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Attachment(s):UPMC Health Options, Inc. Individual Public PDF 1 UPMC-131924266.pdfUPMC Health Options, Inc. Individual Public PDF 2 UPMC-131924266.pdfUPMC Health Options, Inc. Individual Public PDF 3 UPMC-131924266.pdfUPMC Health Options, Inc. Individual Public PDF 4 UPMC-131924266.pdf

Item Status:Status Date:

SERFF Tracking #: UPMC-131924266 State Tracking #: UPMC-131924266 Company Tracking #:

State: Pennsylvania Filing Company: UPMC Health Options, Inc.

TOI/Sub-TOI: H15I Individual Health - Hospital/Surgical/Medical Expense/H15I.001 Health - Hospital/Surgical/Medical Expense

Product Name: 2020 IND Health Options

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number UPMC-131924266 Generated 08/12/2019 08:59 AM

May 21, 2019

Ms. Tracie Gray

Commonwealth of Pennsylvania Insurance Department

Insurance Product Regulation & Market Enforcement

Actuarial Review Division

Bureau of Life, Accident & Health Insurance

1311 Strawberry Square

Harrisburg, PA 17120

Dear Ms. Gray,

UPMC Health Options, Inc. respectfully requests approval of a rate filing for Individual

On and Off Exchange PPO/EPO products. The rates are proposed for effective dates of 1/1/2020

through 12/31/2020.

Company Name/NAIC #: UPMC Health Options, Inc./15345

Market: Individual

On or Off Exchange: On and Off

Effective Date of Coverage: 1/1/2020

Average Rate Change Requested: 4.94% ($13.80)

Range of Rate Change Requested: -40.50% to 8.21% (-$113.06 to $22.92)

Products Offered: PPO, EPO

Rating Areas Where Plans are Offered: 1, 2, 3, 4, 5, 6, 7, 9 (no change from 2019)

Metal Levels Offered: Catastrophic, Bronze, Silver, Gold

Currently Enrolled Lives: 137,526

Currently Enrolled Policyholders: 98,659

Number of Plans Offered in 2020: 36 (3 fewer than 2019)

Total additional annual revenue generated from the proposed rate change: $7,154,698

Corresponding Contract Form #: 663, 664, 667, 671, 672, 673, 674, 675

Binder ID#: UPMC-PA20-125092217

HIOS Issuer ID #: 16322

Submission Tracking #: UPMC-131924266

If you have any questions or require additional information, please call me at 412-454-7849 or email me at

[email protected].

Sincerely,

Michael Lovely, FSA, CERA, MAAA

Attachment I

Rate Change Summary

UPMC Health Options, Inc. – Individual Plans

Rate request filing ID # UPMC-131924266 - 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: 5.22% Revised requested average rate change: 3.20%

Range of requested rate change: -41.48% to 6.41% Effective date: 1/1/2020 Mapped Members: 137,557 Available in: Rating Areas 1, 2, 3, 4, 5, 6, 7, 9

Key information

Jan. 2018-Dec. 2018 financial experience

The company expects its annual medical costs to increase 6.01%.

Explanation of requested rate change

Additional premium is needed to account for the higher cost and utilization of medical services each year. The proposed rate change also accounts for an increase in anticipated Risk Adjustment payable relative to the prior year and projected increases in taxes and fees for 2020.

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:

83.54% 9.78% 4.68% 2.00%

Premiums $842,415,260

Claims $670,631,775

Administrative expenses $85,525,274

Taxes & fees $21,579,781

Company made (after taxes) $64,678,430

http://www.insurance.pa.gov/Consumers/ACARelatedFilings/

August 8, 2019

Ms. Tracie Gray

Commonwealth of Pennsylvania Insurance Department

Insurance Product Regulation & Market Enforcement


Bureau of Life, Accident & Health Insurance

1311 Strawberry Square

Harrisburg, PA 17120

Dear Ms. Gray,

UPMC Health Options, Inc. respectfully requests approval of a rate filing for Individual

On and Off Exchange PPO/EPO products. The rates are proposed for effective dates of 1/1/2020

through 12/31/2020. The revised filing includes the following changes:

1.) In response to Department question 5, round 1, the applied annual trends for each benefit category included in

Tables 3 and 3b of the PA Actuarial Memorandum Exhibits have been corrected.

2.) In response to Department question 13, round 1, the actuarial memoranda have been corrected to include the

proper exchange user fee of 3.0%.

3.) In response to Department question 16, round 1, the completion factors listed in the actuarial memoranda have been corrected.

4.) In response to Department question 25, round 1, the actuarial memoranda have been updated to exclude the outdated language

addressing projected enrollment assumptions across cost-share reduction variants.

5.) In response to Department questions 27 and 28, round 1, the risk adjustment user fee has been removed from table 5 of the PA

Actuarial Memorandum Exhibits and has instead been accounted for in tables 6 and 10.

6.) In response to Department question 29, round 1, the actuarial certifications included at the end of the actuarial

memoranda have been updated.

7.) In response to Department question 33, round 1, the language in the actuarial memroanda has been revised to

better identify the data included in the manual pool for the Individual market.

8.) An additional update to table 10 of the PA Actuarial Memorandum Exhibits was made to correct the plan names

and company-determined pricing actuarial values for the following SCIDs:

16322PA0040025

16322PA0050105

16322PA0050108

9.) An additional correction was made in table 5 of the PA Actuarial Memorandum Exhibits to show that the experience

period data was deemed 100% credible.

10.) Additional language was added to the actuarial memoranda to discuss rounding error included in the projected index rate

shown in the URRT relative to table 5 of the PA Actuarial Memorandum Exhibits.

11.) In response to Department question 2, round 2, tables 2, 2b, 3, and 3b of the PA Actuarial Memoranum Exhibits

as well as the actuarial memoranda have been updated to account for the capitation of pediatric dental claims.

12.) In response to Department question 11, round 2, an adjustment factor accounting for the 3-child maximum has been

incorporated in the age calibration factor, which has been updated in table 10 of the PA Actuarial Memorandum Exhibits.

13.) The change in morbidity factor applied in Table 5 of the PA Actuarial Memorandum Exhibits has been

lowered to better account for the anticipated morbidity of the underlying population during the projection period.

Company Name/NAIC #: UPMC Health Options, Inc./15345

Market: Individual

On or Off Exchange: On and Off

Effective Date of Coverage: 1/1/2020

Average Rate Change Requested: 3.20% ($8.93)

Range of Rate Change Requested: -41.48% to 6.41% (-$115.82 to $17.91)

Products Offered: PPO, EPO

Rating Areas Where Plans are Offered: 1, 2, 3, 4, 5, 6, 7, 9 (no change from 2019)

Metal Levels Offered: Catastrophic, Bronze, Silver, Gold

Currently Enrolled Lives: 137,526

Currently Enrolled Policyholders: 98,659

Number of Plans Offered in 2020: 36 (3 fewer than 2019)

Total additional annual revenue generated from the proposed rate change: -$10,113,303

Corresponding Contract Form #: 663, 664, 667, 671, 672, 673, 674, 675

Binder ID#: UPMC-PA20-125092217

HIOS Issuer ID #: 16322

Submission Tracking #: UPMC-131924266

If you have any questions or require additional information, please call me at 412-454-7849 or email me at

[email protected].

Sincerely,

Michael Lovely, FSA, CERA, MAAA

Basic Information and Data

Company Information

Company Legal Name: UPMC Health Options, Inc.

NAIC #: 15345

HIOS Issuer ID: 16322

Market: Individual

Exchange: On and Off Exchange

Products: PPO, EPO

Effective Date: 1/1/2020

Company Contact Information:

[This information redacted for publication.]

Filing Information:

Rate Filing SERFF Tracking #: UPMC-131924266

Form Filing SERFF Tracking #: UPMC-131919534, UPMC-131919539, UPMC-131919595, UPMC-131919597,

UPMC-131923154, UPMC-131919990, UPMC-131919615, UPMC-131919931

Binder SERFF Tracking #: UPMC-PA20-125092217

Rate History and Proposed Variations in Rate Changes

Year Rate Change

UPMC-130536844 2017 26.5%

2018 41.2%

2019 2.0%UPMC-131495924

PA Actuarial Memorandum

SERFF Tracking #

UPMC-131034732

The purpose of this actuarial memorandum is to provide certain information related to a rate submission for the

company identified below. The relevant index rate is developed in accordance with federal regulations, and plan

specific premiums are generated using the allowable modifiers in accordance with the single risk pool rule.

The following section provides information related to the identification of the company that is submitting this

rate filing. Much of this information is also displayed in Table 0 of the PA Actuarial Memorandum Exhibits.

Historical and proposed rate changes vary by plan due to various changes made to meet AV requirements on a

plan-by-plan basis. The values listed below and overall proposed rate change for 2020 are weighted averages of

the increase for each plan based on projected enrollment. Please see Table 10 of the PA Actuarial Memorandum

Exhibits for a breakdown of plan-by-plan rate increases.

1

mailto:[email protected]

Average Rate Change

• Average rate change in Table 10, column AC of the PA Actuarial Memorandum Exhibits: 3.2%

• Change in 21-year-old non-tobacco premium PMPM in Table 11, cell AN13 of the

PA Actuarial Memorandum Exhibits: -0.3%

Membership Count

Benefit Changes

Single Risk Pool

Experience Period Claims and Premium

Earned Premium:

Paid Claims:

Various breakdowns of the membership count for the captioned company and market are displayed in Table 1

of the PA Actuarial Memorandum Exhibits.

A table with these changes has been included in Appendix I. No plans have actuarial values that fall in the

expanded de minimis range.

This represents the revenue accumulated by the captioned company and market during the experience period.

No adjustments were made for MLR rebates as we do not anticipate owing them. HHS cost-sharing is not

included in the premium data. Please note that the earned premium listed in Table 2 does match the total

premium listed in section I, worksheet 1 of the URRT.

This field includes uncompleted paid medical, pharmacy, and pediatric vision experience period claims for the

captioned company and market.

The single risk pool consists of members that are anticipated to enroll in ACA-compliant policies offered under

the captioned market.

Claims and premium data for all non-grandfathered policies in the single risk pool for the captioned company

and market from the experience period (January 2018 - December 2018) with three months of run-out are

displayed in Table 2 of the PA Actuarial Memorandum Exhibits. This section provides a discussion of each field in

the table and its relation to the corresponding fields on the URRT. Please note that no data for transitional

policies is included in this table.

2

Ultimate Incurred Claims:

Month

1/1/2018

2/1/2018

3/1/2018

4/1/2018

5/1/2018

6/1/2018

7/1/2018

8/1/2018

9/1/2018

10/1/2018

11/1/2018

12/1/2018

Member Months:

Estimated Cost Sharing:

Allowed Claims:

Non-EHB portion of Allowed Claims:

Total Prescription Drug Rebates:

This field displayed the amount of allowed experience period claims that can be attributed to non-EHBs for the

captioned market and company.

0.9994

0.9987

0.9970

0.9933

0.9887

0.9866

0.9786

0.9715

The sum of the experience period member months shown in Table 1 is also displayed in Table 2 and matches the

value shown in section I, worksheet 1 of the URRT.

This field represents the difference between allowed claims and ultimate incurred claims in Table 2.

1.0000

0.9999

0.9997

This field includes allowed medical and pharmacy experience period claims as well as pediatric vision claims

from the experience period for the captioned company and market. Allowed medical claims and pediatric vision

claims are pulled directly from our data warehouse. Please note that the allowed claims shown in Table 2 do not

match the total allowed claims displayed in section I, worksheet 1 of the URRT because the value in the URRT

equals the allowed claims less total prescription drug rebates listed in Table 2.

This field shows the amount of prescription drug rebates received for the captioned company and market during

the experience period. Pharmacy rebates have been removed from the total incurred and allowed claims

displayed in section I, worksheet 1 of the URRT.

1.0000

Completion Factor

This field includes completed paid medical and pharmacy experience period claims for the captioned company

and market. We used the standard Development/Completion Factor Method to calculate IBNR. Factors were

calculated using our entire ACA-related Individual block of business and no unexpected factors were observed.

Because three months run-out is available the impact of IBNR is minimal. The completion factors used are

displayed in the table below. Please note that the ultimate incurred claims shown in Table 2 do not match the

total incurred claims displayed in section I, worksheet 1 of the URRT because the value in the URRT equals the

ultimate incurred claims less total prescription drug rebates listed in Table 2 and HHS cost-sharing.

3

Total EHB Capitation:

Total Non-EHB Capitation:

No non-EHB benefits were paid for via capitation during the experience period.

Estimated Risk Adjustment:

Loss Ratio:

The loss ratio calculated in Table 2 is 78.61%.

Credibility of Data

Trend Identification

Historical Experience

Historical data from the four most recent calendar years for the captioned company and market with three

months of run-out are provided in Table 4. Allowed claims were developed using the same manner described

above for Table 2. The historical data listed in Table 4b belongs to ACA-related Individual business under the

captioned company and is identical to the data in Table 4.

Experience period Risk Adjustment was estimated to be a payment of $42,491,928 per suggestion from the

Pennsylvania Insurance Department based on data accrued through April 2019, which translates to a PMPM of

$26.10. Based on this estimate and past experience, we believe this value is a reasonable estimate until the

actual values are released later this year.

Pediatric dental benefits were paid for via capitation during the experience period. Pediatric dental claims are

administered and paid by Dominion Dental. We receive a separate report from Dominion with the claim detail.

Based on a large member month count of 1,627,833 during the experience period, we believe this data is

credible enough to use 100%, just as was concluded in prior filings for this company and market. Because of this,

the manual data displayed in tables 2b, 3b, and 4b in the PA Actuarial Memorandum Exhibits match the data

displayed in tables 2, 3, and 4.

The overall annual trend used in rate development is 6.01%. Historical allowed claims for our Individual block of

ACA-compliant business were used to develop year over year trend factors for use in the projected rates. The

large enrollment count and consistent makeup of this population make it appropriate for use in trend

development for this filing. Service categories were defined to be consistent with the URRT instructions. Please

see Tables 3 and 3b of the PA Actuarial Memorandum Exhibits for trend development calculations. Please note

that the minor changes made to benefit designs in order to keep plan actuarial values within the allowed ranges

were not significant enough to warrant an adjustment for induced demand with regard to trend, so the induced

demand column has been populated with zeroes in Tables 3 and 3b. Please see Exhibit 2 of the Supporting

Exhibits for trend development. We believe that trends will be lower than what is implied by the historical data,

which is why a value of 6.01% was used in rate development.

4

Rate Development & Change

Projected Index Rate, Market-Adjusted Index Rate, & Total Allowed Claims

Index Rate:

Market-Adjusted Index Rate:

No other adjustments have been applied to the index rate. The average age for our 2018 experience period

Individual risk pool was 44.4 with an average premium factor of 1.85. This is comparable to our 2019 experience

so far with age 44.9 and premium factor 1.87. This change in factors is small enough that the insured population

is considered to be stable, and no additional adjustment for demographics was deemed necessary. Please note

that the Index Rate of Projection Period of $549.05 shown in Table 5 does not exactly match the corresponding

value shown in section II, worksheet 1 of the URRT. This is due to rounding error that is introduced because of

the rounding requirements in the newly re-formatted URRT. The value shown in Table 5 is representative of the

actual index rate.

The Projected Index Rate is adjusted by adding estimates for risk adjustment and marketplace fees (with impacts

and costs spread across the whole risk pool) to obtain the Projected Market Adjusted Index Rate. Projection

period Risk Adjustment PMPM has been estimated to be a payment of $26.11, which is displayed in Table 5.

Please see Exhibit 1 of the Supporting Exhibits for the derivation of this value. The value entered in section II,

worksheet 1 of the URRT was $33.97 since the calculation of the Marketed Adjusted Index Rate is done on an

allowed claims basis in the URRT. The updated PMPM was derived by taking the original paid PMPM divided by

the Paid to Allowed Average Factor. The net amount after accounting for the fee is subtracted from the Index

Rate of the Projection Period as part of the calculation of the Market Adjusted Index Rate. For the URRT and

Table 5 of the PA Actuarial Memorandum Rate Exhibits, it was entered as a negative number because the

calculation subtracts this value. The effect is an increase in premium as additional revenue will be required to

cover the anticipated payment.

Table 5 of the PA Actuarial Memorandum Exhibits shows the development of the projected index rate, Market-

Adjusted Index Rate, and projected total allowed claims. Detailed discussions on the development of each

quantity are provided below.

For this filing, the Index Rate of the Experience Period is calculated from the captioned company's fully-credible

experience period EHB claims data for the single risk pool in the state market, which is demonstrated in Table 2

of the PA Actuarial Memorandum Exhibits. The Index Rate of the Projection Period is then calculated in Table 5

by first applying two years of 6.01% annual trend to the Index Rate of Experience Period. Due to current

uncertainty surrounding the market in 2020 due to the repeal of the Individual Mandate, it has been required by

the Pennsylvania Insurance Department that an assumption for increased morbidity of the single risk pool be

implemented for the projection period. A 6% increase in morbidity has been applied in the filing to account for

this. An additional adjustment factor of 0.977 has been applied to lower the overall morbidity factor to 1.035. As

the premier academic medical center and preeminent provider of high-acuity care in Western Pennsylvania, we

previously assumed that the majority of consumers with significant health needs would choose UPMC Health

Plan products in order to maintain access to UPMC facilities and providers. Given that access to UPMC is now

available through competitors, it is reasonable to assume that some number of consumers who would have

purchased UPMC Health Plan products will instead purchase coverage from a competing carrier, particularly

those with access to multiple provider systems. We believe that individuals with significant health needs are the

most likely, all else being equal, to prioritize decisions on this basis. As such, we believe it is possible that any

shift in consumer coverage purchasing decisions may be skewed toward those with significant health needs,

thereby lowering our expected average morbidity for 2020, which is accounted for in the additional adjustment

factor.

5

Total Allowed Claims:

Retention Items

Administrative Expenses:

Taxes and Fees:

Profit/Contingency:

Projected Loss Ratio

Administrative costs of 9.78% of premium have been displayed in Table 6 and the URRT. This value has been

derived from projected administrative costs for the projection period. These expenses are assumed to be

uniform for all plan designs.

Taxes and Fees increased from 0% in 2019 to 2.45% in 2020 to account for the return of the Health Insurance

Providers Fee in 2020. This load also accounts for the projected Federal Income Tax in 2020. Please note that the

Risk Adjustment Administration Fee was included in the Taxes and Fees field in Table 6 and the URRT.

Retention items related to this filing are shown in Table 6 of the PA Actuarial Memorandum Exhibits. Detailed

discussions on each item are provided below.













The Market-Adjusted Index Rate is further modified to develop the projected total allowed claims PMPM by

adding the projected allowed non-EHB claims PMPM. Benefits that were offered outside EHB include routine

foot care and acupuncture. The projected allowed claims for these benefits is $1.16 PMPM.

The member-weighted average of a 3.0% Marketplace User Fee for Marketplace enrollees combined with 0% for

non-Marketplace enrollees calculates to 2.2%. This load is developed based on fees from on-exchange policies,

but is spread over all policies uniformly. This translates to a PMPM of $11.89, which was entered as a positive

value in Table 5 since the calculation adds this value. The effect for this adjustment is an increase in premium as

additional revenue will be required to cover the anticipated payment.

The projected period loss ratio, using the federally-prescribed MLR methodology without the credibility

adjustment, is 82.0%, as shown in Exhibit 4 of the Supporting Exhibits.

The projected profit margin for this company will remain at 2% for 2020. This value is listed in both Table 6 and

the URRT. The same level of profit margin is expected for each plan included in this filing.

6

Normalized Market-Adjusted Projected Allowed Total Claims

Average Age Factor:

Average Geographic Factor:

Average Tobacco Factor:

Feb 2019

MembersSplit Tobacco Factor

126,079 91.3% 1.000

11,995 8.7% 1.025

138,074 100.0%

Average Benefit Richness:

Average Network Factor:

Components of Rate Change

Benefit richness factors were calculated so that the average value is 1.0 when weighted with current

membership as demonstrated in Table 10 of the PA Actuarial Memorandum Exhibits.

0.089

0.913

Calibration Factor

Normalization factors for 2019 and 2020 are provided in Table 7 of the PA Actuarial Memorandum Exhibits.

2019 factors have been taken from the prior annual rate filing of the captioned company and market. Detailed

discussion on each of the 2020 factors are provided below.

The average tobacco factor was calculated using projected membership, which is assumed to have the same

split for tobacco status as current membership. The member-weighted average of a 2.5% load applied for

enrollees who qualify as tobacco users combined with a 0% load for non-tobacco users yields an average

tobacco factor of 1.002. The derivation of this factor is shown below.

The average age factor was calculated using our projected ACA-related Individual population with the prescribed

HHS Age Factors for 2020. It was assumed this represents the age distribution of the entire single risk-pool. The

number of members under each age bracket was multiplied by the corresponding HHS Age Factor. These were

then summed and divided by the total number of members to obtain the average age factor. For UPMC's entire

block of ACA-compliant Individual business, the average age factor is 1.87 and average age was 44.4 during the

experience period. This preliminary age factor is then multiplied by an adjustment factor of 0.998, which

accounts for the regulation that prohibits charging for more than three children per family, resulting in a final

age calibration factor of 1.86. Please see Exhibit 5 in the Supporting Exhibits for the calculation of this factor.

Network factors were calculated so that the average value is 1.0 when weighted with current membership as

demonstrated in Table 10 of the PA Actuarial Memorandum Exhibits.

Data to support the calculation of the components of the rate change is presented in Tables 8 and 9 of the PA

Actuarial Memorandum Exhibits. Values presented in the 2019 columns have been taken from this company's

2019 annual rate filing.

The calibration factor of 0.999 was calculated as the weighted average of the geographical factors using

projected enrollment for the single risk pool, as shown in Exhibit 6 of the Supporting Exhibits. Please see the

Geographic Factors section below for a discussion on the development of factors applied for each rating area.

Total

User

Non-User

Tobacco Status

1.002

7

Plan Rate Development

Plan Actuarial Value:

Benefit Richness (induced demand)

Benefits in addition to EHBs

Provider Network

Catastrophic Eligibility

No adjustments were made for catastrophic plans. Current enrollment is minimal and not credible.

Non-Funding of CSR Adjustment

The AV for each plan was determined by the issuer's own pricing model based on experience from UPMC's fully-

insured commercial block of business. This model calculates an AV for a given plan by first trending the allowed

claims forward two years to the projection period, calculating paid amounts for each benefit category based on

the benefit design of a given plan and projected allowed claims data, and taking the ratio of the total projected

paid claims to projected allowed claims.

To account for the elimination of funding for cost-share reduction subsidies, the Pennsylvania Insurance

Department has mandated the rates for all silver plans offered both on and off the Federal Marketplace be

increased by a factor of 1.20 in Table 10 of the Actuarial Memorandum Rate Exhibits. Several off-exchange only

silver plans have been included for 2020 to minimize disruption to non-subsidized members enrolled in silver

plans.

Please see Exhibit 3 in the Supporting Exhibits for the induced utilization exhibit. Please note that the average

tobacco factor was set to 1.0 in Exhibit 3 since the tobacco surcharge adjustment was removed from Table 10,

which means that this factor should not be included in the induced utilization development. The benefit richness

adjustment was used to keep relativities between plans similar to what they were in the previous year and

account for differences in induced demand between plans with different metal levels. This will minimize rate

increase variations by plan and consumer confusion that could result. However, factors for bronze plans were

lowered to match those of corresponding silver plans.

Data to support the calculation of the components of the rate change is presented in Tables 8 and 9 of the PA

Actuarial Memorandum Exhibits. Values presented in the 2019 columns have been taken from this company's

2019 annual rate filing.

Benefits that will be offered outside EHB include routine foot care and acupuncture. The projected allowed

claims for these benefits is $1.16 PMPM. The adjustment factor of 1.002 included in Table 10 has been derived

by adding the aforementioned PMPM to the projected index rate for 2020 and dividing this total by the same

index rate, causing the adjustment to be applied uniformly to all plans. This load has not changed from the prior

filing.

Please see the Network Factors section below for a discussion on the development of the provider network

factor applied in Table 10.

Table 10 of the PA Actuarial Memorandum Exhibits has been populated as described in federal and state

guidance to develop 2020 Plan Adjusted Index Rates. The allowable modifiers that are used in rate development

are described below.

8

Plan Premium Development for 21-Year-Old Non-Tobacco User

Plan Factors

Age and Tobacco Factors

Geographic Factors

Region 2019 2020

1 1.00 0.96

2 1.00 1.06

3 1.26 1.22

4 1.00 0.96

5 1.00 0.96

6 1.35 1.30

7 1.37 1.32

9 1.20 1.15

Network Factors

Service Area Composition

The geographic rating areas used within this filing are the same as those defined by the state. To better reflect

the varying costs of delivery between each geographical region in which coverage is offered, rating area factors

have been updated for 2020. The table below summarizes changes in these factors:

As indicated in Table 12 of the PA Actuarial Memorandum Exhibits, the default federal standard age curve for

2020 is used in the development of the Consumer Adjusted Premium Rates. A tobacco load of 2.5% will be used

for all age bands in the Individual market in 2020. This load has not changed from 2019.

Network factors for 2020 were calculated to reflect cost differentials between networks and to ensure

normalization using current membership as demonstrated in Table 10 of the PA Actuarial Memorandum

Exhibits. The current and proposed network factors are also shown in Table 14 of the PA Actuarial Memorandum

Exhibits.


guidance. Please see Exhibit 7 of the Supporting Exhibits for historical rate changes for this company and market

for a 21-year-old non-tobacco user.

Table 13 of the PA Actuarial Memorandum Exhibits shows the areas in which plans will be offered in 2020.

Service area maps for 2019 and 2020 have been uploaded in the Supporting Documentation section in SERFF.

9

Composite Rating

No composite rating is used with these plans.

Warning Alerts

No validation errors appear in the URRT.

10

List of Supporting Exhibits

• Exhibit 1: Development of Risk Adjustment PMPM for Experience and Projection Periods

• Exhibit 2: Derivation of Annual Trend

• Exhibit 3: Induced Utilization Derivation

• Exhibit 4: Derivation of Projection Period MLR

• Exhibit 5: Derivation of Age Calibration Factor

• Exhibit 6: Derivation of Geographical Calibration Factor

• Exhibit 7: Historical Changes in Consumer Adjusted Premium Rate for Age 21, Non-tobacco User

Supporting exhibits have been included with the rate filing to assist with the review process. Below is a list

summarizing the contents of each exhibit.

11

Actuarial Certification

I, Michael Lovely, am a Member of the American Academy of Actuaries. I am currently a Manager in the

Actuarial Services department for UPMC Health Plan. I certify that:

• All factor, benefit and other changes from the prior approved filing have been disclosed in this actuarial

memorandum.

• New plans cannot be considered modifications of existing plans under the uniform modification

standards in 45 CFR 147.106.

• 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.

• The projected Index Rate is:

a. In compliance with all applicable state and Federal statutes and regulations (45 CFR 156.80 and 147.102)

b. Developed in compliance with the applicable Actuarial Standards of Practice

c. Reasonable in relation to the benefits provided and the population anticipated to be covered

d. Neither excessive nor deficient

• The Index Rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 156.80(d)(2) were

used to generate plan level rates.

• The geographic rating factors reflect only differences in the costs of delivery and do not include differences

for population morbidity by geographic area.

• The AV Calculator was used to determine the AV Metal Values shown in Worksheet 2 of the Part I URRT for

all plans except those specified in the certification.

7/19/2019

Date

12

PA Rate Template Part I

Data Relevant to the Rate Filing

Table 0. Identifying Information

Carrier Name: UPMC HEALTH OPTIONS INC.Product(s): PPO, EPOMarket Segment: Individual

Rate Effective Date: 1/1/2020 to 12/31/2020

Base 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 PeriodCurrent Period

(as of 02-01-2019)Projected Rating Period

Average Age 44.4 44.9 44.9

Total 1,627,833 137,557 1,650,684

<18 133,256 9,905 118,860

18-24 104,710 8,565 102,780

25-29 123,920 10,201 122,412

30-34 115,914 10,067 120,804

35-39 108,778 9,474 113,688

40-44 106,447 9,229 110,748

45-49 132,571 11,177 134,124

50-54 172,700 14,684 176,208

55-59 240,151 20,452 245,424

60-63 288,899 25,064 300,768

64+ 100,487 8,739 104,868

*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 MonthsEstimated Cost Sharing

(Member & HHS)Allowed Claims (Non-Capitated)

Non-EHB portion of Allowed

ClaimsTotal Prescription Drug Rebates* Total EHB Capitation Total Non-EHB Capitation Estimated Risk Adjustment

$ 842,415,260.13 $ 665,621,634.09 $ 669,638,797.25 1,627,833 $ 140,963,261.47 $ 810,602,058.73 $ 1,618,965.56 $ (41,851,586.43) $ 992,978.13 $ - (42,491,928.00)$

Experience Period Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 471.87$

Loss Ratio 78.61%

*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Induced Demand* Composite Trend Weight*

19.72% -2.83% 0.00% 16.33% 20.66%

2.41% -2.23% 0.00% 0.12% 26.90%

-0.75% -1.60% 0.00% -2.34% 18.75%

17.64% 1.16% 0.00% 19.01% 12.30%

0.00% 0.13%

3.96% -2.08% 0.00% 1.80% 21.26%

6.01% 100.00%

24

1.124

* 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 PMPMEstimated Annual Cost Sharing

(Member + HHS)Prescription Drug Rebates**

Allowed Claims (Net of

Prescription Drug Rebates)Allowed PMPM

Jan-15 $ 10,896,603.78 1.0000 $ 10,896,603.78 38,102 $ 285.99 $ (541,810.44) $ 13,394,291.76 $ 351.54

Feb-15 $ 12,394,399.95 1.0000 $ 12,394,399.95 44,106 $ 281.01 $ (627,187.32) $ 15,074,741.23 $ 341.78

Mar-15 $ 16,933,009.71 1.0000 $ 16,933,009.71 53,545 $ 316.24 $ (761,409.90) $ 20,366,518.48 $ 380.36

Apr-15 $ 17,923,177.62 1.0000 $ 17,923,177.62 54,073 $ 331.46 $ (768,918.06) $ 21,017,626.41 $ 388.69

May-15 $ 18,227,371.09 1.0000 $ 18,227,371.09 54,241 $ 336.04 $ (771,307.02) $ 21,193,658.38 $ 390.73

Jun-15 $ 19,801,507.80 1.0000 $ 19,801,507.80 54,303 $ 364.65 $ (772,188.66) $ 22,792,001.82 $ 419.72

Jul-15 $ 19,403,930.56 1.0000 $ 19,403,930.56 54,518 $ 355.92 $ (775,245.96) $ 22,281,389.02 $ 408.70

Aug-15 $ 20,747,339.00 1.0000 $ 20,747,339.00 54,894 $ 377.95 $ (780,592.68) $ 23,263,199.42 $ 423.78

Sep-15 $ 18,753,945.77 1.0000 $ 18,753,945.77 55,151 $ 340.05 $ (784,247.22) $ 21,336,242.46 $ 386.87

Oct-15 $ 20,365,810.02 1.0000 $ 20,365,810.02 55,302 $ 368.27 $ (786,394.44) $ 23,280,541.32 $ 420.97

Nov-15 $ 20,049,283.57 1.0000 $ 20,049,283.57 55,356 $ 362.19 $ (787,162.32) $ 23,235,111.94 $ 419.74

Dec-15 $ 20,918,447.43 1.0000 $ 20,918,447.43 55,852 $ 374.53 $ (794,215.44) $ 23,692,961.76 $ 424.21

Jan-16 $ 29,393,195.58 1.0000 $ 29,393,195.58 104,623 $ 280.94 $ (1,487,739.06) $ 37,616,511.22 $ 359.54

Feb-16 $ 36,456,963.48 1.0000 $ 36,456,963.48 110,722 $ 329.27 $ (1,574,466.84) $ 45,047,635.33 $ 406.85

Mar-16 $ 41,078,168.29 1.0000 $ 41,078,168.29 114,417 $ 359.02 $ (1,627,009.74) $ 50,644,607.90 $ 442.63

Apr-16 $ 39,096,237.31 1.0000 $ 39,096,237.31 113,957 $ 343.08 $ (1,620,468.54) $ 46,173,333.20 $ 405.18

May-16 $ 40,142,039.18 1.0000 $ 40,142,039.18 112,966 $ 355.35 $ (1,606,376.52) $ 46,840,074.33 $ 414.64

Jun-16 $ 40,051,075.16 1.0000 $ 40,051,075.16 112,090 $ 357.31 $ (1,593,919.80) $ 46,328,848.58 $ 413.32

Jul-16 $ 39,851,706.10 1.0000 $ 39,851,706.10 111,448 $ 357.58 $ (1,584,790.56) $ 45,587,846.47 $ 409.05

Aug-16 $ 43,265,530.38 1.0000 $ 43,265,530.38 110,687 $ 390.88 $ (1,573,969.14) $ 49,229,019.75 $ 444.76

Sep-16 $ 42,550,411.86 1.0000 $ 42,550,411.86 109,833 $ 387.41 $ (1,561,825.26) $ 48,306,529.56 $ 439.82

Oct-16 $ 43,360,408.29 1.0000 $ 43,360,408.29 108,954 $ 397.97 $ (1,549,325.88) $ 48,974,431.52 $ 449.50

Nov-16 $ 42,245,629.28 1.0000 $ 42,245,629.28 107,587 $ 392.66 $ (1,529,887.14) $ 47,360,352.53 $ 440.21

Dec-16 $ 43,330,877.89 1.0000 $ 43,330,877.89 105,394 $ 411.13 $ (1,498,702.68) $ 48,349,364.69 $ 458.75

Jan-17 $ 40,645,419.75 1.0000 $ 40,645,419.75 139,589 $ 291.18 $ (2,715,006.05) $ 55,914,658.99 $ 400.57

Feb-17 $ 41,700,222.58 1.0000 $ 41,700,222.58 142,743 $ 292.13 $ (2,776,351.35) $ 55,318,357.79 $ 387.54

Mar-17 $ 48,158,615.68 1.0000 $ 48,158,615.68 143,966 $ 334.51 $ (2,800,138.70) $ 62,418,231.03 $ 433.56

Apr-17 $ 44,343,381.27 1.0000 $ 44,343,381.27 142,331 $ 311.55 $ (2,768,337.95) $ 56,608,721.77 $ 397.73

May-17 $ 47,772,985.81 1.0000 $ 47,772,985.81 140,211 $ 340.72 $ (2,727,103.95) $ 60,388,406.05 $ 430.70

Jun-17 $ 46,886,815.77 1.0000 $ 46,886,815.77 138,685 $ 338.08 $ (2,697,423.25) $ 58,427,986.35 $ 421.30

Jul-17 $ 45,866,811.73 1.0000 $ 45,866,811.73 137,198 $ 334.31 $ (2,668,501.10) $ 56,086,109.40 $ 408.80

Aug-17 $ 51,783,922.41 1.0000 $ 51,783,922.41 135,756 $ 381.45 $ (2,640,454.20) $ 62,427,900.23 $ 459.85

Sep-17 $ 46,200,530.05 1.0000 $ 46,200,530.05 134,099 $ 344.53 $ (2,608,225.55) $ 55,966,687.39 $ 417.35

Oct-17 $ 54,151,344.46 1.0000 $ 54,151,344.46 132,473 $ 408.77 $ (2,576,599.85) $ 60,901,507.36 $ 459.73

Nov-17 $ 53,221,421.57 1.0000 $ 53,221,421.57 130,290 $ 408.48 $ (2,534,140.50) $ 59,246,382.80 $ 454.73

Dec-17 $ 50,538,072.17 1.0000 $ 50,538,072.17 126,851 $ 398.40 $ (2,467,251.95) $ 55,895,728.86 $ 440.64

Jan-18 $ 51,448,502.63 1.0000 $ 51,448,502.63 145,009 $ 354.80 $ (3,728,181.39) $ 64,085,756.68 $ 441.94

Feb-18 $ 51,098,205.36 1.0000 $ 51,098,205.36 142,772 $ 357.90 $ (3,670,668.12) $ 61,108,577.61 $ 428.02

Mar-18 $ 53,220,037.00 0.9999 $ 53,224,145.55 140,595 $ 378.56 $ (3,614,697.45) $ 63,496,068.18 $ 451.62

Apr-18 $ 58,722,317.73 0.9997 $ 58,742,797.18 139,104 $ 422.29 $ (3,576,363.84) $ 68,025,894.81 $ 489.03

May-18 $ 56,716,543.69 0.9994 $ 56,747,898.60 137,488 $ 412.75 $ (3,534,816.48) $ 65,909,492.92 $ 479.38

Jun-18 $ 54,096,144.65 0.9987 $ 54,166,689.16 136,012 $ 398.25 $ (3,496,868.52) $ 61,882,490.94 $ 454.98

Jul-18 $ 54,068,924.38 0.9970 $ 54,232,809.88 134,803 $ 402.31 $ (3,465,785.13) $ 61,739,838.92 $ 458.00

Aug-18 $ 58,621,345.09 0.9933 $ 59,015,986.78 133,423 $ 442.32 $ (3,430,305.33) $ 66,541,601.23 $ 498.73

Sep-18 $ 53,625,707.88 0.9887 $ 54,235,951.78 132,009 $ 410.85 $ (3,393,951.39) $ 60,628,839.87 $ 459.28

Oct-18 $ 61,469,390.64 0.9866 $ 62,302,142.17 130,643 $ 476.89 $ (3,358,831.53) $ 69,399,162.37 $ 531.21

Nov-18 $ 56,404,058.49 0.9786 $ 57,637,625.26 129,059 $ 446.60 $ (3,318,106.89) $ 63,646,503.02 $ 493.16

Dec-18 $ 56,130,456.55 0.9715 $ 57,779,021.03 126,916 $ 455.25 $ (3,263,010.36) $ 63,279,223.88 $ 498.59

* Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

$ 170,035,700.46 $ 43,464,137.16

$ 842,415,260.13 $ 140,963,261.47

$ 409,585,471.50 $ 98,444,793.44

$ 621,597,643.21 $ 160,310,669.17

Service Category

Inpatient Hospital

Outpatient Hospital

Total Applied Trend Projection Factor

Professional

Other Medical

Capitation

Prescription Drugs

Total Annual Trend

Months of Trend

Carrier Name: UPMC HEALTH OPTIONS INC.

Product(s): PPO, EPO

Market Segment: Individual

Rate Effective Date: 1/1/2020

Table 2b. Manual Experience Period Claims and Premiums

Earned Premium Paid Claims Ultimate Incurred Claims Member MonthsEstimated Cost Sharing

(Member & HHS)Allowed Claims (Non-Capitated)

Non-EHB portion of Allowed

ClaimsTotal Prescription Drug Rebates* Total EHB Capitation Total Non-EHB Capitation Estimated Risk Adjustment

$ 842,415,260.13 $ 665,621,634.09 $ 669,638,797.25 1,627,833 $ 140,963,261.47 $ 810,602,058.73 $ 1,618,965.56 $ (41,851,586.43) $ 992,978.13 $ - (42,491,928.00)$

Experience Period Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 471.87$

Loss Ratio 78.61%

*Express Prescription Drug Rebates as a negative number

Table 3b. Manual Trend Components

Cost* Utilization* Induced Utilization* Composite Trend Weight*

19.72% -2.83% 0.00% 16.33% 20.66%

2.41% -2.23% 0.00% 0.12% 26.90%

-0.75% -1.60% 0.00% -2.34% 18.75%

17.64% 1.16% 0.00% 19.01% 12.30%

0.00% 0.13%

3.96% -2.08% 0.00% 1.80% 21.26%

6.01% 100.00%

24

1.124* 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 PMPMEstimated Annual Cost Sharing

(Member + HHS)Prescription Drug Rebates**

Allowed Claims (Net of

Prescription Drug Rebates)Allowed PMPM

Jan-15 $ 10,896,603.78 1.0000 $ 10,896,603.78 38,102 $ 285.99 $ (541,810.44) $ 13,394,291.76 $ 351.54

Feb-15 $ 12,394,399.95 1.0000 $ 12,394,399.95 44,106 $ 281.01 $ (627,187.32) $ 15,074,741.23 $ 341.78

Mar-15 $ 16,933,009.71 1.0000 $ 16,933,009.71 53,545 $ 316.24 $ (761,409.90) $ 20,366,518.48 $ 380.36

Apr-15 $ 17,923,177.62 1.0000 $ 17,923,177.62 54,073 $ 331.46 $ (768,918.06) $ 21,017,626.41 $ 388.69

May-15 $ 18,227,371.09 1.0000 $ 18,227,371.09 54,241 $ 336.04 $ (771,307.02) $ 21,193,658.38 $ 390.73

Jun-15 $ 19,801,507.80 1.0000 $ 19,801,507.80 54,303 $ 364.65 $ (772,188.66) $ 22,792,001.82 $ 419.72

Jul-15 $ 19,403,930.56 1.0000 $ 19,403,930.56 54,518 $ 355.92 $ (775,245.96) $ 22,281,389.02 $ 408.70

Aug-15 $ 20,747,339.00 1.0000 $ 20,747,339.00 54,894 $ 377.95 $ (780,592.68) $ 23,263,199.42 $ 423.78

Sep-15 $ 18,753,945.77 1.0000 $ 18,753,945.77 55,151 $ 340.05 $ (784,247.22) $ 21,336,242.46 $ 386.87

Oct-15 $ 20,365,810.02 1.0000 $ 20,365,810.02 55,302 $ 368.27 $ (786,394.44) $ 23,280,541.32 $ 420.97

Nov-15 $ 20,049,283.57 1.0000 $ 20,049,283.57 55,356 $ 362.19 $ (787,162.32) $ 23,235,111.94 $ 419.74

Dec-15 $ 20,918,447.43 1.0000 $ 20,918,447.43 55,852 $ 374.53 $ (794,215.44) $ 23,692,961.76 $ 424.21

Jan-16 $ 29,393,195.58 1.0000 $ 29,393,195.58 104,623 $ 280.94 $ (1,487,739.06) $ 37,616,511.22 $ 359.54

Feb-16 $ 36,456,963.48 1.0000 $ 36,456,963.48 110,722 $ 329.27 $ (1,574,466.84) $ 45,047,635.33 $ 406.85

Mar-16 $ 41,078,168.29 1.0000 $ 41,078,168.29 114,417 $ 359.02 $ (1,627,009.74) $ 50,644,607.90 $ 442.63

Apr-16 $ 39,096,237.31 1.0000 $ 39,096,237.31 113,957 $ 343.08 $ (1,620,468.54) $ 46,173,333.20 $ 405.18

May-16 $ 40,142,039.18 1.0000 $ 40,142,039.18 112,966 $ 355.35 $ (1,606,376.52) $ 46,840,074.33 $ 414.64

Jun-16 $ 40,051,075.16 1.0000 $ 40,051,075.16 112,090 $ 357.31 $ (1,593,919.80) $ 46,328,848.58 $ 413.32

Jul-16 $ 39,851,706.10 1.0000 $ 39,851,706.10 111,448 $ 357.58 $ (1,584,790.56) $ 45,587,846.47 $ 409.05

Aug-16 $ 43,265,530.38 1.0000 $ 43,265,530.38 110,687 $ 390.88 $ (1,573,969.14) $ 49,229,019.75 $ 444.76

Sep-16 $ 42,550,411.86 1.0000 $ 42,550,411.86 109,833 $ 387.41 $ (1,561,825.26) $ 48,306,529.56 $ 439.82

Oct-16 $ 43,360,408.29 1.0000 $ 43,360,408.29 108,954 $ 397.97 $ (1,549,325.88) $ 48,974,431.52 $ 449.50

Nov-16 $ 42,245,629.28 1.0000 $ 42,245,629.28 107,587 $ 392.66 $ (1,529,887.14) $ 47,360,352.53 $ 440.21

Dec-16 $ 43,330,877.89 1.0000 $ 43,330,877.89 105,394 $ 411.13 $ (1,498,702.68) $ 48,349,364.69 $ 458.75

Jan-17 $ 40,645,419.75 1.0000 $ 40,645,419.75 139,589 $ 291.18 $ (2,715,006.05) $ 55,914,658.99 $ 400.57

Feb-17 $ 41,700,222.58 1.0000 $ 41,700,222.58 142,743 $ 292.13 $ (2,776,351.35) $ 55,318,357.79 $ 387.54

Mar-17 $ 48,158,615.68 1.0000 $ 48,158,615.68 143,966 $ 334.51 $ (2,800,138.70) $ 62,418,231.03 $ 433.56

Apr-17 $ 44,343,381.27 1.0000 $ 44,343,381.27 142,331 $ 311.55 $ (2,768,337.95) $ 56,608,721.77 $ 397.73

May-17 $ 47,772,985.81 1.0000 $ 47,772,985.81 140,211 $ 340.72 $ (2,727,103.95) $ 60,388,406.05 $ 430.70

Jun-17 $ 46,886,815.77 1.0000 $ 46,886,815.77 138,685 $ 338.08 $ (2,697,423.25) $ 58,427,986.35 $ 421.30

Jul-17 $ 45,866,811.73 1.0000 $ 45,866,811.73 137,198 $ 334.31 $ (2,668,501.10) $ 56,086,109.40 $ 408.80

Aug-17 $ 51,783,922.41 1.0000 $ 51,783,922.41 135,756 $ 381.45 $ (2,640,454.20) $ 62,427,900.23 $ 459.85

Sep-17 $ 46,200,530.05 1.0000 $ 46,200,530.05 134,099 $ 344.53 $ (2,608,225.55) $ 55,966,687.39 $ 417.35

Oct-17 $ 54,151,344.46 1.0000 $ 54,151,344.46 132,473 $ 408.77 $ (2,576,599.85) $ 60,901,507.36 $ 459.73

Nov-17 $ 53,221,421.57 1.0000 $ 53,221,421.57 130,290 $ 408.48 $ (2,534,140.50) $ 59,246,382.80 $ 454.73

Dec-17 $ 50,538,072.17 1.0000 $ 50,538,072.17 126,851 $ 398.40 $ (2,467,251.95) $ 55,895,728.86 $ 440.64

Jan-18 $ 51,448,502.63 1.0000 $ 51,448,502.63 145,009 $ 354.80 $ (3,728,181.39) $ 64,085,756.68 $ 441.94

Feb-18 $ 51,098,205.36 1.0000 $ 51,098,205.36 142,772 $ 357.90 $ (3,670,668.12) $ 61,108,577.61 $ 428.02

Mar-18 $ 53,220,037.00 0.9999 $ 53,224,145.55 140,595 $ 378.56 $ (3,614,697.45) $ 63,496,068.18 $ 451.62

Apr-18 $ 58,722,317.73 0.9997 $ 58,742,797.18 139,104 $ 422.29 $ (3,576,363.84) $ 68,025,894.81 $ 489.03

May-18 $ 56,716,543.69 0.9994 $ 56,747,898.60 137,488 $ 412.75 $ (3,534,816.48) $ 65,909,492.92 $ 479.38

Jun-18 $ 54,096,144.65 0.9987 $ 54,166,689.16 136,012 $ 398.25 $ (3,496,868.52) $ 61,882,490.94 $ 454.98

Jul-18 $ 54,068,924.38 0.9970 $ 54,232,809.88 134,803 $ 402.31 $ (3,465,785.13) $ 61,739,838.92 $ 458.00

Aug-18 $ 58,621,345.09 0.9933 $ 59,015,986.78 133,423 $ 442.32 $ (3,430,305.33) $ 66,541,601.23 $ 498.73

Sep-18 $ 53,625,707.88 0.9887 $ 54,235,951.78 132,009 $ 410.85 $ (3,393,951.39) $ 60,628,839.87 $ 459.28

Oct-18 $ 61,469,390.64 0.9866 $ 62,302,142.17 130,643 $ 476.89 $ (3,358,831.53) $ 69,399,162.37 $ 531.21

Nov-18 $ 56,404,058.49 0.9786 $ 57,637,625.26 129,059 $ 446.60 $ (3,318,106.89) $ 63,646,503.02 $ 493.16

Dec-18 $ 56,130,456.55 0.9715 $ 57,779,021.03 126,916 $ 455.25 $ (3,263,010.36) $ 63,279,223.88 $ 498.59 * Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

$ 621,597,643.21 $ 160,310,669.17

$ 842,415,260.13 $ 140,963,261.47

Prescription Drugs

Total Annual Trend

Months of Trend

Total Applied Trend Projection Factor

$ 409,585,471.50 $ 98,444,793.44

$ 170,035,700.46 $ 43,464,137.16

Capitation

Service Category

Inpatient Hospital

Outpatient Hospital

Professional

Other Medical

PA Rate Template Part II

Rate Development and ChangeCarrier Name: UPMC HEALTH OPTIONS INC.




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

Development of the Projected Index RateActual Experience

DataManual Data

Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) PMPM 471.87$ 471.87$ <- Actual Experience PMPM should be consistent with the Index Rate for Experience Period on URRT

Two year trend projection Factor 1.124 1.124

Unadjusted Projected Allowed EHB Claims PMPM 530.33$ 530.33$ For Informational Purposes only - No input required.

Single Risk Pool Adjustment Factors

Change in Morbidity 1.035 1.035 <- See URRT Instructions Blended Base Period Unadjusted Claims before Normalization 471.87$ <- Index Rate of Experience Period on URRT

Change in Other 1.000 1.000 Blended Earned Premium 842,415,260.13$

Change in Demographics 1.000 1.000 <- See URRT Instructions Blended Loss Ratio 78.61%

Change in Network 1.000 1.000

Change in Benefits 1.000 1.000 <- See URRT Instructions

Change in Other 1.000 1.000 <- See URRT Instructions

Total Adjusted Projected Allowed EHB Claims PMPM 549.05$ 549.05$

Credibidility Factors 100% 0% <- See Instructions

Blended Projected EHB Claims PMPM 549.05$ <- Projected Index Rate

Development of the Market-Adjusted Index Rate and Total Allowed Claims

Adjusted Projected Allowed EHB Claims PMPM 549.05$ <- 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] 549.05$

Projected Paid to Allowed Ratio 0.769 Effective Date 1/1/2020 4/1/2020 7/1/2020 10/1/2020 Total Single Risk Pool

Projected Paid EHB Claims PMPM 422.02$ # of Member Months Renewing in Quarter 1,650,684 - - - 1,650,684

Market-wide Adjustments Adjusted Projected Allowed EHB Claims PMPM Q1 549.05$ 549.05$ 549.05$ 549.05$ 549.05$

Projected Risk Adjustment PMPM (26.11)$ Months of Trend - 3 6 9

Projected Paid Exchange User Fees PMPM 11.89$ Annual Trend 0.00% 0.00% 0.00% 0.00%

Single Risk Pool Projected Allowed Claims 549.05$ 549.05$ 549.05$ 549.05$ 549.05$

Market-Adjusted Projected Paid EHB Claims PMPM 460.02$ Quarterly Trend Factor 100.0% 100.0% 100.0% 100.0% 100.0%2020 Trend Factors by Quarter 1.0000 1.0000 1.0000 1.0000

Market-Adjusted Projected Allowed EHB Claims PMPM 598.49$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM 1.16$

Market-Adjusted Projected Paid Total Claims PMPM 460.91$

Market-Adjusted Projected Allowed Total Claims PMPM 599.65$

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

Retention Items - Express in percentages Percentages PMPM Amounts Normalization Factors 2019 2020

Administrative Expenses 9.78% $52.54 Average Age Factor 1.837 1.864

General and Claims 7.46% $40.08 Average Geographic Factor 1.070 0.999

Agent/Broker Fees and Commissions 0.27% $1.48 Average Tobacco Factor 1.002 1.002

Quality Improvement Initiatives 2.05% $10.99 Average Benefit Richness (induced demand) 1.000 1.000

Taxes and Fees 2.45% $13.18 Average Network Factor 1.000 1.000

RA User Fee 0.03% $0.18

PA Premium Tax (if applicable) 0.00% $0.00 Market-Adjusted Projected Allowed Total Claims PMPM 628.52$ 599.65$

Federal Income Tax 0.42% $2.26

Health Insurance Providers Fee (Prorated for Small Groups only) 2.00% $10.75Normalized Market-Adjusted Projected Allowed Total Claims PMPM

318.86$ 321.26$

Profit/Contingency (after tax) 2.00% $10.75

Total Retention 14.23% $76.48

Projected Required Revenue PMPM 537.39$

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

Rate Components 2019 2020 Difference Percent Change 2019 2020

A. Calibrated Plan Adjusted Index Rate (PMPM) 279.19$ 288.12$ $8.93 3.2% Paid-to-Allowed 0.732 0.769

B. Base period allowed claims before normalization 429.37$ 471.87$ $42.50 15.2% URRT Trend (Total Applied Trend Factor) 1.149 1.124 <- URRT W1, S2

C. Normalization factor component of change (211.54)$ (219.07)$ -$7.53 -2.7% URRT Morbidity 1.060 1.035 <- URRT W1, S2

URRT "Other" 1.090 1.000 <- URRT W1, S2

D. Change in Normalized Allowed Claims Adjustment Components D1. Base period allowed claims after normalization 217.83$ 252.80$ 34.97$ 12.5% Risk Adjustment 29.97$ 26.11$ <- URRT W1, S3

D2. URRT Trend 32.52$ 31.32$ (1.20)$ -0.4% Exchange User Fee 11.83$ 11.89$ <- URRT W1, S3 D3. URRT Morbidity 15.02$ 10.03$ (4.99)$ -1.8% Capitation -$ -$ <- URRT W1, S2

D4. URRT Other 23.88$ 0.00$ (23.88)$ -8.6%

D5. Normalized URRT RA/RI on an allowed basis 20.78$ 18.20$ (2.58)$ -0.9% Network 0.979 1.000 D6. Normalized Exchange User Fee on an allowed basis 8.20$ 8.29$ 0.09$ 0.0% Pricing AV 0.730 0.769 <- 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) 318.23$ 320.64$ 2.41$ 0.9% Benefit Richness 1.001 1.000

E. Change in Allowable Plan Adjusted Level Components Catastrophic Eligibility 1.000 1.000 E1. Network (6.78)$ (0.11)$ 6.67$ 2.4% E2. Pricing AV -84.23702931 (74.16)$ 10.08$ 3.6% Administrative Expenses 11.44% 9.78% E3. Benefit Richness 0.23$ -$ (0.23)$ -0.1% Taxes and Fees 0.42% 2.45% E4. Catastrophic Eligibility -$ -$ -$ 0.0% Profit and/or Contingency 2.00% 2.00% E5. Subtotal - Sum(E1:E4) (90.78)$ (74.26)$ 16.52$ 5.9%

F. Change in Retention Components

F1. Administrative Expenses 31.95$ 28.17$ (3.78)$ -1.4% F2. Taxes and Fees 1.17$ 7.07$ 5.90$ 2.1% F3. Profit and/or Contingency 5.58$ 5.76$ 0.18$ 0.1% F4. Subtotal - Sum(F1:F3) 38.71$ 41.00$ 2.30$ 0.8%

G. Change in Miscellaneous Items 24.26$ -$ (24.26)$ -8.7%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 290.41$ 287.37$ (3.03)$ -1.1%

PA Rate Template Part IIITable 10. Plan Rates

Age Cal ibration Factor 1.864

Carrier Name: UPMC HEALTH OPTIONS INC. Geographic Ca l ibration Factor 0.999

Product(s): PPO, EPO Tobacco Cal ibration Factor 1.002

Market Segment: Individual Aggregate Cal ibration Factor 1.867


Base Period Start Date 1/1/2018Date of Most Recent Membership 2/1/2019

Market Adjusted Index Rate 598.49$

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

EHB

Provider

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-

2019

Total 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 Total

2020

Continued/

Discontined

Plans

Indicator

Totals 0.728 0.769 1.000 1.002 1.000 1.000 1.079 461.26$ 9.8% 2.5% 2.0% 137,526 98,659 279.19$ 288.12$ 3.2% 16,494 1,565 2,937 88,133 14,912 2,684 6,656 - 4,145 137,526

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 - - N/A N/A N/A N/A - - - - - - - - - - 0

Plan 1 16322PA0040006 PPO

UPMC Advantage Si lver $0/$85 -

Premium Network M 0 Si lver 0.7158 Standard AV On/Off 0.726 0.962 1.002 1.146 1.000 1.200 $575.88 9.8% 2.5% 2.0% 2,709 2,041 345.75$ 359.71$ 4.0% 2.0% 517 134 4 1,046 789 219 - - - 2,709 1

Plan 2 16322PA0040007 PPO

UPMC Advantage Si lver $2,000/$80 -

Premium Network M 0 Si lver 0.7162 Standard AV On/Off 0.721 0.962 1.002 1.146 1.000 1.200 $572.06 9.8% 2.5% 2.0% 5,322 3,930 335.79$ 357.33$ 6.4% 3.9% 1,253 256 5 1,637 1,806 365 - - - 5,322 1

Plan 3 16322PA0040008 PPO


Premium Network M 0 Si lver 0.7151 Standard AV On/Off 0.722 0.962 1.002 1.146 1.000 1.200 $573.03 9.8% 2.5% 2.0% 6,880 5,237 342.49$ 357.93$ 4.5% 5.0% 1,510 305 - 2,262 2,387 413 3 - - 6,880 1

Plan 4 16322PA0040010 PPO

UPMC Advantage Gold $900/$25 -

Premium Network M 0 Gold 0.8197 Standard AV On/Off 0.815 1.070 1.002 1.146 1.000 1.000 $599.16 9.8% 2.5% 2.0% 11,901 7,789 364.25$ 374.26$ 2.7% 8.7% 1,905 479 - 6,089 3,112 314 2 - - 11,901 1

Plan 5 16322PA0040024 PPO

UPMC Advantage Bronze

$7,400/$50 - Premium Network M 0 Bronze 0.6195 Standard AV On/Off 0.592 1.016 1.002 1.146 1.000 1.000 $413.64 9.8% 2.5% 2.0% 5,297 3,920 263.06$ 258.38$ -1.8% 3.9% 1,050 195 - 2,146 1,515 386 5 - - 5,297 1

Plan 6 16322PA0040025 PPO

UPMC Advantage Si lver HSA

$2,800/20% - Premium Network M 0 Si lver 0.7164 Standard AV Off 0.700 0.962 1.002 1.146 1.000 1.000 $463.12 9.8% 2.5% 2.0% 414 240 285.28$ 289.28$ 1.4% 0.3% 102 6 - 219 67 20 - - - 414 1

Plan 7 16322PA0040026 PPO

UPMC Advantage Catastrophic

$8,150/$0 - Premium Network M 0 Catastrophic 0.6119 Standard AV On/Off 0.567 1.016 1.002 1.146 1.000 1.000 $395.80 9.8% 2.5% 2.0% 93 89 249.70$ 247.23$ -1.0% 0.1% 12 5 - 46 22 8 - - - 93 1

Plan 8 16322PA0040037 PPO


Premium Network M 0 Si lver 0.7164 Standard AV Off 0.727 0.962 1.002 1.146 1.000 1.000 $480.67 9.8% 2.5% 2.0% 6,461 4,224 282.17$ 300.25$ 6.4% 4.7% 1,140 185 - 3,609 1,352 175 - - - 6,461 1

Plan 9 16322PA0040039 PPO


$7,400/$50 - Premium Network M 0 Bronze 0.6195 Standard AV On/Off 0.592 1.016 1.002 1.146 1.000 1.000 $413.64 9.8% 2.5% 2.0% 1,760 1,324 263.06$ 258.38$ -1.8% 1.3% - - 134 - - 69 566 - 991 1,760 1

Plan 10 16322PA0040040 PPO


Premium Network M 0 Si lver 0.7151 Standard AV On/Off 0.722 0.962 1.002 1.146 1.000 1.200 $573.03 9.8% 2.5% 2.0% 3,556 2,686 342.49$ 357.93$ 4.5% 2.6% - - 31 - - 109 1,147 - 2,269 3,556 1

Plan 11 16322PA0040041 PPO


Premium Network M 0 Si lver 0.7164 Standard AV Off 0.727 0.962 1.002 1.146 1.000 1.000 $480.67 9.8% 2.5% 2.0% 242 138 282.17$ 300.25$ 6.4% 0.2% - - 16 - - 7 42 - 177 242 1

Plan 12 16322PA0040042 PPO


Premium Network M 0 Gold 0.8197 Standard AV On/Off 0.815 1.070 1.002 1.146 1.000 1.000 $599.16 9.8% 2.5% 2.0% 924 617 368.34$ 374.26$ 1.6% 0.7% - - 48 - - 11 161 - 704 924 1

Plan 13 16322PA0040043 PPO

Tower UPMC Advantage Bronze

$7,400/$50 - Premium Network M 0 Bronze 0.6195 Standard AV On/Off 0.592 1.016 1.002 1.106 1.000 1.000 $399.08 9.8% 2.5% 2.0% 458 352 263.06$ 249.28$ -5.2% 0.3% - - 10 - - 216 232 - - 458 1

Plan 14 16322PA0040044 PPO

Tower UPMC Advantage Si lver

$3,500/$25 - Premium Network M 0 Si lver 0.7151 Standard AV On/Off 0.722 0.962 1.002 1.106 1.000 1.200 $552.86 9.8% 2.5% 2.0% 439 329 342.49$ 345.33$ 0.8% 0.3% - - 2 - - 295 142 - - 439 1

Plan 15 16322PA0040045 PPO


$2,300/$60 - Premium Network M 0 Si lver 0.7164 Standard AV Off 0.727 0.962 1.002 1.106 1.000 1.000 $463.75 9.8% 2.5% 2.0% 28 20 282.17$ 289.68$ 2.7% 0.0% - - 1 - - 7 20 - - 28 1

Plan 16 16322PA0040046 PPO

Tower UPMC Advantage Gold

$900/$25 - Premium Network M 0 Gold 0.8197 Standard AV On/Off 0.815 1.070 1.002 1.106 1.000 1.000 $578.07 9.8% 2.5% 2.0% 124 85 368.34$ 361.09$ -2.0% 0.1% - - - - - 53 71 - - 124 1

Plan 17 16322PA0050029 EPO


Select Network M 0 Si lver 0.7158 Standard AV On/Off 0.705 0.962 1.002 0.945 1.000 1.200 $460.76 9.8% 2.5% 2.0% 3,153 2,375 275.48$ 287.81$ 4.5% 2.3% 3 - - 3,150 - - - - - 3,153 1

Plan 18 16322PA0050030 EPO


Select Network M 0 Si lver 0.7162 Standard AV On/Off 0.702 0.962 1.002 0.945 1.000 1.200 $459.09 9.8% 2.5% 2.0% 1,947 1,453 275.64$ 286.76$ 4.0% 1.4% - - - 1,947 - - - - - 1,947 1

Plan 19 16322PA0050031 EPO


Select Network M 0 Si lver 0.7151 Standard AV On/Off 0.704 0.962 1.002 0.945 1.000 1.200 $460.54 9.8% 2.5% 2.0% 7,703 5,853 271.11$ 287.67$ 6.1% 5.6% - - - 7,701 2 - - - - 7,703 1

Plan 20 16322PA0050033 EPO


Select Network M 0 Gold 0.8197 Standard AV On/Off 0.793 1.070 1.002 0.945 1.000 1.000 $480.92 9.8% 2.5% 2.0% 10,030 6,622 292.32$ 300.40$ 2.8% 7.3% 1 - 2 10,025 2 - - - - 10,030 1

Plan 21 16322PA0050100 EPO


$7,400/$50 - Partner Network M 0 Bronze 0.6195 Standard AV On/Off 0.574 1.016 1.002 0.894 1.000 1.000 $312.80 9.8% 2.5% 2.0% 8,507 6,448 199.37$ 195.39$ -2.0% 6.2% 1,411 - 585 5,878 633 - - - - 8,507 1

Plan 22 16322PA0050101 EPO


$7,400/$50 - Select Network M 0 Bronze 0.6195 Standard AV On/Off 0.574 1.016 1.002 0.945 1.000 1.000 $330.45 9.8% 2.5% 2.0% 5,495 4,051 210.61$ 206.41$ -2.0% 4.0% - - - 5,489 3 3 - - - 5,495 1

Plan 23 16322PA0050102 EPO


Partner Network M 0 Si lver 0.7158 Standard AV On/Off 0.705 0.962 1.002 0.894 1.000 1.200 $436.16 9.8% 2.5% 2.0% 5,461 4,311 260.77$ 272.44$ 4.5% 4.0% 815 - 429 3,783 433 - - - 1 5,461 1

Plan 24 16322PA0050103 EPO


Partner Network M 0 Si lver 0.7162 Standard AV On/Off 0.702 0.962 1.002 0.894 1.000 1.200 $434.57 9.8% 2.5% 2.0% 2,841 2,155 260.92$ 271.45$ 4.0% 2.1% 682 - 137 1,797 225 - - - - 2,841 1

Plan 25 16322PA0050104 EPO


Partner Network M 0 Si lver 0.7151 Standard AV On/Off 0.704 0.962 1.002 0.894 1.000 1.200 $435.94 9.8% 2.5% 2.0% 11,910 9,223 256.63$ 272.31$ 6.1% 8.7% 2,326 - 773 7,827 982 1 - - 1 11,910 1

Plan 26 16322PA0050105 EPO


$2,800/20% - Partner Network M 0 Si lver 0.7164 Standard AV Off 0.682 0.962 1.002 0.894 1.000 1.000 $351.57 9.8% 2.5% 2.0% 533 309 216.77$ 219.61$ 1.3% 0.4% 58 - 23 397 55 - - - - 533 1

Plan 27 16322PA0050106 EPO


Partner Network M 0 Gold 0.8197 Standard AV On/Off 0.793 1.070 1.002 0.894 1.000 1.000 $455.23 9.8% 2.5% 2.0% 12,586 8,700 276.71$ 284.36$ 2.8% 9.2% 2,210 - 563 8,842 968 - 3 - - 12,586 1

Plan 28 16322PA0050108 EPO


$2,800/20% - Select Network M 0 Si lver 0.7164 Standard AV Off 0.682 0.962 1.002 0.945 1.000 1.000 $371.41 9.8% 2.5% 2.0% 446 234 229.00$ 231.99$ 1.3% 0.3% - - - 446 - - - - - 446 1

Plan 29 16322PA0050111 EPO


$8,150/$0 - Partner Network M 0 Catastrophic 0.6119 Standard AV On/Off 0.549 1.016 1.002 0.894 1.000 1.000 $299.13 9.8% 2.5% 2.0% 328 321 189.10$ 186.85$ -1.2% 0.2% 30 - 2 286 10 - - - - 328 1

Plan 30 16322PA0050112 EPO


$8,150/$0 - Select Network M 0 Catastrophic 0.6119 Standard AV On/Off 0.549 1.016 1.002 0.945 1.000 1.000 $316.00 9.8% 2.5% 2.0% 138 135 199.76$ 197.39$ -1.2% 0.1% - - - 138 - - - - - 138 1

Plan 31 16322PA0050117 EPO


$3,500/$25 - Tower Network M 0 Si lver 0.7151 Standard AV On/Off 0.704 0.962 1.002 1.106 1.000 1.200 $539.24 9.8% 2.5% 2.0% 2,353 1,804 317.44$ 336.83$ 6.1% 1.7% - - - - - 2 2,349 - 2 2,353 1

Plan 32 16322PA0050118 EPO

Tower UPMC Advantage Gold

$900/$25 - Tower Network M 0 Gold 0.8197 Standard AV On/Off 0.793 1.070 1.002 1.106 1.000 1.000 $563.10 9.8% 2.5% 2.0% 931 650 342.27$ 351.73$ 2.8% 0.7% - - - - - 1 930 - - 931 1

Plan 33 16322PA0050119 EPO

Tower UPMC Advantage Bronze

$7,400/$50 - Tower Network M 0 Bronze 0.6195 Standard AV On/Off 0.574 1.016 1.002 1.106 1.000 1.000 $386.92 9.8% 2.5% 2.0% 863 627 246.60$ 241.68$ -2.0% 0.6% - - - - - - 863 - - 863 1

Plan 34 16322PA0050120 EPO


Select Network M 0 Si lver 0.7164 Standard AV Off 0.701 0.962 1.002 0.945 1.000 1.000 $381.87 9.8% 2.5% 2.0% 6,939 4,422 224.21$ 238.53$ 6.4% 5.0% - - - 6,936 2 - 1 - - 6,939 1

Plan 35 16322PA0050121 EPO


Partner Network M 0 Si lver 0.7164 Standard AV Off 0.701 0.962 1.002 0.894 1.000 1.000 $361.47 9.8% 2.5% 2.0% 8,024 5,428 212.24$ 225.79$ 6.4% 5.8% 1,423 - 167 5,937 495 2 - - - 8,024 1

Plan 36 16322PA0050123 EPO


$2,300/$60 - Tower Network M 0 Si lver 0.7164 Standard AV Off 0.701 0.962 1.002 1.106 1.000 1.000 $447.12 9.8% 2.5% 2.0% 119 81 262.53$ 279.29$ 6.4% 0.1% - - - - - - 119 - - 119 1

Plan 37 16322PA0040012 PPO

UPMC Advantage Platinum

$250/$20 - Premium Network DM 0 Platinum 0.9165 Standard AV On/Off 0.815 1.070 1.002 1.146 1.000 1.000 $599.16 9.8% 2.5% 2.0% 324 226 638.38$ 374.26$ -41.4% 0.2% 36 - - 244 36 8 - - - 324 1

Plan 38 16322PA0050035 EPO


$250/$20 - Select Network DM 0 Platinum 0.9165 Standard AV On/Off 0.793 1.070 1.002 0.945 1.000 1.000 $480.92 9.8% 2.5% 2.0% 133 95 513.35$ 300.40$ -41.5% 0.1% - - - 133 - - - - - 133 1

Plan 39 16322PA0050107 EPO


$250/$20 - Partner Network DM 0 Platinum 0.9165 Standard AV On/Off 0.793 1.070 1.002 0.894 1.000 1.000 $455.23 9.8% 2.5% 2.0% 154 115 485.94$ 284.36$ -41.5% 0.1% 10 - 5 123 16 - - - - 154 1

Plan 40 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 41 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 42 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 43 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 44 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 45 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 46 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 47 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 48 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 49 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 50 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 51 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 52 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 53 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 54 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 55 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 56 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 57 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 58 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 59 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 60 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 61 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 62 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 63 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 64 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 65 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 66 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 67 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 68 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 69 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 70 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 71 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 72 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 73 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 74 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 75 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

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Plan 185 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 186 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 187 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 188 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 189 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 190 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 191 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 192 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 193 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 194 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 195 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 196 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 197 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 198 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 199 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

Plan 200 0 0 0 0 0 0 0 0 0 0.000 0.000 0.000 0.000 0.000 0.000 $0.00 0.0% 0.0% 0.0% - - -$ -$ 0.0% 0.0% - - - - - - - - - - 1

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

Calibration Total Covered Lives @ 02-01-2019

137,557

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

PA Rate Template Part IV A - IndividualTable 11. Plan Premium Development for 21-Year-Old Non-Tobacco User





Plan Number

HIOS 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 5 6 7 8 9

Average

(weighted

by

enrollment

by rating

area)

Totals 283.13$ 330.79$ 316.63$ 267.68$ 308.78$ 432.05$ 424.07$ -$ 389.02$ 290.18$ 282.51$ 362.58$ 314.40$ 266.08$ 307.75$ 425.52$ 421.70$ -$ 385.43$ 288.94$ -0.2% 9.5% -0.8% -0.4% -0.3% -1.6% -0.8% 0.0% -1.1% -0.3%

Plan 1 16322PA0040006UPMC Advantage Silver $0/$85 - Premium NetworkM 0 Silver On/Off 345.75$ 345.75$ 436.30$ 345.75$ 345.75$ 465.67$ 472.25$ -$ 413.52$ 355.58$ 346.67$ 380.09$ 437.46$ 346.67$ 346.67$ 466.91$ 473.51$ -$ 414.62$ 358.18$ 0.3% 9.9% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.7%

Plan 2 16322PA0040007UPMC Advantage Silver $2,000/$80 - Premium NetworkM 0 Silver On/Off 335.79$ 335.79$ 423.73$ 335.79$ 335.79$ 452.26$ 458.65$ -$ 401.61$ 343.86$ 344.37$ 377.57$ 434.56$ 344.37$ 344.37$ 463.81$ 470.37$ -$ 411.87$ 354.25$ 2.6% 12.4% 2.6% 2.6% 2.6% 2.6% 2.6% 2.6% 3.0%


Plan 4 16322PA0040010UPMC Advantage Gold $900/$25 - Premium NetworkM 0 Gold On/Off 364.25$ 364.25$ 459.63$ 364.25$ 364.25$ 490.58$ 497.52$ -$ 435.64$ 367.60$ 360.69$ 395.46$ 455.15$ 360.69$ 360.69$ 485.79$ 492.66$ -$ 431.39$ 365.41$ -1.0% 8.6% -1.0% -1.0% -1.0% -1.0% -1.0% -1.0% -0.6%

Plan 5 16322PA0040024UPMC Advantage Bronze $7,400/$50 - Premium NetworkM 0 Bronze On/Off 263.06$ 263.06$ 331.95$ 263.06$ 263.06$ 354.30$ 359.31$ -$ 314.62$ 269.80$ 249.01$ 273.01$ 314.22$ 249.01$ 249.01$ 335.37$ 340.12$ -$ 297.81$ 256.27$ -5.3% 3.8% -5.3% -5.3% -5.3% -5.3% -5.3% -5.3% -5.0%

Plan 6 16322PA0040025UPMC Advantage Silver HSA $2,800/20% - Premium NetworkM 0 Silver Off 285.28$ 285.28$ 360.00$ 285.28$ 285.28$ 384.23$ 389.66$ -$ 341.20$ 290.06$ 278.80$ 305.67$ 351.81$ 278.80$ 278.80$ 375.49$ 380.80$ -$ 333.44$ 283.86$ -2.3% 7.1% -2.3% -2.3% -2.3% -2.3% -2.3% -2.3% -2.1%

Plan 7 16322PA0040026UPMC Advantage Catastrophic $8,150/$0 - Premium NetworkM 0 Catastrophic On/Off 249.70$ 249.70$ 315.09$ 249.70$ 249.70$ 336.30$ 341.06$ -$ 298.64$ 257.15$ 238.27$ 261.23$ 300.66$ 238.27$ 238.27$ 320.90$ 325.44$ -$ 284.97$ 246.61$ -4.6% 4.6% -4.6% -4.6% -4.6% -4.6% -4.6% -4.6% -4.1%

Plan 8 16322PA0040037UPMC Advantage Silver $2,300/$60 - Premium NetworkM 0 Silver Off 282.17$ 282.17$ 356.06$ 282.17$ 282.17$ 380.04$ 385.41$ -$ 337.48$ 284.82$ 289.36$ 317.25$ 365.14$ 289.36$ 289.36$ 389.72$ 395.23$ -$ 346.07$ 292.88$ 2.5% 12.4% 2.5% 2.5% 2.5% 2.5% 2.5% 2.5% 2.8%

Plan 9 16322PA0040039UPMC Advantage Bronze $7,400/$50 - Premium NetworkM 0 Bronze On/Off 263.06$ 263.06$ 331.95$ 263.06$ 263.06$ 354.30$ 359.31$ -$ 314.62$ 331.87$ 249.01$ 273.01$ 314.22$ 249.01$ 249.01$ 335.37$ 340.12$ -$ 297.81$ 314.14$ -5.3% 3.8% -5.3% -5.3% -5.3% -5.3% -5.3% -5.3% -5.3%


Plan 11 16322PA0040041UPMC Advantage Silver $2,300/$60 - Premium NetworkM 0 Silver Off 282.17$ 282.17$ 356.06$ 282.17$ 282.17$ 380.04$ 385.41$ -$ 337.48$ 348.26$ 289.36$ 317.25$ 365.14$ 289.36$ 289.36$ 389.72$ 395.23$ -$ 346.07$ 357.13$ 2.5% 12.4% 2.5% 2.5% 2.5% 2.5% 2.5% 2.5% 2.5%

Plan 12 16322PA0040042UPMC Advantage Gold $900/$25 - Premium NetworkM 0 Gold On/Off 368.34$ 368.34$ 464.81$ 368.34$ 368.34$ 496.10$ 503.11$ -$ 440.54$ 453.36$ 360.69$ 395.46$ 455.15$ 360.69$ 360.69$ 485.79$ 492.66$ -$ 431.39$ 443.94$ -2.1% 7.4% -2.1% -2.1% -2.1% -2.1% -2.1% -2.1% -2.1%

Plan 13 16322PA0040043Tower UPMC Advantage Bronze $7,400/$50 - Premium NetworkM 0 Bronze On/Off 263.06$ 263.06$ 331.95$ 263.06$ 263.06$ 354.30$ 359.31$ -$ 314.62$ 356.35$ 240.24$ 263.40$ 303.16$ 240.24$ 240.24$ 323.57$ 328.14$ -$ 287.33$ 325.44$ -8.7% 0.1% -8.7% -8.7% -8.7% -8.7% -8.7% -8.7% -8.7%

Plan 14 16322PA0040044Tower UPMC Advantage Silver $3,500/$25 - Premium NetworkM 0 Silver On/Off 342.49$ 342.49$ 432.18$ 342.49$ 342.49$ 461.28$ 467.80$ -$ 409.62$ 463.26$ 332.81$ 364.90$ 419.97$ 332.81$ 332.81$ 448.24$ 454.58$ -$ 398.05$ 450.17$ -2.8% 6.5% -2.8% -2.8% -2.8% -2.8% -2.8% -2.8% -2.8%

Plan 15 16322PA0040045Tower UPMC Advantage Silver $2,300/$60 - Premium NetworkM 0 Silver Off 282.17$ 282.17$ 356.06$ 282.17$ 282.17$ 380.04$ 385.41$ -$ 337.48$ 383.02$ 279.17$ 306.09$ 352.28$ 279.17$ 279.17$ 376.00$ 381.32$ -$ 333.89$ 378.95$ -1.1% 8.5% -1.1% -1.1% -1.1% -1.1% -1.1% -1.1% -1.1%

Plan 16 16322PA0040046Tower UPMC Advantage Gold $900/$25 - Premium NetworkM 0 Gold On/Off 368.34$ 368.34$ 464.81$ 368.34$ 368.34$ 496.10$ 503.11$ -$ 440.54$ 500.11$ 347.99$ 381.54$ 439.12$ 347.99$ 347.99$ 468.69$ 475.32$ -$ 416.20$ 472.48$ -5.5% 3.6% -5.5% -5.5% -5.5% -5.5% -5.5% -5.5% -5.5%

Plan 17 16322PA0050029UPMC Advantage Silver $0/$85 - Select NetworkM 0 Silver On/Off 275.48$ 275.48$ 347.62$ 275.48$ 275.48$ 371.03$ 376.27$ -$ 329.47$ 275.48$ 277.37$ 304.11$ 350.01$ 277.37$ 277.37$ 373.58$ 378.86$ -$ 331.74$ 277.37$ 0.7% 10.4% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7%

Plan 18 16322PA0050030UPMC Advantage Silver $2,000/$80 - Select NetworkM 0 Silver On/Off 275.64$ 275.64$ 347.83$ 275.64$ 275.64$ 371.24$ 376.49$ -$ 329.67$ 275.64$ 276.36$ 303.00$ 348.74$ 276.36$ 276.36$ 372.22$ 377.48$ -$ 330.53$ 276.36$ 0.3% 9.9% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3%

Plan 19 16322PA0050031UPMC Advantage Silver $3,500/$25 - Select NetworkM 0 Silver On/Off 271.11$ 271.11$ 342.11$ 271.11$ 271.11$ 365.14$ 370.30$ -$ 324.25$ 271.11$ 277.24$ 303.96$ 349.84$ 277.24$ 277.24$ 373.39$ 378.67$ -$ 331.58$ 277.24$ 2.3% 12.1% 2.3% 2.3% 2.3% 2.3% 2.3% 2.3% 2.3%

Plan 20 16322PA0050033UPMC Advantage Gold $900/$25 - Select NetworkM 0 Gold On/Off 292.32$ 292.32$ 368.87$ 292.32$ 292.32$ 393.70$ 399.27$ -$ 349.61$ 292.33$ 289.51$ 317.41$ 365.32$ 289.51$ 289.51$ 389.91$ 395.43$ -$ 346.25$ 289.52$ -1.0% 8.6% -1.0% -1.0% -1.0% -1.0% -1.0% -1.0% -1.0%

Plan 21 16322PA0050100UPMC Advantage Bronze $7,400/$50 - Partner NetworkM 0 Bronze On/Off 199.37$ 199.37$ 251.58$ 199.37$ 199.37$ 268.51$ 272.31$ -$ 238.44$ 202.96$ 188.30$ 206.46$ 237.62$ 188.30$ 188.30$ 253.61$ 257.20$ -$ 225.21$ 191.69$ -5.5% 3.6% -5.5% -5.5% -5.5% -5.5% -5.5% -5.5% -5.5%

Plan 22 16322PA0050101UPMC Advantage Bronze $7,400/$50 - Select NetworkM 0 Bronze On/Off 210.61$ 210.61$ 265.77$ 210.61$ 210.61$ 283.66$ 287.67$ -$ 251.89$ 210.65$ 198.93$ 218.10$ 251.02$ 198.93$ 198.93$ 267.92$ 271.71$ -$ 237.92$ 198.96$ -5.5% 3.6% -5.5% -5.5% -5.5% -5.5% -5.5% -5.5% -5.5%

Plan 23 16322PA0050102UPMC Advantage Silver $0/$85 - Partner NetworkM 0 Silver On/Off 260.77$ 260.77$ 329.06$ 260.77$ 260.77$ 351.21$ 356.18$ -$ 311.88$ 266.14$ 262.56$ 287.87$ 331.32$ 262.56$ 262.56$ 353.63$ 358.63$ -$ 314.02$ 267.97$ 0.7% 10.4% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7% 0.7%

Plan 24 16322PA0050103UPMC Advantage Silver $2,000/$80 - Partner NetworkM 0 Silver On/Off 260.92$ 260.92$ 329.25$ 260.92$ 260.92$ 351.42$ 356.39$ -$ 312.06$ 264.22$ 261.61$ 286.82$ 330.12$ 261.61$ 261.61$ 352.34$ 357.32$ -$ 312.88$ 264.91$ 0.3% 9.9% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3% 0.3%

Plan 25 16322PA0050104UPMC Advantage Silver $3,500/$25 - Partner NetworkM 0 Silver On/Off 256.63$ 256.63$ 323.84$ 256.63$ 256.63$ 345.64$ 350.53$ -$ 306.93$ 261.01$ 262.43$ 287.73$ 331.16$ 262.43$ 262.43$ 353.45$ 358.45$ -$ 313.87$ 266.91$ 2.3% 12.1% 2.3% 2.3% 2.3% 2.3% 2.3% 2.3% 2.3%

Plan 26 16322PA0050105UPMC Advantage Silver HSA $2,800/20% - Partner NetworkM 0 Silver Off 216.77$ 216.77$ 273.54$ 216.77$ 216.77$ 291.95$ 296.08$ -$ 259.26$ 219.22$ 211.64$ 232.04$ 267.07$ 211.64$ 211.64$ 285.05$ 289.08$ -$ 253.13$ 214.03$ -2.4% 7.0% -2.4% -2.4% -2.4% -2.4% -2.4% -2.4% -2.4%

Plan 27 16322PA0050106UPMC Advantage Gold $900/$25 - Partner NetworkM 0 Gold On/Off 276.71$ 276.71$ 349.17$ 276.71$ 276.71$ 372.68$ 377.95$ -$ 330.94$ 279.97$ 274.05$ 300.46$ 345.81$ 274.05$ 274.05$ 369.09$ 374.31$ -$ 327.76$ 277.28$ -1.0% 8.6% -1.0% -1.0% -1.0% -1.0% -1.0% -1.0% -1.0%

Plan 28 16322PA0050108UPMC Advantage Silver HSA $2,800/20% - Select NetworkM 0 Silver Off 229.00$ 229.00$ 288.97$ 229.00$ 229.00$ 308.42$ 312.78$ -$ 273.88$ 229.00$ 223.58$ 245.14$ 282.13$ 223.58$ 223.58$ 301.13$ 305.39$ -$ 267.41$ 223.58$ -2.4% 7.0% -2.4% -2.4% -2.4% -2.4% -2.4% -2.4% -2.4%

Plan 29 16322PA0050111UPMC Advantage Catastrophic $8,150/$0 - Partner NetworkM 0 Catastrophic On/Off 189.10$ 189.10$ 238.62$ 189.10$ 189.10$ 254.68$ 258.28$ -$ 226.16$ 189.40$ 180.07$ 197.43$ 227.23$ 180.07$ 180.07$ 242.53$ 245.96$ -$ 215.37$ 180.36$ -4.8% 4.4% -4.8% -4.8% -4.8% -4.8% -4.8% -4.8% -4.8%

Plan 30 16322PA0050112UPMC Advantage Catastrophic $8,150/$0 - Select NetworkM 0 Catastrophic On/Off 199.76$ 199.76$ 252.08$ 199.76$ 199.76$ 269.05$ 272.85$ -$ 238.92$ 199.76$ 190.23$ 208.57$ 240.05$ 190.23$ 190.23$ 256.21$ 259.83$ -$ 227.51$ 190.23$ -4.8% 4.4% -4.8% -4.8% -4.8% -4.8% -4.8% -4.8% -4.8%

Plan 31 16322PA0050117Tower UPMC Advantage Silver $3,500/$25 - Tower NetworkM 0 Silver On/Off 317.44$ 317.44$ 400.57$ 317.44$ 317.44$ 427.54$ 433.58$ -$ 379.66$ 433.53$ 324.61$ 355.91$ 409.62$ 324.61$ 324.61$ 437.20$ 443.38$ -$ 388.24$ 443.33$ 2.3% 12.1% 2.3% 2.3% 2.3% 2.3% 2.3% 2.3% 2.3%

Plan 32 16322PA0050118Tower UPMC Advantage Gold $900/$25 - Tower NetworkM 0 Gold On/Off 342.27$ 342.27$ 431.90$ 342.27$ 342.27$ 460.98$ 467.50$ -$ 409.35$ 467.49$ 338.98$ 371.65$ 427.75$ 338.98$ 338.98$ 456.55$ 463.00$ -$ 405.42$ 462.99$ -1.0% 8.6% -1.0% -1.0% -1.0% -1.0% -1.0% -1.0% -1.0%

Plan 33 16322PA0050119Tower UPMC Advantage Bronze $7,400/$50 - Tower NetworkM 0 Bronze On/Off 246.60$ 246.60$ 311.19$ 246.60$ 246.60$ 332.14$ 336.83$ -$ 294.94$ 336.83$ 232.92$ 255.37$ 293.92$ 232.92$ 232.92$ 313.70$ 318.14$ -$ 278.57$ 318.14$ -5.5% 3.6% -5.5% -5.5% -5.5% -5.5% -5.5% -5.5% -5.5%

Plan 34 16322PA0050120UPMC Advantage Silver $2,300/$60 - Select NetworkM 0 Silver Off 224.21$ 224.21$ 282.93$ 224.21$ 224.21$ 301.98$ 306.25$ -$ 268.16$ 224.23$ 229.88$ 252.04$ 290.08$ 229.88$ 229.88$ 309.61$ 313.99$ -$ 274.94$ 229.89$ 2.5% 12.4% 2.5% 2.5% 2.5% 2.5% 2.5% 2.5% 2.5%

Plan 35 16322PA0050121UPMC Advantage Silver $2,300/$60 - Partner NetworkM 0 Silver Off 212.24$ 212.24$ 267.82$ 212.24$ 212.24$ 285.85$ 289.90$ -$ 253.84$ 213.42$ 217.60$ 238.58$ 274.59$ 217.60$ 217.60$ 293.07$ 297.22$ -$ 260.25$ 218.81$ 2.5% 12.4% 2.5% 2.5% 2.5% 2.5% 2.5% 2.5% 2.5%

Plan 36 16322PA0050123Tower UPMC Advantage Silver $2,300/$60 - Tower NetworkM 0 Silver Off 262.53$ 262.53$ 331.28$ 262.53$ 262.53$ 353.58$ 358.58$ -$ 313.99$ 358.58$ 269.16$ 295.11$ 339.65$ 269.16$ 269.16$ 362.51$ 367.64$ -$ 321.92$ 367.64$ 2.5% 12.4% 2.5% 2.5% 2.5% 2.5% 2.5% 2.5% 2.5%

Plan 37 16322PA0040012UPMC Advantage Platinum $250/$20 - Premium NetworkDM 0 Platinum On/Off 638.38$ 638.38$ 805.55$ 638.38$ 638.38$ 859.78$ 871.94$ -$ 763.50$ 643.84$ 360.69$ 395.46$ 455.15$ 360.69$ 360.69$ 485.79$ 492.66$ -$ 431.39$ 363.78$ -43.5% -38.1% -43.5% -43.5% -43.5% -43.5% -43.5% -43.5% -43.5%

Plan 38 16322PA0050035UPMC Advantage Platinum $250/$20 - Select NetworkDM 0 Platinum On/Off 513.35$ 513.35$ 647.79$ 513.35$ 513.35$ 691.40$ 701.17$ -$ 613.97$ 513.35$ 289.51$ 317.41$ 365.32$ 289.51$ 289.51$ 389.91$ 395.43$ -$ 346.25$ 289.51$ -43.6% -38.2% -43.6% -43.6% -43.6% -43.6% -43.6% -43.6% -43.6%

Plan 39 16322PA0050107UPMC Advantage Platinum $250/$20 - Partner NetworkDM 0 Platinum On/Off 485.94$ 485.94$ 613.19$ 485.94$ 485.94$ 654.47$ 663.73$ -$ 581.18$ 490.07$ 274.05$ 300.46$ 345.81$ 274.05$ 274.05$ 369.09$ 374.31$ -$ 327.76$ 276.38$ -43.6% -38.2% -43.6% -43.6% -43.6% -43.6% -43.6% -43.6% -43.6%

Plan 40 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 41 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 42 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 43 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 44 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 45 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 46 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 47 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 48 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 49 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 50 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 51 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 52 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 53 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 54 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 55 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 56 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 57 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 58 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 59 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 60 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 61 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 62 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 63 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 64 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 65 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 66 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 67 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 68 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 69 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 70 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 71 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 72 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 73 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 74 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 75 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 76 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 77 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 78 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 79 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 80 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 81 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 82 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 83 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 84 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 85 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 86 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 87 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 88 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 89 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 90 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 91 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 92 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 93 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 94 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 95 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 96 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 97 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 98 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 99 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 100 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 101 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 102 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 103 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 104 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 105 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 106 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 107 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 108 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 109 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 110 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 111 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 112 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 113 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 114 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 115 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 116 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 117 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 118 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 119 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 120 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 121 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 122 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 123 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 124 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 125 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 126 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 127 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 128 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 129 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 130 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 131 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 132 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 133 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 134 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 135 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 136 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 137 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 138 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 139 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 140 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 141 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 142 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 143 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 144 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 145 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 146 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 147 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 148 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 149 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 150 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 151 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 152 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 153 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 154 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 155 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 156 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 157 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 158 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 159 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 160 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 161 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 162 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 163 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 164 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 165 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 166 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 167 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 168 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 169 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 170 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 171 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 172 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 173 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 174 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 175 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 176 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 177 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 178 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 179 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 180 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 181 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 182 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 183 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 184 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 185 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 186 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 187 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 188 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 189 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 190 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 191 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 192 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 193 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 194 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 195 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 196 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 197 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 198 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 199 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

Plan 200 0 0 0 0 0 0 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$

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

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

PA Rate Quarterly Template Part V

Consumer Factors





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

Age

Band

Age

Factor

Tobacco

Factor

Age

Band

Age

Factor

Tobacco

FactorArea Counties

Current

Factor

Proposed

Factor

0-14 0.765 40 1.278 1.025 Rating Area 1Erie, Crawford, Warren, Venango, Forest, Clarion,

Mckean1.000 0.964

15 0.833 41 1.302 1.025 Rating Area 2 Elk, Cameron, Potter 1.000 1.057

16 0.859 42 1.325 1.025 Rating Area 3Bradford, Carbon, Clinton, Lackawanna, Luzerne,

Lycoming, Sullivan, Tioga, Wyoming1.262 1.216

17 0.885 43 1.357 1.025 Rating Area 4

Allegheny, Armstrong, Beaver, Butler, Fayette,

Greene, Indiana, Lawrence, Washington,

Westmoreland

1.000 0.964

18 0.913 1.025 44 1.397 1.025 Rating Area 5Cambria, Blair, Clearfield, Bedford, Somerset,

Jefferson, Huntingdon1.000 0.964

19 0.941 1.025 45 1.444 1.025 Rating Area 6Centre, Columbia, Lehigh, Northampton,

Northumberland, Schuylkill, Snyder, Union1.347 1.298

20 0.970 1.025 46 1.500 1.025 Rating Area 7 Adams, Berks, Lancaster, York 1.366 1.316

21 1.000 1.025 47 1.563 1.025 Rating Area 8

22 1.000 1.025 48 1.635 1.025 Rating Area 9 Cumberland, Dauphin, Lebanon, Perry 1.196 1.153

23 1.000 1.025 49 1.706 1.025

24 1.000 1.025 50 1.786 1.025

25 1.004 1.025 51 1.865 1.025 Table 14. Network Factors26 1.024 1.025 52 1.952 1.025

27 1.048 1.025 53 2.040 1.025

28 1.087 1.025 54 2.135 1.025 Network Name Rating AreaCurrent

Factor

Proposed

Factor

DOH

Approval

Date

29 1.119 1.025 55 2.230 1.025 Partner 1, 3, 4, 5 0.876 0.894135585 1/0/1900

30 1.135 1.025 56 2.333 1.025 Premium 1, 2, 3, 4, 5, 6, 7, 9 1.123 1.146 1/0/1900

31 1.159 1.025 57 2.437 1.025 Select 4 0.925 0.945 1/0/1900

32 1.183 1.025 58 2.548 1.025 Tower 7 1.083 1.106 1/0/1900

33 1.198 1.025 59 2.603 1.025

34 1.214 1.025 60 2.714 1.025

35 1.222 1.025 61 2.810 1.025

36 1.230 1.025 62 2.873 1.025

37 1.238 1.025 63 2.952 1.025

38 1.246 1.025 64+ 3.000 1.025

39 1.262 1.025*PA follows the federal default age curve.

Projection Period Age and Tobacco Factors Geographic Area Factors

Projecion Period Network Factors

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 $265.20 $265.20 $290.77 $290.77 $265.20 $265.20 $265.20 $265.20 $357.19 $357.19 $263.44 $263.44 $288.84 $288.84 $263.44 $263.44 $263.44 $263.44 $354.81

15 $288.78 $288.78 $316.61 $316.61 $288.78 $288.78 $288.78 $288.78 $388.94 $388.94 $286.86 $286.86 $314.52 $314.52 $286.86 $286.86 $286.86 $286.86 $386.35

16 $297.79 $297.79 $326.50 $326.50 $297.79 $297.79 $297.79 $297.79 $401.08 $401.08 $295.81 $295.81 $324.33 $324.33 $295.81 $295.81 $295.81 $295.81 $398.41

17 $306.80 $306.80 $336.38 $336.38 $306.80 $306.80 $306.80 $306.80 $413.22 $413.22 $304.77 $304.77 $334.15 $334.15 $304.77 $304.77 $304.77 $304.77 $410.47

18 $316.51 $324.42 $347.02 $355.70 $316.51 $324.42 $316.51 $324.42 $426.29 $436.95 $314.41 $322.27 $344.72 $353.34 $314.41 $322.27 $314.41 $322.27 $423.46

19 $326.22 $334.37 $357.66 $366.61 $326.22 $334.37 $326.22 $334.37 $439.36 $450.35 $324.05 $332.15 $355.29 $364.18 $324.05 $332.15 $324.05 $332.15 $436.45

20 $336.27 $344.68 $368.69 $377.90 $336.27 $344.68 $336.27 $344.68 $452.90 $464.23 $334.04 $342.39 $366.24 $375.40 $334.04 $342.39 $334.04 $342.39 $449.90

21 $346.67 $355.34 $380.09 $389.59 $346.67 $355.34 $346.67 $355.34 $466.91 $478.58 $344.37 $352.98 $377.57 $387.01 $344.37 $352.98 $344.37 $352.98 $463.81

22 $346.67 $355.34 $380.09 $389.59 $346.67 $355.34 $346.67 $355.34 $466.91 $478.58 $344.37 $352.98 $377.57 $387.01 $344.37 $352.98 $344.37 $352.98 $463.81

23 $346.67 $355.34 $380.09 $389.59 $346.67 $355.34 $346.67 $355.34 $466.91 $478.58 $344.37 $352.98 $377.57 $387.01 $344.37 $352.98 $344.37 $352.98 $463.81

24 $346.67 $355.34 $380.09 $389.59 $346.67 $355.34 $346.67 $355.34 $466.91 $478.58 $344.37 $352.98 $377.57 $387.01 $344.37 $352.98 $344.37 $352.98 $463.81

25 $348.06 $356.76 $381.61 $391.15 $348.06 $356.76 $348.06 $356.76 $468.78 $480.50 $345.75 $354.39 $379.08 $388.56 $345.75 $354.39 $345.75 $354.39 $465.67

26 $354.99 $363.86 $389.21 $398.94 $354.99 $363.86 $354.99 $363.86 $478.12 $490.07 $352.63 $361.45 $386.63 $396.30 $352.63 $361.45 $352.63 $361.45 $474.94

27 $363.31 $372.39 $398.33 $408.29 $363.31 $372.39 $363.31 $372.39 $489.32 $501.55 $360.90 $369.92 $395.69 $405.59 $360.90 $369.92 $360.90 $369.92 $486.07

28 $376.83 $386.25 $413.16 $423.49 $376.83 $386.25 $376.83 $386.25 $507.53 $520.22 $374.33 $383.69 $410.42 $420.68 $374.33 $383.69 $374.33 $383.69 $504.16

29 $387.92 $397.62 $425.32 $435.95 $387.92 $397.62 $387.92 $397.62 $522.47 $535.53 $385.35 $394.98 $422.50 $433.06 $385.35 $394.98 $385.35 $394.98 $519.00

30 $393.47 $403.31 $431.40 $442.19 $393.47 $403.31 $393.47 $403.31 $529.94 $543.19 $390.86 $400.63 $428.54 $439.26 $390.86 $400.63 $390.86 $400.63 $526.42

31 $401.79 $411.84 $440.52 $451.54 $401.79 $411.84 $401.79 $411.84 $541.15 $554.68 $399.12 $409.10 $437.60 $448.54 $399.12 $409.10 $399.12 $409.10 $537.56

32 $410.11 $420.36 $449.65 $460.89 $410.11 $420.36 $410.11 $420.36 $552.35 $566.16 $407.39 $417.57 $446.67 $457.83 $407.39 $417.57 $407.39 $417.57 $548.69

33 $415.31 $425.69 $455.35 $466.73 $415.31 $425.69 $415.31 $425.69 $559.36 $573.34 $412.56 $422.87 $452.33 $463.64 $412.56 $422.87 $412.56 $422.87 $555.64

34 $420.86 $431.38 $461.43 $472.96 $420.86 $431.38 $420.86 $431.38 $566.83 $581.00 $418.07 $428.52 $458.37 $469.83 $418.07 $428.52 $418.07 $428.52 $563.07

35 $423.63 $434.22 $464.47 $476.08 $423.63 $434.22 $423.63 $434.22 $570.56 $584.83 $420.82 $431.34 $461.39 $472.93 $420.82 $431.34 $420.82 $431.34 $566.78

36 $426.40 $437.06 $467.51 $479.20 $426.40 $437.06 $426.40 $437.06 $574.30 $588.66 $423.58 $434.16 $464.41 $476.02 $423.58 $434.16 $423.58 $434.16 $570.49

37 $429.18 $439.91 $470.55 $482.32 $429.18 $439.91 $429.18 $439.91 $578.03 $592.49 $426.33 $436.99 $467.43 $479.12 $426.33 $436.99 $426.33 $436.99 $574.20

38 $431.95 $442.75 $473.59 $485.43 $431.95 $442.75 $431.95 $442.75 $581.77 $596.31 $429.09 $439.81 $470.45 $482.21 $429.09 $439.81 $429.09 $439.81 $577.91

39 $437.50 $448.43 $479.67 $491.67 $437.50 $448.43 $437.50 $448.43 $589.24 $603.97 $434.59 $445.46 $476.49 $488.41 $434.59 $445.46 $434.59 $445.46 $585.33

40 $443.04 $454.12 $485.76 $497.90 $443.04 $454.12 $443.04 $454.12 $596.71 $611.63 $440.10 $451.11 $482.53 $494.60 $440.10 $451.11 $440.10 $451.11 $592.75

41 $451.36 $462.65 $494.88 $507.25 $451.36 $462.65 $451.36 $462.65 $607.92 $623.11 $448.37 $459.58 $491.60 $503.89 $448.37 $459.58 $448.37 $459.58 $603.88

42 $459.34 $470.82 $503.62 $516.21 $459.34 $470.82 $459.34 $470.82 $618.66 $634.12 $456.29 $467.70 $500.28 $512.79 $456.29 $467.70 $456.29 $467.70 $614.55

43 $470.43 $482.19 $515.78 $528.68 $470.43 $482.19 $470.43 $482.19 $633.60 $649.44 $467.31 $478.99 $512.36 $525.17 $467.31 $478.99 $467.31 $478.99 $629.39

44 $484.30 $496.41 $530.99 $544.26 $484.30 $496.41 $484.30 $496.41 $652.27 $668.58 $481.08 $493.11 $527.47 $540.65 $481.08 $493.11 $481.08 $493.11 $647.94

45 $500.59 $513.11 $548.85 $562.57 $500.59 $513.11 $500.59 $513.11 $674.22 $691.07 $497.27 $509.70 $545.21 $558.84 $497.27 $509.70 $497.27 $509.70 $669.74

46 $520.01 $533.01 $570.14 $584.39 $520.01 $533.01 $520.01 $533.01 $700.37 $717.87 $516.56 $529.47 $566.36 $580.51 $516.56 $529.47 $516.56 $529.47 $695.72

47 $541.85 $555.39 $594.08 $608.93 $541.85 $555.39 $541.85 $555.39 $729.78 $748.02 $538.25 $551.71 $590.14 $604.90 $538.25 $551.71 $538.25 $551.71 $724.94

48 $566.81 $580.98 $621.45 $636.98 $566.81 $580.98 $566.81 $580.98 $763.40 $782.48 $563.04 $577.12 $617.33 $632.76 $563.04 $577.12 $563.04 $577.12 $758.33

49 $591.42 $606.20 $648.43 $664.64 $591.42 $606.20 $591.42 $606.20 $796.55 $816.46 $587.50 $602.18 $644.13 $660.24 $587.50 $602.18 $587.50 $602.18 $791.26

50 $619.15 $634.63 $678.84 $695.81 $619.15 $634.63 $619.15 $634.63 $833.90 $854.75 $615.04 $630.42 $674.34 $691.20 $615.04 $630.42 $615.04 $630.42 $828.36

51 $646.54 $662.70 $708.87 $726.59 $646.54 $662.70 $646.54 $662.70 $870.79 $892.56 $642.25 $658.31 $704.17 $721.77 $642.25 $658.31 $642.25 $658.31 $865.01

52 $676.70 $693.62 $741.94 $760.48 $676.70 $693.62 $676.70 $693.62 $911.41 $934.19 $672.21 $689.02 $737.02 $755.44 $672.21 $689.02 $672.21 $689.02 $905.36

53 $707.21 $724.89 $775.38 $794.77 $707.21 $724.89 $707.21 $724.89 $952.50 $976.31 $702.51 $720.08 $770.24 $789.50 $702.51 $720.08 $702.51 $720.08 $946.17

54 $740.14 $758.64 $811.49 $831.78 $740.14 $758.64 $740.14 $758.64 $996.85 $1,021.77 $735.23 $753.61 $806.11 $826.26 $735.23 $753.61 $735.23 $753.61 $990.23

55 $773.07 $792.40 $847.60 $868.79 $773.07 $792.40 $773.07 $792.40 $1,041.21 $1,067.24 $767.95 $787.14 $841.98 $863.03 $767.95 $787.14 $767.95 $787.14 $1,034.30

56 $808.78 $829.00 $886.75 $908.92 $808.78 $829.00 $808.78 $829.00 $1,089.30 $1,116.53 $803.42 $823.50 $880.87 $902.89 $803.42 $823.50 $803.42 $823.50 $1,082.07

57 $844.83 $865.96 $926.28 $949.44 $844.83 $865.96 $844.83 $865.96 $1,137.86 $1,166.31 $839.23 $860.21 $920.14 $943.14 $839.23 $860.21 $839.23 $860.21 $1,130.30

58 $883.32 $905.40 $968.47 $992.68 $883.32 $905.40 $883.32 $905.40 $1,189.69 $1,219.43 $877.45 $899.39 $962.05 $986.10 $877.45 $899.39 $877.45 $899.39 $1,181.79

59 $902.38 $924.94 $989.37 $1,014.11 $902.38 $924.94 $902.38 $924.94 $1,215.37 $1,245.75 $896.40 $918.80 $982.81 $1,007.39 $896.40 $918.80 $896.40 $918.80 $1,207.30

60 $940.86 $964.38 $1,031.56 $1,057.35 $940.86 $964.38 $940.86 $964.38 $1,267.19 $1,298.87 $934.62 $957.99 $1,024.72 $1,050.34 $934.62 $957.99 $934.62 $957.99 $1,258.78

61 $974.14 $998.50 $1,068.05 $1,094.75 $974.14 $998.50 $974.14 $998.50 $1,312.02 $1,344.82 $967.68 $991.87 $1,060.97 $1,087.50 $967.68 $991.87 $967.68 $991.87 $1,303.31

62 $995.98 $1,020.88 $1,092.00 $1,119.30 $995.98 $1,020.88 $995.98 $1,020.88 $1,341.43 $1,374.97 $989.38 $1,014.11 $1,084.76 $1,111.88 $989.38 $1,014.11 $989.38 $1,014.11 $1,332.53

63 $1,023.37 $1,048.95 $1,122.03 $1,150.08 $1,023.37 $1,048.95 $1,023.37 $1,048.95 $1,378.32 $1,412.78 $1,016.58 $1,041.99 $1,114.59 $1,142.45 $1,016.58 $1,041.99 $1,016.58 $1,041.99 $1,369.17

64+ $1,040.01 $1,066.01 $1,140.27 $1,168.78 $1,040.01 $1,066.01 $1,040.01 $1,066.01 $1,400.73 $1,435.75 $1,033.11 $1,058.94 $1,132.71 $1,161.03 $1,033.11 $1,058.94 $1,033.11 $1,058.94 $1,391.43

Yes Yes Yes Yes Yes

$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300

$80 / $90 $80 / $90 $80 / $90 $80 / $90 $80 / $90

80% 80% 80% 80% 80%

$2000/ $4000 $2000/ $4000 $2000/ $4000 $2000/ $4000 $2000/ $4000

Silver Silver Silver Silver Silver

IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020

1 2 4 5 6

663 663 663 663 663

UPMC Advantage Silver $2,000/$80 - Premium NetworkUPMC Advantage Silver $2,000/$80 - Premium NetworkUPMC Advantage Silver $2,000/$80 - Premium NetworkUPMC Advantage Silver $2,000/$80 - Premium NetworkUPMC Advantage Silver $2,000/$80 - Premium Network

16322PA0040007 16322PA0040007 16322PA0040007 16322PA0040007 16322PA0040007

16322PA0040007 16322PA0040007 16322PA0040007 16322PA0040007 16322PA0040007

UPMC Health Options, Inc.

Individual

PPO, EPO

16322PA004000616322PA0040006 16322PA0040006

16322PA0040006

January 1, 2020

UPMC Advantage Silver $0/$85 - Premium Network

663

6

IND PPO Premium West w/Dominion PEDS PPO-2020

Silver

$0/ $0

100%

$85 / $150

$8150/ $16300

Yes

UPMC Advantage Silver $0/$85 - Premium NetworkUPMC Advantage Silver $0/$85 - Premium Network

16322PA0040006

16322PA0040006

December 31, 2020

42

YesYes

$85 / $150

100%

$0/ $0

$85 / $150

SilverSilver

IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020

Yes


16322PA0040006


Silver

1

16322PA0040006

$85 / $150

$0/ $0

100%

$8150/ $16300

663 663663

Yes

663

5

$8150/ $16300

16322PA0040006


Silver

$0/ $0

100%

$85 / $150

$8150/ $16300

16322PA0040006

$8150/ $16300


$0/ $0

100%

Page Number: 1 12/24/2014

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:




Form # =>

Rating Area =>

Network =>

Metal =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


Age Band

0 - 14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64+

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

$354.81 $263.89 $263.89 $289.33 $289.33 $263.89 $263.89 $263.89 $263.89 $355.42 $355.42 $275.93 $275.93 $302.53 $302.53 $275.93 $275.93 $275.93 $275.93

$386.35 $287.35 $287.35 $315.05 $315.05 $287.35 $287.35 $287.35 $287.35 $387.01 $387.01 $300.45 $300.45 $329.42 $329.42 $300.45 $300.45 $300.45 $300.45

$398.41 $296.32 $296.32 $324.88 $324.88 $296.32 $296.32 $296.32 $296.32 $399.09 $399.09 $309.83 $309.83 $339.70 $339.70 $309.83 $309.83 $309.83 $309.83

$410.47 $305.29 $305.29 $334.72 $334.72 $305.29 $305.29 $305.29 $305.29 $411.17 $411.17 $319.21 $319.21 $349.98 $349.98 $319.21 $319.21 $319.21 $319.21

$434.04 $314.95 $322.82 $345.31 $353.94 $314.95 $322.82 $314.95 $322.82 $424.18 $434.78 $329.31 $337.54 $361.05 $370.08 $329.31 $337.54 $329.31 $337.54

$447.36 $324.61 $332.72 $355.90 $364.79 $324.61 $332.72 $324.61 $332.72 $437.19 $448.12 $339.41 $347.89 $372.13 $381.43 $339.41 $347.89 $339.41 $347.89

$461.14 $334.61 $342.98 $366.86 $376.04 $334.61 $342.98 $334.61 $342.98 $450.66 $461.93 $349.87 $358.62 $383.60 $393.19 $349.87 $358.62 $349.87 $358.62

$475.41 $344.96 $353.58 $378.21 $387.67 $344.96 $353.58 $344.96 $353.58 $464.60 $476.22 $360.69 $369.71 $395.46 $405.35 $360.69 $369.71 $360.69 $369.71

$475.41 $344.96 $353.58 $378.21 $387.67 $344.96 $353.58 $344.96 $353.58 $464.60 $476.22 $360.69 $369.71 $395.46 $405.35 $360.69 $369.71 $360.69 $369.71

$475.41 $344.96 $353.58 $378.21 $387.67 $344.96 $353.58 $344.96 $353.58 $464.60 $476.22 $360.69 $369.71 $395.46 $405.35 $360.69 $369.71 $360.69 $369.71

$475.41 $344.96 $353.58 $378.21 $387.67 $344.96 $353.58 $344.96 $353.58 $464.60 $476.22 $360.69 $369.71 $395.46 $405.35 $360.69 $369.71 $360.69 $369.71

$477.31 $346.34 $355.00 $379.72 $389.22 $346.34 $355.00 $346.34 $355.00 $466.46 $478.12 $362.13 $371.19 $397.04 $406.97 $362.13 $371.19 $362.13 $371.19

$486.81 $353.24 $362.07 $387.29 $396.97 $353.24 $362.07 $353.24 $362.07 $475.75 $487.64 $369.35 $378.58 $404.95 $415.07 $369.35 $378.58 $369.35 $378.58

$498.22 $361.52 $370.56 $396.36 $406.27 $361.52 $370.56 $361.52 $370.56 $486.90 $499.07 $378.00 $387.45 $414.44 $424.80 $378.00 $387.45 $378.00 $387.45

$516.77 $374.97 $384.35 $411.11 $421.39 $374.97 $384.35 $374.97 $384.35 $505.02 $517.65 $392.07 $401.87 $429.87 $440.61 $392.07 $401.87 $392.07 $401.87

$531.98 $386.01 $395.66 $423.22 $433.80 $386.01 $395.66 $386.01 $395.66 $519.89 $532.88 $403.61 $413.70 $442.52 $453.58 $403.61 $413.70 $403.61 $413.70

$539.58 $391.53 $401.32 $429.27 $440.00 $391.53 $401.32 $391.53 $401.32 $527.32 $540.50 $409.38 $419.62 $448.85 $460.07 $409.38 $419.62 $409.38 $419.62

$550.99 $399.81 $409.80 $438.35 $449.30 $399.81 $409.80 $399.81 $409.80 $538.47 $551.93 $418.04 $428.49 $458.34 $469.80 $418.04 $428.49 $418.04 $428.49

$562.40 $408.09 $418.29 $447.42 $458.61 $408.09 $418.29 $408.09 $418.29 $549.62 $563.36 $426.70 $437.36 $467.83 $479.52 $426.70 $437.36 $426.70 $437.36

$569.54 $413.26 $423.59 $453.10 $464.42 $413.26 $423.59 $413.26 $423.59 $556.59 $570.51 $432.11 $442.91 $473.76 $485.61 $432.11 $442.91 $432.11 $442.91

$577.14 $418.78 $429.25 $459.15 $470.63 $418.78 $429.25 $418.78 $429.25 $564.02 $578.13 $437.88 $448.82 $480.09 $492.09 $437.88 $448.82 $437.88 $448.82

$580.95 $421.54 $432.08 $462.17 $473.73 $421.54 $432.08 $421.54 $432.08 $567.74 $581.93 $440.76 $451.78 $483.25 $495.33 $440.76 $451.78 $440.76 $451.78

$584.75 $424.30 $434.91 $465.20 $476.83 $424.30 $434.91 $424.30 $434.91 $571.46 $585.74 $443.65 $454.74 $486.42 $498.58 $443.65 $454.74 $443.65 $454.74

$588.55 $427.06 $437.74 $468.22 $479.93 $427.06 $437.74 $427.06 $437.74 $575.17 $589.55 $446.53 $457.70 $489.58 $501.82 $446.53 $457.70 $446.53 $457.70

$592.35 $429.82 $440.57 $471.25 $483.03 $429.82 $440.57 $429.82 $440.57 $578.89 $593.36 $449.42 $460.66 $492.74 $505.06 $449.42 $460.66 $449.42 $460.66

$599.96 $435.34 $446.22 $477.30 $489.23 $435.34 $446.22 $435.34 $446.22 $586.33 $600.98 $455.19 $466.57 $499.07 $511.55 $455.19 $466.57 $455.19 $466.57

$607.57 $440.86 $451.88 $483.35 $495.44 $440.86 $451.88 $440.86 $451.88 $593.76 $608.60 $460.96 $472.49 $505.40 $518.03 $460.96 $472.49 $460.96 $472.49

$618.98 $449.14 $460.37 $492.43 $504.74 $449.14 $460.37 $449.14 $460.37 $604.91 $620.03 $469.62 $481.36 $514.89 $527.76 $469.62 $481.36 $469.62 $481.36

$629.91 $457.07 $468.50 $501.13 $513.66 $457.07 $468.50 $457.07 $468.50 $615.60 $630.98 $477.91 $489.86 $523.98 $537.08 $477.91 $489.86 $477.91 $489.86

$645.12 $468.11 $479.81 $513.23 $526.06 $468.11 $479.81 $468.11 $479.81 $630.46 $646.22 $489.46 $501.69 $536.64 $550.06 $489.46 $501.69 $489.46 $501.69

$664.14 $481.91 $493.96 $528.36 $541.57 $481.91 $493.96 $481.91 $493.96 $649.05 $665.27 $503.88 $516.48 $552.46 $566.27 $503.88 $516.48 $503.88 $516.48

$686.49 $498.12 $510.58 $546.14 $559.79 $498.12 $510.58 $498.12 $510.58 $670.88 $687.65 $520.84 $533.86 $571.04 $585.32 $520.84 $533.86 $520.84 $533.86

$713.11 $517.44 $530.38 $567.32 $581.50 $517.44 $530.38 $517.44 $530.38 $696.90 $714.32 $541.04 $554.56 $593.19 $608.02 $541.04 $554.56 $541.04 $554.56

$743.06 $539.17 $552.65 $591.14 $605.92 $539.17 $552.65 $539.17 $552.65 $726.17 $744.32 $563.76 $577.85 $618.10 $633.56 $563.76 $577.85 $563.76 $577.85

$777.29 $564.01 $578.11 $618.37 $633.83 $564.01 $578.11 $564.01 $578.11 $759.62 $778.61 $589.73 $604.47 $646.58 $662.74 $589.73 $604.47 $589.73 $604.47

$811.04 $588.50 $603.21 $645.23 $661.36 $588.50 $603.21 $588.50 $603.21 $792.61 $812.42 $615.34 $630.72 $674.65 $691.52 $615.34 $630.72 $615.34 $630.72

$849.07 $616.10 $631.50 $675.48 $692.37 $616.10 $631.50 $616.10 $631.50 $829.78 $850.52 $644.19 $660.30 $706.29 $723.95 $644.19 $660.30 $644.19 $660.30

$886.63 $643.35 $659.43 $705.36 $723.00 $643.35 $659.43 $643.35 $659.43 $866.48 $888.14 $672.69 $689.50 $737.53 $755.97 $672.69 $689.50 $672.69 $689.50

$927.99 $673.36 $690.20 $738.27 $756.72 $673.36 $690.20 $673.36 $690.20 $906.90 $929.57 $704.07 $721.67 $771.94 $791.24 $704.07 $721.67 $704.07 $721.67

$969.83 $703.72 $721.31 $771.55 $790.84 $703.72 $721.31 $703.72 $721.31 $947.78 $971.48 $735.81 $754.20 $806.74 $826.91 $735.81 $754.20 $735.81 $754.20

$1,014.99 $736.49 $754.90 $807.48 $827.67 $736.49 $754.90 $736.49 $754.90 $991.92 $1,016.72 $770.07 $789.32 $844.31 $865.41 $770.07 $789.32 $770.07 $789.32

$1,060.15 $769.26 $788.49 $843.41 $864.49 $769.26 $788.49 $769.26 $788.49 $1,036.06 $1,061.96 $804.34 $824.45 $881.88 $903.92 $804.34 $824.45 $804.34 $824.45

$1,109.12 $804.79 $824.91 $882.36 $904.42 $804.79 $824.91 $804.79 $824.91 $1,083.91 $1,111.01 $841.49 $862.53 $922.61 $945.67 $841.49 $862.53 $841.49 $862.53

$1,158.56 $840.67 $861.68 $921.70 $944.74 $840.67 $861.68 $840.67 $861.68 $1,132.23 $1,160.54 $879.00 $900.98 $963.74 $987.83 $879.00 $900.98 $879.00 $900.98

$1,211.33 $878.96 $900.93 $963.68 $987.77 $878.96 $900.93 $878.96 $900.93 $1,183.80 $1,213.40 $919.04 $942.01 $1,007.63 $1,032.82 $919.04 $942.01 $919.04 $942.01

$1,237.48 $897.93 $920.38 $984.48 $1,009.09 $897.93 $920.38 $897.93 $920.38 $1,209.35 $1,239.59 $938.88 $962.35 $1,029.38 $1,055.12 $938.88 $962.35 $938.88 $962.35

$1,290.25 $936.22 $959.63 $1,026.46 $1,052.12 $936.22 $959.63 $936.22 $959.63 $1,260.92 $1,292.45 $978.91 $1,003.39 $1,073.28 $1,100.11 $978.91 $1,003.39 $978.91 $1,003.39

$1,335.89 $969.34 $993.57 $1,062.77 $1,089.34 $969.34 $993.57 $969.34 $993.57 $1,305.53 $1,338.16 $1,013.54 $1,038.88 $1,111.24 $1,139.02 $1,013.54 $1,038.88 $1,013.54 $1,038.88

$1,365.84 $991.07 $1,015.85 $1,086.60 $1,113.76 $991.07 $1,015.85 $991.07 $1,015.85 $1,334.80 $1,368.17 $1,036.26 $1,062.17 $1,136.16 $1,164.56 $1,036.26 $1,062.17 $1,036.26 $1,062.17

$1,403.40 $1,018.32 $1,043.78 $1,116.48 $1,144.39 $1,018.32 $1,043.78 $1,018.32 $1,043.78 $1,371.50 $1,405.79 $1,064.76 $1,091.38 $1,167.40 $1,196.58 $1,064.76 $1,091.38 $1,064.76 $1,091.38

$1,426.22 $1,034.88 $1,060.75 $1,134.63 $1,163.00 $1,034.88 $1,060.75 $1,034.88 $1,060.75 $1,393.80 $1,428.65 $1,082.07 $1,109.12 $1,186.38 $1,216.04 $1,082.07 $1,109.12 $1,082.07 $1,109.12

Yes YesYes Yes Yes Yes Yes Yes Yes Yes

$5200/ $10400$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $5200/ $10400 $5200/ $10400 $5200/ $10400

$80 / $90 $25 / $75 $25 / $75 $25 / $75 $25 / $75 $25 / $75 $25 / $55 $25 / $55 $25 / $55 $25 / $55

90% 90% 90% 90%80% 80% 80% 80% 80%80%

$900/ $1800 $900/ $1800$2000/ $4000 $3500/ $7000 $3500/ $7000 $3500/ $7000 $3500/ $7000 $3500/ $7000 $900/ $1800 $900/ $1800

GoldSilver Silver Silver Silver Silver Silver Gold Gold Gold

IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020

1 2 4 51 2 4 5 66

663 663663 663 663 663 663 663 663 663

UPMC Advantage Gold $900/$25 - Premium NetworkUPMC Advantage Silver $2,000/$80 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium NetworkUPMC Advantage Gold $900/$25 - Premium NetworkUPMC Advantage Gold $900/$25 - Premium NetworkUPMC Advantage Gold $900/$25 - Premium Network

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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

$371.63 $371.63 $190.49 $190.49 $208.85 $208.85 $190.49 $190.49 $190.49 $190.49 $256.56 $256.56 $213.28 $213.28 $233.84 $233.84 $213.28 $213.28 $213.28

$404.66 $404.66 $207.43 $207.43 $227.42 $227.42 $207.43 $207.43 $207.43 $207.43 $279.36 $279.36 $232.24 $232.24 $254.62 $254.62 $232.24 $232.24 $232.24

$417.29 $417.29 $213.90 $213.90 $234.52 $234.52 $213.90 $213.90 $213.90 $213.90 $288.08 $288.08 $239.49 $239.49 $262.57 $262.57 $239.49 $239.49 $239.49

$429.92 $429.92 $220.37 $220.37 $241.61 $241.61 $220.37 $220.37 $220.37 $220.37 $296.80 $296.80 $246.74 $246.74 $270.52 $270.52 $246.74 $246.74 $246.74

$443.53 $454.61 $227.35 $233.03 $249.26 $255.49 $227.35 $233.03 $227.35 $233.03 $306.19 $313.85 $254.54 $260.91 $279.08 $286.05 $254.54 $260.91 $254.54

$457.13 $468.56 $234.32 $240.18 $256.90 $263.32 $234.32 $240.18 $234.32 $240.18 $315.58 $323.47 $262.35 $268.91 $287.64 $294.83 $262.35 $268.91 $262.35

$471.22 $483.00 $241.54 $247.58 $264.82 $271.44 $241.54 $247.58 $241.54 $247.58 $325.31 $333.44 $270.44 $277.20 $296.50 $303.91 $270.44 $277.20 $270.44

$485.79 $497.93 $249.01 $255.24 $273.01 $279.84 $249.01 $255.24 $249.01 $255.24 $335.37 $343.75 $278.80 $285.77 $305.67 $313.31 $278.80 $285.77 $278.80

$485.79 $497.93 $249.01 $255.24 $273.01 $279.84 $249.01 $255.24 $249.01 $255.24 $335.37 $343.75 $278.80 $285.77 $305.67 $313.31 $278.80 $285.77 $278.80

$485.79 $497.93 $249.01 $255.24 $273.01 $279.84 $249.01 $255.24 $249.01 $255.24 $335.37 $343.75 $278.80 $285.77 $305.67 $313.31 $278.80 $285.77 $278.80

$485.79 $497.93 $249.01 $255.24 $273.01 $279.84 $249.01 $255.24 $249.01 $255.24 $335.37 $343.75 $278.80 $285.77 $305.67 $313.31 $278.80 $285.77 $278.80

$487.73 $499.93 $250.01 $256.26 $274.10 $280.95 $250.01 $256.26 $250.01 $256.26 $336.71 $345.13 $279.92 $286.91 $306.89 $314.56 $279.92 $286.91 $279.92

$497.45 $509.89 $254.99 $261.36 $279.56 $286.55 $254.99 $261.36 $254.99 $261.36 $343.42 $352.00 $285.49 $292.63 $313.01 $320.83 $285.49 $292.63 $285.49

$509.11 $521.84 $260.96 $267.49 $286.11 $293.27 $260.96 $267.49 $260.96 $267.49 $351.47 $360.25 $292.18 $299.49 $320.34 $328.35 $292.18 $299.49 $292.18

$528.05 $541.26 $270.67 $277.44 $296.76 $304.18 $270.67 $277.44 $270.67 $277.44 $364.55 $373.66 $303.06 $310.63 $332.26 $340.57 $303.06 $310.63 $303.06

$543.60 $557.19 $278.64 $285.61 $305.50 $313.14 $278.64 $285.61 $278.64 $285.61 $375.28 $384.66 $311.98 $319.78 $342.04 $350.60 $311.98 $319.78 $311.98

$551.37 $565.16 $282.63 $289.69 $309.87 $317.61 $282.63 $289.69 $282.63 $289.69 $380.64 $390.16 $316.44 $324.35 $346.94 $355.61 $316.44 $324.35 $316.44

$563.03 $577.11 $288.60 $295.82 $316.42 $324.33 $288.60 $295.82 $288.60 $295.82 $388.69 $398.41 $323.13 $331.21 $354.27 $363.13 $323.13 $331.21 $323.13

$574.69 $589.06 $294.58 $301.94 $322.97 $331.05 $294.58 $301.94 $294.58 $301.94 $396.74 $406.66 $329.82 $338.07 $361.61 $370.65 $329.82 $338.07 $329.82

$581.98 $596.53 $298.31 $305.77 $327.07 $335.24 $298.31 $305.77 $298.31 $305.77 $401.77 $411.82 $334.00 $342.35 $366.19 $375.35 $334.00 $342.35 $334.00

$589.75 $604.49 $302.30 $309.86 $331.43 $339.72 $302.30 $309.86 $302.30 $309.86 $407.14 $417.32 $338.46 $346.92 $371.08 $380.36 $338.46 $346.92 $338.46

$593.64 $608.48 $304.29 $311.90 $333.62 $341.96 $304.29 $311.90 $304.29 $311.90 $409.82 $420.07 $340.69 $349.21 $373.53 $382.87 $340.69 $349.21 $340.69

$597.52 $612.46 $306.28 $313.94 $335.80 $344.20 $306.28 $313.94 $306.28 $313.94 $412.51 $422.82 $342.92 $351.50 $375.97 $385.37 $342.92 $351.50 $342.92

$601.41 $616.44 $308.27 $315.98 $337.99 $346.44 $308.27 $315.98 $308.27 $315.98 $415.19 $425.57 $345.15 $353.78 $378.42 $387.88 $345.15 $353.78 $345.15

$605.29 $620.43 $310.27 $318.02 $340.17 $348.67 $310.27 $318.02 $310.27 $318.02 $417.87 $428.32 $347.38 $356.07 $380.86 $390.39 $347.38 $356.07 $347.38

$613.07 $628.39 $314.25 $322.11 $344.54 $353.15 $314.25 $322.11 $314.25 $322.11 $423.24 $433.82 $351.85 $360.64 $385.76 $395.40 $351.85 $360.64 $351.85

$620.84 $636.36 $318.23 $326.19 $348.91 $357.63 $318.23 $326.19 $318.23 $326.19 $428.60 $439.32 $356.31 $365.21 $390.65 $400.41 $356.31 $365.21 $356.31

$632.50 $648.31 $324.21 $332.32 $355.46 $364.35 $324.21 $332.32 $324.21 $332.32 $436.65 $447.57 $363.00 $372.07 $397.98 $407.93 $363.00 $372.07 $363.00

$643.67 $659.76 $329.94 $338.19 $361.74 $370.78 $329.94 $338.19 $329.94 $338.19 $444.37 $455.47 $369.41 $378.65 $405.01 $415.14 $369.41 $378.65 $369.41

$659.22 $675.70 $337.91 $346.35 $370.47 $379.74 $337.91 $346.35 $337.91 $346.35 $455.10 $466.47 $378.33 $387.79 $414.79 $425.16 $378.33 $387.79 $378.33

$678.65 $695.61 $347.87 $356.56 $381.39 $390.93 $347.87 $356.56 $347.87 $356.56 $468.51 $480.22 $389.48 $399.22 $427.02 $437.70 $389.48 $399.22 $389.48

$701.48 $719.02 $359.57 $368.56 $394.23 $404.08 $359.57 $368.56 $359.57 $368.56 $484.27 $496.38 $402.59 $412.65 $441.39 $452.42 $402.59 $412.65 $402.59

$728.69 $746.90 $373.52 $382.85 $409.52 $419.75 $373.52 $382.85 $373.52 $382.85 $503.06 $515.63 $418.20 $428.66 $458.51 $469.97 $418.20 $428.66 $418.20

$759.29 $778.27 $389.20 $398.93 $426.71 $437.38 $389.20 $398.93 $389.20 $398.93 $524.18 $537.29 $435.76 $446.66 $477.76 $489.71 $435.76 $446.66 $435.76

$794.27 $814.12 $407.13 $417.31 $446.37 $457.53 $407.13 $417.31 $407.13 $417.31 $548.33 $562.04 $455.84 $467.23 $499.77 $512.26 $455.84 $467.23 $455.84

$828.76 $849.48 $424.81 $435.43 $465.76 $477.40 $424.81 $435.43 $424.81 $435.43 $572.14 $586.44 $475.63 $487.52 $521.47 $534.51 $475.63 $487.52 $475.63

$867.62 $889.31 $444.73 $455.85 $487.60 $499.79 $444.73 $455.85 $444.73 $455.85 $598.97 $613.95 $497.94 $510.39 $545.93 $559.57 $497.94 $510.39 $497.94

$906.00 $928.65 $464.40 $476.01 $509.16 $521.89 $464.40 $476.01 $464.40 $476.01 $625.47 $641.10 $519.96 $532.96 $570.07 $584.33 $519.96 $532.96 $519.96

$948.26 $971.97 $486.07 $498.22 $532.92 $546.24 $486.07 $498.22 $486.07 $498.22 $654.64 $671.01 $544.22 $557.82 $596.67 $611.58 $544.22 $557.82 $544.22

$991.01 $1,015.79 $507.98 $520.68 $556.94 $570.86 $507.98 $520.68 $507.98 $520.68 $684.15 $701.26 $568.75 $582.97 $623.57 $639.16 $568.75 $582.97 $568.75

$1,037.16 $1,063.09 $531.64 $544.93 $582.88 $597.45 $531.64 $544.93 $531.64 $544.93 $716.01 $733.92 $595.24 $610.12 $652.61 $668.92 $595.24 $610.12 $595.24

$1,083.31 $1,110.39 $555.29 $569.17 $608.81 $624.03 $555.29 $569.17 $555.29 $569.17 $747.88 $766.57 $621.72 $637.27 $681.64 $698.69 $621.72 $637.27 $621.72

$1,133.35 $1,161.68 $580.94 $595.46 $636.93 $652.86 $580.94 $595.46 $580.94 $595.46 $782.42 $801.98 $650.44 $666.70 $713.13 $730.96 $650.44 $666.70 $650.44

$1,183.87 $1,213.47 $606.84 $622.01 $665.33 $681.96 $606.84 $622.01 $606.84 $622.01 $817.30 $837.73 $679.44 $696.42 $744.92 $763.54 $679.44 $696.42 $679.44

$1,237.79 $1,268.74 $634.48 $650.34 $695.63 $713.02 $634.48 $650.34 $634.48 $650.34 $854.52 $875.89 $710.38 $728.14 $778.85 $798.32 $710.38 $728.14 $710.38

$1,264.51 $1,296.12 $648.17 $664.38 $710.65 $728.41 $648.17 $664.38 $648.17 $664.38 $872.97 $894.79 $725.72 $743.86 $795.66 $815.55 $725.72 $743.86 $725.72

$1,318.43 $1,351.39 $675.81 $692.71 $740.95 $759.47 $675.81 $692.71 $675.81 $692.71 $910.19 $932.95 $756.66 $775.58 $829.59 $850.33 $756.66 $775.58 $756.66

$1,365.07 $1,399.20 $699.72 $717.21 $767.16 $786.34 $699.72 $717.21 $699.72 $717.21 $942.39 $965.95 $783.43 $803.01 $858.93 $880.41 $783.43 $803.01 $783.43

$1,395.67 $1,430.57 $715.41 $733.29 $784.36 $803.97 $715.41 $733.29 $715.41 $733.29 $963.52 $987.61 $800.99 $821.02 $878.19 $900.14 $800.99 $821.02 $800.99

$1,434.05 $1,469.90 $735.08 $753.45 $805.93 $826.07 $735.08 $753.45 $735.08 $753.45 $990.01 $1,014.76 $823.02 $843.59 $902.34 $924.90 $823.02 $843.59 $823.02

$1,457.37 $1,493.80 $747.03 $765.71 $819.03 $839.51 $747.03 $765.71 $747.03 $765.71 $1,006.11 $1,031.26 $836.40 $857.31 $917.01 $939.94 $836.40 $857.31 $836.40

Yes YesYes Yes Yes Yes YesYes Yes Yes

$5300/ $10600$8150/ $16300 $8150/ $16300 $5300/ $10600 $5300/ $10600 $5300/ $10600$5200/ $10400 $8150/ $16300 $8150/ $16300 $8150/ $16300

$50 / $0 $0/ 20% $0/ 20% $0/ 20% $0/ 20% $25 / $55 $50 / $0 $50 / $0 $50 / $0 $50 / $0

80% 80% 80% 80%100% 100% 100% 100% 100%90%

$2700/ $5400 $2700/ $5400$7400/ $14800 $7400/ $14800 $7400/ $14800 $2700/ $5400 $2700/ $5400$900/ $1800 $7400/ $14800 $7400/ $14800

SilverBronze Bronze Silver Silver SilverGold Bronze Bronze Bronze


1 2 4 51 2 4 5 66

664 664663 663 663 664 664663 663 663

UPMC Advantage Silver HSA $2,800/20% - Premium NetworkUPMC Advantage Bronze $7,400/$50 - Premium NetworkUPMC Advantage Bronze $7,400/$50 - Premium NetworkUPMC Advantage Silver HSA $2,800/20% - Premium NetworkUPMC Advantage Silver HSA $2,800/20% - Premium NetworkUPMC Advantage Silver HSA $2,800/20% - Premium NetworkUPMC Advantage Gold $900/$25 - Premium NetworkUPMC Advantage Bronze $7,400/$50 - Premium NetworkUPMC Advantage Bronze $7,400/$50 - Premium NetworkUPMC Advantage Bronze $7,400/$50 - Premium Network

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64+


$213.28 $287.25 $287.25 $182.28 $182.28 $199.84 $199.84 $182.28 $182.28 $182.28 $182.28 $245.49 $245.49 $221.36 $221.36 $242.70 $242.70 $221.36 $221.36

$232.24 $312.78 $312.78 $198.48 $198.48 $217.60 $217.60 $198.48 $198.48 $198.48 $198.48 $267.31 $267.31 $241.04 $241.04 $264.27 $264.27 $241.04 $241.04

$239.49 $322.55 $322.55 $204.67 $204.67 $224.40 $224.40 $204.67 $204.67 $204.67 $204.67 $275.65 $275.65 $248.56 $248.56 $272.52 $272.52 $248.56 $248.56

$246.74 $332.31 $332.31 $210.87 $210.87 $231.19 $231.19 $210.87 $210.87 $210.87 $210.87 $284.00 $284.00 $256.08 $256.08 $280.77 $280.77 $256.08 $256.08

$260.91 $342.82 $351.39 $217.54 $222.98 $238.50 $244.47 $217.54 $222.98 $217.54 $222.98 $292.98 $300.31 $264.19 $270.79 $289.65 $296.89 $264.19 $270.79

$268.91 $353.34 $362.17 $224.21 $229.82 $245.82 $251.96 $224.21 $229.82 $224.21 $229.82 $301.97 $309.52 $272.29 $279.09 $298.53 $306.00 $272.29 $279.09

$277.20 $364.23 $373.33 $231.12 $236.90 $253.39 $259.73 $231.12 $236.90 $231.12 $236.90 $311.27 $319.05 $280.68 $287.70 $307.73 $315.43 $280.68 $287.70

$285.77 $375.49 $384.88 $238.27 $244.23 $261.23 $267.76 $238.27 $244.23 $238.27 $244.23 $320.90 $328.92 $289.36 $296.59 $317.25 $325.18 $289.36 $296.59

$285.77 $375.49 $384.88 $238.27 $244.23 $261.23 $267.76 $238.27 $244.23 $238.27 $244.23 $320.90 $328.92 $289.36 $296.59 $317.25 $325.18 $289.36 $296.59

$285.77 $375.49 $384.88 $238.27 $244.23 $261.23 $267.76 $238.27 $244.23 $238.27 $244.23 $320.90 $328.92 $289.36 $296.59 $317.25 $325.18 $289.36 $296.59

$285.77 $375.49 $384.88 $238.27 $244.23 $261.23 $267.76 $238.27 $244.23 $238.27 $244.23 $320.90 $328.92 $289.36 $296.59 $317.25 $325.18 $289.36 $296.59

$286.91 $376.99 $386.42 $239.22 $245.20 $262.27 $268.83 $239.22 $245.20 $239.22 $245.20 $322.18 $330.24 $290.52 $297.78 $318.52 $326.48 $290.52 $297.78

$292.63 $384.50 $394.11 $243.99 $250.09 $267.50 $274.19 $243.99 $250.09 $243.99 $250.09 $328.60 $336.82 $296.30 $303.71 $324.86 $332.99 $296.30 $303.71

$299.49 $393.51 $403.35 $249.71 $255.95 $273.77 $280.61 $249.71 $255.95 $249.71 $255.95 $336.30 $344.71 $303.25 $310.83 $332.48 $340.79 $303.25 $310.83

$310.63 $408.16 $418.36 $259.00 $265.47 $283.96 $291.06 $259.00 $265.47 $259.00 $265.47 $348.82 $357.54 $314.53 $322.40 $344.85 $353.47 $314.53 $322.40

$319.78 $420.17 $430.68 $266.62 $273.29 $292.32 $299.62 $266.62 $273.29 $266.62 $273.29 $359.09 $368.06 $323.79 $331.89 $355.00 $363.88 $323.79 $331.89

$324.35 $426.18 $436.84 $270.44 $277.20 $296.50 $303.91 $270.44 $277.20 $270.44 $277.20 $364.22 $373.33 $328.42 $336.63 $360.08 $369.08 $328.42 $336.63

$331.21 $435.19 $446.07 $276.15 $283.06 $302.77 $310.33 $276.15 $283.06 $276.15 $283.06 $371.92 $381.22 $335.37 $343.75 $367.69 $376.89 $335.37 $343.75

$338.07 $444.20 $455.31 $281.87 $288.92 $309.04 $316.76 $281.87 $288.92 $281.87 $288.92 $379.62 $389.12 $342.31 $350.87 $375.31 $384.69 $342.31 $350.87

$342.35 $449.84 $461.08 $285.45 $292.58 $312.95 $320.78 $285.45 $292.58 $285.45 $292.58 $384.44 $394.05 $346.65 $355.32 $380.07 $389.57 $346.65 $355.32

$346.92 $455.84 $467.24 $289.26 $296.49 $317.13 $325.06 $289.26 $296.49 $289.26 $296.49 $389.57 $399.31 $351.28 $360.07 $385.14 $394.77 $351.28 $360.07

$349.21 $458.85 $470.32 $291.17 $298.45 $319.22 $327.20 $291.17 $298.45 $291.17 $298.45 $392.14 $401.94 $353.60 $362.44 $387.68 $397.37 $353.60 $362.44

$351.50 $461.85 $473.40 $293.07 $300.40 $321.31 $329.35 $293.07 $300.40 $293.07 $300.40 $394.71 $404.57 $355.91 $364.81 $390.22 $399.97 $355.91 $364.81

$353.78 $464.86 $476.48 $294.98 $302.35 $323.40 $331.49 $294.98 $302.35 $294.98 $302.35 $397.27 $407.21 $358.23 $367.18 $392.76 $402.57 $358.23 $367.18

$356.07 $467.86 $479.56 $296.88 $304.31 $325.49 $333.63 $296.88 $304.31 $296.88 $304.31 $399.84 $409.84 $360.54 $369.56 $395.29 $405.18 $360.54 $369.56

$360.64 $473.87 $485.72 $300.70 $308.21 $329.67 $337.91 $300.70 $308.21 $300.70 $308.21 $404.98 $415.10 $365.17 $374.30 $400.37 $410.38 $365.17 $374.30

$365.21 $479.88 $491.87 $304.51 $312.12 $333.85 $342.20 $304.51 $312.12 $304.51 $312.12 $410.11 $420.36 $369.80 $379.05 $405.45 $415.58 $369.80 $379.05

$372.07 $488.89 $501.11 $310.23 $317.98 $340.12 $348.62 $310.23 $317.98 $310.23 $317.98 $417.81 $428.26 $376.75 $386.17 $413.06 $423.39 $376.75 $386.17

$378.65 $497.52 $509.96 $315.71 $323.60 $346.13 $354.78 $315.71 $323.60 $315.71 $323.60 $425.19 $435.82 $383.40 $392.99 $420.36 $430.87 $383.40 $392.99

$387.79 $509.54 $522.28 $323.33 $331.42 $354.49 $363.35 $323.33 $331.42 $323.33 $331.42 $435.46 $446.35 $392.66 $402.48 $430.51 $441.27 $392.66 $402.48

$399.22 $524.56 $537.67 $332.86 $341.18 $364.94 $374.06 $332.86 $341.18 $332.86 $341.18 $448.30 $459.50 $404.24 $414.34 $443.20 $454.28 $404.24 $414.34

$412.65 $542.21 $555.76 $344.06 $352.66 $377.22 $386.65 $344.06 $352.66 $344.06 $352.66 $463.38 $474.96 $417.84 $428.28 $458.11 $469.56 $417.84 $428.28

$428.66 $563.24 $577.32 $357.41 $366.34 $391.85 $401.64 $357.41 $366.34 $357.41 $366.34 $481.35 $493.38 $434.04 $444.89 $475.88 $487.77 $434.04 $444.89

$446.66 $586.89 $601.56 $372.42 $381.73 $408.30 $418.51 $372.42 $381.73 $372.42 $381.73 $501.57 $514.11 $452.27 $463.58 $495.86 $508.26 $452.27 $463.58

$467.23 $613.93 $629.27 $389.57 $399.31 $427.11 $437.79 $389.57 $399.31 $389.57 $399.31 $524.67 $537.79 $473.10 $484.93 $518.70 $531.67 $473.10 $484.93

$487.52 $640.59 $656.60 $406.49 $416.65 $445.66 $456.80 $406.49 $416.65 $406.49 $416.65 $547.46 $561.14 $493.65 $505.99 $541.23 $554.76 $493.65 $505.99

$510.39 $670.63 $687.39 $425.55 $436.19 $466.56 $478.22 $425.55 $436.19 $425.55 $436.19 $573.13 $587.46 $516.80 $529.72 $566.61 $580.77 $516.80 $529.72

$532.96 $700.29 $717.80 $444.37 $455.48 $487.19 $499.37 $444.37 $455.48 $444.37 $455.48 $598.48 $613.44 $539.66 $553.15 $591.67 $606.46 $539.66 $553.15

$557.82 $732.96 $751.28 $465.10 $476.73 $509.92 $522.67 $465.10 $476.73 $465.10 $476.73 $626.40 $642.06 $564.83 $578.95 $619.27 $634.75 $564.83 $578.95

$582.97 $766.00 $785.15 $486.07 $498.22 $532.91 $546.23 $486.07 $498.22 $486.07 $498.22 $654.64 $671.00 $590.29 $605.05 $647.19 $663.37 $590.29 $605.05

$610.12 $801.67 $821.71 $508.71 $521.42 $557.73 $571.67 $508.71 $521.42 $508.71 $521.42 $685.12 $702.25 $617.78 $633.23 $677.33 $694.26 $617.78 $633.23

$637.27 $837.34 $858.28 $531.34 $544.63 $582.54 $597.11 $531.34 $544.63 $531.34 $544.63 $715.61 $733.50 $645.27 $661.40 $707.47 $725.15 $645.27 $661.40

$666.70 $876.02 $897.92 $555.88 $569.78 $609.45 $624.69 $555.88 $569.78 $555.88 $569.78 $748.66 $767.38 $675.08 $691.95 $740.14 $758.65 $675.08 $691.95

$696.42 $915.07 $937.95 $580.66 $595.18 $636.62 $652.53 $580.66 $595.18 $580.66 $595.18 $782.03 $801.58 $705.17 $722.80 $773.14 $792.47 $705.17 $722.80

$728.14 $956.75 $980.67 $607.11 $622.29 $665.61 $682.25 $607.11 $622.29 $607.11 $622.29 $817.65 $838.09 $737.29 $755.72 $808.35 $828.56 $737.29 $755.72

$743.86 $977.40 $1,001.84 $620.22 $635.72 $679.98 $696.98 $620.22 $635.72 $620.22 $635.72 $835.30 $856.19 $753.20 $772.03 $825.80 $846.45 $753.20 $772.03

$775.58 $1,019.08 $1,044.56 $646.66 $662.83 $708.98 $726.70 $646.66 $662.83 $646.66 $662.83 $870.92 $892.70 $785.32 $804.96 $861.02 $882.54 $785.32 $804.96

$803.01 $1,055.13 $1,081.51 $669.54 $686.28 $734.06 $752.41 $669.54 $686.28 $669.54 $686.28 $901.73 $924.27 $813.10 $833.43 $891.47 $913.76 $813.10 $833.43

$821.02 $1,078.78 $1,105.75 $684.55 $701.66 $750.51 $769.28 $684.55 $701.66 $684.55 $701.66 $921.95 $944.99 $831.33 $852.11 $911.46 $934.25 $831.33 $852.11

$843.59 $1,108.45 $1,136.16 $703.37 $720.96 $771.15 $790.43 $703.37 $720.96 $703.37 $720.96 $947.30 $970.98 $854.19 $875.55 $936.52 $959.94 $854.19 $875.55

$857.31 $1,126.47 $1,154.63 $714.81 $732.68 $783.69 $803.28 $714.81 $732.68 $714.81 $732.68 $962.70 $986.77 $868.08 $889.78 $951.75 $975.54 $868.08 $889.78

YesYes Yes Yes Yes YesYes Yes Yes Yes

$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300$5300/ $10600 $5300/ $10600 $8150/ $16300 $8150/ $16300 $8150/ $16300

$0/ $0 $60 / $80 $60 / $80 $60 / $80 $0/ 20% $0/ $0 $0/ $0 $0/ $0 $0/ $0 $0/ 20%

80% 80% 80%100% 100% 100% 100% 100%80% 80%

$2300/ $4600$8150/ $16300 $8150/ $16300 $8150/ $16300 $2300/ $4600 $2300/ $4600$2700/ $5400 $2700/ $5400 $8150/ $16300 $8150/ $16300

Catastrophic Catastrophic Silver Silver SilverSilver Silver Catastrophic Catastrophic Catastrophic


1 2 41 2 4 5 65 6

663667 667 667 663 663664 664 667 667

UPMC Advantage Catastrophic $8,150/$0 - Premium NetworkUPMC Advantage Catastrophic $8,150/$0 - Premium NetworkUPMC Advantage Silver $2,300/$60 - Premium NetworkUPMC Advantage Silver $2,300/$60 - Premium NetworkUPMC Advantage Silver $2,300/$60 - Premium NetworkUPMC Advantage Silver HSA $2,800/20% - Premium NetworkUPMC Advantage Silver HSA $2,800/20% - Premium NetworkUPMC Advantage Catastrophic $8,150/$0 - Premium NetworkUPMC Advantage Catastrophic $8,150/$0 - Premium NetworkUPMC Advantage Catastrophic $8,150/$0 - Premium Network


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64+


$221.36 $221.36 $298.14 $298.14 $240.38 $240.38 $256.56 $256.56 $260.19 $260.19 $227.82 $227.82 $333.00 $333.00 $355.42 $355.42 $360.45 $360.45 $315.62

$241.04 $241.04 $324.64 $324.64 $261.75 $261.75 $279.36 $279.36 $283.32 $283.32 $248.08 $248.08 $362.60 $362.60 $387.01 $387.01 $392.48 $392.48 $343.67

$248.56 $248.56 $334.77 $334.77 $269.91 $269.91 $288.08 $288.08 $292.16 $292.16 $255.82 $255.82 $373.91 $373.91 $399.09 $399.09 $404.74 $404.74 $354.40

$256.08 $256.08 $344.90 $344.90 $278.08 $278.08 $296.80 $296.80 $301.01 $301.01 $263.56 $263.56 $385.23 $385.23 $411.17 $411.17 $416.99 $416.99 $365.12

$264.19 $270.79 $355.81 $364.71 $286.88 $294.05 $306.19 $313.85 $310.53 $318.29 $271.90 $278.70 $397.42 $407.36 $424.18 $434.78 $430.18 $440.93 $376.68

$272.29 $279.09 $366.73 $375.89 $295.68 $303.07 $315.58 $323.47 $320.05 $328.05 $280.24 $287.25 $409.61 $419.85 $437.19 $448.12 $443.37 $454.46 $388.23

$280.68 $287.70 $378.03 $387.48 $304.79 $312.41 $325.31 $333.44 $329.92 $338.16 $288.88 $296.10 $422.23 $432.79 $450.66 $461.93 $457.03 $468.46 $400.19

$289.36 $296.59 $389.72 $399.46 $314.22 $322.08 $335.37 $343.75 $340.12 $348.62 $297.81 $305.26 $435.29 $446.17 $464.60 $476.22 $471.17 $482.95 $412.57

$289.36 $296.59 $389.72 $399.46 $314.22 $322.08 $335.37 $343.75 $340.12 $348.62 $297.81 $305.26 $435.29 $446.17 $464.60 $476.22 $471.17 $482.95 $412.57

$289.36 $296.59 $389.72 $399.46 $314.22 $322.08 $335.37 $343.75 $340.12 $348.62 $297.81 $305.26 $435.29 $446.17 $464.60 $476.22 $471.17 $482.95 $412.57

$289.36 $296.59 $389.72 $399.46 $314.22 $322.08 $335.37 $343.75 $340.12 $348.62 $297.81 $305.26 $435.29 $446.17 $464.60 $476.22 $471.17 $482.95 $412.57

$290.52 $297.78 $391.28 $401.06 $315.48 $323.36 $336.71 $345.13 $341.48 $350.02 $299.00 $306.48 $437.03 $447.96 $466.46 $478.12 $473.05 $484.88 $414.22

$296.30 $303.71 $399.07 $409.05 $321.76 $329.81 $343.42 $352.00 $348.28 $356.99 $304.96 $312.58 $445.74 $456.88 $475.75 $487.64 $482.48 $494.54 $422.47

$303.25 $310.83 $408.43 $418.64 $329.30 $337.54 $351.47 $360.25 $356.45 $365.36 $312.10 $319.91 $456.18 $467.59 $486.90 $499.07 $493.79 $506.13 $432.37

$314.53 $322.40 $423.63 $434.22 $341.56 $350.10 $364.55 $373.66 $369.71 $378.95 $323.72 $331.81 $473.16 $484.99 $505.02 $517.65 $512.16 $524.97 $448.46

$323.79 $331.89 $436.10 $447.00 $351.61 $360.40 $375.28 $384.66 $380.59 $390.11 $333.25 $341.58 $487.09 $499.27 $519.89 $532.88 $527.24 $540.42 $461.67

$328.42 $336.63 $442.33 $453.39 $356.64 $365.56 $380.64 $390.16 $386.04 $395.69 $338.01 $346.46 $494.05 $506.41 $527.32 $540.50 $534.78 $548.15 $468.27

$335.37 $343.75 $451.69 $462.98 $364.18 $373.29 $388.69 $398.41 $394.20 $404.05 $345.16 $353.79 $504.50 $517.11 $538.47 $551.93 $546.09 $559.74 $478.17

$342.31 $350.87 $461.04 $472.56 $371.72 $381.02 $396.74 $406.66 $402.36 $412.42 $352.31 $361.12 $514.95 $527.82 $549.62 $563.36 $557.39 $571.33 $488.07

$346.65 $355.32 $466.88 $478.56 $376.44 $385.85 $401.77 $411.82 $407.46 $417.65 $356.78 $365.70 $521.48 $534.51 $556.59 $570.51 $564.46 $578.57 $494.26

$351.28 $360.07 $473.12 $484.95 $381.46 $391.00 $407.14 $417.32 $412.91 $423.23 $361.54 $370.58 $528.44 $541.65 $564.02 $578.13 $572.00 $586.30 $500.86

$353.60 $362.44 $476.24 $488.14 $383.98 $393.58 $409.82 $420.07 $415.63 $426.02 $363.92 $373.02 $531.92 $545.22 $567.74 $581.93 $575.77 $590.16 $504.16

$355.91 $364.81 $479.36 $491.34 $386.49 $396.15 $412.51 $422.82 $418.35 $428.81 $366.31 $375.46 $535.41 $548.79 $571.46 $585.74 $579.54 $594.03 $507.46

$358.23 $367.18 $482.47 $494.54 $389.00 $398.73 $415.19 $425.57 $421.07 $431.60 $368.69 $377.91 $538.89 $552.36 $575.17 $589.55 $583.31 $597.89 $510.76

$360.54 $369.56 $485.59 $497.73 $391.52 $401.31 $417.87 $428.32 $423.79 $434.38 $371.07 $380.35 $542.37 $555.93 $578.89 $593.36 $587.08 $601.75 $514.06

$365.17 $374.30 $491.83 $504.12 $396.55 $406.46 $423.24 $433.82 $429.23 $439.96 $375.84 $385.23 $549.34 $563.07 $586.33 $600.98 $594.62 $609.48 $520.66

$369.80 $379.05 $498.06 $510.51 $401.57 $411.61 $428.60 $439.32 $434.67 $445.54 $380.60 $390.12 $556.30 $570.21 $593.76 $608.60 $602.16 $617.21 $527.26

$376.75 $386.17 $507.42 $520.10 $409.11 $419.34 $436.65 $447.57 $442.84 $453.91 $387.75 $397.44 $566.75 $580.92 $604.91 $620.03 $613.46 $628.80 $537.17

$383.40 $392.99 $516.38 $529.29 $416.34 $426.75 $444.37 $455.47 $450.66 $461.93 $394.60 $404.46 $576.76 $591.18 $615.60 $630.98 $624.30 $639.91 $546.66

$392.66 $402.48 $528.85 $542.07 $426.40 $437.06 $455.10 $466.47 $461.54 $473.08 $404.13 $414.23 $590.69 $605.46 $630.46 $646.22 $639.38 $655.36 $559.86

$404.24 $414.34 $544.44 $558.05 $438.97 $449.94 $468.51 $480.22 $475.15 $487.03 $416.04 $426.44 $608.10 $623.30 $649.05 $665.27 $658.22 $674.68 $576.36

$417.84 $428.28 $562.76 $576.82 $453.73 $465.08 $484.27 $496.38 $491.13 $503.41 $430.04 $440.79 $628.56 $644.27 $670.88 $687.65 $680.37 $697.38 $595.75

$434.04 $444.89 $584.58 $599.19 $471.33 $483.11 $503.06 $515.63 $510.18 $522.93 $446.72 $457.88 $652.94 $669.26 $696.90 $714.32 $706.76 $724.42 $618.86

$452.27 $463.58 $609.13 $624.36 $491.13 $503.40 $524.18 $537.29 $531.61 $544.90 $465.48 $477.11 $680.36 $697.37 $726.17 $744.32 $736.44 $754.85 $644.85

$473.10 $484.93 $637.19 $653.12 $513.75 $526.59 $548.33 $562.04 $556.10 $570.00 $486.92 $499.09 $711.70 $729.49 $759.62 $778.61 $770.36 $789.62 $674.55

$493.65 $505.99 $664.86 $681.48 $536.06 $549.46 $572.14 $586.44 $580.24 $594.75 $508.06 $520.77 $742.60 $761.17 $792.61 $812.42 $803.82 $823.91 $703.84

$516.80 $529.72 $696.04 $713.44 $561.20 $575.23 $598.97 $613.95 $607.45 $622.64 $531.89 $545.19 $777.43 $796.86 $829.78 $850.52 $841.51 $862.55 $736.85

$539.66 $553.15 $726.83 $745.00 $586.02 $600.67 $625.47 $641.10 $634.32 $650.18 $555.42 $569.30 $811.82 $832.11 $866.48 $888.14 $878.73 $900.70 $769.44

$564.83 $578.95 $760.73 $779.75 $613.36 $628.69 $654.64 $671.01 $663.91 $680.51 $581.33 $595.86 $849.69 $870.93 $906.90 $929.57 $919.72 $942.72 $805.34

$590.29 $605.05 $795.03 $814.90 $641.01 $657.03 $684.15 $701.26 $693.84 $711.19 $607.53 $622.72 $887.99 $910.19 $947.78 $971.48 $961.19 $985.22 $841.64

$617.78 $633.23 $832.05 $852.85 $670.86 $687.63 $716.01 $733.92 $726.16 $744.31 $635.82 $651.72 $929.34 $952.58 $991.92 $1,016.72 $1,005.95 $1,031.10 $880.84

$645.27 $661.40 $869.08 $890.80 $700.71 $718.23 $747.88 $766.57 $758.47 $777.43 $664.12 $680.72 $970.70 $994.96 $1,036.06 $1,061.96 $1,050.71 $1,076.98 $920.03

$675.08 $691.95 $909.22 $931.95 $733.08 $751.40 $782.42 $801.98 $793.50 $813.34 $694.79 $712.16 $1,015.53 $1,040.92 $1,083.91 $1,111.01 $1,099.24 $1,126.72 $962.53

$705.17 $722.80 $949.75 $973.49 $765.75 $784.90 $817.30 $837.73 $828.87 $849.59 $725.76 $743.91 $1,060.80 $1,087.32 $1,132.23 $1,160.54 $1,148.24 $1,176.95 $1,005.43

$737.29 $755.72 $993.01 $1,017.83 $800.63 $820.65 $854.52 $875.89 $866.63 $888.29 $758.82 $777.79 $1,109.12 $1,136.85 $1,183.80 $1,213.40 $1,200.54 $1,230.55 $1,051.23

$753.20 $772.03 $1,014.44 $1,039.80 $817.91 $838.36 $872.97 $894.79 $885.33 $907.47 $775.20 $794.58 $1,133.06 $1,161.39 $1,209.35 $1,239.59 $1,226.46 $1,257.12 $1,073.92

$785.32 $804.96 $1,057.70 $1,084.14 $852.79 $874.11 $910.19 $932.95 $923.09 $946.16 $808.26 $828.46 $1,181.38 $1,210.91 $1,260.92 $1,292.45 $1,278.76 $1,310.72 $1,119.71

$813.10 $833.43 $1,095.11 $1,122.49 $882.96 $905.03 $942.39 $965.95 $955.74 $979.63 $836.85 $857.77 $1,223.16 $1,253.74 $1,305.53 $1,338.16 $1,323.99 $1,357.09 $1,159.32

$831.33 $852.11 $1,119.67 $1,147.66 $902.75 $925.32 $963.52 $987.61 $977.16 $1,001.59 $855.61 $877.00 $1,250.59 $1,281.85 $1,334.80 $1,368.17 $1,353.67 $1,387.51 $1,185.31

$854.19 $875.55 $1,150.45 $1,179.21 $927.58 $950.77 $990.01 $1,014.76 $1,004.03 $1,029.14 $879.14 $901.11 $1,284.98 $1,317.10 $1,371.50 $1,405.79 $1,390.89 $1,425.67 $1,217.91

$868.08 $889.78 $1,169.16 $1,198.39 $942.66 $966.23 $1,006.11 $1,031.26 $1,020.36 $1,045.87 $893.43 $915.77 $1,305.87 $1,338.52 $1,393.80 $1,428.65 $1,413.51 $1,448.85 $1,237.71

YesYes Yes Yes Yes YesYes Yes Yes Yes

$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300

$25 / $75 $25 / $75 $25 / $75 $25 / $75 $60 / $80 $50 / $0 $50 / $0 $50 / $0 $50 / $0 $60 / $80

80% 80% 80%100% 100% 100% 100% 80%80% 80%

$3500/ $7000$7400/ $14800 $7400/ $14800 $3500/ $7000 $3500/ $7000 $3500/ $7000$2300/ $4600 $2300/ $4600 $7400/ $14800 $7400/ $14800

Bronze Silver Silver Silver SilverSilver Silver Bronze Bronze Bronze

IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium West w/Dominion PEDS PPO-2020

6 7 93 6 7 9 35 6

663663 663 663 663 663663 663 663 663

UPMC Advantage Bronze $7,400/$50 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium NetworkUPMC Advantage Silver $2,300/$60 - Premium NetworkUPMC Advantage Silver $2,300/$60 - Premium NetworkUPMC Advantage Bronze $7,400/$50 - Premium NetworkUPMC Advantage Bronze $7,400/$50 - Premium NetworkUPMC Advantage Bronze $7,400/$50 - Premium Network


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64+


$315.62 $279.33 $279.33 $298.14 $298.14 $302.35 $302.35 $264.74 $264.74 $348.19 $348.19 $371.63 $371.63 $376.88 $376.88 $330.01 $330.01 $231.92 $231.92

$343.67 $304.16 $304.16 $324.64 $324.64 $329.23 $329.23 $288.28 $288.28 $379.14 $379.14 $404.66 $404.66 $410.39 $410.39 $359.35 $359.35 $252.53 $252.53

$354.40 $313.66 $313.66 $334.77 $334.77 $339.50 $339.50 $297.27 $297.27 $390.97 $390.97 $417.29 $417.29 $423.19 $423.19 $370.56 $370.56 $260.41 $260.41

$365.12 $323.15 $323.15 $344.90 $344.90 $349.78 $349.78 $306.27 $306.27 $402.81 $402.81 $429.92 $429.92 $436.00 $436.00 $381.78 $381.78 $268.30 $268.30

$386.09 $333.37 $341.71 $355.81 $364.71 $360.84 $369.87 $315.96 $323.86 $415.55 $425.94 $443.53 $454.61 $449.80 $461.04 $393.86 $403.71 $276.79 $283.70

$397.93 $343.60 $352.19 $366.73 $375.89 $371.91 $381.21 $325.65 $333.79 $428.30 $439.00 $457.13 $468.56 $463.59 $475.18 $405.94 $416.09 $285.27 $292.41

$410.20 $354.19 $363.04 $378.03 $387.48 $383.37 $392.96 $335.69 $344.08 $441.50 $452.53 $471.22 $483.00 $477.88 $489.83 $418.45 $428.91 $294.07 $301.42

$422.88 $365.14 $374.27 $389.72 $399.46 $395.23 $405.11 $346.07 $354.72 $455.15 $466.53 $485.79 $497.93 $492.66 $504.98 $431.39 $442.17 $303.16 $310.74

$422.88 $365.14 $374.27 $389.72 $399.46 $395.23 $405.11 $346.07 $354.72 $455.15 $466.53 $485.79 $497.93 $492.66 $504.98 $431.39 $442.17 $303.16 $310.74

$422.88 $365.14 $374.27 $389.72 $399.46 $395.23 $405.11 $346.07 $354.72 $455.15 $466.53 $485.79 $497.93 $492.66 $504.98 $431.39 $442.17 $303.16 $310.74

$422.88 $365.14 $374.27 $389.72 $399.46 $395.23 $405.11 $346.07 $354.72 $455.15 $466.53 $485.79 $497.93 $492.66 $504.98 $431.39 $442.17 $303.16 $310.74

$424.58 $366.60 $375.77 $391.28 $401.06 $396.81 $406.73 $347.45 $356.14 $456.97 $468.39 $487.73 $499.93 $494.63 $507.00 $433.12 $443.94 $304.37 $311.98

$433.03 $373.90 $383.25 $399.07 $409.05 $404.72 $414.83 $354.38 $363.24 $466.07 $477.73 $497.45 $509.89 $504.48 $517.10 $441.74 $452.79 $310.44 $318.20

$443.18 $382.67 $392.23 $408.43 $418.64 $414.20 $424.56 $362.68 $371.75 $477.00 $488.92 $509.11 $521.84 $516.31 $529.22 $452.10 $463.40 $317.71 $325.65

$459.68 $396.91 $406.83 $423.63 $434.22 $429.62 $440.36 $376.18 $385.58 $494.75 $507.12 $528.05 $541.26 $535.52 $548.91 $468.92 $480.64 $329.53 $337.77

$473.21 $408.59 $418.81 $436.10 $447.00 $442.26 $453.32 $387.25 $396.93 $509.31 $522.05 $543.60 $557.19 $551.29 $565.07 $482.73 $494.79 $339.24 $347.72

$479.97 $414.43 $424.79 $442.33 $453.39 $448.59 $459.80 $392.79 $402.61 $516.60 $529.51 $551.37 $565.16 $559.17 $573.15 $489.63 $501.87 $344.09 $352.69

$490.12 $423.20 $433.78 $451.69 $462.98 $458.07 $469.52 $401.10 $411.12 $527.52 $540.71 $563.03 $577.11 $570.99 $585.27 $499.98 $512.48 $351.36 $360.15

$500.27 $431.96 $442.76 $461.04 $472.56 $467.56 $479.25 $409.40 $419.64 $538.44 $551.90 $574.69 $589.06 $582.82 $597.39 $510.33 $523.09 $358.64 $367.60

$506.62 $437.44 $448.37 $466.88 $478.56 $473.49 $485.32 $414.59 $424.96 $545.27 $558.90 $581.98 $596.53 $590.21 $604.96 $516.81 $529.73 $363.19 $372.27

$513.38 $443.28 $454.36 $473.12 $484.95 $479.81 $491.80 $420.13 $430.63 $552.55 $566.37 $589.75 $604.49 $598.09 $613.04 $523.71 $536.80 $368.04 $377.24

$516.76 $446.20 $457.36 $476.24 $488.14 $482.97 $495.05 $422.90 $433.47 $556.19 $570.10 $593.64 $608.48 $602.03 $617.08 $527.16 $540.34 $370.46 $379.72

$520.15 $449.12 $460.35 $479.36 $491.34 $486.13 $498.29 $425.67 $436.31 $559.83 $573.83 $597.52 $612.46 $605.97 $621.12 $530.61 $543.87 $372.89 $382.21

$523.53 $452.04 $463.34 $482.47 $494.54 $489.29 $501.53 $428.43 $439.15 $563.48 $577.56 $601.41 $616.44 $609.91 $625.16 $534.06 $547.41 $375.31 $384.69

$526.91 $454.96 $466.34 $485.59 $497.73 $492.46 $504.77 $431.20 $441.98 $567.12 $581.29 $605.29 $620.43 $613.85 $629.20 $537.51 $550.95 $377.74 $387.18

$533.68 $460.81 $472.33 $491.83 $504.12 $498.78 $511.25 $436.74 $447.66 $574.40 $588.76 $613.07 $628.39 $621.74 $637.28 $544.41 $558.02 $382.59 $392.15

$540.45 $466.65 $478.32 $498.06 $510.51 $505.10 $517.73 $442.28 $453.33 $581.68 $596.22 $620.84 $636.36 $629.62 $645.36 $551.32 $565.10 $387.44 $397.12

$550.60 $475.41 $487.30 $507.42 $520.10 $514.59 $527.45 $450.58 $461.85 $592.61 $607.42 $632.50 $648.31 $641.44 $657.48 $561.67 $575.71 $394.71 $404.58

$560.32 $483.81 $495.91 $516.38 $529.29 $523.68 $536.77 $458.54 $470.01 $603.07 $618.15 $643.67 $659.76 $652.77 $669.09 $571.59 $585.88 $401.69 $411.73

$573.85 $495.49 $507.88 $528.85 $542.07 $536.33 $549.74 $469.62 $481.36 $617.64 $633.08 $659.22 $675.70 $668.54 $685.25 $585.40 $600.03 $411.39 $421.67

$590.77 $510.10 $522.85 $544.44 $558.05 $552.14 $565.94 $483.46 $495.55 $635.84 $651.74 $678.65 $695.61 $688.25 $705.45 $602.65 $617.72 $423.51 $434.10

$610.64 $527.26 $540.44 $562.76 $576.82 $570.71 $584.98 $499.73 $512.22 $657.24 $673.67 $701.48 $719.02 $711.40 $729.19 $622.93 $638.50 $437.76 $448.71

$634.33 $547.71 $561.40 $584.58 $599.19 $592.85 $607.67 $519.11 $532.08 $682.73 $699.79 $728.69 $746.90 $738.99 $757.46 $647.09 $663.26 $454.74 $466.11

$660.97 $570.71 $584.98 $609.13 $624.36 $617.74 $633.19 $540.91 $554.43 $711.40 $729.18 $759.29 $778.27 $770.03 $789.28 $674.26 $691.12 $473.84 $485.69

$691.42 $597.00 $611.93 $637.19 $653.12 $646.20 $662.36 $565.82 $579.97 $744.17 $762.77 $794.27 $814.12 $805.50 $825.64 $705.32 $722.96 $495.67 $508.06

$721.44 $622.93 $638.50 $664.86 $681.48 $674.26 $691.12 $590.40 $605.16 $776.49 $795.90 $828.76 $849.48 $840.48 $861.49 $735.95 $754.35 $517.19 $530.12

$755.27 $652.14 $668.44 $696.04 $713.44 $705.88 $723.53 $618.08 $633.53 $812.90 $833.22 $867.62 $889.31 $879.89 $901.89 $770.46 $789.72 $541.44 $554.98

$788.68 $680.99 $698.01 $726.83 $745.00 $737.10 $755.53 $645.42 $661.56 $848.85 $870.08 $906.00 $928.65 $918.81 $941.78 $804.54 $824.66 $565.39 $579.53

$825.47 $712.75 $730.57 $760.73 $779.75 $771.49 $790.78 $675.53 $692.42 $888.45 $910.66 $948.26 $971.97 $961.67 $985.71 $842.07 $863.13 $591.77 $606.56

$862.68 $744.89 $763.51 $795.03 $814.90 $806.27 $826.43 $705.98 $723.63 $928.51 $951.72 $991.01 $1,015.79 $1,005.03 $1,030.15 $880.04 $902.04 $618.45 $633.91

$902.86 $779.57 $799.06 $832.05 $852.85 $843.82 $864.91 $738.86 $757.33 $971.75 $996.04 $1,037.16 $1,063.09 $1,051.83 $1,078.12 $921.02 $944.04 $647.25 $663.43

$943.03 $814.26 $834.62 $869.08 $890.80 $881.36 $903.40 $771.74 $791.03 $1,014.98 $1,040.36 $1,083.31 $1,110.39 $1,098.63 $1,126.10 $962.00 $986.05 $676.05 $692.95

$986.59 $851.87 $873.17 $909.22 $931.95 $922.07 $945.12 $807.38 $827.57 $1,061.86 $1,088.41 $1,133.35 $1,161.68 $1,149.38 $1,178.11 $1,006.43 $1,031.59 $707.27 $724.95

$1,030.57 $889.85 $912.09 $949.75 $973.49 $963.18 $987.25 $843.37 $864.46 $1,109.20 $1,136.93 $1,183.87 $1,213.47 $1,200.61 $1,230.63 $1,051.30 $1,077.58 $738.80 $757.27

$1,077.51 $930.38 $953.64 $993.01 $1,017.83 $1,007.05 $1,032.22 $881.79 $903.83 $1,159.72 $1,188.72 $1,237.79 $1,268.74 $1,255.30 $1,286.68 $1,099.18 $1,126.66 $772.45 $791.76

$1,100.77 $950.46 $974.22 $1,014.44 $1,039.80 $1,028.78 $1,054.50 $900.82 $923.34 $1,184.76 $1,214.37 $1,264.51 $1,296.12 $1,282.39 $1,314.45 $1,122.91 $1,150.98 $789.13 $808.85

$1,147.71 $990.99 $1,015.76 $1,057.70 $1,084.14 $1,072.65 $1,099.47 $939.23 $962.71 $1,235.28 $1,266.16 $1,318.43 $1,351.39 $1,337.08 $1,370.51 $1,170.79 $1,200.06 $822.78 $843.35

$1,188.30 $1,026.04 $1,051.69 $1,095.11 $1,122.49 $1,110.60 $1,138.36 $972.46 $996.77 $1,278.97 $1,310.95 $1,365.07 $1,399.20 $1,384.37 $1,418.98 $1,212.21 $1,242.51 $851.88 $873.18

$1,214.95 $1,049.05 $1,075.27 $1,119.67 $1,147.66 $1,135.50 $1,163.88 $994.26 $1,019.12 $1,307.65 $1,340.34 $1,395.67 $1,430.57 $1,415.41 $1,450.80 $1,239.38 $1,270.37 $870.98 $892.75

$1,248.35 $1,077.89 $1,104.84 $1,150.45 $1,179.21 $1,166.72 $1,195.89 $1,021.60 $1,047.14 $1,343.60 $1,377.19 $1,434.05 $1,469.90 $1,454.33 $1,490.69 $1,273.46 $1,305.30 $894.93 $917.30

$1,268.65 $1,095.42 $1,122.81 $1,169.16 $1,198.39 $1,185.69 $1,215.33 $1,038.21 $1,064.17 $1,365.45 $1,399.59 $1,457.37 $1,493.80 $1,477.98 $1,514.93 $1,294.17 $1,326.52 $909.48 $932.22

Yes Yes Yes Yes YesYes Yes Yes Yes Yes

$5200/ $10400 $5200/ $10400 $5200/ $10400 $8150/ $16300$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $5200/ $10400$8150/ $16300

$25 / $55 $25 / $55 $50 / $0 $60 / $80 $60 / $80 $60 / $80 $25 / $55 $25 / $55 $25 / $75 $60 / $80

90% 100%80% 80% 90% 90% 90%80% 80% 80%

$900/ $1800 $900/ $1800 $900/ $1800 $900/ $1800 $7400/ $14800$3500/ $7000 $2300/ $4600 $2300/ $4600 $2300/ $4600 $2300/ $4600

Gold Gold Gold BronzeSilver Silver Silver Silver GoldSilver

IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020IND PPO Premium East w/Dominion PEDS PPO-2020

9 37 9 3 6 79 3 6

663 663 663 663 675663 663 663 663 663

UPMC Advantage Gold $900/$25 - Premium NetworkUPMC Advantage Gold $900/$25 - Premium NetworkUPMC Advantage Gold $900/$25 - Premium NetworkTower UPMC Advantage Bronze $7,400/$50 - Premium NetworkUPMC Advantage Silver $2,300/$60 - Premium NetworkUPMC Advantage Silver $2,300/$60 - Premium NetworkUPMC Advantage Silver $2,300/$60 - Premium NetworkUPMC Advantage Silver $2,300/$60 - Premium NetworkUPMC Advantage Gold $900/$25 - Premium NetworkUPMC Advantage Silver $3,500/$25 - Premium Network

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64+


$247.53 $247.53 $251.03 $251.03 $321.28 $321.28 $342.90 $342.90 $347.75 $347.75 $269.49 $269.49 $287.64 $287.64 $291.71 $291.71 $335.93 $335.93 $358.55

$269.53 $269.53 $273.34 $273.34 $349.84 $349.84 $373.38 $373.38 $378.67 $378.67 $293.45 $293.45 $313.21 $313.21 $317.64 $317.64 $365.79 $365.79 $390.42

$277.95 $277.95 $281.87 $281.87 $360.75 $360.75 $385.04 $385.04 $390.48 $390.48 $302.61 $302.61 $322.98 $322.98 $327.55 $327.55 $377.20 $377.20 $402.60

$286.36 $286.36 $290.40 $290.40 $371.67 $371.67 $396.69 $396.69 $402.30 $402.30 $311.77 $311.77 $332.76 $332.76 $337.47 $337.47 $388.62 $388.62 $414.79

$295.42 $302.80 $299.59 $307.08 $383.43 $393.02 $409.24 $419.47 $415.03 $425.41 $321.63 $329.67 $343.29 $351.87 $348.15 $356.85 $400.92 $410.94 $427.91

$304.48 $312.09 $308.78 $316.50 $395.19 $405.07 $421.79 $432.34 $427.76 $438.45 $331.50 $339.78 $353.82 $362.66 $358.82 $367.79 $413.21 $423.54 $441.04

$313.86 $321.71 $318.30 $326.25 $407.37 $417.56 $434.79 $445.66 $440.94 $451.97 $341.71 $350.25 $364.72 $373.84 $369.88 $379.13 $425.95 $436.60 $454.63

$323.57 $331.66 $328.14 $336.34 $419.97 $430.47 $448.24 $459.45 $454.58 $465.94 $352.28 $361.09 $376.00 $385.40 $381.32 $390.85 $439.12 $450.10 $468.69

$323.57 $331.66 $328.14 $336.34 $419.97 $430.47 $448.24 $459.45 $454.58 $465.94 $352.28 $361.09 $376.00 $385.40 $381.32 $390.85 $439.12 $450.10 $468.69

$323.57 $331.66 $328.14 $336.34 $419.97 $430.47 $448.24 $459.45 $454.58 $465.94 $352.28 $361.09 $376.00 $385.40 $381.32 $390.85 $439.12 $450.10 $468.69

$323.57 $331.66 $328.14 $336.34 $419.97 $430.47 $448.24 $459.45 $454.58 $465.94 $352.28 $361.09 $376.00 $385.40 $381.32 $390.85 $439.12 $450.10 $468.69

$324.86 $332.99 $329.45 $337.69 $421.65 $432.19 $450.03 $461.28 $456.40 $467.81 $353.69 $362.53 $377.50 $386.94 $382.85 $392.42 $440.88 $451.90 $470.56

$331.34 $339.62 $336.02 $344.42 $430.05 $440.80 $459.00 $470.47 $465.49 $477.13 $360.73 $369.75 $385.02 $394.65 $390.47 $400.23 $449.66 $460.90 $479.94

$339.10 $347.58 $343.89 $352.49 $440.13 $451.13 $469.76 $481.50 $476.40 $488.31 $369.19 $378.42 $394.05 $403.90 $399.62 $409.61 $460.20 $471.70 $491.19

$351.72 $360.51 $356.69 $365.61 $456.51 $467.92 $487.24 $499.42 $494.13 $506.48 $382.93 $392.50 $408.71 $418.93 $414.49 $424.86 $477.32 $489.26 $509.47

$362.07 $371.13 $367.19 $376.37 $469.95 $481.70 $501.58 $514.12 $508.68 $521.39 $394.20 $404.06 $420.74 $431.26 $426.70 $437.36 $491.38 $503.66 $524.46

$367.25 $376.43 $372.44 $381.75 $476.67 $488.58 $508.75 $521.47 $515.95 $528.85 $399.84 $409.83 $426.76 $437.43 $432.80 $443.62 $498.40 $510.86 $531.96

$375.02 $384.39 $380.31 $389.82 $486.75 $498.91 $519.51 $532.50 $526.86 $540.03 $408.29 $418.50 $435.78 $446.68 $441.95 $453.00 $508.94 $521.66 $543.21

$382.78 $392.35 $388.19 $397.89 $496.82 $509.25 $530.27 $543.52 $537.77 $551.21 $416.75 $427.17 $444.81 $455.93 $451.10 $462.38 $519.48 $532.47 $554.46

$387.64 $397.33 $393.11 $402.94 $503.12 $515.70 $536.99 $550.42 $544.59 $558.20 $422.03 $432.58 $450.45 $461.71 $456.82 $468.24 $526.07 $539.22 $561.49

$392.81 $402.63 $398.36 $408.32 $509.84 $522.59 $544.16 $557.77 $551.86 $565.66 $427.67 $438.36 $456.46 $467.88 $462.92 $474.50 $533.09 $546.42 $568.99

$395.40 $405.29 $400.99 $411.01 $513.20 $526.03 $547.75 $561.44 $555.50 $569.38 $430.49 $441.25 $459.47 $470.96 $465.97 $477.62 $536.60 $550.02 $572.74

$397.99 $407.94 $403.61 $413.70 $516.56 $529.48 $551.34 $565.12 $559.13 $573.11 $433.30 $444.14 $462.48 $474.04 $469.02 $480.75 $540.12 $553.62 $576.49

$400.58 $410.59 $406.24 $416.39 $519.92 $532.92 $554.92 $568.79 $562.77 $576.84 $436.12 $447.03 $465.49 $477.13 $472.07 $483.88 $543.63 $557.22 $580.24

$403.17 $413.25 $408.86 $419.08 $523.28 $536.36 $558.51 $572.47 $566.41 $580.57 $438.94 $449.91 $468.50 $480.21 $475.12 $487.00 $547.14 $560.82 $583.99

$408.35 $418.55 $414.11 $424.47 $530.00 $543.25 $565.68 $579.82 $573.68 $588.02 $444.58 $455.69 $474.51 $486.37 $481.23 $493.26 $554.17 $568.02 $591.49

$413.52 $423.86 $419.36 $429.85 $536.72 $550.14 $572.85 $587.17 $580.95 $595.48 $450.21 $461.47 $480.53 $492.54 $487.33 $499.51 $561.20 $575.23 $598.99

$421.29 $431.82 $427.24 $437.92 $546.80 $560.47 $583.61 $598.20 $591.86 $606.66 $458.67 $470.14 $489.55 $501.79 $496.48 $508.89 $571.73 $586.03 $610.23

$428.73 $439.45 $434.79 $445.66 $556.46 $570.37 $593.92 $608.77 $602.32 $617.38 $466.77 $478.44 $498.20 $510.66 $505.25 $517.88 $581.83 $596.38 $621.01

$439.08 $450.06 $445.29 $456.42 $569.90 $584.15 $608.26 $623.47 $616.87 $632.29 $478.04 $490.00 $510.23 $522.99 $517.45 $530.39 $595.89 $610.78 $636.01

$452.03 $463.33 $458.41 $469.87 $586.70 $601.37 $626.19 $641.85 $635.05 $650.92 $492.14 $504.44 $525.27 $538.40 $532.70 $546.02 $613.45 $628.79 $654.76

$467.24 $478.92 $473.83 $485.68 $606.44 $621.60 $647.26 $663.44 $656.41 $672.82 $508.69 $521.41 $542.94 $556.52 $550.63 $564.39 $634.09 $649.94 $676.79

$485.36 $497.49 $492.21 $504.52 $629.96 $645.70 $672.36 $689.17 $681.87 $698.92 $528.42 $541.63 $564.00 $578.10 $571.98 $586.28 $658.68 $675.15 $703.04

$505.74 $518.38 $512.88 $525.70 $656.41 $672.82 $700.60 $718.11 $710.51 $728.27 $550.61 $564.38 $587.69 $602.38 $596.00 $610.90 $686.34 $703.50 $732.56

$529.04 $542.26 $536.51 $549.92 $686.65 $703.82 $732.87 $751.19 $743.24 $761.82 $575.98 $590.38 $614.76 $630.13 $623.46 $639.04 $717.96 $735.91 $766.31

$552.01 $565.81 $559.81 $573.80 $716.47 $734.38 $764.70 $783.81 $775.51 $794.90 $600.99 $616.01 $641.46 $657.49 $650.53 $666.80 $749.14 $767.87 $799.59

$577.90 $592.34 $586.06 $600.71 $750.07 $768.82 $800.56 $820.57 $811.88 $832.18 $629.17 $644.90 $671.54 $688.32 $681.04 $698.06 $784.27 $803.88 $837.08

$603.46 $618.54 $611.98 $627.28 $783.24 $802.83 $835.97 $856.87 $847.79 $868.99 $657.00 $673.43 $701.24 $718.77 $711.16 $728.94 $818.96 $839.43 $874.11

$631.61 $647.40 $640.53 $656.54 $819.78 $840.28 $874.96 $896.84 $887.34 $909.52 $687.65 $704.84 $733.95 $752.30 $744.34 $762.95 $857.16 $878.59 $914.88

$660.08 $676.58 $669.41 $686.14 $856.74 $878.16 $914.41 $937.27 $927.34 $950.53 $718.65 $736.62 $767.04 $786.22 $777.89 $797.34 $895.80 $918.20 $956.13

$690.82 $708.09 $700.58 $718.09 $896.64 $919.05 $956.99 $980.92 $970.53 $994.79 $752.12 $770.92 $802.76 $822.83 $814.12 $834.47 $937.52 $960.96 $1,000.65

$721.56 $739.60 $731.75 $750.05 $936.53 $959.95 $999.58 $1,024.56 $1,013.71 $1,039.06 $785.58 $805.22 $838.48 $859.44 $850.34 $871.60 $979.24 $1,003.72 $1,045.18

$754.89 $773.76 $765.55 $784.69 $979.79 $1,004.28 $1,045.74 $1,071.89 $1,060.54 $1,087.05 $821.87 $842.42 $877.21 $899.14 $889.62 $911.86 $1,024.47 $1,050.08 $1,093.45

$788.54 $808.25 $799.68 $819.67 $1,023.47 $1,049.05 $1,092.36 $1,119.67 $1,107.81 $1,135.51 $858.51 $879.97 $916.31 $939.22 $929.28 $952.51 $1,070.14 $1,096.89 $1,142.20

$824.46 $845.07 $836.10 $857.00 $1,070.08 $1,096.84 $1,142.12 $1,170.67 $1,158.27 $1,187.23 $897.61 $920.05 $958.05 $982.00 $971.60 $995.89 $1,118.88 $1,146.85 $1,194.22

$842.25 $863.31 $854.15 $875.50 $1,093.18 $1,120.51 $1,166.77 $1,195.94 $1,183.27 $1,212.85 $916.98 $939.91 $978.73 $1,003.20 $992.58 $1,017.39 $1,143.03 $1,171.61 $1,220.00

$878.17 $900.12 $890.57 $912.84 $1,139.80 $1,168.29 $1,216.52 $1,246.94 $1,233.73 $1,264.57 $956.09 $979.99 $1,020.46 $1,045.98 $1,034.90 $1,060.78 $1,191.77 $1,221.57 $1,272.02

$909.23 $931.96 $922.07 $945.13 $1,180.12 $1,209.62 $1,259.55 $1,291.04 $1,277.37 $1,309.30 $989.91 $1,014.65 $1,056.56 $1,082.97 $1,071.51 $1,098.30 $1,233.93 $1,264.78 $1,317.02

$929.62 $952.86 $942.75 $966.31 $1,206.57 $1,236.74 $1,287.79 $1,319.99 $1,306.01 $1,338.66 $1,012.10 $1,037.40 $1,080.25 $1,107.25 $1,095.53 $1,122.92 $1,261.59 $1,293.13 $1,346.55

$955.18 $979.06 $968.67 $992.89 $1,239.75 $1,270.75 $1,323.20 $1,356.28 $1,341.92 $1,375.47 $1,039.93 $1,065.93 $1,109.95 $1,137.70 $1,125.66 $1,153.80 $1,296.28 $1,328.69 $1,383.57

$970.71 $994.98 $984.42 $1,009.03 $1,259.91 $1,291.41 $1,344.72 $1,378.34 $1,363.74 $1,397.83 $1,056.84 $1,083.26 $1,128.00 $1,156.20 $1,143.96 $1,172.56 $1,317.36 $1,350.29 $1,406.07

Yes Yes Yes Yes YesYes Yes Yes Yes Yes

$8150/ $16300 $8150/ $16300 $5200/ $10400 $5200/ $10400$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300$8150/ $16300

$60 / $80 $25 / $55 $25 / $55 $25 / $75 $25 / $75 $25 / $75 $60 / $80 $60 / $80 $50 / $0 $50 / $0

90% 90%80% 80% 80% 80% 80%100% 100% 80%

$2300/ $4600 $2300/ $4600 $2300/ $4600 $900/ $1800 $900/ $1800$7400/ $14800 $7400/ $14800 $3500/ $7000 $3500/ $7000 $3500/ $7000

Silver Silver Gold GoldBronze Silver Silver Silver SilverBronze

IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020

3 66 7 3 6 76 7 3

675 675 675 675 675675 675 675 675 675

Tower UPMC Advantage Silver $2,300/$60 - Premium NetworkTower UPMC Advantage Silver $2,300/$60 - Premium NetworkTower UPMC Advantage Gold $900/$25 - Premium NetworkTower UPMC Advantage Gold $900/$25 - Premium NetworkTower UPMC Advantage Bronze $7,400/$50 - Premium NetworkTower UPMC Advantage Silver $3,500/$25 - Premium NetworkTower UPMC Advantage Silver $3,500/$25 - Premium NetworkTower UPMC Advantage Silver $3,500/$25 - Premium NetworkTower UPMC Advantage Silver $2,300/$60 - Premium NetworkTower UPMC Advantage Bronze $7,400/$50 - Premium Network

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64+


$358.55 $363.62 $363.62 $212.19 $212.19 $211.42 $211.42 $212.09 $212.09 $221.48 $221.48 $144.05 $144.05 $181.78 $181.78 $144.05 $144.05 $144.05 $144.05

$390.42 $395.94 $395.94 $231.05 $231.05 $230.21 $230.21 $230.94 $230.94 $241.16 $241.16 $156.85 $156.85 $197.94 $197.94 $156.85 $156.85 $156.85 $156.85

$402.60 $408.30 $408.30 $238.26 $238.26 $237.39 $237.39 $238.15 $238.15 $248.69 $248.69 $161.75 $161.75 $204.12 $204.12 $161.75 $161.75 $161.75 $161.75

$414.79 $420.66 $420.66 $245.47 $245.47 $244.58 $244.58 $245.36 $245.36 $256.22 $256.22 $166.65 $166.65 $210.29 $210.29 $166.65 $166.65 $166.65 $166.65

$438.61 $433.97 $444.82 $253.24 $259.57 $252.32 $258.62 $253.12 $259.45 $264.32 $270.93 $171.92 $176.22 $216.95 $222.37 $171.92 $176.22 $171.92 $176.22

$452.06 $447.28 $458.46 $261.01 $267.53 $260.05 $266.56 $260.88 $267.40 $272.43 $279.24 $177.19 $181.62 $223.60 $229.19 $177.19 $181.62 $177.19 $181.62

$466.00 $461.06 $472.59 $269.05 $275.78 $268.07 $274.77 $268.92 $275.65 $280.82 $287.85 $182.65 $187.22 $230.49 $236.25 $182.65 $187.22 $182.65 $187.22

$480.41 $475.32 $487.20 $277.37 $284.30 $276.36 $283.27 $277.24 $284.17 $289.51 $296.75 $188.30 $193.01 $237.62 $243.56 $188.30 $193.01 $188.30 $193.01

$480.41 $475.32 $487.20 $277.37 $284.30 $276.36 $283.27 $277.24 $284.17 $289.51 $296.75 $188.30 $193.01 $237.62 $243.56 $188.30 $193.01 $188.30 $193.01

$480.41 $475.32 $487.20 $277.37 $284.30 $276.36 $283.27 $277.24 $284.17 $289.51 $296.75 $188.30 $193.01 $237.62 $243.56 $188.30 $193.01 $188.30 $193.01

$480.41 $475.32 $487.20 $277.37 $284.30 $276.36 $283.27 $277.24 $284.17 $289.51 $296.75 $188.30 $193.01 $237.62 $243.56 $188.30 $193.01 $188.30 $193.01

$482.33 $477.22 $489.15 $278.48 $285.44 $277.47 $284.40 $278.35 $285.31 $290.67 $297.93 $189.05 $193.78 $238.57 $244.53 $189.05 $193.78 $189.05 $193.78

$491.94 $486.73 $498.90 $284.03 $291.13 $282.99 $290.07 $283.89 $290.99 $296.46 $303.87 $192.82 $197.64 $243.32 $249.41 $192.82 $197.64 $192.82 $197.64

$503.47 $498.14 $510.59 $290.68 $297.95 $289.63 $296.87 $290.55 $297.81 $303.41 $310.99 $197.34 $202.27 $249.03 $255.25 $197.34 $202.27 $197.34 $202.27

$522.20 $516.67 $529.59 $301.50 $309.04 $300.40 $307.91 $301.36 $308.89 $314.70 $322.56 $204.68 $209.80 $258.29 $264.75 $204.68 $209.80 $204.68 $209.80

$537.58 $531.88 $545.18 $310.38 $318.14 $309.25 $316.98 $310.23 $317.99 $323.96 $332.06 $210.71 $215.98 $265.90 $272.54 $210.71 $215.98 $210.71 $215.98

$545.26 $539.49 $552.98 $314.81 $322.69 $313.67 $321.51 $314.67 $322.53 $328.59 $336.81 $213.72 $219.06 $269.70 $276.44 $213.72 $219.06 $213.72 $219.06

$556.79 $550.90 $564.67 $321.47 $329.51 $320.30 $328.31 $321.32 $329.35 $335.54 $343.93 $218.24 $223.70 $275.40 $282.29 $218.24 $223.70 $218.24 $223.70

$568.32 $562.30 $576.36 $328.13 $336.33 $326.93 $335.11 $327.97 $336.17 $342.49 $351.05 $222.76 $228.33 $281.10 $288.13 $222.76 $228.33 $222.76 $228.33

$575.53 $569.43 $583.67 $332.29 $340.60 $331.08 $339.36 $332.13 $340.44 $346.83 $355.50 $225.58 $231.22 $284.67 $291.79 $225.58 $231.22 $225.58 $231.22

$583.21 $577.04 $591.46 $336.73 $345.15 $335.50 $343.89 $336.57 $344.98 $351.47 $360.25 $228.60 $234.31 $288.47 $295.68 $228.60 $234.31 $228.60 $234.31

$587.06 $580.84 $595.36 $338.95 $347.42 $337.71 $346.15 $338.79 $347.26 $353.78 $362.63 $230.10 $235.86 $290.37 $297.63 $230.10 $235.86 $230.10 $235.86

$590.90 $584.64 $599.26 $341.17 $349.69 $339.92 $348.42 $341.01 $349.53 $356.10 $365.00 $231.61 $237.40 $292.27 $299.58 $231.61 $237.40 $231.61 $237.40

$594.74 $588.45 $603.16 $343.38 $351.97 $342.13 $350.69 $343.22 $351.80 $358.41 $367.37 $233.12 $238.94 $294.17 $301.53 $233.12 $238.94 $233.12 $238.94

$598.59 $592.25 $607.05 $345.60 $354.24 $344.34 $352.95 $345.44 $354.08 $360.73 $369.75 $234.62 $240.49 $296.07 $303.48 $234.62 $240.49 $234.62 $240.49

$606.27 $599.85 $614.85 $350.04 $358.79 $348.77 $357.49 $349.88 $358.62 $365.36 $374.50 $237.63 $243.58 $299.88 $307.37 $237.63 $243.58 $237.63 $243.58

$613.96 $607.46 $622.65 $354.48 $363.34 $353.19 $362.02 $354.31 $363.17 $369.99 $379.24 $240.65 $246.66 $303.68 $311.27 $240.65 $246.66 $240.65 $246.66

$625.49 $618.87 $634.34 $361.14 $370.16 $359.82 $368.82 $360.97 $369.99 $376.94 $386.37 $245.17 $251.30 $309.38 $317.12 $245.17 $251.30 $245.17 $251.30

$636.54 $629.80 $645.54 $367.52 $376.70 $366.18 $375.33 $367.34 $376.53 $383.60 $393.19 $249.50 $255.73 $314.85 $322.72 $249.50 $255.73 $249.50 $255.73

$651.91 $645.01 $661.13 $376.39 $385.80 $375.02 $384.40 $376.21 $385.62 $392.87 $402.69 $255.52 $261.91 $322.45 $330.51 $255.52 $261.91 $255.52 $261.91

$671.13 $664.02 $680.62 $387.49 $397.17 $386.07 $395.73 $387.30 $396.99 $404.45 $414.56 $263.06 $269.63 $331.96 $340.25 $263.06 $269.63 $263.06 $269.63

$693.71 $686.36 $703.52 $400.52 $410.54 $399.06 $409.04 $400.33 $410.34 $418.05 $428.50 $271.91 $278.70 $343.12 $351.70 $271.91 $278.70 $271.91 $278.70

$720.61 $712.98 $730.80 $416.06 $426.46 $414.54 $424.90 $415.86 $426.26 $434.27 $445.12 $282.45 $289.51 $356.43 $365.34 $282.45 $289.51 $282.45 $289.51

$750.88 $742.93 $761.50 $433.53 $444.37 $431.95 $442.75 $433.33 $444.16 $452.50 $463.82 $294.31 $301.67 $371.40 $380.69 $294.31 $301.67 $294.31 $301.67

$785.47 $777.15 $796.58 $453.50 $464.84 $451.85 $463.14 $453.29 $464.62 $473.35 $485.18 $307.87 $315.57 $388.51 $398.22 $307.87 $315.57 $307.87 $315.57

$819.57 $810.90 $831.17 $473.19 $485.02 $471.47 $483.26 $472.97 $484.80 $493.90 $506.25 $321.24 $329.27 $405.38 $415.51 $321.24 $329.27 $321.24 $329.27

$858.01 $848.92 $870.14 $495.38 $507.77 $493.58 $505.92 $495.15 $507.53 $517.06 $529.99 $336.30 $344.71 $424.39 $435.00 $336.30 $344.71 $336.30 $344.71

$895.96 $886.47 $908.63 $517.30 $530.23 $515.41 $528.30 $517.05 $529.98 $539.94 $553.43 $351.18 $359.96 $443.16 $454.24 $351.18 $359.96 $351.18 $359.96

$937.75 $927.82 $951.02 $541.43 $554.96 $539.45 $552.94 $541.17 $554.70 $565.12 $579.25 $367.56 $376.75 $463.83 $475.43 $367.56 $376.75 $367.56 $376.75

$980.03 $969.65 $993.89 $565.83 $579.98 $563.77 $577.87 $565.57 $579.71 $590.60 $605.37 $384.13 $393.74 $484.74 $496.86 $384.13 $393.74 $384.13 $393.74

$1,025.67 $1,014.81 $1,040.18 $592.18 $606.99 $590.03 $604.78 $591.91 $606.71 $618.10 $633.56 $402.02 $412.07 $507.32 $520.00 $402.02 $412.07 $402.02 $412.07

$1,071.31 $1,059.96 $1,086.46 $618.54 $634.00 $616.28 $631.69 $618.25 $633.70 $645.61 $661.75 $419.91 $430.41 $529.89 $543.14 $419.91 $430.41 $419.91 $430.41

$1,120.79 $1,108.92 $1,136.64 $647.10 $663.28 $644.75 $660.87 $646.80 $662.97 $675.43 $692.31 $439.30 $450.29 $554.37 $568.23 $439.30 $450.29 $439.30 $450.29

$1,170.75 $1,158.35 $1,187.31 $675.95 $692.85 $673.49 $690.33 $675.63 $692.52 $705.54 $723.17 $458.89 $470.36 $579.08 $593.56 $458.89 $470.36 $458.89 $470.36

$1,224.08 $1,211.12 $1,241.39 $706.74 $724.41 $704.17 $721.77 $706.41 $724.07 $737.67 $756.11 $479.79 $491.78 $605.46 $620.59 $479.79 $491.78 $479.79 $491.78

$1,250.50 $1,237.26 $1,268.19 $721.99 $740.04 $719.37 $737.35 $721.66 $739.70 $753.59 $772.43 $490.14 $502.40 $618.52 $633.99 $490.14 $502.40 $490.14 $502.40

$1,303.83 $1,290.02 $1,322.27 $752.78 $771.60 $750.04 $768.79 $752.43 $771.24 $785.73 $805.37 $511.05 $523.82 $644.90 $661.02 $511.05 $523.82 $511.05 $523.82

$1,349.94 $1,335.65 $1,369.04 $779.41 $798.89 $776.57 $795.99 $779.04 $798.52 $813.52 $833.86 $529.12 $542.35 $667.71 $684.41 $529.12 $542.35 $529.12 $542.35

$1,380.21 $1,365.59 $1,399.73 $796.88 $816.81 $793.98 $813.83 $796.51 $816.42 $831.76 $852.56 $540.99 $554.51 $682.68 $699.75 $540.99 $554.51 $540.99 $554.51

$1,418.16 $1,403.14 $1,438.22 $818.80 $839.27 $815.81 $836.21 $818.41 $838.87 $854.63 $876.00 $555.86 $569.76 $701.45 $718.99 $555.86 $569.76 $555.86 $569.76

$1,441.22 $1,425.96 $1,461.61 $832.11 $852.91 $829.08 $849.81 $831.72 $852.51 $868.53 $890.24 $564.90 $579.02 $712.86 $730.68 $564.90 $579.02 $564.90 $579.02

Yes Yes Yes YesYes Yes Yes Yes YesYes

$8150/ $16300 $8150/ $16300 $8150/ $16300$8150/ $16300 $8150/ $16300 $8150/ $16300 $5200/ $10400 $8150/ $16300$5200/ $10400 $5200/ $10400

$50 / $0 $50 / $0 $80 / $90 $25 / $75 $25 / $55 $50 / $0 $50 / $0 $25 / $55 $25 / $55 $85 / $150

100%80% 90% 100% 100% 100%90% 90% 100% 80%

$7400/ $14800 $7400/ $14800 $7400/ $14800 $7400/ $14800$900/ $1800 $0/ $0 $2000/ $4000 $3500/ $7000 $900/ $1800$900/ $1800

Bronze Bronze BronzeSilver Silver Silver Gold BronzeGold Gold

IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Select w/Dominion PEDS PPO-2020IND EPO Select w/Dominion PEDS PPO-2020IND EPO Select w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND PPO Tower Premium w/Dominion PEDS PPO-2020IND EPO Select w/Dominion PEDS PPO-2020

54 4 1 3 46 7 4 4

672 672 672 672675 672 672 672 672675

UPMC Advantage Bronze $7,400/$50 - Partner NetworkUPMC Advantage Bronze $7,400/$50 - Partner NetworkUPMC Advantage Bronze $7,400/$50 - Partner NetworkUPMC Advantage Silver $0/$85 - Select NetworkUPMC Advantage Silver $2,000/$80 - Select NetworkUPMC Advantage Silver $3,500/$25 - Select NetworkUPMC Advantage Gold $900/$25 - Select NetworkUPMC Advantage Bronze $7,400/$50 - Partner NetworkTower UPMC Advantage Gold $900/$25 - Premium NetworkTower UPMC Advantage Gold $900/$25 - Premium Network

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RATE PAGES

Company Name:

Market:

Product:





Form # =>

Rating Area =>

Network =>

Metal =>

Deductible =>

Coinsurance =>

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Age Band

0 - 14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

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64+


$152.18 $152.18 $200.86 $200.86 $253.46 $253.46 $200.86 $200.86 $200.86 $200.86 $200.13 $200.13 $252.54 $252.54 $200.13 $200.13 $200.13 $200.13 $200.76

$165.71 $165.71 $218.71 $218.71 $275.99 $275.99 $218.71 $218.71 $218.71 $218.71 $217.92 $217.92 $274.99 $274.99 $217.92 $217.92 $217.92 $217.92 $218.60

$170.88 $170.88 $225.54 $225.54 $284.60 $284.60 $225.54 $225.54 $225.54 $225.54 $224.72 $224.72 $283.57 $283.57 $224.72 $224.72 $224.72 $224.72 $225.43

$176.05 $176.05 $232.37 $232.37 $293.22 $293.22 $232.37 $232.37 $232.37 $232.37 $231.52 $231.52 $292.16 $292.16 $231.52 $231.52 $231.52 $231.52 $232.25

$181.62 $186.16 $239.72 $245.71 $302.50 $310.06 $239.72 $245.71 $239.72 $245.71 $238.85 $244.82 $301.40 $308.93 $238.85 $244.82 $238.85 $244.82 $239.60

$187.19 $191.87 $247.07 $253.25 $311.77 $319.57 $247.07 $253.25 $247.07 $253.25 $246.18 $252.33 $310.64 $318.41 $246.18 $252.33 $246.18 $252.33 $246.95

$192.96 $197.79 $254.68 $261.05 $321.38 $329.41 $254.68 $261.05 $254.68 $261.05 $253.76 $260.11 $320.22 $328.22 $253.76 $260.11 $253.76 $260.11 $254.56

$198.93 $203.90 $262.56 $269.12 $331.32 $339.60 $262.56 $269.12 $262.56 $269.12 $261.61 $268.15 $330.12 $338.37 $261.61 $268.15 $261.61 $268.15 $262.43

$198.93 $203.90 $262.56 $269.12 $331.32 $339.60 $262.56 $269.12 $262.56 $269.12 $261.61 $268.15 $330.12 $338.37 $261.61 $268.15 $261.61 $268.15 $262.43

$198.93 $203.90 $262.56 $269.12 $331.32 $339.60 $262.56 $269.12 $262.56 $269.12 $261.61 $268.15 $330.12 $338.37 $261.61 $268.15 $261.61 $268.15 $262.43

$198.93 $203.90 $262.56 $269.12 $331.32 $339.60 $262.56 $269.12 $262.56 $269.12 $261.61 $268.15 $330.12 $338.37 $261.61 $268.15 $261.61 $268.15 $262.43

$199.73 $204.72 $263.61 $270.20 $332.65 $340.96 $263.61 $270.20 $263.61 $270.20 $262.66 $269.22 $331.44 $339.73 $262.66 $269.22 $262.66 $269.22 $263.48

$203.70 $208.80 $268.86 $275.58 $339.27 $347.75 $268.86 $275.58 $268.86 $275.58 $267.89 $274.59 $338.04 $346.49 $267.89 $274.59 $267.89 $274.59 $268.73

$208.48 $213.69 $275.16 $282.04 $347.22 $355.90 $275.16 $282.04 $275.16 $282.04 $274.17 $281.02 $345.97 $354.61 $274.17 $281.02 $274.17 $281.02 $275.03

$216.24 $221.64 $285.40 $292.54 $360.14 $369.15 $285.40 $292.54 $285.40 $292.54 $284.37 $291.48 $358.84 $367.81 $284.37 $291.48 $284.37 $291.48 $285.26

$222.60 $228.17 $293.80 $301.15 $370.75 $380.02 $293.80 $301.15 $293.80 $301.15 $292.74 $300.06 $369.40 $378.64 $292.74 $300.06 $292.74 $300.06 $293.66

$225.79 $231.43 $298.01 $305.46 $376.05 $385.45 $298.01 $305.46 $298.01 $305.46 $296.93 $304.35 $374.69 $384.05 $296.93 $304.35 $296.93 $304.35 $297.86

$230.56 $236.32 $304.31 $311.91 $384.00 $393.60 $304.31 $311.91 $304.31 $311.91 $303.21 $310.79 $382.61 $392.17 $303.21 $310.79 $303.21 $310.79 $304.16

$235.33 $241.22 $310.61 $318.37 $391.95 $401.75 $310.61 $318.37 $310.61 $318.37 $309.48 $317.22 $390.53 $400.30 $309.48 $317.22 $309.48 $317.22 $310.45

$238.32 $244.28 $314.55 $322.41 $396.92 $406.84 $314.55 $322.41 $314.55 $322.41 $313.41 $321.24 $395.48 $405.37 $313.41 $321.24 $313.41 $321.24 $314.39

$241.50 $247.54 $318.75 $326.72 $402.22 $412.28 $318.75 $326.72 $318.75 $326.72 $317.59 $325.53 $400.77 $410.78 $317.59 $325.53 $317.59 $325.53 $318.59

$243.09 $249.17 $320.85 $328.87 $404.87 $414.99 $320.85 $328.87 $320.85 $328.87 $319.69 $327.68 $403.41 $413.49 $319.69 $327.68 $319.69 $327.68 $320.69

$244.68 $250.80 $322.95 $331.02 $407.52 $417.71 $322.95 $331.02 $322.95 $331.02 $321.78 $329.82 $406.05 $416.20 $321.78 $329.82 $321.78 $329.82 $322.79

$246.28 $252.43 $325.05 $333.18 $410.17 $420.43 $325.05 $333.18 $325.05 $333.18 $323.87 $331.97 $408.69 $418.91 $323.87 $331.97 $323.87 $331.97 $324.89

$247.87 $254.06 $327.15 $335.33 $412.82 $423.15 $327.15 $335.33 $327.15 $335.33 $325.97 $334.12 $411.33 $421.61 $325.97 $334.12 $325.97 $334.12 $326.99

$251.05 $257.33 $331.35 $339.63 $418.13 $428.58 $331.35 $339.63 $331.35 $339.63 $330.15 $338.41 $416.61 $427.03 $330.15 $338.41 $330.15 $338.41 $331.19

$254.23 $260.59 $335.55 $343.94 $423.43 $434.01 $335.55 $343.94 $335.55 $343.94 $334.34 $342.70 $421.89 $432.44 $334.34 $342.70 $334.34 $342.70 $335.39

$259.01 $265.48 $341.85 $350.40 $431.38 $442.16 $341.85 $350.40 $341.85 $350.40 $340.62 $349.13 $429.82 $440.56 $340.62 $349.13 $340.62 $349.13 $341.68

$263.58 $270.17 $347.89 $356.59 $439.00 $449.97 $347.89 $356.59 $347.89 $356.59 $346.63 $355.30 $437.41 $448.34 $346.63 $355.30 $346.63 $355.30 $347.72

$269.95 $276.70 $356.29 $365.20 $449.60 $460.84 $356.29 $365.20 $356.29 $365.20 $355.00 $363.88 $447.97 $459.17 $355.00 $363.88 $355.00 $363.88 $356.12

$277.91 $284.85 $366.80 $375.97 $462.85 $474.43 $366.80 $375.97 $366.80 $375.97 $365.47 $374.61 $461.18 $472.71 $365.47 $374.61 $365.47 $374.61 $366.61

$287.25 $294.44 $379.14 $388.62 $478.43 $490.39 $379.14 $388.62 $379.14 $388.62 $377.76 $387.21 $476.69 $488.61 $377.76 $387.21 $377.76 $387.21 $378.95

$298.40 $305.85 $393.84 $403.69 $496.98 $509.40 $393.84 $403.69 $393.84 $403.69 $392.42 $402.23 $495.18 $507.56 $392.42 $402.23 $392.42 $402.23 $393.65

$310.93 $318.70 $410.38 $420.64 $517.85 $530.80 $410.38 $420.64 $410.38 $420.64 $408.90 $419.12 $515.98 $528.88 $408.90 $419.12 $408.90 $419.12 $410.18

$325.25 $333.38 $429.29 $440.02 $541.71 $555.25 $429.29 $440.02 $429.29 $440.02 $427.73 $438.43 $539.75 $553.24 $427.73 $438.43 $427.73 $438.43 $429.07

$339.37 $347.86 $447.93 $459.13 $565.23 $579.36 $447.93 $459.13 $447.93 $459.13 $446.31 $457.46 $563.18 $577.26 $446.31 $457.46 $446.31 $457.46 $447.71

$355.29 $364.17 $468.93 $480.66 $591.74 $606.53 $468.93 $480.66 $468.93 $480.66 $467.24 $478.92 $589.59 $604.33 $467.24 $478.92 $467.24 $478.92 $468.70

$371.00 $380.28 $489.67 $501.92 $617.91 $633.36 $489.67 $501.92 $489.67 $501.92 $487.90 $500.10 $615.67 $631.07 $487.90 $500.10 $487.90 $500.10 $489.43

$388.31 $398.02 $512.52 $525.33 $646.74 $662.91 $512.52 $525.33 $512.52 $525.33 $510.66 $523.43 $644.39 $660.50 $510.66 $523.43 $510.66 $523.43 $512.26

$405.82 $415.96 $535.62 $549.01 $675.89 $692.79 $535.62 $549.01 $535.62 $549.01 $533.68 $547.03 $673.44 $690.28 $533.68 $547.03 $533.68 $547.03 $535.36

$424.72 $435.33 $560.57 $574.58 $707.37 $725.05 $560.57 $574.58 $560.57 $574.58 $558.54 $572.50 $704.81 $722.43 $558.54 $572.50 $558.54 $572.50 $560.29

$443.61 $454.70 $585.51 $600.15 $738.84 $757.31 $585.51 $600.15 $585.51 $600.15 $583.39 $597.98 $736.17 $754.57 $583.39 $597.98 $583.39 $597.98 $585.22

$464.10 $475.71 $612.55 $627.87 $772.97 $792.29 $612.55 $627.87 $612.55 $627.87 $610.34 $625.59 $770.17 $789.42 $610.34 $625.59 $610.34 $625.59 $612.25

$484.79 $496.91 $639.86 $655.86 $807.43 $827.61 $639.86 $655.86 $639.86 $655.86 $637.54 $653.48 $804.50 $824.62 $637.54 $653.48 $637.54 $653.48 $639.54

$506.87 $519.55 $669.00 $685.73 $844.20 $865.31 $669.00 $685.73 $669.00 $685.73 $666.58 $683.25 $841.15 $862.17 $666.58 $683.25 $666.58 $683.25 $668.67

$517.81 $530.76 $683.44 $700.53 $862.43 $883.99 $683.44 $700.53 $683.44 $700.53 $680.97 $698.00 $859.30 $880.78 $680.97 $698.00 $680.97 $698.00 $683.11

$539.90 $553.39 $712.59 $730.40 $899.20 $921.68 $712.59 $730.40 $712.59 $730.40 $710.01 $727.76 $895.95 $918.34 $710.01 $727.76 $710.01 $727.76 $712.24

$558.99 $572.97 $737.79 $756.24 $931.01 $954.28 $737.79 $756.24 $737.79 $756.24 $735.12 $753.50 $927.64 $950.83 $735.12 $753.50 $735.12 $753.50 $737.43

$571.53 $585.81 $754.33 $773.19 $951.88 $975.68 $754.33 $773.19 $754.33 $773.19 $751.61 $770.40 $948.43 $972.15 $751.61 $770.40 $751.61 $770.40 $753.96

$587.24 $601.92 $775.08 $794.45 $978.06 $1,002.51 $775.08 $794.45 $775.08 $794.45 $772.27 $791.58 $974.51 $998.88 $772.27 $791.58 $772.27 $791.58 $774.69

$596.79 $611.71 $787.68 $807.37 $993.96 $1,018.81 $787.68 $807.37 $787.68 $807.37 $784.83 $804.45 $990.36 $1,015.12 $784.83 $804.45 $784.83 $804.45 $787.29

Yes Yes Yes YesYes Yes Yes Yes YesYes

$8150/ $16300 $8150/ $16300 $8150/ $16300$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300$8150/ $16300 $8150/ $16300

$80 / $90 $25 / $75 $85 / $150 $85 / $150 $80 / $90 $80 / $90 $80 / $90 $50 / $0 $85 / $150 $85 / $150

80%100% 80% 80% 80% 80%100% 100% 100% 100%

$2000/ $4000 $2000/ $4000 $2000/ $4000 $3500/ $7000$0/ $0 $0/ $0 $0/ $0 $0/ $0 $2000/ $4000$7400/ $14800

Silver Silver SilverSilver Silver Silver Silver SilverBronze Silver

IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Select w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020

15 1 3 4 54 1 3 4

672 672 672 672672 672 672 672 672672

UPMC Advantage Silver $2,000/$80 - Partner NetworkUPMC Advantage Silver $2,000/$80 - Partner NetworkUPMC Advantage Silver $3,500/$25 - Partner NetworkUPMC Advantage Silver $0/$85 - Partner NetworkUPMC Advantage Silver $0/$85 - Partner NetworkUPMC Advantage Silver $0/$85 - Partner NetworkUPMC Advantage Silver $2,000/$80 - Partner NetworkUPMC Advantage Silver $2,000/$80 - Partner NetworkUPMC Advantage Bronze $7,400/$50 - Select NetworkUPMC Advantage Silver $0/$85 - Partner Network

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RATE PAGES

Company Name:

Market:

Product:





Form # =>

Rating Area =>

Network =>

Metal =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


Age Band

0 - 14

15

16

17

18

19

20

21

22

23

24

25

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64+


$200.76 $253.34 $253.34 $200.76 $200.76 $200.76 $200.76 $161.90 $161.90 $204.31 $204.31 $161.90 $161.90 $161.90 $161.90 $209.65 $209.65 $264.54 $264.54

$218.60 $275.86 $275.86 $218.60 $218.60 $218.60 $218.60 $176.30 $176.30 $222.47 $222.47 $176.30 $176.30 $176.30 $176.30 $228.28 $228.28 $288.06 $288.06

$225.43 $284.47 $284.47 $225.43 $225.43 $225.43 $225.43 $181.80 $181.80 $229.41 $229.41 $181.80 $181.80 $181.80 $181.80 $235.41 $235.41 $297.05 $297.05

$232.25 $293.08 $293.08 $232.25 $232.25 $232.25 $232.25 $187.30 $187.30 $236.36 $236.36 $187.30 $187.30 $187.30 $187.30 $242.53 $242.53 $306.04 $306.04

$245.59 $302.35 $309.91 $239.60 $245.59 $239.60 $245.59 $193.23 $198.06 $243.83 $249.93 $193.23 $198.06 $193.23 $198.06 $250.21 $256.46 $315.72 $323.62

$253.12 $311.62 $319.41 $246.95 $253.12 $246.95 $253.12 $199.15 $204.13 $251.31 $257.60 $199.15 $204.13 $199.15 $204.13 $257.88 $264.33 $325.41 $333.54

$260.92 $321.23 $329.26 $254.56 $260.92 $254.56 $260.92 $205.29 $210.42 $259.06 $265.53 $205.29 $210.42 $205.29 $210.42 $265.83 $272.47 $335.44 $343.82

$268.99 $331.16 $339.44 $262.43 $268.99 $262.43 $268.99 $211.64 $216.93 $267.07 $273.75 $211.64 $216.93 $211.64 $216.93 $274.05 $280.90 $345.81 $354.46

$268.99 $331.16 $339.44 $262.43 $268.99 $262.43 $268.99 $211.64 $216.93 $267.07 $273.75 $211.64 $216.93 $211.64 $216.93 $274.05 $280.90 $345.81 $354.46

$268.99 $331.16 $339.44 $262.43 $268.99 $262.43 $268.99 $211.64 $216.93 $267.07 $273.75 $211.64 $216.93 $211.64 $216.93 $274.05 $280.90 $345.81 $354.46

$268.99 $331.16 $339.44 $262.43 $268.99 $262.43 $268.99 $211.64 $216.93 $267.07 $273.75 $211.64 $216.93 $211.64 $216.93 $274.05 $280.90 $345.81 $354.46

$270.07 $332.48 $340.80 $263.48 $270.07 $263.48 $270.07 $212.49 $217.80 $268.14 $274.84 $212.49 $217.80 $212.49 $217.80 $275.15 $282.02 $347.19 $355.87

$275.45 $339.11 $347.59 $268.73 $275.45 $268.73 $275.45 $216.72 $222.14 $273.48 $280.32 $216.72 $222.14 $216.72 $222.14 $280.63 $287.64 $354.11 $362.96

$281.90 $347.06 $355.73 $275.03 $281.90 $275.03 $281.90 $221.80 $227.34 $279.89 $286.89 $221.80 $227.34 $221.80 $227.34 $287.20 $294.38 $362.41 $371.47

$292.39 $359.97 $368.97 $285.26 $292.39 $285.26 $292.39 $230.05 $235.80 $290.31 $297.56 $230.05 $235.80 $230.05 $235.80 $297.89 $305.34 $375.90 $385.29

$301.00 $370.57 $379.83 $293.66 $301.00 $293.66 $301.00 $236.83 $242.75 $298.85 $306.32 $236.83 $242.75 $236.83 $242.75 $306.66 $314.33 $386.96 $396.64

$305.30 $375.87 $385.26 $297.86 $305.30 $297.86 $305.30 $240.21 $246.22 $303.12 $310.70 $240.21 $246.22 $240.21 $246.22 $311.05 $318.82 $392.49 $402.31

$311.76 $383.81 $393.41 $304.16 $311.76 $304.16 $311.76 $245.29 $251.42 $309.53 $317.27 $245.29 $251.42 $245.29 $251.42 $317.62 $325.56 $400.79 $410.81

$318.22 $391.76 $401.56 $310.45 $318.22 $310.45 $318.22 $250.37 $256.63 $315.94 $323.84 $250.37 $256.63 $250.37 $256.63 $324.20 $332.31 $409.09 $419.32

$322.25 $396.73 $406.65 $314.39 $322.25 $314.39 $322.25 $253.54 $259.88 $319.95 $327.95 $253.54 $259.88 $253.54 $259.88 $328.31 $336.52 $414.28 $424.64

$326.55 $402.03 $412.08 $318.59 $326.55 $318.59 $326.55 $256.93 $263.35 $324.22 $332.33 $256.93 $263.35 $256.93 $263.35 $332.70 $341.01 $419.81 $430.31

$328.71 $404.68 $414.79 $320.69 $328.71 $320.69 $328.71 $258.62 $265.09 $326.36 $334.52 $258.62 $265.09 $258.62 $265.09 $334.89 $343.26 $422.58 $433.14

$330.86 $407.33 $417.51 $322.79 $330.86 $322.79 $330.86 $260.32 $266.83 $328.50 $336.71 $260.32 $266.83 $260.32 $266.83 $337.08 $345.51 $425.35 $435.98

$333.01 $409.98 $420.23 $324.89 $333.01 $324.89 $333.01 $262.01 $268.56 $330.63 $338.90 $262.01 $268.56 $262.01 $268.56 $339.27 $347.76 $428.11 $438.82

$335.16 $412.63 $422.94 $326.99 $335.16 $326.99 $335.16 $263.70 $270.30 $332.77 $341.09 $263.70 $270.30 $263.70 $270.30 $341.47 $350.00 $430.88 $441.65

$339.47 $417.92 $428.37 $331.19 $339.47 $331.19 $339.47 $267.09 $273.77 $337.04 $345.47 $267.09 $273.77 $267.09 $273.77 $345.85 $354.50 $436.41 $447.32

$343.77 $423.22 $433.80 $335.39 $343.77 $335.39 $343.77 $270.48 $277.24 $341.32 $349.85 $270.48 $277.24 $270.48 $277.24 $350.24 $358.99 $441.95 $452.99

$350.23 $431.17 $441.95 $341.68 $350.23 $341.68 $350.23 $275.56 $282.44 $347.73 $356.42 $275.56 $282.44 $275.56 $282.44 $356.81 $365.73 $450.24 $461.50

$356.41 $438.79 $449.76 $347.72 $356.41 $347.72 $356.41 $280.42 $287.43 $353.87 $362.71 $280.42 $287.43 $280.42 $287.43 $363.12 $372.19 $458.20 $469.65

$365.02 $449.38 $460.62 $356.12 $365.02 $356.12 $365.02 $287.20 $294.38 $362.41 $371.47 $287.20 $294.38 $287.20 $294.38 $371.89 $381.18 $469.26 $481.00

$375.78 $462.63 $474.20 $366.61 $375.78 $366.61 $375.78 $295.66 $303.05 $373.10 $382.42 $295.66 $303.05 $295.66 $303.05 $382.85 $392.42 $483.10 $495.17

$388.42 $478.20 $490.15 $378.95 $388.42 $378.95 $388.42 $305.61 $313.25 $385.65 $395.29 $305.61 $313.25 $305.61 $313.25 $395.73 $405.62 $499.35 $511.83

$403.49 $496.74 $509.16 $393.65 $403.49 $393.65 $403.49 $317.46 $325.40 $400.61 $410.62 $317.46 $325.40 $317.46 $325.40 $411.08 $421.35 $518.72 $531.68

$420.43 $517.60 $530.54 $410.18 $420.43 $410.18 $420.43 $330.79 $339.06 $417.43 $427.87 $330.79 $339.06 $330.79 $339.06 $428.34 $439.05 $540.50 $554.01

$439.80 $541.45 $554.98 $429.07 $439.80 $429.07 $439.80 $346.03 $354.68 $436.66 $447.58 $346.03 $354.68 $346.03 $354.68 $448.07 $459.27 $565.40 $579.53

$458.90 $564.96 $579.08 $447.71 $458.90 $447.71 $458.90 $361.06 $370.08 $455.62 $467.01 $361.06 $370.08 $361.06 $370.08 $467.53 $479.22 $589.95 $604.70

$480.42 $591.45 $606.24 $468.70 $480.42 $468.70 $480.42 $377.99 $387.44 $476.99 $488.91 $377.99 $387.44 $377.99 $387.44 $489.45 $501.69 $617.62 $633.06

$501.67 $617.61 $633.05 $489.43 $501.67 $489.43 $501.67 $394.71 $404.58 $498.09 $510.54 $394.71 $404.58 $394.71 $404.58 $511.10 $523.88 $644.94 $661.06

$525.07 $646.42 $662.58 $512.26 $525.07 $512.26 $525.07 $413.12 $423.45 $521.32 $534.35 $413.12 $423.45 $413.12 $423.45 $534.95 $548.32 $675.02 $691.90

$548.74 $675.57 $692.46 $535.36 $548.74 $535.36 $548.74 $431.75 $442.54 $544.82 $558.44 $431.75 $442.54 $431.75 $442.54 $559.06 $573.04 $705.45 $723.09

$574.30 $707.03 $724.70 $560.29 $574.30 $560.29 $574.30 $451.85 $463.15 $570.19 $584.45 $451.85 $463.15 $451.85 $463.15 $585.10 $599.72 $738.30 $756.76

$599.85 $738.49 $756.95 $585.22 $599.85 $585.22 $599.85 $471.96 $483.76 $595.57 $610.46 $471.96 $483.76 $471.96 $483.76 $611.13 $626.41 $771.16 $790.44

$627.56 $772.60 $791.91 $612.25 $627.56 $612.25 $627.56 $493.76 $506.10 $623.07 $638.65 $493.76 $506.10 $493.76 $506.10 $639.36 $655.34 $806.77 $826.94

$655.53 $807.04 $827.21 $639.54 $655.53 $639.54 $655.53 $515.77 $528.66 $650.85 $667.12 $515.77 $528.66 $515.77 $528.66 $667.86 $684.56 $842.74 $863.81

$685.39 $843.80 $864.89 $668.67 $685.39 $668.67 $685.39 $539.26 $552.74 $680.49 $697.51 $539.26 $552.74 $539.26 $552.74 $698.28 $715.74 $881.12 $903.15

$700.18 $862.01 $883.56 $683.11 $700.18 $683.11 $700.18 $550.90 $564.67 $695.18 $712.56 $550.90 $564.67 $550.90 $564.67 $713.35 $731.19 $900.14 $922.65

$730.04 $898.77 $921.24 $712.24 $730.04 $712.24 $730.04 $574.39 $588.75 $724.83 $742.95 $574.39 $588.75 $574.39 $588.75 $743.77 $762.37 $938.53 $961.99

$755.86 $930.56 $953.82 $737.43 $755.86 $737.43 $755.86 $594.71 $609.58 $750.47 $769.23 $594.71 $609.58 $594.71 $609.58 $770.08 $789.33 $971.73 $996.02

$772.81 $951.42 $975.21 $753.96 $772.81 $753.96 $772.81 $608.04 $623.24 $767.29 $786.47 $608.04 $623.24 $608.04 $623.24 $787.35 $807.03 $993.51 $1,018.35

$794.06 $977.58 $1,002.02 $774.69 $794.06 $774.69 $794.06 $624.76 $640.38 $788.39 $808.10 $624.76 $640.38 $624.76 $640.38 $809.00 $829.22 $1,020.83 $1,046.35

$806.97 $993.48 $1,018.32 $787.29 $806.97 $787.29 $806.97 $634.92 $650.79 $801.21 $821.24 $634.92 $650.79 $634.92 $650.79 $822.15 $842.70 $1,037.43 $1,063.37

Yes Yes YesYes Yes Yes Yes YesYes Yes

$5300/ $10600 $5300/ $10600$8150/ $16300 $8150/ $16300 $8150/ $16300 $5200/ $10400 $5200/ $10400$8150/ $16300 $5300/ $10600 $5300/ $10600

$25 / $55 $0/ 20% $0/ 20% $0/ 20% $0/ 20% $25 / $55 $25 / $75 $25 / $75 $25 / $75 $25 / $75

80% 80% 80% 80% 80% 80% 80% 80% 90% 90%

$3500/ $7000 $3500/ $7000 $2700/ $5400 $2700/ $5400 $2700/ $5400$3500/ $7000 $3500/ $7000 $2700/ $5400 $900/ $1800 $900/ $1800

Gold GoldSilver Silver Silver Silver SilverSilver Silver Silver

IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020 IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020

3 4 5 1 31 3 4 5 1

671 672 672672 672 671 671 671672 672

UPMC Advantage Silver HSA $2,800/20% - Partner NetworkUPMC Advantage Silver HSA $2,800/20% - Partner NetworkUPMC Advantage Silver $3,500/$25 - Partner NetworkUPMC Advantage Silver $3,500/$25 - Partner NetworkUPMC Advantage Silver $3,500/$25 - Partner Network UPMC Advantage Gold $900/$25 - Partner NetworkUPMC Advantage Gold $900/$25 - Partner NetworkUPMC Advantage Silver $3,500/$25 - Partner NetworkUPMC Advantage Silver HSA $2,800/20% - Partner NetworkUPMC Advantage Silver HSA $2,800/20% - Partner Network


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OOP Maximum =>


Age Band

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$209.65 $209.65 $209.65 $209.65 $171.04 $171.04 $137.75 $137.75 $173.83 $173.83 $137.75 $137.75 $137.75 $137.75 $145.53 $145.53 $339.19 $339.19 $354.20

$228.28 $228.28 $228.28 $228.28 $186.24 $186.24 $150.00 $150.00 $189.28 $189.28 $150.00 $150.00 $150.00 $150.00 $158.46 $158.46 $369.34 $369.34 $385.68

$235.41 $235.41 $235.41 $235.41 $192.06 $192.06 $154.68 $154.68 $195.19 $195.19 $154.68 $154.68 $154.68 $154.68 $163.41 $163.41 $380.86 $380.86 $397.72

$242.53 $242.53 $242.53 $242.53 $197.87 $197.87 $159.36 $159.36 $201.10 $201.10 $159.36 $159.36 $159.36 $159.36 $168.35 $168.35 $392.39 $392.39 $409.76

$250.21 $256.46 $250.21 $256.46 $204.13 $209.23 $164.40 $168.51 $207.46 $212.65 $164.40 $168.51 $164.40 $168.51 $173.68 $178.02 $404.81 $414.93 $422.72

$257.88 $264.33 $257.88 $264.33 $210.39 $215.65 $169.45 $173.68 $213.82 $219.17 $169.45 $173.68 $169.45 $173.68 $179.01 $183.48 $417.22 $427.65 $435.68

$265.83 $272.47 $265.83 $272.47 $216.87 $222.29 $174.67 $179.03 $220.41 $225.92 $174.67 $179.03 $174.67 $179.03 $184.52 $189.14 $430.08 $440.83 $449.11

$274.05 $280.90 $274.05 $280.90 $223.58 $229.17 $180.07 $184.57 $227.23 $232.91 $180.07 $184.57 $180.07 $184.57 $190.23 $194.99 $443.38 $454.46 $463.00

$274.05 $280.90 $274.05 $280.90 $223.58 $229.17 $180.07 $184.57 $227.23 $232.91 $180.07 $184.57 $180.07 $184.57 $190.23 $194.99 $443.38 $454.46 $463.00

$274.05 $280.90 $274.05 $280.90 $223.58 $229.17 $180.07 $184.57 $227.23 $232.91 $180.07 $184.57 $180.07 $184.57 $190.23 $194.99 $443.38 $454.46 $463.00

$274.05 $280.90 $274.05 $280.90 $223.58 $229.17 $180.07 $184.57 $227.23 $232.91 $180.07 $184.57 $180.07 $184.57 $190.23 $194.99 $443.38 $454.46 $463.00

$275.15 $282.02 $275.15 $282.02 $224.47 $230.09 $180.79 $185.31 $228.14 $233.84 $180.79 $185.31 $180.79 $185.31 $190.99 $195.77 $445.15 $456.28 $464.85

$280.63 $287.64 $280.63 $287.64 $228.95 $234.67 $184.39 $189.00 $232.68 $238.50 $184.39 $189.00 $184.39 $189.00 $194.80 $199.67 $454.02 $465.37 $474.11

$287.20 $294.38 $287.20 $294.38 $234.31 $240.17 $188.71 $193.43 $238.14 $244.09 $188.71 $193.43 $188.71 $193.43 $199.36 $204.35 $464.66 $476.28 $485.22

$297.89 $305.34 $297.89 $305.34 $243.03 $249.11 $195.74 $200.63 $247.00 $253.17 $195.74 $200.63 $195.74 $200.63 $206.78 $211.95 $481.95 $494.00 $503.28

$306.66 $314.33 $306.66 $314.33 $250.19 $256.44 $201.50 $206.54 $254.27 $260.63 $201.50 $206.54 $201.50 $206.54 $212.87 $218.19 $496.14 $508.55 $518.10

$311.05 $318.82 $311.05 $318.82 $253.76 $260.11 $204.38 $209.49 $257.91 $264.35 $204.38 $209.49 $204.38 $209.49 $215.91 $221.31 $503.24 $515.82 $525.51

$317.62 $325.56 $317.62 $325.56 $259.13 $265.61 $208.70 $213.92 $263.36 $269.94 $208.70 $213.92 $208.70 $213.92 $220.48 $225.99 $513.88 $526.72 $536.62

$324.20 $332.31 $324.20 $332.31 $264.50 $271.11 $213.02 $218.35 $268.81 $275.53 $213.02 $218.35 $213.02 $218.35 $225.04 $230.67 $524.52 $537.63 $547.73

$328.31 $336.52 $328.31 $336.52 $267.85 $274.55 $215.72 $221.12 $272.22 $279.03 $215.72 $221.12 $215.72 $221.12 $227.90 $233.59 $531.17 $544.45 $554.67

$332.70 $341.01 $332.70 $341.01 $271.43 $278.21 $218.60 $224.07 $275.86 $282.75 $218.60 $224.07 $218.60 $224.07 $230.94 $236.71 $538.26 $551.72 $562.08

$334.89 $343.26 $334.89 $343.26 $273.21 $280.05 $220.05 $225.55 $277.68 $284.62 $220.05 $225.55 $220.05 $225.55 $232.46 $238.27 $541.81 $555.36 $565.79

$337.08 $345.51 $337.08 $345.51 $275.00 $281.88 $221.49 $227.02 $279.49 $286.48 $221.49 $227.02 $221.49 $227.02 $233.98 $239.83 $545.36 $558.99 $569.49

$339.27 $347.76 $339.27 $347.76 $276.79 $283.71 $222.93 $228.50 $281.31 $288.34 $222.93 $228.50 $222.93 $228.50 $235.50 $241.39 $548.90 $562.63 $573.19

$341.47 $350.00 $341.47 $350.00 $278.58 $285.55 $224.37 $229.98 $283.13 $290.21 $224.37 $229.98 $224.37 $229.98 $237.03 $242.95 $552.45 $566.26 $576.90

$345.85 $354.50 $345.85 $354.50 $282.16 $289.21 $227.25 $232.93 $286.76 $293.93 $227.25 $232.93 $227.25 $232.93 $240.07 $246.07 $559.55 $573.53 $584.31

$350.24 $358.99 $350.24 $358.99 $285.74 $292.88 $230.13 $235.88 $290.40 $297.66 $230.13 $235.88 $230.13 $235.88 $243.11 $249.19 $566.64 $580.81 $591.71

$356.81 $365.73 $356.81 $365.73 $291.10 $298.38 $234.45 $240.31 $295.85 $303.25 $234.45 $240.31 $234.45 $240.31 $247.68 $253.87 $577.28 $591.71 $602.83

$363.12 $372.19 $363.12 $372.19 $296.24 $303.65 $238.59 $244.56 $301.08 $308.61 $238.59 $244.56 $238.59 $244.56 $252.05 $258.36 $587.48 $602.17 $613.48

$371.89 $381.18 $371.89 $381.18 $303.40 $310.98 $244.35 $250.46 $308.35 $316.06 $244.35 $250.46 $244.35 $250.46 $258.14 $264.60 $601.67 $616.71 $628.29

$382.85 $392.42 $382.85 $392.42 $312.34 $320.15 $251.56 $257.85 $317.44 $325.38 $251.56 $257.85 $251.56 $257.85 $265.75 $272.40 $619.40 $634.89 $646.81

$395.73 $405.62 $395.73 $405.62 $322.85 $330.92 $260.02 $266.52 $328.12 $336.32 $260.02 $266.52 $260.02 $266.52 $274.69 $281.56 $640.24 $656.25 $668.57

$411.08 $421.35 $411.08 $421.35 $335.37 $343.75 $270.11 $276.86 $340.85 $349.37 $270.11 $276.86 $270.11 $276.86 $285.35 $292.48 $665.07 $681.70 $694.50

$428.34 $439.05 $428.34 $439.05 $349.46 $358.19 $281.45 $288.49 $355.16 $364.04 $281.45 $288.49 $281.45 $288.49 $297.33 $304.76 $693.00 $710.33 $723.67

$448.07 $459.27 $448.07 $459.27 $365.55 $374.69 $294.41 $301.77 $371.52 $380.81 $294.41 $301.77 $294.41 $301.77 $311.03 $318.80 $724.93 $743.05 $757.01

$467.53 $479.22 $467.53 $479.22 $381.43 $390.96 $307.20 $314.88 $387.65 $397.35 $307.20 $314.88 $307.20 $314.88 $324.53 $332.65 $756.41 $775.32 $789.88

$489.45 $501.69 $489.45 $501.69 $399.31 $409.30 $321.61 $329.65 $405.83 $415.98 $321.61 $329.65 $321.61 $329.65 $339.75 $348.24 $791.88 $811.67 $826.92

$511.10 $523.88 $511.10 $523.88 $416.98 $427.40 $335.83 $344.23 $423.78 $434.38 $335.83 $344.23 $335.83 $344.23 $354.78 $363.65 $826.90 $847.58 $863.50

$534.95 $548.32 $534.95 $548.32 $436.43 $447.34 $351.50 $360.28 $443.55 $454.64 $351.50 $360.28 $351.50 $360.28 $371.33 $380.61 $865.48 $887.11 $903.78

$559.06 $573.04 $559.06 $573.04 $456.10 $467.51 $367.34 $376.53 $463.55 $475.14 $367.34 $376.53 $367.34 $376.53 $388.07 $397.77 $904.50 $927.11 $944.52

$585.10 $599.72 $585.10 $599.72 $477.34 $489.28 $384.45 $394.06 $485.14 $497.26 $384.45 $394.06 $384.45 $394.06 $406.14 $416.29 $946.62 $970.28 $988.51

$611.13 $626.41 $611.13 $626.41 $498.58 $511.05 $401.56 $411.60 $506.72 $519.39 $401.56 $411.60 $401.56 $411.60 $424.21 $434.82 $988.74 $1,013.46 $1,032.49

$639.36 $655.34 $639.36 $655.34 $521.61 $534.65 $420.10 $430.61 $530.13 $543.38 $420.10 $430.61 $420.10 $430.61 $443.81 $454.90 $1,034.41 $1,060.27 $1,080.18

$667.86 $684.56 $667.86 $684.56 $544.86 $558.49 $438.83 $449.80 $553.76 $567.60 $438.83 $449.80 $438.83 $449.80 $463.59 $475.18 $1,080.52 $1,107.53 $1,128.33

$698.28 $715.74 $698.28 $715.74 $569.68 $583.92 $458.82 $470.29 $578.98 $593.46 $458.82 $470.29 $458.82 $470.29 $484.71 $496.82 $1,129.73 $1,157.98 $1,179.72

$713.35 $731.19 $713.35 $731.19 $581.98 $596.53 $468.72 $480.44 $591.48 $606.27 $468.72 $480.44 $468.72 $480.44 $495.17 $507.55 $1,154.12 $1,182.97 $1,205.19

$743.77 $762.37 $743.77 $762.37 $606.80 $621.97 $488.71 $500.93 $616.70 $632.12 $488.71 $500.93 $488.71 $500.93 $516.28 $529.19 $1,203.33 $1,233.42 $1,256.58

$770.08 $789.33 $770.08 $789.33 $628.26 $643.97 $506.00 $518.65 $638.52 $654.48 $506.00 $518.65 $506.00 $518.65 $534.55 $547.91 $1,245.90 $1,277.05 $1,301.03

$787.35 $807.03 $787.35 $807.03 $642.35 $658.40 $517.34 $530.27 $652.83 $669.15 $517.34 $530.27 $517.34 $530.27 $546.53 $560.19 $1,273.83 $1,305.68 $1,330.20

$809.00 $829.22 $809.00 $829.22 $660.01 $676.51 $531.57 $544.86 $670.78 $687.55 $531.57 $544.86 $531.57 $544.86 $561.56 $575.60 $1,308.86 $1,341.58 $1,366.78

$822.15 $842.70 $822.15 $842.70 $670.74 $687.51 $540.21 $553.72 $681.69 $698.73 $540.21 $553.72 $540.21 $553.72 $570.69 $584.96 $1,330.14 $1,363.39 $1,389.00

Yes Yes YesYes Yes Yes Yes YesYes Yes

$8150/ $16300 $5200/ $10400$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300$5200/ $10400 $5200/ $10400 $5300/ $10600

$25 / $55 $0/ $0 $0/ $0 $0/ $0 $0/ $0 $25 / $75 $25 / $55 $25 / $55 $0/ 20% $0/ $0

100% 100% 100% 80% 90%90% 90% 80% 100% 100%

$8150/ $16300 $3500/ $7000 $900/ $1800$2700/ $5400 $8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300$900/ $1800 $900/ $1800

Silver GoldCatastrophic Catastrophic Catastrophic Catastrophic CatastrophicGold Gold Silver

IND EPO Tower w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Select w/Dominion PEDS PPO-2020IND EPO Tower w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Select w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020

4 5 4 7 74 5 4 1 3

673 674 674671 673 673 673 673672 672

Tower UPMC Advantage Silver $3,500/$25 - Tower NetworkTower UPMC Advantage Gold $900/$25 - Tower NetworkUPMC Advantage Catastrophic $8,150/$0 - Partner NetworkUPMC Advantage Catastrophic $8,150/$0 - Partner NetworkUPMC Advantage Catastrophic $8,150/$0 - Partner NetworkUPMC Advantage Catastrophic $8,150/$0 - Partner NetworkUPMC Advantage Catastrophic $8,150/$0 - Select NetworkUPMC Advantage Gold $900/$25 - Partner NetworkUPMC Advantage Gold $900/$25 - Partner NetworkUPMC Advantage Silver HSA $2,800/20% - Select Network


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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

$354.20 $243.38 $243.38 $175.86 $175.86 $166.46 $166.46 $210.06 $210.06 $166.46 $166.46 $166.46 $166.46 $281.24 $281.24

$385.68 $265.01 $265.01 $191.49 $191.49 $181.26 $181.26 $228.73 $228.73 $181.26 $181.26 $181.26 $181.26 $306.24 $306.24

$397.72 $273.28 $273.28 $197.47 $197.47 $186.92 $186.92 $235.87 $235.87 $186.92 $186.92 $186.92 $186.92 $315.80 $315.80

$409.76 $281.55 $281.55 $203.44 $203.44 $192.58 $192.58 $243.01 $243.01 $192.58 $192.58 $192.58 $192.58 $325.36 $325.36

$433.29 $290.46 $297.72 $209.88 $215.13 $198.67 $203.64 $250.70 $256.97 $198.67 $203.64 $198.67 $203.64 $335.66 $344.05

$446.58 $299.37 $306.85 $216.32 $221.73 $204.76 $209.88 $258.39 $264.85 $204.76 $209.88 $204.76 $209.88 $345.95 $354.60

$460.34 $308.60 $316.31 $222.98 $228.56 $211.07 $216.35 $266.35 $273.01 $211.07 $216.35 $211.07 $216.35 $356.61 $365.53

$474.58 $318.14 $326.09 $229.88 $235.63 $217.60 $223.04 $274.59 $281.45 $217.60 $223.04 $217.60 $223.04 $367.64 $376.83

$474.58 $318.14 $326.09 $229.88 $235.63 $217.60 $223.04 $274.59 $281.45 $217.60 $223.04 $217.60 $223.04 $367.64 $376.83

$474.58 $318.14 $326.09 $229.88 $235.63 $217.60 $223.04 $274.59 $281.45 $217.60 $223.04 $217.60 $223.04 $367.64 $376.83

$474.58 $318.14 $326.09 $229.88 $235.63 $217.60 $223.04 $274.59 $281.45 $217.60 $223.04 $217.60 $223.04 $367.64 $376.83

$476.47 $319.41 $327.40 $230.80 $236.57 $218.47 $223.93 $275.69 $282.58 $218.47 $223.93 $218.47 $223.93 $369.11 $378.34

$485.96 $325.78 $333.92 $235.40 $241.28 $222.82 $228.39 $281.18 $288.21 $222.82 $228.39 $222.82 $228.39 $376.46 $385.87

$497.35 $333.41 $341.75 $240.91 $246.94 $228.04 $233.75 $287.77 $294.96 $228.04 $233.75 $228.04 $233.75 $385.29 $394.92

$515.86 $345.82 $354.46 $249.88 $256.13 $236.53 $242.44 $298.48 $305.94 $236.53 $242.44 $236.53 $242.44 $399.62 $409.62

$531.05 $356.00 $364.90 $257.24 $263.67 $243.49 $249.58 $307.27 $314.95 $243.49 $249.58 $243.49 $249.58 $411.39 $421.67

$538.64 $361.09 $370.12 $260.91 $267.44 $246.98 $253.15 $311.66 $319.45 $246.98 $253.15 $246.98 $253.15 $417.27 $427.70

$550.03 $368.72 $377.94 $266.43 $273.09 $252.20 $258.50 $318.25 $326.21 $252.20 $258.50 $252.20 $258.50 $426.09 $436.75

$561.42 $376.36 $385.77 $271.95 $278.75 $257.42 $263.86 $324.84 $332.96 $257.42 $263.86 $257.42 $263.86 $434.92 $445.79

$568.54 $381.13 $390.66 $275.40 $282.28 $260.68 $267.20 $328.96 $337.18 $260.68 $267.20 $260.68 $267.20 $440.43 $451.44

$576.13 $386.22 $395.88 $279.07 $286.05 $264.17 $270.77 $333.35 $341.69 $264.17 $270.77 $264.17 $270.77 $446.31 $457.47

$579.93 $388.77 $398.49 $280.91 $287.94 $265.91 $272.55 $335.55 $343.94 $265.91 $272.55 $265.91 $272.55 $449.26 $460.49

$583.73 $391.31 $401.10 $282.75 $289.82 $267.65 $274.34 $337.75 $346.19 $267.65 $274.34 $267.65 $274.34 $452.20 $463.50

$587.52 $393.86 $403.70 $284.59 $291.71 $269.39 $276.12 $339.94 $348.44 $269.39 $276.12 $269.39 $276.12 $455.14 $466.52

$591.32 $396.40 $406.31 $286.43 $293.59 $271.13 $277.91 $342.14 $350.69 $271.13 $277.91 $271.13 $277.91 $458.08 $469.53

$598.91 $401.49 $411.53 $290.11 $297.36 $274.61 $281.48 $346.53 $355.20 $274.61 $281.48 $274.61 $281.48 $463.96 $475.56

$606.51 $406.58 $416.75 $293.79 $301.13 $278.09 $285.05 $350.93 $359.70 $278.09 $285.05 $278.09 $285.05 $469.84 $481.59

$617.90 $414.22 $424.57 $299.30 $306.79 $283.32 $290.40 $357.52 $366.45 $283.32 $290.40 $283.32 $290.40 $478.67 $490.63

$628.81 $421.54 $432.07 $304.59 $312.21 $288.32 $295.53 $363.83 $372.93 $288.32 $295.53 $288.32 $295.53 $487.12 $499.30

$644.00 $431.72 $442.51 $311.95 $319.75 $295.28 $302.67 $372.62 $381.93 $295.28 $302.67 $295.28 $302.67 $498.89 $511.36

$662.98 $444.44 $455.55 $321.14 $329.17 $303.99 $311.59 $383.60 $393.19 $303.99 $311.59 $303.99 $311.59 $513.59 $526.43

$685.29 $459.39 $470.88 $331.95 $340.25 $314.21 $322.07 $396.51 $406.42 $314.21 $322.07 $314.21 $322.07 $530.87 $544.14

$711.86 $477.21 $489.14 $344.82 $353.44 $326.40 $334.56 $411.89 $422.18 $326.40 $334.56 $326.40 $334.56 $551.46 $565.25

$741.76 $497.25 $509.68 $359.30 $368.29 $340.11 $348.61 $429.18 $439.91 $340.11 $348.61 $340.11 $348.61 $574.62 $588.99

$775.93 $520.16 $533.16 $375.85 $385.25 $355.78 $364.67 $448.95 $460.18 $355.78 $364.67 $355.78 $364.67 $601.09 $616.12

$809.62 $542.75 $556.32 $392.18 $401.98 $371.23 $380.51 $468.45 $480.16 $371.23 $380.51 $371.23 $380.51 $627.19 $642.87

$847.59 $568.20 $582.40 $410.57 $420.83 $388.63 $398.35 $490.42 $502.68 $388.63 $398.35 $388.63 $398.35 $656.61 $673.02

$885.08 $593.33 $608.16 $428.73 $439.44 $405.82 $415.97 $512.11 $524.91 $405.82 $415.97 $405.82 $415.97 $685.65 $702.79

$926.37 $621.01 $636.53 $448.73 $459.94 $424.76 $435.37 $536.00 $549.40 $424.76 $435.37 $424.76 $435.37 $717.63 $735.57

$968.13 $649.01 $665.23 $468.96 $480.68 $443.90 $455.00 $560.16 $574.17 $443.90 $455.00 $443.90 $455.00 $749.99 $768.74

$1,013.22 $679.23 $696.21 $490.79 $503.06 $464.58 $476.19 $586.25 $600.91 $464.58 $476.19 $464.58 $476.19 $784.91 $804.53

$1,058.30 $709.45 $727.19 $512.63 $525.45 $485.25 $497.38 $612.34 $627.64 $485.25 $497.38 $485.25 $497.38 $819.84 $840.33

$1,107.18 $742.22 $760.78 $536.31 $549.72 $507.66 $520.35 $640.62 $656.63 $507.66 $520.35 $507.66 $520.35 $857.70 $879.15

$1,156.54 $775.31 $794.69 $560.22 $574.22 $530.29 $543.55 $669.18 $685.91 $530.29 $543.55 $530.29 $543.55 $895.94 $918.34

$1,209.22 $810.62 $830.89 $585.73 $600.38 $554.44 $568.31 $699.66 $717.15 $554.44 $568.31 $554.44 $568.31 $936.75 $960.17

$1,235.32 $828.12 $848.82 $598.38 $613.34 $566.41 $580.57 $714.76 $732.63 $566.41 $580.57 $566.41 $580.57 $956.97 $980.89

$1,288.00 $863.43 $885.02 $623.89 $639.49 $590.57 $605.33 $745.24 $763.87 $590.57 $605.33 $590.57 $605.33 $997.77 $1,022.72

$1,333.56 $893.97 $916.32 $645.96 $662.11 $611.46 $626.74 $771.60 $790.89 $611.46 $626.74 $611.46 $626.74 $1,033.07 $1,058.90

$1,363.45 $914.02 $936.87 $660.45 $676.96 $625.16 $640.79 $788.90 $808.62 $625.16 $640.79 $625.16 $640.79 $1,056.23 $1,082.64

$1,400.95 $939.15 $962.63 $678.61 $695.57 $642.36 $658.41 $810.59 $830.85 $642.36 $658.41 $642.36 $658.41 $1,085.27 $1,112.41

$1,423.73 $954.42 $978.28 $689.64 $706.88 $652.80 $669.12 $823.77 $844.36 $652.80 $669.12 $652.80 $669.12 $1,102.92 $1,130.49

Yes Yes Yes Yes YesYes Yes Yes

$8150/ $16300 $8150/ $16300 $8150/ $16300 $8150/ $16300$5200/ $10400 $8150/ $16300 $8150/ $16300 $8150/ $16300

$60 / $80 $60 / $80 $60 / $80 $25 / $55 $50 / $0 $60 / $80 $60 / $80 $60 / $80

80% 80%80% 80%100% 80% 80%90%

$2300/ $4600 $2300/ $4600 $2300/ $4600 $2300/ $4600 $2300/ $4600$900/ $1800 $7400/ $14800 $2300/ $4600

Silver Silver Silver SilverGold Bronze Silver Silver

IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Tower w/Dominion PEDS PPO-2020IND EPO Tower w/Dominion PEDS PPO-2020IND EPO Tower w/Dominion PEDS PPO-2020IND EPO Select w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020IND EPO Partner w/Dominion PEDS PPO-2020

5 77 4 1 3 47

672 672 672 672 674674 674 672

UPMC Advantage Silver $2,300/$60 - Partner NetworkUPMC Advantage Silver $2,300/$60 - Partner NetworkUPMC Advantage Silver $2,300/$60 - Partner NetworkTower UPMC Advantage Silver $2,300/$60 - Tower NetworkTower UPMC Advantage Gold $900/$25 - Tower NetworkTower UPMC Advantage Bronze $7,400/$50 - Tower NetworkUPMC Advantage Silver $2,300/$60 - Select NetworkUPMC Advantage Silver $2,300/$60 - Partner Network

16322PA0050121 16322PA0050121 16322PA005012316322PA0050118 16322PA0050119 16322PA0050120 16322PA0050121 16322PA0050121

16322PA005011916322PA0050118

Page Number: 12 12/24/2014

RATE PAGES

HIOS Plan ID Plan Marketing Name Product Metal

On/Off

Exchange Network Rating Area Counties Covered

16322PA0040006UPMC Advantage Silver $0/$85 - Premium

NetworkPPO Silver On/Off

IND PPO Premium West w/Dominion PEDS PPO-

20201, 2, 4, 5, 6

Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria,

Cameron, Centre, Clarion, Clearfield, Crawford, Elk, Erie, Fayette,

Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, Mckean,

Mercer, Potter, Somerset, Venango, Warren, Washington,

Westmoreland

16322PA0040007UPMC Advantage Silver $2,000/$80 - Premium



20201, 2, 4, 5, 6





Westmoreland




20201, 2, 4, 5, 6





Westmoreland

16322PA0040010UPMC Advantage Gold $900/$25 - Premium

NetworkPPO Gold On/Off


20201, 2, 4, 5, 6





Westmoreland

16322PA0040024UPMC Advantage Bronze $7,400/$50 - Premium

NetworkPPO Bronze On/Off


20201, 2, 4, 5, 6





Westmoreland

16322PA0040025UPMC Advantage Silver HSA $2,800/20% -

Premium NetworkPPO Silver Off


20201, 2, 4, 5, 6





Westmoreland

16322PA0040026UPMC Advantage Catastrophic $8,150/$0 -

Premium NetworkPPO Catastrophic On/Off


20201, 2, 4, 5, 6





Westmoreland


NetworkPPO Silver Off


20201, 2, 4, 5, 6





Westmoreland

16322PA0040039UPMC Advantage Bronze $7,400/$50 - Premium

NetworkPPO Bronze On/Off

IND PPO Premium East w/Dominion PEDS PPO-

20203, 6, 7, 9

Tioga, Lycoming, Clinton, Bradford, Sullivan, Wyoming, Lackawanna,

Luzerne, Columbia, Union, Snyder, Northumberland, Dauphin, Perry,

Cumberland, Adams, York, Lancaster, Lebanon




20203, 6, 7, 9





NetworkPPO Silver Off


20203, 6, 7, 9




16322PA0040042UPMC Advantage Gold $900/$25 - Premium



20203, 6, 7, 9




16322PA0040043Tower UPMC Advantage Bronze $7,400/$50 -

Premium NetworkPPO Bronze On/Off

IND PPO Tower Premium w/Dominion PEDS PPO-

20203, 6, 7 Berks, Carbon, Lehigh, Northampton, Schuylkill

16322PA0040044Tower UPMC Advantage Silver $3,500/$25 -

Premium NetworkPPO Silver On/Off



16322PA0040045Tower UPMC Advantage Silver $2,300/$60 -

Premium NetworkPPO Silver Off



16322PA0040046Tower UPMC Advantage Gold $900/$25 - Premium




16322PA0050029 UPMC Advantage Silver $0/$85 - Select Network EPO Silver On/Off IND EPO Select w/Dominion PEDS PPO-2020 4 Allegheny, Beaver, Butler, Fayette, Washington, Westmoreland

16322PA0050030UPMC Advantage Silver $2,000/$80 - Select

NetworkEPO Silver On/Off IND EPO Select w/Dominion PEDS PPO-2020 4 Allegheny, Beaver, Butler, Fayette, Washington, Westmoreland


NetworkEPO Silver On/Off IND EPO Select w/Dominion PEDS PPO-2020 4 Allegheny, Beaver, Butler, Fayette, Washington, Westmoreland

16322PA0050033 UPMC Advantage Gold $900/$25 - Select Network EPO Gold On/Off IND EPO Select w/Dominion PEDS PPO-2020 4 Allegheny, Beaver, Butler, Fayette, Washington, Westmoreland

16322PA0050100UPMC Advantage Bronze $7,400/$50 - Partner

NetworkEPO Bronze On/Off IND EPO Partner w/Dominion PEDS PPO-2020 1, 3, 4, 5

Allegheny, Bedford, Blair, Clinton, Erie, Lawrence, Lycoming, Mercer,

Tioga, Venango

16322PA0050101UPMC Advantage Bronze $7,400/$50 - Select

NetworkEPO Bronze On/Off IND EPO Select w/Dominion PEDS PPO-2020 4 Allegheny, Beaver, Butler, Fayette, Washington, Westmoreland

16322PA0050102 UPMC Advantage Silver $0/$85 - Partner Network EPO Silver On/Off IND EPO Partner w/Dominion PEDS PPO-2020 1, 3, 4, 5Allegheny, Bedford, Blair, Clinton, Erie, Lawrence, Lycoming, Mercer,

Tioga, Venango

16322PA0050103UPMC Advantage Silver $2,000/$80 - Partner

NetworkEPO Silver On/Off IND EPO Partner w/Dominion PEDS PPO-2020 1, 3, 4, 5


Tioga, Venango


NetworkEPO Silver On/Off IND EPO Partner w/Dominion PEDS PPO-2020 1, 3, 4, 5


Tioga, Venango

16322PA0050105UPMC Advantage Silver HSA $2,800/20% - Partner

NetworkEPO Silver Off IND EPO Partner w/Dominion PEDS PPO-2020 1, 3, 4, 5


Tioga, Venango

16322PA0050106UPMC Advantage Gold $900/$25 - Partner

NetworkEPO Gold On/Off IND EPO Partner w/Dominion PEDS PPO-2020 1, 3, 4, 5


Tioga, Venango

16322PA0050108UPMC Advantage Silver HSA $2,800/20% - Select

NetworkEPO Silver Off IND EPO Select w/Dominion PEDS PPO-2020 4 Allegheny, Beaver, Butler, Fayette, Washington, Westmoreland

16322PA0050111UPMC Advantage Catastrophic $8,150/$0 - Partner

NetworkEPO Catastrophic On/Off IND EPO Partner w/Dominion PEDS PPO-2020 1, 3, 4, 5


Tioga, Venango

16322PA0050112UPMC Advantage Catastrophic $8,150/$0 - Select

NetworkEPO Catastrophic On/Off IND EPO Select w/Dominion PEDS PPO-2020 4 Allegheny, Beaver, Butler, Fayette, Washington, Westmoreland

16322PA0050117Tower UPMC Advantage Silver $3,500/$25 - Tower

NetworkEPO Silver On/Off IND EPO Tower w/Dominion PEDS PPO-2020 7 Berks

16322PA0050118Tower UPMC Advantage Gold $900/$25 - Tower

NetworkEPO Gold On/Off IND EPO Tower w/Dominion PEDS PPO-2020 7 Berks

16322PA0050119Tower UPMC Advantage Bronze $7,400/$50 -

Tower NetworkEPO Bronze On/Off IND EPO Tower w/Dominion PEDS PPO-2020 7 Berks


NetworkEPO Silver Off IND EPO Select w/Dominion PEDS PPO-2020 4 Allegheny, Beaver, Butler, Fayette, Washington, Westmoreland


NetworkEPO Silver Off IND EPO Partner w/Dominion PEDS PPO-2020 1, 3, 4, 5


Tioga, Venango

16322PA0050123Tower UPMC Advantage Silver $2,300/$60 - Tower

NetworkEPO Silver Off IND EPO Tower w/Dominion PEDS PPO-2020 7 Berks

UPMC Health Options, Inc.

Individual

Plan Design Summary

Page Number: 13 12/24/2014

RATE PAGES

Company Name UPMC Health Options, Inc.

Market Individual

RATES FOR AGE 21, NON-TOBACCO USER, BY RATING AREA AND COUNTY

RATING AREA 1

2,070 1,434 6,451 149 866 3,055 1,539 930

HIOS Plan ID Plan Marketing Name Product Metal

On/Off

Exchange Crawford Clarion Erie Forest Mckean Mercer Venango Warren

16322PA0040006 UPMC Advantage Silver $0/$85 - Premium Network PPO Silver On/Off $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $346.67

16322PA0040007UPMC Advantage Silver $2,000/$80 - Premium Network PPO Silver On/Off $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $344.37

16322PA0040008UPMC Advantage Silver $3,500/$25 - Premium Network PPO Silver On/Off $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $344.96

16322PA0040010 UPMC Advantage Gold $900/$25 - Premium Network PPO Gold On/Off $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $360.69

16322PA0040024UPMC Advantage Bronze $7,400/$50 - Premium Network PPO Bronze On/Off $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $249.01

16322PA0040025UPMC Advantage Silver HSA $2,800/20% - Premium Network PPO Silver Off $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $278.80

16322PA0040026UPMC Advantage Catastrophic $8,150/$0 - Premium Network PPO Catastrophic On/Off $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $238.27

16322PA0040037UPMC Advantage Silver $2,300/$60 - Premium Network PPO Silver Off $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $289.36

16322PA0040039UPMC Advantage Bronze $7,400/$50 - Premium Network PPO Bronze On/Off

16322PA0040040UPMC Advantage Silver $3,500/$25 - Premium Network PPO Silver On/Off

16322PA0040041UPMC Advantage Silver $2,300/$60 - Premium Network PPO Silver Off

16322PA0040042 UPMC Advantage Gold $900/$25 - Premium Network PPO Gold On/Off

16322PA0040043Tower UPMC Advantage Bronze $7,400/$50 - Premium NetworkPPO Bronze On/Off

16322PA0040044Tower UPMC Advantage Silver $3,500/$25 - Premium NetworkPPO Silver On/Off

16322PA0040045Tower UPMC Advantage Silver $2,300/$60 - Premium NetworkPPO Silver Off

16322PA0040046Tower UPMC Advantage Gold $900/$25 - Premium Network PPO Gold On/Off

16322PA0050029 UPMC Advantage Silver $0/$85 - Select Network EPO Silver On/Off

16322PA0050030 UPMC Advantage Silver $2,000/$80 - Select Network EPO Silver On/Off

16322PA0050031 UPMC Advantage Silver $3,500/$25 - Select Network EPO Silver On/Off

16322PA0050033 UPMC Advantage Gold $900/$25 - Select Network EPO Gold On/Off

16322PA0050100UPMC Advantage Bronze $7,400/$50 - Partner Network EPO Bronze On/Off $188.30 $188.30 $188.30

16322PA0050101UPMC Advantage Bronze $7,400/$50 - Select Network EPO Bronze On/Off

16322PA0050102 UPMC Advantage Silver $0/$85 - Partner Network EPO Silver On/Off $262.56 $262.56 $262.56

16322PA0050103UPMC Advantage Silver $2,000/$80 - Partner Network EPO Silver On/Off $261.61 $261.61 $261.61

16322PA0050104UPMC Advantage Silver $3,500/$25 - Partner Network EPO Silver On/Off $262.43 $262.43 $262.43

16322PA0050105UPMC Advantage Silver HSA $2,800/20% - Partner Network EPO Silver Off $211.64 $211.64 $211.64

16322PA0050106 UPMC Advantage Gold $900/$25 - Partner Network EPO Gold On/Off $274.05 $274.05 $274.05

16322PA0050108UPMC Advantage Silver HSA $2,800/20% - Select Network EPO Silver Off

16322PA0050111UPMC Advantage Catastrophic $8,150/$0 - Partner Network EPO Catastrophic On/Off $180.07 $180.07 $180.07

16322PA0050112UPMC Advantage Catastrophic $8,150/$0 - Select Network EPO Catastrophic On/Off

16322PA0050117Tower UPMC Advantage Silver $3,500/$25 - Tower Network EPO Silver On/Off

16322PA0050118Tower UPMC Advantage Gold $900/$25 - Tower Network EPO Gold On/Off

16322PA0050119Tower UPMC Advantage Bronze $7,400/$50 - Tower Network EPO Bronze On/Off

16322PA0050120 UPMC Advantage Silver $2,300/$60 - Select Network EPO Silver Off

16322PA0050121UPMC Advantage Silver $2,300/$60 - Partner Network EPO Silver Off $217.60 $217.60 $217.60

16322PA0050123Tower UPMC Advantage Silver $2,300/$60 - Tower Network EPO Silver Off

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

Page Number: 14 12/24/2014

RATE PAGES

RATING AREA 2 RATING AREA 3 RATING AREA 4

932 133 500 49 13 263 55 77 1,872 0 0 0 0 608 0 0 45,217

Elk Cameron Potter Bradford Carbon Clinton Lackawanna Luzerne Lycoming Monroe Pike Sullivan Susquehanna Tioga Wayne Wyoming Allegheny

$380.09 $380.09 $380.09 $346.67

$377.57 $377.57 $377.57 $344.37

$378.21 $378.21 $378.21 $344.96

$395.46 $395.46 $395.46 $360.69

$273.01 $273.01 $273.01 $249.01

$305.67 $305.67 $305.67 $278.80

$261.23 $261.23 $261.23 $238.27

$317.25 $317.25 $317.25 $289.36

$314.22 $314.22 $314.22 $314.22 $314.22 $314.22 $314.22 $314.22

$435.29 $435.29 $435.29 $435.29 $435.29 $435.29 $435.29 $435.29

$365.14 $365.14 $365.14 $365.14 $365.14 $365.14 $365.14 $365.14

$455.15 $455.15 $455.15 $455.15 $455.15 $455.15 $455.15 $455.15

$303.16

$419.97

$352.28

$439.12

$277.37

$276.36

$277.24

$289.51

$237.62 $237.62 $237.62 $188.30

$198.93

$331.32 $331.32 $331.32 $262.56

$330.12 $330.12 $330.12 $261.61

$331.16 $331.16 $331.16 $262.43

$267.07 $267.07 $267.07 $211.64

$345.81 $345.81 $345.81 $274.05

$223.58

$227.23 $227.23 $227.23 $180.07

$190.23

$229.88

$274.59 $274.59 $274.59 $217.60

Page Number: 15 12/24/2014

RATE PAGES


1,848 5,033 7,151 3,737 678 2,064 2,517 7,366 12,522 1,646 3,355 1,854 3,466 956 1,447 2,189 2,196

Armstrong Beaver Butler Fayette Greene Indiana Lawrence Washington Westmoreland Bedford Blair Clearfield Cambria Huntingdon Jefferson Somerset Centre

$346.67 $346.67 ###### $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $346.67 $466.91

$344.37 $344.37 ###### $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $344.37 $463.81

$344.96 $344.96 ###### $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $344.96 $464.60

$360.69 $360.69 ###### $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $360.69 $485.79

$249.01 $249.01 ###### $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $249.01 $335.37

$278.80 $278.80 ###### $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $278.80 $375.49

$238.27 $238.27 ###### $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $238.27 $320.90

$289.36 $289.36 ###### $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $289.36 $389.72

$277.37 ###### $277.37 $277.37 $277.37

$276.36 ###### $276.36 $276.36 $276.36

$277.24 ###### $277.24 $277.24 $277.24

$289.51 ###### $289.51 $289.51 $289.51

$188.30 $188.30 $188.30

$198.93 ###### $198.93 $198.93 $198.93

$262.56 $262.56 $262.56

$261.61 $261.61 $261.61

$262.43 $262.43 $262.43

$211.64 $211.64 $211.64

$274.05 $274.05 $274.05

$223.58 ###### $223.58 $223.58 $223.58

$180.07 $180.07 $180.07

$190.23 ###### $190.23 $190.23 $190.23

$229.88 ###### $229.88 $229.88 $229.88

$217.60 $217.60 $217.60

Page Number: 16 12/24/2014

RATE PAGES


0 292 0 0 0 75 121 0 0 173 4,735 966 783 0 0 0

Columbia Lehigh Mifflin Montour Northampton Northumberland Schuylkill Snyder Union Adams Berks Lancaster York Bucks Chester Delaware

$335.37 $335.37 $335.37 ###### $340.12 $340.12 $340.12

$464.60 $464.60 $464.60 ###### $471.17 $471.17 $471.17

$389.72 $389.72 $389.72 ###### $395.23 $395.23 $395.23

$485.79 $485.79 $485.79 ###### $492.66 $492.66 $492.66

$323.57 $323.57 $323.57 $328.14

$448.24 $448.24 $448.24 $454.58

$376.00 $376.00 $376.00 $381.32

$468.69 $468.69 $468.69 $475.32

$443.38

$463.00

$318.14

$367.64

Page Number: 17 12/24/2014

RATE PAGES

RATING AREA 9

0 0 1,743 1,573 0 0 0 486 343

Montgomery Philadelphia Cumberland Dauphin Franklin Fulton Juniata Lebanon Perry

$297.81 $297.81 $297.81 $297.81

$412.57 $412.57 $412.57 $412.57

$346.07 $346.07 $346.07 $346.07

$431.39 $431.39 $431.39 $431.39

Page Number: 18 12/24/2014

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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA AB AC AD AE

If

mUnified Rate Review v5.0 To add a product to Worksheet 2 - Plan Product Info, select the Add Product button or Ctrl + Shift + P.

To add a plan to Worksheet 2 - Plan Product Info, select the Add Plan button or Ctrl + Shift + L.

Company Legal Name: UPMC HEALTH OPTIONS INC. State: PA To validate, select the Validate button or Ctrl + Shift + I.

HIOS Issuer ID: 16322 Market: Individual To finalize, select the Finalize button or Ctrl + Shift + F.

Effective Date of Rate Change(s): 1/1/2020

Section I: Experience Period Data

Experience Period: 1/1/2018 to 12/31/2018

Total PMPM

$769,743,450.43 $472.91

$0.00 $0.00

$628,780,188.95 $386.31

-$42,491,928.00 -$26.11

$842,415,260.13 $517.56

1,627,678

Section II: Projections

Cost Utilization Cost Utilization

Inpatient Hospital $97.47 1.197 0.972 1.197 0.972 $131.94

Outpatient Hospital $126.94 1.024 0.978 1.024 0.978 $127.31

Professional $88.47 0.993 0.984 0.993 0.984 $84.47

Other Medical $58.06 1.176 1.012 1.176 1.012 $82.23

Capitation $0.61 1.000 1.000 1.000 1.000 $0.61

Prescription Drug $100.31 1.040 0.979 1.040 0.979 $103.99

Total $471.86 $530.56

1.035

1.000

1.000

1.000

1/1/2020 $549.13

$549.05

100.00%

Projected Period Totals

1/1/2020 $549.13 $906,446,694.48

$0.00 $0.00

-$33.97 -$56,074,143.12

2.57% $25,389,290.29

$598.48 $987,910,127.89

1,650,696

Other

Adjusted 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 for

Reinsurance

Risk Adjustment Payment/Charge

Exchange User Fees

Market Adjusted Index Rate

Applied Credibility %

Manual EHB Allowed Claims PMPM

Demographic Shift

Plan Design Changes

Market Level Calculations (Same for all Plans)

Trended EHB Allowed Claims

PMPM

Year 1 Trend Year 2 Trend

Allowed Claims

Reinsurance

Incurred Claims in Experience Period

Risk Adjustment

Experience Period Premium

Experience Period Member Months

Benefit Category

Experience Period Index

Rate PMPM

1 of 5

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells P1 through P4.Product-Plan Data Collection To add a product to Worksheet 2 - Plan Product Info, select the Add Product button or Ctrl + Shift + P.


Company Legal Name: UPMC HEALTH OPTIONS INC. State: PA To validate, select the Validate button or Ctrl + Shift + I.

HIOS Issuer ID: 16322 Market: Individual To finalize, select the Finalize button or Ctrl + Shift + F.

Effective Date of Rate Change(s): 1/1/2020

Field # Section I: General Product and Plan Information

1.1 Product Name

1.2 Product ID

1.3 Plan Name

UPMC Advantage

Silver $0/$85 -

Premium Network

UPMC Advantage

Silver $2,000/$80 -

Premium Network

UPMC Advantage

Silver $3,500/$25 -

Premium Network

UPMC Advantage

Gold $900/$25 -

Premium Network

UPMC Advantage

Bronze

$7,400/$50 -

Premium Network

UPMC Advantage

Silver HSA

$2,800/20% -

Premium Network

UPMC Advantage

Catastrophic

$8,150/$0 -

Premium Network

UPMC Advantage

Silver $2,300/$60 -

Premium Network

UPMC Advantage

Bronze

$7,400/$50 -

Premium Network

UPMC Advantage

Silver $3,500/$25 -

Premium Network

UPMC Advantage

Silver $2,300/$60 -

Premium Network

UPMC Advantage

Gold $900/$25 -

Premium Network

Tower UPMC

Advantage Bronze

$7,400/$50 -

Premium Network

Tower UPMC

Advantage Silver

$3,500/$25 -

Premium Network

Tower UPMC

Advantage Silver

$2,300/$60 -

Premium Network

1.4 Plan ID (Standard Component ID) 16322PA0040006 16322PA0040007 16322PA0040008 16322PA0040010 16322PA0040024 16322PA0040025 16322PA0040026 16322PA0040037 16322PA0040039 16322PA0040040 16322PA0040041 16322PA0040042 16322PA0040043 16322PA0040044 16322PA0040045

1.5 Metal Silver Silver Silver Gold Bronze Silver Catastrophic Silver Bronze Silver Silver Gold Bronze Silver Silver

1.6 AV Metal Value 0.716 0.716 0.715 0.820 0.620 0.716 0.612 0.716 0.620 0.715 0.716 0.820 0.620 0.715 0.716

1.7 Plan Category Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing

1.8 Plan Type PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

1.9 Exchange Plan? Yes Yes Yes Yes Yes No Yes No Yes Yes No Yes Yes Yes No

1.10 Effective Date of Proposed Rates 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 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020 1/1/2020

1.11 Cumulative Rate Change % (over 12 mos prior) 0.73% 3.02% 1.14% -0.60% -5.01% -2.14% -4.10% 2.83% -5.34% 0.72% 2.55% -2.08% -8.67% -2.83% -1.06%

1.12 Product Rate Increase %

1.13 Submission Level Rate Increase %

Worksheet 1 Totals Section II: Experience Period and Current Plan Level Information

2.1 Plan ID (Standard Component ID) Total 16322PA0040006 16322PA0040007 16322PA0040008 16322PA0040010 16322PA0040024 16322PA0040025 16322PA0040026 16322PA0040037 16322PA0040039 16322PA0040040 16322PA0040041 16322PA0040042 16322PA0040043 16322PA0040044 16322PA0040045

$769,743,450 2.2 Allowed Claims $769,747,293 $17,417,434 $15,564,150 $63,640,790 $146,561,483 $26,517,237 $3,733,620 $335,109 $40,930,200 $0 $0 $0 $0 $0 $0 $0

$0 2.3 Reinsurance $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2.4 Member Cost Sharing $140,963,206 $1,879,730 $2,044,211 $6,076,211 $22,793,538 $7,118,411 $526,352 $179,431 $12,405,099 $0 $0 $0 $0 $0 $0 $0

2.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$628,780,189 2.6 Incurred Claims $628,784,087 $15,537,704 $13,519,939 $57,564,580 $123,767,946 $19,398,826 $3,207,268 $155,678 $28,525,101 $0 $0 $0 $0 $0 $0 $0

-$42,491,928 2.7 Risk Adjustment Transfer Amount -$42,491,928 -$637,609 -$489,850 -$2,229,310 -$5,351,622 -$1,610,340 -$85,418 -$49,131 -$2,487,862 $0 $0 $0 $0 $0 $0 $0

$842,415,260 2.8 Premium $842,415,260 $16,425,315 $13,423,315 $58,440,736 $127,370,074 $27,086,269 $2,456,233 $397,369 $45,604,088 $0 $0 $0 $0 $0 $0 $0

1,627,678 2.9 Experience Period Member Months 1,627,678 24,424 18,764 85,395 204,997 61,685 3,272 1,882 95,299 0 0 0 0 0 0 0

2.10 Current Enrollment 137,557 2,709 5,322 6,886 11,903 5,303 414 93 6,462 1,760 3,556 242 924 458 440 28

2.11 Current Premium PMPM $543.51 $676.94 $716.90 $713.09 $680.41 $523.66 $545.88 $269.65 $529.53 $574.28 $813.11 $627.31 $830.86 $678.60 $906.78 $708.07

2.12 Loss Ratio 78.61% 98.42% 104.53% 102.41% 101.43% 76.15% 135.28% 44.70% 66.16% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Per Member Per Month

2.13 Allowed Claims $472.91 $713.13 $829.47 $745.25 $714.94 $429.88 $1,141.08 $178.06 $429.49 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.14 Reinsurance $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!

2.15 Member Cost Sharing $86.60 $76.96 $108.94 $71.15 $111.19 $115.40 $160.87 $95.34 $130.17 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.16 Cost Sharing Reduction $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!

2.17 Incurred Claims $386.31 $636.17 $720.53 $674.10 $603.75 $314.48 $980.22 $82.72 $299.32 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.18 Risk Adjustment Transfer Amount -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

2.19 Premium $517.56 $672.51 $715.38 $684.36 $621.33 $439.11 $750.68 $211.14 $478.54 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Section III: Plan Adjustment Factors

3.1 Plan ID (Standard Component ID) 16322PA0040006 16322PA0040007 16322PA0040008 16322PA0040010 16322PA0040024 16322PA0040025 16322PA0040026 16322PA0040037 16322PA0040039 16322PA0040040 16322PA0040041 16322PA0040042 16322PA0040043 16322PA0040044 16322PA0040045

3.2 Market Adjusted Index Rate

3.3 AV and Cost Sharing Design of Plan 0.8376 0.8321 0.8335 0.8715 0.6016 0.6736 0.5757 0.6991 0.6016 0.8335 0.6991 0.8715 0.6016 0.8335 0.6991

3.4 Provider Network Adjustment 1.1463 1.1463 1.1463 1.1463 1.1463 1.1463 1.1463 1.1463 1.1463 1.1463 1.1463 1.1463 1.1060 1.1060 1.1060

3.5 Benefits in Addition to EHB 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021

Administrative Costs

3.6 Administrative Expense 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78%

3.7 Taxes and Fees 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45%

3.8 Profit & Risk Load 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00%

3.9 Catastrophic Adjustment 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

3.10 Plan Adjusted Index Rate $671.37 $666.96 $668.08 $698.54 $482.21 $539.92 $461.45 $560.36 $482.21 $668.08 $560.36 $698.54 $465.25 $644.59 $540.66

3.11 Age Calibration Factor 0.5365

3.12 Geographic Calibration Factor 1.0008

3.13 Tobacco Calibration Factor 0.9978

3.14 Calibrated Plan Adjusted Index Rate $359.68 $357.32 $357.92 $374.24 $258.34 $289.26 $247.22 $300.21 $258.34 $357.92 $300.21 $374.24 $249.26 $345.34 $289.65

Section IV: Projected Plan Level Information

4.1 Plan ID (Standard Component ID) Total 16322PA0040006 16322PA0040007 16322PA0040008 16322PA0040010 16322PA0040024 16322PA0040025 16322PA0040026 16322PA0040037 16322PA0040039 16322PA0040040 16322PA0040041 16322PA0040042 16322PA0040043 16322PA0040044 16322PA0040045

4.2 Allowed Claims $907,692,856 $19,844,616 $38,866,814 $50,252,469 $96,525,423 $40,904,255 $3,137,405 $845,556 $47,165,821 $13,662,802 $26,010,633 $1,885,274 $7,619,795 $3,523,415 $3,209,575 $315,865

4.3 Reinsurance $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

4.4 Member Cost Sharing $259,096,516 $5,443,103 $10,847,573 $13,963,821 $17,900,490 $16,678,612 $940,122 $366,380 $12,881,474 $5,570,975 $7,227,661 $514,888 $1,413,079 $1,436,664 $891,855 $86,266

4.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

4.6 Incurred Claims $648,596,341 $14,401,513 $28,019,241 $36,288,649 $78,624,932 $24,225,644 $2,197,283 $479,176 $34,284,347 $8,091,827 $18,782,972 $1,370,386 $6,206,716 $2,086,751 $2,317,720 $229,599

4.7 Risk Adjustment Transfer Amount -$43,097,973 -$854,074 -$1,672,753 -$2,162,770 -$3,734,646 -$1,666,800 -$135,028 -$34,455 -$2,029,926 -$556,743 -$1,119,448 -$81,139 -$294,816 -$148,814 -$143,174 -$14,090

4.8 Premium $887,049,449 $21,963,560 $42,731,779 $55,343,344 $99,924,881 $30,788,511 $2,792,539 $608,987 $43,572,175 $10,283,950 $28,645,665 $1,741,632 $7,888,151 $2,652,064 $3,534,725 $291,799

4.9 Projected Member Months 1,650,696 32,712 64,068 82,836 143,040 63,840 5,172 1,320 77,748 21,324 42,876 3,108 11,292 5,700 5,484 540

4.10 Loss Ratio 76.85% 68.22% 68.24% 68.24% 81.74% 83.19% 82.68% 83.40% 82.53% 83.19% 68.24% 82.53% 81.74% 83.36% 68.34% 82.68%

Per Member Per Month

4.11 Allowed Claims $549.88 $606.65 $606.65 $606.65 $674.81 $640.73 $606.61 $640.57 $606.65 $640.72 $606.65 $606.59 $674.80 $618.14 $585.26 $584.94

4.12 Reinsurance $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

4.13 Member Cost Sharing $156.96 $166.39 $169.31 $168.57 $125.14 $261.26 $181.77 $277.56 $165.68 $261.25 $168.57 $165.67 $125.14 $252.05 $162.63 $159.75

4.14 Cost Sharing Reduction $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

4.15 Incurred Claims $392.92 $440.25 $437.34 $438.08 $549.67 $379.47 $424.84 $363.01 $440.97 $379.47 $438.08 $440.92 $549.66 $366.10 $422.63 $425.18

4.16 Risk Adjustment Transfer Amount -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.10 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.09

4.17 Premium $537.38 $671.42 $666.98 $668.11 $698.58 $482.28 $539.93 $461.35 $560.43 $482.27 $668.10 $560.37 $698.56 $465.27 $644.55 $540.37

0.9978

Product/Plan Level Calculations

Individual PPO

16322PA004

-0.01%

1.0008

0.00%

0.5365

$598.48

To add a product to Worksheet 2 - Plan Product Info, select the Add Product button or Ctrl + Shift + P.


Tower UPMC

Advantage Gold

$900/$25 -

Premium Network

UPMC Advantage

Platinum

$250/$20 -

Premium Network

UPMC Advantage

Silver $3,500/$30 -

Premium Network

UPMC Advantage

Gold $1,400/$20 -

Premium Network

UPMC Advantage

Inside Advantage

for Individuals

Bronze

$6,950/$35 -

Premium Network

UPMC Advantage

Inside Advantage

for Individuals

Silver HSA

$2,700/20% -

Premium Network

UPMC Advantage

Inside Advantage

for Individuals

Silver $1,750/$50 -

Premium Network

UPMC Advantage

Inside Advantage

for Individuals

Silver $3,500/$25 -

Premium Network

UPMC Advantage

Inside Advantage

for Individuals

Silver $0/$50 -

Premium Network

UPMC Advantage

Inside Advantage

for Individuals

Gold $800/$20 -

Premium Network

UPMC Advantage

Inside Advantage

for Individuals

Platinum

$250/$20 -

Premium Network

UPMC Advantage

Inside Advantage

for Individuals

Silver $1,800/$50 -

Premium Network

UPMC Advantage

Silver $0/$85 -

Select Network

UPMC Advantage

Silver $2,000/$80 -

Select Network

UPMC Advantage

Silver $3,500/$25 -

Select Network

UPMC Advantage

Gold $900/$25 -

Select Network

UPMC Advantage

Bronze

$7,400/$50 -

Partner Network

UPMC Advantage

Bronze

$7,400/$50 -

Select Network

UPMC Advantage

Silver $0/$85 -

Partner Network

UPMC Advantage

Silver $2,000/$80 -

Partner Network

16322PA0040046 16322PA0040012 16322PA0040027 16322PA0040028 16322PA0040029 16322PA0040030 16322PA0040031 16322PA0040032 16322PA0040033 16322PA0040034 16322PA0040035 16322PA0040038 16322PA0050029 16322PA0050030 16322PA0050031 16322PA0050033 16322PA0050100 16322PA0050101 16322PA0050102 16322PA0050103

Gold Platinum Silver Gold Bronze Silver Silver Silver Silver Gold Platinum Silver Silver Silver Silver Gold Bronze Bronze Silver Silver

0.820 0.912 0.718 0.806 0.609 0.713 0.714 0.714 0.702 0.815 0.909 0.714 0.716 0.716 0.715 0.82 0.62 0.62 0.716 0.716

Renewing Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing

PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO EPO EPO EPO EPO EPO EPO EPO EPO

Yes No No No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes

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 1/1/2020 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 1/1/2020

-5.52% -43.50% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.69% 0.26% 2.26% -0.96% -5.55% -5.55% 0.69% 0.26%


$0 $12,303,721 $16,815,517 $4,015,447 $663,059 $852,936 $1,354,157 $4,809,863 $843,455 $6,658,756 $128,155 $2,464,813 $10,046,977 $6,436,110 $30,899,235 $68,125,237 $14,040,426 $9,545,638 $15,438,207 $11,572,988

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $557,881 $2,410,348 $975,126 $337,832 $82,960 $181,550 $506,098 $105,680 $859,474 $5,822 $579,648 $1,262,879 $1,167,369 $3,827,457 $12,600,218 $6,714,447 $4,487,120 $2,060,750 $1,884,002

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $11,745,840 $14,405,169 $3,040,321 $325,227 $769,977 $1,172,606 $4,303,764 $737,776 $5,799,281 $122,333 $1,885,164 $8,784,098 $5,268,741 $27,071,778 $55,525,019 $7,325,979 $5,058,517 $13,377,457 $9,688,986

$0 -$121,288 -$623,356 -$201,120 -$79,701 -$22,190 -$45,241 -$170,367 -$49,314 -$204,618 -$1,253 -$113,430 -$599,156 -$394,459 -$1,762,328 -$3,728,830 -$2,287,369 -$1,411,387 -$1,034,445 -$691,048

$0 $4,214,168 $16,371,543 $5,207,817 $1,338,840 $646,416 $1,330,011 $4,595,858 $1,299,503 $5,279,014 $42,627 $2,088,269 $12,584,636 $8,916,466 $37,538,903 $72,260,099 $28,643,228 $18,947,465 $20,359,969 $14,712,440

0 4,646 23,878 7,704 3,053 850 1,733 6,526 1,889 7,838 48 4,345 22,951 15,110 67,507 142,835 87,619 54,064 39,625 26,471

124 324 0 0 0 0 0 0 0 0 0 0 3,153 1,947 7,703 10,032 8,507 5,495 5,461 2,841

$883.43 $983.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $515.08 $560.08 $536.81 $534.08 $359.44 $386.96 $481.14 $518.83

#DIV/0! 286.98% 91.47% 60.73% 25.83% 123.35% 91.27% 97.25% 59.01% 114.29% 295.67% 95.46% 73.29% 61.83% 75.67% 81.02% 27.80% 28.85% 69.22% 69.10%

#DIV/0! $2,648.24 $704.23 $521.22 $217.18 $1,003.45 $781.39 $737.03 $446.51 $849.55 $2,669.89 $567.28 $437.76 $425.95 $457.72 $476.95 $160.24 $176.56 $389.61 $437.19

#DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

#DIV/0! $120.08 $100.94 $126.57 $110.66 $97.60 $104.76 $77.55 $55.94 $109.65 $121.28 $133.41 $55.02 $77.26 $56.70 $88.22 $76.63 $83.00 $52.01 $71.17

#DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

#DIV/0! $2,528.16 $603.28 $394.64 $106.53 $905.85 $676.63 $659.48 $390.56 $739.89 $2,548.60 $433.87 $382.73 $348.69 $401.02 $388.74 $83.61 $93.57 $337.60 $366.02

#DIV/0! -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11

#DIV/0! $907.05 $685.63 $675.99 $438.53 $760.49 $767.46 $704.24 $687.93 $673.52 $888.07 $480.61 $548.33 $590.10 $556.07 $505.90 $326.91 $350.46 $513.82 $555.79


0.8715 0.8715 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.8133 0.8104 0.8129 0.8489 0.5833 0.5833 0.8133 0.8104

1.1060 1.1463 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.9446 0.9446 0.9446 0.9446 0.8941 0.9446 0.8941 0.8941

1.0021 1.0021 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021

9.78% 9.78% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78%

2.45% 2.45% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45%

2.00% 2.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00%

1.0000 1.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

$673.98 $698.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $537.19 $535.27 $536.92 $560.70 $364.67 $385.27 $508.47 $506.65

$361.08 $374.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.80 $286.77 $287.65 $300.39 $195.37 $206.41 $272.41 $271.44


$1,101,378 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $19,015,131 $11,780,920 $46,308,382 $67,051,840 $51,119,859 $34,921,166 $31,104,957 $16,228,104

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$204,249 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $5,615,534 $3,509,354 $13,691,784 $13,849,670 $21,766,893 $14,869,471 $9,185,892 $4,834,101

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$897,129 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $13,399,597 $8,271,566 $32,616,598 $53,202,170 $29,352,966 $20,051,695 $21,919,064 $11,394,003

-$44,168 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 -$993,184 -$615,332 -$2,418,744 -$3,148,443 -$2,670,645 -$1,726,956 -$1,716,303 -$895,431

$1,140,167 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $20,435,550 $12,614,858 $49,743,147 $67,614,946 $37,304,855 $25,483,815 $33,428,479 $17,376,845

1,692 0 0 0 0 0 0 0 0 0 0 0 38,040 23,568 92,640 120,588 102,288 66,144 65,736 34,296

81.85% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 68.92% 68.93% 68.92% 82.53% 84.75% 84.40% 69.12% 69.13%

$650.93 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $499.87 $499.87 $499.87 $556.04 $499.76 $527.96 $473.18 $473.18





-$26.10 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11


0.9978

Product/Plan Level Calculations

Individual PPO

16322PA004

-0.01%

1.0008

Individual EPO

16322PA005

0.01%

0.00%

0.5365

$598.48

UPMC Advantage

Silver $3,500/$25 -

Partner Network

UPMC Advantage

Silver HSA

$2,800/20% -

Partner Network

UPMC Advantage

Gold $900/$25 -

Partner Network

UPMC Advantage

Silver HSA

$2,800/20% -

Select Network

UPMC Advantage

Catastrophic

$8,150/$0 -

Partner Network

UPMC Advantage

Catastrophic

$8,150/$0 - Select

Network

Tower UPMC

Advantage Silver

$3,500/$25 -

Tower Network

Tower UPMC

Advantage Gold

$900/$25 - Tower

Network

Tower UPMC

Advantage Bronze

$7,400/$50 -

Tower Network

UPMC Advantage

Silver $2,300/$60 -

Select Network

UPMC Advantage

Silver $2,300/$60 -

Partner Network

Tower UPMC

Advantage Silver

$2,300/$60 -

Tower Network

UPMC Advantage

Platinum

$250/$20 - Select

Network

UPMC Advantage

Platinum

$250/$20 -

Partner Network

UPMC Advantage

Silver $3,500/$30 -

Select Network

UPMC Advantage

Silver $3,500/$30 -

Partner Network

UPMC Advantage

Gold $1,400/$20 -

Select Network

UPMC Advantage

Gold $1,400$20 -

Partner Network

Tower UPMC

Advantage Silver

$3,550/$25 –

Tower Network

16322PA0050104 16322PA0050105 16322PA0050106 16322PA0050108 16322PA0050111 16322PA0050112 16322PA0050117 16322PA0050118 16322PA0050119 16322PA0050120 16322PA0050121 16322PA0050123 16322PA0050035 16322PA0050107 16322PA0050113 16322PA0050114 16322PA0050115 16322PA0050116 16322PA0050122

Silver Silver Gold Silver Catastrophic Catastrophic Silver Gold Bronze Silver Silver Silver Platinum Platinum Silver Silver Gold Gold Silver

0.715 0.716 0.82 0.716 0.612 0.612 0.715 0.82 0.62 0.716 0.716 0.716 0.912 0.912 0.718 0.718 0.806 0.806 0.719

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Terminated Terminated Terminated Terminated Terminated Terminated Terminated

EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO

Yes No Yes No Yes Yes Yes Yes Yes No 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 1/1/2020 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

2.26% -2.37% -0.96% -2.37% -4.77% -4.77% 2.26% -0.96% -5.55% 2.53% 2.53% 2.53% -43.60% -43.60% 0.00% 0.00% 0.00% 0.00% 0.00%


$51,253,386 $2,150,714 $81,274,611 $1,207,205 $414,899 $357,691 $10,216,044 $12,764,251 $1,820,908 $24,632,499 $24,504,975 $0 $2,826,984 $3,969,787 $10,088,232 $2,852,166 $3,089,444 $3,748,172 $860,608

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$6,127,222 $344,844 $15,143,236 $233,073 $256,530 $121,643 $946,228 $1,856,269 $718,210 $8,373,468 $8,760,788 $0 $282,276 $134,200 $1,692,433 $467,668 $751,688 $963,082 $160,704

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$45,126,164 $1,805,870 $66,131,376 $974,132 $158,369 $236,048 $9,269,816 $10,907,982 $1,102,698 $16,259,031 $15,744,186 $0 $2,544,709 $3,835,586 $8,395,799 $2,384,498 $2,337,757 $2,785,089 $699,903

-$3,149,202 -$94,634 -$4,793,166 -$65,526 -$128,441 -$65,578 -$457,897 -$524,780 -$153,163 -$2,396,439 -$2,715,531 $0 -$42,004 -$46,912 -$603,202 -$199,188 -$200,441 -$341,021 -$32,763

$62,572,260 $2,015,140 $88,715,352 $1,409,019 $836,063 $445,352 $14,644,142 $17,225,596 $3,268,793 $35,168,758 $37,225,131 $0 $1,198,098 $1,246,524 $12,903,792 $4,157,119 $4,292,060 $6,551,821 $959,568

120,632 3,625 183,605 2,510 4,920 2,512 17,540 20,102 5,867 91,797 104,020 0 1,609 1,797 23,106 7,630 7,678 13,063 1,255

11,910 533 12,586 446 328 138 2,356 936 865 6,939 8,024 122 133 154 0 0 0 0 0

$502.43 $371.37 $503.09 $379.53 $200.76 $209.17 $814.98 $925.35 $576.12 $405.20 $374.12 $721.82 $790.93 $736.49 $0.00 $0.00 $0.00 $0.00 $0.00

75.94% 94.03% 78.80% 72.51% 22.38% 62.15% 65.34% 65.31% 35.39% 49.61% 45.62% #DIV/0! 220.11% 319.74% 68.26% 60.25% 57.14% 44.84% 75.52%

$424.87 $593.30 $442.66 $480.96 $84.33 $142.39 $582.44 $634.97 $310.36 $268.34 $235.58 #DIV/0! $1,756.98 $2,209.12 $436.61 $373.81 $402.38 $286.93 $685.74

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$50.79 $95.13 $82.48 $92.86 $52.14 $48.42 $53.95 $92.34 $122.42 $91.22 $84.22 #DIV/0! $175.44 $74.68 $73.25 $61.29 $97.90 $73.73 $128.05

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$374.08 $498.17 $360.18 $388.10 $32.19 $93.97 $528.50 $542.63 $187.95 $177.12 $151.36 #DIV/0! $1,581.55 $2,134.44 $363.36 $312.52 $304.47 $213.20 $557.69

-$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 #DIV/0! -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11

$518.70 $555.90 $483.19 $561.36 $169.93 $177.29 $834.90 $856.91 $557.15 $383.11 $357.87 #DIV/0! $744.62 $693.67 $558.46 $544.84 $559.01 $501.56 $764.60


0.8129 0.6556 0.8489 0.6556 0.5578 0.5578 0.8129 0.8489 0.5833 0.6741 0.6741 0.6741 0.8489 0.8489 0.0000 0.0000 0.0000 0.0000 0.0000

0.8941 0.8941 0.8941 0.9446 0.8941 0.9446 1.1060 1.1060 1.1060 0.9446 0.8941 1.1060 0.9446 0.8941 0.0000 0.0000 0.0000 0.0000 0.0000

1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 1.0021 0.0000 0.0000 0.0000 0.0000 0.0000

9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 9.78% 0.00% 0.00% 0.00% 0.00% 0.00%

2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 2.45% 0.00% 0.00% 0.00% 0.00% 0.00%

2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 0.00% 0.00% 0.00% 0.00% 0.00%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.0000 0.0000 0.0000 0.0000 0.0000

$508.22 $409.87 $530.72 $433.02 $348.73 $368.43 $628.66 $656.50 $451.10 $445.24 $421.44 $521.32 $560.70 $530.72 $0.00 $0.00 $0.00 $0.00 $0.00

$272.28 $219.59 $284.33 $231.99 $186.83 $197.38 $336.81 $351.72 $241.68 $238.54 $225.79 $279.30 $300.39 $284.33 $0.00 $0.00 $0.00 $0.00 $0.00


$67,723,592 $3,122,846 $79,602,726 $2,777,147 $2,068,863 $981,828 $16,666,732 $7,445,317 $6,542,603 $41,725,515 $45,658,153 $976,081 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$20,023,520 $994,236 $16,442,076 $884,174 $932,861 $442,711 $4,927,775 $1,537,843 $2,785,847 $12,483,483 $13,660,054 $292,025 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$47,700,072 $2,128,609 $63,160,650 $1,892,972 $1,136,002 $539,117 $11,738,956 $5,907,475 $3,756,755 $29,242,032 $31,998,099 $684,056 $0 $0 $0 $0 $0 $0 $0

-$3,736,839 -$172,312 -$3,948,636 -$145,054 -$108,083 -$48,554 -$743,476 -$298,576 -$276,331 -$2,179,375 -$2,519,316 -$43,541 $0 $0 $0 $0 $0 $0 $0

$72,746,757 $2,705,262 $80,271,236 $2,405,789 $1,443,752 $685,167 $17,902,929 $7,507,844 $4,774,482 $37,163,867 $40,666,569 $869,371 $0 $0 $0 $0 $0 $0 $0

143,124 6,600 151,236 5,556 4,140 1,860 28,476 11,436 10,584 83,472 96,492 1,668 0 0 0 0 0 0 0

69.12% 84.04% 82.75% 83.73% 85.05% 84.69% 68.41% 81.94% 83.52% 83.59% 83.88% 82.83% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$473.18 $473.16 $526.35 $499.85 $499.73 $527.86 $585.29 $651.04 $618.16 $499.87 $473.18 $585.18 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!





-$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.10 -$26.11 -$26.11 -$26.11 -$26.11 -$26.11 -$26.10 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


0.9978

1.0008

Individual EPO

16322PA005

0.01%

0.00%

0.5365

$598.48

Rating Area Data Collection Specify the total number of Rating Areas in your State by selecting the Create Rating Areas button or Ctrl + Shift + R.

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells C1 through C4.Select only the Rating Areas you are offering plans within and add a factor for each area.

To validate, select the Validate button or Ctrl + Shift + I.

To finalize, select the Finalize button or Ctrl + Shift + F.

Rating Area Rating Factor

Rating Area 1 0.9637








Scope and Range of the Rate Increase

Financial Experience of the Product

Premiums $ 842,415,260

Claims $ 670,631,775

Administrative expenses $ 85,525,274

Taxes & fees $ 21,579,781

Company made (after taxes) $ 64,678,430

Changes in Medical Service Costs

Cost and utilization increases are expected to increase by approximately 6.01% for 2020.

Changes in Benefits

No changes in benefits contributed significantly to the increase.

Administrative Costs and Anticipated Profits

No major changes in administrative costs are anticipated. A profit margin of 2% is anticipated for 2020.

RFJ Part II – Consumer Friendly JustificationIndividual Exchange EPO/PPO Rate Filing

The number of individuals affected by this rate increase is 137,526. The proposed rate increase varies by plan

due to various changes made to meet AV requirements on a plan-by-plan basis. The range of the proposed rate

change is -41.48% to 6.41%.

The rate change for UPMC Health Options Individual plans is 3.20% for 2020. Additional premium is needed to

account for the higher cost and utilization of medical services each year. The proposed rate change also

accounts for an increase in anticipated Risk Adjustment payable relative to the prior year and projected

increases in taxes and fees for 2020.

General Information

Company Identifying Information:

Company Legal Name: UPMC Health Options, Inc.

NAIC #: 15345

State: PA

HIOS Issuer ID: 16322

Market: Individual

Exchange: On and Off Exchange

Products: PPO, EPO

Effective Date: 1/1/2020

Company Contact Information:


Filing Information:

Rate Filing SERFF Tracking #: UPMC-131924266

Form Filing SERFF Tracking #: UPMC-131919534, UPMC-131919539, UPMC-131919595, UPMC-131919597,

UPMC-131923154, UPMC-131919990, UPMC-131919615, UPMC-131919931

Binder SERFF Tracking #: UPMC-PA20-125092217

Rate History:

Year Rate Change

2014 0.0%

2015 0.0%

2016 9.7%

2017 26.5%

RFJ Part III: Actuarial Memorandum

SERFF Tracking #

UPMC-129389350

UPMC-129640677

UPMC-130071357

UPMC-130536844

The purpose of this actuarial memorandum is to provide certain information related to a rate submission for the

company identified below. The relevant index rate is developed in accordance with federal regulations, and plan

specific premiums are generated using the allowable modifiers in accordance with the single risk pool rule.

The following section provides information related to the identification of the company that is submitting this

rate filing. Much of this information is also displayed in Table 0 of the PA Actuarial Memorandum Exhibits.

Historical and proposed rate changes vary by plan due to various changes made to meet AV requirements on a

plan-by-plan basis. The values listed below and overall proposed rate change for 2020 are weighted averages of

the increase for each plan based on projected enrollment. Please see Table 10 of the PA Actuarial Memorandum

Exhibits for a breakdown of plan-by-plan rate increases.

1

mailto:[email protected]

2018 41.2%

2019 2.0%

Proposed Rate Increase(s)

Reasons for Rate Increase(s):

The proposed rate increase for PPO products in 2020 is 0.0%

The proposed rate increase for EPO products in 2020 is 0.0%

The major reasons for the increase include the following:

• No increase is proposed for 2020

Market Experience

Single Risk Pool

Experience Period Premium and Claims

Paid Through Date:

The reported claims during the experience period have a paid through date of March 2019.

Current Date:

Current enrollment and premium data is reported as of February 2019.

Premiums (net of MLR Rebate) in Experience Period:

Allowed and Incurred Claims Incurred During the Experience Period:

Section I, worksheet 1 of the URRT contains calendar year 2018 premium for all non-grandfathered policies in

the single risk pool for the captioned company and market. No adjustments were made for MLR rebates as we

do not anticipate owing them. HHS cost-sharing is not included in the premium data. Please note that the

earned premium is also listed in Table 2 of the PA Actuarial Memorandum Exhibits.

Section I, worksheet 1 of the URRT contains calendar year 2018 claims experience for all non-grandfathered

policies in the single risk pool for the captioned company and market, paid through March 2019. Allowed

medical claims and pediatric vision claims are pulled directly from our data warehouse. Pediatric dental claims

are administered and paid by Dominion Dental. We receive a separate report from Dominion with the claim

detail. We used the standard Development/Completion Factor Method to calculate IBNR. Factors were

calculated using our entire block of ACA-related Individual business and no unexpected factors were observed.

Because three months run-out is available the impact of IBNR is minimal.

UPMC-131034732

UPMC-131495924

The single risk pool consists of members that are anticipated to enroll in ACA-compliant policies offered under

the captioned market.

2

Month

1/1/2018

2/1/2018

3/1/2018

4/1/2018

5/1/2018

6/1/2018

7/1/2018

8/1/2018

9/1/2018

10/1/2018

11/1/2018

12/1/2018

Benefit Categories

Drug claims are in separate tables and directly mapped into the Prescription Drugs category.

Projection Factors

Trend Factors (cost/utilization):

PCP Professional

Specialist

Pediatric Vision Other Medical

Diagnostic

Other Other Medical











Other Medical

Professional

Completion Factor

Section I, worksheet 1 of the URRT contains calendar year 2018 claims experience for all non-grandfathered

policies in the single risk pool for the captioned company and market, paid through March 2019. Allowed

medical claims and pediatric vision claims are pulled directly from our data warehouse. Pediatric dental claims

are administered and paid by Dominion Dental. We receive a separate report from Dominion with the claim

detail. We used the standard Development/Completion Factor Method to calculate IBNR. Factors were

calculated using our entire block of ACA-related Individual business and no unexpected factors were observed.

Because three months run-out is available the impact of IBNR is minimal.

1.0000

1.0000

0.9999

0.9997

0.9887

UPMC Benefit Category

Outpatient Outpatient Hospital

Behavioral

0.9994

0.9987

0.9970

ER Other Medical

0.9933

0.9866

0.9786

0.9715

URRT Benefit Category

Inpatient

Medical claims are split into nine categories in our data warehouse. They are mapped into the categories in the

URRT as follows:

Inpatient Hospital

Catastrophic Inpatient Hospital

Outpatient Hospital

Pediatric Dental Other Medical

3

Adjustments to Trended EHB Allowed Claims PMPM

Changes in the Morbidity of the Population Insured:

Changes in Benefits:

No changes were made to the PA EHB Benchmark plan for 2020, so no adjustments were necessary.

Changes in Demographics:

Other Adjustments:

No other adjustments have been applied to the index rate.

Credibility Manual Rate Development

Source and Appropriateness of Manual Rate Used:

Adjustments Made to the Data:

No adjustments were necessary since the rate manual was not used for this filing.

Inclusion of Capitation Payments:

Pediatric dental benefits are projected to be paid for via capitation.

The average age for our 2018 experience period Individual risk pool was 44.4 with an average premium factor of

1.85. This is comparable to our 2019 experience so far with age 44.9 and premium factor 1.87. This change in

factors is small enough that the insured population is considered to be stable, and no additional adjustment for

demographics was deemed necessary.

Due to current uncertainty surrounding the market in 2020 due to the repeal of the Individual Mandate, it has

been required by the Pennsylvania Insurance Department that an assumption for increased morbidity of the

single risk pool be implemented for the projection period. A 6% increase in morbidity has been applied in the

filing to account for this. An additional adjustment factor of 0.977 has been applied to lower the overall

morbidity factor to 1.035. As the premier academic medical center and preeminent provider of high-acuity care

in Western Pennsylvania, we previously assumed that the majority of consumers with significant health needs

would choose UPMC Health Plan products in order to maintain access to UPMC facilities and providers. Given

that access to UPMC is now available through competitors, it is reasonable to assume that some number of

consumers who would have purchased UPMC Health Plan products will instead purchase coverage from a

competing carrier, particularly those with access to multiple provider systems. We believe that individuals with

significant health needs are the most likely, all else being equal, to prioritize decisions on this basis. As such, we

believe it is possible that any shift in consumer coverage purchasing decisions may be skewed toward those with

significant health needs, thereby lowering our expected average morbidity for 2020, which is accounted for in

the additional adjustment factor.











The manual rate was not used as the experience period provided 1,627,833 member months of data, which was

deemed fully credible.

4

Credibility of Experience

Establishing the Index Rate

Paid to Allowed Ratio

Development of the Market Adjusted Index Rate

Experience Period Risk Adjustment and Reinsurance Adjustments PMPM:

Projected Risk Adjustments PMPM:

The Paid to Allowed Average Factor was calculated by taking the weighted average of the company-determined

Actuarial Values for all plans using current membership as demonstrated in Table 10 of the PA Actuarial

Memorandum Exhibits.

The Projected Index Rate is adjusted by adding estimates for Risk Adjustment and Marketplace Fees (with

impacts and costs spread across the whole risk pool) to obtain the projected Market Adjusted Index Rate.

Derivation of the PMPM values used for the Risk Adjustment and Marketplace Fees adjustments are described

above in the Projected Risk Adjustments PMPM and Taxes and Fees sections, respectively.

Experience period Risk Adjustment was estimated to be a payment of $42,491,928 per suggestion from the

Pennsylvania Insurance Department based on data accrued through April 2019, which translates to a PMPM of

$26.10. Based on this estimate and past experience, we believe this value is a reasonable estimate until the

actual values are released later this year. No data for the Transitional Reinsurance Program under PPACA has

been included as this program expired at the end of 2016.

For this filing, the Index Rate of the Experience Period is calculated from the captioned company's fully-credible

experience period EHB claims data for the single risk pool, which is demonstrated in Table 2 of the PA Actuarial

Memorandum Exhibits. The Index Rate of the Projection Period is then calculated in Table 5 by first applying two

years of 6.01% annual trend to the Index Rate of Experience Period. The adjustments described in the Projection

Factors section above were then applied to the trended manual rate to generate the Index Rate of the

Projection Period. Please note that the Index Rate of Projection Period of $549.05 shown in Table 5 does not

exactly match the corresponding value shown in section II, worksheet 1 of the URRT. This is due to rounding

error that is introduced because of the rounding requirements in the newly re-formatted URRT. The value

shown in Table 5 is representative of the actual index rate. Claims for routine foot care and acupuncture were

not included in the calculation of the index rates despite being covered during the experience period since they

are classified as non-EHBs.

Based on the large member month count of the experience period data, we believe the experience period data

is credible enough to use 100%.












5

Exchange User Fees:

Non-Benefit Expenses and Profit & Risk

Administrative Expense Load:

Profit & Risk Margin:

Taxes and Fees:

Plan Adjusted Index Rates

Plan Actuarial Value:


guidance to develop 2020 Plan Adjusted Index Rates. The allowable modifiers that are used in rate development

are described below.

Taxes and Fees increased from 0% in 2019 to 2.45% in 2020 to account for the return of the Health Insurance

Providers Fee in 2020. This load also accounts for the projected Federal Income Tax in 2020. Please note that the

Risk Adjustment Administration Fee was included in the Taxes and Fees field in Table 6 and the URRT.







The projected profit margin for this company will remain at 2% for 2020. This value is listed in both Table 6 and

the URRT. The same level of profit margin is expected for each plan included in this filing.












The member-weighted average of a 3.0% Marketplace User Fee for Marketplace enrollees combined with 0% for

non-Marketplace enrollees calculates to 2.2%. This load is developed based on fees from on-exchange policies,

but is spread over all policies uniformly. This translates to a PMPM of $11.89, which was entered as a positive

value in Table 5 since the calculation adds this value. The effect for this adjustment is an increase in premium as

additional revenue will be required to cover the anticipated payment.

Administrative costs of 9.78% of premium have been displayed in Table 6 and the URRT. This value has been

derived from projected administrative costs for the projection period. These expenses are assumed to be

uniform for all plan designs.

6

Benefit Richness (induced demand)

Benefits in addition to EHBs

Provider Network

Catastrophic Eligibility

No adjustments were made for catastrophic plans. Current enrollment is minimal and not credible.

Non-Funding of CSR Adjustment

Calibration

Age Curve Calibration:














To account for the elimination of funding for cost-share reduction subsidies, the Pennsylvania Insurance

Department has mandated the rates for all silver plans offered both on and off the Federal Marketplace be

increased by a factor of 1.20 in Table 10 of the Actuarial Memorandum Rate Exhibits. Several off-exchange only

silver plans have been included for 2020 to minimize disruption to non-subsidized members enrolled in silver

plans.

Please see Exhibit 3 in the Supporting Exhibits for the induced utilization exhibit. Please note that the average

tobacco factor was set to 1.0 in Exhibit 3 since the tobacco surcharge adjustment was removed from Table 10,

which means that this factor should not be included in the induced utilization development. The benefit richness

adjustment was used to keep relativities between plans similar to what they were in the previous year and

account for differences in induced demand between plans with different metal levels. This will minimize rate

increase variations by plan and consumer confusion that could result. However, factors for bronze plans were

lowered to match those of corresponding silver plans.

Network factors for 2020 were calculated to reflect cost differentials between networks and to ensure

normalization using current membership as demonstrated in Table 10 of the PA Actuarial Memorandum

Exhibits. The current and proposed network factors are also shown in Table 14 of the PA Actuarial Memorandum

Exhibits.

Benefits that will be offered outside EHB include routine foot care and acupuncture. The projected allowed

claims for these benefits is $1.16 PMPM. The adjustment factor of 1.002 included in Table 10 has been derived

by adding the aforementioned PMPM to the projected index rate for 2020 and dividing this total by the same

index rate, causing the adjustment to be applied uniformly to all plans. This load has not changed from the prior

filing.

7

Geographic Factor Calibration:

Region 2019 2020

1 1.00 0.96

2 1.00 1.06

3 1.26 1.22

4 1.00 0.96

5 1.00 0.96

6 1.35 1.30

7 1.37 1.32

9 1.20 1.15

Tobacco Use Rating Factor Calibration:

Feb 2019

MembersSplit Tobacco Factor

126,079 91.3% 1.000

11,995 8.7% 1.025

138,074 100.0%

Consumer Adjusted Premium Rate Development

Projected Loss Ratio

The projected period loss ratio, using the federally-prescribed MLR methodology without the credibility

adjustment, is 82.0%, as shown in Exhibit 4 of the Supporting Exhibits.









The average tobacco factor was calculated using projected membership, which is assumed to have the same

split for tobacco status as current membership. The member-weighted average of a 2.5% load applied for

enrollees who qualify as tobacco users combined with a 0% load for non-tobacco users yields an average

tobacco factor of 1.002. The derivation of this factor is shown below.

Total 1.002

Tobacco Status Calibration Factor

The calibration factor of 0.999 was calculated as the weighted average of the geographical factors using

projected enrollment for the single risk pool, as shown in Exhibit 6 of the Supporting Exhibits.

The geographic rating areas used within this filing are the same as those defined by the state. To better reflect

the varying costs of delivery between each geographical region in which coverage is offered, rating area factors

have been updated for 2020. The table below summarizes changes in these factors:

The Plan Adjusted Index Rates are divided by the age calibration factor then multiplied by the specific age,

geographic, and tobacco factors shown in Tables 12, 13, and 14 of the PA Actuarial Memorandum Exhibits,

respectively, to develop the Consumer Adjusted Premium Rates. Please see Exhibit 7 of the Supporting Exhibits

for historical Consumer Adjusted Premium Rate changes for this company and market for a 21-year-old non-

tobacco user.

Non-User 0.913

User 0.089

8

Plan Product Info

AV Metal Values

Metal values were determined using the final 2020 HHS AV Calculator.

Membership Projections

Terminated Plans and Products

Warning Alerts

Effective Rate Review Information

The Pennsylvania Insurance Department is responsible for conductive effective rate review for all submitted

rates.

No validation errors appear in the URRT.

Please see Table 10 of the PA Actuarial Memorandum Exhibits for a mapping of all terminated SCIDs to a 2020

plan.

Membership projections were developed based on our anticipated competitive positioning in the market

combined with our current enrollment distribution by plan.

9

List of Supporting Exhibits

• Exhibit 1: Development of Risk Adjustment PMPM for Experience and Projection Periods

• Exhibit 2: Derivation of Annual Trend

• Exhibit 3: Induced Utilization Derivation

• Exhibit 4: Derivation of Projection Period MLR

• Exhibit 5: Derivation of Age Calibration Factor

• Exhibit 6: Derivation of Geographical Calibration Factor

• Exhibit 7: Historical Changes in Consumer Adjusted Premium Rate for Age 21, Non-tobacco User

Supporting exhibits have been included with the rate filing to assist with the review process. Below is a list

summarizing the contents of each exhibit.

10

Actuarial Certification

I, Michael Lovely, am a Member of the American Academy of Actuaries. I am currently a Manager in the

Actuarial Services department for UPMC Health Plan. I certify that:

• All factor, benefit and other changes from the prior approved filing have been disclosed in this actuarial

memorandum.

• New plans cannot be considered modifications of existing plans under the uniform modification

standards in 45 CFR 147.106.

• 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.

• The projected Index Rate is:

a. In compliance with all applicable state and Federal statutes and regulations (45 CFR 156.80 and 147.102)

b. Developed in compliance with the applicable Actuarial Standards of Practice

c. Reasonable in relation to the benefits provided and the population anticipated to be covered

d. Neither excessive nor deficient

• The Index Rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 156.80(d)(2) were

used to generate plan level rates.

• The geographic rating factors reflect only differences in the costs of delivery and do not include differences

for population morbidity by geographic area.

• The AV Calculator was used to determine the AV Metal Values shown in Worksheet 2 of the Part I URRT for

all plans except those specified in the certification.

7/19/2019

Date

11

2020 Rates Table Template v9.0 All fields with an asterisk ( * ) are required. To validate press Validate button or Ctrl + Shift + I. To finalize, press Finalize button or Ctrl + Shift + F.

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells B1 through B5.If you are 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.

HIOS Issuer ID* 16322

Federal TIN* 46-2824626

Rate Effective Date* 1/1/2020

Rate Expiration Date* 12/31/2020

Rating Method* Age-Based Rates

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Required:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

Required:

Enter the rate of an Individual tobacco enrollee

on a plan

16322PA0040006 Rating Area 1 Tobacco User/Non-Tobacco User 0-14 265.20 265.20

16322PA0040006 Rating Area 1 Tobacco User/Non-Tobacco User 15 288.78 288.78

















































16322PA0040006 Rating Area 1 Tobacco User/Non-Tobacco User 64 and over 1040.01 1066.01






























































Exhibit 1: Development of Risk Adjustment PMPM for Experience and Projection Periods

2018 Total Received Risk

Adjustment Estimate

2018 ACA Individual

Member Months

Estimated 2018/2020 Received

Risk Adjustment PMPM for

Table 10

Projected Paid to

Allowed Ratio

2020 Projected Received Risk

Adjustment PMPM for URRT

(42,498,246.00)$ 1,627,714 (26.11)$ 0.769 (33.97)$

Exhibit 2: Derivation of Annual Trend

Entire ACA-compliant Individual Block

Base Data Trend Output Trend Adjustment Factor 0.94

Service Category 2018 Allowed Amt Weight Cost Utilization Overall Adj Cost Util Overall

UTILIZATION Inpatient Hospital $158,672,808 20.7% 23.20% 0.00% 23.20% 19.72% -2.83% 16.33%

YEAR ALLOWED AMT ADMIT CNT ENROLLMENT Unit Cost PTPM Outpatient Hospital $206,633,932 26.9% 5.39% 0.61% 6.03% 2.41% -2.23% 0.12%

2017 $130,089,654 9,402 1,644,192 $13,836.38 68.6 Professional $144,018,327 18.7% 2.14% 1.26% 3.43% -0.75% -1.60% -2.34%

2018 $158,672,808 9,308 1,627,833 $17,046.93 68.6 Other Medical $94,516,968 12.3% 21.06% 4.11% 26.03% 17.64% 1.16% 19.01%

Captiation $993,000 0.1% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Prescription Drugs $163,290,915 21.3% 6.98% 0.77% 7.81% 3.96% -2.08% 1.80%

UTILIZATION

YEAR ALLOWED AMT SERVICE CNT ENROLLMENT Unit Cost PTPM Historical Annual Trend 12.27% Annual Trend Applied 6.01%

2017 $196,838,173 535,797 1,644,192 $367.37 3,910.5

2018 $206,633,932 533,720 1,627,833 $387.16 3,934.5 Check 6.01%

UTILIZATION

YEAR ALLOWED AMT SERVICE CNT ENROLLMENT Unit Cost ADMIT PTPM2017 $140,642,186 1,664,656 1,644,192 $84.49 12,149.4

2018 $144,018,327 1,668,869 1,627,833 $86.30 12,302.5

UTILIZATION

YEAR ALLOWED AMT SERVICE CNT ENROLLMENT Unit Cost PTPM2017 $75,343,777 51,104 1,644,192 $1,474.32 373.0

2018 $94,012,048 52,674 1,627,833 $1,784.79 388.3

UTILIZATION

YEAR ALLOWED AMT Prescriptions ENROLLMENT Unit Cost PTPM2017 $152,986,803 1,683,584 1,644,192 $90.87 12,287.5

2018 $163,290,915 1,679,723 1,627,833 $97.21 12,382.5

UTILIZATION

YEAR ALLOWED AMT SERVICE CNT ENROLLMENT Unit Cost PTPM2017 $1,660,634 0 0 #DIV/0! #DIV/0!

2018 $993,000 0 0 #DIV/0! #DIV/0!

UTILIZATION

YEAR ALLOWED AMT SERVICE CNT ENROLLMENT Unit Cost PTPM2017 $509,700 0 0 #DIV/0! #DIV/0!

2018 $504,920 0 0 #DIV/0! #DIV/0!

Pediatric Dental

Pediatric Vision

Inpatient Hospital

Outpatient Hospital

Professional

Other Medical

Prescription Drugs

Exhibit 3: Induced Utilization Derivation

Plan ID (1) Metal Level (2)Projected

Membership (3)

Projected Allowed

Claims (4)

Projected Paid

Claims (5)

Paid to Allowed Factor

(6)

Average

Tobacco Factor

(7)

AV & Cost Sharing

Factor (8)(8)/(6*7)

16322PA0040006 Silver 32,712 19,844,616$ 14,401,513$ 0.726 1.000 0.698 0.962

16322PA0040007 Silver 64,068 38,866,814$ 28,019,241$ 0.721 1.000 0.693 0.962

16322PA0040008 Silver 82,836 50,252,469$ 36,288,649$ 0.722 1.000 0.695 0.962

16322PA0040010 Gold 143,040 96,525,423$ 78,624,932$ 0.815 1.000 0.871 1.070

16322PA0040024 Bronze 63,840 40,904,255$ 24,225,644$ 0.592 1.000 0.602 1.016

16322PA0040025 Silver 5,172 3,137,405$ 2,197,283$ 0.700 1.000 0.674 0.962

16322PA0040026 Catastrophic 1,320 845,556$ 479,176$ 0.567 1.000 0.576 1.016

16322PA0040037 Silver 77,748 47,165,821$ 34,284,347$ 0.727 1.000 0.699 0.962

16322PA0040039 Bronze 21,324 13,662,802$ 8,091,827$ 0.592 1.000 0.602 1.016

16322PA0040040 Silver 42,876 26,010,633$ 18,782,972$ 0.722 1.000 0.695 0.962

16322PA0040041 Silver 3,108 1,885,274$ 1,370,386$ 0.727 1.000 0.699 0.962

16322PA0040042 Gold 11,292 7,619,795$ 6,206,716$ 0.815 1.000 0.871 1.070

16322PA0040043 Bronze 5,700 3,523,415$ 2,086,751$ 0.592 1.000 0.602 1.016

16322PA0040044 Silver 5,484 3,209,575$ 2,317,720$ 0.722 1.000 0.695 0.962

16322PA0040045 Silver 540 315,865$ 229,599$ 0.727 1.000 0.699 0.962

16322PA0040046 Gold 1,692 1,101,378$ 897,129$ 0.815 1.000 0.871 1.070

16322PA0050029 Silver 38,040 19,015,131$ 13,399,597$ 0.705 1.000 0.678 0.962

16322PA0050030 Silver 23,568 11,780,920$ 8,271,566$ 0.702 1.000 0.675 0.962

16322PA0050031 Silver 92,640 46,308,382$ 32,616,598$ 0.704 1.000 0.677 0.962

16322PA0050033 Gold 120,588 67,051,840$ 53,202,170$ 0.793 1.000 0.849 1.070

16322PA0050100 Bronze 102,288 51,119,859$ 29,352,966$ 0.574 1.000 0.583 1.016

16322PA0050101 Bronze 66,144 34,921,166$ 20,051,695$ 0.574 1.000 0.583 1.016

16322PA0050102 Silver 65,736 31,104,957$ 21,919,064$ 0.705 1.000 0.678 0.962

16322PA0050103 Silver 34,296 16,228,104$ 11,394,003$ 0.702 1.000 0.675 0.962

16322PA0050104 Silver 143,124 67,723,592$ 47,700,072$ 0.704 1.000 0.677 0.962

16322PA0050105 Silver 6,600 3,122,846$ 2,128,609$ 0.682 1.000 0.656 0.962

16322PA0050106 Gold 151,236 79,602,726$ 63,160,650$ 0.793 1.000 0.849 1.070

16322PA0050108 Silver 5,556 2,777,147$ 1,892,972$ 0.682 1.000 0.656 0.962

16322PA0050111 Catastrophic 4,140 2,068,863$ 1,136,002$ 0.549 1.000 0.558 1.016

16322PA0050112 Catastrophic 1,860 981,828$ 539,117$ 0.549 1.000 0.558 1.016

16322PA0050117 Silver 28,476 16,666,732$ 11,738,956$ 0.704 1.000 0.677 0.962

16322PA0050118 Gold 11,436 7,445,317$ 5,907,475$ 0.793 1.000 0.849 1.070

16322PA0050119 Bronze 10,584 6,542,603$ 3,756,755$ 0.574 1.000 0.583 1.016

16322PA0050120 Silver 83,472 41,725,515$ 29,242,032$ 0.701 1.000 0.674 0.962

16322PA0050121 Silver 96,492 45,658,153$ 31,998,099$ 0.701 1.000 0.674 0.962

16322PA0050123 Silver 1,668 976,081$ 684,056$ 0.701 1.000 0.674 0.962

Exhibit 4: Derivation of Projection Period MLR

Projected Paid

Claims

Projected Net

Amount of Risk

Adjustment

Projected Quality

Improvement

Initiatives

Projected Taxes &

FeesProjected Premium Loss Ratio

648,596,340.59$ (43,097,973.42)$ 18,144,899.02$ 21,763,947.17$ 887,049,448.50$ 82.0%

Exhibit 5: Derivation of Age Calibration Factor

Age Band Age Factor

Current/Projected

Enrollment

Distribution

0-14 0.765 5.69%

15 0.833 0.49%

16 0.859 0.49%

17 0.885 0.53%

18 0.913 0.57%

19 0.941 0.81%

20 0.970 1.00% Initial Age Factor: 1.869

21 1.000 1.06% 3-child cap Adjustment: 0.998

22 1.000 1.00% Final Age Factor used: 1.864

23 1.000 0.93%

24 1.000 0.86%

25 1.004 0.82%

26 1.024 1.60%

27 1.048 1.64%

28 1.087 1.70%

29 1.119 1.64%

30 1.135 1.58%

31 1.159 1.49%

32 1.183 1.39%

33 1.198 1.43%

34 1.214 1.43%

35 1.222 1.32%

36 1.23 1.38%

37 1.238 1.41%

38 1.246 1.36%

39 1.262 1.41%

40 1.278 1.36%

41 1.302 1.39%

42 1.325 1.25%

43 1.357 1.34%

44 1.397 1.37%

45 1.444 1.41%

46 1.5 1.50%

47 1.563 1.58%

48 1.635 1.85%

49 1.706 1.78%

50 1.786 1.87%

51 1.865 1.98%

52 1.952 2.05%

53 2.04 2.29%

54 2.135 2.48%

55 2.23 2.57%

56 2.333 2.74%

57 2.437 3.01%

58 2.548 3.22%

59 2.603 3.33%

60 2.714 3.78%

61 2.81 4.07%

62 2.873 4.89%

63 2.952 5.47%

64 and over 3 6.35%

Exhibit 6: Derivation of Geographical Calibration Factor

Rating AreasProjected

EnrollmentProposed Factor

Calibration

Factor

1 16,494 0.964 0.999

2 1,565 1.057

3 2,937 1.216

4 88,133 0.964

5 14,912 0.964

6 2,684 1.298

7 6,656 1.316

9 4,145 1.153

Exhibit 7: Historical Changes in Consumer Adjusted Premium Rate for Age 21, Non-tobacco User

2014 2015 2015 2016 2016 2017 2017 2018 2018 2019 2019 2020 2020

Plan ID Metal Level Product Name Plan Name Exchange Plan (Y/N)Age 21,

NT Prem

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

16322PA0040006 Silver Individual PPO UPMC Advantage Silver $0/$50 - Premium Network Y -$ 163.67$ N/A 181.02$ 10.6% 233.68$ 29.1% 353.04$ 51.1% 345.75$ -2.1% 346.67$ 0.3%

16322PA0040007 Silver Individual PPO UPMC Advantage Silver $1,750/$50 - Premium Network Y -$ 161.39$ N/A 180.36$ 11.8% 232.84$ 29.1% 354.71$ 52.3% 335.79$ -5.3% 344.37$ 2.6%


16322PA0040010 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ 207.42$ N/A 223.92$ 8.0% 289.06$ 29.1% 332.61$ 15.1% 364.25$ 9.5% 360.69$ -1.0%

16322PA0040012 Platinum Individual PPO UPMC Advantage Platinum $250/$20 - Premium Network Y -$ 345.15$ N/A 380.01$ 10.1% 490.56$ 29.1% 581.41$ 18.5% 638.38$ 9.8% -$ N/A

16322PA0040024 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ -$ N/A 158.03$ N/A 204.01$ 29.1% 240.21$ 17.7% 263.06$ 9.5% 249.01$ -5.3%

16322PA0040025 Silver Individual PPO UPMC Advantage Silver HSA $2,800/20% - Premium Network N -$ -$ N/A 180.69$ N/A 233.26$ 29.1% 368.05$ 57.8% 285.28$ -22.5% 278.80$ -2.3%

16322PA0040026 Catastrophic Individual PPO UPMC Advantage Catastrophic $7,350/$0 - Premium Network Y -$ -$ N/A 137.48$ N/A 177.48$ 29.1% 205.70$ 15.9% 249.70$ 21.4% 238.27$ -4.6%

16322PA0040027 Silver Individual PPO UPMC Advantage Silver $3,500/$30 - Premium Network Y -$ -$ N/A -$ N/A 226.19$ N/A 352.72$ 55.9% -$ N/A -$ N/A

16322PA0040028 Gold Individual PPO UPMC Advantage Gold $1,400/$20 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A 346.35$ N/A -$ N/A -$ N/A

16322PA0040029 Bronze Individual PPO UPMC Advantage Inside Advantage for Individuals Bronze $6,950/$35 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A 239.66$ N/A -$ N/A -$ N/A

16322PA0040030 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver HSA $2,700/20% - Premium Network Y -$ -$ N/A -$ N/A -$ N/A 342.30$ N/A -$ N/A -$ N/A

16322PA0040031 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $1,750/$50 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A 349.49$ N/A -$ N/A -$ N/A

16322PA0040032 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $3,500/$25 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A 348.80$ N/A -$ N/A -$ N/A

16322PA0040033 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $0/$50 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A 349.95$ N/A -$ N/A -$ N/A

16322PA0040034 Gold Individual PPO UPMC Advantage Inside Advantage for Individuals Gold $800/$20 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A 327.07$ N/A -$ N/A -$ N/A

16322PA0040035 Platinum Individual PPO UPMC Advantage Inside Advantage for Individuals Platinum $250/$20 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A 577.97$ N/A -$ N/A -$ N/A

16322PA0040036 Catastrophic Individual PPO UPMC Advantage Catastrophic $7,350/$0 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A 205.70$ N/A -$ N/A -$ N/A

16322PA0040037 Silver Individual PPO UPMC Advantage Silver $1,800/$50 - Premium Network N -$ -$ N/A -$ N/A -$ N/A 263.78$ N/A 282.17$ 7.0% 289.36$ 2.5%

16322PA0040038 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $1,800/$50 - Premium Network N -$ -$ N/A -$ N/A -$ N/A 259.97$ N/A -$ N/A -$ N/A

16322PA0040039 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0040040 Silver Individual PPO UPMC Advantage Silver $3,500/$25 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0040041 Silver Individual PPO UPMC Advantage Silver $2,000/$60 - Premium Network N -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0040042 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A





16322PA0050029 Silver Individual EPO UPMC Advantage Silver $0/$50 - Select Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050030 Silver Individual EPO UPMC Advantage Silver $1,750/$50 - Select Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A


16322PA0050033 Gold Individual EPO UPMC Advantage Gold $800/$20 - Select Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050035 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Select Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050100 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Partner Network Y -$ -$ N/A 130.55$ N/A 161.64$ 23.8% 190.33$ 17.7% 199.37$ 4.7% 188.30$ -5.6%

16322PA0050101 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Select Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050102 Silver Individual EPO UPMC Advantage Silver $0/$50 - Partner Network Y -$ -$ N/A 149.53$ N/A 185.14$ 23.8% 279.71$ 51.1% 260.77$ -6.8% 262.56$ 0.7%

16322PA0050103 Silver Individual EPO UPMC Advantage Silver $1,750/$50 - Partner Network Y -$ -$ N/A 148.99$ N/A 184.48$ 23.8% 281.03$ 52.3% 260.92$ -7.2% 261.61$ 0.3%


16322PA0050105 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Partner Network N -$ -$ N/A 149.26$ N/A 184.81$ 23.8% 291.60$ 57.8% 216.77$ -25.7% 211.64$ -2.4%

16322PA0050106 Gold Individual EPO UPMC Advantage Gold $800/$20 - Partner Network Y -$ -$ N/A 184.97$ N/A 229.02$ 23.8% 263.53$ 15.1% 276.71$ 5.0% 274.05$ -1.0%

16322PA0050107 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Partner Network Y -$ -$ N/A 313.92$ N/A 388.67$ 23.8% 460.65$ 18.5% 485.94$ 5.5% -$ N/A

16322PA0050108 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Select Network N -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050111 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 - Partner Network Y -$ -$ N/A 113.57$ N/A 140.62$ 23.8% 162.98$ 15.9% 189.10$ 16.0% 180.07$ -4.8%

16322PA0050112 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 – Select Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A


16322PA0050114 Silver Individual EPO UPMC Advantage Silver $3,500/$30 - Partner Network Y -$ -$ N/A -$ N/A 188.52$ N/A 293.98$ 55.9% -$ N/A -$ N/A

16322PA0050115 Gold Individual EPO UPMC Advantage Gold $1,400/$20 - Select Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050116 Gold Individual EPO UPMC Advantage Gold $1,400$20 - Partner Network Y -$ -$ N/A -$ N/A -$ N/A 274.41$ N/A -$ N/A -$ N/A

16322PA0050117 Silver Individual EPO Tower UPMC Advantage Silver $3,500/$25 - Tower Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050118 Gold Individual EPO Tower UPMC Advantage Gold $800/$20 - Tower Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050119 Bronze Individual EPO Tower UPMC Advantage Bronze $6,950/$35 - Tower Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050120 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Select Network N -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0050121 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Partner Network N -$ -$ N/A -$ N/A -$ N/A 208.98$ N/A 212.24$ 1.6% 217.60$ 2.5%

16322PA0050123 Silver Individual EPO UPMC Advantage Silver $2,000/$60 - Tower Network N -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

Geographic Area 1

2014 2015 2015 2016 2016 2017 2017 2018 2018 2019 2019 2020 2020


NT Prem

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change




16322PA0040010 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ 207.42$ N/A 223.92$ 8.0% 289.06$ 29.1% 332.61$ 15.1% 364.25$ 9.5% 395.46$ 8.6%


16322PA0040024 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ -$ N/A 158.03$ N/A 204.01$ 29.1% 240.21$ 17.7% 263.06$ 9.5% 273.01$ 3.8%

16322PA0040025 Silver Individual PPO UPMC Advantage Silver HSA $2,800/20% - Premium Network N -$ -$ N/A 180.69$ N/A 233.26$ 29.1% 368.05$ 57.8% 285.28$ -22.5% 305.67$ 7.1%

16322PA0040026 Catastrophic Individual PPO UPMC Advantage Catastrophic $7,350/$0 - Premium Network Y -$ -$ N/A 137.48$ N/A 177.48$ 29.1% 205.70$ 15.9% 249.70$ 21.4% 261.23$ 4.6%



16322PA0040029 Bronze Individual PPO UPMC Advantage Inside Advantage for Individuals Bronze $6,950/$35 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0040030 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver HSA $2,700/20% - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0040031 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $1,750/$50 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A


16322PA0040033 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $0/$50 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0040034 Gold Individual PPO UPMC Advantage Inside Advantage for Individuals Gold $800/$20 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0040035 Platinum Individual PPO UPMC Advantage Inside Advantage for Individuals Platinum $250/$20 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A

16322PA0040036 Catastrophic Individual PPO UPMC Advantage Catastrophic $7,350/$0 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A


16322PA0040038 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $1,800/$50 - Premium Network N -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A














16322PA0050100 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Partner Network Y -$ -$ N/A 130.55$ N/A 161.64$ 23.8% -$ -100.0% -$ N/A -$ N/A


16322PA0050102 Silver Individual EPO UPMC Advantage Silver $0/$50 - Partner Network Y -$ -$ N/A 149.53$ N/A 185.14$ 23.8% -$ -100.0% -$ N/A -$ N/A

16322PA0050103 Silver Individual EPO UPMC Advantage Silver $1,750/$50 - Partner Network Y -$ -$ N/A 148.99$ N/A 184.48$ 23.8% -$ -100.0% -$ N/A -$ N/A


16322PA0050105 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Partner Network N -$ -$ N/A 149.26$ N/A 184.81$ 23.8% -$ -100.0% -$ N/A -$ N/A

16322PA0050106 Gold Individual EPO UPMC Advantage Gold $800/$20 - Partner Network Y -$ -$ N/A 184.97$ N/A 229.02$ 23.8% -$ -100.0% -$ N/A -$ N/A

16322PA0050107 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Partner Network Y -$ -$ N/A 313.92$ N/A 388.67$ 23.8% -$ -100.0% -$ N/A -$ N/A


16322PA0050111 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 - Partner Network Y -$ -$ N/A 113.57$ N/A 140.62$ 23.8% -$ -100.0% -$ N/A -$ N/A



16322PA0050114 Silver Individual EPO UPMC Advantage Silver $3,500/$30 - Partner Network Y -$ -$ N/A -$ N/A 188.52$ N/A -$ -100.0% -$ N/A -$ N/A


16322PA0050116 Gold Individual EPO UPMC Advantage Gold $1,400$20 - Partner Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A





16322PA0050121 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Partner Network N -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A


Geographic Area 2

2018 2019 2019 2020 2020

Plan ID Metal Level Product Name Plan Name Exchange Plan (Y/N)Age 21, NT

Prem

Age 21, NT

Prem% Change

Age 21, NT

Prem

%

Change

16322PA0040006 Silver Individual PPO UPMC Advantage Silver $0/$50 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040007 Silver Individual PPO UPMC Advantage Silver $1,750/$50 - Premium Network Y -$ -$ N/A -$ N/A


16322PA0040010 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040012 Platinum Individual PPO UPMC Advantage Platinum $250/$20 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040024 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040025 Silver Individual PPO UPMC Advantage Silver HSA $2,800/20% - Premium Network N -$ -$ N/A -$ N/A

16322PA0040026 Catastrophic Individual PPO UPMC Advantage Catastrophic $7,350/$0 - Premium Network Y -$ -$ N/A -$ N/A


16322PA0040028 Gold Individual PPO UPMC Advantage Gold $1,400/$20 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040029 Bronze Individual PPO UPMC Advantage Inside Advantage for Individuals Bronze $6,950/$35 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040030 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver HSA $2,700/20% - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040031 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $1,750/$50 - Premium Network Y -$ -$ N/A -$ N/A


16322PA0040033 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $0/$50 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040034 Gold Individual PPO UPMC Advantage Inside Advantage for Individuals Gold $800/$20 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040035 Platinum Individual PPO UPMC Advantage Inside Advantage for Individuals Platinum $250/$20 - Premium Network Y -$ -$ N/A -$ N/A


16322PA0040037 Silver Individual PPO UPMC Advantage Silver $1,800/$50 - Premium Network N -$ -$ N/A -$ N/A

16322PA0040038 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $1,800/$50 - Premium Network N -$ -$ N/A -$ N/A

16322PA0040039 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ 331.95$ N/A 314.22$ -5.3%

16322PA0040040 Silver Individual PPO UPMC Advantage Silver $3,500/$25 - Premium Network Y -$ 432.18$ N/A 435.29$ 0.7%

16322PA0040041 Silver Individual PPO UPMC Advantage Silver $2,000/$60 - Premium Network N -$ 356.06$ N/A 365.14$ 2.6%

16322PA0040042 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ 464.81$ N/A 455.15$ -2.1%


16322PA0040044 Silver Individual PPO UPMC Advantage Silver $3,500/$25 - Premium Network Y -$ 432.18$ N/A 419.97$ -2.8%

16322PA0040045 Silver Individual PPO UPMC Advantage Silver $2,000/$60 - Premium Network N -$ 356.06$ N/A 352.28$ -1.1%


16322PA0050029 Silver Individual EPO UPMC Advantage Silver $0/$50 - Select Network Y -$ -$ N/A -$ N/A

16322PA0050030 Silver Individual EPO UPMC Advantage Silver $1,750/$50 - Select Network Y -$ -$ N/A -$ N/A


16322PA0050033 Gold Individual EPO UPMC Advantage Gold $800/$20 - Select Network Y -$ -$ N/A -$ N/A

16322PA0050035 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Select Network Y -$ -$ N/A -$ N/A

16322PA0050100 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Partner Network Y 240.45$ 251.58$ 4.6% 237.62$ -5.5%

16322PA0050101 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Select Network Y -$ -$ N/A -$ N/A

16322PA0050102 Silver Individual EPO UPMC Advantage Silver $0/$50 - Partner Network Y 353.36$ 329.06$ -6.9% 331.32$ 0.7%

16322PA0050103 Silver Individual EPO UPMC Advantage Silver $1,750/$50 - Partner Network Y 355.03$ 329.25$ -7.3% 330.12$ 0.3%

16322PA0050104 Silver Individual EPO UPMC Advantage Silver $3,500/$25 - Partner Network Y 345.73$ 323.84$ -6.3% 331.16$ 2.3%

16322PA0050105 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Partner Network N 368.38$ 273.54$ -25.7% 267.07$ -2.4%

16322PA0050106 Gold Individual EPO UPMC Advantage Gold $800/$20 - Partner Network Y 332.92$ 349.17$ 4.9% 345.81$ -1.0%

16322PA0050107 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Partner Network Y 581.95$ 613.19$ 5.4% -$ N/A

16322PA0050108 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Select Network N -$ -$ N/A -$ N/A

16322PA0050111 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 - Partner Network Y 205.89$ 238.62$ 15.9% 227.23$ -4.8%

16322PA0050112 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 – Select Network Y -$ -$ N/A -$ N/A


16322PA0050114 Silver Individual EPO UPMC Advantage Silver $3,500/$30 - Partner Network Y 371.39$ -$ N/A -$ N/A

16322PA0050115 Gold Individual EPO UPMC Advantage Gold $1,400/$20 - Select Network Y -$ -$ N/A -$ N/A

16322PA0050116 Gold Individual EPO UPMC Advantage Gold $1,400$20 - Partner Network Y 346.66$ -$ N/A -$ N/A

16322PA0050117 Silver Individual EPO Tower UPMC Advantage Silver $3,500/$25 - Tower Network Y -$ -$ N/A -$ N/A

16322PA0050118 Gold Individual EPO Tower UPMC Advantage Gold $800/$20 - Tower Network Y -$ -$ N/A -$ N/A

16322PA0050119 Bronze Individual EPO Tower UPMC Advantage Bronze $6,950/$35 - Tower Network Y -$ -$ N/A -$ N/A

16322PA0050120 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Select Network N -$ -$ N/A -$ N/A

16322PA0050121 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Partner Network N 264.01$ 267.82$ 1.4% 274.59$ 2.5%

16322PA0050123 Silver Individual EPO UPMC Advantage Silver $2,000/$60 - Tower Network N -$ -$ N/A -$ N/A

Geographic Area 3

2014 2015 2015 2016 2016 2017 2017 2018 2018 2019 2019 2020 2020

Plan ID Metal Level Product Name Plan NameExchange Plan

(Y/N)

Age 21,

NT Prem

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change





























16322PA0050029 Silver Individual EPO UPMC Advantage Silver $0/$50 - Select Network Y -$ -$ N/A -$ N/A -$ N/A 294.25$ N/A 275.48$ -6.4% 277.37$ 0.7%

16322PA0050030 Silver Individual EPO UPMC Advantage Silver $1,750/$50 - Select Network Y -$ -$ N/A -$ N/A -$ N/A 295.63$ N/A 275.64$ -6.8% 276.36$ 0.3%

16322PA0050031 Silver Individual EPO UPMC Advantage Silver $3,500/$25 - Select Network Y -$ -$ N/A -$ N/A -$ N/A 287.89$ N/A 271.11$ -5.8% 277.24$ 2.3%

16322PA0050033 Gold Individual EPO UPMC Advantage Gold $800/$20 - Select Network Y -$ -$ N/A -$ N/A -$ N/A 277.21$ N/A 292.32$ 5.5% 289.51$ -1.0%

16322PA0050035 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Select Network Y -$ -$ N/A -$ N/A -$ N/A 484.58$ N/A 513.35$ 5.9% -$ N/A


16322PA0050101 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Select Network Y -$ -$ N/A -$ N/A -$ N/A 200.21$ N/A 210.61$ 5.2% 198.93$ -5.5%







16322PA0050108 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Select Network N -$ -$ N/A -$ N/A -$ N/A 306.74$ N/A 229.00$ -25.3% 223.58$ -2.4%


16322PA0050112 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 – Select Network Y -$ -$ N/A -$ N/A -$ N/A 171.44$ N/A 199.76$ 16.5% 190.23$ -4.8%

16322PA0050113 Silver Individual EPO UPMC Advantage Silver $3,500/$30 - Select Network Y -$ -$ N/A -$ N/A -$ N/A 293.98$ N/A -$ N/A -$ N/A


16322PA0050115 Gold Individual EPO UPMC Advantage Gold $1,400/$20 - Select Network Y -$ -$ N/A -$ N/A -$ N/A 288.66$ N/A -$ N/A -$ N/A





16322PA0050120 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Select Network N -$ -$ N/A -$ N/A -$ N/A 219.84$ N/A 224.21$ 2.0% 229.88$ 2.5%



Geographic Area 4

2014 2015 2015 2016 2016 2017 2017 2018 2018 2019 2019 2020 2020


NT Prem

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change























































Geographic Area 5

2014 2015 2015 2016 2016 2017 2017 2018 2018 2019 2019 2020 2020


NT Prem

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

Age 21, NT

Prem

%

Change

16322PA0040006 Silver Individual PPO UPMC Advantage Silver $0/$50 - Premium Network Y -$ 163.67$ N/A 181.02$ 10.6% 233.68$ 29.1% 353.04$ 51.1% 465.67$ 31.9% 466.91$ 0.3%

16322PA0040007 Silver Individual PPO UPMC Advantage Silver $1,750/$50 - Premium Network Y -$ 161.39$ N/A 180.36$ 11.8% 232.84$ 29.1% 354.71$ 52.3% 452.26$ 27.5% 463.81$ 2.6%

16322PA0040008 Silver Individual PPO UPMC Advantage Silver $3,500/$25 - Premium Network Y -$ 163.44$ N/A 177.44$ 8.6% 229.07$ 29.1% 345.42$ 50.8% 461.28$ 33.5% 464.60$ 0.7%




16322PA0040025 Silver Individual PPO UPMC Advantage Silver HSA $2,800/20% - Premium Network N -$ -$ N/A 180.69$ N/A 233.26$ 29.1% 368.05$ 57.8% 384.23$ 4.4% 375.49$ -2.3%














16322PA0040039 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A 354.30$ N/A 335.37$ -5.3%

16322PA0040040 Silver Individual PPO UPMC Advantage Silver $3,500/$25 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A 461.28$ N/A 464.60$ 0.7%

16322PA0040041 Silver Individual PPO UPMC Advantage Silver $2,000/$60 - Premium Network N -$ -$ N/A -$ N/A -$ N/A -$ N/A 380.04$ N/A 389.72$ 2.5%

16322PA0040042 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A 496.10$ N/A 485.79$ -2.1%

16322PA0040043 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A 354.30$ N/A 323.57$ -8.7%

16322PA0040044 Silver Individual PPO UPMC Advantage Silver $3,500/$25 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A 461.28$ N/A 448.24$ -2.8%

16322PA0040045 Silver Individual PPO UPMC Advantage Silver $2,000/$60 - Premium Network N -$ -$ N/A -$ N/A -$ N/A -$ N/A 380.04$ N/A 376.00$ -1.1%

16322PA0040046 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A 496.10$ N/A 468.69$ -5.5%






16322PA0050100 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Partner Network Y -$ -$ N/A 130.55$ N/A 161.64$ 23.8% -$ -100.0% -$ N/A -$ N/A


16322PA0050102 Silver Individual EPO UPMC Advantage Silver $0/$50 - Partner Network Y -$ -$ N/A 149.53$ N/A 185.14$ 23.8% -$ -100.0% -$ N/A -$ N/A



16322PA0050105 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Partner Network N -$ -$ N/A 149.26$ N/A 184.81$ 23.8% -$ -100.0% -$ N/A -$ N/A

16322PA0050106 Gold Individual EPO UPMC Advantage Gold $800/$20 - Partner Network Y -$ -$ N/A 184.97$ N/A 229.02$ 23.8% -$ -100.0% -$ N/A -$ N/A

16322PA0050107 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Partner Network Y -$ -$ N/A 313.92$ N/A 388.67$ 23.8% -$ -100.0% -$ N/A -$ N/A


16322PA0050111 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 - Partner Network Y -$ -$ N/A 113.57$ N/A 140.62$ 23.8% -$ -100.0% -$ N/A -$ N/A



16322PA0050114 Silver Individual EPO UPMC Advantage Silver $3,500/$30 - Partner Network Y -$ -$ N/A -$ N/A 188.52$ N/A -$ -100.0% -$ N/A -$ N/A


16322PA0050116 Gold Individual EPO UPMC Advantage Gold $1,400$20 - Partner Network Y -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A





16322PA0050121 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Partner Network N -$ -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A -$ N/A


Geographic Area 6

2018 2019 2019 2020 2020


Prem

Age 21, NT

Prem% Change

Age 21, NT

Prem

%

Change

16322PA0040006 Silver Individual PPO UPMC Advantage Silver $0/$50 - Premium Network Y -$ -$ N/A -$ N/A



16322PA0040010 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040012 Platinum Individual PPO UPMC Advantage Platinum $250/$20 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040024 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040025 Silver Individual PPO UPMC Advantage Silver HSA $2,800/20% - Premium Network N -$ -$ N/A -$ N/A



16322PA0040028 Gold Individual PPO UPMC Advantage Gold $1,400/$20 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040029 Bronze Individual PPO UPMC Advantage Inside Advantage for Individuals Bronze $6,950/$35 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040030 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver HSA $2,700/20% - Premium Network Y -$ -$ N/A -$ N/A



16322PA0040033 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $0/$50 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040034 Gold Individual PPO UPMC Advantage Inside Advantage for Individuals Gold $800/$20 - Premium Network Y -$ -$ N/A -$ N/A

16322PA0040035 Platinum Individual PPO UPMC Advantage Inside Advantage for Individuals Platinum $250/$20 - Premium Network Y -$ -$ N/A -$ N/A


16322PA0040037 Silver Individual PPO UPMC Advantage Silver $1,800/$50 - Premium Network N -$ -$ N/A -$ N/A

16322PA0040038 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $1,800/$50 - Premium Network N -$ -$ N/A -$ N/A


16322PA0040040 Silver Individual PPO UPMC Advantage Silver $3,500/$25 - Premium Network Y -$ 467.80$ N/A 471.17$ 0.7%

16322PA0040041 Silver Individual PPO UPMC Advantage Silver $2,000/$60 - Premium Network N -$ 385.41$ N/A 395.23$ 2.5%



16322PA0040044 Silver Individual PPO UPMC Advantage Silver $3,500/$25 - Premium Network Y -$ 467.80$ N/A 454.58$ -2.8%

16322PA0040045 Silver Individual PPO UPMC Advantage Silver $2,000/$60 - Premium Network N -$ 385.41$ N/A 381.32$ -1.1%


16322PA0050029 Silver Individual EPO UPMC Advantage Silver $0/$50 - Select Network Y -$ -$ N/A -$ N/A



16322PA0050033 Gold Individual EPO UPMC Advantage Gold $800/$20 - Select Network Y -$ -$ N/A -$ N/A

16322PA0050035 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Select Network Y -$ -$ N/A -$ N/A

16322PA0050100 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Partner Network Y -$ -$ N/A -$ N/A

16322PA0050101 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Select Network Y -$ -$ N/A -$ N/A

16322PA0050102 Silver Individual EPO UPMC Advantage Silver $0/$50 - Partner Network Y -$ -$ N/A -$ N/A

16322PA0050103 Silver Individual EPO UPMC Advantage Silver $1,750/$50 - Partner Network Y -$ -$ N/A -$ N/A


16322PA0050105 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Partner Network N -$ -$ N/A -$ N/A

16322PA0050106 Gold Individual EPO UPMC Advantage Gold $800/$20 - Partner Network Y -$ -$ N/A -$ N/A

16322PA0050107 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Partner Network Y -$ -$ N/A -$ N/A

16322PA0050108 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Select Network N -$ -$ N/A -$ N/A

16322PA0050111 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 - Partner Network Y -$ -$ N/A -$ N/A

16322PA0050112 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 – Select Network Y -$ -$ N/A -$ N/A



16322PA0050115 Gold Individual EPO UPMC Advantage Gold $1,400/$20 - Select Network Y -$ -$ N/A -$ N/A

16322PA0050116 Gold Individual EPO UPMC Advantage Gold $1,400$20 - Partner Network Y -$ -$ N/A -$ N/A

16322PA0050117 Silver Individual EPO Tower UPMC Advantage Silver $3,500/$25 - Tower Network Y 471.80$ 433.58$ -8.1% 443.38$ 2.3%

16322PA0050118 Gold Individual EPO Tower UPMC Advantage Gold $800/$20 - Tower Network Y 454.31$ 467.50$ 2.9% 463.00$ -1.0%

16322PA0050119 Bronze Individual EPO Tower UPMC Advantage Bronze $6,950/$35 - Tower Network Y 328.10$ 336.83$ 2.7% 318.14$ -5.5%

16322PA0050120 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Select Network N -$ -$ N/A -$ N/A

16322PA0050121 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Partner Network N -$ -$ N/A -$ N/A

16322PA0050123 Silver Individual EPO UPMC Advantage Silver $2,000/$60 - Tower Network N -$ 358.58$ N/A 367.64$ 2.5%

Geographic Area 7

2019 2020 2020


Prem

Age 21, NT

Prem% Change

16322PA0040006 Silver Individual PPO UPMC Advantage Silver $0/$50 - Premium Network Y -$ -$ N/A

16322PA0040007 Silver Individual PPO UPMC Advantage Silver $1,750/$50 - Premium Network Y -$ -$ N/A


16322PA0040010 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ -$ N/A

16322PA0040012 Platinum Individual PPO UPMC Advantage Platinum $250/$20 - Premium Network Y -$ -$ N/A

16322PA0040024 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ -$ N/A

16322PA0040025 Silver Individual PPO UPMC Advantage Silver HSA $2,800/20% - Premium Network N -$ -$ N/A

16322PA0040026 Catastrophic Individual PPO UPMC Advantage Catastrophic $7,350/$0 - Premium Network Y -$ -$ N/A


16322PA0040028 Gold Individual PPO UPMC Advantage Gold $1,400/$20 - Premium Network Y -$ -$ N/A

16322PA0040029 Bronze Individual PPO UPMC Advantage Inside Advantage for Individuals Bronze $6,950/$35 - Premium Network Y -$ -$ N/A

16322PA0040030 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver HSA $2,700/20% - Premium Network Y -$ -$ N/A

16322PA0040031 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $1,750/$50 - Premium Network Y -$ -$ N/A

16322PA0040032 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $3,500/$25 - Premium Network Y -$ -$ N/A

16322PA0040033 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $0/$50 - Premium Network Y -$ -$ N/A

16322PA0040034 Gold Individual PPO UPMC Advantage Inside Advantage for Individuals Gold $800/$20 - Premium Network Y -$ -$ N/A

16322PA0040035 Platinum Individual PPO UPMC Advantage Inside Advantage for Individuals Platinum $250/$20 - Premium Network Y -$ -$ N/A

16322PA0040036 Catastrophic Individual PPO UPMC Advantage Catastrophic $7,350/$0 - Premium Network Y -$ -$ N/A

16322PA0040037 Silver Individual PPO UPMC Advantage Silver $1,800/$50 - Premium Network N -$ -$ N/A

16322PA0040038 Silver Individual PPO UPMC Advantage Inside Advantage for Individuals Silver $1,800/$50 - Premium Network N -$ -$ N/A

16322PA0040039 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y 314.62$ 297.81$ -5.3%

16322PA0040040 Silver Individual PPO UPMC Advantage Silver $3,500/$25 - Premium Network Y 409.62$ 412.57$ 0.7%

16322PA0040041 Silver Individual PPO UPMC Advantage Silver $2,000/$60 - Premium Network N 337.48$ 346.07$ 2.5%

16322PA0040042 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y 440.54$ 431.39$ -2.1%

16322PA0040043 Bronze Individual PPO UPMC Advantage Bronze $6,950/$35 - Premium Network Y -$ -$ N/A


16322PA0040045 Silver Individual PPO UPMC Advantage Silver $2,000/$60 - Premium Network N -$ -$ N/A

16322PA0040046 Gold Individual PPO UPMC Advantage Gold $800/$20 - Premium Network Y -$ -$ N/A

16322PA0050029 Silver Individual EPO UPMC Advantage Silver $0/$50 - Select Network Y -$ -$ N/A

16322PA0050030 Silver Individual EPO UPMC Advantage Silver $1,750/$50 - Select Network Y -$ -$ N/A


16322PA0050033 Gold Individual EPO UPMC Advantage Gold $800/$20 - Select Network Y -$ -$ N/A

16322PA0050035 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Select Network Y -$ -$ N/A

16322PA0050100 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Partner Network Y -$ -$ N/A

16322PA0050101 Bronze Individual EPO UPMC Advantage Bronze $6,950/$35 - Select Network Y -$ -$ N/A

16322PA0050102 Silver Individual EPO UPMC Advantage Silver $0/$50 - Partner Network Y -$ -$ N/A

16322PA0050103 Silver Individual EPO UPMC Advantage Silver $1,750/$50 - Partner Network Y -$ -$ N/A


16322PA0050105 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Partner Network N -$ -$ N/A

16322PA0050106 Gold Individual EPO UPMC Advantage Gold $800/$20 - Partner Network Y -$ -$ N/A

16322PA0050107 Platinum Individual EPO UPMC Advantage Platinum $250/$20 - Partner Network Y -$ -$ N/A

16322PA0050108 Silver Individual EPO UPMC Advantage Silver HSA $2,800/20% - Select Network N -$ -$ N/A

16322PA0050111 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 - Partner Network Y -$ -$ N/A

16322PA0050112 Catastrophic Individual EPO UPMC Advantage Catastrophic $7,350/$0 – Select Network Y -$ -$ N/A



16322PA0050115 Gold Individual EPO UPMC Advantage Gold $1,400/$20 - Select Network Y -$ -$ N/A

16322PA0050116 Gold Individual EPO UPMC Advantage Gold $1,400$20 - Partner Network Y -$ -$ N/A

16322PA0050117 Silver Individual EPO Tower UPMC Advantage Silver $3,500/$25 - Tower Network Y -$ -$ N/A

16322PA0050118 Gold Individual EPO Tower UPMC Advantage Gold $800/$20 - Tower Network Y -$ -$ N/A

16322PA0050119 Bronze Individual EPO Tower UPMC Advantage Bronze $6,950/$35 - Tower Network Y -$ -$ N/A

16322PA0050120 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Select Network N -$ -$ N/A

16322PA0050121 Silver Individual EPO UPMC Advantage Silver $1,800/$50 - Partner Network N -$ -$ N/A

16322PA0050123 Silver Individual EPO UPMC Advantage Silver $2,000/$60 - Tower Network N -$ -$ N/A

Geographic Area 9

2020 Business Rules Template v9.0 All fields with an asterisk ( * ) are required. To validate the template, press Validate button or Ctrl + Shift + I. To finalize the template, press Finalize button or Ctrl + Shift + F.

If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells C1 through C4.Enter the Issuer Rule on the first row (no Product ID or Plan ID).

For each Product rule, enter only the Product ID and the business rules that differ from the Issuer Rule.

For each Plan rule, enter only the Plan ID and the business rules that differ from the Product or Issuer Rule

HIOS Issuer ID* 16322TIN* 46-2824626

Product IDPlan ID

(Standard Component)

How are rates for contracts

covering two or more

enrollees calculated?

What are the maximum

number of under age

(under 21) dependents used

to quote a two parent

family?

What are the

maximum number

of under age (under

21) dependents

used to quote a

single parent

family?

Is there a maximum age

for a dependent?

What are the maximum

number of children

used to quote a children-

only contract?

Are domestic partners

treated the same as

secondary subscribers?

Are same-sex partners

treated the same as

secondary subscribers?

How is age determined

for rating and eligibility

purposes?

How is tobacco status

determined for

subscribers and

dependents?

What relationships between primary

and dependent are allowed, and is

the dependent required to live in the

same household as the primary

subscriber?

A different rate (specifically

for parties of two or

more)for each enrollee is

added together

3 or more 3 or more 25 1 Yes Yes Age on effective date 6

Spouse, No; Adopted Child, No;

Foster Child, No; Ward, No;

Stepson or Stepdaughter, No; Self,

Yes; Child, No; Life Partner, No

Dear Mr. Lovely:

The Pennsylvania Insurance Department has received and conducted a review of the above captioned filing.

In order to complete the review, we are requesting the following information. To facilitate a timely review,

we request this information be provided within 7 days of the date of this letter. If you have any questions or

difficulties in providing the information within this time frame, please call me.

Please note, each response to a Department data call must contain a cover letter that details the changes

made to the Actuarial Memorandums and PA Actuarial Memorandum Exhibits and the reasons why the

changes were made, e.g., in response to Department question number 5.

1. The updated URR instructions require the quantitative impacts of the rate increase drivers. Please provide

an estimate of the amount of the average rate increase contributed by the rate increase factors, considering

the rate increase drivers included in the Part III memo do not match Table 8.

The quantitative impacts of the rate increase drivers listed in the Part III memo are:

• Increase in anticipated Risk Adjustment payment relative to prior year: -0.9% (average across

products)

• Return of the Health Insurer Provider's Fee in 2020: 2.2% (average across products)

These aren’t the only factors that exist, which is why they don’t exactly line up with the total.

2. Please explain how morbidity was removed from impacting rate increases per the URR instructions.

All pricing AVs were determined using the same pricing tool, which uses claims data and a base

population from UPMC’s fully insured commercial block of business. Since the same tool was

used for all plans, this eliminates any impact from morbidity at the plan level, and differing rate

increases by product type are purely based on differences in benefit design for all plans within a

given product.

3. Table 1 and Table 2 of the PAAM indicate 1,627,833 member months in the experience, but the URRT

WS1 indicates 1,627,678. Additionally, the projected member months are also slightly different. Please

explain these discrepancies.

These exhibits require different levels of data detail. Not all of this detail is available within our

underlying data. We deemed this discrepancy immaterial.

4. What are the measurement units used for the “Other Medical” category?

Services are the measurement unit for the Other Medical category.

5. Since the trends were not developed from Exhibit 2, please provide support for the trends used in the PA

Exhibits and the URRT. We also note that the URRT trends do not match exactly the ones in the PA Exhibits

please explain.

a. Please explain why the trends provided in Exhibit 2 of the Supporting Exhibits file do not match the PAAM.

b. Please explain why a trend of 6% was chosen.

c. Please explain the high cost trends for the inpatient hospital and other medical benefit categories.

d. Please explain the low trends for prescription drug.

The slight difference in trends shown in the PA Exhibits relative to those in the URRT stems from

rounding error that arises from the requirements of the re-formatted URRT.

a. There was an error with the calculations in exhibit 2, which has been corrected as part of this

correspondence. Please note that the trends displayed in exhibit 2 now match those shown in

the PA Exhibits and the URRT. Also, this correction has not affected the magnitude of the applied

annual trend.

b. The raw historical data implies an annual trend of 12.3% as shown in exhibit 2. We do not

believe that this value accurately represents future trends that will be observed in this market,

leading to the decision to lower the trend applied in rate development. This was done by

introducing an adjustment factor that uniformly decreases the historical trends for each benefit

category so that an overall annual trend of 6.0% is applied in rate development.

c. The raw data used in trend calculations suggest very large increases in unit cost for the

inpatient hospital and other medical benefit categories as indicated in column L of exhibit 2 of

the Supporting Exhibits. We believe actual trends for these categories will be lower than what is

implied by the historical data, which is why an adjustment factor was introduced to lower the

trend as shown in exhibit 2.

d. The low trend observed for prescription drug can be attributed to utilization of brand drugs

shifting over to generic drugs, leading to lower unit costs for pharmacy and ultimately a lower

than expected unit cost trend. It can also be attributed to an increase in pharmacy rebates in

recent years.

6. Please explain why the adjustment method for trend was changed from Plan Year 2019 to Plan Year 2020.

Please recalculate and provide the adjustment factors needed to produce the original requested trends using

a consistent method for both Plan Years so that a comparison may be made.

We feel that the adjustment method used in the current filing makes more sense than the

approach used in the prior filing. The old approach adjusts the trends for each benefit category

by applying a scalar multiplier. The new approach adjusts the trends in a more additive manner.

Despite the fact that this change in adjustment methods results in different annual trends for

each benefit category and noticeably different adjustment factors, the overall annual trend factor

applied in rate development remains the same. The goal of this adjustment process is bring the

trend implied by historical data to a level more reflective of anticipated future trends in the

market, regardless of the adjustment method implemented. Please see exhibit 6 of the response

exhibits Excel file for the derivation of the prior filing's applied trend using the approach

employed in the current filing.

7. Did trend assumptions consider changes in provider contracting? If not, why? If so, what impact did they

have on trend assumptions?

Observed rate increases in experience data are higher than those observed in the projected data.

This is a contributing factor to our decision to decrease the annual trend from 12.3% as implied

by the raw data to the applied annual trend of 6.0% as discussed in the responses to questions 5

and 34.

8. Were trends adjustment for unexpected large claims? If so, what was the impact?

No unexpectedly large claims were observed in terms of frequency and severity. Therefore, no

adjustment was made.

9. If adjustments are made for large claim pooling, was the federal risk adjustment program considered?

We considered the impact of UPMC's expected large claims versus the nation's large claims and

assumed a neutral impact.

10. Regarding Risk Adjustment Data Validation process (RADV):

a. Please describe any adjustments or considerations made due to the Risk Adjustment Data Validation

process (RADV).

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.

a. We considered our position to be in line with other issuers and thus a neutral final impact.

b. Our internal estimates indicate that we will not receive a material adjustment as a result of

RADV, and would not want to make adjustments to risk adjustment to account for this.

11. Is private reinsurance being used for this business? Please discuss its impact on trend adjustment for

large claims.

Reinsurance covers excess non-UPMC hospital claims. In our analysis, this was deemed

immaterial.

12. The term “ACA-related Individual” is used multiple times in both the Federal and Pennsylvania actuarial

memoranda. For each instance, please explain if this means Fully-Compliant ACA, Non-Grandfathered, and

Non-Transitional. Please elaborate if this means something else.

The term ACA-related Individual does refer to Fully-Compliant ACA, Non-Grandfathered, and Non-

Transitional business.

13. Please explain why the actuarial memoranda state that an exchange user fee of 3.5% is being used for

plan year 2020, instead of the fee of 3% published in the Payment Parameters Final Rule for Plan Year 2020.

This was an error in the actuarial memoranda and has been corrected as part of our response.

14. Please provide the development of the exchange user fee based on exchange enrollment.

Please see exhibit 14 of the response exhibits Excel file for this calculation. Please note that the

projected and current member distribution are assumed to be identical.

15. Please provide the list and title of all applicable of ASOPs the actuary is certifying work conformity.

Many ASOPs apply to our work. Per URRT instructions, we place particular emphasis on the

following ASOPS:

• ASOP No. 5, Incurred Health and Disability Claims

• ASOP No. 8, Regulatory Filings for Health Plan Entities

• ASOP No. 12, Risk Classification

• ASOP No. 23, Data Quality

• ASOP No. 25, Credibility Procedures Applicable to Accident and Health, Group Term Life, and

Property/Casualty Coverages

• ASOP No. 26, Compliance with Statutory and Regulatory Requirements for the Actuarial

Certification of Small Employer Health Benefit Plans

• ASOP No. 41, Actuarial Communications

• ASOP No. 50, Determining Minimum Value and Actuarial Value under the Affordable Care Act

16. Please explain why the Pennsylvania Rate Template Table 4 Completion Factors do not match the

actuarial memoranda completion factors by month. Show quantified support.

This was an error, and the completion factors in the memoranda were not correct. This error has

been corrected in the memoranda so that the factors match those in Table 4.

17. Please explain why the Pennsylvania Rate Template Table 8 Change in Miscellaneous Items is shown as -

8.7%. Please explain and quantify what items are included in this.

Per collaboration with the Department, last year we included some large quality improvement

changes in this item. This year, we did not.

18. Pediatric Dental is administered and paid by Dominion Dental. Please identify the fees paid to Dominion

Dental on a PMPM basis. Is this fee paid on a capitation basis or on a fee for service basis? By how much

PMPM is this fee projected to increase from 2019 to 2020?

The fees paid to Dominion Dental are $14.01 PMPM for catastrophic pediatric PPO plans and

$15.93 PMPM for all other deductible levels of pediatric PPO plans. These fees are paid on a

capitation basis and are not projected to change from 2019 to 2020.

19. Please explain why the silver plans have a lower induced demand factor than the bronze plans. Please

explain why this is expected to continue in 2020.

The induced demand factors were kept in relative proportion from last year’s approved filing. We

strived to maintain stability in the market as much as possible by trying to minimize fluctuations

for the overall rate increase as well as the consumer-adjusted premiums for individual members.

20. Please explain why the bronze plans have the same induced demand as the catastrophic plans. Please

explain why this is expected to continue in 2020.

Benefit designs for catastrophic plans are most similar to those of bronze plans. We have not

historically implemented any catastrophic eligibility adjustments as part of rate development and

do not propose such an adjustment for 2020. Because of this, we believe it is most appropriate

to use the same induced demand for bronze and catastrophic plans.

Regarding Table 14 - Network Factors - you have revised all of the network factors contained in this table

but have not provided any supporting documentation or data.

21. Please provide your quantitative analysis and narrative of the development of the network factors. For

each network, provide data including network level claims for calendar years 2016, 2017 and 2018, based

on the enrollees utilizing that network. For each period, this data should show the following network level

data: total ultimate incurred claims, estimated cost sharing, allowed claims, total number of

days/visits/procedures, as appropriate, the number of member months, average age, average tobacco

factor, average benefit factor and capitations. Separate tabs should be provided to show the development of

the average age factor, average tobacco factor and average benefit factor by network. Within each network,

show the estimated impact of favorable provider contracting. Ensure that all data and your in-depth analysis

is submitted to support the current and proposed factors.

No major changes were expected from last year’s factors so we kept the relativities between

them the same and just re-normalized since there is no calibration factor for network.

22. Please fully demonstrate how recent provider contracting has developed the proposed factors. Please

provide the full details of the providers that were renegotiated and their total percent of claims in each

network.

The year over year adjustments by provider were assumed to be consistent (similar fee changes

across all providers).

23. For calendar years 2016, 2017 and 2018, please provide the actual unit cost experience data by network

by benefit category (inpatient, outpatient, physician surgery, physician radiology, etc.) to support the

proposed changes. UPMC must provide data and discussion at the level of detail necessary for the

department or its consultant, to independently calculate and verify all proposed adjustments.

No major changes were expected between networks as a whole or at a particular category level.

So we kept the relativities between them the same and just re-normalized since there is no

calibration factor for network.

24. Did the certifying actuary rely on any information or assumptions provided by another individual? If so,

please specify and provide reliance statements.

We did not rely on any external consultants. Data and other information was sourced internally,

and there were no circumstances which warranted specific mention of reliance.

25. The Federal actuarial memorandum states, “The portion of membership enrolled in cost-share reduction

variants was assumed to remain the same for 2020.” Do you mean the percent of membership in each

specific variant? Be more specific and include an example.

The line referenced above was carryover from actuarial memoranda used in prior filings. This line

was used to address our assumptions for deriving projected enrollment for different CSR variants

for each plan in prior years. This line has been removed from the actuarial memoranda since the

CSR Defunding Adjustment is prescribed by the Department, making this assumption no longer

relevant.

26. Please explain why no catastrophic eligibility adjustment was applied to the catastrophic plans.

As mentioned in the URR instructions, an adjustment accounting for the impact catastrophic

eligibility is permitted but not required. The instructions also state that such an adjustment

must be derived from catastrophic plan experience. Since our catastrophic experience is minimal

and not credible, an adjustment factor was not derived or applied.

27. The updated URR instructions indicate that the risk adjustment on the URRT should no longer be net of

the risk adjustment user fee and should instead be included with taxes and fee. Please update materials so

the risk adjustment fee is not included with risk adjustment transfers as a market-wide adjustment.

This update has been made as part of this correspondence.

28. Regarding Table 6:

a. Using the submitted commission schedules, quantitatively show the development of the percent and

PMPM amounts in cells C51 and D51.

b. Using the 2018 SHCE in the Annual Statement, please quantitatively show the development of the Quality

Improvement Initiatives percent and pmpm amount.

c. 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.

d. Using financial data based on market share, please show the development of the HIT percentage and

PMPM. Also, how much of the HIT was paid, both as a percentage of premium and PMPM, in 2016 and 2018?

a. The commission amounts from the financial statements were adjusted in correspondence with

Finance department to more accurately reflect the projection period operational environment.

b. The QI amounts from the financial statements were adjusted in correspondence with Finance

department to more accurately reflect the projection period operational environment.

c. This change has been made as part of this correspondence.

d. From our internal financial records, 2018 HIT Tax / Revenue eligible = 40.6M/2.06B = 2%

(and so 2% was used for 2020 pricing).

2016 Tax Paid = $23.9M on $1.37B eligible = 1.68%

From table 6: 2% * required revenue ($547.83 PMPM) = $10.96

29. The Actuarial certification in the Federal Actuarial Memorandum appears to be based on last year’s URRT

and instructions. For example, it refers to “The percent of total premium that represents EHB included in

Worksheet 2, Sections III and IV,” which is not part of the current URRT. Please revise the certification

consistent with this year’s URR instructions.

The line referenced above was carryover from actuarial memoranda used in prior filings. This

line has been removed from the memoranda as part of this update.

30. Please identify any rating factors for medical management along with any change in factors from Plan

Year 2019.

No rating factors for medical management have been implemented.

31. Were changes in health policy reserve taken into consideration in the rate development?

We have historically and continue to anticipate that we can change rates to match revenue with

costs annually, so no reserves are necessary.

32. In the PA Actuarial Memo Rate Exhibits, Tables 2 and 4 should contain data from the entity specific to

the filing, i.e. UPMC Heath Options, Inc., whereas Tables 2b and 4b should contain the manual data from all

UPMC companies. However, the data shown in Tables 2 and 4 is identical to that shown in Tables 2b and 4b.

Please review and revise.

For the individual market, the manual data consists of experience period data under the UPMC

Health Options, Inc. legal entity, which is why the data in the tables identified above are

identical.

33. The PA Actuarial Memo indicates that data representing UPMC’s entire block of ACA- compliant individual

business was the basis for the manual rate. Please identify each entity contributing to this aggregate data.

Also, discuss what, if any, adjustments were made to the data to reflect product and regional differences for

this entity and the manual data pool.

a. Further the PA Actuarial Memo indicates that Tables 4 and 4b contain the same data. Please remain

cognizant that the data in Table 4 should contain only the data from the filing entity.

Data belonging to ACA-related individual business under the UPMC Health Options legal entity

was used as the basis for the manual rate. The language in the actuarial memoranda has been

updated to better reflect this. No adjustments were made to this data since there are not

significant differences between this entity and the manual data pool. For this particular filing,

the manual data pool is the experience period data under this legal entity, which is why the data

in Table 4 and 4b are the same.

34. Regarding Trend:

a. Is the data in Table 4b raw unadjusted data or has it been normalized of otherwise adjusted? If the data

has been adjusted, please provide the unadjusted allowed monthly data for the 48 months. Also include the

following monthly data:

i. The average age factor;

ii. The average geographic factor;

iii. The average tobacco factor;

iv. The average benefit factor; and

v. The normalized average pmpm (which should match the allowed PMPMs in column L of table 4b.).

b. Exhibit 2 of the supporting exhibit applies a “Trend Adjustment Factor” of .94 to adjust the developed cost

and utilization assumptions.

vi. Please explain what this factor is adjusting for and how it was developed.

vii. Please provide a numerical development of the factor .94.

viii. Please include the trends based on historical experience for each benefit category for years 2016, 2017,

2018, and 2019 (year to date). We realize 2019 trends will be partially based on estimated claim costs.

a. The data in Table 4b is raw unadjusted data.

b. vi. This factor is used to adjust the annual trend factor implied by the raw historical data

(1.123) to the applied annual trend factor (1.06). As shown in exhibit 2, this factor is simply the

ratio of the latter factor relative to the former factor.

vii. As mentioned above and shown in exhibit 2, this factor is the ratio of the applied annual

trend factor relative to the trend factor implied by the raw historical data.

viii. Please see exhibit 34bviii of the response exhibits Excel file for this data.

35. Regarding Exhibit 3 in the supporting Excel file:

a. The average Tobacco Factor was set to 1.00. Please explain.

b. The AV & Cost Sharing values in Exhibit 3 do not match the AV & Cost Sharing values in Worksheet II of

the URRT. Please reconcile.

a. As mentioned in the Benefit Richness (induced demand) section of the PA actuarial

memorandum, the average tobacco factor was set to 1.0 since the tobacco surcharge adjustment

was removed from Table 10, which means that this factor should no longer be included in the

induced utilization development.

b. The only plans for which the AV & Cost Sharing values do not match between exhibit 3 and the

URRT are the on-exchange silver plans. This is so because the CSR Defunding Adjustment was

not included in the values shown in exhibit 3 while the values in the URRT do account for this

adjustment. Given the way the induced utilization exhibit is set up, it is not possible to use the

AV & Cost Sharing values from the URRT for on-exchange silver plans in this exhibit and arrive at

the proper induced utilization factors since the CSR Defunding Adjustment is not accounted for in

the induced utilization exhibit. Therefore, the AV & Cost Sharing values from the URRT for all on-

exchange silver plans were divided by 1.2 before being inserted into exhibit 3.

36. Regarding Table 10:

a. The supporting Exhibit 4 shows the projected age band distribution. Please revise this exhibit to show the

current member distribution as of 2/1/19 and show the resulting average factor.

b. In the URRT Memorandum, you indicate that no adjustment was made to the demographics for the 3-

child max. Please explain why. Also, provide the current billable member distribution in Exhibit 4 and show

the resulting average factor with the 3-child max.

c. Please provide a supporting exhibit, in Excel, showing the development of the average tobacco factor.

Please show the projected and the current 2/1/19 member distribution.

a. The current and projected age band distributions are assumed to be identical. The heading in

column C of this exhibit was revised to better reflect this.

b. Per the guidance, an adjustment accounting for the 3-child max is permitted but not required.

Such an adjustment was considered but ultimately determined to have negligible impact on the

age calibration factor and enrollment distribution and was not included in rate development.

This approach is consistent with our approach in prior rate filings. Approximately 0.73% of the

population in this market consists of non-billable members.

c. Please see exhibit 36c of the response exhibits Excel file for this calculation. Please note that

the projected and current member distribution are assumed to be identical.

37. Please confirm that you have tested to ensure that the rates in Table 11 of the Actuarial Memorandum

Exhibits, PA Plan Design Summary and Rate Tables, Federal Rates Template and the binder are identical.

We can confirm that we have tested to ensure that the rates match.

38. 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 exhibit 38 of the response exhibits Excel file for this data.

39. Please provide an exhibit showing the financial gains and losses for calendar years 2014 – 2018 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.

Regarding Table 13 - Geographic Rating Area Factor Support you have revised all of the geographic factors

contained in this table but have not provided any supporting documentation or data.

Please see exhibit 39 of the response exhibits Excel file for this data. Due to our financial

partners finalizing restatement in these numbers, the total administrative expense and taxes and

fees section are not completed. We would like to apologize and provide an updated exhibit and

notify the Department by EOD Thursday.

40. Please explain how updated geographic rating factors were determined and how morbidity was removed.

Geographic factors were updated to better reflect cost differences by area. Points of

consideration included differences in fee schedules, anticipated shifts in utilization between

providers, and less favorable contracting terms in areas with few facilities (including those

without UPMC facilities).

41. Please provide your quantitative analysis of the development of the geographic area rating factors. This

data must minimally include county level claims data for calendar years 2016, 2017 and 2018, based on the

residence of the enrollee. For each period, this data should show the following county level data: total

ultimate incurred claims, estimated cost sharing, allowed claims, total number of days/visits/procedures, as

appropriate, the number of member months, average age, average tobacco factor, average benefit factor

and capitations. Separate tabs should be provided to show the development of the average age factor,

average tobacco factor and average benefit factor by county. Within each county, show the estimated

impact of favorable provider contracting. Ensure that all data and your in-depth analysis is submitted to

support the current and proposed factors.

Proposed geographic pricing was developed consistent with prior pricing. We looked at each

rating area as a whole rather than specific county-level data in determining the factors.

42. For calendar years 2016, 2017 and 2018, please provide the actual unit cost experience data by county

by benefit category (inpatient, outpatient, physician surgery, physician radiology, etc.) to support the

proposed changes. UPMC must provide data and discussion at the level of detail necessary for the

department or its consultant, to independently calculate and verify all proposed adjustments.

Proposed geographic pricing was developed consistent with prior pricing. We looked at each

rating area as a whole rather than specific category-level data in determining the factors.

43. Please fully demonstrate how new data and recent provider contracting has developed the proposed

factors, whether changes are proposed for the geographic factors or not. Please provide the full details of

the providers that were renegotiated and their total percent of claims in each county.

Provider contract negotiations happen at all different timeframes and not all are finalized for

2020 at this point. The factors we used represent our best estimate for when they are finalized.

44. Please describe and quantitatively demonstrate how the actual experience utilized in the Area Factor

Analysis was normalized for differences in morbidity between the counties shown.

Differences in contracted rates were the main basis for geographic factors rather than

experience period claims. This method inherently excludes morbidity.

45. Based on a review of Table 10 compared to the 2019 Table 10, there were 55 plans offered in 2019 and

there are now 39 offered in 2020. Please review and explain, excluding plans 37, 38 and 39, where the

plans were discontinued and the enrollees mapped.

In the 2019 version of Table 10, plans 40-55 are 2018 plans that were discontinued and mapped

to a 2019 plan. The mapped SCIDs are identified in column F of Table 10. Please note that each of

these plans also have DM listed in column E of Table 10. Since these plans were discontinued

prior to 2019, there is no reason for them to be included in the 2020 version of Table 10.

46. Appendix 1 indicates that a number of plans had benefit changes; however, the Pricing AVs did not

change. A few are listed below. For other plans, the Pricing AV changed but the plan design did not. Please

review and explain, changing as necessary.

16322PA0040008 16322PA0050100 16322PA0050104 16322PA0050111

16322PA0040040 16322PA0050101 16322PA0050105 16322PA0050112

16322PA0040044 16322PA0050102 16322PA0050108 16322PA0050119

16322PA0050030 16322PA0050103 16322PA0050111 16322PA0050120

In the templates we submitted, the Pricing AVs for all of these plans changed, before rounding.

We refreshed the base data for UPMC's pricing tool, and all AVs were recalculated.

Please be advised that there may be additional questions based on the responses to the above.

Response to this request should be provided via SERFF in Microsoft Excel spreadsheets (version 2013 or

less). Please retain all formulas.

Should you have any questions regarding this correspondence, please contact Cherri Sanders-Jones at (717)

787-5172 or me at (717) 783-0646.

.

Sincerely,

Mike Anstead


Bureau of Accident & Health Insurance

Exhibit 6: Derivation of Trend from Prior Filing using New Method

Entire Fully Insured Block

Base Data Trend Output Trend Adjustment Factor 1.01

Service Category 2017 Allowed Amt Weight Cost Utilization Overall Adj Cost Adj Util Overall

UTILIZATION Inpatient Hospital $247,133,090 18.4% 7.44% 0.20% 7.65% 8.12% 0.82% 9.01%

YEAR ALLOWED AMT ADMIT CNT ENROLLMENT Unit Cost PTPM Outpatient Hospital $443,527,177 28.1% 2.29% 0.47% 2.77% 2.93% 1.10% 4.06%

2016 $211,225,400 15,964 3,135,102 $13,231.36 61.1 Professional $303,594,056 20.3% 1.62% -0.89% 0.72% 2.25% -0.27% 1.98%

2017 $247,133,090 17,384 3,407,249 $14,216.12 61.2 Other Medical $149,327,660 11.0% 7.60% 6.61% 14.72% 8.28% 7.28% 16.16%

Prescription Drugs $341,169,952 22.3% 8.46% -0.18% 8.27% 9.14% 0.45% 9.63%

UTILIZATION Historical Annual Trend 5.88% Annual Trend Applied 7.21%

YEAR ALLOWED AMT SERVICE CNT ENROLLMENT Unit Cost PTPM2016 $397,104,676 991,599 3,135,102 $400.47 3,795.5 Check 7.21%

2017 $443,527,177 1,082,739 3,407,249 $409.63 3,813.3

UTILIZATION

YEAR ALLOWED AMT SERVICE CNT ENROLLMENT Unit Cost ADMIT PTPM2016 $277,361,249 3,324,528 3,135,102 $83.43 12,725.1

2017 $303,594,056 3,581,067 3,407,249 $84.78 12,612.2

UTILIZATION

YEAR ALLOWED AMT SERVICE CNT ENROLLMENT Unit Cost PTPM2016 $119,774,806 72,156 3,135,102 $1,659.94 276.2

2017 $149,327,660 83,603 3,407,249 $1,786.15 294.4

UTILIZATION

YEAR ALLOWED AMT Prescriptions ENROLLMENT Unit Cost PTPM2016 $289,944,004 2,755,880 3,135,102 $105.21 10,548.5

2017 $341,169,952 2,989,831 3,407,249 $114.11 10,529.9

Inpatient Hospital

Outpatient Hospital

Professional

Other Medical

Prescription Drugs

Exhibit 14: Derivation of Exchange User Fee

Exchange StatusCurrent/Projected

Enrollment Distribution

Exchange

Fee

Weighted

Exch Fee

Off Exchange 27.7% 0.0% 0.0%

On Exchange 72.3% 3.0% 2.2%

Total 100.0% 2.2%

Projected Required Revenue PMPM: 547.83$

Projected Paid Exchange User Fees PMPM: 11.89$

Exhibit 34bviii: Historical Data for Trend Development

**2019 data has been extrapolated to cover 12 months

Service Category Year Member_Months Allowed Amt Service Cnt Unit Cost Utilization PTPM Cost Utilization Overall

Inpatient Hospital 2016 1,322,678 109,384,049$ 7,994 13,683.27$ 72.53

Inpatient Hospital 2017 1,644,192 130,089,654$ 9,402 13,836.38$ 68.62 1.12% -5.39% -4.33%

Inpatient Hospital 2018 1,627,833 158,672,808$ 9,308 17,046.93$ 68.62 23.20% 0.00% 23.20%

Inpatient Hospital 2019 1,562,528 139,663,949$ 8,768 15,928.83$ 67.34 -6.56% -1.86% -8.30%

Outpatient Hospital 2016 1,322,678 160,265,260$ 433,329 369.85$ 3931.38

Outpatient Hospital 2017 1,644,192 196,838,173$ 535,797 367.37$ 3910.47 -0.67% -0.53% -1.20%

Outpatient Hospital 2018 1,627,833 206,633,932$ 533,720 387.16$ 3934.46 5.39% 0.61% 6.03%

Outpatient Hospital 2019 1,562,528 194,988,385$ 498,056 391.50$ 3825.00 1.12% -2.78% -1.69%

Professional 2016 1,322,678 115,155,031$ 1,364,599 84.39$ 12380.33

Professional 2017 1,644,192 140,642,186$ 1,664,656 84.49$ 12149.35 0.12% -1.87% -1.75%

Professional 2018 1,627,833 144,018,327$ 1,668,869 86.30$ 12302.51 2.14% 1.26% 3.43%

Professional 2019 1,562,528 136,950,990$ 1,606,664 85.24$ 12338.96 -1.23% 0.30% -0.93%

Other Medical 2016 1,322,678 59,932,376$ 43,153 1,388.83$ 391.51

Other Medical 2017 1,644,192 75,343,777$ 51,104 1,474.32$ 372.98 6.16% -4.73% 1.13%

Other Medical 2018 1,627,833 94,012,048$ 52,674 1,784.79$ 388.30 21.06% 4.11% 26.03%

Other Medical 2019 1,562,528 91,261,148$ 50,408 1,810.45$ 387.13 1.44% -0.30% 1.13%

Prescription Drugs 2016 1,322,678 112,943,039$ 1,333,058 84.72$ 12094.17

Prescription Drugs 2017 1,644,192 152,986,803$ 1,683,584 90.87$ 12287.50 7.25% 1.60% 8.97%


Prescription Drugs 2019 1,562,528 147,859,571$ 1,553,912 95.15$ 11933.83 -2.12% -3.62% -5.67%

Exhibit 36c: Derivation of Tobacco Calibration Factor

Tobacco

Status

Current/Projected

Enrollment

Distribution

Tobacco

Factor

Calibration

Factor

Non-User 91.3% 1.000 0.913

User 8.7% 1.025 0.089

Total 100.0% 1.002

Exhibit 38: Actual and Projected Claims Costs

YearProjected Paid

Claims PMPM

Actual Paid

Claims PMPM

2015 256.31$ 343.82$

2016 364.45$ 363.52$

2017 312.86$ 347.45$

2018 380.19$ 411.98$

Exhibit 39: Historical Financial Data

YearTotal Member

Months

Total

Administrative

Expenses

Total Incurred

Claims

Total Paid Taxes

and FeesTotal Premium Profit

Annual Underwriting

Gain/Loss

Underwriting

Gain/Loss PMPY

2014 n/a n/a n/a n/a n/a n/a n/a n/a

2015 631,403 $26,463,956 $209,959,859 -$403,522 $208,375,563 -$27,644,730 -$1,584,296 -$30

2016 1,326,271 $49,482,400 $409,504,210 -$224,978 $385,724,585 -$73,037,047 -$23,779,626 -$215

2017 1,644,940 $69,826,658 $582,154,576 $1,859,154 $649,904,950 -$3,935,437 $67,750,374 $494

2018 1,630,008 $89,053,379 $681,364,866 $14,535,640 $775,607,681 -$9,346,204 $94,242,815 $694

Dear Mr. Lovely:



we request this information be provided within 7 days of the date of this letter. If you have any questions or

difficulties in providing the information within this time frame, please call me.




1. From the June 25 Responses to Questions 15, 24, 28, and 39: “Did the certifying actuary rely on any

information or assumptions provided by another individual? If so, please specify and provide reliance

statements.” Your responses to these questions demonstrate that you may be relying upon material

information from the Finance department and that you are aware of the ASOP 41 requirements regarding

Reliance. Please provide the required disclosures for this rate filing per ASOP 41.

The reliance statement has been uploaded in the Supporting Documentation section in SERFF.

2. From the June 25 Responses to Question 18: “Pediatric Dental is administered and paid by Dominion

Dental. Please identify the fees paid to Dominion Dental on a PMPM basis. Is this fee paid on a capitation

basis or on a fee for service basis?” Your response indicates that Pediatric Dental is provided via a

capitation. Please correct rate filing materials and templates to reflect the capitation.

Rate filing materials and templates have been updated to reflect the capitation.

3. From the June 25 Responses to Question 19: “Please explain why the silver plans have a lower induced

demand factor than the bronze plans. Please explain why this is expected to continue in 2020.” Your

response indicates that this was allowed for Plan Year 2019. Please justify this relationship for Plan Year

2020.

The induced demand factors for Silver and Bronze as submitted have remained static through our

prior year filings. In the absence of any basis by which to anticipate different market behavior in

induced demand for 2020, we have elected to maintain these values as originally adopted a

number of years ago.

4. From the June 25 Responses to Questions 21, 22, 23, 40, and 41: Please provide a comprehensive

explanation of how changes in provider contracting impacted (or why it did not impact) trend, network

factors, and geographic factors.

While early estimates from our Reimbursement team have included a guarded estimate of

stability, we note that a number of our 2020 provider contracts are not final. As such, while we

do not currently anticipate a material deviation from the trend in prior year contract rates, we

cannot yet rule this out. In the absence of evidence to the contrary, we have initially

incorporated provider contracting as a stable element of factor development.

5. From the June 25 Responses to Question 23: “For calendar years 2016, 2017 and 2018, please provide

the actual unit cost experience data by network by benefit category (inpatient, outpatient, physician

surgery, physician radiology, etc.) to support the proposed changes. UPMC must provide data and discussion

at the level of detail necessary for the department or its consultant, to independently calculate and verify all

proposed adjustments.” We apologize if this question was unclear, but we are actually asking for 3-years of

actual experience of unit cost trends. Please provide quantitative support for your factors at a level of detail

necessary for independent verification of all proposed adjustments.

Please see exhibit 5 of the response exhibits for this information. Please let us know if anything

additional is needed.

6. From the June 25 Responses to Question 28: “Regarding Table 6: a) Using the submitted commission

schedules, quantitatively show the development of the percent and PMPM amounts in cells C51 and D51. b)

Using the 2018 SHCE in the Annual Statement, please quantitatively show the development of the Quality

Improvement Initiatives percent and pmpm amount.” Provide quantitative justification for these amounts

and fully explain the adjustments decided upon based upon Finance department correspondence.

The values for both the Quality Improvement Initiatives and Commissions are directly based on

Finance Department estimates. A reliance statement to this effect has been submitted.

7. From the June 25 Responses to Question 31: “Were changes in health policy reserve taken into

consideration in the rate development.” Please discuss why the increase in health policy reserves of $27.0

million reported in your 2018 Annual Statement would not be considered in rate development.

Due to an accounting change, the estimate for ACA risk adjustment was placed in that field for

the first time in 2018. Since risk adjustment is already accounted for separately, no additional

consideration is needed. That number also includes a PDR for an unrelated product which is also

not a point of consideration for the rate development of this filing.

8. From the June 25 response to questions 41 and 42, you indicated that UPMC reviewed each rating area as

a whole rather than specific county-level data in determining the geographic factors. Please provide the

requested data by rating area. Please be aware that the proposed factors cannot be approved without

detailed quantitative support.

The 2016-2018 data by rating area available in our data warehouse has been uploaded.

9. As requested, you have added the RA User Fees in Table 6. Please confirm that there was no offsetting

adjustments made elsewhere, as this fee was not included in the initial submission.

The RA User Fee was included in the original submission, in the Risk Adjustment row, Table 5,

"Projected Risk Adjustment PMPM" (so the PMPM was a net value, consistent with our

interpretation at the time). Now: the $0.18 user fee PMPM is reflected in Table 6 as requested,

and the table 5 PMPM is $0.18 higher because it no longer subtracts that fee. So, the revised

submission includes the fee, accounted for as requested; but the original submission also

included the fee, so there is no rate impact.

10. 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.

No adjustments were made for RADV as part of this filing.

11. In that the Department’s review authority requires rates to be adequate, not excessive or unfairly

discriminatory, please explain why you believe the rates to be adequate without an adjustment for the 3-

child maximum.

As part of this update, an adjustment accounting for the 3-child maximum has been incorporated

into the derivation of the age calibration factor as shown in exhibit 5 of the supporting exhibits.

12. 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.

No modifications were made to risk adjustment due to the projections being different than final

results.

13. Concerning your network and geographic factors, please provide in Excel your base period member

months, current membership, and projected member months for each network and geographic area. Also

please provide your non-normalized network and geographic factors for 2018, 2019 and 2020.

Please see exhibit 13 of the response exhibits for the requested data.

<Redacted>

Please be advised that there may be additional questions based on the responses to the above.



Should you have any questions regarding this correspondence, please contact me at (717) 787-5172.

Sincerely,

Cherri Sanders-Jones



Exhibit 5: Historical Data by Benefit Category

Service Category Year Member_Months Allowed Amt Service Cnt Unit Cost Utilization PTPM Cost Utilization Overall

Inpatient Hospital 2016 1,322,678 109,384,049$ 7,994 13,683.27$ 72.53

Inpatient Hospital 2017 1,644,192 130,089,654$ 9,402 13,836.38$ 68.62 1.12% -5.39% -4.33%

Inpatient Hospital 2018 1,627,833 158,672,808$ 9,308 17,046.93$ 68.62 23.20% 0.00% 23.20%

Outpatient Hospital 2016 1,322,678 160,265,260$ 433,329 369.85$ 3931.38

Outpatient Hospital 2017 1,644,192 196,838,173$ 535,797 367.37$ 3910.47 -0.67% -0.53% -1.20%

Outpatient Hospital 2018 1,627,833 206,633,932$ 533,720 387.16$ 3934.46 5.39% 0.61% 6.03%

Professional 2016 1,322,678 115,155,031$ 1,364,599 84.39$ 12380.33

Professional 2017 1,644,192 140,642,186$ 1,664,656 84.49$ 12149.35 0.12% -1.87% -1.75%

Professional 2018 1,627,833 144,018,327$ 1,668,869 86.30$ 12302.51 2.14% 1.26% 3.43%

Other Medical 2016 1,322,678 59,932,376$ 43,153 1,388.83$ 391.51

Other Medical 2017 1,644,192 75,343,777$ 51,104 1,474.32$ 372.98 6.16% -4.73% 1.13%

Other Medical 2018 1,627,833 94,012,048$ 52,674 1,784.79$ 388.30 21.06% 4.11% 26.03%

Prescription Drugs 2016 1,322,678 112,943,039$ 1,333,058 84.72$ 12094.17



Capitation 2016 1,322,678 1,203,637$ -

Capitation 2017 1,644,192 1,660,634$ -

Capitation 2018 1,627,833 993,000$ -

Exhibit 13: Data by Geographical Area and Network

Rating Area2018 Member

Months

Feb 2019

Members

2020 Projected

Member Months

2018 Non-

calibrated Factor

2019 Non-

calibrated Factor

2020 Non-

calibrated Factor

Rating Area 1 216,369 16,495 197,940 1.0000 1.0000 1.0000

Rating Area 2 19,578 1,565 18,780 1.0000 1.0000 1.0964

Rating Area 3 26,221 2,937 35,244 1.2633 1.2619 1.2619

Rating Area 4 1,094,384 88,135 1,057,620 1.0000 1.0000 1.0000

Rating Area 5 189,038 14,912 178,944 1.0000 1.0000 1.0000

Rating Area 6 37,452 2,684 32,208 1.0000 1.3468 1.3468

Rating Area 7 44,847 6,656 79,872 1.3659 1.3659 1.3659

Rating Area 8 - - - N/A N/A N/A

Rating Area 9 - 4,145 49,740 N/A 1.1960 1.1960

Network2018 Member

Months

Feb 2019

Members

2020 Projected

Member Months

2018 Non-

calibrated Factor

2019 Non-

calibrated Factor

2020 Non-

calibrated Factor

Premium Network 558,243 46,932 563,184 1.2876 1.2821 1.2821

Partner Network 593,103 50,344 604,128 1.0000 1.0000 1.0000

Select Network 431,667 35,984 431,808 1.0620 1.0564 1.0564

Tower Network 44,840 4,266 51,192 1.2876 1.2369 1.2369



we request this information be provided by July 18, 2019. If you have any questions, please call me.




1. From the June 25 Responses to Question 19 regarding the silver plans having a lower induced demand

factor than the bronze plans, your response indicates that this was allowed for Plan Year 2019. Please justify

this relationship for Plan Year 2020. The prior year approval doesn’t justify this.

Market behavior is only allowed to the extent that it is economically based not based on morbidity. We

consider the risk adjustment induced demand factors a “safe harbor”. Any factor larger than the risk

adjustment factors, will need significant support. It is irrelevant what was used in the past for your 2020

filings, which must stand on their own.

The factor for the bronze plans has been updated to match corresponding silver plans.

<Redacted>



Should you have any questions regarding this correspondence, please contact me at (717) 787-5172.

Sincerely,

Cherri Sanders-Jones



BlairCambria

HuntingdonWestmoreland

ClearfieldCentre

CumberlandLancaster

Lebanon

Dauphin

Schuylkill

Carbon

Cameron

York

Adams

Franklin

Juniata

Mifflin

Northumberland

Columbia

Montour

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

Wayne

Wyoming

2019 Service Area

Issuer: UPMC Health Options, Inc.

Market: Individual

Key (modify as needed)

: 2019 On-exchange service area

: 2019 Off-exchange service area

BlairCambria

HuntingdonWestmoreland

ClearfieldCentre

CumberlandLancaster

Lebanon

Dauphin

Schuylkill

Carbon

Cameron

York

Adams

Franklin

Juniata

Mifflin

Northumberland

Columbia

Montour

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

Wayne

Wyoming

2020 Service Area

Issuer: UPMC Health Options, Inc.

Market: Individual

Key (modify as needed)

: 2020 On-exchange service area

: 2020 Off-exchange service area

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