rate/rule schedule...eq2_raterule_20160 816.pdf, sg_16-43_revised_caac_p po_fedratestemplat...

Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Rates and Plan Design New SG_16-43_Revised_CAAC_PPO_PIDRates_RateRule_20160816.xlsx,SG_16-43_Revised_CAAC_PPO_PIDRates_RateRule_20160816.pdf,

2 Federal Rates Template New SG_16-43_Revised_CAAC_PPO_FedRatesTemplate_RateRule_20160816.xls, SG_16-43_Revised_CAAC_PPO_FedRatesTemplateInd_RateRule_20160816.pdf, SG_16-43_Revised_CAAC_PPO_FedRatesTemplateQ1_RateRule_20160816.pdf, SG_16-43_Revised_CAAC_PPO_FedRatesTemplateQ2_RateRule_20160816.pdf, SG_16-43_Revised_CAAC_PPO_FedRatesTemplateQ3_RateRule_20160816.pdf, SG_16-43_Revised_CAAC_PPO_FedRatesTemplateQ4_RateRule_20160816.pdf,

SERFF Tracking #: CABC-130539601 State Tracking #: CABC-130539601 Company Tracking #: 16-43

State: Pennsylvania Filing Company: Capital Advantage Assurance Company

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

Product Name: Rates - CAAC Small Group PPO

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number CABC-130539601 Generated 10/14/2016 11:57 AM

Attachment SG_16-43_Revised_CAAC_PPO_PIDRates_RateRule_20160816.xlsx is not a PDF documentand cannot be reproduced here.

Attachment SG_16-43_Revised_CAAC_PPO_FedRatesTemplate_RateRule_20160816.xls is not a PDFdocument and cannot be reproduced here.

SERFF Tracking #: CABC-130539601 State Tracking #: CABC-130539601 Company Tracking #: 16-43

State: Pennsylvania Filing Company: Capital Advantage Assurance Company

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

Product Name: Rates - CAAC Small Group PPO

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number CABC-130539601 Generated 10/14/2016 11:57 AM

HIOS Plan ID

On/Off

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

45127PA0010054 Off PPO Platinum Platinum PPO 0/0/15 | Rx 250 PPO 6,7,9 None




45127PA0010116 Off PPO Gold Gold PPO 500/0/40 | Rx 250 PPO 6,7,9 None








45127PA0010073 Off PPO Gold Gold PPO HRA 4000/0/30 - 1100 | Rx 0 PPO 6,7,9 None




45127PA0010161 Off PPO Gold Gold HSA 1500/0/15 | Combined PPO 6,7,9 None

45127PA0010144 Off PPO Silver Silver PPO 3000/0/45 | Rx 0 PPO 6,7,9 None



45127PA0010124 Off PPO Silver Silver HSA 2250/0/25 | Combined PPO 6,7,9 None





45127PA0010170 Off PPO Silver Silver HSA 3500/0/15 | Combined PPO 6,7,9 None


45127PA0010135 Off PPO Bronze Bronze HSA 6350/0/0 | Combined PPO 6,7,9 None

Capital Advantage Assurance CompanySmall Group

Plan Design Summary

12/24/2014

RATE PAGES

Company Name: Capital Advantage Assurance CompanyMarket: Small GroupProduct: PPOEffective Date of Rates: Ending date of Rates:

45127PA0010054 45127PA0010054 45127PA0010054 45127PA0010054 45127PA0010054 45127PA0010054 45127PA0010055 45127PA0010055

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

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

0 0 - 20 $263.93 $263.93 $266.56 $266.56 $261.29 $261.29 $268.31 $268.31

21 21 $415.63 $415.63 $419.79 $419.79 $411.47 $411.47 $422.54 $422.54

22 22 $415.63 $415.63 $419.79 $419.79 $411.47 $411.47 $422.54 $422.54

23 23 $415.63 $415.63 $419.79 $419.79 $411.47 $411.47 $422.54 $422.54

24 24 $415.63 $415.63 $419.79 $419.79 $411.47 $411.47 $422.54 $422.54

25 25 $417.29 $417.29 $421.47 $421.47 $413.12 $413.12 $424.23 $424.23

26 26 $425.61 $425.61 $429.86 $429.86 $421.35 $421.35 $432.68 $432.68

27 27 $435.58 $435.58 $439.94 $439.94 $431.22 $431.22 $442.82 $442.82

28 28 $451.79 $451.79 $456.31 $456.31 $447.27 $447.27 $459.30 $459.30

29 29 $465.09 $465.09 $469.74 $469.74 $460.44 $460.44 $472.82 $472.82

30 30 $471.74 $471.74 $476.46 $476.46 $467.02 $467.02 $479.58 $479.58

31 31 $481.72 $481.72 $486.53 $486.53 $476.90 $476.90 $489.72 $489.72

32 32 $491.69 $491.69 $496.61 $496.61 $486.77 $486.77 $499.86 $499.86

33 33 $497.92 $497.92 $502.90 $502.90 $492.95 $492.95 $506.20 $506.20

34 34 $504.57 $504.57 $509.62 $509.62 $499.53 $499.53 $512.96 $512.96

35 35 $507.90 $507.90 $512.98 $512.98 $502.82 $502.82 $516.34 $516.34

36 36 $511.22 $511.22 $516.34 $516.34 $506.11 $506.11 $519.72 $519.72

37 37 $514.55 $514.55 $519.70 $519.70 $509.40 $509.40 $523.10 $523.10

38 38 $517.87 $517.87 $523.05 $523.05 $512.70 $512.70 $526.48 $526.48

39 39 $524.53 $524.53 $529.77 $529.77 $519.28 $519.28 $533.25 $533.25

40 40 $531.18 $531.18 $536.49 $536.49 $525.86 $525.86 $540.01 $540.01

41 41 $541.15 $541.15 $546.56 $546.56 $535.74 $535.74 $550.15 $550.15

42 42 $550.71 $550.71 $556.22 $556.22 $545.20 $545.20 $559.87 $559.87

43 43 $564.01 $564.01 $569.65 $569.65 $558.37 $558.37 $573.39 $573.39

44 44 $580.64 $580.64 $586.44 $586.44 $574.83 $574.83 $590.29 $590.29

45 45 $600.17 $600.17 $606.17 $606.17 $594.17 $594.17 $610.15 $610.15

46 46 $623.45 $623.45 $629.68 $629.68 $617.21 $617.21 $633.81 $633.81

47 47 $649.63 $649.63 $656.13 $656.13 $643.13 $643.13 $660.43 $660.43

48 48 $679.56 $679.56 $686.35 $686.35 $672.76 $672.76 $690.85 $690.85

49 49 $709.06 $709.06 $716.16 $716.16 $701.97 $701.97 $720.85 $720.85

50 50 $742.32 $742.32 $749.74 $749.74 $734.89 $734.89 $754.66 $754.66

51 51 $775.15 $775.15 $782.90 $782.90 $767.40 $767.40 $788.04 $788.04

52 52 $811.31 $811.31 $819.42 $819.42 $803.20 $803.20 $824.80 $824.80

53 53 $847.89 $847.89 $856.36 $856.36 $839.41 $839.41 $861.98 $861.98

54 54 $887.37 $887.37 $896.24 $896.24 $878.50 $878.50 $902.12 $902.12

55 55 $926.85 $926.85 $936.12 $936.12 $917.59 $917.59 $942.26 $942.26

56 56 $969.66 $969.66 $979.36 $979.36 $959.97 $959.97 $985.79 $985.79

57 57 $1,012.89 $1,012.89 $1,023.02 $1,023.02 $1,002.76 $1,002.76 $1,029.73 $1,029.73

58 58 $1,059.03 $1,059.03 $1,069.62 $1,069.62 $1,048.43 $1,048.43 $1,076.63 $1,076.63

59 59 $1,081.88 $1,081.88 $1,092.70 $1,092.70 $1,071.07 $1,071.07 $1,099.87 $1,099.87

60 60 $1,128.02 $1,128.02 $1,139.30 $1,139.30 $1,116.74 $1,116.74 $1,146.77 $1,146.77

61 61 $1,167.92 $1,167.92 $1,179.60 $1,179.60 $1,156.24 $1,156.24 $1,187.34 $1,187.34

62 62 $1,194.10 $1,194.10 $1,206.05 $1,206.05 $1,182.16 $1,182.16 $1,213.96 $1,213.96

63 63 $1,226.94 $1,226.94 $1,239.21 $1,239.21 $1,214.67 $1,214.67 $1,247.34 $1,247.34

64+ 64+ $1,246.88 $1,246.88 $1,259.36 $1,259.36 $1,234.41 $1,234.41 $1,267.61 $1,267.61

January 1, 2017

6 7 9

Yes Yes Yes

C17-CAAC-SGP C17-CAAC-SGP

45127PA0010054 45127PA0010055

Platinum

Platinum PPO 0/0/15 | Rx 250

C17-CAAC-SGPC17-CAAC-SGP

PPO PPO PPO

Platinum PPO 0/0/15 | Rx 250 Platinum PPO 0/0/15 | Rx 250 Platinum PPO 0/0/15 | Rx 0

45127PA0010054 45127PA0010054

Yes

6

PPO

$0 /$250 Med/Rx

0%

$3000 Med/Rx Combined

45127PA0010054 45127PA0010054 45127PA0010054 45127PA0010055

$15/$30/$100 PCP/SPC/ER

None None None None

Platinum Platinum Platinum

$0 /$250 Med/Rx $0 /$250 Med/Rx $0 /$0 Med/Rx

0% 0% 0%

$15/$30/$100 PCP/SPC/ER $15/$30/$100 PCP/SPC/ER $15/$30/$100 PCP/SPC/ER

$3000 Med/Rx Combined $3000 Med/Rx Combined $3000 Med/Rx Combined

March 31, 2017

Page Number: 2 12/24/2014

RATE PAGES

Company Name:Market:Product:Effective Date of Rates:



Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


Age Band

0 0 - 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

31 31

32 32

33 33

34 34

35 35

36 36

37 37

38 38

39 39

40 40

41 41

42 42

43 43

44 44

45 45

46 46

47 47

48 48

49 49

50 50

51 51

52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64+ 64+


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

$271.00 $271.00 $265.63 $265.63 $253.48 $253.48 $256.01 $256.01

$426.77 $426.77 $418.31 $418.31 $399.18 $399.18 $403.17 $403.17

$426.77 $426.77 $418.31 $418.31 $399.18 $399.18 $403.17 $403.17

$426.77 $426.77 $418.31 $418.31 $399.18 $399.18 $403.17 $403.17

$426.77 $426.77 $418.31 $418.31 $399.18 $399.18 $403.17 $403.17

$428.47 $428.47 $419.99 $419.99 $400.78 $400.78 $404.78 $404.78

$437.01 $437.01 $428.35 $428.35 $408.76 $408.76 $412.85 $412.85

$447.25 $447.25 $438.39 $438.39 $418.34 $418.34 $422.52 $422.52

$463.89 $463.89 $454.71 $454.71 $433.91 $433.91 $438.25 $438.25

$477.55 $477.55 $468.09 $468.09 $446.68 $446.68 $451.15 $451.15

$484.38 $484.38 $474.79 $474.79 $453.07 $453.07 $457.60 $457.60

$494.62 $494.62 $484.83 $484.83 $462.65 $462.65 $467.28 $467.28

$504.86 $504.86 $494.87 $494.87 $472.23 $472.23 $476.95 $476.95

$511.26 $511.26 $501.14 $501.14 $478.22 $478.22 $483.00 $483.00

$518.09 $518.09 $507.83 $507.83 $484.60 $484.60 $489.45 $489.45

$521.51 $521.51 $511.18 $511.18 $487.80 $487.80 $492.68 $492.68

$524.92 $524.92 $514.53 $514.53 $490.99 $490.99 $495.90 $495.90

$528.34 $528.34 $517.87 $517.87 $494.18 $494.18 $499.13 $499.13

$531.75 $531.75 $521.22 $521.22 $497.38 $497.38 $502.35 $502.35

$538.58 $538.58 $527.91 $527.91 $503.77 $503.77 $508.80 $508.80

$545.41 $545.41 $534.61 $534.61 $510.15 $510.15 $515.25 $515.25

$555.65 $555.65 $544.65 $544.65 $519.73 $519.73 $524.93 $524.93

$565.46 $565.46 $554.27 $554.27 $528.91 $528.91 $534.20 $534.20

$579.12 $579.12 $567.65 $567.65 $541.69 $541.69 $547.10 $547.10

$596.19 $596.19 $584.39 $584.39 $557.65 $557.65 $563.23 $563.23

$616.25 $616.25 $604.05 $604.05 $576.42 $576.42 $582.18 $582.18

$640.15 $640.15 $627.47 $627.47 $598.77 $598.77 $604.76 $604.76

$667.03 $667.03 $653.83 $653.83 $623.92 $623.92 $630.16 $630.16

$697.76 $697.76 $683.94 $683.94 $652.66 $652.66 $659.19 $659.19

$728.06 $728.06 $713.64 $713.64 $681.00 $681.00 $687.81 $687.81

$762.20 $762.20 $747.11 $747.11 $712.94 $712.94 $720.06 $720.06

$795.92 $795.92 $780.16 $780.16 $744.47 $744.47 $751.92 $751.92

$833.05 $833.05 $816.55 $816.55 $779.20 $779.20 $786.99 $786.99

$870.60 $870.60 $853.36 $853.36 $814.33 $814.33 $822.47 $822.47

$911.14 $911.14 $893.10 $893.10 $852.25 $852.25 $860.77 $860.77

$951.69 $951.69 $932.84 $932.84 $890.17 $890.17 $899.07 $899.07

$995.64 $995.64 $975.93 $975.93 $931.29 $931.29 $940.60 $940.60

$1,040.03 $1,040.03 $1,019.43 $1,019.43 $972.80 $972.80 $982.53 $982.53

$1,087.40 $1,087.40 $1,065.87 $1,065.87 $1,017.11 $1,017.11 $1,027.28 $1,027.28

$1,110.87 $1,110.87 $1,088.87 $1,088.87 $1,039.07 $1,039.07 $1,049.46 $1,049.46

$1,158.24 $1,158.24 $1,135.31 $1,135.31 $1,083.37 $1,083.37 $1,094.21 $1,094.21

$1,199.21 $1,199.21 $1,175.46 $1,175.46 $1,121.70 $1,121.70 $1,132.91 $1,132.91

$1,226.10 $1,226.10 $1,201.82 $1,201.82 $1,146.84 $1,146.84 $1,158.31 $1,158.31

$1,259.81 $1,259.81 $1,234.86 $1,234.86 $1,178.38 $1,178.38 $1,190.16 $1,190.16

$1,280.30 $1,280.30 $1,254.93 $1,254.93 $1,197.53 $1,197.53 $1,209.51 $1,209.51

Yes

7

45127PA0010055

C17-CAAC-SGP

9

PPO

Yes

45127PA0010055


C17-CAAC-SGP


45127PA0010055

PPO

45127PA0010057

C17-CAAC-SGP

7

PPO

Yes

45127PA0010057


45127PA0010057

C17-CAAC-SGP

6

PPO

Yes

45127PA0010057


45127PA0010055

None None None None

Platinum Platinum Platinum Platinum

$0 /$0 Med/Rx $0 /$0 Med/Rx $250 /$250 Med/Rx $250 /$250 Med/Rx

0% 0% 0% 0%

$15/$30/$100 PCP/SPC/ER $15/$30/$100 PCP/SPC/ER $15/$30/$150 PCP/SPC/ER $15/$30/$150 PCP/SPC/ER

$3000 Med/Rx Combined $3000 Med/Rx Combined $6350 Med/Rx Combined $6350 Med/Rx Combined


RATE PAGES




Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


Age Band

0 0 - 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

31 31

32 32

33 33

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50 50

51 51

52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64+ 64+



$250.94 $250.94 $257.87 $257.87 $260.45 $260.45 $255.29 $255.29

$395.19 $395.19 $406.09 $406.09 $410.15 $410.15 $402.03 $402.03

$395.19 $395.19 $406.09 $406.09 $410.15 $410.15 $402.03 $402.03

$395.19 $395.19 $406.09 $406.09 $410.15 $410.15 $402.03 $402.03

$395.19 $395.19 $406.09 $406.09 $410.15 $410.15 $402.03 $402.03

$396.77 $396.77 $407.71 $407.71 $411.79 $411.79 $403.64 $403.64

$404.67 $404.67 $415.84 $415.84 $419.99 $419.99 $411.68 $411.68

$414.16 $414.16 $425.58 $425.58 $429.84 $429.84 $421.33 $421.33

$429.57 $429.57 $441.42 $441.42 $445.83 $445.83 $437.01 $437.01

$442.22 $442.22 $454.41 $454.41 $458.96 $458.96 $449.87 $449.87

$448.54 $448.54 $460.91 $460.91 $465.52 $465.52 $456.30 $456.30

$458.02 $458.02 $470.66 $470.66 $475.36 $475.36 $465.95 $465.95

$467.51 $467.51 $480.40 $480.40 $485.21 $485.21 $475.60 $475.60

$473.44 $473.44 $486.50 $486.50 $491.36 $491.36 $481.63 $481.63

$479.76 $479.76 $492.99 $492.99 $497.92 $497.92 $488.06 $488.06

$482.92 $482.92 $496.24 $496.24 $501.20 $501.20 $491.28 $491.28

$486.08 $486.08 $499.49 $499.49 $504.49 $504.49 $494.50 $494.50

$489.24 $489.24 $502.74 $502.74 $507.77 $507.77 $497.71 $497.71

$492.40 $492.40 $505.99 $505.99 $511.05 $511.05 $500.93 $500.93

$498.73 $498.73 $512.49 $512.49 $517.61 $517.61 $507.36 $507.36

$505.05 $505.05 $518.98 $518.98 $524.17 $524.17 $513.79 $513.79

$514.54 $514.54 $528.73 $528.73 $534.02 $534.02 $523.44 $523.44

$523.62 $523.62 $538.07 $538.07 $543.45 $543.45 $532.69 $532.69

$536.27 $536.27 $551.06 $551.06 $556.57 $556.57 $545.55 $545.55

$552.08 $552.08 $567.31 $567.31 $572.98 $572.98 $561.63 $561.63

$570.65 $570.65 $586.39 $586.39 $592.26 $592.26 $580.53 $580.53

$592.78 $592.78 $609.14 $609.14 $615.23 $615.23 $603.04 $603.04

$617.68 $617.68 $634.72 $634.72 $641.07 $641.07 $628.37 $628.37

$646.13 $646.13 $663.96 $663.96 $670.60 $670.60 $657.32 $657.32

$674.19 $674.19 $692.79 $692.79 $699.72 $699.72 $685.86 $685.86

$705.81 $705.81 $725.28 $725.28 $732.53 $732.53 $718.02 $718.02

$737.03 $737.03 $757.36 $757.36 $764.93 $764.93 $749.78 $749.78

$771.41 $771.41 $792.69 $792.69 $800.61 $800.61 $784.76 $784.76

$806.18 $806.18 $828.42 $828.42 $836.71 $836.71 $820.14 $820.14

$843.73 $843.73 $867.00 $867.00 $875.67 $875.67 $858.33 $858.33

$881.27 $881.27 $905.58 $905.58 $914.64 $914.64 $896.52 $896.52

$921.97 $921.97 $947.41 $947.41 $956.88 $956.88 $937.93 $937.93

$963.07 $963.07 $989.64 $989.64 $999.54 $999.54 $979.74 $979.74

$1,006.94 $1,006.94 $1,034.72 $1,034.72 $1,045.06 $1,045.06 $1,024.37 $1,024.37

$1,028.67 $1,028.67 $1,057.05 $1,057.05 $1,067.62 $1,067.62 $1,046.48 $1,046.48

$1,072.54 $1,072.54 $1,102.13 $1,102.13 $1,113.15 $1,113.15 $1,091.11 $1,091.11

$1,110.48 $1,110.48 $1,141.11 $1,141.11 $1,152.52 $1,152.52 $1,129.70 $1,129.70

$1,135.38 $1,135.38 $1,166.70 $1,166.70 $1,178.36 $1,178.36 $1,155.03 $1,155.03

$1,166.60 $1,166.60 $1,198.78 $1,198.78 $1,210.77 $1,210.77 $1,186.79 $1,186.79

$1,185.56 $1,185.56 $1,218.26 $1,218.26 $1,230.44 $1,230.44 $1,206.08 $1,206.08

45127PA0010057 45127PA0010058 45127PA0010058

C17-CAAC-SGP C17-CAAC-SGP C17-CAAC-SGP

45127PA0010057 45127PA0010058 45127PA0010058

Yes Yes Yes

C17-CAAC-SGP

9

PPO

Yes

Platinum PPO 250/0/15 | Rx 250 Platinum PPO 250/0/15 | Rx 0 Platinum PPO 250/0/15 | Rx 0 Platinum PPO 250/0/15 | Rx 0

9 6 7

PPO PPO PPO

45127PA0010058

45127PA0010058

None None None None

Platinum Platinum Platinum Platinum


0% 0% 0% 0%




RATE PAGES




Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


Age Band

0 0 - 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

31 31

32 32

33 33

34 34

35 35

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50 50

51 51

52 52

53 53

54 54

55 55

56 56

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58 58

59 59

60 60

61 61

62 62

63 63

64+ 64+



$235.09 $235.09 $237.44 $237.44 $232.74 $232.74 $238.58 $238.58

$370.22 $370.22 $373.92 $373.92 $366.52 $366.52 $375.72 $375.72

$370.22 $370.22 $373.92 $373.92 $366.52 $366.52 $375.72 $375.72

$370.22 $370.22 $373.92 $373.92 $366.52 $366.52 $375.72 $375.72

$370.22 $370.22 $373.92 $373.92 $366.52 $366.52 $375.72 $375.72

$371.70 $371.70 $375.42 $375.42 $367.98 $367.98 $377.22 $377.22

$379.11 $379.11 $382.90 $382.90 $375.31 $375.31 $384.74 $384.74

$387.99 $387.99 $391.87 $391.87 $384.11 $384.11 $393.75 $393.75

$402.43 $402.43 $406.45 $406.45 $398.40 $398.40 $408.41 $408.41

$414.28 $414.28 $418.42 $418.42 $410.13 $410.13 $420.43 $420.43

$420.20 $420.20 $424.40 $424.40 $416.00 $416.00 $426.44 $426.44

$429.08 $429.08 $433.38 $433.38 $424.79 $424.79 $435.46 $435.46

$437.97 $437.97 $442.35 $442.35 $433.59 $433.59 $444.48 $444.48

$443.52 $443.52 $447.96 $447.96 $439.09 $439.09 $450.11 $450.11

$449.45 $449.45 $453.94 $453.94 $444.95 $444.95 $456.12 $456.12

$452.41 $452.41 $456.93 $456.93 $447.88 $447.88 $459.13 $459.13

$455.37 $455.37 $459.92 $459.92 $450.82 $450.82 $462.14 $462.14

$458.33 $458.33 $462.92 $462.92 $453.75 $453.75 $465.14 $465.14

$461.29 $461.29 $465.91 $465.91 $456.68 $456.68 $468.15 $468.15

$467.22 $467.22 $471.89 $471.89 $462.55 $462.55 $474.16 $474.16

$473.14 $473.14 $477.87 $477.87 $468.41 $468.41 $480.17 $480.17

$482.03 $482.03 $486.85 $486.85 $477.21 $477.21 $489.19 $489.19

$490.54 $490.54 $495.45 $495.45 $485.64 $485.64 $497.83 $497.83

$502.39 $502.39 $507.41 $507.41 $497.36 $497.36 $509.85 $509.85

$517.20 $517.20 $522.37 $522.37 $512.03 $512.03 $524.88 $524.88

$534.60 $534.60 $539.94 $539.94 $529.25 $529.25 $542.54 $542.54

$555.33 $555.33 $560.88 $560.88 $549.78 $549.78 $563.58 $563.58

$578.65 $578.65 $584.44 $584.44 $572.87 $572.87 $587.25 $587.25

$605.31 $605.31 $611.36 $611.36 $599.26 $599.26 $614.30 $614.30

$631.60 $631.60 $637.91 $637.91 $625.28 $625.28 $640.98 $640.98

$661.21 $661.21 $667.83 $667.83 $654.60 $654.60 $671.04 $671.04

$690.46 $690.46 $697.36 $697.36 $683.56 $683.56 $700.72 $700.72

$722.67 $722.67 $729.90 $729.90 $715.44 $715.44 $733.41 $733.41

$755.25 $755.25 $762.80 $762.80 $747.70 $747.70 $766.47 $766.47

$790.42 $790.42 $798.32 $798.32 $782.52 $782.52 $802.16 $802.16

$825.59 $825.59 $833.85 $833.85 $817.33 $817.33 $837.86 $837.86

$863.72 $863.72 $872.36 $872.36 $855.09 $855.09 $876.55 $876.55

$902.23 $902.23 $911.25 $911.25 $893.20 $893.20 $915.63 $915.63

$943.32 $943.32 $952.75 $952.75 $933.89 $933.89 $957.33 $957.33

$963.68 $963.68 $973.32 $973.32 $954.05 $954.05 $978.00 $978.00

$1,004.78 $1,004.78 $1,014.82 $1,014.82 $994.73 $994.73 $1,019.70 $1,019.70

$1,040.32 $1,040.32 $1,050.72 $1,050.72 $1,029.92 $1,029.92 $1,055.77 $1,055.77

$1,063.64 $1,063.64 $1,074.28 $1,074.28 $1,053.01 $1,053.01 $1,079.44 $1,079.44

$1,092.89 $1,092.89 $1,103.82 $1,103.82 $1,081.96 $1,081.96 $1,109.13 $1,109.13

$1,110.65 $1,110.65 $1,121.76 $1,121.76 $1,099.55 $1,099.55 $1,127.15 $1,127.15

45127PA0010100

Yes Yes Yes

PPO

Gold

Gold PPO 500/0/40 | Rx 250 Gold PPO 500/0/40 | Rx 250 Gold PPO 500/0/40 | Rx 250

0%

$40/$65/$250 PCP/SPC/ER $40/$65/$250 PCP/SPC/ER

6 7 9

PPO PPO PPO

None None

45127PA0010116 45127PA0010116 45127PA0010116


Yes

None

Gold

Gold PPO 0/0/35 | Rx 250

C17-CAAC-SGP

6

45127PA0010100

45127PA0010116 45127PA0010116 45127PA0010116

None

Gold Gold


0% 0% 0%

$35/$65/$300 PCP/SPC/ER$40/$65/$250 PCP/SPC/ER



RATE PAGES




Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


Age Band

0 0 - 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

31 31

32 32

33 33

34 34

35 35

36 36

37 37

38 38

39 39

40 40

41 41

42 42

43 43

44 44

45 45

46 46

47 47

48 48

49 49

50 50

51 51

52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64+ 64+



$240.97 $240.97 $236.20 $236.20 $239.48 $239.48 $241.87 $241.87

$379.48 $379.48 $371.96 $371.96 $377.13 $377.13 $380.90 $380.90

$379.48 $379.48 $371.96 $371.96 $377.13 $377.13 $380.90 $380.90

$379.48 $379.48 $371.96 $371.96 $377.13 $377.13 $380.90 $380.90

$379.48 $379.48 $371.96 $371.96 $377.13 $377.13 $380.90 $380.90

$381.00 $381.00 $373.45 $373.45 $378.64 $378.64 $382.42 $382.42

$388.58 $388.58 $380.89 $380.89 $386.18 $386.18 $390.04 $390.04

$397.69 $397.69 $389.82 $389.82 $395.23 $395.23 $399.18 $399.18

$412.49 $412.49 $404.32 $404.32 $409.94 $409.94 $414.04 $414.04

$424.63 $424.63 $416.23 $416.23 $422.01 $422.01 $426.23 $426.23

$430.71 $430.71 $422.18 $422.18 $428.04 $428.04 $432.32 $432.32

$439.81 $439.81 $431.10 $431.10 $437.09 $437.09 $441.46 $441.46

$448.92 $448.92 $440.03 $440.03 $446.14 $446.14 $450.61 $450.61

$454.61 $454.61 $445.61 $445.61 $451.80 $451.80 $456.32 $456.32

$460.69 $460.69 $451.56 $451.56 $457.84 $457.84 $462.41 $462.41

$463.72 $463.72 $454.54 $454.54 $460.85 $460.85 $465.46 $465.46

$466.76 $466.76 $457.51 $457.51 $463.87 $463.87 $468.51 $468.51

$469.79 $469.79 $460.49 $460.49 $466.89 $466.89 $471.56 $471.56

$472.83 $472.83 $463.47 $463.47 $469.90 $469.90 $474.60 $474.60

$478.90 $478.90 $469.42 $469.42 $475.94 $475.94 $480.70 $480.70

$484.97 $484.97 $475.37 $475.37 $481.97 $481.97 $486.79 $486.79

$494.08 $494.08 $484.30 $484.30 $491.02 $491.02 $495.93 $495.93

$502.81 $502.81 $492.85 $492.85 $499.70 $499.70 $504.69 $504.69

$514.95 $514.95 $504.75 $504.75 $511.77 $511.77 $516.88 $516.88

$530.13 $530.13 $519.63 $519.63 $526.85 $526.85 $532.12 $532.12

$547.97 $547.97 $537.11 $537.11 $544.58 $544.58 $550.02 $550.02

$569.22 $569.22 $557.94 $557.94 $565.70 $565.70 $571.35 $571.35

$593.12 $593.12 $581.38 $581.38 $589.45 $589.45 $595.35 $595.35

$620.45 $620.45 $608.16 $608.16 $616.61 $616.61 $622.77 $622.77

$647.39 $647.39 $634.57 $634.57 $643.38 $643.38 $649.82 $649.82

$677.75 $677.75 $664.33 $664.33 $673.55 $673.55 $680.29 $680.29

$707.72 $707.72 $693.71 $693.71 $703.35 $703.35 $710.38 $710.38

$740.74 $740.74 $726.07 $726.07 $736.16 $736.16 $743.52 $743.52

$774.13 $774.13 $758.80 $758.80 $769.35 $769.35 $777.04 $777.04

$810.18 $810.18 $794.14 $794.14 $805.17 $805.17 $813.22 $813.22

$846.23 $846.23 $829.48 $829.48 $841.00 $841.00 $849.41 $849.41

$885.32 $885.32 $867.79 $867.79 $879.84 $879.84 $888.64 $888.64

$924.79 $924.79 $906.47 $906.47 $919.07 $919.07 $928.26 $928.26

$966.91 $966.91 $947.76 $947.76 $960.93 $960.93 $970.54 $970.54

$987.78 $987.78 $968.22 $968.22 $981.67 $981.67 $991.49 $991.49

$1,029.90 $1,029.90 $1,009.51 $1,009.51 $1,023.53 $1,023.53 $1,033.77 $1,033.77

$1,066.33 $1,066.33 $1,045.22 $1,045.22 $1,059.74 $1,059.74 $1,070.33 $1,070.33

$1,090.24 $1,090.24 $1,068.65 $1,068.65 $1,083.49 $1,083.49 $1,094.33 $1,094.33

$1,120.22 $1,120.22 $1,098.03 $1,098.03 $1,113.29 $1,113.29 $1,124.42 $1,124.42

$1,138.43 $1,138.43 $1,115.88 $1,115.88 $1,131.38 $1,131.38 $1,142.69 $1,142.69

45127PA0010100

45127PA0010100 45127PA0010100

PPO

$0 /$250 Med/Rx

0%

45127PA0010117


45127PA0010117

45127PA0010117 45127PA0010117

PPO

Yes Yes

6

Yes

None None

Gold Gold Gold

Gold PPO 0/0/35 | Rx 250

45127PA0010100


7 9

Yes

7

PPO PPO

None None

Gold



0% 0% 0%


$6350 Med/Rx Combined $6350 Med/Rx Combined$6350 Med/Rx Combined $6350 Med/Rx Combined


RATE PAGES




Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


Age Band

0 0 - 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

31 31

32 32

33 33

34 34

35 35

36 36

37 37

38 38

39 39

40 40

41 41

42 42

43 43

44 44

45 45

46 46

47 47

48 48

49 49

50 50

51 51

52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64+ 64+



$237.08 $237.08 $231.76 $231.76 $234.07 $234.07 $229.44 $229.44

$373.36 $373.36 $364.97 $364.97 $368.62 $368.62 $361.32 $361.32

$373.36 $373.36 $364.97 $364.97 $368.62 $368.62 $361.32 $361.32

$373.36 $373.36 $364.97 $364.97 $368.62 $368.62 $361.32 $361.32

$373.36 $373.36 $364.97 $364.97 $368.62 $368.62 $361.32 $361.32

$374.85 $374.85 $366.43 $366.43 $370.09 $370.09 $362.77 $362.77

$382.32 $382.32 $373.73 $373.73 $377.47 $377.47 $369.99 $369.99

$391.28 $391.28 $382.49 $382.49 $386.31 $386.31 $378.66 $378.66

$405.84 $405.84 $396.72 $396.72 $400.69 $400.69 $392.76 $392.76

$417.79 $417.79 $408.40 $408.40 $412.49 $412.49 $404.32 $404.32

$423.76 $423.76 $414.24 $414.24 $418.38 $418.38 $410.10 $410.10

$432.72 $432.72 $423.00 $423.00 $427.23 $427.23 $418.77 $418.77

$441.68 $441.68 $431.76 $431.76 $436.08 $436.08 $427.44 $427.44

$447.28 $447.28 $437.23 $437.23 $441.61 $441.61 $432.86 $432.86

$453.26 $453.26 $443.07 $443.07 $447.50 $447.50 $438.64 $438.64

$456.24 $456.24 $445.99 $445.99 $450.45 $450.45 $441.53 $441.53

$459.23 $459.23 $448.91 $448.91 $453.40 $453.40 $444.42 $444.42

$462.22 $462.22 $451.83 $451.83 $456.35 $456.35 $447.31 $447.31

$465.20 $465.20 $454.75 $454.75 $459.30 $459.30 $450.21 $450.21

$471.18 $471.18 $460.59 $460.59 $465.20 $465.20 $455.99 $455.99

$477.15 $477.15 $466.43 $466.43 $471.10 $471.10 $461.77 $461.77

$486.11 $486.11 $475.19 $475.19 $479.94 $479.94 $470.44 $470.44

$494.70 $494.70 $483.59 $483.59 $488.42 $488.42 $478.75 $478.75

$506.65 $506.65 $495.26 $495.26 $500.22 $500.22 $490.31 $490.31

$521.58 $521.58 $509.86 $509.86 $514.96 $514.96 $504.76 $504.76

$539.13 $539.13 $527.02 $527.02 $532.29 $532.29 $521.75 $521.75

$560.04 $560.04 $547.46 $547.46 $552.93 $552.93 $541.98 $541.98

$583.56 $583.56 $570.45 $570.45 $576.15 $576.15 $564.74 $564.74

$610.44 $610.44 $596.73 $596.73 $602.69 $602.69 $590.76 $590.76

$636.95 $636.95 $622.64 $622.64 $628.87 $628.87 $616.41 $616.41

$666.82 $666.82 $651.84 $651.84 $658.35 $658.35 $645.32 $645.32

$696.31 $696.31 $680.67 $680.67 $687.48 $687.48 $673.86 $673.86

$728.80 $728.80 $712.42 $712.42 $719.55 $719.55 $705.30 $705.30

$761.65 $761.65 $744.54 $744.54 $751.98 $751.98 $737.09 $737.09

$797.12 $797.12 $779.21 $779.21 $787.00 $787.00 $771.42 $771.42

$832.59 $832.59 $813.88 $813.88 $822.02 $822.02 $805.74 $805.74

$871.05 $871.05 $851.48 $851.48 $859.99 $859.99 $842.96 $842.96

$909.88 $909.88 $889.43 $889.43 $898.33 $898.33 $880.54 $880.54

$951.32 $951.32 $929.94 $929.94 $939.24 $939.24 $920.64 $920.64

$971.85 $971.85 $950.02 $950.02 $959.52 $959.52 $940.52 $940.52

$1,013.30 $1,013.30 $990.53 $990.53 $1,000.43 $1,000.43 $980.62 $980.62

$1,049.14 $1,049.14 $1,025.57 $1,025.57 $1,035.82 $1,035.82 $1,015.31 $1,015.31

$1,072.66 $1,072.66 $1,048.56 $1,048.56 $1,059.04 $1,059.04 $1,038.07 $1,038.07

$1,102.15 $1,102.15 $1,077.39 $1,077.39 $1,088.17 $1,088.17 $1,066.62 $1,066.62

$1,120.07 $1,120.07 $1,094.90 $1,094.90 $1,105.85 $1,105.85 $1,083.95 $1,083.95

45127PA0010117

C17-CAAC-SGP

45127PA0010117

Yes


6 7 9

PPO PPO PPO

Yes Yes

9

PPO

None None None

$1000 /$250 Med/Rx


Yes

None

Gold PPO 1000/0/25 | Rx 250

$1000 /$250 Med/Rx

45127PA0010084

45127PA0010084

45127PA0010084

45127PA0010084

45127PA0010084

45127PA0010084

Gold PPO 1000/0/25 | Rx 250

Gold Gold Gold Gold

$500 /$0 Med/Rx $1000 /$250 Med/Rx

Gold PPO 500/0/40 | Rx 0 Gold PPO 1000/0/25 | Rx 250

0% 0%0% 0%




RATE PAGES




Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


Age Band

0 0 - 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

31 31

32 32

33 33

34 34

35 35

36 36

37 37

38 38

39 39

40 40

41 41

42 42

43 43

44 44

45 45

46 46

47 47

48 48

49 49

50 50

51 51

52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64+ 64+



$242.97 $242.97 $245.40 $245.40 $240.54 $240.54 $236.14 $236.14

$382.63 $382.63 $386.46 $386.46 $378.80 $378.80 $371.87 $371.87

$382.63 $382.63 $386.46 $386.46 $378.80 $378.80 $371.87 $371.87

$382.63 $382.63 $386.46 $386.46 $378.80 $378.80 $371.87 $371.87

$382.63 $382.63 $386.46 $386.46 $378.80 $378.80 $371.87 $371.87

$384.16 $384.16 $388.00 $388.00 $380.32 $380.32 $373.36 $373.36

$391.81 $391.81 $395.73 $395.73 $387.89 $387.89 $380.79 $380.79

$401.00 $401.00 $405.01 $405.01 $396.99 $396.99 $389.72 $389.72

$415.92 $415.92 $420.08 $420.08 $411.76 $411.76 $404.22 $404.22

$428.16 $428.16 $432.44 $432.44 $423.88 $423.88 $416.12 $416.12

$434.29 $434.29 $438.63 $438.63 $429.94 $429.94 $422.07 $422.07

$443.47 $443.47 $447.90 $447.90 $439.03 $439.03 $431.00 $431.00

$452.65 $452.65 $457.18 $457.18 $448.12 $448.12 $439.92 $439.92

$458.39 $458.39 $462.97 $462.97 $453.81 $453.81 $445.50 $445.50

$464.51 $464.51 $469.16 $469.16 $459.87 $459.87 $451.45 $451.45

$467.57 $467.57 $472.25 $472.25 $462.90 $462.90 $454.43 $454.43

$470.63 $470.63 $475.34 $475.34 $465.93 $465.93 $457.40 $457.40

$473.70 $473.70 $478.43 $478.43 $468.96 $468.96 $460.38 $460.38

$476.76 $476.76 $481.52 $481.52 $471.99 $471.99 $463.35 $463.35

$482.88 $482.88 $487.71 $487.71 $478.05 $478.05 $469.30 $469.30

$489.00 $489.00 $493.89 $493.89 $484.11 $484.11 $475.25 $475.25

$498.18 $498.18 $503.17 $503.17 $493.20 $493.20 $484.17 $484.17

$506.98 $506.98 $512.05 $512.05 $501.91 $501.91 $492.73 $492.73

$519.23 $519.23 $524.42 $524.42 $514.04 $514.04 $504.63 $504.63

$534.53 $534.53 $539.88 $539.88 $529.19 $529.19 $519.50 $519.50

$552.52 $552.52 $558.04 $558.04 $546.99 $546.99 $536.98 $536.98

$573.95 $573.95 $579.68 $579.68 $568.21 $568.21 $557.80 $557.80

$598.05 $598.05 $604.03 $604.03 $592.07 $592.07 $581.23 $581.23

$625.60 $625.60 $631.86 $631.86 $619.34 $619.34 $608.01 $608.01

$652.77 $652.77 $659.29 $659.29 $646.24 $646.24 $634.41 $634.41

$683.38 $683.38 $690.21 $690.21 $676.54 $676.54 $664.16 $664.16

$713.60 $713.60 $720.74 $720.74 $706.47 $706.47 $693.54 $693.54

$746.89 $746.89 $754.36 $754.36 $739.42 $739.42 $725.89 $725.89

$780.57 $780.57 $788.37 $788.37 $772.76 $772.76 $758.61 $758.61

$816.92 $816.92 $825.08 $825.08 $808.75 $808.75 $793.94 $793.94

$853.26 $853.26 $861.80 $861.80 $844.73 $844.73 $829.27 $829.27

$892.68 $892.68 $901.60 $901.60 $883.75 $883.75 $867.57 $867.57

$932.47 $932.47 $941.79 $941.79 $923.14 $923.14 $906.25 $906.25

$974.94 $974.94 $984.69 $984.69 $965.19 $965.19 $947.52 $947.52

$995.99 $995.99 $1,005.95 $1,005.95 $986.03 $986.03 $967.98 $967.98

$1,038.46 $1,038.46 $1,048.84 $1,048.84 $1,028.07 $1,028.07 $1,009.26 $1,009.26

$1,075.19 $1,075.19 $1,085.94 $1,085.94 $1,064.44 $1,064.44 $1,044.95 $1,044.95

$1,099.30 $1,099.30 $1,110.29 $1,110.29 $1,088.30 $1,088.30 $1,068.38 $1,068.38

$1,129.52 $1,129.52 $1,140.82 $1,140.82 $1,118.23 $1,118.23 $1,097.76 $1,097.76

$1,147.88 $1,147.88 $1,159.37 $1,159.37 $1,136.40 $1,136.40 $1,115.60 $1,115.60

C17-CAAC-SGP

45127PA0010085


6 7 9

PPO PPO PPO

Yes Yes Yes Yes

NoneNone None


$0 /$0 Med/Rx

Gold PPO 1000/0/25 | Rx 0

$1000 /$0 Med/Rx

6

PPO

None

45127PA0010101

45127PA0010101

45127PA0010101

45127PA0010101

45127PA0010101

45127PA0010101

45127PA0010085

Gold Gold GoldGold

$0 /$0 Med/Rx $0 /$0 Med/Rx

0%0% 0% 0%




RATE PAGES




Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


Age Band

0 0 - 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

31 31

32 32

33 33

34 34

35 35

36 36

37 37

38 38

39 39

40 40

41 41

42 42

43 43

44 44

45 45

46 46

47 47

48 48

49 49

50 50

51 51

52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64+ 64+



$238.50 $238.50 $233.78 $233.78 $217.65 $217.65 $219.82 $219.82

$375.59 $375.59 $368.15 $368.15 $342.75 $342.75 $346.18 $346.18

$375.59 $375.59 $368.15 $368.15 $342.75 $342.75 $346.18 $346.18

$375.59 $375.59 $368.15 $368.15 $342.75 $342.75 $346.18 $346.18

$375.59 $375.59 $368.15 $368.15 $342.75 $342.75 $346.18 $346.18

$377.09 $377.09 $369.62 $369.62 $344.12 $344.12 $347.56 $347.56

$384.60 $384.60 $376.99 $376.99 $350.98 $350.98 $354.49 $354.49

$393.62 $393.62 $385.82 $385.82 $359.20 $359.20 $362.79 $362.79

$408.26 $408.26 $400.18 $400.18 $372.57 $372.57 $376.29 $376.29

$420.28 $420.28 $411.96 $411.96 $383.54 $383.54 $387.37 $387.37

$426.29 $426.29 $417.85 $417.85 $389.02 $389.02 $392.91 $392.91

$435.31 $435.31 $426.69 $426.69 $397.25 $397.25 $401.22 $401.22

$444.32 $444.32 $435.52 $435.52 $405.47 $405.47 $409.53 $409.53

$449.96 $449.96 $441.05 $441.05 $410.61 $410.61 $414.72 $414.72

$455.96 $455.96 $446.94 $446.94 $416.10 $416.10 $420.26 $420.26

$458.97 $458.97 $449.88 $449.88 $418.84 $418.84 $423.03 $423.03

$461.97 $461.97 $452.83 $452.83 $421.58 $421.58 $425.80 $425.80

$464.98 $464.98 $455.77 $455.77 $424.32 $424.32 $428.57 $428.57

$467.98 $467.98 $458.72 $458.72 $427.07 $427.07 $431.34 $431.34

$473.99 $473.99 $464.61 $464.61 $432.55 $432.55 $436.88 $436.88

$480.00 $480.00 $470.50 $470.50 $438.03 $438.03 $442.41 $442.41

$489.02 $489.02 $479.33 $479.33 $446.26 $446.26 $450.72 $450.72

$497.66 $497.66 $487.80 $487.80 $454.14 $454.14 $458.69 $458.69

$509.67 $509.67 $499.58 $499.58 $465.11 $465.11 $469.76 $469.76

$524.70 $524.70 $514.31 $514.31 $478.82 $478.82 $483.61 $483.61

$542.35 $542.35 $531.61 $531.61 $494.93 $494.93 $499.88 $499.88

$563.38 $563.38 $552.23 $552.23 $514.12 $514.12 $519.27 $519.27

$587.05 $587.05 $575.42 $575.42 $535.72 $535.72 $541.08 $541.08

$614.09 $614.09 $601.93 $601.93 $560.40 $560.40 $566.00 $566.00

$640.75 $640.75 $628.07 $628.07 $584.73 $584.73 $590.58 $590.58

$670.80 $670.80 $657.52 $657.52 $612.15 $612.15 $618.27 $618.27

$700.47 $700.47 $686.60 $686.60 $639.23 $639.23 $645.62 $645.62

$733.15 $733.15 $718.63 $718.63 $669.05 $669.05 $675.74 $675.74

$766.20 $766.20 $751.03 $751.03 $699.21 $699.21 $706.20 $706.20

$801.88 $801.88 $786.00 $786.00 $731.77 $731.77 $739.09 $739.09

$837.56 $837.56 $820.98 $820.98 $764.33 $764.33 $771.98 $771.98

$876.25 $876.25 $858.90 $858.90 $799.64 $799.64 $807.63 $807.63

$915.31 $915.31 $897.18 $897.18 $835.28 $835.28 $843.63 $843.63

$957.00 $957.00 $938.05 $938.05 $873.33 $873.33 $882.06 $882.06

$977.66 $977.66 $958.30 $958.30 $892.18 $892.18 $901.10 $901.10

$1,019.35 $1,019.35 $999.16 $999.16 $930.22 $930.22 $939.53 $939.53

$1,055.40 $1,055.40 $1,034.51 $1,034.51 $963.13 $963.13 $972.76 $972.76

$1,079.07 $1,079.07 $1,057.70 $1,057.70 $984.72 $984.72 $994.57 $994.57

$1,108.74 $1,108.74 $1,086.78 $1,086.78 $1,011.80 $1,011.80 $1,021.92 $1,021.92

$1,126.76 $1,126.76 $1,104.44 $1,104.44 $1,028.24 $1,028.24 $1,038.53 $1,038.53


45127PA0010085 45127PA0010085

Yes Yes

Gold



7 9

PPO PPO

None None

Yes Yes

None

Gold Gold



6 7

45127PA0010089

45127PA0010089

45127PA0010089

45127PA0010089

None

PPO PPO

45127PA0010085 45127PA0010085

Gold

0% 0% 0% 0%

$25/$40/$125 PCP/SPC/ER $25/$40/$125 PCP/SPC/ER$25/$50/$150 PCP/SPC/ER $25/$50/$150 PCP/SPC/ER



RATE PAGES




Form # =>

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Age Band

0 0 - 20

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64+ 64+



$215.47 $215.47 $222.03 $222.03 $224.25 $224.25 $219.81 $219.81

$339.32 $339.32 $349.66 $349.66 $353.16 $353.16 $346.16 $346.16

$339.32 $339.32 $349.66 $349.66 $353.16 $353.16 $346.16 $346.16

$339.32 $339.32 $349.66 $349.66 $353.16 $353.16 $346.16 $346.16

$339.32 $339.32 $349.66 $349.66 $353.16 $353.16 $346.16 $346.16

$340.68 $340.68 $351.06 $351.06 $354.57 $354.57 $347.55 $347.55

$347.47 $347.47 $358.05 $358.05 $361.63 $361.63 $354.47 $354.47

$355.61 $355.61 $366.44 $366.44 $370.11 $370.11 $362.78 $362.78

$368.84 $368.84 $380.08 $380.08 $383.88 $383.88 $376.28 $376.28

$379.70 $379.70 $391.27 $391.27 $395.18 $395.18 $387.36 $387.36

$385.13 $385.13 $396.86 $396.86 $400.83 $400.83 $392.90 $392.90

$393.27 $393.27 $405.26 $405.26 $409.31 $409.31 $401.20 $401.20

$401.42 $401.42 $413.65 $413.65 $417.78 $417.78 $409.51 $409.51

$406.51 $406.51 $418.89 $418.89 $423.08 $423.08 $414.70 $414.70

$411.94 $411.94 $424.49 $424.49 $428.73 $428.73 $420.24 $420.24

$414.65 $414.65 $427.28 $427.28 $431.56 $431.56 $423.01 $423.01

$417.37 $417.37 $430.08 $430.08 $434.38 $434.38 $425.78 $425.78

$420.08 $420.08 $432.88 $432.88 $437.21 $437.21 $428.55 $428.55

$422.80 $422.80 $435.68 $435.68 $440.03 $440.03 $431.32 $431.32

$428.22 $428.22 $441.27 $441.27 $445.68 $445.68 $436.86 $436.86

$433.65 $433.65 $446.87 $446.87 $451.33 $451.33 $442.40 $442.40

$441.80 $441.80 $455.26 $455.26 $459.81 $459.81 $450.70 $450.70

$449.60 $449.60 $463.30 $463.30 $467.93 $467.93 $458.67 $458.67

$460.46 $460.46 $474.49 $474.49 $479.23 $479.23 $469.74 $469.74

$474.03 $474.03 $488.48 $488.48 $493.36 $493.36 $483.59 $483.59

$489.98 $489.98 $504.91 $504.91 $509.96 $509.96 $499.86 $499.86

$508.98 $508.98 $524.49 $524.49 $529.73 $529.73 $519.25 $519.25

$530.36 $530.36 $546.52 $546.52 $551.98 $551.98 $541.05 $541.05

$554.79 $554.79 $571.69 $571.69 $577.41 $577.41 $565.98 $565.98

$578.88 $578.88 $596.52 $596.52 $602.49 $602.49 $590.55 $590.55

$606.03 $606.03 $624.49 $624.49 $630.74 $630.74 $618.25 $618.25

$632.84 $632.84 $652.12 $652.12 $658.64 $658.64 $645.59 $645.59

$662.36 $662.36 $682.54 $682.54 $689.36 $689.36 $675.71 $675.71

$692.22 $692.22 $713.31 $713.31 $720.44 $720.44 $706.17 $706.17

$724.45 $724.45 $746.52 $746.52 $753.99 $753.99 $739.06 $739.06

$756.69 $756.69 $779.74 $779.74 $787.54 $787.54 $771.94 $771.94

$791.64 $791.64 $815.76 $815.76 $823.91 $823.91 $807.60 $807.60

$826.93 $826.93 $852.12 $852.12 $860.64 $860.64 $843.60 $843.60

$864.59 $864.59 $890.93 $890.93 $899.84 $899.84 $882.02 $882.02

$883.26 $883.26 $910.16 $910.16 $919.27 $919.27 $901.06 $901.06

$920.92 $920.92 $948.98 $948.98 $958.47 $958.47 $939.49 $939.49

$953.50 $953.50 $982.54 $982.54 $992.37 $992.37 $972.72 $972.72

$974.87 $974.87 $1,004.57 $1,004.57 $1,014.62 $1,014.62 $994.53 $994.53

$1,001.68 $1,001.68 $1,032.20 $1,032.20 $1,042.52 $1,042.52 $1,021.87 $1,021.87

$1,017.96 $1,017.96 $1,048.97 $1,048.97 $1,059.47 $1,059.47 $1,038.48 $1,038.48

PPO

Yes

6

Yes

None

Gold Gold

Gold PPO 2000/0/25 | Rx 250

45127PA0010089

C17-CAAC-SGP

9

45127PA0010089


Yes Yes

7 9

PPO PPO PPO

None None None


$2000 /$0 Med/Rx

45127PA0010090 45127PA001009045127PA0010090

45127PA0010090 45127PA0010090 45127PA0010090


Gold Gold


0% 0% 0% 0%



Page Number: 10 12/24/2014

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Age Band

0 0 - 20

21 21

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64+ 64+



$197.15 $197.15 $199.13 $199.13 $195.18 $195.18 $192.77 $192.77

$310.48 $310.48 $313.58 $313.58 $307.38 $307.38 $303.57 $303.57

$310.48 $310.48 $313.58 $313.58 $307.38 $307.38 $303.57 $303.57

$310.48 $310.48 $313.58 $313.58 $307.38 $307.38 $303.57 $303.57

$310.48 $310.48 $313.58 $313.58 $307.38 $307.38 $303.57 $303.57

$311.72 $311.72 $314.84 $314.84 $308.60 $308.60 $304.78 $304.78

$317.93 $317.93 $321.11 $321.11 $314.75 $314.75 $310.86 $310.86

$325.38 $325.38 $328.64 $328.64 $322.13 $322.13 $318.14 $318.14

$337.49 $337.49 $340.87 $340.87 $334.12 $334.12 $329.98 $329.98

$347.43 $347.43 $350.90 $350.90 $343.95 $343.95 $339.69 $339.69

$352.39 $352.39 $355.92 $355.92 $348.87 $348.87 $344.55 $344.55

$359.85 $359.85 $363.44 $363.44 $356.25 $356.25 $351.84 $351.84

$367.30 $367.30 $370.97 $370.97 $363.62 $363.62 $359.12 $359.12

$371.96 $371.96 $375.67 $375.67 $368.24 $368.24 $363.68 $363.68

$376.92 $376.92 $380.69 $380.69 $373.15 $373.15 $368.53 $368.53

$379.41 $379.41 $383.20 $383.20 $375.61 $375.61 $370.96 $370.96

$381.89 $381.89 $385.71 $385.71 $378.07 $378.07 $373.39 $373.39

$384.37 $384.37 $388.22 $388.22 $380.53 $380.53 $375.82 $375.82

$386.86 $386.86 $390.73 $390.73 $382.99 $382.99 $378.25 $378.25

$391.83 $391.83 $395.74 $395.74 $387.91 $387.91 $383.11 $383.11

$396.79 $396.79 $400.76 $400.76 $392.83 $392.83 $387.96 $387.96

$404.24 $404.24 $408.29 $408.29 $400.20 $400.20 $395.25 $395.25

$411.39 $411.39 $415.50 $415.50 $407.27 $407.27 $402.23 $402.23

$421.32 $421.32 $425.53 $425.53 $417.11 $417.11 $411.94 $411.94

$433.74 $433.74 $438.08 $438.08 $429.40 $429.40 $424.09 $424.09

$448.33 $448.33 $452.82 $452.82 $443.85 $443.85 $438.36 $438.36

$465.72 $465.72 $470.38 $470.38 $461.06 $461.06 $455.36 $455.36

$485.28 $485.28 $490.13 $490.13 $480.43 $480.43 $474.48 $474.48

$507.63 $507.63 $512.71 $512.71 $502.56 $502.56 $496.34 $496.34

$529.68 $529.68 $534.98 $534.98 $524.38 $524.38 $517.89 $517.89

$554.52 $554.52 $560.06 $560.06 $548.97 $548.97 $542.18 $542.18

$579.05 $579.05 $584.84 $584.84 $573.25 $573.25 $566.16 $566.16

$606.06 $606.06 $612.12 $612.12 $600.00 $600.00 $592.57 $592.57

$633.38 $633.38 $639.71 $639.71 $627.05 $627.05 $619.28 $619.28

$662.87 $662.87 $669.50 $669.50 $656.25 $656.25 $648.12 $648.12

$692.37 $692.37 $699.29 $699.29 $685.45 $685.45 $676.96 $676.96

$724.35 $724.35 $731.59 $731.59 $717.11 $717.11 $708.23 $708.23

$756.64 $756.64 $764.21 $764.21 $749.07 $749.07 $739.80 $739.80

$791.10 $791.10 $799.01 $799.01 $783.19 $783.19 $773.50 $773.50

$808.18 $808.18 $816.26 $816.26 $800.10 $800.10 $790.19 $790.19

$842.64 $842.64 $851.07 $851.07 $834.22 $834.22 $823.89 $823.89

$872.45 $872.45 $881.17 $881.17 $863.72 $863.72 $853.03 $853.03

$892.01 $892.01 $900.93 $900.93 $883.09 $883.09 $872.16 $872.16

$916.54 $916.54 $925.70 $925.70 $907.37 $907.37 $896.14 $896.14

$931.43 $931.43 $940.74 $940.74 $922.13 $922.13 $910.70 $910.70


6 7 9

PPO PPO PPO

Yes Yes

$4000 /$0 Med/Rx

Yes

C17-CAAC-SGP

6

PPO

Yes

45127PA0010073

45127PA0010073

45127PA0010073

45127PA0010073

45127PA0010073

45127PA0010073

45127PA0010072

45127PA0010072

Gold PPO HRA 4000/0/30 - 1100 | Rx 0 Gold PPO HRA 4000/0/30 - 1100 | Rx 250Gold PPO HRA 4000/0/30 - 1100 | Rx 0 Gold PPO HRA 4000/0/30 - 1100 | Rx 0

None None None None

GoldGold Gold Gold


0% 0% 0%0%



Page Number: 11 12/24/2014

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Age Band

0 0 - 20

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64+ 64+



$194.69 $194.69 $190.84 $190.84 $201.63 $201.63 $203.64 $203.64

$306.61 $306.61 $300.53 $300.53 $317.52 $317.52 $320.70 $320.70

$306.61 $306.61 $300.53 $300.53 $317.52 $317.52 $320.70 $320.70

$306.61 $306.61 $300.53 $300.53 $317.52 $317.52 $320.70 $320.70

$306.61 $306.61 $300.53 $300.53 $317.52 $317.52 $320.70 $320.70

$307.83 $307.83 $301.74 $301.74 $318.79 $318.79 $321.98 $321.98

$313.96 $313.96 $307.75 $307.75 $325.14 $325.14 $328.39 $328.39

$321.32 $321.32 $314.96 $314.96 $332.76 $332.76 $336.09 $336.09

$333.28 $333.28 $326.68 $326.68 $345.14 $345.14 $348.60 $348.60

$343.09 $343.09 $336.30 $336.30 $355.30 $355.30 $358.86 $358.86

$348.00 $348.00 $341.11 $341.11 $360.39 $360.39 $363.99 $363.99

$355.36 $355.36 $348.32 $348.32 $368.01 $368.01 $371.69 $371.69

$362.71 $362.71 $355.53 $355.53 $375.63 $375.63 $379.38 $379.38

$367.31 $367.31 $360.04 $360.04 $380.39 $380.39 $384.19 $384.19

$372.22 $372.22 $364.85 $364.85 $385.47 $385.47 $389.32 $389.32

$374.67 $374.67 $367.25 $367.25 $388.01 $388.01 $391.89 $391.89

$377.13 $377.13 $369.66 $369.66 $390.55 $390.55 $394.46 $394.46

$379.58 $379.58 $372.06 $372.06 $393.09 $393.09 $397.02 $397.02

$382.03 $382.03 $374.47 $374.47 $395.63 $395.63 $399.59 $399.59

$386.94 $386.94 $379.27 $379.27 $400.71 $400.71 $404.72 $404.72

$391.84 $391.84 $384.08 $384.08 $405.79 $405.79 $409.85 $409.85

$399.20 $399.20 $391.30 $391.30 $413.41 $413.41 $417.55 $417.55

$406.25 $406.25 $398.21 $398.21 $420.71 $420.71 $424.92 $424.92

$416.06 $416.06 $407.83 $407.83 $430.87 $430.87 $435.18 $435.18

$428.33 $428.33 $419.85 $419.85 $443.58 $443.58 $448.01 $448.01

$442.74 $442.74 $433.97 $433.97 $458.50 $458.50 $463.08 $463.08

$459.91 $459.91 $450.80 $450.80 $476.28 $476.28 $481.04 $481.04

$479.22 $479.22 $469.74 $469.74 $496.28 $496.28 $501.25 $501.25

$501.30 $501.30 $491.37 $491.37 $519.15 $519.15 $524.34 $524.34

$523.07 $523.07 $512.71 $512.71 $541.69 $541.69 $547.11 $547.11

$547.60 $547.60 $536.75 $536.75 $567.09 $567.09 $572.76 $572.76

$571.82 $571.82 $560.50 $560.50 $592.17 $592.17 $598.10 $598.10

$598.49 $598.49 $586.64 $586.64 $619.80 $619.80 $626.00 $626.00

$625.48 $625.48 $613.09 $613.09 $647.74 $647.74 $654.22 $654.22

$654.60 $654.60 $641.64 $641.64 $677.91 $677.91 $684.68 $684.68

$683.73 $683.73 $670.19 $670.19 $708.07 $708.07 $715.15 $715.15

$715.31 $715.31 $701.15 $701.15 $740.77 $740.77 $748.18 $748.18

$747.20 $747.20 $732.40 $732.40 $773.80 $773.80 $781.53 $781.53

$781.23 $781.23 $765.76 $765.76 $809.04 $809.04 $817.13 $817.13

$798.09 $798.09 $782.29 $782.29 $826.50 $826.50 $834.77 $834.77

$832.13 $832.13 $815.65 $815.65 $861.75 $861.75 $870.37 $870.37

$861.56 $861.56 $844.50 $844.50 $892.23 $892.23 $901.15 $901.15

$880.88 $880.88 $863.44 $863.44 $912.23 $912.23 $921.36 $921.36

$905.10 $905.10 $887.18 $887.18 $937.32 $937.32 $946.69 $946.69

$919.82 $919.82 $901.59 $901.59 $952.55 $952.55 $962.09 $962.09


45127PA0010070 45127PA0010070


7 9

PPO PPO

Yes Yes Yes Yes

Gold PPO HRA 3000/0/45 - 800 | Rx 0

$3000 /$0 Med/Rx $3000 /$0 Med/Rx

0%

6 7

PPO PPO

45127PA0010070 45127PA001007045127PA0010072

45127PA0010072

45127PA0010072

45127PA0010072

Gold PPO HRA 4000/0/30 - 1100 | Rx 250 Gold PPO HRA 4000/0/30 - 1100 | Rx 250 Gold PPO HRA 3000/0/45 - 800 | Rx 0

None None NoneNone

Gold Gold Gold Gold

$4000 /$250 Med/Rx $4000 /$250 Med/Rx

0%0% 0%


$6550 Med/Rx Combined$6550 Med/Rx Combined $6550 Med/Rx Combined $6550 Med/Rx Combined

Page Number: 12 12/24/2014

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0 0 - 20

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64+ 64+



$199.61 $199.61 $197.24 $197.24 $199.21 $199.21 $195.26 $195.26

$314.34 $314.34 $310.61 $310.61 $313.72 $313.72 $307.50 $307.50

$314.34 $314.34 $310.61 $310.61 $313.72 $313.72 $307.50 $307.50

$314.34 $314.34 $310.61 $310.61 $313.72 $313.72 $307.50 $307.50

$314.34 $314.34 $310.61 $310.61 $313.72 $313.72 $307.50 $307.50

$315.60 $315.60 $311.85 $311.85 $314.97 $314.97 $308.73 $308.73

$321.89 $321.89 $318.06 $318.06 $321.25 $321.25 $314.88 $314.88

$329.43 $329.43 $325.52 $325.52 $328.77 $328.77 $322.26 $322.26

$341.69 $341.69 $337.63 $337.63 $341.01 $341.01 $334.26 $334.26

$351.75 $351.75 $347.57 $347.57 $351.05 $351.05 $344.10 $344.10

$356.78 $356.78 $352.54 $352.54 $356.07 $356.07 $349.02 $349.02

$364.33 $364.33 $360.00 $360.00 $363.60 $363.60 $356.40 $356.40

$371.87 $371.87 $367.45 $367.45 $371.13 $371.13 $363.78 $363.78

$376.59 $376.59 $372.11 $372.11 $375.83 $375.83 $368.39 $368.39

$381.61 $381.61 $377.08 $377.08 $380.85 $380.85 $373.31 $373.31

$384.13 $384.13 $379.57 $379.57 $383.36 $383.36 $375.77 $375.77

$386.64 $386.64 $382.05 $382.05 $385.87 $385.87 $378.23 $378.23

$389.16 $389.16 $384.54 $384.54 $388.38 $388.38 $380.69 $380.69

$391.67 $391.67 $387.02 $387.02 $390.89 $390.89 $383.15 $383.15

$396.70 $396.70 $391.99 $391.99 $395.91 $395.91 $388.07 $388.07

$401.73 $401.73 $396.96 $396.96 $400.93 $400.93 $392.99 $392.99

$409.28 $409.28 $404.41 $404.41 $408.46 $408.46 $400.37 $400.37

$416.51 $416.51 $411.56 $411.56 $415.67 $415.67 $407.44 $407.44

$426.57 $426.57 $421.50 $421.50 $425.71 $425.71 $417.28 $417.28

$439.14 $439.14 $433.92 $433.92 $438.26 $438.26 $429.58 $429.58

$453.91 $453.91 $448.52 $448.52 $453.01 $453.01 $444.04 $444.04

$471.52 $471.52 $465.92 $465.92 $470.57 $470.57 $461.26 $461.26

$491.32 $491.32 $485.48 $485.48 $490.34 $490.34 $480.63 $480.63

$513.95 $513.95 $507.85 $507.85 $512.93 $512.93 $502.77 $502.77

$536.27 $536.27 $529.90 $529.90 $535.20 $535.20 $524.60 $524.60

$561.42 $561.42 $554.75 $554.75 $560.30 $560.30 $549.20 $549.20

$586.25 $586.25 $579.29 $579.29 $585.08 $585.08 $573.49 $573.49

$613.60 $613.60 $606.31 $606.31 $612.37 $612.37 $600.25 $600.25

$641.26 $641.26 $633.64 $633.64 $639.98 $639.98 $627.31 $627.31

$671.13 $671.13 $663.15 $663.15 $669.78 $669.78 $656.52 $656.52

$700.99 $700.99 $692.66 $692.66 $699.59 $699.59 $685.73 $685.73

$733.37 $733.37 $724.65 $724.65 $731.90 $731.90 $717.41 $717.41

$766.06 $766.06 $756.96 $756.96 $764.53 $764.53 $749.39 $749.39

$800.95 $800.95 $791.43 $791.43 $799.35 $799.35 $783.52 $783.52

$818.24 $818.24 $808.52 $808.52 $816.60 $816.60 $800.43 $800.43

$853.13 $853.13 $843.00 $843.00 $851.43 $851.43 $834.57 $834.57

$883.31 $883.31 $872.81 $872.81 $881.54 $881.54 $864.09 $864.09

$903.11 $903.11 $892.38 $892.38 $901.31 $901.31 $883.46 $883.46

$927.95 $927.95 $916.92 $916.92 $926.09 $926.09 $907.75 $907.75

$943.02 $943.02 $931.82 $931.82 $941.15 $941.15 $922.50 $922.50

C17-CAAC-SGP

45127PA0010070


6 7 9

45127PA0010069

45127PA0010069

45127PA0010069

45127PA0010069 45127PA0010069

Yes

PPO PPO

Gold

Gold PPO HRA 3000/0/45 - 800 | Rx 0


9

PPO PPO

Yes Yes Yes

None None

Gold Gold Gold

Gold PPO HRA 3000/0/45 - 800 | Rx 250 Gold PPO HRA 3000/0/45 - 800 | Rx 250 Gold PPO HRA 3000/0/45 - 800 | Rx 250

45127PA0010069

C17-CAAC-SGP

45127PA0010070

None None

$3000 /$250 Med/Rx

0% 0% 0% 0%



Page Number: 13 12/24/2014

RATE PAGES




Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

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OOP Maximum =>


Age Band

0 0 - 20

21 21

22 22

23 23

24 24

25 25

26 26

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50 50

51 51

52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64+ 64+



$223.04 $223.04 $225.27 $225.27 $220.81 $220.81 $200.50 $200.50

$351.24 $351.24 $354.75 $354.75 $347.73 $347.73 $315.75 $315.75

$351.24 $351.24 $354.75 $354.75 $347.73 $347.73 $315.75 $315.75

$351.24 $351.24 $354.75 $354.75 $347.73 $347.73 $315.75 $315.75

$351.24 $351.24 $354.75 $354.75 $347.73 $347.73 $315.75 $315.75

$352.64 $352.64 $356.17 $356.17 $349.12 $349.12 $317.01 $317.01

$359.67 $359.67 $363.27 $363.27 $356.07 $356.07 $323.33 $323.33

$368.10 $368.10 $371.78 $371.78 $364.42 $364.42 $330.91 $330.91

$381.80 $381.80 $385.62 $385.62 $377.98 $377.98 $343.22 $343.22

$393.04 $393.04 $396.97 $396.97 $389.11 $389.11 $353.32 $353.32

$398.66 $398.66 $402.64 $402.64 $394.67 $394.67 $358.38 $358.38

$407.09 $407.09 $411.16 $411.16 $403.02 $403.02 $365.95 $365.95

$415.52 $415.52 $419.67 $419.67 $411.36 $411.36 $373.53 $373.53

$420.79 $420.79 $424.99 $424.99 $416.58 $416.58 $378.27 $378.27

$426.41 $426.41 $430.67 $430.67 $422.14 $422.14 $383.32 $383.32

$429.22 $429.22 $433.51 $433.51 $424.92 $424.92 $385.85 $385.85

$432.03 $432.03 $436.35 $436.35 $427.70 $427.70 $388.37 $388.37

$434.84 $434.84 $439.18 $439.18 $430.49 $430.49 $390.90 $390.90

$437.65 $437.65 $442.02 $442.02 $433.27 $433.27 $393.42 $393.42

$443.26 $443.26 $447.70 $447.70 $438.83 $438.83 $398.48 $398.48

$448.88 $448.88 $453.37 $453.37 $444.40 $444.40 $403.53 $403.53

$457.31 $457.31 $461.89 $461.89 $452.74 $452.74 $411.11 $411.11

$465.39 $465.39 $470.05 $470.05 $460.74 $460.74 $418.37 $418.37

$476.63 $476.63 $481.40 $481.40 $471.87 $471.87 $428.47 $428.47

$490.68 $490.68 $495.59 $495.59 $485.78 $485.78 $441.10 $441.10

$507.19 $507.19 $512.26 $512.26 $502.12 $502.12 $455.94 $455.94

$526.86 $526.86 $532.13 $532.13 $521.59 $521.59 $473.62 $473.62

$548.99 $548.99 $554.48 $554.48 $543.50 $543.50 $493.52 $493.52

$574.28 $574.28 $580.02 $580.02 $568.53 $568.53 $516.25 $516.25

$599.22 $599.22 $605.21 $605.21 $593.22 $593.22 $538.67 $538.67

$627.31 $627.31 $633.59 $633.59 $621.04 $621.04 $563.93 $563.93

$655.06 $655.06 $661.61 $661.61 $648.51 $648.51 $588.87 $588.87

$685.62 $685.62 $692.48 $692.48 $678.76 $678.76 $616.34 $616.34

$716.53 $716.53 $723.69 $723.69 $709.36 $709.36 $644.13 $644.13

$749.90 $749.90 $757.40 $757.40 $742.40 $742.40 $674.13 $674.13

$783.27 $783.27 $791.10 $791.10 $775.43 $775.43 $704.12 $704.12

$819.44 $819.44 $827.64 $827.64 $811.25 $811.25 $736.64 $736.64

$855.97 $855.97 $864.53 $864.53 $847.41 $847.41 $769.48 $769.48

$894.96 $894.96 $903.91 $903.91 $886.01 $886.01 $804.53 $804.53

$914.28 $914.28 $923.42 $923.42 $905.13 $905.13 $821.90 $821.90

$953.27 $953.27 $962.80 $962.80 $943.73 $943.73 $856.95 $856.95

$986.98 $986.98 $996.85 $996.85 $977.11 $977.11 $887.26 $887.26

$1,009.11 $1,009.11 $1,019.20 $1,019.20 $999.02 $999.02 $907.15 $907.15

$1,036.86 $1,036.86 $1,047.23 $1,047.23 $1,026.49 $1,026.49 $932.09 $932.09

$1,053.71 $1,053.71 $1,064.25 $1,064.25 $1,043.18 $1,043.18 $947.24 $947.24

PPO PPO PPO

None None None

45127PA0010161 45127PA0010161


45127PA0010161

45127PA0010161 45127PA0010161 45127PA0010161

6

Yes

Gold

Yes Yes

C17-CAAC-SGP

6

PPO

Yes

7 9

45127PA0010144

45127PA0010144

None

Gold Gold Silver

Gold HSA 1500/0/15 | Combined Gold HSA 1500/0/15 | Combined Gold HSA 1500/0/15 | Combined Silver PPO 3000/0/45 | Rx 0

$1500 Med/Rx Combined $1500 Med/Rx Combined $1500 Med/Rx Combined $3000 /$0 Med/Rx

0% 0% 0% 0%

$15/$30/$100 PCP/SPC/ER $45/$75/$350 PCP/SPC/ER$15/$30/$100 PCP/SPC/ER $15/$30/$100 PCP/SPC/ER


Page Number: 14 12/24/2014

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OOP Maximum =>


Age Band

0 0 - 20

21 21

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23 23

24 24

25 25

26 26

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31 31

32 32

33 33

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50 50

51 51

52 52

53 53

54 54

55 55

56 56

57 57

58 58

59 59

60 60

61 61

62 62

63 63

64+ 64+



$202.51 $202.51 $198.50 $198.50 $196.11 $196.11 $198.07 $198.07

$318.91 $318.91 $312.59 $312.59 $308.84 $308.84 $311.93 $311.93

$318.91 $318.91 $312.59 $312.59 $308.84 $308.84 $311.93 $311.93

$318.91 $318.91 $312.59 $312.59 $308.84 $308.84 $311.93 $311.93

$318.91 $318.91 $312.59 $312.59 $308.84 $308.84 $311.93 $311.93

$320.18 $320.18 $313.84 $313.84 $310.08 $310.08 $313.18 $313.18

$326.56 $326.56 $320.09 $320.09 $316.25 $316.25 $319.41 $319.41

$334.22 $334.22 $327.60 $327.60 $323.66 $323.66 $326.90 $326.90

$346.65 $346.65 $339.79 $339.79 $335.71 $335.71 $339.07 $339.07

$356.86 $356.86 $349.79 $349.79 $345.59 $345.59 $349.05 $349.05

$361.96 $361.96 $354.79 $354.79 $350.53 $350.53 $354.04 $354.04

$369.61 $369.61 $362.29 $362.29 $357.95 $357.95 $361.53 $361.53

$377.27 $377.27 $369.80 $369.80 $365.36 $365.36 $369.01 $369.01

$382.05 $382.05 $374.49 $374.49 $369.99 $369.99 $373.69 $373.69

$387.15 $387.15 $379.49 $379.49 $374.93 $374.93 $378.68 $378.68

$389.70 $389.70 $381.99 $381.99 $377.40 $377.40 $381.18 $381.18

$392.26 $392.26 $384.49 $384.49 $379.87 $379.87 $383.67 $383.67

$394.81 $394.81 $386.99 $386.99 $382.34 $382.34 $386.17 $386.17

$397.36 $397.36 $389.49 $389.49 $384.81 $384.81 $388.66 $388.66

$402.46 $402.46 $394.49 $394.49 $389.76 $389.76 $393.65 $393.65

$407.56 $407.56 $399.49 $399.49 $394.70 $394.70 $398.64 $398.64

$415.22 $415.22 $407.00 $407.00 $402.11 $402.11 $406.13 $406.13

$422.55 $422.55 $414.19 $414.19 $409.21 $409.21 $413.31 $413.31

$432.76 $432.76 $424.19 $424.19 $419.10 $419.10 $423.29 $423.29

$445.51 $445.51 $436.69 $436.69 $431.45 $431.45 $435.76 $435.76

$460.50 $460.50 $451.38 $451.38 $445.96 $445.96 $450.42 $450.42

$478.36 $478.36 $468.89 $468.89 $463.26 $463.26 $467.89 $467.89

$498.45 $498.45 $488.58 $488.58 $482.72 $482.72 $487.54 $487.54

$521.41 $521.41 $511.09 $511.09 $504.95 $504.95 $510.00 $510.00

$544.06 $544.06 $533.28 $533.28 $526.88 $526.88 $532.15 $532.15

$569.57 $569.57 $558.29 $558.29 $551.59 $551.59 $557.10 $557.10

$594.76 $594.76 $582.99 $582.99 $575.99 $575.99 $581.75 $581.75

$622.51 $622.51 $610.18 $610.18 $602.86 $602.86 $608.88 $608.88

$650.57 $650.57 $637.69 $637.69 $630.03 $630.03 $636.33 $636.33

$680.87 $680.87 $667.38 $667.38 $659.37 $659.37 $665.97 $665.97

$711.16 $711.16 $697.08 $697.08 $688.71 $688.71 $695.60 $695.60

$744.01 $744.01 $729.28 $729.28 $720.52 $720.52 $727.73 $727.73

$777.18 $777.18 $761.79 $761.79 $752.64 $752.64 $760.17 $760.17

$812.58 $812.58 $796.49 $796.49 $786.92 $786.92 $794.79 $794.79

$830.12 $830.12 $813.68 $813.68 $803.91 $803.91 $811.95 $811.95

$865.51 $865.51 $848.38 $848.38 $838.19 $838.19 $846.57 $846.57

$896.13 $896.13 $878.38 $878.38 $867.84 $867.84 $876.52 $876.52

$916.22 $916.22 $898.08 $898.08 $887.30 $887.30 $896.17 $896.17

$941.41 $941.41 $922.77 $922.77 $911.70 $911.70 $920.81 $920.81

$956.72 $956.72 $937.77 $937.77 $926.51 $926.51 $935.78 $935.78

Yes


6 7

PPO PPO

Yes Yes


7 9

PPO PPO

Yes

$45/$75/$350 PCP/SPC/ER

45127PA0010143

45127PA0010143

45127PA0010143

45127PA0010143

45127PA0010144

45127PA0010144

45127PA0010144

45127PA0010144

None None None None

Silver Silver Silver Silver

Silver PPO 3000/0/45 | Rx 0 Silver PPO 3000/0/45 | Rx 250 Silver PPO 3000/0/45 | Rx 250Silver PPO 3000/0/45 | Rx 0


0% 0% 0% 0%



Page Number: 15 12/24/2014

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Form # =>

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Network =>

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OOP Maximum =>


Age Band

0 0 - 20

21 21

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23 23

24 24

25 25

26 26

27 27

28 28

29 29

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31 31

32 32

33 33

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64+ 64+



$194.15 $194.15 $196.02 $196.02 $197.98 $197.98 $194.06 $194.06

$305.75 $305.75 $308.70 $308.70 $311.79 $311.79 $305.61 $305.61

$305.75 $305.75 $308.70 $308.70 $311.79 $311.79 $305.61 $305.61

$305.75 $305.75 $308.70 $308.70 $311.79 $311.79 $305.61 $305.61

$305.75 $305.75 $308.70 $308.70 $311.79 $311.79 $305.61 $305.61

$306.97 $306.97 $309.93 $309.93 $313.03 $313.03 $306.84 $306.84

$313.09 $313.09 $316.11 $316.11 $319.27 $319.27 $312.95 $312.95

$320.43 $320.43 $323.52 $323.52 $326.75 $326.75 $320.28 $320.28

$332.35 $332.35 $335.56 $335.56 $338.91 $338.91 $332.20 $332.20

$342.14 $342.14 $345.44 $345.44 $348.89 $348.89 $341.98 $341.98

$347.03 $347.03 $350.37 $350.37 $353.88 $353.88 $346.87 $346.87

$354.37 $354.37 $357.78 $357.78 $361.36 $361.36 $354.21 $354.21

$361.70 $361.70 $365.19 $365.19 $368.84 $368.84 $361.54 $361.54

$366.29 $366.29 $369.82 $369.82 $373.52 $373.52 $366.12 $366.12

$371.18 $371.18 $374.76 $374.76 $378.51 $378.51 $371.01 $371.01

$373.63 $373.63 $377.23 $377.23 $381.00 $381.00 $373.46 $373.46

$376.07 $376.07 $379.70 $379.70 $383.50 $383.50 $375.90 $375.90

$378.52 $378.52 $382.17 $382.17 $385.99 $385.99 $378.35 $378.35

$380.97 $380.97 $384.64 $384.64 $388.49 $388.49 $380.79 $380.79

$385.86 $385.86 $389.58 $389.58 $393.48 $393.48 $385.68 $385.68

$390.75 $390.75 $394.52 $394.52 $398.46 $398.46 $390.57 $390.57

$398.09 $398.09 $401.93 $401.93 $405.95 $405.95 $397.91 $397.91

$405.12 $405.12 $409.03 $409.03 $413.12 $413.12 $404.94 $404.94

$414.90 $414.90 $418.91 $418.91 $423.09 $423.09 $414.72 $414.72

$427.13 $427.13 $431.25 $431.25 $435.57 $435.57 $426.94 $426.94

$441.51 $441.51 $445.76 $445.76 $450.22 $450.22 $441.31 $441.31

$458.63 $458.63 $463.05 $463.05 $467.68 $467.68 $458.42 $458.42

$477.89 $477.89 $482.50 $482.50 $487.32 $487.32 $477.67 $477.67

$499.90 $499.90 $504.72 $504.72 $509.77 $509.77 $499.68 $499.68

$521.61 $521.61 $526.64 $526.64 $531.91 $531.91 $521.38 $521.38

$546.07 $546.07 $551.34 $551.34 $556.85 $556.85 $545.82 $545.82

$570.23 $570.23 $575.73 $575.73 $581.48 $581.48 $569.97 $569.97

$596.83 $596.83 $602.58 $602.58 $608.61 $608.61 $596.56 $596.56

$623.73 $623.73 $629.75 $629.75 $636.05 $636.05 $623.45 $623.45

$652.78 $652.78 $659.07 $659.07 $665.67 $665.67 $652.48 $652.48

$681.83 $681.83 $688.40 $688.40 $695.29 $695.29 $681.52 $681.52

$713.32 $713.32 $720.20 $720.20 $727.40 $727.40 $713.00 $713.00

$745.12 $745.12 $752.30 $752.30 $759.82 $759.82 $744.78 $744.78

$779.06 $779.06 $786.57 $786.57 $794.43 $794.43 $778.70 $778.70

$795.87 $795.87 $803.55 $803.55 $811.58 $811.58 $795.51 $795.51

$829.81 $829.81 $837.81 $837.81 $846.19 $846.19 $829.43 $829.43

$859.16 $859.16 $867.45 $867.45 $876.12 $876.12 $858.77 $858.77

$878.42 $878.42 $886.90 $886.90 $895.76 $895.76 $878.03 $878.03

$902.58 $902.58 $911.28 $911.28 $920.40 $920.40 $902.17 $902.17

$917.24 $917.24 $926.09 $926.09 $935.36 $935.36 $916.83 $916.83

45127PA0010132

C17-CAAC-SGP

9

PPO

Yes

0%

$45/$75/$350 PCP/SPC/ER

Yes Yes Yes

Silver

Silver PPO 4000/0/30 | Rx 0 Silver PPO 4000/0/30 | Rx 0


0%

6 7 9

PPO PPO PPO

45127PA0010132 45127PA0010132 45127PA0010132


45127PA0010132 45127PA0010132

45127PA0010143

45127PA0010143

None None NoneNone

Silver Silver Silver

Silver PPO 3000/0/45 | Rx 250 Silver PPO 4000/0/30 | Rx 0

$3000 /$250 Med/Rx

0% 0%



Page Number: 16 12/24/2014

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Network =>

Metal =>

Plan Name =>

Deductible =>

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OOP Maximum =>


Age Band

0 0 - 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 28

29 29

30 30

31 31

32 32

33 33

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35 35

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51 51

52 52

53 53

54 54

55 55

56 56

57 57

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60 60

61 61

62 62

63 63

64+ 64+



$202.30 $202.30 $204.33 $204.33 $200.28 $200.28 $191.64 $191.64

$318.59 $318.59 $321.78 $321.78 $315.40 $315.40 $301.80 $301.80

$318.59 $318.59 $321.78 $321.78 $315.40 $315.40 $301.80 $301.80

$318.59 $318.59 $321.78 $321.78 $315.40 $315.40 $301.80 $301.80

$318.59 $318.59 $321.78 $321.78 $315.40 $315.40 $301.80 $301.80

$319.86 $319.86 $323.06 $323.06 $316.67 $316.67 $303.01 $303.01

$326.24 $326.24 $329.50 $329.50 $322.97 $322.97 $309.04 $309.04

$333.88 $333.88 $337.22 $337.22 $330.54 $330.54 $316.29 $316.29

$346.31 $346.31 $349.77 $349.77 $342.84 $342.84 $328.06 $328.06

$356.50 $356.50 $360.07 $360.07 $352.94 $352.94 $337.71 $337.71

$361.60 $361.60 $365.22 $365.22 $357.98 $357.98 $342.54 $342.54

$369.25 $369.25 $372.94 $372.94 $365.55 $365.55 $349.79 $349.79

$376.89 $376.89 $380.66 $380.66 $373.12 $373.12 $357.03 $357.03

$381.67 $381.67 $385.49 $385.49 $377.85 $377.85 $361.56 $361.56

$386.77 $386.77 $390.64 $390.64 $382.90 $382.90 $366.39 $366.39

$389.32 $389.32 $393.21 $393.21 $385.42 $385.42 $368.80 $368.80

$391.87 $391.87 $395.78 $395.78 $387.95 $387.95 $371.21 $371.21

$394.41 $394.41 $398.36 $398.36 $390.47 $390.47 $373.63 $373.63

$396.96 $396.96 $400.93 $400.93 $392.99 $392.99 $376.04 $376.04

$402.06 $402.06 $406.08 $406.08 $398.04 $398.04 $380.87 $380.87

$407.16 $407.16 $411.23 $411.23 $403.09 $403.09 $385.70 $385.70

$414.80 $414.80 $418.95 $418.95 $410.66 $410.66 $392.94 $392.94

$422.13 $422.13 $426.35 $426.35 $417.91 $417.91 $399.88 $399.88

$432.33 $432.33 $436.65 $436.65 $428.00 $428.00 $409.54 $409.54

$445.07 $445.07 $449.52 $449.52 $440.62 $440.62 $421.61 $421.61

$460.04 $460.04 $464.64 $464.64 $455.44 $455.44 $435.80 $435.80

$477.88 $477.88 $482.66 $482.66 $473.11 $473.11 $452.70 $452.70

$497.96 $497.96 $502.94 $502.94 $492.98 $492.98 $471.71 $471.71

$520.89 $520.89 $526.10 $526.10 $515.69 $515.69 $493.44 $493.44

$543.51 $543.51 $548.95 $548.95 $538.08 $538.08 $514.87 $514.87

$569.00 $569.00 $574.69 $574.69 $563.31 $563.31 $539.01 $539.01

$594.17 $594.17 $600.11 $600.11 $588.23 $588.23 $562.86 $562.86

$621.89 $621.89 $628.11 $628.11 $615.67 $615.67 $589.11 $589.11

$649.92 $649.92 $656.42 $656.42 $643.42 $643.42 $615.67 $615.67

$680.19 $680.19 $686.99 $686.99 $673.39 $673.39 $644.34 $644.34

$710.46 $710.46 $717.56 $717.56 $703.35 $703.35 $673.01 $673.01

$743.27 $743.27 $750.70 $750.70 $735.84 $735.84 $704.10 $704.10

$776.40 $776.40 $784.17 $784.17 $768.64 $768.64 $735.49 $735.49

$811.77 $811.77 $819.88 $819.88 $803.65 $803.65 $768.99 $768.99

$829.29 $829.29 $837.58 $837.58 $821.00 $821.00 $785.59 $785.59

$864.65 $864.65 $873.30 $873.30 $856.01 $856.01 $819.09 $819.09

$895.24 $895.24 $904.19 $904.19 $886.29 $886.29 $848.06 $848.06

$915.31 $915.31 $924.46 $924.46 $906.16 $906.16 $867.07 $867.07

$940.48 $940.48 $949.88 $949.88 $931.07 $931.07 $890.91 $890.91

$955.76 $955.76 $965.33 $965.33 $946.20 $946.20 $905.39 $905.39

45127PA0010124

45127PA0010124

45127PA0010124 45127PA0010124

PPO PPO

$2250 Med/Rx Combined $2250 Med/Rx Combined

C17-CAAC-SGP

45127PA0010131

45127PA0010131

PPO

Yes Yes Yes

6

Yes

None None

Silver Silver Silver Silver

Silver HSA 2250/0/25 | Combined Silver HSA 2250/0/25 | Combined Silver HSA 2250/0/25 | Combined

45127PA0010124


6 7 9

45127PA0010124

PPO

NoneNone

Silver PPO 4000/0/30 | Rx 250

$2250 Med/Rx Combined $4000 /$250 Med/Rx

0% 0% 0% 0%

$25/$45/$250 PCP/SPC/ER $25/$45/$250 PCP/SPC/ER $30/$50/$250 PCP/SPC/ER$25/$45/$250 PCP/SPC/ER

$6550 Med/Rx Combined$6550 Med/Rx Combined $6550 Med/Rx Combined $6550 Med/Rx Combined

Page Number: 17 12/24/2014

RATE PAGES




Form # =>

Rating Area =>


Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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64+ 64+



$193.56 $193.56 $189.73 $189.73 $190.78 $190.78 $192.69 $192.69

$304.82 $304.82 $298.78 $298.78 $300.44 $300.44 $303.44 $303.44

$304.82 $304.82 $298.78 $298.78 $300.44 $300.44 $303.44 $303.44

$304.82 $304.82 $298.78 $298.78 $300.44 $300.44 $303.44 $303.44

$304.82 $304.82 $298.78 $298.78 $300.44 $300.44 $303.44 $303.44

$306.04 $306.04 $299.98 $299.98 $301.64 $301.64 $304.66 $304.66

$312.13 $312.13 $305.95 $305.95 $307.65 $307.65 $310.73 $310.73

$319.45 $319.45 $313.12 $313.12 $314.86 $314.86 $318.01 $318.01

$33

rate/rule schedule...eq2_raterule_20160 816.pdf, sg_16-43_revised_caac_p po_fedratestemplat...

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