rate/rule schedule · 2016-10-17 · ppo-sm/wg-4, hdhp-sm/wg-4, conb/epo-sm/wg-1 new pa plan design...

Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Rate Tables HMK Small GroupoffX PDFs

PPO-SM/WG-4, HDHP-SM/WG-4, CONB/EPO-SM/WG-1

New RateTables_HMKSmall Group_offX1Q2017Final.pdf,RateTables_HMKSmall Group_offX2Q2017Final.pdf,RateTables_HMKSmall Group_offX3Q2017Final.pdf,RateTables_HMKSmall Group_offX4Q2017Final.pdf,

2 Plan Design Summary andRate Tables PDFs

PPO-SM/WG-4, HDHP-SM/WG-4, CONB/EPO-SM/WG-1

New PA Plan DesignSummary and RateTables HMK1Q2017Final.pdf, PAPlan Design Summaryand Rate Tables HMK2Q2017Final.pdf, PAPlan Design Summaryand Rate Tables HMK3Q2017Final.pdf, PAPlan Design Summaryand Rate Tables HMK4Q2017Final.pdf,

SERFF Tracking #: HGHM-130535904 State Tracking #: HGHM-130535904 Company Tracking #: 1A-SG-HIGHMARK-2016

State: Pennsylvania Filing Company: Highmark

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

Product Name: HIGHMARK Small Group 2017 ACA Rate Filing

Project Name/Number: HIGHMARK 2017 ACA Rate Filing/1A-SG-HIGHMARK-2016

PDF Pipeline for SERFF Tracking Number HGHM-130535904 Generated 10/14/2016 10:11 AM

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

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

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

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

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

HIOS Issuer ID* 33709Federal TIN* 23-1294723

Rate Effective Date* 01/01/2017Rate Expiration Date* 03/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

33709PA0560007 Rating Area 1 No Preference 0-20 225.4333709PA0560007 Rating Area 1 No Preference 21 355.0033709PA0560007 Rating Area 1 No Preference 22 355.0033709PA0560007 Rating Area 1 No Preference 23 355.0033709PA0560007 Rating Area 1 No Preference 24 355.0033709PA0560007 Rating Area 1 No Preference 25 356.4233709PA0560007 Rating Area 1 No Preference 26 363.5233709PA0560007 Rating Area 1 No Preference 27 372.0433709PA0560007 Rating Area 1 No Preference 28 385.8933709PA0560007 Rating Area 1 No Preference 29 397.2533709PA0560007 Rating Area 1 No Preference 30 402.9333709PA0560007 Rating Area 1 No Preference 31 411.4533709PA0560007 Rating Area 1 No Preference 32 419.9733709PA0560007 Rating Area 1 No Preference 33 425.2933709PA0560007 Rating Area 1 No Preference 34 430.9733709PA0560007 Rating Area 1 No Preference 35 433.8133709PA0560007 Rating Area 1 No Preference 36 436.6533709PA0560007 Rating Area 1 No Preference 37 439.4933709PA0560007 Rating Area 1 No Preference 38 442.3333709PA0560007 Rating Area 1 No Preference 39 448.0133709PA0560007 Rating Area 1 No Preference 40 453.6933709PA0560007 Rating Area 1 No Preference 41 462.2133709PA0560007 Rating Area 1 No Preference 42 470.3833709PA0560007 Rating Area 1 No Preference 43 481.7433709PA0560007 Rating Area 1 No Preference 44 495.9433709PA0560007 Rating Area 1 No Preference 45 512.6233709PA0560007 Rating Area 1 No Preference 46 532.5033709PA0560007 Rating Area 1 No Preference 47 554.8733709PA0560007 Rating Area 1 No Preference 48 580.4333709PA0560007 Rating Area 1 No Preference 49 605.6333709PA0560007 Rating Area 1 No Preference 50 634.0333709PA0560007 Rating Area 1 No Preference 51 662.0833709PA0560007 Rating Area 1 No Preference 52 692.9633709PA0560007 Rating Area 1 No Preference 53 724.2033709PA0560007 Rating Area 1 No Preference 54 757.9333709PA0560007 Rating Area 1 No Preference 55 791.6533709PA0560007 Rating Area 1 No Preference 56 828.2233709PA0560007 Rating Area 1 No Preference 57 865.1433709PA0560007 Rating Area 1 No Preference 58 904.5433709PA0560007 Rating Area 1 No Preference 59 924.0733709PA0560007 Rating Area 1 No Preference 60 963.4733709PA0560007 Rating Area 1 No Preference 61 997.5533709PA0560007 Rating Area 1 No Preference 62 1019.9233709PA0560007 Rating Area 1 No Preference 63 1047.9633709PA0560007 Rating Area 1 No Preference 64 1065.0033709PA0560007 Rating Area 1 No Preference 65 and over 1065.00



Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0560009 Rating Area 1 No Preference 0-20 221.6833709PA0560009 Rating Area 1 No Preference 21 349.1033709PA0560009 Rating Area 1 No Preference 22 349.1033709PA0560009 Rating Area 1 No Preference 23 349.1033709PA0560009 Rating Area 1 No Preference 24 349.1033709PA0560009 Rating Area 1 No Preference 25 350.5033709PA0560009 Rating Area 1 No Preference 26 357.4833709PA0560009 Rating Area 1 No Preference 27 365.8633709PA0560009 Rating Area 1 No Preference 28 379.4733709PA0560009 Rating Area 1 No Preference 29 390.6533709PA0560009 Rating Area 1 No Preference 30 396.2333709PA0560009 Rating Area 1 No Preference 31 404.6133709PA0560009 Rating Area 1 No Preference 32 412.9933709PA0560009 Rating Area 1 No Preference 33 418.2333709PA0560009 Rating Area 1 No Preference 34 423.8133709PA0560009 Rating Area 1 No Preference 35 426.6033709PA0560009 Rating Area 1 No Preference 36 429.4033709PA0560009 Rating Area 1 No Preference 37 432.1933709PA0560009 Rating Area 1 No Preference 38 434.9833709PA0560009 Rating Area 1 No Preference 39 440.5733709PA0560009 Rating Area 1 No Preference 40 446.1533709PA0560009 Rating Area 1 No Preference 41 454.5333709PA0560009 Rating Area 1 No Preference 42 462.5633709PA0560009 Rating Area 1 No Preference 43 473.7333709PA0560009 Rating Area 1 No Preference 44 487.7033709PA0560009 Rating Area 1 No Preference 45 504.1033709PA0560009 Rating Area 1 No Preference 46 523.6533709PA0560009 Rating Area 1 No Preference 47 545.6533709PA0560009 Rating Area 1 No Preference 48 570.7833709PA0560009 Rating Area 1 No Preference 49 595.5733709PA0560009 Rating Area 1 No Preference 50 623.5033709PA0560009 Rating Area 1 No Preference 51 651.0833709PA0560009 Rating Area 1 No Preference 52 681.4533709PA0560009 Rating Area 1 No Preference 53 712.1733709PA0560009 Rating Area 1 No Preference 54 745.3333709PA0560009 Rating Area 1 No Preference 55 778.5033709PA0560009 Rating Area 1 No Preference 56 814.4633709PA0560009 Rating Area 1 No Preference 57 850.7633709PA0560009 Rating Area 1 No Preference 58 889.5133709PA0560009 Rating Area 1 No Preference 59 908.7233709PA0560009 Rating Area 1 No Preference 60 947.4733709PA0560009 Rating Area 1 No Preference 61 980.9833709PA0560009 Rating Area 1 No Preference 62 1002.9733709PA0560009 Rating Area 1 No Preference 63 1030.5533709PA0560009 Rating Area 1 No Preference 64 1047.3033709PA0560009 Rating Area 1 No Preference 65 and over 1047.3033709PA0560009 Rating Area 4 No Preference 0-20 221.6833709PA0560009 Rating Area 4 No Preference 21 349.1033709PA0560009 Rating Area 4 No Preference 22 349.1033709PA0560009 Rating Area 4 No Preference 23 349.1033709PA0560009 Rating Area 4 No Preference 24 349.1033709PA0560009 Rating Area 4 No Preference 25 350.5033709PA0560009 Rating Area 4 No Preference 26 357.4833709PA0560009 Rating Area 4 No Preference 27 365.8633709PA0560009 Rating Area 4 No Preference 28 379.4733709PA0560009 Rating Area 4 No Preference 29 390.6533709PA0560009 Rating Area 4 No Preference 30 396.2333709PA0560009 Rating Area 4 No Preference 31 404.6133709PA0560009 Rating Area 4 No Preference 32 412.9933709PA0560009 Rating Area 4 No Preference 33 418.2333709PA0560009 Rating Area 4 No Preference 34 423.8133709PA0560009 Rating Area 4 No Preference 35 426.6033709PA0560009 Rating Area 4 No Preference 36 429.4033709PA0560009 Rating Area 4 No Preference 37 432.1933709PA0560009 Rating Area 4 No Preference 38 434.9833709PA0560009 Rating Area 4 No Preference 39 440.5733709PA0560009 Rating Area 4 No Preference 40 446.1533709PA0560009 Rating Area 4 No Preference 41 454.5333709PA0560009 Rating Area 4 No Preference 42 462.5633709PA0560009 Rating Area 4 No Preference 43 473.7333709PA0560009 Rating Area 4 No Preference 44 487.7033709PA0560009 Rating Area 4 No Preference 45 504.1033709PA0560009 Rating Area 4 No Preference 46 523.6533709PA0560009 Rating Area 4 No Preference 47 545.6533709PA0560009 Rating Area 4 No Preference 48 570.7833709PA0560009 Rating Area 4 No Preference 49 595.5733709PA0560009 Rating Area 4 No Preference 50 623.5033709PA0560009 Rating Area 4 No Preference 51 651.0833709PA0560009 Rating Area 4 No Preference 52 681.4533709PA0560009 Rating Area 4 No Preference 53 712.1733709PA0560009 Rating Area 4 No Preference 54 745.3333709PA0560009 Rating Area 4 No Preference 55 778.5033709PA0560009 Rating Area 4 No Preference 56 814.4633709PA0560009 Rating Area 4 No Preference 57 850.7633709PA0560009 Rating Area 4 No Preference 58 889.5133709PA0560009 Rating Area 4 No Preference 59 908.7233709PA0560009 Rating Area 4 No Preference 60 947.4733709PA0560009 Rating Area 4 No Preference 61 980.9833709PA0560009 Rating Area 4 No Preference 62 1002.9733709PA0560009 Rating Area 4 No Preference 63 1030.5533709PA0560009 Rating Area 4 No Preference 64 1047.3033709PA0560009 Rating Area 4 No Preference 65 and over 1047.3033709PA0560011 Rating Area 1 No Preference 0-20 190.8833709PA0560011 Rating Area 1 No Preference 21 300.5933709PA0560011 Rating Area 1 No Preference 22 300.5933709PA0560011 Rating Area 1 No Preference 23 300.5933709PA0560011 Rating Area 1 No Preference 24 300.5933709PA0560011 Rating Area 1 No Preference 25 301.8033709PA0560011 Rating Area 1 No Preference 26 307.8133709PA0560011 Rating Area 1 No Preference 27 315.0233709PA0560011 Rating Area 1 No Preference 28 326.7433709PA0560011 Rating Area 1 No Preference 29 336.3633709PA0560011 Rating Area 1 No Preference 30 341.1733709PA0560011 Rating Area 1 No Preference 31 348.39


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0560011 Rating Area 1 No Preference 32 355.6033709PA0560011 Rating Area 1 No Preference 33 360.1133709PA0560011 Rating Area 1 No Preference 34 364.9233709PA0560011 Rating Area 1 No Preference 35 367.3333709PA0560011 Rating Area 1 No Preference 36 369.7333709PA0560011 Rating Area 1 No Preference 37 372.1333709PA0560011 Rating Area 1 No Preference 38 374.5433709PA0560011 Rating Area 1 No Preference 39 379.3533709PA0560011 Rating Area 1 No Preference 40 384.1633709PA0560011 Rating Area 1 No Preference 41 391.3733709PA0560011 Rating Area 1 No Preference 42 398.2933709PA0560011 Rating Area 1 No Preference 43 407.9133709PA0560011 Rating Area 1 No Preference 44 419.9333709PA0560011 Rating Area 1 No Preference 45 434.0633709PA0560011 Rating Area 1 No Preference 46 450.8933709PA0560011 Rating Area 1 No Preference 47 469.8333709PA0560011 Rating Area 1 No Preference 48 491.4733709PA0560011 Rating Area 1 No Preference 49 512.8133709PA0560011 Rating Area 1 No Preference 50 536.8633709PA0560011 Rating Area 1 No Preference 51 560.6133709PA0560011 Rating Area 1 No Preference 52 586.7633709PA0560011 Rating Area 1 No Preference 53 613.2133709PA0560011 Rating Area 1 No Preference 54 641.7733709PA0560011 Rating Area 1 No Preference 55 670.3233709PA0560011 Rating Area 1 No Preference 56 701.2833709PA0560011 Rating Area 1 No Preference 57 732.5533709PA0560011 Rating Area 1 No Preference 58 765.9133709PA0560011 Rating Area 1 No Preference 59 782.4433709PA0560011 Rating Area 1 No Preference 60 815.8133709PA0560011 Rating Area 1 No Preference 61 844.6733709PA0560011 Rating Area 1 No Preference 62 863.6033709PA0560011 Rating Area 1 No Preference 63 887.3533709PA0560011 Rating Area 1 No Preference 64 901.7733709PA0560011 Rating Area 1 No Preference 65 and over 901.7733709PA0560011 Rating Area 4 No Preference 0-20 190.8833709PA0560011 Rating Area 4 No Preference 21 300.5933709PA0560011 Rating Area 4 No Preference 22 300.5933709PA0560011 Rating Area 4 No Preference 23 300.5933709PA0560011 Rating Area 4 No Preference 24 300.5933709PA0560011 Rating Area 4 No Preference 25 301.8033709PA0560011 Rating Area 4 No Preference 26 307.8133709PA0560011 Rating Area 4 No Preference 27 315.0233709PA0560011 Rating Area 4 No Preference 28 326.7433709PA0560011 Rating Area 4 No Preference 29 336.3633709PA0560011 Rating Area 4 No Preference 30 341.1733709PA0560011 Rating Area 4 No Preference 31 348.3933709PA0560011 Rating Area 4 No Preference 32 355.6033709PA0560011 Rating Area 4 No Preference 33 360.1133709PA0560011 Rating Area 4 No Preference 34 364.9233709PA0560011 Rating Area 4 No Preference 35 367.3333709PA0560011 Rating Area 4 No Preference 36 369.7333709PA0560011 Rating Area 4 No Preference 37 372.1333709PA0560011 Rating Area 4 No Preference 38 374.5433709PA0560011 Rating Area 4 No Preference 39 379.3533709PA0560011 Rating Area 4 No Preference 40 384.1633709PA0560011 Rating Area 4 No Preference 41 391.3733709PA0560011 Rating Area 4 No Preference 42 398.2933709PA0560011 Rating Area 4 No Preference 43 407.9133709PA0560011 Rating Area 4 No Preference 44 419.9333709PA0560011 Rating Area 4 No Preference 45 434.0633709PA0560011 Rating Area 4 No Preference 46 450.8933709PA0560011 Rating Area 4 No Preference 47 469.8333709PA0560011 Rating Area 4 No Preference 48 491.4733709PA0560011 Rating Area 4 No Preference 49 512.8133709PA0560011 Rating Area 4 No Preference 50 536.8633709PA0560011 Rating Area 4 No Preference 51 560.6133709PA0560011 Rating Area 4 No Preference 52 586.7633709PA0560011 Rating Area 4 No Preference 53 613.2133709PA0560011 Rating Area 4 No Preference 54 641.7733709PA0560011 Rating Area 4 No Preference 55 670.3233709PA0560011 Rating Area 4 No Preference 56 701.2833709PA0560011 Rating Area 4 No Preference 57 732.5533709PA0560011 Rating Area 4 No Preference 58 765.9133709PA0560011 Rating Area 4 No Preference 59 782.4433709PA0560011 Rating Area 4 No Preference 60 815.8133709PA0560011 Rating Area 4 No Preference 61 844.6733709PA0560011 Rating Area 4 No Preference 62 863.6033709PA0560011 Rating Area 4 No Preference 63 887.3533709PA0560011 Rating Area 4 No Preference 64 901.7733709PA0560011 Rating Area 4 No Preference 65 and over 901.7733709PA0560013 Rating Area 1 No Preference 0-20 193.5733709PA0560013 Rating Area 1 No Preference 21 304.8433709PA0560013 Rating Area 1 No Preference 22 304.8433709PA0560013 Rating Area 1 No Preference 23 304.8433709PA0560013 Rating Area 1 No Preference 24 304.8433709PA0560013 Rating Area 1 No Preference 25 306.0633709PA0560013 Rating Area 1 No Preference 26 312.1633709PA0560013 Rating Area 1 No Preference 27 319.4733709PA0560013 Rating Area 1 No Preference 28 331.3633709PA0560013 Rating Area 1 No Preference 29 341.1233709PA0560013 Rating Area 1 No Preference 30 346.0033709PA0560013 Rating Area 1 No Preference 31 353.3133709PA0560013 Rating Area 1 No Preference 32 360.6333709PA0560013 Rating Area 1 No Preference 33 365.2033709PA0560013 Rating Area 1 No Preference 34 370.0833709PA0560013 Rating Area 1 No Preference 35 372.5233709PA0560013 Rating Area 1 No Preference 36 374.9633709PA0560013 Rating Area 1 No Preference 37 377.3933709PA0560013 Rating Area 1 No Preference 38 379.8333709PA0560013 Rating Area 1 No Preference 39 384.7133709PA0560013 Rating Area 1 No Preference 40 389.5933709PA0560013 Rating Area 1 No Preference 41 396.9033709PA0560013 Rating Area 1 No Preference 42 403.9233709PA0560013 Rating Area 1 No Preference 43 413.67


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0560013 Rating Area 1 No Preference 44 425.8633709PA0560013 Rating Area 1 No Preference 45 440.1933709PA0560013 Rating Area 1 No Preference 46 457.2633709PA0560013 Rating Area 1 No Preference 47 476.4733709PA0560013 Rating Area 1 No Preference 48 498.4233709PA0560013 Rating Area 1 No Preference 49 520.0633709PA0560013 Rating Area 1 No Preference 50 544.4533709PA0560013 Rating Area 1 No Preference 51 568.5333709PA0560013 Rating Area 1 No Preference 52 595.0533709PA0560013 Rating Area 1 No Preference 53 621.8833709PA0560013 Rating Area 1 No Preference 54 650.8433709PA0560013 Rating Area 1 No Preference 55 679.8033709PA0560013 Rating Area 1 No Preference 56 711.2033709PA0560013 Rating Area 1 No Preference 57 742.9033709PA0560013 Rating Area 1 No Preference 58 776.7433709PA0560013 Rating Area 1 No Preference 59 793.5033709PA0560013 Rating Area 1 No Preference 60 827.3433709PA0560013 Rating Area 1 No Preference 61 856.6133709PA0560013 Rating Area 1 No Preference 62 875.8133709PA0560013 Rating Area 1 No Preference 63 899.8933709PA0560013 Rating Area 1 No Preference 64 914.5233709PA0560013 Rating Area 1 No Preference 65 and over 914.5233709PA0560013 Rating Area 4 No Preference 0-20 193.5733709PA0560013 Rating Area 4 No Preference 21 304.8433709PA0560013 Rating Area 4 No Preference 22 304.8433709PA0560013 Rating Area 4 No Preference 23 304.8433709PA0560013 Rating Area 4 No Preference 24 304.8433709PA0560013 Rating Area 4 No Preference 25 306.0633709PA0560013 Rating Area 4 No Preference 26 312.1633709PA0560013 Rating Area 4 No Preference 27 319.4733709PA0560013 Rating Area 4 No Preference 28 331.3633709PA0560013 Rating Area 4 No Preference 29 341.1233709PA0560013 Rating Area 4 No Preference 30 346.0033709PA0560013 Rating Area 4 No Preference 31 353.3133709PA0560013 Rating Area 4 No Preference 32 360.6333709PA0560013 Rating Area 4 No Preference 33 365.2033709PA0560013 Rating Area 4 No Preference 34 370.0833709PA0560013 Rating Area 4 No Preference 35 372.5233709PA0560013 Rating Area 4 No Preference 36 374.9633709PA0560013 Rating Area 4 No Preference 37 377.3933709PA0560013 Rating Area 4 No Preference 38 379.8333709PA0560013 Rating Area 4 No Preference 39 384.7133709PA0560013 Rating Area 4 No Preference 40 389.5933709PA0560013 Rating Area 4 No Preference 41 396.9033709PA0560013 Rating Area 4 No Preference 42 403.9233709PA0560013 Rating Area 4 No Preference 43 413.6733709PA0560013 Rating Area 4 No Preference 44 425.8633709PA0560013 Rating Area 4 No Preference 45 440.1933709PA0560013 Rating Area 4 No Preference 46 457.2633709PA0560013 Rating Area 4 No Preference 47 476.4733709PA0560013 Rating Area 4 No Preference 48 498.4233709PA0560013 Rating Area 4 No Preference 49 520.0633709PA0560013 Rating Area 4 No Preference 50 544.4533709PA0560013 Rating Area 4 No Preference 51 568.5333709PA0560013 Rating Area 4 No Preference 52 595.0533709PA0560013 Rating Area 4 No Preference 53 621.8833709PA0560013 Rating Area 4 No Preference 54 650.8433709PA0560013 Rating Area 4 No Preference 55 679.8033709PA0560013 Rating Area 4 No Preference 56 711.2033709PA0560013 Rating Area 4 No Preference 57 742.9033709PA0560013 Rating Area 4 No Preference 58 776.7433709PA0560013 Rating Area 4 No Preference 59 793.5033709PA0560013 Rating Area 4 No Preference 60 827.3433709PA0560013 Rating Area 4 No Preference 61 856.6133709PA0560013 Rating Area 4 No Preference 62 875.8133709PA0560013 Rating Area 4 No Preference 63 899.8933709PA0560013 Rating Area 4 No Preference 64 914.5233709PA0560013 Rating Area 4 No Preference 65 and over 914.5233709PA0560015 Rating Area 1 No Preference 0-20 189.3933709PA0560015 Rating Area 1 No Preference 21 298.2533709PA0560015 Rating Area 1 No Preference 22 298.2533709PA0560015 Rating Area 1 No Preference 23 298.2533709PA0560015 Rating Area 1 No Preference 24 298.2533709PA0560015 Rating Area 1 No Preference 25 299.4433709PA0560015 Rating Area 1 No Preference 26 305.4033709PA0560015 Rating Area 1 No Preference 27 312.5633709PA0560015 Rating Area 1 No Preference 28 324.1933709PA0560015 Rating Area 1 No Preference 29 333.7433709PA0560015 Rating Area 1 No Preference 30 338.5133709PA0560015 Rating Area 1 No Preference 31 345.6733709PA0560015 Rating Area 1 No Preference 32 352.8233709PA0560015 Rating Area 1 No Preference 33 357.3033709PA0560015 Rating Area 1 No Preference 34 362.0733709PA0560015 Rating Area 1 No Preference 35 364.4633709PA0560015 Rating Area 1 No Preference 36 366.8433709PA0560015 Rating Area 1 No Preference 37 369.2333709PA0560015 Rating Area 1 No Preference 38 371.6133709PA0560015 Rating Area 1 No Preference 39 376.3933709PA0560015 Rating Area 1 No Preference 40 381.1633709PA0560015 Rating Area 1 No Preference 41 388.3233709PA0560015 Rating Area 1 No Preference 42 395.1833709PA0560015 Rating Area 1 No Preference 43 404.7233709PA0560015 Rating Area 1 No Preference 44 416.6533709PA0560015 Rating Area 1 No Preference 45 430.6733709PA0560015 Rating Area 1 No Preference 46 447.3733709PA0560015 Rating Area 1 No Preference 47 466.1633709PA0560015 Rating Area 1 No Preference 48 487.6333709PA0560015 Rating Area 1 No Preference 49 508.8133709PA0560015 Rating Area 1 No Preference 50 532.6733709PA0560015 Rating Area 1 No Preference 51 556.2333709PA0560015 Rating Area 1 No Preference 52 582.1833709PA0560015 Rating Area 1 No Preference 53 608.4233709PA0560015 Rating Area 1 No Preference 54 636.7533709PA0560015 Rating Area 1 No Preference 55 665.09


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0560015 Rating Area 1 No Preference 56 695.8133709PA0560015 Rating Area 1 No Preference 57 726.8333709PA0560015 Rating Area 1 No Preference 58 759.9333709PA0560015 Rating Area 1 No Preference 59 776.3333709PA0560015 Rating Area 1 No Preference 60 809.4433709PA0560015 Rating Area 1 No Preference 61 838.0733709PA0560015 Rating Area 1 No Preference 62 856.8633709PA0560015 Rating Area 1 No Preference 63 880.4233709PA0560015 Rating Area 1 No Preference 64 894.7433709PA0560015 Rating Area 1 No Preference 65 and over 894.7433709PA0560015 Rating Area 4 No Preference 0-20 189.3933709PA0560015 Rating Area 4 No Preference 21 298.2533709PA0560015 Rating Area 4 No Preference 22 298.2533709PA0560015 Rating Area 4 No Preference 23 298.2533709PA0560015 Rating Area 4 No Preference 24 298.2533709PA0560015 Rating Area 4 No Preference 25 299.4433709PA0560015 Rating Area 4 No Preference 26 305.4033709PA0560015 Rating Area 4 No Preference 27 312.5633709PA0560015 Rating Area 4 No Preference 28 324.1933709PA0560015 Rating Area 4 No Preference 29 333.7433709PA0560015 Rating Area 4 No Preference 30 338.5133709PA0560015 Rating Area 4 No Preference 31 345.6733709PA0560015 Rating Area 4 No Preference 32 352.8233709PA0560015 Rating Area 4 No Preference 33 357.3033709PA0560015 Rating Area 4 No Preference 34 362.0733709PA0560015 Rating Area 4 No Preference 35 364.4633709PA0560015 Rating Area 4 No Preference 36 366.8433709PA0560015 Rating Area 4 No Preference 37 369.2333709PA0560015 Rating Area 4 No Preference 38 371.6133709PA0560015 Rating Area 4 No Preference 39 376.3933709PA0560015 Rating Area 4 No Preference 40 381.1633709PA0560015 Rating Area 4 No Preference 41 388.3233709PA0560015 Rating Area 4 No Preference 42 395.1833709PA0560015 Rating Area 4 No Preference 43 404.7233709PA0560015 Rating Area 4 No Preference 44 416.6533709PA0560015 Rating Area 4 No Preference 45 430.6733709PA0560015 Rating Area 4 No Preference 46 447.3733709PA0560015 Rating Area 4 No Preference 47 466.1633709PA0560015 Rating Area 4 No Preference 48 487.6333709PA0560015 Rating Area 4 No Preference 49 508.8133709PA0560015 Rating Area 4 No Preference 50 532.6733709PA0560015 Rating Area 4 No Preference 51 556.2333709PA0560015 Rating Area 4 No Preference 52 582.1833709PA0560015 Rating Area 4 No Preference 53 608.4233709PA0560015 Rating Area 4 No Preference 54 636.7533709PA0560015 Rating Area 4 No Preference 55 665.0933709PA0560015 Rating Area 4 No Preference 56 695.8133709PA0560015 Rating Area 4 No Preference 57 726.8333709PA0560015 Rating Area 4 No Preference 58 759.9333709PA0560015 Rating Area 4 No Preference 59 776.3333709PA0560015 Rating Area 4 No Preference 60 809.4433709PA0560015 Rating Area 4 No Preference 61 838.0733709PA0560015 Rating Area 4 No Preference 62 856.8633709PA0560015 Rating Area 4 No Preference 63 880.4233709PA0560015 Rating Area 4 No Preference 64 894.7433709PA0560015 Rating Area 4 No Preference 65 and over 894.7433709PA0560017 Rating Area 1 No Preference 0-20 186.9733709PA0560017 Rating Area 1 No Preference 21 294.4333709PA0560017 Rating Area 1 No Preference 22 294.4333709PA0560017 Rating Area 1 No Preference 23 294.4333709PA0560017 Rating Area 1 No Preference 24 294.4333709PA0560017 Rating Area 1 No Preference 25 295.6133709PA0560017 Rating Area 1 No Preference 26 301.5033709PA0560017 Rating Area 1 No Preference 27 308.5733709PA0560017 Rating Area 1 No Preference 28 320.0533709PA0560017 Rating Area 1 No Preference 29 329.4733709PA0560017 Rating Area 1 No Preference 30 334.1833709PA0560017 Rating Area 1 No Preference 31 341.2533709PA0560017 Rating Area 1 No Preference 32 348.3233709PA0560017 Rating Area 1 No Preference 33 352.7333709PA0560017 Rating Area 1 No Preference 34 357.4433709PA0560017 Rating Area 1 No Preference 35 359.8033709PA0560017 Rating Area 1 No Preference 36 362.1533709PA0560017 Rating Area 1 No Preference 37 364.5133709PA0560017 Rating Area 1 No Preference 38 366.8633709PA0560017 Rating Area 1 No Preference 39 371.5833709PA0560017 Rating Area 1 No Preference 40 376.2933709PA0560017 Rating Area 1 No Preference 41 383.3533709PA0560017 Rating Area 1 No Preference 42 390.1233709PA0560017 Rating Area 1 No Preference 43 399.5533709PA0560017 Rating Area 1 No Preference 44 411.3233709PA0560017 Rating Area 1 No Preference 45 425.1633709PA0560017 Rating Area 1 No Preference 46 441.6533709PA0560017 Rating Area 1 No Preference 47 460.2033709PA0560017 Rating Area 1 No Preference 48 481.4033709PA0560017 Rating Area 1 No Preference 49 502.3033709PA0560017 Rating Area 1 No Preference 50 525.8633709PA0560017 Rating Area 1 No Preference 51 549.1233709PA0560017 Rating Area 1 No Preference 52 574.7333709PA0560017 Rating Area 1 No Preference 53 600.6433709PA0560017 Rating Area 1 No Preference 54 628.6233709PA0560017 Rating Area 1 No Preference 55 656.5933709PA0560017 Rating Area 1 No Preference 56 686.9133709PA0560017 Rating Area 1 No Preference 57 717.5433709PA0560017 Rating Area 1 No Preference 58 750.2233709PA0560017 Rating Area 1 No Preference 59 766.4133709PA0560017 Rating Area 1 No Preference 60 799.0933709PA0560017 Rating Area 1 No Preference 61 827.3633709PA0560017 Rating Area 1 No Preference 62 845.9133709PA0560017 Rating Area 1 No Preference 63 869.1733709PA0560017 Rating Area 1 No Preference 64 883.2933709PA0560017 Rating Area 1 No Preference 65 and over 883.2933709PA0560017 Rating Area 4 No Preference 0-20 186.9733709PA0560017 Rating Area 4 No Preference 21 294.43


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0560017 Rating Area 4 No Preference 22 294.4333709PA0560017 Rating Area 4 No Preference 23 294.4333709PA0560017 Rating Area 4 No Preference 24 294.4333709PA0560017 Rating Area 4 No Preference 25 295.6133709PA0560017 Rating Area 4 No Preference 26 301.5033709PA0560017 Rating Area 4 No Preference 27 308.5733709PA0560017 Rating Area 4 No Preference 28 320.0533709PA0560017 Rating Area 4 No Preference 29 329.4733709PA0560017 Rating Area 4 No Preference 30 334.1833709PA0560017 Rating Area 4 No Preference 31 341.2533709PA0560017 Rating Area 4 No Preference 32 348.3233709PA0560017 Rating Area 4 No Preference 33 352.7333709PA0560017 Rating Area 4 No Preference 34 357.4433709PA0560017 Rating Area 4 No Preference 35 359.8033709PA0560017 Rating Area 4 No Preference 36 362.1533709PA0560017 Rating Area 4 No Preference 37 364.5133709PA0560017 Rating Area 4 No Preference 38 366.8633709PA0560017 Rating Area 4 No Preference 39 371.5833709PA0560017 Rating Area 4 No Preference 40 376.2933709PA0560017 Rating Area 4 No Preference 41 383.3533709PA0560017 Rating Area 4 No Preference 42 390.1233709PA0560017 Rating Area 4 No Preference 43 399.5533709PA0560017 Rating Area 4 No Preference 44 411.3233709PA0560017 Rating Area 4 No Preference 45 425.1633709PA0560017 Rating Area 4 No Preference 46 441.6533709PA0560017 Rating Area 4 No Preference 47 460.2033709PA0560017 Rating Area 4 No Preference 48 481.4033709PA0560017 Rating Area 4 No Preference 49 502.3033709PA0560017 Rating Area 4 No Preference 50 525.8633709PA0560017 Rating Area 4 No Preference 51 549.1233709PA0560017 Rating Area 4 No Preference 52 574.7333709PA0560017 Rating Area 4 No Preference 53 600.6433709PA0560017 Rating Area 4 No Preference 54 628.6233709PA0560017 Rating Area 4 No Preference 55 656.5933709PA0560017 Rating Area 4 No Preference 56 686.9133709PA0560017 Rating Area 4 No Preference 57 717.5433709PA0560017 Rating Area 4 No Preference 58 750.2233709PA0560017 Rating Area 4 No Preference 59 766.4133709PA0560017 Rating Area 4 No Preference 60 799.0933709PA0560017 Rating Area 4 No Preference 61 827.3633709PA0560017 Rating Area 4 No Preference 62 845.9133709PA0560017 Rating Area 4 No Preference 63 869.1733709PA0560017 Rating Area 4 No Preference 64 883.2933709PA0560017 Rating Area 4 No Preference 65 and over 883.2933709PA0560019 Rating Area 1 No Preference 0-20 183.9633709PA0560019 Rating Area 1 No Preference 21 289.7033709PA0560019 Rating Area 1 No Preference 22 289.7033709PA0560019 Rating Area 1 No Preference 23 289.7033709PA0560019 Rating Area 1 No Preference 24 289.7033709PA0560019 Rating Area 1 No Preference 25 290.8633709PA0560019 Rating Area 1 No Preference 26 296.6533709PA0560019 Rating Area 1 No Preference 27 303.6133709PA0560019 Rating Area 1 No Preference 28 314.9033709PA0560019 Rating Area 1 No Preference 29 324.1733709PA0560019 Rating Area 1 No Preference 30 328.8133709PA0560019 Rating Area 1 No Preference 31 335.7633709PA0560019 Rating Area 1 No Preference 32 342.7233709PA0560019 Rating Area 1 No Preference 33 347.0633709PA0560019 Rating Area 1 No Preference 34 351.7033709PA0560019 Rating Area 1 No Preference 35 354.0133709PA0560019 Rating Area 1 No Preference 36 356.3333709PA0560019 Rating Area 1 No Preference 37 358.6533709PA0560019 Rating Area 1 No Preference 38 360.9733709PA0560019 Rating Area 1 No Preference 39 365.6033709PA0560019 Rating Area 1 No Preference 40 370.2433709PA0560019 Rating Area 1 No Preference 41 377.1933709PA0560019 Rating Area 1 No Preference 42 383.8533709PA0560019 Rating Area 1 No Preference 43 393.1233709PA0560019 Rating Area 1 No Preference 44 404.7133709PA0560019 Rating Area 1 No Preference 45 418.3333709PA0560019 Rating Area 1 No Preference 46 434.5533709PA0560019 Rating Area 1 No Preference 47 452.8033709PA0560019 Rating Area 1 No Preference 48 473.6633709PA0560019 Rating Area 1 No Preference 49 494.2333709PA0560019 Rating Area 1 No Preference 50 517.4033709PA0560019 Rating Area 1 No Preference 51 540.2933709PA0560019 Rating Area 1 No Preference 52 565.4933709PA0560019 Rating Area 1 No Preference 53 590.9933709PA0560019 Rating Area 1 No Preference 54 618.5133709PA0560019 Rating Area 1 No Preference 55 646.0333709PA0560019 Rating Area 1 No Preference 56 675.8733709PA0560019 Rating Area 1 No Preference 57 706.0033709PA0560019 Rating Area 1 No Preference 58 738.1633709PA0560019 Rating Area 1 No Preference 59 754.0933709PA0560019 Rating Area 1 No Preference 60 786.2533709PA0560019 Rating Area 1 No Preference 61 814.0633709PA0560019 Rating Area 1 No Preference 62 832.3133709PA0560019 Rating Area 1 No Preference 63 855.1933709PA0560019 Rating Area 1 No Preference 64 869.1033709PA0560019 Rating Area 1 No Preference 65 and over 869.1033709PA0560019 Rating Area 4 No Preference 0-20 183.9633709PA0560019 Rating Area 4 No Preference 21 289.7033709PA0560019 Rating Area 4 No Preference 22 289.7033709PA0560019 Rating Area 4 No Preference 23 289.7033709PA0560019 Rating Area 4 No Preference 24 289.7033709PA0560019 Rating Area 4 No Preference 25 290.8633709PA0560019 Rating Area 4 No Preference 26 296.6533709PA0560019 Rating Area 4 No Preference 27 303.6133709PA0560019 Rating Area 4 No Preference 28 314.9033709PA0560019 Rating Area 4 No Preference 29 324.1733709PA0560019 Rating Area 4 No Preference 30 328.8133709PA0560019 Rating Area 4 No Preference 31 335.7633709PA0560019 Rating Area 4 No Preference 32 342.7233709PA0560019 Rating Area 4 No Preference 33 347.06


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0560019 Rating Area 4 No Preference 34 351.7033709PA0560019 Rating Area 4 No Preference 35 354.0133709PA0560019 Rating Area 4 No Preference 36 356.3333709PA0560019 Rating Area 4 No Preference 37 358.6533709PA0560019 Rating Area 4 No Preference 38 360.9733709PA0560019 Rating Area 4 No Preference 39 365.6033709PA0560019 Rating Area 4 No Preference 40 370.2433709PA0560019 Rating Area 4 No Preference 41 377.1933709PA0560019 Rating Area 4 No Preference 42 383.8533709PA0560019 Rating Area 4 No Preference 43 393.1233709PA0560019 Rating Area 4 No Preference 44 404.7133709PA0560019 Rating Area 4 No Preference 45 418.3333709PA0560019 Rating Area 4 No Preference 46 434.5533709PA0560019 Rating Area 4 No Preference 47 452.8033709PA0560019 Rating Area 4 No Preference 48 473.6633709PA0560019 Rating Area 4 No Preference 49 494.2333709PA0560019 Rating Area 4 No Preference 50 517.4033709PA0560019 Rating Area 4 No Preference 51 540.2933709PA0560019 Rating Area 4 No Preference 52 565.4933709PA0560019 Rating Area 4 No Preference 53 590.9933709PA0560019 Rating Area 4 No Preference 54 618.5133709PA0560019 Rating Area 4 No Preference 55 646.0333709PA0560019 Rating Area 4 No Preference 56 675.8733709PA0560019 Rating Area 4 No Preference 57 706.0033709PA0560019 Rating Area 4 No Preference 58 738.1633709PA0560019 Rating Area 4 No Preference 59 754.0933709PA0560019 Rating Area 4 No Preference 60 786.2533709PA0560019 Rating Area 4 No Preference 61 814.0633709PA0560019 Rating Area 4 No Preference 62 832.3133709PA0560019 Rating Area 4 No Preference 63 855.1933709PA0560019 Rating Area 4 No Preference 64 869.1033709PA0560019 Rating Area 4 No Preference 65 and over 869.1033709PA0560021 Rating Area 1 No Preference 0-20 182.5233709PA0560021 Rating Area 1 No Preference 21 287.4333709PA0560021 Rating Area 1 No Preference 22 287.4333709PA0560021 Rating Area 1 No Preference 23 287.4333709PA0560021 Rating Area 1 No Preference 24 287.4333709PA0560021 Rating Area 1 No Preference 25 288.5833709PA0560021 Rating Area 1 No Preference 26 294.3333709PA0560021 Rating Area 1 No Preference 27 301.2333709PA0560021 Rating Area 1 No Preference 28 312.4433709PA0560021 Rating Area 1 No Preference 29 321.6333709PA0560021 Rating Area 1 No Preference 30 326.2333709PA0560021 Rating Area 1 No Preference 31 333.1333709PA0560021 Rating Area 1 No Preference 32 340.0333709PA0560021 Rating Area 1 No Preference 33 344.3433709PA0560021 Rating Area 1 No Preference 34 348.9433709PA0560021 Rating Area 1 No Preference 35 351.2433709PA0560021 Rating Area 1 No Preference 36 353.5433709PA0560021 Rating Area 1 No Preference 37 355.8433709PA0560021 Rating Area 1 No Preference 38 358.1433709PA0560021 Rating Area 1 No Preference 39 362.7433709PA0560021 Rating Area 1 No Preference 40 367.3433709PA0560021 Rating Area 1 No Preference 41 374.2333709PA0560021 Rating Area 1 No Preference 42 380.8533709PA0560021 Rating Area 1 No Preference 43 390.0433709PA0560021 Rating Area 1 No Preference 44 401.5433709PA0560021 Rating Area 1 No Preference 45 415.0533709PA0560021 Rating Area 1 No Preference 46 431.1533709PA0560021 Rating Area 1 No Preference 47 449.2533709PA0560021 Rating Area 1 No Preference 48 469.9533709PA0560021 Rating Area 1 No Preference 49 490.3633709PA0560021 Rating Area 1 No Preference 50 513.3533709PA0560021 Rating Area 1 No Preference 51 536.0633709PA0560021 Rating Area 1 No Preference 52 561.0633709PA0560021 Rating Area 1 No Preference 53 586.3633709PA0560021 Rating Area 1 No Preference 54 613.6633709PA0560021 Rating Area 1 No Preference 55 640.9733709PA0560021 Rating Area 1 No Preference 56 670.5833709PA0560021 Rating Area 1 No Preference 57 700.4733709PA0560021 Rating Area 1 No Preference 58 732.3733709PA0560021 Rating Area 1 No Preference 59 748.1833709PA0560021 Rating Area 1 No Preference 60 780.0933709PA0560021 Rating Area 1 No Preference 61 807.6833709PA0560021 Rating Area 1 No Preference 62 825.7933709PA0560021 Rating Area 1 No Preference 63 848.4933709PA0560021 Rating Area 1 No Preference 64 862.2933709PA0560021 Rating Area 1 No Preference 65 and over 862.2933709PA0560021 Rating Area 4 No Preference 0-20 182.5233709PA0560021 Rating Area 4 No Preference 21 287.4333709PA0560021 Rating Area 4 No Preference 22 287.4333709PA0560021 Rating Area 4 No Preference 23 287.4333709PA0560021 Rating Area 4 No Preference 24 287.4333709PA0560021 Rating Area 4 No Preference 25 288.5833709PA0560021 Rating Area 4 No Preference 26 294.3333709PA0560021 Rating Area 4 No Preference 27 301.2333709PA0560021 Rating Area 4 No Preference 28 312.4433709PA0560021 Rating Area 4 No Preference 29 321.6333709PA0560021 Rating Area 4 No Preference 30 326.2333709PA0560021 Rating Area 4 No Preference 31 333.1333709PA0560021 Rating Area 4 No Preference 32 340.0333709PA0560021 Rating Area 4 No Preference 33 344.3433709PA0560021 Rating Area 4 No Preference 34 348.9433709PA0560021 Rating Area 4 No Preference 35 351.2433709PA0560021 Rating Area 4 No Preference 36 353.5433709PA0560021 Rating Area 4 No Preference 37 355.8433709PA0560021 Rating Area 4 No Preference 38 358.1433709PA0560021 Rating Area 4 No Preference 39 362.7433709PA0560021 Rating Area 4 No Preference 40 367.3433709PA0560021 Rating Area 4 No Preference 41 374.2333709PA0560021 Rating Area 4 No Preference 42 380.8533709PA0560021 Rating Area 4 No Preference 43 390.0433709PA0560021 Rating Area 4 No Preference 44 401.5433709PA0560021 Rating Area 4 No Preference 45 415.05


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0560021 Rating Area 4 No Preference 46 431.1533709PA0560021 Rating Area 4 No Preference 47 449.2533709PA0560021 Rating Area 4 No Preference 48 469.9533709PA0560021 Rating Area 4 No Preference 49 490.3633709PA0560021 Rating Area 4 No Preference 50 513.3533709PA0560021 Rating Area 4 No Preference 51 536.0633709PA0560021 Rating Area 4 No Preference 52 561.0633709PA0560021 Rating Area 4 No Preference 53 586.3633709PA0560021 Rating Area 4 No Preference 54 613.6633709PA0560021 Rating Area 4 No Preference 55 640.9733709PA0560021 Rating Area 4 No Preference 56 670.5833709PA0560021 Rating Area 4 No Preference 57 700.4733709PA0560021 Rating Area 4 No Preference 58 732.3733709PA0560021 Rating Area 4 No Preference 59 748.1833709PA0560021 Rating Area 4 No Preference 60 780.0933709PA0560021 Rating Area 4 No Preference 61 807.6833709PA0560021 Rating Area 4 No Preference 62 825.7933709PA0560021 Rating Area 4 No Preference 63 848.4933709PA0560021 Rating Area 4 No Preference 64 862.2933709PA0560021 Rating Area 4 No Preference 65 and over 862.2933709PA0560023 Rating Area 1 No Preference 0-20 181.1633709PA0560023 Rating Area 1 No Preference 21 285.3033709PA0560023 Rating Area 1 No Preference 22 285.3033709PA0560023 Rating Area 1 No Preference 23 285.3033709PA0560023 Rating Area 1 No Preference 24 285.3033709PA0560023 Rating Area 1 No Preference 25 286.4433709PA0560023 Rating Area 1 No Preference 26 292.1433709PA0560023 Rating Area 1 No Preference 27 298.9933709PA0560023 Rating Area 1 No Preference 28 310.1233709PA0560023 Rating Area 1 No Preference 29 319.2533709PA0560023 Rating Area 1 No Preference 30 323.8133709PA0560023 Rating Area 1 No Preference 31 330.6633709PA0560023 Rating Area 1 No Preference 32 337.5133709PA0560023 Rating Area 1 No Preference 33 341.7933709PA0560023 Rating Area 1 No Preference 34 346.3533709PA0560023 Rating Area 1 No Preference 35 348.6333709PA0560023 Rating Area 1 No Preference 36 350.9133709PA0560023 Rating Area 1 No Preference 37 353.2033709PA0560023 Rating Area 1 No Preference 38 355.4833709PA0560023 Rating Area 1 No Preference 39 360.0433709PA0560023 Rating Area 1 No Preference 40 364.6133709PA0560023 Rating Area 1 No Preference 41 371.4633709PA0560023 Rating Area 1 No Preference 42 378.0233709PA0560023 Rating Area 1 No Preference 43 387.1533709PA0560023 Rating Area 1 No Preference 44 398.5633709PA0560023 Rating Area 1 No Preference 45 411.9733709PA0560023 Rating Area 1 No Preference 46 427.9433709PA0560023 Rating Area 1 No Preference 47 445.9233709PA0560023 Rating Area 1 No Preference 48 466.4633709PA0560023 Rating Area 1 No Preference 49 486.7233709PA0560023 Rating Area 1 No Preference 50 509.5433709PA0560023 Rating Area 1 No Preference 51 532.0833709PA0560023 Rating Area 1 No Preference 52 556.9033709PA0560023 Rating Area 1 No Preference 53 582.0033709PA0560023 Rating Area 1 No Preference 54 609.1133709PA0560023 Rating Area 1 No Preference 55 636.2133709PA0560023 Rating Area 1 No Preference 56 665.6033709PA0560023 Rating Area 1 No Preference 57 695.2733709PA0560023 Rating Area 1 No Preference 58 726.9433709PA0560023 Rating Area 1 No Preference 59 742.6333709PA0560023 Rating Area 1 No Preference 60 774.2933709PA0560023 Rating Area 1 No Preference 61 801.6833709PA0560023 Rating Area 1 No Preference 62 819.6633709PA0560023 Rating Area 1 No Preference 63 842.1933709PA0560023 Rating Area 1 No Preference 64 855.8933709PA0560023 Rating Area 1 No Preference 65 and over 855.8933709PA0560023 Rating Area 4 No Preference 0-20 181.1633709PA0560023 Rating Area 4 No Preference 21 285.3033709PA0560023 Rating Area 4 No Preference 22 285.3033709PA0560023 Rating Area 4 No Preference 23 285.3033709PA0560023 Rating Area 4 No Preference 24 285.3033709PA0560023 Rating Area 4 No Preference 25 286.4433709PA0560023 Rating Area 4 No Preference 26 292.1433709PA0560023 Rating Area 4 No Preference 27 298.9933709PA0560023 Rating Area 4 No Preference 28 310.1233709PA0560023 Rating Area 4 No Preference 29 319.2533709PA0560023 Rating Area 4 No Preference 30 323.8133709PA0560023 Rating Area 4 No Preference 31 330.6633709PA0560023 Rating Area 4 No Preference 32 337.5133709PA0560023 Rating Area 4 No Preference 33 341.7933709PA0560023 Rating Area 4 No Preference 34 346.3533709PA0560023 Rating Area 4 No Preference 35 348.6333709PA0560023 Rating Area 4 No Preference 36 350.9133709PA0560023 Rating Area 4 No Preference 37 353.2033709PA0560023 Rating Area 4 No Preference 38 355.4833709PA0560023 Rating Area 4 No Preference 39 360.0433709PA0560023 Rating Area 4 No Preference 40 364.6133709PA0560023 Rating Area 4 No Preference 41 371.4633709PA0560023 Rating Area 4 No Preference 42 378.0233709PA0560023 Rating Area 4 No Preference 43 387.1533709PA0560023 Rating Area 4 No Preference 44 398.5633709PA0560023 Rating Area 4 No Preference 45 411.9733709PA0560023 Rating Area 4 No Preference 46 427.9433709PA0560023 Rating Area 4 No Preference 47 445.9233709PA0560023 Rating Area 4 No Preference 48 466.4633709PA0560023 Rating Area 4 No Preference 49 486.7233709PA0560023 Rating Area 4 No Preference 50 509.5433709PA0560023 Rating Area 4 No Preference 51 532.0833709PA0560023 Rating Area 4 No Preference 52 556.9033709PA0560023 Rating Area 4 No Preference 53 582.0033709PA0560023 Rating Area 4 No Preference 54 609.1133709PA0560023 Rating Area 4 No Preference 55 636.2133709PA0560023 Rating Area 4 No Preference 56 665.6033709PA0560023 Rating Area 4 No Preference 57 695.27


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0560023 Rating Area 4 No Preference 58 726.9433709PA0560023 Rating Area 4 No Preference 59 742.6333709PA0560023 Rating Area 4 No Preference 60 774.2933709PA0560023 Rating Area 4 No Preference 61 801.6833709PA0560023 Rating Area 4 No Preference 62 819.6633709PA0560023 Rating Area 4 No Preference 63 842.1933709PA0560023 Rating Area 4 No Preference 64 855.8933709PA0560023 Rating Area 4 No Preference 65 and over 855.8933709PA0560027 Rating Area 1 No Preference 0-20 179.2333709PA0560027 Rating Area 1 No Preference 21 282.2533709PA0560027 Rating Area 1 No Preference 22 282.2533709PA0560027 Rating Area 1 No Preference 23 282.2533709PA0560027 Rating Area 1 No Preference 24 282.2533709PA0560027 Rating Area 1 No Preference 25 283.3833709PA0560027 Rating Area 1 No Preference 26 289.0233709PA0560027 Rating Area 1 No Preference 27 295.8033709PA0560027 Rating Area 1 No Preference 28 306.8133709PA0560027 Rating Area 1 No Preference 29 315.8433709PA0560027 Rating Area 1 No Preference 30 320.3533709PA0560027 Rating Area 1 No Preference 31 327.1333709PA0560027 Rating Area 1 No Preference 32 333.9033709PA0560027 Rating Area 1 No Preference 33 338.1433709PA0560027 Rating Area 1 No Preference 34 342.6533709PA0560027 Rating Area 1 No Preference 35 344.9133709PA0560027 Rating Area 1 No Preference 36 347.1733709PA0560027 Rating Area 1 No Preference 37 349.4333709PA0560027 Rating Area 1 No Preference 38 351.6833709PA0560027 Rating Area 1 No Preference 39 356.2033709PA0560027 Rating Area 1 No Preference 40 360.7233709PA0560027 Rating Area 1 No Preference 41 367.4933709PA0560027 Rating Area 1 No Preference 42 373.9833709PA0560027 Rating Area 1 No Preference 43 383.0133709PA0560027 Rating Area 1 No Preference 44 394.3033709PA0560027 Rating Area 1 No Preference 45 407.5733709PA0560027 Rating Area 1 No Preference 46 423.3833709PA0560027 Rating Area 1 No Preference 47 441.1633709PA0560027 Rating Area 1 No Preference 48 461.4833709PA0560027 Rating Area 1 No Preference 49 481.5233709PA0560027 Rating Area 1 No Preference 50 504.1033709PA0560027 Rating Area 1 No Preference 51 526.4033709PA0560027 Rating Area 1 No Preference 52 550.9533709PA0560027 Rating Area 1 No Preference 53 575.7933709PA0560027 Rating Area 1 No Preference 54 602.6133709PA0560027 Rating Area 1 No Preference 55 629.4233709PA0560027 Rating Area 1 No Preference 56 658.4933709PA0560027 Rating Area 1 No Preference 57 687.8433709PA0560027 Rating Area 1 No Preference 58 719.1733709PA0560027 Rating Area 1 No Preference 59 734.7033709PA0560027 Rating Area 1 No Preference 60 766.0333709PA0560027 Rating Area 1 No Preference 61 793.1233709PA0560027 Rating Area 1 No Preference 62 810.9133709PA0560027 Rating Area 1 No Preference 63 833.2033709PA0560027 Rating Area 1 No Preference 64 846.7533709PA0560027 Rating Area 1 No Preference 65 and over 846.7533709PA0560027 Rating Area 4 No Preference 0-20 179.2333709PA0560027 Rating Area 4 No Preference 21 282.2533709PA0560027 Rating Area 4 No Preference 22 282.2533709PA0560027 Rating Area 4 No Preference 23 282.2533709PA0560027 Rating Area 4 No Preference 24 282.2533709PA0560027 Rating Area 4 No Preference 25 283.3833709PA0560027 Rating Area 4 No Preference 26 289.0233709PA0560027 Rating Area 4 No Preference 27 295.8033709PA0560027 Rating Area 4 No Preference 28 306.8133709PA0560027 Rating Area 4 No Preference 29 315.8433709PA0560027 Rating Area 4 No Preference 30 320.3533709PA0560027 Rating Area 4 No Preference 31 327.1333709PA0560027 Rating Area 4 No Preference 32 333.9033709PA0560027 Rating Area 4 No Preference 33 338.1433709PA0560027 Rating Area 4 No Preference 34 342.6533709PA0560027 Rating Area 4 No Preference 35 344.9133709PA0560027 Rating Area 4 No Preference 36 347.1733709PA0560027 Rating Area 4 No Preference 37 349.4333709PA0560027 Rating Area 4 No Preference 38 351.6833709PA0560027 Rating Area 4 No Preference 39 356.2033709PA0560027 Rating Area 4 No Preference 40 360.7233709PA0560027 Rating Area 4 No Preference 41 367.4933709PA0560027 Rating Area 4 No Preference 42 373.9833709PA0560027 Rating Area 4 No Preference 43 383.0133709PA0560027 Rating Area 4 No Preference 44 394.3033709PA0560027 Rating Area 4 No Preference 45 407.5733709PA0560027 Rating Area 4 No Preference 46 423.3833709PA0560027 Rating Area 4 No Preference 47 441.1633709PA0560027 Rating Area 4 No Preference 48 461.4833709PA0560027 Rating Area 4 No Preference 49 481.5233709PA0560027 Rating Area 4 No Preference 50 504.1033709PA0560027 Rating Area 4 No Preference 51 526.4033709PA0560027 Rating Area 4 No Preference 52 550.9533709PA0560027 Rating Area 4 No Preference 53 575.7933709PA0560027 Rating Area 4 No Preference 54 602.6133709PA0560027 Rating Area 4 No Preference 55 629.4233709PA0560027 Rating Area 4 No Preference 56 658.4933709PA0560027 Rating Area 4 No Preference 57 687.8433709PA0560027 Rating Area 4 No Preference 58 719.1733709PA0560027 Rating Area 4 No Preference 59 734.7033709PA0560027 Rating Area 4 No Preference 60 766.0333709PA0560027 Rating Area 4 No Preference 61 793.1233709PA0560027 Rating Area 4 No Preference 62 810.9133709PA0560027 Rating Area 4 No Preference 63 833.2033709PA0560027 Rating Area 4 No Preference 64 846.7533709PA0560027 Rating Area 4 No Preference 65 and over 846.7533709PA0560029 Rating Area 1 No Preference 0-20 160.7333709PA0560029 Rating Area 1 No Preference 21 253.1233709PA0560029 Rating Area 1 No Preference 22 253.1233709PA0560029 Rating Area 1 No Preference 23 253.12


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0560029 Rating Area 1 No Preference 24 253.1233709PA0560029 Rating Area 1 No Preference 25 254.1333709PA0560029 Rating Area 1 No Preference 26 259.2033709PA0560029 Rating Area 1 No Preference 27 265.2733709PA0560029 Rating Area 1 No Preference 28 275.1433709PA0560029 Rating Area 1 No Preference 29 283.2433709PA0560029 Rating Area 1 No Preference 30 287.2933709PA0560029 Rating Area 1 No Preference 31 293.3733709PA0560029 Rating Area 1 No Preference 32 299.4433709PA0560029 Rating Area 1 No Preference 33 303.2433709PA0560029 Rating Area 1 No Preference 34 307.2933709PA0560029 Rating Area 1 No Preference 35 309.3133709PA0560029 Rating Area 1 No Preference 36 311.3433709PA0560029 Rating Area 1 No Preference 37 313.3633709PA0560029 Rating Area 1 No Preference 38 315.3933709PA0560029 Rating Area 1 No Preference 39 319.4433709PA0560029 Rating Area 1 No Preference 40 323.4933709PA0560029 Rating Area 1 No Preference 41 329.5633709PA0560029 Rating Area 1 No Preference 42 335.3933709PA0560029 Rating Area 1 No Preference 43 343.4933709PA0560029 Rating Area 1 No Preference 44 353.6133709PA0560029 Rating Area 1 No Preference 45 365.5133709PA0560029 Rating Area 1 No Preference 46 379.6833709PA0560029 Rating Area 1 No Preference 47 395.6333709PA0560029 Rating Area 1 No Preference 48 413.8533709PA0560029 Rating Area 1 No Preference 49 431.8333709PA0560029 Rating Area 1 No Preference 50 452.0733709PA0560029 Rating Area 1 No Preference 51 472.0733709PA0560029 Rating Area 1 No Preference 52 494.0933709PA0560029 Rating Area 1 No Preference 53 516.3733709PA0560029 Rating Area 1 No Preference 54 540.4133709PA0560029 Rating Area 1 No Preference 55 564.4633709PA0560029 Rating Area 1 No Preference 56 590.5333709PA0560029 Rating Area 1 No Preference 57 616.8633709PA0560029 Rating Area 1 No Preference 58 644.9533709PA0560029 Rating Area 1 No Preference 59 658.8833709PA0560029 Rating Area 1 No Preference 60 686.9733709PA0560029 Rating Area 1 No Preference 61 711.2733709PA0560029 Rating Area 1 No Preference 62 727.2233709PA0560029 Rating Area 1 No Preference 63 747.2133709PA0560029 Rating Area 1 No Preference 64 759.3633709PA0560029 Rating Area 1 No Preference 65 and over 759.3633709PA0560029 Rating Area 4 No Preference 0-20 160.7333709PA0560029 Rating Area 4 No Preference 21 253.1233709PA0560029 Rating Area 4 No Preference 22 253.1233709PA0560029 Rating Area 4 No Preference 23 253.1233709PA0560029 Rating Area 4 No Preference 24 253.1233709PA0560029 Rating Area 4 No Preference 25 254.1333709PA0560029 Rating Area 4 No Preference 26 259.2033709PA0560029 Rating Area 4 No Preference 27 265.2733709PA0560029 Rating Area 4 No Preference 28 275.1433709PA0560029 Rating Area 4 No Preference 29 283.2433709PA0560029 Rating Area 4 No Preference 30 287.2933709PA0560029 Rating Area 4 No Preference 31 293.3733709PA0560029 Rating Area 4 No Preference 32 299.4433709PA0560029 Rating Area 4 No Preference 33 303.2433709PA0560029 Rating Area 4 No Preference 34 307.2933709PA0560029 Rating Area 4 No Preference 35 309.3133709PA0560029 Rating Area 4 No Preference 36 311.3433709PA0560029 Rating Area 4 No Preference 37 313.3633709PA0560029 Rating Area 4 No Preference 38 315.3933709PA0560029 Rating Area 4 No Preference 39 319.4433709PA0560029 Rating Area 4 No Preference 40 323.4933709PA0560029 Rating Area 4 No Preference 41 329.5633709PA0560029 Rating Area 4 No Preference 42 335.3933709PA0560029 Rating Area 4 No Preference 43 343.4933709PA0560029 Rating Area 4 No Preference 44 353.6133709PA0560029 Rating Area 4 No Preference 45 365.5133709PA0560029 Rating Area 4 No Preference 46 379.6833709PA0560029 Rating Area 4 No Preference 47 395.6333709PA0560029 Rating Area 4 No Preference 48 413.8533709PA0560029 Rating Area 4 No Preference 49 431.8333709PA0560029 Rating Area 4 No Preference 50 452.0733709PA0560029 Rating Area 4 No Preference 51 472.0733709PA0560029 Rating Area 4 No Preference 52 494.0933709PA0560029 Rating Area 4 No Preference 53 516.3733709PA0560029 Rating Area 4 No Preference 54 540.4133709PA0560029 Rating Area 4 No Preference 55 564.4633709PA0560029 Rating Area 4 No Preference 56 590.5333709PA0560029 Rating Area 4 No Preference 57 616.8633709PA0560029 Rating Area 4 No Preference 58 644.9533709PA0560029 Rating Area 4 No Preference 59 658.8833709PA0560029 Rating Area 4 No Preference 60 686.9733709PA0560029 Rating Area 4 No Preference 61 711.2733709PA0560029 Rating Area 4 No Preference 62 727.2233709PA0560029 Rating Area 4 No Preference 63 747.2133709PA0560029 Rating Area 4 No Preference 64 759.3633709PA0560029 Rating Area 4 No Preference 65 and over 759.3633709PA0570007 Rating Area 1 No Preference 0-20 159.3633709PA0570007 Rating Area 1 No Preference 21 250.9633709PA0570007 Rating Area 1 No Preference 22 250.9633709PA0570007 Rating Area 1 No Preference 23 250.9633709PA0570007 Rating Area 1 No Preference 24 250.9633709PA0570007 Rating Area 1 No Preference 25 251.9633709PA0570007 Rating Area 1 No Preference 26 256.9833709PA0570007 Rating Area 1 No Preference 27 263.0033709PA0570007 Rating Area 1 No Preference 28 272.7933709PA0570007 Rating Area 1 No Preference 29 280.8233709PA0570007 Rating Area 1 No Preference 30 284.8433709PA0570007 Rating Area 1 No Preference 31 290.8633709PA0570007 Rating Area 1 No Preference 32 296.8833709PA0570007 Rating Area 1 No Preference 33 300.6533709PA0570007 Rating Area 1 No Preference 34 304.6633709PA0570007 Rating Area 1 No Preference 35 306.67


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0570007 Rating Area 1 No Preference 36 308.6833709PA0570007 Rating Area 1 No Preference 37 310.6933709PA0570007 Rating Area 1 No Preference 38 312.6933709PA0570007 Rating Area 1 No Preference 39 316.7133709PA0570007 Rating Area 1 No Preference 40 320.7233709PA0570007 Rating Area 1 No Preference 41 326.7533709PA0570007 Rating Area 1 No Preference 42 332.5233709PA0570007 Rating Area 1 No Preference 43 340.5533709PA0570007 Rating Area 1 No Preference 44 350.5933709PA0570007 Rating Area 1 No Preference 45 362.3833709PA0570007 Rating Area 1 No Preference 46 376.4433709PA0570007 Rating Area 1 No Preference 47 392.2533709PA0570007 Rating Area 1 No Preference 48 410.3233709PA0570007 Rating Area 1 No Preference 49 428.1433709PA0570007 Rating Area 1 No Preference 50 448.2133709PA0570007 Rating Area 1 No Preference 51 468.0433709PA0570007 Rating Area 1 No Preference 52 489.8733709PA0570007 Rating Area 1 No Preference 53 511.9633709PA0570007 Rating Area 1 No Preference 54 535.8033709PA0570007 Rating Area 1 No Preference 55 559.6433709PA0570007 Rating Area 1 No Preference 56 585.4933709PA0570007 Rating Area 1 No Preference 57 611.5933709PA0570007 Rating Area 1 No Preference 58 639.4433709PA0570007 Rating Area 1 No Preference 59 653.2433709PA0570007 Rating Area 1 No Preference 60 681.1033709PA0570007 Rating Area 1 No Preference 61 705.1933709PA0570007 Rating Area 1 No Preference 62 721.0033709PA0570007 Rating Area 1 No Preference 63 740.8333709PA0570007 Rating Area 1 No Preference 64 752.8833709PA0570007 Rating Area 1 No Preference 65 and over 752.8833709PA0570007 Rating Area 4 No Preference 0-20 159.3633709PA0570007 Rating Area 4 No Preference 21 250.9633709PA0570007 Rating Area 4 No Preference 22 250.9633709PA0570007 Rating Area 4 No Preference 23 250.9633709PA0570007 Rating Area 4 No Preference 24 250.9633709PA0570007 Rating Area 4 No Preference 25 251.9633709PA0570007 Rating Area 4 No Preference 26 256.9833709PA0570007 Rating Area 4 No Preference 27 263.0033709PA0570007 Rating Area 4 No Preference 28 272.7933709PA0570007 Rating Area 4 No Preference 29 280.8233709PA0570007 Rating Area 4 No Preference 30 284.8433709PA0570007 Rating Area 4 No Preference 31 290.8633709PA0570007 Rating Area 4 No Preference 32 296.8833709PA0570007 Rating Area 4 No Preference 33 300.6533709PA0570007 Rating Area 4 No Preference 34 304.6633709PA0570007 Rating Area 4 No Preference 35 306.6733709PA0570007 Rating Area 4 No Preference 36 308.6833709PA0570007 Rating Area 4 No Preference 37 310.6933709PA0570007 Rating Area 4 No Preference 38 312.6933709PA0570007 Rating Area 4 No Preference 39 316.7133709PA0570007 Rating Area 4 No Preference 40 320.7233709PA0570007 Rating Area 4 No Preference 41 326.7533709PA0570007 Rating Area 4 No Preference 42 332.5233709PA0570007 Rating Area 4 No Preference 43 340.5533709PA0570007 Rating Area 4 No Preference 44 350.5933709PA0570007 Rating Area 4 No Preference 45 362.3833709PA0570007 Rating Area 4 No Preference 46 376.4433709PA0570007 Rating Area 4 No Preference 47 392.2533709PA0570007 Rating Area 4 No Preference 48 410.3233709PA0570007 Rating Area 4 No Preference 49 428.1433709PA0570007 Rating Area 4 No Preference 50 448.2133709PA0570007 Rating Area 4 No Preference 51 468.0433709PA0570007 Rating Area 4 No Preference 52 489.8733709PA0570007 Rating Area 4 No Preference 53 511.9633709PA0570007 Rating Area 4 No Preference 54 535.8033709PA0570007 Rating Area 4 No Preference 55 559.6433709PA0570007 Rating Area 4 No Preference 56 585.4933709PA0570007 Rating Area 4 No Preference 57 611.5933709PA0570007 Rating Area 4 No Preference 58 639.4433709PA0570007 Rating Area 4 No Preference 59 653.2433709PA0570007 Rating Area 4 No Preference 60 681.1033709PA0570007 Rating Area 4 No Preference 61 705.1933709PA0570007 Rating Area 4 No Preference 62 721.0033709PA0570007 Rating Area 4 No Preference 63 740.8333709PA0570007 Rating Area 4 No Preference 64 752.8833709PA0570007 Rating Area 4 No Preference 65 and over 752.8833709PA0570004 Rating Area 1 No Preference 0-20 156.8033709PA0570004 Rating Area 1 No Preference 21 246.9333709PA0570004 Rating Area 1 No Preference 22 246.9333709PA0570004 Rating Area 1 No Preference 23 246.9333709PA0570004 Rating Area 1 No Preference 24 246.9333709PA0570004 Rating Area 1 No Preference 25 247.9233709PA0570004 Rating Area 1 No Preference 26 252.8633709PA0570004 Rating Area 1 No Preference 27 258.7933709PA0570004 Rating Area 1 No Preference 28 268.4233709PA0570004 Rating Area 1 No Preference 29 276.3233709PA0570004 Rating Area 1 No Preference 30 280.2733709PA0570004 Rating Area 1 No Preference 31 286.2033709PA0570004 Rating Area 1 No Preference 32 292.1233709PA0570004 Rating Area 1 No Preference 33 295.8333709PA0570004 Rating Area 1 No Preference 34 299.7833709PA0570004 Rating Area 1 No Preference 35 301.7533709PA0570004 Rating Area 1 No Preference 36 303.7333709PA0570004 Rating Area 1 No Preference 37 305.7033709PA0570004 Rating Area 1 No Preference 38 307.6833709PA0570004 Rating Area 1 No Preference 39 311.6333709PA0570004 Rating Area 1 No Preference 40 315.5833709PA0570004 Rating Area 1 No Preference 41 321.5133709PA0570004 Rating Area 1 No Preference 42 327.1933709PA0570004 Rating Area 1 No Preference 43 335.0933709PA0570004 Rating Area 1 No Preference 44 344.9733709PA0570004 Rating Area 1 No Preference 45 356.5733709PA0570004 Rating Area 1 No Preference 46 370.4033709PA0570004 Rating Area 1 No Preference 47 385.96


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0570004 Rating Area 1 No Preference 48 403.7433709PA0570004 Rating Area 1 No Preference 49 421.2733709PA0570004 Rating Area 1 No Preference 50 441.0233709PA0570004 Rating Area 1 No Preference 51 460.5333709PA0570004 Rating Area 1 No Preference 52 482.0133709PA0570004 Rating Area 1 No Preference 53 503.7433709PA0570004 Rating Area 1 No Preference 54 527.2033709PA0570004 Rating Area 1 No Preference 55 550.6633709PA0570004 Rating Area 1 No Preference 56 576.0933709PA0570004 Rating Area 1 No Preference 57 601.7833709PA0570004 Rating Area 1 No Preference 58 629.1933709PA0570004 Rating Area 1 No Preference 59 642.7733709PA0570004 Rating Area 1 No Preference 60 670.1833709PA0570004 Rating Area 1 No Preference 61 693.8833709PA0570004 Rating Area 1 No Preference 62 709.4433709PA0570004 Rating Area 1 No Preference 63 728.9533709PA0570004 Rating Area 1 No Preference 64 740.7933709PA0570004 Rating Area 1 No Preference 65 and over 740.7933709PA0570004 Rating Area 4 No Preference 0-20 156.8033709PA0570004 Rating Area 4 No Preference 21 246.9333709PA0570004 Rating Area 4 No Preference 22 246.9333709PA0570004 Rating Area 4 No Preference 23 246.9333709PA0570004 Rating Area 4 No Preference 24 246.9333709PA0570004 Rating Area 4 No Preference 25 247.9233709PA0570004 Rating Area 4 No Preference 26 252.8633709PA0570004 Rating Area 4 No Preference 27 258.7933709PA0570004 Rating Area 4 No Preference 28 268.4233709PA0570004 Rating Area 4 No Preference 29 276.3233709PA0570004 Rating Area 4 No Preference 30 280.2733709PA0570004 Rating Area 4 No Preference 31 286.2033709PA0570004 Rating Area 4 No Preference 32 292.1233709PA0570004 Rating Area 4 No Preference 33 295.8333709PA0570004 Rating Area 4 No Preference 34 299.7833709PA0570004 Rating Area 4 No Preference 35 301.7533709PA0570004 Rating Area 4 No Preference 36 303.7333709PA0570004 Rating Area 4 No Preference 37 305.7033709PA0570004 Rating Area 4 No Preference 38 307.6833709PA0570004 Rating Area 4 No Preference 39 311.6333709PA0570004 Rating Area 4 No Preference 40 315.5833709PA0570004 Rating Area 4 No Preference 41 321.5133709PA0570004 Rating Area 4 No Preference 42 327.1933709PA0570004 Rating Area 4 No Preference 43 335.0933709PA0570004 Rating Area 4 No Preference 44 344.9733709PA0570004 Rating Area 4 No Preference 45 356.5733709PA0570004 Rating Area 4 No Preference 46 370.4033709PA0570004 Rating Area 4 No Preference 47 385.9633709PA0570004 Rating Area 4 No Preference 48 403.7433709PA0570004 Rating Area 4 No Preference 49 421.2733709PA0570004 Rating Area 4 No Preference 50 441.0233709PA0570004 Rating Area 4 No Preference 51 460.5333709PA0570004 Rating Area 4 No Preference 52 482.0133709PA0570004 Rating Area 4 No Preference 53 503.7433709PA0570004 Rating Area 4 No Preference 54 527.2033709PA0570004 Rating Area 4 No Preference 55 550.6633709PA0570004 Rating Area 4 No Preference 56 576.0933709PA0570004 Rating Area 4 No Preference 57 601.7833709PA0570004 Rating Area 4 No Preference 58 629.1933709PA0570004 Rating Area 4 No Preference 59 642.7733709PA0570004 Rating Area 4 No Preference 60 670.1833709PA0570004 Rating Area 4 No Preference 61 693.8833709PA0570004 Rating Area 4 No Preference 62 709.4433709PA0570004 Rating Area 4 No Preference 63 728.9533709PA0570004 Rating Area 4 No Preference 64 740.7933709PA0570004 Rating Area 4 No Preference 65 and over 740.7933709PA0570006 Rating Area 1 No Preference 0-20 155.2533709PA0570006 Rating Area 1 No Preference 21 244.4933709PA0570006 Rating Area 1 No Preference 22 244.4933709PA0570006 Rating Area 1 No Preference 23 244.4933709PA0570006 Rating Area 1 No Preference 24 244.4933709PA0570006 Rating Area 1 No Preference 25 245.4733709PA0570006 Rating Area 1 No Preference 26 250.3633709PA0570006 Rating Area 1 No Preference 27 256.2233709PA0570006 Rating Area 1 No Preference 28 265.7633709PA0570006 Rating Area 1 No Preference 29 273.5833709PA0570006 Rating Area 1 No Preference 30 277.4933709PA0570006 Rating Area 1 No Preference 31 283.3633709PA0570006 Rating Area 1 No Preference 32 289.2333709PA0570006 Rating Area 1 No Preference 33 292.9033709PA0570006 Rating Area 1 No Preference 34 296.8133709PA0570006 Rating Area 1 No Preference 35 298.7633709PA0570006 Rating Area 1 No Preference 36 300.7233709PA0570006 Rating Area 1 No Preference 37 302.6833709PA0570006 Rating Area 1 No Preference 38 304.6333709PA0570006 Rating Area 1 No Preference 39 308.5433709PA0570006 Rating Area 1 No Preference 40 312.4633709PA0570006 Rating Area 1 No Preference 41 318.3233709PA0570006 Rating Area 1 No Preference 42 323.9533709PA0570006 Rating Area 1 No Preference 43 331.7733709PA0570006 Rating Area 1 No Preference 44 341.5533709PA0570006 Rating Area 1 No Preference 45 353.0433709PA0570006 Rating Area 1 No Preference 46 366.7333709PA0570006 Rating Area 1 No Preference 47 382.1433709PA0570006 Rating Area 1 No Preference 48 399.7433709PA0570006 Rating Area 1 No Preference 49 417.1033709PA0570006 Rating Area 1 No Preference 50 436.6633709PA0570006 Rating Area 1 No Preference 51 455.9733709PA0570006 Rating Area 1 No Preference 52 477.2433709PA0570006 Rating Area 1 No Preference 53 498.7633709PA0570006 Rating Area 1 No Preference 54 521.9833709PA0570006 Rating Area 1 No Preference 55 545.2133709PA0570006 Rating Area 1 No Preference 56 570.3933709PA0570006 Rating Area 1 No Preference 57 595.8233709PA0570006 Rating Area 1 No Preference 58 622.9633709PA0570006 Rating Area 1 No Preference 59 636.40


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0570006 Rating Area 1 No Preference 60 663.5433709PA0570006 Rating Area 1 No Preference 61 687.0133709PA0570006 Rating Area 1 No Preference 62 702.4233709PA0570006 Rating Area 1 No Preference 63 721.7333709PA0570006 Rating Area 1 No Preference 64 733.4733709PA0570006 Rating Area 1 No Preference 65 and over 733.4733709PA0570006 Rating Area 4 No Preference 0-20 155.2533709PA0570006 Rating Area 4 No Preference 21 244.4933709PA0570006 Rating Area 4 No Preference 22 244.4933709PA0570006 Rating Area 4 No Preference 23 244.4933709PA0570006 Rating Area 4 No Preference 24 244.4933709PA0570006 Rating Area 4 No Preference 25 245.4733709PA0570006 Rating Area 4 No Preference 26 250.3633709PA0570006 Rating Area 4 No Preference 27 256.2233709PA0570006 Rating Area 4 No Preference 28 265.7633709PA0570006 Rating Area 4 No Preference 29 273.5833709PA0570006 Rating Area 4 No Preference 30 277.4933709PA0570006 Rating Area 4 No Preference 31 283.3633709PA0570006 Rating Area 4 No Preference 32 289.2333709PA0570006 Rating Area 4 No Preference 33 292.9033709PA0570006 Rating Area 4 No Preference 34 296.8133709PA0570006 Rating Area 4 No Preference 35 298.7633709PA0570006 Rating Area 4 No Preference 36 300.7233709PA0570006 Rating Area 4 No Preference 37 302.6833709PA0570006 Rating Area 4 No Preference 38 304.6333709PA0570006 Rating Area 4 No Preference 39 308.5433709PA0570006 Rating Area 4 No Preference 40 312.4633709PA0570006 Rating Area 4 No Preference 41 318.3233709PA0570006 Rating Area 4 No Preference 42 323.9533709PA0570006 Rating Area 4 No Preference 43 331.7733709PA0570006 Rating Area 4 No Preference 44 341.5533709PA0570006 Rating Area 4 No Preference 45 353.0433709PA0570006 Rating Area 4 No Preference 46 366.7333709PA0570006 Rating Area 4 No Preference 47 382.1433709PA0570006 Rating Area 4 No Preference 48 399.7433709PA0570006 Rating Area 4 No Preference 49 417.1033709PA0570006 Rating Area 4 No Preference 50 436.6633709PA0570006 Rating Area 4 No Preference 51 455.9733709PA0570006 Rating Area 4 No Preference 52 477.2433709PA0570006 Rating Area 4 No Preference 53 498.7633709PA0570006 Rating Area 4 No Preference 54 521.9833709PA0570006 Rating Area 4 No Preference 55 545.2133709PA0570006 Rating Area 4 No Preference 56 570.3933709PA0570006 Rating Area 4 No Preference 57 595.8233709PA0570006 Rating Area 4 No Preference 58 622.9633709PA0570006 Rating Area 4 No Preference 59 636.4033709PA0570006 Rating Area 4 No Preference 60 663.5433709PA0570006 Rating Area 4 No Preference 61 687.0133709PA0570006 Rating Area 4 No Preference 62 702.4233709PA0570006 Rating Area 4 No Preference 63 721.7333709PA0570006 Rating Area 4 No Preference 64 733.4733709PA0570006 Rating Area 4 No Preference 65 and over 733.4733709PA0450004 Rating Area 1 No Preference 0-20 177.3933709PA0450004 Rating Area 1 No Preference 21 279.3633709PA0450004 Rating Area 1 No Preference 22 279.3633709PA0450004 Rating Area 1 No Preference 23 279.3633709PA0450004 Rating Area 1 No Preference 24 279.3633709PA0450004 Rating Area 1 No Preference 25 280.4833709PA0450004 Rating Area 1 No Preference 26 286.0633709PA0450004 Rating Area 1 No Preference 27 292.7733709PA0450004 Rating Area 1 No Preference 28 303.6633709PA0450004 Rating Area 1 No Preference 29 312.6033709PA0450004 Rating Area 1 No Preference 30 317.0733709PA0450004 Rating Area 1 No Preference 31 323.7833709PA0450004 Rating Area 1 No Preference 32 330.4833709PA0450004 Rating Area 1 No Preference 33 334.6733709PA0450004 Rating Area 1 No Preference 34 339.1433709PA0450004 Rating Area 1 No Preference 35 341.3833709PA0450004 Rating Area 1 No Preference 36 343.6133709PA0450004 Rating Area 1 No Preference 37 345.8533709PA0450004 Rating Area 1 No Preference 38 348.0833709PA0450004 Rating Area 1 No Preference 39 352.5533709PA0450004 Rating Area 1 No Preference 40 357.0233709PA0450004 Rating Area 1 No Preference 41 363.7333709PA0450004 Rating Area 1 No Preference 42 370.1533709PA0450004 Rating Area 1 No Preference 43 379.0933709PA0450004 Rating Area 1 No Preference 44 390.2733709PA0450004 Rating Area 1 No Preference 45 403.4033709PA0450004 Rating Area 1 No Preference 46 419.0433709PA0450004 Rating Area 1 No Preference 47 436.6433709PA0450004 Rating Area 1 No Preference 48 456.7533709PA0450004 Rating Area 1 No Preference 49 476.5933709PA0450004 Rating Area 1 No Preference 50 498.9433709PA0450004 Rating Area 1 No Preference 51 521.0133709PA0450004 Rating Area 1 No Preference 52 545.3133709PA0450004 Rating Area 1 No Preference 53 569.8933709PA0450004 Rating Area 1 No Preference 54 596.4333709PA0450004 Rating Area 1 No Preference 55 622.9733709PA0450004 Rating Area 1 No Preference 56 651.7533709PA0450004 Rating Area 1 No Preference 57 680.8033709PA0450004 Rating Area 1 No Preference 58 711.8133709PA0450004 Rating Area 1 No Preference 59 727.1733709PA0450004 Rating Area 1 No Preference 60 758.1833709PA0450004 Rating Area 1 No Preference 61 785.0033709PA0450004 Rating Area 1 No Preference 62 802.6033709PA0450004 Rating Area 1 No Preference 63 824.6733709PA0450004 Rating Area 1 No Preference 64 838.0833709PA0450004 Rating Area 1 No Preference 65 and over 838.0833709PA0450004 Rating Area 4 No Preference 0-20 177.3933709PA0450004 Rating Area 4 No Preference 21 279.3633709PA0450004 Rating Area 4 No Preference 22 279.3633709PA0450004 Rating Area 4 No Preference 23 279.3633709PA0450004 Rating Area 4 No Preference 24 279.3633709PA0450004 Rating Area 4 No Preference 25 280.48


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0450004 Rating Area 4 No Preference 26 286.0633709PA0450004 Rating Area 4 No Preference 27 292.7733709PA0450004 Rating Area 4 No Preference 28 303.6633709PA0450004 Rating Area 4 No Preference 29 312.6033709PA0450004 Rating Area 4 No Preference 30 317.0733709PA0450004 Rating Area 4 No Preference 31 323.7833709PA0450004 Rating Area 4 No Preference 32 330.4833709PA0450004 Rating Area 4 No Preference 33 334.6733709PA0450004 Rating Area 4 No Preference 34 339.1433709PA0450004 Rating Area 4 No Preference 35 341.3833709PA0450004 Rating Area 4 No Preference 36 343.6133709PA0450004 Rating Area 4 No Preference 37 345.8533709PA0450004 Rating Area 4 No Preference 38 348.0833709PA0450004 Rating Area 4 No Preference 39 352.5533709PA0450004 Rating Area 4 No Preference 40 357.0233709PA0450004 Rating Area 4 No Preference 41 363.7333709PA0450004 Rating Area 4 No Preference 42 370.1533709PA0450004 Rating Area 4 No Preference 43 379.0933709PA0450004 Rating Area 4 No Preference 44 390.2733709PA0450004 Rating Area 4 No Preference 45 403.4033709PA0450004 Rating Area 4 No Preference 46 419.0433709PA0450004 Rating Area 4 No Preference 47 436.6433709PA0450004 Rating Area 4 No Preference 48 456.7533709PA0450004 Rating Area 4 No Preference 49 476.5933709PA0450004 Rating Area 4 No Preference 50 498.9433709PA0450004 Rating Area 4 No Preference 51 521.0133709PA0450004 Rating Area 4 No Preference 52 545.3133709PA0450004 Rating Area 4 No Preference 53 569.8933709PA0450004 Rating Area 4 No Preference 54 596.4333709PA0450004 Rating Area 4 No Preference 55 622.9733709PA0450004 Rating Area 4 No Preference 56 651.7533709PA0450004 Rating Area 4 No Preference 57 680.8033709PA0450004 Rating Area 4 No Preference 58 711.8133709PA0450004 Rating Area 4 No Preference 59 727.1733709PA0450004 Rating Area 4 No Preference 60 758.1833709PA0450004 Rating Area 4 No Preference 61 785.0033709PA0450004 Rating Area 4 No Preference 62 802.6033709PA0450004 Rating Area 4 No Preference 63 824.6733709PA0450004 Rating Area 4 No Preference 64 838.0833709PA0450004 Rating Area 4 No Preference 65 and over 838.0833709PA0640001 Rating Area 1 No Preference 0-20 156.9633709PA0640001 Rating Area 1 No Preference 21 247.1933709PA0640001 Rating Area 1 No Preference 22 247.1933709PA0640001 Rating Area 1 No Preference 23 247.1933709PA0640001 Rating Area 1 No Preference 24 247.1933709PA0640001 Rating Area 1 No Preference 25 248.1733709PA0640001 Rating Area 1 No Preference 26 253.1233709PA0640001 Rating Area 1 No Preference 27 259.0533709PA0640001 Rating Area 1 No Preference 28 268.6933709PA0640001 Rating Area 1 No Preference 29 276.6033709PA0640001 Rating Area 1 No Preference 30 280.5633709PA0640001 Rating Area 1 No Preference 31 286.4933709PA0640001 Rating Area 1 No Preference 32 292.4233709PA0640001 Rating Area 1 No Preference 33 296.1333709PA0640001 Rating Area 1 No Preference 34 300.0833709PA0640001 Rating Area 1 No Preference 35 302.0633709PA0640001 Rating Area 1 No Preference 36 304.0433709PA0640001 Rating Area 1 No Preference 37 306.0233709PA0640001 Rating Area 1 No Preference 38 307.9933709PA0640001 Rating Area 1 No Preference 39 311.9533709PA0640001 Rating Area 1 No Preference 40 315.9033709PA0640001 Rating Area 1 No Preference 41 321.8433709PA0640001 Rating Area 1 No Preference 42 327.5233709PA0640001 Rating Area 1 No Preference 43 335.4333709PA0640001 Rating Area 1 No Preference 44 345.3233709PA0640001 Rating Area 1 No Preference 45 356.9433709PA0640001 Rating Area 1 No Preference 46 370.7833709PA0640001 Rating Area 1 No Preference 47 386.3533709PA0640001 Rating Area 1 No Preference 48 404.1533709PA0640001 Rating Area 1 No Preference 49 421.7033709PA0640001 Rating Area 1 No Preference 50 441.4733709PA0640001 Rating Area 1 No Preference 51 461.0033709PA0640001 Rating Area 1 No Preference 52 482.5133709PA0640001 Rating Area 1 No Preference 53 504.2633709PA0640001 Rating Area 1 No Preference 54 527.7433709PA0640001 Rating Area 1 No Preference 55 551.2233709PA0640001 Rating Area 1 No Preference 56 576.6833709PA0640001 Rating Area 1 No Preference 57 602.3933709PA0640001 Rating Area 1 No Preference 58 629.8333709PA0640001 Rating Area 1 No Preference 59 643.4233709PA0640001 Rating Area 1 No Preference 60 670.8633709PA0640001 Rating Area 1 No Preference 61 694.5933709PA0640001 Rating Area 1 No Preference 62 710.1633709PA0640001 Rating Area 1 No Preference 63 729.6933709PA0640001 Rating Area 1 No Preference 64 741.5633709PA0640001 Rating Area 1 No Preference 65 and over 741.5633709PA0640001 Rating Area 4 No Preference 0-20 156.9633709PA0640001 Rating Area 4 No Preference 21 247.1933709PA0640001 Rating Area 4 No Preference 22 247.1933709PA0640001 Rating Area 4 No Preference 23 247.1933709PA0640001 Rating Area 4 No Preference 24 247.1933709PA0640001 Rating Area 4 No Preference 25 248.1733709PA0640001 Rating Area 4 No Preference 26 253.1233709PA0640001 Rating Area 4 No Preference 27 259.0533709PA0640001 Rating Area 4 No Preference 28 268.6933709PA0640001 Rating Area 4 No Preference 29 276.6033709PA0640001 Rating Area 4 No Preference 30 280.5633709PA0640001 Rating Area 4 No Preference 31 286.4933709PA0640001 Rating Area 4 No Preference 32 292.4233709PA0640001 Rating Area 4 No Preference 33 296.1333709PA0640001 Rating Area 4 No Preference 34 300.0833709PA0640001 Rating Area 4 No Preference 35 302.0633709PA0640001 Rating Area 4 No Preference 36 304.0433709PA0640001 Rating Area 4 No Preference 37 306.02


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0640001 Rating Area 4 No Preference 38 307.9933709PA0640001 Rating Area 4 No Preference 39 311.9533709PA0640001 Rating Area 4 No Preference 40 315.9033709PA0640001 Rating Area 4 No Preference 41 321.8433709PA0640001 Rating Area 4 No Preference 42 327.5233709PA0640001 Rating Area 4 No Preference 43 335.4333709PA0640001 Rating Area 4 No Preference 44 345.3233709PA0640001 Rating Area 4 No Preference 45 356.9433709PA0640001 Rating Area 4 No Preference 46 370.7833709PA0640001 Rating Area 4 No Preference 47 386.3533709PA0640001 Rating Area 4 No Preference 48 404.1533709PA0640001 Rating Area 4 No Preference 49 421.7033709PA0640001 Rating Area 4 No Preference 50 441.4733709PA0640001 Rating Area 4 No Preference 51 461.0033709PA0640001 Rating Area 4 No Preference 52 482.5133709PA0640001 Rating Area 4 No Preference 53 504.2633709PA0640001 Rating Area 4 No Preference 54 527.7433709PA0640001 Rating Area 4 No Preference 55 551.2233709PA0640001 Rating Area 4 No Preference 56 576.6833709PA0640001 Rating Area 4 No Preference 57 602.3933709PA0640001 Rating Area 4 No Preference 58 629.8333709PA0640001 Rating Area 4 No Preference 59 643.4233709PA0640001 Rating Area 4 No Preference 60 670.8633709PA0640001 Rating Area 4 No Preference 61 694.5933709PA0640001 Rating Area 4 No Preference 62 710.1633709PA0640001 Rating Area 4 No Preference 63 729.6933709PA0640001 Rating Area 4 No Preference 64 741.5633709PA0640001 Rating Area 4 No Preference 65 and over 741.5633709PA0640002 Rating Area 1 No Preference 0-20 152.9833709PA0640002 Rating Area 1 No Preference 21 240.9233709PA0640002 Rating Area 1 No Preference 22 240.9233709PA0640002 Rating Area 1 No Preference 23 240.9233709PA0640002 Rating Area 1 No Preference 24 240.9233709PA0640002 Rating Area 1 No Preference 25 241.8833709PA0640002 Rating Area 1 No Preference 26 246.7033709PA0640002 Rating Area 1 No Preference 27 252.4833709PA0640002 Rating Area 1 No Preference 28 261.8833709PA0640002 Rating Area 1 No Preference 29 269.5933709PA0640002 Rating Area 1 No Preference 30 273.4433709PA0640002 Rating Area 1 No Preference 31 279.2333709PA0640002 Rating Area 1 No Preference 32 285.0133709PA0640002 Rating Area 1 No Preference 33 288.6233709PA0640002 Rating Area 1 No Preference 34 292.4833709PA0640002 Rating Area 1 No Preference 35 294.4033709PA0640002 Rating Area 1 No Preference 36 296.3333709PA0640002 Rating Area 1 No Preference 37 298.2633709PA0640002 Rating Area 1 No Preference 38 300.1833709PA0640002 Rating Area 1 No Preference 39 304.0433709PA0640002 Rating Area 1 No Preference 40 307.8933709PA0640002 Rating Area 1 No Preference 41 313.6833709PA0640002 Rating Area 1 No Preference 42 319.2233709PA0640002 Rating Area 1 No Preference 43 326.9333709PA0640002 Rating Area 1 No Preference 44 336.5633709PA0640002 Rating Area 1 No Preference 45 347.8933709PA0640002 Rating Area 1 No Preference 46 361.3833709PA0640002 Rating Area 1 No Preference 47 376.5633709PA0640002 Rating Area 1 No Preference 48 393.9033709PA0640002 Rating Area 1 No Preference 49 411.0133709PA0640002 Rating Area 1 No Preference 50 430.2833709PA0640002 Rating Area 1 No Preference 51 449.3133709PA0640002 Rating Area 1 No Preference 52 470.2733709PA0640002 Rating Area 1 No Preference 53 491.4733709PA0640002 Rating Area 1 No Preference 54 514.3633709PA0640002 Rating Area 1 No Preference 55 537.2533709PA0640002 Rating Area 1 No Preference 56 562.0633709PA0640002 Rating Area 1 No Preference 57 587.1233709PA0640002 Rating Area 1 No Preference 58 613.8633709PA0640002 Rating Area 1 No Preference 59 627.1133709PA0640002 Rating Area 1 No Preference 60 653.8533709PA0640002 Rating Area 1 No Preference 61 676.9833709PA0640002 Rating Area 1 No Preference 62 692.1633709PA0640002 Rating Area 1 No Preference 63 711.1933709PA0640002 Rating Area 1 No Preference 64 722.7633709PA0640002 Rating Area 1 No Preference 65 and over 722.7633709PA0640002 Rating Area 4 No Preference 0-20 152.9833709PA0640002 Rating Area 4 No Preference 21 240.9233709PA0640002 Rating Area 4 No Preference 22 240.9233709PA0640002 Rating Area 4 No Preference 23 240.9233709PA0640002 Rating Area 4 No Preference 24 240.9233709PA0640002 Rating Area 4 No Preference 25 241.8833709PA0640002 Rating Area 4 No Preference 26 246.7033709PA0640002 Rating Area 4 No Preference 27 252.4833709PA0640002 Rating Area 4 No Preference 28 261.8833709PA0640002 Rating Area 4 No Preference 29 269.5933709PA0640002 Rating Area 4 No Preference 30 273.4433709PA0640002 Rating Area 4 No Preference 31 279.2333709PA0640002 Rating Area 4 No Preference 32 285.0133709PA0640002 Rating Area 4 No Preference 33 288.6233709PA0640002 Rating Area 4 No Preference 34 292.4833709PA0640002 Rating Area 4 No Preference 35 294.4033709PA0640002 Rating Area 4 No Preference 36 296.3333709PA0640002 Rating Area 4 No Preference 37 298.2633709PA0640002 Rating Area 4 No Preference 38 300.1833709PA0640002 Rating Area 4 No Preference 39 304.0433709PA0640002 Rating Area 4 No Preference 40 307.8933709PA0640002 Rating Area 4 No Preference 41 313.6833709PA0640002 Rating Area 4 No Preference 42 319.2233709PA0640002 Rating Area 4 No Preference 43 326.9333709PA0640002 Rating Area 4 No Preference 44 336.5633709PA0640002 Rating Area 4 No Preference 45 347.8933709PA0640002 Rating Area 4 No Preference 46 361.3833709PA0640002 Rating Area 4 No Preference 47 376.5633709PA0640002 Rating Area 4 No Preference 48 393.9033709PA0640002 Rating Area 4 No Preference 49 411.01


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0640002 Rating Area 4 No Preference 50 430.2833709PA0640002 Rating Area 4 No Preference 51 449.3133709PA0640002 Rating Area 4 No Preference 52 470.2733709PA0640002 Rating Area 4 No Preference 53 491.4733709PA0640002 Rating Area 4 No Preference 54 514.3633709PA0640002 Rating Area 4 No Preference 55 537.2533709PA0640002 Rating Area 4 No Preference 56 562.0633709PA0640002 Rating Area 4 No Preference 57 587.1233709PA0640002 Rating Area 4 No Preference 58 613.8633709PA0640002 Rating Area 4 No Preference 59 627.1133709PA0640002 Rating Area 4 No Preference 60 653.8533709PA0640002 Rating Area 4 No Preference 61 676.9833709PA0640002 Rating Area 4 No Preference 62 692.1633709PA0640002 Rating Area 4 No Preference 63 711.1933709PA0640002 Rating Area 4 No Preference 64 722.7633709PA0640002 Rating Area 4 No Preference 65 and over 722.7633709PA0640003 Rating Area 1 No Preference 0-20 127.1533709PA0640003 Rating Area 1 No Preference 21 200.2433709PA0640003 Rating Area 1 No Preference 22 200.2433709PA0640003 Rating Area 1 No Preference 23 200.2433709PA0640003 Rating Area 1 No Preference 24 200.2433709PA0640003 Rating Area 1 No Preference 25 201.0433709PA0640003 Rating Area 1 No Preference 26 205.0433709PA0640003 Rating Area 1 No Preference 27 209.8533709PA0640003 Rating Area 1 No Preference 28 217.6633709PA0640003 Rating Area 1 No Preference 29 224.0733709PA0640003 Rating Area 1 No Preference 30 227.2733709PA0640003 Rating Area 1 No Preference 31 232.0733709PA0640003 Rating Area 1 No Preference 32 236.8833709PA0640003 Rating Area 1 No Preference 33 239.8833709PA0640003 Rating Area 1 No Preference 34 243.0933709PA0640003 Rating Area 1 No Preference 35 244.6933709PA0640003 Rating Area 1 No Preference 36 246.2933709PA0640003 Rating Area 1 No Preference 37 247.8933709PA0640003 Rating Area 1 No Preference 38 249.5033709PA0640003 Rating Area 1 No Preference 39 252.7033709PA0640003 Rating Area 1 No Preference 40 255.9033709PA0640003 Rating Area 1 No Preference 41 260.7133709PA0640003 Rating Area 1 No Preference 42 265.3133709PA0640003 Rating Area 1 No Preference 43 271.7233709PA0640003 Rating Area 1 No Preference 44 279.7333709PA0640003 Rating Area 1 No Preference 45 289.1433709PA0640003 Rating Area 1 No Preference 46 300.3633709PA0640003 Rating Area 1 No Preference 47 312.9733709PA0640003 Rating Area 1 No Preference 48 327.3933709PA0640003 Rating Area 1 No Preference 49 341.6033709PA0640003 Rating Area 1 No Preference 50 357.6233709PA0640003 Rating Area 1 No Preference 51 373.4433709PA0640003 Rating Area 1 No Preference 52 390.8633709PA0640003 Rating Area 1 No Preference 53 408.4833709PA0640003 Rating Area 1 No Preference 54 427.5133709PA0640003 Rating Area 1 No Preference 55 446.5333709PA0640003 Rating Area 1 No Preference 56 467.1533709PA0640003 Rating Area 1 No Preference 57 487.9833709PA0640003 Rating Area 1 No Preference 58 510.2033709PA0640003 Rating Area 1 No Preference 59 521.2233709PA0640003 Rating Area 1 No Preference 60 543.4433709PA0640003 Rating Area 1 No Preference 61 562.6733709PA0640003 Rating Area 1 No Preference 62 575.2833709PA0640003 Rating Area 1 No Preference 63 591.1033709PA0640003 Rating Area 1 No Preference 64 600.7133709PA0640003 Rating Area 1 No Preference 65 and over 600.7133709PA0640003 Rating Area 4 No Preference 0-20 127.1533709PA0640003 Rating Area 4 No Preference 21 200.2433709PA0640003 Rating Area 4 No Preference 22 200.2433709PA0640003 Rating Area 4 No Preference 23 200.2433709PA0640003 Rating Area 4 No Preference 24 200.2433709PA0640003 Rating Area 4 No Preference 25 201.0433709PA0640003 Rating Area 4 No Preference 26 205.0433709PA0640003 Rating Area 4 No Preference 27 209.8533709PA0640003 Rating Area 4 No Preference 28 217.6633709PA0640003 Rating Area 4 No Preference 29 224.0733709PA0640003 Rating Area 4 No Preference 30 227.2733709PA0640003 Rating Area 4 No Preference 31 232.0733709PA0640003 Rating Area 4 No Preference 32 236.8833709PA0640003 Rating Area 4 No Preference 33 239.8833709PA0640003 Rating Area 4 No Preference 34 243.0933709PA0640003 Rating Area 4 No Preference 35 244.6933709PA0640003 Rating Area 4 No Preference 36 246.2933709PA0640003 Rating Area 4 No Preference 37 247.8933709PA0640003 Rating Area 4 No Preference 38 249.5033709PA0640003 Rating Area 4 No Preference 39 252.7033709PA0640003 Rating Area 4 No Preference 40 255.9033709PA0640003 Rating Area 4 No Preference 41 260.7133709PA0640003 Rating Area 4 No Preference 42 265.3133709PA0640003 Rating Area 4 No Preference 43 271.7233709PA0640003 Rating Area 4 No Preference 44 279.7333709PA0640003 Rating Area 4 No Preference 45 289.1433709PA0640003 Rating Area 4 No Preference 46 300.3633709PA0640003 Rating Area 4 No Preference 47 312.9733709PA0640003 Rating Area 4 No Preference 48 327.3933709PA0640003 Rating Area 4 No Preference 49 341.6033709PA0640003 Rating Area 4 No Preference 50 357.6233709PA0640003 Rating Area 4 No Preference 51 373.4433709PA0640003 Rating Area 4 No Preference 52 390.8633709PA0640003 Rating Area 4 No Preference 53 408.4833709PA0640003 Rating Area 4 No Preference 54 427.5133709PA0640003 Rating Area 4 No Preference 55 446.5333709PA0640003 Rating Area 4 No Preference 56 467.1533709PA0640003 Rating Area 4 No Preference 57 487.9833709PA0640003 Rating Area 4 No Preference 58 510.2033709PA0640003 Rating Area 4 No Preference 59 521.2233709PA0640003 Rating Area 4 No Preference 60 543.4433709PA0640003 Rating Area 4 No Preference 61 562.67


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0640003 Rating Area 4 No Preference 62 575.2833709PA0640003 Rating Area 4 No Preference 63 591.1033709PA0640003 Rating Area 4 No Preference 64 600.7133709PA0640003 Rating Area 4 No Preference 65 and over 600.7133709PA0640005 Rating Area 1 No Preference 0-20 127.5633709PA0640005 Rating Area 1 No Preference 21 200.8933709PA0640005 Rating Area 1 No Preference 22 200.8933709PA0640005 Rating Area 1 No Preference 23 200.8933709PA0640005 Rating Area 1 No Preference 24 200.8933709PA0640005 Rating Area 1 No Preference 25 201.6933709PA0640005 Rating Area 1 No Preference 26 205.7133709PA0640005 Rating Area 1 No Preference 27 210.5333709PA0640005 Rating Area 1 No Preference 28 218.3633709PA0640005 Rating Area 1 No Preference 29 224.7933709PA0640005 Rating Area 1 No Preference 30 228.0133709PA0640005 Rating Area 1 No Preference 31 232.8333709PA0640005 Rating Area 1 No Preference 32 237.6533709PA0640005 Rating Area 1 No Preference 33 240.6633709PA0640005 Rating Area 1 No Preference 34 243.8833709PA0640005 Rating Area 1 No Preference 35 245.4833709PA0640005 Rating Area 1 No Preference 36 247.0933709PA0640005 Rating Area 1 No Preference 37 248.7033709PA0640005 Rating Area 1 No Preference 38 250.3133709PA0640005 Rating Area 1 No Preference 39 253.5233709PA0640005 Rating Area 1 No Preference 40 256.7333709PA0640005 Rating Area 1 No Preference 41 261.5533709PA0640005 Rating Area 1 No Preference 42 266.1833709PA0640005 Rating Area 1 No Preference 43 272.6033709PA0640005 Rating Area 1 No Preference 44 280.6433709PA0640005 Rating Area 1 No Preference 45 290.0833709PA0640005 Rating Area 1 No Preference 46 301.3333709PA0640005 Rating Area 1 No Preference 47 313.9933709PA0640005 Rating Area 1 No Preference 48 328.4533709PA0640005 Rating Area 1 No Preference 49 342.7133709PA0640005 Rating Area 1 No Preference 50 358.7833709PA0640005 Rating Area 1 No Preference 51 374.6533709PA0640005 Rating Area 1 No Preference 52 392.1333709PA0640005 Rating Area 1 No Preference 53 409.8133709PA0640005 Rating Area 1 No Preference 54 428.8933709PA0640005 Rating Area 1 No Preference 55 447.9833709PA0640005 Rating Area 1 No Preference 56 468.6733709PA0640005 Rating Area 1 No Preference 57 489.5633709PA0640005 Rating Area 1 No Preference 58 511.8633709PA0640005 Rating Area 1 No Preference 59 522.9133709PA0640005 Rating Area 1 No Preference 60 545.2133709PA0640005 Rating Area 1 No Preference 61 564.4933709PA0640005 Rating Area 1 No Preference 62 577.1533709PA0640005 Rating Area 1 No Preference 63 593.0233709PA0640005 Rating Area 1 No Preference 64 602.6633709PA0640005 Rating Area 1 No Preference 65 and over 602.6633709PA0640005 Rating Area 4 No Preference 0-20 127.5633709PA0640005 Rating Area 4 No Preference 21 200.8933709PA0640005 Rating Area 4 No Preference 22 200.8933709PA0640005 Rating Area 4 No Preference 23 200.8933709PA0640005 Rating Area 4 No Preference 24 200.8933709PA0640005 Rating Area 4 No Preference 25 201.6933709PA0640005 Rating Area 4 No Preference 26 205.7133709PA0640005 Rating Area 4 No Preference 27 210.5333709PA0640005 Rating Area 4 No Preference 28 218.3633709PA0640005 Rating Area 4 No Preference 29 224.7933709PA0640005 Rating Area 4 No Preference 30 228.0133709PA0640005 Rating Area 4 No Preference 31 232.8333709PA0640005 Rating Area 4 No Preference 32 237.6533709PA0640005 Rating Area 4 No Preference 33 240.6633709PA0640005 Rating Area 4 No Preference 34 243.8833709PA0640005 Rating Area 4 No Preference 35 245.4833709PA0640005 Rating Area 4 No Preference 36 247.0933709PA0640005 Rating Area 4 No Preference 37 248.7033709PA0640005 Rating Area 4 No Preference 38 250.3133709PA0640005 Rating Area 4 No Preference 39 253.5233709PA0640005 Rating Area 4 No Preference 40 256.7333709PA0640005 Rating Area 4 No Preference 41 261.5533709PA0640005 Rating Area 4 No Preference 42 266.1833709PA0640005 Rating Area 4 No Preference 43 272.6033709PA0640005 Rating Area 4 No Preference 44 280.6433709PA0640005 Rating Area 4 No Preference 45 290.0833709PA0640005 Rating Area 4 No Preference 46 301.3333709PA0640005 Rating Area 4 No Preference 47 313.9933709PA0640005 Rating Area 4 No Preference 48 328.4533709PA0640005 Rating Area 4 No Preference 49 342.7133709PA0640005 Rating Area 4 No Preference 50 358.7833709PA0640005 Rating Area 4 No Preference 51 374.6533709PA0640005 Rating Area 4 No Preference 52 392.1333709PA0640005 Rating Area 4 No Preference 53 409.8133709PA0640005 Rating Area 4 No Preference 54 428.8933709PA0640005 Rating Area 4 No Preference 55 447.9833709PA0640005 Rating Area 4 No Preference 56 468.6733709PA0640005 Rating Area 4 No Preference 57 489.5633709PA0640005 Rating Area 4 No Preference 58 511.8633709PA0640005 Rating Area 4 No Preference 59 522.9133709PA0640005 Rating Area 4 No Preference 60 545.2133709PA0640005 Rating Area 4 No Preference 61 564.4933709PA0640005 Rating Area 4 No Preference 62 577.1533709PA0640005 Rating Area 4 No Preference 63 593.0233709PA0640005 Rating Area 4 No Preference 64 602.6633709PA0640005 Rating Area 4 No Preference 65 and over 602.6633709PA0460012 Rating Area 1 No Preference 0-20 190.7233709PA0460012 Rating Area 1 No Preference 21 300.3433709PA0460012 Rating Area 1 No Preference 22 300.3433709PA0460012 Rating Area 1 No Preference 23 300.3433709PA0460012 Rating Area 1 No Preference 24 300.3433709PA0460012 Rating Area 1 No Preference 25 301.5433709PA0460012 Rating Area 1 No Preference 26 307.5533709PA0460012 Rating Area 1 No Preference 27 314.76


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0460012 Rating Area 1 No Preference 28 326.4733709PA0460012 Rating Area 1 No Preference 29 336.0833709PA0460012 Rating Area 1 No Preference 30 340.8933709PA0460012 Rating Area 1 No Preference 31 348.1033709PA0460012 Rating Area 1 No Preference 32 355.3033709PA0460012 Rating Area 1 No Preference 33 359.8133709PA0460012 Rating Area 1 No Preference 34 364.6133709PA0460012 Rating Area 1 No Preference 35 367.0233709PA0460012 Rating Area 1 No Preference 36 369.4233709PA0460012 Rating Area 1 No Preference 37 371.8233709PA0460012 Rating Area 1 No Preference 38 374.2333709PA0460012 Rating Area 1 No Preference 39 379.0333709PA0460012 Rating Area 1 No Preference 40 383.8433709PA0460012 Rating Area 1 No Preference 41 391.0433709PA0460012 Rating Area 1 No Preference 42 397.9533709PA0460012 Rating Area 1 No Preference 43 407.5633709PA0460012 Rating Area 1 No Preference 44 419.5833709PA0460012 Rating Area 1 No Preference 45 433.6933709PA0460012 Rating Area 1 No Preference 46 450.5133709PA0460012 Rating Area 1 No Preference 47 469.4333709PA0460012 Rating Area 1 No Preference 48 491.0633709PA0460012 Rating Area 1 No Preference 49 512.3833709PA0460012 Rating Area 1 No Preference 50 536.4133709PA0460012 Rating Area 1 No Preference 51 560.1433709PA0460012 Rating Area 1 No Preference 52 586.2733709PA0460012 Rating Area 1 No Preference 53 612.7033709PA0460012 Rating Area 1 No Preference 54 641.2333709PA0460012 Rating Area 1 No Preference 55 669.7633709PA0460012 Rating Area 1 No Preference 56 700.7033709PA0460012 Rating Area 1 No Preference 57 731.9333709PA0460012 Rating Area 1 No Preference 58 765.2733709PA0460012 Rating Area 1 No Preference 59 781.7933709PA0460012 Rating Area 1 No Preference 60 815.1333709PA0460012 Rating Area 1 No Preference 61 843.9633709PA0460012 Rating Area 1 No Preference 62 862.8833709PA0460012 Rating Area 1 No Preference 63 886.6133709PA0460012 Rating Area 1 No Preference 64 901.0233709PA0460012 Rating Area 1 No Preference 65 and over 901.0233709PA0460012 Rating Area 4 No Preference 0-20 190.7233709PA0460012 Rating Area 4 No Preference 21 300.3433709PA0460012 Rating Area 4 No Preference 22 300.3433709PA0460012 Rating Area 4 No Preference 23 300.3433709PA0460012 Rating Area 4 No Preference 24 300.3433709PA0460012 Rating Area 4 No Preference 25 301.5433709PA0460012 Rating Area 4 No Preference 26 307.5533709PA0460012 Rating Area 4 No Preference 27 314.7633709PA0460012 Rating Area 4 No Preference 28 326.4733709PA0460012 Rating Area 4 No Preference 29 336.0833709PA0460012 Rating Area 4 No Preference 30 340.8933709PA0460012 Rating Area 4 No Preference 31 348.1033709PA0460012 Rating Area 4 No Preference 32 355.3033709PA0460012 Rating Area 4 No Preference 33 359.8133709PA0460012 Rating Area 4 No Preference 34 364.6133709PA0460012 Rating Area 4 No Preference 35 367.0233709PA0460012 Rating Area 4 No Preference 36 369.4233709PA0460012 Rating Area 4 No Preference 37 371.8233709PA0460012 Rating Area 4 No Preference 38 374.2333709PA0460012 Rating Area 4 No Preference 39 379.0333709PA0460012 Rating Area 4 No Preference 40 383.8433709PA0460012 Rating Area 4 No Preference 41 391.0433709PA0460012 Rating Area 4 No Preference 42 397.9533709PA0460012 Rating Area 4 No Preference 43 407.5633709PA0460012 Rating Area 4 No Preference 44 419.5833709PA0460012 Rating Area 4 No Preference 45 433.6933709PA0460012 Rating Area 4 No Preference 46 450.5133709PA0460012 Rating Area 4 No Preference 47 469.4333709PA0460012 Rating Area 4 No Preference 48 491.0633709PA0460012 Rating Area 4 No Preference 49 512.3833709PA0460012 Rating Area 4 No Preference 50 536.4133709PA0460012 Rating Area 4 No Preference 51 560.1433709PA0460012 Rating Area 4 No Preference 52 586.2733709PA0460012 Rating Area 4 No Preference 53 612.7033709PA0460012 Rating Area 4 No Preference 54 641.2333709PA0460012 Rating Area 4 No Preference 55 669.7633709PA0460012 Rating Area 4 No Preference 56 700.7033709PA0460012 Rating Area 4 No Preference 57 731.9333709PA0460012 Rating Area 4 No Preference 58 765.2733709PA0460012 Rating Area 4 No Preference 59 781.7933709PA0460012 Rating Area 4 No Preference 60 815.1333709PA0460012 Rating Area 4 No Preference 61 843.9633709PA0460012 Rating Area 4 No Preference 62 862.8833709PA0460012 Rating Area 4 No Preference 63 886.6133709PA0460012 Rating Area 4 No Preference 64 901.0233709PA0460012 Rating Area 4 No Preference 65 and over 901.0233709PA0640004 Rating Area 1 No Preference 0-20 136.0333709PA0640004 Rating Area 1 No Preference 21 214.2233709PA0640004 Rating Area 1 No Preference 22 214.2233709PA0640004 Rating Area 1 No Preference 23 214.2233709PA0640004 Rating Area 1 No Preference 24 214.2233709PA0640004 Rating Area 1 No Preference 25 215.0833709PA0640004 Rating Area 1 No Preference 26 219.3733709PA0640004 Rating Area 1 No Preference 27 224.5133709PA0640004 Rating Area 1 No Preference 28 232.8633709PA0640004 Rating Area 1 No Preference 29 239.7233709PA0640004 Rating Area 1 No Preference 30 243.1433709PA0640004 Rating Area 1 No Preference 31 248.2933709PA0640004 Rating Area 1 No Preference 32 253.4333709PA0640004 Rating Area 1 No Preference 33 256.6433709PA0640004 Rating Area 1 No Preference 34 260.0733709PA0640004 Rating Area 1 No Preference 35 261.7833709PA0640004 Rating Area 1 No Preference 36 263.5033709PA0640004 Rating Area 1 No Preference 37 265.2133709PA0640004 Rating Area 1 No Preference 38 266.9233709PA0640004 Rating Area 1 No Preference 39 270.35


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0640004 Rating Area 1 No Preference 40 273.7833709PA0640004 Rating Area 1 No Preference 41 278.9233709PA0640004 Rating Area 1 No Preference 42 283.8533709PA0640004 Rating Area 1 No Preference 43 290.7033709PA0640004 Rating Area 1 No Preference 44 299.2733709PA0640004 Rating Area 1 No Preference 45 309.3433709PA0640004 Rating Area 1 No Preference 46 321.3433709PA0640004 Rating Area 1 No Preference 47 334.8333709PA0640004 Rating Area 1 No Preference 48 350.2633709PA0640004 Rating Area 1 No Preference 49 365.4733709PA0640004 Rating Area 1 No Preference 50 382.6033709PA0640004 Rating Area 1 No Preference 51 399.5333709PA0640004 Rating Area 1 No Preference 52 418.1733709PA0640004 Rating Area 1 No Preference 53 437.0233709PA0640004 Rating Area 1 No Preference 54 457.3733709PA0640004 Rating Area 1 No Preference 55 477.7233709PA0640004 Rating Area 1 No Preference 56 499.7933709PA0640004 Rating Area 1 No Preference 57 522.0733709PA0640004 Rating Area 1 No Preference 58 545.8433709PA0640004 Rating Area 1 No Preference 59 557.6333709PA0640004 Rating Area 1 No Preference 60 581.4133709PA0640004 Rating Area 1 No Preference 61 601.9733709PA0640004 Rating Area 1 No Preference 62 615.4733709PA0640004 Rating Area 1 No Preference 63 632.3933709PA0640004 Rating Area 1 No Preference 64 642.6633709PA0640004 Rating Area 1 No Preference 65 and over 642.6633709PA0640004 Rating Area 2 No Preference 0-20 136.0333709PA0640004 Rating Area 2 No Preference 21 214.2233709PA0640004 Rating Area 2 No Preference 22 214.2233709PA0640004 Rating Area 2 No Preference 23 214.2233709PA0640004 Rating Area 2 No Preference 24 214.2233709PA0640004 Rating Area 2 No Preference 25 215.0833709PA0640004 Rating Area 2 No Preference 26 219.3733709PA0640004 Rating Area 2 No Preference 27 224.5133709PA0640004 Rating Area 2 No Preference 28 232.8633709PA0640004 Rating Area 2 No Preference 29 239.7233709PA0640004 Rating Area 2 No Preference 30 243.1433709PA0640004 Rating Area 2 No Preference 31 248.2933709PA0640004 Rating Area 2 No Preference 32 253.4333709PA0640004 Rating Area 2 No Preference 33 256.6433709PA0640004 Rating Area 2 No Preference 34 260.0733709PA0640004 Rating Area 2 No Preference 35 261.7833709PA0640004 Rating Area 2 No Preference 36 263.5033709PA0640004 Rating Area 2 No Preference 37 265.2133709PA0640004 Rating Area 2 No Preference 38 266.9233709PA0640004 Rating Area 2 No Preference 39 270.3533709PA0640004 Rating Area 2 No Preference 40 273.7833709PA0640004 Rating Area 2 No Preference 41 278.9233709PA0640004 Rating Area 2 No Preference 42 283.8533709PA0640004 Rating Area 2 No Preference 43 290.7033709PA0640004 Rating Area 2 No Preference 44 299.2733709PA0640004 Rating Area 2 No Preference 45 309.3433709PA0640004 Rating Area 2 No Preference 46 321.3433709PA0640004 Rating Area 2 No Preference 47 334.8333709PA0640004 Rating Area 2 No Preference 48 350.2633709PA0640004 Rating Area 2 No Preference 49 365.4733709PA0640004 Rating Area 2 No Preference 50 382.6033709PA0640004 Rating Area 2 No Preference 51 399.5333709PA0640004 Rating Area 2 No Preference 52 418.1733709PA0640004 Rating Area 2 No Preference 53 437.0233709PA0640004 Rating Area 2 No Preference 54 457.3733709PA0640004 Rating Area 2 No Preference 55 477.7233709PA0640004 Rating Area 2 No Preference 56 499.7933709PA0640004 Rating Area 2 No Preference 57 522.0733709PA0640004 Rating Area 2 No Preference 58 545.8433709PA0640004 Rating Area 2 No Preference 59 557.6333709PA0640004 Rating Area 2 No Preference 60 581.4133709PA0640004 Rating Area 2 No Preference 61 601.9733709PA0640004 Rating Area 2 No Preference 62 615.4733709PA0640004 Rating Area 2 No Preference 63 632.3933709PA0640004 Rating Area 2 No Preference 64 642.6633709PA0640004 Rating Area 2 No Preference 65 and over 642.6633709PA0640004 Rating Area 5 No Preference 0-20 136.0333709PA0640004 Rating Area 5 No Preference 21 214.2233709PA0640004 Rating Area 5 No Preference 22 214.2233709PA0640004 Rating Area 5 No Preference 23 214.2233709PA0640004 Rating Area 5 No Preference 24 214.2233709PA0640004 Rating Area 5 No Preference 25 215.0833709PA0640004 Rating Area 5 No Preference 26 219.3733709PA0640004 Rating Area 5 No Preference 27 224.5133709PA0640004 Rating Area 5 No Preference 28 232.8633709PA0640004 Rating Area 5 No Preference 29 239.7233709PA0640004 Rating Area 5 No Preference 30 243.1433709PA0640004 Rating Area 5 No Preference 31 248.2933709PA0640004 Rating Area 5 No Preference 32 253.4333709PA0640004 Rating Area 5 No Preference 33 256.6433709PA0640004 Rating Area 5 No Preference 34 260.0733709PA0640004 Rating Area 5 No Preference 35 261.7833709PA0640004 Rating Area 5 No Preference 36 263.5033709PA0640004 Rating Area 5 No Preference 37 265.2133709PA0640004 Rating Area 5 No Preference 38 266.9233709PA0640004 Rating Area 5 No Preference 39 270.3533709PA0640004 Rating Area 5 No Preference 40 273.7833709PA0640004 Rating Area 5 No Preference 41 278.9233709PA0640004 Rating Area 5 No Preference 42 283.8533709PA0640004 Rating Area 5 No Preference 43 290.7033709PA0640004 Rating Area 5 No Preference 44 299.2733709PA0640004 Rating Area 5 No Preference 45 309.3433709PA0640004 Rating Area 5 No Preference 46 321.3433709PA0640004 Rating Area 5 No Preference 47 334.8333709PA0640004 Rating Area 5 No Preference 48 350.2633709PA0640004 Rating Area 5 No Preference 49 365.4733709PA0640004 Rating Area 5 No Preference 50 382.6033709PA0640004 Rating Area 5 No Preference 51 399.53


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0640004 Rating Area 5 No Preference 52 418.1733709PA0640004 Rating Area 5 No Preference 53 437.0233709PA0640004 Rating Area 5 No Preference 54 457.3733709PA0640004 Rating Area 5 No Preference 55 477.7233709PA0640004 Rating Area 5 No Preference 56 499.7933709PA0640004 Rating Area 5 No Preference 57 522.0733709PA0640004 Rating Area 5 No Preference 58 545.8433709PA0640004 Rating Area 5 No Preference 59 557.6333709PA0640004 Rating Area 5 No Preference 60 581.4133709PA0640004 Rating Area 5 No Preference 61 601.9733709PA0640004 Rating Area 5 No Preference 62 615.4733709PA0640004 Rating Area 5 No Preference 63 632.3933709PA0640004 Rating Area 5 No Preference 64 642.6633709PA0640004 Rating Area 5 No Preference 65 and over 642.6633709PA0640004 Rating Area 6 No Preference 0-20 145.8533709PA0640004 Rating Area 6 No Preference 21 229.6833709PA0640004 Rating Area 6 No Preference 22 229.6833709PA0640004 Rating Area 6 No Preference 23 229.6833709PA0640004 Rating Area 6 No Preference 24 229.6833709PA0640004 Rating Area 6 No Preference 25 230.6033709PA0640004 Rating Area 6 No Preference 26 235.2033709PA0640004 Rating Area 6 No Preference 27 240.7133709PA0640004 Rating Area 6 No Preference 28 249.6733709PA0640004 Rating Area 6 No Preference 29 257.0233709PA0640004 Rating Area 6 No Preference 30 260.6933709PA0640004 Rating Area 6 No Preference 31 266.2033709PA0640004 Rating Area 6 No Preference 32 271.7233709PA0640004 Rating Area 6 No Preference 33 275.1633709PA0640004 Rating Area 6 No Preference 34 278.8433709PA0640004 Rating Area 6 No Preference 35 280.6733709PA0640004 Rating Area 6 No Preference 36 282.5133709PA0640004 Rating Area 6 No Preference 37 284.3533709PA0640004 Rating Area 6 No Preference 38 286.1933709PA0640004 Rating Area 6 No Preference 39 289.8633709PA0640004 Rating Area 6 No Preference 40 293.5433709PA0640004 Rating Area 6 No Preference 41 299.0533709PA0640004 Rating Area 6 No Preference 42 304.3333709PA0640004 Rating Area 6 No Preference 43 311.6833709PA0640004 Rating Area 6 No Preference 44 320.8733709PA0640004 Rating Area 6 No Preference 45 331.6633709PA0640004 Rating Area 6 No Preference 46 344.5333709PA0640004 Rating Area 6 No Preference 47 359.0033709PA0640004 Rating Area 6 No Preference 48 375.5333709PA0640004 Rating Area 6 No Preference 49 391.8433709PA0640004 Rating Area 6 No Preference 50 410.2233709PA0640004 Rating Area 6 No Preference 51 428.3633709PA0640004 Rating Area 6 No Preference 52 448.3433709PA0640004 Rating Area 6 No Preference 53 468.5633709PA0640004 Rating Area 6 No Preference 54 490.3833709PA0640004 Rating Area 6 No Preference 55 512.2033709PA0640004 Rating Area 6 No Preference 56 535.8533709PA0640004 Rating Area 6 No Preference 57 559.7433709PA0640004 Rating Area 6 No Preference 58 585.2333709PA0640004 Rating Area 6 No Preference 59 597.8733709PA0640004 Rating Area 6 No Preference 60 623.3633709PA0640004 Rating Area 6 No Preference 61 645.4133709PA0640004 Rating Area 6 No Preference 62 659.8833709PA0640004 Rating Area 6 No Preference 63 678.0333709PA0640004 Rating Area 6 No Preference 64 689.0433709PA0640004 Rating Area 6 No Preference 65 and over 689.0433709PA0460007 Rating Area 2 No Preference 0-20 199.7233709PA0460007 Rating Area 2 No Preference 21 314.5233709PA0460007 Rating Area 2 No Preference 22 314.5233709PA0460007 Rating Area 2 No Preference 23 314.5233709PA0460007 Rating Area 2 No Preference 24 314.5233709PA0460007 Rating Area 2 No Preference 25 315.7833709PA0460007 Rating Area 2 No Preference 26 322.0733709PA0460007 Rating Area 2 No Preference 27 329.6233709PA0460007 Rating Area 2 No Preference 28 341.8933709PA0460007 Rating Area 2 No Preference 29 351.9533709PA0460007 Rating Area 2 No Preference 30 356.9833709PA0460007 Rating Area 2 No Preference 31 364.5333709PA0460007 Rating Area 2 No Preference 32 372.0833709PA0460007 Rating Area 2 No Preference 33 376.8033709PA0460007 Rating Area 2 No Preference 34 381.8333709PA0460007 Rating Area 2 No Preference 35 384.3533709PA0460007 Rating Area 2 No Preference 36 386.8633709PA0460007 Rating Area 2 No Preference 37 389.3833709PA0460007 Rating Area 2 No Preference 38 391.9033709PA0460007 Rating Area 2 No Preference 39 396.9333709PA0460007 Rating Area 2 No Preference 40 401.9633709PA0460007 Rating Area 2 No Preference 41 409.5133709PA0460007 Rating Area 2 No Preference 42 416.7433709PA0460007 Rating Area 2 No Preference 43 426.8133709PA0460007 Rating Area 2 No Preference 44 439.3933709PA0460007 Rating Area 2 No Preference 45 454.1733709PA0460007 Rating Area 2 No Preference 46 471.7833709PA0460007 Rating Area 2 No Preference 47 491.6033709PA0460007 Rating Area 2 No Preference 48 514.2433709PA0460007 Rating Area 2 No Preference 49 536.5833709PA0460007 Rating Area 2 No Preference 50 561.7433709PA0460007 Rating Area 2 No Preference 51 586.5833709PA0460007 Rating Area 2 No Preference 52 613.9533709PA0460007 Rating Area 2 No Preference 53 641.6333709PA0460007 Rating Area 2 No Preference 54 671.5133709PA0460007 Rating Area 2 No Preference 55 701.3933709PA0460007 Rating Area 2 No Preference 56 733.7833709PA0460007 Rating Area 2 No Preference 57 766.4933709PA0460007 Rating Area 2 No Preference 58 801.4033709PA0460007 Rating Area 2 No Preference 59 818.7033709PA0460007 Rating Area 2 No Preference 60 853.6133709PA0460007 Rating Area 2 No Preference 61 883.8133709PA0460007 Rating Area 2 No Preference 62 903.6233709PA0460007 Rating Area 2 No Preference 63 928.47


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0460007 Rating Area 2 No Preference 64 943.5633709PA0460007 Rating Area 2 No Preference 65 and over 943.5633709PA0460007 Rating Area 5 No Preference 0-20 199.7233709PA0460007 Rating Area 5 No Preference 21 314.5233709PA0460007 Rating Area 5 No Preference 22 314.5233709PA0460007 Rating Area 5 No Preference 23 314.5233709PA0460007 Rating Area 5 No Preference 24 314.5233709PA0460007 Rating Area 5 No Preference 25 315.7833709PA0460007 Rating Area 5 No Preference 26 322.0733709PA0460007 Rating Area 5 No Preference 27 329.6233709PA0460007 Rating Area 5 No Preference 28 341.8933709PA0460007 Rating Area 5 No Preference 29 351.9533709PA0460007 Rating Area 5 No Preference 30 356.9833709PA0460007 Rating Area 5 No Preference 31 364.5333709PA0460007 Rating Area 5 No Preference 32 372.0833709PA0460007 Rating Area 5 No Preference 33 376.8033709PA0460007 Rating Area 5 No Preference 34 381.8333709PA0460007 Rating Area 5 No Preference 35 384.3533709PA0460007 Rating Area 5 No Preference 36 386.8633709PA0460007 Rating Area 5 No Preference 37 389.3833709PA0460007 Rating Area 5 No Preference 38 391.9033709PA0460007 Rating Area 5 No Preference 39 396.9333709PA0460007 Rating Area 5 No Preference 40 401.9633709PA0460007 Rating Area 5 No Preference 41 409.5133709PA0460007 Rating Area 5 No Preference 42 416.7433709PA0460007 Rating Area 5 No Preference 43 426.8133709PA0460007 Rating Area 5 No Preference 44 439.3933709PA0460007 Rating Area 5 No Preference 45 454.1733709PA0460007 Rating Area 5 No Preference 46 471.7833709PA0460007 Rating Area 5 No Preference 47 491.6033709PA0460007 Rating Area 5 No Preference 48 514.2433709PA0460007 Rating Area 5 No Preference 49 536.5833709PA0460007 Rating Area 5 No Preference 50 561.7433709PA0460007 Rating Area 5 No Preference 51 586.5833709PA0460007 Rating Area 5 No Preference 52 613.9533709PA0460007 Rating Area 5 No Preference 53 641.6333709PA0460007 Rating Area 5 No Preference 54 671.5133709PA0460007 Rating Area 5 No Preference 55 701.3933709PA0460007 Rating Area 5 No Preference 56 733.7833709PA0460007 Rating Area 5 No Preference 57 766.4933709PA0460007 Rating Area 5 No Preference 58 801.4033709PA0460007 Rating Area 5 No Preference 59 818.7033709PA0460007 Rating Area 5 No Preference 60 853.6133709PA0460007 Rating Area 5 No Preference 61 883.8133709PA0460007 Rating Area 5 No Preference 62 903.6233709PA0460007 Rating Area 5 No Preference 63 928.4733709PA0460007 Rating Area 5 No Preference 64 943.5633709PA0460007 Rating Area 5 No Preference 65 and over 943.5633709PA0460007 Rating Area 6 No Preference 0-20 214.1333709PA0460007 Rating Area 6 No Preference 21 337.2233709PA0460007 Rating Area 6 No Preference 22 337.2233709PA0460007 Rating Area 6 No Preference 23 337.2233709PA0460007 Rating Area 6 No Preference 24 337.2233709PA0460007 Rating Area 6 No Preference 25 338.5733709PA0460007 Rating Area 6 No Preference 26 345.3133709PA0460007 Rating Area 6 No Preference 27 353.4133709PA0460007 Rating Area 6 No Preference 28 366.5633709PA0460007 Rating Area 6 No Preference 29 377.3533709PA0460007 Rating Area 6 No Preference 30 382.7433709PA0460007 Rating Area 6 No Preference 31 390.8433709PA0460007 Rating Area 6 No Preference 32 398.9333709PA0460007 Rating Area 6 No Preference 33 403.9933709PA0460007 Rating Area 6 No Preference 34 409.3933709PA0460007 Rating Area 6 No Preference 35 412.0833709PA0460007 Rating Area 6 No Preference 36 414.7833709PA0460007 Rating Area 6 No Preference 37 417.4833709PA0460007 Rating Area 6 No Preference 38 420.1833709PA0460007 Rating Area 6 No Preference 39 425.5733709PA0460007 Rating Area 6 No Preference 40 430.9733709PA0460007 Rating Area 6 No Preference 41 439.0633709PA0460007 Rating Area 6 No Preference 42 446.8233709PA0460007 Rating Area 6 No Preference 43 457.6133709PA0460007 Rating Area 6 No Preference 44 471.1033709PA0460007 Rating Area 6 No Preference 45 486.9533709PA0460007 Rating Area 6 No Preference 46 505.8333709PA0460007 Rating Area 6 No Preference 47 527.0733709PA0460007 Rating Area 6 No Preference 48 551.3533709PA0460007 Rating Area 6 No Preference 49 575.3033709PA0460007 Rating Area 6 No Preference 50 602.2733709PA0460007 Rating Area 6 No Preference 51 628.9233709PA0460007 Rating Area 6 No Preference 52 658.2533709PA0460007 Rating Area 6 No Preference 53 687.9333709PA0460007 Rating Area 6 No Preference 54 719.9633709PA0460007 Rating Area 6 No Preference 55 752.0033709PA0460007 Rating Area 6 No Preference 56 786.7333709PA0460007 Rating Area 6 No Preference 57 821.8133709PA0460007 Rating Area 6 No Preference 58 859.2433709PA0460007 Rating Area 6 No Preference 59 877.7833709PA0460007 Rating Area 6 No Preference 60 915.2233709PA0460007 Rating Area 6 No Preference 61 947.5933709PA0460007 Rating Area 6 No Preference 62 968.8333709PA0460007 Rating Area 6 No Preference 63 995.4733709PA0460007 Rating Area 6 No Preference 64 1011.6633709PA0460007 Rating Area 6 No Preference 65 and over 1011.6633709PA0460008 Rating Area 1 No Preference 0-20 188.7333709PA0460008 Rating Area 1 No Preference 21 297.2133709PA0460008 Rating Area 1 No Preference 22 297.2133709PA0460008 Rating Area 1 No Preference 23 297.2133709PA0460008 Rating Area 1 No Preference 24 297.2133709PA0460008 Rating Area 1 No Preference 25 298.4033709PA0460008 Rating Area 1 No Preference 26 304.3433709PA0460008 Rating Area 1 No Preference 27 311.4733709PA0460008 Rating Area 1 No Preference 28 323.0733709PA0460008 Rating Area 1 No Preference 29 332.58


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0460008 Rating Area 1 No Preference 30 337.3333709PA0460008 Rating Area 1 No Preference 31 344.4633709PA0460008 Rating Area 1 No Preference 32 351.6033709PA0460008 Rating Area 1 No Preference 33 356.0633709PA0460008 Rating Area 1 No Preference 34 360.8133709PA0460008 Rating Area 1 No Preference 35 363.1933709PA0460008 Rating Area 1 No Preference 36 365.5733709PA0460008 Rating Area 1 No Preference 37 367.9433709PA0460008 Rating Area 1 No Preference 38 370.3233709PA0460008 Rating Area 1 No Preference 39 375.0833709PA0460008 Rating Area 1 No Preference 40 379.8333709PA0460008 Rating Area 1 No Preference 41 386.9633709PA0460008 Rating Area 1 No Preference 42 393.8033709PA0460008 Rating Area 1 No Preference 43 403.3133709PA0460008 Rating Area 1 No Preference 44 415.2033709PA0460008 Rating Area 1 No Preference 45 429.1733709PA0460008 Rating Area 1 No Preference 46 445.8133709PA0460008 Rating Area 1 No Preference 47 464.5433709PA0460008 Rating Area 1 No Preference 48 485.9433709PA0460008 Rating Area 1 No Preference 49 507.0433709PA0460008 Rating Area 1 No Preference 50 530.8133709PA0460008 Rating Area 1 No Preference 51 554.2933709PA0460008 Rating Area 1 No Preference 52 580.1533709PA0460008 Rating Area 1 No Preference 53 606.3033709PA0460008 Rating Area 1 No Preference 54 634.5433709PA0460008 Rating Area 1 No Preference 55 662.7733709PA0460008 Rating Area 1 No Preference 56 693.3933709PA0460008 Rating Area 1 No Preference 57 724.3033709PA0460008 Rating Area 1 No Preference 58 757.2933709PA0460008 Rating Area 1 No Preference 59 773.6333709PA0460008 Rating Area 1 No Preference 60 806.6233709PA0460008 Rating Area 1 No Preference 61 835.1533709PA0460008 Rating Area 1 No Preference 62 853.8833709PA0460008 Rating Area 1 No Preference 63 877.3633709PA0460008 Rating Area 1 No Preference 64 891.6233709PA0460008 Rating Area 1 No Preference 65 and over 891.6233709PA0460008 Rating Area 2 No Preference 0-20 188.7333709PA0460008 Rating Area 2 No Preference 21 297.2133709PA0460008 Rating Area 2 No Preference 22 297.2133709PA0460008 Rating Area 2 No Preference 23 297.2133709PA0460008 Rating Area 2 No Preference 24 297.2133709PA0460008 Rating Area 2 No Preference 25 298.4033709PA0460008 Rating Area 2 No Preference 26 304.3433709PA0460008 Rating Area 2 No Preference 27 311.4733709PA0460008 Rating Area 2 No Preference 28 323.0733709PA0460008 Rating Area 2 No Preference 29 332.5833709PA0460008 Rating Area 2 No Preference 30 337.3333709PA0460008 Rating Area 2 No Preference 31 344.4633709PA0460008 Rating Area 2 No Preference 32 351.6033709PA0460008 Rating Area 2 No Preference 33 356.0633709PA0460008 Rating Area 2 No Preference 34 360.8133709PA0460008 Rating Area 2 No Preference 35 363.1933709PA0460008 Rating Area 2 No Preference 36 365.5733709PA0460008 Rating Area 2 No Preference 37 367.9433709PA0460008 Rating Area 2 No Preference 38 370.3233709PA0460008 Rating Area 2 No Preference 39 375.0833709PA0460008 Rating Area 2 No Preference 40 379.8333709PA0460008 Rating Area 2 No Preference 41 386.9633709PA0460008 Rating Area 2 No Preference 42 393.8033709PA0460008 Rating Area 2 No Preference 43 403.3133709PA0460008 Rating Area 2 No Preference 44 415.2033709PA0460008 Rating Area 2 No Preference 45 429.1733709PA0460008 Rating Area 2 No Preference 46 445.8133709PA0460008 Rating Area 2 No Preference 47 464.5433709PA0460008 Rating Area 2 No Preference 48 485.9433709PA0460008 Rating Area 2 No Preference 49 507.0433709PA0460008 Rating Area 2 No Preference 50 530.8133709PA0460008 Rating Area 2 No Preference 51 554.2933709PA0460008 Rating Area 2 No Preference 52 580.1533709PA0460008 Rating Area 2 No Preference 53 606.3033709PA0460008 Rating Area 2 No Preference 54 634.5433709PA0460008 Rating Area 2 No Preference 55 662.7733709PA0460008 Rating Area 2 No Preference 56 693.3933709PA0460008 Rating Area 2 No Preference 57 724.3033709PA0460008 Rating Area 2 No Preference 58 757.2933709PA0460008 Rating Area 2 No Preference 59 773.6333709PA0460008 Rating Area 2 No Preference 60 806.6233709PA0460008 Rating Area 2 No Preference 61 835.1533709PA0460008 Rating Area 2 No Preference 62 853.8833709PA0460008 Rating Area 2 No Preference 63 877.3633709PA0460008 Rating Area 2 No Preference 64 891.6233709PA0460008 Rating Area 2 No Preference 65 and over 891.6233709PA0460008 Rating Area 4 No Preference 0-20 188.7333709PA0460008 Rating Area 4 No Preference 21 297.2133709PA0460008 Rating Area 4 No Preference 22 297.2133709PA0460008 Rating Area 4 No Preference 23 297.2133709PA0460008 Rating Area 4 No Preference 24 297.2133709PA0460008 Rating Area 4 No Preference 25 298.4033709PA0460008 Rating Area 4 No Preference 26 304.3433709PA0460008 Rating Area 4 No Preference 27 311.4733709PA0460008 Rating Area 4 No Preference 28 323.0733709PA0460008 Rating Area 4 No Preference 29 332.5833709PA0460008 Rating Area 4 No Preference 30 337.3333709PA0460008 Rating Area 4 No Preference 31 344.4633709PA0460008 Rating Area 4 No Preference 32 351.6033709PA0460008 Rating Area 4 No Preference 33 356.0633709PA0460008 Rating Area 4 No Preference 34 360.8133709PA0460008 Rating Area 4 No Preference 35 363.1933709PA0460008 Rating Area 4 No Preference 36 365.5733709PA0460008 Rating Area 4 No Preference 37 367.9433709PA0460008 Rating Area 4 No Preference 38 370.3233709PA0460008 Rating Area 4 No Preference 39 375.0833709PA0460008 Rating Area 4 No Preference 40 379.8333709PA0460008 Rating Area 4 No Preference 41 386.96


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0460008 Rating Area 4 No Preference 42 393.8033709PA0460008 Rating Area 4 No Preference 43 403.3133709PA0460008 Rating Area 4 No Preference 44 415.2033709PA0460008 Rating Area 4 No Preference 45 429.1733709PA0460008 Rating Area 4 No Preference 46 445.8133709PA0460008 Rating Area 4 No Preference 47 464.5433709PA0460008 Rating Area 4 No Preference 48 485.9433709PA0460008 Rating Area 4 No Preference 49 507.0433709PA0460008 Rating Area 4 No Preference 50 530.8133709PA0460008 Rating Area 4 No Preference 51 554.2933709PA0460008 Rating Area 4 No Preference 52 580.1533709PA0460008 Rating Area 4 No Preference 53 606.3033709PA0460008 Rating Area 4 No Preference 54 634.5433709PA0460008 Rating Area 4 No Preference 55 662.7733709PA0460008 Rating Area 4 No Preference 56 693.3933709PA0460008 Rating Area 4 No Preference 57 724.3033709PA0460008 Rating Area 4 No Preference 58 757.2933709PA0460008 Rating Area 4 No Preference 59 773.6333709PA0460008 Rating Area 4 No Preference 60 806.6233709PA0460008 Rating Area 4 No Preference 61 835.1533709PA0460008 Rating Area 4 No Preference 62 853.8833709PA0460008 Rating Area 4 No Preference 63 877.3633709PA0460008 Rating Area 4 No Preference 64 891.6233709PA0460008 Rating Area 4 No Preference 65 and over 891.6233709PA0460008 Rating Area 5 No Preference 0-20 188.7333709PA0460008 Rating Area 5 No Preference 21 297.2133709PA0460008 Rating Area 5 No Preference 22 297.2133709PA0460008 Rating Area 5 No Preference 23 297.2133709PA0460008 Rating Area 5 No Preference 24 297.2133709PA0460008 Rating Area 5 No Preference 25 298.4033709PA0460008 Rating Area 5 No Preference 26 304.3433709PA0460008 Rating Area 5 No Preference 27 311.4733709PA0460008 Rating Area 5 No Preference 28 323.0733709PA0460008 Rating Area 5 No Preference 29 332.5833709PA0460008 Rating Area 5 No Preference 30 337.3333709PA0460008 Rating Area 5 No Preference 31 344.4633709PA0460008 Rating Area 5 No Preference 32 351.6033709PA0460008 Rating Area 5 No Preference 33 356.0633709PA0460008 Rating Area 5 No Preference 34 360.8133709PA0460008 Rating Area 5 No Preference 35 363.1933709PA0460008 Rating Area 5 No Preference 36 365.5733709PA0460008 Rating Area 5 No Preference 37 367.9433709PA0460008 Rating Area 5 No Preference 38 370.3233709PA0460008 Rating Area 5 No Preference 39 375.0833709PA0460008 Rating Area 5 No Preference 40 379.8333709PA0460008 Rating Area 5 No Preference 41 386.9633709PA0460008 Rating Area 5 No Preference 42 393.8033709PA0460008 Rating Area 5 No Preference 43 403.3133709PA0460008 Rating Area 5 No Preference 44 415.2033709PA0460008 Rating Area 5 No Preference 45 429.1733709PA0460008 Rating Area 5 No Preference 46 445.8133709PA0460008 Rating Area 5 No Preference 47 464.5433709PA0460008 Rating Area 5 No Preference 48 485.9433709PA0460008 Rating Area 5 No Preference 49 507.0433709PA0460008 Rating Area 5 No Preference 50 530.8133709PA0460008 Rating Area 5 No Preference 51 554.2933709PA0460008 Rating Area 5 No Preference 52 580.1533709PA0460008 Rating Area 5 No Preference 53 606.3033709PA0460008 Rating Area 5 No Preference 54 634.5433709PA0460008 Rating Area 5 No Preference 55 662.7733709PA0460008 Rating Area 5 No Preference 56 693.3933709PA0460008 Rating Area 5 No Preference 57 724.3033709PA0460008 Rating Area 5 No Preference 58 757.2933709PA0460008 Rating Area 5 No Preference 59 773.6333709PA0460008 Rating Area 5 No Preference 60 806.6233709PA0460008 Rating Area 5 No Preference 61 835.1533709PA0460008 Rating Area 5 No Preference 62 853.8833709PA0460008 Rating Area 5 No Preference 63 877.3633709PA0460008 Rating Area 5 No Preference 64 891.6233709PA0460008 Rating Area 5 No Preference 65 and over 891.6233709PA0460013 Rating Area 1 No Preference 0-20 203.1033709PA0460013 Rating Area 1 No Preference 21 319.8433709PA0460013 Rating Area 1 No Preference 22 319.8433709PA0460013 Rating Area 1 No Preference 23 319.8433709PA0460013 Rating Area 1 No Preference 24 319.8433709PA0460013 Rating Area 1 No Preference 25 321.1233709PA0460013 Rating Area 1 No Preference 26 327.5133709PA0460013 Rating Area 1 No Preference 27 335.1933709PA0460013 Rating Area 1 No Preference 28 347.6633709PA0460013 Rating Area 1 No Preference 29 357.9033709PA0460013 Rating Area 1 No Preference 30 363.0233709PA0460013 Rating Area 1 No Preference 31 370.6933709PA0460013 Rating Area 1 No Preference 32 378.3733709PA0460013 Rating Area 1 No Preference 33 383.1733709PA0460013 Rating Area 1 No Preference 34 388.2833709PA0460013 Rating Area 1 No Preference 35 390.8433709PA0460013 Rating Area 1 No Preference 36 393.4033709PA0460013 Rating Area 1 No Preference 37 395.9633709PA0460013 Rating Area 1 No Preference 38 398.5233709PA0460013 Rating Area 1 No Preference 39 403.6433709PA0460013 Rating Area 1 No Preference 40 408.7533709PA0460013 Rating Area 1 No Preference 41 416.4333709PA0460013 Rating Area 1 No Preference 42 423.7933709PA0460013 Rating Area 1 No Preference 43 434.0233709PA0460013 Rating Area 1 No Preference 44 446.8133709PA0460013 Rating Area 1 No Preference 45 461.8533709PA0460013 Rating Area 1 No Preference 46 479.7633709PA0460013 Rating Area 1 No Preference 47 499.9133709PA0460013 Rating Area 1 No Preference 48 522.9433709PA0460013 Rating Area 1 No Preference 49 545.6433709PA0460013 Rating Area 1 No Preference 50 571.2333709PA0460013 Rating Area 1 No Preference 51 596.5033709PA0460013 Rating Area 1 No Preference 52 624.3233709PA0460013 Rating Area 1 No Preference 53 652.47


Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0460013 Rating Area 1 No Preference 54 682.8533709PA0460013 Rating Area 1 No Preference 55 713.2433709PA0460013 Rating Area 1 No Preference 56 746.1833709PA0460013 Rating Area 1 No Preference 57 779.4533709PA0460013 Rating Area 1 No Preference 58 814.9533709PA0460013 Rating Area 1 No Preference 59 832.5433709PA0460013 Rating Area 1 No Preference 60 868.0433709PA0460013 Rating Area 1 No Preference 61 898.7533709PA0460013 Rating Area 1 No Preference 62 918.8933709PA0460013 Rating Area 1 No Preference 63 944.1633709PA0460013 Rating Area 1 No Preference 64 959.5133709PA0460013 Rating Area 1 No Preference 65 and over 959.5133709PA0460013 Rating Area 2 No Preference 0-20 203.1033709PA0460013 Rating Area 2 No Preference 21 319.8433709PA0460013 Rating Area 2 No Preference 22 319.8433709PA0460013 Rating Area 2 No Preference 23 319.8433709PA0460013 Rating Area 2 No Preference 24 319.8433709PA0460013 Rating Area 2 No Preference 25 321.1233709PA0460013 Rating Area 2 No Preference 26 327.5133709PA0460013 Rating Area 2 No Preference 27 335.1933709PA0460013 Rating Area 2 No Preference 28 347.6633709PA0460013 Rating Area 2 No Preference 29 357.9033709PA0460013 Rating Area 2 No Preference 30 363.0233709PA0460013 Rating Area 2 No Preference 31 370.6933709PA0460013 Rating Area 2 No Preference 32 378.3733709PA0460013 Rating Area 2 No Preference 33 383.1733709PA0460013 Rating Area 2 No Preference 34 388.2833709PA0460013 Rating Area 2 No Preference 35 390.8433709PA0460013 Rating Area 2 No Preference 36 393.4033709PA0460013 Rating Area 2 No Preference 37 395.9633709PA0460013 Rating Area 2 No Preference 38 398.5233709PA0460013 Rating Area 2 No Preference 39 403.6433709PA0460013 Rating Area 2 No Preference 40 408.7533709PA0460013 Rating Area 2 No Preference 41 416.4333709PA0460013 Rating Area 2 No Preference 42 423.7933709PA0460013 Rating Area 2 No Preference 43 434.0233709PA0460013 Rating Area 2 No Preference 44 446.8133709PA0460013 Rating Area 2 No Preference 45 461.8533709PA0460013 Rating Area 2 No Preference 46 479.7633709PA0460013 Rating Area 2 No Preference 47 499.9133709PA0460013 Rating Area 2 No Preference 48 522.9433709PA0460013 Rating Area 2 No Preference 49 545.6433709PA0460013 Rating Area 2 No Preference 50 571.2333709PA0460013 Rating Area 2 No Preference 51 596.5033709PA0460013 Rating Area 2 No Preference 52 624.3233709PA0460013 Rating Area 2 No Preference 53 652.4733709PA0460013 Rating Area 2 No Preference 54 682.8533709PA0460013 Rating Area 2 No Preference 55 713.2433709PA0460013 Rating Area 2 No Preference 56 746.1833709PA0460013 Rating Area 2 No Preference 57 779.4533709PA0460013 Rating Area 2 No Preference 58 814.9533709PA0460013 Rating Area 2 No Preference 59 832.5433709PA0460013 Rating Area 2 No Preference 60 868.0433709PA0460013 Rating Area 2 No Preference 61 898.7533709PA0460013 Rating Area 2 No Preference 62 918.8933709PA0460013 Rating Area 2 No Preference 63 944.1633709PA0460013 Rating Area 2 No Preference 64 959.5133709PA0460013 Rating Area 2 No Preference 65 and over 959.5133709PA0460013 Rating Area 5 No Preference 0-20 203.1033709PA0460013 Rating Area 5 No Preference 21 319.8433709PA0460013 Rating Area 5 No Preference 22 319.8433709PA0460013 Rating Area 5 No Preference 23 319.8433709PA0460013 Rating Area 5 No Preference 24 319.8433709PA0460013 Rating Area 5 No Preference 25 321.1233709PA0460013 Rating Area 5 No Preference 26 327.5133709PA0460013 Rating Area 5 No Preference 27 335.1933709PA0460013 Rating Area 5 No Preference 28 347.6633709PA0460013 Rating Area 5 No Preference 29 357.9033709PA0460013 Rating Area 5 No Preference 30 363.0233709PA0460013 Rating Area 5 No Preference 31 370.6933709PA0460013 Rating Area 5 No Preference 32 378.3733709PA0460013 Rating Area 5 No Preference 33 383.1733709PA0460013 Rating Area 5 No Preference 34 388.2833709PA0460013 Rating Area 5 No Preference 35 390.8433709PA0460013 Rating Area 5 No Preference 36 393.4033709PA0460013 Rating Area 5 No Preference 37 395.9633709PA0460013 Rating Area 5 No Preference 38 398.5233709PA0460013 Rating Area 5 No Preference 39 403.6433709PA0460013 Rating Area 5 No Preference 40 408.7533709PA0460013 Rating Area 5 No Preference 41 416.4333709PA0460013 Rating Area 5 No Preference 42 423.7933709PA0460013 Rating Area 5 No Preference 43 434.0233709PA0460013 Rating Area 5 No Preference 44 446.8133709PA0460013 Rating Area 5 No Preference 45 461.8533709PA0460013 Rating Area 5 No Preference 46 479.7633709PA0460013 Rating Area 5 No Preference 47 499.9133709PA0460013 Rating Area 5 No Preference 48 522.9433709PA0460013 Rating Area 5 No Preference 49 545.6433709PA0460013 Rating Area 5 No Preference 50 571.2333709PA0460013 Rating Area 5 No Preference 51 596.5033709PA0460013 Rating Area 5 No Preference 52 624.3233709PA0460013 Rating Area 5 No Preference 53 652.4733709PA0460013 Rating Area 5 No Preference 54 682.8533709PA0460013 Rating Area 5 No Preference 55 713.2433709PA0460013 Rating Area 5 No Preference 56 746.1833709PA0460013 Rating Area 5 No Preference 57 779.4533709PA0460013 Rating Area 5 No Preference 58 814.9533709PA0460013 Rating Area 5 No Preference 59 832.5433709PA0460013 Rating Area 5 No Preference 60 868.0433709PA0460013 Rating Area 5 No Preference 61 898.7533709PA0460013 Rating Area 5 No Preference 62 918.8933709PA0460013 Rating Area 5 No Preference 63 944.1633709PA0460013 Rating Area 5 No Preference 64 959.5133709PA0460013 Rating Area 5 No Preference 65 and over 959.51


Required:


Required:


Require:



plan

Required:


rate

Required:





Required:


Required:


Require:



plan

Required:


rate

Required:



33709PA0630009 Rating Area 1 No Preference 26 230.5933709PA0630009 Rating Area 1 No Preference 27 235.9933709PA0630009 Rating Area 1 No Preference 28 244.7833709PA0630009 Rating Area 1 No Preference 29 251.9833709PA0630009 Rating Area 1 No Preference 30 255.5933709PA0630009 Rating Area 1 No Preference 31 260.9933709PA0630009 Rating Area 1 No Preference 32 266.3933709PA0630009 Rating Area 1 No Preference 33 269.7733709PA0630009 Rating Area 1 No Preference 34 273.3833709PA0630009 Rating Area 1 No Preference 35 275.1833709PA0630009 Rating Area 1 No Preference 36 276.9833709PA0630009 Rating Area 1 No Preference 37 278.7833709PA0630009 Rating Area 1 No Preference 38 280.5833709PA0630009 Rating Area 1 No Preference 39 284.1833709PA0630009 Rating Area 1 No Preference 40 287.7933709PA0630009 Rating Area 1 No Preference 41 293.1933709PA0630009 Rating Area 1 No Preference 42 298.3733709PA0630009 Rating Area 1 No Preference 43 305.5833709PA0630009 Rating Area 1 No Preference 44 314.5833709PA0630009 Rating Area 1 No Preference 45 325.1733709PA0630009 Rating Area 1 No Preference 46 337.7833709PA0630009 Rating Area 1 No Preference 47 351.9633709PA0630009 Rating Area 1 No Preference 48 368.1833709PA0630009 Rating Area 1 No Preference 49 384.1733709PA0630009 Rating Area 1 No Preference 50 402.1833709PA0630009 Rating Area 1 No Preference 51 419.9733709PA0630009 Rating Area 1 No Preference 52 439.5633709PA0630009 Rating Area 1 No Preference 53 459.3833709PA0630009 Rating Area 1 No Preference 54 480.7733709PA0630009 Rating Area 1 No Preference 55 502.1633709PA0630009 Rating Area 1 No Preference 56 525.3633709PA0630009 Rating Area 1 No Preference 57 548.7833709PA0630009 Rating Area 1 No Preference 58 573.7733709PA0630009 Rating Area 1 No Preference 59 586.1633709PA0630009 Rating Area 1 No Preference 60 611.1533709PA0630009 Rating Area 1 No Preference 61 632.7733709PA0630009 Rating Area 1 No Preference 62 646.9633709PA0630009 Rating Area 1 No Preference 63 664.7533709PA0630009 Rating Area 1 No Preference 64 675.5633709PA0630009 Rating Area 1 No Preference 65 and over 675.5633709PA0630009 Rating Area 4 No Preference 0-20 142.9933709PA0630009 Rating Area 4 No Preference 21 225.1933709PA0630009 Rating Area 4 No Preference 22 225.1933709PA0630009 Rating Area 4 No Preference 23 225.1933709PA0630009 Rating Area 4 No Preference 24 225.1933709PA0630009 Rating Area 4 No Preference 25 226.0933709PA0630009 Rating Area 4 No Preference 26 230.5933709PA0630009 Rating Area 4 No Preference 27 235.9933709PA0630009 Rating Area 4 No Preference 28 244.7833709PA0630009 Rating Area 4 No Preference 29 251.9833709PA0630009 Rating Area 4 No Preference 30 255.5933709PA0630009 Rating Area 4 No Preference 31 260.9933709PA0630009 Rating Area 4 No Preference 32 266.3933709PA0630009 Rating Area 4 No Preference 33 269.7733709PA0630009 Rating Area 4 No Preference 34 273.3833709PA0630009 Rating Area 4 No Preference 35 275.1833709PA0630009 Rating Area 4 No Preference 36 276.9833709PA0630009 Rating Area 4 No Preference 37 278.7833709PA0630009 Rating Area 4 No Preference 38 280.5833709PA0630009 Rating Area 4 No Preference 39 284.1833709PA0630009 Rating Area 4 No Preference 40 287.7933709PA0630009 Rating Area 4 No Preference 41 293.1933709PA0630009 Rating Area 4 No Preference 42 298.3733709PA0630009 Rating Area 4 No Preference 43 305.5833709PA0630009 Rating Area 4 No Preference 44 314.5833709PA0630009 Rating Area 4 No Preference 45 325.1733709PA0630009 Rating Area 4 No Preference 46 337.7833709PA0630009 Rating Area 4 No Preference 47 351.9633709PA0630009 Rating Area 4 No Preference 48 368.1833709PA0630009 Rating Area 4 No Preference 49 384.1733709PA0630009 Rating Area 4 No Preference 50 402.1833709PA0630009 Rating Area 4 No Preference 51 419.9733709PA0630009 Rating Area 4 No Preference 52 439.5633709PA0630009 Rating Area 4 No Preference 53 459.3833709PA0630009 Rating Area 4 No Preference 54 480.7733709PA0630009 Rating Area 4 No Preference 55 502.1633709PA0630009 Rating Area 4 No Preference 56 525.3633709PA0630009 Rating Area 4 No Preference 57 548.7833709PA0630009 Rating Area 4 No Preference 58 573.7733709PA0630009 Rating Area 4 No Preference 59 586.1633709PA0630009 Rating Area 4 No Preference 60 611.1533709PA0630009 Rating Area 4 No Preference 61 632.7733709PA0630009 Rating Area 4 No Preference 62 646.9633709PA0630009 Rating Area 4 No Preference 63 664.7533709PA0630009 Rating Area 4 No Preference 64 675.5633709PA0630009 Rating Area 4 No Preference 65 and over 675.56









Required:


Required:


Require:



plan

Required:


rate

Required:





Exhibit V

HIOS Plan ID

On/Off

Exchange Product Metal Plan Design Marketing Name Network Rating Area Counties Excluded

33709PA0560007 Off Only Premier Balance PPO Platinum Premier Balance PPO $0 Platinum A a Community Blue Flex Plan A 1,4 Clarion, Forest, Venango


33709PA0560011 Off Only Premier Balance PPO Gold Premier Balance PPO $0 Gold A a Community Blue Flex Plan A 1,4 Clarion, Forest, Venango


33709PA0560015 Off Only Premier Balance PPO Gold Premier Balance PPO $500 A a Community Blue Flex Plan A 1,4 Clarion, Forest, Venango






33709PA0560029 Off Only Premier Balance PPO Silver Premier Balance PPO $1400 A a Community Blue Flex Plan A 1,4 Clarion, Forest, Venango

33709PA0570007 Off Only Balance PPO Silver Balance PPO $1000 A a Community Blue Flex Plan A 1,4 Clarion, Forest, Venango



33709PA0450004 Off Only Health Savings PPO Gold Health Savings PPO $1500 a Community Blue Flex Plan A 1,4 Clarion, Forest, Venango

33709PA0640001 Off Only Health Savings PPO Silver Health Savings PPO Embedded $2600 a Community Blue Flex Plan A 1,4 Clarion, Forest, Venango


33709PA0640003 Off Only Health Savings PPO Bronze Health Savings PPO Embedded $5500 a Community Blue Flex Plan A 1,4 Clarion, Forest, Venango

33709PA0640004 Off Only Health Savings PPO Bronze Health Savings PPO Embedded $5500 a Community Blue Flex Plan B 1,2,5,6 Crawford, Erie, McKean, Mercer, Warren


33709PA0460007 Off Only Health Savings PPO Gold Flex PPO $500/$1500 Penn Highlands Region a Community Blue Plan H 2, 5, 6 Bedford, Blair, Cambria, Huntingdon, Somerset, Cameron, Potter

33709PA0460008 Off Only Health Savings PPO Gold Flex PPO PA Mountains Healthcare Region $500/$1500 a Community Blue Plan G 1, 2, 4, 5

Allegheny, Beaver, Butler, Erie, Fayette, Greene, Mercer, Warren,

Washington, Westmoreland, Bedford, Cambria, Clearfield, Elk,

Venango

33709PA0460012 Off Only Flex PPO Gold Flex PPO $500 Total Health a Community Blue Plan A 1,4 Clarion, Forest, Venango

33709PA0460013 Off Only Flex PPO Gold Flex PPO $500 Total Health a Community Blue Plan B 1,2,5,6 Crawford, Erie, McKean, Mercer, Warren

33709PA0630002 Off Only Connect Blue EPO Gold Connect Blue EPO $100 a Community Blue Plan J 1,4Crawford, McKean, Mercer, Warren, Clarion, Forest, Venango,

Armstrong, Fayette, Greene, Indiana, Lawrence











33709PA0630007 Off Only Connect Blue EPO Silver Connect Blue EPO $2500 a Community Blue Plan J 1,4Crawford, McKean, Mercer, Warren, Clarion, Forest, Venango,




33709PA0440014 Off Only Premier Balance PPO Gold Premier Balance PPO $250 IP A a Community Blue Flex Plan B 1,2,5,6 Crawford, Erie, McKean, Mercer, Warren


33709PA0440013 Off Only Premier Balance PPO Silver Premier Balance PPO $1500 IP A a Community Blue Flex Plan B 1,2,5,6 Crawford, Erie, McKean, Mercer, Warren

Highmark Inc.

Small Group Market

Plan Design Summary

Filing # 1A-SG-Highmark-2016 Proprietary Confidential 08/11/2016

Exhibit VI-A-WPA-Zone ACompany Name: Highmark Inc., d/b/a as Highmark Blue Cross Blue Shield PA (Western, PA Region) - Service Zone AProduct (Small Group Market):Effective Date of Rates:

HIOS Plan ID (Off Exchange)

Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

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

0 - 20 $225.43 $225.43 $221.68 $221.68 $190.88 $190.88 $193.57 $193.57 $189.39 $189.39 $186.97 $186.97

21 $355.00 $355.00 $349.10 $349.10 $300.59 $300.59 $304.84 $304.84 $298.25 $298.25 $294.43 $294.43

22 $355.00 $355.00 $349.10 $349.10 $300.59 $300.59 $304.84 $304.84 $298.25 $298.25 $294.43 $294.43

23 $355.00 $355.00 $349.10 $349.10 $300.59 $300.59 $304.84 $304.84 $298.25 $298.25 $294.43 $294.43

24 $355.00 $355.00 $349.10 $349.10 $300.59 $300.59 $304.84 $304.84 $298.25 $298.25 $294.43 $294.43

25 $356.42 $356.42 $350.50 $350.50 $301.80 $301.80 $306.06 $306.06 $299.44 $299.44 $295.61 $295.61

26 $363.52 $363.52 $357.48 $357.48 $307.81 $307.81 $312.16 $312.16 $305.40 $305.40 $301.50 $301.50

27 $372.04 $372.04 $365.86 $365.86 $315.02 $315.02 $319.47 $319.47 $312.56 $312.56 $308.57 $308.57

28 $385.89 $385.89 $379.47 $379.47 $326.74 $326.74 $331.36 $331.36 $324.19 $324.19 $320.05 $320.05

29 $397.25 $397.25 $390.65 $390.65 $336.36 $336.36 $341.12 $341.12 $333.74 $333.74 $329.47 $329.47

30 $402.93 $402.93 $396.23 $396.23 $341.17 $341.17 $346.00 $346.00 $338.51 $338.51 $334.18 $334.18

31 $411.45 $411.45 $404.61 $404.61 $348.39 $348.39 $353.31 $353.31 $345.67 $345.67 $341.25 $341.25

32 $419.97 $419.97 $412.99 $412.99 $355.60 $355.60 $360.63 $360.63 $352.82 $352.82 $348.32 $348.32

33 $425.29 $425.29 $418.23 $418.23 $360.11 $360.11 $365.20 $365.20 $357.30 $357.30 $352.73 $352.73

34 $430.97 $430.97 $423.81 $423.81 $364.92 $364.92 $370.08 $370.08 $362.07 $362.07 $357.44 $357.44

35 $433.81 $433.81 $426.60 $426.60 $367.33 $367.33 $372.52 $372.52 $364.46 $364.46 $359.80 $359.80

36 $436.65 $436.65 $429.40 $429.40 $369.73 $369.73 $374.96 $374.96 $366.84 $366.84 $362.15 $362.15

37 $439.49 $439.49 $432.19 $432.19 $372.13 $372.13 $377.39 $377.39 $369.23 $369.23 $364.51 $364.51

38 $442.33 $442.33 $434.98 $434.98 $374.54 $374.54 $379.83 $379.83 $371.61 $371.61 $366.86 $366.86

39 $448.01 $448.01 $440.57 $440.57 $379.35 $379.35 $384.71 $384.71 $376.39 $376.39 $371.58 $371.58

40 $453.69 $453.69 $446.15 $446.15 $384.16 $384.16 $389.59 $389.59 $381.16 $381.16 $376.29 $376.29

41 $462.21 $462.21 $454.53 $454.53 $391.37 $391.37 $396.90 $396.90 $388.32 $388.32 $383.35 $383.35

42 $470.38 $470.38 $462.56 $462.56 $398.29 $398.29 $403.92 $403.92 $395.18 $395.18 $390.12 $390.12

43 $481.74 $481.74 $473.73 $473.73 $407.91 $407.91 $413.67 $413.67 $404.72 $404.72 $399.55 $399.55

44 $495.94 $495.94 $487.70 $487.70 $419.93 $419.93 $425.86 $425.86 $416.65 $416.65 $411.32 $411.32

45 $512.62 $512.62 $504.10 $504.10 $434.06 $434.06 $440.19 $440.19 $430.67 $430.67 $425.16 $425.16

46 $532.50 $532.50 $523.65 $523.65 $450.89 $450.89 $457.26 $457.26 $447.37 $447.37 $441.65 $441.65

47 $554.87 $554.87 $545.65 $545.65 $469.83 $469.83 $476.47 $476.47 $466.16 $466.16 $460.20 $460.20

48 $580.43 $580.43 $570.78 $570.78 $491.47 $491.47 $498.42 $498.42 $487.63 $487.63 $481.40 $481.40

49 $605.63 $605.63 $595.57 $595.57 $512.81 $512.81 $520.06 $520.06 $508.81 $508.81 $502.30 $502.30

50 $634.03 $634.03 $623.50 $623.50 $536.86 $536.86 $544.45 $544.45 $532.67 $532.67 $525.86 $525.86

51 $662.08 $662.08 $651.08 $651.08 $560.61 $560.61 $568.53 $568.53 $556.23 $556.23 $549.12 $549.12

52 $692.96 $692.96 $681.45 $681.45 $586.76 $586.76 $595.05 $595.05 $582.18 $582.18 $574.73 $574.73

53 $724.20 $724.20 $712.17 $712.17 $613.21 $613.21 $621.88 $621.88 $608.42 $608.42 $600.64 $600.64

54 $757.93 $757.93 $745.33 $745.33 $641.77 $641.77 $650.84 $650.84 $636.75 $636.75 $628.62 $628.62

55 $791.65 $791.65 $778.50 $778.50 $670.32 $670.32 $679.80 $679.80 $665.09 $665.09 $656.59 $656.59

56 $828.22 $828.22 $814.46 $814.46 $701.28 $701.28 $711.20 $711.20 $695.81 $695.81 $686.91 $686.91

57 $865.14 $865.14 $850.76 $850.76 $732.55 $732.55 $742.90 $742.90 $726.83 $726.83 $717.54 $717.54

58 $904.54 $904.54 $889.51 $889.51 $765.91 $765.91 $776.74 $776.74 $759.93 $759.93 $750.22 $750.22

59 $924.07 $924.07 $908.72 $908.72 $782.44 $782.44 $793.50 $793.50 $776.33 $776.33 $766.41 $766.41

60 $963.47 $963.47 $947.47 $947.47 $815.81 $815.81 $827.34 $827.34 $809.44 $809.44 $799.09 $799.09

61 $997.55 $997.55 $980.98 $980.98 $844.67 $844.67 $856.61 $856.61 $838.07 $838.07 $827.36 $827.36

62 $1,019.92 $1,019.92 $1,002.97 $1,002.97 $863.60 $863.60 $875.81 $875.81 $856.86 $856.86 $845.91 $845.91

63 $1,047.96 $1,047.96 $1,030.55 $1,030.55 $887.35 $887.35 $899.89 $899.89 $880.42 $880.42 $869.17 $869.17

64 $1,065.00 $1,065.00 $1,047.30 $1,047.30 $901.77 $901.77 $914.52 $914.52 $894.74 $894.74 $883.29 $883.29

65+ $1,065.00 $1,065.00 $1,047.30 $1,047.30 $901.77 $901.77 $914.52 $914.52 $894.74 $894.74 $883.29 $883.29

Yes Yes Yes Yes Yes Yes

$1,600 $1,300 $7,150 $7,150 $5,300 $4,800

$10/$40 $10/$40 $25/$70 $20/$60 $20/$60 $20/$60

100%/70%/50% 100%/70%/50% 100%/60%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$0/$500 $250/$750 $0/$5,000 $250/$750 $500/$1,500 $750/$1,500

Premier Balance PPO $0 Platinum A

a Community Blue Flex Plan

Premier Balance PPO $250

Platinum A a Community Blue Flex

Plan

Premier Balance PPO $0 Gold A a

Community Blue Flex Plan



Premier Balance PPO $500 A a




Platinum Platinum Gold Gold Gold Gold

A A A A A A

Area 1, 4 Area 1, 4 Area 1, 4 Area 1, 4 Area 1, 4 Area 1, 4

PPO-SM/WG-4 PPO-SM/WG-4 PPO-SM/WG-4 PPO-SM/WG-4 PPO-SM/WG-4 PPO-SM/WG-4

33709PA0560011 33709PA0560013 33709PA0560015 33709PA056001733709PA0560007 33709PA0560009

Premier Balance PPO Premier Balance PPO Premier Balance PPO Premier Balance PPO

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17

Premier Balance PPO Premier Balance PPO




Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+

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

$183.96 $183.96 $182.52 $182.52 $181.16 $181.16 $179.23 $179.23 $160.73 $160.73 $159.36 $159.36

$289.70 $289.70 $287.43 $287.43 $285.30 $285.30 $282.25 $282.25 $253.12 $253.12 $250.96 $250.96

$289.70 $289.70 $287.43 $287.43 $285.30 $285.30 $282.25 $282.25 $253.12 $253.12 $250.96 $250.96

$289.70 $289.70 $287.43 $287.43 $285.30 $285.30 $282.25 $282.25 $253.12 $253.12 $250.96 $250.96

$289.70 $289.70 $287.43 $287.43 $285.30 $285.30 $282.25 $282.25 $253.12 $253.12 $250.96 $250.96

$290.86 $290.86 $288.58 $288.58 $286.44 $286.44 $283.38 $283.38 $254.13 $254.13 $251.96 $251.96

$296.65 $296.65 $294.33 $294.33 $292.14 $292.14 $289.02 $289.02 $259.20 $259.20 $256.98 $256.98

$303.61 $303.61 $301.23 $301.23 $298.99 $298.99 $295.80 $295.80 $265.27 $265.27 $263.00 $263.00

$314.90 $314.90 $312.44 $312.44 $310.12 $310.12 $306.81 $306.81 $275.14 $275.14 $272.79 $272.79

$324.17 $324.17 $321.63 $321.63 $319.25 $319.25 $315.84 $315.84 $283.24 $283.24 $280.82 $280.82

$328.81 $328.81 $326.23 $326.23 $323.81 $323.81 $320.35 $320.35 $287.29 $287.29 $284.84 $284.84

$335.76 $335.76 $333.13 $333.13 $330.66 $330.66 $327.13 $327.13 $293.37 $293.37 $290.86 $290.86

$342.72 $342.72 $340.03 $340.03 $337.51 $337.51 $333.90 $333.90 $299.44 $299.44 $296.88 $296.88

$347.06 $347.06 $344.34 $344.34 $341.79 $341.79 $338.14 $338.14 $303.24 $303.24 $300.65 $300.65

$351.70 $351.70 $348.94 $348.94 $346.35 $346.35 $342.65 $342.65 $307.29 $307.29 $304.66 $304.66

$354.01 $354.01 $351.24 $351.24 $348.63 $348.63 $344.91 $344.91 $309.31 $309.31 $306.67 $306.67

$356.33 $356.33 $353.54 $353.54 $350.91 $350.91 $347.17 $347.17 $311.34 $311.34 $308.68 $308.68

$358.65 $358.65 $355.84 $355.84 $353.20 $353.20 $349.43 $349.43 $313.36 $313.36 $310.69 $310.69

$360.97 $360.97 $358.14 $358.14 $355.48 $355.48 $351.68 $351.68 $315.39 $315.39 $312.69 $312.69

$365.60 $365.60 $362.74 $362.74 $360.04 $360.04 $356.20 $356.20 $319.44 $319.44 $316.71 $316.71

$370.24 $370.24 $367.34 $367.34 $364.61 $364.61 $360.72 $360.72 $323.49 $323.49 $320.72 $320.72

$377.19 $377.19 $374.23 $374.23 $371.46 $371.46 $367.49 $367.49 $329.56 $329.56 $326.75 $326.75

$383.85 $383.85 $380.85 $380.85 $378.02 $378.02 $373.98 $373.98 $335.39 $335.39 $332.52 $332.52

$393.12 $393.12 $390.04 $390.04 $387.15 $387.15 $383.01 $383.01 $343.49 $343.49 $340.55 $340.55

$404.71 $404.71 $401.54 $401.54 $398.56 $398.56 $394.30 $394.30 $353.61 $353.61 $350.59 $350.59

$418.33 $418.33 $415.05 $415.05 $411.97 $411.97 $407.57 $407.57 $365.51 $365.51 $362.38 $362.38

$434.55 $434.55 $431.15 $431.15 $427.94 $427.94 $423.38 $423.38 $379.68 $379.68 $376.44 $376.44

$452.80 $452.80 $449.25 $449.25 $445.92 $445.92 $441.16 $441.16 $395.63 $395.63 $392.25 $392.25

$473.66 $473.66 $469.95 $469.95 $466.46 $466.46 $461.48 $461.48 $413.85 $413.85 $410.32 $410.32

$494.23 $494.23 $490.36 $490.36 $486.72 $486.72 $481.52 $481.52 $431.83 $431.83 $428.14 $428.14

$517.40 $517.40 $513.35 $513.35 $509.54 $509.54 $504.10 $504.10 $452.07 $452.07 $448.21 $448.21

$540.29 $540.29 $536.06 $536.06 $532.08 $532.08 $526.40 $526.40 $472.07 $472.07 $468.04 $468.04

$565.49 $565.49 $561.06 $561.06 $556.90 $556.90 $550.95 $550.95 $494.09 $494.09 $489.87 $489.87

$590.99 $590.99 $586.36 $586.36 $582.00 $582.00 $575.79 $575.79 $516.37 $516.37 $511.96 $511.96

$618.51 $618.51 $613.66 $613.66 $609.11 $609.11 $602.61 $602.61 $540.41 $540.41 $535.80 $535.80

$646.03 $646.03 $640.97 $640.97 $636.21 $636.21 $629.42 $629.42 $564.46 $564.46 $559.64 $559.64

$675.87 $675.87 $670.58 $670.58 $665.60 $665.60 $658.49 $658.49 $590.53 $590.53 $585.49 $585.49

$706.00 $706.00 $700.47 $700.47 $695.27 $695.27 $687.84 $687.84 $616.86 $616.86 $611.59 $611.59

$738.16 $738.16 $732.37 $732.37 $726.94 $726.94 $719.17 $719.17 $644.95 $644.95 $639.44 $639.44

$754.09 $754.09 $748.18 $748.18 $742.63 $742.63 $734.70 $734.70 $658.88 $658.88 $653.24 $653.24

$786.25 $786.25 $780.09 $780.09 $774.29 $774.29 $766.03 $766.03 $686.97 $686.97 $681.10 $681.10

$814.06 $814.06 $807.68 $807.68 $801.68 $801.68 $793.12 $793.12 $711.27 $711.27 $705.19 $705.19

$832.31 $832.31 $825.79 $825.79 $819.66 $819.66 $810.91 $810.91 $727.22 $727.22 $721.00 $721.00

$855.19 $855.19 $848.49 $848.49 $842.19 $842.19 $833.20 $833.20 $747.21 $747.21 $740.83 $740.83

$869.10 $869.10 $862.29 $862.29 $855.89 $855.89 $846.75 $846.75 $759.36 $759.36 $752.88 $752.88

$869.10 $869.10 $862.29 $862.29 $855.89 $855.89 $846.75 $846.75 $759.36 $759.36 $752.88 $752.88

Yes Yes Yes YesYes Yes

$4,800 $4,000 $3,700 $3,450 $7,150 $7,150

$20/$60 $20/$60 $40/$75 $45/$75*$20/$60 $20/$60

100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 90%/70%/50%

$1,500/$3,000 $2,000/$3,000 $1,400/$5,000 $1,000/$5,000$1,000/$2,000 $1,250/$2,500











Balance PPO $1000 A a Community

Blue Flex Plan

Gold Gold Silver SilverGold Gold

A A A A A A

Area 1, 4 Area 1, 4 Area 1, 4 Area 1, 4Area 1, 4 Area 1, 4


01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17

33709PA0560019 33709PA0560021 33709PA0560023 33709PA0560027 33709PA0560029 33709PA0570007

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17

Premier Balance PPO Premier Balance PPO Premier Balance PPO Premier Balance PPO Premier Balance PPO Balance PPO




Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$156.80 $156.80 $155.25 $155.25 $177.39 $177.39 $156.96 $156.96 $152.98 $152.98 $127.15 $127.15

$246.93 $246.93 $244.49 $244.49 $279.36 $279.36 $247.19 $247.19 $240.92 $240.92 $200.24 $200.24

$246.93 $246.93 $244.49 $244.49 $279.36 $279.36 $247.19 $247.19 $240.92 $240.92 $200.24 $200.24

$246.93 $246.93 $244.49 $244.49 $279.36 $279.36 $247.19 $247.19 $240.92 $240.92 $200.24 $200.24

$246.93 $246.93 $244.49 $244.49 $279.36 $279.36 $247.19 $247.19 $240.92 $240.92 $200.24 $200.24

$247.92 $247.92 $245.47 $245.47 $280.48 $280.48 $248.17 $248.17 $241.88 $241.88 $201.04 $201.04

$252.86 $252.86 $250.36 $250.36 $286.06 $286.06 $253.12 $253.12 $246.70 $246.70 $205.04 $205.04

$258.79 $258.79 $256.22 $256.22 $292.77 $292.77 $259.05 $259.05 $252.48 $252.48 $209.85 $209.85

$268.42 $268.42 $265.76 $265.76 $303.66 $303.66 $268.69 $268.69 $261.88 $261.88 $217.66 $217.66

$276.32 $276.32 $273.58 $273.58 $312.60 $312.60 $276.60 $276.60 $269.59 $269.59 $224.07 $224.07

$280.27 $280.27 $277.49 $277.49 $317.07 $317.07 $280.56 $280.56 $273.44 $273.44 $227.27 $227.27

$286.20 $286.20 $283.36 $283.36 $323.78 $323.78 $286.49 $286.49 $279.23 $279.23 $232.07 $232.07

$292.12 $292.12 $289.23 $289.23 $330.48 $330.48 $292.42 $292.42 $285.01 $285.01 $236.88 $236.88

$295.83 $295.83 $292.90 $292.90 $334.67 $334.67 $296.13 $296.13 $288.62 $288.62 $239.88 $239.88

$299.78 $299.78 $296.81 $296.81 $339.14 $339.14 $300.08 $300.08 $292.48 $292.48 $243.09 $243.09

$301.75 $301.75 $298.76 $298.76 $341.38 $341.38 $302.06 $302.06 $294.40 $294.40 $244.69 $244.69

$303.73 $303.73 $300.72 $300.72 $343.61 $343.61 $304.04 $304.04 $296.33 $296.33 $246.29 $246.29

$305.70 $305.70 $302.68 $302.68 $345.85 $345.85 $306.02 $306.02 $298.26 $298.26 $247.89 $247.89

$307.68 $307.68 $304.63 $304.63 $348.08 $348.08 $307.99 $307.99 $300.18 $300.18 $249.50 $249.50

$311.63 $311.63 $308.54 $308.54 $352.55 $352.55 $311.95 $311.95 $304.04 $304.04 $252.70 $252.70

$315.58 $315.58 $312.46 $312.46 $357.02 $357.02 $315.90 $315.90 $307.89 $307.89 $255.90 $255.90

$321.51 $321.51 $318.32 $318.32 $363.73 $363.73 $321.84 $321.84 $313.68 $313.68 $260.71 $260.71

$327.19 $327.19 $323.95 $323.95 $370.15 $370.15 $327.52 $327.52 $319.22 $319.22 $265.31 $265.31

$335.09 $335.09 $331.77 $331.77 $379.09 $379.09 $335.43 $335.43 $326.93 $326.93 $271.72 $271.72

$344.97 $344.97 $341.55 $341.55 $390.27 $390.27 $345.32 $345.32 $336.56 $336.56 $279.73 $279.73

$356.57 $356.57 $353.04 $353.04 $403.40 $403.40 $356.94 $356.94 $347.89 $347.89 $289.14 $289.14

$370.40 $370.40 $366.73 $366.73 $419.04 $419.04 $370.78 $370.78 $361.38 $361.38 $300.36 $300.36

$385.96 $385.96 $382.14 $382.14 $436.64 $436.64 $386.35 $386.35 $376.56 $376.56 $312.97 $312.97

$403.74 $403.74 $399.74 $399.74 $456.75 $456.75 $404.15 $404.15 $393.90 $393.90 $327.39 $327.39

$421.27 $421.27 $417.10 $417.10 $476.59 $476.59 $421.70 $421.70 $411.01 $411.01 $341.60 $341.60

$441.02 $441.02 $436.66 $436.66 $498.94 $498.94 $441.47 $441.47 $430.28 $430.28 $357.62 $357.62

$460.53 $460.53 $455.97 $455.97 $521.01 $521.01 $461.00 $461.00 $449.31 $449.31 $373.44 $373.44

$482.01 $482.01 $477.24 $477.24 $545.31 $545.31 $482.51 $482.51 $470.27 $470.27 $390.86 $390.86

$503.74 $503.74 $498.76 $498.76 $569.89 $569.89 $504.26 $504.26 $491.47 $491.47 $408.48 $408.48

$527.20 $527.20 $521.98 $521.98 $596.43 $596.43 $527.74 $527.74 $514.36 $514.36 $427.51 $427.51

$550.66 $550.66 $545.21 $545.21 $622.97 $622.97 $551.22 $551.22 $537.25 $537.25 $446.53 $446.53

$576.09 $576.09 $570.39 $570.39 $651.75 $651.75 $576.68 $576.68 $562.06 $562.06 $467.15 $467.15

$601.78 $601.78 $595.82 $595.82 $680.80 $680.80 $602.39 $602.39 $587.12 $587.12 $487.98 $487.98

$629.19 $629.19 $622.96 $622.96 $711.81 $711.81 $629.83 $629.83 $613.86 $613.86 $510.20 $510.20

$642.77 $642.77 $636.40 $636.40 $727.17 $727.17 $643.42 $643.42 $627.11 $627.11 $521.22 $521.22

$670.18 $670.18 $663.54 $663.54 $758.18 $758.18 $670.86 $670.86 $653.85 $653.85 $543.44 $543.44

$693.88 $693.88 $687.01 $687.01 $785.00 $785.00 $694.59 $694.59 $676.98 $676.98 $562.67 $562.67

$709.44 $709.44 $702.42 $702.42 $802.60 $802.60 $710.16 $710.16 $692.16 $692.16 $575.28 $575.28

$728.95 $728.95 $721.73 $721.73 $824.67 $824.67 $729.69 $729.69 $711.19 $711.19 $591.10 $591.10

$740.79 $740.79 $733.47 $733.47 $838.08 $838.08 $741.56 $741.56 $722.76 $722.76 $600.71 $600.71

$740.79 $740.79 $733.47 $733.47 $838.08 $838.08 $741.56 $741.56 $722.76 $722.76 $600.71 $600.71

Yes Yes YesYes Yes

$7,150 $7,150 $3,500 $6,550 $6,550 $6,550

Yes

$15*/$50* 100%*/$30* 100%* /70%* 80%*/60%*$35/$65 $35/$65

90%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 80%/60%/50%90%/70%/50%

$2,600 $3,000 $5,500$1,750/$5,250 $2,000/$6,000


Blue Flex Plan


Blue Flex Plan

Health Savings PPO $1500 a


Health Savings PPO Embedded

$2600 a Community Blue Flex Plan





$1,500

Gold Silver Silver BronzeSilver Silver

A A A A AA

Area 1, 4 Area 1, 4 Area 1, 4Area 1, 4 Area 1, 4

PPO-SM/WG-4 PPO-SM/WG-4 HDHP-SM/WG-4 HDHP-SM/WG-4 HDHP-SM/WG-4 HDHP-SM/WG-4

Area 1, 4

33709PA0570006 33709PA0450004 33709PA0640001 33709PA0640002 33709PA0640003

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17

33709PA0570004

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17

Balance PPO Balance PPO Health Savings PPO Health Savings PPO Health Savings PPO Health Savings PPO

01/1/17, 02/1/17, 03/1/17




Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco

$127.56 $127.56 $190.72 $190.72

$200.89 $200.89 $300.34 $300.34

$200.89 $200.89 $300.34 $300.34

$200.89 $200.89 $300.34 $300.34

$200.89 $200.89 $300.34 $300.34

$201.69 $201.69 $301.54 $301.54

$205.71 $205.71 $307.55 $307.55

$210.53 $210.53 $314.76 $314.76

$218.36 $218.36 $326.47 $326.47

$224.79 $224.79 $336.08 $336.08

$228.01 $228.01 $340.89 $340.89

$232.83 $232.83 $348.10 $348.10

$237.65 $237.65 $355.30 $355.30

$240.66 $240.66 $359.81 $359.81

$243.88 $243.88 $364.61 $364.61

$245.48 $245.48 $367.02 $367.02

$247.09 $247.09 $369.42 $369.42

$248.70 $248.70 $371.82 $371.82

$250.31 $250.31 $374.23 $374.23

$253.52 $253.52 $379.03 $379.03

$256.73 $256.73 $383.84 $383.84

$261.55 $261.55 $391.04 $391.04

$266.18 $266.18 $397.95 $397.95

$272.60 $272.60 $407.56 $407.56

$280.64 $280.64 $419.58 $419.58

$290.08 $290.08 $433.69 $433.69

$301.33 $301.33 $450.51 $450.51

$313.99 $313.99 $469.43 $469.43

$328.45 $328.45 $491.06 $491.06

$342.71 $342.71 $512.38 $512.38

$358.78 $358.78 $536.41 $536.41

$374.65 $374.65 $560.14 $560.14

$392.13 $392.13 $586.27 $586.27

$409.81 $409.81 $612.70 $612.70

$428.89 $428.89 $641.23 $641.23

$447.98 $447.98 $669.76 $669.76

$468.67 $468.67 $700.70 $700.70

$489.56 $489.56 $731.93 $731.93

$511.86 $511.86 $765.27 $765.27

$522.91 $522.91 $781.79 $781.79

$545.21 $545.21 $815.13 $815.13

$564.49 $564.49 $843.96 $843.96

$577.15 $577.15 $862.88 $862.88

$593.02 $593.02 $886.61 $886.61

$602.66 $602.66 $901.02 $901.02

$602.66 $602.66 $901.02 $901.02

Yes Yes

$5,500

100%*/70%

$6,550

RC - $35

100%/70%/50% 100%/70%/50%

$6,000 $500/$1,500

Flex PPO $500 Total Health a

Community Blue Plan

Bronze



Gold

A A

Area 1, 4 Area 1, 4

PPO-SM/WG-4HDHP-SM/WG-4

33709PA0640005 33709PA0460012

01/1/17, 02/1/17, 03/1/1701/1/17, 02/1/17, 03/1/17

Health Savings PPO Flex PPO


Exhibit VI-B-WPA-Zone B, G, HCompany Name: Highmark Inc., d/b/a as Highmark Blue Cross Blue Shield PA (Western, PA Region) - Service Zone B, G & H

Product (Small Group Market):Effective Date of Rates:


Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>


0 - 20 $136.03 $136.03 $145.85 $145.85 $199.72 $199.72 $214.13 $214.13 $188.73 $188.73 $203.10 $203.10

21 $214.22 $214.22 $229.68 $229.68 $314.52 $314.52 $337.22 $337.22 $297.21 $297.21 $319.84 $319.84

22 $214.22 $214.22 $229.68 $229.68 $314.52 $314.52 $337.22 $337.22 $297.21 $297.21 $319.84 $319.84

23 $214.22 $214.22 $229.68 $229.68 $314.52 $314.52 $337.22 $337.22 $297.21 $297.21 $319.84 $319.84

24 $214.22 $214.22 $229.68 $229.68 $314.52 $314.52 $337.22 $337.22 $297.21 $297.21 $319.84 $319.84

25 $215.08 $215.08 $230.60 $230.60 $315.78 $315.78 $338.57 $338.57 $298.40 $298.40 $321.12 $321.12

26 $219.37 $219.37 $235.20 $235.20 $322.07 $322.07 $345.31 $345.31 $304.34 $304.34 $327.51 $327.51

27 $224.51 $224.51 $240.71 $240.71 $329.62 $329.62 $353.41 $353.41 $311.47 $311.47 $335.19 $335.19

28 $232.86 $232.86 $249.67 $249.67 $341.89 $341.89 $366.56 $366.56 $323.07 $323.07 $347.66 $347.66

29 $239.72 $239.72 $257.02 $257.02 $351.95 $351.95 $377.35 $377.35 $332.58 $332.58 $357.90 $357.90

30 $243.14 $243.14 $260.69 $260.69 $356.98 $356.98 $382.74 $382.74 $337.33 $337.33 $363.02 $363.02

31 $248.29 $248.29 $266.20 $266.20 $364.53 $364.53 $390.84 $390.84 $344.46 $344.46 $370.69 $370.69

32 $253.43 $253.43 $271.72 $271.72 $372.08 $372.08 $398.93 $398.93 $351.60 $351.60 $378.37 $378.37

33 $256.64 $256.64 $275.16 $275.16 $376.80 $376.80 $403.99 $403.99 $356.06 $356.06 $383.17 $383.17

34 $260.07 $260.07 $278.84 $278.84 $381.83 $381.83 $409.39 $409.39 $360.81 $360.81 $388.28 $388.28

35 $261.78 $261.78 $280.67 $280.67 $384.35 $384.35 $412.08 $412.08 $363.19 $363.19 $390.84 $390.84

36 $263.50 $263.50 $282.51 $282.51 $386.86 $386.86 $414.78 $414.78 $365.57 $365.57 $393.40 $393.40

37 $265.21 $265.21 $284.35 $284.35 $389.38 $389.38 $417.48 $417.48 $367.94 $367.94 $395.96 $395.96

38 $266.92 $266.92 $286.19 $286.19 $391.90 $391.90 $420.18 $420.18 $370.32 $370.32 $398.52 $398.52

39 $270.35 $270.35 $289.86 $289.86 $396.93 $396.93 $425.57 $425.57 $375.08 $375.08 $403.64 $403.64

40 $273.78 $273.78 $293.54 $293.54 $401.96 $401.96 $430.97 $430.97 $379.83 $379.83 $408.75 $408.75

41 $278.92 $278.92 $299.05 $299.05 $409.51 $409.51 $439.06 $439.06 $386.96 $386.96 $416.43 $416.43

42 $283.85 $283.85 $304.33 $304.33 $416.74 $416.74 $446.82 $446.82 $393.80 $393.80 $423.79 $423.79

43 $290.70 $290.70 $311.68 $311.68 $426.81 $426.81 $457.61 $457.61 $403.31 $403.31 $434.02 $434.02

44 $299.27 $299.27 $320.87 $320.87 $439.39 $439.39 $471.10 $471.10 $415.20 $415.20 $446.81 $446.81

45 $309.34 $309.34 $331.66 $331.66 $454.17 $454.17 $486.95 $486.95 $429.17 $429.17 $461.85 $461.85

46 $321.34 $321.34 $344.53 $344.53 $471.78 $471.78 $505.83 $505.83 $445.81 $445.81 $479.76 $479.76

47 $334.83 $334.83 $359.00 $359.00 $491.60 $491.60 $527.07 $527.07 $464.54 $464.54 $499.91 $499.91

48 $350.26 $350.26 $375.53 $375.53 $514.24 $514.24 $551.35 $551.35 $485.94 $485.94 $522.94 $522.94

49 $365.47 $365.47 $391.84 $391.84 $536.58 $536.58 $575.30 $575.30 $507.04 $507.04 $545.64 $545.64

50 $382.60 $382.60 $410.22 $410.22 $561.74 $561.74 $602.27 $602.27 $530.81 $530.81 $571.23 $571.23

51 $399.53 $399.53 $428.36 $428.36 $586.58 $586.58 $628.92 $628.92 $554.29 $554.29 $596.50 $596.50

52 $418.17 $418.17 $448.34 $448.34 $613.95 $613.95 $658.25 $658.25 $580.15 $580.15 $624.32 $624.32

53 $437.02 $437.02 $468.56 $468.56 $641.63 $641.63 $687.93 $687.93 $606.30 $606.30 $652.47 $652.47

54 $457.37 $457.37 $490.38 $490.38 $671.51 $671.51 $719.96 $719.96 $634.54 $634.54 $682.85 $682.85

55 $477.72 $477.72 $512.20 $512.20 $701.39 $701.39 $752.00 $752.00 $662.77 $662.77 $713.24 $713.24

56 $499.79 $499.79 $535.85 $535.85 $733.78 $733.78 $786.73 $786.73 $693.39 $693.39 $746.18 $746.18

57 $522.07 $522.07 $559.74 $559.74 $766.49 $766.49 $821.81 $821.81 $724.30 $724.30 $779.45 $779.45

58 $545.84 $545.84 $585.23 $585.23 $801.40 $801.40 $859.24 $859.24 $757.29 $757.29 $814.95 $814.95

59 $557.63 $557.63 $597.87 $597.87 $818.70 $818.70 $877.78 $877.78 $773.63 $773.63 $832.54 $832.54

60 $581.41 $581.41 $623.36 $623.36 $853.61 $853.61 $915.22 $915.22 $806.62 $806.62 $868.04 $868.04

61 $601.97 $601.97 $645.41 $645.41 $883.81 $883.81 $947.59 $947.59 $835.15 $835.15 $898.75 $898.75

62 $615.47 $615.47 $659.88 $659.88 $903.62 $903.62 $968.83 $968.83 $853.88 $853.88 $918.89 $918.89

63 $632.39 $632.39 $678.03 $678.03 $928.47 $928.47 $995.47 $995.47 $877.36 $877.36 $944.16 $944.16

64 $642.66 $642.66 $689.04 $689.04 $943.56 $943.56 $1,011.66 $1,011.66 $891.62 $891.62 $959.51 $959.51

65+ $642.66 $642.66 $689.04 $689.04 $943.56 $943.56 $1,011.66 $1,011.66 $891.62 $891.62 $959.51 $959.51


$6,550 $6,550 $5,500 $5,500 $5,300 $5,500

80%*/60%* 80%*/60%* $20/$50 $20/$50 $20/$50 $10/$40

80%/60%/50% 80%/60%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$5,500 $5,500 $500 $500 $500 $500/$1,500

Health Savings PPO Embedded $5500




Flex PPO $500/$1500 Penn

Highlands Region a Community Blue

Plan



Plan

Flex PPO PA Mountains Healthcare

Region $500/$1500 a Community

Blue Plan


Community Blue Plan

Bronze Bronze Gold Gold Gold Gold

B B H H G B

Area 1, 2, 5 Area 6 Area 2, 5 Area 6 Area 1, 2, 4, 5 Area 1, 2, 5

HDHP-SM/WG-4 HDHP-SM/WG-4 FL/PPO-SM/WG-3 FL/PPO-SM/WG-3 FL/PPO-SM/WG-3 PPO-SM/WG-4

33709PA0640004 33709PA0640004 33709PA0460007 33709PA0460007 33709PA0460008 33709PA0460013

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17

Health Savings PPO Health Savings PPO Flex PPO Flex PPO Flex PPO Flex PPO





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+

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

$217.75 $217.75 $205.84 $205.84 $220.69 $220.69 $197.21 $197.21 $211.45 $211.45

$342.92 $342.92 $324.15 $324.15 $347.55 $347.55 $310.57 $310.57 $332.99 $332.99

$342.92 $342.92 $324.15 $324.15 $347.55 $347.55 $310.57 $310.57 $332.99 $332.99

$342.92 $342.92 $324.15 $324.15 $347.55 $347.55 $310.57 $310.57 $332.99 $332.99

$342.92 $342.92 $324.15 $324.15 $347.55 $347.55 $310.57 $310.57 $332.99 $332.99

$344.29 $344.29 $325.45 $325.45 $348.94 $348.94 $311.82 $311.82 $334.32 $334.32

$351.15 $351.15 $331.93 $331.93 $355.89 $355.89 $318.03 $318.03 $340.98 $340.98

$359.38 $359.38 $339.71 $339.71 $364.23 $364.23 $325.48 $325.48 $348.97 $348.97

$372.75 $372.75 $352.36 $352.36 $377.78 $377.78 $337.59 $337.59 $361.96 $361.96

$383.73 $383.73 $362.73 $362.73 $388.91 $388.91 $347.53 $347.53 $372.61 $372.61

$389.21 $389.21 $367.92 $367.92 $394.47 $394.47 $352.50 $352.50 $377.94 $377.94

$397.44 $397.44 $375.70 $375.70 $402.81 $402.81 $359.96 $359.96 $385.93 $385.93

$405.67 $405.67 $383.47 $383.47 $411.15 $411.15 $367.41 $367.41 $393.92 $393.92

$410.82 $410.82 $388.34 $388.34 $416.36 $416.36 $372.07 $372.07 $398.92 $398.92

$416.30 $416.30 $393.52 $393.52 $421.92 $421.92 $377.04 $377.04 $404.25 $404.25

$419.05 $419.05 $396.12 $396.12 $424.70 $424.70 $379.52 $379.52 $406.91 $406.91

$421.79 $421.79 $398.71 $398.71 $427.48 $427.48 $382.01 $382.01 $409.57 $409.57

$424.53 $424.53 $401.30 $401.30 $430.26 $430.26 $384.49 $384.49 $412.24 $412.24

$427.28 $427.28 $403.90 $403.90 $433.04 $433.04 $386.98 $386.98 $414.90 $414.90

$432.76 $432.76 $409.08 $409.08 $438.60 $438.60 $391.95 $391.95 $420.23 $420.23

$438.25 $438.25 $414.27 $414.27 $444.17 $444.17 $396.91 $396.91 $425.56 $425.56

$446.48 $446.48 $422.05 $422.05 $452.51 $452.51 $404.37 $404.37 $433.55 $433.55

$454.37 $454.37 $429.50 $429.50 $460.50 $460.50 $411.51 $411.51 $441.21 $441.21

$465.34 $465.34 $439.88 $439.88 $471.62 $471.62 $421.45 $421.45 $451.86 $451.86

$479.06 $479.06 $452.84 $452.84 $485.52 $485.52 $433.87 $433.87 $465.18 $465.18

$495.18 $495.18 $468.08 $468.08 $501.86 $501.86 $448.47 $448.47 $480.83 $480.83

$514.38 $514.38 $486.23 $486.23 $521.32 $521.32 $465.86 $465.86 $499.48 $499.48

$535.98 $535.98 $506.65 $506.65 $543.22 $543.22 $485.43 $485.43 $520.46 $520.46

$560.67 $560.67 $529.99 $529.99 $568.24 $568.24 $507.79 $507.79 $544.43 $544.43

$585.02 $585.02 $553.01 $553.01 $592.92 $592.92 $529.84 $529.84 $568.08 $568.08

$612.45 $612.45 $578.94 $578.94 $620.72 $620.72 $554.69 $554.69 $594.72 $594.72

$639.54 $639.54 $604.55 $604.55 $648.18 $648.18 $579.22 $579.22 $621.02 $621.02

$669.38 $669.38 $632.75 $632.75 $678.41 $678.41 $606.24 $606.24 $649.99 $649.99

$699.56 $699.56 $661.28 $661.28 $709.00 $709.00 $633.57 $633.57 $679.29 $679.29

$732.13 $732.13 $692.07 $692.07 $742.01 $742.01 $663.08 $663.08 $710.93 $710.93

$764.71 $764.71 $722.86 $722.86 $775.03 $775.03 $692.58 $692.58 $742.56 $742.56

$800.03 $800.03 $756.25 $756.25 $810.83 $810.83 $724.57 $724.57 $776.86 $776.86

$835.69 $835.69 $789.96 $789.96 $846.97 $846.97 $756.87 $756.87 $811.49 $811.49

$873.76 $873.76 $825.95 $825.95 $885.55 $885.55 $791.34 $791.34 $848.45 $848.45

$892.62 $892.62 $843.77 $843.77 $904.67 $904.67 $808.43 $808.43 $866.77 $866.77

$930.68 $930.68 $879.76 $879.76 $943.24 $943.24 $842.90 $842.90 $903.73 $903.73

$963.60 $963.60 $910.87 $910.87 $976.61 $976.61 $872.71 $872.71 $935.69 $935.69

$985.21 $985.21 $931.30 $931.30 $998.50 $998.50 $892.28 $892.28 $956.67 $956.67

$1,012.30 $1,012.30 $956.90 $956.90 $1,025.96 $1,025.96 $916.82 $916.82 $982.98 $982.98

$1,028.76 $1,028.76 $972.45 $972.45 $1,042.64 $1,042.64 $931.71 $931.71 $998.96 $998.96

$1,028.76 $1,028.76 $972.45 $972.45 $1,042.64 $1,042.64 $931.71 $931.71 $998.96 $998.96

Yes YesYes Yes Yes

$5,500 $7,150 $7,150 $4,800 $4,800

$30/$60 $30/$60$10/$40 $20/$60 $20/$60

$750/$1,500 $750/$1,500

100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$500/$1,500 $250/$750 $250/$750

Gold Gold


Community Blue Plan

Premier Balance PPO $250 IP A a








Gold Gold Gold

Area 1, 2, 5 Area 6

B B B B B

Area 6 Area 1, 2, 5 Area 6

PPO-SM/WG-4 PPO-SM/WG-4 PPO-SM/WG-4 PPO-SM/WG-4 PPO-SM/WG-4

33709PA0460013 33709PA0440014 33709PA0440014 33709PA0440009 33709PA0440009

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17

Flex PPO Premier Balance PPO Premier Balance PPO Premier Balance PPO Premier Balance PPO

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$170.30 $170.30 $182.59 $182.59

$268.20 $268.20 $287.55 $287.55

$268.20 $268.20 $287.55 $287.55

$268.20 $268.20 $287.55 $287.55

$268.20 $268.20 $287.55 $287.55

$269.27 $269.27 $288.70 $288.70

$274.63 $274.63 $294.45 $294.45

$281.07 $281.07 $301.35 $301.35

$291.53 $291.53 $312.57 $312.57

$300.11 $300.11 $321.77 $321.77

$304.40 $304.40 $326.37 $326.37

$310.84 $310.84 $333.27 $333.27

$317.28 $317.28 $340.17 $340.17

$321.30 $321.30 $344.48 $344.48

$325.59 $325.59 $349.09 $349.09

$327.73 $327.73 $351.39 $351.39

$329.88 $329.88 $353.69 $353.69

$332.03 $332.03 $355.99 $355.99

$334.17 $334.17 $358.29 $358.29

$338.46 $338.46 $362.89 $362.89

$342.75 $342.75 $367.49 $367.49

$349.19 $349.19 $374.39 $374.39

$355.36 $355.36 $381.00 $381.00

$363.94 $363.94 $390.20 $390.20

$374.67 $374.67 $401.71 $401.71

$387.27 $387.27 $415.22 $415.22

$402.29 $402.29 $431.32 $431.32

$419.19 $419.19 $449.44 $449.44

$438.50 $438.50 $470.14 $470.14

$457.54 $457.54 $490.56 $490.56

$479.00 $479.00 $513.56 $513.56

$500.18 $500.18 $536.28 $536.28

$523.52 $523.52 $561.30 $561.30

$547.12 $547.12 $586.60 $586.60

$572.60 $572.60 $613.92 $613.92

$598.08 $598.08 $641.24 $641.24

$625.70 $625.70 $670.85 $670.85

$653.59 $653.59 $700.76 $700.76

$683.36 $683.36 $732.68 $732.68

$698.11 $698.11 $748.49 $748.49

$727.88 $727.88 $780.41 $780.41

$753.63 $753.63 $808.01 $808.01

$770.53 $770.53 $826.13 $826.13

$791.71 $791.71 $848.85 $848.85

$804.59 $804.59 $862.65 $862.65

$804.59 $804.59 $862.65 $862.65

Yes Yes

$7,150$7,150

$45/$70* $45/$70*

$1,500/$4,500 $1,500/$4,500

100%/70%/50%100%/70%/50%

Silver Silver





Area 1, 2, 5 Area 6

BB

PPO-SM/WG-4PPO-SM/WG-4

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17

33709PA044001333709PA0440013

Premier Balance PPOPremier Balance PPO


Exhibit VI-C-WPA-Zone J, L

Company Name: Highmark Inc., d/b/a as Highmark Blue Cross Blue Shield PA (Western, PA Region) - Service Zone J & LProduct (Small Group Market):Effective Date of Rates:


Form #

Region =>

Service Zone =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dentail (Yes/No) =>


0 - 20 $177.61 $177.61 $176.88 $176.88 $174.37 $174.37 $173.38 $173.38 $169.47 $169.47 $168.11 $168.11

21 $279.70 $279.70 $278.55 $278.55 $274.60 $274.60 $273.05 $273.05 $266.88 $266.88 $264.74 $264.74

22 $279.70 $279.70 $278.55 $278.55 $274.60 $274.60 $273.05 $273.05 $266.88 $266.88 $264.74 $264.74

23 $279.70 $279.70 $278.55 $278.55 $274.60 $274.60 $273.05 $273.05 $266.88 $266.88 $264.74 $264.74

24 $279.70 $279.70 $278.55 $278.55 $274.60 $274.60 $273.05 $273.05 $266.88 $266.88 $264.74 $264.74

25 $280.82 $280.82 $279.67 $279.67 $275.70 $275.70 $274.14 $274.14 $267.94 $267.94 $265.80 $265.80

26 $286.41 $286.41 $285.24 $285.24 $281.19 $281.19 $279.60 $279.60 $273.28 $273.28 $271.10 $271.10

27 $293.13 $293.13 $291.93 $291.93 $287.78 $287.78 $286.15 $286.15 $279.69 $279.69 $277.45 $277.45

28 $304.03 $304.03 $302.79 $302.79 $298.49 $298.49 $296.80 $296.80 $290.09 $290.09 $287.77 $287.77

29 $312.98 $312.98 $311.70 $311.70 $307.27 $307.27 $305.54 $305.54 $298.63 $298.63 $296.25 $296.25

30 $317.46 $317.46 $316.16 $316.16 $311.67 $311.67 $309.91 $309.91 $302.90 $302.90 $300.48 $300.48

31 $324.17 $324.17 $322.85 $322.85 $318.26 $318.26 $316.46 $316.46 $309.31 $309.31 $306.84 $306.84

32 $330.88 $330.88 $329.53 $329.53 $324.85 $324.85 $323.01 $323.01 $315.71 $315.71 $313.19 $313.19

33 $335.08 $335.08 $333.71 $333.71 $328.97 $328.97 $327.11 $327.11 $319.72 $319.72 $317.16 $317.16

34 $339.56 $339.56 $338.17 $338.17 $333.36 $333.36 $331.48 $331.48 $323.99 $323.99 $321.40 $321.40

35 $341.79 $341.79 $340.39 $340.39 $335.56 $335.56 $333.66 $333.66 $326.12 $326.12 $323.51 $323.51

36 $344.03 $344.03 $342.62 $342.62 $337.75 $337.75 $335.85 $335.85 $328.26 $328.26 $325.63 $325.63

37 $346.27 $346.27 $344.85 $344.85 $339.95 $339.95 $338.03 $338.03 $330.39 $330.39 $327.75 $327.75

38 $348.51 $348.51 $347.08 $347.08 $342.15 $342.15 $340.21 $340.21 $332.53 $332.53 $329.87 $329.87

39 $352.98 $352.98 $351.54 $351.54 $346.54 $346.54 $344.58 $344.58 $336.80 $336.80 $334.10 $334.10

40 $357.46 $357.46 $355.99 $355.99 $350.94 $350.94 $348.95 $348.95 $341.07 $341.07 $338.34 $338.34

41 $364.17 $364.17 $362.68 $362.68 $357.53 $357.53 $355.50 $355.50 $347.47 $347.47 $344.69 $344.69

42 $370.60 $370.60 $369.09 $369.09 $363.84 $363.84 $361.79 $361.79 $353.61 $353.61 $350.78 $350.78

43 $379.55 $379.55 $378.00 $378.00 $372.63 $372.63 $370.52 $370.52 $362.15 $362.15 $359.26 $359.26

44 $390.74 $390.74 $389.14 $389.14 $383.61 $383.61 $381.44 $381.44 $372.83 $372.83 $369.84 $369.84

45 $403.89 $403.89 $402.23 $402.23 $396.52 $396.52 $394.28 $394.28 $385.37 $385.37 $382.29 $382.29

46 $419.55 $419.55 $417.83 $417.83 $411.90 $411.90 $409.57 $409.57 $400.31 $400.31 $397.11 $397.11

47 $437.17 $437.17 $435.38 $435.38 $429.20 $429.20 $426.77 $426.77 $417.13 $417.13 $413.79 $413.79

48 $457.31 $457.31 $455.44 $455.44 $448.97 $448.97 $446.43 $446.43 $436.34 $436.34 $432.85 $432.85

49 $477.17 $477.17 $475.21 $475.21 $468.46 $468.46 $465.82 $465.82 $455.29 $455.29 $451.65 $451.65

50 $499.54 $499.54 $497.50 $497.50 $490.43 $490.43 $487.66 $487.66 $476.64 $476.64 $472.83 $472.83

51 $521.64 $521.64 $519.50 $519.50 $512.12 $512.12 $509.23 $509.23 $497.72 $497.72 $493.74 $493.74

52 $545.97 $545.97 $543.74 $543.74 $536.01 $536.01 $532.98 $532.98 $520.94 $520.94 $516.78 $516.78

53 $570.59 $570.59 $568.25 $568.25 $560.18 $560.18 $557.01 $557.01 $544.43 $544.43 $540.07 $540.07

54 $597.16 $597.16 $594.71 $594.71 $586.27 $586.27 $582.95 $582.95 $569.78 $569.78 $565.22 $565.22

55 $623.73 $623.73 $621.18 $621.18 $612.35 $612.35 $608.89 $608.89 $595.13 $595.13 $590.37 $590.37

56 $652.54 $652.54 $649.87 $649.87 $640.64 $640.64 $637.01 $637.01 $622.62 $622.62 $617.64 $617.64

57 $681.63 $681.63 $678.84 $678.84 $669.19 $669.19 $665.41 $665.41 $650.38 $650.38 $645.18 $645.18

58 $712.67 $712.67 $709.76 $709.76 $699.67 $699.67 $695.72 $695.72 $680.00 $680.00 $674.56 $674.56

59 $728.06 $728.06 $725.08 $725.08 $714.78 $714.78 $710.74 $710.74 $694.68 $694.68 $689.12 $689.12

60 $759.10 $759.10 $756.00 $756.00 $745.26 $745.26 $741.04 $741.04 $724.30 $724.30 $718.51 $718.51

61 $785.96 $785.96 $782.74 $782.74 $771.62 $771.62 $767.26 $767.26 $749.92 $749.92 $743.93 $743.93

62 $803.58 $803.58 $800.29 $800.29 $788.92 $788.92 $784.46 $784.46 $766.74 $766.74 $760.60 $760.60

63 $825.67 $825.67 $822.29 $822.29 $810.61 $810.61 $806.03 $806.03 $787.82 $787.82 $781.52 $781.52

64 $839.10 $839.10 $835.65 $835.65 $823.79 $823.79 $819.14 $819.14 $800.63 $800.63 $794.22 $794.22

65+ $839.10 $839.10 $835.65 $835.65 $823.79 $823.79 $819.14 $819.14 $800.63 $800.63 $794.22 $794.22


$7,150 $7,150 $7,150 $6,100 $7,150 $6,800

$25 $10 $10 $0 $10 $10

100% 100% 100% 100% 100% 100%

$100 $250 $500 $750 $900 $1,100

Connect Blue EPO $100 a

Community Blue Plan


Community Blue Plan


Community Blue Plan


Community Blue Plan


Community Blue Plan


Community Blue Plan

Gold Gold Gold Gold Gold Gold

J J J J J J


CONB/EPO-SM/WG-1 CONB/EPO-SM/WG-1 CONB/EPO-SM/WG-1 CONB/EPO-SM/WG-1 CONB/EPO-SM/WG-1 CONB/EPO-SM/WG-1

33709PA0630002 33709PA0630003 33709PA0630004 33709PA0630005 33709PA0630006 33709PA0630008

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17

Connect Blue EPO Connect Blue EPO Connect Blue EPO Connect Blue EPO Connect Blue EPO Connect Blue EPO





Form #

Region =>

Service Zone =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dentail (Yes/No) =>

Age Band

0 - 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

65+


$145.81 $145.81 $142.99 $142.99

$229.63 $229.63 $225.19 $225.19

$229.63 $229.63 $225.19 $225.19

$229.63 $229.63 $225.19 $225.19

$229.63 $229.63 $225.19 $225.19

$230.55 $230.55 $226.09 $226.09

$235.14 $235.14 $230.59 $230.59

$240.65 $240.65 $235.99 $235.99

$249.61 $249.61 $244.78 $244.78

$256.95 $256.95 $251.98 $251.98

$260.63 $260.63 $255.59 $255.59

$266.14 $266.14 $260.99 $260.99

$271.65 $271.65 $266.39 $266.39

$275.09 $275.09 $269.77 $269.77

$278.77 $278.77 $273.38 $273.38

$280.61 $280.61 $275.18 $275.18

$282.44 $282.44 $276.98 $276.98

$284.28 $284.28 $278.78 $278.78

$286.12 $286.12 $280.58 $280.58

$289.79 $289.79 $284.18 $284.18

$293.46 $293.46 $287.79 $287.79

$298.98 $298.98 $293.19 $293.19

$304.26 $304.26 $298.37 $298.37

$311.61 $311.61 $305.58 $305.58

$320.79 $320.79 $314.58 $314.58

$331.58 $331.58 $325.17 $325.17

$344.44 $344.44 $337.78 $337.78

$358.91 $358.91 $351.96 $351.96

$375.44 $375.44 $368.18 $368.18

$391.75 $391.75 $384.17 $384.17

$410.12 $410.12 $402.18 $402.18

$428.26 $428.26 $419.97 $419.97

$448.23 $448.23 $439.56 $439.56

$468.44 $468.44 $459.38 $459.38

$490.26 $490.26 $480.77 $480.77

$512.07 $512.07 $502.16 $502.16

$535.72 $535.72 $525.36 $525.36

$559.60 $559.60 $548.78 $548.78

$585.09 $585.09 $573.77 $573.77

$597.72 $597.72 $586.16 $586.16

$623.21 $623.21 $611.15 $611.15

$645.25 $645.25 $632.77 $632.77

$659.72 $659.72 $646.96 $646.96

$677.86 $677.86 $664.75 $664.75

$688.88 $688.88 $675.56 $675.56

$688.88 $688.88 $675.56 $675.56

$7,150 $7,150

Yes Yes

100% 100%

$25 $25


Community Blue Plan


Community Blue Plan

$2,500 $3200

J J

Silver Silver

CONB/EPO-SM/WG-1 CONB/EPO-SM/WG-1

Area 1, 4 Area 1, 4

33709PA0630007 33709PA0630009

Connect Blue EPO Connect Blue EPO

01/1/17, 02/1/17, 03/1/17 01/1/17, 02/1/17, 03/1/17


Silver Plan Rates for Age 21 Non-Smoker, by Geographic Area and Exchange Status

HIOS Plan ID # Rating Area 1 Rating Area 2 Rating Area 3 Rating Area 4 Rating Area 5 Rating Area 6 Rating Area 7 Rating Area 8 Rating Area 9

33709PA0560029 $253.12 $253.12

33709PA0570007 $250.96 $250.96

33709PA0570004 $246.93 $246.93

33709PA0570006 $244.49 $244.49

33709PA0640001 $247.19 $247.19

33709PA0640002 $240.92 $240.92

33709PA0630007 $229.63 $229.63

33709PA0630009 $225.19 $225.19

33709PA0440013 $268.20 $268.20 $268.20 $287.55

2017 Off-Exchange Silver Plan Rates


Exhibit V

HIOS Plan ID

On/Off

Exchange Product MetalPlan Design Marketing Name

Network Rating Area Counties Excluded

























Venango






















Highmark Inc.

Small Group Market

Plan Design Summary


Exhibit VI-A-WPA-Zone ACompany Name: Highmark Inc., d/b/a as Highmark Blue Cross Blue Shield PA (Western, PA Region) - Service Zone A



Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>


0 - 20 $232.60 $232.60 $228.73 $228.73 $196.95 $196.95 $199.74 $199.74 $195.41 $195.41 $192.92 $192.92

21 $366.29 $366.29 $360.21 $360.21 $310.16 $310.16 $314.55 $314.55 $307.73 $307.73 $303.80 $303.80

22 $366.29 $366.29 $360.21 $360.21 $310.16 $310.16 $314.55 $314.55 $307.73 $307.73 $303.80 $303.80

23 $366.29 $366.29 $360.21 $360.21 $310.16 $310.16 $314.55 $314.55 $307.73 $307.73 $303.80 $303.80

24 $366.29 $366.29 $360.21 $360.21 $310.16 $310.16 $314.55 $314.55 $307.73 $307.73 $303.80 $303.80

25 $367.76 $367.76 $361.65 $361.65 $311.40 $311.40 $315.81 $315.81 $308.96 $308.96 $305.02 $305.02

26 $375.08 $375.08 $368.85 $368.85 $317.60 $317.60 $322.10 $322.10 $315.12 $315.12 $311.10 $311.10

27 $383.87 $383.87 $377.50 $377.50 $325.05 $325.05 $329.65 $329.65 $322.50 $322.50 $318.39 $318.39

28 $398.16 $398.16 $391.55 $391.55 $337.14 $337.14 $341.92 $341.92 $334.51 $334.51 $330.23 $330.23

29 $409.88 $409.88 $403.07 $403.07 $347.07 $347.07 $351.98 $351.98 $344.35 $344.35 $339.96 $339.96

30 $415.74 $415.74 $408.84 $408.84 $352.03 $352.03 $357.02 $357.02 $349.28 $349.28 $344.82 $344.82

31 $424.53 $424.53 $417.48 $417.48 $359.47 $359.47 $364.57 $364.57 $356.66 $356.66 $352.11 $352.11

32 $433.32 $433.32 $426.13 $426.13 $366.92 $366.92 $372.11 $372.11 $364.05 $364.05 $359.40 $359.40

33 $438.82 $438.82 $431.53 $431.53 $371.57 $371.57 $376.83 $376.83 $368.66 $368.66 $363.96 $363.96

34 $444.68 $444.68 $437.29 $437.29 $376.53 $376.53 $381.87 $381.87 $373.59 $373.59 $368.82 $368.82

35 $447.61 $447.61 $440.18 $440.18 $379.01 $379.01 $384.38 $384.38 $376.05 $376.05 $371.25 $371.25

36 $450.54 $450.54 $443.06 $443.06 $381.49 $381.49 $386.90 $386.90 $378.51 $378.51 $373.68 $373.68

37 $453.47 $453.47 $445.94 $445.94 $383.97 $383.97 $389.41 $389.41 $380.97 $380.97 $376.11 $376.11

38 $456.40 $456.40 $448.82 $448.82 $386.46 $386.46 $391.93 $391.93 $383.43 $383.43 $378.54 $378.54

39 $462.26 $462.26 $454.58 $454.58 $391.42 $391.42 $396.96 $396.96 $388.36 $388.36 $383.40 $383.40

40 $468.12 $468.12 $460.35 $460.35 $396.38 $396.38 $402.00 $402.00 $393.28 $393.28 $388.26 $388.26

41 $476.91 $476.91 $468.99 $468.99 $403.83 $403.83 $409.55 $409.55 $400.67 $400.67 $395.55 $395.55

42 $485.34 $485.34 $477.28 $477.28 $410.96 $410.96 $416.78 $416.78 $407.75 $407.75 $402.54 $402.54

43 $497.06 $497.06 $488.80 $488.80 $420.88 $420.88 $426.85 $426.85 $417.59 $417.59 $412.26 $412.26

44 $511.71 $511.71 $503.21 $503.21 $433.29 $433.29 $439.43 $439.43 $429.90 $429.90 $424.41 $424.41

45 $528.92 $528.92 $520.14 $520.14 $447.87 $447.87 $454.21 $454.21 $444.37 $444.37 $438.69 $438.69

46 $549.44 $549.44 $540.31 $540.31 $465.24 $465.24 $471.83 $471.83 $461.60 $461.60 $455.71 $455.71

47 $572.51 $572.51 $563.01 $563.01 $484.78 $484.78 $491.64 $491.64 $480.99 $480.99 $474.85 $474.85

48 $598.89 $598.89 $588.94 $588.94 $507.11 $507.11 $514.29 $514.29 $503.14 $503.14 $496.72 $496.72

49 $624.89 $624.89 $614.52 $614.52 $529.13 $529.13 $536.63 $536.63 $524.99 $524.99 $518.29 $518.29

50 $654.20 $654.20 $643.33 $643.33 $553.94 $553.94 $561.79 $561.79 $549.61 $549.61 $542.59 $542.59

51 $683.13 $683.13 $671.79 $671.79 $578.44 $578.44 $586.64 $586.64 $573.92 $573.92 $566.59 $566.59

52 $715.00 $715.00 $703.13 $703.13 $605.43 $605.43 $614.00 $614.00 $600.69 $600.69 $593.03 $593.03

53 $747.23 $747.23 $734.83 $734.83 $632.72 $632.72 $641.69 $641.69 $627.77 $627.77 $619.76 $619.76

54 $782.03 $782.03 $769.05 $769.05 $662.19 $662.19 $671.57 $671.57 $657.01 $657.01 $648.62 $648.62

55 $816.83 $816.83 $803.27 $803.27 $691.65 $691.65 $701.45 $701.45 $686.24 $686.24 $677.48 $677.48

56 $854.56 $854.56 $840.37 $840.37 $723.60 $723.60 $733.85 $733.85 $717.94 $717.94 $708.77 $708.77

57 $892.65 $892.65 $877.83 $877.83 $755.85 $755.85 $766.56 $766.56 $749.94 $749.94 $740.37 $740.37

58 $933.31 $933.31 $917.81 $917.81 $790.28 $790.28 $801.48 $801.48 $784.10 $784.10 $774.09 $774.09

59 $953.46 $953.46 $937.63 $937.63 $807.34 $807.34 $818.78 $818.78 $801.03 $801.03 $790.80 $790.80

60 $994.11 $994.11 $977.61 $977.61 $841.77 $841.77 $853.69 $853.69 $835.19 $835.19 $824.52 $824.52

61 $1,029.28 $1,029.28 $1,012.19 $1,012.19 $871.54 $871.54 $883.89 $883.89 $864.73 $864.73 $853.69 $853.69

62 $1,052.36 $1,052.36 $1,034.88 $1,034.88 $891.08 $891.08 $903.71 $903.71 $884.12 $884.12 $872.83 $872.83

63 $1,081.29 $1,081.29 $1,063.34 $1,063.34 $915.58 $915.58 $928.56 $928.56 $908.43 $908.43 $896.83 $896.83

64 $1,098.87 $1,098.87 $1,080.63 $1,080.63 $930.47 $930.47 $943.65 $943.65 $923.19 $923.19 $911.40 $911.40

65+ $1,098.87 $1,098.87 $1,080.63 $1,080.63 $930.47 $930.47 $943.65 $943.65 $923.19 $923.19 $911.40 $911.40

04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17

Premier Balance PPO Premier Balance PPO Premier Balance PPO Premier Balance PPO Premier Balance PPO Premier Balance PPO

33709PA0560007 33709PA0560009 33709PA0560011 33709PA0560013 33709PA0560015 33709PA0560017

PPO-SM/WG-4 PPO-SM/WG-4 PPO-SM/WG-4 PPO-SM/WG-4


PPO-SM/WG-4 PPO-SM/WG-4


A A A A A A









$0/$500 $250/$750 $0/$5,000 $250/$750 $500/$1,500 $750/$1,500

Premier Balance PPO $0 Platinum A a


Premier Balance PPO $250 Platinum

A a Community Blue Flex Plan

$10/$40 $10/$40 $25/$70 $20/$60 $20/$60 $20/$60

100%/70%/50% 100%/70%/50% 100%/60%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$7,150 $7,150 $5,300 $4,800


$1,600 $1,300





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$189.82 $189.82 $188.32 $188.32 $186.93 $186.93 $184.93 $184.93 $165.85 $165.85 $164.43 $164.43

$298.92 $298.92 $296.57 $296.57 $294.38 $294.38 $291.23 $291.23 $261.18 $261.18 $258.94 $258.94

$298.92 $298.92 $296.57 $296.57 $294.38 $294.38 $291.23 $291.23 $261.18 $261.18 $258.94 $258.94

$298.92 $298.92 $296.57 $296.57 $294.38 $294.38 $291.23 $291.23 $261.18 $261.18 $258.94 $258.94

$298.92 $298.92 $296.57 $296.57 $294.38 $294.38 $291.23 $291.23 $261.18 $261.18 $258.94 $258.94

$300.12 $300.12 $297.75 $297.75 $295.55 $295.55 $292.40 $292.40 $262.23 $262.23 $259.98 $259.98

$306.10 $306.10 $303.69 $303.69 $301.44 $301.44 $298.22 $298.22 $267.45 $267.45 $265.16 $265.16

$313.27 $313.27 $310.80 $310.80 $308.51 $308.51 $305.21 $305.21 $273.72 $273.72 $271.37 $271.37

$324.93 $324.93 $322.37 $322.37 $319.99 $319.99 $316.57 $316.57 $283.91 $283.91 $281.47 $281.47

$334.50 $334.50 $331.86 $331.86 $329.41 $329.41 $325.89 $325.89 $292.26 $292.26 $289.76 $289.76

$339.28 $339.28 $336.60 $336.60 $334.12 $334.12 $330.55 $330.55 $296.44 $296.44 $293.90 $293.90

$346.45 $346.45 $343.72 $343.72 $341.18 $341.18 $337.54 $337.54 $302.71 $302.71 $300.11 $300.11

$353.63 $353.63 $350.84 $350.84 $348.25 $348.25 $344.53 $344.53 $308.98 $308.98 $306.33 $306.33

$358.11 $358.11 $355.29 $355.29 $352.66 $352.66 $348.90 $348.90 $312.90 $312.90 $310.21 $310.21

$362.89 $362.89 $360.03 $360.03 $357.37 $357.37 $353.56 $353.56 $317.08 $317.08 $314.35 $314.35

$365.29 $365.29 $362.41 $362.41 $359.73 $359.73 $355.89 $355.89 $319.16 $319.16 $316.43 $316.43

$367.68 $367.68 $364.78 $364.78 $362.08 $362.08 $358.22 $358.22 $321.25 $321.25 $318.50 $318.50

$370.07 $370.07 $367.15 $367.15 $364.44 $364.44 $360.55 $360.55 $323.34 $323.34 $320.57 $320.57

$372.46 $372.46 $369.52 $369.52 $366.79 $366.79 $362.88 $362.88 $325.43 $325.43 $322.64 $322.64

$377.24 $377.24 $374.27 $374.27 $371.50 $371.50 $367.54 $367.54 $329.61 $329.61 $326.78 $326.78

$382.03 $382.03 $379.01 $379.01 $376.21 $376.21 $372.20 $372.20 $333.79 $333.79 $330.93 $330.93

$389.20 $389.20 $386.13 $386.13 $383.28 $383.28 $379.19 $379.19 $340.06 $340.06 $337.14 $337.14

$396.08 $396.08 $392.95 $392.95 $390.05 $390.05 $385.88 $385.88 $346.07 $346.07 $343.10 $343.10

$405.64 $405.64 $402.44 $402.44 $399.47 $399.47 $395.20 $395.20 $354.42 $354.42 $351.38 $351.38

$417.60 $417.60 $414.31 $414.31 $411.24 $411.24 $406.85 $406.85 $364.87 $364.87 $361.74 $361.74

$431.65 $431.65 $428.24 $428.24 $425.08 $425.08 $420.54 $420.54 $377.15 $377.15 $373.91 $373.91

$448.39 $448.39 $444.85 $444.85 $441.56 $441.56 $436.85 $436.85 $391.77 $391.77 $388.41 $388.41

$467.22 $467.22 $463.54 $463.54 $460.11 $460.11 $455.20 $455.20 $408.23 $408.23 $404.73 $404.73

$488.74 $488.74 $484.89 $484.89 $481.30 $481.30 $476.17 $476.17 $427.03 $427.03 $423.37 $423.37

$509.97 $509.97 $505.94 $505.94 $502.20 $502.20 $496.84 $496.84 $445.58 $445.58 $441.75 $441.75

$533.88 $533.88 $529.67 $529.67 $525.75 $525.75 $520.14 $520.14 $466.47 $466.47 $462.47 $462.47

$557.49 $557.49 $553.10 $553.10 $549.01 $549.01 $543.15 $543.15 $487.10 $487.10 $482.93 $482.93

$583.50 $583.50 $578.90 $578.90 $574.62 $574.62 $568.49 $568.49 $509.83 $509.83 $505.45 $505.45

$609.81 $609.81 $605.00 $605.00 $600.53 $600.53 $594.11 $594.11 $532.81 $532.81 $528.24 $528.24

$638.20 $638.20 $633.17 $633.17 $628.49 $628.49 $621.78 $621.78 $557.62 $557.62 $552.84 $552.84

$666.60 $666.60 $661.35 $661.35 $656.46 $656.46 $649.45 $649.45 $582.44 $582.44 $577.44 $577.44

$697.39 $697.39 $691.89 $691.89 $686.78 $686.78 $679.45 $679.45 $609.34 $609.34 $604.11 $604.11

$728.48 $728.48 $722.74 $722.74 $717.39 $717.39 $709.73 $709.73 $636.50 $636.50 $631.04 $631.04

$761.66 $761.66 $755.65 $755.65 $750.07 $750.07 $742.06 $742.06 $665.49 $665.49 $659.78 $659.78

$778.10 $778.10 $771.97 $771.97 $766.26 $766.26 $758.08 $758.08 $679.86 $679.86 $674.02 $674.02

$811.28 $811.28 $804.89 $804.89 $798.94 $798.94 $790.41 $790.41 $708.85 $708.85 $702.77 $702.77

$839.98 $839.98 $833.36 $833.36 $827.20 $827.20 $818.36 $818.36 $733.92 $733.92 $727.63 $727.63

$858.81 $858.81 $852.04 $852.04 $845.74 $845.74 $836.71 $836.71 $750.38 $750.38 $743.94 $743.94

$882.43 $882.43 $875.47 $875.47 $869.00 $869.00 $859.72 $859.72 $771.01 $771.01 $764.40 $764.40

$896.76 $896.76 $889.70 $889.70 $883.13 $883.13 $873.69 $873.69 $783.54 $783.54 $776.82 $776.82

$896.76 $896.76 $889.70 $889.70 $883.13 $883.13 $873.69 $873.69 $783.54 $783.54 $776.82 $776.82

04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17


04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17

33709PA0560019 33709PA0560021 33709PA0560023 33709PA0560027 33709PA0560029 33709PA0570007

Area 1, 4 Area 1, 4


Area 1, 4 Area 1, 4 Area 1, 4 Area 1, 4

Gold Gold

A A A A A A

Gold Gold Silver Silver

$1,000/$2,000 $1,250/$2,500












Blue Flex Plan

$1,500/$3,000 $2,000/$3,000 $1,400/$5,000 $1,000/$5,000

$20/$60 $20/$60

100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 90%/70%/50%

$20/$60 $20/$60 $40/$75 $45/$75*

Yes Yes

$4,800 $4,000 $3,700 $3,450 $7,150 $7,150

Yes Yes Yes Yes





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$161.80 $161.80 $160.19 $160.19 $183.04 $183.04 $161.95 $161.95 $157.85 $157.85 $131.20 $131.20

$254.80 $254.80 $252.27 $252.27 $288.25 $288.25 $255.04 $255.04 $248.58 $248.58 $206.61 $206.61

$254.80 $254.80 $252.27 $252.27 $288.25 $288.25 $255.04 $255.04 $248.58 $248.58 $206.61 $206.61

$254.80 $254.80 $252.27 $252.27 $288.25 $288.25 $255.04 $255.04 $248.58 $248.58 $206.61 $206.61

$254.80 $254.80 $252.27 $252.27 $288.25 $288.25 $255.04 $255.04 $248.58 $248.58 $206.61 $206.61

$255.82 $255.82 $253.28 $253.28 $289.40 $289.40 $256.06 $256.06 $249.58 $249.58 $207.44 $207.44

$260.91 $260.91 $258.32 $258.32 $295.16 $295.16 $261.16 $261.16 $254.55 $254.55 $211.57 $211.57

$267.03 $267.03 $264.38 $264.38 $302.08 $302.08 $267.28 $267.28 $260.51 $260.51 $216.53 $216.53

$276.97 $276.97 $274.22 $274.22 $313.32 $313.32 $277.23 $277.23 $270.21 $270.21 $224.59 $224.59

$285.12 $285.12 $282.29 $282.29 $322.55 $322.55 $285.39 $285.39 $278.16 $278.16 $231.20 $231.20

$289.20 $289.20 $286.32 $286.32 $327.16 $327.16 $289.47 $289.47 $282.14 $282.14 $234.50 $234.50

$295.31 $295.31 $292.38 $292.38 $334.08 $334.08 $295.59 $295.59 $288.11 $288.11 $239.46 $239.46

$301.43 $301.43 $298.43 $298.43 $340.99 $340.99 $301.71 $301.71 $294.07 $294.07 $244.42 $244.42

$305.25 $305.25 $302.22 $302.22 $345.32 $345.32 $305.54 $305.54 $297.80 $297.80 $247.52 $247.52

$309.33 $309.33 $306.25 $306.25 $349.93 $349.93 $309.62 $309.62 $301.78 $301.78 $250.82 $250.82

$311.37 $311.37 $308.27 $308.27 $352.24 $352.24 $311.66 $311.66 $303.77 $303.77 $252.48 $252.48

$313.40 $313.40 $310.29 $310.29 $354.54 $354.54 $313.70 $313.70 $305.76 $305.76 $254.13 $254.13

$315.44 $315.44 $312.31 $312.31 $356.85 $356.85 $315.74 $315.74 $307.74 $307.74 $255.78 $255.78

$317.48 $317.48 $314.33 $314.33 $359.15 $359.15 $317.78 $317.78 $309.73 $309.73 $257.44 $257.44

$321.56 $321.56 $318.36 $318.36 $363.77 $363.77 $321.86 $321.86 $313.71 $313.71 $260.74 $260.74

$325.63 $325.63 $322.40 $322.40 $368.38 $368.38 $325.94 $325.94 $317.69 $317.69 $264.05 $264.05

$331.75 $331.75 $328.45 $328.45 $375.30 $375.30 $332.06 $332.06 $323.65 $323.65 $269.01 $269.01

$337.61 $337.61 $334.25 $334.25 $381.92 $381.92 $337.93 $337.93 $329.37 $329.37 $273.76 $273.76

$345.76 $345.76 $342.33 $342.33 $391.15 $391.15 $346.09 $346.09 $337.33 $337.33 $280.37 $280.37

$355.96 $355.96 $352.42 $352.42 $402.68 $402.68 $356.29 $356.29 $347.27 $347.27 $288.63 $288.63

$367.93 $367.93 $364.27 $364.27 $416.23 $416.23 $368.28 $368.28 $358.95 $358.95 $298.34 $298.34

$382.20 $382.20 $378.40 $378.40 $432.37 $432.37 $382.56 $382.56 $372.87 $372.87 $309.92 $309.92

$398.25 $398.25 $394.29 $394.29 $450.53 $450.53 $398.63 $398.63 $388.53 $388.53 $322.93 $322.93

$416.60 $416.60 $412.46 $412.46 $471.28 $471.28 $416.99 $416.99 $406.43 $406.43 $337.81 $337.81

$434.69 $434.69 $430.37 $430.37 $491.75 $491.75 $435.10 $435.10 $424.08 $424.08 $352.48 $352.48

$455.07 $455.07 $450.55 $450.55 $514.81 $514.81 $455.51 $455.51 $443.97 $443.97 $369.01 $369.01

$475.20 $475.20 $470.48 $470.48 $537.58 $537.58 $475.65 $475.65 $463.61 $463.61 $385.33 $385.33

$497.37 $497.37 $492.43 $492.43 $562.65 $562.65 $497.84 $497.84 $485.23 $485.23 $403.30 $403.30

$519.79 $519.79 $514.63 $514.63 $588.02 $588.02 $520.29 $520.29 $507.11 $507.11 $421.48 $421.48

$544.00 $544.00 $538.59 $538.59 $615.40 $615.40 $544.51 $544.51 $530.72 $530.72 $441.11 $441.11

$568.20 $568.20 $562.56 $562.56 $642.79 $642.79 $568.74 $568.74 $554.34 $554.34 $460.74 $460.74

$594.45 $594.45 $588.54 $588.54 $672.48 $672.48 $595.01 $595.01 $579.94 $579.94 $482.02 $482.02

$620.95 $620.95 $614.78 $614.78 $702.45 $702.45 $621.54 $621.54 $605.79 $605.79 $503.51 $503.51

$649.23 $649.23 $642.78 $642.78 $734.45 $734.45 $649.85 $649.85 $633.39 $633.39 $526.44 $526.44

$663.24 $663.24 $656.65 $656.65 $750.30 $750.30 $663.87 $663.87 $647.06 $647.06 $537.81 $537.81

$691.53 $691.53 $684.66 $684.66 $782.30 $782.30 $692.18 $692.18 $674.65 $674.65 $560.74 $560.74

$715.99 $715.99 $708.87 $708.87 $809.97 $809.97 $716.67 $716.67 $698.52 $698.52 $580.57 $580.57

$732.04 $732.04 $724.77 $724.77 $828.13 $828.13 $732.74 $732.74 $714.18 $714.18 $593.59 $593.59

$752.17 $752.17 $744.69 $744.69 $850.90 $850.90 $752.88 $752.88 $733.81 $733.81 $609.91 $609.91

$764.40 $764.40 $756.80 $756.80 $864.74 $864.74 $765.12 $765.12 $745.74 $745.74 $619.83 $619.83

$764.40 $764.40 $756.80 $756.80 $864.74 $864.74 $765.12 $765.12 $745.74 $745.74 $619.83 $619.83


04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/1704/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17

33709PA0570004 33709PA0570006 33709PA0450004 33709PA0640001 33709PA0640002 33709PA0640003



A

Silver Silver

A A A A A

Gold Silver Silver Bronze


Blue Flex Plan


Blue Flex Plan









$1,500 $2,600 $3,000 $5,500 $1,750/$5,250 $2,000/$6,000

90%/70%/50%

$35/$65 $35/$65

90%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 80%/60%/50%

$15*/$50* 100%*/$30* 100%* /70%* 80%*/60%*

$7,150 $7,150 $3,500 $6,550 $6,550 $6,550






Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$131.62 $131.62 $196.78 $196.78

$207.27 $207.27 $309.89 $309.89

$207.27 $207.27 $309.89 $309.89

$207.27 $207.27 $309.89 $309.89

$207.27 $207.27 $309.89 $309.89

$208.10 $208.10 $311.13 $311.13

$212.24 $212.24 $317.32 $317.32

$217.22 $217.22 $324.76 $324.76

$225.30 $225.30 $336.85 $336.85

$231.93 $231.93 $346.76 $346.76

$235.25 $235.25 $351.72 $351.72

$240.23 $240.23 $359.16 $359.16

$245.20 $245.20 $366.60 $366.60

$248.31 $248.31 $371.24 $371.24

$251.63 $251.63 $376.20 $376.20

$253.28 $253.28 $378.68 $378.68

$254.94 $254.94 $381.16 $381.16

$256.60 $256.60 $383.64 $383.64

$258.26 $258.26 $386.12 $386.12

$261.57 $261.57 $391.08 $391.08

$264.89 $264.89 $396.03 $396.03

$269.87 $269.87 $403.47 $403.47

$274.63 $274.63 $410.60 $410.60

$281.26 $281.26 $420.52 $420.52

$289.56 $289.56 $432.91 $432.91

$299.30 $299.30 $447.48 $447.48

$310.90 $310.90 $464.83 $464.83

$323.96 $323.96 $484.35 $484.35

$338.89 $338.89 $506.66 $506.66

$353.60 $353.60 $528.67 $528.67

$370.18 $370.18 $553.46 $553.46

$386.56 $386.56 $577.94 $577.94

$404.59 $404.59 $604.90 $604.90

$422.83 $422.83 $632.17 $632.17

$442.52 $442.52 $661.61 $661.61

$462.21 $462.21 $691.05 $691.05

$483.56 $483.56 $722.96 $722.96

$505.12 $505.12 $755.19 $755.19

$528.12 $528.12 $789.59 $789.59

$539.52 $539.52 $806.63 $806.63

$562.53 $562.53 $841.03 $841.03

$582.43 $582.43 $870.78 $870.78

$595.49 $595.49 $890.30 $890.30

$611.86 $611.86 $914.78 $914.78

$621.81 $621.81 $929.66 $929.66

$621.81 $621.81 $929.66 $929.66

Flex PPO

04/1/17, 05/1/17, 06/1/17

Health Savings PPO

04/1/17, 05/1/17, 06/1/17

33709PA0640005 33709PA0460012

HDHP-SM/WG-4 PPO-SM/WG-4

Area 1, 4 Area 1, 4

Gold

A A

Bronze




Community Blue Plan

$6,000 $500/$1,500

$10/$40

100%/70%/50% 100%/70%/50%

100%*/70%

$6,550 $5,500

Yes Yes





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>


0 - 20 $140.37 $140.37 $150.50 $150.50 $206.08 $206.08 $220.95 $220.95 $194.73 $194.73 $209.56 $209.56

21 $221.05 $221.05 $237.01 $237.01 $324.53 $324.53 $347.95 $347.95 $306.67 $306.67 $330.02 $330.02

22 $221.05 $221.05 $237.01 $237.01 $324.53 $324.53 $347.95 $347.95 $306.67 $306.67 $330.02 $330.02

23 $221.05 $221.05 $237.01 $237.01 $324.53 $324.53 $347.95 $347.95 $306.67 $306.67 $330.02 $330.02

24 $221.05 $221.05 $237.01 $237.01 $324.53 $324.53 $347.95 $347.95 $306.67 $306.67 $330.02 $330.02

25 $221.94 $221.94 $237.95 $237.95 $325.83 $325.83 $349.34 $349.34 $307.89 $307.89 $331.34 $331.34

26 $226.36 $226.36 $242.69 $242.69 $332.32 $332.32 $356.30 $356.30 $314.03 $314.03 $337.94 $337.94

27 $231.66 $231.66 $248.38 $248.38 $340.11 $340.11 $364.65 $364.65 $321.39 $321.39 $345.86 $345.86

28 $240.28 $240.28 $257.63 $257.63 $352.77 $352.77 $378.22 $378.22 $333.35 $333.35 $358.74 $358.74

29 $247.36 $247.36 $265.21 $265.21 $363.15 $363.15 $389.36 $389.36 $343.16 $343.16 $369.30 $369.30

30 $250.90 $250.90 $269.00 $269.00 $368.34 $368.34 $394.93 $394.93 $348.07 $348.07 $374.58 $374.58

31 $256.20 $256.20 $274.69 $274.69 $376.13 $376.13 $403.28 $403.28 $355.43 $355.43 $382.50 $382.50

32 $261.51 $261.51 $280.38 $280.38 $383.92 $383.92 $411.63 $411.63 $362.79 $362.79 $390.42 $390.42

33 $264.82 $264.82 $283.93 $283.93 $388.79 $388.79 $416.85 $416.85 $367.39 $367.39 $395.37 $395.37

34 $268.36 $268.36 $287.72 $287.72 $393.98 $393.98 $422.41 $422.41 $372.29 $372.29 $400.65 $400.65

35 $270.13 $270.13 $289.62 $289.62 $396.58 $396.58 $425.20 $425.20 $374.75 $374.75 $403.29 $403.29

36 $271.90 $271.90 $291.52 $291.52 $399.18 $399.18 $427.98 $427.98 $377.20 $377.20 $405.93 $405.93

37 $273.66 $273.66 $293.41 $293.41 $401.77 $401.77 $430.77 $430.77 $379.65 $379.65 $408.57 $408.57

38 $275.43 $275.43 $295.31 $295.31 $404.37 $404.37 $433.55 $433.55 $382.11 $382.11 $411.21 $411.21

39 $278.97 $278.97 $299.10 $299.10 $409.56 $409.56 $439.12 $439.12 $387.01 $387.01 $416.49 $416.49

40 $282.51 $282.51 $302.89 $302.89 $414.75 $414.75 $444.68 $444.68 $391.92 $391.92 $421.77 $421.77

41 $287.81 $287.81 $308.58 $308.58 $422.54 $422.54 $453.03 $453.03 $399.28 $399.28 $429.69 $429.69

42 $292.90 $292.90 $314.03 $314.03 $430.01 $430.01 $461.04 $461.04 $406.33 $406.33 $437.28 $437.28

43 $299.97 $299.97 $321.62 $321.62 $440.39 $440.39 $472.17 $472.17 $416.15 $416.15 $447.84 $447.84

44 $308.81 $308.81 $331.10 $331.10 $453.37 $453.37 $486.09 $486.09 $428.41 $428.41 $461.04 $461.04

45 $319.20 $319.20 $342.24 $342.24 $468.63 $468.63 $502.44 $502.44 $442.82 $442.82 $476.55 $476.55

46 $331.58 $331.58 $355.51 $355.51 $486.80 $486.80 $521.93 $521.93 $460.00 $460.00 $495.03 $495.03

47 $345.51 $345.51 $370.44 $370.44 $507.24 $507.24 $543.85 $543.85 $479.32 $479.32 $515.83 $515.83

48 $361.42 $361.42 $387.50 $387.50 $530.61 $530.61 $568.90 $568.90 $501.40 $501.40 $539.59 $539.59

49 $377.12 $377.12 $404.33 $404.33 $553.65 $553.65 $593.61 $593.61 $523.17 $523.17 $563.02 $563.02

50 $394.80 $394.80 $423.29 $423.29 $579.62 $579.62 $621.44 $621.44 $547.70 $547.70 $589.42 $589.42

51 $412.26 $412.26 $442.02 $442.02 $605.25 $605.25 $648.93 $648.93 $571.93 $571.93 $615.49 $615.49

52 $431.50 $431.50 $462.63 $462.63 $633.49 $633.49 $679.20 $679.20 $598.61 $598.61 $644.21 $644.21

53 $450.95 $450.95 $483.49 $483.49 $662.05 $662.05 $709.82 $709.82 $625.60 $625.60 $673.25 $673.25

54 $471.95 $471.95 $506.01 $506.01 $692.88 $692.88 $742.88 $742.88 $654.73 $654.73 $704.60 $704.60

55 $492.95 $492.95 $528.52 $528.52 $723.71 $723.71 $775.93 $775.93 $683.86 $683.86 $735.95 $735.95

56 $515.72 $515.72 $552.93 $552.93 $757.14 $757.14 $811.77 $811.77 $715.45 $715.45 $769.94 $769.94

57 $538.71 $538.71 $577.58 $577.58 $790.89 $790.89 $847.96 $847.96 $747.34 $747.34 $804.27 $804.27

58 $563.24 $563.24 $603.89 $603.89 $826.91 $826.91 $886.58 $886.58 $781.38 $781.38 $840.90 $840.90

59 $575.40 $575.40 $616.93 $616.93 $844.76 $844.76 $905.72 $905.72 $798.25 $798.25 $859.05 $859.05

60 $599.94 $599.94 $643.23 $643.23 $880.78 $880.78 $944.34 $944.34 $832.29 $832.29 $895.68 $895.68

61 $621.16 $621.16 $665.99 $665.99 $911.94 $911.94 $977.75 $977.75 $861.73 $861.73 $927.36 $927.36

62 $635.09 $635.09 $680.92 $680.92 $932.38 $932.38 $999.67 $999.67 $881.05 $881.05 $948.16 $948.16

63 $652.55 $652.55 $699.64 $699.64 $958.02 $958.02 $1,027.16 $1,027.16 $905.28 $905.28 $974.23 $974.23

64 $663.15 $663.15 $711.02 $711.02 $973.59 $973.59 $1,043.85 $1,043.85 $920.00 $920.00 $990.06 $990.06

65+ $663.15 $663.15 $711.02 $711.02 $973.59 $973.59 $1,043.85 $1,043.85 $920.00 $920.00 $990.06 $990.06

04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17


33709PA0640004 33709PA0640004 33709PA0460007 33709PA0460007 33709PA0460008 33709PA0460013



Gold

B B H H G B





Flex PPO $500/$1500 Penn Highlands

Region a Community Blue Plan

Flex PPO $500/$1500 Penn Highlands

Region a Community Blue Plan



Blue Plan


Community Blue Plan

Bronze Bronze Gold Gold Gold

80%/60%/50% 80%/60%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$5,500 $5,500 $500 $500 $500 $500/$1,500

$6,550 $6,550 $5,500 $5,500 $5,300 $5,500

80%*/60%* 80%*/60%* $20/$50 $20/$50 $20/$50 $10/$40






Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$224.69 $224.69 $212.39 $212.39 $227.72 $227.72 $203.49 $203.49 $218.18 $218.18

$353.84 $353.84 $334.48 $334.48 $358.61 $358.61 $320.46 $320.46 $343.58 $343.58

$353.84 $353.84 $334.48 $334.48 $358.61 $358.61 $320.46 $320.46 $343.58 $343.58

$353.84 $353.84 $334.48 $334.48 $358.61 $358.61 $320.46 $320.46 $343.58 $343.58

$353.84 $353.84 $334.48 $334.48 $358.61 $358.61 $320.46 $320.46 $343.58 $343.58

$355.25 $355.25 $335.81 $335.81 $360.05 $360.05 $321.74 $321.74 $344.96 $344.96

$362.33 $362.33 $342.50 $342.50 $367.22 $367.22 $328.15 $328.15 $351.83 $351.83

$370.82 $370.82 $350.53 $350.53 $375.83 $375.83 $335.84 $335.84 $360.08 $360.08

$384.62 $384.62 $363.57 $363.57 $389.81 $389.81 $348.34 $348.34 $373.48 $373.48

$395.95 $395.95 $374.28 $374.28 $401.29 $401.29 $358.59 $358.59 $384.47 $384.47

$401.61 $401.61 $379.63 $379.63 $407.03 $407.03 $363.72 $363.72 $389.97 $389.97

$410.10 $410.10 $387.66 $387.66 $415.63 $415.63 $371.41 $371.41 $398.21 $398.21

$418.59 $418.59 $395.68 $395.68 $424.24 $424.24 $379.10 $379.10 $406.46 $406.46

$423.90 $423.90 $400.70 $400.70 $429.62 $429.62 $383.91 $383.91 $411.61 $411.61

$429.56 $429.56 $406.05 $406.05 $435.36 $435.36 $389.04 $389.04 $417.11 $417.11

$432.39 $432.39 $408.73 $408.73 $438.22 $438.22 $391.60 $391.60 $419.86 $419.86

$435.22 $435.22 $411.40 $411.40 $441.09 $441.09 $394.16 $394.16 $422.61 $422.61

$438.05 $438.05 $414.08 $414.08 $443.96 $443.96 $396.73 $396.73 $425.36 $425.36

$440.88 $440.88 $416.76 $416.76 $446.83 $446.83 $399.29 $399.29 $428.11 $428.11

$446.55 $446.55 $422.11 $422.11 $452.57 $452.57 $404.42 $404.42 $433.60 $433.60

$452.21 $452.21 $427.46 $427.46 $458.31 $458.31 $409.55 $409.55 $439.10 $439.10

$460.70 $460.70 $435.49 $435.49 $466.91 $466.91 $417.24 $417.24 $447.35 $447.35

$468.84 $468.84 $443.18 $443.18 $475.16 $475.16 $424.61 $424.61 $455.25 $455.25

$480.16 $480.16 $453.88 $453.88 $486.64 $486.64 $434.86 $434.86 $466.24 $466.24

$494.31 $494.31 $467.26 $467.26 $500.98 $500.98 $447.68 $447.68 $479.99 $479.99

$510.94 $510.94 $482.98 $482.98 $517.84 $517.84 $462.74 $462.74 $496.14 $496.14

$530.76 $530.76 $501.71 $501.71 $537.92 $537.92 $480.69 $480.69 $515.38 $515.38

$553.05 $553.05 $522.79 $522.79 $560.51 $560.51 $500.88 $500.88 $537.02 $537.02

$578.53 $578.53 $546.87 $546.87 $586.33 $586.33 $523.95 $523.95 $561.76 $561.76

$603.65 $603.65 $570.62 $570.62 $611.79 $611.79 $546.70 $546.70 $586.16 $586.16

$631.96 $631.96 $597.37 $597.37 $640.48 $640.48 $572.34 $572.34 $613.64 $613.64

$659.91 $659.91 $623.80 $623.80 $668.81 $668.81 $597.66 $597.66 $640.79 $640.79

$690.69 $690.69 $652.90 $652.90 $700.01 $700.01 $625.54 $625.54 $670.68 $670.68

$721.83 $721.83 $682.33 $682.33 $731.57 $731.57 $653.74 $653.74 $700.91 $700.91

$755.45 $755.45 $714.10 $714.10 $765.64 $765.64 $684.18 $684.18 $733.55 $733.55

$789.06 $789.06 $745.88 $745.88 $799.71 $799.71 $714.62 $714.62 $766.19 $766.19

$825.51 $825.51 $780.33 $780.33 $836.64 $836.64 $747.63 $747.63 $801.58 $801.58

$862.31 $862.31 $815.12 $815.12 $873.94 $873.94 $780.96 $780.96 $837.32 $837.32

$901.58 $901.58 $852.24 $852.24 $913.75 $913.75 $816.53 $816.53 $875.45 $875.45

$921.04 $921.04 $870.64 $870.64 $933.47 $933.47 $834.15 $834.15 $894.35 $894.35

$960.32 $960.32 $907.77 $907.77 $973.28 $973.28 $869.73 $869.73 $932.49 $932.49

$994.29 $994.29 $939.88 $939.88 $1,007.70 $1,007.70 $900.49 $900.49 $965.47 $965.47

$1,016.58 $1,016.58 $960.95 $960.95 $1,030.29 $1,030.29 $920.68 $920.68 $987.12 $987.12

$1,044.53 $1,044.53 $987.37 $987.37 $1,058.62 $1,058.62 $945.99 $945.99 $1,014.26 $1,014.26

$1,061.52 $1,061.52 $1,003.43 $1,003.43 $1,075.83 $1,075.83 $961.38 $961.38 $1,030.74 $1,030.74

$1,061.52 $1,061.52 $1,003.43 $1,003.43 $1,075.83 $1,075.83 $961.38 $961.38 $1,030.74 $1,030.74

04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17


04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17

33709PA0460013 33709PA0440014 33709PA0440014 33709PA0440009 33709PA0440009



Area 1, 2, 5 Area 6

Gold Gold Gold

B B B B B

$250/$750 $250/$750

Gold Gold


Community Blue Plan









$750/$1,500 $750/$1,500

100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$500/$1,500

$30/$60 $30/$60$10/$40 $20/$60 $20/$60

Yes YesYes Yes Yes

$5,500 $7,150 $7,150 $4,800 $4,800





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$175.72 $175.72 $188.41 $188.41

$276.73 $276.73 $296.70 $296.70

$276.73 $276.73 $296.70 $296.70

$276.73 $276.73 $296.70 $296.70

$276.73 $276.73 $296.70 $296.70

$277.84 $277.84 $297.89 $297.89

$283.37 $283.37 $303.82 $303.82

$290.01 $290.01 $310.94 $310.94

$300.81 $300.81 $322.51 $322.51

$309.66 $309.66 $332.01 $332.01

$314.09 $314.09 $336.76 $336.76

$320.73 $320.73 $343.88 $343.88

$327.37 $327.37 $351.00 $351.00

$331.52 $331.52 $355.45 $355.45

$335.95 $335.95 $360.20 $360.20

$338.17 $338.17 $362.57 $362.57

$340.38 $340.38 $364.94 $364.94

$342.59 $342.59 $367.32 $367.32

$344.81 $344.81 $369.69 $369.69

$349.23 $349.23 $374.44 $374.44

$353.66 $353.66 $379.18 $379.18

$360.30 $360.30 $386.31 $386.31

$366.67 $366.67 $393.13 $393.13

$375.52 $375.52 $402.62 $402.62

$386.59 $386.59 $414.49 $414.49

$399.60 $399.60 $428.44 $428.44

$415.10 $415.10 $445.05 $445.05

$432.53 $432.53 $463.74 $463.74

$452.46 $452.46 $485.11 $485.11

$472.10 $472.10 $506.17 $506.17

$494.24 $494.24 $529.91 $529.91

$516.10 $516.10 $553.35 $553.35

$540.18 $540.18 $579.16 $579.16

$564.53 $564.53 $605.27 $605.27

$590.82 $590.82 $633.46 $633.46

$617.11 $617.11 $661.64 $661.64

$645.61 $645.61 $692.20 $692.20

$674.39 $674.39 $723.06 $723.06

$705.11 $705.11 $756.00 $756.00

$720.33 $720.33 $772.31 $772.31

$751.05 $751.05 $805.25 $805.25

$777.61 $777.61 $833.73 $833.73

$795.05 $795.05 $852.42 $852.42

$816.91 $816.91 $875.86 $875.86

$830.19 $830.19 $890.10 $890.10

$830.19 $830.19 $890.10 $890.10


04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17

33709PA044001333709PA0440013


Area 1, 2, 5 Area 6

BB

Silver Silver





$1,500/$4,500 $1,500/$4,500

100%/70%/50%100%/70%/50%

$45/$70* $45/$70*

Yes Yes

$7,150 $7,150



Company Name: Highmark Inc., d/b/a as Highmark Blue Cross Blue Shield PA (Western, PA Region) - Service Zone J & L



Form #

Region =>

Service Zone =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dentail (Yes/No) =>


0 - 20 $183.26 $183.26 $182.52 $182.52 $179.92 $179.92 $178.90 $178.90 $174.86 $174.86 $173.46 $173.46

21 $288.60 $288.60 $287.43 $287.43 $283.34 $283.34 $281.74 $281.74 $275.37 $275.37 $273.16 $273.16

22 $288.60 $288.60 $287.43 $287.43 $283.34 $283.34 $281.74 $281.74 $275.37 $275.37 $273.16 $273.16

23 $288.60 $288.60 $287.43 $287.43 $283.34 $283.34 $281.74 $281.74 $275.37 $275.37 $273.16 $273.16

24 $288.60 $288.60 $287.43 $287.43 $283.34 $283.34 $281.74 $281.74 $275.37 $275.37 $273.16 $273.16

25 $289.76 $289.76 $288.58 $288.58 $284.47 $284.47 $282.86 $282.86 $276.47 $276.47 $274.25 $274.25

26 $295.53 $295.53 $294.33 $294.33 $290.14 $290.14 $288.50 $288.50 $281.98 $281.98 $279.72 $279.72

27 $302.46 $302.46 $301.23 $301.23 $296.94 $296.94 $295.26 $295.26 $288.59 $288.59 $286.27 $286.27

28 $313.71 $313.71 $312.44 $312.44 $307.99 $307.99 $306.25 $306.25 $299.33 $299.33 $296.93 $296.93

29 $322.95 $322.95 $321.63 $321.63 $317.05 $317.05 $315.26 $315.26 $308.14 $308.14 $305.67 $305.67

30 $327.57 $327.57 $326.23 $326.23 $321.59 $321.59 $319.77 $319.77 $312.55 $312.55 $310.04 $310.04

31 $334.49 $334.49 $333.13 $333.13 $328.39 $328.39 $326.53 $326.53 $319.16 $319.16 $316.59 $316.59

32 $341.42 $341.42 $340.03 $340.03 $335.19 $335.19 $333.29 $333.29 $325.77 $325.77 $323.15 $323.15

33 $345.75 $345.75 $344.34 $344.34 $339.44 $339.44 $337.52 $337.52 $329.90 $329.90 $327.25 $327.25

34 $350.37 $350.37 $348.94 $348.94 $343.97 $343.97 $342.03 $342.03 $334.30 $334.30 $331.62 $331.62

35 $352.67 $352.67 $351.24 $351.24 $346.24 $346.24 $344.28 $344.28 $336.51 $336.51 $333.80 $333.80

36 $354.98 $354.98 $353.54 $353.54 $348.50 $348.50 $346.54 $346.54 $338.71 $338.71 $335.99 $335.99

37 $357.29 $357.29 $355.84 $355.84 $350.77 $350.77 $348.79 $348.79 $340.91 $340.91 $338.17 $338.17

38 $359.60 $359.60 $358.14 $358.14 $353.04 $353.04 $351.04 $351.04 $343.12 $343.12 $340.36 $340.36

39 $364.22 $364.22 $362.74 $362.74 $357.57 $357.57 $355.55 $355.55 $347.52 $347.52 $344.73 $344.73

40 $368.84 $368.84 $367.34 $367.34 $362.10 $362.10 $360.06 $360.06 $351.93 $351.93 $349.10 $349.10

41 $375.76 $375.76 $374.23 $374.23 $368.90 $368.90 $366.82 $366.82 $358.54 $358.54 $355.66 $355.66

42 $382.40 $382.40 $380.85 $380.85 $375.42 $375.42 $373.30 $373.30 $364.87 $364.87 $361.94 $361.94

43 $391.64 $391.64 $390.04 $390.04 $384.49 $384.49 $382.32 $382.32 $373.68 $373.68 $370.68 $370.68

44 $403.18 $403.18 $401.54 $401.54 $395.82 $395.82 $393.59 $393.59 $384.70 $384.70 $381.61 $381.61

45 $416.74 $416.74 $415.05 $415.05 $409.14 $409.14 $406.83 $406.83 $397.64 $397.64 $394.45 $394.45

46 $432.91 $432.91 $431.15 $431.15 $425.01 $425.01 $422.60 $422.60 $413.06 $413.06 $409.74 $409.74

47 $451.09 $451.09 $449.25 $449.25 $442.86 $442.86 $440.35 $440.35 $430.41 $430.41 $426.95 $426.95

48 $471.87 $471.87 $469.95 $469.95 $463.26 $463.26 $460.64 $460.64 $450.24 $450.24 $446.62 $446.62

49 $492.36 $492.36 $490.36 $490.36 $483.37 $483.37 $480.64 $480.64 $469.79 $469.79 $466.01 $466.01

50 $515.45 $515.45 $513.35 $513.35 $506.04 $506.04 $503.18 $503.18 $491.82 $491.82 $487.87 $487.87

51 $538.25 $538.25 $536.06 $536.06 $528.42 $528.42 $525.44 $525.44 $513.57 $513.57 $509.45 $509.45

52 $563.36 $563.36 $561.06 $561.06 $553.07 $553.07 $549.95 $549.95 $537.53 $537.53 $533.21 $533.21

53 $588.75 $588.75 $586.36 $586.36 $578.01 $578.01 $574.74 $574.74 $561.76 $561.76 $557.25 $557.25

54 $616.17 $616.17 $613.66 $613.66 $604.92 $604.92 $601.51 $601.51 $587.92 $587.92 $583.20 $583.20

55 $643.59 $643.59 $640.97 $640.97 $631.84 $631.84 $628.27 $628.27 $614.08 $614.08 $609.15 $609.15

56 $673.31 $673.31 $670.58 $670.58 $661.03 $661.03 $657.29 $657.29 $642.45 $642.45 $637.29 $637.29

57 $703.33 $703.33 $700.47 $700.47 $690.49 $690.49 $686.59 $686.59 $671.08 $671.08 $665.70 $665.70

58 $735.36 $735.36 $732.37 $732.37 $721.94 $721.94 $717.86 $717.86 $701.65 $701.65 $696.02 $696.02

59 $751.24 $751.24 $748.18 $748.18 $737.53 $737.53 $733.36 $733.36 $716.80 $716.80 $711.04 $711.04

60 $783.27 $783.27 $780.09 $780.09 $768.98 $768.98 $764.63 $764.63 $747.36 $747.36 $741.36 $741.36

61 $810.98 $810.98 $807.68 $807.68 $796.18 $796.18 $791.68 $791.68 $773.80 $773.80 $767.58 $767.58

62 $829.16 $829.16 $825.79 $825.79 $814.03 $814.03 $809.43 $809.43 $791.15 $791.15 $784.79 $784.79

63 $851.96 $851.96 $848.49 $848.49 $836.41 $836.41 $831.69 $831.69 $812.90 $812.90 $806.37 $806.37

64 $865.80 $865.80 $862.29 $862.29 $850.01 $850.01 $845.21 $845.21 $826.11 $826.11 $819.48 $819.48

65+ $865.80 $865.80 $862.29 $862.29 $850.01 $850.01 $845.21 $845.21 $826.11 $826.11 $819.48 $819.48

04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17


33709PA0630002 33709PA0630003 33709PA0630004 33709PA0630005 33709PA0630006 33709PA0630008




J J J J J J

$100 $250 $500 $750 $900 $1,100

Connect Blue EPO $100 a Community

Blue Plan


Blue Plan


Blue Plan


Blue Plan


Blue Plan


Community Blue Plan

$25 $10 $10 $0 $10 $10

100% 100% 100% 100% 100% 100%


$7,150 $7,150 $7,150 $6,100 $7,150 $6,800



Company Name: Highmark Inc., d/b/a as Highmark Blue Cross Blue Shield PA (Western, PA Region) - Service Zone J & L



Form #

Region =>

Service Zone =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dentail (Yes/No) =>

Age Band

0 - 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

65+


$150.46 $150.46 $147.54 $147.54

$236.94 $236.94 $232.35 $232.35

$236.94 $236.94 $232.35 $232.35

$236.94 $236.94 $232.35 $232.35

$236.94 $236.94 $232.35 $232.35

$237.89 $237.89 $233.28 $233.28

$242.63 $242.63 $237.93 $237.93

$248.32 $248.32 $243.51 $243.51

$257.56 $257.56 $252.57 $252.57

$265.14 $265.14 $260.00 $260.00

$268.93 $268.93 $263.72 $263.72

$274.62 $274.62 $269.30 $269.30

$280.30 $280.30 $274.87 $274.87

$283.86 $283.86 $278.36 $278.36

$287.65 $287.65 $282.08 $282.08

$289.54 $289.54 $283.94 $283.94

$291.44 $291.44 $285.80 $285.80

$293.33 $293.33 $287.65 $287.65

$295.23 $295.23 $289.51 $289.51

$299.02 $299.02 $293.23 $293.23

$302.81 $302.81 $296.95 $296.95

$308.50 $308.50 $302.52 $302.52

$313.95 $313.95 $307.87 $307.87

$321.53 $321.53 $315.30 $315.30

$331.01 $331.01 $324.60 $324.60

$342.14 $342.14 $335.52 $335.52

$355.41 $355.41 $348.53 $348.53

$370.34 $370.34 $363.17 $363.17

$387.40 $387.40 $379.90 $379.90

$404.22 $404.22 $396.40 $396.40

$423.18 $423.18 $414.98 $414.98

$441.90 $441.90 $433.34 $433.34

$462.51 $462.51 $453.55 $453.55

$483.36 $483.36 $474.00 $474.00

$505.87 $505.87 $496.08 $496.08

$528.38 $528.38 $518.15 $518.15

$552.79 $552.79 $542.08 $542.08

$577.43 $577.43 $566.25 $566.25

$603.73 $603.73 $592.04 $592.04

$616.76 $616.76 $604.82 $604.82

$643.06 $643.06 $630.61 $630.61

$665.81 $665.81 $652.91 $652.91

$680.73 $680.73 $667.55 $667.55

$699.45 $699.45 $685.91 $685.91

$710.82 $710.82 $697.05 $697.05

$710.82 $710.82 $697.05 $697.05


04/1/17, 05/1/17, 06/1/17 04/1/17, 05/1/17, 06/1/17

33709PA0630007 33709PA0630009


Area 1, 4 Area 1, 4

J J

Silver Silver


Community Blue Plan


Community Blue Plan

$2,500 $3200

100% 100%

$25 $25

$7,150 $7,150

Yes Yes




HIOS Plan ID $261.18 $261.18

33709PA0570007 $258.94 $258.94

33709PA0570004 $254.80 $254.80

33709PA0570006 $252.27 $252.27

33709PA0640001 $255.04 $255.04

33709PA0640002 $248.58 $248.58

33709PA0630007 $236.94 $236.94

33709PA0630009 $232.35 $232.35

33709PA0440013 $276.73 $276.73 $276.73 $296.70



Exhibit V

HIOS Plan ID

On/Off


























Venango






















Highmark Inc.

Small Group Market

Plan Design Summary




Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>


0 - 20 $240.02 $240.02 $236.03 $236.03 $203.24 $203.24 $206.12 $206.12 $201.65 $201.65 $199.07 $199.07

21 $377.99 $377.99 $371.70 $371.70 $320.06 $320.06 $324.59 $324.59 $317.56 $317.56 $313.49 $313.49

22 $377.99 $377.99 $371.70 $371.70 $320.06 $320.06 $324.59 $324.59 $317.56 $317.56 $313.49 $313.49

23 $377.99 $377.99 $371.70 $371.70 $320.06 $320.06 $324.59 $324.59 $317.56 $317.56 $313.49 $313.49

24 $377.99 $377.99 $371.70 $371.70 $320.06 $320.06 $324.59 $324.59 $317.56 $317.56 $313.49 $313.49

25 $379.50 $379.50 $373.19 $373.19 $321.34 $321.34 $325.89 $325.89 $318.83 $318.83 $314.75 $314.75

26 $387.06 $387.06 $380.62 $380.62 $327.74 $327.74 $332.38 $332.38 $325.18 $325.18 $321.02 $321.02

27 $396.13 $396.13 $389.55 $389.55 $335.42 $335.42 $340.17 $340.17 $332.80 $332.80 $328.54 $328.54

28 $410.87 $410.87 $404.04 $404.04 $347.91 $347.91 $352.83 $352.83 $345.19 $345.19 $340.77 $340.77

29 $422.97 $422.97 $415.94 $415.94 $358.15 $358.15 $363.22 $363.22 $355.35 $355.35 $350.80 $350.80

30 $429.02 $429.02 $421.88 $421.88 $363.27 $363.27 $368.41 $368.41 $360.43 $360.43 $355.82 $355.82

31 $438.09 $438.09 $430.80 $430.80 $370.95 $370.95 $376.20 $376.20 $368.05 $368.05 $363.34 $363.34

32 $447.16 $447.16 $439.73 $439.73 $378.63 $378.63 $383.99 $383.99 $375.67 $375.67 $370.86 $370.86

33 $452.83 $452.83 $445.30 $445.30 $383.43 $383.43 $388.86 $388.86 $380.44 $380.44 $375.57 $375.57

34 $458.88 $458.88 $451.25 $451.25 $388.55 $388.55 $394.05 $394.05 $385.52 $385.52 $380.58 $380.58

35 $461.90 $461.90 $454.22 $454.22 $391.11 $391.11 $396.65 $396.65 $388.06 $388.06 $383.09 $383.09

36 $464.93 $464.93 $457.20 $457.20 $393.68 $393.68 $399.25 $399.25 $390.60 $390.60 $385.60 $385.60

37 $467.95 $467.95 $460.17 $460.17 $396.24 $396.24 $401.84 $401.84 $393.14 $393.14 $388.11 $388.11

38 $470.98 $470.98 $463.14 $463.14 $398.80 $398.80 $404.44 $404.44 $395.68 $395.68 $390.61 $390.61

39 $477.02 $477.02 $469.09 $469.09 $403.92 $403.92 $409.63 $409.63 $400.76 $400.76 $395.63 $395.63

40 $483.07 $483.07 $475.04 $475.04 $409.04 $409.04 $414.83 $414.83 $405.84 $405.84 $400.65 $400.65

41 $492.14 $492.14 $483.96 $483.96 $416.72 $416.72 $422.62 $422.62 $413.46 $413.46 $408.17 $408.17

42 $500.84 $500.84 $492.51 $492.51 $424.08 $424.08 $430.08 $430.08 $420.77 $420.77 $415.38 $415.38

43 $512.93 $512.93 $504.40 $504.40 $434.32 $434.32 $440.47 $440.47 $430.93 $430.93 $425.41 $425.41

44 $528.05 $528.05 $519.27 $519.27 $447.13 $447.13 $453.45 $453.45 $443.63 $443.63 $437.95 $437.95

45 $545.82 $545.82 $536.74 $536.74 $462.17 $462.17 $468.71 $468.71 $458.55 $458.55 $452.69 $452.69

46 $566.98 $566.98 $557.56 $557.56 $480.09 $480.09 $486.89 $486.89 $476.34 $476.34 $470.24 $470.24

47 $590.80 $590.80 $580.97 $580.97 $500.26 $500.26 $507.34 $507.34 $496.34 $496.34 $489.99 $489.99

48 $618.01 $618.01 $607.74 $607.74 $523.30 $523.30 $530.71 $530.71 $519.21 $519.21 $512.56 $512.56

49 $644.85 $644.85 $634.13 $634.13 $546.02 $546.02 $553.75 $553.75 $541.75 $541.75 $534.82 $534.82

50 $675.09 $675.09 $663.86 $663.86 $571.63 $571.63 $579.72 $579.72 $567.16 $567.16 $559.90 $559.90

51 $704.95 $704.95 $693.23 $693.23 $596.91 $596.91 $605.36 $605.36 $592.25 $592.25 $584.67 $584.67

52 $737.84 $737.84 $725.57 $725.57 $624.76 $624.76 $633.60 $633.60 $619.87 $619.87 $611.94 $611.94

53 $771.10 $771.10 $758.28 $758.28 $652.92 $652.92 $662.17 $662.17 $647.82 $647.82 $639.53 $639.53

54 $807.01 $807.01 $793.59 $793.59 $683.33 $683.33 $693.00 $693.00 $677.99 $677.99 $669.31 $669.31

55 $842.92 $842.92 $828.90 $828.90 $713.74 $713.74 $723.84 $723.84 $708.16 $708.16 $699.09 $699.09

56 $881.85 $881.85 $867.19 $867.19 $746.70 $746.70 $757.27 $757.27 $740.86 $740.86 $731.38 $731.38

57 $921.16 $921.16 $905.84 $905.84 $779.99 $779.99 $791.03 $791.03 $773.89 $773.89 $763.99 $763.99

58 $963.12 $963.12 $947.10 $947.10 $815.52 $815.52 $827.06 $827.06 $809.14 $809.14 $798.78 $798.78

59 $983.91 $983.91 $967.55 $967.55 $833.12 $833.12 $844.91 $844.91 $826.61 $826.61 $816.03 $816.03

60 $1,025.86 $1,025.86 $1,008.80 $1,008.80 $868.65 $868.65 $880.94 $880.94 $861.85 $861.85 $850.82 $850.82

61 $1,062.15 $1,062.15 $1,044.49 $1,044.49 $899.37 $899.37 $912.10 $912.10 $892.34 $892.34 $880.92 $880.92

62 $1,085.96 $1,085.96 $1,067.91 $1,067.91 $919.54 $919.54 $932.55 $932.55 $912.35 $912.35 $900.67 $900.67

63 $1,115.83 $1,115.83 $1,097.27 $1,097.27 $944.82 $944.82 $958.19 $958.19 $937.43 $937.43 $925.44 $925.44

64 $1,133.97 $1,133.97 $1,115.10 $1,115.10 $960.18 $960.18 $973.77 $973.77 $952.68 $952.68 $940.47 $940.47

65+ $1,133.97 $1,133.97 $1,115.10 $1,115.10 $960.18 $960.18 $973.77 $973.77 $952.68 $952.68 $940.47 $940.47


$1,600 $1,300 $7,150 $7,150 $5,300 $4,800

$10/$40 $10/$40 $25/$70 $20/$60 $20/$60 $20/$60

100%/70%/50% 100%/70%/50% 100%/60%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$0/$500 $250/$750 $0/$5,000 $250/$750 $500/$1,500 $750/$1,500





Plan










A A A A A A



33709PA0560011 33709PA0560013 33709PA0560015 33709PA056001733709PA0560007 33709PA0560009


07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$195.87 $195.87 $194.33 $194.33 $192.89 $192.89 $190.84 $190.84 $171.14 $171.14 $169.68 $169.68

$308.45 $308.45 $306.04 $306.04 $303.77 $303.77 $300.54 $300.54 $269.51 $269.51 $267.21 $267.21

$308.45 $308.45 $306.04 $306.04 $303.77 $303.77 $300.54 $300.54 $269.51 $269.51 $267.21 $267.21

$308.45 $308.45 $306.04 $306.04 $303.77 $303.77 $300.54 $300.54 $269.51 $269.51 $267.21 $267.21

$308.45 $308.45 $306.04 $306.04 $303.77 $303.77 $300.54 $300.54 $269.51 $269.51 $267.21 $267.21

$309.68 $309.68 $307.26 $307.26 $304.98 $304.98 $301.74 $301.74 $270.59 $270.59 $268.27 $268.27

$315.85 $315.85 $313.38 $313.38 $311.06 $311.06 $307.75 $307.75 $275.98 $275.98 $273.62 $273.62

$323.26 $323.26 $320.72 $320.72 $318.35 $318.35 $314.96 $314.96 $282.45 $282.45 $280.03 $280.03

$335.29 $335.29 $332.66 $332.66 $330.19 $330.19 $326.68 $326.68 $292.96 $292.96 $290.45 $290.45

$345.16 $345.16 $342.45 $342.45 $339.91 $339.91 $336.30 $336.30 $301.59 $301.59 $299.00 $299.00

$350.09 $350.09 $347.35 $347.35 $344.77 $344.77 $341.11 $341.11 $305.90 $305.90 $303.28 $303.28

$357.49 $357.49 $354.69 $354.69 $352.06 $352.06 $348.32 $348.32 $312.37 $312.37 $309.69 $309.69

$364.90 $364.90 $362.04 $362.04 $359.35 $359.35 $355.53 $355.53 $318.84 $318.84 $316.10 $316.10

$369.52 $369.52 $366.63 $366.63 $363.91 $363.91 $360.04 $360.04 $322.88 $322.88 $320.11 $320.11

$374.46 $374.46 $371.53 $371.53 $368.77 $368.77 $364.85 $364.85 $327.19 $327.19 $324.39 $324.39

$376.93 $376.93 $373.97 $373.97 $371.20 $371.20 $367.25 $367.25 $329.35 $329.35 $326.53 $326.53

$379.39 $379.39 $376.42 $376.42 $373.63 $373.63 $369.66 $369.66 $331.50 $331.50 $328.66 $328.66

$381.86 $381.86 $378.87 $378.87 $376.06 $376.06 $372.06 $372.06 $333.66 $333.66 $330.80 $330.80

$384.33 $384.33 $381.32 $381.32 $378.49 $378.49 $374.47 $374.47 $335.82 $335.82 $332.94 $332.94

$389.26 $389.26 $386.22 $386.22 $383.35 $383.35 $379.28 $379.28 $340.13 $340.13 $337.21 $337.21

$394.20 $394.20 $391.11 $391.11 $388.21 $388.21 $384.08 $384.08 $344.44 $344.44 $341.49 $341.49

$401.60 $401.60 $398.46 $398.46 $395.50 $395.50 $391.30 $391.30 $350.91 $350.91 $347.90 $347.90

$408.70 $408.70 $405.50 $405.50 $402.49 $402.49 $398.21 $398.21 $357.11 $357.11 $354.05 $354.05

$418.57 $418.57 $415.29 $415.29 $412.21 $412.21 $407.83 $407.83 $365.73 $365.73 $362.60 $362.60

$430.91 $430.91 $427.53 $427.53 $424.36 $424.36 $419.85 $419.85 $376.51 $376.51 $373.29 $373.29

$445.40 $445.40 $441.91 $441.91 $438.64 $438.64 $433.97 $433.97 $389.18 $389.18 $385.85 $385.85

$462.68 $462.68 $459.05 $459.05 $455.65 $455.65 $450.80 $450.80 $404.27 $404.27 $400.81 $400.81

$482.11 $482.11 $478.33 $478.33 $474.79 $474.79 $469.74 $469.74 $421.25 $421.25 $417.64 $417.64

$504.32 $504.32 $500.37 $500.37 $496.66 $496.66 $491.37 $491.37 $440.66 $440.66 $436.88 $436.88

$526.22 $526.22 $522.10 $522.10 $518.22 $518.22 $512.71 $512.71 $459.79 $459.79 $455.85 $455.85

$550.89 $550.89 $546.58 $546.58 $542.52 $542.52 $536.76 $536.76 $481.35 $481.35 $477.23 $477.23

$575.26 $575.26 $570.76 $570.76 $566.52 $566.52 $560.50 $560.50 $502.64 $502.64 $498.34 $498.34

$602.09 $602.09 $597.38 $597.38 $592.95 $592.95 $586.64 $586.64 $526.09 $526.09 $521.59 $521.59

$629.24 $629.24 $624.31 $624.31 $619.68 $619.68 $613.09 $613.09 $549.81 $549.81 $545.10 $545.10

$658.54 $658.54 $653.38 $653.38 $648.54 $648.54 $641.64 $641.64 $575.41 $575.41 $570.48 $570.48

$687.84 $687.84 $682.46 $682.46 $677.40 $677.40 $670.19 $670.19 $601.02 $601.02 $595.87 $595.87

$719.61 $719.61 $713.98 $713.98 $708.68 $708.68 $701.15 $701.15 $628.78 $628.78 $623.39 $623.39

$751.69 $751.69 $745.81 $745.81 $740.28 $740.28 $732.40 $732.40 $656.81 $656.81 $651.18 $651.18

$785.93 $785.93 $779.78 $779.78 $773.99 $773.99 $765.76 $765.76 $686.72 $686.72 $680.84 $680.84

$802.90 $802.90 $796.61 $796.61 $790.70 $790.70 $782.29 $782.29 $701.55 $701.55 $695.54 $695.54

$837.13 $837.13 $830.58 $830.58 $824.42 $824.42 $815.65 $815.65 $731.46 $731.46 $725.20 $725.20

$866.75 $866.75 $859.96 $859.96 $853.58 $853.58 $844.50 $844.50 $757.34 $757.34 $750.85 $750.85

$886.18 $886.18 $879.24 $879.24 $872.72 $872.72 $863.44 $863.44 $774.32 $774.32 $767.68 $767.68

$910.55 $910.55 $903.42 $903.42 $896.71 $896.71 $887.18 $887.18 $795.61 $795.61 $788.79 $788.79

$925.35 $925.35 $918.11 $918.11 $911.30 $911.30 $901.61 $901.61 $808.53 $808.53 $801.62 $801.62

$925.35 $925.35 $918.11 $918.11 $911.30 $911.30 $901.61 $901.61 $808.53 $808.53 $801.62 $801.62


$4,800 $4,000 $3,700 $3,450 $7,150 $7,150

$20/$60 $20/$60 $40/$75 $45/$75*$20/$60 $20/$60

100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 90%/70%/50%

$1,500/$3,000 $2,000/$3,000 $1,400/$5,000 $1,000/$5,000$1,000/$2,000 $1,250/$2,500












Blue Flex Plan


A A A A A A



07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17

33709PA0560019 33709PA0560021 33709PA0560023 33709PA0560027 33709PA0560029 33709PA0570007

07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$166.95 $166.95 $165.30 $165.30 $188.87 $188.87 $167.13 $167.13 $162.89 $162.89 $135.38 $135.38

$262.92 $262.92 $260.32 $260.32 $297.44 $297.44 $263.19 $263.19 $256.52 $256.52 $213.20 $213.20

$262.92 $262.92 $260.32 $260.32 $297.44 $297.44 $263.19 $263.19 $256.52 $256.52 $213.20 $213.20

$262.92 $262.92 $260.32 $260.32 $297.44 $297.44 $263.19 $263.19 $256.52 $256.52 $213.20 $213.20

$262.92 $262.92 $260.32 $260.32 $297.44 $297.44 $263.19 $263.19 $256.52 $256.52 $213.20 $213.20

$263.97 $263.97 $261.36 $261.36 $298.63 $298.63 $264.24 $264.24 $257.54 $257.54 $214.05 $214.05

$269.23 $269.23 $266.57 $266.57 $304.58 $304.58 $269.51 $269.51 $262.67 $262.67 $218.31 $218.31

$275.54 $275.54 $272.81 $272.81 $311.72 $311.72 $275.82 $275.82 $268.83 $268.83 $223.43 $223.43

$285.79 $285.79 $282.97 $282.97 $323.32 $323.32 $286.09 $286.09 $278.83 $278.83 $231.74 $231.74

$294.21 $294.21 $291.30 $291.30 $332.84 $332.84 $294.51 $294.51 $287.04 $287.04 $238.57 $238.57

$298.41 $298.41 $295.46 $295.46 $337.60 $337.60 $298.72 $298.72 $291.15 $291.15 $241.98 $241.98

$304.72 $304.72 $301.71 $301.71 $344.73 $344.73 $305.04 $305.04 $297.30 $297.30 $247.09 $247.09

$311.03 $311.03 $307.96 $307.96 $351.87 $351.87 $311.35 $311.35 $303.46 $303.46 $252.21 $252.21

$314.98 $314.98 $311.86 $311.86 $356.33 $356.33 $315.30 $315.30 $307.31 $307.31 $255.41 $255.41

$319.18 $319.18 $316.03 $316.03 $361.09 $361.09 $319.51 $319.51 $311.41 $311.41 $258.82 $258.82

$321.29 $321.29 $318.11 $318.11 $363.47 $363.47 $321.62 $321.62 $313.46 $313.46 $260.53 $260.53

$323.39 $323.39 $320.19 $320.19 $365.85 $365.85 $323.72 $323.72 $315.52 $315.52 $262.23 $262.23

$325.49 $325.49 $322.27 $322.27 $368.23 $368.23 $325.83 $325.83 $317.57 $317.57 $263.94 $263.94

$327.60 $327.60 $324.36 $324.36 $370.61 $370.61 $327.93 $327.93 $319.62 $319.62 $265.64 $265.64

$331.80 $331.80 $328.52 $328.52 $375.37 $375.37 $332.15 $332.15 $323.72 $323.72 $269.05 $269.05

$336.01 $336.01 $332.69 $332.69 $380.13 $380.13 $336.36 $336.36 $327.83 $327.83 $272.46 $272.46

$342.32 $342.32 $338.94 $338.94 $387.27 $387.27 $342.67 $342.67 $333.98 $333.98 $277.58 $277.58

$348.37 $348.37 $344.92 $344.92 $394.11 $394.11 $348.73 $348.73 $339.88 $339.88 $282.49 $282.49

$356.78 $356.78 $353.25 $353.25 $403.63 $403.63 $357.15 $357.15 $348.09 $348.09 $289.31 $289.31

$367.30 $367.30 $363.67 $363.67 $415.52 $415.52 $367.68 $367.68 $358.35 $358.35 $297.84 $297.84

$379.65 $379.65 $375.90 $375.90 $429.50 $429.50 $380.05 $380.05 $370.41 $370.41 $307.86 $307.86

$394.38 $394.38 $390.48 $390.48 $446.16 $446.16 $394.79 $394.79 $384.77 $384.77 $319.79 $319.79

$410.94 $410.94 $406.88 $406.88 $464.90 $464.90 $411.37 $411.37 $400.94 $400.94 $333.23 $333.23

$429.87 $429.87 $425.62 $425.62 $486.32 $486.32 $430.32 $430.32 $419.40 $419.40 $348.58 $348.58

$448.54 $448.54 $444.10 $444.10 $507.43 $507.43 $449.00 $449.00 $437.62 $437.62 $363.71 $363.71

$469.57 $469.57 $464.93 $464.93 $531.23 $531.23 $470.06 $470.06 $458.14 $458.14 $380.77 $380.77

$490.34 $490.34 $485.49 $485.49 $554.73 $554.73 $490.85 $490.85 $478.40 $478.40 $397.61 $397.61

$513.22 $513.22 $508.14 $508.14 $580.60 $580.60 $513.75 $513.75 $500.72 $500.72 $416.16 $416.16

$536.35 $536.35 $531.05 $531.05 $606.78 $606.78 $536.91 $536.91 $523.29 $523.29 $434.92 $434.92

$561.33 $561.33 $555.78 $555.78 $635.04 $635.04 $561.91 $561.91 $547.66 $547.66 $455.17 $455.17

$586.31 $586.31 $580.51 $580.51 $663.29 $663.29 $586.91 $586.91 $572.03 $572.03 $475.43 $475.43

$613.39 $613.39 $607.32 $607.32 $693.93 $693.93 $614.02 $614.02 $598.45 $598.45 $497.39 $497.39

$640.73 $640.73 $634.40 $634.40 $724.86 $724.86 $641.39 $641.39 $625.13 $625.13 $519.56 $519.56

$669.92 $669.92 $663.29 $663.29 $757.88 $757.88 $670.61 $670.61 $653.60 $653.60 $543.22 $543.22

$684.38 $684.38 $677.61 $677.61 $774.24 $774.24 $685.08 $685.08 $667.71 $667.71 $554.95 $554.95

$713.56 $713.56 $706.51 $706.51 $807.25 $807.25 $714.30 $714.30 $696.19 $696.19 $578.61 $578.61

$738.80 $738.80 $731.50 $731.50 $835.81 $835.81 $739.56 $739.56 $720.81 $720.81 $599.08 $599.08

$755.36 $755.36 $747.90 $747.90 $854.55 $854.55 $756.15 $756.15 $736.97 $736.97 $612.51 $612.51

$776.14 $776.14 $768.46 $768.46 $878.05 $878.05 $776.94 $776.94 $757.24 $757.24 $629.36 $629.36

$788.76 $788.76 $780.96 $780.96 $892.32 $892.32 $789.57 $789.57 $769.55 $769.55 $639.59 $639.59

$788.76 $788.76 $780.96 $780.96 $892.32 $892.32 $789.57 $789.57 $769.55 $769.55 $639.59 $639.59

Yes Yes YesYes Yes

$7,150 $7,150 $3,500 $6,550 $6,550 $6,550

Yes

$15*/$50* 100%*/$30* 100%* /70%* 80%*/60%*$35/$65 $35/$65

90%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 80%/60%/50%90%/70%/50%

$2,600 $3,000 $5,500$1,750/$5,250 $2,000/$6,000


Blue Flex Plan


Blue Flex Plan









$1,500


A A A A AA



Area 1, 4

33709PA0570006 33709PA0450004 33709PA0640001 33709PA0640002 33709PA0640003

07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17

33709PA0570004

07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17


07/1/17, 08/1/17, 09/1/17




Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$135.82 $135.82 $203.06 $203.06

$213.89 $213.89 $319.78 $319.78

$213.89 $213.89 $319.78 $319.78

$213.89 $213.89 $319.78 $319.78

$213.89 $213.89 $319.78 $319.78

$214.75 $214.75 $321.06 $321.06

$219.03 $219.03 $327.45 $327.45

$224.16 $224.16 $335.13 $335.13

$232.50 $232.50 $347.60 $347.60

$239.35 $239.35 $357.83 $357.83

$242.77 $242.77 $362.95 $362.95

$247.90 $247.90 $370.62 $370.62

$253.04 $253.04 $378.30 $378.30

$256.25 $256.25 $383.10 $383.10

$259.67 $259.67 $388.21 $388.21

$261.38 $261.38 $390.77 $390.77

$263.09 $263.09 $393.33 $393.33

$264.80 $264.80 $395.89 $395.89

$266.51 $266.51 $398.45 $398.45

$269.94 $269.94 $403.56 $403.56

$273.36 $273.36 $408.68 $408.68

$278.49 $278.49 $416.35 $416.35

$283.41 $283.41 $423.71 $423.71

$290.26 $290.26 $433.94 $433.94

$298.81 $298.81 $446.73 $446.73

$308.86 $308.86 $461.76 $461.76

$320.84 $320.84 $479.67 $479.67

$334.32 $334.32 $499.82 $499.82

$349.72 $349.72 $522.84 $522.84

$364.90 $364.90 $545.54 $545.54

$382.02 $382.02 $571.13 $571.13

$398.91 $398.91 $596.39 $596.39

$417.52 $417.52 $624.21 $624.21

$436.35 $436.35 $652.35 $652.35

$456.67 $456.67 $682.73 $682.73

$476.99 $476.99 $713.11 $713.11

$499.02 $499.02 $746.05 $746.05

$521.26 $521.26 $779.30 $779.30

$545.00 $545.00 $814.80 $814.80

$556.77 $556.77 $832.39 $832.39

$580.51 $580.51 $867.88 $867.88

$601.04 $601.04 $898.58 $898.58

$614.52 $614.52 $918.73 $918.73

$631.42 $631.42 $943.99 $943.99

$641.67 $641.67 $959.34 $959.34

$641.67 $641.67 $959.34 $959.34

Yes Yes

$5,500

100%*/70%

$6,550

RC - $35

100%/70%/50% 100%/70%/50%

$6,000 $500/$1,500


Community Blue Plan

Bronze



Gold

A A

Area 1, 4 Area 1, 4


33709PA0640005 33709PA0460012

07/1/17, 08/1/17, 09/1/1707/1/17, 08/1/17, 09/1/17






Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>


0 - 20 $144.85 $144.85 $155.30 $155.30 $212.66 $212.66 $228.00 $228.00 $200.95 $200.95 $216.25 $216.25

21 $228.11 $228.11 $244.57 $244.57 $334.89 $334.89 $359.06 $359.06 $316.46 $316.46 $340.56 $340.56

22 $228.11 $228.11 $244.57 $244.57 $334.89 $334.89 $359.06 $359.06 $316.46 $316.46 $340.56 $340.56

23 $228.11 $228.11 $244.57 $244.57 $334.89 $334.89 $359.06 $359.06 $316.46 $316.46 $340.56 $340.56

24 $228.11 $228.11 $244.57 $244.57 $334.89 $334.89 $359.06 $359.06 $316.46 $316.46 $340.56 $340.56

25 $229.02 $229.02 $245.54 $245.54 $336.23 $336.23 $360.50 $360.50 $317.73 $317.73 $341.92 $341.92

26 $233.58 $233.58 $250.44 $250.44 $342.93 $342.93 $367.68 $367.68 $324.06 $324.06 $348.73 $348.73

27 $239.05 $239.05 $256.31 $256.31 $350.97 $350.97 $376.29 $376.29 $331.65 $331.65 $356.90 $356.90

28 $247.95 $247.95 $265.84 $265.84 $364.03 $364.03 $390.30 $390.30 $343.99 $343.99 $370.19 $370.19

29 $255.25 $255.25 $273.67 $273.67 $374.74 $374.74 $401.79 $401.79 $354.12 $354.12 $381.08 $381.08

30 $258.90 $258.90 $277.58 $277.58 $380.10 $380.10 $407.53 $407.53 $359.18 $359.18 $386.53 $386.53

31 $264.37 $264.37 $283.45 $283.45 $388.14 $388.14 $416.15 $416.15 $366.78 $366.78 $394.71 $394.71

32 $269.85 $269.85 $289.32 $289.32 $396.18 $396.18 $424.77 $424.77 $374.38 $374.38 $402.88 $402.88

33 $273.27 $273.27 $292.99 $292.99 $401.20 $401.20 $430.15 $430.15 $379.12 $379.12 $407.99 $407.99

34 $276.92 $276.92 $296.90 $296.90 $406.56 $406.56 $435.90 $435.90 $384.19 $384.19 $413.44 $413.44

35 $278.74 $278.74 $298.86 $298.86 $409.24 $409.24 $438.77 $438.77 $386.72 $386.72 $416.16 $416.16

36 $280.57 $280.57 $300.82 $300.82 $411.92 $411.92 $441.64 $441.64 $389.25 $389.25 $418.89 $418.89

37 $282.39 $282.39 $302.77 $302.77 $414.60 $414.60 $444.52 $444.52 $391.78 $391.78 $421.61 $421.61

38 $284.22 $284.22 $304.73 $304.73 $417.28 $417.28 $447.39 $447.39 $394.31 $394.31 $424.33 $424.33

39 $287.87 $287.87 $308.64 $308.64 $422.63 $422.63 $453.13 $453.13 $399.38 $399.38 $429.78 $429.78

40 $291.52 $291.52 $312.56 $312.56 $427.99 $427.99 $458.88 $458.88 $404.44 $404.44 $435.23 $435.23

41 $296.99 $296.99 $318.43 $318.43 $436.03 $436.03 $467.50 $467.50 $412.03 $412.03 $443.41 $443.41

42 $302.24 $302.24 $324.05 $324.05 $443.73 $443.73 $475.75 $475.75 $419.31 $419.31 $451.24 $451.24

43 $309.54 $309.54 $331.88 $331.88 $454.45 $454.45 $487.24 $487.24 $429.44 $429.44 $462.14 $462.14

44 $318.66 $318.66 $341.66 $341.66 $467.84 $467.84 $501.61 $501.61 $442.10 $442.10 $475.76 $475.76

45 $329.38 $329.38 $353.15 $353.15 $483.58 $483.58 $518.48 $518.48 $456.97 $456.97 $491.76 $491.76

46 $342.16 $342.16 $366.85 $366.85 $502.34 $502.34 $538.59 $538.59 $474.69 $474.69 $510.84 $510.84

47 $356.53 $356.53 $382.26 $382.26 $523.44 $523.44 $561.21 $561.21 $494.63 $494.63 $532.29 $532.29

48 $372.95 $372.95 $399.87 $399.87 $547.55 $547.55 $587.06 $587.06 $517.42 $517.42 $556.81 $556.81

49 $389.15 $389.15 $417.23 $417.23 $571.33 $571.33 $612.56 $612.56 $539.89 $539.89 $580.99 $580.99

50 $407.40 $407.40 $436.80 $436.80 $598.12 $598.12 $641.28 $641.28 $565.20 $565.20 $608.24 $608.24

51 $425.42 $425.42 $456.12 $456.12 $624.57 $624.57 $669.65 $669.65 $590.20 $590.20 $635.14 $635.14

52 $445.26 $445.26 $477.39 $477.39 $653.71 $653.71 $700.89 $700.89 $617.73 $617.73 $664.77 $664.77

53 $465.33 $465.33 $498.92 $498.92 $683.18 $683.18 $732.48 $732.48 $645.58 $645.58 $694.74 $694.74

54 $487.00 $487.00 $522.15 $522.15 $715.00 $715.00 $766.59 $766.59 $675.65 $675.65 $727.09 $727.09

55 $508.67 $508.67 $545.38 $545.38 $746.81 $746.81 $800.70 $800.70 $705.71 $705.71 $759.44 $759.44

56 $532.17 $532.17 $570.57 $570.57 $781.30 $781.30 $837.69 $837.69 $738.31 $738.31 $794.52 $794.52

57 $555.89 $555.89 $596.01 $596.01 $816.13 $816.13 $875.03 $875.03 $771.22 $771.22 $829.94 $829.94

58 $581.21 $581.21 $623.16 $623.16 $853.31 $853.31 $914.88 $914.88 $806.35 $806.35 $867.74 $867.74

59 $593.76 $593.76 $636.61 $636.61 $871.73 $871.73 $934.63 $934.63 $823.75 $823.75 $886.47 $886.47

60 $619.08 $619.08 $663.75 $663.75 $908.90 $908.90 $974.49 $974.49 $858.88 $858.88 $924.27 $924.27

61 $640.98 $640.98 $687.23 $687.23 $941.05 $941.05 $1,008.96 $1,008.96 $889.26 $889.26 $956.97 $956.97

62 $655.35 $655.35 $702.64 $702.64 $962.15 $962.15 $1,031.58 $1,031.58 $909.20 $909.20 $978.42 $978.42

63 $673.37 $673.37 $721.96 $721.96 $988.60 $988.60 $1,059.95 $1,059.95 $934.20 $934.20 $1,005.33 $1,005.33

64 $684.32 $684.32 $733.70 $733.70 $1,004.67 $1,004.67 $1,077.18 $1,077.18 $949.38 $949.38 $1,021.67 $1,021.67

65+ $684.32 $684.32 $733.70 $733.70 $1,004.67 $1,004.67 $1,077.18 $1,077.18 $949.38 $949.38 $1,021.67 $1,021.67


$6,550 $6,550 $5,500 $5,500 $5,300 $5,500

80%*/60%* 80%*/60%* $20/$50 $20/$50 $20/$50 $10/$40

80%/60%/50% 80%/60%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$5,500 $5,500 $500 $500 $500 $500/$1,500







Plan



Plan



Blue Plan


Community Blue Plan


B B H H G B



33709PA0640004 33709PA0640004 33709PA0460007 33709PA0460007 33709PA0460008 33709PA0460013

07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17






Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$231.86 $231.86 $219.17 $219.17 $234.98 $234.98 $209.98 $209.98 $225.14 $225.14

$365.13 $365.13 $345.15 $345.15 $370.05 $370.05 $330.68 $330.68 $354.55 $354.55

$365.13 $365.13 $345.15 $345.15 $370.05 $370.05 $330.68 $330.68 $354.55 $354.55

$365.13 $365.13 $345.15 $345.15 $370.05 $370.05 $330.68 $330.68 $354.55 $354.55

$365.13 $365.13 $345.15 $345.15 $370.05 $370.05 $330.68 $330.68 $354.55 $354.55

$366.59 $366.59 $346.53 $346.53 $371.53 $371.53 $332.01 $332.01 $355.96 $355.96

$373.90 $373.90 $353.43 $353.43 $378.93 $378.93 $338.62 $338.62 $363.06 $363.06

$382.66 $382.66 $361.71 $361.71 $387.82 $387.82 $346.56 $346.56 $371.56 $371.56

$396.90 $396.90 $375.17 $375.17 $402.25 $402.25 $359.45 $359.45 $385.39 $385.39

$408.58 $408.58 $386.22 $386.22 $414.09 $414.09 $370.03 $370.03 $396.74 $396.74

$414.43 $414.43 $391.74 $391.74 $420.01 $420.01 $375.32 $375.32 $402.41 $402.41

$423.19 $423.19 $400.02 $400.02 $428.89 $428.89 $383.26 $383.26 $410.92 $410.92

$431.95 $431.95 $408.31 $408.31 $437.77 $437.77 $391.20 $391.20 $419.43 $419.43

$437.43 $437.43 $413.48 $413.48 $443.32 $443.32 $396.16 $396.16 $424.75 $424.75

$443.27 $443.27 $419.01 $419.01 $449.24 $449.24 $401.45 $401.45 $430.42 $430.42

$446.19 $446.19 $421.77 $421.77 $452.20 $452.20 $404.09 $404.09 $433.26 $433.26

$449.11 $449.11 $424.53 $424.53 $455.16 $455.16 $406.74 $406.74 $436.09 $436.09

$452.04 $452.04 $427.29 $427.29 $458.13 $458.13 $409.39 $409.39 $438.93 $438.93

$454.96 $454.96 $430.05 $430.05 $461.09 $461.09 $412.03 $412.03 $441.76 $441.76

$460.80 $460.80 $435.57 $435.57 $467.01 $467.01 $417.32 $417.32 $447.44 $447.44

$466.64 $466.64 $441.10 $441.10 $472.93 $472.93 $422.61 $422.61 $453.11 $453.11

$475.40 $475.40 $449.38 $449.38 $481.81 $481.81 $430.55 $430.55 $461.62 $461.62

$483.80 $483.80 $457.32 $457.32 $490.32 $490.32 $438.15 $438.15 $469.77 $469.77

$495.49 $495.49 $468.36 $468.36 $502.16 $502.16 $448.74 $448.74 $481.12 $481.12

$510.09 $510.09 $482.17 $482.17 $516.96 $516.96 $461.96 $461.96 $495.30 $495.30

$527.25 $527.25 $498.39 $498.39 $534.36 $534.36 $477.51 $477.51 $511.97 $511.97

$547.70 $547.70 $517.72 $517.72 $555.08 $555.08 $496.02 $496.02 $531.82 $531.82

$570.70 $570.70 $539.46 $539.46 $578.39 $578.39 $516.86 $516.86 $554.16 $554.16

$596.99 $596.99 $564.31 $564.31 $605.04 $605.04 $540.67 $540.67 $579.68 $579.68

$622.92 $622.92 $588.82 $588.82 $631.31 $631.31 $564.14 $564.14 $604.86 $604.86

$652.13 $652.13 $616.43 $616.43 $660.91 $660.91 $590.60 $590.60 $633.22 $633.22

$680.97 $680.97 $643.70 $643.70 $690.15 $690.15 $616.72 $616.72 $661.23 $661.23

$712.74 $712.74 $673.72 $673.72 $722.34 $722.34 $645.49 $645.49 $692.07 $692.07

$744.87 $744.87 $704.10 $704.10 $754.91 $754.91 $674.59 $674.59 $723.27 $723.27

$779.56 $779.56 $736.89 $736.89 $790.06 $790.06 $706.01 $706.01 $756.96 $756.96

$814.25 $814.25 $769.67 $769.67 $825.22 $825.22 $737.42 $737.42 $790.64 $790.64

$851.86 $851.86 $805.22 $805.22 $863.33 $863.33 $771.48 $771.48 $827.16 $827.16

$889.83 $889.83 $841.12 $841.12 $901.82 $901.82 $805.87 $805.87 $864.03 $864.03

$930.36 $930.36 $879.43 $879.43 $942.89 $942.89 $842.58 $842.58 $903.38 $903.38

$950.44 $950.44 $898.41 $898.41 $963.25 $963.25 $860.77 $860.77 $922.88 $922.88

$990.97 $990.97 $936.72 $936.72 $1,004.32 $1,004.32 $897.47 $897.47 $962.24 $962.24

$1,026.03 $1,026.03 $969.86 $969.86 $1,039.85 $1,039.85 $929.22 $929.22 $996.28 $996.28

$1,049.03 $1,049.03 $991.60 $991.60 $1,063.16 $1,063.16 $950.05 $950.05 $1,018.61 $1,018.61

$1,077.87 $1,077.87 $1,018.87 $1,018.87 $1,092.40 $1,092.40 $976.18 $976.18 $1,046.62 $1,046.62

$1,095.39 $1,095.39 $1,035.44 $1,035.44 $1,110.15 $1,110.15 $992.04 $992.04 $1,063.64 $1,063.64

$1,095.39 $1,095.39 $1,035.44 $1,035.44 $1,110.15 $1,110.15 $992.04 $992.04 $1,063.64 $1,063.64

Yes YesYes Yes Yes

$5,500 $7,150 $7,150 $4,800 $4,800

$30/$60 $30/$60$10/$40 $20/$60 $20/$60

$750/$1,500 $750/$1,500

100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$500/$1,500 $250/$750 $250/$750

Gold Gold


Community Blue Plan









Gold Gold Gold

Area 1, 2, 5 Area 6

B B B B B



33709PA0460013 33709PA0440014 33709PA0440014 33709PA0440009 33709PA0440009

07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17


07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$181.33 $181.33 $194.42 $194.42

$285.56 $285.56 $306.17 $306.17

$285.56 $285.56 $306.17 $306.17

$285.56 $285.56 $306.17 $306.17

$285.56 $285.56 $306.17 $306.17

$286.70 $286.70 $307.39 $307.39

$292.41 $292.41 $313.51 $313.51

$299.27 $299.27 $320.86 $320.86

$310.40 $310.40 $332.80 $332.80

$319.54 $319.54 $342.60 $342.60

$324.11 $324.11 $347.50 $347.50

$330.96 $330.96 $354.85 $354.85

$337.82 $337.82 $362.19 $362.19

$342.10 $342.10 $366.79 $366.79

$346.67 $346.67 $371.69 $371.69

$348.95 $348.95 $374.13 $374.13

$351.24 $351.24 $376.58 $376.58

$353.52 $353.52 $379.03 $379.03

$355.81 $355.81 $381.48 $381.48

$360.37 $360.37 $386.38 $386.38

$364.94 $364.94 $391.28 $391.28

$371.80 $371.80 $398.63 $398.63

$378.36 $378.36 $405.67 $405.67

$387.50 $387.50 $415.47 $415.47

$398.92 $398.92 $427.71 $427.71

$412.35 $412.35 $442.10 $442.10

$428.34 $428.34 $459.25 $459.25

$446.33 $446.33 $478.54 $478.54

$466.89 $466.89 $500.58 $500.58

$487.16 $487.16 $522.32 $522.32

$510.01 $510.01 $546.81 $546.81

$532.57 $532.57 $571.00 $571.00

$557.41 $557.41 $597.64 $597.64

$582.54 $582.54 $624.58 $624.58

$609.67 $609.67 $653.66 $653.66

$636.80 $636.80 $682.75 $682.75

$666.21 $666.21 $714.28 $714.28

$695.91 $695.91 $746.13 $746.13

$727.60 $727.60 $780.11 $780.11

$743.31 $743.31 $796.95 $796.95

$775.01 $775.01 $830.93 $830.93

$802.42 $802.42 $860.33 $860.33

$820.41 $820.41 $879.61 $879.61

$842.97 $842.97 $903.80 $903.80

$856.67 $856.67 $918.50 $918.50

$856.67 $856.67 $918.50 $918.50

Yes Yes

$7,150$7,150

$45/$70* $45/$70*

$1,500/$4,500 $1,500/$4,500

100%/70%/50%100%/70%/50%

Silver Silver





Area 1, 2, 5 Area 6

BB


07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17

33709PA044001333709PA0440013






Form #

Region =>

Service Zone =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dentail (Yes/No) =>


0 - 20 $189.12 $189.12 $188.35 $188.35 $185.67 $185.67 $184.61 $184.61 $180.44 $180.44 $178.99 $178.99

21 $297.82 $297.82 $296.61 $296.61 $292.39 $292.39 $290.73 $290.73 $284.15 $284.15 $281.87 $281.87

22 $297.82 $297.82 $296.61 $296.61 $292.39 $292.39 $290.73 $290.73 $284.15 $284.15 $281.87 $281.87

23 $297.82 $297.82 $296.61 $296.61 $292.39 $292.39 $290.73 $290.73 $284.15 $284.15 $281.87 $281.87

24 $297.82 $297.82 $296.61 $296.61 $292.39 $292.39 $290.73 $290.73 $284.15 $284.15 $281.87 $281.87

25 $299.01 $299.01 $297.79 $297.79 $293.56 $293.56 $291.89 $291.89 $285.29 $285.29 $283.00 $283.00

26 $304.97 $304.97 $303.73 $303.73 $299.40 $299.40 $297.71 $297.71 $290.97 $290.97 $288.64 $288.64

27 $312.11 $312.11 $310.84 $310.84 $306.42 $306.42 $304.68 $304.68 $297.79 $297.79 $295.40 $295.40

28 $323.73 $323.73 $322.41 $322.41 $317.82 $317.82 $316.02 $316.02 $308.87 $308.87 $306.40 $306.40

29 $333.26 $333.26 $331.90 $331.90 $327.18 $327.18 $325.33 $325.33 $317.97 $317.97 $315.42 $315.42

30 $338.02 $338.02 $336.65 $336.65 $331.86 $331.86 $329.98 $329.98 $322.51 $322.51 $319.93 $319.93

31 $345.17 $345.17 $343.77 $343.77 $338.88 $338.88 $336.95 $336.95 $329.33 $329.33 $326.69 $326.69

32 $352.32 $352.32 $350.89 $350.89 $345.89 $345.89 $343.93 $343.93 $336.15 $336.15 $333.45 $333.45

33 $356.79 $356.79 $355.33 $355.33 $350.28 $350.28 $348.29 $348.29 $340.41 $340.41 $337.68 $337.68

34 $361.55 $361.55 $360.08 $360.08 $354.96 $354.96 $352.94 $352.94 $344.96 $344.96 $342.19 $342.19

35 $363.93 $363.93 $362.45 $362.45 $357.30 $357.30 $355.27 $355.27 $347.23 $347.23 $344.45 $344.45

36 $366.32 $366.32 $364.83 $364.83 $359.64 $359.64 $357.60 $357.60 $349.51 $349.51 $346.70 $346.70

37 $368.70 $368.70 $367.20 $367.20 $361.98 $361.98 $359.92 $359.92 $351.78 $351.78 $348.96 $348.96

38 $371.08 $371.08 $369.57 $369.57 $364.31 $364.31 $362.25 $362.25 $354.05 $354.05 $351.21 $351.21

39 $375.85 $375.85 $374.32 $374.32 $368.99 $368.99 $366.90 $366.90 $358.60 $358.60 $355.72 $355.72

40 $380.61 $380.61 $379.06 $379.06 $373.67 $373.67 $371.55 $371.55 $363.15 $363.15 $360.23 $360.23

41 $387.76 $387.76 $386.18 $386.18 $380.69 $380.69 $378.53 $378.53 $369.97 $369.97 $367.00 $367.00

42 $394.61 $394.61 $393.00 $393.00 $387.41 $387.41 $385.22 $385.22 $376.50 $376.50 $373.48 $373.48

43 $404.14 $404.14 $402.50 $402.50 $396.77 $396.77 $394.52 $394.52 $385.59 $385.59 $382.50 $382.50

44 $416.05 $416.05 $414.36 $414.36 $408.46 $408.46 $406.15 $406.15 $396.96 $396.96 $393.78 $393.78

45 $430.05 $430.05 $428.30 $428.30 $422.21 $422.21 $419.81 $419.81 $410.32 $410.32 $407.02 $407.02

46 $446.73 $446.73 $444.91 $444.91 $438.58 $438.58 $436.09 $436.09 $426.23 $426.23 $422.81 $422.81

47 $465.49 $465.49 $463.60 $463.60 $457.00 $457.00 $454.41 $454.41 $444.13 $444.13 $440.57 $440.57

48 $486.93 $486.93 $484.95 $484.95 $478.05 $478.05 $475.34 $475.34 $464.59 $464.59 $460.86 $460.86

49 $508.08 $508.08 $506.01 $506.01 $498.81 $498.81 $495.98 $495.98 $484.76 $484.76 $480.87 $480.87

50 $531.90 $531.90 $529.74 $529.74 $522.20 $522.20 $519.24 $519.24 $507.50 $507.50 $503.42 $503.42

51 $555.43 $555.43 $553.17 $553.17 $545.30 $545.30 $542.21 $542.21 $529.94 $529.94 $525.69 $525.69

52 $581.34 $581.34 $578.98 $578.98 $570.74 $570.74 $567.50 $567.50 $554.66 $554.66 $550.21 $550.21

53 $607.55 $607.55 $605.08 $605.08 $596.47 $596.47 $593.09 $593.09 $579.67 $579.67 $575.02 $575.02

54 $635.84 $635.84 $633.26 $633.26 $624.25 $624.25 $620.71 $620.71 $606.66 $606.66 $601.80 $601.80

55 $664.14 $664.14 $661.43 $661.43 $652.02 $652.02 $648.32 $648.32 $633.66 $633.66 $628.58 $628.58

56 $694.81 $694.81 $691.98 $691.98 $682.14 $682.14 $678.27 $678.27 $662.93 $662.93 $657.61 $657.61

57 $725.79 $725.79 $722.83 $722.83 $712.55 $712.55 $708.51 $708.51 $692.48 $692.48 $686.92 $686.92

58 $758.84 $758.84 $755.75 $755.75 $745.00 $745.00 $740.78 $740.78 $724.02 $724.02 $718.21 $718.21

59 $775.22 $775.22 $772.07 $772.07 $761.08 $761.08 $756.77 $756.77 $739.65 $739.65 $733.71 $733.71

60 $808.28 $808.28 $804.99 $804.99 $793.54 $793.54 $789.04 $789.04 $771.19 $771.19 $765.00 $765.00

61 $836.87 $836.87 $833.46 $833.46 $821.61 $821.61 $816.95 $816.95 $798.47 $798.47 $792.06 $792.06

62 $855.63 $855.63 $852.15 $852.15 $840.03 $840.03 $835.26 $835.26 $816.37 $816.37 $809.82 $809.82

63 $879.16 $879.16 $875.58 $875.58 $863.13 $863.13 $858.23 $858.23 $838.82 $838.82 $832.09 $832.09

64 $893.46 $893.46 $889.82 $889.82 $877.16 $877.16 $872.19 $872.19 $852.45 $852.45 $845.61 $845.61

65+ $893.46 $893.46 $889.82 $889.82 $877.16 $877.16 $872.19 $872.19 $852.45 $852.45 $845.61 $845.61


$7,150 $7,150 $7,150 $6,100 $7,150 $6,800

$25 $10 $10 $0 $10 $10

100% 100% 100% 100% 100% 100%

$100 $250 $500 $750 $900 $1,100


Community Blue Plan


Community Blue Plan


Community Blue Plan


Community Blue Plan


Community Blue Plan


Community Blue Plan


J J J J J J



33709PA0630002 33709PA0630003 33709PA0630004 33709PA0630005 33709PA0630006 33709PA0630008

07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17






Form #

Region =>

Service Zone =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dentail (Yes/No) =>

Age Band

0 - 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

65+


$155.26 $155.26 $152.26 $152.26

$244.50 $244.50 $239.77 $239.77

$244.50 $244.50 $239.77 $239.77

$244.50 $244.50 $239.77 $239.77

$244.50 $244.50 $239.77 $239.77

$245.48 $245.48 $240.73 $240.73

$250.37 $250.37 $245.53 $245.53

$256.23 $256.23 $251.28 $251.28

$265.77 $265.77 $260.63 $260.63

$273.59 $273.59 $268.31 $268.31

$277.51 $277.51 $272.14 $272.14

$283.37 $283.37 $277.90 $277.90

$289.24 $289.24 $283.65 $283.65

$292.91 $292.91 $287.25 $287.25

$296.82 $296.82 $291.09 $291.09

$298.78 $298.78 $293.00 $293.00

$300.73 $300.73 $294.92 $294.92

$302.69 $302.69 $296.84 $296.84

$304.64 $304.64 $298.76 $298.76

$308.56 $308.56 $302.60 $302.60

$312.47 $312.47 $306.43 $306.43

$318.34 $318.34 $312.19 $312.19

$323.96 $323.96 $317.70 $317.70

$331.78 $331.78 $325.37 $325.37

$341.56 $341.56 $334.96 $334.96

$353.06 $353.06 $346.23 $346.23

$366.75 $366.75 $359.66 $359.66

$382.15 $382.15 $374.77 $374.77

$399.75 $399.75 $392.03 $392.03

$417.11 $417.11 $409.05 $409.05

$436.67 $436.67 $428.24 $428.24

$455.99 $455.99 $447.18 $447.18

$477.26 $477.26 $468.04 $468.04

$498.78 $498.78 $489.14 $489.14

$522.00 $522.00 $511.92 $511.92

$545.23 $545.23 $534.70 $534.70

$570.41 $570.41 $559.39 $559.39

$595.84 $595.84 $584.33 $584.33

$622.98 $622.98 $610.94 $610.94

$636.43 $636.43 $624.13 $624.13

$663.57 $663.57 $650.75 $650.75

$687.04 $687.04 $673.77 $673.77

$702.44 $702.44 $688.87 $688.87

$721.76 $721.76 $707.81 $707.81

$733.49 $733.49 $719.31 $719.31

$733.49 $733.49 $719.31 $719.31

$7,150 $7,150

Yes Yes

100% 100%

$25 $25


Community Blue Plan


Community Blue Plan

$2,500 $3200

J J

Silver Silver


Area 1, 4 Area 1, 4

33709PA0630007 33709PA0630009


07/1/17, 08/1/17, 09/1/17 07/1/17, 08/1/17, 09/1/17




33709PA0560029 $269.51 $269.51

33709PA0570007 $267.21 $267.21

33709PA0570004 $262.92 $262.92

33709PA0570006 $260.32 $260.32

33709PA0640001 $263.19 $263.19

33709PA0640002 $256.52 $256.52

33709PA0630007 $244.50 $244.50

33709PA0630009 $239.77 $239.77

33709PA0440013 $285.56 $285.56 $285.56 $306.17



Exhibit V

HIOS Plan ID

On/Off


























Venango






















Highmark Inc.

Small Group Market

Plan Design Summary




Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>


0 - 20 $247.70 $247.70 $243.59 $243.59 $209.75 $209.75 $212.71 $212.71 $208.10 $208.10 $205.44 $205.44

21 $390.09 $390.09 $383.61 $383.61 $330.31 $330.31 $334.98 $334.98 $327.72 $327.72 $323.53 $323.53

22 $390.09 $390.09 $383.61 $383.61 $330.31 $330.31 $334.98 $334.98 $327.72 $327.72 $323.53 $323.53

23 $390.09 $390.09 $383.61 $383.61 $330.31 $330.31 $334.98 $334.98 $327.72 $327.72 $323.53 $323.53

24 $390.09 $390.09 $383.61 $383.61 $330.31 $330.31 $334.98 $334.98 $327.72 $327.72 $323.53 $323.53

25 $391.65 $391.65 $385.14 $385.14 $331.64 $331.64 $336.32 $336.32 $329.04 $329.04 $324.83 $324.83

26 $399.45 $399.45 $392.81 $392.81 $338.24 $338.24 $343.02 $343.02 $335.59 $335.59 $331.30 $331.30

27 $408.81 $408.81 $402.02 $402.02 $346.17 $346.17 $351.06 $351.06 $343.45 $343.45 $339.06 $339.06

28 $424.02 $424.02 $416.98 $416.98 $359.05 $359.05 $364.12 $364.12 $356.24 $356.24 $351.68 $351.68

29 $436.51 $436.51 $429.26 $429.26 $369.62 $369.62 $374.84 $374.84 $366.72 $366.72 $362.03 $362.03

30 $442.75 $442.75 $435.39 $435.39 $374.91 $374.91 $380.20 $380.20 $371.97 $371.97 $367.21 $367.21

31 $452.11 $452.11 $444.60 $444.60 $382.83 $382.83 $388.24 $388.24 $379.83 $379.83 $374.98 $374.98

32 $461.47 $461.47 $453.81 $453.81 $390.76 $390.76 $396.28 $396.28 $387.70 $387.70 $382.74 $382.74

33 $467.32 $467.32 $459.56 $459.56 $395.72 $395.72 $401.31 $401.31 $392.61 $392.61 $387.59 $387.59

34 $473.56 $473.56 $465.70 $465.70 $401.00 $401.00 $406.67 $406.67 $397.86 $397.86 $392.77 $392.77

35 $476.68 $476.68 $468.77 $468.77 $403.64 $403.64 $409.35 $409.35 $400.48 $400.48 $395.36 $395.36

36 $479.81 $479.81 $471.84 $471.84 $406.29 $406.29 $412.03 $412.03 $403.10 $403.10 $397.95 $397.95

37 $482.93 $482.93 $474.90 $474.90 $408.93 $408.93 $414.70 $414.70 $405.72 $405.72 $400.53 $400.53

38 $486.05 $486.05 $477.97 $477.97 $411.57 $411.57 $417.38 $417.38 $408.34 $408.34 $403.12 $403.12

39 $492.29 $492.29 $484.11 $484.11 $416.86 $416.86 $422.74 $422.74 $413.59 $413.59 $408.30 $408.30

40 $498.53 $498.53 $490.25 $490.25 $422.14 $422.14 $428.10 $428.10 $418.83 $418.83 $413.48 $413.48

41 $507.89 $507.89 $499.45 $499.45 $430.07 $430.07 $436.14 $436.14 $426.70 $426.70 $421.24 $421.24

42 $516.86 $516.86 $508.28 $508.28 $437.67 $437.67 $443.85 $443.85 $434.23 $434.23 $428.68 $428.68

43 $529.35 $529.35 $520.55 $520.55 $448.24 $448.24 $454.57 $454.57 $444.72 $444.72 $439.04 $439.04

44 $544.95 $544.95 $535.90 $535.90 $461.45 $461.45 $467.97 $467.97 $457.83 $457.83 $451.98 $451.98

45 $563.28 $563.28 $553.93 $553.93 $476.97 $476.97 $483.71 $483.71 $473.23 $473.23 $467.18 $467.18

46 $585.13 $585.13 $575.41 $575.41 $495.47 $495.47 $502.47 $502.47 $491.59 $491.59 $485.30 $485.30

47 $609.70 $609.70 $599.58 $599.58 $516.28 $516.28 $523.57 $523.57 $512.23 $512.23 $505.68 $505.68

48 $637.79 $637.79 $627.20 $627.20 $540.06 $540.06 $547.69 $547.69 $535.83 $535.83 $528.98 $528.98

49 $665.49 $665.49 $654.43 $654.43 $563.52 $563.52 $571.48 $571.48 $559.10 $559.10 $551.95 $551.95

50 $696.69 $696.69 $685.12 $685.12 $589.94 $589.94 $598.27 $598.27 $585.32 $585.32 $577.83 $577.83

51 $727.51 $727.51 $715.43 $715.43 $616.04 $616.04 $624.74 $624.74 $611.21 $611.21 $603.39 $603.39

52 $761.45 $761.45 $748.80 $748.80 $644.77 $644.77 $653.88 $653.88 $639.72 $639.72 $631.54 $631.54

53 $795.77 $795.77 $782.56 $782.56 $673.84 $673.84 $683.36 $683.36 $668.56 $668.56 $660.01 $660.01

54 $832.83 $832.83 $819.00 $819.00 $705.22 $705.22 $715.18 $715.18 $699.69 $699.69 $690.74 $690.74

55 $869.89 $869.89 $855.44 $855.44 $736.60 $736.60 $747.00 $747.00 $730.82 $730.82 $721.48 $721.48

56 $910.07 $910.07 $894.95 $894.95 $770.62 $770.62 $781.51 $781.51 $764.58 $764.58 $754.80 $754.80

57 $950.64 $950.64 $934.85 $934.85 $804.98 $804.98 $816.35 $816.35 $798.66 $798.66 $788.45 $788.45

58 $993.94 $993.94 $977.43 $977.43 $841.64 $841.64 $853.53 $853.53 $835.04 $835.04 $824.36 $824.36

59 $1,015.39 $1,015.39 $998.53 $998.53 $859.81 $859.81 $871.95 $871.95 $853.07 $853.07 $842.16 $842.16

60 $1,058.69 $1,058.69 $1,041.11 $1,041.11 $896.47 $896.47 $909.14 $909.14 $889.44 $889.44 $878.07 $878.07

61 $1,096.14 $1,096.14 $1,077.93 $1,077.93 $928.18 $928.18 $941.29 $941.29 $920.91 $920.91 $909.13 $909.13

62 $1,120.72 $1,120.72 $1,102.10 $1,102.10 $948.99 $948.99 $962.40 $962.40 $941.55 $941.55 $929.51 $929.51

63 $1,151.53 $1,151.53 $1,132.40 $1,132.40 $975.09 $975.09 $988.86 $988.86 $967.44 $967.44 $955.07 $955.07

64 $1,170.26 $1,170.26 $1,150.82 $1,150.82 $990.93 $990.93 $1,004.94 $1,004.94 $983.16 $983.16 $970.59 $970.59

65+ $1,170.26 $1,170.26 $1,150.82 $1,150.82 $990.93 $990.93 $1,004.94 $1,004.94 $983.16 $983.16 $970.59 $970.59


$1,600 $1,300 $7,150 $7,150 $5,300 $4,800

$10/$40 $10/$40 $25/$70 $20/$60 $20/$60 $20/$60

100%/70%/50% 100%/70%/50% 100%/60%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$0/$500 $250/$750 $0/$5,000 $250/$750 $500/$1,500 $750/$1,500





Plan










A A A A A A



33709PA0560011 33709PA0560013 33709PA0560015 33709PA056001733709PA0560007 33709PA0560009


10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$202.14 $202.14 $200.55 $200.55 $199.08 $199.08 $196.95 $196.95 $176.62 $176.62 $175.11 $175.11

$318.33 $318.33 $315.83 $315.83 $313.50 $313.50 $310.16 $310.16 $278.15 $278.15 $275.76 $275.76

$318.33 $318.33 $315.83 $315.83 $313.50 $313.50 $310.16 $310.16 $278.15 $278.15 $275.76 $275.76

$318.33 $318.33 $315.83 $315.83 $313.50 $313.50 $310.16 $310.16 $278.15 $278.15 $275.76 $275.76

$318.33 $318.33 $315.83 $315.83 $313.50 $313.50 $310.16 $310.16 $278.15 $278.15 $275.76 $275.76

$319.61 $319.61 $317.10 $317.10 $314.76 $314.76 $311.40 $311.40 $279.26 $279.26 $276.86 $276.86

$325.97 $325.97 $323.41 $323.41 $321.03 $321.03 $317.60 $317.60 $284.82 $284.82 $282.38 $282.38

$333.61 $333.61 $330.99 $330.99 $328.55 $328.55 $325.05 $325.05 $291.50 $291.50 $289.00 $289.00

$346.03 $346.03 $343.31 $343.31 $340.78 $340.78 $337.14 $337.14 $302.35 $302.35 $299.75 $299.75

$356.22 $356.22 $353.42 $353.42 $350.81 $350.81 $347.07 $347.07 $311.25 $311.25 $308.58 $308.58

$361.31 $361.31 $358.47 $358.47 $355.83 $355.83 $352.03 $352.03 $315.70 $315.70 $312.99 $312.99

$368.95 $368.95 $366.05 $366.05 $363.35 $363.35 $359.47 $359.47 $322.37 $322.37 $319.61 $319.61

$376.59 $376.59 $373.63 $373.63 $370.88 $370.88 $366.92 $366.92 $329.05 $329.05 $326.23 $326.23

$381.36 $381.36 $378.37 $378.37 $375.58 $375.58 $371.57 $371.57 $333.22 $333.22 $330.36 $330.36

$386.46 $386.46 $383.42 $383.42 $380.59 $380.59 $376.53 $376.53 $337.67 $337.67 $334.77 $334.77

$389.00 $389.00 $385.95 $385.95 $383.10 $383.10 $379.01 $379.01 $339.90 $339.90 $336.98 $336.98

$391.55 $391.55 $388.47 $388.47 $385.61 $385.61 $381.49 $381.49 $342.12 $342.12 $339.19 $339.19

$394.10 $394.10 $391.00 $391.00 $388.12 $388.12 $383.97 $383.97 $344.35 $344.35 $341.39 $341.39

$396.64 $396.64 $393.53 $393.53 $390.63 $390.63 $386.46 $386.46 $346.57 $346.57 $343.60 $343.60

$401.74 $401.74 $398.58 $398.58 $395.64 $395.64 $391.42 $391.42 $351.02 $351.02 $348.01 $348.01

$406.83 $406.83 $403.63 $403.63 $400.66 $400.66 $396.38 $396.38 $355.47 $355.47 $352.42 $352.42

$414.47 $414.47 $411.21 $411.21 $408.18 $408.18 $403.83 $403.83 $362.15 $362.15 $359.04 $359.04

$421.79 $421.79 $418.48 $418.48 $415.39 $415.39 $410.96 $410.96 $368.55 $368.55 $365.38 $365.38

$431.98 $431.98 $428.58 $428.58 $425.42 $425.42 $420.88 $420.88 $377.45 $377.45 $374.21 $374.21

$444.71 $444.71 $441.22 $441.22 $437.97 $437.97 $433.29 $433.29 $388.57 $388.57 $385.24 $385.24

$459.68 $459.68 $456.06 $456.06 $452.70 $452.70 $447.87 $447.87 $401.64 $401.64 $398.20 $398.20

$477.50 $477.50 $473.75 $473.75 $470.26 $470.26 $465.24 $465.24 $417.22 $417.22 $413.64 $413.64

$497.56 $497.56 $493.65 $493.65 $490.01 $490.01 $484.78 $484.78 $434.74 $434.74 $431.01 $431.01

$520.48 $520.48 $516.39 $516.39 $512.58 $512.58 $507.11 $507.11 $454.77 $454.77 $450.87 $450.87

$543.08 $543.08 $538.81 $538.81 $534.84 $534.84 $529.13 $529.13 $474.52 $474.52 $470.45 $470.45

$568.55 $568.55 $564.08 $564.08 $559.92 $559.92 $553.94 $553.94 $496.77 $496.77 $492.51 $492.51

$593.69 $593.69 $589.03 $589.03 $584.68 $584.68 $578.44 $578.44 $518.75 $518.75 $514.29 $514.29

$621.39 $621.39 $616.50 $616.50 $611.96 $611.96 $605.43 $605.43 $542.94 $542.94 $538.29 $538.29

$649.40 $649.40 $644.30 $644.30 $639.55 $639.55 $632.72 $632.72 $567.42 $567.42 $562.55 $562.55

$679.64 $679.64 $674.30 $674.30 $669.33 $669.33 $662.19 $662.19 $593.84 $593.84 $588.75 $588.75

$709.89 $709.89 $704.31 $704.31 $699.11 $699.11 $691.65 $691.65 $620.27 $620.27 $614.95 $614.95

$742.67 $742.67 $736.84 $736.84 $731.40 $731.40 $723.60 $723.60 $648.92 $648.92 $643.35 $643.35

$775.78 $775.78 $769.68 $769.68 $764.01 $764.01 $755.85 $755.85 $677.85 $677.85 $672.03 $672.03

$811.12 $811.12 $804.74 $804.74 $798.81 $798.81 $790.28 $790.28 $708.72 $708.72 $702.64 $702.64

$828.62 $828.62 $822.11 $822.11 $816.05 $816.05 $807.34 $807.34 $724.02 $724.02 $717.81 $717.81

$863.96 $863.96 $857.17 $857.17 $850.85 $850.85 $841.77 $841.77 $754.89 $754.89 $748.42 $748.42

$894.52 $894.52 $887.49 $887.49 $880.95 $880.95 $871.54 $871.54 $781.59 $781.59 $774.89 $774.89

$914.58 $914.58 $907.39 $907.39 $900.70 $900.70 $891.08 $891.08 $799.12 $799.12 $792.26 $792.26

$939.72 $939.72 $932.34 $932.34 $925.46 $925.46 $915.58 $915.58 $821.09 $821.09 $814.05 $814.05

$954.99 $954.99 $947.49 $947.49 $940.50 $940.50 $930.47 $930.47 $834.44 $834.44 $827.28 $827.28

$954.99 $954.99 $947.49 $947.49 $940.50 $940.50 $930.47 $930.47 $834.44 $834.44 $827.28 $827.28


$4,800 $4,000 $3,700 $3,450 $7,150 $7,150

$20/$60 $20/$60 $40/$75 $45/$75*$20/$60 $20/$60

100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 90%/70%/50%

$1,500/$3,000 $2,000/$3,000 $1,400/$5,000 $1,000/$5,000$1,000/$2,000 $1,250/$2,500












Blue Flex Plan


A A A A A A



10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17

33709PA0560019 33709PA0560021 33709PA0560023 33709PA0560027 33709PA0560029 33709PA0570007

10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$172.31 $172.31 $170.59 $170.59 $194.92 $194.92 $172.47 $172.47 $168.10 $168.10 $139.72 $139.72

$271.35 $271.35 $268.65 $268.65 $306.97 $306.97 $271.61 $271.61 $264.72 $264.72 $220.03 $220.03

$271.35 $271.35 $268.65 $268.65 $306.97 $306.97 $271.61 $271.61 $264.72 $264.72 $220.03 $220.03

$271.35 $271.35 $268.65 $268.65 $306.97 $306.97 $271.61 $271.61 $264.72 $264.72 $220.03 $220.03

$271.35 $271.35 $268.65 $268.65 $306.97 $306.97 $271.61 $271.61 $264.72 $264.72 $220.03 $220.03

$272.43 $272.43 $269.73 $269.73 $308.19 $308.19 $272.70 $272.70 $265.78 $265.78 $220.91 $220.91

$277.86 $277.86 $275.10 $275.10 $314.33 $314.33 $278.13 $278.13 $271.08 $271.08 $225.31 $225.31

$284.37 $284.37 $281.55 $281.55 $321.70 $321.70 $284.65 $284.65 $277.43 $277.43 $230.59 $230.59

$294.96 $294.96 $292.02 $292.02 $333.67 $333.67 $295.24 $295.24 $287.75 $287.75 $239.17 $239.17

$303.64 $303.64 $300.62 $300.62 $343.50 $343.50 $303.93 $303.93 $296.22 $296.22 $246.21 $246.21

$307.98 $307.98 $304.92 $304.92 $348.41 $348.41 $308.28 $308.28 $300.46 $300.46 $249.73 $249.73

$314.49 $314.49 $311.37 $311.37 $355.77 $355.77 $314.80 $314.80 $306.81 $306.81 $255.01 $255.01

$321.00 $321.00 $317.81 $317.81 $363.14 $363.14 $321.31 $321.31 $313.17 $313.17 $260.29 $260.29

$325.07 $325.07 $321.84 $321.84 $367.75 $367.75 $325.39 $325.39 $317.14 $317.14 $263.59 $263.59

$329.42 $329.42 $326.14 $326.14 $372.66 $372.66 $329.73 $329.73 $321.37 $321.37 $267.11 $267.11

$331.59 $331.59 $328.29 $328.29 $375.11 $375.11 $331.91 $331.91 $323.49 $323.49 $268.87 $268.87

$333.76 $333.76 $330.44 $330.44 $377.57 $377.57 $334.08 $334.08 $325.61 $325.61 $270.63 $270.63

$335.93 $335.93 $332.59 $332.59 $380.02 $380.02 $336.25 $336.25 $327.73 $327.73 $272.39 $272.39

$338.10 $338.10 $334.74 $334.74 $382.48 $382.48 $338.43 $338.43 $329.84 $329.84 $274.15 $274.15

$342.44 $342.44 $339.04 $339.04 $387.39 $387.39 $342.77 $342.77 $334.08 $334.08 $277.67 $277.67

$346.78 $346.78 $343.34 $343.34 $392.30 $392.30 $347.12 $347.12 $338.32 $338.32 $281.19 $281.19

$353.29 $353.29 $349.78 $349.78 $399.67 $399.67 $353.64 $353.64 $344.67 $344.67 $286.47 $286.47

$359.54 $359.54 $355.96 $355.96 $406.73 $406.73 $359.88 $359.88 $350.76 $350.76 $291.53 $291.53

$368.22 $368.22 $364.56 $364.56 $416.55 $416.55 $368.57 $368.57 $359.23 $359.23 $298.57 $298.57

$379.07 $379.07 $375.31 $375.31 $428.83 $428.83 $379.44 $379.44 $369.82 $369.82 $307.38 $307.38

$391.83 $391.83 $387.93 $387.93 $443.26 $443.26 $392.20 $392.20 $382.26 $382.26 $317.72 $317.72

$407.02 $407.02 $402.98 $402.98 $460.45 $460.45 $407.41 $407.41 $397.08 $397.08 $330.04 $330.04

$424.12 $424.12 $419.90 $419.90 $479.79 $479.79 $424.53 $424.53 $413.76 $413.76 $343.90 $343.90

$443.65 $443.65 $439.24 $439.24 $501.89 $501.89 $444.08 $444.08 $432.82 $432.82 $359.74 $359.74

$462.92 $462.92 $458.32 $458.32 $523.68 $523.68 $463.37 $463.37 $451.62 $451.62 $375.36 $375.36

$484.63 $484.63 $479.81 $479.81 $548.24 $548.24 $485.09 $485.09 $472.79 $472.79 $392.96 $392.96

$506.06 $506.06 $501.03 $501.03 $572.49 $572.49 $506.55 $506.55 $493.71 $493.71 $410.35 $410.35

$529.67 $529.67 $524.41 $524.41 $599.20 $599.20 $530.18 $530.18 $516.74 $516.74 $429.49 $429.49

$553.55 $553.55 $548.05 $548.05 $626.21 $626.21 $554.08 $554.08 $540.03 $540.03 $448.85 $448.85

$579.33 $579.33 $573.57 $573.57 $655.37 $655.37 $579.89 $579.89 $565.18 $565.18 $469.75 $469.75

$605.11 $605.11 $599.09 $599.09 $684.53 $684.53 $605.69 $605.69 $590.33 $590.33 $490.66 $490.66

$633.05 $633.05 $626.76 $626.76 $716.15 $716.15 $633.67 $633.67 $617.60 $617.60 $513.32 $513.32

$661.27 $661.27 $654.70 $654.70 $748.08 $748.08 $661.91 $661.91 $645.13 $645.13 $536.20 $536.20

$691.39 $691.39 $684.52 $684.52 $782.15 $782.15 $692.06 $692.06 $674.51 $674.51 $560.62 $560.62

$706.32 $706.32 $699.30 $699.30 $799.03 $799.03 $707.00 $707.00 $689.07 $689.07 $572.73 $572.73

$736.44 $736.44 $729.12 $729.12 $833.11 $833.11 $737.15 $737.15 $718.46 $718.46 $597.15 $597.15

$762.49 $762.49 $754.91 $754.91 $862.58 $862.58 $763.22 $763.22 $743.87 $743.87 $618.27 $618.27

$779.58 $779.58 $771.83 $771.83 $881.91 $881.91 $780.33 $780.33 $760.55 $760.55 $632.13 $632.13

$801.02 $801.02 $793.06 $793.06 $906.16 $906.16 $801.79 $801.79 $781.46 $781.46 $649.51 $649.51

$814.04 $814.04 $805.95 $805.95 $920.90 $920.90 $814.83 $814.83 $794.16 $794.16 $660.08 $660.08

$814.04 $814.04 $805.95 $805.95 $920.90 $920.90 $814.83 $814.83 $794.16 $794.16 $660.08 $660.08

Yes Yes YesYes Yes

$7,150 $7,150 $3,500 $6,550 $6,550 $6,550

Yes

$15*/$50* 100%*/$30* 100%* /70%* 80%*/60%*$35/$65 $35/$65

90%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 80%/60%/50%90%/70%/50%

$2,600 $3,000 $5,500$1,750/$5,250 $2,000/$6,000


Blue Flex Plan


Blue Flex Plan









$1,500


A A A A AA



Area 1, 4

33709PA0570006 33709PA0450004 33709PA0640001 33709PA0640002 33709PA0640003

10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17

33709PA0570004

10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17


10/1/17, 11/1/17, 12/1/17




Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$140.17 $140.17 $209.56 $209.56

$220.73 $220.73 $330.02 $330.02

$220.73 $220.73 $330.02 $330.02

$220.73 $220.73 $330.02 $330.02

$220.73 $220.73 $330.02 $330.02

$221.62 $221.62 $331.34 $331.34

$226.03 $226.03 $337.94 $337.94

$231.33 $231.33 $345.86 $345.86

$239.94 $239.94 $358.74 $358.74

$247.00 $247.00 $369.30 $369.30

$250.53 $250.53 $374.58 $374.58

$255.83 $255.83 $382.50 $382.50

$261.13 $261.13 $390.42 $390.42

$264.44 $264.44 $395.37 $395.37

$267.97 $267.97 $400.65 $400.65

$269.74 $269.74 $403.29 $403.29

$271.50 $271.50 $405.93 $405.93

$273.27 $273.27 $408.57 $408.57

$275.03 $275.03 $411.21 $411.21

$278.57 $278.57 $416.49 $416.49

$282.10 $282.10 $421.77 $421.77

$287.39 $287.39 $429.69 $429.69

$292.47 $292.47 $437.28 $437.28

$299.53 $299.53 $447.84 $447.84

$308.36 $308.36 $461.04 $461.04

$318.74 $318.74 $476.55 $476.55

$331.10 $331.10 $495.03 $495.03

$345.01 $345.01 $515.83 $515.83

$360.90 $360.90 $539.59 $539.59

$376.57 $376.57 $563.02 $563.02

$394.23 $394.23 $589.42 $589.42

$411.67 $411.67 $615.49 $615.49

$430.87 $430.87 $644.21 $644.21

$450.30 $450.30 $673.25 $673.25

$471.27 $471.27 $704.60 $704.60

$492.24 $492.24 $735.95 $735.95

$514.97 $514.97 $769.94 $769.94

$537.93 $537.93 $804.27 $804.27

$562.43 $562.43 $840.90 $840.90

$574.57 $574.57 $859.05 $859.05

$599.07 $599.07 $895.68 $895.68

$620.26 $620.26 $927.36 $927.36

$634.17 $634.17 $948.16 $948.16

$651.60 $651.60 $974.23 $974.23

$662.19 $662.19 $990.06 $990.06

$662.19 $662.19 $990.06 $990.06

Yes Yes

$5,500

100%*/70%

$6,550

RC - $35

100%/70%/50% 100%/70%/50%

$6,000 $500/$1,500


Community Blue Plan

Bronze



Gold

A A

Area 1, 4 Area 1, 4


33709PA0640005 33709PA0460012

10/1/17, 11/1/17, 12/1/1710/1/17, 11/1/17, 12/1/17






Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>


0 - 20 $149.48 $149.48 $160.27 $160.27 $219.46 $219.46 $235.30 $235.30 $207.38 $207.38 $223.18 $223.18

21 $235.40 $235.40 $252.39 $252.39 $345.61 $345.61 $370.55 $370.55 $326.59 $326.59 $351.46 $351.46

22 $235.40 $235.40 $252.39 $252.39 $345.61 $345.61 $370.55 $370.55 $326.59 $326.59 $351.46 $351.46

23 $235.40 $235.40 $252.39 $252.39 $345.61 $345.61 $370.55 $370.55 $326.59 $326.59 $351.46 $351.46

24 $235.40 $235.40 $252.39 $252.39 $345.61 $345.61 $370.55 $370.55 $326.59 $326.59 $351.46 $351.46

25 $236.34 $236.34 $253.40 $253.40 $346.99 $346.99 $372.03 $372.03 $327.90 $327.90 $352.87 $352.87

26 $241.05 $241.05 $258.44 $258.44 $353.91 $353.91 $379.45 $379.45 $334.43 $334.43 $359.90 $359.90

27 $246.70 $246.70 $264.50 $264.50 $362.20 $362.20 $388.34 $388.34 $342.27 $342.27 $368.33 $368.33

28 $255.88 $255.88 $274.34 $274.34 $375.68 $375.68 $402.79 $402.79 $355.00 $355.00 $382.04 $382.04

29 $263.41 $263.41 $282.42 $282.42 $386.74 $386.74 $414.65 $414.65 $365.45 $365.45 $393.28 $393.28

30 $267.18 $267.18 $286.46 $286.46 $392.27 $392.27 $420.58 $420.58 $370.68 $370.68 $398.91 $398.91

31 $272.83 $272.83 $292.52 $292.52 $400.56 $400.56 $429.47 $429.47 $378.52 $378.52 $407.34 $407.34

32 $278.48 $278.48 $298.57 $298.57 $408.86 $408.86 $438.36 $438.36 $386.36 $386.36 $415.78 $415.78

33 $282.01 $282.01 $302.36 $302.36 $414.04 $414.04 $443.92 $443.92 $391.25 $391.25 $421.05 $421.05

34 $285.78 $285.78 $306.40 $306.40 $419.57 $419.57 $449.85 $449.85 $396.48 $396.48 $426.67 $426.67

35 $287.66 $287.66 $308.42 $308.42 $422.34 $422.34 $452.81 $452.81 $399.09 $399.09 $429.48 $429.48

36 $289.54 $289.54 $310.44 $310.44 $425.10 $425.10 $455.78 $455.78 $401.70 $401.70 $432.30 $432.30

37 $291.42 $291.42 $312.46 $312.46 $427.87 $427.87 $458.74 $458.74 $404.32 $404.32 $435.11 $435.11

38 $293.31 $293.31 $314.47 $314.47 $430.63 $430.63 $461.71 $461.71 $406.93 $406.93 $437.92 $437.92

39 $297.07 $297.07 $318.51 $318.51 $436.16 $436.16 $467.64 $467.64 $412.16 $412.16 $443.54 $443.54

40 $300.84 $300.84 $322.55 $322.55 $441.69 $441.69 $473.57 $473.57 $417.38 $417.38 $449.17 $449.17

41 $306.49 $306.49 $328.61 $328.61 $449.99 $449.99 $482.46 $482.46 $425.22 $425.22 $457.60 $457.60

42 $311.90 $311.90 $334.41 $334.41 $457.93 $457.93 $490.98 $490.98 $432.73 $432.73 $465.68 $465.68

43 $319.44 $319.44 $342.49 $342.49 $468.99 $468.99 $502.84 $502.84 $443.18 $443.18 $476.93 $476.93

44 $328.85 $328.85 $352.58 $352.58 $482.82 $482.82 $517.66 $517.66 $456.25 $456.25 $490.99 $490.99

45 $339.92 $339.92 $364.45 $364.45 $499.06 $499.06 $535.08 $535.08 $471.59 $471.59 $507.51 $507.51

46 $353.10 $353.10 $378.58 $378.58 $518.42 $518.42 $555.83 $555.83 $489.88 $489.88 $527.19 $527.19

47 $367.93 $367.93 $394.48 $394.48 $540.19 $540.19 $579.17 $579.17 $510.46 $510.46 $549.33 $549.33

48 $384.88 $384.88 $412.65 $412.65 $565.07 $565.07 $605.85 $605.85 $533.97 $533.97 $574.64 $574.64

49 $401.59 $401.59 $430.57 $430.57 $589.61 $589.61 $632.16 $632.16 $557.16 $557.16 $599.59 $599.59

50 $420.42 $420.42 $450.76 $450.76 $617.26 $617.26 $661.81 $661.81 $583.29 $583.29 $627.71 $627.71

51 $439.02 $439.02 $470.70 $470.70 $644.56 $644.56 $691.08 $691.08 $609.09 $609.09 $655.47 $655.47

52 $459.50 $459.50 $492.66 $492.66 $674.63 $674.63 $723.32 $723.32 $637.50 $637.50 $686.05 $686.05

53 $480.22 $480.22 $514.87 $514.87 $705.05 $705.05 $755.93 $755.93 $666.24 $666.24 $716.98 $716.98

54 $502.58 $502.58 $538.85 $538.85 $737.88 $737.88 $791.13 $791.13 $697.27 $697.27 $750.37 $750.37

55 $524.94 $524.94 $562.82 $562.82 $770.71 $770.71 $826.33 $826.33 $728.29 $728.29 $783.76 $783.76

56 $549.19 $549.19 $588.82 $588.82 $806.31 $806.31 $864.50 $864.50 $761.93 $761.93 $819.96 $819.96

57 $573.67 $573.67 $615.07 $615.07 $842.25 $842.25 $903.04 $903.04 $795.90 $795.90 $856.51 $856.51

58 $599.80 $599.80 $643.08 $643.08 $880.62 $880.62 $944.17 $944.17 $832.15 $832.15 $895.52 $895.52

59 $612.75 $612.75 $656.96 $656.96 $899.63 $899.63 $964.55 $964.55 $850.11 $850.11 $914.85 $914.85

60 $638.87 $638.87 $684.98 $684.98 $937.99 $937.99 $1,005.68 $1,005.68 $886.36 $886.36 $953.86 $953.86

61 $661.47 $661.47 $709.21 $709.21 $971.17 $971.17 $1,041.25 $1,041.25 $917.72 $917.72 $987.60 $987.60

62 $676.30 $676.30 $725.11 $725.11 $992.94 $992.94 $1,064.60 $1,064.60 $938.29 $938.29 $1,009.74 $1,009.74

63 $694.90 $694.90 $745.05 $745.05 $1,020.24 $1,020.24 $1,093.87 $1,093.87 $964.09 $964.09 $1,037.51 $1,037.51

64 $706.20 $706.20 $757.16 $757.16 $1,036.83 $1,036.83 $1,111.65 $1,111.65 $979.77 $979.77 $1,054.38 $1,054.38

65+ $706.20 $706.20 $757.16 $757.16 $1,036.83 $1,036.83 $1,111.65 $1,111.65 $979.77 $979.77 $1,054.38 $1,054.38


$6,550 $6,550 $5,500 $5,500 $5,300 $5,500

80%*/60%* 80%*/60%* $20/$50 $20/$50 $20/$50 $10/$40

80%/60%/50% 80%/60%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$5,500 $5,500 $500 $500 $500 $500/$1,500







Plan



Plan



Blue Plan


Community Blue Plan


B B H H G B



33709PA0640004 33709PA0640004 33709PA0460007 33709PA0460007 33709PA0460008 33709PA0460013

10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17






Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$239.28 $239.28 $226.19 $226.19 $242.51 $242.51 $216.71 $216.71 $232.35 $232.35

$376.82 $376.82 $356.20 $356.20 $381.91 $381.91 $341.28 $341.28 $365.90 $365.90

$376.82 $376.82 $356.20 $356.20 $381.91 $381.91 $341.28 $341.28 $365.90 $365.90

$376.82 $376.82 $356.20 $356.20 $381.91 $381.91 $341.28 $341.28 $365.90 $365.90

$376.82 $376.82 $356.20 $356.20 $381.91 $381.91 $341.28 $341.28 $365.90 $365.90

$378.33 $378.33 $357.63 $357.63 $383.44 $383.44 $342.64 $342.64 $367.37 $367.37

$385.87 $385.87 $364.75 $364.75 $391.07 $391.07 $349.47 $349.47 $374.68 $374.68

$394.91 $394.91 $373.30 $373.30 $400.24 $400.24 $357.66 $357.66 $383.47 $383.47

$409.61 $409.61 $387.19 $387.19 $415.13 $415.13 $370.97 $370.97 $397.74 $397.74

$421.67 $421.67 $398.59 $398.59 $427.36 $427.36 $381.89 $381.89 $409.45 $409.45

$427.69 $427.69 $404.29 $404.29 $433.47 $433.47 $387.35 $387.35 $415.30 $415.30

$436.74 $436.74 $412.84 $412.84 $442.63 $442.63 $395.54 $395.54 $424.08 $424.08

$445.78 $445.78 $421.39 $421.39 $451.80 $451.80 $403.73 $403.73 $432.86 $432.86

$451.43 $451.43 $426.73 $426.73 $457.53 $457.53 $408.85 $408.85 $438.35 $438.35

$457.46 $457.46 $432.43 $432.43 $463.64 $463.64 $414.31 $414.31 $444.21 $444.21

$460.48 $460.48 $435.28 $435.28 $466.69 $466.69 $417.04 $417.04 $447.13 $447.13

$463.49 $463.49 $438.13 $438.13 $469.75 $469.75 $419.77 $419.77 $450.06 $450.06

$466.51 $466.51 $440.98 $440.98 $472.80 $472.80 $422.50 $422.50 $452.99 $452.99

$469.52 $469.52 $443.83 $443.83 $475.86 $475.86 $425.23 $425.23 $455.92 $455.92

$475.55 $475.55 $449.53 $449.53 $481.97 $481.97 $430.69 $430.69 $461.77 $461.77

$481.58 $481.58 $455.23 $455.23 $488.08 $488.08 $436.15 $436.15 $467.62 $467.62

$490.62 $490.62 $463.78 $463.78 $497.25 $497.25 $444.34 $444.34 $476.41 $476.41

$499.29 $499.29 $471.97 $471.97 $506.03 $506.03 $452.19 $452.19 $484.82 $484.82

$511.35 $511.35 $483.37 $483.37 $518.25 $518.25 $463.11 $463.11 $496.53 $496.53

$526.42 $526.42 $497.62 $497.62 $533.53 $533.53 $476.76 $476.76 $511.17 $511.17

$544.13 $544.13 $514.36 $514.36 $551.48 $551.48 $492.80 $492.80 $528.36 $528.36

$565.23 $565.23 $534.31 $534.31 $572.86 $572.86 $511.91 $511.91 $548.85 $548.85

$588.97 $588.97 $556.75 $556.75 $596.92 $596.92 $533.41 $533.41 $571.91 $571.91

$616.11 $616.11 $582.39 $582.39 $624.42 $624.42 $557.98 $557.98 $598.25 $598.25

$642.86 $642.86 $607.68 $607.68 $651.54 $651.54 $582.22 $582.22 $624.23 $624.23

$673.01 $673.01 $636.18 $636.18 $682.09 $682.09 $609.52 $609.52 $653.50 $653.50

$702.78 $702.78 $664.32 $664.32 $712.26 $712.26 $636.48 $636.48 $682.41 $682.41

$735.56 $735.56 $695.31 $695.31 $745.49 $745.49 $666.17 $666.17 $714.24 $714.24

$768.72 $768.72 $726.65 $726.65 $779.09 $779.09 $696.20 $696.20 $746.44 $746.44

$804.52 $804.52 $760.49 $760.49 $815.38 $815.38 $728.62 $728.62 $781.20 $781.20

$840.32 $840.32 $794.33 $794.33 $851.66 $851.66 $761.04 $761.04 $815.96 $815.96

$879.13 $879.13 $831.02 $831.02 $890.99 $890.99 $796.19 $796.19 $853.65 $853.65

$918.32 $918.32 $868.07 $868.07 $930.71 $930.71 $831.69 $831.69 $891.71 $891.71

$960.15 $960.15 $907.61 $907.61 $973.10 $973.10 $869.57 $869.57 $932.32 $932.32

$980.87 $980.87 $927.20 $927.20 $994.11 $994.11 $888.34 $888.34 $952.45 $952.45

$1,022.70 $1,022.70 $966.74 $966.74 $1,036.50 $1,036.50 $926.22 $926.22 $993.06 $993.06

$1,058.87 $1,058.87 $1,000.93 $1,000.93 $1,073.16 $1,073.16 $958.98 $958.98 $1,028.19 $1,028.19

$1,082.61 $1,082.61 $1,023.37 $1,023.37 $1,097.22 $1,097.22 $980.48 $980.48 $1,051.24 $1,051.24

$1,112.38 $1,112.38 $1,051.51 $1,051.51 $1,127.39 $1,127.39 $1,007.44 $1,007.44 $1,080.15 $1,080.15

$1,130.46 $1,130.46 $1,068.60 $1,068.60 $1,145.73 $1,145.73 $1,023.83 $1,023.83 $1,097.70 $1,097.70

$1,130.46 $1,130.46 $1,068.60 $1,068.60 $1,145.73 $1,145.73 $1,023.83 $1,023.83 $1,097.70 $1,097.70

Yes YesYes Yes Yes

$5,500 $7,150 $7,150 $4,800 $4,800

$30/$60 $30/$60$10/$40 $20/$60 $20/$60

$750/$1,500 $750/$1,500

100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50% 100%/70%/50%

$500/$1,500 $250/$750 $250/$750

Gold Gold


Community Blue Plan









Gold Gold Gold

Area 1, 2, 5 Area 6

B B B B B



33709PA0460013 33709PA0440014 33709PA0440014 33709PA0440009 33709PA0440009

10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17


10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17





Form #

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dental (Yes/No) =>

Age Band

0 - 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

65+


$187.14 $187.14 $200.65 $200.65

$294.72 $294.72 $315.98 $315.98

$294.72 $294.72 $315.98 $315.98

$294.72 $294.72 $315.98 $315.98

$294.72 $294.72 $315.98 $315.98

$295.89 $295.89 $317.25 $317.25

$301.79 $301.79 $323.57 $323.57

$308.86 $308.86 $331.15 $331.15

$320.36 $320.36 $343.47 $343.47

$329.79 $329.79 $353.59 $353.59

$334.50 $334.50 $358.64 $358.64

$341.57 $341.57 $366.22 $366.22

$348.65 $348.65 $373.81 $373.81

$353.07 $353.07 $378.55 $378.55

$357.78 $357.78 $383.60 $383.60

$360.14 $360.14 $386.13 $386.13

$362.50 $362.50 $388.66 $388.66

$364.86 $364.86 $391.19 $391.19

$367.22 $367.22 $393.72 $393.72

$371.93 $371.93 $398.77 $398.77

$376.65 $376.65 $403.83 $403.83

$383.72 $383.72 $411.41 $411.41

$390.50 $390.50 $418.68 $418.68

$399.93 $399.93 $428.79 $428.79

$411.72 $411.72 $441.43 $441.43

$425.57 $425.57 $456.28 $456.28

$442.07 $442.07 $473.97 $473.97

$460.64 $460.64 $493.88 $493.88

$481.86 $481.86 $516.63 $516.63

$502.78 $502.78 $539.07 $539.07

$526.36 $526.36 $564.35 $564.35

$549.64 $549.64 $589.31 $589.31

$575.28 $575.28 $616.80 $616.80

$601.22 $601.22 $644.61 $644.61

$629.22 $629.22 $674.62 $674.62

$657.21 $657.21 $704.64 $704.64

$687.57 $687.57 $737.19 $737.19

$718.22 $718.22 $770.05 $770.05

$750.93 $750.93 $805.13 $805.13

$767.14 $767.14 $822.50 $822.50

$799.86 $799.86 $857.58 $857.58

$828.15 $828.15 $887.91 $887.91

$846.72 $846.72 $907.82 $907.82

$870.00 $870.00 $932.78 $932.78

$884.15 $884.15 $947.94 $947.94

$884.15 $884.15 $947.94 $947.94

Yes Yes

$7,150$7,150

$45/$70* $45/$70*

$1,500/$4,500 $1,500/$4,500

100%/70%/50%100%/70%/50%

Silver Silver





Area 1, 2, 5 Area 6

BB


10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17

33709PA044001333709PA0440013






Form #

Region =>

Service Zone =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dentail (Yes/No) =>


0 - 20 $195.16 $195.16 $194.38 $194.38 $191.61 $191.61 $190.52 $190.52 $186.22 $186.22 $184.72 $184.72

21 $307.34 $307.34 $306.10 $306.10 $301.75 $301.75 $300.03 $300.03 $293.26 $293.26 $290.90 $290.90

22 $307.34 $307.34 $306.10 $306.10 $301.75 $301.75 $300.03 $300.03 $293.26 $293.26 $290.90 $290.90

23 $307.34 $307.34 $306.10 $306.10 $301.75 $301.75 $300.03 $300.03 $293.26 $293.26 $290.90 $290.90

24 $307.34 $307.34 $306.10 $306.10 $301.75 $301.75 $300.03 $300.03 $293.26 $293.26 $290.90 $290.90

25 $308.57 $308.57 $307.33 $307.33 $302.95 $302.95 $301.23 $301.23 $294.43 $294.43 $292.07 $292.07

26 $314.72 $314.72 $313.45 $313.45 $308.99 $308.99 $307.23 $307.23 $300.30 $300.30 $297.88 $297.88

27 $322.10 $322.10 $320.80 $320.80 $316.23 $316.23 $314.43 $314.43 $307.34 $307.34 $304.87 $304.87

28 $334.08 $334.08 $332.73 $332.73 $328.00 $328.00 $326.13 $326.13 $318.77 $318.77 $316.21 $316.21

29 $343.92 $343.92 $342.53 $342.53 $337.66 $337.66 $335.73 $335.73 $328.16 $328.16 $325.52 $325.52

30 $348.84 $348.84 $347.43 $347.43 $342.48 $342.48 $340.53 $340.53 $332.85 $332.85 $330.17 $330.17

31 $356.21 $356.21 $354.77 $354.77 $349.73 $349.73 $347.74 $347.74 $339.89 $339.89 $337.16 $337.16

32 $363.59 $363.59 $362.12 $362.12 $356.97 $356.97 $354.94 $354.94 $346.93 $346.93 $344.14 $344.14

33 $368.20 $368.20 $366.71 $366.71 $361.49 $361.49 $359.44 $359.44 $351.33 $351.33 $348.50 $348.50

34 $373.12 $373.12 $371.61 $371.61 $366.32 $366.32 $364.24 $364.24 $356.02 $356.02 $353.16 $353.16

35 $375.57 $375.57 $374.06 $374.06 $368.74 $368.74 $366.64 $366.64 $358.36 $358.36 $355.48 $355.48

36 $378.03 $378.03 $376.51 $376.51 $371.15 $371.15 $369.04 $369.04 $360.71 $360.71 $357.81 $357.81

37 $380.49 $380.49 $378.96 $378.96 $373.56 $373.56 $371.44 $371.44 $363.06 $363.06 $360.14 $360.14

38 $382.95 $382.95 $381.40 $381.40 $375.98 $375.98 $373.84 $373.84 $365.40 $365.40 $362.47 $362.47

39 $387.87 $387.87 $386.30 $386.30 $380.81 $380.81 $378.64 $378.64 $370.09 $370.09 $367.12 $367.12

40 $392.79 $392.79 $391.20 $391.20 $385.63 $385.63 $383.44 $383.44 $374.79 $374.79 $371.77 $371.77

41 $400.16 $400.16 $398.55 $398.55 $392.88 $392.88 $390.64 $390.64 $381.82 $381.82 $378.76 $378.76

42 $407.23 $407.23 $405.59 $405.59 $399.82 $399.82 $397.54 $397.54 $388.57 $388.57 $385.45 $385.45

43 $417.07 $417.07 $415.38 $415.38 $409.47 $409.47 $407.14 $407.14 $397.95 $397.95 $394.76 $394.76

44 $429.36 $429.36 $427.63 $427.63 $421.54 $421.54 $419.14 $419.14 $409.68 $409.68 $406.39 $406.39

45 $443.81 $443.81 $442.01 $442.01 $435.72 $435.72 $433.24 $433.24 $423.47 $423.47 $420.06 $420.06

46 $461.02 $461.02 $459.15 $459.15 $452.62 $452.62 $450.05 $450.05 $439.89 $439.89 $436.35 $436.35

47 $480.38 $480.38 $478.44 $478.44 $471.63 $471.63 $468.95 $468.95 $458.37 $458.37 $454.68 $454.68

48 $502.51 $502.51 $500.48 $500.48 $493.36 $493.36 $490.55 $490.55 $479.48 $479.48 $475.63 $475.63

49 $524.33 $524.33 $522.21 $522.21 $514.78 $514.78 $511.85 $511.85 $500.30 $500.30 $496.28 $496.28

50 $548.92 $548.92 $546.70 $546.70 $538.92 $538.92 $535.85 $535.85 $523.76 $523.76 $519.55 $519.55

51 $573.20 $573.20 $570.88 $570.88 $562.76 $562.76 $559.56 $559.56 $546.93 $546.93 $542.53 $542.53

52 $599.94 $599.94 $597.51 $597.51 $589.01 $589.01 $585.66 $585.66 $572.44 $572.44 $567.84 $567.84

53 $626.98 $626.98 $624.45 $624.45 $615.57 $615.57 $612.06 $612.06 $598.25 $598.25 $593.44 $593.44

54 $656.18 $656.18 $653.53 $653.53 $644.23 $644.23 $640.57 $640.57 $626.11 $626.11 $621.08 $621.08

55 $685.38 $685.38 $682.61 $682.61 $672.90 $672.90 $669.07 $669.07 $653.97 $653.97 $648.71 $648.71

56 $717.03 $717.03 $714.14 $714.14 $703.98 $703.98 $699.97 $699.97 $684.18 $684.18 $678.68 $678.68

57 $749.00 $749.00 $745.97 $745.97 $735.36 $735.36 $731.17 $731.17 $714.67 $714.67 $708.93 $708.93

58 $783.11 $783.11 $779.95 $779.95 $768.85 $768.85 $764.48 $764.48 $747.23 $747.23 $741.22 $741.22

59 $800.02 $800.02 $796.79 $796.79 $785.45 $785.45 $780.98 $780.98 $763.36 $763.36 $757.22 $757.22

60 $834.13 $834.13 $830.76 $830.76 $818.94 $818.94 $814.28 $814.28 $795.91 $795.91 $789.51 $789.51

61 $863.64 $863.64 $860.15 $860.15 $847.91 $847.91 $843.09 $843.09 $824.06 $824.06 $817.44 $817.44

62 $883.00 $883.00 $879.43 $879.43 $866.92 $866.92 $861.99 $861.99 $842.54 $842.54 $835.76 $835.76

63 $907.28 $907.28 $903.62 $903.62 $890.76 $890.76 $885.69 $885.69 $865.70 $865.70 $858.75 $858.75

64 $922.02 $922.02 $918.30 $918.30 $905.24 $905.24 $900.09 $900.09 $879.78 $879.78 $872.70 $872.70

65+ $922.02 $922.02 $918.30 $918.30 $905.24 $905.24 $900.09 $900.09 $879.78 $879.78 $872.70 $872.70


$7,150 $7,150 $7,150 $6,100 $7,150 $6,800

$25 $10 $10 $0 $10 $10

100% 100% 100% 100% 100% 100%

$100 $250 $500 $750 $900 $1,100


Community Blue Plan


Community Blue Plan


Community Blue Plan


Community Blue Plan


Community Blue Plan


Community Blue Plan


J J J J J J



33709PA0630002 33709PA0630003 33709PA0630004 33709PA0630005 33709PA0630006 33709PA0630008

10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17






Form #

Region =>

Service Zone =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Dentail (Yes/No) =>

Age Band

0 - 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

65+


$160.23 $160.23 $157.13 $157.13

$252.33 $252.33 $247.45 $247.45

$252.33 $252.33 $247.45 $247.45

$252.33 $252.33 $247.45 $247.45

$252.33 $252.33 $247.45 $247.45

$253.34 $253.34 $248.44 $248.44

$258.38 $258.38 $253.39 $253.39

$264.44 $264.44 $259.32 $259.32

$274.28 $274.28 $268.97 $268.97

$282.35 $282.35 $276.89 $276.89

$286.39 $286.39 $280.85 $280.85

$292.45 $292.45 $286.79 $286.79

$298.50 $298.50 $292.73 $292.73

$302.29 $302.29 $296.44 $296.44

$306.32 $306.32 $300.40 $300.40

$308.34 $308.34 $302.38 $302.38

$310.36 $310.36 $304.36 $304.36

$312.38 $312.38 $306.34 $306.34

$314.40 $314.40 $308.32 $308.32

$318.44 $318.44 $312.28 $312.28

$322.47 $322.47 $316.24 $316.24

$328.53 $328.53 $322.18 $322.18

$334.33 $334.33 $327.87 $327.87

$342.41 $342.41 $335.79 $335.79

$352.50 $352.50 $345.68 $345.68

$364.36 $364.36 $357.31 $357.31

$378.49 $378.49 $371.17 $371.17

$394.39 $394.39 $386.76 $386.76

$412.55 $412.55 $404.58 $404.58

$430.47 $430.47 $422.14 $422.14

$450.65 $450.65 $441.94 $441.94

$470.59 $470.59 $461.49 $461.49

$492.54 $492.54 $483.02 $483.02

$514.75 $514.75 $504.79 $504.79

$538.72 $538.72 $528.30 $528.30

$562.69 $562.69 $551.81 $551.81

$588.68 $588.68 $577.29 $577.29

$614.92 $614.92 $603.03 $603.03

$642.93 $642.93 $630.49 $630.49

$656.80 $656.80 $644.10 $644.10

$684.81 $684.81 $671.57 $671.57

$709.04 $709.04 $695.33 $695.33

$724.93 $724.93 $710.92 $710.92

$744.87 $744.87 $730.46 $730.46

$756.98 $756.98 $742.34 $742.34

$756.98 $756.98 $742.34 $742.34

$7,150 $7,150

Yes Yes

100% 100%

$25 $25


Community Blue Plan


Community Blue Plan

$2,500 $3200

J J

Silver Silver


Area 1, 4 Area 1, 4

33709PA0630007 33709PA0630009


10/1/17, 11/1/17, 12/1/17 10/1/17, 11/1/17, 12/1/17




33709PA0560029 $278.15 $278.15

33709PA0570007 $275.76 $275.76

33709PA0570004 $271.35 $271.35

33709PA0570006 $268.65 $268.65

33709PA0640001 $271.61 $271.61

33709PA0640002 $264.72 $264.72

33709PA0630007 $252.33 $252.33

33709PA0630009 $247.45 $247.45

33709PA0440013 $294.72 $294.72 $294.72 $315.98



Supporting Document Schedules Satisfied - Item: Revised Redacted Memorandums & Rate Exhibits & URRT (PDF)Comments: Attached

Attachment(s):2017 Unified_Rate_Review_Template_PA Small Group_HIGHMARK_v4 FINAL-Add 2 Plans.pdfHighmark - FINAL 2017 PA Actuarial Memorandum Rate Exhibits Rev 4-21-2016 v2 - FINAL - Val.pdf33709_01012017_SG_RedactedAMv3.pdf2017 PID Act Memo SG PA - Highmark - FINAL (Redacted)v3.pdf

Item Status:Status Date:

SERFF Tracking #: HGHM-130535904 State Tracking #: HGHM-130535904 Company Tracking #: 1A-SG-HIGHMARK-2016

State: Pennsylvania Filing Company: Highmark

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

Product Name: HIGHMARK Small Group 2017 ACA Rate Filing

Project Name/Number: HIGHMARK 2017 ACA Rate Filing/1A-SG-HIGHMARK-2016

PDF Pipeline for SERFF Tracking Number HGHM-130535904 Generated 10/14/2016 10:11 AM

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

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A B C D E F G H I J K L M N O P Q R S T U V W X Y

Ac

tioUnified Rate Review v3.3

Company Legal Name: Highmark State: PA

HIOS Issuer ID: 33709 Market: Small Group

Effective Date of Rate Change(s): 01/01/2017

Market Level Calculations (Same for all Plans)

Section I: Experience period data

Experience Period: 01/01/2015 to 12/31/2015

Experience Period

Aggregate Amount PMPM % of Prem

Premiums (net of MLR Rebate) in Experience Period: $79,651,361 $348.21 100.00%

Incurred Claims in Experience Period $78,124,305 341.53 98.08%

Allowed Claims: $92,441,081 404.12 116.06%

Index Rate of Experience Period $404.00

Experience Period Member Months 228,747

Section II: Allowed Claims, PMPM basis

Experience Period Projection Period: 01/01/2017 to 12/31/2017 Mid-point to Mid-point, Experience to Projection: 24 months

on Actual Experience Allowed

Adj't. from Experience to

Projection Period Projections, before credibility Adjustment Credibility Manual

Benefit Category

Utilization

Description

Utilization per

1,000

Average

Cost/Service PMPM

Pop'l risk

Morbidity Other Cost Util

Utilization per

1,000

Average

Cost/Service PMPM

Utilization

per 1,000

Average

Cost/Service PMPM

Inpatient Hospital Admits 69.96 $11,439.00 $66.69 1.075 0.982 1.058 1.026 79.23 $12,583.94 $83.08 0.00 $0.00 $0.00

Outpatient Hospital Visits 2,568.94 560.49 119.99 1.075 0.982 1.058 1.026 2,909.23 616.59 149.48 0.00 0.00 0.00

Professional Visits 16,392.91 89.23 121.90 1.075 0.982 1.058 1.026 18,564.34 98.17 151.86 0.00 0.00 0.00

Other Medical Other 740.56 181.00 11.17 1.075 0.982 1.058 1.026 838.65 199.12 13.92 0.00 0.00 0.00

Capitation Other 0.00 0.00 0.00 1.000 1.000 1.000 1.000 0.00 0.00 0.00 0.00 0.00 0.00

Prescription Drug Prescriptions 11,758.92 86.10 84.37 1.075 0.982 1.058 1.026 13,316.52 94.72 105.11 0.00 0.00 0.00

Total $404.12 $503.46 $0.00

After Credibility Projected Period Totals

Section III: Projected Experience: Projected Allowed Experience Claims PMPM (w/applied credibility if applicable) 100.00% 0.00% $503.46 $84,061,046

Paid to Allowed Average Factor in Projection Period 0.850

Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM $427.93 $71,450,601

Projected Risk Adjustments PMPM -1.70 (283,877)

Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM $429.63 $71,734,478

Projected ACA reinsurance recoveries, net of rein prem, PMPM 0.00 0

Projected Incurred Claims $429.63 $71,734,478

Administrative Expense Load 10.03% 47.93 8,002,776

Profit & Risk Load 0.00% 0.00 0

Taxes & Fees 0.04% 0.19 31,724

Single Risk Pool Gross Premium Avg. Rate, PMPM $477.75 $79,768,978

Index Rate for Projection Period $521.58

% increase over Experience Period 37.20%

% Increase, annualized: 17.13%

Projected Member Months 166,968

Information Not Releasable to the Public Unless Authorized by Law: This information has not been publically disclosed and may be privileged and confidential. It is for internal government use only and must not be

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Annualized Trend

Factors

1 of 11

Action

Keyboard Product-Plan Data Collection

Company Legal Name: Highmark State: PA

HIOS Issuer ID: 33709 Market: Small Group

Effective Date of Rate Change(s):

Product/Plan Level Calculations

Section I: General Product and Plan Information

Product

Product ID:

Metal: Platinum Platinum Gold Gold Gold Gold Gold Gold Silver Silver Silver Silver Gold

AV Metal Value 0.918 0.893 0.817 0.805 0.794 0.781 0.803 0.786 0.703 0.691 0.681 0.717 0.809

AV Pricing Value 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.924 0.010 0.010 0.010 0.798 0.964

Plan Category Terminated Terminated Terminated Terminated Terminated Terminated Terminated Renewing Terminated Terminated Terminated Renewing Renewing

Plan Type: PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

Plan NameShared Cost PPO

0 A Community

Blue Plan

Shared Cost PPO

250 A Community

Blue Plan

Shared Cost PPO

500 A Community

Blue Plan

Shared Cost PPO

750 A Community

Blue Plan

Shared Cost PPO

1000 A

Community Blue

Plan

Shared Cost PPO

1500 A

Community Blue

Plan

Shared Cost PPO

2000 HRA A

Community Blue

Plan

Premier Balance

PPO 750 IP A a

Community Blue

Flex Plan

Shared Cost PPO

1500 Integrated

RX A Community

Blue Plan

Shared Cost PPO

1750 A

Community Blue

Plan

Shared Cost PPO

2000 A

Community Blue

Plan

Premier Balance

PPO 1500 IP A a

Community Blue

Flex Plan

Premier Balance

PPO 250 IP A a

Community Blue

Flex Plan

Plan ID (Standard Component ID): 33709PA0440001 33709PA0440002 33709PA0440004 33709PA0440005 33709PA0440006 33709PA0440007 33709PA0440008 33709PA0440009 33709PA0440010 33709PA0440011 33709PA0440012 33709PA0440013 33709PA0440014

Exchange Plan? No No No No No No No No No No No No No

Historical Rate Increase - Calendar Year - 2

Historical Rate Increase - Calendar Year - 1

Historical Rate Increase - Calendar Year 0

Effective Date of Proposed Rates 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2017 01/01/2016 01/01/2016 01/01/2016 01/01/2017 01/01/2017

Rate Change % (over prior filing) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% -1.55% 0.00% 0.00% 0.00% 0.25% -0.44%

Cum'tive Rate Change % (over 12 mos prior) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 1.65% 0.00% 0.00% 0.00% 3.51% 2.80%

Proj'd Per Rate Change % (over Exper. Period) -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% 15.96% -100.00% -100.00% -100.00% 16.65% 11.19%

Product Rate Increase %

Section II: Components of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM)

Plan ID (Standard Component ID): Total 33709PA0440001 33709PA0440002 33709PA0440004 33709PA0440005 33709PA0440006 33709PA0440007 33709PA0440008 33709PA0440009 33709PA0440010 33709PA0440011 33709PA0440012 33709PA0440013 33709PA0440014

Inpatient -$2.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$7.75 $0.00 $0.00 $0.00 -$5.77 -$7.08

Outpatient $1.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.02 $0.00 $0.00 $0.00 $3.21 $3.71

Professional $0.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$1.60 $0.00 $0.00 $0.00 $0.15 $0.00

Prescription Drug $0.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$0.19 $0.00 $0.00 $0.00 $0.89 $0.96

Other -$0.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$1.37 $0.00 $0.00 $0.00 -$1.03 -$1.27

Capitation $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Administration $2.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.91 $0.00 $0.00 $0.00 $6.62 $7.70

Taxes & Fees -$1.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$5.70 $0.00 $0.00 $0.00 -$3.03 -$6.26

Risk & Profit Charge $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Total Rate Increase $0.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$7.69 $0.00 $0.00 $0.00 $1.05 -$2.24

Member Cost Share Increase $4.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.17 $0.00 $0.00 $0.00 $11.64 $11.78

Average Current Rate PMPM $498.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $494.54 $0.00 $0.00 $0.00 $419.38 $510.38

Projected Member Months 166,968 0 0 0 0 0 0 0 2,136 0 0 0 2,292 3,252

Section III: Experience Period Information

Warning Alert Wsht 1 Total Plan ID (Standard Component ID): Total 33709PA0440001 33709PA0440002 33709PA0440004 33709PA0440005 33709PA0440006 33709PA0440007 33709PA0440008 33709PA0440009 33709PA0440010 33709PA0440011 33709PA0440012 33709PA0440013 33709PA0440014

OK 348.21$ Plan Adjusted Index Rate $384.75 $389.02 $378.17 $329.67 $323.79 $318.70 $311.64 $298.31 $417.12 $277.40 $274.42 $271.42 $358.08 $454.04

OK 228,747 Member Months 228,747 14,830 4,836 3,708 996 3,854 1,717 722 1,640 329 258 1,010 1,031 3,058

WARNING $79,651,361 Total Premium (TP) $88,010,967 $5,769,153 $1,828,820 $1,222,423 $322,494 $1,228,261 $535,088 $215,377 $684,084 $91,263 $70,800 $274,131 $369,182 $1,388,448

EHB Percent of TP, [see instructions] 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

state mandated benefits portion of TP that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TP 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

OK $92,441,081 Total Allowed Claims (TAC) $92,441,081 $6,305,908 $2,056,578 $1,302,224 $315,832 $1,143,692 $679,777 $447,973 $441,927 $101,606 $65,481 $232,485 $326,931 $1,205,246

EHB Percent of TAC, [see instructions] 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% state mandated benefits portion of TAC that are

other than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TAC 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Allowed Claims which are not the issuer's obligation: $6,897,403 $688,555 $29,926 $40,680 -$80,545 -$39,091 $8,584 $115,788 -$89,410 -$16,382 -$10,292 -$65,736 -$111,560 $28,020Portion of above payable by HHS's funds on

behalf of insured person, in dollars $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0Portion of above payable by HHS on behalf of

insured person, as % 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%OK $78,124,305 Total Incurred claims, payable with issuer funds $85,543,678 $5,617,354 $2,026,652 $1,261,545 $396,376 $1,182,783 $671,193 $332,185 $531,337 $117,987 $75,774 $298,220 $438,491 $1,177,226

Net Amt of Rein -$839,501.49 -$54,426.10 -$17,748.12 -$13,608.36 -$3,655.32 -$14,144.18 -$6,301.39 -$2,649.74 -$6,018.80 -$1,207.43 -$946.86 -$3,706.70 -$3,783.77 -$11,222.86

Net Amt of Risk Adj -$7,453,684.77 $196,249.09 -$171,241.39 -$133,580.87 -$126,406.90 -$225,173.85 -$109,617.93 $60,800.75 -$180,731.12 -$45,614.43 -$30,319.87 -$142,537.83 -$208,483.61 -$139,105.61

OK 341.53$ Incurred Claims PMPM $373.97 $378.78 $419.08 $340.22 $397.97 $306.90 $390.91 $460.09 $323.99 $358.62 $293.70 $295.27 $425.31 $384.97

OK 404.12$ Allowed Claims PMPM $404.12 $425.21 $425.26 $351.19 $317.10 $296.75 $395.91 $620.46 $269.47 $308.83 $253.80 $230.18 $317.10 $394.13

EHB portion of Allowed Claims, PMPM $404.12 $425.21 $425.26 $351.19 $317.10 $296.75 $395.91 $620.46 $269.47 $308.83 $253.80 $230.18 $317.10 $394.13

Section IV: Projected (12 months following effective date)

Cla

ims

Info

rmat

ion

01/01/2017

Pre

miu

m In

form

atio

nShared Cost PPO

33709PA044

0.00%

8.92%

9.26%

2.65%

Warning Alert Wsht 1 Total Plan ID (Standard Component ID): Total 33709PA0440001 33709PA0440002 33709PA0440004 33709PA0440005 33709PA0440006 33709PA0440007 33709PA0440008 33709PA0440009 33709PA0440010 33709PA0440011 33709PA0440012 33709PA0440013 33709PA0440014

OK 477.75$ Plan Adjusted Index Rate $499.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.69 $0.00 $0.00 $0.00 $417.70 $504.84

OK 166,968 Member Months 166,968 - - - - - - - 2,136 - - - 2,292 3,252

OK $79,768,978 Total Premium (TP) $83,384,556 $0 $0 $0 $0 $0 $0 $0 $1,033,171 $0 $0 $0 $957,357 $1,641,753

EHB Percent of TP, [see instructions] 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

state mandated benefits portion of TP that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TP 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

OK 84,061,046 Total Allowed Claims (TAC) $84,100,238 $0 $0 $0 $0 $0 $0 $0 $1,114,901 $0 $0 $0 $1,140,941 $1,697,405

EHB Percent of TAC, [see instructions] 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

state mandated benefits portion of TAC that are

other than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TAC 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Allowed Claims which are not the issuer's obligation $12,636,276 $0 $0 $0 $0 $0 $0 $0 $229,326 $0 $0 $0 $319,858 $290,412

Portion of above payable by HHS's funds on

behalf of insured person, in dollars $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Portion of above payable by HHS on behalf of

insured person, as % 0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.00% #DIV/0! #DIV/0! #DIV/0! 0.00% 0.00%

OK 71,734,478 Total Incurred claims, payable with issuer funds $71,463,962 $0 $0 $0 $0 $0 $0 $0 $885,575 $0 $0 $0 $821,083 $1,406,993

#DIV/0! - Net Amt of Rein $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Net Amt of Risk Adj -$283,877 $0 $0 $0 $0 $0 $0 $0 -$3,632 $0 $0 $0 -$3,897 -$5,529

OK 429.63$ Incurred Claims PMPM $428.01 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $414.60 #DIV/0! #DIV/0! #DIV/0! $358.24 $432.65

OK 503.46$ Allowed Claims PMPM $503.69 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $521.96 #DIV/0! #DIV/0! #DIV/0! $497.79 $521.96

EHB portion of Allowed Claims, PMPM $503.69 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $521.96 #DIV/0! #DIV/0! #DIV/0! $497.79 $521.96

Pre

miu

m In

form

atio

nC

laim

s In

form

atio

n

Health Savings

33709PA047

Bronze Bronze Bronze Gold Platinum Gold Silver Gold Gold Silver Gold Gold Bronze Gold Gold Silver Silver Gold Gold

0.619 0.606 0.608 0.783 0.911 0.815 0.695 0.796 0.794 0.719 0.797 0.799 0.615 0.799 0.799 0.704 0.704 0.820 0.820

0.010 0.010 0.010 0.831 0.010 0.010 0.010 0.935 0.884 0.010 0.893 0.951 0.010 0.010 0.010 0.010 0.010 0.010 0.010

Terminated Terminated Terminated Renewing Terminated Terminated Terminated Renewing Renewing Terminated Renewing Renewing Terminated Terminated Terminated Terminated Terminated Terminated Terminated

PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO EPO EPO EPO EPO EPO EPOHealth Savings

PPO Q 3500 A

Community Blue

Plan

Health Savings

PPO Q 4000 A

Community Blue

Plan

High Deductible

PPO 4000 IP

Qualified A a

Community Blue

Health Savings

PPO 1500 a

Community Blue

Flex Plan

Flex PPO 0 500 A

Community Blue

Plan

Flex PPO 500

1500 A

Community Blue

Plan

Flex PPO 1500 A

Community Blue

Plan

Flex PPO 500 1500

Penn Highlands

Region a

Community Blue

Flex PPO PA

Mountains

Healthcare Region

500 1500 a

Flex PPO 2000

4000 a

Community Blue

Plan

Flex PPO 500 Total

Health a

Community Blue

Plan

Flex PPO 500 Total

Health a

Community Blue

Plan

Health Savings Q

4000 A

Community Blue

Plan

Comprehensive

Care EPO 1500 A

Community Blue

Plan

Comprehensive

Care EPO 1500 A

Community Blue

Plan

Comprehensive

Care EPO 2000 A

Community Blue

Plan

Comprehensive

Care EPO 2000 A

Community Blue

Plan

FLEX EPO 500

1000 A

Community Blue

Plan

FLEX EPO 500

1000 A

Community Blue

Plan

33709PA0450001 33709PA0450002 33709PA0450003 33709PA0450004 33709PA0460001 33709PA0460003 33709PA0460005 33709PA0460007 33709PA0460008 33709PA0460011 33709PA0460012 33709PA0460013 33709PA0470001 33709PA0480001 33709PA0480002 33709PA0480003 33709PA0480004 33709PA0490001 33709PA0490002

No No No No No No No Yes Yes No No No No No No No No No No

0.00%

21.60%

0.00%

01/01/2016 01/01/2016 01/01/2016 01/01/2017 01/01/2016 01/01/2016 01/01/2016 01/01/2017 01/01/2017 01/01/2016 01/01/2017 01/01/2017 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016

0.00% 0.00% 0.00% 1.45% 0.00% 0.00% 0.00% -0.95% 0.73% 0.00% 0.54% -1.60% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 4.76% 0.00% 0.00% 0.00% 2.28% 4.01% 0.00% 3.82% 1.60% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

-100.00% -100.00% -100.00% #DIV/0! -100.00% -100.00% -100.00% 15.19% 10.84% -100.00% 13.15% 9.76% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00%

0.00%


$0.00 $0.00 $0.00 -$5.10 $0.00 $0.00 $0.00 -$7.34 -$5.82 $0.00 -$5.99 -$7.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $4.79 $0.00 $0.00 $0.00 $2.86 $4.48 $0.00 $4.35 $2.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $1.67 $0.00 $0.00 $0.00 -$0.77 $1.13 $0.00 $0.96 -$1.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.40 $1.65 $0.00 $1.54 -$0.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 -$0.92 $0.00 $0.00 $0.00 -$1.31 -$1.05 $0.00 -$1.08 -$1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $7.26 $7.52 $0.00 $7.53 $7.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 -$3.46 $0.00 $0.00 $0.00 -$5.81 -$4.56 $0.00 -$4.76 -$6.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $6.27 $0.00 $0.00 $0.00 -$4.72 $3.36 $0.00 $2.54 -$8.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $11.81 $0.00 $0.00 $0.00 $12.38 $11.25 $0.00 $17.00 $16.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $431.65 $0.00 $0.00 $0.00 $497.76 $462.55 $0.00 $468.26 $509.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

0 0 0 408 0 0 0 288 60 0 648 1,272 0 0 0 0 0 0 0


$213.42 $206.88 $275.88 $0.00 $489.03 $420.15 $286.88 $425.25 $417.60 $351.76 $413.41 $453.85 $291.18 $374.17 $410.80 $315.16 $346.01 $426.56 $441.71

297 358 247 0 3,421 10,498 2,744 336 242 4,804 469 2,308 436 149 0 438 0 196 34,080

$63,386 $74,064 $68,141 $0 $1,672,976 $4,410,687 $787,203 $142,884 $101,060 $1,689,847 $193,888 $1,047,479 $126,954 $55,751 $0 $138,041 $0 $83,606 $15,053,388

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$55,347 $198,526 $92,993 $0 $1,596,646 $5,299,862 $1,413,701 $152,710 $272,648 $1,549,278 $157,418 $1,177,118 $141,739 $48,189 $0 $257,258 $0 $43,265 $13,917,752

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

-$12,917 $72,193 $15,130 $0 $18,764 $681,346 $234,784 -$123 $209,156 -$364,411 $34,206 $145,871 $4,626 $46,062 $0 $88,855 $0 -$19,265 -$131,565

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% #DIV/0! 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% #DIV/0! 0.00% #DIV/0! 0.00% 0.00%$68,264 $126,334 $77,863 $0 $1,577,882 $4,618,516 $1,178,916 $152,833 $63,492 $1,913,688 $123,212 $1,031,246 $137,114 $2,128 $0 $168,403 $0 $62,530 $14,049,317

-$1,089.99 -$1,313.86 -$906.49 $0.00 -$12,555.07 -$38,527.66 -$10,070.48 -$1,233.12 -$888.14 -$17,630.68 -$1,721.23 -$8,470.36 -$1,600.12 -$546.83 $0.00 -$1,607.46 $0.00 -$719.32 -$125,073.60

-$37,473.26 $22,181.48 -$37,538.70 $0.00 -$108,309.77 $100,679.94 $12,162.88 -$24,809.29 $188,877.50 -$683,664.36 -$1,023.58 $8,759.29 -$57,853.41 $36,168.13 $0.00 $54,459.89 $0.00 -$30,095.73 -$2,100,867.31

$229.85 $352.89 $315.23 #DIV/0! $461.23 $439.94 $429.63 $454.86 $262.37 $398.35 $262.71 $446.81 $314.48 $14.28 #DIV/0! $384.48 #DIV/0! $319.03 $412.25

$186.35 $554.54 $376.49 #DIV/0! $466.72 $504.84 $515.20 $454.50 $1,126.65 $322.50 $335.65 $510.02 $325.09 $323.42 #DIV/0! $587.35 #DIV/0! $220.74 $408.38

$186.35 $554.54 $376.49 #DIV/0! $466.72 $504.84 $515.20 $454.50 $1,126.65 $322.50 $335.65 $510.02 $325.09 $323.42 #DIV/0! $587.35 #DIV/0! $220.74 $408.38

4.76%

Flex PPO

33709PA046

0.00%

0.00%

10.51%

2.34%

Health Savings PPO Q

33709PA045

0.00%

21.90%

0.00%

0.00%

Flex EPO

33709PA049

0.00%

21.60%

0.00%

0.00%

Comprehensive Care EPO

33709PA048

0.00%

18.78%

10.03%


$0.00 $0.00 $0.00 $435.07 $0.00 $0.00 $0.00 $489.84 $462.88 $0.00 $467.75 $498.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

- - - 408 - - - 288 60 - 648 1,272 - - - - - - -

$0 $0 $0 $177,509 $0 $0 $0 $141,073 $27,773 $0 $303,102 $633,617 $0 $0 $0 $0 $0 $0 $0

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$0 $0 $0 $199,047 $0 $0 $0 $148,571 $29,508 $0 $316,133 $658,925 $0 $0 $0 $0 $0 $0 $0

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$0 $0 $0 $46,832 $0 $0 $0 $27,657 $5,698 $0 $56,297 $115,884 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

#DIV/0! #DIV/0! #DIV/0! 0.00% #DIV/0! #DIV/0! #DIV/0! 0.00% 0.00% #DIV/0! 0.00% 0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$0 $0 $0 $152,215 $0 $0 $0 $120,914 $23,810 $0 $259,836 $543,041 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 -$694 $0 $0 $0 -$490 -$102 $0 -$1,102 -$2,163 $0 $0 $0 $0 $0 $0 $0

#DIV/0! #DIV/0! #DIV/0! $373.08 #DIV/0! #DIV/0! #DIV/0! $419.84 $396.83 #DIV/0! $400.98 $426.92 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!



Silver Silver Gold Gold Gold Gold Gold Gold Platinum Platinum Gold Gold Gold Gold Gold Gold Gold Gold Silver

0.691 0.691 0.820 0.819 0.800 0.792 0.785 0.780 0.903 0.895 0.813 0.807 0.799 0.793 0.783 0.783 0.782 0.781 0.717

0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 1.056 1.038 0.894 0.907 0.887 0.876 0.862 0.855 0.849 0.839 0.753

Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing

EPO EPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

FLEX EPO 1650 A

Community Blue

Plan

FLEX EPO 1650 A

Community Blue

Plan

Premier Balance

PPO 0 Gold A

Community Blue

Plan

Premier Balance

PPO 500 A

Community Blue

Plan

Premier Balance

PPO 1000 A

Community Blue

Plan

Premier Balance

PPO 1250 A

Community Blue

Plan

Premier Balance

PPO 1500 A

Community Blue

Plan

Premier Balance

PPO 2000 A

Community Blue

Plan

Premier Balance

PPO 0 Platinum A

a Community Blue

Flex Plan

Premier Balance

PPO 250 Platinum

A a Community

Blue Flex Plan

Premier Balance

PPO 0 Gold A a

Community Blue

Flex Plan

Premier Balance

PPO 250 Gold A a

Community Blue

Flex Plan

Premier Balance

PPO 500 A a

Community Blue

Flex Plan

Premier Balance

PPO 750 A a

Community Blue

Flex Plan

Premier Balance

PPO 1000 A a

Community Blue

Flex Plan

Premier Balance

PPO 1250 A a

Community Blue

Flex Plan

Premier Balance

PPO 1500 A a

Community Blue

Flex Plan

Premier Balance

PPO 2000 A a

Community Blue

Flex Plan

Premier Balance

PPO 1400 A a

Community Blue

Flex Plan


No No No No No No No No No No No No No No No No No No No

01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 1.40% 1.26% 1.37% 0.50% -0.26% -0.10% -0.25% 0.21% 0.21% 0.15% 0.03%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 4.70% 4.56% 4.68% 3.77% 2.99% 3.16% 3.00% 3.47% 3.48% 3.42% 3.29%

-100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% 15.86% 17.20% 13.60% 13.88% 13.64% 14.06% 13.86% 14.63% 15.20% 15.99% 13.24%


$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$5.96 -$6.01 -$5.39 -$6.08 -$6.55 -$6.38 -$6.42 -$6.06 -$6.03 -$6.03 -$5.70

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.94 $6.58 $5.32 $4.42 $3.35 $3.45 $3.17 $3.64 $3.59 $3.45 $2.62

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.01 $2.71 $1.97 $0.97 -$0.06 $0.09 -$0.15 $0.37 $0.35 $0.23 -$0.28

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.11 $2.88 $2.23 $1.56 $0.84 $0.93 $0.75 $1.10 $1.08 $0.99 $0.55

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$1.08 -$1.09 -$0.97 -$1.09 -$1.17 -$1.14 -$1.15 -$1.08 -$1.08 -$1.08 -$1.02

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.30 $9.08 $7.86 $7.63 $7.16 $7.13 $6.96 $7.08 $7.03 $6.93 $6.17

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$7.62 -$7.32 -$4.64 -$5.02 -$4.78 -$4.54 -$4.30 -$4.10 -$3.98 -$3.82 -$2.22

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.70 $6.82 $6.38 $2.38 -$1.22 -$0.46 -$1.14 $0.93 $0.96 $0.67 $0.12

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.57 $8.70 $10.16 $13.08 $16.48 $16.14 $17.02 $15.53 $15.65 $16.10 $16.93

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $548.80 $540.43 $464.83 $475.50 $468.75 $462.01 $455.27 $449.64 $446.27 $441.78 $396.68

0 0 0 0 0 0 0 0 50,556 40,224 8,760 2,232 13,944 1,968 9,648 2,196 4,704 2,724 7,056


$347.78 $360.13 $328.01 $328.40 $317.59 $313.37 $309.12 $303.34 $477.19 $463.89 $412.12 $416.92 $408.75 $402.03 $396.27 $390.50 $385.70 $378.97 $348.14

229 17,106 6,186 8,619 7,472 2,670 4,390 3,030 13,734 4,845 6,681 3,018 13,388 2,045 9,029 1,537 4,500 2,136 4,897

$79,642 $6,160,422 $2,029,057 $2,830,455 $2,373,057 $836,686 $1,357,057 $919,121 $6,553,673 $2,247,539 $2,753,346 $1,258,262 $5,472,393 $822,149 $3,577,879 $600,201 $1,735,642 $809,488 $1,704,862

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$51,619 $5,911,432 $2,679,075 $4,124,121 $2,633,401 $1,620,267 $1,580,601 $949,569 $7,707,526 $1,857,205 $2,581,325 $1,442,991 $5,242,574 $641,236 $3,055,777 $943,957 $2,055,439 $821,252 $1,936,738

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

-$10,693 -$11,841 $658,905 $431,372 $527,796 $593,175 $165,171 $198,798 $1,465,321 $10,718 -$161,261 $567,144 $382,884 -$144,111 $80,676 $156,338 $238,968 $112,359 $196,771

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%$62,312 $5,923,273 $2,020,170 $3,692,750 $2,105,604 $1,027,092 $1,415,429 $750,771 $6,242,205 $1,846,487 $2,742,586 $875,848 $4,859,691 $785,347 $2,975,101 $787,619 $1,816,471 $708,893 $1,739,967

-$840.43 -$62,779.02 -$22,702.62 -$31,631.73 -$27,422.24 -$9,798.90 -$16,111.30 -$11,120.10 -$50,403.78 -$17,781.15 -$24,519.27 -$11,076.06 -$49,133.96 -$7,505.15 -$33,136.43 -$5,640.79 -$16,515.00 -$7,839.12 -$17,971.99

-$33,043.20 -$1,542,368.96 $369,208.74 -$47,356.61 $91,716.65 $221,136.35 -$149,265.01 $19,821.70 $709,363.35 -$193,325.33 -$465,988.06 $410,503.79 -$431,988.67 -$277,672.15 -$438,595.52 -$9,030.82 -$157,033.07 -$44,122.64 -$200,662.86

$272.10 $346.27 $326.57 $428.44 $281.80 $384.68 $322.42 $247.78 $454.51 $381.11 $410.51 $290.21 $362.99 $384.03 $329.51 $512.44 $403.66 $331.88 $355.31

$225.41 $345.58 $433.09 $478.49 $352.44 $606.84 $360.05 $313.39 $561.20 $383.32 $386.37 $478.13 $391.59 $313.56 $338.44 $614.16 $456.76 $384.48 $395.49

$225.41 $345.58 $433.09 $478.49 $352.44 $606.84 $360.05 $313.39 $561.20 $383.32 $386.37 $478.13 $391.59 $313.56 $338.44 $614.16 $456.76 $384.48 $395.49

Flex EPO

33709PA049

0.00%

21.60%

0.00%

0.00% 4.24%

Premier Balance PPO

33709PA056

0.00%

0.00%

9.77%


$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.88 $543.70 $468.15 $474.78 $464.49 $458.55 $451.18 $447.64 $444.33 $439.58 $394.22

- - - - - - - - 50,556 40,224 8,760 2,232 13,944 1,968 9,648 2,196 4,704 2,724 7,056

$0 $0 $0 $0 $0 $0 $0 $0 $27,951,476 $21,869,594 $4,100,999 $1,059,705 $6,476,905 $902,431 $4,353,004 $983,017 $2,090,110 $1,197,427 $2,781,635

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$0 $0 $0 $0 $0 $0 $0 $0 $26,262,842 $20,895,572 $4,273,651 $1,088,903 $6,802,715 $960,108 $4,706,870 $1,071,340 $2,294,892 $1,328,930 $3,282,970

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$0 $0 $0 $0 $0 $0 $0 $0 $2,315,789 $2,158,040 $758,066 $180,520 $1,250,213 $186,435 $974,706 $228,497 $502,768 $302,174 $896,662

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$0 $0 $0 $0 $0 $0 $0 $0 $23,947,053 $18,737,532 $3,515,584 $908,383 $5,552,502 $773,673 $3,732,165 $842,843 $1,792,124 $1,026,756 $2,386,308

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 -$85,955 -$68,388 -$14,894 -$3,795 -$23,707 -$3,346 -$16,403 -$3,734 -$7,998 -$4,631 -$11,997

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $473.67 $465.83 $401.32 $406.98 $398.20 $393.13 $386.83 $383.81 $380.98 $376.93 $338.20



Silver Silver Silver Silver Silver Silver Bronze Bronze Bronze Silver Silver Bronze Bronze Bronze Bronze Gold Gold Gold Gold

0.718 0.716 0.710 0.719 0.683 0.680 0.620 0.619 0.582 0.699 0.683 0.616 0.614 0.599 0.610 0.803 0.818 0.818 0.812

0.010 0.734 0.727 0.746 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.010 0.832 0.828 0.817

Terminated Renewing Renewing Renewing Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Terminated Renewing Renewing Renewing

PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO EPO EPO EPO EPO

Balance PPO 1750

A Community Blue

Plan

Balance PPO 1750

A a Community

Blue Flex Plan

Balance PPO 2000

A a Community

Blue Flex Plan

Balance PPO 1000

A a Community

Blue Flex Plan

High Deductible

PPO 1500

Qualified A

Community Blue

High Deductible

PPO 1750

Qualified A

Community Blue

High Deductible

PPO 2500

Qualified A

Community Blue

High Deductible

PPO 3000

Qualified A

Community Blue

High Deductible

PPO 6300

Qualified A

Community Blue

High Deductible

PPO 1500

Qualified A a

Community Blue

High Deductible

PPO 1750

Qualified A a

Community Blue

High Deductible

PPO 2600

Qualified A a

Community Blue

High Deductible

PPO 3000

Qualified A a

Community Blue

High Deductible

PPO 3500

Qualified A a

Community Blue

High Deductible

PPO 4000

Qualified A a

Community Blue

Connect Blue EPO

0 a Community

Blue Plan

Connect Blue EPO

100 a Community

Blue Plan

Connect Blue EPO

250 a Community

Blue Plan

Connect Blue EPO

500 a Community

Blue Plan


No No No No No No No No No No No No No No No No No No No

01/01/2016 01/01/2017 01/01/2017 01/01/2017 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2016 01/01/2017 01/01/2017 01/01/2017

0.00% 0.44% 0.42% 0.81% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 2.82% 0.88% 2.22%

0.00% 3.71% 3.69% 4.10% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 6.16% 4.16% 5.55%

-100.00% 15.48% 16.09% #DIV/0! -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% -100.00% #DIV/0! #DIV/0! #DIV/0! 17.29%


$0.00 -$5.36 -$5.34 -$5.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$4.20 -$5.48 -$4.55

$0.00 $2.87 $2.78 $3.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.24 $4.15 $5.45

$0.00 $0.05 -$0.01 $0.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.18 $1.01 $2.42

$0.00 $0.76 $0.71 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $1.51 $2.46

$0.00 -$0.96 -$0.95 -$0.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$0.77 -$0.99 -$0.83

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $6.16 $6.09 $6.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.83 $7.11 $7.48

$0.00 -$1.82 -$1.69 -$1.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$3.28 -$3.51 -$3.09

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $1.69 $1.59 $3.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.01 $3.80 $9.34

$0.00 $16.13 $16.38 $14.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 -$0.10 $6.60 $2.41

$0.00 $385.40 $381.66 $390.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $426.45 $432.88 $421.12

0 2,028 2,808 276 0 0 0 0 0 0 0 0 0 0 0 0 216 108 504


$266.50 $333.03 $327.99 $0.00 $268.34 $261.72 $235.19 $230.20 $188.43 $334.86 $326.61 $290.86 $286.86 $274.85 $255.73 $0.00 $0.00 $0.00 $364.62

947 1,961 2,473 0 1,695 453 1,306 362 467 2,109 573 591 239 277 716 0 0 0 47

$252,375 $653,067 $811,115 $0 $454,834 $118,560 $307,156 $83,331 $87,997 $706,219 $187,150 $171,899 $68,559 $76,134 $183,100 $0 $0 $0 $17,137

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$380,686 $520,134 $638,982 $0 $443,515 $64,904 $289,331 $67,963 $71,007 $489,301 $245,550 $109,483 $49,294 $115,253 $88,724 $0 $0 $0 $30,237

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$97,987 -$92,442 -$59,859 $0 $53,115 -$78,284 $24,387 -$18,934 $6,724 $65,269 -$55,000 -$10,422 -$27,964 $32,782 -$25,078 $0 $0 $0 $5,061

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% #DIV/0! 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% #DIV/0! #DIV/0! #DIV/0! 0.00%$282,699 $612,576 $698,842 $0 $390,400 $143,189 $264,944 $86,898 $64,283 $424,032 $300,551 $119,905 $77,258 $82,471 $113,802 $0 $0 $0 $25,176

-$3,475.49 -$7,196.87 -$9,075.91 $0.00 -$6,220.65 -$1,662.51 -$4,793.02 -$1,328.54 -$1,713.89 -$7,740.03 -$2,102.91 -$2,168.97 -$877.13 -$1,016.59 -$2,627.72 $0.00 $0.00 $0.00 -$172.49

$322.68 -$240,570.72 -$245,165.77 $0.00 -$84,160.99 -$102,564.09 -$107,236.63 -$57,730.37 -$39,270.86 -$154,995.42 -$119,048.69 -$66,686.04 -$51,410.12 -$10,868.61 -$91,478.85 $0.00 $0.00 $0.00 -$7.05

$298.52 $312.38 $282.59 #DIV/0! $230.32 $316.09 $202.87 $240.05 $137.65 $201.06 $524.52 $202.88 $323.26 $297.73 $158.94 #DIV/0! #DIV/0! #DIV/0! $535.66

$401.99 $265.24 $258.38 #DIV/0! $261.66 $143.28 $221.54 $187.74 $152.05 $232.01 $428.53 $185.25 $206.25 $416.08 $123.92 #DIV/0! #DIV/0! #DIV/0! $643.34

$401.99 $265.24 $258.38 #DIV/0! $261.66 $143.28 $221.54 $187.74 $152.05 $232.01 $428.53 $185.25 $206.25 $416.08 $123.92 #DIV/0! #DIV/0! #DIV/0! $643.34

Balance PPO

33709PA057

0.00%

0.00%

10.45%

3.72% 0.00%

Connect Blue EPO

33709PA063

0.00%

0.00%

0.00%

5.21%

High Deductible PPO

33709PA058

0.00%

0.00%

0.00%


$0.00 $384.58 $380.76 $390.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $435.61 $433.84 $427.67

- 2,028 2,808 276 - - - - - - - - - - - - 216 108 504

$0 $779,925 $1,069,186 $107,873 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $94,092 $46,855 $215,543

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$0 $943,575 $1,306,488 $128,416 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $99,032 $49,516 $231,076

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$0 $274,415 $389,105 $35,870 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $18,348 $9,338 $46,232

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

#DIV/0! 0.00% 0.00% 0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 0.00% 0.00% 0.00%

$0 $669,159 $917,383 $92,546 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $80,684 $40,179 $184,843

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 -$3,448 -$4,774 -$469 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 -$367 -$184 -$857

#DIV/0! $329.96 $326.70 $335.31 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $373.54 $372.02 $366.75



Gold Gold Silver Gold Silver Silver Silver Bronze Bronze Bronze

0.810 0.791 0.720 0.786 0.707 0.702 0.689 0.619 0.619 0.619

0.812 0.794 0.683 0.787 0.670 0.735 0.717 0.596 0.637 0.597

Renewing Renewing Renewing New New Renewing Renewing Renewing Renewing Renewing

EPO EPO EPO EPO EPO PPO PPO PPO PPO PPO

Connect Blue EPO

750 a Community

Blue Plan

Connect Blue EPO

900 a Community

Blue Plan

Connect Blue EPO

2500 a

Community Blue

Plan

Connect Blue EPO

1100 a

Community Blue

Plan

Connect Blue EPO

3200 a

Community Blue

Plan

Health Savings

PPO Embedded

2600 a

Community Blue

Health Savings

PPO Embedded

3000 a

Community Blue

Health Savings

PPO Embedded

5500 a

Community Blue

Health Savings

PPO Embedded

5500 a

Community Blue

Health Savings

PPO Embedded

6000 a

Community Blue

33709PA0630005 33709PA0630006 33709PA0630007 33709PA0630008 33709PA0630009 33709PA0640001 33709PA0640002 33709PA0640003 33709PA0640004 33709PA0640005

No No No No No No No No No No

01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017 01/01/2017

2.81% 1.01% -0.10% 0.00% 0.00% -6.00% -6.31% -3.65% -5.02% -1.93%

6.16% 4.30% 3.15% 0.00% 0.00% -2.94% -3.26% -0.51% -1.93% 1.27%

17.98% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


-$4.16 -$5.26 -$5.44 $0.00 $0.00 -$9.53 -$9.55 -$6.83 -$7.96 -$5.94

$6.01 $3.97 $1.94 $0.00 $0.00 -$3.78 -$4.11 -$1.66 -$2.81 -$0.21

$3.02 $0.96 -$0.71 $0.00 $0.00 -$6.90 -$7.17 -$4.12 -$5.49 -$2.61

$2.87 $1.44 $0.19 $0.00 $0.00 -$4.00 -$4.20 -$2.24 -$3.13 -$1.20

-$0.76 -$0.94 -$0.97 $0.00 $0.00 -$1.66 -$1.66 -$1.20 -$1.39 -$1.05

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$7.64 $6.85 $5.56 $0.00 $0.00 $3.92 $3.71 $3.87 $3.71 $4.37

-$2.92 -$2.84 -$0.93 $0.00 $0.00 -$2.78 -$2.46 $0.29 -$0.70 $0.46

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$11.71 $4.18 -$0.37 $0.00 $0.00 -$24.74 -$25.44 -$11.89 -$17.76 -$6.19

$0.61 $7.14 $12.14 $0.00 $0.00 $48.74 $38.47 $47.20 $60.61 $24.81

$416.31 $414.18 $360.34 $412.21 $403.10 $325.79 $353.59 $321.09

120 156 132 156 156 3,228 132 2,004 480 96


$360.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

7 0 0 0 0 0 0 0 0 0

$2,523 $0 $0 $0 $0 $0 $0 $0 $0 $0

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$501 $0 $0 $0 $0 $0 $0 $0 $0 $0

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$325 $0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$177 $0 $0 $0 $0 $0 $0 $0 $0 $0

-$25.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

-$1.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$25.23 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!



Connect Blue EPO

33709PA063

0.00%

0.00%

0.00%

5.21% -2.11%


33709PA064

0.00%

0.00%

16.02%


$425.25 $415.64 $357.63 $412.31 $350.72 $384.96 $375.21 $311.85 $333.65 $312.86

120 156 132 156 156 3,228 132 2,004 480 96

$51,030 $64,840 $47,207 $64,320 $54,712 $1,242,650 $49,527 $624,953 $160,152 $30,034

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$55,018 $71,523 $57,718 $71,523 $68,212 $1,501,903 $61,416 $905,251 $231,981 $43,365

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$11,255 $15,912 $17,200 $16,356 $21,249 $435,740 $18,918 $368,459 $94,475 $17,568

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

$43,763 $55,611 $40,517 $55,168 $46,963 $1,066,163 $42,498 $536,792 $137,507 $25,797

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

-$204 -$265 -$224 -$265 -$265 -$5,488 -$224 -$3,407 -$816 -$163

$364.69 $356.48 $306.95 $353.64 $301.05 $330.29 $321.96 $267.86 $286.47 $268.72

$458.48 $458.48 $437.26 $458.48 $437.26 $465.27 $465.27 $451.72 $483.29 $451.72

$458.48 $458.48 $437.26 $458.48 $437.26 $465.27 $465.27 $451.72 $483.29 $451.72

PA Rate Template Part I

Data Relevant to the Rate Filing

Table 1. Number of Members

Member-months Members Member-months

Experience PeriodCurrent Period

(as of Feb. 1, 2016)

Projected Rating

Period

Total 155,033 15,580 166,968

<18 25,505 2,628 28,164

18-24 15,751 1,595 17,094

25-29 12,196 1,266 13,567

30-34 11,697 1,228 13160

35-39 11,298 1,150 12324

40-44 12,233 1,216 13032

45-49 13,834 1,416 15175

50-54 17,064 1,734 18583

55-59 17,358 1,688 18090

60-63 11,066 1,065 11413

64+ 7,031 594 6366

Table 2. Experience Period Claims and Premiums

Earned Premium Paid ClaimsUltimate Incurred

ClaimsMember Months

Estimated Cost

Sharing

(Member & HHS)

Allowed Claims

(Non-Capitated)

Non-EHB

portion of

Allowed Claims

Total Prescription

Drug Rebates*

Total EHB

CapitationTotal Non-EHB Capitation

Estimated Risk

Adjustment

Estimated

Reinsurance

Recoveries

$ 87,070,733.72 $ 78,230,888.42 $ 80,052,642.21 228,747 $ 14,316,776.00 $ 94,369,418.21 $ - $ (1,928,337.21) $ - $ - (7,419,372.72)$ -$

2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 404.12$

Loss Ratio 98.08%

*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Composite Weight*

5.83% 3.00% 9.00% 16.50% <- Annualized Trend Factors on URRT

5.83% 3.00% 9.00% 29.69%

5.83% 3.00% 9.00% 30.16%

5.83% 3.00% 9.00% 2.76%

0.00% 0.00%

5.83% 3.00% 9.00% 20.88%

9.00% 100.00%

1.188

* Express Cost, Utilization, and Weight as percentages

Table 4. Historical Experience

Month-Year Total Annual Premium Incurred Claims Completion Factors*Ultimate Incurred

ClaimsMembers

Ultimate

Incurred PMPM

Estimated Annual

Cost Sharing

(Member + HHS)

Prescription

Drug Rebates**

Allowed Claims (Net of

Prescription Drug Rebates)Allowed PMPM

Jan-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!

Feb-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Mar-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Apr-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!

May-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Jun-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Jul-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!

Aug-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Sep-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Oct-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Nov-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!

Dec-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!

Jan-14 $ 560,050.89 0.9993 $ 560,443.63 1,392 $ 402.62 $ (10,509.60) $ 637,758.46 $ 458.16Feb-14 $ 615,894.92 0.9991 $ 616,430.00 1,616 $ 381.45 $ (12,200.80) $ 737,104.23 $ 456.13Mar-14 $ 813,436.50 0.9990 $ 814,265.83 2,492 $ 326.75 $ (18,814.60) $ 956,834.15 $ 383.96Apr-14 $ 1,377,568.82 0.9989 $ 1,379,126.64 4,349 $ 317.11 $ (32,834.95) $ 1,651,991.98 $ 379.86

May-14 $ 1,263,402.64 0.9983 $ 1,265,538.85 4,995 $ 253.36 $ (37,712.25) $ 1,539,541.56 $ 308.22Jun-14 $ 1,516,293.10 0.9981 $ 1,519,198.62 5,601 $ 271.24 $ (42,287.55) $ 1,810,506.49 $ 323.25Jul-14 $ 2,364,658.63 0.9980 $ 2,369,397.51 6,849 $ 345.95 $ (51,709.95) $ 2,786,734.73 $ 406.88

Aug-14 $ 2,437,448.35 0.9977 $ 2,443,173.00 7,156 $ 341.42 $ (54,027.80) $ 2,863,862.48 $ 400.20Sep-14 $ 2,131,216.88 0.9972 $ 2,137,230.29 7,576 $ 282.11 $ (57,198.80) $ 2,557,207.44 $ 337.54Oct-14 $ 3,055,051.51 0.9975 $ 3,062,739.61 8,182 $ 374.33 $ (61,774.10) $ 3,548,067.30 $ 433.64Nov-14 $ 2,647,880.64 0.9968 $ 2,656,324.31 8,632 $ 307.73 $ (65,171.60) $ 3,081,509.12 $ 356.99

Dec-14 $ 4,977,321.84 0.9966 $ 4,994,340.62 16,314 $ 306.14 $ (123,170.70) $ 6,092,881.13 $ 373.48

Jan-15 $ 5,334,615.25 0.9966 $ 5,352,987.01 17,615 $ 303.89 $ (148,494.45) $ 6,593,109.88 $ 374.29Feb-15 $ 5,037,457.26 0.9958 $ 5,058,590.36 17,663 $ 286.39 $ (148,899.09) $ 6,114,857.30 $ 346.20Mar-15 $ 6,492,490.47 0.9956 $ 6,521,119.76 17,794 $ 366.48 $ (150,003.42) $ 7,773,514.16 $ 436.86Apr-15 $ 6,140,456.36 0.9930 $ 6,183,958.17 18,367 $ 336.69 $ (154,833.81) $ 7,409,899.71 $ 403.44

May-15 $ 5,480,855.98 0.9919 $ 5,525,631.65 18,549 $ 297.89 $ (156,368.07) $ 6,598,157.19 $ 355.71Jun-15 $ 5,837,139.77 0.9903 $ 5,894,457.93 18,761 $ 314.19 $ (158,155.23) $ 7,091,576.09 $ 378.00Jul-15 $ 6,544,398.37 0.9889 $ 6,617,826.88 19,699 $ 335.95 $ (166,062.57) $ 7,947,793.12 $ 403.46

Aug-15 $ 6,398,836.14 0.9854 $ 6,493,503.40 19,714 $ 329.39 $ (166,189.02) $ 7,620,071.03 $ 386.53Sep-15 $ 7,125,147.50 0.9811 $ 7,262,113.38 19,737 $ 367.94 $ (166,382.91) $ 8,375,698.14 $ 424.37Oct-15 $ 7,503,532.78 0.9539 $ 7,865,991.31 20,151 $ 390.35 $ (169,872.93) $ 9,073,767.34 $ 450.29Nov-15 $ 7,540,986.93 0.9493 $ 7,943,889.20 20,316 $ 391.02 $ (171,263.88) $ 9,072,333.47 $ 446.56

Dec-15 $ 6,586,925.07 0.8896 $ 7,404,235.95 20,381 $ 363.29 $ (171,811.83) $ 8,770,303.57 $ 430.32

2 Year Trend Projection Factor

Service Category

Other Medical

Capitation

Prescription Drugs

Total Annual Trend

Inpatient Hospital

Outpatient Hospital

Professional

$ -

$ 4,445,790.15

$ 14,316,776.00

$ -

$ 26,544,827.70

$ 79,651,361.00

Table 2b. Experience Period Claims and Premiums Table 2c. Experience Period Claims and Premiums

Earned

PremiumPaid Claims

Ultimate

Incurred

Claims

Member

Months

Estimated Cost

Sharing

(Member & HHS)

Allowed Claims

(Non-

Capitated)

Non-EHB

portion of

Allowed

Claims

Total

Prescription

Drug

Rebates*

Total EHB

Capitation

Total Non-

EHB

Capitation

Estimated Risk

Adjustment

Estimated

Reinsurance

Recoveries

Earned

PremiumPaid Claims

Ultimate

Incurred Claims

Member

Months

Estimated Cost

Sharing

(Member &

HHS)

Allowed

Claims (Non-

Capitated)

Non-EHB

portion of

Allowed

Claims

Total

Prescription

Drug Rebates*

Total EHB

Capitation

Total Non-

EHB

Capitation

Estimated Risk

Adjustment

Estimated

Reinsurance

Recoveries

########## ########### ############ 1,036,544 $ 55,193,455.76 ############ $ - ########### $ - $ - -$ -$

2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 385.67$ 2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) #DIV/0!

Loss Ratio 85.88% Loss Ratio #DIV/0!

*Express Prescription Drug Rebates as a negative number *Express Prescription Drug Rebates as a negative number

Table 3b. Trend Components

Cost* Utilization* Composite Weight*

5.83% 2.62% 8.59% 16.50% <- Annualized Trend Factors on URRT

5.83% 2.62% 8.59% 29.69%

5.83% 2.62% 8.59% 30.16%

5.83% 2.62% 8.59% 2.76%

0.00%

5.83% 2.62% 8.59% 20.88%

8.59% 100.00%

1.179


Table 4b. Historical Experience

Month-YearTotal Annual

Premium

Incurred

Claims

Completion

Factors*

Ultimate Incurred

ClaimsMembers

Ultimate

Incurred

PMPM

Estimated

Annual Cost

Sharing

(Member +

HHS)

Prescription

Drug

Rebates**

Allowed

Claims (Net of

Prescription

Drug Rebates)

Allowed

PMPM

Jan-13 ############ 1.0000 $ 47,093,492.22 137,343 $ 342.89 ########### ########### $ 400.83

Feb-13 ############ 1.0000 $ 42,290,894.96 137,101 $ 308.47 ########### ########### $ 355.40

Mar-13 ############ 0.9999 $ 45,919,671.11 136,821 $ 335.62 ########### ########### $ 382.17

Apr-13 ############ 0.9999 $ 43,303,948.97 134,482 $ 322.01 ########### ########### $ 374.86

May-13 ############ 0.9999 $ 45,934,292.91 134,609 $ 341.24 ########### ########### $ 390.36

Jun-13 ############ 0.9998 $ 41,484,881.67 134,246 $ 309.02 ########### ########### $ 351.30

Jul-13 ############ 0.9998 $ 41,865,311.06 128,461 $ 325.90 ########### ########### $ 383.74

Aug-13 ############ 0.9996 $ 41,229,689.18 127,697 $ 322.87 ########### ########### $ 373.36

Sep-13 ############ 0.9995 $ 41,218,432.04 127,667 $ 322.86 ########### ########### $ 368.59

Oct-13 ############ 0.9996 $ 45,582,621.00 126,284 $ 360.95 ########### ########### $ 412.19

Nov-13 ############ 0.9994 $ 41,753,300.30 126,594 $ 329.82 ########### ########### $ 372.03

Dec-13 ############ 0.9994 $ 38,980,275.90 126,253 $ 308.75 ########### ########### $ 364.33

Jan-14 ############ 0.9993 $ 41,475,187.00 122,764 $ 337.84 ########### ########### $ 395.50

Feb-14 ############ 0.9991 $ 41,576,686.64 122,489 $ 339.43 ########### ########### $ 387.16

Mar-14 ############ 0.9990 $ 42,844,842.67 122,813 $ 348.86 ########### ########### $ 399.64

Apr-14 ############ 0.9989 $ 43,038,256.83 121,283 $ 354.86 ########### ########### $ 403.49

May-14 ############ 0.9983 $ 40,488,902.28 120,778 $ 335.23 ########### ########### $ 379.13

Jun-14 ############ 0.9981 $ 41,347,042.75 120,730 $ 342.48 ########### ########### $ 384.83

Jul-14 ############ 0.9980 $ 39,815,313.18 116,304 $ 342.34 ########### ########### $ 390.17

Aug-14 ############ 0.9977 $ 38,608,631.45 116,474 $ 331.48 ########### ########### $ 374.70

Sep-14 ############ 0.9972 $ 39,589,954.25 116,843 $ 338.83 ########### ########### $ 381.70

Oct-14 ############ 0.9975 $ 47,030,424.14 115,629 $ 406.74 ########### ########### $ 451.61

Nov-14 ############ 0.9968 $ 40,754,657.01 114,676 $ 355.39 ########### ########### $ 394.26

Dec-14 ############ 0.9966 $ 30,726,039.13 95,765 $ 320.85 ########### ########### $ 385.21

Jan-15 ############ 0.9966 $ 29,355,328.53 90,834 $ 323.18 ########### ########### $ 386.75

Feb-15 ############ 0.9958 $ 28,738,203.63 90,004 $ 319.30 ########### ########### $ 374.46

Mar-15 ############ 0.9956 $ 30,960,856.51 89,533 $ 345.80 ########### ########### $ 403.63

Apr-15 ############ 0.9930 $ 28,961,288.07 88,321 $ 327.91 ########### ########### $ 380.83

May-15 ############ 0.9919 $ 27,901,816.35 87,982 $ 317.13 ########### ########### $ 363.78

Jun-15 ############ 0.9903 $ 30,371,246.88 87,861 $ 345.67 ########### ########### $ 396.35

Jul-15 ############ 0.9889 $ 29,662,092.99 85,857 $ 345.48 ########### ########### $ 399.39

Aug-15 ############ 0.9854 $ 26,962,708.00 85,437 $ 315.59 ########### ########### $ 362.47

Sep-15 ############ 0.9811 $ 29,023,114.60 85,248 $ 340.46 ########### ########### $ 386.63

Oct-15 ############ 0.9539 $ 29,585,047.79 83,905 $ 352.60 ########### ########### $ 402.28

Nov-15 ############ 0.9493 $ 28,972,971.00 83,603 $ 346.55 ########### ########### $ 391.99

Dec-15 ############ 0.8896 $ 24,071,038.94 77,959 $ 308.77 ########### ########### $ 379.41

* Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

########### ###########

Prescription Drugs

Total Annual Trend

2 Year Trend Projection

########### ###########

########### ###########

Capitation

Service Category

Inpatient Hospital

Outpatient Hospital

Professional

Other Medical

PA Rate Template Part IIRate Development and Change

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

2015 Total Allowed EHB Claims PMPM + EHB Capitation PMPM (net of prescription drug rebates) $404.12 <- Index Rate of Experience Period on URRT Table 5A. Small Group Projected Index Rate with Quarterly Trend2 Year Trend Projection Factor 1.188

Unadjusted Projected Allowed EHB Claims PMPM 480.13$ January April July October Total Single Risk Pool

Single Risk Pool Adjustment Factors <- Adj't. from Experience to Projection Period - Pop'l risk Morbidity on URRT # of Member Months Renewing in Quarter 3,935 2,515 2,297 5,167 13,914.00Change in Morbidity 1.075 <- Adj't. from Experience to Projection Period - Other on URRT Percent of Members Months Renewing in Quarter 28% 18% 17% 37% 100%Change in Other 0.975 Base Allowed Claims 503.46$ 503.46$ 503.46$ 503.46$ 503.46$

Change in Demographics 1.035 Months of Trend - 3 6 9 5Change in Network 0.933 Annual Trend 9.00% 9.00% 9.00% 9.00% 9.00%Change in Benefits 1.017 Single Risk Pool Projected Allowed Claims 503.46$ 514.42$ 525.62$ 537.07$ 521.58$

Change in Other 0.993Adjusted Projected Allowed EHB Claims PMPM 503.46$ <- Index Rate for Projection Period on URRT - Individual (Small Group 1rst Qtr)

Adjusted Projected Allowed EHB Claims PMPM [will only populate for small group filings] 521.58$ <- Index Rate for Projection Period on URRT - Small Group

Projected Paid to Allowed Ratio 0.849984673 <- Paid to Allowed Average Factor in Projection Period on URRT

Projected Paid EHB Claims PMPM 443.3352071Market-wide Adjustments

Projected Paid Net Risk Adjustment PMPM 1.76$Projected Paid Exchange User Fees PMPM -$

Market-Adjusted Projected Paid EHB Claims PMPM 445.10$

Market-Adjusted Projected Allowed EHB Claims PMPM 523.65$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM

Market-Adjusted Projected Paid Total Claims PMPM 445.10$

Market-Adjusted Projected Allowed Total Claims PMPM 523.65$

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

Retention Items - Express in percentages Normalization Factors 2016 2017

Administrative Expenses 10% Average Age Factor 1.459 1.484

General and Claims ############# Average Geographic Factor 0.970 0.970

Agent/Broker Fees and Commissions 2.74% Average Tobacco Factor 1.000 1.000

Quality Improvement Initiatives 0.51% Average Benefit Richness (induced demand) 1.120 1.115

Taxes and Fees 1.42% Average Network Factor 0.912 0.933

PCORI Fees (Enter $ amount here: $______________ ) 0.04%Pa Premium Tax (if applicable) 0.00% Market-Adjusted Projected Allowed Total Claims PMPM 485.54$ 523.65$

Federal Income Tax 0.00%

Health Insurance Providers Fee (only for small group market, prorated for coverage in 2018) 1.42% Normalized Market-Adjusted Projected Allowed Total Claims PMPM 335.82$ 349.50$

Profit/Contingency 0%

Total Retention 11%<- Single Pool Gross Premium Avg. Rate, PMPM on URRT

Projected Required Revenue PMPM 502.90$

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

Rate Components 2016 2017 Difference Percent Change 2016 2017

A. Calibrated Plan Adjusted Index Rate (PMPM) 313.0770781 323.2023635 $10.13 3.2% Paid-to-Allowed 0.85727371 0.84998467

B. Base period allowed claims before normalization 367.74$ 404.12$ $36.38 12% URRT Trend (2-Year Trend Factor) 1.21 1.19 <- URRT W1, S2

C. Normalization factor component of change (113.40)$ -134.3968337 -$21.00 -$0.07 URRT Morbidity 1.13272011 1.075 <- URRT W1, S2

URRT "Other" 0.94265191 0.975 <- URRT W1, S2

D. Change in Normalized Allowed Claims Adjustment Components

D1. Base period allowed claims after normalization 254.34$ 269.72$ 15.39$ 5% Risk Adjustment (11.04)$ 1.76$ <- URRT W1, S3

D2. URRT Trend 53.41$ 50.73$ (2.68)$ -1% Reinsurance 2.25$ -$ <- URRT W1, S3

D3. URRT Morbidity 40.84$ 24.18$ (16.66)$ -5% Exchange User Fee 0.83$ -$ <- URRT W1, S3

D4. URRT Other (19.99)$ (8.62)$ 11.37$ 4% Capitation -$ -$ <- URRT W1, S2

D5. Normalized URRT RA/RI on an allowed basis (7.09)$ 1.38$ 8.48$ 3%

D6. Normalized Exchange User Fee on an allowed basis 0.67$ -$ (0.67)$ 0% Network 0.921 0.93596773

D7. Subtotal - Sum(D1:D6) 322.17$ 337.41$ 15.23$ 5% Pricing AV 0.834 0.80206919E. Change in Allowable Plan Adjusted Level Components Benefit Richness 1.092 1.08306675

E1. Network (25.42)$ -21.60488077 3.81$ 1% Catastrophic Eligibility 1.000 1

E2. Pricing AV (49.35)$ (62.51)$ (13.16)$ -4%

E3. Benefit Richness 22.83$ 21.04$ (1.79)$ -1% Administrative Expenses 8.52% 10.03%

E4. Catastrophic Eligibility -$ -$ -$ 0% Taxes and Fees 3.20% 1.46%

E5. Subtotal - Sum(E1:E4) (51.94)$ (63.07)$ (11.14)$ -4% Profit and/or Contingency 0.00% 0.00%

F. Change in Retention Components

F1. Administrative Expenses 26.67$ 32.43$ 5.76$ 2%

F2. Taxes and Fees 10.02$ 4.72$ (5.29)$ -2%

F3. Profit and/or Contingency -$ -$ -$ 0%

F4. Subtotal - Sum(F1:F3) 36.69$ 37.15$ 0.46$ 0%

G. Change in Miscellaneous Items -$ 0%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 306.93$ 311.48$ 4.56$ 1%

PA Rate Template Part IIITable 10. Plan Rates

Age Calibration Factor

Carrier Name: Highmark Geographic Calibration Factor

Plan Type(s): PPO/EPO Aggregate Calibration Factor

Market Segment: Small Group

Rate Effective Date: 01/01/2017

Market Adjusted Index Rate 523.65$

Plan Number HIOS Plan ID (Standard Component)

Plan Type

(HMO, POS, PPO, EPO,

Indemnity, Other)

1/1/16 Plan

Marketing Name

Discontinued, New,

Modified, Existing

(D,N,M,E) for 2017

1/1/17 Plan

Marketing Name

(If 1/1/16 Plan

Discontinued) Metallic Tier

Metallic Tier

Actuarial

Value

Standard AV,

Approach (1),

Approach (2)

Exchange

On/Off or

Off

Pricing AV

(company-

determined

AV)

Benefit

Richness

(induced

demand)

Benefits in

addition to

EHB

Provider

Network

Catastrophic

Eligibility

Tobacco

Surcharge

Adjustment

Pure

Premium Admin Costs

Totals 0.759 0.802 0.971 1.000 1.003 1.000 1.000 410.33$ 10.1%

Plan 1 33709PA0560007 PPO Premier Balance PPO $0 Platinum A a Community Blue Flex PlanM Premier Balance PPO $0 Platinum A a Community Blue Flex PlanPlatinum 0.90283164 Standard Off 0.909 1.031 1.000 0.996 1.000 1.000 $489.10 10.1%

Plan 2 33709PA0560009 PPO Premier Balance PPO $250 Platinum A a Community Blue Flex PlanM Premier Balance PPO $250 Platinum A a Community Blue Flex PlanPlatinum 0.89529369 Standard Off 0.894 1.031 1.000 0.996 1.000 1.000 $480.97 10.1%

Plan 3 33709PA0560011 PPO Premier Balance PPO $0 Gold A a Community Blue Flex PlanM Premier Balance PPO $0 Gold A a Community Blue Flex PlanGold 0.81299199 Standard Off 0.819 0.969 1.000 0.996 1.000 1.000 $414.14 10.1%

Plan 4 33709PA0560013 PPO Premier Balance PPO $250 Gold A a Community Blue Flex PlanM Premier Balance PPO $250 Gold A a Community Blue Flex PlanGold 0.80730215 Standard Off 0.831 0.969 1.000 0.996 1.000 1.000 $420.01 10.1%

Plan 5 33709PA0560015 PPO Premier Balance PPO $500 A a Community Blue Flex PlanM Premier Balance PPO $500 A a Community Blue Flex PlanGold 0.7987237 Standard Off 0.813 0.969 1.000 0.996 1.000 1.000 $410.91 10.1%






Plan 11 33709PA0560029 PPO Premier Balance PPO $1400 A a Community Blue Flex PlanM Premier Balance PPO $1400 A a Community Blue Flex PlanSilver 0.71692269 Standard Off 0.724 0.924 1.000 0.996 1.000 1.000 $348.74 10.1%

Plan 12 33709PA0570007 PPO Balance PPO $1000 A a Community Blue Flex PlanM Balance PPO $1000 A a Community Blue Flex PlanSilver 0.71893487 Standard Off 0.717 0.924 1.000 0.996 1.000 1.000 $345.76 10.1%



Plan 15 33709PA0450004 PPO Health Savings PPO $1500 a Community Blue Flex PlanM Health Savings PPO $1500 a Community Blue Flex PlanGold 0.78310018 Standard Off 0.762 0.969 1.000 0.996 1.000 1.000 $384.88 10.1%

Plan 16 33709PA0640001 PPO Health Savings PPO Embedded $2600 a Community Blue Flex PlanM Health Savings PPO Embedded $2600 a Community Blue Flex PlanSilver 0.70242325 Standard Off 0.707 0.924 1.000 0.996 1.000 1.000 $340.55 10.1%

Plan 17 33709PA0640002 PPO Health Savings PPO Embedded $3000 a Community Blue Flex PlanM Health Savings PPO Embedded $3000 a Community Blue Flex PlanSilver 0.68864547 Standard Off 0.689 0.924 1.000 0.996 1.000 1.000 $331.92 10.1%

Plan 18 33709PA0640003 PPO Health Savings PPO Embedded $5500 a Community Blue Flex PlanM Health Savings PPO Embedded $5500 a Community Blue Flex PlanBronze 0.61867689 Standard Off 0.590 0.897 1.000 0.996 1.000 1.000 $275.88 10.1%



Plan 21 33709PA0460012 PPO Flex PPO $500 Total Health a Community Blue PlanM Flex PPO $500 Total Health a Community Blue PlanGold 0.79744542 Standard Off 0.819 0.969 1.000 0.996 1.000 1.000 $413.79 10.1%

Plan 22 33709PA0460013 PPO Flex PPO $500 Total Health a Community Blue PlanM Flex PPO $500 Total Health a Community Blue PlanGold 0.79867497 Standard Off 0.821 0.969 1.000 1.058 1.000 1.000 $440.66 10.1%

Plan 23 33709PA0630002 EPO Connect Blue EPO $100 a Community Blue PlanM Connect Blue EPO $100 a Community Blue PlanGold 0.81791609 Standard Off 0.811 0.969 1.000 0.936 1.000 1.000 $385.36 10.1%





Plan 28 33709PA0630008 EPO N Connect Blue EPO $1100 a Community Blue PlanGold 0.78577049 Standard Off 0.768 0.969 1.000 0.936 1.000 1.000 $364.74 10.1%

Plan 29 33709PA0630007 EPO Connect Blue EPO $2500 a Community Blue PlanM Connect Blue EPO $2500 a Community Blue PlanSilver 0.7195701 Standard Off 0.698 0.924 1.000 0.936 1.000 1.000 $316.37 10.1%

Plan 30 33709PA0630009 EPO N Connect Blue EPO $3200 a Community Blue PlanSilver 0.70662667 Standard Off 0.685 0.924 1.000 0.936 1.000 1.000 $310.26 10.1%

Plan 31 33709PA0440014 PPO Premier Balance PPO $250 IP A a Community Blue Flex PlanM Premier Balance PPO $250 IP A a Community Blue Flex PlanGold 0.80948214 Standard Off 0.826 0.969 1.000 1.066 1.000 1.000 $446.60 10.1%

Plan 32 33709PA0440009 PPO Premier Balance PPO $750 IP A a Community Blue Flex PlanM Premier Balance PPO $750 IP A a Community Blue Flex PlanGold 0.78629524 Standard Off 0.791 0.969 1.000 1.066 1.000 1.000 $427.89 10.1%

Plan 33 33709PA0440013 PPO Premier Balance PPO $1500 IP A a Community Blue Flex PlanM Premier Balance PPO $1500 IP A a Community Blue Flex PlanSilver 0.71744206 Standard Off 0.717 0.924 1.000 1.066 1.000 1.000 $369.51 10.1%

Plan 34 33709PA0460007 PPO Flex PPO $500/$1500 Penn Highlands Region a Community Blue PlanM Flex PPO $500/$1500 Penn Highlands Region a Community Blue PlanGold 0.7963 Standard Off 0.811 0.969 1.000 1.054 1.000 1.000 $433.33 10.1%

Plan 35 33709PA0460008 PPO Flex PPO PA Mountains Healthcare Region $500/$1500 a Community Blue PlanM Flex PPO PA Mountains Healthcare Region $500/$1500 a Community Blue PlanGold 0.7936 Standard Off 0.804 0.969 1.000 1.004 1.000 1.000 $409.48 10.1%

Plan 36 33709PA0480001 PPO Comprehensive Care EPO $1500 A Community Blue PlanD 2016 Premier Balance PPO $1500 A a Community Blue Flex PlanGold Standard Off 0.778 0.969 1.000 0.996 1.000 1.000 $393.07 10.1%

Plan 37 33709PA0480002 PPO Comprehensive Care EPO $1500 A Community Blue PlanD 2016 Premier Balance PPO $750 IP A a Community Blue Flex PlanGold Standard Off 0.791 0.969 1.000 1.066 1.000 1.000 $427.89 10.1%

Plan 38 33709PA0480003 PPO Comprehensive Care EPO $2000 A Community Blue PlanD 2016 Balance PPO $2000 A a Community Blue Flex PlanSilver Standard Off 0.699 0.924 1.000 0.996 1.000 1.000 $336.84 10.1%

Plan 39 33709PA0480004 PPO Comprehensive Care EPO $2000 A Community Blue PlanD 2016 Premier Balance PPO $1500 IP A a Community Blue Flex PlanSilver Standard Off 0.717 0.924 1.000 1.066 1.000 1.000 $369.51 10.1%

Plan 40 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 10.1%

Plan 41 33709PA0580006 PPO D 2015 Health Savings PPO Embedded $2600 a Community Blue Flex PlanSilver Standard Off 0.707 0.924 1.000 0.996 1.000 1.000 $340.55 10.1%

Plan 42 33709PA0580008 PPO D 2015 Health Savings PPO Embedded $2600 a Community Blue Flex PlanSilver Standard Off 0.707 0.924 1.000 0.996 1.000 1.000 $340.55 10.1%

Plan 43 33709PA0580010 PPO D 2015 Health Savings PPO Embedded $5500 a Community Blue Flex PlanBronze Standard Off 0.590 0.897 1.000 0.996 1.000 1.000 $275.88 10.1%





Plan 48 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9%

Plan 49 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9%

Plan 50 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9%

Plan 51 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9%

Plan 52 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9%

Plan 53 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9%

Plan 54 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9%

Plan 55 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9%

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

Age Calibration Factor 1.478541976

Geographic Calibration Factor 0.970

Aggregate Calibration Factor 1.434

Taxes & Fees (not

including Exchange

fees)

Profit or

Contingency

Total

Covered Lives @

2/1/2016

Total Policyholders

@ 2/1/2016

2016

Calibrated Plan

Adjusted Index

Rate PMPM

2017 Calibrated

Plan Adjusted

Index Rate

PMPM

Proposed Rate

Change

Compared to

Prior 12

months

% of Total

Covered Lives

1.4% 0.0% 15,580 8,754 313.08$ 323.20$ 3.23%

1.4% 0.0% 2,456 1,286 368.57$ $385.25 4.5% 15.8%

1.4% 0.0% 794 415 362.95$ $378.84 4.4% 5.1%

1.4% 0.0% 1,444 749 312.17$ $326.21 4.5% 9.3%

1.4% 0.0% 366 236 319.34$ $330.82 3.6% 2.3%

1.4% 0.0% 2,277 1,288 314.81$ $323.66 2.8% 14.6%

1.4% 0.0% 312 204 310.28$ $319.52 3.0% 2.0%

1.4% 0.0% 1,568 890 305.75$ $314.38 2.8% 10.1%

1.4% 0.0% 360 213 301.97$ $311.91 3.3% 2.3%

1.4% 0.0% 745 368 299.71$ $309.60 3.3% 4.8%

1.4% 0.0% 445 273 296.69$ $306.30 3.2% 2.9%

1.4% 0.0% 1,157 643 266.39$ $274.69 3.1% 7.4%

1.4% 0.0% 43 36 262.07$ $272.34 3.9% 0.3%

1.4% 0.0% 335 204 258.83$ $267.97 3.5% 2.2%

1.4% 0.0% 435 262 256.32$ $265.31 3.5% 2.8%

1.4% 0.0% 66 34 289.90$ $303.16 4.6% 0.4%

1.4% 0.0% 20 11 276.83$ $268.24 -3.1% 0.1%

1.4% 0.0% 21 15 270.71$ $261.44 -3.4% 0.1%

1.4% 0.0% 50 27 218.79$ $217.30 -0.7% 0.3%

1.4% 0.0% - - 237.46$ $232.49 -2.1% 0.0%

1.4% 0.0% 6 3 215.65$ $218.00 1.1% 0.0%

1.4% 0.0% 102 57 314.47$ $325.93 3.6% 0.7%

1.4% 0.0% 215 130 342.20$ $347.09 1.4% 1.4%

1.4% 0.0% 36 20 286.41$ $303.53 6.0% 0.2%

1.4% 0.0% 6 6 290.71$ $302.30 4.0% 0.0%

1.4% 0.0% 82 55 282.82$ $298.00 5.4% 0.5%

1.4% 0.0% 9 7 279.59$ $296.31 6.0% 0.1%

1.4% 0.0% - - 278.15$ $289.61 4.1% 0.0%

1.4% 0.0% - - -$ $287.30 #DIV/0! 0.0%

1.4% 0.0% 22 12 242.00$ $249.20 3.0% 0.1%

1.4% 0.0% - - -$ $244.38 #DIV/0! 0.0%

1.4% 0.0% 530 302 342.76$ $351.77 2.6% 3.4%

1.4% 0.0% 348 208 332.13$ $337.04 1.5% 2.2%

1.4% 0.0% 375 239 281.65$ $291.05 3.3% 2.4%

1.4% 0.0% 47 28 334.29$ $341.32 2.1% 0.3%

1.4% 0.0% 10 5 310.64$ $322.54 3.8% 0.1%

1.4% 0.0% 16 9 294.05$ $309.60 5.3% 0.1%

1.4% 0.0% - - 318.63$ $337.04 5.8% 0.0%

1.4% 0.0% 23 13 247.68$ $265.31 7.1% 0.1%

1.4% 0.0% - - 268.38$ $291.05 8.4% 0.0%

1.4% 0.0% - - -$ $412.46 #DIV/0! 0.0%

1.4% 0.0% 458 255 276.83$ $268.24 -3.1% 2.9%

1.4% 0.0% 43 33 276.83$ $268.24 -3.1% 0.3%

1.4% 0.0% 107 52 218.79$ $217.30 -0.7% 0.7%

1.4% 0.0% 20 18 218.79$ $217.30 -0.7% 0.1%

1.4% 0.0% 28 21 218.79$ $217.30 -0.7% 0.2%

1.4% 0.0% 122 77 218.79$ $217.30 -0.7% 0.8%

1.4% 0.0% 81 50 237.46$ $232.49 -2.1% 0.5%

1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%

1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%

1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%

1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%

1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%

1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%

1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%

1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%

Calibration

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

Carrier Name: Highmark

Plan Type(s): PPO/EPO

Market Segment: Small Group

Rate Effective Date: 01/01/2017


1/1/16 Plan

Marketing Name

Discontinued,

New, Modified,

Existing

(D,N,M,E) for

2017

1/1/17 Plan

Marketing Name

(If 1/1/16 Plan

Discontinued) Metallic Tier

Exchange

On/Off or

Off 1 2 3 4 5 6 7 8 9 Total 1 2 3

Totals 3,476 209 - 10,668 1,117 110 - - - 15,580 296.75$ 317.42$ -$

Plan 1 33709PA0560007 Premier Balance PPO $0 Platinum A a Community Blue Flex PlanM Premier Balance PPO $0 Platinum A a Community Blue Flex PlanPlatinum Off 442 - - 2,014 - - - - - 2,456 357.52$ -$ -$

Plan 2 33709PA0560009 Premier Balance PPO $250 Platinum A a Community Blue Flex PlanM Premier Balance PPO $250 Platinum A a Community Blue Flex PlanPlatinum Off 130 - - 664 - - - - - 794 352.06$ -$ -$

Plan 3 33709PA0560011 Premier Balance PPO $0 Gold A a Community Blue Flex PlanM Premier Balance PPO $0 Gold A a Community Blue Flex PlanGold Off 135 - - 1,309 - - - - - 1,444 302.80$ -$ -$

Plan 4 33709PA0560013 Premier Balance PPO $250 Gold A a Community Blue Flex PlanM Premier Balance PPO $250 Gold A a Community Blue Flex PlanGold Off 73 - - 293 - - - - - 366 309.76$ -$ -$

Plan 5 33709PA0560015 Premier Balance PPO $500 A a Community Blue Flex PlanM Premier Balance PPO $500 A a Community Blue Flex PlanGold Off 566 - - 1,711 - - - - - 2,277 305.36$ -$ -$

Plan 6 33709PA0560017 Premier Balance PPO $750 A a Community Blue Flex PlanM Premier Balance PPO $750 A a Community Blue Flex PlanGold Off 126 - - 186 - - - - - 312 300.97$ -$ -$

Plan 7 33709PA0560019 Premier Balance PPO $1000 A a Community Blue Flex PlanM Premier Balance PPO $1000 A a Community Blue Flex PlanGold Off 382 - - 1,186 - - - - - 1,568 296.58$ -$ -$




Plan 11 33709PA0560029 Premier Balance PPO $1400 A a Community Blue Flex PlanM Premier Balance PPO $1400 A a Community Blue Flex PlanSilver Off 409 - - 748 - - - - - 1,157 258.40$ -$ -$

Plan 12 33709PA0570007 Balance PPO $1000 A a Community Blue Flex PlanM Balance PPO $1000 A a Community Blue Flex PlanSilver Off 2 - - 41 - - - - - 43 254.21$ -$ -$



Plan 15 33709PA0450004 Health Savings PPO $1500 a Community Blue Flex PlanM Health Savings PPO $1500 a Community Blue Flex PlanGold Off - - - 66 - - - - - 66 -$ -$ -$

Plan 16 33709PA0640001 Health Savings PPO Embedded $2600 a Community Blue Flex PlanM Health Savings PPO Embedded $2600 a Community Blue Flex PlanSilver Off 2 - - 18 - - - - - 20 268.53$ -$ -$

Plan 17 33709PA0640002 Health Savings PPO Embedded $3000 a Community Blue Flex PlanM Health Savings PPO Embedded $3000 a Community Blue Flex PlanSilver Off - - - 21 - - - - - 21 -$ -$ -$

Plan 18 33709PA0640003 Health Savings PPO Embedded $5500 a Community Blue Flex PlanM Health Savings PPO Embedded $5500 a Community Blue Flex PlanBronze Off 1 - - 49 - - - - - 50 212.23$ -$ -$

Plan 19 33709PA0640004 Health Savings PPO Embedded $5500 a Community Blue Flex PlanM Health Savings PPO Embedded $5500 a Community Blue Flex PlanBronze Off - - - - - - - - - - -$ -$ -$

Plan 20 33709PA0640005 Health Savings PPO Embedded $6000 a Community Blue Flex PlanM Health Savings PPO Embedded $6000 a Community Blue Flex PlanBronze Off 2 - - 4 - - - - - 6 209.18$ -$ -$

Plan 21 33709PA0460012 Flex PPO $500 Total Health a Community Blue PlanM Flex PPO $500 Total Health a Community Blue PlanGold Off - - - 102 - - - - - 102 -$ -$ -$

Plan 22 33709PA0460013 Flex PPO $500 Total Health a Community Blue PlanM Flex PPO $500 Total Health a Community Blue PlanGold Off 54 27 - - 134 - - - - 215 331.94$ 331.94$ -$

Plan 23 33709PA0630002 Connect Blue EPO $100 a Community Blue PlanM Connect Blue EPO $100 a Community Blue PlanGold Off 11 - - 25 - - - - - 36 277.81$ -$ -$

Plan 24 33709PA0630003 Connect Blue EPO $250 a Community Blue PlanM Connect Blue EPO $250 a Community Blue PlanGold Off - - - 6 - - - - - 6 -$ -$ -$

Plan 25 33709PA0630004 Connect Blue EPO $500 a Community Blue PlanM Connect Blue EPO $500 a Community Blue PlanGold Off - - - 82 - - - - - 82 -$ -$ -$

Plan 26 33709PA0630005 Connect Blue EPO $750 a Community Blue PlanM Connect Blue EPO $750 a Community Blue PlanGold Off 6 - - 3 - - - - - 9 271.20$ -$ -$

Plan 27 33709PA0630006 Connect Blue EPO $900 a Community Blue PlanM Connect Blue EPO $900 a Community Blue PlanGold Off - - - - - - - - - - -$ -$ -$

Plan 28 33709PA0630008 0 N Connect Blue EPO $1100 a Community Blue PlanGold Off - - - - - - - - - - -$ -$ -$

Plan 29 33709PA0630007 Connect Blue EPO $2500 a Community Blue PlanM Connect Blue EPO $2500 a Community Blue PlanSilver Off 3 - - 19 - - - - - 22 234.74$ -$ -$

Plan 30 33709PA0630009 0 N Connect Blue EPO $3200 a Community Blue PlanSilver Off - - - - - - - - - - -$ -$ -$

Plan 31 33709PA0440014 Premier Balance PPO $250 IP A a Community Blue Flex PlanM Premier Balance PPO $250 IP A a Community Blue Flex PlanGold Off - 49 - - 391 90 - - - 530 -$ 332.48$ -$

Plan 32 33709PA0440009 Premier Balance PPO $750 IP A a Community Blue Flex PlanM Premier Balance PPO $750 IP A a Community Blue Flex PlanGold Off 11 96 - - 221 20 - - - 348 322.17$ 322.17$ -$

Plan 33 33709PA0440013 Premier Balance PPO $1500 IP A a Community Blue Flex PlanM Premier Balance PPO $1500 IP A a Community Blue Flex PlanSilver Off 95 36 - - 244 - - - - 375 273.20$ 273.20$ -$

Plan 34 33709PA0460007 Flex PPO $500/$1500 Penn Highlands Region a Community Blue PlanM Flex PPO $500/$1500 Penn Highlands Region a Community Blue PlanGold Off - 1 - - 46 - - - - 47 -$ 324.26$ -$

Plan 35 33709PA0460008 Flex PPO PA Mountains Healthcare Region $500/$1500 a Community Blue PlanM Flex PPO PA Mountains Healthcare Region $500/$1500 a Community Blue PlanGold Off 10 - - - - - - - - 10 301.32$ -$ -$

Plan 36 33709PA0480001 Comprehensive Care EPO $1500 A Community Blue PlanD 2016 Premier Balance PPO $1500 A a Community Blue Flex PlanGold Off - - - 16 - - - - - 16 -$ -$ -$

Plan 37 33709PA0480002 Comprehensive Care EPO $1500 A Community Blue PlanD 2016 Premier Balance PPO $750 IP A a Community Blue Flex PlanGold Off - - - - - - - - - - -$ -$ -$

Plan 38 33709PA0480003 Comprehensive Care EPO $2000 A Community Blue PlanD 2016 Balance PPO $2000 A a Community Blue Flex PlanSilver Off - - - 23 - - - - - 23 -$ -$ -$

Plan 39 33709PA0480004 Comprehensive Care EPO $2000 A Community Blue PlanD 2016 Premier Balance PPO $1500 IP A a Community Blue Flex PlanSilver Off - - - - - - - - - - -$ -$ -$

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

Plan 41 33709PA0580006 0 D 2015 Health Savings PPO Embedded $2600 a Community Blue Flex PlanSilver Off 181 - - 277 - - - - - 458 268.53$ -$ -$

Plan 42 33709PA0580008 0 D 2015 Health Savings PPO Embedded $2600 a Community Blue Flex PlanSilver Off 7 - - 36 - - - - - 43 268.53$ -$ -$

Plan 43 33709PA0580010 0 D 2015 Health Savings PPO Embedded $5500 a Community Blue Flex PlanBronze Off 23 - - 84 - - - - - 107 212.23$ -$ -$




Plan 47 33709PA0450003 0 D 2015 Health Savings PPO Embedded $5500 a Community Blue Flex PlanBronze Off - - - - 81 - - - - 81 -$ -$ -$

These cells auto-fill using the data entered in Table 9.

2/1/16 Number of Covered Lives(in small group market, average monthly premium weighted for quarterly trend)

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

304.77$ 309.68$ 354.46$ -$ -$ -$ 303.85$ 305.73$ 323.87$ -$ 315.30$ 316.17$ 363.06$ -$ -$ -$ 313.68$ 2.9% 2.1% 0.0% 3.4% 2.0% 2.4% 0.0%

357.52$ -$ -$ -$ -$ -$ 357.52$ 373.69$ -$ -$ 373.69$ -$ -$ -$ -$ -$ 373.69$ 4.5% 0.0% 0.0% 4.5% 0.0% 0.0% 0.0%

352.06$ -$ -$ -$ -$ -$ 352.06$ 367.48$ -$ -$ 367.48$ -$ -$ -$ -$ -$ 367.48$ 4.4% 0.0% 0.0% 4.4% 0.0% 0.0% 0.0%

302.80$ -$ -$ -$ -$ -$ 302.80$ 316.42$ -$ -$ 316.42$ -$ -$ -$ -$ -$ 316.42$ 4.5% 0.0% 0.0% 4.5% 0.0% 0.0% 0.0%

309.76$ -$ -$ -$ -$ -$ 309.76$ 320.90$ -$ -$ 320.90$ -$ -$ -$ -$ -$ 320.90$ 3.6% 0.0% 0.0% 3.6% 0.0% 0.0% 0.0%

305.36$ -$ -$ -$ -$ -$ 305.36$ 313.95$ -$ -$ 313.95$ -$ -$ -$ -$ -$ 313.95$ 2.8% 0.0% 0.0% 2.8% 0.0% 0.0% 0.0%

300.97$ -$ -$ -$ -$ -$ 300.97$ 309.93$ -$ -$ 309.93$ -$ -$ -$ -$ -$ 309.93$ 3.0% 0.0% 0.0% 3.0% 0.0% 0.0% 0.0%

296.58$ -$ -$ -$ -$ -$ 296.58$ 304.95$ -$ -$ 304.95$ -$ -$ -$ -$ -$ 304.95$ 2.8% 0.0% 0.0% 2.8% 0.0% 0.0% 0.0%

292.92$ -$ -$ -$ -$ -$ 292.92$ 302.56$ -$ -$ 302.56$ -$ -$ -$ -$ -$ 302.56$ 3.3% 0.0% 0.0% 3.3% 0.0% 0.0% 0.0%

290.72$ -$ -$ -$ -$ -$ 290.72$ 300.32$ -$ -$ 300.32$ -$ -$ -$ -$ -$ 300.32$ 3.3% 0.0% 0.0% 3.3% 0.0% 0.0% 0.0%

287.79$ -$ -$ -$ -$ -$ 287.79$ 297.11$ -$ -$ 297.11$ -$ -$ -$ -$ -$ 297.11$ 3.2% 0.0% 0.0% 3.2% 0.0% 0.0% 0.0%

258.40$ -$ -$ -$ -$ -$ 258.40$ 266.45$ -$ -$ 266.45$ -$ -$ -$ -$ -$ 266.45$ 3.1% 0.0% 0.0% 3.1% 0.0% 0.0% 0.0%

254.21$ -$ -$ -$ -$ -$ 254.21$ 264.17$ -$ -$ 264.17$ -$ -$ -$ -$ -$ 264.17$ 3.9% 0.0% 0.0% 3.9% 0.0% 0.0% 0.0%

251.07$ -$ -$ -$ -$ -$ 251.07$ 259.93$ -$ -$ 259.93$ -$ -$ -$ -$ -$ 259.93$ 3.5% 0.0% 0.0% 3.5% 0.0% 0.0% 0.0%

248.63$ -$ -$ -$ -$ -$ 248.63$ 257.36$ -$ -$ 257.36$ -$ -$ -$ -$ -$ 257.36$ 3.5% 0.0% 0.0% 3.5% 0.0% 0.0% 0.0%

281.20$ -$ -$ -$ -$ -$ 281.20$ -$ -$ -$ 294.06$ -$ -$ -$ -$ -$ 294.06$ 0.0% 0.0% 0.0% 4.6% 0.0% 0.0% 0.0%

268.53$ -$ -$ -$ -$ -$ 268.53$ 260.19$ -$ -$ 260.19$ -$ -$ -$ -$ -$ 260.19$ -3.1% 0.0% 0.0% -3.1% 0.0% 0.0% 0.0%

262.59$ -$ -$ -$ -$ -$ 262.59$ -$ -$ -$ 253.60$ -$ -$ -$ -$ -$ 253.60$ 0.0% 0.0% 0.0% -3.4% 0.0% 0.0% 0.0%

212.23$ -$ -$ -$ -$ -$ 212.23$ 210.78$ -$ -$ 210.78$ -$ -$ -$ -$ -$ 210.78$ -0.7% 0.0% 0.0% -0.7% 0.0% 0.0% 0.0%

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

209.18$ -$ -$ -$ -$ -$ 209.18$ 211.46$ -$ -$ 211.46$ -$ -$ -$ -$ -$ 211.46$ 1.1% 0.0% 0.0% 1.1% 0.0% 0.0% 0.0%

305.04$ -$ -$ -$ -$ -$ 305.04$ -$ -$ -$ 316.15$ -$ -$ -$ -$ -$ 316.15$ 0.0% 0.0% 0.0% 3.6% 0.0% 0.0% 0.0%

-$ 331.94$ -$ -$ -$ -$ 331.94$ 336.68$ 336.68$ -$ -$ 336.68$ -$ -$ -$ -$ 336.68$ 1.4% 1.4% 0.0% 0.0% 1.4% 0.0% 0.0%

277.81$ -$ -$ -$ -$ -$ 277.81$ 294.43$ -$ -$ 294.43$ -$ -$ -$ -$ -$ 294.43$ 6.0% 0.0% 0.0% 6.0% 0.0% 0.0% 0.0%

281.99$ -$ -$ -$ -$ -$ 281.99$ -$ -$ -$ 293.23$ -$ -$ -$ -$ -$ 293.23$ 0.0% 0.0% 0.0% 4.0% 0.0% 0.0% 0.0%

274.33$ -$ -$ -$ -$ -$ 274.33$ -$ -$ -$ 289.06$ -$ -$ -$ -$ -$ 289.06$ 0.0% 0.0% 0.0% 5.4% 0.0% 0.0% 0.0%

271.20$ -$ -$ -$ -$ -$ 271.20$ 287.42$ -$ -$ 287.42$ -$ -$ -$ -$ -$ 287.42$ 6.0% 0.0% 0.0% 6.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

234.74$ -$ -$ -$ -$ -$ 234.74$ 241.72$ -$ -$ 241.72$ -$ -$ -$ -$ -$ 241.72$ 3.0% 0.0% 0.0% 3.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

-$ 332.48$ 356.48$ -$ -$ -$ 336.56$ -$ 341.22$ -$ -$ 341.22$ 365.84$ -$ -$ -$ 345.40$ 0.0% 2.6% 0.0% 0.0% 2.6% 2.6% 0.0%

-$ 322.17$ 345.42$ -$ -$ -$ 323.50$ 326.93$ 326.93$ -$ -$ 326.93$ 350.52$ -$ -$ -$ 328.28$ 1.5% 1.5% 0.0% 0.0% 1.5% 1.5% 0.0%

-$ 273.20$ -$ -$ -$ -$ 273.20$ 282.32$ 282.32$ -$ -$ 282.32$ -$ -$ -$ -$ 282.32$ 3.3% 3.3% 0.0% 0.0% 3.3% 0.0% 0.0%

-$ 324.26$ -$ -$ -$ -$ 324.26$ -$ 331.08$ -$ -$ 331.08$ -$ -$ -$ -$ 331.08$ 0.0% 2.1% 0.0% 0.0% 2.1% 0.0% 0.0%

-$ -$ -$ -$ -$ -$ 301.32$ 312.86$ -$ -$ -$ -$ -$ -$ -$ -$ 312.86$ 3.8% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

285.23$ -$ -$ -$ -$ -$ 285.23$ -$ -$ -$ 300.32$ -$ -$ -$ -$ -$ 300.32$ 0.0% 0.0% 0.0% 5.3% 0.0% 0.0% 0.0%

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

240.24$ -$ -$ -$ -$ -$ 240.24$ -$ -$ -$ 257.36$ -$ -$ -$ -$ -$ 257.36$ 0.0% 0.0% 0.0% 7.1% 0.0% 0.0% 0.0%

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

268.53$ -$ -$ -$ -$ -$ 268.53$ 260.19$ -$ -$ 260.19$ -$ -$ -$ -$ -$ 260.19$ -3.1% 0.0% 0.0% -3.1% 0.0% 0.0% 0.0%

268.53$ -$ -$ -$ -$ -$ 268.53$ 260.19$ -$ -$ 260.19$ -$ -$ -$ -$ -$ 260.19$ -3.1% 0.0% 0.0% -3.1% 0.0% 0.0% 0.0%

212.23$ -$ -$ -$ -$ -$ 212.23$ 210.78$ -$ -$ 210.78$ -$ -$ -$ -$ -$ 210.78$ -0.7% 0.0% 0.0% -0.7% 0.0% 0.0% 0.0%

212.23$ -$ -$ -$ -$ -$ 212.23$ 210.78$ -$ -$ 210.78$ -$ -$ -$ -$ -$ 210.78$ -0.7% 0.0% 0.0% -0.7% 0.0% 0.0% 0.0%

212.23$ -$ -$ -$ -$ -$ 212.23$ 210.78$ -$ -$ 210.78$ -$ -$ -$ -$ -$ 210.78$ -0.7% 0.0% 0.0% -0.7% 0.0% 0.0% 0.0%

212.23$ -$ -$ -$ -$ -$ 212.23$ 210.78$ -$ -$ 210.78$ -$ -$ -$ -$ -$ 210.78$ -0.7% 0.0% 0.0% -0.7% 0.0% 0.0% 0.0%

-$ 230.34$ -$ -$ -$ -$ 230.34$ -$ -$ -$ -$ 225.51$ -$ -$ -$ -$ 225.51$ 0.0% 0.0% 0.0% 0.0% -2.1% 0.0% 0.0%

Change in 21-year-old Non-Tobacco Premium PMPM2016 21-year-old Non-Tobacco Premium PMPM

(in small group market, average monthly premium weighted for quarterly trend)

2017 21-year-old Non-Tobacco Premium PMPM

(in small group market, average monthly premium weighted for quarterly trend)

8 9

Average

(weighted by

enrollment by

rating area)

0.0% 0.0% 3.1%

0.0% 0.0% 4.5%

0.0% 0.0% 4.4%

0.0% 0.0% 4.5%

0.0% 0.0% 3.6%

0.0% 0.0% 2.8%

0.0% 0.0% 3.0%

0.0% 0.0% 2.8%

0.0% 0.0% 3.3%

0.0% 0.0% 3.3%

0.0% 0.0% 3.2%

0.0% 0.0% 3.1%

0.0% 0.0% 3.9%

0.0% 0.0% 3.5%

0.0% 0.0% 3.5%

0.0% 0.0% 4.6%

0.0% 0.0% -3.1%

0.0% 0.0% -3.4%

0.0% 0.0% -0.7%

0.0% 0.0% 0.0%

0.0% 0.0% 1.1%

0.0% 0.0% 3.6%

0.0% 0.0% 1.4%

0.0% 0.0% 6.0%

0.0% 0.0% 4.0%

0.0% 0.0% 5.4%

0.0% 0.0% 6.0%

0.0% 0.0% 0.0%

0.0% 0.0% 0.0%

0.0% 0.0% 3.0%

0.0% 0.0% 0.0%

0.0% 0.0% 2.6%

0.0% 0.0% 1.5%

0.0% 0.0% 3.3%

0.0% 0.0% 2.1%

0.0% 0.0% 3.8%

0.0% 0.0% 5.3%

0.0% 0.0% 0.0%

0.0% 0.0% 7.1%

0.0% 0.0% 0.0%

0.0% 0.0% 0.0%

0.0% 0.0% -3.1%

0.0% 0.0% -3.1%

0.0% 0.0% -0.7%

0.0% 0.0% -0.7%

0.0% 0.0% -0.7%

0.0% 0.0% -0.7%

0.0% 0.0% -2.1%

Change in 21-year-old Non-Tobacco Premium PMPM

PA Rate Template Part VConsumer Factors

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

Age BandAge

Factor

Tobacco

FactorAge Band

Age

Factor

Tobacco

FactorArea Counties

Current

Factor

Proposed

Factor

0-20 0.635 43 1.357 1 Rating Area 1Crawford, Erie, McKean, Mercer, Warren, Clarion,

Forest, Venango0.970 0.970

21 1.000 1 44 1.397 1 Rating Area 2 Cameron, Elk, Potter 0.970 0.97022 1.000 1 45 1.444 1 Rating Area 3

23 1.000 1 46 1.500 1 Rating Area 4

Allegheny, Armstrong, Beaver, Butler, Fayette,

Greene, Indiana, Lawrence, Washington,

Westmoreland

0.970 0.970

24 1.000 1 47 1.563 1 Rating Area 5Bedford, Blair, Cambria, Clearfield, Huntingdon,

Jefferson, Somerset0.970 0.970

25 1.004 1 48 1.635 1 Rating Area 6

Centre, Columbia, Lehigh, Mifflin, Montour,

Northampton, Northumberland, Snyder, Union,

Schuylkill

1.040 1.040

26 1.024 1 49 1.706 1 Rating Area 7 Adams, Berks, Lancaster, York 1.040 1.04027 1.048 1 50 1.786 1 Rating Area 8

28 1.087 1 51 1.865 1 Rating Area 9Cumberland, Dauphin, Franklin, Fulton, Juniata,

Lebanon, Perry1.020 1.020

29 1.119 1 52 1.952 130 1.135 1 53 2.040 1

31 1.159 1 54 2.135 1 Table 14. Network Factors32 1.183 1 55 2.230 1

33 1.198 1 56 2.333 1

34 1.214 1 57 2.437 1 Network Name Rating AreaCurrent

Factor

Proposed

Factor

DOH

Approval

Date35 1.222 1 58 2.548 1 A 1,4 0.915 0.93

36 1.230 1 59 2.603 1 B 1,2,5,6 0.992 0.995

37 1.238 1 60 2.714 1 J 1,4 0.870 0.874

38 1.246 1 61 2.810 1 G 1,2,4,5 0.926 0.938

39 1.262 1 62 2.873 1 H 2, 5, 6 0.983 0.983

40 1.278 1 63 2.952 141 1.302 1 64+ 3.000 1

42 1.325 1*PA follows the federal default age curve.

Geographic Area Factors2017 Age and Tobacco Factors

2017 Network Factors

08/12/2016

Part III Actuarial Memorandum

Redacted Version

Highmark Inc.

Small Group Rate Filing

Effective January 1, 2017

08/12/2016

TABLE OF CONTENTS

I. GENERAL INFORMATION ................................................................................................................... 1

II. PROPOSED RATE INCREASE(S) .......................................................................................................... 2

III. EXPERIENCE PERIOD PREMIUM AND CLAIMS .............................................................................. 2

IV. BENEFIT CATEGORIES ......................................................................................................................... 3

V. PROJECTION FACTORS ....................................................................................................................... 4

VI. CREDIBILITY MANUAL RATE DEVELOPMENT .............................................................................. 5

VII. CREDIBILITY OF EXPERIENCE .......................................................................................................... 5

VIII. PAID TO ALLOWED RATIO ................................................................................................................. 5

IX. RISK ADJUSTMENT AND REINSURANCE ........................................................................................ 5

X. NON-BENEFIT EXPENSES AND PROFIT & RISK ............................................................................. 6

XI. PROJECTED LOSS RATIO ..................................................................................................................... 7

XII. SINGLE RISK POOL ............................................................................................................................... 7

XIII. INDEX RATE ........................................................................................................................................... 7

XIV. MARKET ADJUSTED INDEX RATE .................................................................................................... 8

XV. PLAN ADJUSTED INDEX RATES ........................................................................................................ 8

XVI. CALIBRATION ........................................................................................................................................ 8

XVII. CONSUMER ADJUSTED PREMIUM RATE DEVELOPMENT .......................................................... 9

XVIII. AV METAL VALUES .............................................................................................................................. 9

XIX. AV PRICING VALUES ........................................................................................................................... 9

XX. MEMBERSHIP PROJECTIONS ............................................................................................................ 10

XXI. TERMINATED PRODUCTS ................................................................................................................. 10

XXII. PLAN TYPE ............................................................................................................................................ 10

XXIII. WARNING ALERTS .............................................................................................................................. 10

XXIV. ACTUARIAL CERTIFICATION ........................................................................................................... 10

1

02/12/2016 01/29/2009

I. General Information

Document Overview

This document contains the Part III Actuarial Memorandum for Highmark Inc.’s

(“Highmark”) small group block of business rate filing (“Filing”), for products with effective

dates in calendar year 2017. This actuarial memorandum is submitted in conjunction with

the Part I Unified Rate Review Template.

The purpose of the actuarial memorandum is to provide certain information related to the

submission, including support for the values entered into the Part I Unified Rate Review

Template, which supports compliance with the market rating rules and reasonableness of

applicable rate increases. This information may not be appropriate for other purposes.

This information is intended for use by the State of Pennsylvania Department of Insurance,

the Center for Consumer Information and Insurance Oversight (CCIIO), and their

subcontractors to assist in the review of Highmark’s Filing. However, we recognize that this

certification may become a public document. Highmark makes no representations or

warranties regarding the contents of this letter to third parties. Likewise, third parties are

instructed that they are to place no reliance upon this actuarial memorandum prepared by

Highmark that would result in the creation of any duty or liability under any theory of law by

Highmark or its employees to third parties.

The results are actuarial projections. Actual experience is likely to differ for a number of

reasons, including population changes, claims experience, and random deviations from

assumptions.

I.1 Company Identifying Information:

Company Legal Name: Highmark Inc.

State: The State of Pennsylvania has regulatory authority over these policies.

HIOS Issuer ID: 33709

Market: Small Group

Effective Date: January 1, 2017

2

02/12/2016 01/29/2009

II. Proposed Rate Increase(s)

For all rate increases by plan please see the ‘Cum'tive Rate Change % (over 12 mos prior)’

found in Worksheet 2 Row 27 of the URRT. The proposed rate increases for each plan differ

due to benefit changes made in the plan designs from 2016 to 2017. Many plans required

benefit changes because of the new Actuarial Value (AV) calculator released for 2017

effective dates. The plan changes were required so that the plans remained within the

defined metal level AV requirements. The components of the rate increase by plan are

shown in rows 34 to 42 of Worksheet 2 of the URRT.

Per discussion with the Pennsylvania Insurance Department, Highmark has reduced the rate

increase presented in this Filing to 3.9%. The primary drivers of the originally filed 6.3%

rate increase (weighted on the projected enrollment for renewing plans in the URRT) were an

increase in base experience claims of 9.9%, offset by a decrease (-5.1%) in the projected

population change (morbidity) for 2017 versus 2016. This decrease is due to the anticipated

stabilization in the ACA risk pool over time. Additionally, we are projecting an increase in

the projected risk adjustment transfer payment for 2017 versus 2016.

We expect that the lower cost small groups will continue to renew their transitional policies

and stay outside of the small group single risk pool in 2017, while the higher cost small

groups migrate into the ACA single risk pool.

III. Experience Period Premium and Claims

III.1 Paid through Date:

Experience period claims were based on incurred calendar year 2015, paid through January

2016. We only include the non-grandfathered, insured members in Highmark’s 2015 book-

of-business.

III.2 Premiums (net of MLR Rebate) in Experience Period:

The premiums shown for the experience period were based on calendar 2015 actual revenues,

adjusted for anticipated risk adjustment transfer payments, in accordance with the Unified

Rate Review Instructions.

Based on preliminary information for calendar year 2015, no MLR rebates are anticipated to

be refunded to enrollees. Therefore, we did not include an adjustment for MLR rebates in the

2015 premium amounts.

III.3 Allowed and Incurred Claims Incurred During the Experience Period:

Historical Experience: To complete the URRT historical experience

section we chose Highmark’s current experience for the small group block

of business for the period January 1, 2015 through December 31, 2015,

with claims paid through January, 2016.

3

02/12/2016 01/29/2009

Claims Incurred During the 12-month experience period: Worksheet 1,

Section I shows our best estimate of the amount of claims that were

incurred during the 12-month experience period for Highmark’s book-of-

business. This section includes:

- The amount of claims which were processed through our claims

system,

- Claims processed outside of our claims system (Rx rebates,

settlements), and

- Our best estimate of claims incurred but not paid as of the Paid

through Date stated above.

Method for Determining Allowed Claims: For non-capitated claims, the

allowed charges are summarized from Highmark’s detailed claim-level

historical data. We only include the non-grandfathered, insured members

from Highmark’s 2015 book-of-business.

Paid Claims: We also summarized the paid claims from detailed member

records. The paid-to-allowed ratio for the experience period reflects the

2015 plan designs chosen by each member.

Incurred but Not Paid (IBNR) Claims Estimate: Highmark’s estimate of

the remaining incurred but not recorded (IBNR) claims reflects the

anticipated IBNR as of the end of the paid claim run out period. The

IBNR completion factor of 0.977 was developed for Highmark’s total

small group business through analysis of historical claim completion

factors. The completion factor was applied equally to both paid and

allowed total claims (as a change in utilization) to complete the

experience.

IV. Benefit Categories

Historical cost and utilization data were pulled from Highmark’s claims systems by the

defined benefit categories included in Worksheet 1, Section II of the URRT. This data was

used to allocate Highmark’s total claims into its components on the URRT.

The data provided in this section closely adheres to the preferred definitions of the Benefit

Categories included in the URRT instructions, including the “Other Medical” category. The

“Other Medical” category units reflect visits for PDN/home health, trips for ambulance and

procedures for DME/prosthetics. Prescription drug utilization is converted to a 30-day script

count.

4

02/12/2016 01/29/2009

V. Projection Factors

V.1 Changes in the Morbidity of the Population Insured

The morbidity adjustment reflects the anticipated changes in the average morbidity of the

covered population (beyond allowable rating factors). Because of the transitional policies

available in the small group market, the population expected to enroll in the ACA qualifying

products is expected to have higher morbidity than the population in the experience period.

We expect the relatively lower cost groups to remain outside the ACA single-risk pool. We

also considered the combined experience of Highmark, Highmark Health Insurance

Company, Highmark Coverage Advantage and Highmark Choice Company when projecting

2017 morbidity, since that better represents the expected total market. Based on the rates

available to small groups under each rating structure, we estimate an increase of 7.5% over

two years due to the disruptions affecting the small group market and the higher morbidity

population selecting these products.

V.2 Changes in Benefits

We made the following adjustments to reflect the expected differences in benefits between

the experience period and projection period:

We reflected the additional cost of the following benefits that must now be

covered under the essential health benefit package for members moving into ACA

compliant policies from the transitional pre-ACA policies which do not cover

these benefits:

- Pediatric dental and vision benefits: +$7.91

- Autism benefits: +0.24%

We reflected the following newly mandated benefits required under state law,

which are not reflected in the experience period claims: None.

We made an adjustment to reflect the removal of benefits covered in the

experience period claims that will not be covered in the projection period: None.

V.3 Changes in Demographics

We are projecting an increase in the average age from the experience period to the projection

period due to the fact that the combined experience and lower cost groups mentioned above

in section V.1 will be slightly younger than the remaining pool and will remain in transitional

policies. There is no change assumed in the projected area factor.

V.4 Trend Factors (cost/utilization)

This development of the CY 2017 rates reflects an annual trend rate of 9.0%. Highmark is

expecting an annual trend rate of 10.2% (7.0% cost, 3.0% utilization), as presented in the

original filing, but reduced the trend used in the rate development based upon the request of

5

02/12/2016 01/29/2009

the Pennsylvania Insurance Department. These trends reflect Highmark’s expectations

regarding increases in in-network contractual reimbursement. The annual trend estimates

include the impact of trends in both projected in-network and out-of-network costs. These

estimates measure and normalize for benefit leverage, population aging, and historical

changes for fee schedules, as well as company-wide utilization management programs, and

external trend drivers.

The trend represents a blended average for all types of service and is applied to the aggregate

experience for pricing. These trends represent assumed community-wide expectations.

Claim variations due to the specific projected enrolled population in this single risk pool are

reflected in the morbidity adjustment.

We reflected anticipated changes in the average utilization of services due to differences in

average cost sharing requirements during the experience period and average cost sharing

requirements in the projection period: -0.7%.

VI. Credibility Manual Rate Development

VI. 1 Source and Appropriateness of Experience Data Used

Highmark’s small group experience is fully credible; no manual rate is developed or used in

this projection.

VII. Credibility of Experience

The experience is for Highmark’s non-grandfathered plans in 2015. It is large enough to be

fully credible. Our results are based 100% on the experience rate, adjusted as described

herein.

VIII. Paid to Allowed Ratio

For 2017, an average paid-to-allowed ratio of 85.0% is projected. This is a slight increase

from the 84.5% in the experience period as we have terminated our products in the Central

PA region, which tended to have lower paid-to-allowed ratios in the benefit elections.

IX. Risk Adjustment and Reinsurance

IX.1 Projected Risk Adjustments PMPM:

As we have seen in 2014 and 2015, many of the Small Group market customers have

retained their pre-ACA coverage through the transitional coverage provisions, and have yet

to join the ACA risk pool. With the transitional coverage provisions extension through the

end of 2017, we continue to believe that many groups will retain their current transitional

coverage until required to transfer coverage by January 1, 2018. The customers who have

transitioned to the ACA pool to date have included members with relatively higher morbidity

6

02/12/2016 01/29/2009

and since that is the case across the ACA risk pool, we do not anticipate that the risk

adjustment transfers will offset the higher average cost of these members.

To determine our estimated risk transfer for 2017, we examined historical risk scores

calculated from the factors in the HHS Notice of Benefit and Payment Parameters, and other

risk adjustment transfer formula components, for those members anticipated to be covered by

Highmark in 2017. We then estimate the statewide average risk scores and other transfer

formula components by examining the risk transfer results from 2014, and utilizing other

information we are able to obtain regarding the statewide risk profile. This information set

includes the results from our participation in a risk adjustment study, which provides insight

into the 2015 risk adjustment transfer results, and publicly available market-wide data, such

as MLR reports. We do not anticipate significant migration into the small group risk pool

from external populations (such as the uninsured).

Given the anticipated profile of the membership within Highmark in 2017, and our estimated

market-wide profile, we are assuming that Highmark members will have a risk adjustment

profile slightly more favourable than the market-wide averages, and that Highmark will be

making a small contribution into the risk adjustment program in 2017, increasing premiums

in the rate development by $1.70 PMPM.

IX.2 Projected ACA Reinsurance Recoveries Net of Reinsurance:

The Individual ACA Reinsurance program will be terminating at the end of 2016. For the

2017 rating period, there is no Reinsurance Premium amount to include in the rate

development.

X. Non-Benefit Expenses and Profit & Risk

X.1 Administrative Expense Load:

The proposed rates reflect internal administrative costs, including commissions and quality

improvement admin. This cost was developed based on its standard expense allocation

methods.

X.2 Profit (or Contribution to Surplus) & Risk Margin:

These revised rates reflect a 0% risk/contribution to surplus margin for all products and

plans.

X.3 Taxes and Fees:

Although the Health Insurance Provider Fee will not be collected in 2017, the fee will be

collected in 2018. As such, for any groups with renewal dates other than January 1, 2017,

the group’s renewal period will extend into 2018, where the premiums will need to include a

charge for this fee. For the 2017 rate development, the quarterly rates have been adjusted so

that the appropriate pro rata portion of this fee is collected based on a group’s renewal

quarter as follows:

7

02/12/2016 01/29/2009

Renewal

Quarter

Health Insurance

Provider Fee

1Q 0.000%

2Q 0.875%

3Q 1.750%

4Q 2.625%

In total, the following fees were added:

$0.19 Per Member Per Month for the Patient Centered Outcomes Research Fee

(included above in admin)

Percent indicated as above based on renewal quarter for the Health Insurance

Provider Fee; the premium weighted average of the above table is 1.6%, which is

used in the URRT, Worksheet 2, in determining the projected period Plan Adjusted

Index Rate

XI. Projected Loss Ratio

The anticipated medical loss ratio is about 90.0% relative to total premium less taxes and

fees. This loss ratio is calculated consistent with the federally prescribed MLR methodology.

XII. Single Risk Pool

As described above the base experience used includes all of Highmark’s small group non-

grandfathered members in accordance with the Single Risk Pool regulations. The projected

membership and their corresponding premiums and claims only include those members who

will be enrolled in a fully ACA-compliant plan in 2017 under Highmark.

XIII. Index Rate

The index rates as shown on Worksheet 1 of the URRT are simply the average allowed

claims for the Essential Health benefits for the experience and projected populations,

respectively, for Highmark. It is not adjusted for the risk adjustment program or any other

fee. For the projection period, it is the member-weighted average of the quarterly rate

indices (Jan 1, Apr 1, Jul 1, and Oct 1) based on the assumed membership distribution

effective in each quarter, as shown in the table below.

2017 % of Members Projected Quarterly

Index Rate PMPM

1Q 28.3% $503.46

2Q 18.1% $514.42

3Q 16.5% $525.62

4Q 37.1% $537.07

Composite 100.0% $521.58

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02/12/2016 01/29/2009

See the sections below for a description of how the projected index rate is adjusted to arrive

at each plan adjusted index rate.

XIV. Market Adjusted Index Rate

Please see Exhibit I for a numerical demonstration of the Market Adjusted Index Rate

development. The Market Adjusted Index Rate is the Index Rate further adjusted for risk

adjustment and the exchange fee (all grossed up from paid to imputed allowed values). The

Risk Adjustment factor is developed by taking one minus the grossed up expected risk

transfer (net of the fee) and dividing by the projected incurred claims before risk adjustment.

The Exchange User Fee factor is developed by adding the expected average exchange fee

PMPM to the projected incurred claims after risk adjuster, then dividing by the projected

incurred claims after risk adjuster. These adjustments were developed as factors in

accordance with the Part III instructions.

XV. Plan Adjusted Index Rates

Plan Adjusted Index Rates are developed by taking the Market Adjusted Index Rate and

adjusting for each plan’s actuarial value, relative benefit richness, relative network, and

remaining administrative expenses (including profit and risk, and taxes and fees). Please see

Exhibit II for the development of the Plan Adjusted Index Rate for each plan. The

administrative expenses do not vary by plan.

Note that component (iv) of the URRT AV pricing value (administrative costs, excluding

Exchange user fees) includes the Health Insurance Provider Fee, which varies throughout the

year based on renewal date (see section X.3 above). This component of the AV pricing value

is presented in Exhibit II as the premium weighted average administrative charge for the

year. The Plan Adjusted Index Rates presented in Exhibit II match those on the URRT.

XVI. Calibration

XVI.1 Age Curve Calibration (to age 46, non-smoker, area with 1.0 geographic

factor, January 1 effective date):

The projected weighted average age factor is 1.479. Each Plan Adjusted Index Rate

represents the rate for an average member (i.e., a member with an age factor is 1.479).

Please note that no member will pay these rates because the age factor of 1.479 is not found

on the HHS Age Curve. It only represents the average age factor of the projected population.

The closest age factor (1.500) is the factor for a person age 46. Please see Exhibit I for the

development of the calibration factor.

XVI.2 Geographic Factor Calibration:

The projected weighted average geographic factor is 0.9702. Each Plan Adjusted Index Rate

represents the rate for an average member with a geographic factor of 0.9702. Please note

that no member will pay these rates because Highmark is not using a geographic factor of

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02/12/2016 01/29/2009

0.9702 for any of the Pennsylvania rating areas. It only represents the average geographic

factor of the projected population. Please see Exhibit I for the development of the calibration

factor.

XVI.3 Quarterly Trend Factor Calibration:

The Plan Adjusted Index Rate represents the average rate renewing over the four quarters of

2017. Exhibit I also shows the factors to de-trend to calibrate to the rate for a 1/1/2017

renewal.

XVII. Consumer Adjusted Premium Rate Development

The Plan Adjusted Index Rate represents the rate for a non-smoker average age and average

geographic member for an average quarterly renewal. Highmark is filing quarterly Index

Rate trends of 2.18% per quarter. In addition to the Index Rate trends, the quarterly Plan

Adjusted Index Rates will also increase by the quarterly change in the Health Insurance

Provider Fee (discussed above). The Plan Adjusted Index Rates in Worksheet 2 Row 81

reflect an average combined trend of 5.3% for the four quarter renewal rating period.

The appropriate value to calibrate the Plan Adjusted Index Rate by is located at the bottom of

Exhibit I. By applying the ‘Combined Calibration Factor’ found in Exhibit I to the plan

adjusted index rates the resulting value will represent the plan premium for a 46 year old in a

1.0 area on 1/1/2017. The standard HHS Age Curve and area factors of 0.97 for regions 1, 2,

4, and 5; and 1.04 for region 6 can be used to calculate any rate found in the QHP rate

template.

XVIII. AV Metal Values

The AV Metal Values included in Worksheet 2 of the Part I Unified Rate Review Template

were based entirely on the Federal AV Calculator. No adjustments were needed for any

benefits from those values produced by the AV calculator.

XIX. AV Pricing Values

The “URRT AV Pricing Value” shows the adjustment from the Market Average Index Rate

to the Plan Adjusted Index Rates on Exhibit II. Please see Exhibit II for the portion of each

AV pricing value that is attributable to each of the allowable modifiers.

As mentioned above, component (iv) of the URRT AV pricing value (administrative costs,

excluding Exchange user fees) includes the Health Insurance Provider Fee, which varies

throughout the year based on renewal date (see section X.3 above). This component of the

AV pricing value is presented in Exhibit II as the premium weighted average administrative

charge for the year.

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02/12/2016 01/29/2009

XX. Membership Projections

We project that the bulk of the members in the small group market will remain outside of the

ACA compliant products, and remain outside the single-risk pool. Since Highmark

terminated its products in Central PA Service Zones D and E (see below), Highmark is

expecting to see a drop in enrollment from the 2015 experience period to 2017. See row 48

of Worksheet 2 to the URRT to see projected membership by plan.

XXI. Terminated Products

Highmark is terminating 45 QHP products that were new in 2014, 2015, and 2016. For

products in Service Zones A, B, and J, these products need to be terminated due to changes in

the CMS Actuarial Value calculator for 2016 and 2017, which would have valued these plans

outside of the regulated metal level bands. These products will be mapped to a

corresponding QHP product of similar metal level and plan design, and the experience period

members and allowed charges will be moved to the mapped plans in the URRT.

Highmark will no longer be offering products in Service Zones D and E. As such, we are

terminating all products in these service zones, and will not be mapping their experience in

the URRT.

Exhibit III lists all terminating plans, as well as plan mappings for the terminated QHP plans.

XXII. Plan Type

The Plan types listed in Worksheet 2, Section I of the Part I Unified Rate Review Template

describe Highmark’s plans adequately. No differences are needed.

XXIII. Warning Alerts

The following differences between the plan-level projections in Worksheet 2 and the total

projected amounts found in Worksheet 1 were noted. Explanations regarding these

differences are as follows:

Total Premium in the Experience Period in Section III – The Total Premium in the

Experience Period in worksheet 2 is a weighted average of the plan adjusted index

rates. The Premiums in the Experience Period from Worksheet 1 would include the

anticipated risk adjustment transfer payments for 2015, which are significant enough

to trigger the warning alert in comparing the two experience premium values.

XXIV. Actuarial Certification

I am a member of the American Academy of Actuaries and meet its qualification standards for actuaries

issuing statements of actuarial opinions in the United States. This filing is prepared on behalf of

Highmark to accompany its rate filing (for calendar year 2017) for the small group combined market on

and off the Pennsylvania Exchange.

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02/12/2016 01/29/2009

I hereby certify that the projected index rate is, to the best of my knowledge and understanding:

In compliance with all applicable State and Federal Statutes and Regulations (45 CFR

156.80(d)(1)), and

Developed in compliance with the applicable Actuarial Standards of Practice.

As originally filed, the rates were not excessive, inadequate, or unfairly discriminatory, and were

reasonable in relationship to the benefits provided. The Pennsylvania Insurance Department has

required Highmark to re-submit lower rates.

I certify that the index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 45

CFR 156.80(d)(2) were used to generate plan level rates. The allowable modifiers used to generate

plan-level rates were:

The actuarial value and cost-sharing design of the plan.

The plan’s provider network, delivery system characteristics, and utilization management

practices.

The benefits provided under the plan that are in addition to the essential health benefits.

These estimated benefits were pooled with similar benefits within the single risk pool and the

claims experience from those benefits was utilized to determine rate variations.

Administrative costs, excluding Exchange user fees.

I certify that the percent of total premium that represents essential health benefits included in Worksheet

2, Sections III and IV were calculated in accordance with actuarial standards of practice.

I certify that the benefits included in Highmark’s plans are substantially equivalent to the Essential

Health Benefits (EHBs) in the State of Pennsylvania’s benchmark plans. I certify that any benefit

substitutions are:

Actuarially equivalent to the benefits being replaced,

Are made within only the same essential health benefit category,

Are based on a standardized plan population,

Are determined regardless of cost-sharing,

Are not prescription drug benefits, and

Are based on an analysis performed in accordance with generally accepted actuarial

principles and methodologies.

I certify that the AV Metal Values included in Worksheet 2 of the Part I Unified Rate Review Template

were based entirely on the Federal AV Calculator.

12

02/12/2016 01/29/2009

I certify that the geographic rating factors reflect only differences in the costs of delivery (which can

include unit cost and provider practice pattern differences) and do not include differences for population

morbidity by geographic area.

The Part I Unified Rate Review Template does not demonstrate the process used by Highmark to

develop the rates. Rather, it represents information required by Federal regulation to be provided in

support of the review of rate increases, for certification of qualified health plans for federally facilitated

exchanges and for certification that the index rate is developed in accordance with Federal regulation

and used consistently and only adjusted by the allowable modifiers.

Signed: [Redacted]

Date: 08/12/2016

13

05/11/2016

Exhibit I

Highmark, Inc.

2017

Pennsylvania Small Group Market Base Rate

1/1/2017 Values Trended Values*

CY2017 Projected Period Average Members 13,914 13,914

CY2017 Allowed Claims $503.46 $521.58

Projected Non-EHBs

None $0.00

CY2017 Allowed Claims for EHB Only (Index Rate) $503.46 $521.58

Market Index Rate Adjustments

Risk Adjustment (Includes Risk Adjuster Fee) 1.004

Federal Reinsurance Program (Includes Reinsurance Premium) 1.000

Exchange User Fee Adjustment 1.000

CY2017 Market Adjusted Index Rate $505.46 $523.65

Calibration

Calibration from Plan Adjusted Index Rate to Age 46, 1.0 Area, Non-Smoker, January 1, 2017 Rate

(a) Average Age Factor 1.479

(b) Age 46 (Nearest Age on HHS Age Curve) Age Factor 1.500

(c) Average Geographic Factor 0.9702

(d) Weighted Average Quarterly Trend 1.036

(e) Weighted Average Quarterly Insurer Fee Impact 1.017

Combined Calibration Factor 1/((a/b)*c*d*e) 0.9929

*Quarterly Index Rate trends are being set at 2.18%.

The following member renewal distribution by quarter is projected: 28.3% / 18.1% / 16.5% / 37.1%.

14

05/11/2016

Highmark Inc.d/b/a Highmark Blue Cross Blue Shield Exhibit II - 1

Western, PA (WPA) Regions

Unified Rate Review Template (URRT) AV Pricing Value Development

Plan Design Summary Plan Adjusted

Metallic Service Regions On or Off Index URRT AV

Highmark HIOS Plan ID Level Zone Offered Exchange Rate Pricing Value (i) (ii) (iii) (iv) (v)

33709PA0560007 Platinum Premier Balance PPO $0 Platinum A a Community Blue Flex Plan A 1,4 Off Only $552.88 1.0558 1.004 0.930 1.000 1.130 1.000

33709PA0560009 Platinum Premier Balance PPO $250 Platinum A a Community Blue Flex Plan A 1,4 Off Only $543.70 1.0383 0.988 0.930 1.000 1.130 1.000

33709PA0560011 Gold Premier Balance PPO $0 Gold A a Community Blue Flex Plan A 1,4 Off Only $468.15 0.8940 0.850 0.930 1.000 1.130 1.000

33709PA0560013 Gold Premier Balance PPO $250 Gold A a Community Blue Flex Plan A 1,4 Off Only $474.78 0.9067 0.862 0.930 1.000 1.130 1.000

33709PA0560015 Gold Premier Balance PPO $500 A a Community Blue Flex Plan A 1,4 Off Only $464.49 0.8870 0.844 0.930 1.000 1.130 1.000






33709PA0560029 Silver Premier Balance PPO $1400 A a Community Blue Flex Plan A 1,4 Off Only $394.22 0.7528 0.716 0.930 1.000 1.130 1.000

33709PA0570007 Silver Balance PPO $1000 A a Community Blue Flex Plan A 1,4 Off Only $390.84 0.7464 0.710 0.930 1.000 1.130 1.000



33709PA0450004 Gold Health Savings PPO $1500 a Community Blue Flex Plan A 1,4 Off Only $435.07 0.8308 0.790 0.930 1.000 1.130 1.000

33709PA0640001 Silver Health Savings PPO Embedded $2600 a Community Blue Flex Plan A 1,4 Off Only $384.96 0.7351 0.699 0.930 1.000 1.130 1.000

33709PA0640002 Silver Health Savings PPO Embedded $3000 a Community Blue Flex Plan A 1,4 Off Only $375.21 0.7165 0.682 0.930 1.000 1.130 1.000

33709PA0640003 Bronze Health Savings PPO Embedded $5500 a Community Blue Flex Plan A 1,4 Off Only $311.85 0.5955 0.566 0.930 1.000 1.130 1.000

33709PA0640004 Bronze Health Savings PPO Embedded $5500 a Community Blue Flex Plan B 1,2,5,6 Off Only $333.65 0.6372 0.566 0.995 1.000 1.130 1.000

33709PA0640005 Bronze Health Savings PPO Embedded $6000 a Community Blue Flex Plan A 1,4 Off Only $312.86 0.5975 0.568 0.930 1.000 1.130 1.000

[1] Permitted Plan-Level Adjustments to the Index Rate as prescribed in 45 CFR Part 156, §156.80(d)(2):

(i) The actuarial value and cost-sharing design of the plan.

(ii) The plan's provider network, delivery system characteristics, and utilization management practices.

(iii) The benefits provided under the plan that are in addition to the essential health benefits.

(iv) Administrative costs, excluding Exchange user fees.

(v) With respect to catastrophic plans, the expected impact of the specific eligibility categories for those plans.

Plan Design Marketing NamePortion of URRT AV Pricing Value Attributable to each Allowable Modifier[1]

Premier

Balance

PPO

Balance

PPO

Health

Savings

PPO

15

05/11/2016

Highmark Inc.d/b/a Highmark Blue Cross Blue Shield Exhibit II - 2

Western, PA (WPA) Regions

Unified Rate Review Template (URRT) AV Pricing Value Development

Plan Design Summary Plan Adjusted

Metallic Service Regions On or Off Index URRT AV

Highmark HIOS Plan ID Level Zone Offered Exchange Rate Pricing Value (i) (ii) (iii) (iv) (v)

33709PA0460007 Gold Flex PPO $500/$1500 Penn Highlands Region a Community Blue Plan H 2, 5, 6 Off Only $489.84 0.9354 0.841 0.983 1.000 1.130 1.000

33709PA0460008 Gold Flex PPO PA Mountains Healthcare Region $500/$1500 a Community Blue Plan G 1, 2, 4, 5 Off Only $462.88 0.8840 0.834 0.938 1.000 1.130 1.000

33709PA0460012 Gold Flex PPO $500 Total Health a Community Blue Plan A 1,4 Off Only $467.75 0.8932 0.850 0.930 1.000 1.130 1.000

33709PA0460013 Gold Flex PPO $500 Total Health a Community Blue Plan B 1,2,5,6 Off Only $498.13 0.9513 0.852 0.988 1.000 1.130 1.000

33709PA0630002 Gold Connect Blue EPO $100 a Community Blue Plan J 1,4 Off Only $435.61 0.8319 0.842 0.874 1.000 1.130 1.000






33709PA0630007 Silver Connect Blue EPO $2500 a Community Blue Plan J 1,4 Off Only $357.63 0.6830 0.691 0.874 1.000 1.130 1.000

33709PA0630009 Silver Connect Blue EPO $3200 a Community Blue Plan J 1,4 Off Only $350.72 0.6698 0.678 0.874 1.000 1.130 1.000

33709PA0440014 Gold Premier Balance PPO $250 IP A a Community Blue Flex Plan B 1,2,5,6 Off Only $504.84 0.9641 0.857 0.995 1.000 1.130 1.000

33709PA0440009 Gold Premier Balance PPO $750 IP A a Community Blue Flex Plan B 1,2,5,6 Off Only $483.69 0.9237 0.821 0.995 1.000 1.130 1.000

33709PA0440013 Silver Premier Balance PPO $1500 IP A a Community Blue Flex Plan B 1,2,5,6 Off Only $417.70 0.7977 0.709 0.995 1.000 1.130 1.000

[1] Permitted Plan-Level Adjustments to the Index Rate as prescribed in 45 CFR Part 156, §156.80(d)(2):

(i) The actuarial value and cost-sharing design of the plan.

(ii) The plan's provider network, delivery system characteristics, and utilization management practices.

(iii) The benefits provided under the plan that are in addition to the essential health benefits.

(iv) Administrative costs, excluding Exchange user fees.

(v) With respect to catastrophic plans, the expected impact of the specific eligibility categories for those plans.

Premier

Balance

PPO

Plan Design Marketing NamePortion of URRT AV Pricing Value Attributable to each Allowable Modifier[1]

Connect

Blue EPO

Flex PPO

16

05/11/2016

Exhibit III

Highmark Inc.

Small Group Market

Terminated ACA Plans

Service

Exchange Zone Regions HIOS ID Plan Design Name HIOS ID Plan Design Name

Off A 1, 4 33709PA0440001 Shared Cost PPO $0 A Community Blue Plan 33709PA0560007 Premier Balance PPO $0 Platinum A a Community Blue Flex Plan

Off A 1, 4 33709PA0440002 Shared Cost PPO $250 A Community Blue Plan 33709PA0560009 Premier Balance PPO $250 Platinum A a Community Blue Flex Plan

Off A 1, 4 33709PA0440004 Shared Cost PPO $500 A Community Blue Plan 33709PA0560015 Premier Balance PPO $500 A a Community Blue Flex Plan




Off A 1, 4 33709PA0440008 Shared Cost PPO $2000 HRA A Community Blue Plan 33709PA0560027 Premier Balance PPO $2000 A a Community Blue Flex Plan

Off A 1, 4 33709PA0440010 Shared Cost PPO $1500 Integrated RX A Community Blue Plan 33709PA0560029 Premier Balance PPO $1400 A a Community Blue Flex Plan

Off A 1, 4 33709PA0440011 Shared Cost PPO $1750 A Community Blue Plan 33709PA0570004 Balance PPO $1750 A a Community Blue Flex Plan

Off A 1, 4 33709PA0440012 Shared Cost PPO $2000 A Community Blue Plan 33709PA0570006 Balance PPO $2000 A a Community Blue Flex Plan

Off A 1, 4 33709PA0450001 Health Savings PPO Q$3500 A Community Blue Plan 33709PA0640003 Health Savings PPO Embedded $5500 a Community Blue Flex Plan

Off A 1, 4 33709PA0450002 Health Savings PPO Q$4000 A Community Blue Plan 33709PA0640003 Health Savings PPO Embedded $5500 a Community Blue Flex Plan

Off B 1, 2, 5, 6 33709PA0450003 Health Savings PPO Q$4000 A Community Blue Plan 33709PA0640004 Health Savings PPO Embedded $5500 a Community Blue Flex Plan

Off D 6, 9 33709PA0460001 Flex PPO $0/$500 A Community Blue Plan

Off D 6, 9 33709PA0460003 Flex PPO $500/$1500 A Community Blue Plan

Off D 6, 9 33709PA0460005 Flex PPO $1500 A Community Blue Plan

On & Off D 6,9 33709PA0460011 Flex PPO $2000/$4000 a Community Blue Plan

Off D 6, 9 33709PA0470001 Health Savings Q$4000 A Community Blue Plan

On A 1,4 33709PA0480001 Comprehensive Care EPO $1500 A Community Blue Plan 33709PA0560023 Premier Balance PPO $1500 A a Community Blue Flex Plan

On B 1,2,5,6 33709PA0480002 Comprehensive Care EPO $1500 A Community Blue Plan 33709PA0440009 Premier Balance PPO $750 IP A a Community Blue Flex Plan

On A 1,4 33709PA0480003 Comprehensive Care EPO $2000 A Community Blue Plan 33709PA0570006 Balance PPO $2000 A a Community Blue Flex Plan

On B 1,2,5,6 33709PA0480004 Comprehensive Care EPO $2000 A Community Blue Plan 33709PA0440013 Premier Balance PPO $1500 IP A a Community Blue Flex Plan

On D 6,9 33709PA0490001 FLEX EPO $500/$1000 A Community Blue Plan

On E 6,7,9 33709PA0490002 FLEX EPO $500/$1000 A Community Blue Plan

On D 6,9 33709PA0490003 FLEX EPO $1650 A Community Blue Plan

On E 6,7,9 33709PA0490004 FLEX EPO $1650 A Community Blue Plan

Terminating Plans Mapping To…

(none)

(none)

(none)

(none)

(none)

(none)

(none)

(none)

(none)

17

05/11/2016

Exhibit III (cont'd)

Highmark Inc.

Small Group Market

Terminated ACA Plans (cont'd)

Service

Exchange Zone Regions HIOS ID Plan Design Name HIOS ID Plan Design Name

Off A 1, 4 33709PA0560001 Premier Balance PPO $0 Gold A Community Blue Plan 33709PA0560011 Premier Balance PPO $0 Gold A a Community Blue Flex Plan

Off A 1, 4 33709PA0560002 Premier Balance PPO $500 A Community Blue Plan 33709PA0560015 Premier Balance PPO $500 A a Community Blue Flex Plan





Off A 1, 4 33709PA0570001 Balance PPO $1750 A Community Blue Plan 33709PA0570004 Balance PPO $1750 A a Community Blue Flex Plan

Off A 1, 4 33709PA0580001 High Deductible PPO $1500 Qualified A Community Blue Plan 33709PA0640001 Health Savings PPO Embedded $2600 a Community Blue Flex Plan





On & Off A 1,4 33709PA0580006 High Deductible PPO $1500 Qualified A a Community Blue Flex Plan 33709PA0640001 Health Savings PPO Embedded $2600 a Community Blue Flex Plan






On & Off J 1,4 33709PA0630001 Connect Blue EPO $0 a Community Blue Plan

Terminating Plans

(none)

Mapping To…

1 08/12/2016

Pennsylvania Actuarial Memorandum

REDACTED VERSION

1. Basic Information and Data

A. Company Information 1. Company Name & NAIC #: Highmark Inc., NAIC # 54771 (“Company”)

2. Market (Individual or Small Group): Small Group (“Market”)

3. On or Off Exchange: This Company sells Off Exchange only in the Small Group Market

4. Effective date of coverage: January 1, 2017

5. Average rate change requested: 3.23% increase

6. Range of rate change requested: -3.43% to 8.45% (PA Actuarial Memorandum Exhibits); -3.26% to

6.16% (URRT Worksheet 2 Row 27 Cumulative Rate Change % (over 12 mos prior))

Please note the rate increases by plan design will slightly differ between the PID’s Final 2017 PA

Actuarial Memorandum Rate Exhibits Rev 4-21-2017.xlsx template and URRT worksheet 2 row

27 since we maintained the 2016 quarterly distribution of enrollment as filed last year when

calculating the average 2016 Calibrated Plan Adjusted Index Rate PMPMs in column Z of table

10 in the PA Rate Exhibits while the URRT utilizes a consistent enrollment distribution by quarter

for both years based on the 2017 projected distribution. Therefore, we have included above the

range of rate changes requested from both templates. The range from the URRT would be the

more accurate way to calculate the average rate increases since it uses a consistent enrollment

basis and would not be skewed by the change in quarterly enrollment from one year to the next.

7. Product(s) (Indemnity, HMO, POS (HMOs only), PPO, or EPO): PPO, EPO

8. Rating Areas: Regions 1, 2, 4, 5, 6 (Western, PA only)

9. Metal Levels and Catastrophic Plans: This Company sells the following Metal Levels of coverage in the

Small Group Market: Platinum, Gold, Silver, Bronze

10. Current number of covered lives and of policyholders: 15,580 covered lives; 8,754 policyholders

11. Number of plans offered in 2017: 35

Inclusion of premium rates in this filing for a given offering should not be construed to mean

that the offering will ultimately be made available for sale in the market. Final offering decisions

will be made consistent with and within the timelines set forth in CMS rules and/or ACA

regulations.

2 08/12/2016

12. Corresponding contract form #, SERFF and Binder ID #s: The corresponding SERFF binder number is

HGHM-PA17-125059898 affecting the following Company products and forms:

Product Name / Type Contract Form & SERFF #

PPO PPO-SM/WG-4; HGHM-130517539

HDHP HDHP-SM/WG-4; HGHM-130517598

EPO CONB/EPO-SM/WG-1; HGHM-130517679

Flex PPO FL/PPO-SM-WG-3; HGHM-130666969

13. HIOS Issuer ID # and submission tracking #: HIOS Issuer ID # 33709, Company Filing # 1A-SG-

HIGHMARK-2016 (SERFF Filing # HGHM-130535904)

B. Rate History and Proposed Variations in Rate Changes The three most recent rate changes in Pennsylvania for the Company are as follows:

Year Avg. Increase SERFF ID#

2016 9.9% HGHM-130064391

2015 20.8% HGHM-129610942

2014 n/a – initial ACA rate filing HGHM-128994564

Rate changes tend to vary by plan, as plan benefits may need adjusted to help maintain compliance with

metal level requirements, and other base rate components are re-evaluated each year (pricing actuarial

factor and network discount). For 2017, the Company’s proposed rate revisions vary by plan, according

to the detail presented in the URRT, Worksheet 2, and the PA Rate Template Table 10.

C. Average Rate Change The SERFF Rate Review Detail Screen presents the “percent rate change requested” as a 3.23% increase.

For comparison, the change in 21-year-old non-tobacco premium PMPM calculated in Table 11, cell

AZ13, is a 3.1% increase.

D. Membership Count Please see Table 1 for the age breakdown and total number of small group members with ACA policies

only for the periods shown.

E. Benefit Changes Many plans required benefit changes because of the new Actuarial Value (AV) calculator released for

2017 effective dates. The plan changes were mostly required so that the plans remained within the

defined metal level AV requirements, and were enacted by slightly increasing member cost sharing and

the maximum out of pocket levels.

The following were changes to the Essential Health Benefits due to the 2017 Benchmark Plan:

Hospice Benefit – addition of respite care for 7 days per six months

Coverage for Artificial Insemination, including specific related medications

3 08/12/2016

Coverage for Dental Accident

Added visits for Habilitative Therapy Services

In addition, the non-EHB benefit of the Adult Vision Eye exam was removed from plan coverage.

The screenshots from the AV calculator, showing the plan benefits and the resulting actuarial value,

have been submitted as separate attachments in SERFF. Also submitted in SERFF is a detailed summary

by plan design (including HIOS ID) highlighting the benefit changes from 2016 to 2017.

F. Experience Period Claims and Premium Please see Table 2 for the experience period data for the most recent calendar year, for the Company

and Market. The experience period paid claims data represents the 2015 calendar year results for all

non-grandfathered policies (including transitional policies) in the single risk pool, with run out through

January 2016. This data is consistent with the data reported in Section I of Worksheet I of the URRT (see

below commentary).

The components of this exhibit were developed as follows:

The Earned Premium represents actual revenues earned in the experience period. Unlike the

Premiums shown in the URRT, the Earned Premiums in Table 2 have not been adjusted for

anticipated risk adjustment transfer payments. The sum of the Earned Premium and Estimated

Risk Adjustment from Table 2 total the Premiums in the URRT.

The Allowed Claims represent our best estimate of the total claims prior to member cost sharing

incurred during the experience period. The Allowed Claims include:

o One month of run out from the end of the experience period,

o Claims processed outside of the Company’s claims system (e.g., claim settlement costs),

and

o Our best estimate of claims incurred but not paid as of the end of the run out period.

Note that the Incurred Claims and Allowed Claims presented in the URRT are net of the

Prescription Drug Rebates, while Table 2 has the Prescription Drug Rebates separately

identified.

There are no non-EHB benefits or costs in the experience period.

There are no capitated claim services in the experience period.

Prescription Drug Rebates are used to reduce the level of Incurred Claims in the experience

period.

The Estimated Risk Adjustment represents our best estimate of the year end risk adjustment

transfer payment that the Company will incur based on the results in the experience period.

This amount is developed based on an analysis of Company data (risk scores as defined in the

HHS Notice of Benefit and Payment Parameters, as well as other risk transfer formula

components), and an estimate as to the Market-wide risk transfer component profile. This

Market-wide profile is developed from available Market data, including prior years’ risk

adjustment transfer results, publicly available data (such as MLR reports), and outside expertise

from actuarial consultants.

4 08/12/2016

The Small Group Market is ineligible for Reinsurance Recoveries.

G. Credibility of Data The experience period data for this Company is large enough to be fully credible. The results are based

100% on the experience period data, adjusted as described herein.

For the trend component development, this Company uses results from the combined experience of the

following companies: Highmark Inc., Highmark Choice Company, Highmark Health Insurance Company,

and Highmark Coverage Advantage. The combined experience used is limited to the Company’s Rating

Areas specified in section 1.A.8, and provides a more thorough analysis of the trend effects impacting

the business in the Company’s Market. As such, this combined experience is a more appropriate basis

to use for developing the trend component assumptions.

Given the combined company experience used in the trend analysis, the Company has provided the

requested Tables 2b and 4b within this filing submission.

H. Trend Identification Table 3 identifies the annual medical and prescription drug allowed claims cost and utilization trends, as

requested by the Pennsylvania Insurance Department. The underlying total annual trend is 9.0%, which

represents a reduction from the Company’s requested annual trend of 10.2%. The definitions of service

categories, cost, and utilization in Table 3 are consistent with the URRT instructions. The numbers

entered in the Cost and Utilization columns are consistent with those entered in Worksheet I, Section 2

of the URRT, except as noted below.

The Company’s originally filed cost trends reflect the Company’s expectations regarding increases in in-

network contractual reimbursement, as well as projected out-of-network costs. These estimates

measure and normalize for benefit leverage, population aging, and historical changes for fee schedules,

as well as company-wide utilization management programs, and external trend drivers.

The trend components represent a blended average for all types of service and are applied to the

aggregate experience for pricing, and as such Table 2 shows the same trend components for each

service category.

Note that the URRT instructions require that anticipated changes in the average utilization of services

due to differences in average cost sharing requirements from the experience period to the projection

period be reflected in the Utilization trend component shown in Worksheet I, Section 2. This

component of the trend is not reflected in Table 3, as the inclusion of this component would have

altered the underlying pricing trend required for our quarterly rate development in table 5A – Small

Group Projected Index Rate with Quarterly Trend. Therefore, the Company has provided Table 3b,

which would reflect the actual trend component values presented in the URRT. Table 3b was provided

for informational purposes only.

For this Small Group Market filing, quarterly rates are proposed, with rates adjusted each quarter based

on the Total Annual Trend presented in Table 3.

5 08/12/2016

I. Historical Experience Table 4 presents the most recent 36 months (3 calendar years) of Company data with run-out through

January 2016.

As mentioned above within Credibility of Data section, the Company utilizes experience combined from

several its available corporate entities to develop the experience used in the trend development.

Combined Historical Experience data from the above referenced companies is presented in Table 4b.

2. Rate Development & Change

A. Development of Projected Index Rate, Market-Adjusted Index Rate, & Total

Allowed Claims The development of the Projected Index Rate, Projected Market-Adjusted Index Rate, and Projected

Total Allowed Claims, shown in Table 5, closely follows that utilized the development presented in

Worksheet 1 of the URRT , a discussion of which can be found in the Part III Actuarial Memorandum

submitted in the Rate Filing Justification. Some of the items separately identified in Table 5 include:

The Change in Demographics adjustment reflects the change in age and geography factors we

expect from the experience period to the projection period.

The Change in Network adjustment reflects the change in the allowed claims we anticipate due

to network contracting changes between the experience period and the projection period.

The Change in Benefits adjustment reflects the change in the EHB benefits (autism and pediatric

benefits) we anticipate between the experience period and the projection period.

The Change in Other adjustment reflects the change in the utilization of services due to benefit

elections we anticipate between the experience period and the projection period.

Note that the URRT develops the Index Rate and the Plan Adjusted Index Rate using the projected

distribution of members by plan, whereas Table 5 uses a recent distribution (as of February 1, 2016) of

members by plan. Any comparison between the URRT values and the Table 5 values will show variances

to the extent that there are variances in the assumed underlying membership distributions.

For this Small Group Market filing, Table 5A has been completed, showing the number of member

months renewing by quarter, and the quarterly Single Risk Pool Projected Allowed Claims.

B. Retention Items Table 6 has been completed with the requested retention elements for the proposed rates for the rating

period. The amounts presented separately sum to the total administrative expenses and taxes and fees

presented in the rate development. Administrative costs reflect internal costs that the Company is

projected to incur in the projected experience period, and are developed from standard expense

allocation methods. Agent/broker fees and commissions reflect our anticipated costs for these items in

the experience period.

Note the following regarding plan level retention items:

6 08/12/2016

These revised rates reflect a 0% risk/contribution to surplus margin for all products and plans.

The Health Insurer Provider Fee is being applied quarterly, at a prorated level appropriate for

the level of premium renewing in 2018. Although the Health Insurance Provider Fee will not be

collected in 2017, the fee will be collected in 2018. As such, for any groups with renewal dates

other than January 1, 2017, the group’s renewal period will extend into 2018, where the

premiums will need to include a charge for this fee. For the 2017 rate development, the

quarterly rates have been adjusted so that the appropriate pro rata portion of this fee is

collected based on a group’s renewal quarter as follows:

Renewal Quarter

Health Insurance Provider Fee

1Q 0.000%

2Q 0.875%

3Q 1.750%

4Q 2.625%

The administrative expenses do not vary by plan.

The $0.19 PMPM Patient Centered Outcomes Research Fee was factored into the administrative

expense percentage of premium.

Expenses for Quality Improvement Initiatives are included in the general and claims admin

percentage and were not broken out separately.

Please note that for the Small Group Market the Projected Required Revenue PMPM shown in Table 6

will not match the URRT Worksheet 1 Single Risk Pool Gross Premium Average Rate PMPM since the

value in the URRT is based on a January 1 effective date without reflecting the impact of quarterly rates

in the small group market.

C. Normalized Market-Adjusted Projected Allowed Total Claims The normalization factors presented in Table 7 are each determined from the underlying membership

demographics expected in the projected rating period. The 2016 values are pulled from the prior year’s

filing, while the 2017 values represent our projection for 2017 assumed in the 2017 rate development.

D. Components of Rate Change Table 8 presents the components of change in the proposed 2017 Calibrated Plan Adjusted Index Rate

(PMPM). The 2016 base period allowed claims as developed from the 2016 rate filing. Row H of Table 8

may differ from Row A due to the detailed breakdown of all the components of the increases in rows B

through G not calculating exactly to the change in the calibrated plan adjusted index rate in Row A,

which is the more accurate percentage change based on the rate development.

Table 9 presents the data elements supporting the calculations in Table 8. Note the following

differences between the Table 9 values presented for 2016 and the values from the 2016 URRT:

The 2-year trend shown in the URRT (Cost and Util components combined) would include the

anticipated changes in the average utilization of services due to differences in average cost

sharing requirements from the experience period to the projection period. This trend

7 08/12/2016

component is removed from the URRT Trend (2-Year Trend Factor) shown in Table 9 to be

consistent with the reporting from Table 3.

The adjustment representing the anticipated changes in the average utilization of services due

to differences in average cost sharing requirements from the experience period to the

projection period is included in the URRT “Other” factor shown in Table 9 (see preceding

comment).

The Risk Adjustment shown in Table 9 is the average risk adjustment charge for the projected

experience year. In the URRT, the Projected Risk Adjustments represent the risk transfer

adjustment for January 1 effective dates only.

Taxes and Fees shown in Table 9 differ from the Taxes and Fees from the URRT as the Table 9

separates out the Exchange User Fee into a separate line item. In the URRT the Exchange User

Fee is included in the Taxes and Fees line item.

3. Plan Rate Development Table 10 showing the plan rate development has been completed following the instructions in the

Health Insurance Rate Filing Guidance. This table shows the plans that the Company intends to offer in

2017, as well as plans recently discontinued from the 2016 portfolio for 2017 or the 2015 portfolio as

members still exist in 2015 plans as of February 1, 2016 (small groups in these 2015 plans have not

renewed yet in 2016 and were included to complete the company’s enrollment in ACA plans as of

February 1, 2016). The calibrated plan adjusted index rates for 2017 and 2016, and all of the supporting

factors, are calculated according to the instructions. The rate change percentages calculated in Table 10

column AC by plan design will slightly differ between URRT worksheet 2 row 27 since the PID

spreadsheet maintains the 2016 quarterly distribution of enrollment as filed last year while the URRT

values utilizes a consistent enrollment distribution by quarter for both years based on this year’s

distribution.

Note that the HHS Actuarial Value Calculator was able to accommodate all of the Company’s benefit

designs, and that no adjustments were needed from the values produced by the calculator.

4. Plan Premium Development for 21-Year-Old Non-Tobacco User Table 11 presents the Company’s 21-year-old non-tobacco premium in the Market, premium weighted

for quarterly trend and the prorated quarterly insurer fee. As mentioned in Section 1.C above, the

change in 21-year-old non-tobacco premium PMPM calculated in this table is a 3.1% increase, which is

close to the SERFF Rate Review Detail Screen “percent rate change requested” of 3.23% which comes

from table 10.

5. Plan Factors

A. Age and Tobacco Factors Please see Table 12 for the Company’s age and tobacco factors.

8 08/12/2016

B. Geographic Factors Please see Table 13 for the Company’s geographic factors. The Company’s factors for the rating period

are unchanged from the currently approved factors.

C. Network Factors Please see Table 14 for the Company’s network rating factors.

D. Service Area Composition The Company follows the Rating Area designations created by the state. All counties within a Rating

Area are serviced by the Company, according to the Rating Areas specified in Table 14.

E. Composite Rating The Company is currently not planning to use CMS’s composite rating method for any of its off-SHOP

plans offered during the rating period; however, the Company is interested in the state adopting a

methodology for the PA Marketplace that is more consumer friendly than the CMS method by utilizing

composite rating tiers similar to transitional small group policies currently in the market (i.e. rates by

contract types of Individual, Parent/Child(ren), Two Person (Adults), and Family).

6. Actuarial Certifications I am a member of the American Academy of Actuaries and meet its qualification standards for actuaries

issuing statements of actuarial opinions in the United States. This filing is prepared on behalf of the

Company to accompany its rate filing (for calendar year 2017) for the small group combined Market on

and off the Pennsylvania Exchange.

I hereby certify that the projected index rate is, to the best of my knowledge and understanding:

In compliance with all applicable State and Federal Statutes and Regulations (45 CFR

156.80(d)(1)), and

Developed in compliance with the applicable Actuarial Standards of Practice.

As originally filed, the rates were not excessive, inadequate, or unfairly discriminatory, and were

reasonable in relationship to the benefits provided. The Pennsylvania Insurance Department has

required the Company to re-submit lower rates.

I certify that the index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 45

CFR 156.80(d)(2) were used to generate plan level rates. The allowable modifiers used to generate plan-

level rates were:

The actuarial value and cost-sharing design of the plan.

The plan’s provider network, delivery system characteristics, and utilization management

practices.

9 08/12/2016

The benefits provided under the plan that are in addition to the essential health benefits. These

estimated benefits were pooled with similar benefits within the single risk pool and the claims

experience from those benefits was utilized to determine rate variations.

Administrative costs, excluding Exchange user fees.

I certify that all factor, benefit and other changes from the prior approved filing have been disclosed in

the 2017 PA Actuarial Memorandum Rate Exhibits.

I certify that the percent of total premium that represents essential health benefits included in

Worksheet 2, Sections III and IV were calculated in accordance with actuarial standards of practice.

I certify that the benefits included in the Company’s plans are substantially equivalent to the Essential

Health Benefits (EHBs) in the State of Pennsylvania’s benchmark plans. I certify that any benefit

substitutions are:

Actuarially equivalent to the benefits being replaced,

Are made within only the same essential health benefit category,

Are based on a standardized plan population,

Are determined regardless of cost-sharing,

Are not prescription drug benefits, and

Are based on an analysis performed in accordance with generally accepted actuarial principles

and methodologies.

I certify that new plans are not considered modifications of existing plans (per the uniform modification

standards in 45 CFR 147.106).

I certify that the AV Metal Values included in Worksheet 2 of the Part I Unified Rate Review Template

were based entirely on the Federal AV Calculator.

I certify that the geographic rating factors reflect only differences in the costs of delivery (which can

include unit cost and provider practice pattern differences) and do not include differences for

population morbidity by geographic area.

The Part I Unified Rate Review Template does not demonstrate the process used by the Company to

develop the rates. Rather, it represents information required by Federal regulation to be provided in

support of the review of rate increases, for certification of qualified health plans for federally facilitated

exchanges and for certification that the index rate is developed in accordance with Federal regulation

and used consistently and only adjusted by the allowable modifiers.

I certify that the information presented in the PA Actuarial Memorandum and PA Actuarial

Memorandum Rate Exhibits is consistent with the information presented in the 2017 Rate Filing

Justification.

Signed: [Redacted]

Date: 08/12/2016

PA Rate Template Part IData Relevant to the Rate Filing

Table 1. Number of Members

Member-months Members Member-months

Experience PeriodCurrent Period

(as of Feb. 1, 2016)Projected Rating

Period

Total 155,033 15,580 166,968 <18 25,505 2,628 28,164 18-24 15,751 1,595 17,094 25-29 12,196 1,266 13,567 30-34 11,697 1,228 1316035-39 11,298 1,150 1232440-44 12,233 1,216 1303245-49 13,834 1,416 1517550-54 17,064 1,734 1858355-59 17,358 1,688 1809060-63 11,066 1,065 1141364+ 7,031 594 6366

Table 2. Experience Period Claims and Premiums


ClaimsMember Months

Estimated Cost Sharing

(Member & HHS)

Allowed Claims (Non-Capitated)

Non-EHB portion of Allowed

Claims

Total Prescription Drug Rebates*

Total EHB Capitation

Total Non-EHB Capitation Estimated Risk

Adjustment

Estimated Reinsurance Recoveries

$ 87,070,733.72 $ 78,230,888.42 $ 80,052,642.21 228,747 $ 14,316,776.00 $ 94,369,418.21 $ - $ (1,928,337.21) $ - $ - (7,419,372.72)$ -$ 2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 404.12$ Loss Ratio 98.08%*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Composite Weight*5.83% 3.00% 9.00% 16.50% <- Annualized Trend Factors on URRT5.83% 3.00% 9.00% 29.69%5.83% 3.00% 9.00% 30.16%5.83% 3.00% 9.00% 2.76%

0.00% 0.00%5.83% 3.00% 9.00% 20.88%

9.00% 100.00%1.188


Table 4. Historical Experience

Month-Year Total Annual Premium Incurred Claims Completion Factors*Ultimate Incurred

ClaimsMembers

Ultimate Incurred PMPM

Estimated Annual Cost Sharing

(Member + HHS)

Prescription Drug Rebates**

Allowed Claims (Net of Prescription Drug Rebates)

Allowed PMPM

Jan-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Feb-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!

Mar-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Apr-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!

May-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Jun-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Jul-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!

Aug-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Sep-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Oct-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!

Nov-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Dec-13 $ - 0.0000 #DIV/0! - #DIV/0! $ - $ - #DIV/0!Jan-14 $ 560,050.89 0.9993 $ 560,443.63 1,392 $ 402.62 $ (10,509.60) $ 637,758.46 $ 458.16 Feb-14 $ 615,894.92 0.9991 $ 616,430.00 1,616 $ 381.45 $ (12,200.80) $ 737,104.23 $ 456.13

Mar-14 $ 813,436.50 0.9990 $ 814,265.83 2,492 $ 326.75 $ (18,814.60) $ 956,834.15 $ 383.96 Apr-14 $ 1,377,568.82 0.9989 $ 1,379,126.64 4,349 $ 317.11 $ (32,834.95) $ 1,651,991.98 $ 379.86

May-14 $ 1,263,402.64 0.9983 $ 1,265,538.85 4,995 $ 253.36 $ (37,712.25) $ 1,539,541.56 $ 308.22 Jun-14 $ 1,516,293.10 0.9981 $ 1,519,198.62 5,601 $ 271.24 $ (42,287.55) $ 1,810,506.49 $ 323.25 Jul-14 $ 2,364,658.63 0.9980 $ 2,369,397.51 6,849 $ 345.95 $ (51,709.95) $ 2,786,734.73 $ 406.88

Aug-14 $ 2,437,448.35 0.9977 $ 2,443,173.00 7,156 $ 341.42 $ (54,027.80) $ 2,863,862.48 $ 400.20 Sep-14 $ 2,131,216.88 0.9972 $ 2,137,230.29 7,576 $ 282.11 $ (57,198.80) $ 2,557,207.44 $ 337.54 Oct-14 $ 3,055,051.51 0.9975 $ 3,062,739.61 8,182 $ 374.33 $ (61,774.10) $ 3,548,067.30 $ 433.64

Nov-14 $ 2,647,880.64 0.9968 $ 2,656,324.31 8,632 $ 307.73 $ (65,171.60) $ 3,081,509.12 $ 356.99 Dec-14 $ 4,977,321.84 0.9966 $ 4,994,340.62 16,314 $ 306.14 $ (123,170.70) $ 6,092,881.13 $ 373.48 Jan-15 $ 5,334,615.25 0.9966 $ 5,352,987.01 17,615 $ 303.89 $ (148,494.45) $ 6,593,109.88 $ 374.29 Feb-15 $ 5,037,457.26 0.9958 $ 5,058,590.36 17,663 $ 286.39 $ (148,899.09) $ 6,114,857.30 $ 346.20

Mar-15 $ 6,492,490.47 0.9956 $ 6,521,119.76 17,794 $ 366.48 $ (150,003.42) $ 7,773,514.16 $ 436.86 Apr-15 $ 6,140,456.36 0.9930 $ 6,183,958.17 18,367 $ 336.69 $ (154,833.81) $ 7,409,899.71 $ 403.44

May-15 $ 5,480,855.98 0.9919 $ 5,525,631.65 18,549 $ 297.89 $ (156,368.07) $ 6,598,157.19 $ 355.71 Jun-15 $ 5,837,139.77 0.9903 $ 5,894,457.93 18,761 $ 314.19 $ (158,155.23) $ 7,091,576.09 $ 378.00 Jul-15 $ 6,544,398.37 0.9889 $ 6,617,826.88 19,699 $ 335.95 $ (166,062.57) $ 7,947,793.12 $ 403.46

Aug-15 $ 6,398,836.14 0.9854 $ 6,493,503.40 19,714 $ 329.39 $ (166,189.02) $ 7,620,071.03 $ 386.53 Sep-15 $ 7,125,147.50 0.9811 $ 7,262,113.38 19,737 $ 367.94 $ (166,382.91) $ 8,375,698.14 $ 424.37 Oct-15 $ 7,503,532.78 0.9539 $ 7,865,991.31 20,151 $ 390.35 $ (169,872.93) $ 9,073,767.34 $ 450.29

Nov-15 $ 7,540,986.93 0.9493 $ 7,943,889.20 20,316 $ 391.02 $ (171,263.88) $ 9,072,333.47 $ 446.56 Dec-15 $ 6,586,925.07 0.8896 $ 7,404,235.95 20,381 $ 363.29 $ (171,811.83) $ 8,770,303.57 $ 430.32

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

$ -

$ 4,445,790.15

$ 14,316,776.00

$ -

$ 26,544,827.70

$ 79,651,361.00

2 Year Trend Projection Factor

Service Category

Other Medical CapitationPrescription DrugsTotal Annual Trend

Inpatient HospitalOutpatient HospitalProfessional

Table 2b. Experience Period Claims and Premiums Table 2c. Experience Period Claims and Premiums


ClaimsMember Months


(Member & HHS)

Allowed Claims (Non-Capitated)

Non-EHB portion of

Allowed Claims

Total Prescription Drug

Rebates*


Total Non-EHB Capitation

Estimated Risk Adjustment


Earned Premium

Paid ClaimsUltimate

Incurred ClaimsMember Months


(Member & HHS)

Allowed Claims (Non-

Capitated)

Non-EHB portion of

Allowed Claims

Total Prescription

Drug Rebates*


Total Non-EHB

Capitation

Estimated Risk Adjustment


$ 401,198,742.84 $ 345,462,515.27 $ 353,303,779.19 1,036,544 $ 55,193,455.76 $ 408,497,234.96 $ - $ (8,738,065.92) $ - $ - -$ -$ 2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 385.67$ 2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) #DIV/0!Loss Ratio 85.88% Loss Ratio #DIV/0!*Express Prescription Drug Rebates as a negative number *Express Prescription Drug Rebates as a negative number

Table 3b. Trend Components

Cost* Utilization* Composite Weight*5.83% 2.62% 8.59% 16.50% <- Annualized Trend Factors on URRT5.83% 2.62% 8.59% 29.69%5.83% 2.62% 8.59% 30.16%5.83% 2.62% 8.59% 2.76%

0.00%5.83% 2.62% 8.59% 20.88%

8.59% 100.00%1.179


Table 4b. Historical Experience

Month-YearTotal Annual

PremiumIncurred Claims

Completion Factors*

Ultimate Incurred Claims

MembersUltimate Incurred PMPM

Estimated Annual Cost

Sharing (Member + HHS)

Prescription Drug Rebates**

Allowed Claims (Net of

Prescription Drug Rebates)

Allowed PMPM

Jan-13 $ 47,094,100.75 1.0000 $ 47,093,492.22 137,343 $ 342.89 $ (863,887.47) $ 55,051,478.26 $ 400.83 Feb-13 $ 42,289,281.67 1.0000 $ 42,290,894.96 137,101 $ 308.47 $ (862,365.29) $ 48,725,875.56 $ 355.40

Mar-13 $ 45,916,195.65 0.9999 $ 45,919,671.11 136,821 $ 335.62 $ (860,604.09) $ 52,288,991.26 $ 382.17 Apr-13 $ 43,298,690.68 0.9999 $ 43,303,948.97 134,482 $ 322.01 $ (845,891.78) $ 50,411,534.16 $ 374.86

May-13 $ 45,927,805.79 0.9999 $ 45,934,292.91 134,609 $ 341.24 $ (846,690.61) $ 52,546,336.11 $ 390.36 Jun-13 $ 41,476,721.49 0.9998 $ 41,484,881.67 134,246 $ 309.02 $ (844,407.34) $ 47,160,285.37 $ 351.30 Jul-13 $ 41,856,841.83 0.9998 $ 41,865,311.06 128,461 $ 325.90 $ (808,019.69) $ 49,296,224.61 $ 383.74

Aug-13 $ 41,213,055.72 0.9996 $ 41,229,689.18 127,697 $ 322.87 $ (803,214.13) $ 47,676,979.45 $ 373.36 Sep-13 $ 41,199,719.57 0.9995 $ 41,218,432.04 127,667 $ 322.86 $ (803,025.43) $ 47,056,849.78 $ 368.59 Oct-13 $ 45,564,252.71 0.9996 $ 45,582,621.00 126,284 $ 360.95 $ (794,326.36) $ 52,052,508.26 $ 412.19

Nov-13 $ 41,727,970.42 0.9994 $ 41,753,300.30 126,594 $ 329.82 $ (796,276.26) $ 47,097,256.50 $ 372.03 Dec-13 $ 38,955,637.94 0.9994 $ 38,980,275.90 126,253 $ 308.75 $ (794,131.37) $ 45,997,725.16 $ 364.33 Jan-14 $ 41,446,123.07 0.9993 $ 41,475,187.00 122,764 $ 337.84 $ (926,868.20) $ 48,552,739.40 $ 395.50 Feb-14 $ 41,540,596.26 0.9991 $ 41,576,686.64 122,489 $ 339.43 $ (924,791.95) $ 47,422,458.69 $ 387.16

Mar-14 $ 42,801,205.14 0.9990 $ 42,844,842.67 122,813 $ 348.86 $ (927,238.15) $ 49,081,221.54 $ 399.64 Apr-14 $ 42,989,641.93 0.9989 $ 43,038,256.83 121,283 $ 354.86 $ (915,686.65) $ 48,937,045.39 $ 403.49

May-14 $ 40,420,557.64 0.9983 $ 40,488,902.28 120,778 $ 335.23 $ (911,873.90) $ 45,790,299.80 $ 379.13 Jun-14 $ 41,267,965.12 0.9981 $ 41,347,042.75 120,730 $ 342.48 $ (911,511.50) $ 46,460,705.05 $ 384.83 Jul-14 $ 39,735,681.03 0.9980 $ 39,815,313.18 116,304 $ 342.34 $ (878,095.20) $ 45,378,254.34 $ 390.17

Aug-14 $ 38,518,166.81 0.9977 $ 38,608,631.45 116,474 $ 331.48 $ (879,378.70) $ 43,642,954.44 $ 374.70 Sep-14 $ 39,478,562.17 0.9972 $ 39,589,954.25 116,843 $ 338.83 $ (882,164.65) $ 44,599,237.44 $ 381.70 Oct-14 $ 46,912,368.28 0.9975 $ 47,030,424.14 115,629 $ 406.74 $ (872,998.95) $ 52,219,729.42 $ 451.61

Nov-14 $ 40,625,109.99 0.9968 $ 40,754,657.01 114,676 $ 355.39 $ (865,803.80) $ 45,212,402.41 $ 394.26 Dec-14 $ 30,621,336.72 0.9966 $ 30,726,039.13 95,765 $ 320.85 $ (723,025.75) $ 36,889,165.32 $ 385.21 Jan-15 $ 29,254,579.34 0.9966 $ 29,355,328.53 90,834 $ 323.18 $ (765,730.62) $ 35,130,215.98 $ 386.75 Feb-15 $ 28,618,144.97 0.9958 $ 28,738,203.63 90,004 $ 319.30 $ (758,733.72) $ 33,702,866.00 $ 374.46

Mar-15 $ 30,824,930.90 0.9956 $ 30,960,856.51 89,533 $ 345.80 $ (754,763.19) $ 36,138,372.23 $ 403.63 Apr-15 $ 28,757,556.35 0.9930 $ 28,961,288.07 88,321 $ 327.91 $ (744,546.03) $ 33,635,610.07 $ 380.83

May-15 $ 27,675,720.45 0.9919 $ 27,901,816.35 87,982 $ 317.13 $ (741,688.26) $ 32,005,815.13 $ 363.78 Jun-15 $ 30,075,914.51 0.9903 $ 30,371,246.88 87,861 $ 345.67 $ (740,668.23) $ 34,823,959.83 $ 396.35 Jul-15 $ 29,332,975.40 0.9889 $ 29,662,092.99 85,857 $ 345.48 $ (723,774.51) $ 34,290,851.41 $ 399.39

Aug-15 $ 26,569,625.03 0.9854 $ 26,962,708.00 85,437 $ 315.59 $ (720,233.91) $ 30,968,548.72 $ 362.47 Sep-15 $ 28,475,728.97 0.9811 $ 29,023,114.60 85,248 $ 340.46 $ (718,640.64) $ 32,959,279.95 $ 386.63 Oct-15 $ 28,221,792.68 0.9539 $ 29,585,047.79 83,905 $ 352.60 $ (707,319.15) $ 33,753,036.85 $ 402.28

Nov-15 $ 27,503,504.89 0.9493 $ 28,972,971.00 83,603 $ 346.55 $ (704,773.29) $ 32,771,914.19 $ 391.99 Dec-15 $ 21,413,975.85 0.8896 $ 24,071,038.94 77,959 $ 308.77 $ (657,194.37) $ 29,578,712.80 $ 379.41

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

Capitation

Service CategoryInpatient HospitalOutpatient HospitalProfessionalOther Medical

$ 401,198,742.84 $ 55,193,469.89

Prescription DrugsTotal Annual Trend2 Year Trend Projection Factor

$ 580,213,211.27 $ 78,705,233.16

$ 517,240,157.74 $ 66,890,275.90

PA Rate Template Part IIRate Development and Change

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

2015 Total Allowed EHB Claims PMPM + EHB Capitation PMPM (net of prescription drug rebates) $404.12 <- Index Rate of Experience Period on URRT Table 5A. Small Group Projected Index Rate with Quarterly Trend 2 Year Trend Projection Factor 1.188Unadjusted Projected Allowed EHB Claims PMPM 480.13$ January April July October Total Single Risk PoolSingle Risk Pool Adjustment Factors <- Adj't. from Experience to Projection Period - Pop'l risk Morbidity on URRT # of Member Months Renewing in Quarter 3,935 2,515 2,297 5,167 13,914.00 Change in Morbidity 1.075 <- Adj't. from Experience to Projection Period - Other on URRT Percent of Members Months Renewing in Quarter 28% 18% 17% 37% 100% Change in Other 0.975 Base Allowed Claims 503.46$ 503.46$ 503.46$ 503.46$ 503.46$ Change in Demographics 1.035 Months of Trend - 3 6 9 5 Change in Network 0.933 Annual Trend 9.00% 9.00% 9.00% 9.00% 9.00% Change in Benefits 1.017 Single Risk Pool Projected Allowed Claims 503.46$ 514.42$ 525.62$ 537.07$ 521.58$ Change in Other 0.993Adjusted Projected Allowed EHB Claims PMPM 503.46$ <- Index Rate for Projection Period on URRT - Individual (Small Group 1rst Qtr)Adjusted Projected Allowed EHB Claims PMPM [will only populate for small group filings] 521.58$ <- Index Rate for Projection Period on URRT - Small Group Projected Paid to Allowed Ratio 0.849984673 <- Paid to Allowed Average Factor in Projection Period on URRTProjected Paid EHB Claims PMPM 443.3352071Market-wide Adjustments Projected Paid Net Risk Adjustment PMPM 1.76$ Projected Paid Exchange User Fees PMPM -$

Market-Adjusted Projected Paid EHB Claims PMPM 445.10$

Market-Adjusted Projected Allowed EHB Claims PMPM 523.65$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM

Market-Adjusted Projected Paid Total Claims PMPM 445.10$

Market-Adjusted Projected Allowed Total Claims PMPM 523.65$

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

Retention Items - Express in percentages Normalization Factors 2016 2017Administrative Expenses 10% Average Age Factor 1.459 1.484 General and Claims 6.78% Average Geographic Factor 0.970 0.970

Agent/Broker Fees and Commissions 2.74% Average Tobacco Factor 1.000 1.000 Quality Improvement Initiatives 0.51% Average Benefit Richness (induced demand) 1.120 1.115Taxes and Fees 1.42% Average Network Factor 0.912 0.933 PCORI Fees (Enter $ amount here: $______________ ) 0.04% Pa Premium Tax (if applicable) 0.00% Market-Adjusted Projected Allowed Total Claims PMPM 485.54$ 523.65$ Federal Income Tax 0.00% Health Insurance Providers Fee (only for small group market, prorated for coverage in 2018) 1.42% Normalized Market-Adjusted Projected Allowed Total Claims PMPM 335.82$ 349.50$

Profit/Contingency 0%

Total Retention 11%<- Single Pool Gross Premium Avg. Rate, PMPM on URRT

Projected Required Revenue PMPM 502.90$

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

Rate Components 2016 2017 Difference Percent Change 2016 2017

A. Calibrated Plan Adjusted Index Rate (PMPM) 313.0770781 323.2023635 $10.13 3.2% Paid-to-Allowed 0.857273712 0.849984673

B. Base period allowed claims before normalization 367.74$ 404.12$ $36.38 12% URRT Trend (2-Year Trend Factor) 1.21 1.19 <- URRT W1, S2 C. Normalization factor component of change (113.40)$ -134.3968337 -$21.00 -$0.07 URRT Morbidity 1.132720109 1.075 <- URRT W1, S2

URRT "Other" 0.942651908 0.975 <- URRT W1, S2D. Change in Normalized Allowed Claims Adjustment Components D1. Base period allowed claims after normalization 254.34$ 269.72$ 15.39$ 5% Risk Adjustment (11.04)$ 1.76$ <- URRT W1, S3 D2. URRT Trend 53.41$ 50.73$ (2.68)$ -1% Reinsurance 2.25$ -$ <- URRT W1, S3 D3. URRT Morbidity 40.84$ 24.18$ (16.66)$ -5% Exchange User Fee 0.83$ -$ <- URRT W1, S3 D4. URRT Other (19.99)$ (8.62)$ 11.37$ 4% Capitation -$ -$ <- URRT W1, S2 D5. Normalized URRT RA/RI on an allowed basis (7.09)$ 1.38$ 8.48$ 3% D6. Normalized Exchange User Fee on an allowed basis 0.67$ -$ (0.67)$ 0% Network 0.921 0.935967734 D7. Subtotal - Sum(D1:D6) 322.17$ 337.41$ 15.23$ 5% Pricing AV 0.834 0.802069191E. Change in Allowable Plan Adjusted Level Components Benefit Richness 1.092 1.083066752 E1. Network (25.42)$ -21.60488077 3.81$ 1% Catastrophic Eligibility 1.000 1 E2. Pricing AV (49.35)$ (62.51)$ (13.16)$ -4% E3. Benefit Richness 22.83$ 21.04$ (1.79)$ -1% Administrative Expenses 8.52% 10.03% E4. Catastrophic Eligibility -$ -$ -$ 0% Taxes and Fees 3.20% 1.46% E5. Subtotal - Sum(E1:E4) (51.94)$ (63.07)$ (11.14)$ -4% Profit and/or Contingency 0.00% 0.00%F. Change in Retention Components F1. Administrative Expenses 26.67$ 32.43$ 5.76$ 2% F2. Taxes and Fees 10.02$ 4.72$ (5.29)$ -2% F3. Profit and/or Contingency -$ -$ -$ 0% F4. Subtotal - Sum(F1:F3) 36.69$ 37.15$ 0.46$ 0%

G. Change in Miscellaneous Items -$ 0%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 306.93$ 311.48$ 4.56$ 1%

PA Rate Template Part IIITable 10. Plan Rates

Age Calibration Factor 1.478541976Carrier Name: Highmark Geographic Calibration Factor 0.970Plan Type(s): PPO/EPO Aggregate Calibration Factor 1.434Market Segment: Small GroupRate Effective Date: 1/1/2017Market Adjusted Index Rate 523.65$


Plan Type (HMO, POS, PPO, EPO,

Indemnity, Other)1/1/16 Plan

Marketing Name

Discontinued, New, Modified, Existing (D,N,M,E) for 2017

1/1/17 Plan Marketing Name

(If 1/1/16 Plan Discontinued) Metallic Tier

Metallic Tier Actuarial

Value

Standard AV, Approach (1), Approach (2)

Exchange On/Off or

Off

Pricing AV (company-determined

AV)

Benefit Richness (induced demand)

Benefits in addition to

EHBProvider Network

Catastrophic Eligibility

Tobacco Surcharge

AdjustmentPure

Premium Admin Costs

Taxes & Fees (not including Exchange

fees)Profit or

Contingency

Total Covered Lives @

2/1/2016

Total Policyholders @

2/1/2016

2016 Calibrated Plan Adjusted Index

Rate PMPM

2017 Calibrated Plan Adjusted Index

Rate PMPM

Change

Compared to Prior 12 months

% of Total Covered Lives

Totals 0.759 0.802 0.971 1.000 1.003 1.000 1.000 410.33$ 10.1% 1.4% 0.0% 15,580 8,754 313.08$ 323.20$ 3.23%

Plan 1 33709PA0560007 PPO Premier Balance PPO $0 Plati M Premier Balance PPO $0 Pla Platinum 0.90283164 Standard Off 0.909 1.031 1.000 0.996 1.000 1.000 $489.10 10.1% 1.4% 0.0% 2,456 1,286 368.57$ $385.25 4.5% 15.8%Plan 2 33709PA0560009 PPO Premier Balance PPO $250 Pl M Premier Balance PPO $250 P Platinum 0.89529369 Standard Off 0.894 1.031 1.000 0.996 1.000 1.000 $480.97 10.1% 1.4% 0.0% 794 415 362.95$ $378.84 4.4% 5.1%Plan 3 33709PA0560011 PPO Premier Balance PPO $0 Gold M Premier Balance PPO $0 Go Gold 0.81299199 Standard Off 0.819 0.969 1.000 0.996 1.000 1.000 $414.14 10.1% 1.4% 0.0% 1,444 749 312.17$ $326.21 4.5% 9.3%Plan 4 33709PA0560013 PPO Premier Balance PPO $250 Go M Premier Balance PPO $250 G Gold 0.80730215 Standard Off 0.831 0.969 1.000 0.996 1.000 1.000 $420.01 10.1% 1.4% 0.0% 366 236 319.34$ $330.82 3.6% 2.3%Plan 5 33709PA0560015 PPO Premier Balance PPO $500 A M Premier Balance PPO $500 A Gold 0.7987237 Standard Off 0.813 0.969 1.000 0.996 1.000 1.000 $410.91 10.1% 1.4% 0.0% 2,277 1,288 314.81$ $323.66 2.8% 14.6%Plan 6 33709PA0560017 PPO Premier Balance PPO $750 A M Premier Balance PPO $750 A Gold 0.79261365 Standard Off 0.803 0.969 1.000 0.996 1.000 1.000 $405.65 10.1% 1.4% 0.0% 312 204 310.28$ $319.52 3.0% 2.0%Plan 7 33709PA0560019 PPO Premier Balance PPO $1000 A M Premier Balance PPO $1000 Gold 0.7828763 Standard Off 0.790 0.969 1.000 0.996 1.000 1.000 $399.13 10.1% 1.4% 0.0% 1,568 890 305.75$ $314.38 2.8% 10.1%Plan 8 33709PA0560021 PPO Premier Balance PPO $1250 A M Premier Balance PPO $1250 Gold 0.78293044 Standard Off 0.784 0.969 1.000 0.996 1.000 1.000 $396.00 10.1% 1.4% 0.0% 360 213 301.97$ $311.91 3.3% 2.3%Plan 9 33709PA0560023 PPO Premier Balance PPO $1500 A M Premier Balance PPO $1500 Gold 0.78179497 Standard Off 0.778 0.969 1.000 0.996 1.000 1.000 $393.07 10.1% 1.4% 0.0% 745 368 299.71$ $309.60 3.3% 4.8%Plan 10 33709PA0560027 PPO Premier Balance PPO $2000 A M Premier Balance PPO $2000 Gold 0.78071105 Standard Off 0.769 0.969 1.000 0.996 1.000 1.000 $388.87 10.1% 1.4% 0.0% 445 273 296.69$ $306.30 3.2% 2.9%Plan 11 33709PA0560029 PPO Premier Balance PPO $1400 A M Premier Balance PPO $1400 Silver 0.71692269 Standard Off 0.724 0.924 1.000 0.996 1.000 1.000 $348.74 10.1% 1.4% 0.0% 1,157 643 266.39$ $274.69 3.1% 7.4%Plan 12 33709PA0570007 PPO Balance PPO $1000 A a Comm M Balance PPO $1000 A a Com Silver 0.71893487 Standard Off 0.717 0.924 1.000 0.996 1.000 1.000 $345.76 10.1% 1.4% 0.0% 43 36 262.07$ $272.34 3.9% 0.3%Plan 13 33709PA0570004 PPO Balance PPO $1750 A a Comm M Balance PPO $1750 A a Com Silver 0.71643663 Standard Off 0.706 0.924 1.000 0.996 1.000 1.000 $340.21 10.1% 1.4% 0.0% 335 204 258.83$ $267.97 3.5% 2.2%Plan 14 33709PA0570006 PPO Balance PPO $2000 A a Comm M Balance PPO $2000 A a Com Silver 0.71031073 Standard Off 0.699 0.924 1.000 0.996 1.000 1.000 $336.84 10.1% 1.4% 0.0% 435 262 256.32$ $265.31 3.5% 2.8%Plan 15 33709PA0450004 PPO Health Savings PPO $1500 a C M Health Savings PPO $1500 a Gold 0.78310018 Standard Off 0.762 0.969 1.000 0.996 1.000 1.000 $384.88 10.1% 1.4% 0.0% 66 34 289.90$ $303.16 4.6% 0.4%Plan 16 33709PA0640001 PPO Health Savings PPO Embedde M Health Savings PPO Embedd Silver 0.70242325 Standard Off 0.707 0.924 1.000 0.996 1.000 1.000 $340.55 10.1% 1.4% 0.0% 20 11 276.83$ $268.24 -3.1% 0.1%Plan 17 33709PA0640002 PPO Health Savings PPO Embedde M Health Savings PPO Embedd Silver 0.68864547 Standard Off 0.689 0.924 1.000 0.996 1.000 1.000 $331.92 10.1% 1.4% 0.0% 21 15 270.71$ $261.44 -3.4% 0.1%Plan 18 33709PA0640003 PPO Health Savings PPO Embedde M Health Savings PPO Embedd Bronze 0.61867689 Standard Off 0.590 0.897 1.000 0.996 1.000 1.000 $275.88 10.1% 1.4% 0.0% 50 27 218.79$ $217.30 -0.7% 0.3%Plan 19 33709PA0640004 PPO Health Savings PPO Embedde M Health Savings PPO Embedd Bronze 0.61871587 Standard Off 0.590 0.897 1.000 1.066 1.000 1.000 $295.16 10.1% 1.4% 0.0% - - 237.46$ $232.49 -2.1% 0.0%Plan 20 33709PA0640005 PPO Health Savings PPO Embedde M Health Savings PPO Embedd Bronze 0.61875661 Standard Off 0.591 0.897 1.000 0.996 1.000 1.000 $276.77 10.1% 1.4% 0.0% 6 3 215.65$ $218.00 1.1% 0.0%Plan 21 33709PA0460012 PPO Flex PPO $500 Total Health a M Flex PPO $500 Total Health Gold 0.79744542 Standard Off 0.819 0.969 1.000 0.996 1.000 1.000 $413.79 10.1% 1.4% 0.0% 102 57 314.47$ $325.93 3.6% 0.7%Plan 22 33709PA0460013 PPO Flex PPO $500 Total Health a M Flex PPO $500 Total Health Gold 0.79867497 Standard Off 0.821 0.969 1.000 1.058 1.000 1.000 $440.66 10.1% 1.4% 0.0% 215 130 342.20$ $347.09 1.4% 1.4%Plan 23 33709PA0630002 EPO Connect Blue EPO $100 a Co M Connect Blue EPO $100 a Co Gold 0.81791609 Standard Off 0.811 0.969 1.000 0.936 1.000 1.000 $385.36 10.1% 1.4% 0.0% 36 20 286.41$ $303.53 6.0% 0.2%Plan 24 33709PA0630003 EPO Connect Blue EPO $250 a Co M Connect Blue EPO $250 a Co Gold 0.81839759 Standard Off 0.808 0.969 1.000 0.936 1.000 1.000 $383.79 10.1% 1.4% 0.0% 6 6 290.71$ $302.30 4.0% 0.0%Plan 25 33709PA0630004 EPO Connect Blue EPO $500 a Co M Connect Blue EPO $500 a Co Gold 0.81187654 Standard Off 0.797 0.969 1.000 0.936 1.000 1.000 $378.33 10.1% 1.4% 0.0% 82 55 282.82$ $298.00 5.4% 0.5%Plan 26 33709PA0630005 EPO Connect Blue EPO $750 a Co M Connect Blue EPO $750 a Co Gold 0.80967813 Standard Off 0.792 0.969 1.000 0.936 1.000 1.000 $376.19 10.1% 1.4% 0.0% 9 7 279.59$ $296.31 6.0% 0.1%Plan 27 33709PA0630006 EPO Connect Blue EPO $900 a Co M Connect Blue EPO $900 a Co Gold 0.79100727 Standard Off 0.774 0.969 1.000 0.936 1.000 1.000 $367.69 10.1% 1.4% 0.0% - - 278.15$ $289.61 4.1% 0.0%Plan 28 33709PA0630008 EPO N Connect Blue EPO $1100 a C Gold 0.78577049 Standard Off 0.768 0.969 1.000 0.936 1.000 1.000 $364.74 10.1% 1.4% 0.0% - - -$ $287.30 #DIV/0! 0.0%Plan 29 33709PA0630007 EPO Connect Blue EPO $2500 a Co M Connect Blue EPO $2500 a C Silver 0.7195701 Standard Off 0.698 0.924 1.000 0.936 1.000 1.000 $316.37 10.1% 1.4% 0.0% 22 12 242.00$ $249.20 3.0% 0.1%Plan 30 33709PA0630009 EPO N Connect Blue EPO $3200 a C Silver 0.70662667 Standard Off 0.685 0.924 1.000 0.936 1.000 1.000 $310.26 10.1% 1.4% 0.0% - - -$ $244.38 #DIV/0! 0.0%Plan 31 33709PA0440014 PPO Premier Balance PPO $250 IP M Premier Balance PPO $250 I Gold 0.80948214 Standard Off 0.826 0.969 1.000 1.066 1.000 1.000 $446.60 10.1% 1.4% 0.0% 530 302 342.76$ $351.77 2.6% 3.4%Plan 32 33709PA0440009 PPO Premier Balance PPO $750 IP M Premier Balance PPO $750 I Gold 0.78629524 Standard Off 0.791 0.969 1.000 1.066 1.000 1.000 $427.89 10.1% 1.4% 0.0% 348 208 332.13$ $337.04 1.5% 2.2%Plan 33 33709PA0440013 PPO Premier Balance PPO $1500 I M Premier Balance PPO $1500 Silver 0.71744206 Standard Off 0.717 0.924 1.000 1.066 1.000 1.000 $369.51 10.1% 1.4% 0.0% 375 239 281.65$ $291.05 3.3% 2.4%Plan 34 33709PA0460007 PPO Flex PPO $500/$1500 Penn H M Flex PPO $500/$1500 Penn Gold 0.7963 Standard Off 0.811 0.969 1.000 1.054 1.000 1.000 $433.33 10.1% 1.4% 0.0% 47 28 334.29$ $341.32 2.1% 0.3%Plan 35 33709PA0460008 PPO Flex PPO PA Mountains Healt M Flex PPO PA Mountains Hea Gold 0.7936 Standard Off 0.804 0.969 1.000 1.004 1.000 1.000 $409.48 10.1% 1.4% 0.0% 10 5 310.64$ $322.54 3.8% 0.1%Plan 36 33709PA0480001 PPO Comprehensive Care EPO $15 D 2016 Premier Balance PPO $1500 Gold Standard Off 0.778 0.969 1.000 0.996 1.000 1.000 $393.07 10.1% 1.4% 0.0% 16 9 294.05$ $309.60 5.3% 0.1%Plan 37 33709PA0480002 PPO Comprehensive Care EPO $15 D 2016 Premier Balance PPO $750 I Gold Standard Off 0.791 0.969 1.000 1.066 1.000 1.000 $427.89 10.1% 1.4% 0.0% - - 318.63$ $337.04 5.8% 0.0%Plan 38 33709PA0480003 PPO Comprehensive Care EPO $20 D 2016 Balance PPO $2000 A a Com Silver Standard Off 0.699 0.924 1.000 0.996 1.000 1.000 $336.84 10.1% 1.4% 0.0% 23 13 247.68$ $265.31 7.1% 0.1%Plan 39 33709PA0480004 PPO Comprehensive Care EPO $20 D 2016 Premier Balance PPO $1500 Silver Standard Off 0.717 0.924 1.000 1.066 1.000 1.000 $369.51 10.1% 1.4% 0.0% - - 268.38$ $291.05 8.4% 0.0%Plan 40 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 10.1% 1.4% 0.0% - - -$ $412.46 #DIV/0! 0.0%Plan 41 33709PA0580006 PPO D 2015 Health Savings PPO Embedd Silver Standard Off 0.707 0.924 1.000 0.996 1.000 1.000 $340.55 10.1% 1.4% 0.0% 458 255 276.83$ $268.24 -3.1% 2.9%Plan 42 33709PA0580008 PPO D 2015 Health Savings PPO Embedd Silver Standard Off 0.707 0.924 1.000 0.996 1.000 1.000 $340.55 10.1% 1.4% 0.0% 43 33 276.83$ $268.24 -3.1% 0.3%Plan 43 33709PA0580010 PPO D 2015 Health Savings PPO Embedd Bronze Standard Off 0.590 0.897 1.000 0.996 1.000 1.000 $275.88 10.1% 1.4% 0.0% 107 52 218.79$ $217.30 -0.7% 0.7%Plan 44 33709PA0580012 PPO D 2015 Health Savings PPO Embedd Bronze Standard Off 0.590 0.897 1.000 0.996 1.000 1.000 $275.88 10.1% 1.4% 0.0% 20 18 218.79$ $217.30 -0.7% 0.1%Plan 45 33709PA0580014 PPO D 2015 Health Savings PPO Embedd Bronze Standard Off 0.590 0.897 1.000 0.996 1.000 1.000 $275.88 10.1% 1.4% 0.0% 28 21 218.79$ $217.30 -0.7% 0.2%Plan 46 33709PA0580016 PPO D 2015 Health Savings PPO Embedd Bronze Standard Off 0.590 0.897 1.000 0.996 1.000 1.000 $275.88 10.1% 1.4% 0.0% 122 77 218.79$ $217.30 -0.7% 0.8%Plan 47 33709PA0450003 PPO D 2015 Health Savings PPO Embedd Bronze Standard Off 0.590 0.897 1.000 1.066 1.000 1.000 $295.16 10.1% 1.4% 0.0% 81 50 237.46$ $232.49 -2.1% 0.5%Plan 48 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9% 1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%Plan 49 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9% 1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%Plan 50 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9% 1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%Plan 51 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9% 1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%Plan 52 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9% 1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%Plan 53 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9% 1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%Plan 54 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9% 1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%Plan 55 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 9.9% 1.4% 0.0% - - -$ $411.56 #DIV/0! 0.0%Plan 56 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 57 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 58 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 59 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 60 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 61 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 62 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 63 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 64 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 65 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 66 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 67 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 68 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 69 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 70 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 71 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 72 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 73 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 74 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 75 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 76 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 77 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 78 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 79 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 80 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 81 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 82 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 83 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 84 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 85 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 86 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 87 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 88 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 89 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 90 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 91 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 92 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 93 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 94 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 95 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 96 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 97 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 98 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 99 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%Plan 100 1.000 1.000 1.000 1.000 1.000 1.000 $523.65 0.0% 0.0% 0.0% - $365.05 #DIV/0! 0.0%

Calibration

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

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

Carrier Name: HighmarkPlan Type(s): PPO/EPOMarket Segment: Small GroupRate Effective Date: 1/1/2017

Plan Number HIOS Plan ID (Standard Component)1/1/16 Plan

Marketing Name

New,

Modified, Existing

(D,N,M,E) for 2017

1/1/17 Plan Marketing Name

(If 1/1/16 Plan Discontinued)

Metallic Tier

Exchange On/Off or

Off 1 2 3 4 5 6 7 8 9 Total 1 2 3 4 5 6 7 8 9

Average (weighted by enrollment by

rating area) 1 2 3 4 5 6 7 8 9

Average (weighted by enrollment

by rating area) 1 2 3 4 5 6 7 8 9

Average (weighted by enrollment

by rating area)

Totals 3,476 209 - 10,668 1,117 110 - - - 15,580 296.75$ 317.42$ -$ 304.77$ 309.68$ 354.46$ -$ -$ -$ 303.85$ 305.73$ 323.87$ -$ 315.30$ 316.17$ 363.06$ -$ -$ -$ 313.68$ 2.9% 2.1% 0.0% 3.4% 2.0% 2.4% 0.0% 0.0% 0.0% 3.1%

Plan 1 33709PA0560007 Premier Balance PPO $0 M Premier Balance PPO $0 P Platinum Off 442 - - 2,014 - - - - - 2,456 357.52$ -$ -$ 357.52$ -$ -$ -$ -$ -$ 357.52$ 373.69$ -$ -$ 373.69$ -$ -$ -$ -$ -$ 373.69$ 4.5% 0.0% 0.0% 4.5% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5%Plan 2 33709PA0560009 Premier Balance PPO $2 M Premier Balance PPO $250 Platinum Off 130 - - 664 - - - - - 794 352.06$ -$ -$ 352.06$ -$ -$ -$ -$ -$ 352.06$ 367.48$ -$ -$ 367.48$ -$ -$ -$ -$ -$ 367.48$ 4.4% 0.0% 0.0% 4.4% 0.0% 0.0% 0.0% 0.0% 0.0% 4.4%Plan 3 33709PA0560011 Premier Balance PPO $0 M Premier Balance PPO $0 G Gold Off 135 - - 1,309 - - - - - 1,444 302.80$ -$ -$ 302.80$ -$ -$ -$ -$ -$ 302.80$ 316.42$ -$ -$ 316.42$ -$ -$ -$ -$ -$ 316.42$ 4.5% 0.0% 0.0% 4.5% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5%Plan 4 33709PA0560013 Premier Balance PPO $2 M Premier Balance PPO $250 Gold Off 73 - - 293 - - - - - 366 309.76$ -$ -$ 309.76$ -$ -$ -$ -$ -$ 309.76$ 320.90$ -$ -$ 320.90$ -$ -$ -$ -$ -$ 320.90$ 3.6% 0.0% 0.0% 3.6% 0.0% 0.0% 0.0% 0.0% 0.0% 3.6%Plan 5 33709PA0560015 Premier Balance PPO $5 M Premier Balance PPO $500 Gold Off 566 - - 1,711 - - - - - 2,277 305.36$ -$ -$ 305.36$ -$ -$ -$ -$ -$ 305.36$ 313.95$ -$ -$ 313.95$ -$ -$ -$ -$ -$ 313.95$ 2.8% 0.0% 0.0% 2.8% 0.0% 0.0% 0.0% 0.0% 0.0% 2.8%Plan 6 33709PA0560017 Premier Balance PPO $7 M Premier Balance PPO $750 Gold Off 126 - - 186 - - - - - 312 300.97$ -$ -$ 300.97$ -$ -$ -$ -$ -$ 300.97$ 309.93$ -$ -$ 309.93$ -$ -$ -$ -$ -$ 309.93$ 3.0% 0.0% 0.0% 3.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.0%Plan 7 33709PA0560019 Premier Balance PPO $1 M Premier Balance PPO $100 Gold Off 382 - - 1,186 - - - - - 1,568 296.58$ -$ -$ 296.58$ -$ -$ -$ -$ -$ 296.58$ 304.95$ -$ -$ 304.95$ -$ -$ -$ -$ -$ 304.95$ 2.8% 0.0% 0.0% 2.8% 0.0% 0.0% 0.0% 0.0% 0.0% 2.8%Plan 8 33709PA0560021 Premier Balance PPO $1 M Premier Balance PPO $125 Gold Off 128 - - 232 - - - - - 360 292.92$ -$ -$ 292.92$ -$ -$ -$ -$ -$ 292.92$ 302.56$ -$ -$ 302.56$ -$ -$ -$ -$ -$ 302.56$ 3.3% 0.0% 0.0% 3.3% 0.0% 0.0% 0.0% 0.0% 0.0% 3.3%Plan 9 33709PA0560023 Premier Balance PPO $1 M Premier Balance PPO $150 Gold Off 238 - - 507 - - - - - 745 290.72$ -$ -$ 290.72$ -$ -$ -$ -$ -$ 290.72$ 300.32$ -$ -$ 300.32$ -$ -$ -$ -$ -$ 300.32$ 3.3% 0.0% 0.0% 3.3% 0.0% 0.0% 0.0% 0.0% 0.0% 3.3%Plan 10 33709PA0560027 Premier Balance PPO $2 M Premier Balance PPO $200 Gold Off 195 - - 250 - - - - - 445 287.79$ -$ -$ 287.79$ -$ -$ -$ -$ -$ 287.79$ 297.11$ -$ -$ 297.11$ -$ -$ -$ -$ -$ 297.11$ 3.2% 0.0% 0.0% 3.2% 0.0% 0.0% 0.0% 0.0% 0.0% 3.2%Plan 11 33709PA0560029 Premier Balance PPO $1 M Premier Balance PPO $140 Silver Off 409 - - 748 - - - - - 1,157 258.40$ -$ -$ 258.40$ -$ -$ -$ -$ -$ 258.40$ 266.45$ -$ -$ 266.45$ -$ -$ -$ -$ -$ 266.45$ 3.1% 0.0% 0.0% 3.1% 0.0% 0.0% 0.0% 0.0% 0.0% 3.1%Plan 12 33709PA0570007 Balance PPO $1000 A a C M Balance PPO $1000 A a Co Silver Off 2 - - 41 - - - - - 43 254.21$ -$ -$ 254.21$ -$ -$ -$ -$ -$ 254.21$ 264.17$ -$ -$ 264.17$ -$ -$ -$ -$ -$ 264.17$ 3.9% 0.0% 0.0% 3.9% 0.0% 0.0% 0.0% 0.0% 0.0% 3.9%Plan 13 33709PA0570004 Balance PPO $1750 A a C M Balance PPO $1750 A a Co Silver Off 39 - - 296 - - - - - 335 251.07$ -$ -$ 251.07$ -$ -$ -$ -$ -$ 251.07$ 259.93$ -$ -$ 259.93$ -$ -$ -$ -$ -$ 259.93$ 3.5% 0.0% 0.0% 3.5% 0.0% 0.0% 0.0% 0.0% 0.0% 3.5%Plan 14 33709PA0570006 Balance PPO $2000 A a C M Balance PPO $2000 A a Co Silver Off 152 - - 283 - - - - - 435 248.63$ -$ -$ 248.63$ -$ -$ -$ -$ -$ 248.63$ 257.36$ -$ -$ 257.36$ -$ -$ -$ -$ -$ 257.36$ 3.5% 0.0% 0.0% 3.5% 0.0% 0.0% 0.0% 0.0% 0.0% 3.5%Plan 15 33709PA0450004 Health Savings PPO $15 M Health Savings PPO $1500 Gold Off - - - 66 - - - - - 66 -$ -$ -$ 281.20$ -$ -$ -$ -$ -$ 281.20$ -$ -$ -$ 294.06$ -$ -$ -$ -$ -$ 294.06$ 0.0% 0.0% 0.0% 4.6% 0.0% 0.0% 0.0% 0.0% 0.0% 4.6%Plan 16 33709PA0640001 Health Savings PPO Em M Health Savings PPO Embe Silver Off 2 - - 18 - - - - - 20 268.53$ -$ -$ 268.53$ -$ -$ -$ -$ -$ 268.53$ 260.19$ -$ -$ 260.19$ -$ -$ -$ -$ -$ 260.19$ -3.1% 0.0% 0.0% -3.1% 0.0% 0.0% 0.0% 0.0% 0.0% -3.1%Plan 17 33709PA0640002 Health Savings PPO Em M Health Savings PPO Embe Silver Off - - - 21 - - - - - 21 -$ -$ -$ 262.59$ -$ -$ -$ -$ -$ 262.59$ -$ -$ -$ 253.60$ -$ -$ -$ -$ -$ 253.60$ 0.0% 0.0% 0.0% -3.4% 0.0% 0.0% 0.0% 0.0% 0.0% -3.4%Plan 18 33709PA0640003 Health Savings PPO Em M Health Savings PPO Embe Bronze Off 1 - - 49 - - - - - 50 212.23$ -$ -$ 212.23$ -$ -$ -$ -$ -$ 212.23$ 210.78$ -$ -$ 210.78$ -$ -$ -$ -$ -$ 210.78$ -0.7% 0.0% 0.0% -0.7% 0.0% 0.0% 0.0% 0.0% 0.0% -0.7%Plan 19 33709PA0640004 Health Savings PPO Em M Health Savings PPO Embe Bronze Off - - - - - - - - - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 20 33709PA0640005 Health Savings PPO Em M Health Savings PPO Embe Bronze Off 2 - - 4 - - - - - 6 209.18$ -$ -$ 209.18$ -$ -$ -$ -$ -$ 209.18$ 211.46$ -$ -$ 211.46$ -$ -$ -$ -$ -$ 211.46$ 1.1% 0.0% 0.0% 1.1% 0.0% 0.0% 0.0% 0.0% 0.0% 1.1%Plan 21 33709PA0460012 Flex PPO $500 Total Hea M Flex PPO $500 Total Healt Gold Off - - - 102 - - - - - 102 -$ -$ -$ 305.04$ -$ -$ -$ -$ -$ 305.04$ -$ -$ -$ 316.15$ -$ -$ -$ -$ -$ 316.15$ 0.0% 0.0% 0.0% 3.6% 0.0% 0.0% 0.0% 0.0% 0.0% 3.6%Plan 22 33709PA0460013 Flex PPO $500 Total Hea M Flex PPO $500 Total Healt Gold Off 54 27 - - 134 - - - - 215 331.94$ 331.94$ -$ -$ 331.94$ -$ -$ -$ -$ 331.94$ 336.68$ 336.68$ -$ -$ 336.68$ -$ -$ -$ -$ 336.68$ 1.4% 1.4% 0.0% 0.0% 1.4% 0.0% 0.0% 0.0% 0.0% 1.4%Plan 23 33709PA0630002 Connect Blue EPO $100 M Connect Blue EPO $100 a C Gold Off 11 - - 25 - - - - - 36 277.81$ -$ -$ 277.81$ -$ -$ -$ -$ -$ 277.81$ 294.43$ -$ -$ 294.43$ -$ -$ -$ -$ -$ 294.43$ 6.0% 0.0% 0.0% 6.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.0%Plan 24 33709PA0630003 Connect Blue EPO $250 M Connect Blue EPO $250 a C Gold Off - - - 6 - - - - - 6 -$ -$ -$ 281.99$ -$ -$ -$ -$ -$ 281.99$ -$ -$ -$ 293.23$ -$ -$ -$ -$ -$ 293.23$ 0.0% 0.0% 0.0% 4.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.0%Plan 25 33709PA0630004 Connect Blue EPO $500 M Connect Blue EPO $500 a C Gold Off - - - 82 - - - - - 82 -$ -$ -$ 274.33$ -$ -$ -$ -$ -$ 274.33$ -$ -$ -$ 289.06$ -$ -$ -$ -$ -$ 289.06$ 0.0% 0.0% 0.0% 5.4% 0.0% 0.0% 0.0% 0.0% 0.0% 5.4%Plan 26 33709PA0630005 Connect Blue EPO $750 M Connect Blue EPO $750 a C Gold Off 6 - - 3 - - - - - 9 271.20$ -$ -$ 271.20$ -$ -$ -$ -$ -$ 271.20$ 287.42$ -$ -$ 287.42$ -$ -$ -$ -$ -$ 287.42$ 6.0% 0.0% 0.0% 6.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.0%Plan 27 33709PA0630006 Connect Blue EPO $900 M Connect Blue EPO $900 a C Gold Off - - - - - - - - - - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%Plan 28 33709PA0630008 0 N Connect Blue EPO $1100 a Gold Off - 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Change in 21-year-old Non-Tobacco Premium PMPM

These cells auto-fill using the data entered in Table 9.

2/1/16 Number of Covered Lives 2016 21-year-old Non-Tobacco Premium PMPM (in small group market, average monthly premium weighted for quarterly trend)

2017 21-year-old Non-Tobacco Premium PMPM (in small group market, average monthly premium weighted for quarterly trend)

PA Rate Template Part VConsumer Factors

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

Age Band

Age Factor

Tobacco Factor

Age Band

Age Factor

Tobacco Factor

Area CountiesCurrent Factor

Proposed Factor

0-20 0.635 43 1.357 1 Rating Area 1Crawford, Erie, McKean, Mercer, Warren, Clarion, Forest, Venango

0.970 0.970

21 1.000 1 44 1.397 1 Rating Area 2 Cameron, Elk, Potter 0.970 0.97022 1.000 1 45 1.444 1 Rating Area 3

23 1.000 1 46 1.500 1 Rating Area 4 Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Washington, Westmoreland

0.970 0.970

24 1.000 1 47 1.563 1 Rating Area 5Bedford, Blair, Cambria, Clearfield, Huntingdon, Jefferson, Somerset

0.970 0.970

25 1.004 1 48 1.635 1 Rating Area 6Centre, Columbia, Lehigh, Mifflin, Montour, Northampton, Northumberland, Snyder, Union, Schuylkill

1.040 1.040

26 1.024 1 49 1.706 1 Rating Area 7 Adams, Berks, Lancaster, York 1.040 1.04027 1.048 1 50 1.786 1 Rating Area 8

28 1.087 1 51 1.865 1 Rating Area 9Cumberland, Dauphin, Franklin, Fulton, Juniata, Lebanon, Perry

1.020 1.020

29 1.119 1 52 1.952 130 1.135 1 53 2.040 131 1.159 1 54 2.135 1 Table 14. Network Factors32 1.183 1 55 2.230 133 1.198 1 56 2.333 1

34 1.214 1 57 2.437 1 Network Name Rating AreaCurrent Factor

Proposed Factor

DOH Approval

Date35 1.222 1 58 2.548 1 A 1,4 0.915 0.9336 1.230 1 59 2.603 1 B 1,2,5,6 0.992 0.99537 1.238 1 60 2.714 1 J 1,4 0.870 0.87438 1.246 1 61 2.810 1 G 1,2,4,5 0.926 0.93839 1.262 1 62 2.873 1 H 2, 5, 6 0.983 0.98340 1.278 1 63 2.952 141 1.302 1 64+ 3.000 142 1.325 1

*PA follows the federal default age curve.

Geographic Area Factors2017 Age and Tobacco Factors

2017 Network Factors

rate/rule schedule · 2016-10-17 · ppo-sm/wg-4, hdhp-sm/wg-4, conb/epo-sm/wg-1 new pa plan design...

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