531.77 $540.70 $540.70 $518.87 $518.87 $445.90 $445.90 $424.14 $424.14 $450.72 $450.72

$544.10 $544.61 $544.61 $553.76 $553.76 $531.40 $531.40 $456.67 $456.67 $434.38 $434.38 $461.61 $461.61

$560.14 $560.67 $560.67 $570.08 $570.08 $547.06 $547.06 $470.13 $470.13 $447.19 $447.19 $475.21 $475.21

$578.98 $579.53 $579.53 $589.26 $589.26 $565.47 $565.47 $485.94 $485.94 $462.23 $462.23 $491.20 $491.20

$601.44 $602.01 $602.01 $612.12 $612.12 $587.40 $587.40 $504.79 $504.79 $480.16 $480.16 $510.25 $510.25

$626.70 $627.29 $627.29 $637.82 $637.82 $612.07 $612.07 $525.99 $525.99 $500.33 $500.33 $531.68 $531.68

$655.56 $656.19 $656.19 $667.21 $667.21 $640.26 $640.26 $550.22 $550.22 $523.37 $523.37 $556.17 $556.17

$684.03 $684.68 $684.68 $696.18 $696.18 $668.06 $668.06 $574.12 $574.12 $546.10 $546.10 $580.33 $580.33

$716.11 $716.79 $716.79 $728.83 $728.83 $699.39 $699.39 $601.04 $601.04 $571.71 $571.71 $607.54 $607.54

$747.79 $748.49 $748.49 $761.06 $761.06 $730.33 $730.33 $627.62 $627.62 $597.00 $597.00 $634.41 $634.41

$782.67 $783.41 $783.41 $796.57 $796.57 $764.40 $764.40 $656.90 $656.90 $624.85 $624.85 $664.01 $664.01

$817.95 $818.73 $818.73 $832.48 $832.48 $798.86 $798.86 $686.52 $686.52 $653.02 $653.02 $693.94 $693.94

$856.04 $856.86 $856.86 $871.25 $871.25 $836.06 $836.06 $718.49 $718.49 $683.43 $683.43 $726.26 $726.26

$894.14 $894.98 $894.98 $910.01 $910.01 $873.26 $873.26 $750.46 $750.46 $713.84 $713.84 $758.57 $758.57

$935.43 $936.32 $936.32 $952.05 $952.05 $913.60 $913.60 $785.12 $785.12 $746.81 $746.81 $793.61 $793.61

$977.13 $978.06 $978.06 $994.49 $994.49 $954.32 $954.32 $820.12 $820.12 $780.10 $780.10 $828.99 $828.99

$1,021.64 $1,022.61 $1,022.61 $1,039.78 $1,039.78 $997.79 $997.79 $857.47 $857.47 $815.64 $815.64 $866.75 $866.75

$1,043.69 $1,044.68 $1,044.68 $1,062.23 $1,062.23 $1,019.33 $1,019.33 $875.98 $875.98 $833.24 $833.24 $885.46 $885.46

$1,088.20 $1,089.23 $1,089.23 $1,107.52 $1,107.52 $1,062.80 $1,062.80 $913.34 $913.34 $868.77 $868.77 $923.22 $923.22

$1,126.69 $1,127.76 $1,127.76 $1,146.70 $1,146.70 $1,100.39 $1,100.39 $945.64 $945.64 $899.50 $899.50 $955.87 $955.87

$1,151.95 $1,153.04 $1,153.04 $1,172.41 $1,172.41 $1,125.06 $1,125.06 $966.85 $966.85 $919.67 $919.67 $977.30 $977.30

$1,183.63 $1,184.75 $1,184.75 $1,204.65 $1,204.65 $1,156.00 $1,156.00 $993.43 $993.43 $944.96 $944.96 $1,004.18 $1,004.18

$1,202.88 $1,204.02 $1,204.02 $1,224.24 $1,224.24 $1,174.80 $1,174.80 $1,009.59 $1,009.59 $960.33 $960.33 $1,020.51 $1,020.51

55957PA0270008 55957PA0270009 55957PA0270010 55957PA0270011 55957PA0270022

FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16

55957PA0270019 55957PA0270020

Rating Area 3

FP-1-SG-EHB PPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None None

PPOPPO PPO PPO PPO PPO PPO

SilverGold Gold Gold Gold Silver SilverBlueCare PPO Gold 12 BlueCare PPO Gold 24 BlueCare PPO Silver 10 BlueCare PPO Silver 2 BlueCare PPO Silver 6

$1,250 $1,500

BlueCare PPO Gold 18 BlueCare PPO Gold 19

$1,500 $2,000 - 1 per family $1,400 $1,750 $2,500

100% 100% 90% 90%100% 100% 90%$35/$60 $20/$40 $25/$50 $15/$30 $45/$75 $45/$65 $25/$50

$7,150 $7,150 $5,000 $6,000 - 1 per family $7,150 $7,150 $7,150

No No No No NoNo No

Page Number: 24 12/24/2014

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HIOS Plan ID (Off Exchange)=>

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Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

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64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco

$213.74 $213.74 $172.15 $172.15 $252.58 $252.58 $254.29 $254.29 $252.73 $252.73 $249.83 $249.83 $228.42

$336.60 $336.60 $271.11 $271.11 $397.77 $397.77 $400.46 $400.46 $398.00 $398.00 $393.44 $393.44 $359.72

$336.60 $336.60 $271.11 $271.11 $397.77 $397.77 $400.46 $400.46 $398.00 $398.00 $393.44 $393.44 $359.72

$336.60 $336.60 $271.11 $271.11 $397.77 $397.77 $400.46 $400.46 $398.00 $398.00 $393.44 $393.44 $359.72

$336.60 $336.60 $271.11 $271.11 $397.77 $397.77 $400.46 $400.46 $398.00 $398.00 $393.44 $393.44 $359.72

$337.94 $337.94 $272.19 $272.19 $399.36 $399.36 $402.06 $402.06 $399.59 $399.59 $395.01 $395.01 $361.15

$344.67 $344.67 $277.61 $277.61 $407.31 $407.31 $410.07 $410.07 $407.55 $407.55 $402.88 $402.88 $368.35

$352.75 $352.75 $284.12 $284.12 $416.86 $416.86 $419.68 $419.68 $417.10 $417.10 $412.32 $412.32 $376.98

$365.88 $365.88 $294.69 $294.69 $432.37 $432.37 $435.30 $435.30 $432.62 $432.62 $427.66 $427.66 $391.01

$376.65 $376.65 $303.37 $303.37 $445.10 $445.10 $448.11 $448.11 $445.36 $445.36 $440.25 $440.25 $402.52

$382.04 $382.04 $307.70 $307.70 $451.46 $451.46 $454.52 $454.52 $451.73 $451.73 $446.55 $446.55 $408.28

$390.11 $390.11 $314.21 $314.21 $461.01 $461.01 $464.13 $464.13 $461.28 $461.28 $455.99 $455.99 $416.91

$398.19 $398.19 $320.72 $320.72 $470.56 $470.56 $473.74 $473.74 $470.83 $470.83 $465.43 $465.43 $425.54

$403.24 $403.24 $324.78 $324.78 $476.52 $476.52 $479.75 $479.75 $476.80 $476.80 $471.34 $471.34 $430.94

$408.63 $408.63 $329.12 $329.12 $482.89 $482.89 $486.15 $486.15 $483.17 $483.17 $477.63 $477.63 $436.70

$411.32 $411.32 $331.29 $331.29 $486.07 $486.07 $489.36 $489.36 $486.35 $486.35 $480.78 $480.78 $439.57

$414.01 $414.01 $333.46 $333.46 $489.25 $489.25 $492.56 $492.56 $489.54 $489.54 $483.93 $483.93 $442.45

$416.71 $416.71 $335.63 $335.63 $492.43 $492.43 $495.76 $495.76 $492.72 $492.72 $487.07 $487.07 $445.33

$419.40 $419.40 $337.80 $337.80 $495.62 $495.62 $498.97 $498.97 $495.90 $495.90 $490.22 $490.22 $448.21

$424.78 $424.78 $342.14 $342.14 $501.98 $501.98 $505.38 $505.38 $502.27 $502.27 $496.52 $496.52 $453.96

$430.17 $430.17 $346.47 $346.47 $508.35 $508.35 $511.78 $511.78 $508.64 $508.64 $502.81 $502.81 $459.72

$438.25 $438.25 $352.98 $352.98 $517.89 $517.89 $521.39 $521.39 $518.19 $518.19 $512.25 $512.25 $468.35

$445.99 $445.99 $359.22 $359.22 $527.04 $527.04 $530.60 $530.60 $527.35 $527.35 $521.30 $521.30 $476.62

$456.76 $456.76 $367.89 $367.89 $539.77 $539.77 $543.42 $543.42 $540.08 $540.08 $533.89 $533.89 $488.14

$470.23 $470.23 $378.74 $378.74 $555.68 $555.68 $559.44 $559.44 $556.00 $556.00 $549.63 $549.63 $502.52

$486.05 $486.05 $391.48 $391.48 $574.37 $574.37 $578.26 $578.26 $574.71 $574.71 $568.12 $568.12 $519.43

$504.90 $504.90 $406.66 $406.66 $596.65 $596.65 $600.69 $600.69 $597.00 $597.00 $590.16 $590.16 $539.58

$526.10 $526.10 $423.74 $423.74 $621.71 $621.71 $625.91 $625.91 $622.07 $622.07 $614.94 $614.94 $562.24

$550.34 $550.34 $443.26 $443.26 $650.35 $650.35 $654.75 $654.75 $650.73 $650.73 $643.27 $643.27 $588.14

$574.23 $574.23 $462.51 $462.51 $678.59 $678.59 $683.18 $683.18 $678.98 $678.98 $671.20 $671.20 $613.68

$601.16 $601.16 $484.20 $484.20 $710.41 $710.41 $715.22 $715.22 $710.82 $710.82 $702.68 $702.68 $642.45

$627.75 $627.75 $505.62 $505.62 $741.84 $741.84 $746.85 $746.85 $742.27 $742.27 $733.76 $733.76 $670.87

$657.04 $657.04 $529.20 $529.20 $776.44 $776.44 $781.69 $781.69 $776.89 $776.89 $767.99 $767.99 $702.17

$686.66 $686.66 $553.06 $553.06 $811.45 $811.45 $816.93 $816.93 $811.92 $811.92 $802.61 $802.61 $733.82

$718.64 $718.64 $578.81 $578.81 $849.23 $849.23 $854.98 $854.98 $849.73 $849.73 $839.99 $839.99 $768.00

$750.61 $750.61 $604.57 $604.57 $887.02 $887.02 $893.02 $893.02 $887.54 $887.54 $877.37 $877.37 $802.17

$785.28 $785.28 $632.49 $632.49 $927.99 $927.99 $934.27 $934.27 $928.53 $928.53 $917.89 $917.89 $839.22

$820.29 $820.29 $660.69 $660.69 $969.36 $969.36 $975.92 $975.92 $969.92 $969.92 $958.81 $958.81 $876.63

$857.65 $857.65 $690.78 $690.78 $1,013.51 $1,013.51 $1,020.37 $1,020.37 $1,014.10 $1,014.10 $1,002.48 $1,002.48 $916.56

$876.16 $876.16 $705.69 $705.69 $1,035.39 $1,035.39 $1,042.39 $1,042.39 $1,035.99 $1,035.99 $1,024.12 $1,024.12 $936.35

$913.53 $913.53 $735.79 $735.79 $1,079.54 $1,079.54 $1,086.84 $1,086.84 $1,080.17 $1,080.17 $1,067.79 $1,067.79 $976.28

$945.84 $945.84 $761.81 $761.81 $1,117.73 $1,117.73 $1,125.29 $1,125.29 $1,118.38 $1,118.38 $1,105.56 $1,105.56 $1,010.81

$967.05 $967.05 $778.89 $778.89 $1,142.79 $1,142.79 $1,150.52 $1,150.52 $1,143.45 $1,143.45 $1,130.35 $1,130.35 $1,033.47

$993.64 $993.64 $800.31 $800.31 $1,174.21 $1,174.21 $1,182.15 $1,182.15 $1,174.89 $1,174.89 $1,161.43 $1,161.43 $1,061.89

$1,009.80 $1,009.80 $813.33 $813.33 $1,193.31 $1,193.31 $1,201.38 $1,201.38 $1,194.00 $1,194.00 $1,180.32 $1,180.32 $1,079.16

55957PA0290002 55957PA0290006 55957PA029002255957PA0270021 55957PA0270013 55957PA0290007 55957PA0290008

FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB PPO-1/1/16 FP-1-SG-EHB PPO-1/1/16FP-1-SG-EHB-CustomPPO-1/1/16

FP-1-X-SG-CustomPPO-1/1/16FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None NoneNone

Rating Area 3

PPO PPO CustomPPO CustomPPO CustomPPO CustomPPO CustomPPO

Silver BronzeBlueCare PPO Silver 9 BlueCare PPO Bronze 4 BlueCare Custom PPO Platinum 12 BlueCare Custom PPO Platinum 13 BlueCare Custom PPO Gold 27BlueCare Custom PPO Platinum 2 BlueCare Custom PPO Platinum 11

Platinum Platinum Platinum Platinum Gold

$5,000 $0 $250 $500 $750 $500$4,000

100% 50% 100% 100% 100% 100% 100%$25/$50 50%*/50%* $25/$50 $10/$20 $10/$20 $10/$20 $20/$40

$7,000 $7,150 $2,500 $4,000 $2,000 $1,500 $6,000

No No No No No No No

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Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$228.42 $210.32 $210.32 $213.87 $213.87 $214.07 $214.07 $217.67 $217.67 $208.96 $208.96 $179.50 $179.50

$359.72 $331.22 $331.22 $336.81 $336.81 $337.13 $337.13 $342.79 $342.79 $329.08 $329.08 $282.69 $282.69

$359.72 $331.22 $331.22 $336.81 $336.81 $337.13 $337.13 $342.79 $342.79 $329.08 $329.08 $282.69 $282.69

$359.72 $331.22 $331.22 $336.81 $336.81 $337.13 $337.13 $342.79 $342.79 $329.08 $329.08 $282.69 $282.69

$359.72 $331.22 $331.22 $336.81 $336.81 $337.13 $337.13 $342.79 $342.79 $329.08 $329.08 $282.69 $282.69

$361.15 $332.54 $332.54 $338.15 $338.15 $338.47 $338.47 $344.16 $344.16 $330.39 $330.39 $283.82 $283.82

$368.35 $339.16 $339.16 $344.89 $344.89 $345.22 $345.22 $351.01 $351.01 $336.97 $336.97 $289.47 $289.47

$376.98 $347.11 $347.11 $352.97 $352.97 $353.31 $353.31 $359.24 $359.24 $344.87 $344.87 $296.25 $296.25

$391.01 $360.03 $360.03 $366.11 $366.11 $366.46 $366.46 $372.61 $372.61 $357.70 $357.70 $307.28 $307.28

$402.52 $370.63 $370.63 $376.89 $376.89 $377.24 $377.24 $383.58 $383.58 $368.24 $368.24 $316.33 $316.33

$408.28 $375.93 $375.93 $382.27 $382.27 $382.64 $382.64 $389.06 $389.06 $373.50 $373.50 $320.85 $320.85

$416.91 $383.88 $383.88 $390.36 $390.36 $390.73 $390.73 $397.29 $397.29 $381.40 $381.40 $327.63 $327.63

$425.54 $391.83 $391.83 $398.44 $398.44 $398.82 $398.82 $405.52 $405.52 $389.30 $389.30 $334.42 $334.42

$430.94 $396.80 $396.80 $403.49 $403.49 $403.88 $403.88 $410.66 $410.66 $394.23 $394.23 $338.66 $338.66

$436.70 $402.10 $402.10 $408.88 $408.88 $409.27 $409.27 $416.14 $416.14 $399.50 $399.50 $343.18 $343.18

$439.57 $404.75 $404.75 $411.58 $411.58 $411.97 $411.97 $418.88 $418.88 $402.13 $402.13 $345.44 $345.44

$442.45 $407.40 $407.40 $414.27 $414.27 $414.66 $414.66 $421.63 $421.63 $404.76 $404.76 $347.70 $347.70

$445.33 $410.05 $410.05 $416.97 $416.97 $417.36 $417.36 $424.37 $424.37 $407.40 $407.40 $349.97 $349.97

$448.21 $412.70 $412.70 $419.66 $419.66 $420.06 $420.06 $427.11 $427.11 $410.03 $410.03 $352.23 $352.23

$453.96 $417.99 $417.99 $425.05 $425.05 $425.45 $425.45 $432.60 $432.60 $415.29 $415.29 $356.75 $356.75

$459.72 $423.29 $423.29 $430.44 $430.44 $430.85 $430.85 $438.08 $438.08 $420.56 $420.56 $361.27 $361.27

$468.35 $431.24 $431.24 $438.52 $438.52 $438.94 $438.94 $446.31 $446.31 $428.46 $428.46 $368.06 $368.06

$476.62 $438.86 $438.86 $446.27 $446.27 $446.69 $446.69 $454.19 $454.19 $436.03 $436.03 $374.56 $374.56

$488.14 $449.46 $449.46 $457.05 $457.05 $457.48 $457.48 $465.16 $465.16 $446.56 $446.56 $383.61 $383.61

$502.52 $462.71 $462.71 $470.52 $470.52 $470.97 $470.97 $478.87 $478.87 $459.72 $459.72 $394.91 $394.91

$519.43 $478.28 $478.28 $486.35 $486.35 $486.81 $486.81 $494.98 $494.98 $475.19 $475.19 $408.20 $408.20

$539.58 $496.83 $496.83 $505.21 $505.21 $505.69 $505.69 $514.18 $514.18 $493.62 $493.62 $424.03 $424.03

$562.24 $517.69 $517.69 $526.43 $526.43 $526.93 $526.93 $535.78 $535.78 $514.35 $514.35 $441.84 $441.84

$588.14 $541.54 $541.54 $550.68 $550.68 $551.20 $551.20 $560.46 $560.46 $538.04 $538.04 $462.19 $462.19

$613.68 $565.06 $565.06 $574.59 $574.59 $575.14 $575.14 $584.79 $584.79 $561.41 $561.41 $482.26 $482.26

$642.45 $591.55 $591.55 $601.54 $601.54 $602.11 $602.11 $612.22 $612.22 $587.73 $587.73 $504.88 $504.88

$670.87 $617.72 $617.72 $628.15 $628.15 $628.74 $628.74 $639.30 $639.30 $613.73 $613.73 $527.21 $527.21

$702.17 $646.54 $646.54 $657.45 $657.45 $658.07 $658.07 $669.12 $669.12 $642.36 $642.36 $551.81 $551.81

$733.82 $675.68 $675.68 $687.09 $687.09 $687.74 $687.74 $699.29 $699.29 $671.32 $671.32 $576.68 $576.68

$768.00 $707.15 $707.15 $719.08 $719.08 $719.77 $719.77 $731.85 $731.85 $702.58 $702.58 $603.54 $603.54

$802.17 $738.62 $738.62 $751.08 $751.08 $751.79 $751.79 $764.42 $764.42 $733.84 $733.84 $630.39 $630.39

$839.22 $772.73 $772.73 $785.77 $785.77 $786.52 $786.52 $799.72 $799.72 $767.74 $767.74 $659.51 $659.51

$876.63 $807.18 $807.18 $820.80 $820.80 $821.58 $821.58 $835.37 $835.37 $801.96 $801.96 $688.91 $688.91

$916.56 $843.94 $843.94 $858.19 $858.19 $859.00 $859.00 $873.42 $873.42 $838.49 $838.49 $720.29 $720.29

$936.35 $862.16 $862.16 $876.71 $876.71 $877.54 $877.54 $892.28 $892.28 $856.59 $856.59 $735.84 $735.84

$976.28 $898.93 $898.93 $914.10 $914.10 $914.97 $914.97 $930.33 $930.33 $893.12 $893.12 $767.22 $767.22

$1,010.81 $930.72 $930.72 $946.43 $946.43 $947.33 $947.33 $963.23 $963.23 $924.71 $924.71 $794.35 $794.35

$1,033.47 $951.59 $951.59 $967.65 $967.65 $968.57 $968.57 $984.83 $984.83 $945.44 $945.44 $812.16 $812.16

$1,061.89 $977.76 $977.76 $994.26 $994.26 $995.20 $995.20 $1,011.91 $1,011.91 $971.44 $971.44 $834.50 $834.50

$1,079.16 $993.66 $993.66 $1,010.43 $1,010.43 $1,011.39 $1,011.39 $1,028.37 $1,028.37 $987.24 $987.24 $848.07 $848.07

55957PA0290014 55957PA0290016 55957PA029002355957PA0290022 55957PA0290012 55957PA0290011 55957PA0290013

FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16

Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None None None None None None None

Rating Area 3 Rating Area 3

CustomPPO CustomPPO CustomPPO CustomPPO CustomPPOCustomPPO CustomPPO

BlueCare Custom PPO Gold 12 BlueCare Custom PPO Gold 18 BlueCare Custom PPO Gold 19 BlueCare Custom PPO Gold 24BlueCare Custom PPO Gold 27 BlueCare Custom PPO Gold 15Gold SilverGold Gold Gold Gold Gold

BlueCare Custom PPO Silver 10

$500 $1,000 $1,250 $1,500 $1,500 $2,000 - 1 per family $1,400

100% 100% 90% 100% 100%100% 80%$20/$40 $35/$60 $20/$40 $25/$50 $15/$30 $45/$75$20/$40

$6,000 $5,000 $7,150 $7,150 $5,000 $6,000 - 1 per family $7,150

No No No No No NoNo

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco

$170.74 $170.74 $181.44 $181.44 $179.53 $179.53 $144.60 $144.60 $169.99 $169.99 $170.48 $170.48 $214.21

$268.89 $268.89 $285.74 $285.74 $282.74 $282.74 $227.73 $227.73 $267.71 $267.71 $268.48 $268.48 $337.34

$268.89 $268.89 $285.74 $285.74 $282.74 $282.74 $227.73 $227.73 $267.71 $267.71 $268.48 $268.48 $337.34

$268.89 $268.89 $285.74 $285.74 $282.74 $282.74 $227.73 $227.73 $267.71 $267.71 $268.48 $268.48 $337.34

$268.89 $268.89 $285.74 $285.74 $282.74 $282.74 $227.73 $227.73 $267.71 $267.71 $268.48 $268.48 $337.34

$269.96 $269.96 $286.88 $286.88 $283.87 $283.87 $228.64 $228.64 $268.78 $268.78 $269.55 $269.55 $338.68

$275.34 $275.34 $292.59 $292.59 $289.52 $289.52 $233.19 $233.19 $274.13 $274.13 $274.92 $274.92 $345.43

$281.79 $281.79 $299.45 $299.45 $296.31 $296.31 $238.66 $238.66 $280.56 $280.56 $281.36 $281.36 $353.53

$292.28 $292.28 $310.59 $310.59 $307.33 $307.33 $247.54 $247.54 $291.00 $291.00 $291.83 $291.83 $366.68

$300.88 $300.88 $319.74 $319.74 $316.38 $316.38 $254.82 $254.82 $299.56 $299.56 $300.42 $300.42 $377.48

$305.19 $305.19 $324.31 $324.31 $320.90 $320.90 $258.47 $258.47 $303.85 $303.85 $304.72 $304.72 $382.88

$311.64 $311.64 $331.17 $331.17 $327.69 $327.69 $263.93 $263.93 $310.27 $310.27 $311.16 $311.16 $390.97

$318.09 $318.09 $338.03 $338.03 $334.48 $334.48 $269.40 $269.40 $316.70 $316.70 $317.61 $317.61 $399.07

$322.13 $322.13 $342.31 $342.31 $338.72 $338.72 $272.82 $272.82 $320.71 $320.71 $321.63 $321.63 $404.13

$326.43 $326.43 $346.88 $346.88 $343.24 $343.24 $276.46 $276.46 $324.99 $324.99 $325.93 $325.93 $409.53

$328.58 $328.58 $349.17 $349.17 $345.50 $345.50 $278.28 $278.28 $327.14 $327.14 $328.08 $328.08 $412.22

$330.73 $330.73 $351.46 $351.46 $347.77 $347.77 $280.10 $280.10 $329.28 $329.28 $330.23 $330.23 $414.92

$332.88 $332.88 $353.74 $353.74 $350.03 $350.03 $281.92 $281.92 $331.42 $331.42 $332.37 $332.37 $417.62

$335.03 $335.03 $356.03 $356.03 $352.29 $352.29 $283.75 $283.75 $333.56 $333.56 $334.52 $334.52 $420.32

$339.33 $339.33 $360.60 $360.60 $356.81 $356.81 $287.39 $287.39 $337.85 $337.85 $338.82 $338.82 $425.72

$343.64 $343.64 $365.17 $365.17 $361.34 $361.34 $291.03 $291.03 $342.13 $342.13 $343.11 $343.11 $431.12

$350.09 $350.09 $372.03 $372.03 $368.12 $368.12 $296.50 $296.50 $348.55 $348.55 $349.56 $349.56 $439.21

$356.27 $356.27 $378.60 $378.60 $374.63 $374.63 $301.74 $301.74 $354.71 $354.71 $355.73 $355.73 $446.97

$364.88 $364.88 $387.74 $387.74 $383.67 $383.67 $309.02 $309.02 $363.28 $363.28 $364.32 $364.32 $457.77

$375.63 $375.63 $399.17 $399.17 $394.98 $394.98 $318.13 $318.13 $373.99 $373.99 $375.06 $375.06 $471.26

$388.27 $388.27 $412.60 $412.60 $408.27 $408.27 $328.84 $328.84 $386.57 $386.57 $387.68 $387.68 $487.11

$403.33 $403.33 $428.61 $428.61 $424.11 $424.11 $341.59 $341.59 $401.56 $401.56 $402.72 $402.72 $506.01

$420.27 $420.27 $446.61 $446.61 $441.92 $441.92 $355.94 $355.94 $418.43 $418.43 $419.63 $419.63 $527.26

$439.63 $439.63 $467.18 $467.18 $462.27 $462.27 $372.33 $372.33 $437.70 $437.70 $438.96 $438.96 $551.55

$458.72 $458.72 $487.47 $487.47 $482.35 $482.35 $388.50 $388.50 $456.71 $456.71 $458.02 $458.02 $575.50

$480.23 $480.23 $510.33 $510.33 $504.97 $504.97 $406.72 $406.72 $478.13 $478.13 $479.50 $479.50 $602.48

$501.47 $501.47 $532.90 $532.90 $527.31 $527.31 $424.71 $424.71 $499.27 $499.27 $500.71 $500.71 $629.13

$524.87 $524.87 $557.76 $557.76 $551.90 $551.90 $444.52 $444.52 $522.56 $522.56 $524.07 $524.07 $658.48

$548.53 $548.53 $582.90 $582.90 $576.78 $576.78 $464.56 $464.56 $546.12 $546.12 $547.69 $547.69 $688.17

$574.08 $574.08 $610.05 $610.05 $603.64 $603.64 $486.20 $486.20 $571.56 $571.56 $573.20 $573.20 $720.22

$599.62 $599.62 $637.20 $637.20 $630.51 $630.51 $507.83 $507.83 $596.99 $596.99 $598.71 $598.71 $752.26

$627.32 $627.32 $666.63 $666.63 $659.63 $659.63 $531.29 $531.29 $624.56 $624.56 $626.36 $626.36 $787.01

$655.28 $655.28 $696.34 $696.34 $689.03 $689.03 $554.97 $554.97 $652.40 $652.40 $654.28 $654.28 $822.09

$685.13 $685.13 $728.06 $728.06 $720.42 $720.42 $580.25 $580.25 $682.12 $682.12 $684.08 $684.08 $859.54

$699.92 $699.92 $743.78 $743.78 $735.97 $735.97 $592.78 $592.78 $696.84 $696.84 $698.85 $698.85 $878.09

$729.76 $729.76 $775.49 $775.49 $767.35 $767.35 $618.05 $618.05 $726.56 $726.56 $728.65 $728.65 $915.54

$755.58 $755.58 $802.92 $802.92 $794.49 $794.49 $639.92 $639.92 $752.26 $752.26 $754.42 $754.42 $947.92

$772.52 $772.52 $820.93 $820.93 $812.31 $812.31 $654.26 $654.26 $769.13 $769.13 $771.34 $771.34 $969.17

$793.76 $793.76 $843.50 $843.50 $834.64 $834.64 $672.25 $672.25 $790.27 $790.27 $792.55 $792.55 $995.82

$806.67 $806.67 $857.22 $857.22 $848.22 $848.22 $683.19 $683.19 $803.13 $803.13 $805.44 $805.44 $1,012.02

55957PA0290021 55957PA0280001 55957PA0280002 55957PA028000355957PA0290017 55957PA0290018 55957PA0290019

FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-CustomPPO-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16

Rating Area 3 Rating Area 3Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

None NoneNone None None None None

CustomPPO CustomPPO CustomPPO PPO PPO PPOCustomPPO

SilverBronze BronzeSilver Silver Silver BronzeBlueCare QHD PPO Bronze 4 BlueCare QHD PPO Silver 1BlueCare Custom PPO Silver 2 BlueCare Custom PPO Silver 6 BlueCare Custom PPO Silver 9 BlueCare Custom PPO Bronze 4 BlueCare QHD PPO Bronze 3

$4,000 $5,000 $4,750 $5,500 $2,000$1,750 $2,500

90% 90% 100% 50% 60% 80% 80%60%*/60%* 80%*/80%* 80%*/80%*$45/$65 $25/$50 $25/$50 50%*/50%*

$7,150 $7,000 $7,150 $6,550 $6,550 $6,550$7,150

NoNo No No No No No

Page Number: 27 12/24/2014

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

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Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$214.21 $248.53 $248.53 $232.47 $232.47 $199.07 $199.07 $261.41 $261.41 $249.84 $249.84 $205.13 $205.13

$337.34 $391.40 $391.40 $366.10 $366.10 $313.50 $313.50 $411.67 $411.67 $393.46 $393.46 $323.04 $323.04

$337.34 $391.40 $391.40 $366.10 $366.10 $313.50 $313.50 $411.67 $411.67 $393.46 $393.46 $323.04 $323.04

$337.34 $391.40 $391.40 $366.10 $366.10 $313.50 $313.50 $411.67 $411.67 $393.46 $393.46 $323.04 $323.04

$337.34 $391.40 $391.40 $366.10 $366.10 $313.50 $313.50 $411.67 $411.67 $393.46 $393.46 $323.04 $323.04

$338.68 $392.96 $392.96 $367.56 $367.56 $314.75 $314.75 $413.31 $413.31 $395.03 $395.03 $324.33 $324.33

$345.43 $400.79 $400.79 $374.88 $374.88 $321.02 $321.02 $421.55 $421.55 $402.90 $402.90 $330.79 $330.79

$353.53 $410.18 $410.18 $383.67 $383.67 $328.54 $328.54 $431.43 $431.43 $412.34 $412.34 $338.54 $338.54

$366.68 $425.45 $425.45 $397.95 $397.95 $340.77 $340.77 $447.48 $447.48 $427.69 $427.69 $351.14 $351.14

$377.48 $437.97 $437.97 $409.66 $409.66 $350.80 $350.80 $460.65 $460.65 $440.28 $440.28 $361.48 $361.48

$382.88 $444.23 $444.23 $415.52 $415.52 $355.82 $355.82 $467.24 $467.24 $446.57 $446.57 $366.65 $366.65

$390.97 $453.63 $453.63 $424.30 $424.30 $363.34 $363.34 $477.12 $477.12 $456.02 $456.02 $374.40 $374.40

$399.07 $463.02 $463.02 $433.09 $433.09 $370.87 $370.87 $487.00 $487.00 $465.46 $465.46 $382.15 $382.15

$404.13 $468.89 $468.89 $438.58 $438.58 $375.57 $375.57 $493.18 $493.18 $471.36 $471.36 $387.00 $387.00

$409.53 $475.15 $475.15 $444.44 $444.44 $380.58 $380.58 $499.76 $499.76 $477.66 $477.66 $392.17 $392.17

$412.22 $478.29 $478.29 $447.37 $447.37 $383.09 $383.09 $503.06 $503.06 $480.80 $480.80 $394.75 $394.75

$414.92 $481.42 $481.42 $450.30 $450.30 $385.60 $385.60 $506.35 $506.35 $483.95 $483.95 $397.33 $397.33

$417.62 $484.55 $484.55 $453.23 $453.23 $388.11 $388.11 $509.64 $509.64 $487.10 $487.10 $399.92 $399.92

$420.32 $487.68 $487.68 $456.16 $456.16 $390.62 $390.62 $512.94 $512.94 $490.25 $490.25 $402.50 $402.50

$425.72 $493.94 $493.94 $462.01 $462.01 $395.63 $395.63 $519.52 $519.52 $496.54 $496.54 $407.67 $407.67

$431.12 $500.20 $500.20 $467.87 $467.87 $400.65 $400.65 $526.11 $526.11 $502.84 $502.84 $412.84 $412.84

$439.21 $509.60 $509.60 $476.66 $476.66 $408.17 $408.17 $535.99 $535.99 $512.28 $512.28 $420.59 $420.59

$446.97 $518.60 $518.60 $485.08 $485.08 $415.38 $415.38 $545.46 $545.46 $521.33 $521.33 $428.02 $428.02

$457.77 $531.12 $531.12 $496.79 $496.79 $425.41 $425.41 $558.63 $558.63 $533.92 $533.92 $438.36 $438.36

$471.26 $546.78 $546.78 $511.44 $511.44 $437.95 $437.95 $575.10 $575.10 $549.66 $549.66 $451.28 $451.28

$487.11 $565.18 $565.18 $528.64 $528.64 $452.69 $452.69 $594.45 $594.45 $568.15 $568.15 $466.46 $466.46

$506.01 $587.10 $587.10 $549.15 $549.15 $470.25 $470.25 $617.50 $617.50 $590.19 $590.19 $484.56 $484.56

$527.26 $611.75 $611.75 $572.21 $572.21 $490.00 $490.00 $643.44 $643.44 $614.97 $614.97 $504.91 $504.91

$551.55 $639.93 $639.93 $598.57 $598.57 $512.57 $512.57 $673.08 $673.08 $643.30 $643.30 $528.17 $528.17

$575.50 $667.72 $667.72 $624.56 $624.56 $534.83 $534.83 $702.30 $702.30 $671.24 $671.24 $551.10 $551.10

$602.48 $699.04 $699.04 $653.85 $653.85 $559.91 $559.91 $735.24 $735.24 $702.71 $702.71 $576.94 $576.94

$629.13 $729.96 $729.96 $682.77 $682.77 $584.67 $584.67 $767.76 $767.76 $733.80 $733.80 $602.46 $602.46

$658.48 $764.01 $764.01 $714.62 $714.62 $611.95 $611.95 $803.57 $803.57 $768.03 $768.03 $630.57 $630.57

$688.17 $798.45 $798.45 $746.84 $746.84 $639.54 $639.54 $839.80 $839.80 $802.65 $802.65 $659.00 $659.00

$720.22 $835.63 $835.63 $781.62 $781.62 $669.32 $669.32 $878.91 $878.91 $840.03 $840.03 $689.69 $689.69

$752.26 $872.82 $872.82 $816.40 $816.40 $699.10 $699.10 $918.02 $918.02 $877.41 $877.41 $720.37 $720.37

$787.01 $913.13 $913.13 $854.11 $854.11 $731.39 $731.39 $960.42 $960.42 $917.94 $917.94 $753.65 $753.65

$822.09 $953.84 $953.84 $892.18 $892.18 $763.99 $763.99 $1,003.23 $1,003.23 $958.86 $958.86 $787.24 $787.24

$859.54 $997.28 $997.28 $932.82 $932.82 $798.79 $798.79 $1,048.93 $1,048.93 $1,002.53 $1,002.53 $823.10 $823.10

$878.09 $1,018.81 $1,018.81 $952.95 $952.95 $816.04 $816.04 $1,071.57 $1,071.57 $1,024.17 $1,024.17 $840.87 $840.87

$915.54 $1,062.25 $1,062.25 $993.59 $993.59 $850.83 $850.83 $1,117.27 $1,117.27 $1,067.85 $1,067.85 $876.73 $876.73

$947.92 $1,099.83 $1,099.83 $1,028.74 $1,028.74 $880.93 $880.93 $1,156.79 $1,156.79 $1,105.62 $1,105.62 $907.74 $907.74

$969.17 $1,124.49 $1,124.49 $1,051.80 $1,051.80 $900.68 $900.68 $1,182.72 $1,182.72 $1,130.41 $1,130.41 $928.09 $928.09

$995.82 $1,155.41 $1,155.41 $1,080.72 $1,080.72 $925.45 $925.45 $1,215.24 $1,215.24 $1,161.49 $1,161.49 $953.61 $953.61

$1,012.02 $1,174.20 $1,174.20 $1,098.30 $1,098.30 $940.50 $940.50 $1,235.01 $1,235.01 $1,180.38 $1,180.38 $969.12 $969.12

55957PA038000155957PA0280003 55957PA0280004 55957PA0300001 55957PA0300002 55957PA0370001 55957PA0370002

FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-QHDHP-1/1/16 FP-1-SG-EHB-AffordaBlue-1/1/16

FP-1-SG-X-AffordaBlue-1/1/16FP-1-SG-EHB-AffordaBlue-1/1/16

Rating Area 3 Rating Area 3Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3 Rating Area 3

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

None None None None

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

Tioga, Bradford, Susquehanna,

Wayne, Clinton, Lycoming, Sullivan,

Wyoming, Luzerne, Lackawanna,

Pike, Carbon

PPO PPO PPOPPO PPO Tiered CustomPPO Tiered CustomPPO

Gold Gold SilverSilver Gold Platinum GoldLehigh Valley Flex Blue PPO 1250G Lehigh Valley Flex Blue PPO BlueCare QHD PPO Silver 1 BlueCare QHD PPO Gold 1 AffordaBlue Platinum1 AffordaBlue Gold Option 1 Lehigh Valley Flex Blue PPO 500G

$3,000/$3,000$2,000 $1,500 $250/ $750 $1,500/$2,000 $500/$1,500 $1,250/$3,750

100% 100%/70% 100%/70% 100%/70% 100%/70% 90%/70%80%$10/$50 / $20/$75 $10/$50 / $20/$75 90%/70%* / 90%/70%*80%*/80%* $20*/$40* $20/70%* / $40 /70%* $25/70%* / $50/70%*

$7,150/$7,150 $6,550/$6,550$6,550 $3,100 $1,000/$5,000 $3,000/$4,000 $7,150/$7,150

NoNo No No No No No

Page Number: 28 12/24/2014

Silver Plan Rates for Age 21 Non-Smoker, by Geographic Area and Exchange Status

HIOS Plan ID # Rating Area 1 Rating Area 2 Rating Area 3 Rating Area 4 Rating Area 5 Rating Area 6 Rating Area 7 Rating Area 8 Rating Area 9

2017 On-Exchange Silver Plan Rates

Silver Plan Rates for Age 21 Non-Smoker, by Geographic Area and Exchange Status

HIOS Plan ID # Rating Area 1 Rating Area 2 Rating Area 3 Rating Area 4 Rating Area 5 Rating Area 6 Rating Area 7 Rating Area 8 Rating Area 9

55957PA0270022 $ 309.26

55957PA0270019 $ 294.17

55957PA0270020 $ 312.60

55957PA0270021 $ 309.32

55957PA0290023 $ 259.78

55957PA0290017 $ 247.10

55957PA0290018 $ 262.59

55957PA0290019 $ 259.83

55957PA0280003 $ 310.00

55957PA0380001 $ 296.87

2017 Off-Exchange Silver Plan Rates

Supporting Document Schedules Satisfied - Item: Unified Rate Review TemplateComments: Revised 8-12-16. Unified Rate Review Template (both excel and PDF format) required.

Attachment(s): Unified_Rate_Review_Template PID OFFER FINAL.pdfUnified_Rate_Review_Template PID OFFER FINAL.xlsm

Item Status:Status Date:

Satisfied - Item: Redacted Non-Confidential PID Actuarial MemorandumComments: Revised 8-12-16. Redacted Non-Confidential PID Actuarial Memorandum required.Attachment(s): PID Actuarial Memorandum - FPLIC SG - PID OFFER FINAL REDACTED.pdfItem Status:Status Date:

Satisfied - Item: Redacted Non-Confidential Part III Actuarial Memorandum and CertificationsComments: Redacted Non-Confidential Part III Actuarial Memorandum and Certifications required.Attachment(s):Item Status:Status Date:

SERFF Tracking #: HGHM-130536975 State Tracking #: HGHM-130536975 Company Tracking #:

State: Pennsylvania Filing Company: First Priority Life Insurance Compnay

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

Product Name: FPLIC Small Group Rates 2017

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number HGHM-130536975 Generated 10/14/2016 09:46 AM

Attachment Unified_Rate_Review_Template PID OFFER FINAL.xlsm is not a PDF document and cannotbe reproduced here.

SERFF Tracking #: HGHM-130536975 State Tracking #: HGHM-130536975 Company Tracking #:

State: Pennsylvania Filing Company: First Priority Life Insurance Compnay

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

Product Name: FPLIC Small Group Rates 2017

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number HGHM-130536975 Generated 10/14/2016 09:46 AM

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A B C D E F G H I J K L M N O P Q R S T U V W X Y

Ac

tioUnified Rate Review v3.3

Company Legal Name: First Priority Life Insurance CompanyState: PA

HIOS Issuer ID: 55957 Market: Small Group

Effective Date of Rate Change(s): 1/1/2017

Market Level Calculations (Same for all Plans)

Section I: Experience period data

Experience Period: 1/1/2015 to 12/31/2015

Experience Period

Aggregate Amount PMPM % of Prem

Premiums (net of MLR Rebate) in Experience Period: $188,549,084 $405.31 100.00%

Incurred Claims in Experience Period $163,753,832 352.01 86.85%

Allowed Claims: $190,800,682 410.15 101.19%

Index Rate of Experience Period $410.00

Experience Period Member Months 465,201

Section II: Allowed Claims, PMPM basis

Experience Period Projection Period: 1/1/2017 to 12/31/2017 Mid-point to Mid-point, Experience to Projection: 24 months

on Actual Experience Allowed

Adj't. from Experience to

Projection Period Projections, before credibility Adjustment Credibility Manual

Benefit Category

Utilization

Description

Utilization per

1,000

Average

Cost/Service PMPM

Pop'l risk

Morbidity Other Cost Util

Utilization per

1,000

Average

Cost/Service PMPM

Utilization

per 1,000

Average

Cost/Service PMPM

Inpatient Hospital Admits 63.88 $14,208.49 $75.64 1.169 0.929 1.070 1.021 77.85 $15,112.32 $98.04 0.00 $0.00 $0.00

Outpatient Hospital Services 2,239.52 810.51 151.26 1.169 0.929 1.070 1.021 2,729.10 862.06 196.06 0.00 0.00 0.00

Professional Services 8,101.18 153.44 103.58 1.169 0.929 1.056 1.015 9,756.52 158.95 129.24 0.00 0.00 0.00

Other Medical Services 1.00 10.00 0.00 1.000 7,860.000 1.000 1.000 1.00 78,600.00 6.55 0.00 0.00 0.00

Capitation Other 0.00 0.00 0.00 1.000 1.000 1.000 1.000 0.00 0.00 0.00 0.00 0.00 0.00

Prescription Drug Prescriptions 7,787.86 122.75 79.66 1.169 0.944 1.078 1.020 9,471.81 134.66 106.29 0.00 0.00 0.00

Total $410.15 $536.16 $0.00

After Credibility Projected Period Totals

Section III: Projected Experience: Projected Allowed Experience Claims PMPM (w/applied credibility if applicable) 100.00% 0.00% $536.16 $32,169,900

Paid to Allowed Average Factor in Projection Period 0.872

Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM $467.54 $28,052,153

Projected Risk Adjustments PMPM -0.13 (7,800)

Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM $467.67 $28,059,953

Projected ACA reinsurance recoveries, net of rein prem, PMPM 0.00 0

Projected Incurred Claims $467.67 $28,059,953

Administrative Expense Load 8.11% 42.26 2,535,557

Profit & Risk Load 0.00% 0.00 0

Taxes & Fees 2.14% 11.15 669,062

Single Risk Pool Gross Premium Avg. Rate, PMPM $521.08 $31,264,571

Index Rate for Projection Period $549.08

% increase over Experience Period 28.56%

% Increase, annualized: 13.39%

Projected Member Months 60,000

Information Not Releasable to the Public Unless Authorized by Law: This information has not been publically disclosed and may be privileged and confidential. It is for internal government use only and must not be

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Annualized Trend

Factors

1 of 5

Product-Plan Data Collection

Company Legal Name: First Priority Life Insurance Company State: PA

HIOS Issuer ID: 55957 Market: Small Group

Effective Date of Rate Change(s):

Product/Plan Level Calculations

Section I: General Product and Plan Information

Product

Product ID:

Metal: Platinum Platinum Platinum Gold Gold Gold Gold Bronze Platinum Gold Gold Silver Silver Silver Silver Bronze Bronze Silver Gold Platinum Platinum Platinum

AV Metal Value 0.884 0.885 0.885 0.783 0.792 0.800 0.784 0.615 0.889 0.804 0.809 0.696 0.708 0.691 0.689 0.620 0.619 0.704 0.782 0.884 0.885 0.885

AV Pricing Value 1.287 1.272 1.286 1.089 1.090 1.109 1.064 0.736 1.295 1.163 1.071 0.870 0.924 0.914 0.914 0.727 0.729 0.916 1.063 1.081 1.069 1.081

Plan Category Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing New New New New New New Renewing Renewing New New Renewing Renewing Renewing

Plan Type: PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

Plan Name BlueCare PPO

Platinum 2

BlueCare PPO

Platinum 11

BlueCare PPO

Platinum 12

BlueCare PPO

Gold 12

BlueCare PPO

Gold 18

BlueCare PPO

Gold 19

BlueCare PPO

Gold 24

BlueCare PPO

Bronze 4

BlueCare PPO

Platinum 13

BlueCare PPO

Gold 27

BlueCare PPO

Gold 15

BlueCare PPO

Silver 2

BlueCare PPO

Silver 6

BlueCare PPO

Silver 9

BlueCare PPO

Silver 10

BlueCare QHD

PPO Bronze 3

BlueCare QHD

PPO Bronze 4

BlueCare QHD

PPO Silver 1

BlueCare QHD

PPO Gold 1

BlueCare Custom

PPO Platinum 2

BlueCare Custom

PPO Platinum 11

BlueCare Custom

PPO Platinum 12

Plan ID (Standard Component ID): 55957PA0270002 55957PA0270006 55957PA0270007 55957PA0270008 55957PA0270009 55957PA0270010 55957PA0270011 55957PA0270013 55957PA0270016 55957PA0270017 55957PA0270018 55957PA0270019 55957PA0270020 55957PA0270021 55957PA0270022 55957PA0280001 55957PA0280002 55957PA0280003 55957PA0280004 55957PA0290002 55957PA0290006 55957PA0290007

Exchange Plan? No No Yes No No No No No No No No No No No No No No No No No No No

Historical Rate Increase - Calendar Year - 2

Historical Rate Increase - Calendar Year - 1

Historical Rate Increase - Calendar Year 0

Effective Date of Proposed Rates 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017

Rate Change % (over prior filing) 1.84% 1.94% -0.48% -6.34% -6.16% -4.35% -6.70% -9.57% 3.32% 0.00% -2.36% 0.00% -6.30% 0.00% 0.00% -10.59% -9.82% 0.00% 0.00% 1.85% 1.95% -0.48%

Cum'tive Rate Change % (over 12 mos prior) 5.24% 5.34% 2.83% -3.22% -3.04% -1.16% -3.60% -6.54% 6.76% 0.00% 0.92% 0.00% -3.15% 0.00% 0.00% -7.38% -6.89% 0.00% 0.00% 5.24% 5.34% 2.83%

Proj'd Per Rate Change % (over Exper. Period) 16.68% 16.78% 13.74% 5.15% 7.91% 10.01% 7.26% -10.46% #DIV/0! #DIV/0! 12.13% #DIV/0! 7.78% #DIV/0! #DIV/0! 0.23% -0.51% #DIV/0! #DIV/0! 16.68% 16.78% 13.74%

Product Rate Increase %

Section II: Components of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM)

Plan ID (Standard Component ID): Total 55957PA0270002 55957PA0270006 55957PA0270007 55957PA0270008 55957PA0270009 55957PA0270010 55957PA0270011 55957PA0270013 55957PA0270016 55957PA0270017 55957PA0270018 55957PA0270019 55957PA0270020 55957PA0270021 55957PA0270022 55957PA0280001 55957PA0280002 55957PA0280003 55957PA0280004 55957PA0290002 55957PA0290006 55957PA0290007

Inpatient $0.31 $14.64 $14.56 $12.45 $5.47 $5.64 $7.39 $5.01 $1.63 $16.07 $0.00 $8.83 $0.00 $4.67 $0.00 $0.00 $1.16 $1.36 $0.00 $0.00 $12.30 $12.23 $10.45

Outpatient $0.67 $30.79 $30.62 $26.44 $12.33 $12.67 $16.17 $11.39 $4.25 $33.65 $0.00 $18.98 $0.00 $10.53 $0.00 $0.00 $3.29 $3.70 $0.00 $0.00 $25.87 $25.72 $22.21

Professional -$0.16 $1.21 $1.33 -$2.09 -$9.44 -$9.20 -$6.84 -$9.71 -$9.50 $3.25 $0.00 -$4.06 $0.00 -$7.95 $0.00 $0.00 -$10.07 -$9.79 $0.00 $0.00 $1.02 $1.12 -$1.76

Prescription Drug $0.45 $19.58 $19.45 $17.29 $9.34 $9.52 $11.41 $8.78 $4.16 $21.10 $0.00 $12.79 $0.00 $7.96 $0.00 $0.00 $3.63 $3.85 $0.00 $0.00 $16.45 $16.34 $14.52

Other $0.22 $7.23 $7.15 $7.22 $6.12 $6.12 $6.23 $5.97 $4.14 $7.27 $0.00 $6.02 $0.00 $5.19 $0.00 $0.00 $4.08 $4.10 $0.00 $0.00 $6.07 $6.00 $6.07

Capitation $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Administration $0.05 $4.09 $4.09 $2.94 -$0.19 -$0.10 $0.77 -$0.36 -$1.22 $4.83 $0.00 $1.64 $0.00 -$0.14 $0.00 $0.00 -$1.44 -$1.34 $0.00 $0.00 $3.44 $3.44 $2.47

Taxes & Fees -$1.07 -$33.22 -$32.79 -$34.31 -$31.62 -$31.57 -$31.26 -$31.05 -$22.43 -$32.74 $0.00 -$29.35 $0.00 -$26.81 $0.00 $0.00 -$22.38 -$22.34 $0.00 $0.00 -$27.90 -$27.55 -$28.82

Risk & Profit Charge -$1.02 -$32.38 -$31.97 -$33.11 -$29.79 -$29.77 -$29.69 -$29.21 -$20.86 -$32.11 $0.00 -$28.11 $0.00 -$25.26 $0.00 $0.00 -$20.76 -$20.75 $0.00 $0.00 -$27.20 -$26.86 -$27.82

Total Rate Increase -$0.54 $11.95 $12.44 -$3.18 -$37.79 -$36.69 -$25.82 -$39.18 -$39.82 $21.32 $0.00 -$13.27 $0.00 -$31.81 $0.00 $0.00 -$42.49 -$41.21 $0.00 $0.00 $10.06 $10.45 -$2.67

Member Cost Share Increase $0.73 -$7.02 -$6.67 $5.14 $42.63 $41.69 $32.09 $45.00 $61.78 -$14.89 $0.00 $23.90 $0.00 $46.03 $0.00 $0.00 $64.34 $63.22 $0.00 $0.00 -$5.90 -$5.61 $4.33

Average Current Rate PMPM $502.86 $647.55 $639.50 $662.28 $595.89 $595.31 $593.83 $584.24 $417.18 $642.25 $0.00 $562.11 $0.00 $505.29 $0.00 $0.00 $415.11 $414.91 $0.00 $0.00 $543.92 $537.17 $556.32

Projected Member Months 60,000 4,609 5,214 1,738 2,349 150 244 2,227 100 1,504 646 96 90 13 28 60 13 11 490 100 9,292 4,039 3,221

Section III: Experience Period Information

Plan ID (Standard Component ID): Total 55957PA0270002 55957PA0270006 55957PA0270007 55957PA0270008 55957PA0270009 55957PA0270010 55957PA0270011 55957PA0270013 55957PA0270016 55957PA0270017 55957PA0270018 55957PA0270019 55957PA0270020 55957PA0270021 55957PA0270022 55957PA0280001 55957PA0280002 55957PA0280003 55957PA0280004 55957PA0290002 55957PA0290006 55957PA0290007

Plan Adjusted Index Rate $39.07 $565.22 $558.24 $579.50 $530.74 $517.67 $516.31 $508.17 $421.46 $0.00 $0.00 $489.46 $0.00 $439.31 $0.00 $0.00 $371.78 $375.60 $0.00 $0.00 $474.79 $468.92 $486.78

Member Months 465,201 1,705 223 1,103 197 95 0 1,207 0 0 0 13 0 57 0 0 0 0 0 0 2,407 509 2,045

Total Premium (TP) $18,173,445 $963,700 $124,488 $639,189 $104,556 $49,179 $0 $613,361 $0 $0 $0 $6,363 $0 $25,041 $0 $0 $0 $0 $0 $0 $1,142,820 $238,680 $995,465

EHB Percent of TP, [see instructions] 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 0.00% 99.96% 0.00% 0.00% 0.00% 99.96% 0.00% 99.96% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 99.96% 99.96% 99.96%

state mandated benefits portion of TP that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TP 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 100.00% 0.04% 100.00% 100.00% 100.00% 0.04% 100.00% 0.04% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 0.04% 0.04% 0.04%

Total Allowed Claims (TAC) $190,689,548 $978,004 $86,606 $691,312 $83,294 $43,786 $0 $1,185,488 $0 $0 $0 $40,598 $0 $10,022 $0 $0 $0 $0 $0 $0 $1,013,246 $207,153 $944,602

EHB Percent of TAC, [see instructions] 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 0.00% 99.96% 0.00% 0.00% 0.00% 99.96% 0.00% 99.96% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 99.96% 99.96% 99.96% state mandated benefits portion of TAC that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TAC 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 100.00% 0.04% 100.00% 100.00% 100.00% 0.04% 100.00% 0.04% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 0.04% 0.04% 0.04%

Allowed Claims which are not the issuer's obligation: $27,046,850 $77,981 $10,792 $30,595 $15,400 $7,128 $0 $132,634 $0 $0 $0 $3,449 $0 $6,059 $0 $0 $0 $0 $0 $0 $137,987 $31,652 $70,009Portion of above payable by HHS's funds on

behalf of insured person, in dollars $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0Portion of above payable by HHS on behalf

of insured person, as % 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% #DIV/0! 0.00% #DIV/0! #DIV/0! #DIV/0! 0.00% #DIV/0! 0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.00% 0.00% 0.00% Total Incurred claims, payable with issuer funds $163,642,698 $900,023 $75,814 $660,718 $67,894 $36,659 $0 $1,052,853 $0 $0 $0 $37,149 $0 $3,963 $0 $0 $0 $0 $0 $0 $875,259 $175,501 $874,593

Net Amt of Rein -$1,707,287.67 -$6,257.35 -$818.41 -$4,048.01 -$722.99 -$348.65 $0.00 -$4,429.69 $0.00 $0.00 $0.00 -$47.71 $0.00 -$209.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$8,833.69 -$1,868.03 -$7,505.15

Net Amt of Risk Adj -$5,499.08 -$248.65 -$32.52 -$160.85 -$28.73 -$13.85 $0.00 -$176.02 $0.00 $0.00 $0.00 -$1.90 $0.00 -$8.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$351.02 -$74.23 -$298.23

Incurred Claims PMPM $351.77 $527.87 $339.97 $599.02 $344.64 $385.88 #DIV/0! $872.29 #DIV/0! #DIV/0! #DIV/0! $2,857.64 #DIV/0! $69.53 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $363.63 $344.80 $427.67

Allowed Claims PMPM $409.91 $573.61 $388.37 $626.76 $422.81 $460.91 #DIV/0! $982.18 #DIV/0! #DIV/0! #DIV/0! $3,122.94 #DIV/0! $175.83 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $420.96 $406.98 $461.91

EHB portion of Allowed Claims, PMPM $409.74 $573.38 $388.21 $626.51 $422.64 $460.72 #DIV/0! $981.78 #DIV/0! #DIV/0! #DIV/0! $3,121.69 #DIV/0! $175.76 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $420.79 $406.82 $461.72

Section IV: Projected (12 months following effective date)

Plan ID (Standard Component ID): Total 55957PA0270002 55957PA0270006 55957PA0270007 55957PA0270008 55957PA0270009 55957PA0270010 55957PA0270011 55957PA0270013 55957PA0270016 55957PA0270017 55957PA0270018 55957PA0270019 55957PA0270020 55957PA0270021 55957PA0270022 55957PA0280001 55957PA0280002 55957PA0280003 55957PA0280004 55957PA0290002 55957PA0290006 55957PA0290007

Plan Adjusted Index Rate $538.08 $659.50 $651.94 $659.10 $558.09 $558.63 $568.01 $545.07 $377.36 $663.57 $596.07 $548.84 $445.55 $473.47 $468.51 $468.42 $372.62 $373.70 $469.54 $544.79 $553.98 $547.63 $553.65

Member Months 60,000 4,609 5,214 1,738 2,349 150 244 2,227 100 1,504 646 96 90 13 28 60 13 11 490 100 9,292 4,039 3,221

Total Premium (TP) $32,284,632 $3,039,614 $3,399,192 $1,145,523 $1,310,957 $83,794 $138,594 $1,213,865 $37,736 $998,010 $385,059 $52,689 $40,100 $6,155 $13,118 $28,105 $4,844 $4,111 $230,072 $54,479 $5,147,545 $2,211,861 $1,783,298

EHB Percent of TP, [see instructions] 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

state mandated benefits portion of TP that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TP 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04%

Total Allowed Claims (TAC) $32,163,640 $2,863,008 $3,238,821 $1,079,607 $1,370,329 $87,505 $142,342 $1,299,158 $54,015 $934,251 $376,855 $56,003 $50,072 $7,233 $15,578 $33,382 $7,022 $5,942 $272,616 $58,337 $4,848,466 $2,107,507 $1,680,683

EHB Percent of TAC, [see instructions] 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

state mandated benefits portion of TAC that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TAC 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04%

Allowed Claims which are not the issuer's obligation $4,125,583 $223,211 $286,743 $84,761 $231,810 $14,733 $21,977 $244,960 $21,243 $67,515 $42,445 $10,245 $15,247 $1,887 $4,185 $8,973 $2,815 $2,372 $72,806 $11,023 $378,006 $186,584 $131,952

Portion of above payable by HHS's funds on

behalf of insured person, in dollars $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Portion of above payable by HHS on behalf

of insured person, as % 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Total Incurred claims, payable with issuer funds $28,038,057 $2,639,797 $2,952,078 $994,846 $1,138,519 $72,772 $120,364 $1,054,199 $32,772 $866,736 $334,410 $45,758 $34,825 $5,346 $11,393 $24,408 $4,207 $3,570 $199,810 $47,313 $4,470,460 $1,920,923 $1,548,731

Net Amt of Rein $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Net Amt of Risk Adj -$7,800 -$599 -$678 -$226 -$305 -$20 -$32 -$290 -$13 -$196 -$84 -$12 -$12 -$2 -$4 -$8 -$2 -$1 -$64 -$13 -$1,208 -$525 -$419

-7.16%

BlueCare CustomPPO

55957PA029

0.00%

-0.62%

9.13%

0.64%

BlueCare QHD PPO

55957PA028

0.00%

0.08%

6.61%

1/1/2017

BlueCare PPO

55957PA027

0.00%

-0.49%

9.48%

2.92%

Lehigh Valley Flex Blue PPO HDHP

55957PA038

Platinum Gold Gold Gold Gold Gold Silver Silver Silver Bronze Gold Silver Platinum Gold Gold Gold Silver Silver Platinum Platinum Platinum Platinum Platinum Platinum Gold Gold

0.889 0.783 0.809 0.792 0.800 0.784 0.696 0.708 0.691 0.615 0.804 0.689 0.891 0.796 0.816 0.782 0.694 0.717 0.903 0.892 0.901 0.898 0.902 0.887 0.815 0.808

1.088 0.915 0.900 0.916 0.931 0.894 0.730 0.776 0.768 0.619 0.977 0.768 0.995 0.852 1.118 1.069 0.878 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing New New Renewing Renewing New New New Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated

PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

BlueCare Custom

PPO Platinum 13

BlueCare Custom

PPO Gold 12

BlueCare Custom

PPO Gold 15

BlueCare Custom

PPO Gold 18

BlueCare Custom

PPO Gold 19

BlueCare Custom

PPO Gold 24

BlueCare Custom

PPO Silver 2

BlueCare Custom

PPO Silver 6

BlueCare Custom

PPO Silver 9

BlueCare Custom

PPO Bronze 4

BlueCare Custom

PPO Gold 27

BlueCare Custom

PPO Silver 10

AffordaBlue

Platinum1

AffordaBlue Gold

Option 1

Lehigh Valley Flex

Blue PPO 500G

Lehigh Valley Flex

Blue PPO 1250G

Lehigh Valley Flex

Blue PPO 3000SQE

BlueCare PPO

Silver Option 2

BlueCare PPO

Platinum 1

BlueCare PPO

Platinum 3

BlueCare PPO

Platinum 6

BlueCare PPO

Platinum 7

BlueCare PPO

Platinum Option 5

BlueCare PPO

Platinum Option 8

BlueCare PPO

Gold Option 1

BlueCare PPO

Gold Option 2

55957PA0290008 55957PA0290011 55957PA0290012 55957PA0290013 55957PA0290014 55957PA0290016 55957PA0290017 55957PA0290018 55957PA0290019 55957PA0290021 55957PA0290022 55957PA0290023 55957PA0300001 55957PA0300002 55957PA0370001 55957PA0370002 55957PA0380001 55957PA0050001 55957PA0050003 55957PA0050005 55957PA0050008 55957PA0050009 55957PA0050007 55957PA0050010 55957PA0050015 55957PA0050016

Yes No No No No No Yes No Yes No No No Yes Yes No No No No No No No No No No No No

0.00%

0.00%

0.00%

1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017

3.29% -6.34% -2.51% -6.17% -4.35% -6.71% -10.15% -6.59% -10.83% -9.56% 0.00% 0.00% 2.97% -5.71% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

6.75% -3.22% 0.74% -3.04% -1.16% -3.60% -7.15% -3.48% -7.86% -6.54% 0.00% 0.00% 6.40% -2.57% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

#DIV/0! 5.15% 12.13% 7.91% 10.01% 7.30% 1.12% 7.41% 2.50% -10.46% #DIV/0! #DIV/0! 18.03% 5.63% #DIV/0! #DIV/0! #DIV/0! -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00%

0.00%

55957PA0290008 55957PA0290011 55957PA0290012 55957PA0290013 55957PA0290014 55957PA0290016 55957PA0290017 55957PA0290018 55957PA0290019 55957PA0290021 55957PA0290022 55957PA0290023 55957PA0300001 55957PA0300002 55957PA0370001 55957PA0370002 55957PA0380001 55957PA0050001 55957PA0050003 55957PA0050005 55957PA0050008 55957PA0050009 55957PA0050007 55957PA0050010 55957PA0050015 55957PA0050016

$13.50 $4.59 $7.31 $4.73 $6.21 $4.21 $1.22 $3.73 $0.80 $1.37 $0.00 $0.00 $12.10 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$28.27 $10.36 $15.74 $10.64 $13.58 $9.57 $3.42 $8.46 $2.63 $3.56 $0.00 $0.00 $25.36 $10.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$2.73 -$7.93 -$3.56 -$7.73 -$5.75 -$8.16 -$10.02 -$6.97 -$11.28 -$7.98 $0.00 $0.00 $2.13 -$6.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$17.73 $7.84 $10.64 $8.00 $9.58 $7.38 $3.71 $6.48 $3.39 $3.49 $0.00 $0.00 $15.95 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$6.11 $5.14 $5.05 $5.14 $5.23 $5.02 $4.10 $4.36 $4.31 $3.47 $0.00 $0.00 $5.59 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$4.06 -$0.16 $1.32 -$0.09 $0.65 -$0.30 -$1.42 -$0.22 -$1.75 -$1.02 $0.00 $0.00 $3.58 $0.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

-$27.50 -$26.56 -$24.70 -$26.52 -$26.26 -$26.10 -$22.45 -$22.62 -$23.85 -$18.84 $0.00 $0.00 -$25.27 -$24.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

-$26.97 -$25.03 -$23.64 -$25.00 -$24.94 -$24.55 -$20.83 -$21.29 -$22.07 -$17.52 $0.00 $0.00 -$24.74 -$23.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$17.91 -$31.75 -$11.85 -$30.82 -$21.70 -$32.93 -$42.26 -$28.07 -$47.81 -$33.47 $0.00 $0.00 $14.70 -$26.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

-$12.51 $35.81 $20.66 $35.02 $26.95 $37.79 $53.39 $39.74 $55.96 $51.88 $0.00 $0.00 -$8.62 $31.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$539.49 $500.55 $472.87 $500.07 $498.84 $490.98 $416.52 $425.79 $441.35 $350.45 $0.00 $0.00 $494.88 $462.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

100 6,403 465 1,008 619 6,388 1,054 977 1,144 66 3,354 102 1,089 697 100 100 100 0 0 0 0 0 0 0 0 0

55957PA0290008 55957PA0290011 55957PA0290012 55957PA0290013 55957PA0290014 55957PA0290016 55957PA0290017 55957PA0290018 55957PA0290019 55957PA0290021 55957PA0290022 55957PA0290023 55957PA0300001 55957PA0300002 55957PA0370001 55957PA0370002 55957PA0380001 55957PA0050001 55957PA0050003 55957PA0050005 55957PA0050008 55957PA0050009 55957PA0050007 55957PA0050010 55957PA0050015 55957PA0050016

$0.00 $445.83 $411.15 $434.84 $433.70 $426.88 $370.12 $370.29 $383.93 $354.02 $0.00 $0.00 $431.74 $413.08 $0.00 $0.00 $0.00 $440.61 $566.25 $564.47 $563.30 $562.86 $563.93 $562.49 $549.53 $547.70

0 376 139 386 393 4,055 669 446 594 0 0 0 691 355 0 0 0 38 3,087 955 718 288 155 60 187 155

$0 $167,632 $57,150 $167,848 $170,444 $1,730,998 $247,610 $165,149 $228,054 $0 $0 $0 $298,332 $146,643 $0 $0 $0 $16,743 $1,748,014 $539,069 $404,449 $162,104 $87,409 $33,749 $102,762 $84,894

0.00% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 0.00% 0.00% 0.00% 99.96% 99.96% 0.00% 0.00% 0.00% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

100.00% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 100.00% 100.00% 100.00% 0.04% 0.04% 100.00% 100.00% 100.00% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04%

$0 $136,852 $53,228 $160,249 $308,516 $1,460,240 $330,804 $134,737 $134,036 $0 $0 $0 $230,640 $148,039 $0 $0 $0 $8,384 $1,808,103 $429,214 $601,913 $122,902 $61,403 $44,437 $72,537 $41,183

0.00% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 0.00% 0.00% 0.00% 99.96% 99.96% 0.00% 0.00% 0.00% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

100.00% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 100.00% 100.00% 100.00% 0.04% 0.04% 100.00% 100.00% 100.00% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04%

$0 $32,276 $14,715 $34,019 $27,013 $314,448 $85,507 $55,023 $69,254 $0 $0 $0 $32,175 $26,905 $0 $0 $0 $4,572 $135,419 $46,669 $44,195 $13,894 $8,617 $2,900 $8,894 $9,155

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

#DIV/0! 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% #DIV/0! #DIV/0! #DIV/0! 0.00% 0.00% #DIV/0! #DIV/0! #DIV/0! 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%$0 $104,575 $38,513 $126,230 $281,502 $1,145,792 $245,297 $79,714 $64,782 $0 $0 $0 $198,465 $121,135 $0 $0 $0 $3,812 $1,672,685 $382,545 $557,718 $109,008 $52,785 $41,537 $63,643 $32,028

$0.00 -$1,379.92 -$510.13 -$1,416.62 -$1,442.31 -$14,881.85 -$2,455.23 -$1,636.82 -$2,179.98 $0.00 $0.00 $0.00 -$2,535.97 -$1,302.85 $0.00 $0.00 $0.00 -$139.46 -$11,329.29 -$3,504.85 -$2,635.06 -$1,056.96 -$568.85 -$220.20 -$686.29 -$568.85

$0.00 -$54.83 -$20.27 -$56.29 -$57.31 -$591.35 -$97.56 -$65.04 -$86.63 $0.00 $0.00 $0.00 -$100.77 -$51.77 $0.00 $0.00 $0.00 -$5.54 -$450.19 -$139.27 -$104.71 -$42.00 -$22.60 -$8.75 -$27.27 -$22.60

#DIV/0! $278.13 $277.07 $327.02 $716.29 $282.56 $366.66 $178.73 $109.06 #DIV/0! #DIV/0! #DIV/0! $287.21 $341.22 #DIV/0! #DIV/0! #DIV/0! $100.33 $541.85 $400.57 $776.77 $378.50 $340.55 $692.28 $340.34 $206.63

#DIV/0! $363.97 $382.94 $415.15 $785.03 $360.11 $494.47 $302.10 $225.65 #DIV/0! #DIV/0! #DIV/0! $333.78 $417.01 #DIV/0! #DIV/0! #DIV/0! $220.63 $585.72 $449.44 $838.32 $426.74 $396.15 $740.62 $387.90 $265.70

#DIV/0! $363.82 $382.78 $414.99 $784.71 $359.96 $494.28 $301.98 $225.56 #DIV/0! #DIV/0! #DIV/0! $333.64 $416.85 #DIV/0! #DIV/0! #DIV/0! $220.54 $585.48 $449.26 $837.98 $426.57 $395.99 $740.32 $387.74 $265.59

55957PA0290008 55957PA0290011 55957PA0290012 55957PA0290013 55957PA0290014 55957PA0290016 55957PA0290017 55957PA0290018 55957PA0290019 55957PA0290021 55957PA0290022 55957PA0290023 55957PA0300001 55957PA0300002 55957PA0370001 55957PA0370002 55957PA0380001 55957PA0050001 55957PA0050003 55957PA0050005 55957PA0050008 55957PA0050009 55957PA0050007 55957PA0050010 55957PA0050015 55957PA0050016

$557.40 $468.80 $461.03 $469.25 $477.13 $458.05 $374.26 $397.72 $393.55 $316.98 $500.70 $393.47 $509.57 $436.35 $573.00 $547.66 $449.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

100 6,403 465 1,008 619 6,388 1,054 977 1,144 66 3,354 102 1,089 697 100 100 100 - - - - - - - - -

$55,740 $3,001,706 $214,377 $473,001 $295,345 $2,926,001 $394,474 $388,571 $450,217 $20,921 $1,679,332 $40,134 $554,925 $304,139 $57,300 $54,766 $44,964 $0 $0 $0 $0 $0 $0 $0 $0 $0

99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

$52,179 $3,137,651 $227,863 $493,948 $303,327 $3,130,300 $492,578 $456,593 $534,639 $29,946 $1,643,555 $47,669 $534,405 $321,219 $57,228 $57,228 $54,579 $0 $0 $0 $0 $0 $0 $0 $0 $0

99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

$3,771 $530,776 $41,684 $83,163 $46,831 $589,172 $149,992 $119,133 $143,641 $11,777 $185,114 $12,814 $52,473 $57,086 $7,465 $9,666 $15,529 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$48,408 $2,606,875 $186,179 $410,785 $256,497 $2,541,128 $342,587 $337,460 $390,998 $18,169 $1,458,440 $34,855 $481,933 $264,134 $49,763 $47,562 $39,049 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

-$13 -$832 -$60 -$131 -$80 -$830 -$137 -$127 -$149 -$9 -$436 -$13 -$142 -$91 -$13 -$13 -$13 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00%

BlueCare PPO

55957PA005

0.00%

0.00%

0.00%

3.04%

Lehigh Valley Flex Blue PPO

55957PA037

0.00%

0.00%

0.00%

0.00%

AffordaBlue

55957PA030

0.00%

-0.81%

8.80%

BlueCare CustomPPO

55957PA029

0.00%

-0.62%

9.13%

0.64%

Gold Gold Gold Gold Gold Gold Gold Gold Gold Silver Silver Silver Bronze Silver Platinum Platinum Platinum Platinum Platinum Gold Bronze Platinum Gold Gold Gold Gold

0.802 0.806 0.818 0.812 0.807 0.806 0.801 0.797 0.782 0.688 0.715 0.689 0.610 0.681 0.902 0.903 0.892 0.901 0.898 0.804 0.612 0.890 0.815 0.808 0.802 0.817

0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010

Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated

PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

BlueCare PPO

Gold Option 3

BlueCare PPO

Gold Option 7

BlueCare PPO

Gold Option 9

BlueCare PPO

Gold Option 10

BlueCare PPO

Gold Option 11

BlueCare PPO

Gold Option 15

BlueCare PPO

Gold Option 21

BlueCare PPO

Gold Option 22

BlueCare PPO

Gold Option 26

BlueCare PPO

Silver Option 6

BlueCare PPO

Silver Option 8

BlueCare QHD

PPO Silver Option

4

BlueCare QHD

PPO Bronze

Option 2

BlueCare QHD

PPO Silver Option

5

BlueCare

CustomPPO

Platinum Option 5

BlueCare Custom

PPO Platinum 1

BlueCare Custom

PPO Platinum 3

BlueCare Custom

PPO Platinum 6

BlueCare Custom

PPO Platinum 7

BlueCare Custom

PPO Gold 20

BlueCare Custom

PPO Bronze 3

BlueCare

CustomPPO

Platinum Option 9

BlueCare Custom

PPO Gold Option 1

BlueCare Custom

PPO Gold Option 2

BlueCare Custom

PPO Gold Option 3

BlueCare Custom

PPO Gold Option 4

55957PA0050017 55957PA0050021 55957PA0050023 55957PA0050024 55957PA0050025 55957PA0050028 55957PA0050034 55957PA0050035 55957PA0050044 55957PA0050046 55957PA0050048 55957PA0070004 55957PA0070007 55957PA0070011 55957PA0080005 55957PA0080001 55957PA0080003 55957PA0080006 55957PA0080007 55957PA0080032 55957PA0080054 55957PA0080009 55957PA0080013 55957PA0080014 55957PA0080015 55957PA0080016

No No No No No No No No No No No No No No No No No No No No No No No No No No

1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

-100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00%

55957PA0050017 55957PA0050021 55957PA0050023 55957PA0050024 55957PA0050025 55957PA0050028 55957PA0050034 55957PA0050035 55957PA0050044 55957PA0050046 55957PA0050048 55957PA0070004 55957PA0070007 55957PA0070011 55957PA0080005 55957PA0080001 55957PA0080003 55957PA0080006 55957PA0080007 55957PA0080032 55957PA0080054 55957PA0080009 55957PA0080013 55957PA0080014 55957PA0080015 55957PA0080016

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

55957PA0050017 55957PA0050021 55957PA0050023 55957PA0050024 55957PA0050025 55957PA0050028 55957PA0050034 55957PA0050035 55957PA0050044 55957PA0050046 55957PA0050048 55957PA0070004 55957PA0070007 55957PA0070011 55957PA0080005 55957PA0080001 55957PA0080003 55957PA0080006 55957PA0080007 55957PA0080032 55957PA0080054 55957PA0080009 55957PA0080013 55957PA0080014 55957PA0080015 55957PA0080016

$546.16 $504.51 $535.46 $533.56 $532.03 $489.46 $502.84 $501.92 $549.48 $440.82 $449.98 $445.58 $391.74 $472.47 $473.70 $475.64 $474.16 $473.16 $472.80 $423.24 $370.12 $460.65 $461.60 $460.06 $458.78 $432.27

28 24 179 407 700 48 48 159 179 8 18 172 15 139 259 2,055 1,484 613 969 126 42 167 904 392 229 74

$15,292 $12,108 $95,847 $217,159 $372,421 $23,494 $24,136 $79,805 $98,357 $3,527 $8,100 $76,640 $5,876 $65,673 $122,688 $977,440 $703,653 $290,047 $458,143 $53,328 $15,545 $76,929 $417,286 $180,344 $105,061 $31,988

99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04%

$2,765 $10,542 $148,868 $313,503 $811,187 $34,378 $54,341 $114,618 $85,489 $263 $613 $25,516 $16,217 $62,911 $216,065 $1,209,619 $525,461 $210,775 $738,059 $35,695 $23,122 $32,771 $231,530 $146,610 $35,486 $37,786

99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04%

$639 $2,403 $15,259 $39,850 $48,524 $11,094 $4,848 $14,532 $12,177 $66 $143 $11,945 $5,840 $18,517 $14,477 $116,174 $64,850 $34,174 $60,605 $10,012 $6,798 $7,942 $44,103 $18,691 $10,621 $6,051

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%$2,126 $8,139 $133,610 $273,653 $762,663 $23,284 $49,492 $100,086 $73,311 $196 $470 $13,571 $10,377 $44,394 $201,588 $1,093,445 $460,611 $176,600 $677,454 $25,684 $16,324 $24,829 $187,427 $127,919 $24,865 $31,735

-$102.76 -$88.08 -$656.93 -$1,493.69 -$2,569.00 -$176.16 -$176.16 -$583.53 -$656.93 -$29.36 -$66.06 -$631.24 -$55.05 -$510.13 -$950.53 -$7,541.85 -$5,446.28 -$2,249.71 -$3,556.23 -$462.42 -$154.14 -$612.89 -$3,317.68 -$1,438.64 -$840.43 -$271.58

-$4.08 -$3.50 -$26.10 -$59.35 -$102.08 -$7.00 -$7.00 -$23.19 -$26.10 -$1.17 -$2.63 -$25.08 -$2.19 -$20.27 -$37.77 -$299.69 -$216.42 -$89.40 -$141.31 -$18.38 -$6.13 -$24.35 -$131.83 -$57.17 -$33.40 -$10.79

$75.94 $339.11 $746.42 $672.37 $1,089.52 $485.09 $1,031.09 $629.47 $409.56 $24.54 $26.09 $78.90 $691.81 $319.38 $778.33 $532.09 $310.38 $288.09 $699.13 $203.84 $388.66 $148.68 $207.33 $326.32 $108.58 $428.85

$98.75 $439.23 $831.67 $770.28 $1,158.84 $716.21 $1,132.10 $720.87 $477.59 $32.84 $34.04 $148.35 $1,081.12 $452.59 $834.23 $588.62 $354.08 $343.84 $761.67 $283.30 $550.52 $196.24 $256.12 $374.01 $154.96 $510.62

$98.71 $439.06 $831.33 $769.97 $1,158.38 $715.92 $1,131.65 $720.58 $477.40 $32.83 $34.03 $148.29 $1,080.69 $452.41 $833.89 $588.39 $353.94 $343.70 $761.37 $283.18 $550.30 $196.16 $256.01 $373.86 $154.90 $510.42

55957PA0050017 55957PA0050021 55957PA0050023 55957PA0050024 55957PA0050025 55957PA0050028 55957PA0050034 55957PA0050035 55957PA0050044 55957PA0050046 55957PA0050048 55957PA0070004 55957PA0070007 55957PA0070011 55957PA0080005 55957PA0080001 55957PA0080003 55957PA0080006 55957PA0080007 55957PA0080032 55957PA0080054 55957PA0080009 55957PA0080013 55957PA0080014 55957PA0080015 55957PA0080016

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

- - - - - - - - - - - - - - - - - - - - - - - - - -

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

#VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

#VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00%

BlueCare CustomPPO

55957PA008

0.00%

0.00%

0.00%

0.00%

BlueCare QHD PPO

55957PA007

0.00%

0.00%

0.00%

0.00%

BlueCare PPO

55957PA005

0.00%

0.00%

0.00%

AffordaBlue 2015 Experience

55957PA011 55957PA006

Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Silver Silver Silver Silver Gold Not Applicable

0.800 0.818 0.812 0.807 0.815 0.806 0.801 0.797 0.793 0.782 0.711 0.715 0.700 0.705 0.812 0.000

0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010

Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated

PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

BlueCare Custom

PPO Gold Option 8

BlueCare Custom

PPO Gold Option 9

BlueCare Custom

PPO Gold Option

10

BlueCare Custom

PPO Gold Option

11

BlueCare Custom

PPO Gold Option

13

BlueCare Custom

PPO Gold Option

17

BlueCare Custom

PPO Gold Option

21

BlueCare Custom

PPO Gold Option

22

BlueCare Custom

PPO Gold Option

23

BlueCare Custom

PPO Gold Option

26

BlueCare Custom

PPO Silver Option

5

BlueCare Custom

PPO Silver Option

8

BlueCare Custom

PPO Silver Option

12

BlueCare Custom

PPO Silver Option

14

AffordaBlue Gold

Option 4 2015 Experience

55957PA0080020 55957PA0080021 55957PA0080022 55957PA0080023 55957PA0080025 55957PA0080029 55957PA0080033 55957PA0080034 55957PA0080035 55957PA0080044 55957PA0080045 55957PA0080048 55957PA0080052 55957PA0080056 55957PA0110005 55957PA0060001

No No No No No No No No No No No No No No No No

0.00% 0.00%

0.00% 0.00%

0.00% 0.00%

1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

-100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% #DIV/0!

0.00% 0.00%

55957PA0080020 55957PA0080021 55957PA0080022 55957PA0080023 55957PA0080025 55957PA0080029 55957PA0080033 55957PA0080034 55957PA0080035 55957PA0080044 55957PA0080045 55957PA0080048 55957PA0080052 55957PA0080056 55957PA0110005 55957PA0060001

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

55957PA0080020 55957PA0080021 55957PA0080022 55957PA0080023 55957PA0080025 55957PA0080029 55957PA0080033 55957PA0080034 55957PA0080035 55957PA0080044 55957PA0080045 55957PA0080048 55957PA0080052 55957PA0080056 55957PA0110005 55957PA0060001

$422.39 $449.79 $448.18 $446.90 $413.40 $436.13 $422.39 $421.60 $420.88 $461.57 $369.01 $377.98 $372.36 $354.02 $396.48 $0.00

20 361 1,928 857 156 254 74 210 36 607 174 132 20 45 88 427,493

$8,448 $162,374 $864,091 $382,993 $64,490 $110,777 $31,257 $88,536 $15,152 $280,173 $64,208 $49,893 $7,447 $15,931 $34,890 $0

99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04%

$2,022 $179,268 $745,627 $280,881 $44,389 $210,456 $25,031 $727,497 $133 $268,034 $16,241 $81,745 $825 $1,318 $17,732 $171,392,631

99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96% 99.96%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04% 0.04%

$1,102 $25,439 $138,709 $61,994 $10,136 $28,868 $5,085 $30,503 $84 $35,261 $5,435 $13,618 $317 $687 $7,973 $24,611,967

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%$920 $153,830 $606,919 $218,886 $34,253 $181,588 $19,947 $696,994 $49 $232,773 $10,806 $68,127 $508 $631 $9,759 $146,780,664

-$73.40 -$1,324.87 -$7,075.76 -$3,145.19 -$572.52 -$932.18 -$271.58 -$770.70 -$132.12 -$2,227.69 -$638.58 -$484.44 -$73.40 -$165.15 -$322.96 -$1,568,899.31

-$2.92 -$52.65 -$281.17 -$124.98 -$22.75 -$37.04 -$10.79 -$30.63 -$5.25 -$88.52 -$25.38 -$19.25 -$2.92 -$6.56 -$12.83 $0.00

$45.99 $426.12 $314.79 $255.41 $219.57 $714.92 $269.55 $3,319.02 $1.35 $383.48 $62.10 $516.11 $25.42 $14.03 $110.89 $343.35

$101.08 $496.59 $386.74 $327.75 $284.55 $828.57 $338.26 $3,464.27 $3.69 $441.57 $93.34 $619.28 $41.26 $29.29 $201.50 $400.92

$101.04 $496.39 $386.58 $327.62 $284.43 $828.24 $338.13 $3,462.89 $3.68 $441.39 $93.30 $619.03 $41.24 $29.28 $201.42 $400.76

55957PA0080020 55957PA0080021 55957PA0080022 55957PA0080023 55957PA0080025 55957PA0080029 55957PA0080033 55957PA0080034 55957PA0080035 55957PA0080044 55957PA0080045 55957PA0080048 55957PA0080052 55957PA0080056 55957PA0110005 55957PA0060001

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

- - - - - - - - - - - - - - - -

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

#VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

#VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00%

BlueCare CustomPPO

55957PA008

0.00%

0.00%

0.00%

Pennsylvania Actuarial Memorandum

First Priority Life Insurance Company

Small Group – ACA Compliant

Effective 1/1/2017

REDACTED

1

1. Basic Information and Data A. Company Information

As shown on the Cover letter, below is the company information. Company Name: First Priority Life Insurance Company (NAIC 60147) Market: Small Group On and Off Exchange Effective: January 1, 2017 Average Rate Change Requested: 3.5% Range of Rate Change Requested: -13.9% to 9.5%. Products: PPO Rating Areas: 3 Metal Levels and Catastrophic Plans: Platinum, Gold, Silver, Bronze Current Number of Covered Lives: 4,448 Current Number of Policyholders: 2,837 Number of plans offered in 2017: 39 Contract Form #s:

Small Group Product Form # Lehigh Valley Flex Blue QHDPPO off exchange FP-1-SG-LVFB-EHB-QHDPPO-1/1/17 Lehigh Valley Flex Blue PPO off exchange FP-1-SG-LVFB-EHB-PPO-1/1/17 BlueCare PPO off exchange FP-1-SG-EHB-PPO-1/1/17 BlueCare PPO SHOP FP-1-X-SG-PPO-1/1/17 BlueCare Custom PPO off exchange FP-1-SG-EHB-CustomPPO-1/1/17 BlueCare Custom PPO SHOP FP-1-X-SG-CustomPPO-1/1/17 BlueCare QHDPPO off exchange FP-1-SG-EHB-QHDHP-1/1/17 AffordaBlue off exchange FP-1-SG-EHB-AffordaBlue-1/1/17 AffordaBlue SHOP FP-1-SG-X-AffordaBlue-1/1/17

SERFF ID #: HGHM-130536975 SERFF Binder #: HGHM-PA17-125061839 HIOS ID #: 55957 HIOS Submission Tracking #: 55957-687033686918477945 Inclusion of premium rates in this filing for a given offering should not be

construed to mean that the offering will ultimately be made available for sale in the market. Final offering decisions will be made consistent with and within the timelines set forth in CMS rules and/or ACA regulations.

2

B. Rate History and Proposed Variations in Rate Changes 2014 – SERFF ID# BCNP-129018157 & BCNP-129063510

o In 2014, there were no prior rates from which to calculate a rate change.

2015 – SERFF ID # BCNP-129633483 o The quarterly index applied to the 2015 rates was 1.8% which was

slightly lower than the 2014 quarterly index of 2.1%. o The 1Q2015 rate increase was 0.1%.

2016 – SERFF ID # BCNP-130071709 o The average rate increase was 9.5%, with the same quarterly index

applied as in 2015.

C. Average Rate Change The SERFF Rate Review Detail Screen presents the “percent rate change

requested” as 3.5%, which is consistent with the increase calculated in Table 10, cell AC15.

FPLIC is calculating the average increase as 1.6% consistent with the URRT. o The increase calculated in Table 11 is, in part, a function of the

quarterly distribution used to calculate each of the 2016 average monthly premium and the 2017 monthly premium.

o In 2017, a lower percentage of projected enrollment is concentrated in the first quarter than was used in the 2016 filing. Therefore, the increase calculated on this worksheet is higher than the increase input in the SERFF Rate Review Detail Screen.

o In addition, the increase calculated in Table 10 is based on enrollment by product as of February 2016, whereas the increase calculated by FPLIC is based on the projected enrollment consistent with that provided in the URRT.

o There is also a difference due to rounding between the Age 21 rate calculated in Table 11 and the Age 21 rate filed by FPLIC.

o There is also a difference between the increase calculated in Table 11 and Table 10. The Table 11 increase is calculated as 5.2% whereas the Table 10 increase is calculated as 5.7%.

The Table 10 increase is based on the average 2017 rate divided by the average 2016 rate.

The Table 11 increase is based on the weighted average of increases by plan.

3

Below is a breakout of the difference between the increase calculated by the PID Actuarial Memorandum exhibits compared to the increase calculated by FPLIC:

Increase – PID Exhibits - Table 11 3.0%

Impact of enrollment Distribution mix -0.1%

Increase - Using Table 11 Rates with Projected 2017 enrollment

2.9%

Impact of 2016 vs. 2017 quarterly distribution -0.8%

Required Increase - using projected enrollment by product and quarter

2.1%

Difference between calculated Table 11 2017 Age 21 rate and FPLIC filed Age 21 rate (due to rounding)

-0.1%

FPLIC Calculated Required Increase 2.0%

D. Membership Count Please see Table 1 for the age breakdown and the total number of members

for the periods shown.

E. Benefit Changes Many plans required benefit changes because of the new Actuarial Value

(AV) calculator released for 2017 effective dates. The plan changes were mostly required so that plans remained within the defined metal level AV requirements.

In addition, certain benefit changes were made to align the benefits with Highmark’s standards, including removing any deductibles from drug benefits, except under the QHD plans. The specialty drug benefit is also changing from copay to 20%/30% member coinsurance up to $350/$500

The following were changes to the Essential Health Benefits due to the 2017 Benchmark Plan:

o Hospice Benefit – addition of respite care for 7 days per six months. o Coverage for Artificial Insemination, including specific related medical

conditions o Coverage for Dental Accident o Added visits for Habilitative Therapy services.

The screenshots from the AV calculator, showing the plan benefits and the resulting actuarial value have been submitted as separate attachments in SERFF. This exhibit is consistent with Table 2.3 in the Part III Actuarial Memorandum.

4

F. Experience Period Claims and Premium Please see Table 2 for the experience period data for the most recent

calendar year. The experience period paid claims data represents the 2015 calendar year results for all non-grandfathered policies (including transitional policies) in the single risk pool, with runout through February 2016. This data is consistent with the data reported in Section I of Worksheet 1 of the URRT.

The components of this exhibit are: o The Earned Premium represents actual revenues earned in the

experience period. The Earned Premiums in Table 2 have not been adjusted for anticipated risk adjustment transfer payments.

o The Allowed Claims represent our best estimate of the total claims prior to member cost sharing incurred during the experience period. The allowed claims include:

Two months of runout from the end of the experience period. Claims processed outside the Company’s claims system Our best estimate of incurred but not paid as of the end of the

runout period. Note that the Incurred Claims and Allowed Claims presented in

the URRT are net of the Prescription Drug Rebates, while Table 2 has the Prescription Drug Rebates separately identified.

o There were non-EHB benefits and costs for emergency care outside the United States.

o There are no capitated claim services in the experience period. o Prescription drug rebates are used to reduce the level of Incurred

Claims in the experience period. o The Estimated Risk Adjustment represents our best estimate of the

year end risk adjustment transfer payment that FPLIC will incur based on the results in the experience period.

o The Small Group Market is ineligible for reinsurance recoveries

G. Credibility of Data

The experience period data for this Company is large enough to be fully credible. The results are based 100% on the experience period data.

5

H. Trend Identification The development of the premium rates reflects and annual trend rate of

8.9% developed by FPLIC. The information below reflects FPLIC’s expectations regarding increases in in-network contractual reimbursement as well as utilization. The annual trend estimates include in-area hospital, out-of-area hospital, doctor, and prescription drug utilization and cost.

The analysis was based on utilization and unit costs for FPLIC PPO and CustomPPO small group markets. Given relatively minor changes in age/gender and that benefit mix changes were incorporated elsewhere, these were not incorporated in the trend.

Given that we’re seeing medical trends rise in our PPO and CustomPPO business through the end of 2015 (8.6% as of the end of 2015 paid through March 2016), we expect trend levels to remain at that level on average through 2016 and 2017. This is driven in large part due to overall increasing hospital costs as well as significant increases in out of area hospital costs.

The table below summarizes the projected 2014 to 2017 annual utilization, unit cost and claim cost trends:

FIRST PRIORITY LIFE INSURANCE COMPANY Trend Projection

Service Type Cost Utilization Total

Hospital In Area 6.5% 2.0% 8.7% Hospital Out of Area 8.0% 2.2% 10.4%

Total Hospital 7.0% 2.1% 9.2%

Doctor 5.6% 1.5% 7.2%

Total Medical 6.6% 1.9% 8.6%

Rx 7.8% 2.0% 10.0%

Overall Trend 8.9%

I. Historical Experience

Table 4 presents the most recent 36 months of Company data with runout through February 2016.

o Note that Table 4 consists of experience for the SG ACA products. o Table 4b consists of experience for the SG ACA products plus the

transitional products combined. This data was used for trend development.

The IBNR reserve was estimated using the standard lag development method. We calculated completion factors separately for the medical and prescription drug claims.

o For the small group ACA compliant claims, completion factors are calculated using only the small group ACA compliant pool.

o For the small group transitional non-ACA compliant plans, the completion factors are based on all plans except for the SG ACA and

6

Individual ACA compliant plans, including large group, small group and individual products.

o For the more recent months, we used a combination of historical trends, seasonality patterns, and actuarial judgment to develop pure premiums.

For each product, the completion factors for the medical and prescription drug claims for all FPLIC products were the starting point. We then applied these completion factors to the small group paid and incurred claims, separately. We reviewed the incurred claims for the most recent months for reasonableness and adjusted them. FPLIC does not adjudicate claims by product, so we would expect the completion factors for all the medical claims to be similar. Paid and allowed claims were completed using the same methodology.

2. Rate Development and Change

A. Development of Projected Index Rate, Market-Adjusted Index Rate, & Total Allowed Claims The development of the Projected Index Rate, Projected Market-Adjusted

Index Rate, and Projected Total Allowed Claims, shown in Table 5, closely follows that utilized in the development presented in Worksheet 1 of the URRT, a discussion of which can be found in the Part III Actuarial Memorandum submitted in the Rate Filing Justification. Some of the items separately identified in Table 5 include:

o The Change in Demographics adjustment reflects the change in age and geography factors we expect from the experience period to the projection period.

o The Change in Network Adjustment reflects the change in the allowed claims we anticipate due to network contracting changes between the experience period and the projection period.

o The Change in Benefits adjustment reflects the change in the EHB benefits we anticipate between the experience period and the projection period.

o The Change in Other adjustment reflects the change in the utilization of services due to benefit elections we anticipate between the experience period and the projection period.

Note that the URRT develops the Index Rate and the Plan Adjusted Index Rate using the projected distribution of members by plan, whereas Table 5 uses a recent distribution of members by plan. Any comparison between the URRT values and the Table 5 values will show variances to the extent that there are variances in the assumed underlying membership distributions.

For this Small Group Market filing, Table 5A has been completed, showing the number of member months renewing by quarter, and the quarterly Single Risk Pool Projected Allowed Claims.

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B. Retention Items Table 6 has been completed with the requested retention elements for the

proposed rates for the rating period. The amounts are presented separately. Administrative costs reflect internal costs that FPLIC is projected to incur in the projected experience period, and are developed from standard expense allocation methods. Agent/broker fees and commission reflect our anticipated costs for these items in the experience period.

Note the following regarding plan level retention items o These revised rates reflect a 0% risk/contribution to surplus margin

for all products and plans. o The Health Insurer Provider Fee is being applied quarterly, at a

prorated level appropriate for the level of premium in 2018. Although this fee will not be collected in 2017, the fee will be collected in 2018. As such, for any groups with renewal dates other than January 1, 2017, the group’s renewal period will extend into 2018, where the premiums will need to include a charge for this fee. For the 2017 rate development, the quarterly rates have been adjusted so that the appropriate pro rata portion of this fee is collected based on the group’s renewal quarter as follows:

Renewal Quarter

Health Insurance

Provider Fee 1Q 0.0% 2Q 0.5% 3Q 1.0% 4Q 1.5%

o The administrative expenses as a percent of premium do not vary by

plan. o 2.0% premium tax is included o The $0.19 PMPM PCORI fee was factored into the taxes/fees percent

of premium.

C. Normalized Market-Adjusted Projected Allowed Total Claims

o The normalization factors presented in Table 7 are each determined from the underlying membership demographics expected in the projected rating period. The 2016 values are pulled from the prior year’s filing, while the 2017 values represent our projection for 2017 assumed in the 2017 rate development.

8

D. Components of Rate Change o Table 8 presents the components of change in the proposed 2017

Calibrated Plan Adjusted Index Rate (PMPM). The 2016 base period allowed claims as developed from the 2016 rate filing. Row H of Table 8 may differ from Row A due to the detailed breakdown of all the components of the increases in rows B through G not calculating exactly to the change in the calibrated plan adjusted index rate in Row A.

o Table 9 presents the data elements supporting the calculations in Table 8. Note the following differences between the Table 9 values presented for 2016 and the values from the 2016 URRT:

The Risk Adjustment shown in Table 9 is the average risk adjustment charge for the projected experience year. In the URRT, the Projected Risk Adjustments represent the risk transfer adjustment for January 1 effective dates only.

Taxes and Fees shown in Table 9 differ from the Taxes and Fees from the URRT as the Table 9 separates out the Exchange User Fee into a separate line item. In the URRT the Exchange User Fee is included in the Taxes and Fees line item.

3. Plan Rate Development Table 10 showing the plan rate development has been completed following

the instructions in the Health Insurance Rate Filing Guidance. This table shows the plans that the company intends to offer in 2017, as well as plans recently discontinued from the 2016 portfolio for 2017 and plans from the 2015 portfolio as members are still enrolled in 2015 plans as of February 1, 2016. Small groups in these 2015 plans have not renewed yet in 2016 and were included to complete the company’s enrollment in ACA plans as of February 1, 2016. The calibrated plan adjusted index rates for 2017 and 2016, and all supporting factors, are calculated according to the instructions.

The rate change percentages calculated in Table 10 column AC by plan design will slightly differ between URRT worksheet 2 row 27 since the PID spreadsheet maintains the 2016 quarterly distribution of enrollment as filed last year while the URRT values utilizes a consistent enrollment distribution by quarter for both years based on this year’s distribution. Please refer to Section 1.C for a more detailed discussion.

Note that the HHS Actuarial Value Calculator was able to accommodate all of the Company’s benefit designs and so no adjustments were needed from the values produced by the calculator.

9

4. Plan Premium Development for 21-Year Old Non-Tobacco User Table 11 presents the Company’s 21-year-old non-tobacco premium in the

Market, premium weighted for quarterly trend and the prorated quarterly insurer fee. As mentioned in Section 1.c above, the change in the 21-year-old non-tobacco premium PMPM calculated in this table is 3.0%. Please refer to Section 1.C discussing this increase percentage.

5. Plan Factors

A. Age and Tobacco Factors Please see Table 12 for FPLIC’s age and tobacco factors

B. Geographic Factors Please see Table 13 for FPLIC’s geographic factors. The Company’s factors

for the rating period are unchanged from the currently approved factors.

C. Network Factors

Please see table 14 for FPLIC’s network rating factors. These factors are unchanged from the currently approved factors. A factor for the new Lehigh Valley plans has been added.

D. Service Area Composition

FPLIC follows the Rating Area designations created by the State. All counties within a Rating Area are serviced by the Company, according to the Rating Areas specified in Table 14.

E. Composite Rating

The Company is currently not planning to use CMS’s composite rating method for any of its off-SHOP plans offered during the rating period; however, the Company is interested in the state adopting a methodology for the PA Marketplace that is more consumer friendly than the CMS method by utilizing composite rating tiers similar to transitional small group policies currently in the market (i.e. rates by contract types of Individual, Parent/Child(ren), Two Person (Adults), and Family).

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6. Actuarial Certifications I, XXXXXXXXXXX, am a member of the American Academy of Actuaries and meet its qualification standards for actuaries issuing statements of actuarial opinions in the United States. This filing is prepared on behalf of First Priority Life Insurance Company (FPLIC) to accompany its rate filing (for calendar year 2017) for the small group combined Market on and off the Pennsylvania Exchange.

As originally filed, the rates were not excessive, inadequate, or unfairly discriminatory, and were reasonable in relationship to the benefits provided. The Pennsylvania Insurance Department has required FPLIC to re-submit lower rates.

I hereby certify that the projected index rate is, to the best of my knowledge and understanding:

In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.80(d)(1)),

Developed in compliance with the applicable Actuarial Standards of Practice Reasonable in relation to the benefits provided and the population anticipated to be

covered Neither excessive nor deficient.

I certify that the index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 45 CFR 156.80(d)(2) were used to generate plan level rates. The allowable modifiers used to generate plan-level rates were:

The actuarial value and cost-sharing design of the plan. The plan’s provider network, delivery system characteristics, and utilization

management practices. The benefits provided under the plan that are in addition to the essential health

benefits. These estimated benefits were pooled with similar benefits within the single risk pool and the claims experience from those benefits was utilized to determine rate variations.

Administrative costs, excluding Exchange user fees. I certify that all factors, benefit and other changes from the prior approved filing have been disclosed in the 2017 PA Actuarial Memorandum Rate Exhibits.

I certify that the percent of total premium that represents essential health benefits included in Worksheet 2, Sections III and IV were calculated in accordance with actuarial standards of practice.

I certify that the benefits included in FPLIC’s plans are substantially equivalent to the Essential Health Benefits (EHBs) in the State of Pennsylvania’s benchmark plans. I certify that any benefit substitutions are:

Actuarially equivalent to the benefits being replaced, Are made within only the same essential health benefit category, Are based on a standardized plan population,

11

Are determined regardless of cost-sharing, Are not prescription drug benefits, and Are based on an analysis performed in accordance with generally accepted actuarial

principles and methodologies.

I certify that new plans are not considered modifications of existing plans (per the uniform modification standards in 45 CFR 147.106).

I certify that the AV Metal Values included in Worksheet 2 of the Part I Unified Rate Review Template were based entirely on the Federal AV Calculator.

I certify that the geographic rating factors reflect only differences in the costs of delivery (which can include unit cost and provider practice pattern differences) and do not include differences for population morbidity by geographic area.

The Part I Unified Rate Review Template does not demonstrate the process used by Highmark to develop the rates. Rather, it represents information required by Federal regulation to be provided in support of the review of rate increases, for certification of qualified health plans for federally facilitated exchanges and for certification that the index rate is developed in accordance with Federal regulation and used consistently and only adjusted by the allowable modifiers.

I certify that the information presented in the PA Actuarial Memorandum and PA Actuarial Memorandum Rate Exhibits is consistent with the information presented in the 2017 Rate Filing Justification.

Date: 8/12/2016

PA Rate Template Part IData Relevant to the Rate Filing

Table 1. Number of Members

Member-months Members Member-months

Experience PeriodCurrent Period

(as of Feb. 1, 2016)Projected Rating

Period

Total 37,708 4,448 60,000 <18 5,642 641 8,647 18-24 3,607 428 5,773 25-29 3,239 388 5,234 30-34 3,052 370 499135-39 2,984 332 447840-44 3,490 384 518045-49 3,738 470 634050-54 4,249 473 638055-59 4,068 514 693360-63 2,776 323 435764+ 863 125 1687

Table 2. Experience Period Claims and Premiums

Earned Premium Paid ClaimsUltimate Incurred

ClaimsMember Months

Estimated Cost Sharing

(Member & HHS)

Allowed Claims (Non-Capitated)

Non-EHB portion of

Allowed Claims

Total Prescription Drug Rebates*

Total EHB Capitation

Total Non-EHB Capitation Estimated Risk

Adjustment

Estimated Reinsurance Recoveries

$ 188,549,084.46 $ 163,670,918.35 $ 166,872,734.02 465,201 $ 27,046,849.67 $ 193,919,583.69 $ 71,734.19 $ (3,118,901.73) $ - $ - -$ -$ 2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 409.99$ Loss Ratio 86.85%*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Composite Weight*7.00% 2.10% 9.25% 18.44% <- Annualized Trend Factors on URRT7.00% 2.10% 9.25% 36.88%5.60% 1.50% 7.18% 25.26%0.00% 0.00% 0.00% 0.00%

0.00% 0.00%7.80% 2.00% 9.96% 19.42%

8.86% 100.00%1.185

* Express Cost, Utilization, and Weight as percentages

Table 4. Historical Experience

Month-Year Total Annual Premium Incurred Claims Completion Factors*Ultimate Incurred

ClaimsMembers

Ultimate Incurred PMPM

Estimated Annual Cost Sharing

(Member + HHS)

Prescription Drug Rebates**

Allowed Claims (Net of Prescription Drug Rebates)

Allowed PMPM

Jan-13 #DIV/0! #DIV/0! #DIV/0!Feb-13 #DIV/0! #DIV/0! #DIV/0!Mar-13 #DIV/0! #DIV/0! #DIV/0!Apr-13 #DIV/0! #DIV/0! #DIV/0!

May-13 #DIV/0! #DIV/0! #DIV/0!Jun-13 #DIV/0! #DIV/0! #DIV/0!Jul-13 #DIV/0! #DIV/0! #DIV/0!

Aug-13 #DIV/0! #DIV/0! #DIV/0!Sep-13 #DIV/0! #DIV/0! #DIV/0!Oct-13 #DIV/0! #DIV/0! #DIV/0!

Nov-13 #DIV/0! #DIV/0! #DIV/0!Dec-13 #DIV/0! #DIV/0! #DIV/0!Jan-14 $ 78,013.65 1.0000 $ 78,013.65 313 $ 249.24 $ (1,535.47) $ 106,233.57 $ 339.40 Feb-14 $ 119,183.36 1.0000 $ 119,183.36 380 $ 313.64 $ (1,222.41) $ 149,567.80 $ 393.60 Mar-14 $ 157,918.81 1.0000 $ 157,918.81 479 $ 329.68 $ (2,102.23) $ 193,922.25 $ 404.85 Apr-14 $ 425,697.51 1.0000 $ 425,697.51 631 $ 674.64 $ (3,500.01) $ 478,780.16 $ 758.76

May-14 $ 267,536.35 1.0000 $ 267,536.35 788 $ 339.51 $ (5,176.92) $ 319,911.36 $ 405.98 Jun-14 $ 423,567.57 0.9999 $ 423,602.26 875 $ 484.12 $ (6,056.89) $ 485,284.72 $ 554.61 Jul-14 $ 470,030.14 0.9998 $ 470,105.88 971 $ 484.15 $ (7,154.02) $ 522,532.99 $ 538.14

Aug-14 $ 351,447.93 0.9997 $ 351,550.28 993 $ 354.03 $ (6,985.19) $ 411,857.55 $ 414.76 Sep-14 $ 403,512.18 0.9997 $ 403,623.99 1,108 $ 364.28 $ (7,178.03) $ 460,226.56 $ 415.37 Oct-14 $ 595,086.47 0.9992 $ 595,537.08 1,177 $ 505.98 $ (10,668.36) $ 667,923.33 $ 567.48

Nov-14 $ 737,952.84 0.9989 $ 738,800.86 1,231 $ 600.16 $ (9,774.64) $ 809,318.30 $ 657.45 Dec-14 $ 670,549.70 0.9989 $ 671,289.86 1,305 $ 514.40 $ (10,752.92) $ 729,650.08 $ 559.12 Jan-15 $ 1,432,019.76 0.9988 $ 1,433,786.11 2,350 $ 610.12 $ (21,223.06) $ 1,612,069.62 $ 685.99 Feb-15 $ 1,287,997.76 0.9986 $ 1,289,774.72 2,476 $ 520.91 $ (21,598.59) $ 1,432,337.32 $ 578.49 Mar-15 $ 1,775,978.53 0.9982 $ 1,779,200.76 2,655 $ 670.13 $ (30,369.97) $ 1,945,253.14 $ 732.68 Apr-15 $ 1,228,976.95 0.9972 $ 1,232,414.95 2,852 $ 432.12 $ (22,296.94) $ 1,421,799.23 $ 498.53

May-15 $ 1,121,670.36 0.9966 $ 1,125,443.63 3,004 $ 374.65 $ (22,877.67) $ 1,294,360.33 $ 430.88 Jun-15 $ 1,202,770.47 0.9928 $ 1,211,488.06 3,140 $ 385.82 $ (26,213.54) $ 1,365,613.26 $ 434.91 Jul-15 $ 1,477,530.31 0.9932 $ 1,487,576.64 3,225 $ 461.26 $ (28,228.02) $ 1,674,590.38 $ 519.25

Aug-15 $ 1,411,160.20 0.9853 $ 1,432,200.34 3,315 $ 432.04 $ (28,760.51) $ 1,600,380.70 $ 482.77 Sep-15 $ 1,401,080.61 0.9818 $ 1,427,112.99 3,420 $ 417.28 $ (29,619.73) $ 1,600,482.92 $ 467.98 Oct-15 $ 1,643,949.72 0.9733 $ 1,689,066.90 3,546 $ 476.33 $ (30,609.26) $ 1,889,056.17 $ 532.73

Nov-15 $ 1,536,817.85 0.9626 $ 1,596,495.52 3,620 $ 441.02 $ (31,248.75) $ 1,770,449.43 $ 489.07 Dec-15 $ 1,528,321.51 0.9477 $ 1,612,680.63 4,105 $ 392.86 $ (35,302.53) $ 1,817,382.95 $ 442.72

* Express Completion Factor as a percentage**Express Prescription Drug Rebates as a negative number

$ 704,455.87

$ 2,434,882.77

$ 5,082,527.80

$ 18,351,830.97

2 Year Trend Projection Factor

Service Category

Other Medical CapitationPrescription DrugsTotal Annual Trend

Inpatient HospitalOutpatient HospitalProfessional

Table 2b. Experience Period Claims and Premiums Table 2c. Experience Period Claims and Premiums

Earned Premium

Paid ClaimsUltimate

Incurred ClaimsMember Months

Estimated Cost Sharing

(Member & HHS)

Allowed Claims (Non-

Capitated)

Non-EHB portion of Allowed Claims

Total Prescription Drug

Rebates*

Total EHB Capitation

Total Non-EHB Capitation

Estimated Risk Adjustment

Estimated Reinsurance Recoveries

Earned Premium

Paid ClaimsUltimate

Incurred ClaimsMember Months

Estimated Cost Sharing

(Member & HHS)

Allowed Claims (Non-

Capitated)

Non-EHB portion of Allowed Claims

Total Prescription

Drug Rebates*

Total EHB Capitation

Total Non-EHB

Capitation

Estimated Risk Adjustment

Estimated Reinsurance Recoveries

2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) #DIV/0! 2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) #DIV/0!Loss Ratio #DIV/0! Loss Ratio #DIV/0!*Express Prescription Drug Rebates as a negative number *Express Prescription Drug Rebates as a negative number

Table 3b. Trend Components

Cost* Utilization* Composite Weight*

0.00% <- Annualized Trend Factors on URRT0.00%0.00%0.00%

0.00%0.00% 0.00%1.000

* Express Cost, Utilization, and Weight as percentages

Table 4b. Historical Experience

Month-YearTotal Annual

PremiumIncurred Claims

Completion Factors*

Ultimate Incurred Claims

MembersUltimate Incurred PMPM

Estimated Annual Cost

Sharing (Member + HHS)

Prescription Drug

Rebates**

Allowed Claims (Net of

Prescription Drug Rebates)

Allowed PMPM

Jan-13 $ 14,172,372.62 1.0000 $ 14,172,372.62 42,564 $ 332.97 $ (152,689.95) $ 17,031,259.93 $ 400.13 Feb-13 $ 12,573,865.32 1.0000 $ 12,573,865.32 42,525 $ 295.68 $ (138,057.30) $ 14,793,411.54 $ 347.88 Mar-13 $ 12,130,759.58 0.9654 $ 12,565,435.74 40,326 $ 311.60 $ (176,518.30) $ 14,766,886.32 $ 366.19 Apr-13 $ 11,891,477.57 1.0000 $ 11,891,477.57 40,139 $ 296.26 $ (143,424.65) $ 13,947,602.67 $ 347.48

May-13 $ 12,088,457.77 1.0000 $ 12,088,457.77 39,816 $ 303.61 $ (153,219.42) $ 14,057,906.93 $ 353.07 Jun-13 $ 12,079,848.91 1.0000 $ 12,079,848.91 40,019 $ 301.85 $ (174,471.68) $ 13,846,015.31 $ 345.99 Jul-13 $ 12,595,589.29 1.0000 $ 12,595,589.29 39,961 $ 315.20 $ (140,334.59) $ 14,500,154.59 $ 362.86

Aug-13 $ 12,198,132.03 1.0000 $ 12,198,132.03 39,388 $ 309.69 $ (138,483.43) $ 14,023,701.07 $ 356.04 Sep-13 $ 12,225,063.82 1.0000 $ 12,225,063.82 39,495 $ 309.53 $ (194,057.92) $ 13,899,399.26 $ 351.93 Oct-13 $ 13,250,522.29 1.0000 $ 13,250,522.29 39,508 $ 335.39 $ (154,170.74) $ 15,222,840.79 $ 385.31 Nov-13 $ 12,698,431.51 1.0000 $ 12,698,431.51 40,020 $ 317.30 $ (151,393.62) $ 14,560,977.05 $ 363.84 Dec-13 $ 13,376,294.69 1.0000 $ 13,376,294.69 42,170 $ 317.20 $ (200,952.81) $ 15,275,434.65 $ 362.23 Jan-14 $ 13,367,885.27 1.0000 $ 13,367,885.27 41,792 $ 319.87 $ (200,128.41) $ 16,153,141.08 $ 386.51 Feb-14 $ 12,263,110.29 1.0000 $ 12,263,110.29 41,613 $ 294.69 $ (178,945.55) $ 14,378,154.39 $ 345.52 Mar-14 $ 13,353,396.15 1.0000 $ 13,353,396.15 41,374 $ 322.75 $ (200,673.90) $ 15,603,001.54 $ 377.12 Apr-14 $ 13,069,060.06 0.9998 $ 13,071,060.70 40,892 $ 319.65 $ (208,282.71) $ 15,159,423.75 $ 370.72

May-14 $ 12,976,435.28 0.9998 $ 12,978,465.77 40,727 $ 318.67 $ (240,379.16) $ 14,898,868.54 $ 365.82 Jun-14 $ 13,367,224.22 0.9998 $ 13,369,345.11 40,603 $ 329.27 $ (220,394.11) $ 15,131,044.32 $ 372.66 Jul-14 $ 13,975,031.70 0.9996 $ 13,980,543.49 40,594 $ 344.40 $ (227,671.32) $ 15,753,266.18 $ 388.07

Aug-14 $ 12,843,488.07 0.9992 $ 12,853,439.26 40,563 $ 316.88 $ (240,462.52) $ 14,395,211.73 $ 354.89 Sep-14 $ 14,338,959.15 0.9990 $ 14,353,897.29 40,629 $ 353.29 $ (221,055.65) $ 15,998,603.79 $ 393.77 Oct-14 $ 14,664,081.71 0.9984 $ 14,687,162.64 40,512 $ 362.54 $ (240,930.64) $ 16,336,918.70 $ 403.26 Nov-14 $ 12,901,377.88 0.9980 $ 12,927,798.80 40,392 $ 320.06 $ (223,761.44) $ 14,390,218.19 $ 356.26 Dec-14 $ 14,595,479.75 0.9978 $ 14,627,161.98 40,277 $ 363.16 $ (265,588.09) $ 16,101,130.12 $ 399.76 Jan-15 $ 13,121,298.94 0.9976 $ 13,153,390.56 39,421 $ 333.66 $ (248,237.59) $ 16,179,248.45 $ 410.42 Feb-15 $ 12,515,298.77 0.9936 $ 12,596,040.43 39,311 $ 320.42 $ (220,495.88) $ 15,107,576.84 $ 384.31 Mar-15 $ 14,578,311.14 0.9968 $ 14,624,722.37 39,252 $ 372.59 $ (273,289.24) $ 16,992,066.35 $ 432.90 Apr-15 $ 13,855,702.61 0.9700 $ 14,284,575.08 39,232 $ 364.11 $ (267,858.74) $ 16,525,141.31 $ 421.22

May-15 $ 13,323,562.71 0.9703 $ 13,731,320.40 38,821 $ 353.71 $ (273,438.84) $ 15,723,763.60 $ 405.03 Jun-15 $ 13,769,864.25 0.9895 $ 13,915,492.00 38,703 $ 359.55 $ (286,495.73) $ 15,786,929.51 $ 407.90 Jul-15 $ 13,704,303.54 0.9932 $ 13,797,985.31 38,662 $ 356.89 $ (259,076.52) $ 15,580,489.10 $ 402.99

Aug-15 $ 13,285,365.60 0.9827 $ 13,519,465.96 38,603 $ 350.22 $ (258,876.26) $ 15,199,021.70 $ 393.73 Sep-15 $ 14,224,835.10 0.9776 $ 14,551,378.79 38,488 $ 378.08 $ (258,809.20) $ 16,155,318.73 $ 419.75 Oct-15 $ 14,505,910.28 0.9751 $ 14,876,345.58 38,196 $ 389.47 $ (256,769.82) $ 16,579,246.25 $ 434.06 Nov-15 $ 13,021,466.97 0.9808 $ 13,275,924.12 38,113 $ 348.33 $ (256,335.29) $ 14,787,037.49 $ 387.98 Dec-15 $ 13,740,579.45 0.9446 $ 14,546,093.42 38,399 $ 378.81 $ (259,218.63) $ 16,184,842.65 $ 421.49

* Express Completion Factor as a percentage**Express Prescription Drug Rebates as a negative number

Capitation

Service Category

Inpatient HospitalOutpatient HospitalProfessionalOther Medical

$ 188,549,084.46 $ 27,046,849.67

Prescription DrugsTotal Annual Trend2 Year Trend Projection Factor

$ 189,561,017.85 $ 26,127,872.96

$ 187,607,491.32 $ 25,133,989.10

PA Rate Template Part IIRate Development and Change

Table 5. Development of the Projected Index Rate, Market-Adjusted Index Rate, and Total Allowed Claims

2015 Total Allowed EHB Claims PMPM + EHB Capitation PMPM (net of prescription drug rebates) 409.98$ <- Index Rate of Experience Period on URRT Table 5A. Small Group Projected Index Rate with Quarterly Trend 2 Year Trend Projection Factor 1.185Unadjusted Projected Allowed EHB Claims PMPM 485.92$ January April July October Total Single Risk PoolSingle Risk Pool Adjustment Factors <- Adj't. from Experience to Projection Period - Pop'l risk Morbidity on URRT # of Member Months Renewing in Quarter 26,280 12,570 7,688 13,462 60,000.00 Change in Morbidity 1.166 <- Adj't. from Experience to Projection Period - Other on URRT Percent of Members Months Renewing in Quarter 44% 21% 13% 22% 100% Change in Other 0.946 Base Allowed Claims 535.94$ 535.94$ 535.94$ 535.94$ 535.94$ Change in Demographics 1.000 Months of Trend - 3 6 9 3 Change in Network 1.000 Annual Trend 8.86% 8.86% 8.86% 8.86% 8.86% Change in Benefits 1.013 Single Risk Pool Projected Allowed Claims 535.94$ 547.44$ 559.19$ 571.19$ 549.24$ Change in Other 0.933Adjusted Projected Allowed EHB Claims PMPM 535.94$ <- Index Rate for Projection Period on URRT - Individual (Small Group 1rst Qtr)Adjusted Projected Allowed EHB Claims PMPM [will only populate for small group filings] 549.24$ <- Index Rate for Projection Period on URRT - Small Group Projected Paid to Allowed Ratio 0.872 <- Paid to Allowed Average Factor in Projection Period on URRTProjected Paid EHB Claims PMPM 478.9351319Market-wide Adjustments Projected Paid Net Risk Adjustment PMPM 0.13$ Projected Paid Exchange User Fees PMPM 0.54$

Market-Adjusted Projected Paid EHB Claims PMPM 479.60$

Market-Adjusted Projected Allowed EHB Claims PMPM 550.00$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM 0.25$

Market-Adjusted Projected Paid Total Claims PMPM 479.82$

Market-Adjusted Projected Allowed Total Claims PMPM 550.26$

Table 6. Retention Table 7. Normalized Market-Adjusted Projected Allowed Total Claims

Retention Items - Express in percentages Normalization Factors 2016 2017Administrative Expenses 8% Average Age Factor 1.449 1.466 General and Claims 5.29% Average Geographic Factor 1.000 1.000

Agent/Broker Fees and Commissions 1.54% Average Tobacco Factor 1.000 1.000 Quality Improvement Initiatives 0.92% Average Benefit Richness (induced demand) 1.000 1.000Taxes and Fees 2.91% Average Network Factor 1.000 1.000 PCORI Fees (Enter $ amount here: $______________ ) 0.03% Pa Premium Tax (if applicable) 2.00% Market-Adjusted Projected Allowed Total Claims PMPM 472.61$ 550.26$ Federal Income Tax 0.31% Health Insurance Providers Fee (only for small group market, prorated for coverage in 2018) 0.57% Normalized Market-Adjusted Projected Allowed Total Claims PMPM 326.16$ 375.35$

Profit/Contingency 0%

Total Retention 11%<- Single Pool Gross Premium Avg. Rate, PMPM on URRT

Projected Required Revenue PMPM 538.16$

Table 8. Components of Rate Change Table 9. Year-over-Year Data to Support Table 8

Rate Components 2016 2017 Difference Percent Change 2016 2017

A. Calibrated Plan Adjusted Index Rate (PMPM) 349.4823002 361.8392483 $12.36 3.5% Paid-to-Allowed 0.901 0.872

B. Base period allowed claims before normalization 395.00$ 409.98$ $14.98 4% URRT Trend (2-Year Trend Factor) 1.081655966 1.19 <- URRT W1, S2 C. Normalization factor component of change (122.40)$ -130.321943 -$7.92 -$0.02 URRT Morbidity 1.083 1.166 <- URRT W1, S2

URRT "Other" 1 0.946 <- URRT W1, S2D. Change in Normalized Allowed Claims Adjustment Components D1. Base period allowed claims after normalization 272.60$ 279.66$ 7.06$ 2% Risk Adjustment 0.15$ 0.13$ <- URRT W1, S3 D2. URRT Trend 22.26$ 51.77$ 29.51$ 8% Reinsurance 2.25$ -$ <- URRT W1, S3 D3. URRT Morbidity 24.47$ 55.12$ 30.65$ 9% Exchange User Fee 0.72$ 0.54$ <- URRT W1, S3 D4. URRT Other -$ (21.01)$ (21.01)$ -6% Capitation -$ -$ <- URRT W1, S2 D5. Normalized URRT RA/RI on an allowed basis 1.84$ 0.10$ (1.74)$ 0% D6. Normalized Exchange User Fee on an allowed basis 0.55$ 0.42$ (0.13)$ 0% Network 1.002 0.994137975 D7. Subtotal - Sum(D1:D6) 321.72$ 366.07$ 44.35$ 13% Pricing AV 0.885 0.86150374E. Change in Allowable Plan Adjusted Level Components Benefit Richness 1.000 0.998155824 E1. Network 0.52$ -2.14592052 (2.67)$ -1% Catastrophic Eligibility 1.000 1 E2. Pricing AV (36.92)$ (50.40)$ (13.48)$ -4% E3. Benefit Richness -$ (0.58)$ (0.58)$ 0% Administrative Expenses 7.63% 7.76% E4. Catastrophic Eligibility -$ -$ -$ 0% Taxes and Fees 6.73% 2.91% E5. Subtotal - Sum(E1:E4) (36.40)$ (53.13)$ (16.72)$ -5% Profit and/or Contingency 5.00% 0.00%F. Change in Retention Components F1. Administrative Expenses 26.67$ 28.08$ 1.41$ 0% F2. Taxes and Fees 23.52$ 10.53$ (12.99)$ -4% F3. Profit and/or Contingency 17.47$ -$ (17.47)$ -5% F4. Subtotal - Sum(F1:F3) 67.66$ 38.61$ (29.05)$ -8%

G. Change in Miscellaneous Items 2.81$ 2.81$ 1%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 352.98$ 354.36$ 1.38$ 0%

PA Rate Template Part IIITable 10. Plan Rates

Age Calibration Factor 1.466Carrier Name: First Priority Life Insurance Company Geographic Calibration Factor 1.000Plan Type(s): PPO Aggregate Calibration Factor 1.466Market Segment: Small GroupRate Effective Date: 1/1/2017Market Adjusted Index Rate 550.00$

Plan Number HIOS Plan ID (Standard Component)

Plan Type (HMO, POS, PPO, EPO,

Indemnity, Other)1/1/16 Plan

Marketing Name

Discontinued, New, Modified, Existing (D,N,M,E) for 2017

1/1/17 Plan Marketing Name

(If 1/1/16 Plan Discontinued) Metallic Tier

Metallic Tier Actuarial

Value

Standard AV, Approach (1), Approach (2)

Exchange On/Off or

Off

Pricing AV (company-determined

AV)

Benefit Richness (induced demand)

Benefits in addition to

EHBProvider Network

Catastrophic Eligibility

Tobacco Surcharge

AdjustmentPure

Premium Admin Costs

Taxes & Fees (not including Exchange

fees)Profit or

Contingency

Total Covered Lives @

2/1/2016

Total Policyholders @

2/1/2016

2016 Calibrated Plan Adjusted Index

Rate PMPM

2017 Calibrated Plan Adjusted Index

Rate PMPM

Change

Compared to Prior 12 months

% of Total Covered Lives

Totals 0.833 0.862 0.998 1.000 0.994 1.000 1.000 472.95$ 7.9% 2.9% 0.0% 4,448 2,837 349.48$ 361.84$ 3.54%

Plan 1 55957PA0270001 PPO BlueCare PPO Platinum 1 D BlueCare PPO Platinum 2 Platinum 0.903 Standard AV Off 0.922 1.034 1.000 1.121 1.000 1.000 $588.22 7.9% 2.9% 0.0% 309 158 419.60$ $450.03 7.3% 6.9%Plan 2 55957PA0270002 PPO BlueCare PPO Platinum 2 M Platinum 0.884 Standard AV Off 0.922 1.034 1.000 1.121 1.000 1.000 $588.22 7.9% 2.9% 0.0% 243 130 418.88$ $450.03 7.4% 5.5%Plan 3 55957PA0270003 PPO BlueCare PPO Platinum 3 D BlueCare PPO Platinum 2 Platinum 0.892 Standard AV Off 0.922 1.034 1.000 1.121 1.000 1.000 $588.22 7.9% 2.9% 0.0% 102 58 418.35$ $450.03 7.6% 2.3%Plan 4 55957PA0270004 PPO BlueCare PPO Platinum 6 D BlueCare PPO Platinum 2 Platinum 0.901 Standard AV Off 0.922 1.034 1.000 1.121 1.000 1.000 $588.22 7.9% 2.9% 0.0% 91 52 417.44$ $450.03 7.8% 2.0%Plan 5 55957PA0270005 PPO BlueCare PPO Platinum 7 D BlueCare PPO Platinum 2 Platinum 0.898 Standard AV Off 0.922 1.034 1.000 1.121 1.000 1.000 $588.22 7.9% 2.9% 0.0% 33 20 417.15$ $450.03 7.9% 0.7%Plan 6 55957PA0270006 PPO BlueCare PPO Platinum 11 M Platinum 0.885 Standard AV Off 0.911 1.034 1.000 1.121 1.000 1.000 $581.48 7.9% 2.9% 0.0% 37 21 413.68$ $444.87 7.5% 0.8%Plan 7 55957PA0270007 PPO BlueCare PPO Platinum 12 M Platinum 0.885 Standard AV On/Off 0.921 1.034 1.000 1.121 1.000 1.000 $587.87 7.9% 2.9% 0.0% 151 102 428.42$ $449.76 5.0% 3.4%Plan 8 55957PA0270008 PPO BlueCare PPO Gold 12 M Gold 0.783 Standard AV Off 0.831 0.971 1.000 1.121 1.000 1.000 $497.78 7.9% 2.9% 0.0% 82 49 385.48$ $380.83 -1.2% 1.8%Plan 9 55957PA0270009 PPO BlueCare PPO Gold 18 M Gold 0.792 Standard AV Off 0.832 0.971 1.000 1.121 1.000 1.000 $498.26 7.9% 2.9% 0.0% 17 12 385.10$ $381.20 -1.0% 0.4%Plan 10 55957PA0270010 PPO BlueCare PPO Gold 19 M Gold 0.8 Standard AV Off 0.846 0.971 1.000 1.121 1.000 1.000 $506.62 7.9% 2.9% 0.0% - - 384.15$ $387.60 0.9% 0.0%Plan 11 55957PA0270011 PPO BlueCare PPO Gold 24 M Gold 0.784 Standard AV Off 0.811 0.971 1.000 1.121 1.000 1.000 $486.16 7.9% 2.9% 0.0% 104 61 377.94$ $371.94 -1.6% 2.3%Plan 12 55957PA0270012 PPO BlueCare PPO Bronze 3 D BlueCare PPO Bronze 4 Bronze 0.612 Standard AV Off 0.607 0.899 1.000 1.121 1.000 1.000 $336.57 7.9% 2.9% 0.0% - - 299.02$ $257.50 -13.9% 0.0%Plan 13 55957PA0270013 PPO BlueCare PPO Bronze 4 M Bronze 0.615 Standard AV Off 0.607 0.899 1.000 1.121 1.000 1.000 $336.57 7.9% 2.9% 0.0% 15 13 269.88$ $257.50 -4.6% 0.3%Plan 14 55957PA0270016 PPO BlueCare PPO Platinum 13 M Platinum 0.889 Standard AV Off 0.928 1.034 1.000 1.121 1.000 1.000 $591.86 7.9% 2.9% 0.0% 4 2 415.47$ $452.81 9.0% 0.1%Plan 15 55957PA0270017 PPO BlueCare PPO Gold 27 N Gold 0.804 Standard AV Off 0.887 0.971 1.000 1.121 1.000 1.000 $531.65 7.9% 2.9% 0.0% - - -$ $406.74 #DIV/0! 0.0%Plan 16 55957PA0270018 PPO BlueCare PPO Gold 15 N Gold 0.809 Standard AV Off 0.817 0.971 1.000 1.121 1.000 1.000 $489.53 7.9% 2.9% 0.0% - - -$ $374.52 #DIV/0! 0.0%Plan 17 55957PA0270019 PPO BlueCare PPO Silver 2 N Silver 0.696 Standard AV Off 0.695 0.926 1.000 1.121 1.000 1.000 $397.40 7.9% 2.9% 0.0% - - -$ $304.04 #DIV/0! 0.0%Plan 18 55957PA0270020 PPO BlueCare PPO Silver 6 N Silver 0.708 Standard AV Off 0.739 0.926 1.000 1.121 1.000 1.000 $422.30 7.9% 2.9% 0.0% - - -$ $323.09 #DIV/0! 0.0%Plan 19 55957PA0270021 PPO BlueCare PPO Silver 9 N Silver 0.691 Standard AV Off 0.731 0.926 1.000 1.121 1.000 1.000 $417.88 7.9% 2.9% 0.0% - - -$ $319.70 #DIV/0! 0.0%Plan 20 55957PA0270022 PPO BlueCare PPO Silver 10 N Silver 0.689 Standard AV Off 0.731 0.926 1.000 1.121 1.000 1.000 $417.79 7.9% 2.9% 0.0% - - -$ $319.64 #DIV/0! 0.0%Plan 21 55957PA0280001 PPO BlueCare QHD PPO Bronze 3 M Bronze 0.62 Standard AV Off 0.599 0.899 1.000 1.121 1.000 1.000 $332.35 7.9% 2.9% 0.0% - - 268.53$ $254.27 -5.3% 0.0%Plan 22 55957PA0280002 PPO BlueCare QHD PPO Bronze 4 M Bronze 0.619 Standard AV Off 0.601 0.899 1.000 1.121 1.000 1.000 $333.31 7.9% 2.9% 0.0% - - 268.40$ $255.00 -5.0% 0.0%Plan 23 55957PA0280003 PPO BlueCare QHD PPO Silver 1 N Silver 0.704 Standard AV Off 0.733 0.926 1.000 1.121 1.000 1.000 $418.79 7.9% 2.9% 0.0% - - -$ $320.40 #DIV/0! 0.0%Plan 24 55957PA0280004 PPO BlueCare QHD PPO Gold 1 N Gold 0.782 Standard AV Off 0.811 0.971 1.000 1.121 1.000 1.000 $485.91 7.9% 2.9% 0.0% - - -$ $371.75 #DIV/0! 0.0%Plan 25 55957PA0290001 PPO BlueCare Custom PPO Platinu D BlueCare Custom PPO Platin Platinum 0.903 Standard AV Off 0.922 1.034 1.000 0.942 1.000 1.000 $494.11 7.9% 2.9% 0.0% 142 99 352.46$ $378.02 7.3% 3.2%Plan 26 55957PA0290002 PPO BlueCare Custom PPO Platinu M Platinum 0.884 Standard AV Off 0.922 1.034 1.000 0.942 1.000 1.000 $494.11 7.9% 2.9% 0.0% 283 185 351.86$ $378.02 7.4% 6.4%Plan 27 55957PA0290003 PPO BlueCare Custom PPO Platinu D BlueCare Custom PPO Platin Platinum 0.892 Standard AV Off 0.922 1.034 1.000 0.942 1.000 1.000 $494.11 7.9% 2.9% 0.0% 123 76 351.41$ $378.02 7.6% 2.8%Plan 28 55957PA0290004 PPO BlueCare Custom PPO Platinu D BlueCare Custom PPO Platin Platinum 0.901 Standard AV Off 0.922 1.034 1.000 0.942 1.000 1.000 $494.11 7.9% 2.9% 0.0% 40 30 350.65$ $378.02 7.8% 0.9%Plan 29 55957PA0290005 PPO BlueCare Custom PPO Platinu D BlueCare Custom PPO Platin Platinum 0.898 Standard AV Off 0.922 1.034 1.000 0.942 1.000 1.000 $494.11 7.9% 2.9% 0.0% 106 73 350.40$ $378.02 7.9% 2.4%Plan 30 55957PA0290006 PPO BlueCare Custom PPO Platinu M Platinum 0.885 Standard AV Off 0.911 1.034 1.000 0.942 1.000 1.000 $488.44 7.9% 2.9% 0.0% 83 59 347.49$ $373.69 7.5% 1.9%Plan 31 55957PA0290007 PPO BlueCare Custom PPO Platinu M Platinum 0.885 Standard AV Off 0.921 1.034 1.000 0.942 1.000 1.000 $493.81 7.9% 2.9% 0.0% 246 197 359.88$ $377.80 5.0% 5.5%Plan 32 55957PA0290008 PPO BlueCare Custom PPO Platinu M Platinum 0.889 Standard AV On/Off 0.928 1.034 1.000 0.942 1.000 1.000 $497.16 7.9% 2.9% 0.0% 35 16 349.00$ $380.36 9.0% 0.8%Plan 33 55957PA0290009 PPO BlueCare Custom PPO Platinu D BlueCare Custom PPO Platin Platinum 0.881 Standard AV Off 0.922 1.034 1.000 0.942 1.000 1.000 $494.11 7.9% 2.9% 0.0% 40 27 345.15$ $378.02 9.5% 0.9%Plan 34 55957PA0290010 PPO BlueCare Custom PPO Platinu D BlueCare Custom PPO Platin Platinum 0.89 Standard AV Off 0.922 1.034 1.000 0.942 1.000 1.000 $494.11 7.9% 2.9% 0.0% 10 9 346.53$ $378.02 9.1% 0.2%Plan 35 55957PA0290011 PPO BlueCare Custom PPO Gold 1M Gold 0.783 Standard AV Off 0.831 0.971 1.000 0.942 1.000 1.000 $418.13 7.9% 2.9% 0.0% 281 175 323.80$ $319.90 -1.2% 6.3%Plan 36 55957PA0290012 PPO BlueCare Custom PPO Gold 1M Gold 0.809 Standard AV Off 0.817 0.971 1.000 0.942 1.000 1.000 $411.20 7.9% 2.9% 0.0% 14 14 305.91$ $314.59 2.8% 0.3%Plan 37 55957PA0290013 PPO BlueCare Custom PPO Gold 1M Gold 0.792 Standard AV Off 0.832 0.971 1.000 0.942 1.000 1.000 $418.53 7.9% 2.9% 0.0% 46 29 323.49$ $320.20 -1.0% 1.0%Plan 38 55957PA0290014 PPO BlueCare Custom PPO Gold 1M Gold 0.8 Standard AV Off 0.846 0.971 1.000 0.942 1.000 1.000 $425.57 7.9% 2.9% 0.0% 46 25 322.69$ $325.59 0.9% 1.0%Plan 39 55957PA0290015 PPO BlueCare Custom PPO Gold 2D BlueCare Custom PPO Gold Gold 0.804 Standard AV Off 0.846 0.971 1.000 0.942 1.000 1.000 $425.57 7.9% 2.9% 0.0% 14 13 310.60$ $325.59 4.8% 0.3%Plan 40 55957PA0290016 PPO BlueCare Custom PPO Gold 2M Gold 0.784 Standard AV Off 0.812 0.971 1.000 0.942 1.000 1.000 $408.54 7.9% 2.9% 0.0% 528 313 317.60$ $312.56 -1.6% 11.9%Plan 41 55957PA0290017 PPO BlueCare Custom PPO Silver 2M Silver 0.696 Standard AV On/Off 0.695 0.926 1.000 0.942 1.000 1.000 $333.82 7.9% 2.9% 0.0% 94 64 269.45$ $255.39 -5.2% 2.1%Plan 42 55957PA0290018 PPO BlueCare Custom PPO Silver 6M Silver 0.708 Standard AV Off 0.739 0.926 1.000 0.942 1.000 1.000 $354.74 7.9% 2.9% 0.0% 143 92 275.43$ $271.39 -1.5% 3.2%Plan 43 55957PA0290019 PPO BlueCare Custom PPO Silver 9M Silver 0.691 Standard AV On/Off 0.731 0.926 1.000 0.942 1.000 1.000 $351.02 7.9% 2.9% 0.0% 64 36 285.50$ $268.55 -5.9% 1.4%Plan 44 55957PA0290020 PPO BlueCare Custom PPO Bronze D BlueCare Custom PPO Bronz Bronze 0.612 Standard AV Off 0.607 0.899 1.000 0.942 1.000 1.000 $282.72 7.9% 2.9% 0.0% 6 6 251.18$ $216.30 -13.9% 0.1%Plan 45 55957PA0290021 PPO BlueCare Custom PPO Bronze M Bronze 0.615 Standard AV Off 0.607 0.899 1.000 0.942 1.000 1.000 $282.72 7.9% 2.9% 0.0% - - 226.70$ $216.30 -4.6% 0.0%Plan 46 55957PA0290022 PPO BlueCare Custom PPO Gold 2N Gold 0.804 Standard AV Off 0.887 0.971 1.000 0.942 1.000 1.000 $446.58 7.9% 2.9% 0.0% - - -$ $341.66 #DIV/0! 0.0%Plan 47 55957PA0290023 PPO BlueCare Custom PPO Silver 1N Silver 0.689 Standard AV Off 0.731 0.926 1.000 0.942 1.000 1.000 $350.95 7.9% 2.9% 0.0% - - -$ $268.49 #DIV/0! 0.0%Plan 48 55957PA0300001 PPO AffordaBlue Platinum1 M Platinum 0.891 Standard AV On/Off 0.902 1.034 1.000 0.886 1.000 1.000 $454.50 7.9% 2.9% 0.0% 118 91 320.14$ $347.72 8.6% 2.7%Plan 49 55957PA0300002 PPO AffordaBlue Gold Option 1 M Gold 0.796 Standard AV On/Off 0.822 0.971 1.000 0.886 1.000 1.000 $389.20 7.9% 2.9% 0.0% 51 40 299.39$ $297.76 -0.5% 1.1%Plan 50 55957PA0370001 PPO Lehigh Valley Flex Blue PPO 5N Gold 0.816 Standard AV Off 0.870 0.971 1.000 1.100 1.000 1.000 $511.08 7.9% 2.9% 0.0% - - -$ $391.00 #DIV/0! 0.0%Plan 51 55957PA0370002 PPO Lehigh Valley Flex Blue PPO 1N Gold 0.782 Standard AV Off 0.831 0.971 1.000 1.100 1.000 1.000 $488.47 7.9% 2.9% 0.0% - - -$ $373.71 #DIV/0! 0.0%Plan 52 55957PA0380001 PPO Lehigh Valley Flex Blue PPO 3N Silver 0.694 Standard AV Off 0.715 0.926 1.000 1.100 1.000 1.000 $401.04 7.9% 2.9% 0.0% - - -$ $306.82 #DIV/0! 0.0%Plan 53 55957PA0080045 PPO BlueCare Custom PPO Silver O D BlueCare Custom PPO Silver Silver 0.711 Standard AV Off 0.695 0.926 1.000 0.942 1.000 1.000 $333.82 7.9% 2.9% 0.0% 55 26 269.45$ $255.39 -5.2% 1.2%Plan 54 55957PA0080014 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.808 Standard AV Off 0.817 0.971 1.000 0.942 1.000 1.000 $411.20 7.9% 2.9% 0.0% 71 50 305.91$ $314.59 2.8% 1.6%Plan 55 55957PA0270015 PPO BlueCare PPO Silver 5 D BlueCare PPO Silver 6 Silver 0.717 Standard AV Off 0.739 0.926 1.000 1.121 1.000 1.000 $422.30 7.9% 2.9% 0.0% 18 9 326.86$ $323.09 -1.2% 0.4%Plan 56 55957PA0050007 PPO BlueCare PPO Platinum Optio D BlueCare PPO Platinum 2 Platinum 0.902 Standard AV Off 0.922 1.034 1.000 1.121 1.000 1.000 $588.22 7.9% 2.9% 0.0% 2 2 418.88$ $450.03 7.4% 0.0%Plan 57 55957PA0050025 PPO BlueCare PPO Gold Option 11D BlueCare PPO Gold 12 Gold 0.807 Standard AV Off 0.831 0.971 1.000 1.121 1.000 1.000 $497.78 7.9% 2.9% 0.0% 26 21 385.48$ $380.83 -1.2% 0.6%Plan 58 55957PA0080009 PPO BlueCare CustomPPO Platinu D BlueCare Custom PPO Platin Platinum 0.89 Standard AV Off 0.922 1.034 1.000 0.942 1.000 1.000 $494.11 7.9% 2.9% 0.0% 18 7 351.86$ $378.02 7.4% 0.4%Plan 59 55957PA0050001 PPO BlueCare PPO Silver Option 2D BlueCare PPO Silver 6 Silver 0.717 Standard AV Off 0.739 0.926 1.000 1.121 1.000 1.000 $422.30 7.9% 2.9% 0.0% 2 2 -$ $323.09 #DIV/0! 0.0%Plan 60 55957PA0080013 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.815 Standard AV Off 0.817 0.971 1.000 0.942 1.000 1.000 $411.20 7.9% 2.9% 0.0% 50 33 305.91$ $314.59 2.8% 1.1%Plan 61 55957PA0050024 PPO BlueCare PPO Gold Option 10D BlueCare PPO Gold 12 Gold 0.812 Standard AV Off 0.831 0.971 1.000 1.121 1.000 1.000 $497.78 7.9% 2.9% 0.0% 9 5 385.48$ $380.83 -1.2% 0.2%Plan 62 55957PA0050034 PPO BlueCare PPO Gold Option 21D BlueCare PPO Gold 18 Gold 0.801 Standard AV Off 0.832 0.971 1.000 1.121 1.000 1.000 $498.26 7.9% 2.9% 0.0% 4 4 385.10$ $381.20 -1.0% 0.1%Plan 63 55957PA0080005 PPO BlueCare CustomPPO Platinu D BlueCare Custom PPO Platin Platinum 0.902 Standard AV Off 0.922 1.034 1.000 0.942 1.000 1.000 $494.11 7.9% 2.9% 0.0% 28 22 351.86$ $378.02 7.4% 0.6%Plan 64 55957PA0080029 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.806 Standard AV Off 0.832 0.971 1.000 0.942 1.000 1.000 $418.53 7.9% 2.9% 0.0% 7 7 323.49$ $320.20 -1.0% 0.2%Plan 65 55957PA0050046 PPO BlueCare PPO Silver Option 6D BlueCare PPO Silver 6 Silver 0.688 Standard AV Off 0.739 0.926 1.000 1.121 1.000 1.000 $422.30 7.9% 2.9% 0.0% 1 1 -$ $323.09 #DIV/0! 0.0%Plan 66 55957PA0080022 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.812 Standard AV Off 0.831 0.971 1.000 0.942 1.000 1.000 $418.13 7.9% 2.9% 0.0% 101 77 323.80$ $319.90 -1.2% 2.3%Plan 67 55957PA0050021 PPO BlueCare PPO Gold Option 7 D BlueCare PPO Gold 12 Gold 0.806 Standard AV Off 0.831 0.971 1.000 1.121 1.000 1.000 $497.78 7.9% 2.9% 0.0% 2 2 385.48$ $380.83 -1.2% 0.0%Plan 68 55957PA0080044 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.782 Standard AV Off 0.817 0.971 1.000 0.942 1.000 1.000 $411.20 7.9% 2.9% 0.0% 97 64 305.91$ $314.59 2.8% 2.2%Plan 69 55957PA0270014 PPO BlueCare PPO Gold 13 D BlueCare PPO Gold 15 Gold 0.8 Standard AV Off 0.817 0.971 1.000 1.121 1.000 1.000 $489.53 7.9% 2.9% 0.0% 4 2 363.63$ $374.52 3.0% 0.1%Plan 70 55957PA0050035 PPO BlueCare PPO Gold Option 22D BlueCare PPO Gold 18 Gold 0.797 Standard AV Off 0.832 0.971 1.000 1.121 1.000 1.000 $498.26 7.9% 2.9% 0.0% 25 13 385.10$ $381.20 -1.0% 0.6%Plan 71 55957PA0080021 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.818 Standard AV Off 0.831 0.971 1.000 0.942 1.000 1.000 $418.13 7.9% 2.9% 0.0% 6 2 323.80$ $319.90 -1.2% 0.1%Plan 72 55957PA0070004 PPO BlueCare QHD PPO Silver Opt D BlueCare QHD PPO Bronze 4 Silver 0.689 Standard AV Off 0.601 0.926 1.000 1.121 1.000 1.000 $343.31 7.9% 2.9% 0.0% 17 10 268.40$ $262.65 -2.1% 0.4%Plan 73 55957PA0080034 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.797 Standard AV Off 0.846 0.971 1.000 0.942 1.000 1.000 $425.57 7.9% 2.9% 0.0% 64 33 322.69$ $325.59 0.9% 1.4%Plan 74 55957PA0080023 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.807 Standard AV Off 0.831 0.971 1.000 0.942 1.000 1.000 $418.13 7.9% 2.9% 0.0% 46 30 323.80$ $319.90 -1.2% 1.0%Plan 75 55957PA0070011 PPO BlueCare QHD PPO Silver Opt D BlueCare QHD PPO Bronze 4 Silver 0.681 Standard AV Off 0.601 0.926 1.000 1.121 1.000 1.000 $343.31 7.9% 2.9% 0.0% 10 6 268.40$ $262.65 -2.1% 0.2%Plan 76 55957PA0050015 PPO BlueCare PPO Gold Option 1 D BlueCare PPO Platinum 2 Gold 0.815 Standard AV Off 0.922 0.971 1.000 1.121 1.000 1.000 $552.42 7.9% 2.9% 0.0% 2 2 418.88$ $422.63 0.9% 0.0%Plan 77 55957PA0080056 PPO BlueCare Custom PPO Silver O D BlueCare Custom PPO Silver Silver 0.705 Standard AV Off 0.739 0.926 1.000 0.942 1.000 1.000 $354.74 7.9% 2.9% 0.0% 3 3 275.43$ $271.39 -1.5% 0.1%Plan 78 55957PA0050023 PPO BlueCare PPO Gold Option 9 D BlueCare PPO Gold 12 Gold 0.818 Standard AV Off 0.831 0.971 1.000 1.121 1.000 1.000 $497.78 7.9% 2.9% 0.0% 2 2 385.48$ $380.83 -1.2% 0.0%Plan 79 55957PA0080025 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.815 Standard AV Off 0.817 0.971 1.000 0.942 1.000 1.000 $411.20 7.9% 2.9% 0.0% 13 5 305.91$ $314.59 2.8% 0.3%Plan 80 55957PA0080016 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.817 Standard AV Off 0.831 0.971 1.000 0.942 1.000 1.000 $418.13 7.9% 2.9% 0.0% 5 5 323.80$ $319.90 -1.2% 0.1%Plan 81 55957PA0080020 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.8 Standard AV Off 0.831 0.971 1.000 0.942 1.000 1.000 $418.13 7.9% 2.9% 0.0% 2 2 323.80$ $319.90 -1.2% 0.0%Plan 82 55957PA0080033 PPO BlueCare Custom PPO Gold O D BlueCare Custom PPO Gold Gold 0.801 Standard AV Off 0.846 0.971 1.000 0.942 1.000 1.000 $425.57 7.9% 2.9% 0.0% 9 8 322.69$ $325.59 0.9% 0.2%Plan 83 55957PA0050048 PPO BlueCare PPO Silver Option 8D BlueCare PPO Silver 6 Silver 0.715 Standard AV Off 0.739 0.926 1.000 1.121 1.000 1.000 $422.30 7.9% 2.9% 0.0% 2 2 -$ $323.09 #DIV/0! 0.0%Plan 84 55957PA0070007 PPO BlueCare QHD PPO Bronze O D BlueCare QHD PPO Bronze 4 Bronze 0.61 Standard AV Off 0.601 0.899 1.000 1.121 1.000 1.000 $333.31 7.9% 2.9% 0.0% 1 1 268.40$ $255.00 -5.0% 0.0%Plan 85 55957PA0050017 PPO BlueCare PPO Gold Option 3 D BlueCare PPO Platinum 2 Gold 0.802 Standard AV Off 0.922 0.971 1.000 1.121 1.000 1.000 $552.42 7.9% 2.9% 0.0% 4 3 418.88$ $422.63 0.9% 0.1%Plan 86 55957PA0110005 PPO AffordaBlue Gold Option 4 D AffordaBlue Gold Option 1 Gold 0.812 Standard AV Off 0.822 0.971 1.000 0.886 1.000 1.000 $389.20 7.9% 2.9% 0.0% 7 7 299.39$ $297.76 -0.5% 0.2%Plan 87 55957PA0050016 PPO BlueCare PPO Gold Option 2 D BlueCare PPO Platinum 2 Gold 0.808 Standard AV Off 0.922 0.971 1.000 1.121 1.000 1.000 $552.42 7.9% 2.9% 0.0% 28 19 418.88$ $422.63 0.9% 0.6%Plan 88 55957PA0080048 PPO BlueCare Custom PPO Silver O D BlueCare Custom PPO Silver Silver 0.715 Standard AV Off 0.739 0.926 1.000 0.942 1.000 1.000 $354.74 7.9% 2.9% 0.0% 6 3 275.43$ $271.39 -1.5% 0.1%Plan 89 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 90 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 91 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 92 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 93 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 94 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 95 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 96 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 97 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 98 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 99 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%Plan 100 1.000 1.000 1.000 1.000 1.000 1.000 $550.00 0.0% 0.0% 0.0% - - $375.17 #DIV/0! 0.0%

Calibration

45 CFR Part 156.8 (d) (2) Allowable Factors

PA Rate Template Part IVTable 11. Plan Premium Development for 21-Year-Old Non-Tobacco User

Carrier Name: First Priority Life Insurance CompanyPlan Type(s): PPOMarket Segment: Small GroupRate Effective Date: 1/1/2017

Plan Number HIOS Plan ID (Standard Component)1/1/16 Plan

Marketing Name

Discontinued, New, Modified,

Existing (D,N,M,E) for

2017

1/1/17 Plan Marketing Name (If 1/1/16 Plan Discontinued)

Metallic Tier

Exchange On/Off or

Off 1 2 3 4 5 6 7 8 9 Total 1 2 3 4 5 6 7 8 9

Average (weighted by

enrollment by rating area) 1 2 3 4 5 6 7 8 9

Average (weighted by

enrollment by rating area) 1 2 3 4 5 6 7 8 9

Average (weighted by

enrollment by rating area)

Totals - - 4,448 - - - - - - 4,448 -$ -$ 349.48$ -$ -$ -$ -$ -$ -$ 349.48$ -$ -$ 361.84$ -$ -$ -$ -$ -$ -$ 361.84$ 0.0% 0.0% 3.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.0%

Plan 1 55957PA0270001 BlueCare PPO Platinum 1 D BlueCare PPO Platinum 2 Platinum Off 309 309 -$ -$ 419.60$ -$ -$ -$ -$ -$ -$ 419.60$ -$ -$ 450.03$ -$ -$ -$ -$ -$ -$ 450.03$ 0.0% 0.0% 7.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.3%Plan 2 55957PA0270002 BlueCare PPO Platinum 2 M Platinum Off 243 243 -$ -$ 418.88$ -$ -$ -$ -$ -$ -$ 418.88$ -$ -$ 450.03$ -$ -$ -$ -$ -$ -$ 450.03$ 0.0% 0.0% 7.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.4%Plan 3 55957PA0270003 BlueCare PPO Platinum 3 D BlueCare PPO Platinum 2 Platinum Off 102 102 -$ -$ 418.35$ -$ -$ -$ -$ -$ -$ 418.35$ -$ -$ 450.03$ -$ -$ -$ -$ -$ -$ 450.03$ 0.0% 0.0% 7.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.6%Plan 4 55957PA0270004 BlueCare PPO Platinum 6 D BlueCare PPO Platinum 2 Platinum Off 91 91 -$ -$ 417.44$ -$ -$ -$ -$ -$ -$ 417.44$ -$ -$ 450.03$ -$ -$ -$ -$ -$ -$ 450.03$ 0.0% 0.0% 7.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.8%Plan 5 55957PA0270005 BlueCare PPO Platinum 7 D BlueCare PPO Platinum 2 Platinum Off 33 33 -$ -$ 417.15$ -$ -$ -$ -$ -$ -$ 417.15$ -$ -$ 450.03$ -$ -$ -$ -$ -$ -$ 450.03$ 0.0% 0.0% 7.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.9%Plan 6 55957PA0270006 BlueCare PPO Platinum 1 M Platinum Off 37 37 -$ -$ 413.68$ -$ -$ -$ -$ -$ -$ 413.68$ -$ -$ 444.87$ -$ -$ -$ -$ -$ -$ 444.87$ 0.0% 0.0% 7.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.5%Plan 7 55957PA0270007 BlueCare PPO Platinum 1 M Platinum On/Off 151 151 -$ -$ 428.42$ -$ -$ -$ -$ -$ -$ 428.42$ -$ -$ 449.76$ -$ -$ -$ -$ -$ -$ 449.76$ 0.0% 0.0% 5.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.0%Plan 8 55957PA0270008 BlueCare PPO Gold 12 M Gold Off 82 82 -$ -$ 385.48$ -$ -$ -$ -$ -$ -$ 385.48$ -$ -$ 380.83$ -$ -$ -$ -$ -$ -$ 380.83$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 9 55957PA0270009 BlueCare PPO Gold 18 M Gold Off 17 17 -$ -$ 385.10$ -$ -$ -$ -$ -$ -$ 385.10$ -$ -$ 381.20$ -$ -$ -$ -$ -$ -$ 381.20$ 0.0% 0.0% -1.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.0%Plan 10 55957PA0270010 BlueCare PPO Gold 19 M Gold Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 11 55957PA0270011 BlueCare PPO Gold 24 M Gold Off 104 104 -$ -$ 377.94$ -$ -$ -$ -$ -$ -$ 377.94$ -$ -$ 371.94$ -$ -$ -$ -$ -$ -$ 371.94$ 0.0% 0.0% -1.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.6%Plan 12 55957PA0270012 BlueCare PPO Bronze 3 D BlueCare PPO Bronze 4 Bronze Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 13 55957PA0270013 BlueCare PPO Bronze 4 M Bronze Off 15 15 -$ -$ 269.88$ -$ -$ -$ -$ -$ -$ 269.88$ -$ -$ 257.50$ -$ -$ -$ -$ -$ -$ 257.50$ 0.0% 0.0% -4.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -4.6%Plan 14 55957PA0270016 BlueCare PPO Platinum 1 M Platinum Off 4 4 -$ -$ 415.47$ -$ -$ -$ -$ -$ -$ 415.47$ -$ -$ 452.81$ -$ -$ -$ -$ -$ -$ 452.81$ 0.0% 0.0% 9.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 9.0%Plan 15 55957PA0270017 BlueCare PPO Gold 27 N Gold Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 16 55957PA0270018 BlueCare PPO Gold 15 N Gold Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 17 55957PA0270019 BlueCare PPO Silver 2 N Silver Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 18 55957PA0270020 BlueCare PPO Silver 6 N Silver Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 19 55957PA0270021 BlueCare PPO Silver 9 N Silver Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 20 55957PA0270022 BlueCare PPO Silver 10 N Silver Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 21 55957PA0280001 BlueCare QHD PPO Bronz M Bronze Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 22 55957PA0280002 BlueCare QHD PPO Bronz M Bronze Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 23 55957PA0280003 BlueCare QHD PPO Silver N Silver Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 24 55957PA0280004 BlueCare QHD PPO Gold N Gold Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 25 55957PA0290001 BlueCare Custom PPO Pl D BlueCare Custom PPO Plati Platinum Off 142 142 -$ -$ 352.46$ -$ -$ -$ -$ -$ -$ 352.46$ -$ -$ 378.02$ -$ -$ -$ -$ -$ -$ 378.02$ 0.0% 0.0% 7.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.3%Plan 26 55957PA0290002 BlueCare Custom PPO Pl M Platinum Off 283 283 -$ -$ 351.86$ -$ -$ -$ -$ -$ -$ 351.86$ -$ -$ 378.02$ -$ -$ -$ -$ -$ -$ 378.02$ 0.0% 0.0% 7.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.4%Plan 27 55957PA0290003 BlueCare Custom PPO Pl D BlueCare Custom PPO Plati Platinum Off 123 123 -$ -$ 351.41$ -$ -$ -$ -$ -$ -$ 351.41$ -$ -$ 378.02$ -$ -$ -$ -$ -$ -$ 378.02$ 0.0% 0.0% 7.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.6%Plan 28 55957PA0290004 BlueCare Custom PPO Pl D BlueCare Custom PPO Plati Platinum Off 40 40 -$ -$ 350.65$ -$ -$ -$ -$ -$ -$ 350.65$ -$ -$ 378.02$ -$ -$ -$ -$ -$ -$ 378.02$ 0.0% 0.0% 7.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.8%Plan 29 55957PA0290005 BlueCare Custom PPO Pl D BlueCare Custom PPO Plati Platinum Off 106 106 -$ -$ 350.40$ -$ -$ -$ -$ -$ -$ 350.40$ -$ -$ 378.02$ -$ -$ -$ -$ -$ -$ 378.02$ 0.0% 0.0% 7.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.9%Plan 30 55957PA0290006 BlueCare Custom PPO Pl M Platinum Off 83 83 -$ -$ 347.49$ -$ -$ -$ -$ -$ -$ 347.49$ -$ -$ 373.69$ -$ -$ -$ -$ -$ -$ 373.69$ 0.0% 0.0% 7.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.5%Plan 31 55957PA0290007 BlueCare Custom PPO Pl M Platinum Off 246 246 -$ -$ 359.88$ -$ -$ -$ -$ -$ -$ 359.88$ -$ -$ 377.80$ -$ -$ -$ -$ -$ -$ 377.80$ 0.0% 0.0% 5.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.0%Plan 32 55957PA0290008 BlueCare Custom PPO Pl M Platinum On/Off 35 35 -$ -$ 349.00$ -$ -$ -$ -$ -$ -$ 349.00$ -$ -$ 380.36$ -$ -$ -$ -$ -$ -$ 380.36$ 0.0% 0.0% 9.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 9.0%Plan 33 55957PA0290009 BlueCare Custom PPO Pl D BlueCare Custom PPO Plati Platinum Off 40 40 -$ -$ 345.15$ -$ -$ -$ -$ -$ -$ 345.15$ -$ -$ 378.02$ -$ -$ -$ -$ -$ -$ 378.02$ 0.0% 0.0% 9.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 9.5%Plan 34 55957PA0290010 BlueCare Custom PPO Pl D BlueCare Custom PPO Plati Platinum Off 10 10 -$ -$ 346.53$ -$ -$ -$ -$ -$ -$ 346.53$ -$ -$ 378.02$ -$ -$ -$ -$ -$ -$ 378.02$ 0.0% 0.0% 9.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 9.1%Plan 35 55957PA0290011 BlueCare Custom PPO Go M Gold Off 281 281 -$ -$ 323.80$ -$ -$ -$ -$ -$ -$ 323.80$ -$ -$ 319.90$ -$ -$ -$ -$ -$ -$ 319.90$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 36 55957PA0290012 BlueCare Custom PPO Go M Gold Off 14 14 -$ -$ 305.91$ -$ -$ -$ -$ -$ -$ 305.91$ -$ -$ 314.59$ -$ -$ -$ -$ -$ -$ 314.59$ 0.0% 0.0% 2.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.8%Plan 37 55957PA0290013 BlueCare Custom PPO Go M Gold Off 46 46 -$ -$ 323.49$ -$ -$ -$ -$ -$ -$ 323.49$ -$ -$ 320.20$ -$ -$ -$ -$ -$ -$ 320.20$ 0.0% 0.0% -1.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.0%Plan 38 55957PA0290014 BlueCare Custom PPO Go M Gold Off 46 46 -$ -$ 322.69$ -$ -$ -$ -$ -$ -$ 322.69$ -$ -$ 325.59$ -$ -$ -$ -$ -$ -$ 325.59$ 0.0% 0.0% 0.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.9%Plan 39 55957PA0290015 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 14 14 -$ -$ 310.60$ -$ -$ -$ -$ -$ -$ 310.60$ -$ -$ 325.59$ -$ -$ -$ -$ -$ -$ 325.59$ 0.0% 0.0% 4.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.8%Plan 40 55957PA0290016 BlueCare Custom PPO Go M Gold Off 528 528 -$ -$ 317.60$ -$ -$ -$ -$ -$ -$ 317.60$ -$ -$ 312.56$ -$ -$ -$ -$ -$ -$ 312.56$ 0.0% 0.0% -1.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.6%Plan 41 55957PA0290017 BlueCare Custom PPO Si M Silver On/Off 94 94 -$ -$ 269.45$ -$ -$ -$ -$ -$ -$ 269.45$ -$ -$ 255.39$ -$ -$ -$ -$ -$ -$ 255.39$ 0.0% 0.0% -5.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -5.2%Plan 42 55957PA0290018 BlueCare Custom PPO Si M Silver Off 143 143 -$ -$ 275.43$ -$ -$ -$ -$ -$ -$ 275.43$ -$ -$ 271.39$ -$ -$ -$ -$ -$ -$ 271.39$ 0.0% 0.0% -1.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.5%Plan 43 55957PA0290019 BlueCare Custom PPO Si M Silver On/Off 64 64 -$ -$ 285.50$ -$ -$ -$ -$ -$ -$ 285.50$ -$ -$ 268.55$ -$ -$ -$ -$ -$ -$ 268.55$ 0.0% 0.0% -5.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -5.9%Plan 44 55957PA0290020 BlueCare Custom PPO Br D BlueCare Custom PPO Bron Bronze Off 6 6 -$ -$ 251.18$ -$ -$ -$ -$ -$ -$ 251.18$ -$ -$ 216.30$ -$ -$ -$ -$ -$ -$ 216.30$ 0.0% 0.0% -13.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -13.9%Plan 45 55957PA0290021 BlueCare Custom PPO Br M Bronze Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 46 55957PA0290022 BlueCare Custom PPO Go N Gold Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 47 55957PA0290023 BlueCare Custom PPO Si N Silver Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 48 55957PA0300001 AffordaBlue Platinum1 M Platinum On/Off 118 118 -$ -$ 320.14$ -$ -$ -$ -$ -$ -$ 320.14$ -$ -$ 347.72$ -$ -$ -$ -$ -$ -$ 347.72$ 0.0% 0.0% 8.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 8.6%Plan 49 55957PA0300002 AffordaBlue Gold Option M Gold On/Off 51 51 -$ -$ 299.39$ -$ -$ -$ -$ -$ -$ 299.39$ -$ -$ 297.76$ -$ -$ -$ -$ -$ -$ 297.76$ 0.0% 0.0% -0.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -0.5%Plan 50 55957PA0370001 Lehigh Valley Flex Blue P N Gold Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 51 55957PA0370002 Lehigh Valley Flex Blue P N Gold Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 52 55957PA0380001 Lehigh Valley Flex Blue P N Silver Off - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 53 55957PA0080045 BlueCare Custom PPO Si D BlueCare Custom PPO Silve Silver Off 55 55 -$ -$ 269.45$ -$ -$ -$ -$ -$ -$ 269.45$ -$ -$ 255.39$ -$ -$ -$ -$ -$ -$ 255.39$ 0.0% 0.0% -5.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -5.2%Plan 54 55957PA0080014 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 71 71 -$ -$ 305.91$ -$ -$ -$ -$ -$ -$ 305.91$ -$ -$ 314.59$ -$ -$ -$ -$ -$ -$ 314.59$ 0.0% 0.0% 2.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.8%Plan 55 55957PA0270015 BlueCare PPO Silver 5 D BlueCare PPO Silver 6 Silver Off 18 18 -$ -$ 326.86$ -$ -$ -$ -$ -$ -$ 326.86$ -$ -$ 323.09$ -$ -$ -$ -$ -$ -$ 323.09$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 56 55957PA0050007 BlueCare PPO Platinum O D BlueCare PPO Platinum 2 Platinum Off 2 2 -$ -$ 418.88$ -$ -$ -$ -$ -$ -$ 418.88$ -$ -$ 450.03$ -$ -$ -$ -$ -$ -$ 450.03$ 0.0% 0.0% 7.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.4%Plan 57 55957PA0050025 BlueCare PPO Gold Optio D BlueCare PPO Gold 12 Gold Off 26 26 -$ -$ 385.48$ -$ -$ -$ -$ -$ -$ 385.48$ -$ -$ 380.83$ -$ -$ -$ -$ -$ -$ 380.83$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 58 55957PA0080009 BlueCare CustomPPO Pla D BlueCare Custom PPO Plati Platinum Off 18 18 -$ -$ 351.86$ -$ -$ -$ -$ -$ -$ 351.86$ -$ -$ 378.02$ -$ -$ -$ -$ -$ -$ 378.02$ 0.0% 0.0% 7.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.4%Plan 59 55957PA0050001 BlueCare PPO Silver Opti D BlueCare PPO Silver 6 Silver Off 2 2 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 323.09$ -$ -$ -$ -$ -$ -$ 323.09$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 60 55957PA0080013 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 50 50 -$ -$ 305.91$ -$ -$ -$ -$ -$ -$ 305.91$ -$ -$ 314.59$ -$ -$ -$ -$ -$ -$ 314.59$ 0.0% 0.0% 2.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.8%Plan 61 55957PA0050024 BlueCare PPO Gold Optio D BlueCare PPO Gold 12 Gold Off 9 9 -$ -$ 385.48$ -$ -$ -$ -$ -$ -$ 385.48$ -$ -$ 380.83$ -$ -$ -$ -$ -$ -$ 380.83$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 62 55957PA0050034 BlueCare PPO Gold Optio D BlueCare PPO Gold 18 Gold Off 4 4 -$ -$ 385.10$ -$ -$ -$ -$ -$ -$ 385.10$ -$ -$ 381.20$ -$ -$ -$ -$ -$ -$ 381.20$ 0.0% 0.0% -1.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.0%Plan 63 55957PA0080005 BlueCare CustomPPO Pla D BlueCare Custom PPO Plati Platinum Off 28 28 -$ -$ 351.86$ -$ -$ -$ -$ -$ -$ 351.86$ -$ -$ 378.02$ -$ -$ -$ -$ -$ -$ 378.02$ 0.0% 0.0% 7.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.4%Plan 64 55957PA0080029 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 7 7 -$ -$ 323.49$ -$ -$ -$ -$ -$ -$ 323.49$ -$ -$ 320.20$ -$ -$ -$ -$ -$ -$ 320.20$ 0.0% 0.0% -1.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.0%Plan 65 55957PA0050046 BlueCare PPO Silver Opti D BlueCare PPO Silver 6 Silver Off 1 1 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 323.09$ -$ -$ -$ -$ -$ -$ 323.09$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 66 55957PA0080022 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 101 101 -$ -$ 323.80$ -$ -$ -$ -$ -$ -$ 323.80$ -$ -$ 319.90$ -$ -$ -$ -$ -$ -$ 319.90$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 67 55957PA0050021 BlueCare PPO Gold Optio D BlueCare PPO Gold 12 Gold Off 2 2 -$ -$ 385.48$ -$ -$ -$ -$ -$ -$ 385.48$ -$ -$ 380.83$ -$ -$ -$ -$ -$ -$ 380.83$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 68 55957PA0080044 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 97 97 -$ -$ 305.91$ -$ -$ -$ -$ -$ -$ 305.91$ -$ -$ 314.59$ -$ -$ -$ -$ -$ -$ 314.59$ 0.0% 0.0% 2.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.8%Plan 69 55957PA0270014 BlueCare PPO Gold 13 D BlueCare PPO Gold 15 Gold Off 4 4 -$ -$ 363.63$ -$ -$ -$ -$ -$ -$ 363.63$ -$ -$ 374.52$ -$ -$ -$ -$ -$ -$ 374.52$ 0.0% 0.0% 3.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.0%Plan 70 55957PA0050035 BlueCare PPO Gold Optio D BlueCare PPO Gold 18 Gold Off 25 25 -$ -$ 385.10$ -$ -$ -$ -$ -$ -$ 385.10$ -$ -$ 381.20$ -$ -$ -$ -$ -$ -$ 381.20$ 0.0% 0.0% -1.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.0%Plan 71 55957PA0080021 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 6 6 -$ -$ 323.80$ -$ -$ -$ -$ -$ -$ 323.80$ -$ -$ 319.90$ -$ -$ -$ -$ -$ -$ 319.90$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 72 55957PA0070004 BlueCare QHD PPO Silver D BlueCare QHD PPO Bronze 4 Silver Off 17 17 -$ -$ 268.40$ -$ -$ -$ -$ -$ -$ 268.40$ -$ -$ 262.65$ -$ -$ -$ -$ -$ -$ 262.65$ 0.0% 0.0% -2.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -2.1%Plan 73 55957PA0080034 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 64 64 -$ -$ 322.69$ -$ -$ -$ -$ -$ -$ 322.69$ -$ -$ 325.59$ -$ -$ -$ -$ -$ -$ 325.59$ 0.0% 0.0% 0.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.9%Plan 74 55957PA0080023 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 46 46 -$ -$ 323.80$ -$ -$ -$ -$ -$ -$ 323.80$ -$ -$ 319.90$ -$ -$ -$ -$ -$ -$ 319.90$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 75 55957PA0070011 BlueCare QHD PPO Silver D BlueCare QHD PPO Bronze 4 Silver Off 10 10 -$ -$ 268.40$ -$ -$ -$ -$ -$ -$ 268.40$ -$ -$ 262.65$ -$ -$ -$ -$ -$ -$ 262.65$ 0.0% 0.0% -2.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -2.1%Plan 76 55957PA0050015 BlueCare PPO Gold Optio D BlueCare PPO Platinum 2 Gold Off 2 2 -$ -$ 418.88$ -$ -$ -$ -$ -$ -$ 418.88$ -$ -$ 422.63$ -$ -$ -$ -$ -$ -$ 422.63$ 0.0% 0.0% 0.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.9%Plan 77 55957PA0080056 BlueCare Custom PPO Si D BlueCare Custom PPO Silve Silver Off 3 3 -$ -$ 275.43$ -$ -$ -$ -$ -$ -$ 275.43$ -$ -$ 271.39$ -$ -$ -$ -$ -$ -$ 271.39$ 0.0% 0.0% -1.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.5%Plan 78 55957PA0050023 BlueCare PPO Gold Optio D BlueCare PPO Gold 12 Gold Off 2 2 -$ -$ 385.48$ -$ -$ -$ -$ -$ -$ 385.48$ -$ -$ 380.83$ -$ -$ -$ -$ -$ -$ 380.83$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 79 55957PA0080025 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 13 13 -$ -$ 305.91$ -$ -$ -$ -$ -$ -$ 305.91$ -$ -$ 314.59$ -$ -$ -$ -$ -$ -$ 314.59$ 0.0% 0.0% 2.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.8%Plan 80 55957PA0080016 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 5 5 -$ -$ 323.80$ -$ -$ -$ -$ -$ -$ 323.80$ -$ -$ 319.90$ -$ -$ -$ -$ -$ -$ 319.90$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 81 55957PA0080020 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 2 2 -$ -$ 323.80$ -$ -$ -$ -$ -$ -$ 323.80$ -$ -$ 319.90$ -$ -$ -$ -$ -$ -$ 319.90$ 0.0% 0.0% -1.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.2%Plan 82 55957PA0080033 BlueCare Custom PPO Go D BlueCare Custom PPO Gold Gold Off 9 9 -$ -$ 322.69$ -$ -$ -$ -$ -$ -$ 322.69$ -$ -$ 325.59$ -$ -$ -$ -$ -$ -$ 325.59$ 0.0% 0.0% 0.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.9%Plan 83 55957PA0050048 BlueCare PPO Silver Opti D BlueCare PPO Silver 6 Silver Off 2 2 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 323.09$ -$ -$ -$ -$ -$ -$ 323.09$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 84 55957PA0070007 BlueCare QHD PPO Bronz D BlueCare QHD PPO Bronze 4 Bronze Off 1 1 -$ -$ 268.40$ -$ -$ -$ -$ -$ -$ 268.40$ -$ -$ 255.00$ -$ -$ -$ -$ -$ -$ 255.00$ 0.0% 0.0% -5.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -5.0%Plan 85 55957PA0050017 BlueCare PPO Gold Optio D BlueCare PPO Platinum 2 Gold Off 4 4 -$ -$ 418.88$ -$ -$ -$ -$ -$ -$ 418.88$ -$ -$ 422.63$ -$ -$ -$ -$ -$ -$ 422.63$ 0.0% 0.0% 0.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.9%Plan 86 55957PA0110005 AffordaBlue Gold Option D AffordaBlue Gold Option 1 Gold Off 7 7 -$ -$ 299.39$ -$ -$ -$ -$ -$ -$ 299.39$ -$ -$ 297.76$ -$ -$ -$ -$ -$ -$ 297.76$ 0.0% 0.0% -0.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -0.5%Plan 87 55957PA0050016 BlueCare PPO Gold Optio D BlueCare PPO Platinum 2 Gold Off 28 28 -$ -$ 418.88$ -$ -$ -$ -$ -$ -$ 418.88$ -$ -$ 422.63$ -$ -$ -$ -$ -$ -$ 422.63$ 0.0% 0.0% 0.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.9%Plan 88 55957PA0080048 BlueCare Custom PPO Si D BlueCare Custom PPO Silve Silver Off 6 6 -$ -$ 275.43$ -$ -$ -$ -$ -$ -$ 275.43$ -$ -$ 271.39$ -$ -$ -$ -$ -$ -$ 271.39$ 0.0% 0.0% -1.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% -1.5%Plan 89 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 90 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 91 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 92 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 93 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 94 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 95 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 96 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 97 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 98 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 99 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 100 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Change in 21-year-old Non-Tobacco Premium PMPM

These cells auto-fill using the data entered in Table 9.

2/1/16 Number of Covered Lives 2016 21-year-old Non-Tobacco Premium PMPM (in small group market, average monthly premium weighted for quarterly trend)

2017 21-year-old Non-Tobacco Premium PMPM (in small group market, average monthly premium weighted for quarterly trend)

PA Rate Template Part VConsumer Factors

Table 12. Age and Tobacco Factors Table 13. Geographic Factors

Age Band

Age Factor

Tobacco Factor

Age Band

Age Factor

Tobacco Factor

Area CountiesCurrent Factor

Proposed Factor

0-20 0.635 43 1.357 1 Rating Area 121 1.000 1 44 1.397 1 Rating Area 2

22 1.000 1 45 1.444 1 Rating Area 3Tioga, Bradford, Susquehanna, Wayne, Clinton, Lycoming, Sullivan, Wyoming, Lackawanna, Pike, Luzerne, Carbon, Monroe

1.000 1.000

23 1.000 1 46 1.500 1 Rating Area 4 24 1.000 1 47 1.563 1 Rating Area 525 1.004 1 48 1.635 1 Rating Area 626 1.024 1 49 1.706 1 Rating Area 7 27 1.048 1 50 1.786 1 Rating Area 828 1.087 1 51 1.865 1 Rating Area 929 1.119 1 52 1.952 130 1.135 1 53 2.040 131 1.159 1 54 2.135 1 Table 14. Network Factors32 1.183 1 55 2.230 133 1.198 1 56 2.333 1

34 1.214 1 57 2.437 1 Network Name Rating AreaCurrent Factor

Proposed Factor

DOH Approval

Date35 1.222 1 58 2.548 1 PPO (Including QHD) Rating Area 3 1.000 1 1/1/200736 1.230 1 59 2.603 1 CustomPPO Rating Area 3 0.840 0.840 2/19/200937 1.238 1 60 2.714 1 AffordaBlue Rating Area 3 0.790 0.79038 1.246 1 61 2.810 1 Lehigh Valley Flex Blue Rating Area 3 0.981 0.981 4/21/201639 1.262 1 62 2.873 140 1.278 1 63 2.952 141 1.302 1 64+ 3.000 142 1.325 1

*PA follows the federal default age curve.

Geographic Area Factors2017 Age and Tobacco Factors

2017 Network Factors