supporting document schedules · 12. number of plans offered in 2020: 10 platinum plans, 21 gold...

Supporting Document Schedules Satisfied - Item: ACA Public Rate Filing PDFComments:Attachment(s): Public_Filing_PDF_GQO_SmGrp_071919.pdfItem Status:Status Date:

SERFF Tracking #: GSHP-131915683 State Tracking #: GSHP-131915683 Company Tracking #: ACTUARIAL GQO SG

State: Pennsylvania Filing Company: Geisinger Quality Options

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

Product Name: PPO

Project Name/Number: GQO SG/

PDF Pipeline for SERFF Tracking Number GSHP-131915683 Generated 08/13/2019 11:18 AM

Actuarial Department 100 N. Academy Ave.

Danville, PA 17822-5002

Tel.• 800-447-4000 GeisingerHealthPlan.com

May 16, 2019

Ms. Tracie Gray - Director Bureau of Life, Accident and Health Insurance Pennsylvania Insurance Department Email [email protected] Phone: 717-705-7257

Dear Ms. Gray:

Geisinger Health Plan

The following is in response to the Department's guidance as of April 3, 2019:

1. C ompany Name & NAIC#: Geisinger Quality Options - NAIC# 127432. Market: Small Group3. Off Exchange only4. Effective date of coverage: January 1, 20205. Average rate change: 17.8%6. Range of rate change requested: 15.4% to 23.9%7. Total additional annual revenue generated from the proposed rate change: $18,699,0048. Product: PPO9. Rating areas: 2, 3, 5, 6, 7, and 9 (no changes from 2019)10. Metal Levels & Catastrophic Plans: Platinum, Gold, Silver and Bronze plans11. Current number of covered lives and of policyholders as of 2/1/19: 16,094 covered lives and

9,865 policyholders12. Number of plans offered in 2020: 10 platinum plans, 21 gold plans, 10 silver plans and 2 bronze

plans (for a total of 43 plans); Number of plans offered in 2019: 11 platinum plans, 22 gold plans,10 silver plans and 2 bronze plans (for a total of 45 plans)

13. Contract form#: M-152-121-F Rev. 1/20, M-152-243-F Rev. 1/20, M-152-122-F Rev. 1/20, M-152-367-F Dev. 1/20; SERFF #: GSHP-131915683; Binder ID#: GSHP-PA20-125092066

14. HIOS issuer ID: 75729; HIOS submission tracking#: 75729-1488942398695937030

For a detailed explanation of our rate development, please refer to the "actuarial memorandum and

attestation" uploaded in SERFF under the "supporting documentation" tab.

Thank you for your consideration. Please contact me if you have any additional questions.

Sincerely,

cc. Sarah MacDerment, FSA, MAAA, Actuarial DirectorEverard Riley, ASA, MAAA, Associate ActuaryDevon Dietrich, Actuarial Analyst

Geisinger Health Plan may refer collectively to Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company, unless otherwise noted.

Attachment I

Rate Change Summary

Geisinger Quality Options – Small Group Plans Rate request filing ID # GSHP-131915683 - This document is prepared by the insurance company submitting the rate filing as a consumer tool to help explain the rate filing. It is not intended to describe or include all factors or information considered in the review process. For more information, see the filing at http://www.insurance.pa.gov/Consumers/ACARelatedFilings/

Overview Initial requested average rate change: 18.1%Revised requested average rate change: 18.3%

Range of requested rate change: 13.2% - 24.3% Effective date: 1/1/2020 Mapped Members: 16,094 Available in: Rating Areas 2, 3, 5, 6, 7 and 9

Key information Jan. 2018-Dec. 2018 financial experience

The company expects its annual medical costs to increase 7.85%.

Explanation of requested rate change Geisinger Quality Options has proposed an overall base rate increase of 18.3% for Small Group PPO members effective January 1, 2020 through December 1, 2020. The actual range of proposed rate increases vary from a minimum of 13.2% to a maximum of 24.3%. The key drivers of this increase are changes in the single risk pool experience, medical inflation, utilization trend, administrative expense, federal taxes and risk adjustment. The total projected 2020 administrative costs are slightly higher than those used for the current 2019 rates. As required by federal regulations and using the Federally prescribed MLR methodology, the projected loss ratio exceeds 80%. There were minimal benefit changes proposed for 2020 to maintain the desired metallic level.

How it plans to spend your premium This is how the insurance company plans to spend the premium it collects in 2020:

Claims: Administrative: Taxes & fees: Profit:

86.3% 8.0% 3.7% 2.0%

Premiums $88,190,030 Claims $79,665,668 Administrative expenses $7,526,911 Taxes & fees $2,189,564

Company made (after taxes) -$1,192,113

of 10 Devised 5/16/19 Revised 7/19/19

Actuarial Memorandum – Small Group GQO

1.Basic Information and Data

General Information

Company Identifying Information (as included in Table 0)

Company Legal Name: Geisinger Quality Options State: Pennsylvania

HIOS Issuer ID: 75729

NAIC Number: 12743 Market: Small Group

Effective Date: 1/1/2020

Company Contact Information

Primary Contact Name: Sarah MacDerment

Primary Contact Phone: 570-214-2348

Primary Contact email address: [email protected]

Filing Information

HIOS Submission Tracking Number: 75729-1488942398695937030

Contract Form Number: M-152-121-F Rev. 1/20, M-152-243-F Rev. 1/20, M-152-122-F Rev. 1/20, M-152-

367-F Dev. 1/20

SERFF Number: GSHP-131915683

Binder ID Number: GSHP-PA20-125092066

Rate History and Proposed Variations in Rate Changes Rate History The recent historical rate increases are summarized in the table below.

Year SERFF ID Average Increase

Minimum Increase

Maximum Increase

2015 GSHP-129625169 24.3% 21.2% 26.9%

2016 GSHP-130072619 9.9% -7.9% 11.6%

2017 GSHP-130558380 -0.3% -5.9% 1.4%

2018 GSHP-131024110 8.2% 1.1% 17.6%

2019 GSHP-131502028 -3.7% -12.6% 3.7%

For 2015 - 2019, the increases were not uniform but varied by plan.

Proposed Rate Increase

This filing applies to PPO products, sold on and off exchange in rating areas 2, 3, 5, 6, 7 and 9. There will be 10 platinum plan, 21 gold plans, 10 silver plans, and 2 bronze plans, for a total of 43 plans offered in 2020. As of February 2019, 16,094 covered lives and 9,865 policyholders will be impacted by this filing. The

proposed overall rate increase is 18.3% but is not uniform by plan. The increases range from 13.2% to

24.3%. Table 10 shows the increases at the plan level. These increases vary by plan due to benefit

changes necessary to maintain the desired metal level as well as changes in pricing factors.


Average Rate Change

The average rate change from Table 10, cell AC15 is 18.3% and is entered as the “percent rate change

requested” in the SERFF Rate Review Detail Screen. It is the change in the Calibrated Plan-adjusted Index

rate (as instructed by the Department). In addition, the change in 21-year-old non-tobacco premium

PMPM, as calculated in Table 11, cell AN13, is 19.5%.

Membership Count

Table 1 shows the average age and the member months in the experience period of calendar year 2018,

as well as the average age and the current members as of February 1, 2019 by age range. The projected

member months for the rating period are also included.

Benefit Changes

To maintain current metal tier levels, several existing plans experienced cost sharing adjustments that

were necessitated by the 2020 AV calculator. The first item we looked to update was the Maximum Out

of Pocket. After that, we looked at the additional cost sharing elements to maintain metallic level. The

‘Benefit Change’ tab in the file “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”

summarizes the changes made by HIOS ID.

Reason for Rate Increase

The components of this rate increase are:

• Single Risk Pool experience (i.e. the “Base period allowed claims before normalization” on Table

8) which is more adverse than assumed in current rates;

• Medical Inflation;

• Utilization trend;

• Changes in administrative expenses;

• Changes in ACA fees;

• Changes in Risk Adjustment;

Each of these components is discussed in detail later in this document and are displayed in Table 8 of the exhibits.

Experience Period Claims and Premium Paid Through Date

The Experience Period data provided in the URRT Worksheet 1, Section I and in Table 2 is incurred in

calendar year 2018 and paid through February 2019. As discussed below, the data in Table 2 of the

exhibits is consistent with the data provided in the URRT in Worksheet 1, Section 1 (except for the

incurred claims and the allowed claims). This includes only experience for ACA compliant plans and does

not include experience for transitional business.

Premiums (net of MLR Rebate) in Experience Period

Premiums include earned premiums for calendar year 2018 for the Single Risk Pool. Premiums are not

reduced by taxes and/or assessments. MLR rebates are not expected to be paid for this block of

business. Initial estimates of rebates have been completed utilizing the methodology required for the CY

2018 rebate filing. Estimates suggest that the individual market MLR will be above the minimum MLR

target of 80%.


Allowed and Incurred Claims Incurred During the Experience Period

The Experience Period Claims are based on small group ACA compliant business incurred and paid claims

with IBNR added for the tail of claims incurred but not paid. Allowed claims are calculated by combining

paid claims and estimated member cost share. The same IBNR factors were used for both paid and

allowed claims. The IBNR factors were based on legal-entity and market segment level claim lag tables.

This method is appropriate to assure proper credibility and because timing of claims payment to

providers does not vary by market or product.

There were no non-EHB benefits in the experience period.

Geisinger outsources several benefits and therefore has capitation expenses. The capitated expenses

cover chiropractic services, nurse line, mental health services and quality fund/ PQS. The capitation

amount for the experience period is displayed on Table 2 and is included in both the Incurred Claims and

Allowed Claims on Worksheet 1 of the URRT. The capitation charges are uniform and do not vary by age.

The historical capitation amounts are on the “Capitation” tab of the file

“PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”.

Pharmacy rebates are listed on Table 2. These rebate dollars would be removed from the Ultimate

Incurred Claim liability to the insurer and are removed from the Incurred Claims and the Allowed Claims

on Worksheet 1 of the URRT.

The estimated risk adjustment for the experience period is based on an external analysis performed by

the Pennsylvania Insurance Department. They estimated the Risk Adjustment transfer payment based

on the population risk scores relative to an assumed market average risk score and market average

premium.

The calendar 2018 loss ratio, as displayed on Table 2 is 90.33%. The Federal MLR calculation that

determines if a rebate is necessary is more complex than the MLR displayed on Table 2. For example,

the Federal MLR calculation allows issuers to combine 3 years of experience when determining if a

rebate is necessary.

Benefit Categories

Benefit categories are determined by the classification of claims in the Milliman Health Cost Guidelines.

Credibility of Data

The Credibility Manual Rate is a combination of our GHP and GQO experience, giving us an even more

credible manual rate than if we determined them separately by product. Combining the GHP and GQO

Single Risk Pools also aids in consistency between the products. Historically, we have seen enrollment

move between our GHP and GQO products, so it is very important that our premium rates are

consistent. To avoid double counting the Experience Period and avoid complicated adjustments to

reflect the expected distribution of enrollment in each segment, the credibility of the Experience Period

is set to 0.0%. This approach is consistent with the Actuarial Standard of Practice #25.

The credibility manual data is shown in Table 2b. Since the credibility manual data is given a weight of

100%, the “blended” data would be the same as the data in Table 2b.

The experience period data in Table 2 or 4 does not include data for any transitional business.


Adjustments Made to the Data

The population represented in the Experience Period is expected to continue into the Projection Period.

The Projected Allowed Experience Claims are adjusted for changes as described in the section below.

Morbidity Adjustments

We view the small group ACA as fairly stable and therefore expect the morbidity of the base period to

continue into the projection period.

Changes in Benefits

We have no planned changes to the scope of benefits covered.

Changes in Demographics

We are applying a 1.0% adjustment factor to account for the unfavorable demographic shift between

CY2018 and February 2019. This adjustment factor is developed on the “Manual_Age_Factor” tab of file

“PID_Response_Exhibits_GQO_SG_071219.xlsx”. The Change in Demographics factor on Table 5 is 1.010

and is 1.549/1.533.

Change in Network

To account for the Geisinger Global Risk Arrangement, which began in July 2018, a network adjustment

factor is used. The claims experience in Table 2, does not reflects payment transfers as a result of the

Geisinger Global Risk Arrangement. An adjustment on Table 5 is necessary to account for a full year of

the global risk arrangement. The factor is .93.

Change in Other

The capitation amount paid for our private reinsurance, as well as the recoveries from that program are

reflected in the “Other” factor. Only slight changes are expected. This is developed on the “Reinsurance”

tab in the file “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”.

Trend Identification

Experience data was trended using an annual trend of 7.85%. Table 3b shows the breakdown between

service category and cost vs. utilization. Table 3b uses the PMPM by service category to weight to

develop the total composite trend. Trend factors are projected for unit cost and utilization components:

• Unit cost trend factors are based on recorded anticipated increases in facility and professional

fees from the Experience to Projection Period. These increases are composited across all

facilities and provider groups.

• Utilization trend projections are based on least-square regression modeling, taking into account

historical claims patterns, anticipated economic activity and changes in care patterns.

• Seasonality adjustments are made to the claims to account for changes in work days.

• Further adjustments have been made to the trends to reflect expected changes due to new

medical management initiatives that are expected to yield savings in the projection period.

Our trends are analyzed at a higher level than these individual segments and are the same for the

experience data and the credibility manual data. Due to the lack of stability in the ACA experience, we

based our trends on data from our commercial large group experience. Table 4b is provided for this

large group experience.

The Composite URR Trend in Table 5, Cell C12 is 1.163 and is used to project the experience period data

to the rating period. The aggregate URR Trend reported in Worksheet I, Section 2 is 597.60 / 513.70 =

1.163 and matches the Composite Trend in Table 3 of the Department’s rate exhibits.


Historical Experience Table 4 includes the most recent 48 months of data with run out through February 2019. Allowed claims are calculated by combining paid claims and estimated member cost share. As mentioned above, Table 4b displays the large group data that was used to determine the trends used. As requested by the Department, the most recent 48 months of data for our transitional (non-ACA non- GF) Small Group GQO block is:

Non-ACA PPO 2015 2016 2017 2018

Premium $87,291,847 $77,777,845 $70,560,453 $61,935,057

Incurred Claims $65,976,559 $64,920,284 $59,806,168 $53,240,989

Member Months 210,310 173,640 151,194 130,528

2. Rate Development & Change Development of Projected Index Rate, Market-Adjusted Index Rate & Total Allowed Claims Single Risk Pool The Single Risk Pool has been established in accordance with the requirements in 45 CFR 156.80(d) as was discussed previously in the Experience Period Premium and Claims section. Index Rate The Experience Period Index Rate is based on the manual Allowed Claims PMPM and is the starting value on Table 5. The Credibility Manual Rate is a combination of our GHP and GQO experience, giving us an even more credible manual rate. No benefits were covered in addition to Essential Health benefits in the policies being offered.

The Projected Index Rate for this Single Risk Pool is the Adjusted Projected Allowed EHB Claims PMPM and is the manual rate. The projected claims reflect the trend and benefits described earlier in this memorandum. As discussed above, the Manual Data is weighted 100% since it includes the Actual Experience Data as well as the experience data for our ACA compliant GHP business. If we gave any weight to the Actual Experience Data, it would be double counted since it is also in the Manual Data. Market Adjusted Index Rate The Market Adjusted Index Rate and Market Adjusted Total Allowed Claims are calculated in Table 5. The Projected Index Rate is converted to a paid basis by multiplying by the Projected Paid to Allowed ratio.

Paid to Allowed Ratio The Projected Paid to Allowed Average Ratio is 0.896 and is displayed on Table 5. It is determined for the Projection Period based on the member weighted average Pricing AV for each plan times the projected member months in each plan. This is consistent with the calculation on Table 10 in cell K15. There are variations between the AV Pricing Values and the AV Calculator values because of different cost structures and management approaches than what is reflected in the national average data used in the AV Calculator.


Projected Risk Adjustments PMPM Our Small Group Exchange population had a healthier risk profile than the state average in 2018 resulting in potential payment transfers into the Risk Adjustment program. Premium levels for 2020 need to incorporate the expected payment into the Risk Adjustment program. We have used the Department’s estimated 2018 Risk Adjustment for the starting point for 2020. The risk adjustment model applied to the 2020 contract year will be an updated version of what was used for 2018. Specifically, the coefficients will be changing. We have used a 3rd party consultant’s tool to analyze the impact on our population. The result is an expected increase in transfer payment and is applied to the actual payment transfer from 2018. The expected payment transfer for 2020 is shown on Table 5 as -40.92. All of our small group plans are sold Off Exchange, so there is no Exchange user Fees to include. The allowable market-wide modifiers (risk adjustment of -$40.92 and Exchange User Fees of $0.00) are added to this paid basis PMPM. This PMPM is then converted back to an allowed basis, again using the projected paid to allowed ratio. Any non-EHB claims would then be added to this value if we had some but we don’t so this PMPM is the Market-Adjusted Projected Total Allowed Claims PMPM, $616.42 as shown on Table 5 in cell C42.

Retention Items Administration Expense Administration expenses are based on activity-based allocation by product for calendar year 2020. This methodology applies for all variable costs and all fixed costs. For the 2020 plan year, we are combining the GHP and GQO estimates to create one overall PMPM estimate. Again, this helps maintain appropriate relativities between the GHP and GQO plans. The historical administrative exhibits are displayed on the ‘Administrative_Expense’ tab of the file “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”. Table 6 provides a breakdown of the administrative expenses, as well as the taxes and fees. The administrative expenses are developed as a PMPM expense, but applied as a consistent percentage of premium and do not vary by plan. The proposed percentage of premium for 2020 is 7.97% and is shown in both Tables 6 and 10. Agent/Broker Fees and Commissions Commissions for Small Group ACA business are paid based on the schedules in the files “Broker Commissions Fiscal Year 2019.pdf”. The amount they receive is based on their entire employer group book of business with Geisinger (not just their small group ACA book). Broker commissions do not vary by geographic location, metal level, plan or enrollment type (open enrollment vs SEP enrollment). The development of the broker commission is displayed on the ‘Commission’ tab of the file “PID_Response_round3_Exhibits_GQO_SmGrp_071919.xlsx”. Quality Improvement Initiatives The Quality Initiatives amount is based on the latest estimate for this product. They are reported on line 6.6 of the Supplement Health Care Exhibit of the Annual Statement. The estimated % of premium is 1.80% and is calculated using the PMPM of $11.49 that is displayed on the ‘Quality_Improvement’ tab of the file ‘PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx’. Profit & Risk Margin The risk margin is set at 2% of premium. This risk margin is applied consistently across all plans.


Taxes, Fees, and Subsidies For 2020, the federal government will again collect the Health Insurer Provider Fee. For this product, we include 2.81% in cell C57. Federal Income tax will also be collected. It is calculated on the “Taxes” tab of the file “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”. Projected Loss Ratio The anticipated loss ratio is 91.5% in aggregate as shown below using the Federally-prescribed MLR methodology: MLR Numerator = Projected Claims + Quality Initiatives + Risk Adjustment = 511.09 + 11.49 + 40.92 = 563.50 MLR Denominator = Projected Premiums – Taxes and Fees = 639.72 – 0 – 23.93 = 615.79 Federal MLR = 563.50 / 615.79 = 91.5% Normalized Market-Adjusted Projected Allowed Total Claims The Market-Adjusted Projected Allowed Total Claims is normalized using the projected average factors for age, geography, tobacco, benefit richness (induced demand) and network. These average factors for 2019 and 2020 are displayed on Table 7. Projected Membership For the overall Small Group ACA market, membership is expected to remain approximately at the current levels. February 2019 membership is expected to best represent calendar year 2020 in total for the Small Group ACA market. There is no enrollment in the discontinued plans and therefore they are labeled as discontinued not mapped. Projected membership is used to calculate the normalization factors discussed below. Normalization Factors Age Factor The federal age curve, as shown in Table 12, is used to determine a normalization factor to account for the age mix of business used in generating the Index Rate. The average age factor includes a factor of 0 for non-billable members. The average factors for 2019 and 2020 are shown on Table 7 and are developed on the ‘Age_Calibration’ tab of the file “PID_Response_Exhibits_GQO_SG_071219.xlsx”. Geographic Factor The geographic rating area factors used to determine premium rates are shown on Table 13. These factors are consistent with the current approved factors. The normalization factor is determined using these factors weighted using projected membership by area and is shown on the ‘Area_Calibration’ tab of the file “PID_Response_Exhibits_GQO_SG_071219.xlsx”. Tobacco Factor We are not applying a tobacco load in 2020. Benefit Richness (Induced Demand) Induced Demand factors are applied to each metallic to reflect the expected utilization, not the expected health status. To ensure revenue neutrality, a normalization factor is applied. The average benefit richness factor shown on Table 7.


Network Factors For 2020, Geisinger is introducing a new network into this ACA market. This network is called the “Geisinger Choices PPO” and is a tiered provider network. Our historical provider network is divided into two tiers. There is no adjustment factor so a factor of 1.00 is shown in Table 14. Components of Rate Change Table 8 shows the components of the Rate Change developed in this filing. The key drivers of the increase are the change in base period claims and change in Network as part of the change in the “URRT Other” category. Table 9 supports the calculations in Table 8. Row A approximately equals Row H. The amounts shown in the 2019 columns for B, C, and D match those entered in the 2019 column in the plan year 2019 rate filing. The amounts shown in the 2019 columns for A, E, F and H do not match those entered in the 2019 rate filing due to the shift in enrollment between what was projected in the 2019 rate filing and the Feb 2019 enrollment.

3. Plan Rate Development The projected market-adjusted index rate is used to develop the calibrated plan adjusted index rates in columns AA of Table 10. Each plan’s rate is developed as the product of the market-adjusted index rate, the allowable factor and calibration for age, geography and tobacco. Each plan is identified as either modified, new, discontinued & not mapped, or existing. Column G lists the metallic tier. Column H is the value we calculated using the HHS Actuarial Value Calculator. Screen shots of this calculation are provided in file “AV_Screenshots_GQO_SmGrp_050619.pdf.” The Actuarial Certification, at the end of this document, includes attestation that the Federal AV calculator was used to determine the metallic values. Please also refer to the “AV_UniquePlanDesignJust_GQO_SmGrp_051419.pdf” document for further details. Columns L and N were normalized using projected (CY2020) membership. The supporting exhibit for column L [“Benefit Richness (induced demand)”] is shown on the ‘Induced_Util_Exhibit’ tab of the file “PID_Response_round3_Exhibits_GQO_SmGrp_071919.xlsx”.

4. Plan Premium Development for 21-Year-Old Non-Tobacco User The projected calibrated plan-adjusted index rate is used to develop the 21-year-old non-tobacco premium in the individual market. These rates are displayed on Table 10, column AA. Table 11 uses the 21-year-old non-tobacco premiums from Table 10, adjusted by the current approved geographic factors (from Table 13), to develop the 21-year-old non-tobacco premiums by rating area.

5. Plan Factors The Consumer Adjusted Premium Rates are developed by applying the following allowable rating factors to the calibrated Plan Adjusted Index Rates:

1. Age – reflecting the HHS defined age curve 2. Geographic – as discussed above

The final Premium rates for all filed benefit plans are displayed in the QHP Rating Template. Network Factors As we discussed above, there will be 2 networks in 2020. Both have a rating factor of 1.00. Our established network is not changing, but is now referred to as the “Geisinger All-Access PPO” network.


Service Area Composition GHP will maintain the same counties of operation from 2019. All counties and service areas are defined in the QHP Service Area template. These service areas are defined on the “Service Areas” tab of the file “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”. Composite Rating Composite rating is not used. Plan Type All plan offerings meet the plan type definitions available in the URRT Worksheet 2, Section I. Changes to URRT We acknowledge that each time the URRT is changed in SERFF, it will also be updated in HIOS. Reliance We relied on the Department’s projected risk adjustment payment for 2020. We relied on Milliman for their classification of benefit categories in the claim data. We have also relied on a 3rd party’s risk adjustment model analysis tool, to model the changes to the model. Additional Exhibits The following required exhibits have been uploaded in SERFF under the tabs noted next to the exhibit: • Department Plan Design Summary – submitted under the “Rate/Rule Schedule” tab; • Service Area Map – submitted under the “Supporting Documentation” tab.

Actuarial Certification I certify that:

1. I am a member of the American Academy of Actuaries, meet the Qualification Standards for Actuaries Issuing Statements of Actuarial Opinion in the United States promulgated by the American Academy of Actuaries, and have the education and experience necessary to perform this work. 2. The projected Index Rate is:

a. In compliance with all applicable state and Federal regulations including 45 CFR 156.80(d)(1) b. Developed in compliance with the applicable Actuarial Standards of Practice, c. Is reasonable in relation to the benefits provided and the population anticipated to be covered, d. Is neither excessive nor deficient based on available information.

3. The Index Rate is used to develop the plan level rates using only the allowable modifiers in accordance with 45 CFR 156.80(d)(1) and 45 CFR 156.80(d)(2). 4. The essential health benefits are determined in accordance with 45 CFR Part 156. 5. The geographic rating factors reflect only differences in the costs of delivery and do not include differences for population morbidity by geographic area. 6. The Federal AV Calculator was utilized, with an acceptable alternative methodology when appropriate, to determine the AV Metal Values shown on Table 10 and in Worksheet 2, Section I of the URRT, following ASOP 50. Please refer to the ”AV_UniquePlanDesignJust_GQO_SmGrp_051419.pdf” document for further details. 7. All factor, benefit and other changes from the prior (2019) approved filing have been disclosed in the actuarial memorandum. 8. New plans have not been considered modifications of existing plans under the uniform modification standards in 45 CFR 147.106.


9. The information presented in the PA Actuarial Memorandum and PA Actuarial Memorandum Rate Exhibits is consistent with the information presented in the 2020 Rate Filing Justification.

I confirm that the rates submitted comply with the ACA rating requirements and with the Single Risk Pool per market requirement. The URRT does not demonstrate the process used 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 Marketplaces, and for certification that the Index Rate is developed in accordance with Federal regulation and used consistently and only adjusted by the allowable modifiers.

7/19/19 ______________________________ ____________________ Sarah MacDerment Date FSA, MAAA Attesting Actuary

PA Rate Template Part IData Relevant to the Rate Filing

Table 0. Identifying Information

Carrier Name: Geisinger Quality OptionsProduct(s): PPOMarket Segment: Small GroupRate Effective Date: 1/1/2020 to 12/31/2020Base Period Start Date 1/1/2018 to 12/31/2018Date of Most Recent Membership 2/1/2019

Table 1. Number of Members

Member-months Members Member-months

Experience Period Current Period (as of 02-01-2019)

Projected Rating Period

Average Age 38.0 38.0 38.0

Total 172,899 16,094 193,128<18 28,880 2,603 30,87818-24 14,785 1,373 16,28725-29 14,288 1,354 16,30930-34 14,544 1,337 16,13235-39 14,629 1,360 16,15440-44 13,852 1,304 15,71145-49 17,003 1,562 18,78250-54 19,237 1,758 21,22155-59 18,244 1,741 21,11060-63 12,509 1,210 14,54664+ 4,928 492 5,998*Tables 1, 2 and 4 must include data for all non-grandfathered business (ACA compliant and Transitional)

Table 2. Experience Period Claims and Premiums

Earned Premium Paid Claims Ultimate Incurred Claims Member 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

$ 92,073,230.76 $ 77,093,221.28 $ 78,624,404.56 172,899 $ 9,153,920.99 $ 87,778,325.55 $ - $ (1,464,492.06) $ 2,505,755.57 $ - (3,883,201.00)$ Experience Period Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 513.71$ Loss Ratio 90.33%*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Induced Demand* Composite Trend Weight*3.21% 0.04% 5.65% 9.08% 16.32%0.89% 2.68% 6.00% 9.81% 37.31%2.71% 0.77% 1.32% 4.87% 21.71%0.00% 0.00% 0.00% 0.00% 2.24%

5.00% 2.82%9.01% 0.62% -1.85% 7.66% 19.60%

7.87% 100.00%24

1.163* Express Cost, Utilization, Induced Utilization and Weight as percentages** Should = URRT Trend

Table 4. Historical Experience

Month-Year Total Annual Premium Incurred Claims Completion Factors* Ultimate Incurred Claims Members Ultimate Incurred PMPM Estimated Annual Cost Sharing (Member + HHS)

Prescription Drug Rebates** Allowed Claims (Net of Prescription Drug Rebates)

Allowed PMPM

Jan-15 $2,834,448.00 1.0000 $ 2,834,448.00 7,254 $ 390.74 ($41,257.67) $3,149,685.77 $ 434.20 Feb-15 $2,305,565.87 1.0000 $ 2,305,565.87 6,933 $ 332.55 ($35,937.47) $2,559,936.65 $ 369.24 Mar-15 $2,568,281.49 1.0000 $ 2,568,281.49 6,536 $ 392.94 ($45,783.85) $2,808,309.00 $ 429.67 Apr-15 $2,247,384.46 1.0000 $ 2,247,384.46 6,125 $ 366.92 ($58,790.02) $2,495,971.70 $ 407.51

May-15 $1,928,437.77 1.0000 $ 1,928,437.77 5,814 $ 331.69 ($46,467.38) $2,125,289.77 $ 365.55 Jun-15 $1,991,695.35 1.0000 $ 1,991,695.35 5,562 $ 358.09 ($36,996.25) $2,204,644.68 $ 396.38 Jul-15 $2,118,779.48 1.0000 $ 2,118,779.48 5,441 $ 389.41 ($40,308.15) $2,314,859.55 $ 425.45

Aug-15 $2,259,075.59 1.0000 $ 2,259,075.59 5,376 $ 420.21 ($36,882.14) $2,443,147.39 $ 454.45 Sep-15 $2,120,357.40 1.0000 $ 2,120,357.40 5,299 $ 400.14 ($46,989.38) $2,299,621.09 $ 433.97 Oct-15 $2,029,708.46 1.0000 $ 2,029,708.46 5,088 $ 398.92 ($40,517.34) $2,204,432.31 $ 433.26 Nov-15 $1,925,730.71 1.0000 $ 1,925,730.71 5,016 $ 383.92 ($40,326.17) $2,096,780.33 $ 418.02 Dec-15 $4,237,569.36 1.0000 $ 4,237,569.36 4,343 $ 975.72 ($31,213.79) $4,385,130.05 $ 1,009.70 Jan-16 $2,054,648.18 1.0000 $ 2,054,648.18 3,979 $ 516.37 ($31,399.91) $2,207,694.97 $ 554.84 Feb-16 $1,855,888.15 1.0000 $ 1,855,888.15 3,945 $ 470.44 ($29,965.85) $2,011,426.98 $ 509.87 Mar-16 $1,643,101.08 1.0000 $ 1,643,101.08 3,899 $ 421.42 ($30,317.60) $1,788,449.15 $ 458.69 Apr-16 $1,463,048.26 1.0000 $ 1,463,048.26 3,754 $ 389.73 ($28,122.41) $1,604,647.93 $ 427.45

May-16 $1,534,562.95 1.0000 $ 1,534,562.95 3,666 $ 418.59 ($31,344.50) $1,668,315.63 $ 455.08 Jun-16 $1,391,375.07 1.0000 $ 1,391,375.07 3,500 $ 397.54 ($27,877.38) $1,512,871.12 $ 432.25 Jul-16 $1,764,296.29 1.0000 $ 1,764,296.29 3,482 $ 506.69 ($38,261.85) $1,908,462.52 $ 548.09

Aug-16 $1,900,678.74 1.0000 $ 1,900,678.74 3,503 $ 542.59 ($38,333.92) $2,065,673.01 $ 589.69 Sep-16 $1,512,755.21 1.0000 $ 1,512,755.21 3,434 $ 440.52 ($39,748.51) $1,641,385.50 $ 477.98 Oct-16 $1,633,082.72 1.0000 $ 1,633,082.72 3,424 $ 476.95 ($22,832.64) $1,772,716.57 $ 517.73 Nov-16 $1,424,513.44 1.0000 $ 1,424,513.44 3,424 $ 416.04 ($28,912.67) $1,551,708.26 $ 453.19 Dec-16 $1,353,603.89 1.0000 $ 1,353,603.89 3,323 $ 407.34 ($28,128.55) $1,487,426.04 $ 447.62 Jan-17 $1,738,856.50 1.0000 $ 1,738,856.50 4,844 $ 358.97 ($38,800.67) $1,952,394.08 $ 403.05 Feb-17 $2,063,852.00 1.0000 $ 2,063,852.00 5,342 $ 386.34 ($57,697.52) $2,328,192.18 $ 435.83 Mar-17 $2,651,098.42 1.0000 $ 2,651,098.42 5,673 $ 467.32 ($75,722.99) $2,911,869.19 $ 513.29 Apr-17 $2,636,167.25 1.0000 $ 2,636,167.25 6,252 $ 421.65 ($44,265.75) $2,927,773.14 $ 468.29

May-17 $3,103,224.35 1.0000 $ 3,103,224.35 7,005 $ 443.00 ($58,049.21) $3,452,981.88 $ 492.93 Jun-17 $3,063,450.27 1.0000 $ 3,063,450.27 7,646 $ 400.66 ($55,813.76) $3,392,034.08 $ 443.64 Jul-17 $3,329,039.71 0.9238 $ 3,603,619.38 8,393 $ 429.36 ($59,117.76) $3,974,812.08 $ 473.59

Aug-17 $3,858,694.34 0.9999 $ 3,858,995.51 8,781 $ 439.47 ($67,876.17) $4,270,115.79 $ 486.29 Sep-17 $3,999,803.54 0.9999 $ 4,000,158.96 9,489 $ 421.56 ($65,898.59) $4,442,301.78 $ 468.15 Oct-17 $4,832,337.55 0.9999 $ 4,832,838.12 10,210 $ 473.34 ($75,090.89) $5,307,664.85 $ 519.85 Nov-17 $4,913,946.49 0.9999 $ 4,914,533.07 10,904 $ 450.71 ($72,023.89) $5,455,025.27 $ 500.28 Dec-17 $5,539,899.77 0.9999 $ 5,540,419.48 13,982 $ 396.25 ($88,433.96) $6,262,289.17 $ 447.88 Jan-18 $7,053,483.53 0.9999 $ 7,054,151.26 14,577 $ 483.92 ($110,686.20) $7,942,261.55 $ 544.85 Feb-18 $6,266,767.75 0.9475 $ 6,614,274.92 14,619 $ 452.44 ($94,601.83) $7,382,406.74 $ 504.99 Mar-18 $8,246,354.77 0.9998 $ 8,247,745.50 14,664 $ 562.45 ($104,327.95) $9,053,564.33 $ 617.40 Apr-18 $6,804,938.15 0.9996 $ 6,807,455.45 14,718 $ 462.53 ($106,216.99) $7,606,682.86 $ 516.83

May-18 $6,693,907.75 0.9996 $ 6,696,567.05 14,595 $ 458.83 ($107,038.15) $7,525,319.64 $ 515.61 Jun-18 $6,026,955.77 0.9995 $ 6,030,172.44 14,551 $ 414.42 ($105,518.61) $6,743,793.20 $ 463.46 Jul-18 $5,756,174.97 0.9984 $ 5,765,501.43 14,414 $ 399.99 ($145,370.76) $6,469,546.47 $ 448.84

Aug-18 $6,075,280.71 0.9989 $ 6,081,825.35 14,280 $ 425.90 ($151,329.14) $6,829,184.63 $ 478.23 Sep-18 $5,823,993.79 0.9967 $ 5,843,312.00 14,270 $ 409.48 ($123,228.61) $6,541,283.18 $ 458.39 Oct-18 $7,117,159.64 0.9932 $ 7,165,644.22 14,248 $ 502.92 ($150,385.91) $7,942,750.40 $ 557.46 Nov-18 $6,443,961.18 0.9807 $ 6,570,535.66 14,118 $ 465.40 ($147,813.92) $7,262,968.75 $ 514.45 Dec-18 $5,825,506.78 0.8581 $ 6,788,482.79 13,845 $ 490.32 ($117,974.00) $7,519,827.31 $ 543.14

* Express Completion Factor as a percentage**Express Prescription Drug Rebates as a negative number

Service CategoryInpatient HospitalOutpatient Hospital

Total Applied Trend Projection Factor

ProfessionalOther Medical CapitationPrescription DrugsTotal Annual TrendMonths of Trend

$31,191,392.96 $2,520,774.35

$92,073,230.76 $9,153,920.99

$23,489,054.95 $1,689,223.70

$50,089,319.59 $4,670,240.21

Carrier Name: Geisinger Quality OptionsProduct(s): PPOMarket Segment: Small GroupRate Effective Date: 1/1/2020

Table 2b. Manual Experience Period Claims and Premiums

Earned Premium Paid Claims Ultimate Incurred Claims Member 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

$ 99,607,881.48 $ 83,977,044.73 $ 85,613,531.00 189,767 $ 10,076,991.08 $ 95,690,522.08 $ - $ (1,606,279.67) $ 2,758,161.37 $ - (4,743,477.00)$ Experience Period Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 510.32$ Loss Ratio 91.46%*Express Prescription Drug Rebates as a negative number

Table 3b. Manual Trend Components

Cost* Utilization* Induced Utilization* Composite Trend Weight*3.21% 0.04% 5.65% 9.08% 16.29%0.89% 2.68% 6.00% 9.81% 36.80%2.71% 0.77% 1.32% 4.87% 21.95%0.00% 0.00% 0.00% 0.00% 2.17%

5.00% 2.85%9.01% 0.62% -1.85% 7.66% 19.94%

7.85% 100.00%24

1.163* Express Cost, Utilization, Induced Utilization and Weight as percentages

Table 4b. Historical Manual Experience

Month-Year Total Annual Premium Incurred Claims Completion Factors* Ultimate Incurred Claims Members Ultimate Incurred PMPM Estimated Annual Cost Sharing (Member + HHS) Prescription Drug Rebates** Allowed Claims (Net of

Prescription Drug Rebates) Allowed PMPM

Jan-15 $22,194,731.72 1.0000 $ 22,194,731.72 61,822 $ 359.01 ($441,598.18) $25,869,275.26 $ 418.45 Feb-15 $19,828,896.40 1.0000 $ 19,828,896.40 62,616 $ 316.67 ($419,602.96) $23,263,515.05 $ 371.53

Mar-15 $23,283,534.64 1.0000 $ 23,283,534.64 61,960 $ 375.78 ($445,548.28) $26,915,994.92 $ 434.41 Apr-15 $22,195,004.46 1.0000 $ 22,195,004.46 61,318 $ 361.97 ($450,011.44) $25,597,609.73 $ 417.46

May-15 $21,778,374.81 1.0000 $ 21,778,374.81 60,671 $ 358.96 ($457,824.23) $24,926,598.77 $ 410.85 Jun-15 $20,811,308.46 1.0000 $ 20,811,308.46 59,625 $ 349.04 ($471,798.03) $23,977,792.69 $ 402.14 Jul-15 $21,855,685.99 1.0000 $ 21,855,685.99 58,871 $ 371.25 ($481,720.32) $24,981,248.20 $ 424.34

Aug-15 $19,248,696.00 1.0000 $ 19,248,696.00 58,986 $ 326.33 ($488,395.42) $22,232,701.88 $ 376.91 Sep-15 $20,880,035.73 1.0000 $ 20,880,035.73 59,932 $ 348.40 ($474,315.90) $23,970,352.08 $ 399.96 Oct-15 $22,919,535.83 1.0000 $ 22,919,535.83 60,621 $ 378.08 ($511,625.33) $26,198,361.96 $ 432.17 Nov-15 $20,830,444.07 1.0000 $ 20,830,444.07 60,208 $ 345.97 ($483,753.61) $23,844,001.18 $ 396.03 Dec-15 $21,980,385.48 1.0000 $ 21,980,385.48 60,022 $ 366.21 ($505,052.38) $25,125,603.02 $ 418.61 Jan-16 $20,943,767.43 1.0000 $ 20,943,767.43 60,868 $ 344.09 ($494,504.69) $24,704,877.99 $ 405.88 Feb-16 $22,318,997.92 1.0000 $ 22,318,997.92 60,622 $ 368.17 ($513,443.10) $26,140,128.25 $ 431.20

Mar-16 $25,667,756.27 1.0000 $ 25,667,756.27 60,681 $ 422.99 ($560,380.28) $29,784,369.23 $ 490.84 Apr-16 $23,660,286.00 1.0000 $ 23,660,286.00 61,476 $ 384.87 ($502,049.23) $27,301,138.55 $ 444.09

May-16 $23,082,834.44 1.0000 $ 23,082,834.44 61,450 $ 375.64 ($515,282.98) $26,670,331.23 $ 434.02 Jun-16 $26,749,371.56 1.0000 $ 26,749,371.56 61,911 $ 432.06 ($520,508.52) $30,258,229.24 $ 488.74 Jul-16 $22,445,741.47 1.0000 $ 22,445,741.47 62,287 $ 360.36 ($520,535.09) $25,776,383.24 $ 413.83


Mar-17 $25,497,081.88 1.0000 $ 25,497,081.88 63,069 $ 404.27 ($642,440.74) $29,900,678.28 $ 474.09 Apr-17 $24,703,632.65 1.0000 $ 24,703,632.65 62,940 $ 392.49 ($477,354.69) $28,859,721.21 $ 458.53

May-17 $28,435,027.09 1.0000 $ 28,435,027.09 62,644 $ 453.91 ($529,727.43) $32,756,915.82 $ 522.91 Jun-17 $26,950,873.93 1.0000 $ 26,950,873.93 62,597 $ 430.55 ($507,845.99) $30,981,805.90 $ 494.94 Jul-17 $24,905,950.61 0.9996 $ 24,915,390.43 62,126 $ 401.05 ($513,055.01) $28,738,307.83 $ 462.58


Mar-18 $23,634,893.78 0.9863 $ 23,963,361.49 54,239 $ 441.81 ($444,287.62) $27,993,919.30 $ 516.12 Apr-18 $22,765,578.64 0.9985 $ 22,799,685.02 53,656 $ 424.92 ($437,939.47) $26,539,107.75 $ 494.62

May-18 $25,930,366.66 0.9977 $ 25,990,464.63 53,303 $ 487.60 ($454,826.55) $29,808,795.18 $ 559.23 Jun-18 $21,715,444.84 0.9881 $ 21,977,535.09 53,191 $ 413.18 ($438,349.98) $25,437,409.96 $ 478.23 Jul-18 $23,585,896.34 0.9965 $ 23,668,463.27 52,709 $ 449.04 ($572,683.06) $27,179,632.90 $ 515.65

Aug-18 $24,323,034.96 0.9794 $ 24,834,895.32 51,759 $ 479.82 ($610,869.72) $28,548,958.08 $ 551.57 Sep-18 $21,592,641.39 0.9785 $ 22,065,991.85 51,434 $ 429.02 ($492,571.00) $25,764,783.72 $ 500.93 Oct-18 $24,329,706.59 0.9582 $ 25,390,706.58 51,250 $ 495.43 ($573,675.98) $29,539,589.99 $ 576.38 Nov-18 $22,496,874.76 0.9677 $ 23,248,032.53 50,772 $ 457.89 ($562,351.36) $26,683,443.70 $ 525.55 Dec-18 $21,862,282.49 0.9212 $ 23,732,447.53 50,303 $ 471.79 ($486,692.09) $27,194,751.50 $ 540.62

* Express Completion Factor as a percentage**Express Prescription Drug Rebates as a negative number

Capitation

Service CategoryInpatient HospitalOutpatient HospitalProfessionalOther Medical

$337,525,701.50 $49,165,402.96

$307,615,453.44 $45,554,370.04

Prescription DrugsTotal Annual TrendMonths of TrendTotal Applied Trend Projection Factor

$319,193,255.27 $44,200,031.98

$297,321,129.91 $39,096,421.15

PA Rate Template Part IIRate Development and ChangeCarrier Name: Geisinger Quality OptionsProduct(s): PPO

Market Segment: Small Group

Rate Effective Date: 1/1/2020

Table 5. Development of the Projected Index Rate, Market-Adjusted Index Rate, and Total Allowed Claims

Development of the Projected Index Rate Actual Experience Data

Manual Data

Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) PMPM 513.71$ 510.32$ <- Actual Experience PMPM should be consistent with the Index Rate for Experience Period on URRT

Two year trend projection Factor 1.163 1.163

Unadjusted Projected Allowed EHB Claims PMPM 597.70$ 593.60$ For Informational Purposes only - No input required.Single Risk Pool Adjustment Factors

Change in Morbidity 1.000 1.000 <- See URRT Instructions Blended Base Period Unadjusted Claims before Normalization 510.32$ <- Index Rate of Experience Period on URRT Change in Other 1.000 0.940 Blended Earned Premium 99,607,881.48$ Change in Demographics 1.000 1.010 <- See URRT Instructions Blended Loss Ratio 91.46% Change in Network 1.000 0.930 Change in Benefits 1.000 1.000 <- See URRT Instructions

Change in Other 1.000 1.001 <- See URRT Instructions

Total Adjusted Projected Allowed EHB Claims PMPM 597.70$ 558.23$

Credibidility Factors 0% 100% <- See InstructionsBlended Projected EHB Claims PMPM 558.23$ <- Projected Index Rate Development of the Market-Adjusted Index Rate and Total Allowed Claims

Adjusted Projected Allowed EHB Claims PMPM 558.23$ <- Index Rate for Projection Period on URRT - Individual or First Quarter Small Group Table 5A. Small Group Projected Index Rate with Quarterly TrendAdjusted Projected Allowed EHB Claims PMPM [will only populate for small group filings] 570.73$ Projected Paid to Allowed Ratio 0.896 Effective Date 1/1/2020 4/1/2020 7/1/2020 10/1/2020 Total Single Risk PoolProjected Paid EHB Claims PMPM 511.09$ # of Member Months Renewing in Quarter 94,452 36,756 28,212 49,608 209,028 Market-wide Adjustments Adjusted Projected Allowed EHB Claims PMPM Q1 558.23$ 558.23$ 558.23$ 558.23$ 558.23$ Projected Risk Adjustment PMPM ($40.92) Months of Trend - 3 6 9 Projected Paid Exchange User Fees PMPM -$ Annual Trend 7.85% 7.85% 7.85% 7.85%

Single Risk Pool Projected Allowed Claims 558.23$ 568.88$ 579.73$ 590.78$ 570.73$ Market-Adjusted Projected Paid EHB Claims PMPM 552.01$ Quarterly Trend Factor 100.0% 101.9% 103.9% 105.8% 102.2%

2020 Trend Factors by Quarter 0.9781 0.9968 1.0158 1.0351Market-Adjusted Projected Allowed EHB Claims PMPM 616.42$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM $0.00

Market-Adjusted Projected Paid Total Claims PMPM 552.01$

Market-Adjusted Projected Allowed Total Claims PMPM 616.42$

Table 6. Retention Table 7. Normalized Market-Adjusted Projected Allowed Total Claims

Retention Items - Express in percentages Percentages PMPM Amounts Normalization Factors 2019 2020Administrative Expenses 7.97% $50.99 Average Age Factor 1.530 1.549 General and Claims 4.11% $26.29 Average Geographic Factor 0.925 0.915 Agent/Broker Fees and Commissions 2.06% $13.20 Average Tobacco Factor 1.000 1.000 Quality Improvement Initiatives 1.80% $11.49 Average Benefit Richness (induced demand) 0.901 1.103Taxes and Fees 3.74% $23.93 Average Network Factor 1.000 1.000 RA User Fee 0.03% $0.18 PA Premium Tax (if applicable) 0.00% $0.00 Market-Adjusted Projected Allowed Total Claims PMPM $543.38 616.42$ Federal Income Tax 0.90% $5.76

Health Insurance Providers Fee (Prorated for Small Groups only) 2.81% $17.98 Normalized Market-Adjusted Projected Allowed Total Claims PMPM 426.13$ 394.30$

Profit/Contingency (after tax) 2.00% $12.79

Total Retention 13.71% $87.71

Projected Required Revenue PMPM 639.72$

Table 8. Components of Rate Change Table 9. Year-over-Year Data to Support Table 8

Rate Components 2019 2020 Difference Percent Change 2019 2020A. Calibrated Plan Adjusted Index Rate (PMPM) 382.32$ 452.36$ $70.04 18.3% Paid-to-Allowed 0.868 0.896

B. Base period allowed claims before normalization $471.33 510.32$ $38.99 10.2% URRT Trend (Total Applied Trend Factor) 1.174 1.163 <- URRT W1, S2 C. Normalization factor component of change (101.70)$ (183.89)$ -$82.19 -21.5% URRT Morbidity 1.000 1.000 <- URRT W1, S2

URRT "Other" 0.893 0.940 <- URRT W1, S2D. Change in Normalized Allowed Claims Adjustment Components D1. Base period allowed claims after normalization 369.63$ 326.44$ (43.19)$ -11.3% Risk Adjustment $28.31 40.92$ <- URRT W1, S3 D2. URRT Trend 64.26$ 53.27$ (10.99)$ -2.9% Exchange User Fee $0.00 -$ <- URRT W1, S3 D3. URRT Morbidity -$ -$ -$ 0.0% Capitation $14.43 $16.02 <- URRT W1, S2 D4. URRT Other (46.24)$ (22.63)$ 23.61$ 6.2% D5. Normalized URRT RA/RI on an allowed basis 25.57$ 29.23$ 3.65$ 1.0% Network 1.000 1.000 D6. Normalized Exchange User Fee on an allowed basis -$ -$ -$ 0.0% Pricing AV 0.869 0.896 <- For 2019 in cell J81, please include a factor equal to the product of the average Pricing AV and the Non-Funding of CSR Adjustment D7. Subtotal - Sum(D1:D6) 413.23$ 386.31$ (26.92)$ -7.0% Benefit Richness 0.901 1.103E. Change in Allowable Plan Adjusted Level Components Catastrophic Eligibility 1.000 1.000 E1. Network -$ -$ -$ 0.0% E2. Pricing AV -54.06698791 (40.37)$ 13.70$ 3.6% Administrative Expenses 8.03% 7.97% E3. Benefit Richness (35.56)$ 35.63$ 71.19$ 18.6% Taxes and Fees 2.26% 3.74% E4. Catastrophic Eligibility -$ -$ -$ 0.0% Profit and/or Contingency 2.00% 2.00% E5. Subtotal - Sum(E1:E4) (89.62)$ (4.73)$ 84.89$ 22.2%F. Change in Retention Components F1. Administrative Expenses 30.70$ 36.05$ 5.35$ 1.4% F2. Taxes and Fees 8.64$ 16.92$ 8.28$ 2.2% F3. Profit and/or Contingency 7.65$ 9.05$ 1.40$ 0.4% F4. Subtotal - Sum(F1:F3) 46.99$ 62.02$ 15.03$ 3.9%

G. Change in Miscellaneous Items $0.00 $0.00 -$ 0.0%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 370.60$ 443.59$ 73.00$ 19.1%

PA Rate Template Part IIITable 10. Plan Rates

Age Calibration Factor 1.549Carrier Name: Geisinger Quality Options Geographic Calibration Factor 0.915Product(s): PPO Tobacco Calibration Factor 1.000Market Segment: Small Group Aggregate Calibration Factor 1.417Rate Effective Date: 1/1/2020Base Period Start Date 1/1/2018Date of Most Recent Membership 2/1/2019Market Adjusted Index Rate 616.42$

Plan Number

HIOS Plan ID (Standard

Component)

Plan Type (HMO, POS, PPO, EPO,

Indemnity, Other)1/1/2019 Plan

Marketing Name

Existing, Modified, New, Discontinued &

Mapped, Discontinued & Not Mapped (E,M,N,DM,

DNM) for 2020

1/1/2020 Plan HIOS Plan ID (If 1/1/2019 Plan Discontinued &

Mapped)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

Non-Funding of CSR

Adjustment Pure Premium Admin Costs

Taxes & Fees (not including Exchange

fees)Profit or

Contingency

Total Covered Lives

Mapped into 2020 Plans @ 02-01-

2019Total Policyholders

@ 02-01-2019

2019 Calibrated Plan Adjusted

Index Rate PMPM

2020 Calibrated Plan Adjusted Index

Rate PMPM

Proposed Rate Change

Compared to Prior 12 months

% of Total Covered Lives 1 2 3 4 5 6 7 8 9

Totals 0.843 0.896 1.000 1.000 1.000 1.000 1.000 553.25$ 8.0% 3.7% 2.0% 16,094 16,086 382.32$ 452.36$ 18.3% - 36 10,328 - 736 11,493 2,722 - 912

Transitional Plans TRANSITIONAL N/A TRANSITIONAL DNM TRANSITIONAL N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A - 6,221 N/A N/A N/A N/A - 36 3,485 - 482 3,144 2,569 - 417 Plan 1 75729PA0050062 PPO Geisinger Marketplace QHDHP PPO 6500 E 75729PA0050062 Bronze 0.6313 Approach (1) Off 0.709 0.907 1.000 1.000 1.000 1.000 $396.40 8.0% 3.7% 2.0% 266 150 $261.72 324.12$ 23.8% 1.7% - - 38 - - 163 20 - 45

Plan 2 75729PA0050068 PPO Geisinger Marketplace Extra PPO 10/60/500 M 75729PA0050068 Gold 0.8165 Approach (1) Off 0.880 0.979 1.000 1.000 1.000 1.000 $531.49 8.0% 3.7% 2.0% 4,092 2,506 $375.10 434.57$ 15.9% 25.4% - - 1,751 - - 2,271 - - 70 Plan 3 75729PA0050070 PPO Geisinger Marketplace PPO 20/40/1000 M 75729PA0050070 Gold 0.8162 Approach (1) Off 0.888 0.979 1.000 1.000 1.000 1.000 $536.00 8.0% 3.7% 2.0% 723 474 $386.53 438.26$ 13.4% 4.5% - - 316 - 60 318 3 - 26 Plan 4 75729PA0050071 PPO Geisinger Marketplace PPO 25/50/2750 E 75729PA0050071 Gold 0.8182 Approach (1) Off 0.842 0.979 1.000 1.000 1.000 1.000 $508.15 8.0% 3.7% 2.0% 515 332 $361.00 415.49$ 15.1% 3.2% - - 44 - 11 422 24 - 14 Plan 5 75729PA0050073 PPO Geisinger Marketplace PPO 30/60/6000 E 75729PA0050073 Silver 0.7173 Approach (1) Off 0.756 0.952 1.000 1.000 1.000 1.000 $443.90 8.0% 3.7% 2.0% 165 105 $308.10 362.96$ 17.8% 1.0% - - 15 - 2 130 7 - 11 Plan 6 75729PA0050075 PPO Geisinger Marketplace PPO 25/50/6750 E 75729PA0050075 Silver 0.7129 Approach (1) Off 0.750 0.952 1.000 1.000 1.000 1.000 $440.22 8.0% 3.7% 2.0% 75 39 $304.49 359.95$ 18.2% 0.5% - - 53 - - 22 - - - Plan 7 75729PA0050078 PPO Geisinger Marketplace QHDHP PPO 2000 M 75729PA0050078 Gold 0.82 Approach (1) Off 0.883 0.979 1.000 1.000 1.000 1.000 $533.01 8.0% 3.7% 2.0% 193 102 $378.09 435.82$ 15.3% 1.2% - - 58 - 4 131 - - - Plan 8 75729PA0050079 PPO Geisinger Marketplace QHDHP PPO 4000 M 75729PA0050079 Silver 0.7192 Approach (1) Off 0.790 0.952 1.000 1.000 1.000 1.000 $463.83 8.0% 3.7% 2.0% 158 107 $329.48 379.25$ 15.1% 1.0% - - 20 - 7 108 4 - 19 Plan 9 75729PA0050080 PPO Geisinger Marketplace PPO 15/30/250 E 75729PA0050080 Platinum 0.9195 Approach (1) Off 0.946 1.043 1.000 1.000 1.000 1.000 $608.41 8.0% 3.7% 2.0% 491 305 $412.10 497.47$ 20.7% 3.1% - - 352 - 6 133 - - -

Plan 10 75729PA0050082 PPO Geisinger Marketplace Extra PPO 10/40/250 E 75729PA0050082 Platinum 0.912 Approach (1) Off 0.933 1.043 1.000 1.000 1.000 1.000 $599.51 8.0% 3.7% 2.0% 1,173 703 $394.47 490.19$ 24.3% 7.3% - - 551 - - 613 - - 9 Plan 11 75729PA0050096 PPO Geisinger Marketplace PPO 30/60/3500 E 75729PA0050096 Gold 0.7974 Approach (1) Off 0.821 0.979 1.000 1.000 1.000 1.000 $495.79 8.0% 3.7% 2.0% 226 146 $349.96 405.38$ 15.8% 1.4% - - 20 - - 193 13 - -

Plan 12 75729PA0050097 PPO Geisinger Marketplace Extra PPO 20/60/3500 E 75729PA0050097 Gold 0.7915 Approach (1) Off 0.793 0.979 1.000 1.000 1.000 1.000 $478.89 8.0% 3.7% 2.0% 417 280 $330.98 391.56$ 18.3% 2.6% - - 125 - - 257 - - 35 Plan 13 75729PA0050102 PPO Geisinger Marketplace PPO 20/40/500 M 75729PA0050102 Gold 0.8173 Approach (1) Off 0.917 0.979 1.000 1.000 1.000 1.000 $553.45 8.0% 3.7% 2.0% 280 152 $399.71 452.53$ 13.2% 1.7% - - 240 - - 34 3 - 3 Plan 14 75729PA0050103 PPO Geisinger Marketplace PPO 20/40/1500 E 75729PA0050103 Gold 0.8133 Approach (1) Off 0.871 0.979 1.000 1.000 1.000 1.000 $525.56 8.0% 3.7% 2.0% 171 115 $377.35 429.73$ 13.9% 1.1% - - 139 - - 32 - - - Plan 15 75729PA0050104 PPO Geisinger Marketplace PPO 25/50/2000 E 75729PA0050104 Gold 0.7981 Approach (1) Off 0.854 0.979 1.000 1.000 1.000 1.000 $515.34 8.0% 3.7% 2.0% 79 45 $367.39 421.37$ 14.7% 0.5% - - 51 - - 28 - - - Plan 16 75729PA0050105 PPO Geisinger Marketplace PPO 35/70/4000 M 75729PA0050105 Silver 0.7198 Approach (1) Off 0.786 0.952 1.000 1.000 1.000 1.000 $461.43 8.0% 3.7% 2.0% 15 13 $328.76 377.29$ 14.8% 0.1% - - 4 - - 11 - - - Plan 17 75729PA0050106 PPO Geisinger Marketplace PPO 35/70/5000 M 75729PA0050106 Silver 0.7193 Approach (1) Off 0.780 0.952 1.000 1.000 1.000 1.000 $457.58 8.0% 3.7% 2.0% 72 56 $321.33 374.14$ 16.4% 0.4% - - 41 - - 31 - - - Plan 18 75729PA0050107 PPO Geisinger Marketplace PPO 40/90/7000 M 75729PA0050107 Bronze 0.6493 Approach (1) Off 0.719 0.907 1.000 1.000 1.000 1.000 $401.94 8.0% 3.7% 2.0% 23 13 $267.53 328.64$ 22.8% 0.1% - - 1 - - 22 - - -

Plan 19 75729PA0050108 PPO Geisinger Marketplace Extra PPO 20/60/4000 M 75729PA0050108 Silver 0.72 Approach (1) Off 0.761 0.952 1.000 1.000 1.000 1.000 $446.46 8.0% 3.7% 2.0% 98 57 $311.47 365.05$ 17.2% 0.6% - - 43 - - 55 - - -

Plan 20 75729PA0050109 PPO Geisinger Marketplace Options PPO 10/20/250 DNM $0.00 - - $379.70 -$ 0.0% 0.0% - - - - - - - - -



Plan 23 75729PA0050112 PPOGeisinger Marketplace Options PPO 20/40/1000 DNM $0.00 - - $348.54 -$ 0.0% 0.0% - - - - - - - - -















Plan 38 75729PA0050127 PPO Geisinger Marketplace PPO 25/50/2000 1xded E 75729PA0050127 Gold 0.7981 Approach (1) Off 0.869 0.979 1.000 1.000 1.000 1.000 $524.41 8.0% 3.7% 2.0% 94 64 $374.31 428.78$ 14.6% 0.6% - - 63 - - 31 - - - Plan 39 75729PA0050128 PPO Geisinger Marketplace PPO 10/20/0 M 75729PA0050128 Platinum 0.9199 Approach (1) Off 0.985 1.043 1.000 1.000 1.000 1.000 $633.40 8.0% 3.7% 2.0% 2,006 1,174 $430.52 517.90$ 20.3% 12.5% - - 1,021 - 115 768 31 - 71 Plan 40 75729PA0050129 PPO Geisinger Marketplace PPO 15/30/0 E 75729PA0050129 Platinum 0.9151 Approach (1) Off 0.983 1.043 1.000 1.000 1.000 1.000 $631.60 8.0% 3.7% 2.0% 808 473 $426.23 516.43$ 21.2% 5.0% - - 257 - 22 486 13 - 30 Plan 41 75729PA0050130 PPO Geisinger Marketplace PPO 25/50/500 E 75729PA0050130 Gold 0.8077 Approach (1) Off 0.869 0.979 1.000 1.000 1.000 1.000 $524.71 8.0% 3.7% 2.0% 811 512 $372.73 429.03$ 15.1% 5.0% - - 279 - 27 456 35 - 14 Plan 42 75729PA0050131 PPO Geisinger Marketplace Extra PPO 10/40/0 M 75729PA0050131 Platinum 0.9198 Approach (1) Off 0.957 1.043 1.000 1.000 1.000 1.000 $615.31 8.0% 3.7% 2.0% 1,407 875 $406.15 503.10$ 23.9% 8.7% - - 567 - - 828 - - 12

Plan 43 75729PA0050132 PPO Geisinger Marketplace Extra PPO 10/60/1000 E 75729PA0050132 Gold 0.8115 Approach (1) Off 0.860 0.979 1.000 1.000 1.000 1.000 $518.98 8.0% 3.7% 2.0% 1,060 638 $365.15 424.35$ 16.2% 6.6% - - 519 - - 438 - - 103

Plan 44 75729PA0050133 PPO Geisinger Marketplace Extra PPO 10/60/2000 E 75729PA0050133 Gold 0.79 Approach (1) Off 0.826 0.979 1.000 1.000 1.000 1.000 $498.68 8.0% 3.7% 2.0% 527 328 $348.06 407.74$ 17.1% 3.3% - - 247 - - 251 - - 29

Plan 45 75729PA0050134 PPO Geisinger Marketplace Extra PPO 20/60/6250 E 75729PA0050134 Silver 0.7199 Approach (1) Off 0.749 0.952 1.000 1.000 1.000 1.000 $439.33 8.0% 3.7% 2.0% 149 101 $299.87 359.22$ 19.8% 0.9% - - 28 - - 117 - - 4 Plan 46 75729PA0050135 PPO Geisinger All-Access QHDHP PPO 1500 N 75729PA0050135 Platinum 0.8655 Approach (1) Off 0.915 1.043 1.000 1.000 1.000 1.000 $588.24 8.0% 3.7% 2.0% - - 480.97$ 0.0% 0.0% - - - - - - - - - Plan 47 75729PA0050136 PPO Geisinger All-Access PPO 15/30/1500 N 75729PA0050136 Platinum 0.8727 Approach (1) Off 0.902 1.043 1.000 1.000 1.000 1.000 $579.86 8.0% 3.7% 2.0% - - 474.12$ 0.0% 0.0% - - - - - - - - -

Plan 48 75729PA0050137 PPO Geisinger All-Access PPO 25/50/4500 1x ded N 75729PA0050137 Gold 0.7639 Approach (1) Off 0.830 0.979 1.000 1.000 1.000 1.000 $501.08 8.0% 3.7% 2.0% - - 409.71$ 0.0% 0.0% - - - - - - - - -

Plan 49 75729PA0050138 PPO Geisinger All-Access QHDHP PPO 20/40/1500 N 75729PA0050138 Gold 0.7602 Approach (1) Off 0.895 0.979 1.000 1.000 1.000 1.000 $540.05 8.0% 3.7% 2.0% - - 441.57$ 0.0% 0.0% - - - - - - - - - Plan 50 75729PA0050140 PPO Geisinger Choices PPO 10/20/0 N 75729PA0050140 Platinum 0.9086 Approach (1) Off 0.941 1.043 1.000 1.000 1.000 1.000 $604.76 8.0% 3.7% 2.0% - - 494.48$ 0.0% 0.0% - - - - - - - - - Plan 51 75729PA0050141 PPO Geisinger Choices PPO 20/40/1000 N 75729PA0050141 Gold 0.8044 Approach (1) Off 0.842 0.979 1.000 1.000 1.000 1.000 $508.48 8.0% 3.7% 2.0% - - 415.76$ 0.0% 0.0% - - - - - - - - - Plan 52 75729PA0050142 PPO Geisinger Choices PPO 20/40/2000 N 75729PA0050142 Gold 0.7796 Approach (1) Off 0.807 0.979 1.000 1.000 1.000 1.000 $487.31 8.0% 3.7% 2.0% - - 398.45$ 0.0% 0.0% - - - - - - - - - Plan 53 75729PA0050143 PPO Geisinger Choices PPO 20/40/4000 N 75729PA0050143 Silver 0.7173 Approach (1) Off 0.752 0.952 1.000 1.000 1.000 1.000 $441.19 8.0% 3.7% 2.0% - - 360.74$ 0.0% 0.0% - - - - - - - - - Plan 54 75729PA0050144 PPO Geisinger Choices PPO 10/20/0 N 75729PA0050144 Platinum 0.9086 Approach (1) Off 0.941 1.043 1.000 1.000 1.000 1.000 $604.76 8.0% 3.7% 2.0% - - 494.48$ 0.0% 0.0% - - - - - - - - - Plan 55 75729PA0050145 PPO Geisinger Choices PPO 20/40/1000 N 75729PA0050145 Gold 0.8044 Approach (1) Off 0.842 0.979 1.000 1.000 1.000 1.000 $508.48 8.0% 3.7% 2.0% - - 415.76$ 0.0% 0.0% - - - - - - - - - Plan 56 75729PA0050146 PPO Geisinger Choices PPO 20/40/2000 N 75729PA0050146 Gold 0.7796 Approach (1) Off 0.807 0.979 1.000 1.000 1.000 1.000 $487.31 8.0% 3.7% 2.0% - - 398.45$ 0.0% 0.0% - - - - - - - - - Plan 57 75729PA0050147 PPO Geisinger Choices PPO 20/40/4000 N 75729PA0050147 Silver 0.7173 Approach (1) Off 0.752 0.952 1.000 1.000 1.000 1.000 $441.19 8.0% 3.7% 2.0% - - 360.74$ 0.0% 0.0% - - - - - - - - - Plan 58 75729PA0050148 PPO Geisinger Choices PPO 10/20/0 N 75729PA0050148 Platinum 0.9086 Approach (1) Off 0.941 1.043 1.000 1.000 1.000 1.000 $604.76 8.0% 3.7% 2.0% - - 494.48$ 0.0% 0.0% - - - - - - - - - Plan 59 75729PA0050149 PPO Geisinger Choices PPO 20/40/1000 N 75729PA0050149 Gold 0.8044 Approach (1) Off 0.842 0.979 1.000 1.000 1.000 1.000 $508.48 8.0% 3.7% 2.0% - - 415.76$ 0.0% 0.0% - - - - - - - - - Plan 60 75729PA0050150 PPO Geisinger Choices PPO 20/40/2000 N 75729PA0050150 Gold 0.7796 Approach (1) Off 0.807 0.979 1.000 1.000 1.000 1.000 $487.31 8.0% 3.7% 2.0% - - 398.45$ 0.0% 0.0% - - - - - - - - - Plan 61 75729PA0050151 PPO Geisinger Choices PPO 20/40/4000 N 75729PA0050151 Silver 0.7173 Approach (1) Off 0.752 0.952 1.000 1.000 1.000 1.000 $441.19 8.0% 3.7% 2.0% - - 360.74$ 0.0% 0.0% - - - - - - - - -

02-01-2019 Number of Covered Lives by Rating Area

Calibration Total Covered Lives @ 02-01-201916,094

45 CFR Part 156.8 (d) (2) Allowable Factors

PA Rate Template Part IIITable 10. Plan Rates

Carrier Name: Geisinger Quality OptionsProduct(s): PPOMarket Segment: Small GroupRate Effective Date: 1/1/2020Base Period Start Date 1/1/2018Date of Most Recent Membership 2/1/2019Market Adjusted Index Rate 616.42$

Plan Number

HIOS Plan ID (Standard

Component)


Indemnity, Other)

Totals

Transitional Plans TRANSITIONAL N/APlan 1 75729PA0050062 PPO

Plan 2 75729PA0050068 PPOPlan 3 75729PA0050070 PPOPlan 4 75729PA0050071 PPOPlan 5 75729PA0050073 PPOPlan 6 75729PA0050075 PPOPlan 7 75729PA0050078 PPOPlan 8 75729PA0050079 PPOPlan 9 75729PA0050080 PPO

Plan 10 75729PA0050082 PPOPlan 11 75729PA0050096 PPO

Plan 12 75729PA0050097 PPOPlan 13 75729PA0050102 PPOPlan 14 75729PA0050103 PPOPlan 15 75729PA0050104 PPOPlan 16 75729PA0050105 PPOPlan 17 75729PA0050106 PPOPlan 18 75729PA0050107 PPO

Plan 19 75729PA0050108 PPO

Plan 20 75729PA0050109 PPO

Plan 21 75729PA0050110 PPO

Plan 22 75729PA0050111 PPO

Plan 23 75729PA0050112 PPO

Plan 24 75729PA0050113 PPO

Plan 25 75729PA0050114 PPO

Plan 26 75729PA0050115 PPO

Plan 27 75729PA0050116 PPO

Plan 28 75729PA0050117 PPO

Plan 29 75729PA0050118 PPO

Plan 30 75729PA0050119 PPO

Plan 31 75729PA0050120 PPO

Plan 32 75729PA0050121 PPO

Plan 33 75729PA0050122 PPO

Plan 34 75729PA0050123 PPO

Plan 35 75729PA0050124 PPO

Plan 36 75729PA0050125 PPO

Plan 37 75729PA0050126 PPO

Plan 38 75729PA0050127 PPOPlan 39 75729PA0050128 PPOPlan 40 75729PA0050129 PPOPlan 41 75729PA0050130 PPOPlan 42 75729PA0050131 PPO

Plan 43 75729PA0050132 PPO

Plan 44 75729PA0050133 PPO

Plan 45 75729PA0050134 PPOPlan 46 75729PA0050135 PPOPlan 47 75729PA0050136 PPO

Plan 48 75729PA0050137 PPO

Plan 49 75729PA0050138 PPOPlan 50 75729PA0050140 PPOPlan 51 75729PA0050141 PPOPlan 52 75729PA0050142 PPOPlan 53 75729PA0050143 PPOPlan 54 75729PA0050144 PPOPlan 55 75729PA0050145 PPOPlan 56 75729PA0050146 PPOPlan 57 75729PA0050147 PPOPlan 58 75729PA0050148 PPOPlan 59 75729PA0050149 PPOPlan 60 75729PA0050150 PPOPlan 61 75729PA0050151 PPO

Total

2020 Continued/ Discontined

Plans Indicator

26,227

10,133 0266 1

4,092 1723 1515 1165 1

75 1193 1158 1491 1

1,173 1226 1

417 1280 1171 1

79 115 172 123 1

98 1

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

- 0

94 12,006 1

808 1811 1

1,407 1

1,060 1

527 1

149 1- 1- 1

- 1

- 1- 1- 1- 1- 1- 1- 1- 1- 1- 1- 1- 1- 1

PA Rate Template Part IV B - Small Group AnnualTable 11. Plan Premium Development for 21-Year-Old Non-Tobacco User

Carrier Name: Geisinger Quality OptionsProduct(s): PPOMarket Segment: Small GroupRate Effective Date: 1/1/2020

Plan NumberHIOS Plan ID (Standard

Component)1/1/2019 Plan

Marketing Name

Discontinued, New, Modified,

Existing (D,N,M,E) for

2020

1/1/2020 Plan HIOS Plan ID (If 1/1/2019 Plan

Discontinued & Mapped) Metallic Tier

Exchange On/Off or

Off 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

Totals -$ -$ 319.05$ -$ 357.20$ 351.44$ 413.18$ -$ 350.19$ 338.31$ -$ -$ 381.56$ -$ 425.69$ 420.36$ 492.05$ -$ 417.68$ 404.54$ 0.0% 0.0% 19.5% 0.0%

Plan 1 75729PA0050062 Geisinger Marketplace QHDHP PPO 6500 E 75729PA0050062 Bronze Off $0.00 $225.43 $215.55 $0.00 $230.50 $242.91 $294.33 $0.00 $250.00 244.07$ -$ 282.15$ 269.78$ -$ 288.49$ 304.02$ 368.38$ -$ 312.90$ 305.47$ 25.2% 25.2%Plan 2 75729PA0050068 Geisinger Marketplace Extra PPO 10/60/500 M 75729PA0050068 Gold Off $0.00 $323.08 $308.93 $0.00 $330.34 $348.13 $421.82 $0.00 $358.30 331.53$ -$ 378.30$ 361.72$ -$ 386.80$ 407.63$ 493.92$ -$ 419.53$ 388.19$ 17.1% 17.1%Plan 3 75729PA0050070 Geisinger Marketplace PPO 20/40/1000 M 75729PA0050070 Gold Off $0.00 $332.93 $318.34 $0.00 $340.41 $358.74 $434.68 $0.00 $369.22 340.25$ -$ 381.51$ 364.79$ -$ 390.08$ 411.09$ 498.11$ -$ 423.09$ 389.90$ 14.6% 14.6%Plan 4 75729PA0050071 Geisinger Marketplace PPO 25/50/2750 E 75729PA0050071 Gold Off $0.00 $310.95 $297.32 $0.00 $317.93 $335.05 $405.98 $0.00 $344.84 335.03$ -$ 361.68$ 345.83$ -$ 369.81$ 389.72$ 472.22$ -$ 401.10$ 389.70$ 16.3% 16.3%Plan 5 75729PA0050073 Geisinger Marketplace PPO 30/60/6000 E 75729PA0050073 Silver Off $0.00 $265.38 $253.75 $0.00 $271.35 $285.96 $346.49 $0.00 $294.31 285.98$ -$ 315.95$ 302.11$ -$ 323.05$ 340.45$ 412.52$ -$ 350.39$ 340.47$ 19.1% 19.1%Plan 6 75729PA0050075 Geisinger Marketplace PPO 25/50/6750 E 75729PA0050075 Silver Off $0.00 $262.27 $250.77 $0.00 $268.16 $282.60 $342.42 $0.00 $290.85 260.11$ -$ 313.34$ 299.60$ -$ 320.38$ 337.63$ 409.10$ -$ 347.49$ 310.76$ 19.5% 19.5%Plan 7 75729PA0050078 Geisinger Marketplace QHDHP PPO 2000 M 75729PA0050078 Gold Off $0.00 $325.66 $311.39 $0.00 $332.98 $350.91 $425.19 $0.00 $361.16 338.66$ -$ 379.38$ 362.76$ -$ 387.91$ 408.80$ 495.33$ -$ 420.73$ 394.53$ 16.5% 16.5%Plan 8 75729PA0050079 Geisinger Marketplace QHDHP PPO 4000 M 75729PA0050079 Silver Off $0.00 $283.79 $271.36 $0.00 $290.17 $305.79 $370.52 $0.00 $314.72 303.45$ -$ 330.14$ 315.67$ -$ 337.56$ 355.73$ 431.03$ -$ 366.12$ 353.01$ 16.3% 16.3%Plan 9 75729PA0050080 Geisinger Marketplace PPO 15/30/250 E 75729PA0050080 Platinum Off $0.00 $354.96 $339.40 $0.00 $362.93 $382.48 $463.44 $0.00 $393.64 351.36$ -$ 433.05$ 414.07$ -$ 442.78$ 466.62$ 565.39$ -$ 480.24$ 428.66$ 22.0% 22.0%Plan 10 75729PA0050082 Geisinger Marketplace Extra PPO 10/40/250 E 75729PA0050082 Platinum Off $0.00 $339.77 $324.88 $0.00 $347.40 $366.11 $443.61 $0.00 $376.80 346.82$ -$ 426.71$ 408.02$ -$ 436.30$ 459.80$ 557.13$ -$ 473.22$ 435.58$ 25.6% 25.6%Plan 11 75729PA0050096 Geisinger Marketplace PPO 30/60/3500 E 75729PA0050096 Gold Off $0.00 $301.43 $288.22 $0.00 $308.21 $324.80 $393.56 $0.00 $334.29 325.52$ -$ 352.89$ 337.42$ -$ 360.82$ 380.25$ 460.74$ -$ 391.35$ 381.09$ 17.1% 17.1%Plan 12 75729PA0050097 Geisinger Marketplace Extra PPO 20/60/3500 E 75729PA0050097 Gold Off $0.00 $285.08 $272.59 $0.00 $291.49 $307.19 $372.21 $0.00 $316.16 297.57$ -$ 340.86$ 325.92$ -$ 348.52$ 367.28$ 445.03$ -$ 378.01$ 355.78$ 19.6% 19.6%Plan 13 75729PA0050102 Geisinger Marketplace PPO 20/40/500 M 75729PA0050102 Gold Off $0.00 $344.29 $329.20 $0.00 $352.02 $370.98 $449.51 $0.00 $381.81 336.13$ -$ 393.93$ 376.67$ -$ 402.78$ 424.47$ 514.32$ -$ 436.87$ 384.59$ 14.4% 14.4%Plan 14 75729PA0050103 Geisinger Marketplace PPO 20/40/1500 E 75729PA0050103 Gold Off $0.00 $325.03 $310.78 $0.00 $332.33 $350.23 $424.36 $0.00 $360.45 318.16$ -$ 374.08$ 357.69$ -$ 382.49$ 403.08$ 488.41$ -$ 414.85$ 366.18$ 15.1% 15.1%Plan 15 75729PA0050104 Geisinger Marketplace PPO 25/50/2000 E 75729PA0050104 Gold Off $0.00 $316.44 $302.58 $0.00 $323.55 $340.98 $413.15 $0.00 $350.93 316.19$ -$ 366.81$ 350.73$ -$ 375.05$ 395.24$ 478.91$ -$ 406.78$ 366.51$ 15.9% 15.9%Plan 16 75729PA0050105 Geisinger Marketplace PPO 35/70/4000 M 75729PA0050105 Silver Off $0.00 $283.17 $270.76 $0.00 $289.53 $305.12 $369.71 $0.00 $314.03 295.96$ -$ 328.43$ 314.04$ -$ 335.81$ 353.90$ 428.81$ -$ 364.23$ 343.27$ 16.0% 16.0%Plan 17 75729PA0050106 Geisinger Marketplace PPO 35/70/5000 M 75729PA0050106 Silver Off $0.00 $276.77 $264.64 $0.00 $282.99 $298.23 $361.36 $0.00 $306.94 279.10$ -$ 325.69$ 311.42$ -$ 333.01$ 350.94$ 425.22$ -$ 361.18$ 328.43$ 17.7% 17.7%Plan 18 75729PA0050107 Geisinger Marketplace PPO 40/90/7000 M 75729PA0050107 Bronze Off $0.00 $230.43 $220.33 $0.00 $235.61 $248.29 $300.85 $0.00 $255.54 247.07$ -$ 286.08$ 273.55$ -$ 292.51$ 308.26$ 373.52$ -$ 317.27$ 306.76$ 24.2% 24.2%Plan 19 75729PA0050108 Geisinger Marketplace Extra PPO 20/60/4000 M 75729PA0050108 Silver Off $0.00 $268.28 $256.52 $0.00 $274.31 $289.08 $350.27 $0.00 $297.52 274.79$ -$ 317.78$ 303.85$ -$ 324.92$ 342.41$ 414.89$ -$ 352.41$ 325.49$ 18.4% 18.5%Plan 20 75729PA0050109 Geisinger Marketplace Options PPO 10/20/250 DNM 0 0 0 $0.00 $327.05 $312.72 $0.00 $334.40 $352.41 $427.01 $0.00 $362.70 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 21 75729PA0050110 Geisinger Marketplace Options PPO 10/20/0 DNM 0 0 0 $0.00 $334.51 $319.85 $0.00 $342.02 $360.44 $436.74 $0.00 $370.96 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 22 75729PA0050111 Geisinger Marketplace Options PPO 20/40/500 DNM 0 0 0 $0.00 $313.17 $299.45 $0.00 $320.21 $337.45 $408.88 $0.00 $347.31 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 23 75729PA0050112 Geisinger Marketplace Options PPO 20/40/1000 DNM 0 0 0 $0.00 $300.21 $287.06 $0.00 $306.96 $323.49 $391.96 $0.00 $332.93 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 24 75729PA0050113 Geisinger Marketplace Options PPO 20/40/2000 DNM 0 0 0 $0.00 $283.52 $271.09 $0.00 $289.89 $305.50 $370.16 $0.00 $314.42 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 25 75729PA0050114 Geisinger Marketplace Options PPO 20/40/4000 DNM 0 0 0 $0.00 $253.02 $241.94 $0.00 $258.71 $272.64 $330.35 $0.00 $280.60 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 26 75729PA0050115 Geisinger Marketplace Options PPO 10/20/250 DNM 0 0 0 $0.00 $337.72 $322.92 $0.00 $345.30 $363.90 $440.93 $0.00 $374.52 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 27 75729PA0050116 Geisinger Marketplace Options PPO 10/20/0 DNM 0 0 0 $0.00 $345.41 $330.28 $0.00 $353.18 $372.19 $450.98 $0.00 $383.06 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 28 75729PA0050117 Geisinger Marketplace Options PPO 20/40/500 DNM 0 0 0 $0.00 $323.39 $309.21 $0.00 $330.65 $348.46 $422.22 $0.00 $358.63 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 29 75729PA0050118 Geisinger Marketplace Options PPO 20/40/1000 DNM 0 0 0 $0.00 $310.00 $296.42 $0.00 $316.97 $334.03 $404.74 $0.00 $343.79 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 30 75729PA0050119 Geisinger Marketplace Options PPO 20/40/2000 DNM 0 0 0 $0.00 $292.76 $279.93 $0.00 $299.34 $315.46 $382.23 $0.00 $324.67 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 31 75729PA0050120 Geisinger Marketplace Options PPO 20/40/4000 DNM 0 0 0 $0.00 $261.28 $249.83 $0.00 $267.15 $281.54 $341.13 $0.00 $289.76 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 32 75729PA0050121 Geisinger Marketplace Options PPO 10/20/250 DNM 0 0 0 $0.00 $337.72 $322.92 $0.00 $345.30 $363.90 $440.93 $0.00 $374.52 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 33 75729PA0050122 Geisinger Marketplace Options PPO 10/20/0 DNM 0 0 0 $0.00 $345.41 $330.28 $0.00 $353.18 $372.19 $450.98 $0.00 $383.06 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 34 75729PA0050123 Geisinger Marketplace Options PPO 20/40/500 DNM 0 0 0 $0.00 $323.39 $309.21 $0.00 $330.65 $348.46 $422.22 $0.00 $358.63 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 35 75729PA0050124 Geisinger Marketplace Options PPO 20/40/1000 DNM 0 0 0 $0.00 $310.00 $296.42 $0.00 $316.97 $334.03 $404.74 $0.00 $343.79 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 36 75729PA0050125 Geisinger Marketplace Options PPO 20/40/2000 DNM 0 0 0 $0.00 $292.76 $279.93 $0.00 $299.34 $315.46 $382.23 $0.00 $324.67 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 37 75729PA0050126 Geisinger Marketplace Options PPO 20/40/4000 DNM 0 0 0 $0.00 $261.28 $249.83 $0.00 $267.15 $281.54 $341.13 $0.00 $289.76 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ Plan 38 75729PA0050127 Geisinger Marketplace PPO 25/50/2000 1xded E 75729PA0050127 Gold Off $0.00 $322.41 $308.28 $0.00 $329.65 $347.40 $420.94 $0.00 $357.54 321.18$ -$ 373.26$ 356.90$ -$ 381.64$ 402.19$ 487.33$ -$ 413.94$ 371.84$ 15.8% 15.8%Plan 39 75729PA0050128 Geisinger Marketplace PPO 10/20/0 M 75729PA0050128 Platinum Off $0.00 $370.82 $354.57 $0.00 $379.15 $399.57 $484.15 $0.00 $411.24 377.22$ -$ 450.83$ 431.08$ -$ 460.97$ 485.79$ 588.62$ -$ 499.97$ 458.61$ 21.6% 21.6%Plan 40 75729PA0050129 Geisinger Marketplace PPO 15/30/0 E 75729PA0050129 Platinum Off $0.00 $367.12 $351.04 $0.00 $375.37 $395.59 $479.32 $0.00 $407.14 382.65$ -$ 449.55$ 429.85$ -$ 459.66$ 484.41$ 586.95$ -$ 498.55$ 468.56$ 22.5% 22.5%Plan 41 75729PA0050130 Geisinger Marketplace PPO 25/50/500 E 75729PA0050130 Gold Off $0.00 $321.05 $306.98 $0.00 $328.26 $345.94 $419.17 $0.00 $356.04 335.28$ -$ 373.47$ 357.11$ -$ 381.87$ 402.43$ 487.61$ -$ 414.18$ 390.03$ 16.3% 16.3%Plan 42 75729PA0050131 Geisinger Marketplace Extra PPO 10/40/0 M 75729PA0050131 Platinum Off $0.00 $349.83 $334.50 $0.00 $357.69 $376.95 $456.74 $0.00 $387.96 359.94$ -$ 437.96$ 418.76$ -$ 447.80$ 471.91$ 571.80$ -$ 485.69$ 450.61$ 25.2% 25.2%Plan 43 75729PA0050132 Geisinger Marketplace Extra PPO 10/60/1000 E 75729PA0050132 Gold Off $0.00 $314.52 $300.73 $0.00 $321.58 $338.90 $410.64 $0.00 $348.79 321.17$ -$ 369.40$ 353.21$ -$ 377.70$ 398.04$ 482.29$ -$ 409.66$ 377.22$ 17.4% 17.5%Plan 44 75729PA0050133 Geisinger Marketplace Extra PPO 10/60/2000 E 75729PA0050133 Gold Off $0.00 $299.80 $286.66 $0.00 $306.53 $323.04 $391.42 $0.00 $332.47 306.51$ -$ 354.94$ 339.39$ -$ 362.92$ 382.46$ 463.42$ -$ 393.63$ 362.89$ 18.4% 18.4%Plan 45 75729PA0050134 Geisinger Marketplace Extra PPO 20/60/6250 E 75729PA0050134 Silver Off $0.00 $258.29 $246.97 $0.00 $264.09 $278.31 $337.22 $0.00 $286.44 272.64$ -$ 312.70$ 299.00$ -$ 319.73$ 336.95$ 408.27$ -$ 346.79$ 330.08$ 21.1% 21.1%Plan 46 75729PA0050135 Geisinger All-Access QHDHP PPO 1500 N 75729PA0050135 Platinum Off -$ -$ 418.69$ 400.34$ -$ 428.10$ 451.15$ 546.65$ -$ 464.32$ -$ Plan 47 75729PA0050136 Geisinger All-Access PPO 15/30/1500 N 75729PA0050136 Platinum Off -$ -$ 412.72$ 394.64$ -$ 422.00$ 444.72$ 538.86$ -$ 457.70$ -$ Plan 48 75729PA0050137 Geisinger All-Access PPO 25/50/4500 1x ded N 75729PA0050137 Gold Off -$ -$ 356.65$ 341.02$ -$ 364.67$ 384.30$ 465.65$ -$ 395.52$ -$ Plan 49 75729PA0050138 Geisinger All-Access QHDHP PPO 20/40/1500 N 75729PA0050138 Gold Off -$ -$ 384.39$ 367.54$ -$ 393.03$ 414.19$ 501.86$ -$ 426.28$ -$ Plan 50 75729PA0050140 Geisinger Choices PPO 10/20/0 N 75729PA0050140 Platinum Off -$ -$ 430.45$ 411.59$ -$ 440.12$ 463.82$ 562.00$ -$ 477.36$ -$ Plan 51 75729PA0050141 Geisinger Choices PPO 20/40/1000 N 75729PA0050141 Gold Off -$ -$ 361.92$ 346.06$ -$ 370.05$ 389.98$ 472.53$ -$ 401.37$ -$ Plan 52 75729PA0050142 Geisinger Choices PPO 20/40/2000 N 75729PA0050142 Gold Off -$ -$ 346.85$ 331.65$ -$ 354.65$ 373.74$ 452.86$ -$ 384.65$ -$ Plan 53 75729PA0050143 Geisinger Choices PPO 20/40/4000 N 75729PA0050143 Silver Off -$ -$ 314.02$ 300.26$ -$ 321.08$ 338.37$ 410.00$ -$ 348.25$ -$ Plan 54 75729PA0050144 Geisinger Choices PPO 10/20/0 N 75729PA0050144 Platinum Off -$ -$ 430.45$ 411.59$ -$ 440.12$ 463.82$ 562.00$ -$ 477.36$ -$ Plan 55 75729PA0050145 Geisinger Choices PPO 20/40/1000 N 75729PA0050145 Gold Off -$ -$ 361.92$ 346.06$ -$ 370.05$ 389.98$ 472.53$ -$ 401.37$ -$ Plan 56 75729PA0050146 Geisinger Choices PPO 20/40/2000 N 75729PA0050146 Gold Off -$ -$ 346.85$ 331.65$ -$ 354.65$ 373.74$ 452.86$ -$ 384.65$ -$ Plan 57 75729PA0050147 Geisinger Choices PPO 20/40/4000 N 75729PA0050147 Silver Off -$ -$ 314.02$ 300.26$ -$ 321.08$ 338.37$ 410.00$ -$ 348.25$ -$ Plan 58 75729PA0050148 Geisinger Choices PPO 10/20/0 N 75729PA0050148 Platinum Off -$ -$ 430.45$ 411.59$ -$ 440.12$ 463.82$ 562.00$ -$ 477.36$ -$ Plan 59 75729PA0050149 Geisinger Choices PPO 20/40/1000 N 75729PA0050149 Gold Off -$ -$ 361.92$ 346.06$ -$ 370.05$ 389.98$ 472.53$ -$ 401.37$ -$ Plan 60 75729PA0050150 Geisinger Choices PPO 20/40/2000 N 75729PA0050150 Gold Off -$ -$ 346.85$ 331.65$ -$ 354.65$ 373.74$ 452.86$ -$ 384.65$ -$ Plan 61 75729PA0050151 Geisinger Choices PPO 20/40/4000 N 75729PA0050151 Silver Off -$ -$ 314.02$ 300.26$ -$ 321.08$ 338.37$ 410.00$ -$ 348.25$ -$

These cells auto-fill using the data entered in Table 10.

Quarter 1 2019, 21-year-old Non-Tobacco Premium PMPM Quarter 1 2020, 21-year-old Non-Tobacco Premium PMPM Change in Quarter

PA Rate Template Part IV B -Table 11. Plan Premium Developm

Carrier Name:Product(s):Market Segment:Rate Effective Date:


Component)

Totals

Plan 1 75729PA0050062Plan 2 75729PA0050068Plan 3 75729PA0050070Plan 4 75729PA0050071Plan 5 75729PA0050073Plan 6 75729PA0050075Plan 7 75729PA0050078Plan 8 75729PA0050079Plan 9 75729PA0050080Plan 10 75729PA0050082Plan 11 75729PA0050096Plan 12 75729PA0050097Plan 13 75729PA0050102Plan 14 75729PA0050103Plan 15 75729PA0050104Plan 16 75729PA0050105Plan 17 75729PA0050106Plan 18 75729PA0050107Plan 19 75729PA0050108Plan 20 75729PA0050109Plan 21 75729PA0050110Plan 22 75729PA0050111Plan 23 75729PA0050112Plan 24 75729PA0050113Plan 25 75729PA0050114Plan 26 75729PA0050115Plan 27 75729PA0050116Plan 28 75729PA0050117Plan 29 75729PA0050118Plan 30 75729PA0050119Plan 31 75729PA0050120Plan 32 75729PA0050121Plan 33 75729PA0050122Plan 34 75729PA0050123Plan 35 75729PA0050124Plan 36 75729PA0050125Plan 37 75729PA0050126Plan 38 75729PA0050127Plan 39 75729PA0050128Plan 40 75729PA0050129Plan 41 75729PA0050130Plan 42 75729PA0050131Plan 43 75729PA0050132Plan 44 75729PA0050133Plan 45 75729PA0050134Plan 46 75729PA0050135Plan 47 75729PA0050136Plan 48 75729PA0050137Plan 49 75729PA0050138Plan 50 75729PA0050140Plan 51 75729PA0050141Plan 52 75729PA0050142Plan 53 75729PA0050143Plan 54 75729PA0050144Plan 55 75729PA0050145Plan 56 75729PA0050146Plan 57 75729PA0050147Plan 58 75729PA0050148Plan 59 75729PA0050149Plan 60 75729PA0050150Plan 61 75729PA0050151

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) 1 2 3 4 5 6 7

19.0% 19.5% 19.2% 0.0% 19.3% 19.5% -$ -$ 388.83$ -$ 433.81$ 428.38$ 501.43$ -$ 425.65$ 412.26$ -$ -$ 396.25$ -$ 442.08$ 436.55$ 511.00$ -$ 433.77$ 420.13$ -$ -$ 403.81$ -$ 450.51$ 444.88$ 520.75$

25.2% 25.2% 25.2% 25.2% 25.2% -$ 287.53$ 274.93$ -$ 293.99$ 309.82$ 375.40$ -$ 318.87$ 311.30$ -$ 293.01$ 280.17$ -$ 299.60$ 315.73$ 382.56$ -$ 324.95$ 317.23$ -$ 298.60$ 285.52$ -$ 305.31$ 321.75$ 389.86$ 17.1% 17.1% 17.1% 17.1% 17.1% -$ 385.52$ 368.62$ -$ 394.18$ 415.40$ 503.34$ -$ 427.53$ 395.59$ -$ 392.87$ 375.65$ -$ 401.70$ 423.33$ 512.94$ -$ 435.69$ 403.14$ -$ 400.36$ 382.82$ -$ 409.36$ 431.40$ 522.72$ 14.6% 14.6% 14.6% 14.6% 14.6% -$ 388.79$ 371.75$ -$ 397.52$ 418.93$ 507.61$ -$ 431.16$ 397.34$ -$ 396.20$ 378.84$ -$ 405.11$ 426.92$ 517.29$ -$ 439.38$ 404.92$ -$ 403.76$ 386.07$ -$ 412.83$ 435.06$ 527.16$ 16.3% 16.3% 16.3% 16.3% 16.3% -$ 368.58$ 352.43$ -$ 376.87$ 397.16$ 481.23$ -$ 408.75$ 397.14$ -$ 375.61$ 359.15$ -$ 384.05$ 404.73$ 490.41$ -$ 416.55$ 404.71$ -$ 382.78$ 366.01$ -$ 391.38$ 412.45$ 499.76$ 19.1% 19.1% 19.1% 19.1% 19.1% -$ 321.98$ 307.87$ -$ 329.22$ 346.94$ 420.38$ -$ 357.07$ 346.97$ -$ 328.12$ 313.74$ -$ 335.50$ 353.56$ 428.40$ -$ 363.89$ 353.59$ -$ 334.38$ 319.73$ -$ 341.90$ 360.31$ 436.58$ 19.5% 19.5% 19.5% 19.5% 19.5% -$ 319.31$ 305.32$ -$ 326.49$ 344.07$ 416.90$ -$ 354.11$ 316.69$ -$ 325.40$ 311.14$ -$ 332.72$ 350.63$ 424.85$ -$ 360.87$ 322.73$ -$ 331.61$ 317.08$ -$ 339.06$ 357.32$ 432.96$ 16.5% 16.5% 16.5% 16.5% 16.5% -$ 386.62$ 369.68$ -$ 395.31$ 416.59$ 504.78$ -$ 428.76$ 402.05$ -$ 393.99$ 376.73$ -$ 402.85$ 424.54$ 514.41$ -$ 436.94$ 409.72$ -$ 401.51$ 383.92$ -$ 410.53$ 432.64$ 524.22$ 16.3% 16.3% 16.3% 16.3% 16.3% -$ 336.43$ 321.69$ -$ 343.99$ 362.52$ 439.25$ -$ 373.10$ 359.74$ -$ 342.85$ 327.83$ -$ 350.56$ 369.43$ 447.63$ -$ 380.22$ 366.61$ -$ 349.39$ 334.08$ -$ 357.24$ 376.48$ 456.17$ 22.0% 22.0% 22.0% 22.0% 22.0% -$ 441.31$ 421.97$ -$ 451.22$ 475.52$ 576.18$ -$ 489.40$ 436.83$ -$ 449.72$ 430.02$ -$ 459.83$ 484.59$ 587.17$ -$ 498.74$ 445.16$ -$ 458.30$ 438.22$ -$ 468.60$ 493.83$ 598.37$ 25.6% 25.6% 25.6% 25.6% 25.6% -$ 434.85$ 415.80$ -$ 444.63$ 468.57$ 567.75$ -$ 482.25$ 443.88$ -$ 443.15$ 423.73$ -$ 453.11$ 477.50$ 578.58$ -$ 491.45$ 452.35$ -$ 451.60$ 431.81$ -$ 461.75$ 486.61$ 589.62$ 17.1% 17.1% 17.1% 17.1% 17.1% -$ 359.62$ 343.86$ -$ 367.70$ 387.50$ 469.53$ -$ 398.81$ 388.36$ -$ 366.48$ 350.42$ -$ 374.72$ 394.89$ 478.48$ -$ 406.42$ 395.76$ -$ 373.47$ 357.10$ -$ 381.86$ 402.42$ 487.61$ 19.6% 19.6% 19.6% 19.6% 19.6% -$ 347.36$ 332.14$ -$ 355.17$ 374.29$ 453.52$ -$ 385.22$ 362.57$ -$ 353.99$ 338.47$ -$ 361.94$ 381.43$ 462.17$ -$ 392.57$ 369.49$ -$ 360.74$ 344.93$ -$ 368.84$ 388.70$ 470.99$ 14.4% 14.4% 14.4% 14.4% 14.4% -$ 401.45$ 383.85$ -$ 410.47$ 432.57$ 524.13$ -$ 445.20$ 391.93$ -$ 409.10$ 391.18$ -$ 418.30$ 440.82$ 534.13$ -$ 453.69$ 399.41$ -$ 416.91$ 398.64$ -$ 426.28$ 449.23$ 544.32$ 15.1% 15.1% 15.1% 15.1% 15.1% -$ 381.22$ 364.51$ -$ 389.78$ 410.77$ 497.72$ -$ 422.76$ 373.17$ -$ 388.49$ 371.46$ -$ 397.22$ 418.61$ 507.22$ -$ 430.83$ 380.29$ -$ 395.90$ 378.55$ -$ 404.79$ 426.59$ 516.89$ 15.9% 15.9% 15.9% 15.9% 15.9% -$ 373.80$ 357.42$ -$ 382.20$ 402.78$ 488.04$ -$ 414.54$ 373.50$ -$ 380.93$ 364.24$ -$ 389.49$ 410.47$ 497.35$ -$ 422.45$ 380.62$ -$ 388.20$ 371.19$ -$ 396.92$ 418.30$ 506.84$ 16.0% 16.0% 16.0% 16.0% 16.0% -$ 334.70$ 320.03$ -$ 342.22$ 360.65$ 436.99$ -$ 371.18$ 349.82$ -$ 341.08$ 326.14$ -$ 348.75$ 367.53$ 445.32$ -$ 378.26$ 356.49$ -$ 347.59$ 332.36$ -$ 355.40$ 374.54$ 453.82$ 17.7% 17.7% 17.7% 17.7% 17.7% -$ 331.90$ 317.36$ -$ 339.36$ 357.63$ 433.34$ -$ 368.07$ 334.70$ -$ 338.23$ 323.41$ -$ 345.83$ 364.45$ 441.60$ -$ 375.10$ 341.08$ -$ 344.68$ 329.58$ -$ 352.43$ 371.41$ 450.02$ 24.2% 24.2% 24.2% 24.2% 24.2% -$ 291.54$ 278.77$ -$ 298.09$ 314.14$ 380.64$ -$ 323.32$ 312.61$ -$ 297.10$ 284.08$ -$ 303.78$ 320.14$ 387.90$ -$ 329.48$ 318.57$ -$ 302.77$ 289.50$ -$ 309.57$ 326.24$ 395.30$ 18.4% 18.4% 18.4% 18.4% 18.4% -$ 323.84$ 309.65$ -$ 331.11$ 348.94$ 422.81$ -$ 359.13$ 331.70$ -$ 330.01$ 315.55$ -$ 337.43$ 355.60$ 430.87$ -$ 365.98$ 338.03$ -$ 336.31$ 321.57$ -$ 343.87$ 362.38$ 439.09$

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

15.8% 15.8% 15.8% 15.8% 15.8% -$ 380.38$ 363.71$ -$ 388.92$ 409.86$ 496.62$ -$ 421.83$ 378.93$ -$ 387.63$ 370.64$ -$ 396.34$ 417.68$ 506.10$ -$ 429.88$ 386.16$ -$ 395.02$ 377.71$ -$ 403.90$ 425.65$ 515.75$ 21.6% 21.6% 21.6% 21.6% 21.6% -$ 459.43$ 439.30$ -$ 469.76$ 495.05$ 599.85$ -$ 509.51$ 467.36$ -$ 468.20$ 447.68$ -$ 478.72$ 504.50$ 611.29$ -$ 519.23$ 476.27$ -$ 477.13$ 456.22$ -$ 487.85$ 514.12$ 622.95$ 22.5% 22.5% 22.5% 22.5% 22.5% -$ 458.13$ 438.05$ -$ 468.42$ 493.65$ 598.14$ -$ 508.06$ 477.49$ -$ 466.87$ 446.41$ -$ 477.36$ 503.06$ 609.55$ -$ 517.75$ 486.60$ -$ 475.77$ 454.92$ -$ 486.46$ 512.66$ 621.18$ 16.3% 16.3% 16.3% 16.3% 16.3% -$ 380.60$ 363.92$ -$ 389.15$ 410.11$ 496.92$ -$ 422.08$ 397.47$ -$ 387.86$ 370.86$ -$ 396.57$ 417.93$ 506.39$ -$ 430.13$ 405.05$ -$ 395.26$ 377.94$ -$ 404.14$ 425.90$ 516.05$ 25.2% 25.2% 25.2% 25.2% 25.2% -$ 446.31$ 426.75$ -$ 456.34$ 480.91$ 582.71$ -$ 494.95$ 459.21$ -$ 454.82$ 434.89$ -$ 465.04$ 490.08$ 593.82$ -$ 504.39$ 467.96$ -$ 463.50$ 443.19$ -$ 473.91$ 499.43$ 605.15$ 17.5% 17.4% 17.4% 17.5% 17.5% -$ 376.44$ 359.95$ -$ 384.90$ 405.63$ 491.49$ -$ 417.47$ 384.41$ -$ 383.62$ 366.81$ -$ 392.24$ 413.37$ 500.87$ -$ 425.43$ 391.75$ -$ 390.94$ 373.81$ -$ 399.73$ 421.25$ 510.42$ 18.4% 18.4% 18.4% 18.4% 18.4% -$ 361.71$ 345.86$ -$ 369.84$ 389.76$ 472.26$ -$ 401.14$ 369.81$ -$ 368.61$ 352.46$ -$ 376.90$ 397.19$ 481.27$ -$ 408.79$ 376.86$ -$ 375.64$ 359.18$ -$ 384.09$ 404.77$ 490.45$ 21.1% 21.1% 21.1% 21.1% 21.1% -$ 318.67$ 304.71$ -$ 325.83$ 343.38$ 416.06$ -$ 353.40$ 336.38$ -$ 324.75$ 310.52$ -$ 332.05$ 349.93$ 424.00$ -$ 360.14$ 342.79$ -$ 330.94$ 316.44$ -$ 338.38$ 356.60$ 432.08$

-$ 426.68$ 407.98$ -$ 436.26$ 459.75$ 557.08$ -$ 473.18$ -$ -$ 434.81$ 415.76$ -$ 444.59$ 468.52$ 567.70$ -$ 482.20$ -$ -$ 443.11$ 423.69$ -$ 453.07$ 477.46$ 578.53$ -$ 420.60$ 402.16$ -$ 430.05$ 453.20$ 549.14$ -$ 466.44$ -$ -$ 428.62$ 409.84$ -$ 438.25$ 461.85$ 559.61$ -$ 475.33$ -$ -$ 436.79$ 417.65$ -$ 446.61$ 470.66$ 570.29$ -$ 363.46$ 347.53$ -$ 371.62$ 391.63$ 474.53$ -$ 403.07$ -$ -$ 370.39$ 354.16$ -$ 378.71$ 399.10$ 483.59$ -$ 410.76$ -$ -$ 377.45$ 360.91$ -$ 385.94$ 406.72$ 492.81$ -$ 391.72$ 374.56$ -$ 400.52$ 422.09$ 511.44$ -$ 434.41$ -$ -$ 399.19$ 381.70$ -$ 408.16$ 430.14$ 521.19$ -$ 442.70$ -$ -$ 406.81$ 388.98$ -$ 415.95$ 438.35$ 531.13$ -$ 438.66$ 419.44$ -$ 448.52$ 472.67$ 572.72$ -$ 486.47$ -$ -$ 447.03$ 427.44$ -$ 457.07$ 481.68$ 583.64$ -$ 495.75$ -$ -$ 455.55$ 435.59$ -$ 465.79$ 490.87$ 594.78$ -$ 368.82$ 352.66$ -$ 377.11$ 397.42$ 481.54$ -$ 409.02$ -$ -$ 375.86$ 359.39$ -$ 384.31$ 405.00$ 490.73$ -$ 416.82$ -$ -$ 383.03$ 366.24$ -$ 391.64$ 412.72$ 500.09$ -$ 353.47$ 337.98$ -$ 361.41$ 380.87$ 461.49$ -$ 391.99$ -$ -$ 360.21$ 344.43$ -$ 368.30$ 388.14$ 470.30$ -$ 399.47$ -$ -$ 367.08$ 351.00$ -$ 375.33$ 395.54$ 479.27$ -$ 320.01$ 305.99$ -$ 327.21$ 344.82$ 417.82$ -$ 354.89$ -$ -$ 326.12$ 311.83$ -$ 333.45$ 351.40$ 425.79$ -$ 361.66$ -$ -$ 332.34$ 317.78$ -$ 339.81$ 358.11$ 433.91$ -$ 438.66$ 419.44$ -$ 448.52$ 472.67$ 572.72$ -$ 486.47$ -$ -$ 447.03$ 427.44$ -$ 457.07$ 481.68$ 583.64$ -$ 495.75$ -$ -$ 455.55$ 435.59$ -$ 465.79$ 490.87$ 594.78$ -$ 368.82$ 352.66$ -$ 377.11$ 397.42$ 481.54$ -$ 409.02$ -$ -$ 375.86$ 359.39$ -$ 384.31$ 405.00$ 490.73$ -$ 416.82$ -$ -$ 383.03$ 366.24$ -$ 391.64$ 412.72$ 500.09$ -$ 353.47$ 337.98$ -$ 361.41$ 380.87$ 461.49$ -$ 391.99$ -$ -$ 360.21$ 344.43$ -$ 368.30$ 388.14$ 470.30$ -$ 399.47$ -$ -$ 367.08$ 351.00$ -$ 375.33$ 395.54$ 479.27$ -$ 320.01$ 305.99$ -$ 327.21$ 344.82$ 417.82$ -$ 354.89$ -$ -$ 326.12$ 311.83$ -$ 333.45$ 351.40$ 425.79$ -$ 361.66$ -$ -$ 332.34$ 317.78$ -$ 339.81$ 358.11$ 433.91$ -$ 438.66$ 419.44$ -$ 448.52$ 472.67$ 572.72$ -$ 486.47$ -$ -$ 447.03$ 427.44$ -$ 457.07$ 481.68$ 583.64$ -$ 495.75$ -$ -$ 455.55$ 435.59$ -$ 465.79$ 490.87$ 594.78$ -$ 368.82$ 352.66$ -$ 377.11$ 397.42$ 481.54$ -$ 409.02$ -$ -$ 375.86$ 359.39$ -$ 384.31$ 405.00$ 490.73$ -$ 416.82$ -$ -$ 383.03$ 366.24$ -$ 391.64$ 412.72$ 500.09$ -$ 353.47$ 337.98$ -$ 361.41$ 380.87$ 461.49$ -$ 391.99$ -$ -$ 360.21$ 344.43$ -$ 368.30$ 388.14$ 470.30$ -$ 399.47$ -$ -$ 367.08$ 351.00$ -$ 375.33$ 395.54$ 479.27$ -$ 320.01$ 305.99$ -$ 327.21$ 344.82$ 417.82$ -$ 354.89$ -$ -$ 326.12$ 311.83$ -$ 333.45$ 351.40$ 425.79$ -$ 361.66$ -$ -$ 332.34$ 317.78$ -$ 339.81$ 358.11$ 433.91$

Quarter 3 2020, 21-year-old Non-Tobacco Premium PMPM Quarter 4 2020, 21-year-old Non-Tobacco Premium PMP1, 21-year-old Non-Tobacco Premium PMPM Quarter 2 2020, 21-year-old Non-Tobacco Premium PMPM

PA Rate Template Part IV B -Table 11. Plan Premium Developm

Carrier Name:Product(s):Market Segment:Rate Effective Date:


Component)

Totals

Plan 1 75729PA0050062Plan 2 75729PA0050068Plan 3 75729PA0050070Plan 4 75729PA0050071Plan 5 75729PA0050073Plan 6 75729PA0050075Plan 7 75729PA0050078Plan 8 75729PA0050079Plan 9 75729PA0050080Plan 10 75729PA0050082Plan 11 75729PA0050096Plan 12 75729PA0050097Plan 13 75729PA0050102Plan 14 75729PA0050103Plan 15 75729PA0050104Plan 16 75729PA0050105Plan 17 75729PA0050106Plan 18 75729PA0050107Plan 19 75729PA0050108Plan 20 75729PA0050109Plan 21 75729PA0050110Plan 22 75729PA0050111Plan 23 75729PA0050112Plan 24 75729PA0050113Plan 25 75729PA0050114Plan 26 75729PA0050115Plan 27 75729PA0050116Plan 28 75729PA0050117Plan 29 75729PA0050118Plan 30 75729PA0050119Plan 31 75729PA0050120Plan 32 75729PA0050121Plan 33 75729PA0050122Plan 34 75729PA0050123Plan 35 75729PA0050124Plan 36 75729PA0050125Plan 37 75729PA0050126Plan 38 75729PA0050127Plan 39 75729PA0050128Plan 40 75729PA0050129Plan 41 75729PA0050130Plan 42 75729PA0050131Plan 43 75729PA0050132Plan 44 75729PA0050133Plan 45 75729PA0050134Plan 46 75729PA0050135Plan 47 75729PA0050136Plan 48 75729PA0050137Plan 49 75729PA0050138Plan 50 75729PA0050140Plan 51 75729PA0050141Plan 52 75729PA0050142Plan 53 75729PA0050143Plan 54 75729PA0050144Plan 55 75729PA0050145Plan 56 75729PA0050146Plan 57 75729PA0050147Plan 58 75729PA0050148Plan 59 75729PA0050149Plan 60 75729PA0050150Plan 61 75729PA0050151

8 9

Average (weighted

by enrollment

by rating area)

-$ 442.04$ 428.14$

-$ 331.15$ 323.29$ -$ 444.00$ 410.83$ -$ 447.77$ 412.64$ -$ 424.50$ 412.43$ -$ 370.83$ 360.33$ -$ 367.75$ 328.88$ -$ 445.27$ 417.54$ -$ 387.47$ 373.60$ -$ 508.25$ 453.66$ -$ 500.82$ 460.98$ -$ 414.17$ 403.31$ -$ 400.05$ 376.54$ -$ 462.35$ 407.02$ -$ 439.05$ 387.54$ -$ 430.51$ 387.88$ -$ 385.47$ 363.29$ -$ 382.25$ 347.59$ -$ 335.77$ 324.65$ -$ 372.96$ 344.48$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 438.08$ 393.52$ -$ 529.13$ 485.36$ -$ 527.63$ 495.88$ -$ 438.34$ 412.78$ -$ 514.01$ 476.89$ -$ 433.55$ 399.22$ -$ 416.58$ 384.05$ -$ 367.01$ 349.33$ -$ 491.40$ -$ -$ 484.40$ -$ -$ 418.59$ -$ -$ 451.14$ -$ -$ 505.20$ -$ -$ 424.77$ -$ -$ 407.09$ -$ -$ 368.56$ -$ -$ 505.20$ -$ -$ 424.77$ -$ -$ 407.09$ -$ -$ 368.56$ -$ -$ 505.20$ -$ -$ 424.77$ -$ -$ 407.09$ -$ -$ 368.56$ -$

PM

PA Rate Quarterly Template Part VConsumer Factors

Carrier Name: Geisinger Quality Options

Product(s): PPO

Market Segment: Small Group

Rate Effective Date: 1/1/2020

Table 12. Age and Tobacco Factors Table 13. Geographic Factors

Age Band

Age Factor

Tobacco Factor

Age Band

Age Factor

Tobacco Factor

Area Counties Current Factor

Proposed Factor

0-14 0.765 40 1.278 1.000 Rating Area 1 0.000 0.00015 0.833 41 1.302 1.000 Rating Area 2 Cameron, Elk, Potter 0.890 0.890

16 0.859 42 1.325 1.000 Rating Area 3Tioga, Clinton, Lycoming, Sullivan, Bradford, Susquehanna, Wyoming, Lackawanna, Wayne, Pike, Monroe, Carbon, Luzerne

0.851 0.851

17 0.885 43 1.357 1.000 Rating Area 4 0.000 0.000

18 0.913 1.000 44 1.397 1.000 Rating Area 5 Jefferson, Clearfield, Cambria, Somerset, Blair, Huntingdon

0.910 0.910

19 0.941 1.000 45 1.444 1.000 Rating Area 6Centre, Mifflin, Union, Snyder, Montour, Northumberland, Columbia, Schuylkill, Lehigh, Northampton

0.959 0.959

20 0.970 1.000 46 1.500 1.000 Rating Area 7 Adams, York, Lancaster, Berks 1.162 1.16221 1.000 1.000 47 1.563 1.000 Rating Area 8 0.000 0.000

22 1.000 1.000 48 1.635 1.000 Rating Area 9 Fulton, Cumberland, Perry, Juniata, Dauphin, Lebanon

0.987 0.987

23 1.000 1.000 49 1.706 1.00024 1.000 1.000 50 1.786 1.00025 1.004 1.000 51 1.865 1.000 Table 14. Network Factors26 1.024 1.000 52 1.952 1.00027 1.048 1.000 53 2.040 1.000

28 1.087 1.000 54 2.135 1.000 Network Name Rating AreaCurrent Factor

Proposed Factor

DOH Approval

Date29 1.119 1.000 55 2.230 1.000 Geisinger All-Access PPO 2,3,5,6,7,8,9 1.000 1 8/15/201330 1.135 1.000 56 2.333 1.000 Geisinger Choices PPO 3,6,7,9 1.000 1.000 10/31/201831 1.159 1.000 57 2.437 1.00032 1.183 1.000 58 2.548 1.00033 1.198 1.000 59 2.603 1.00034 1.214 1.000 60 2.714 1.00035 1.222 1.000 61 2.810 1.00036 1.230 1.000 62 2.873 1.00037 1.238 1.000 63 2.952 1.00038 1.246 1.000 64+ 3.000 1.00039 1.262 1.000

*PA follows the federal default age curve.

Projection Period Age and Tobacco Factors Geographic Area Factors

Projecion Period Network Factors

Geisinger Quality OptionsSmall Group Filing for 2020Projected Reinsurance Calculation

PMPMReinsurance Premium July 2018 - June 2019 $2.14Assumed Reinsurance Premium July 2019 - June 2020 $2.46Assumed Reinsurance Premium July 2020 - June 2021 $2.83Estimated Reinsurance Premium Jan 2020 - Dec 2020 $2.65

Estimated Reinsurance Recoveries $2.04

Net Reinsurance $0.60Other Factor - Other 1.00118

Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) PMPM $510.32

Geisinger Quality OptionsSmall Group Filing for 2020Projected Tax Estimates

Federal Income TaxProjected Margin: 2%

Projected Federal Income Tax Rate: 21%Projected State Income Tax Rate: 9.99%

Estimated Federal Income Tax: 0.90%

Health Insurance Provider Fee2020 2021

Applicable amount $16,400,000,000 $17,500,000,000Expected National Premium in Data Year $816,272,140,887 $873,411,190,749Expected GQO Total Premium in Data Year $497,906,138 $532,759,568Applicable % expected for GQO 0.061% 0.061%Expected GQO Fee Amount $10,003,601 $10,674,574Expected GQO Total Premium in Fee Year $355,443,485 $380,324,529Expected Tax 2.81% 2.81%

Quarter Average Fee for Quarter Member Months WeightsQ1 2.81% 88,140 45.42%Q2 2.81% 33,288 17.15%Q3 2.81% 26,556 13.68%Q4 2.81% 46,080 23.74%

Total: 2.81% 194,064 100.00%

Month for estimateEstimated ACA Insurer Fee

Contract Effective Date

Estimated ACA Insurer Fee

Jan-19 0.00% Jan-19 0.00%Feb-19 0.00% Feb-19 0.23%Mar-19 0.00% Mar-19 0.47%Apr-19 0.00% Apr-19 0.70%

May-19 0.00% May-19 0.94%Jun-19 0.00% Jun-19 1.17%Jul-19 0.00% Jul-19 1.41%

Aug-19 0.00% Aug-19 1.64%Sep-19 0.00% Sep-19 1.88%Oct-19 0.00% Oct-19 2.11%

Nov-19 0.00% Nov-19 2.35%Dec-19 0.00% Dec-19 2.58%Jan-20 2.81% Jan-20 2.81%Feb-20 2.81% Feb-20 2.81%Mar-20 2.81% Mar-20 2.81%Apr-20 2.81% Apr-20 2.81%

May-20 2.81% May-20 2.81%Jun-20 2.81% Jun-20 2.81%Jul-20 2.81% Jul-20 2.81%

Aug-20 2.81% Aug-20 2.81%

Geisinger Quality OptionsSmall Group Filing for 2020Projected Tax Estimates

Sep-20 2.81% Sep-20 2.81%Oct-20 2.81% Oct-20 2.81%

Nov-20 2.81% Nov-20 2.81%Dec-20 2.81% Dec-20 2.81%Jan-21 2.81% Jan-21 2.81%Feb-21 2.81%Mar-21 2.81%Apr-21 2.81%

May-21 2.81%Jun-21 2.81%Jul-21 2.81%

Aug-21 2.81%Sep-21 2.81%Oct-21 2.81%

Nov-21 2.81%Dec-21 2.81%

Geisinger Quality OptionsSmall Group Filing for 2020Quality Improvement Initiatives Estimates

ANNUAL STATEMENT FOR THE YEAR 2018 OF THE Geisinger Health Plan and Geisinger Quality Options, Inc.SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1

Business Subject to MLRComprehensive Health Coverage

Small Group EmployerLine 6.6 TOTAL of Defined Expenses Incurred for Improving Health

Care Quality (Lines 6.1 + 6.2 + 6.3 + 6.4 + 6.5) . . . . . . . . . . . . . . 2,180,540

Member Months for GHP and GQO combined 189,767 Estimated PMPM: $11.49

RATE PAGES

Company Name:Market:

Product:Effective Date of Rates: Ending date of Rates:

HIOS Plan ID (On Exchange)=>HIOS Plan ID (Off Exchange)=>

Plan Marketing Name =>Form # =>

Rating Area =>

Network =>Metal =>

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

0 - 14 $215.84 $215.84 $206.38 $206.38 $220.69 $220.69 $232.58 $232.58 $281.81 $281.81 $239.37 $239.37 $276.72 $276.72 $311.84 $311.84 $320.94 $320.94 $291.8515 $235.03 $235.03 $224.73 $224.73 $240.31 $240.31 $253.25 $253.25 $306.86 $306.86 $260.64 $260.64 $301.31 $301.31 $339.55 $339.55 $349.47 $349.47 $317.8016 $242.36 $242.36 $231.74 $231.74 $247.81 $247.81 $261.15 $261.15 $316.43 $316.43 $268.78 $268.78 $310.72 $310.72 $350.15 $350.15 $360.38 $360.38 $327.7217 $249.70 $249.70 $238.76 $238.76 $255.31 $255.31 $269.06 $269.06 $326.01 $326.01 $276.91 $276.91 $320.12 $320.12 $360.75 $360.75 $371.28 $371.28 $337.6418 $257.60 $257.60 $246.31 $246.31 $263.39 $263.39 $277.57 $277.57 $336.33 $336.33 $285.67 $285.67 $330.25 $330.25 $372.17 $372.17 $383.03 $383.03 $348.3219 $265.50 $265.50 $253.87 $253.87 $271.47 $271.47 $286.08 $286.08 $346.64 $346.64 $294.44 $294.44 $340.38 $340.38 $383.58 $383.58 $394.78 $394.78 $359.0020 $273.68 $273.68 $261.69 $261.69 $279.83 $279.83 $294.90 $294.90 $357.32 $357.32 $303.51 $303.51 $350.87 $350.87 $395.40 $395.40 $406.94 $406.94 $370.0621 $282.15 $282.15 $269.79 $269.79 $288.49 $288.49 $304.03 $304.03 $368.38 $368.38 $312.90 $312.90 $361.73 $361.73 $407.63 $407.63 $419.54 $419.54 $381.5122 $282.15 $282.15 $269.79 $269.79 $288.49 $288.49 $304.03 $304.03 $368.38 $368.38 $312.90 $312.90 $361.73 $361.73 $407.63 $407.63 $419.54 $419.54 $381.5123 $282.15 $282.15 $269.79 $269.79 $288.49 $288.49 $304.03 $304.03 $368.38 $368.38 $312.90 $312.90 $361.73 $361.73 $407.63 $407.63 $419.54 $419.54 $381.5124 $282.15 $282.15 $269.79 $269.79 $288.49 $288.49 $304.03 $304.03 $368.38 $368.38 $312.90 $312.90 $361.73 $361.73 $407.63 $407.63 $419.54 $419.54 $381.5125 $283.27 $283.27 $270.86 $270.86 $289.64 $289.64 $305.24 $305.24 $369.85 $369.85 $314.15 $314.15 $363.17 $363.17 $409.26 $409.26 $421.21 $421.21 $383.0426 $288.92 $288.92 $276.26 $276.26 $295.41 $295.41 $311.32 $311.32 $377.22 $377.22 $320.41 $320.41 $370.40 $370.40 $417.41 $417.41 $429.60 $429.60 $390.6727 $295.69 $295.69 $282.73 $282.73 $302.33 $302.33 $318.61 $318.61 $386.06 $386.06 $327.92 $327.92 $379.09 $379.09 $427.19 $427.19 $439.67 $439.67 $399.8228 $306.69 $306.69 $293.25 $293.25 $313.58 $313.58 $330.47 $330.47 $400.42 $400.42 $340.12 $340.12 $393.19 $393.19 $443.09 $443.09 $456.03 $456.03 $414.7029 $315.72 $315.72 $301.89 $301.89 $322.82 $322.82 $340.20 $340.20 $412.21 $412.21 $350.13 $350.13 $404.77 $404.77 $456.14 $456.14 $469.45 $469.45 $426.9130 $320.24 $320.24 $306.20 $306.20 $327.43 $327.43 $345.06 $345.06 $418.11 $418.11 $355.14 $355.14 $410.56 $410.56 $462.66 $462.66 $476.17 $476.17 $433.0131 $327.01 $327.01 $312.68 $312.68 $334.36 $334.36 $352.36 $352.36 $426.95 $426.95 $362.65 $362.65 $419.24 $419.24 $472.44 $472.44 $486.24 $486.24 $442.1732 $333.78 $333.78 $319.15 $319.15 $341.28 $341.28 $359.66 $359.66 $435.79 $435.79 $370.16 $370.16 $427.92 $427.92 $482.22 $482.22 $496.30 $496.30 $451.3333 $338.01 $338.01 $323.20 $323.20 $345.61 $345.61 $364.22 $364.22 $441.31 $441.31 $374.85 $374.85 $433.34 $433.34 $488.34 $488.34 $502.60 $502.60 $457.0534 $342.53 $342.53 $327.52 $327.52 $350.22 $350.22 $369.08 $369.08 $447.21 $447.21 $379.86 $379.86 $439.13 $439.13 $494.86 $494.86 $509.31 $509.31 $463.1535 $344.78 $344.78 $329.67 $329.67 $352.53 $352.53 $371.51 $371.51 $450.15 $450.15 $382.36 $382.36 $442.03 $442.03 $498.12 $498.12 $512.67 $512.67 $466.2036 $347.04 $347.04 $331.83 $331.83 $354.84 $354.84 $373.94 $373.94 $453.10 $453.10 $384.86 $384.86 $444.92 $444.92 $501.38 $501.38 $516.02 $516.02 $469.2637 $349.30 $349.30 $333.99 $333.99 $357.15 $357.15 $376.38 $376.38 $456.05 $456.05 $387.37 $387.37 $447.81 $447.81 $504.64 $504.64 $519.38 $519.38 $472.3138 $351.55 $351.55 $336.15 $336.15 $359.45 $359.45 $378.81 $378.81 $459.00 $459.00 $389.87 $389.87 $450.71 $450.71 $507.91 $507.91 $522.73 $522.73 $475.3639 $356.07 $356.07 $340.47 $340.47 $364.07 $364.07 $383.67 $383.67 $464.89 $464.89 $394.88 $394.88 $456.49 $456.49 $514.43 $514.43 $529.45 $529.45 $481.4640 $360.58 $360.58 $344.78 $344.78 $368.69 $368.69 $388.54 $388.54 $470.78 $470.78 $399.88 $399.88 $462.28 $462.28 $520.95 $520.95 $536.16 $536.16 $487.5741 $367.35 $367.35 $351.26 $351.26 $375.61 $375.61 $395.83 $395.83 $479.62 $479.62 $407.39 $407.39 $470.96 $470.96 $530.73 $530.73 $546.23 $546.23 $496.7242 $373.84 $373.84 $357.46 $357.46 $382.24 $382.24 $402.83 $402.83 $488.10 $488.10 $414.59 $414.59 $479.28 $479.28 $540.11 $540.11 $555.88 $555.88 $505.5043 $382.87 $382.87 $366.09 $366.09 $391.48 $391.48 $412.56 $412.56 $499.88 $499.88 $424.60 $424.60 $490.86 $490.86 $553.15 $553.15 $569.30 $569.30 $517.7144 $394.16 $394.16 $376.89 $376.89 $403.02 $403.02 $424.72 $424.72 $514.62 $514.62 $437.12 $437.12 $505.33 $505.33 $569.46 $569.46 $586.08 $586.08 $532.9745 $407.42 $407.42 $389.57 $389.57 $416.57 $416.57 $439.01 $439.01 $531.93 $531.93 $451.82 $451.82 $522.33 $522.33 $588.62 $588.62 $605.80 $605.80 $550.9046 $423.22 $423.22 $404.67 $404.67 $432.73 $432.73 $456.03 $456.03 $552.56 $552.56 $469.35 $469.35 $542.58 $542.58 $611.44 $611.44 $629.30 $629.30 $572.2647 $440.99 $440.99 $421.67 $421.67 $450.90 $450.90 $475.18 $475.18 $575.77 $575.77 $489.06 $489.06 $565.37 $565.37 $637.12 $637.12 $655.73 $655.73 $596.3048 $461.31 $461.31 $441.09 $441.09 $471.68 $471.68 $497.07 $497.07 $602.29 $602.29 $511.59 $511.59 $591.42 $591.42 $666.47 $666.47 $685.93 $685.93 $623.7749 $481.34 $481.34 $460.25 $460.25 $492.16 $492.16 $518.66 $518.66 $628.45 $628.45 $533.80 $533.80 $617.10 $617.10 $695.41 $695.41 $715.72 $715.72 $650.8550 $503.91 $503.91 $481.83 $481.83 $515.24 $515.24 $542.98 $542.98 $657.92 $657.92 $558.83 $558.83 $646.04 $646.04 $728.02 $728.02 $749.28 $749.28 $681.3851 $526.20 $526.20 $503.14 $503.14 $538.03 $538.03 $567.00 $567.00 $687.02 $687.02 $583.55 $583.55 $674.61 $674.61 $760.23 $760.23 $782.42 $782.42 $711.5152 $550.75 $550.75 $526.62 $526.62 $563.13 $563.13 $593.45 $593.45 $719.07 $719.07 $610.77 $610.77 $706.08 $706.08 $795.69 $795.69 $818.92 $818.92 $744.7153 $575.58 $575.58 $550.36 $550.36 $588.51 $588.51 $620.20 $620.20 $751.48 $751.48 $638.31 $638.31 $737.91 $737.91 $831.56 $831.56 $855.84 $855.84 $778.2854 $602.38 $602.38 $575.99 $575.99 $615.92 $615.92 $649.08 $649.08 $786.48 $786.48 $668.03 $668.03 $772.28 $772.28 $870.29 $870.29 $895.70 $895.70 $814.5255 $629.19 $629.19 $601.61 $601.61 $643.32 $643.32 $677.97 $677.97 $821.48 $821.48 $697.76 $697.76 $806.64 $806.64 $909.01 $909.01 $935.55 $935.55 $850.7756 $658.25 $658.25 $629.40 $629.40 $673.04 $673.04 $709.28 $709.28 $859.42 $859.42 $729.99 $729.99 $843.90 $843.90 $951.00 $951.00 $978.76 $978.76 $890.0657 $687.59 $687.59 $657.46 $657.46 $703.04 $703.04 $740.90 $740.90 $897.73 $897.73 $762.53 $762.53 $881.52 $881.52 $993.39 $993.39 $1,022.40 $1,022.40 $929.7458 $718.91 $718.91 $687.41 $687.41 $735.06 $735.06 $774.64 $774.64 $938.62 $938.62 $797.26 $797.26 $921.67 $921.67 $1,038.64 $1,038.64 $1,068.96 $1,068.96 $972.0959 $734.43 $734.43 $702.24 $702.24 $750.93 $750.93 $791.36 $791.36 $958.88 $958.88 $814.47 $814.47 $941.56 $941.56 $1,061.06 $1,061.06 $1,092.04 $1,092.04 $993.0760 $765.74 $765.74 $732.19 $732.19 $782.95 $782.95 $825.11 $825.11 $999.77 $999.77 $849.20 $849.20 $981.72 $981.72 $1,106.30 $1,106.30 $1,138.61 $1,138.61 $1,035.4261 $792.83 $792.83 $758.09 $758.09 $810.65 $810.65 $854.30 $854.30 $1,035.13 $1,035.13 $879.24 $879.24 $1,016.44 $1,016.44 $1,145.44 $1,145.44 $1,178.88 $1,178.88 $1,072.0462 $810.61 $810.61 $775.08 $775.08 $828.82 $828.82 $873.45 $873.45 $1,058.34 $1,058.34 $898.95 $898.95 $1,039.23 $1,039.23 $1,171.12 $1,171.12 $1,205.31 $1,205.31 $1,096.0863 $832.90 $832.90 $796.40 $796.40 $851.61 $851.61 $897.47 $897.47 $1,087.44 $1,087.44 $923.67 $923.67 $1,067.81 $1,067.81 $1,203.32 $1,203.32 $1,238.45 $1,238.45 $1,126.22

64+ $846.44 $846.44 $809.35 $809.35 $865.46 $865.46 $912.06 $912.06 $1,105.12 $1,105.12 $938.69 $938.69 $1,085.17 $1,085.17 $1,222.89 $1,222.89 $1,258.59 $1,258.59 $1,144.53

$20 /

75729PAGeisinger All

20/40/M-152-121-

Rating M-152-243-F Rev. 1/20

Rating Area 9

Geisinger All-Access PPO

GoldMed: $500 / Rx: $0

0%$60 / $60$8,150

Yes

Geisinger Extra PPO 10/60/500

M-152-243-F Rev. 1/20Rating Area 6


Gold

$8,1Ye

Geisinger All

GoMed: $1,00

0%

75729PA0050068 75729PA0050068 75729PA0050068

Med: $500 / Rx: $00%

$60 / $60$8,150

Yes




GoldCombined: $6,500

0%0% After Deductible

$6,500Yes

Geisinger All-Access QHDHP PPO 6500



BronzeMed: $500 / Rx: $0

0%$60 / $60$8,150

Yes


Combined: $6,5000%

0% After Deductible$6,500

Yes




Bronze

Geisinger Quality OptionsSmall Group

PPOJanuary 1, 2020

75729PA0050062 75729PA0050062Geisinger All-Access QHDHP

PPO 6500Geisinger All-Access QHDHP

PPO 6500

75729PA0050062

March 31, 2020

Rating Area 5Rating Area 3

YesYes

0% After Deductible0%

Combined: $6,500

0% After Deductible

BronzeBronze

Geisinger All-Access PPOGeisinger All-Access PPO

Yes



Bronze

Rating Area 2

75729PA0050062

0% After Deductible

Combined: $6,5000%

$6,500

M-152-122-F Rev. 1/20 M-152-122-F Rev. 1/20M-152-122-F Rev. 1/20

Yes


$6,500

75729PA0050062


BronzeCombined: $6,500


$6,500

75729PA0050062

$6,500


Combined: $6,5000%

Page Number: 1 12/24/2014

RATE PAGES


Product:Effective Date of Rates:



Rating Area =>

Network =>Metal =>



Pediatric Dental (Yes/No) =>Age Band

0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$291.85 $279.07 $279.07 $298.41 $298.41 $314.48 $314.48 $381.05 $381.05 $323.66 $323.66 $276.69 $276.69 $264.56 $264.56 $282.91 $282.91 $298.14 $298.14$317.80 $303.87 $303.87 $324.94 $324.94 $342.44 $342.44 $414.92 $414.92 $352.43 $352.43 $301.28 $301.28 $288.08 $288.08 $308.05 $308.05 $324.64 $324.64$327.72 $313.36 $313.36 $335.08 $335.08 $353.12 $353.12 $427.87 $427.87 $363.43 $363.43 $310.69 $310.69 $297.07 $297.07 $317.67 $317.67 $334.77 $334.77$337.64 $322.84 $322.84 $345.22 $345.22 $363.81 $363.81 $440.82 $440.82 $374.43 $374.43 $320.09 $320.09 $306.06 $306.06 $327.28 $327.28 $344.91 $344.91$348.32 $333.05 $333.05 $356.15 $356.15 $375.32 $375.32 $454.77 $454.77 $386.28 $386.28 $330.22 $330.22 $315.75 $315.75 $337.64 $337.64 $355.82 $355.82$359.00 $343.27 $343.27 $367.07 $367.07 $386.83 $386.83 $468.72 $468.72 $398.13 $398.13 $340.35 $340.35 $325.43 $325.43 $347.99 $347.99 $366.73 $366.73$370.06 $353.85 $353.85 $378.38 $378.38 $398.75 $398.75 $483.16 $483.16 $410.40 $410.40 $350.83 $350.83 $335.46 $335.46 $358.72 $358.72 $378.03 $378.03$381.51 $364.80 $364.80 $390.09 $390.09 $411.09 $411.09 $498.11 $498.11 $423.09 $423.09 $361.69 $361.69 $345.84 $345.84 $369.82 $369.82 $389.73 $389.73$381.51 $364.80 $364.80 $390.09 $390.09 $411.09 $411.09 $498.11 $498.11 $423.09 $423.09 $361.69 $361.69 $345.84 $345.84 $369.82 $369.82 $389.73 $389.73$381.51 $364.80 $364.80 $390.09 $390.09 $411.09 $411.09 $498.11 $498.11 $423.09 $423.09 $361.69 $361.69 $345.84 $345.84 $369.82 $369.82 $389.73 $389.73$381.51 $364.80 $364.80 $390.09 $390.09 $411.09 $411.09 $498.11 $498.11 $423.09 $423.09 $361.69 $361.69 $345.84 $345.84 $369.82 $369.82 $389.73 $389.73$383.04 $366.25 $366.25 $391.64 $391.64 $412.73 $412.73 $500.10 $500.10 $424.78 $424.78 $363.13 $363.13 $347.22 $347.22 $371.29 $371.29 $391.28 $391.28$390.67 $373.55 $373.55 $399.44 $399.44 $420.95 $420.95 $510.06 $510.06 $433.24 $433.24 $370.36 $370.36 $354.14 $354.14 $378.69 $378.69 $399.08 $399.08$399.82 $382.30 $382.30 $408.81 $408.81 $430.82 $430.82 $522.01 $522.01 $443.40 $443.40 $379.05 $379.05 $362.44 $362.44 $387.56 $387.56 $408.43 $408.43$414.70 $396.53 $396.53 $424.02 $424.02 $446.85 $446.85 $541.44 $541.44 $459.90 $459.90 $393.15 $393.15 $375.92 $375.92 $401.99 $401.99 $423.63 $423.63$426.91 $408.20 $408.20 $436.50 $436.50 $460.01 $460.01 $557.38 $557.38 $473.44 $473.44 $404.72 $404.72 $386.99 $386.99 $413.82 $413.82 $436.10 $436.10$433.01 $414.04 $414.04 $442.74 $442.74 $466.58 $466.58 $565.35 $565.35 $480.21 $480.21 $410.51 $410.51 $392.52 $392.52 $419.74 $419.74 $442.34 $442.34$442.17 $422.79 $422.79 $452.11 $452.11 $476.45 $476.45 $577.30 $577.30 $490.36 $490.36 $419.19 $419.19 $400.82 $400.82 $428.61 $428.61 $451.69 $451.69$451.33 $431.55 $431.55 $461.47 $461.47 $486.32 $486.32 $589.26 $589.26 $500.51 $500.51 $427.87 $427.87 $409.12 $409.12 $437.49 $437.49 $461.04 $461.04$457.05 $437.02 $437.02 $467.32 $467.32 $492.48 $492.48 $596.73 $596.73 $506.86 $506.86 $433.30 $433.30 $414.31 $414.31 $443.03 $443.03 $466.89 $466.89$463.15 $442.86 $442.86 $473.56 $473.56 $499.06 $499.06 $604.70 $604.70 $513.63 $513.63 $439.08 $439.08 $419.84 $419.84 $448.95 $448.95 $473.13 $473.13$466.20 $445.78 $445.78 $476.68 $476.68 $502.35 $502.35 $608.68 $608.68 $517.02 $517.02 $441.98 $441.98 $422.61 $422.61 $451.91 $451.91 $476.24 $476.24$469.26 $448.69 $448.69 $479.80 $479.80 $505.64 $505.64 $612.67 $612.67 $520.40 $520.40 $444.87 $444.87 $425.38 $425.38 $454.87 $454.87 $479.36 $479.36$472.31 $451.61 $451.61 $482.92 $482.92 $508.93 $508.93 $616.65 $616.65 $523.78 $523.78 $447.77 $447.77 $428.14 $428.14 $457.83 $457.83 $482.48 $482.48$475.36 $454.53 $454.53 $486.04 $486.04 $512.21 $512.21 $620.64 $620.64 $527.17 $527.17 $450.66 $450.66 $430.91 $430.91 $460.79 $460.79 $485.60 $485.60$481.46 $460.37 $460.37 $492.28 $492.28 $518.79 $518.79 $628.61 $628.61 $533.94 $533.94 $456.45 $456.45 $436.44 $436.44 $466.70 $466.70 $491.83 $491.83$487.57 $466.20 $466.20 $498.53 $498.53 $525.37 $525.37 $636.58 $636.58 $540.71 $540.71 $462.23 $462.23 $441.98 $441.98 $472.62 $472.62 $498.07 $498.07$496.72 $474.96 $474.96 $507.89 $507.89 $535.24 $535.24 $648.53 $648.53 $550.86 $550.86 $470.91 $470.91 $450.28 $450.28 $481.50 $481.50 $507.42 $507.42$505.50 $483.35 $483.35 $516.86 $516.86 $544.69 $544.69 $659.99 $659.99 $560.59 $560.59 $479.23 $479.23 $458.23 $458.23 $490.00 $490.00 $516.39 $516.39$517.71 $495.02 $495.02 $529.34 $529.34 $557.84 $557.84 $675.93 $675.93 $574.13 $574.13 $490.81 $490.81 $469.30 $469.30 $501.84 $501.84 $528.86 $528.86$532.97 $509.61 $509.61 $544.95 $544.95 $574.29 $574.29 $695.85 $695.85 $591.06 $591.06 $505.27 $505.27 $483.13 $483.13 $516.63 $516.63 $544.45 $544.45$550.90 $526.76 $526.76 $563.28 $563.28 $593.61 $593.61 $719.26 $719.26 $610.94 $610.94 $522.27 $522.27 $499.39 $499.39 $534.01 $534.01 $562.76 $562.76$572.26 $547.19 $547.19 $585.12 $585.12 $616.63 $616.63 $747.16 $747.16 $634.63 $634.63 $542.53 $542.53 $518.75 $518.75 $554.72 $554.72 $584.59 $584.59$596.30 $570.17 $570.17 $609.70 $609.70 $642.53 $642.53 $778.54 $778.54 $661.29 $661.29 $565.31 $565.31 $540.54 $540.54 $578.02 $578.02 $609.14 $609.14$623.77 $596.43 $596.43 $637.78 $637.78 $672.13 $672.13 $814.40 $814.40 $691.75 $691.75 $591.35 $591.35 $565.44 $565.44 $604.64 $604.64 $637.20 $637.20$650.85 $622.33 $622.33 $665.48 $665.48 $701.31 $701.31 $849.77 $849.77 $721.79 $721.79 $617.03 $617.03 $590.00 $590.00 $630.90 $630.90 $664.87 $664.87$681.38 $651.52 $651.52 $696.69 $696.69 $734.20 $734.20 $889.62 $889.62 $755.64 $755.64 $645.97 $645.97 $617.66 $617.66 $660.48 $660.48 $696.05 $696.05$711.51 $680.34 $680.34 $727.50 $727.50 $766.68 $766.68 $928.97 $928.97 $789.06 $789.06 $674.54 $674.54 $644.98 $644.98 $689.70 $689.70 $726.84 $726.84$744.71 $712.07 $712.07 $761.44 $761.44 $802.44 $802.44 $972.30 $972.30 $825.87 $825.87 $706.01 $706.01 $675.07 $675.07 $721.87 $721.87 $760.74 $760.74$778.28 $744.17 $744.17 $795.77 $795.77 $838.62 $838.62 $1,016.13 $1,016.13 $863.10 $863.10 $737.84 $737.84 $705.50 $705.50 $754.42 $754.42 $795.04 $795.04$814.52 $778.83 $778.83 $832.83 $832.83 $877.67 $877.67 $1,063.45 $1,063.45 $903.30 $903.30 $772.20 $772.20 $738.36 $738.36 $789.55 $789.55 $832.06 $832.06$850.77 $813.48 $813.48 $869.88 $869.88 $916.72 $916.72 $1,110.77 $1,110.77 $943.49 $943.49 $806.56 $806.56 $771.21 $771.21 $824.68 $824.68 $869.09 $869.09$890.06 $851.06 $851.06 $910.06 $910.06 $959.07 $959.07 $1,162.08 $1,162.08 $987.07 $987.07 $843.81 $843.81 $806.83 $806.83 $862.77 $862.77 $909.23 $909.23$929.74 $889.00 $889.00 $950.63 $950.63 $1,001.82 $1,001.82 $1,213.88 $1,213.88 $1,031.07 $1,031.07 $881.42 $881.42 $842.80 $842.80 $901.23 $901.23 $949.76 $949.76$972.09 $929.49 $929.49 $993.93 $993.93 $1,047.45 $1,047.45 $1,269.17 $1,269.17 $1,078.03 $1,078.03 $921.57 $921.57 $881.19 $881.19 $942.28 $942.28 $993.02 $993.02$993.07 $949.55 $949.55 $1,015.38 $1,015.38 $1,070.06 $1,070.06 $1,296.57 $1,296.57 $1,101.30 $1,101.30 $941.46 $941.46 $900.21 $900.21 $962.62 $962.62 $1,014.45 $1,014.45

$1,035.42 $990.04 $990.04 $1,058.68 $1,058.68 $1,115.69 $1,115.69 $1,351.86 $1,351.86 $1,148.26 $1,148.26 $981.61 $981.61 $938.60 $938.60 $1,003.67 $1,003.67 $1,057.71 $1,057.71$1,072.04 $1,025.06 $1,025.06 $1,096.13 $1,096.13 $1,155.15 $1,155.15 $1,399.68 $1,399.68 $1,188.88 $1,188.88 $1,016.33 $1,016.33 $971.80 $971.80 $1,039.17 $1,039.17 $1,095.13 $1,095.13$1,096.08 $1,048.05 $1,048.05 $1,120.71 $1,120.71 $1,181.05 $1,181.05 $1,431.06 $1,431.06 $1,215.54 $1,215.54 $1,039.12 $1,039.12 $993.58 $993.58 $1,062.47 $1,062.47 $1,119.68 $1,119.68$1,126.22 $1,076.86 $1,076.86 $1,151.52 $1,151.52 $1,213.53 $1,213.53 $1,470.41 $1,470.41 $1,248.96 $1,248.96 $1,067.69 $1,067.69 $1,020.91 $1,020.91 $1,091.69 $1,091.69 $1,150.47 $1,150.47$1,144.53 $1,094.37 $1,094.37 $1,170.25 $1,170.25 $1,233.26 $1,233.26 $1,494.32 $1,494.32 $1,269.27 $1,269.27 $1,085.05 $1,085.05 $1,037.51 $1,037.51 $1,109.44 $1,109.44 $1,169.18 $1,169.18

$7,350Yes

75729PA0050071Geisinger All-Access PPO

25/50/2750M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


GoldMed: $2,750 / Rx: $0

0%$25 / $50


25/50/2750M-152-121-F Rev. 1/20

Rating Area 5

$7,350Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


GoldMed: $2,750 / Rx: $0

0%$25 / $50


25/50/2750M-152-121-F Rev. 1/20

Rating Area 2

$8,150Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


GoldMed: $1,000 / Rx: $0

0%$20 / $40


20/40/1000M-152-121-F Rev. 1/20

Rating Area 7

/ $40

A0050070l-Access PPO /1000-F Rev. 1/20Area 2

$8,150Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


GoldMed: $1,000 / Rx: $0

0%$20 / $40


20/40/1000M-152-121-F Rev. 1/20

Rating Area 5

150es


20/40/1000M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes

l-Access PPO

old00 / Rx: $0%


RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$361.25 $361.25 $306.84 $306.84 $241.71 $241.71 $231.11 $231.11 $247.14 $247.14 $260.44 $260.44 $315.57 $315.57 $268.05 $268.05 $239.70 $239.70 $229.20$393.36 $393.36 $334.12 $334.12 $263.19 $263.19 $251.66 $251.66 $269.10 $269.10 $283.59 $283.59 $343.63 $343.63 $291.87 $291.87 $261.01 $261.01 $249.57$405.64 $405.64 $344.55 $344.55 $271.40 $271.40 $259.51 $259.51 $277.50 $277.50 $292.45 $292.45 $354.35 $354.35 $300.98 $300.98 $269.15 $269.15 $257.36$417.92 $417.92 $354.98 $354.98 $279.62 $279.62 $267.37 $267.37 $285.90 $285.90 $301.30 $301.30 $365.08 $365.08 $310.10 $310.10 $277.30 $277.30 $265.15$431.14 $431.14 $366.21 $366.21 $288.47 $288.47 $275.83 $275.83 $294.95 $294.95 $310.83 $310.83 $376.63 $376.63 $319.91 $319.91 $286.08 $286.08 $273.54$444.36 $444.36 $377.44 $377.44 $297.31 $297.31 $284.28 $284.28 $303.99 $303.99 $320.36 $320.36 $388.18 $388.18 $329.72 $329.72 $294.85 $294.85 $281.93$458.06 $458.06 $389.07 $389.07 $306.48 $306.48 $293.05 $293.05 $313.36 $313.36 $330.24 $330.24 $400.14 $400.14 $339.88 $339.88 $303.94 $303.94 $290.62$472.23 $472.23 $401.11 $401.11 $315.96 $315.96 $302.11 $302.11 $323.06 $323.06 $340.45 $340.45 $412.52 $412.52 $350.39 $350.39 $313.34 $313.34 $299.61$472.23 $472.23 $401.11 $401.11 $315.96 $315.96 $302.11 $302.11 $323.06 $323.06 $340.45 $340.45 $412.52 $412.52 $350.39 $350.39 $313.34 $313.34 $299.61$472.23 $472.23 $401.11 $401.11 $315.96 $315.96 $302.11 $302.11 $323.06 $323.06 $340.45 $340.45 $412.52 $412.52 $350.39 $350.39 $313.34 $313.34 $299.61$472.23 $472.23 $401.11 $401.11 $315.96 $315.96 $302.11 $302.11 $323.06 $323.06 $340.45 $340.45 $412.52 $412.52 $350.39 $350.39 $313.34 $313.34 $299.61$474.11 $474.11 $402.71 $402.71 $317.22 $317.22 $303.32 $303.32 $324.35 $324.35 $341.81 $341.81 $414.17 $414.17 $351.79 $351.79 $314.59 $314.59 $300.80$483.56 $483.56 $410.73 $410.73 $323.54 $323.54 $309.36 $309.36 $330.81 $330.81 $348.62 $348.62 $422.42 $422.42 $358.80 $358.80 $320.86 $320.86 $306.80$494.89 $494.89 $420.36 $420.36 $331.12 $331.12 $316.61 $316.61 $338.56 $338.56 $356.79 $356.79 $432.32 $432.32 $367.21 $367.21 $328.38 $328.38 $313.99$513.30 $513.30 $436.00 $436.00 $343.44 $343.44 $328.39 $328.39 $351.16 $351.16 $370.07 $370.07 $448.40 $448.40 $380.87 $380.87 $340.60 $340.60 $325.67$528.42 $528.42 $448.84 $448.84 $353.55 $353.55 $338.06 $338.06 $361.50 $361.50 $380.96 $380.96 $461.61 $461.61 $392.09 $392.09 $350.62 $350.62 $335.26$535.97 $535.97 $455.25 $455.25 $358.61 $358.61 $342.89 $342.89 $366.67 $366.67 $386.41 $386.41 $468.21 $468.21 $397.69 $397.69 $355.64 $355.64 $340.05$547.30 $547.30 $464.88 $464.88 $366.19 $366.19 $350.14 $350.14 $374.42 $374.42 $394.58 $394.58 $478.11 $478.11 $406.10 $406.10 $363.16 $363.16 $347.24$558.64 $558.64 $474.51 $474.51 $373.77 $373.77 $357.40 $357.40 $382.17 $382.17 $402.75 $402.75 $488.01 $488.01 $414.51 $414.51 $370.68 $370.68 $354.43$565.72 $565.72 $480.52 $480.52 $378.51 $378.51 $361.93 $361.93 $387.02 $387.02 $407.86 $407.86 $494.19 $494.19 $419.77 $419.77 $375.38 $375.38 $358.93$573.28 $573.28 $486.94 $486.94 $383.57 $383.57 $366.76 $366.76 $392.19 $392.19 $413.31 $413.31 $500.79 $500.79 $425.37 $425.37 $380.39 $380.39 $363.72$577.05 $577.05 $490.15 $490.15 $386.10 $386.10 $369.18 $369.18 $394.77 $394.77 $416.03 $416.03 $504.09 $504.09 $428.18 $428.18 $382.90 $382.90 $366.12$580.83 $580.83 $493.36 $493.36 $388.62 $388.62 $371.59 $371.59 $397.36 $397.36 $418.75 $418.75 $507.39 $507.39 $430.98 $430.98 $385.40 $385.40 $368.51$584.61 $584.61 $496.57 $496.57 $391.15 $391.15 $374.01 $374.01 $399.94 $399.94 $421.48 $421.48 $510.69 $510.69 $433.78 $433.78 $387.91 $387.91 $370.91$588.39 $588.39 $499.78 $499.78 $393.68 $393.68 $376.43 $376.43 $402.53 $402.53 $424.20 $424.20 $513.99 $513.99 $436.59 $436.59 $390.42 $390.42 $373.31$595.94 $595.94 $506.19 $506.19 $398.73 $398.73 $381.26 $381.26 $407.69 $407.69 $429.65 $429.65 $520.59 $520.59 $442.19 $442.19 $395.43 $395.43 $378.10$603.50 $603.50 $512.61 $512.61 $403.79 $403.79 $386.10 $386.10 $412.86 $412.86 $435.09 $435.09 $527.20 $527.20 $447.80 $447.80 $400.44 $400.44 $382.89$614.83 $614.83 $522.24 $522.24 $411.37 $411.37 $393.35 $393.35 $420.62 $420.62 $443.27 $443.27 $537.10 $537.10 $456.21 $456.21 $407.96 $407.96 $390.09$625.69 $625.69 $531.46 $531.46 $418.64 $418.64 $400.29 $400.29 $428.05 $428.05 $451.10 $451.10 $546.58 $546.58 $464.27 $464.27 $415.17 $415.17 $396.98$640.80 $640.80 $544.30 $544.30 $428.75 $428.75 $409.96 $409.96 $438.39 $438.39 $461.99 $461.99 $559.78 $559.78 $475.48 $475.48 $425.20 $425.20 $406.56$659.69 $659.69 $560.34 $560.34 $441.39 $441.39 $422.05 $422.05 $451.31 $451.31 $475.61 $475.61 $576.28 $576.28 $489.49 $489.49 $437.73 $437.73 $418.55$681.89 $681.89 $579.19 $579.19 $456.24 $456.24 $436.25 $436.25 $466.49 $466.49 $491.61 $491.61 $595.67 $595.67 $505.96 $505.96 $452.46 $452.46 $432.63$708.33 $708.33 $601.66 $601.66 $473.93 $473.93 $453.16 $453.16 $484.58 $484.58 $510.67 $510.67 $618.77 $618.77 $525.58 $525.58 $470.00 $470.00 $449.41$738.08 $738.08 $626.93 $626.93 $493.84 $493.84 $472.20 $472.20 $504.93 $504.93 $532.12 $532.12 $644.76 $644.76 $547.66 $547.66 $489.74 $489.74 $468.28$772.08 $772.08 $655.80 $655.80 $516.59 $516.59 $493.95 $493.95 $528.19 $528.19 $556.64 $556.64 $674.46 $674.46 $572.89 $572.89 $512.30 $512.30 $489.85$805.61 $805.61 $684.28 $684.28 $539.02 $539.02 $515.40 $515.40 $551.13 $551.13 $580.81 $580.81 $703.75 $703.75 $597.77 $597.77 $534.55 $534.55 $511.13$843.39 $843.39 $716.37 $716.37 $564.29 $564.29 $539.57 $539.57 $576.98 $576.98 $608.04 $608.04 $736.75 $736.75 $625.80 $625.80 $559.62 $559.62 $535.09$880.69 $880.69 $748.06 $748.06 $589.26 $589.26 $563.43 $563.43 $602.50 $602.50 $634.94 $634.94 $769.34 $769.34 $653.48 $653.48 $584.37 $584.37 $558.76$921.78 $921.78 $782.95 $782.95 $616.74 $616.74 $589.72 $589.72 $630.60 $630.60 $664.56 $664.56 $805.23 $805.23 $683.96 $683.96 $611.63 $611.63 $584.83$963.33 $963.33 $818.25 $818.25 $644.55 $644.55 $616.30 $616.30 $659.03 $659.03 $694.52 $694.52 $841.53 $841.53 $714.80 $714.80 $639.20 $639.20 $611.19

$1,008.19 $1,008.19 $856.36 $856.36 $674.56 $674.56 $645.00 $645.00 $689.72 $689.72 $726.86 $726.86 $880.72 $880.72 $748.08 $748.08 $668.97 $668.97 $639.66$1,053.05 $1,053.05 $894.46 $894.46 $704.58 $704.58 $673.70 $673.70 $720.41 $720.41 $759.20 $759.20 $919.91 $919.91 $781.37 $781.37 $698.74 $698.74 $668.12$1,101.69 $1,101.69 $935.78 $935.78 $737.12 $737.12 $704.82 $704.82 $753.69 $753.69 $794.27 $794.27 $962.40 $962.40 $817.46 $817.46 $731.01 $731.01 $698.98$1,150.80 $1,150.80 $977.49 $977.49 $769.98 $769.98 $736.24 $736.24 $787.28 $787.28 $829.68 $829.68 $1,005.30 $1,005.30 $853.90 $853.90 $763.60 $763.60 $730.14$1,203.22 $1,203.22 $1,022.01 $1,022.01 $805.05 $805.05 $769.77 $769.77 $823.14 $823.14 $867.47 $867.47 $1,051.09 $1,051.09 $892.79 $892.79 $798.38 $798.38 $763.39$1,229.19 $1,229.19 $1,044.07 $1,044.07 $822.43 $822.43 $786.39 $786.39 $840.91 $840.91 $886.19 $886.19 $1,073.78 $1,073.78 $912.07 $912.07 $815.61 $815.61 $779.87$1,281.61 $1,281.61 $1,088.60 $1,088.60 $857.50 $857.50 $819.92 $819.92 $876.77 $876.77 $923.98 $923.98 $1,119.57 $1,119.57 $950.96 $950.96 $850.39 $850.39 $813.13$1,326.94 $1,326.94 $1,127.10 $1,127.10 $887.83 $887.83 $848.93 $848.93 $907.78 $907.78 $956.66 $956.66 $1,159.17 $1,159.17 $984.60 $984.60 $880.47 $880.47 $841.89$1,356.69 $1,356.69 $1,152.37 $1,152.37 $907.74 $907.74 $867.96 $867.96 $928.14 $928.14 $978.11 $978.11 $1,185.16 $1,185.16 $1,006.67 $1,006.67 $900.21 $900.21 $860.76$1,394.00 $1,394.00 $1,184.06 $1,184.06 $932.70 $932.70 $891.83 $891.83 $953.66 $953.66 $1,005.01 $1,005.01 $1,217.75 $1,217.75 $1,034.35 $1,034.35 $924.97 $924.97 $884.43$1,416.67 $1,416.67 $1,203.31 $1,203.31 $947.86 $947.86 $906.33 $906.33 $969.16 $969.16 $1,021.35 $1,021.35 $1,237.55 $1,237.55 $1,051.17 $1,051.17 $940.01 $940.01 $898.81

$7,350Yes

75729PAGeisinger Al

25/50M-152-121-

Rating

Geisinger Al

SilMed: $6,75

0$25 /$7,3

Y


SilverMed: $6,750 / Rx: $500

0%$25 / $50


25/50/6750M-152-121-F Rev. 1/20

Rating Area 2

$7,350Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


SilverMed: $6,000 / Rx: $500

0%$30 / $60


30/60/6000M-152-121-F Rev. 1/20

Rating Area 7

$7,350Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


SilverMed: $6,000 / Rx: $500

0%$30 / $60


30/60/6000M-152-121-F Rev. 1/20

Rating Area 5

$7,350Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


SilverMed: $6,000 / Rx: $500

0%$30 / $60


30/60/6000M-152-121-F Rev. 1/20

Rating Area 2

$7,350Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


GoldMed: $2,750 / Rx: $0

0%$25 / $50


25/50/2750M-152-121-F Rev. 1/20

Rating Area 7


RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$229.20 $245.09 $245.09 $258.29 $258.29 $312.96 $312.96 $265.83 $265.83 $290.23 $290.23 $277.51 $277.51 $296.75 $296.75 $312.73 $312.73 $378.93 $378.93$249.57 $266.87 $266.87 $281.24 $281.24 $340.78 $340.78 $289.46 $289.46 $316.03 $316.03 $302.18 $302.18 $323.13 $323.13 $340.53 $340.53 $412.61 $412.61$257.36 $275.20 $275.20 $290.02 $290.02 $351.41 $351.41 $298.49 $298.49 $325.89 $325.89 $311.61 $311.61 $333.21 $333.21 $351.16 $351.16 $425.49 $425.49$265.15 $283.53 $283.53 $298.80 $298.80 $362.05 $362.05 $307.52 $307.52 $335.75 $335.75 $321.04 $321.04 $343.30 $343.30 $361.78 $361.78 $438.37 $438.37$273.54 $292.50 $292.50 $308.25 $308.25 $373.50 $373.50 $317.25 $317.25 $346.38 $346.38 $331.20 $331.20 $354.16 $354.16 $373.23 $373.23 $452.24 $452.24$281.93 $301.47 $301.47 $317.71 $317.71 $384.96 $384.96 $326.98 $326.98 $357.00 $357.00 $341.36 $341.36 $365.02 $365.02 $384.68 $384.68 $466.10 $466.10$290.62 $310.77 $310.77 $327.50 $327.50 $396.82 $396.82 $337.06 $337.06 $368.00 $368.00 $351.88 $351.88 $376.27 $376.27 $396.53 $396.53 $480.47 $480.47$299.61 $320.38 $320.38 $337.63 $337.63 $409.10 $409.10 $347.49 $347.49 $379.39 $379.39 $362.76 $362.76 $387.91 $387.91 $408.80 $408.80 $495.33 $495.33$299.61 $320.38 $320.38 $337.63 $337.63 $409.10 $409.10 $347.49 $347.49 $379.39 $379.39 $362.76 $362.76 $387.91 $387.91 $408.80 $408.80 $495.33 $495.33$299.61 $320.38 $320.38 $337.63 $337.63 $409.10 $409.10 $347.49 $347.49 $379.39 $379.39 $362.76 $362.76 $387.91 $387.91 $408.80 $408.80 $495.33 $495.33$299.61 $320.38 $320.38 $337.63 $337.63 $409.10 $409.10 $347.49 $347.49 $379.39 $379.39 $362.76 $362.76 $387.91 $387.91 $408.80 $408.80 $495.33 $495.33$300.80 $321.66 $321.66 $338.98 $338.98 $410.73 $410.73 $348.88 $348.88 $380.90 $380.90 $364.21 $364.21 $389.46 $389.46 $410.43 $410.43 $497.31 $497.31$306.80 $328.07 $328.07 $345.73 $345.73 $418.91 $418.91 $355.82 $355.82 $388.49 $388.49 $371.46 $371.46 $397.22 $397.22 $418.61 $418.61 $507.22 $507.22$313.99 $335.75 $335.75 $353.83 $353.83 $428.73 $428.73 $364.16 $364.16 $397.59 $397.59 $380.17 $380.17 $406.53 $406.53 $428.42 $428.42 $519.11 $519.11$325.67 $348.25 $348.25 $367.00 $367.00 $444.69 $444.69 $377.72 $377.72 $412.39 $412.39 $394.32 $394.32 $421.66 $421.66 $444.36 $444.36 $538.42 $538.42$335.26 $358.50 $358.50 $377.81 $377.81 $457.78 $457.78 $388.84 $388.84 $424.53 $424.53 $405.93 $405.93 $434.07 $434.07 $457.44 $457.44 $554.27 $554.27$340.05 $363.63 $363.63 $383.21 $383.21 $464.32 $464.32 $394.40 $394.40 $430.60 $430.60 $411.73 $411.73 $440.28 $440.28 $463.98 $463.98 $562.20 $562.20$347.24 $371.32 $371.32 $391.31 $391.31 $474.14 $474.14 $402.74 $402.74 $439.70 $439.70 $420.44 $420.44 $449.59 $449.59 $473.79 $473.79 $574.09 $574.09$354.43 $379.01 $379.01 $399.41 $399.41 $483.96 $483.96 $411.07 $411.07 $448.81 $448.81 $429.14 $429.14 $458.90 $458.90 $483.61 $483.61 $585.97 $585.97$358.93 $383.81 $383.81 $404.48 $404.48 $490.10 $490.10 $416.29 $416.29 $454.50 $454.50 $434.58 $434.58 $464.71 $464.71 $489.74 $489.74 $593.40 $593.40$363.72 $388.94 $388.94 $409.88 $409.88 $496.64 $496.64 $421.85 $421.85 $460.57 $460.57 $440.39 $440.39 $470.92 $470.92 $496.28 $496.28 $601.33 $601.33$366.12 $391.50 $391.50 $412.58 $412.58 $499.92 $499.92 $424.63 $424.63 $463.61 $463.61 $443.29 $443.29 $474.02 $474.02 $499.55 $499.55 $605.29 $605.29$368.51 $394.06 $394.06 $415.28 $415.28 $503.19 $503.19 $427.41 $427.41 $466.64 $466.64 $446.19 $446.19 $477.13 $477.13 $502.82 $502.82 $609.25 $609.25$370.91 $396.63 $396.63 $417.98 $417.98 $506.46 $506.46 $430.19 $430.19 $469.68 $469.68 $449.09 $449.09 $480.23 $480.23 $506.09 $506.09 $613.22 $613.22$373.31 $399.19 $399.19 $420.68 $420.68 $509.73 $509.73 $432.97 $432.97 $472.71 $472.71 $452.00 $452.00 $483.33 $483.33 $509.36 $509.36 $617.18 $617.18$378.10 $404.32 $404.32 $426.09 $426.09 $516.28 $516.28 $438.53 $438.53 $478.78 $478.78 $457.80 $457.80 $489.54 $489.54 $515.90 $515.90 $625.11 $625.11$382.89 $409.44 $409.44 $431.49 $431.49 $522.82 $522.82 $444.09 $444.09 $484.85 $484.85 $463.61 $463.61 $495.75 $495.75 $522.44 $522.44 $633.03 $633.03$390.09 $417.13 $417.13 $439.59 $439.59 $532.64 $532.64 $452.43 $452.43 $493.96 $493.96 $472.31 $472.31 $505.06 $505.06 $532.25 $532.25 $644.92 $644.92$396.98 $424.50 $424.50 $447.36 $447.36 $542.05 $542.05 $460.42 $460.42 $502.68 $502.68 $480.65 $480.65 $513.98 $513.98 $541.65 $541.65 $656.31 $656.31$406.56 $434.75 $434.75 $458.16 $458.16 $555.14 $555.14 $471.54 $471.54 $514.82 $514.82 $492.26 $492.26 $526.39 $526.39 $554.74 $554.74 $672.16 $672.16$418.55 $447.57 $447.57 $471.67 $471.67 $571.51 $571.51 $485.44 $485.44 $530.00 $530.00 $506.77 $506.77 $541.91 $541.91 $571.09 $571.09 $691.97 $691.97$432.63 $462.62 $462.62 $487.53 $487.53 $590.73 $590.73 $501.77 $501.77 $547.83 $547.83 $523.82 $523.82 $560.14 $560.14 $590.30 $590.30 $715.26 $715.26$449.41 $480.56 $480.56 $506.44 $506.44 $613.64 $613.64 $521.23 $521.23 $569.07 $569.07 $544.14 $544.14 $581.86 $581.86 $613.19 $613.19 $742.99 $742.99$468.28 $500.75 $500.75 $527.71 $527.71 $639.42 $639.42 $543.12 $543.12 $592.98 $592.98 $566.99 $566.99 $606.30 $606.30 $638.95 $638.95 $774.20 $774.20$489.85 $523.82 $523.82 $552.02 $552.02 $668.87 $668.87 $568.14 $568.14 $620.29 $620.29 $593.11 $593.11 $634.23 $634.23 $668.38 $668.38 $809.86 $809.86$511.13 $546.56 $546.56 $575.99 $575.99 $697.92 $697.92 $592.81 $592.81 $647.23 $647.23 $618.87 $618.87 $661.77 $661.77 $697.41 $697.41 $845.03 $845.03$535.09 $572.19 $572.19 $603.00 $603.00 $730.65 $730.65 $620.61 $620.61 $677.58 $677.58 $647.89 $647.89 $692.80 $692.80 $730.11 $730.11 $884.66 $884.66$558.76 $597.50 $597.50 $629.68 $629.68 $762.96 $762.96 $648.06 $648.06 $707.55 $707.55 $676.54 $676.54 $723.45 $723.45 $762.40 $762.40 $923.79 $923.79$584.83 $625.37 $625.37 $659.05 $659.05 $798.56 $798.56 $678.29 $678.29 $740.56 $740.56 $708.10 $708.10 $757.20 $757.20 $797.97 $797.97 $966.88 $966.88$611.19 $653.57 $653.57 $688.76 $688.76 $834.56 $834.56 $708.87 $708.87 $773.94 $773.94 $740.03 $740.03 $791.33 $791.33 $833.94 $833.94 $1,010.47 $1,010.47$639.66 $684.00 $684.00 $720.83 $720.83 $873.42 $873.42 $741.88 $741.88 $809.98 $809.98 $774.49 $774.49 $828.18 $828.18 $872.78 $872.78 $1,057.53 $1,057.53$668.12 $714.44 $714.44 $752.91 $752.91 $912.28 $912.28 $774.89 $774.89 $846.02 $846.02 $808.95 $808.95 $865.04 $865.04 $911.61 $911.61 $1,104.58 $1,104.58$698.98 $747.44 $747.44 $787.68 $787.68 $954.42 $954.42 $810.68 $810.68 $885.10 $885.10 $846.32 $846.32 $904.99 $904.99 $953.72 $953.72 $1,155.60 $1,155.60$730.14 $780.76 $780.76 $822.80 $822.80 $996.97 $996.97 $846.82 $846.82 $924.56 $924.56 $884.04 $884.04 $945.33 $945.33 $996.24 $996.24 $1,207.12 $1,207.12$763.39 $816.32 $816.32 $860.27 $860.27 $1,042.38 $1,042.38 $885.39 $885.39 $966.67 $966.67 $924.31 $924.31 $988.39 $988.39 $1,041.61 $1,041.61 $1,262.10 $1,262.10$779.87 $833.94 $833.94 $878.84 $878.84 $1,064.88 $1,064.88 $904.50 $904.50 $987.53 $987.53 $944.26 $944.26 $1,009.73 $1,009.73 $1,064.10 $1,064.10 $1,289.34 $1,289.34$813.13 $869.50 $869.50 $916.32 $916.32 $1,110.29 $1,110.29 $943.07 $943.07 $1,029.65 $1,029.65 $984.53 $984.53 $1,052.78 $1,052.78 $1,109.47 $1,109.47 $1,344.32 $1,344.32$841.89 $900.26 $900.26 $948.73 $948.73 $1,149.56 $1,149.56 $976.43 $976.43 $1,066.07 $1,066.07 $1,019.35 $1,019.35 $1,090.02 $1,090.02 $1,148.72 $1,148.72 $1,391.88 $1,391.88$860.76 $920.44 $920.44 $970.00 $970.00 $1,175.33 $1,175.33 $998.32 $998.32 $1,089.97 $1,089.97 $1,042.20 $1,042.20 $1,114.46 $1,114.46 $1,174.47 $1,174.47 $1,423.08 $1,423.08$884.43 $945.75 $945.75 $996.68 $996.68 $1,207.65 $1,207.65 $1,025.78 $1,025.78 $1,119.94 $1,119.94 $1,070.86 $1,070.86 $1,145.11 $1,145.11 $1,206.77 $1,206.77 $1,462.21 $1,462.21$898.81 $961.13 $961.13 $1,012.88 $1,012.88 $1,227.29 $1,227.29 $1,042.46 $1,042.46 $1,138.15 $1,138.15 $1,088.27 $1,088.27 $1,163.73 $1,163.73 $1,226.39 $1,226.39 $1,485.99 $1,485.99

$2,100Yes




75729PA0050078Geisinger All-Access QHDHP

PPO 2100M-152-122-F Rev. 1/20

Rating Area 7

$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 6




$2,100Yes





PPO 2100M-152-122-F Rev. 1/20

Rating Area 5

$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 3




$2,100Yes





PPO 2100M-152-122-F Rev. 1/20

Rating Area 2

$7,350Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


SilverMed: $6,750 / Rx: $500

0%$25 / $50


25/50/6750M-152-121-F Rev. 1/20

Rating Area 7

$7,350Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


SilverMed: $6,750 / Rx: $500

0%$25 / $50


25/50/6750M-152-121-F Rev. 1/20

Rating Area 5


l-Access PPO

ver0 / Rx: $500%/ $50350es


RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$321.86 $321.86 $252.56 $252.56 $241.49 $241.49 $258.23 $258.23 $272.14 $272.14 $329.74 $329.74 $280.08 $280.08 $331.28 $331.28 $316.76 $316.76 $338.73$350.47 $350.47 $275.00 $275.00 $262.95 $262.95 $281.18 $281.18 $296.33 $296.33 $359.05 $359.05 $304.98 $304.98 $360.73 $360.73 $344.92 $344.92 $368.83$361.41 $361.41 $283.59 $283.59 $271.16 $271.16 $289.96 $289.96 $305.57 $305.57 $370.26 $370.26 $314.50 $314.50 $371.99 $371.99 $355.69 $355.69 $380.35$372.35 $372.35 $292.17 $292.17 $279.37 $279.37 $298.74 $298.74 $314.82 $314.82 $381.46 $381.46 $324.02 $324.02 $383.25 $383.25 $366.45 $366.45 $391.86$384.13 $384.13 $301.42 $301.42 $288.21 $288.21 $308.19 $308.19 $324.78 $324.78 $393.53 $393.53 $334.27 $334.27 $395.37 $395.37 $378.05 $378.05 $404.26$395.91 $395.91 $310.66 $310.66 $297.05 $297.05 $317.64 $317.64 $334.74 $334.74 $405.60 $405.60 $344.52 $344.52 $407.50 $407.50 $389.64 $389.64 $416.65$408.11 $408.11 $320.23 $320.23 $306.20 $306.20 $327.43 $327.43 $345.06 $345.06 $418.10 $418.10 $355.14 $355.14 $420.06 $420.06 $401.65 $401.65 $429.49$420.74 $420.74 $330.14 $330.14 $315.68 $315.68 $337.56 $337.56 $355.74 $355.74 $431.04 $431.04 $366.12 $366.12 $433.05 $433.05 $414.08 $414.08 $442.78$420.74 $420.74 $330.14 $330.14 $315.68 $315.68 $337.56 $337.56 $355.74 $355.74 $431.04 $431.04 $366.12 $366.12 $433.05 $433.05 $414.08 $414.08 $442.78$420.74 $420.74 $330.14 $330.14 $315.68 $315.68 $337.56 $337.56 $355.74 $355.74 $431.04 $431.04 $366.12 $366.12 $433.05 $433.05 $414.08 $414.08 $442.78$420.74 $420.74 $330.14 $330.14 $315.68 $315.68 $337.56 $337.56 $355.74 $355.74 $431.04 $431.04 $366.12 $366.12 $433.05 $433.05 $414.08 $414.08 $442.78$422.41 $422.41 $331.46 $331.46 $316.93 $316.93 $338.91 $338.91 $357.16 $357.16 $432.76 $432.76 $367.58 $367.58 $434.78 $434.78 $415.73 $415.73 $444.55$430.83 $430.83 $338.06 $338.06 $323.25 $323.25 $345.66 $345.66 $364.27 $364.27 $441.38 $441.38 $374.91 $374.91 $443.44 $443.44 $424.01 $424.01 $453.40$440.93 $440.93 $345.98 $345.98 $330.82 $330.82 $353.76 $353.76 $372.81 $372.81 $451.72 $451.72 $383.69 $383.69 $453.83 $453.83 $433.95 $433.95 $464.03$457.34 $457.34 $358.86 $358.86 $343.13 $343.13 $366.92 $366.92 $386.68 $386.68 $468.53 $468.53 $397.97 $397.97 $470.72 $470.72 $450.09 $450.09 $481.30$470.80 $470.80 $369.42 $369.42 $353.24 $353.24 $377.73 $377.73 $398.06 $398.06 $482.33 $482.33 $409.69 $409.69 $484.58 $484.58 $463.34 $463.34 $495.47$477.53 $477.53 $374.71 $374.71 $358.29 $358.29 $383.13 $383.13 $403.76 $403.76 $489.22 $489.22 $415.54 $415.54 $491.51 $491.51 $469.97 $469.97 $502.55$487.63 $487.63 $382.63 $382.63 $365.86 $365.86 $391.23 $391.23 $412.29 $412.29 $499.57 $499.57 $424.33 $424.33 $501.90 $501.90 $479.91 $479.91 $513.18$497.73 $497.73 $390.55 $390.55 $373.44 $373.44 $399.33 $399.33 $420.83 $420.83 $509.91 $509.91 $433.12 $433.12 $512.29 $512.29 $489.85 $489.85 $523.81$504.04 $504.04 $395.50 $395.50 $378.17 $378.17 $404.39 $404.39 $426.17 $426.17 $516.38 $516.38 $438.61 $438.61 $518.79 $518.79 $496.06 $496.06 $530.45$510.77 $510.77 $400.79 $400.79 $383.22 $383.22 $409.79 $409.79 $431.86 $431.86 $523.27 $523.27 $444.47 $444.47 $525.72 $525.72 $502.68 $502.68 $537.53$514.13 $514.13 $403.43 $403.43 $385.75 $385.75 $412.49 $412.49 $434.71 $434.71 $526.72 $526.72 $447.40 $447.40 $529.18 $529.18 $505.99 $505.99 $541.07$517.50 $517.50 $406.07 $406.07 $388.28 $388.28 $415.19 $415.19 $437.55 $437.55 $530.17 $530.17 $450.33 $450.33 $532.65 $532.65 $509.31 $509.31 $544.62$520.87 $520.87 $408.71 $408.71 $390.80 $390.80 $417.89 $417.89 $440.40 $440.40 $533.62 $533.62 $453.26 $453.26 $536.11 $536.11 $512.62 $512.62 $548.16$524.23 $524.23 $411.35 $411.35 $393.33 $393.33 $420.60 $420.60 $443.24 $443.24 $537.07 $537.07 $456.18 $456.18 $539.58 $539.58 $515.93 $515.93 $551.70$530.96 $530.96 $416.63 $416.63 $398.38 $398.38 $426.00 $426.00 $448.93 $448.93 $543.96 $543.96 $462.04 $462.04 $546.50 $546.50 $522.56 $522.56 $558.79$537.69 $537.69 $421.92 $421.92 $403.43 $403.43 $431.40 $431.40 $454.63 $454.63 $550.86 $550.86 $467.90 $467.90 $553.43 $553.43 $529.18 $529.18 $565.87$547.79 $547.79 $429.84 $429.84 $411.00 $411.00 $439.50 $439.50 $463.16 $463.16 $561.21 $561.21 $476.69 $476.69 $563.83 $563.83 $539.12 $539.12 $576.50$557.47 $557.47 $437.43 $437.43 $418.26 $418.26 $447.26 $447.26 $471.35 $471.35 $571.12 $571.12 $485.11 $485.11 $573.79 $573.79 $548.64 $548.64 $586.68$570.93 $570.93 $448.00 $448.00 $428.37 $428.37 $458.06 $458.06 $482.73 $482.73 $584.91 $584.91 $496.82 $496.82 $587.64 $587.64 $561.89 $561.89 $600.85$587.76 $587.76 $461.20 $461.20 $440.99 $440.99 $471.57 $471.57 $496.96 $496.96 $602.15 $602.15 $511.47 $511.47 $604.97 $604.97 $578.46 $578.46 $618.56$607.54 $607.54 $476.72 $476.72 $455.83 $455.83 $487.43 $487.43 $513.68 $513.68 $622.41 $622.41 $528.68 $528.68 $625.32 $625.32 $597.92 $597.92 $639.37$631.10 $631.10 $495.21 $495.21 $473.51 $473.51 $506.33 $506.33 $533.60 $533.60 $646.55 $646.55 $549.18 $549.18 $649.57 $649.57 $621.11 $621.11 $664.17$657.60 $657.60 $516.00 $516.00 $493.39 $493.39 $527.60 $527.60 $556.01 $556.01 $673.71 $673.71 $572.24 $572.24 $676.85 $676.85 $647.19 $647.19 $692.06$687.90 $687.90 $539.77 $539.77 $516.12 $516.12 $551.90 $551.90 $581.62 $581.62 $704.74 $704.74 $598.60 $598.60 $708.03 $708.03 $677.00 $677.00 $723.94$717.77 $717.77 $563.21 $563.21 $538.53 $538.53 $575.87 $575.87 $606.88 $606.88 $735.34 $735.34 $624.60 $624.60 $738.78 $738.78 $706.40 $706.40 $755.38$751.43 $751.43 $589.63 $589.63 $563.79 $563.79 $602.88 $602.88 $635.34 $635.34 $769.83 $769.83 $653.89 $653.89 $773.42 $773.42 $739.53 $739.53 $790.80$784.66 $784.66 $615.71 $615.71 $588.73 $588.73 $629.54 $629.54 $663.44 $663.44 $803.88 $803.88 $682.81 $682.81 $807.63 $807.63 $772.24 $772.24 $825.78$821.27 $821.27 $644.43 $644.43 $616.19 $616.19 $658.91 $658.91 $694.39 $694.39 $841.38 $841.38 $714.66 $714.66 $845.31 $845.31 $808.27 $808.27 $864.30$858.29 $858.29 $673.48 $673.48 $643.97 $643.97 $688.61 $688.61 $725.69 $725.69 $879.31 $879.31 $746.88 $746.88 $883.41 $883.41 $844.70 $844.70 $903.27$898.26 $898.26 $704.84 $704.84 $673.96 $673.96 $720.68 $720.68 $759.49 $759.49 $920.26 $920.26 $781.66 $781.66 $924.55 $924.55 $884.04 $884.04 $945.33$938.23 $938.23 $736.21 $736.21 $703.95 $703.95 $752.75 $752.75 $793.28 $793.28 $961.20 $961.20 $816.44 $816.44 $965.69 $965.69 $923.38 $923.38 $987.39$981.57 $981.57 $770.21 $770.21 $736.46 $736.46 $787.52 $787.52 $829.92 $829.92 $1,005.60 $1,005.60 $854.16 $854.16 $1,010.30 $1,010.30 $966.03 $966.03 $1,033.00

$1,025.32 $1,025.32 $804.55 $804.55 $769.29 $769.29 $822.62 $822.62 $866.92 $866.92 $1,050.43 $1,050.43 $892.23 $892.23 $1,055.33 $1,055.33 $1,009.09 $1,009.09 $1,079.05$1,072.02 $1,072.02 $841.19 $841.19 $804.33 $804.33 $860.09 $860.09 $906.41 $906.41 $1,098.27 $1,098.27 $932.87 $932.87 $1,103.40 $1,103.40 $1,055.05 $1,055.05 $1,128.20$1,095.16 $1,095.16 $859.35 $859.35 $821.69 $821.69 $878.66 $878.66 $925.97 $925.97 $1,121.98 $1,121.98 $953.01 $953.01 $1,127.22 $1,127.22 $1,077.82 $1,077.82 $1,152.55$1,141.87 $1,141.87 $895.99 $895.99 $856.73 $856.73 $916.13 $916.13 $965.46 $965.46 $1,169.82 $1,169.82 $993.65 $993.65 $1,175.29 $1,175.29 $1,123.79 $1,123.79 $1,201.70$1,182.26 $1,182.26 $927.69 $927.69 $887.03 $887.03 $948.53 $948.53 $999.61 $999.61 $1,211.20 $1,211.20 $1,028.79 $1,028.79 $1,216.86 $1,216.86 $1,163.54 $1,163.54 $1,244.21$1,208.76 $1,208.76 $948.49 $948.49 $906.92 $906.92 $969.80 $969.80 $1,022.02 $1,022.02 $1,238.36 $1,238.36 $1,051.86 $1,051.86 $1,244.14 $1,244.14 $1,189.62 $1,189.62 $1,272.10$1,242.00 $1,242.00 $974.57 $974.57 $931.86 $931.86 $996.47 $996.47 $1,050.12 $1,050.12 $1,272.41 $1,272.41 $1,080.78 $1,080.78 $1,278.35 $1,278.35 $1,222.34 $1,222.34 $1,307.08$1,262.19 $1,262.19 $990.41 $990.41 $947.01 $947.01 $1,012.67 $1,012.67 $1,067.20 $1,067.20 $1,293.10 $1,293.10 $1,098.36 $1,098.36 $1,299.14 $1,299.14 $1,242.21 $1,242.21 $1,328.33

$7,3Y

Geisinger Al

PlatiMed: $25

0$15 /

75729PAGeisinger Al

15/30M-152-121-

Rating

$7,350Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 3


PlatinumMed: $250 / Rx: $0

0%$15 / $30$7,350

Yes



0%$15 / $30


15/30/250M-152-121-F Rev. 1/20

Rating Area 2

$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 9


SilverCombined: $4,100


$4,100Yes





PPO 4100M-152-122-F Rev. 1/20

Rating Area 7

$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 6




$4,100Yes





PPO 4100M-152-122-F Rev. 1/20

Rating Area 5

$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 3




$4,100Yes





PPO 4100M-152-122-F Rev. 1/20

Rating Area 2


PPO 2100M-152-122-F Rev. 1/20

Rating Area 9




$2,100Yes


RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$338.73 $356.96 $356.96 $432.53 $432.53 $367.39 $367.39 $312.13 $312.13 $351.74 $351.74 $362.01 $362.01 $269.96 $269.96 $258.13 $258.13 $276.03 $276.03$368.83 $388.69 $388.69 $470.97 $470.97 $400.04 $400.04 $339.88 $339.88 $383.01 $383.01 $394.19 $394.19 $293.96 $293.96 $281.07 $281.07 $300.56 $300.56$380.35 $400.83 $400.83 $485.67 $485.67 $412.53 $412.53 $350.49 $350.49 $394.97 $394.97 $406.50 $406.50 $303.13 $303.13 $289.85 $289.85 $309.94 $309.94$391.86 $412.96 $412.96 $500.37 $500.37 $425.02 $425.02 $361.09 $361.09 $406.92 $406.92 $418.80 $418.80 $312.31 $312.31 $298.62 $298.62 $319.32 $319.32$404.26 $426.02 $426.02 $516.20 $516.20 $438.46 $438.46 $372.52 $372.52 $419.79 $419.79 $432.05 $432.05 $322.19 $322.19 $308.07 $308.07 $329.43 $329.43$416.65 $439.09 $439.09 $532.03 $532.03 $451.91 $451.91 $383.94 $383.94 $432.67 $432.67 $445.30 $445.30 $332.07 $332.07 $317.52 $317.52 $339.53 $339.53$429.49 $452.62 $452.62 $548.43 $548.43 $465.84 $465.84 $395.77 $395.77 $446.00 $446.00 $459.02 $459.02 $342.30 $342.30 $327.30 $327.30 $349.99 $349.99$442.78 $466.62 $466.62 $565.40 $565.40 $480.25 $480.25 $408.02 $408.02 $459.80 $459.80 $473.23 $473.23 $352.89 $352.89 $337.43 $337.43 $360.82 $360.82$442.78 $466.62 $466.62 $565.40 $565.40 $480.25 $480.25 $408.02 $408.02 $459.80 $459.80 $473.23 $473.23 $352.89 $352.89 $337.43 $337.43 $360.82 $360.82$442.78 $466.62 $466.62 $565.40 $565.40 $480.25 $480.25 $408.02 $408.02 $459.80 $459.80 $473.23 $473.23 $352.89 $352.89 $337.43 $337.43 $360.82 $360.82$442.78 $466.62 $466.62 $565.40 $565.40 $480.25 $480.25 $408.02 $408.02 $459.80 $459.80 $473.23 $473.23 $352.89 $352.89 $337.43 $337.43 $360.82 $360.82$444.55 $468.49 $468.49 $567.65 $567.65 $482.16 $482.16 $409.65 $409.65 $461.64 $461.64 $475.11 $475.11 $354.30 $354.30 $338.77 $338.77 $362.26 $362.26$453.40 $477.82 $477.82 $578.96 $578.96 $491.77 $491.77 $417.81 $417.81 $470.83 $470.83 $484.58 $484.58 $361.36 $361.36 $345.52 $345.52 $369.48 $369.48$464.03 $489.02 $489.02 $592.53 $592.53 $503.30 $503.30 $427.60 $427.60 $481.87 $481.87 $495.94 $495.94 $369.83 $369.83 $353.62 $353.62 $378.14 $378.14$481.30 $507.22 $507.22 $614.58 $614.58 $522.02 $522.02 $443.51 $443.51 $499.80 $499.80 $514.39 $514.39 $383.59 $383.59 $366.78 $366.78 $392.21 $392.21$495.47 $522.15 $522.15 $632.67 $632.67 $537.39 $537.39 $456.57 $456.57 $514.51 $514.51 $529.53 $529.53 $394.88 $394.88 $377.58 $377.58 $403.76 $403.76$502.55 $529.61 $529.61 $641.72 $641.72 $545.08 $545.08 $463.10 $463.10 $521.87 $521.87 $537.11 $537.11 $400.53 $400.53 $382.98 $382.98 $409.53 $409.53$513.18 $540.81 $540.81 $655.29 $655.29 $556.60 $556.60 $472.89 $472.89 $532.90 $532.90 $548.46 $548.46 $409.00 $409.00 $391.08 $391.08 $418.19 $418.19$523.81 $552.01 $552.01 $668.86 $668.86 $568.13 $568.13 $482.68 $482.68 $543.94 $543.94 $559.82 $559.82 $417.47 $417.47 $399.17 $399.17 $426.85 $426.85$530.45 $559.01 $559.01 $677.34 $677.34 $575.33 $575.33 $488.80 $488.80 $550.84 $550.84 $566.92 $566.92 $422.76 $422.76 $404.24 $404.24 $432.26 $432.26$537.53 $566.48 $566.48 $686.39 $686.39 $583.02 $583.02 $495.33 $495.33 $558.19 $558.19 $574.49 $574.49 $428.41 $428.41 $409.63 $409.63 $438.03 $438.03$541.07 $570.21 $570.21 $690.91 $690.91 $586.86 $586.86 $498.59 $498.59 $561.87 $561.87 $578.28 $578.28 $431.23 $431.23 $412.33 $412.33 $440.92 $440.92$544.62 $573.94 $573.94 $695.43 $695.43 $590.70 $590.70 $501.86 $501.86 $565.55 $565.55 $582.06 $582.06 $434.05 $434.05 $415.03 $415.03 $443.81 $443.81$548.16 $577.68 $577.68 $699.96 $699.96 $594.54 $594.54 $505.12 $505.12 $569.23 $569.23 $585.85 $585.85 $436.88 $436.88 $417.73 $417.73 $446.69 $446.69$551.70 $581.41 $581.41 $704.48 $704.48 $598.38 $598.38 $508.39 $508.39 $572.91 $572.91 $589.63 $589.63 $439.70 $439.70 $420.43 $420.43 $449.58 $449.58$558.79 $588.87 $588.87 $713.53 $713.53 $606.07 $606.07 $514.92 $514.92 $580.26 $580.26 $597.21 $597.21 $445.35 $445.35 $425.83 $425.83 $455.35 $455.35$565.87 $596.34 $596.34 $722.57 $722.57 $613.75 $613.75 $521.44 $521.44 $587.62 $587.62 $604.78 $604.78 $450.99 $450.99 $431.23 $431.23 $461.13 $461.13$576.50 $607.54 $607.54 $736.14 $736.14 $625.28 $625.28 $531.24 $531.24 $598.65 $598.65 $616.13 $616.13 $459.46 $459.46 $439.33 $439.33 $469.79 $469.79$586.68 $618.27 $618.27 $749.15 $749.15 $636.32 $636.32 $540.62 $540.62 $609.23 $609.23 $627.02 $627.02 $467.58 $467.58 $447.09 $447.09 $478.08 $478.08$600.85 $633.20 $633.20 $767.24 $767.24 $651.69 $651.69 $553.68 $553.68 $623.94 $623.94 $642.16 $642.16 $478.87 $478.87 $457.89 $457.89 $489.63 $489.63$618.56 $651.87 $651.87 $789.85 $789.85 $670.90 $670.90 $570.00 $570.00 $642.34 $642.34 $661.09 $661.09 $492.99 $492.99 $471.38 $471.38 $504.06 $504.06$639.37 $673.80 $673.80 $816.43 $816.43 $693.47 $693.47 $589.17 $589.17 $663.95 $663.95 $683.33 $683.33 $509.57 $509.57 $487.24 $487.24 $521.02 $521.02$664.17 $699.93 $699.93 $848.09 $848.09 $720.37 $720.37 $612.02 $612.02 $689.69 $689.69 $709.83 $709.83 $529.33 $529.33 $506.14 $506.14 $541.23 $541.23$692.06 $729.33 $729.33 $883.71 $883.71 $750.62 $750.62 $637.73 $637.73 $718.66 $718.66 $739.64 $739.64 $551.56 $551.56 $527.40 $527.40 $563.96 $563.96$723.94 $762.92 $762.92 $924.42 $924.42 $785.20 $785.20 $667.11 $667.11 $751.77 $751.77 $773.72 $773.72 $576.97 $576.97 $551.69 $551.69 $589.94 $589.94$755.38 $796.05 $796.05 $964.56 $964.56 $819.30 $819.30 $696.07 $696.07 $784.41 $784.41 $807.32 $807.32 $602.03 $602.03 $575.65 $575.65 $615.56 $615.56$790.80 $833.38 $833.38 $1,009.79 $1,009.79 $857.72 $857.72 $728.72 $728.72 $821.20 $821.20 $845.17 $845.17 $630.26 $630.26 $602.64 $602.64 $644.42 $644.42$825.78 $870.25 $870.25 $1,054.46 $1,054.46 $895.65 $895.65 $760.95 $760.95 $857.52 $857.52 $882.56 $882.56 $658.14 $658.14 $629.30 $629.30 $672.93 $672.93$864.30 $910.84 $910.84 $1,103.65 $1,103.65 $937.44 $937.44 $796.45 $796.45 $897.52 $897.52 $923.73 $923.73 $688.84 $688.84 $658.65 $658.65 $704.32 $704.32$903.27 $951.90 $951.90 $1,153.40 $1,153.40 $979.70 $979.70 $832.35 $832.35 $937.98 $937.98 $965.37 $965.37 $719.89 $719.89 $688.35 $688.35 $736.07 $736.07$945.33 $996.23 $996.23 $1,207.11 $1,207.11 $1,025.32 $1,025.32 $871.11 $871.11 $981.67 $981.67 $1,010.33 $1,010.33 $753.42 $753.42 $720.40 $720.40 $770.35 $770.35$987.39 $1,040.56 $1,040.56 $1,260.83 $1,260.83 $1,070.94 $1,070.94 $909.87 $909.87 $1,025.35 $1,025.35 $1,055.28 $1,055.28 $786.94 $786.94 $752.46 $752.46 $804.63 $804.63

$1,033.00 $1,088.62 $1,088.62 $1,319.06 $1,319.06 $1,120.41 $1,120.41 $951.90 $951.90 $1,072.70 $1,072.70 $1,104.02 $1,104.02 $823.29 $823.29 $787.21 $787.21 $841.79 $841.79$1,079.05 $1,137.15 $1,137.15 $1,377.86 $1,377.86 $1,170.35 $1,170.35 $994.33 $994.33 $1,120.52 $1,120.52 $1,153.24 $1,153.24 $859.99 $859.99 $822.30 $822.30 $879.32 $879.32$1,128.20 $1,188.95 $1,188.95 $1,440.62 $1,440.62 $1,223.66 $1,223.66 $1,039.62 $1,039.62 $1,171.56 $1,171.56 $1,205.77 $1,205.77 $899.16 $899.16 $859.76 $859.76 $919.37 $919.37$1,152.55 $1,214.61 $1,214.61 $1,471.72 $1,471.72 $1,250.07 $1,250.07 $1,062.06 $1,062.06 $1,196.85 $1,196.85 $1,231.79 $1,231.79 $918.57 $918.57 $878.32 $878.32 $939.21 $939.21$1,201.70 $1,266.41 $1,266.41 $1,534.48 $1,534.48 $1,303.38 $1,303.38 $1,107.35 $1,107.35 $1,247.89 $1,247.89 $1,284.32 $1,284.32 $957.74 $957.74 $915.77 $915.77 $979.26 $979.26$1,244.21 $1,311.20 $1,311.20 $1,588.75 $1,588.75 $1,349.48 $1,349.48 $1,146.52 $1,146.52 $1,292.03 $1,292.03 $1,329.75 $1,329.75 $991.62 $991.62 $948.16 $948.16 $1,013.90 $1,013.90$1,272.10 $1,340.60 $1,340.60 $1,624.37 $1,624.37 $1,379.74 $1,379.74 $1,172.23 $1,172.23 $1,321.00 $1,321.00 $1,359.56 $1,359.56 $1,013.85 $1,013.85 $969.42 $969.42 $1,036.63 $1,036.63$1,307.08 $1,377.46 $1,377.46 $1,669.04 $1,669.04 $1,417.68 $1,417.68 $1,204.46 $1,204.46 $1,357.32 $1,357.32 $1,396.95 $1,396.95 $1,041.73 $1,041.73 $996.08 $996.08 $1,065.14 $1,065.14$1,328.33 $1,399.86 $1,399.86 $1,696.18 $1,696.18 $1,440.73 $1,440.73 $1,224.05 $1,224.05 $1,379.39 $1,379.39 $1,419.66 $1,419.66 $1,058.67 $1,058.67 $1,012.27 $1,012.27 $1,082.46 $1,082.46

$7,350Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


GoldMed: $3,500 / Rx: $0

0%$30 / $60


30/60/3500M-152-121-F Rev. 1/20

Rating Area 3

$2,250Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes



0%$40 / $40

75729PA0050082Geisinger Extra PPO

10/40/250M-152-243-F Rev. 1/20

Rating Area 9

$2,250Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 6



0%$40 / $40$2,250

Yes



0%$40 / $40


10/40/250M-152-243-F Rev. 1/20

Rating Area 3

$7,350Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$7,350

Yes



0%$15 / $30


15/30/250M-152-121-F Rev. 1/20

Rating Area 7

350es


15/30/250M-152-121-F Rev. 1/20

Rating Area 6



0%$15 / $30$7,350

Yes

l-Access PPO

num0 / Rx: $0%/ $30

A0050080l-Access PPO 0/250-F Rev. 1/20Area 5


RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$290.89 $290.89 $352.46 $352.46 $299.38 $299.38 $249.33 $249.33 $280.97 $280.97 $289.18 $289.18 $301.36 $301.36 $288.15 $288.15 $308.13 $308.13 $324.72$316.75 $316.75 $383.79 $383.79 $325.99 $325.99 $271.49 $271.49 $305.95 $305.95 $314.88 $314.88 $328.15 $328.15 $313.77 $313.77 $335.52 $335.52 $353.59$326.63 $326.63 $395.77 $395.77 $336.17 $336.17 $279.97 $279.97 $315.50 $315.50 $324.71 $324.71 $338.39 $338.39 $323.56 $323.56 $345.99 $345.99 $364.62$336.52 $336.52 $407.75 $407.75 $346.34 $346.34 $288.44 $288.44 $325.05 $325.05 $334.54 $334.54 $348.63 $348.63 $333.35 $333.35 $356.46 $356.46 $375.66$347.17 $347.17 $420.65 $420.65 $357.30 $357.30 $297.57 $297.57 $335.33 $335.33 $345.12 $345.12 $359.66 $359.66 $343.90 $343.90 $367.74 $367.74 $387.54$357.81 $357.81 $433.55 $433.55 $368.26 $368.26 $306.69 $306.69 $345.61 $345.61 $355.70 $355.70 $370.69 $370.69 $354.45 $354.45 $379.02 $379.02 $399.43$368.84 $368.84 $446.92 $446.92 $379.61 $379.61 $316.14 $316.14 $356.27 $356.27 $366.67 $366.67 $382.11 $382.11 $365.37 $365.37 $390.70 $390.70 $411.74$380.25 $380.25 $460.74 $460.74 $391.35 $391.35 $325.93 $325.93 $367.29 $367.29 $378.01 $378.01 $393.94 $393.94 $376.67 $376.67 $402.79 $402.79 $424.48$380.25 $380.25 $460.74 $460.74 $391.35 $391.35 $325.93 $325.93 $367.29 $367.29 $378.01 $378.01 $393.94 $393.94 $376.67 $376.67 $402.79 $402.79 $424.48$380.25 $380.25 $460.74 $460.74 $391.35 $391.35 $325.93 $325.93 $367.29 $367.29 $378.01 $378.01 $393.94 $393.94 $376.67 $376.67 $402.79 $402.79 $424.48$380.25 $380.25 $460.74 $460.74 $391.35 $391.35 $325.93 $325.93 $367.29 $367.29 $378.01 $378.01 $393.94 $393.94 $376.67 $376.67 $402.79 $402.79 $424.48$381.77 $381.77 $462.58 $462.58 $392.91 $392.91 $327.22 $327.22 $368.75 $368.75 $379.52 $379.52 $395.51 $395.51 $378.18 $378.18 $404.40 $404.40 $426.17$389.37 $389.37 $471.80 $471.80 $400.74 $400.74 $333.74 $333.74 $376.10 $376.10 $387.08 $387.08 $403.39 $403.39 $385.71 $385.71 $412.45 $412.45 $434.66$398.50 $398.50 $482.85 $482.85 $410.13 $410.13 $341.57 $341.57 $384.91 $384.91 $396.15 $396.15 $412.84 $412.84 $394.75 $394.75 $422.12 $422.12 $444.85$413.33 $413.33 $500.82 $500.82 $425.40 $425.40 $354.28 $354.28 $399.24 $399.24 $410.89 $410.89 $428.20 $428.20 $409.44 $409.44 $437.83 $437.83 $461.40$425.50 $425.50 $515.57 $515.57 $437.92 $437.92 $364.71 $364.71 $410.99 $410.99 $422.99 $422.99 $440.81 $440.81 $421.49 $421.49 $450.72 $450.72 $474.98$431.58 $431.58 $522.94 $522.94 $444.18 $444.18 $369.92 $369.92 $416.87 $416.87 $429.04 $429.04 $447.11 $447.11 $427.52 $427.52 $457.16 $457.16 $481.78$440.71 $440.71 $533.99 $533.99 $453.57 $453.57 $377.74 $377.74 $425.68 $425.68 $438.11 $438.11 $456.57 $456.57 $436.56 $436.56 $466.83 $466.83 $491.96$449.83 $449.83 $545.05 $545.05 $462.97 $462.97 $385.56 $385.56 $434.50 $434.50 $447.18 $447.18 $466.02 $466.02 $445.60 $445.60 $476.49 $476.49 $502.15$455.54 $455.54 $551.96 $551.96 $468.84 $468.84 $390.45 $390.45 $440.01 $440.01 $452.85 $452.85 $471.93 $471.93 $451.25 $451.25 $482.54 $482.54 $508.52$461.62 $461.62 $559.34 $559.34 $475.10 $475.10 $395.67 $395.67 $445.88 $445.88 $458.90 $458.90 $478.23 $478.23 $457.28 $457.28 $488.98 $488.98 $515.31$464.66 $464.66 $563.02 $563.02 $478.23 $478.23 $398.28 $398.28 $448.82 $448.82 $461.92 $461.92 $481.38 $481.38 $460.29 $460.29 $492.20 $492.20 $518.71$467.70 $467.70 $566.71 $566.71 $481.36 $481.36 $400.88 $400.88 $451.76 $451.76 $464.95 $464.95 $484.54 $484.54 $463.30 $463.30 $495.42 $495.42 $522.10$470.75 $470.75 $570.39 $570.39 $484.49 $484.49 $403.49 $403.49 $454.70 $454.70 $467.97 $467.97 $487.69 $487.69 $466.32 $466.32 $498.65 $498.65 $525.50$473.79 $473.79 $574.08 $574.08 $487.62 $487.62 $406.10 $406.10 $457.64 $457.64 $471.00 $471.00 $490.84 $490.84 $469.33 $469.33 $501.87 $501.87 $528.89$479.87 $479.87 $581.45 $581.45 $493.88 $493.88 $411.31 $411.31 $463.51 $463.51 $477.05 $477.05 $497.14 $497.14 $475.36 $475.36 $508.31 $508.31 $535.68$485.96 $485.96 $588.82 $588.82 $500.14 $500.14 $416.53 $416.53 $469.39 $469.39 $483.09 $483.09 $503.44 $503.44 $481.38 $481.38 $514.76 $514.76 $542.48$495.08 $495.08 $599.88 $599.88 $509.54 $509.54 $424.35 $424.35 $478.20 $478.20 $492.17 $492.17 $512.90 $512.90 $490.42 $490.42 $524.43 $524.43 $552.66$503.83 $503.83 $610.48 $610.48 $518.54 $518.54 $431.85 $431.85 $486.65 $486.65 $500.86 $500.86 $521.96 $521.96 $499.09 $499.09 $533.69 $533.69 $562.43$516.00 $516.00 $625.22 $625.22 $531.06 $531.06 $442.27 $442.27 $498.40 $498.40 $512.96 $512.96 $534.57 $534.57 $511.14 $511.14 $546.58 $546.58 $576.01$531.21 $531.21 $643.65 $643.65 $546.72 $546.72 $455.31 $455.31 $513.10 $513.10 $528.08 $528.08 $550.32 $550.32 $526.21 $526.21 $562.69 $562.69 $592.99$549.08 $549.08 $665.31 $665.31 $565.11 $565.11 $470.63 $470.63 $530.36 $530.36 $545.84 $545.84 $568.84 $568.84 $543.91 $543.91 $581.62 $581.62 $612.94$570.37 $570.37 $691.11 $691.11 $587.02 $587.02 $488.88 $488.88 $550.93 $550.93 $567.01 $567.01 $590.90 $590.90 $565.00 $565.00 $604.18 $604.18 $636.71$594.33 $594.33 $720.13 $720.13 $611.68 $611.68 $509.41 $509.41 $574.06 $574.06 $590.83 $590.83 $615.72 $615.72 $588.73 $588.73 $629.55 $629.55 $663.45$621.70 $621.70 $753.31 $753.31 $639.86 $639.86 $532.88 $532.88 $600.51 $600.51 $618.04 $618.04 $644.08 $644.08 $615.85 $615.85 $658.55 $658.55 $694.01$648.70 $648.70 $786.02 $786.02 $667.64 $667.64 $556.02 $556.02 $626.59 $626.59 $644.88 $644.88 $672.05 $672.05 $642.60 $642.60 $687.15 $687.15 $724.15$679.12 $679.12 $822.88 $822.88 $698.95 $698.95 $582.10 $582.10 $655.97 $655.97 $675.12 $675.12 $703.56 $703.56 $672.73 $672.73 $719.37 $719.37 $758.11$709.16 $709.16 $859.28 $859.28 $729.87 $729.87 $607.84 $607.84 $684.98 $684.98 $704.98 $704.98 $734.68 $734.68 $702.49 $702.49 $751.19 $751.19 $791.64$742.24 $742.24 $899.36 $899.36 $763.91 $763.91 $636.20 $636.20 $716.94 $716.94 $737.87 $737.87 $768.95 $768.95 $735.26 $735.26 $786.23 $786.23 $828.57$775.70 $775.70 $939.90 $939.90 $798.35 $798.35 $664.88 $664.88 $749.26 $749.26 $771.13 $771.13 $803.62 $803.62 $768.41 $768.41 $821.68 $821.68 $865.92$811.83 $811.83 $983.67 $983.67 $835.53 $835.53 $695.84 $695.84 $784.15 $784.15 $807.05 $807.05 $841.04 $841.04 $804.19 $804.19 $859.94 $859.94 $906.25$847.95 $847.95 $1,027.44 $1,027.44 $872.71 $872.71 $726.80 $726.80 $819.04 $819.04 $842.96 $842.96 $878.47 $878.47 $839.97 $839.97 $898.21 $898.21 $946.57$887.12 $887.12 $1,074.90 $1,074.90 $913.02 $913.02 $760.37 $760.37 $856.87 $856.87 $881.89 $881.89 $919.04 $919.04 $878.77 $878.77 $939.70 $939.70 $990.29$926.66 $926.66 $1,122.82 $1,122.82 $953.72 $953.72 $794.27 $794.27 $895.07 $895.07 $921.20 $921.20 $960.01 $960.01 $917.94 $917.94 $981.59 $981.59 $1,034.44$968.87 $968.87 $1,173.96 $1,173.96 $997.16 $997.16 $830.45 $830.45 $935.84 $935.84 $963.16 $963.16 $1,003.74 $1,003.74 $959.75 $959.75 $1,026.29 $1,026.29 $1,081.56$989.78 $989.78 $1,199.30 $1,199.30 $1,018.68 $1,018.68 $848.37 $848.37 $956.04 $956.04 $983.95 $983.95 $1,025.40 $1,025.40 $980.47 $980.47 $1,048.45 $1,048.45 $1,104.90

$1,031.99 $1,031.99 $1,250.44 $1,250.44 $1,062.12 $1,062.12 $884.55 $884.55 $996.81 $996.81 $1,025.91 $1,025.91 $1,069.13 $1,069.13 $1,022.28 $1,022.28 $1,093.16 $1,093.16 $1,152.02$1,068.50 $1,068.50 $1,294.67 $1,294.67 $1,099.69 $1,099.69 $915.84 $915.84 $1,032.07 $1,032.07 $1,062.20 $1,062.20 $1,106.95 $1,106.95 $1,058.44 $1,058.44 $1,131.82 $1,131.82 $1,192.77$1,092.45 $1,092.45 $1,323.70 $1,323.70 $1,124.35 $1,124.35 $936.37 $936.37 $1,055.21 $1,055.21 $1,086.01 $1,086.01 $1,131.77 $1,131.77 $1,082.17 $1,082.17 $1,157.20 $1,157.20 $1,219.51$1,122.49 $1,122.49 $1,360.10 $1,360.10 $1,155.26 $1,155.26 $962.12 $962.12 $1,084.22 $1,084.22 $1,115.88 $1,115.88 $1,162.89 $1,162.89 $1,111.93 $1,111.93 $1,189.02 $1,189.02 $1,253.04$1,140.74 $1,140.74 $1,382.21 $1,382.21 $1,174.05 $1,174.05 $977.76 $977.76 $1,101.85 $1,101.85 $1,134.02 $1,134.02 $1,181.80 $1,181.80 $1,130.01 $1,130.01 $1,208.35 $1,208.35 $1,273.42

$8,150Yes

75729PAGeisinger Al

20/40M-152-121-

Rating

Geisinger Al

GoMed: $50

0$20 /$8,1

Y



0%$20 / $40


20/40/500M-152-121-F Rev. 1/20

Rating Area 5

$8,150Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 3



0%$20 / $40$8,150

Yes



0%$20 / $40


20/40/500M-152-121-F Rev. 1/20

Rating Area 2

$7,350Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


GoldMed: $3,500 / Rx: $0

0%$60 / $60


20/60/3500M-152-243-F Rev. 1/20

Rating Area 6

$7,350Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


GoldMed: $3,500 / Rx: $0

0%$30 / $60


30/60/3500M-152-121-F Rev. 1/20

Rating Area 9

$7,350Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


GoldMed: $3,500 / Rx: $0

0%$30 / $60


30/60/3500M-152-121-F Rev. 1/20

Rating Area 6


RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$324.72 $393.46 $393.46 $334.20 $334.20 $286.17 $286.17 $273.63 $273.63 $292.60 $292.60 $308.36 $308.36 $373.63 $373.63 $317.36 $317.36 $280.61 $280.61$353.59 $428.43 $428.43 $363.91 $363.91 $311.61 $311.61 $297.95 $297.95 $318.61 $318.61 $335.77 $335.77 $406.84 $406.84 $345.57 $345.57 $305.55 $305.55$364.62 $441.80 $441.80 $375.27 $375.27 $321.34 $321.34 $307.25 $307.25 $328.56 $328.56 $346.25 $346.25 $419.54 $419.54 $356.36 $356.36 $315.09 $315.09$375.66 $455.18 $455.18 $386.63 $386.63 $331.06 $331.06 $316.55 $316.55 $338.50 $338.50 $356.73 $356.73 $432.24 $432.24 $367.14 $367.14 $324.62 $324.62$387.54 $469.58 $469.58 $398.86 $398.86 $341.54 $341.54 $326.57 $326.57 $349.21 $349.21 $368.01 $368.01 $445.91 $445.91 $378.76 $378.76 $334.89 $334.89$399.43 $483.98 $483.98 $411.09 $411.09 $352.01 $352.01 $336.58 $336.58 $359.92 $359.92 $379.30 $379.30 $459.59 $459.59 $390.37 $390.37 $345.16 $345.16$411.74 $498.89 $498.89 $423.76 $423.76 $362.86 $362.86 $346.96 $346.96 $371.01 $371.01 $390.99 $390.99 $473.75 $473.75 $402.41 $402.41 $355.80 $355.80$424.48 $514.33 $514.33 $436.87 $436.87 $374.09 $374.09 $357.69 $357.69 $382.49 $382.49 $403.09 $403.09 $488.41 $488.41 $414.86 $414.86 $366.81 $366.81$424.48 $514.33 $514.33 $436.87 $436.87 $374.09 $374.09 $357.69 $357.69 $382.49 $382.49 $403.09 $403.09 $488.41 $488.41 $414.86 $414.86 $366.81 $366.81$424.48 $514.33 $514.33 $436.87 $436.87 $374.09 $374.09 $357.69 $357.69 $382.49 $382.49 $403.09 $403.09 $488.41 $488.41 $414.86 $414.86 $366.81 $366.81$424.48 $514.33 $514.33 $436.87 $436.87 $374.09 $374.09 $357.69 $357.69 $382.49 $382.49 $403.09 $403.09 $488.41 $488.41 $414.86 $414.86 $366.81 $366.81$426.17 $516.38 $516.38 $438.61 $438.61 $375.58 $375.58 $359.12 $359.12 $384.02 $384.02 $404.69 $404.69 $490.36 $490.36 $416.51 $416.51 $368.27 $368.27$434.66 $526.67 $526.67 $447.35 $447.35 $383.06 $383.06 $366.27 $366.27 $391.67 $391.67 $412.76 $412.76 $500.13 $500.13 $424.81 $424.81 $375.61 $375.61$444.85 $539.01 $539.01 $457.84 $457.84 $392.04 $392.04 $374.86 $374.86 $400.85 $400.85 $422.43 $422.43 $511.85 $511.85 $434.76 $434.76 $384.41 $384.41$461.40 $559.07 $559.07 $474.87 $474.87 $406.63 $406.63 $388.81 $388.81 $415.76 $415.76 $438.15 $438.15 $530.90 $530.90 $450.94 $450.94 $398.72 $398.72$474.98 $575.53 $575.53 $488.85 $488.85 $418.60 $418.60 $400.25 $400.25 $428.00 $428.00 $451.05 $451.05 $546.53 $546.53 $464.22 $464.22 $410.46 $410.46$481.78 $583.76 $583.76 $495.84 $495.84 $424.58 $424.58 $405.98 $405.98 $434.12 $434.12 $457.50 $457.50 $554.34 $554.34 $470.86 $470.86 $416.32 $416.32$491.96 $596.10 $596.10 $506.33 $506.33 $433.56 $433.56 $414.56 $414.56 $443.30 $443.30 $467.17 $467.17 $566.06 $566.06 $480.81 $480.81 $425.13 $425.13$502.15 $608.45 $608.45 $516.81 $516.81 $442.54 $442.54 $423.14 $423.14 $452.48 $452.48 $476.85 $476.85 $577.78 $577.78 $490.77 $490.77 $433.93 $433.93$508.52 $616.16 $616.16 $523.37 $523.37 $448.15 $448.15 $428.51 $428.51 $458.22 $458.22 $482.89 $482.89 $585.11 $585.11 $496.99 $496.99 $439.43 $439.43$515.31 $624.39 $624.39 $530.36 $530.36 $454.13 $454.13 $434.23 $434.23 $464.34 $464.34 $489.34 $489.34 $592.92 $592.92 $503.63 $503.63 $445.30 $445.30$518.71 $628.50 $628.50 $533.85 $533.85 $457.13 $457.13 $437.09 $437.09 $467.40 $467.40 $492.57 $492.57 $596.83 $596.83 $506.95 $506.95 $448.24 $448.24$522.10 $632.62 $632.62 $537.35 $537.35 $460.12 $460.12 $439.96 $439.96 $470.46 $470.46 $495.79 $495.79 $600.74 $600.74 $510.27 $510.27 $451.17 $451.17$525.50 $636.73 $636.73 $540.84 $540.84 $463.11 $463.11 $442.82 $442.82 $473.52 $473.52 $499.02 $499.02 $604.65 $604.65 $513.59 $513.59 $454.11 $454.11$528.89 $640.85 $640.85 $544.33 $544.33 $466.10 $466.10 $445.68 $445.68 $476.58 $476.58 $502.24 $502.24 $608.55 $608.55 $516.90 $516.90 $457.04 $457.04$535.68 $649.08 $649.08 $551.32 $551.32 $472.09 $472.09 $451.40 $451.40 $482.70 $482.70 $508.69 $508.69 $616.37 $616.37 $523.54 $523.54 $462.91 $462.91$542.48 $657.31 $657.31 $558.31 $558.31 $478.07 $478.07 $457.13 $457.13 $488.82 $488.82 $515.14 $515.14 $624.18 $624.18 $530.18 $530.18 $468.78 $468.78$552.66 $669.65 $669.65 $568.80 $568.80 $487.05 $487.05 $465.71 $465.71 $498.00 $498.00 $524.81 $524.81 $635.90 $635.90 $540.14 $540.14 $477.58 $477.58$562.43 $681.48 $681.48 $578.85 $578.85 $495.66 $495.66 $473.94 $473.94 $506.79 $506.79 $534.08 $534.08 $647.14 $647.14 $549.68 $549.68 $486.02 $486.02$576.01 $697.94 $697.94 $592.83 $592.83 $507.63 $507.63 $485.38 $485.38 $519.03 $519.03 $546.98 $546.98 $662.77 $662.77 $562.95 $562.95 $497.76 $497.76$592.99 $718.51 $718.51 $610.30 $610.30 $522.59 $522.59 $499.69 $499.69 $534.33 $534.33 $563.11 $563.11 $682.30 $682.30 $579.55 $579.55 $512.43 $512.43$612.94 $742.68 $742.68 $630.83 $630.83 $540.17 $540.17 $516.50 $516.50 $552.31 $552.31 $582.05 $582.05 $705.26 $705.26 $599.04 $599.04 $529.67 $529.67$636.71 $771.49 $771.49 $655.30 $655.30 $561.12 $561.12 $536.53 $536.53 $573.73 $573.73 $604.62 $604.62 $732.61 $732.61 $622.28 $622.28 $550.21 $550.21$663.45 $803.89 $803.89 $682.82 $682.82 $584.69 $584.69 $559.07 $559.07 $597.83 $597.83 $630.02 $630.02 $763.38 $763.38 $648.41 $648.41 $573.32 $573.32$694.01 $840.92 $840.92 $714.28 $714.28 $611.62 $611.62 $584.82 $584.82 $625.37 $625.37 $659.04 $659.04 $798.54 $798.54 $678.28 $678.28 $599.73 $599.73$724.15 $877.44 $877.44 $745.29 $745.29 $638.18 $638.18 $610.22 $610.22 $652.52 $652.52 $687.66 $687.66 $833.22 $833.22 $707.74 $707.74 $625.77 $625.77$758.11 $918.58 $918.58 $780.24 $780.24 $668.11 $668.11 $638.83 $638.83 $683.12 $683.12 $719.90 $719.90 $872.29 $872.29 $740.92 $740.92 $655.11 $655.11$791.64 $959.22 $959.22 $814.75 $814.75 $697.66 $697.66 $667.09 $667.09 $713.34 $713.34 $751.75 $751.75 $910.88 $910.88 $773.70 $773.70 $684.09 $684.09$828.57 $1,003.96 $1,003.96 $852.76 $852.76 $730.20 $730.20 $698.21 $698.21 $746.61 $746.61 $786.82 $786.82 $953.37 $953.37 $809.79 $809.79 $716.00 $716.00$865.92 $1,049.22 $1,049.22 $891.21 $891.21 $763.12 $763.12 $729.68 $729.68 $780.27 $780.27 $822.29 $822.29 $996.35 $996.35 $846.30 $846.30 $748.28 $748.28$906.25 $1,098.08 $1,098.08 $932.71 $932.71 $798.66 $798.66 $763.66 $763.66 $816.61 $816.61 $860.58 $860.58 $1,042.75 $1,042.75 $885.71 $885.71 $783.13 $783.13$946.57 $1,146.94 $1,146.94 $974.21 $974.21 $834.20 $834.20 $797.64 $797.64 $852.95 $852.95 $898.87 $898.87 $1,089.15 $1,089.15 $925.12 $925.12 $817.98 $817.98$990.29 $1,199.92 $1,199.92 $1,019.21 $1,019.21 $872.73 $872.73 $834.49 $834.49 $892.34 $892.34 $940.39 $940.39 $1,139.45 $1,139.45 $967.85 $967.85 $855.76 $855.76

$1,034.44 $1,253.41 $1,253.41 $1,064.64 $1,064.64 $911.63 $911.63 $871.69 $871.69 $932.12 $932.12 $982.31 $982.31 $1,190.25 $1,190.25 $1,010.99 $1,010.99 $893.90 $893.90$1,081.56 $1,310.50 $1,310.50 $1,113.13 $1,113.13 $953.16 $953.16 $911.39 $911.39 $974.58 $974.58 $1,027.05 $1,027.05 $1,244.46 $1,244.46 $1,057.04 $1,057.04 $934.62 $934.62$1,104.90 $1,338.79 $1,338.79 $1,137.16 $1,137.16 $973.73 $973.73 $931.06 $931.06 $995.61 $995.61 $1,049.22 $1,049.22 $1,271.32 $1,271.32 $1,079.86 $1,079.86 $954.79 $954.79$1,152.02 $1,395.88 $1,395.88 $1,185.65 $1,185.65 $1,015.25 $1,015.25 $970.77 $970.77 $1,038.07 $1,038.07 $1,093.96 $1,093.96 $1,325.53 $1,325.53 $1,125.91 $1,125.91 $995.51 $995.51$1,192.77 $1,445.25 $1,445.25 $1,227.59 $1,227.59 $1,051.17 $1,051.17 $1,005.10 $1,005.10 $1,074.79 $1,074.79 $1,132.66 $1,132.66 $1,372.42 $1,372.42 $1,165.73 $1,165.73 $1,030.72 $1,030.72$1,219.51 $1,477.65 $1,477.65 $1,255.12 $1,255.12 $1,074.73 $1,074.73 $1,027.64 $1,027.64 $1,098.88 $1,098.88 $1,158.05 $1,158.05 $1,403.19 $1,403.19 $1,191.87 $1,191.87 $1,053.83 $1,053.83$1,253.04 $1,518.29 $1,518.29 $1,289.63 $1,289.63 $1,104.29 $1,104.29 $1,055.90 $1,055.90 $1,129.10 $1,129.10 $1,189.90 $1,189.90 $1,441.77 $1,441.77 $1,224.64 $1,224.64 $1,082.81 $1,082.81$1,273.42 $1,542.97 $1,542.97 $1,310.60 $1,310.60 $1,122.24 $1,122.24 $1,073.06 $1,073.06 $1,147.46 $1,147.46 $1,209.25 $1,209.25 $1,465.22 $1,465.22 $1,244.55 $1,244.55 $1,100.42 $1,100.42

$7,350Yes


GoldMed: $2,000 / Rx: $0

0%$25 / $50


25/50/2000M-152-121-F Rev. 1/20

Rating Area 2

$7,350Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


GoldMed: $1,500 / Rx: $0

0%$20 / $40


20/40/1500M-152-121-F Rev. 1/20

Rating Area 7

$7,350Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


GoldMed: $1,500 / Rx: $0

0%$20 / $40


20/40/1500M-152-121-F Rev. 1/20

Rating Area 5

$7,350Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


GoldMed: $1,500 / Rx: $0

0%$20 / $40


20/40/1500M-152-121-F Rev. 1/20

Rating Area 2

$8,150Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 9



0%$20 / $40$8,150

Yes



0%$20 / $40


20/40/500M-152-121-F Rev. 1/20

Rating Area 7


l-Access PPO

old0 / Rx: $0%/ $40150es


RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$268.31 $268.31 $286.91 $286.91 $302.36 $302.36 $366.36 $366.36 $311.19 $311.19 $251.25 $251.25 $240.24 $240.24 $256.90 $256.90 $270.73 $270.73 $328.04$292.16 $292.16 $312.42 $312.42 $329.24 $329.24 $398.93 $398.93 $338.85 $338.85 $273.58 $273.58 $261.60 $261.60 $279.73 $279.73 $294.80 $294.80 $357.20$301.28 $301.28 $322.17 $322.17 $339.51 $339.51 $411.38 $411.38 $349.43 $349.43 $282.12 $282.12 $269.76 $269.76 $288.46 $288.46 $304.00 $304.00 $368.35$310.40 $310.40 $331.92 $331.92 $349.79 $349.79 $423.83 $423.83 $360.00 $360.00 $290.66 $290.66 $277.93 $277.93 $297.20 $297.20 $313.20 $313.20 $379.50$320.22 $320.22 $342.42 $342.42 $360.86 $360.86 $437.24 $437.24 $371.39 $371.39 $299.86 $299.86 $286.72 $286.72 $306.60 $306.60 $323.11 $323.11 $391.50$330.04 $330.04 $352.92 $352.92 $371.92 $371.92 $450.65 $450.65 $382.78 $382.78 $309.06 $309.06 $295.51 $295.51 $316.00 $316.00 $333.02 $333.02 $403.51$340.21 $340.21 $363.80 $363.80 $383.39 $383.39 $464.54 $464.54 $394.58 $394.58 $318.58 $318.58 $304.62 $304.62 $325.74 $325.74 $343.28 $343.28 $415.94$350.74 $350.74 $375.05 $375.05 $395.25 $395.25 $478.91 $478.91 $406.79 $406.79 $328.44 $328.44 $314.05 $314.05 $335.82 $335.82 $353.90 $353.90 $428.81$350.74 $350.74 $375.05 $375.05 $395.25 $395.25 $478.91 $478.91 $406.79 $406.79 $328.44 $328.44 $314.05 $314.05 $335.82 $335.82 $353.90 $353.90 $428.81$350.74 $350.74 $375.05 $375.05 $395.25 $395.25 $478.91 $478.91 $406.79 $406.79 $328.44 $328.44 $314.05 $314.05 $335.82 $335.82 $353.90 $353.90 $428.81$350.74 $350.74 $375.05 $375.05 $395.25 $395.25 $478.91 $478.91 $406.79 $406.79 $328.44 $328.44 $314.05 $314.05 $335.82 $335.82 $353.90 $353.90 $428.81$352.13 $352.13 $376.55 $376.55 $396.82 $396.82 $480.82 $480.82 $408.41 $408.41 $329.75 $329.75 $315.30 $315.30 $337.16 $337.16 $355.31 $355.31 $430.52$359.15 $359.15 $384.05 $384.05 $404.73 $404.73 $490.40 $490.40 $416.55 $416.55 $336.32 $336.32 $321.58 $321.58 $343.87 $343.87 $362.39 $362.39 $439.10$367.57 $367.57 $393.05 $393.05 $414.21 $414.21 $501.90 $501.90 $426.31 $426.31 $344.20 $344.20 $329.12 $329.12 $351.93 $351.93 $370.88 $370.88 $449.39$381.25 $381.25 $407.68 $407.68 $429.63 $429.63 $520.57 $520.57 $442.17 $442.17 $357.01 $357.01 $341.36 $341.36 $365.03 $365.03 $384.68 $384.68 $466.11$392.47 $392.47 $419.68 $419.68 $442.28 $442.28 $535.90 $535.90 $455.19 $455.19 $367.52 $367.52 $351.41 $351.41 $375.78 $375.78 $396.01 $396.01 $479.84$398.08 $398.08 $425.68 $425.68 $448.60 $448.60 $543.56 $543.56 $461.70 $461.70 $372.77 $372.77 $356.44 $356.44 $381.15 $381.15 $401.67 $401.67 $486.70$406.50 $406.50 $434.68 $434.68 $458.09 $458.09 $555.05 $555.05 $471.46 $471.46 $380.65 $380.65 $363.97 $363.97 $389.21 $389.21 $410.17 $410.17 $496.99$414.92 $414.92 $443.68 $443.68 $467.57 $467.57 $566.55 $566.55 $481.22 $481.22 $388.54 $388.54 $371.51 $371.51 $397.27 $397.27 $418.66 $418.66 $507.28$420.18 $420.18 $449.31 $449.31 $473.50 $473.50 $573.73 $573.73 $487.33 $487.33 $393.46 $393.46 $376.22 $376.22 $402.30 $402.30 $423.97 $423.97 $513.71$425.79 $425.79 $455.31 $455.31 $479.83 $479.83 $581.39 $581.39 $493.83 $493.83 $398.72 $398.72 $381.25 $381.25 $407.68 $407.68 $429.63 $429.63 $520.57$428.59 $428.59 $458.31 $458.31 $482.99 $482.99 $585.23 $585.23 $497.09 $497.09 $401.35 $401.35 $383.76 $383.76 $410.36 $410.36 $432.46 $432.46 $524.00$431.40 $431.40 $461.31 $461.31 $486.15 $486.15 $589.06 $589.06 $500.34 $500.34 $403.97 $403.97 $386.27 $386.27 $413.05 $413.05 $435.29 $435.29 $527.43$434.21 $434.21 $464.31 $464.31 $489.31 $489.31 $592.89 $592.89 $503.60 $503.60 $406.60 $406.60 $388.78 $388.78 $415.74 $415.74 $438.12 $438.12 $530.86$437.01 $437.01 $467.31 $467.31 $492.47 $492.47 $596.72 $596.72 $506.85 $506.85 $409.23 $409.23 $391.30 $391.30 $418.42 $418.42 $440.95 $440.95 $534.30$442.62 $442.62 $473.31 $473.31 $498.80 $498.80 $604.38 $604.38 $513.36 $513.36 $414.48 $414.48 $396.32 $396.32 $423.80 $423.80 $446.62 $446.62 $541.16$448.24 $448.24 $479.31 $479.31 $505.12 $505.12 $612.04 $612.04 $519.87 $519.87 $419.74 $419.74 $401.34 $401.34 $429.17 $429.17 $452.28 $452.28 $548.02$456.65 $456.65 $488.31 $488.31 $514.61 $514.61 $623.54 $623.54 $529.63 $529.63 $427.62 $427.62 $408.88 $408.88 $437.23 $437.23 $460.77 $460.77 $558.31$464.72 $464.72 $496.94 $496.94 $523.70 $523.70 $634.55 $634.55 $538.99 $538.99 $435.17 $435.17 $416.10 $416.10 $444.95 $444.95 $468.91 $468.91 $568.17$475.94 $475.94 $508.94 $508.94 $536.35 $536.35 $649.88 $649.88 $552.00 $552.00 $445.68 $445.68 $426.15 $426.15 $455.70 $455.70 $480.24 $480.24 $581.89$489.97 $489.97 $523.94 $523.94 $552.15 $552.15 $669.03 $669.03 $568.28 $568.28 $458.82 $458.82 $438.72 $438.72 $469.13 $469.13 $494.39 $494.39 $599.05$506.46 $506.46 $541.57 $541.57 $570.73 $570.73 $691.54 $691.54 $587.39 $587.39 $474.26 $474.26 $453.48 $453.48 $484.91 $484.91 $511.03 $511.03 $619.20$526.10 $526.10 $562.57 $562.57 $592.86 $592.86 $718.36 $718.36 $610.17 $610.17 $492.65 $492.65 $471.06 $471.06 $503.72 $503.72 $530.84 $530.84 $643.21$548.19 $548.19 $586.20 $586.20 $617.77 $617.77 $748.53 $748.53 $635.80 $635.80 $513.34 $513.34 $490.85 $490.85 $524.88 $524.88 $553.14 $553.14 $670.23$573.45 $573.45 $613.20 $613.20 $646.22 $646.22 $783.01 $783.01 $665.09 $665.09 $536.99 $536.99 $513.46 $513.46 $549.06 $549.06 $578.62 $578.62 $701.10$598.35 $598.35 $639.83 $639.83 $674.28 $674.28 $817.02 $817.02 $693.97 $693.97 $560.31 $560.31 $535.75 $535.75 $572.90 $572.90 $603.75 $603.75 $731.55$626.41 $626.41 $669.84 $669.84 $705.90 $705.90 $855.33 $855.33 $726.51 $726.51 $586.58 $586.58 $560.88 $560.88 $599.76 $599.76 $632.06 $632.06 $765.85$654.12 $654.12 $699.47 $699.47 $737.13 $737.13 $893.16 $893.16 $758.65 $758.65 $612.53 $612.53 $585.69 $585.69 $626.29 $626.29 $660.02 $660.02 $799.73$684.63 $684.63 $732.09 $732.09 $771.51 $771.51 $934.83 $934.83 $794.04 $794.04 $641.10 $641.10 $613.01 $613.01 $655.51 $655.51 $690.80 $690.80 $837.03$715.49 $715.49 $765.10 $765.10 $806.30 $806.30 $976.97 $976.97 $829.84 $829.84 $670.00 $670.00 $640.64 $640.64 $685.06 $685.06 $721.95 $721.95 $874.77$748.81 $748.81 $800.73 $800.73 $843.84 $843.84 $1,022.47 $1,022.47 $868.48 $868.48 $701.20 $701.20 $670.48 $670.48 $716.96 $716.96 $755.57 $755.57 $915.51$782.13 $782.13 $836.36 $836.36 $881.39 $881.39 $1,067.96 $1,067.96 $907.13 $907.13 $732.41 $732.41 $700.31 $700.31 $748.86 $748.86 $789.19 $789.19 $956.24$818.26 $818.26 $874.99 $874.99 $922.10 $922.10 $1,117.29 $1,117.29 $949.03 $949.03 $766.23 $766.23 $732.66 $732.66 $783.45 $783.45 $825.64 $825.64 $1,000.41$854.73 $854.73 $913.99 $913.99 $963.21 $963.21 $1,167.10 $1,167.10 $991.33 $991.33 $800.39 $800.39 $765.32 $765.32 $818.38 $818.38 $862.44 $862.44 $1,045.01$893.67 $893.67 $955.62 $955.62 $1,007.08 $1,007.08 $1,220.26 $1,220.26 $1,036.48 $1,036.48 $836.85 $836.85 $800.18 $800.18 $855.65 $855.65 $901.73 $901.73 $1,092.60$912.96 $912.96 $976.25 $976.25 $1,028.82 $1,028.82 $1,246.60 $1,246.60 $1,058.86 $1,058.86 $854.91 $854.91 $817.45 $817.45 $874.12 $874.12 $921.19 $921.19 $1,116.19$951.89 $951.89 $1,017.88 $1,017.88 $1,072.69 $1,072.69 $1,299.76 $1,299.76 $1,104.01 $1,104.01 $891.37 $891.37 $852.31 $852.31 $911.40 $911.40 $960.47 $960.47 $1,163.79$985.56 $985.56 $1,053.89 $1,053.89 $1,110.63 $1,110.63 $1,345.73 $1,345.73 $1,143.06 $1,143.06 $922.90 $922.90 $882.46 $882.46 $943.64 $943.64 $994.45 $994.45 $1,204.95

$1,007.65 $1,007.65 $1,077.51 $1,077.51 $1,135.53 $1,135.53 $1,375.90 $1,375.90 $1,168.69 $1,168.69 $943.59 $943.59 $902.24 $902.24 $964.79 $964.79 $1,016.74 $1,016.74 $1,231.97$1,035.36 $1,035.36 $1,107.14 $1,107.14 $1,166.76 $1,166.76 $1,413.74 $1,413.74 $1,200.82 $1,200.82 $969.53 $969.53 $927.05 $927.05 $991.32 $991.32 $1,044.70 $1,044.70 $1,265.84$1,052.20 $1,052.20 $1,125.14 $1,125.14 $1,185.73 $1,185.73 $1,436.72 $1,436.72 $1,220.35 $1,220.35 $985.30 $985.30 $942.12 $942.12 $1,007.44 $1,007.44 $1,061.69 $1,061.69 $1,286.42

$8,1Y

Geisinger Al

SilMed: $4,30

0$35 /

75729PAGeisinger Al

35/70M-152-121-

Rating

$8,150Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


SilverMed: $4,300 / Rx: $500

0%$35 / $70


35/70/4300M-152-121-F Rev. 1/20

Rating Area 5

$8,150Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


SilverMed: $4,300 / Rx: $500

0%$35 / $70


35/70/4300M-152-121-F Rev. 1/20

Rating Area 2

$7,350Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


GoldMed: $2,000 / Rx: $0

0%$25 / $50


25/50/2000M-152-121-F Rev. 1/20

Rating Area 7

$7,350Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


GoldMed: $2,000 / Rx: $0

0%$25 / $50


25/50/2000M-152-121-F Rev. 1/20

Rating Area 5


25/50/2000M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$328.04 $278.63 $278.63 $249.15 $249.15 $238.23 $238.23 $254.75 $254.75 $268.47 $268.47 $325.30 $325.30 $276.31 $276.31 $218.86 $218.86 $209.26 $209.26$357.20 $303.40 $303.40 $271.30 $271.30 $259.41 $259.41 $277.40 $277.40 $292.33 $292.33 $354.21 $354.21 $300.87 $300.87 $238.31 $238.31 $227.87 $227.87$368.35 $312.87 $312.87 $279.77 $279.77 $267.51 $267.51 $286.05 $286.05 $301.46 $301.46 $365.27 $365.27 $310.26 $310.26 $245.75 $245.75 $234.98 $234.98$379.50 $322.34 $322.34 $288.23 $288.23 $275.60 $275.60 $294.71 $294.71 $310.58 $310.58 $376.32 $376.32 $319.65 $319.65 $253.19 $253.19 $242.09 $242.09$391.50 $332.54 $332.54 $297.35 $297.35 $284.32 $284.32 $304.04 $304.04 $320.41 $320.41 $388.23 $388.23 $329.76 $329.76 $261.20 $261.20 $249.75 $249.75$403.51 $342.74 $342.74 $306.47 $306.47 $293.04 $293.04 $313.36 $313.36 $330.23 $330.23 $400.14 $400.14 $339.87 $339.87 $269.21 $269.21 $257.41 $257.41$415.94 $353.30 $353.30 $315.92 $315.92 $302.07 $302.07 $323.02 $323.02 $340.41 $340.41 $412.47 $412.47 $350.35 $350.35 $277.50 $277.50 $265.34 $265.34$428.81 $364.23 $364.23 $325.69 $325.69 $311.42 $311.42 $333.01 $333.01 $350.94 $350.94 $425.23 $425.23 $361.19 $361.19 $286.09 $286.09 $273.55 $273.55$428.81 $364.23 $364.23 $325.69 $325.69 $311.42 $311.42 $333.01 $333.01 $350.94 $350.94 $425.23 $425.23 $361.19 $361.19 $286.09 $286.09 $273.55 $273.55$428.81 $364.23 $364.23 $325.69 $325.69 $311.42 $311.42 $333.01 $333.01 $350.94 $350.94 $425.23 $425.23 $361.19 $361.19 $286.09 $286.09 $273.55 $273.55$428.81 $364.23 $364.23 $325.69 $325.69 $311.42 $311.42 $333.01 $333.01 $350.94 $350.94 $425.23 $425.23 $361.19 $361.19 $286.09 $286.09 $273.55 $273.55$430.52 $365.69 $365.69 $326.99 $326.99 $312.66 $312.66 $334.34 $334.34 $352.34 $352.34 $426.93 $426.93 $362.63 $362.63 $287.23 $287.23 $274.64 $274.64$439.10 $372.97 $372.97 $333.50 $333.50 $318.89 $318.89 $341.00 $341.00 $359.36 $359.36 $435.43 $435.43 $369.85 $369.85 $292.95 $292.95 $280.11 $280.11$449.39 $381.71 $381.71 $341.32 $341.32 $326.36 $326.36 $348.99 $348.99 $367.78 $367.78 $445.64 $445.64 $378.52 $378.52 $299.82 $299.82 $286.68 $286.68$466.11 $395.92 $395.92 $354.02 $354.02 $338.51 $338.51 $361.98 $361.98 $381.47 $381.47 $462.22 $462.22 $392.61 $392.61 $310.97 $310.97 $297.35 $297.35$479.84 $407.57 $407.57 $364.45 $364.45 $348.48 $348.48 $372.64 $372.64 $392.70 $392.70 $475.83 $475.83 $404.17 $404.17 $320.13 $320.13 $306.10 $306.10$486.70 $413.40 $413.40 $369.66 $369.66 $353.46 $353.46 $377.96 $377.96 $398.32 $398.32 $482.63 $482.63 $409.94 $409.94 $324.71 $324.71 $310.48 $310.48$496.99 $422.14 $422.14 $377.47 $377.47 $360.93 $360.93 $385.96 $385.96 $406.74 $406.74 $492.84 $492.84 $418.61 $418.61 $331.57 $331.57 $317.04 $317.04$507.28 $430.88 $430.88 $385.29 $385.29 $368.41 $368.41 $393.95 $393.95 $415.16 $415.16 $503.04 $503.04 $427.28 $427.28 $338.44 $338.44 $323.61 $323.61$513.71 $436.35 $436.35 $390.17 $390.17 $373.08 $373.08 $398.94 $398.94 $420.42 $420.42 $509.42 $509.42 $432.70 $432.70 $342.73 $342.73 $327.71 $327.71$520.57 $442.17 $442.17 $395.39 $395.39 $378.06 $378.06 $404.27 $404.27 $426.04 $426.04 $516.22 $516.22 $438.48 $438.48 $347.31 $347.31 $332.09 $332.09$524.00 $445.09 $445.09 $397.99 $397.99 $380.55 $380.55 $406.93 $406.93 $428.85 $428.85 $519.62 $519.62 $441.37 $441.37 $349.60 $349.60 $334.28 $334.28$527.43 $448.00 $448.00 $400.60 $400.60 $383.04 $383.04 $409.60 $409.60 $431.65 $431.65 $523.03 $523.03 $444.26 $444.26 $351.88 $351.88 $336.47 $336.47$530.86 $450.92 $450.92 $403.20 $403.20 $385.53 $385.53 $412.26 $412.26 $434.46 $434.46 $526.43 $526.43 $447.15 $447.15 $354.17 $354.17 $338.65 $338.65$534.30 $453.83 $453.83 $405.81 $405.81 $388.03 $388.03 $414.93 $414.93 $437.27 $437.27 $529.83 $529.83 $450.04 $450.04 $356.46 $356.46 $340.84 $340.84$541.16 $459.66 $459.66 $411.02 $411.02 $393.01 $393.01 $420.26 $420.26 $442.88 $442.88 $536.63 $536.63 $455.82 $455.82 $361.04 $361.04 $345.22 $345.22$548.02 $465.48 $465.48 $416.23 $416.23 $397.99 $397.99 $425.58 $425.58 $448.50 $448.50 $543.44 $543.44 $461.59 $461.59 $365.62 $365.62 $349.60 $349.60$558.31 $474.23 $474.23 $424.05 $424.05 $405.46 $405.46 $433.58 $433.58 $456.92 $456.92 $553.64 $553.64 $470.26 $470.26 $372.48 $372.48 $356.16 $356.16$568.17 $482.60 $482.60 $431.54 $431.54 $412.63 $412.63 $441.23 $441.23 $464.99 $464.99 $563.42 $563.42 $478.57 $478.57 $379.06 $379.06 $362.45 $362.45$581.89 $494.26 $494.26 $441.96 $441.96 $422.59 $422.59 $451.89 $451.89 $476.22 $476.22 $577.03 $577.03 $490.13 $490.13 $388.22 $388.22 $371.21 $371.21$599.05 $508.83 $508.83 $454.99 $454.99 $435.05 $435.05 $465.21 $465.21 $490.26 $490.26 $594.04 $594.04 $504.58 $504.58 $399.66 $399.66 $382.15 $382.15$619.20 $525.95 $525.95 $470.29 $470.29 $449.69 $449.69 $480.86 $480.86 $506.76 $506.76 $614.02 $614.02 $521.55 $521.55 $413.11 $413.11 $395.00 $395.00$643.21 $546.34 $546.34 $488.53 $488.53 $467.12 $467.12 $499.51 $499.51 $526.41 $526.41 $637.84 $637.84 $541.78 $541.78 $429.13 $429.13 $410.32 $410.32$670.23 $569.29 $569.29 $509.05 $509.05 $486.74 $486.74 $520.49 $520.49 $548.52 $548.52 $664.63 $664.63 $564.53 $564.53 $447.15 $447.15 $427.56 $427.56$701.10 $595.51 $595.51 $532.50 $532.50 $509.17 $509.17 $544.47 $544.47 $573.78 $573.78 $695.24 $695.24 $590.54 $590.54 $467.75 $467.75 $447.25 $447.25$731.55 $621.37 $621.37 $555.62 $555.62 $531.28 $531.28 $568.11 $568.11 $598.70 $598.70 $725.43 $725.43 $616.18 $616.18 $488.06 $488.06 $466.67 $466.67$765.85 $650.51 $650.51 $581.68 $581.68 $556.19 $556.19 $594.75 $594.75 $626.78 $626.78 $759.45 $759.45 $645.08 $645.08 $510.95 $510.95 $488.56 $488.56$799.73 $679.29 $679.29 $607.41 $607.41 $580.79 $580.79 $621.06 $621.06 $654.50 $654.50 $793.04 $793.04 $673.61 $673.61 $533.55 $533.55 $510.17 $510.17$837.03 $710.97 $710.97 $635.74 $635.74 $607.89 $607.89 $650.03 $650.03 $685.03 $685.03 $830.04 $830.04 $705.03 $705.03 $558.44 $558.44 $533.97 $533.97$874.77 $743.03 $743.03 $664.40 $664.40 $635.29 $635.29 $679.33 $679.33 $715.91 $715.91 $867.46 $867.46 $736.82 $736.82 $583.61 $583.61 $558.04 $558.04$915.51 $777.63 $777.63 $695.34 $695.34 $664.87 $664.87 $710.97 $710.97 $749.25 $749.25 $907.85 $907.85 $771.13 $771.13 $610.79 $610.79 $584.03 $584.03$956.24 $812.23 $812.23 $726.29 $726.29 $694.46 $694.46 $742.61 $742.61 $782.59 $782.59 $948.25 $948.25 $805.44 $805.44 $637.97 $637.97 $610.01 $610.01

$1,000.41 $849.75 $849.75 $759.83 $759.83 $726.54 $726.54 $776.91 $776.91 $818.74 $818.74 $992.05 $992.05 $842.64 $842.64 $667.44 $667.44 $638.19 $638.19$1,045.01 $887.63 $887.63 $793.70 $793.70 $758.92 $758.92 $811.54 $811.54 $855.24 $855.24 $1,036.27 $1,036.27 $880.21 $880.21 $697.19 $697.19 $666.64 $666.64$1,092.60 $928.05 $928.05 $829.85 $829.85 $793.49 $793.49 $848.50 $848.50 $894.19 $894.19 $1,083.47 $1,083.47 $920.30 $920.30 $728.94 $728.94 $697.00 $697.00$1,116.19 $948.09 $948.09 $847.77 $847.77 $810.62 $810.62 $866.82 $866.82 $913.49 $913.49 $1,106.86 $1,106.86 $940.16 $940.16 $744.68 $744.68 $712.05 $712.05$1,163.79 $988.52 $988.52 $883.92 $883.92 $845.18 $845.18 $903.78 $903.78 $952.45 $952.45 $1,154.06 $1,154.06 $980.26 $980.26 $776.44 $776.44 $742.41 $742.41$1,204.95 $1,023.48 $1,023.48 $915.18 $915.18 $875.08 $875.08 $935.75 $935.75 $986.14 $986.14 $1,194.88 $1,194.88 $1,014.93 $1,014.93 $803.90 $803.90 $768.67 $768.67$1,231.97 $1,046.43 $1,046.43 $935.70 $935.70 $894.70 $894.70 $956.73 $956.73 $1,008.25 $1,008.25 $1,221.67 $1,221.67 $1,037.68 $1,037.68 $821.92 $821.92 $785.91 $785.91$1,265.84 $1,075.20 $1,075.20 $961.43 $961.43 $919.30 $919.30 $983.04 $983.04 $1,035.97 $1,035.97 $1,255.26 $1,255.26 $1,066.22 $1,066.22 $844.52 $844.52 $807.52 $807.52$1,286.42 $1,092.69 $1,092.69 $977.07 $977.07 $934.25 $934.25 $999.02 $999.02 $1,052.82 $1,052.82 $1,275.67 $1,275.67 $1,083.55 $1,083.55 $858.26 $858.26 $820.65 $820.65

$7,200Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 3



0%$40 / $90$7,200

Yes



0%$40 / $90


40/90/7200M-152-121-F Rev. 1/20

Rating Area 2

$7,700Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


SilverMed: $5,000 / Rx: $500

0%$35 / $70


35/70/5000M-152-121-F Rev. 1/20

Rating Area 7

$7,700Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


SilverMed: $5,000 / Rx: $500

0%$35 / $70


35/70/5000M-152-121-F Rev. 1/20

Rating Area 5

$7,700Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


SilverMed: $5,000 / Rx: $500

0%$35 / $70


35/70/5000M-152-121-F Rev. 1/20

Rating Area 2

150es


35/70/4300M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes

l-Access PPO

ver0 / Rx: $500%/ $70


Page Number: 10 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$223.77 $223.77 $235.82 $235.82 $285.74 $285.74 $242.71 $242.71 $232.45 $232.45 $261.95 $261.95 $269.59 $269.59 $285.54 $285.54 $273.03 $273.03 $291.96$243.66 $243.66 $256.78 $256.78 $311.14 $311.14 $264.28 $264.28 $253.11 $253.11 $285.23 $285.23 $293.56 $293.56 $310.92 $310.92 $297.30 $297.30 $317.91$251.27 $251.27 $264.80 $264.80 $320.85 $320.85 $272.53 $272.53 $261.01 $261.01 $294.13 $294.13 $302.72 $302.72 $320.63 $320.63 $306.58 $306.58 $327.83$258.87 $258.87 $272.81 $272.81 $330.56 $330.56 $280.78 $280.78 $268.91 $268.91 $303.04 $303.04 $311.88 $311.88 $330.33 $330.33 $315.86 $315.86 $337.75$267.07 $267.07 $281.45 $281.45 $341.02 $341.02 $289.66 $289.66 $277.42 $277.42 $312.62 $312.62 $321.75 $321.75 $340.78 $340.78 $325.85 $325.85 $348.44$275.26 $275.26 $290.08 $290.08 $351.48 $351.48 $298.55 $298.55 $285.92 $285.92 $322.21 $322.21 $331.62 $331.62 $351.23 $351.23 $335.84 $335.84 $359.13$283.74 $283.74 $299.02 $299.02 $362.31 $362.31 $307.75 $307.75 $294.74 $294.74 $332.14 $332.14 $341.84 $341.84 $362.06 $362.06 $346.19 $346.19 $370.19$292.52 $292.52 $308.27 $308.27 $373.52 $373.52 $317.27 $317.27 $303.86 $303.86 $342.42 $342.42 $352.42 $352.42 $373.26 $373.26 $356.90 $356.90 $381.65$292.52 $292.52 $308.27 $308.27 $373.52 $373.52 $317.27 $317.27 $303.86 $303.86 $342.42 $342.42 $352.42 $352.42 $373.26 $373.26 $356.90 $356.90 $381.65$292.52 $292.52 $308.27 $308.27 $373.52 $373.52 $317.27 $317.27 $303.86 $303.86 $342.42 $342.42 $352.42 $352.42 $373.26 $373.26 $356.90 $356.90 $381.65$292.52 $292.52 $308.27 $308.27 $373.52 $373.52 $317.27 $317.27 $303.86 $303.86 $342.42 $342.42 $352.42 $352.42 $373.26 $373.26 $356.90 $356.90 $381.65$293.68 $293.68 $309.50 $309.50 $375.01 $375.01 $318.53 $318.53 $305.07 $305.07 $343.78 $343.78 $353.82 $353.82 $374.75 $374.75 $358.33 $358.33 $383.17$299.53 $299.53 $315.66 $315.66 $382.48 $382.48 $324.88 $324.88 $311.14 $311.14 $350.63 $350.63 $360.87 $360.87 $382.21 $382.21 $365.46 $365.46 $390.80$306.55 $306.55 $323.06 $323.06 $391.45 $391.45 $332.49 $332.49 $318.44 $318.44 $358.85 $358.85 $369.33 $369.33 $391.17 $391.17 $374.03 $374.03 $399.96$317.96 $317.96 $335.08 $335.08 $406.01 $406.01 $344.87 $344.87 $330.29 $330.29 $372.20 $372.20 $383.07 $383.07 $405.73 $405.73 $387.95 $387.95 $414.85$327.32 $327.32 $344.95 $344.95 $417.97 $417.97 $355.02 $355.02 $340.01 $340.01 $383.16 $383.16 $394.35 $394.35 $417.67 $417.67 $399.37 $399.37 $427.06$332.00 $332.00 $349.88 $349.88 $423.94 $423.94 $360.10 $360.10 $344.87 $344.87 $388.64 $388.64 $399.99 $399.99 $423.64 $423.64 $405.08 $405.08 $433.16$339.02 $339.02 $357.28 $357.28 $432.91 $432.91 $367.71 $367.71 $352.16 $352.16 $396.86 $396.86 $408.44 $408.44 $432.60 $432.60 $413.65 $413.65 $442.32$346.04 $346.04 $364.68 $364.68 $441.87 $441.87 $375.32 $375.32 $359.46 $359.46 $405.07 $405.07 $416.90 $416.90 $441.56 $441.56 $422.21 $422.21 $451.48$350.43 $350.43 $369.30 $369.30 $447.47 $447.47 $380.08 $380.08 $364.01 $364.01 $410.21 $410.21 $422.19 $422.19 $447.16 $447.16 $427.57 $427.57 $457.21$355.11 $355.11 $374.23 $374.23 $453.45 $453.45 $385.16 $385.16 $368.88 $368.88 $415.69 $415.69 $427.83 $427.83 $453.13 $453.13 $433.28 $433.28 $463.31$357.45 $357.45 $376.70 $376.70 $456.44 $456.44 $387.70 $387.70 $371.31 $371.31 $418.43 $418.43 $430.65 $430.65 $456.12 $456.12 $436.13 $436.13 $466.37$359.79 $359.79 $379.17 $379.17 $459.43 $459.43 $390.24 $390.24 $373.74 $373.74 $421.17 $421.17 $433.46 $433.46 $459.10 $459.10 $438.99 $438.99 $469.42$362.13 $362.13 $381.63 $381.63 $462.42 $462.42 $392.77 $392.77 $376.17 $376.17 $423.91 $423.91 $436.28 $436.28 $462.09 $462.09 $441.84 $441.84 $472.47$364.47 $364.47 $384.10 $384.10 $465.40 $465.40 $395.31 $395.31 $378.60 $378.60 $426.65 $426.65 $439.10 $439.10 $465.08 $465.08 $444.70 $444.70 $475.53$369.15 $369.15 $389.03 $389.03 $471.38 $471.38 $400.39 $400.39 $383.46 $383.46 $432.13 $432.13 $444.74 $444.74 $471.05 $471.05 $450.41 $450.41 $481.63$373.83 $373.83 $393.96 $393.96 $477.36 $477.36 $405.46 $405.46 $388.32 $388.32 $437.60 $437.60 $450.38 $450.38 $477.02 $477.02 $456.12 $456.12 $487.74$380.85 $380.85 $401.36 $401.36 $486.32 $486.32 $413.08 $413.08 $395.61 $395.61 $445.82 $445.82 $458.84 $458.84 $485.98 $485.98 $464.68 $464.68 $496.90$387.58 $387.58 $408.45 $408.45 $494.91 $494.91 $420.38 $420.38 $402.60 $402.60 $453.70 $453.70 $466.94 $466.94 $494.56 $494.56 $472.89 $472.89 $505.68$396.94 $396.94 $418.32 $418.32 $506.86 $506.86 $430.53 $430.53 $412.33 $412.33 $464.65 $464.65 $478.22 $478.22 $506.51 $506.51 $484.31 $484.31 $517.89$408.64 $408.64 $430.65 $430.65 $521.80 $521.80 $443.22 $443.22 $424.48 $424.48 $478.35 $478.35 $492.32 $492.32 $521.44 $521.44 $498.59 $498.59 $533.16$422.39 $422.39 $445.13 $445.13 $539.36 $539.36 $458.13 $458.13 $438.76 $438.76 $494.44 $494.44 $508.88 $508.88 $538.98 $538.98 $515.36 $515.36 $551.09$438.77 $438.77 $462.40 $462.40 $560.28 $560.28 $475.90 $475.90 $455.78 $455.78 $513.62 $513.62 $528.62 $528.62 $559.88 $559.88 $535.35 $535.35 $572.46$457.20 $457.20 $481.82 $481.82 $583.81 $583.81 $495.89 $495.89 $474.92 $474.92 $535.19 $535.19 $550.82 $550.82 $583.40 $583.40 $557.83 $557.83 $596.51$478.26 $478.26 $504.01 $504.01 $610.70 $610.70 $518.73 $518.73 $496.80 $496.80 $559.85 $559.85 $576.19 $576.19 $610.27 $610.27 $583.53 $583.53 $623.99$499.03 $499.03 $525.90 $525.90 $637.22 $637.22 $541.25 $541.25 $518.37 $518.37 $584.16 $584.16 $601.21 $601.21 $636.77 $636.77 $608.87 $608.87 $651.08$522.43 $522.43 $550.56 $550.56 $667.10 $667.10 $566.64 $566.64 $542.68 $542.68 $611.55 $611.55 $629.40 $629.40 $666.63 $666.63 $637.42 $637.42 $681.61$545.54 $545.54 $574.91 $574.91 $696.61 $696.61 $591.70 $591.70 $566.68 $566.68 $638.60 $638.60 $657.25 $657.25 $696.12 $696.12 $665.62 $665.62 $711.76$570.99 $570.99 $601.73 $601.73 $729.11 $729.11 $619.30 $619.30 $593.12 $593.12 $668.39 $668.39 $687.90 $687.90 $728.59 $728.59 $696.67 $696.67 $744.97$596.73 $596.73 $628.86 $628.86 $761.98 $761.98 $647.22 $647.22 $619.86 $619.86 $698.52 $698.52 $718.92 $718.92 $761.44 $761.44 $728.07 $728.07 $778.55$624.52 $624.52 $658.15 $658.15 $797.46 $797.46 $677.36 $677.36 $648.72 $648.72 $731.05 $731.05 $752.40 $752.40 $796.90 $796.90 $761.98 $761.98 $814.81$652.31 $652.31 $687.43 $687.43 $832.94 $832.94 $707.50 $707.50 $677.59 $677.59 $763.58 $763.58 $785.88 $785.88 $832.36 $832.36 $795.89 $795.89 $851.06$682.44 $682.44 $719.18 $719.18 $871.42 $871.42 $740.18 $740.18 $708.88 $708.88 $798.85 $798.85 $822.17 $822.17 $870.80 $870.80 $832.65 $832.65 $890.37$712.86 $712.86 $751.24 $751.24 $910.26 $910.26 $773.18 $773.18 $740.49 $740.49 $834.46 $834.46 $858.82 $858.82 $909.62 $909.62 $869.76 $869.76 $930.06$745.33 $745.33 $785.46 $785.46 $951.72 $951.72 $808.39 $808.39 $774.21 $774.21 $872.47 $872.47 $897.94 $897.94 $951.05 $951.05 $909.38 $909.38 $972.43$761.41 $761.41 $802.41 $802.41 $972.27 $972.27 $825.84 $825.84 $790.92 $790.92 $891.30 $891.30 $917.32 $917.32 $971.58 $971.58 $929.01 $929.01 $993.42$793.88 $793.88 $836.63 $836.63 $1,013.73 $1,013.73 $861.06 $861.06 $824.65 $824.65 $929.31 $929.31 $956.44 $956.44 $1,013.01 $1,013.01 $968.62 $968.62 $1,035.78$821.96 $821.96 $866.22 $866.22 $1,049.59 $1,049.59 $891.52 $891.52 $853.82 $853.82 $962.18 $962.18 $990.27 $990.27 $1,048.85 $1,048.85 $1,002.89 $1,002.89 $1,072.42$840.39 $840.39 $885.64 $885.64 $1,073.12 $1,073.12 $911.50 $911.50 $872.96 $872.96 $983.75 $983.75 $1,012.47 $1,012.47 $1,072.36 $1,072.36 $1,025.37 $1,025.37 $1,096.46$863.50 $863.50 $910.00 $910.00 $1,102.62 $1,102.62 $936.57 $936.57 $896.97 $896.97 $1,010.80 $1,010.80 $1,040.32 $1,040.32 $1,101.85 $1,101.85 $1,053.57 $1,053.57 $1,126.61$877.54 $877.54 $924.79 $924.79 $1,120.55 $1,120.55 $951.80 $951.80 $911.55 $911.55 $1,027.24 $1,027.24 $1,057.23 $1,057.23 $1,119.77 $1,119.77 $1,070.70 $1,070.70 $1,144.93

$7,350Yes

75729PAGeisinger Al

25/50/20M-152-121-

Rating

Geisinger Al

GoMed: $2,0

0$25 /$7,3

Y


GoldMed: $2,000 / Rx: $0

0%$25 / $50


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 3

$8,150Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


SilverMed: $4,300 / Rx: $500

0%$60 / $60


20/60/4300M-152-243-F Rev. 1/20

Rating Area 9

$8,150Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 6


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


SilverMed: $4,300 / Rx: $500

0%$60 / $60


20/60/4300M-152-243-F Rev. 1/20

Rating Area 3

$7,200Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 9



0%$40 / $90$7,200

Yes



0%$40 / $90


40/90/7200M-152-121-F Rev. 1/20

Rating Area 7

$7,200Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 6



0%$40 / $90$7,200

Yes



0%$40 / $90


40/90/7200M-152-121-F Rev. 1/20

Rating Area 5

Page Number: 11 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$291.96 $307.68 $307.68 $372.81 $372.81 $316.66 $316.66 $344.89 $344.89 $329.78 $329.78 $352.64 $352.64 $371.63 $371.63 $450.29 $450.29 $382.48 $382.48$317.91 $335.03 $335.03 $405.94 $405.94 $344.81 $344.81 $375.55 $375.55 $359.09 $359.09 $383.98 $383.98 $404.66 $404.66 $490.32 $490.32 $416.48 $416.48$327.83 $345.48 $345.48 $418.62 $418.62 $355.57 $355.57 $387.27 $387.27 $370.30 $370.30 $395.97 $395.97 $417.29 $417.29 $505.62 $505.62 $429.47 $429.47$337.75 $355.94 $355.94 $431.29 $431.29 $366.33 $366.33 $398.99 $398.99 $381.51 $381.51 $407.95 $407.95 $429.92 $429.92 $520.93 $520.93 $442.47 $442.47$348.44 $367.20 $367.20 $444.93 $444.93 $377.92 $377.92 $411.61 $411.61 $393.58 $393.58 $420.86 $420.86 $443.52 $443.52 $537.41 $537.41 $456.47 $456.47$359.13 $378.46 $378.46 $458.58 $458.58 $389.51 $389.51 $424.24 $424.24 $405.65 $405.65 $433.77 $433.77 $457.13 $457.13 $553.89 $553.89 $470.47 $470.47$370.19 $390.13 $390.13 $472.71 $472.71 $401.52 $401.52 $437.31 $437.31 $418.15 $418.15 $447.14 $447.14 $471.21 $471.21 $570.96 $570.96 $484.97 $484.97$381.65 $402.20 $402.20 $487.33 $487.33 $413.94 $413.94 $450.84 $450.84 $431.08 $431.08 $460.97 $460.97 $485.79 $485.79 $588.62 $588.62 $499.98 $499.98$381.65 $402.20 $402.20 $487.33 $487.33 $413.94 $413.94 $450.84 $450.84 $431.08 $431.08 $460.97 $460.97 $485.79 $485.79 $588.62 $588.62 $499.98 $499.98$381.65 $402.20 $402.20 $487.33 $487.33 $413.94 $413.94 $450.84 $450.84 $431.08 $431.08 $460.97 $460.97 $485.79 $485.79 $588.62 $588.62 $499.98 $499.98$381.65 $402.20 $402.20 $487.33 $487.33 $413.94 $413.94 $450.84 $450.84 $431.08 $431.08 $460.97 $460.97 $485.79 $485.79 $588.62 $588.62 $499.98 $499.98$383.17 $403.80 $403.80 $489.28 $489.28 $415.59 $415.59 $452.64 $452.64 $432.80 $432.80 $462.81 $462.81 $487.73 $487.73 $590.97 $590.97 $501.97 $501.97$390.80 $411.85 $411.85 $499.02 $499.02 $423.87 $423.87 $461.65 $461.65 $441.43 $441.43 $472.03 $472.03 $497.45 $497.45 $602.74 $602.74 $511.97 $511.97$399.96 $421.50 $421.50 $510.72 $510.72 $433.80 $433.80 $472.47 $472.47 $451.77 $451.77 $483.09 $483.09 $509.10 $509.10 $616.87 $616.87 $523.97 $523.97$414.85 $437.18 $437.18 $529.73 $529.73 $449.95 $449.95 $490.06 $490.06 $468.58 $468.58 $501.07 $501.07 $528.05 $528.05 $639.83 $639.83 $543.47 $543.47$427.06 $450.05 $450.05 $545.32 $545.32 $463.19 $463.19 $504.48 $504.48 $482.38 $482.38 $515.82 $515.82 $543.60 $543.60 $658.66 $658.66 $559.47 $559.47$433.16 $456.49 $456.49 $553.12 $553.12 $469.82 $469.82 $511.70 $511.70 $489.27 $489.27 $523.20 $523.20 $551.37 $551.37 $668.08 $668.08 $567.47 $567.47$442.32 $466.14 $466.14 $564.81 $564.81 $479.75 $479.75 $522.52 $522.52 $499.62 $499.62 $534.26 $534.26 $563.03 $563.03 $682.21 $682.21 $579.47 $579.47$451.48 $475.79 $475.79 $576.51 $576.51 $489.69 $489.69 $533.34 $533.34 $509.97 $509.97 $545.32 $545.32 $574.69 $574.69 $696.34 $696.34 $591.47 $591.47$457.21 $481.83 $481.83 $583.82 $583.82 $495.90 $495.90 $540.10 $540.10 $516.43 $516.43 $552.24 $552.24 $581.97 $581.97 $705.16 $705.16 $598.96 $598.96$463.31 $488.26 $488.26 $591.62 $591.62 $502.52 $502.52 $547.31 $547.31 $523.33 $523.33 $559.61 $559.61 $589.75 $589.75 $714.58 $714.58 $606.96 $606.96$466.37 $491.48 $491.48 $595.52 $595.52 $505.83 $505.83 $550.92 $550.92 $526.78 $526.78 $563.30 $563.30 $593.63 $593.63 $719.29 $719.29 $610.96 $610.96$469.42 $494.70 $494.70 $599.41 $599.41 $509.14 $509.14 $554.53 $554.53 $530.23 $530.23 $566.99 $566.99 $597.52 $597.52 $724.00 $724.00 $614.96 $614.96$472.47 $497.92 $497.92 $603.31 $603.31 $512.45 $512.45 $558.13 $558.13 $533.68 $533.68 $570.68 $570.68 $601.40 $601.40 $728.71 $728.71 $618.96 $618.96$475.53 $501.13 $501.13 $607.21 $607.21 $515.76 $515.76 $561.74 $561.74 $537.12 $537.12 $574.36 $574.36 $605.29 $605.29 $733.42 $733.42 $622.96 $622.96$481.63 $507.57 $507.57 $615.01 $615.01 $522.39 $522.39 $568.95 $568.95 $544.02 $544.02 $581.74 $581.74 $613.06 $613.06 $742.84 $742.84 $630.96 $630.96$487.74 $514.00 $514.00 $622.81 $622.81 $529.01 $529.01 $576.17 $576.17 $550.92 $550.92 $589.11 $589.11 $620.84 $620.84 $752.25 $752.25 $638.96 $638.96$496.90 $523.66 $523.66 $634.50 $634.50 $538.94 $538.94 $586.99 $586.99 $561.27 $561.27 $600.18 $600.18 $632.49 $632.49 $766.38 $766.38 $650.96 $650.96$505.68 $532.91 $532.91 $645.71 $645.71 $548.47 $548.47 $597.36 $597.36 $571.18 $571.18 $610.78 $610.78 $643.67 $643.67 $779.92 $779.92 $662.46 $662.46$517.89 $545.78 $545.78 $661.31 $661.31 $561.71 $561.71 $611.78 $611.78 $584.97 $584.97 $625.53 $625.53 $659.21 $659.21 $798.75 $798.75 $678.46 $678.46$533.16 $561.86 $561.86 $680.80 $680.80 $578.27 $578.27 $629.82 $629.82 $602.22 $602.22 $643.97 $643.97 $678.64 $678.64 $822.30 $822.30 $698.46 $698.46$551.09 $580.77 $580.77 $703.70 $703.70 $597.72 $597.72 $651.01 $651.01 $622.48 $622.48 $665.63 $665.63 $701.48 $701.48 $849.96 $849.96 $721.96 $721.96$572.46 $603.29 $603.29 $730.99 $730.99 $620.90 $620.90 $676.25 $676.25 $646.62 $646.62 $691.45 $691.45 $728.68 $728.68 $882.93 $882.93 $749.96 $749.96$596.51 $628.63 $628.63 $761.70 $761.70 $646.98 $646.98 $704.65 $704.65 $673.78 $673.78 $720.49 $720.49 $759.29 $759.29 $920.01 $920.01 $781.45 $781.45$623.99 $657.59 $657.59 $796.78 $796.78 $676.79 $676.79 $737.11 $737.11 $704.81 $704.81 $753.68 $753.68 $794.26 $794.26 $962.39 $962.39 $817.45 $817.45$651.08 $686.14 $686.14 $831.38 $831.38 $706.17 $706.17 $769.12 $769.12 $735.42 $735.42 $786.41 $786.41 $828.75 $828.75 $1,004.18 $1,004.18 $852.95 $852.95$681.61 $718.32 $718.32 $870.37 $870.37 $739.29 $739.29 $805.19 $805.19 $769.91 $769.91 $823.29 $823.29 $867.62 $867.62 $1,051.27 $1,051.27 $892.95 $892.95$711.76 $750.09 $750.09 $908.87 $908.87 $771.99 $771.99 $840.81 $840.81 $803.96 $803.96 $859.70 $859.70 $905.99 $905.99 $1,097.77 $1,097.77 $932.45 $932.45$744.97 $785.08 $785.08 $951.27 $951.27 $808.00 $808.00 $880.03 $880.03 $841.47 $841.47 $899.81 $899.81 $948.26 $948.26 $1,148.98 $1,148.98 $975.94 $975.94$778.55 $820.47 $820.47 $994.15 $994.15 $844.43 $844.43 $919.70 $919.70 $879.40 $879.40 $940.37 $940.37 $991.01 $991.01 $1,200.78 $1,200.78 $1,019.94 $1,019.94$814.81 $858.68 $858.68 $1,040.45 $1,040.45 $883.75 $883.75 $962.53 $962.53 $920.35 $920.35 $984.16 $984.16 $1,037.16 $1,037.16 $1,256.70 $1,256.70 $1,067.44 $1,067.44$851.06 $896.89 $896.89 $1,086.74 $1,086.74 $923.08 $923.08 $1,005.36 $1,005.36 $961.31 $961.31 $1,027.95 $1,027.95 $1,083.31 $1,083.31 $1,312.62 $1,312.62 $1,114.93 $1,114.93$890.37 $938.32 $938.32 $1,136.94 $1,136.94 $965.71 $965.71 $1,051.80 $1,051.80 $1,005.71 $1,005.71 $1,075.43 $1,075.43 $1,133.34 $1,133.34 $1,373.25 $1,373.25 $1,166.43 $1,166.43$930.06 $980.14 $980.14 $1,187.62 $1,187.62 $1,008.76 $1,008.76 $1,098.68 $1,098.68 $1,050.54 $1,050.54 $1,123.37 $1,123.37 $1,183.86 $1,183.86 $1,434.46 $1,434.46 $1,218.43 $1,218.43$972.43 $1,024.79 $1,024.79 $1,241.71 $1,241.71 $1,054.71 $1,054.71 $1,148.73 $1,148.73 $1,098.39 $1,098.39 $1,174.54 $1,174.54 $1,237.79 $1,237.79 $1,499.80 $1,499.80 $1,273.93 $1,273.93$993.42 $1,046.91 $1,046.91 $1,268.52 $1,268.52 $1,077.48 $1,077.48 $1,173.52 $1,173.52 $1,122.10 $1,122.10 $1,199.89 $1,199.89 $1,264.50 $1,264.50 $1,532.17 $1,532.17 $1,301.42 $1,301.42

$1,035.78 $1,091.55 $1,091.55 $1,322.61 $1,322.61 $1,123.42 $1,123.42 $1,223.57 $1,223.57 $1,169.95 $1,169.95 $1,251.06 $1,251.06 $1,318.43 $1,318.43 $1,597.51 $1,597.51 $1,356.92 $1,356.92$1,072.42 $1,130.16 $1,130.16 $1,369.39 $1,369.39 $1,163.16 $1,163.16 $1,266.85 $1,266.85 $1,211.33 $1,211.33 $1,295.31 $1,295.31 $1,365.06 $1,365.06 $1,654.02 $1,654.02 $1,404.92 $1,404.92$1,096.46 $1,155.50 $1,155.50 $1,400.10 $1,400.10 $1,189.24 $1,189.24 $1,295.25 $1,295.25 $1,238.49 $1,238.49 $1,324.36 $1,324.36 $1,395.67 $1,395.67 $1,691.10 $1,691.10 $1,436.42 $1,436.42$1,126.61 $1,187.27 $1,187.27 $1,438.59 $1,438.59 $1,221.94 $1,221.94 $1,330.86 $1,330.86 $1,272.55 $1,272.55 $1,360.77 $1,360.77 $1,434.04 $1,434.04 $1,737.60 $1,737.60 $1,475.91 $1,475.91$1,144.93 $1,206.58 $1,206.58 $1,461.99 $1,461.99 $1,241.81 $1,241.81 $1,352.50 $1,352.50 $1,293.24 $1,293.24 $1,382.90 $1,382.90 $1,457.36 $1,457.36 $1,765.85 $1,765.85 $1,499.91 $1,499.91

$2,900Yes



0%$10 / $20


10/20/0M-152-121-F Rev. 1/20

Rating Area 9

$2,900Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 7



0%$10 / $20$2,900

Yes



0%$10 / $20


10/20/0M-152-121-F Rev. 1/20

Rating Area 6

$2,900Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 5



0%$10 / $20$2,900

Yes



0%$10 / $20


10/20/0M-152-121-F Rev. 1/20

Rating Area 3

$7,350Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 2



0%$10 / $20$2,900

Yes


GoldMed: $2,000 / Rx: $0

0%$25 / $50


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 9

$7,350Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


GoldMed: $2,000 / Rx: $0

0%$25 / $50


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 6

A0050127l-Access PPO 00 1xded

-F Rev. 1/20Area 5

l-Access PPO

old00 / Rx: $0%/ $50350es

Page Number: 12 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$343.91 $343.91 $328.84 $328.84 $351.64 $351.64 $370.57 $370.57 $449.01 $449.01 $381.39 $381.39 $285.71 $285.71 $273.19 $273.19 $292.13 $292.13 $307.86$374.48 $374.48 $358.07 $358.07 $382.89 $382.89 $403.51 $403.51 $488.93 $488.93 $415.29 $415.29 $311.10 $311.10 $297.47 $297.47 $318.10 $318.10 $335.22$386.17 $386.17 $369.25 $369.25 $394.84 $394.84 $416.11 $416.11 $504.19 $504.19 $428.25 $428.25 $320.81 $320.81 $306.76 $306.76 $328.02 $328.02 $345.69$397.86 $397.86 $380.42 $380.42 $406.80 $406.80 $428.70 $428.70 $519.45 $519.45 $441.22 $441.22 $330.52 $330.52 $316.04 $316.04 $337.95 $337.95 $356.15$410.44 $410.44 $392.46 $392.46 $419.67 $419.67 $442.26 $442.26 $535.88 $535.88 $455.18 $455.18 $340.98 $340.98 $326.04 $326.04 $348.64 $348.64 $367.42$423.03 $423.03 $404.49 $404.49 $432.54 $432.54 $455.83 $455.83 $552.32 $552.32 $469.14 $469.14 $351.44 $351.44 $336.04 $336.04 $359.34 $359.34 $378.69$436.07 $436.07 $416.96 $416.96 $445.87 $445.87 $469.87 $469.87 $569.34 $569.34 $483.59 $483.59 $362.27 $362.27 $346.40 $346.40 $370.41 $370.41 $390.36$449.56 $449.56 $429.86 $429.86 $459.66 $459.66 $484.41 $484.41 $586.95 $586.95 $498.56 $498.56 $373.48 $373.48 $357.11 $357.11 $381.87 $381.87 $402.43$449.56 $449.56 $429.86 $429.86 $459.66 $459.66 $484.41 $484.41 $586.95 $586.95 $498.56 $498.56 $373.48 $373.48 $357.11 $357.11 $381.87 $381.87 $402.43$449.56 $449.56 $429.86 $429.86 $459.66 $459.66 $484.41 $484.41 $586.95 $586.95 $498.56 $498.56 $373.48 $373.48 $357.11 $357.11 $381.87 $381.87 $402.43$449.56 $449.56 $429.86 $429.86 $459.66 $459.66 $484.41 $484.41 $586.95 $586.95 $498.56 $498.56 $373.48 $373.48 $357.11 $357.11 $381.87 $381.87 $402.43$451.35 $451.35 $431.57 $431.57 $461.50 $461.50 $486.34 $486.34 $589.29 $589.29 $500.54 $500.54 $374.97 $374.97 $358.54 $358.54 $383.39 $383.39 $404.04$460.34 $460.34 $440.17 $440.17 $470.69 $470.69 $496.03 $496.03 $601.03 $601.03 $510.52 $510.52 $382.44 $382.44 $365.68 $365.68 $391.03 $391.03 $412.09$471.13 $471.13 $450.49 $450.49 $481.72 $481.72 $507.66 $507.66 $615.12 $615.12 $522.48 $522.48 $391.40 $391.40 $374.25 $374.25 $400.20 $400.20 $421.75$488.67 $488.67 $467.25 $467.25 $499.65 $499.65 $526.55 $526.55 $638.01 $638.01 $541.92 $541.92 $405.97 $405.97 $388.18 $388.18 $415.09 $415.09 $437.44$503.05 $503.05 $481.01 $481.01 $514.36 $514.36 $542.05 $542.05 $656.79 $656.79 $557.88 $557.88 $417.92 $417.92 $399.60 $399.60 $427.31 $427.31 $450.32$510.24 $510.24 $487.88 $487.88 $521.71 $521.71 $549.80 $549.80 $666.18 $666.18 $565.85 $565.85 $423.89 $423.89 $405.32 $405.32 $433.42 $433.42 $456.76$521.03 $521.03 $498.20 $498.20 $532.74 $532.74 $561.43 $561.43 $680.27 $680.27 $577.82 $577.82 $432.86 $432.86 $413.89 $413.89 $442.58 $442.58 $466.42$531.82 $531.82 $508.52 $508.52 $543.77 $543.77 $573.05 $573.05 $694.36 $694.36 $589.79 $589.79 $441.82 $441.82 $422.46 $422.46 $451.75 $451.75 $476.07$538.57 $538.57 $514.97 $514.97 $550.67 $550.67 $580.32 $580.32 $703.16 $703.16 $597.26 $597.26 $447.42 $447.42 $427.82 $427.82 $457.48 $457.48 $482.11$545.76 $545.76 $521.84 $521.84 $558.02 $558.02 $588.07 $588.07 $712.55 $712.55 $605.24 $605.24 $453.40 $453.40 $433.53 $433.53 $463.59 $463.59 $488.55$549.36 $549.36 $525.28 $525.28 $561.70 $561.70 $591.95 $591.95 $717.25 $717.25 $609.23 $609.23 $456.39 $456.39 $436.39 $436.39 $466.64 $466.64 $491.77$552.95 $552.95 $528.72 $528.72 $565.38 $565.38 $595.82 $595.82 $721.94 $721.94 $613.22 $613.22 $459.37 $459.37 $439.24 $439.24 $469.70 $469.70 $494.99$556.55 $556.55 $532.16 $532.16 $569.05 $569.05 $599.70 $599.70 $726.64 $726.64 $617.21 $617.21 $462.36 $462.36 $442.10 $442.10 $472.75 $472.75 $498.21$560.14 $560.14 $535.60 $535.60 $572.73 $572.73 $603.57 $603.57 $731.33 $731.33 $621.19 $621.19 $465.35 $465.35 $444.96 $444.96 $475.81 $475.81 $501.43$567.34 $567.34 $542.48 $542.48 $580.09 $580.09 $611.32 $611.32 $740.73 $740.73 $629.17 $629.17 $471.32 $471.32 $450.67 $450.67 $481.92 $481.92 $507.87$574.53 $574.53 $549.35 $549.35 $587.44 $587.44 $619.07 $619.07 $750.12 $750.12 $637.15 $637.15 $477.30 $477.30 $456.38 $456.38 $488.03 $488.03 $514.30$585.32 $585.32 $559.67 $559.67 $598.47 $598.47 $630.70 $630.70 $764.20 $764.20 $649.11 $649.11 $486.26 $486.26 $464.96 $464.96 $497.19 $497.19 $523.96$595.66 $595.66 $569.56 $569.56 $609.04 $609.04 $641.84 $641.84 $777.70 $777.70 $660.58 $660.58 $494.85 $494.85 $473.17 $473.17 $505.97 $505.97 $533.22$610.04 $610.04 $583.31 $583.31 $623.75 $623.75 $657.34 $657.34 $796.49 $796.49 $676.53 $676.53 $506.80 $506.80 $484.60 $484.60 $518.19 $518.19 $546.10$628.03 $628.03 $600.51 $600.51 $642.14 $642.14 $676.72 $676.72 $819.96 $819.96 $696.48 $696.48 $521.74 $521.74 $498.88 $498.88 $533.47 $533.47 $562.19$649.16 $649.16 $620.71 $620.71 $663.74 $663.74 $699.48 $699.48 $847.55 $847.55 $719.91 $719.91 $539.30 $539.30 $515.66 $515.66 $551.42 $551.42 $581.11$674.33 $674.33 $644.78 $644.78 $689.48 $689.48 $726.61 $726.61 $880.42 $880.42 $747.83 $747.83 $560.21 $560.21 $535.66 $535.66 $572.80 $572.80 $603.64$702.65 $702.65 $671.86 $671.86 $718.44 $718.44 $757.13 $757.13 $917.40 $917.40 $779.23 $779.23 $583.74 $583.74 $558.16 $558.16 $596.86 $596.86 $629.00$735.02 $735.02 $702.81 $702.81 $751.54 $751.54 $792.01 $792.01 $959.66 $959.66 $815.13 $815.13 $610.63 $610.63 $583.87 $583.87 $624.35 $624.35 $657.97$766.94 $766.94 $733.33 $733.33 $784.17 $784.17 $826.40 $826.40 $1,001.33 $1,001.33 $850.53 $850.53 $637.15 $637.15 $609.23 $609.23 $651.46 $651.46 $686.54$802.90 $802.90 $767.72 $767.72 $820.95 $820.95 $865.15 $865.15 $1,048.29 $1,048.29 $890.41 $890.41 $667.03 $667.03 $637.80 $637.80 $682.01 $682.01 $718.74$838.42 $838.42 $801.68 $801.68 $857.26 $857.26 $903.42 $903.42 $1,094.65 $1,094.65 $929.80 $929.80 $696.53 $696.53 $666.01 $666.01 $712.18 $712.18 $750.53$877.53 $877.53 $839.08 $839.08 $897.25 $897.25 $945.56 $945.56 $1,145.72 $1,145.72 $973.17 $973.17 $729.02 $729.02 $697.08 $697.08 $745.40 $745.40 $785.54$917.09 $917.09 $876.90 $876.90 $937.70 $937.70 $988.19 $988.19 $1,197.37 $1,197.37 $1,017.04 $1,017.04 $761.89 $761.89 $728.50 $728.50 $779.01 $779.01 $820.96$959.80 $959.80 $917.74 $917.74 $981.37 $981.37 $1,034.21 $1,034.21 $1,253.13 $1,253.13 $1,064.41 $1,064.41 $797.37 $797.37 $762.43 $762.43 $815.29 $815.29 $859.19

$1,002.51 $1,002.51 $958.58 $958.58 $1,025.03 $1,025.03 $1,080.23 $1,080.23 $1,308.89 $1,308.89 $1,111.77 $1,111.77 $832.85 $832.85 $796.35 $796.35 $851.56 $851.56 $897.42$1,048.81 $1,048.81 $1,002.85 $1,002.85 $1,072.38 $1,072.38 $1,130.12 $1,130.12 $1,369.34 $1,369.34 $1,163.12 $1,163.12 $871.32 $871.32 $833.13 $833.13 $890.90 $890.90 $938.87$1,095.56 $1,095.56 $1,047.56 $1,047.56 $1,120.18 $1,120.18 $1,180.50 $1,180.50 $1,430.39 $1,430.39 $1,214.97 $1,214.97 $910.16 $910.16 $870.27 $870.27 $930.61 $930.61 $980.72$1,145.46 $1,145.46 $1,095.27 $1,095.27 $1,171.20 $1,171.20 $1,234.27 $1,234.27 $1,495.54 $1,495.54 $1,270.31 $1,270.31 $951.61 $951.61 $909.91 $909.91 $973.00 $973.00 $1,025.39$1,170.19 $1,170.19 $1,118.91 $1,118.91 $1,196.49 $1,196.49 $1,260.91 $1,260.91 $1,527.82 $1,527.82 $1,297.73 $1,297.73 $972.15 $972.15 $929.55 $929.55 $994.00 $994.00 $1,047.52$1,220.09 $1,220.09 $1,166.63 $1,166.63 $1,247.51 $1,247.51 $1,314.68 $1,314.68 $1,592.97 $1,592.97 $1,353.07 $1,353.07 $1,013.61 $1,013.61 $969.19 $969.19 $1,036.39 $1,036.39 $1,092.19$1,263.25 $1,263.25 $1,207.89 $1,207.89 $1,291.63 $1,291.63 $1,361.18 $1,361.18 $1,649.32 $1,649.32 $1,400.93 $1,400.93 $1,049.46 $1,049.46 $1,003.47 $1,003.47 $1,073.05 $1,073.05 $1,130.83$1,291.57 $1,291.57 $1,234.97 $1,234.97 $1,320.59 $1,320.59 $1,391.70 $1,391.70 $1,686.30 $1,686.30 $1,432.34 $1,432.34 $1,072.99 $1,072.99 $1,025.97 $1,025.97 $1,097.10 $1,097.10 $1,156.18$1,327.08 $1,327.08 $1,268.93 $1,268.93 $1,356.91 $1,356.91 $1,429.97 $1,429.97 $1,732.66 $1,732.66 $1,471.72 $1,471.72 $1,102.50 $1,102.50 $1,054.18 $1,054.18 $1,127.27 $1,127.27 $1,187.97$1,348.66 $1,348.66 $1,289.56 $1,289.56 $1,378.97 $1,378.97 $1,453.22 $1,453.22 $1,760.84 $1,760.84 $1,495.65 $1,495.65 $1,120.42 $1,120.42 $1,071.33 $1,071.33 $1,145.60 $1,145.60 $1,207.29

$6,8Y

Geisinger Al

GoMed: $500

20$25 /

75729PAGeisinger Al

25/50M-152-121-

Rating

$6,850Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


GoldMed: $500 / Rx: $250

20%$25 / $50


25/50/500M-152-121-F Rev. 1/20

Rating Area 3

$2,500Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes



0%$15 / $30


15/30/0M-152-121-F Rev. 1/20

Rating Area 9

$2,500Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$2,500

Yes



0%$15 / $30


15/30/0M-152-121-F Rev. 1/20

Rating Area 6

$2,500Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 5



0%$15 / $30$2,500

Yes



0%$15 / $30


15/30/0M-152-121-F Rev. 1/20

Rating Area 3


15/30/0M-152-121-F Rev. 1/20

Rating Area 2



0%$15 / $30$2,500

Yes

Page Number: 13 12/24/2014

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Rating Area =>

Network =>Metal =>




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64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$307.86 $373.03 $373.03 $316.85 $316.85 $320.35 $320.35 $361.01 $361.01 $371.55 $371.55 $270.21 $270.21 $304.50 $304.50 $313.39 $313.39 $259.63 $259.63$335.22 $406.18 $406.18 $345.01 $345.01 $348.83 $348.83 $393.10 $393.10 $404.58 $404.58 $294.22 $294.22 $331.56 $331.56 $341.24 $341.24 $282.71 $282.71$345.69 $418.86 $418.86 $355.78 $355.78 $359.72 $359.72 $405.37 $405.37 $417.21 $417.21 $303.41 $303.41 $341.91 $341.91 $351.90 $351.90 $291.54 $291.54$356.15 $431.54 $431.54 $366.55 $366.55 $370.61 $370.61 $417.64 $417.64 $429.83 $429.83 $312.59 $312.59 $352.26 $352.26 $362.55 $362.55 $300.36 $300.36$367.42 $445.19 $445.19 $378.15 $378.15 $382.33 $382.33 $430.85 $430.85 $443.43 $443.43 $322.48 $322.48 $363.41 $363.41 $374.02 $374.02 $309.86 $309.86$378.69 $458.85 $458.85 $389.74 $389.74 $394.06 $394.06 $444.07 $444.07 $457.03 $457.03 $332.37 $332.37 $374.55 $374.55 $385.49 $385.49 $319.37 $319.37$390.36 $472.99 $472.99 $401.75 $401.75 $406.20 $406.20 $457.75 $457.75 $471.12 $471.12 $342.61 $342.61 $386.09 $386.09 $397.37 $397.37 $329.21 $329.21$402.43 $487.62 $487.62 $414.18 $414.18 $418.77 $418.77 $471.91 $471.91 $485.69 $485.69 $353.22 $353.22 $398.04 $398.04 $409.66 $409.66 $339.39 $339.39$402.43 $487.62 $487.62 $414.18 $414.18 $418.77 $418.77 $471.91 $471.91 $485.69 $485.69 $353.22 $353.22 $398.04 $398.04 $409.66 $409.66 $339.39 $339.39$402.43 $487.62 $487.62 $414.18 $414.18 $418.77 $418.77 $471.91 $471.91 $485.69 $485.69 $353.22 $353.22 $398.04 $398.04 $409.66 $409.66 $339.39 $339.39$402.43 $487.62 $487.62 $414.18 $414.18 $418.77 $418.77 $471.91 $471.91 $485.69 $485.69 $353.22 $353.22 $398.04 $398.04 $409.66 $409.66 $339.39 $339.39$404.04 $489.57 $489.57 $415.84 $415.84 $420.44 $420.44 $473.80 $473.80 $487.63 $487.63 $354.62 $354.62 $399.63 $399.63 $411.30 $411.30 $340.75 $340.75$412.09 $499.32 $499.32 $424.12 $424.12 $428.81 $428.81 $483.24 $483.24 $497.34 $497.34 $361.69 $361.69 $407.59 $407.59 $419.49 $419.49 $347.53 $347.53$421.75 $511.02 $511.02 $434.06 $434.06 $438.87 $438.87 $494.56 $494.56 $509.00 $509.00 $370.16 $370.16 $417.14 $417.14 $429.32 $429.32 $355.68 $355.68$437.44 $530.04 $530.04 $450.21 $450.21 $455.20 $455.20 $512.97 $512.97 $527.94 $527.94 $383.94 $383.94 $432.66 $432.66 $445.30 $445.30 $368.92 $368.92$450.32 $545.64 $545.64 $463.47 $463.47 $468.60 $468.60 $528.07 $528.07 $543.48 $543.48 $395.24 $395.24 $445.40 $445.40 $458.41 $458.41 $379.78 $379.78$456.76 $553.44 $553.44 $470.09 $470.09 $475.30 $475.30 $535.62 $535.62 $551.26 $551.26 $400.89 $400.89 $451.77 $451.77 $464.96 $464.96 $385.21 $385.21$466.42 $565.15 $565.15 $480.03 $480.03 $485.35 $485.35 $546.94 $546.94 $562.91 $562.91 $409.37 $409.37 $461.32 $461.32 $474.79 $474.79 $393.35 $393.35$476.07 $576.85 $576.85 $489.97 $489.97 $495.40 $495.40 $558.27 $558.27 $574.57 $574.57 $417.85 $417.85 $470.88 $470.88 $484.62 $484.62 $401.50 $401.50$482.11 $584.16 $584.16 $496.19 $496.19 $501.68 $501.68 $565.35 $565.35 $581.85 $581.85 $423.15 $423.15 $476.85 $476.85 $490.77 $490.77 $406.59 $406.59$488.55 $591.96 $591.96 $502.81 $502.81 $508.38 $508.38 $572.90 $572.90 $589.63 $589.63 $428.80 $428.80 $483.22 $483.22 $497.32 $497.32 $412.02 $412.02$491.77 $595.87 $595.87 $506.13 $506.13 $511.73 $511.73 $576.67 $576.67 $593.51 $593.51 $431.62 $431.62 $486.40 $486.40 $500.60 $500.60 $414.73 $414.73$494.99 $599.77 $599.77 $509.44 $509.44 $515.08 $515.08 $580.45 $580.45 $597.40 $597.40 $434.45 $434.45 $489.58 $489.58 $503.88 $503.88 $417.45 $417.45$498.21 $603.67 $603.67 $512.75 $512.75 $518.43 $518.43 $584.22 $584.22 $601.28 $601.28 $437.27 $437.27 $492.77 $492.77 $507.16 $507.16 $420.16 $420.16$501.43 $607.57 $607.57 $516.07 $516.07 $521.78 $521.78 $588.00 $588.00 $605.17 $605.17 $440.10 $440.10 $495.95 $495.95 $510.43 $510.43 $422.88 $422.88$507.87 $615.37 $615.37 $522.69 $522.69 $528.48 $528.48 $595.55 $595.55 $612.94 $612.94 $445.75 $445.75 $502.32 $502.32 $516.99 $516.99 $428.31 $428.31$514.30 $623.17 $623.17 $529.32 $529.32 $535.18 $535.18 $603.10 $603.10 $620.71 $620.71 $451.40 $451.40 $508.69 $508.69 $523.54 $523.54 $433.74 $433.74$523.96 $634.87 $634.87 $539.26 $539.26 $545.23 $545.23 $614.43 $614.43 $632.37 $632.37 $459.88 $459.88 $518.24 $518.24 $533.37 $533.37 $441.88 $441.88$533.22 $646.09 $646.09 $548.79 $548.79 $554.86 $554.86 $625.28 $625.28 $643.54 $643.54 $468.00 $468.00 $527.40 $527.40 $542.80 $542.80 $449.69 $449.69$546.10 $661.69 $661.69 $562.04 $562.04 $568.26 $568.26 $640.38 $640.38 $659.08 $659.08 $479.31 $479.31 $540.13 $540.13 $555.90 $555.90 $460.55 $460.55$562.19 $681.20 $681.20 $578.61 $578.61 $585.01 $585.01 $659.26 $659.26 $678.51 $678.51 $493.43 $493.43 $556.06 $556.06 $572.29 $572.29 $474.13 $474.13$581.11 $704.12 $704.12 $598.07 $598.07 $604.70 $604.70 $681.44 $681.44 $701.33 $701.33 $510.04 $510.04 $574.76 $574.76 $591.55 $591.55 $490.08 $490.08$603.64 $731.42 $731.42 $621.27 $621.27 $628.15 $628.15 $707.86 $707.86 $728.53 $728.53 $529.82 $529.82 $597.05 $597.05 $614.49 $614.49 $509.08 $509.08$629.00 $762.14 $762.14 $647.36 $647.36 $654.53 $654.53 $737.59 $737.59 $759.13 $759.13 $552.07 $552.07 $622.13 $622.13 $640.29 $640.29 $530.47 $530.47$657.97 $797.25 $797.25 $677.18 $677.18 $684.68 $684.68 $771.57 $771.57 $794.10 $794.10 $577.50 $577.50 $650.79 $650.79 $669.79 $669.79 $554.90 $554.90$686.54 $831.87 $831.87 $706.59 $706.59 $714.41 $714.41 $805.08 $805.08 $828.58 $828.58 $602.58 $602.58 $679.05 $679.05 $698.88 $698.88 $579.00 $579.00$718.74 $870.88 $870.88 $739.72 $739.72 $747.91 $747.91 $842.83 $842.83 $867.44 $867.44 $630.83 $630.83 $710.89 $710.89 $731.65 $731.65 $606.15 $606.15$750.53 $909.40 $909.40 $772.44 $772.44 $781.00 $781.00 $880.11 $880.11 $905.81 $905.81 $658.74 $658.74 $742.34 $742.34 $764.01 $764.01 $632.96 $632.96$785.54 $951.82 $951.82 $808.48 $808.48 $817.43 $817.43 $921.17 $921.17 $948.06 $948.06 $689.47 $689.47 $776.97 $776.97 $799.65 $799.65 $662.49 $662.49$820.96 $994.73 $994.73 $844.92 $844.92 $854.28 $854.28 $962.70 $962.70 $990.80 $990.80 $720.55 $720.55 $811.99 $811.99 $835.70 $835.70 $692.35 $692.35$859.19 $1,041.06 $1,041.06 $884.27 $884.27 $894.06 $894.06 $1,007.53 $1,007.53 $1,036.94 $1,036.94 $754.10 $754.10 $849.81 $849.81 $874.62 $874.62 $724.60 $724.60$897.42 $1,087.38 $1,087.38 $923.62 $923.62 $933.84 $933.84 $1,052.36 $1,052.36 $1,083.08 $1,083.08 $787.66 $787.66 $887.62 $887.62 $913.54 $913.54 $756.84 $756.84$938.87 $1,137.61 $1,137.61 $966.28 $966.28 $976.98 $976.98 $1,100.96 $1,100.96 $1,133.11 $1,133.11 $824.04 $824.04 $928.62 $928.62 $955.73 $955.73 $791.79 $791.79$980.72 $1,188.32 $1,188.32 $1,009.35 $1,009.35 $1,020.53 $1,020.53 $1,150.04 $1,150.04 $1,183.62 $1,183.62 $860.77 $860.77 $970.01 $970.01 $998.33 $998.33 $827.09 $827.09

$1,025.39 $1,242.44 $1,242.44 $1,055.33 $1,055.33 $1,067.01 $1,067.01 $1,202.43 $1,202.43 $1,237.53 $1,237.53 $899.98 $899.98 $1,014.20 $1,014.20 $1,043.81 $1,043.81 $864.76 $864.76$1,047.52 $1,269.26 $1,269.26 $1,078.11 $1,078.11 $1,090.04 $1,090.04 $1,228.38 $1,228.38 $1,264.25 $1,264.25 $919.41 $919.41 $1,036.09 $1,036.09 $1,066.34 $1,066.34 $883.43 $883.43$1,092.19 $1,323.39 $1,323.39 $1,124.08 $1,124.08 $1,136.53 $1,136.53 $1,280.76 $1,280.76 $1,318.16 $1,318.16 $958.61 $958.61 $1,080.27 $1,080.27 $1,111.81 $1,111.81 $921.10 $921.10$1,130.83 $1,370.20 $1,370.20 $1,163.84 $1,163.84 $1,176.73 $1,176.73 $1,326.07 $1,326.07 $1,364.78 $1,364.78 $992.52 $992.52 $1,118.48 $1,118.48 $1,151.14 $1,151.14 $953.68 $953.68$1,156.18 $1,400.92 $1,400.92 $1,189.94 $1,189.94 $1,203.11 $1,203.11 $1,355.80 $1,355.80 $1,395.38 $1,395.38 $1,014.77 $1,014.77 $1,143.56 $1,143.56 $1,176.95 $1,176.95 $975.06 $975.06$1,187.97 $1,439.44 $1,439.44 $1,222.66 $1,222.66 $1,236.19 $1,236.19 $1,393.08 $1,393.08 $1,433.75 $1,433.75 $1,042.68 $1,042.68 $1,175.00 $1,175.00 $1,209.31 $1,209.31 $1,001.88 $1,001.88$1,207.29 $1,462.84 $1,462.84 $1,242.54 $1,242.54 $1,256.29 $1,256.29 $1,415.73 $1,415.73 $1,457.06 $1,457.06 $1,059.63 $1,059.63 $1,194.11 $1,194.11 $1,228.97 $1,228.97 $1,018.17 $1,018.17

$7,350Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


GoldMed: $1,000 / Rx: $0

0%$60 / $60


10/60/1000M-152-243-F Rev. 1/20

Rating Area 9

$7,350Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


GoldMed: $1,000 / Rx: $0

0%$60 / $60


10/60/1000M-152-243-F Rev. 1/20

Rating Area 3

$1,600Yes

75729PA0050131





0%$40 / $40$1,600

Yes



0%$40 / $40

75729PA0050131



$6,850Yes

75729PA0050131





0%$40 / $40$1,600

Yes


GoldMed: $500 / Rx: $250

20%$25 / $50


25/50/500M-152-121-F Rev. 1/20

Rating Area 9

850es


25/50/500M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes

l-Access PPO

old / Rx: $250

0%/ $50


Page Number: 14 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$292.58 $292.58 $301.12 $301.12 $228.74 $228.74 $257.76 $257.76 $265.29 $265.29 $320.30 $320.30 $306.26 $306.26 $327.49 $327.49 $345.13 $345.13 $418.19$318.59 $318.59 $327.89 $327.89 $249.07 $249.07 $280.68 $280.68 $288.87 $288.87 $348.77 $348.77 $333.48 $333.48 $356.61 $356.61 $375.81 $375.81 $455.36$328.53 $328.53 $338.13 $338.13 $256.84 $256.84 $289.44 $289.44 $297.89 $297.89 $359.65 $359.65 $343.89 $343.89 $367.74 $367.74 $387.54 $387.54 $469.57$338.48 $338.48 $348.36 $348.36 $264.62 $264.62 $298.20 $298.20 $306.91 $306.91 $370.54 $370.54 $354.30 $354.30 $378.87 $378.87 $399.27 $399.27 $483.78$349.19 $349.19 $359.38 $359.38 $272.99 $272.99 $307.63 $307.63 $316.62 $316.62 $382.26 $382.26 $365.51 $365.51 $390.85 $390.85 $411.90 $411.90 $499.09$359.90 $359.90 $370.40 $370.40 $281.36 $281.36 $317.07 $317.07 $326.33 $326.33 $393.99 $393.99 $376.72 $376.72 $402.84 $402.84 $424.53 $424.53 $514.40$370.99 $370.99 $381.82 $381.82 $290.03 $290.03 $326.84 $326.84 $336.38 $336.38 $406.13 $406.13 $388.33 $388.33 $415.25 $415.25 $437.61 $437.61 $530.25$382.47 $382.47 $393.63 $393.63 $299.01 $299.01 $336.95 $336.95 $346.79 $346.79 $418.69 $418.69 $400.35 $400.35 $428.10 $428.10 $451.15 $451.15 $546.65$382.47 $382.47 $393.63 $393.63 $299.01 $299.01 $336.95 $336.95 $346.79 $346.79 $418.69 $418.69 $400.35 $400.35 $428.10 $428.10 $451.15 $451.15 $546.65$382.47 $382.47 $393.63 $393.63 $299.01 $299.01 $336.95 $336.95 $346.79 $346.79 $418.69 $418.69 $400.35 $400.35 $428.10 $428.10 $451.15 $451.15 $546.65$382.47 $382.47 $393.63 $393.63 $299.01 $299.01 $336.95 $336.95 $346.79 $346.79 $418.69 $418.69 $400.35 $400.35 $428.10 $428.10 $451.15 $451.15 $546.65$383.99 $383.99 $395.20 $395.20 $300.20 $300.20 $338.30 $338.30 $348.17 $348.17 $420.36 $420.36 $401.94 $401.94 $429.81 $429.81 $452.95 $452.95 $548.83$391.64 $391.64 $403.07 $403.07 $306.18 $306.18 $345.03 $345.03 $355.11 $355.11 $428.74 $428.74 $409.95 $409.95 $438.37 $438.37 $461.98 $461.98 $559.77$400.82 $400.82 $412.52 $412.52 $313.35 $313.35 $353.12 $353.12 $363.43 $363.43 $438.79 $438.79 $419.56 $419.56 $448.65 $448.65 $472.80 $472.80 $572.89$415.73 $415.73 $427.87 $427.87 $325.01 $325.01 $366.26 $366.26 $376.96 $376.96 $455.11 $455.11 $435.17 $435.17 $465.34 $465.34 $490.40 $490.40 $594.21$427.97 $427.97 $440.47 $440.47 $334.58 $334.58 $377.04 $377.04 $388.05 $388.05 $468.51 $468.51 $447.98 $447.98 $479.04 $479.04 $504.84 $504.84 $611.70$434.09 $434.09 $446.77 $446.77 $339.37 $339.37 $382.44 $382.44 $393.60 $393.60 $475.21 $475.21 $454.39 $454.39 $485.89 $485.89 $512.05 $512.05 $620.45$443.27 $443.27 $456.21 $456.21 $346.54 $346.54 $390.52 $390.52 $401.92 $401.92 $485.26 $485.26 $464.00 $464.00 $496.17 $496.17 $522.88 $522.88 $633.56$452.45 $452.45 $465.66 $465.66 $353.72 $353.72 $398.61 $398.61 $410.25 $410.25 $495.31 $495.31 $473.60 $473.60 $506.44 $506.44 $533.71 $533.71 $646.68$458.19 $458.19 $471.57 $471.57 $358.20 $358.20 $403.66 $403.66 $415.45 $415.45 $501.59 $501.59 $479.61 $479.61 $512.86 $512.86 $540.48 $540.48 $654.88$464.31 $464.31 $477.86 $477.86 $362.99 $362.99 $409.05 $409.05 $421.00 $421.00 $508.29 $508.29 $486.02 $486.02 $519.71 $519.71 $547.69 $547.69 $663.63$467.37 $467.37 $481.01 $481.01 $365.38 $365.38 $411.75 $411.75 $423.77 $423.77 $511.64 $511.64 $489.22 $489.22 $523.14 $523.14 $551.30 $551.30 $668.00$470.43 $470.43 $484.16 $484.16 $367.77 $367.77 $414.45 $414.45 $426.55 $426.55 $514.99 $514.99 $492.42 $492.42 $526.56 $526.56 $554.91 $554.91 $672.38$473.49 $473.49 $487.31 $487.31 $370.16 $370.16 $417.14 $417.14 $429.32 $429.32 $518.34 $518.34 $495.62 $495.62 $529.98 $529.98 $558.52 $558.52 $676.75$476.55 $476.55 $490.46 $490.46 $372.56 $372.56 $419.84 $419.84 $432.09 $432.09 $521.69 $521.69 $498.83 $498.83 $533.41 $533.41 $562.13 $562.13 $681.12$482.67 $482.67 $496.76 $496.76 $377.34 $377.34 $425.23 $425.23 $437.64 $437.64 $528.39 $528.39 $505.23 $505.23 $540.26 $540.26 $569.35 $569.35 $689.87$488.78 $488.78 $503.06 $503.06 $382.12 $382.12 $430.62 $430.62 $443.19 $443.19 $535.08 $535.08 $511.64 $511.64 $547.11 $547.11 $576.57 $576.57 $698.62$497.96 $497.96 $512.50 $512.50 $389.30 $389.30 $438.71 $438.71 $451.51 $451.51 $545.13 $545.13 $521.25 $521.25 $557.38 $557.38 $587.40 $587.40 $711.74$506.76 $506.76 $521.56 $521.56 $396.18 $396.18 $446.46 $446.46 $459.49 $459.49 $554.76 $554.76 $530.45 $530.45 $567.23 $567.23 $597.77 $597.77 $724.31$519.00 $519.00 $534.15 $534.15 $405.74 $405.74 $457.24 $457.24 $470.59 $470.59 $568.16 $568.16 $543.26 $543.26 $580.93 $580.93 $612.21 $612.21 $741.80$534.30 $534.30 $549.90 $549.90 $417.70 $417.70 $470.72 $470.72 $484.46 $484.46 $584.91 $584.91 $559.28 $559.28 $598.05 $598.05 $630.26 $630.26 $763.67$552.27 $552.27 $568.40 $568.40 $431.76 $431.76 $486.55 $486.55 $500.76 $500.76 $604.59 $604.59 $578.09 $578.09 $618.17 $618.17 $651.46 $651.46 $789.36$573.69 $573.69 $590.44 $590.44 $448.50 $448.50 $505.42 $505.42 $520.18 $520.18 $628.03 $628.03 $600.51 $600.51 $642.15 $642.15 $676.72 $676.72 $819.97$597.79 $597.79 $615.24 $615.24 $467.34 $467.34 $526.65 $526.65 $542.03 $542.03 $654.41 $654.41 $625.73 $625.73 $669.12 $669.12 $705.15 $705.15 $854.41$625.32 $625.32 $643.58 $643.58 $488.87 $488.87 $550.91 $550.91 $566.99 $566.99 $684.56 $684.56 $654.56 $654.56 $699.94 $699.94 $737.63 $737.63 $893.77$652.48 $652.48 $671.53 $671.53 $510.10 $510.10 $574.83 $574.83 $591.62 $591.62 $714.28 $714.28 $682.98 $682.98 $730.33 $730.33 $769.66 $769.66 $932.58$683.07 $683.07 $703.02 $703.02 $534.02 $534.02 $601.79 $601.79 $619.36 $619.36 $747.78 $747.78 $715.01 $715.01 $764.58 $764.58 $805.75 $805.75 $976.31$713.29 $713.29 $734.12 $734.12 $557.64 $557.64 $628.41 $628.41 $646.75 $646.75 $780.85 $780.85 $746.64 $746.64 $798.40 $798.40 $841.39 $841.39 $1,019.50$746.56 $746.56 $768.36 $768.36 $583.65 $583.65 $657.72 $657.72 $676.93 $676.93 $817.28 $817.28 $781.47 $781.47 $835.65 $835.65 $880.64 $880.64 $1,067.06$780.22 $780.22 $803.00 $803.00 $609.96 $609.96 $687.37 $687.37 $707.44 $707.44 $854.13 $854.13 $816.70 $816.70 $873.32 $873.32 $920.34 $920.34 $1,115.16$816.55 $816.55 $840.39 $840.39 $638.37 $638.37 $719.38 $719.38 $740.39 $740.39 $893.90 $893.90 $854.73 $854.73 $913.99 $913.99 $963.20 $963.20 $1,167.09$852.89 $852.89 $877.79 $877.79 $666.77 $666.77 $751.39 $751.39 $773.33 $773.33 $933.68 $933.68 $892.76 $892.76 $954.66 $954.66 $1,006.06 $1,006.06 $1,219.02$892.28 $892.28 $918.33 $918.33 $697.57 $697.57 $786.10 $786.10 $809.05 $809.05 $976.80 $976.80 $934.00 $934.00 $998.75 $998.75 $1,052.53 $1,052.53 $1,275.33$932.06 $932.06 $959.27 $959.27 $728.67 $728.67 $821.14 $821.14 $845.12 $845.12 $1,020.34 $1,020.34 $975.63 $975.63 $1,043.27 $1,043.27 $1,099.45 $1,099.45 $1,332.18$974.51 $974.51 $1,002.96 $1,002.96 $761.86 $761.86 $858.54 $858.54 $883.61 $883.61 $1,066.82 $1,066.82 $1,020.07 $1,020.07 $1,090.79 $1,090.79 $1,149.53 $1,149.53 $1,392.86$995.55 $995.55 $1,024.61 $1,024.61 $778.30 $778.30 $877.07 $877.07 $902.68 $902.68 $1,089.85 $1,089.85 $1,042.09 $1,042.09 $1,114.34 $1,114.34 $1,174.34 $1,174.34 $1,422.92

$1,038.00 $1,038.00 $1,068.30 $1,068.30 $811.49 $811.49 $914.48 $914.48 $941.18 $941.18 $1,136.32 $1,136.32 $1,086.53 $1,086.53 $1,161.86 $1,161.86 $1,224.42 $1,224.42 $1,483.60$1,074.71 $1,074.71 $1,106.09 $1,106.09 $840.19 $840.19 $946.82 $946.82 $974.47 $974.47 $1,176.52 $1,176.52 $1,124.96 $1,124.96 $1,202.95 $1,202.95 $1,267.73 $1,267.73 $1,536.08$1,098.81 $1,098.81 $1,130.89 $1,130.89 $859.03 $859.03 $968.05 $968.05 $996.31 $996.31 $1,202.89 $1,202.89 $1,150.18 $1,150.18 $1,229.92 $1,229.92 $1,296.15 $1,296.15 $1,570.52$1,129.02 $1,129.02 $1,161.99 $1,161.99 $882.65 $882.65 $994.67 $994.67 $1,023.71 $1,023.71 $1,235.97 $1,235.97 $1,181.81 $1,181.81 $1,263.74 $1,263.74 $1,331.79 $1,331.79 $1,613.70$1,147.38 $1,147.38 $1,180.88 $1,180.88 $897.00 $897.00 $1,010.84 $1,010.84 $1,040.36 $1,040.36 $1,256.07 $1,256.07 $1,201.03 $1,201.03 $1,284.29 $1,284.29 $1,353.45 $1,353.45 $1,639.94

$1,500Yes

75729PAGeisinger All-A

PPO M-152-122-

Rating

Geisinger Al

PlatiCombine

00% After D

$1,5Y


PlatinumCombined: $1,500



PPO 1500M-152-122-F Rev. 1/20

Rating Area 6

$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 5




$1,500Yes





PPO 1500M-152-122-F Rev. 1/20

Rating Area 3

$7,350Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 2




$1,500Yes


SilverMed: $6,250 / Rx: $500

0%$60 / $60


20/60/6250M-152-243-F Rev. 1/20

Rating Area 9

$7,350Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 6


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


SilverMed: $6,250 / Rx: $500

0%$60 / $60


20/60/6250M-152-243-F Rev. 1/20

Rating Area 3

$7,350Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


GoldMed: $2,000 / Rx: $0

0%$60 / $60


10/60/2000M-152-243-F Rev. 1/20

Rating Area 6

Page Number: 15 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$418.19 $355.21 $355.21 $315.73 $315.73 $301.90 $301.90 $322.83 $322.83 $340.21 $340.21 $412.23 $412.23 $350.14 $350.14 $272.84 $272.84 $260.88 $260.88$455.36 $386.78 $386.78 $343.80 $343.80 $328.73 $328.73 $351.52 $351.52 $370.45 $370.45 $448.87 $448.87 $381.27 $381.27 $297.09 $297.09 $284.07 $284.07$469.57 $398.85 $398.85 $354.53 $354.53 $338.99 $338.99 $362.50 $362.50 $382.01 $382.01 $462.88 $462.88 $393.17 $393.17 $306.36 $306.36 $292.94 $292.94$483.78 $410.92 $410.92 $365.26 $365.26 $349.25 $349.25 $373.47 $373.47 $393.58 $393.58 $476.89 $476.89 $405.07 $405.07 $315.64 $315.64 $301.81 $301.81$499.09 $423.93 $423.93 $376.82 $376.82 $360.30 $360.30 $385.28 $385.28 $406.03 $406.03 $491.98 $491.98 $417.88 $417.88 $325.62 $325.62 $311.35 $311.35$514.40 $436.93 $436.93 $388.37 $388.37 $371.35 $371.35 $397.10 $397.10 $418.48 $418.48 $507.07 $507.07 $430.70 $430.70 $335.61 $335.61 $320.90 $320.90$530.25 $450.39 $450.39 $400.34 $400.34 $382.80 $382.80 $409.34 $409.34 $431.38 $431.38 $522.69 $522.69 $443.97 $443.97 $345.95 $345.95 $330.79 $330.79$546.65 $464.33 $464.33 $412.73 $412.73 $394.64 $394.64 $422.00 $422.00 $444.72 $444.72 $538.86 $538.86 $457.71 $457.71 $356.66 $356.66 $341.03 $341.03$546.65 $464.33 $464.33 $412.73 $412.73 $394.64 $394.64 $422.00 $422.00 $444.72 $444.72 $538.86 $538.86 $457.71 $457.71 $356.66 $356.66 $341.03 $341.03$546.65 $464.33 $464.33 $412.73 $412.73 $394.64 $394.64 $422.00 $422.00 $444.72 $444.72 $538.86 $538.86 $457.71 $457.71 $356.66 $356.66 $341.03 $341.03$546.65 $464.33 $464.33 $412.73 $412.73 $394.64 $394.64 $422.00 $422.00 $444.72 $444.72 $538.86 $538.86 $457.71 $457.71 $356.66 $356.66 $341.03 $341.03$548.83 $466.18 $466.18 $414.37 $414.37 $396.22 $396.22 $423.69 $423.69 $446.50 $446.50 $541.01 $541.01 $459.54 $459.54 $358.08 $358.08 $342.39 $342.39$559.77 $475.47 $475.47 $422.63 $422.63 $404.11 $404.11 $432.12 $432.12 $455.39 $455.39 $551.79 $551.79 $468.69 $468.69 $365.21 $365.21 $349.21 $349.21$572.89 $486.61 $486.61 $432.53 $432.53 $413.58 $413.58 $442.25 $442.25 $466.07 $466.07 $564.72 $564.72 $479.67 $479.67 $373.77 $373.77 $357.39 $357.39$594.21 $504.72 $504.72 $448.63 $448.63 $428.97 $428.97 $458.71 $458.71 $483.41 $483.41 $585.74 $585.74 $497.52 $497.52 $387.68 $387.68 $370.69 $370.69$611.70 $519.58 $519.58 $461.84 $461.84 $441.60 $441.60 $472.21 $472.21 $497.64 $497.64 $602.98 $602.98 $512.17 $512.17 $399.09 $399.09 $381.61 $381.61$620.45 $527.00 $527.00 $468.44 $468.44 $447.91 $447.91 $478.97 $478.97 $504.76 $504.76 $611.60 $611.60 $519.49 $519.49 $404.80 $404.80 $387.06 $387.06$633.56 $538.15 $538.15 $478.35 $478.35 $457.38 $457.38 $489.09 $489.09 $515.43 $515.43 $624.54 $624.54 $530.48 $530.48 $413.36 $413.36 $395.25 $395.25$646.68 $549.29 $549.29 $488.25 $488.25 $466.86 $466.86 $499.22 $499.22 $526.10 $526.10 $637.47 $637.47 $541.46 $541.46 $421.92 $421.92 $403.43 $403.43$654.88 $556.26 $556.26 $494.44 $494.44 $472.77 $472.77 $505.55 $505.55 $532.77 $532.77 $645.55 $645.55 $548.33 $548.33 $427.27 $427.27 $408.55 $408.55$663.63 $563.69 $563.69 $501.04 $501.04 $479.09 $479.09 $512.30 $512.30 $539.89 $539.89 $654.17 $654.17 $555.65 $555.65 $432.98 $432.98 $414.00 $414.00$668.00 $567.40 $567.40 $504.35 $504.35 $482.25 $482.25 $515.68 $515.68 $543.45 $543.45 $658.48 $658.48 $559.31 $559.31 $435.83 $435.83 $416.73 $416.73$672.38 $571.12 $571.12 $507.65 $507.65 $485.40 $485.40 $519.06 $519.06 $547.01 $547.01 $662.80 $662.80 $562.98 $562.98 $438.68 $438.68 $419.46 $419.46$676.75 $574.83 $574.83 $510.95 $510.95 $488.56 $488.56 $522.43 $522.43 $550.56 $550.56 $667.11 $667.11 $566.64 $566.64 $441.54 $441.54 $422.19 $422.19$681.12 $578.54 $578.54 $514.25 $514.25 $491.72 $491.72 $525.81 $525.81 $554.12 $554.12 $671.42 $671.42 $570.30 $570.30 $444.39 $444.39 $424.92 $424.92$689.87 $585.97 $585.97 $520.86 $520.86 $498.03 $498.03 $532.56 $532.56 $561.24 $561.24 $680.04 $680.04 $577.62 $577.62 $450.10 $450.10 $430.37 $430.37$698.62 $593.40 $593.40 $527.46 $527.46 $504.35 $504.35 $539.31 $539.31 $568.35 $568.35 $688.66 $688.66 $584.95 $584.95 $455.80 $455.80 $435.83 $435.83$711.74 $604.55 $604.55 $537.36 $537.36 $513.82 $513.82 $549.44 $549.44 $579.03 $579.03 $701.59 $701.59 $595.93 $595.93 $464.36 $464.36 $444.01 $444.01$724.31 $615.23 $615.23 $546.86 $546.86 $522.89 $522.89 $559.15 $559.15 $589.25 $589.25 $713.99 $713.99 $606.46 $606.46 $472.56 $472.56 $451.86 $451.86$741.80 $630.08 $630.08 $560.06 $560.06 $535.52 $535.52 $572.65 $572.65 $603.48 $603.48 $731.23 $731.23 $621.10 $621.10 $483.98 $483.98 $462.77 $462.77$763.67 $648.66 $648.66 $576.57 $576.57 $551.31 $551.31 $589.53 $589.53 $621.27 $621.27 $752.78 $752.78 $639.41 $639.41 $498.24 $498.24 $476.41 $476.41$789.36 $670.48 $670.48 $595.97 $595.97 $569.86 $569.86 $609.36 $609.36 $642.18 $642.18 $778.11 $778.11 $660.93 $660.93 $515.01 $515.01 $492.44 $492.44$819.97 $696.48 $696.48 $619.08 $619.08 $591.96 $591.96 $633.00 $633.00 $667.08 $667.08 $808.29 $808.29 $686.56 $686.56 $534.98 $534.98 $511.54 $511.54$854.41 $725.73 $725.73 $645.09 $645.09 $616.82 $616.82 $659.58 $659.58 $695.10 $695.10 $842.23 $842.23 $715.39 $715.39 $557.45 $557.45 $533.02 $533.02$893.77 $759.17 $759.17 $674.80 $674.80 $645.23 $645.23 $689.97 $689.97 $727.12 $727.12 $881.03 $881.03 $748.35 $748.35 $583.13 $583.13 $557.57 $557.57$932.58 $792.13 $792.13 $704.10 $704.10 $673.25 $673.25 $719.93 $719.93 $758.69 $758.69 $919.29 $919.29 $780.84 $780.84 $608.45 $608.45 $581.79 $581.79$976.31 $829.28 $829.28 $737.12 $737.12 $704.82 $704.82 $753.69 $753.69 $794.27 $794.27 $962.40 $962.40 $817.46 $817.46 $636.98 $636.98 $609.07 $609.07

$1,019.50 $865.96 $865.96 $769.73 $769.73 $736.00 $736.00 $787.02 $787.02 $829.40 $829.40 $1,004.97 $1,004.97 $853.62 $853.62 $665.16 $665.16 $636.01 $636.01$1,067.06 $906.36 $906.36 $805.63 $805.63 $770.33 $770.33 $823.74 $823.74 $868.09 $868.09 $1,051.85 $1,051.85 $893.44 $893.44 $696.19 $696.19 $665.68 $665.68$1,115.16 $947.22 $947.22 $841.95 $841.95 $805.06 $805.06 $860.87 $860.87 $907.23 $907.23 $1,099.27 $1,099.27 $933.72 $933.72 $727.57 $727.57 $695.69 $695.69$1,167.09 $991.33 $991.33 $881.16 $881.16 $842.55 $842.55 $900.96 $900.96 $949.48 $949.48 $1,150.46 $1,150.46 $977.20 $977.20 $761.45 $761.45 $728.09 $728.09$1,219.02 $1,035.44 $1,035.44 $920.37 $920.37 $880.04 $880.04 $941.05 $941.05 $991.73 $991.73 $1,201.65 $1,201.65 $1,020.68 $1,020.68 $795.33 $795.33 $760.48 $760.48$1,275.33 $1,083.26 $1,083.26 $962.88 $962.88 $920.69 $920.69 $984.52 $984.52 $1,037.53 $1,037.53 $1,257.16 $1,257.16 $1,067.82 $1,067.82 $832.07 $832.07 $795.61 $795.61$1,332.18 $1,131.55 $1,131.55 $1,005.80 $1,005.80 $961.73 $961.73 $1,028.41 $1,028.41 $1,083.78 $1,083.78 $1,313.20 $1,313.20 $1,115.43 $1,115.43 $869.16 $869.16 $831.07 $831.07$1,392.86 $1,183.09 $1,183.09 $1,051.62 $1,051.62 $1,005.53 $1,005.53 $1,075.25 $1,075.25 $1,133.15 $1,133.15 $1,373.01 $1,373.01 $1,166.23 $1,166.23 $908.75 $908.75 $868.93 $868.93$1,422.92 $1,208.63 $1,208.63 $1,074.32 $1,074.32 $1,027.24 $1,027.24 $1,098.46 $1,098.46 $1,157.61 $1,157.61 $1,402.65 $1,402.65 $1,191.40 $1,191.40 $928.37 $928.37 $887.68 $887.68$1,483.60 $1,260.17 $1,260.17 $1,120.13 $1,120.13 $1,071.04 $1,071.04 $1,145.30 $1,145.30 $1,206.97 $1,206.97 $1,462.46 $1,462.46 $1,242.21 $1,242.21 $967.95 $967.95 $925.54 $925.54$1,536.08 $1,304.74 $1,304.74 $1,159.75 $1,159.75 $1,108.93 $1,108.93 $1,185.81 $1,185.81 $1,249.66 $1,249.66 $1,514.19 $1,514.19 $1,286.15 $1,286.15 $1,002.19 $1,002.19 $958.28 $958.28$1,570.52 $1,334.00 $1,334.00 $1,185.75 $1,185.75 $1,133.79 $1,133.79 $1,212.40 $1,212.40 $1,277.68 $1,277.68 $1,548.14 $1,548.14 $1,314.98 $1,314.98 $1,024.66 $1,024.66 $979.76 $979.76$1,613.70 $1,370.68 $1,370.68 $1,218.36 $1,218.36 $1,164.97 $1,164.97 $1,245.74 $1,245.74 $1,312.81 $1,312.81 $1,590.71 $1,590.71 $1,351.14 $1,351.14 $1,052.84 $1,052.84 $1,006.70 $1,006.70$1,639.94 $1,392.96 $1,392.96 $1,238.17 $1,238.17 $1,183.91 $1,183.91 $1,265.99 $1,265.99 $1,334.16 $1,334.16 $1,616.57 $1,616.57 $1,373.11 $1,373.11 $1,069.96 $1,069.96 $1,023.07 $1,023.07

$7,350Yes


GoldMed: $4,500 / Rx: $0

0%$25 / $50


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 3

$5,000Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


PlatinumMed: $1,500 / Rx: $0

0%$15 / $30


15/30/1500M-152-121-F Rev. 1/20

Rating Area 9

$5,000Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$5,000

Yes



0%$15 / $30


15/30/1500M-152-121-F Rev. 1/20

Rating Area 6

$5,000Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 5



0%$15 / $30$5,000

Yes



0%$15 / $30


15/30/1500M-152-121-F Rev. 1/20

Rating Area 3

$1,500Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 2



0%$15 / $30$5,000

Yes





PPO 1500M-152-122-F Rev. 1/20

Rating Area 9

A0050135Access QHDHP 1500-F Rev. 1/20Area 7

l-Access PPO

numd: $1,500%

Deductible500es

Page Number: 16 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$278.97 $278.97 $293.99 $293.99 $356.22 $356.22 $302.58 $302.58 $294.06 $294.06 $281.17 $281.17 $300.67 $300.67 $316.85 $316.85 $383.93 $383.93 $326.11$303.77 $303.77 $320.12 $320.12 $387.89 $387.89 $329.47 $329.47 $320.20 $320.20 $306.16 $306.16 $327.39 $327.39 $345.02 $345.02 $418.05 $418.05 $355.09$313.25 $313.25 $330.12 $330.12 $399.99 $399.99 $339.75 $339.75 $330.19 $330.19 $315.72 $315.72 $337.61 $337.61 $355.79 $355.79 $431.10 $431.10 $366.18$322.73 $322.73 $340.11 $340.11 $412.10 $412.10 $350.04 $350.04 $340.18 $340.18 $325.28 $325.28 $347.83 $347.83 $366.56 $366.56 $444.15 $444.15 $377.26$332.94 $332.94 $350.87 $350.87 $425.14 $425.14 $361.11 $361.11 $350.95 $350.95 $335.57 $335.57 $358.83 $358.83 $378.15 $378.15 $458.20 $458.20 $389.20$343.15 $343.15 $361.63 $361.63 $438.18 $438.18 $372.19 $372.19 $361.71 $361.71 $345.86 $345.86 $369.84 $369.84 $389.75 $389.75 $472.25 $472.25 $401.13$353.73 $353.73 $372.77 $372.77 $451.68 $451.68 $383.66 $383.66 $372.86 $372.86 $356.52 $356.52 $381.24 $381.24 $401.76 $401.76 $486.81 $486.81 $413.49$364.67 $364.67 $384.31 $384.31 $465.66 $465.66 $395.53 $395.53 $384.39 $384.39 $367.55 $367.55 $393.03 $393.03 $414.19 $414.19 $501.87 $501.87 $426.29$364.67 $364.67 $384.31 $384.31 $465.66 $465.66 $395.53 $395.53 $384.39 $384.39 $367.55 $367.55 $393.03 $393.03 $414.19 $414.19 $501.87 $501.87 $426.29$364.67 $364.67 $384.31 $384.31 $465.66 $465.66 $395.53 $395.53 $384.39 $384.39 $367.55 $367.55 $393.03 $393.03 $414.19 $414.19 $501.87 $501.87 $426.29$364.67 $364.67 $384.31 $384.31 $465.66 $465.66 $395.53 $395.53 $384.39 $384.39 $367.55 $367.55 $393.03 $393.03 $414.19 $414.19 $501.87 $501.87 $426.29$366.13 $366.13 $385.84 $385.84 $467.51 $467.51 $397.11 $397.11 $385.93 $385.93 $369.01 $369.01 $394.60 $394.60 $415.85 $415.85 $503.87 $503.87 $427.99$373.42 $373.42 $393.53 $393.53 $476.83 $476.83 $405.02 $405.02 $393.61 $393.61 $376.37 $376.37 $402.46 $402.46 $424.13 $424.13 $513.91 $513.91 $436.51$382.17 $382.17 $402.75 $402.75 $488.00 $488.00 $414.51 $414.51 $402.84 $402.84 $385.19 $385.19 $411.89 $411.89 $434.07 $434.07 $525.95 $525.95 $446.74$396.39 $396.39 $417.74 $417.74 $506.16 $506.16 $429.93 $429.93 $417.83 $417.83 $399.52 $399.52 $427.22 $427.22 $450.22 $450.22 $545.53 $545.53 $463.37$408.06 $408.06 $430.03 $430.03 $521.06 $521.06 $442.59 $442.59 $430.13 $430.13 $411.28 $411.28 $439.80 $439.80 $463.48 $463.48 $561.59 $561.59 $477.01$413.90 $413.90 $436.18 $436.18 $528.51 $528.51 $448.92 $448.92 $436.28 $436.28 $417.16 $417.16 $446.08 $446.08 $470.10 $470.10 $569.62 $569.62 $483.83$422.65 $422.65 $445.41 $445.41 $539.69 $539.69 $458.41 $458.41 $445.51 $445.51 $425.98 $425.98 $455.52 $455.52 $480.05 $480.05 $581.66 $581.66 $494.06$431.40 $431.40 $454.63 $454.63 $550.87 $550.87 $467.90 $467.90 $454.73 $454.73 $434.80 $434.80 $464.95 $464.95 $489.99 $489.99 $593.71 $593.71 $504.29$436.87 $436.87 $460.39 $460.39 $557.85 $557.85 $473.84 $473.84 $460.50 $460.50 $440.32 $440.32 $470.85 $470.85 $496.20 $496.20 $601.23 $601.23 $510.69$442.71 $442.71 $466.54 $466.54 $565.30 $565.30 $480.17 $480.17 $466.65 $466.65 $446.20 $446.20 $477.13 $477.13 $502.83 $502.83 $609.26 $609.26 $517.51$445.62 $445.62 $469.62 $469.62 $569.03 $569.03 $483.33 $483.33 $469.72 $469.72 $449.14 $449.14 $480.28 $480.28 $506.14 $506.14 $613.28 $613.28 $520.92$448.54 $448.54 $472.69 $472.69 $572.75 $572.75 $486.49 $486.49 $472.80 $472.80 $452.08 $452.08 $483.42 $483.42 $509.45 $509.45 $617.29 $617.29 $524.33$451.46 $451.46 $475.77 $475.77 $576.48 $576.48 $489.66 $489.66 $475.87 $475.87 $455.02 $455.02 $486.57 $486.57 $512.77 $512.77 $621.31 $621.31 $527.74$454.38 $454.38 $478.84 $478.84 $580.20 $580.20 $492.82 $492.82 $478.95 $478.95 $457.96 $457.96 $489.71 $489.71 $516.08 $516.08 $625.32 $625.32 $531.15$460.21 $460.21 $484.99 $484.99 $587.65 $587.65 $499.15 $499.15 $485.10 $485.10 $463.84 $463.84 $496.00 $496.00 $522.71 $522.71 $633.35 $633.35 $537.97$466.04 $466.04 $491.14 $491.14 $595.10 $595.10 $505.48 $505.48 $491.25 $491.25 $469.72 $469.72 $502.29 $502.29 $529.33 $529.33 $641.38 $641.38 $544.79$474.80 $474.80 $500.36 $500.36 $606.28 $606.28 $514.97 $514.97 $500.47 $500.47 $478.54 $478.54 $511.72 $511.72 $539.27 $539.27 $653.43 $653.43 $555.02$483.18 $483.18 $509.20 $509.20 $616.99 $616.99 $524.07 $524.07 $509.31 $509.31 $487.00 $487.00 $520.76 $520.76 $548.80 $548.80 $664.97 $664.97 $564.82$494.85 $494.85 $521.50 $521.50 $631.89 $631.89 $536.73 $536.73 $521.61 $521.61 $498.76 $498.76 $533.34 $533.34 $562.05 $562.05 $681.03 $681.03 $578.47$509.44 $509.44 $536.87 $536.87 $650.52 $650.52 $552.55 $552.55 $536.99 $536.99 $513.46 $513.46 $549.06 $549.06 $578.62 $578.62 $701.10 $701.10 $595.52$526.58 $526.58 $554.93 $554.93 $672.40 $672.40 $571.14 $571.14 $555.06 $555.06 $530.73 $530.73 $567.53 $567.53 $598.09 $598.09 $724.69 $724.69 $615.55$547.00 $547.00 $576.45 $576.45 $698.48 $698.48 $593.29 $593.29 $576.58 $576.58 $551.32 $551.32 $589.54 $589.54 $621.28 $621.28 $752.80 $752.80 $639.42$569.97 $569.97 $600.67 $600.67 $727.81 $727.81 $618.20 $618.20 $600.80 $600.80 $574.47 $574.47 $614.30 $614.30 $647.38 $647.38 $784.41 $784.41 $666.28$596.23 $596.23 $628.34 $628.34 $761.34 $761.34 $646.68 $646.68 $628.47 $628.47 $600.94 $600.94 $642.60 $642.60 $677.20 $677.20 $820.55 $820.55 $696.97$622.12 $622.12 $655.62 $655.62 $794.40 $794.40 $674.76 $674.76 $655.77 $655.77 $627.03 $627.03 $670.50 $670.50 $706.61 $706.61 $856.18 $856.18 $727.24$651.30 $651.30 $686.37 $686.37 $831.65 $831.65 $706.40 $706.40 $686.52 $686.52 $656.43 $656.43 $701.94 $701.94 $739.74 $739.74 $896.33 $896.33 $761.34$680.10 $680.10 $716.72 $716.72 $868.44 $868.44 $737.65 $737.65 $716.88 $716.88 $685.47 $685.47 $732.99 $732.99 $772.46 $772.46 $935.98 $935.98 $795.02$711.83 $711.83 $750.16 $750.16 $908.95 $908.95 $772.06 $772.06 $750.33 $750.33 $717.45 $717.45 $767.19 $767.19 $808.50 $808.50 $979.64 $979.64 $832.10$743.92 $743.92 $783.98 $783.98 $949.93 $949.93 $806.87 $806.87 $784.15 $784.15 $749.79 $749.79 $801.77 $801.77 $844.95 $844.95 $1,023.80 $1,023.80 $869.62$778.56 $778.56 $820.49 $820.49 $994.17 $994.17 $844.44 $844.44 $820.67 $820.67 $784.71 $784.71 $839.11 $839.11 $884.29 $884.29 $1,071.48 $1,071.48 $910.11$813.21 $813.21 $857.00 $857.00 $1,038.40 $1,038.40 $882.02 $882.02 $857.19 $857.19 $819.62 $819.62 $876.45 $876.45 $923.64 $923.64 $1,119.16 $1,119.16 $950.61$850.77 $850.77 $896.58 $896.58 $1,086.37 $1,086.37 $922.76 $922.76 $896.78 $896.78 $857.48 $857.48 $916.93 $916.93 $966.30 $966.30 $1,170.85 $1,170.85 $994.52$888.69 $888.69 $936.55 $936.55 $1,134.79 $1,134.79 $963.89 $963.89 $936.75 $936.75 $895.71 $895.71 $957.81 $957.81 $1,009.38 $1,009.38 $1,223.04 $1,223.04 $1,038.85$929.17 $929.17 $979.20 $979.20 $1,186.48 $1,186.48 $1,007.79 $1,007.79 $979.42 $979.42 $936.50 $936.50 $1,001.43 $1,001.43 $1,055.35 $1,055.35 $1,278.75 $1,278.75 $1,086.17$949.23 $949.23 $1,000.34 $1,000.34 $1,212.09 $1,212.09 $1,029.55 $1,029.55 $1,000.56 $1,000.56 $956.72 $956.72 $1,023.05 $1,023.05 $1,078.13 $1,078.13 $1,306.35 $1,306.35 $1,109.61$989.71 $989.71 $1,043.00 $1,043.00 $1,263.78 $1,263.78 $1,073.45 $1,073.45 $1,043.23 $1,043.23 $997.52 $997.52 $1,066.67 $1,066.67 $1,124.11 $1,124.11 $1,362.06 $1,362.06 $1,156.93

$1,024.71 $1,024.71 $1,079.89 $1,079.89 $1,308.48 $1,308.48 $1,111.42 $1,111.42 $1,080.13 $1,080.13 $1,032.80 $1,032.80 $1,104.40 $1,104.40 $1,163.87 $1,163.87 $1,410.24 $1,410.24 $1,197.85$1,047.69 $1,047.69 $1,104.10 $1,104.10 $1,337.82 $1,337.82 $1,136.34 $1,136.34 $1,104.35 $1,104.35 $1,055.95 $1,055.95 $1,129.16 $1,129.16 $1,189.97 $1,189.97 $1,441.86 $1,441.86 $1,224.71$1,076.50 $1,076.50 $1,134.46 $1,134.46 $1,374.60 $1,374.60 $1,167.59 $1,167.59 $1,134.71 $1,134.71 $1,084.99 $1,084.99 $1,160.21 $1,160.21 $1,222.69 $1,222.69 $1,481.50 $1,481.50 $1,258.39$1,094.00 $1,094.00 $1,152.91 $1,152.91 $1,396.96 $1,396.96 $1,186.57 $1,186.57 $1,153.16 $1,153.16 $1,102.63 $1,102.63 $1,179.08 $1,179.08 $1,242.57 $1,242.57 $1,505.59 $1,505.59 $1,278.85

$7,0Y

Geisinger Al

GoCombine

0$20 / $40 Aft


PPO 20/M-152-122-

Rating

$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 7



0%$20 / $40 After Deductible

$7,000Yes





PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 6

$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 5




$7,000Yes





PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 3

$7,350Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 2




$7,000Yes


GoldMed: $4,500 / Rx: $0

0%$25 / $50


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 9

$7,350Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


GoldMed: $4,500 / Rx: $0

0%$25 / $50


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 6


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes

Page Number: 17 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$326.11 $354.82 $354.82 $298.33 $298.33 $285.91 $285.91 $258.85 $258.85 $314.86 $314.86 $354.82 $354.82 $264.74 $264.74 $298.33 $298.33 $253.71 $253.71$355.09 $386.36 $386.36 $324.85 $324.85 $311.33 $311.33 $281.86 $281.86 $342.85 $342.85 $386.36 $386.36 $288.27 $288.27 $324.85 $324.85 $276.27 $276.27$366.18 $398.42 $398.42 $334.99 $334.99 $321.04 $321.04 $290.66 $290.66 $353.55 $353.55 $398.42 $398.42 $297.27 $297.27 $334.99 $334.99 $284.89 $284.89$377.26 $410.48 $410.48 $345.13 $345.13 $330.76 $330.76 $299.46 $299.46 $364.25 $364.25 $410.48 $410.48 $306.26 $306.26 $345.13 $345.13 $293.51 $293.51$389.20 $423.47 $423.47 $356.05 $356.05 $341.23 $341.23 $308.93 $308.93 $375.78 $375.78 $423.47 $423.47 $315.95 $315.95 $356.05 $356.05 $302.80 $302.80$401.13 $436.45 $436.45 $366.97 $366.97 $351.69 $351.69 $318.41 $318.41 $387.30 $387.30 $436.45 $436.45 $325.64 $325.64 $366.97 $366.97 $312.09 $312.09$413.49 $449.90 $449.90 $378.28 $378.28 $362.53 $362.53 $328.22 $328.22 $399.24 $399.24 $449.90 $449.90 $335.68 $335.68 $378.28 $378.28 $321.70 $321.70$426.29 $463.82 $463.82 $389.98 $389.98 $373.75 $373.75 $338.38 $338.38 $411.59 $411.59 $463.82 $463.82 $346.07 $346.07 $389.98 $389.98 $331.66 $331.66$426.29 $463.82 $463.82 $389.98 $389.98 $373.75 $373.75 $338.38 $338.38 $411.59 $411.59 $463.82 $463.82 $346.07 $346.07 $389.98 $389.98 $331.66 $331.66$426.29 $463.82 $463.82 $389.98 $389.98 $373.75 $373.75 $338.38 $338.38 $411.59 $411.59 $463.82 $463.82 $346.07 $346.07 $389.98 $389.98 $331.66 $331.66$426.29 $463.82 $463.82 $389.98 $389.98 $373.75 $373.75 $338.38 $338.38 $411.59 $411.59 $463.82 $463.82 $346.07 $346.07 $389.98 $389.98 $331.66 $331.66$427.99 $465.67 $465.67 $391.54 $391.54 $375.24 $375.24 $339.72 $339.72 $413.23 $413.23 $465.67 $465.67 $347.45 $347.45 $391.54 $391.54 $332.98 $332.98$436.51 $474.95 $474.95 $399.34 $399.34 $382.71 $382.71 $346.49 $346.49 $421.46 $421.46 $474.95 $474.95 $354.37 $354.37 $399.34 $399.34 $339.61 $339.61$446.74 $486.08 $486.08 $408.70 $408.70 $391.68 $391.68 $354.61 $354.61 $431.34 $431.34 $486.08 $486.08 $362.67 $362.67 $408.70 $408.70 $347.57 $347.57$463.37 $504.17 $504.17 $423.91 $423.91 $406.26 $406.26 $367.81 $367.81 $447.39 $447.39 $504.17 $504.17 $376.17 $376.17 $423.91 $423.91 $360.51 $360.51$477.01 $519.01 $519.01 $436.39 $436.39 $418.22 $418.22 $378.64 $378.64 $460.56 $460.56 $519.01 $519.01 $387.24 $387.24 $436.39 $436.39 $371.12 $371.12$483.83 $526.44 $526.44 $442.63 $442.63 $424.20 $424.20 $384.05 $384.05 $467.15 $467.15 $526.44 $526.44 $392.78 $392.78 $442.63 $442.63 $376.43 $376.43$494.06 $537.57 $537.57 $451.99 $451.99 $433.17 $433.17 $392.17 $392.17 $477.03 $477.03 $537.57 $537.57 $401.08 $401.08 $451.99 $451.99 $384.39 $384.39$504.29 $548.70 $548.70 $461.35 $461.35 $442.14 $442.14 $400.29 $400.29 $486.91 $486.91 $548.70 $548.70 $409.39 $409.39 $461.35 $461.35 $392.34 $392.34$510.69 $555.66 $555.66 $467.20 $467.20 $447.74 $447.74 $405.37 $405.37 $493.08 $493.08 $555.66 $555.66 $414.58 $414.58 $467.20 $467.20 $397.32 $397.32$517.51 $563.08 $563.08 $473.43 $473.43 $453.72 $453.72 $410.78 $410.78 $499.66 $499.66 $563.08 $563.08 $420.12 $420.12 $473.43 $473.43 $402.63 $402.63$520.92 $566.79 $566.79 $476.55 $476.55 $456.71 $456.71 $413.49 $413.49 $502.96 $502.96 $566.79 $566.79 $422.89 $422.89 $476.55 $476.55 $405.28 $405.28$524.33 $570.50 $570.50 $479.67 $479.67 $459.70 $459.70 $416.20 $416.20 $506.25 $506.25 $570.50 $570.50 $425.65 $425.65 $479.67 $479.67 $407.93 $407.93$527.74 $574.21 $574.21 $482.79 $482.79 $462.69 $462.69 $418.90 $418.90 $509.54 $509.54 $574.21 $574.21 $428.42 $428.42 $482.79 $482.79 $410.59 $410.59$531.15 $577.92 $577.92 $485.91 $485.91 $465.68 $465.68 $421.61 $421.61 $512.84 $512.84 $577.92 $577.92 $431.19 $431.19 $485.91 $485.91 $413.24 $413.24$537.97 $585.34 $585.34 $492.15 $492.15 $471.66 $471.66 $427.02 $427.02 $519.42 $519.42 $585.34 $585.34 $436.73 $436.73 $492.15 $492.15 $418.55 $418.55$544.79 $592.76 $592.76 $498.39 $498.39 $477.64 $477.64 $432.44 $432.44 $526.01 $526.01 $592.76 $592.76 $442.27 $442.27 $498.39 $498.39 $423.85 $423.85$555.02 $603.89 $603.89 $507.75 $507.75 $486.61 $486.61 $440.56 $440.56 $535.88 $535.88 $603.89 $603.89 $450.57 $450.57 $507.75 $507.75 $431.81 $431.81$564.82 $614.56 $614.56 $516.72 $516.72 $495.21 $495.21 $448.34 $448.34 $545.35 $545.35 $614.56 $614.56 $458.53 $458.53 $516.72 $516.72 $439.44 $439.44$578.47 $629.40 $629.40 $529.20 $529.20 $507.17 $507.17 $459.17 $459.17 $558.52 $558.52 $629.40 $629.40 $469.60 $469.60 $529.20 $529.20 $450.05 $450.05$595.52 $647.96 $647.96 $544.80 $544.80 $522.12 $522.12 $472.70 $472.70 $574.98 $574.98 $647.96 $647.96 $483.45 $483.45 $544.80 $544.80 $463.32 $463.32$615.55 $669.76 $669.76 $563.13 $563.13 $539.68 $539.68 $488.61 $488.61 $594.33 $594.33 $669.76 $669.76 $499.71 $499.71 $563.13 $563.13 $478.91 $478.91$639.42 $695.73 $695.73 $584.97 $584.97 $560.61 $560.61 $507.56 $507.56 $617.38 $617.38 $695.73 $695.73 $519.09 $519.09 $584.97 $584.97 $497.48 $497.48$666.28 $724.95 $724.95 $609.54 $609.54 $584.16 $584.16 $528.87 $528.87 $643.31 $643.31 $724.95 $724.95 $540.89 $540.89 $609.54 $609.54 $518.37 $518.37$696.97 $758.34 $758.34 $637.62 $637.62 $611.07 $611.07 $553.24 $553.24 $672.94 $672.94 $758.34 $758.34 $565.81 $565.81 $637.62 $637.62 $542.25 $542.25$727.24 $791.28 $791.28 $665.30 $665.30 $637.60 $637.60 $577.26 $577.26 $702.16 $702.16 $791.28 $791.28 $590.38 $590.38 $665.30 $665.30 $565.80 $565.80$761.34 $828.38 $828.38 $696.50 $696.50 $667.50 $667.50 $604.33 $604.33 $735.09 $735.09 $828.38 $828.38 $618.06 $618.06 $696.50 $696.50 $592.33 $592.33$795.02 $865.02 $865.02 $727.31 $727.31 $697.03 $697.03 $631.06 $631.06 $767.61 $767.61 $865.02 $865.02 $645.40 $645.40 $727.31 $727.31 $618.53 $618.53$832.10 $905.38 $905.38 $761.24 $761.24 $729.55 $729.55 $660.50 $660.50 $803.41 $803.41 $905.38 $905.38 $675.51 $675.51 $761.24 $761.24 $647.39 $647.39$869.62 $946.19 $946.19 $795.56 $795.56 $762.43 $762.43 $690.28 $690.28 $839.63 $839.63 $946.19 $946.19 $705.96 $705.96 $795.56 $795.56 $676.57 $676.57$910.11 $990.25 $990.25 $832.61 $832.61 $797.94 $797.94 $722.42 $722.42 $878.73 $878.73 $990.25 $990.25 $738.84 $738.84 $832.61 $832.61 $708.08 $708.08$950.61 $1,034.32 $1,034.32 $869.65 $869.65 $833.45 $833.45 $754.57 $754.57 $917.84 $917.84 $1,034.32 $1,034.32 $771.72 $771.72 $869.65 $869.65 $739.59 $739.59$994.52 $1,082.09 $1,082.09 $909.82 $909.82 $871.94 $871.94 $789.42 $789.42 $960.23 $960.23 $1,082.09 $1,082.09 $807.36 $807.36 $909.82 $909.82 $773.75 $773.75

$1,038.85 $1,130.33 $1,130.33 $950.38 $950.38 $910.81 $910.81 $824.61 $824.61 $1,003.03 $1,003.03 $1,130.33 $1,130.33 $843.35 $843.35 $950.38 $950.38 $808.24 $808.24$1,086.17 $1,181.81 $1,181.81 $993.67 $993.67 $952.30 $952.30 $862.17 $862.17 $1,048.72 $1,048.72 $1,181.81 $1,181.81 $881.76 $881.76 $993.67 $993.67 $845.05 $845.05$1,109.61 $1,207.32 $1,207.32 $1,015.12 $1,015.12 $972.85 $972.85 $880.78 $880.78 $1,071.36 $1,071.36 $1,207.32 $1,207.32 $900.80 $900.80 $1,015.12 $1,015.12 $863.29 $863.29$1,156.93 $1,258.81 $1,258.81 $1,058.40 $1,058.40 $1,014.34 $1,014.34 $918.34 $918.34 $1,117.04 $1,117.04 $1,258.81 $1,258.81 $939.21 $939.21 $1,058.40 $1,058.40 $900.11 $900.11$1,197.85 $1,303.33 $1,303.33 $1,095.84 $1,095.84 $1,050.22 $1,050.22 $950.82 $950.82 $1,156.55 $1,156.55 $1,303.33 $1,303.33 $972.43 $972.43 $1,095.84 $1,095.84 $931.94 $931.94$1,224.71 $1,332.55 $1,332.55 $1,120.41 $1,120.41 $1,073.76 $1,073.76 $972.14 $972.14 $1,182.48 $1,182.48 $1,332.55 $1,332.55 $994.23 $994.23 $1,120.41 $1,120.41 $952.84 $952.84$1,258.39 $1,369.19 $1,369.19 $1,151.22 $1,151.22 $1,103.29 $1,103.29 $998.87 $998.87 $1,215.00 $1,215.00 $1,369.19 $1,369.19 $1,021.57 $1,021.57 $1,151.22 $1,151.22 $979.04 $979.04$1,278.85 $1,391.46 $1,391.46 $1,169.94 $1,169.94 $1,121.23 $1,121.23 $1,015.11 $1,015.11 $1,234.76 $1,234.76 $1,391.46 $1,391.46 $1,038.18 $1,038.18 $1,169.94 $1,169.94 $994.96 $994.96

$7,350Yes

75729PA0050146Geisinger Choices PPO

20/40/2000M-152-367-F Dev. 1/20

Rating Area 3

Geisinger Choices PPO

GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


GoldMed: $1,000 / Rx: $0

0%$20 / $40


20/40/1000M-152-367-F Dev. 1/20

Rating Area 6

$2,000Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes



0%$10 / $20


10/20/0M-152-367-F Dev. 1/20

Rating Area 6

$7,900Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 3



0%$10 / $20$2,000

Yes


SilverMed: $4,000 / Rx: $500

0%$20 / $40


20/40/4000M-152-367-F Dev. 1/20

Rating Area 6

$7,350Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


GoldMed: $1,000 / Rx: $0

0%$20 / $40


20/40/1000M-152-367-F Dev. 1/20

Rating Area 6

000es


10/20/0M-152-367-F Dev. 1/20

Rating Area 6



0%$10 / $20$2,000

Yes

l-Access PPO

oldd: $1,500%er Deductible

A0050138Access QHDHP 40/1500-F Rev. 1/20Area 9

Page Number: 18 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$285.91 $285.91 $229.70 $229.70 $258.85 $258.85 $314.86 $314.86 $264.74 $264.74 $253.71 $253.71 $229.70 $229.70$311.33 $311.33 $250.12 $250.12 $281.86 $281.86 $342.85 $342.85 $288.27 $288.27 $276.27 $276.27 $250.12 $250.12$321.04 $321.04 $257.93 $257.93 $290.66 $290.66 $353.55 $353.55 $297.27 $297.27 $284.89 $284.89 $257.93 $257.93$330.76 $330.76 $265.73 $265.73 $299.46 $299.46 $364.25 $364.25 $306.26 $306.26 $293.51 $293.51 $265.73 $265.73$341.23 $341.23 $274.14 $274.14 $308.93 $308.93 $375.78 $375.78 $315.95 $315.95 $302.80 $302.80 $274.14 $274.14$351.69 $351.69 $282.55 $282.55 $318.41 $318.41 $387.30 $387.30 $325.64 $325.64 $312.09 $312.09 $282.55 $282.55$362.53 $362.53 $291.26 $291.26 $328.22 $328.22 $399.24 $399.24 $335.68 $335.68 $321.70 $321.70 $291.26 $291.26$373.75 $373.75 $300.27 $300.27 $338.38 $338.38 $411.59 $411.59 $346.07 $346.07 $331.66 $331.66 $300.27 $300.27$373.75 $373.75 $300.27 $300.27 $338.38 $338.38 $411.59 $411.59 $346.07 $346.07 $331.66 $331.66 $300.27 $300.27$373.75 $373.75 $300.27 $300.27 $338.38 $338.38 $411.59 $411.59 $346.07 $346.07 $331.66 $331.66 $300.27 $300.27$373.75 $373.75 $300.27 $300.27 $338.38 $338.38 $411.59 $411.59 $346.07 $346.07 $331.66 $331.66 $300.27 $300.27$375.24 $375.24 $301.47 $301.47 $339.72 $339.72 $413.23 $413.23 $347.45 $347.45 $332.98 $332.98 $301.47 $301.47$382.71 $382.71 $307.47 $307.47 $346.49 $346.49 $421.46 $421.46 $354.37 $354.37 $339.61 $339.61 $307.47 $307.47$391.68 $391.68 $314.68 $314.68 $354.61 $354.61 $431.34 $431.34 $362.67 $362.67 $347.57 $347.57 $314.68 $314.68$406.26 $406.26 $326.39 $326.39 $367.81 $367.81 $447.39 $447.39 $376.17 $376.17 $360.51 $360.51 $326.39 $326.39$418.22 $418.22 $336.00 $336.00 $378.64 $378.64 $460.56 $460.56 $387.24 $387.24 $371.12 $371.12 $336.00 $336.00$424.20 $424.20 $340.80 $340.80 $384.05 $384.05 $467.15 $467.15 $392.78 $392.78 $376.43 $376.43 $340.80 $340.80$433.17 $433.17 $348.01 $348.01 $392.17 $392.17 $477.03 $477.03 $401.08 $401.08 $384.39 $384.39 $348.01 $348.01$442.14 $442.14 $355.21 $355.21 $400.29 $400.29 $486.91 $486.91 $409.39 $409.39 $392.34 $392.34 $355.21 $355.21$447.74 $447.74 $359.72 $359.72 $405.37 $405.37 $493.08 $493.08 $414.58 $414.58 $397.32 $397.32 $359.72 $359.72$453.72 $453.72 $364.52 $364.52 $410.78 $410.78 $499.66 $499.66 $420.12 $420.12 $402.63 $402.63 $364.52 $364.52$456.71 $456.71 $366.92 $366.92 $413.49 $413.49 $502.96 $502.96 $422.89 $422.89 $405.28 $405.28 $366.92 $366.92$459.70 $459.70 $369.33 $369.33 $416.20 $416.20 $506.25 $506.25 $425.65 $425.65 $407.93 $407.93 $369.33 $369.33$462.69 $462.69 $371.73 $371.73 $418.90 $418.90 $509.54 $509.54 $428.42 $428.42 $410.59 $410.59 $371.73 $371.73$465.68 $465.68 $374.13 $374.13 $421.61 $421.61 $512.84 $512.84 $431.19 $431.19 $413.24 $413.24 $374.13 $374.13$471.66 $471.66 $378.93 $378.93 $427.02 $427.02 $519.42 $519.42 $436.73 $436.73 $418.55 $418.55 $378.93 $378.93$477.64 $477.64 $383.74 $383.74 $432.44 $432.44 $526.01 $526.01 $442.27 $442.27 $423.85 $423.85 $383.74 $383.74$486.61 $486.61 $390.94 $390.94 $440.56 $440.56 $535.88 $535.88 $450.57 $450.57 $431.81 $431.81 $390.94 $390.94$495.21 $495.21 $397.85 $397.85 $448.34 $448.34 $545.35 $545.35 $458.53 $458.53 $439.44 $439.44 $397.85 $397.85$507.17 $507.17 $407.46 $407.46 $459.17 $459.17 $558.52 $558.52 $469.60 $469.60 $450.05 $450.05 $407.46 $407.46$522.12 $522.12 $419.47 $419.47 $472.70 $472.70 $574.98 $574.98 $483.45 $483.45 $463.32 $463.32 $419.47 $419.47$539.68 $539.68 $433.58 $433.58 $488.61 $488.61 $594.33 $594.33 $499.71 $499.71 $478.91 $478.91 $433.58 $433.58$560.61 $560.61 $450.40 $450.40 $507.56 $507.56 $617.38 $617.38 $519.09 $519.09 $497.48 $497.48 $450.40 $450.40$584.16 $584.16 $469.31 $469.31 $528.87 $528.87 $643.31 $643.31 $540.89 $540.89 $518.37 $518.37 $469.31 $469.31$611.07 $611.07 $490.93 $490.93 $553.24 $553.24 $672.94 $672.94 $565.81 $565.81 $542.25 $542.25 $490.93 $490.93$637.60 $637.60 $512.25 $512.25 $577.26 $577.26 $702.16 $702.16 $590.38 $590.38 $565.80 $565.80 $512.25 $512.25$667.50 $667.50 $536.27 $536.27 $604.33 $604.33 $735.09 $735.09 $618.06 $618.06 $592.33 $592.33 $536.27 $536.27$697.03 $697.03 $559.99 $559.99 $631.06 $631.06 $767.61 $767.61 $645.40 $645.40 $618.53 $618.53 $559.99 $559.99$729.55 $729.55 $586.12 $586.12 $660.50 $660.50 $803.41 $803.41 $675.51 $675.51 $647.39 $647.39 $586.12 $586.12$762.43 $762.43 $612.54 $612.54 $690.28 $690.28 $839.63 $839.63 $705.96 $705.96 $676.57 $676.57 $612.54 $612.54$797.94 $797.94 $641.06 $641.06 $722.42 $722.42 $878.73 $878.73 $738.84 $738.84 $708.08 $708.08 $641.06 $641.06$833.45 $833.45 $669.59 $669.59 $754.57 $754.57 $917.84 $917.84 $771.72 $771.72 $739.59 $739.59 $669.59 $669.59$871.94 $871.94 $700.52 $700.52 $789.42 $789.42 $960.23 $960.23 $807.36 $807.36 $773.75 $773.75 $700.52 $700.52$910.81 $910.81 $731.74 $731.74 $824.61 $824.61 $1,003.03 $1,003.03 $843.35 $843.35 $808.24 $808.24 $731.74 $731.74$952.30 $952.30 $765.07 $765.07 $862.17 $862.17 $1,048.72 $1,048.72 $881.76 $881.76 $845.05 $845.05 $765.07 $765.07$972.85 $972.85 $781.59 $781.59 $880.78 $880.78 $1,071.36 $1,071.36 $900.80 $900.80 $863.29 $863.29 $781.59 $781.59

$1,014.34 $1,014.34 $814.92 $814.92 $918.34 $918.34 $1,117.04 $1,117.04 $939.21 $939.21 $900.11 $900.11 $814.92 $814.92$1,050.22 $1,050.22 $843.74 $843.74 $950.82 $950.82 $1,156.55 $1,156.55 $972.43 $972.43 $931.94 $931.94 $843.74 $843.74$1,073.76 $1,073.76 $862.66 $862.66 $972.14 $972.14 $1,182.48 $1,182.48 $994.23 $994.23 $952.84 $952.84 $862.66 $862.66$1,103.29 $1,103.29 $886.38 $886.38 $998.87 $998.87 $1,215.00 $1,215.00 $1,021.57 $1,021.57 $979.04 $979.04 $886.38 $886.38$1,121.23 $1,121.23 $900.79 $900.79 $1,015.11 $1,015.11 $1,234.76 $1,234.76 $1,038.18 $1,038.18 $994.96 $994.96 $900.79 $900.79

$7,900Yes


SilverMed: $4,000 / Rx: $500

0%$20 / $40


20/40/4000M-152-367-F Dev. 1/20

Rating Area 3

$7,350Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


GoldMed: $1,000 / Rx: $0

0%$20 / $40


20/40/1000M-152-367-F Dev. 1/20

Rating Area 3

$7,900Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 3



0%$10 / $20$2,000

Yes


SilverMed: $4,000 / Rx: $500

0%$20 / $40


20/40/4000M-152-367-F Dev. 1/20

Rating Area 6

$7,350Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 3


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


GoldMed: $2,000 / Rx: $0

0%$20 / $40


20/40/2000M-152-367-F Dev. 1/20

Rating Area 6

Page Number: 19 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 14 $219.96 $219.96 $210.32 $210.32 $224.90 $224.90 $237.01 $237.01 $287.18 $287.18 $243.93 $243.93 $282.00 $282.00 $317.78 $317.78 $327.06 $327.06 $297.4215 $239.51 $239.51 $229.02 $229.02 $244.89 $244.89 $258.08 $258.08 $312.71 $312.71 $265.61 $265.61 $307.06 $307.06 $346.03 $346.03 $356.13 $356.13 $323.8616 $246.99 $246.99 $236.16 $236.16 $252.54 $252.54 $266.13 $266.13 $322.47 $322.47 $273.91 $273.91 $316.65 $316.65 $356.83 $356.83 $367.25 $367.25 $333.9717 $254.46 $254.46 $243.31 $243.31 $260.18 $260.18 $274.19 $274.19 $332.23 $332.23 $282.20 $282.20 $326.23 $326.23 $367.63 $367.63 $378.37 $378.37 $344.0818 $262.51 $262.51 $251.01 $251.01 $268.41 $268.41 $282.87 $282.87 $342.74 $342.74 $291.12 $291.12 $336.55 $336.55 $379.26 $379.26 $390.34 $390.34 $354.9619 $270.56 $270.56 $258.71 $258.71 $276.64 $276.64 $291.54 $291.54 $353.25 $353.25 $300.05 $300.05 $346.87 $346.87 $390.90 $390.90 $402.31 $402.31 $365.8520 $278.90 $278.90 $266.68 $266.68 $285.17 $285.17 $300.52 $300.52 $364.14 $364.14 $309.30 $309.30 $357.56 $357.56 $402.94 $402.94 $414.71 $414.71 $377.1221 $287.53 $287.53 $274.93 $274.93 $293.99 $293.99 $309.82 $309.82 $375.41 $375.41 $318.87 $318.87 $368.63 $368.63 $415.41 $415.41 $427.54 $427.54 $388.7922 $287.53 $287.53 $274.93 $274.93 $293.99 $293.99 $309.82 $309.82 $375.41 $375.41 $318.87 $318.87 $368.63 $368.63 $415.41 $415.41 $427.54 $427.54 $388.7923 $287.53 $287.53 $274.93 $274.93 $293.99 $293.99 $309.82 $309.82 $375.41 $375.41 $318.87 $318.87 $368.63 $368.63 $415.41 $415.41 $427.54 $427.54 $388.7924 $287.53 $287.53 $274.93 $274.93 $293.99 $293.99 $309.82 $309.82 $375.41 $375.41 $318.87 $318.87 $368.63 $368.63 $415.41 $415.41 $427.54 $427.54 $388.7925 $288.68 $288.68 $276.03 $276.03 $295.17 $295.17 $311.06 $311.06 $376.90 $376.90 $320.14 $320.14 $370.10 $370.10 $417.07 $417.07 $429.24 $429.24 $390.3426 $294.43 $294.43 $281.53 $281.53 $301.04 $301.04 $317.25 $317.25 $384.41 $384.41 $326.52 $326.52 $377.47 $377.47 $425.37 $425.37 $437.79 $437.79 $398.1227 $301.33 $301.33 $288.12 $288.12 $308.10 $308.10 $324.69 $324.69 $393.42 $393.42 $334.17 $334.17 $386.32 $386.32 $435.34 $435.34 $448.05 $448.05 $407.4528 $312.54 $312.54 $298.85 $298.85 $319.57 $319.57 $336.77 $336.77 $408.06 $408.06 $346.61 $346.61 $400.69 $400.69 $451.54 $451.54 $464.73 $464.73 $422.6129 $321.74 $321.74 $307.64 $307.64 $328.97 $328.97 $346.69 $346.69 $420.07 $420.07 $356.81 $356.81 $412.49 $412.49 $464.84 $464.84 $478.41 $478.41 $435.0530 $326.34 $326.34 $312.04 $312.04 $333.68 $333.68 $351.64 $351.64 $426.08 $426.08 $361.91 $361.91 $418.39 $418.39 $471.48 $471.48 $485.25 $485.25 $441.2731 $333.24 $333.24 $318.64 $318.64 $340.73 $340.73 $359.08 $359.08 $435.09 $435.09 $369.56 $369.56 $427.23 $427.23 $481.45 $481.45 $495.51 $495.51 $450.6032 $340.15 $340.15 $325.24 $325.24 $347.79 $347.79 $366.52 $366.52 $444.10 $444.10 $377.22 $377.22 $436.08 $436.08 $491.42 $491.42 $505.77 $505.77 $459.9333 $344.46 $344.46 $329.36 $329.36 $352.20 $352.20 $371.16 $371.16 $449.73 $449.73 $382.00 $382.00 $441.61 $441.61 $497.65 $497.65 $512.18 $512.18 $465.7734 $349.06 $349.06 $333.76 $333.76 $356.90 $356.90 $376.12 $376.12 $455.74 $455.74 $387.10 $387.10 $447.51 $447.51 $504.30 $504.30 $519.02 $519.02 $471.9935 $351.36 $351.36 $335.96 $335.96 $359.25 $359.25 $378.60 $378.60 $458.74 $458.74 $389.65 $389.65 $450.46 $450.46 $507.62 $507.62 $522.45 $522.45 $475.1036 $353.66 $353.66 $338.16 $338.16 $361.61 $361.61 $381.08 $381.08 $461.74 $461.74 $392.20 $392.20 $453.41 $453.41 $510.95 $510.95 $525.87 $525.87 $478.2137 $355.96 $355.96 $340.36 $340.36 $363.96 $363.96 $383.56 $383.56 $464.75 $464.75 $394.76 $394.76 $456.35 $456.35 $514.27 $514.27 $529.29 $529.29 $481.3238 $358.26 $358.26 $342.56 $342.56 $366.31 $366.31 $386.03 $386.03 $467.75 $467.75 $397.31 $397.31 $459.30 $459.30 $517.59 $517.59 $532.71 $532.71 $484.4339 $362.86 $362.86 $346.96 $346.96 $371.01 $371.01 $390.99 $390.99 $473.76 $473.76 $402.41 $402.41 $465.20 $465.20 $524.24 $524.24 $539.55 $539.55 $490.6540 $367.46 $367.46 $351.36 $351.36 $375.72 $375.72 $395.95 $395.95 $479.76 $479.76 $407.51 $407.51 $471.10 $471.10 $530.89 $530.89 $546.39 $546.39 $496.8741 $374.36 $374.36 $357.96 $357.96 $382.77 $382.77 $403.38 $403.38 $488.77 $488.77 $415.16 $415.16 $479.95 $479.95 $540.86 $540.86 $556.65 $556.65 $506.2042 $380.97 $380.97 $364.28 $364.28 $389.54 $389.54 $410.51 $410.51 $497.41 $497.41 $422.50 $422.50 $488.42 $488.42 $550.41 $550.41 $566.48 $566.48 $515.1443 $390.18 $390.18 $373.08 $373.08 $398.94 $398.94 $420.42 $420.42 $509.42 $509.42 $432.70 $432.70 $500.22 $500.22 $563.70 $563.70 $580.16 $580.16 $527.5844 $401.68 $401.68 $384.07 $384.07 $410.70 $410.70 $432.82 $432.82 $524.44 $524.44 $445.45 $445.45 $514.97 $514.97 $580.32 $580.32 $597.26 $597.26 $543.1445 $415.19 $415.19 $397.00 $397.00 $424.52 $424.52 $447.38 $447.38 $542.08 $542.08 $460.44 $460.44 $532.29 $532.29 $599.84 $599.84 $617.36 $617.36 $561.4146 $431.29 $431.29 $412.39 $412.39 $440.98 $440.98 $464.73 $464.73 $563.10 $563.10 $478.30 $478.30 $552.93 $552.93 $623.11 $623.11 $641.30 $641.30 $583.1847 $449.41 $449.41 $429.71 $429.71 $459.51 $459.51 $484.25 $484.25 $586.75 $586.75 $498.39 $498.39 $576.16 $576.16 $649.28 $649.28 $668.23 $668.23 $607.6748 $470.11 $470.11 $449.51 $449.51 $480.67 $480.67 $506.55 $506.55 $613.78 $613.78 $521.34 $521.34 $602.70 $602.70 $679.19 $679.19 $699.02 $699.02 $635.6749 $490.52 $490.52 $469.03 $469.03 $501.55 $501.55 $528.55 $528.55 $640.44 $640.44 $543.98 $543.98 $628.87 $628.87 $708.68 $708.68 $729.37 $729.37 $663.2750 $513.52 $513.52 $491.02 $491.02 $525.06 $525.06 $553.34 $553.34 $670.47 $670.47 $569.49 $569.49 $658.36 $658.36 $741.91 $741.91 $763.57 $763.57 $694.3751 $536.24 $536.24 $512.74 $512.74 $548.29 $548.29 $577.81 $577.81 $700.12 $700.12 $594.68 $594.68 $687.48 $687.48 $774.73 $774.73 $797.35 $797.35 $725.0952 $561.25 $561.25 $536.66 $536.66 $573.87 $573.87 $604.77 $604.77 $732.78 $732.78 $622.42 $622.42 $719.55 $719.55 $810.87 $810.87 $834.54 $834.54 $758.9153 $586.56 $586.56 $560.85 $560.85 $599.74 $599.74 $632.03 $632.03 $765.82 $765.82 $650.48 $650.48 $751.99 $751.99 $847.42 $847.42 $872.17 $872.17 $793.1254 $613.87 $613.87 $586.97 $586.97 $627.67 $627.67 $661.46 $661.46 $801.48 $801.48 $680.78 $680.78 $787.01 $787.01 $886.89 $886.89 $912.78 $912.78 $830.0655 $641.19 $641.19 $613.09 $613.09 $655.60 $655.60 $690.90 $690.90 $837.15 $837.15 $711.07 $711.07 $822.03 $822.03 $926.35 $926.35 $953.40 $953.40 $866.9956 $670.80 $670.80 $641.41 $641.41 $685.88 $685.88 $722.81 $722.81 $875.81 $875.81 $743.91 $743.91 $860.00 $860.00 $969.14 $969.14 $997.43 $997.43 $907.0457 $700.71 $700.71 $670.00 $670.00 $716.45 $716.45 $755.03 $755.03 $914.85 $914.85 $777.07 $777.07 $898.33 $898.33 $1,012.34 $1,012.34 $1,041.90 $1,041.90 $947.4758 $732.62 $732.62 $700.52 $700.52 $749.08 $749.08 $789.42 $789.42 $956.52 $956.52 $812.47 $812.47 $939.25 $939.25 $1,058.45 $1,058.45 $1,089.35 $1,089.35 $990.6359 $748.43 $748.43 $715.64 $715.64 $765.25 $765.25 $806.46 $806.46 $977.17 $977.17 $830.01 $830.01 $959.52 $959.52 $1,081.30 $1,081.30 $1,112.87 $1,112.87 $1,012.0160 $780.35 $780.35 $746.16 $746.16 $797.89 $797.89 $840.85 $840.85 $1,018.84 $1,018.84 $865.40 $865.40 $1,000.44 $1,000.44 $1,127.41 $1,127.41 $1,160.32 $1,160.32 $1,055.1761 $807.95 $807.95 $772.55 $772.55 $826.11 $826.11 $870.59 $870.59 $1,054.88 $1,054.88 $896.01 $896.01 $1,035.83 $1,035.83 $1,167.29 $1,167.29 $1,201.37 $1,201.37 $1,092.4962 $826.07 $826.07 $789.87 $789.87 $844.63 $844.63 $890.11 $890.11 $1,078.53 $1,078.53 $916.10 $916.10 $1,059.05 $1,059.05 $1,193.46 $1,193.46 $1,228.30 $1,228.30 $1,116.9863 $848.78 $848.78 $811.59 $811.59 $867.86 $867.86 $914.59 $914.59 $1,108.19 $1,108.19 $941.29 $941.29 $1,088.17 $1,088.17 $1,226.27 $1,226.27 $1,262.08 $1,262.08 $1,147.70

64+ $862.58 $862.58 $824.78 $824.78 $881.97 $881.97 $929.46 $929.46 $1,126.20 $1,126.20 $956.60 $956.60 $1,105.87 $1,105.87 $1,246.21 $1,246.21 $1,282.60 $1,282.60 $1,166.36

GoMed: $1,00

0%$20 /$8,1

Ye


20/40/M-152-121-

Rating

Geisinger All


0%$60 / $60$8,150

Yes


10/60/500M-152-243-F Rev. 1/20

Rating Area 9



0%$60 / $60$8,150

Yes

0%$60 / $60$8,150

Yes


10/60/500M-152-243-F Rev. 1/20

Rating Area 6






$6,500 $6,500 $6,500 $6,500Yes Yes Yes Yes

0% 0% 0% 0%0% After Deductible 0% After Deductible 0% After Deductible 0% After Deductible



$6,500Yes


$6,500Yes


75729PA0050062 75729PA0050068

Bronze Bronze Bronze BronzeCombined: $6,500 Combined: $6,500 Combined: $6,500 Combined: $6,500

Rating Area 2 Rating Area 3 Rating Area 5 Rating Area 6

Geisinger All-Access PPO Geisinger All-Access PPO Geisinger All-Access PPO Geisinger All-Access PPO


PPO 6500M-152-122-F Rev. 1/20

Rating Area 9






PPOApril 1, 2020 June 30, 2020





M-152-122-F Rev. 1/20 M-152-122-F Rev. 1/20 M-152-122-F Rev. 1/20 M-152-122-F Rev. 1/20

75729PA0050062 75729PA0050062 75729PA0050062 75729PA0050062

Page Number: 20 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$297.42 $284.39 $284.39 $304.11 $304.11 $320.48 $320.48 $388.32 $388.32 $329.84 $329.84 $281.97 $281.97 $269.61 $269.61 $288.30 $288.30 $303.83 $303.83$323.86 $309.67 $309.67 $331.14 $331.14 $348.97 $348.97 $422.84 $422.84 $359.16 $359.16 $307.03 $307.03 $293.58 $293.58 $313.93 $313.93 $330.83 $330.83$333.97 $319.33 $319.33 $341.47 $341.47 $359.86 $359.86 $436.03 $436.03 $370.37 $370.37 $316.61 $316.61 $302.74 $302.74 $323.73 $323.73 $341.16 $341.16$344.08 $329.00 $329.00 $351.81 $351.81 $370.75 $370.75 $449.23 $449.23 $381.58 $381.58 $326.20 $326.20 $311.90 $311.90 $333.53 $333.53 $351.49 $351.49$354.96 $339.41 $339.41 $362.94 $362.94 $382.48 $382.48 $463.45 $463.45 $393.65 $393.65 $336.52 $336.52 $321.77 $321.77 $344.08 $344.08 $362.61 $362.61$365.85 $349.82 $349.82 $374.07 $374.07 $394.21 $394.21 $477.66 $477.66 $405.72 $405.72 $346.84 $346.84 $331.64 $331.64 $354.63 $354.63 $373.73 $373.73$377.12 $360.60 $360.60 $385.60 $385.60 $406.36 $406.36 $492.38 $492.38 $418.23 $418.23 $357.53 $357.53 $341.86 $341.86 $365.56 $365.56 $385.24 $385.24$388.79 $371.75 $371.75 $397.53 $397.53 $418.93 $418.93 $507.61 $507.61 $431.17 $431.17 $368.59 $368.59 $352.44 $352.44 $376.87 $376.87 $397.16 $397.16$388.79 $371.75 $371.75 $397.53 $397.53 $418.93 $418.93 $507.61 $507.61 $431.17 $431.17 $368.59 $368.59 $352.44 $352.44 $376.87 $376.87 $397.16 $397.16$388.79 $371.75 $371.75 $397.53 $397.53 $418.93 $418.93 $507.61 $507.61 $431.17 $431.17 $368.59 $368.59 $352.44 $352.44 $376.87 $376.87 $397.16 $397.16$388.79 $371.75 $371.75 $397.53 $397.53 $418.93 $418.93 $507.61 $507.61 $431.17 $431.17 $368.59 $368.59 $352.44 $352.44 $376.87 $376.87 $397.16 $397.16$390.34 $373.24 $373.24 $399.11 $399.11 $420.60 $420.60 $509.64 $509.64 $432.88 $432.88 $370.06 $370.06 $353.84 $353.84 $378.37 $378.37 $398.75 $398.75$398.12 $380.67 $380.67 $407.06 $407.06 $428.98 $428.98 $519.79 $519.79 $441.51 $441.51 $377.43 $377.43 $360.89 $360.89 $385.91 $385.91 $406.69 $406.69$407.45 $389.59 $389.59 $416.60 $416.60 $439.04 $439.04 $531.97 $531.97 $451.86 $451.86 $386.27 $386.27 $369.35 $369.35 $394.96 $394.96 $416.22 $416.22$422.61 $404.09 $404.09 $432.11 $432.11 $455.38 $455.38 $551.77 $551.77 $468.67 $468.67 $400.65 $400.65 $383.09 $383.09 $409.65 $409.65 $431.71 $431.71$435.05 $415.99 $415.99 $444.83 $444.83 $468.78 $468.78 $568.01 $568.01 $482.47 $482.47 $412.44 $412.44 $394.37 $394.37 $421.71 $421.71 $444.42 $444.42$441.27 $421.94 $421.94 $451.19 $451.19 $475.48 $475.48 $576.13 $576.13 $489.37 $489.37 $418.34 $418.34 $400.01 $400.01 $427.74 $427.74 $450.77 $450.77$450.60 $430.86 $430.86 $460.73 $460.73 $485.54 $485.54 $588.32 $588.32 $499.71 $499.71 $427.19 $427.19 $408.47 $408.47 $436.79 $436.79 $460.31 $460.31$459.93 $439.78 $439.78 $470.27 $470.27 $495.59 $495.59 $600.50 $600.50 $510.06 $510.06 $436.03 $436.03 $416.93 $416.93 $445.83 $445.83 $469.84 $469.84$465.77 $445.36 $445.36 $476.23 $476.23 $501.88 $501.88 $608.11 $608.11 $516.53 $516.53 $441.56 $441.56 $422.21 $422.21 $451.48 $451.48 $475.80 $475.80$471.99 $451.30 $451.30 $482.59 $482.59 $508.58 $508.58 $616.23 $616.23 $523.43 $523.43 $447.46 $447.46 $427.85 $427.85 $457.51 $457.51 $482.15 $482.15$475.10 $454.28 $454.28 $485.77 $485.77 $511.93 $511.93 $620.30 $620.30 $526.88 $526.88 $450.41 $450.41 $430.67 $430.67 $460.53 $460.53 $485.33 $485.33$478.21 $457.25 $457.25 $488.95 $488.95 $515.28 $515.28 $624.36 $624.36 $530.33 $530.33 $453.36 $453.36 $433.49 $433.49 $463.54 $463.54 $488.50 $488.50$481.32 $460.23 $460.23 $492.13 $492.13 $518.63 $518.63 $628.42 $628.42 $533.78 $533.78 $456.31 $456.31 $436.31 $436.31 $466.56 $466.56 $491.68 $491.68$484.43 $463.20 $463.20 $495.31 $495.31 $521.99 $521.99 $632.48 $632.48 $537.23 $537.23 $459.25 $459.25 $439.13 $439.13 $469.57 $469.57 $494.86 $494.86$490.65 $469.15 $469.15 $501.67 $501.67 $528.69 $528.69 $640.60 $640.60 $544.12 $544.12 $465.15 $465.15 $444.77 $444.77 $475.60 $475.60 $501.21 $501.21$496.87 $475.10 $475.10 $508.04 $508.04 $535.39 $535.39 $648.72 $648.72 $551.02 $551.02 $471.05 $471.05 $450.41 $450.41 $481.63 $481.63 $507.57 $507.57$506.20 $484.02 $484.02 $517.58 $517.58 $545.45 $545.45 $660.90 $660.90 $561.37 $561.37 $479.89 $479.89 $458.87 $458.87 $490.68 $490.68 $517.10 $517.10$515.14 $492.57 $492.57 $526.72 $526.72 $555.08 $555.08 $672.58 $672.58 $571.29 $571.29 $488.37 $488.37 $466.97 $466.97 $499.35 $499.35 $526.23 $526.23$527.58 $504.46 $504.46 $539.44 $539.44 $568.49 $568.49 $688.82 $688.82 $585.08 $585.08 $500.17 $500.17 $478.25 $478.25 $511.41 $511.41 $538.94 $538.94$543.14 $519.33 $519.33 $555.34 $555.34 $585.24 $585.24 $709.13 $709.13 $602.33 $602.33 $514.91 $514.91 $492.35 $492.35 $526.48 $526.48 $554.83 $554.83$561.41 $536.81 $536.81 $574.02 $574.02 $604.93 $604.93 $732.98 $732.98 $622.60 $622.60 $532.23 $532.23 $508.91 $508.91 $544.19 $544.19 $573.50 $573.50$583.18 $557.62 $557.62 $596.29 $596.29 $628.39 $628.39 $761.41 $761.41 $646.74 $646.74 $552.87 $552.87 $528.65 $528.65 $565.30 $565.30 $595.74 $595.74$607.67 $581.05 $581.05 $621.33 $621.33 $654.79 $654.79 $793.39 $793.39 $673.90 $673.90 $576.09 $576.09 $550.85 $550.85 $589.04 $589.04 $620.76 $620.76$635.67 $607.81 $607.81 $649.95 $649.95 $684.95 $684.95 $829.94 $829.94 $704.95 $704.95 $602.63 $602.63 $576.23 $576.23 $616.18 $616.18 $649.35 $649.35$663.27 $634.21 $634.21 $678.18 $678.18 $714.69 $714.69 $865.98 $865.98 $735.56 $735.56 $628.80 $628.80 $601.25 $601.25 $642.93 $642.93 $677.55 $677.55$694.37 $663.95 $663.95 $709.98 $709.98 $748.21 $748.21 $906.59 $906.59 $770.05 $770.05 $658.29 $658.29 $629.44 $629.44 $673.08 $673.08 $709.32 $709.32$725.09 $693.31 $693.31 $741.38 $741.38 $781.30 $781.30 $946.69 $946.69 $804.11 $804.11 $687.41 $687.41 $657.28 $657.28 $702.85 $702.85 $740.70 $740.70$758.91 $725.66 $725.66 $775.97 $775.97 $817.75 $817.75 $990.85 $990.85 $841.62 $841.62 $719.47 $719.47 $687.95 $687.95 $735.64 $735.64 $775.25 $775.25$793.12 $758.37 $758.37 $810.95 $810.95 $854.61 $854.61 $1,035.52 $1,035.52 $879.57 $879.57 $751.91 $751.91 $718.96 $718.96 $768.81 $768.81 $810.20 $810.20$830.06 $793.69 $793.69 $848.71 $848.71 $894.41 $894.41 $1,083.74 $1,083.74 $920.53 $920.53 $786.92 $786.92 $752.44 $752.44 $804.61 $804.61 $847.93 $847.93$866.99 $829.00 $829.00 $886.48 $886.48 $934.21 $934.21 $1,131.96 $1,131.96 $961.49 $961.49 $821.94 $821.94 $785.92 $785.92 $840.41 $840.41 $885.66 $885.66$907.04 $867.29 $867.29 $927.42 $927.42 $977.36 $977.36 $1,184.25 $1,184.25 $1,005.90 $1,005.90 $859.90 $859.90 $822.22 $822.22 $879.23 $879.23 $926.57 $926.57$947.47 $905.95 $905.95 $968.76 $968.76 $1,020.93 $1,020.93 $1,237.04 $1,237.04 $1,050.74 $1,050.74 $898.24 $898.24 $858.88 $858.88 $918.42 $918.42 $967.87 $967.87$990.63 $947.22 $947.22 $1,012.89 $1,012.89 $1,067.43 $1,067.43 $1,293.38 $1,293.38 $1,098.60 $1,098.60 $939.15 $939.15 $898.00 $898.00 $960.25 $960.25 $1,011.96 $1,011.96

$1,012.01 $967.67 $967.67 $1,034.75 $1,034.75 $1,090.47 $1,090.47 $1,321.30 $1,321.30 $1,122.31 $1,122.31 $959.42 $959.42 $917.38 $917.38 $980.98 $980.98 $1,033.80 $1,033.80$1,055.17 $1,008.93 $1,008.93 $1,078.88 $1,078.88 $1,136.97 $1,136.97 $1,377.65 $1,377.65 $1,170.17 $1,170.17 $1,000.33 $1,000.33 $956.50 $956.50 $1,022.81 $1,022.81 $1,077.89 $1,077.89$1,092.49 $1,044.62 $1,044.62 $1,117.04 $1,117.04 $1,177.19 $1,177.19 $1,426.38 $1,426.38 $1,211.56 $1,211.56 $1,035.72 $1,035.72 $990.33 $990.33 $1,058.99 $1,058.99 $1,116.01 $1,116.01$1,116.98 $1,068.04 $1,068.04 $1,142.08 $1,142.08 $1,203.58 $1,203.58 $1,458.35 $1,458.35 $1,238.72 $1,238.72 $1,058.94 $1,058.94 $1,012.54 $1,012.54 $1,082.73 $1,082.73 $1,141.04 $1,141.04$1,147.70 $1,097.41 $1,097.41 $1,173.49 $1,173.49 $1,236.68 $1,236.68 $1,498.46 $1,498.46 $1,272.78 $1,272.78 $1,088.06 $1,088.06 $1,040.38 $1,040.38 $1,112.51 $1,112.51 $1,172.41 $1,172.41$1,166.36 $1,115.25 $1,115.25 $1,192.57 $1,192.57 $1,256.79 $1,256.79 $1,522.82 $1,522.82 $1,293.48 $1,293.48 $1,105.75 $1,105.75 $1,057.29 $1,057.29 $1,130.60 $1,130.60 $1,191.48 $1,191.48

GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 3


old00 / Rx: $0%/ $40150es


l-Access PPO

Page Number: 21 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 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$368.14 $368.14 $312.70 $312.70 $246.32 $246.32 $235.52 $235.52 $251.85 $251.85 $265.41 $265.41 $321.59 $321.59 $273.16 $273.16 $244.27 $244.27 $233.57$400.86 $400.86 $340.49 $340.49 $268.21 $268.21 $256.46 $256.46 $274.24 $274.24 $289.00 $289.00 $350.18 $350.18 $297.44 $297.44 $265.99 $265.99 $254.33$413.38 $413.38 $351.12 $351.12 $276.58 $276.58 $264.46 $264.46 $282.80 $282.80 $298.03 $298.03 $361.11 $361.11 $306.73 $306.73 $274.29 $274.29 $262.27$425.89 $425.89 $361.75 $361.75 $284.95 $284.95 $272.47 $272.47 $291.36 $291.36 $307.05 $307.05 $372.04 $372.04 $316.01 $316.01 $282.59 $282.59 $270.21$439.36 $439.36 $373.19 $373.19 $293.97 $293.97 $281.09 $281.09 $300.58 $300.58 $316.76 $316.76 $383.81 $383.81 $326.01 $326.01 $291.53 $291.53 $278.76$452.84 $452.84 $384.64 $384.64 $302.98 $302.98 $289.71 $289.71 $309.79 $309.79 $326.47 $326.47 $395.58 $395.58 $336.01 $336.01 $300.47 $300.47 $287.31$466.79 $466.79 $396.49 $396.49 $312.32 $312.32 $298.64 $298.64 $319.34 $319.34 $336.54 $336.54 $407.77 $407.77 $346.36 $346.36 $309.73 $309.73 $296.16$481.23 $481.23 $408.76 $408.76 $321.99 $321.99 $307.88 $307.88 $329.22 $329.22 $346.95 $346.95 $420.39 $420.39 $357.08 $357.08 $319.32 $319.32 $305.33$481.23 $481.23 $408.76 $408.76 $321.99 $321.99 $307.88 $307.88 $329.22 $329.22 $346.95 $346.95 $420.39 $420.39 $357.08 $357.08 $319.32 $319.32 $305.33$481.23 $481.23 $408.76 $408.76 $321.99 $321.99 $307.88 $307.88 $329.22 $329.22 $346.95 $346.95 $420.39 $420.39 $357.08 $357.08 $319.32 $319.32 $305.33$481.23 $481.23 $408.76 $408.76 $321.99 $321.99 $307.88 $307.88 $329.22 $329.22 $346.95 $346.95 $420.39 $420.39 $357.08 $357.08 $319.32 $319.32 $305.33$483.15 $483.15 $410.39 $410.39 $323.27 $323.27 $309.10 $309.10 $330.53 $330.53 $348.33 $348.33 $422.07 $422.07 $358.50 $358.50 $320.59 $320.59 $306.54$492.78 $492.78 $418.56 $418.56 $329.71 $329.71 $315.26 $315.26 $337.12 $337.12 $355.27 $355.27 $430.47 $430.47 $365.64 $365.64 $326.98 $326.98 $312.65$504.33 $504.33 $428.37 $428.37 $337.44 $337.44 $322.65 $322.65 $345.02 $345.02 $363.60 $363.60 $440.56 $440.56 $374.21 $374.21 $334.64 $334.64 $319.98$523.10 $523.10 $444.32 $444.32 $349.99 $349.99 $334.66 $334.66 $357.86 $357.86 $377.13 $377.13 $456.96 $456.96 $388.14 $388.14 $347.09 $347.09 $331.88$538.49 $538.49 $457.40 $457.40 $360.30 $360.30 $344.51 $344.51 $368.39 $368.39 $388.23 $388.23 $470.41 $470.41 $399.57 $399.57 $357.31 $357.31 $341.65$546.19 $546.19 $463.94 $463.94 $365.45 $365.45 $349.43 $349.43 $373.66 $373.66 $393.78 $393.78 $477.14 $477.14 $405.28 $405.28 $362.42 $362.42 $346.54$557.74 $557.74 $473.75 $473.75 $373.18 $373.18 $356.82 $356.82 $381.56 $381.56 $402.11 $402.11 $487.23 $487.23 $413.85 $413.85 $370.08 $370.08 $353.87$569.29 $569.29 $483.56 $483.56 $380.90 $380.90 $364.21 $364.21 $389.46 $389.46 $410.43 $410.43 $497.32 $497.32 $422.42 $422.42 $377.75 $377.75 $361.19$576.51 $576.51 $489.69 $489.69 $385.73 $385.73 $368.83 $368.83 $394.40 $394.40 $415.64 $415.64 $503.62 $503.62 $427.77 $427.77 $382.54 $382.54 $365.77$584.21 $584.21 $496.23 $496.23 $390.89 $390.89 $373.76 $373.76 $399.67 $399.67 $421.19 $421.19 $510.35 $510.35 $433.49 $433.49 $387.65 $387.65 $370.66$588.06 $588.06 $499.50 $499.50 $393.46 $393.46 $376.22 $376.22 $402.30 $402.30 $423.97 $423.97 $513.71 $513.71 $436.34 $436.34 $390.20 $390.20 $373.10$591.91 $591.91 $502.77 $502.77 $396.04 $396.04 $378.68 $378.68 $404.94 $404.94 $426.74 $426.74 $517.07 $517.07 $439.20 $439.20 $392.75 $392.75 $375.54$595.76 $595.76 $506.04 $506.04 $398.61 $398.61 $381.15 $381.15 $407.57 $407.57 $429.52 $429.52 $520.44 $520.44 $442.06 $442.06 $395.31 $395.31 $377.99$599.61 $599.61 $509.31 $509.31 $401.19 $401.19 $383.61 $383.61 $410.20 $410.20 $432.29 $432.29 $523.80 $523.80 $444.91 $444.91 $397.86 $397.86 $380.43$607.31 $607.31 $515.85 $515.85 $406.34 $406.34 $388.53 $388.53 $415.47 $415.47 $437.84 $437.84 $530.53 $530.53 $450.63 $450.63 $402.97 $402.97 $385.31$615.01 $615.01 $522.39 $522.39 $411.49 $411.49 $393.46 $393.46 $420.74 $420.74 $443.39 $443.39 $537.25 $537.25 $456.34 $456.34 $408.08 $408.08 $390.20$626.56 $626.56 $532.20 $532.20 $419.22 $419.22 $400.85 $400.85 $428.64 $428.64 $451.72 $451.72 $547.34 $547.34 $464.91 $464.91 $415.74 $415.74 $397.53$637.63 $637.63 $541.60 $541.60 $426.63 $426.63 $407.93 $407.93 $436.21 $436.21 $459.70 $459.70 $557.01 $557.01 $473.12 $473.12 $423.09 $423.09 $404.55$653.03 $653.03 $554.68 $554.68 $436.93 $436.93 $417.78 $417.78 $446.75 $446.75 $470.80 $470.80 $570.46 $570.46 $484.55 $484.55 $433.31 $433.31 $414.32$672.28 $672.28 $571.03 $571.03 $449.81 $449.81 $430.10 $430.10 $459.92 $459.92 $484.68 $484.68 $587.28 $587.28 $498.83 $498.83 $446.08 $446.08 $426.53$694.89 $694.89 $590.24 $590.24 $464.94 $464.94 $444.57 $444.57 $475.39 $475.39 $500.99 $500.99 $607.04 $607.04 $515.61 $515.61 $461.09 $461.09 $440.88$721.84 $721.84 $613.13 $613.13 $482.97 $482.97 $461.81 $461.81 $493.83 $493.83 $520.42 $520.42 $630.58 $630.58 $535.61 $535.61 $478.97 $478.97 $457.98$752.16 $752.16 $638.88 $638.88 $503.26 $503.26 $481.20 $481.20 $514.57 $514.57 $542.27 $542.27 $657.06 $657.06 $558.11 $558.11 $499.09 $499.09 $477.22$786.81 $786.81 $668.31 $668.31 $526.44 $526.44 $503.37 $503.37 $538.27 $538.27 $567.25 $567.25 $687.33 $687.33 $583.82 $583.82 $522.08 $522.08 $499.20$820.98 $820.98 $697.33 $697.33 $549.30 $549.30 $525.23 $525.23 $561.64 $561.64 $591.89 $591.89 $717.18 $717.18 $609.17 $609.17 $544.75 $544.75 $520.88$859.47 $859.47 $730.04 $730.04 $575.06 $575.06 $549.86 $549.86 $587.98 $587.98 $619.64 $619.64 $750.81 $750.81 $637.73 $637.73 $570.29 $570.29 $545.30$897.49 $897.49 $762.33 $762.33 $600.50 $600.50 $574.18 $574.18 $613.99 $613.99 $647.05 $647.05 $784.02 $784.02 $665.94 $665.94 $595.52 $595.52 $569.42$939.36 $939.36 $797.89 $797.89 $628.51 $628.51 $600.97 $600.97 $642.63 $642.63 $677.23 $677.23 $820.59 $820.59 $697.01 $697.01 $623.30 $623.30 $595.98$981.71 $981.71 $833.86 $833.86 $656.84 $656.84 $628.06 $628.06 $671.60 $671.60 $707.77 $707.77 $857.59 $857.59 $728.43 $728.43 $651.40 $651.40 $622.85

$1,027.42 $1,027.42 $872.69 $872.69 $687.43 $687.43 $657.31 $657.31 $702.88 $702.88 $740.73 $740.73 $897.52 $897.52 $762.35 $762.35 $681.73 $681.73 $651.86$1,073.14 $1,073.14 $911.52 $911.52 $718.02 $718.02 $686.56 $686.56 $734.15 $734.15 $773.69 $773.69 $937.46 $937.46 $796.27 $796.27 $712.07 $712.07 $680.86$1,122.71 $1,122.71 $953.62 $953.62 $751.18 $751.18 $718.27 $718.27 $768.06 $768.06 $809.42 $809.42 $980.76 $980.76 $833.05 $833.05 $744.96 $744.96 $712.31$1,172.75 $1,172.75 $996.13 $996.13 $784.67 $784.67 $750.28 $750.28 $802.30 $802.30 $845.50 $845.50 $1,024.48 $1,024.48 $870.19 $870.19 $778.16 $778.16 $744.07$1,226.17 $1,226.17 $1,041.51 $1,041.51 $820.41 $820.41 $784.46 $784.46 $838.85 $838.85 $884.01 $884.01 $1,071.14 $1,071.14 $909.82 $909.82 $813.61 $813.61 $777.96$1,252.64 $1,252.64 $1,063.99 $1,063.99 $838.12 $838.12 $801.39 $801.39 $856.95 $856.95 $903.10 $903.10 $1,094.26 $1,094.26 $929.46 $929.46 $831.17 $831.17 $794.75$1,306.05 $1,306.05 $1,109.36 $1,109.36 $873.86 $873.86 $835.57 $835.57 $893.50 $893.50 $941.61 $941.61 $1,140.92 $1,140.92 $969.10 $969.10 $866.61 $866.61 $828.64$1,352.25 $1,352.25 $1,148.60 $1,148.60 $904.77 $904.77 $865.12 $865.12 $925.10 $925.10 $974.91 $974.91 $1,181.28 $1,181.28 $1,003.38 $1,003.38 $897.27 $897.27 $857.95$1,382.57 $1,382.57 $1,174.35 $1,174.35 $925.05 $925.05 $884.52 $884.52 $945.84 $945.84 $996.77 $996.77 $1,207.77 $1,207.77 $1,025.87 $1,025.87 $917.38 $917.38 $877.18$1,420.59 $1,420.59 $1,206.64 $1,206.64 $950.49 $950.49 $908.84 $908.84 $971.85 $971.85 $1,024.18 $1,024.18 $1,240.98 $1,240.98 $1,054.08 $1,054.08 $942.61 $942.61 $901.30$1,443.69 $1,443.69 $1,226.26 $1,226.26 $965.94 $965.94 $923.62 $923.62 $987.65 $987.65 $1,040.83 $1,040.83 $1,261.15 $1,261.15 $1,071.22 $1,071.22 $957.94 $957.94 $915.96

SilMed: $6,75

0$25 /$7,3

Y

75729PAGeisinger Al

25/50M-152-121-

Rating

Geisinger Al

SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 7


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 5


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 7


Page Number: 22 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$233.57 $249.76 $249.76 $263.21 $263.21 $318.93 $318.93 $270.90 $270.90 $295.76 $295.76 $282.80 $282.80 $302.41 $302.41 $318.69 $318.69 $386.15 $386.15$254.33 $271.96 $271.96 $286.61 $286.61 $347.28 $347.28 $294.98 $294.98 $322.05 $322.05 $307.94 $307.94 $329.29 $329.29 $347.02 $347.02 $420.48 $420.48$262.27 $280.45 $280.45 $295.55 $295.55 $358.12 $358.12 $304.18 $304.18 $332.11 $332.11 $317.55 $317.55 $339.57 $339.57 $357.85 $357.85 $433.60 $433.60$270.21 $288.94 $288.94 $304.50 $304.50 $368.96 $368.96 $313.39 $313.39 $342.16 $342.16 $327.16 $327.16 $349.85 $349.85 $368.69 $368.69 $446.73 $446.73$278.76 $298.08 $298.08 $314.13 $314.13 $380.63 $380.63 $323.31 $323.31 $352.98 $352.98 $337.52 $337.52 $360.92 $360.92 $380.35 $380.35 $460.86 $460.86$287.31 $307.23 $307.23 $323.77 $323.77 $392.30 $392.30 $333.22 $333.22 $363.81 $363.81 $347.87 $347.87 $371.98 $371.98 $392.01 $392.01 $475.00 $475.00$296.16 $316.69 $316.69 $333.75 $333.75 $404.39 $404.39 $343.49 $343.49 $375.02 $375.02 $358.59 $358.59 $383.45 $383.45 $404.10 $404.10 $489.63 $489.63$305.33 $326.49 $326.49 $344.07 $344.07 $416.91 $416.91 $354.12 $354.12 $386.62 $386.62 $369.68 $369.68 $395.31 $395.31 $416.60 $416.60 $504.78 $504.78$305.33 $326.49 $326.49 $344.07 $344.07 $416.91 $416.91 $354.12 $354.12 $386.62 $386.62 $369.68 $369.68 $395.31 $395.31 $416.60 $416.60 $504.78 $504.78$305.33 $326.49 $326.49 $344.07 $344.07 $416.91 $416.91 $354.12 $354.12 $386.62 $386.62 $369.68 $369.68 $395.31 $395.31 $416.60 $416.60 $504.78 $504.78$305.33 $326.49 $326.49 $344.07 $344.07 $416.91 $416.91 $354.12 $354.12 $386.62 $386.62 $369.68 $369.68 $395.31 $395.31 $416.60 $416.60 $504.78 $504.78$306.54 $327.79 $327.79 $345.44 $345.44 $418.57 $418.57 $355.53 $355.53 $388.17 $388.17 $371.16 $371.16 $396.89 $396.89 $418.26 $418.26 $506.80 $506.80$312.65 $334.32 $334.32 $352.33 $352.33 $426.91 $426.91 $362.61 $362.61 $395.90 $395.90 $378.55 $378.55 $404.80 $404.80 $426.59 $426.59 $516.89 $516.89$319.98 $342.16 $342.16 $360.58 $360.58 $436.91 $436.91 $371.11 $371.11 $405.18 $405.18 $387.42 $387.42 $414.28 $414.28 $436.59 $436.59 $529.01 $529.01$331.88 $354.89 $354.89 $374.00 $374.00 $453.17 $453.17 $384.92 $384.92 $420.26 $420.26 $401.84 $401.84 $429.70 $429.70 $452.84 $452.84 $548.69 $548.69$341.65 $365.34 $365.34 $385.01 $385.01 $466.51 $466.51 $396.25 $396.25 $432.63 $432.63 $413.67 $413.67 $442.35 $442.35 $466.17 $466.17 $564.85 $564.85$346.54 $370.56 $370.56 $390.52 $390.52 $473.18 $473.18 $401.92 $401.92 $438.81 $438.81 $419.58 $419.58 $448.67 $448.67 $472.83 $472.83 $572.92 $572.92$353.87 $378.40 $378.40 $398.77 $398.77 $483.19 $483.19 $410.42 $410.42 $448.09 $448.09 $428.46 $428.46 $458.16 $458.16 $482.83 $482.83 $585.04 $585.04$361.19 $386.24 $386.24 $407.03 $407.03 $493.19 $493.19 $418.92 $418.92 $457.37 $457.37 $437.33 $437.33 $467.65 $467.65 $492.83 $492.83 $597.15 $597.15$365.77 $391.13 $391.13 $412.19 $412.19 $499.45 $499.45 $424.23 $424.23 $463.17 $463.17 $442.87 $442.87 $473.58 $473.58 $499.08 $499.08 $604.72 $604.72$370.66 $396.36 $396.36 $417.70 $417.70 $506.12 $506.12 $429.89 $429.89 $469.36 $469.36 $448.79 $448.79 $479.90 $479.90 $505.74 $505.74 $612.80 $612.80$373.10 $398.97 $398.97 $420.45 $420.45 $509.45 $509.45 $432.73 $432.73 $472.45 $472.45 $451.75 $451.75 $483.07 $483.07 $509.08 $509.08 $616.84 $616.84$375.54 $401.58 $401.58 $423.20 $423.20 $512.79 $512.79 $435.56 $435.56 $475.54 $475.54 $454.70 $454.70 $486.23 $486.23 $512.41 $512.41 $620.88 $620.88$377.99 $404.19 $404.19 $425.96 $425.96 $516.12 $516.12 $438.39 $438.39 $478.64 $478.64 $457.66 $457.66 $489.39 $489.39 $515.74 $515.74 $624.91 $624.91$380.43 $406.80 $406.80 $428.71 $428.71 $519.46 $519.46 $441.23 $441.23 $481.73 $481.73 $460.62 $460.62 $492.55 $492.55 $519.08 $519.08 $628.95 $628.95$385.31 $412.03 $412.03 $434.21 $434.21 $526.13 $526.13 $446.89 $446.89 $487.91 $487.91 $466.53 $466.53 $498.88 $498.88 $525.74 $525.74 $637.03 $637.03$390.20 $417.25 $417.25 $439.72 $439.72 $532.80 $532.80 $452.56 $452.56 $494.10 $494.10 $472.45 $472.45 $505.20 $505.20 $532.41 $532.41 $645.11 $645.11$397.53 $425.09 $425.09 $447.98 $447.98 $542.80 $542.80 $461.06 $461.06 $503.38 $503.38 $481.32 $481.32 $514.69 $514.69 $542.40 $542.40 $657.22 $657.22$404.55 $432.60 $432.60 $455.89 $455.89 $552.39 $552.39 $469.20 $469.20 $512.27 $512.27 $489.82 $489.82 $523.78 $523.78 $551.99 $551.99 $668.83 $668.83$414.32 $443.04 $443.04 $466.90 $466.90 $565.73 $565.73 $480.53 $480.53 $524.64 $524.64 $501.65 $501.65 $536.43 $536.43 $565.32 $565.32 $684.98 $684.98$426.53 $456.10 $456.10 $480.66 $480.66 $582.41 $582.41 $494.70 $494.70 $540.11 $540.11 $516.44 $516.44 $552.24 $552.24 $581.98 $581.98 $705.17 $705.17$440.88 $471.45 $471.45 $496.83 $496.83 $602.00 $602.00 $511.34 $511.34 $558.28 $558.28 $533.81 $533.81 $570.82 $570.82 $601.56 $601.56 $728.90 $728.90$457.98 $489.73 $489.73 $516.10 $516.10 $625.35 $625.35 $531.17 $531.17 $579.93 $579.93 $554.52 $554.52 $592.96 $592.96 $624.89 $624.89 $757.17 $757.17$477.22 $510.30 $510.30 $537.78 $537.78 $651.61 $651.61 $553.48 $553.48 $604.29 $604.29 $577.81 $577.81 $617.87 $617.87 $651.14 $651.14 $788.97 $788.97$499.20 $533.81 $533.81 $562.55 $562.55 $681.63 $681.63 $578.98 $578.98 $632.12 $632.12 $604.42 $604.42 $646.33 $646.33 $681.13 $681.13 $825.31 $825.31$520.88 $556.99 $556.99 $586.98 $586.98 $711.23 $711.23 $604.12 $604.12 $659.57 $659.57 $630.67 $630.67 $674.39 $674.39 $710.71 $710.71 $861.15 $861.15$545.30 $583.11 $583.11 $614.51 $614.51 $744.58 $744.58 $632.45 $632.45 $690.50 $690.50 $660.24 $660.24 $706.02 $706.02 $744.04 $744.04 $901.53 $901.53$569.42 $608.90 $608.90 $641.69 $641.69 $777.52 $777.52 $660.42 $660.42 $721.05 $721.05 $689.45 $689.45 $737.25 $737.25 $776.95 $776.95 $941.41 $941.41$595.98 $637.30 $637.30 $671.62 $671.62 $813.79 $813.79 $691.23 $691.23 $754.68 $754.68 $721.61 $721.61 $771.64 $771.64 $813.19 $813.19 $985.33 $985.33$622.85 $666.04 $666.04 $701.90 $701.90 $850.48 $850.48 $722.39 $722.39 $788.70 $788.70 $754.14 $754.14 $806.43 $806.43 $849.85 $849.85 $1,029.75 $1,029.75$651.86 $697.05 $697.05 $734.59 $734.59 $890.08 $890.08 $756.03 $756.03 $825.43 $825.43 $789.26 $789.26 $843.98 $843.98 $889.43 $889.43 $1,077.70 $1,077.70$680.86 $728.07 $728.07 $767.27 $767.27 $929.69 $929.69 $789.67 $789.67 $862.16 $862.16 $824.38 $824.38 $881.54 $881.54 $929.00 $929.00 $1,125.65 $1,125.65$712.31 $761.70 $761.70 $802.71 $802.71 $972.63 $972.63 $826.15 $826.15 $901.98 $901.98 $862.46 $862.46 $922.25 $922.25 $971.91 $971.91 $1,177.65 $1,177.65$744.07 $795.65 $795.65 $838.49 $838.49 $1,015.99 $1,015.99 $862.98 $862.98 $942.19 $942.19 $900.90 $900.90 $963.36 $963.36 $1,015.24 $1,015.24 $1,230.14 $1,230.14$777.96 $831.89 $831.89 $876.69 $876.69 $1,062.26 $1,062.26 $902.28 $902.28 $985.11 $985.11 $941.94 $941.94 $1,007.24 $1,007.24 $1,061.48 $1,061.48 $1,286.17 $1,286.17$794.75 $849.85 $849.85 $895.61 $895.61 $1,085.19 $1,085.19 $921.76 $921.76 $1,006.37 $1,006.37 $962.27 $962.27 $1,028.99 $1,028.99 $1,084.39 $1,084.39 $1,313.94 $1,313.94$828.64 $886.09 $886.09 $933.80 $933.80 $1,131.47 $1,131.47 $961.07 $961.07 $1,049.29 $1,049.29 $1,003.31 $1,003.31 $1,072.86 $1,072.86 $1,130.63 $1,130.63 $1,369.97 $1,369.97$857.95 $917.43 $917.43 $966.83 $966.83 $1,171.49 $1,171.49 $995.06 $995.06 $1,086.40 $1,086.40 $1,038.79 $1,038.79 $1,110.81 $1,110.81 $1,170.63 $1,170.63 $1,418.42 $1,418.42$877.18 $938.00 $938.00 $988.51 $988.51 $1,197.75 $1,197.75 $1,017.37 $1,017.37 $1,110.76 $1,110.76 $1,062.08 $1,062.08 $1,135.72 $1,135.72 $1,196.87 $1,196.87 $1,450.23 $1,450.23$901.30 $963.79 $963.79 $1,015.69 $1,015.69 $1,230.69 $1,230.69 $1,045.34 $1,045.34 $1,141.30 $1,141.30 $1,091.29 $1,091.29 $1,166.95 $1,166.95 $1,229.78 $1,229.78 $1,490.10 $1,490.10$915.96 $979.46 $979.46 $1,032.20 $1,032.20 $1,250.70 $1,250.70 $1,062.34 $1,062.34 $1,159.86 $1,159.86 $1,109.03 $1,109.03 $1,185.92 $1,185.92 $1,249.78 $1,249.78 $1,514.33 $1,514.33



$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 7




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 6




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 5




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 3




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 2


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 7


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 5


ver0 / Rx: $500%/ $50350es


l-Access PPO

Page Number: 23 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$328.00 $328.00 $257.37 $257.37 $246.09 $246.09 $263.16 $263.16 $277.33 $277.33 $336.03 $336.03 $285.42 $285.42 $337.60 $337.60 $322.81 $322.81 $345.19$357.15 $357.15 $280.25 $280.25 $267.97 $267.97 $286.55 $286.55 $301.98 $301.98 $365.90 $365.90 $310.79 $310.79 $367.61 $367.61 $351.50 $351.50 $375.87$368.30 $368.30 $289.00 $289.00 $276.33 $276.33 $295.49 $295.49 $311.40 $311.40 $377.32 $377.32 $320.49 $320.49 $379.08 $379.08 $362.47 $362.47 $387.60$379.45 $379.45 $297.74 $297.74 $284.70 $284.70 $304.44 $304.44 $320.83 $320.83 $388.74 $388.74 $330.20 $330.20 $390.56 $390.56 $373.44 $373.44 $399.33$391.45 $391.45 $307.16 $307.16 $293.70 $293.70 $314.07 $314.07 $330.98 $330.98 $401.04 $401.04 $340.64 $340.64 $402.91 $402.91 $385.26 $385.26 $411.97$403.46 $403.46 $316.58 $316.58 $302.71 $302.71 $323.70 $323.70 $341.13 $341.13 $413.34 $413.34 $351.09 $351.09 $415.27 $415.27 $397.07 $397.07 $424.60$415.89 $415.89 $326.34 $326.34 $312.04 $312.04 $333.67 $333.67 $351.64 $351.64 $426.08 $426.08 $361.91 $361.91 $428.07 $428.07 $409.31 $409.31 $437.69$428.76 $428.76 $336.44 $336.44 $321.70 $321.70 $344.00 $344.00 $362.52 $362.52 $439.26 $439.26 $373.11 $373.11 $441.31 $441.31 $421.97 $421.97 $451.23$428.76 $428.76 $336.44 $336.44 $321.70 $321.70 $344.00 $344.00 $362.52 $362.52 $439.26 $439.26 $373.11 $373.11 $441.31 $441.31 $421.97 $421.97 $451.23$428.76 $428.76 $336.44 $336.44 $321.70 $321.70 $344.00 $344.00 $362.52 $362.52 $439.26 $439.26 $373.11 $373.11 $441.31 $441.31 $421.97 $421.97 $451.23$428.76 $428.76 $336.44 $336.44 $321.70 $321.70 $344.00 $344.00 $362.52 $362.52 $439.26 $439.26 $373.11 $373.11 $441.31 $441.31 $421.97 $421.97 $451.23$430.47 $430.47 $337.78 $337.78 $322.98 $322.98 $345.37 $345.37 $363.97 $363.97 $441.01 $441.01 $374.59 $374.59 $443.07 $443.07 $423.66 $423.66 $453.03$439.05 $439.05 $344.51 $344.51 $329.41 $329.41 $352.25 $352.25 $371.22 $371.22 $449.80 $449.80 $382.06 $382.06 $451.90 $451.90 $432.10 $432.10 $462.05$449.34 $449.34 $352.58 $352.58 $337.13 $337.13 $360.51 $360.51 $379.92 $379.92 $460.34 $460.34 $391.01 $391.01 $462.49 $462.49 $442.22 $442.22 $472.88$466.06 $466.06 $365.70 $365.70 $349.68 $349.68 $373.92 $373.92 $394.06 $394.06 $477.47 $477.47 $405.56 $405.56 $479.70 $479.70 $458.68 $458.68 $490.48$479.78 $479.78 $376.47 $376.47 $359.97 $359.97 $384.93 $384.93 $405.66 $405.66 $491.53 $491.53 $417.50 $417.50 $493.82 $493.82 $472.18 $472.18 $504.92$486.64 $486.64 $381.85 $381.85 $365.12 $365.12 $390.43 $390.43 $411.46 $411.46 $498.55 $498.55 $423.47 $423.47 $500.88 $500.88 $478.93 $478.93 $512.14$496.93 $496.93 $389.93 $389.93 $372.84 $372.84 $398.69 $398.69 $420.16 $420.16 $509.10 $509.10 $432.42 $432.42 $511.47 $511.47 $489.06 $489.06 $522.97$507.22 $507.22 $398.00 $398.00 $380.56 $380.56 $406.95 $406.95 $428.86 $428.86 $519.64 $519.64 $441.38 $441.38 $522.07 $522.07 $499.19 $499.19 $533.80$513.65 $513.65 $403.05 $403.05 $385.39 $385.39 $412.11 $412.11 $434.30 $434.30 $526.23 $526.23 $446.98 $446.98 $528.69 $528.69 $505.52 $505.52 $540.57$520.51 $520.51 $408.43 $408.43 $390.53 $390.53 $417.61 $417.61 $440.10 $440.10 $533.26 $533.26 $452.95 $452.95 $535.75 $535.75 $512.27 $512.27 $547.79$523.94 $523.94 $411.12 $411.12 $393.11 $393.11 $420.36 $420.36 $443.00 $443.00 $536.77 $536.77 $455.93 $455.93 $539.28 $539.28 $515.65 $515.65 $551.40$527.37 $527.37 $413.81 $413.81 $395.68 $395.68 $423.11 $423.11 $445.90 $445.90 $540.28 $540.28 $458.92 $458.92 $542.81 $542.81 $519.02 $519.02 $555.00$530.80 $530.80 $416.51 $416.51 $398.25 $398.25 $425.87 $425.87 $448.80 $448.80 $543.80 $543.80 $461.90 $461.90 $546.34 $546.34 $522.40 $522.40 $558.61$534.23 $534.23 $419.20 $419.20 $400.83 $400.83 $428.62 $428.62 $451.70 $451.70 $547.31 $547.31 $464.88 $464.88 $549.87 $549.87 $525.77 $525.77 $562.22$541.09 $541.09 $424.58 $424.58 $405.97 $405.97 $434.12 $434.12 $457.50 $457.50 $554.34 $554.34 $470.85 $470.85 $556.93 $556.93 $532.52 $532.52 $569.44$547.95 $547.95 $429.96 $429.96 $411.12 $411.12 $439.63 $439.63 $463.30 $463.30 $561.37 $561.37 $476.82 $476.82 $563.99 $563.99 $539.28 $539.28 $576.66$558.24 $558.24 $438.04 $438.04 $418.84 $418.84 $447.88 $447.88 $472.00 $472.00 $571.91 $571.91 $485.78 $485.78 $574.58 $574.58 $549.40 $549.40 $587.49$568.10 $568.10 $445.78 $445.78 $426.24 $426.24 $455.79 $455.79 $480.34 $480.34 $582.01 $582.01 $494.36 $494.36 $584.73 $584.73 $559.11 $559.11 $597.87$581.82 $581.82 $456.54 $456.54 $436.54 $436.54 $466.80 $466.80 $491.94 $491.94 $596.07 $596.07 $506.30 $506.30 $598.85 $598.85 $572.61 $572.61 $612.31$598.97 $598.97 $470.00 $470.00 $449.40 $449.40 $480.56 $480.56 $506.44 $506.44 $613.64 $613.64 $521.22 $521.22 $616.51 $616.51 $589.49 $589.49 $630.36$619.12 $619.12 $485.81 $485.81 $464.52 $464.52 $496.73 $496.73 $523.48 $523.48 $634.28 $634.28 $538.76 $538.76 $637.25 $637.25 $609.32 $609.32 $651.57$643.14 $643.14 $504.65 $504.65 $482.54 $482.54 $515.99 $515.99 $543.78 $543.78 $658.88 $658.88 $559.65 $559.65 $661.96 $661.96 $632.95 $632.95 $676.84$670.15 $670.15 $525.85 $525.85 $502.80 $502.80 $537.66 $537.66 $566.61 $566.61 $686.55 $686.55 $583.16 $583.16 $689.76 $689.76 $659.54 $659.54 $705.26$701.02 $701.02 $550.07 $550.07 $525.97 $525.97 $562.43 $562.43 $592.72 $592.72 $718.18 $718.18 $610.02 $610.02 $721.54 $721.54 $689.92 $689.92 $737.75$731.46 $731.46 $573.96 $573.96 $548.81 $548.81 $586.85 $586.85 $618.45 $618.45 $749.37 $749.37 $636.51 $636.51 $752.87 $752.87 $719.88 $719.88 $769.79$765.76 $765.76 $600.87 $600.87 $574.54 $574.54 $614.37 $614.37 $647.46 $647.46 $784.51 $784.51 $666.36 $666.36 $788.17 $788.17 $753.64 $753.64 $805.89$799.63 $799.63 $627.45 $627.45 $599.95 $599.95 $641.55 $641.55 $676.09 $676.09 $819.21 $819.21 $695.83 $695.83 $823.04 $823.04 $786.97 $786.97 $841.53$836.93 $836.93 $656.72 $656.72 $627.94 $627.94 $671.48 $671.48 $707.63 $707.63 $857.42 $857.42 $728.29 $728.29 $861.43 $861.43 $823.68 $823.68 $880.79$874.66 $874.66 $686.33 $686.33 $656.25 $656.25 $701.75 $701.75 $739.54 $739.54 $896.08 $896.08 $761.13 $761.13 $900.27 $900.27 $860.82 $860.82 $920.50$915.40 $915.40 $718.29 $718.29 $686.81 $686.81 $734.43 $734.43 $773.97 $773.97 $937.81 $937.81 $796.57 $796.57 $942.19 $942.19 $900.90 $900.90 $963.36$956.13 $956.13 $750.25 $750.25 $717.37 $717.37 $767.11 $767.11 $808.41 $808.41 $979.54 $979.54 $832.02 $832.02 $984.11 $984.11 $940.99 $940.99 $1,006.23

$1,000.29 $1,000.29 $784.90 $784.90 $750.51 $750.51 $802.54 $802.54 $845.75 $845.75 $1,024.78 $1,024.78 $870.45 $870.45 $1,029.57 $1,029.57 $984.45 $984.45 $1,052.70$1,044.88 $1,044.88 $819.89 $819.89 $783.96 $783.96 $838.31 $838.31 $883.45 $883.45 $1,070.46 $1,070.46 $909.25 $909.25 $1,075.46 $1,075.46 $1,028.34 $1,028.34 $1,099.63$1,092.47 $1,092.47 $857.23 $857.23 $819.67 $819.67 $876.50 $876.50 $923.69 $923.69 $1,119.22 $1,119.22 $950.66 $950.66 $1,124.45 $1,124.45 $1,075.18 $1,075.18 $1,149.72$1,116.05 $1,116.05 $875.74 $875.74 $837.36 $837.36 $895.42 $895.42 $943.63 $943.63 $1,143.38 $1,143.38 $971.18 $971.18 $1,148.72 $1,148.72 $1,098.38 $1,098.38 $1,174.53$1,163.65 $1,163.65 $913.08 $913.08 $873.07 $873.07 $933.60 $933.60 $983.87 $983.87 $1,192.14 $1,192.14 $1,012.60 $1,012.60 $1,197.71 $1,197.71 $1,145.22 $1,145.22 $1,224.62$1,204.81 $1,204.81 $945.38 $945.38 $903.95 $903.95 $966.62 $966.62 $1,018.67 $1,018.67 $1,234.31 $1,234.31 $1,048.42 $1,048.42 $1,240.07 $1,240.07 $1,185.73 $1,185.73 $1,267.94$1,231.82 $1,231.82 $966.58 $966.58 $924.22 $924.22 $988.30 $988.30 $1,041.51 $1,041.51 $1,261.98 $1,261.98 $1,071.92 $1,071.92 $1,267.87 $1,267.87 $1,212.32 $1,212.32 $1,296.37$1,265.69 $1,265.69 $993.15 $993.15 $949.63 $949.63 $1,015.47 $1,015.47 $1,070.15 $1,070.15 $1,296.68 $1,296.68 $1,101.40 $1,101.40 $1,302.74 $1,302.74 $1,245.65 $1,245.65 $1,332.01$1,286.27 $1,286.27 $1,009.30 $1,009.30 $965.07 $965.07 $1,031.98 $1,031.98 $1,087.55 $1,087.55 $1,317.76 $1,317.76 $1,119.31 $1,119.31 $1,323.92 $1,323.92 $1,265.91 $1,265.91 $1,353.67

PlatiMed: $25

0$15 /$7,3

Y

75729PAGeisinger Al

15/30M-152-121-

Rating

Geisinger Al


0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 3



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 2




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 9




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 7




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 6




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 5




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 3




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 2




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 9


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64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$345.19 $363.77 $363.77 $440.78 $440.78 $374.39 $374.39 $318.09 $318.09 $358.45 $358.45 $368.92 $368.92 $275.11 $275.11 $263.05 $263.05 $281.29 $281.29$375.87 $396.11 $396.11 $479.96 $479.96 $407.67 $407.67 $346.36 $346.36 $390.32 $390.32 $401.71 $401.71 $299.56 $299.56 $286.44 $286.44 $306.29 $306.29$387.60 $408.47 $408.47 $494.94 $494.94 $420.40 $420.40 $357.17 $357.17 $402.50 $402.50 $414.25 $414.25 $308.91 $308.91 $295.38 $295.38 $315.86 $315.86$399.33 $420.84 $420.84 $509.92 $509.92 $433.12 $433.12 $367.98 $367.98 $414.68 $414.68 $426.79 $426.79 $318.26 $318.26 $304.32 $304.32 $325.42 $325.42$411.97 $434.15 $434.15 $526.05 $526.05 $446.83 $446.83 $379.62 $379.62 $427.80 $427.80 $440.29 $440.29 $328.33 $328.33 $313.95 $313.95 $335.71 $335.71$424.60 $447.46 $447.46 $542.18 $542.18 $460.53 $460.53 $391.27 $391.27 $440.92 $440.92 $453.80 $453.80 $338.40 $338.40 $323.57 $323.57 $346.01 $346.01$437.69 $461.25 $461.25 $558.89 $558.89 $474.72 $474.72 $403.32 $403.32 $454.51 $454.51 $467.78 $467.78 $348.83 $348.83 $333.55 $333.55 $356.67 $356.67$451.23 $475.53 $475.53 $576.18 $576.18 $489.41 $489.41 $415.80 $415.80 $468.57 $468.57 $482.25 $482.25 $359.62 $359.62 $343.87 $343.87 $367.71 $367.71$451.23 $475.53 $475.53 $576.18 $576.18 $489.41 $489.41 $415.80 $415.80 $468.57 $468.57 $482.25 $482.25 $359.62 $359.62 $343.87 $343.87 $367.71 $367.71$451.23 $475.53 $475.53 $576.18 $576.18 $489.41 $489.41 $415.80 $415.80 $468.57 $468.57 $482.25 $482.25 $359.62 $359.62 $343.87 $343.87 $367.71 $367.71$451.23 $475.53 $475.53 $576.18 $576.18 $489.41 $489.41 $415.80 $415.80 $468.57 $468.57 $482.25 $482.25 $359.62 $359.62 $343.87 $343.87 $367.71 $367.71$453.03 $477.42 $477.42 $578.48 $578.48 $491.36 $491.36 $417.46 $417.46 $470.44 $470.44 $484.18 $484.18 $361.06 $361.06 $345.24 $345.24 $369.17 $369.17$462.05 $486.93 $486.93 $590.01 $590.01 $501.15 $501.15 $425.78 $425.78 $479.81 $479.81 $493.82 $493.82 $368.25 $368.25 $352.11 $352.11 $376.53 $376.53$472.88 $498.35 $498.35 $603.83 $603.83 $512.90 $512.90 $435.76 $435.76 $491.06 $491.06 $505.40 $505.40 $376.88 $376.88 $360.37 $360.37 $385.35 $385.35$490.48 $516.89 $516.89 $626.31 $626.31 $531.98 $531.98 $451.97 $451.97 $509.33 $509.33 $524.20 $524.20 $390.91 $390.91 $373.78 $373.78 $399.69 $399.69$504.92 $532.11 $532.11 $644.74 $644.74 $547.64 $547.64 $465.28 $465.28 $524.33 $524.33 $539.64 $539.64 $402.41 $402.41 $384.78 $384.78 $411.46 $411.46$512.14 $539.72 $539.72 $653.96 $653.96 $555.47 $555.47 $471.93 $471.93 $531.82 $531.82 $547.35 $547.35 $408.17 $408.17 $390.28 $390.28 $417.34 $417.34$522.97 $551.13 $551.13 $667.79 $667.79 $567.22 $567.22 $481.91 $481.91 $543.07 $543.07 $558.93 $558.93 $416.80 $416.80 $398.53 $398.53 $426.17 $426.17$533.80 $562.54 $562.54 $681.62 $681.62 $578.96 $578.96 $491.89 $491.89 $554.32 $554.32 $570.50 $570.50 $425.43 $425.43 $406.79 $406.79 $434.99 $434.99$540.57 $569.67 $569.67 $690.26 $690.26 $586.31 $586.31 $498.13 $498.13 $561.34 $561.34 $577.73 $577.73 $430.82 $430.82 $411.95 $411.95 $440.51 $440.51$547.79 $577.28 $577.28 $699.48 $699.48 $594.14 $594.14 $504.78 $504.78 $568.84 $568.84 $585.45 $585.45 $436.58 $436.58 $417.45 $417.45 $446.39 $446.39$551.40 $581.09 $581.09 $704.09 $704.09 $598.05 $598.05 $508.11 $508.11 $572.59 $572.59 $589.31 $589.31 $439.46 $439.46 $420.20 $420.20 $449.33 $449.33$555.00 $584.89 $584.89 $708.70 $708.70 $601.97 $601.97 $511.43 $511.43 $576.34 $576.34 $593.17 $593.17 $442.33 $442.33 $422.95 $422.95 $452.27 $452.27$558.61 $588.69 $588.69 $713.31 $713.31 $605.88 $605.88 $514.76 $514.76 $580.09 $580.09 $597.02 $597.02 $445.21 $445.21 $425.70 $425.70 $455.21 $455.21$562.22 $592.50 $592.50 $717.92 $717.92 $609.80 $609.80 $518.09 $518.09 $583.83 $583.83 $600.88 $600.88 $448.09 $448.09 $428.45 $428.45 $458.16 $458.16$569.44 $600.11 $600.11 $727.14 $727.14 $617.63 $617.63 $524.74 $524.74 $591.33 $591.33 $608.60 $608.60 $453.84 $453.84 $433.95 $433.95 $464.04 $464.04$576.66 $607.71 $607.71 $736.36 $736.36 $625.46 $625.46 $531.39 $531.39 $598.83 $598.83 $616.31 $616.31 $459.59 $459.59 $439.45 $439.45 $469.92 $469.92$587.49 $619.13 $619.13 $750.18 $750.18 $637.20 $637.20 $541.37 $541.37 $610.07 $610.07 $627.89 $627.89 $468.22 $468.22 $447.71 $447.71 $478.75 $478.75$597.87 $630.06 $630.06 $763.44 $763.44 $648.46 $648.46 $550.93 $550.93 $620.85 $620.85 $638.98 $638.98 $476.50 $476.50 $455.62 $455.62 $487.20 $487.20$612.31 $645.28 $645.28 $781.87 $781.87 $664.12 $664.12 $564.24 $564.24 $635.85 $635.85 $654.41 $654.41 $488.00 $488.00 $466.62 $466.62 $498.97 $498.97$630.36 $664.30 $664.30 $804.92 $804.92 $683.70 $683.70 $580.87 $580.87 $654.59 $654.59 $673.70 $673.70 $502.39 $502.39 $480.37 $480.37 $513.68 $513.68$651.57 $686.65 $686.65 $832.00 $832.00 $706.70 $706.70 $600.41 $600.41 $676.61 $676.61 $696.37 $696.37 $519.29 $519.29 $496.54 $496.54 $530.96 $530.96$676.84 $713.28 $713.28 $864.27 $864.27 $734.11 $734.11 $623.70 $623.70 $702.85 $702.85 $723.37 $723.37 $539.43 $539.43 $515.79 $515.79 $551.55 $551.55$705.26 $743.24 $743.24 $900.57 $900.57 $764.94 $764.94 $649.89 $649.89 $732.37 $732.37 $753.75 $753.75 $562.09 $562.09 $537.45 $537.45 $574.72 $574.72$737.75 $777.48 $777.48 $942.05 $942.05 $800.18 $800.18 $679.83 $679.83 $766.11 $766.11 $788.48 $788.48 $587.98 $587.98 $562.21 $562.21 $601.19 $601.19$769.79 $811.24 $811.24 $982.96 $982.96 $834.92 $834.92 $709.35 $709.35 $799.38 $799.38 $822.72 $822.72 $613.51 $613.51 $586.63 $586.63 $627.30 $627.30$805.89 $849.28 $849.28 $1,029.05 $1,029.05 $874.08 $874.08 $742.62 $742.62 $836.86 $836.86 $861.30 $861.30 $642.28 $642.28 $614.14 $614.14 $656.71 $656.71$841.53 $886.85 $886.85 $1,074.57 $1,074.57 $912.74 $912.74 $775.46 $775.46 $873.88 $873.88 $899.39 $899.39 $670.69 $670.69 $641.30 $641.30 $685.76 $685.76$880.79 $928.22 $928.22 $1,124.70 $1,124.70 $955.32 $955.32 $811.64 $811.64 $914.64 $914.64 $941.35 $941.35 $701.98 $701.98 $671.22 $671.22 $717.75 $717.75$920.50 $970.06 $970.06 $1,175.40 $1,175.40 $998.38 $998.38 $848.23 $848.23 $955.88 $955.88 $983.79 $983.79 $733.62 $733.62 $701.48 $701.48 $750.11 $750.11$963.36 $1,015.24 $1,015.24 $1,230.14 $1,230.14 $1,044.88 $1,044.88 $887.73 $887.73 $1,000.39 $1,000.39 $1,029.60 $1,029.60 $767.79 $767.79 $734.14 $734.14 $785.04 $785.04

$1,006.23 $1,060.41 $1,060.41 $1,284.88 $1,284.88 $1,091.37 $1,091.37 $927.23 $927.23 $1,044.91 $1,044.91 $1,075.41 $1,075.41 $801.95 $801.95 $766.81 $766.81 $819.97 $819.97$1,052.70 $1,109.39 $1,109.39 $1,344.22 $1,344.22 $1,141.78 $1,141.78 $970.06 $970.06 $1,093.17 $1,093.17 $1,125.09 $1,125.09 $838.99 $838.99 $802.23 $802.23 $857.85 $857.85$1,099.63 $1,158.84 $1,158.84 $1,404.15 $1,404.15 $1,192.68 $1,192.68 $1,013.30 $1,013.30 $1,141.90 $1,141.90 $1,175.24 $1,175.24 $876.39 $876.39 $837.99 $837.99 $896.09 $896.09$1,149.72 $1,211.63 $1,211.63 $1,468.10 $1,468.10 $1,247.00 $1,247.00 $1,059.45 $1,059.45 $1,193.91 $1,193.91 $1,228.77 $1,228.77 $916.31 $916.31 $876.16 $876.16 $936.90 $936.90$1,174.53 $1,237.78 $1,237.78 $1,499.79 $1,499.79 $1,273.92 $1,273.92 $1,082.32 $1,082.32 $1,219.68 $1,219.68 $1,255.29 $1,255.29 $936.09 $936.09 $895.07 $895.07 $957.13 $957.13$1,224.62 $1,290.56 $1,290.56 $1,563.75 $1,563.75 $1,328.24 $1,328.24 $1,128.48 $1,128.48 $1,271.69 $1,271.69 $1,308.82 $1,308.82 $976.01 $976.01 $933.24 $933.24 $997.94 $997.94$1,267.94 $1,336.21 $1,336.21 $1,619.06 $1,619.06 $1,375.23 $1,375.23 $1,168.39 $1,168.39 $1,316.67 $1,316.67 $1,355.12 $1,355.12 $1,010.53 $1,010.53 $966.25 $966.25 $1,033.24 $1,033.24$1,296.37 $1,366.17 $1,366.17 $1,655.36 $1,655.36 $1,406.06 $1,406.06 $1,194.59 $1,194.59 $1,346.19 $1,346.19 $1,385.50 $1,385.50 $1,033.19 $1,033.19 $987.91 $987.91 $1,056.40 $1,056.40$1,332.01 $1,403.74 $1,403.74 $1,700.88 $1,700.88 $1,444.72 $1,444.72 $1,227.44 $1,227.44 $1,383.21 $1,383.21 $1,423.60 $1,423.60 $1,061.60 $1,061.60 $1,015.08 $1,015.08 $1,085.45 $1,085.45$1,353.67 $1,426.56 $1,426.56 $1,728.53 $1,728.53 $1,468.21 $1,468.21 $1,247.40 $1,247.40 $1,405.70 $1,405.70 $1,446.74 $1,446.74 $1,078.86 $1,078.86 $1,031.58 $1,031.58 $1,103.10 $1,103.10

GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 2



0%$40 / $40$2,250

Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 9



0%$40 / $40$2,250

Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 6



0%$40 / $40$2,250

Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 3



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 6


num0 / Rx: $0%/ $30350es


l-Access PPO

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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$296.44 $296.44 $359.19 $359.19 $305.09 $305.09 $254.09 $254.09 $286.33 $286.33 $294.69 $294.69 $307.11 $307.11 $293.65 $293.65 $314.01 $314.01 $330.92$322.79 $322.79 $391.12 $391.12 $332.21 $332.21 $276.67 $276.67 $311.78 $311.78 $320.89 $320.89 $334.40 $334.40 $319.75 $319.75 $341.92 $341.92 $360.33$332.86 $332.86 $403.32 $403.32 $342.58 $342.58 $285.31 $285.31 $321.51 $321.51 $330.90 $330.90 $344.84 $344.84 $329.73 $329.73 $352.59 $352.59 $371.58$342.94 $342.94 $415.53 $415.53 $352.95 $352.95 $293.94 $293.94 $331.25 $331.25 $340.92 $340.92 $355.28 $355.28 $339.71 $339.71 $363.26 $363.26 $382.82$353.79 $353.79 $428.68 $428.68 $364.12 $364.12 $303.24 $303.24 $341.73 $341.73 $351.70 $351.70 $366.52 $366.52 $350.46 $350.46 $374.76 $374.76 $394.94$364.64 $364.64 $441.82 $441.82 $375.28 $375.28 $312.54 $312.54 $352.21 $352.21 $362.49 $362.49 $377.76 $377.76 $361.21 $361.21 $386.25 $386.25 $407.05$375.88 $375.88 $455.44 $455.44 $386.85 $386.85 $322.17 $322.17 $363.06 $363.06 $373.66 $373.66 $389.40 $389.40 $372.34 $372.34 $398.15 $398.15 $419.59$387.51 $387.51 $469.53 $469.53 $398.82 $398.82 $332.14 $332.14 $374.29 $374.29 $385.22 $385.22 $401.45 $401.45 $383.86 $383.86 $410.47 $410.47 $432.57$387.51 $387.51 $469.53 $469.53 $398.82 $398.82 $332.14 $332.14 $374.29 $374.29 $385.22 $385.22 $401.45 $401.45 $383.86 $383.86 $410.47 $410.47 $432.57$387.51 $387.51 $469.53 $469.53 $398.82 $398.82 $332.14 $332.14 $374.29 $374.29 $385.22 $385.22 $401.45 $401.45 $383.86 $383.86 $410.47 $410.47 $432.57$387.51 $387.51 $469.53 $469.53 $398.82 $398.82 $332.14 $332.14 $374.29 $374.29 $385.22 $385.22 $401.45 $401.45 $383.86 $383.86 $410.47 $410.47 $432.57$389.05 $389.05 $471.40 $471.40 $400.41 $400.41 $333.47 $333.47 $375.79 $375.79 $386.76 $386.76 $403.05 $403.05 $385.39 $385.39 $412.11 $412.11 $434.30$396.80 $396.80 $480.79 $480.79 $408.39 $408.39 $340.11 $340.11 $383.27 $383.27 $394.46 $394.46 $411.08 $411.08 $393.07 $393.07 $420.32 $420.32 $442.95$406.10 $406.10 $492.06 $492.06 $417.96 $417.96 $348.08 $348.08 $392.25 $392.25 $403.71 $403.71 $420.72 $420.72 $402.28 $402.28 $430.17 $430.17 $453.33$421.21 $421.21 $510.37 $510.37 $433.51 $433.51 $361.03 $361.03 $406.85 $406.85 $418.73 $418.73 $436.37 $436.37 $417.25 $417.25 $446.18 $446.18 $470.20$433.61 $433.61 $525.40 $525.40 $446.27 $446.27 $371.66 $371.66 $418.83 $418.83 $431.06 $431.06 $449.22 $449.22 $429.53 $429.53 $459.31 $459.31 $484.05$439.81 $439.81 $532.91 $532.91 $452.65 $452.65 $376.98 $376.98 $424.82 $424.82 $437.22 $437.22 $455.64 $455.64 $435.67 $435.67 $465.88 $465.88 $490.97$449.11 $449.11 $544.18 $544.18 $462.23 $462.23 $384.95 $384.95 $433.80 $433.80 $446.47 $446.47 $465.28 $465.28 $444.89 $444.89 $475.73 $475.73 $501.35$458.41 $458.41 $555.45 $555.45 $471.80 $471.80 $392.92 $392.92 $442.78 $442.78 $455.71 $455.71 $474.91 $474.91 $454.10 $454.10 $485.58 $485.58 $511.73$464.23 $464.23 $562.49 $562.49 $477.78 $477.78 $397.90 $397.90 $448.40 $448.40 $461.49 $461.49 $480.93 $480.93 $459.86 $459.86 $491.74 $491.74 $518.22$470.43 $470.43 $570.00 $570.00 $484.16 $484.16 $403.22 $403.22 $454.39 $454.39 $467.65 $467.65 $487.36 $487.36 $466.00 $466.00 $498.31 $498.31 $525.14$473.53 $473.53 $573.76 $573.76 $487.35 $487.35 $405.87 $405.87 $457.38 $457.38 $470.74 $470.74 $490.57 $490.57 $469.07 $469.07 $501.59 $501.59 $528.60$476.63 $476.63 $577.52 $577.52 $490.54 $490.54 $408.53 $408.53 $460.38 $460.38 $473.82 $473.82 $493.78 $493.78 $472.14 $472.14 $504.87 $504.87 $532.06$479.73 $479.73 $581.27 $581.27 $493.73 $493.73 $411.19 $411.19 $463.37 $463.37 $476.90 $476.90 $496.99 $496.99 $475.21 $475.21 $508.16 $508.16 $535.52$482.83 $482.83 $585.03 $585.03 $496.92 $496.92 $413.84 $413.84 $466.36 $466.36 $479.98 $479.98 $500.20 $500.20 $478.28 $478.28 $511.44 $511.44 $538.98$489.03 $489.03 $592.54 $592.54 $503.30 $503.30 $419.16 $419.16 $472.35 $472.35 $486.14 $486.14 $506.62 $506.62 $484.42 $484.42 $518.01 $518.01 $545.90$495.23 $495.23 $600.05 $600.05 $509.68 $509.68 $424.47 $424.47 $478.34 $478.34 $492.31 $492.31 $513.05 $513.05 $490.57 $490.57 $524.58 $524.58 $552.82$504.53 $504.53 $611.32 $611.32 $519.26 $519.26 $432.44 $432.44 $487.32 $487.32 $501.55 $501.55 $522.68 $522.68 $499.78 $499.78 $534.43 $534.43 $563.21$513.44 $513.44 $622.12 $622.12 $528.43 $528.43 $440.08 $440.08 $495.93 $495.93 $510.41 $510.41 $531.92 $531.92 $508.61 $508.61 $543.87 $543.87 $573.15$525.84 $525.84 $637.15 $637.15 $541.19 $541.19 $450.71 $450.71 $507.91 $507.91 $522.74 $522.74 $544.76 $544.76 $520.89 $520.89 $557.00 $557.00 $587.00$541.34 $541.34 $655.93 $655.93 $557.14 $557.14 $464.00 $464.00 $522.88 $522.88 $538.15 $538.15 $560.82 $560.82 $536.24 $536.24 $573.42 $573.42 $604.30$559.55 $559.55 $678.00 $678.00 $575.89 $575.89 $479.61 $479.61 $540.47 $540.47 $556.25 $556.25 $579.69 $579.69 $554.29 $554.29 $592.71 $592.71 $624.63$581.25 $581.25 $704.29 $704.29 $598.22 $598.22 $498.21 $498.21 $561.43 $561.43 $577.83 $577.83 $602.17 $602.17 $575.78 $575.78 $615.70 $615.70 $648.85$605.66 $605.66 $733.87 $733.87 $623.35 $623.35 $519.13 $519.13 $585.01 $585.01 $602.09 $602.09 $627.46 $627.46 $599.96 $599.96 $641.56 $641.56 $676.11$633.56 $633.56 $767.67 $767.67 $652.06 $652.06 $543.05 $543.05 $611.96 $611.96 $629.83 $629.83 $656.36 $656.36 $627.60 $627.60 $671.11 $671.11 $707.25$661.08 $661.08 $801.01 $801.01 $680.38 $680.38 $566.63 $566.63 $638.54 $638.54 $657.18 $657.18 $684.87 $684.87 $654.86 $654.86 $700.26 $700.26 $737.96$692.08 $692.08 $838.57 $838.57 $712.28 $712.28 $593.20 $593.20 $668.48 $668.48 $688.00 $688.00 $716.98 $716.98 $685.56 $685.56 $733.09 $733.09 $772.57$722.69 $722.69 $875.67 $875.67 $743.79 $743.79 $619.44 $619.44 $698.05 $698.05 $718.43 $718.43 $748.70 $748.70 $715.89 $715.89 $765.52 $765.52 $806.74$756.40 $756.40 $916.51 $916.51 $778.49 $778.49 $648.33 $648.33 $730.61 $730.61 $751.94 $751.94 $783.62 $783.62 $749.28 $749.28 $801.23 $801.23 $844.38$790.50 $790.50 $957.83 $957.83 $813.58 $813.58 $677.56 $677.56 $763.55 $763.55 $785.84 $785.84 $818.95 $818.95 $783.06 $783.06 $837.35 $837.35 $882.44$827.31 $827.31 $1,002.44 $1,002.44 $851.47 $851.47 $709.11 $709.11 $799.11 $799.11 $822.44 $822.44 $857.09 $857.09 $819.53 $819.53 $876.35 $876.35 $923.54$864.13 $864.13 $1,047.04 $1,047.04 $889.36 $889.36 $740.67 $740.67 $834.66 $834.66 $859.03 $859.03 $895.22 $895.22 $856.00 $856.00 $915.34 $915.34 $964.63$904.04 $904.04 $1,095.40 $1,095.40 $930.43 $930.43 $774.88 $774.88 $873.22 $873.22 $898.71 $898.71 $936.57 $936.57 $895.53 $895.53 $957.62 $957.62 $1,009.18$944.34 $944.34 $1,144.23 $1,144.23 $971.91 $971.91 $809.42 $809.42 $912.14 $912.14 $938.77 $938.77 $978.32 $978.32 $935.45 $935.45 $1,000.31 $1,000.31 $1,054.17$987.35 $987.35 $1,196.35 $1,196.35 $1,016.18 $1,016.18 $846.29 $846.29 $953.69 $953.69 $981.53 $981.53 $1,022.88 $1,022.88 $978.06 $978.06 $1,045.87 $1,045.87 $1,102.19

$1,008.66 $1,008.66 $1,222.18 $1,222.18 $1,038.11 $1,038.11 $864.55 $864.55 $974.27 $974.27 $1,002.72 $1,002.72 $1,044.96 $1,044.96 $999.17 $999.17 $1,068.45 $1,068.45 $1,125.98$1,051.68 $1,051.68 $1,274.29 $1,274.29 $1,082.38 $1,082.38 $901.42 $901.42 $1,015.82 $1,015.82 $1,045.48 $1,045.48 $1,089.52 $1,089.52 $1,041.78 $1,041.78 $1,114.01 $1,114.01 $1,173.99$1,088.88 $1,088.88 $1,319.37 $1,319.37 $1,120.67 $1,120.67 $933.31 $933.31 $1,051.75 $1,051.75 $1,082.46 $1,082.46 $1,128.06 $1,128.06 $1,078.63 $1,078.63 $1,153.41 $1,153.41 $1,215.52$1,113.29 $1,113.29 $1,348.95 $1,348.95 $1,145.79 $1,145.79 $954.23 $954.23 $1,075.33 $1,075.33 $1,106.73 $1,106.73 $1,153.35 $1,153.35 $1,102.81 $1,102.81 $1,179.27 $1,179.27 $1,242.77$1,143.90 $1,143.90 $1,386.04 $1,386.04 $1,177.30 $1,177.30 $980.47 $980.47 $1,104.90 $1,104.90 $1,137.16 $1,137.16 $1,185.07 $1,185.07 $1,133.14 $1,133.14 $1,211.70 $1,211.70 $1,276.94$1,162.50 $1,162.50 $1,408.58 $1,408.58 $1,196.44 $1,196.44 $996.41 $996.41 $1,122.87 $1,122.87 $1,155.65 $1,155.65 $1,204.34 $1,204.34 $1,151.56 $1,151.56 $1,231.40 $1,231.40 $1,297.71

GoMed: $50

0$20 /$8,1

Y

75729PAGeisinger Al

20/40M-152-121-

Rating

Geisinger Al


0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 5



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 3



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 6


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 6


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Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$330.92 $400.96 $400.96 $340.58 $340.58 $291.63 $291.63 $278.85 $278.85 $298.18 $298.18 $314.24 $314.24 $380.76 $380.76 $323.41 $323.41 $285.96 $285.96$360.33 $436.60 $436.60 $370.85 $370.85 $317.55 $317.55 $303.64 $303.64 $324.69 $324.69 $342.17 $342.17 $414.60 $414.60 $352.16 $352.16 $311.38 $311.38$371.58 $450.23 $450.23 $382.43 $382.43 $327.46 $327.46 $313.12 $313.12 $334.82 $334.82 $352.85 $352.85 $427.54 $427.54 $363.15 $363.15 $321.10 $321.10$382.82 $463.86 $463.86 $394.00 $394.00 $337.38 $337.38 $322.59 $322.59 $344.96 $344.96 $363.53 $363.53 $440.48 $440.48 $374.15 $374.15 $330.82 $330.82$394.94 $478.54 $478.54 $406.47 $406.47 $348.05 $348.05 $332.80 $332.80 $355.87 $355.87 $375.03 $375.03 $454.42 $454.42 $385.98 $385.98 $341.28 $341.28$407.05 $493.21 $493.21 $418.93 $418.93 $358.72 $358.72 $343.01 $343.01 $366.79 $366.79 $386.54 $386.54 $468.36 $468.36 $397.82 $397.82 $351.75 $351.75$419.59 $508.41 $508.41 $431.84 $431.84 $369.78 $369.78 $353.58 $353.58 $378.09 $378.09 $398.45 $398.45 $482.79 $482.79 $410.08 $410.08 $362.59 $362.59$432.57 $524.14 $524.14 $445.20 $445.20 $381.22 $381.22 $364.52 $364.52 $389.79 $389.79 $410.78 $410.78 $497.73 $497.73 $422.77 $422.77 $373.81 $373.81$432.57 $524.14 $524.14 $445.20 $445.20 $381.22 $381.22 $364.52 $364.52 $389.79 $389.79 $410.78 $410.78 $497.73 $497.73 $422.77 $422.77 $373.81 $373.81$432.57 $524.14 $524.14 $445.20 $445.20 $381.22 $381.22 $364.52 $364.52 $389.79 $389.79 $410.78 $410.78 $497.73 $497.73 $422.77 $422.77 $373.81 $373.81$432.57 $524.14 $524.14 $445.20 $445.20 $381.22 $381.22 $364.52 $364.52 $389.79 $389.79 $410.78 $410.78 $497.73 $497.73 $422.77 $422.77 $373.81 $373.81$434.30 $526.23 $526.23 $446.98 $446.98 $382.74 $382.74 $365.97 $365.97 $391.34 $391.34 $412.41 $412.41 $499.71 $499.71 $424.46 $424.46 $375.30 $375.30$442.95 $536.71 $536.71 $455.88 $455.88 $390.37 $390.37 $373.26 $373.26 $399.14 $399.14 $420.63 $420.63 $509.67 $509.67 $432.91 $432.91 $382.77 $382.77$453.33 $549.29 $549.29 $466.57 $466.57 $399.51 $399.51 $382.01 $382.01 $408.49 $408.49 $430.49 $430.49 $521.61 $521.61 $443.06 $443.06 $391.75 $391.75$470.20 $569.73 $569.73 $483.93 $483.93 $414.38 $414.38 $396.22 $396.22 $423.69 $423.69 $446.51 $446.51 $541.02 $541.02 $459.55 $459.55 $406.32 $406.32$484.05 $586.51 $586.51 $498.18 $498.18 $426.58 $426.58 $407.89 $407.89 $436.17 $436.17 $459.65 $459.65 $556.95 $556.95 $473.07 $473.07 $418.29 $418.29$490.97 $594.89 $594.89 $505.30 $505.30 $432.68 $432.68 $413.72 $413.72 $442.40 $442.40 $466.23 $466.23 $564.92 $564.92 $479.84 $479.84 $424.27 $424.27$501.35 $607.47 $607.47 $515.99 $515.99 $441.83 $441.83 $422.47 $422.47 $451.76 $451.76 $476.08 $476.08 $576.86 $576.86 $489.98 $489.98 $433.24 $433.24$511.73 $620.05 $620.05 $526.67 $526.67 $450.98 $450.98 $431.22 $431.22 $461.11 $461.11 $485.94 $485.94 $588.81 $588.81 $500.13 $500.13 $442.21 $442.21$518.22 $627.91 $627.91 $533.35 $533.35 $456.70 $456.70 $436.68 $436.68 $466.96 $466.96 $492.10 $492.10 $596.27 $596.27 $506.47 $506.47 $447.82 $447.82$525.14 $636.30 $636.30 $540.47 $540.47 $462.80 $462.80 $442.52 $442.52 $473.20 $473.20 $498.68 $498.68 $604.24 $604.24 $513.24 $513.24 $453.80 $453.80$528.60 $640.49 $640.49 $544.03 $544.03 $465.85 $465.85 $445.43 $445.43 $476.31 $476.31 $501.96 $501.96 $608.22 $608.22 $516.62 $516.62 $456.79 $456.79$532.06 $644.69 $644.69 $547.59 $547.59 $468.90 $468.90 $448.35 $448.35 $479.43 $479.43 $505.25 $505.25 $612.20 $612.20 $520.00 $520.00 $459.78 $459.78$535.52 $648.88 $648.88 $551.16 $551.16 $471.95 $471.95 $451.27 $451.27 $482.55 $482.55 $508.53 $508.53 $616.18 $616.18 $523.38 $523.38 $462.77 $462.77$538.98 $653.07 $653.07 $554.72 $554.72 $475.00 $475.00 $454.18 $454.18 $485.67 $485.67 $511.82 $511.82 $620.16 $620.16 $526.76 $526.76 $465.76 $465.76$545.90 $661.46 $661.46 $561.84 $561.84 $481.10 $481.10 $460.01 $460.01 $491.91 $491.91 $518.39 $518.39 $628.13 $628.13 $533.53 $533.53 $471.74 $471.74$552.82 $669.84 $669.84 $568.96 $568.96 $487.19 $487.19 $465.85 $465.85 $498.14 $498.14 $524.97 $524.97 $636.09 $636.09 $540.29 $540.29 $477.72 $477.72$563.21 $682.42 $682.42 $579.65 $579.65 $496.34 $496.34 $474.59 $474.59 $507.50 $507.50 $534.82 $534.82 $648.04 $648.04 $550.44 $550.44 $486.69 $486.69$573.15 $694.48 $694.48 $589.89 $589.89 $505.11 $505.11 $482.98 $482.98 $516.46 $516.46 $544.27 $544.27 $659.48 $659.48 $560.16 $560.16 $495.29 $495.29$587.00 $711.25 $711.25 $604.14 $604.14 $517.31 $517.31 $494.64 $494.64 $528.94 $528.94 $557.42 $557.42 $675.41 $675.41 $573.69 $573.69 $507.25 $507.25$604.30 $732.22 $732.22 $621.94 $621.94 $532.56 $532.56 $509.22 $509.22 $544.53 $544.53 $573.85 $573.85 $695.32 $695.32 $590.60 $590.60 $522.20 $522.20$624.63 $756.85 $756.85 $642.87 $642.87 $550.48 $550.48 $526.35 $526.35 $562.85 $562.85 $593.15 $593.15 $718.71 $718.71 $610.47 $610.47 $539.77 $539.77$648.85 $786.20 $786.20 $667.80 $667.80 $571.82 $571.82 $546.77 $546.77 $584.67 $584.67 $616.16 $616.16 $746.58 $746.58 $634.15 $634.15 $560.70 $560.70$676.11 $819.22 $819.22 $695.85 $695.85 $595.84 $595.84 $569.73 $569.73 $609.23 $609.23 $642.04 $642.04 $777.94 $777.94 $660.78 $660.78 $584.25 $584.25$707.25 $856.96 $856.96 $727.90 $727.90 $623.29 $623.29 $595.98 $595.98 $637.30 $637.30 $671.61 $671.61 $813.78 $813.78 $691.22 $691.22 $611.17 $611.17$737.96 $894.17 $894.17 $759.51 $759.51 $650.36 $650.36 $621.86 $621.86 $664.97 $664.97 $700.78 $700.78 $849.12 $849.12 $721.24 $721.24 $637.71 $637.71$772.57 $936.11 $936.11 $795.13 $795.13 $680.85 $680.85 $651.02 $651.02 $696.15 $696.15 $733.64 $733.64 $888.93 $888.93 $755.06 $755.06 $667.61 $667.61$806.74 $977.51 $977.51 $830.30 $830.30 $710.97 $710.97 $679.81 $679.81 $726.95 $726.95 $766.09 $766.09 $928.25 $928.25 $788.46 $788.46 $697.14 $697.14$844.38 $1,023.11 $1,023.11 $869.03 $869.03 $744.13 $744.13 $711.53 $711.53 $760.86 $760.86 $801.83 $801.83 $971.56 $971.56 $825.24 $825.24 $729.66 $729.66$882.44 $1,069.24 $1,069.24 $908.21 $908.21 $777.68 $777.68 $743.60 $743.60 $795.16 $795.16 $837.97 $837.97 $1,015.35 $1,015.35 $862.44 $862.44 $762.56 $762.56$923.54 $1,119.03 $1,119.03 $950.50 $950.50 $813.90 $813.90 $778.23 $778.23 $832.19 $832.19 $877.00 $877.00 $1,062.64 $1,062.64 $902.60 $902.60 $798.07 $798.07$964.63 $1,168.82 $1,168.82 $992.79 $992.79 $850.11 $850.11 $812.86 $812.86 $869.22 $869.22 $916.02 $916.02 $1,109.92 $1,109.92 $942.77 $942.77 $833.58 $833.58

$1,009.18 $1,222.81 $1,222.81 $1,038.65 $1,038.65 $889.38 $889.38 $850.41 $850.41 $909.36 $909.36 $958.33 $958.33 $1,161.19 $1,161.19 $986.31 $986.31 $872.08 $872.08$1,054.17 $1,277.32 $1,277.32 $1,084.95 $1,084.95 $929.02 $929.02 $888.31 $888.31 $949.90 $949.90 $1,001.05 $1,001.05 $1,212.95 $1,212.95 $1,030.28 $1,030.28 $910.96 $910.96$1,102.19 $1,335.50 $1,335.50 $1,134.37 $1,134.37 $971.34 $971.34 $928.78 $928.78 $993.17 $993.17 $1,046.65 $1,046.65 $1,268.20 $1,268.20 $1,077.20 $1,077.20 $952.45 $952.45$1,125.98 $1,364.32 $1,364.32 $1,158.85 $1,158.85 $992.31 $992.31 $948.82 $948.82 $1,014.61 $1,014.61 $1,069.24 $1,069.24 $1,295.57 $1,295.57 $1,100.46 $1,100.46 $973.01 $973.01$1,173.99 $1,422.50 $1,422.50 $1,208.27 $1,208.27 $1,034.62 $1,034.62 $989.28 $989.28 $1,057.87 $1,057.87 $1,114.83 $1,114.83 $1,350.82 $1,350.82 $1,147.38 $1,147.38 $1,014.50 $1,014.50$1,215.52 $1,472.82 $1,472.82 $1,251.01 $1,251.01 $1,071.22 $1,071.22 $1,024.28 $1,024.28 $1,095.29 $1,095.29 $1,154.27 $1,154.27 $1,398.60 $1,398.60 $1,187.97 $1,187.97 $1,050.39 $1,050.39$1,242.77 $1,505.84 $1,505.84 $1,279.06 $1,279.06 $1,095.23 $1,095.23 $1,047.24 $1,047.24 $1,119.85 $1,119.85 $1,180.15 $1,180.15 $1,429.96 $1,429.96 $1,214.60 $1,214.60 $1,073.94 $1,073.94$1,276.94 $1,547.25 $1,547.25 $1,314.23 $1,314.23 $1,125.35 $1,125.35 $1,076.04 $1,076.04 $1,150.64 $1,150.64 $1,212.60 $1,212.60 $1,469.28 $1,469.28 $1,248.00 $1,248.00 $1,103.47 $1,103.47$1,297.71 $1,572.41 $1,572.41 $1,335.60 $1,335.60 $1,143.65 $1,143.65 $1,093.53 $1,093.53 $1,169.35 $1,169.35 $1,232.31 $1,232.31 $1,493.17 $1,493.17 $1,268.29 $1,268.29 $1,121.41 $1,121.41

GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 2



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 9



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 7


old0 / Rx: $0%/ $40150es


l-Access PPO

Page Number: 27 12/24/2014

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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$273.43 $273.43 $292.39 $292.39 $308.13 $308.13 $373.35 $373.35 $317.13 $317.13 $256.04 $256.04 $244.82 $244.82 $261.80 $261.80 $275.89 $275.89 $334.30$297.73 $297.73 $318.37 $318.37 $335.52 $335.52 $406.54 $406.54 $345.31 $345.31 $278.80 $278.80 $266.59 $266.59 $285.07 $285.07 $300.42 $300.42 $364.01$307.03 $307.03 $328.31 $328.31 $345.99 $345.99 $419.23 $419.23 $356.09 $356.09 $287.51 $287.51 $274.91 $274.91 $293.97 $293.97 $309.80 $309.80 $375.37$316.32 $316.32 $338.25 $338.25 $356.46 $356.46 $431.92 $431.92 $366.87 $366.87 $296.21 $296.21 $283.23 $283.23 $302.86 $302.86 $319.17 $319.17 $386.73$326.33 $326.33 $348.95 $348.95 $367.74 $367.74 $445.58 $445.58 $378.48 $378.48 $305.58 $305.58 $292.19 $292.19 $312.45 $312.45 $329.27 $329.27 $398.97$336.33 $336.33 $359.65 $359.65 $379.02 $379.02 $459.25 $459.25 $390.08 $390.08 $314.95 $314.95 $301.15 $301.15 $322.03 $322.03 $339.37 $339.37 $411.21$346.70 $346.70 $370.74 $370.74 $390.70 $390.70 $473.40 $473.40 $402.11 $402.11 $324.66 $324.66 $310.43 $310.43 $331.95 $331.95 $349.83 $349.83 $423.88$357.43 $357.43 $382.21 $382.21 $402.79 $402.79 $488.05 $488.05 $414.55 $414.55 $334.70 $334.70 $320.04 $320.04 $342.22 $342.22 $360.65 $360.65 $436.99$357.43 $357.43 $382.21 $382.21 $402.79 $402.79 $488.05 $488.05 $414.55 $414.55 $334.70 $334.70 $320.04 $320.04 $342.22 $342.22 $360.65 $360.65 $436.99$357.43 $357.43 $382.21 $382.21 $402.79 $402.79 $488.05 $488.05 $414.55 $414.55 $334.70 $334.70 $320.04 $320.04 $342.22 $342.22 $360.65 $360.65 $436.99$357.43 $357.43 $382.21 $382.21 $402.79 $402.79 $488.05 $488.05 $414.55 $414.55 $334.70 $334.70 $320.04 $320.04 $342.22 $342.22 $360.65 $360.65 $436.99$358.85 $358.85 $383.73 $383.73 $404.39 $404.39 $490.00 $490.00 $416.20 $416.20 $336.04 $336.04 $321.31 $321.31 $343.59 $343.59 $362.09 $362.09 $438.74$366.00 $366.00 $391.38 $391.38 $412.45 $412.45 $499.76 $499.76 $424.49 $424.49 $342.73 $342.73 $327.71 $327.71 $350.43 $350.43 $369.30 $369.30 $447.48$374.58 $374.58 $400.55 $400.55 $422.12 $422.12 $511.47 $511.47 $434.44 $434.44 $350.76 $350.76 $335.39 $335.39 $358.65 $358.65 $377.96 $377.96 $457.96$388.52 $388.52 $415.45 $415.45 $437.82 $437.82 $530.50 $530.50 $450.61 $450.61 $363.82 $363.82 $347.87 $347.87 $371.99 $371.99 $392.02 $392.02 $475.01$399.96 $399.96 $427.68 $427.68 $450.71 $450.71 $546.12 $546.12 $463.87 $463.87 $374.53 $374.53 $358.12 $358.12 $382.94 $382.94 $403.56 $403.56 $488.99$405.67 $405.67 $433.80 $433.80 $457.16 $457.16 $553.93 $553.93 $470.51 $470.51 $379.88 $379.88 $363.24 $363.24 $388.42 $388.42 $409.33 $409.33 $495.98$414.25 $414.25 $442.97 $442.97 $466.83 $466.83 $565.64 $565.64 $480.46 $480.46 $387.91 $387.91 $370.92 $370.92 $396.63 $396.63 $417.99 $417.99 $506.47$422.83 $422.83 $452.15 $452.15 $476.49 $476.49 $577.36 $577.36 $490.40 $490.40 $395.95 $395.95 $378.60 $378.60 $404.85 $404.85 $426.64 $426.64 $516.96$428.19 $428.19 $457.88 $457.88 $482.53 $482.53 $584.68 $584.68 $496.62 $496.62 $400.97 $400.97 $383.40 $383.40 $409.98 $409.98 $432.05 $432.05 $523.51$433.91 $433.91 $463.99 $463.99 $488.98 $488.98 $592.48 $592.48 $503.26 $503.26 $406.32 $406.32 $388.52 $388.52 $415.45 $415.45 $437.82 $437.82 $530.50$436.77 $436.77 $467.05 $467.05 $492.20 $492.20 $596.39 $596.39 $506.57 $506.57 $409.00 $409.00 $391.08 $391.08 $418.19 $418.19 $440.71 $440.71 $534.00$439.63 $439.63 $470.11 $470.11 $495.42 $495.42 $600.29 $600.29 $509.89 $509.89 $411.68 $411.68 $393.64 $393.64 $420.93 $420.93 $443.59 $443.59 $537.49$442.49 $442.49 $473.17 $473.17 $498.65 $498.65 $604.20 $604.20 $513.20 $513.20 $414.36 $414.36 $396.20 $396.20 $423.67 $423.67 $446.48 $446.48 $540.99$445.35 $445.35 $476.22 $476.22 $501.87 $501.87 $608.10 $608.10 $516.52 $516.52 $417.03 $417.03 $398.76 $398.76 $426.41 $426.41 $449.37 $449.37 $544.49$451.07 $451.07 $482.34 $482.34 $508.31 $508.31 $615.91 $615.91 $523.15 $523.15 $422.39 $422.39 $403.88 $403.88 $431.88 $431.88 $455.14 $455.14 $551.48$456.79 $456.79 $488.46 $488.46 $514.76 $514.76 $623.72 $623.72 $529.79 $529.79 $427.74 $427.74 $409.00 $409.00 $437.36 $437.36 $460.91 $460.91 $558.47$465.36 $465.36 $497.63 $497.63 $524.42 $524.42 $635.43 $635.43 $539.73 $539.73 $435.78 $435.78 $416.68 $416.68 $445.57 $445.57 $469.56 $469.56 $568.96$473.58 $473.58 $506.42 $506.42 $533.69 $533.69 $646.66 $646.66 $549.27 $549.27 $443.47 $443.47 $424.04 $424.04 $453.44 $453.44 $477.86 $477.86 $579.01$485.02 $485.02 $518.65 $518.65 $546.58 $546.58 $662.28 $662.28 $562.53 $562.53 $454.18 $454.18 $434.28 $434.28 $464.39 $464.39 $489.40 $489.40 $592.99$499.32 $499.32 $533.94 $533.94 $562.69 $562.69 $681.80 $681.80 $579.12 $579.12 $467.57 $467.57 $447.08 $447.08 $478.08 $478.08 $503.82 $503.82 $610.47$516.12 $516.12 $551.90 $551.90 $581.62 $581.62 $704.73 $704.73 $598.60 $598.60 $483.30 $483.30 $462.13 $462.13 $494.16 $494.16 $520.77 $520.77 $631.01$536.13 $536.13 $573.30 $573.30 $604.17 $604.17 $732.07 $732.07 $621.81 $621.81 $502.05 $502.05 $480.05 $480.05 $513.33 $513.33 $540.97 $540.97 $655.48$558.65 $558.65 $597.38 $597.38 $629.55 $629.55 $762.81 $762.81 $647.93 $647.93 $523.13 $523.13 $500.21 $500.21 $534.89 $534.89 $563.69 $563.69 $683.01$584.39 $584.39 $624.90 $624.90 $658.55 $658.55 $797.95 $797.95 $677.78 $677.78 $547.23 $547.23 $523.25 $523.25 $559.53 $559.53 $589.66 $589.66 $714.47$609.76 $609.76 $652.04 $652.04 $687.15 $687.15 $832.60 $832.60 $707.21 $707.21 $570.99 $570.99 $545.97 $545.97 $583.83 $583.83 $615.26 $615.26 $745.50$638.36 $638.36 $682.61 $682.61 $719.37 $719.37 $871.65 $871.65 $740.37 $740.37 $597.77 $597.77 $571.58 $571.58 $611.20 $611.20 $644.11 $644.11 $780.46$666.59 $666.59 $712.81 $712.81 $751.19 $751.19 $910.20 $910.20 $773.12 $773.12 $624.21 $624.21 $596.86 $596.86 $638.24 $638.24 $672.61 $672.61 $814.98$697.69 $697.69 $746.06 $746.06 $786.23 $786.23 $952.66 $952.66 $809.19 $809.19 $653.33 $653.33 $624.70 $624.70 $668.01 $668.01 $703.98 $703.98 $853.00$729.14 $729.14 $779.69 $779.69 $821.68 $821.68 $995.61 $995.61 $845.67 $845.67 $682.78 $682.78 $652.86 $652.86 $698.13 $698.13 $735.72 $735.72 $891.45$763.10 $763.10 $816.00 $816.00 $859.94 $859.94 $1,041.97 $1,041.97 $885.05 $885.05 $714.58 $714.58 $683.27 $683.27 $730.64 $730.64 $769.98 $769.98 $932.97$797.05 $797.05 $852.31 $852.31 $898.21 $898.21 $1,088.34 $1,088.34 $924.43 $924.43 $746.38 $746.38 $713.67 $713.67 $763.15 $763.15 $804.24 $804.24 $974.48$833.87 $833.87 $891.68 $891.68 $939.69 $939.69 $1,138.61 $1,138.61 $967.13 $967.13 $780.85 $780.85 $746.63 $746.63 $798.40 $798.40 $841.39 $841.39 $1,019.49$871.04 $871.04 $931.43 $931.43 $981.58 $981.58 $1,189.36 $1,189.36 $1,010.24 $1,010.24 $815.66 $815.66 $779.92 $779.92 $833.99 $833.99 $878.90 $878.90 $1,064.94$910.71 $910.71 $973.85 $973.85 $1,026.29 $1,026.29 $1,243.53 $1,243.53 $1,056.26 $1,056.26 $852.81 $852.81 $815.44 $815.44 $871.97 $871.97 $918.93 $918.93 $1,113.44$930.37 $930.37 $994.87 $994.87 $1,048.44 $1,048.44 $1,270.38 $1,270.38 $1,079.06 $1,079.06 $871.22 $871.22 $833.04 $833.04 $890.80 $890.80 $938.76 $938.76 $1,137.48$970.04 $970.04 $1,037.30 $1,037.30 $1,093.15 $1,093.15 $1,324.55 $1,324.55 $1,125.07 $1,125.07 $908.37 $908.37 $868.56 $868.56 $928.78 $928.78 $978.79 $978.79 $1,185.98

$1,004.36 $1,004.36 $1,073.99 $1,073.99 $1,131.82 $1,131.82 $1,371.40 $1,371.40 $1,164.87 $1,164.87 $940.50 $940.50 $899.29 $899.29 $961.64 $961.64 $1,013.42 $1,013.42 $1,227.93$1,026.87 $1,026.87 $1,098.07 $1,098.07 $1,157.20 $1,157.20 $1,402.15 $1,402.15 $1,190.98 $1,190.98 $961.59 $961.59 $919.45 $919.45 $983.20 $983.20 $1,036.14 $1,036.14 $1,255.47$1,055.11 $1,055.11 $1,128.26 $1,128.26 $1,189.02 $1,189.02 $1,440.70 $1,440.70 $1,223.73 $1,223.73 $988.03 $988.03 $944.73 $944.73 $1,010.23 $1,010.23 $1,064.63 $1,064.63 $1,289.99$1,072.27 $1,072.27 $1,146.61 $1,146.61 $1,208.35 $1,208.35 $1,464.13 $1,464.13 $1,243.63 $1,243.63 $1,004.09 $1,004.09 $960.09 $960.09 $1,026.66 $1,026.66 $1,081.94 $1,081.94 $1,310.96

SilMed: $4,30

0$35 /$8,1

Y

75729PAGeisinger Al

35/70M-152-121-

Rating

Geisinger Al

SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 5


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 3


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64+


$1,019.49 $865.95 $865.95 $774.32 $774.32 $740.39 $740.39 $791.72 $791.72 $834.36 $834.36 $1,010.97 $1,010.97 $858.72 $858.72 $680.17 $680.17 $650.36 $650.36$1,064.94 $904.56 $904.56 $808.84 $808.84 $773.40 $773.40 $827.02 $827.02 $871.55 $871.55 $1,056.04 $1,056.04 $897.00 $897.00 $710.49 $710.49 $679.35 $679.35$1,113.44 $945.76 $945.76 $845.68 $845.68 $808.62 $808.62 $864.69 $864.69 $911.25 $911.25 $1,104.14 $1,104.14 $937.85 $937.85 $742.85 $742.85 $710.30 $710.30$1,137.48 $966.17 $966.17 $863.94 $863.94 $826.08 $826.08 $883.35 $883.35 $930.92 $930.92 $1,127.97 $1,127.97 $958.10 $958.10 $758.88 $758.88 $725.63 $725.63$1,185.98 $1,007.37 $1,007.37 $900.78 $900.78 $861.31 $861.31 $921.02 $921.02 $970.61 $970.61 $1,176.07 $1,176.07 $998.95 $998.95 $791.24 $791.24 $756.57 $756.57$1,227.93 $1,043.00 $1,043.00 $932.64 $932.64 $891.77 $891.77 $953.60 $953.60 $1,004.95 $1,004.95 $1,217.67 $1,217.67 $1,034.29 $1,034.29 $819.23 $819.23 $783.33 $783.33$1,255.47 $1,066.39 $1,066.39 $953.55 $953.55 $911.77 $911.77 $974.98 $974.98 $1,027.48 $1,027.48 $1,244.97 $1,244.97 $1,057.48 $1,057.48 $837.60 $837.60 $800.90 $800.90$1,289.99 $1,095.71 $1,095.71 $979.77 $979.77 $936.84 $936.84 $1,001.79 $1,001.79 $1,055.73 $1,055.73 $1,279.21 $1,279.21 $1,086.55 $1,086.55 $860.63 $860.63 $822.92 $822.92$1,310.96 $1,113.53 $1,113.53 $995.70 $995.70 $952.07 $952.07 $1,018.08 $1,018.08 $1,072.90 $1,072.90 $1,300.01 $1,300.01 $1,104.22 $1,104.22 $874.63 $874.63 $836.30 $836.30


0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 3



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 7


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 5


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 9


ver0 / Rx: $500%/ $70150es


l-Access PPO

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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$228.04 $228.04 $240.32 $240.32 $291.19 $291.19 $247.34 $247.34 $236.88 $236.88 $266.94 $266.94 $274.74 $274.74 $290.99 $290.99 $278.24 $278.24 $297.53$248.31 $248.31 $261.68 $261.68 $317.07 $317.07 $269.32 $269.32 $257.94 $257.94 $290.67 $290.67 $299.16 $299.16 $316.85 $316.85 $302.97 $302.97 $323.97$256.06 $256.06 $269.85 $269.85 $326.97 $326.97 $277.73 $277.73 $265.99 $265.99 $299.74 $299.74 $308.49 $308.49 $326.74 $326.74 $312.42 $312.42 $334.08$263.81 $263.81 $278.02 $278.02 $336.87 $336.87 $286.14 $286.14 $274.04 $274.04 $308.82 $308.82 $317.83 $317.83 $336.63 $336.63 $321.88 $321.88 $344.20$272.16 $272.16 $286.81 $286.81 $347.53 $347.53 $295.19 $295.19 $282.71 $282.71 $318.59 $318.59 $327.89 $327.89 $347.28 $347.28 $332.06 $332.06 $355.09$280.51 $280.51 $295.61 $295.61 $358.18 $358.18 $304.24 $304.24 $291.38 $291.38 $328.36 $328.36 $337.94 $337.94 $357.93 $357.93 $342.25 $342.25 $365.98$289.15 $289.15 $304.72 $304.72 $369.22 $369.22 $313.62 $313.62 $300.36 $300.36 $338.48 $338.48 $348.36 $348.36 $368.96 $368.96 $352.80 $352.80 $377.26$298.10 $298.10 $314.15 $314.15 $380.65 $380.65 $323.32 $323.32 $309.65 $309.65 $348.95 $348.95 $359.14 $359.14 $380.38 $380.38 $363.71 $363.71 $388.93$298.10 $298.10 $314.15 $314.15 $380.65 $380.65 $323.32 $323.32 $309.65 $309.65 $348.95 $348.95 $359.14 $359.14 $380.38 $380.38 $363.71 $363.71 $388.93$298.10 $298.10 $314.15 $314.15 $380.65 $380.65 $323.32 $323.32 $309.65 $309.65 $348.95 $348.95 $359.14 $359.14 $380.38 $380.38 $363.71 $363.71 $388.93$298.10 $298.10 $314.15 $314.15 $380.65 $380.65 $323.32 $323.32 $309.65 $309.65 $348.95 $348.95 $359.14 $359.14 $380.38 $380.38 $363.71 $363.71 $388.93$299.29 $299.29 $315.40 $315.40 $382.16 $382.16 $324.61 $324.61 $310.89 $310.89 $350.34 $350.34 $360.57 $360.57 $381.90 $381.90 $365.16 $365.16 $390.48$305.25 $305.25 $321.68 $321.68 $389.78 $389.78 $331.08 $331.08 $317.08 $317.08 $357.32 $357.32 $367.75 $367.75 $389.50 $389.50 $372.44 $372.44 $398.26$312.40 $312.40 $329.22 $329.22 $398.91 $398.91 $338.84 $338.84 $324.51 $324.51 $365.69 $365.69 $376.37 $376.37 $398.63 $398.63 $381.17 $381.17 $407.59$324.03 $324.03 $341.47 $341.47 $413.76 $413.76 $351.45 $351.45 $336.59 $336.59 $379.30 $379.30 $390.38 $390.38 $413.47 $413.47 $395.35 $395.35 $422.76$333.57 $333.57 $351.53 $351.53 $425.94 $425.94 $361.79 $361.79 $346.49 $346.49 $390.47 $390.47 $401.87 $401.87 $425.64 $425.64 $406.99 $406.99 $435.20$338.34 $338.34 $356.55 $356.55 $432.03 $432.03 $366.96 $366.96 $351.45 $351.45 $396.05 $396.05 $407.61 $407.61 $431.73 $431.73 $412.81 $412.81 $441.43$345.49 $345.49 $364.09 $364.09 $441.16 $441.16 $374.72 $374.72 $358.88 $358.88 $404.43 $404.43 $416.23 $416.23 $440.85 $440.85 $421.54 $421.54 $450.76$352.64 $352.64 $371.63 $371.63 $450.30 $450.30 $382.48 $382.48 $366.31 $366.31 $412.80 $412.80 $424.85 $424.85 $449.98 $449.98 $430.27 $430.27 $460.10$357.12 $357.12 $376.35 $376.35 $456.01 $456.01 $387.33 $387.33 $370.96 $370.96 $418.03 $418.03 $430.24 $430.24 $455.69 $455.69 $435.72 $435.72 $465.93$361.89 $361.89 $381.37 $381.37 $462.10 $462.10 $392.51 $392.51 $375.91 $375.91 $423.62 $423.62 $435.99 $435.99 $461.78 $461.78 $441.54 $441.54 $472.15$364.27 $364.27 $383.88 $383.88 $465.14 $465.14 $395.09 $395.09 $378.39 $378.39 $426.41 $426.41 $438.86 $438.86 $464.82 $464.82 $444.45 $444.45 $475.26$366.65 $366.65 $386.40 $386.40 $468.19 $468.19 $397.68 $397.68 $380.87 $380.87 $429.20 $429.20 $441.73 $441.73 $467.86 $467.86 $447.36 $447.36 $478.38$369.04 $369.04 $388.91 $388.91 $471.23 $471.23 $400.27 $400.27 $383.34 $383.34 $431.99 $431.99 $444.61 $444.61 $470.90 $470.90 $450.27 $450.27 $481.49$371.42 $371.42 $391.42 $391.42 $474.28 $474.28 $402.85 $402.85 $385.82 $385.82 $434.78 $434.78 $447.48 $447.48 $473.95 $473.95 $453.18 $453.18 $484.60$376.19 $376.19 $396.45 $396.45 $480.37 $480.37 $408.03 $408.03 $390.77 $390.77 $440.37 $440.37 $453.22 $453.22 $480.03 $480.03 $459.00 $459.00 $490.82$380.96 $380.96 $401.48 $401.48 $486.46 $486.46 $413.20 $413.20 $395.73 $395.73 $445.95 $445.95 $458.97 $458.97 $486.12 $486.12 $464.82 $464.82 $497.04$388.12 $388.12 $409.02 $409.02 $495.60 $495.60 $420.96 $420.96 $403.16 $403.16 $454.32 $454.32 $467.59 $467.59 $495.25 $495.25 $473.55 $473.55 $506.38$394.97 $394.97 $416.24 $416.24 $504.35 $504.35 $428.39 $428.39 $410.28 $410.28 $462.35 $462.35 $475.85 $475.85 $504.00 $504.00 $481.91 $481.91 $515.32$404.51 $404.51 $426.29 $426.29 $516.53 $516.53 $438.74 $438.74 $420.19 $420.19 $473.52 $473.52 $487.34 $487.34 $516.17 $516.17 $493.55 $493.55 $527.77$416.44 $416.44 $438.86 $438.86 $531.76 $531.76 $451.67 $451.67 $432.58 $432.58 $487.47 $487.47 $501.71 $501.71 $531.38 $531.38 $508.10 $508.10 $543.33$430.45 $430.45 $453.62 $453.62 $549.65 $549.65 $466.87 $466.87 $447.13 $447.13 $503.87 $503.87 $518.59 $518.59 $549.26 $549.26 $525.19 $525.19 $561.60$447.14 $447.14 $471.22 $471.22 $570.96 $570.96 $484.97 $484.97 $464.47 $464.47 $523.42 $523.42 $538.70 $538.70 $570.56 $570.56 $545.56 $545.56 $583.38$465.92 $465.92 $491.01 $491.01 $594.94 $594.94 $505.34 $505.34 $483.98 $483.98 $545.40 $545.40 $561.32 $561.32 $594.53 $594.53 $568.47 $568.47 $607.89$487.38 $487.38 $513.63 $513.63 $622.35 $622.35 $528.62 $528.62 $506.27 $506.27 $570.52 $570.52 $587.18 $587.18 $621.91 $621.91 $594.66 $594.66 $635.89$508.55 $508.55 $535.93 $535.93 $649.38 $649.38 $551.58 $551.58 $528.26 $528.26 $595.30 $595.30 $612.68 $612.68 $648.92 $648.92 $620.48 $620.48 $663.50$532.39 $532.39 $561.06 $561.06 $679.83 $679.83 $577.44 $577.44 $553.03 $553.03 $623.21 $623.21 $641.41 $641.41 $679.35 $679.35 $649.58 $649.58 $694.62$555.94 $555.94 $585.88 $585.88 $709.90 $709.90 $602.99 $602.99 $577.49 $577.49 $650.78 $650.78 $669.78 $669.78 $709.40 $709.40 $678.31 $678.31 $725.34$581.88 $581.88 $613.21 $613.21 $743.01 $743.01 $631.11 $631.11 $604.43 $604.43 $681.14 $681.14 $701.03 $701.03 $742.49 $742.49 $709.96 $709.96 $759.18$608.11 $608.11 $640.85 $640.85 $776.51 $776.51 $659.57 $659.57 $631.68 $631.68 $711.85 $711.85 $732.63 $732.63 $775.97 $775.97 $741.96 $741.96 $793.40$636.43 $636.43 $670.70 $670.70 $812.67 $812.67 $690.28 $690.28 $661.10 $661.10 $744.99 $744.99 $766.75 $766.75 $812.10 $812.10 $776.51 $776.51 $830.35$664.75 $664.75 $700.54 $700.54 $848.83 $848.83 $721.00 $721.00 $690.51 $690.51 $778.14 $778.14 $800.86 $800.86 $848.24 $848.24 $811.07 $811.07 $867.30$695.45 $695.45 $732.90 $732.90 $888.04 $888.04 $754.30 $754.30 $722.41 $722.41 $814.09 $814.09 $837.85 $837.85 $887.42 $887.42 $848.53 $848.53 $907.36$726.45 $726.45 $765.57 $765.57 $927.62 $927.62 $787.92 $787.92 $754.61 $754.61 $850.38 $850.38 $875.20 $875.20 $926.97 $926.97 $886.35 $886.35 $947.81$759.54 $759.54 $800.44 $800.44 $969.88 $969.88 $823.81 $823.81 $788.98 $788.98 $889.11 $889.11 $915.07 $915.07 $969.20 $969.20 $926.73 $926.73 $990.98$775.94 $775.94 $817.72 $817.72 $990.81 $990.81 $841.59 $841.59 $806.01 $806.01 $908.30 $908.30 $934.82 $934.82 $990.12 $990.12 $946.73 $946.73 $1,012.37$809.03 $809.03 $852.59 $852.59 $1,033.06 $1,033.06 $877.48 $877.48 $840.38 $840.38 $947.03 $947.03 $974.68 $974.68 $1,032.34 $1,032.34 $987.10 $987.10 $1,055.54$837.64 $837.64 $882.75 $882.75 $1,069.60 $1,069.60 $908.52 $908.52 $870.11 $870.11 $980.53 $980.53 $1,009.16 $1,009.16 $1,068.85 $1,068.85 $1,022.02 $1,022.02 $1,092.87$856.42 $856.42 $902.54 $902.54 $1,093.58 $1,093.58 $928.89 $928.89 $889.61 $889.61 $1,002.52 $1,002.52 $1,031.79 $1,031.79 $1,092.82 $1,092.82 $1,044.93 $1,044.93 $1,117.38$879.97 $879.97 $927.35 $927.35 $1,123.66 $1,123.66 $954.43 $954.43 $914.08 $914.08 $1,030.08 $1,030.08 $1,060.16 $1,060.16 $1,122.87 $1,122.87 $1,073.66 $1,073.66 $1,148.10$894.28 $894.28 $942.43 $942.43 $1,141.93 $1,141.93 $969.95 $969.95 $928.94 $928.94 $1,046.83 $1,046.83 $1,077.40 $1,077.40 $1,141.13 $1,141.13 $1,091.12 $1,091.12 $1,166.77

GoMed: $2,0

0$25 /$7,3

Y

75729PAGeisinger Al

25/50/20M-152-121-

Rating

Geisinger Al

GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 9


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 6


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 3



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 9



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 7



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 6



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 5


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0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$297.53 $313.55 $313.55 $379.92 $379.92 $322.70 $322.70 $351.47 $351.47 $336.07 $336.07 $359.37 $359.37 $378.72 $378.72 $458.88 $458.88 $389.77 $389.77$323.97 $341.42 $341.42 $413.69 $413.69 $351.39 $351.39 $382.71 $382.71 $365.94 $365.94 $391.31 $391.31 $412.38 $412.38 $499.67 $499.67 $424.42 $424.42$334.08 $352.07 $352.07 $426.60 $426.60 $362.35 $362.35 $394.65 $394.65 $377.36 $377.36 $403.52 $403.52 $425.25 $425.25 $515.27 $515.27 $437.67 $437.67$344.20 $362.73 $362.73 $439.51 $439.51 $373.32 $373.32 $406.60 $406.60 $388.78 $388.78 $415.74 $415.74 $438.12 $438.12 $530.86 $530.86 $450.91 $450.91$355.09 $374.21 $374.21 $453.42 $453.42 $385.13 $385.13 $419.46 $419.46 $401.08 $401.08 $428.89 $428.89 $451.98 $451.98 $547.66 $547.66 $465.18 $465.18$365.98 $385.68 $385.68 $467.32 $467.32 $396.94 $396.94 $432.33 $432.33 $413.38 $413.38 $442.04 $442.04 $465.85 $465.85 $564.46 $564.46 $479.45 $479.45$377.26 $397.57 $397.57 $481.73 $481.73 $409.18 $409.18 $445.65 $445.65 $426.12 $426.12 $455.67 $455.67 $480.20 $480.20 $581.85 $581.85 $494.22 $494.22$388.93 $409.87 $409.87 $496.63 $496.63 $421.84 $421.84 $459.44 $459.44 $439.31 $439.31 $469.76 $469.76 $495.06 $495.06 $599.85 $599.85 $509.51 $509.51$388.93 $409.87 $409.87 $496.63 $496.63 $421.84 $421.84 $459.44 $459.44 $439.31 $439.31 $469.76 $469.76 $495.06 $495.06 $599.85 $599.85 $509.51 $509.51$388.93 $409.87 $409.87 $496.63 $496.63 $421.84 $421.84 $459.44 $459.44 $439.31 $439.31 $469.76 $469.76 $495.06 $495.06 $599.85 $599.85 $509.51 $509.51$388.93 $409.87 $409.87 $496.63 $496.63 $421.84 $421.84 $459.44 $459.44 $439.31 $439.31 $469.76 $469.76 $495.06 $495.06 $599.85 $599.85 $509.51 $509.51$390.48 $411.50 $411.50 $498.61 $498.61 $423.52 $423.52 $461.27 $461.27 $441.06 $441.06 $471.64 $471.64 $497.03 $497.03 $602.25 $602.25 $511.55 $511.55$398.26 $419.70 $419.70 $508.54 $508.54 $431.96 $431.96 $470.46 $470.46 $449.85 $449.85 $481.03 $481.03 $506.94 $506.94 $614.24 $614.24 $521.74 $521.74$407.59 $429.54 $429.54 $520.46 $520.46 $442.08 $442.08 $481.49 $481.49 $460.39 $460.39 $492.31 $492.31 $518.82 $518.82 $628.64 $628.64 $533.96 $533.96$422.76 $445.52 $445.52 $539.83 $539.83 $458.53 $458.53 $499.41 $499.41 $477.52 $477.52 $510.63 $510.63 $538.12 $538.12 $652.03 $652.03 $553.84 $553.84$435.20 $458.64 $458.64 $555.72 $555.72 $472.03 $472.03 $514.11 $514.11 $491.58 $491.58 $525.66 $525.66 $553.97 $553.97 $671.23 $671.23 $570.14 $570.14$441.43 $465.20 $465.20 $563.67 $563.67 $478.78 $478.78 $521.46 $521.46 $498.61 $498.61 $533.18 $533.18 $561.89 $561.89 $680.83 $680.83 $578.29 $578.29$450.76 $475.03 $475.03 $575.59 $575.59 $488.90 $488.90 $532.49 $532.49 $509.15 $509.15 $544.45 $544.45 $573.77 $573.77 $695.22 $695.22 $590.52 $590.52$460.10 $484.87 $484.87 $587.51 $587.51 $499.03 $499.03 $543.51 $543.51 $519.69 $519.69 $555.73 $555.73 $585.65 $585.65 $709.62 $709.62 $602.75 $602.75$465.93 $491.02 $491.02 $594.96 $594.96 $505.35 $505.35 $550.40 $550.40 $526.28 $526.28 $562.77 $562.77 $593.07 $593.07 $718.62 $718.62 $610.39 $610.39$472.15 $497.58 $497.58 $602.90 $602.90 $512.10 $512.10 $557.75 $557.75 $533.31 $533.31 $570.29 $570.29 $601.00 $601.00 $728.21 $728.21 $618.54 $618.54$475.26 $500.86 $500.86 $606.88 $606.88 $515.48 $515.48 $561.43 $561.43 $536.83 $536.83 $574.05 $574.05 $604.96 $604.96 $733.01 $733.01 $622.62 $622.62$478.38 $504.13 $504.13 $610.85 $610.85 $518.85 $518.85 $565.10 $565.10 $540.34 $540.34 $577.80 $577.80 $608.92 $608.92 $737.81 $737.81 $626.70 $626.70$481.49 $507.41 $507.41 $614.82 $614.82 $522.23 $522.23 $568.78 $568.78 $543.86 $543.86 $581.56 $581.56 $612.88 $612.88 $742.61 $742.61 $630.77 $630.77$484.60 $510.69 $510.69 $618.79 $618.79 $525.60 $525.60 $572.46 $572.46 $547.37 $547.37 $585.32 $585.32 $616.84 $616.84 $747.41 $747.41 $634.85 $634.85$490.82 $517.25 $517.25 $626.74 $626.74 $532.35 $532.35 $579.81 $579.81 $554.40 $554.40 $592.84 $592.84 $624.76 $624.76 $757.01 $757.01 $643.00 $643.00$497.04 $523.81 $523.81 $634.69 $634.69 $539.10 $539.10 $587.16 $587.16 $561.43 $561.43 $600.35 $600.35 $632.68 $632.68 $766.60 $766.60 $651.15 $651.15$506.38 $533.64 $533.64 $646.61 $646.61 $549.23 $549.23 $598.18 $598.18 $571.97 $571.97 $611.63 $611.63 $644.56 $644.56 $781.00 $781.00 $663.38 $663.38$515.32 $543.07 $543.07 $658.03 $658.03 $558.93 $558.93 $608.75 $608.75 $582.08 $582.08 $622.43 $622.43 $655.95 $655.95 $794.80 $794.80 $675.10 $675.10$527.77 $556.19 $556.19 $673.92 $673.92 $572.43 $572.43 $623.45 $623.45 $596.13 $596.13 $637.46 $637.46 $671.79 $671.79 $813.99 $813.99 $691.40 $691.40$543.33 $572.58 $572.58 $693.78 $693.78 $589.30 $589.30 $641.83 $641.83 $613.71 $613.71 $656.25 $656.25 $691.59 $691.59 $837.99 $837.99 $711.78 $711.78$561.60 $591.85 $591.85 $717.13 $717.13 $609.13 $609.13 $663.42 $663.42 $634.35 $634.35 $678.33 $678.33 $714.86 $714.86 $866.18 $866.18 $735.73 $735.73$583.38 $614.80 $614.80 $744.94 $744.94 $632.75 $632.75 $689.15 $689.15 $658.95 $658.95 $704.64 $704.64 $742.58 $742.58 $899.77 $899.77 $764.26 $764.26$607.89 $640.62 $640.62 $776.22 $776.22 $659.32 $659.32 $718.10 $718.10 $686.63 $686.63 $734.23 $734.23 $773.77 $773.77 $937.56 $937.56 $796.36 $796.36$635.89 $670.13 $670.13 $811.98 $811.98 $689.70 $689.70 $751.18 $751.18 $718.26 $718.26 $768.06 $768.06 $809.41 $809.41 $980.75 $980.75 $833.05 $833.05$663.50 $699.23 $699.23 $847.24 $847.24 $719.65 $719.65 $783.80 $783.80 $749.45 $749.45 $801.41 $801.41 $844.56 $844.56 $1,023.34 $1,023.34 $869.22 $869.22$694.62 $732.02 $732.02 $886.97 $886.97 $753.39 $753.39 $820.55 $820.55 $784.59 $784.59 $838.99 $838.99 $884.17 $884.17 $1,071.33 $1,071.33 $909.98 $909.98$725.34 $764.40 $764.40 $926.21 $926.21 $786.72 $786.72 $856.85 $856.85 $819.30 $819.30 $876.10 $876.10 $923.28 $923.28 $1,118.71 $1,118.71 $950.23 $950.23$759.18 $800.06 $800.06 $969.41 $969.41 $823.42 $823.42 $896.82 $896.82 $857.52 $857.52 $916.97 $916.97 $966.35 $966.35 $1,170.90 $1,170.90 $994.56 $994.56$793.40 $836.12 $836.12 $1,013.11 $1,013.11 $860.54 $860.54 $937.25 $937.25 $896.18 $896.18 $958.31 $958.31 $1,009.91 $1,009.91 $1,223.69 $1,223.69 $1,039.40 $1,039.40$830.35 $875.06 $875.06 $1,060.29 $1,060.29 $900.61 $900.61 $980.89 $980.89 $937.91 $937.91 $1,002.94 $1,002.94 $1,056.94 $1,056.94 $1,280.67 $1,280.67 $1,087.80 $1,087.80$867.30 $914.00 $914.00 $1,107.47 $1,107.47 $940.69 $940.69 $1,024.54 $1,024.54 $979.64 $979.64 $1,047.56 $1,047.56 $1,103.97 $1,103.97 $1,337.66 $1,337.66 $1,136.20 $1,136.20$907.36 $956.22 $956.22 $1,158.63 $1,158.63 $984.13 $984.13 $1,071.86 $1,071.86 $1,024.89 $1,024.89 $1,095.95 $1,095.95 $1,154.96 $1,154.96 $1,399.44 $1,399.44 $1,188.68 $1,188.68$947.81 $998.84 $998.84 $1,210.27 $1,210.27 $1,028.00 $1,028.00 $1,119.64 $1,119.64 $1,070.58 $1,070.58 $1,144.80 $1,144.80 $1,206.45 $1,206.45 $1,461.83 $1,461.83 $1,241.67 $1,241.67$990.98 $1,044.34 $1,044.34 $1,265.40 $1,265.40 $1,074.83 $1,074.83 $1,170.64 $1,170.64 $1,119.34 $1,119.34 $1,196.95 $1,196.95 $1,261.40 $1,261.40 $1,528.41 $1,528.41 $1,298.23 $1,298.23

$1,012.37 $1,066.88 $1,066.88 $1,292.71 $1,292.71 $1,098.03 $1,098.03 $1,195.91 $1,195.91 $1,143.50 $1,143.50 $1,222.78 $1,222.78 $1,288.63 $1,288.63 $1,561.40 $1,561.40 $1,326.25 $1,326.25$1,055.54 $1,112.37 $1,112.37 $1,347.84 $1,347.84 $1,144.85 $1,144.85 $1,246.91 $1,246.91 $1,192.27 $1,192.27 $1,274.93 $1,274.93 $1,343.58 $1,343.58 $1,627.98 $1,627.98 $1,382.81 $1,382.81$1,092.87 $1,151.72 $1,151.72 $1,395.52 $1,395.52 $1,185.35 $1,185.35 $1,291.01 $1,291.01 $1,234.44 $1,234.44 $1,320.02 $1,320.02 $1,391.10 $1,391.10 $1,685.57 $1,685.57 $1,431.72 $1,431.72$1,117.38 $1,177.54 $1,177.54 $1,426.80 $1,426.80 $1,211.92 $1,211.92 $1,319.96 $1,319.96 $1,262.12 $1,262.12 $1,349.62 $1,349.62 $1,422.29 $1,422.29 $1,723.36 $1,723.36 $1,463.82 $1,463.82$1,148.10 $1,209.92 $1,209.92 $1,466.04 $1,466.04 $1,245.25 $1,245.25 $1,356.25 $1,356.25 $1,296.82 $1,296.82 $1,386.73 $1,386.73 $1,461.40 $1,461.40 $1,770.75 $1,770.75 $1,504.07 $1,504.07$1,166.77 $1,229.60 $1,229.60 $1,489.87 $1,489.87 $1,265.50 $1,265.50 $1,378.30 $1,378.30 $1,317.91 $1,317.91 $1,409.28 $1,409.28 $1,485.16 $1,485.16 $1,799.54 $1,799.54 $1,528.52 $1,528.52


0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 9



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 7



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 6



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 5



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 3



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 6


old00 / Rx: $0%/ $50350es


-F Rev. 1/20Area 5

l-Access PPO

Page Number: 31 12/24/2014

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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$350.47 $350.47 $335.11 $335.11 $358.34 $358.34 $377.64 $377.64 $457.58 $457.58 $388.67 $388.67 $291.16 $291.16 $278.40 $278.40 $297.70 $297.70 $313.73$381.62 $381.62 $364.90 $364.90 $390.20 $390.20 $411.21 $411.21 $498.25 $498.25 $423.21 $423.21 $317.04 $317.04 $303.15 $303.15 $324.16 $324.16 $341.62$393.53 $393.53 $376.29 $376.29 $402.38 $402.38 $424.04 $424.04 $513.80 $513.80 $436.42 $436.42 $326.93 $326.93 $312.61 $312.61 $334.28 $334.28 $352.28$405.44 $405.44 $387.68 $387.68 $414.56 $414.56 $436.88 $436.88 $529.36 $529.36 $449.63 $449.63 $336.83 $336.83 $322.07 $322.07 $344.40 $344.40 $362.94$418.27 $418.27 $399.94 $399.94 $427.67 $427.67 $450.70 $450.70 $546.10 $546.10 $463.86 $463.86 $347.49 $347.49 $332.26 $332.26 $355.30 $355.30 $374.43$431.10 $431.10 $412.21 $412.21 $440.79 $440.79 $464.52 $464.52 $562.85 $562.85 $478.08 $478.08 $358.14 $358.14 $342.45 $342.45 $366.19 $366.19 $385.91$444.39 $444.39 $424.91 $424.91 $454.37 $454.37 $478.84 $478.84 $580.20 $580.20 $492.82 $492.82 $369.18 $369.18 $353.00 $353.00 $377.48 $377.48 $397.80$458.13 $458.13 $438.06 $438.06 $468.43 $468.43 $493.65 $493.65 $598.15 $598.15 $508.07 $508.07 $380.60 $380.60 $363.93 $363.93 $389.16 $389.16 $410.11$458.13 $458.13 $438.06 $438.06 $468.43 $468.43 $493.65 $493.65 $598.15 $598.15 $508.07 $508.07 $380.60 $380.60 $363.93 $363.93 $389.16 $389.16 $410.11$458.13 $458.13 $438.06 $438.06 $468.43 $468.43 $493.65 $493.65 $598.15 $598.15 $508.07 $508.07 $380.60 $380.60 $363.93 $363.93 $389.16 $389.16 $410.11$458.13 $458.13 $438.06 $438.06 $468.43 $468.43 $493.65 $493.65 $598.15 $598.15 $508.07 $508.07 $380.60 $380.60 $363.93 $363.93 $389.16 $389.16 $410.11$459.96 $459.96 $439.81 $439.81 $470.30 $470.30 $495.62 $495.62 $600.53 $600.53 $510.09 $510.09 $382.12 $382.12 $365.38 $365.38 $390.71 $390.71 $411.75$469.12 $469.12 $448.57 $448.57 $479.67 $479.67 $505.49 $505.49 $612.50 $612.50 $520.25 $520.25 $389.73 $389.73 $372.65 $372.65 $398.49 $398.49 $419.95$480.12 $480.12 $459.08 $459.08 $490.91 $490.91 $517.34 $517.34 $626.85 $626.85 $532.45 $532.45 $398.87 $398.87 $381.39 $381.39 $407.83 $407.83 $429.79$497.99 $497.99 $476.16 $476.16 $509.18 $509.18 $536.59 $536.59 $650.18 $650.18 $552.26 $552.26 $413.71 $413.71 $395.58 $395.58 $423.01 $423.01 $445.79$512.65 $512.65 $490.18 $490.18 $524.17 $524.17 $552.39 $552.39 $669.32 $669.32 $568.52 $568.52 $425.89 $425.89 $407.23 $407.23 $435.46 $435.46 $458.91$519.98 $519.98 $497.19 $497.19 $531.66 $531.66 $560.29 $560.29 $678.89 $678.89 $576.65 $576.65 $431.98 $431.98 $413.05 $413.05 $441.69 $441.69 $465.47$530.97 $530.97 $507.70 $507.70 $542.90 $542.90 $572.14 $572.14 $693.25 $693.25 $588.84 $588.84 $441.11 $441.11 $421.78 $421.78 $451.03 $451.03 $475.31$541.97 $541.97 $518.22 $518.22 $554.15 $554.15 $583.98 $583.98 $707.60 $707.60 $601.04 $601.04 $450.25 $450.25 $430.52 $430.52 $460.37 $460.37 $485.16$548.84 $548.84 $524.79 $524.79 $561.17 $561.17 $591.39 $591.39 $716.57 $716.57 $608.66 $608.66 $455.96 $455.96 $435.98 $435.98 $466.20 $466.20 $491.31$556.17 $556.17 $531.80 $531.80 $568.67 $568.67 $599.29 $599.29 $726.14 $726.14 $616.79 $616.79 $462.05 $462.05 $441.80 $441.80 $472.43 $472.43 $497.87$559.83 $559.83 $535.30 $535.30 $572.41 $572.41 $603.24 $603.24 $730.93 $730.93 $620.85 $620.85 $465.09 $465.09 $444.71 $444.71 $475.54 $475.54 $501.15$563.50 $563.50 $538.81 $538.81 $576.16 $576.16 $607.19 $607.19 $735.71 $735.71 $624.91 $624.91 $468.14 $468.14 $447.62 $447.62 $478.66 $478.66 $504.43$567.16 $567.16 $542.31 $542.31 $579.91 $579.91 $611.14 $611.14 $740.50 $740.50 $628.98 $628.98 $471.18 $471.18 $450.53 $450.53 $481.77 $481.77 $507.71$570.83 $570.83 $545.82 $545.82 $583.66 $583.66 $615.08 $615.08 $745.28 $745.28 $633.04 $633.04 $474.23 $474.23 $453.45 $453.45 $484.88 $484.88 $510.99$578.16 $578.16 $552.82 $552.82 $591.15 $591.15 $622.98 $622.98 $754.85 $754.85 $641.17 $641.17 $480.32 $480.32 $459.27 $459.27 $491.11 $491.11 $517.55$585.49 $585.49 $559.83 $559.83 $598.65 $598.65 $630.88 $630.88 $764.43 $764.43 $649.30 $649.30 $486.41 $486.41 $465.09 $465.09 $497.34 $497.34 $524.12$596.48 $596.48 $570.35 $570.35 $609.89 $609.89 $642.73 $642.73 $778.78 $778.78 $661.49 $661.49 $495.54 $495.54 $473.82 $473.82 $506.68 $506.68 $533.96$607.02 $607.02 $580.42 $580.42 $620.66 $620.66 $654.08 $654.08 $792.54 $792.54 $673.18 $673.18 $504.29 $504.29 $482.20 $482.20 $515.63 $515.63 $543.39$621.68 $621.68 $594.44 $594.44 $635.65 $635.65 $669.88 $669.88 $811.68 $811.68 $689.44 $689.44 $516.47 $516.47 $493.84 $493.84 $528.08 $528.08 $556.51$640.01 $640.01 $611.96 $611.96 $654.39 $654.39 $689.63 $689.63 $835.60 $835.60 $709.76 $709.76 $531.70 $531.70 $508.40 $508.40 $543.64 $543.64 $572.92$661.54 $661.54 $632.55 $632.55 $676.40 $676.40 $712.83 $712.83 $863.72 $863.72 $733.64 $733.64 $549.58 $549.58 $525.50 $525.50 $561.93 $561.93 $592.19$687.19 $687.19 $657.08 $657.08 $702.64 $702.64 $740.47 $740.47 $897.21 $897.21 $762.09 $762.09 $570.90 $570.90 $545.88 $545.88 $583.73 $583.73 $615.16$716.06 $716.06 $684.68 $684.68 $732.15 $732.15 $771.57 $771.57 $934.90 $934.90 $794.10 $794.10 $594.88 $594.88 $568.81 $568.81 $608.24 $608.24 $641.00$749.04 $749.04 $716.22 $716.22 $765.87 $765.87 $807.11 $807.11 $977.96 $977.96 $830.68 $830.68 $622.28 $622.28 $595.01 $595.01 $636.26 $636.26 $670.52$781.57 $781.57 $747.32 $747.32 $799.13 $799.13 $842.16 $842.16 $1,020.43 $1,020.43 $866.75 $866.75 $649.30 $649.30 $620.85 $620.85 $663.89 $663.89 $699.64$818.22 $818.22 $782.36 $782.36 $836.61 $836.61 $881.65 $881.65 $1,068.28 $1,068.28 $907.40 $907.40 $679.75 $679.75 $649.96 $649.96 $695.02 $695.02 $732.45$854.41 $854.41 $816.97 $816.97 $873.61 $873.61 $920.65 $920.65 $1,115.53 $1,115.53 $947.53 $947.53 $709.82 $709.82 $678.71 $678.71 $725.77 $725.77 $764.85$894.27 $894.27 $855.08 $855.08 $914.36 $914.36 $963.60 $963.60 $1,167.57 $1,167.57 $991.73 $991.73 $742.93 $742.93 $710.37 $710.37 $759.62 $759.62 $800.53$934.58 $934.58 $893.63 $893.63 $955.59 $955.59 $1,007.04 $1,007.04 $1,220.21 $1,220.21 $1,036.44 $1,036.44 $776.42 $776.42 $742.40 $742.40 $793.87 $793.87 $836.62$978.11 $978.11 $935.25 $935.25 $1,000.09 $1,000.09 $1,053.94 $1,053.94 $1,277.03 $1,277.03 $1,084.71 $1,084.71 $812.58 $812.58 $776.97 $776.97 $830.84 $830.84 $875.58

$1,021.63 $1,021.63 $976.86 $976.86 $1,044.59 $1,044.59 $1,100.83 $1,100.83 $1,333.86 $1,333.86 $1,132.97 $1,132.97 $848.74 $848.74 $811.54 $811.54 $867.81 $867.81 $914.54$1,068.82 $1,068.82 $1,021.98 $1,021.98 $1,092.83 $1,092.83 $1,151.68 $1,151.68 $1,395.46 $1,395.46 $1,185.30 $1,185.30 $887.94 $887.94 $849.03 $849.03 $907.89 $907.89 $956.78$1,116.46 $1,116.46 $1,067.54 $1,067.54 $1,141.55 $1,141.55 $1,203.02 $1,203.02 $1,457.67 $1,457.67 $1,238.14 $1,238.14 $927.52 $927.52 $886.87 $886.87 $948.36 $948.36 $999.43$1,167.31 $1,167.31 $1,116.16 $1,116.16 $1,193.55 $1,193.55 $1,257.81 $1,257.81 $1,524.07 $1,524.07 $1,294.54 $1,294.54 $969.77 $969.77 $927.27 $927.27 $991.56 $991.56 $1,044.95$1,192.51 $1,192.51 $1,140.25 $1,140.25 $1,219.31 $1,219.31 $1,284.96 $1,284.96 $1,556.96 $1,556.96 $1,322.48 $1,322.48 $990.70 $990.70 $947.29 $947.29 $1,012.96 $1,012.96 $1,067.51$1,243.36 $1,243.36 $1,188.88 $1,188.88 $1,271.30 $1,271.30 $1,339.76 $1,339.76 $1,623.36 $1,623.36 $1,378.88 $1,378.88 $1,032.94 $1,032.94 $987.68 $987.68 $1,056.16 $1,056.16 $1,113.03$1,287.34 $1,287.34 $1,230.93 $1,230.93 $1,316.27 $1,316.27 $1,387.15 $1,387.15 $1,680.78 $1,680.78 $1,427.65 $1,427.65 $1,069.48 $1,069.48 $1,022.62 $1,022.62 $1,093.52 $1,093.52 $1,152.40$1,316.21 $1,316.21 $1,258.53 $1,258.53 $1,345.78 $1,345.78 $1,418.25 $1,418.25 $1,718.46 $1,718.46 $1,459.66 $1,459.66 $1,093.46 $1,093.46 $1,045.54 $1,045.54 $1,118.03 $1,118.03 $1,178.23$1,352.40 $1,352.40 $1,293.14 $1,293.14 $1,382.79 $1,382.79 $1,457.25 $1,457.25 $1,765.71 $1,765.71 $1,499.79 $1,499.79 $1,123.53 $1,123.53 $1,074.29 $1,074.29 $1,148.78 $1,148.78 $1,210.63$1,374.39 $1,374.39 $1,314.16 $1,314.16 $1,405.27 $1,405.27 $1,480.94 $1,480.94 $1,794.43 $1,794.43 $1,524.18 $1,524.18 $1,141.80 $1,141.80 $1,091.76 $1,091.76 $1,167.45 $1,167.45 $1,230.32

GoMed: $500

20$25 /$6,8

Y

75729PAGeisinger Al

25/50M-152-121-

Rating

Geisinger Al

GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 2



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 6



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 5



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 3



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 2


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Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$313.73 $380.14 $380.14 $322.89 $322.89 $326.47 $326.47 $367.90 $367.90 $378.64 $378.64 $275.36 $275.36 $310.31 $310.31 $319.37 $319.37 $264.58 $264.58$341.62 $413.93 $413.93 $351.59 $351.59 $355.48 $355.48 $400.60 $400.60 $412.29 $412.29 $299.84 $299.84 $337.89 $337.89 $347.75 $347.75 $288.10 $288.10$352.28 $426.85 $426.85 $362.57 $362.57 $366.58 $366.58 $413.10 $413.10 $425.16 $425.16 $309.19 $309.19 $348.43 $348.43 $358.61 $358.61 $297.10 $297.10$362.94 $439.77 $439.77 $373.54 $373.54 $377.68 $377.68 $425.61 $425.61 $438.03 $438.03 $318.55 $318.55 $358.98 $358.98 $369.46 $369.46 $306.09 $306.09$374.43 $453.68 $453.68 $385.36 $385.36 $389.62 $389.62 $439.07 $439.07 $451.89 $451.89 $328.63 $328.63 $370.34 $370.34 $381.15 $381.15 $315.77 $315.77$385.91 $467.60 $467.60 $397.18 $397.18 $401.57 $401.57 $452.54 $452.54 $465.75 $465.75 $338.71 $338.71 $381.70 $381.70 $392.84 $392.84 $325.46 $325.46$397.80 $482.01 $482.01 $409.42 $409.42 $413.95 $413.95 $466.48 $466.48 $480.10 $480.10 $349.15 $349.15 $393.46 $393.46 $404.95 $404.95 $335.49 $335.49$410.11 $496.92 $496.92 $422.08 $422.08 $426.76 $426.76 $480.92 $480.92 $494.96 $494.96 $359.95 $359.95 $405.63 $405.63 $417.48 $417.48 $345.87 $345.87$410.11 $496.92 $496.92 $422.08 $422.08 $426.76 $426.76 $480.92 $480.92 $494.96 $494.96 $359.95 $359.95 $405.63 $405.63 $417.48 $417.48 $345.87 $345.87$410.11 $496.92 $496.92 $422.08 $422.08 $426.76 $426.76 $480.92 $480.92 $494.96 $494.96 $359.95 $359.95 $405.63 $405.63 $417.48 $417.48 $345.87 $345.87$410.11 $496.92 $496.92 $422.08 $422.08 $426.76 $426.76 $480.92 $480.92 $494.96 $494.96 $359.95 $359.95 $405.63 $405.63 $417.48 $417.48 $345.87 $345.87$411.75 $498.90 $498.90 $423.77 $423.77 $428.46 $428.46 $482.83 $482.83 $496.93 $496.93 $361.39 $361.39 $407.25 $407.25 $419.14 $419.14 $347.25 $347.25$419.95 $508.84 $508.84 $432.21 $432.21 $436.99 $436.99 $492.45 $492.45 $506.83 $506.83 $368.59 $368.59 $415.36 $415.36 $427.49 $427.49 $354.16 $354.16$429.79 $520.77 $520.77 $442.34 $442.34 $447.24 $447.24 $503.99 $503.99 $518.71 $518.71 $377.22 $377.22 $425.10 $425.10 $437.51 $437.51 $362.46 $362.46$445.79 $540.15 $540.15 $458.80 $458.80 $463.88 $463.88 $522.75 $522.75 $538.01 $538.01 $391.26 $391.26 $440.92 $440.92 $453.79 $453.79 $375.95 $375.95$458.91 $556.05 $556.05 $472.31 $472.31 $477.54 $477.54 $538.14 $538.14 $553.85 $553.85 $402.78 $402.78 $453.90 $453.90 $467.15 $467.15 $387.02 $387.02$465.47 $564.00 $564.00 $479.06 $479.06 $484.36 $484.36 $545.83 $545.83 $561.77 $561.77 $408.54 $408.54 $460.39 $460.39 $473.83 $473.83 $392.55 $392.55$475.31 $575.93 $575.93 $489.19 $489.19 $494.61 $494.61 $557.38 $557.38 $573.65 $573.65 $417.18 $417.18 $470.12 $470.12 $483.85 $483.85 $400.85 $400.85$485.16 $587.85 $587.85 $499.32 $499.32 $504.85 $504.85 $568.92 $568.92 $585.53 $585.53 $425.82 $425.82 $479.86 $479.86 $493.87 $493.87 $409.16 $409.16$491.31 $595.31 $595.31 $505.65 $505.65 $511.25 $511.25 $576.13 $576.13 $592.95 $592.95 $431.22 $431.22 $485.94 $485.94 $500.13 $500.13 $414.34 $414.34$497.87 $603.26 $603.26 $512.40 $512.40 $518.08 $518.08 $583.83 $583.83 $600.87 $600.87 $436.98 $436.98 $492.43 $492.43 $506.81 $506.81 $419.88 $419.88$501.15 $607.23 $607.23 $515.78 $515.78 $521.49 $521.49 $587.67 $587.67 $604.83 $604.83 $439.86 $439.86 $495.68 $495.68 $510.15 $510.15 $422.64 $422.64$504.43 $611.21 $611.21 $519.16 $519.16 $524.90 $524.90 $591.52 $591.52 $608.79 $608.79 $442.74 $442.74 $498.92 $498.92 $513.49 $513.49 $425.41 $425.41$507.71 $615.18 $615.18 $522.53 $522.53 $528.32 $528.32 $595.37 $595.37 $612.75 $612.75 $445.61 $445.61 $502.17 $502.17 $516.83 $516.83 $428.18 $428.18$510.99 $619.16 $619.16 $525.91 $525.91 $531.73 $531.73 $599.21 $599.21 $616.71 $616.71 $448.49 $448.49 $505.41 $505.41 $520.17 $520.17 $430.94 $430.94$517.55 $627.11 $627.11 $532.66 $532.66 $538.56 $538.56 $606.91 $606.91 $624.63 $624.63 $454.25 $454.25 $511.90 $511.90 $526.85 $526.85 $436.48 $436.48$524.12 $635.06 $635.06 $539.42 $539.42 $545.39 $545.39 $614.60 $614.60 $632.55 $632.55 $460.01 $460.01 $518.39 $518.39 $533.53 $533.53 $442.01 $442.01$533.96 $646.99 $646.99 $549.55 $549.55 $555.63 $555.63 $626.15 $626.15 $644.43 $644.43 $468.65 $468.65 $528.13 $528.13 $543.55 $543.55 $450.31 $450.31$543.39 $658.41 $658.41 $559.26 $559.26 $565.45 $565.45 $637.21 $637.21 $655.81 $655.81 $476.93 $476.93 $537.46 $537.46 $553.15 $553.15 $458.27 $458.27$556.51 $674.32 $674.32 $572.76 $572.76 $579.10 $579.10 $652.60 $652.60 $671.65 $671.65 $488.45 $488.45 $550.44 $550.44 $566.51 $566.51 $469.34 $469.34$572.92 $694.19 $694.19 $589.65 $589.65 $596.17 $596.17 $671.83 $671.83 $691.45 $691.45 $502.85 $502.85 $566.66 $566.66 $583.21 $583.21 $483.17 $483.17$592.19 $717.55 $717.55 $609.48 $609.48 $616.23 $616.23 $694.44 $694.44 $714.71 $714.71 $519.76 $519.76 $585.73 $585.73 $602.83 $602.83 $499.43 $499.43$615.16 $745.37 $745.37 $633.12 $633.12 $640.13 $640.13 $721.37 $721.37 $742.43 $742.43 $539.92 $539.92 $608.44 $608.44 $626.21 $626.21 $518.79 $518.79$641.00 $776.68 $776.68 $659.71 $659.71 $667.01 $667.01 $751.66 $751.66 $773.61 $773.61 $562.60 $562.60 $634.00 $634.00 $652.51 $652.51 $540.58 $540.58$670.52 $812.46 $812.46 $690.10 $690.10 $697.74 $697.74 $786.29 $786.29 $809.25 $809.25 $588.51 $588.51 $663.20 $663.20 $682.57 $682.57 $565.49 $565.49$699.64 $847.74 $847.74 $720.07 $720.07 $728.04 $728.04 $820.43 $820.43 $844.39 $844.39 $614.07 $614.07 $692.00 $692.00 $712.21 $712.21 $590.04 $590.04$732.45 $887.49 $887.49 $753.83 $753.83 $762.18 $762.18 $858.91 $858.91 $883.98 $883.98 $642.87 $642.87 $724.45 $724.45 $745.60 $745.60 $617.71 $617.71$764.85 $926.75 $926.75 $787.18 $787.18 $795.89 $795.89 $896.90 $896.90 $923.09 $923.09 $671.30 $671.30 $756.50 $756.50 $778.58 $778.58 $645.03 $645.03$800.53 $969.98 $969.98 $823.90 $823.90 $833.02 $833.02 $938.74 $938.74 $966.15 $966.15 $702.62 $702.62 $791.79 $791.79 $814.90 $814.90 $675.12 $675.12$836.62 $1,013.71 $1,013.71 $861.04 $861.04 $870.57 $870.57 $981.06 $981.06 $1,009.70 $1,009.70 $734.29 $734.29 $827.48 $827.48 $851.64 $851.64 $705.56 $705.56$875.58 $1,060.92 $1,060.92 $901.14 $901.14 $911.12 $911.12 $1,026.74 $1,026.74 $1,056.72 $1,056.72 $768.49 $768.49 $866.02 $866.02 $891.30 $891.30 $738.42 $738.42$914.54 $1,108.12 $1,108.12 $941.24 $941.24 $951.66 $951.66 $1,072.43 $1,072.43 $1,103.74 $1,103.74 $802.68 $802.68 $904.55 $904.55 $930.96 $930.96 $771.27 $771.27$956.78 $1,159.31 $1,159.31 $984.71 $984.71 $995.61 $995.61 $1,121.96 $1,121.96 $1,154.72 $1,154.72 $839.76 $839.76 $946.33 $946.33 $973.96 $973.96 $806.90 $806.90$999.43 $1,210.99 $1,210.99 $1,028.61 $1,028.61 $1,039.99 $1,039.99 $1,171.98 $1,171.98 $1,206.20 $1,206.20 $877.19 $877.19 $988.52 $988.52 $1,017.38 $1,017.38 $842.87 $842.87

$1,044.95 $1,266.14 $1,266.14 $1,075.46 $1,075.46 $1,087.36 $1,087.36 $1,225.36 $1,225.36 $1,261.14 $1,261.14 $917.15 $917.15 $1,033.54 $1,033.54 $1,063.72 $1,063.72 $881.26 $881.26$1,067.51 $1,293.47 $1,293.47 $1,098.67 $1,098.67 $1,110.83 $1,110.83 $1,251.81 $1,251.81 $1,288.36 $1,288.36 $936.94 $936.94 $1,055.85 $1,055.85 $1,086.68 $1,086.68 $900.28 $900.28$1,113.03 $1,348.63 $1,348.63 $1,145.52 $1,145.52 $1,158.20 $1,158.20 $1,305.19 $1,305.19 $1,343.30 $1,343.30 $976.90 $976.90 $1,100.88 $1,100.88 $1,133.02 $1,133.02 $938.67 $938.67$1,152.40 $1,396.34 $1,396.34 $1,186.04 $1,186.04 $1,199.17 $1,199.17 $1,351.36 $1,351.36 $1,390.81 $1,390.81 $1,011.45 $1,011.45 $1,139.82 $1,139.82 $1,173.09 $1,173.09 $971.87 $971.87$1,178.23 $1,427.64 $1,427.64 $1,212.63 $1,212.63 $1,226.06 $1,226.06 $1,381.66 $1,381.66 $1,422.00 $1,422.00 $1,034.13 $1,034.13 $1,165.37 $1,165.37 $1,199.40 $1,199.40 $993.66 $993.66$1,210.63 $1,466.90 $1,466.90 $1,245.98 $1,245.98 $1,259.77 $1,259.77 $1,419.65 $1,419.65 $1,461.10 $1,461.10 $1,062.56 $1,062.56 $1,197.41 $1,197.41 $1,232.38 $1,232.38 $1,020.99 $1,020.99$1,230.32 $1,490.75 $1,490.75 $1,266.24 $1,266.24 $1,280.26 $1,280.26 $1,442.73 $1,442.73 $1,484.86 $1,484.86 $1,079.84 $1,079.84 $1,216.88 $1,216.88 $1,252.41 $1,252.41 $1,037.59 $1,037.59

GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 3



0%$40 / $40$1,600

Yes

75729PA0050131





0%$40 / $40$1,600

Yes

75729PA0050131





0%$40 / $40$1,600

Yes

75729PA0050131




GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 7


old / Rx: $250

0%/ $50850es


l-Access PPO

Page Number: 33 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$298.16 $298.16 $306.87 $306.87 $233.10 $233.10 $262.68 $262.68 $270.35 $270.35 $326.41 $326.41 $312.10 $312.10 $333.74 $333.74 $351.71 $351.71 $426.16$324.67 $324.67 $334.15 $334.15 $253.82 $253.82 $286.03 $286.03 $294.38 $294.38 $355.42 $355.42 $339.85 $339.85 $363.41 $363.41 $382.98 $382.98 $464.04$334.80 $334.80 $344.58 $344.58 $261.74 $261.74 $294.96 $294.96 $303.57 $303.57 $366.51 $366.51 $350.45 $350.45 $374.75 $374.75 $394.93 $394.93 $478.53$344.93 $344.93 $355.00 $355.00 $269.66 $269.66 $303.89 $303.89 $312.76 $312.76 $377.61 $377.61 $361.06 $361.06 $386.09 $386.09 $406.88 $406.88 $493.01$355.85 $355.85 $366.24 $366.24 $278.20 $278.20 $313.50 $313.50 $322.66 $322.66 $389.55 $389.55 $372.48 $372.48 $398.31 $398.31 $419.76 $419.76 $508.61$366.76 $366.76 $377.47 $377.47 $286.73 $286.73 $323.12 $323.12 $332.55 $332.55 $401.50 $401.50 $383.91 $383.91 $410.52 $410.52 $432.63 $432.63 $524.21$378.06 $378.06 $389.10 $389.10 $295.56 $295.56 $333.07 $333.07 $342.80 $342.80 $413.88 $413.88 $395.74 $395.74 $423.18 $423.18 $445.96 $445.96 $540.36$389.76 $389.76 $401.14 $401.14 $304.71 $304.71 $343.38 $343.38 $353.41 $353.41 $426.68 $426.68 $407.98 $407.98 $436.27 $436.27 $459.76 $459.76 $557.08$389.76 $389.76 $401.14 $401.14 $304.71 $304.71 $343.38 $343.38 $353.41 $353.41 $426.68 $426.68 $407.98 $407.98 $436.27 $436.27 $459.76 $459.76 $557.08$389.76 $389.76 $401.14 $401.14 $304.71 $304.71 $343.38 $343.38 $353.41 $353.41 $426.68 $426.68 $407.98 $407.98 $436.27 $436.27 $459.76 $459.76 $557.08$389.76 $389.76 $401.14 $401.14 $304.71 $304.71 $343.38 $343.38 $353.41 $353.41 $426.68 $426.68 $407.98 $407.98 $436.27 $436.27 $459.76 $459.76 $557.08$391.31 $391.31 $402.74 $402.74 $305.92 $305.92 $344.75 $344.75 $354.81 $354.81 $428.38 $428.38 $409.61 $409.61 $438.01 $438.01 $461.59 $461.59 $559.30$399.11 $399.11 $410.76 $410.76 $312.02 $312.02 $351.62 $351.62 $361.88 $361.88 $436.92 $436.92 $417.77 $417.77 $446.73 $446.73 $470.79 $470.79 $570.45$408.46 $408.46 $420.39 $420.39 $319.33 $319.33 $359.86 $359.86 $370.36 $370.36 $447.16 $447.16 $427.56 $427.56 $457.20 $457.20 $481.82 $481.82 $583.82$423.66 $423.66 $436.03 $436.03 $331.22 $331.22 $373.25 $373.25 $384.15 $384.15 $463.80 $463.80 $443.47 $443.47 $474.22 $474.22 $499.75 $499.75 $605.54$436.14 $436.14 $448.87 $448.87 $340.97 $340.97 $384.24 $384.24 $395.46 $395.46 $477.45 $477.45 $456.53 $456.53 $488.18 $488.18 $514.47 $514.47 $623.37$442.37 $442.37 $455.29 $455.29 $345.84 $345.84 $389.73 $389.73 $401.11 $401.11 $484.28 $484.28 $463.06 $463.06 $495.16 $495.16 $521.82 $521.82 $632.28$451.73 $451.73 $464.92 $464.92 $353.15 $353.15 $397.97 $397.97 $409.59 $409.59 $494.52 $494.52 $472.85 $472.85 $505.63 $505.63 $532.86 $532.86 $645.65$461.08 $461.08 $474.54 $474.54 $360.47 $360.47 $406.21 $406.21 $418.07 $418.07 $504.76 $504.76 $482.64 $482.64 $516.10 $516.10 $543.89 $543.89 $659.02$466.93 $466.93 $480.56 $480.56 $365.04 $365.04 $411.36 $411.36 $423.37 $423.37 $511.16 $511.16 $488.76 $488.76 $522.64 $522.64 $550.79 $550.79 $667.38$473.16 $473.16 $486.98 $486.98 $369.91 $369.91 $416.86 $416.86 $429.03 $429.03 $517.98 $517.98 $495.29 $495.29 $529.62 $529.62 $558.14 $558.14 $676.29$476.28 $476.28 $490.19 $490.19 $372.35 $372.35 $419.61 $419.61 $431.86 $431.86 $521.40 $521.40 $498.55 $498.55 $533.11 $533.11 $561.82 $561.82 $680.75$479.40 $479.40 $493.40 $493.40 $374.79 $374.79 $422.35 $422.35 $434.68 $434.68 $524.81 $524.81 $501.81 $501.81 $536.60 $536.60 $565.50 $565.50 $685.20$482.52 $482.52 $496.61 $496.61 $377.23 $377.23 $425.10 $425.10 $437.51 $437.51 $528.22 $528.22 $505.08 $505.08 $540.09 $540.09 $569.18 $569.18 $689.66$485.64 $485.64 $499.81 $499.81 $379.66 $379.66 $427.85 $427.85 $440.34 $440.34 $531.64 $531.64 $508.34 $508.34 $543.58 $543.58 $572.85 $572.85 $694.12$491.87 $491.87 $506.23 $506.23 $384.54 $384.54 $433.34 $433.34 $445.99 $445.99 $538.46 $538.46 $514.87 $514.87 $550.57 $550.57 $580.21 $580.21 $703.03$498.11 $498.11 $512.65 $512.65 $389.41 $389.41 $438.83 $438.83 $451.65 $451.65 $545.29 $545.29 $521.40 $521.40 $557.55 $557.55 $587.57 $587.57 $711.94$507.46 $507.46 $522.28 $522.28 $396.73 $396.73 $447.08 $447.08 $460.13 $460.13 $555.53 $555.53 $531.19 $531.19 $568.02 $568.02 $598.60 $598.60 $725.31$516.43 $516.43 $531.50 $531.50 $403.73 $403.73 $454.97 $454.97 $468.26 $468.26 $565.35 $565.35 $540.57 $540.57 $578.05 $578.05 $609.18 $609.18 $738.13$528.90 $528.90 $544.34 $544.34 $413.49 $413.49 $465.96 $465.96 $479.57 $479.57 $579.00 $579.00 $553.63 $553.63 $592.01 $592.01 $623.89 $623.89 $755.95$544.49 $544.49 $560.39 $560.39 $425.67 $425.67 $479.70 $479.70 $493.70 $493.70 $596.07 $596.07 $569.95 $569.95 $609.46 $609.46 $642.28 $642.28 $778.23$562.81 $562.81 $579.24 $579.24 $439.99 $439.99 $495.83 $495.83 $510.31 $510.31 $616.12 $616.12 $589.12 $589.12 $629.97 $629.97 $663.89 $663.89 $804.42$584.63 $584.63 $601.70 $601.70 $457.06 $457.06 $515.06 $515.06 $530.10 $530.10 $640.01 $640.01 $611.97 $611.97 $654.40 $654.40 $689.63 $689.63 $835.61$609.19 $609.19 $626.97 $626.97 $476.25 $476.25 $536.70 $536.70 $552.37 $552.37 $666.89 $666.89 $637.67 $637.67 $681.88 $681.88 $718.60 $718.60 $870.71$637.25 $637.25 $655.86 $655.86 $498.19 $498.19 $561.42 $561.42 $577.81 $577.81 $697.61 $697.61 $667.05 $667.05 $713.29 $713.29 $751.70 $751.70 $910.82$664.92 $664.92 $684.34 $684.34 $519.83 $519.83 $585.80 $585.80 $602.90 $602.90 $727.91 $727.91 $696.01 $696.01 $744.27 $744.27 $784.34 $784.34 $950.37$696.10 $696.10 $716.43 $716.43 $544.20 $544.20 $613.27 $613.27 $631.17 $631.17 $762.04 $762.04 $728.65 $728.65 $779.17 $779.17 $821.12 $821.12 $994.94$726.89 $726.89 $748.12 $748.12 $568.28 $568.28 $640.40 $640.40 $659.09 $659.09 $795.75 $795.75 $760.88 $760.88 $813.63 $813.63 $857.44 $857.44 $1,038.95$760.80 $760.80 $783.02 $783.02 $594.79 $594.79 $670.27 $670.27 $689.84 $689.84 $832.87 $832.87 $796.37 $796.37 $851.59 $851.59 $897.44 $897.44 $1,087.41$795.10 $795.10 $818.32 $818.32 $621.60 $621.60 $700.49 $700.49 $720.94 $720.94 $870.42 $870.42 $832.28 $832.28 $889.98 $889.98 $937.90 $937.90 $1,136.43$832.13 $832.13 $856.42 $856.42 $650.55 $650.55 $733.11 $733.11 $754.51 $754.51 $910.95 $910.95 $871.03 $871.03 $931.42 $931.42 $981.58 $981.58 $1,189.36$869.16 $869.16 $894.53 $894.53 $679.49 $679.49 $765.73 $765.73 $788.08 $788.08 $951.49 $951.49 $909.79 $909.79 $972.87 $972.87 $1,025.25 $1,025.25 $1,242.28$909.30 $909.30 $935.85 $935.85 $710.88 $710.88 $801.10 $801.10 $824.49 $824.49 $995.43 $995.43 $951.81 $951.81 $1,017.80 $1,017.80 $1,072.61 $1,072.61 $1,299.66$949.83 $949.83 $977.57 $977.57 $742.57 $742.57 $836.81 $836.81 $861.24 $861.24 $1,039.81 $1,039.81 $994.24 $994.24 $1,063.18 $1,063.18 $1,120.42 $1,120.42 $1,357.59$993.10 $993.10 $1,022.09 $1,022.09 $776.39 $776.39 $874.92 $874.92 $900.47 $900.47 $1,087.17 $1,087.17 $1,039.53 $1,039.53 $1,111.60 $1,111.60 $1,171.46 $1,171.46 $1,419.43

$1,014.53 $1,014.53 $1,044.16 $1,044.16 $793.15 $793.15 $893.81 $893.81 $919.90 $919.90 $1,110.64 $1,110.64 $1,061.97 $1,061.97 $1,135.60 $1,135.60 $1,196.74 $1,196.74 $1,450.07$1,057.80 $1,057.80 $1,088.68 $1,088.68 $826.97 $826.97 $931.92 $931.92 $959.13 $959.13 $1,158.00 $1,158.00 $1,107.25 $1,107.25 $1,184.02 $1,184.02 $1,247.78 $1,247.78 $1,511.90$1,095.21 $1,095.21 $1,127.19 $1,127.19 $856.22 $856.22 $964.89 $964.89 $993.06 $993.06 $1,198.96 $1,198.96 $1,146.42 $1,146.42 $1,225.90 $1,225.90 $1,291.91 $1,291.91 $1,565.38$1,119.77 $1,119.77 $1,152.46 $1,152.46 $875.42 $875.42 $986.52 $986.52 $1,015.32 $1,015.32 $1,225.84 $1,225.84 $1,172.12 $1,172.12 $1,253.39 $1,253.39 $1,320.88 $1,320.88 $1,600.48$1,150.56 $1,150.56 $1,184.15 $1,184.15 $899.49 $899.49 $1,013.65 $1,013.65 $1,043.24 $1,043.24 $1,259.55 $1,259.55 $1,204.35 $1,204.35 $1,287.85 $1,287.85 $1,357.20 $1,357.20 $1,644.49$1,169.27 $1,169.27 $1,203.41 $1,203.41 $914.12 $914.12 $1,030.13 $1,030.13 $1,060.20 $1,060.20 $1,280.03 $1,280.03 $1,223.94 $1,223.94 $1,308.79 $1,308.79 $1,379.27 $1,379.27 $1,671.23

PlatiCombine

00% After D

$1,5Y


PPO M-152-122-

Rating

Geisinger Al



$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 6




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 5




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 3




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 2


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 9


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 6


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 6


Page Number: 34 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$426.16 $361.98 $361.98 $321.76 $321.76 $307.66 $307.66 $328.99 $328.99 $346.70 $346.70 $420.09 $420.09 $356.82 $356.82 $278.04 $278.04 $265.86 $265.86$464.04 $394.16 $394.16 $350.36 $350.36 $335.00 $335.00 $358.23 $358.23 $377.52 $377.52 $457.43 $457.43 $388.54 $388.54 $302.76 $302.76 $289.49 $289.49$478.53 $406.46 $406.46 $361.29 $361.29 $345.46 $345.46 $369.41 $369.41 $389.30 $389.30 $471.71 $471.71 $400.67 $400.67 $312.21 $312.21 $298.53 $298.53$493.01 $418.76 $418.76 $372.23 $372.23 $355.92 $355.92 $380.59 $380.59 $401.08 $401.08 $485.99 $485.99 $412.80 $412.80 $321.66 $321.66 $307.56 $307.56$508.61 $432.01 $432.01 $384.00 $384.00 $367.18 $367.18 $392.63 $392.63 $413.77 $413.77 $501.36 $501.36 $425.86 $425.86 $331.83 $331.83 $317.29 $317.29$524.21 $445.26 $445.26 $395.78 $395.78 $378.44 $378.44 $404.67 $404.67 $426.46 $426.46 $516.74 $516.74 $438.92 $438.92 $342.01 $342.01 $327.02 $327.02$540.36 $458.98 $458.98 $407.98 $407.98 $390.10 $390.10 $417.15 $417.15 $439.61 $439.61 $532.66 $532.66 $452.44 $452.44 $352.55 $352.55 $337.10 $337.10$557.08 $473.18 $473.18 $420.60 $420.60 $402.17 $402.17 $430.05 $430.05 $453.21 $453.21 $549.14 $549.14 $466.44 $466.44 $363.46 $363.46 $347.53 $347.53$557.08 $473.18 $473.18 $420.60 $420.60 $402.17 $402.17 $430.05 $430.05 $453.21 $453.21 $549.14 $549.14 $466.44 $466.44 $363.46 $363.46 $347.53 $347.53$557.08 $473.18 $473.18 $420.60 $420.60 $402.17 $402.17 $430.05 $430.05 $453.21 $453.21 $549.14 $549.14 $466.44 $466.44 $363.46 $363.46 $347.53 $347.53$557.08 $473.18 $473.18 $420.60 $420.60 $402.17 $402.17 $430.05 $430.05 $453.21 $453.21 $549.14 $549.14 $466.44 $466.44 $363.46 $363.46 $347.53 $347.53$559.30 $475.07 $475.07 $422.28 $422.28 $403.77 $403.77 $431.77 $431.77 $455.02 $455.02 $551.33 $551.33 $468.30 $468.30 $364.91 $364.91 $348.92 $348.92$570.45 $484.53 $484.53 $430.69 $430.69 $411.82 $411.82 $440.37 $440.37 $464.08 $464.08 $562.32 $562.32 $477.63 $477.63 $372.18 $372.18 $355.87 $355.87$583.82 $495.89 $495.89 $440.78 $440.78 $421.47 $421.47 $450.69 $450.69 $474.96 $474.96 $575.50 $575.50 $488.82 $488.82 $380.90 $380.90 $364.21 $364.21$605.54 $514.35 $514.35 $457.19 $457.19 $437.15 $437.15 $467.46 $467.46 $492.63 $492.63 $596.91 $596.91 $507.02 $507.02 $395.08 $395.08 $377.76 $377.76$623.37 $529.49 $529.49 $470.65 $470.65 $450.02 $450.02 $481.22 $481.22 $507.13 $507.13 $614.48 $614.48 $521.94 $521.94 $406.71 $406.71 $388.88 $388.88$632.28 $537.06 $537.06 $477.38 $477.38 $456.46 $456.46 $488.10 $488.10 $514.39 $514.39 $623.27 $623.27 $529.40 $529.40 $412.52 $412.52 $394.45 $394.45$645.65 $548.41 $548.41 $487.47 $487.47 $466.11 $466.11 $498.42 $498.42 $525.26 $525.26 $636.45 $636.45 $540.60 $540.60 $421.24 $421.24 $402.79 $402.79$659.02 $559.77 $559.77 $497.56 $497.56 $475.76 $475.76 $508.75 $508.75 $536.14 $536.14 $649.63 $649.63 $551.79 $551.79 $429.97 $429.97 $411.13 $411.13$667.38 $566.87 $566.87 $503.87 $503.87 $481.79 $481.79 $515.20 $515.20 $542.94 $542.94 $657.87 $657.87 $558.79 $558.79 $435.42 $435.42 $416.34 $416.34$676.29 $574.44 $574.44 $510.60 $510.60 $488.23 $488.23 $522.08 $522.08 $550.19 $550.19 $666.65 $666.65 $566.25 $566.25 $441.24 $441.24 $421.90 $421.90$680.75 $578.22 $578.22 $513.97 $513.97 $491.45 $491.45 $525.52 $525.52 $553.81 $553.81 $671.05 $671.05 $569.98 $569.98 $444.14 $444.14 $424.68 $424.68$685.20 $582.01 $582.01 $517.33 $517.33 $494.66 $494.66 $528.96 $528.96 $557.44 $557.44 $675.44 $675.44 $573.72 $573.72 $447.05 $447.05 $427.46 $427.46$689.66 $585.80 $585.80 $520.70 $520.70 $497.88 $497.88 $532.40 $532.40 $561.07 $561.07 $679.83 $679.83 $577.45 $577.45 $449.96 $449.96 $430.24 $430.24$694.12 $589.58 $589.58 $524.06 $524.06 $501.10 $501.10 $535.84 $535.84 $564.69 $564.69 $684.22 $684.22 $581.18 $581.18 $452.87 $452.87 $433.02 $433.02$703.03 $597.15 $597.15 $530.79 $530.79 $507.53 $507.53 $542.72 $542.72 $571.94 $571.94 $693.01 $693.01 $588.64 $588.64 $458.68 $458.68 $438.58 $438.58$711.94 $604.72 $604.72 $537.52 $537.52 $513.97 $513.97 $549.60 $549.60 $579.19 $579.19 $701.80 $701.80 $596.10 $596.10 $464.50 $464.50 $444.14 $444.14$725.31 $616.08 $616.08 $547.62 $547.62 $523.62 $523.62 $559.92 $559.92 $590.07 $590.07 $714.98 $714.98 $607.30 $607.30 $473.22 $473.22 $452.48 $452.48$738.13 $626.96 $626.96 $557.29 $557.29 $532.87 $532.87 $569.81 $569.81 $600.49 $600.49 $727.61 $727.61 $618.03 $618.03 $481.58 $481.58 $460.48 $460.48$755.95 $642.10 $642.10 $570.75 $570.75 $545.74 $545.74 $583.57 $583.57 $615.00 $615.00 $745.18 $745.18 $632.95 $632.95 $493.21 $493.21 $471.60 $471.60$778.23 $661.03 $661.03 $587.57 $587.57 $561.82 $561.82 $600.78 $600.78 $633.12 $633.12 $767.14 $767.14 $651.61 $651.61 $507.75 $507.75 $485.50 $485.50$804.42 $683.27 $683.27 $607.34 $607.34 $580.73 $580.73 $620.99 $620.99 $654.43 $654.43 $792.95 $792.95 $673.53 $673.53 $524.83 $524.83 $501.83 $501.83$835.61 $709.77 $709.77 $630.89 $630.89 $603.25 $603.25 $645.07 $645.07 $679.80 $679.80 $823.71 $823.71 $699.65 $699.65 $545.18 $545.18 $521.29 $521.29$870.71 $739.58 $739.58 $657.39 $657.39 $628.58 $628.58 $672.16 $672.16 $708.36 $708.36 $858.30 $858.30 $729.04 $729.04 $568.08 $568.08 $543.19 $543.19$910.82 $773.65 $773.65 $687.67 $687.67 $657.54 $657.54 $703.13 $703.13 $740.99 $740.99 $897.84 $897.84 $762.62 $762.62 $594.25 $594.25 $568.21 $568.21$950.37 $807.24 $807.24 $717.54 $717.54 $686.09 $686.09 $733.66 $733.66 $773.16 $773.16 $936.83 $936.83 $795.74 $795.74 $620.06 $620.06 $592.88 $592.88$994.94 $845.10 $845.10 $751.18 $751.18 $718.27 $718.27 $768.06 $768.06 $809.42 $809.42 $980.76 $980.76 $833.05 $833.05 $649.13 $649.13 $620.69 $620.69

$1,038.95 $882.48 $882.48 $784.41 $784.41 $750.04 $750.04 $802.04 $802.04 $845.22 $845.22 $1,024.14 $1,024.14 $869.90 $869.90 $677.84 $677.84 $648.14 $648.14$1,087.41 $923.64 $923.64 $821.00 $821.00 $785.03 $785.03 $839.45 $839.45 $884.65 $884.65 $1,071.92 $1,071.92 $910.48 $910.48 $709.47 $709.47 $678.38 $678.38$1,136.43 $965.28 $965.28 $858.01 $858.01 $820.42 $820.42 $877.30 $877.30 $924.53 $924.53 $1,120.24 $1,120.24 $951.53 $951.53 $741.45 $741.45 $708.96 $708.96$1,189.36 $1,010.24 $1,010.24 $897.97 $897.97 $858.62 $858.62 $918.15 $918.15 $967.59 $967.59 $1,172.41 $1,172.41 $995.84 $995.84 $775.98 $775.98 $741.97 $741.97$1,242.28 $1,055.19 $1,055.19 $937.93 $937.93 $896.83 $896.83 $959.00 $959.00 $1,010.64 $1,010.64 $1,224.58 $1,224.58 $1,040.15 $1,040.15 $810.51 $810.51 $774.99 $774.99$1,299.66 $1,103.93 $1,103.93 $981.25 $981.25 $938.25 $938.25 $1,003.30 $1,003.30 $1,057.32 $1,057.32 $1,281.14 $1,281.14 $1,088.19 $1,088.19 $847.94 $847.94 $810.78 $810.78$1,357.59 $1,153.14 $1,153.14 $1,024.99 $1,024.99 $980.08 $980.08 $1,048.02 $1,048.02 $1,104.46 $1,104.46 $1,338.25 $1,338.25 $1,136.70 $1,136.70 $885.74 $885.74 $846.93 $846.93$1,419.43 $1,205.66 $1,205.66 $1,071.68 $1,071.68 $1,024.72 $1,024.72 $1,095.76 $1,095.76 $1,154.76 $1,154.76 $1,399.20 $1,399.20 $1,188.48 $1,188.48 $926.08 $926.08 $885.50 $885.50$1,450.07 $1,231.68 $1,231.68 $1,094.81 $1,094.81 $1,046.83 $1,046.83 $1,119.41 $1,119.41 $1,179.69 $1,179.69 $1,429.40 $1,429.40 $1,214.13 $1,214.13 $946.07 $946.07 $904.62 $904.62$1,511.90 $1,284.21 $1,284.21 $1,141.50 $1,141.50 $1,091.48 $1,091.48 $1,167.15 $1,167.15 $1,229.99 $1,229.99 $1,490.36 $1,490.36 $1,265.91 $1,265.91 $986.42 $986.42 $943.19 $943.19$1,565.38 $1,329.63 $1,329.63 $1,181.87 $1,181.87 $1,130.08 $1,130.08 $1,208.43 $1,208.43 $1,273.50 $1,273.50 $1,543.07 $1,543.07 $1,310.68 $1,310.68 $1,021.31 $1,021.31 $976.56 $976.56$1,600.48 $1,359.44 $1,359.44 $1,208.37 $1,208.37 $1,155.42 $1,155.42 $1,235.52 $1,235.52 $1,302.05 $1,302.05 $1,577.67 $1,577.67 $1,340.07 $1,340.07 $1,044.21 $1,044.21 $998.45 $998.45$1,644.49 $1,396.82 $1,396.82 $1,241.60 $1,241.60 $1,187.19 $1,187.19 $1,269.50 $1,269.50 $1,337.86 $1,337.86 $1,621.05 $1,621.05 $1,376.92 $1,376.92 $1,072.92 $1,072.92 $1,025.91 $1,025.91$1,671.23 $1,419.54 $1,419.54 $1,261.79 $1,261.79 $1,206.49 $1,206.49 $1,290.14 $1,290.14 $1,359.61 $1,359.61 $1,647.41 $1,647.41 $1,399.31 $1,399.31 $1,090.37 $1,090.37 $1,042.59 $1,042.59

GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 2



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 6



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 5



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 3



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 2




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 9


numd: $1,500%

Deductible500es


l-Access PPO

Page Number: 35 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$284.29 $284.29 $299.60 $299.60 $363.02 $363.02 $308.35 $308.35 $299.67 $299.67 $286.54 $286.54 $306.40 $306.40 $322.90 $322.90 $391.25 $391.25 $332.33$309.56 $309.56 $326.23 $326.23 $395.29 $395.29 $335.76 $335.76 $326.30 $326.30 $312.00 $312.00 $333.64 $333.64 $351.60 $351.60 $426.03 $426.03 $361.87$319.22 $319.22 $336.41 $336.41 $407.62 $407.62 $346.24 $346.24 $336.49 $336.49 $321.74 $321.74 $344.05 $344.05 $362.58 $362.58 $439.33 $439.33 $373.16$328.89 $328.89 $346.60 $346.60 $419.96 $419.96 $356.72 $356.72 $346.67 $346.67 $331.48 $331.48 $354.46 $354.46 $373.55 $373.55 $452.62 $452.62 $384.46$339.29 $339.29 $357.56 $357.56 $433.25 $433.25 $368.00 $368.00 $357.64 $357.64 $341.97 $341.97 $365.68 $365.68 $385.37 $385.37 $466.94 $466.94 $396.62$349.70 $349.70 $368.53 $368.53 $446.54 $446.54 $379.29 $379.29 $368.61 $368.61 $352.46 $352.46 $376.89 $376.89 $397.19 $397.19 $481.26 $481.26 $408.78$360.47 $360.47 $379.88 $379.88 $460.30 $460.30 $390.98 $390.98 $379.97 $379.97 $363.32 $363.32 $388.51 $388.51 $409.43 $409.43 $496.09 $496.09 $421.38$371.63 $371.63 $391.64 $391.64 $474.54 $474.54 $403.07 $403.07 $391.73 $391.73 $374.56 $374.56 $400.53 $400.53 $422.10 $422.10 $511.44 $511.44 $434.42$371.63 $371.63 $391.64 $391.64 $474.54 $474.54 $403.07 $403.07 $391.73 $391.73 $374.56 $374.56 $400.53 $400.53 $422.10 $422.10 $511.44 $511.44 $434.42$371.63 $371.63 $391.64 $391.64 $474.54 $474.54 $403.07 $403.07 $391.73 $391.73 $374.56 $374.56 $400.53 $400.53 $422.10 $422.10 $511.44 $511.44 $434.42$371.63 $371.63 $391.64 $391.64 $474.54 $474.54 $403.07 $403.07 $391.73 $391.73 $374.56 $374.56 $400.53 $400.53 $422.10 $422.10 $511.44 $511.44 $434.42$373.11 $373.11 $393.20 $393.20 $476.43 $476.43 $404.68 $404.68 $393.29 $393.29 $376.05 $376.05 $402.13 $402.13 $423.78 $423.78 $513.48 $513.48 $436.15$380.54 $380.54 $401.03 $401.03 $485.92 $485.92 $412.74 $412.74 $401.12 $401.12 $383.55 $383.55 $410.14 $410.14 $432.22 $432.22 $523.71 $523.71 $444.84$389.46 $389.46 $410.43 $410.43 $497.31 $497.31 $422.42 $422.42 $410.52 $410.52 $392.53 $392.53 $419.75 $419.75 $442.35 $442.35 $535.99 $535.99 $455.27$403.95 $403.95 $425.71 $425.71 $515.82 $515.82 $438.14 $438.14 $425.80 $425.80 $407.14 $407.14 $435.37 $435.37 $458.81 $458.81 $555.93 $555.93 $472.21$415.85 $415.85 $438.24 $438.24 $531.00 $531.00 $451.03 $451.03 $438.34 $438.34 $419.13 $419.13 $448.19 $448.19 $472.32 $472.32 $572.30 $572.30 $486.11$421.79 $421.79 $444.50 $444.50 $538.60 $538.60 $457.48 $457.48 $444.60 $444.60 $425.12 $425.12 $454.59 $454.59 $479.07 $479.07 $580.48 $580.48 $493.06$430.71 $430.71 $453.90 $453.90 $549.98 $549.98 $467.16 $467.16 $454.00 $454.00 $434.11 $434.11 $464.21 $464.21 $489.20 $489.20 $592.76 $592.76 $503.49$439.63 $439.63 $463.30 $463.30 $561.37 $561.37 $476.83 $476.83 $463.41 $463.41 $443.10 $443.10 $473.82 $473.82 $499.33 $499.33 $605.03 $605.03 $513.91$445.20 $445.20 $469.18 $469.18 $568.49 $568.49 $482.88 $482.88 $469.28 $469.28 $448.72 $448.72 $479.83 $479.83 $505.66 $505.66 $612.70 $612.70 $520.43$451.15 $451.15 $475.44 $475.44 $576.08 $576.08 $489.32 $489.32 $475.55 $475.55 $454.71 $454.71 $486.24 $486.24 $512.42 $512.42 $620.89 $620.89 $527.38$454.12 $454.12 $478.58 $478.58 $579.88 $579.88 $492.55 $492.55 $478.68 $478.68 $457.71 $457.71 $489.44 $489.44 $515.79 $515.79 $624.98 $624.98 $530.85$457.10 $457.10 $481.71 $481.71 $583.68 $583.68 $495.77 $495.77 $481.82 $481.82 $460.70 $460.70 $492.64 $492.64 $519.17 $519.17 $629.07 $629.07 $534.33$460.07 $460.07 $484.84 $484.84 $587.47 $587.47 $499.00 $499.00 $484.95 $484.95 $463.70 $463.70 $495.85 $495.85 $522.55 $522.55 $633.16 $633.16 $537.80$463.04 $463.04 $487.98 $487.98 $591.27 $591.27 $502.22 $502.22 $488.08 $488.08 $466.70 $466.70 $499.05 $499.05 $525.92 $525.92 $637.25 $637.25 $541.28$468.99 $468.99 $494.24 $494.24 $598.86 $598.86 $508.67 $508.67 $494.35 $494.35 $472.69 $472.69 $505.46 $505.46 $532.68 $532.68 $645.43 $645.43 $548.23$474.93 $474.93 $500.51 $500.51 $606.45 $606.45 $515.12 $515.12 $500.62 $500.62 $478.68 $478.68 $511.87 $511.87 $539.43 $539.43 $653.62 $653.62 $555.18$483.85 $483.85 $509.91 $509.91 $617.84 $617.84 $524.79 $524.79 $510.02 $510.02 $487.67 $487.67 $521.48 $521.48 $549.56 $549.56 $665.89 $665.89 $565.61$492.40 $492.40 $518.91 $518.91 $628.76 $628.76 $534.07 $534.07 $519.03 $519.03 $496.29 $496.29 $530.69 $530.69 $559.27 $559.27 $677.66 $677.66 $575.60$504.29 $504.29 $531.45 $531.45 $643.94 $643.94 $546.96 $546.96 $531.57 $531.57 $508.27 $508.27 $543.51 $543.51 $572.78 $572.78 $694.02 $694.02 $589.50$519.16 $519.16 $547.11 $547.11 $662.92 $662.92 $563.09 $563.09 $547.23 $547.23 $523.25 $523.25 $559.53 $559.53 $589.66 $589.66 $714.48 $714.48 $606.88$536.62 $536.62 $565.52 $565.52 $685.23 $685.23 $582.03 $582.03 $565.65 $565.65 $540.86 $540.86 $578.36 $578.36 $609.50 $609.50 $738.52 $738.52 $627.29$557.43 $557.43 $587.45 $587.45 $711.80 $711.80 $604.60 $604.60 $587.58 $587.58 $561.83 $561.83 $600.79 $600.79 $633.14 $633.14 $767.16 $767.16 $651.62$580.85 $580.85 $612.12 $612.12 $741.70 $741.70 $630.00 $630.00 $612.26 $612.26 $585.43 $585.43 $626.02 $626.02 $659.73 $659.73 $799.38 $799.38 $678.99$607.60 $607.60 $640.32 $640.32 $775.86 $775.86 $659.02 $659.02 $640.46 $640.46 $612.40 $612.40 $654.86 $654.86 $690.12 $690.12 $836.20 $836.20 $710.27$633.99 $633.99 $668.13 $668.13 $809.56 $809.56 $687.63 $687.63 $668.28 $668.28 $638.99 $638.99 $683.29 $683.29 $720.09 $720.09 $872.51 $872.51 $741.11$663.72 $663.72 $699.46 $699.46 $847.52 $847.52 $719.88 $719.88 $699.61 $699.61 $668.96 $668.96 $715.34 $715.34 $753.85 $753.85 $913.43 $913.43 $775.86$693.08 $693.08 $730.40 $730.40 $885.01 $885.01 $751.72 $751.72 $730.56 $730.56 $698.55 $698.55 $746.98 $746.98 $787.20 $787.20 $953.83 $953.83 $810.18$725.41 $725.41 $764.47 $764.47 $926.29 $926.29 $786.79 $786.79 $764.64 $764.64 $731.13 $731.13 $781.82 $781.82 $823.92 $823.92 $998.33 $998.33 $847.98$758.11 $758.11 $798.93 $798.93 $968.05 $968.05 $822.26 $822.26 $799.11 $799.11 $764.09 $764.09 $817.07 $817.07 $861.06 $861.06 $1,043.33 $1,043.33 $886.21$793.42 $793.42 $836.14 $836.14 $1,013.13 $1,013.13 $860.55 $860.55 $836.32 $836.32 $799.68 $799.68 $855.12 $855.12 $901.16 $901.16 $1,091.92 $1,091.92 $927.47$828.72 $828.72 $873.34 $873.34 $1,058.21 $1,058.21 $898.84 $898.84 $873.54 $873.54 $835.26 $835.26 $893.17 $893.17 $941.26 $941.26 $1,140.51 $1,140.51 $968.74$867.00 $867.00 $913.68 $913.68 $1,107.09 $1,107.09 $940.36 $940.36 $913.89 $913.89 $873.84 $873.84 $934.42 $934.42 $984.74 $984.74 $1,193.18 $1,193.18 $1,013.49$905.65 $905.65 $954.41 $954.41 $1,156.44 $1,156.44 $982.28 $982.28 $954.62 $954.62 $912.79 $912.79 $976.08 $976.08 $1,028.63 $1,028.63 $1,246.37 $1,246.37 $1,058.67$946.90 $946.90 $997.88 $997.88 $1,209.11 $1,209.11 $1,027.02 $1,027.02 $998.11 $998.11 $954.37 $954.37 $1,020.53 $1,020.53 $1,075.49 $1,075.49 $1,303.14 $1,303.14 $1,106.89$967.33 $967.33 $1,019.42 $1,019.42 $1,235.21 $1,235.21 $1,049.19 $1,049.19 $1,019.65 $1,019.65 $974.97 $974.97 $1,042.56 $1,042.56 $1,098.70 $1,098.70 $1,331.27 $1,331.27 $1,130.78

$1,008.59 $1,008.59 $1,062.89 $1,062.89 $1,287.89 $1,287.89 $1,093.93 $1,093.93 $1,063.13 $1,063.13 $1,016.54 $1,016.54 $1,087.02 $1,087.02 $1,145.55 $1,145.55 $1,388.04 $1,388.04 $1,179.00$1,044.26 $1,044.26 $1,100.49 $1,100.49 $1,333.44 $1,333.44 $1,132.62 $1,132.62 $1,100.74 $1,100.74 $1,052.50 $1,052.50 $1,125.47 $1,125.47 $1,186.07 $1,186.07 $1,437.14 $1,437.14 $1,220.70$1,067.67 $1,067.67 $1,125.16 $1,125.16 $1,363.34 $1,363.34 $1,158.01 $1,158.01 $1,125.41 $1,125.41 $1,076.10 $1,076.10 $1,150.70 $1,150.70 $1,212.67 $1,212.67 $1,469.36 $1,469.36 $1,248.07$1,097.03 $1,097.03 $1,156.10 $1,156.10 $1,400.82 $1,400.82 $1,189.86 $1,189.86 $1,156.36 $1,156.36 $1,105.69 $1,105.69 $1,182.35 $1,182.35 $1,246.01 $1,246.01 $1,509.77 $1,509.77 $1,282.39$1,114.87 $1,114.87 $1,174.90 $1,174.90 $1,423.60 $1,423.60 $1,209.20 $1,209.20 $1,175.16 $1,175.16 $1,123.67 $1,123.67 $1,201.57 $1,201.57 $1,266.27 $1,266.27 $1,534.31 $1,534.31 $1,303.24

GoCombine

0$20 / $40 Aft

$7,0Y


PPO 20/M-152-122-

Rating

Geisinger Al



$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 7




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 6




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 5




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 3




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 2


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 5


Page Number: 36 12/24/2014

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Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$332.33 $361.59 $361.59 $304.02 $304.02 $291.37 $291.37 $263.79 $263.79 $320.87 $320.87 $361.59 $361.59 $269.79 $269.79 $304.02 $304.02 $258.55 $258.55$361.87 $393.73 $393.73 $331.05 $331.05 $317.27 $317.27 $287.24 $287.24 $349.39 $349.39 $393.73 $393.73 $293.77 $293.77 $331.05 $331.05 $281.54 $281.54$373.16 $406.02 $406.02 $341.38 $341.38 $327.17 $327.17 $296.20 $296.20 $360.30 $360.30 $406.02 $406.02 $302.94 $302.94 $341.38 $341.38 $290.32 $290.32$384.46 $418.31 $418.31 $351.72 $351.72 $337.07 $337.07 $305.17 $305.17 $371.20 $371.20 $418.31 $418.31 $312.11 $312.11 $351.72 $351.72 $299.11 $299.11$396.62 $431.54 $431.54 $362.84 $362.84 $347.74 $347.74 $314.82 $314.82 $382.94 $382.94 $431.54 $431.54 $321.98 $321.98 $362.84 $362.84 $308.57 $308.57$408.78 $444.78 $444.78 $373.97 $373.97 $358.40 $358.40 $324.48 $324.48 $394.69 $394.69 $444.78 $444.78 $331.85 $331.85 $373.97 $373.97 $318.04 $318.04$421.38 $458.49 $458.49 $385.50 $385.50 $369.45 $369.45 $334.48 $334.48 $406.85 $406.85 $458.49 $458.49 $342.08 $342.08 $385.50 $385.50 $327.84 $327.84$434.42 $472.67 $472.67 $397.42 $397.42 $380.88 $380.88 $344.83 $344.83 $419.44 $419.44 $472.67 $472.67 $352.67 $352.67 $397.42 $397.42 $337.98 $337.98$434.42 $472.67 $472.67 $397.42 $397.42 $380.88 $380.88 $344.83 $344.83 $419.44 $419.44 $472.67 $472.67 $352.67 $352.67 $397.42 $397.42 $337.98 $337.98$434.42 $472.67 $472.67 $397.42 $397.42 $380.88 $380.88 $344.83 $344.83 $419.44 $419.44 $472.67 $472.67 $352.67 $352.67 $397.42 $397.42 $337.98 $337.98$434.42 $472.67 $472.67 $397.42 $397.42 $380.88 $380.88 $344.83 $344.83 $419.44 $419.44 $472.67 $472.67 $352.67 $352.67 $397.42 $397.42 $337.98 $337.98$436.15 $474.56 $474.56 $399.01 $399.01 $382.40 $382.40 $346.20 $346.20 $421.11 $421.11 $474.56 $474.56 $354.07 $354.07 $399.01 $399.01 $339.33 $339.33$444.84 $484.01 $484.01 $406.96 $406.96 $390.01 $390.01 $353.10 $353.10 $429.50 $429.50 $484.01 $484.01 $361.13 $361.13 $406.96 $406.96 $346.09 $346.09$455.27 $495.35 $495.35 $416.49 $416.49 $399.15 $399.15 $361.38 $361.38 $439.57 $439.57 $495.35 $495.35 $369.59 $369.59 $416.49 $416.49 $354.20 $354.20$472.21 $513.79 $513.79 $431.99 $431.99 $414.01 $414.01 $374.82 $374.82 $455.93 $455.93 $513.79 $513.79 $383.34 $383.34 $431.99 $431.99 $367.38 $367.38$486.11 $528.91 $528.91 $444.71 $444.71 $426.20 $426.20 $385.86 $385.86 $469.35 $469.35 $528.91 $528.91 $394.63 $394.63 $444.71 $444.71 $378.20 $378.20$493.06 $536.48 $536.48 $451.07 $451.07 $432.29 $432.29 $391.38 $391.38 $476.06 $476.06 $536.48 $536.48 $400.27 $400.27 $451.07 $451.07 $383.61 $383.61$503.49 $547.82 $547.82 $460.61 $460.61 $441.43 $441.43 $399.65 $399.65 $486.13 $486.13 $547.82 $547.82 $408.74 $408.74 $460.61 $460.61 $391.72 $391.72$513.91 $559.16 $559.16 $470.15 $470.15 $450.57 $450.57 $407.93 $407.93 $496.19 $496.19 $559.16 $559.16 $417.20 $417.20 $470.15 $470.15 $399.83 $399.83$520.43 $566.25 $566.25 $476.11 $476.11 $456.28 $456.28 $413.10 $413.10 $502.48 $502.48 $566.25 $566.25 $422.49 $422.49 $476.11 $476.11 $404.90 $404.90$527.38 $573.82 $573.82 $482.47 $482.47 $462.38 $462.38 $418.62 $418.62 $509.20 $509.20 $573.82 $573.82 $428.13 $428.13 $482.47 $482.47 $410.31 $410.31$530.85 $577.60 $577.60 $485.65 $485.65 $465.43 $465.43 $421.38 $421.38 $512.55 $512.55 $577.60 $577.60 $430.95 $430.95 $485.65 $485.65 $413.01 $413.01$534.33 $581.38 $581.38 $488.82 $488.82 $468.47 $468.47 $424.13 $424.13 $515.91 $515.91 $581.38 $581.38 $433.77 $433.77 $488.82 $488.82 $415.71 $415.71$537.80 $585.16 $585.16 $492.00 $492.00 $471.52 $471.52 $426.89 $426.89 $519.26 $519.26 $585.16 $585.16 $436.60 $436.60 $492.00 $492.00 $418.42 $418.42$541.28 $588.94 $588.94 $495.18 $495.18 $474.57 $474.57 $429.65 $429.65 $522.62 $522.62 $588.94 $588.94 $439.42 $439.42 $495.18 $495.18 $421.12 $421.12$548.23 $596.50 $596.50 $501.54 $501.54 $480.66 $480.66 $435.17 $435.17 $529.33 $529.33 $596.50 $596.50 $445.06 $445.06 $501.54 $501.54 $426.53 $426.53$555.18 $604.07 $604.07 $507.90 $507.90 $486.75 $486.75 $440.69 $440.69 $536.04 $536.04 $604.07 $604.07 $450.70 $450.70 $507.90 $507.90 $431.94 $431.94$565.61 $615.41 $615.41 $517.44 $517.44 $495.89 $495.89 $448.96 $448.96 $546.11 $546.11 $615.41 $615.41 $459.17 $459.17 $517.44 $517.44 $440.05 $440.05$575.60 $626.28 $626.28 $526.58 $526.58 $504.65 $504.65 $456.89 $456.89 $555.75 $555.75 $626.28 $626.28 $467.28 $467.28 $526.58 $526.58 $447.82 $447.82$589.50 $641.41 $641.41 $539.30 $539.30 $516.84 $516.84 $467.93 $467.93 $569.17 $569.17 $641.41 $641.41 $478.56 $478.56 $539.30 $539.30 $458.64 $458.64$606.88 $660.31 $660.31 $555.19 $555.19 $532.08 $532.08 $481.72 $481.72 $585.95 $585.95 $660.31 $660.31 $492.67 $492.67 $555.19 $555.19 $472.16 $472.16$627.29 $682.53 $682.53 $573.87 $573.87 $549.98 $549.98 $497.93 $497.93 $605.67 $605.67 $682.53 $682.53 $509.24 $509.24 $573.87 $573.87 $488.04 $488.04$651.62 $709.00 $709.00 $596.13 $596.13 $571.31 $571.31 $517.24 $517.24 $629.15 $629.15 $709.00 $709.00 $528.99 $528.99 $596.13 $596.13 $506.97 $506.97$678.99 $738.78 $738.78 $621.16 $621.16 $595.30 $595.30 $538.96 $538.96 $655.58 $655.58 $738.78 $738.78 $551.21 $551.21 $621.16 $621.16 $528.26 $528.26$710.27 $772.81 $772.81 $649.78 $649.78 $622.73 $622.73 $563.79 $563.79 $685.78 $685.78 $772.81 $772.81 $576.60 $576.60 $649.78 $649.78 $552.60 $552.60$741.11 $806.37 $806.37 $678.00 $678.00 $649.77 $649.77 $588.27 $588.27 $715.56 $715.56 $806.37 $806.37 $601.64 $601.64 $678.00 $678.00 $576.59 $576.59$775.86 $844.18 $844.18 $709.79 $709.79 $680.24 $680.24 $615.86 $615.86 $749.11 $749.11 $844.18 $844.18 $629.85 $629.85 $709.79 $709.79 $603.63 $603.63$810.18 $881.52 $881.52 $741.19 $741.19 $710.33 $710.33 $643.10 $643.10 $782.25 $782.25 $881.52 $881.52 $657.71 $657.71 $741.19 $741.19 $630.33 $630.33$847.98 $922.64 $922.64 $775.76 $775.76 $743.46 $743.46 $673.10 $673.10 $818.74 $818.74 $922.64 $922.64 $688.40 $688.40 $775.76 $775.76 $659.73 $659.73$886.21 $964.24 $964.24 $810.73 $810.73 $776.98 $776.98 $703.44 $703.44 $855.65 $855.65 $964.24 $964.24 $719.43 $719.43 $810.73 $810.73 $689.48 $689.48$927.47 $1,009.14 $1,009.14 $848.49 $848.49 $813.16 $813.16 $736.20 $736.20 $895.50 $895.50 $1,009.14 $1,009.14 $752.93 $752.93 $848.49 $848.49 $721.58 $721.58$968.74 $1,054.05 $1,054.05 $886.24 $886.24 $849.34 $849.34 $768.96 $768.96 $935.34 $935.34 $1,054.05 $1,054.05 $786.44 $786.44 $886.24 $886.24 $753.69 $753.69

$1,013.49 $1,102.73 $1,102.73 $927.18 $927.18 $888.57 $888.57 $804.48 $804.48 $978.54 $978.54 $1,102.73 $1,102.73 $822.76 $822.76 $927.18 $927.18 $788.50 $788.50$1,058.67 $1,151.89 $1,151.89 $968.51 $968.51 $928.18 $928.18 $840.34 $840.34 $1,022.16 $1,022.16 $1,151.89 $1,151.89 $859.44 $859.44 $968.51 $968.51 $823.65 $823.65$1,106.89 $1,204.35 $1,204.35 $1,012.62 $1,012.62 $970.46 $970.46 $878.61 $878.61 $1,068.72 $1,068.72 $1,204.35 $1,204.35 $898.58 $898.58 $1,012.62 $1,012.62 $861.17 $861.17$1,130.78 $1,230.35 $1,230.35 $1,034.48 $1,034.48 $991.41 $991.41 $897.58 $897.58 $1,091.79 $1,091.79 $1,230.35 $1,230.35 $917.98 $917.98 $1,034.48 $1,034.48 $879.76 $879.76$1,179.00 $1,282.82 $1,282.82 $1,078.59 $1,078.59 $1,033.69 $1,033.69 $935.85 $935.85 $1,138.35 $1,138.35 $1,282.82 $1,282.82 $957.12 $957.12 $1,078.59 $1,078.59 $917.27 $917.27$1,220.70 $1,328.19 $1,328.19 $1,116.75 $1,116.75 $1,070.25 $1,070.25 $968.96 $968.96 $1,178.61 $1,178.61 $1,328.19 $1,328.19 $990.98 $990.98 $1,116.75 $1,116.75 $949.72 $949.72$1,248.07 $1,357.97 $1,357.97 $1,141.78 $1,141.78 $1,094.24 $1,094.24 $990.68 $990.68 $1,205.04 $1,205.04 $1,357.97 $1,357.97 $1,013.20 $1,013.20 $1,141.78 $1,141.78 $971.01 $971.01$1,282.39 $1,395.31 $1,395.31 $1,173.18 $1,173.18 $1,124.33 $1,124.33 $1,017.92 $1,017.92 $1,238.17 $1,238.17 $1,395.31 $1,395.31 $1,041.06 $1,041.06 $1,173.18 $1,173.18 $997.71 $997.71$1,303.24 $1,418.00 $1,418.00 $1,192.25 $1,192.25 $1,142.61 $1,142.61 $1,034.47 $1,034.47 $1,258.31 $1,258.31 $1,418.00 $1,418.00 $1,057.99 $1,057.99 $1,192.25 $1,192.25 $1,013.94 $1,013.94

GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 3



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 6



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 3


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 6



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 6


oldd: $1,500%er Deductible000es


l-Access PPO

Page Number: 37 12/24/2014

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Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$291.37 $291.37 $234.08 $234.08 $263.79 $263.79 $320.87 $320.87 $269.79 $269.79 $258.55 $258.55 $234.08 $234.08$317.27 $317.27 $254.89 $254.89 $287.24 $287.24 $349.39 $349.39 $293.77 $293.77 $281.54 $281.54 $254.89 $254.89$327.17 $327.17 $262.85 $262.85 $296.20 $296.20 $360.30 $360.30 $302.94 $302.94 $290.32 $290.32 $262.85 $262.85$337.07 $337.07 $270.80 $270.80 $305.17 $305.17 $371.20 $371.20 $312.11 $312.11 $299.11 $299.11 $270.80 $270.80$347.74 $347.74 $279.37 $279.37 $314.82 $314.82 $382.94 $382.94 $321.98 $321.98 $308.57 $308.57 $279.37 $279.37$358.40 $358.40 $287.94 $287.94 $324.48 $324.48 $394.69 $394.69 $331.85 $331.85 $318.04 $318.04 $287.94 $287.94$369.45 $369.45 $296.81 $296.81 $334.48 $334.48 $406.85 $406.85 $342.08 $342.08 $327.84 $327.84 $296.81 $296.81$380.88 $380.88 $306.00 $306.00 $344.83 $344.83 $419.44 $419.44 $352.67 $352.67 $337.98 $337.98 $306.00 $306.00$380.88 $380.88 $306.00 $306.00 $344.83 $344.83 $419.44 $419.44 $352.67 $352.67 $337.98 $337.98 $306.00 $306.00$380.88 $380.88 $306.00 $306.00 $344.83 $344.83 $419.44 $419.44 $352.67 $352.67 $337.98 $337.98 $306.00 $306.00$380.88 $380.88 $306.00 $306.00 $344.83 $344.83 $419.44 $419.44 $352.67 $352.67 $337.98 $337.98 $306.00 $306.00$382.40 $382.40 $307.22 $307.22 $346.20 $346.20 $421.11 $421.11 $354.07 $354.07 $339.33 $339.33 $307.22 $307.22$390.01 $390.01 $313.34 $313.34 $353.10 $353.10 $429.50 $429.50 $361.13 $361.13 $346.09 $346.09 $313.34 $313.34$399.15 $399.15 $320.68 $320.68 $361.38 $361.38 $439.57 $439.57 $369.59 $369.59 $354.20 $354.20 $320.68 $320.68$414.01 $414.01 $332.61 $332.61 $374.82 $374.82 $455.93 $455.93 $383.34 $383.34 $367.38 $367.38 $332.61 $332.61$426.20 $426.20 $342.40 $342.40 $385.86 $385.86 $469.35 $469.35 $394.63 $394.63 $378.20 $378.20 $342.40 $342.40$432.29 $432.29 $347.30 $347.30 $391.38 $391.38 $476.06 $476.06 $400.27 $400.27 $383.61 $383.61 $347.30 $347.30$441.43 $441.43 $354.64 $354.64 $399.65 $399.65 $486.13 $486.13 $408.74 $408.74 $391.72 $391.72 $354.64 $354.64$450.57 $450.57 $361.99 $361.99 $407.93 $407.93 $496.19 $496.19 $417.20 $417.20 $399.83 $399.83 $361.99 $361.99$456.28 $456.28 $366.58 $366.58 $413.10 $413.10 $502.48 $502.48 $422.49 $422.49 $404.90 $404.90 $366.58 $366.58$462.38 $462.38 $371.47 $371.47 $418.62 $418.62 $509.20 $509.20 $428.13 $428.13 $410.31 $410.31 $371.47 $371.47$465.43 $465.43 $373.92 $373.92 $421.38 $421.38 $512.55 $512.55 $430.95 $430.95 $413.01 $413.01 $373.92 $373.92$468.47 $468.47 $376.37 $376.37 $424.13 $424.13 $515.91 $515.91 $433.77 $433.77 $415.71 $415.71 $376.37 $376.37$471.52 $471.52 $378.82 $378.82 $426.89 $426.89 $519.26 $519.26 $436.60 $436.60 $418.42 $418.42 $378.82 $378.82$474.57 $474.57 $381.27 $381.27 $429.65 $429.65 $522.62 $522.62 $439.42 $439.42 $421.12 $421.12 $381.27 $381.27$480.66 $480.66 $386.16 $386.16 $435.17 $435.17 $529.33 $529.33 $445.06 $445.06 $426.53 $426.53 $386.16 $386.16$486.75 $486.75 $391.06 $391.06 $440.69 $440.69 $536.04 $536.04 $450.70 $450.70 $431.94 $431.94 $391.06 $391.06$495.89 $495.89 $398.40 $398.40 $448.96 $448.96 $546.11 $546.11 $459.17 $459.17 $440.05 $440.05 $398.40 $398.40$504.65 $504.65 $405.44 $405.44 $456.89 $456.89 $555.75 $555.75 $467.28 $467.28 $447.82 $447.82 $405.44 $405.44$516.84 $516.84 $415.23 $415.23 $467.93 $467.93 $569.17 $569.17 $478.56 $478.56 $458.64 $458.64 $415.23 $415.23$532.08 $532.08 $427.47 $427.47 $481.72 $481.72 $585.95 $585.95 $492.67 $492.67 $472.16 $472.16 $427.47 $427.47$549.98 $549.98 $441.85 $441.85 $497.93 $497.93 $605.67 $605.67 $509.24 $509.24 $488.04 $488.04 $441.85 $441.85$571.31 $571.31 $458.99 $458.99 $517.24 $517.24 $629.15 $629.15 $528.99 $528.99 $506.97 $506.97 $458.99 $458.99$595.30 $595.30 $478.26 $478.26 $538.96 $538.96 $655.58 $655.58 $551.21 $551.21 $528.26 $528.26 $478.26 $478.26$622.73 $622.73 $500.30 $500.30 $563.79 $563.79 $685.78 $685.78 $576.60 $576.60 $552.60 $552.60 $500.30 $500.30$649.77 $649.77 $522.02 $522.02 $588.27 $588.27 $715.56 $715.56 $601.64 $601.64 $576.59 $576.59 $522.02 $522.02$680.24 $680.24 $546.50 $546.50 $615.86 $615.86 $749.11 $749.11 $629.85 $629.85 $603.63 $603.63 $546.50 $546.50$710.33 $710.33 $570.67 $570.67 $643.10 $643.10 $782.25 $782.25 $657.71 $657.71 $630.33 $630.33 $570.67 $570.67$743.46 $743.46 $597.30 $597.30 $673.10 $673.10 $818.74 $818.74 $688.40 $688.40 $659.73 $659.73 $597.30 $597.30$776.98 $776.98 $624.22 $624.22 $703.44 $703.44 $855.65 $855.65 $719.43 $719.43 $689.48 $689.48 $624.22 $624.22$813.16 $813.16 $653.29 $653.29 $736.20 $736.20 $895.50 $895.50 $752.93 $752.93 $721.58 $721.58 $653.29 $653.29$849.34 $849.34 $682.36 $682.36 $768.96 $768.96 $935.34 $935.34 $786.44 $786.44 $753.69 $753.69 $682.36 $682.36$888.57 $888.57 $713.88 $713.88 $804.48 $804.48 $978.54 $978.54 $822.76 $822.76 $788.50 $788.50 $713.88 $713.88$928.18 $928.18 $745.70 $745.70 $840.34 $840.34 $1,022.16 $1,022.16 $859.44 $859.44 $823.65 $823.65 $745.70 $745.70$970.46 $970.46 $779.67 $779.67 $878.61 $878.61 $1,068.72 $1,068.72 $898.58 $898.58 $861.17 $861.17 $779.67 $779.67$991.41 $991.41 $796.50 $796.50 $897.58 $897.58 $1,091.79 $1,091.79 $917.98 $917.98 $879.76 $879.76 $796.50 $796.50

$1,033.69 $1,033.69 $830.46 $830.46 $935.85 $935.85 $1,138.35 $1,138.35 $957.12 $957.12 $917.27 $917.27 $830.46 $830.46$1,070.25 $1,070.25 $859.84 $859.84 $968.96 $968.96 $1,178.61 $1,178.61 $990.98 $990.98 $949.72 $949.72 $859.84 $859.84$1,094.24 $1,094.24 $879.11 $879.11 $990.68 $990.68 $1,205.04 $1,205.04 $1,013.20 $1,013.20 $971.01 $971.01 $879.11 $879.11$1,124.33 $1,124.33 $903.29 $903.29 $1,017.92 $1,017.92 $1,238.17 $1,238.17 $1,041.06 $1,041.06 $997.71 $997.71 $903.29 $903.29$1,142.61 $1,142.61 $917.97 $917.97 $1,034.47 $1,034.47 $1,258.31 $1,258.31 $1,057.99 $1,057.99 $1,013.94 $1,013.94 $917.97 $917.97

SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 3



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 3


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 6


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 6


Page Number: 38 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 14 $224.15 $224.15 $214.33 $214.33 $229.19 $229.19 $241.53 $241.53 $292.66 $292.66 $248.59 $248.59 $287.38 $287.38 $323.85 $323.85 $333.30 $333.30 $303.1015 $244.08 $244.08 $233.38 $233.38 $249.56 $249.56 $263.00 $263.00 $318.67 $318.67 $270.68 $270.68 $312.92 $312.92 $352.63 $352.63 $362.93 $362.93 $330.0416 $251.70 $251.70 $240.67 $240.67 $257.35 $257.35 $271.21 $271.21 $328.62 $328.62 $279.13 $279.13 $322.69 $322.69 $363.64 $363.64 $374.26 $374.26 $340.3417 $259.32 $259.32 $247.95 $247.95 $265.14 $265.14 $279.42 $279.42 $338.57 $338.57 $287.58 $287.58 $332.45 $332.45 $374.65 $374.65 $385.58 $385.58 $350.6418 $267.52 $267.52 $255.80 $255.80 $273.53 $273.53 $288.26 $288.26 $349.28 $349.28 $296.68 $296.68 $342.97 $342.97 $386.50 $386.50 $397.78 $397.78 $361.7319 $275.73 $275.73 $263.64 $263.64 $281.92 $281.92 $297.10 $297.10 $359.99 $359.99 $305.78 $305.78 $353.49 $353.49 $398.35 $398.35 $409.98 $409.98 $372.8320 $284.22 $284.22 $271.77 $271.77 $290.61 $290.61 $306.26 $306.26 $371.09 $371.09 $315.20 $315.20 $364.38 $364.38 $410.63 $410.63 $422.62 $422.62 $384.3221 $293.02 $293.02 $280.18 $280.18 $299.60 $299.60 $315.73 $315.73 $382.57 $382.57 $324.95 $324.95 $375.66 $375.66 $423.33 $423.33 $435.69 $435.69 $396.2122 $293.02 $293.02 $280.18 $280.18 $299.60 $299.60 $315.73 $315.73 $382.57 $382.57 $324.95 $324.95 $375.66 $375.66 $423.33 $423.33 $435.69 $435.69 $396.2123 $293.02 $293.02 $280.18 $280.18 $299.60 $299.60 $315.73 $315.73 $382.57 $382.57 $324.95 $324.95 $375.66 $375.66 $423.33 $423.33 $435.69 $435.69 $396.2124 $293.02 $293.02 $280.18 $280.18 $299.60 $299.60 $315.73 $315.73 $382.57 $382.57 $324.95 $324.95 $375.66 $375.66 $423.33 $423.33 $435.69 $435.69 $396.2125 $294.18 $294.18 $281.29 $281.29 $300.80 $300.80 $316.99 $316.99 $384.09 $384.09 $326.25 $326.25 $377.16 $377.16 $425.02 $425.02 $437.43 $437.43 $397.7926 $300.05 $300.05 $286.90 $286.90 $306.79 $306.79 $323.31 $323.31 $391.74 $391.74 $332.75 $332.75 $384.67 $384.67 $433.49 $433.49 $446.14 $446.14 $405.7127 $307.08 $307.08 $293.62 $293.62 $313.98 $313.98 $330.88 $330.88 $400.93 $400.93 $340.55 $340.55 $393.69 $393.69 $443.65 $443.65 $456.60 $456.60 $415.2228 $318.51 $318.51 $304.55 $304.55 $325.66 $325.66 $343.20 $343.20 $415.85 $415.85 $353.22 $353.22 $408.34 $408.34 $460.16 $460.16 $473.59 $473.59 $430.6729 $327.88 $327.88 $313.51 $313.51 $335.25 $335.25 $353.30 $353.30 $428.09 $428.09 $363.62 $363.62 $420.36 $420.36 $473.70 $473.70 $487.54 $487.54 $443.3530 $332.57 $332.57 $318.00 $318.00 $340.04 $340.04 $358.35 $358.35 $434.21 $434.21 $368.82 $368.82 $426.37 $426.37 $480.48 $480.48 $494.51 $494.51 $449.6931 $339.60 $339.60 $324.72 $324.72 $347.23 $347.23 $365.93 $365.93 $443.39 $443.39 $376.61 $376.61 $435.38 $435.38 $490.64 $490.64 $504.96 $504.96 $459.2032 $346.63 $346.63 $331.44 $331.44 $354.42 $354.42 $373.51 $373.51 $452.57 $452.57 $384.41 $384.41 $444.40 $444.40 $500.80 $500.80 $515.42 $515.42 $468.7133 $351.03 $351.03 $335.65 $335.65 $358.92 $358.92 $378.24 $378.24 $458.31 $458.31 $389.29 $389.29 $450.03 $450.03 $507.15 $507.15 $521.95 $521.95 $474.6534 $355.72 $355.72 $340.13 $340.13 $363.71 $363.71 $383.30 $383.30 $464.43 $464.43 $394.49 $394.49 $456.04 $456.04 $513.92 $513.92 $528.93 $528.93 $480.9935 $358.06 $358.06 $342.37 $342.37 $366.11 $366.11 $385.82 $385.82 $467.49 $467.49 $397.09 $397.09 $459.05 $459.05 $517.31 $517.31 $532.41 $532.41 $484.1636 $360.41 $360.41 $344.61 $344.61 $368.50 $368.50 $388.35 $388.35 $470.55 $470.55 $399.69 $399.69 $462.05 $462.05 $520.69 $520.69 $535.90 $535.90 $487.3337 $362.75 $362.75 $346.85 $346.85 $370.90 $370.90 $390.87 $390.87 $473.61 $473.61 $402.29 $402.29 $465.06 $465.06 $524.08 $524.08 $539.38 $539.38 $490.5038 $365.09 $365.09 $349.10 $349.10 $373.30 $373.30 $393.40 $393.40 $476.67 $476.67 $404.89 $404.89 $468.07 $468.07 $527.47 $527.47 $542.87 $542.87 $493.6739 $369.78 $369.78 $353.58 $353.58 $378.09 $378.09 $398.45 $398.45 $482.79 $482.79 $410.08 $410.08 $474.08 $474.08 $534.24 $534.24 $549.84 $549.84 $500.0140 $374.47 $374.47 $358.06 $358.06 $382.89 $382.89 $403.50 $403.50 $488.92 $488.92 $415.28 $415.28 $480.09 $480.09 $541.01 $541.01 $556.81 $556.81 $506.3541 $381.50 $381.50 $364.79 $364.79 $390.08 $390.08 $411.08 $411.08 $498.10 $498.10 $423.08 $423.08 $489.10 $489.10 $551.17 $551.17 $567.27 $567.27 $515.8642 $388.24 $388.24 $371.23 $371.23 $396.97 $396.97 $418.34 $418.34 $506.90 $506.90 $430.56 $430.56 $497.74 $497.74 $560.91 $560.91 $577.29 $577.29 $524.9743 $397.62 $397.62 $380.19 $380.19 $406.55 $406.55 $428.45 $428.45 $519.14 $519.14 $440.95 $440.95 $509.76 $509.76 $574.46 $574.46 $591.23 $591.23 $537.6544 $409.34 $409.34 $391.40 $391.40 $418.54 $418.54 $441.07 $441.07 $534.44 $534.44 $453.95 $453.95 $524.79 $524.79 $591.39 $591.39 $608.66 $608.66 $553.5045 $423.11 $423.11 $404.57 $404.57 $432.62 $432.62 $455.91 $455.91 $552.42 $552.42 $469.22 $469.22 $542.44 $542.44 $611.29 $611.29 $629.13 $629.13 $572.1246 $439.52 $439.52 $420.26 $420.26 $449.40 $449.40 $473.59 $473.59 $573.84 $573.84 $487.42 $487.42 $563.48 $563.48 $634.99 $634.99 $653.53 $653.53 $594.3047 $457.98 $457.98 $437.91 $437.91 $468.27 $468.27 $493.49 $493.49 $597.95 $597.95 $507.89 $507.89 $587.15 $587.15 $661.66 $661.66 $680.98 $680.98 $619.2748 $479.08 $479.08 $458.08 $458.08 $489.84 $489.84 $516.22 $516.22 $625.49 $625.49 $531.29 $531.29 $614.19 $614.19 $692.14 $692.14 $712.35 $712.35 $647.7949 $499.88 $499.88 $477.98 $477.98 $511.11 $511.11 $538.63 $538.63 $652.65 $652.65 $554.36 $554.36 $640.87 $640.87 $722.20 $722.20 $743.28 $743.28 $675.9250 $523.32 $523.32 $500.39 $500.39 $535.08 $535.08 $563.89 $563.89 $683.26 $683.26 $580.36 $580.36 $670.92 $670.92 $756.06 $756.06 $778.14 $778.14 $707.6251 $546.47 $546.47 $522.52 $522.52 $558.75 $558.75 $588.84 $588.84 $713.48 $713.48 $606.03 $606.03 $700.60 $700.60 $789.51 $789.51 $812.56 $812.56 $738.9252 $571.96 $571.96 $546.90 $546.90 $584.81 $584.81 $616.30 $616.30 $746.76 $746.76 $634.30 $634.30 $733.28 $733.28 $826.34 $826.34 $850.46 $850.46 $773.3953 $597.75 $597.75 $571.55 $571.55 $611.18 $611.18 $644.09 $644.09 $780.43 $780.43 $662.89 $662.89 $766.33 $766.33 $863.59 $863.59 $888.80 $888.80 $808.2554 $625.58 $625.58 $598.17 $598.17 $639.64 $639.64 $674.08 $674.08 $816.77 $816.77 $693.76 $693.76 $802.02 $802.02 $903.81 $903.81 $930.19 $930.19 $845.8955 $653.42 $653.42 $624.79 $624.79 $668.10 $668.10 $704.08 $704.08 $853.12 $853.12 $724.63 $724.63 $837.71 $837.71 $944.02 $944.02 $971.59 $971.59 $883.5356 $683.60 $683.60 $653.64 $653.64 $698.96 $698.96 $736.60 $736.60 $892.52 $892.52 $758.10 $758.10 $876.40 $876.40 $987.63 $987.63 $1,016.46 $1,016.46 $924.3457 $714.07 $714.07 $682.78 $682.78 $730.12 $730.12 $769.43 $769.43 $932.31 $932.31 $791.90 $791.90 $915.47 $915.47 $1,031.65 $1,031.65 $1,061.77 $1,061.77 $965.5558 $746.60 $746.60 $713.88 $713.88 $763.37 $763.37 $804.48 $804.48 $974.77 $974.77 $827.97 $827.97 $957.17 $957.17 $1,078.64 $1,078.64 $1,110.13 $1,110.13 $1,009.5359 $762.71 $762.71 $729.29 $729.29 $779.85 $779.85 $821.84 $821.84 $995.81 $995.81 $845.84 $845.84 $977.83 $977.83 $1,101.92 $1,101.92 $1,134.10 $1,134.10 $1,031.3260 $795.24 $795.24 $760.39 $760.39 $813.11 $813.11 $856.89 $856.89 $1,038.28 $1,038.28 $881.91 $881.91 $1,019.53 $1,019.53 $1,148.91 $1,148.91 $1,182.46 $1,182.46 $1,075.3061 $823.37 $823.37 $787.29 $787.29 $841.87 $841.87 $887.20 $887.20 $1,075.00 $1,075.00 $913.10 $913.10 $1,055.59 $1,055.59 $1,189.55 $1,189.55 $1,224.28 $1,224.28 $1,113.3362 $841.83 $841.83 $804.94 $804.94 $860.74 $860.74 $907.09 $907.09 $1,099.10 $1,099.10 $933.58 $933.58 $1,079.26 $1,079.26 $1,216.22 $1,216.22 $1,251.73 $1,251.73 $1,138.2963 $864.97 $864.97 $827.07 $827.07 $884.41 $884.41 $932.03 $932.03 $1,129.33 $1,129.33 $959.25 $959.25 $1,108.93 $1,108.93 $1,249.67 $1,249.67 $1,286.15 $1,286.15 $1,169.59

64+ $879.04 $879.04 $840.52 $840.52 $898.79 $898.79 $947.19 $947.19 $1,147.69 $1,147.69 $974.84 $974.84 $1,126.96 $1,126.96 $1,269.99 $1,269.99 $1,307.07 $1,307.07 $1,188.61

GoMed: $1,00

0%$20 /$8,1

Ye


20/40/M-152-121-

Rating

Geisinger All


0%$60 / $60$8,150

Yes


10/60/500M-152-243-F Rev. 1/20

Rating Area 9



0%$60 / $60$8,150

Yes

0%$60 / $60$8,150

Yes


10/60/500M-152-243-F Rev. 1/20

Rating Area 6






$6,500 $6,500 $6,500 $6,500Yes Yes Yes Yes




$6,500Yes


$6,500Yes


75729PA0050062 75729PA0050068





PPO 6500M-152-122-F Rev. 1/20

Rating Area 9






PPOJuly 1, 2020 September 30, 2020






75729PA0050062 75729PA0050062 75729PA0050062 75729PA0050062

Page Number: 39 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$303.10 $289.81 $289.81 $309.91 $309.91 $326.59 $326.59 $395.73 $395.73 $336.13 $336.13 $287.34 $287.34 $274.75 $274.75 $293.80 $293.80 $309.62 $309.62$330.04 $315.57 $315.57 $337.45 $337.45 $355.62 $355.62 $430.90 $430.90 $366.01 $366.01 $312.89 $312.89 $299.18 $299.18 $319.92 $319.92 $337.14 $337.14$340.34 $325.42 $325.42 $347.99 $347.99 $366.72 $366.72 $444.35 $444.35 $377.43 $377.43 $322.65 $322.65 $308.51 $308.51 $329.90 $329.90 $347.67 $347.67$350.64 $335.27 $335.27 $358.52 $358.52 $377.82 $377.82 $457.80 $457.80 $388.86 $388.86 $332.42 $332.42 $317.85 $317.85 $339.89 $339.89 $358.19 $358.19$361.73 $345.88 $345.88 $369.86 $369.86 $389.78 $389.78 $472.29 $472.29 $401.16 $401.16 $342.94 $342.94 $327.91 $327.91 $350.64 $350.64 $369.52 $369.52$372.83 $356.49 $356.49 $381.21 $381.21 $401.73 $401.73 $486.77 $486.77 $413.46 $413.46 $353.45 $353.45 $337.96 $337.96 $361.40 $361.40 $380.86 $380.86$384.32 $367.48 $367.48 $392.95 $392.95 $414.11 $414.11 $501.77 $501.77 $426.20 $426.20 $364.35 $364.35 $348.38 $348.38 $372.53 $372.53 $392.59 $392.59$396.21 $378.85 $378.85 $405.11 $405.11 $426.92 $426.92 $517.29 $517.29 $439.39 $439.39 $375.62 $375.62 $359.16 $359.16 $384.06 $384.06 $404.74 $404.74$396.21 $378.85 $378.85 $405.11 $405.11 $426.92 $426.92 $517.29 $517.29 $439.39 $439.39 $375.62 $375.62 $359.16 $359.16 $384.06 $384.06 $404.74 $404.74$396.21 $378.85 $378.85 $405.11 $405.11 $426.92 $426.92 $517.29 $517.29 $439.39 $439.39 $375.62 $375.62 $359.16 $359.16 $384.06 $384.06 $404.74 $404.74$396.21 $378.85 $378.85 $405.11 $405.11 $426.92 $426.92 $517.29 $517.29 $439.39 $439.39 $375.62 $375.62 $359.16 $359.16 $384.06 $384.06 $404.74 $404.74$397.79 $380.36 $380.36 $406.73 $406.73 $428.63 $428.63 $519.36 $519.36 $441.14 $441.14 $377.12 $377.12 $360.59 $360.59 $385.59 $385.59 $406.35 $406.35$405.71 $387.93 $387.93 $414.83 $414.83 $437.17 $437.17 $529.70 $529.70 $449.93 $449.93 $384.63 $384.63 $367.77 $367.77 $393.27 $393.27 $414.45 $414.45$415.22 $397.03 $397.03 $424.55 $424.55 $447.41 $447.41 $542.12 $542.12 $460.48 $460.48 $393.64 $393.64 $376.39 $376.39 $402.49 $402.49 $424.16 $424.16$430.67 $411.80 $411.80 $440.35 $440.35 $464.06 $464.06 $562.29 $562.29 $477.61 $477.61 $408.29 $408.29 $390.40 $390.40 $417.47 $417.47 $439.95 $439.95$443.35 $423.92 $423.92 $453.31 $453.31 $477.72 $477.72 $578.85 $578.85 $491.67 $491.67 $420.31 $420.31 $401.89 $401.89 $429.76 $429.76 $452.90 $452.90$449.69 $429.98 $429.98 $459.80 $459.80 $484.55 $484.55 $587.12 $587.12 $498.70 $498.70 $426.32 $426.32 $407.64 $407.64 $435.90 $435.90 $459.37 $459.37$459.20 $439.08 $439.08 $469.52 $469.52 $494.80 $494.80 $599.54 $599.54 $509.25 $509.25 $435.34 $435.34 $416.26 $416.26 $445.12 $445.12 $469.09 $469.09$468.71 $448.17 $448.17 $479.24 $479.24 $505.05 $505.05 $611.95 $611.95 $519.79 $519.79 $444.35 $444.35 $424.88 $424.88 $454.34 $454.34 $478.80 $478.80$474.65 $453.85 $453.85 $485.32 $485.32 $511.45 $511.45 $619.71 $619.71 $526.38 $526.38 $449.99 $449.99 $430.27 $430.27 $460.10 $460.10 $484.87 $484.87$480.99 $459.91 $459.91 $491.80 $491.80 $518.28 $518.28 $627.99 $627.99 $533.41 $533.41 $456.00 $456.00 $436.01 $436.01 $466.24 $466.24 $491.35 $491.35$484.16 $462.94 $462.94 $495.04 $495.04 $521.70 $521.70 $632.13 $632.13 $536.93 $536.93 $459.00 $459.00 $438.89 $438.89 $469.31 $469.31 $494.59 $494.59$487.33 $465.97 $465.97 $498.28 $498.28 $525.11 $525.11 $636.27 $636.27 $540.44 $540.44 $462.00 $462.00 $441.76 $441.76 $472.39 $472.39 $497.82 $497.82$490.50 $469.01 $469.01 $501.52 $501.52 $528.53 $528.53 $640.40 $640.40 $543.96 $543.96 $465.01 $465.01 $444.63 $444.63 $475.46 $475.46 $501.06 $501.06$493.67 $472.04 $472.04 $504.76 $504.76 $531.94 $531.94 $644.54 $644.54 $547.47 $547.47 $468.01 $468.01 $447.51 $447.51 $478.53 $478.53 $504.30 $504.30$500.01 $478.10 $478.10 $511.24 $511.24 $538.77 $538.77 $652.82 $652.82 $554.50 $554.50 $474.02 $474.02 $453.25 $453.25 $484.68 $484.68 $510.77 $510.77$506.35 $484.16 $484.16 $517.73 $517.73 $545.60 $545.60 $661.10 $661.10 $561.53 $561.53 $480.03 $480.03 $459.00 $459.00 $490.82 $490.82 $517.25 $517.25$515.86 $493.25 $493.25 $527.45 $527.45 $555.85 $555.85 $673.51 $673.51 $572.08 $572.08 $489.05 $489.05 $467.62 $467.62 $500.04 $500.04 $526.96 $526.96$524.97 $501.96 $501.96 $536.77 $536.77 $565.67 $565.67 $685.41 $685.41 $582.18 $582.18 $497.69 $497.69 $475.88 $475.88 $508.87 $508.87 $536.27 $536.27$537.65 $514.09 $514.09 $549.73 $549.73 $579.33 $579.33 $701.96 $701.96 $596.25 $596.25 $509.71 $509.71 $487.37 $487.37 $521.16 $521.16 $549.22 $549.22$553.50 $529.24 $529.24 $565.93 $565.93 $596.41 $596.41 $722.65 $722.65 $613.82 $613.82 $524.73 $524.73 $501.74 $501.74 $536.52 $536.52 $565.41 $565.41$572.12 $547.05 $547.05 $584.97 $584.97 $616.47 $616.47 $746.97 $746.97 $634.47 $634.47 $542.39 $542.39 $518.62 $518.62 $554.57 $554.57 $584.44 $584.44$594.30 $568.26 $568.26 $607.66 $607.66 $640.38 $640.38 $775.93 $775.93 $659.08 $659.08 $563.42 $563.42 $538.73 $538.73 $576.08 $576.08 $607.10 $607.10$619.27 $592.13 $592.13 $633.18 $633.18 $667.28 $667.28 $808.52 $808.52 $686.76 $686.76 $587.08 $587.08 $561.36 $561.36 $600.28 $600.28 $632.60 $632.60$647.79 $619.41 $619.41 $662.35 $662.35 $698.01 $698.01 $845.77 $845.77 $718.39 $718.39 $614.13 $614.13 $587.22 $587.22 $627.93 $627.93 $661.74 $661.74$675.92 $646.30 $646.30 $691.11 $691.11 $728.33 $728.33 $882.50 $882.50 $749.59 $749.59 $640.80 $640.80 $612.72 $612.72 $655.20 $655.20 $690.48 $690.48$707.62 $676.61 $676.61 $723.52 $723.52 $762.48 $762.48 $923.88 $923.88 $784.74 $784.74 $670.85 $670.85 $641.45 $641.45 $685.92 $685.92 $722.86 $722.86$738.92 $706.54 $706.54 $755.52 $755.52 $796.21 $796.21 $964.75 $964.75 $819.45 $819.45 $700.52 $700.52 $669.82 $669.82 $716.26 $716.26 $754.83 $754.83$773.39 $739.50 $739.50 $790.77 $790.77 $833.35 $833.35 $1,009.75 $1,009.75 $857.68 $857.68 $733.20 $733.20 $701.07 $701.07 $749.67 $749.67 $790.04 $790.04$808.25 $772.84 $772.84 $826.42 $826.42 $870.92 $870.92 $1,055.27 $1,055.27 $896.34 $896.34 $766.25 $766.25 $732.67 $732.67 $783.47 $783.47 $825.66 $825.66$845.89 $808.83 $808.83 $864.90 $864.90 $911.47 $911.47 $1,104.41 $1,104.41 $938.09 $938.09 $801.94 $801.94 $766.79 $766.79 $819.96 $819.96 $864.11 $864.11$883.53 $844.82 $844.82 $903.39 $903.39 $952.03 $952.03 $1,153.56 $1,153.56 $979.83 $979.83 $837.62 $837.62 $800.91 $800.91 $856.44 $856.44 $902.56 $902.56$924.34 $883.84 $883.84 $945.11 $945.11 $996.00 $996.00 $1,206.84 $1,206.84 $1,025.08 $1,025.08 $876.31 $876.31 $837.91 $837.91 $896.00 $896.00 $944.25 $944.25$965.55 $923.24 $923.24 $987.24 $987.24 $1,040.40 $1,040.40 $1,260.64 $1,260.64 $1,070.78 $1,070.78 $915.37 $915.37 $875.26 $875.26 $935.94 $935.94 $986.34 $986.34

$1,009.53 $965.29 $965.29 $1,032.21 $1,032.21 $1,087.79 $1,087.79 $1,318.05 $1,318.05 $1,119.55 $1,119.55 $957.06 $957.06 $915.13 $915.13 $978.57 $978.57 $1,031.26 $1,031.26$1,031.32 $986.12 $986.12 $1,054.49 $1,054.49 $1,111.27 $1,111.27 $1,346.51 $1,346.51 $1,143.72 $1,143.72 $977.72 $977.72 $934.88 $934.88 $999.69 $999.69 $1,053.52 $1,053.52$1,075.30 $1,028.18 $1,028.18 $1,099.46 $1,099.46 $1,158.66 $1,158.66 $1,403.92 $1,403.92 $1,192.49 $1,192.49 $1,019.42 $1,019.42 $974.74 $974.74 $1,042.32 $1,042.32 $1,098.45 $1,098.45$1,113.33 $1,064.54 $1,064.54 $1,138.35 $1,138.35 $1,199.65 $1,199.65 $1,453.58 $1,453.58 $1,234.67 $1,234.67 $1,055.47 $1,055.47 $1,009.22 $1,009.22 $1,079.19 $1,079.19 $1,137.30 $1,137.30$1,138.29 $1,088.41 $1,088.41 $1,163.87 $1,163.87 $1,226.54 $1,226.54 $1,486.17 $1,486.17 $1,262.35 $1,262.35 $1,079.14 $1,079.14 $1,031.85 $1,031.85 $1,103.39 $1,103.39 $1,162.80 $1,162.80$1,169.59 $1,118.34 $1,118.34 $1,195.87 $1,195.87 $1,260.27 $1,260.27 $1,527.04 $1,527.04 $1,297.06 $1,297.06 $1,108.81 $1,108.81 $1,060.22 $1,060.22 $1,133.73 $1,133.73 $1,194.78 $1,194.78$1,188.61 $1,136.52 $1,136.52 $1,215.32 $1,215.32 $1,280.76 $1,280.76 $1,551.87 $1,551.87 $1,318.15 $1,318.15 $1,126.84 $1,126.84 $1,077.46 $1,077.46 $1,152.16 $1,152.16 $1,214.20 $1,214.20

GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 3


old00 / Rx: $0%/ $40150es


l-Access PPO

Page Number: 40 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 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$375.16 $375.16 $318.66 $318.66 $251.01 $251.01 $240.01 $240.01 $256.66 $256.66 $270.48 $270.48 $327.73 $327.73 $278.37 $278.37 $248.93 $248.93 $238.03$408.51 $408.51 $346.99 $346.99 $273.33 $273.33 $261.35 $261.35 $279.47 $279.47 $294.52 $294.52 $356.86 $356.86 $303.12 $303.12 $271.06 $271.06 $259.18$421.26 $421.26 $357.82 $357.82 $281.86 $281.86 $269.51 $269.51 $288.19 $288.19 $303.71 $303.71 $368.00 $368.00 $312.58 $312.58 $279.52 $279.52 $267.27$434.01 $434.01 $368.65 $368.65 $290.39 $290.39 $277.66 $277.66 $296.91 $296.91 $312.90 $312.90 $379.14 $379.14 $322.04 $322.04 $287.98 $287.98 $275.36$447.74 $447.74 $380.31 $380.31 $299.58 $299.58 $286.45 $286.45 $306.31 $306.31 $322.80 $322.80 $391.13 $391.13 $332.23 $332.23 $297.09 $297.09 $284.07$461.47 $461.47 $391.97 $391.97 $308.76 $308.76 $295.23 $295.23 $315.70 $315.70 $332.70 $332.70 $403.13 $403.13 $342.42 $342.42 $306.20 $306.20 $292.79$475.70 $475.70 $404.05 $404.05 $318.28 $318.28 $304.33 $304.33 $325.43 $325.43 $342.96 $342.96 $415.55 $415.55 $352.97 $352.97 $315.64 $315.64 $301.81$490.41 $490.41 $416.56 $416.56 $328.13 $328.13 $313.75 $313.75 $335.50 $335.50 $353.57 $353.57 $428.41 $428.41 $363.89 $363.89 $325.41 $325.41 $311.15$490.41 $490.41 $416.56 $416.56 $328.13 $328.13 $313.75 $313.75 $335.50 $335.50 $353.57 $353.57 $428.41 $428.41 $363.89 $363.89 $325.41 $325.41 $311.15$490.41 $490.41 $416.56 $416.56 $328.13 $328.13 $313.75 $313.75 $335.50 $335.50 $353.57 $353.57 $428.41 $428.41 $363.89 $363.89 $325.41 $325.41 $311.15$490.41 $490.41 $416.56 $416.56 $328.13 $328.13 $313.75 $313.75 $335.50 $335.50 $353.57 $353.57 $428.41 $428.41 $363.89 $363.89 $325.41 $325.41 $311.15$492.37 $492.37 $418.22 $418.22 $329.44 $329.44 $315.00 $315.00 $336.84 $336.84 $354.98 $354.98 $430.12 $430.12 $365.34 $365.34 $326.71 $326.71 $312.39$502.18 $502.18 $426.55 $426.55 $336.00 $336.00 $321.27 $321.27 $343.55 $343.55 $362.05 $362.05 $438.69 $438.69 $372.62 $372.62 $333.21 $333.21 $318.61$513.95 $513.95 $436.55 $436.55 $343.87 $343.87 $328.80 $328.80 $351.60 $351.60 $370.53 $370.53 $448.97 $448.97 $381.35 $381.35 $341.02 $341.02 $326.08$533.07 $533.07 $452.79 $452.79 $356.67 $356.67 $341.04 $341.04 $364.69 $364.69 $384.32 $384.32 $465.67 $465.67 $395.54 $395.54 $353.71 $353.71 $338.21$548.77 $548.77 $466.12 $466.12 $367.17 $367.17 $351.08 $351.08 $375.42 $375.42 $395.64 $395.64 $479.38 $479.38 $407.19 $407.19 $364.13 $364.13 $348.17$556.61 $556.61 $472.79 $472.79 $372.42 $372.42 $356.10 $356.10 $380.79 $380.79 $401.29 $401.29 $486.24 $486.24 $413.01 $413.01 $369.33 $369.33 $353.15$568.38 $568.38 $482.78 $482.78 $380.30 $380.30 $363.63 $363.63 $388.84 $388.84 $409.78 $409.78 $496.52 $496.52 $421.74 $421.74 $377.14 $377.14 $360.62$580.15 $580.15 $492.78 $492.78 $388.17 $388.17 $371.16 $371.16 $396.89 $396.89 $418.26 $418.26 $506.80 $506.80 $430.48 $430.48 $384.95 $384.95 $368.08$587.51 $587.51 $499.03 $499.03 $393.09 $393.09 $375.87 $375.87 $401.93 $401.93 $423.57 $423.57 $513.23 $513.23 $435.93 $435.93 $389.83 $389.83 $372.75$595.36 $595.36 $505.69 $505.69 $398.34 $398.34 $380.89 $380.89 $407.29 $407.29 $429.22 $429.22 $520.08 $520.08 $441.76 $441.76 $395.04 $395.04 $377.73$599.28 $599.28 $509.03 $509.03 $400.97 $400.97 $383.40 $383.40 $409.98 $409.98 $432.05 $432.05 $523.51 $523.51 $444.67 $444.67 $397.64 $397.64 $380.22$603.20 $603.20 $512.36 $512.36 $403.59 $403.59 $385.91 $385.91 $412.66 $412.66 $434.88 $434.88 $526.94 $526.94 $447.58 $447.58 $400.25 $400.25 $382.71$607.13 $607.13 $515.69 $515.69 $406.22 $406.22 $388.42 $388.42 $415.35 $415.35 $437.71 $437.71 $530.36 $530.36 $450.49 $450.49 $402.85 $402.85 $385.20$611.05 $611.05 $519.02 $519.02 $408.84 $408.84 $390.93 $390.93 $418.03 $418.03 $440.54 $440.54 $533.79 $533.79 $453.40 $453.40 $405.45 $405.45 $387.69$618.90 $618.90 $525.69 $525.69 $414.09 $414.09 $395.95 $395.95 $423.40 $423.40 $446.20 $446.20 $540.65 $540.65 $459.22 $459.22 $410.66 $410.66 $392.66$626.74 $626.74 $532.35 $532.35 $419.34 $419.34 $400.97 $400.97 $428.77 $428.77 $451.85 $451.85 $547.50 $547.50 $465.05 $465.05 $415.87 $415.87 $397.64$638.51 $638.51 $542.35 $542.35 $427.22 $427.22 $408.50 $408.50 $436.82 $436.82 $460.34 $460.34 $557.78 $557.78 $473.78 $473.78 $423.68 $423.68 $405.11$649.79 $649.79 $551.93 $551.93 $434.76 $434.76 $415.71 $415.71 $444.53 $444.53 $468.47 $468.47 $567.64 $567.64 $482.15 $482.15 $431.16 $431.16 $412.27$665.48 $665.48 $565.26 $565.26 $445.26 $445.26 $425.75 $425.75 $455.27 $455.27 $479.78 $479.78 $581.34 $581.34 $493.79 $493.79 $441.57 $441.57 $422.22$685.10 $685.10 $581.92 $581.92 $458.39 $458.39 $438.30 $438.30 $468.69 $468.69 $493.93 $493.93 $598.48 $598.48 $508.35 $508.35 $454.59 $454.59 $434.67$708.15 $708.15 $601.50 $601.50 $473.81 $473.81 $453.05 $453.05 $484.46 $484.46 $510.54 $510.54 $618.62 $618.62 $525.45 $525.45 $469.88 $469.88 $449.29$735.61 $735.61 $624.83 $624.83 $492.19 $492.19 $470.62 $470.62 $503.25 $503.25 $530.34 $530.34 $642.61 $642.61 $545.83 $545.83 $488.11 $488.11 $466.72$766.51 $766.51 $651.07 $651.07 $512.86 $512.86 $490.38 $490.38 $524.38 $524.38 $552.62 $552.62 $669.60 $669.60 $568.75 $568.75 $508.61 $508.61 $486.32$801.82 $801.82 $681.06 $681.06 $536.48 $536.48 $512.97 $512.97 $548.54 $548.54 $578.07 $578.07 $700.44 $700.44 $594.95 $594.95 $532.03 $532.03 $508.72$836.64 $836.64 $710.64 $710.64 $559.78 $559.78 $535.25 $535.25 $572.36 $572.36 $603.18 $603.18 $730.86 $730.86 $620.79 $620.79 $555.14 $555.14 $530.81$875.87 $875.87 $743.96 $743.96 $586.03 $586.03 $560.35 $560.35 $599.20 $599.20 $631.46 $631.46 $765.13 $765.13 $649.90 $649.90 $581.17 $581.17 $555.70$914.61 $914.61 $776.87 $776.87 $611.95 $611.95 $585.13 $585.13 $625.70 $625.70 $659.39 $659.39 $798.97 $798.97 $678.65 $678.65 $606.88 $606.88 $580.28$957.28 $957.28 $813.11 $813.11 $640.50 $640.50 $612.43 $612.43 $654.89 $654.89 $690.15 $690.15 $836.24 $836.24 $710.30 $710.30 $635.19 $635.19 $607.35

$1,000.43 $1,000.43 $849.77 $849.77 $669.37 $669.37 $640.04 $640.04 $684.41 $684.41 $721.27 $721.27 $873.94 $873.94 $742.33 $742.33 $663.82 $663.82 $634.73$1,047.02 $1,047.02 $889.34 $889.34 $700.54 $700.54 $669.85 $669.85 $716.29 $716.29 $754.86 $754.86 $914.64 $914.64 $776.89 $776.89 $694.74 $694.74 $664.29$1,093.61 $1,093.61 $928.91 $928.91 $731.72 $731.72 $699.65 $699.65 $748.16 $748.16 $788.44 $788.44 $955.34 $955.34 $811.46 $811.46 $725.65 $725.65 $693.85$1,144.12 $1,144.12 $971.81 $971.81 $765.51 $765.51 $731.97 $731.97 $782.71 $782.71 $824.86 $824.86 $999.47 $999.47 $848.94 $848.94 $759.17 $759.17 $725.90$1,195.12 $1,195.12 $1,015.14 $1,015.14 $799.64 $799.64 $764.60 $764.60 $817.61 $817.61 $861.63 $861.63 $1,044.02 $1,044.02 $886.79 $886.79 $793.01 $793.01 $758.26$1,249.56 $1,249.56 $1,061.37 $1,061.37 $836.06 $836.06 $799.42 $799.42 $854.85 $854.85 $900.88 $900.88 $1,091.57 $1,091.57 $927.18 $927.18 $829.13 $829.13 $792.80$1,276.53 $1,276.53 $1,084.28 $1,084.28 $854.11 $854.11 $816.68 $816.68 $873.30 $873.30 $920.32 $920.32 $1,115.14 $1,115.14 $947.19 $947.19 $847.03 $847.03 $809.91$1,330.97 $1,330.97 $1,130.52 $1,130.52 $890.53 $890.53 $851.50 $851.50 $910.54 $910.54 $959.57 $959.57 $1,162.69 $1,162.69 $987.58 $987.58 $883.15 $883.15 $844.45$1,378.05 $1,378.05 $1,170.51 $1,170.51 $922.03 $922.03 $881.62 $881.62 $942.75 $942.75 $993.51 $993.51 $1,203.81 $1,203.81 $1,022.52 $1,022.52 $914.38 $914.38 $874.32$1,408.94 $1,408.94 $1,196.75 $1,196.75 $942.70 $942.70 $901.39 $901.39 $963.88 $963.88 $1,015.78 $1,015.78 $1,230.80 $1,230.80 $1,045.44 $1,045.44 $934.88 $934.88 $893.92$1,447.68 $1,447.68 $1,229.66 $1,229.66 $968.62 $968.62 $926.18 $926.18 $990.39 $990.39 $1,043.72 $1,043.72 $1,264.65 $1,264.65 $1,074.19 $1,074.19 $960.59 $960.59 $918.50$1,471.22 $1,471.22 $1,249.65 $1,249.65 $984.37 $984.37 $941.23 $941.23 $1,006.49 $1,006.49 $1,060.69 $1,060.69 $1,285.21 $1,285.21 $1,091.66 $1,091.66 $976.21 $976.21 $933.43

SilMed: $6,75

0$25 /$7,3

Y

75729PAGeisinger Al

25/50M-152-121-

Rating

Geisinger Al

SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 7


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 5


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 7


Page Number: 41 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$238.03 $254.53 $254.53 $268.23 $268.23 $325.01 $325.01 $276.06 $276.06 $301.41 $301.41 $288.20 $288.20 $308.18 $308.18 $324.77 $324.77 $393.52 $393.52$259.18 $277.15 $277.15 $292.08 $292.08 $353.90 $353.90 $300.60 $300.60 $328.20 $328.20 $313.82 $313.82 $335.57 $335.57 $353.64 $353.64 $428.50 $428.50$267.27 $285.80 $285.80 $301.19 $301.19 $364.95 $364.95 $309.99 $309.99 $338.44 $338.44 $323.61 $323.61 $346.05 $346.05 $364.68 $364.68 $441.87 $441.87$275.36 $294.45 $294.45 $310.31 $310.31 $375.99 $375.99 $319.37 $319.37 $348.68 $348.68 $333.41 $333.41 $356.52 $356.52 $375.72 $375.72 $455.25 $455.25$284.07 $303.77 $303.77 $320.13 $320.13 $387.89 $387.89 $329.47 $329.47 $359.72 $359.72 $343.95 $343.95 $367.80 $367.80 $387.60 $387.60 $469.65 $469.65$292.79 $313.09 $313.09 $329.94 $329.94 $399.79 $399.79 $339.58 $339.58 $370.75 $370.75 $354.50 $354.50 $379.08 $379.08 $399.49 $399.49 $484.06 $484.06$301.81 $322.73 $322.73 $340.11 $340.11 $412.11 $412.11 $350.04 $350.04 $382.17 $382.17 $365.43 $365.43 $390.76 $390.76 $411.80 $411.80 $498.97 $498.97$311.15 $332.72 $332.72 $350.64 $350.64 $424.86 $424.86 $360.87 $360.87 $394.00 $394.00 $376.73 $376.73 $402.85 $402.85 $424.54 $424.54 $514.41 $514.41$311.15 $332.72 $332.72 $350.64 $350.64 $424.86 $424.86 $360.87 $360.87 $394.00 $394.00 $376.73 $376.73 $402.85 $402.85 $424.54 $424.54 $514.41 $514.41$311.15 $332.72 $332.72 $350.64 $350.64 $424.86 $424.86 $360.87 $360.87 $394.00 $394.00 $376.73 $376.73 $402.85 $402.85 $424.54 $424.54 $514.41 $514.41$311.15 $332.72 $332.72 $350.64 $350.64 $424.86 $424.86 $360.87 $360.87 $394.00 $394.00 $376.73 $376.73 $402.85 $402.85 $424.54 $424.54 $514.41 $514.41$312.39 $334.05 $334.05 $352.03 $352.03 $426.55 $426.55 $362.31 $362.31 $395.57 $395.57 $378.24 $378.24 $404.46 $404.46 $426.24 $426.24 $516.46 $516.46$318.61 $340.70 $340.70 $359.05 $359.05 $435.05 $435.05 $369.53 $369.53 $403.45 $403.45 $385.77 $385.77 $412.52 $412.52 $434.73 $434.73 $526.75 $526.75$326.08 $348.69 $348.69 $367.46 $367.46 $445.25 $445.25 $378.19 $378.19 $412.91 $412.91 $394.81 $394.81 $422.18 $422.18 $444.92 $444.92 $539.10 $539.10$338.21 $361.66 $361.66 $381.14 $381.14 $461.81 $461.81 $392.26 $392.26 $428.27 $428.27 $409.50 $409.50 $437.90 $437.90 $461.47 $461.47 $559.16 $559.16$348.17 $372.31 $372.31 $392.36 $392.36 $475.41 $475.41 $403.81 $403.81 $440.88 $440.88 $421.56 $421.56 $450.79 $450.79 $475.06 $475.06 $575.62 $575.62$353.15 $377.63 $377.63 $397.97 $397.97 $482.21 $482.21 $409.59 $409.59 $447.18 $447.18 $427.59 $427.59 $457.23 $457.23 $481.85 $481.85 $583.85 $583.85$360.62 $385.62 $385.62 $406.38 $406.38 $492.40 $492.40 $418.25 $418.25 $456.64 $456.64 $436.63 $436.63 $466.90 $466.90 $492.04 $492.04 $596.20 $596.20$368.08 $393.60 $393.60 $414.80 $414.80 $502.60 $502.60 $426.91 $426.91 $466.10 $466.10 $445.67 $445.67 $476.57 $476.57 $502.23 $502.23 $608.54 $608.54$372.75 $398.59 $398.59 $420.06 $420.06 $508.97 $508.97 $432.32 $432.32 $472.00 $472.00 $451.32 $451.32 $482.61 $482.61 $508.60 $508.60 $616.26 $616.26$377.73 $403.92 $403.92 $425.67 $425.67 $515.77 $515.77 $438.09 $438.09 $478.31 $478.31 $457.35 $457.35 $489.06 $489.06 $515.39 $515.39 $624.49 $624.49$380.22 $406.58 $406.58 $428.47 $428.47 $519.17 $519.17 $440.98 $440.98 $481.46 $481.46 $460.36 $460.36 $492.28 $492.28 $518.79 $518.79 $628.60 $628.60$382.71 $409.24 $409.24 $431.28 $431.28 $522.57 $522.57 $443.87 $443.87 $484.61 $484.61 $463.38 $463.38 $495.50 $495.50 $522.18 $522.18 $632.72 $632.72$385.20 $411.90 $411.90 $434.08 $434.08 $525.97 $525.97 $446.76 $446.76 $487.76 $487.76 $466.39 $466.39 $498.73 $498.73 $525.58 $525.58 $636.83 $636.83$387.69 $414.56 $414.56 $436.89 $436.89 $529.37 $529.37 $449.64 $449.64 $490.92 $490.92 $469.40 $469.40 $501.95 $501.95 $528.98 $528.98 $640.95 $640.95$392.66 $419.89 $419.89 $442.50 $442.50 $536.16 $536.16 $455.42 $455.42 $497.22 $497.22 $475.43 $475.43 $508.39 $508.39 $535.77 $535.77 $649.18 $649.18$397.64 $425.21 $425.21 $448.11 $448.11 $542.96 $542.96 $461.19 $461.19 $503.52 $503.52 $481.46 $481.46 $514.84 $514.84 $542.56 $542.56 $657.41 $657.41$405.11 $433.20 $433.20 $456.52 $456.52 $553.16 $553.16 $469.85 $469.85 $512.98 $512.98 $490.50 $490.50 $524.51 $524.51 $552.75 $552.75 $669.76 $669.76$412.27 $440.85 $440.85 $464.59 $464.59 $562.93 $562.93 $478.15 $478.15 $522.04 $522.04 $499.17 $499.17 $533.77 $533.77 $562.52 $562.52 $681.59 $681.59$422.22 $451.50 $451.50 $475.81 $475.81 $576.53 $576.53 $489.70 $489.70 $534.65 $534.65 $511.22 $511.22 $546.66 $546.66 $576.10 $576.10 $698.05 $698.05$434.67 $464.80 $464.80 $489.83 $489.83 $593.52 $593.52 $504.13 $504.13 $550.41 $550.41 $526.29 $526.29 $562.78 $562.78 $593.08 $593.08 $718.62 $718.62$449.29 $480.44 $480.44 $506.31 $506.31 $613.49 $613.49 $521.09 $521.09 $568.93 $568.93 $544.00 $544.00 $581.71 $581.71 $613.04 $613.04 $742.80 $742.80$466.72 $499.07 $499.07 $525.95 $525.95 $637.28 $637.28 $541.30 $541.30 $590.99 $590.99 $565.09 $565.09 $604.27 $604.27 $636.81 $636.81 $771.61 $771.61$486.32 $520.04 $520.04 $548.04 $548.04 $664.04 $664.04 $564.04 $564.04 $615.81 $615.81 $588.83 $588.83 $629.65 $629.65 $663.56 $663.56 $804.02 $804.02$508.72 $543.99 $543.99 $573.28 $573.28 $694.63 $694.63 $590.02 $590.02 $644.18 $644.18 $615.95 $615.95 $658.66 $658.66 $694.12 $694.12 $841.05 $841.05$530.81 $567.61 $567.61 $598.18 $598.18 $724.80 $724.80 $615.64 $615.64 $672.15 $672.15 $642.70 $642.70 $687.26 $687.26 $724.26 $724.26 $877.58 $877.58$555.70 $594.23 $594.23 $626.23 $626.23 $758.79 $758.79 $644.51 $644.51 $703.67 $703.67 $672.84 $672.84 $719.49 $719.49 $758.23 $758.23 $918.73 $918.73$580.28 $620.52 $620.52 $653.93 $653.93 $792.35 $792.35 $673.02 $673.02 $734.80 $734.80 $702.60 $702.60 $751.31 $751.31 $791.77 $791.77 $959.37 $959.37$607.35 $649.46 $649.46 $684.43 $684.43 $829.31 $829.31 $704.42 $704.42 $769.08 $769.08 $735.38 $735.38 $786.36 $786.36 $828.70 $828.70 $1,004.12 $1,004.12$634.73 $678.74 $678.74 $715.29 $715.29 $866.70 $866.70 $736.17 $736.17 $803.75 $803.75 $768.53 $768.53 $821.81 $821.81 $866.06 $866.06 $1,049.39 $1,049.39$664.29 $710.35 $710.35 $748.60 $748.60 $907.06 $907.06 $770.46 $770.46 $841.18 $841.18 $804.32 $804.32 $860.08 $860.08 $906.39 $906.39 $1,098.26 $1,098.26$693.85 $741.96 $741.96 $781.91 $781.91 $947.42 $947.42 $804.74 $804.74 $878.61 $878.61 $840.11 $840.11 $898.35 $898.35 $946.72 $946.72 $1,147.12 $1,147.12$725.90 $776.23 $776.23 $818.02 $818.02 $991.18 $991.18 $841.91 $841.91 $919.19 $919.19 $878.91 $878.91 $939.84 $939.84 $990.45 $990.45 $1,200.11 $1,200.11$758.26 $810.83 $810.83 $854.49 $854.49 $1,035.37 $1,035.37 $879.44 $879.44 $960.16 $960.16 $918.09 $918.09 $981.74 $981.74 $1,034.60 $1,034.60 $1,253.61 $1,253.61$792.80 $847.76 $847.76 $893.41 $893.41 $1,082.52 $1,082.52 $919.49 $919.49 $1,003.90 $1,003.90 $959.91 $959.91 $1,026.46 $1,026.46 $1,081.73 $1,081.73 $1,310.71 $1,310.71$809.91 $866.06 $866.06 $912.69 $912.69 $1,105.89 $1,105.89 $939.34 $939.34 $1,025.57 $1,025.57 $980.63 $980.63 $1,048.61 $1,048.61 $1,105.08 $1,105.08 $1,339.00 $1,339.00$844.45 $902.99 $902.99 $951.61 $951.61 $1,153.05 $1,153.05 $979.40 $979.40 $1,069.30 $1,069.30 $1,022.44 $1,022.44 $1,093.33 $1,093.33 $1,152.20 $1,152.20 $1,396.10 $1,396.10$874.32 $934.93 $934.93 $985.27 $985.27 $1,193.84 $1,193.84 $1,014.04 $1,014.04 $1,107.12 $1,107.12 $1,058.61 $1,058.61 $1,132.00 $1,132.00 $1,192.96 $1,192.96 $1,445.48 $1,445.48$893.92 $955.89 $955.89 $1,007.36 $1,007.36 $1,220.60 $1,220.60 $1,036.78 $1,036.78 $1,131.95 $1,131.95 $1,082.34 $1,082.34 $1,157.38 $1,157.38 $1,219.70 $1,219.70 $1,477.89 $1,477.89$918.50 $982.18 $982.18 $1,035.06 $1,035.06 $1,254.17 $1,254.17 $1,065.29 $1,065.29 $1,163.07 $1,163.07 $1,112.10 $1,112.10 $1,189.21 $1,189.21 $1,253.24 $1,253.24 $1,518.53 $1,518.53$933.43 $998.15 $998.15 $1,051.89 $1,051.89 $1,274.56 $1,274.56 $1,082.61 $1,082.61 $1,181.98 $1,181.98 $1,130.19 $1,130.19 $1,208.54 $1,208.54 $1,273.62 $1,273.62 $1,543.22 $1,543.22



$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 7




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 6




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 5




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 3




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 2


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 7


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 5


ver0 / Rx: $500%/ $50350es


l-Access PPO

Page Number: 42 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$334.26 $334.26 $262.28 $262.28 $250.79 $250.79 $268.18 $268.18 $282.62 $282.62 $342.44 $342.44 $290.87 $290.87 $344.04 $344.04 $328.96 $328.96 $351.77$363.97 $363.97 $285.60 $285.60 $273.08 $273.08 $292.01 $292.01 $307.74 $307.74 $372.88 $372.88 $316.72 $316.72 $374.62 $374.62 $358.20 $358.20 $383.04$375.33 $375.33 $294.51 $294.51 $281.60 $281.60 $301.13 $301.13 $317.34 $317.34 $384.52 $384.52 $326.61 $326.61 $386.31 $386.31 $369.38 $369.38 $394.99$386.69 $386.69 $303.42 $303.42 $290.13 $290.13 $310.24 $310.24 $326.95 $326.95 $396.16 $396.16 $336.49 $336.49 $398.01 $398.01 $380.57 $380.57 $406.95$398.92 $398.92 $313.02 $313.02 $299.31 $299.31 $320.06 $320.06 $337.29 $337.29 $408.69 $408.69 $347.14 $347.14 $410.60 $410.60 $392.61 $392.61 $419.83$411.16 $411.16 $322.62 $322.62 $308.49 $308.49 $329.87 $329.87 $347.64 $347.64 $421.22 $421.22 $357.79 $357.79 $423.19 $423.19 $404.65 $404.65 $432.70$423.83 $423.83 $332.57 $332.57 $317.99 $317.99 $340.04 $340.04 $358.35 $358.35 $434.20 $434.20 $368.81 $368.81 $436.23 $436.23 $417.12 $417.12 $446.04$436.94 $436.94 $342.86 $342.86 $327.83 $327.83 $350.56 $350.56 $369.44 $369.44 $447.64 $447.64 $380.22 $380.22 $449.73 $449.73 $430.02 $430.02 $459.84$436.94 $436.94 $342.86 $342.86 $327.83 $327.83 $350.56 $350.56 $369.44 $369.44 $447.64 $447.64 $380.22 $380.22 $449.73 $449.73 $430.02 $430.02 $459.84$436.94 $436.94 $342.86 $342.86 $327.83 $327.83 $350.56 $350.56 $369.44 $369.44 $447.64 $447.64 $380.22 $380.22 $449.73 $449.73 $430.02 $430.02 $459.84$436.94 $436.94 $342.86 $342.86 $327.83 $327.83 $350.56 $350.56 $369.44 $369.44 $447.64 $447.64 $380.22 $380.22 $449.73 $449.73 $430.02 $430.02 $459.84$438.68 $438.68 $344.22 $344.22 $329.14 $329.14 $351.96 $351.96 $370.91 $370.91 $449.42 $449.42 $381.74 $381.74 $451.52 $451.52 $431.74 $431.74 $461.67$447.42 $447.42 $351.08 $351.08 $335.70 $335.70 $358.97 $358.97 $378.30 $378.30 $458.38 $458.38 $389.34 $389.34 $460.52 $460.52 $440.34 $440.34 $470.87$457.91 $457.91 $359.31 $359.31 $343.56 $343.56 $367.38 $367.38 $387.17 $387.17 $469.12 $469.12 $398.47 $398.47 $471.31 $471.31 $450.66 $450.66 $481.90$474.95 $474.95 $372.68 $372.68 $356.35 $356.35 $381.05 $381.05 $401.57 $401.57 $486.58 $486.58 $413.30 $413.30 $488.85 $488.85 $467.43 $467.43 $499.84$488.93 $488.93 $383.65 $383.65 $366.84 $366.84 $392.27 $392.27 $413.40 $413.40 $500.90 $500.90 $425.47 $425.47 $503.24 $503.24 $481.19 $481.19 $514.55$495.92 $495.92 $389.14 $389.14 $372.08 $372.08 $397.88 $397.88 $419.31 $419.31 $508.06 $508.06 $431.55 $431.55 $510.44 $510.44 $488.07 $488.07 $521.91$506.41 $506.41 $397.37 $397.37 $379.95 $379.95 $406.30 $406.30 $428.17 $428.17 $518.81 $518.81 $440.67 $440.67 $521.23 $521.23 $498.39 $498.39 $532.94$516.89 $516.89 $405.59 $405.59 $387.82 $387.82 $414.71 $414.71 $437.04 $437.04 $529.55 $529.55 $449.80 $449.80 $532.02 $532.02 $508.71 $508.71 $543.98$523.45 $523.45 $410.74 $410.74 $392.74 $392.74 $419.97 $419.97 $442.58 $442.58 $536.27 $536.27 $455.50 $455.50 $538.77 $538.77 $515.16 $515.16 $550.88$530.44 $530.44 $416.22 $416.22 $397.98 $397.98 $425.58 $425.58 $448.49 $448.49 $543.43 $543.43 $461.59 $461.59 $545.97 $545.97 $522.04 $522.04 $558.23$533.93 $533.93 $418.97 $418.97 $400.61 $400.61 $428.38 $428.38 $451.45 $451.45 $547.01 $547.01 $464.63 $464.63 $549.56 $549.56 $525.48 $525.48 $561.91$537.43 $537.43 $421.71 $421.71 $403.23 $403.23 $431.18 $431.18 $454.40 $454.40 $550.59 $550.59 $467.67 $467.67 $553.16 $553.16 $528.92 $528.92 $565.59$540.93 $540.93 $424.45 $424.45 $405.85 $405.85 $433.99 $433.99 $457.36 $457.36 $554.17 $554.17 $470.71 $470.71 $556.76 $556.76 $532.36 $532.36 $569.27$544.42 $544.42 $427.19 $427.19 $408.47 $408.47 $436.79 $436.79 $460.31 $460.31 $557.75 $557.75 $473.75 $473.75 $560.36 $560.36 $535.80 $535.80 $572.95$551.41 $551.41 $432.68 $432.68 $413.72 $413.72 $442.40 $442.40 $466.22 $466.22 $564.91 $564.91 $479.84 $479.84 $567.55 $567.55 $542.68 $542.68 $580.31$558.40 $558.40 $438.16 $438.16 $418.96 $418.96 $448.01 $448.01 $472.13 $472.13 $572.08 $572.08 $485.92 $485.92 $574.75 $574.75 $549.56 $549.56 $587.66$568.89 $568.89 $446.39 $446.39 $426.83 $426.83 $456.42 $456.42 $481.00 $481.00 $582.82 $582.82 $495.05 $495.05 $585.54 $585.54 $559.88 $559.88 $598.70$578.94 $578.94 $454.28 $454.28 $434.37 $434.37 $464.49 $464.49 $489.50 $489.50 $593.11 $593.11 $503.79 $503.79 $595.88 $595.88 $569.77 $569.77 $609.28$592.92 $592.92 $465.25 $465.25 $444.86 $444.86 $475.71 $475.71 $501.32 $501.32 $607.44 $607.44 $515.96 $515.96 $610.28 $610.28 $583.53 $583.53 $623.99$610.40 $610.40 $478.96 $478.96 $457.98 $457.98 $489.73 $489.73 $516.10 $516.10 $625.34 $625.34 $531.17 $531.17 $628.26 $628.26 $600.73 $600.73 $642.38$630.93 $630.93 $495.08 $495.08 $473.38 $473.38 $506.20 $506.20 $533.46 $533.46 $646.38 $646.38 $549.04 $549.04 $649.40 $649.40 $620.94 $620.94 $663.99$655.40 $655.40 $514.28 $514.28 $491.74 $491.74 $525.83 $525.83 $554.15 $554.15 $671.45 $671.45 $570.33 $570.33 $674.59 $674.59 $645.03 $645.03 $689.75$682.93 $682.93 $535.88 $535.88 $512.40 $512.40 $547.92 $547.92 $577.42 $577.42 $699.65 $699.65 $594.28 $594.28 $702.92 $702.92 $672.12 $672.12 $718.71$714.39 $714.39 $560.56 $560.56 $536.00 $536.00 $573.16 $573.16 $604.02 $604.02 $731.88 $731.88 $621.66 $621.66 $735.30 $735.30 $703.08 $703.08 $751.82$745.41 $745.41 $584.91 $584.91 $559.27 $559.27 $598.05 $598.05 $630.25 $630.25 $763.66 $763.66 $648.65 $648.65 $767.23 $767.23 $733.61 $733.61 $784.47$780.37 $780.37 $612.33 $612.33 $585.50 $585.50 $626.09 $626.09 $659.81 $659.81 $799.47 $799.47 $679.07 $679.07 $803.21 $803.21 $768.01 $768.01 $821.26$814.88 $814.88 $639.42 $639.42 $611.40 $611.40 $653.79 $653.79 $688.99 $688.99 $834.84 $834.84 $709.11 $709.11 $838.74 $838.74 $801.98 $801.98 $857.58$852.90 $852.90 $669.25 $669.25 $639.92 $639.92 $684.29 $684.29 $721.13 $721.13 $873.78 $873.78 $742.19 $742.19 $877.86 $877.86 $839.39 $839.39 $897.59$891.35 $891.35 $699.42 $699.42 $668.77 $668.77 $715.14 $715.14 $753.64 $753.64 $913.17 $913.17 $775.65 $775.65 $917.44 $917.44 $877.23 $877.23 $938.05$932.86 $932.86 $731.99 $731.99 $699.91 $699.91 $748.44 $748.44 $788.74 $788.74 $955.70 $955.70 $811.77 $811.77 $960.16 $960.16 $918.09 $918.09 $981.74$974.37 $974.37 $764.56 $764.56 $731.06 $731.06 $781.74 $781.74 $823.83 $823.83 $998.22 $998.22 $847.89 $847.89 $1,002.88 $1,002.88 $958.94 $958.94 $1,025.42

$1,019.37 $1,019.37 $799.87 $799.87 $764.82 $764.82 $817.85 $817.85 $861.89 $861.89 $1,044.33 $1,044.33 $887.05 $887.05 $1,049.21 $1,049.21 $1,003.23 $1,003.23 $1,072.78$1,064.81 $1,064.81 $835.53 $835.53 $798.92 $798.92 $854.31 $854.31 $900.31 $900.31 $1,090.88 $1,090.88 $926.59 $926.59 $1,095.98 $1,095.98 $1,047.95 $1,047.95 $1,120.61$1,113.31 $1,113.31 $873.59 $873.59 $835.31 $835.31 $893.22 $893.22 $941.31 $941.31 $1,140.57 $1,140.57 $968.80 $968.80 $1,145.90 $1,145.90 $1,095.68 $1,095.68 $1,171.65$1,137.34 $1,137.34 $892.44 $892.44 $853.34 $853.34 $912.50 $912.50 $961.63 $961.63 $1,165.19 $1,165.19 $989.71 $989.71 $1,170.63 $1,170.63 $1,119.33 $1,119.33 $1,196.94$1,185.84 $1,185.84 $930.50 $930.50 $889.73 $889.73 $951.41 $951.41 $1,002.64 $1,002.64 $1,214.88 $1,214.88 $1,031.91 $1,031.91 $1,220.55 $1,220.55 $1,167.07 $1,167.07 $1,247.98$1,227.79 $1,227.79 $963.41 $963.41 $921.20 $921.20 $985.06 $985.06 $1,038.11 $1,038.11 $1,257.85 $1,257.85 $1,068.42 $1,068.42 $1,263.72 $1,263.72 $1,208.35 $1,208.35 $1,292.12$1,255.31 $1,255.31 $985.01 $985.01 $941.85 $941.85 $1,007.15 $1,007.15 $1,061.38 $1,061.38 $1,286.05 $1,286.05 $1,092.37 $1,092.37 $1,292.06 $1,292.06 $1,235.44 $1,235.44 $1,321.09$1,289.83 $1,289.83 $1,012.10 $1,012.10 $967.75 $967.75 $1,034.84 $1,034.84 $1,090.57 $1,090.57 $1,321.41 $1,321.41 $1,122.41 $1,122.41 $1,327.59 $1,327.59 $1,269.41 $1,269.41 $1,357.42$1,310.81 $1,310.81 $1,028.56 $1,028.56 $983.48 $983.48 $1,051.67 $1,051.67 $1,108.30 $1,108.30 $1,342.90 $1,342.90 $1,140.66 $1,140.66 $1,349.17 $1,349.17 $1,290.05 $1,290.05 $1,379.49

PlatiMed: $25

0$15 /$7,3

Y

75729PAGeisinger Al

15/30M-152-121-

Rating

Geisinger Al


0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 3



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 2




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 9




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 7




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 6




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 5




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 3




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 2




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 9


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Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$351.77 $370.71 $370.71 $449.18 $449.18 $381.54 $381.54 $324.15 $324.15 $365.29 $365.29 $375.96 $375.96 $280.36 $280.36 $268.07 $268.07 $286.66 $286.66$383.04 $403.66 $403.66 $489.11 $489.11 $415.45 $415.45 $352.97 $352.97 $397.76 $397.76 $409.38 $409.38 $305.28 $305.28 $291.90 $291.90 $312.14 $312.14$394.99 $416.26 $416.26 $504.38 $504.38 $428.42 $428.42 $363.98 $363.98 $410.18 $410.18 $422.15 $422.15 $314.81 $314.81 $301.01 $301.01 $321.88 $321.88$406.95 $428.86 $428.86 $519.64 $519.64 $441.38 $441.38 $375.00 $375.00 $422.59 $422.59 $434.93 $434.93 $324.33 $324.33 $310.12 $310.12 $331.62 $331.62$419.83 $442.43 $442.43 $536.08 $536.08 $455.35 $455.35 $386.87 $386.87 $435.96 $435.96 $448.69 $448.69 $334.60 $334.60 $319.93 $319.93 $342.12 $342.12$432.70 $456.00 $456.00 $552.52 $552.52 $469.31 $469.31 $398.73 $398.73 $449.33 $449.33 $462.45 $462.45 $344.86 $344.86 $329.75 $329.75 $352.61 $352.61$446.04 $470.05 $470.05 $569.55 $569.55 $483.78 $483.78 $411.02 $411.02 $463.18 $463.18 $476.70 $476.70 $355.49 $355.49 $339.91 $339.91 $363.47 $363.47$459.84 $484.60 $484.60 $587.17 $587.17 $498.74 $498.74 $423.73 $423.73 $477.51 $477.51 $491.45 $491.45 $366.48 $366.48 $350.43 $350.43 $374.72 $374.72$459.84 $484.60 $484.60 $587.17 $587.17 $498.74 $498.74 $423.73 $423.73 $477.51 $477.51 $491.45 $491.45 $366.48 $366.48 $350.43 $350.43 $374.72 $374.72$459.84 $484.60 $484.60 $587.17 $587.17 $498.74 $498.74 $423.73 $423.73 $477.51 $477.51 $491.45 $491.45 $366.48 $366.48 $350.43 $350.43 $374.72 $374.72$459.84 $484.60 $484.60 $587.17 $587.17 $498.74 $498.74 $423.73 $423.73 $477.51 $477.51 $491.45 $491.45 $366.48 $366.48 $350.43 $350.43 $374.72 $374.72$461.67 $486.53 $486.53 $589.52 $589.52 $500.73 $500.73 $425.42 $425.42 $479.42 $479.42 $493.41 $493.41 $367.95 $367.95 $351.82 $351.82 $376.21 $376.21$470.87 $496.22 $496.22 $601.26 $601.26 $510.71 $510.71 $433.90 $433.90 $488.97 $488.97 $503.24 $503.24 $375.28 $375.28 $358.83 $358.83 $383.71 $383.71$481.90 $507.85 $507.85 $615.35 $615.35 $522.68 $522.68 $444.07 $444.07 $500.43 $500.43 $515.04 $515.04 $384.07 $384.07 $367.24 $367.24 $392.70 $392.70$499.84 $526.75 $526.75 $638.25 $638.25 $542.13 $542.13 $460.59 $460.59 $519.05 $519.05 $534.20 $534.20 $398.36 $398.36 $380.91 $380.91 $407.32 $407.32$514.55 $542.26 $542.26 $657.04 $657.04 $558.09 $558.09 $474.15 $474.15 $534.33 $534.33 $549.93 $549.93 $410.09 $410.09 $392.12 $392.12 $419.31 $419.31$521.91 $550.01 $550.01 $666.44 $666.44 $566.07 $566.07 $480.93 $480.93 $541.97 $541.97 $557.79 $557.79 $415.95 $415.95 $397.73 $397.73 $425.30 $425.30$532.94 $561.64 $561.64 $680.53 $680.53 $578.04 $578.04 $491.10 $491.10 $553.43 $553.43 $569.59 $569.59 $424.75 $424.75 $406.14 $406.14 $434.29 $434.29$543.98 $573.27 $573.27 $694.62 $694.62 $590.01 $590.01 $501.27 $501.27 $564.89 $564.89 $581.38 $581.38 $433.55 $433.55 $414.55 $414.55 $443.29 $443.29$550.88 $580.54 $580.54 $703.43 $703.43 $597.49 $597.49 $507.63 $507.63 $572.05 $572.05 $588.75 $588.75 $439.04 $439.04 $419.80 $419.80 $448.91 $448.91$558.23 $588.29 $588.29 $712.82 $712.82 $605.47 $605.47 $514.41 $514.41 $579.69 $579.69 $596.62 $596.62 $444.91 $444.91 $425.41 $425.41 $454.90 $454.90$561.91 $592.17 $592.17 $717.52 $717.52 $609.46 $609.46 $517.80 $517.80 $583.51 $583.51 $600.55 $600.55 $447.84 $447.84 $428.21 $428.21 $457.90 $457.90$565.59 $596.05 $596.05 $722.22 $722.22 $613.45 $613.45 $521.19 $521.19 $587.33 $587.33 $604.48 $604.48 $450.77 $450.77 $431.02 $431.02 $460.90 $460.90$569.27 $599.92 $599.92 $726.91 $726.91 $617.44 $617.44 $524.58 $524.58 $591.15 $591.15 $608.41 $608.41 $453.70 $453.70 $433.82 $433.82 $463.90 $463.90$572.95 $603.80 $603.80 $731.61 $731.61 $621.43 $621.43 $527.97 $527.97 $594.97 $594.97 $612.34 $612.34 $456.63 $456.63 $436.62 $436.62 $466.90 $466.90$580.31 $611.55 $611.55 $741.01 $741.01 $629.41 $629.41 $534.75 $534.75 $602.61 $602.61 $620.21 $620.21 $462.50 $462.50 $442.23 $442.23 $472.89 $472.89$587.66 $619.31 $619.31 $750.40 $750.40 $637.39 $637.39 $541.53 $541.53 $610.25 $610.25 $628.07 $628.07 $468.36 $468.36 $447.84 $447.84 $478.89 $478.89$598.70 $630.94 $630.94 $764.49 $764.49 $649.36 $649.36 $551.70 $551.70 $621.71 $621.71 $639.86 $639.86 $477.16 $477.16 $456.25 $456.25 $487.88 $487.88$609.28 $642.08 $642.08 $778.00 $778.00 $660.83 $660.83 $561.44 $561.44 $632.69 $632.69 $651.17 $651.17 $485.59 $485.59 $464.31 $464.31 $496.50 $496.50$623.99 $657.59 $657.59 $796.79 $796.79 $676.79 $676.79 $575.00 $575.00 $647.97 $647.97 $666.89 $666.89 $497.31 $497.31 $475.52 $475.52 $508.49 $508.49$642.38 $676.97 $676.97 $820.27 $820.27 $696.74 $696.74 $591.95 $591.95 $667.07 $667.07 $686.55 $686.55 $511.97 $511.97 $489.54 $489.54 $523.48 $523.48$663.99 $699.75 $699.75 $847.87 $847.87 $720.18 $720.18 $611.87 $611.87 $689.52 $689.52 $709.65 $709.65 $529.20 $529.20 $506.01 $506.01 $541.09 $541.09$689.75 $726.89 $726.89 $880.75 $880.75 $748.11 $748.11 $635.59 $635.59 $716.26 $716.26 $737.17 $737.17 $549.72 $549.72 $525.63 $525.63 $562.07 $562.07$718.71 $757.41 $757.41 $917.74 $917.74 $779.53 $779.53 $662.29 $662.29 $746.34 $746.34 $768.13 $768.13 $572.81 $572.81 $547.71 $547.71 $585.68 $585.68$751.82 $792.31 $792.31 $960.02 $960.02 $815.44 $815.44 $692.80 $692.80 $780.72 $780.72 $803.52 $803.52 $599.19 $599.19 $572.94 $572.94 $612.66 $612.66$784.47 $826.71 $826.71 $1,001.71 $1,001.71 $850.85 $850.85 $722.88 $722.88 $814.62 $814.62 $838.41 $838.41 $625.21 $625.21 $597.82 $597.82 $639.26 $639.26$821.26 $865.48 $865.48 $1,048.68 $1,048.68 $890.75 $890.75 $756.78 $756.78 $852.82 $852.82 $877.72 $877.72 $654.53 $654.53 $625.85 $625.85 $669.24 $669.24$857.58 $903.76 $903.76 $1,095.07 $1,095.07 $930.15 $930.15 $790.26 $790.26 $890.55 $890.55 $916.55 $916.55 $683.48 $683.48 $653.53 $653.53 $698.84 $698.84$897.59 $945.92 $945.92 $1,146.15 $1,146.15 $973.54 $973.54 $827.12 $827.12 $932.09 $932.09 $959.30 $959.30 $715.37 $715.37 $684.02 $684.02 $731.44 $731.44$938.05 $988.56 $988.56 $1,197.82 $1,197.82 $1,017.43 $1,017.43 $864.41 $864.41 $974.11 $974.11 $1,002.55 $1,002.55 $747.62 $747.62 $714.86 $714.86 $764.42 $764.42$981.74 $1,034.60 $1,034.60 $1,253.60 $1,253.60 $1,064.81 $1,064.81 $904.66 $904.66 $1,019.47 $1,019.47 $1,049.24 $1,049.24 $782.43 $782.43 $748.15 $748.15 $800.02 $800.02

$1,025.42 $1,080.64 $1,080.64 $1,309.38 $1,309.38 $1,112.19 $1,112.19 $944.92 $944.92 $1,064.84 $1,064.84 $1,095.93 $1,095.93 $817.25 $817.25 $781.44 $781.44 $835.62 $835.62$1,072.78 $1,130.55 $1,130.55 $1,369.86 $1,369.86 $1,163.56 $1,163.56 $988.56 $988.56 $1,114.02 $1,114.02 $1,146.55 $1,146.55 $855.00 $855.00 $817.53 $817.53 $874.21 $874.21$1,120.61 $1,180.95 $1,180.95 $1,430.93 $1,430.93 $1,215.43 $1,215.43 $1,032.63 $1,032.63 $1,163.68 $1,163.68 $1,197.66 $1,197.66 $893.11 $893.11 $853.97 $853.97 $913.18 $913.18$1,171.65 $1,234.74 $1,234.74 $1,496.10 $1,496.10 $1,270.79 $1,270.79 $1,079.66 $1,079.66 $1,216.68 $1,216.68 $1,252.21 $1,252.21 $933.79 $933.79 $892.87 $892.87 $954.77 $954.77$1,196.94 $1,261.39 $1,261.39 $1,528.40 $1,528.40 $1,298.22 $1,298.22 $1,102.97 $1,102.97 $1,242.95 $1,242.95 $1,279.24 $1,279.24 $953.95 $953.95 $912.14 $912.14 $975.38 $975.38$1,247.98 $1,315.18 $1,315.18 $1,593.57 $1,593.57 $1,353.58 $1,353.58 $1,150.00 $1,150.00 $1,295.95 $1,295.95 $1,333.79 $1,333.79 $994.63 $994.63 $951.04 $951.04 $1,016.98 $1,016.98$1,292.12 $1,361.70 $1,361.70 $1,649.94 $1,649.94 $1,401.46 $1,401.46 $1,190.68 $1,190.68 $1,341.79 $1,341.79 $1,380.97 $1,380.97 $1,029.81 $1,029.81 $984.68 $984.68 $1,052.95 $1,052.95$1,321.09 $1,392.23 $1,392.23 $1,686.93 $1,686.93 $1,432.88 $1,432.88 $1,217.38 $1,217.38 $1,371.87 $1,371.87 $1,411.93 $1,411.93 $1,052.90 $1,052.90 $1,006.76 $1,006.76 $1,076.56 $1,076.56$1,357.42 $1,430.51 $1,430.51 $1,733.32 $1,733.32 $1,472.28 $1,472.28 $1,250.85 $1,250.85 $1,409.60 $1,409.60 $1,450.75 $1,450.75 $1,081.85 $1,081.85 $1,034.44 $1,034.44 $1,106.16 $1,106.16$1,379.49 $1,453.77 $1,453.77 $1,761.50 $1,761.50 $1,496.22 $1,496.22 $1,271.19 $1,271.19 $1,432.52 $1,432.52 $1,474.34 $1,474.34 $1,099.44 $1,099.44 $1,051.26 $1,051.26 $1,124.15 $1,124.15

GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 2



0%$40 / $40$2,250

Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 9



0%$40 / $40$2,250

Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 6



0%$40 / $40$2,250

Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 3



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 6


num0 / Rx: $0%/ $30350es


l-Access PPO

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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$302.09 $302.09 $366.04 $366.04 $310.91 $310.91 $258.93 $258.93 $291.79 $291.79 $300.31 $300.31 $312.96 $312.96 $299.25 $299.25 $320.00 $320.00 $337.23$328.95 $328.95 $398.58 $398.58 $338.55 $338.55 $281.95 $281.95 $317.73 $317.73 $327.01 $327.01 $340.78 $340.78 $325.85 $325.85 $348.44 $348.44 $367.20$339.21 $339.21 $411.02 $411.02 $349.12 $349.12 $290.75 $290.75 $327.65 $327.65 $337.21 $337.21 $351.42 $351.42 $336.02 $336.02 $359.32 $359.32 $378.66$349.48 $349.48 $423.46 $423.46 $359.68 $359.68 $299.55 $299.55 $337.56 $337.56 $347.42 $347.42 $362.06 $362.06 $346.19 $346.19 $370.19 $370.19 $390.13$360.54 $360.54 $436.85 $436.85 $371.06 $371.06 $309.03 $309.03 $348.24 $348.24 $358.41 $358.41 $373.51 $373.51 $357.14 $357.14 $381.91 $381.91 $402.47$371.59 $371.59 $450.25 $450.25 $382.44 $382.44 $318.50 $318.50 $358.92 $358.92 $369.40 $369.40 $384.97 $384.97 $368.10 $368.10 $393.62 $393.62 $414.81$383.05 $383.05 $464.13 $464.13 $394.23 $394.23 $328.32 $328.32 $369.99 $369.99 $380.79 $380.79 $396.83 $396.83 $379.44 $379.44 $405.75 $405.75 $427.60$394.90 $394.90 $478.49 $478.49 $406.43 $406.43 $338.48 $338.48 $381.43 $381.43 $392.57 $392.57 $409.11 $409.11 $391.18 $391.18 $418.30 $418.30 $440.83$394.90 $394.90 $478.49 $478.49 $406.43 $406.43 $338.48 $338.48 $381.43 $381.43 $392.57 $392.57 $409.11 $409.11 $391.18 $391.18 $418.30 $418.30 $440.83$394.90 $394.90 $478.49 $478.49 $406.43 $406.43 $338.48 $338.48 $381.43 $381.43 $392.57 $392.57 $409.11 $409.11 $391.18 $391.18 $418.30 $418.30 $440.83$394.90 $394.90 $478.49 $478.49 $406.43 $406.43 $338.48 $338.48 $381.43 $381.43 $392.57 $392.57 $409.11 $409.11 $391.18 $391.18 $418.30 $418.30 $440.83$396.47 $396.47 $480.40 $480.40 $408.05 $408.05 $339.83 $339.83 $382.95 $382.95 $394.14 $394.14 $410.74 $410.74 $392.74 $392.74 $419.97 $419.97 $442.58$404.37 $404.37 $489.97 $489.97 $416.18 $416.18 $346.60 $346.60 $390.58 $390.58 $401.99 $401.99 $418.92 $418.92 $400.56 $400.56 $428.34 $428.34 $451.40$413.85 $413.85 $501.45 $501.45 $425.93 $425.93 $354.72 $354.72 $399.74 $399.74 $411.41 $411.41 $428.74 $428.74 $409.95 $409.95 $438.38 $438.38 $461.98$429.25 $429.25 $520.11 $520.11 $441.78 $441.78 $367.92 $367.92 $414.61 $414.61 $426.72 $426.72 $444.70 $444.70 $425.21 $425.21 $454.69 $454.69 $479.17$441.88 $441.88 $535.42 $535.42 $454.79 $454.79 $378.75 $378.75 $426.82 $426.82 $439.28 $439.28 $457.79 $457.79 $437.73 $437.73 $468.07 $468.07 $493.28$448.20 $448.20 $543.08 $543.08 $461.29 $461.29 $384.17 $384.17 $432.92 $432.92 $445.56 $445.56 $464.33 $464.33 $443.99 $443.99 $474.77 $474.77 $500.33$457.68 $457.68 $554.56 $554.56 $471.04 $471.04 $392.29 $392.29 $442.08 $442.08 $454.98 $454.98 $474.15 $474.15 $453.37 $453.37 $484.81 $484.81 $510.91$467.16 $467.16 $566.04 $566.04 $480.80 $480.80 $400.41 $400.41 $451.23 $451.23 $464.40 $464.40 $483.97 $483.97 $462.76 $462.76 $494.85 $494.85 $521.49$473.08 $473.08 $573.22 $573.22 $486.89 $486.89 $405.49 $405.49 $456.95 $456.95 $470.29 $470.29 $490.11 $490.11 $468.63 $468.63 $501.12 $501.12 $528.10$479.40 $479.40 $580.88 $580.88 $493.40 $493.40 $410.91 $410.91 $463.05 $463.05 $476.57 $476.57 $496.65 $496.65 $474.89 $474.89 $507.81 $507.81 $535.16$482.56 $482.56 $584.71 $584.71 $496.65 $496.65 $413.61 $413.61 $466.11 $466.11 $479.71 $479.71 $499.92 $499.92 $478.02 $478.02 $511.16 $511.16 $538.68$485.72 $485.72 $588.53 $588.53 $499.90 $499.90 $416.32 $416.32 $469.16 $469.16 $482.86 $482.86 $503.20 $503.20 $481.15 $481.15 $514.51 $514.51 $542.21$488.88 $488.88 $592.36 $592.36 $503.15 $503.15 $419.03 $419.03 $472.21 $472.21 $486.00 $486.00 $506.47 $506.47 $484.28 $484.28 $517.85 $517.85 $545.74$492.04 $492.04 $596.19 $596.19 $506.40 $506.40 $421.74 $421.74 $475.26 $475.26 $489.14 $489.14 $509.74 $509.74 $487.41 $487.41 $521.20 $521.20 $549.26$498.35 $498.35 $603.84 $603.84 $512.90 $512.90 $427.15 $427.15 $481.36 $481.36 $495.42 $495.42 $516.29 $516.29 $493.66 $493.66 $527.89 $527.89 $556.32$504.67 $504.67 $611.50 $611.50 $519.41 $519.41 $432.57 $432.57 $487.47 $487.47 $501.70 $501.70 $522.83 $522.83 $499.92 $499.92 $534.58 $534.58 $563.37$514.15 $514.15 $622.98 $622.98 $529.16 $529.16 $440.69 $440.69 $496.62 $496.62 $511.12 $511.12 $532.65 $532.65 $509.31 $509.31 $544.62 $544.62 $573.95$523.23 $523.23 $633.99 $633.99 $538.51 $538.51 $448.48 $448.48 $505.39 $505.39 $520.15 $520.15 $542.06 $542.06 $518.31 $518.31 $554.24 $554.24 $584.09$535.87 $535.87 $649.30 $649.30 $551.51 $551.51 $459.31 $459.31 $517.60 $517.60 $532.71 $532.71 $555.15 $555.15 $530.83 $530.83 $567.63 $567.63 $598.19$551.66 $551.66 $668.44 $668.44 $567.77 $567.77 $472.85 $472.85 $532.86 $532.86 $548.41 $548.41 $571.52 $571.52 $546.47 $546.47 $584.36 $584.36 $615.83$570.22 $570.22 $690.93 $690.93 $586.87 $586.87 $488.76 $488.76 $550.78 $550.78 $566.86 $566.86 $590.75 $590.75 $564.86 $564.86 $604.02 $604.02 $636.55$592.34 $592.34 $717.72 $717.72 $609.63 $609.63 $507.71 $507.71 $572.14 $572.14 $588.85 $588.85 $613.66 $613.66 $586.76 $586.76 $627.45 $627.45 $661.23$617.22 $617.22 $747.87 $747.87 $635.24 $635.24 $529.03 $529.03 $596.17 $596.17 $613.58 $613.58 $639.43 $639.43 $611.41 $611.41 $653.80 $653.80 $689.00$645.65 $645.65 $782.32 $782.32 $664.50 $664.50 $553.40 $553.40 $623.64 $623.64 $641.84 $641.84 $668.88 $668.88 $639.57 $639.57 $683.92 $683.92 $720.74$673.69 $673.69 $816.29 $816.29 $693.36 $693.36 $577.44 $577.44 $650.72 $650.72 $669.72 $669.72 $697.93 $697.93 $667.35 $667.35 $713.61 $713.61 $752.04$705.28 $705.28 $854.57 $854.57 $725.87 $725.87 $604.51 $604.51 $681.23 $681.23 $701.12 $701.12 $730.66 $730.66 $698.64 $698.64 $747.08 $747.08 $787.31$736.47 $736.47 $892.37 $892.37 $757.98 $757.98 $631.25 $631.25 $711.36 $711.36 $732.13 $732.13 $762.98 $762.98 $729.54 $729.54 $780.12 $780.12 $822.13$770.83 $770.83 $934.00 $934.00 $793.34 $793.34 $660.70 $660.70 $744.55 $744.55 $766.29 $766.29 $798.57 $798.57 $763.58 $763.58 $816.52 $816.52 $860.48$805.58 $805.58 $976.10 $976.10 $829.10 $829.10 $690.49 $690.49 $778.11 $778.11 $800.83 $800.83 $834.57 $834.57 $798.00 $798.00 $853.33 $853.33 $899.27$843.09 $843.09 $1,021.56 $1,021.56 $867.71 $867.71 $722.64 $722.64 $814.35 $814.35 $838.13 $838.13 $873.44 $873.44 $835.16 $835.16 $893.06 $893.06 $941.15$880.61 $880.61 $1,067.02 $1,067.02 $906.32 $906.32 $754.80 $754.80 $850.59 $850.59 $875.42 $875.42 $912.30 $912.30 $872.32 $872.32 $932.80 $932.80 $983.03$921.28 $921.28 $1,116.30 $1,116.30 $948.18 $948.18 $789.66 $789.66 $889.87 $889.87 $915.86 $915.86 $954.44 $954.44 $912.62 $912.62 $975.89 $975.89 $1,028.43$962.35 $962.35 $1,166.06 $1,166.06 $990.45 $990.45 $824.86 $824.86 $929.54 $929.54 $956.68 $956.68 $996.99 $996.99 $953.30 $953.30 $1,019.39 $1,019.39 $1,074.28

$1,006.19 $1,006.19 $1,219.17 $1,219.17 $1,035.56 $1,035.56 $862.43 $862.43 $971.88 $971.88 $1,000.26 $1,000.26 $1,042.40 $1,042.40 $996.72 $996.72 $1,065.82 $1,065.82 $1,123.21$1,027.90 $1,027.90 $1,245.49 $1,245.49 $1,057.92 $1,057.92 $881.05 $881.05 $992.86 $992.86 $1,021.85 $1,021.85 $1,064.90 $1,064.90 $1,018.23 $1,018.23 $1,088.83 $1,088.83 $1,147.46$1,071.74 $1,071.74 $1,298.60 $1,298.60 $1,103.03 $1,103.03 $918.62 $918.62 $1,035.20 $1,035.20 $1,065.42 $1,065.42 $1,110.31 $1,110.31 $1,061.65 $1,061.65 $1,135.26 $1,135.26 $1,196.39$1,109.65 $1,109.65 $1,344.54 $1,344.54 $1,142.05 $1,142.05 $951.11 $951.11 $1,071.81 $1,071.81 $1,103.11 $1,103.11 $1,149.58 $1,149.58 $1,099.21 $1,099.21 $1,175.41 $1,175.41 $1,238.71$1,134.53 $1,134.53 $1,374.68 $1,374.68 $1,167.65 $1,167.65 $972.43 $972.43 $1,095.85 $1,095.85 $1,127.84 $1,127.84 $1,175.35 $1,175.35 $1,123.85 $1,123.85 $1,201.77 $1,201.77 $1,266.48$1,165.72 $1,165.72 $1,412.48 $1,412.48 $1,199.76 $1,199.76 $999.17 $999.17 $1,125.98 $1,125.98 $1,158.85 $1,158.85 $1,207.67 $1,207.67 $1,154.75 $1,154.75 $1,234.81 $1,234.81 $1,301.30$1,184.68 $1,184.68 $1,435.45 $1,435.45 $1,219.27 $1,219.27 $1,015.42 $1,015.42 $1,144.29 $1,144.29 $1,177.70 $1,177.70 $1,227.31 $1,227.31 $1,173.53 $1,173.53 $1,254.89 $1,254.89 $1,322.46

GoMed: $50

0$20 /$8,1

Y

75729PAGeisinger Al

20/40M-152-121-

Rating

Geisinger Al


0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 5



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 3



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 6


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 6


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64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$337.23 $408.61 $408.61 $347.07 $347.07 $297.19 $297.19 $284.17 $284.17 $303.87 $303.87 $320.23 $320.23 $388.02 $388.02 $329.58 $329.58 $291.41 $291.41$367.20 $444.93 $444.93 $377.92 $377.92 $323.61 $323.61 $309.43 $309.43 $330.88 $330.88 $348.70 $348.70 $422.51 $422.51 $358.88 $358.88 $317.32 $317.32$378.66 $458.82 $458.82 $389.72 $389.72 $333.71 $333.71 $319.09 $319.09 $341.21 $341.21 $359.58 $359.58 $435.70 $435.70 $370.08 $370.08 $327.22 $327.22$390.13 $472.71 $472.71 $401.52 $401.52 $343.81 $343.81 $328.75 $328.75 $351.54 $351.54 $370.47 $370.47 $448.89 $448.89 $381.28 $381.28 $337.13 $337.13$402.47 $487.66 $487.66 $414.22 $414.22 $354.69 $354.69 $339.15 $339.15 $362.66 $362.66 $382.19 $382.19 $463.09 $463.09 $393.35 $393.35 $347.79 $347.79$414.81 $502.62 $502.62 $426.92 $426.92 $365.57 $365.57 $349.55 $349.55 $373.78 $373.78 $393.91 $393.91 $477.29 $477.29 $405.41 $405.41 $358.46 $358.46$427.60 $518.11 $518.11 $440.08 $440.08 $376.83 $376.83 $360.32 $360.32 $385.30 $385.30 $406.05 $406.05 $492.00 $492.00 $417.90 $417.90 $369.51 $369.51$440.83 $534.14 $534.14 $453.70 $453.70 $388.49 $388.49 $371.47 $371.47 $397.22 $397.22 $418.61 $418.61 $507.22 $507.22 $430.83 $430.83 $380.94 $380.94$440.83 $534.14 $534.14 $453.70 $453.70 $388.49 $388.49 $371.47 $371.47 $397.22 $397.22 $418.61 $418.61 $507.22 $507.22 $430.83 $430.83 $380.94 $380.94$440.83 $534.14 $534.14 $453.70 $453.70 $388.49 $388.49 $371.47 $371.47 $397.22 $397.22 $418.61 $418.61 $507.22 $507.22 $430.83 $430.83 $380.94 $380.94$440.83 $534.14 $534.14 $453.70 $453.70 $388.49 $388.49 $371.47 $371.47 $397.22 $397.22 $418.61 $418.61 $507.22 $507.22 $430.83 $430.83 $380.94 $380.94$442.58 $536.27 $536.27 $455.51 $455.51 $390.04 $390.04 $372.95 $372.95 $398.81 $398.81 $420.28 $420.28 $509.25 $509.25 $432.55 $432.55 $382.46 $382.46$451.40 $546.95 $546.95 $464.58 $464.58 $397.81 $397.81 $380.38 $380.38 $406.75 $406.75 $428.65 $428.65 $519.39 $519.39 $441.17 $441.17 $390.08 $390.08$461.98 $559.77 $559.77 $475.47 $475.47 $407.14 $407.14 $389.29 $389.29 $416.28 $416.28 $438.70 $438.70 $531.56 $531.56 $451.51 $451.51 $399.22 $399.22$479.17 $580.60 $580.60 $493.16 $493.16 $422.29 $422.29 $403.78 $403.78 $431.78 $431.78 $455.03 $455.03 $551.34 $551.34 $468.31 $468.31 $414.07 $414.07$493.28 $597.69 $597.69 $507.68 $507.68 $434.72 $434.72 $415.67 $415.67 $444.49 $444.49 $468.42 $468.42 $567.58 $567.58 $482.10 $482.10 $426.26 $426.26$500.33 $606.24 $606.24 $514.94 $514.94 $440.93 $440.93 $421.61 $421.61 $450.84 $450.84 $475.12 $475.12 $575.69 $575.69 $488.99 $488.99 $432.36 $432.36$510.91 $619.06 $619.06 $525.83 $525.83 $450.26 $450.26 $430.53 $430.53 $460.38 $460.38 $485.16 $485.16 $587.86 $587.86 $499.33 $499.33 $441.50 $441.50$521.49 $631.88 $631.88 $536.72 $536.72 $459.58 $459.58 $439.44 $439.44 $469.91 $469.91 $495.21 $495.21 $600.04 $600.04 $509.67 $509.67 $450.64 $450.64$528.10 $639.89 $639.89 $543.52 $543.52 $465.41 $465.41 $445.01 $445.01 $475.87 $475.87 $501.49 $501.49 $607.65 $607.65 $516.13 $516.13 $456.36 $456.36$535.16 $648.44 $648.44 $550.78 $550.78 $471.62 $471.62 $450.96 $450.96 $482.22 $482.22 $508.19 $508.19 $615.76 $615.76 $523.03 $523.03 $462.45 $462.45$538.68 $652.71 $652.71 $554.41 $554.41 $474.73 $474.73 $453.93 $453.93 $485.40 $485.40 $511.54 $511.54 $619.82 $619.82 $526.47 $526.47 $465.50 $465.50$542.21 $656.98 $656.98 $558.04 $558.04 $477.84 $477.84 $456.90 $456.90 $488.58 $488.58 $514.89 $514.89 $623.88 $623.88 $529.92 $529.92 $468.55 $468.55$545.74 $661.26 $661.26 $561.67 $561.67 $480.95 $480.95 $459.87 $459.87 $491.76 $491.76 $518.23 $518.23 $627.93 $627.93 $533.37 $533.37 $471.60 $471.60$549.26 $665.53 $665.53 $565.30 $565.30 $484.06 $484.06 $462.84 $462.84 $494.93 $494.93 $521.58 $521.58 $631.99 $631.99 $536.81 $536.81 $474.64 $474.64$556.32 $674.08 $674.08 $572.56 $572.56 $490.27 $490.27 $468.79 $468.79 $501.29 $501.29 $528.28 $528.28 $640.11 $640.11 $543.71 $543.71 $480.74 $480.74$563.37 $682.62 $682.62 $579.82 $579.82 $496.49 $496.49 $474.73 $474.73 $507.64 $507.64 $534.98 $534.98 $648.22 $648.22 $550.60 $550.60 $486.83 $486.83$573.95 $695.44 $695.44 $590.71 $590.71 $505.81 $505.81 $483.65 $483.65 $517.18 $517.18 $545.03 $545.03 $660.40 $660.40 $560.94 $560.94 $495.98 $495.98$584.09 $707.73 $707.73 $601.14 $601.14 $514.75 $514.75 $492.19 $492.19 $526.31 $526.31 $554.65 $554.65 $672.06 $672.06 $570.85 $570.85 $504.74 $504.74$598.19 $724.82 $724.82 $615.66 $615.66 $527.18 $527.18 $504.08 $504.08 $539.02 $539.02 $568.05 $568.05 $688.29 $688.29 $584.63 $584.63 $516.93 $516.93$615.83 $746.18 $746.18 $633.81 $633.81 $542.72 $542.72 $518.94 $518.94 $554.91 $554.91 $584.79 $584.79 $708.58 $708.58 $601.87 $601.87 $532.16 $532.16$636.55 $771.29 $771.29 $655.13 $655.13 $560.98 $560.98 $536.39 $536.39 $573.58 $573.58 $604.47 $604.47 $732.42 $732.42 $622.12 $622.12 $550.07 $550.07$661.23 $801.20 $801.20 $680.54 $680.54 $582.73 $582.73 $557.20 $557.20 $595.83 $595.83 $627.91 $627.91 $760.82 $760.82 $646.24 $646.24 $571.40 $571.40$689.00 $834.85 $834.85 $709.12 $709.12 $607.21 $607.21 $580.60 $580.60 $620.85 $620.85 $654.28 $654.28 $792.78 $792.78 $673.38 $673.38 $595.40 $595.40$720.74 $873.31 $873.31 $741.79 $741.79 $635.18 $635.18 $607.34 $607.34 $649.45 $649.45 $684.42 $684.42 $829.30 $829.30 $704.40 $704.40 $622.83 $622.83$752.04 $911.23 $911.23 $774.00 $774.00 $662.76 $662.76 $633.72 $633.72 $677.65 $677.65 $714.14 $714.14 $865.31 $865.31 $734.99 $734.99 $649.87 $649.87$787.31 $953.96 $953.96 $810.29 $810.29 $693.84 $693.84 $663.43 $663.43 $709.43 $709.43 $747.63 $747.63 $905.89 $905.89 $769.46 $769.46 $680.35 $680.35$822.13 $996.16 $996.16 $846.13 $846.13 $724.53 $724.53 $692.78 $692.78 $740.81 $740.81 $780.70 $780.70 $945.96 $945.96 $803.50 $803.50 $710.44 $710.44$860.48 $1,042.63 $1,042.63 $885.61 $885.61 $758.33 $758.33 $725.10 $725.10 $775.37 $775.37 $817.12 $817.12 $990.09 $990.09 $840.98 $840.98 $743.58 $743.58$899.27 $1,089.63 $1,089.63 $925.53 $925.53 $792.51 $792.51 $757.79 $757.79 $810.32 $810.32 $853.96 $853.96 $1,034.72 $1,034.72 $878.89 $878.89 $777.10 $777.10$941.15 $1,140.37 $1,140.37 $968.63 $968.63 $829.42 $829.42 $793.08 $793.08 $848.06 $848.06 $893.72 $893.72 $1,082.91 $1,082.91 $919.82 $919.82 $813.29 $813.29$983.03 $1,191.12 $1,191.12 $1,011.73 $1,011.73 $866.33 $866.33 $828.36 $828.36 $885.80 $885.80 $933.49 $933.49 $1,131.09 $1,131.09 $960.75 $960.75 $849.48 $849.48

$1,028.43 $1,246.13 $1,246.13 $1,058.46 $1,058.46 $906.34 $906.34 $866.63 $866.63 $926.71 $926.71 $976.61 $976.61 $1,183.34 $1,183.34 $1,005.12 $1,005.12 $888.72 $888.72$1,074.28 $1,301.68 $1,301.68 $1,105.65 $1,105.65 $946.74 $946.74 $905.26 $905.26 $968.02 $968.02 $1,020.14 $1,020.14 $1,236.09 $1,236.09 $1,049.93 $1,049.93 $928.33 $928.33$1,123.21 $1,360.97 $1,360.97 $1,156.01 $1,156.01 $989.87 $989.87 $946.49 $946.49 $1,012.11 $1,012.11 $1,066.61 $1,066.61 $1,292.39 $1,292.39 $1,097.75 $1,097.75 $970.62 $970.62$1,147.46 $1,390.35 $1,390.35 $1,180.96 $1,180.96 $1,011.23 $1,011.23 $966.92 $966.92 $1,033.96 $1,033.96 $1,089.63 $1,089.63 $1,320.28 $1,320.28 $1,121.45 $1,121.45 $991.57 $991.57$1,196.39 $1,449.64 $1,449.64 $1,231.32 $1,231.32 $1,054.36 $1,054.36 $1,008.15 $1,008.15 $1,078.05 $1,078.05 $1,136.10 $1,136.10 $1,376.59 $1,376.59 $1,169.27 $1,169.27 $1,033.85 $1,033.85$1,238.71 $1,500.91 $1,500.91 $1,274.87 $1,274.87 $1,091.65 $1,091.65 $1,043.81 $1,043.81 $1,116.18 $1,116.18 $1,176.28 $1,176.28 $1,425.28 $1,425.28 $1,210.63 $1,210.63 $1,070.42 $1,070.42$1,266.48 $1,534.56 $1,534.56 $1,303.46 $1,303.46 $1,116.13 $1,116.13 $1,067.22 $1,067.22 $1,141.21 $1,141.21 $1,202.66 $1,202.66 $1,457.23 $1,457.23 $1,237.77 $1,237.77 $1,094.42 $1,094.42$1,301.30 $1,576.76 $1,576.76 $1,339.30 $1,339.30 $1,146.82 $1,146.82 $1,096.56 $1,096.56 $1,172.59 $1,172.59 $1,235.73 $1,235.73 $1,497.30 $1,497.30 $1,271.81 $1,271.81 $1,124.52 $1,124.52$1,322.46 $1,602.40 $1,602.40 $1,361.07 $1,361.07 $1,165.46 $1,165.46 $1,114.39 $1,114.39 $1,191.65 $1,191.65 $1,255.82 $1,255.82 $1,521.65 $1,521.65 $1,292.49 $1,292.49 $1,142.80 $1,142.80

GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 2



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 9



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 7


old0 / Rx: $0%/ $40150es


l-Access PPO

Page Number: 46 12/24/2014

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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$278.64 $278.64 $297.96 $297.96 $314.01 $314.01 $380.48 $380.48 $323.17 $323.17 $260.93 $260.93 $249.49 $249.49 $266.79 $266.79 $281.16 $281.16 $340.67$303.41 $303.41 $324.45 $324.45 $341.92 $341.92 $414.30 $414.30 $351.90 $351.90 $284.12 $284.12 $271.67 $271.67 $290.51 $290.51 $306.15 $306.15 $370.95$312.88 $312.88 $334.58 $334.58 $352.59 $352.59 $427.23 $427.23 $362.89 $362.89 $292.99 $292.99 $280.15 $280.15 $299.57 $299.57 $315.70 $315.70 $382.53$322.35 $322.35 $344.70 $344.70 $363.26 $363.26 $440.16 $440.16 $373.87 $373.87 $301.86 $301.86 $288.63 $288.63 $308.64 $308.64 $325.26 $325.26 $394.11$332.55 $332.55 $355.61 $355.61 $374.76 $374.76 $454.08 $454.08 $385.70 $385.70 $311.41 $311.41 $297.76 $297.76 $318.41 $318.41 $335.55 $335.55 $406.58$342.75 $342.75 $366.51 $366.51 $386.25 $386.25 $468.01 $468.01 $397.53 $397.53 $320.96 $320.96 $306.89 $306.89 $328.17 $328.17 $345.84 $345.84 $419.05$353.31 $353.31 $377.81 $377.81 $398.15 $398.15 $482.43 $482.43 $409.78 $409.78 $330.85 $330.85 $316.35 $316.35 $338.28 $338.28 $356.50 $356.50 $431.96$364.25 $364.25 $389.50 $389.50 $410.47 $410.47 $497.36 $497.36 $422.46 $422.46 $341.09 $341.09 $326.14 $326.14 $348.75 $348.75 $367.53 $367.53 $445.33$364.25 $364.25 $389.50 $389.50 $410.47 $410.47 $497.36 $497.36 $422.46 $422.46 $341.09 $341.09 $326.14 $326.14 $348.75 $348.75 $367.53 $367.53 $445.33$364.25 $364.25 $389.50 $389.50 $410.47 $410.47 $497.36 $497.36 $422.46 $422.46 $341.09 $341.09 $326.14 $326.14 $348.75 $348.75 $367.53 $367.53 $445.33$364.25 $364.25 $389.50 $389.50 $410.47 $410.47 $497.36 $497.36 $422.46 $422.46 $341.09 $341.09 $326.14 $326.14 $348.75 $348.75 $367.53 $367.53 $445.33$365.70 $365.70 $391.05 $391.05 $412.11 $412.11 $499.34 $499.34 $424.14 $424.14 $342.45 $342.45 $327.44 $327.44 $350.14 $350.14 $369.00 $369.00 $447.10$372.98 $372.98 $398.84 $398.84 $420.32 $420.32 $509.29 $509.29 $432.59 $432.59 $349.27 $349.27 $333.96 $333.96 $357.12 $357.12 $376.35 $376.35 $456.01$381.72 $381.72 $408.19 $408.19 $430.17 $430.17 $521.23 $521.23 $442.73 $442.73 $357.45 $357.45 $341.79 $341.79 $365.49 $365.49 $385.17 $385.17 $466.70$395.93 $395.93 $423.38 $423.38 $446.18 $446.18 $540.62 $540.62 $459.20 $459.20 $370.76 $370.76 $354.51 $354.51 $379.09 $379.09 $399.50 $399.50 $484.07$407.59 $407.59 $435.84 $435.84 $459.31 $459.31 $556.54 $556.54 $472.72 $472.72 $381.67 $381.67 $364.95 $364.95 $390.25 $390.25 $411.26 $411.26 $498.32$413.41 $413.41 $442.08 $442.08 $465.88 $465.88 $564.50 $564.50 $479.48 $479.48 $387.13 $387.13 $370.16 $370.16 $395.83 $395.83 $417.14 $417.14 $505.44$422.16 $422.16 $451.42 $451.42 $475.73 $475.73 $576.43 $576.43 $489.62 $489.62 $395.31 $395.31 $377.99 $377.99 $404.20 $404.20 $425.96 $425.96 $516.13$430.90 $430.90 $460.77 $460.77 $485.58 $485.58 $588.37 $588.37 $499.76 $499.76 $403.50 $403.50 $385.82 $385.82 $412.57 $412.57 $434.78 $434.78 $526.82$436.36 $436.36 $466.61 $466.61 $491.74 $491.74 $595.83 $595.83 $506.10 $506.10 $408.62 $408.62 $390.71 $390.71 $417.80 $417.80 $440.30 $440.30 $533.50$442.19 $442.19 $472.85 $472.85 $498.31 $498.31 $603.79 $603.79 $512.86 $512.86 $414.07 $414.07 $395.93 $395.93 $423.38 $423.38 $446.18 $446.18 $540.62$445.10 $445.10 $475.96 $475.96 $501.59 $501.59 $607.77 $607.77 $516.23 $516.23 $416.80 $416.80 $398.54 $398.54 $426.17 $426.17 $449.12 $449.12 $544.18$448.02 $448.02 $479.08 $479.08 $504.87 $504.87 $611.74 $611.74 $519.61 $519.61 $419.53 $419.53 $401.15 $401.15 $428.96 $428.96 $452.06 $452.06 $547.75$450.93 $450.93 $482.19 $482.19 $508.16 $508.16 $615.72 $615.72 $522.99 $522.99 $422.26 $422.26 $403.76 $403.76 $431.75 $431.75 $455.00 $455.00 $551.31$453.84 $453.84 $485.31 $485.31 $511.44 $511.44 $619.70 $619.70 $526.37 $526.37 $424.99 $424.99 $406.36 $406.36 $434.54 $434.54 $457.94 $457.94 $554.87$459.67 $459.67 $491.54 $491.54 $518.01 $518.01 $627.66 $627.66 $533.13 $533.13 $430.45 $430.45 $411.58 $411.58 $440.12 $440.12 $463.82 $463.82 $562.00$465.50 $465.50 $497.77 $497.77 $524.58 $524.58 $635.62 $635.62 $539.89 $539.89 $435.90 $435.90 $416.80 $416.80 $445.70 $445.70 $469.70 $469.70 $569.12$474.24 $474.24 $507.12 $507.12 $534.43 $534.43 $647.55 $647.55 $550.03 $550.03 $444.09 $444.09 $424.63 $424.63 $454.07 $454.07 $478.52 $478.52 $579.81$482.62 $482.62 $516.08 $516.08 $543.87 $543.87 $658.99 $658.99 $559.75 $559.75 $451.93 $451.93 $432.13 $432.13 $462.09 $462.09 $486.97 $486.97 $590.05$494.27 $494.27 $528.54 $528.54 $557.00 $557.00 $674.91 $674.91 $573.27 $573.27 $462.85 $462.85 $442.57 $442.57 $473.25 $473.25 $498.73 $498.73 $604.30$508.84 $508.84 $544.12 $544.12 $573.42 $573.42 $694.80 $694.80 $590.16 $590.16 $476.49 $476.49 $455.61 $455.61 $487.20 $487.20 $513.43 $513.43 $622.12$525.96 $525.96 $562.43 $562.43 $592.71 $592.71 $718.18 $718.18 $610.02 $610.02 $492.52 $492.52 $470.94 $470.94 $503.59 $503.59 $530.71 $530.71 $643.05$546.36 $546.36 $584.24 $584.24 $615.70 $615.70 $746.03 $746.03 $633.68 $633.68 $511.62 $511.62 $489.20 $489.20 $523.12 $523.12 $551.29 $551.29 $667.98$569.31 $569.31 $608.78 $608.78 $641.56 $641.56 $777.36 $777.36 $660.29 $660.29 $533.11 $533.11 $509.75 $509.75 $545.09 $545.09 $574.44 $574.44 $696.04$595.53 $595.53 $636.82 $636.82 $671.11 $671.11 $813.17 $813.17 $690.71 $690.71 $557.67 $557.67 $533.23 $533.23 $570.20 $570.20 $600.90 $600.90 $728.10$621.39 $621.39 $664.48 $664.48 $700.26 $700.26 $848.48 $848.48 $720.70 $720.70 $581.89 $581.89 $556.39 $556.39 $594.96 $594.96 $627.00 $627.00 $759.72$650.53 $650.53 $695.64 $695.64 $733.09 $733.09 $888.27 $888.27 $754.50 $754.50 $609.17 $609.17 $582.48 $582.48 $622.86 $622.86 $656.40 $656.40 $795.35$679.31 $679.31 $726.41 $726.41 $765.52 $765.52 $927.56 $927.56 $787.87 $787.87 $636.12 $636.12 $608.24 $608.24 $650.41 $650.41 $685.43 $685.43 $830.53$711.00 $711.00 $760.29 $760.29 $801.23 $801.23 $970.83 $970.83 $824.62 $824.62 $665.79 $665.79 $636.62 $636.62 $680.75 $680.75 $717.41 $717.41 $869.27$743.05 $743.05 $794.57 $794.57 $837.35 $837.35 $1,014.60 $1,014.60 $861.80 $861.80 $695.81 $695.81 $665.32 $665.32 $711.44 $711.44 $749.75 $749.75 $908.46$777.65 $777.65 $831.57 $831.57 $876.35 $876.35 $1,061.85 $1,061.85 $901.93 $901.93 $728.21 $728.21 $696.30 $696.30 $744.57 $744.57 $784.67 $784.67 $950.76$812.26 $812.26 $868.57 $868.57 $915.34 $915.34 $1,109.10 $1,109.10 $942.07 $942.07 $760.61 $760.61 $727.28 $727.28 $777.70 $777.70 $819.58 $819.58 $993.07$849.77 $849.77 $908.69 $908.69 $957.62 $957.62 $1,160.33 $1,160.33 $985.58 $985.58 $795.74 $795.74 $760.87 $760.87 $813.63 $813.63 $857.44 $857.44 $1,038.94$887.65 $887.65 $949.20 $949.20 $1,000.31 $1,000.31 $1,212.05 $1,212.05 $1,029.51 $1,029.51 $831.22 $831.22 $794.79 $794.79 $849.90 $849.90 $895.66 $895.66 $1,085.25$928.09 $928.09 $992.43 $992.43 $1,045.87 $1,045.87 $1,267.26 $1,267.26 $1,076.40 $1,076.40 $869.08 $869.08 $830.99 $830.99 $888.61 $888.61 $936.45 $936.45 $1,134.68$948.12 $948.12 $1,013.85 $1,013.85 $1,068.44 $1,068.44 $1,294.61 $1,294.61 $1,099.64 $1,099.64 $887.84 $887.84 $848.93 $848.93 $907.79 $907.79 $956.67 $956.67 $1,159.17$988.55 $988.55 $1,057.09 $1,057.09 $1,114.01 $1,114.01 $1,349.82 $1,349.82 $1,146.53 $1,146.53 $925.70 $925.70 $885.13 $885.13 $946.50 $946.50 $997.46 $997.46 $1,208.61

$1,023.52 $1,023.52 $1,094.48 $1,094.48 $1,153.41 $1,153.41 $1,397.56 $1,397.56 $1,187.09 $1,187.09 $958.44 $958.44 $916.44 $916.44 $979.98 $979.98 $1,032.75 $1,032.75 $1,251.36$1,046.46 $1,046.46 $1,119.02 $1,119.02 $1,179.27 $1,179.27 $1,428.90 $1,428.90 $1,213.70 $1,213.70 $979.93 $979.93 $936.99 $936.99 $1,001.95 $1,001.95 $1,055.90 $1,055.90 $1,279.41$1,075.24 $1,075.24 $1,149.79 $1,149.79 $1,211.70 $1,211.70 $1,468.19 $1,468.19 $1,247.07 $1,247.07 $1,006.87 $1,006.87 $962.75 $962.75 $1,029.50 $1,029.50 $1,084.93 $1,084.93 $1,314.59$1,092.72 $1,092.72 $1,168.48 $1,168.48 $1,231.40 $1,231.40 $1,492.06 $1,492.06 $1,267.35 $1,267.35 $1,023.25 $1,023.25 $978.41 $978.41 $1,046.24 $1,046.24 $1,102.58 $1,102.58 $1,335.97

SilMed: $4,30

0$35 /$8,1

Y

75729PAGeisinger Al

35/70M-152-121-

Rating

Geisinger Al

SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 5


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 3


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64+


$1,038.94 $882.47 $882.47 $789.10 $789.10 $754.52 $754.52 $806.83 $806.83 $850.27 $850.27 $1,030.26 $1,030.26 $875.10 $875.10 $693.14 $693.14 $662.77 $662.77$1,085.25 $921.81 $921.81 $824.27 $824.27 $788.15 $788.15 $842.79 $842.79 $888.18 $888.18 $1,076.18 $1,076.18 $914.11 $914.11 $724.04 $724.04 $692.31 $692.31$1,134.68 $963.80 $963.80 $861.82 $861.82 $824.05 $824.05 $881.18 $881.18 $928.63 $928.63 $1,125.20 $1,125.20 $955.74 $955.74 $757.02 $757.02 $723.85 $723.85$1,159.17 $984.60 $984.60 $880.42 $880.42 $841.84 $841.84 $900.20 $900.20 $948.68 $948.68 $1,149.49 $1,149.49 $976.37 $976.37 $773.36 $773.36 $739.47 $739.47$1,208.61 $1,026.59 $1,026.59 $917.96 $917.96 $877.74 $877.74 $938.59 $938.59 $989.13 $989.13 $1,198.51 $1,198.51 $1,018.01 $1,018.01 $806.34 $806.34 $771.00 $771.00$1,251.36 $1,062.90 $1,062.90 $950.43 $950.43 $908.78 $908.78 $971.79 $971.79 $1,024.12 $1,024.12 $1,240.90 $1,240.90 $1,054.02 $1,054.02 $834.86 $834.86 $798.28 $798.28$1,279.41 $1,086.73 $1,086.73 $971.74 $971.74 $929.16 $929.16 $993.58 $993.58 $1,047.08 $1,047.08 $1,268.72 $1,268.72 $1,077.65 $1,077.65 $853.58 $853.58 $816.17 $816.17$1,314.59 $1,116.61 $1,116.61 $998.46 $998.46 $954.71 $954.71 $1,020.90 $1,020.90 $1,075.87 $1,075.87 $1,303.61 $1,303.61 $1,107.28 $1,107.28 $877.05 $877.05 $838.62 $838.62$1,335.97 $1,134.77 $1,134.77 $1,014.70 $1,014.70 $970.23 $970.23 $1,037.50 $1,037.50 $1,093.36 $1,093.36 $1,324.81 $1,324.81 $1,125.29 $1,125.29 $891.31 $891.31 $852.25 $852.25


0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 3



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 7


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 5


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 9


ver0 / Rx: $500%/ $70150es


l-Access PPO

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0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$232.39 $232.39 $244.90 $244.90 $296.75 $296.75 $252.06 $252.06 $241.40 $241.40 $272.03 $272.03 $279.98 $279.98 $296.54 $296.54 $283.54 $283.54 $303.20$253.05 $253.05 $266.67 $266.67 $323.12 $323.12 $274.46 $274.46 $262.86 $262.86 $296.21 $296.21 $304.86 $304.86 $322.90 $322.90 $308.75 $308.75 $330.15$260.95 $260.95 $275.00 $275.00 $333.21 $333.21 $283.03 $283.03 $271.06 $271.06 $305.46 $305.46 $314.38 $314.38 $332.97 $332.97 $318.38 $318.38 $340.46$268.85 $268.85 $283.32 $283.32 $343.29 $343.29 $291.59 $291.59 $279.26 $279.26 $314.71 $314.71 $323.89 $323.89 $343.05 $343.05 $328.02 $328.02 $350.76$277.35 $277.35 $292.29 $292.29 $354.16 $354.16 $300.82 $300.82 $288.10 $288.10 $324.66 $324.66 $334.14 $334.14 $353.91 $353.91 $338.40 $338.40 $361.86$285.86 $285.86 $301.25 $301.25 $365.02 $365.02 $310.04 $310.04 $296.94 $296.94 $334.62 $334.62 $344.39 $344.39 $364.76 $364.76 $348.78 $348.78 $372.96$294.67 $294.67 $310.53 $310.53 $376.27 $376.27 $319.60 $319.60 $306.09 $306.09 $344.93 $344.93 $355.00 $355.00 $376.00 $376.00 $359.53 $359.53 $384.45$303.78 $303.78 $320.14 $320.14 $387.91 $387.91 $329.49 $329.49 $315.56 $315.56 $355.61 $355.61 $365.99 $365.99 $387.64 $387.64 $370.65 $370.65 $396.35$303.78 $303.78 $320.14 $320.14 $387.91 $387.91 $329.49 $329.49 $315.56 $315.56 $355.61 $355.61 $365.99 $365.99 $387.64 $387.64 $370.65 $370.65 $396.35$303.78 $303.78 $320.14 $320.14 $387.91 $387.91 $329.49 $329.49 $315.56 $315.56 $355.61 $355.61 $365.99 $365.99 $387.64 $387.64 $370.65 $370.65 $396.35$303.78 $303.78 $320.14 $320.14 $387.91 $387.91 $329.49 $329.49 $315.56 $315.56 $355.61 $355.61 $365.99 $365.99 $387.64 $387.64 $370.65 $370.65 $396.35$304.99 $304.99 $321.42 $321.42 $389.46 $389.46 $330.80 $330.80 $316.82 $316.82 $357.02 $357.02 $367.45 $367.45 $389.18 $389.18 $372.13 $372.13 $397.93$311.07 $311.07 $327.82 $327.82 $397.21 $397.21 $337.39 $337.39 $323.13 $323.13 $364.13 $364.13 $374.77 $374.77 $396.93 $396.93 $379.54 $379.54 $405.85$318.36 $318.36 $335.50 $335.50 $406.52 $406.52 $345.30 $345.30 $330.70 $330.70 $372.67 $372.67 $383.55 $383.55 $406.24 $406.24 $388.44 $388.44 $415.37$330.21 $330.21 $347.99 $347.99 $421.65 $421.65 $358.15 $358.15 $343.01 $343.01 $386.54 $386.54 $397.82 $397.82 $421.35 $421.35 $402.89 $402.89 $430.82$339.93 $339.93 $358.23 $358.23 $434.06 $434.06 $368.69 $368.69 $353.10 $353.10 $397.92 $397.92 $409.53 $409.53 $433.76 $433.76 $414.75 $414.75 $443.51$344.79 $344.79 $363.36 $363.36 $440.27 $440.27 $373.96 $373.96 $358.15 $358.15 $403.61 $403.61 $415.39 $415.39 $439.96 $439.96 $420.68 $420.68 $449.85$352.08 $352.08 $371.04 $371.04 $449.58 $449.58 $381.87 $381.87 $365.73 $365.73 $412.14 $412.14 $424.17 $424.17 $449.26 $449.26 $429.58 $429.58 $459.36$359.37 $359.37 $378.72 $378.72 $458.89 $458.89 $389.78 $389.78 $373.30 $373.30 $420.67 $420.67 $432.96 $432.96 $458.57 $458.57 $438.47 $438.47 $468.87$363.93 $363.93 $383.52 $383.52 $464.71 $464.71 $394.72 $394.72 $378.03 $378.03 $426.01 $426.01 $438.45 $438.45 $464.38 $464.38 $444.03 $444.03 $474.82$368.79 $368.79 $388.65 $388.65 $470.91 $470.91 $399.99 $399.99 $383.08 $383.08 $431.70 $431.70 $444.30 $444.30 $470.58 $470.58 $449.96 $449.96 $481.16$371.22 $371.22 $391.21 $391.21 $474.02 $474.02 $402.63 $402.63 $385.61 $385.61 $434.54 $434.54 $447.23 $447.23 $473.68 $473.68 $452.93 $452.93 $484.33$373.65 $373.65 $393.77 $393.77 $477.12 $477.12 $405.27 $405.27 $388.13 $388.13 $437.39 $437.39 $450.16 $450.16 $476.79 $476.79 $455.89 $455.89 $487.50$376.08 $376.08 $396.33 $396.33 $480.22 $480.22 $407.90 $407.90 $390.66 $390.66 $440.23 $440.23 $453.09 $453.09 $479.89 $479.89 $458.86 $458.86 $490.67$378.51 $378.51 $398.89 $398.89 $483.33 $483.33 $410.54 $410.54 $393.18 $393.18 $443.08 $443.08 $456.01 $456.01 $482.99 $482.99 $461.82 $461.82 $493.84$383.37 $383.37 $404.01 $404.01 $489.53 $489.53 $415.81 $415.81 $398.23 $398.23 $448.77 $448.77 $461.87 $461.87 $489.19 $489.19 $467.75 $467.75 $500.18$388.23 $388.23 $409.14 $409.14 $495.74 $495.74 $421.08 $421.08 $403.28 $403.28 $454.46 $454.46 $467.73 $467.73 $495.39 $495.39 $473.68 $473.68 $506.52$395.52 $395.52 $416.82 $416.82 $505.05 $505.05 $428.99 $428.99 $410.85 $410.85 $462.99 $462.99 $476.51 $476.51 $504.70 $504.70 $482.58 $482.58 $516.04$402.51 $402.51 $424.18 $424.18 $513.97 $513.97 $436.57 $436.57 $418.11 $418.11 $471.17 $471.17 $484.93 $484.93 $513.61 $513.61 $491.10 $491.10 $525.15$412.23 $412.23 $434.43 $434.43 $526.39 $526.39 $447.11 $447.11 $428.21 $428.21 $482.55 $482.55 $496.64 $496.64 $526.01 $526.01 $502.96 $502.96 $537.84$424.38 $424.38 $447.23 $447.23 $541.90 $541.90 $460.29 $460.29 $440.83 $440.83 $496.77 $496.77 $511.28 $511.28 $541.52 $541.52 $517.79 $517.79 $553.69$438.66 $438.66 $462.28 $462.28 $560.13 $560.13 $475.78 $475.78 $455.66 $455.66 $513.49 $513.49 $528.48 $528.48 $559.74 $559.74 $535.21 $535.21 $572.32$455.67 $455.67 $480.21 $480.21 $581.86 $581.86 $494.23 $494.23 $473.33 $473.33 $533.40 $533.40 $548.97 $548.97 $581.45 $581.45 $555.97 $555.97 $594.51$474.81 $474.81 $500.37 $500.37 $606.29 $606.29 $514.98 $514.98 $493.21 $493.21 $555.80 $555.80 $572.03 $572.03 $605.87 $605.87 $579.32 $579.32 $619.48$496.68 $496.68 $523.42 $523.42 $634.22 $634.22 $538.71 $538.71 $515.93 $515.93 $581.41 $581.41 $598.38 $598.38 $633.78 $633.78 $606.00 $606.00 $648.02$518.25 $518.25 $546.15 $546.15 $661.76 $661.76 $562.10 $562.10 $538.33 $538.33 $606.65 $606.65 $624.37 $624.37 $661.30 $661.30 $632.32 $632.32 $676.16$542.55 $542.55 $571.77 $571.77 $692.80 $692.80 $588.46 $588.46 $563.58 $563.58 $635.10 $635.10 $653.64 $653.64 $692.31 $692.31 $661.97 $661.97 $707.87$566.55 $566.55 $597.06 $597.06 $723.44 $723.44 $614.49 $614.49 $588.51 $588.51 $663.19 $663.19 $682.56 $682.56 $722.93 $722.93 $691.25 $691.25 $739.18$592.98 $592.98 $624.91 $624.91 $757.19 $757.19 $643.15 $643.15 $615.96 $615.96 $694.13 $694.13 $714.40 $714.40 $756.65 $756.65 $723.50 $723.50 $773.66$619.71 $619.71 $653.08 $653.08 $791.32 $791.32 $672.15 $672.15 $643.73 $643.73 $725.42 $725.42 $746.60 $746.60 $790.77 $790.77 $756.11 $756.11 $808.54$648.57 $648.57 $683.49 $683.49 $828.17 $828.17 $703.45 $703.45 $673.71 $673.71 $759.21 $759.21 $781.37 $781.37 $827.59 $827.59 $791.33 $791.33 $846.19$677.43 $677.43 $713.91 $713.91 $865.02 $865.02 $734.75 $734.75 $703.68 $703.68 $792.99 $792.99 $816.14 $816.14 $864.42 $864.42 $826.54 $826.54 $883.84$708.72 $708.72 $746.88 $746.88 $904.98 $904.98 $768.69 $768.69 $736.19 $736.19 $829.61 $829.61 $853.84 $853.84 $904.34 $904.34 $864.71 $864.71 $924.66$740.31 $740.31 $780.17 $780.17 $945.32 $945.32 $802.95 $802.95 $769.00 $769.00 $866.60 $866.60 $891.90 $891.90 $944.66 $944.66 $903.26 $903.26 $965.88$774.03 $774.03 $815.71 $815.71 $988.38 $988.38 $839.53 $839.53 $804.03 $804.03 $906.07 $906.07 $932.52 $932.52 $987.68 $987.68 $944.40 $944.40 $1,009.88$790.74 $790.74 $833.32 $833.32 $1,009.71 $1,009.71 $857.65 $857.65 $821.39 $821.39 $925.63 $925.63 $952.65 $952.65 $1,009.00 $1,009.00 $964.79 $964.79 $1,031.68$824.46 $824.46 $868.85 $868.85 $1,052.77 $1,052.77 $894.22 $894.22 $856.41 $856.41 $965.10 $965.10 $993.28 $993.28 $1,052.03 $1,052.03 $1,005.93 $1,005.93 $1,075.67$853.62 $853.62 $899.59 $899.59 $1,090.01 $1,090.01 $925.85 $925.85 $886.70 $886.70 $999.24 $999.24 $1,028.41 $1,028.41 $1,089.24 $1,089.24 $1,041.51 $1,041.51 $1,113.72$872.76 $872.76 $919.75 $919.75 $1,114.45 $1,114.45 $946.61 $946.61 $906.58 $906.58 $1,021.64 $1,021.64 $1,051.47 $1,051.47 $1,113.66 $1,113.66 $1,064.86 $1,064.86 $1,138.69$896.76 $896.76 $945.05 $945.05 $1,145.09 $1,145.09 $972.64 $972.64 $931.51 $931.51 $1,049.73 $1,049.73 $1,080.38 $1,080.38 $1,144.29 $1,144.29 $1,094.14 $1,094.14 $1,170.00$911.34 $911.34 $960.41 $960.41 $1,163.71 $1,163.71 $988.45 $988.45 $946.66 $946.66 $1,066.80 $1,066.80 $1,097.95 $1,097.95 $1,162.89 $1,162.89 $1,111.93 $1,111.93 $1,189.02

GoMed: $2,0

0$25 /$7,3

Y

75729PAGeisinger Al

25/50/20M-152-121-

Rating

Geisinger Al

GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 9


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 6


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 3



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 9



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 7



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 6



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 5


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Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$303.20 $319.53 $319.53 $387.16 $387.16 $328.86 $328.86 $358.17 $358.17 $342.48 $342.48 $366.22 $366.22 $385.94 $385.94 $467.64 $467.64 $397.21 $397.21$330.15 $347.93 $347.93 $421.58 $421.58 $358.09 $358.09 $390.01 $390.01 $372.92 $372.92 $398.77 $398.77 $420.25 $420.25 $509.20 $509.20 $432.52 $432.52$340.46 $358.79 $358.79 $434.74 $434.74 $369.27 $369.27 $402.18 $402.18 $384.56 $384.56 $411.22 $411.22 $433.36 $433.36 $525.10 $525.10 $446.02 $446.02$350.76 $369.65 $369.65 $447.90 $447.90 $380.44 $380.44 $414.36 $414.36 $396.20 $396.20 $423.67 $423.67 $446.48 $446.48 $540.99 $540.99 $459.52 $459.52$361.86 $381.34 $381.34 $462.07 $462.07 $392.48 $392.48 $427.47 $427.47 $408.73 $408.73 $437.07 $437.07 $460.61 $460.61 $558.11 $558.11 $474.05 $474.05$372.96 $393.04 $393.04 $476.24 $476.24 $404.52 $404.52 $440.58 $440.58 $421.27 $421.27 $450.48 $450.48 $474.73 $474.73 $575.22 $575.22 $488.59 $488.59$384.45 $405.15 $405.15 $490.91 $490.91 $416.98 $416.98 $454.15 $454.15 $434.25 $434.25 $464.36 $464.36 $489.36 $489.36 $592.95 $592.95 $503.65 $503.65$396.35 $417.69 $417.69 $506.10 $506.10 $429.88 $429.88 $468.20 $468.20 $447.69 $447.69 $478.73 $478.73 $504.50 $504.50 $611.29 $611.29 $519.23 $519.23$396.35 $417.69 $417.69 $506.10 $506.10 $429.88 $429.88 $468.20 $468.20 $447.69 $447.69 $478.73 $478.73 $504.50 $504.50 $611.29 $611.29 $519.23 $519.23$396.35 $417.69 $417.69 $506.10 $506.10 $429.88 $429.88 $468.20 $468.20 $447.69 $447.69 $478.73 $478.73 $504.50 $504.50 $611.29 $611.29 $519.23 $519.23$396.35 $417.69 $417.69 $506.10 $506.10 $429.88 $429.88 $468.20 $468.20 $447.69 $447.69 $478.73 $478.73 $504.50 $504.50 $611.29 $611.29 $519.23 $519.23$397.93 $419.35 $419.35 $508.12 $508.12 $431.60 $431.60 $470.07 $470.07 $449.47 $449.47 $480.63 $480.63 $506.52 $506.52 $613.73 $613.73 $521.30 $521.30$405.85 $427.71 $427.71 $518.24 $518.24 $440.20 $440.20 $479.44 $479.44 $458.43 $458.43 $490.21 $490.21 $516.61 $516.61 $625.96 $625.96 $531.69 $531.69$415.37 $437.73 $437.73 $530.39 $530.39 $450.51 $450.51 $490.67 $490.67 $469.17 $469.17 $501.70 $501.70 $528.71 $528.71 $640.63 $640.63 $544.15 $544.15$430.82 $454.02 $454.02 $550.13 $550.13 $467.28 $467.28 $508.93 $508.93 $486.63 $486.63 $520.37 $520.37 $548.39 $548.39 $664.47 $664.47 $564.40 $564.40$443.51 $467.39 $467.39 $566.32 $566.32 $481.03 $481.03 $523.91 $523.91 $500.96 $500.96 $535.69 $535.69 $564.53 $564.53 $684.03 $684.03 $581.02 $581.02$449.85 $474.07 $474.07 $574.42 $574.42 $487.91 $487.91 $531.41 $531.41 $508.12 $508.12 $543.35 $543.35 $572.60 $572.60 $693.81 $693.81 $589.32 $589.32$459.36 $484.09 $484.09 $586.57 $586.57 $498.23 $498.23 $542.64 $542.64 $518.86 $518.86 $554.84 $554.84 $584.71 $584.71 $708.48 $708.48 $601.78 $601.78$468.87 $494.12 $494.12 $598.71 $598.71 $508.55 $508.55 $553.88 $553.88 $529.61 $529.61 $566.33 $566.33 $596.82 $596.82 $723.15 $723.15 $614.25 $614.25$474.82 $500.38 $500.38 $606.30 $606.30 $514.99 $514.99 $560.90 $560.90 $536.32 $536.32 $573.51 $573.51 $604.39 $604.39 $732.32 $732.32 $622.03 $622.03$481.16 $507.07 $507.07 $614.40 $614.40 $521.87 $521.87 $568.39 $568.39 $543.49 $543.49 $581.17 $581.17 $612.46 $612.46 $742.10 $742.10 $630.34 $630.34$484.33 $510.41 $510.41 $618.45 $618.45 $525.31 $525.31 $572.14 $572.14 $547.07 $547.07 $585.00 $585.00 $616.50 $616.50 $746.99 $746.99 $634.50 $634.50$487.50 $513.75 $513.75 $622.50 $622.50 $528.75 $528.75 $575.88 $575.88 $550.65 $550.65 $588.83 $588.83 $620.53 $620.53 $751.89 $751.89 $638.65 $638.65$490.67 $517.09 $517.09 $626.55 $626.55 $532.19 $532.19 $579.63 $579.63 $554.23 $554.23 $592.66 $592.66 $624.57 $624.57 $756.78 $756.78 $642.80 $642.80$493.84 $520.43 $520.43 $630.60 $630.60 $535.63 $535.63 $583.38 $583.38 $557.81 $557.81 $596.49 $596.49 $628.60 $628.60 $761.67 $761.67 $646.96 $646.96$500.18 $527.12 $527.12 $638.70 $638.70 $542.51 $542.51 $590.87 $590.87 $564.97 $564.97 $604.14 $604.14 $636.68 $636.68 $771.45 $771.45 $655.26 $655.26$506.52 $533.80 $533.80 $646.79 $646.79 $549.38 $549.38 $598.36 $598.36 $572.14 $572.14 $611.80 $611.80 $644.75 $644.75 $781.23 $781.23 $663.57 $663.57$516.04 $543.82 $543.82 $658.94 $658.94 $559.70 $559.70 $609.59 $609.59 $582.88 $582.88 $623.29 $623.29 $656.86 $656.86 $795.90 $795.90 $676.03 $676.03$525.15 $553.43 $553.43 $670.58 $670.58 $569.59 $569.59 $620.36 $620.36 $593.18 $593.18 $634.30 $634.30 $668.46 $668.46 $809.96 $809.96 $687.98 $687.98$537.84 $566.80 $566.80 $686.77 $686.77 $583.34 $583.34 $635.35 $635.35 $607.50 $607.50 $649.62 $649.62 $684.60 $684.60 $829.52 $829.52 $704.59 $704.59$553.69 $583.50 $583.50 $707.02 $707.02 $600.54 $600.54 $654.07 $654.07 $625.41 $625.41 $668.77 $668.77 $704.78 $704.78 $853.97 $853.97 $725.36 $725.36$572.32 $603.13 $603.13 $730.80 $730.80 $620.74 $620.74 $676.08 $676.08 $646.45 $646.45 $691.27 $691.27 $728.49 $728.49 $882.70 $882.70 $749.76 $749.76$594.51 $626.52 $626.52 $759.15 $759.15 $644.82 $644.82 $702.30 $702.30 $671.52 $671.52 $718.08 $718.08 $756.75 $756.75 $916.93 $916.93 $778.84 $778.84$619.48 $652.84 $652.84 $791.03 $791.03 $671.90 $671.90 $731.79 $731.79 $699.73 $699.73 $748.24 $748.24 $788.53 $788.53 $955.44 $955.44 $811.55 $811.55$648.02 $682.91 $682.91 $827.47 $827.47 $702.85 $702.85 $765.50 $765.50 $731.96 $731.96 $782.71 $782.71 $824.85 $824.85 $999.46 $999.46 $848.94 $848.94$676.16 $712.57 $712.57 $863.40 $863.40 $733.37 $733.37 $798.75 $798.75 $763.75 $763.75 $816.70 $816.70 $860.67 $860.67 $1,042.86 $1,042.86 $885.80 $885.80$707.87 $745.98 $745.98 $903.89 $903.89 $767.76 $767.76 $836.20 $836.20 $799.56 $799.56 $854.99 $854.99 $901.03 $901.03 $1,091.76 $1,091.76 $927.34 $927.34$739.18 $778.98 $778.98 $943.87 $943.87 $801.72 $801.72 $873.19 $873.19 $834.93 $834.93 $892.81 $892.81 $940.89 $940.89 $1,140.05 $1,140.05 $968.36 $968.36$773.66 $815.32 $815.32 $987.90 $987.90 $839.12 $839.12 $913.92 $913.92 $873.88 $873.88 $934.46 $934.46 $984.78 $984.78 $1,193.24 $1,193.24 $1,013.53 $1,013.53$808.54 $852.07 $852.07 $1,032.44 $1,032.44 $876.95 $876.95 $955.13 $955.13 $913.27 $913.27 $976.59 $976.59 $1,029.17 $1,029.17 $1,247.03 $1,247.03 $1,059.22 $1,059.22$846.19 $891.75 $891.75 $1,080.52 $1,080.52 $917.79 $917.79 $999.60 $999.60 $955.80 $955.80 $1,022.07 $1,022.07 $1,077.10 $1,077.10 $1,305.10 $1,305.10 $1,108.55 $1,108.55$883.84 $931.43 $931.43 $1,128.60 $1,128.60 $958.63 $958.63 $1,044.08 $1,044.08 $998.33 $998.33 $1,067.55 $1,067.55 $1,125.03 $1,125.03 $1,363.17 $1,363.17 $1,157.88 $1,157.88$924.66 $974.45 $974.45 $1,180.73 $1,180.73 $1,002.91 $1,002.91 $1,092.31 $1,092.31 $1,044.44 $1,044.44 $1,116.85 $1,116.85 $1,176.99 $1,176.99 $1,426.14 $1,426.14 $1,211.36 $1,211.36$965.88 $1,017.89 $1,017.89 $1,233.36 $1,233.36 $1,047.61 $1,047.61 $1,141.00 $1,141.00 $1,091.00 $1,091.00 $1,166.64 $1,166.64 $1,229.46 $1,229.46 $1,489.71 $1,489.71 $1,265.36 $1,265.36

$1,009.88 $1,064.26 $1,064.26 $1,289.54 $1,289.54 $1,095.33 $1,095.33 $1,192.97 $1,192.97 $1,140.69 $1,140.69 $1,219.78 $1,219.78 $1,285.46 $1,285.46 $1,557.56 $1,557.56 $1,322.99 $1,322.99$1,031.68 $1,087.23 $1,087.23 $1,317.37 $1,317.37 $1,118.97 $1,118.97 $1,218.72 $1,218.72 $1,165.32 $1,165.32 $1,246.11 $1,246.11 $1,313.21 $1,313.21 $1,591.18 $1,591.18 $1,351.55 $1,351.55$1,075.67 $1,133.59 $1,133.59 $1,373.55 $1,373.55 $1,166.69 $1,166.69 $1,270.69 $1,270.69 $1,215.01 $1,215.01 $1,299.25 $1,299.25 $1,369.21 $1,369.21 $1,659.04 $1,659.04 $1,409.18 $1,409.18$1,113.72 $1,173.69 $1,173.69 $1,422.13 $1,422.13 $1,207.96 $1,207.96 $1,315.64 $1,315.64 $1,257.99 $1,257.99 $1,345.20 $1,345.20 $1,417.64 $1,417.64 $1,717.72 $1,717.72 $1,459.03 $1,459.03$1,138.69 $1,200.00 $1,200.00 $1,454.02 $1,454.02 $1,235.04 $1,235.04 $1,345.13 $1,345.13 $1,286.19 $1,286.19 $1,375.36 $1,375.36 $1,449.42 $1,449.42 $1,756.23 $1,756.23 $1,491.74 $1,491.74$1,170.00 $1,233.00 $1,233.00 $1,494.00 $1,494.00 $1,269.00 $1,269.00 $1,382.12 $1,382.12 $1,321.56 $1,321.56 $1,413.18 $1,413.18 $1,489.28 $1,489.28 $1,804.52 $1,804.52 $1,532.76 $1,532.76$1,189.02 $1,253.05 $1,253.05 $1,518.29 $1,518.29 $1,289.63 $1,289.63 $1,404.60 $1,404.60 $1,343.05 $1,343.05 $1,436.16 $1,436.16 $1,513.49 $1,513.49 $1,833.87 $1,833.87 $1,557.68 $1,557.68


0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 9



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 7



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 6



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 5



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 3



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 6


old00 / Rx: $0%/ $50350es


-F Rev. 1/20Area 5

l-Access PPO

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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$357.15 $357.15 $341.50 $341.50 $365.18 $365.18 $384.84 $384.84 $466.31 $466.31 $396.08 $396.08 $296.71 $296.71 $283.71 $283.71 $303.38 $303.38 $319.72$388.90 $388.90 $371.86 $371.86 $397.64 $397.64 $419.05 $419.05 $507.76 $507.76 $431.29 $431.29 $323.09 $323.09 $308.93 $308.93 $330.35 $330.35 $348.13$401.04 $401.04 $383.47 $383.47 $410.05 $410.05 $432.13 $432.13 $523.60 $523.60 $444.75 $444.75 $333.17 $333.17 $318.57 $318.57 $340.66 $340.66 $359.00$413.18 $413.18 $395.07 $395.07 $422.46 $422.46 $445.21 $445.21 $539.45 $539.45 $458.21 $458.21 $343.25 $343.25 $328.21 $328.21 $350.97 $350.97 $369.87$426.25 $426.25 $407.57 $407.57 $435.83 $435.83 $459.30 $459.30 $556.52 $556.52 $472.71 $472.71 $354.11 $354.11 $338.60 $338.60 $362.07 $362.07 $381.57$439.32 $439.32 $420.07 $420.07 $449.20 $449.20 $473.38 $473.38 $573.59 $573.59 $487.20 $487.20 $364.97 $364.97 $348.98 $348.98 $373.18 $373.18 $393.27$452.86 $452.86 $433.02 $433.02 $463.04 $463.04 $487.97 $487.97 $591.26 $591.26 $502.22 $502.22 $376.22 $376.22 $359.74 $359.74 $384.68 $384.68 $405.39$466.87 $466.87 $446.41 $446.41 $477.36 $477.36 $503.07 $503.07 $609.56 $609.56 $517.76 $517.76 $387.86 $387.86 $370.87 $370.87 $396.58 $396.58 $417.93$466.87 $466.87 $446.41 $446.41 $477.36 $477.36 $503.07 $503.07 $609.56 $609.56 $517.76 $517.76 $387.86 $387.86 $370.87 $370.87 $396.58 $396.58 $417.93$466.87 $466.87 $446.41 $446.41 $477.36 $477.36 $503.07 $503.07 $609.56 $609.56 $517.76 $517.76 $387.86 $387.86 $370.87 $370.87 $396.58 $396.58 $417.93$466.87 $466.87 $446.41 $446.41 $477.36 $477.36 $503.07 $503.07 $609.56 $609.56 $517.76 $517.76 $387.86 $387.86 $370.87 $370.87 $396.58 $396.58 $417.93$468.74 $468.74 $448.20 $448.20 $479.27 $479.27 $505.08 $505.08 $611.99 $611.99 $519.82 $519.82 $389.41 $389.41 $372.35 $372.35 $398.16 $398.16 $419.60$478.07 $478.07 $457.12 $457.12 $488.82 $488.82 $515.14 $515.14 $624.18 $624.18 $530.18 $530.18 $397.17 $397.17 $379.76 $379.76 $406.09 $406.09 $427.96$489.28 $489.28 $467.84 $467.84 $500.27 $500.27 $527.21 $527.21 $638.81 $638.81 $542.60 $542.60 $406.48 $406.48 $388.66 $388.66 $415.61 $415.61 $437.99$507.49 $507.49 $485.25 $485.25 $518.89 $518.89 $546.83 $546.83 $662.58 $662.58 $562.80 $562.80 $421.60 $421.60 $403.13 $403.13 $431.08 $431.08 $454.29$522.43 $522.43 $499.53 $499.53 $534.17 $534.17 $562.93 $562.93 $682.09 $682.09 $579.36 $579.36 $434.01 $434.01 $415.00 $415.00 $443.77 $443.77 $467.66$529.90 $529.90 $506.68 $506.68 $541.80 $541.80 $570.98 $570.98 $691.84 $691.84 $587.65 $587.65 $440.22 $440.22 $420.93 $420.93 $450.11 $450.11 $474.35$541.10 $541.10 $517.39 $517.39 $553.26 $553.26 $583.05 $583.05 $706.47 $706.47 $600.07 $600.07 $449.53 $449.53 $429.83 $429.83 $459.63 $459.63 $484.38$552.31 $552.31 $528.10 $528.10 $564.72 $564.72 $595.12 $595.12 $721.10 $721.10 $612.50 $612.50 $458.84 $458.84 $438.73 $438.73 $469.15 $469.15 $494.41$559.31 $559.31 $534.80 $534.80 $571.88 $571.88 $602.67 $602.67 $730.24 $730.24 $620.27 $620.27 $464.65 $464.65 $444.29 $444.29 $475.10 $475.10 $500.68$566.78 $566.78 $541.94 $541.94 $579.51 $579.51 $610.72 $610.72 $740.00 $740.00 $628.55 $628.55 $470.86 $470.86 $450.23 $450.23 $481.44 $481.44 $507.37$570.51 $570.51 $545.51 $545.51 $583.33 $583.33 $614.74 $614.74 $744.87 $744.87 $632.69 $632.69 $473.96 $473.96 $453.19 $453.19 $484.61 $484.61 $510.71$574.25 $574.25 $549.08 $549.08 $587.15 $587.15 $618.77 $618.77 $749.75 $749.75 $636.83 $636.83 $477.07 $477.07 $456.16 $456.16 $487.79 $487.79 $514.05$577.98 $577.98 $552.66 $552.66 $590.97 $590.97 $622.79 $622.79 $754.62 $754.62 $640.98 $640.98 $480.17 $480.17 $459.13 $459.13 $490.96 $490.96 $517.40$581.72 $581.72 $556.23 $556.23 $594.79 $594.79 $626.82 $626.82 $759.50 $759.50 $645.12 $645.12 $483.27 $483.27 $462.09 $462.09 $494.13 $494.13 $520.74$589.19 $589.19 $563.37 $563.37 $602.43 $602.43 $634.87 $634.87 $769.25 $769.25 $653.40 $653.40 $489.48 $489.48 $468.03 $468.03 $500.48 $500.48 $527.43$596.66 $596.66 $570.51 $570.51 $610.07 $610.07 $642.92 $642.92 $779.01 $779.01 $661.69 $661.69 $495.68 $495.68 $473.96 $473.96 $506.82 $506.82 $534.11$607.86 $607.86 $581.23 $581.23 $621.52 $621.52 $654.99 $654.99 $793.64 $793.64 $674.11 $674.11 $504.99 $504.99 $482.86 $482.86 $516.34 $516.34 $544.14$618.60 $618.60 $591.49 $591.49 $632.50 $632.50 $666.56 $666.56 $807.66 $807.66 $686.02 $686.02 $513.91 $513.91 $491.39 $491.39 $525.46 $525.46 $553.76$633.54 $633.54 $605.78 $605.78 $647.78 $647.78 $682.66 $682.66 $827.16 $827.16 $702.59 $702.59 $526.32 $526.32 $503.26 $503.26 $538.15 $538.15 $567.13$652.21 $652.21 $623.63 $623.63 $666.87 $666.87 $702.78 $702.78 $851.54 $851.54 $723.30 $723.30 $541.84 $541.84 $518.09 $518.09 $554.01 $554.01 $583.85$674.16 $674.16 $644.62 $644.62 $689.31 $689.31 $726.42 $726.42 $880.19 $880.19 $747.63 $747.63 $560.07 $560.07 $535.53 $535.53 $572.65 $572.65 $603.49$700.30 $700.30 $669.61 $669.61 $716.04 $716.04 $754.60 $754.60 $914.33 $914.33 $776.63 $776.63 $581.79 $581.79 $556.29 $556.29 $594.86 $594.86 $626.89$729.71 $729.71 $697.74 $697.74 $746.11 $746.11 $786.29 $786.29 $952.73 $952.73 $809.25 $809.25 $606.22 $606.22 $579.66 $579.66 $619.85 $619.85 $653.22$763.33 $763.33 $729.88 $729.88 $780.48 $780.48 $822.51 $822.51 $996.62 $996.62 $846.52 $846.52 $634.15 $634.15 $606.36 $606.36 $648.40 $648.40 $683.31$796.48 $796.48 $761.58 $761.58 $814.38 $814.38 $858.23 $858.23 $1,039.89 $1,039.89 $883.28 $883.28 $661.69 $661.69 $632.69 $632.69 $676.56 $676.56 $712.99$833.83 $833.83 $797.29 $797.29 $852.56 $852.56 $898.47 $898.47 $1,088.66 $1,088.66 $924.70 $924.70 $692.72 $692.72 $662.36 $662.36 $708.28 $708.28 $746.42$870.71 $870.71 $832.55 $832.55 $890.28 $890.28 $938.21 $938.21 $1,136.81 $1,136.81 $965.61 $965.61 $723.36 $723.36 $691.66 $691.66 $739.61 $739.61 $779.44$911.33 $911.33 $871.39 $871.39 $931.81 $931.81 $981.98 $981.98 $1,189.84 $1,189.84 $1,010.65 $1,010.65 $757.10 $757.10 $723.92 $723.92 $774.11 $774.11 $815.80$952.41 $952.41 $910.68 $910.68 $973.81 $973.81 $1,026.25 $1,026.25 $1,243.49 $1,243.49 $1,056.21 $1,056.21 $791.23 $791.23 $756.56 $756.56 $809.01 $809.01 $852.57$996.76 $996.76 $953.09 $953.09 $1,019.16 $1,019.16 $1,074.04 $1,074.04 $1,301.39 $1,301.39 $1,105.40 $1,105.40 $828.08 $828.08 $791.79 $791.79 $846.69 $846.69 $892.28

$1,041.12 $1,041.12 $995.49 $995.49 $1,064.51 $1,064.51 $1,121.83 $1,121.83 $1,359.30 $1,359.30 $1,154.59 $1,154.59 $864.92 $864.92 $827.02 $827.02 $884.36 $884.36 $931.98$1,089.20 $1,089.20 $1,041.47 $1,041.47 $1,113.68 $1,113.68 $1,173.65 $1,173.65 $1,422.08 $1,422.08 $1,207.91 $1,207.91 $904.87 $904.87 $865.22 $865.22 $925.21 $925.21 $975.03$1,137.76 $1,137.76 $1,087.90 $1,087.90 $1,163.33 $1,163.33 $1,225.97 $1,225.97 $1,485.48 $1,485.48 $1,261.76 $1,261.76 $945.21 $945.21 $903.79 $903.79 $966.45 $966.45 $1,018.49$1,189.58 $1,189.58 $1,137.45 $1,137.45 $1,216.31 $1,216.31 $1,281.81 $1,281.81 $1,553.14 $1,553.14 $1,319.23 $1,319.23 $988.26 $988.26 $944.96 $944.96 $1,010.47 $1,010.47 $1,064.88$1,215.26 $1,215.26 $1,162.01 $1,162.01 $1,242.57 $1,242.57 $1,309.47 $1,309.47 $1,586.66 $1,586.66 $1,347.71 $1,347.71 $1,009.60 $1,009.60 $965.35 $965.35 $1,032.28 $1,032.28 $1,087.87$1,267.08 $1,267.08 $1,211.56 $1,211.56 $1,295.55 $1,295.55 $1,365.31 $1,365.31 $1,654.32 $1,654.32 $1,405.18 $1,405.18 $1,052.65 $1,052.65 $1,006.52 $1,006.52 $1,076.30 $1,076.30 $1,134.26$1,311.90 $1,311.90 $1,254.41 $1,254.41 $1,341.38 $1,341.38 $1,413.61 $1,413.61 $1,712.84 $1,712.84 $1,454.88 $1,454.88 $1,089.88 $1,089.88 $1,042.12 $1,042.12 $1,114.37 $1,114.37 $1,174.38$1,341.31 $1,341.31 $1,282.54 $1,282.54 $1,371.45 $1,371.45 $1,445.30 $1,445.30 $1,751.24 $1,751.24 $1,487.50 $1,487.50 $1,114.32 $1,114.32 $1,065.49 $1,065.49 $1,139.36 $1,139.36 $1,200.71$1,378.19 $1,378.19 $1,317.80 $1,317.80 $1,409.17 $1,409.17 $1,485.04 $1,485.04 $1,799.40 $1,799.40 $1,528.40 $1,528.40 $1,144.96 $1,144.96 $1,094.79 $1,094.79 $1,170.69 $1,170.69 $1,233.72$1,400.60 $1,400.60 $1,339.23 $1,339.23 $1,432.08 $1,432.08 $1,509.19 $1,509.19 $1,828.65 $1,828.65 $1,553.25 $1,553.25 $1,163.58 $1,163.58 $1,112.59 $1,112.59 $1,189.72 $1,189.72 $1,253.79

GoMed: $500

20$25 /$6,8

Y

75729PAGeisinger Al

25/50M-152-121-

Rating

Geisinger Al

GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 2



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 6



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 5



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 3



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 2


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Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$319.72 $387.39 $387.39 $329.05 $329.05 $332.69 $332.69 $374.91 $374.91 $385.86 $385.86 $280.61 $280.61 $316.22 $316.22 $325.46 $325.46 $269.63 $269.63$348.13 $421.83 $421.83 $358.30 $358.30 $362.27 $362.27 $408.24 $408.24 $420.16 $420.16 $305.56 $305.56 $344.33 $344.33 $354.39 $354.39 $293.60 $293.60$359.00 $434.99 $434.99 $369.48 $369.48 $373.57 $373.57 $420.98 $420.98 $433.27 $433.27 $315.09 $315.09 $355.08 $355.08 $365.45 $365.45 $302.76 $302.76$369.87 $448.16 $448.16 $380.67 $380.67 $384.88 $384.88 $433.72 $433.72 $446.39 $446.39 $324.63 $324.63 $365.83 $365.83 $376.51 $376.51 $311.93 $311.93$381.57 $462.34 $462.34 $392.71 $392.71 $397.06 $397.06 $447.45 $447.45 $460.51 $460.51 $334.90 $334.90 $377.40 $377.40 $388.42 $388.42 $321.80 $321.80$393.27 $476.52 $476.52 $404.75 $404.75 $409.23 $409.23 $461.17 $461.17 $474.63 $474.63 $345.17 $345.17 $388.98 $388.98 $400.33 $400.33 $331.66 $331.66$405.39 $491.20 $491.20 $417.23 $417.23 $421.85 $421.85 $475.38 $475.38 $489.26 $489.26 $355.81 $355.81 $400.96 $400.96 $412.67 $412.67 $341.89 $341.89$417.93 $506.40 $506.40 $430.14 $430.14 $434.90 $434.90 $490.09 $490.09 $504.40 $504.40 $366.82 $366.82 $413.37 $413.37 $425.44 $425.44 $352.46 $352.46$417.93 $506.40 $506.40 $430.14 $430.14 $434.90 $434.90 $490.09 $490.09 $504.40 $504.40 $366.82 $366.82 $413.37 $413.37 $425.44 $425.44 $352.46 $352.46$417.93 $506.40 $506.40 $430.14 $430.14 $434.90 $434.90 $490.09 $490.09 $504.40 $504.40 $366.82 $366.82 $413.37 $413.37 $425.44 $425.44 $352.46 $352.46$417.93 $506.40 $506.40 $430.14 $430.14 $434.90 $434.90 $490.09 $490.09 $504.40 $504.40 $366.82 $366.82 $413.37 $413.37 $425.44 $425.44 $352.46 $352.46$419.60 $508.42 $508.42 $431.85 $431.85 $436.63 $436.63 $492.04 $492.04 $506.41 $506.41 $368.28 $368.28 $415.02 $415.02 $427.14 $427.14 $353.87 $353.87$427.96 $518.55 $518.55 $440.45 $440.45 $445.33 $445.33 $501.85 $501.85 $516.50 $516.50 $375.62 $375.62 $423.29 $423.29 $435.64 $435.64 $360.92 $360.92$437.99 $530.70 $530.70 $450.78 $450.78 $455.77 $455.77 $513.61 $513.61 $528.60 $528.60 $384.42 $384.42 $433.21 $433.21 $445.86 $445.86 $369.38 $369.38$454.29 $550.45 $550.45 $467.55 $467.55 $472.73 $472.73 $532.72 $532.72 $548.28 $548.28 $398.73 $398.73 $449.33 $449.33 $462.45 $462.45 $383.12 $383.12$467.66 $566.66 $566.66 $481.32 $481.32 $486.64 $486.64 $548.40 $548.40 $564.42 $564.42 $410.46 $410.46 $462.56 $462.56 $476.06 $476.06 $394.40 $394.40$474.35 $574.76 $574.76 $488.20 $488.20 $493.60 $493.60 $556.25 $556.25 $572.49 $572.49 $416.33 $416.33 $469.17 $469.17 $482.87 $482.87 $400.04 $400.04$484.38 $586.91 $586.91 $498.52 $498.52 $504.04 $504.04 $568.01 $568.01 $584.59 $584.59 $425.14 $425.14 $479.09 $479.09 $493.08 $493.08 $408.50 $408.50$494.41 $599.07 $599.07 $508.84 $508.84 $514.48 $514.48 $579.77 $579.77 $596.70 $596.70 $433.94 $433.94 $489.01 $489.01 $503.29 $503.29 $416.96 $416.96$500.68 $606.66 $606.66 $515.30 $515.30 $521.00 $521.00 $587.12 $587.12 $604.26 $604.26 $439.44 $439.44 $495.21 $495.21 $509.67 $509.67 $422.25 $422.25$507.37 $614.76 $614.76 $522.18 $522.18 $527.96 $527.96 $594.96 $594.96 $612.33 $612.33 $445.31 $445.31 $501.83 $501.83 $516.48 $516.48 $427.89 $427.89$510.71 $618.81 $618.81 $525.62 $525.62 $531.44 $531.44 $598.88 $598.88 $616.37 $616.37 $448.25 $448.25 $505.13 $505.13 $519.88 $519.88 $430.71 $430.71$514.05 $622.87 $622.87 $529.06 $529.06 $534.92 $534.92 $602.80 $602.80 $620.40 $620.40 $451.18 $451.18 $508.44 $508.44 $523.28 $523.28 $433.53 $433.53$517.40 $626.92 $626.92 $532.50 $532.50 $538.40 $538.40 $606.72 $606.72 $624.44 $624.44 $454.11 $454.11 $511.75 $511.75 $526.69 $526.69 $436.34 $436.34$520.74 $630.97 $630.97 $535.94 $535.94 $541.88 $541.88 $610.65 $610.65 $628.47 $628.47 $457.05 $457.05 $515.05 $515.05 $530.09 $530.09 $439.16 $439.16$527.43 $639.07 $639.07 $542.82 $542.82 $548.83 $548.83 $618.49 $618.49 $636.54 $636.54 $462.92 $462.92 $521.67 $521.67 $536.90 $536.90 $444.80 $444.80$534.11 $647.17 $647.17 $549.71 $549.71 $555.79 $555.79 $626.33 $626.33 $644.61 $644.61 $468.79 $468.79 $528.28 $528.28 $543.71 $543.71 $450.44 $450.44$544.14 $659.33 $659.33 $560.03 $560.03 $566.23 $566.23 $638.09 $638.09 $656.72 $656.72 $477.59 $477.59 $538.20 $538.20 $553.92 $553.92 $458.90 $458.90$553.76 $670.97 $670.97 $569.92 $569.92 $576.23 $576.23 $649.36 $649.36 $668.32 $668.32 $486.03 $486.03 $547.71 $547.71 $563.70 $563.70 $467.01 $467.01$567.13 $687.18 $687.18 $583.69 $583.69 $590.15 $590.15 $665.04 $665.04 $684.46 $684.46 $497.77 $497.77 $560.94 $560.94 $577.31 $577.31 $478.29 $478.29$583.85 $707.43 $707.43 $600.89 $600.89 $607.54 $607.54 $684.65 $684.65 $704.64 $704.64 $512.44 $512.44 $577.47 $577.47 $594.33 $594.33 $492.39 $492.39$603.49 $731.23 $731.23 $621.11 $621.11 $627.98 $627.98 $707.68 $707.68 $728.34 $728.34 $529.68 $529.68 $596.90 $596.90 $614.33 $614.33 $508.95 $508.95$626.89 $759.59 $759.59 $645.20 $645.20 $652.34 $652.34 $735.13 $735.13 $756.59 $756.59 $550.22 $550.22 $620.05 $620.05 $638.15 $638.15 $528.69 $528.69$653.22 $791.50 $791.50 $672.29 $672.29 $679.74 $679.74 $766.00 $766.00 $788.37 $788.37 $573.33 $573.33 $646.09 $646.09 $664.95 $664.95 $550.89 $550.89$683.31 $827.96 $827.96 $703.26 $703.26 $711.05 $711.05 $801.29 $801.29 $824.68 $824.68 $599.74 $599.74 $675.85 $675.85 $695.59 $695.59 $576.27 $576.27$712.99 $863.91 $863.91 $733.80 $733.80 $741.93 $741.93 $836.08 $836.08 $860.50 $860.50 $625.78 $625.78 $705.20 $705.20 $725.79 $725.79 $601.30 $601.30$746.42 $904.42 $904.42 $768.21 $768.21 $776.72 $776.72 $875.29 $875.29 $900.85 $900.85 $655.13 $655.13 $738.27 $738.27 $759.83 $759.83 $629.49 $629.49$779.44 $944.43 $944.43 $802.19 $802.19 $811.07 $811.07 $914.01 $914.01 $940.69 $940.69 $684.11 $684.11 $770.93 $770.93 $793.44 $793.44 $657.34 $657.34$815.80 $988.48 $988.48 $839.62 $839.62 $848.91 $848.91 $956.64 $956.64 $984.58 $984.58 $716.02 $716.02 $806.89 $806.89 $830.45 $830.45 $688.00 $688.00$852.57 $1,033.05 $1,033.05 $877.47 $877.47 $887.18 $887.18 $999.77 $999.77 $1,028.96 $1,028.96 $748.30 $748.30 $843.27 $843.27 $867.89 $867.89 $719.02 $719.02$892.28 $1,081.15 $1,081.15 $918.33 $918.33 $928.50 $928.50 $1,046.33 $1,046.33 $1,076.88 $1,076.88 $783.15 $783.15 $882.54 $882.54 $908.30 $908.30 $752.50 $752.50$931.98 $1,129.26 $1,129.26 $959.19 $959.19 $969.81 $969.81 $1,092.89 $1,092.89 $1,124.80 $1,124.80 $817.99 $817.99 $921.80 $921.80 $948.72 $948.72 $785.98 $785.98$975.03 $1,181.42 $1,181.42 $1,003.49 $1,003.49 $1,014.60 $1,014.60 $1,143.37 $1,143.37 $1,176.75 $1,176.75 $855.78 $855.78 $964.38 $964.38 $992.54 $992.54 $822.29 $822.29

$1,018.49 $1,234.08 $1,234.08 $1,048.23 $1,048.23 $1,059.83 $1,059.83 $1,194.34 $1,194.34 $1,229.21 $1,229.21 $893.92 $893.92 $1,007.37 $1,007.37 $1,036.78 $1,036.78 $858.94 $858.94$1,064.88 $1,290.29 $1,290.29 $1,095.97 $1,095.97 $1,108.11 $1,108.11 $1,248.74 $1,248.74 $1,285.19 $1,285.19 $934.64 $934.64 $1,053.26 $1,053.26 $1,084.01 $1,084.01 $898.07 $898.07$1,087.87 $1,318.15 $1,318.15 $1,119.63 $1,119.63 $1,132.03 $1,132.03 $1,275.69 $1,275.69 $1,312.94 $1,312.94 $954.82 $954.82 $1,075.99 $1,075.99 $1,107.41 $1,107.41 $917.45 $917.45$1,134.26 $1,374.36 $1,374.36 $1,167.37 $1,167.37 $1,180.30 $1,180.30 $1,330.09 $1,330.09 $1,368.92 $1,368.92 $995.53 $995.53 $1,121.87 $1,121.87 $1,154.63 $1,154.63 $956.58 $956.58$1,174.38 $1,422.97 $1,422.97 $1,208.67 $1,208.67 $1,222.05 $1,222.05 $1,377.14 $1,377.14 $1,417.35 $1,417.35 $1,030.75 $1,030.75 $1,161.56 $1,161.56 $1,195.47 $1,195.47 $990.41 $990.41$1,200.71 $1,454.87 $1,454.87 $1,235.77 $1,235.77 $1,249.45 $1,249.45 $1,408.01 $1,408.01 $1,449.12 $1,449.12 $1,053.85 $1,053.85 $1,187.60 $1,187.60 $1,222.27 $1,222.27 $1,012.62 $1,012.62$1,233.72 $1,494.88 $1,494.88 $1,269.75 $1,269.75 $1,283.80 $1,283.80 $1,446.73 $1,446.73 $1,488.97 $1,488.97 $1,082.83 $1,082.83 $1,220.25 $1,220.25 $1,255.88 $1,255.88 $1,040.46 $1,040.46$1,253.79 $1,519.18 $1,519.18 $1,290.39 $1,290.39 $1,304.68 $1,304.68 $1,470.25 $1,470.25 $1,513.18 $1,513.18 $1,100.44 $1,100.44 $1,240.10 $1,240.10 $1,276.30 $1,276.30 $1,057.38 $1,057.38

GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 3



0%$40 / $40$1,600

Yes

75729PA0050131





0%$40 / $40$1,600

Yes

75729PA0050131





0%$40 / $40$1,600

Yes

75729PA0050131




GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 7


old / Rx: $250

0%/ $50850es


l-Access PPO

Page Number: 52 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$303.85 $303.85 $312.72 $312.72 $237.55 $237.55 $267.69 $267.69 $275.51 $275.51 $332.63 $332.63 $318.06 $318.06 $340.11 $340.11 $358.42 $358.42 $434.29$330.86 $330.86 $340.52 $340.52 $258.66 $258.66 $291.49 $291.49 $300.00 $300.00 $362.20 $362.20 $346.33 $346.33 $370.34 $370.34 $390.28 $390.28 $472.89$341.19 $341.19 $351.15 $351.15 $266.73 $266.73 $300.59 $300.59 $309.36 $309.36 $373.51 $373.51 $357.14 $357.14 $381.90 $381.90 $402.46 $402.46 $487.66$351.51 $351.51 $361.78 $361.78 $274.81 $274.81 $309.68 $309.68 $318.73 $318.73 $384.81 $384.81 $367.95 $367.95 $393.46 $393.46 $414.64 $414.64 $502.42$362.63 $362.63 $373.22 $373.22 $283.50 $283.50 $319.48 $319.48 $328.81 $328.81 $396.99 $396.99 $379.59 $379.59 $405.91 $405.91 $427.76 $427.76 $518.31$373.76 $373.76 $384.67 $384.67 $292.20 $292.20 $329.28 $329.28 $338.89 $338.89 $409.16 $409.16 $391.23 $391.23 $418.35 $418.35 $440.88 $440.88 $534.21$385.27 $385.27 $396.52 $396.52 $301.20 $301.20 $339.43 $339.43 $349.34 $349.34 $421.77 $421.77 $403.29 $403.29 $431.25 $431.25 $454.47 $454.47 $550.67$397.19 $397.19 $408.79 $408.79 $310.52 $310.52 $349.93 $349.93 $360.15 $360.15 $434.82 $434.82 $415.77 $415.77 $444.59 $444.59 $468.53 $468.53 $567.71$397.19 $397.19 $408.79 $408.79 $310.52 $310.52 $349.93 $349.93 $360.15 $360.15 $434.82 $434.82 $415.77 $415.77 $444.59 $444.59 $468.53 $468.53 $567.71$397.19 $397.19 $408.79 $408.79 $310.52 $310.52 $349.93 $349.93 $360.15 $360.15 $434.82 $434.82 $415.77 $415.77 $444.59 $444.59 $468.53 $468.53 $567.71$397.19 $397.19 $408.79 $408.79 $310.52 $310.52 $349.93 $349.93 $360.15 $360.15 $434.82 $434.82 $415.77 $415.77 $444.59 $444.59 $468.53 $468.53 $567.71$398.78 $398.78 $410.42 $410.42 $311.76 $311.76 $351.32 $351.32 $361.58 $361.58 $436.55 $436.55 $417.42 $417.42 $446.36 $446.36 $470.40 $470.40 $569.97$406.72 $406.72 $418.60 $418.60 $317.97 $317.97 $358.32 $358.32 $368.78 $368.78 $445.25 $445.25 $425.74 $425.74 $455.26 $455.26 $479.77 $479.77 $581.33$416.26 $416.26 $428.41 $428.41 $325.42 $325.42 $366.72 $366.72 $377.43 $377.43 $455.69 $455.69 $435.72 $435.72 $465.93 $465.93 $491.01 $491.01 $594.95$431.75 $431.75 $444.35 $444.35 $337.53 $337.53 $380.37 $380.37 $391.47 $391.47 $472.64 $472.64 $451.93 $451.93 $483.26 $483.26 $509.29 $509.29 $617.09$444.46 $444.46 $457.43 $457.43 $347.47 $347.47 $391.57 $391.57 $403.00 $403.00 $486.56 $486.56 $465.24 $465.24 $497.49 $497.49 $524.28 $524.28 $635.26$450.81 $450.81 $463.97 $463.97 $352.44 $352.44 $397.16 $397.16 $408.76 $408.76 $493.51 $493.51 $471.89 $471.89 $504.60 $504.60 $531.78 $531.78 $644.34$460.34 $460.34 $473.78 $473.78 $359.89 $359.89 $405.56 $405.56 $417.40 $417.40 $503.95 $503.95 $481.87 $481.87 $515.27 $515.27 $543.02 $543.02 $657.97$469.88 $469.88 $483.59 $483.59 $367.34 $367.34 $413.96 $413.96 $426.05 $426.05 $514.38 $514.38 $491.84 $491.84 $525.94 $525.94 $554.26 $554.26 $671.59$475.83 $475.83 $489.73 $489.73 $372.00 $372.00 $419.21 $419.21 $431.45 $431.45 $520.91 $520.91 $498.08 $498.08 $532.61 $532.61 $561.29 $561.29 $680.11$482.19 $482.19 $496.27 $496.27 $376.97 $376.97 $424.81 $424.81 $437.21 $437.21 $527.86 $527.86 $504.73 $504.73 $539.73 $539.73 $568.79 $568.79 $689.19$485.37 $485.37 $499.54 $499.54 $379.45 $379.45 $427.61 $427.61 $440.09 $440.09 $531.34 $531.34 $508.06 $508.06 $543.28 $543.28 $572.54 $572.54 $693.73$488.54 $488.54 $502.81 $502.81 $381.94 $381.94 $430.41 $430.41 $442.97 $442.97 $534.82 $534.82 $511.39 $511.39 $546.84 $546.84 $576.28 $576.28 $698.27$491.72 $491.72 $506.08 $506.08 $384.42 $384.42 $433.21 $433.21 $445.86 $445.86 $538.30 $538.30 $514.71 $514.71 $550.40 $550.40 $580.03 $580.03 $702.81$494.90 $494.90 $509.35 $509.35 $386.90 $386.90 $436.01 $436.01 $448.74 $448.74 $541.78 $541.78 $518.04 $518.04 $553.95 $553.95 $583.78 $583.78 $707.36$501.25 $501.25 $515.89 $515.89 $391.87 $391.87 $441.60 $441.60 $454.50 $454.50 $548.74 $548.74 $524.69 $524.69 $561.07 $561.07 $591.28 $591.28 $716.44$507.61 $507.61 $522.43 $522.43 $396.84 $396.84 $447.20 $447.20 $460.26 $460.26 $555.69 $555.69 $531.34 $531.34 $568.18 $568.18 $598.77 $598.77 $725.52$517.14 $517.14 $532.24 $532.24 $404.29 $404.29 $455.60 $455.60 $468.90 $468.90 $566.13 $566.13 $541.32 $541.32 $578.85 $578.85 $610.02 $610.02 $739.15$526.28 $526.28 $541.64 $541.64 $411.44 $411.44 $463.65 $463.65 $477.19 $477.19 $576.13 $576.13 $550.88 $550.88 $589.08 $589.08 $620.79 $620.79 $752.20$538.99 $538.99 $554.72 $554.72 $421.37 $421.37 $474.85 $474.85 $488.71 $488.71 $590.04 $590.04 $564.19 $564.19 $603.30 $603.30 $635.79 $635.79 $770.37$554.87 $554.87 $571.08 $571.08 $433.79 $433.79 $488.84 $488.84 $503.12 $503.12 $607.44 $607.44 $580.82 $580.82 $621.09 $621.09 $654.53 $654.53 $793.08$573.54 $573.54 $590.29 $590.29 $448.39 $448.39 $505.29 $505.29 $520.04 $520.04 $627.87 $627.87 $600.36 $600.36 $641.98 $641.98 $676.55 $676.55 $819.76$595.78 $595.78 $613.18 $613.18 $465.78 $465.78 $524.89 $524.89 $540.21 $540.21 $652.22 $652.22 $623.64 $623.64 $666.88 $666.88 $702.79 $702.79 $851.55$620.81 $620.81 $638.93 $638.93 $485.34 $485.34 $546.93 $546.93 $562.90 $562.90 $679.61 $679.61 $649.83 $649.83 $694.89 $694.89 $732.30 $732.30 $887.32$649.41 $649.41 $668.37 $668.37 $507.70 $507.70 $572.13 $572.13 $588.83 $588.83 $710.92 $710.92 $679.77 $679.77 $726.90 $726.90 $766.04 $766.04 $928.19$677.61 $677.61 $697.39 $697.39 $529.74 $529.74 $596.97 $596.97 $614.40 $614.40 $741.79 $741.79 $709.29 $709.29 $758.46 $758.46 $799.30 $799.30 $968.50$709.38 $709.38 $730.09 $730.09 $554.58 $554.58 $624.97 $624.97 $643.21 $643.21 $776.58 $776.58 $742.55 $742.55 $794.03 $794.03 $836.78 $836.78 $1,013.91$740.76 $740.76 $762.39 $762.39 $579.11 $579.11 $652.61 $652.61 $671.66 $671.66 $810.93 $810.93 $775.39 $775.39 $829.15 $829.15 $873.80 $873.80 $1,058.76$775.31 $775.31 $797.95 $797.95 $606.13 $606.13 $683.05 $683.05 $703.00 $703.00 $848.76 $848.76 $811.56 $811.56 $867.83 $867.83 $914.56 $914.56 $1,108.15$810.27 $810.27 $833.93 $833.93 $633.45 $633.45 $713.85 $713.85 $734.69 $734.69 $887.02 $887.02 $848.15 $848.15 $906.95 $906.95 $955.79 $955.79 $1,158.11$848.00 $848.00 $872.76 $872.76 $662.95 $662.95 $747.09 $747.09 $768.90 $768.90 $928.33 $928.33 $887.65 $887.65 $949.19 $949.19 $1,000.30 $1,000.30 $1,212.04$885.73 $885.73 $911.59 $911.59 $692.45 $692.45 $780.33 $780.33 $803.12 $803.12 $969.64 $969.64 $927.15 $927.15 $991.42 $991.42 $1,044.81 $1,044.81 $1,265.97$926.64 $926.64 $953.70 $953.70 $724.44 $724.44 $816.37 $816.37 $840.21 $840.21 $1,014.42 $1,014.42 $969.97 $969.97 $1,037.22 $1,037.22 $1,093.07 $1,093.07 $1,324.45$967.95 $967.95 $996.21 $996.21 $756.73 $756.73 $852.77 $852.77 $877.66 $877.66 $1,059.64 $1,059.64 $1,013.21 $1,013.21 $1,083.45 $1,083.45 $1,141.79 $1,141.79 $1,383.49

$1,012.04 $1,012.04 $1,041.59 $1,041.59 $791.20 $791.20 $891.61 $891.61 $917.64 $917.64 $1,107.91 $1,107.91 $1,059.36 $1,059.36 $1,132.80 $1,132.80 $1,193.80 $1,193.80 $1,446.50$1,033.89 $1,033.89 $1,064.07 $1,064.07 $808.28 $808.28 $910.85 $910.85 $937.45 $937.45 $1,131.82 $1,131.82 $1,082.22 $1,082.22 $1,157.25 $1,157.25 $1,219.57 $1,219.57 $1,477.73$1,077.97 $1,077.97 $1,109.45 $1,109.45 $842.74 $842.74 $949.70 $949.70 $977.42 $977.42 $1,180.09 $1,180.09 $1,128.37 $1,128.37 $1,206.60 $1,206.60 $1,271.57 $1,271.57 $1,540.74$1,116.10 $1,116.10 $1,148.69 $1,148.69 $872.55 $872.55 $983.29 $983.29 $1,012.00 $1,012.00 $1,221.83 $1,221.83 $1,168.29 $1,168.29 $1,249.28 $1,249.28 $1,316.55 $1,316.55 $1,595.24$1,141.13 $1,141.13 $1,174.44 $1,174.44 $892.12 $892.12 $1,005.33 $1,005.33 $1,034.69 $1,034.69 $1,249.22 $1,249.22 $1,194.48 $1,194.48 $1,277.29 $1,277.29 $1,346.07 $1,346.07 $1,631.00$1,172.50 $1,172.50 $1,206.74 $1,206.74 $916.65 $916.65 $1,032.98 $1,032.98 $1,063.14 $1,063.14 $1,283.57 $1,283.57 $1,227.32 $1,227.32 $1,312.42 $1,312.42 $1,383.08 $1,383.08 $1,675.85$1,191.57 $1,191.57 $1,226.36 $1,226.36 $931.55 $931.55 $1,049.77 $1,049.77 $1,080.42 $1,080.42 $1,304.44 $1,304.44 $1,247.28 $1,247.28 $1,333.76 $1,333.76 $1,405.57 $1,405.57 $1,703.10

PlatiCombine

00% After D

$1,5Y


PPO M-152-122-

Rating

Geisinger Al



$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 6




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 5




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 3




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 2


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 9


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 6


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 6


Page Number: 53 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$434.29 $368.89 $368.89 $327.89 $327.89 $313.52 $313.52 $335.26 $335.26 $353.31 $353.31 $428.10 $428.10 $363.63 $363.63 $283.35 $283.35 $270.93 $270.93$472.89 $401.68 $401.68 $357.04 $357.04 $341.39 $341.39 $365.06 $365.06 $384.72 $384.72 $466.16 $466.16 $395.95 $395.95 $308.53 $308.53 $295.01 $295.01$487.66 $414.21 $414.21 $368.18 $368.18 $352.05 $352.05 $376.46 $376.46 $396.73 $396.73 $480.71 $480.71 $408.31 $408.31 $318.16 $318.16 $304.22 $304.22$502.42 $426.75 $426.75 $379.33 $379.33 $362.71 $362.71 $387.85 $387.85 $408.74 $408.74 $495.26 $495.26 $420.67 $420.67 $327.79 $327.79 $313.43 $313.43$518.31 $440.25 $440.25 $391.33 $391.33 $374.18 $374.18 $400.12 $400.12 $421.67 $421.67 $510.93 $510.93 $433.98 $433.98 $338.16 $338.16 $323.35 $323.35$534.21 $453.75 $453.75 $403.33 $403.33 $385.66 $385.66 $412.39 $412.39 $434.60 $434.60 $526.60 $526.60 $447.29 $447.29 $348.54 $348.54 $333.26 $333.26$550.67 $467.74 $467.74 $415.76 $415.76 $397.54 $397.54 $425.10 $425.10 $447.99 $447.99 $542.82 $542.82 $461.07 $461.07 $359.28 $359.28 $343.53 $343.53$567.71 $482.21 $482.21 $428.62 $428.62 $409.84 $409.84 $438.26 $438.26 $461.85 $461.85 $559.62 $559.62 $475.34 $475.34 $370.39 $370.39 $354.16 $354.16$567.71 $482.21 $482.21 $428.62 $428.62 $409.84 $409.84 $438.26 $438.26 $461.85 $461.85 $559.62 $559.62 $475.34 $475.34 $370.39 $370.39 $354.16 $354.16$567.71 $482.21 $482.21 $428.62 $428.62 $409.84 $409.84 $438.26 $438.26 $461.85 $461.85 $559.62 $559.62 $475.34 $475.34 $370.39 $370.39 $354.16 $354.16$567.71 $482.21 $482.21 $428.62 $428.62 $409.84 $409.84 $438.26 $438.26 $461.85 $461.85 $559.62 $559.62 $475.34 $475.34 $370.39 $370.39 $354.16 $354.16$569.97 $484.13 $484.13 $430.33 $430.33 $411.48 $411.48 $440.00 $440.00 $463.70 $463.70 $561.85 $561.85 $477.23 $477.23 $371.87 $371.87 $355.57 $355.57$581.33 $493.78 $493.78 $438.91 $438.91 $419.67 $419.67 $448.77 $448.77 $472.93 $472.93 $573.04 $573.04 $486.74 $486.74 $379.28 $379.28 $362.66 $362.66$594.95 $505.35 $505.35 $449.19 $449.19 $429.51 $429.51 $459.29 $459.29 $484.02 $484.02 $586.47 $586.47 $498.15 $498.15 $388.17 $388.17 $371.16 $371.16$617.09 $524.16 $524.16 $465.91 $465.91 $445.49 $445.49 $476.38 $476.38 $502.03 $502.03 $608.30 $608.30 $516.69 $516.69 $402.61 $402.61 $384.97 $384.97$635.26 $539.59 $539.59 $479.62 $479.62 $458.61 $458.61 $490.40 $490.40 $516.81 $516.81 $626.21 $626.21 $531.90 $531.90 $414.46 $414.46 $396.30 $396.30$644.34 $547.30 $547.30 $486.48 $486.48 $465.16 $465.16 $497.41 $497.41 $524.20 $524.20 $635.16 $635.16 $539.50 $539.50 $420.39 $420.39 $401.97 $401.97$657.97 $558.87 $558.87 $496.77 $496.77 $475.00 $475.00 $507.93 $507.93 $535.28 $535.28 $648.59 $648.59 $550.91 $550.91 $429.28 $429.28 $410.47 $410.47$671.59 $570.45 $570.45 $507.06 $507.06 $484.84 $484.84 $518.45 $518.45 $546.37 $546.37 $662.02 $662.02 $562.32 $562.32 $438.17 $438.17 $418.97 $418.97$680.11 $577.68 $577.68 $513.49 $513.49 $490.98 $490.98 $525.02 $525.02 $553.29 $553.29 $670.42 $670.42 $569.45 $569.45 $443.73 $443.73 $424.28 $424.28$689.19 $585.40 $585.40 $520.34 $520.34 $497.54 $497.54 $532.04 $532.04 $560.68 $560.68 $679.37 $679.37 $577.05 $577.05 $449.65 $449.65 $429.95 $429.95$693.73 $589.25 $589.25 $523.77 $523.77 $500.82 $500.82 $535.54 $535.54 $564.38 $564.38 $683.85 $683.85 $580.86 $580.86 $452.61 $452.61 $432.78 $432.78$698.27 $593.11 $593.11 $527.20 $527.20 $504.10 $504.10 $539.05 $539.05 $568.07 $568.07 $688.32 $688.32 $584.66 $584.66 $455.58 $455.58 $435.61 $435.61$702.81 $596.97 $596.97 $530.63 $530.63 $507.38 $507.38 $542.55 $542.55 $571.77 $571.77 $692.80 $692.80 $588.46 $588.46 $458.54 $458.54 $438.45 $438.45$707.36 $600.83 $600.83 $534.06 $534.06 $510.66 $510.66 $546.06 $546.06 $575.46 $575.46 $697.28 $697.28 $592.27 $592.27 $461.50 $461.50 $441.28 $441.28$716.44 $608.54 $608.54 $540.92 $540.92 $517.21 $517.21 $553.07 $553.07 $582.85 $582.85 $706.23 $706.23 $599.87 $599.87 $467.43 $467.43 $446.95 $446.95$725.52 $616.26 $616.26 $547.77 $547.77 $523.77 $523.77 $560.08 $560.08 $590.24 $590.24 $715.18 $715.18 $607.48 $607.48 $473.36 $473.36 $452.61 $452.61$739.15 $627.83 $627.83 $558.06 $558.06 $533.61 $533.61 $570.60 $570.60 $601.33 $601.33 $728.62 $728.62 $618.88 $618.88 $482.25 $482.25 $461.11 $461.11$752.20 $638.92 $638.92 $567.92 $567.92 $543.03 $543.03 $580.68 $580.68 $611.95 $611.95 $741.49 $741.49 $629.82 $629.82 $490.76 $490.76 $469.26 $469.26$770.37 $654.35 $654.35 $581.64 $581.64 $556.15 $556.15 $594.71 $594.71 $626.73 $626.73 $759.39 $759.39 $645.03 $645.03 $502.62 $502.62 $480.59 $480.59$793.08 $673.64 $673.64 $598.78 $598.78 $572.54 $572.54 $612.24 $612.24 $645.20 $645.20 $781.78 $781.78 $664.04 $664.04 $517.43 $517.43 $494.76 $494.76$819.76 $696.30 $696.30 $618.93 $618.93 $591.80 $591.80 $632.83 $632.83 $666.91 $666.91 $808.08 $808.08 $686.38 $686.38 $534.84 $534.84 $511.40 $511.40$851.55 $723.31 $723.31 $642.93 $642.93 $614.75 $614.75 $657.38 $657.38 $692.77 $692.77 $839.42 $839.42 $713.00 $713.00 $555.58 $555.58 $531.24 $531.24$887.32 $753.68 $753.68 $669.93 $669.93 $640.57 $640.57 $684.99 $684.99 $721.87 $721.87 $874.67 $874.67 $742.95 $742.95 $578.92 $578.92 $553.55 $553.55$928.19 $788.40 $788.40 $700.79 $700.79 $670.08 $670.08 $716.54 $716.54 $755.12 $755.12 $914.97 $914.97 $777.17 $777.17 $605.59 $605.59 $579.05 $579.05$968.50 $822.64 $822.64 $731.22 $731.22 $699.18 $699.18 $747.66 $747.66 $787.91 $787.91 $954.70 $954.70 $810.92 $810.92 $631.88 $631.88 $604.19 $604.19

$1,013.91 $861.22 $861.22 $765.51 $765.51 $731.97 $731.97 $782.72 $782.72 $824.86 $824.86 $999.47 $999.47 $848.95 $848.95 $661.51 $661.51 $632.53 $632.53$1,058.76 $899.31 $899.31 $799.37 $799.37 $764.35 $764.35 $817.34 $817.34 $861.35 $861.35 $1,043.68 $1,043.68 $886.50 $886.50 $690.77 $690.77 $660.50 $660.50$1,108.15 $941.26 $941.26 $836.66 $836.66 $800.00 $800.00 $855.47 $855.47 $901.53 $901.53 $1,092.36 $1,092.36 $927.85 $927.85 $723.00 $723.00 $691.32 $691.32$1,158.11 $983.70 $983.70 $874.38 $874.38 $836.07 $836.07 $894.03 $894.03 $942.17 $942.17 $1,141.61 $1,141.61 $969.68 $969.68 $755.59 $755.59 $722.48 $722.48$1,212.04 $1,029.51 $1,029.51 $915.10 $915.10 $875.00 $875.00 $935.66 $935.66 $986.05 $986.05 $1,194.77 $1,194.77 $1,014.84 $1,014.84 $790.78 $790.78 $756.13 $756.13$1,265.97 $1,075.31 $1,075.31 $955.82 $955.82 $913.94 $913.94 $977.30 $977.30 $1,029.92 $1,029.92 $1,247.94 $1,247.94 $1,059.99 $1,059.99 $825.97 $825.97 $789.77 $789.77$1,324.45 $1,124.98 $1,124.98 $999.97 $999.97 $956.15 $956.15 $1,022.44 $1,022.44 $1,077.49 $1,077.49 $1,305.58 $1,305.58 $1,108.95 $1,108.95 $864.12 $864.12 $826.25 $826.25$1,383.49 $1,175.13 $1,175.13 $1,044.54 $1,044.54 $998.77 $998.77 $1,068.02 $1,068.02 $1,125.53 $1,125.53 $1,363.77 $1,363.77 $1,158.39 $1,158.39 $902.64 $902.64 $863.08 $863.08$1,446.50 $1,228.66 $1,228.66 $1,092.12 $1,092.12 $1,044.26 $1,044.26 $1,116.66 $1,116.66 $1,176.79 $1,176.79 $1,425.89 $1,425.89 $1,211.15 $1,211.15 $943.75 $943.75 $902.39 $902.39$1,477.73 $1,255.18 $1,255.18 $1,115.69 $1,115.69 $1,066.80 $1,066.80 $1,140.77 $1,140.77 $1,202.19 $1,202.19 $1,456.67 $1,456.67 $1,237.29 $1,237.29 $964.12 $964.12 $921.87 $921.87$1,540.74 $1,308.70 $1,308.70 $1,163.27 $1,163.27 $1,112.30 $1,112.30 $1,189.41 $1,189.41 $1,253.46 $1,253.46 $1,518.79 $1,518.79 $1,290.05 $1,290.05 $1,005.23 $1,005.23 $961.19 $961.19$1,595.24 $1,354.99 $1,354.99 $1,204.42 $1,204.42 $1,151.64 $1,151.64 $1,231.48 $1,231.48 $1,297.79 $1,297.79 $1,572.51 $1,572.51 $1,335.69 $1,335.69 $1,040.79 $1,040.79 $995.18 $995.18$1,631.00 $1,385.37 $1,385.37 $1,231.42 $1,231.42 $1,177.46 $1,177.46 $1,259.09 $1,259.09 $1,326.89 $1,326.89 $1,607.77 $1,607.77 $1,365.63 $1,365.63 $1,064.13 $1,064.13 $1,017.50 $1,017.50$1,675.85 $1,423.47 $1,423.47 $1,265.28 $1,265.28 $1,209.84 $1,209.84 $1,293.72 $1,293.72 $1,363.38 $1,363.38 $1,651.98 $1,651.98 $1,403.18 $1,403.18 $1,093.39 $1,093.39 $1,045.47 $1,045.47$1,703.10 $1,446.61 $1,446.61 $1,285.86 $1,285.86 $1,229.51 $1,229.51 $1,314.75 $1,314.75 $1,385.55 $1,385.55 $1,678.84 $1,678.84 $1,426.00 $1,426.00 $1,111.17 $1,111.17 $1,062.47 $1,062.47

GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 2



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 6



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 5



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 3



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 2




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 9


numd: $1,500%

Deductible500es


l-Access PPO

Page Number: 54 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$289.71 $289.71 $305.31 $305.31 $369.94 $369.94 $314.23 $314.23 $305.38 $305.38 $292.00 $292.00 $312.24 $312.24 $329.06 $329.06 $398.71 $398.71 $338.67$315.47 $315.47 $332.45 $332.45 $402.83 $402.83 $342.16 $342.16 $332.53 $332.53 $317.96 $317.96 $340.00 $340.00 $358.31 $358.31 $434.15 $434.15 $368.77$325.31 $325.31 $342.83 $342.83 $415.40 $415.40 $352.84 $352.84 $342.91 $342.91 $327.88 $327.88 $350.61 $350.61 $369.49 $369.49 $447.70 $447.70 $380.28$335.16 $335.16 $353.21 $353.21 $427.97 $427.97 $363.52 $363.52 $353.29 $353.29 $337.80 $337.80 $361.22 $361.22 $380.67 $380.67 $461.26 $461.26 $391.79$345.76 $345.76 $364.38 $364.38 $441.51 $441.51 $375.02 $375.02 $364.46 $364.46 $348.49 $348.49 $372.65 $372.65 $392.72 $392.72 $475.85 $475.85 $404.19$356.37 $356.37 $375.56 $375.56 $455.05 $455.05 $386.52 $386.52 $375.64 $375.64 $359.18 $359.18 $384.08 $384.08 $404.76 $404.76 $490.44 $490.44 $416.58$367.35 $367.35 $387.13 $387.13 $469.08 $469.08 $398.43 $398.43 $387.22 $387.22 $370.25 $370.25 $395.92 $395.92 $417.24 $417.24 $505.56 $505.56 $429.42$378.72 $378.72 $399.11 $399.11 $483.59 $483.59 $410.76 $410.76 $399.20 $399.20 $381.70 $381.70 $408.17 $408.17 $430.15 $430.15 $521.20 $521.20 $442.71$378.72 $378.72 $399.11 $399.11 $483.59 $483.59 $410.76 $410.76 $399.20 $399.20 $381.70 $381.70 $408.17 $408.17 $430.15 $430.15 $521.20 $521.20 $442.71$378.72 $378.72 $399.11 $399.11 $483.59 $483.59 $410.76 $410.76 $399.20 $399.20 $381.70 $381.70 $408.17 $408.17 $430.15 $430.15 $521.20 $521.20 $442.71$378.72 $378.72 $399.11 $399.11 $483.59 $483.59 $410.76 $410.76 $399.20 $399.20 $381.70 $381.70 $408.17 $408.17 $430.15 $430.15 $521.20 $521.20 $442.71$380.23 $380.23 $400.70 $400.70 $485.52 $485.52 $412.40 $412.40 $400.79 $400.79 $383.23 $383.23 $409.80 $409.80 $431.86 $431.86 $523.28 $523.28 $444.47$387.80 $387.80 $408.68 $408.68 $495.19 $495.19 $420.61 $420.61 $408.77 $408.77 $390.86 $390.86 $417.96 $417.96 $440.46 $440.46 $533.70 $533.70 $453.32$396.89 $396.89 $418.26 $418.26 $506.80 $506.80 $430.47 $430.47 $418.35 $418.35 $400.02 $400.02 $427.76 $427.76 $450.79 $450.79 $546.21 $546.21 $463.95$411.66 $411.66 $433.83 $433.83 $525.66 $525.66 $446.49 $446.49 $433.92 $433.92 $414.91 $414.91 $443.67 $443.67 $467.56 $467.56 $566.54 $566.54 $481.22$423.78 $423.78 $446.60 $446.60 $541.13 $541.13 $459.64 $459.64 $446.70 $446.70 $427.12 $427.12 $456.73 $456.73 $481.33 $481.33 $583.21 $583.21 $495.38$429.84 $429.84 $452.98 $452.98 $548.87 $548.87 $466.21 $466.21 $453.08 $453.08 $433.23 $433.23 $463.27 $463.27 $488.21 $488.21 $591.55 $591.55 $502.46$438.93 $438.93 $462.56 $462.56 $560.48 $560.48 $476.07 $476.07 $462.66 $462.66 $442.39 $442.39 $473.06 $473.06 $498.53 $498.53 $604.06 $604.06 $513.09$448.02 $448.02 $472.14 $472.14 $572.08 $572.08 $485.93 $485.93 $472.24 $472.24 $451.55 $451.55 $482.86 $482.86 $508.86 $508.86 $616.57 $616.57 $523.71$453.70 $453.70 $478.13 $478.13 $579.34 $579.34 $492.09 $492.09 $478.23 $478.23 $457.28 $457.28 $488.98 $488.98 $515.31 $515.31 $624.39 $624.39 $530.35$459.76 $459.76 $484.51 $484.51 $587.07 $587.07 $498.66 $498.66 $484.62 $484.62 $463.38 $463.38 $495.51 $495.51 $522.19 $522.19 $632.73 $632.73 $537.44$462.79 $462.79 $487.71 $487.71 $590.94 $590.94 $501.94 $501.94 $487.81 $487.81 $466.44 $466.44 $498.78 $498.78 $525.63 $525.63 $636.90 $636.90 $540.98$465.82 $465.82 $490.90 $490.90 $594.81 $594.81 $505.23 $505.23 $491.01 $491.01 $469.49 $469.49 $502.04 $502.04 $529.07 $529.07 $641.07 $641.07 $544.52$468.85 $468.85 $494.09 $494.09 $598.68 $598.68 $508.52 $508.52 $494.20 $494.20 $472.54 $472.54 $505.31 $505.31 $532.51 $532.51 $645.24 $645.24 $548.06$471.88 $471.88 $497.28 $497.28 $602.55 $602.55 $511.80 $511.80 $497.39 $497.39 $475.60 $475.60 $508.57 $508.57 $535.96 $535.96 $649.41 $649.41 $551.60$477.93 $477.93 $503.67 $503.67 $610.29 $610.29 $518.38 $518.38 $503.78 $503.78 $481.71 $481.71 $515.10 $515.10 $542.84 $542.84 $657.75 $657.75 $558.69$483.99 $483.99 $510.06 $510.06 $618.02 $618.02 $524.95 $524.95 $510.17 $510.17 $487.81 $487.81 $521.63 $521.63 $549.72 $549.72 $666.08 $666.08 $565.77$493.08 $493.08 $519.63 $519.63 $629.63 $629.63 $534.81 $534.81 $519.75 $519.75 $496.97 $496.97 $531.43 $531.43 $560.04 $560.04 $678.59 $678.59 $576.40$501.79 $501.79 $528.81 $528.81 $640.75 $640.75 $544.25 $544.25 $528.93 $528.93 $505.75 $505.75 $540.82 $540.82 $569.94 $569.94 $690.58 $690.58 $586.58$513.91 $513.91 $541.58 $541.58 $656.23 $656.23 $557.40 $557.40 $541.70 $541.70 $517.97 $517.97 $553.88 $553.88 $583.70 $583.70 $707.26 $707.26 $600.74$529.06 $529.06 $557.55 $557.55 $675.57 $675.57 $573.83 $573.83 $557.67 $557.67 $533.23 $533.23 $570.20 $570.20 $600.91 $600.91 $728.11 $728.11 $618.45$546.86 $546.86 $576.31 $576.31 $698.30 $698.30 $593.13 $593.13 $576.43 $576.43 $551.17 $551.17 $589.39 $589.39 $621.12 $621.12 $752.60 $752.60 $639.26$568.07 $568.07 $598.66 $598.66 $725.38 $725.38 $616.14 $616.14 $598.79 $598.79 $572.55 $572.55 $612.24 $612.24 $645.21 $645.21 $781.79 $781.79 $664.05$591.93 $591.93 $623.80 $623.80 $755.85 $755.85 $642.01 $642.01 $623.94 $623.94 $596.60 $596.60 $637.96 $637.96 $672.31 $672.31 $814.62 $814.62 $691.94$619.19 $619.19 $652.54 $652.54 $790.66 $790.66 $671.59 $671.59 $652.68 $652.68 $624.08 $624.08 $667.35 $667.35 $703.28 $703.28 $852.15 $852.15 $723.81$646.08 $646.08 $680.87 $680.87 $825.00 $825.00 $700.75 $700.75 $681.02 $681.02 $651.18 $651.18 $696.33 $696.33 $733.82 $733.82 $889.16 $889.16 $755.25$676.38 $676.38 $712.80 $712.80 $863.68 $863.68 $733.61 $733.61 $712.96 $712.96 $681.72 $681.72 $728.98 $728.98 $768.23 $768.23 $930.85 $930.85 $790.66$706.30 $706.30 $744.33 $744.33 $901.89 $901.89 $766.06 $766.06 $744.49 $744.49 $711.87 $711.87 $761.22 $761.22 $802.21 $802.21 $972.02 $972.02 $825.64$739.25 $739.25 $779.05 $779.05 $943.96 $943.96 $801.80 $801.80 $779.22 $779.22 $745.08 $745.08 $796.73 $796.73 $839.64 $839.64 $1,017.37 $1,017.37 $864.15$772.57 $772.57 $814.17 $814.17 $986.52 $986.52 $837.94 $837.94 $814.35 $814.35 $778.67 $778.67 $832.65 $832.65 $877.49 $877.49 $1,063.23 $1,063.23 $903.11$808.55 $808.55 $852.09 $852.09 $1,032.46 $1,032.46 $876.97 $876.97 $852.28 $852.28 $814.93 $814.93 $871.43 $871.43 $918.35 $918.35 $1,112.75 $1,112.75 $945.16$844.53 $844.53 $890.00 $890.00 $1,078.40 $1,078.40 $915.99 $915.99 $890.20 $890.20 $851.19 $851.19 $910.20 $910.20 $959.21 $959.21 $1,162.26 $1,162.26 $987.22$883.54 $883.54 $931.11 $931.11 $1,128.21 $1,128.21 $958.30 $958.30 $931.32 $931.32 $890.51 $890.51 $952.24 $952.24 $1,003.52 $1,003.52 $1,215.94 $1,215.94 $1,032.82$922.92 $922.92 $972.62 $972.62 $1,178.50 $1,178.50 $1,001.01 $1,001.01 $972.83 $972.83 $930.20 $930.20 $994.69 $994.69 $1,048.25 $1,048.25 $1,270.15 $1,270.15 $1,078.86$964.96 $964.96 $1,016.92 $1,016.92 $1,232.18 $1,232.18 $1,046.61 $1,046.61 $1,017.14 $1,017.14 $972.57 $972.57 $1,040.00 $1,040.00 $1,096.00 $1,096.00 $1,328.00 $1,328.00 $1,128.00$985.79 $985.79 $1,038.87 $1,038.87 $1,258.77 $1,258.77 $1,069.20 $1,069.20 $1,039.10 $1,039.10 $993.56 $993.56 $1,062.45 $1,062.45 $1,119.66 $1,119.66 $1,356.67 $1,356.67 $1,152.35

$1,027.82 $1,027.82 $1,083.17 $1,083.17 $1,312.45 $1,312.45 $1,114.79 $1,114.79 $1,083.41 $1,083.41 $1,035.93 $1,035.93 $1,107.75 $1,107.75 $1,167.40 $1,167.40 $1,414.52 $1,414.52 $1,201.49$1,064.18 $1,064.18 $1,121.48 $1,121.48 $1,358.88 $1,358.88 $1,154.23 $1,154.23 $1,121.73 $1,121.73 $1,072.58 $1,072.58 $1,146.94 $1,146.94 $1,208.70 $1,208.70 $1,464.55 $1,464.55 $1,243.99$1,088.04 $1,088.04 $1,146.63 $1,146.63 $1,389.34 $1,389.34 $1,180.10 $1,180.10 $1,146.88 $1,146.88 $1,096.62 $1,096.62 $1,172.65 $1,172.65 $1,235.80 $1,235.80 $1,497.39 $1,497.39 $1,271.88$1,117.96 $1,117.96 $1,178.16 $1,178.16 $1,427.55 $1,427.55 $1,212.55 $1,212.55 $1,178.42 $1,178.42 $1,126.78 $1,126.78 $1,204.90 $1,204.90 $1,269.78 $1,269.78 $1,538.56 $1,538.56 $1,306.85$1,136.14 $1,136.14 $1,197.31 $1,197.31 $1,450.76 $1,450.76 $1,232.27 $1,232.27 $1,197.58 $1,197.58 $1,145.10 $1,145.10 $1,224.49 $1,224.49 $1,290.42 $1,290.42 $1,563.58 $1,563.58 $1,328.10

GoCombine

0$20 / $40 Aft

$7,0Y


PPO 20/M-152-122-

Rating

Geisinger Al



$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 7




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 6




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 5




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 3




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 2


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 5


Page Number: 55 12/24/2014

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Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$338.67 $368.49 $368.49 $309.82 $309.82 $296.92 $296.92 $268.82 $268.82 $326.99 $326.99 $368.49 $368.49 $274.93 $274.93 $309.82 $309.82 $263.49 $263.49$368.77 $401.24 $401.24 $337.36 $337.36 $323.32 $323.32 $292.72 $292.72 $356.05 $356.05 $401.24 $401.24 $299.37 $299.37 $337.36 $337.36 $286.91 $286.91$380.28 $413.77 $413.77 $347.89 $347.89 $333.41 $333.41 $301.85 $301.85 $367.17 $367.17 $413.77 $413.77 $308.72 $308.72 $347.89 $347.89 $295.86 $295.86$391.79 $426.29 $426.29 $358.42 $358.42 $343.50 $343.50 $310.99 $310.99 $378.28 $378.28 $426.29 $426.29 $318.06 $318.06 $358.42 $358.42 $304.82 $304.82$404.19 $439.78 $439.78 $369.76 $369.76 $354.37 $354.37 $320.83 $320.83 $390.25 $390.25 $439.78 $439.78 $328.12 $328.12 $369.76 $369.76 $314.46 $314.46$416.58 $453.26 $453.26 $381.10 $381.10 $365.24 $365.24 $330.67 $330.67 $402.22 $402.22 $453.26 $453.26 $338.19 $338.19 $381.10 $381.10 $324.10 $324.10$429.42 $467.23 $467.23 $392.85 $392.85 $376.49 $376.49 $340.86 $340.86 $414.61 $414.61 $467.23 $467.23 $348.61 $348.61 $392.85 $392.85 $334.09 $334.09$442.71 $481.69 $481.69 $405.00 $405.00 $388.14 $388.14 $351.41 $351.41 $427.44 $427.44 $481.69 $481.69 $359.39 $359.39 $405.00 $405.00 $344.43 $344.43$442.71 $481.69 $481.69 $405.00 $405.00 $388.14 $388.14 $351.41 $351.41 $427.44 $427.44 $481.69 $481.69 $359.39 $359.39 $405.00 $405.00 $344.43 $344.43$442.71 $481.69 $481.69 $405.00 $405.00 $388.14 $388.14 $351.41 $351.41 $427.44 $427.44 $481.69 $481.69 $359.39 $359.39 $405.00 $405.00 $344.43 $344.43$442.71 $481.69 $481.69 $405.00 $405.00 $388.14 $388.14 $351.41 $351.41 $427.44 $427.44 $481.69 $481.69 $359.39 $359.39 $405.00 $405.00 $344.43 $344.43$444.47 $483.61 $483.61 $406.62 $406.62 $389.69 $389.69 $352.81 $352.81 $429.15 $429.15 $483.61 $483.61 $360.83 $360.83 $406.62 $406.62 $345.80 $345.80$453.32 $493.24 $493.24 $414.72 $414.72 $397.45 $397.45 $359.84 $359.84 $437.70 $437.70 $493.24 $493.24 $368.01 $368.01 $414.72 $414.72 $352.69 $352.69$463.95 $504.80 $504.80 $424.44 $424.44 $406.77 $406.77 $368.27 $368.27 $447.95 $447.95 $504.80 $504.80 $376.64 $376.64 $424.44 $424.44 $360.96 $360.96$481.22 $523.59 $523.59 $440.23 $440.23 $421.90 $421.90 $381.97 $381.97 $464.62 $464.62 $523.59 $523.59 $390.66 $390.66 $440.23 $440.23 $374.39 $374.39$495.38 $539.00 $539.00 $453.19 $453.19 $434.32 $434.32 $393.22 $393.22 $478.30 $478.30 $539.00 $539.00 $402.16 $402.16 $453.19 $453.19 $385.41 $385.41$502.46 $546.71 $546.71 $459.67 $459.67 $440.53 $440.53 $398.84 $398.84 $485.14 $485.14 $546.71 $546.71 $407.91 $407.91 $459.67 $459.67 $390.92 $390.92$513.09 $558.27 $558.27 $469.39 $469.39 $449.85 $449.85 $407.28 $407.28 $495.40 $495.40 $558.27 $558.27 $416.53 $416.53 $469.39 $469.39 $399.19 $399.19$523.71 $569.83 $569.83 $479.11 $479.11 $459.16 $459.16 $415.71 $415.71 $505.66 $505.66 $569.83 $569.83 $425.16 $425.16 $479.11 $479.11 $407.46 $407.46$530.35 $577.06 $577.06 $485.19 $485.19 $464.99 $464.99 $420.98 $420.98 $512.07 $512.07 $577.06 $577.06 $430.55 $430.55 $485.19 $485.19 $412.62 $412.62$537.44 $584.76 $584.76 $491.67 $491.67 $471.20 $471.20 $426.60 $426.60 $518.91 $518.91 $584.76 $584.76 $436.30 $436.30 $491.67 $491.67 $418.13 $418.13$540.98 $588.62 $588.62 $494.91 $494.91 $474.30 $474.30 $429.41 $429.41 $522.33 $522.33 $588.62 $588.62 $439.17 $439.17 $494.91 $494.91 $420.89 $420.89$544.52 $592.47 $592.47 $498.15 $498.15 $477.41 $477.41 $432.23 $432.23 $525.75 $525.75 $592.47 $592.47 $442.05 $442.05 $498.15 $498.15 $423.64 $423.64$548.06 $596.32 $596.32 $501.39 $501.39 $480.51 $480.51 $435.04 $435.04 $529.17 $529.17 $596.32 $596.32 $444.92 $444.92 $501.39 $501.39 $426.40 $426.40$551.60 $600.18 $600.18 $504.63 $504.63 $483.62 $483.62 $437.85 $437.85 $532.59 $532.59 $600.18 $600.18 $447.80 $447.80 $504.63 $504.63 $429.15 $429.15$558.69 $607.88 $607.88 $511.11 $511.11 $489.83 $489.83 $443.47 $443.47 $539.43 $539.43 $607.88 $607.88 $453.55 $453.55 $511.11 $511.11 $434.66 $434.66$565.77 $615.59 $615.59 $517.59 $517.59 $496.04 $496.04 $449.09 $449.09 $546.26 $546.26 $615.59 $615.59 $459.30 $459.30 $517.59 $517.59 $440.18 $440.18$576.40 $627.15 $627.15 $527.31 $527.31 $505.35 $505.35 $457.53 $457.53 $556.52 $556.52 $627.15 $627.15 $467.92 $467.92 $527.31 $527.31 $448.44 $448.44$586.58 $638.23 $638.23 $536.62 $536.62 $514.28 $514.28 $465.61 $465.61 $566.35 $566.35 $638.23 $638.23 $476.19 $476.19 $536.62 $536.62 $456.36 $456.36$600.74 $653.64 $653.64 $549.58 $549.58 $526.70 $526.70 $476.85 $476.85 $580.03 $580.03 $653.64 $653.64 $487.69 $487.69 $549.58 $549.58 $467.39 $467.39$618.45 $672.91 $672.91 $565.78 $565.78 $542.23 $542.23 $490.91 $490.91 $597.13 $597.13 $672.91 $672.91 $502.07 $502.07 $565.78 $565.78 $481.16 $481.16$639.26 $695.55 $695.55 $584.82 $584.82 $560.47 $560.47 $507.43 $507.43 $617.22 $617.22 $695.55 $695.55 $518.96 $518.96 $584.82 $584.82 $497.35 $497.35$664.05 $722.52 $722.52 $607.50 $607.50 $582.20 $582.20 $527.10 $527.10 $641.16 $641.16 $722.52 $722.52 $539.08 $539.08 $607.50 $607.50 $516.64 $516.64$691.94 $752.87 $752.87 $633.01 $633.01 $606.66 $606.66 $549.24 $549.24 $668.08 $668.08 $752.87 $752.87 $561.73 $561.73 $633.01 $633.01 $538.34 $538.34$723.81 $787.55 $787.55 $662.17 $662.17 $634.60 $634.60 $574.54 $574.54 $698.86 $698.86 $787.55 $787.55 $587.60 $587.60 $662.17 $662.17 $563.14 $563.14$755.25 $821.75 $821.75 $690.93 $690.93 $662.16 $662.16 $599.49 $599.49 $729.21 $729.21 $821.75 $821.75 $613.12 $613.12 $690.93 $690.93 $587.59 $587.59$790.66 $860.29 $860.29 $723.33 $723.33 $693.21 $693.21 $627.60 $627.60 $763.40 $763.40 $860.29 $860.29 $641.87 $641.87 $723.33 $723.33 $615.14 $615.14$825.64 $898.34 $898.34 $755.32 $755.32 $723.87 $723.87 $655.37 $655.37 $797.17 $797.17 $898.34 $898.34 $670.26 $670.26 $755.32 $755.32 $642.35 $642.35$864.15 $940.24 $940.24 $790.56 $790.56 $757.64 $757.64 $685.94 $685.94 $834.36 $834.36 $940.24 $940.24 $701.53 $701.53 $790.56 $790.56 $672.32 $672.32$903.11 $982.63 $982.63 $826.20 $826.20 $791.80 $791.80 $716.86 $716.86 $871.97 $871.97 $982.63 $982.63 $733.15 $733.15 $826.20 $826.20 $702.63 $702.63$945.16 $1,028.39 $1,028.39 $864.67 $864.67 $828.67 $828.67 $750.24 $750.24 $912.58 $912.58 $1,028.39 $1,028.39 $767.30 $767.30 $864.67 $864.67 $735.35 $735.35$987.22 $1,074.15 $1,074.15 $903.15 $903.15 $865.54 $865.54 $783.63 $783.63 $953.18 $953.18 $1,074.15 $1,074.15 $801.44 $801.44 $903.15 $903.15 $768.07 $768.07

$1,032.82 $1,123.77 $1,123.77 $944.86 $944.86 $905.52 $905.52 $819.82 $819.82 $997.21 $997.21 $1,123.77 $1,123.77 $838.46 $838.46 $944.86 $944.86 $803.54 $803.54$1,078.86 $1,173.86 $1,173.86 $986.98 $986.98 $945.89 $945.89 $856.37 $856.37 $1,041.66 $1,041.66 $1,173.86 $1,173.86 $875.83 $875.83 $986.98 $986.98 $839.36 $839.36$1,128.00 $1,227.33 $1,227.33 $1,031.94 $1,031.94 $988.97 $988.97 $895.37 $895.37 $1,089.11 $1,089.11 $1,227.33 $1,227.33 $915.72 $915.72 $1,031.94 $1,031.94 $877.60 $877.60$1,152.35 $1,253.82 $1,253.82 $1,054.21 $1,054.21 $1,010.32 $1,010.32 $914.70 $914.70 $1,112.62 $1,112.62 $1,253.82 $1,253.82 $935.49 $935.49 $1,054.21 $1,054.21 $896.54 $896.54$1,201.49 $1,307.29 $1,307.29 $1,099.17 $1,099.17 $1,053.40 $1,053.40 $953.71 $953.71 $1,160.06 $1,160.06 $1,307.29 $1,307.29 $975.38 $975.38 $1,099.17 $1,099.17 $934.77 $934.77$1,243.99 $1,353.53 $1,353.53 $1,138.05 $1,138.05 $1,090.66 $1,090.66 $987.44 $987.44 $1,201.10 $1,201.10 $1,353.53 $1,353.53 $1,009.88 $1,009.88 $1,138.05 $1,138.05 $967.83 $967.83$1,271.88 $1,383.87 $1,383.87 $1,163.56 $1,163.56 $1,115.11 $1,115.11 $1,009.58 $1,009.58 $1,228.03 $1,228.03 $1,383.87 $1,383.87 $1,032.53 $1,032.53 $1,163.56 $1,163.56 $989.53 $989.53$1,306.85 $1,421.93 $1,421.93 $1,195.56 $1,195.56 $1,145.78 $1,145.78 $1,037.34 $1,037.34 $1,261.79 $1,261.79 $1,421.93 $1,421.93 $1,060.92 $1,060.92 $1,195.56 $1,195.56 $1,016.74 $1,016.74$1,328.10 $1,445.05 $1,445.05 $1,215.00 $1,215.00 $1,164.41 $1,164.41 $1,054.21 $1,054.21 $1,282.31 $1,282.31 $1,445.05 $1,445.05 $1,078.17 $1,078.17 $1,215.00 $1,215.00 $1,033.28 $1,033.28

GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 3



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 6



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 3


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 6



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 6




l-Access PPO

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0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$296.92 $296.92 $238.55 $238.55 $268.82 $268.82 $326.99 $326.99 $274.93 $274.93 $263.49 $263.49 $238.55 $238.55$323.32 $323.32 $259.75 $259.75 $292.72 $292.72 $356.05 $356.05 $299.37 $299.37 $286.91 $286.91 $259.75 $259.75$333.41 $333.41 $267.86 $267.86 $301.85 $301.85 $367.17 $367.17 $308.72 $308.72 $295.86 $295.86 $267.86 $267.86$343.50 $343.50 $275.97 $275.97 $310.99 $310.99 $378.28 $378.28 $318.06 $318.06 $304.82 $304.82 $275.97 $275.97$354.37 $354.37 $284.70 $284.70 $320.83 $320.83 $390.25 $390.25 $328.12 $328.12 $314.46 $314.46 $284.70 $284.70$365.24 $365.24 $293.43 $293.43 $330.67 $330.67 $402.22 $402.22 $338.19 $338.19 $324.10 $324.10 $293.43 $293.43$376.49 $376.49 $302.47 $302.47 $340.86 $340.86 $414.61 $414.61 $348.61 $348.61 $334.09 $334.09 $302.47 $302.47$388.14 $388.14 $311.83 $311.83 $351.41 $351.41 $427.44 $427.44 $359.39 $359.39 $344.43 $344.43 $311.83 $311.83$388.14 $388.14 $311.83 $311.83 $351.41 $351.41 $427.44 $427.44 $359.39 $359.39 $344.43 $344.43 $311.83 $311.83$388.14 $388.14 $311.83 $311.83 $351.41 $351.41 $427.44 $427.44 $359.39 $359.39 $344.43 $344.43 $311.83 $311.83$388.14 $388.14 $311.83 $311.83 $351.41 $351.41 $427.44 $427.44 $359.39 $359.39 $344.43 $344.43 $311.83 $311.83$389.69 $389.69 $313.08 $313.08 $352.81 $352.81 $429.15 $429.15 $360.83 $360.83 $345.80 $345.80 $313.08 $313.08$397.45 $397.45 $319.31 $319.31 $359.84 $359.84 $437.70 $437.70 $368.01 $368.01 $352.69 $352.69 $319.31 $319.31$406.77 $406.77 $326.80 $326.80 $368.27 $368.27 $447.95 $447.95 $376.64 $376.64 $360.96 $360.96 $326.80 $326.80$421.90 $421.90 $338.96 $338.96 $381.97 $381.97 $464.62 $464.62 $390.66 $390.66 $374.39 $374.39 $338.96 $338.96$434.32 $434.32 $348.94 $348.94 $393.22 $393.22 $478.30 $478.30 $402.16 $402.16 $385.41 $385.41 $348.94 $348.94$440.53 $440.53 $353.93 $353.93 $398.84 $398.84 $485.14 $485.14 $407.91 $407.91 $390.92 $390.92 $353.93 $353.93$449.85 $449.85 $361.41 $361.41 $407.28 $407.28 $495.40 $495.40 $416.53 $416.53 $399.19 $399.19 $361.41 $361.41$459.16 $459.16 $368.89 $368.89 $415.71 $415.71 $505.66 $505.66 $425.16 $425.16 $407.46 $407.46 $368.89 $368.89$464.99 $464.99 $373.57 $373.57 $420.98 $420.98 $512.07 $512.07 $430.55 $430.55 $412.62 $412.62 $373.57 $373.57$471.20 $471.20 $378.56 $378.56 $426.60 $426.60 $518.91 $518.91 $436.30 $436.30 $418.13 $418.13 $378.56 $378.56$474.30 $474.30 $381.05 $381.05 $429.41 $429.41 $522.33 $522.33 $439.17 $439.17 $420.89 $420.89 $381.05 $381.05$477.41 $477.41 $383.55 $383.55 $432.23 $432.23 $525.75 $525.75 $442.05 $442.05 $423.64 $423.64 $383.55 $383.55$480.51 $480.51 $386.04 $386.04 $435.04 $435.04 $529.17 $529.17 $444.92 $444.92 $426.40 $426.40 $386.04 $386.04$483.62 $483.62 $388.54 $388.54 $437.85 $437.85 $532.59 $532.59 $447.80 $447.80 $429.15 $429.15 $388.54 $388.54$489.83 $489.83 $393.53 $393.53 $443.47 $443.47 $539.43 $539.43 $453.55 $453.55 $434.66 $434.66 $393.53 $393.53$496.04 $496.04 $398.52 $398.52 $449.09 $449.09 $546.26 $546.26 $459.30 $459.30 $440.18 $440.18 $398.52 $398.52$505.35 $505.35 $406.00 $406.00 $457.53 $457.53 $556.52 $556.52 $467.92 $467.92 $448.44 $448.44 $406.00 $406.00$514.28 $514.28 $413.17 $413.17 $465.61 $465.61 $566.35 $566.35 $476.19 $476.19 $456.36 $456.36 $413.17 $413.17$526.70 $526.70 $423.15 $423.15 $476.85 $476.85 $580.03 $580.03 $487.69 $487.69 $467.39 $467.39 $423.15 $423.15$542.23 $542.23 $435.62 $435.62 $490.91 $490.91 $597.13 $597.13 $502.07 $502.07 $481.16 $481.16 $435.62 $435.62$560.47 $560.47 $450.28 $450.28 $507.43 $507.43 $617.22 $617.22 $518.96 $518.96 $497.35 $497.35 $450.28 $450.28$582.20 $582.20 $467.74 $467.74 $527.10 $527.10 $641.16 $641.16 $539.08 $539.08 $516.64 $516.64 $467.74 $467.74$606.66 $606.66 $487.39 $487.39 $549.24 $549.24 $668.08 $668.08 $561.73 $561.73 $538.34 $538.34 $487.39 $487.39$634.60 $634.60 $509.84 $509.84 $574.54 $574.54 $698.86 $698.86 $587.60 $587.60 $563.14 $563.14 $509.84 $509.84$662.16 $662.16 $531.98 $531.98 $599.49 $599.49 $729.21 $729.21 $613.12 $613.12 $587.59 $587.59 $531.98 $531.98$693.21 $693.21 $556.93 $556.93 $627.60 $627.60 $763.40 $763.40 $641.87 $641.87 $615.14 $615.14 $556.93 $556.93$723.87 $723.87 $581.56 $581.56 $655.37 $655.37 $797.17 $797.17 $670.26 $670.26 $642.35 $642.35 $581.56 $581.56$757.64 $757.64 $608.69 $608.69 $685.94 $685.94 $834.36 $834.36 $701.53 $701.53 $672.32 $672.32 $608.69 $608.69$791.80 $791.80 $636.13 $636.13 $716.86 $716.86 $871.97 $871.97 $733.15 $733.15 $702.63 $702.63 $636.13 $636.13$828.67 $828.67 $665.75 $665.75 $750.24 $750.24 $912.58 $912.58 $767.30 $767.30 $735.35 $735.35 $665.75 $665.75$865.54 $865.54 $695.38 $695.38 $783.63 $783.63 $953.18 $953.18 $801.44 $801.44 $768.07 $768.07 $695.38 $695.38$905.52 $905.52 $727.50 $727.50 $819.82 $819.82 $997.21 $997.21 $838.46 $838.46 $803.54 $803.54 $727.50 $727.50$945.89 $945.89 $759.93 $759.93 $856.37 $856.37 $1,041.66 $1,041.66 $875.83 $875.83 $839.36 $839.36 $759.93 $759.93$988.97 $988.97 $794.54 $794.54 $895.37 $895.37 $1,089.11 $1,089.11 $915.72 $915.72 $877.60 $877.60 $794.54 $794.54

$1,010.32 $1,010.32 $811.69 $811.69 $914.70 $914.70 $1,112.62 $1,112.62 $935.49 $935.49 $896.54 $896.54 $811.69 $811.69$1,053.40 $1,053.40 $846.30 $846.30 $953.71 $953.71 $1,160.06 $1,160.06 $975.38 $975.38 $934.77 $934.77 $846.30 $846.30$1,090.66 $1,090.66 $876.24 $876.24 $987.44 $987.44 $1,201.10 $1,201.10 $1,009.88 $1,009.88 $967.83 $967.83 $876.24 $876.24$1,115.11 $1,115.11 $895.88 $895.88 $1,009.58 $1,009.58 $1,228.03 $1,228.03 $1,032.53 $1,032.53 $989.53 $989.53 $895.88 $895.88$1,145.78 $1,145.78 $920.52 $920.52 $1,037.34 $1,037.34 $1,261.79 $1,261.79 $1,060.92 $1,060.92 $1,016.74 $1,016.74 $920.52 $920.52$1,164.41 $1,164.41 $935.49 $935.49 $1,054.21 $1,054.21 $1,282.31 $1,282.31 $1,078.17 $1,078.17 $1,033.28 $1,033.28 $935.49 $935.49

SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 3



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 3


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 6


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 6


Page Number: 57 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 14 $228.43 $228.43 $218.42 $218.42 $233.56 $233.56 $246.14 $246.14 $298.24 $298.24 $253.33 $253.33 $292.86 $292.86 $330.02 $330.02 $339.66 $339.66 $308.8815 $248.74 $248.74 $237.84 $237.84 $254.33 $254.33 $268.02 $268.02 $324.75 $324.75 $275.84 $275.84 $318.89 $318.89 $359.36 $359.36 $369.85 $369.85 $336.3316 $256.50 $256.50 $245.26 $245.26 $262.26 $262.26 $276.39 $276.39 $334.89 $334.89 $284.45 $284.45 $328.84 $328.84 $370.58 $370.58 $381.40 $381.40 $346.8317 $264.26 $264.26 $252.68 $252.68 $270.20 $270.20 $284.75 $284.75 $345.03 $345.03 $293.06 $293.06 $338.80 $338.80 $381.79 $381.79 $392.94 $392.94 $357.3318 $272.62 $272.62 $260.68 $260.68 $278.75 $278.75 $293.76 $293.76 $355.94 $355.94 $302.34 $302.34 $349.51 $349.51 $393.87 $393.87 $405.37 $405.37 $368.6319 $280.98 $280.98 $268.67 $268.67 $287.30 $287.30 $302.77 $302.77 $366.86 $366.86 $311.61 $311.61 $360.23 $360.23 $405.95 $405.95 $417.80 $417.80 $379.9420 $289.64 $289.64 $276.95 $276.95 $296.15 $296.15 $312.10 $312.10 $378.16 $378.16 $321.21 $321.21 $371.34 $371.34 $418.46 $418.46 $430.68 $430.68 $391.6521 $298.61 $298.61 $285.52 $285.52 $305.32 $305.32 $321.76 $321.76 $389.87 $389.87 $331.15 $331.15 $382.82 $382.82 $431.41 $431.41 $444.00 $444.00 $403.7722 $298.61 $298.61 $285.52 $285.52 $305.32 $305.32 $321.76 $321.76 $389.87 $389.87 $331.15 $331.15 $382.82 $382.82 $431.41 $431.41 $444.00 $444.00 $403.7723 $298.61 $298.61 $285.52 $285.52 $305.32 $305.32 $321.76 $321.76 $389.87 $389.87 $331.15 $331.15 $382.82 $382.82 $431.41 $431.41 $444.00 $444.00 $403.7724 $298.61 $298.61 $285.52 $285.52 $305.32 $305.32 $321.76 $321.76 $389.87 $389.87 $331.15 $331.15 $382.82 $382.82 $431.41 $431.41 $444.00 $444.00 $403.7725 $299.80 $299.80 $286.66 $286.66 $306.53 $306.53 $323.04 $323.04 $391.42 $391.42 $332.47 $332.47 $384.35 $384.35 $433.13 $433.13 $445.77 $445.77 $405.3826 $305.77 $305.77 $292.37 $292.37 $312.64 $312.64 $329.47 $329.47 $399.22 $399.22 $339.09 $339.09 $392.01 $392.01 $441.76 $441.76 $454.65 $454.65 $413.4527 $312.94 $312.94 $299.22 $299.22 $319.97 $319.97 $337.20 $337.20 $408.57 $408.57 $347.04 $347.04 $401.20 $401.20 $452.11 $452.11 $465.31 $465.31 $423.1428 $324.58 $324.58 $310.36 $310.36 $331.87 $331.87 $349.74 $349.74 $423.78 $423.78 $359.96 $359.96 $416.13 $416.13 $468.94 $468.94 $482.63 $482.63 $438.8929 $334.14 $334.14 $319.49 $319.49 $341.64 $341.64 $360.04 $360.04 $436.25 $436.25 $370.55 $370.55 $428.38 $428.38 $482.74 $482.74 $496.83 $496.83 $451.8130 $338.91 $338.91 $324.06 $324.06 $346.53 $346.53 $365.19 $365.19 $442.49 $442.49 $375.85 $375.85 $434.50 $434.50 $489.64 $489.64 $503.94 $503.94 $458.2731 $346.08 $346.08 $330.91 $330.91 $353.86 $353.86 $372.91 $372.91 $451.85 $451.85 $383.80 $383.80 $443.69 $443.69 $500.00 $500.00 $514.59 $514.59 $467.9632 $353.25 $353.25 $337.77 $337.77 $361.18 $361.18 $380.63 $380.63 $461.20 $461.20 $391.75 $391.75 $452.88 $452.88 $510.35 $510.35 $525.25 $525.25 $477.6533 $357.73 $357.73 $342.05 $342.05 $365.76 $365.76 $385.46 $385.46 $467.05 $467.05 $396.71 $396.71 $458.62 $458.62 $516.82 $516.82 $531.91 $531.91 $483.7134 $362.50 $362.50 $346.62 $346.62 $370.65 $370.65 $390.61 $390.61 $473.29 $473.29 $402.01 $402.01 $464.74 $464.74 $523.72 $523.72 $539.01 $539.01 $490.1735 $364.89 $364.89 $348.90 $348.90 $373.09 $373.09 $393.18 $393.18 $476.41 $476.41 $404.66 $404.66 $467.81 $467.81 $527.17 $527.17 $542.57 $542.57 $493.4036 $367.28 $367.28 $351.19 $351.19 $375.53 $375.53 $395.76 $395.76 $479.53 $479.53 $407.31 $407.31 $470.87 $470.87 $530.63 $530.63 $546.12 $546.12 $496.6337 $369.67 $369.67 $353.47 $353.47 $377.98 $377.98 $398.33 $398.33 $482.65 $482.65 $409.96 $409.96 $473.93 $473.93 $534.08 $534.08 $549.67 $549.67 $499.8638 $372.06 $372.06 $355.75 $355.75 $380.42 $380.42 $400.90 $400.90 $485.77 $485.77 $412.61 $412.61 $476.99 $476.99 $537.53 $537.53 $553.22 $553.22 $503.0939 $376.84 $376.84 $360.32 $360.32 $385.30 $385.30 $406.05 $406.05 $492.00 $492.00 $417.91 $417.91 $483.12 $483.12 $544.43 $544.43 $560.33 $560.33 $509.5540 $381.61 $381.61 $364.89 $364.89 $390.19 $390.19 $411.20 $411.20 $498.24 $498.24 $423.21 $423.21 $489.24 $489.24 $551.33 $551.33 $567.43 $567.43 $516.0141 $388.78 $388.78 $371.74 $371.74 $397.52 $397.52 $418.92 $418.92 $507.60 $507.60 $431.15 $431.15 $498.43 $498.43 $561.69 $561.69 $578.09 $578.09 $525.7042 $395.65 $395.65 $378.31 $378.31 $404.54 $404.54 $426.32 $426.32 $516.56 $516.56 $438.77 $438.77 $507.24 $507.24 $571.61 $571.61 $588.30 $588.30 $534.9843 $405.20 $405.20 $387.45 $387.45 $414.31 $414.31 $436.62 $436.62 $529.04 $529.04 $449.37 $449.37 $519.49 $519.49 $585.41 $585.41 $602.51 $602.51 $547.9044 $417.15 $417.15 $398.87 $398.87 $426.52 $426.52 $449.49 $449.49 $544.63 $544.63 $462.61 $462.61 $534.80 $534.80 $602.67 $602.67 $620.27 $620.27 $564.0545 $431.18 $431.18 $412.29 $412.29 $440.87 $440.87 $464.61 $464.61 $562.96 $562.96 $478.18 $478.18 $552.79 $552.79 $622.95 $622.95 $641.13 $641.13 $583.0346 $447.90 $447.90 $428.28 $428.28 $457.97 $457.97 $482.63 $482.63 $584.79 $584.79 $496.72 $496.72 $574.23 $574.23 $647.10 $647.10 $666.00 $666.00 $605.6447 $466.72 $466.72 $446.26 $446.26 $477.20 $477.20 $502.90 $502.90 $609.35 $609.35 $517.58 $517.58 $598.35 $598.35 $674.28 $674.28 $693.97 $693.97 $631.0848 $488.21 $488.21 $466.82 $466.82 $499.19 $499.19 $526.06 $526.06 $637.42 $637.42 $541.42 $541.42 $625.91 $625.91 $705.34 $705.34 $725.94 $725.94 $660.1549 $509.42 $509.42 $487.09 $487.09 $520.86 $520.86 $548.91 $548.91 $665.10 $665.10 $564.94 $564.94 $653.09 $653.09 $735.97 $735.97 $757.46 $757.46 $688.8250 $533.30 $533.30 $509.93 $509.93 $545.29 $545.29 $574.65 $574.65 $696.29 $696.29 $591.43 $591.43 $683.72 $683.72 $770.49 $770.49 $792.98 $792.98 $721.1251 $556.89 $556.89 $532.49 $532.49 $569.41 $569.41 $600.07 $600.07 $727.09 $727.09 $617.59 $617.59 $713.96 $713.96 $804.57 $804.57 $828.06 $828.06 $753.0152 $582.87 $582.87 $557.33 $557.33 $595.97 $595.97 $628.06 $628.06 $761.01 $761.01 $646.40 $646.40 $747.26 $747.26 $842.10 $842.10 $866.69 $866.69 $788.1453 $609.15 $609.15 $582.46 $582.46 $622.84 $622.84 $656.37 $656.37 $795.32 $795.32 $675.54 $675.54 $780.95 $780.95 $880.06 $880.06 $905.76 $905.76 $823.6754 $637.52 $637.52 $609.58 $609.58 $651.84 $651.84 $686.94 $686.94 $832.35 $832.35 $707.00 $707.00 $817.32 $817.32 $921.05 $921.05 $947.94 $947.94 $862.0355 $665.88 $665.88 $636.70 $636.70 $680.85 $680.85 $717.51 $717.51 $869.39 $869.39 $738.46 $738.46 $853.69 $853.69 $962.03 $962.03 $990.12 $990.12 $900.3956 $696.64 $696.64 $666.11 $666.11 $712.29 $712.29 $750.65 $750.65 $909.54 $909.54 $772.56 $772.56 $893.12 $893.12 $1,006.46 $1,006.46 $1,035.85 $1,035.85 $941.9757 $727.69 $727.69 $695.81 $695.81 $744.05 $744.05 $784.11 $784.11 $950.09 $950.09 $807.00 $807.00 $932.93 $932.93 $1,051.33 $1,051.33 $1,082.03 $1,082.03 $983.9758 $760.84 $760.84 $727.50 $727.50 $777.94 $777.94 $819.82 $819.82 $993.36 $993.36 $843.76 $843.76 $975.42 $975.42 $1,099.22 $1,099.22 $1,131.31 $1,131.31 $1,028.7859 $777.26 $777.26 $743.20 $743.20 $794.73 $794.73 $837.52 $837.52 $1,014.81 $1,014.81 $861.97 $861.97 $996.48 $996.48 $1,122.94 $1,122.94 $1,155.73 $1,155.73 $1,050.9960 $810.41 $810.41 $774.89 $774.89 $828.62 $828.62 $873.24 $873.24 $1,058.08 $1,058.08 $898.73 $898.73 $1,038.97 $1,038.97 $1,170.83 $1,170.83 $1,205.01 $1,205.01 $1,095.8161 $839.07 $839.07 $802.30 $802.30 $857.93 $857.93 $904.12 $904.12 $1,095.51 $1,095.51 $930.52 $930.52 $1,075.72 $1,075.72 $1,212.24 $1,212.24 $1,247.64 $1,247.64 $1,134.5762 $857.88 $857.88 $820.29 $820.29 $877.16 $877.16 $924.39 $924.39 $1,120.07 $1,120.07 $951.38 $951.38 $1,099.84 $1,099.84 $1,239.42 $1,239.42 $1,275.61 $1,275.61 $1,160.0163 $881.47 $881.47 $842.85 $842.85 $901.28 $901.28 $949.81 $949.81 $1,150.87 $1,150.87 $977.54 $977.54 $1,130.08 $1,130.08 $1,273.50 $1,273.50 $1,310.69 $1,310.69 $1,191.90

64+ $895.81 $895.81 $856.55 $856.55 $915.94 $915.94 $965.26 $965.26 $1,169.58 $1,169.58 $993.44 $993.44 $1,148.46 $1,148.46 $1,294.21 $1,294.21 $1,332.00 $1,332.00 $1,211.28

GoMed: $1,00

0%$20 /$8,1

Ye


20/40/M-152-121-

Rating

Geisinger All


0%$60 / $60$8,150

Yes


10/60/500M-152-243-F Rev. 1/20

Rating Area 9



0%$60 / $60$8,150

Yes

0%$60 / $60$8,150

Yes


10/60/500M-152-243-F Rev. 1/20

Rating Area 6






$6,500 $6,500 $6,500 $6,500Yes Yes Yes Yes




$6,500Yes


$6,500Yes


75729PA0050062 75729PA0050068





PPO 6500M-152-122-F Rev. 1/20

Rating Area 9






PPOOctober 1, 2020 December 31, 2020






75729PA0050062 75729PA0050062 75729PA0050062 75729PA0050062

Page Number: 58 12/24/2014

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Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$308.88 $295.34 $295.34 $315.82 $315.82 $332.82 $332.82 $403.28 $403.28 $342.54 $342.54 $292.83 $292.83 $279.99 $279.99 $299.41 $299.41 $315.53 $315.53$336.33 $321.59 $321.59 $343.89 $343.89 $362.41 $362.41 $439.12 $439.12 $372.99 $372.99 $318.86 $318.86 $304.88 $304.88 $326.02 $326.02 $343.58 $343.58$346.83 $331.63 $331.63 $354.62 $354.62 $373.72 $373.72 $452.83 $452.83 $384.63 $384.63 $328.81 $328.81 $314.40 $314.40 $336.20 $336.20 $354.30 $354.30$357.33 $341.67 $341.67 $365.36 $365.36 $385.03 $385.03 $466.53 $466.53 $396.27 $396.27 $338.76 $338.76 $323.92 $323.92 $346.37 $346.37 $365.02 $365.02$368.63 $352.48 $352.48 $376.92 $376.92 $397.21 $397.21 $481.29 $481.29 $408.81 $408.81 $349.48 $349.48 $334.16 $334.16 $357.33 $357.33 $376.57 $376.57$379.94 $363.29 $363.29 $388.48 $388.48 $409.40 $409.40 $496.06 $496.06 $421.35 $421.35 $360.20 $360.20 $344.41 $344.41 $368.29 $368.29 $388.12 $388.12$391.65 $374.49 $374.49 $400.45 $400.45 $422.01 $422.01 $511.34 $511.34 $434.33 $434.33 $371.30 $371.30 $355.03 $355.03 $379.64 $379.64 $400.08 $400.08$403.77 $386.07 $386.07 $412.84 $412.84 $435.07 $435.07 $527.16 $527.16 $447.77 $447.77 $382.78 $382.78 $366.01 $366.01 $391.39 $391.39 $412.46 $412.46$403.77 $386.07 $386.07 $412.84 $412.84 $435.07 $435.07 $527.16 $527.16 $447.77 $447.77 $382.78 $382.78 $366.01 $366.01 $391.39 $391.39 $412.46 $412.46$403.77 $386.07 $386.07 $412.84 $412.84 $435.07 $435.07 $527.16 $527.16 $447.77 $447.77 $382.78 $382.78 $366.01 $366.01 $391.39 $391.39 $412.46 $412.46$403.77 $386.07 $386.07 $412.84 $412.84 $435.07 $435.07 $527.16 $527.16 $447.77 $447.77 $382.78 $382.78 $366.01 $366.01 $391.39 $391.39 $412.46 $412.46$405.38 $387.61 $387.61 $414.49 $414.49 $436.80 $436.80 $529.27 $529.27 $449.56 $449.56 $384.31 $384.31 $367.47 $367.47 $392.95 $392.95 $414.11 $414.11$413.45 $395.33 $395.33 $422.74 $422.74 $445.51 $445.51 $539.81 $539.81 $458.51 $458.51 $391.97 $391.97 $374.79 $374.79 $400.77 $400.77 $422.35 $422.35$423.14 $404.60 $404.60 $432.65 $432.65 $455.95 $455.95 $552.46 $552.46 $469.26 $469.26 $401.15 $401.15 $383.57 $383.57 $410.17 $410.17 $432.25 $432.25$438.89 $419.66 $419.66 $448.75 $448.75 $472.91 $472.91 $573.02 $573.02 $486.72 $486.72 $416.08 $416.08 $397.85 $397.85 $425.43 $425.43 $448.34 $448.34$451.81 $432.01 $432.01 $461.96 $461.96 $486.84 $486.84 $589.89 $589.89 $501.05 $501.05 $428.33 $428.33 $409.56 $409.56 $437.96 $437.96 $461.54 $461.54$458.27 $438.19 $438.19 $468.57 $468.57 $493.80 $493.80 $598.32 $598.32 $508.21 $508.21 $434.45 $434.45 $415.42 $415.42 $444.22 $444.22 $468.14 $468.14$467.96 $447.45 $447.45 $478.47 $478.47 $504.24 $504.24 $610.98 $610.98 $518.96 $518.96 $443.64 $443.64 $424.20 $424.20 $453.61 $453.61 $478.04 $478.04$477.65 $456.72 $456.72 $488.38 $488.38 $514.68 $514.68 $623.63 $623.63 $529.71 $529.71 $452.83 $452.83 $432.98 $432.98 $463.00 $463.00 $487.93 $487.93$483.71 $462.51 $462.51 $494.58 $494.58 $521.21 $521.21 $631.53 $631.53 $536.42 $536.42 $458.57 $458.57 $438.47 $438.47 $468.87 $468.87 $494.12 $494.12$490.17 $468.69 $468.69 $501.18 $501.18 $528.17 $528.17 $639.97 $639.97 $543.59 $543.59 $464.69 $464.69 $444.33 $444.33 $475.14 $475.14 $500.72 $500.72$493.40 $471.78 $471.78 $504.48 $504.48 $531.65 $531.65 $644.19 $644.19 $547.17 $547.17 $467.76 $467.76 $447.26 $447.26 $478.27 $478.27 $504.02 $504.02$496.63 $474.86 $474.86 $507.79 $507.79 $535.13 $535.13 $648.40 $648.40 $550.75 $550.75 $470.82 $470.82 $450.19 $450.19 $481.40 $481.40 $507.32 $507.32$499.86 $477.95 $477.95 $511.09 $511.09 $538.61 $538.61 $652.62 $652.62 $554.33 $554.33 $473.88 $473.88 $453.12 $453.12 $484.53 $484.53 $510.62 $510.62$503.09 $481.04 $481.04 $514.39 $514.39 $542.09 $542.09 $656.84 $656.84 $557.92 $557.92 $476.94 $476.94 $456.04 $456.04 $487.66 $487.66 $513.92 $513.92$509.55 $487.22 $487.22 $521.00 $521.00 $549.05 $549.05 $665.27 $665.27 $565.08 $565.08 $483.07 $483.07 $461.90 $461.90 $493.92 $493.92 $520.52 $520.52$516.01 $493.39 $493.39 $527.60 $527.60 $556.01 $556.01 $673.71 $673.71 $572.25 $572.25 $489.19 $489.19 $467.76 $467.76 $500.18 $500.18 $527.12 $527.12$525.70 $502.66 $502.66 $537.51 $537.51 $566.45 $566.45 $686.36 $686.36 $582.99 $582.99 $498.38 $498.38 $476.54 $476.54 $509.58 $509.58 $537.02 $537.02$534.98 $511.54 $511.54 $547.01 $547.01 $576.46 $576.46 $698.48 $698.48 $593.29 $593.29 $507.18 $507.18 $484.96 $484.96 $518.58 $518.58 $546.50 $546.50$547.90 $523.89 $523.89 $560.22 $560.22 $590.38 $590.38 $715.35 $715.35 $607.62 $607.62 $519.43 $519.43 $496.67 $496.67 $531.10 $531.10 $559.70 $559.70$564.05 $539.34 $539.34 $576.73 $576.73 $607.78 $607.78 $736.44 $736.44 $625.53 $625.53 $534.74 $534.74 $511.31 $511.31 $546.76 $546.76 $576.20 $576.20$583.03 $557.48 $557.48 $596.13 $596.13 $628.23 $628.23 $761.22 $761.22 $646.57 $646.57 $552.73 $552.73 $528.51 $528.51 $565.15 $565.15 $595.59 $595.59$605.64 $579.10 $579.10 $619.25 $619.25 $652.60 $652.60 $790.74 $790.74 $671.65 $671.65 $574.17 $574.17 $549.01 $549.01 $587.07 $587.07 $618.68 $618.68$631.08 $603.42 $603.42 $645.26 $645.26 $680.00 $680.00 $823.95 $823.95 $699.86 $699.86 $598.28 $598.28 $572.07 $572.07 $611.73 $611.73 $644.67 $644.67$660.15 $631.22 $631.22 $674.98 $674.98 $711.33 $711.33 $861.90 $861.90 $732.10 $732.10 $625.84 $625.84 $598.42 $598.42 $639.91 $639.91 $674.36 $674.36$688.82 $658.63 $658.63 $704.30 $704.30 $742.22 $742.22 $899.33 $899.33 $763.89 $763.89 $653.02 $653.02 $624.41 $624.41 $667.70 $667.70 $703.65 $703.65$721.12 $689.52 $689.52 $737.32 $737.32 $777.02 $777.02 $941.50 $941.50 $799.71 $799.71 $683.64 $683.64 $653.69 $653.69 $699.01 $699.01 $736.65 $736.65$753.01 $720.02 $720.02 $769.94 $769.94 $811.39 $811.39 $983.15 $983.15 $835.08 $835.08 $713.88 $713.88 $682.60 $682.60 $729.93 $729.93 $769.23 $769.23$788.14 $753.60 $753.60 $805.85 $805.85 $849.24 $849.24 $1,029.01 $1,029.01 $874.04 $874.04 $747.19 $747.19 $714.44 $714.44 $763.98 $763.98 $805.11 $805.11$823.67 $787.58 $787.58 $842.18 $842.18 $887.53 $887.53 $1,075.40 $1,075.40 $913.44 $913.44 $780.87 $780.87 $746.65 $746.65 $798.42 $798.42 $841.41 $841.41$862.03 $824.26 $824.26 $881.40 $881.40 $928.86 $928.86 $1,125.48 $1,125.48 $955.98 $955.98 $817.23 $817.23 $781.42 $781.42 $835.60 $835.60 $880.59 $880.59$900.39 $860.93 $860.93 $920.62 $920.62 $970.19 $970.19 $1,175.56 $1,175.56 $998.52 $998.52 $853.60 $853.60 $816.19 $816.19 $872.78 $872.78 $919.78 $919.78$941.97 $900.70 $900.70 $963.14 $963.14 $1,015.00 $1,015.00 $1,229.86 $1,229.86 $1,044.64 $1,044.64 $893.02 $893.02 $853.89 $853.89 $913.09 $913.09 $962.26 $962.26$983.97 $940.85 $940.85 $1,006.08 $1,006.08 $1,060.25 $1,060.25 $1,284.68 $1,284.68 $1,091.21 $1,091.21 $932.83 $932.83 $891.96 $891.96 $953.80 $953.80 $1,005.15 $1,005.15

$1,028.78 $983.70 $983.70 $1,051.90 $1,051.90 $1,108.54 $1,108.54 $1,343.20 $1,343.20 $1,140.91 $1,140.91 $975.32 $975.32 $932.58 $932.58 $997.24 $997.24 $1,050.94 $1,050.94$1,050.99 $1,004.94 $1,004.94 $1,074.61 $1,074.61 $1,132.47 $1,132.47 $1,372.19 $1,372.19 $1,165.54 $1,165.54 $996.37 $996.37 $952.71 $952.71 $1,018.76 $1,018.76 $1,073.62 $1,073.62$1,095.81 $1,047.79 $1,047.79 $1,120.43 $1,120.43 $1,180.76 $1,180.76 $1,430.71 $1,430.71 $1,215.24 $1,215.24 $1,038.86 $1,038.86 $993.34 $993.34 $1,062.21 $1,062.21 $1,119.40 $1,119.40$1,134.57 $1,084.85 $1,084.85 $1,160.06 $1,160.06 $1,222.53 $1,222.53 $1,481.31 $1,481.31 $1,258.22 $1,258.22 $1,075.61 $1,075.61 $1,028.48 $1,028.48 $1,099.78 $1,099.78 $1,159.00 $1,159.00$1,160.01 $1,109.17 $1,109.17 $1,186.07 $1,186.07 $1,249.94 $1,249.94 $1,514.52 $1,514.52 $1,286.43 $1,286.43 $1,099.72 $1,099.72 $1,051.53 $1,051.53 $1,124.44 $1,124.44 $1,184.98 $1,184.98$1,191.90 $1,139.67 $1,139.67 $1,218.69 $1,218.69 $1,284.31 $1,284.31 $1,556.17 $1,556.17 $1,321.81 $1,321.81 $1,129.96 $1,129.96 $1,080.45 $1,080.45 $1,155.36 $1,155.36 $1,217.57 $1,217.57$1,211.28 $1,158.20 $1,158.20 $1,238.50 $1,238.50 $1,305.19 $1,305.19 $1,581.47 $1,581.47 $1,343.30 $1,343.30 $1,148.34 $1,148.34 $1,098.02 $1,098.02 $1,174.14 $1,174.14 $1,237.37 $1,237.37

GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $1,000 / Rx: $0

0%$20 / $40$8,150

Yes


20/40/1000M-152-121-F Rev. 1/20

Rating Area 3


old00 / Rx: $0%/ $40150es


l-Access PPO

Page Number: 59 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 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$382.32 $382.32 $324.74 $324.74 $255.80 $255.80 $244.59 $244.59 $261.55 $261.55 $275.63 $275.63 $333.98 $333.98 $283.68 $283.68 $253.68 $253.68 $242.57$416.30 $416.30 $353.61 $353.61 $278.54 $278.54 $266.33 $266.33 $284.80 $284.80 $300.13 $300.13 $363.67 $363.67 $308.90 $308.90 $276.23 $276.23 $264.13$429.30 $429.30 $364.64 $364.64 $287.23 $287.23 $274.65 $274.65 $293.69 $293.69 $309.50 $309.50 $375.02 $375.02 $318.54 $318.54 $284.85 $284.85 $272.37$442.29 $442.29 $375.68 $375.68 $295.93 $295.93 $282.96 $282.96 $302.58 $302.58 $318.87 $318.87 $386.37 $386.37 $328.18 $328.18 $293.48 $293.48 $280.62$456.28 $456.28 $387.57 $387.57 $305.29 $305.29 $291.91 $291.91 $312.15 $312.15 $328.96 $328.96 $398.59 $398.59 $338.56 $338.56 $302.76 $302.76 $289.49$470.28 $470.28 $399.45 $399.45 $314.65 $314.65 $300.87 $300.87 $321.72 $321.72 $339.05 $339.05 $410.82 $410.82 $348.95 $348.95 $312.05 $312.05 $298.37$484.77 $484.77 $411.76 $411.76 $324.35 $324.35 $310.14 $310.14 $331.64 $331.64 $349.50 $349.50 $423.48 $423.48 $359.70 $359.70 $321.66 $321.66 $307.57$499.77 $499.77 $424.50 $424.50 $334.39 $334.39 $319.73 $319.73 $341.90 $341.90 $360.31 $360.31 $436.58 $436.58 $370.83 $370.83 $331.62 $331.62 $317.08$499.77 $499.77 $424.50 $424.50 $334.39 $334.39 $319.73 $319.73 $341.90 $341.90 $360.31 $360.31 $436.58 $436.58 $370.83 $370.83 $331.62 $331.62 $317.08$499.77 $499.77 $424.50 $424.50 $334.39 $334.39 $319.73 $319.73 $341.90 $341.90 $360.31 $360.31 $436.58 $436.58 $370.83 $370.83 $331.62 $331.62 $317.08$499.77 $499.77 $424.50 $424.50 $334.39 $334.39 $319.73 $319.73 $341.90 $341.90 $360.31 $360.31 $436.58 $436.58 $370.83 $370.83 $331.62 $331.62 $317.08$501.76 $501.76 $426.20 $426.20 $335.72 $335.72 $321.01 $321.01 $343.26 $343.26 $361.75 $361.75 $438.32 $438.32 $372.31 $372.31 $332.94 $332.94 $318.35$511.76 $511.76 $434.69 $434.69 $342.41 $342.41 $327.40 $327.40 $350.10 $350.10 $368.95 $368.95 $447.05 $447.05 $379.73 $379.73 $339.57 $339.57 $324.69$523.75 $523.75 $444.87 $444.87 $350.43 $350.43 $335.08 $335.08 $358.31 $358.31 $377.60 $377.60 $457.53 $457.53 $388.63 $388.63 $347.53 $347.53 $332.30$543.24 $543.24 $461.43 $461.43 $363.47 $363.47 $347.55 $347.55 $371.64 $371.64 $391.65 $391.65 $474.56 $474.56 $403.09 $403.09 $360.46 $360.46 $344.67$559.24 $559.24 $475.01 $475.01 $374.17 $374.17 $357.78 $357.78 $382.58 $382.58 $403.18 $403.18 $488.53 $488.53 $414.95 $414.95 $371.07 $371.07 $354.81$567.23 $567.23 $481.81 $481.81 $379.52 $379.52 $362.89 $362.89 $388.05 $388.05 $408.95 $408.95 $495.51 $495.51 $420.89 $420.89 $376.38 $376.38 $359.88$579.23 $579.23 $491.99 $491.99 $387.55 $387.55 $370.57 $370.57 $396.26 $396.26 $417.59 $417.59 $505.99 $505.99 $429.79 $429.79 $384.34 $384.34 $367.49$591.22 $591.22 $502.18 $502.18 $395.57 $395.57 $378.24 $378.24 $404.46 $404.46 $426.24 $426.24 $516.47 $516.47 $438.69 $438.69 $392.30 $392.30 $375.10$598.72 $598.72 $508.55 $508.55 $400.59 $400.59 $383.04 $383.04 $409.59 $409.59 $431.65 $431.65 $523.02 $523.02 $444.25 $444.25 $397.27 $397.27 $379.86$606.71 $606.71 $515.34 $515.34 $405.94 $405.94 $388.15 $388.15 $415.06 $415.06 $437.41 $437.41 $530.00 $530.00 $450.18 $450.18 $402.58 $402.58 $384.93$610.71 $610.71 $518.74 $518.74 $408.61 $408.61 $390.71 $390.71 $417.80 $417.80 $440.29 $440.29 $533.49 $533.49 $453.15 $453.15 $405.23 $405.23 $387.47$614.71 $614.71 $522.13 $522.13 $411.29 $411.29 $393.27 $393.27 $420.53 $420.53 $443.18 $443.18 $536.99 $536.99 $456.12 $456.12 $407.88 $407.88 $390.01$618.71 $618.71 $525.53 $525.53 $413.96 $413.96 $395.82 $395.82 $423.27 $423.27 $446.06 $446.06 $540.48 $540.48 $459.08 $459.08 $410.53 $410.53 $392.54$622.71 $622.71 $528.92 $528.92 $416.64 $416.64 $398.38 $398.38 $426.00 $426.00 $448.94 $448.94 $543.97 $543.97 $462.05 $462.05 $413.19 $413.19 $395.08$630.70 $630.70 $535.72 $535.72 $421.99 $421.99 $403.50 $403.50 $431.47 $431.47 $454.71 $454.71 $550.96 $550.96 $467.98 $467.98 $418.49 $418.49 $400.15$638.70 $638.70 $542.51 $542.51 $427.34 $427.34 $408.61 $408.61 $436.94 $436.94 $460.47 $460.47 $557.94 $557.94 $473.92 $473.92 $423.80 $423.80 $405.23$650.69 $650.69 $552.70 $552.70 $435.37 $435.37 $416.29 $416.29 $445.15 $445.15 $469.12 $469.12 $568.42 $568.42 $482.82 $482.82 $431.76 $431.76 $412.84$662.19 $662.19 $562.46 $562.46 $443.06 $443.06 $423.64 $423.64 $453.01 $453.01 $477.41 $477.41 $578.46 $578.46 $491.34 $491.34 $439.38 $439.38 $420.13$678.18 $678.18 $576.04 $576.04 $453.76 $453.76 $433.87 $433.87 $463.95 $463.95 $488.94 $488.94 $592.43 $592.43 $503.21 $503.21 $450.00 $450.00 $430.28$698.17 $698.17 $593.02 $593.02 $467.13 $467.13 $446.66 $446.66 $477.63 $477.63 $503.35 $503.35 $609.90 $609.90 $518.04 $518.04 $463.26 $463.26 $442.96$721.66 $721.66 $612.97 $612.97 $482.85 $482.85 $461.69 $461.69 $493.70 $493.70 $520.28 $520.28 $630.41 $630.41 $535.47 $535.47 $478.85 $478.85 $457.86$749.65 $749.65 $636.75 $636.75 $501.57 $501.57 $479.59 $479.59 $512.84 $512.84 $540.46 $540.46 $654.86 $654.86 $556.24 $556.24 $497.42 $497.42 $475.62$781.13 $781.13 $663.49 $663.49 $522.64 $522.64 $499.74 $499.74 $534.38 $534.38 $563.16 $563.16 $682.37 $682.37 $579.60 $579.60 $518.31 $518.31 $495.59$817.11 $817.11 $694.05 $694.05 $546.71 $546.71 $522.76 $522.76 $559.00 $559.00 $589.10 $589.10 $713.80 $713.80 $606.30 $606.30 $542.18 $542.18 $518.42$852.60 $852.60 $724.19 $724.19 $570.46 $570.46 $545.46 $545.46 $583.27 $583.27 $614.68 $614.68 $744.80 $744.80 $632.63 $632.63 $565.73 $565.73 $540.94$892.58 $892.58 $758.15 $758.15 $597.21 $597.21 $571.04 $571.04 $610.63 $610.63 $643.51 $643.51 $779.72 $779.72 $662.29 $662.29 $592.26 $592.26 $566.30$932.06 $932.06 $791.69 $791.69 $623.62 $623.62 $596.29 $596.29 $637.64 $637.64 $671.97 $671.97 $814.21 $814.21 $691.59 $691.59 $618.45 $618.45 $591.35$975.54 $975.54 $828.62 $828.62 $652.71 $652.71 $624.11 $624.11 $667.38 $667.38 $703.32 $703.32 $852.19 $852.19 $723.85 $723.85 $647.30 $647.30 $618.94

$1,019.52 $1,019.52 $865.98 $865.98 $682.14 $682.14 $652.25 $652.25 $697.47 $697.47 $735.02 $735.02 $890.61 $890.61 $756.48 $756.48 $676.49 $676.49 $646.84$1,066.99 $1,066.99 $906.30 $906.30 $713.91 $713.91 $682.62 $682.62 $729.95 $729.95 $769.25 $769.25 $932.09 $932.09 $791.71 $791.71 $707.99 $707.99 $676.96$1,114.47 $1,114.47 $946.63 $946.63 $745.67 $745.67 $713.00 $713.00 $762.43 $762.43 $803.48 $803.48 $973.56 $973.56 $826.94 $826.94 $739.49 $739.49 $707.09$1,165.95 $1,165.95 $990.35 $990.35 $780.11 $780.11 $745.93 $745.93 $797.64 $797.64 $840.59 $840.59 $1,018.53 $1,018.53 $865.14 $865.14 $773.65 $773.65 $739.75$1,217.92 $1,217.92 $1,034.50 $1,034.50 $814.89 $814.89 $779.18 $779.18 $833.20 $833.20 $878.07 $878.07 $1,063.93 $1,063.93 $903.70 $903.70 $808.13 $808.13 $772.72$1,273.40 $1,273.40 $1,081.62 $1,081.62 $852.01 $852.01 $814.67 $814.67 $871.15 $871.15 $918.06 $918.06 $1,112.39 $1,112.39 $944.86 $944.86 $844.94 $844.94 $807.92$1,300.88 $1,300.88 $1,104.97 $1,104.97 $870.40 $870.40 $832.26 $832.26 $889.96 $889.96 $937.88 $937.88 $1,136.40 $1,136.40 $965.26 $965.26 $863.18 $863.18 $825.36$1,356.36 $1,356.36 $1,152.09 $1,152.09 $907.51 $907.51 $867.75 $867.75 $927.91 $927.91 $977.87 $977.87 $1,184.86 $1,184.86 $1,006.42 $1,006.42 $899.99 $899.99 $860.55$1,404.34 $1,404.34 $1,192.84 $1,192.84 $939.61 $939.61 $898.44 $898.44 $960.73 $960.73 $1,012.46 $1,012.46 $1,226.78 $1,226.78 $1,042.02 $1,042.02 $931.83 $931.83 $890.99$1,435.82 $1,435.82 $1,219.58 $1,219.58 $960.68 $960.68 $918.58 $918.58 $982.27 $982.27 $1,035.16 $1,035.16 $1,254.28 $1,254.28 $1,065.38 $1,065.38 $952.72 $952.72 $910.97$1,475.30 $1,475.30 $1,253.12 $1,253.12 $987.10 $987.10 $943.84 $943.84 $1,009.28 $1,009.28 $1,063.62 $1,063.62 $1,288.77 $1,288.77 $1,094.68 $1,094.68 $978.91 $978.91 $936.02$1,499.29 $1,499.29 $1,273.49 $1,273.49 $1,003.15 $1,003.15 $959.19 $959.19 $1,025.69 $1,025.69 $1,080.92 $1,080.92 $1,309.73 $1,309.73 $1,112.48 $1,112.48 $994.83 $994.83 $951.24

SilMed: $6,75

0$25 /$7,3

Y

75729PAGeisinger Al

25/50M-152-121-

Rating

Geisinger Al

SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 7


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 5


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $6,000 / Rx: $500

0%$30 / $60$7,350

Yes


30/60/6000M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,750 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2750M-152-121-F Rev. 1/20

Rating Area 7


Page Number: 60 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$242.57 $259.38 $259.38 $273.35 $273.35 $331.21 $331.21 $281.33 $281.33 $307.15 $307.15 $293.70 $293.70 $314.06 $314.06 $330.97 $330.97 $401.03 $401.03$264.13 $282.44 $282.44 $297.65 $297.65 $360.65 $360.65 $306.34 $306.34 $334.46 $334.46 $319.80 $319.80 $341.97 $341.97 $360.39 $360.39 $436.67 $436.67$272.37 $291.25 $291.25 $306.94 $306.94 $371.91 $371.91 $315.90 $315.90 $344.90 $344.90 $329.78 $329.78 $352.65 $352.65 $371.64 $371.64 $450.30 $450.30$280.62 $300.07 $300.07 $316.23 $316.23 $383.17 $383.17 $325.46 $325.46 $355.34 $355.34 $339.76 $339.76 $363.32 $363.32 $382.88 $382.88 $463.93 $463.93$289.49 $309.56 $309.56 $326.23 $326.23 $395.29 $395.29 $335.76 $335.76 $366.58 $366.58 $350.51 $350.51 $374.82 $374.82 $395.00 $395.00 $478.61 $478.61$298.37 $319.06 $319.06 $336.24 $336.24 $407.41 $407.41 $346.05 $346.05 $377.82 $377.82 $361.26 $361.26 $386.31 $386.31 $407.11 $407.11 $493.29 $493.29$307.57 $328.89 $328.89 $346.60 $346.60 $419.97 $419.97 $356.72 $356.72 $389.46 $389.46 $372.40 $372.40 $398.22 $398.22 $419.66 $419.66 $508.49 $508.49$317.08 $339.07 $339.07 $357.32 $357.32 $432.96 $432.96 $367.76 $367.76 $401.51 $401.51 $383.92 $383.92 $410.54 $410.54 $432.64 $432.64 $524.22 $524.22$317.08 $339.07 $339.07 $357.32 $357.32 $432.96 $432.96 $367.76 $367.76 $401.51 $401.51 $383.92 $383.92 $410.54 $410.54 $432.64 $432.64 $524.22 $524.22$317.08 $339.07 $339.07 $357.32 $357.32 $432.96 $432.96 $367.76 $367.76 $401.51 $401.51 $383.92 $383.92 $410.54 $410.54 $432.64 $432.64 $524.22 $524.22$317.08 $339.07 $339.07 $357.32 $357.32 $432.96 $432.96 $367.76 $367.76 $401.51 $401.51 $383.92 $383.92 $410.54 $410.54 $432.64 $432.64 $524.22 $524.22$318.35 $340.42 $340.42 $358.75 $358.75 $434.69 $434.69 $369.22 $369.22 $403.12 $403.12 $385.45 $385.45 $412.17 $412.17 $434.37 $434.37 $526.31 $526.31$324.69 $347.20 $347.20 $365.90 $365.90 $443.35 $443.35 $376.58 $376.58 $411.15 $411.15 $393.13 $393.13 $420.38 $420.38 $443.02 $443.02 $536.80 $536.80$332.30 $355.34 $355.34 $374.47 $374.47 $453.74 $453.74 $385.40 $385.40 $420.78 $420.78 $402.34 $402.34 $430.24 $430.24 $453.40 $453.40 $549.38 $549.38$344.67 $368.56 $368.56 $388.41 $388.41 $470.62 $470.62 $399.75 $399.75 $436.44 $436.44 $417.32 $417.32 $446.25 $446.25 $470.28 $470.28 $569.82 $569.82$354.81 $379.41 $379.41 $399.84 $399.84 $484.48 $484.48 $411.51 $411.51 $449.29 $449.29 $429.60 $429.60 $459.39 $459.39 $484.12 $484.12 $586.60 $586.60$359.88 $384.84 $384.84 $405.56 $405.56 $491.41 $491.41 $417.40 $417.40 $455.71 $455.71 $435.74 $435.74 $465.95 $465.95 $491.04 $491.04 $594.99 $594.99$367.49 $392.97 $392.97 $414.13 $414.13 $501.80 $501.80 $426.22 $426.22 $465.35 $465.35 $444.96 $444.96 $475.81 $475.81 $501.43 $501.43 $607.57 $607.57$375.10 $401.11 $401.11 $422.71 $422.71 $512.19 $512.19 $435.05 $435.05 $474.99 $474.99 $454.17 $454.17 $485.66 $485.66 $511.81 $511.81 $620.15 $620.15$379.86 $406.20 $406.20 $428.07 $428.07 $518.68 $518.68 $440.57 $440.57 $481.01 $481.01 $459.93 $459.93 $491.82 $491.82 $518.30 $518.30 $628.01 $628.01$384.93 $411.62 $411.62 $433.79 $433.79 $525.61 $525.61 $446.45 $446.45 $487.43 $487.43 $466.07 $466.07 $498.39 $498.39 $525.22 $525.22 $636.40 $636.40$387.47 $414.33 $414.33 $436.64 $436.64 $529.07 $529.07 $449.39 $449.39 $490.64 $490.64 $469.14 $469.14 $501.67 $501.67 $528.68 $528.68 $640.59 $640.59$390.01 $417.05 $417.05 $439.50 $439.50 $532.54 $532.54 $452.34 $452.34 $493.86 $493.86 $472.22 $472.22 $504.95 $504.95 $532.14 $532.14 $644.79 $644.79$392.54 $419.76 $419.76 $442.36 $442.36 $536.00 $536.00 $455.28 $455.28 $497.07 $497.07 $475.29 $475.29 $508.24 $508.24 $535.61 $535.61 $648.98 $648.98$395.08 $422.47 $422.47 $445.22 $445.22 $539.46 $539.46 $458.22 $458.22 $500.28 $500.28 $478.36 $478.36 $511.52 $511.52 $539.07 $539.07 $653.18 $653.18$400.15 $427.90 $427.90 $450.94 $450.94 $546.39 $546.39 $464.10 $464.10 $506.70 $506.70 $484.50 $484.50 $518.09 $518.09 $545.99 $545.99 $661.56 $661.56$405.23 $433.32 $433.32 $456.65 $456.65 $553.32 $553.32 $469.99 $469.99 $513.13 $513.13 $490.64 $490.64 $524.66 $524.66 $552.91 $552.91 $669.95 $669.95$412.84 $441.46 $441.46 $465.23 $465.23 $563.71 $563.71 $478.81 $478.81 $522.77 $522.77 $499.86 $499.86 $534.51 $534.51 $563.29 $563.29 $682.53 $682.53$420.13 $449.26 $449.26 $473.45 $473.45 $573.67 $573.67 $487.27 $487.27 $532.00 $532.00 $508.69 $508.69 $543.95 $543.95 $573.24 $573.24 $694.59 $694.59$430.28 $460.11 $460.11 $484.88 $484.88 $587.52 $587.52 $499.04 $499.04 $544.85 $544.85 $520.97 $520.97 $557.09 $557.09 $587.09 $587.09 $711.36 $711.36$442.96 $473.67 $473.67 $499.18 $499.18 $604.84 $604.84 $513.75 $513.75 $560.91 $560.91 $536.33 $536.33 $573.51 $573.51 $604.39 $604.39 $732.33 $732.33$457.86 $489.61 $489.61 $515.97 $515.97 $625.19 $625.19 $531.03 $531.03 $579.78 $579.78 $554.37 $554.37 $592.81 $592.81 $624.73 $624.73 $756.97 $756.97$475.62 $508.59 $508.59 $535.98 $535.98 $649.43 $649.43 $551.63 $551.63 $602.26 $602.26 $575.87 $575.87 $615.80 $615.80 $648.96 $648.96 $786.33 $786.33$495.59 $529.95 $529.95 $558.49 $558.49 $676.71 $676.71 $574.80 $574.80 $627.56 $627.56 $600.06 $600.06 $641.66 $641.66 $676.21 $676.21 $819.35 $819.35$518.42 $554.37 $554.37 $584.22 $584.22 $707.88 $707.88 $601.27 $601.27 $656.47 $656.47 $627.70 $627.70 $671.22 $671.22 $707.36 $707.36 $857.10 $857.10$540.94 $578.44 $578.44 $609.59 $609.59 $738.62 $738.62 $627.39 $627.39 $684.97 $684.97 $654.96 $654.96 $700.37 $700.37 $738.08 $738.08 $894.32 $894.32$566.30 $605.57 $605.57 $638.17 $638.17 $773.26 $773.26 $656.81 $656.81 $717.10 $717.10 $685.67 $685.67 $733.21 $733.21 $772.69 $772.69 $936.25 $936.25$591.35 $632.35 $632.35 $666.40 $666.40 $807.46 $807.46 $685.86 $685.86 $748.81 $748.81 $716.00 $716.00 $765.64 $765.64 $806.87 $806.87 $977.67 $977.67$618.94 $661.85 $661.85 $697.49 $697.49 $845.13 $845.13 $717.85 $717.85 $783.75 $783.75 $749.40 $749.40 $801.36 $801.36 $844.51 $844.51 $1,023.27 $1,023.27$646.84 $691.69 $691.69 $728.93 $728.93 $883.23 $883.23 $750.21 $750.21 $819.08 $819.08 $783.19 $783.19 $837.49 $837.49 $882.58 $882.58 $1,069.40 $1,069.40$676.96 $723.90 $723.90 $762.88 $762.88 $924.36 $924.36 $785.15 $785.15 $857.22 $857.22 $819.66 $819.66 $876.49 $876.49 $923.68 $923.68 $1,119.20 $1,119.20$707.09 $756.11 $756.11 $796.82 $796.82 $965.49 $965.49 $820.09 $820.09 $895.37 $895.37 $856.13 $856.13 $915.49 $915.49 $964.78 $964.78 $1,169.01 $1,169.01$739.75 $791.03 $791.03 $833.63 $833.63 $1,010.09 $1,010.09 $857.97 $857.97 $936.72 $936.72 $895.67 $895.67 $957.77 $957.77 $1,009.34 $1,009.34 $1,223.00 $1,223.00$772.72 $826.29 $826.29 $870.79 $870.79 $1,055.12 $1,055.12 $896.21 $896.21 $978.48 $978.48 $935.60 $935.60 $1,000.47 $1,000.47 $1,054.34 $1,054.34 $1,277.52 $1,277.52$807.92 $863.93 $863.93 $910.45 $910.45 $1,103.17 $1,103.17 $937.03 $937.03 $1,023.05 $1,023.05 $978.22 $978.22 $1,046.04 $1,046.04 $1,102.36 $1,102.36 $1,335.71 $1,335.71$825.36 $882.58 $882.58 $930.10 $930.10 $1,126.99 $1,126.99 $957.26 $957.26 $1,045.13 $1,045.13 $999.33 $999.33 $1,068.61 $1,068.61 $1,126.16 $1,126.16 $1,364.54 $1,364.54$860.55 $920.22 $920.22 $969.77 $969.77 $1,175.04 $1,175.04 $998.08 $998.08 $1,089.70 $1,089.70 $1,041.95 $1,041.95 $1,114.18 $1,114.18 $1,174.18 $1,174.18 $1,422.73 $1,422.73$890.99 $952.77 $952.77 $1,004.07 $1,004.07 $1,216.61 $1,216.61 $1,033.38 $1,033.38 $1,128.24 $1,128.24 $1,078.80 $1,078.80 $1,153.59 $1,153.59 $1,215.71 $1,215.71 $1,473.05 $1,473.05$910.97 $974.13 $974.13 $1,026.58 $1,026.58 $1,243.88 $1,243.88 $1,056.55 $1,056.55 $1,153.54 $1,153.54 $1,102.99 $1,102.99 $1,179.46 $1,179.46 $1,242.97 $1,242.97 $1,506.08 $1,506.08$936.02 $1,000.91 $1,000.91 $1,054.81 $1,054.81 $1,278.09 $1,278.09 $1,085.60 $1,085.60 $1,185.26 $1,185.26 $1,133.32 $1,133.32 $1,211.89 $1,211.89 $1,277.15 $1,277.15 $1,547.49 $1,547.49$951.24 $1,017.19 $1,017.19 $1,071.96 $1,071.96 $1,298.87 $1,298.87 $1,103.26 $1,103.26 $1,204.53 $1,204.53 $1,151.75 $1,151.75 $1,231.60 $1,231.60 $1,297.91 $1,297.91 $1,572.65 $1,572.65



$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 7




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 6




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 5




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 3




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 2


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 7


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $6,750 / Rx: $500

0%$25 / $50$7,350

Yes


25/50/6750M-152-121-F Rev. 1/20

Rating Area 5


ver0 / Rx: $500%/ $50350es


l-Access PPO

Page Number: 61 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$340.63 $340.63 $267.28 $267.28 $255.57 $255.57 $273.29 $273.29 $288.01 $288.01 $348.97 $348.97 $296.42 $296.42 $350.60 $350.60 $335.24 $335.24 $358.48$370.91 $370.91 $291.04 $291.04 $278.29 $278.29 $297.58 $297.58 $313.61 $313.61 $379.99 $379.99 $322.76 $322.76 $381.77 $381.77 $365.04 $365.04 $390.35$382.49 $382.49 $300.13 $300.13 $286.98 $286.98 $306.87 $306.87 $323.40 $323.40 $391.85 $391.85 $332.84 $332.84 $393.68 $393.68 $376.43 $376.43 $402.53$394.06 $394.06 $309.21 $309.21 $295.66 $295.66 $316.16 $316.16 $333.18 $333.18 $403.71 $403.71 $342.91 $342.91 $405.60 $405.60 $387.82 $387.82 $414.71$406.53 $406.53 $318.99 $318.99 $305.02 $305.02 $326.16 $326.16 $343.73 $343.73 $416.49 $416.49 $353.76 $353.76 $418.43 $418.43 $400.09 $400.09 $427.83$419.00 $419.00 $328.78 $328.78 $314.37 $314.37 $336.17 $336.17 $354.27 $354.27 $429.26 $429.26 $364.61 $364.61 $431.26 $431.26 $412.36 $412.36 $440.95$431.91 $431.91 $338.91 $338.91 $324.06 $324.06 $346.53 $346.53 $365.19 $365.19 $442.49 $442.49 $375.85 $375.85 $444.55 $444.55 $425.07 $425.07 $454.54$445.27 $445.27 $349.40 $349.40 $334.09 $334.09 $357.25 $357.25 $376.48 $376.48 $456.18 $456.18 $387.48 $387.48 $458.31 $458.31 $438.22 $438.22 $468.61$445.27 $445.27 $349.40 $349.40 $334.09 $334.09 $357.25 $357.25 $376.48 $376.48 $456.18 $456.18 $387.48 $387.48 $458.31 $458.31 $438.22 $438.22 $468.61$445.27 $445.27 $349.40 $349.40 $334.09 $334.09 $357.25 $357.25 $376.48 $376.48 $456.18 $456.18 $387.48 $387.48 $458.31 $458.31 $438.22 $438.22 $468.61$445.27 $445.27 $349.40 $349.40 $334.09 $334.09 $357.25 $357.25 $376.48 $376.48 $456.18 $456.18 $387.48 $387.48 $458.31 $458.31 $438.22 $438.22 $468.61$447.05 $447.05 $350.79 $350.79 $335.42 $335.42 $358.67 $358.67 $377.99 $377.99 $458.00 $458.00 $389.02 $389.02 $460.14 $460.14 $439.97 $439.97 $470.48$455.96 $455.96 $357.78 $357.78 $342.10 $342.10 $365.82 $365.82 $385.51 $385.51 $467.12 $467.12 $396.77 $396.77 $469.30 $469.30 $448.74 $448.74 $479.85$466.64 $466.64 $366.16 $366.16 $350.12 $350.12 $374.39 $374.39 $394.55 $394.55 $478.07 $478.07 $406.07 $406.07 $480.30 $480.30 $459.25 $459.25 $491.09$484.01 $484.01 $379.79 $379.79 $363.15 $363.15 $388.32 $388.32 $409.23 $409.23 $495.86 $495.86 $421.18 $421.18 $498.18 $498.18 $476.35 $476.35 $509.37$498.26 $498.26 $390.97 $390.97 $373.84 $373.84 $399.76 $399.76 $421.28 $421.28 $510.46 $510.46 $433.58 $433.58 $512.84 $512.84 $490.37 $490.37 $524.37$505.38 $505.38 $396.56 $396.56 $379.18 $379.18 $405.47 $405.47 $427.30 $427.30 $517.76 $517.76 $439.78 $439.78 $520.17 $520.17 $497.38 $497.38 $531.86$516.07 $516.07 $404.95 $404.95 $387.20 $387.20 $414.04 $414.04 $436.34 $436.34 $528.70 $528.70 $449.08 $449.08 $531.17 $531.17 $507.90 $507.90 $543.11$526.75 $526.75 $413.33 $413.33 $395.22 $395.22 $422.62 $422.62 $445.38 $445.38 $539.65 $539.65 $458.38 $458.38 $542.17 $542.17 $518.41 $518.41 $554.36$533.43 $533.43 $418.57 $418.57 $400.23 $400.23 $427.98 $427.98 $451.02 $451.02 $546.49 $546.49 $464.19 $464.19 $549.05 $549.05 $524.99 $524.99 $561.38$540.56 $540.56 $424.16 $424.16 $405.57 $405.57 $433.69 $433.69 $457.05 $457.05 $553.79 $553.79 $470.39 $470.39 $556.38 $556.38 $532.00 $532.00 $568.88$544.12 $544.12 $426.96 $426.96 $408.25 $408.25 $436.55 $436.55 $460.06 $460.06 $557.44 $557.44 $473.49 $473.49 $560.05 $560.05 $535.50 $535.50 $572.63$547.68 $547.68 $429.75 $429.75 $410.92 $410.92 $439.41 $439.41 $463.07 $463.07 $561.09 $561.09 $476.59 $476.59 $563.71 $563.71 $539.01 $539.01 $576.38$551.24 $551.24 $432.55 $432.55 $413.59 $413.59 $442.27 $442.27 $466.08 $466.08 $564.74 $564.74 $479.69 $479.69 $567.38 $567.38 $542.52 $542.52 $580.13$554.81 $554.81 $435.34 $435.34 $416.27 $416.27 $445.13 $445.13 $469.09 $469.09 $568.39 $568.39 $482.79 $482.79 $571.05 $571.05 $546.02 $546.02 $583.88$561.93 $561.93 $440.93 $440.93 $421.61 $421.61 $450.84 $450.84 $475.12 $475.12 $575.69 $575.69 $488.99 $488.99 $578.38 $578.38 $553.03 $553.03 $591.38$569.05 $569.05 $446.52 $446.52 $426.96 $426.96 $456.56 $456.56 $481.14 $481.14 $582.99 $582.99 $495.19 $495.19 $585.71 $585.71 $560.05 $560.05 $598.87$579.74 $579.74 $454.91 $454.91 $434.97 $434.97 $465.13 $465.13 $490.18 $490.18 $593.94 $593.94 $504.49 $504.49 $596.71 $596.71 $570.56 $570.56 $610.12$589.98 $589.98 $462.94 $462.94 $442.66 $442.66 $473.35 $473.35 $498.84 $498.84 $604.43 $604.43 $513.40 $513.40 $607.25 $607.25 $580.64 $580.64 $620.90$604.23 $604.23 $474.12 $474.12 $453.35 $453.35 $484.78 $484.78 $510.88 $510.88 $619.03 $619.03 $525.80 $525.80 $621.92 $621.92 $594.66 $594.66 $635.89$622.04 $622.04 $488.10 $488.10 $466.71 $466.71 $499.07 $499.07 $525.94 $525.94 $637.27 $637.27 $541.30 $541.30 $640.25 $640.25 $612.19 $612.19 $654.64$642.97 $642.97 $504.52 $504.52 $482.41 $482.41 $515.86 $515.86 $543.64 $543.64 $658.71 $658.71 $559.51 $559.51 $661.79 $661.79 $632.79 $632.79 $676.66$667.90 $667.90 $524.09 $524.09 $501.12 $501.12 $535.86 $535.86 $564.72 $564.72 $684.26 $684.26 $581.21 $581.21 $687.45 $687.45 $657.33 $657.33 $702.90$695.96 $695.96 $546.10 $546.10 $522.17 $522.17 $558.37 $558.37 $588.44 $588.44 $713.00 $713.00 $605.62 $605.62 $716.33 $716.33 $684.94 $684.94 $732.42$728.02 $728.02 $571.26 $571.26 $546.22 $546.22 $584.09 $584.09 $615.54 $615.54 $745.84 $745.84 $633.52 $633.52 $749.33 $749.33 $716.49 $716.49 $766.16$759.63 $759.63 $596.06 $596.06 $569.94 $569.94 $609.46 $609.46 $642.27 $642.27 $778.23 $778.23 $661.03 $661.03 $781.86 $781.86 $747.60 $747.60 $799.43$795.25 $795.25 $624.01 $624.01 $596.67 $596.67 $638.04 $638.04 $672.39 $672.39 $814.72 $814.72 $692.02 $692.02 $818.53 $818.53 $782.66 $782.66 $836.92$830.43 $830.43 $651.62 $651.62 $623.06 $623.06 $666.26 $666.26 $702.13 $702.13 $850.76 $850.76 $722.63 $722.63 $854.73 $854.73 $817.28 $817.28 $873.94$869.17 $869.17 $682.01 $682.01 $652.13 $652.13 $697.34 $697.34 $734.89 $734.89 $890.45 $890.45 $756.34 $756.34 $894.61 $894.61 $855.41 $855.41 $914.71$908.35 $908.35 $712.76 $712.76 $681.53 $681.53 $728.78 $728.78 $768.02 $768.02 $930.59 $930.59 $790.44 $790.44 $934.94 $934.94 $893.97 $893.97 $955.95$950.65 $950.65 $745.95 $745.95 $713.26 $713.26 $762.71 $762.71 $803.78 $803.78 $973.93 $973.93 $827.25 $827.25 $978.48 $978.48 $935.60 $935.60 $1,000.46$992.95 $992.95 $779.14 $779.14 $745.00 $745.00 $796.65 $796.65 $839.55 $839.55 $1,017.26 $1,017.26 $864.06 $864.06 $1,022.02 $1,022.02 $977.23 $977.23 $1,044.98

$1,038.81 $1,038.81 $815.13 $815.13 $779.41 $779.41 $833.45 $833.45 $878.33 $878.33 $1,064.25 $1,064.25 $903.97 $903.97 $1,069.22 $1,069.22 $1,022.37 $1,022.37 $1,093.25$1,085.12 $1,085.12 $851.47 $851.47 $814.16 $814.16 $870.60 $870.60 $917.48 $917.48 $1,111.69 $1,111.69 $944.27 $944.27 $1,116.88 $1,116.88 $1,067.94 $1,067.94 $1,141.98$1,134.55 $1,134.55 $890.25 $890.25 $851.24 $851.24 $910.26 $910.26 $959.27 $959.27 $1,162.33 $1,162.33 $987.28 $987.28 $1,167.76 $1,167.76 $1,116.58 $1,116.58 $1,194.00$1,159.04 $1,159.04 $909.47 $909.47 $869.61 $869.61 $929.90 $929.90 $979.98 $979.98 $1,187.42 $1,187.42 $1,008.59 $1,008.59 $1,192.96 $1,192.96 $1,140.69 $1,140.69 $1,219.77$1,208.46 $1,208.46 $948.25 $948.25 $906.70 $906.70 $969.56 $969.56 $1,021.77 $1,021.77 $1,238.05 $1,238.05 $1,051.60 $1,051.60 $1,243.83 $1,243.83 $1,189.33 $1,189.33 $1,271.79$1,251.21 $1,251.21 $981.79 $981.79 $938.77 $938.77 $1,003.85 $1,003.85 $1,057.91 $1,057.91 $1,281.84 $1,281.84 $1,088.79 $1,088.79 $1,287.83 $1,287.83 $1,231.40 $1,231.40 $1,316.77$1,279.26 $1,279.26 $1,003.80 $1,003.80 $959.82 $959.82 $1,026.36 $1,026.36 $1,081.63 $1,081.63 $1,310.58 $1,310.58 $1,113.21 $1,113.21 $1,316.70 $1,316.70 $1,259.01 $1,259.01 $1,346.29$1,314.43 $1,314.43 $1,031.40 $1,031.40 $986.21 $986.21 $1,054.58 $1,054.58 $1,111.37 $1,111.37 $1,346.62 $1,346.62 $1,143.82 $1,143.82 $1,352.91 $1,352.91 $1,293.63 $1,293.63 $1,383.31$1,335.81 $1,335.81 $1,048.18 $1,048.18 $1,002.24 $1,002.24 $1,071.73 $1,071.73 $1,129.44 $1,129.44 $1,368.52 $1,368.52 $1,162.41 $1,162.41 $1,374.91 $1,374.91 $1,314.66 $1,314.66 $1,405.81

PlatiMed: $25

0$15 /$7,3

Y

75729PAGeisinger Al

15/30M-152-121-

Rating

Geisinger Al


0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 3



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 2




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 9




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 7




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 6




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 5




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 3




$4,100Yes


PPO 4100M-152-122-F Rev. 1/20

Rating Area 2




$2,100Yes


PPO 2100M-152-122-F Rev. 1/20

Rating Area 9


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64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$358.48 $377.78 $377.78 $457.75 $457.75 $388.81 $388.81 $330.34 $330.34 $372.26 $372.26 $383.13 $383.13 $285.70 $285.70 $273.18 $273.18 $292.12 $292.12$390.35 $411.36 $411.36 $498.44 $498.44 $423.37 $423.37 $359.70 $359.70 $405.35 $405.35 $417.18 $417.18 $311.10 $311.10 $297.47 $297.47 $318.09 $318.09$402.53 $424.20 $424.20 $514.00 $514.00 $436.59 $436.59 $370.93 $370.93 $418.00 $418.00 $430.20 $430.20 $320.81 $320.81 $306.75 $306.75 $328.02 $328.02$414.71 $437.04 $437.04 $529.56 $529.56 $449.80 $449.80 $382.15 $382.15 $430.65 $430.65 $443.23 $443.23 $330.52 $330.52 $316.04 $316.04 $337.95 $337.95$427.83 $450.87 $450.87 $546.31 $546.31 $464.03 $464.03 $394.24 $394.24 $444.28 $444.28 $457.25 $457.25 $340.98 $340.98 $326.04 $326.04 $348.64 $348.64$440.95 $464.70 $464.70 $563.06 $563.06 $478.27 $478.27 $406.33 $406.33 $457.90 $457.90 $471.27 $471.27 $351.44 $351.44 $336.04 $336.04 $359.33 $359.33$454.54 $479.02 $479.02 $580.42 $580.42 $493.01 $493.01 $418.86 $418.86 $472.01 $472.01 $485.80 $485.80 $362.27 $362.27 $346.39 $346.39 $370.41 $370.41$468.61 $493.84 $493.84 $598.37 $598.37 $508.26 $508.26 $431.82 $431.82 $486.62 $486.62 $500.83 $500.83 $373.47 $373.47 $357.11 $357.11 $381.87 $381.87$468.61 $493.84 $493.84 $598.37 $598.37 $508.26 $508.26 $431.82 $431.82 $486.62 $486.62 $500.83 $500.83 $373.47 $373.47 $357.11 $357.11 $381.87 $381.87$468.61 $493.84 $493.84 $598.37 $598.37 $508.26 $508.26 $431.82 $431.82 $486.62 $486.62 $500.83 $500.83 $373.47 $373.47 $357.11 $357.11 $381.87 $381.87$468.61 $493.84 $493.84 $598.37 $598.37 $508.26 $508.26 $431.82 $431.82 $486.62 $486.62 $500.83 $500.83 $373.47 $373.47 $357.11 $357.11 $381.87 $381.87$470.48 $495.81 $495.81 $600.76 $600.76 $510.29 $510.29 $433.54 $433.54 $488.56 $488.56 $502.82 $502.82 $374.96 $374.96 $358.53 $358.53 $383.39 $383.39$479.85 $505.69 $505.69 $612.73 $612.73 $520.45 $520.45 $442.18 $442.18 $498.29 $498.29 $512.84 $512.84 $382.43 $382.43 $365.67 $365.67 $391.03 $391.03$491.09 $517.54 $517.54 $627.09 $627.09 $532.65 $532.65 $452.54 $452.54 $509.97 $509.97 $524.86 $524.86 $391.40 $391.40 $374.25 $374.25 $400.19 $400.19$509.37 $536.80 $536.80 $650.43 $650.43 $552.47 $552.47 $469.38 $469.38 $528.95 $528.95 $544.39 $544.39 $405.96 $405.96 $388.17 $388.17 $415.08 $415.08$524.37 $552.60 $552.60 $669.57 $669.57 $568.73 $568.73 $483.20 $483.20 $544.52 $544.52 $560.42 $560.42 $417.91 $417.91 $399.60 $399.60 $427.30 $427.30$531.86 $560.50 $560.50 $679.15 $679.15 $576.87 $576.87 $490.11 $490.11 $552.31 $552.31 $568.43 $568.43 $423.89 $423.89 $405.31 $405.31 $433.41 $433.41$543.11 $572.35 $572.35 $693.51 $693.51 $589.06 $589.06 $500.47 $500.47 $563.98 $563.98 $580.45 $580.45 $432.85 $432.85 $413.88 $413.88 $442.58 $442.58$554.36 $584.21 $584.21 $707.87 $707.87 $601.26 $601.26 $510.83 $510.83 $575.66 $575.66 $592.47 $592.47 $441.81 $441.81 $422.45 $422.45 $451.74 $451.74$561.38 $591.61 $591.61 $716.85 $716.85 $608.89 $608.89 $517.31 $517.31 $582.96 $582.96 $599.98 $599.98 $447.42 $447.42 $427.81 $427.81 $457.47 $457.47$568.88 $599.51 $599.51 $726.42 $726.42 $617.02 $617.02 $524.22 $524.22 $590.75 $590.75 $608.00 $608.00 $453.39 $453.39 $433.52 $433.52 $463.58 $463.58$572.63 $603.47 $603.47 $731.21 $731.21 $621.08 $621.08 $527.67 $527.67 $594.64 $594.64 $612.00 $612.00 $456.38 $456.38 $436.38 $436.38 $466.64 $466.64$576.38 $607.42 $607.42 $735.99 $735.99 $625.15 $625.15 $531.13 $531.13 $598.53 $598.53 $616.01 $616.01 $459.37 $459.37 $439.24 $439.24 $469.69 $469.69$580.13 $611.37 $611.37 $740.78 $740.78 $629.22 $629.22 $534.58 $534.58 $602.43 $602.43 $620.02 $620.02 $462.36 $462.36 $442.10 $442.10 $472.75 $472.75$583.88 $615.32 $615.32 $745.57 $745.57 $633.28 $633.28 $538.04 $538.04 $606.32 $606.32 $624.02 $624.02 $465.34 $465.34 $444.95 $444.95 $475.80 $475.80$591.38 $623.22 $623.22 $755.14 $755.14 $641.41 $641.41 $544.95 $544.95 $614.11 $614.11 $632.04 $632.04 $471.32 $471.32 $450.67 $450.67 $481.91 $481.91$598.87 $631.12 $631.12 $764.71 $764.71 $649.55 $649.55 $551.86 $551.86 $621.89 $621.89 $640.05 $640.05 $477.29 $477.29 $456.38 $456.38 $488.02 $488.02$610.12 $642.97 $642.97 $779.08 $779.08 $661.75 $661.75 $562.22 $562.22 $633.57 $633.57 $652.07 $652.07 $486.26 $486.26 $464.95 $464.95 $497.18 $497.18$620.90 $654.33 $654.33 $792.84 $792.84 $673.43 $673.43 $572.15 $572.15 $644.76 $644.76 $663.59 $663.59 $494.85 $494.85 $473.16 $473.16 $505.97 $505.97$635.89 $670.13 $670.13 $811.99 $811.99 $689.70 $689.70 $585.97 $585.97 $660.33 $660.33 $679.61 $679.61 $506.80 $506.80 $484.59 $484.59 $518.19 $518.19$654.64 $689.89 $689.89 $835.92 $835.92 $710.03 $710.03 $603.24 $603.24 $679.80 $679.80 $699.65 $699.65 $521.74 $521.74 $498.87 $498.87 $533.46 $533.46$676.66 $713.10 $713.10 $864.04 $864.04 $733.92 $733.92 $623.54 $623.54 $702.67 $702.67 $723.18 $723.18 $539.29 $539.29 $515.66 $515.66 $551.41 $551.41$702.90 $740.75 $740.75 $897.55 $897.55 $762.38 $762.38 $647.72 $647.72 $729.92 $729.92 $751.23 $751.23 $560.20 $560.20 $535.66 $535.66 $572.79 $572.79$732.42 $771.86 $771.86 $935.25 $935.25 $794.40 $794.40 $674.92 $674.92 $760.58 $760.58 $782.78 $782.78 $583.73 $583.73 $558.15 $558.15 $596.85 $596.85$766.16 $807.42 $807.42 $978.33 $978.33 $830.99 $830.99 $706.01 $706.01 $795.61 $795.61 $818.84 $818.84 $610.62 $610.62 $583.87 $583.87 $624.35 $624.35$799.43 $842.48 $842.48 $1,020.82 $1,020.82 $867.08 $867.08 $736.67 $736.67 $830.16 $830.16 $854.40 $854.40 $637.14 $637.14 $609.22 $609.22 $651.46 $651.46$836.92 $881.99 $881.99 $1,068.69 $1,068.69 $907.74 $907.74 $771.22 $771.22 $869.09 $869.09 $894.47 $894.47 $667.02 $667.02 $637.79 $637.79 $682.01 $682.01$873.94 $921.00 $921.00 $1,115.96 $1,115.96 $947.89 $947.89 $805.33 $805.33 $907.53 $907.53 $934.03 $934.03 $696.52 $696.52 $666.00 $666.00 $712.17 $712.17$914.71 $963.96 $963.96 $1,168.02 $1,168.02 $992.11 $992.11 $842.90 $842.90 $949.87 $949.87 $977.60 $977.60 $729.01 $729.01 $697.07 $697.07 $745.40 $745.40$955.95 $1,007.42 $1,007.42 $1,220.67 $1,220.67 $1,036.84 $1,036.84 $880.90 $880.90 $992.69 $992.69 $1,021.67 $1,021.67 $761.88 $761.88 $728.49 $728.49 $779.00 $779.00

$1,000.46 $1,054.34 $1,054.34 $1,277.52 $1,277.52 $1,085.12 $1,085.12 $921.92 $921.92 $1,038.92 $1,038.92 $1,069.25 $1,069.25 $797.36 $797.36 $762.42 $762.42 $815.28 $815.28$1,044.98 $1,101.25 $1,101.25 $1,334.36 $1,334.36 $1,133.40 $1,133.40 $962.94 $962.94 $1,085.15 $1,085.15 $1,116.83 $1,116.83 $832.84 $832.84 $796.34 $796.34 $851.55 $851.55$1,093.25 $1,152.12 $1,152.12 $1,395.99 $1,395.99 $1,185.75 $1,185.75 $1,007.42 $1,007.42 $1,135.27 $1,135.27 $1,168.41 $1,168.41 $871.31 $871.31 $833.12 $833.12 $890.88 $890.88$1,141.98 $1,203.47 $1,203.47 $1,458.22 $1,458.22 $1,238.61 $1,238.61 $1,052.33 $1,052.33 $1,185.88 $1,185.88 $1,220.50 $1,220.50 $910.15 $910.15 $870.26 $870.26 $930.60 $930.60$1,194.00 $1,258.29 $1,258.29 $1,524.64 $1,524.64 $1,295.03 $1,295.03 $1,100.26 $1,100.26 $1,239.89 $1,239.89 $1,276.09 $1,276.09 $951.60 $951.60 $909.90 $909.90 $972.99 $972.99$1,219.77 $1,285.45 $1,285.45 $1,557.55 $1,557.55 $1,322.98 $1,322.98 $1,124.01 $1,124.01 $1,266.65 $1,266.65 $1,303.64 $1,303.64 $972.14 $972.14 $929.54 $929.54 $993.99 $993.99$1,271.79 $1,340.27 $1,340.27 $1,623.97 $1,623.97 $1,379.40 $1,379.40 $1,171.94 $1,171.94 $1,320.67 $1,320.67 $1,359.23 $1,359.23 $1,013.60 $1,013.60 $969.18 $969.18 $1,036.37 $1,036.37$1,316.77 $1,387.67 $1,387.67 $1,681.42 $1,681.42 $1,428.19 $1,428.19 $1,213.39 $1,213.39 $1,367.38 $1,367.38 $1,407.31 $1,407.31 $1,049.45 $1,049.45 $1,003.46 $1,003.46 $1,073.03 $1,073.03$1,346.29 $1,418.79 $1,418.79 $1,719.11 $1,719.11 $1,460.21 $1,460.21 $1,240.60 $1,240.60 $1,398.04 $1,398.04 $1,438.86 $1,438.86 $1,072.98 $1,072.98 $1,025.96 $1,025.96 $1,097.09 $1,097.09$1,383.31 $1,457.80 $1,457.80 $1,766.38 $1,766.38 $1,500.36 $1,500.36 $1,274.71 $1,274.71 $1,436.48 $1,436.48 $1,478.42 $1,478.42 $1,102.48 $1,102.48 $1,054.17 $1,054.17 $1,127.26 $1,127.26$1,405.81 $1,481.50 $1,481.50 $1,795.11 $1,795.11 $1,524.76 $1,524.76 $1,295.44 $1,295.44 $1,459.84 $1,459.84 $1,502.46 $1,502.46 $1,120.41 $1,120.41 $1,071.31 $1,071.31 $1,145.59 $1,145.59

GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 2



0%$40 / $40$2,250

Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 9



0%$40 / $40$2,250

Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 6



0%$40 / $40$2,250

Yes


10/40/250M-152-243-F Rev. 1/20

Rating Area 3



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$7,350

Yes


15/30/250M-152-121-F Rev. 1/20

Rating Area 6


num0 / Rx: $0%/ $30350es


l-Access PPO

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$307.85 $307.85 $373.02 $373.02 $316.84 $316.84 $263.87 $263.87 $297.36 $297.36 $306.04 $306.04 $318.93 $318.93 $304.96 $304.96 $326.10 $326.10 $343.66$335.22 $335.22 $406.18 $406.18 $345.01 $345.01 $287.33 $287.33 $323.79 $323.79 $333.24 $333.24 $347.28 $347.28 $332.07 $332.07 $355.09 $355.09 $374.21$345.68 $345.68 $418.86 $418.86 $355.78 $355.78 $296.29 $296.29 $333.90 $333.90 $343.65 $343.65 $358.12 $358.12 $342.43 $342.43 $366.17 $366.17 $385.89$356.15 $356.15 $431.53 $431.53 $366.54 $366.54 $305.26 $305.26 $344.00 $344.00 $354.05 $354.05 $368.96 $368.96 $352.79 $352.79 $377.25 $377.25 $397.57$367.41 $367.41 $445.19 $445.19 $378.14 $378.14 $314.92 $314.92 $354.89 $354.89 $365.25 $365.25 $380.64 $380.64 $363.96 $363.96 $389.19 $389.19 $410.15$378.68 $378.68 $458.84 $458.84 $389.74 $389.74 $324.58 $324.58 $365.77 $365.77 $376.45 $376.45 $392.31 $392.31 $375.12 $375.12 $401.13 $401.13 $422.72$390.35 $390.35 $472.98 $472.98 $401.75 $401.75 $334.58 $334.58 $377.04 $377.04 $388.05 $388.05 $404.40 $404.40 $386.68 $386.68 $413.49 $413.49 $435.75$402.43 $402.43 $487.61 $487.61 $414.18 $414.18 $344.93 $344.93 $388.71 $388.71 $400.06 $400.06 $416.91 $416.91 $398.64 $398.64 $426.28 $426.28 $449.23$402.43 $402.43 $487.61 $487.61 $414.18 $414.18 $344.93 $344.93 $388.71 $388.71 $400.06 $400.06 $416.91 $416.91 $398.64 $398.64 $426.28 $426.28 $449.23$402.43 $402.43 $487.61 $487.61 $414.18 $414.18 $344.93 $344.93 $388.71 $388.71 $400.06 $400.06 $416.91 $416.91 $398.64 $398.64 $426.28 $426.28 $449.23$402.43 $402.43 $487.61 $487.61 $414.18 $414.18 $344.93 $344.93 $388.71 $388.71 $400.06 $400.06 $416.91 $416.91 $398.64 $398.64 $426.28 $426.28 $449.23$404.03 $404.03 $489.56 $489.56 $415.83 $415.83 $346.31 $346.31 $390.26 $390.26 $401.65 $401.65 $418.57 $418.57 $400.23 $400.23 $427.98 $427.98 $451.03$412.08 $412.08 $499.31 $499.31 $424.11 $424.11 $353.21 $353.21 $398.03 $398.03 $409.66 $409.66 $426.91 $426.91 $408.21 $408.21 $436.51 $436.51 $460.01$421.74 $421.74 $511.01 $511.01 $434.05 $434.05 $361.49 $361.49 $407.36 $407.36 $419.26 $419.26 $436.92 $436.92 $417.77 $417.77 $446.74 $446.74 $470.79$437.44 $437.44 $530.03 $530.03 $450.21 $450.21 $374.94 $374.94 $422.52 $422.52 $434.86 $434.86 $453.18 $453.18 $433.32 $433.32 $463.36 $463.36 $488.31$450.31 $450.31 $545.63 $545.63 $463.46 $463.46 $385.98 $385.98 $434.96 $434.96 $447.66 $447.66 $466.52 $466.52 $446.08 $446.08 $477.00 $477.00 $502.69$456.75 $456.75 $553.44 $553.44 $470.09 $470.09 $391.50 $391.50 $441.18 $441.18 $454.06 $454.06 $473.19 $473.19 $452.45 $452.45 $483.82 $483.82 $509.88$466.41 $466.41 $565.14 $565.14 $480.03 $480.03 $399.77 $399.77 $450.51 $450.51 $463.66 $463.66 $483.20 $483.20 $462.02 $462.02 $494.05 $494.05 $520.66$476.07 $476.07 $576.84 $576.84 $489.97 $489.97 $408.05 $408.05 $459.84 $459.84 $473.26 $473.26 $493.20 $493.20 $471.59 $471.59 $504.28 $504.28 $531.44$482.10 $482.10 $584.16 $584.16 $496.18 $496.18 $413.23 $413.23 $465.67 $465.67 $479.26 $479.26 $499.45 $499.45 $477.57 $477.57 $510.68 $510.68 $538.18$488.54 $488.54 $591.96 $591.96 $502.81 $502.81 $418.74 $418.74 $471.89 $471.89 $485.67 $485.67 $506.13 $506.13 $483.95 $483.95 $517.50 $517.50 $545.36$491.76 $491.76 $595.86 $595.86 $506.12 $506.12 $421.50 $421.50 $475.00 $475.00 $488.87 $488.87 $509.46 $509.46 $487.14 $487.14 $520.91 $520.91 $548.96$494.98 $494.98 $599.76 $599.76 $509.43 $509.43 $424.26 $424.26 $478.11 $478.11 $492.07 $492.07 $512.80 $512.80 $490.32 $490.32 $524.32 $524.32 $552.55$498.20 $498.20 $603.66 $603.66 $512.75 $512.75 $427.02 $427.02 $481.22 $481.22 $495.27 $495.27 $516.13 $516.13 $493.51 $493.51 $527.73 $527.73 $556.15$501.42 $501.42 $607.56 $607.56 $516.06 $516.06 $429.78 $429.78 $484.33 $484.33 $498.47 $498.47 $519.47 $519.47 $496.70 $496.70 $531.14 $531.14 $559.74$507.86 $507.86 $615.36 $615.36 $522.69 $522.69 $435.30 $435.30 $490.55 $490.55 $504.87 $504.87 $526.14 $526.14 $503.08 $503.08 $537.96 $537.96 $566.93$514.30 $514.30 $623.16 $623.16 $529.31 $529.31 $440.82 $440.82 $496.76 $496.76 $511.27 $511.27 $532.81 $532.81 $509.46 $509.46 $544.78 $544.78 $574.11$523.96 $523.96 $634.87 $634.87 $539.25 $539.25 $449.10 $449.10 $506.09 $506.09 $520.87 $520.87 $542.81 $542.81 $519.03 $519.03 $555.01 $555.01 $584.90$533.21 $533.21 $646.08 $646.08 $548.78 $548.78 $457.03 $457.03 $515.03 $515.03 $530.07 $530.07 $552.40 $552.40 $528.20 $528.20 $564.82 $564.82 $595.23$546.09 $546.09 $661.69 $661.69 $562.03 $562.03 $468.07 $468.07 $527.47 $527.47 $542.87 $542.87 $565.74 $565.74 $540.95 $540.95 $578.46 $578.46 $609.60$562.19 $562.19 $681.19 $681.19 $578.60 $578.60 $481.87 $481.87 $543.02 $543.02 $558.88 $558.88 $582.42 $582.42 $556.90 $556.90 $595.51 $595.51 $627.57$581.10 $581.10 $704.11 $704.11 $598.07 $598.07 $498.08 $498.08 $561.29 $561.29 $577.68 $577.68 $602.01 $602.01 $575.63 $575.63 $615.54 $615.54 $648.69$603.64 $603.64 $731.41 $731.41 $621.26 $621.26 $517.39 $517.39 $583.06 $583.06 $600.08 $600.08 $625.36 $625.36 $597.96 $597.96 $639.41 $639.41 $673.84$628.99 $628.99 $762.13 $762.13 $647.35 $647.35 $539.13 $539.13 $607.55 $607.55 $625.28 $625.28 $651.63 $651.63 $623.07 $623.07 $666.27 $666.27 $702.15$657.96 $657.96 $797.24 $797.24 $677.17 $677.17 $563.96 $563.96 $635.53 $635.53 $654.09 $654.09 $681.64 $681.64 $651.77 $651.77 $696.96 $696.96 $734.49$686.54 $686.54 $831.86 $831.86 $706.58 $706.58 $588.45 $588.45 $663.13 $663.13 $682.49 $682.49 $711.24 $711.24 $680.08 $680.08 $727.23 $727.23 $766.38$718.73 $718.73 $870.87 $870.87 $739.71 $739.71 $616.04 $616.04 $694.23 $694.23 $714.50 $714.50 $744.60 $744.60 $711.97 $711.97 $761.33 $761.33 $802.32$750.52 $750.52 $909.39 $909.39 $772.43 $772.43 $643.29 $643.29 $724.93 $724.93 $746.10 $746.10 $777.53 $777.53 $743.46 $743.46 $795.00 $795.00 $837.81$785.53 $785.53 $951.81 $951.81 $808.47 $808.47 $673.30 $673.30 $758.75 $758.75 $780.91 $780.91 $813.80 $813.80 $778.14 $778.14 $832.09 $832.09 $876.90$820.95 $820.95 $994.72 $994.72 $844.91 $844.91 $703.66 $703.66 $792.96 $792.96 $816.11 $816.11 $850.49 $850.49 $813.22 $813.22 $869.60 $869.60 $916.43$859.18 $859.18 $1,041.04 $1,041.04 $884.26 $884.26 $736.43 $736.43 $829.88 $829.88 $854.11 $854.11 $890.10 $890.10 $851.09 $851.09 $910.10 $910.10 $959.10$897.41 $897.41 $1,087.37 $1,087.37 $923.61 $923.61 $769.19 $769.19 $866.81 $866.81 $892.12 $892.12 $929.70 $929.70 $888.96 $888.96 $950.60 $950.60 $1,001.78$938.86 $938.86 $1,137.59 $1,137.59 $966.27 $966.27 $804.72 $804.72 $906.85 $906.85 $933.33 $933.33 $972.64 $972.64 $930.02 $930.02 $994.50 $994.50 $1,048.05$980.71 $980.71 $1,188.30 $1,188.30 $1,009.34 $1,009.34 $840.59 $840.59 $947.27 $947.27 $974.93 $974.93 $1,016.00 $1,016.00 $971.48 $971.48 $1,038.83 $1,038.83 $1,094.77

$1,025.38 $1,025.38 $1,242.43 $1,242.43 $1,055.31 $1,055.31 $878.88 $878.88 $990.42 $990.42 $1,019.34 $1,019.34 $1,062.28 $1,062.28 $1,015.73 $1,015.73 $1,086.15 $1,086.15 $1,144.64$1,047.51 $1,047.51 $1,269.25 $1,269.25 $1,078.09 $1,078.09 $897.85 $897.85 $1,011.80 $1,011.80 $1,041.34 $1,041.34 $1,085.21 $1,085.21 $1,037.66 $1,037.66 $1,109.60 $1,109.60 $1,169.34$1,092.18 $1,092.18 $1,323.37 $1,323.37 $1,124.07 $1,124.07 $936.14 $936.14 $1,054.94 $1,054.94 $1,085.75 $1,085.75 $1,131.49 $1,131.49 $1,081.90 $1,081.90 $1,156.91 $1,156.91 $1,219.21$1,130.81 $1,130.81 $1,370.18 $1,370.18 $1,163.83 $1,163.83 $969.25 $969.25 $1,092.26 $1,092.26 $1,124.15 $1,124.15 $1,171.51 $1,171.51 $1,120.17 $1,120.17 $1,197.84 $1,197.84 $1,262.33$1,156.16 $1,156.16 $1,400.90 $1,400.90 $1,189.92 $1,189.92 $990.98 $990.98 $1,116.75 $1,116.75 $1,149.35 $1,149.35 $1,197.77 $1,197.77 $1,145.29 $1,145.29 $1,224.69 $1,224.69 $1,290.64$1,187.96 $1,187.96 $1,439.42 $1,439.42 $1,222.64 $1,222.64 $1,018.23 $1,018.23 $1,147.46 $1,147.46 $1,180.96 $1,180.96 $1,230.71 $1,230.71 $1,176.78 $1,176.78 $1,258.37 $1,258.37 $1,326.12$1,207.27 $1,207.27 $1,462.83 $1,462.83 $1,242.52 $1,242.52 $1,034.79 $1,034.79 $1,166.11 $1,166.11 $1,200.16 $1,200.16 $1,250.72 $1,250.72 $1,195.91 $1,195.91 $1,278.83 $1,278.83 $1,347.69

GoMed: $50

0$20 /$8,1

Y

75729PAGeisinger Al

20/40M-152-121-

Rating

Geisinger Al


0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 5



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 3



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 6


GoldMed: $3,500 / Rx: $0

0%$60 / $60$7,350

Yes


20/60/3500M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $3,500 / Rx: $0

0%$30 / $60$7,350

Yes


30/60/3500M-152-121-F Rev. 1/20

Rating Area 6


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64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$343.66 $416.41 $416.41 $353.69 $353.69 $302.86 $302.86 $289.59 $289.59 $309.67 $309.67 $326.34 $326.34 $395.42 $395.42 $335.87 $335.87 $296.97 $296.97$374.21 $453.42 $453.42 $385.13 $385.13 $329.78 $329.78 $315.33 $315.33 $337.19 $337.19 $355.35 $355.35 $430.57 $430.57 $365.73 $365.73 $323.37 $323.37$385.89 $467.57 $467.57 $397.15 $397.15 $340.08 $340.08 $325.17 $325.17 $347.72 $347.72 $366.44 $366.44 $444.01 $444.01 $377.14 $377.14 $333.46 $333.46$397.57 $481.72 $481.72 $409.18 $409.18 $350.37 $350.37 $335.02 $335.02 $358.24 $358.24 $377.53 $377.53 $457.45 $457.45 $388.56 $388.56 $343.56 $343.56$410.15 $496.97 $496.97 $422.12 $422.12 $361.45 $361.45 $345.62 $345.62 $369.58 $369.58 $389.48 $389.48 $471.92 $471.92 $400.85 $400.85 $354.43 $354.43$422.72 $512.21 $512.21 $435.07 $435.07 $372.54 $372.54 $356.22 $356.22 $380.91 $380.91 $401.42 $401.42 $486.39 $486.39 $413.14 $413.14 $365.30 $365.30$435.75 $527.99 $527.99 $448.47 $448.47 $384.02 $384.02 $367.19 $367.19 $392.65 $392.65 $413.79 $413.79 $501.38 $501.38 $425.87 $425.87 $376.55 $376.55$449.23 $544.33 $544.33 $462.35 $462.35 $395.90 $395.90 $378.55 $378.55 $404.80 $404.80 $426.60 $426.60 $516.90 $516.90 $439.05 $439.05 $388.20 $388.20$449.23 $544.33 $544.33 $462.35 $462.35 $395.90 $395.90 $378.55 $378.55 $404.80 $404.80 $426.60 $426.60 $516.90 $516.90 $439.05 $439.05 $388.20 $388.20$449.23 $544.33 $544.33 $462.35 $462.35 $395.90 $395.90 $378.55 $378.55 $404.80 $404.80 $426.60 $426.60 $516.90 $516.90 $439.05 $439.05 $388.20 $388.20$449.23 $544.33 $544.33 $462.35 $462.35 $395.90 $395.90 $378.55 $378.55 $404.80 $404.80 $426.60 $426.60 $516.90 $516.90 $439.05 $439.05 $388.20 $388.20$451.03 $546.50 $546.50 $464.19 $464.19 $397.48 $397.48 $380.06 $380.06 $406.41 $406.41 $428.30 $428.30 $518.96 $518.96 $440.80 $440.80 $389.75 $389.75$460.01 $557.39 $557.39 $473.44 $473.44 $405.40 $405.40 $387.63 $387.63 $414.51 $414.51 $436.83 $436.83 $529.30 $529.30 $449.58 $449.58 $397.52 $397.52$470.79 $570.45 $570.45 $484.54 $484.54 $414.90 $414.90 $396.72 $396.72 $424.22 $424.22 $447.07 $447.07 $541.70 $541.70 $460.12 $460.12 $406.83 $406.83$488.31 $591.68 $591.68 $502.57 $502.57 $430.34 $430.34 $411.48 $411.48 $440.01 $440.01 $463.70 $463.70 $561.86 $561.86 $477.24 $477.24 $421.97 $421.97$502.69 $609.10 $609.10 $517.36 $517.36 $443.01 $443.01 $423.60 $423.60 $452.96 $452.96 $477.36 $477.36 $578.40 $578.40 $491.29 $491.29 $434.40 $434.40$509.88 $617.80 $617.80 $524.76 $524.76 $449.34 $449.34 $429.65 $429.65 $459.44 $459.44 $484.18 $484.18 $586.67 $586.67 $498.32 $498.32 $440.61 $440.61$520.66 $630.87 $630.87 $535.86 $535.86 $458.85 $458.85 $438.74 $438.74 $469.16 $469.16 $494.42 $494.42 $599.08 $599.08 $508.85 $508.85 $449.92 $449.92$531.44 $643.93 $643.93 $546.95 $546.95 $468.35 $468.35 $447.82 $447.82 $478.87 $478.87 $504.66 $504.66 $611.48 $611.48 $519.39 $519.39 $459.24 $459.24$538.18 $652.10 $652.10 $553.89 $553.89 $474.29 $474.29 $453.50 $453.50 $484.94 $484.94 $511.06 $511.06 $619.24 $619.24 $525.98 $525.98 $465.06 $465.06$545.36 $660.81 $660.81 $561.29 $561.29 $480.62 $480.62 $459.56 $459.56 $491.42 $491.42 $517.88 $517.88 $627.51 $627.51 $533.00 $533.00 $471.27 $471.27$548.96 $665.16 $665.16 $564.99 $564.99 $483.79 $483.79 $462.59 $462.59 $494.66 $494.66 $521.29 $521.29 $631.64 $631.64 $536.51 $536.51 $474.38 $474.38$552.55 $669.52 $669.52 $568.68 $568.68 $486.95 $486.95 $465.62 $465.62 $497.90 $497.90 $524.71 $524.71 $635.78 $635.78 $540.03 $540.03 $477.49 $477.49$556.15 $673.87 $673.87 $572.38 $572.38 $490.12 $490.12 $468.64 $468.64 $501.14 $501.14 $528.12 $528.12 $639.91 $639.91 $543.54 $543.54 $480.59 $480.59$559.74 $678.22 $678.22 $576.08 $576.08 $493.29 $493.29 $471.67 $471.67 $504.37 $504.37 $531.53 $531.53 $644.05 $644.05 $547.05 $547.05 $483.70 $483.70$566.93 $686.93 $686.93 $583.48 $583.48 $499.62 $499.62 $477.73 $477.73 $510.85 $510.85 $538.36 $538.36 $652.32 $652.32 $554.08 $554.08 $489.91 $489.91$574.11 $695.64 $695.64 $590.88 $590.88 $505.96 $505.96 $483.79 $483.79 $517.33 $517.33 $545.18 $545.18 $660.59 $660.59 $561.10 $561.10 $496.12 $496.12$584.90 $708.71 $708.71 $601.97 $601.97 $515.46 $515.46 $492.87 $492.87 $527.04 $527.04 $555.42 $555.42 $672.99 $672.99 $571.64 $571.64 $505.44 $505.44$595.23 $721.23 $721.23 $612.61 $612.61 $524.56 $524.56 $501.58 $501.58 $536.35 $536.35 $565.23 $565.23 $684.88 $684.88 $581.74 $581.74 $514.36 $514.36$609.60 $738.64 $738.64 $627.40 $627.40 $537.23 $537.23 $513.69 $513.69 $549.31 $549.31 $578.88 $578.88 $701.42 $701.42 $595.79 $595.79 $526.79 $526.79$627.57 $760.42 $760.42 $645.90 $645.90 $553.07 $553.07 $528.83 $528.83 $565.50 $565.50 $595.95 $595.95 $722.10 $722.10 $613.35 $613.35 $542.31 $542.31$648.69 $786.00 $786.00 $667.63 $667.63 $571.68 $571.68 $546.63 $546.63 $584.52 $584.52 $616.00 $616.00 $746.39 $746.39 $633.98 $633.98 $560.56 $560.56$673.84 $816.48 $816.48 $693.52 $693.52 $593.85 $593.85 $567.82 $567.82 $607.19 $607.19 $639.89 $639.89 $775.34 $775.34 $658.57 $658.57 $582.30 $582.30$702.15 $850.77 $850.77 $722.65 $722.65 $618.79 $618.79 $591.67 $591.67 $632.69 $632.69 $666.76 $666.76 $807.90 $807.90 $686.23 $686.23 $606.76 $606.76$734.49 $889.97 $889.97 $755.93 $755.93 $647.29 $647.29 $618.93 $618.93 $661.84 $661.84 $697.48 $697.48 $845.12 $845.12 $717.84 $717.84 $634.71 $634.71$766.38 $928.61 $928.61 $788.76 $788.76 $675.40 $675.40 $645.81 $645.81 $690.58 $690.58 $727.76 $727.76 $881.82 $881.82 $749.01 $749.01 $662.27 $662.27$802.32 $972.16 $972.16 $825.75 $825.75 $707.07 $707.07 $676.09 $676.09 $722.96 $722.96 $761.89 $761.89 $923.17 $923.17 $784.14 $784.14 $693.32 $693.32$837.81 $1,015.16 $1,015.16 $862.27 $862.27 $738.35 $738.35 $705.99 $705.99 $754.94 $754.94 $795.59 $795.59 $964.00 $964.00 $818.82 $818.82 $723.99 $723.99$876.90 $1,062.52 $1,062.52 $902.50 $902.50 $772.79 $772.79 $738.93 $738.93 $790.16 $790.16 $832.71 $832.71 $1,008.97 $1,008.97 $857.02 $857.02 $757.77 $757.77$916.43 $1,110.42 $1,110.42 $943.18 $943.18 $807.63 $807.63 $772.24 $772.24 $825.78 $825.78 $870.25 $870.25 $1,054.46 $1,054.46 $895.65 $895.65 $791.93 $791.93$959.10 $1,162.13 $1,162.13 $987.11 $987.11 $845.24 $845.24 $808.20 $808.20 $864.24 $864.24 $910.77 $910.77 $1,103.56 $1,103.56 $937.36 $937.36 $828.81 $828.81

$1,001.78 $1,213.84 $1,213.84 $1,031.03 $1,031.03 $882.85 $882.85 $844.17 $844.17 $902.69 $902.69 $951.30 $951.30 $1,152.67 $1,152.67 $979.07 $979.07 $865.68 $865.68$1,048.05 $1,269.90 $1,269.90 $1,078.65 $1,078.65 $923.63 $923.63 $883.16 $883.16 $944.39 $944.39 $995.24 $995.24 $1,205.91 $1,205.91 $1,024.29 $1,024.29 $905.67 $905.67$1,094.77 $1,326.51 $1,326.51 $1,126.74 $1,126.74 $964.80 $964.80 $922.53 $922.53 $986.48 $986.48 $1,039.60 $1,039.60 $1,259.66 $1,259.66 $1,069.96 $1,069.96 $946.04 $946.04$1,144.64 $1,386.93 $1,386.93 $1,178.06 $1,178.06 $1,008.75 $1,008.75 $964.54 $964.54 $1,031.42 $1,031.42 $1,086.95 $1,086.95 $1,317.04 $1,317.04 $1,118.69 $1,118.69 $989.13 $989.13$1,169.34 $1,416.87 $1,416.87 $1,203.48 $1,203.48 $1,030.52 $1,030.52 $985.36 $985.36 $1,053.68 $1,053.68 $1,110.42 $1,110.42 $1,345.47 $1,345.47 $1,142.84 $1,142.84 $1,010.48 $1,010.48$1,219.21 $1,477.29 $1,477.29 $1,254.81 $1,254.81 $1,074.47 $1,074.47 $1,027.38 $1,027.38 $1,098.61 $1,098.61 $1,157.77 $1,157.77 $1,402.84 $1,402.84 $1,191.57 $1,191.57 $1,053.57 $1,053.57$1,262.33 $1,529.54 $1,529.54 $1,299.19 $1,299.19 $1,112.47 $1,112.47 $1,063.72 $1,063.72 $1,137.47 $1,137.47 $1,198.72 $1,198.72 $1,452.46 $1,452.46 $1,233.72 $1,233.72 $1,090.84 $1,090.84$1,290.64 $1,563.84 $1,563.84 $1,328.32 $1,328.32 $1,137.41 $1,137.41 $1,087.57 $1,087.57 $1,162.97 $1,162.97 $1,225.60 $1,225.60 $1,485.03 $1,485.03 $1,261.38 $1,261.38 $1,115.30 $1,115.30$1,326.12 $1,606.84 $1,606.84 $1,364.84 $1,364.84 $1,168.69 $1,168.69 $1,117.48 $1,117.48 $1,194.95 $1,194.95 $1,259.30 $1,259.30 $1,525.86 $1,525.86 $1,296.06 $1,296.06 $1,145.96 $1,145.96$1,347.69 $1,632.96 $1,632.96 $1,387.04 $1,387.04 $1,187.69 $1,187.69 $1,135.65 $1,135.65 $1,214.38 $1,214.38 $1,279.77 $1,279.77 $1,550.67 $1,550.67 $1,317.14 $1,317.14 $1,164.60 $1,164.60

GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $1,500 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1500M-152-121-F Rev. 1/20

Rating Area 2



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 9



0%$20 / $40$8,150

Yes


20/40/500M-152-121-F Rev. 1/20

Rating Area 7


old0 / Rx: $0%/ $40150es


l-Access PPO

Page Number: 65 12/24/2014

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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$283.96 $283.96 $303.65 $303.65 $320.00 $320.00 $387.73 $387.73 $329.34 $329.34 $265.90 $265.90 $254.25 $254.25 $271.88 $271.88 $286.52 $286.52 $347.17$309.20 $309.20 $330.64 $330.64 $348.44 $348.44 $422.20 $422.20 $358.61 $358.61 $289.54 $289.54 $276.85 $276.85 $296.05 $296.05 $311.99 $311.99 $378.03$318.85 $318.85 $340.96 $340.96 $359.32 $359.32 $435.38 $435.38 $369.81 $369.81 $298.58 $298.58 $285.49 $285.49 $305.29 $305.29 $321.73 $321.73 $389.83$328.50 $328.50 $351.28 $351.28 $370.19 $370.19 $448.55 $448.55 $381.00 $381.00 $307.62 $307.62 $294.14 $294.14 $314.53 $314.53 $331.46 $331.46 $401.63$338.89 $338.89 $362.39 $362.39 $381.90 $381.90 $462.74 $462.74 $393.05 $393.05 $317.35 $317.35 $303.44 $303.44 $324.48 $324.48 $341.95 $341.95 $414.33$349.29 $349.29 $373.50 $373.50 $393.62 $393.62 $476.94 $476.94 $405.11 $405.11 $327.08 $327.08 $312.75 $312.75 $334.43 $334.43 $352.44 $352.44 $427.04$360.05 $360.05 $385.02 $385.02 $405.75 $405.75 $491.63 $491.63 $417.59 $417.59 $337.16 $337.16 $322.39 $322.39 $344.74 $344.74 $363.30 $363.30 $440.20$371.19 $371.19 $396.93 $396.93 $418.30 $418.30 $506.84 $506.84 $430.51 $430.51 $347.59 $347.59 $332.36 $332.36 $355.40 $355.40 $374.54 $374.54 $453.82$371.19 $371.19 $396.93 $396.93 $418.30 $418.30 $506.84 $506.84 $430.51 $430.51 $347.59 $347.59 $332.36 $332.36 $355.40 $355.40 $374.54 $374.54 $453.82$371.19 $371.19 $396.93 $396.93 $418.30 $418.30 $506.84 $506.84 $430.51 $430.51 $347.59 $347.59 $332.36 $332.36 $355.40 $355.40 $374.54 $374.54 $453.82$371.19 $371.19 $396.93 $396.93 $418.30 $418.30 $506.84 $506.84 $430.51 $430.51 $347.59 $347.59 $332.36 $332.36 $355.40 $355.40 $374.54 $374.54 $453.82$372.67 $372.67 $398.51 $398.51 $419.97 $419.97 $508.87 $508.87 $432.23 $432.23 $348.98 $348.98 $333.69 $333.69 $356.82 $356.82 $376.03 $376.03 $455.63$380.10 $380.10 $406.45 $406.45 $428.33 $428.33 $519.00 $519.00 $440.84 $440.84 $355.93 $355.93 $340.33 $340.33 $363.93 $363.93 $383.52 $383.52 $464.71$389.01 $389.01 $415.98 $415.98 $438.37 $438.37 $531.17 $531.17 $451.17 $451.17 $364.27 $364.27 $348.31 $348.31 $372.46 $372.46 $392.51 $392.51 $475.60$403.48 $403.48 $431.46 $431.46 $454.69 $454.69 $550.94 $550.94 $467.96 $467.96 $377.83 $377.83 $361.27 $361.27 $386.32 $386.32 $407.12 $407.12 $493.30$415.36 $415.36 $444.16 $444.16 $468.07 $468.07 $567.15 $567.15 $481.74 $481.74 $388.95 $388.95 $371.91 $371.91 $397.69 $397.69 $419.11 $419.11 $507.82$421.30 $421.30 $450.51 $450.51 $474.77 $474.77 $575.26 $575.26 $488.63 $488.63 $394.51 $394.51 $377.22 $377.22 $403.38 $403.38 $425.10 $425.10 $515.08$430.21 $430.21 $460.03 $460.03 $484.80 $484.80 $587.43 $587.43 $498.96 $498.96 $402.85 $402.85 $385.20 $385.20 $411.91 $411.91 $434.09 $434.09 $525.97$439.12 $439.12 $469.56 $469.56 $494.84 $494.84 $599.59 $599.59 $509.29 $509.29 $411.20 $411.20 $393.18 $393.18 $420.44 $420.44 $443.08 $443.08 $536.87$444.68 $444.68 $475.51 $475.51 $501.12 $501.12 $607.19 $607.19 $515.75 $515.75 $416.41 $416.41 $398.16 $398.16 $425.77 $425.77 $448.69 $448.69 $543.67$450.62 $450.62 $481.86 $481.86 $507.81 $507.81 $615.30 $615.30 $522.64 $522.64 $421.97 $421.97 $403.48 $403.48 $431.45 $431.45 $454.69 $454.69 $550.93$453.59 $453.59 $485.04 $485.04 $511.16 $511.16 $619.36 $619.36 $526.08 $526.08 $424.75 $424.75 $406.14 $406.14 $434.30 $434.30 $457.68 $457.68 $554.56$456.56 $456.56 $488.22 $488.22 $514.50 $514.50 $623.41 $623.41 $529.53 $529.53 $427.53 $427.53 $408.80 $408.80 $437.14 $437.14 $460.68 $460.68 $558.19$459.53 $459.53 $491.39 $491.39 $517.85 $517.85 $627.47 $627.47 $532.97 $532.97 $430.31 $430.31 $411.46 $411.46 $439.98 $439.98 $463.67 $463.67 $561.83$462.50 $462.50 $494.57 $494.57 $521.20 $521.20 $631.52 $631.52 $536.41 $536.41 $433.09 $433.09 $414.12 $414.12 $442.83 $442.83 $466.67 $466.67 $565.46$468.44 $468.44 $500.92 $500.92 $527.89 $527.89 $639.63 $639.63 $543.30 $543.30 $438.66 $438.66 $419.43 $419.43 $448.51 $448.51 $472.66 $472.66 $572.72$474.38 $474.38 $507.27 $507.27 $534.58 $534.58 $647.74 $647.74 $550.19 $550.19 $444.22 $444.22 $424.75 $424.75 $454.20 $454.20 $478.66 $478.66 $579.98$483.29 $483.29 $516.79 $516.79 $544.62 $544.62 $659.91 $659.91 $560.52 $560.52 $452.56 $452.56 $432.73 $432.73 $462.73 $462.73 $487.65 $487.65 $590.87$491.82 $491.82 $525.92 $525.92 $554.24 $554.24 $671.56 $671.56 $570.42 $570.42 $460.55 $460.55 $440.37 $440.37 $470.90 $470.90 $496.26 $496.26 $601.31$503.70 $503.70 $538.62 $538.62 $567.63 $567.63 $687.78 $687.78 $584.20 $584.20 $471.68 $471.68 $451.01 $451.01 $482.28 $482.28 $508.24 $508.24 $615.83$518.55 $518.55 $554.50 $554.50 $584.36 $584.36 $708.06 $708.06 $601.42 $601.42 $485.58 $485.58 $464.30 $464.30 $496.49 $496.49 $523.23 $523.23 $633.98$536.00 $536.00 $573.16 $573.16 $604.02 $604.02 $731.88 $731.88 $621.65 $621.65 $501.92 $501.92 $479.92 $479.92 $513.20 $513.20 $540.83 $540.83 $655.31$556.78 $556.78 $595.38 $595.38 $627.44 $627.44 $760.26 $760.26 $645.76 $645.76 $521.38 $521.38 $498.53 $498.53 $533.10 $533.10 $561.80 $561.80 $680.73$580.17 $580.17 $620.39 $620.39 $653.80 $653.80 $792.19 $792.19 $672.89 $672.89 $543.28 $543.28 $519.47 $519.47 $555.49 $555.49 $585.40 $585.40 $709.32$606.89 $606.89 $648.97 $648.97 $683.91 $683.91 $828.68 $828.68 $703.88 $703.88 $568.31 $568.31 $543.40 $543.40 $581.08 $581.08 $612.37 $612.37 $741.99$633.25 $633.25 $677.15 $677.15 $713.61 $713.61 $864.67 $864.67 $734.45 $734.45 $592.98 $592.98 $567.00 $567.00 $606.31 $606.31 $638.96 $638.96 $774.21$662.94 $662.94 $708.90 $708.90 $747.08 $747.08 $905.22 $905.22 $768.89 $768.89 $620.79 $620.79 $593.59 $593.59 $634.74 $634.74 $668.92 $668.92 $810.52$692.27 $692.27 $740.26 $740.26 $780.12 $780.12 $945.26 $945.26 $802.90 $802.90 $648.25 $648.25 $619.84 $619.84 $662.82 $662.82 $698.51 $698.51 $846.37$724.56 $724.56 $774.79 $774.79 $816.51 $816.51 $989.35 $989.35 $840.35 $840.35 $678.49 $678.49 $648.76 $648.76 $693.74 $693.74 $731.09 $731.09 $885.85$757.22 $757.22 $809.72 $809.72 $853.32 $853.32 $1,033.95 $1,033.95 $878.24 $878.24 $709.08 $709.08 $678.01 $678.01 $725.01 $725.01 $764.05 $764.05 $925.79$792.49 $792.49 $847.43 $847.43 $893.06 $893.06 $1,082.10 $1,082.10 $919.14 $919.14 $742.10 $742.10 $709.58 $709.58 $758.78 $758.78 $799.63 $799.63 $968.90$827.75 $827.75 $885.14 $885.14 $932.80 $932.80 $1,130.25 $1,130.25 $960.03 $960.03 $775.12 $775.12 $741.15 $741.15 $792.54 $792.54 $835.21 $835.21 $1,012.01$865.98 $865.98 $926.02 $926.02 $975.88 $975.88 $1,182.46 $1,182.46 $1,004.38 $1,004.38 $810.92 $810.92 $775.39 $775.39 $829.15 $829.15 $873.79 $873.79 $1,058.75$904.59 $904.59 $967.30 $967.30 $1,019.39 $1,019.39 $1,235.17 $1,235.17 $1,049.15 $1,049.15 $847.07 $847.07 $809.95 $809.95 $866.11 $866.11 $912.74 $912.74 $1,105.95$945.79 $945.79 $1,011.36 $1,011.36 $1,065.82 $1,065.82 $1,291.43 $1,291.43 $1,096.94 $1,096.94 $885.65 $885.65 $846.84 $846.84 $905.56 $905.56 $954.32 $954.32 $1,156.33$966.20 $966.20 $1,033.19 $1,033.19 $1,088.82 $1,088.82 $1,319.30 $1,319.30 $1,120.61 $1,120.61 $904.77 $904.77 $865.12 $865.12 $925.10 $925.10 $974.92 $974.92 $1,181.29

$1,007.41 $1,007.41 $1,077.25 $1,077.25 $1,135.25 $1,135.25 $1,375.56 $1,375.56 $1,168.40 $1,168.40 $943.35 $943.35 $902.02 $902.02 $964.55 $964.55 $1,016.49 $1,016.49 $1,231.66$1,043.04 $1,043.04 $1,115.35 $1,115.35 $1,175.41 $1,175.41 $1,424.22 $1,424.22 $1,209.73 $1,209.73 $976.72 $976.72 $933.92 $933.92 $998.67 $998.67 $1,052.44 $1,052.44 $1,275.23$1,066.42 $1,066.42 $1,140.36 $1,140.36 $1,201.76 $1,201.76 $1,456.15 $1,456.15 $1,236.85 $1,236.85 $998.62 $998.62 $954.86 $954.86 $1,021.06 $1,021.06 $1,076.04 $1,076.04 $1,303.82$1,095.75 $1,095.75 $1,171.72 $1,171.72 $1,234.81 $1,234.81 $1,496.19 $1,496.19 $1,270.86 $1,270.86 $1,026.08 $1,026.08 $981.12 $981.12 $1,049.14 $1,049.14 $1,105.63 $1,105.63 $1,339.67$1,113.56 $1,113.56 $1,190.77 $1,190.77 $1,254.89 $1,254.89 $1,520.52 $1,520.52 $1,291.53 $1,291.53 $1,042.76 $1,042.76 $997.07 $997.07 $1,066.20 $1,066.20 $1,123.61 $1,123.61 $1,361.45

SilMed: $4,30

0$35 /$8,1

Y

75729PAGeisinger Al

35/70M-152-121-

Rating

Geisinger Al

SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 5


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000M-152-121-F Rev. 1/20

Rating Area 3


Page Number: 66 12/24/2014

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Network =>Metal =>




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64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$347.17 $294.89 $294.89 $263.68 $263.68 $252.13 $252.13 $269.61 $269.61 $284.13 $284.13 $344.27 $344.27 $292.42 $292.42 $231.62 $231.62 $221.47 $221.47$378.03 $321.10 $321.10 $287.12 $287.12 $274.54 $274.54 $293.57 $293.57 $309.38 $309.38 $374.87 $374.87 $318.41 $318.41 $252.21 $252.21 $241.16 $241.16$389.83 $331.12 $331.12 $296.08 $296.08 $283.11 $283.11 $302.74 $302.74 $319.04 $319.04 $386.57 $386.57 $328.35 $328.35 $260.08 $260.08 $248.68 $248.68$401.63 $341.14 $341.14 $305.05 $305.05 $291.68 $291.68 $311.90 $311.90 $328.69 $328.69 $398.27 $398.27 $338.29 $338.29 $267.95 $267.95 $256.21 $256.21$414.33 $351.93 $351.93 $314.70 $314.70 $300.91 $300.91 $321.77 $321.77 $339.09 $339.09 $410.87 $410.87 $348.99 $348.99 $276.43 $276.43 $264.32 $264.32$427.04 $362.73 $362.73 $324.35 $324.35 $310.13 $310.13 $331.64 $331.64 $349.49 $349.49 $423.47 $423.47 $359.70 $359.70 $284.91 $284.91 $272.42 $272.42$440.20 $373.91 $373.91 $334.34 $334.34 $319.69 $319.69 $341.86 $341.86 $360.26 $360.26 $436.52 $436.52 $370.78 $370.78 $293.69 $293.69 $280.82 $280.82$453.82 $385.48 $385.48 $344.69 $344.69 $329.58 $329.58 $352.43 $352.43 $371.41 $371.41 $450.03 $450.03 $382.26 $382.26 $302.78 $302.78 $289.51 $289.51$453.82 $385.48 $385.48 $344.69 $344.69 $329.58 $329.58 $352.43 $352.43 $371.41 $371.41 $450.03 $450.03 $382.26 $382.26 $302.78 $302.78 $289.51 $289.51$453.82 $385.48 $385.48 $344.69 $344.69 $329.58 $329.58 $352.43 $352.43 $371.41 $371.41 $450.03 $450.03 $382.26 $382.26 $302.78 $302.78 $289.51 $289.51$453.82 $385.48 $385.48 $344.69 $344.69 $329.58 $329.58 $352.43 $352.43 $371.41 $371.41 $450.03 $450.03 $382.26 $382.26 $302.78 $302.78 $289.51 $289.51$455.63 $387.01 $387.01 $346.06 $346.06 $330.90 $330.90 $353.84 $353.84 $372.89 $372.89 $451.83 $451.83 $383.78 $383.78 $303.98 $303.98 $290.66 $290.66$464.71 $394.72 $394.72 $352.96 $352.96 $337.49 $337.49 $360.89 $360.89 $380.32 $380.32 $460.83 $460.83 $391.42 $391.42 $310.04 $310.04 $296.45 $296.45$475.60 $403.97 $403.97 $361.23 $361.23 $345.40 $345.40 $369.35 $369.35 $389.23 $389.23 $471.63 $471.63 $400.60 $400.60 $317.30 $317.30 $303.40 $303.40$493.30 $419.01 $419.01 $374.67 $374.67 $358.25 $358.25 $383.09 $383.09 $403.72 $403.72 $489.18 $489.18 $415.51 $415.51 $329.11 $329.11 $314.69 $314.69$507.82 $431.34 $431.34 $385.70 $385.70 $368.80 $368.80 $394.37 $394.37 $415.60 $415.60 $503.58 $503.58 $427.74 $427.74 $338.80 $338.80 $323.95 $323.95$515.08 $437.51 $437.51 $391.22 $391.22 $374.07 $374.07 $400.01 $400.01 $421.55 $421.55 $510.78 $510.78 $433.85 $433.85 $343.64 $343.64 $328.59 $328.59$525.97 $446.76 $446.76 $399.49 $399.49 $381.98 $381.98 $408.47 $408.47 $430.46 $430.46 $521.58 $521.58 $443.03 $443.03 $350.91 $350.91 $335.53 $335.53$536.87 $456.01 $456.01 $407.76 $407.76 $389.89 $389.89 $416.92 $416.92 $439.37 $439.37 $532.38 $532.38 $452.20 $452.20 $358.18 $358.18 $342.48 $342.48$543.67 $461.79 $461.79 $412.93 $412.93 $394.84 $394.84 $422.21 $422.21 $444.94 $444.94 $539.13 $539.13 $457.94 $457.94 $362.72 $362.72 $346.83 $346.83$550.93 $467.96 $467.96 $418.45 $418.45 $400.11 $400.11 $427.85 $427.85 $450.89 $450.89 $546.33 $546.33 $464.05 $464.05 $367.56 $367.56 $351.46 $351.46$554.56 $471.05 $471.05 $421.20 $421.20 $402.75 $402.75 $430.67 $430.67 $453.86 $453.86 $549.93 $549.93 $467.11 $467.11 $369.99 $369.99 $353.77 $353.77$558.19 $474.13 $474.13 $423.96 $423.96 $405.38 $405.38 $433.49 $433.49 $456.83 $456.83 $553.53 $553.53 $470.17 $470.17 $372.41 $372.41 $356.09 $356.09$561.83 $477.21 $477.21 $426.72 $426.72 $408.02 $408.02 $436.31 $436.31 $459.80 $459.80 $557.13 $557.13 $473.23 $473.23 $374.83 $374.83 $358.41 $358.41$565.46 $480.30 $480.30 $429.48 $429.48 $410.66 $410.66 $439.13 $439.13 $462.77 $462.77 $560.73 $560.73 $476.28 $476.28 $377.25 $377.25 $360.72 $360.72$572.72 $486.46 $486.46 $434.99 $434.99 $415.93 $415.93 $444.77 $444.77 $468.71 $468.71 $567.93 $567.93 $482.40 $482.40 $382.10 $382.10 $365.35 $365.35$579.98 $492.63 $492.63 $440.51 $440.51 $421.20 $421.20 $450.40 $450.40 $474.66 $474.66 $575.13 $575.13 $488.52 $488.52 $386.94 $386.94 $369.99 $369.99$590.87 $501.88 $501.88 $448.78 $448.78 $429.11 $429.11 $458.86 $458.86 $483.57 $483.57 $585.93 $585.93 $497.69 $497.69 $394.21 $394.21 $376.93 $376.93$601.31 $510.75 $510.75 $456.71 $456.71 $436.69 $436.69 $466.97 $466.97 $492.11 $492.11 $596.28 $596.28 $506.48 $506.48 $401.17 $401.17 $383.59 $383.59$615.83 $523.08 $523.08 $467.74 $467.74 $447.24 $447.24 $478.25 $478.25 $504.00 $504.00 $610.68 $610.68 $518.71 $518.71 $410.86 $410.86 $392.86 $392.86$633.98 $538.50 $538.50 $481.52 $481.52 $460.42 $460.42 $492.34 $492.34 $518.85 $518.85 $628.69 $628.69 $534.00 $534.00 $422.97 $422.97 $404.44 $404.44$655.31 $556.62 $556.62 $497.72 $497.72 $475.91 $475.91 $508.91 $508.91 $536.31 $536.31 $649.84 $649.84 $551.97 $551.97 $437.20 $437.20 $418.04 $418.04$680.73 $578.21 $578.21 $517.03 $517.03 $494.37 $494.37 $528.64 $528.64 $557.11 $557.11 $675.04 $675.04 $573.38 $573.38 $454.16 $454.16 $434.26 $434.26$709.32 $602.49 $602.49 $538.74 $538.74 $515.13 $515.13 $550.85 $550.85 $580.51 $580.51 $703.39 $703.39 $597.46 $597.46 $473.23 $473.23 $452.49 $452.49$741.99 $630.24 $630.24 $563.56 $563.56 $538.86 $538.86 $576.22 $576.22 $607.25 $607.25 $735.79 $735.79 $624.98 $624.98 $495.03 $495.03 $473.34 $473.34$774.21 $657.61 $657.61 $588.03 $588.03 $562.26 $562.26 $601.24 $601.24 $633.62 $633.62 $767.74 $767.74 $652.12 $652.12 $516.53 $516.53 $493.89 $493.89$810.52 $688.45 $688.45 $615.60 $615.60 $588.63 $588.63 $629.44 $629.44 $663.33 $663.33 $803.74 $803.74 $682.70 $682.70 $540.75 $540.75 $517.05 $517.05$846.37 $718.90 $718.90 $642.84 $642.84 $614.67 $614.67 $657.28 $657.28 $692.67 $692.67 $839.30 $839.30 $712.90 $712.90 $564.67 $564.67 $539.92 $539.92$885.85 $752.44 $752.44 $672.82 $672.82 $643.34 $643.34 $687.94 $687.94 $724.99 $724.99 $878.45 $878.45 $746.15 $746.15 $591.01 $591.01 $565.11 $565.11$925.79 $786.36 $786.36 $703.15 $703.15 $672.34 $672.34 $718.96 $718.96 $757.67 $757.67 $918.05 $918.05 $779.79 $779.79 $617.65 $617.65 $590.59 $590.59$968.90 $822.98 $822.98 $735.90 $735.90 $703.65 $703.65 $752.44 $752.44 $792.95 $792.95 $960.80 $960.80 $816.10 $816.10 $646.42 $646.42 $618.09 $618.09

$1,012.01 $859.60 $859.60 $768.64 $768.64 $734.96 $734.96 $785.92 $785.92 $828.24 $828.24 $1,003.56 $1,003.56 $852.42 $852.42 $675.18 $675.18 $645.59 $645.59$1,058.75 $899.30 $899.30 $804.15 $804.15 $768.91 $768.91 $822.22 $822.22 $866.49 $866.49 $1,049.91 $1,049.91 $891.79 $891.79 $706.36 $706.36 $675.41 $675.41$1,105.95 $939.39 $939.39 $839.99 $839.99 $803.19 $803.19 $858.87 $858.87 $905.12 $905.12 $1,096.71 $1,096.71 $931.54 $931.54 $737.85 $737.85 $705.52 $705.52$1,156.33 $982.18 $982.18 $878.25 $878.25 $839.77 $839.77 $897.99 $897.99 $946.34 $946.34 $1,146.66 $1,146.66 $973.97 $973.97 $771.46 $771.46 $737.65 $737.65$1,181.29 $1,003.38 $1,003.38 $897.21 $897.21 $857.90 $857.90 $917.37 $917.37 $966.77 $966.77 $1,171.42 $1,171.42 $995.00 $995.00 $788.11 $788.11 $753.58 $753.58$1,231.66 $1,046.17 $1,046.17 $935.47 $935.47 $894.48 $894.48 $956.49 $956.49 $1,008.00 $1,008.00 $1,221.37 $1,221.37 $1,037.43 $1,037.43 $821.72 $821.72 $785.71 $785.71$1,275.23 $1,083.17 $1,083.17 $968.56 $968.56 $926.12 $926.12 $990.33 $990.33 $1,043.65 $1,043.65 $1,264.57 $1,264.57 $1,074.12 $1,074.12 $850.79 $850.79 $813.50 $813.50$1,303.82 $1,107.46 $1,107.46 $990.28 $990.28 $946.88 $946.88 $1,012.53 $1,012.53 $1,067.05 $1,067.05 $1,292.92 $1,292.92 $1,098.21 $1,098.21 $869.86 $869.86 $831.74 $831.74$1,339.67 $1,137.91 $1,137.91 $1,017.51 $1,017.51 $972.92 $972.92 $1,040.37 $1,040.37 $1,096.39 $1,096.39 $1,328.47 $1,328.47 $1,128.40 $1,128.40 $893.78 $893.78 $854.61 $854.61$1,361.45 $1,156.41 $1,156.41 $1,034.05 $1,034.05 $988.74 $988.74 $1,057.29 $1,057.29 $1,114.22 $1,114.22 $1,350.08 $1,350.08 $1,146.75 $1,146.75 $908.31 $908.31 $868.51 $868.51


0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 3



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 9


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 7


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 6


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 5


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 3


SilverMed: $5,000 / Rx: $500

0%$35 / $70$7,700

Yes


35/70/5000M-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $4,300 / Rx: $500

0%$35 / $70$8,150

Yes


35/70/4300M-152-121-F Rev. 1/20

Rating Area 9


ver0 / Rx: $500%/ $70150es


l-Access PPO

Page Number: 67 12/24/2014

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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$236.82 $236.82 $249.58 $249.58 $302.41 $302.41 $256.86 $256.86 $246.00 $246.00 $277.22 $277.22 $285.32 $285.32 $302.19 $302.19 $288.95 $288.95 $308.98$257.88 $257.88 $271.76 $271.76 $329.29 $329.29 $279.70 $279.70 $267.87 $267.87 $301.87 $301.87 $310.68 $310.68 $329.06 $329.06 $314.64 $314.64 $336.45$265.92 $265.92 $280.24 $280.24 $339.57 $339.57 $288.43 $288.43 $276.23 $276.23 $311.29 $311.29 $320.38 $320.38 $339.33 $339.33 $324.46 $324.46 $346.95$273.97 $273.97 $288.73 $288.73 $349.84 $349.84 $297.16 $297.16 $284.59 $284.59 $320.71 $320.71 $330.07 $330.07 $349.60 $349.60 $334.28 $334.28 $357.45$282.64 $282.64 $297.86 $297.86 $360.91 $360.91 $306.56 $306.56 $293.60 $293.60 $330.86 $330.86 $340.52 $340.52 $360.66 $360.66 $344.85 $344.85 $368.76$291.31 $291.31 $307.00 $307.00 $371.98 $371.98 $315.96 $315.96 $302.60 $302.60 $341.00 $341.00 $350.96 $350.96 $371.72 $371.72 $355.43 $355.43 $380.07$300.29 $300.29 $316.46 $316.46 $383.44 $383.44 $325.70 $325.70 $311.93 $311.93 $351.51 $351.51 $361.77 $361.77 $383.17 $383.17 $366.38 $366.38 $391.78$309.58 $309.58 $326.25 $326.25 $395.31 $395.31 $335.77 $335.77 $321.58 $321.58 $362.39 $362.39 $372.97 $372.97 $395.03 $395.03 $377.72 $377.72 $403.91$309.58 $309.58 $326.25 $326.25 $395.31 $395.31 $335.77 $335.77 $321.58 $321.58 $362.39 $362.39 $372.97 $372.97 $395.03 $395.03 $377.72 $377.72 $403.91$309.58 $309.58 $326.25 $326.25 $395.31 $395.31 $335.77 $335.77 $321.58 $321.58 $362.39 $362.39 $372.97 $372.97 $395.03 $395.03 $377.72 $377.72 $403.91$309.58 $309.58 $326.25 $326.25 $395.31 $395.31 $335.77 $335.77 $321.58 $321.58 $362.39 $362.39 $372.97 $372.97 $395.03 $395.03 $377.72 $377.72 $403.91$310.81 $310.81 $327.55 $327.55 $396.88 $396.88 $337.11 $337.11 $322.86 $322.86 $363.83 $363.83 $374.46 $374.46 $396.60 $396.60 $379.23 $379.23 $405.52$317.00 $317.00 $334.07 $334.07 $404.79 $404.79 $343.83 $343.83 $329.29 $329.29 $371.08 $371.08 $381.91 $381.91 $404.51 $404.51 $386.78 $386.78 $413.60$324.43 $324.43 $341.90 $341.90 $414.28 $414.28 $351.89 $351.89 $337.01 $337.01 $379.78 $379.78 $390.87 $390.87 $413.99 $413.99 $395.84 $395.84 $423.29$336.51 $336.51 $354.63 $354.63 $429.69 $429.69 $364.98 $364.98 $349.55 $349.55 $393.91 $393.91 $405.41 $405.41 $429.39 $429.39 $410.58 $410.58 $439.04$346.41 $346.41 $365.07 $365.07 $442.34 $442.34 $375.73 $375.73 $359.84 $359.84 $405.51 $405.51 $417.35 $417.35 $442.03 $442.03 $422.66 $422.66 $451.97$351.37 $351.37 $370.29 $370.29 $448.67 $448.67 $381.10 $381.10 $364.98 $364.98 $411.30 $411.30 $423.31 $423.31 $448.35 $448.35 $428.71 $428.71 $458.43$358.80 $358.80 $378.12 $378.12 $458.16 $458.16 $389.16 $389.16 $372.70 $372.70 $420.00 $420.00 $432.26 $432.26 $457.83 $457.83 $437.77 $437.77 $468.12$366.23 $366.23 $385.95 $385.95 $467.64 $467.64 $397.22 $397.22 $380.42 $380.42 $428.70 $428.70 $441.22 $441.22 $467.31 $467.31 $446.84 $446.84 $477.82$370.87 $370.87 $390.84 $390.84 $473.57 $473.57 $402.25 $402.25 $385.24 $385.24 $434.13 $434.13 $446.81 $446.81 $473.24 $473.24 $452.50 $452.50 $483.87$375.82 $375.82 $396.06 $396.06 $479.90 $479.90 $407.62 $407.62 $390.39 $390.39 $439.93 $439.93 $452.78 $452.78 $479.56 $479.56 $458.55 $458.55 $490.34$378.30 $378.30 $398.67 $398.67 $483.06 $483.06 $410.31 $410.31 $392.96 $392.96 $442.83 $442.83 $455.76 $455.76 $482.72 $482.72 $461.57 $461.57 $493.57$380.78 $380.78 $401.28 $401.28 $486.22 $486.22 $413.00 $413.00 $395.53 $395.53 $445.73 $445.73 $458.75 $458.75 $485.88 $485.88 $464.59 $464.59 $496.80$383.25 $383.25 $403.89 $403.89 $489.39 $489.39 $415.68 $415.68 $398.11 $398.11 $448.63 $448.63 $461.73 $461.73 $489.04 $489.04 $467.61 $467.61 $500.03$385.73 $385.73 $406.50 $406.50 $492.55 $492.55 $418.37 $418.37 $400.68 $400.68 $451.53 $451.53 $464.71 $464.71 $492.20 $492.20 $470.63 $470.63 $503.26$390.68 $390.68 $411.72 $411.72 $498.87 $498.87 $423.74 $423.74 $405.82 $405.82 $457.33 $457.33 $470.68 $470.68 $498.52 $498.52 $476.68 $476.68 $509.72$395.64 $395.64 $416.94 $416.94 $505.20 $505.20 $429.11 $429.11 $410.97 $410.97 $463.13 $463.13 $476.65 $476.65 $504.84 $504.84 $482.72 $482.72 $516.19$403.07 $403.07 $424.77 $424.77 $514.68 $514.68 $437.17 $437.17 $418.69 $418.69 $471.82 $471.82 $485.60 $485.60 $514.32 $514.32 $491.78 $491.78 $525.88$410.19 $410.19 $432.27 $432.27 $523.78 $523.78 $444.89 $444.89 $426.08 $426.08 $480.16 $480.16 $494.18 $494.18 $523.41 $523.41 $500.47 $500.47 $535.17$420.09 $420.09 $442.71 $442.71 $536.43 $536.43 $455.64 $455.64 $436.37 $436.37 $491.75 $491.75 $506.11 $506.11 $536.05 $536.05 $512.56 $512.56 $548.09$432.48 $432.48 $455.76 $455.76 $552.24 $552.24 $469.07 $469.07 $449.24 $449.24 $506.25 $506.25 $521.03 $521.03 $551.85 $551.85 $527.67 $527.67 $564.25$447.03 $447.03 $471.10 $471.10 $570.82 $570.82 $484.85 $484.85 $464.35 $464.35 $523.28 $523.28 $538.56 $538.56 $570.42 $570.42 $545.42 $545.42 $583.23$464.36 $464.36 $489.37 $489.37 $592.95 $592.95 $503.65 $503.65 $482.36 $482.36 $543.57 $543.57 $559.45 $559.45 $592.54 $592.54 $566.57 $566.57 $605.85$483.87 $483.87 $509.92 $509.92 $617.86 $617.86 $524.81 $524.81 $502.62 $502.62 $566.40 $566.40 $582.94 $582.94 $617.42 $617.42 $590.37 $590.37 $631.30$506.15 $506.15 $533.41 $533.41 $646.32 $646.32 $548.98 $548.98 $525.77 $525.77 $592.50 $592.50 $609.80 $609.80 $645.87 $645.87 $617.56 $617.56 $660.38$528.13 $528.13 $556.57 $556.57 $674.39 $674.39 $572.82 $572.82 $548.60 $548.60 $618.23 $618.23 $636.28 $636.28 $673.91 $673.91 $644.38 $644.38 $689.06$552.90 $552.90 $582.67 $582.67 $706.01 $706.01 $599.68 $599.68 $574.33 $574.33 $647.22 $647.22 $666.11 $666.11 $705.51 $705.51 $674.60 $674.60 $721.37$577.36 $577.36 $608.45 $608.45 $737.24 $737.24 $626.21 $626.21 $599.73 $599.73 $675.84 $675.84 $695.58 $695.58 $736.72 $736.72 $704.44 $704.44 $753.28$604.29 $604.29 $636.83 $636.83 $771.63 $771.63 $655.42 $655.42 $627.71 $627.71 $707.37 $707.37 $728.02 $728.02 $771.09 $771.09 $737.30 $737.30 $788.42$631.53 $631.53 $665.54 $665.54 $806.42 $806.42 $684.97 $684.97 $656.01 $656.01 $739.26 $739.26 $760.85 $760.85 $805.85 $805.85 $770.54 $770.54 $823.96$660.94 $660.94 $696.53 $696.53 $843.97 $843.97 $716.87 $716.87 $686.56 $686.56 $773.69 $773.69 $796.28 $796.28 $843.38 $843.38 $806.42 $806.42 $862.33$690.35 $690.35 $727.52 $727.52 $881.53 $881.53 $748.77 $748.77 $717.11 $717.11 $808.11 $808.11 $831.71 $831.71 $880.91 $880.91 $842.30 $842.30 $900.70$722.24 $722.24 $761.13 $761.13 $922.24 $922.24 $783.35 $783.35 $750.23 $750.23 $845.44 $845.44 $870.12 $870.12 $921.59 $921.59 $881.21 $881.21 $942.30$754.43 $754.43 $795.06 $795.06 $963.35 $963.35 $818.27 $818.27 $783.67 $783.67 $883.13 $883.13 $908.91 $908.91 $962.68 $962.68 $920.49 $920.49 $984.31$788.80 $788.80 $831.27 $831.27 $1,007.23 $1,007.23 $855.54 $855.54 $819.37 $819.37 $923.35 $923.35 $950.31 $950.31 $1,006.52 $1,006.52 $962.42 $962.42 $1,029.14$805.82 $805.82 $849.21 $849.21 $1,028.97 $1,028.97 $874.01 $874.01 $837.05 $837.05 $943.28 $943.28 $970.82 $970.82 $1,028.25 $1,028.25 $983.19 $983.19 $1,051.36$840.19 $840.19 $885.43 $885.43 $1,072.85 $1,072.85 $911.28 $911.28 $872.75 $872.75 $983.51 $983.51 $1,012.22 $1,012.22 $1,072.10 $1,072.10 $1,025.12 $1,025.12 $1,096.19$869.90 $869.90 $916.75 $916.75 $1,110.80 $1,110.80 $943.51 $943.51 $903.62 $903.62 $1,018.30 $1,018.30 $1,048.03 $1,048.03 $1,110.02 $1,110.02 $1,061.38 $1,061.38 $1,134.96$889.41 $889.41 $937.30 $937.30 $1,135.71 $1,135.71 $964.67 $964.67 $923.88 $923.88 $1,041.13 $1,041.13 $1,071.52 $1,071.52 $1,134.91 $1,134.91 $1,085.17 $1,085.17 $1,160.41$913.86 $913.86 $963.07 $963.07 $1,166.93 $1,166.93 $991.19 $991.19 $949.28 $949.28 $1,069.75 $1,069.75 $1,100.99 $1,100.99 $1,166.11 $1,166.11 $1,115.01 $1,115.01 $1,192.32$928.72 $928.72 $978.73 $978.73 $1,185.91 $1,185.91 $1,007.31 $1,007.31 $964.72 $964.72 $1,087.15 $1,087.15 $1,118.89 $1,118.89 $1,185.07 $1,185.07 $1,133.14 $1,133.14 $1,211.71

GoMed: $2,0

0$25 /$7,3

Y

75729PAGeisinger Al

25/50/20M-152-121-

Rating

Geisinger Al

GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 2


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 9


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 6


SilverMed: $4,300 / Rx: $500

0%$60 / $60$8,150

Yes


20/60/4300M-152-243-F Rev. 1/20

Rating Area 3



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 9



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 7



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 6



0%$40 / $90$7,200

Yes


40/90/7200M-152-121-F Rev. 1/20

Rating Area 5


Page Number: 68 12/24/2014

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64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$308.98 $325.62 $325.62 $394.55 $394.55 $335.13 $335.13 $365.00 $365.00 $349.01 $349.01 $373.21 $373.21 $393.30 $393.30 $476.56 $476.56 $404.78 $404.78$336.45 $354.57 $354.57 $429.62 $429.62 $364.92 $364.92 $397.45 $397.45 $380.03 $380.03 $406.38 $406.38 $428.26 $428.26 $518.92 $518.92 $440.77 $440.77$346.95 $365.63 $365.63 $443.03 $443.03 $376.31 $376.31 $409.85 $409.85 $391.89 $391.89 $419.06 $419.06 $441.63 $441.63 $535.11 $535.11 $454.52 $454.52$357.45 $376.70 $376.70 $456.44 $456.44 $387.70 $387.70 $422.26 $422.26 $403.76 $403.76 $431.75 $431.75 $455.00 $455.00 $551.31 $551.31 $468.28 $468.28$368.76 $388.62 $388.62 $470.88 $470.88 $399.97 $399.97 $435.62 $435.62 $416.53 $416.53 $445.41 $445.41 $469.39 $469.39 $568.75 $568.75 $483.10 $483.10$380.07 $400.54 $400.54 $485.32 $485.32 $412.23 $412.23 $448.98 $448.98 $429.30 $429.30 $459.07 $459.07 $483.79 $483.79 $586.19 $586.19 $497.91 $497.91$391.78 $412.88 $412.88 $500.28 $500.28 $424.94 $424.94 $462.82 $462.82 $442.53 $442.53 $473.22 $473.22 $498.70 $498.70 $604.26 $604.26 $513.26 $513.26$403.91 $425.66 $425.66 $515.76 $515.76 $438.08 $438.08 $477.13 $477.13 $456.23 $456.23 $487.86 $487.86 $514.12 $514.12 $622.95 $622.95 $529.14 $529.14$403.91 $425.66 $425.66 $515.76 $515.76 $438.08 $438.08 $477.13 $477.13 $456.23 $456.23 $487.86 $487.86 $514.12 $514.12 $622.95 $622.95 $529.14 $529.14$403.91 $425.66 $425.66 $515.76 $515.76 $438.08 $438.08 $477.13 $477.13 $456.23 $456.23 $487.86 $487.86 $514.12 $514.12 $622.95 $622.95 $529.14 $529.14$403.91 $425.66 $425.66 $515.76 $515.76 $438.08 $438.08 $477.13 $477.13 $456.23 $456.23 $487.86 $487.86 $514.12 $514.12 $622.95 $622.95 $529.14 $529.14$405.52 $427.35 $427.35 $517.81 $517.81 $439.83 $439.83 $479.04 $479.04 $458.05 $458.05 $489.80 $489.80 $516.18 $516.18 $625.44 $625.44 $531.25 $531.25$413.60 $435.87 $435.87 $528.13 $528.13 $448.59 $448.59 $488.58 $488.58 $467.17 $467.17 $499.56 $499.56 $526.46 $526.46 $637.90 $637.90 $541.83 $541.83$423.29 $446.08 $446.08 $540.51 $540.51 $459.11 $459.11 $500.03 $500.03 $478.12 $478.12 $511.27 $511.27 $538.80 $538.80 $652.85 $652.85 $554.53 $554.53$439.04 $462.68 $462.68 $560.62 $560.62 $476.19 $476.19 $518.64 $518.64 $495.91 $495.91 $530.29 $530.29 $558.85 $558.85 $677.14 $677.14 $575.17 $575.17$451.97 $476.30 $476.30 $577.13 $577.13 $490.21 $490.21 $533.91 $533.91 $510.51 $510.51 $545.91 $545.91 $575.30 $575.30 $697.08 $697.08 $592.10 $592.10$458.43 $483.11 $483.11 $585.38 $585.38 $497.22 $497.22 $541.54 $541.54 $517.81 $517.81 $553.71 $553.71 $583.53 $583.53 $707.05 $707.05 $600.56 $600.56$468.12 $493.33 $493.33 $597.76 $597.76 $507.73 $507.73 $552.99 $552.99 $528.76 $528.76 $565.42 $565.42 $595.86 $595.86 $722.00 $722.00 $613.26 $613.26$477.82 $503.54 $503.54 $610.13 $610.13 $518.25 $518.25 $564.44 $564.44 $539.71 $539.71 $577.13 $577.13 $608.20 $608.20 $736.95 $736.95 $625.96 $625.96$483.87 $509.93 $509.93 $617.87 $617.87 $524.82 $524.82 $571.60 $571.60 $546.55 $546.55 $584.45 $584.45 $615.92 $615.92 $746.29 $746.29 $633.90 $633.90$490.34 $516.74 $516.74 $626.12 $626.12 $531.83 $531.83 $579.23 $579.23 $553.85 $553.85 $592.25 $592.25 $624.14 $624.14 $756.26 $756.26 $642.36 $642.36$493.57 $520.14 $520.14 $630.25 $630.25 $535.33 $535.33 $583.05 $583.05 $557.50 $557.50 $596.15 $596.15 $628.25 $628.25 $761.24 $761.24 $646.60 $646.60$496.80 $523.55 $523.55 $634.37 $634.37 $538.84 $538.84 $586.87 $586.87 $561.15 $561.15 $600.06 $600.06 $632.37 $632.37 $766.23 $766.23 $650.83 $650.83$500.03 $526.95 $526.95 $638.50 $638.50 $542.34 $542.34 $590.69 $590.69 $564.80 $564.80 $603.96 $603.96 $636.48 $636.48 $771.21 $771.21 $655.06 $655.06$503.26 $530.36 $530.36 $642.63 $642.63 $545.85 $545.85 $594.50 $594.50 $568.45 $568.45 $607.86 $607.86 $640.59 $640.59 $776.19 $776.19 $659.30 $659.30$509.72 $537.17 $537.17 $650.88 $650.88 $552.85 $552.85 $602.14 $602.14 $575.75 $575.75 $615.67 $615.67 $648.82 $648.82 $786.16 $786.16 $667.76 $667.76$516.19 $543.98 $543.98 $659.13 $659.13 $559.86 $559.86 $609.77 $609.77 $583.05 $583.05 $623.47 $623.47 $657.05 $657.05 $796.13 $796.13 $676.23 $676.23$525.88 $554.20 $554.20 $671.51 $671.51 $570.38 $570.38 $621.22 $621.22 $594.00 $594.00 $635.18 $635.18 $669.38 $669.38 $811.08 $811.08 $688.93 $688.93$535.17 $563.99 $563.99 $683.37 $683.37 $580.45 $580.45 $632.20 $632.20 $604.49 $604.49 $646.40 $646.40 $681.21 $681.21 $825.41 $825.41 $701.10 $701.10$548.09 $577.61 $577.61 $699.87 $699.87 $594.47 $594.47 $647.46 $647.46 $619.09 $619.09 $662.01 $662.01 $697.66 $697.66 $845.34 $845.34 $718.03 $718.03$564.25 $594.63 $594.63 $720.50 $720.50 $611.99 $611.99 $666.55 $666.55 $637.34 $637.34 $681.53 $681.53 $718.23 $718.23 $870.26 $870.26 $739.20 $739.20$583.23 $614.64 $614.64 $744.74 $744.74 $632.58 $632.58 $688.97 $688.97 $658.78 $658.78 $704.46 $704.46 $742.39 $742.39 $899.54 $899.54 $764.06 $764.06$605.85 $638.48 $638.48 $773.63 $773.63 $657.12 $657.12 $715.69 $715.69 $684.33 $684.33 $731.78 $731.78 $771.18 $771.18 $934.42 $934.42 $793.70 $793.70$631.30 $665.29 $665.29 $806.12 $806.12 $684.72 $684.72 $745.75 $745.75 $713.07 $713.07 $762.51 $762.51 $803.57 $803.57 $973.67 $973.67 $827.03 $827.03$660.38 $695.94 $695.94 $843.25 $843.25 $716.26 $716.26 $780.11 $780.11 $745.92 $745.92 $797.64 $797.64 $840.59 $840.59 $1,018.52 $1,018.52 $865.13 $865.13$689.06 $726.16 $726.16 $879.87 $879.87 $747.36 $747.36 $813.98 $813.98 $778.31 $778.31 $832.27 $832.27 $877.09 $877.09 $1,062.75 $1,062.75 $902.70 $902.70$721.37 $760.21 $760.21 $921.13 $921.13 $782.41 $782.41 $852.15 $852.15 $814.81 $814.81 $871.30 $871.30 $918.22 $918.22 $1,112.59 $1,112.59 $945.03 $945.03$753.28 $793.84 $793.84 $961.88 $961.88 $817.02 $817.02 $889.85 $889.85 $850.85 $850.85 $909.84 $909.84 $958.83 $958.83 $1,161.80 $1,161.80 $986.83 $986.83$788.42 $830.87 $830.87 $1,006.75 $1,006.75 $855.13 $855.13 $931.36 $931.36 $890.54 $890.54 $952.29 $952.29 $1,003.56 $1,003.56 $1,215.99 $1,215.99 $1,032.86 $1,032.86$823.96 $868.33 $868.33 $1,052.13 $1,052.13 $893.68 $893.68 $973.34 $973.34 $930.69 $930.69 $995.22 $995.22 $1,048.80 $1,048.80 $1,270.81 $1,270.81 $1,079.43 $1,079.43$862.33 $908.76 $908.76 $1,101.13 $1,101.13 $935.30 $935.30 $1,018.67 $1,018.67 $974.03 $974.03 $1,041.56 $1,041.56 $1,097.65 $1,097.65 $1,329.99 $1,329.99 $1,129.69 $1,129.69$900.70 $949.20 $949.20 $1,150.13 $1,150.13 $976.91 $976.91 $1,064.00 $1,064.00 $1,017.37 $1,017.37 $1,087.91 $1,087.91 $1,146.49 $1,146.49 $1,389.17 $1,389.17 $1,179.96 $1,179.96$942.30 $993.04 $993.04 $1,203.25 $1,203.25 $1,022.04 $1,022.04 $1,113.14 $1,113.14 $1,064.36 $1,064.36 $1,138.16 $1,138.16 $1,199.44 $1,199.44 $1,453.34 $1,453.34 $1,234.46 $1,234.46$984.31 $1,037.31 $1,037.31 $1,256.89 $1,256.89 $1,067.60 $1,067.60 $1,162.76 $1,162.76 $1,111.81 $1,111.81 $1,188.89 $1,188.89 $1,252.91 $1,252.91 $1,518.12 $1,518.12 $1,289.49 $1,289.49

$1,029.14 $1,084.56 $1,084.56 $1,314.13 $1,314.13 $1,116.22 $1,116.22 $1,215.72 $1,215.72 $1,162.45 $1,162.45 $1,243.04 $1,243.04 $1,309.98 $1,309.98 $1,587.27 $1,587.27 $1,348.23 $1,348.23$1,051.36 $1,107.97 $1,107.97 $1,342.50 $1,342.50 $1,140.32 $1,140.32 $1,241.97 $1,241.97 $1,187.54 $1,187.54 $1,269.88 $1,269.88 $1,338.25 $1,338.25 $1,621.53 $1,621.53 $1,377.33 $1,377.33$1,096.19 $1,155.21 $1,155.21 $1,399.75 $1,399.75 $1,188.94 $1,188.94 $1,294.93 $1,294.93 $1,238.18 $1,238.18 $1,324.03 $1,324.03 $1,395.32 $1,395.32 $1,690.68 $1,690.68 $1,436.06 $1,436.06$1,134.96 $1,196.08 $1,196.08 $1,449.26 $1,449.26 $1,231.00 $1,231.00 $1,340.73 $1,340.73 $1,281.98 $1,281.98 $1,370.86 $1,370.86 $1,444.68 $1,444.68 $1,750.48 $1,750.48 $1,486.86 $1,486.86$1,160.41 $1,222.89 $1,222.89 $1,481.75 $1,481.75 $1,258.60 $1,258.60 $1,370.79 $1,370.79 $1,310.72 $1,310.72 $1,401.60 $1,401.60 $1,477.07 $1,477.07 $1,789.73 $1,789.73 $1,520.19 $1,520.19$1,192.32 $1,256.52 $1,256.52 $1,522.50 $1,522.50 $1,293.21 $1,293.21 $1,408.48 $1,408.48 $1,346.76 $1,346.76 $1,440.14 $1,440.14 $1,517.68 $1,517.68 $1,838.94 $1,838.94 $1,561.99 $1,561.99$1,211.71 $1,276.95 $1,276.95 $1,547.25 $1,547.25 $1,314.23 $1,314.23 $1,431.39 $1,431.39 $1,368.66 $1,368.66 $1,463.55 $1,463.55 $1,542.36 $1,542.36 $1,868.84 $1,868.84 $1,587.39 $1,587.39


0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 9



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 7



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 6



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 5



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 3



0%$10 / $20$2,900

Yes


10/20/0M-152-121-F Rev. 1/20

Rating Area 2


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $2,000 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/2000 1xdedM-152-121-F Rev. 1/20

Rating Area 6


old00 / Rx: $0%/ $50350es


-F Rev. 1/20Area 5

l-Access PPO

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Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$363.97 $363.97 $348.02 $348.02 $372.15 $372.15 $392.18 $392.18 $475.20 $475.20 $403.64 $403.64 $302.37 $302.37 $289.12 $289.12 $309.17 $309.17 $325.81$396.32 $396.32 $378.95 $378.95 $405.23 $405.23 $427.05 $427.05 $517.44 $517.44 $439.51 $439.51 $329.25 $329.25 $314.82 $314.82 $336.65 $336.65 $354.78$408.69 $408.69 $390.78 $390.78 $417.87 $417.87 $440.37 $440.37 $533.59 $533.59 $453.23 $453.23 $339.53 $339.53 $324.65 $324.65 $347.16 $347.16 $365.85$421.06 $421.06 $402.61 $402.61 $430.52 $430.52 $453.70 $453.70 $549.74 $549.74 $466.95 $466.95 $349.80 $349.80 $334.47 $334.47 $357.66 $357.66 $376.92$434.38 $434.38 $415.35 $415.35 $444.14 $444.14 $468.06 $468.06 $567.14 $567.14 $481.72 $481.72 $360.87 $360.87 $345.06 $345.06 $368.98 $368.98 $388.85$447.70 $447.70 $428.08 $428.08 $457.76 $457.76 $482.41 $482.41 $584.53 $584.53 $496.50 $496.50 $371.94 $371.94 $355.64 $355.64 $380.29 $380.29 $400.77$461.50 $461.50 $441.28 $441.28 $471.87 $471.87 $497.28 $497.28 $602.54 $602.54 $511.80 $511.80 $383.40 $383.40 $366.60 $366.60 $392.02 $392.02 $413.12$475.78 $475.78 $454.93 $454.93 $486.47 $486.47 $512.66 $512.66 $621.18 $621.18 $527.63 $527.63 $395.26 $395.26 $377.94 $377.94 $404.14 $404.14 $425.91$475.78 $475.78 $454.93 $454.93 $486.47 $486.47 $512.66 $512.66 $621.18 $621.18 $527.63 $527.63 $395.26 $395.26 $377.94 $377.94 $404.14 $404.14 $425.91$475.78 $475.78 $454.93 $454.93 $486.47 $486.47 $512.66 $512.66 $621.18 $621.18 $527.63 $527.63 $395.26 $395.26 $377.94 $377.94 $404.14 $404.14 $425.91$475.78 $475.78 $454.93 $454.93 $486.47 $486.47 $512.66 $512.66 $621.18 $621.18 $527.63 $527.63 $395.26 $395.26 $377.94 $377.94 $404.14 $404.14 $425.91$477.68 $477.68 $456.74 $456.74 $488.41 $488.41 $514.71 $514.71 $623.66 $623.66 $529.74 $529.74 $396.84 $396.84 $379.45 $379.45 $405.76 $405.76 $427.60$487.19 $487.19 $465.84 $465.84 $498.14 $498.14 $524.96 $524.96 $636.09 $636.09 $540.29 $540.29 $404.74 $404.74 $387.01 $387.01 $413.84 $413.84 $436.12$498.61 $498.61 $476.76 $476.76 $509.82 $509.82 $537.27 $537.27 $651.00 $651.00 $552.95 $552.95 $414.23 $414.23 $396.08 $396.08 $423.54 $423.54 $446.34$517.17 $517.17 $494.50 $494.50 $528.79 $528.79 $557.26 $557.26 $675.22 $675.22 $573.53 $573.53 $429.64 $429.64 $410.82 $410.82 $439.30 $439.30 $462.95$532.39 $532.39 $509.06 $509.06 $544.35 $544.35 $573.67 $573.67 $695.10 $695.10 $590.42 $590.42 $442.29 $442.29 $422.91 $422.91 $452.23 $452.23 $476.58$540.00 $540.00 $516.34 $516.34 $552.14 $552.14 $581.87 $581.87 $705.04 $705.04 $598.86 $598.86 $448.62 $448.62 $428.96 $428.96 $458.70 $458.70 $483.40$551.42 $551.42 $527.26 $527.26 $563.81 $563.81 $594.17 $594.17 $719.95 $719.95 $611.52 $611.52 $458.10 $458.10 $438.03 $438.03 $468.40 $468.40 $493.62$562.84 $562.84 $538.18 $538.18 $575.49 $575.49 $606.48 $606.48 $734.85 $734.85 $624.18 $624.18 $467.59 $467.59 $447.10 $447.10 $478.10 $478.10 $503.84$569.98 $569.98 $545.00 $545.00 $582.79 $582.79 $614.17 $614.17 $744.17 $744.17 $632.10 $632.10 $473.52 $473.52 $452.77 $452.77 $484.16 $484.16 $510.23$577.59 $577.59 $552.28 $552.28 $590.57 $590.57 $622.37 $622.37 $754.11 $754.11 $640.54 $640.54 $479.84 $479.84 $458.82 $458.82 $490.62 $490.62 $517.04$581.40 $581.40 $555.92 $555.92 $594.46 $594.46 $626.47 $626.47 $759.08 $759.08 $644.76 $644.76 $483.00 $483.00 $461.84 $461.84 $493.86 $493.86 $520.45$585.20 $585.20 $559.56 $559.56 $598.35 $598.35 $630.57 $630.57 $764.05 $764.05 $648.98 $648.98 $486.17 $486.17 $464.86 $464.86 $497.09 $497.09 $523.86$589.01 $589.01 $563.20 $563.20 $602.24 $602.24 $634.67 $634.67 $769.02 $769.02 $653.20 $653.20 $489.33 $489.33 $467.89 $467.89 $500.32 $500.32 $527.26$592.81 $592.81 $566.84 $566.84 $606.14 $606.14 $638.77 $638.77 $773.99 $773.99 $657.42 $657.42 $492.49 $492.49 $470.91 $470.91 $503.56 $503.56 $530.67$600.43 $600.43 $574.12 $574.12 $613.92 $613.92 $646.98 $646.98 $783.93 $783.93 $665.87 $665.87 $498.81 $498.81 $476.96 $476.96 $510.02 $510.02 $537.49$608.04 $608.04 $581.39 $581.39 $621.70 $621.70 $655.18 $655.18 $793.87 $793.87 $674.31 $674.31 $505.14 $505.14 $483.00 $483.00 $516.49 $516.49 $544.30$619.46 $619.46 $592.31 $592.31 $633.38 $633.38 $667.48 $667.48 $808.77 $808.77 $686.97 $686.97 $514.62 $514.62 $492.07 $492.07 $526.19 $526.19 $554.52$630.40 $630.40 $602.78 $602.78 $644.57 $644.57 $679.27 $679.27 $823.06 $823.06 $699.11 $699.11 $523.72 $523.72 $500.77 $500.77 $535.48 $535.48 $564.32$645.62 $645.62 $617.33 $617.33 $660.13 $660.13 $695.68 $695.68 $842.94 $842.94 $715.99 $715.99 $536.36 $536.36 $512.86 $512.86 $548.42 $548.42 $577.95$664.66 $664.66 $635.53 $635.53 $679.59 $679.59 $716.19 $716.19 $867.79 $867.79 $737.10 $737.10 $552.17 $552.17 $527.98 $527.98 $564.58 $564.58 $594.98$687.02 $687.02 $656.91 $656.91 $702.46 $702.46 $740.28 $740.28 $896.98 $896.98 $761.89 $761.89 $570.75 $570.75 $545.74 $545.74 $583.58 $583.58 $615.00$713.66 $713.66 $682.39 $682.39 $729.70 $729.70 $768.99 $768.99 $931.77 $931.77 $791.44 $791.44 $592.89 $592.89 $566.91 $566.91 $606.21 $606.21 $638.85$743.63 $743.63 $711.05 $711.05 $760.34 $760.34 $801.29 $801.29 $970.90 $970.90 $824.68 $824.68 $617.79 $617.79 $590.72 $590.72 $631.67 $631.67 $665.68$777.89 $777.89 $743.80 $743.80 $795.37 $795.37 $838.20 $838.20 $1,015.63 $1,015.63 $862.67 $862.67 $646.25 $646.25 $617.93 $617.93 $660.77 $660.77 $696.35$811.67 $811.67 $776.10 $776.10 $829.91 $829.91 $874.60 $874.60 $1,059.73 $1,059.73 $900.13 $900.13 $674.31 $674.31 $644.76 $644.76 $689.46 $689.46 $726.59$849.73 $849.73 $812.50 $812.50 $868.83 $868.83 $915.61 $915.61 $1,109.42 $1,109.42 $942.34 $942.34 $705.93 $705.93 $675.00 $675.00 $721.79 $721.79 $760.66$887.32 $887.32 $848.44 $848.44 $907.26 $907.26 $956.11 $956.11 $1,158.50 $1,158.50 $984.03 $984.03 $737.15 $737.15 $704.85 $704.85 $753.72 $753.72 $794.30$928.71 $928.71 $888.01 $888.01 $949.58 $949.58 $1,000.71 $1,000.71 $1,212.54 $1,212.54 $1,029.93 $1,029.93 $771.54 $771.54 $737.73 $737.73 $788.88 $788.88 $831.36$970.58 $970.58 $928.05 $928.05 $992.39 $992.39 $1,045.83 $1,045.83 $1,267.20 $1,267.20 $1,076.36 $1,076.36 $806.32 $806.32 $770.99 $770.99 $824.44 $824.44 $868.84

$1,015.78 $1,015.78 $971.26 $971.26 $1,038.60 $1,038.60 $1,094.53 $1,094.53 $1,326.22 $1,326.22 $1,126.48 $1,126.48 $843.87 $843.87 $806.89 $806.89 $862.84 $862.84 $909.30$1,060.97 $1,060.97 $1,014.48 $1,014.48 $1,084.82 $1,084.82 $1,143.23 $1,143.23 $1,385.23 $1,385.23 $1,176.61 $1,176.61 $881.42 $881.42 $842.80 $842.80 $901.23 $901.23 $949.76$1,109.98 $1,109.98 $1,061.34 $1,061.34 $1,134.92 $1,134.92 $1,196.03 $1,196.03 $1,449.21 $1,449.21 $1,230.95 $1,230.95 $922.13 $922.13 $881.73 $881.73 $942.86 $942.86 $993.63$1,159.46 $1,159.46 $1,108.65 $1,108.65 $1,185.52 $1,185.52 $1,249.35 $1,249.35 $1,513.81 $1,513.81 $1,285.83 $1,285.83 $963.24 $963.24 $921.03 $921.03 $984.89 $984.89 $1,037.92$1,212.27 $1,212.27 $1,159.15 $1,159.15 $1,239.51 $1,239.51 $1,306.26 $1,306.26 $1,582.76 $1,582.76 $1,344.39 $1,344.39 $1,007.11 $1,007.11 $962.98 $962.98 $1,029.75 $1,029.75 $1,085.19$1,238.44 $1,238.44 $1,184.17 $1,184.17 $1,266.27 $1,266.27 $1,334.45 $1,334.45 $1,616.93 $1,616.93 $1,373.41 $1,373.41 $1,028.85 $1,028.85 $983.77 $983.77 $1,051.97 $1,051.97 $1,108.62$1,291.25 $1,291.25 $1,234.67 $1,234.67 $1,320.27 $1,320.27 $1,391.36 $1,391.36 $1,685.88 $1,685.88 $1,431.98 $1,431.98 $1,072.73 $1,072.73 $1,025.72 $1,025.72 $1,096.83 $1,096.83 $1,155.89$1,336.92 $1,336.92 $1,278.34 $1,278.34 $1,366.97 $1,366.97 $1,440.57 $1,440.57 $1,745.51 $1,745.51 $1,482.63 $1,482.63 $1,110.67 $1,110.67 $1,062.00 $1,062.00 $1,135.63 $1,135.63 $1,196.78$1,366.90 $1,366.90 $1,307.00 $1,307.00 $1,397.61 $1,397.61 $1,472.87 $1,472.87 $1,784.65 $1,784.65 $1,515.87 $1,515.87 $1,135.57 $1,135.57 $1,085.81 $1,085.81 $1,161.09 $1,161.09 $1,223.61$1,404.48 $1,404.48 $1,342.94 $1,342.94 $1,436.04 $1,436.04 $1,513.37 $1,513.37 $1,833.72 $1,833.72 $1,557.56 $1,557.56 $1,166.80 $1,166.80 $1,115.67 $1,115.67 $1,193.02 $1,193.02 $1,257.26$1,427.32 $1,427.32 $1,364.78 $1,364.78 $1,459.40 $1,459.40 $1,537.98 $1,537.98 $1,863.54 $1,863.54 $1,582.88 $1,582.88 $1,185.77 $1,185.77 $1,133.81 $1,133.81 $1,212.42 $1,212.42 $1,277.70

GoMed: $500

20$25 /$6,8

Y

75729PAGeisinger Al

25/50M-152-121-

Rating

Geisinger Al

GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 5


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 2



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 6



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 5



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 3



0%$15 / $30$2,500

Yes


15/30/0M-152-121-F Rev. 1/20

Rating Area 2


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Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$325.81 $394.78 $394.78 $335.33 $335.33 $339.04 $339.04 $382.07 $382.07 $393.22 $393.22 $285.96 $285.96 $322.26 $322.26 $331.67 $331.67 $274.78 $274.78$354.78 $429.87 $429.87 $365.13 $365.13 $369.18 $369.18 $416.03 $416.03 $428.17 $428.17 $311.38 $311.38 $350.90 $350.90 $361.15 $361.15 $299.20 $299.20$365.85 $443.29 $443.29 $376.53 $376.53 $380.70 $380.70 $429.01 $429.01 $441.54 $441.54 $321.10 $321.10 $361.85 $361.85 $372.42 $372.42 $308.54 $308.54$376.92 $456.71 $456.71 $387.93 $387.93 $392.22 $392.22 $442.00 $442.00 $454.90 $454.90 $330.82 $330.82 $372.81 $372.81 $383.69 $383.69 $317.88 $317.88$388.85 $471.16 $471.16 $400.20 $400.20 $404.63 $404.63 $455.98 $455.98 $469.30 $469.30 $341.29 $341.29 $384.60 $384.60 $395.83 $395.83 $327.93 $327.93$400.77 $485.61 $485.61 $412.47 $412.47 $417.04 $417.04 $469.97 $469.97 $483.69 $483.69 $351.76 $351.76 $396.40 $396.40 $407.97 $407.97 $337.99 $337.99$413.12 $500.57 $500.57 $425.19 $425.19 $429.89 $429.89 $484.45 $484.45 $498.59 $498.59 $362.60 $362.60 $408.61 $408.61 $420.54 $420.54 $348.41 $348.41$425.91 $516.06 $516.06 $438.34 $438.34 $443.19 $443.19 $499.44 $499.44 $514.02 $514.02 $373.82 $373.82 $421.26 $421.26 $433.55 $433.55 $359.19 $359.19$425.91 $516.06 $516.06 $438.34 $438.34 $443.19 $443.19 $499.44 $499.44 $514.02 $514.02 $373.82 $373.82 $421.26 $421.26 $433.55 $433.55 $359.19 $359.19$425.91 $516.06 $516.06 $438.34 $438.34 $443.19 $443.19 $499.44 $499.44 $514.02 $514.02 $373.82 $373.82 $421.26 $421.26 $433.55 $433.55 $359.19 $359.19$425.91 $516.06 $516.06 $438.34 $438.34 $443.19 $443.19 $499.44 $499.44 $514.02 $514.02 $373.82 $373.82 $421.26 $421.26 $433.55 $433.55 $359.19 $359.19$427.60 $518.12 $518.12 $440.09 $440.09 $444.96 $444.96 $501.43 $501.43 $516.07 $516.07 $375.31 $375.31 $422.94 $422.94 $435.28 $435.28 $360.62 $360.62$436.12 $528.44 $528.44 $448.86 $448.86 $453.82 $453.82 $511.42 $511.42 $526.35 $526.35 $382.78 $382.78 $431.36 $431.36 $443.95 $443.95 $367.80 $367.80$446.34 $540.83 $540.83 $459.38 $459.38 $464.46 $464.46 $523.41 $523.41 $538.69 $538.69 $391.75 $391.75 $441.47 $441.47 $454.36 $454.36 $376.42 $376.42$462.95 $560.95 $560.95 $476.47 $476.47 $481.75 $481.75 $542.88 $542.88 $558.73 $558.73 $406.33 $406.33 $457.90 $457.90 $471.27 $471.27 $390.43 $390.43$476.58 $577.47 $577.47 $490.50 $490.50 $495.93 $495.93 $558.87 $558.87 $575.18 $575.18 $418.29 $418.29 $471.38 $471.38 $485.14 $485.14 $401.93 $401.93$483.40 $585.72 $585.72 $497.51 $497.51 $503.02 $503.02 $566.86 $566.86 $583.41 $583.41 $424.27 $424.27 $478.12 $478.12 $492.08 $492.08 $407.67 $407.67$493.62 $598.11 $598.11 $508.03 $508.03 $513.65 $513.65 $578.84 $578.84 $595.74 $595.74 $433.25 $433.25 $488.23 $488.23 $502.48 $502.48 $416.29 $416.29$503.84 $610.49 $610.49 $518.55 $518.55 $524.29 $524.29 $590.83 $590.83 $608.08 $608.08 $442.22 $442.22 $498.34 $498.34 $512.89 $512.89 $424.91 $424.91$510.23 $618.23 $618.23 $525.13 $525.13 $530.94 $530.94 $598.32 $598.32 $615.79 $615.79 $447.82 $447.82 $504.66 $504.66 $519.39 $519.39 $430.30 $430.30$517.04 $626.49 $626.49 $532.14 $532.14 $538.03 $538.03 $606.31 $606.31 $624.01 $624.01 $453.81 $453.81 $511.40 $511.40 $526.33 $526.33 $436.05 $436.05$520.45 $630.62 $630.62 $535.65 $535.65 $541.58 $541.58 $610.31 $610.31 $628.13 $628.13 $456.80 $456.80 $514.77 $514.77 $529.80 $529.80 $438.92 $438.92$523.86 $634.75 $634.75 $539.15 $539.15 $545.12 $545.12 $614.30 $614.30 $632.24 $632.24 $459.79 $459.79 $518.14 $518.14 $533.27 $533.27 $441.80 $441.80$527.26 $638.88 $638.88 $542.66 $542.66 $548.67 $548.67 $618.30 $618.30 $636.35 $636.35 $462.78 $462.78 $521.51 $521.51 $536.73 $536.73 $444.67 $444.67$530.67 $643.00 $643.00 $546.17 $546.17 $552.21 $552.21 $622.29 $622.29 $640.46 $640.46 $465.77 $465.77 $524.88 $524.88 $540.20 $540.20 $447.54 $447.54$537.49 $651.26 $651.26 $553.18 $553.18 $559.30 $559.30 $630.28 $630.28 $648.69 $648.69 $471.75 $471.75 $531.62 $531.62 $547.14 $547.14 $453.29 $453.29$544.30 $659.52 $659.52 $560.19 $560.19 $566.39 $566.39 $638.28 $638.28 $656.91 $656.91 $477.73 $477.73 $538.36 $538.36 $554.08 $554.08 $459.04 $459.04$554.52 $671.90 $671.90 $570.71 $570.71 $577.03 $577.03 $650.26 $650.26 $669.25 $669.25 $486.70 $486.70 $548.47 $548.47 $564.48 $564.48 $467.66 $467.66$564.32 $683.77 $683.77 $580.79 $580.79 $587.22 $587.22 $661.75 $661.75 $681.07 $681.07 $495.30 $495.30 $558.16 $558.16 $574.45 $574.45 $475.92 $475.92$577.95 $700.29 $700.29 $594.82 $594.82 $601.41 $601.41 $677.73 $677.73 $697.52 $697.52 $507.26 $507.26 $571.64 $571.64 $588.33 $588.33 $487.41 $487.41$594.98 $720.93 $720.93 $612.35 $612.35 $619.13 $619.13 $697.71 $697.71 $718.08 $718.08 $522.21 $522.21 $588.49 $588.49 $605.67 $605.67 $501.78 $501.78$615.00 $745.18 $745.18 $632.96 $632.96 $639.96 $639.96 $721.18 $721.18 $742.24 $742.24 $539.78 $539.78 $608.29 $608.29 $626.05 $626.05 $518.66 $518.66$638.85 $774.08 $774.08 $657.50 $657.50 $664.78 $664.78 $749.15 $749.15 $771.02 $771.02 $560.72 $560.72 $631.88 $631.88 $650.32 $650.32 $538.77 $538.77$665.68 $806.59 $806.59 $685.12 $685.12 $692.70 $692.70 $780.61 $780.61 $803.41 $803.41 $584.27 $584.27 $658.41 $658.41 $677.64 $677.64 $561.40 $561.40$696.35 $843.75 $843.75 $716.68 $716.68 $724.61 $724.61 $816.57 $816.57 $840.41 $840.41 $611.18 $611.18 $688.74 $688.74 $708.85 $708.85 $587.26 $587.26$726.59 $880.39 $880.39 $747.80 $747.80 $756.08 $756.08 $852.03 $852.03 $876.91 $876.91 $637.72 $637.72 $718.65 $718.65 $739.64 $739.64 $612.77 $612.77$760.66 $921.67 $921.67 $782.87 $782.87 $791.53 $791.53 $891.99 $891.99 $918.03 $918.03 $667.63 $667.63 $752.35 $752.35 $774.32 $774.32 $641.50 $641.50$794.30 $962.44 $962.44 $817.50 $817.50 $826.55 $826.55 $931.44 $931.44 $958.64 $958.64 $697.16 $697.16 $785.63 $785.63 $808.57 $808.57 $669.88 $669.88$831.36 $1,007.34 $1,007.34 $855.63 $855.63 $865.10 $865.10 $974.89 $974.89 $1,003.36 $1,003.36 $729.68 $729.68 $822.28 $822.28 $846.29 $846.29 $701.13 $701.13$868.84 $1,052.75 $1,052.75 $894.20 $894.20 $904.10 $904.10 $1,018.84 $1,018.84 $1,048.59 $1,048.59 $762.57 $762.57 $859.35 $859.35 $884.44 $884.44 $732.73 $732.73$909.30 $1,101.78 $1,101.78 $935.85 $935.85 $946.21 $946.21 $1,066.29 $1,066.29 $1,097.42 $1,097.42 $798.08 $798.08 $899.37 $899.37 $925.63 $925.63 $766.86 $766.86$949.76 $1,150.80 $1,150.80 $977.49 $977.49 $988.31 $988.31 $1,113.74 $1,113.74 $1,146.25 $1,146.25 $833.60 $833.60 $939.39 $939.39 $966.82 $966.82 $800.98 $800.98$993.63 $1,203.96 $1,203.96 $1,022.64 $1,022.64 $1,033.96 $1,033.96 $1,165.18 $1,165.18 $1,199.20 $1,199.20 $872.10 $872.10 $982.78 $982.78 $1,011.47 $1,011.47 $837.97 $837.97

$1,037.92 $1,257.63 $1,257.63 $1,068.22 $1,068.22 $1,080.05 $1,080.05 $1,217.12 $1,217.12 $1,252.65 $1,252.65 $910.98 $910.98 $1,026.59 $1,026.59 $1,056.56 $1,056.56 $875.33 $875.33$1,085.19 $1,314.91 $1,314.91 $1,116.88 $1,116.88 $1,129.24 $1,129.24 $1,272.55 $1,272.55 $1,309.71 $1,309.71 $952.47 $952.47 $1,073.35 $1,073.35 $1,104.68 $1,104.68 $915.20 $915.20$1,108.62 $1,343.29 $1,343.29 $1,140.99 $1,140.99 $1,153.62 $1,153.62 $1,300.02 $1,300.02 $1,337.98 $1,337.98 $973.03 $973.03 $1,096.51 $1,096.51 $1,128.53 $1,128.53 $934.95 $934.95$1,155.89 $1,400.57 $1,400.57 $1,189.64 $1,189.64 $1,202.81 $1,202.81 $1,355.46 $1,355.46 $1,395.04 $1,395.04 $1,014.52 $1,014.52 $1,143.27 $1,143.27 $1,176.65 $1,176.65 $974.82 $974.82$1,196.78 $1,450.11 $1,450.11 $1,231.72 $1,231.72 $1,245.36 $1,245.36 $1,403.41 $1,403.41 $1,444.38 $1,444.38 $1,050.41 $1,050.41 $1,183.71 $1,183.71 $1,218.27 $1,218.27 $1,009.30 $1,009.30$1,223.61 $1,482.63 $1,482.63 $1,259.34 $1,259.34 $1,273.28 $1,273.28 $1,434.87 $1,434.87 $1,476.76 $1,476.76 $1,073.96 $1,073.96 $1,210.25 $1,210.25 $1,245.59 $1,245.59 $1,031.93 $1,031.93$1,257.26 $1,523.39 $1,523.39 $1,293.97 $1,293.97 $1,308.29 $1,308.29 $1,474.33 $1,474.33 $1,517.37 $1,517.37 $1,103.49 $1,103.49 $1,243.53 $1,243.53 $1,279.84 $1,279.84 $1,060.31 $1,060.31$1,277.70 $1,548.16 $1,548.16 $1,315.01 $1,315.01 $1,329.56 $1,329.56 $1,498.30 $1,498.30 $1,542.04 $1,542.04 $1,121.43 $1,121.43 $1,263.75 $1,263.75 $1,300.65 $1,300.65 $1,077.55 $1,077.55

GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/1000M-152-243-F Rev. 1/20

Rating Area 3



0%$40 / $40$1,600

Yes

75729PA0050131





0%$40 / $40$1,600

Yes

75729PA0050131





0%$40 / $40$1,600

Yes

75729PA0050131




GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $500 / Rx: $250

20%$25 / $50$6,850

Yes


25/50/500M-152-121-F Rev. 1/20

Rating Area 7


old / Rx: $250

0%/ $50850es


l-Access PPO

Page Number: 71 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




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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 Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$309.65 $309.65 $318.69 $318.69 $242.08 $242.08 $272.80 $272.80 $280.76 $280.76 $338.98 $338.98 $324.12 $324.12 $346.60 $346.60 $365.26 $365.26 $442.58$337.17 $337.17 $347.02 $347.02 $263.60 $263.60 $297.05 $297.05 $305.72 $305.72 $369.11 $369.11 $352.94 $352.94 $377.40 $377.40 $397.73 $397.73 $481.92$347.69 $347.69 $357.85 $357.85 $271.82 $271.82 $306.32 $306.32 $315.26 $315.26 $380.63 $380.63 $363.95 $363.95 $389.18 $389.18 $410.14 $410.14 $496.96$358.22 $358.22 $368.68 $368.68 $280.05 $280.05 $315.59 $315.59 $324.81 $324.81 $392.15 $392.15 $374.97 $374.97 $400.96 $400.96 $422.55 $422.55 $512.00$369.55 $369.55 $380.34 $380.34 $288.91 $288.91 $325.58 $325.58 $335.08 $335.08 $404.56 $404.56 $386.83 $386.83 $413.65 $413.65 $435.92 $435.92 $528.20$380.89 $380.89 $392.01 $392.01 $297.77 $297.77 $335.56 $335.56 $345.36 $345.36 $416.97 $416.97 $398.69 $398.69 $426.34 $426.34 $449.29 $449.29 $544.40$392.62 $392.62 $404.09 $404.09 $306.95 $306.95 $345.90 $345.90 $356.00 $356.00 $429.82 $429.82 $410.98 $410.98 $439.47 $439.47 $463.14 $463.14 $561.17$404.77 $404.77 $416.59 $416.59 $316.45 $316.45 $356.61 $356.61 $367.02 $367.02 $443.11 $443.11 $423.70 $423.70 $453.07 $453.07 $477.47 $477.47 $578.54$404.77 $404.77 $416.59 $416.59 $316.45 $316.45 $356.61 $356.61 $367.02 $367.02 $443.11 $443.11 $423.70 $423.70 $453.07 $453.07 $477.47 $477.47 $578.54$404.77 $404.77 $416.59 $416.59 $316.45 $316.45 $356.61 $356.61 $367.02 $367.02 $443.11 $443.11 $423.70 $423.70 $453.07 $453.07 $477.47 $477.47 $578.54$404.77 $404.77 $416.59 $416.59 $316.45 $316.45 $356.61 $356.61 $367.02 $367.02 $443.11 $443.11 $423.70 $423.70 $453.07 $453.07 $477.47 $477.47 $578.54$406.39 $406.39 $418.25 $418.25 $317.71 $317.71 $358.03 $358.03 $368.48 $368.48 $444.88 $444.88 $425.39 $425.39 $454.88 $454.88 $479.37 $479.37 $580.84$414.48 $414.48 $426.58 $426.58 $324.04 $324.04 $365.16 $365.16 $375.82 $375.82 $453.74 $453.74 $433.86 $433.86 $463.94 $463.94 $488.92 $488.92 $592.42$424.20 $424.20 $436.58 $436.58 $331.63 $331.63 $373.72 $373.72 $384.63 $384.63 $464.38 $464.38 $444.03 $444.03 $474.81 $474.81 $500.38 $500.38 $606.30$439.98 $439.98 $452.83 $452.83 $343.97 $343.97 $387.62 $387.62 $398.94 $398.94 $481.66 $481.66 $460.55 $460.55 $492.48 $492.48 $519.00 $519.00 $628.86$452.93 $452.93 $466.16 $466.16 $354.10 $354.10 $399.04 $399.04 $410.69 $410.69 $495.84 $495.84 $474.11 $474.11 $506.98 $506.98 $534.28 $534.28 $647.38$459.41 $459.41 $472.82 $472.82 $359.16 $359.16 $404.74 $404.74 $416.56 $416.56 $502.93 $502.93 $480.89 $480.89 $514.23 $514.23 $541.92 $541.92 $656.63$469.13 $469.13 $482.82 $482.82 $366.76 $366.76 $413.30 $413.30 $425.37 $425.37 $513.56 $513.56 $491.06 $491.06 $525.10 $525.10 $553.38 $553.38 $670.52$478.84 $478.84 $492.82 $492.82 $374.35 $374.35 $421.86 $421.86 $434.18 $434.18 $524.20 $524.20 $501.23 $501.23 $535.98 $535.98 $564.84 $564.84 $684.40$484.91 $484.91 $499.07 $499.07 $379.10 $379.10 $427.21 $427.21 $439.68 $439.68 $530.84 $530.84 $507.58 $507.58 $542.77 $542.77 $572.00 $572.00 $693.08$491.39 $491.39 $505.73 $505.73 $384.16 $384.16 $432.91 $432.91 $445.55 $445.55 $537.93 $537.93 $514.36 $514.36 $550.02 $550.02 $579.64 $579.64 $702.34$494.63 $494.63 $509.07 $509.07 $386.69 $386.69 $435.77 $435.77 $448.49 $448.49 $541.48 $541.48 $517.75 $517.75 $553.65 $553.65 $583.46 $583.46 $706.96$497.86 $497.86 $512.40 $512.40 $389.22 $389.22 $438.62 $438.62 $451.42 $451.42 $545.02 $545.02 $521.14 $521.14 $557.27 $557.27 $587.28 $587.28 $711.59$501.10 $501.10 $515.73 $515.73 $391.75 $391.75 $441.47 $441.47 $454.36 $454.36 $548.57 $548.57 $524.53 $524.53 $560.90 $560.90 $591.10 $591.10 $716.22$504.34 $504.34 $519.06 $519.06 $394.29 $394.29 $444.32 $444.32 $457.30 $457.30 $552.11 $552.11 $527.92 $527.92 $564.52 $564.52 $594.92 $594.92 $720.85$510.82 $510.82 $525.73 $525.73 $399.35 $399.35 $450.03 $450.03 $463.17 $463.17 $559.20 $559.20 $534.70 $534.70 $571.77 $571.77 $602.56 $602.56 $730.11$517.29 $517.29 $532.40 $532.40 $404.41 $404.41 $455.74 $455.74 $469.04 $469.04 $566.29 $566.29 $541.48 $541.48 $579.02 $579.02 $610.20 $610.20 $739.36$527.01 $527.01 $542.39 $542.39 $412.01 $412.01 $464.29 $464.29 $477.85 $477.85 $576.93 $576.93 $551.65 $551.65 $589.89 $589.89 $621.66 $621.66 $753.25$536.32 $536.32 $551.98 $551.98 $419.28 $419.28 $472.50 $472.50 $486.29 $486.29 $587.12 $587.12 $561.39 $561.39 $600.31 $600.31 $632.64 $632.64 $766.55$549.27 $549.27 $565.31 $565.31 $429.41 $429.41 $483.91 $483.91 $498.04 $498.04 $601.30 $601.30 $574.95 $574.95 $614.81 $614.81 $647.92 $647.92 $785.07$565.46 $565.46 $581.97 $581.97 $442.07 $442.07 $498.17 $498.17 $512.72 $512.72 $619.02 $619.02 $591.90 $591.90 $632.93 $632.93 $667.01 $667.01 $808.21$584.48 $584.48 $601.55 $601.55 $456.94 $456.94 $514.93 $514.93 $529.97 $529.97 $639.85 $639.85 $611.81 $611.81 $654.23 $654.23 $689.46 $689.46 $835.40$607.15 $607.15 $624.88 $624.88 $474.66 $474.66 $534.90 $534.90 $550.52 $550.52 $664.66 $664.66 $635.54 $635.54 $679.60 $679.60 $716.19 $716.19 $867.80$632.65 $632.65 $651.12 $651.12 $494.60 $494.60 $557.37 $557.37 $573.64 $573.64 $692.58 $692.58 $662.23 $662.23 $708.14 $708.14 $746.27 $746.27 $904.24$661.79 $661.79 $681.12 $681.12 $517.38 $517.38 $583.04 $583.04 $600.06 $600.06 $724.48 $724.48 $692.74 $692.74 $740.76 $740.76 $780.65 $780.65 $945.90$690.53 $690.53 $710.69 $710.69 $539.85 $539.85 $608.36 $608.36 $626.12 $626.12 $755.94 $755.94 $722.82 $722.82 $772.93 $772.93 $814.55 $814.55 $986.97$722.91 $722.91 $744.02 $744.02 $565.16 $565.16 $636.89 $636.89 $655.48 $655.48 $791.39 $791.39 $756.71 $756.71 $809.18 $809.18 $852.75 $852.75 $1,033.26$754.89 $754.89 $776.93 $776.93 $590.16 $590.16 $665.06 $665.06 $684.48 $684.48 $826.40 $826.40 $790.18 $790.18 $844.97 $844.97 $890.47 $890.47 $1,078.96$790.11 $790.11 $813.17 $813.17 $617.69 $617.69 $696.08 $696.08 $716.41 $716.41 $864.95 $864.95 $827.05 $827.05 $884.39 $884.39 $932.01 $932.01 $1,129.29$825.72 $825.72 $849.83 $849.83 $645.54 $645.54 $727.46 $727.46 $748.70 $748.70 $903.94 $903.94 $864.33 $864.33 $924.26 $924.26 $974.02 $974.02 $1,180.20$864.18 $864.18 $889.41 $889.41 $675.60 $675.60 $761.34 $761.34 $783.57 $783.57 $946.04 $946.04 $904.58 $904.58 $967.30 $967.30 $1,019.38 $1,019.38 $1,235.16$902.63 $902.63 $928.98 $928.98 $705.66 $705.66 $795.22 $795.22 $818.44 $818.44 $988.13 $988.13 $944.83 $944.83 $1,010.34 $1,010.34 $1,064.74 $1,064.74 $1,290.12$944.32 $944.32 $971.89 $971.89 $738.26 $738.26 $831.95 $831.95 $856.24 $856.24 $1,033.77 $1,033.77 $988.47 $988.47 $1,057.00 $1,057.00 $1,113.92 $1,113.92 $1,349.71$986.42 $986.42 $1,015.22 $1,015.22 $771.17 $771.17 $869.03 $869.03 $894.41 $894.41 $1,079.86 $1,079.86 $1,032.54 $1,032.54 $1,104.12 $1,104.12 $1,163.58 $1,163.58 $1,409.88

$1,031.35 $1,031.35 $1,061.46 $1,061.46 $806.29 $806.29 $908.62 $908.62 $935.15 $935.15 $1,129.04 $1,129.04 $1,079.57 $1,079.57 $1,154.41 $1,154.41 $1,216.57 $1,216.57 $1,474.10$1,053.61 $1,053.61 $1,084.37 $1,084.37 $823.70 $823.70 $928.23 $928.23 $955.33 $955.33 $1,153.41 $1,153.41 $1,102.87 $1,102.87 $1,179.33 $1,179.33 $1,242.83 $1,242.83 $1,505.92$1,098.54 $1,098.54 $1,130.61 $1,130.61 $858.82 $858.82 $967.81 $967.81 $996.07 $996.07 $1,202.60 $1,202.60 $1,149.90 $1,149.90 $1,229.62 $1,229.62 $1,295.83 $1,295.83 $1,570.13$1,137.40 $1,137.40 $1,170.60 $1,170.60 $889.20 $889.20 $1,002.05 $1,002.05 $1,031.30 $1,031.30 $1,245.14 $1,245.14 $1,190.57 $1,190.57 $1,273.12 $1,273.12 $1,341.67 $1,341.67 $1,625.67$1,162.90 $1,162.90 $1,196.85 $1,196.85 $909.13 $909.13 $1,024.51 $1,024.51 $1,054.43 $1,054.43 $1,273.05 $1,273.05 $1,217.27 $1,217.27 $1,301.66 $1,301.66 $1,371.75 $1,371.75 $1,662.12$1,194.87 $1,194.87 $1,229.76 $1,229.76 $934.13 $934.13 $1,052.68 $1,052.68 $1,083.42 $1,083.42 $1,308.06 $1,308.06 $1,250.74 $1,250.74 $1,337.45 $1,337.45 $1,409.47 $1,409.47 $1,707.82$1,214.30 $1,214.30 $1,249.76 $1,249.76 $949.32 $949.32 $1,069.80 $1,069.80 $1,101.04 $1,101.04 $1,329.33 $1,329.33 $1,271.07 $1,271.07 $1,359.20 $1,359.20 $1,432.39 $1,432.39 $1,735.59

PlatiCombine

00% After D

$1,5Y


PPO M-152-122-

Rating

Geisinger Al



$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 6




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 5




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 3




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 2


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 9


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 6


SilverMed: $6,250 / Rx: $500

0%$60 / $60$7,350

Yes


20/60/6250M-152-243-F Rev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 9


GoldMed: $2,000 / Rx: $0

0%$60 / $60$7,350

Yes


10/60/2000M-152-243-F Rev. 1/20

Rating Area 6


Page Number: 72 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$442.58 $375.92 $375.92 $334.15 $334.15 $319.51 $319.51 $341.66 $341.66 $360.05 $360.05 $436.27 $436.27 $370.57 $370.57 $288.75 $288.75 $276.10 $276.10$481.92 $409.34 $409.34 $363.85 $363.85 $347.91 $347.91 $372.03 $372.03 $392.06 $392.06 $475.05 $475.05 $403.51 $403.51 $314.42 $314.42 $300.64 $300.64$496.96 $422.11 $422.11 $375.21 $375.21 $358.76 $358.76 $383.64 $383.64 $404.30 $404.30 $489.88 $489.88 $416.10 $416.10 $324.23 $324.23 $310.02 $310.02$512.00 $434.89 $434.89 $386.56 $386.56 $369.62 $369.62 $395.25 $395.25 $416.53 $416.53 $504.70 $504.70 $428.69 $428.69 $334.05 $334.05 $319.41 $319.41$528.20 $448.65 $448.65 $398.79 $398.79 $381.32 $381.32 $407.75 $407.75 $429.71 $429.71 $520.67 $520.67 $442.26 $442.26 $344.61 $344.61 $329.51 $329.51$544.40 $462.41 $462.41 $411.02 $411.02 $393.01 $393.01 $420.26 $420.26 $442.89 $442.89 $536.64 $536.64 $455.82 $455.82 $355.18 $355.18 $339.62 $339.62$561.17 $476.66 $476.66 $423.69 $423.69 $405.12 $405.12 $433.21 $433.21 $456.54 $456.54 $553.18 $553.18 $469.87 $469.87 $366.13 $366.13 $350.09 $350.09$578.54 $491.41 $491.41 $436.80 $436.80 $417.66 $417.66 $446.61 $446.61 $470.66 $470.66 $570.29 $570.29 $484.40 $484.40 $377.46 $377.46 $360.92 $360.92$578.54 $491.41 $491.41 $436.80 $436.80 $417.66 $417.66 $446.61 $446.61 $470.66 $470.66 $570.29 $570.29 $484.40 $484.40 $377.46 $377.46 $360.92 $360.92$578.54 $491.41 $491.41 $436.80 $436.80 $417.66 $417.66 $446.61 $446.61 $470.66 $470.66 $570.29 $570.29 $484.40 $484.40 $377.46 $377.46 $360.92 $360.92$578.54 $491.41 $491.41 $436.80 $436.80 $417.66 $417.66 $446.61 $446.61 $470.66 $470.66 $570.29 $570.29 $484.40 $484.40 $377.46 $377.46 $360.92 $360.92$580.84 $493.37 $493.37 $438.54 $438.54 $419.32 $419.32 $448.40 $448.40 $472.54 $472.54 $572.57 $572.57 $486.34 $486.34 $378.96 $378.96 $362.36 $362.36$592.42 $503.20 $503.20 $447.28 $447.28 $427.68 $427.68 $457.33 $457.33 $481.95 $481.95 $583.97 $583.97 $496.03 $496.03 $386.51 $386.51 $369.58 $369.58$606.30 $514.99 $514.99 $457.76 $457.76 $437.70 $437.70 $468.05 $468.05 $493.25 $493.25 $597.66 $597.66 $507.65 $507.65 $395.57 $395.57 $378.24 $378.24$628.86 $534.15 $534.15 $474.80 $474.80 $453.99 $453.99 $485.46 $485.46 $511.61 $511.61 $619.90 $619.90 $526.54 $526.54 $410.29 $410.29 $392.31 $392.31$647.38 $549.88 $549.88 $488.77 $488.77 $467.35 $467.35 $499.76 $499.76 $526.67 $526.67 $638.15 $638.15 $542.04 $542.04 $422.37 $422.37 $403.86 $403.86$656.63 $557.74 $557.74 $495.76 $495.76 $474.04 $474.04 $506.90 $506.90 $534.20 $534.20 $647.28 $647.28 $549.79 $549.79 $428.41 $428.41 $409.64 $409.64$670.52 $569.54 $569.54 $506.24 $506.24 $484.06 $484.06 $517.62 $517.62 $545.49 $545.49 $660.96 $660.96 $561.42 $561.42 $437.47 $437.47 $418.30 $418.30$684.40 $581.33 $581.33 $516.73 $516.73 $494.08 $494.08 $528.34 $528.34 $556.79 $556.79 $674.65 $674.65 $573.05 $573.05 $446.53 $446.53 $426.96 $426.96$693.08 $588.70 $588.70 $523.28 $523.28 $500.35 $500.35 $535.04 $535.04 $563.85 $563.85 $683.20 $683.20 $580.31 $580.31 $452.19 $452.19 $432.37 $432.37$702.34 $596.56 $596.56 $530.27 $530.27 $507.03 $507.03 $542.18 $542.18 $571.38 $571.38 $692.33 $692.33 $588.06 $588.06 $458.23 $458.23 $438.15 $438.15$706.96 $600.49 $600.49 $533.76 $533.76 $510.37 $510.37 $545.76 $545.76 $575.14 $575.14 $696.89 $696.89 $591.94 $591.94 $461.25 $461.25 $441.04 $441.04$711.59 $604.43 $604.43 $537.26 $537.26 $513.71 $513.71 $549.33 $549.33 $578.91 $578.91 $701.45 $701.45 $595.81 $595.81 $464.27 $464.27 $443.92 $443.92$716.22 $608.36 $608.36 $540.75 $540.75 $517.06 $517.06 $552.90 $552.90 $582.67 $582.67 $706.01 $706.01 $599.69 $599.69 $467.29 $467.29 $446.81 $446.81$720.85 $612.29 $612.29 $544.25 $544.25 $520.40 $520.40 $556.48 $556.48 $586.44 $586.44 $710.58 $710.58 $603.56 $603.56 $470.31 $470.31 $449.70 $449.70$730.11 $620.15 $620.15 $551.23 $551.23 $527.08 $527.08 $563.62 $563.62 $593.97 $593.97 $719.70 $719.70 $611.31 $611.31 $476.35 $476.35 $455.47 $455.47$739.36 $628.01 $628.01 $558.22 $558.22 $533.76 $533.76 $570.77 $570.77 $601.50 $601.50 $728.83 $728.83 $619.06 $619.06 $482.39 $482.39 $461.25 $461.25$753.25 $639.81 $639.81 $568.71 $568.71 $543.79 $543.79 $581.49 $581.49 $612.80 $612.80 $742.51 $742.51 $630.69 $630.69 $491.44 $491.44 $469.91 $469.91$766.55 $651.11 $651.11 $578.75 $578.75 $553.39 $553.39 $591.76 $591.76 $623.62 $623.62 $755.63 $755.63 $641.83 $641.83 $500.13 $500.13 $478.21 $478.21$785.07 $666.83 $666.83 $592.73 $592.73 $566.76 $566.76 $606.05 $606.05 $638.68 $638.68 $773.88 $773.88 $657.33 $657.33 $512.20 $512.20 $489.76 $489.76$808.21 $686.49 $686.49 $610.20 $610.20 $583.46 $583.46 $623.91 $623.91 $657.51 $657.51 $796.69 $796.69 $676.71 $676.71 $527.30 $527.30 $504.20 $504.20$835.40 $709.59 $709.59 $630.73 $630.73 $603.09 $603.09 $644.90 $644.90 $679.63 $679.63 $823.49 $823.49 $699.47 $699.47 $545.04 $545.04 $521.16 $521.16$867.80 $737.10 $737.10 $655.19 $655.19 $626.48 $626.48 $669.91 $669.91 $705.99 $705.99 $855.43 $855.43 $726.60 $726.60 $566.18 $566.18 $541.37 $541.37$904.24 $768.06 $768.06 $682.71 $682.71 $652.79 $652.79 $698.05 $698.05 $735.64 $735.64 $891.36 $891.36 $757.12 $757.12 $589.96 $589.96 $564.11 $564.11$945.90 $803.44 $803.44 $714.16 $714.16 $682.86 $682.86 $730.21 $730.21 $769.53 $769.53 $932.42 $932.42 $791.99 $791.99 $617.14 $617.14 $590.09 $590.09$986.97 $838.33 $838.33 $745.17 $745.17 $712.52 $712.52 $761.92 $761.92 $802.94 $802.94 $972.91 $972.91 $826.39 $826.39 $643.94 $643.94 $615.72 $615.72

$1,033.26 $877.65 $877.65 $780.11 $780.11 $745.93 $745.93 $797.65 $797.65 $840.60 $840.60 $1,018.53 $1,018.53 $865.14 $865.14 $674.13 $674.13 $644.59 $644.59$1,078.96 $916.47 $916.47 $814.62 $814.62 $778.92 $778.92 $832.93 $832.93 $877.78 $877.78 $1,063.58 $1,063.58 $903.41 $903.41 $703.95 $703.95 $673.10 $673.10$1,129.29 $959.22 $959.22 $852.62 $852.62 $815.26 $815.26 $871.78 $871.78 $918.72 $918.72 $1,113.20 $1,113.20 $945.55 $945.55 $736.79 $736.79 $704.50 $704.50$1,180.20 $1,002.46 $1,002.46 $891.06 $891.06 $852.01 $852.01 $911.08 $911.08 $960.14 $960.14 $1,163.38 $1,163.38 $988.18 $988.18 $770.01 $770.01 $736.26 $736.26$1,235.16 $1,049.14 $1,049.14 $932.56 $932.56 $891.69 $891.69 $953.51 $953.51 $1,004.85 $1,004.85 $1,217.56 $1,217.56 $1,034.19 $1,034.19 $805.86 $805.86 $770.55 $770.55$1,290.12 $1,095.83 $1,095.83 $974.05 $974.05 $931.37 $931.37 $995.94 $995.94 $1,049.57 $1,049.57 $1,271.74 $1,271.74 $1,080.21 $1,080.21 $841.72 $841.72 $804.84 $804.84$1,349.71 $1,146.44 $1,146.44 $1,019.04 $1,019.04 $974.39 $974.39 $1,041.94 $1,041.94 $1,098.05 $1,098.05 $1,330.48 $1,330.48 $1,130.10 $1,130.10 $880.60 $880.60 $842.01 $842.01$1,409.88 $1,197.55 $1,197.55 $1,064.47 $1,064.47 $1,017.82 $1,017.82 $1,088.39 $1,088.39 $1,146.99 $1,146.99 $1,389.79 $1,389.79 $1,180.48 $1,180.48 $919.85 $919.85 $879.55 $879.55$1,474.10 $1,252.09 $1,252.09 $1,112.95 $1,112.95 $1,064.18 $1,064.18 $1,137.96 $1,137.96 $1,199.24 $1,199.24 $1,453.09 $1,453.09 $1,234.25 $1,234.25 $961.75 $961.75 $919.61 $919.61$1,505.92 $1,279.12 $1,279.12 $1,136.98 $1,136.98 $1,087.15 $1,087.15 $1,162.53 $1,162.53 $1,225.12 $1,225.12 $1,484.46 $1,484.46 $1,260.89 $1,260.89 $982.51 $982.51 $939.46 $939.46$1,570.13 $1,333.67 $1,333.67 $1,185.46 $1,185.46 $1,133.51 $1,133.51 $1,212.10 $1,212.10 $1,277.37 $1,277.37 $1,547.76 $1,547.76 $1,314.66 $1,314.66 $1,024.41 $1,024.41 $979.52 $979.52$1,625.67 $1,380.84 $1,380.84 $1,227.39 $1,227.39 $1,173.61 $1,173.61 $1,254.97 $1,254.97 $1,322.55 $1,322.55 $1,602.50 $1,602.50 $1,361.16 $1,361.16 $1,060.64 $1,060.64 $1,014.17 $1,014.17$1,662.12 $1,411.80 $1,411.80 $1,254.91 $1,254.91 $1,199.92 $1,199.92 $1,283.11 $1,283.11 $1,352.20 $1,352.20 $1,638.43 $1,638.43 $1,391.68 $1,391.68 $1,084.42 $1,084.42 $1,036.90 $1,036.90$1,707.82 $1,450.62 $1,450.62 $1,289.42 $1,289.42 $1,232.91 $1,232.91 $1,318.39 $1,318.39 $1,389.38 $1,389.38 $1,683.49 $1,683.49 $1,429.95 $1,429.95 $1,114.24 $1,114.24 $1,065.42 $1,065.42$1,735.59 $1,474.21 $1,474.21 $1,310.38 $1,310.38 $1,252.96 $1,252.96 $1,339.83 $1,339.83 $1,411.97 $1,411.97 $1,710.86 $1,710.86 $1,453.20 $1,453.20 $1,132.36 $1,132.36 $1,082.74 $1,082.74

GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 3


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 2



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 9



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 7



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 6



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 5



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 3



0%$15 / $30$5,000

Yes


15/30/1500M-152-121-F Rev. 1/20

Rating Area 2




$1,500Yes


PPO 1500M-152-122-F Rev. 1/20

Rating Area 9


numd: $1,500%

Deductible500es


l-Access PPO

Page Number: 73 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco$295.24 $295.24 $311.14 $311.14 $377.00 $377.00 $320.22 $320.22 $311.21 $311.21 $297.57 $297.57 $318.20 $318.20 $335.34 $335.34 $406.32 $406.32 $345.13$321.48 $321.48 $338.80 $338.80 $410.51 $410.51 $348.69 $348.69 $338.87 $338.87 $324.02 $324.02 $346.49 $346.49 $365.14 $365.14 $442.44 $442.44 $375.80$331.52 $331.52 $349.37 $349.37 $423.32 $423.32 $359.57 $359.57 $349.45 $349.45 $334.13 $334.13 $357.30 $357.30 $376.54 $376.54 $456.25 $456.25 $387.53$341.55 $341.55 $359.94 $359.94 $436.14 $436.14 $370.45 $370.45 $360.02 $360.02 $344.25 $344.25 $368.12 $368.12 $387.94 $387.94 $470.05 $470.05 $399.26$352.36 $352.36 $371.33 $371.33 $449.94 $449.94 $382.17 $382.17 $371.42 $371.42 $355.14 $355.14 $379.76 $379.76 $400.21 $400.21 $484.93 $484.93 $411.90$363.17 $363.17 $382.72 $382.72 $463.73 $463.73 $393.89 $393.89 $382.81 $382.81 $366.03 $366.03 $391.41 $391.41 $412.48 $412.48 $499.80 $499.80 $424.53$374.36 $374.36 $394.52 $394.52 $478.03 $478.03 $406.03 $406.03 $394.60 $394.60 $377.31 $377.31 $403.47 $403.47 $425.20 $425.20 $515.20 $515.20 $437.61$385.94 $385.94 $406.72 $406.72 $492.82 $492.82 $418.60 $418.60 $406.81 $406.81 $388.99 $388.99 $415.95 $415.95 $438.35 $438.35 $531.14 $531.14 $451.15$385.94 $385.94 $406.72 $406.72 $492.82 $492.82 $418.60 $418.60 $406.81 $406.81 $388.99 $388.99 $415.95 $415.95 $438.35 $438.35 $531.14 $531.14 $451.15$385.94 $385.94 $406.72 $406.72 $492.82 $492.82 $418.60 $418.60 $406.81 $406.81 $388.99 $388.99 $415.95 $415.95 $438.35 $438.35 $531.14 $531.14 $451.15$385.94 $385.94 $406.72 $406.72 $492.82 $492.82 $418.60 $418.60 $406.81 $406.81 $388.99 $388.99 $415.95 $415.95 $438.35 $438.35 $531.14 $531.14 $451.15$387.48 $387.48 $408.34 $408.34 $494.78 $494.78 $420.27 $420.27 $408.43 $408.43 $390.54 $390.54 $417.61 $417.61 $440.10 $440.10 $533.26 $533.26 $452.95$395.20 $395.20 $416.48 $416.48 $504.64 $504.64 $428.64 $428.64 $416.57 $416.57 $398.32 $398.32 $425.93 $425.93 $448.87 $448.87 $543.88 $543.88 $461.97$404.46 $404.46 $426.24 $426.24 $516.46 $516.46 $438.68 $438.68 $426.33 $426.33 $407.65 $407.65 $435.91 $435.91 $459.39 $459.39 $556.63 $556.63 $472.80$419.51 $419.51 $442.10 $442.10 $535.68 $535.68 $455.01 $455.01 $442.20 $442.20 $422.82 $422.82 $452.14 $452.14 $476.48 $476.48 $577.34 $577.34 $490.39$431.86 $431.86 $455.12 $455.12 $551.45 $551.45 $468.40 $468.40 $455.22 $455.22 $435.27 $435.27 $465.45 $465.45 $490.51 $490.51 $594.34 $594.34 $504.83$438.04 $438.04 $461.62 $461.62 $559.34 $559.34 $475.10 $475.10 $461.73 $461.73 $441.49 $441.49 $472.10 $472.10 $497.52 $497.52 $602.84 $602.84 $512.05$447.30 $447.30 $471.38 $471.38 $571.17 $571.17 $485.15 $485.15 $471.49 $471.49 $450.83 $450.83 $482.09 $482.09 $508.04 $508.04 $615.59 $615.59 $522.88$456.56 $456.56 $481.15 $481.15 $582.99 $582.99 $495.19 $495.19 $481.25 $481.25 $460.16 $460.16 $492.07 $492.07 $518.56 $518.56 $628.33 $628.33 $533.70$462.35 $462.35 $487.25 $487.25 $590.39 $590.39 $501.47 $501.47 $487.36 $487.36 $466.00 $466.00 $498.31 $498.31 $525.14 $525.14 $636.30 $636.30 $540.47$468.53 $468.53 $493.75 $493.75 $598.27 $598.27 $508.17 $508.17 $493.86 $493.86 $472.22 $472.22 $504.96 $504.96 $532.15 $532.15 $644.80 $644.80 $547.69$471.61 $471.61 $497.01 $497.01 $602.21 $602.21 $511.52 $511.52 $497.12 $497.12 $475.33 $475.33 $508.29 $508.29 $535.66 $535.66 $649.05 $649.05 $551.30$474.70 $474.70 $500.26 $500.26 $606.16 $606.16 $514.87 $514.87 $500.37 $500.37 $478.45 $478.45 $511.62 $511.62 $539.17 $539.17 $653.30 $653.30 $554.91$477.79 $477.79 $503.52 $503.52 $610.10 $610.10 $518.22 $518.22 $503.63 $503.63 $481.56 $481.56 $514.95 $514.95 $542.67 $542.67 $657.55 $657.55 $558.52$480.88 $480.88 $506.77 $506.77 $614.04 $614.04 $521.57 $521.57 $506.88 $506.88 $484.67 $484.67 $518.27 $518.27 $546.18 $546.18 $661.79 $661.79 $562.13$487.05 $487.05 $513.28 $513.28 $621.93 $621.93 $528.26 $528.26 $513.39 $513.39 $490.89 $490.89 $524.93 $524.93 $553.19 $553.19 $670.29 $670.29 $569.34$493.23 $493.23 $519.78 $519.78 $629.81 $629.81 $534.96 $534.96 $519.90 $519.90 $497.12 $497.12 $531.58 $531.58 $560.21 $560.21 $678.79 $678.79 $576.56$502.49 $502.49 $529.55 $529.55 $641.64 $641.64 $545.01 $545.01 $529.66 $529.66 $506.45 $506.45 $541.57 $541.57 $570.73 $570.73 $691.54 $691.54 $587.39$511.36 $511.36 $538.90 $538.90 $652.97 $652.97 $554.63 $554.63 $539.02 $539.02 $515.40 $515.40 $551.13 $551.13 $580.81 $580.81 $703.75 $703.75 $597.77$523.71 $523.71 $551.91 $551.91 $668.74 $668.74 $568.03 $568.03 $552.04 $552.04 $527.85 $527.85 $564.44 $564.44 $594.84 $594.84 $720.75 $720.75 $612.20$539.15 $539.15 $568.18 $568.18 $688.46 $688.46 $584.77 $584.77 $568.31 $568.31 $543.41 $543.41 $581.08 $581.08 $612.37 $612.37 $742.00 $742.00 $630.25$557.29 $557.29 $587.30 $587.30 $711.62 $711.62 $604.45 $604.45 $587.43 $587.43 $561.69 $561.69 $600.63 $600.63 $632.97 $632.97 $766.96 $766.96 $651.45$578.90 $578.90 $610.08 $610.08 $739.22 $739.22 $627.89 $627.89 $610.21 $610.21 $583.47 $583.47 $623.92 $623.92 $657.52 $657.52 $796.70 $796.70 $676.72$603.22 $603.22 $635.70 $635.70 $770.26 $770.26 $654.26 $654.26 $635.84 $635.84 $607.98 $607.98 $650.13 $650.13 $685.14 $685.14 $830.16 $830.16 $705.14$631.00 $631.00 $664.98 $664.98 $805.74 $805.74 $684.40 $684.40 $665.13 $665.13 $635.98 $635.98 $680.08 $680.08 $716.70 $716.70 $868.41 $868.41 $737.62$658.41 $658.41 $693.86 $693.86 $840.73 $840.73 $714.12 $714.12 $694.01 $694.01 $663.60 $663.60 $709.61 $709.61 $747.82 $747.82 $906.12 $906.12 $769.65$689.28 $689.28 $726.40 $726.40 $880.16 $880.16 $747.60 $747.60 $726.56 $726.56 $694.72 $694.72 $742.89 $742.89 $782.89 $782.89 $948.61 $948.61 $805.74$719.77 $719.77 $758.53 $758.53 $919.09 $919.09 $780.67 $780.67 $758.70 $758.70 $725.45 $725.45 $775.75 $775.75 $817.52 $817.52 $990.57 $990.57 $841.39$753.35 $753.35 $793.91 $793.91 $961.97 $961.97 $817.09 $817.09 $794.09 $794.09 $759.29 $759.29 $811.93 $811.93 $855.65 $855.65 $1,036.78 $1,036.78 $880.63$787.31 $787.31 $829.70 $829.70 $1,005.33 $1,005.33 $853.93 $853.93 $829.89 $829.89 $793.52 $793.52 $848.54 $848.54 $894.23 $894.23 $1,083.52 $1,083.52 $920.34$823.97 $823.97 $868.34 $868.34 $1,052.15 $1,052.15 $893.69 $893.69 $868.53 $868.53 $830.47 $830.47 $888.05 $888.05 $935.87 $935.87 $1,133.97 $1,133.97 $963.19$860.64 $860.64 $906.98 $906.98 $1,098.97 $1,098.97 $933.46 $933.46 $907.18 $907.18 $867.43 $867.43 $927.57 $927.57 $977.51 $977.51 $1,184.43 $1,184.43 $1,006.05$900.39 $900.39 $948.87 $948.87 $1,149.73 $1,149.73 $976.57 $976.57 $949.08 $949.08 $907.49 $907.49 $970.41 $970.41 $1,022.66 $1,022.66 $1,239.14 $1,239.14 $1,052.52$940.52 $940.52 $991.17 $991.17 $1,200.98 $1,200.98 $1,020.11 $1,020.11 $991.39 $991.39 $947.95 $947.95 $1,013.67 $1,013.67 $1,068.25 $1,068.25 $1,294.38 $1,294.38 $1,099.44$983.36 $983.36 $1,036.31 $1,036.31 $1,255.68 $1,255.68 $1,066.57 $1,066.57 $1,036.55 $1,036.55 $991.12 $991.12 $1,059.84 $1,059.84 $1,116.91 $1,116.91 $1,353.33 $1,353.33 $1,149.52

$1,004.59 $1,004.59 $1,058.68 $1,058.68 $1,282.78 $1,282.78 $1,089.59 $1,089.59 $1,058.92 $1,058.92 $1,012.52 $1,012.52 $1,082.72 $1,082.72 $1,141.02 $1,141.02 $1,382.54 $1,382.54 $1,174.33$1,047.43 $1,047.43 $1,103.83 $1,103.83 $1,337.49 $1,337.49 $1,136.06 $1,136.06 $1,104.08 $1,104.08 $1,055.69 $1,055.69 $1,128.89 $1,128.89 $1,189.67 $1,189.67 $1,441.50 $1,441.50 $1,224.41$1,084.48 $1,084.48 $1,142.87 $1,142.87 $1,384.80 $1,384.80 $1,176.24 $1,176.24 $1,143.13 $1,143.13 $1,093.04 $1,093.04 $1,168.82 $1,168.82 $1,231.75 $1,231.75 $1,492.49 $1,492.49 $1,267.72$1,108.79 $1,108.79 $1,168.50 $1,168.50 $1,415.84 $1,415.84 $1,202.61 $1,202.61 $1,168.76 $1,168.76 $1,117.54 $1,117.54 $1,195.02 $1,195.02 $1,259.37 $1,259.37 $1,525.95 $1,525.95 $1,296.14$1,139.28 $1,139.28 $1,200.63 $1,200.63 $1,454.78 $1,454.78 $1,235.68 $1,235.68 $1,200.90 $1,200.90 $1,148.27 $1,148.27 $1,227.88 $1,227.88 $1,294.00 $1,294.00 $1,567.91 $1,567.91 $1,331.78$1,157.81 $1,157.81 $1,220.15 $1,220.15 $1,478.43 $1,478.43 $1,255.77 $1,255.77 $1,220.42 $1,220.42 $1,166.94 $1,166.94 $1,247.85 $1,247.85 $1,315.04 $1,315.04 $1,593.41 $1,593.41 $1,353.43

GoCombine

0$20 / $40 Aft

$7,0Y


PPO 20/M-152-122-

Rating

Geisinger Al



$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 7




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 6




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 5




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 3




$7,000Yes


PPO 20/40/1500M-152-122-F Rev. 1/20

Rating Area 2


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 9


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 7


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 6


GoldMed: $4,500 / Rx: $0

0%$25 / $50$7,350

Yes


25/50/4500 1x dedM-152-121-F Rev. 1/20

Rating Area 5


Page Number: 74 12/24/2014

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64+

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$345.13 $375.52 $375.52 $315.73 $315.73 $302.59 $302.59 $273.95 $273.95 $333.23 $333.23 $375.52 $375.52 $280.18 $280.18 $315.73 $315.73 $268.51 $268.51$375.80 $408.90 $408.90 $343.80 $343.80 $329.49 $329.49 $298.30 $298.30 $362.85 $362.85 $408.90 $408.90 $305.08 $305.08 $343.80 $343.80 $292.38 $292.38$387.53 $421.66 $421.66 $354.53 $354.53 $339.77 $339.77 $307.61 $307.61 $374.17 $374.17 $421.66 $421.66 $314.60 $314.60 $354.53 $354.53 $301.51 $301.51$399.26 $434.42 $434.42 $365.26 $365.26 $350.05 $350.05 $316.92 $316.92 $385.50 $385.50 $434.42 $434.42 $324.13 $324.13 $365.26 $365.26 $310.63 $310.63$411.90 $448.17 $448.17 $376.82 $376.82 $361.13 $361.13 $326.95 $326.95 $397.69 $397.69 $448.17 $448.17 $334.38 $334.38 $376.82 $376.82 $320.46 $320.46$424.53 $461.91 $461.91 $388.37 $388.37 $372.20 $372.20 $336.98 $336.98 $409.89 $409.89 $461.91 $461.91 $344.64 $344.64 $388.37 $388.37 $330.29 $330.29$437.61 $476.14 $476.14 $400.34 $400.34 $383.67 $383.67 $347.36 $347.36 $422.52 $422.52 $476.14 $476.14 $355.26 $355.26 $400.34 $400.34 $340.47 $340.47$451.15 $490.88 $490.88 $412.73 $412.73 $395.55 $395.55 $358.11 $358.11 $435.60 $435.60 $490.88 $490.88 $366.25 $366.25 $412.73 $412.73 $351.00 $351.00$451.15 $490.88 $490.88 $412.73 $412.73 $395.55 $395.55 $358.11 $358.11 $435.60 $435.60 $490.88 $490.88 $366.25 $366.25 $412.73 $412.73 $351.00 $351.00$451.15 $490.88 $490.88 $412.73 $412.73 $395.55 $395.55 $358.11 $358.11 $435.60 $435.60 $490.88 $490.88 $366.25 $366.25 $412.73 $412.73 $351.00 $351.00$451.15 $490.88 $490.88 $412.73 $412.73 $395.55 $395.55 $358.11 $358.11 $435.60 $435.60 $490.88 $490.88 $366.25 $366.25 $412.73 $412.73 $351.00 $351.00$452.95 $492.83 $492.83 $414.38 $414.38 $397.12 $397.12 $359.54 $359.54 $437.33 $437.33 $492.83 $492.83 $367.71 $367.71 $414.38 $414.38 $352.40 $352.40$461.97 $502.65 $502.65 $422.63 $422.63 $405.03 $405.03 $366.70 $366.70 $446.04 $446.04 $502.65 $502.65 $375.03 $375.03 $422.63 $422.63 $359.42 $359.42$472.80 $514.43 $514.43 $432.54 $432.54 $414.53 $414.53 $375.29 $375.29 $456.50 $456.50 $514.43 $514.43 $383.82 $383.82 $432.54 $432.54 $367.84 $367.84$490.39 $533.58 $533.58 $448.63 $448.63 $429.95 $429.95 $389.26 $389.26 $473.49 $473.49 $533.58 $533.58 $398.11 $398.11 $448.63 $448.63 $381.53 $381.53$504.83 $549.28 $549.28 $461.84 $461.84 $442.61 $442.61 $400.72 $400.72 $487.43 $487.43 $549.28 $549.28 $409.83 $409.83 $461.84 $461.84 $392.76 $392.76$512.05 $557.14 $557.14 $468.44 $468.44 $448.94 $448.94 $406.45 $406.45 $494.39 $494.39 $557.14 $557.14 $415.69 $415.69 $468.44 $468.44 $398.38 $398.38$522.88 $568.92 $568.92 $478.35 $478.35 $458.43 $458.43 $415.04 $415.04 $504.85 $504.85 $568.92 $568.92 $424.48 $424.48 $478.35 $478.35 $406.80 $406.80$533.70 $580.70 $580.70 $488.25 $488.25 $467.92 $467.92 $423.64 $423.64 $515.30 $515.30 $580.70 $580.70 $433.27 $433.27 $488.25 $488.25 $415.23 $415.23$540.47 $588.06 $588.06 $494.44 $494.44 $473.86 $473.86 $429.01 $429.01 $521.84 $521.84 $588.06 $588.06 $438.76 $438.76 $494.44 $494.44 $420.49 $420.49$547.69 $595.92 $595.92 $501.05 $501.05 $480.19 $480.19 $434.74 $434.74 $528.81 $528.81 $595.92 $595.92 $444.62 $444.62 $501.05 $501.05 $426.11 $426.11$551.30 $599.84 $599.84 $504.35 $504.35 $483.35 $483.35 $437.60 $437.60 $532.29 $532.29 $599.84 $599.84 $447.55 $447.55 $504.35 $504.35 $428.92 $428.92$554.91 $603.77 $603.77 $507.65 $507.65 $486.51 $486.51 $440.47 $440.47 $535.78 $535.78 $603.77 $603.77 $450.48 $450.48 $507.65 $507.65 $431.72 $431.72$558.52 $607.70 $607.70 $510.95 $510.95 $489.68 $489.68 $443.33 $443.33 $539.26 $539.26 $607.70 $607.70 $453.41 $453.41 $510.95 $510.95 $434.53 $434.53$562.13 $611.63 $611.63 $514.26 $514.26 $492.84 $492.84 $446.20 $446.20 $542.75 $542.75 $611.63 $611.63 $456.34 $456.34 $514.26 $514.26 $437.34 $437.34$569.34 $619.48 $619.48 $520.86 $520.86 $499.17 $499.17 $451.93 $451.93 $549.71 $549.71 $619.48 $619.48 $462.20 $462.20 $520.86 $520.86 $442.96 $442.96$576.56 $627.33 $627.33 $527.46 $527.46 $505.50 $505.50 $457.66 $457.66 $556.68 $556.68 $627.33 $627.33 $468.06 $468.06 $527.46 $527.46 $448.57 $448.57$587.39 $639.11 $639.11 $537.37 $537.37 $514.99 $514.99 $466.25 $466.25 $567.14 $567.14 $639.11 $639.11 $476.85 $476.85 $537.37 $537.37 $457.00 $457.00$597.77 $650.40 $650.40 $546.86 $546.86 $524.09 $524.09 $474.49 $474.49 $577.16 $577.16 $650.40 $650.40 $485.27 $485.27 $546.86 $546.86 $465.07 $465.07$612.20 $666.11 $666.11 $560.07 $560.07 $536.75 $536.75 $485.95 $485.95 $591.10 $591.10 $666.11 $666.11 $496.99 $496.99 $560.07 $560.07 $476.30 $476.30$630.25 $685.75 $685.75 $576.58 $576.58 $552.57 $552.57 $500.27 $500.27 $608.52 $608.52 $685.75 $685.75 $511.64 $511.64 $576.58 $576.58 $490.34 $490.34$651.45 $708.82 $708.82 $595.97 $595.97 $571.16 $571.16 $517.10 $517.10 $628.99 $628.99 $708.82 $708.82 $528.86 $528.86 $595.97 $595.97 $506.84 $506.84$676.72 $736.31 $736.31 $619.09 $619.09 $593.31 $593.31 $537.16 $537.16 $653.39 $653.39 $736.31 $736.31 $549.37 $549.37 $619.09 $619.09 $526.49 $526.49$705.14 $767.23 $767.23 $645.09 $645.09 $618.23 $618.23 $559.72 $559.72 $680.83 $680.83 $767.23 $767.23 $572.44 $572.44 $645.09 $645.09 $548.61 $548.61$737.62 $802.57 $802.57 $674.81 $674.81 $646.71 $646.71 $585.50 $585.50 $712.19 $712.19 $802.57 $802.57 $598.81 $598.81 $674.81 $674.81 $573.88 $573.88$769.65 $837.43 $837.43 $704.11 $704.11 $674.79 $674.79 $610.93 $610.93 $743.12 $743.12 $837.43 $837.43 $624.81 $624.81 $704.11 $704.11 $598.80 $598.80$805.74 $876.70 $876.70 $737.13 $737.13 $706.44 $706.44 $639.58 $639.58 $777.96 $777.96 $876.70 $876.70 $654.11 $654.11 $737.13 $737.13 $626.88 $626.88$841.39 $915.47 $915.47 $769.73 $769.73 $737.68 $737.68 $667.87 $667.87 $812.38 $812.38 $915.47 $915.47 $683.05 $683.05 $769.73 $769.73 $654.61 $654.61$880.63 $958.18 $958.18 $805.64 $805.64 $772.10 $772.10 $699.02 $699.02 $850.27 $850.27 $958.18 $958.18 $714.91 $714.91 $805.64 $805.64 $685.14 $685.14$920.34 $1,001.38 $1,001.38 $841.96 $841.96 $806.90 $806.90 $730.53 $730.53 $888.60 $888.60 $1,001.38 $1,001.38 $747.14 $747.14 $841.96 $841.96 $716.03 $716.03$963.19 $1,048.01 $1,048.01 $881.17 $881.17 $844.48 $844.48 $764.55 $764.55 $929.99 $929.99 $1,048.01 $1,048.01 $781.93 $781.93 $881.17 $881.17 $749.38 $749.38

$1,006.05 $1,094.64 $1,094.64 $920.38 $920.38 $882.06 $882.06 $798.57 $798.57 $971.37 $971.37 $1,094.64 $1,094.64 $816.73 $816.73 $920.38 $920.38 $782.72 $782.72$1,052.52 $1,145.20 $1,145.20 $962.89 $962.89 $922.80 $922.80 $835.46 $835.46 $1,016.23 $1,016.23 $1,145.20 $1,145.20 $854.45 $854.45 $962.89 $962.89 $818.87 $818.87$1,099.44 $1,196.25 $1,196.25 $1,005.81 $1,005.81 $963.93 $963.93 $872.70 $872.70 $1,061.53 $1,061.53 $1,196.25 $1,196.25 $892.54 $892.54 $1,005.81 $1,005.81 $855.38 $855.38$1,149.52 $1,250.74 $1,250.74 $1,051.62 $1,051.62 $1,007.84 $1,007.84 $912.45 $912.45 $1,109.88 $1,109.88 $1,250.74 $1,250.74 $933.19 $933.19 $1,051.62 $1,051.62 $894.34 $894.34$1,174.33 $1,277.74 $1,277.74 $1,074.32 $1,074.32 $1,029.59 $1,029.59 $932.15 $932.15 $1,133.84 $1,133.84 $1,277.74 $1,277.74 $953.34 $953.34 $1,074.32 $1,074.32 $913.64 $913.64$1,224.41 $1,332.22 $1,332.22 $1,120.14 $1,120.14 $1,073.50 $1,073.50 $971.90 $971.90 $1,182.19 $1,182.19 $1,332.22 $1,332.22 $993.99 $993.99 $1,120.14 $1,120.14 $952.60 $952.60$1,267.72 $1,379.35 $1,379.35 $1,159.76 $1,159.76 $1,111.47 $1,111.47 $1,006.28 $1,006.28 $1,224.01 $1,224.01 $1,379.35 $1,379.35 $1,029.15 $1,029.15 $1,159.76 $1,159.76 $986.30 $986.30$1,296.14 $1,410.27 $1,410.27 $1,185.76 $1,185.76 $1,136.39 $1,136.39 $1,028.84 $1,028.84 $1,251.45 $1,251.45 $1,410.27 $1,410.27 $1,052.22 $1,052.22 $1,185.76 $1,185.76 $1,008.41 $1,008.41$1,331.78 $1,449.05 $1,449.05 $1,218.36 $1,218.36 $1,167.64 $1,167.64 $1,057.13 $1,057.13 $1,285.86 $1,285.86 $1,449.05 $1,449.05 $1,081.15 $1,081.15 $1,218.36 $1,218.36 $1,036.14 $1,036.14$1,353.43 $1,472.61 $1,472.61 $1,238.17 $1,238.17 $1,186.62 $1,186.62 $1,074.31 $1,074.31 $1,306.77 $1,306.77 $1,472.61 $1,472.61 $1,098.73 $1,098.73 $1,238.17 $1,238.17 $1,052.99 $1,052.99

GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 3



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 6



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 3


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 6


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 6



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 6




l-Access PPO

Page Number: 75 12/24/2014

RATE PAGES





Rating Area =>

Network =>Metal =>




0 - 1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263

64+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$302.59 $302.59 $243.10 $243.10 $273.95 $273.95 $333.23 $333.23 $280.18 $280.18 $268.51 $268.51 $243.10 $243.10$329.49 $329.49 $264.71 $264.71 $298.30 $298.30 $362.85 $362.85 $305.08 $305.08 $292.38 $292.38 $264.71 $264.71$339.77 $339.77 $272.97 $272.97 $307.61 $307.61 $374.17 $374.17 $314.60 $314.60 $301.51 $301.51 $272.97 $272.97$350.05 $350.05 $281.23 $281.23 $316.92 $316.92 $385.50 $385.50 $324.13 $324.13 $310.63 $310.63 $281.23 $281.23$361.13 $361.13 $290.13 $290.13 $326.95 $326.95 $397.69 $397.69 $334.38 $334.38 $320.46 $320.46 $290.13 $290.13$372.20 $372.20 $299.03 $299.03 $336.98 $336.98 $409.89 $409.89 $344.64 $344.64 $330.29 $330.29 $299.03 $299.03$383.67 $383.67 $308.24 $308.24 $347.36 $347.36 $422.52 $422.52 $355.26 $355.26 $340.47 $340.47 $308.24 $308.24$395.55 $395.55 $317.78 $317.78 $358.11 $358.11 $435.60 $435.60 $366.25 $366.25 $351.00 $351.00 $317.78 $317.78$395.55 $395.55 $317.78 $317.78 $358.11 $358.11 $435.60 $435.60 $366.25 $366.25 $351.00 $351.00 $317.78 $317.78$395.55 $395.55 $317.78 $317.78 $358.11 $358.11 $435.60 $435.60 $366.25 $366.25 $351.00 $351.00 $317.78 $317.78$395.55 $395.55 $317.78 $317.78 $358.11 $358.11 $435.60 $435.60 $366.25 $366.25 $351.00 $351.00 $317.78 $317.78$397.12 $397.12 $319.05 $319.05 $359.54 $359.54 $437.33 $437.33 $367.71 $367.71 $352.40 $352.40 $319.05 $319.05$405.03 $405.03 $325.40 $325.40 $366.70 $366.70 $446.04 $446.04 $375.03 $375.03 $359.42 $359.42 $325.40 $325.40$414.53 $414.53 $333.03 $333.03 $375.29 $375.29 $456.50 $456.50 $383.82 $383.82 $367.84 $367.84 $333.03 $333.03$429.95 $429.95 $345.42 $345.42 $389.26 $389.26 $473.49 $473.49 $398.11 $398.11 $381.53 $381.53 $345.42 $345.42$442.61 $442.61 $355.59 $355.59 $400.72 $400.72 $487.43 $487.43 $409.83 $409.83 $392.76 $392.76 $355.59 $355.59$448.94 $448.94 $360.68 $360.68 $406.45 $406.45 $494.39 $494.39 $415.69 $415.69 $398.38 $398.38 $360.68 $360.68$458.43 $458.43 $368.30 $368.30 $415.04 $415.04 $504.85 $504.85 $424.48 $424.48 $406.80 $406.80 $368.30 $368.30$467.92 $467.92 $375.93 $375.93 $423.64 $423.64 $515.30 $515.30 $433.27 $433.27 $415.23 $415.23 $375.93 $375.93$473.86 $473.86 $380.70 $380.70 $429.01 $429.01 $521.84 $521.84 $438.76 $438.76 $420.49 $420.49 $380.70 $380.70$480.19 $480.19 $385.78 $385.78 $434.74 $434.74 $528.81 $528.81 $444.62 $444.62 $426.11 $426.11 $385.78 $385.78$483.35 $483.35 $388.32 $388.32 $437.60 $437.60 $532.29 $532.29 $447.55 $447.55 $428.92 $428.92 $388.32 $388.32$486.51 $486.51 $390.86 $390.86 $440.47 $440.47 $535.78 $535.78 $450.48 $450.48 $431.72 $431.72 $390.86 $390.86$489.68 $489.68 $393.41 $393.41 $443.33 $443.33 $539.26 $539.26 $453.41 $453.41 $434.53 $434.53 $393.41 $393.41$492.84 $492.84 $395.95 $395.95 $446.20 $446.20 $542.75 $542.75 $456.34 $456.34 $437.34 $437.34 $395.95 $395.95$499.17 $499.17 $401.03 $401.03 $451.93 $451.93 $549.71 $549.71 $462.20 $462.20 $442.96 $442.96 $401.03 $401.03$505.50 $505.50 $406.12 $406.12 $457.66 $457.66 $556.68 $556.68 $468.06 $468.06 $448.57 $448.57 $406.12 $406.12$514.99 $514.99 $413.74 $413.74 $466.25 $466.25 $567.14 $567.14 $476.85 $476.85 $457.00 $457.00 $413.74 $413.74$524.09 $524.09 $421.05 $421.05 $474.49 $474.49 $577.16 $577.16 $485.27 $485.27 $465.07 $465.07 $421.05 $421.05$536.75 $536.75 $431.22 $431.22 $485.95 $485.95 $591.10 $591.10 $496.99 $496.99 $476.30 $476.30 $431.22 $431.22$552.57 $552.57 $443.93 $443.93 $500.27 $500.27 $608.52 $608.52 $511.64 $511.64 $490.34 $490.34 $443.93 $443.93$571.16 $571.16 $458.87 $458.87 $517.10 $517.10 $628.99 $628.99 $528.86 $528.86 $506.84 $506.84 $458.87 $458.87$593.31 $593.31 $476.66 $476.66 $537.16 $537.16 $653.39 $653.39 $549.37 $549.37 $526.49 $526.49 $476.66 $476.66$618.23 $618.23 $496.68 $496.68 $559.72 $559.72 $680.83 $680.83 $572.44 $572.44 $548.61 $548.61 $496.68 $496.68$646.71 $646.71 $519.56 $519.56 $585.50 $585.50 $712.19 $712.19 $598.81 $598.81 $573.88 $573.88 $519.56 $519.56$674.79 $674.79 $542.13 $542.13 $610.93 $610.93 $743.12 $743.12 $624.81 $624.81 $598.80 $598.80 $542.13 $542.13$706.44 $706.44 $567.55 $567.55 $639.58 $639.58 $777.96 $777.96 $654.11 $654.11 $626.88 $626.88 $567.55 $567.55$737.68 $737.68 $592.65 $592.65 $667.87 $667.87 $812.38 $812.38 $683.05 $683.05 $654.61 $654.61 $592.65 $592.65$772.10 $772.10 $620.30 $620.30 $699.02 $699.02 $850.27 $850.27 $714.91 $714.91 $685.14 $685.14 $620.30 $620.30$806.90 $806.90 $648.26 $648.26 $730.53 $730.53 $888.60 $888.60 $747.14 $747.14 $716.03 $716.03 $648.26 $648.26$844.48 $844.48 $678.45 $678.45 $764.55 $764.55 $929.99 $929.99 $781.93 $781.93 $749.38 $749.38 $678.45 $678.45$882.06 $882.06 $708.64 $708.64 $798.57 $798.57 $971.37 $971.37 $816.73 $816.73 $782.72 $782.72 $708.64 $708.64$922.80 $922.80 $741.37 $741.37 $835.46 $835.46 $1,016.23 $1,016.23 $854.45 $854.45 $818.87 $818.87 $741.37 $741.37$963.93 $963.93 $774.42 $774.42 $872.70 $872.70 $1,061.53 $1,061.53 $892.54 $892.54 $855.38 $855.38 $774.42 $774.42

$1,007.84 $1,007.84 $809.69 $809.69 $912.45 $912.45 $1,109.88 $1,109.88 $933.19 $933.19 $894.34 $894.34 $809.69 $809.69$1,029.59 $1,029.59 $827.17 $827.17 $932.15 $932.15 $1,133.84 $1,133.84 $953.34 $953.34 $913.64 $913.64 $827.17 $827.17$1,073.50 $1,073.50 $862.44 $862.44 $971.90 $971.90 $1,182.19 $1,182.19 $993.99 $993.99 $952.60 $952.60 $862.44 $862.44$1,111.47 $1,111.47 $892.95 $892.95 $1,006.28 $1,006.28 $1,224.01 $1,224.01 $1,029.15 $1,029.15 $986.30 $986.30 $892.95 $892.95$1,136.39 $1,136.39 $912.97 $912.97 $1,028.84 $1,028.84 $1,251.45 $1,251.45 $1,052.22 $1,052.22 $1,008.41 $1,008.41 $912.97 $912.97$1,167.64 $1,167.64 $938.08 $938.08 $1,057.13 $1,057.13 $1,285.86 $1,285.86 $1,081.15 $1,081.15 $1,036.14 $1,036.14 $938.08 $938.08$1,186.62 $1,186.62 $953.33 $953.33 $1,074.31 $1,074.31 $1,306.77 $1,306.77 $1,098.73 $1,098.73 $1,052.99 $1,052.99 $953.33 $953.33

SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $1,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/1000M-152-367-F Dev. 1/20

Rating Area 3



0%$10 / $20$2,000

Yes


10/20/0M-152-367-F Dev. 1/20

Rating Area 3


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 6


SilverMed: $4,000 / Rx: $500

0%$20 / $40$7,900

Yes


20/40/4000M-152-367-F Dev. 1/20

Rating Area 3


GoldMed: $2,000 / Rx: $0

0%$20 / $40$7,350

Yes


20/40/2000M-152-367-F Dev. 1/20

Rating Area 6


Page Number: 76 12/24/2014

HIOS Plan ID Plan Marketing Name Product MetalOn/Off

Exchange Network Rating Area Counties Covered

75729PA0050062 Geisinger All-Access QHDHP PPO 6500 PPO Bronze Off Geisinger All-Access PPO

Rating Area 2, Rating Area 3, Rating Area 5, Rating Area 6, Rating Area 7, Rating Area 9

Cameron, Elk, Potter, Bradford, Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Pike, Sullivan, Susquehanna, Tioga, Wayne, Wyoming, Blair, Cambria, Clearfield, Huntingdon, Jefferson, Somerset, Centre, Columbia, Lehigh, Mifflin, Montour, Northampton, Northumberland, Schuylkill, Snyder, Union, Adams, Berks, Lancaster, York, Cumberland, Dauphin, Fulton, Juniata, Lebanon, Perry

75729PA0050068 Geisinger Extra PPO 10/60/500 PPO Gold Off Geisinger All-Access PPO

Rating Area 3, Rating Area 6, Rating Area 9

Carbon, Clinton, Lackawanna, Luzerne, Lycoming, Monroe, Susquehanna, Wayne, Wyoming, Centre, Columbia, Lehigh, Mifflin, Montour, Northampton, Northumberland, Schuylkill, Snyder, Union, Cumberland, Dauphin, Juniata, Perry

75729PA0050070 Geisinger All-Access PPO 20/40/1000 PPO Gold Off Geisinger All-Access PPO






75729PA0050073 Geisinger All-Access PPO 30/60/6000 PPO Silver Off Geisinger All-Access PPO






75729PA0050078 Geisinger All-Access QHDHP PPO 2100 PPO Gold Off Geisinger All-Access PPO



75729PA0050079 Geisinger All-Access QHDHP PPO 4100 PPO Silver Off Geisinger All-Access PPO




Plan Design Summary

8/5/2019\\geisinger.edu\dfs\0004\0259\259018\Actuarial Services\ACA Rate Filing and QHP application\2020 QHP Application\Public PDF files\GQO SmGrp 20190719\6_Rate2020_SmGrp_GQO_PDSRateTable_071919




Plan Design Summary

75729PA0050080 Geisinger All-Access PPO 15/30/250 PPO Platinum Off Geisinger All-Access PPO



75729PA0050082 Geisinger Extra PPO 10/40/250 PPO Platinum Off Geisinger All-Access PPO

























Plan Design Summary




75729PA0050107 Geisinger All-Access PPO 40/90/7200 PPO Bronze Off Geisinger All-Access PPO



75729PA0050108 Geisinger Extra PPO 20/60/4300 PPO Silver Off Geisinger All-Access PPO



75729PA0050127 Geisinger All-Access PPO 25/50/2000 1xded PPO Gold Off Geisinger All-Access PPO












75729PA0050131 Geisinger Extra PPO 10/40/0 PPO Platinum Off Geisinger All-Access PPO







Plan Design Summary







75729PA0050134 Geisinger Extra PPO 20/60/6250 PPO Silver Off Geisinger All-Access PPO



75729PA0050135 Geisinger All-Access QHDHP PPO 1500 PPO Platinum Off Geisinger All-Access PPO






75729PA0050137 Geisinger All-Access PPO 25/50/4500 1x ded PPO Gold Off Geisinger All-Access PPO



75729PA0050138 Geisinger All-Access QHDHP PPO 20/40/1500 PPO Gold Off Geisinger All-Access PPO



75729PA0050140 Geisinger Choices PPO 10/20/0 PPO Platinum Off Geisinger Choices PPO Rating Area 6Centre, Columbia, Mifflin, Montour, Northumberland, Snyder, Union

75729PA0050141 Geisinger Choices PPO 20/40/1000 PPO Gold Off Geisinger Choices PPO Rating Area 6Centre, Columbia, Mifflin, Montour, Northumberland, Snyder, Union

75729PA0050142 Geisinger Choices PPO 20/40/2000 PPO Gold Off Geisinger Choices PPO Rating Area 6Centre, Columbia, Mifflin, Montour, Northumberland, Snyder, Union

75729PA0050143 Geisinger Choices PPO 20/40/4000 PPO Silver Off Geisinger Choices PPO Rating Area 6Centre, Columbia, Mifflin, Montour, Northumberland, Snyder, Union

75729PA0050144 Geisinger Choices PPO 10/20/0 PPO Platinum Off Geisinger Choices PPORating Area 3, Rating Area 6 Carbon, Monroe, Lehigh, Northampton, Schuylkill

75729PA0050145 Geisinger Choices PPO 20/40/1000 PPO Gold Off Geisinger Choices PPORating Area 3, Rating Area 6 Carbon, Monroe, Lehigh, Northampton, Schuylkill

75729PA0050146 Geisinger Choices PPO 20/40/2000 PPO Gold Off Geisinger Choices PPORating Area 3, Rating Area 6 Carbon, Monroe, Lehigh, Northampton, Schuylkill

75729PA0050147 Geisinger Choices PPO 20/40/4000 PPO Silver Off Geisinger Choices PPORating Area 3, Rating Area 6 Carbon, Monroe, Lehigh, Northampton, Schuylkill

75729PA0050148 Geisinger Choices PPO 10/20/0 PPO Platinum Off Geisinger Choices PPO Rating Area 3 Lackawanna, Luzerne, Wayne75729PA0050149 Geisinger Choices PPO 20/40/1000 PPO Gold Off Geisinger Choices PPO Rating Area 3 Lackawanna, Luzerne, Wayne75729PA0050150 Geisinger Choices PPO 20/40/2000 PPO Gold Off Geisinger Choices PPO Rating Area 3 Lackawanna, Luzerne, Wayne





Plan Design Summary

75729PA0050151 Geisinger Choices PPO 20/40/4000 PPO Silver Off Geisinger Choices PPO Rating Area 3 Lackawanna, Luzerne, Wayne


Company Name Geisinger Quality OptionsMarket Small GroupRATES FOR AGE 21, NON-TOBACCO USER, BY RATING AREA AND COUNTY

RATING AREA 1 RATING AREA 2 RATING AREA 30 0 0 0 0 0 0 0 0 0 0 4 219 284


Exchange Crawford Clarion Erie Forest Mckean Mercer Venango Warren Elk Cameron Potter Bradford Carbon Clinton75729PA0050062 Geisinger All-Access QHDHP PPO 6500 PPO Bronze Off $282.15 $282.15 $282.15 $269.79 $269.79 $269.7975729PA0050068 Geisinger Extra PPO 10/60/500 PPO Gold Off $361.73 $361.7375729PA0050070 Geisinger All-Access PPO 20/40/1000 PPO Gold Off $381.51 $381.51 $381.51 $364.80 $364.80 $364.8075729PA0050071 Geisinger All-Access PPO 25/50/2750 PPO Gold Off $361.69 $361.69 $361.69 $345.84 $345.84 $345.8475729PA0050073 Geisinger All-Access PPO 30/60/6000 PPO Silver Off $315.96 $315.96 $315.96 $302.11 $302.11 $302.1175729PA0050075 Geisinger All-Access PPO 25/50/6750 PPO Silver Off $313.34 $313.34 $313.34 $299.61 $299.61 $299.6175729PA0050078 Geisinger All-Access QHDHP PPO 2100 PPO Gold Off $379.39 $379.39 $379.39 $362.76 $362.76 $362.7675729PA0050079 Geisinger All-Access QHDHP PPO 4100 PPO Silver Off $330.14 $330.14 $330.14 $315.68 $315.68 $315.6875729PA0050080 Geisinger All-Access PPO 15/30/250 PPO Platinum Off $433.05 $433.05 $433.05 $414.08 $414.08 $414.0875729PA0050082 Geisinger Extra PPO 10/40/250 PPO Platinum Off $408.02 $408.0275729PA0050096 Geisinger All-Access PPO 30/60/3500 PPO Gold Off $352.89 $352.89 $352.89 $337.43 $337.43 $337.4375729PA0050097 Geisinger Extra PPO 20/60/3500 PPO Gold Off $325.93 $325.9375729PA0050102 Geisinger All-Access PPO 20/40/500 PPO Gold Off $393.94 $393.94 $393.94 $376.67 $376.67 $376.6775729PA0050103 Geisinger All-Access PPO 20/40/1500 PPO Gold Off $374.09 $374.09 $374.09 $357.69 $357.69 $357.6975729PA0050104 Geisinger All-Access PPO 25/50/2000 PPO Gold Off $366.81 $366.81 $366.81 $350.74 $350.74 $350.7475729PA0050105 Geisinger All-Access PPO 35/70/4300 PPO Silver Off $328.44 $328.44 $328.44 $314.05 $314.05 $314.0575729PA0050106 Geisinger All-Access PPO 35/70/5000 PPO Silver Off $325.69 $325.69 $325.69 $311.42 $311.42 $311.4275729PA0050107 Geisinger All-Access PPO 40/90/7200 PPO Bronze Off $286.09 $286.09 $286.09 $273.55 $273.55 $273.5575729PA0050108 Geisinger Extra PPO 20/60/4300 PPO Silver Off $303.86 $303.8675729PA0050127 Geisinger All-Access PPO 25/50/2000 1xded PPO Gold Off $373.26 $373.26 $373.26 $356.90 $356.90 $356.9075729PA0050128 Geisinger All-Access PPO 10/20/0 PPO Platinum Off $450.84 $450.84 $450.84 $431.08 $431.08 $431.0875729PA0050129 Geisinger All-Access PPO 15/30/0 PPO Platinum Off $449.56 $449.56 $449.56 $429.86 $429.86 $429.8675729PA0050130 Geisinger All-Access PPO 25/50/500 PPO Gold Off $373.48 $373.48 $373.48 $357.11 $357.11 $357.1175729PA0050131 Geisinger Extra PPO 10/40/0 PPO Platinum Off $418.77 $418.7775729PA0050132 Geisinger Extra PPO 10/60/1000 PPO Gold Off $353.22 $353.2275729PA0050133 Geisinger Extra PPO 10/60/2000 PPO Gold Off $339.39 $339.3975729PA0050134 Geisinger Extra PPO 20/60/6250 PPO Silver Off $299.01 $299.0175729PA0050135 Geisinger All-Access QHDHP PPO 1500 PPO Platinum Off $418.69 $418.69 $418.69 $400.35 $400.35 $400.3575729PA0050136 Geisinger All-Access PPO 15/30/1500 PPO Platinum Off $412.73 $412.73 $412.73 $394.64 $394.64 $394.6475729PA0050137 Geisinger All-Access PPO 25/50/4500 1x ded PPO Gold Off $356.66 $356.66 $356.66 $341.03 $341.03 $341.0375729PA0050138 Geisinger All-Access QHDHP PPO 20/40/1500 PPO Gold Off $384.39 $384.39 $384.39 $367.55 $367.55 $367.5575729PA0050140 Geisinger Choices PPO 10/20/0 PPO Platinum Off75729PA0050141 Geisinger Choices PPO 20/40/1000 PPO Gold Off75729PA0050142 Geisinger Choices PPO 20/40/2000 PPO Gold Off75729PA0050143 Geisinger Choices PPO 20/40/4000 PPO Silver Off75729PA0050144 Geisinger Choices PPO 10/20/0 PPO Platinum Off $411.5975729PA0050145 Geisinger Choices PPO 20/40/1000 PPO Gold Off $346.0775729PA0050146 Geisinger Choices PPO 20/40/2000 PPO Gold Off $331.6675729PA0050147 Geisinger Choices PPO 20/40/4000 PPO Silver Off $300.2775729PA0050148 Geisinger Choices PPO 10/20/0 PPO Platinum Off75729PA0050149 Geisinger Choices PPO 20/40/1000 PPO Gold Off75729PA0050150 Geisinger Choices PPO 20/40/2000 PPO Gold Off75729PA0050151 Geisinger Choices PPO 20/40/4000 PPO Silver Off

02-01-2019 Number of Covered Lives by Rating County

\\geisinger.edu\dfs\0004\0259\259018\Actuarial Services\ACA Rate Filing and QHP application\2020 QHP Application\Public PDF files\GQO SmGrp 20190719\6_Rate2020_SmGrp_GQO_PDSRateTable_071919

Company Name Geisinger Quality OptionsMarket Small GroupRATES FOR AGE 21, NON-TOBACCO USER, BY RATING AREA AND C

HIOS Plan ID Plan Marketing Name75729PA0050062 Geisinger All-Access QHDHP PPO 650075729PA0050068 Geisinger Extra PPO 10/60/50075729PA0050070 Geisinger All-Access PPO 20/40/100075729PA0050071 Geisinger All-Access PPO 25/50/275075729PA0050073 Geisinger All-Access PPO 30/60/600075729PA0050075 Geisinger All-Access PPO 25/50/675075729PA0050078 Geisinger All-Access QHDHP PPO 210075729PA0050079 Geisinger All-Access QHDHP PPO 410075729PA0050080 Geisinger All-Access PPO 15/30/25075729PA0050082 Geisinger Extra PPO 10/40/25075729PA0050096 Geisinger All-Access PPO 30/60/350075729PA0050097 Geisinger Extra PPO 20/60/350075729PA0050102 Geisinger All-Access PPO 20/40/50075729PA0050103 Geisinger All-Access PPO 20/40/150075729PA0050104 Geisinger All-Access PPO 25/50/200075729PA0050105 Geisinger All-Access PPO 35/70/430075729PA0050106 Geisinger All-Access PPO 35/70/500075729PA0050107 Geisinger All-Access PPO 40/90/720075729PA0050108 Geisinger Extra PPO 20/60/430075729PA0050127 Geisinger All-Access PPO 25/50/2000 1xded75729PA0050128 Geisinger All-Access PPO 10/20/075729PA0050129 Geisinger All-Access PPO 15/30/075729PA0050130 Geisinger All-Access PPO 25/50/50075729PA0050131 Geisinger Extra PPO 10/40/075729PA0050132 Geisinger Extra PPO 10/60/100075729PA0050133 Geisinger Extra PPO 10/60/200075729PA0050134 Geisinger Extra PPO 20/60/625075729PA0050135 Geisinger All-Access QHDHP PPO 150075729PA0050136 Geisinger All-Access PPO 15/30/150075729PA0050137 Geisinger All-Access PPO 25/50/4500 1x ded75729PA0050138 Geisinger All-Access QHDHP PPO 20/40/150075729PA0050140 Geisinger Choices PPO 10/20/075729PA0050141 Geisinger Choices PPO 20/40/100075729PA0050142 Geisinger Choices PPO 20/40/200075729PA0050143 Geisinger Choices PPO 20/40/400075729PA0050144 Geisinger Choices PPO 10/20/075729PA0050145 Geisinger Choices PPO 20/40/100075729PA0050146 Geisinger Choices PPO 20/40/200075729PA0050147 Geisinger Choices PPO 20/40/400075729PA0050148 Geisinger Choices PPO 10/20/075729PA0050149 Geisinger Choices PPO 20/40/100075729PA0050150 Geisinger Choices PPO 20/40/200075729PA0050151 Geisinger Choices PPO 20/40/4000

02-01-2019 Number of Covered LiveRATING AREA 4

1,699 1,794 1,267 580 58 23 172 132 342 269 0 0 0 0 0 0 0

Lackawanna Luzerne Lycoming Monroe Pike Sullivan Susquehanna Tioga Wayne Wyoming Allegheny Armstrong Beaver Butler Fayette Greene Indiana$269.79 $269.79 $269.79 $269.79 $269.79 $269.79 $269.79 $269.79 $269.79 $269.79$361.73 $361.73 $361.73 $361.73 $361.73 $361.73 $361.73$364.80 $364.80 $364.80 $364.80 $364.80 $364.80 $364.80 $364.80 $364.80 $364.80$345.84 $345.84 $345.84 $345.84 $345.84 $345.84 $345.84 $345.84 $345.84 $345.84$302.11 $302.11 $302.11 $302.11 $302.11 $302.11 $302.11 $302.11 $302.11 $302.11$299.61 $299.61 $299.61 $299.61 $299.61 $299.61 $299.61 $299.61 $299.61 $299.61$362.76 $362.76 $362.76 $362.76 $362.76 $362.76 $362.76 $362.76 $362.76 $362.76$315.68 $315.68 $315.68 $315.68 $315.68 $315.68 $315.68 $315.68 $315.68 $315.68$414.08 $414.08 $414.08 $414.08 $414.08 $414.08 $414.08 $414.08 $414.08 $414.08$408.02 $408.02 $408.02 $408.02 $408.02 $408.02 $408.02$337.43 $337.43 $337.43 $337.43 $337.43 $337.43 $337.43 $337.43 $337.43 $337.43$325.93 $325.93 $325.93 $325.93 $325.93 $325.93 $325.93$376.67 $376.67 $376.67 $376.67 $376.67 $376.67 $376.67 $376.67 $376.67 $376.67$357.69 $357.69 $357.69 $357.69 $357.69 $357.69 $357.69 $357.69 $357.69 $357.69$350.74 $350.74 $350.74 $350.74 $350.74 $350.74 $350.74 $350.74 $350.74 $350.74$314.05 $314.05 $314.05 $314.05 $314.05 $314.05 $314.05 $314.05 $314.05 $314.05$311.42 $311.42 $311.42 $311.42 $311.42 $311.42 $311.42 $311.42 $311.42 $311.42$273.55 $273.55 $273.55 $273.55 $273.55 $273.55 $273.55 $273.55 $273.55 $273.55$303.86 $303.86 $303.86 $303.86 $303.86 $303.86 $303.86$356.90 $356.90 $356.90 $356.90 $356.90 $356.90 $356.90 $356.90 $356.90 $356.90$431.08 $431.08 $431.08 $431.08 $431.08 $431.08 $431.08 $431.08 $431.08 $431.08$429.86 $429.86 $429.86 $429.86 $429.86 $429.86 $429.86 $429.86 $429.86 $429.86$357.11 $357.11 $357.11 $357.11 $357.11 $357.11 $357.11 $357.11 $357.11 $357.11$418.77 $418.77 $418.77 $418.77 $418.77 $418.77 $418.77$353.22 $353.22 $353.22 $353.22 $353.22 $353.22 $353.22$339.39 $339.39 $339.39 $339.39 $339.39 $339.39 $339.39$299.01 $299.01 $299.01 $299.01 $299.01 $299.01 $299.01$400.35 $400.35 $400.35 $400.35 $400.35 $400.35 $400.35 $400.35 $400.35 $400.35$394.64 $394.64 $394.64 $394.64 $394.64 $394.64 $394.64 $394.64 $394.64 $394.64$341.03 $341.03 $341.03 $341.03 $341.03 $341.03 $341.03 $341.03 $341.03 $341.03$367.55 $367.55 $367.55 $367.55 $367.55 $367.55 $367.55 $367.55 $367.55 $367.55

$411.59$346.07$331.66$300.27

$411.59 $411.59 $411.59$346.07 $346.07 $346.07$331.66 $331.66 $331.66$300.27 $300.27 $300.27




02-01-2019 Number of Covered LiveRATING AREA 5 RATING AREA 6

0 0 0 0 39 78 3 134 0 0 1,666 709 1,000 697 278

Lawrence Washington Westmoreland Bedford Blair Clearfield Cambria Huntingdon Jefferson Somerset Centre Columbia Lehigh Mifflin Montour$288.49 $288.49 $288.49 $288.49 $288.49 $288.49 $304.03 $304.03 $304.03 $304.03 $304.03

$407.63 $407.63 $407.63 $407.63 $407.63$390.09 $390.09 $390.09 $390.09 $390.09 $390.09 $411.09 $411.09 $411.09 $411.09 $411.09$369.82 $369.82 $369.82 $369.82 $369.82 $369.82 $389.73 $389.73 $389.73 $389.73 $389.73$323.06 $323.06 $323.06 $323.06 $323.06 $323.06 $340.45 $340.45 $340.45 $340.45 $340.45$320.38 $320.38 $320.38 $320.38 $320.38 $320.38 $337.63 $337.63 $337.63 $337.63 $337.63$387.91 $387.91 $387.91 $387.91 $387.91 $387.91 $408.80 $408.80 $408.80 $408.80 $408.80$337.56 $337.56 $337.56 $337.56 $337.56 $337.56 $355.74 $355.74 $355.74 $355.74 $355.74$442.78 $442.78 $442.78 $442.78 $442.78 $442.78 $466.62 $466.62 $466.62 $466.62 $466.62

$459.80 $459.80 $459.80 $459.80 $459.80$360.82 $360.82 $360.82 $360.82 $360.82 $360.82 $380.25 $380.25 $380.25 $380.25 $380.25

$367.29 $367.29 $367.29 $367.29 $367.29$402.79 $402.79 $402.79 $402.79 $402.79 $402.79 $424.48 $424.48 $424.48 $424.48 $424.48$382.49 $382.49 $382.49 $382.49 $382.49 $382.49 $403.09 $403.09 $403.09 $403.09 $403.09$375.05 $375.05 $375.05 $375.05 $375.05 $375.05 $395.25 $395.25 $395.25 $395.25 $395.25$335.82 $335.82 $335.82 $335.82 $335.82 $335.82 $353.90 $353.90 $353.90 $353.90 $353.90$333.01 $333.01 $333.01 $333.01 $333.01 $333.01 $350.94 $350.94 $350.94 $350.94 $350.94$292.52 $292.52 $292.52 $292.52 $292.52 $292.52 $308.27 $308.27 $308.27 $308.27 $308.27

$342.42 $342.42 $342.42 $342.42 $342.42$381.65 $381.65 $381.65 $381.65 $381.65 $381.65 $402.20 $402.20 $402.20 $402.20 $402.20$460.97 $460.97 $460.97 $460.97 $460.97 $460.97 $485.79 $485.79 $485.79 $485.79 $485.79$459.66 $459.66 $459.66 $459.66 $459.66 $459.66 $484.41 $484.41 $484.41 $484.41 $484.41$381.87 $381.87 $381.87 $381.87 $381.87 $381.87 $402.43 $402.43 $402.43 $402.43 $402.43

$471.91 $471.91 $471.91 $471.91 $471.91$398.04 $398.04 $398.04 $398.04 $398.04$382.47 $382.47 $382.47 $382.47 $382.47$336.95 $336.95 $336.95 $336.95 $336.95

$428.10 $428.10 $428.10 $428.10 $428.10 $428.10 $451.15 $451.15 $451.15 $451.15 $451.15$422.00 $422.00 $422.00 $422.00 $422.00 $422.00 $444.72 $444.72 $444.72 $444.72 $444.72$364.67 $364.67 $364.67 $364.67 $364.67 $364.67 $384.31 $384.31 $384.31 $384.31 $384.31$393.03 $393.03 $393.03 $393.03 $393.03 $393.03 $414.19 $414.19 $414.19 $414.19 $414.19

$463.82 $463.82 $463.82 $463.82$389.98 $389.98 $389.98 $389.98$373.75 $373.75 $373.75 $373.75$338.38 $338.38 $338.38 $338.38

$463.82$389.98$373.75$338.38




02-01-2019 Number of Covered LiveRATING AREA 7 RATING AREA 8

599 1,203 886 759 552 11 22 69 51 0 0 0 0 0

Northampton Northumberland Schuylkill Snyder Union Adams Berks Lancaster York Bucks Chester Delaware Montgomery Philadelphia$304.03 $304.03 $304.03 $304.03 $304.03 $368.38 $368.38 $368.38 $368.38$407.63 $407.63 $407.63 $407.63 $407.63$411.09 $411.09 $411.09 $411.09 $411.09 $498.11 $498.11 $498.11 $498.11$389.73 $389.73 $389.73 $389.73 $389.73 $472.23 $472.23 $472.23 $472.23$340.45 $340.45 $340.45 $340.45 $340.45 $412.52 $412.52 $412.52 $412.52$337.63 $337.63 $337.63 $337.63 $337.63 $409.10 $409.10 $409.10 $409.10$408.80 $408.80 $408.80 $408.80 $408.80 $495.33 $495.33 $495.33 $495.33$355.74 $355.74 $355.74 $355.74 $355.74 $431.04 $431.04 $431.04 $431.04$466.62 $466.62 $466.62 $466.62 $466.62 $565.40 $565.40 $565.40 $565.40$459.80 $459.80 $459.80 $459.80 $459.80$380.25 $380.25 $380.25 $380.25 $380.25 $460.74 $460.74 $460.74 $460.74$367.29 $367.29 $367.29 $367.29 $367.29$424.48 $424.48 $424.48 $424.48 $424.48 $514.33 $514.33 $514.33 $514.33$403.09 $403.09 $403.09 $403.09 $403.09 $488.41 $488.41 $488.41 $488.41$395.25 $395.25 $395.25 $395.25 $395.25 $478.91 $478.91 $478.91 $478.91$353.90 $353.90 $353.90 $353.90 $353.90 $428.81 $428.81 $428.81 $428.81$350.94 $350.94 $350.94 $350.94 $350.94 $425.23 $425.23 $425.23 $425.23$308.27 $308.27 $308.27 $308.27 $308.27 $373.52 $373.52 $373.52 $373.52$342.42 $342.42 $342.42 $342.42 $342.42$402.20 $402.20 $402.20 $402.20 $402.20 $487.33 $487.33 $487.33 $487.33$485.79 $485.79 $485.79 $485.79 $485.79 $588.62 $588.62 $588.62 $588.62$484.41 $484.41 $484.41 $484.41 $484.41 $586.95 $586.95 $586.95 $586.95$402.43 $402.43 $402.43 $402.43 $402.43 $487.62 $487.62 $487.62 $487.62$471.91 $471.91 $471.91 $471.91 $471.91$398.04 $398.04 $398.04 $398.04 $398.04$382.47 $382.47 $382.47 $382.47 $382.47$336.95 $336.95 $336.95 $336.95 $336.95$451.15 $451.15 $451.15 $451.15 $451.15 $546.65 $546.65 $546.65 $546.65$444.72 $444.72 $444.72 $444.72 $444.72 $538.86 $538.86 $538.86 $538.86$384.31 $384.31 $384.31 $384.31 $384.31 $465.66 $465.66 $465.66 $465.66$414.19 $414.19 $414.19 $414.19 $414.19 $501.87 $501.87 $501.87 $501.87

$463.82 $463.82 $463.82$389.98 $389.98 $389.98$373.75 $373.75 $373.75$338.38 $338.38 $338.38

$463.82 $463.82$389.98 $389.98$373.75 $373.75$338.38 $338.38




02-01-2019 Number of Covered LiveRATING AREA 9

129 164 0 0 139 33 30

Cumberland Dauphin Franklin Fulton Juniata Lebanon Perry$312.90 $312.90 $312.90 $312.90 $312.90 $312.90$419.54 $419.54 $419.54 $419.54$423.09 $423.09 $423.09 $423.09 $423.09 $423.09$401.11 $401.11 $401.11 $401.11 $401.11 $401.11$350.39 $350.39 $350.39 $350.39 $350.39 $350.39$347.49 $347.49 $347.49 $347.49 $347.49 $347.49$420.74 $420.74 $420.74 $420.74 $420.74 $420.74$366.12 $366.12 $366.12 $366.12 $366.12 $366.12$480.25 $480.25 $480.25 $480.25 $480.25 $480.25$473.23 $473.23 $473.23 $473.23$391.35 $391.35 $391.35 $391.35 $391.35 $391.35$378.01 $378.01 $378.01 $378.01$436.87 $436.87 $436.87 $436.87 $436.87 $436.87$414.86 $414.86 $414.86 $414.86 $414.86 $414.86$406.79 $406.79 $406.79 $406.79 $406.79 $406.79$364.23 $364.23 $364.23 $364.23 $364.23 $364.23$361.19 $361.19 $361.19 $361.19 $361.19 $361.19$317.27 $317.27 $317.27 $317.27 $317.27 $317.27$352.42 $352.42 $352.42 $352.42$413.94 $413.94 $413.94 $413.94 $413.94 $413.94$499.98 $499.98 $499.98 $499.98 $499.98 $499.98$498.56 $498.56 $498.56 $498.56 $498.56 $498.56$414.18 $414.18 $414.18 $414.18 $414.18 $414.18$485.69 $485.69 $485.69 $485.69$409.66 $409.66 $409.66 $409.66$393.63 $393.63 $393.63 $393.63$346.79 $346.79 $346.79 $346.79$464.33 $464.33 $464.33 $464.33 $464.33 $464.33$457.71 $457.71 $457.71 $457.71 $457.71 $457.71$395.53 $395.53 $395.53 $395.53 $395.53 $395.53$426.29 $426.29 $426.29 $426.29 $426.29 $426.29


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232425262728293031323334353637383940414243444546474849

5051

A B C D E F G H I J K L M N O P QIf Unified Rate Review v5.0 To add a product to Worksheet 2 - Plan Product Info, select the Add Product butto

To add a plan to Worksheet 2 - Plan Product Info, select the Add Plan button or CtCompany Legal Name: Geisinger Quality Options State: PA To validate, select the Validate button or Ctrl + Shift + I.HIOS Issuer ID: 75729 Market: Small Group To finalize, select the Finalize button or Ctrl + Shift + F.

Effective Date of Rate Change(s): 1/1/2020

Section I: Experience Period DataExperience Period: 1/1/2018 to 12/31/2018

Total PMPM$88,819,589.06 $513.71

$0.00 $0.00$79,665,668.07 $460.76-$3,883,201.00 -$22.46$92,073,230.76 $532.53

172,899

Section II: Projections

Cost Utilization Cost UtilizationInpatient Hospital $83.84 1.032 1.057 1.032 1.057 $99.76Outpatient Hospital $191.64 1.009 1.088 1.009 1.088 $230.95Professional $111.54 1.027 1.021 1.027 1.021 $122.64Other Medical $11.51 1.000 1.000 1.000 1.000 $11.51Capitation $14.49 1.050 1.000 1.050 1.000 $15.98Prescription Drug $100.68 1.090 0.988 1.090 0.988 $116.76Total $513.70 $597.60

1.0001.0101.0000.931

1/1/2020 $561.93

$558.230.00%

Projected Period Totals1/1/2020 $558.23 $107,809,843.44

$0.00 $0.00-$45.69 -$8,824,018.32

0.00% $0.00$603.92 $116,633,861.76

193,128

Market Level Calculations (Same for all Plans)

Trended EHB Allowed Claims PMPM

Year 1 Trend Year 2 Trend

Allowed ClaimsReinsuranceIncurred Claims in Experience PeriodRisk AdjustmentExperience Period PremiumExperience Period Member Months

Benefit CategoryExperience Period Index

Rate PMPM

OtherAdjusted Trended EHB Allowed Claims PMPM for

Morbidity Adjustment

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.

Projected Member Months

Projected Index Rate forReinsuranceRisk Adjustment Payment/ChargeExchange User FeesMarket Adjusted Index Rate

Applied Credibility %Manual EHB Allowed Claims PMPM

Demographic ShiftPlan Design Changes

1 of 1

If macros are disabled, press a Product-Plan Data Collection

Company Legal Name: Geisinger Quality Options

HIOS Issuer ID: 75729

Effective Date of Rate Change(s): 1/1/2020

Field # Section I: General Product and Plan Information1.1 Product Name1.2 Product ID

1.3 Plan Name

Geisinger Marketplace PPO

15/30/0


10/20/0


25/50/500

Geisinger All-Access QHDHP

PPO 6500

Geisinger Marketplace Extra

PPO 10/40/01.4 Plan ID (Standard Component ID) 75729PA0050050 75729PA0050051 75729PA0050052 75729PA0050062 75729PA00500661.5 Metal Platinum Platinum Gold Bronze Platinum1.6 AV Metal Value 0.881 0.891 0.783 0.631 0.8881.7 Plan Category Terminated Terminated Terminated Renewing Terminated1.8 Plan Type PPO PPO PPO PPO PPO1.9 Exchange Plan? No No No No No

1.10 Effective Date of Proposed Rates 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/20201.11 Cumulative Rate Change % (over 12 mos prior) 0.00% 0.00% 0.00% 23.84% 0.00%1.12 Product Rate Increase %1.13 Submission Level Rate Increase %

Worksheet 1 Totals Section II: Experience Period and Current Plan Level Information2.1 Plan ID (Standard Component ID) Total 75729PA0050050 75729PA0050051 75729PA0050052 75729PA0050062 75729PA0050066

$88,819,589 2.2 Allowed Claims $88,819,589 $5,639,199 $13,218,340 $4,609,000 $363,793 $10,450,756$0 2.3 Reinsurance $0 $0 $0 $0 $0 $0

2.4 Member Cost Sharing $9,153,921 $268,532 $693,184 $644,839 $189,789 $591,7942.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $0

$79,665,668 2.6 Incurred Claims $79,665,668 $5,370,667 $12,525,156 $3,964,161 $174,005 $9,858,963-$3,883,201 2.7 Risk Adjustment Transfer Amount -$3,883,201 -$222,123 -$507,582 -$227,603 -$42,987 -$447,054$92,073,231 2.8 Premium $92,073,231 $5,888,218 $13,620,834 $5,194,857 $704,263 $11,403,770

172,899 2.9 Experience Period Member Months 172,899 9,890 22,600 10,134 1,914 19,9052.10 Current Enrollment 16,094 0 0 0 266 02.11 Current Premium PMPM $541.88 $0.00 $0.00 $0.00 $370.95 $0.002.12 Loss Ratio 90.33% 94.79% 95.52% 79.81% 26.31% 89.98%

Per Member Per Month2.13 Allowed Claims $513.71 $570.19 $584.88 $454.81 $190.07 $525.032.14 Reinsurance $0.00 $0.00 $0.00 $0.00 $0.00 $0.002.15 Member Cost Sharing $52.94 $27.15 $30.67 $63.63 $99.16 $29.732.16 Cost Sharing Reduction $0.00 $0.00 $0.00 $0.00 $0.00 $0.002.17 Incurred Claims $460.76 $543.04 $554.21 $391.17 $90.91 $495.302.18 Risk Adjustment Transfer Amount -$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.462.19 Premium $532.53 $595.37 $602.69 $512.62 $367.95 $572.91

Product/Plan Level Calculations

Section III: Plan Adjustment Factors3.1 Plan ID (Standard Component ID) 75729PA0050050 75729PA0050051 75729PA0050052 75729PA0050062 75729PA00500663.2 Market Adjusted Index Rate3.3 AV and Cost Sharing Design of Plan 0.0000 0.0000 0.0000 0.6431 0.00003.4 Provider Network Adjustment 0.0000 0.0000 0.0000 1.0000 0.00003.5 Benefits in Addition to EHB 0.0000 0.0000 0.0000 1.0000 0.0000

Administrative Costs3.6 Administrative Expense 0.00% 0.00% 0.00% 7.97% 0.00%3.7 Taxes and Fees 0.00% 0.00% 0.00% 3.74% 0.00%3.8 Profit & Risk Load 0.00% 0.00% 0.00% 2.00% 0.00%3.9 Catastrophic Adjustment 0.0000 0.0000 0.0000 1.0000 0.0000

3.10 Plan Adjusted Index Rate $0.00 $0.00 $0.00 $450.09 $0.00

3.11 Age Calibration Factor 0.64563.12 Geographic Calibration Factor 1.09293.13 Tobacco Calibration Factor 1.00003.14 Calibrated Plan Adjusted Index Rate $0.00 $0.00 $0.00 $317.57 $0.00

Section IV: Projected Plan Level Information4.1 Plan ID (Standard Component ID) Total 75729PA0050050 75729PA0050051 75729PA0050052 75729PA0050062 75729PA00500664.2 Allowed Claims $119,048,441 $0 $0 $0 $1,967,621 $04.3 Reinsurance $0 $0 $0 $0 $0 $04.4 Member Cost Sharing $12,439,347 $0 $0 $0 $205,596 $04.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $04.6 Incurred Claims $106,609,094 $0 $0 $0 $1,762,024 $04.7 Risk Adjustment Transfer Amount -$7,902,798 $0 $0 $0 -$130,617 $04.8 Premium $121,310,757 $0 $0 $0 $1,436,681 $04.9 Projected Member Months 193,128 0 0 0 3,192 0

4.10 Loss Ratio 94.00% #DIV/0! #DIV/0! #DIV/0! 134.91% #DIV/0!Per Member Per Month

4.11 Allowed Claims $616.42 #DIV/0! #DIV/0! #DIV/0! $616.42 #DIV/0!4.12 Reinsurance $0.00 #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0!4.13 Member Cost Sharing $64.41 #DIV/0! #DIV/0! #DIV/0! $64.41 #DIV/0!4.14 Cost Sharing Reduction $0.00 #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0!4.15 Incurred Claims $552.01 #DIV/0! #DIV/0! #DIV/0! $552.01 #DIV/0!4.16 Risk Adjustment Transfer Amount -$40.92 #DIV/0! #DIV/0! #DIV/0! -$40.92 #DIV/0!4.17 Premium $628.14 #DIV/0! #DIV/0! #DIV/0! $450.09 #DIV/0!

To add a product to Worksheet 2 - Plan Product Info, select the Add Product but

To add a plan to Worksheet 2 - Plan Product Info, select the Add Plan button or

State: PA To validate, select the Validate button or Ctrl + Shift + I.

Market: Small Group To finalize, select the Finalize button or Ctrl + Shift + F.



PPO 10/50/1000

Geisinger All-Access PPO 20/40/1000



PPO 20/60/6250




PPO 2100


PPO 4100


75729PA0050068 75729PA0050069 75729PA0050070 75729PA0050071 75729PA0050072 75729PA0050073 75729PA0050075 75729PA0050078 75729PA0050079 75729PA0050080Gold Gold Gold Gold Silver Silver Silver Gold Silver Platinum

0.817 0.807 0.816 0.818 0.690 0.717 0.713 0.820 0.719 0.920Renewing Terminated Renewing Renewing Terminated Renewing Renewing Renewing Renewing Renewing

PPO PPO PPO PPO PPO PPO PPO PPO PPO PPONo No No No No No No No No No

1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/202015.86% 0.00% 13.38% 15.09% 0.00% 17.80% 18.21% 15.27% 15.11% 20.71%

75729PA0050068 75729PA0050069 75729PA0050070 75729PA0050071 75729PA0050072 75729PA0050073 75729PA0050075 75729PA0050078 75729PA0050079 75729PA0050080$21,298,229 $4,148,074 $1,805,009 $2,528,750 $3,941,051 $2,098,684 $319,961 $1,259,181 $1,173,172 $2,073,998

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$2,019,506 $608,839 $251,681 $458,363 $731,470 $452,395 $58,614 $207,238 $277,187 $148,903

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$19,278,724 $3,539,235 $1,553,327 $2,070,388 $3,209,581 $1,646,289 $261,347 $1,051,943 $895,985 $1,925,095

-$876,072 -$226,592 -$108,389 -$146,525 -$186,637 -$106,031 -$15,946 -$55,385 -$65,110 -$95,812$19,642,374 $5,126,710 $2,595,161 $3,235,478 $3,720,987 $2,112,581 $317,558 $1,312,148 $1,268,117 $2,634,884

39,007 10,089 4,826 6,524 8,310 4,721 710 2,466 2,899 4,2664,092 0 723 515 0 165 75 193 158 491

$531.64 $0.00 $547.84 $511.66 $0.00 $436.69 $431.56 $535.88 $466.98 $584.08102.73% 72.23% 62.46% 67.03% 90.81% 82.05% 86.65% 83.70% 74.48% 75.82%

$546.01 $411.15 $374.02 $387.61 $474.25 $444.54 $450.65 $510.62 $404.68 $486.17$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$51.77 $60.35 $52.15 $70.26 $88.02 $95.83 $82.56 $84.04 $95.61 $34.90$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$494.24 $350.80 $321.87 $317.35 $386.23 $348.72 $368.09 $426.58 $309.07 $451.26-$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46$503.56 $508.15 $537.75 $495.93 $447.77 $447.49 $447.26 $532.10 $437.43 $617.65

75729PA0050068 75729PA0050069 75729PA0050070 75729PA0050071 75729PA0050072 75729PA0050073 75729PA0050075 75729PA0050078 75729PA0050079 75729PA0050080

0.8622 0.0000 0.8695 0.8244 0.0000 0.7201 0.7142 0.8647 0.7524 0.98701.0000 0.0000 1.0000 1.0000 0.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 0.0000 1.0000 1.0000 0.0000 1.0000 1.0000 1.0000 1.0000 1.0000

7.97% 0.00% 7.97% 7.97% 0.00% 7.97% 7.97% 7.97% 7.97% 7.97%3.74% 0.00% 3.74% 3.74% 0.00% 3.74% 3.74% 3.74% 3.74% 3.74%2.00% 0.00% 2.00% 2.00% 0.00% 2.00% 2.00% 2.00% 2.00% 2.00%

1.0000 0.0000 1.0000 1.0000 0.0000 1.0000 1.0000 1.0000 1.0000 1.0000$603.43 $0.00 $608.54 $576.97 $0.00 $503.98 $499.85 $605.18 $526.58 $690.77

$425.77 $0.00 $429.37 $407.10 $0.00 $355.60 $352.68 $427.00 $371.55 $487.39

75729PA0050068 75729PA0050069 75729PA0050070 75729PA0050071 75729PA0050072 75729PA0050073 75729PA0050075 75729PA0050078 75729PA0050079 75729PA0050080$30,268,810 $0 $5,348,081 $3,809,491 $0 $1,220,517 $554,780 $1,427,634 $1,168,737 $3,631,961

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$3,162,782 $0 $558,820 $398,053 $0 $127,532 $57,969 $149,173 $122,121 $379,503

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$27,106,028 $0 $4,789,262 $3,411,438 $0 $1,092,985 $496,811 $1,278,461 $1,046,616 $3,252,458-$2,009,336 $0 -$355,022 -$252,886 $0 -$81,022 -$36,828 -$94,771 -$77,584 -$241,101$29,630,831 $0 $5,279,686 $3,565,705 $0 $997,877 $449,864 $1,401,596 $998,403 $4,070,041

49,104 0 8,676 6,180 0 1,980 900 2,316 1,896 5,89298.13% #DIV/0! 97.25% 102.98% #DIV/0! 119.21% 120.28% 97.83% 113.66% 84.94%

$616.42 #DIV/0! $616.42 $616.42 #DIV/0! $616.42 $616.42 $616.42 $616.42 $616.42$0.00 #DIV/0! $0.00 $0.00 #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00

$64.41 #DIV/0! $64.41 $64.41 #DIV/0! $64.41 $64.41 $64.41 $64.41 $64.41$0.00 #DIV/0! $0.00 $0.00 #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00

$552.01 #DIV/0! $552.01 $552.01 #DIV/0! $552.01 $552.01 $552.01 $552.01 $552.01-$40.92 #DIV/0! -$40.92 -$40.92 #DIV/0! -$40.92 -$40.92 -$40.92 -$40.92 -$40.92$603.43 #DIV/0! $608.54 $576.97 #DIV/0! $503.98 $499.85 $605.18 $526.58 $690.77

tton or Ctrl + Shift + P.

Ctrl + Shift + L.



PPO 10/50/2000

Geisinger Marketplace

Select PPO 10/20/0


Select PPO 15/30/0


Select PPO 15/30/250











75729PA0050082 75729PA0050083 75729PA0050084 75729PA0050086 75729PA0050087 75729PA0050088 75729PA0050089 75729PA0050091 75729PA0050093 75729PA0050094Platinum Gold Platinum Platinum Platinum Gold Gold Gold Silver Silver

0.912 0.795 0.891 0.881 0.908 0.783 0.811 0.801 0.691 0.686Renewing Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated


1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/202024.27% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

75729PA0050082 75729PA0050083 75729PA0050084 75729PA0050086 75729PA0050087 75729PA0050088 75729PA0050089 75729PA0050091 75729PA0050093 75729PA0050094$7,759,020 $3,097,048 $21,082 $126,239 $294 $45,474 $269,347 $51,424 $34,275 $80,023

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$625,856 $472,864 $4,752 $7,721 $0 $14,582 $51,080 $9,262 $14,029 $7,955

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$7,133,164 $2,624,184 $16,330 $118,518 $294 $30,892 $218,267 $42,162 $20,246 $72,068

-$285,167 -$138,821 -$809 -$5,615 -$606 -$3,638 -$9,343 -$1,662 -$3,122 -$2,538$7,386,413 $3,112,506 $20,612 $141,402 $15,843 $78,891 $212,519 $34,864 $59,090 $48,013

12,697 6,181 36 250 27 162 416 74 139 1131,173 0 0 0 0 0 0 0 0 0

$559.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00100.45% 88.25% 82.46% 87.28% 1.93% 41.05% 107.43% 126.99% 36.17% 158.48%

$611.09 $501.06 $585.61 $504.96 $10.89 $280.70 $647.47 $694.92 $246.58 $708.17$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$49.29 $76.50 $132.00 $30.88 $0.00 $90.01 $122.79 $125.17 $100.93 $70.40$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$561.80 $424.56 $453.61 $474.07 $10.89 $190.69 $524.68 $569.75 $145.65 $637.77-$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46 -$22.46$581.74 $503.56 $572.56 $565.61 $586.77 $486.98 $510.86 $471.14 $425.11 $424.90


0.9726 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.00001.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.00001.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000

7.97% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%3.74% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%2.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

1.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000$680.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$480.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

75729PA0050082 75729PA0050083 75729PA0050084 75729PA0050086 75729PA0050087 75729PA0050088 75729PA0050089 75729PA0050091 75729PA0050093 75729PA0050094$8,676,763 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$906,633 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$7,770,130 $0 $0 $0 $0 $0 $0 $0 $0 $0

-$575,990 $0 $0 $0 $0 $0 $0 $0 $0 $0$9,581,477 $0 $0 $0 $0 $0 $0 $0 $0 $0

14,076 0 0 0 0 0 0 0 0 086.28% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$616.42 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


$552.01 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!-$40.92 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$680.70 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!






20/50/5000


PPO 10/50/5000







75729PA0050096 75729PA0050097 75729PA0050098 75729PA0050099 75729PA0050100 75729PA0050101 75729PA0050102 75729PA0050103 75729PA0050104 75729PA0050105Gold Gold Gold Gold Gold Gold Gold Gold Gold Silver

0.797 0.792 0.778 0.771 0.764 0.771 0.817 0.813 0.798 0.720Renewing Renewing Terminated Terminated Terminated Terminated Renewing Renewing Renewing Renewing


1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/202015.84% 18.30% 0.00% 0.00% 0.00% 0.00% 13.21% 13.88% 14.69% 14.76%

75729PA0050096 75729PA0050097 75729PA0050098 75729PA0050099 75729PA0050100 75729PA0050101 75729PA0050102 75729PA0050103 75729PA0050104 75729PA0050105$505,768 $1,766,462 $60,099 $68,434 $7,400 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$78,526 $235,822 $11,435 $16,151 $1,553 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$427,242 $1,530,641 $48,663 $52,284 $5,847 $0 $0 $0 $0 $0-$27,917 -$57,474 -$5,884 -$7,120 -$3,638 $0 $0 $0 $0 $0$602,826 $1,229,479 $120,710 $154,059 $78,064 $0 $0 $0 $0 $0

1,243 2,559 262 317 162 0 0 0 0 0226 417 0 0 0 0 280 171 79 15

$496.01 $469.11 $0.00 $0.00 $0.00 $0.00 $566.53 $534.83 $520.71 $465.9674.31% 130.60% 42.38% 35.58% 7.86% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$406.89 $690.29 $229.38 $215.88 $45.68 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$63.17 $92.15 $43.65 $50.95 $9.59 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$343.72 $598.14 $185.74 $164.93 $36.10 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!-$22.46 -$22.46 -$22.46 -$22.46 -$22.46 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$484.98 $480.45 $460.72 $485.99 $481.87 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Geisinger Quality Options PPO75729PA005

18.32%18.32%


0.8043 0.7769 0.0000 0.0000 0.0000 0.0000 0.8978 0.8526 0.8360 0.74861.0000 1.0000 0.0000 0.0000 0.0000 0.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 0.0000 0.0000 0.0000 0.0000 1.0000 1.0000 1.0000 1.0000

7.97% 7.97% 0.00% 0.00% 0.00% 0.00% 7.97% 7.97% 7.97% 7.97%3.74% 3.74% 0.00% 0.00% 0.00% 0.00% 3.74% 3.74% 3.74% 3.74%2.00% 2.00% 0.00% 0.00% 0.00% 0.00% 2.00% 2.00% 2.00% 2.00%

1.0000 1.0000 0.0000 0.0000 0.0000 0.0000 1.0000 1.0000 1.0000 1.0000$562.91 $543.73 $0.00 $0.00 $0.00 $0.00 $628.35 $596.71 $585.09 $523.92

$397.17 $383.64 $0.00 $0.00 $0.00 $0.00 $443.35 $421.03 $412.83 $369.67

75729PA0050096 75729PA0050097 75729PA0050098 75729PA0050099 75729PA0050100 75729PA0050101 75729PA0050102 75729PA0050103 75729PA0050104 75729PA0050105$1,671,738 $3,084,578 $0 $0 $0 $0 $2,071,180 $1,264,899 $584,369 $110,956

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$174,680 $322,307 $0 $0 $0 $0 $216,417 $132,169 $61,061 $11,594

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$1,497,058 $2,762,271 $0 $0 $0 $0 $1,854,762 $1,132,730 $523,308 $99,362

-$110,975 -$204,764 $0 $0 $0 $0 -$137,491 -$83,968 -$38,792 -$7,366$1,526,605 $2,720,830 $0 $0 $0 $0 $2,111,241 $1,224,452 $554,669 $94,306

2,712 5,004 0 0 0 0 3,360 2,052 948 180105.75% 109.79% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 93.97% 99.32% 101.44% 114.29%

$616.42 $616.42 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $616.42 $616.42 $616.42 $616.42$0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00

$64.41 $64.41 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $64.41 $64.41 $64.41 $64.41$0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00

$552.01 $552.01 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $552.01 $552.01 $552.01 $552.01-$40.92 -$40.92 #DIV/0! #DIV/0! #DIV/0! #DIV/0! -$40.92 -$40.92 -$40.92 -$40.92$562.91 $543.73 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $628.35 $596.71 $585.09 $523.92

0.64561.09291.0000

$603.92





25/50/2000 1xded


10/20/0


15/30/0





75729PA0050106 75729PA0050107 75729PA0050108 75729PA0050127 75729PA0050128 75729PA0050129 75729PA0050130 75729PA0050131 75729PA0050132 75729PA0050133Silver Bronze Silver Gold Platinum Platinum Gold Platinum Gold Gold0.719 0.649 0.720 0.798 0.920 0.915 0.808 0.920 0.812 0.790

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingPPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

No No No No No No No No No No1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020

16.43% 22.85% 17.20% 14.55% 20.30% 21.16% 15.10% 23.87% 16.21% 17.15%

75729PA0050106 75729PA0050107 75729PA0050108 75729PA0050127 75729PA0050128 75729PA0050129 75729PA0050130 75729PA0050131 75729PA0050132 75729PA0050133$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 0 072 23 98 94 2,006 808 811 1,407 1,060 527

$455.43 $379.17 $441.45 $530.52 $610.19 $604.11 $528.29 $575.65 $517.54 $493.32#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! #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! #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! #DIV/0! #DIV/0!


0.7423 0.6520 0.7243 0.8507 1.0275 1.0246 0.8512 0.9982 0.8419 0.80901.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

7.97% 7.97% 7.97% 7.97% 7.97% 7.97% 7.97% 7.97% 7.97% 7.97%3.74% 3.74% 3.74% 3.74% 3.74% 3.74% 3.74% 3.74% 3.74% 3.74%2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$519.52 $456.32 $506.92 $595.38 $719.12 $717.09 $595.73 $698.61 $589.22 $566.20

$366.56 $321.97 $357.67 $420.09 $507.39 $505.96 $420.33 $492.92 $415.74 $399.50

75729PA0050106 75729PA0050107 75729PA0050108 75729PA0050127 75729PA0050128 75729PA0050129 75729PA0050130 75729PA0050131 75729PA0050132 75729PA0050133$532,589 $170,133 $724,913 $695,325 $14,838,522 $5,976,832 $5,999,024 $10,407,677 $7,840,894 $3,898,256

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$55,650 $17,777 $75,746 $72,654 $1,550,474 $624,518 $626,837 $1,087,496 $819,293 $407,328

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$476,939 $152,355 $649,167 $622,670 $13,288,048 $5,352,314 $5,372,187 $9,320,181 $7,021,601 $3,490,928-$35,355 -$11,294 -$48,122 -$46,158 -$985,026 -$396,760 -$398,233 -$690,893 -$520,502 -$258,778$448,861 $125,943 $596,135 $671,590 $17,310,633 $6,952,899 $5,797,659 $11,795,378 $7,494,912 $3,580,629

864 276 1,176 1,128 24,072 9,696 9,732 16,884 12,720 6,324115.34% 132.89% 118.46% 99.56% 81.39% 81.64% 99.50% 83.93% 100.68% 105.09%

$616.42 $616.42 $616.42 $616.42 $616.42 $616.42 $616.42 $616.42 $616.42 $616.42$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$64.41 $64.41 $64.41 $64.41 $64.41 $64.41 $64.41 $64.41 $64.41 $64.41$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$552.01 $552.01 $552.01 $552.01 $552.01 $552.01 $552.01 $552.01 $552.01 $552.01-$40.92 -$40.92 -$40.92 -$40.92 -$40.92 -$40.92 -$40.92 -$40.92 -$40.92 -$40.92$519.52 $456.32 $506.92 $595.38 $719.12 $717.09 $595.73 $698.61 $589.22 $566.20



PPO 1500



25/50/4500 1x ded


PPO 20/40/1500Geisinger Choices

PPO 10/20/0Geisinger Choices PPO 20/40/1000

Geisinger Choices PPO 20/40/2000



75729PA0050134 75729PA0050135 75729PA0050136 75729PA0050137 75729PA0050138 75729PA0050140 75729PA0050141 75729PA0050142 75729PA0050143 75729PA0050144Silver Platinum Platinum Gold Gold Platinum Gold Gold Silver Platinum0.720 0.866 0.873 0.764 0.760 0.909 0.804 0.780 0.717 0.909

Renewing New New New New New New New New NewPPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

No No No No No No No No No No1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020

19.79% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

75729PA0050134 75729PA0050135 75729PA0050136 75729PA0050137 75729PA0050138 75729PA0050140 75729PA0050141 75729PA0050142 75729PA0050143 75729PA0050144$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 0149 0 0 0 0 0 0 0 0 0

$425.01 $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! #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! #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! #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!


0.7127 0.9543 0.9407 0.8129 0.8761 0.9811 0.8249 0.7905 0.7157 0.98111.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

7.97% 7.97% 7.97% 7.97% 7.97% 7.97% 7.97% 7.97% 7.97% 7.97%3.74% 3.74% 3.74% 3.74% 3.74% 3.74% 3.74% 3.74% 3.74% 3.74%2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$498.80 $667.89 $658.37 $568.93 $613.16 $686.64 $577.32 $553.25 $500.90 $686.64

$351.94 $471.25 $464.53 $401.42 $432.63 $484.48 $407.35 $390.36 $353.42 $484.48

75729PA0050134 75729PA0050135 75729PA0050136 75729PA0050137 75729PA0050138 75729PA0050140 75729PA0050141 75729PA0050142 75729PA0050143 75729PA0050144$1,102,163 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$115,165 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0$986,999 $0 $0 $0 $0 $0 $0 $0 $0 $0-$73,165 $0 $0 $0 $0 $0 $0 $0 $0 $0$891,853 $0 $0 $0 $0 $0 $0 $0 $0 $0

1,788 0 0 0 0 0 0 0 0 0120.56% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!



$552.01 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!-$40.92 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$498.80 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!








75729PA0050145 75729PA0050146 75729PA0050147 75729PA0050148 75729PA0050149 75729PA0050150 75729PA0050151Gold Gold Silver Platinum Gold Gold Silver

0.804 0.780 0.717 0.909 0.804 0.780 0.717New New New New New New NewPPO PPO PPO PPO PPO PPO PPO

No No No No No No No1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

75729PA0050145 75729PA0050146 75729PA0050147 75729PA0050148 75729PA0050149 75729PA0050150 75729PA0050151$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 0 0 0 0 0 0

$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! #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!#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!

75729PA0050145 75729PA0050146 75729PA0050147 75729PA0050148 75729PA0050149 75729PA0050150 75729PA0050151

0.8249 0.7905 0.7157 0.9811 0.8249 0.7905 0.71571.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

7.97% 7.97% 7.97% 7.97% 7.97% 7.97% 7.97%3.74% 3.74% 3.74% 3.74% 3.74% 3.74% 3.74%2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$577.32 $553.25 $500.90 $686.64 $577.32 $553.25 $500.90

$407.35 $390.36 $353.42 $484.48 $407.35 $390.36 $353.42

75729PA0050145 75729PA0050146 75729PA0050147 75729PA0050148 75729PA0050149 75729PA0050150 75729PA0050151$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#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! #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! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Rating Area Data CollectionIf macros are disabled, press and hold the ALT key and press the F, then

Rating Area Rating FactorRating Area 2 0.8900Rating Area 3 0.8510Rating Area 5 0.9100Rating Area 6 0.9590Rating Area 7 1.1620Rating Area 9 0.9870

RFJ Part II - Consumer Friendly Justification Geisinger Quality Options Small Group Geisinger Quality Options has proposed an overall base rate increase of 18.3% for Small Group PPO members effective January 1, 2020 through December 1, 2020. The actual range of proposed rate increases vary from a minimum of 13.2% to a maximum of 24.3%. The key drivers of this increase are changes in the single risk pool experience, medical inflation, utilization trend, administrative expense, federal taxes and risk adjustment. The total projected 2020 administrative costs are slightly higher than those used for the current 2019 rates. As required by federal regulations and using the Federally prescribed MLR methodology, the projected loss ratio exceeds 80%. There were minimal benefit changes proposed for 2020 to maintain the desired metallic level.

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 you are in a community rating state, select Family-Tier Rates under Rating Method and fill in all columns.If you are not in a community rating state, select Age-Based Rates under Rating Method 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.

BlairCambria

HuntingdonWestmoreland

ClearfieldCentre

CumberlandLancaster

Lebanon

DauphinSchuylkill

Carbon

Cameron

York

Adams

Franklin

JuniataMifflin

Northumberland

ColumbiaMontour

Luzerne

Lackawanna

Lehigh

DelawareFulton

Allegheny

Washington

Butler

Lawrence

Erie

Armstrong

Beaver

Bedford

Berks

Bradford

Bucks

Chester

Clarion Clinton

Crawford

Elk

Fayette

Forest

Greene

Indiana

Jefferson

Lycoming

Mckean

Mercer

Monroe

Montgomery

Northampton

Perry

Philadelphia

Pike

Potter

Snyder

Somerset

Sullivan

SusquehannaTioga

Union

Venango

Warren

WayneWyoming

2019 and 2020 Service AreaIssuer: Geisinger Quality Options (Issuer 75729)Market: Small Group - Off Exchange

Key:2019 and 2020 Off-exchange service area

Geisinger Quality Options Small Group Filing for 2020 Response to Questions SERFF Tracking Number: GSHP-131915683 1. Please confirm that the Tables in the ‘I Data’ tab is populated with unadjusted data specific to the GQO small group market for ACA-compliant plans only. Confirmed 2. Please clarify the data source and markets used in populating the ‘I.b.Manual’ Tab. Tables on the I.b.Manual tab are all populated with data sourced from our data warehouse which compiles data from our claim payment, billing and vendor systems. Tables 2b and 3b show GHP and GQO combined small group market experience. Table 4b is populated with data for the large group market as requested to support our trend assumptions. 3. The updated URR instructions require a quantitative impact of rate increase drivers. Please provide the approximate rate increase percentage contributed by each of the drivers listed page 2 of the actuarial memorandum. The quantitative impacts are either from Table 8 or Table 9 and are shown here to match the updated file named “2020_SmGrp_GQO_PAAMExhibits_062119.xlsm”.

• Single Risk Pool experience (i.e. the “Base period allowed claims before normalization” on Table 8) which is more adverse than assumed in current rates; 10.2% from cell F72 on Table 8 • Medical Inflation and Utilization trend; 0.2% from cell F77 on Table 8 • Changes in administrative expenses; 1.4% from cell F90 on Table 8 • Changes in ACA fees; 2.1% from cell F91 on Table 8 • Changes in Risk Adjustment; 3.3% = (40.92– 28.31)/ 382.32 The PMPMs from Table 9, cells J76 and K76, over the PMPM from 2019 in Table 8, cell C70

4. Page 1 of the actuarial memorandum says the filing is requesting a 17.8% decrease, however, it is an increase. Please correct. This has been corrected. 5. Please provide discussion and calculations of factors applied to reflect changes in benefits for 2020 by plan. On table 5, we used a 1.0 benefit change factor as the scope of covered benefits has not changed. 6. Please provide an exhibit that shows, by HIOS Plan ID, summary benefit and cost sharing changes for 2020 relative to the 2019 design for all plans to be offered in 2020. Include Pricing AV columns for 2019 and 2020. Please show the approved 2019 Pricing AVs for all plans in the 2019 column and the proposed 2020 Pricing AVs in the 2020 column. Also provide a supporting worksheet that shows the quantitative development of the proposed factors. Please see the worksheet named “Benefit Changes” of the file named “PID_Response_Exhibits_GQO_SG_062119.xlsx”. Please refer to question #32b for the development of the pricing AV factors. 7. The updated URR instructions require an explanation of how morbidity was removed from impacting the variations in rate increases. Please provide this explanation. The change in morbidity does not vary by plan. We projected claims at the aggregate level and not at the plan level therefore morbidity does not vary by plan.

8. Regarding Adjustment Data Validation process (RADV): a. Please describe any adjustments or considerations made due to the Risk Adjustment Data Validation process (RADV). No adjustments were made due to RADV. We do not fully understand the impact to plan year 2020 at this time. b. As you know CMS is performing a risk adjustment validation starting with 2017 risk adjustment data. We are considering allowing an estimate of the impact of risk adjustment modifications in rate filings as an adjustment to the projected risk adjustment. Before implementation, we are soliciting feedback from our issuers on the pros and cons of the inclusion of this adjustment. If allowed, all issuers would be required to submit an estimate. The estimate may be $0. Please provide any feedback that you would like us to consider. We do not know how to adjust for RADV in our risk adjustment estimates, especially when you consider the significant lag time and complexity of the issue. We have large population and mix changes from year to year and do not know how to account for insufficient documentation of that changing population, at this time. 9. Please explain the 0.9238 completion factor applied to July 2017 as well as the 0.9475 completion factor applied to February 2018 in Table 4, considering the months surrounding these months are considered much more complete. As the mix of services change from month to month, so do the completion factors. They do not always increase or decrease in a smooth pattern from month to month. 10. Please explain why the prescription drug rebates and capitation are included in the paid claims in Table 4 such that the completion factors are applied to the rebates and capitation. Please explain whether these amounts were also included in the derivation of the IBNP factors used. Prescription drug rebates are not included in the incurred claims on Table 4. They are in a separate column titled Prescription Drug Rebates. Capitation is not included in development of IBNR and does not have completion factors applied. 11. Explain why the completion factors on Table 4b are not used to calculate incurred claims on Table 4. Table 4b is large group experience while Table 4 is Small Group experience. The completion factors are different for these markets. 12. Please provide detail on the adjustments to the experience trend from Table 4b listed on page 4 of the Actuarial Memorandum under “Trend Identification”. Table 4b is our large group market experience. As instructed on page 13 of the PID instructions, Table 4b was provided as this was the data used to develop our trends. This data is not adjusted to the experience trend. 13. As a supplemental exhibit, please provide an exhibit similar to Table 4b populated with GHP/GQO small group ACA-compliant data only. Please ensure that this is raw unadjusted data. Also include the following monthly data a. The average age factor; b. The average geographic factor; c. The average tobacco factor; d. The average benefit factor; and e. The normalized average pmpm

Please see the worksheet named “Table 4c” of the file named “PID_Response_Exhibits_GQO_SG_062119.xlsx”. Our data warehouse does not include the ACA rating factors. We are able to review the current enrollment and add this information in order to determine the calibration factors. This process would take several weeks to accurately include this data for Table 4. 14. Please explain why you believe the membership nearly tripled in 2017, and why you expect continued stability for 2020 from February 2019 membership. In 2017, we moved our Extra plans from an GHP platform to a GQO platform. We believe this to be the reason for the movement in membership. We are optimistic that we will be able to maintain our current membership. 15. Why are the outpatient hospital cost trends so much lower than inpatient and professional, considering the utilization trends are so much higher? Geisinger projects unit cost and utilization trends individually using historical experience, regression analysis, and actuarial judgement for each component separately. The unit cost trends for facility and professional services are projected based on expected changes in the underlying contracted rates. Utilization trend is not a component of unit cost trend. 16. Were trends adjusted for unexpected large claims? If so, please explain the process. Trends are developed from historical experience after removing the reimbursement from our reinsurance. That is, trends are developed removing large claims. Large claims are included in the reinsurance estimates, which is further explained in #33. 17. Are trends adjusted due to fluctuation in large claim amounts? If so, please explain how. Please see the response to #16 above. 18. If adjustments are made for large claim pooling, was the federal risk adjustment program considered? There was no adjustment made for large claim pooling outside of our adjustment for reinsurance, which is further explained in #33. 19. Please provide detail on the development of each of the trend components (cost, utilization, and induced demand) by service category. Please refer to the file named “Trend Documentation.pdf” 20. Regarding the Global Risk Arrangement a. Please provide a detailed discussion of this arrangement, including the parties involved; Please see the file titled ‘VBRS Memo FINAL-shared.pdf’. b. If this arrangement is for something other than changes in the provider network, why do you believe Table 5 cell d18 is the appropriate place to include this adjustment? We believe Table 5 cell D18 is the more appropriate place for this adjustment because it reflects a change in our provider network. c. Please provide quantitative support for the development of the 0.93 network factor. The Global Risk Arrangement defines a new relationship with our clinical enterprise, through the Value Based Risk Share (VBRS). Our network factor on Table 5 is our best representation of the impact the VBRS will have on the Small Group GQO market. It would not be meaningful to review historical claims when valuing this prospective risk arrangement. d. The PA AM indicates that the claims experience in Table 2 reflects payment transfers as a result of this arrangement. Please explain. Also, revise Table 2 to show unadjusted data. The PA AM has been corrected. Table 2 does not include payment transfers as a result of the Global Risk Arrangement.

e. Please explain why you do not have separate network actors in Tables 10 and 14 for the Global Risk Arrangement reflected in the Change in Network factor in Table 5. The Global Risk Arrangement is not a new network but impacts all our networks. We do not believe a network factor is the appropriate way to reflect the impact of the arrangement. As submitted, we believe the most appropriate way to reflect the impact is with the Change in Network adjustment on Table 5. 21. How was the 5% annual trend applied to the capitation amounts included on the URRT determined? Please see the worksheet named “Capitation” of the file named “PID_Response_Exhibits_GQO_SG_062119.xlsx”. The 5% trend was selected using actuarial judgement and was influenced by the historical capitation trends for all our filings. 22. The capitation includes a Quality Fund/PQS payment. According to the URRT Instructions, allowed claims should not include payments for services other than medical care provided such as medical management, quality improvement, etc. Given this, explain why you believe it is appropriate to include this payment in capitation. Also, explain the difference between these payments and the quality improvement initiatives payment. Quality Fund/PQS is not an administrative expense and therefore does not meet the federal definition of a quality incentive payment. The term “Quality Fund” is internal Geisinger nomenclature and should not be confused with the quality incentive category referenced in the federal guidelines. This expense is not directly related to specific claims and is allocated to lines of business using a PMPM, which is included here in capitation since those expenses are on a PMPM basis. 23. Please discuss why the capitation amount in Table 9 shows a value of $7.11 for 2020 and why the URRT Wkst 1 shows projected amount of $15.98 This was an error. Table 9 has been updated to reflect the combined GHP and GQO projected capitation of $16.02. There was no change to the rates due to this. 24. The URR instructions specify that the URRT should reflect the index rate for the quarter being changed (i.e. 1Q2020 in this filing) and not an average of the quarterly trended index rates. Please correct the index rate on the URRT WS1 to reflect the $557.12 calculated in the PAAM and not the $569.60. We have corrected the updated “URRT_GQO_SmGrp_2020_062119.xlsm” file to reflect the 1Q2020 index rate. 25. In Table 5, quantitatively show the development of the paid to allowed factor of 0.894. The Allowed ratio of 0.894 is calculated in column (8) of the “Induced_Util_Exhibit” tab of the “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx” file. 26. Please explain why the demographic shift factor was calculated using a weighted average age factor for 2020 essentially using a factor of 0 for the members without premium to a weighted average factor for 2018 using actual age for all members. Upon further review we believe it would be appropriate to include the members with no premium in both weighted averages, as was done in the 2018 weighted average. We expect that changing this would increase the filed rates by an additional 0.2%. 27. Please provide quantitative support for the impact of changes to the risk model to the risk adjustment. Additionally, please provide the completed risk adjustment formula with all assumptions used.

We have used the Department’s estimated 2018 Risk Adjustment as the starting point for 2020. We combine our GHP and GQO experience to provide greater consistency. The Department’s estimate is $25.00 PMPM. This is calculated as (-$860,276 + -$3,883,201) / (16,868 + 172,899) = -$25.00 PMPM. Calendar year enrollment is from Table 2 for each market. Next, we used a 3rd party consultant’s tool to analyze the impact of the coefficient changes. The result of the tool is an impact of a 63.7% increase. We applied this increase to the Department’s estimate to arrive at -$40.92 = -$25.00*1.637. 28. The risk adjustment transfers should be included as an adjustment in the MLR numerator and not the denominator. Please correct. Please note the risk adjustment user fee of $0.18 PMPM should be included with taxes and fees in the adjustment to the MLR denominator. Please provide detail discussion and exhibits showing where this is included. The Actuarial Memorandum has been updated to reflect this change in the MLR calculation. The risk adjustment user fee is now shown in Table 6 of the updated exhibits. 29. We see that the induced demand factors are normalized to a factor of 1.0 for GHP and GQO product offerings, however, we believe the single risk pool requirements require that the induced demand factors should be normalized for each company separately. Please provide updated materials which normalize the induced demand for GQO on its own. The 2020 Unified Rate Review Instructions, section 1.5 on page 7 states under Single Risk Pool: “The single risk pool, as specified in 45 CFR 156.80(a-c), includes ALL non-grandfathered covered persons (lives) an issuer has in a state, within a market (individual, small group, or combined).” It is our interpretation that an issuer should use all available information to estimate the total Small Group market projected allowed PMPM in the state. Page 3 of the Actuarial Memorandum describes that we believe that combining the experience of Geisinger Health Plan and Geisinger Quality Options is a better representation of the Single Risk Pool. Our intention is to accurately project the Single Risk Pool experience based on all available information for that Single Risk Pool and we believe that combining the experience of HMO, POS and PPO products will accomplish that. 30. Please explain why the induced demand factors for the platinum plans are the same as the gold plans. Due to the change in contracting, Geisinger Health System believes that the increased utilization for Platinum level plans in preventive and other low-cost services will lead to reduced utilization in higher cost services. The overall effect will be the induced utilization that we filed for 2019 and we are not changing this assumption in 2020. 31. The gold/bronze induced demand relativities are around 11.6%, and the silver/bronze induced demand relativities are around 9.9% which is higher than the 8% ratio gold/bronze and the 5% ratio silver/bronze included in the HHS risk adjustment model. Please provide narrative and quantitative support for these induced demand factors, including discussion how health status is excluded. The HHS Risk Adjustment Model is based on national claims data. We do not believe this accurately reflects the best estimate for induced demand factors. The induced demand factors do not include health status. 32. Regarding the Induced Utilization Exhibit a. Please confirm that the ratio in Column (9) represents the pure induced utilization for each plan. Confirmed

b. Please show quantitatively, including an Excel spreadsheet with formulas, the derivation of the AV and cost sharing factors for each plan. Please note that it is assumed that the AV and cost sharing factor includes the average tobacco factor. Geisinger develops the paid to allowed factor shown in Column (6) of the Induced Utilization Exhibit and shown in the Pricing AV column of Table 10 from a rating model that determines a paid to allowed ratio based on the specific plan cost sharing. The rating model uses a claims probability distribution to determine values of deductible, coinsurance and out-of-pocket maximums. The rating model uses average utilization and cost to determine values for copays. The AV and cost sharing factors are shown as required in the Induced Utilization Exhibit by multiplying the paid to allowed ratio by the average tobacco factor. c. Please provide any additional justification for induced utilization assumptions in the Company’s pricing. We believe the induced utilization factors are actuarially appropriate. d. Please confirm that each plan’s induced utilization factor was normalized by an aggregate factor, and that the resulting sum product (against 2/1/2019 membership or the projected membership distribution) produces Please see the worksheet named “Induced_Util_Exhibit” of the file named “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”. e. Please quantitatively demonstrate the calculation of the induced calibration factor. Please see the worksheet named “Induced_Util_Exhibit” of the file named “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”. f. Please quantitatively show and provide a detailed description as to how the induced demand factor shown in Table 7 relates to the induced utilization factors calculated in the “Induced Utilization Exhibit” shown in the Actuarial Memorandum. The pre-normalization factors can be determined by multiplying column (9) of the Induced Utilization Exhibit by the factor shown in Table 7 cell K52. 33. Regarding Reinsurance a. Please describe the reinsurance arrangement We have reinsurance on all our Commercial products, including ACA compliant plans. Our attachment point is $750,000 with 90% coinsurance. Our coverage excludes professional services, but covers all other services (inpatient, outpatient and drug). b. Please confirm that the July 2018 – June 2019 pmpm is the actual contracted pmpm amount. Confirmed i. What is the year-to-date associated reinsurance recovery pmpm for this period. For Small Group GQO July 2018 – June 2019 there have been no reinsurance recoveries. c. In projecting the reinsurance pmpm for rating period, Geisinger applies a 15% annual increase in the pmpm. Please support this assumption. This was a general assumption based on the recent experience of high dollar claims. After we submitted the filing, we did receive our reinsurance renewal. The increase from the carrier was 64%. 34. Please provide the total commissions paid and the member months associated with those payments for calendar year 2018 for small group ACA-Compliant business. The calendar year 2018 member months for GQO small group ACA-compliant business is shown on table 1 as 172,899. Broker Commissions for this period are $2,005,394.

35. The calibration factors seem to be based on the projected membership of both GQO and GHP. Please note per the single risk pool requirements the calibration factors for GHP and GQO should be calculated and applied separately. The projected 2020 Index Rate which has been developed is the same between the GHP and GQO Small Group rate filings. Because the projected Index Rate is the same between the two filings, the projected mix of membership by age and gender, geographic rating area, tobacco use, and morbidity is also being projected to be the same. 36. Please explain why you used an age calibration factor that excluded members with $0 premium, rather than including those members using a factor of 0. This was used both on the URRT Wkst 2 and on Table 10. Our interpretation of the guidance was to remove the members with $0 premium from the calibration. 37. Please provide discussion and detail for the development of projected administrative expenses compared to experience period administrative expenses, and the development and appropriateness of the trend used. Discuss whether exchange user fees are included or excluded in the historical experience shown on the Administrative Expense tab of the additional exhibits worksheet. CY20 projected administrative expenses are based primarily on the FY 2020 budget. The FY 2020 budget is developed at the department level after meeting with each department head and assessing what is required in the upcoming year to best serve our members. The departmental budgets are then reviewed and approved by GHP's Leadership Team (CEO, CFO, and Chief Officers). Exchange user fees are not included in the historical administrative expense exhibit. There are several factors causing the admin increase from CY18 to CY20, including:

1. Shared Services allocation 2. Full year impact of increased staffing in several areas 3. Facets depreciation 4. Special Investigations Unit investment in Change Healthcare Fraud, Waste, and Abuse software 5. Rx Vendor Solutions

All projected administrative expenses are appropriate. 38. What portion of the general administrative expenses are for marketing? We assume sales and marketing are under this category. If they are not, where are they? Please provide breakdown of the general administrative expense item. As shown in the worksheet named “Administrative Expense” of the file named “PID_Response_Exhibits_GQO_SG_062119.xlsx”, marketing expense accounts for 1% of administrative expenses. 39. Please provide detail supporting the geographic factors buildup including discussion regarding how changes in morbidity were not included. The geographic factors used in the filing are consistent with the current approved factors. As is stated in the Actuarial Certification, the geographic rating factors reflect only differences in the costs of delivery and do not include differences for population morbidity by geographic area. 40. Please provide detail on the alternative method used for the AV calculation, the adjustments to the benefits used in the AV calculator (approach 1) and show calculations of the adjustments. Please see the worksheet named “AV Calculator” in the file named “PID_Response_Exhibits_GQO_SG_062119.xlsx”.

41. Please comment on whether the care management efforts between the HMO, POS and PPO products vary. If so, wouldn’t the retention costs also vary? Care management efforts do not vary by product. 42. Please provide discussion and mapping document discussing whether or not members from plans terminated in 2018 were mapped to new or existing plans in 2019. Please see the worksheet named “2018 to 2019 Mapping” of the file named “PID_Response_Exhibits_GQO_SG_062119”. This shows that all the discontinued 2018 plans were mapped to 2019 plans and is also shown on Table 10 of the 2019 filing. 43. Please provide total amount of reserves. The year end reserve for CY2018 for GQO Small Group ACA is $6,676,366. 44. Please provide discussion of any changes to pharmacy formulary and where those changes were reflected in the trends. The routine changes to the formulary that occur every year are included in the trend regression analysis without any explicit adjustment. There were no significant formulary changes brought up in discussion with the pharmacy team when developing the trend projections. 45. For the expanded Bronze plans, please demonstrate that the copay is less than or equal to the 50% coinsurance for that category. The professional copays on the expanded bronze plans for primary and specialty care are below 50% coinsurance. The expanded bronze plans in this market have a primary care copay of $30 and a specialty copay of $60. Projected average cost per visit for this population for primary care is $96 and for specialty is $195. 46. Please provide an exhibit that quantitatively shows a comparison of the actual to projected claim cost pmpms for calendar years 2015 – 2018, as applicable. Please see the worksheet named “Projected vs Actual” of the file named “PID_Response_Exhibits_GQO_SG_062119.xlsx”. 47. Please provide an exhibit showing the actual experience for calendar years 2014 – 2018 and the projections for 2019 for the following categories: Member months, total administrative expenses, total incurred claims, total premium, total actual paid taxes and fees, profit, annual underwriting gain/loss and underwriting gain/loss pmpy. Also show how this reconciles with the Annual Financial Statements for those periods. financial gains and losses. Please see the worksheet named “Financial Performance” of the file named “PID_Response_Exhibits_GQO_SG_062119.xlsx”. This requested information does not include the risk adjustment transfer payments and does not accurately reflect the experience of this market. Annual Financial Statements are reported on a paid basis and do not reconcile to this data as shown since it is on an incurred basis. 48. We have repurposed row 54 to capture RA User Fees. Please provide the RA User Fee percentage and pmpm amount in cells C54 and D54, respectively. The filing has been updated to reflect this change. The RA User Fee has been moved from Table 5 to Table 6. This has slightly changed the rate projections due to moving this fee out of the Index Rate and into taxes and fees. 49. Please explain the derivation of the Health Insurance Provider fee included in the Taxes tab of the additional exhibits worksheet. In particular, explain the development of the Expected Premium from Data Year and Premium in fee year. Please see the worksheet named “Taxes” of the file named “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”. The expected national premium and

expected Geisinger premium in the data year are based on historical totals trended to the data year period at an assumed 7% annual trend. Geisinger premium is total entity premium for all markets that are subject to this fee. The data year Geisinger premium is adjusted as required to calculate the net premium. The estimated fee is then determined as Geisinger premium divided by national premium, multiplied by the applicable amount. a. Provide the actual paid HIT fees on a pmpm and percent of premium for calendar years 2018 and 2016. Please see the worksheet named “HIT” of the file named “PID_Response_Exhibits_GQO_SG_062119.xlsx”. This fee is determined for all insurance markets and Geisinger entities combined and does not reflect the % of premium or PMPM for any specific entity and/or market. Each of the ACA market rate filings assigns a % of premium charge appropriately using the methodology shown on the worksheet named “Taxes” in the file named “PA_Act_Memo_Additional_Exhibits_GQO_SmGrp_051519.xlsx”. 50. The PA AM indicates that a new tiered provider network is being offered in areas 3,6,7 and 9 with a network factor of 1.00. The All-Access PPO network also has a network factor of 1.00 and is offered in areas 1,2,3,5,6,7 and 9. Both networks will be offered in areas 3, 6, 7 and 9. Please discuss the differences in these networks and why they both have a factor of 1.00. The new tiered network is filed and approved as a distinct network offered only in a limited number of counties. The providers and the contracts in both networks are the same. There is no network adjustment applied, therefore both have a 1.00 factor. 51. Please confirm that you have tested to ensure that the PID rate exhibits and the Federal rates template included in this filing and in the binder are all the same. Confirmed.

Geisinger Quality OptionsSmall Group Filing for 2020AV Calculator Adjustment to Pharmacy Cost Sharing

Tier Desc. % Allowed AV Calculator Tier % AllowedZero 12%Generic Preferred 13%Generic NonPreferred 75% Generic 100%

Total 100% 100%

By Drug Plan IDTier Desc. PAF001 PAF002 PAF003 PAF004 PAF005 PAF006 PAF007 PAF008 PAF009 PAF010 PAF011 PAF012Zero $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0% $0.00Generic Preferred $0.00 $0.00 $10.00 $3.00 $3.00 $5.00 $3.00 $3.00 $3.00 $3.00 0% $3.00Generic NonPreferred $0.00 $1.00 $20.00 $15.00 $5.00 $15.00 $15.00 $20.00 $20.00 $20.00 0% $15.00

AV Calculator Tier PAF001 PAF002 PAF003 PAF004 PAF005 PAF006 PAF007 PAF008 PAF009 PAF010 PAF011 PAF012Generic $0.00 $0.75 $16.30 $11.64 $4.14 $11.90 $11.64 $15.39 $15.39 $15.39 0% $11.64

Geisinger Quality OptionsSmall Group Filing for 2020Administrative Expense Distribution

CY20Customer Services 13%Medical Management 15%Information Technology 11%Finance/Actuarial/Underwriting 8%Out-of-Ntwk Claims Repricer Fees 5%Sales 14%Product Dev & Mkt Research 3%Marketing 1%Government Programs Regulatory 1%Provider Network Management 1%Overhead 28%Total 100%

Geisinger Quality OptionsSmall Group Filing for 2020Capitation History

2015 2016 2017 2018 2019 2020Chiropractic Coverage: $0.74 $0.78 $0.72 $0.22 $0.60 $0.24

Nurseline: $0.07 $0.32 $0.20 $0.03 $0.04 $0.03Mental Health & Substance Abuse/Autism: $5.43 $7.17 $8.50 $7.85 $7.36 $8.67

Quality Fund/PQS: $3.81 $4.70 $5.01 $6.40 $7.19 $7.08Total Capitation: $10.05 $12.96 $14.43 $14.49 $15.18 $16.02

Trend: 29% 11% 0% 5% 6%

Geisinger Quality OptionsSmall Group Filing for 2020Health Insurance Provider Fee

2016 2018Actual Fee $22,341,452.87 $32,799,320.02Net Premiums Written $2,197,741,157.00 $2,821,808,101.00Member Months 4,862,871 5,317,599 Fee as % of Premium 1.0% 1.2%Fee as PMPM $4.59 $6.17

The Health Insurance Provider Fee is calculated based on all Geisinger insurance operations for all entities and markets.The % of premium and PMPM shown here are not used by Geisinger for any specific entity or market.Geisinger Health Plan is a not-for-profit organization and receives significant reductions to premium in the calculation.Geisinger Quality Options is a for-profit organization which does not qualify for additional exceptions in premium.

Geisinger Quality OptionsSmall Group Filing for 2020Projected versus Actual Comparison

Total Claims Members PMPM Total Claims Members PMPM Total Claims Members PMPM Total Claims Members PMPM1) Projected Claims $16,049,561 41,949 $382.60 $65,728,820 149,262 $440.36 $26,633,221 57,816 $460.65 $33,845,300 65,376 $517.702) Actual Claims $28,065,564 68,787 $408.01 $19,156,308 43,333 $442.07 $41,248,422 98,521 $418.68 $78,201,176 172,899 $452.293) Ratio of Actual to Projected (#2/#1): 1.0664 1.0039 0.9089 0.8737

CY 2015 CY 2016 CY 2017 CY 2018

Geisinger Quality OptionsSmall Group Filing for 2020Financial Performance (PMPM's)

Rating Year Member Months

Total Premium Total Incurred Claims

Total Administrative

Expenses

Total Paid Taxes and Fees

ProfitAnnual

Underwriting Gain/Loss

Underwriting Gain/Loss PMPY

CY2019 Projected 193,128 $123,109,774 $98,291,693 $9,848,782 $4,604,306 $10,364,993 $24,818,081 $1,542

CY2018 172,899 $92,073,231 $78,201,176 $7,558,351 -$400,856 $6,714,559 $13,872,055 $963CY2017 98,521 $50,089,320 $41,248,422 $3,968,279 $1,807,580 $3,065,038 $8,840,897 $1,077CY2016 43,333 $23,489,055 $19,156,308 $1,786,845 -$90,995 $2,636,897 $4,332,747 $1,200CY2015 68,787 $31,191,393 $28,065,564 $3,102,982 -$228,443 $251,290 $3,125,829 $545CY2014 55,985 $22,217,731 $18,196,670 $2,141,473 -$622,736 $2,502,323 $4,021,061 $862

This requested information does not include the risk adjustment transfer payments and does not accurately reflect the experience of this market.

Geisinger Quality OptionsSmall Group Filing for 20202018 to 2019 Mapping


Component)


Indemnity, Other)1/1/2018 Plan

Marketing Name

Existing, Modified, New, Discontinued & Mapped,

Discontinued & Not Mapped (E,M,N,DM, DNM)

for 2019

1/1/2019 Plan HIOS Plan ID (If 1/1/2018 Plan

Discontinued & Mapped)Plan 1 75729PA0050050 PPO Geisinger Marketplace PPO 15/30/0 DM 75729PA0050129Plan 2 75729PA0050051 PPO Geisinger Marketplace PPO 10/20/0 DM 75729PA0050128Plan 3 75729PA0050052 PPO Geisinger Marketplace PPO 25/50/500 DM 75729PA0050130Plan 4 75729PA0050062 PPO Geisinger Marketplace QHDHP PPO 6500 E 75729PA0050062Plan 5 75729PA0050066 PPO Geisinger Marketplace Extra PPO 10/40/0 DM 75729PA0050131Plan 6 75729PA0050068 PPO Geisinger Marketplace Extra PPO 10/60/500 E 75729PA0050068Plan 7 75729PA0050069 PPO Geisinger Marketplace Extra PPO 10/50/1000 DM 75729PA0050132Plan 8 75729PA0050070 PPO Geisinger Marketplace PPO 20/40/1000 E 75729PA0050070Plan 9 75729PA0050071 PPO Geisinger Marketplace PPO 25/50/2750 E 75729PA0050071Plan 10 75729PA0050072 PPO Geisinger Marketplace Extra PPO 20/60/6250 DM 75729PA0050134Plan 11 75729PA0050073 PPO Geisinger Marketplace PPO 30/60/6000 E 75729PA0050073Plan 12 75729PA0050075 PPO Geisinger Marketplace PPO 25/50/6750 E 75729PA0050075Plan 13 75729PA0050078 PPO Geisinger Marketplace QHDHP PPO 2000 E 75729PA0050078Plan 14 75729PA0050079 PPO Geisinger Marketplace QHDHP PPO 4000 E 75729PA0050079Plan 15 75729PA0050080 PPO Geisinger Marketplace PPO 15/30/250 E 75729PA0050080Plan 16 75729PA0050082 PPO Geisinger Marketplace Extra PPO 10/40/250 E 75729PA0050082Plan 17 75729PA0050083 PPO Geisinger Marketplace Extra PPO 10/50/2000 DM 75729PA0050133Plan 18 75729PA0050084 PPO Geisinger Marketplace Select PPO 10/20/0 DM 75729PA0050128Plan 19 75729PA0050086 PPO Geisinger Marketplace Select PPO 15/30/0 DM 75729PA0050129Plan 20 75729PA0050087 PPO Geisinger Marketplace Select PPO 15/30/250 DM 75729PA0050080Plan 21 75729PA0050088 PPO Geisinger Marketplace Select PPO 25/50/500 DM 75729PA0050130Plan 22 75729PA0050089 PPO Geisinger Marketplace Select PPO 20/40/1000 DM 75729PA0050070Plan 23 75729PA0050091 PPO Geisinger Marketplace Select PPO 25/50/2750 DM 75729PA0050071Plan 24 75729PA0050093 PPO Geisinger Marketplace Select PPO 30/60/6000 DM 75729PA0050073Plan 25 75729PA0050094 PPO Geisinger Marketplace Select PPO 25/50/6750 DM 75729PA0050075Plan 26 75729PA0050096 PPO Geisinger Marketplace PPO 30/60/3500 E 75729PA0050096Plan 27 75729PA0050097 PPO Geisinger Marketplace Extra PPO 20/60/3500 E 75729PA0050097Plan 28 75729PA0050098 PPO Geisinger Marketplace Select PPO 30/60/3500 DM 75729PA0050096Plan 29 75729PA0050099 PPO Geisinger Marketplace PPO 20/50/5000 DM 75729PA0050106Plan 30 75729PA0050100 PPO Geisinger Marketplace Extra PPO 10/50/5000 DM 75729PA0050108Plan 31 75729PA0050101 PPO Geisinger Marketplace Select PPO 20/50/5000 DM 75729PA0050106Plan 32 75729PA0050110 PPO Geisinger Marketplace Options PPO 10/20/0 N 75729PA0050110Plan 33 75729PA0050116 PPO Geisinger Marketplace Options PPO 10/20/0 N 75729PA0050116Plan 34 75729PA0050122 PPO Geisinger Marketplace Options PPO 10/20/0 N 75729PA0050122Plan 35 75729PA0050109 PPO Geisinger Marketplace Options PPO 10/20/250 N 75729PA0050109Plan 36 75729PA0050115 PPO Geisinger Marketplace Options PPO 10/20/250 N 75729PA0050115Plan 37 75729PA0050121 PPO Geisinger Marketplace Options PPO 10/20/250 N 75729PA0050121Plan 38 75729PA0050111 PPO Geisinger Marketplace Options PPO 20/40/500 N 75729PA0050111Plan 39 75729PA0050117 PPO Geisinger Marketplace Options PPO 20/40/500 N 75729PA0050117Plan 40 75729PA0050123 PPO Geisinger Marketplace Options PPO 20/40/500 N 75729PA0050123Plan 41 75729PA0050112 PPO Geisinger Marketplace Options PPO 20/40/1000 N 75729PA0050112Plan 42 75729PA0050118 PPO Geisinger Marketplace Options PPO 20/40/1000 N 75729PA0050118Plan 43 75729PA0050124 PPO Geisinger Marketplace Options PPO 20/40/1000 N 75729PA0050124Plan 44 75729PA0050113 PPO Geisinger Marketplace Options PPO 20/40/2000 N 75729PA0050113Plan 45 75729PA0050119 PPO Geisinger Marketplace Options PPO 20/40/2000 N 75729PA0050119Plan 46 75729PA0050125 PPO Geisinger Marketplace Options PPO 20/40/2000 N 75729PA0050125Plan 47 75729PA0050114 PPO Geisinger Marketplace Options PPO 20/40/4000 N 75729PA0050114Plan 48 75729PA0050120 PPO Geisinger Marketplace Options PPO 20/40/4000 N 75729PA0050120Plan 49 75729PA0050126 PPO Geisinger Marketplace Options PPO 20/40/4000 N 75729PA0050126Plan 50 75729PA0050108 PPO Geisinger Marketplace Extra PPO 20/60/4000 N 75729PA0050108Plan 51 75729PA0050102 PPO Geisinger Marketplace PPO 20/40/500 N 75729PA0050102Plan 52 75729PA0050103 PPO Geisinger Marketplace PPO 20/40/1500 N 75729PA0050103Plan 53 75729PA0050104 PPO Geisinger Marketplace PPO 25/50/2000 N 75729PA0050104Plan 54 75729PA0050127 PPO Geisinger Marketplace PPO 25/50/2000 1xded N 75729PA0050127Plan 55 75729PA0050105 PPO Geisinger Marketplace PPO 35/70/4000 N 75729PA0050105Plan 56 75729PA0050106 PPO Geisinger Marketplace PPO 35/70/5000 N 75729PA0050106Plan 57 75729PA0050107 PPO Geisinger Marketplace PPO 40/90/7000 N 75729PA0050107

TREND DOCUMENTATION Utilization trends were determined by analyzing historical trend patterns and using regression analysis to project future utilization per 1000 members. These projected trends were adjusted to account for medical management initiatives that have taken place or will take place in future time periods. The adjustments to the regression analysis were determined during meetings with Actuarial Services, Medical Management and/or Pharmacy Department leadership. Unit Cost trends are determined by using a Unit Cost Forecast Model maintained by our Actuarial Services and Provider Network Management teams. The forecast model determines future unit cost trends for Inpatient, Outpatient and Professional services using expected contract unit cost changes and historical provider mix. There are also adjustments made to the pharmacy unit cost trends to account for expected pharmacy changes as suggested by our Pharmacy Department leadership. There is an additional mix trend component included in all the trends which was developed to account for an overall impact of intensity/mix. This trend component encompasses changes in provider mix, changes in unit cost intensity, increased costs due to technology, provider coding changes just to name a few. We have used the experience of our HMO and PPO Large Group market to develop our trends. This ensures we have credible data for the development of trends for all markets. The provider contracts are the same for all Commercial products. Inpatient trends: Unit Cost trends are determined using the Unit Cost Forecast Model as explained above. From discussions with our Medical Management leadership we adjust inpatient utilization trends from the regression analysis for medical management initiatives when appropriate. Outpatient trends: Unit Cost trends are determined using the Unit Cost Forecast Model as explained above. From discussions with our Medical Management leadership we adjust outpatient utilization trends from the regression analysis for medical management initiatives when appropriate. Professional trends: Unit Cost trends are determined using the Unit Cost Model as explained above. From discussions with our Medical Management leadership we adjust outpatient utilization trends from the regression analysis for medical management initiatives when appropriate. Pharmacy trends: Pharmacy trends are selected using regression analysis and actuarial judgement after having discussions with our Pharmacy Department leadership about their expectation of future pharmacy costs. Historical utilization trends are used to separate the total allowed PMPM trend into the utilization, unit cost and mix components. The unit cost trends are calculated from the assumed total allowed PMPM trend removing the utilization and mix components. The increase in unit cost trend is to account for increased costs in specialty and high cost biologics which are not accounted for in the historical trends or in our regression analysis.

Geisinger Quality Options Small Group Filing for 2020 Response to Questions Round 2 SERFF Tracking Number: GSHP-131915683 1. Follow up to question 5 and 6: Thank you for the additional exhibit requested. What we are looking for is the benefit change factors used for plans that had benefit changes, such as the MOOP and deductible increasing. For those plans, we would like to see how the benefit changes affected the pricing AV values, so we can determine the reasonableness of the resulting pricing AVs as compared to what they would be without the benefit changes. Please provide the breakdown by plan to show the change in pricing AV without benefit changes and the pricing AV with the benefit changes and the effect of the benefit changes themselves. Please see the worksheet named “Benefit Changes” of the file named “PID_Response_Exhibits_GQO_SG_071219.xlsx”. 2. Follow up to question 9: Did some large claims come in relatively late that decreased the completion factors for July 2017 and February 2018? Were claims being held for a large provider until a contract could be settled? Please provide logical reasoning behind these factors. There are high dollar accruals effecting the factors. These are for claims that we are expecting to pay, but, have not paid yet. For July 2017, we have one claim for $300k and for Feb 2018 we have 2 claims, one for $200k and the other one for $150k. 3. Follow up to question 10: We disagree that Table 4 in the original and revised PAAM exhibits (and new Table 4c) do not include capitation or prescription drug rebates in the paid claims column. Using values shown in Table 2 for paid and ultimate incurred to compare to the sum of the values shown in Table 4 for the incurred claims column (paid) and the ultimate incurred claims column over each month in CY2018, you can see that the difference in the values equals the capitation and prescription drug rebate. Thus, the question remains to be answered. Please explain why the prescription drug rebates and capitation are included in the paid claims in Table 4 such that the completion factors are applied to the rebates and capitation. Please explain whether these amounts were also included in the derivation of the IBNP factors used. We have removed capitation from all columns and added back in prescription drug rebates to incurred claims and ultimate incurred claims columns in the worksheet named “Table 4c” of the file named “PID_Response_Exhibits_GQO_SG_071219.xlsx”. As previously stated, capitation is not included in the derivation of completion and completion was not applied to capitation expense. Prescription drug rebates are not included in the derivation of completion and completion was not applied to prescription drug rebates. We have populated each version of Table 4 with the claims experience from our data systems. Completion is applied at the claim level within our data systems. We are not applying a completion factor at the level of detail shown in Table 4. We are simply providing the claims data and the completion factor at this level to accurately show ultimate incurred claims in the format provided. 4. Follow up to question 11 and 13: Table 4b you state is large group experience, which you use for trends. Since Table 2b and Table 4b do not match, please correct Table 4c provided with your responses to reflect the values in Table 2b. These should be the Table 4c values except please remove the

capitation and prescription drug rebates from the values in Table 4c in the incurred claims and ultimate incurred claims columns. You can tell they are included in Table 4c by adding the ultimate incurred for each of the months in calendar 2018, then subtracting the total capitation and prescription drug rebates listed in Table 2b, which results in the ultimate incurred claims (and paid claims) prior to capitation and prescription drug rebates shown in Table 2b. In addition, the completion factors shown in Table 4b, you state, are based on large group experience. The PAAM Actuarial Memorandum on page 3 states that, “The IBNR factors were based on legal-entity level claims completion tables which include individual and group experience.” When you update Table 4c values to equal values on Table 2b, please show the IBNR factors based on the experience used and described in the Actuarial Memorandum. We note that with the addition of Table 4c provided in your response, there are now 3 different sets of completion factors shown. It is correct that Table 4, Table 4b and Table 4c all include different claims. Table 4 includes claims for GQO small group ACA market only. This data is not used in developing trends, therefore, Table 4b is provided and includes the claims of our commercial large group market. Table 4c is the combined GHP and GQO claims data for the small group ACA market as requested. We have removed capitation from all columns and we have also added prescription drug rebates to the incurred claims and ultimate incurred claims columns in the worksheet named “Table 4c” of the file named “PID_Response_Exhibits_GQO_SG_071219.xlsx”. Upon further review, the sentence referenced on page 3 of the Actuarial Memorandum is confusing and perhaps misleading. The completion factors are determined separately by entity and market, meaning individual completion factors are developed separate from group completion factors. We have changed the sentence in the memo to “The IBNR factors were based on legal-entity and market segment level claim lag tables. claims completion tables which include individual and group commercial experience.” 5. Follow up to question 15: Please provide qualitative and quantitative support for the unit cost trends for inpatient, outpatient and professional. Explain occurrences driving the unit cost trend lower for outpatient hospital. Tables reflecting changes in contracted rates with distributions of expected usage by contract would be appropriate. Unit Cost trends are determined by using a Unit Cost Forecast Model maintained by our Actuarial Services and Provider Network Management teams. The forecast model estimates future unit cost trends for Inpatient, Outpatient and Professional services using expected contract unit cost changes and historical provider mix. Our interpretation of the ‘Instructions” tab of the Completeness and Redaction Checklist was that the Department would not request specific provider contract information. Due to Geisinger’s size, providing contract specific information would be detrimental to our competitive position. 6. Follow up to question 19: Please provide quantitative support including historical analysis with adjustments for forward looking changes used to develop the utilization and induced demand trends. Include items mentioned on page 4 of the Actuarial memorandum for the medical management savings. Please see the worksheet named “Explanation” in the file named “PID_Response_Trend_Support_071219.xlsx”. 7. Follow up to question 20b: The document provided entitled, “VBRS Memo FINAL-Shared.pdf” does not describe any change in the underlying network. Based on the description of the accounting for this

arrangement, this seems more like a unit cost trend factor, to account for different contractual arrangements. The supporting correspondence indicates that this arrangement was approved by the PID. a. Please provide the details of the PID approval. The PID approval is the file named “Geisinger PID IDS ltr of no objection 18_08_10.pdf”. b. The Department’s website shows instructions for filing HMO/IDS arrangements but do not reference PPOs. Please discuss where guidance is provided for the PPO/IDS arrangement. In submitting the VBRS arrangement to the Department, we filed the HMO and PPO together, following the HMO instructions that provide for filing the arrangement with the Department following initial submission to Department of Health. c. What percentage of the ACA population is covered by this arrangement. The small group ACA population as of February 2019 has about 84% of the population covered by the VBRS arrangement. 8. Follow up to question 20c: As previously requested, please provide quantitative and qualitative support for the development of the 0.93 network factor. Include numerical effect on 2018, and the projection to 2020 claims to account for a full year’s effect versus only a half year’s effect in the base period, savings on utilization expected, etc., as appropriate. The Global Risk Arrangement defines a new relationship with our clinical enterprise, through the Value Based Risk Share (VBRS). Our network factor on Table 5 is our best representation of the impact the VBRS will have on the Small Group GHP market. It would not be meaningful to review historical claims when valuing this prospective risk arrangement. 9. Follow up to question 22: Please fully describe what the Quality Fund/PQS payment is for, what services are provided, whether it is an incentive program. Quality Fund/PQS are provider pay-for-quality incentive programs with the intent of improving HEDIS results. Quality Fund/PQS were allocated to the experience period used in the rate filings based on member months. The funds set aside for the program are paid to the doctors based on their results and are expected to benefit all Geisinger Quality Options and Geisinger Health Plan members utilizing Geisinger Clinic physicians through increased cost efficiency and higher quality care. For financial reporting and federal MLR filing requirements this expense is a medical expense and not an administrative expense. a. Your response did not address why you believe it is appropriate to include this payment in capitation, given the URRT Instructions. Please explain. The URRT instructions provide only “preferred definitions” of service category. We believe capitation is the appropriate category to use since this is the only category using a PMPM value for a fixed expense. This expense should not be included in facility or professional services since this is not billed by facilities or physicians. This program is also not linked to specific services and does not meet the “preferred definition” of other services. This expense is determined annually and allocated by member months, much like a capitated arrangement. 10. Follow up to question 26: We agree that you should include all members, whether a premium is paid or not, since the demographic factor is meant to project changes in claims costs for changes in demographics. Please make this change and update tables and documentation.

The demographic factor used on Table 5 has been updated to include all members. The worksheets named “Feb_Age_Factor” and “Manual_Age_Factor” of the file named “PID_Response_Exhibits_GQO_SG_071219.xlsx” show the calculation of the demographic factor. 11. Follow up to question 27: Please provide the detail with each component of the risk adjustment transfer formula, as requested. Please provide narrative and quantitative support for the 63.7% adjustment to the risk score based on the impact of the coefficient change, providing information on the elements driving the change. We do not have a completed risk adjustment formula calculated and therefore, cannot share each component with you. We have used the 2018 Risk Adjustment transfer payment as the starting point for 2020. We combine our GHP and GQO experience to provide greater consistency and accuracy. We then used the results of the 3rd party consultant’s tool to analyze the impact of the coefficient changes to the model. The tool uses risk scoring components (prevalence rates of condition categories and demographic buckets) and rescoring the risk scores of our population and the market wide population captured in 2018 in their reports using 2020 risk coefficients as published by CMS. The tool does not make any assumption on changes in market morbidity from 2018 to 2020. It only measures the differences in relative risk due to coefficient changes published by CMS. We also note that the market wide population did not include every issuer in PA. 12. Follow up to question 29: We believe that the use of combined data from two separate companies to develop manual rates is not unreasonable. However, when developing each companies separate rates, the induced demand factors must be normalized separately for each companies’ projected experience. Therefore, please update the calculations to reflect the projected member months separately for GHP and GQO. We believe that the combined GHP and GQO experience is our best estimate of the projection period. We continue to see year over year changes in enrollment that make pricing in this market extremely difficult. By separately normalizing the entities rate development we will risk creating adverse selection. We do not agree that the single risk pool regulation requires us to do each entity individually as we are one single issuer. However, as instructed by the rate reviewer, we have changed the induced demand factor normalization as shown in the file named “2020_SmGrp_GQO_PAAMExhibits_071219.xlsx”. 13. Follow up to question 31 and 32c: As previously requested, please provide justification, both qualitative and quantitative, for the induced utilization factors shown in Table 10. Provide source of data, adjustments to remove health status by plan, and calculations for each plan. Stating that the factors do not reflect health status does not allow another actuary to determine the reasonableness of that statement. ASOP 41, section 3.2 states, “In the actuarial report, the actuary should state the actuarial findings, and identify methods, procedures, assumptions, and data used by the actuary with sufficient clarity that another actuary qualified in the same practice area could make an objective appraisal of the reasonableness of the actuary’s work as presented in the actuarial report.” Because Geisinger presents a small piece of the ACA market (less than 15% statewide) we believe the competitor’s data is more credible than ours when trying to determine induced demand for the market. We look to the competitors to ensure the broader accuracy of the induced demand factors we apply.

We have used the competitor’s filings and we are assuming the competitors have made adjustments to remove health status from their analysis as required. 14. Follow up to question 31b: As requested, please show quantitatively, including an Excel spreadsheet with formulas, the derivation of the AV and cost sharing factors for a bronze plan, a silver plan and a gold plan. Geisinger develops the paid to allowed factor shown in Column (6) of the Induced Utilization Exhibit and shown in the Pricing AV column of Table 10 from a rating model that determines a paid to allowed ratio based on the specific plan cost sharing. The rating model uses a claims probability distribution to determine values of deductible, coinsurance and out-of-pocket maximums. The rating model uses average utilization and cost to determine values for copays. We have provided an example of 3 plans in the worksheet named “Pricing AV” of the file named “PID_Response_Exhibits_GQO_SG_071219.xlsx”. 15. Follow up to question 32d: Please update the normalization of the induced utilization factor to reflect GQO membership only. Please see the worksheet named “Induced_Util_Exhibit” of the file named “PID_Response_Exhibits_GQO_SG_071219.xlsx”. 16. Follow up to question 32e and 32 f: As part of the information provided in response to the follow up question 31 and 32c, please provide the pre-normalized values by plan which aggregate to the induced demand factor shown in Table 7 cell K52. Please see column (10) on the worksheet named “Induced_Util_Exhibit” of the file named “PID_Response_Exhibits_GQO_SG_071219.xlsx”. 17. Follow up to question 35: There is a large disparity in the member month projections for GHP (15,900) and GQO (193,128). As noted in question 35, the single risk pool requires the calibration factors for GHP and GQO to be calculated and applied separately. Therefore, please update the calculations to reflect the projected member months separately for GHP and GQO. We believe that the combined GHP and GQO experience is our best estimate of the projection period. We continue to see year over year changes in enrollment that make pricing in this market extremely difficult. By separately calibrating the allowable rating factors for the entities rate development we will risk creating adverse selection. We do not agree that the single risk pool regulation requires us to do each entity individually as we are one single issuer. However, as instructed by the rate reviewer, we have changed the induced demand factor normalization as shown in the file named “2020_SmGrp_GQO_PAAMExhibits_071219.xlsx”. The worksheets named “Age_calibration” and “Area_calibration” of the file named “PID_Response_Exhibits_GQO_SG_071219.xlsx” have also been updated to reflect this change. 18. Follow up to question 40: We think we understand the math behind the alternative method used. However, for documentation purposes, please provide the narrative behind the alternative method used. Geisinger Health Plan uses three separate tiers of generic drugs within the Pharmacy benefit. The three tiers are labeled Zero, Generic Preferred, and Generic Nonpreferred. We use total allowed amounts for each of the three tiers to get the percentage in each tier. We then use these percentages to weight the three copay levels together to get the final generic copay amount used in the AV Calculator for each plan.

19. Follow up to question 47: Financial statements should be on an incurred basis, as IBNP reserves adjust the paid basis to reflect the ultimate incurred. We understand the data requested does not include the risk adjustment transfers. What we are looking for is for you to reconcile these results to the financial statements. Please make those adjustments to show how the results reconcile. We have reviewed the annual financial statements and found that the closest exhibit to reconcile this data is the Analysis of Operations by Lines of Business on page 7. For the years provided, the small group ACA market has made up 7% - 35% of the total GQO experience shown in this exhibit for the commercial market line of business in column 2. The information we supplied in response to question 47 accounts for only 7% - 35% of the underwriting gain (loss) on line 24 of page 7. The remaining 93% - 65% of the underwriting gain (loss) is attributable to other GQO commercial lines of business. This includes ACA individual, non-ACA individual (grandfathered and transitional), small group (transitional) and large group markets. Also, the annual financial statements report premium net of the ACA risk adjustment transfer payments. 20. As requested, you have added the RA User Fees in Table 6. Please identify where offsetting adjustments were made elsewhere. The RA User Fee was previously included in the Projected Risk Adjustment PMPM row of Table 5. We removed the impact of the RA User Fee from Table 5 when we added it into Table 6. 21. In response to the Department’s RADV survey, issuers indicated that they did not include an adjustment in the initial submission, as there was no supportable reason for a RADV adjustment in the 2020 rate submission. Therefore, the Department has determined that there should be no RADV adjustments in the 2020 rate filings; please modify the filing accordingly, if necessary. Acknowledged. We did not make an adjustment for RADV therefore we have no adjustment to make to our filings. 22. If the risk adjustment results released on June 28, 2019 are inconsistent with your projected assumptions, you may modify the risk adjustment transfer amount in Table 5. Supporting documentation must be provided for all modification. If such a modification is made, revise all the documents and exhibits impacted and the PA Actuarial Memorandum to discuss this change. This change must be made with your responses due by July 12, 2019. The risk adjustment results released on June 28, 2019 were consistent with our projected assumptions, therefore no adjustment to our filings have been made.

Geisinger Quality OptionsSmall Group Filing for 2020Calibration of Age Factors

(1) X (2)(2) (1) X (2) (2)

Feb Members Factor X Members Calibation Factor:Total members with premium: 16,006 24,794.70 1.549

Members in 0-20 age with no premium: 88 Total: 16,094

(1) (2) (1) X (2)Min Max HHS defined age curve Members Factor X Members

0 14 0.765 1,985 1,518.53 15 16 0.833 168 139.94 16 17 0.859 191 164.07 17 18 0.885 172 152.22 18 19 0.913 152 138.78 19 20 0.941 201 189.14 20 21 0.970 185 179.45 21 22 1.000 190 190.00 22 23 1.000 233 233.00 23 24 1.000 196 196.00 24 25 1.000 215 215.00 25 26 1.004 235 235.94 26 27 1.024 243 248.83 27 28 1.048 287 300.78 28 29 1.087 292 317.40 29 30 1.119 297 332.34 30 31 1.135 273 309.86 31 32 1.159 277 321.04 32 33 1.183 261 308.76 33 34 1.198 247 295.91 34 35 1.214 279 338.71 35 36 1.222 262 320.16 36 37 1.230 283 348.09 37 38 1.238 250 309.50 38 39 1.246 298 371.31 39 40 1.262 267 336.95 40 41 1.278 255 325.89 41 42 1.302 246 320.29 42 43 1.325 244 323.30 43 44 1.357 281 381.32 44 45 1.397 278 388.37 45 46 1.444 275 397.10 46 47 1.500 320 480.00 47 48 1.563 331 517.35

48 49 1.635 306 500.31 49 50 1.706 330 562.98 50 51 1.786 357 637.60 51 52 1.865 304 566.96 52 53 1.952 342 667.58 53 54 2.040 381 777.24 54 55 2.135 374 798.49 55 56 2.230 355 791.65 56 57 2.333 337 786.22 57 58 2.437 349 850.51 58 59 2.548 359 914.73 59 60 2.603 341 887.62 60 61 2.714 307 833.20 61 62 2.810 296 831.76 62 63 2.873 321 922.23 63 64 2.952 286 844.27 64 200 3.000 492 1,476.00

Min Max HHS defined age curve Members Factor X Members(1) (2) (1) X (2)

Geisinger Quality OptionsSmall Group Filing for 2020Calibration of Area Factors

(1) X (2)(1) (2) (1) X (2) (2)

Region Area Factors Feb Members Factor X Members Calibation Factor:2 0.890 - - 3 0.851 6,843 5,823.39 5 0.910 254 231.14 6 0.959 8,349 8,006.69 7 1.162 153 177.79 9 0.987 495 488.57

16,094 14,727.58 0.915

Geisinger Quality OptionsSmall Group Filing for 2020February Average Age Factor

(1) X (2)(2) (1) X (2) (2)

Feb Members Factor X Members For Manual Relativity:Total members with premium: 17,419 26,982.36 1.549

(1) (2) (1) X (2)Min Max HHS defined age curve Members Factor X Members

0 14 0.765 2,215 1,694.48 15 16 0.833 179 149.11 16 17 0.859 206 176.95 17 18 0.885 185 163.73 18 19 0.913 167 152.47 19 20 0.941 213 200.43 20 21 0.970 196 190.12 21 22 1.000 201 201.00 22 23 1.000 246 246.00 23 24 1.000 211 211.00 24 25 1.000 235 235.00 25 26 1.004 249 250.00 26 27 1.024 265 271.36 27 28 1.048 305 319.64 28 29 1.087 327 355.45 29 30 1.119 325 363.68 30 31 1.135 296 335.96 31 32 1.159 294 340.75 32 33 1.183 291 344.25 33 34 1.198 266 318.67 34 35 1.214 308 373.91 35 36 1.222 280 342.16 36 37 1.230 307 377.61 37 38 1.238 262 324.36 38 39 1.246 316 393.74 39 40 1.262 292 368.50 40 41 1.278 284 362.95 41 42 1.302 268 348.94 42 43 1.325 267 353.78 43 44 1.357 298 404.39 44 45 1.397 300 419.10 45 46 1.444 291 420.20 46 47 1.500 335 502.50 47 48 1.563 359 561.12

48 49 1.635 346 565.71 49 50 1.706 363 619.28 50 51 1.786 381 680.47 51 52 1.865 338 630.37 52 53 1.952 361 704.67 53 54 2.040 413 842.52 54 55 2.135 421 898.84 55 56 2.230 395 880.85 56 57 2.333 372 867.88 57 58 2.437 380 926.06 58 59 2.548 385 980.98 59 60 2.603 372 968.32 60 61 2.714 333 903.76 61 62 2.810 326 916.06 62 63 2.873 346 994.06 63 64 2.952 307 906.26 64 200 3.000 541 1,623.00

Min Max HHS defined age curve - Factor X Members(1) Members (1) X (2)

Geisinger Quality OptionsSmall Group Filing for 2020Average Age Factor in Manual Rate

(1) X (2)(2) (1) X (2) (2)

2018 Member Months Factor X Member Months Manual Enrollment Factor:Total members: 189,767 290,996.75 1.533

February Enrollment Factor:1.549

Table 5 Factor:(1) (2) (1) X (2) 1.010

Min Max HHS defined age curve Members Factor X Members0 14 0.765 25,477 19,489.91

15 16 0.833 2,045 1,703.49 16 17 0.859 2,150 1,846.85 17 18 0.885 2,004 1,773.54 18 19 0.913 2,193 2,002.21 19 20 0.941 2,109 1,984.57 20 21 0.970 2,041 1,979.77 21 22 1.000 2,355 2,355.00 22 23 1.000 2,444 2,444.00 23 24 1.000 2,325 2,325.00 24 25 1.000 2,479 2,479.00 25 26 1.004 2,605 2,615.42 26 27 1.024 2,640 2,703.36 27 28 1.048 3,587 3,759.18 28 29 1.087 3,673 3,992.55 29 30 1.119 3,245 3,631.16 30 31 1.135 3,157 3,583.20 31 32 1.159 3,139 3,638.10 32 33 1.183 2,979 3,524.16 33 34 1.198 3,316 3,972.57 34 35 1.214 3,470 4,212.58 35 36 1.222 3,147 3,845.63 36 37 1.230 3,145 3,868.35 37 38 1.238 3,434 4,251.29 38 39 1.246 3,327 4,145.44 39 40 1.262 2,896 3,654.75 40 41 1.278 3,043 3,888.95 41 42 1.302 3,192 4,155.98 42 43 1.325 2,959 3,920.68 43 44 1.357 3,165 4,294.91 44 45 1.397 3,038 4,244.09 45 46 1.444 3,423 4,942.81 46 47 1.500 3,730 5,595.00 47 48 1.563 3,746 5,855.00 48 49 1.635 3,600 5,886.00 49 50 1.706 4,289 7,317.03 50 51 1.786 3,419 6,106.33 51 52 1.865 3,995 7,450.68 52 53 1.952 4,438 8,662.98 53 54 2.040 4,829 9,851.16 54 55 2.135 4,400 9,394.00 55 56 2.230 3,918 8,737.14

56 57 2.333 4,212 9,826.60 57 58 2.437 4,154 10,123.30 58 59 2.548 4,083 10,403.48 59 60 2.603 3,586 9,334.36 60 61 2.714 3,468 9,412.15 61 62 2.810 3,692 10,374.52 62 63 2.873 3,377 9,702.12 63 64 2.952 3,137 9,260.42 64 200 3.000 5,492 16,476.00

Min Max HHS defined age curve Members Factor X Members(1) (2) (1) X (2)

Geisinger Quality OptionsSmall Group Filing for 2020Benefit Changes

2020 Plan Name HIOS IDs Plan Changes 2019 Pricing AV2020 Pricing AV

Before Plan Changes

2020 Pricing AV Impact of Plan Changes

Geisinger All-Access PPO 10/20/0 75729PA0050128 MOOP increased 2000 to 2900 0.981 0.991 0.985 -0.006Geisinger All-Access PPO 15/30/0 75729PA0050129 No Changes 0.971 0.983

Geisinger All-Access PPO 15/30/1500 75729PA0050136 New Plan 0.902Geisinger All-Access PPO 15/30/250 75729PA0050080 No Changes 0.939 0.946

Geisinger All-Access PPO 20/40/1000 75729PA0050070MOOP increased 7350 to 8150, OP Facility

copay increased 100 to 125 0.881 0.890 0.888 -0.002

Geisinger All-Access PPO 20/40/1500 75729PA0050103 No Changes 0.860 0.871

Geisinger All-Access PPO 20/40/500 75729PA0050102

MOOP increased 7350 to 8150, ER copay increased 150 to 200, Imaging copay

increased 150 to 200, OP Facility copay increased 150 to 200

0.911 0.921 0.917 -0.004

Geisinger All-Access PPO 25/50/2000 75729PA0050104 No Changes 0.837 0.854Geisinger All-Access PPO 25/50/2000 1xded 75729PA0050127 No Changes 0.853 0.869

Geisinger All-Access PPO 25/50/2750 75729PA0050071 No Changes 0.822 0.842Geisinger All-Access PPO 25/50/4500 1xded 75729PA0050137 New Plan 0.830

Geisinger All-Access PPO 25/50/500 75729PA0050130 No Changes 0.849 0.869Geisinger All-Access PPO 25/50/6750 75729PA0050075 No Changes 0.704 0.750Geisinger All-Access PPO 30/60/3500 75729PA0050096 No Changes 0.797 0.821Geisinger All-Access PPO 30/60/6000 75729PA0050073 No Changes 0.713 0.756

Geisinger All-Access PPO 35/70/4300 75729PA0050105MOOP increased 7500 to 8150, Deductible

increased 4000 to 4300, Imaging copay increased 150 to 200

0.761 0.795 0.786 -0.009

Geisinger All-Access PPO 35/70/5000 75729PA0050106 MOOP increased 7500 to 7700 0.743 0.781 0.780 -0.001

Geisinger All-Access PPO 40/90/7200 75729PA0050107MOOP increased 7000 to 7200, Deductible

increased 7000 to 7200 0.680 0.724 0.719 -0.005

Geisinger All-Access QHDHP PPO 1500 75729PA0050135 New Plan 0.915Geisinger All-Access QHDHP PPO 20/40/1500 75729PA0050138 New Plan 0.895

Geisinger All-Access QHDHP PPO 2100 75729PA0050078MOOP increased 2000 to 2100, Deductible

increased 2000 to 2100 0.861 0.888 0.883 -0.005

Geisinger All-Access QHDHP PPO 4100 75729PA0050079MOOP increased 4000 to 4100, Deductible

increased 4000 to 4100 0.762 0.794 0.790 -0.004

Geisinger All-Access QHDHP PPO 6500 75729PA0050062 No Changes 0.665 0.709Geisinger Choices PPO 10/20/0 75729PA0050140 New Plan 0.941Geisinger Choices PPO 10/20/0 75729PA0050144 New Plan 0.941Geisinger Choices PPO 10/20/0 75729PA0050148 New Plan 0.941

Geisinger Choices PPO 20/40/1000 75729PA0050141 New Plan 0.842Geisinger Choices PPO 20/40/1000 75729PA0050145 New Plan 0.842Geisinger Choices PPO 20/40/1000 75729PA0050149 New Plan 0.842Geisinger Choices PPO 20/40/2000 75729PA0050142 New Plan 0.807Geisinger Choices PPO 20/40/2000 75729PA0050146 New Plan 0.807Geisinger Choices PPO 20/40/2000 75729PA0050150 New Plan 0.807Geisinger Choices PPO 20/40/4000 75729PA0050143 New Plan 0.752Geisinger Choices PPO 20/40/4000 75729PA0050147 New Plan 0.752Geisinger Choices PPO 20/40/4000 75729PA0050151 New Plan 0.752

Geisinger Extra PPO 10/40/0 75729PA0050131 MOOP increased 1500 to 1600 0.925 0.959 0.957 -0.002Geisinger Extra PPO 10/40/250 75729PA0050082 No Changes 0.899 0.933

Geisinger Extra PPO 10/60/1000 75729PA0050132 No Changes 0.832 0.860Geisinger Extra PPO 10/60/2000 75729PA0050133 No Changes 0.793 0.826

Geisinger Extra PPO 10/60/500 75729PA0050068MOOP increased 7350 to 8150, IP copay increased 100 to 150, OP Facility copay

increased 100 to 1250.855 0.883 0.880 -0.003

Geisinger Extra PPO 20/60/3500 75729PA0050097 No Changes 0.754 0.793

Geisinger Extra PPO 20/60/4300 75729PA0050108MOOP increased 7500 to 8150, Deductible

increased 4000 to 4300 0.721 0.769 0.761 -0.008

Geisinger Extra PPO 20/60/6250 75729PA0050134 No Changes 0.694 0.749

Geisinger Quality OptionsSmall Group Filing for 2020Pricing AV Example

Plan Name:Geisinger PPO 20/40/1000

Geisinger PPO 30/60/6000

Geisinger QHDHP PPO 6500

HIOS ID: 75729PA0050070 75729PA0050073 75729PA0050062Metallic Level: Gold Silver BronzePricing AV Table 10: 0.888 0.756 0.709

Benefit Component Cost Sharing Value Cost Sharing Value Cost Sharing ValuePCP 0% 1% 0%SPC 1% 1% 0%Skilled Nursing Facility 0% 0% 0%Urgent Care 0% 0% 0%PT/OT/ST 0% 0% 0%ER 1% 1% 0%IP (inc MH) 0% 0% 0%OP Surgery 0% 0% 0%MRI/CAT/PET 0% 0% 0%Pharmacy 6% 5% 7%Coinsurance 0% 0% 0%Deductible 6% 24% 23%MOOP -2% -6% 0%Out-of-Network -2% -2% -2%

Pricing AV 0.888 0.756 0.709

Geisinger Quality OptionsSmall Group Filing for 2020Table 4c. Historical Experience for GHP and GQO Combined

Month-Year Total Annual Premium

Incurred 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-15 $ 7,425,192.89 1.0000 $ 7,425,192.89 19,919 $ 372.77 $ (110,408.47) $ 8,223,895.50 $ 412.87 Feb-15 $ 6,501,370.27 1.0000 $ 6,501,370.27 19,523 $ 333.01 $ (98,819.09) $ 7,210,731.87 $ 369.35 Mar-15 $ 6,875,671.97 1.0000 $ 6,875,671.97 18,882 $ 364.14 $ (113,736.26) $ 7,616,717.73 $ 403.39 Apr-15 $ 7,317,220.55 1.0000 $ 7,317,220.55 18,372 $ 398.28 $ (129,693.11) $ 8,060,186.83 $ 438.72

May-15 $ 6,319,904.20 1.0000 $ 6,319,904.20 17,769 $ 355.67 $ (114,990.74) $ 6,964,932.53 $ 391.97 Jun-15 $ 6,469,039.27 1.0000 $ 6,469,039.27 17,364 $ 372.55 $ (112,779.01) $ 7,118,855.97 $ 409.98 Jul-15 $ 6,900,218.06 1.0000 $ 6,900,218.06 16,949 $ 407.12 $ (112,206.45) $ 7,556,177.09 $ 445.82

Aug-15 $ 6,233,388.77 1.0000 $ 6,233,388.77 16,672 $ 373.88 $ (104,273.50) $ 6,808,849.28 $ 408.40 Sep-15 $ 5,934,102.03 1.0000 $ 5,934,102.03 16,333 $ 363.32 $ (112,050.37) $ 6,507,894.45 $ 398.45 Oct-15 $ 6,061,979.46 1.0000 $ 6,061,979.46 15,844 $ 382.60 $ (109,571.76) $ 6,641,239.92 $ 419.16 Nov-15 $ 6,685,756.31 1.0000 $ 6,685,756.31 15,635 $ 427.61 $ (109,715.53) $ 7,229,176.96 $ 462.37 Dec-15 $ 8,332,568.06 1.0000 $ 8,332,568.06 13,664 $ 609.82 $ (90,592.62) $ 8,873,039.69 $ 649.37 Jan-16 $ 6,132,925.35 1.0000 $ 6,132,925.35 13,465 $ 455.47 $ (101,684.71) $ 6,679,121.29 $ 496.04 Feb-16 $ 5,870,077.20 1.0000 $ 5,870,077.20 13,300 $ 441.36 $ (101,070.17) $ 6,430,045.25 $ 483.46 Mar-16 $ 6,080,387.09 1.0000 $ 6,080,387.09 13,320 $ 456.49 $ (106,753.02) $ 6,643,249.36 $ 498.74 Apr-16 $ 5,088,304.33 1.0000 $ 5,088,304.33 13,228 $ 384.66 $ (109,430.47) $ 5,621,789.22 $ 424.99

May-16 $ 5,297,818.54 1.0000 $ 5,297,818.54 12,992 $ 407.78 $ (107,503.88) $ 5,807,157.16 $ 446.98 Jun-16 $ 5,041,319.86 1.0000 $ 5,041,319.86 12,910 $ 390.50 $ (100,545.46) $ 5,525,299.01 $ 427.99 Jul-16 $ 5,254,203.30 1.0000 $ 5,254,203.30 12,964 $ 405.29 $ (120,743.34) $ 5,741,642.39 $ 442.89


May-17 $ 5,502,438.95 1.0000 $ 5,502,438.95 13,682 $ 402.17 $ (105,113.65) $ 6,033,068.81 $ 440.95 Jun-17 $ 5,424,758.77 1.0000 $ 5,424,758.77 13,752 $ 394.47 $ (96,634.77) $ 5,893,416.83 $ 428.55 Jul-17 $ 5,162,003.10 0.9495 $ 5,436,620.46 13,978 $ 388.94 $ (94,899.39) $ 5,944,115.36 $ 425.25


May-18 $ 7,026,512.38 0.9995 $ 7,030,097.99 16,069 $ 437.49 $ (117,335.86) $ 7,822,724.65 $ 486.82 Jun-18 $ 6,369,719.63 0.9994 $ 6,373,515.58 15,982 $ 398.79 $ (116,600.52) $ 7,057,992.44 $ 441.62 Jul-18 $ 6,281,970.70 0.9978 $ 6,295,993.89 15,839 $ 397.50 $ (158,019.86) $ 6,916,753.56 $ 436.69

Aug-18 $ 6,739,512.03 0.9984 $ 6,750,250.36 15,699 $ 429.98 $ (165,698.18) $ 7,396,150.30 $ 471.12 Sep-18 $ 6,222,691.40 0.9953 $ 6,251,858.84 15,525 $ 402.70 $ (134,193.02) $ 6,875,402.10 $ 442.86 Oct-18 $ 7,643,819.29 0.9915 $ 7,709,282.80 15,516 $ 496.86 $ (163,654.31) $ 8,401,929.80 $ 541.50 Nov-18 $ 6,924,754.53 0.9779 $ 7,080,996.58 15,368 $ 460.76 $ (160,184.67) $ 7,675,215.61 $ 499.43 Dec-18 $ 6,209,611.04 0.8612 $ 7,210,747.55 15,023 $ 479.98 $ (129,993.47) $ 7,904,361.20 $ 526.15 $ 99,607,881.48 $ 10,076,991.08

$ 88,494,424.60 $ 9,074,122.89

$ 81,665,733.38 $ 7,727,279.45

$ 85,670,666.36 $ 7,778,264.43

Geisinger Quality Options Small Group Filing for 2020 Response to Questions Round 3 SERFF Tracking Number: GSHP-131915683 1. Follow up to Question 8 of Letter 2: As previously requested, please provide quantitative and qualitative support for the development of the 0.93 network factor. Include numerical effect on 2018, and the projection to 2020 claims to account for a full year’s effect versus only a half year’s effect in the base period, savings on utilization expected, etc., as appropriate. Stating that the factor “is the best representation of the impact” does not allow another actuary to determine the reasonableness of this assumption. When projecting a change, it is typical that experience is used to apply the prospective changes when modeling the potential effect. Therefore, historical experience is appropriate and meaningful to consider the effect of this prospective arrangement. Show the adjustments assumed to the historical experience to get to the 0.93 factor. The exhibit on worksheet named “Network Factor” in the file named “PID_Response_round3_Exhibits_GQO_SmGrp_071919.xlsx” has been provided to demonstrate the reduction in overall claim PMPM for the small group ACA market in our emerging experience. This reduction in claim expense PMPM is sufficient evidence for the clinical enterprise to take on additional risk under the Global Risk Arrangement consistent with the Change in Network factor utilized in our filing. 2. Follow up to Question 11 of Letter 2: You provided a narrative describing the 63.7% adjustment to the risk score based on the impact of the coefficient change; however, you provided no quantitative information. Please provide a summary showing the risk scores before the new coefficients are used and the risk scores after the new coefficients are used that support the 63.7%. Using the 3rd party consultant’s tool, our PLRS before the coefficient change is 1.4013 and after the coefficient change it’s 1.2298. We did not use this to estimate our impact, but instead used the change in the transfer payment before and after the coefficient change. Their estimate of our transfer payment before the change in coefficient was -$1,373,653 while after the change it was -$2,248,671. This is how we developed our 63.8% adjustment (-$2,248,671/-$1,373,653= 1.637). 3. Follow up to Question 13 of Letter 2: We do not allow the use of competitor induced utilization factors unless your own experience can support them. Therefore, either provide quantitative and qualitative support showing your experience supports the use of the competitor factors, or else use the induced utilization factors from the Risk Adjustment program, normalized to 1.0 for the GQO population. These factors are as follows: Platinum = 1.15, Gold = 1.08, Silver = 1.05, Bronze = 1.0. Use of these factors will require updating of all supporting. As previously mentioned, Geisinger represents a small piece of the ACA market. Therefore, we do not believe our data is credible enough to reflect the induced demand for the market. We have updated Table 7 and Table 10 to use the induced utilization factors from the Risk Adjustment program. The worksheet named “Induced_Util_Exhibit” of the file named “PID_Response_round3_Exhibits_GQO_SmGrp_071919.xlsx” has also been updated to reflect this change.

4. New Question: The Projected Revenue PMPM on URRT Worksheet 2 cell D82 = $627.24 but the Required Revenue PMPM in Table 6, cell c63 = $638.47. Part of the difference is that the URRT shows 1st quarter values for small group, whereas Table 6 and 10 reflect annualized values. The rest of the difference looks to be due to the use of an aggregate paid to allowed factor across both GHP and GQO in Table 5. Using the average paid to allowed factor from Table 10 across GQO plans only, the values become closer. Also, the average required premium calculated from Table 10 using the pure premium divided by 1 minus the retention components, adjusted for the difference in time period, results in a value similar to the URRT. This occurs also for the GHP. Please revise Table 5 for GGQ to use the average paid to allowed ratio for GQO only. Note this also requires updating the components of the MAIR calculation (the risk adjustment % calculation for the URRT input). This correction will require updating all supporting documentation. Table 5 has been revised to use the average paid to allowed ratio for GHP only. Now the Projected Revenue PMPM on URRT Worksheet 2 cell D82 is $628.14 and the Required Revenue PMPM in Table 6, cell C63 is $639.72. The change in the paid to allowed factor resulted in changes to the projected experience. As a result, the Commission exhibit has been updated to reflect the updated projections.

Geisinger Quality OptionsSmall Group Filing for 2020Network Factor

Member Months Total Expense Expense PMPMJan - Mar 2018 48,529 $24,246,945 $499.64Jan - Mar 2018 Trend to 2019 $538.87Jan - Mar 2019 51,808 $24,710,576 $476.96Actual over projected -11.5%

Plan ID Metal Level Projected Membership

Projected Allowed Claims

Projected Paid Claims

Paid to Allowed Factor

Average Tobacco Factor

AV & Cost Sharing Factor

(8)/(6*7)Pre-

Normalized Factors

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)75729PA0050062 Bronze 266 $1,784,219 $1,265,314 0.7092 1.000 0.6431 0.90679 1.000 75729PA0050068 Gold 4,092 $29,643,153 $26,098,425 0.8804 1.000 0.8622 0.97933 1.080 75729PA0050070 Gold 723 $5,237,537 $4,650,356 0.8879 1.000 0.8695 0.97933 1.080 75729PA0050071 Gold 515 $3,730,749 $3,140,358 0.8418 1.000 0.8244 0.97933 1.080 75729PA0050073 Silver 165 $1,162,090 $878,924 0.7563 1.000 0.7201 0.95213 1.050 75729PA0050075 Silver 75 $528,223 $396,199 0.7501 1.000 0.7142 0.95213 1.050 75729PA0050078 Gold 193 $1,398,125 $1,234,461 0.8829 1.000 0.8647 0.97933 1.080 75729PA0050079 Silver 158 $1,112,790 $879,415 0.7903 1.000 0.7524 0.95213 1.050 75729PA0050080 Platinum 491 $3,787,409 $3,584,745 0.9465 1.000 0.9870 1.04280 1.150 75729PA0050082 Platinum 1,173 $9,048,128 $8,438,737 0.9327 1.000 0.9726 1.04280 1.150 75729PA0050096 Gold 226 $1,637,183 $1,344,586 0.8213 1.000 0.8043 0.97933 1.080 75729PA0050097 Gold 417 $3,020,820 $2,396,356 0.7933 1.000 0.7769 0.97933 1.080 75729PA0050102 Gold 280 $2,028,368 $1,859,608 0.9168 1.000 0.8978 0.97933 1.080 75729PA0050103 Gold 171 $1,238,753 $1,078,459 0.8706 1.000 0.8526 0.97933 1.080 75729PA0050104 Gold 79 $572,290 $488,546 0.8537 1.000 0.8360 0.97933 1.080 75729PA0050105 Silver 15 $105,645 $83,058 0.7862 1.000 0.7486 0.95213 1.050 75729PA0050106 Silver 72 $507,094 $395,346 0.7796 1.000 0.7423 0.95213 1.050 75729PA0050107 Bronze 23 $154,275 $110,934 0.7191 1.000 0.6520 0.90679 1.000 75729PA0050108 Silver 98 $690,211 $525,037 0.7607 1.000 0.7243 0.95213 1.050 75729PA0050127 Gold 94 $680,952 $591,530 0.8687 1.000 0.8507 0.97933 1.080 75729PA0050128 Platinum 2,006 $15,473,611 $15,247,232 0.9854 1.000 1.0275 1.04280 1.150 75729PA0050129 Platinum 808 $6,232,641 $6,124,006 0.9826 1.000 1.0246 1.04280 1.150 75729PA0050130 Gold 811 $5,875,024 $5,106,512 0.8692 1.000 0.8512 0.97933 1.080 75729PA0050131 Platinum 1,407 $10,853,126 $10,388,829 0.9572 1.000 0.9982 1.04280 1.150 75729PA0050132 Gold 1,060 $7,678,823 $6,601,484 0.8597 1.000 0.8419 0.97933 1.080 75729PA0050133 Gold 527 $3,817,679 $3,153,632 0.8261 1.000 0.8090 0.97933 1.080 75729PA0050134 Silver 149 $1,049,403 $785,530 0.7486 1.000 0.7127 0.95213 1.050 75729PA0050135 Platinum - $0 $0 0.9151 1.000 0.9543 1.04280 1.150 75729PA0050136 Platinum - $0 $0 0.9021 1.000 0.9407 1.04280 1.150 75729PA0050137 Gold - $0 $0 0.8300 1.000 0.8129 0.97933 1.080 75729PA0050138 Gold - $0 $0 0.8946 1.000 0.8761 0.97933 1.080 75729PA0050140 Platinum - $0 $0 0.9408 1.000 0.9811 1.04280 1.150 75729PA0050141 Gold - $0 $0 0.8423 1.000 0.8249 0.97933 1.080 75729PA0050142 Gold - $0 $0 0.8072 1.000 0.7905 0.97933 1.080 75729PA0050143 Silver - $0 $0 0.7517 1.000 0.7157 0.95213 1.050 75729PA0050144 Platinum - $0 $0 0.9408 1.000 0.9811 1.04280 1.150 75729PA0050145 Gold - $0 $0 0.8423 1.000 0.8249 0.97933 1.080 75729PA0050146 Gold - $0 $0 0.8072 1.000 0.7905 0.97933 1.080 75729PA0050147 Silver - $0 $0 0.7517 1.000 0.7157 0.95213 1.050 75729PA0050148 Platinum - $0 $0 0.9408 1.000 0.9811 1.04280 1.150 75729PA0050149 Gold - $0 $0 0.8423 1.000 0.8249 0.97933 1.080 75729PA0050150 Gold - $0 $0 0.8072 1.000 0.7905 0.97933 1.080 75729PA0050151 Silver - $0 $0 0.7517 1.000 0.7157 0.95213 1.050 Total 16,094 $119,048,319 $106,847,618 0.8955 1.0000 0.8975 1.0000 1.103

Table B: Induced Utilization Exhibit

supporting document schedules · 12. number of plans offered in 2020: 10 platinum plans, 21 gold...

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