Rate/Rule Schedule · 04142016 (Q4) RV With Silver.pdf, 33871khperate_04262 016_ind_sg.pdf, SERFF...

Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Rate Files KE 670 WPR GMC Rev. 1.17,KE 670 SG EXC-ON Rev.1.17, KE 670 SG EXC-ON.TierRev. 1.17, KE 670 SG EXC-ON.Direct Rev. 1.17, KE 670SG EXC-OFF Rev. 1.17, KE670 SG EXC-OFF.Tier Rev.1.17, KE 670 SG EXC-OFF.Direct Rev. 1.17, KE 670SG EXC-OFF.Direct.ADentalRev. 1.17, PREV/SCH-I Rev.1.17

New 33871KHPE v1-104142016 (Q1) RVWith Silver.pdf,33871KHPE v1-104142016 (Q2) RVWith Silver.pdf,33871KHPE v1-104142016 (Q3) RVWith Silver.pdf,33871KHPE v1-104142016 (Q4) RVWith Silver.pdf,33871khperate_04262016_ind_sg.pdf,

SERFF Tracking #: INAC-130539718 State Tracking #: INAC-130539718 Company Tracking #: KHPE SG 1-1-2017

State: Pennsylvania Filing Company: Keystone Health Plan East, Inc.

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

Product Name: KHPE Small Group HMO eff 1-1-2017

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number INAC-130539718 Generated 06/14/2016 09:28 AM

Company On/Off Metal Network Rating

Exchange HIOS Plan ID Level AreaKHPE ON 33871PA0100001 Platinum Keystone HMO Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE ON 33871PA0100002 Platinum Keystone HMO Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE ON 33871PA0100003 Gold Keystone HMO Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE ON 33871PA0100004 Gold Keystone HMO Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE ON 33871PA0100005 Silver Keystone HMO Silver Classic $2,500 $25/$50/70% Keystone Health Plan East Network 8KHPE ON 33871PA0100006 Silver Keystone HMO Silver Classic $2,750/$30/$60/50% Keystone Health Plan East Network 8KHPE ON 33871PA0100007 Bronze Keystone HMO Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8KHPE ON 33871PA0100008 Gold Keystone HMO Gold Proactive Keystone Health Plan East Network 8KHPE ON 33871PA0100009 Silver Keystone HMO Silver Proactive Keystone Health Plan East Network 8KHPE OFF 33871PA0100020 Platinum Keystone HMO Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE OFF 33871PA0100021 Platinum Keystone HMO Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE OFF 33871PA0100022 Gold Keystone HMO Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE OFF 33871PA0100023 Gold Keystone HMO Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE OFF 33871PA0100024 Silver Keystone HMO Silver Classic $2,500/$25/$50/70% Keystone Health Plan East Network 8KHPE OFF 33871PA0100025 Silver Keystone HMO Silver Classic $2,750/$30/$60/50% Keystone Health Plan East Network 8

KHPE OFF 33871PA0100026 Bronze Keystone HMO Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8

KHPE ON 33871PA0100035 Gold Keystone HMO Gold Classic $2,000/$40/$80/100% Keystone Health Plan East Network 8

KHPE ON 33871PA0100036 Silver Keystone HMO Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8

KHPE ON 33871PA0100037 Silver Keystone HMO Silver Secure $3,500 $40/$80/$600 Keystone Health Plan East Network 8

KHPE OFF 33871PA0100044 Gold Keystone HMO Gold Proactive Keystone Health Plan East Network 8

KHPE OFF 33871PA0100045 Silver Keystone HMO Silver Proactive Keystone Health Plan East Network 8

KHPE OFF 33871PA0100047 Gold Keystone HMO Gold Classic $2,000 $40/$80/100% Keystone Health Plan East Network 8

KHPE OFF 33871PA0100048 Silver Keystone HMO Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8

KHPE OFF 33871PA0100049 Silver Keystone HMO Silver Secure $3,500 $40/$80/$600 Keystone Health Plan East Network 8

KHPE ON 33871PA0110001 Platinum Keystone DPOS Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8


KHPE ON 33871PA0110003 Gold Keystone DPOS Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8

KHPE ON 33871PA0110004 Gold Keystone DPOS Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8


KHPE ON 33871PA0110006 Silver Keystone DPOS Silver Classic $2,500/$25/$50/70% Keystone Health Plan East Network 8

KHPE ON 33871PA0110007 Silver Keystone DPOS Silver Secure $3,500/$40/$80/$600 Keystone Health Plan East Network 8

KHPE ON 33871PA0110008 Silver Keystone DPOS Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8


KHPE ON 33871PA0110010 Bronze Keystone DPOS Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8

KHPE OFF 33871PA0110011 Platinum Keystone DPOS Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8


KHPE OFF 33871PA0110013 Gold Keystone DPOS Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8

KHPE OFF 33871PA0110014 Gold Keystone DPOS Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8

KHPE OFF 33871PA0110015 Gold Keystone DPOS Gold Classic $2,000/$40/$80/100% Keystone Health Plan East Network 8

KHPE OFF 33871PA0110016 Silver Keystone DPOS Silver Classic $2,500/$25/$50/70% Keystone Health Plan East Network 8

KHPE OFF 33871PA0110017 Silver Keystone DPOS Silver Secure $3,500 $40/$80/$600 Keystone Health Plan East Network 8

KHPE OFF 33871PA0110018 Silver Keystone DPOS Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8


KHPE OFF 33871PA0110020 Bronze Keystone DPOS Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8

Keystone Health Plan East

Plan Design Summary

Plan Design Marketing Name

05/15/2015

RATE PAGES

Company Name: Keystone Health Plan East

Product: HMO

Effective Date of Rates: January 1, 2017 - March 31, 201733871PA0100001 33871PA0100002

Plan ID (On Exchange)=>

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

0-20 $274.54 $274.54 $262.43 $262.43

21 $432.34 $486.39 $413.28 $464.94

22 $432.34 $486.39 $413.28 $464.94

23 $432.34 $486.39 $413.28 $464.94

24 $432.34 $486.39 $413.28 $464.94

25 $434.07 $488.33 $414.93 $466.80

26 $442.72 $498.06 $423.20 $476.10

27 $453.10 $509.73 $433.12 $487.26

28 $469.96 $528.70 $449.24 $505.39

29 $483.79 $544.27 $462.46 $520.27

30 $490.71 $576.58 $469.07 $551.16

31 $501.09 $588.78 $478.99 $562.82

32 $511.46 $600.97 $488.91 $574.47

33 $517.95 $608.59 $495.11 $581.75

34 $524.86 $616.72 $501.72 $589.52

35 $528.32 $620.78 $505.03 $593.41

36 $531.78 $624.84 $508.34 $597.29

37 $535.24 $628.91 $511.64 $601.18

38 $538.70 $632.97 $514.95 $605.06

39 $545.62 $641.10 $521.56 $612.83

40 $552.53 $676.86 $528.17 $647.01

41 $562.91 $689.57 $538.09 $659.16

42 $572.86 $701.75 $547.60 $670.81

43 $586.69 $718.70 $560.82 $687.01

44 $603.98 $739.88 $577.35 $707.26

45 $624.30 $764.77 $596.78 $731.05

46 $648.52 $794.43 $619.92 $759.40

47 $675.75 $827.80 $645.96 $791.30

48 $706.88 $865.93 $675.71 $827.75

49 $737.58 $903.53 $705.06 $863.69

50 $772.17 $1,061.73 $738.12 $1,014.91

51 $806.32 $1,108.69 $770.77 $1,059.81

52 $843.93 $1,160.41 $806.72 $1,109.25

53 $881.98 $1,212.72 $843.09 $1,159.25

54 $923.05 $1,269.20 $882.35 $1,213.24

55 $964.13 $1,325.67 $921.62 $1,267.22

56 $1,008.66 $1,386.90 $964.18 $1,325.75

57 $1,053.62 $1,448.73 $1,007.17 $1,384.85

58 $1,101.61 $1,514.72 $1,053.04 $1,447.93

59 $1,125.39 $1,547.41 $1,075.77 $1,479.18

60 $1,173.38 $1,613.40 $1,121.64 $1,542.26

61 $1,214.89 $1,670.47 $1,161.32 $1,596.81

62 $1,242.12 $1,707.92 $1,187.36 $1,632.61

63 $1,276.28 $1,754.88 $1,220.00 $1,677.51

64 $1,297.02 $1,783.42 $1,239.84 $1,704.78

65+ $1,297.02 $1,783.42 $1,239.84 $1,704.78

$0

0%

$3,000

Keystone HMO Platinum Preferred $20/$40/$150

$0

0%

No

Platinum

$4,000

Platinum


No

33871PA0100001

KE 670 WPR GMC

8

33871PA0100002

8

KE 670 WPR GMC

Keystone Health Plan East Network Keystone Health Plan East Network

$10/$20 $20/$40

Page Number: 2 05/05/2016

RATE PAGES


Product: HMO

Effective Date of Rates: January 1, 2017 - March 31, 2017



Form # =>

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Network =>

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Dental (Yes/No)Age Band

0-20

21

22

23

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64

65+

33871PA0100003 33871PA0100004

Non-Tobacco Tobacco Non-Tobacco Tobacco

$216.40 $216.40 $223.43 $223.43

$340.78 $383.38 $351.86 $395.84

$340.78 $383.38 $351.86 $395.84

$340.78 $383.38 $351.86 $395.84

$340.78 $383.38 $351.86 $395.84

$342.14 $384.91 $353.27 $397.43

$348.96 $392.58 $360.31 $405.34

$357.14 $401.78 $368.75 $414.85

$370.43 $416.73 $382.47 $430.28

$381.33 $429.00 $393.73 $442.95

$386.79 $454.47 $399.36 $469.25

$394.96 $464.08 $407.81 $479.17

$403.14 $473.69 $416.25 $489.10

$408.25 $479.70 $421.53 $495.30

$413.71 $486.11 $427.16 $501.91

$416.43 $489.31 $429.98 $505.22

$419.16 $492.51 $432.79 $508.53

$421.89 $495.72 $435.60 $511.84

$424.61 $498.92 $438.42 $515.14

$430.06 $505.33 $444.05 $521.76

$435.52 $533.51 $449.68 $550.86

$443.70 $543.53 $458.12 $561.20

$451.53 $553.13 $466.22 $571.12

$462.44 $566.49 $477.48 $584.91

$476.07 $583.19 $491.55 $602.15

$492.09 $602.81 $508.09 $622.41

$511.17 $626.18 $527.79 $646.55

$532.64 $652.48 $549.96 $673.70

$557.18 $682.54 $575.29 $704.74

$581.37 $712.18 $600.28 $735.34

$608.63 $836.87 $628.43 $864.08

$635.56 $873.89 $656.22 $902.31

$665.20 $914.65 $686.83 $944.40

$695.19 $955.89 $717.80 $986.97

$727.57 $1,000.40 $751.23 $1,032.93

$759.94 $1,044.92 $784.65 $1,078.90

$795.04 $1,093.18 $820.89 $1,128.73

$830.48 $1,141.91 $857.49 $1,179.05

$868.31 $1,193.92 $896.54 $1,232.75

$887.05 $1,219.70 $915.90 $1,259.36

$924.88 $1,271.71 $954.95 $1,313.06

$957.59 $1,316.69 $988.73 $1,359.51

$979.06 $1,346.21 $1,010.90 $1,389.99

$1,005.98 $1,383.23 $1,038.70 $1,428.21

$1,022.34 $1,405.72 $1,055.58 $1,451.43

$1,022.34 $1,405.72 $1,055.58 $1,451.43

Gold

Keystone HMO Gold Classic $1,000 $25/$50/90%

$1,000

10%

$5,500

33871PA0100004

Gold

Keystone HMO Gold Preferred $30/$60/$650

$0

0%

$7,150

No No

33871PA0100003

KE 670 WPR GMC

8

Keystone Health Plan East Network

KE 670 WPR GMC

8


$30/$60 $25 no ded/$50 no ded


RATE PAGES


Product: HMO




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61

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63

64

65+

33871PA0100005 33871PA0100006


$191.32 $191.32 $181.92 $181.92

$301.28 $338.94 $286.49 $322.30

$301.28 $338.94 $286.49 $322.30

$301.28 $338.94 $286.49 $322.30

$301.28 $338.94 $286.49 $322.30

$302.49 $340.30 $287.64 $323.59

$308.51 $347.08 $293.37 $330.04

$315.75 $355.21 $300.24 $337.77

$327.50 $368.43 $311.41 $350.34

$337.14 $379.28 $320.58 $360.66

$341.96 $401.80 $325.17 $382.07

$349.19 $410.30 $332.04 $390.15

$356.42 $418.79 $338.92 $398.23

$360.94 $424.10 $343.22 $403.28

$365.76 $429.77 $347.80 $408.66

$368.17 $432.60 $350.09 $411.36

$370.58 $435.43 $352.38 $414.05

$372.99 $438.26 $354.67 $416.74

$375.40 $441.09 $356.97 $419.44

$380.22 $446.76 $361.55 $424.82

$385.04 $471.67 $366.13 $448.51

$392.27 $480.53 $373.01 $456.94

$399.20 $489.02 $379.60 $465.01

$408.84 $500.83 $388.77 $476.24

$420.89 $515.59 $400.23 $490.28

$435.05 $532.94 $413.69 $506.77

$451.93 $553.61 $429.74 $526.43

$470.91 $576.86 $447.78 $548.54

$492.60 $603.43 $468.41 $573.80

$513.99 $629.64 $488.75 $598.72

$538.09 $739.88 $511.67 $703.55

$561.89 $772.60 $534.30 $734.67

$588.11 $808.65 $559.23 $768.94

$614.62 $845.10 $584.44 $803.60

$643.24 $884.46 $611.66 $841.03

$671.86 $923.81 $638.87 $878.45

$702.89 $966.48 $668.38 $919.02

$734.23 $1,009.56 $698.18 $959.99

$767.67 $1,055.55 $729.98 $1,003.72

$784.24 $1,078.33 $745.73 $1,025.38

$817.68 $1,124.31 $777.53 $1,069.11

$846.61 $1,164.08 $805.04 $1,106.93

$865.59 $1,190.18 $823.09 $1,131.74

$889.39 $1,222.91 $845.72 $1,162.86

$903.84 $1,242.79 $859.47 $1,181.77

$903.84 $1,242.79 $859.47 $1,181.77

33871PA0100005

$2,500

30%

$7,150

No

Silver

Keystone HMO Silver Classic $2,500 $25/$50/70%

KE 670 WPR GMC

8


$30 no ded/$60 no ded

Silver

Keystone HMO Silver Classic $2,750/$30/$60/50%

$2,750

50%

$7,150

No

33871PA0100006

KE 670 WPR GMC

8




RATE PAGES


Product: HMO




Form # =>

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51

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53

54

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60

61

62

63

64

65+

33871PA0100007 33871PA0100008


$135.45 $135.45 $193.47 $193.47

$213.30 $239.96 $304.68 $342.77

$213.30 $239.96 $304.68 $342.77

$213.30 $239.96 $304.68 $342.77

$213.30 $239.96 $304.68 $342.77

$214.15 $240.92 $305.90 $344.14

$218.42 $245.72 $311.99 $350.99

$223.54 $251.48 $319.31 $359.22

$231.86 $260.84 $331.19 $372.59

$238.68 $268.52 $340.94 $383.56

$242.09 $284.46 $345.81 $406.33

$247.21 $290.48 $353.13 $414.92

$252.33 $296.49 $360.44 $423.52

$255.53 $300.25 $365.01 $428.89

$258.95 $304.26 $369.88 $434.61

$260.65 $306.27 $372.32 $437.48

$262.36 $308.27 $374.76 $440.34

$264.06 $310.28 $377.20 $443.21

$265.77 $312.28 $379.63 $446.07

$269.18 $316.29 $384.51 $451.80

$272.60 $333.93 $389.38 $477.00

$277.72 $340.20 $396.70 $485.95

$282.62 $346.21 $403.70 $494.54

$289.45 $354.57 $413.45 $506.48

$297.98 $365.02 $425.64 $521.41

$308.00 $377.31 $439.96 $538.95

$319.95 $391.94 $457.02 $559.85

$333.39 $408.40 $476.22 $583.37

$348.74 $427.21 $498.16 $610.24

$363.89 $445.76 $519.79 $636.74

$380.95 $523.81 $544.16 $748.22

$397.80 $546.98 $568.23 $781.32

$416.36 $572.50 $594.74 $817.77

$435.13 $598.30 $621.55 $854.63

$455.39 $626.17 $650.50 $894.43

$475.66 $654.03 $679.44 $934.23

$497.63 $684.24 $710.82 $977.38

$519.81 $714.74 $742.51 $1,020.95

$543.49 $747.29 $776.33 $1,067.45

$555.22 $763.43 $793.09 $1,090.50

$578.89 $795.98 $826.91 $1,137.00

$599.37 $824.14 $856.16 $1,177.22

$612.81 $842.61 $875.35 $1,203.61

$629.66 $865.78 $899.42 $1,236.71

$639.90 $879.86 $914.04 $1,256.81

$639.90 $879.86 $914.04 $1,256.81

33871PA0100007

Bronze

KE 670 WPR GMC

8


Keystone HMO Bronze Essential $6,850/$50/$100/$700

$6,850

50%

$7,150

No


No

$15/$40, $30/$60, $45/$80

Gold

Keystone HMO Gold Proactive

$0

0%/20%/30%

$7,150

33871PA0100008

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

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65+

33871PA0100009 33871PA0110001


$153.46 $153.46 $287.26 $287.26

$241.68 $271.88 $452.39 $508.93

$241.68 $271.88 $452.39 $508.93

$241.68 $271.88 $452.39 $508.93

$241.68 $271.88 $452.39 $508.93

$242.64 $272.97 $454.19 $510.97

$247.48 $278.41 $463.24 $521.15

$253.28 $284.94 $474.10 $533.36

$262.70 $295.54 $491.74 $553.21

$270.43 $304.24 $506.22 $569.50

$274.30 $322.30 $513.46 $603.31

$280.10 $329.12 $524.31 $616.07

$285.90 $335.93 $535.17 $628.83

$289.53 $340.19 $541.96 $636.80

$293.39 $344.74 $549.20 $645.30

$295.33 $347.01 $552.81 $649.56

$297.26 $349.28 $556.43 $653.81

$299.19 $351.55 $560.05 $658.06

$301.13 $353.83 $563.67 $662.31

$304.99 $358.37 $570.91 $670.82

$308.86 $378.36 $578.15 $708.23

$314.66 $385.46 $589.01 $721.53

$320.22 $392.27 $599.41 $734.28

$327.95 $401.74 $613.89 $752.01

$337.62 $413.59 $631.98 $774.18

$348.98 $427.50 $653.24 $800.22

$362.51 $444.08 $678.58 $831.26

$377.74 $462.73 $707.08 $866.17

$395.14 $484.05 $739.65 $906.07

$412.30 $505.07 $771.77 $945.42

$431.63 $593.49 $807.96 $1,110.94

$450.72 $619.75 $843.70 $1,160.08

$471.75 $648.66 $883.06 $1,214.20

$493.02 $677.90 $922.87 $1,268.94

$515.98 $709.47 $965.84 $1,328.03

$538.94 $741.04 $1,008.82 $1,387.13

$563.83 $775.26 $1,055.41 $1,451.19

$588.96 $809.82 $1,102.46 $1,515.89

$615.79 $846.71 $1,152.68 $1,584.93

$629.08 $864.99 $1,177.56 $1,619.14

$655.91 $901.87 $1,227.77 $1,688.19

$679.11 $933.77 $1,271.20 $1,747.90

$694.33 $954.71 $1,299.70 $1,787.09

$713.43 $980.96 $1,335.44 $1,836.23

$725.03 $996.91 $1,357.16 $1,866.09

$725.03 $996.91 $1,357.16 $1,866.09

33871PA0100009

KE 670 WPR GMC

8


Silver

Keystone HMO Silver Proactive

$0/$5500/$5500

0%/5%/10%

$7,150

No

$30/$60, $40 no ded/$80 no ded, $50 no ded/$100 no ded

No

$10/$20

Platinum

Keystone DPOS Platinum Preferred $10/$20/$100

$0

0%

$3,000

33871PA0110001

KE 670 WPR GMC

8



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Product: HMO




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64

65+

33871PA0110002 33871PA0110003


$274.60 $274.60 $226.06 $226.06

$432.44 $486.50 $356.00 $400.49

$432.44 $486.50 $356.00 $400.49

$432.44 $486.50 $356.00 $400.49

$432.44 $486.50 $356.00 $400.49

$434.17 $488.44 $357.42 $402.10

$442.82 $498.17 $364.54 $410.11

$453.20 $509.85 $373.08 $419.72

$470.06 $528.82 $386.97 $435.34

$483.90 $544.39 $398.36 $448.15

$490.82 $576.71 $404.05 $474.76

$501.20 $588.91 $412.60 $484.80

$511.58 $601.10 $421.14 $494.84

$518.06 $608.73 $426.48 $501.12

$524.98 $616.86 $432.18 $507.81

$528.44 $620.92 $435.03 $511.16

$531.90 $624.99 $437.87 $514.50

$535.36 $629.05 $440.72 $517.85

$538.82 $633.11 $443.57 $521.19

$545.74 $641.24 $449.27 $527.89

$552.66 $677.01 $454.96 $557.33

$563.04 $689.72 $463.51 $567.79

$572.98 $701.91 $471.69 $577.82

$586.82 $718.86 $483.09 $591.78

$604.12 $740.05 $497.33 $609.22

$624.44 $764.94 $514.06 $629.72

$648.66 $794.61 $533.99 $654.14

$675.90 $827.98 $556.42 $681.62

$707.04 $866.12 $582.05 $713.01

$737.74 $903.74 $607.33 $743.98

$772.34 $1,061.97 $635.81 $874.24

$806.50 $1,108.94 $663.93 $912.91

$844.12 $1,160.67 $694.90 $955.49

$882.18 $1,213.00 $726.23 $998.57

$923.26 $1,269.48 $760.05 $1,045.07

$964.34 $1,325.97 $793.87 $1,091.57

$1,008.88 $1,387.22 $830.54 $1,141.99

$1,053.86 $1,449.05 $867.56 $1,192.90

$1,101.86 $1,515.06 $907.08 $1,247.23

$1,125.64 $1,547.76 $926.66 $1,274.15

$1,173.64 $1,613.76 $966.17 $1,328.49

$1,215.16 $1,670.84 $1,000.35 $1,375.48

$1,242.40 $1,708.30 $1,022.77 $1,406.31

$1,276.57 $1,755.28 $1,050.90 $1,444.98

$1,297.32 $1,783.82 $1,067.99 $1,468.48

$1,297.32 $1,783.82 $1,067.99 $1,468.48

33871PA0110002

KE 670 WPR GMC

8


Platinum


$0

0%

$4,000

No

$20/$40

No

$30/$60

Gold

Keystone DPOS Gold Preferred $30/$60/$650

$0

0%

$7,150

33871PA0110003

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

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65+

33871PA0110004 33871PA0110005


$232.67 $232.67 $228.93 $228.93

$366.40 $412.20 $360.51 $405.58

$366.40 $412.20 $360.51 $405.58

$366.40 $412.20 $360.51 $405.58

$366.40 $412.20 $360.51 $405.58

$367.87 $413.85 $361.96 $407.20

$375.20 $422.10 $369.17 $415.31

$383.99 $431.99 $377.82 $425.05

$398.28 $448.06 $391.88 $440.86

$410.00 $461.25 $403.42 $453.84

$415.87 $488.64 $409.18 $480.79

$424.66 $498.98 $417.84 $490.96

$433.45 $509.31 $426.49 $501.12

$438.95 $515.77 $431.90 $507.48

$444.81 $522.65 $437.66 $514.26

$447.74 $526.10 $440.55 $517.65

$450.67 $529.54 $443.43 $521.03

$453.61 $532.99 $446.32 $524.42

$456.54 $536.43 $449.20 $527.81

$462.40 $543.32 $454.97 $534.59

$468.26 $573.62 $460.74 $564.40

$477.06 $584.39 $469.39 $575.00

$485.48 $594.72 $477.68 $585.16

$497.21 $609.08 $489.22 $599.29

$511.86 $627.03 $503.64 $616.96

$529.09 $648.13 $520.58 $637.71

$549.60 $673.26 $540.77 $662.45

$572.69 $701.54 $563.48 $690.27

$599.07 $733.86 $589.44 $722.07

$625.08 $765.73 $615.04 $753.42

$654.39 $899.79 $643.88 $885.33

$683.34 $939.59 $672.36 $924.49

$715.22 $983.42 $703.72 $967.62

$747.46 $1,027.76 $735.45 $1,011.24

$782.27 $1,075.62 $769.70 $1,058.34

$817.08 $1,123.48 $803.95 $1,105.43

$854.82 $1,175.37 $841.08 $1,156.49

$892.92 $1,227.77 $878.57 $1,208.04

$933.59 $1,283.69 $918.59 $1,263.06

$953.75 $1,311.40 $938.42 $1,290.33

$994.42 $1,367.32 $978.44 $1,345.35

$1,029.59 $1,415.69 $1,013.05 $1,392.94

$1,052.67 $1,447.43 $1,035.76 $1,424.17

$1,081.62 $1,487.23 $1,064.24 $1,463.33

$1,099.20 $1,511.41 $1,081.53 $1,487.12

$1,099.20 $1,511.41 $1,081.53 $1,487.12

33871PA0110004

KE 670 WPR GMC

8


Gold

Keystone DPOS Gold Classic $1,000 $25/$50/90%

$1,000

10%

$5,500

No


No


GoldKeystone DPOS Gold Classic

$2,000 $40/$80/100%

$2,000

0%

$3,500

33871PA0110005

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110006 33871PA0110010


$199.85 $199.85 $141.33 $141.33

$314.73 $354.07 $222.57 $250.39

$314.73 $354.07 $222.57 $250.39

$314.73 $354.07 $222.57 $250.39

$314.73 $354.07 $222.57 $250.39

$315.99 $355.49 $223.46 $251.39

$322.28 $362.57 $227.91 $256.40

$329.84 $371.07 $233.25 $262.41

$342.11 $384.88 $241.93 $272.17

$352.18 $396.21 $249.06 $280.19

$357.22 $419.73 $252.62 $296.82

$364.77 $428.61 $257.96 $303.10

$372.33 $437.48 $263.30 $309.38

$377.05 $443.03 $266.64 $313.30

$382.08 $448.95 $270.20 $317.48

$384.60 $451.91 $271.98 $319.58

$387.12 $454.86 $273.76 $321.67

$389.64 $457.82 $275.54 $323.76

$392.15 $460.78 $277.32 $325.85

$397.19 $466.70 $280.88 $330.04

$402.23 $492.73 $284.44 $348.44

$409.78 $501.98 $289.79 $354.99

$417.02 $510.85 $294.90 $361.26

$427.09 $523.18 $302.03 $369.98

$439.68 $538.61 $310.93 $380.89

$454.47 $556.73 $321.39 $393.70

$472.10 $578.32 $333.85 $408.97

$491.92 $602.61 $347.88 $426.15

$514.58 $630.37 $363.90 $445.78

$536.93 $657.74 $379.70 $465.14

$562.11 $772.90 $397.51 $546.57

$586.97 $807.09 $415.09 $570.75

$614.35 $844.74 $434.46 $597.38

$642.05 $882.82 $454.04 $624.31

$671.95 $923.93 $475.19 $653.38

$701.85 $965.04 $496.33 $682.45

$734.27 $1,009.62 $519.25 $713.97

$767.00 $1,054.62 $542.40 $745.80

$801.93 $1,102.66 $567.11 $779.77

$819.24 $1,126.46 $579.35 $796.60

$854.18 $1,174.50 $604.05 $830.57

$884.39 $1,216.04 $625.42 $859.95

$904.22 $1,243.30 $639.44 $879.23

$929.08 $1,277.49 $657.02 $903.41

$944.19 $1,298.26 $667.71 $918.10

$944.19 $1,298.26 $667.71 $918.10

33871PA0110006

KE 670 WPR GMC

8


Silver

Keystone DPOS Silver Classic $2,500/$25/$50/70%

$2,500

30%

$7,150

No


No


Bronze

Keystone DPOS Bronze Essential $6,850/$50/$100/$700

$6,850

50%

$7,150

33871PA0110010

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0100020 33871PA0100021


$275.08 $275.08 $262.98 $262.98

$433.20 $487.35 $414.13 $465.90

$433.20 $487.35 $414.13 $465.90

$433.20 $487.35 $414.13 $465.90

$433.20 $487.35 $414.13 $465.90

$434.93 $489.30 $415.79 $467.77

$443.59 $499.04 $424.07 $477.08

$453.99 $510.74 $434.01 $488.26

$470.89 $529.75 $450.16 $506.43

$484.75 $545.34 $463.42 $521.34

$491.68 $577.72 $470.04 $552.30

$502.08 $589.94 $479.98 $563.98

$512.47 $602.16 $489.92 $575.66

$518.97 $609.79 $496.13 $582.96

$525.90 $617.93 $502.76 $590.74

$529.37 $622.01 $506.07 $594.64

$532.83 $626.08 $509.39 $598.53

$536.30 $630.15 $512.70 $602.42

$539.76 $634.22 $516.01 $606.31

$546.69 $642.37 $522.64 $614.10

$553.63 $678.19 $529.26 $648.35

$564.02 $690.93 $539.20 $660.52

$573.99 $703.13 $548.73 $672.19

$587.85 $720.11 $561.98 $688.43

$605.18 $741.34 $578.55 $708.72

$625.54 $766.28 $598.01 $732.56

$649.80 $796.00 $621.20 $760.97

$677.09 $829.43 $647.29 $792.93

$708.28 $867.64 $677.11 $829.46

$739.03 $905.32 $706.51 $865.48

$773.69 $1,063.82 $739.64 $1,017.01

$807.91 $1,110.88 $772.36 $1,062.00

$845.60 $1,162.70 $808.39 $1,111.54

$883.72 $1,215.12 $844.83 $1,161.65

$924.88 $1,271.70 $884.18 $1,215.74

$966.03 $1,328.29 $923.52 $1,269.84

$1,010.65 $1,389.64 $966.18 $1,328.49

$1,055.70 $1,451.59 $1,009.25 $1,387.71

$1,103.79 $1,517.71 $1,055.21 $1,450.92

$1,127.61 $1,550.47 $1,077.99 $1,482.24

$1,175.70 $1,616.58 $1,123.96 $1,545.45

$1,217.28 $1,673.77 $1,163.72 $1,600.11

$1,244.58 $1,711.29 $1,189.81 $1,635.99

$1,278.80 $1,758.35 $1,222.53 $1,680.97

$1,299.59 $1,786.94 $1,242.39 $1,708.31

$1,299.59 $1,786.94 $1,242.39 $1,708.31

KE 670 WPR GMC

8


Yes

33871PA0100021

KE 670 WPR GMC

8


Platinum


$0

0%

$4,000

Yes

Platinum


$0

0%

$3,000

33871PA0100020

$10/$20 $20/$40

Page Number: 10 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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64

65+

33871PA0100022 33871PA0100023


$216.94 $216.94 $223.97 $223.97

$341.63 $384.34 $352.72 $396.81

$341.63 $384.34 $352.72 $396.81

$341.63 $384.34 $352.72 $396.81

$341.63 $384.34 $352.72 $396.81

$343.00 $385.88 $354.13 $398.39

$349.83 $393.56 $361.18 $406.33

$358.03 $402.79 $369.65 $415.85

$371.36 $417.78 $383.40 $431.33

$382.29 $430.07 $394.69 $444.02

$387.75 $455.61 $400.33 $470.39

$395.95 $465.25 $408.80 $480.34

$404.15 $474.88 $417.26 $490.28

$409.28 $480.90 $422.55 $496.50

$414.74 $487.32 $428.20 $503.13

$417.48 $490.54 $431.02 $506.45

$420.21 $493.75 $433.84 $509.76

$422.94 $496.96 $436.66 $513.08

$425.68 $500.17 $439.48 $516.39

$431.14 $506.59 $445.13 $523.02

$436.61 $534.85 $450.77 $552.19

$444.81 $544.89 $459.24 $562.56

$452.67 $554.51 $467.35 $572.50

$463.60 $567.91 $478.64 $586.33

$477.26 $584.65 $492.74 $603.61

$493.32 $604.32 $509.32 $623.92

$512.45 $627.75 $529.07 $648.11

$533.97 $654.12 $551.29 $675.34

$558.57 $684.25 $576.69 $706.45

$582.83 $713.96 $601.73 $737.12

$610.16 $838.97 $629.95 $866.18

$637.15 $876.08 $657.81 $904.50

$666.87 $916.95 $688.50 $946.69

$696.93 $958.28 $719.54 $989.37

$729.39 $1,002.91 $753.05 $1,035.44

$761.84 $1,047.54 $786.56 $1,081.51

$797.03 $1,095.92 $822.89 $1,131.47

$832.56 $1,144.77 $859.57 $1,181.91

$870.48 $1,196.92 $898.72 $1,235.74

$889.27 $1,222.75 $918.12 $1,262.41

$927.19 $1,274.89 $957.27 $1,316.25

$959.99 $1,319.99 $991.13 $1,362.81

$981.51 $1,349.58 $1,013.35 $1,393.36

$1,008.50 $1,386.69 $1,041.22 $1,431.67

$1,024.89 $1,409.24 $1,058.15 $1,454.95

$1,024.89 $1,409.24 $1,058.15 $1,454.95

Yes

33871PA0100023

KE 670 WPR GMC

8


Gold


$1,000

10%

$5,500

Yes

Gold


$0

0%

$7,150

33871PA0100022

KE 670 WPR GMC

8


$30/$60 $25 no ded/$50 no ded

Page Number: 11 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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61

62

63

64

65+

33871PA0100024 33871PA0100025


$191.86 $191.86 $182.46 $182.46

$302.14 $339.90 $287.34 $323.26

$302.14 $339.90 $287.34 $323.26

$302.14 $339.90 $287.34 $323.26

$302.14 $339.90 $287.34 $323.26

$303.35 $341.26 $288.49 $324.55

$309.39 $348.06 $294.24 $331.02

$316.64 $356.22 $301.14 $338.78

$328.42 $369.48 $312.34 $351.39

$338.09 $380.35 $321.54 $361.73

$342.93 $402.94 $326.14 $383.21

$350.18 $411.46 $333.03 $391.31

$357.43 $419.98 $339.93 $399.42

$361.96 $425.30 $344.24 $404.48

$366.79 $430.98 $348.84 $409.88

$369.21 $433.82 $351.13 $412.58

$371.63 $436.66 $353.43 $415.28

$374.05 $439.50 $355.73 $417.98

$376.46 $442.34 $358.03 $420.69

$381.30 $448.02 $362.63 $426.09

$386.13 $473.01 $367.23 $449.85

$393.38 $481.89 $374.12 $458.30

$400.33 $490.41 $380.73 $466.40

$410.00 $502.25 $389.93 $477.66

$422.09 $517.06 $401.42 $491.74

$436.29 $534.45 $414.92 $508.28

$453.21 $555.18 $431.02 $527.99

$472.24 $578.49 $449.12 $550.17

$493.99 $605.14 $469.81 $575.51

$515.45 $631.42 $490.21 $600.51

$539.62 $741.97 $513.20 $705.64

$563.49 $774.79 $535.90 $736.86

$589.77 $810.94 $560.90 $771.23

$616.36 $847.50 $586.18 $806.00

$645.06 $886.96 $613.48 $843.53

$673.77 $926.43 $640.78 $881.07

$704.89 $969.22 $670.37 $921.76

$736.31 $1,012.42 $700.26 $962.85

$769.85 $1,058.54 $732.15 $1,006.71

$786.46 $1,081.39 $747.96 $1,028.44

$820.00 $1,127.50 $779.85 $1,072.30

$849.01 $1,167.38 $807.44 $1,110.23

$868.04 $1,193.56 $825.54 $1,135.12

$891.91 $1,226.38 $848.24 $1,166.33

$906.41 $1,246.32 $862.02 $1,185.29

$906.41 $1,246.32 $862.02 $1,185.29

Yes

33871PA0100025

KE 670 WPR GMC

8


Silver


$2,750

50%

$7,150

Yes

Silver


$2,500

30%

$7,150

33871PA0100024

KE 670 WPR GMC

8


$25 no ded/$50 no ded $30 no ded/$60 no ded

Page Number: 12 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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61

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64

65+

33871PA0100026 33871PA0110011


$135.99 $135.99 $287.81 $287.81

$214.15 $240.92 $453.24 $509.89

$214.15 $240.92 $453.24 $509.89

$214.15 $240.92 $453.24 $509.89

$214.15 $240.92 $453.24 $509.89

$215.01 $241.89 $455.05 $511.93

$219.29 $246.70 $464.12 $522.13

$224.43 $252.49 $474.99 $534.37

$232.78 $261.88 $492.67 $554.25

$239.64 $269.59 $507.17 $570.57

$243.06 $285.60 $514.43 $604.45

$248.20 $291.64 $525.30 $617.23

$253.34 $297.68 $536.18 $630.01

$256.56 $301.45 $542.98 $638.00

$259.98 $305.48 $550.23 $646.52

$261.70 $307.49 $553.86 $650.78

$263.41 $309.51 $557.48 $655.04

$265.12 $311.52 $561.11 $659.30

$266.83 $313.53 $564.74 $663.56

$270.26 $317.56 $571.99 $672.09

$273.69 $335.27 $579.24 $709.57

$278.83 $341.56 $590.12 $722.89

$283.75 $347.60 $600.54 $735.66

$290.61 $355.99 $615.05 $753.43

$299.17 $366.49 $633.17 $775.64

$309.24 $378.82 $654.48 $801.73

$321.23 $393.51 $679.86 $832.83

$334.72 $410.03 $708.41 $867.81

$350.14 $428.92 $741.05 $907.78

$365.35 $447.55 $773.23 $947.20

$382.48 $525.91 $809.48 $1,113.04

$399.40 $549.17 $845.29 $1,162.27

$418.03 $574.79 $884.72 $1,216.49

$436.87 $600.70 $924.61 $1,271.34

$457.22 $628.67 $967.67 $1,330.54

$477.56 $656.65 $1,010.72 $1,389.74

$499.62 $686.98 $1,057.41 $1,453.93

$521.89 $717.60 $1,104.54 $1,518.75

$545.66 $750.29 $1,154.85 $1,587.92

$557.44 $766.48 $1,179.78 $1,622.20

$581.21 $799.17 $1,230.09 $1,691.37

$601.77 $827.43 $1,273.60 $1,751.20

$615.26 $845.99 $1,302.16 $1,790.46

$632.18 $869.25 $1,337.96 $1,839.70

$642.45 $883.38 $1,359.72 $1,869.61

$642.45 $883.38 $1,359.72 $1,869.61

Yes

33871PA0110011

KE 670 WPR GMC

8


Platinum


$0

0%

$3,000

Yes

Bronze


$6,850

50%

$7,150

33871PA0100026

KE 670 WPR GMC

8


$10/$20$50 no ded/$100 no ded

Page Number: 13 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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63

64

65+

33871PA0110012 33871PA0110013


$275.14 $275.14 $226.60 $226.60

$433.29 $487.46 $356.85 $401.46

$433.29 $487.46 $356.85 $401.46

$433.29 $487.46 $356.85 $401.46

$433.29 $487.46 $356.85 $401.46

$435.03 $489.41 $358.28 $403.06

$443.69 $499.16 $365.41 $411.09

$454.09 $510.85 $373.98 $420.72

$470.99 $529.87 $387.89 $436.38

$484.86 $545.46 $399.31 $449.23

$491.79 $577.85 $405.02 $475.90

$502.19 $590.07 $413.59 $485.97

$512.59 $602.29 $422.15 $496.03

$519.09 $609.93 $427.51 $502.32

$526.02 $618.07 $433.21 $509.03

$529.49 $622.15 $436.07 $512.38

$532.95 $626.22 $438.92 $515.74

$536.42 $630.29 $441.78 $519.09

$539.89 $634.36 $444.63 $522.44

$546.82 $642.51 $450.34 $529.15

$553.75 $678.34 $456.05 $558.66

$564.15 $691.08 $464.62 $569.16

$574.12 $703.29 $472.82 $579.21

$587.98 $720.28 $484.24 $593.20

$605.31 $741.51 $498.52 $610.68

$625.68 $766.45 $515.29 $631.23

$649.94 $796.18 $535.27 $655.71

$677.24 $829.62 $557.76 $683.25

$708.44 $867.83 $583.45 $714.72

$739.20 $905.52 $608.78 $745.76

$773.86 $1,064.06 $637.33 $876.33

$808.09 $1,111.13 $665.52 $915.09

$845.79 $1,162.96 $696.57 $957.78

$883.92 $1,215.39 $727.97 $1,000.96

$925.08 $1,271.99 $761.87 $1,047.57

$966.25 $1,328.59 $795.77 $1,094.19

$1,010.88 $1,389.95 $832.53 $1,144.73

$1,055.94 $1,451.92 $869.64 $1,195.76

$1,104.03 $1,518.05 $909.25 $1,250.22

$1,127.87 $1,550.82 $928.88 $1,277.21

$1,175.96 $1,616.95 $968.49 $1,331.67

$1,217.56 $1,674.14 $1,002.75 $1,378.78

$1,244.86 $1,711.68 $1,025.23 $1,409.69

$1,279.09 $1,758.74 $1,053.42 $1,448.45

$1,299.87 $1,787.34 $1,070.55 $1,472.00

$1,299.87 $1,787.34 $1,070.55 $1,472.00

Yes

33871PA0110013

KE 670 WPR GMC

8


Gold


$0

0%

$7,150

Yes

Platinum


$0

0%

$4,000

33871PA0110012

KE 670 WPR GMC

8


$20/$40 $30/$60

Page Number: 14 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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62

63

64

65+

33871PA0110014 33871PA0110016


$233.21 $233.21 $200.40 $200.40

$367.26 $413.16 $315.58 $355.03

$367.26 $413.16 $315.58 $355.03

$367.26 $413.16 $315.58 $355.03

$367.26 $413.16 $315.58 $355.03

$368.73 $414.82 $316.85 $356.45

$376.07 $423.08 $323.16 $363.55

$384.88 $433.00 $330.73 $372.07

$399.21 $449.11 $343.04 $385.92

$410.96 $462.33 $353.14 $397.28

$416.84 $489.78 $358.19 $420.87

$425.65 $500.14 $365.76 $429.77

$434.46 $510.50 $373.34 $438.67

$439.97 $516.97 $378.07 $444.23

$445.85 $523.87 $383.12 $450.17

$448.79 $527.32 $385.64 $453.13

$451.73 $530.78 $388.17 $456.10

$454.66 $534.23 $390.69 $459.06

$457.60 $537.68 $393.22 $462.03

$463.48 $544.59 $398.27 $467.96

$469.35 $574.96 $403.32 $494.06

$478.17 $585.76 $410.89 $503.34

$486.61 $596.10 $418.15 $512.23

$498.37 $610.50 $428.25 $524.60

$513.06 $628.49 $440.87 $540.07

$530.32 $649.64 $455.70 $558.24

$550.88 $674.83 $473.38 $579.89

$574.02 $703.18 $493.26 $604.24

$600.46 $735.57 $515.98 $632.08

$626.54 $767.51 $538.39 $659.52

$655.92 $901.89 $563.63 $775.00

$684.93 $941.78 $588.56 $809.28

$716.88 $985.72 $616.02 $847.03

$749.20 $1,030.15 $643.79 $885.21

$784.09 $1,078.13 $673.77 $926.44

$818.98 $1,126.10 $703.75 $967.66

$856.81 $1,178.11 $736.26 $1,012.36

$895.00 $1,230.63 $769.08 $1,057.48

$935.77 $1,286.68 $804.11 $1,105.65

$955.97 $1,314.46 $821.47 $1,129.52

$996.73 $1,370.51 $856.50 $1,177.68

$1,031.99 $1,418.99 $886.79 $1,219.34

$1,055.13 $1,450.80 $906.67 $1,246.68

$1,084.14 $1,490.69 $931.61 $1,280.96

$1,101.77 $1,514.93 $946.74 $1,301.79

$1,101.77 $1,514.93 $946.74 $1,301.79

Yes

33871PA0110016

KE 670 WPR GMC

8


Silver


$2,500

30%

$7,150

Yes

Gold


$1,000

10%

$5,500

33871PA0110014

KE 670 WPR GMC

8


$25 no ded/$50 no ded$25 no ded/$50 no ded

Page Number: 15 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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56

57

58

59

60

61

62

63

64

65+

33871PA0110019 33871PA0110020


$190.53 $190.53 $141.87 $141.87

$300.05 $337.56 $223.42 $251.35

$300.05 $337.56 $223.42 $251.35

$300.05 $337.56 $223.42 $251.35

$300.05 $337.56 $223.42 $251.35

$301.25 $338.91 $224.32 $252.36

$307.25 $345.66 $228.79 $257.38

$314.45 $353.76 $234.15 $263.42

$326.16 $366.93 $242.86 $273.22

$335.76 $377.73 $250.01 $281.26

$340.56 $400.16 $253.59 $297.96

$347.76 $408.62 $258.95 $304.26

$354.96 $417.08 $264.31 $310.56

$359.46 $422.37 $267.66 $314.50

$364.26 $428.01 $271.24 $318.70

$366.66 $430.83 $273.02 $320.80

$369.06 $433.65 $274.81 $322.90

$371.46 $436.47 $276.60 $325.00

$373.86 $439.29 $278.39 $327.10

$378.67 $444.93 $281.96 $331.30

$383.47 $469.75 $285.53 $349.78

$390.67 $478.57 $290.90 $356.35

$397.57 $487.02 $296.04 $362.64

$407.17 $498.78 $303.19 $371.40

$419.17 $513.49 $312.12 $382.35

$433.27 $530.76 $322.62 $395.21

$450.08 $551.34 $335.13 $410.54

$468.98 $574.50 $349.21 $427.78

$490.58 $600.97 $365.30 $447.49

$511.89 $627.06 $381.16 $466.92

$535.89 $736.85 $399.03 $548.67

$559.60 $769.44 $416.68 $572.94

$585.70 $805.34 $436.12 $599.67

$612.11 $841.64 $455.78 $626.70

$640.61 $880.84 $477.01 $655.89

$669.11 $920.03 $498.23 $685.07

$700.02 $962.53 $521.25 $716.71

$731.23 $1,005.44 $544.48 $748.66

$764.53 $1,051.23 $569.28 $782.76

$781.03 $1,073.92 $581.57 $799.66

$814.34 $1,119.72 $606.37 $833.76

$843.14 $1,159.32 $627.82 $863.25

$862.05 $1,185.32 $641.89 $882.61

$885.75 $1,217.91 $659.55 $906.87

$900.15 $1,237.71 $670.26 $921.62

$900.15 $1,237.71 $670.26 $921.62

Yes

33871PA0110020

Yes

$6,850


50%

Bronze

$7,150


8

KE 670 WPR GMC


Silver


$2,750

50%

$7,150

33871PA0110019

KE 670 WPR GMC

8



Page Number: 16 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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59

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61

62

63

64

65+

33871PA0100044 33871PA0100045


$194.02 $194.02 $154.01 $154.01

$305.54 $343.73 $242.53 $272.85

$305.54 $343.73 $242.53 $272.85

$305.54 $343.73 $242.53 $272.85

$305.54 $343.73 $242.53 $272.85

$306.76 $345.10 $243.50 $273.94

$312.87 $351.98 $248.35 $279.39

$320.20 $360.23 $254.17 $285.94

$332.12 $373.63 $263.63 $296.58

$341.89 $384.63 $271.39 $305.31

$346.78 $407.47 $275.27 $323.44

$354.12 $416.09 $281.09 $330.28

$361.45 $424.70 $286.91 $337.12

$366.03 $430.09 $290.55 $341.40

$370.92 $435.83 $294.43 $345.96

$373.36 $438.70 $296.37 $348.24

$375.81 $441.58 $298.31 $350.52

$378.25 $444.45 $300.25 $352.80

$380.70 $447.32 $302.19 $355.08

$385.59 $453.06 $306.07 $359.63

$390.48 $478.33 $309.95 $379.69

$397.81 $487.31 $315.77 $386.82

$404.84 $495.92 $321.35 $393.66

$414.61 $507.90 $329.11 $403.16

$426.83 $522.87 $338.81 $415.05

$441.19 $540.46 $350.21 $429.01

$458.30 $561.42 $363.79 $445.65

$477.55 $585.00 $379.07 $464.36

$499.55 $611.95 $396.54 $485.76

$521.24 $638.52 $413.75 $506.85

$545.69 $750.32 $433.16 $595.59

$569.82 $783.51 $452.32 $621.94

$596.41 $820.06 $473.42 $650.95

$623.29 $857.03 $494.76 $680.29

$652.32 $896.94 $517.80 $711.98

$681.35 $936.85 $540.84 $743.66

$712.82 $980.12 $565.82 $778.00

$744.59 $1,023.81 $591.04 $812.69

$778.51 $1,070.45 $617.96 $849.70

$795.31 $1,093.55 $631.30 $868.04

$829.22 $1,140.18 $658.22 $905.06

$858.56 $1,180.51 $681.51 $937.07

$877.80 $1,206.98 $696.79 $958.08

$901.94 $1,240.17 $715.95 $984.43

$916.61 $1,260.34 $727.59 $1,000.43

$916.61 $1,260.34 $727.59 $1,000.43

33871PA0100044

KE 670 WPR GMC

8


Yes

$0


0%/20%/30%

Gold

$7,150

$15/$40, $30/$60, $45/$80

Yes

$0/$5500/$5500


0%/5%/10%

Silver

33871PA0100045

KE 670 WPR GMC

8



$7,150

Page Number: 17 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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54

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61

62

63

64

65+

33871PA0100035 33871PA0100037


$222.33 $222.33 $174.66 $174.66

$350.13 $393.90 $275.06 $309.44

$350.13 $393.90 $275.06 $309.44

$350.13 $393.90 $275.06 $309.44

$350.13 $393.90 $275.06 $309.44

$351.53 $395.48 $276.16 $310.68

$358.54 $403.35 $281.66 $316.87

$366.94 $412.81 $288.26 $324.30

$380.59 $428.17 $298.99 $336.37

$391.80 $440.77 $307.79 $346.27

$397.40 $466.95 $312.19 $366.83

$405.80 $476.82 $318.80 $374.59

$414.21 $486.69 $325.40 $382.34

$419.46 $492.86 $329.52 $387.19

$425.06 $499.45 $333.92 $392.36

$427.86 $502.74 $336.12 $394.95

$430.66 $506.03 $338.33 $397.53

$433.46 $509.32 $340.53 $400.12

$436.27 $512.61 $342.73 $402.70

$441.87 $519.19 $347.13 $407.87

$447.47 $548.15 $351.53 $430.62

$455.87 $558.44 $358.13 $438.71

$463.93 $568.31 $364.46 $446.46

$475.13 $582.03 $373.26 $457.24

$489.14 $599.19 $384.26 $470.72

$505.59 $619.35 $397.19 $486.56

$525.20 $643.37 $412.59 $505.42

$547.26 $670.39 $429.92 $526.65

$572.47 $701.27 $449.72 $550.91

$597.33 $731.73 $469.25 $574.84

$625.34 $859.84 $491.26 $675.48

$653.00 $897.87 $512.99 $705.36

$683.46 $939.76 $536.92 $738.26

$714.27 $982.12 $561.12 $771.55

$747.53 $1,027.86 $587.26 $807.48

$780.80 $1,073.60 $613.39 $843.41

$816.86 $1,123.18 $641.72 $882.36

$853.27 $1,173.25 $670.32 $921.70

$892.14 $1,226.69 $700.86 $963.68

$911.40 $1,253.17 $715.98 $984.48

$950.26 $1,306.61 $746.52 $1,026.46

$983.87 $1,352.83 $772.92 $1,062.77

$1,005.93 $1,383.16 $790.25 $1,086.59

$1,033.59 $1,421.19 $811.98 $1,116.47

$1,050.39 $1,444.30 $825.18 $1,134.63

$1,050.39 $1,444.30 $825.18 $1,134.63

33871PA0100035

KE 670 WPR GMC

8


No

Gold Silver

$2,000 $3,500

$3,500 $7,150

No

0%


0%

Keystone HMO Gold Classic $2,000/$40/$80/100% Keystone HMO Silver Secure $3,500 $40/$80/$600

33871PA0100037

KE 670 WPR GMC

8



Page Number: 18 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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64

65+

33871PA0100036 33871PA0110007


$185.04 $185.04 $182.41 $182.41

$291.40 $327.83 $287.26 $323.17

$291.40 $327.83 $287.26 $323.17

$291.40 $327.83 $287.26 $323.17

$291.40 $327.83 $287.26 $323.17

$292.57 $329.14 $288.41 $324.46

$298.40 $335.70 $294.16 $330.93

$305.39 $343.56 $301.05 $338.68

$316.75 $356.35 $312.26 $351.29

$326.08 $366.84 $321.45 $361.63

$330.74 $388.62 $326.04 $383.10

$337.74 $396.84 $332.94 $391.20

$344.73 $405.06 $339.83 $399.30

$349.10 $410.19 $344.14 $404.37

$353.76 $415.67 $348.74 $409.77

$356.09 $418.41 $351.04 $412.47

$358.42 $421.15 $353.33 $415.17

$360.76 $423.89 $355.63 $417.87

$363.09 $426.63 $357.93 $420.57

$367.75 $432.11 $362.53 $425.97

$372.41 $456.20 $367.12 $449.72

$379.41 $464.77 $374.02 $458.17

$386.11 $472.98 $380.62 $466.26

$395.43 $484.41 $389.82 $477.52

$407.09 $498.68 $401.31 $491.60

$420.78 $515.46 $414.81 $508.14

$437.10 $535.45 $430.89 $527.85

$455.46 $557.94 $448.99 $550.02

$476.44 $583.64 $469.68 $575.35

$497.13 $608.99 $490.07 $600.34

$520.44 $715.61 $513.05 $705.45

$543.46 $747.26 $535.75 $736.65

$568.82 $782.12 $560.74 $771.01

$594.46 $817.38 $586.02 $805.77

$622.14 $855.45 $613.31 $843.30

$649.83 $893.51 $640.60 $880.82

$679.84 $934.78 $670.18 $921.50

$710.15 $976.45 $700.06 $962.58

$742.49 $1,020.93 $731.95 $1,006.43

$758.52 $1,042.96 $747.75 $1,028.15

$790.87 $1,087.44 $779.63 $1,071.99

$818.84 $1,125.91 $807.21 $1,109.91

$837.20 $1,151.15 $825.31 $1,134.80

$860.22 $1,182.80 $848.00 $1,166.00

$874.20 $1,202.03 $861.78 $1,184.96

$874.20 $1,202.03 $861.78 $1,184.96


KE 670 WPR GMC

No

Silver Silver

$4,250 $3,500

$7,150 $7,150

No

Keystone HMO Silver Classic $4,250 $40/$80/100% Keystone DPOS Silver Secure $3,500/$40/$80/$600

0% 0%

33871PA0110007

8

33871PA0100036

KE 670 WPR GMC

8



Page Number: 19 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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61

62

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64

65+

33871PA0110008 33871PA0110009


$193.25 $193.25 $189.99 $189.99

$304.32 $342.36 $299.20 $336.60

$304.32 $342.36 $299.20 $336.60

$304.32 $342.36 $299.20 $336.60

$304.32 $342.36 $299.20 $336.60

$305.54 $343.73 $300.39 $337.94

$311.63 $350.58 $306.38 $344.68

$318.93 $358.80 $313.56 $352.75

$330.80 $372.15 $325.23 $365.88

$340.54 $383.11 $334.80 $376.65

$345.41 $405.85 $339.59 $399.02

$352.71 $414.44 $346.77 $407.45

$360.02 $423.02 $353.95 $415.89

$364.58 $428.38 $358.44 $421.17

$369.45 $434.10 $363.23 $426.79

$371.88 $436.96 $365.62 $429.60

$374.32 $439.82 $368.01 $432.42

$376.75 $442.69 $370.41 $435.23

$379.19 $445.55 $372.80 $438.04

$384.06 $451.27 $377.59 $443.67

$388.93 $476.43 $382.37 $468.41

$396.23 $485.38 $389.56 $477.21

$403.23 $493.96 $396.44 $485.64

$412.97 $505.89 $406.01 $497.36

$425.14 $520.80 $417.98 $512.02

$439.44 $538.32 $432.04 $529.25

$456.49 $559.20 $448.80 $549.78

$475.66 $582.68 $467.65 $572.87

$497.57 $609.52 $489.19 $599.26

$519.18 $635.99 $510.43 $625.28

$543.52 $747.34 $534.37 $734.75

$567.56 $780.40 $558.00 $767.26

$594.04 $816.81 $584.03 $803.05

$620.82 $853.63 $610.36 $839.25

$649.73 $893.38 $638.79 $878.33

$678.64 $933.13 $667.21 $917.42

$709.99 $976.23 $698.03 $959.79

$741.64 $1,019.75 $729.14 $1,002.57

$775.42 $1,066.20 $762.36 $1,048.24

$792.16 $1,089.21 $778.81 $1,070.87

$825.94 $1,135.66 $812.02 $1,116.53

$855.15 $1,175.83 $840.75 $1,156.03

$874.32 $1,202.19 $859.60 $1,181.94

$898.36 $1,235.25 $883.23 $1,214.44

$912.96 $1,255.34 $897.59 $1,234.19

$912.96 $1,255.34 $897.59 $1,234.19


8

KE 670 WPR GMC

50%


Keystone DPOS Silver Classic $4,250 $40/$80/100%

NoNo

0%

Silver

$4,250 $2,750


Silver

33871PA0110009


KE 670 WPR GMC

33871PA0110008

8

$7,150


$7,150

Page Number: 20 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

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Plan Name =>

Deductible =>

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OOP Maximum =>


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65+

33871PA0100047 33871PA0100049


$222.88 $222.88 $175.21 $175.21

$350.99 $394.86 $275.91 $310.40

$350.99 $394.86 $275.91 $310.40

$350.99 $394.86 $275.91 $310.40

$350.99 $394.86 $275.91 $310.40

$352.39 $396.44 $277.02 $311.65

$359.41 $404.34 $282.54 $317.85

$367.83 $413.81 $289.16 $325.30

$381.52 $429.21 $299.92 $337.41

$392.75 $441.85 $308.75 $347.34

$398.37 $468.08 $313.16 $367.97

$406.79 $477.98 $319.79 $375.75

$415.22 $487.88 $326.41 $383.53

$420.48 $494.07 $330.55 $388.39

$426.10 $500.67 $334.96 $393.58

$428.91 $503.96 $337.17 $396.17

$431.71 $507.26 $339.38 $398.77

$434.52 $510.56 $341.58 $401.36

$437.33 $513.86 $343.79 $403.95

$442.95 $520.46 $348.20 $409.14

$448.56 $549.49 $352.62 $431.96

$456.98 $559.81 $359.24 $440.07

$465.06 $569.70 $365.59 $447.84

$476.29 $583.45 $374.42 $458.66

$490.33 $600.65 $385.45 $472.18

$506.82 $620.86 $398.42 $488.07

$526.48 $644.94 $413.87 $506.99

$548.59 $672.03 $431.26 $528.29

$573.86 $702.98 $451.12 $552.62

$598.78 $733.51 $470.71 $576.62

$626.86 $861.94 $492.78 $677.58

$654.59 $900.06 $514.58 $707.55

$685.13 $942.05 $538.59 $740.56

$716.01 $984.52 $562.87 $773.94

$749.36 $1,030.37 $589.08 $809.98

$782.70 $1,076.21 $615.29 $846.02

$818.85 $1,125.92 $643.71 $885.10

$855.35 $1,176.11 $672.40 $924.56

$894.31 $1,229.68 $703.03 $966.67

$913.62 $1,256.23 $718.21 $987.53

$952.58 $1,309.79 $748.83 $1,029.65

$986.27 $1,356.13 $775.32 $1,066.07

$1,008.38 $1,386.53 $792.70 $1,089.97

$1,036.11 $1,424.66 $814.50 $1,119.94

$1,052.96 $1,447.82 $827.73 $1,138.15

$1,052.96 $1,447.82 $827.73 $1,138.15

33871PA0100047

KE 670 WPR GMC

33871PA0100049

KE 670 WPR GMC


Yes Yes

Gold

$2,000

8


8

Keystone HMO Silver Secure $3,500 $40/$80/$600

0% 0%


$3,500


Silver

$3,500 $7,150

Page Number: 21 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

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OOP Maximum =>


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65+

33871PA0100048 33871PA0110015


$185.58 $185.58 $229.47 $229.47

$292.26 $328.79 $361.37 $406.54

$292.26 $328.79 $361.37 $406.54

$292.26 $328.79 $361.37 $406.54

$292.26 $328.79 $361.37 $406.54

$293.42 $330.10 $362.81 $408.17

$299.27 $336.68 $370.04 $416.30

$306.28 $344.57 $378.71 $426.05

$317.68 $357.39 $392.81 $441.91

$327.03 $367.91 $404.37 $454.92

$331.71 $389.76 $410.15 $481.93

$338.72 $398.00 $418.83 $492.12

$345.74 $406.24 $427.50 $502.31

$350.12 $411.39 $432.92 $508.68

$354.80 $416.89 $438.70 $515.47

$357.14 $419.64 $441.59 $518.87

$359.47 $422.38 $444.48 $522.27

$361.81 $425.13 $447.37 $525.66

$364.15 $427.88 $450.27 $529.06

$368.83 $433.37 $456.05 $535.86

$373.50 $457.54 $461.83 $565.74

$380.52 $466.13 $470.50 $576.36

$387.24 $474.37 $478.81 $586.55

$396.59 $485.82 $490.38 $600.71

$408.28 $500.14 $504.83 $618.42

$422.02 $516.97 $521.82 $639.22

$438.38 $537.02 $542.05 $664.01

$456.80 $559.58 $564.82 $691.90

$477.84 $585.35 $590.84 $723.78

$498.59 $610.77 $616.49 $755.21

$521.97 $717.71 $645.40 $887.43

$545.06 $749.45 $673.95 $926.68

$570.48 $784.41 $705.39 $969.91

$596.20 $819.78 $737.19 $1,013.64

$623.97 $857.95 $771.52 $1,060.84

$651.73 $896.13 $805.85 $1,108.05

$681.83 $937.52 $843.07 $1,159.23

$712.23 $979.31 $880.66 $1,210.90

$744.67 $1,023.92 $920.77 $1,266.05

$760.74 $1,046.02 $940.64 $1,293.38

$793.18 $1,090.63 $980.75 $1,348.54

$821.24 $1,129.20 $1,015.45 $1,396.24

$839.65 $1,154.52 $1,038.21 $1,427.54

$862.74 $1,186.27 $1,066.76 $1,466.79

$876.77 $1,205.56 $1,084.11 $1,490.65

$876.77 $1,205.56 $1,084.11 $1,490.65

Yes

33871PA0110015

0%


$3,500

Gold

Keystone DPOS Gold Classic $2,000/$40/$80/100%

$2,000

KE 670 WPR GMC

8


KE 670 WPR GMC

33871PA0100048

8


Silver

$4,250

0%



Yes

$7,150

Page Number: 22 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110017 33871PA0110018


$182.95 $182.95 $193.79 $193.79

$288.12 $324.13 $305.18 $343.33

$288.12 $324.13 $305.18 $343.33

$288.12 $324.13 $305.18 $343.33

$288.12 $324.13 $305.18 $343.33

$289.27 $325.43 $306.40 $344.70

$295.03 $331.91 $312.50 $351.57

$301.95 $339.69 $319.83 $359.80

$313.18 $352.33 $331.73 $373.19

$322.40 $362.70 $341.49 $384.18

$327.01 $384.24 $346.38 $406.99

$333.93 $392.36 $353.70 $415.60

$340.84 $400.49 $361.03 $424.21

$345.16 $405.57 $365.60 $429.58

$349.77 $410.98 $370.49 $435.32

$352.08 $413.69 $372.93 $438.19

$354.38 $416.40 $375.37 $441.06

$356.69 $419.11 $377.81 $443.93

$358.99 $421.82 $380.25 $446.80

$363.60 $427.23 $385.13 $452.53

$368.21 $451.06 $390.02 $477.77

$375.13 $459.53 $397.34 $486.74

$381.75 $467.65 $404.36 $495.34

$390.97 $478.94 $414.13 $507.30

$402.50 $493.06 $426.33 $522.26

$416.04 $509.65 $440.68 $539.83

$432.18 $529.41 $457.77 $560.76

$450.33 $551.65 $476.99 $584.32

$471.07 $577.06 $498.97 $611.23

$491.53 $602.12 $520.63 $637.78

$514.58 $707.54 $545.05 $749.44

$537.34 $738.84 $569.16 $782.59

$562.40 $773.31 $595.71 $819.10

$587.76 $808.17 $622.56 $856.02

$615.13 $845.80 $651.55 $895.89

$642.50 $883.44 $680.55 $935.75

$672.18 $924.24 $711.98 $978.97

$702.14 $965.44 $743.72 $1,022.61

$734.12 $1,009.42 $777.59 $1,069.19

$749.97 $1,031.21 $794.38 $1,092.27

$781.95 $1,075.18 $828.25 $1,138.85

$809.61 $1,113.21 $857.55 $1,179.13

$827.76 $1,138.17 $876.78 $1,205.57

$850.52 $1,169.47 $900.89 $1,238.72

$864.35 $1,188.48 $915.53 $1,258.86

$864.35 $1,188.48 $915.53 $1,258.86

Yes Yes

33871PA0110017

0% 0%


$7,150 $7,150


Silver Silver

Keystone DPOS Silver Secure $3,500 $40/$80/$600 Keystone DPOS Silver Classic $4,250 $40/$80/100%

KE 670 WPR GMC

$3,500 $4,250

33871PA0110018

KE 670 WPR GMC

8 8


Page Number: 23 05/05/2016

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

33871PA0100005 301.28

33871PA0100006 286.49

33871PA0100009 241.68

33871PA0100036 291.4

33871PA0100037 275.06

33871PA0110006 314.73

33871PA0110007 287.26

33871PA0110008 304.32

33871PA0110009 299.2

2017 On-Exchange Silver Plan Rates



33871PA0100024 302.14

33871PA0100025 287.34

33871PA0100045 242.53

33871PA0100048 292.26

33871PA0100049 275.91

33871PA0110016 315.58

33871PA0110017 288.12

33871PA0110018 305.18

33871PA0110019 300.05

2017 Off-Exchange Silver Plan Rates


Exchange HIOS Plan ID Level AreaKHPE ON 33871PA0100001 Platinum Keystone HMO Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE ON 33871PA0100002 Platinum Keystone HMO Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE ON 33871PA0100003 Gold Keystone HMO Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE ON 33871PA0100004 Gold Keystone HMO Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE ON 33871PA0100005 Silver Keystone HMO Silver Classic $2,500 $25/$50/70% Keystone Health Plan East Network 8KHPE ON 33871PA0100006 Silver Keystone HMO Silver Classic $2,750/$30/$60/50% Keystone Health Plan East Network 8KHPE ON 33871PA0100007 Bronze Keystone HMO Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8KHPE ON 33871PA0100008 Gold Keystone HMO Gold Proactive Keystone Health Plan East Network 8KHPE ON 33871PA0100009 Silver Keystone HMO Silver Proactive Keystone Health Plan East Network 8KHPE OFF 33871PA0100020 Platinum Keystone HMO Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE OFF 33871PA0100021 Platinum Keystone HMO Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE OFF 33871PA0100022 Gold Keystone HMO Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE OFF 33871PA0100023 Gold Keystone HMO Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE OFF 33871PA0100024 Silver Keystone HMO Silver Classic $2,500/$25/$50/70% Keystone Health Plan East Network 8KHPE OFF 33871PA0100025 Silver Keystone HMO Silver Classic $2,750/$30/$60/50% Keystone Health Plan East Network 8

KHPE OFF 33871PA0100026 Bronze Keystone HMO Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8

KHPE ON 33871PA0100035 Gold Keystone HMO Gold Classic $2,000/$40/$80/100% Keystone Health Plan East Network 8

KHPE ON 33871PA0100036 Silver Keystone HMO Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8

KHPE ON 33871PA0100037 Silver Keystone HMO Silver Secure $3,500 $40/$80/$600 Keystone Health Plan East Network 8

KHPE OFF 33871PA0100044 Gold Keystone HMO Gold Proactive Keystone Health Plan East Network 8

KHPE OFF 33871PA0100045 Silver Keystone HMO Silver Proactive Keystone Health Plan East Network 8

KHPE OFF 33871PA0100047 Gold Keystone HMO Gold Classic $2,000 $40/$80/100% Keystone Health Plan East Network 8

KHPE OFF 33871PA0100048 Silver Keystone HMO Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8

KHPE OFF 33871PA0100049 Silver Keystone HMO Silver Secure $3,500 $40/$80/$600 Keystone Health Plan East Network 8



KHPE ON 33871PA0110003 Gold Keystone DPOS Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8




KHPE ON 33871PA0110007 Silver Keystone DPOS Silver Secure $3,500/$40/$80/$600 Keystone Health Plan East Network 8

KHPE ON 33871PA0110008 Silver Keystone DPOS Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8














Plan Design Summary


05/15/2015

RATE PAGES


Product: HMO

Effective Date of Rates: April 1, 2017 - June 30, 201733871PA0100001 33871PA0100002



Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20 $282.50 $282.50 $270.04 $270.04

21 $444.88 $500.49 $425.27 $478.42

22 $444.88 $500.49 $425.27 $478.42

23 $444.88 $500.49 $425.27 $478.42

24 $444.88 $500.49 $425.27 $478.42

25 $446.66 $502.49 $426.97 $480.34

26 $455.56 $512.50 $435.47 $489.91

27 $466.24 $524.52 $445.68 $501.39

28 $483.59 $544.03 $462.26 $520.05

29 $497.82 $560.05 $475.87 $535.36

30 $504.94 $593.30 $482.68 $567.15

31 $515.62 $605.85 $492.88 $579.14

32 $526.29 $618.40 $503.09 $591.13

33 $532.97 $626.24 $509.47 $598.63

34 $540.09 $634.60 $516.27 $606.62

35 $543.65 $638.78 $519.67 $610.62

36 $547.20 $642.96 $523.08 $614.62

37 $550.76 $647.15 $526.48 $618.61

38 $554.32 $651.33 $529.88 $622.61

39 $561.44 $659.69 $536.69 $630.61

40 $568.56 $696.48 $543.49 $665.78

41 $579.24 $709.56 $553.70 $678.28

42 $589.47 $722.10 $563.48 $690.26

43 $603.70 $739.54 $577.09 $706.93

44 $621.50 $761.34 $594.10 $727.77

45 $642.41 $786.95 $614.08 $752.25

46 $667.32 $817.47 $637.90 $781.43

47 $695.35 $851.80 $664.69 $814.25

48 $727.38 $891.04 $695.31 $851.75

49 $758.97 $929.74 $725.50 $888.74

50 $794.56 $1,092.52 $759.52 $1,044.35

51 $829.70 $1,140.84 $793.12 $1,090.54

52 $868.41 $1,194.06 $830.12 $1,141.41

53 $907.56 $1,247.89 $867.54 $1,192.87

54 $949.82 $1,306.01 $907.94 $1,248.42

55 $992.09 $1,364.12 $948.34 $1,303.97

56 $1,037.91 $1,427.12 $992.15 $1,364.20

57 $1,084.18 $1,490.74 $1,036.37 $1,425.01

58 $1,133.56 $1,558.64 $1,083.58 $1,489.92

59 $1,158.03 $1,592.29 $1,106.97 $1,522.08

60 $1,207.41 $1,660.19 $1,154.17 $1,586.99

61 $1,250.12 $1,718.91 $1,195.00 $1,643.12

62 $1,278.14 $1,757.45 $1,221.79 $1,679.96

63 $1,313.29 $1,805.77 $1,255.38 $1,726.15

64 $1,334.64 $1,835.14 $1,275.80 $1,754.22

65+ $1,334.64 $1,835.14 $1,275.80 $1,754.22

$0

0%

$3,000


$0

0%

No

Platinum

$4,000

Platinum


No

33871PA0100001

KE 670 WPR GMC

8

33871PA0100002

8

KE 670 WPR GMC


$10/$20 $20/$40


RATE PAGES


Product: HMO

Effective Date of Rates: April 1, 2017 - June 30, 2017



Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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65+

33871PA0100003 33871PA0100004


$222.67 $222.67 $229.91 $229.91

$350.66 $394.50 $362.07 $407.32

$350.66 $394.50 $362.07 $407.32

$350.66 $394.50 $362.07 $407.32

$350.66 $394.50 $362.07 $407.32

$352.07 $396.07 $363.51 $408.95

$359.08 $403.96 $370.76 $417.10

$367.49 $413.43 $379.44 $426.88

$381.17 $428.82 $393.57 $442.76

$392.39 $441.44 $405.15 $455.80

$398.00 $467.65 $410.94 $482.86

$406.42 $477.54 $419.63 $493.07

$414.83 $487.43 $428.32 $503.28

$420.09 $493.61 $433.75 $509.66

$425.70 $500.20 $439.55 $516.47

$428.51 $503.50 $442.44 $519.87

$431.32 $506.80 $445.34 $523.28

$434.12 $510.09 $448.24 $526.68

$436.93 $513.39 $451.13 $530.08

$442.54 $519.98 $456.93 $536.89

$448.15 $548.98 $462.72 $566.83

$456.56 $559.29 $471.41 $577.48

$464.63 $569.17 $479.74 $587.68

$475.85 $582.92 $491.32 $601.87

$489.88 $600.10 $505.81 $619.61

$506.36 $620.29 $522.82 $640.46

$525.99 $644.34 $543.10 $665.30

$548.09 $671.41 $565.91 $693.24

$573.33 $702.33 $591.98 $725.17

$598.23 $732.83 $617.68 $756.66

$626.28 $861.14 $646.65 $889.14

$653.99 $899.23 $675.25 $928.47

$684.49 $941.18 $706.75 $971.78

$715.35 $983.61 $738.61 $1,015.59

$748.67 $1,029.41 $773.01 $1,062.89

$781.98 $1,075.22 $807.41 $1,110.18

$818.10 $1,124.88 $844.70 $1,161.46

$854.57 $1,175.03 $882.35 $1,213.24

$893.49 $1,228.55 $922.54 $1,268.50

$912.78 $1,255.07 $942.46 $1,295.88

$951.70 $1,308.59 $982.65 $1,351.14

$985.36 $1,354.87 $1,017.40 $1,398.93

$1,007.45 $1,385.25 $1,040.22 $1,430.30

$1,035.16 $1,423.34 $1,068.82 $1,469.63

$1,051.98 $1,446.48 $1,086.20 $1,493.52

$1,051.98 $1,446.48 $1,086.20 $1,493.52

Gold


$1,000

10%

$5,500

33871PA0100004

Gold


$0

0%

$7,150

No No

33871PA0100003

KE 670 WPR GMC

8


KE 670 WPR GMC

8


$30/$60 $25 no ded/$50 no ded


RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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54

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57

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59

60

61

62

63

64

65+

33871PA0100005 33871PA0100006


$196.86 $196.86 $187.20 $187.20

$310.02 $348.77 $294.80 $331.65

$310.02 $348.77 $294.80 $331.65

$310.02 $348.77 $294.80 $331.65

$310.02 $348.77 $294.80 $331.65

$311.26 $350.17 $295.98 $332.97

$317.46 $357.14 $301.87 $339.61

$324.90 $365.51 $308.95 $347.57

$336.99 $379.12 $320.45 $360.50

$346.91 $390.28 $329.88 $371.11

$351.87 $413.45 $334.60 $393.15

$359.31 $422.19 $341.67 $401.46

$366.75 $430.94 $348.75 $409.78

$371.40 $436.40 $353.17 $414.97

$376.37 $442.23 $357.89 $420.52

$378.85 $445.14 $360.24 $423.29

$381.33 $448.06 $362.60 $426.06

$383.81 $450.97 $364.96 $428.83

$386.29 $453.89 $367.32 $431.60

$391.25 $459.71 $372.04 $437.14

$396.21 $485.35 $376.75 $461.52

$403.65 $494.47 $383.83 $470.19

$410.78 $503.20 $390.61 $478.49

$420.70 $515.36 $400.04 $490.05

$433.10 $530.55 $411.83 $504.50

$447.67 $548.40 $425.69 $521.47

$465.03 $569.66 $442.20 $541.69

$484.56 $593.59 $460.77 $564.44

$506.88 $620.93 $482.00 $590.44

$528.90 $647.90 $502.93 $616.08

$553.70 $761.33 $526.51 $723.95

$578.19 $795.01 $549.80 $755.97

$605.16 $832.10 $575.45 $791.24

$632.44 $869.61 $601.39 $826.91

$661.89 $910.10 $629.39 $865.42

$691.35 $950.60 $657.40 $903.93

$723.28 $994.51 $687.76 $945.68

$755.52 $1,038.84 $718.42 $987.83

$789.93 $1,086.16 $751.15 $1,032.83

$806.98 $1,109.60 $767.36 $1,055.12

$841.40 $1,156.92 $800.08 $1,100.11

$871.16 $1,197.84 $828.38 $1,139.03

$890.69 $1,224.70 $846.96 $1,164.56

$915.18 $1,258.37 $870.24 $1,196.59

$930.06 $1,278.84 $884.39 $1,216.04

$930.06 $1,278.84 $884.39 $1,216.04

33871PA0100005

$2,500

30%

$7,150

No

Silver


KE 670 WPR GMC

8



Silver


$2,750

50%

$7,150

No

33871PA0100006

KE 670 WPR GMC

8




RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

22

23

24

25

26

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31

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37

38

39

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49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65+

33871PA0100007 33871PA0100008


$139.37 $139.37 $199.08 $199.08

$219.49 $246.92 $313.52 $352.71

$219.49 $246.92 $313.52 $352.71

$219.49 $246.92 $313.52 $352.71

$219.49 $246.92 $313.52 $352.71

$220.36 $247.91 $314.77 $354.12

$224.75 $252.85 $321.04 $361.17

$230.02 $258.77 $328.57 $369.64

$238.58 $268.40 $340.79 $383.39

$245.60 $276.30 $350.83 $394.68

$249.12 $292.71 $355.84 $418.12

$254.38 $298.90 $363.37 $426.96

$259.65 $305.09 $370.89 $435.80

$262.94 $308.96 $375.59 $441.32

$266.45 $313.08 $380.61 $447.22

$268.21 $315.15 $383.12 $450.16

$269.97 $317.21 $385.63 $453.11

$271.72 $319.27 $388.14 $456.06

$273.48 $321.34 $390.64 $459.01

$276.99 $325.46 $395.66 $464.90

$280.50 $343.61 $400.68 $490.83

$285.77 $350.07 $408.20 $500.05

$290.82 $356.25 $415.41 $508.88

$297.84 $364.86 $425.44 $521.17

$306.62 $375.61 $437.98 $536.53

$316.94 $388.25 $452.72 $554.58

$329.23 $403.30 $470.28 $576.09

$343.06 $420.24 $490.03 $600.29

$358.86 $439.60 $512.60 $627.94

$374.44 $458.69 $534.86 $655.21

$392.00 $539.00 $559.94 $769.92

$409.34 $562.84 $584.71 $803.98

$428.44 $589.10 $611.99 $841.48

$447.75 $615.66 $639.58 $879.42

$468.60 $644.33 $669.36 $920.37

$489.45 $673.00 $699.15 $961.32

$512.06 $704.08 $731.44 $1,005.73

$534.89 $735.47 $764.04 $1,050.56

$559.25 $768.97 $798.84 $1,098.41

$571.32 $785.56 $816.09 $1,122.12

$595.68 $819.06 $850.89 $1,169.97

$616.75 $848.04 $880.99 $1,211.36

$630.58 $867.05 $900.74 $1,238.51

$647.92 $890.89 $925.51 $1,272.57

$658.46 $905.38 $940.55 $1,293.26

$658.46 $905.38 $940.55 $1,293.26

33871PA0100007

Bronze

KE 670 WPR GMC

8



$6,850

50%

$7,150

No


No

$15/$40, $30/$60, $45/$80

Gold


$0

0%/20%/30%

$7,150

33871PA0100008

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

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36

37

38

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49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65+

33871PA0100009 33871PA0110001


$157.91 $157.91 $295.60 $295.60

$248.68 $279.77 $465.50 $523.69

$248.68 $279.77 $465.50 $523.69

$248.68 $279.77 $465.50 $523.69

$248.68 $279.77 $465.50 $523.69

$249.68 $280.89 $467.37 $525.79

$254.65 $286.48 $476.68 $536.26

$260.62 $293.20 $487.85 $548.83

$270.32 $304.11 $506.00 $569.25

$278.28 $313.06 $520.90 $586.01

$282.26 $331.65 $528.35 $620.81

$288.22 $338.66 $539.52 $633.94

$294.19 $345.68 $550.69 $647.06

$297.92 $350.06 $557.67 $655.27

$301.90 $354.74 $565.12 $664.02

$303.89 $357.07 $568.85 $668.39

$305.88 $359.41 $572.57 $672.77

$307.87 $361.75 $576.29 $677.15

$309.86 $364.09 $580.02 $681.52

$313.84 $368.76 $587.47 $690.27

$317.82 $389.33 $594.91 $728.77

$323.79 $396.64 $606.09 $742.46

$329.51 $403.65 $616.79 $755.57

$337.46 $413.39 $631.69 $773.82

$347.41 $425.58 $650.31 $796.63

$359.10 $439.90 $672.19 $823.43

$373.03 $456.96 $698.26 $855.36

$388.69 $476.15 $727.58 $891.29

$406.60 $498.08 $761.10 $932.35

$424.26 $519.71 $794.15 $972.83

$444.15 $610.71 $831.39 $1,143.16

$463.80 $637.72 $868.17 $1,193.73

$485.43 $667.47 $908.66 $1,249.41

$507.32 $697.56 $949.63 $1,305.74

$530.94 $730.04 $993.85 $1,366.55

$554.57 $762.53 $1,038.07 $1,427.35

$580.18 $797.75 $1,086.02 $1,493.28

$606.04 $833.31 $1,134.43 $1,559.85

$633.65 $871.26 $1,186.10 $1,630.89

$647.32 $890.07 $1,211.71 $1,666.10

$674.93 $928.03 $1,263.38 $1,737.15

$698.80 $960.85 $1,308.07 $1,798.59

$714.47 $982.40 $1,337.39 $1,838.92

$734.12 $1,009.41 $1,374.17 $1,889.48

$746.04 $1,025.82 $1,396.50 $1,920.21

$746.04 $1,025.82 $1,396.50 $1,920.21

33871PA0100009

KE 670 WPR GMC

8


Silver


$0/$5500/$5500

0%/5%/10%

$7,150

No


No

$10/$20

Platinum


$0

0%

$3,000

33871PA0110001

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

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45

46

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49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65+

33871PA0110002 33871PA0110003


$282.56 $282.56 $232.61 $232.61

$444.98 $500.60 $366.32 $412.11

$444.98 $500.60 $366.32 $412.11

$444.98 $500.60 $366.32 $412.11

$444.98 $500.60 $366.32 $412.11

$446.76 $502.61 $367.78 $413.76

$455.66 $512.62 $375.11 $422.00

$466.34 $524.63 $383.90 $431.89

$483.69 $544.16 $398.19 $447.96

$497.93 $560.18 $409.91 $461.15

$505.05 $593.44 $415.77 $488.53

$515.73 $605.99 $424.56 $498.86

$526.41 $618.54 $433.36 $509.19

$533.09 $626.38 $438.85 $515.65

$540.21 $634.74 $444.71 $522.54

$543.77 $638.93 $447.64 $525.98

$547.33 $643.11 $450.57 $529.42

$550.89 $647.29 $453.50 $532.87

$554.45 $651.48 $456.43 $536.31

$561.57 $659.84 $462.29 $543.20

$568.69 $696.64 $468.16 $573.49

$579.37 $709.72 $476.95 $584.26

$589.60 $722.26 $485.37 $594.58

$603.84 $739.70 $497.09 $608.94

$621.64 $761.51 $511.75 $626.89

$642.55 $787.13 $528.96 $647.98

$667.47 $817.65 $549.48 $673.11

$695.51 $852.00 $572.56 $701.38

$727.54 $891.24 $598.93 $733.69

$759.14 $929.94 $624.94 $765.55

$794.74 $1,092.76 $654.25 $899.59

$829.89 $1,141.10 $683.19 $939.38

$868.60 $1,194.33 $715.05 $983.20

$907.76 $1,248.17 $747.29 $1,027.52

$950.04 $1,306.30 $782.09 $1,075.38

$992.31 $1,364.42 $816.89 $1,123.23

$1,038.14 $1,427.45 $854.62 $1,175.11

$1,084.42 $1,491.08 $892.72 $1,227.49

$1,133.81 $1,558.99 $933.38 $1,283.40

$1,158.29 $1,592.64 $953.53 $1,311.10

$1,207.68 $1,660.56 $994.19 $1,367.01

$1,250.40 $1,719.30 $1,029.36 $1,415.37

$1,278.43 $1,757.84 $1,052.43 $1,447.10

$1,313.59 $1,806.18 $1,081.37 $1,486.89

$1,334.94 $1,835.55 $1,098.96 $1,511.07

$1,334.94 $1,835.55 $1,098.96 $1,511.07

33871PA0110002

KE 670 WPR GMC

8


Platinum


$0

0%

$4,000

No

$20/$40

No

$30/$60

Gold


$0

0%

$7,150

33871PA0110003

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

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45

46

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49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65+

33871PA0110004 33871PA0110005


$239.41 $239.41 $235.57 $235.57

$377.03 $424.16 $370.97 $417.34

$377.03 $424.16 $370.97 $417.34

$377.03 $424.16 $370.97 $417.34

$377.03 $424.16 $370.97 $417.34

$378.54 $425.85 $372.45 $419.01

$386.08 $434.34 $379.87 $427.36

$395.13 $444.52 $388.78 $437.37

$409.83 $461.06 $403.24 $453.65

$421.89 $474.63 $415.12 $467.00

$427.93 $502.81 $421.05 $494.73

$436.98 $513.45 $429.95 $505.20

$446.02 $524.08 $438.86 $515.66

$451.68 $530.72 $444.42 $522.20

$457.71 $537.81 $450.36 $529.17

$460.73 $541.36 $453.32 $532.66

$463.74 $544.90 $456.29 $536.14

$466.76 $548.44 $459.26 $539.63

$469.78 $551.99 $462.23 $543.12

$475.81 $559.08 $468.16 $550.09

$481.84 $590.26 $474.10 $580.77

$490.89 $601.34 $483.00 $591.68

$499.56 $611.96 $491.53 $602.13

$511.63 $626.74 $503.41 $616.67

$526.71 $645.22 $518.24 $634.85

$544.43 $666.92 $535.68 $656.21

$565.54 $692.79 $556.45 $681.66

$589.29 $721.89 $579.83 $710.29

$616.44 $755.14 $606.54 $743.01

$643.21 $787.93 $632.87 $775.27

$673.37 $925.89 $662.55 $911.01

$703.16 $966.84 $691.86 $951.31

$735.96 $1,011.94 $724.13 $995.68

$769.14 $1,057.56 $756.78 $1,040.57

$804.95 $1,106.81 $792.02 $1,089.03

$840.77 $1,156.06 $827.26 $1,137.49

$879.61 $1,209.46 $865.47 $1,190.02

$918.82 $1,263.37 $904.05 $1,243.07

$960.67 $1,320.92 $945.23 $1,299.69

$981.40 $1,349.43 $965.63 $1,327.75

$1,023.25 $1,406.97 $1,006.81 $1,384.37

$1,059.45 $1,456.74 $1,042.42 $1,433.33

$1,083.20 $1,489.40 $1,065.80 $1,465.47

$1,112.99 $1,530.36 $1,095.10 $1,505.77

$1,131.08 $1,555.24 $1,112.91 $1,530.25

$1,131.08 $1,555.24 $1,112.91 $1,530.25

33871PA0110004

KE 670 WPR GMC

8


Gold


$1,000

10%

$5,500

No


No


GoldKeystone DPOS Gold Classic

$2,000 $40/$80/100%

$2,000

0%

$3,500

33871PA0110005

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

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46

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48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65+

33871PA0110006 33871PA0110010


$205.65 $205.65 $145.43 $145.43

$323.86 $364.34 $229.02 $257.65

$323.86 $364.34 $229.02 $257.65

$323.86 $364.34 $229.02 $257.65

$323.86 $364.34 $229.02 $257.65

$325.15 $365.80 $229.94 $258.68

$331.63 $373.08 $234.52 $263.84

$339.40 $381.83 $240.02 $270.02

$352.03 $396.04 $248.95 $280.07

$362.40 $407.70 $256.28 $288.31

$367.58 $431.90 $259.94 $305.43

$375.35 $441.04 $265.44 $311.89

$383.12 $450.17 $270.94 $318.35

$387.98 $455.88 $274.37 $322.39

$393.16 $461.97 $278.03 $326.69

$395.75 $465.01 $279.87 $328.84

$398.35 $468.06 $281.70 $331.00

$400.94 $471.10 $283.53 $333.15

$403.53 $474.14 $285.36 $335.30

$408.71 $480.23 $289.03 $339.61

$413.89 $507.02 $292.69 $358.55

$421.66 $516.54 $298.19 $365.28

$429.11 $525.66 $303.46 $371.73

$439.47 $538.36 $310.79 $380.71

$452.43 $554.23 $319.95 $391.93

$467.65 $572.87 $330.71 $405.12

$485.79 $595.09 $343.54 $420.83

$506.19 $620.08 $357.96 $438.51

$529.51 $648.65 $374.45 $458.71

$552.50 $676.81 $390.71 $478.63

$578.41 $795.31 $409.04 $562.43

$603.99 $830.49 $427.13 $587.30

$632.17 $869.23 $447.05 $614.70

$660.67 $908.42 $467.21 $642.41

$691.44 $950.72 $488.97 $672.33

$722.20 $993.03 $510.72 $702.24

$755.56 $1,038.90 $534.31 $734.68

$789.24 $1,085.21 $558.13 $767.43

$825.19 $1,134.64 $583.55 $802.39

$843.00 $1,159.13 $596.15 $819.70

$878.95 $1,208.56 $621.57 $854.66

$910.04 $1,251.31 $643.56 $884.89

$930.44 $1,279.36 $657.99 $904.73

$956.03 $1,314.54 $676.08 $929.61

$971.57 $1,335.91 $687.06 $944.72

$971.57 $1,335.91 $687.06 $944.72

33871PA0110006

KE 670 WPR GMC

8


Silver


$2,500

30%

$7,150

No


No


Bronze


$6,850

50%

$7,150

33871PA0110010

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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+

33871PA0100020 33871PA0100021


$283.06 $283.06 $270.60 $270.60

$445.76 $501.48 $426.14 $479.41

$445.76 $501.48 $426.14 $479.41

$445.76 $501.48 $426.14 $479.41

$445.76 $501.48 $426.14 $479.41

$447.54 $503.49 $427.85 $481.33

$456.46 $513.52 $436.37 $490.92

$467.16 $525.55 $446.60 $502.42

$484.54 $545.11 $463.22 $521.12

$498.81 $561.16 $476.86 $536.46

$505.94 $594.48 $483.67 $568.32

$516.64 $607.05 $493.90 $580.33

$527.33 $619.62 $504.13 $592.35

$534.02 $627.47 $510.52 $599.86

$541.15 $635.85 $517.34 $607.87

$544.72 $640.04 $520.75 $611.88

$548.28 $644.23 $524.16 $615.89

$551.85 $648.42 $527.57 $619.89

$555.42 $652.61 $530.98 $623.90

$562.55 $661.00 $537.79 $631.91

$569.68 $697.86 $544.61 $667.15

$580.38 $710.96 $554.84 $679.68

$590.63 $723.52 $564.64 $691.69

$604.90 $741.00 $578.28 $708.39

$622.73 $762.84 $595.32 $729.27

$643.68 $788.50 $615.35 $753.81

$668.64 $819.08 $639.22 $783.04

$696.72 $853.49 $666.06 $815.93

$728.82 $892.80 $696.75 $853.51

$760.47 $931.57 $727.00 $890.58

$796.13 $1,094.68 $761.09 $1,046.50

$831.34 $1,143.10 $794.76 $1,092.79

$870.12 $1,196.42 $831.83 $1,143.77

$909.35 $1,250.36 $869.33 $1,195.34

$951.70 $1,308.58 $909.82 $1,251.00

$994.04 $1,366.81 $950.30 $1,306.67

$1,039.96 $1,429.94 $994.20 $1,367.02

$1,086.32 $1,493.69 $1,038.51 $1,427.96

$1,135.80 $1,561.72 $1,085.82 $1,493.00

$1,160.31 $1,595.43 $1,109.25 $1,525.22

$1,209.79 $1,663.46 $1,156.56 $1,590.26

$1,252.59 $1,722.31 $1,197.47 $1,646.52

$1,280.67 $1,760.92 $1,224.31 $1,683.43

$1,315.88 $1,809.34 $1,257.98 $1,729.72

$1,337.28 $1,838.76 $1,278.42 $1,757.85

$1,337.28 $1,838.76 $1,278.42 $1,757.85

KE 670 WPR GMC

8


Yes

33871PA0100021

KE 670 WPR GMC

8


Platinum


$0

0%

$4,000

Yes

Platinum


$0

0%

$3,000

33871PA0100020

$10/$20 $20/$40

Page Number: 10 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

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65+

33871PA0100022 33871PA0100023


$223.23 $223.23 $230.47 $230.47

$351.54 $395.48 $362.94 $408.31

$351.54 $395.48 $362.94 $408.31

$351.54 $395.48 $362.94 $408.31

$351.54 $395.48 $362.94 $408.31

$352.95 $397.07 $364.40 $409.95

$359.98 $404.98 $371.66 $418.11

$368.42 $414.47 $380.37 $427.91

$382.13 $429.89 $394.52 $443.84

$393.37 $442.55 $406.13 $456.90

$399.00 $468.82 $411.94 $484.03

$407.44 $478.74 $420.65 $494.27

$415.87 $488.65 $429.36 $504.50

$421.15 $494.85 $434.81 $510.90

$426.77 $501.46 $440.61 $517.72

$429.58 $504.76 $443.52 $521.13

$432.40 $508.07 $446.42 $524.55

$435.21 $511.37 $449.33 $527.96

$438.02 $514.67 $452.23 $531.37

$443.65 $521.28 $458.04 $538.19

$449.27 $550.36 $463.84 $568.21

$457.71 $560.69 $472.55 $578.88

$465.79 $570.60 $480.90 $589.10

$477.04 $584.38 $492.52 $603.33

$491.10 $601.60 $507.03 $621.12

$507.63 $621.84 $524.09 $642.01

$527.31 $645.96 $544.42 $666.91

$549.46 $673.09 $567.28 $694.92

$574.77 $704.09 $593.41 $726.93

$599.73 $734.67 $619.18 $758.50

$627.85 $863.30 $648.22 $891.30

$655.62 $901.48 $676.89 $930.73

$686.21 $943.54 $708.47 $974.14

$717.14 $986.07 $740.41 $1,018.06

$750.54 $1,031.99 $774.89 $1,065.47

$783.94 $1,077.91 $809.37 $1,112.88

$820.15 $1,127.70 $846.75 $1,164.28

$856.71 $1,177.97 $884.50 $1,216.18

$895.73 $1,231.63 $924.78 $1,271.58

$915.06 $1,258.21 $944.74 $1,299.02

$954.08 $1,311.86 $985.03 $1,354.42

$987.83 $1,358.27 $1,019.87 $1,402.33

$1,009.98 $1,388.72 $1,042.74 $1,433.77

$1,037.75 $1,426.91 $1,071.41 $1,473.19

$1,054.62 $1,450.11 $1,088.82 $1,497.15

$1,054.62 $1,450.11 $1,088.82 $1,497.15

Yes

33871PA0100023

KE 670 WPR GMC

8


Gold


$1,000

10%

$5,500

Yes

Gold


$0

0%

$7,150

33871PA0100022

KE 670 WPR GMC

8


$30/$60 $25 no ded/$50 no ded

Page Number: 11 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

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Plan Name =>

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65+

33871PA0100024 33871PA0100025


$197.42 $197.42 $187.75 $187.75

$310.90 $349.76 $295.68 $332.64

$310.90 $349.76 $295.68 $332.64

$310.90 $349.76 $295.68 $332.64

$310.90 $349.76 $295.68 $332.64

$312.14 $351.16 $296.86 $333.97

$318.36 $358.16 $302.77 $340.62

$325.82 $366.55 $309.87 $348.60

$337.95 $380.19 $321.40 $361.58

$347.90 $391.38 $330.86 $372.22

$352.87 $414.62 $335.59 $394.32

$360.33 $423.39 $342.69 $402.66

$367.79 $432.16 $349.79 $411.00

$372.46 $437.64 $354.22 $416.21

$377.43 $443.48 $358.95 $421.77

$379.92 $446.40 $361.32 $424.55

$382.41 $449.33 $363.68 $427.33

$384.89 $452.25 $366.05 $430.11

$387.38 $455.17 $368.41 $432.89

$392.36 $461.02 $373.14 $438.44

$397.33 $486.73 $377.88 $462.90

$404.79 $495.87 $384.97 $471.59

$411.94 $504.63 $391.77 $479.92

$421.89 $516.82 $401.23 $491.51

$434.33 $532.05 $413.06 $506.00

$448.94 $549.95 $426.96 $523.02

$466.35 $571.28 $443.52 $543.31

$485.94 $595.27 $462.14 $566.13

$508.32 $622.69 $483.43 $592.20

$530.39 $649.73 $504.42 $617.92

$555.27 $763.49 $528.08 $726.11

$579.83 $797.26 $551.44 $758.23

$606.88 $834.45 $577.16 $793.60

$634.23 $872.07 $603.18 $829.37

$663.77 $912.68 $631.27 $868.00

$693.31 $953.30 $659.36 $906.62

$725.33 $997.33 $689.81 $948.49

$757.66 $1,041.78 $720.56 $990.78

$792.17 $1,089.24 $753.38 $1,035.90

$809.27 $1,112.75 $769.65 $1,058.26

$843.78 $1,160.20 $802.47 $1,103.39

$873.63 $1,201.24 $830.85 $1,142.42

$893.21 $1,228.17 $849.48 $1,168.03

$917.77 $1,261.94 $872.84 $1,200.15

$932.70 $1,282.46 $887.03 $1,219.67

$932.70 $1,282.46 $887.03 $1,219.67

Yes

33871PA0100025

KE 670 WPR GMC

8


Silver


$2,750

50%

$7,150

Yes

Silver


$2,500

30%

$7,150

33871PA0100024

KE 670 WPR GMC

8



Page Number: 12 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

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OOP Maximum =>


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65+

33871PA0100026 33871PA0110011


$139.93 $139.93 $296.15 $296.15

$220.36 $247.91 $466.38 $524.68

$220.36 $247.91 $466.38 $524.68

$220.36 $247.91 $466.38 $524.68

$220.36 $247.91 $466.38 $524.68

$221.25 $248.90 $468.25 $526.78

$225.65 $253.86 $477.58 $537.27

$230.94 $259.81 $488.77 $549.87

$239.54 $269.48 $506.96 $570.33

$246.59 $277.41 $521.88 $587.12

$250.11 $293.88 $529.34 $621.98

$255.40 $300.10 $540.54 $635.13

$260.69 $306.31 $551.73 $648.28

$264.00 $310.19 $558.73 $656.50

$267.52 $314.34 $566.19 $665.27

$269.28 $316.41 $569.92 $669.66

$271.05 $318.48 $573.65 $674.04

$272.81 $320.55 $577.38 $678.42

$274.57 $322.62 $581.11 $682.81

$278.10 $326.77 $588.58 $691.58

$281.62 $344.99 $596.04 $730.15

$286.91 $351.47 $607.23 $743.86

$291.98 $357.68 $617.96 $757.00

$299.03 $366.32 $632.88 $775.28

$307.85 $377.11 $651.54 $798.13

$318.21 $389.80 $673.46 $824.98

$330.55 $404.92 $699.57 $856.98

$344.43 $421.92 $728.96 $892.97

$360.29 $441.36 $762.54 $934.11

$375.94 $460.53 $795.65 $974.67

$393.57 $541.16 $832.96 $1,145.32

$410.98 $565.10 $869.80 $1,195.98

$430.15 $591.46 $910.38 $1,251.77

$449.54 $618.12 $951.42 $1,308.20

$470.48 $646.91 $995.73 $1,369.13

$491.41 $675.69 $1,040.03 $1,430.05

$514.11 $706.90 $1,088.07 $1,496.10

$537.03 $738.41 $1,136.57 $1,562.79

$561.49 $772.04 $1,188.34 $1,633.97

$573.61 $788.71 $1,213.99 $1,669.24

$598.07 $822.34 $1,265.76 $1,740.42

$619.22 $851.43 $1,310.54 $1,801.99

$633.10 $870.52 $1,339.92 $1,842.39

$650.51 $894.46 $1,376.76 $1,893.05

$661.08 $909.00 $1,399.14 $1,923.83

$661.08 $909.00 $1,399.14 $1,923.83

Yes

33871PA0110011

KE 670 WPR GMC

8


Platinum


$0

0%

$3,000

Yes

Bronze


$6,850

50%

$7,150

33871PA0100026

KE 670 WPR GMC

8


$10/$20$50 no ded/$100 no ded

Page Number: 13 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

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Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110012 33871PA0110013


$283.12 $283.12 $233.17 $233.17

$445.86 $501.59 $367.20 $413.10

$445.86 $501.59 $367.20 $413.10

$445.86 $501.59 $367.20 $413.10

$445.86 $501.59 $367.20 $413.10

$447.64 $503.60 $368.67 $414.75

$456.56 $513.63 $376.01 $423.01

$467.26 $525.67 $384.82 $432.93

$484.65 $545.23 $399.14 $449.04

$498.92 $561.28 $410.89 $462.26

$506.05 $594.61 $416.77 $489.70

$516.75 $607.18 $425.58 $500.06

$527.45 $619.76 $434.39 $510.41

$534.14 $627.62 $439.90 $516.89

$541.27 $636.00 $445.78 $523.79

$544.84 $640.19 $448.72 $527.24

$548.41 $644.38 $451.65 $530.69

$551.97 $648.57 $454.59 $534.14

$555.54 $652.76 $457.53 $537.60

$562.68 $661.14 $463.40 $544.50

$569.81 $698.02 $469.28 $574.87

$580.51 $711.12 $478.09 $585.66

$590.76 $723.69 $486.54 $596.01

$605.03 $741.16 $498.29 $610.40

$622.87 $763.01 $512.98 $628.39

$643.82 $788.68 $530.23 $649.54

$668.79 $819.27 $550.80 $674.73

$696.88 $853.68 $573.93 $703.06

$728.98 $893.00 $600.37 $735.45

$760.64 $931.78 $626.44 $767.39

$796.31 $1,094.92 $655.81 $901.75

$831.53 $1,143.35 $684.82 $941.63

$870.32 $1,196.69 $716.77 $985.56

$909.55 $1,250.64 $749.08 $1,029.99

$951.91 $1,308.88 $783.97 $1,077.95

$994.27 $1,367.12 $818.85 $1,125.92

$1,040.19 $1,430.26 $856.67 $1,177.92

$1,086.56 $1,494.02 $894.86 $1,230.43

$1,136.05 $1,562.07 $935.62 $1,286.48

$1,160.57 $1,595.79 $955.82 $1,314.25

$1,210.06 $1,663.84 $996.57 $1,370.29

$1,252.87 $1,722.69 $1,031.83 $1,418.76

$1,280.96 $1,761.31 $1,054.96 $1,450.57

$1,316.18 $1,809.75 $1,083.97 $1,490.46

$1,337.58 $1,839.17 $1,101.59 $1,514.69

$1,337.58 $1,839.17 $1,101.59 $1,514.69

Yes

33871PA0110013

KE 670 WPR GMC

8


Gold


$0

0%

$7,150

Yes

Platinum


$0

0%

$4,000

33871PA0110012

KE 670 WPR GMC

8


$20/$40 $30/$60

Page Number: 14 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110014 33871PA0110016


$239.97 $239.97 $206.21 $206.21

$377.91 $425.14 $324.74 $365.33

$377.91 $425.14 $324.74 $365.33

$377.91 $425.14 $324.74 $365.33

$377.91 $425.14 $324.74 $365.33

$379.42 $426.85 $326.04 $366.79

$386.98 $435.35 $332.53 $374.10

$396.05 $445.55 $340.32 $382.86

$410.78 $462.13 $352.99 $397.11

$422.88 $475.74 $363.38 $408.80

$428.92 $503.99 $368.58 $433.08

$437.99 $514.64 $376.37 $442.23

$447.06 $525.30 $384.16 $451.39

$452.73 $531.96 $389.03 $457.12

$458.78 $539.06 $394.23 $463.22

$461.80 $542.62 $396.83 $466.27

$464.83 $546.17 $399.43 $469.33

$467.85 $549.72 $402.02 $472.38

$470.87 $553.27 $404.62 $475.43

$476.92 $560.38 $409.82 $481.54

$482.96 $591.63 $415.01 $508.39

$492.03 $602.74 $422.81 $517.94

$500.73 $613.39 $430.28 $527.09

$512.82 $628.20 $440.67 $539.82

$527.94 $646.72 $453.66 $555.73

$545.70 $668.48 $468.92 $574.43

$566.86 $694.40 $487.10 $596.70

$590.67 $723.57 $507.56 $621.76

$617.88 $756.90 $530.94 $650.41

$644.71 $789.77 $554.00 $678.65

$674.94 $928.04 $579.98 $797.47

$704.80 $969.09 $605.63 $832.75

$737.67 $1,014.30 $633.89 $871.59

$770.93 $1,060.03 $662.46 $910.89

$806.83 $1,109.39 $693.31 $953.30

$842.73 $1,158.76 $724.16 $995.72

$881.66 $1,212.28 $757.61 $1,041.71

$920.96 $1,266.32 $791.38 $1,088.15

$962.91 $1,324.00 $827.43 $1,137.71

$983.69 $1,352.58 $845.29 $1,162.27

$1,025.64 $1,410.25 $881.33 $1,211.83

$1,061.92 $1,460.14 $912.51 $1,254.70

$1,085.73 $1,492.87 $932.97 $1,282.83

$1,115.58 $1,533.92 $958.62 $1,318.10

$1,133.72 $1,558.86 $974.21 $1,339.54

$1,133.72 $1,558.86 $974.21 $1,339.54

Yes

33871PA0110016

KE 670 WPR GMC

8


Silver


$2,500

30%

$7,150

Yes

Gold


$1,000

10%

$5,500

33871PA0110014

KE 670 WPR GMC

8



Page Number: 15 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110019 33871PA0110020


$196.06 $196.06 $145.99 $145.99

$308.75 $347.35 $229.90 $258.64

$308.75 $347.35 $229.90 $258.64

$308.75 $347.35 $229.90 $258.64

$308.75 $347.35 $229.90 $258.64

$309.99 $348.74 $230.82 $259.67

$316.16 $355.68 $235.42 $264.85

$323.57 $364.02 $240.94 $271.05

$335.61 $377.57 $249.90 $281.14

$345.49 $388.68 $257.26 $289.42

$350.43 $411.76 $260.94 $306.60

$357.84 $420.47 $266.46 $313.09

$365.25 $429.17 $271.97 $319.57

$369.89 $434.62 $275.42 $323.62

$374.83 $440.42 $279.10 $327.94

$377.30 $443.32 $280.94 $330.11

$379.77 $446.23 $282.78 $332.27

$382.24 $449.13 $284.62 $334.43

$384.71 $452.03 $286.46 $336.59

$389.65 $457.83 $290.14 $340.91

$394.59 $483.37 $293.82 $359.92

$402.00 $492.45 $299.33 $366.68

$409.10 $501.14 $304.62 $373.16

$418.98 $513.25 $311.98 $382.17

$431.33 $528.38 $321.17 $393.44

$445.84 $546.15 $331.98 $406.67

$463.13 $567.33 $344.85 $422.45

$482.58 $591.16 $359.34 $440.19

$504.81 $618.39 $375.89 $460.47

$526.73 $645.25 $392.21 $480.46

$551.43 $758.22 $410.61 $564.58

$575.82 $791.76 $428.77 $589.56

$602.69 $828.69 $448.77 $617.06

$629.86 $866.05 $469.00 $644.88

$659.19 $906.38 $490.84 $674.91

$688.52 $946.71 $512.68 $704.94

$720.32 $990.44 $536.36 $737.50

$752.43 $1,034.59 $560.27 $770.37

$786.70 $1,081.72 $585.79 $805.46

$803.68 $1,105.07 $598.44 $822.85

$837.96 $1,152.19 $623.96 $857.94

$867.60 $1,192.94 $646.03 $888.29

$887.05 $1,219.69 $660.51 $908.20

$911.44 $1,253.23 $678.67 $933.17

$926.25 $1,273.61 $689.70 $948.35

$926.25 $1,273.61 $689.70 $948.35

Yes

33871PA0110020

Yes

$6,850


50%

Bronze

$7,150


8

KE 670 WPR GMC


Silver


$2,750

50%

$7,150

33871PA0110019

KE 670 WPR GMC

8



Page Number: 16 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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65+

33871PA0100044 33871PA0100045


$199.64 $199.64 $158.47 $158.47

$314.40 $353.70 $249.56 $280.76

$314.40 $353.70 $249.56 $280.76

$314.40 $353.70 $249.56 $280.76

$314.40 $353.70 $249.56 $280.76

$315.65 $355.11 $250.56 $281.88

$321.94 $362.18 $255.55 $287.50

$329.49 $370.67 $261.54 $294.23

$341.75 $384.47 $271.27 $305.18

$351.81 $395.79 $279.26 $314.17

$356.84 $419.29 $283.25 $332.82

$364.39 $428.15 $289.24 $339.86

$371.93 $437.02 $295.23 $346.90

$376.65 $442.56 $298.98 $351.30

$381.68 $448.47 $302.97 $355.99

$384.19 $451.43 $304.97 $358.33

$386.71 $454.38 $306.96 $360.68

$389.22 $457.34 $308.96 $363.03

$391.74 $460.29 $310.96 $365.37

$396.77 $466.20 $314.95 $370.06

$401.80 $492.20 $318.94 $390.70

$409.34 $501.45 $324.93 $398.04

$416.58 $510.30 $330.67 $405.07

$426.64 $522.63 $338.66 $414.85

$439.21 $538.03 $348.64 $427.08

$453.99 $556.14 $360.37 $441.45

$471.59 $577.70 $374.34 $458.57

$491.40 $601.97 $390.07 $477.83

$514.04 $629.70 $408.03 $499.84

$536.36 $657.04 $425.75 $521.55

$561.51 $772.08 $445.72 $612.86

$586.35 $806.23 $465.43 $639.97

$613.70 $843.84 $487.15 $669.83

$641.37 $881.88 $509.11 $700.02

$671.24 $922.95 $532.82 $732.62

$701.10 $964.02 $556.52 $765.22

$733.49 $1,008.54 $582.23 $800.57

$766.18 $1,053.50 $608.18 $836.25

$801.08 $1,101.49 $635.89 $874.34

$818.37 $1,125.26 $649.61 $893.22

$853.27 $1,173.25 $677.31 $931.31

$883.45 $1,214.75 $701.27 $964.25

$903.26 $1,241.98 $716.99 $985.87

$928.10 $1,276.14 $736.71 $1,012.97

$943.19 $1,296.89 $748.68 $1,029.45

$943.19 $1,296.89 $748.68 $1,029.45

33871PA0100044

KE 670 WPR GMC

8


Yes

$0


0%/20%/30%

Gold

$7,150

$15/$40, $30/$60, $45/$80

Yes

$0/$5500/$5500


0%/5%/10%

Silver

33871PA0100045

KE 670 WPR GMC

8



$7,150

Page Number: 17 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

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Copays =>

OOP Maximum =>


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65+

33871PA0100035 33871PA0100037


$228.78 $228.78 $179.73 $179.73

$360.29 $405.32 $283.04 $318.42

$360.29 $405.32 $283.04 $318.42

$360.29 $405.32 $283.04 $318.42

$360.29 $405.32 $283.04 $318.42

$361.73 $406.94 $284.17 $319.69

$368.93 $415.05 $289.83 $326.06

$377.58 $424.78 $296.62 $333.70

$391.63 $440.59 $307.66 $346.12

$403.16 $453.56 $316.72 $356.31

$408.93 $480.49 $321.25 $377.47

$417.57 $490.65 $328.04 $385.45

$426.22 $500.81 $334.83 $393.43

$431.62 $507.16 $339.08 $398.42

$437.39 $513.93 $343.61 $403.74

$440.27 $517.32 $345.87 $406.40

$443.15 $520.70 $348.14 $409.06

$446.04 $524.09 $350.40 $411.72

$448.92 $527.48 $352.67 $414.38

$454.68 $534.25 $357.19 $419.70

$460.45 $564.05 $361.72 $443.11

$469.09 $574.64 $368.52 $451.43

$477.38 $584.79 $375.03 $459.41

$488.91 $598.91 $384.08 $470.50

$503.32 $616.57 $395.40 $484.37

$520.25 $637.31 $408.71 $500.67

$540.43 $662.03 $424.56 $520.08

$563.13 $689.83 $442.39 $541.93

$589.07 $721.61 $462.77 $566.89

$614.65 $752.95 $482.86 $591.51

$643.47 $884.77 $505.51 $695.07

$671.93 $923.91 $527.87 $725.82

$703.28 $967.01 $552.49 $759.67

$734.99 $1,010.60 $577.40 $793.92

$769.21 $1,057.67 $604.29 $830.89

$803.44 $1,104.73 $631.17 $867.86

$840.55 $1,155.75 $660.33 $907.95

$878.02 $1,207.28 $689.76 $948.42

$918.01 $1,262.26 $721.18 $991.62

$937.83 $1,289.51 $736.75 $1,013.03

$977.82 $1,344.50 $768.16 $1,056.23

$1,012.41 $1,392.06 $795.34 $1,093.59

$1,035.10 $1,423.27 $813.17 $1,118.11

$1,063.57 $1,462.40 $835.53 $1,148.85

$1,080.86 $1,486.18 $849.11 $1,167.53

$1,080.86 $1,486.18 $849.11 $1,167.53

33871PA0100035

KE 670 WPR GMC

8


No

Gold Silver

$2,000 $3,500

$3,500 $7,150

No

0%


0%


33871PA0100037

KE 670 WPR GMC

8



Page Number: 18 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0100036 33871PA0110007


$190.41 $190.41 $187.70 $187.70

$299.85 $337.33 $295.59 $332.54

$299.85 $337.33 $295.59 $332.54

$299.85 $337.33 $295.59 $332.54

$299.85 $337.33 $295.59 $332.54

$301.05 $338.68 $296.78 $333.87

$307.05 $345.43 $302.69 $340.52

$314.25 $353.53 $309.78 $348.51

$325.94 $366.68 $321.31 $361.47

$335.54 $377.48 $330.77 $372.12

$340.33 $399.89 $335.50 $394.21

$347.53 $408.35 $342.59 $402.55

$354.73 $416.80 $349.69 $410.88

$359.22 $422.09 $354.12 $416.09

$364.02 $427.73 $358.85 $421.65

$366.42 $430.54 $361.22 $424.43

$368.82 $433.36 $363.58 $427.21

$371.22 $436.18 $365.95 $429.99

$373.62 $439.00 $368.31 $432.76

$378.41 $444.64 $373.04 $438.32

$383.21 $469.43 $377.77 $462.77

$390.41 $478.25 $384.86 $471.46

$397.30 $486.70 $391.66 $479.79

$406.90 $498.45 $401.12 $491.37

$418.89 $513.15 $412.94 $505.86

$432.99 $530.41 $426.84 $522.88

$449.78 $550.98 $443.39 $543.15

$468.67 $574.12 $462.01 $565.97

$490.26 $600.57 $483.30 $592.04

$511.55 $626.65 $504.28 $617.75

$535.54 $736.36 $527.93 $725.90

$559.23 $768.94 $551.28 $758.01

$585.31 $804.80 $577.00 $793.37

$611.70 $841.09 $603.01 $829.14

$640.19 $880.26 $631.09 $867.75

$668.67 $919.42 $659.17 $906.36

$699.56 $961.89 $689.62 $948.23

$730.74 $1,004.77 $720.36 $990.50

$764.02 $1,050.53 $753.17 $1,035.61

$780.52 $1,073.21 $769.43 $1,057.97

$813.80 $1,118.98 $802.24 $1,103.08

$842.59 $1,158.56 $830.62 $1,142.10

$861.48 $1,184.53 $849.24 $1,167.71

$885.17 $1,217.10 $872.59 $1,199.82

$899.55 $1,236.89 $886.77 $1,219.32

$899.55 $1,236.89 $886.77 $1,219.32


KE 670 WPR GMC

No

Silver Silver

$4,250 $3,500

$7,150 $7,150

No


0% 0%

33871PA0110007

8

33871PA0100036

KE 670 WPR GMC

8



Page Number: 19 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110008 33871PA0110009


$198.85 $198.85 $195.50 $195.50

$313.15 $352.29 $307.87 $346.36

$313.15 $352.29 $307.87 $346.36

$313.15 $352.29 $307.87 $346.36

$313.15 $352.29 $307.87 $346.36

$314.40 $353.70 $309.11 $347.74

$320.67 $360.75 $315.26 $354.67

$328.18 $369.20 $322.65 $362.98

$340.39 $382.94 $334.66 $376.49

$350.41 $394.22 $344.51 $387.58

$355.42 $417.62 $349.44 $410.59

$362.94 $426.45 $356.83 $419.27

$370.46 $435.29 $364.22 $427.95

$375.15 $440.80 $368.83 $433.38

$380.16 $446.69 $373.76 $439.17

$382.67 $449.64 $376.22 $442.06

$385.17 $452.58 $378.69 $444.96

$387.68 $455.52 $381.15 $447.85

$390.18 $458.47 $383.61 $450.74

$395.19 $464.35 $388.54 $456.53

$400.21 $490.25 $393.46 $481.99

$407.72 $499.46 $400.85 $491.04

$414.92 $508.28 $407.93 $499.72

$424.94 $520.56 $417.79 $511.79

$437.47 $535.90 $430.10 $526.87

$452.19 $553.93 $444.57 $544.60

$469.72 $575.41 $461.81 $565.72

$489.45 $599.58 $481.21 $589.48

$512.00 $627.20 $503.37 $616.63

$534.23 $654.44 $525.23 $643.41

$559.29 $769.02 $549.86 $756.06

$584.02 $803.03 $574.19 $789.51

$611.27 $840.49 $600.97 $826.34

$638.83 $878.38 $628.06 $863.59

$668.57 $919.29 $657.31 $903.80

$698.32 $960.19 $686.56 $944.02

$730.58 $1,004.54 $718.27 $987.62

$763.15 $1,049.33 $750.29 $1,031.65

$797.91 $1,097.12 $784.46 $1,078.64

$815.13 $1,120.80 $801.40 $1,101.92

$849.89 $1,168.60 $835.57 $1,148.91

$879.95 $1,209.93 $865.13 $1,189.55

$899.68 $1,237.06 $884.52 $1,216.22

$924.42 $1,271.07 $908.85 $1,249.66

$939.45 $1,291.74 $923.61 $1,269.98

$939.45 $1,291.74 $923.61 $1,269.98


8

KE 670 WPR GMC

50%



NoNo

0%

Silver

$4,250 $2,750


Silver

33871PA0110009


KE 670 WPR GMC

33871PA0110008

8

$7,150


$7,150

Page Number: 20 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0100047 33871PA0100049


$229.34 $229.34 $180.29 $180.29

$361.17 $406.31 $283.92 $319.41

$361.17 $406.31 $283.92 $319.41

$361.17 $406.31 $283.92 $319.41

$361.17 $406.31 $283.92 $319.41

$362.61 $407.94 $285.05 $320.68

$369.83 $416.06 $290.73 $327.07

$378.50 $425.81 $297.54 $334.74

$392.59 $441.66 $308.62 $347.19

$404.14 $454.66 $317.70 $357.42

$409.92 $481.66 $322.25 $378.64

$418.59 $491.84 $329.06 $386.64

$427.26 $502.03 $335.87 $394.65

$432.68 $508.39 $340.13 $399.65

$438.45 $515.18 $344.67 $404.99

$441.34 $518.58 $346.95 $407.66

$444.23 $521.97 $349.22 $410.33

$447.12 $525.37 $351.49 $413.00

$450.01 $528.76 $353.76 $415.67

$455.79 $535.55 $358.30 $421.01

$461.57 $565.42 $362.85 $444.49

$470.24 $576.04 $369.66 $452.83

$478.54 $586.22 $376.19 $460.83

$490.10 $600.37 $385.27 $471.96

$504.55 $618.07 $396.63 $485.87

$521.52 $638.87 $409.98 $502.22

$541.75 $663.64 $425.87 $521.70

$564.50 $691.51 $443.76 $543.61

$590.51 $723.37 $464.20 $568.65

$616.15 $754.78 $484.36 $593.34

$645.04 $886.93 $507.07 $697.23

$673.57 $926.16 $529.50 $728.07

$704.99 $969.37 $554.20 $762.03

$736.78 $1,013.07 $579.19 $796.39

$771.09 $1,060.25 $606.16 $833.47

$805.40 $1,107.42 $633.13 $870.56

$842.60 $1,158.57 $662.38 $910.77

$880.16 $1,210.22 $691.90 $951.37

$920.25 $1,265.34 $723.42 $994.70

$940.11 $1,292.66 $739.03 $1,016.17

$980.20 $1,347.78 $770.55 $1,059.51

$1,014.87 $1,395.45 $797.81 $1,096.98

$1,037.63 $1,426.74 $815.69 $1,121.58

$1,066.16 $1,465.97 $838.12 $1,152.42

$1,083.50 $1,489.81 $851.75 $1,171.16

$1,083.50 $1,489.81 $851.75 $1,171.16

33871PA0100047

KE 670 WPR GMC

33871PA0100049

KE 670 WPR GMC


Yes Yes

Gold

$2,000

8


8


0% 0%


$3,500


Silver

$3,500 $7,150

Page Number: 21 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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65+

33871PA0100048 33871PA0110015


$190.96 $190.96 $236.12 $236.12

$300.73 $338.32 $371.85 $418.33

$300.73 $338.32 $371.85 $418.33

$300.73 $338.32 $371.85 $418.33

$300.73 $338.32 $371.85 $418.33

$301.93 $339.68 $373.34 $420.00

$307.95 $346.44 $380.77 $428.37

$315.17 $354.56 $389.70 $438.41

$326.89 $367.76 $404.20 $454.72

$336.52 $378.58 $416.10 $468.11

$341.33 $401.06 $422.05 $495.91

$348.55 $409.54 $430.97 $506.39

$355.77 $418.02 $439.90 $516.88

$360.28 $423.32 $445.47 $523.43

$365.09 $428.98 $451.42 $530.42

$367.49 $431.81 $454.40 $533.92

$369.90 $434.63 $457.37 $537.41

$372.31 $437.46 $460.35 $540.91

$374.71 $440.29 $463.32 $544.40

$379.52 $445.94 $469.27 $551.40

$384.33 $470.81 $475.22 $582.15

$391.55 $479.65 $484.15 $593.08

$398.47 $488.12 $492.70 $603.56

$408.09 $499.91 $504.60 $618.13

$420.12 $514.65 $519.47 $636.35

$434.26 $531.96 $536.95 $657.76

$451.10 $552.59 $557.77 $683.27

$470.04 $575.80 $581.20 $711.97

$491.70 $602.33 $607.97 $744.77

$513.05 $628.48 $634.37 $777.11

$537.11 $738.52 $664.12 $913.17

$560.86 $771.19 $693.50 $953.56

$587.03 $807.16 $725.85 $998.04

$613.49 $843.55 $758.57 $1,043.03

$642.06 $882.83 $793.90 $1,091.61

$670.63 $922.12 $829.22 $1,140.18

$701.61 $964.71 $867.52 $1,192.84

$732.88 $1,007.71 $906.19 $1,246.02

$766.26 $1,053.61 $947.47 $1,302.77

$782.80 $1,076.36 $967.92 $1,330.89

$816.18 $1,122.25 $1,009.20 $1,387.64

$845.06 $1,161.95 $1,044.89 $1,436.73

$864.00 $1,188.00 $1,068.32 $1,468.94

$887.76 $1,220.67 $1,097.70 $1,509.33

$902.19 $1,240.52 $1,115.54 $1,533.87

$902.19 $1,240.52 $1,115.54 $1,533.87

Yes

33871PA0110015

0%


$3,500

Gold


$2,000

KE 670 WPR GMC

8


KE 670 WPR GMC

33871PA0100048

8


Silver

$4,250

0%



Yes

$7,150

Page Number: 22 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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61

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64

65+

33871PA0110017 33871PA0110018


$188.26 $188.26 $199.41 $199.41

$296.47 $333.53 $314.03 $353.28

$296.47 $333.53 $314.03 $353.28

$296.47 $333.53 $314.03 $353.28

$296.47 $333.53 $314.03 $353.28

$297.66 $334.87 $315.28 $354.69

$303.59 $341.54 $321.56 $361.76

$310.70 $349.54 $329.10 $370.24

$322.27 $362.55 $341.35 $384.02

$331.75 $373.22 $351.40 $395.32

$336.50 $395.38 $356.42 $418.80

$343.61 $403.74 $363.96 $427.65

$350.73 $412.10 $371.50 $436.51

$355.17 $417.33 $376.21 $442.04

$359.92 $422.90 $381.23 $447.95

$362.29 $425.69 $383.74 $450.90

$364.66 $428.48 $386.25 $453.85

$367.03 $431.26 $388.77 $456.80

$369.40 $434.05 $391.28 $459.75

$374.15 $439.62 $396.30 $465.66

$378.89 $464.14 $401.33 $491.63

$386.01 $472.86 $408.86 $500.86

$392.83 $481.21 $416.09 $509.71

$402.31 $492.83 $426.14 $522.02

$414.17 $507.36 $438.70 $537.40

$428.11 $524.43 $453.46 $555.48

$444.71 $544.77 $471.04 $577.03

$463.39 $567.65 $490.83 $601.26

$484.73 $593.80 $513.44 $628.96

$505.78 $619.58 $535.73 $656.27

$529.50 $728.06 $560.85 $771.17

$552.92 $760.27 $585.66 $805.29

$578.71 $795.73 $612.98 $842.85

$604.80 $831.60 $640.62 $880.85

$632.97 $870.33 $670.45 $921.87

$661.13 $909.06 $700.28 $962.89

$691.67 $951.05 $732.63 $1,007.36

$722.50 $993.44 $765.29 $1,052.27

$755.41 $1,038.69 $800.14 $1,100.20

$771.72 $1,061.11 $817.42 $1,123.95

$804.63 $1,106.36 $852.27 $1,171.87

$833.09 $1,145.50 $882.42 $1,213.33

$851.77 $1,171.18 $902.20 $1,240.53

$875.19 $1,203.38 $927.01 $1,274.64

$889.41 $1,222.95 $942.08 $1,295.37

$889.41 $1,222.95 $942.08 $1,295.37

Yes Yes

33871PA0110017

0% 0%


$7,150 $7,150


Silver Silver


KE 670 WPR GMC

$3,500 $4,250

33871PA0110018

KE 670 WPR GMC

8 8


Page Number: 23 05/05/2016



33871PA0100005 310.02

33871PA0100006 294.8

33871PA0100009 248.68

33871PA0100036 299.85

33871PA0100037 283.04

33871PA0110006 323.86

33871PA0110007 295.59

33871PA0110008 313.15

33871PA0110009 307.87




33871PA0100024 310.9

33871PA0100025 295.68

33871PA0100045 249.56

33871PA0100048 300.73

33871PA0100049 283.92

33871PA0110016 324.74

33871PA0110017 296.47

33871PA0110018 314.03

33871PA0110019 308.75



Exchange HIOS Plan ID Level AreaKHPE ON 33871PA0100001 Platinum Keystone HMO Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE ON 33871PA0100002 Platinum Keystone HMO Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE ON 33871PA0100003 Gold Keystone HMO Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE ON 33871PA0100004 Gold Keystone HMO Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE ON 33871PA0100005 Silver Keystone HMO Silver Classic $2,500 $25/$50/70% Keystone Health Plan East Network 8KHPE ON 33871PA0100006 Silver Keystone HMO Silver Classic $2,750/$30/$60/50% Keystone Health Plan East Network 8KHPE ON 33871PA0100007 Bronze Keystone HMO Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8KHPE ON 33871PA0100008 Gold Keystone HMO Gold Proactive Keystone Health Plan East Network 8KHPE ON 33871PA0100009 Silver Keystone HMO Silver Proactive Keystone Health Plan East Network 8KHPE OFF 33871PA0100020 Platinum Keystone HMO Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE OFF 33871PA0100021 Platinum Keystone HMO Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE OFF 33871PA0100022 Gold Keystone HMO Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE OFF 33871PA0100023 Gold Keystone HMO Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE OFF 33871PA0100024 Silver Keystone HMO Silver Classic $2,500/$25/$50/70% Keystone Health Plan East Network 8KHPE OFF 33871PA0100025 Silver Keystone HMO Silver Classic $2,750/$30/$60/50% Keystone Health Plan East Network 8KHPE OFF 33871PA0100026 Bronze Keystone HMO Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8KHPE ON 33871PA0100035 Gold Keystone HMO Gold Classic $2,000/$40/$80/100% Keystone Health Plan East Network 8KHPE ON 33871PA0100036 Silver Keystone HMO Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8KHPE ON 33871PA0100037 Silver Keystone HMO Silver Secure $3,500 $40/$80/$600 Keystone Health Plan East Network 8KHPE OFF 33871PA0100044 Gold Keystone HMO Gold Proactive Keystone Health Plan East Network 8KHPE OFF 33871PA0100045 Silver Keystone HMO Silver Proactive Keystone Health Plan East Network 8KHPE OFF 33871PA0100047 Gold Keystone HMO Gold Classic $2,000 $40/$80/100% Keystone Health Plan East Network 8KHPE OFF 33871PA0100048 Silver Keystone HMO Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8KHPE OFF 33871PA0100049 Silver Keystone HMO Silver Secure $3,500 $40/$80/$600 Keystone Health Plan East Network 8KHPE ON 33871PA0110001 Platinum Keystone DPOS Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE ON 33871PA0110002 Platinum Keystone DPOS Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE ON 33871PA0110003 Gold Keystone DPOS Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE ON 33871PA0110004 Gold Keystone DPOS Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE ON 33871PA0110005 Gold Keystone DPOS Gold Classic $2,000 $40/$80/100% Keystone Health Plan East Network 8KHPE ON 33871PA0110006 Silver Keystone DPOS Silver Classic $2,500/$25/$50/70% Keystone Health Plan East Network 8KHPE ON 33871PA0110007 Silver Keystone DPOS Silver Secure $3,500/$40/$80/$600 Keystone Health Plan East Network 8KHPE ON 33871PA0110008 Silver Keystone DPOS Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8














Plan Design Summary


05/15/2015

RATE PAGES


Product: HMO

Effective Date of Rates: July 1, 2017 - September 30, 201733871PA0100001 33871PA0100002



Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20 $290.71 $290.71 $277.89 $277.89

21 $457.81 $515.03 $437.62 $492.33

22 $457.81 $515.03 $437.62 $492.33

23 $457.81 $515.03 $437.62 $492.33

24 $457.81 $515.03 $437.62 $492.33

25 $459.64 $517.09 $439.37 $494.30

26 $468.80 $527.40 $448.13 $504.14

27 $479.78 $539.76 $458.63 $515.96

28 $497.64 $559.84 $475.70 $535.16

29 $512.29 $576.32 $489.70 $550.91

30 $519.61 $610.54 $496.70 $583.62

31 $530.60 $623.46 $507.21 $595.97

32 $541.59 $636.37 $517.71 $608.31

33 $548.45 $644.43 $524.27 $616.02

34 $555.78 $653.04 $531.27 $624.25

35 $559.44 $657.34 $534.78 $628.36

36 $563.10 $661.65 $538.28 $632.47

37 $566.77 $665.95 $541.78 $636.59

38 $570.43 $670.25 $545.28 $640.70

39 $577.75 $678.86 $552.28 $648.93

40 $585.08 $716.72 $559.28 $685.12

41 $596.07 $730.18 $569.79 $697.99

42 $606.60 $743.08 $579.85 $710.32

43 $621.25 $761.03 $593.85 $727.47

44 $639.56 $783.46 $611.36 $748.92

45 $661.08 $809.82 $631.93 $774.11

46 $686.71 $841.22 $656.43 $804.13

47 $715.55 $876.55 $684.00 $837.91

48 $748.52 $916.93 $715.51 $876.50

49 $781.02 $956.75 $746.58 $914.57

50 $817.65 $1,124.26 $781.59 $1,074.69

51 $853.81 $1,173.99 $816.17 $1,122.23

52 $893.64 $1,228.76 $854.24 $1,174.58

53 $933.93 $1,284.15 $892.75 $1,227.53

54 $977.42 $1,343.95 $934.33 $1,284.70

55 $1,020.91 $1,403.76 $975.90 $1,341.86

56 $1,068.07 $1,468.59 $1,020.97 $1,403.84

57 $1,115.68 $1,534.06 $1,066.49 $1,466.42

58 $1,166.50 $1,603.93 $1,115.06 $1,533.21

59 $1,191.68 $1,638.55 $1,139.13 $1,566.31

60 $1,242.49 $1,708.43 $1,187.71 $1,633.10

61 $1,286.44 $1,768.86 $1,229.72 $1,690.87

62 $1,315.28 $1,808.52 $1,257.29 $1,728.78

63 $1,351.45 $1,858.24 $1,291.86 $1,776.31

64 $1,373.43 $1,888.46 $1,312.86 $1,805.19

65+ $1,373.43 $1,888.46 $1,312.86 $1,805.19

$0

0%

$3,000


$0

0%

No

#NAME?

$4,000

#NAME?


No

33871PA0100001

KE 670 WPR GMC

8

33871PA0100002

8

KE 670 WPR GMC


$10/$20 $20/$40


RATE PAGES


Product: HMO

Effective Date of Rates: July 1, 2017 - September 30, 2017



Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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+

33871PA0100003 33871PA0100004


$229.14 $229.14 $236.59 $236.59

$360.85 $405.96 $372.59 $419.16

$360.85 $405.96 $372.59 $419.16

$360.85 $405.96 $372.59 $419.16

$360.85 $405.96 $372.59 $419.16

$362.30 $407.58 $374.08 $420.84

$369.51 $415.70 $381.53 $429.22

$378.17 $425.44 $390.47 $439.28

$392.25 $441.28 $405.00 $455.63

$403.79 $454.27 $416.92 $469.04

$409.57 $481.24 $422.89 $496.89

$418.23 $491.42 $431.83 $507.40

$426.89 $501.59 $440.77 $517.90

$432.30 $507.95 $446.36 $524.47

$438.07 $514.74 $452.32 $531.48

$440.96 $518.13 $455.30 $534.98

$443.85 $521.52 $458.28 $538.48

$446.74 $524.91 $461.26 $541.98

$449.62 $528.31 $464.24 $545.49

$455.40 $535.09 $470.20 $552.49

$461.17 $564.93 $476.17 $583.30

$469.83 $575.54 $485.11 $594.26

$478.13 $585.71 $493.68 $604.75

$489.68 $599.85 $505.60 $619.36

$504.11 $617.54 $520.50 $637.62

$521.07 $638.31 $538.01 $659.07

$541.28 $663.07 $558.88 $684.63

$564.01 $690.91 $582.35 $713.38

$589.99 $722.74 $609.18 $746.24

$615.61 $754.13 $635.63 $778.65

$644.48 $886.16 $665.44 $914.98

$672.99 $925.36 $694.87 $955.45

$704.38 $968.53 $727.29 $1,000.02

$736.14 $1,012.19 $760.08 $1,045.11

$770.42 $1,059.33 $795.47 $1,093.77

$804.70 $1,106.46 $830.87 $1,142.44

$841.87 $1,157.57 $869.24 $1,195.21

$879.40 $1,209.17 $907.99 $1,248.49

$919.45 $1,264.25 $949.35 $1,305.36

$939.30 $1,291.54 $969.84 $1,333.53

$979.35 $1,346.61 $1,011.20 $1,390.40

$1,013.99 $1,394.24 $1,046.97 $1,439.58

$1,036.73 $1,425.50 $1,070.44 $1,471.86

$1,065.24 $1,464.70 $1,099.88 $1,512.33

$1,082.55 $1,488.52 $1,117.76 $1,536.92

$1,082.55 $1,488.52 $1,117.76 $1,536.92

#NAME?


$1,000

10%

$5,500

33871PA0100004

#NAME?


$0

0%

$7,150

No No

33871PA0100003

KE 670 WPR GMC

8


KE 670 WPR GMC

8


$30/$60 $25 no ded/$50 no ded


RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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+

33871PA0100005 33871PA0100006


$202.58 $202.58 $192.64 $192.64

$319.03 $358.91 $303.36 $341.28

$319.03 $358.91 $303.36 $341.28

$319.03 $358.91 $303.36 $341.28

$319.03 $358.91 $303.36 $341.28

$320.31 $360.34 $304.58 $342.65

$326.69 $367.52 $310.65 $349.48

$334.34 $376.14 $317.93 $357.67

$346.78 $390.13 $329.76 $370.98

$356.99 $401.62 $339.46 $381.90

$362.10 $425.47 $344.32 $404.57

$369.75 $434.46 $351.60 $413.13

$377.41 $443.46 $358.88 $421.68

$382.20 $449.08 $363.43 $427.03

$387.30 $455.08 $368.28 $432.73

$389.85 $458.08 $370.71 $435.59

$392.41 $461.08 $373.14 $438.44

$394.96 $464.08 $375.57 $441.29

$397.51 $467.07 $377.99 $444.14

$402.61 $473.07 $382.85 $449.84

$407.72 $499.46 $387.70 $474.93

$415.38 $508.84 $394.98 $483.85

$422.71 $517.82 $401.96 $492.40

$432.92 $530.33 $411.67 $504.29

$445.68 $545.96 $423.80 $519.16

$460.68 $564.33 $438.06 $536.62

$478.54 $586.22 $455.05 $557.43

$498.64 $610.84 $474.16 $580.84

$521.61 $638.98 $496.00 $607.60

$544.26 $666.72 $517.54 $633.99

$569.79 $783.46 $541.81 $744.99

$594.99 $818.11 $565.77 $777.94

$622.74 $856.27 $592.17 $814.23

$650.82 $894.88 $618.86 $850.94

$681.13 $936.55 $647.68 $890.56

$711.44 $978.22 $676.50 $930.19

$744.30 $1,023.41 $707.75 $973.16

$777.47 $1,069.03 $739.30 $1,016.54

$812.89 $1,117.72 $772.97 $1,062.84

$830.43 $1,141.85 $789.66 $1,085.78

$865.85 $1,190.54 $823.33 $1,132.08

$896.47 $1,232.65 $852.45 $1,172.12

$916.57 $1,260.28 $871.57 $1,198.40

$941.77 $1,294.94 $895.53 $1,231.36

$957.09 $1,316.00 $910.08 $1,251.38

$957.09 $1,316.00 $910.08 $1,251.38

33871PA0100005

$2,500

30%

$7,150

No

#NAME?


KE 670 WPR GMC

8



#NAME?


$2,750

50%

$7,150

No

33871PA0100006

KE 670 WPR GMC

8




RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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+

33871PA0100007 33871PA0100008


$143.42 $143.42 $204.87 $204.87

$225.86 $254.10 $322.63 $362.96

$225.86 $254.10 $322.63 $362.96

$225.86 $254.10 $322.63 $362.96

$225.86 $254.10 $322.63 $362.96

$226.77 $255.11 $323.92 $364.41

$231.28 $260.19 $330.37 $371.67

$236.70 $266.29 $338.11 $380.38

$245.51 $276.20 $350.70 $394.53

$252.74 $284.33 $361.02 $406.15

$256.35 $301.22 $366.18 $430.26

$261.77 $307.59 $373.93 $439.36

$267.20 $313.95 $381.67 $448.46

$270.58 $317.94 $386.51 $454.15

$274.20 $322.18 $391.67 $460.21

$276.00 $324.31 $394.25 $463.25

$277.81 $326.43 $396.83 $466.28

$279.62 $328.55 $399.41 $469.31

$281.43 $330.67 $401.99 $472.34

$285.04 $334.92 $407.16 $478.41

$288.65 $353.60 $412.32 $505.09

$294.07 $360.24 $420.06 $514.58

$299.27 $366.60 $427.48 $523.67

$306.50 $375.46 $437.81 $536.31

$315.53 $386.52 $450.71 $552.12

$326.15 $399.53 $465.87 $570.70

$338.79 $415.02 $483.94 $592.83

$353.02 $432.45 $504.27 $617.73

$369.29 $452.37 $527.50 $646.18

$385.32 $472.02 $550.40 $674.24

$403.39 $554.66 $576.21 $792.29

$421.23 $579.20 $601.70 $827.34

$440.88 $606.22 $629.77 $865.93

$460.76 $633.55 $658.16 $904.97

$482.22 $663.05 $688.81 $947.11

$503.67 $692.55 $719.46 $989.26

$526.94 $724.54 $752.69 $1,034.95

$550.43 $756.84 $786.24 $1,081.09

$575.50 $791.31 $822.06 $1,130.33

$587.92 $808.39 $839.80 $1,154.73

$612.99 $842.86 $875.61 $1,203.97

$634.67 $872.68 $906.58 $1,246.55

$648.90 $892.24 $926.91 $1,274.50

$666.75 $916.78 $952.40 $1,309.55

$677.58 $931.68 $967.88 $1,330.84

$677.58 $931.68 $967.88 $1,330.84

33871PA0100007

#NAME?

KE 670 WPR GMC

8



$6,850

50%

$7,150

No


No

$15/$40, $30/$60, $45/$80

#NAME?


$0

0%/20%/30%

$7,150

33871PA0100008

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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+

33871PA0100009 33871PA0110001


$162.50 $162.50 $304.18 $304.18

$255.91 $287.90 $479.03 $538.91

$255.91 $287.90 $479.03 $538.91

$255.91 $287.90 $479.03 $538.91

$255.91 $287.90 $479.03 $538.91

$256.93 $289.05 $480.95 $541.07

$262.05 $294.81 $490.53 $551.84

$268.19 $301.72 $502.02 $564.78

$278.17 $312.95 $520.71 $585.79

$286.36 $322.16 $536.04 $603.04

$290.46 $341.29 $543.70 $638.85

$296.60 $348.50 $555.20 $652.36

$302.74 $355.72 $566.69 $665.86

$306.58 $360.23 $573.88 $674.31

$310.67 $365.04 $581.54 $683.31

$312.72 $367.45 $585.38 $687.82

$314.77 $369.85 $589.21 $692.32

$316.82 $372.26 $593.04 $696.82

$318.86 $374.67 $596.87 $701.32

$322.96 $379.48 $604.54 $710.33

$327.05 $400.64 $612.20 $749.95

$333.20 $408.16 $623.70 $764.03

$339.08 $415.37 $634.72 $777.53

$347.27 $425.41 $650.04 $796.30

$357.51 $437.95 $669.21 $819.78

$369.53 $452.68 $691.72 $847.36

$383.87 $470.23 $718.55 $880.22

$399.99 $489.98 $748.72 $917.19

$418.41 $512.56 $783.21 $959.44

$436.58 $534.81 $817.23 $1,001.10

$457.06 $628.45 $855.55 $1,176.38

$477.27 $656.25 $893.39 $1,228.41

$499.54 $686.86 $935.07 $1,285.72

$522.06 $717.83 $977.22 $1,343.68

$546.37 $751.26 $1,022.73 $1,406.25

$570.68 $784.68 $1,068.24 $1,468.83

$597.04 $820.93 $1,117.58 $1,536.67

$623.65 $857.52 $1,167.40 $1,605.17

$652.06 $896.58 $1,220.57 $1,678.28

$666.13 $915.93 $1,246.92 $1,714.51

$694.54 $954.99 $1,300.09 $1,787.62

$719.11 $988.77 $1,346.08 $1,850.85

$735.23 $1,010.94 $1,376.25 $1,892.35

$755.45 $1,038.74 $1,414.10 $1,944.39

$767.73 $1,055.63 $1,437.09 $1,976.00

$767.73 $1,055.63 $1,437.09 $1,976.00

33871PA0100009

KE 670 WPR GMC

8


#NAME?


$0/$5500/$5500

0%/5%/10%

$7,150

No


No

$10/$20

#NAME?


$0

0%

$3,000

33871PA0110001

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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+

33871PA0110002 33871PA0110003


$290.77 $290.77 $239.37 $239.37

$457.91 $515.15 $376.96 $424.08

$457.91 $515.15 $376.96 $424.08

$457.91 $515.15 $376.96 $424.08

$457.91 $515.15 $376.96 $424.08

$459.74 $517.21 $378.47 $425.78

$468.90 $527.51 $386.01 $434.26

$479.89 $539.88 $395.06 $444.44

$497.75 $559.97 $409.76 $460.98

$512.40 $576.45 $421.82 $474.55

$519.73 $610.68 $427.85 $502.73

$530.72 $623.60 $436.90 $513.36

$541.71 $636.51 $445.95 $523.99

$548.58 $644.58 $451.60 $530.63

$555.90 $653.19 $457.63 $537.72

$559.57 $657.49 $460.65 $541.26

$563.23 $661.80 $463.66 $544.81

$566.89 $666.10 $466.68 $548.35

$570.56 $670.41 $469.70 $551.89

$577.88 $679.01 $475.73 $558.98

$585.21 $716.88 $481.76 $590.15

$596.20 $730.35 $490.81 $601.24

$606.73 $743.25 $499.48 $611.86

$621.39 $761.20 $511.54 $626.64

$639.70 $783.64 $526.62 $645.11

$661.22 $810.00 $544.34 $666.81

$686.87 $841.41 $565.44 $692.67

$715.72 $876.75 $589.19 $721.76

$748.69 $917.14 $616.34 $755.01

$781.20 $956.97 $643.10 $787.80

$817.83 $1,124.52 $673.26 $925.73

$854.01 $1,174.26 $703.04 $966.68

$893.84 $1,229.03 $735.83 $1,011.77

$934.14 $1,284.44 $769.01 $1,057.38

$977.64 $1,344.26 $804.82 $1,106.62

$1,021.14 $1,404.07 $840.63 $1,155.86

$1,068.31 $1,468.92 $879.46 $1,209.25

$1,115.93 $1,534.40 $918.66 $1,263.16

$1,166.76 $1,604.29 $960.50 $1,320.69

$1,191.94 $1,638.92 $981.24 $1,349.20

$1,242.77 $1,708.81 $1,023.08 $1,406.73

$1,286.73 $1,769.26 $1,059.27 $1,456.49

$1,315.58 $1,808.92 $1,083.02 $1,489.15

$1,351.75 $1,858.66 $1,112.80 $1,530.09

$1,373.73 $1,888.89 $1,130.88 $1,554.97

$1,373.73 $1,888.89 $1,130.88 $1,554.97

33871PA0110002

KE 670 WPR GMC

8


#NAME?


$0

0%

$4,000

No

$20/$40

No

$30/$60

#NAME?


$0

0%

$7,150

33871PA0110003

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110004 33871PA0110005


$246.37 $246.37 $242.41 $242.41

$387.98 $436.48 $381.75 $429.47

$387.98 $436.48 $381.75 $429.47

$387.98 $436.48 $381.75 $429.47

$387.98 $436.48 $381.75 $429.47

$389.54 $438.23 $383.28 $431.19

$397.30 $446.96 $390.91 $439.77

$406.61 $457.43 $400.07 $450.08

$421.74 $474.46 $414.96 $466.83

$434.15 $488.42 $427.18 $480.57

$440.36 $517.42 $433.29 $509.11

$449.67 $528.37 $442.45 $519.88

$458.98 $539.31 $451.61 $530.64

$464.80 $546.15 $457.34 $537.37

$471.01 $553.44 $463.44 $544.55

$474.12 $557.09 $466.50 $548.13

$477.22 $560.73 $469.55 $551.72

$480.32 $564.38 $472.61 $555.31

$483.43 $568.03 $475.66 $558.90

$489.64 $575.32 $481.77 $566.08

$495.84 $607.41 $487.88 $597.65

$505.15 $618.81 $497.04 $608.87

$514.08 $629.75 $505.82 $619.63

$526.49 $644.95 $518.03 $634.59

$542.01 $663.97 $533.30 $653.30

$560.25 $686.30 $551.25 $675.28

$581.98 $712.92 $572.62 $701.46

$606.42 $742.86 $596.67 $730.93

$634.35 $777.08 $624.16 $764.60

$661.90 $810.83 $651.26 $797.80

$692.94 $952.79 $681.80 $937.48

$723.59 $994.94 $711.96 $978.95

$757.34 $1,041.35 $745.17 $1,024.61

$791.49 $1,088.29 $778.77 $1,070.81

$828.34 $1,138.97 $815.03 $1,120.67

$865.20 $1,189.65 $851.30 $1,170.54

$905.17 $1,244.60 $890.62 $1,224.60

$945.52 $1,300.08 $930.32 $1,279.19

$988.58 $1,359.30 $972.70 $1,337.46

$1,009.92 $1,388.64 $993.69 $1,366.33

$1,052.99 $1,447.86 $1,036.07 $1,424.59

$1,090.23 $1,499.07 $1,072.71 $1,474.98

$1,114.68 $1,532.68 $1,096.76 $1,508.05

$1,145.33 $1,574.83 $1,126.92 $1,549.52

$1,163.94 $1,600.43 $1,145.25 $1,574.71

$1,163.94 $1,600.43 $1,145.25 $1,574.71

33871PA0110004

KE 670 WPR GMC

8


#NAME?


$1,000

10%

$5,500

No


No


#NAME?Keystone DPOS Gold Classic

$2,000 $40/$80/100%

$2,000

0%

$3,500

33871PA0110005

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110006 33871PA0110010


$211.63 $211.63 $149.66 $149.66

$333.27 $374.93 $235.68 $265.14

$333.27 $374.93 $235.68 $265.14

$333.27 $374.93 $235.68 $265.14

$333.27 $374.93 $235.68 $265.14

$334.60 $376.43 $236.62 $266.20

$341.27 $383.92 $241.33 $271.50

$349.27 $392.92 $246.99 $277.87

$362.26 $407.55 $256.18 $288.21

$372.93 $419.54 $263.72 $296.69

$378.26 $444.45 $267.50 $314.31

$386.26 $453.85 $273.15 $320.95

$394.26 $463.25 $278.81 $327.60

$399.26 $469.12 $282.34 $331.75

$404.59 $475.39 $286.11 $336.18

$407.25 $478.52 $288.00 $338.40

$409.92 $481.66 $289.88 $340.61

$412.59 $484.79 $291.77 $342.83

$415.25 $487.92 $293.66 $345.05

$420.58 $494.19 $297.43 $349.48

$425.92 $521.75 $301.20 $368.97

$433.92 $531.55 $306.85 $375.90

$441.58 $540.94 $312.27 $382.54

$452.24 $554.00 $319.82 $391.77

$465.58 $570.33 $329.24 $403.32

$481.24 $589.52 $340.32 $416.89

$499.90 $612.38 $353.52 $433.06

$520.90 $638.10 $368.37 $451.25

$544.89 $667.49 $385.33 $472.03

$568.56 $696.48 $402.07 $492.53

$595.22 $818.42 $420.92 $578.77

$621.55 $854.62 $439.54 $604.37

$650.54 $894.49 $460.04 $632.56

$679.87 $934.82 $480.78 $661.08

$711.53 $978.35 $503.17 $691.86

$743.19 $1,021.88 $525.56 $722.65

$777.51 $1,069.08 $549.84 $756.03

$812.17 $1,116.74 $574.35 $789.73

$849.17 $1,167.61 $600.51 $825.70

$867.50 $1,192.81 $613.47 $843.52

$904.49 $1,243.67 $639.63 $879.49

$936.48 $1,287.66 $662.26 $910.60

$957.48 $1,316.53 $677.10 $931.02

$983.81 $1,352.74 $695.72 $956.62

$999.80 $1,374.73 $707.04 $972.17

$999.80 $1,374.73 $707.04 $972.17

33871PA0110006

KE 670 WPR GMC

8


#NAME?


$2,500

30%

$7,150

No


No


#NAME?


$6,850

50%

$7,150

33871PA0110010

KE 670 WPR GMC

8



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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65+

33871PA0100020 33871PA0100021


$291.28 $291.28 $278.46 $278.46

$458.71 $516.05 $438.53 $493.34

$458.71 $516.05 $438.53 $493.34

$458.71 $516.05 $438.53 $493.34

$458.71 $516.05 $438.53 $493.34

$460.55 $518.12 $440.28 $495.32

$469.72 $528.44 $449.05 $505.18

$480.73 $540.82 $459.58 $517.02

$498.62 $560.95 $476.68 $536.26

$513.30 $577.46 $490.71 $552.05

$520.64 $611.75 $497.73 $584.83

$531.65 $624.69 $508.25 $597.20

$542.66 $637.62 $518.78 $609.56

$549.54 $645.71 $525.36 $617.29

$556.88 $654.33 $532.37 $625.54

$560.55 $658.64 $535.88 $629.66

$564.22 $662.95 $539.39 $633.78

$567.89 $667.27 $542.90 $637.90

$571.56 $671.58 $546.40 $642.03

$578.90 $680.20 $553.42 $650.27

$586.23 $718.14 $560.44 $686.54

$597.24 $731.62 $570.96 $699.43

$607.79 $744.55 $581.05 $711.78

$622.47 $762.53 $595.08 $728.97

$640.82 $785.01 $612.62 $750.46

$662.38 $811.42 $633.23 $775.71

$688.07 $842.88 $657.79 $805.79

$716.97 $878.29 $685.42 $839.64

$750.00 $918.74 $716.99 $878.31

$782.56 $958.64 $748.13 $916.46

$819.26 $1,126.48 $783.21 $1,076.91

$855.50 $1,176.31 $817.85 $1,124.55

$895.41 $1,231.18 $856.00 $1,177.01

$935.77 $1,286.69 $894.60 $1,230.07

$979.35 $1,346.61 $936.26 $1,287.35

$1,022.93 $1,406.53 $977.92 $1,344.63

$1,070.18 $1,471.49 $1,023.08 $1,406.74

$1,117.88 $1,537.09 $1,068.69 $1,469.45

$1,168.80 $1,607.10 $1,117.37 $1,536.38

$1,194.03 $1,641.79 $1,141.49 $1,569.54

$1,244.95 $1,711.80 $1,190.16 $1,636.47

$1,288.98 $1,772.35 $1,232.26 $1,694.36

$1,317.88 $1,812.09 $1,259.89 $1,732.35

$1,354.12 $1,861.91 $1,294.53 $1,779.98

$1,376.13 $1,892.19 $1,315.58 $1,808.92

$1,376.13 $1,892.19 $1,315.58 $1,808.92

KE 670 WPR GMC

8


Yes

33871PA0100021

KE 670 WPR GMC

8


#NAME?


$0

0%

$4,000

Yes

#NAME?


$0

0%

$3,000

33871PA0100020

$10/$20 $20/$40

Page Number: 10 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0100022 33871PA0100023


$229.72 $229.72 $237.17 $237.17

$361.76 $406.98 $373.49 $420.18

$361.76 $406.98 $373.49 $420.18

$361.76 $406.98 $373.49 $420.18

$361.76 $406.98 $373.49 $420.18

$363.20 $408.60 $374.98 $421.86

$370.44 $416.74 $382.45 $430.26

$379.12 $426.51 $391.42 $440.35

$393.23 $442.38 $405.98 $456.73

$404.81 $455.41 $417.94 $470.18

$410.59 $482.45 $423.91 $498.10

$419.28 $492.65 $432.88 $508.63

$427.96 $502.85 $441.84 $519.16

$433.38 $509.23 $447.44 $525.74

$439.17 $516.03 $453.42 $532.77

$442.07 $519.43 $456.41 $536.28

$444.96 $522.83 $459.39 $539.79

$447.85 $526.23 $462.38 $543.30

$450.75 $529.63 $465.37 $546.81

$456.54 $536.43 $471.35 $553.83

$462.32 $566.35 $477.32 $584.72

$471.01 $576.98 $486.28 $595.70

$479.33 $587.18 $494.88 $606.22

$490.90 $601.36 $506.83 $620.86

$505.37 $619.08 $521.77 $639.16

$522.38 $639.91 $539.32 $660.67

$542.63 $664.73 $560.24 $686.29

$565.43 $692.65 $583.77 $715.11

$591.47 $724.55 $610.66 $748.05

$617.16 $756.02 $637.17 $780.54

$646.10 $888.38 $667.05 $917.20

$674.68 $927.68 $696.56 $957.77

$706.15 $970.95 $729.05 $1,002.45

$737.98 $1,014.73 $761.92 $1,047.64

$772.35 $1,061.98 $797.40 $1,096.43

$806.72 $1,109.24 $832.88 $1,145.22

$843.98 $1,160.47 $871.35 $1,198.11

$881.60 $1,212.20 $910.20 $1,251.52

$921.76 $1,267.41 $951.65 $1,308.52

$941.65 $1,294.77 $972.20 $1,336.77

$981.81 $1,349.98 $1,013.65 $1,393.77

$1,016.54 $1,397.74 $1,049.51 $1,443.07

$1,039.33 $1,429.07 $1,073.04 $1,475.43

$1,067.90 $1,468.37 $1,102.54 $1,516.00

$1,085.27 $1,492.24 $1,120.47 $1,540.65

$1,085.27 $1,492.24 $1,120.47 $1,540.65

Yes

33871PA0100023

KE 670 WPR GMC

8


#NAME?


$1,000

10%

$5,500

Yes

#NAME?


$0

0%

$7,150

33871PA0100022

KE 670 WPR GMC

8


$30/$60 $25 no ded/$50 no ded

Page Number: 11 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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65+

33871PA0100024 33871PA0100025


$203.16 $203.16 $193.21 $193.21

$319.93 $359.92 $304.27 $342.30

$319.93 $359.92 $304.27 $342.30

$319.93 $359.92 $304.27 $342.30

$319.93 $359.92 $304.27 $342.30

$321.21 $361.36 $305.49 $343.67

$327.61 $368.56 $311.57 $350.52

$335.29 $377.20 $318.87 $358.73

$347.77 $391.24 $330.74 $372.08

$358.01 $402.76 $340.48 $383.04

$363.12 $426.67 $345.34 $405.78

$370.80 $435.69 $352.65 $414.36

$378.48 $444.72 $359.95 $422.94

$383.28 $450.35 $364.51 $428.30

$388.40 $456.37 $369.38 $434.02

$390.96 $459.38 $371.82 $436.88

$393.52 $462.38 $374.25 $439.74

$396.08 $465.39 $376.68 $442.60

$398.64 $468.40 $379.12 $445.46

$403.76 $474.41 $383.99 $451.18

$408.87 $500.87 $388.86 $476.35

$416.55 $510.28 $396.16 $485.29

$423.91 $519.29 $403.16 $493.87

$434.15 $531.83 $412.89 $505.79

$446.95 $547.51 $425.06 $520.70

$461.98 $565.93 $439.36 $538.22

$479.90 $587.88 $456.40 $559.09

$500.06 $612.57 $475.57 $582.58

$523.09 $640.79 $497.48 $609.41

$545.81 $668.61 $519.08 $635.88

$571.40 $785.68 $543.42 $747.21

$596.68 $820.43 $567.46 $780.26

$624.51 $858.70 $593.93 $816.66

$652.66 $897.41 $620.71 $853.47

$683.06 $939.20 $649.61 $893.22

$713.45 $981.00 $678.52 $932.96

$746.40 $1,026.31 $709.86 $976.06

$779.68 $1,072.06 $741.50 $1,019.57

$815.19 $1,120.89 $775.28 $1,066.00

$832.79 $1,145.08 $792.01 $1,089.01

$868.30 $1,193.91 $825.78 $1,135.45

$899.01 $1,236.14 $854.99 $1,175.62

$919.17 $1,263.86 $874.16 $1,201.97

$944.44 $1,298.61 $898.20 $1,235.03

$959.79 $1,319.72 $912.81 $1,255.11

$959.79 $1,319.72 $912.81 $1,255.11

Yes

33871PA0100025

KE 670 WPR GMC

8


#NAME?


$2,750

50%

$7,150

Yes

#NAME?


$2,500

30%

$7,150

33871PA0100024

KE 670 WPR GMC

8



Page Number: 12 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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65+

33871PA0100026 33871PA0110011


$144.00 $144.00 $304.76 $304.76

$226.77 $255.11 $479.93 $539.93

$226.77 $255.11 $479.93 $539.93

$226.77 $255.11 $479.93 $539.93

$226.77 $255.11 $479.93 $539.93

$227.67 $256.13 $481.85 $542.09

$232.21 $261.24 $491.45 $552.88

$237.65 $267.36 $502.97 $565.84

$246.50 $277.31 $521.69 $586.90

$253.75 $285.47 $537.05 $604.18

$257.38 $302.42 $544.73 $640.05

$262.82 $308.82 $556.24 $653.59

$268.27 $315.21 $567.76 $667.12

$271.67 $319.21 $574.96 $675.58

$275.30 $323.47 $582.64 $684.60

$277.11 $325.60 $586.48 $689.11

$278.92 $327.73 $590.32 $693.63

$280.74 $329.87 $594.16 $698.14

$282.55 $332.00 $598.00 $702.65

$286.18 $336.26 $605.68 $711.67

$289.81 $355.01 $613.36 $751.36

$295.25 $361.68 $624.87 $765.47

$300.47 $368.07 $635.91 $778.99

$307.72 $376.96 $651.27 $797.81

$316.79 $388.07 $670.47 $821.32

$327.45 $401.13 $693.03 $848.96

$340.15 $416.68 $719.90 $881.88

$354.44 $434.18 $750.14 $918.92

$370.76 $454.19 $784.69 $961.25

$386.86 $473.91 $818.77 $1,002.99

$405.01 $556.88 $857.16 $1,178.60

$422.92 $581.52 $895.08 $1,230.73

$442.65 $608.64 $936.83 $1,288.14

$462.60 $636.08 $979.07 $1,346.22

$484.15 $665.70 $1,024.66 $1,408.91

$505.69 $695.32 $1,070.25 $1,471.60

$529.05 $727.44 $1,119.69 $1,539.57

$552.63 $759.87 $1,169.60 $1,608.20

$577.80 $794.48 $1,222.87 $1,681.45

$590.27 $811.63 $1,249.27 $1,717.75

$615.45 $846.24 $1,302.54 $1,791.00

$637.21 $876.17 $1,348.62 $1,854.35

$651.50 $895.81 $1,378.85 $1,895.92

$669.42 $920.45 $1,416.77 $1,948.05

$680.30 $935.41 $1,439.79 $1,979.73

$680.30 $935.41 $1,439.79 $1,979.73

Yes

33871PA0110011

KE 670 WPR GMC

8


#NAME?


$0

0%

$3,000

Yes

#NAME?


$6,850

50%

$7,150

33871PA0100026

KE 670 WPR GMC

8


$10/$20$50 no ded/$100 no ded

Page Number: 13 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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61

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64

65+

33871PA0110012 33871PA0110013


$291.35 $291.35 $239.95 $239.95

$458.82 $516.17 $377.87 $425.10

$458.82 $516.17 $377.87 $425.10

$458.82 $516.17 $377.87 $425.10

$458.82 $516.17 $377.87 $425.10

$460.65 $518.23 $379.38 $426.80

$469.83 $528.56 $386.94 $435.30

$480.84 $540.94 $396.01 $445.51

$498.73 $561.07 $410.74 $462.08

$513.41 $577.59 $422.83 $475.69

$520.76 $611.89 $428.88 $503.93

$531.77 $624.83 $437.95 $514.59

$542.78 $637.77 $447.02 $525.25

$549.66 $645.85 $452.69 $531.91

$557.00 $654.48 $458.73 $539.01

$560.67 $658.79 $461.75 $542.56

$564.34 $663.10 $464.78 $546.11

$568.01 $667.42 $467.80 $549.66

$571.68 $671.73 $470.82 $553.22

$579.03 $680.35 $476.87 $560.32

$586.37 $718.30 $482.91 $591.57

$597.38 $731.79 $491.98 $602.68

$607.93 $744.72 $500.67 $613.33

$622.61 $762.70 $512.77 $628.14

$640.97 $785.18 $527.88 $646.65

$662.53 $811.60 $545.64 $668.41

$688.22 $843.07 $566.80 $694.33

$717.13 $878.48 $590.61 $723.49

$750.16 $918.95 $617.81 $756.82

$782.74 $958.86 $644.64 $789.69

$819.44 $1,126.74 $674.87 $927.95

$855.69 $1,176.58 $704.72 $968.99

$895.61 $1,231.46 $737.60 $1,014.20

$935.98 $1,286.98 $770.85 $1,059.92

$979.57 $1,346.91 $806.75 $1,109.28

$1,023.16 $1,406.84 $842.64 $1,158.64

$1,070.42 $1,471.82 $881.56 $1,212.15

$1,118.13 $1,537.43 $920.86 $1,266.19

$1,169.06 $1,607.46 $962.81 $1,323.86

$1,194.30 $1,642.16 $983.59 $1,352.43

$1,245.23 $1,712.19 $1,025.53 $1,410.11

$1,289.27 $1,772.75 $1,061.81 $1,459.99

$1,318.18 $1,812.49 $1,085.61 $1,492.72

$1,354.42 $1,862.33 $1,115.46 $1,533.76

$1,376.45 $1,892.61 $1,133.60 $1,558.70

$1,376.45 $1,892.61 $1,133.60 $1,558.70

Yes

33871PA0110013

KE 670 WPR GMC

8


#NAME?


$0

0%

$7,150

Yes

#NAME?


$0

0%

$4,000

33871PA0110012

KE 670 WPR GMC

8


$20/$40 $30/$60

Page Number: 14 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110014 33871PA0110016


$246.94 $246.94 $212.20 $212.20

$388.89 $437.50 $334.17 $375.94

$388.89 $437.50 $334.17 $375.94

$388.89 $437.50 $334.17 $375.94

$388.89 $437.50 $334.17 $375.94

$390.44 $439.25 $335.51 $377.45

$398.22 $448.00 $342.19 $384.97

$407.55 $458.50 $350.21 $393.99

$422.72 $475.56 $363.25 $408.65

$435.17 $489.56 $373.94 $420.68

$441.39 $518.63 $379.29 $445.66

$450.72 $529.60 $387.31 $455.08

$460.05 $540.56 $395.33 $464.51

$465.89 $547.42 $400.34 $470.40

$472.11 $554.73 $405.69 $476.68

$475.22 $558.38 $408.36 $479.82

$478.33 $562.04 $411.03 $482.96

$481.44 $565.70 $413.71 $486.10

$484.55 $569.35 $416.38 $489.24

$490.78 $576.66 $421.73 $495.53

$497.00 $608.82 $427.07 $523.16

$506.33 $620.26 $435.09 $532.99

$515.28 $631.21 $442.78 $542.40

$527.72 $646.46 $453.47 $555.50

$543.28 $665.51 $466.84 $571.88

$561.55 $687.90 $482.54 $591.12

$583.33 $714.58 $501.26 $614.04

$607.83 $744.59 $522.31 $639.83

$635.83 $778.89 $546.37 $669.31

$663.44 $812.72 $570.10 $698.37

$694.55 $955.01 $596.83 $820.64

$725.28 $997.25 $623.23 $856.94

$759.11 $1,043.77 $652.30 $896.92

$793.33 $1,090.83 $681.71 $937.35

$830.28 $1,141.63 $713.46 $981.00

$867.22 $1,192.43 $745.20 $1,024.66

$907.27 $1,247.50 $779.62 $1,071.98

$947.72 $1,303.11 $814.38 $1,119.77

$990.89 $1,362.47 $851.47 $1,170.77

$1,012.27 $1,391.88 $869.85 $1,196.04

$1,055.44 $1,451.23 $906.94 $1,247.05

$1,092.77 $1,502.56 $939.02 $1,291.16

$1,117.27 $1,536.25 $960.08 $1,320.11

$1,148.00 $1,578.49 $986.48 $1,356.41

$1,166.66 $1,604.16 $1,002.51 $1,378.46

$1,166.66 $1,604.16 $1,002.51 $1,378.46

Yes

33871PA0110016

KE 670 WPR GMC

8


#NAME?


$2,500

30%

$7,150

Yes

#NAME?


$1,000

10%

$5,500

33871PA0110014

KE 670 WPR GMC

8



Page Number: 15 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

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OOP Maximum =>


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65+

33871PA0110019 33871PA0110020


$201.76 $201.76 $150.23 $150.23

$317.72 $357.44 $236.58 $266.16

$317.72 $357.44 $236.58 $266.16

$317.72 $357.44 $236.58 $266.16

$317.72 $357.44 $236.58 $266.16

$319.00 $358.87 $237.53 $267.22

$325.35 $366.02 $242.26 $272.54

$332.98 $374.60 $247.94 $278.93

$345.37 $388.54 $257.17 $289.31

$355.53 $399.98 $264.74 $297.83

$360.62 $423.73 $268.52 $315.51

$368.24 $432.69 $274.20 $322.18

$375.87 $441.65 $279.88 $328.86

$380.63 $447.25 $283.43 $333.03

$385.72 $453.22 $287.21 $337.47

$388.26 $456.20 $289.10 $339.70

$390.80 $459.19 $291.00 $341.92

$393.34 $462.18 $292.89 $344.15

$395.88 $465.16 $294.78 $346.37

$400.97 $471.14 $298.57 $350.82

$406.05 $497.41 $302.35 $370.38

$413.68 $506.75 $308.03 $377.34

$420.99 $515.71 $313.47 $384.00

$431.15 $528.16 $321.04 $393.28

$443.86 $543.73 $330.51 $404.87

$458.79 $562.02 $341.63 $418.49

$476.59 $583.82 $354.87 $434.72

$496.60 $608.34 $369.78 $452.98

$519.48 $636.36 $386.81 $473.85

$542.04 $664.00 $403.61 $494.42

$567.46 $780.25 $422.54 $580.99

$592.56 $814.77 $441.23 $606.69

$620.20 $852.77 $461.81 $634.99

$648.16 $891.22 $482.63 $663.61

$678.34 $932.72 $505.10 $694.52

$708.53 $974.22 $527.58 $725.42

$741.25 $1,019.22 $551.95 $758.93

$774.29 $1,064.66 $576.55 $792.76

$809.56 $1,113.15 $602.81 $828.87

$827.04 $1,137.18 $615.82 $846.76

$862.30 $1,185.67 $642.09 $882.87

$892.81 $1,227.61 $664.80 $914.10

$912.82 $1,255.13 $679.70 $934.59

$937.92 $1,289.64 $698.39 $960.29

$953.16 $1,310.61 $709.74 $975.90

$953.16 $1,310.61 $709.74 $975.90

Yes

33871PA0110020

Yes

$6,850


50%

#NAME?

$7,150


8

KE 670 WPR GMC


#NAME?


$2,750

50%

$7,150

33871PA0110019

KE 670 WPR GMC

8



Page Number: 16 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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61

62

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64

65+

33871PA0100044 33871PA0100045


$205.44 $205.44 $163.08 $163.08

$323.53 $363.97 $256.81 $288.92

$323.53 $363.97 $256.81 $288.92

$323.53 $363.97 $256.81 $288.92

$323.53 $363.97 $256.81 $288.92

$324.83 $365.43 $257.84 $290.07

$331.30 $372.71 $262.98 $295.85

$339.06 $381.44 $269.14 $302.78

$351.68 $395.64 $279.16 $314.05

$362.03 $407.29 $287.38 $323.30

$367.21 $431.47 $291.48 $342.49

$374.97 $440.59 $297.65 $349.74

$382.74 $449.72 $303.81 $356.98

$387.59 $455.42 $307.66 $361.50

$392.77 $461.50 $311.77 $366.33

$395.36 $464.54 $313.83 $368.75

$397.94 $467.58 $315.88 $371.16

$400.53 $470.63 $317.94 $373.57

$403.12 $473.67 $319.99 $375.99

$408.30 $479.75 $324.10 $380.82

$413.47 $506.51 $328.21 $402.06

$421.24 $516.02 $334.37 $409.61

$428.68 $525.13 $340.28 $416.84

$439.03 $537.82 $348.50 $426.91

$451.97 $553.67 $358.77 $439.49

$467.18 $572.30 $370.84 $454.28

$485.30 $594.49 $385.22 $471.90

$505.68 $619.46 $401.40 $491.72

$528.97 $647.99 $419.89 $514.37

$551.95 $676.13 $438.13 $536.70

$577.83 $794.51 $458.67 $630.67

$603.39 $829.66 $478.96 $658.57

$631.53 $868.36 $501.30 $689.29

$660.01 $907.51 $523.90 $720.36

$690.74 $949.77 $548.30 $753.91

$721.48 $992.03 $572.70 $787.46

$754.80 $1,037.85 $599.15 $823.83

$788.45 $1,084.12 $625.86 $860.55

$824.36 $1,133.49 $654.36 $899.75

$842.15 $1,157.96 $668.49 $919.17

$878.07 $1,207.34 $696.99 $958.37

$909.13 $1,250.05 $721.65 $992.27

$929.51 $1,278.07 $737.83 $1,014.51

$955.07 $1,313.22 $758.12 $1,042.41

$970.59 $1,334.57 $770.43 $1,059.36

$970.59 $1,334.57 $770.43 $1,059.36

33871PA0100044

KE 670 WPR GMC

8


Yes

$0


0%/20%/30%

#NAME?

$7,150

$15/$40, $30/$60, $45/$80

Yes

$0/$5500/$5500


0%/5%/10%

#NAME?

33871PA0100045

KE 670 WPR GMC

8



$7,150

Page Number: 17 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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64

65+

33871PA0100035 33871PA0100037


$235.43 $235.43 $184.95 $184.95

$370.76 $417.10 $291.26 $327.67

$370.76 $417.10 $291.26 $327.67

$370.76 $417.10 $291.26 $327.67

$370.76 $417.10 $291.26 $327.67

$372.24 $418.77 $292.43 $328.98

$379.65 $427.11 $298.25 $335.53

$388.55 $437.12 $305.24 $343.40

$403.01 $453.39 $316.60 $356.18

$414.88 $466.74 $325.92 $366.66

$420.81 $494.45 $330.58 $388.43

$429.71 $504.90 $337.57 $396.65

$438.60 $515.36 $344.56 $404.86

$444.17 $521.89 $348.93 $410.00

$450.10 $528.86 $353.59 $415.47

$453.06 $532.35 $355.92 $418.21

$456.03 $535.83 $358.25 $420.95

$459.00 $539.32 $360.58 $423.68

$461.96 $542.80 $362.91 $426.42

$467.89 $549.78 $367.57 $431.90

$473.83 $580.44 $372.23 $455.99

$482.72 $591.34 $379.22 $464.55

$491.25 $601.78 $385.92 $472.75

$503.12 $616.32 $395.24 $484.17

$517.95 $634.48 $406.89 $498.44

$535.37 $655.83 $420.58 $515.21

$556.13 $681.26 $436.89 $535.19

$579.49 $709.88 $455.24 $557.67

$606.19 $742.58 $476.21 $583.36

$632.51 $774.82 $496.89 $608.69

$662.17 $910.48 $520.19 $715.27

$691.46 $950.76 $543.20 $746.91

$723.72 $995.11 $568.54 $781.75

$756.34 $1,039.97 $594.17 $816.99

$791.56 $1,088.40 $621.84 $855.04

$826.79 $1,136.83 $649.51 $893.08

$864.97 $1,189.34 $679.51 $934.33

$903.53 $1,242.36 $709.81 $975.98

$944.69 $1,298.94 $742.14 $1,020.44

$965.08 $1,326.98 $758.16 $1,042.46

$1,006.23 $1,383.57 $790.49 $1,086.92

$1,041.82 $1,432.51 $818.45 $1,125.36

$1,065.18 $1,464.62 $836.80 $1,150.59

$1,094.47 $1,504.90 $859.81 $1,182.23

$1,112.27 $1,529.37 $873.78 $1,201.46

$1,112.27 $1,529.37 $873.78 $1,201.46

33871PA0100035

KE 670 WPR GMC

8


No

#NAME? #NAME?

$2,000 $3,500

$3,500 $7,150

No

0%


0%


33871PA0100037

KE 670 WPR GMC

8



Page Number: 18 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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65+

33871PA0100036 33871PA0110007


$195.94 $195.94 $193.16 $193.16

$308.57 $347.14 $304.18 $342.21

$308.57 $347.14 $304.18 $342.21

$308.57 $347.14 $304.18 $342.21

$308.57 $347.14 $304.18 $342.21

$309.80 $348.52 $305.40 $343.57

$315.97 $355.47 $311.48 $350.42

$323.38 $363.80 $318.78 $358.63

$335.41 $377.34 $330.65 $371.98

$345.29 $388.45 $340.38 $382.93

$350.22 $411.51 $345.25 $405.67

$357.63 $420.21 $352.55 $414.24

$365.03 $428.91 $359.85 $422.82

$369.66 $434.35 $364.41 $428.18

$374.60 $440.15 $369.28 $433.90

$377.07 $443.05 $371.71 $436.76

$379.54 $445.95 $374.15 $439.62

$382.00 $448.86 $376.58 $442.48

$384.47 $451.76 $379.01 $445.34

$389.41 $457.56 $383.88 $451.06

$394.35 $483.08 $388.75 $476.21

$401.75 $492.15 $396.05 $485.16

$408.85 $500.84 $403.04 $493.73

$418.72 $512.94 $412.78 $505.65

$431.07 $528.06 $424.94 $520.56

$445.57 $545.82 $439.24 $538.07

$462.85 $566.99 $456.27 $558.94

$482.29 $590.80 $475.44 $582.41

$504.50 $618.02 $497.34 $609.24

$526.41 $644.86 $518.94 $635.70

$551.10 $757.76 $543.27 $747.00

$575.48 $791.28 $567.30 $780.04

$602.32 $828.19 $593.77 $816.43

$629.47 $865.53 $620.53 $853.23

$658.79 $905.83 $649.43 $892.97

$688.10 $946.14 $678.33 $932.70

$719.88 $989.84 $709.66 $975.78

$751.97 $1,033.97 $741.29 $1,019.28

$786.23 $1,081.06 $775.06 $1,065.71

$803.20 $1,104.40 $791.79 $1,088.71

$837.45 $1,151.49 $825.55 $1,135.13

$867.07 $1,192.22 $854.75 $1,175.29

$886.51 $1,218.95 $873.92 $1,201.64

$910.89 $1,252.47 $897.95 $1,234.68

$925.70 $1,272.83 $912.54 $1,254.75

$925.70 $1,272.83 $912.54 $1,254.75


KE 670 WPR GMC

No

#NAME? #NAME?

$4,250 $3,500

$7,150 $7,150

No


0% 0%

33871PA0110007

8

33871PA0100036

KE 670 WPR GMC

8



Page Number: 19 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0110008 33871PA0110009


$204.63 $204.63 $201.18 $201.18

$322.25 $362.53 $316.82 $356.42

$322.25 $362.53 $316.82 $356.42

$322.25 $362.53 $316.82 $356.42

$322.25 $362.53 $316.82 $356.42

$323.54 $363.98 $318.09 $357.85

$329.98 $371.23 $324.42 $364.98

$337.72 $379.93 $332.03 $373.53

$350.28 $394.07 $344.38 $387.43

$360.60 $405.67 $354.52 $398.84

$365.75 $429.76 $359.59 $422.52

$373.49 $438.85 $367.19 $431.45

$381.22 $447.93 $374.80 $440.39

$386.05 $453.61 $379.55 $445.97

$391.21 $459.67 $384.62 $451.93

$393.79 $462.70 $387.15 $454.91

$396.37 $465.73 $389.69 $457.88

$398.94 $468.76 $392.22 $460.86

$401.52 $471.79 $394.76 $463.84

$406.68 $477.85 $399.83 $469.80

$411.83 $504.50 $404.90 $496.00

$419.57 $513.97 $412.50 $505.31

$426.98 $523.05 $419.79 $514.24

$437.29 $535.68 $429.93 $526.66

$450.18 $551.47 $442.60 $542.18

$465.33 $570.03 $457.49 $560.42

$483.37 $592.13 $475.23 $582.16

$503.67 $617.00 $495.19 $606.61

$526.88 $645.42 $518.00 $634.55

$549.76 $673.45 $540.50 $662.11

$575.54 $791.36 $565.84 $778.03

$600.99 $826.37 $590.87 $812.45

$629.03 $864.92 $618.43 $850.35

$657.39 $903.91 $646.31 $888.68

$688.00 $946.00 $676.41 $930.07

$718.61 $988.10 $706.51 $971.45

$751.81 $1,033.73 $739.14 $1,016.32

$785.32 $1,079.82 $772.09 $1,061.63

$821.09 $1,129.00 $807.26 $1,109.98

$838.81 $1,153.37 $824.68 $1,133.94

$874.58 $1,202.55 $859.85 $1,182.29

$905.52 $1,245.09 $890.27 $1,224.12

$925.82 $1,273.00 $910.23 $1,251.56

$951.28 $1,308.01 $935.25 $1,285.97

$966.75 $1,329.28 $950.46 $1,306.88

$966.75 $1,329.28 $950.46 $1,306.88


8

KE 670 WPR GMC

50%



NoNo

0%

#NAME?

$4,250 $2,750


#NAME?

33871PA0110009


KE 670 WPR GMC

33871PA0110008

8

$7,150


$7,150

Page Number: 20 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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65+

33871PA0100047 33871PA0100049


$236.00 $236.00 $185.53 $185.53

$371.66 $418.12 $292.17 $328.69

$371.66 $418.12 $292.17 $328.69

$371.66 $418.12 $292.17 $328.69

$371.66 $418.12 $292.17 $328.69

$373.15 $419.79 $293.33 $330.00

$380.58 $428.15 $299.18 $336.58

$389.50 $438.19 $306.19 $344.46

$403.99 $454.49 $317.58 $357.28

$415.89 $467.87 $326.93 $367.80

$421.83 $495.65 $331.61 $389.64

$430.75 $506.14 $338.62 $397.88

$439.67 $516.62 $345.63 $406.12

$445.25 $523.17 $350.02 $411.27

$451.20 $530.15 $354.69 $416.76

$454.17 $533.65 $357.03 $419.51

$457.14 $537.14 $359.36 $422.25

$460.11 $540.64 $361.70 $425.00

$463.09 $544.13 $364.04 $427.75

$469.03 $551.12 $368.71 $433.24

$474.98 $581.85 $373.39 $457.40

$483.90 $592.78 $380.40 $465.99

$492.45 $603.25 $387.12 $474.22

$504.34 $617.82 $396.47 $485.68

$519.21 $636.03 $408.16 $499.99

$536.68 $657.43 $421.89 $516.81

$557.49 $682.93 $438.25 $536.86

$580.90 $711.61 $456.66 $559.40

$607.66 $744.39 $477.69 $585.17

$634.05 $776.71 $498.44 $610.58

$663.78 $912.70 $521.81 $717.49

$693.15 $953.08 $544.89 $749.22

$725.48 $997.54 $570.31 $784.17

$758.19 $1,042.51 $596.02 $819.53

$793.49 $1,091.05 $623.78 $857.69

$828.80 $1,139.60 $651.53 $895.85

$867.08 $1,192.24 $681.62 $937.23

$905.74 $1,245.39 $712.01 $979.01

$946.99 $1,302.11 $744.44 $1,023.60

$967.43 $1,330.22 $760.51 $1,045.70

$1,008.68 $1,386.94 $792.94 $1,090.29

$1,044.36 $1,436.00 $820.99 $1,128.86

$1,067.78 $1,468.20 $839.39 $1,154.17

$1,097.14 $1,508.57 $862.47 $1,185.90

$1,114.98 $1,533.10 $876.50 $1,205.19

$1,114.98 $1,533.10 $876.50 $1,205.19

33871PA0100047

KE 670 WPR GMC

33871PA0100049

KE 670 WPR GMC


Yes Yes

#NAME?

$2,000

8


8


0% 0%


$3,500


#NAME?

$3,500 $7,150

Page Number: 21 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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65+

33871PA0100048 33871PA0110015


$196.51 $196.51 $242.98 $242.98

$309.47 $348.15 $382.65 $430.48

$309.47 $348.15 $382.65 $430.48

$309.47 $348.15 $382.65 $430.48

$309.47 $348.15 $382.65 $430.48

$310.71 $349.55 $384.18 $432.21

$316.90 $356.51 $391.84 $440.82

$324.32 $364.86 $401.02 $451.15

$336.39 $378.44 $415.94 $467.94

$346.30 $389.58 $428.19 $481.71

$351.25 $412.72 $434.31 $510.32

$358.68 $421.44 $443.49 $521.11

$366.10 $430.17 $452.68 $531.90

$370.74 $435.63 $458.42 $538.64

$375.70 $441.44 $464.54 $545.84

$378.17 $444.35 $467.60 $549.43

$380.65 $447.26 $470.66 $553.03

$383.12 $450.17 $473.72 $556.63

$385.60 $453.08 $476.79 $560.22

$390.55 $458.90 $482.91 $567.42

$395.50 $484.49 $489.03 $599.06

$402.93 $493.59 $498.21 $610.31

$410.05 $502.31 $507.02 $621.09

$419.95 $514.44 $519.26 $636.09

$432.33 $529.60 $534.57 $654.84

$446.87 $547.42 $552.55 $676.88

$464.20 $568.65 $573.98 $703.13

$483.70 $592.53 $598.09 $732.66

$505.98 $619.83 $625.64 $766.41

$527.96 $646.75 $652.81 $799.69

$552.71 $759.98 $683.42 $939.70

$577.16 $793.60 $713.65 $981.27

$604.09 $830.62 $746.94 $1,027.04

$631.32 $868.06 $780.61 $1,073.34

$660.72 $908.49 $816.96 $1,123.33

$690.12 $948.91 $853.32 $1,173.31

$721.99 $992.74 $892.73 $1,227.50

$754.18 $1,036.99 $932.53 $1,282.22

$788.53 $1,084.23 $975.00 $1,340.63

$805.55 $1,107.63 $996.05 $1,369.56

$839.90 $1,154.86 $1,038.52 $1,427.97

$869.61 $1,195.71 $1,075.26 $1,478.48

$889.11 $1,222.52 $1,099.36 $1,511.62

$913.55 $1,256.14 $1,129.59 $1,553.19

$928.41 $1,276.56 $1,147.95 $1,578.44

$928.41 $1,276.56 $1,147.95 $1,578.44

Yes

33871PA0110015

0%


$3,500

#NAME?


$2,000

KE 670 WPR GMC

8


KE 670 WPR GMC

33871PA0100048

8


#NAME?

$4,250

0%



Yes

$7,150

Page Number: 22 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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64

65+

33871PA0110017 33871PA0110018


$193.73 $193.73 $205.20 $205.20

$305.09 $343.22 $323.15 $363.55

$305.09 $343.22 $323.15 $363.55

$305.09 $343.22 $323.15 $363.55

$305.09 $343.22 $323.15 $363.55

$306.31 $344.60 $324.45 $365.00

$312.41 $351.46 $330.91 $372.27

$319.73 $359.70 $338.66 $381.00

$331.63 $373.08 $351.27 $395.18

$341.39 $384.07 $361.61 $406.81

$346.27 $406.87 $366.78 $430.96

$353.60 $415.48 $374.53 $440.08

$360.92 $424.08 $382.29 $449.19

$365.49 $429.46 $387.14 $454.89

$370.38 $435.19 $392.31 $460.96

$372.82 $438.06 $394.89 $464.00

$375.26 $440.93 $397.48 $467.04

$377.70 $443.79 $400.06 $470.07

$380.14 $446.66 $402.65 $473.11

$385.02 $452.40 $407.82 $479.19

$389.90 $477.63 $412.99 $505.91

$397.22 $486.60 $420.75 $515.41

$404.24 $495.19 $428.18 $524.52

$414.00 $507.15 $438.52 $537.19

$426.21 $522.10 $451.44 $553.02

$440.55 $539.67 $466.63 $571.63

$457.63 $560.60 $484.73 $593.79

$476.85 $584.14 $505.09 $618.73

$498.82 $611.05 $528.36 $647.23

$520.48 $637.59 $551.30 $675.34

$544.89 $749.22 $577.15 $793.58

$568.99 $782.36 $602.68 $828.69

$595.53 $818.85 $630.79 $867.34

$622.38 $855.77 $659.23 $906.44

$651.36 $895.62 $689.93 $948.66

$680.34 $935.47 $720.63 $990.87

$711.77 $978.68 $753.92 $1,036.63

$743.50 $1,022.31 $787.52 $1,082.85

$777.36 $1,068.87 $823.39 $1,132.17

$794.14 $1,091.94 $841.17 $1,156.60

$828.01 $1,138.51 $877.04 $1,205.93

$857.29 $1,178.78 $908.06 $1,248.58

$876.52 $1,205.21 $928.42 $1,276.58

$900.62 $1,238.35 $953.95 $1,311.68

$915.26 $1,258.48 $969.45 $1,333.01

$915.26 $1,258.48 $969.45 $1,333.01

Yes Yes

33871PA0110017

0% 0%


$7,150 $7,150


#NAME? #NAME?


KE 670 WPR GMC

$3,500 $4,250

33871PA0110018

KE 670 WPR GMC

8 8


Page Number: 23 05/05/2016



33871PA0100005 319.03

33871PA0100006 303.36

33871PA0100009 255.91

33871PA0100036 308.57

33871PA0100037 291.26

33871PA0110006 333.27

33871PA0110007 304.18

33871PA0110008 322.25

33871PA0110009 316.82




33871PA0100024 319.93

33871PA0100025 304.27

33871PA0100045 256.81

33871PA0100048 309.47

33871PA0100049 292.17

33871PA0110016 334.17

33871PA0110017 305.09

33871PA0110018 323.15

33871PA0110019 317.72



Exchange HIOS Plan ID Level AreaKHPE ON 33871PA0100001 Platinum Keystone HMO Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE ON 33871PA0100002 Platinum Keystone HMO Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE ON 33871PA0100003 Gold Keystone HMO Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE ON 33871PA0100004 Gold Keystone HMO Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE ON 33871PA0100005 Silver Keystone HMO Silver Classic $2,500 $25/$50/70% Keystone Health Plan East Network 8KHPE ON 33871PA0100006 Silver Keystone HMO Silver Classic $2,750/$30/$60/50% Keystone Health Plan East Network 8KHPE ON 33871PA0100007 Bronze Keystone HMO Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8KHPE ON 33871PA0100008 Gold Keystone HMO Gold Proactive Keystone Health Plan East Network 8KHPE ON 33871PA0100009 Silver Keystone HMO Silver Proactive Keystone Health Plan East Network 8KHPE OFF 33871PA0100020 Platinum Keystone HMO Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE OFF 33871PA0100021 Platinum Keystone HMO Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE OFF 33871PA0100022 Gold Keystone HMO Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE OFF 33871PA0100023 Gold Keystone HMO Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE OFF 33871PA0100024 Silver Keystone HMO Silver Classic $2,500/$25/$50/70% Keystone Health Plan East Network 8KHPE OFF 33871PA0100025 Silver Keystone HMO Silver Classic $2,750/$30/$60/50% Keystone Health Plan East Network 8KHPE OFF 33871PA0100026 Bronze Keystone HMO Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8KHPE ON 33871PA0100035 Gold Keystone HMO Gold Classic $2,000/$40/$80/100% Keystone Health Plan East Network 8KHPE ON 33871PA0100036 Silver Keystone HMO Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8KHPE ON 33871PA0100037 Silver Keystone HMO Silver Secure $3,500 $40/$80/$600 Keystone Health Plan East Network 8KHPE OFF 33871PA0100044 Gold Keystone HMO Gold Proactive Keystone Health Plan East Network 8KHPE OFF 33871PA0100045 Silver Keystone HMO Silver Proactive Keystone Health Plan East Network 8KHPE OFF 33871PA0100047 Gold Keystone HMO Gold Classic $2,000 $40/$80/100% Keystone Health Plan East Network 8KHPE OFF 33871PA0100048 Silver Keystone HMO Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8KHPE OFF 33871PA0100049 Silver Keystone HMO Silver Secure $3,500 $40/$80/$600 Keystone Health Plan East Network 8KHPE ON 33871PA0110001 Platinum Keystone DPOS Platinum Preferred $10/$20/$100 Keystone Health Plan East Network 8KHPE ON 33871PA0110002 Platinum Keystone DPOS Platinum Preferred $20/$40/$150 Keystone Health Plan East Network 8KHPE ON 33871PA0110003 Gold Keystone DPOS Gold Preferred $30/$60/$650 Keystone Health Plan East Network 8KHPE ON 33871PA0110004 Gold Keystone DPOS Gold Classic $1,000 $25/$50/90% Keystone Health Plan East Network 8KHPE ON 33871PA0110005 Gold Keystone DPOS Gold Classic $2,000 $40/$80/100% Keystone Health Plan East Network 8KHPE ON 33871PA0110006 Silver Keystone DPOS Silver Classic $2,500/$25/$50/70% Keystone Health Plan East Network 8KHPE ON 33871PA0110007 Silver Keystone DPOS Silver Secure $3,500/$40/$80/$600 Keystone Health Plan East Network 8KHPE ON 33871PA0110008 Silver Keystone DPOS Silver Classic $4,250 $40/$80/100% Keystone Health Plan East Network 8KHPE ON 33871PA0110009 Silver Keystone DPOS Silver Classic $2,750/$30/$60/50% Keystone Health Plan East Network 8KHPE ON 33871PA0110010 Bronze Keystone DPOS Bronze Essential $6,850/$50/$100/$700 Keystone Health Plan East Network 8












Plan Design Summary


05/15/2015

RATE PAGES


Product: HMO

Effective Date of Rates: October 1, 2017 - December 31, 201733871PA0100001 33871PA0100002



Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20 $299.14 $299.14 $285.95 $285.95

21 $471.08 $529.97 $450.31 $506.60

22 $471.08 $529.97 $450.31 $506.60

23 $471.08 $529.97 $450.31 $506.60

24 $471.08 $529.97 $450.31 $506.60

25 $472.97 $532.09 $452.11 $508.63

26 $482.39 $542.69 $461.12 $518.76

27 $493.69 $555.41 $471.93 $530.92

28 $512.07 $576.07 $489.49 $550.67

29 $527.14 $593.03 $503.90 $566.88

30 $534.68 $628.25 $511.10 $600.55

31 $545.98 $641.53 $521.91 $613.24

32 $557.29 $654.81 $532.72 $625.94

33 $564.36 $663.12 $539.47 $633.88

34 $571.89 $671.97 $546.68 $642.35

35 $575.66 $676.40 $550.28 $646.58

36 $579.43 $680.83 $553.88 $650.81

37 $583.20 $685.26 $557.48 $655.04

38 $586.97 $689.69 $561.09 $659.28

39 $594.50 $698.54 $568.29 $667.74

40 $602.04 $737.50 $575.50 $704.98

41 $613.35 $751.35 $586.30 $718.22

42 $624.18 $764.62 $596.66 $730.91

43 $639.26 $783.09 $611.07 $748.56

44 $658.10 $806.17 $629.08 $770.63

45 $680.24 $833.30 $650.25 $796.55

46 $706.62 $865.61 $675.47 $827.45

47 $736.30 $901.97 $703.84 $862.20

48 $770.22 $943.52 $736.26 $901.92

49 $803.66 $984.49 $768.23 $941.08

50 $841.35 $1,156.86 $804.25 $1,105.85

51 $878.57 $1,208.03 $839.83 $1,154.77

52 $919.55 $1,264.38 $879.01 $1,208.63

53 $961.01 $1,321.38 $918.63 $1,263.12

54 $1,005.76 $1,382.92 $961.41 $1,321.94

55 $1,050.51 $1,444.45 $1,004.19 $1,380.77

56 $1,099.03 $1,511.17 $1,050.57 $1,444.54

57 $1,148.03 $1,578.54 $1,097.41 $1,508.93

58 $1,200.32 $1,650.43 $1,147.39 $1,577.66

59 $1,226.22 $1,686.06 $1,172.16 $1,611.72

60 $1,278.52 $1,757.96 $1,222.14 $1,680.45

61 $1,323.74 $1,820.14 $1,265.37 $1,739.89

62 $1,353.42 $1,860.95 $1,293.74 $1,778.90

63 $1,390.63 $1,912.12 $1,329.32 $1,827.81

64 $1,413.24 $1,943.21 $1,350.93 $1,857.53

65+ $1,413.24 $1,943.21 $1,350.93 $1,857.53

$10/$20 $20/$40


33871PA0100001

KE 670 WPR GMC

8

33871PA0100002

8

KE 670 WPR GMC


$0

0%

$3,000


$0

0%

No

#NAME?

$4,000

#NAME?


No


RATE PAGES


Product: HMO

Effective Date of Rates: October 1, 2017 - December 31, 2017



Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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63

64

65+

33871PA0100003 33871PA0100004


$235.78 $235.78 $243.45 $243.45

$371.31 $417.73 $383.39 $431.31

$371.31 $417.73 $383.39 $431.31

$371.31 $417.73 $383.39 $431.31

$371.31 $417.73 $383.39 $431.31

$372.80 $419.40 $384.92 $433.04

$380.23 $427.75 $392.59 $441.66

$389.14 $437.78 $401.79 $452.02

$403.62 $454.07 $416.74 $468.84

$415.50 $467.44 $429.01 $482.64

$421.44 $495.19 $435.15 $511.30

$430.35 $505.66 $444.35 $522.11

$439.26 $516.14 $453.55 $532.92

$444.83 $522.68 $459.30 $539.68

$450.78 $529.66 $465.43 $546.88

$453.75 $533.15 $468.50 $550.49

$456.72 $536.64 $471.57 $554.09

$459.69 $540.13 $474.64 $557.70

$462.66 $543.62 $477.70 $561.30

$468.60 $550.60 $483.84 $568.51

$474.54 $581.31 $489.97 $600.21

$483.45 $592.23 $499.17 $611.49

$491.99 $602.69 $507.99 $622.29

$503.87 $617.24 $520.26 $637.32

$518.73 $635.44 $535.59 $656.10

$536.18 $656.82 $553.61 $678.18

$556.97 $682.29 $575.08 $704.48

$580.36 $710.95 $599.24 $734.06

$607.10 $743.70 $626.84 $767.88

$633.46 $775.99 $654.06 $801.22

$663.17 $911.85 $684.73 $941.51

$692.50 $952.19 $715.02 $983.15

$724.81 $996.61 $748.37 $1,029.02

$757.48 $1,041.54 $782.11 $1,075.41

$792.76 $1,090.04 $818.53 $1,125.49

$828.03 $1,138.54 $854.96 $1,175.57

$866.28 $1,191.13 $894.45 $1,229.86

$904.89 $1,244.23 $934.32 $1,284.69

$946.11 $1,300.90 $976.87 $1,343.20

$966.53 $1,328.98 $997.96 $1,372.20

$1,007.75 $1,385.65 $1,040.52 $1,430.71

$1,043.39 $1,434.67 $1,077.32 $1,481.32

$1,066.79 $1,466.83 $1,101.48 $1,514.53

$1,096.12 $1,507.16 $1,131.76 $1,556.17

$1,113.93 $1,531.67 $1,150.17 $1,581.48

$1,113.93 $1,531.67 $1,150.17 $1,581.48

$30/$60 $25 no ded/$50 no ded

KE 670 WPR GMC

8


33871PA0100003

KE 670 WPR GMC

8


#NAME?


$0

0%

$7,150

No No

#NAME?


$1,000

10%

$5,500

33871PA0100004


RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

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50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65+

33871PA0100005 33871PA0100006


$208.46 $208.46 $198.22 $198.22

$328.28 $369.31 $312.16 $351.18

$328.28 $369.31 $312.16 $351.18

$328.28 $369.31 $312.16 $351.18

$328.28 $369.31 $312.16 $351.18

$329.59 $370.79 $313.41 $352.58

$336.16 $378.18 $319.65 $359.61

$344.04 $387.04 $327.14 $368.04

$356.84 $401.44 $339.32 $381.73

$367.34 $413.26 $349.31 $392.97

$372.60 $437.80 $354.30 $416.30

$380.47 $447.06 $361.79 $425.11

$388.35 $456.32 $369.28 $433.91

$393.28 $462.10 $373.97 $439.41

$398.53 $468.27 $378.96 $445.28

$401.16 $471.36 $381.46 $448.21

$403.78 $474.44 $383.96 $451.15

$406.41 $477.53 $386.45 $454.08

$409.04 $480.62 $388.95 $457.02

$414.29 $486.79 $393.95 $462.89

$419.54 $513.94 $398.94 $488.70

$427.42 $523.59 $406.43 $497.88

$434.97 $532.84 $413.61 $506.67

$445.47 $545.71 $423.60 $518.91

$458.61 $561.79 $436.09 $534.21

$474.03 $580.69 $450.76 $552.18

$492.42 $603.21 $468.24 $573.59

$513.10 $628.55 $487.91 $597.68

$536.74 $657.50 $510.38 $625.22

$560.04 $686.05 $532.54 $652.37

$586.31 $806.17 $557.52 $766.59

$612.24 $841.83 $582.18 $800.49

$640.80 $881.10 $609.34 $837.84

$669.69 $920.82 $636.81 $875.61

$700.87 $963.70 $666.46 $916.38

$732.06 $1,006.58 $696.12 $957.16

$765.87 $1,053.08 $728.27 $1,001.37

$800.01 $1,100.02 $760.73 $1,046.01

$836.45 $1,150.12 $795.38 $1,093.65

$854.51 $1,174.95 $812.55 $1,117.26

$890.95 $1,225.05 $847.20 $1,164.90

$922.46 $1,268.39 $877.17 $1,206.11

$943.14 $1,296.82 $896.83 $1,233.15

$969.08 $1,332.48 $921.50 $1,267.06

$984.84 $1,354.15 $936.48 $1,287.66

$984.84 $1,354.15 $936.48 $1,287.66


33871PA0100006

KE 670 WPR GMC

8



#NAME?


$2,750

50%

$7,150

No

KE 670 WPR GMC

8


#NAME?


33871PA0100005

$2,500

30%

$7,150

No


RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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63

64

65+

33871PA0100007 33871PA0100008


$147.58 $147.58 $210.81 $210.81

$232.41 $261.46 $331.98 $373.48

$232.41 $261.46 $331.98 $373.48

$232.41 $261.46 $331.98 $373.48

$232.41 $261.46 $331.98 $373.48

$233.34 $262.51 $333.31 $374.97

$237.99 $267.74 $339.95 $382.44

$243.57 $274.01 $347.92 $391.41

$252.63 $284.21 $360.86 $405.97

$260.07 $292.58 $371.49 $417.92

$263.79 $309.95 $376.80 $442.74

$269.36 $316.50 $384.77 $452.10

$274.94 $323.06 $392.73 $461.46

$278.43 $327.15 $397.71 $467.31

$282.15 $331.52 $403.03 $473.56

$284.01 $333.71 $405.68 $476.68

$285.87 $335.89 $408.34 $479.80

$287.72 $338.08 $410.99 $482.92

$289.58 $340.26 $413.65 $486.04

$293.30 $344.63 $418.96 $492.28

$297.02 $363.85 $424.27 $519.73

$302.60 $370.68 $432.24 $529.49

$307.94 $377.23 $439.88 $538.85

$315.38 $386.34 $450.50 $551.86

$324.68 $397.73 $463.78 $568.13

$335.60 $411.11 $479.38 $587.24

$348.62 $427.06 $497.97 $610.02

$363.26 $444.99 $518.89 $635.64

$379.99 $465.49 $542.79 $664.92

$396.49 $485.70 $566.36 $693.79

$415.09 $570.74 $592.92 $815.26

$433.45 $595.99 $619.15 $851.33

$453.67 $623.79 $648.03 $891.04

$474.12 $651.91 $677.24 $931.21

$496.20 $682.27 $708.78 $974.57

$518.28 $712.63 $740.32 $1,017.94

$542.22 $745.55 $774.51 $1,064.96

$566.39 $778.78 $809.04 $1,112.43

$592.18 $814.25 $845.89 $1,163.10

$604.97 $831.83 $864.15 $1,188.20

$630.76 $867.30 $901.00 $1,238.87

$653.08 $897.98 $932.87 $1,282.69

$667.72 $918.11 $953.78 $1,311.45

$686.08 $943.36 $980.01 $1,347.51

$697.23 $958.70 $995.94 $1,369.42

$697.23 $958.70 $995.94 $1,369.42

33871PA0100008

KE 670 WPR GMC

8


No

$15/$40, $30/$60, $45/$80

#NAME?


$0

0%/20%/30%

$7,150


$6,850

50%

$7,150

No


KE 670 WPR GMC

8


33871PA0100007

#NAME?


RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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59

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61

62

63

64

65+

33871PA0100009 33871PA0110001


$167.21 $167.21 $313.00 $313.00

$263.33 $296.25 $492.92 $554.53

$263.33 $296.25 $492.92 $554.53

$263.33 $296.25 $492.92 $554.53

$263.33 $296.25 $492.92 $554.53

$264.38 $297.43 $494.89 $556.75

$269.65 $303.36 $504.75 $567.84

$275.97 $310.47 $516.58 $581.15

$286.24 $322.02 $535.80 $602.78

$294.67 $331.50 $551.58 $620.52

$298.88 $351.18 $559.46 $657.37

$305.20 $358.61 $571.29 $671.27

$311.52 $366.03 $583.12 $685.17

$315.47 $370.68 $590.52 $693.86

$319.68 $375.63 $598.40 $703.12

$321.79 $378.10 $602.35 $707.76

$323.90 $380.58 $606.29 $712.39

$326.00 $383.05 $610.23 $717.02

$328.11 $385.53 $614.18 $721.66

$332.32 $390.48 $622.06 $730.92

$336.54 $412.26 $629.95 $771.69

$342.86 $420.00 $641.78 $786.18

$348.91 $427.42 $653.12 $800.07

$357.34 $437.74 $668.89 $819.39

$367.87 $450.64 $688.61 $843.54

$380.25 $465.80 $711.77 $871.92

$394.99 $483.87 $739.38 $905.74

$411.58 $504.19 $770.43 $943.78

$430.54 $527.42 $805.92 $987.25

$449.24 $550.32 $840.92 $1,030.13

$470.31 $646.67 $880.35 $1,210.49

$491.11 $675.28 $919.29 $1,264.03

$514.02 $706.78 $962.18 $1,322.99

$537.19 $738.64 $1,005.55 $1,382.64

$562.21 $773.04 $1,052.38 $1,447.02

$587.23 $807.43 $1,099.21 $1,511.41

$614.35 $844.73 $1,149.98 $1,581.22

$641.73 $882.38 $1,201.24 $1,651.71

$670.96 $922.58 $1,255.96 $1,726.94

$685.45 $942.49 $1,283.07 $1,764.22

$714.68 $982.68 $1,337.78 $1,839.45

$739.96 $1,017.44 $1,385.10 $1,904.51

$756.55 $1,040.25 $1,416.16 $1,947.21

$777.35 $1,068.85 $1,455.10 $2,000.76

$789.99 $1,086.23 $1,478.76 $2,033.29

$789.99 $1,086.23 $1,478.76 $2,033.29

33871PA0110001

KE 670 WPR GMC

8


No

$10/$20

#NAME?


$0

0%

$3,000

33871PA0100009

KE 670 WPR GMC

8


#NAME?


$0/$5500/$5500

0%/5%/10%

$7,150

No



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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62

63

64

65+

33871PA0110002 33871PA0110003


$299.20 $299.20 $246.31 $246.31

$471.19 $530.09 $387.89 $436.38

$471.19 $530.09 $387.89 $436.38

$471.19 $530.09 $387.89 $436.38

$471.19 $530.09 $387.89 $436.38

$473.07 $532.21 $389.44 $438.12

$482.50 $542.81 $397.20 $446.85

$493.80 $555.53 $406.51 $457.33

$512.18 $576.20 $421.64 $474.34

$527.26 $593.17 $434.05 $488.31

$534.80 $628.39 $440.26 $517.30

$546.11 $641.67 $449.57 $528.24

$557.41 $654.96 $458.88 $539.18

$564.48 $663.27 $464.70 $546.02

$572.02 $672.13 $470.90 $553.31

$575.79 $676.55 $474.00 $556.96

$579.56 $680.98 $477.11 $560.60

$583.33 $685.41 $480.21 $564.25

$587.10 $689.84 $483.31 $567.89

$594.64 $698.70 $489.52 $575.19

$602.18 $737.67 $495.73 $607.26

$613.49 $751.52 $505.04 $618.67

$624.32 $764.80 $513.96 $629.60

$639.40 $783.27 $526.37 $644.80

$658.25 $806.35 $541.89 $663.81

$680.39 $833.48 $560.12 $686.14

$706.78 $865.81 $581.84 $712.75

$736.47 $902.17 $606.28 $742.69

$770.39 $943.73 $634.20 $776.90

$803.85 $984.71 $661.74 $810.64

$841.54 $1,157.12 $692.78 $952.57

$878.76 $1,208.30 $723.42 $994.70

$919.76 $1,264.67 $757.17 $1,041.10

$961.22 $1,321.68 $791.30 $1,088.04

$1,005.99 $1,383.23 $828.15 $1,138.71

$1,050.75 $1,444.78 $865.00 $1,189.38

$1,099.28 $1,511.51 $904.95 $1,244.31

$1,148.28 $1,578.89 $945.29 $1,299.78

$1,200.59 $1,650.81 $988.35 $1,358.98

$1,226.50 $1,686.44 $1,009.68 $1,388.32

$1,278.80 $1,758.35 $1,052.74 $1,447.52

$1,324.04 $1,820.55 $1,089.98 $1,498.72

$1,353.72 $1,861.37 $1,114.41 $1,532.32

$1,390.95 $1,912.55 $1,145.06 $1,574.46

$1,413.56 $1,943.65 $1,163.67 $1,600.06

$1,413.56 $1,943.65 $1,163.67 $1,600.06

33871PA0110003

KE 670 WPR GMC

8


No

$30/$60

#NAME?


$0

0%

$7,150

33871PA0110002

KE 670 WPR GMC

8


#NAME?


$0

0%

$4,000

No

$20/$40


RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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63

64

65+

33871PA0110004 33871PA0110005


$253.51 $253.51 $249.44 $249.44

$399.23 $449.14 $392.82 $441.92

$399.23 $449.14 $392.82 $441.92

$399.23 $449.14 $392.82 $441.92

$399.23 $449.14 $392.82 $441.92

$400.83 $450.93 $394.39 $443.69

$408.81 $459.92 $402.24 $452.53

$418.40 $470.69 $411.67 $463.13

$433.97 $488.21 $426.99 $480.37

$446.74 $502.58 $439.56 $494.51

$453.13 $532.43 $445.85 $523.87

$462.71 $543.68 $455.27 $534.95

$472.29 $554.94 $464.70 $546.03

$478.28 $561.98 $470.59 $552.95

$484.67 $569.48 $476.88 $560.33

$487.86 $573.24 $480.02 $564.03

$491.06 $576.99 $483.16 $567.72

$494.25 $580.74 $486.31 $571.41

$497.44 $584.50 $489.45 $575.10

$503.83 $592.00 $495.73 $582.49

$510.22 $625.02 $502.02 $614.97

$519.80 $636.76 $511.45 $626.52

$528.98 $648.00 $520.48 $637.59

$541.76 $663.65 $533.05 $652.99

$557.73 $683.22 $548.77 $672.24

$576.49 $706.20 $567.23 $694.85

$598.85 $733.59 $589.23 $721.80

$624.00 $764.40 $613.97 $752.12

$652.74 $799.61 $642.26 $786.76

$681.09 $834.34 $670.15 $820.93

$713.03 $980.41 $701.57 $964.66

$744.57 $1,023.78 $732.60 $1,007.33

$779.30 $1,071.54 $766.78 $1,054.32

$814.43 $1,119.85 $801.35 $1,101.85

$852.36 $1,172.00 $838.66 $1,153.16

$890.29 $1,224.15 $875.98 $1,204.47

$931.41 $1,280.69 $916.44 $1,260.11

$972.93 $1,337.78 $957.29 $1,316.28

$1,017.24 $1,398.71 $1,000.90 $1,376.23

$1,039.20 $1,428.90 $1,022.50 $1,405.94

$1,083.52 $1,489.83 $1,066.10 $1,465.89

$1,121.84 $1,542.53 $1,103.82 $1,517.75

$1,146.99 $1,577.12 $1,128.56 $1,551.77

$1,178.53 $1,620.48 $1,159.60 $1,594.44

$1,197.69 $1,646.83 $1,178.45 $1,620.37

$1,197.69 $1,646.83 $1,178.45 $1,620.37

33871PA0110005

KE 670 WPR GMC

8


No


#NAME?Keystone DPOS Gold Classic

$2,000 $40/$80/100%

$2,000

0%

$3,500

33871PA0110004

KE 670 WPR GMC

8


#NAME?


$1,000

10%

$5,500

No



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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63

64

65+

33871PA0110006 33871PA0110010


$217.76 $217.76 $153.99 $153.99

$342.93 $385.80 $242.51 $272.83

$342.93 $385.80 $242.51 $272.83

$342.93 $385.80 $242.51 $272.83

$342.93 $385.80 $242.51 $272.83

$344.30 $387.34 $243.48 $273.92

$351.16 $395.06 $248.33 $279.37

$359.39 $404.31 $254.15 $285.92

$372.77 $419.36 $263.61 $296.56

$383.74 $431.71 $271.37 $305.29

$389.23 $457.34 $275.25 $323.42

$397.46 $467.01 $281.07 $330.26

$405.69 $476.68 $286.89 $337.10

$410.83 $482.73 $290.53 $341.37

$416.32 $489.17 $294.41 $345.93

$419.06 $492.40 $296.35 $348.21

$421.80 $495.62 $298.29 $350.49

$424.55 $498.84 $300.23 $352.77

$427.29 $502.07 $302.17 $355.05

$432.78 $508.51 $306.05 $359.61

$438.27 $536.87 $309.93 $379.66

$446.50 $546.96 $315.75 $386.79

$454.38 $556.62 $321.33 $393.63

$465.36 $570.06 $329.09 $403.13

$479.07 $586.87 $338.79 $415.02

$495.19 $606.61 $350.19 $428.98

$514.40 $630.13 $363.77 $445.61

$536.00 $656.60 $379.05 $464.33

$560.69 $686.85 $396.51 $485.72

$585.04 $716.67 $413.72 $506.81

$612.47 $842.15 $433.13 $595.55

$639.57 $879.40 $452.28 $621.89

$669.40 $920.43 $473.38 $650.90

$699.58 $961.92 $494.72 $680.24

$732.16 $1,006.72 $517.76 $711.92

$764.73 $1,051.51 $540.80 $743.60

$800.06 $1,100.08 $565.78 $777.95

$835.72 $1,149.12 $591.00 $812.63

$873.79 $1,201.46 $617.92 $849.64

$892.65 $1,227.39 $631.26 $867.98

$930.71 $1,279.73 $658.18 $904.99

$963.63 $1,325.00 $681.46 $937.00

$985.24 $1,354.70 $696.74 $958.01

$1,012.33 $1,391.95 $715.89 $984.35

$1,028.79 $1,414.59 $727.53 $1,000.36

$1,028.79 $1,414.59 $727.53 $1,000.36

No


#NAME?


$6,850

50%

$7,150

33871PA0110010

KE 670 WPR GMC

8


33871PA0110006

KE 670 WPR GMC

8


#NAME?


$2,500

30%

$7,150

No



RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

22

23

24

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61

62

63

64

65+

33871PA0100020 33871PA0100021


$299.73 $299.73 $286.54 $286.54

$472.01 $531.01 $451.24 $507.65

$472.01 $531.01 $451.24 $507.65

$472.01 $531.01 $451.24 $507.65

$472.01 $531.01 $451.24 $507.65

$473.90 $533.14 $453.05 $509.68

$483.34 $543.76 $462.07 $519.83

$494.67 $556.50 $472.90 $532.01

$513.08 $577.21 $490.50 $551.81

$528.18 $594.20 $504.94 $568.06

$535.73 $629.49 $512.16 $601.79

$547.06 $642.80 $522.99 $614.51

$558.39 $656.11 $533.82 $627.24

$565.47 $664.43 $540.59 $635.19

$573.02 $673.30 $547.81 $643.67

$576.80 $677.74 $551.42 $647.91

$580.57 $682.17 $555.03 $652.16

$584.35 $686.61 $558.64 $656.40

$588.13 $691.05 $562.25 $660.64

$595.68 $699.92 $569.47 $669.12

$603.23 $738.96 $576.69 $706.44

$614.56 $752.84 $587.52 $719.71

$625.42 $766.13 $597.89 $732.42

$640.52 $784.64 $612.33 $750.11

$659.40 $807.77 $630.38 $772.22

$681.58 $834.94 $651.59 $798.20

$708.02 $867.32 $676.86 $829.16

$737.75 $903.75 $705.29 $863.98

$771.74 $945.38 $737.78 $903.78

$805.25 $986.43 $769.82 $943.03

$843.01 $1,159.14 $805.92 $1,108.14

$880.30 $1,210.42 $841.56 $1,157.15

$921.37 $1,266.88 $880.82 $1,211.13

$962.90 $1,323.99 $920.53 $1,265.73

$1,007.75 $1,385.65 $963.40 $1,324.67

$1,052.59 $1,447.31 $1,006.27 $1,383.62

$1,101.20 $1,514.15 $1,052.75 $1,447.52

$1,150.29 $1,581.65 $1,099.67 $1,512.05

$1,202.69 $1,653.69 $1,149.76 $1,580.92

$1,228.65 $1,689.39 $1,174.58 $1,615.05

$1,281.04 $1,761.43 $1,224.67 $1,683.92

$1,326.35 $1,823.74 $1,267.99 $1,743.48

$1,356.09 $1,864.62 $1,296.42 $1,782.57

$1,393.38 $1,915.90 $1,332.06 $1,831.59

$1,416.03 $1,947.05 $1,353.72 $1,861.37

$1,416.03 $1,947.05 $1,353.72 $1,861.37

$10/$20 $20/$40

Yes

33871PA0100021

KE 670 WPR GMC

8


#NAME?


$0

0%

$4,000

Yes

#NAME?


$0

0%

$3,000

33871PA0100020

KE 670 WPR GMC

8


Page Number: 10 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

21

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65+

33871PA0100022 33871PA0100023


$236.38 $236.38 $244.04 $244.04

$372.24 $418.78 $384.32 $432.36

$372.24 $418.78 $384.32 $432.36

$372.24 $418.78 $384.32 $432.36

$372.24 $418.78 $384.32 $432.36

$373.73 $420.45 $385.86 $434.09

$381.18 $428.83 $393.54 $442.74

$390.11 $438.88 $402.77 $453.11

$404.63 $455.21 $417.75 $469.97

$416.54 $468.61 $430.05 $483.81

$422.50 $496.43 $436.20 $512.54

$431.43 $506.93 $445.43 $523.38

$440.37 $517.43 $454.65 $534.21

$445.95 $523.99 $460.41 $540.99

$451.90 $530.99 $466.56 $548.21

$454.88 $534.49 $469.64 $551.82

$457.86 $537.99 $472.71 $555.44

$460.84 $541.49 $475.79 $559.05

$463.82 $544.98 $478.86 $562.66

$469.77 $551.98 $485.01 $569.89

$475.73 $582.77 $491.16 $601.67

$484.66 $593.71 $500.38 $612.97

$493.22 $604.20 $509.22 $623.80

$505.14 $618.79 $521.52 $638.86

$520.03 $637.03 $536.89 $657.69

$537.52 $658.46 $554.96 $679.82

$558.37 $684.00 $576.48 $706.19

$581.82 $712.73 $600.69 $735.85

$608.62 $745.56 $628.36 $769.74

$635.05 $777.94 $655.65 $803.17

$664.83 $914.14 $686.39 $943.79

$694.24 $954.57 $716.75 $985.54

$726.62 $999.10 $750.19 $1,031.51

$759.38 $1,044.15 $784.01 $1,078.01

$794.74 $1,092.77 $820.52 $1,128.22

$830.11 $1,141.39 $857.03 $1,178.42

$868.45 $1,194.11 $896.62 $1,232.85

$907.16 $1,247.34 $936.59 $1,287.80

$948.48 $1,304.16 $979.24 $1,346.46

$968.95 $1,332.31 $1,000.38 $1,375.53

$1,010.27 $1,389.12 $1,043.04 $1,434.18

$1,046.01 $1,438.26 $1,079.94 $1,484.91

$1,069.46 $1,470.51 $1,104.15 $1,518.20

$1,098.87 $1,510.94 $1,134.51 $1,559.95

$1,116.72 $1,535.51 $1,152.96 $1,585.32

$1,116.72 $1,535.51 $1,152.96 $1,585.32

$30/$60 $25 no ded/$50 no ded

Yes

33871PA0100023

KE 670 WPR GMC

8


#NAME?


$1,000

10%

$5,500

Yes

#NAME?


$0

0%

$7,150

33871PA0100022

KE 670 WPR GMC

8


Page Number: 11 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

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OOP Maximum =>


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65+

33871PA0100024 33871PA0100025


$209.05 $209.05 $198.81 $198.81

$329.21 $370.36 $313.09 $352.23

$329.21 $370.36 $313.09 $352.23

$329.21 $370.36 $313.09 $352.23

$329.21 $370.36 $313.09 $352.23

$330.53 $371.84 $314.34 $353.64

$337.11 $379.25 $320.60 $360.68

$345.01 $388.14 $328.12 $369.13

$357.85 $402.58 $340.33 $382.87

$368.38 $414.43 $350.35 $394.14

$373.65 $439.04 $355.36 $417.54

$381.55 $448.32 $362.87 $426.37

$389.45 $457.61 $370.39 $435.20

$394.39 $463.41 $375.08 $440.72

$399.66 $469.60 $380.09 $446.61

$402.29 $472.69 $382.60 $449.55

$404.93 $475.79 $385.10 $452.49

$407.56 $478.88 $387.61 $455.44

$410.19 $481.98 $390.11 $458.38

$415.46 $488.17 $395.12 $464.27

$420.73 $515.39 $400.13 $490.16

$428.63 $525.07 $407.64 $499.36

$436.20 $534.35 $414.84 $508.18

$446.74 $547.25 $424.86 $520.46

$459.90 $563.38 $437.39 $535.80

$475.38 $582.34 $452.10 $553.82

$493.81 $604.92 $469.63 $575.30

$514.55 $630.33 $489.36 $599.47

$538.26 $659.36 $511.90 $627.08

$561.63 $688.00 $534.13 $654.31

$587.97 $808.45 $559.18 $768.87

$613.97 $844.22 $583.91 $802.88

$642.62 $883.60 $611.15 $840.33

$671.59 $923.43 $638.70 $878.22

$702.86 $966.43 $668.45 $919.11

$734.14 $1,009.44 $698.19 $960.01

$768.04 $1,056.06 $730.44 $1,004.35

$802.28 $1,103.14 $763.00 $1,049.13

$838.82 $1,153.38 $797.75 $1,096.91

$856.93 $1,178.28 $814.97 $1,120.59

$893.47 $1,228.53 $849.73 $1,168.37

$925.08 $1,271.98 $879.78 $1,209.70

$945.82 $1,300.50 $899.51 $1,236.82

$971.82 $1,336.26 $924.24 $1,270.83

$987.63 $1,357.99 $939.27 $1,291.50

$987.63 $1,357.99 $939.27 $1,291.50


Yes

33871PA0100025

KE 670 WPR GMC

8


#NAME?


$2,750

50%

$7,150

Yes

#NAME?


$2,500

30%

$7,150

33871PA0100024

KE 670 WPR GMC

8


Page Number: 12 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


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65+

33871PA0100026 33871PA0110011


$148.17 $148.17 $313.59 $313.59

$233.34 $262.51 $493.85 $555.58

$233.34 $262.51 $493.85 $555.58

$233.34 $262.51 $493.85 $555.58

$233.34 $262.51 $493.85 $555.58

$234.27 $263.56 $495.82 $557.80

$238.94 $268.81 $505.70 $568.91

$244.54 $275.11 $517.55 $582.25

$253.64 $285.35 $536.81 $603.92

$261.11 $293.75 $552.62 $621.69

$264.84 $311.19 $560.52 $658.61

$270.44 $317.77 $572.37 $672.54

$276.04 $324.35 $584.22 $686.46

$279.54 $328.46 $591.63 $695.17

$283.28 $332.85 $599.53 $704.45

$285.14 $335.04 $603.48 $709.09

$287.01 $337.24 $607.43 $713.74

$288.88 $339.43 $611.39 $718.38

$290.74 $341.62 $615.34 $723.02

$294.48 $346.01 $623.24 $732.30

$298.21 $365.31 $631.14 $773.15

$303.81 $372.17 $642.99 $787.66

$309.18 $378.74 $654.35 $801.58

$316.64 $387.89 $670.15 $820.94

$325.98 $399.32 $689.91 $845.14

$336.94 $412.76 $713.12 $873.57

$350.01 $428.76 $740.77 $907.45

$364.71 $446.77 $771.89 $945.56

$381.51 $467.35 $807.44 $989.12

$398.08 $487.65 $842.51 $1,032.07

$416.75 $573.03 $882.01 $1,212.77

$435.18 $598.37 $921.03 $1,266.41

$455.48 $626.29 $963.99 $1,325.49

$476.02 $654.52 $1,007.45 $1,385.25

$498.18 $685.00 $1,054.37 $1,449.76

$520.35 $715.48 $1,101.28 $1,514.26

$544.39 $748.53 $1,152.15 $1,584.21

$568.65 $781.90 $1,203.51 $1,654.83

$594.55 $817.51 $1,258.33 $1,730.20

$607.39 $835.16 $1,285.49 $1,767.55

$633.29 $870.77 $1,340.31 $1,842.92

$655.69 $901.57 $1,387.72 $1,908.11

$670.39 $921.79 $1,418.83 $1,950.89

$688.82 $947.13 $1,457.84 $2,004.53

$700.02 $962.53 $1,481.55 $2,037.13

$700.02 $962.53 $1,481.55 $2,037.13


Yes

33871PA0110011

KE 670 WPR GMC

8


#NAME?


$0

0%

$3,000

Yes

#NAME?


$6,850

50%

$7,150

33871PA0100026

KE 670 WPR GMC

8


$10/$20

Page Number: 13 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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65+

33871PA0110012 33871PA0110013


$299.79 $299.79 $246.90 $246.90

$472.12 $531.13 $388.82 $437.43

$472.12 $531.13 $388.82 $437.43

$472.12 $531.13 $388.82 $437.43

$472.12 $531.13 $388.82 $437.43

$474.01 $533.26 $390.38 $439.18

$483.45 $543.88 $398.15 $447.92

$494.78 $556.63 $407.49 $458.42

$513.19 $577.34 $422.65 $475.48

$528.30 $594.34 $435.09 $489.48

$535.85 $629.63 $441.31 $518.54

$547.18 $642.94 $450.65 $529.51

$558.52 $656.26 $459.98 $540.47

$565.60 $664.58 $465.81 $547.33

$573.15 $673.45 $472.03 $554.64

$576.93 $677.89 $475.14 $558.29

$580.70 $682.33 $478.25 $561.95

$584.48 $686.77 $481.36 $565.60

$588.26 $691.20 $484.47 $569.26

$595.81 $700.08 $490.69 $576.57

$603.37 $739.12 $496.92 $608.72

$614.70 $753.00 $506.25 $620.15

$625.56 $766.31 $515.19 $631.11

$640.66 $784.81 $527.63 $646.35

$659.55 $807.95 $543.19 $665.40

$681.74 $835.13 $561.46 $687.79

$708.18 $867.52 $583.23 $714.46

$737.92 $903.95 $607.73 $744.47

$771.91 $945.59 $635.73 $778.76

$805.43 $986.66 $663.33 $812.58

$843.20 $1,159.40 $694.44 $954.85

$880.50 $1,210.69 $725.15 $997.09

$921.57 $1,267.16 $758.98 $1,043.60

$963.12 $1,324.29 $793.20 $1,090.65

$1,007.97 $1,385.96 $830.14 $1,141.44

$1,052.82 $1,447.63 $867.07 $1,192.23

$1,101.45 $1,514.49 $907.12 $1,247.29

$1,150.55 $1,582.01 $947.56 $1,302.90

$1,202.96 $1,654.06 $990.72 $1,362.24

$1,228.92 $1,689.77 $1,012.11 $1,391.65

$1,281.33 $1,761.83 $1,055.26 $1,450.99

$1,326.65 $1,824.15 $1,092.59 $1,502.31

$1,356.39 $1,865.04 $1,117.09 $1,536.00

$1,393.69 $1,916.33 $1,147.80 $1,578.23

$1,416.35 $1,947.49 $1,166.46 $1,603.89

$1,416.35 $1,947.49 $1,166.46 $1,603.89

$30/$60

Yes

33871PA0110013

KE 670 WPR GMC

8


#NAME?


$0

0%

$7,150

Yes

#NAME?


$0

0%

$4,000

33871PA0110012

KE 670 WPR GMC

8


$20/$40

Page Number: 14 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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64

65+

33871PA0110014 33871PA0110016


$254.10 $254.10 $218.35 $218.35

$400.16 $450.18 $343.86 $386.84

$400.16 $450.18 $343.86 $386.84

$400.16 $450.18 $343.86 $386.84

$400.16 $450.18 $343.86 $386.84

$401.76 $451.98 $345.24 $388.39

$409.77 $460.99 $352.11 $396.13

$419.37 $471.79 $360.37 $405.41

$434.98 $489.35 $373.78 $420.50

$447.78 $503.75 $384.78 $432.88

$454.18 $533.67 $390.28 $458.58

$463.79 $544.95 $398.53 $468.28

$473.39 $556.24 $406.79 $477.98

$479.39 $563.29 $411.95 $484.04

$485.80 $570.81 $417.45 $490.50

$489.00 $574.57 $420.20 $493.73

$492.20 $578.33 $422.95 $496.96

$495.40 $582.10 $425.70 $500.20

$498.60 $585.86 $428.45 $503.43

$505.00 $593.38 $433.95 $509.89

$511.41 $626.47 $439.45 $538.33

$521.01 $638.24 $447.71 $548.44

$530.22 $649.51 $455.62 $558.13

$543.02 $665.20 $466.62 $571.61

$559.03 $684.81 $480.37 $588.46

$577.83 $707.85 $496.53 $608.26

$600.24 $735.30 $515.79 $631.84

$625.45 $766.18 $537.45 $658.38

$654.27 $801.48 $562.21 $688.71

$682.68 $836.28 $586.63 $718.62

$714.69 $982.70 $614.14 $844.44

$746.30 $1,026.17 $641.30 $881.79

$781.12 $1,074.04 $671.22 $922.92

$816.33 $1,122.46 $701.48 $964.53

$854.35 $1,174.73 $734.14 $1,009.45

$892.36 $1,227.00 $766.81 $1,054.36

$933.58 $1,283.67 $802.23 $1,103.06

$975.20 $1,340.89 $837.99 $1,152.23

$1,019.61 $1,401.97 $876.16 $1,204.72

$1,041.62 $1,432.23 $895.07 $1,230.72

$1,086.04 $1,493.31 $933.24 $1,283.20

$1,124.46 $1,546.13 $966.25 $1,328.59

$1,149.67 $1,580.79 $987.91 $1,358.38

$1,181.28 $1,624.26 $1,015.08 $1,395.73

$1,200.48 $1,650.67 $1,031.58 $1,418.43

$1,200.48 $1,650.67 $1,031.58 $1,418.43


Yes

33871PA0110016

KE 670 WPR GMC

8


#NAME?


$2,500

30%

$7,150

Yes

#NAME?


$1,000

10%

$5,500

33871PA0110014

KE 670 WPR GMC

8



Page Number: 15 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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64

65+

33871PA0110019 33871PA0110020


$207.60 $207.60 $154.59 $154.59

$326.94 $367.80 $243.44 $273.87

$326.94 $367.80 $243.44 $273.87

$326.94 $367.80 $243.44 $273.87

$326.94 $367.80 $243.44 $273.87

$328.24 $369.27 $244.42 $274.97

$334.78 $376.63 $249.28 $280.45

$342.63 $385.46 $255.13 $287.02

$355.38 $399.80 $264.62 $297.70

$365.84 $411.57 $272.41 $306.46

$371.07 $436.01 $276.31 $324.66

$378.92 $445.23 $282.15 $331.53

$386.77 $454.45 $287.99 $338.39

$391.67 $460.21 $291.64 $342.68

$396.90 $466.36 $295.54 $347.26

$399.52 $469.43 $297.49 $349.55

$402.13 $472.50 $299.43 $351.83

$404.75 $475.58 $301.38 $354.12

$407.36 $478.65 $303.33 $356.41

$412.59 $484.80 $307.22 $360.99

$417.82 $511.83 $311.12 $381.12

$425.67 $521.45 $316.96 $388.28

$433.19 $530.66 $322.56 $395.14

$443.65 $543.47 $330.35 $404.68

$456.73 $559.49 $340.09 $416.61

$472.10 $578.32 $351.53 $430.62

$490.40 $600.75 $365.16 $447.32

$511.00 $625.98 $380.50 $466.11

$534.54 $654.81 $398.03 $487.58

$557.75 $683.25 $415.31 $508.76

$583.91 $802.87 $434.79 $597.83

$609.74 $838.39 $454.02 $624.28

$638.18 $877.50 $475.20 $653.40

$666.95 $917.06 $496.62 $682.85

$698.01 $959.76 $519.75 $714.65

$729.07 $1,002.47 $542.88 $746.45

$762.74 $1,048.77 $567.95 $780.93

$796.74 $1,095.52 $593.27 $815.74

$833.03 $1,145.42 $620.29 $852.90

$851.01 $1,170.15 $633.68 $871.31

$887.30 $1,220.04 $660.70 $908.46

$918.69 $1,263.20 $684.07 $940.60

$939.29 $1,291.52 $699.41 $961.69

$965.12 $1,327.03 $718.64 $988.13

$980.81 $1,348.61 $730.32 $1,004.20

$980.81 $1,348.61 $730.32 $1,004.20

#NAME?


$2,750

50%

$7,150

33871PA0110019

KE 670 WPR GMC

8



$6,850


50%

#NAME?

$7,150


8

KE 670 WPR GMC


Yes

33871PA0110020

Yes

Page Number: 16 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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64

65+

33871PA0100044 33871PA0100045


$211.40 $211.40 $167.81 $167.81

$332.91 $374.53 $264.26 $297.29

$332.91 $374.53 $264.26 $297.29

$332.91 $374.53 $264.26 $297.29

$332.91 $374.53 $264.26 $297.29

$334.24 $376.02 $265.32 $298.48

$340.90 $383.51 $270.60 $304.43

$348.89 $392.50 $276.94 $311.56

$361.88 $407.11 $287.25 $323.16

$372.53 $419.09 $295.71 $332.67

$377.86 $443.98 $299.94 $352.42

$385.85 $453.37 $306.28 $359.88

$393.83 $462.76 $312.62 $367.33

$398.83 $468.62 $316.58 $371.99

$404.16 $474.88 $320.81 $376.95

$406.82 $478.01 $322.93 $379.44

$409.48 $481.14 $325.04 $381.92

$412.15 $484.27 $327.15 $384.41

$414.81 $487.40 $329.27 $386.89

$420.13 $493.66 $333.50 $391.86

$425.46 $521.19 $337.72 $413.71

$433.45 $530.98 $344.07 $421.48

$441.11 $540.36 $350.14 $428.93

$451.76 $553.41 $358.60 $439.29

$465.08 $569.72 $369.17 $452.23

$480.72 $588.89 $381.59 $467.45

$499.37 $611.73 $396.39 $485.58

$520.34 $637.42 $413.04 $505.97

$544.31 $666.78 $432.06 $529.28

$567.95 $695.74 $450.83 $552.26

$594.58 $817.55 $471.97 $648.96

$620.88 $853.71 $492.84 $677.66

$649.84 $893.54 $515.84 $709.27

$679.14 $933.82 $539.09 $741.25

$710.77 $977.30 $564.19 $775.77

$742.39 $1,020.79 $589.30 $810.29

$776.68 $1,067.94 $616.52 $847.71

$811.31 $1,115.55 $644.00 $885.50

$848.26 $1,166.36 $673.33 $925.83

$866.57 $1,191.53 $687.87 $945.82

$903.52 $1,242.34 $717.20 $986.15

$935.48 $1,286.29 $742.57 $1,021.03

$956.46 $1,315.13 $759.22 $1,043.93

$982.76 $1,351.29 $780.10 $1,072.63

$998.73 $1,373.26 $792.78 $1,090.07

$998.73 $1,373.26 $792.78 $1,090.07

Yes

$0/$5500/$5500


0%/5%/10%

#NAME?

33871PA0100045

KE 670 WPR GMC

8



$7,150

KE 670 WPR GMC

8


Yes

$0


0%/20%/30%

#NAME?

$7,150

$15/$40, $30/$60, $45/$80

33871PA0100044

Page Number: 17 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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61

62

63

64

65+

33871PA0100035 33871PA0100037


$242.26 $242.26 $190.31 $190.31

$381.50 $429.19 $299.71 $337.17

$381.50 $429.19 $299.71 $337.17

$381.50 $429.19 $299.71 $337.17

$381.50 $429.19 $299.71 $337.17

$383.03 $430.91 $300.91 $338.52

$390.66 $439.49 $306.90 $345.26

$399.82 $449.79 $314.09 $353.35

$414.70 $466.53 $325.78 $366.50

$426.90 $480.27 $335.37 $377.29

$433.01 $508.78 $340.17 $399.70

$442.16 $519.54 $347.36 $408.15

$451.32 $530.30 $354.55 $416.60

$457.04 $537.03 $359.05 $421.88

$463.15 $544.20 $363.84 $427.52

$466.20 $547.78 $366.24 $430.33

$469.25 $551.37 $368.64 $433.15

$472.30 $554.96 $371.04 $435.97

$475.36 $558.54 $373.43 $438.79

$481.46 $565.71 $378.23 $444.42

$487.56 $597.26 $383.03 $469.21

$496.72 $608.48 $390.22 $478.02

$505.49 $619.23 $397.11 $486.46

$517.70 $634.19 $406.70 $498.21

$532.96 $652.88 $418.69 $512.90

$550.89 $674.84 $432.78 $530.15

$572.26 $701.02 $449.56 $550.71

$596.29 $730.46 $468.44 $573.84

$623.76 $764.11 $490.02 $600.27

$650.85 $797.29 $511.30 $626.34

$681.37 $936.88 $535.28 $736.00

$711.51 $978.32 $558.95 $768.56

$744.70 $1,023.96 $585.03 $804.41

$778.27 $1,070.12 $611.40 $840.68

$814.51 $1,119.96 $639.87 $879.83

$850.76 $1,169.79 $668.35 $918.98

$890.05 $1,223.82 $699.22 $961.42

$929.73 $1,278.38 $730.38 $1,004.28

$972.07 $1,336.60 $763.65 $1,050.02

$993.06 $1,365.45 $780.14 $1,072.69

$1,035.40 $1,423.68 $813.40 $1,118.43

$1,072.03 $1,474.04 $842.18 $1,157.99

$1,096.06 $1,507.09 $861.06 $1,183.95

$1,126.20 $1,548.53 $884.73 $1,216.51

$1,144.50 $1,573.71 $899.12 $1,236.29

$1,144.50 $1,573.71 $899.12 $1,236.29



33871PA0100037

KE 670 WPR GMC

8


0%

#NAME? #NAME?

$2,000 $3,500

$3,500 $7,150

No

0%


33871PA0100035

KE 670 WPR GMC

8


No

Page Number: 18 05/05/2016

RATE PAGES


Product: HMO




Form # =>

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65+

33871PA0100036 33871PA0110007


$201.62 $201.62 $198.76 $198.76

$317.51 $357.20 $313.00 $352.13

$317.51 $357.20 $313.00 $352.13

$317.51 $357.20 $313.00 $352.13

$317.51 $357.20 $313.00 $352.13

$318.78 $358.63 $314.25 $353.54

$325.13 $365.77 $320.51 $360.58

$332.75 $374.35 $328.03 $369.03

$345.14 $388.28 $340.23 $382.76

$355.30 $399.71 $350.25 $394.03

$360.38 $423.44 $355.26 $417.43

$368.00 $432.40 $362.77 $426.25

$375.62 $441.35 $370.28 $435.08

$380.38 $446.95 $374.98 $440.60

$385.46 $452.91 $379.98 $446.48

$388.00 $455.90 $382.49 $449.42

$390.54 $458.88 $384.99 $452.37

$393.08 $461.87 $387.50 $455.31

$395.62 $464.85 $390.00 $458.25

$400.70 $470.82 $395.01 $464.13

$405.78 $497.08 $400.02 $490.02

$413.40 $506.42 $407.53 $499.22

$420.70 $515.36 $414.73 $508.04

$430.86 $527.81 $424.74 $520.31

$443.56 $543.37 $437.26 $535.65

$458.49 $561.65 $451.97 $553.67

$476.27 $583.43 $469.50 $575.14

$496.27 $607.93 $489.22 $599.30

$519.13 $635.94 $511.76 $626.90

$541.68 $663.55 $533.98 $654.13

$567.08 $779.73 $559.02 $768.65

$592.16 $814.22 $583.75 $802.65

$619.78 $852.20 $610.98 $840.10

$647.72 $890.62 $638.52 $877.97

$677.89 $932.10 $668.26 $918.86

$708.05 $973.57 $697.99 $959.74

$740.75 $1,018.54 $730.23 $1,004.07

$773.78 $1,063.94 $762.79 $1,048.83

$809.02 $1,112.40 $797.53 $1,096.60

$826.48 $1,136.41 $814.74 $1,120.27

$861.73 $1,184.87 $849.49 $1,168.05

$892.21 $1,226.79 $879.54 $1,209.36

$912.21 $1,254.29 $899.25 $1,236.48

$937.29 $1,288.78 $923.98 $1,270.47

$952.53 $1,309.74 $939.00 $1,291.13

$952.53 $1,309.74 $939.00 $1,291.13


33871PA0110007

8

33871PA0100036

KE 670 WPR GMC

8


0% 0%

No

#NAME? #NAME?

$4,250 $3,500

$7,150 $7,150

No


KE 670 WPR GMC


Page Number: 19 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

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65+

33871PA0110008 33871PA0110009


$210.56 $210.56 $207.01 $207.01

$331.59 $373.04 $326.01 $366.76

$331.59 $373.04 $326.01 $366.76

$331.59 $373.04 $326.01 $366.76

$331.59 $373.04 $326.01 $366.76

$332.92 $374.53 $327.31 $368.22

$339.55 $381.99 $333.83 $375.56

$347.51 $390.95 $341.65 $384.36

$360.44 $405.50 $354.37 $398.66

$371.05 $417.43 $364.80 $410.40

$376.36 $442.22 $370.02 $434.77

$384.31 $451.57 $377.84 $443.96

$392.27 $460.92 $385.66 $453.16

$397.25 $466.76 $390.56 $458.90

$402.55 $473.00 $395.77 $465.03

$405.20 $476.12 $398.38 $468.10

$407.86 $479.23 $400.99 $471.16

$410.51 $482.35 $403.60 $474.22

$413.16 $485.47 $406.20 $477.29

$418.47 $491.70 $411.42 $483.42

$423.77 $519.12 $416.64 $510.38

$431.73 $528.87 $424.46 $519.96

$439.36 $538.21 $431.96 $529.15

$449.97 $551.21 $442.39 $541.93

$463.23 $567.46 $455.43 $557.90

$478.82 $586.55 $470.75 $576.67

$497.39 $609.30 $489.01 $599.04

$518.28 $634.89 $509.55 $624.20

$542.15 $664.14 $533.02 $652.95

$565.70 $692.98 $556.17 $681.30

$592.22 $814.31 $582.25 $800.59

$618.42 $850.33 $608.00 $836.00

$647.27 $889.99 $636.36 $875.00

$676.45 $930.11 $665.05 $914.45

$707.95 $973.43 $696.02 $957.03

$739.45 $1,016.74 $726.99 $999.62

$773.60 $1,063.70 $760.57 $1,045.79

$808.09 $1,111.12 $794.48 $1,092.40

$844.90 $1,161.73 $830.66 $1,142.16

$863.13 $1,186.81 $848.59 $1,166.82

$899.94 $1,237.42 $884.78 $1,216.57

$931.77 $1,281.19 $916.08 $1,259.61

$952.66 $1,309.91 $936.61 $1,287.85

$978.86 $1,345.93 $962.37 $1,323.26

$994.77 $1,367.82 $978.02 $1,344.77

$994.77 $1,367.82 $978.02 $1,344.77

$7,150


$7,150

#NAME?

$4,250 $2,750


#NAME?

33871PA0110009


KE 670 WPR GMC

33871PA0110008

8

0% 50%



NoNo

8

KE 670 WPR GMC


Page Number: 20 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

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65+

OFF

33871PA0100047 33871PA0100049


$242.85 $242.85 $190.90 $190.90

$382.44 $430.24 $300.64 $338.22

$382.44 $430.24 $300.64 $338.22

$382.44 $430.24 $300.64 $338.22

$382.44 $430.24 $300.64 $338.22

$383.96 $431.96 $301.84 $339.57

$391.61 $440.57 $307.85 $346.33

$400.79 $450.89 $315.07 $354.45

$415.71 $467.67 $326.79 $367.64

$427.94 $481.44 $336.41 $378.46

$434.06 $510.03 $341.22 $400.94

$443.24 $520.81 $348.44 $409.41

$452.42 $531.59 $355.65 $417.89

$458.16 $538.33 $360.16 $423.19

$464.28 $545.52 $364.97 $428.84

$467.34 $549.12 $367.38 $431.67

$470.40 $552.71 $369.78 $434.50

$473.45 $556.31 $372.19 $437.32

$476.51 $559.90 $374.59 $440.15

$482.63 $567.09 $379.40 $445.80

$488.75 $598.72 $384.21 $470.66

$497.93 $609.96 $391.43 $479.50

$506.73 $620.74 $398.34 $487.97

$518.96 $635.73 $407.96 $499.76

$534.26 $654.47 $419.99 $514.49

$552.24 $676.49 $434.12 $531.80

$573.65 $702.72 $450.96 $552.42

$597.75 $732.24 $469.90 $575.62

$625.28 $765.97 $491.54 $602.14

$652.43 $799.23 $512.89 $628.29

$683.03 $939.17 $536.94 $738.29

$713.24 $980.71 $560.69 $770.95

$746.51 $1,026.46 $586.84 $806.91

$780.17 $1,072.73 $613.30 $843.29

$816.50 $1,122.69 $641.86 $882.56

$852.83 $1,172.64 $670.42 $921.83

$892.22 $1,226.80 $701.39 $964.41

$931.99 $1,281.49 $732.65 $1,007.40

$974.44 $1,339.86 $766.02 $1,053.28

$995.48 $1,368.78 $782.56 $1,076.02

$1,037.93 $1,427.15 $815.93 $1,121.90

$1,074.64 $1,477.63 $844.79 $1,161.59

$1,098.74 $1,510.76 $863.73 $1,187.63

$1,128.95 $1,552.30 $887.48 $1,220.29

$1,147.31 $1,577.55 $901.91 $1,240.13

$1,147.31 $1,577.55 $901.91 $1,240.13

$3,500 $7,150

Yes

#NAME?

$2,000

8


8


0% 0%


$3,500


#NAME?


Yes

33871PA0100047

KE 670 WPR GMC

33871PA0100049

KE 670 WPR GMC

Page Number: 21 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

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OOP Maximum =>


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33871PA0100048 33871PA0110015


$202.21 $202.21 $250.03 $250.03

$318.44 $358.25 $393.75 $442.97

$318.44 $358.25 $393.75 $442.97

$318.44 $358.25 $393.75 $442.97

$318.44 $358.25 $393.75 $442.97

$319.72 $359.68 $395.32 $444.74

$326.08 $366.85 $403.20 $453.60

$333.73 $375.44 $412.65 $464.23

$346.15 $389.41 $428.00 $481.50

$356.34 $400.88 $440.60 $495.68

$361.43 $424.68 $446.90 $525.11

$369.07 $433.66 $456.35 $536.21

$376.72 $442.64 $465.80 $547.32

$381.49 $448.25 $471.71 $554.26

$386.59 $454.24 $478.01 $561.66

$389.14 $457.24 $481.16 $565.36

$391.68 $460.23 $484.31 $569.06

$394.23 $463.22 $487.46 $572.76

$396.78 $466.22 $490.61 $576.47

$401.87 $472.20 $496.91 $583.87

$406.97 $498.54 $503.21 $616.43

$414.61 $507.90 $512.66 $628.01

$421.94 $516.87 $521.71 $639.10

$432.13 $529.35 $534.31 $654.54

$444.86 $544.96 $550.06 $673.83

$459.83 $563.29 $568.57 $696.50

$477.66 $585.14 $590.62 $723.51

$497.72 $609.71 $615.43 $753.90

$520.65 $637.80 $643.78 $788.63

$543.26 $665.50 $671.73 $822.87

$568.74 $782.01 $703.23 $966.94

$593.89 $816.60 $734.34 $1,009.72

$621.60 $854.70 $768.59 $1,056.82

$649.62 $893.23 $803.24 $1,104.46

$679.87 $934.83 $840.65 $1,155.89

$710.13 $976.42 $878.06 $1,207.33

$742.93 $1,021.52 $918.61 $1,263.09

$776.04 $1,067.06 $959.56 $1,319.40

$811.39 $1,115.66 $1,003.27 $1,379.49

$828.90 $1,139.74 $1,024.92 $1,409.27

$864.25 $1,188.35 $1,068.63 $1,469.37

$894.82 $1,230.38 $1,106.43 $1,521.34

$914.88 $1,257.97 $1,131.24 $1,555.45

$940.04 $1,292.56 $1,162.34 $1,598.22

$955.32 $1,313.57 $1,181.24 $1,624.21

$955.32 $1,313.57 $1,181.24 $1,624.21


#NAME?

$4,250

0%



Yes

$7,150

33871PA0100048

8 8


KE 670 WPR GMC

Yes

33871PA0110015

0%


$3,500

#NAME?


$2,000

KE 670 WPR GMC

Page Number: 22 05/05/2016

RATE PAGES


Product: HMO




Form # =>

Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>


0-20

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61

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64

65+

33871PA0110017 33871PA0110018


$199.35 $199.35 $211.15 $211.15

$313.93 $353.17 $332.52 $374.09

$313.93 $353.17 $332.52 $374.09

$313.93 $353.17 $332.52 $374.09

$313.93 $353.17 $332.52 $374.09

$315.19 $354.59 $333.85 $375.58

$321.47 $361.65 $340.50 $383.07

$329.00 $370.13 $348.48 $392.04

$341.24 $383.90 $361.45 $406.63

$351.29 $395.20 $372.09 $418.60

$356.31 $418.67 $377.41 $443.46

$363.85 $427.52 $385.39 $452.84

$371.38 $436.37 $393.37 $462.21

$376.09 $441.91 $398.36 $468.07

$381.11 $447.81 $403.68 $474.33

$383.63 $450.76 $406.34 $477.45

$386.14 $453.71 $409.00 $480.58

$388.65 $456.66 $411.66 $483.70

$391.16 $459.61 $414.32 $486.83

$396.18 $465.51 $419.64 $493.08

$401.21 $491.48 $424.96 $520.58

$408.74 $500.71 $432.94 $530.36

$415.96 $509.55 $440.59 $539.72

$426.01 $521.86 $451.23 $552.76

$438.56 $537.24 $464.53 $569.05

$453.32 $555.31 $480.16 $588.20

$470.90 $576.85 $498.78 $611.01

$490.68 $601.08 $519.73 $636.67

$513.28 $628.77 $543.67 $666.00

$535.57 $656.07 $567.28 $694.92

$560.68 $770.94 $593.88 $816.59

$585.48 $805.04 $620.15 $852.71

$612.80 $842.59 $649.08 $892.49

$640.42 $880.58 $678.34 $932.72

$670.25 $921.59 $709.93 $976.16

$700.07 $962.59 $741.52 $1,019.60

$732.40 $1,007.06 $775.77 $1,066.69

$765.05 $1,051.95 $810.36 $1,114.24

$799.90 $1,099.86 $847.27 $1,164.99

$817.17 $1,123.60 $865.55 $1,190.14

$852.01 $1,171.52 $902.46 $1,240.89

$882.15 $1,212.96 $934.39 $1,284.78

$901.93 $1,240.15 $955.34 $1,313.59

$926.73 $1,274.25 $981.60 $1,349.71

$941.79 $1,294.97 $997.56 $1,371.65

$941.79 $1,294.97 $997.56 $1,371.65

$3,500 $4,250

33871PA0110018

KE 670 WPR GMC

8 8


Yes Yes

33871PA0110017

0% 0%


$7,150 $7,150


#NAME? #NAME?


KE 670 WPR GMC

Page Number: 23 05/05/2016



33871PA0100005 328.28

33871PA0100006 312.16

33871PA0100009 263.33

33871PA0100036 317.51

33871PA0100037 299.71

33871PA0110006 342.93

33871PA0110007 313

33871PA0110008 331.59

33871PA0110009 326.01




33871PA0100024 329.21

33871PA0100025 313.09

33871PA0100045 264.26

33871PA0100048 318.44

33871PA0100049 300.64

33871PA0110016 343.86

33871PA0110017 313.93

33871PA0110018 332.52

33871PA0110019 326.94


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* 33871

Federal TIN* 23-2405376

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

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

Required:

Enter the rate of an Individual tobacco enrollee

on a plan

33871PA0100001 Rating Area 8 Tobacco User/Non-Tobacco User0-20

274.54 274.54

33871PA0100001 Rating Area 8 Tobacco User/Non-Tobacco User21

432.34 486.39


432.34 486.39


432.34 486.39


432.34 486.39


434.07 488.33


442.72 498.06


453.10 509.73


469.96 528.70


483.79 544.27


490.71 576.58


501.09 588.78


511.46 600.97


517.95 608.59


524.86 616.72


528.32 620.78


531.78 624.84


535.24 628.91


538.70 632.97


545.62 641.10


552.53 676.86


562.91 689.57


572.86 701.75


586.69 718.70


603.98 739.88


624.30 764.77


648.52 794.43


675.75 827.80


706.88 865.93


737.58 903.53


772.17 1061.73


806.32 1108.69


843.93 1160.41


881.98 1212.72


923.05 1269.20


964.13 1325.67


1008.66 1386.90


1053.62 1448.73


1101.61 1514.72


1125.39 1547.41


1173.38 1613.40


1214.89 1670.47


1242.12 1707.92


1276.28 1754.88


1297.02 1783.42

33871PA0100001 Rating Area 8 Tobacco User/Non-Tobacco User65 and over

1297.02 1783.42


262.43 262.43


413.28 464.94


413.28 464.94


413.28 464.94


413.28 464.94


414.93 466.80


423.20 476.10


433.12 487.26


449.24 505.39


462.46 520.27


469.07 551.16


478.99 562.82


488.91 574.47


495.11 581.75


501.72 589.52


505.03 593.41


508.34 597.29


511.64 601.18


514.95 605.06


521.56 612.83


528.17 647.01


538.09 659.16


547.60 670.81


560.82 687.01


577.35 707.26


596.78 731.05


619.92 759.40


645.96 791.30


675.71 827.75


705.06 863.69


738.12 1014.91


770.77 1059.81


806.72 1109.25


843.09 1159.25


882.35 1213.24


921.62 1267.22


964.18 1325.75


1007.17 1384.85


1053.04 1447.93


1075.77 1479.18


1121.64 1542.26


1161.32 1596.81


1187.36 1632.61


1220.00 1677.51


1239.84 1704.78


1239.84 1704.78


216.40 216.40


340.78 383.38


340.78 383.38


340.78 383.38


340.78 383.38


342.14 384.91


348.96 392.58


357.14 401.78


370.43 416.73


381.33 429.00


386.79 454.47


394.96 464.08


403.14 473.69


408.25 479.70


413.71 486.11


416.43 489.31


419.16 492.51


421.89 495.72


424.61 498.92


430.06 505.33


435.52 533.51


443.70 543.53


451.53 553.13


462.44 566.49


476.07 583.19


492.09 602.81


511.17 626.18


532.64 652.48


557.18 682.54


581.37 712.18


608.63 836.87


635.56 873.89


665.20 914.65


695.19 955.89


727.57 1000.40


759.94 1044.92


795.04 1093.18


830.48 1141.91


868.31 1193.92


887.05 1219.70


924.88 1271.71


957.59 1316.69


979.06 1346.21


1005.98 1383.23


1022.34 1405.72


1022.34 1405.72


223.43 223.43


351.86 395.84


351.86 395.84


351.86 395.84


351.86 395.84


353.27 397.43


360.31 405.34


368.75 414.85


382.47 430.28


393.73 442.95


399.36 469.25


407.81 479.17


416.25 489.10


421.53 495.30


427.16 501.91


429.98 505.22


432.79 508.53


435.60 511.84


438.42 515.14


444.05 521.76


449.68 550.86


458.12 561.20


466.22 571.12


477.48 584.91


491.55 602.15


508.09 622.41


527.79 646.55


549.96 673.70


575.29 704.74


600.28 735.34


628.43 864.08


656.22 902.31


686.83 944.40


717.80 986.97


751.23 1032.93


784.65 1078.90


820.89 1128.73


857.49 1179.05


896.54 1232.75


915.90 1259.36


954.95 1313.06


988.73 1359.51


1010.90 1389.99


1038.70 1428.21


1055.58 1451.43


1055.58 1451.43


191.32 191.32


301.28 338.94


301.28 338.94


301.28 338.94


301.28 338.94


302.49 340.30


308.51 347.08


315.75 355.21


327.50 368.43


337.14 379.28


341.96 401.80


349.19 410.30


356.42 418.79


360.94 424.10


365.76 429.77


368.17 432.60


370.58 435.43


372.99 438.26


375.40 441.09


380.22 446.76


385.04 471.67


392.27 480.53


399.20 489.02


408.84 500.83


420.89 515.59


435.05 532.94


451.93 553.61


470.91 576.86


492.60 603.43


513.99 629.64


538.09 739.88


561.89 772.60


588.11 808.65


614.62 845.10


643.24 884.46


671.86 923.81


702.89 966.48


734.23 1009.56


767.67 1055.55


784.24 1078.33


817.68 1124.31


846.61 1164.08


865.59 1190.18


889.39 1222.91


903.84 1242.79


903.84 1242.79


181.92 181.92


286.49 322.30


286.49 322.30


286.49 322.30


286.49 322.30


287.64 323.59


293.37 330.04


300.24 337.77


311.41 350.34


320.58 360.66


325.17 382.07


332.04 390.15


338.92 398.23


343.22 403.28


347.80 408.66


350.09 411.36


352.38 414.05


354.67 416.74


356.97 419.44


361.55 424.82


366.13 448.51


373.01 456.94


379.60 465.01


388.77 476.24


400.23 490.28


413.69 506.77


429.74 526.43


447.78 548.54


468.41 573.80


488.75 598.72


511.67 703.55


534.30 734.67


559.23 768.94


584.44 803.60


611.66 841.03


638.87 878.45


668.38 919.02


698.18 959.99


729.98 1003.72


745.73 1025.38


777.53 1069.11


805.04 1106.93


823.09 1131.74


845.72 1162.86


859.47 1181.77


859.47 1181.77


135.45 135.45


213.30 239.96


213.30 239.96


213.30 239.96


213.30 239.96


214.15 240.92


218.42 245.72


223.54 251.48


231.86 260.84


238.68 268.52


242.09 284.46


247.21 290.48


252.33 296.49


255.53 300.25


258.95 304.26


260.65 306.27


262.36 308.27


264.06 310.28


265.77 312.28


269.18 316.29


272.60 333.93


277.72 340.20


282.62 346.21


289.45 354.57


297.98 365.02


308.00 377.31


319.95 391.94


333.39 408.40


348.74 427.21


363.89 445.76


380.95 523.81


397.80 546.98


416.36 572.50


435.13 598.30


455.39 626.17


475.66 654.03


497.63 684.24


519.81 714.74


543.49 747.29


555.22 763.43


578.89 795.98


599.37 824.14


612.81 842.61


629.66 865.78


639.90 879.86


639.90 879.86


193.47 193.47


304.68 342.77


304.68 342.77


304.68 342.77


304.68 342.77


305.90 344.14


311.99 350.99


319.31 359.22


331.19 372.59


340.94 383.56


345.81 406.33


353.13 414.92


360.44 423.52


365.01 428.89


369.88 434.61


372.32 437.48


374.76 440.34


377.20 443.21


379.63 446.07


384.51 451.80


389.38 477.00


396.70 485.95


403.70 494.54


413.45 506.48


425.64 521.41


439.96 538.95


457.02 559.85


476.22 583.37


498.16 610.24


519.79 636.74


544.16 748.22


568.23 781.32


594.74 817.77


621.55 854.63


650.50 894.43


679.44 934.23


710.82 977.38


742.51 1020.95


776.33 1067.45


793.09 1090.50


826.91 1137.00


856.16 1177.22


875.35 1203.61


899.42 1236.71


914.04 1256.81


914.04 1256.81


153.46 153.46


241.68 271.88


241.68 271.88


241.68 271.88


241.68 271.88


242.64 272.97


247.48 278.41


253.28 284.94


262.70 295.54


270.43 304.24


274.30 322.30


280.10 329.12


285.90 335.93


289.53 340.19


293.39 344.74


295.33 347.01


297.26 349.28


299.19 351.55


301.13 353.83


304.99 358.37


308.86 378.36


314.66 385.46


320.22 392.27


327.95 401.74


337.62 413.59


348.98 427.50


362.51 444.08


377.74 462.73


395.14 484.05


412.30 505.07


431.63 593.49


450.72 619.75


471.75 648.66


493.02 677.90


515.98 709.47


538.94 741.04


563.83 775.26


588.96 809.82


615.79 846.71


629.08 864.99


655.91 901.87


679.11 933.77


694.33 954.71


713.43 980.96


725.03 996.91


725.03 996.91


222.33 222.33


350.13 393.90


350.13 393.90


350.13 393.90


350.13 393.90


351.53 395.48


358.54 403.35


366.94 412.81


380.59 428.17


391.80 440.77


397.40 466.95


405.80 476.82


414.21 486.69


419.46 492.86


425.06 499.45


427.86 502.74


430.66 506.03


433.46 509.32


436.27 512.61


441.87 519.19


447.47 548.15


455.87 558.44


463.93 568.31


475.13 582.03


489.14 599.19


505.59 619.35


525.20 643.37


547.26 670.39


572.47 701.27


597.33 731.73


625.34 859.84


653.00 897.87


683.46 939.76


714.27 982.12


747.53 1027.86


780.80 1073.60


816.86 1123.18


853.27 1173.25


892.14 1226.69


911.40 1253.17


950.26 1306.61


983.87 1352.83


1005.93 1383.16


1033.59 1421.19


1050.39 1444.30


1050.39 1444.30


185.04 185.04


291.40 327.83


291.40 327.83


291.40 327.83


291.40 327.83


292.57 329.14


298.40 335.70


305.39 343.56


316.75 356.35


326.08 366.84


330.74 388.62


337.74 396.84


344.73 405.06


349.10 410.19


353.76 415.67


356.09 418.41


358.42 421.15


360.76 423.89


363.09 426.63


367.75 432.11


372.41 456.20


379.41 464.77


386.11 472.98


395.43 484.41


407.09 498.68


420.78 515.46


437.10 535.45


455.46 557.94


476.44 583.64


497.13 608.99


520.44 715.61


543.46 747.26


568.82 782.12


594.46 817.38


622.14 855.45


649.83 893.51


679.84 934.78


710.15 976.45


742.49 1020.93


758.52 1042.96


790.87 1087.44


818.84 1125.91


837.20 1151.15


860.22 1182.80


874.20 1202.03


874.20 1202.03


174.66 174.66


275.06 309.44


275.06 309.44


275.06 309.44


275.06 309.44


276.16 310.68


281.66 316.87


288.26 324.30


298.99 336.37


307.79 346.27


312.19 366.83


318.80 374.59


325.40 382.34


329.52 387.19


333.92 392.36


336.12 394.95


338.33 397.53


340.53 400.12


342.73 402.70


347.13 407.87


351.53 430.62


358.13 438.71


364.46 446.46


373.26 457.24


384.26 470.72


397.19 486.56


412.59 505.42


429.92 526.65


449.72 550.91


469.25 574.84


491.26 675.48


512.99 705.36


536.92 738.26


561.12 771.55


587.26 807.48


613.39 843.41


641.72 882.36


670.32 921.70


700.86 963.68


715.98 984.48


746.52 1026.46


772.92 1062.77


790.25 1086.59


811.98 1116.47


825.18 1134.63


825.18 1134.63


287.26 287.26


452.39 508.93


452.39 508.93


452.39 508.93


452.39 508.93


454.19 510.97


463.24 521.15


474.10 533.36


491.74 553.21


506.22 569.50


513.46 603.31


524.31 616.07


535.17 628.83


541.96 636.80


549.20 645.30


552.81 649.56


556.43 653.81


560.05 658.06


563.67 662.31


570.91 670.82


578.15 708.23


589.01 721.53


599.41 734.28


613.89 752.01


631.98 774.18


653.24 800.22


678.58 831.26


707.08 866.17


739.65 906.07


771.77 945.42


807.96 1110.94


843.70 1160.08


883.06 1214.20


922.87 1268.94


965.84 1328.03


1008.82 1387.13


1055.41 1451.19


1102.46 1515.89


1152.68 1584.93


1177.56 1619.14


1227.77 1688.19


1271.20 1747.90


1299.70 1787.09


1335.44 1836.23


1357.16 1866.09


1357.16 1866.09


274.60 274.60


432.44 486.50


432.44 486.50


432.44 486.50


432.44 486.50


434.17 488.44


442.82 498.17


453.20 509.85


470.06 528.82


483.90 544.39


490.82 576.71


501.20 588.91


511.58 601.10


518.06 608.73


524.98 616.86


528.44 620.92


531.90 624.99


535.36 629.05


538.82 633.11


545.74 641.24


552.66 677.01


563.04 689.72


572.98 701.91


586.82 718.86


604.12 740.05


624.44 764.94


648.66 794.61


675.90 827.98


707.04 866.12


737.74 903.74


772.34 1061.97


806.50 1108.94


844.12 1160.67


882.18 1213.00


923.26 1269.48


964.34 1325.97


1008.88 1387.22


1053.86 1449.05


1101.86 1515.06


1125.64 1547.76


1173.64 1613.76


1215.16 1670.84


1242.40 1708.30


1276.57 1755.28


1297.32 1783.82


1297.32 1783.82


226.06 226.06


356.00 400.49


356.00 400.49


356.00 400.49


356.00 400.49


357.42 402.10


364.54 410.11


373.08 419.72


386.97 435.34


398.36 448.15


404.05 474.76


412.60 484.80


421.14 494.84


426.48 501.12


432.18 507.81


435.03 511.16


437.87 514.50


440.72 517.85


443.57 521.19


449.27 527.89


454.96 557.33


463.51 567.79


471.69 577.82


483.09 591.78


497.33 609.22


514.06 629.72


533.99 654.14


556.42 681.62


582.05 713.01


607.33 743.98


635.81 874.24


663.93 912.91


694.90 955.49


726.23 998.57


760.05 1045.07


793.87 1091.57


830.54 1141.99


867.56 1192.90


907.08 1247.23


926.66 1274.15


966.17 1328.49


1000.35 1375.48


1022.77 1406.31


1050.90 1444.98


1067.99 1468.48


1067.99 1468.48


232.67 232.67


366.40 412.20


366.40 412.20


366.40 412.20


366.40 412.20


367.87 413.85


375.20 422.10


383.99 431.99


398.28 448.06


410.00 461.25


415.87 488.64


424.66 498.98


433.45 509.31


438.95 515.77


444.81 522.65


447.74 526.10


450.67 529.54


453.61 532.99


456.54 536.43


462.40 543.32


468.26 573.62


477.06 584.39


485.48 594.72


497.21 609.08


511.86 627.03


529.09 648.13


549.60 673.26


572.69 701.54


599.07 733.86


625.08 765.73


654.39 899.79


683.34 939.59


715.22 983.42


747.46 1027.76


782.27 1075.62


817.08 1123.48


854.82 1175.37


892.92 1227.77


933.59 1283.69


953.75 1311.40


994.42 1367.32


1029.59 1415.69


1052.67 1447.43


1081.62 1487.23


1099.20 1511.41


1099.20 1511.41


228.93 228.93


360.51 405.58


360.51 405.58


360.51 405.58


360.51 405.58


361.96 407.20


369.17 415.31


377.82 425.05


391.88 440.86


403.42 453.84


409.18 480.79


417.84 490.96


426.49 501.12


431.90 507.48


437.66 514.26


440.55 517.65


443.43 521.03


446.32 524.42


449.20 527.81


454.97 534.59


460.74 564.40


469.39 575.00


477.68 585.16


489.22 599.29


503.64 616.96


520.58 637.71


540.77 662.45


563.48 690.27


589.44 722.07


615.04 753.42


643.88 885.33


672.36 924.49


703.72 967.62


735.45 1011.24


769.70 1058.34


803.95 1105.43


841.08 1156.49


878.57 1208.04


918.59 1263.06


938.42 1290.33


978.44 1345.35


1013.05 1392.94


1035.76 1424.17


1064.24 1463.33


1081.53 1487.12


1081.53 1487.12


199.85 199.85


314.73 354.07


314.73 354.07


314.73 354.07


314.73 354.07


315.99 355.49


322.28 362.57


329.84 371.07


342.11 384.88


352.18 396.21


357.22 419.73


364.77 428.61


372.33 437.48


377.05 443.03


382.08 448.95


384.60 451.91


387.12 454.86


389.64 457.82


392.15 460.78


397.19 466.70


402.23 492.73


409.78 501.98


417.02 510.85


427.09 523.18


439.68 538.61


454.47 556.73


472.10 578.32


491.92 602.61


514.58 630.37


536.93 657.74


562.11 772.90


586.97 807.09


614.35 844.74


642.05 882.82


671.95 923.93


701.85 965.04


734.27 1009.62


767.00 1054.62


801.93 1102.66


819.24 1126.46


854.18 1174.50


884.39 1216.04


904.22 1243.30


929.08 1277.49


944.19 1298.26


944.19 1298.26


182.41 182.41


287.26 323.17


287.26 323.17


287.26 323.17


287.26 323.17


288.41 324.46


294.16 330.93


301.05 338.68


312.26 351.29


321.45 361.63


326.04 383.10


332.94 391.20


339.83 399.30


344.14 404.37


348.74 409.77


351.04 412.47


353.33 415.17


355.63 417.87


357.93 420.57


362.53 425.97


367.12 449.72


374.02 458.17


380.62 466.26


389.82 477.52


401.31 491.60


414.81 508.14


430.89 527.85


448.99 550.02


469.68 575.35


490.07 600.34


513.05 705.45


535.75 736.65


560.74 771.01


586.02 805.77


613.31 843.30


640.60 880.82


670.18 921.50


700.06 962.58


731.95 1006.43


747.75 1028.15


779.63 1071.99


807.21 1109.91


825.31 1134.80


848.00 1166.00


861.78 1184.96


861.78 1184.96


193.25 193.25


304.32 342.36


304.32 342.36


304.32 342.36


304.32 342.36


305.54 343.73


311.63 350.58


318.93 358.80


330.80 372.15


340.54 383.11


345.41 405.85


352.71 414.44


360.02 423.02


364.58 428.38


369.45 434.10


371.88 436.96


374.32 439.82


376.75 442.69


379.19 445.55


384.06 451.27


388.93 476.43


396.23 485.38


403.23 493.96


412.97 505.89


425.14 520.80


439.44 538.32


456.49 559.20


475.66 582.68


497.57 609.52


519.18 635.99


543.52 747.34


567.56 780.40


594.04 816.81


620.82 853.63


649.73 893.38


678.64 933.13


709.99 976.23


741.64 1019.75


775.42 1066.20


792.16 1089.21


825.94 1135.66


855.15 1175.83


874.32 1202.19


898.36 1235.25


912.96 1255.34


912.96 1255.34


189.99 189.99


299.20 336.60


299.20 336.60


299.20 336.60


299.20 336.60


300.39 337.94


306.38 344.68


313.56 352.75


325.23 365.88


334.80 376.65


339.59 399.02


346.77 407.45


353.95 415.89


358.44 421.17


363.23 426.79


365.62 429.60


368.01 432.42


370.41 435.23


372.80 438.04


377.59 443.67


382.37 468.41


389.56 477.21


396.44 485.64


406.01 497.36


417.98 512.02


432.04 529.25


448.80 549.78


467.65 572.87


489.19 599.26


510.43 625.28


534.37 734.75


558.00 767.26


584.03 803.05


610.36 839.25


638.79 878.33


667.21 917.42


698.03 959.79


729.14 1002.57


762.36 1048.24


778.81 1070.87


812.02 1116.53


840.75 1156.03


859.60 1181.94


883.23 1214.44


897.59 1234.19


897.59 1234.19


141.33 141.33


222.57 250.39


222.57 250.39


222.57 250.39


222.57 250.39


223.46 251.39


227.91 256.40


233.25 262.41


241.93 272.17


249.06 280.19


252.62 296.82


257.96 303.10


263.30 309.38


266.64 313.30


270.20 317.48


271.98 319.58


273.76 321.67


275.54 323.76


277.32 325.85


280.88 330.04


284.44 348.44


289.79 354.99


294.90 361.26


302.03 369.98


310.93 380.89


321.39 393.70


333.85 408.97


347.88 426.15


363.90 445.78


379.70 465.14


397.51 546.57


415.09 570.75


434.46 597.38


454.04 624.31


475.19 653.38


496.33 682.45


519.25 713.97


542.40 745.80


567.11 779.77


579.35 796.60


604.05 830.57


625.42 859.95


639.44 879.23


657.02 903.41


667.71 918.10


667.71 918.10











Required:


Required:


Require:



plan

Required:


rate

Required:



Required:


on a plan


282.50 282.50


444.88 500.49


444.88 500.49


444.88 500.49


444.88 500.49


446.66 502.49


455.56 512.50


466.24 524.52


483.59 544.03


497.82 560.05


504.94 593.30


515.62 605.85


526.29 618.40


532.97 626.24


540.09 634.60


543.65 638.78


547.20 642.96


550.76 647.15


554.32 651.33


561.44 659.69


568.56 696.48


579.24 709.56


589.47 722.10


603.70 739.54


621.50 761.34


642.41 786.95


667.32 817.47


695.35 851.80


727.38 891.04


758.97 929.74


794.56 1092.52


829.70 1140.84


868.41 1194.06


907.56 1247.89


949.82 1306.01


992.09 1364.12


1037.91 1427.12


1084.18 1490.74


1133.56 1558.64


1158.03 1592.29


1207.41 1660.19


1250.12 1718.91


1278.14 1757.45


1313.29 1805.77


1334.64 1835.14


1334.64 1835.14


270.04 270.04


425.27 478.42


425.27 478.42


425.27 478.42


425.27 478.42


426.97 480.34


435.47 489.91


445.68 501.39


462.26 520.05


475.87 535.36


482.68 567.15


492.88 579.14


503.09 591.13


509.47 598.63


516.27 606.62


519.67 610.62


523.08 614.62


526.48 618.61


529.88 622.61


536.69 630.61


543.49 665.78


553.70 678.28


563.48 690.26


577.09 706.93


594.10 727.77


614.08 752.25


637.90 781.43


664.69 814.25


695.31 851.75


725.50 888.74


759.52 1044.35


793.12 1090.54


830.12 1141.41


867.54 1192.87


907.94 1248.42


948.34 1303.97


992.15 1364.20


1036.37 1425.01


1083.58 1489.92


1106.97 1522.08


1154.17 1586.99


1195.00 1643.12


1221.79 1679.96


1255.38 1726.15


1275.80 1754.22


1275.80 1754.22


222.67 222.67


350.66 394.50


350.66 394.50


350.66 394.50


350.66 394.50


352.07 396.07


359.08 403.96


367.49 413.43


381.17 428.82


392.39 441.44


398.00 467.65


406.42 477.54


414.83 487.43


420.09 493.61


425.70 500.20


428.51 503.50


431.32 506.80


434.12 510.09


436.93 513.39


442.54 519.98


448.15 548.98


456.56 559.29


464.63 569.17


475.85 582.92


489.88 600.10


506.36 620.29


525.99 644.34


548.09 671.41


573.33 702.33


598.23 732.83


626.28 861.14


653.99 899.23


684.49 941.18


715.35 983.61


748.67 1029.41


781.98 1075.22


818.10 1124.88


854.57 1175.03


893.49 1228.55


912.78 1255.07


951.70 1308.59


985.36 1354.87


1007.45 1385.25


1035.16 1423.34


1051.98 1446.48


1051.98 1446.48


229.91 229.91


362.07 407.32


362.07 407.32


362.07 407.32


362.07 407.32


363.51 408.95


370.76 417.10


379.44 426.88


393.57 442.76


405.15 455.80


410.94 482.86


419.63 493.07


428.32 503.28


433.75 509.66


439.55 516.47


442.44 519.87


445.34 523.28


448.24 526.68


451.13 530.08


456.93 536.89


462.72 566.83


471.41 577.48


479.74 587.68


491.32 601.87


505.81 619.61


522.82 640.46


543.10 665.30


565.91 693.24


591.98 725.17


617.68 756.66


646.65 889.14


675.25 928.47


706.75 971.78


738.61 1015.59


773.01 1062.89


807.41 1110.18


844.70 1161.46


882.35 1213.24


922.54 1268.50


942.46 1295.88


982.65 1351.14


1017.40 1398.93


1040.22 1430.30


1068.82 1469.63


1086.20 1493.52


1086.20 1493.52


196.86 196.86


310.02 348.77


310.02 348.77


310.02 348.77


310.02 348.77


311.26 350.17


317.46 357.14


324.90 365.51


336.99 379.12


346.91 390.28


351.87 413.45


359.31 422.19


366.75 430.94


371.40 436.40


376.37 442.23


378.85 445.14


381.33 448.06


383.81 450.97


386.29 453.89


391.25 459.71


396.21 485.35


403.65 494.47


410.78 503.20


420.70 515.36


433.10 530.55


447.67 548.40


465.03 569.66


484.56 593.59


506.88 620.93


528.90 647.90


553.70 761.33


578.19 795.01


605.16 832.10


632.44 869.61


661.89 910.10


691.35 950.60


723.28 994.51


755.52 1038.84


789.93 1086.16


806.98 1109.60


841.40 1156.92


871.16 1197.84


890.69 1224.70


915.18 1258.37


930.06 1278.84


930.06 1278.84


187.20 187.20


294.80 331.65


294.80 331.65


294.80 331.65


294.80 331.65


295.98 332.97


301.87 339.61


308.95 347.57


320.45 360.50


329.88 371.11


334.60 393.15


341.67 401.46


348.75 409.78


353.17 414.97


357.89 420.52


360.24 423.29


362.60 426.06


364.96 428.83


367.32 431.60


372.04 437.14


376.75 461.52


383.83 470.19


390.61 478.49


400.04 490.05


411.83 504.50


425.69 521.47


442.20 541.69


460.77 564.44


482.00 590.44


502.93 616.08


526.51 723.95


549.80 755.97


575.45 791.24


601.39 826.91


629.39 865.42


657.40 903.93


687.76 945.68


718.42 987.83


751.15 1032.83


767.36 1055.12


800.08 1100.11


828.38 1139.03


846.96 1164.56


870.24 1196.59


884.39 1216.04


884.39 1216.04


139.37 139.37


219.49 246.92


219.49 246.92


219.49 246.92


219.49 246.92


220.36 247.91


224.75 252.85


230.02 258.77


238.58 268.40


245.60 276.30


249.12 292.71


254.38 298.90


259.65 305.09


262.94 308.96


266.45 313.08


268.21 315.15


269.97 317.21


271.72 319.27


273.48 321.34


276.99 325.46


280.50 343.61


285.77 350.07


290.82 356.25


297.84 364.86


306.62 375.61


316.94 388.25


329.23 403.30


343.06 420.24


358.86 439.60


374.44 458.69


392.00 539.00


409.34 562.84


428.44 589.10


447.75 615.66


468.60 644.33


489.45 673.00


512.06 704.08


534.89 735.47


559.25 768.97


571.32 785.56


595.68 819.06


616.75 848.04


630.58 867.05


647.92 890.89


658.46 905.38


658.46 905.38


199.08 199.08


313.52 352.71


313.52 352.71


313.52 352.71


313.52 352.71


314.77 354.12


321.04 361.17


328.57 369.64


340.79 383.39


350.83 394.68


355.84 418.12


363.37 426.96


370.89 435.80


375.59 441.32


380.61 447.22


383.12 450.16


385.63 453.11


388.14 456.06


390.64 459.01


395.66 464.90


400.68 490.83


408.20 500.05


415.41 508.88


425.44 521.17


437.98 536.53


452.72 554.58


470.28 576.09


490.03 600.29


512.60 627.94


534.86 655.21


559.94 769.92


584.71 803.98


611.99 841.48


639.58 879.42


669.36 920.37


699.15 961.32


731.44 1005.73


764.04 1050.56


798.84 1098.41


816.09 1122.12


850.89 1169.97


880.99 1211.36


900.74 1238.51


925.51 1272.57


940.55 1293.26


940.55 1293.26


157.91 157.91


248.68 279.77


248.68 279.77


248.68 279.77


248.68 279.77


249.68 280.89


254.65 286.48


260.62 293.20


270.32 304.11


278.28 313.06


282.26 331.65


288.22 338.66


294.19 345.68


297.92 350.06


301.90 354.74


303.89 357.07


305.88 359.41


307.87 361.75


309.86 364.09


313.84 368.76


317.82 389.33


323.79 396.64


329.51 403.65


337.46 413.39


347.41 425.58


359.10 439.90


373.03 456.96


388.69 476.15


406.60 498.08


424.26 519.71


444.15 610.71


463.80 637.72


485.43 667.47


507.32 697.56


530.94 730.04


554.57 762.53


580.18 797.75


606.04 833.31


633.65 871.26


647.32 890.07


674.93 928.03


698.80 960.85


714.47 982.40


734.12 1009.41


746.04 1025.82


746.04 1025.82


228.78 228.78


360.29 405.32


360.29 405.32


360.29 405.32


360.29 405.32


361.73 406.94


368.93 415.05


377.58 424.78


391.63 440.59


403.16 453.56


408.93 480.49


417.57 490.65


426.22 500.81


431.62 507.16


437.39 513.93


440.27 517.32


443.15 520.70


446.04 524.09


448.92 527.48


454.68 534.25


460.45 564.05


469.09 574.64


477.38 584.79


488.91 598.91


503.32 616.57


520.25 637.31


540.43 662.03


563.13 689.83


589.07 721.61


614.65 752.95


643.47 884.77


671.93 923.91


703.28 967.01


734.99 1010.60


769.21 1057.67


803.44 1104.73


840.55 1155.75


878.02 1207.28


918.01 1262.26


937.83 1289.51


977.82 1344.50


1012.41 1392.06


1035.10 1423.27


1063.57 1462.40


1080.86 1486.18


1080.86 1486.18


190.41 190.41


299.85 337.33


299.85 337.33


299.85 337.33


299.85 337.33


301.05 338.68


307.05 345.43


314.25 353.53


325.94 366.68


335.54 377.48


340.33 399.89


347.53 408.35


354.73 416.80


359.22 422.09


364.02 427.73


366.42 430.54


368.82 433.36


371.22 436.18


373.62 439.00


378.41 444.64


383.21 469.43


390.41 478.25


397.30 486.70


406.90 498.45


418.89 513.15


432.99 530.41


449.78 550.98


468.67 574.12


490.26 600.57


511.55 626.65


535.54 736.36


559.23 768.94


585.31 804.80


611.70 841.09


640.19 880.26


668.67 919.42


699.56 961.89


730.74 1004.77


764.02 1050.53


780.52 1073.21


813.80 1118.98


842.59 1158.56


861.48 1184.53


885.17 1217.10


899.55 1236.89


899.55 1236.89


179.73 179.73


283.04 318.42


283.04 318.42


283.04 318.42


283.04 318.42


284.17 319.69


289.83 326.06


296.62 333.70


307.66 346.12


316.72 356.31


321.25 377.47


328.04 385.45


334.83 393.43


339.08 398.42


343.61 403.74


345.87 406.40


348.14 409.06


350.40 411.72


352.67 414.38


357.19 419.70


361.72 443.11


368.52 451.43


375.03 459.41


384.08 470.50


395.40 484.37


408.71 500.67


424.56 520.08


442.39 541.93


462.77 566.89


482.86 591.51


505.51 695.07


527.87 725.82


552.49 759.67


577.40 793.92


604.29 830.89


631.17 867.86


660.33 907.95


689.76 948.42


721.18 991.62


736.75 1013.03


768.16 1056.23


795.34 1093.59


813.17 1118.11


835.53 1148.85


849.11 1167.53


849.11 1167.53


295.60 295.60


465.50 523.69


465.50 523.69


465.50 523.69


465.50 523.69


467.37 525.79


476.68 536.26


487.85 548.83


506.00 569.25


520.90 586.01


528.35 620.81


539.52 633.94


550.69 647.06


557.67 655.27


565.12 664.02


568.85 668.39


572.57 672.77


576.29 677.15


580.02 681.52


587.47 690.27


594.91 728.77


606.09 742.46


616.79 755.57


631.69 773.82


650.31 796.63


672.19 823.43


698.26 855.36


727.58 891.29


761.10 932.35


794.15 972.83


831.39 1143.16


868.17 1193.73


908.66 1249.41


949.63 1305.74


993.85 1366.55


1038.07 1427.35


1086.02 1493.28


1134.43 1559.85


1186.10 1630.89


1211.71 1666.10


1263.38 1737.15


1308.07 1798.59


1337.39 1838.92


1374.17 1889.48


1396.50 1920.21


1396.50 1920.21


282.56 282.56


444.98 500.60


444.98 500.60


444.98 500.60


444.98 500.60


446.76 502.61


455.66 512.62


466.34 524.63


483.69 544.16


497.93 560.18


505.05 593.44


515.73 605.99


526.41 618.54


533.09 626.38


540.21 634.74


543.77 638.93


547.33 643.11


550.89 647.29


554.45 651.48


561.57 659.84


568.69 696.64


579.37 709.72


589.60 722.26


603.84 739.70


621.64 761.51


642.55 787.13


667.47 817.65


695.51 852.00


727.54 891.24


759.14 929.94


794.74 1092.76


829.89 1141.10


868.60 1194.33


907.76 1248.17


950.04 1306.30


992.31 1364.42


1038.14 1427.45


1084.42 1491.08


1133.81 1558.99


1158.29 1592.64


1207.68 1660.56


1250.40 1719.30


1278.43 1757.84


1313.59 1806.18


1334.94 1835.55


1334.94 1835.55


232.61 232.61


366.32 412.11


366.32 412.11


366.32 412.11


366.32 412.11


367.78 413.76


375.11 422.00


383.90 431.89


398.19 447.96


409.91 461.15


415.77 488.53


424.56 498.86


433.36 509.19


438.85 515.65


444.71 522.54


447.64 525.98


450.57 529.42


453.50 532.87


456.43 536.31


462.29 543.20


468.16 573.49


476.95 584.26


485.37 594.58


497.09 608.94


511.75 626.89


528.96 647.98


549.48 673.11


572.56 701.38


598.93 733.69


624.94 765.55


654.25 899.59


683.19 939.38


715.05 983.20


747.29 1027.52


782.09 1075.38


816.89 1123.23


854.62 1175.11


892.72 1227.49


933.38 1283.40


953.53 1311.10


994.19 1367.01


1029.36 1415.37


1052.43 1447.10


1081.37 1486.89


1098.96 1511.07


1098.96 1511.07


239.41 239.41


377.03 424.16


377.03 424.16


377.03 424.16


377.03 424.16


378.54 425.85


386.08 434.34


395.13 444.52


409.83 461.06


421.89 474.63


427.93 502.81


436.98 513.45


446.02 524.08


451.68 530.72


457.71 537.81


460.73 541.36


463.74 544.90


466.76 548.44


469.78 551.99


475.81 559.08


481.84 590.26


490.89 601.34


499.56 611.96


511.63 626.74


526.71 645.22


544.43 666.92


565.54 692.79


589.29 721.89


616.44 755.14


643.21 787.93


673.37 925.89


703.16 966.84


735.96 1011.94


769.14 1057.56


804.95 1106.81


840.77 1156.06


879.61 1209.46


918.82 1263.37


960.67 1320.92


981.40 1349.43


1023.25 1406.97


1059.45 1456.74


1083.20 1489.40


1112.99 1530.36


1131.08 1555.24


1131.08 1555.24


235.57 235.57


370.97 417.34


370.97 417.34


370.97 417.34


370.97 417.34


372.45 419.01


379.87 427.36


388.78 437.37


403.24 453.65


415.12 467.00


421.05 494.73


429.95 505.20


438.86 515.66


444.42 522.20


450.36 529.17


453.32 532.66


456.29 536.14


459.26 539.63


462.23 543.12


468.16 550.09


474.10 580.77


483.00 591.68


491.53 602.13


503.41 616.67


518.24 634.85


535.68 656.21


556.45 681.66


579.83 710.29


606.54 743.01


632.87 775.27


662.55 911.01


691.86 951.31


724.13 995.68


756.78 1040.57


792.02 1089.03


827.26 1137.49


865.47 1190.02


904.05 1243.07


945.23 1299.69


965.63 1327.75


1006.81 1384.37


1042.42 1433.33


1065.80 1465.47


1095.10 1505.77


1112.91 1530.25


1112.91 1530.25


205.65 205.65


323.86 364.34


323.86 364.34


323.86 364.34


323.86 364.34


325.15 365.80


331.63 373.08


339.40 381.83


352.03 396.04


362.40 407.70


367.58 431.90


375.35 441.04


383.12 450.17


387.98 455.88


393.16 461.97


395.75 465.01


398.35 468.06


400.94 471.10


403.53 474.14


408.71 480.23


413.89 507.02


421.66 516.54


429.11 525.66


439.47 538.36


452.43 554.23


467.65 572.87


485.79 595.09


506.19 620.08


529.51 648.65


552.50 676.81


578.41 795.31


603.99 830.49


632.17 869.23


660.67 908.42


691.44 950.72


722.20 993.03


755.56 1038.90


789.24 1085.21


825.19 1134.64


843.00 1159.13


878.95 1208.56


910.04 1251.31


930.44 1279.36


956.03 1314.54


971.57 1335.91


971.57 1335.91


187.70 187.70


295.59 332.54


295.59 332.54


295.59 332.54


295.59 332.54


296.78 333.87


302.69 340.52


309.78 348.51


321.31 361.47


330.77 372.12


335.50 394.21


342.59 402.55


349.69 410.88


354.12 416.09


358.85 421.65


361.22 424.43


363.58 427.21


365.95 429.99


368.31 432.76


373.04 438.32


377.77 462.77


384.86 471.46


391.66 479.79


401.12 491.37


412.94 505.86


426.84 522.88


443.39 543.15


462.01 565.97


483.30 592.04


504.28 617.75


527.93 725.90


551.28 758.01


577.00 793.37


603.01 829.14


631.09 867.75


659.17 906.36


689.62 948.23


720.36 990.50


753.17 1035.61


769.43 1057.97


802.24 1103.08


830.62 1142.10


849.24 1167.71


872.59 1199.82


886.77 1219.32


886.77 1219.32


198.85 198.85


313.15 352.29


313.15 352.29


313.15 352.29


313.15 352.29


314.40 353.70


320.67 360.75


328.18 369.20


340.39 382.94


350.41 394.22


355.42 417.62


362.94 426.45


370.46 435.29


375.15 440.80


380.16 446.69


382.67 449.64


385.17 452.58


387.68 455.52


390.18 458.47


395.19 464.35


400.21 490.25


407.72 499.46


414.92 508.28


424.94 520.56


437.47 535.90


452.19 553.93


469.72 575.41


489.45 599.58


512.00 627.20


534.23 654.44


559.29 769.02


584.02 803.03


611.27 840.49


638.83 878.38


668.57 919.29


698.32 960.19


730.58 1004.54


763.15 1049.33


797.91 1097.12


815.13 1120.80


849.89 1168.60


879.95 1209.93


899.68 1237.06


924.42 1271.07


939.45 1291.74


939.45 1291.74


195.50 195.50


307.87 346.36


307.87 346.36


307.87 346.36


307.87 346.36


309.11 347.74


315.26 354.67


322.65 362.98


334.66 376.49


344.51 387.58


349.44 410.59


356.83 419.27


364.22 427.95


368.83 433.38


373.76 439.17


376.22 442.06


378.69 444.96


381.15 447.85


383.61 450.74


388.54 456.53


393.46 481.99


400.85 491.04


407.93 499.72


417.79 511.79


430.10 526.87


444.57 544.60


461.81 565.72


481.21 589.48


503.37 616.63


525.23 643.41


549.86 756.06


574.19 789.51


600.97 826.34


628.06 863.59


657.31 903.80


686.56 944.02


718.27 987.62


750.29 1031.65


784.46 1078.64


801.40 1101.92


835.57 1148.91


865.13 1189.55


884.52 1216.22


908.85 1249.66


923.61 1269.98


923.61 1269.98


145.43 145.43


229.02 257.65


229.02 257.65


229.02 257.65


229.02 257.65


229.94 258.68


234.52 263.84


240.02 270.02


248.95 280.07


256.28 288.31


259.94 305.43


265.44 311.89


270.94 318.35


274.37 322.39


278.03 326.69


279.87 328.84


281.70 331.00


283.53 333.15


285.36 335.30


289.03 339.61


292.69 358.55


298.19 365.28


303.46 371.73


310.79 380.71


319.95 391.93


330.71 405.12


343.54 420.83


357.96 438.51


374.45 458.71


390.71 478.63


409.04 562.43


427.13 587.30


447.05 614.70


467.21 642.41


488.97 672.33


510.72 702.24


534.31 734.68


558.13 767.43


583.55 802.39


596.15 819.70


621.57 854.66


643.56 884.89


657.99 904.73


676.08 929.61


687.06 944.72


687.06 944.72











Required:


Required:


Require:



plan

Required:


rate

Required:



Required:


on a plan


290.71 290.71


457.81 515.03


457.81 515.03


457.81 515.03


457.81 515.03


459.64 517.09


468.80 527.40


479.78 539.76


497.64 559.84


512.29 576.32


519.61 610.54


530.60 623.46


541.59 636.37


548.45 644.43


555.78 653.04


559.44 657.34


563.10 661.65


566.77 665.95


570.43 670.25


577.75 678.86


585.08 716.72


596.07 730.18


606.60 743.08


621.25 761.03


639.56 783.46


661.08 809.82


686.71 841.22


715.55 876.55


748.52 916.93


781.02 956.75


817.65 1124.26


853.81 1173.99


893.64 1228.76


933.93 1284.15


977.42 1343.95


1020.91 1403.76


1068.07 1468.59


1115.68 1534.06


1166.50 1603.93


1191.68 1638.55


1242.49 1708.43


1286.44 1768.86


1315.28 1808.52


1351.45 1858.24


1373.43 1888.46


1373.43 1888.46


277.89 277.89


437.62 492.33


437.62 492.33


437.62 492.33


437.62 492.33


439.37 494.30


448.13 504.14


458.63 515.96


475.70 535.16


489.70 550.91


496.70 583.62


507.21 595.97


517.71 608.31


524.27 616.02


531.27 624.25


534.78 628.36


538.28 632.47


541.78 636.59


545.28 640.70


552.28 648.93


559.28 685.12


569.79 697.99


579.85 710.32


593.85 727.47


611.36 748.92


631.93 774.11


656.43 804.13


684.00 837.91


715.51 876.50


746.58 914.57


781.59 1074.69


816.17 1122.23


854.24 1174.58


892.75 1227.53


934.33 1284.70


975.90 1341.86


1020.97 1403.84


1066.49 1466.42


1115.06 1533.21


1139.13 1566.31


1187.71 1633.10


1229.72 1690.87


1257.29 1728.78


1291.86 1776.31


1312.86 1805.19


1312.86 1805.19


229.14 229.14


360.85 405.96


360.85 405.96


360.85 405.96


360.85 405.96


362.30 407.58


369.51 415.70


378.17 425.44


392.25 441.28


403.79 454.27


409.57 481.24


418.23 491.42


426.89 501.59


432.30 507.95


438.07 514.74


440.96 518.13


443.85 521.52


446.74 524.91


449.62 528.31


455.40 535.09


461.17 564.93


469.83 575.54


478.13 585.71


489.68 599.85


504.11 617.54


521.07 638.31


541.28 663.07


564.01 690.91


589.99 722.74


615.61 754.13


644.48 886.16


672.99 925.36


704.38 968.53


736.14 1012.19


770.42 1059.33


804.70 1106.46


841.87 1157.57


879.40 1209.17


919.45 1264.25


939.30 1291.54


979.35 1346.61


1013.99 1394.24


1036.73 1425.50


1065.24 1464.70


1082.55 1488.52


1082.55 1488.52


236.59 236.59


372.59 419.16


372.59 419.16


372.59 419.16


372.59 419.16


374.08 420.84


381.53 429.22


390.47 439.28


405.00 455.63


416.92 469.04


422.89 496.89


431.83 507.40


440.77 517.90


446.36 524.47


452.32 531.48


455.30 534.98


458.28 538.48


461.26 541.98


464.24 545.49


470.20 552.49


476.17 583.30


485.11 594.26


493.68 604.75


505.60 619.36


520.50 637.62


538.01 659.07


558.88 684.63


582.35 713.38


609.18 746.24


635.63 778.65


665.44 914.98


694.87 955.45


727.29 1000.02


760.08 1045.11


795.47 1093.77


830.87 1142.44


869.24 1195.21


907.99 1248.49


949.35 1305.36


969.84 1333.53


1011.20 1390.40


1046.97 1439.58


1070.44 1471.86


1099.88 1512.33


1117.76 1536.92


1117.76 1536.92


202.58 202.58


319.03 358.91


319.03 358.91


319.03 358.91


319.03 358.91


320.31 360.34


326.69 367.52


334.34 376.14


346.78 390.13


356.99 401.62


362.10 425.47


369.75 434.46


377.41 443.46


382.20 449.08


387.30 455.08


389.85 458.08


392.41 461.08


394.96 464.08


397.51 467.07


402.61 473.07


407.72 499.46


415.38 508.84


422.71 517.82


432.92 530.33


445.68 545.96


460.68 564.33


478.54 586.22


498.64 610.84


521.61 638.98


544.26 666.72


569.79 783.46


594.99 818.11


622.74 856.27


650.82 894.88


681.13 936.55


711.44 978.22


744.30 1023.41


777.47 1069.03


812.89 1117.72


830.43 1141.85


865.85 1190.54


896.47 1232.65


916.57 1260.28


941.77 1294.94


957.09 1316.00


957.09 1316.00


192.64 192.64


303.36 341.28


303.36 341.28


303.36 341.28


303.36 341.28


304.58 342.65


310.65 349.48


317.93 357.67


329.76 370.98


339.46 381.90


344.32 404.57


351.60 413.13


358.88 421.68


363.43 427.03


368.28 432.73


370.71 435.59


373.14 438.44


375.57 441.29


377.99 444.14


382.85 449.84


387.70 474.93


394.98 483.85


401.96 492.40


411.67 504.29


423.80 519.16


438.06 536.62


455.05 557.43


474.16 580.84


496.00 607.60


517.54 633.99


541.81 744.99


565.77 777.94


592.17 814.23


618.86 850.94


647.68 890.56


676.50 930.19


707.75 973.16


739.30 1016.54


772.97 1062.84


789.66 1085.78


823.33 1132.08


852.45 1172.12


871.57 1198.40


895.53 1231.36


910.08 1251.38


910.08 1251.38


143.42 143.42


225.86 254.10


225.86 254.10


225.86 254.10


225.86 254.10


226.77 255.11


231.28 260.19


236.70 266.29


245.51 276.20


252.74 284.33


256.35 301.22


261.77 307.59


267.20 313.95


270.58 317.94


274.20 322.18


276.00 324.31


277.81 326.43


279.62 328.55


281.43 330.67


285.04 334.92


288.65 353.60


294.07 360.24


299.27 366.60


306.50 375.46


315.53 386.52


326.15 399.53


338.79 415.02


353.02 432.45


369.29 452.37


385.32 472.02


403.39 554.66


421.23 579.20


440.88 606.22


460.76 633.55


482.22 663.05


503.67 692.55


526.94 724.54


550.43 756.84


575.50 791.31


587.92 808.39


612.99 842.86


634.67 872.68


648.90 892.24


666.75 916.78


677.58 931.68


677.58 931.68


204.87 204.87


322.63 362.96


322.63 362.96


322.63 362.96


322.63 362.96


323.92 364.41


330.37 371.67


338.11 380.38


350.70 394.53


361.02 406.15


366.18 430.26


373.93 439.36


381.67 448.46


386.51 454.15


391.67 460.21


394.25 463.25


396.83 466.28


399.41 469.31


401.99 472.34


407.16 478.41


412.32 505.09


420.06 514.58


427.48 523.67


437.81 536.31


450.71 552.12


465.87 570.70


483.94 592.83


504.27 617.73


527.50 646.18


550.40 674.24


576.21 792.29


601.70 827.34


629.77 865.93


658.16 904.97


688.81 947.11


719.46 989.26


752.69 1034.95


786.24 1081.09


822.06 1130.33


839.80 1154.73


875.61 1203.97


906.58 1246.55


926.91 1274.50


952.40 1309.55


967.88 1330.84


967.88 1330.84


162.50 162.50


255.91 287.90


255.91 287.90


255.91 287.90


255.91 287.90


256.93 289.05


262.05 294.81


268.19 301.72


278.17 312.95


286.36 322.16


290.46 341.29


296.60 348.50


302.74 355.72


306.58 360.23


310.67 365.04


312.72 367.45


314.77 369.85


316.82 372.26


318.86 374.67


322.96 379.48


327.05 400.64


333.20 408.16


339.08 415.37


347.27 425.41


357.51 437.95


369.53 452.68


383.87 470.23


399.99 489.98


418.41 512.56


436.58 534.81


457.06 628.45


477.27 656.25


499.54 686.86


522.06 717.83


546.37 751.26


570.68 784.68


597.04 820.93


623.65 857.52


652.06 896.58


666.13 915.93


694.54 954.99


719.11 988.77


735.23 1010.94


755.45 1038.74


767.73 1055.63


767.73 1055.63


235.43 235.43


370.76 417.10


370.76 417.10


370.76 417.10


370.76 417.10


372.24 418.77


379.65 427.11


388.55 437.12


403.01 453.39


414.88 466.74


420.81 494.45


429.71 504.90


438.60 515.36


444.17 521.89


450.10 528.86


453.06 532.35


456.03 535.83


459.00 539.32


461.96 542.80


467.89 549.78


473.83 580.44


482.72 591.34


491.25 601.78


503.12 616.32


517.95 634.48


535.37 655.83


556.13 681.26


579.49 709.88


606.19 742.58


632.51 774.82


662.17 910.48


691.46 950.76


723.72 995.11


756.34 1039.97


791.56 1088.40


826.79 1136.83


864.97 1189.34


903.53 1242.36


944.69 1298.94


965.08 1326.98


1006.23 1383.57


1041.82 1432.51


1065.18 1464.62


1094.47 1504.90


1112.27 1529.37


1112.27 1529.37


195.94 195.94


308.57 347.14


308.57 347.14


308.57 347.14


308.57 347.14


309.80 348.52


315.97 355.47


323.38 363.80


335.41 377.34


345.29 388.45


350.22 411.51


357.63 420.21


365.03 428.91


369.66 434.35


374.60 440.15


377.07 443.05


379.54 445.95


382.00 448.86


384.47 451.76


389.41 457.56


394.35 483.08


401.75 492.15


408.85 500.84


418.72 512.94


431.07 528.06


445.57 545.82


462.85 566.99


482.29 590.80


504.50 618.02


526.41 644.86


551.10 757.76


575.48 791.28


602.32 828.19


629.47 865.53


658.79 905.83


688.10 946.14


719.88 989.84


751.97 1033.97


786.23 1081.06


803.20 1104.40


837.45 1151.49


867.07 1192.22


886.51 1218.95


910.89 1252.47


925.70 1272.83


925.70 1272.83


184.95 184.95


291.26 327.67


291.26 327.67


291.26 327.67


291.26 327.67


292.43 328.98


298.25 335.53


305.24 343.40


316.60 356.18


325.92 366.66


330.58 388.43


337.57 396.65


344.56 404.86


348.93 410.00


353.59 415.47


355.92 418.21


358.25 420.95


360.58 423.68


362.91 426.42


367.57 431.90


372.23 455.99


379.22 464.55


385.92 472.75


395.24 484.17


406.89 498.44


420.58 515.21


436.89 535.19


455.24 557.67


476.21 583.36


496.89 608.69


520.19 715.27


543.20 746.91


568.54 781.75


594.17 816.99


621.84 855.04


649.51 893.08


679.51 934.33


709.81 975.98


742.14 1020.44


758.16 1042.46


790.49 1086.92


818.45 1125.36


836.80 1150.59


859.81 1182.23


873.78 1201.46


873.78 1201.46


304.18 304.18


479.03 538.91


479.03 538.91


479.03 538.91


479.03 538.91


480.95 541.07


490.53 551.84


502.02 564.78


520.71 585.79


536.04 603.04


543.70 638.85


555.20 652.36


566.69 665.86


573.88 674.31


581.54 683.31


585.38 687.82


589.21 692.32


593.04 696.82


596.87 701.32


604.54 710.33


612.20 749.95


623.70 764.03


634.72 777.53


650.04 796.30


669.21 819.78


691.72 847.36


718.55 880.22


748.72 917.19


783.21 959.44


817.23 1001.10


855.55 1176.38


893.39 1228.41


935.07 1285.72


977.22 1343.68


1022.73 1406.25


1068.24 1468.83


1117.58 1536.67


1167.40 1605.17


1220.57 1678.28


1246.92 1714.51


1300.09 1787.62


1346.08 1850.85


1376.25 1892.35


1414.10 1944.39


1437.09 1976.00


1437.09 1976.00


290.77 290.77


457.91 515.15


457.91 515.15


457.91 515.15


457.91 515.15


459.74 517.21


468.90 527.51


479.89 539.88


497.75 559.97


512.40 576.45


519.73 610.68


530.72 623.60


541.71 636.51


548.58 644.58


555.90 653.19


559.57 657.49


563.23 661.80


566.89 666.10


570.56 670.41


577.88 679.01


585.21 716.88


596.20 730.35


606.73 743.25


621.39 761.20


639.70 783.64


661.22 810.00


686.87 841.41


715.72 876.75


748.69 917.14


781.20 956.97


817.83 1124.52


854.01 1174.26


893.84 1229.03


934.14 1284.44


977.64 1344.26


1021.14 1404.07


1068.31 1468.92


1115.93 1534.40


1166.76 1604.29


1191.94 1638.92


1242.77 1708.81


1286.73 1769.26


1315.58 1808.92


1351.75 1858.66


1373.73 1888.89


1373.73 1888.89


239.37 239.37


376.96 424.08


376.96 424.08


376.96 424.08


376.96 424.08


378.47 425.78


386.01 434.26


395.06 444.44


409.76 460.98


421.82 474.55


427.85 502.73


436.90 513.36


445.95 523.99


451.60 530.63


457.63 537.72


460.65 541.26


463.66 544.81


466.68 548.35


469.70 551.89


475.73 558.98


481.76 590.15


490.81 601.24


499.48 611.86


511.54 626.64


526.62 645.11


544.34 666.81


565.44 692.67


589.19 721.76


616.34 755.01


643.10 787.80


673.26 925.73


703.04 966.68


735.83 1011.77


769.01 1057.38


804.82 1106.62


840.63 1155.86


879.46 1209.25


918.66 1263.16


960.50 1320.69


981.24 1349.20


1023.08 1406.73


1059.27 1456.49


1083.02 1489.15


1112.80 1530.09


1130.88 1554.97


1130.88 1554.97


246.37 246.37


387.98 436.48


387.98 436.48


387.98 436.48


387.98 436.48


389.54 438.23


397.30 446.96


406.61 457.43


421.74 474.46


434.15 488.42


440.36 517.42


449.67 528.37


458.98 539.31


464.80 546.15


471.01 553.44


474.12 557.09


477.22 560.73


480.32 564.38


483.43 568.03


489.64 575.32


495.84 607.41


505.15 618.81


514.08 629.75


526.49 644.95


542.01 663.97


560.25 686.30


581.98 712.92


606.42 742.86


634.35 777.08


661.90 810.83


692.94 952.79


723.59 994.94


757.34 1041.35


791.49 1088.29


828.34 1138.97


865.20 1189.65


905.17 1244.60


945.52 1300.08


988.58 1359.30


1009.92 1388.64


1052.99 1447.86


1090.23 1499.07


1114.68 1532.68


1145.33 1574.83


1163.94 1600.43


1163.94 1600.43


242.41 242.41


381.75 429.47


381.75 429.47


381.75 429.47


381.75 429.47


383.28 431.19


390.91 439.77


400.07 450.08


414.96 466.83


427.18 480.57


433.29 509.11


442.45 519.88


451.61 530.64


457.34 537.37


463.44 544.55


466.50 548.13


469.55 551.72


472.61 555.31


475.66 558.90


481.77 566.08


487.88 597.65


497.04 608.87


505.82 619.63


518.03 634.59


533.30 653.30


551.25 675.28


572.62 701.46


596.67 730.93


624.16 764.60


651.26 797.80


681.80 937.48


711.96 978.95


745.17 1024.61


778.77 1070.81


815.03 1120.67


851.30 1170.54


890.62 1224.60


930.32 1279.19


972.70 1337.46


993.69 1366.33


1036.07 1424.59


1072.71 1474.98


1096.76 1508.05


1126.92 1549.52


1145.25 1574.71


1145.25 1574.71


211.63 211.63


333.27 374.93


333.27 374.93


333.27 374.93


333.27 374.93


334.60 376.43


341.27 383.92


349.27 392.92


362.26 407.55


372.93 419.54


378.26 444.45


386.26 453.85


394.26 463.25


399.26 469.12


404.59 475.39


407.25 478.52


409.92 481.66


412.59 484.79


415.25 487.92


420.58 494.19


425.92 521.75


433.92 531.55


441.58 540.94


452.24 554.00


465.58 570.33


481.24 589.52


499.90 612.38


520.90 638.10


544.89 667.49


568.56 696.48


595.22 818.42


621.55 854.62


650.54 894.49


679.87 934.82


711.53 978.35


743.19 1021.88


777.51 1069.08


812.17 1116.74


849.17 1167.61


867.50 1192.81


904.49 1243.67


936.48 1287.66


957.48 1316.53


983.81 1352.74


999.80 1374.73


999.80 1374.73


193.16 193.16


304.18 342.21


304.18 342.21


304.18 342.21


304.18 342.21


305.40 343.57


311.48 350.42


318.78 358.63


330.65 371.98


340.38 382.93


345.25 405.67


352.55 414.24


359.85 422.82


364.41 428.18


369.28 433.90


371.71 436.76


374.15 439.62


376.58 442.48


379.01 445.34


383.88 451.06


388.75 476.21


396.05 485.16


403.04 493.73


412.78 505.65


424.94 520.56


439.24 538.07


456.27 558.94


475.44 582.41


497.34 609.24


518.94 635.70


543.27 747.00


567.30 780.04


593.77 816.43


620.53 853.23


649.43 892.97


678.33 932.70


709.66 975.78


741.29 1019.28


775.06 1065.71


791.79 1088.71


825.55 1135.13


854.75 1175.29


873.92 1201.64


897.95 1234.68


912.54 1254.75


912.54 1254.75


204.63 204.63


322.25 362.53


322.25 362.53


322.25 362.53


322.25 362.53


323.54 363.98


329.98 371.23


337.72 379.93


350.28 394.07


360.60 405.67


365.75 429.76


373.49 438.85


381.22 447.93


386.05 453.61


391.21 459.67


393.79 462.70


396.37 465.73


398.94 468.76


401.52 471.79


406.68 477.85


411.83 504.50


419.57 513.97


426.98 523.05


437.29 535.68


450.18 551.47


465.33 570.03


483.37 592.13


503.67 617.00


526.88 645.42


549.76 673.45


575.54 791.36


600.99 826.37


629.03 864.92


657.39 903.91


688.00 946.00


718.61 988.10


751.81 1033.73


785.32 1079.82


821.09 1129.00


838.81 1153.37


874.58 1202.55


905.52 1245.09


925.82 1273.00


951.28 1308.01


966.75 1329.28


966.75 1329.28


201.18 201.18


316.82 356.42


316.82 356.42


316.82 356.42


316.82 356.42


318.09 357.85


324.42 364.98


332.03 373.53


344.38 387.43


354.52 398.84


359.59 422.52


367.19 431.45


374.80 440.39


379.55 445.97


384.62 451.93


387.15 454.91


389.69 457.88


392.22 460.86


394.76 463.84


399.83 469.80


404.90 496.00


412.50 505.31


419.79 514.24


429.93 526.66


442.60 542.18


457.49 560.42


475.23 582.16


495.19 606.61


518.00 634.55


540.50 662.11


565.84 778.03


590.87 812.45


618.43 850.35


646.31 888.68


676.41 930.07


706.51 971.45


739.14 1016.32


772.09 1061.63


807.26 1109.98


824.68 1133.94


859.85 1182.29


890.27 1224.12


910.23 1251.56


935.25 1285.97


950.46 1306.88


950.46 1306.88


149.66 149.66


235.68 265.14


235.68 265.14


235.68 265.14


235.68 265.14


236.62 266.20


241.33 271.50


246.99 277.87


256.18 288.21


263.72 296.69


267.50 314.31


273.15 320.95


278.81 327.60


282.34 331.75


286.11 336.18


288.00 338.40


289.88 340.61


291.77 342.83


293.66 345.05


297.43 349.48


301.20 368.97


306.85 375.90


312.27 382.54


319.82 391.77


329.24 403.32


340.32 416.89


353.52 433.06


368.37 451.25


385.33 472.03


402.07 492.53


420.92 578.77


439.54 604.37


460.04 632.56


480.78 661.08


503.17 691.86


525.56 722.65


549.84 756.03


574.35 789.73


600.51 825.70


613.47 843.52


639.63 879.49


662.26 910.60


677.10 931.02


695.72 956.62


707.04 972.17


707.04 972.17











Required:


Required:


Require:



plan

Required:


rate

Required:



Required:


on a plan


299.14 299.14


471.08 529.97


471.08 529.97


471.08 529.97


471.08 529.97


472.97 532.09


482.39 542.69


493.69 555.41


512.07 576.07


527.14 593.03


534.68 628.25


545.98 641.53


557.29 654.81


564.36 663.12


571.89 671.97


575.66 676.40


579.43 680.83


583.20 685.26


586.97 689.69


594.50 698.54


602.04 737.50


613.35 751.35


624.18 764.62


639.26 783.09


658.10 806.17


680.24 833.30


706.62 865.61


736.30 901.97


770.22 943.52


803.66 984.49


841.35 1156.86


878.57 1208.03


919.55 1264.38


961.01 1321.38


1005.76 1382.92


1050.51 1444.45


1099.03 1511.17


1148.03 1578.54


1200.32 1650.43


1226.22 1686.06


1278.52 1757.96


1323.74 1820.14


1353.42 1860.95


1390.63 1912.12


1413.24 1943.21


1413.24 1943.21


285.95 285.95


450.31 506.60


450.31 506.60


450.31 506.60


450.31 506.60


452.11 508.63


461.12 518.76


471.93 530.92


489.49 550.67


503.90 566.88


511.10 600.55


521.91 613.24


532.72 625.94


539.47 633.88


546.68 642.35


550.28 646.58


553.88 650.81


557.48 655.04


561.09 659.28


568.29 667.74


575.50 704.98


586.30 718.22


596.66 730.91


611.07 748.56


629.08 770.63


650.25 796.55


675.47 827.45


703.84 862.20


736.26 901.92


768.23 941.08


804.25 1105.85


839.83 1154.77


879.01 1208.63


918.63 1263.12


961.41 1321.94


1004.19 1380.77


1050.57 1444.54


1097.41 1508.93


1147.39 1577.66


1172.16 1611.72


1222.14 1680.45


1265.37 1739.89


1293.74 1778.90


1329.32 1827.81


1350.93 1857.53


1350.93 1857.53


235.78 235.78


371.31 417.73


371.31 417.73


371.31 417.73


371.31 417.73


372.80 419.40


380.23 427.75


389.14 437.78


403.62 454.07


415.50 467.44


421.44 495.19


430.35 505.66


439.26 516.14


444.83 522.68


450.78 529.66


453.75 533.15


456.72 536.64


459.69 540.13


462.66 543.62


468.60 550.60


474.54 581.31


483.45 592.23


491.99 602.69


503.87 617.24


518.73 635.44


536.18 656.82


556.97 682.29


580.36 710.95


607.10 743.70


633.46 775.99


663.17 911.85


692.50 952.19


724.81 996.61


757.48 1041.54


792.76 1090.04


828.03 1138.54


866.28 1191.13


904.89 1244.23


946.11 1300.90


966.53 1328.98


1007.75 1385.65


1043.39 1434.67


1066.79 1466.83


1096.12 1507.16


1113.93 1531.67


1113.93 1531.67


243.45 243.45


383.39 431.31


383.39 431.31


383.39 431.31


383.39 431.31


384.92 433.04


392.59 441.66


401.79 452.02


416.74 468.84


429.01 482.64


435.15 511.30


444.35 522.11


453.55 532.92


459.30 539.68


465.43 546.88


468.50 550.49


471.57 554.09


474.64 557.70


477.70 561.30


483.84 568.51


489.97 600.21


499.17 611.49


507.99 622.29


520.26 637.32


535.59 656.10


553.61 678.18


575.08 704.48


599.24 734.06


626.84 767.88


654.06 801.22


684.73 941.51


715.02 983.15


748.37 1029.02


782.11 1075.41


818.53 1125.49


854.96 1175.57


894.45 1229.86


934.32 1284.69


976.87 1343.20


997.96 1372.20


1040.52 1430.71


1077.32 1481.32


1101.48 1514.53


1131.76 1556.17


1150.17 1581.48


1150.17 1581.48


208.46 208.46


328.28 369.31


328.28 369.31


328.28 369.31


328.28 369.31


329.59 370.79


336.16 378.18


344.04 387.04


356.84 401.44


367.34 413.26


372.60 437.80


380.47 447.06


388.35 456.32


393.28 462.10


398.53 468.27


401.16 471.36


403.78 474.44


406.41 477.53


409.04 480.62


414.29 486.79


419.54 513.94


427.42 523.59


434.97 532.84


445.47 545.71


458.61 561.79


474.03 580.69


492.42 603.21


513.10 628.55


536.74 657.50


560.04 686.05


586.31 806.17


612.24 841.83


640.80 881.10


669.69 920.82


700.87 963.70


732.06 1006.58


765.87 1053.08


800.01 1100.02


836.45 1150.12


854.51 1174.95


890.95 1225.05


922.46 1268.39


943.14 1296.82


969.08 1332.48


984.84 1354.15


984.84 1354.15


198.22 198.22


312.16 351.18


312.16 351.18


312.16 351.18


312.16 351.18


313.41 352.58


319.65 359.61


327.14 368.04


339.32 381.73


349.31 392.97


354.30 416.30


361.79 425.11


369.28 433.91


373.97 439.41


378.96 445.28


381.46 448.21


383.96 451.15


386.45 454.08


388.95 457.02


393.95 462.89


398.94 488.70


406.43 497.88


413.61 506.67


423.60 518.91


436.09 534.21


450.76 552.18


468.24 573.59


487.91 597.68


510.38 625.22


532.54 652.37


557.52 766.59


582.18 800.49


609.34 837.84


636.81 875.61


666.46 916.38


696.12 957.16


728.27 1001.37


760.73 1046.01


795.38 1093.65


812.55 1117.26


847.20 1164.90


877.17 1206.11


896.83 1233.15


921.50 1267.06


936.48 1287.66


936.48 1287.66


147.58 147.58


232.41 261.46


232.41 261.46


232.41 261.46


232.41 261.46


233.34 262.51


237.99 267.74


243.57 274.01


252.63 284.21


260.07 292.58


263.79 309.95


269.36 316.50


274.94 323.06


278.43 327.15


282.15 331.52


284.01 333.71


285.87 335.89


287.72 338.08


289.58 340.26


293.30 344.63


297.02 363.85


302.60 370.68


307.94 377.23


315.38 386.34


324.68 397.73


335.60 411.11


348.62 427.06


363.26 444.99


379.99 465.49


396.49 485.70


415.09 570.74


433.45 595.99


453.67 623.79


474.12 651.91


496.20 682.27


518.28 712.63


542.22 745.55


566.39 778.78


592.18 814.25


604.97 831.83


630.76 867.30


653.08 897.98


667.72 918.11


686.08 943.36


697.23 958.70


697.23 958.70


210.81 210.81


331.98 373.48


331.98 373.48


331.98 373.48


331.98 373.48


333.31 374.97


339.95 382.44


347.92 391.41


360.86 405.97


371.49 417.92


376.80 442.74


384.77 452.10


392.73 461.46


397.71 467.31


403.03 473.56


405.68 476.68


408.34 479.80


410.99 482.92


413.65 486.04


418.96 492.28


424.27 519.73


432.24 529.49


439.88 538.85


450.50 551.86


463.78 568.13


479.38 587.24


497.97 610.02


518.89 635.64


542.79 664.92


566.36 693.79


592.92 815.26


619.15 851.33


648.03 891.04


677.24 931.21


708.78 974.57


740.32 1017.94


774.51 1064.96


809.04 1112.43


845.89 1163.10


864.15 1188.20


901.00 1238.87


932.87 1282.69


953.78 1311.45


980.01 1347.51


995.94 1369.42


995.94 1369.42


167.21 167.21


263.33 296.25


263.33 296.25


263.33 296.25


263.33 296.25


264.38 297.43


269.65 303.36


275.97 310.47


286.24 322.02


294.67 331.50


298.88 351.18


305.20 358.61


311.52 366.03


315.47 370.68


319.68 375.63


321.79 378.10


323.90 380.58


326.00 383.05


328.11 385.53


332.32 390.48


336.54 412.26


342.86 420.00


348.91 427.42


357.34 437.74


367.87 450.64


380.25 465.80


394.99 483.87


411.58 504.19


430.54 527.42


449.24 550.32


470.31 646.67


491.11 675.28


514.02 706.78


537.19 738.64


562.21 773.04


587.23 807.43


614.35 844.73


641.73 882.38


670.96 922.58


685.45 942.49


714.68 982.68


739.96 1017.44


756.55 1040.25


777.35 1068.85


789.99 1086.23


789.99 1086.23


242.26 242.26


381.50 429.19


381.50 429.19


381.50 429.19


381.50 429.19


383.03 430.91


390.66 439.49


399.82 449.79


414.70 466.53


426.90 480.27


433.01 508.78


442.16 519.54


451.32 530.30


457.04 537.03


463.15 544.20


466.20 547.78


469.25 551.37


472.30 554.96


475.36 558.54


481.46 565.71


487.56 597.26


496.72 608.48


505.49 619.23


517.70 634.19


532.96 652.88


550.89 674.84


572.26 701.02


596.29 730.46


623.76 764.11


650.85 797.29


681.37 936.88


711.51 978.32


744.70 1023.96


778.27 1070.12


814.51 1119.96


850.76 1169.79


890.05 1223.82


929.73 1278.38


972.07 1336.60


993.06 1365.45


1035.40 1423.68


1072.03 1474.04


1096.06 1507.09


1126.20 1548.53


1144.50 1573.71


1144.50 1573.71


201.62 201.62


317.51 357.20


317.51 357.20


317.51 357.20


317.51 357.20


318.78 358.63


325.13 365.77


332.75 374.35


345.14 388.28


355.30 399.71


360.38 423.44


368.00 432.40


375.62 441.35


380.38 446.95


385.46 452.91


388.00 455.90


390.54 458.88


393.08 461.87


395.62 464.85


400.70 470.82


405.78 497.08


413.40 506.42


420.70 515.36


430.86 527.81


443.56 543.37


458.49 561.65


476.27 583.43


496.27 607.93


519.13 635.94


541.68 663.55


567.08 779.73


592.16 814.22


619.78 852.20


647.72 890.62


677.89 932.10


708.05 973.57


740.75 1018.54


773.78 1063.94


809.02 1112.40


826.48 1136.41


861.73 1184.87


892.21 1226.79


912.21 1254.29


937.29 1288.78


952.53 1309.74


952.53 1309.74


190.31 190.31


299.71 337.17


299.71 337.17


299.71 337.17


299.71 337.17


300.91 338.52


306.90 345.26


314.09 353.35


325.78 366.50


335.37 377.29


340.17 399.70


347.36 408.15


354.55 416.60


359.05 421.88


363.84 427.52


366.24 430.33


368.64 433.15


371.04 435.97


373.43 438.79


378.23 444.42


383.03 469.21


390.22 478.02


397.11 486.46


406.70 498.21


418.69 512.90


432.78 530.15


449.56 550.71


468.44 573.84


490.02 600.27


511.30 626.34


535.28 736.00


558.95 768.56


585.03 804.41


611.40 840.68


639.87 879.83


668.35 918.98


699.22 961.42


730.38 1004.28


763.65 1050.02


780.14 1072.69


813.40 1118.43


842.18 1157.99


861.06 1183.95


884.73 1216.51


899.12 1236.29


899.12 1236.29


313.00 313.00


492.92 554.53


492.92 554.53


492.92 554.53


492.92 554.53


494.89 556.75


504.75 567.84


516.58 581.15


535.80 602.78


551.58 620.52


559.46 657.37


571.29 671.27


583.12 685.17


590.52 693.86


598.40 703.12


602.35 707.76


606.29 712.39


610.23 717.02


614.18 721.66


622.06 730.92


629.95 771.69


641.78 786.18


653.12 800.07


668.89 819.39


688.61 843.54


711.77 871.92


739.38 905.74


770.43 943.78


805.92 987.25


840.92 1030.13


880.35 1210.49


919.29 1264.03


962.18 1322.99


1005.55 1382.64


1052.38 1447.02


1099.21 1511.41


1149.98 1581.22


1201.24 1651.71


1255.96 1726.94


1283.07 1764.22


1337.78 1839.45


1385.10 1904.51


1416.16 1947.21


1455.10 2000.76


1478.76 2033.29


1478.76 2033.29


299.20 299.20


471.19 530.09


471.19 530.09


471.19 530.09


471.19 530.09


473.07 532.21


482.50 542.81


493.80 555.53


512.18 576.20


527.26 593.17


534.80 628.39


546.11 641.67


557.41 654.96


564.48 663.27


572.02 672.13


575.79 676.55


579.56 680.98


583.33 685.41


587.10 689.84


594.64 698.70


602.18 737.67


613.49 751.52


624.32 764.80


639.40 783.27


658.25 806.35


680.39 833.48


706.78 865.81


736.47 902.17


770.39 943.73


803.85 984.71


841.54 1157.12


878.76 1208.30


919.76 1264.67


961.22 1321.68


1005.99 1383.23


1050.75 1444.78


1099.28 1511.51


1148.28 1578.89


1200.59 1650.81


1226.50 1686.44


1278.80 1758.35


1324.04 1820.55


1353.72 1861.37


1390.95 1912.55


1413.56 1943.65


1413.56 1943.65


246.31 246.31


387.89 436.38


387.89 436.38


387.89 436.38


387.89 436.38


389.44 438.12


397.20 446.85


406.51 457.33


421.64 474.34


434.05 488.31


440.26 517.30


449.57 528.24


458.88 539.18


464.70 546.02


470.90 553.31


474.00 556.96


477.11 560.60


480.21 564.25


483.31 567.89


489.52 575.19


495.73 607.26


505.04 618.67


513.96 629.60


526.37 644.80


541.89 663.81


560.12 686.14


581.84 712.75


606.28 742.69


634.20 776.90


661.74 810.64


692.78 952.57


723.42 994.70


757.17 1041.10


791.30 1088.04


828.15 1138.71


865.00 1189.38


904.95 1244.31


945.29 1299.78


988.35 1358.98


1009.68 1388.32


1052.74 1447.52


1089.98 1498.72


1114.41 1532.32


1145.06 1574.46


1163.67 1600.06


1163.67 1600.06


253.51 253.51


399.23 449.14


399.23 449.14


399.23 449.14


399.23 449.14


400.83 450.93


408.81 459.92


418.40 470.69


433.97 488.21


446.74 502.58


453.13 532.43


462.71 543.68


472.29 554.94


478.28 561.98


484.67 569.48


487.86 573.24


491.06 576.99


494.25 580.74


497.44 584.50


503.83 592.00


510.22 625.02


519.80 636.76


528.98 648.00


541.76 663.65


557.73 683.22


576.49 706.20


598.85 733.59


624.00 764.40


652.74 799.61


681.09 834.34


713.03 980.41


744.57 1023.78


779.30 1071.54


814.43 1119.85


852.36 1172.00


890.29 1224.15


931.41 1280.69


972.93 1337.78


1017.24 1398.71


1039.20 1428.90


1083.52 1489.83


1121.84 1542.53


1146.99 1577.12


1178.53 1620.48


1197.69 1646.83


1197.69 1646.83


249.44 249.44


392.82 441.92


392.82 441.92


392.82 441.92


392.82 441.92


394.39 443.69


402.24 452.53


411.67 463.13


426.99 480.37


439.56 494.51


445.85 523.87


455.27 534.95


464.70 546.03


470.59 552.95


476.88 560.33


480.02 564.03


483.16 567.72


486.31 571.41


489.45 575.10


495.73 582.49


502.02 614.97


511.45 626.52


520.48 637.59


533.05 652.99


548.77 672.24


567.23 694.85


589.23 721.80


613.97 752.12


642.26 786.76


670.15 820.93


701.57 964.66


732.60 1007.33


766.78 1054.32


801.35 1101.85


838.66 1153.16


875.98 1204.47


916.44 1260.11


957.29 1316.28


1000.90 1376.23


1022.50 1405.94


1066.10 1465.89


1103.82 1517.75


1128.56 1551.77


1159.60 1594.44


1178.45 1620.37


1178.45 1620.37


217.76 217.76


342.93 385.80


342.93 385.80


342.93 385.80


342.93 385.80


344.30 387.34


351.16 395.06


359.39 404.31


372.77 419.36


383.74 431.71


389.23 457.34


397.46 467.01


405.69 476.68


410.83 482.73


416.32 489.17


419.06 492.40


421.80 495.62


424.55 498.84


427.29 502.07


432.78 508.51


438.27 536.87


446.50 546.96


454.38 556.62


465.36 570.06


479.07 586.87


495.19 606.61


514.40 630.13


536.00 656.60


560.69 686.85


585.04 716.67


612.47 842.15


639.57 879.40


669.40 920.43


699.58 961.92


732.16 1006.72


764.73 1051.51


800.06 1100.08


835.72 1149.12


873.79 1201.46


892.65 1227.39


930.71 1279.73


963.63 1325.00


985.24 1354.70


1012.33 1391.95


1028.79 1414.59


1028.79 1414.59


198.76 198.76


313.00 352.13


313.00 352.13


313.00 352.13


313.00 352.13


314.25 353.54


320.51 360.58


328.03 369.03


340.23 382.76


350.25 394.03


355.26 417.43


362.77 426.25


370.28 435.08


374.98 440.60


379.98 446.48


382.49 449.42


384.99 452.37


387.50 455.31


390.00 458.25


395.01 464.13


400.02 490.02


407.53 499.22


414.73 508.04


424.74 520.31


437.26 535.65


451.97 553.67


469.50 575.14


489.22 599.30


511.76 626.90


533.98 654.13


559.02 768.65


583.75 802.65


610.98 840.10


638.52 877.97


668.26 918.86


697.99 959.74


730.23 1004.07


762.79 1048.83


797.53 1096.60


814.74 1120.27


849.49 1168.05


879.54 1209.36


899.25 1236.48


923.98 1270.47


939.00 1291.13


939.00 1291.13


210.56 210.56


331.59 373.04


331.59 373.04


331.59 373.04


331.59 373.04


332.92 374.53


339.55 381.99


347.51 390.95


360.44 405.50


371.05 417.43


376.36 442.22


384.31 451.57


392.27 460.92


397.25 466.76


402.55 473.00


405.20 476.12


407.86 479.23


410.51 482.35


413.16 485.47


418.47 491.70


423.77 519.12


431.73 528.87


439.36 538.21


449.97 551.21


463.23 567.46


478.82 586.55


497.39 609.30


518.28 634.89


542.15 664.14


565.70 692.98


592.22 814.31


618.42 850.33


647.27 889.99


676.45 930.11


707.95 973.43


739.45 1016.74


773.60 1063.70


808.09 1111.12


844.90 1161.73


863.13 1186.81


899.94 1237.42


931.77 1281.19


952.66 1309.91


978.86 1345.93


994.77 1367.82


994.77 1367.82


207.01 207.01


326.01 366.76


326.01 366.76


326.01 366.76


326.01 366.76


327.31 368.22


333.83 375.56


341.65 384.36


354.37 398.66


364.80 410.40


370.02 434.77


377.84 443.96


385.66 453.16


390.56 458.90


395.77 465.03


398.38 468.10


400.99 471.16


403.60 474.22


406.20 477.29


411.42 483.42


416.64 510.38


424.46 519.96


431.96 529.15


442.39 541.93


455.43 557.90


470.75 576.67


489.01 599.04


509.55 624.20


533.02 652.95


556.17 681.30


582.25 800.59


608.00 836.00


636.36 875.00


665.05 914.45


696.02 957.03


726.99 999.62


760.57 1045.79


794.48 1092.40


830.66 1142.16


848.59 1166.82


884.78 1216.57


916.08 1259.61


936.61 1287.85


962.37 1323.26


978.02 1344.77


978.02 1344.77


153.99 153.99


242.51 272.83


242.51 272.83


242.51 272.83


242.51 272.83


243.48 273.92


248.33 279.37


254.15 285.92


263.61 296.56


271.37 305.29


275.25 323.42


281.07 330.26


286.89 337.10


290.53 341.37


294.41 345.93


296.35 348.21


298.29 350.49


300.23 352.77


302.17 355.05


306.05 359.61


309.93 379.66


315.75 386.79


321.33 393.63


329.09 403.13


338.79 415.02


350.19 428.98


363.77 445.61


379.05 464.33


396.51 485.72


413.72 506.81


433.13 595.55


452.28 621.89


473.38 650.90


494.72 680.24


517.76 711.92


540.80 743.60


565.78 777.95


591.00 812.63


617.92 849.64


631.26 867.98


658.18 904.99


681.46 937.00


696.74 958.01


715.89 984.35


727.53 1000.36


727.53 1000.36











Required:


Required:


Require:



plan

Required:


rate

Required:



Required:


on a plan


361.72 361.72


569.63 640.83


569.63 640.83


569.63 640.83


569.63 640.83


571.91 643.40


583.30 656.21


596.97 671.59


619.19 696.59


637.42 717.09


646.53 759.67


660.20 775.74


673.87 791.80


682.42 801.84


691.53 812.55


696.09 817.90


700.64 823.26


705.20 828.61


709.76 833.97


718.87 844.68


727.99 891.78


741.66 908.53


754.76 924.58


772.99 946.91


795.77 974.82


822.55 1007.62


854.45 1046.70


890.33 1090.66


931.35 1140.90


971.79 1190.44


1017.36 1398.87


1062.36 1460.74


1111.92 1528.89


1162.05 1597.81


1216.16 1672.22


1270.27 1746.63


1328.95 1827.30


1388.19 1908.76


1451.42 1995.70


1482.75 2038.78


1545.98 2125.72


1600.66 2200.91


1636.55 2250.25


1681.55 2312.13


1708.89 2349.72


1708.89 2349.72


247.91 247.91


390.41 439.21


390.41 439.21


390.41 439.21


390.41 439.21


391.97 440.97


399.78 449.75


409.15 460.29


424.38 477.42


436.87 491.48


443.12 520.66


452.49 531.67


461.86 542.68


467.71 549.56


473.96 556.90


477.08 560.57


480.20 564.24


483.33 567.91


486.45 571.58


492.70 578.92


498.94 611.21


508.31 622.68


517.29 633.68


529.79 648.99


545.40 668.12


563.75 690.60


585.62 717.38


610.21 747.51


638.32 781.94


666.04 815.90


697.27 958.75


728.11 1001.16


762.08 1047.86


796.44 1095.10


833.53 1146.10


870.61 1197.09


910.83 1252.39


951.43 1308.22


994.76 1367.80


1016.24 1397.33


1059.57 1456.91


1097.05 1508.45


1121.65 1542.27


1152.49 1584.67


1171.23 1610.44


1171.23 1610.44


193.05 193.05


304.01 342.01


304.01 342.01


304.01 342.01


304.01 342.01


305.23 343.38


311.31 350.22


318.60 358.43


330.46 371.77


340.19 382.71


345.05 405.44


352.35 414.01


359.64 422.58


364.20 427.94


369.07 433.66


371.50 436.51


373.93 439.37


376.36 442.23


378.80 445.09


383.66 450.80


388.52 475.94


395.82 484.88


402.81 493.45


412.54 505.36


424.70 520.26


438.99 537.76


456.02 558.62


475.17 582.08


497.06 608.89


518.64 635.34


542.96 746.57


566.98 779.60


593.43 815.96


620.18 852.75


649.06 892.46


677.94 932.17


709.26 975.23


740.87 1018.70


774.62 1065.10


791.34 1088.09


825.08 1134.49


854.27 1174.62


873.42 1200.95


897.44 1233.98


912.03 1254.04


912.03 1254.04


116.59 116.59


183.61 206.56


183.61 206.56


183.61 206.56


183.61 206.56


184.34 207.39


188.02 211.52


192.42 216.48


199.58 224.53


205.46 231.14


208.40 244.87


212.80 250.04


217.21 255.22


219.96 258.46


222.90 261.91


224.37 263.64


225.84 265.36


227.31 267.09


228.78 268.81


231.72 272.27


234.65 287.45


239.06 292.85


243.28 298.02


249.16 305.22


256.50 314.22


265.13 324.79


275.42 337.38


286.98 351.55


300.20 367.75


313.24 383.72


327.93 450.90


342.43 470.84


358.41 492.81


374.56 515.03


392.01 539.01


409.45 562.99


428.36 589.00


447.46 615.25


467.84 643.28


477.94 657.16


498.32 685.19


515.94 709.42


527.51 725.33


542.02 745.27


550.83 757.39


550.83 757.39


225.13 225.13


354.53 398.85


354.53 398.85


354.53 398.85


354.53 398.85


355.95 400.44


363.04 408.42


371.55 417.99


385.37 433.55


396.72 446.31


402.39 472.81


410.90 482.81


419.41 492.81


424.73 499.05


430.40 505.72


433.24 509.05


436.07 512.38


438.91 515.72


441.74 519.05


447.42 525.71


453.09 555.03


461.60 565.46


469.75 575.45


481.10 589.34


495.28 606.72


511.94 627.13


531.80 651.45


554.13 678.81


579.66 710.08


604.83 740.91


633.19 870.64


661.20 909.15


692.04 951.56


723.24 994.46


756.92 1040.77


790.60 1087.08


827.12 1137.29


863.99 1187.99


903.34 1242.10


922.84 1268.91


962.19 1323.02


996.23 1369.82


1018.56 1400.53


1046.57 1439.04


1063.59 1462.44


1063.59 1462.44


175.99 175.99


277.15 311.79


277.15 311.79


277.15 311.79


277.15 311.79


278.26 313.04


283.80 319.28


290.45 326.76


301.26 338.92


310.13 348.90


314.57 369.61


321.22 377.43


327.87 385.25


332.03 390.13


336.46 395.34


338.68 397.95


340.89 400.55


343.11 403.16


345.33 405.76


349.76 410.97


354.20 433.89


360.85 442.04


367.22 449.85


376.09 460.71


387.18 474.29


400.20 490.25


415.73 509.26


433.19 530.65


453.14 555.10


472.82 579.20


494.99 680.61


516.88 710.72


541.00 743.87


565.39 777.41


591.72 813.61


618.04 849.81


646.59 889.06


675.41 928.70


706.18 971.00


721.42 991.95


752.19 1034.25


778.79 1070.84


796.25 1094.85


818.15 1124.95


831.45 1143.24


831.45 1143.24


155.40 155.40


244.73 275.32


244.73 275.32


244.73 275.32


244.73 275.32


245.71 276.42


250.60 281.93


256.48 288.54


266.02 299.27


273.85 308.08


277.77 326.38


283.64 333.28


289.52 340.18


293.19 344.49


297.10 349.10


299.06 351.40


301.02 353.70


302.98 356.00


304.93 358.30


308.85 362.90


312.76 383.14


318.64 390.33


324.27 397.23


332.10 406.82


341.89 418.81


353.39 432.90


367.10 449.69


382.51 468.58


400.13 490.16


417.51 511.45


437.09 601.00


456.42 627.58


477.71 656.86


499.25 686.47


522.50 718.44


545.75 750.40


570.96 785.06


596.41 820.06


623.57 857.41


637.03 875.92


664.20 913.27


687.69 945.58


703.11 966.78


722.44 993.36


734.19 1009.51


734.19 1009.51

Supporting Document Schedules Satisfied - Item: REDACTED FILING DOCUMENTSComments:

Attachment(s): R-PA-KHPE Small Group Federal Actuarial Memorandum 2017.pdfR-PA-KHPE Small Group Pennsylvania Actuarial Memorandum 2017.pdf

Item Status:Status Date:

Satisfied - Item: Non-Confidential PDF FilesComments:

Attachment(s):

2017 PA SG Actuarial Memorandum Rate Exhibits KHPE (Entity-Specific Gross Premium) FINAL RV.pdfKHPE Small Group Rate Change Request Summary 2017.pdfKHPE PA Small Group Bulletin Information.pdfKHPE Small Group URRT_Part2.pdf33871khpeurrtpt1_SG_5172016.pdfR-KHPE cover letter SG_Redacted.pdf

Item Status:Status Date:

SERFF Tracking #: INAC-130539718 State Tracking #: INAC-130539718 Company Tracking #: KHPE SG 1-1-2017

State: Pennsylvania Filing Company: Keystone Health Plan East, Inc.

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

Product Name: KHPE Small Group HMO eff 1-1-2017

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number INAC-130539718 Generated 06/14/2016 09:28 AM

GENERAL OVERVIEW

PURPOSES

This Actuarial Memorandum is provided along with the Unified Rate Review Template (URRT) to provide

certain information to support the gross premium for the single risk pool for small group market health

care insurance underwritten by Keystone Health Plan East in the Commonwealth of Pennsylvania. It is

provided as a component of an application for certification as a Qualified Health Plan and a state rate

filing. This submission may not be appropriate for other purposes.

GENERAL INFORMATION

COMPANY IDENTIFYING INFORMATION

Company Legal Name: Keystone Health Plan East (“KHPE”)

State: Pennsylvania

HIOS Issuer ID (5-digit): 33871

Market: Small Group

Effective Date(s): 1/1/2017-3/31/2017, 4/1/2017 – 6/30/2017, 7/1/2017 – 9/30/2017,

10/1/2017 – 12/31/2017

Worksheet 1 of the accompanying URRT contains experience period data and development of the

projected Single Risk Pool Gross Premium Average Rate PMPM for the small group market for KHPE.

Worksheet 2 contains experience period data and projections by product for the single risk pool for the

same entities. This memorandum pertains only to plans denoted in Worksheet 2 by Plan IDs starting

with the sequence 33871.

COMPANY CONTACT INFORMATION

Primary Contact Name: xxxxxxxxxxxx

Primary Contact Telephone Number: xxxxxxxxxxxx

Primary Contact Email Address: xxxxxxxxxxxxxxxxxxxxxx

PROPOSED RATE INCREASE

The changes to the single risk pool gross premium average rate per member per month (PMPM) from

calendar year 2015 to calendar year 2017 were incorporated into the pricing and reflected in the Unified

Rate Review Template. The changes are driven by factors including: changes in market-wide population

risk morbidity and covered services, increasing unit costs for medical services, increasing utilization of

medical services, increasing fees and taxes imposed by the federal government, anticipated costs to

administer the plan, anticipated revenue or payments due to market-wide risk adjustment, and the

discontinuance of net reinsurance payments from the Federal Transitional Reinsurance Program.

The weighted average increase across KHPE plans based on projected membership, inclusive of the

impact of benefit and cost sharing changes, is 3.7%. The minimum increase is 1.2% and the maximum

increase is 5.8%.

WORKSHEET 1: DATA COLLECTION TEMPLATE

SECTION I: EXPERIENCE PERIOD PREMIUM AND CLAIMS

PAID THROUGH DATE

Experience period premium, claims, and member months are obtained from the company’s internal

data warehouse. The claims data is collected for incurred dates from January through December 2015

and paid through January 2016. Earned premiums and member months are for January through

December 2015. The data are for all direct-written small group business of KHPE in the Commonwealth

of Pennsylvania

PREMIUMS (NET OF MLR REBATE) IN EXPERIENCE PERIOD

Earned Premiums (net of MLR Rebate) in Experience Period are developed by summing the earned

premium reported in the company’s internal data warehouse and adjusting for MLR rebates, if any, for

the period. Although 2015 federal MLR rebate calculations are not final as of the writing of this

memorandum, no federal MLR rebates are expected for calendar year 2015, so no adjustment to earned

premium for MLR rebates is needed.

The calculation for federal minimum loss ratio rebates is based on 2013, 2014, and 2015 experience of

earned premium, incurred claims, quality improvement expenses, and taxes. The three years of

experience is blended for all segments.

ALLOWED AND INCURRED CLAIMS INCURRED DURING THE EXPERIENCE PERIOD

Paid-to-Date and Incurred Claims, and Member Months

Insurer fee-for-service claims expenses and member liabilities for dates of service in January 2015

through December 2015 and paid through January 2016 are sourced from the IBCFOC’s internal data

warehouse. The claims and member liabilities are completed with incurred but not reported (IBNR)

adjustments to develop ultimate incurred insurer fee-for-service claims expenses and member liabilities

for the January through December 2015 period. Capitation amounts are also sourced from the internal

data warehouse for the January through December 2015 period but they are not adjusted for IBNR.

Allowed Claims

Allowed claims are determined by separately obtaining paid-to-date fee-for-service claims and member

cost-sharing amounts, applying claim lag factors to those amounts to estimate ultimate incurred fee-for-

service claims and member-sharing amounts and adding them together with capitation amounts.

Allowed claims do not include ineligible claims, payments for services other than medical care provided,

recovery payments related to internal large claim pooling mechanisms, or active live reserves.

IBNR Development

Medical fee for service incurred but not reported (IBNR) claims are modeled through the use of standard

claim lag methodologies. A range of results is developed, and a provision for adverse deviation is

applied. The provision for adverse deviation is dependent on many factors such as stability, size, product

mix, etc.

The completion factors are developed annually in the 2Q – 3Q period. We do not believe our IBNR is

unusually high or unusually low for incurred 2015 paid through January 2016.

Experience Period Index Rate

The Index Rate of Experience Period is estimated by removing cost and utilization trend from the Index

Rate for Projection Period.

SECTION II: ALLOWED CLAIMS, PMPM BASIS

BENEFIT CATEGORIES

Utilization and Unit Cost data for allowed claims in the experience period are provided in Section II. The

data is provided by benefit category using a standardized indicator from the internal data warehouse

that assigns each claim line to a category based on the type of provider and the location of the service.

The utilization and unit cost data are provided for the following categories: Inpatient Hospital admits,

Outpatient Hospital visits, Professional visits, Other Medical visits, Capitation per member per month

(PMPM), and Prescription Drug scripts.

Experience Period capitation is reported as a per member per month (PMPM) value. In order to

complete the URRT, the Utilization per 1,000 statistics for capitated services only is reported as 1,000 so

that the appropriate capitation PMPM is reported.

PROJECTION FACTORS

The estimated incurred claims experience on an allowed basis for January 2015 through December 2015

is projected to the future rating period by several factors. Factors were calculated from the combined

experience of QCC and KHPE.

Changes in Population Risk Morbidity

Experience period allowed claims are adjusted to account for differences in the average morbidity of

the single risk pool population underlying the experience and the anticipated population in the

projection period. This adjustment reflects changes in the small group market-wide morbidity due to

one or more of the following: guarantee issue, the individual mandate, Medicaid and CHIP migration,

take-up of insurance by the previously uninsured, health status of the newly insured, enrollment from

prior high risk pools, subsidy effects, dumping of enrollment from group markets to the individual

market, and market-wide impact of transitional products/plans.

Changes in Other Factors

Experience period allowed claims are adjusted to account for differences in the single risk pool

population underlying the experience and the anticipated population in the projection period pertaining

to several factors not due to changes in morbidity or the costs and utilization of medical care. This

adjustment reflects: additional benefits required to be covered as essential health benefits; recently

mandated benefits required by state law that are not reflected in the experience period data; benefits in

the experience that are removed for the projection period; 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; changes in demographic

characteristics of the single risk pool experience period population and the projection period population

(including age, gender, region, and tobacco use); changes in the provider network (adding or removing a

provider system or introducing a limited network option); and anticipated changes in pharmacy rebates.

Trend Factors

a. Annualized Cost Trend

Annual cost trend reflects changes in costs of medical treatment due to medical inflation and changes in

the distribution of services across network providers. The trend value is developed by reviewing

historical medical costs for the single risk pool and adjusting them for anticipated future provider

contracting reimbursement levels. The data is normalized for changes in age, benefit changes during the

experience period, changes to provider contracts, and prescription drug formulary, and new drugs

brought to market.

b. Annualized Utilization Trend

Annual utilization trend reflects the change in the number of units per 1,000 members for a fixed level

of illness burden and includes changes due to the mix and intensity of services provided and changes

related to shifts in product mix. It also includes effects of selection, if any, since this cannot be reflected

in the relative cost of the various products and plans offered.

CREDIBILITY MANUAL RATE DEVELOPMENT

The experience period claims for the single risk pool are determined to be fully credible; therefore no

credibility adjustment is required.

SECTION III: PROJECTED EXPERIENCE

PAID TO ALLOWED RATIO

The Projected Allowed Experience Claims PMPM shown in Worksheet 1 represents projected allowed

claims experience PMPM for the projected portfolio of plans. The Paid to Allowed Average Factor in

Projection Period adjusts the allowed down to Projected Incurred Claims before ACA reinsurance and

risk adjustment for the population anticipated to be covered in the projection period. The Projected

Incurred Claims before ACA reinsurance and risk adjustment represents the net amount of incurred

insurer claim liability expected in the projection period, net of member cost sharing and cost sharing

paid by HHS on behalf of low-income members. It reflects the average benefit level anticipated during

the projection period. The ratio was calculated using incurred (before ACA reinsurance and risk

adjustment) and allowed PMPMs from worksheet two of the URRT.

RISK ADJUSTMENT AND REINSURANCE

Projected Risk Adjustment PMPM

Projected Risk Adjustment is accounted for in Projected Incurred Claims before ACA Reinsurance and

Risk Adjustment to reflect anticipated risk adjustment transfer amounts for the projection period. The

amount reflects the projected morbidity for the single risk pool for IBCFOC in the projection period.

The estimated risk adjustment revenue for all of the plans in the risk pool is developed using the

following methodology. We recognize that the HHS payment transfer formula implies that the projected

incurred claims based solely on the experience period single risk pool claims need to be adjusted by the

ratio of the current statewide market’s risk relative to allowable rating factor (ARF) for age compared to

the single risk pool’s risk relative to ARF presented during the experience period. This adjustment,

together with the assumed future changes in population risk morbidity, results in the issuer’s pricing

being consistent with the anticipated morbidity level of the future statewide market.

Estimating the current statewide market’s risk and ARF is difficult, because we do not have access to the

relevant data from other carriers operating in this market. In order to gain insight, we participated in

the Wakely Consulting Group’s risk adjustment reporting project for this market. Our assumptions are

the result of a combination of measurements based on Wakely’s reports and our own actuarial

judgment.

The anticipated risk adjustment transfer revenue is allocated proportionally based on plan premium.

The Projected Risk Adjustment is subtracted from Projected Incurred Claims before ACA Reinsurance

and Risk Adjustment to reflect anticipated receipt of risk adjustment transfer amounts for the projection

period.

When the projected risk adjustment amounts for KHPE and QCC are combined, the result is consistent

with the projection made in our initial submission, and is comparable to the Wakely projection. We also

considered 2014 risk transfer results.

Projected ACA Reinsurance Recoveries Net of Reinsurance Premium (Individual Market Only)

With the expiration of the reinsurance program at the end of the 2016 benefit year, there is no

reinsurance premium assumed in the rates.

NON-BENEFIT EXPENSES AND PROFIT & RISK

Administrative Expense Load

An Administrative Expense Load is applied to Projected Incurred Claims to reflect expenses related to

quality improvement and fraud detection/recovery and other expenses of operating a business, broker

commissions, and premium payment processing fees.

Profit & Risk Load/Contribution to Surplus

A Profit & Risk Load/Contribution to Surplus for the single risk pool is applied to Projected Incurred

Claims for the projection period, if applicable.

Taxes and Fees

A Taxes & Fees load is applied to Projected Incurred Claims to pass through the fees and taxes levied by

the federal and state governments.

PROJECTED LOSS RATIO

The projected loss ratio for the single risk pool is estimated to exceed 80% reflecting premium

adjustments permitted by the federal MLR calculation.

SINGLE RISK POOL

The single risk pool reflects all covered lives for every small group non-grandfathered product and plan combination for KHPE in the state of Pennsylvania. It is established according to the Single Risk Pool requirements in 45 CFR § 156.80(d).

INDEX RATE

The Index Rate is defined as the EHB portion of projected allowed claims divided by all projected single risk pool lives. The Index Rate is the same value for all non-grandfathered plans for KHPE small group Plans in Pennsylvania. The Index Rate reflects the twelve month projection for calendar year 2017. It has been developed following the specifications of 45 CFR § 156.80(d)(1).

MARKET ADJUSTED INDEX RATE

The Market Adjusted Index rate is calculated as the Index Rate adjusted for all allowable market-wide

modifiers defined in the market rating rules: federal reinsurance program adjustment, risk adjustment

and exchange user fees. The Market Adjusted Index Rate reflects the average demographic

characteristics of the single risk pool.

PLAN ADJUSTED INDEX RATE

The Plan Adjusted Index Rate is calculated as the issuer Market Adjusted Index Rate adjusted for all

allowable plan level modifiers defined in the market rating rule. These include actuarial value and cost

sharing adjustment, provider network, delivery system and utilization management adjustment,

adjustment for benefits in addition to the EHBs, impact of specific eligibility categories for the

catastrophic plan and administrative costs.

CALIBRATION

The plan adjusted index rate is projected for all products using the same anticipated age distribution

and the mandated age curve. Therefore the consumer adjusted premium rate is the plan adjusted index

rate divided by the average age, geographic and tobacco factors for the expected distribution. The

average age of the combined small group risk pool population is 46.

The Average Age factor is the weighted average age factor based on the projected membership. The

Tobacco Factor is calculated as the projected average factor for tobacco users multiplied by the

projected tobacco use prevalence.

There is only one geographic rating area for this filing. The geographic rating area factor for this filing is

1.0.

WORKSHEET 2: PRODUCT-PLAN DATA COLLECTION

AV METAL VALUES

The AV Metal Values included in Worksheet 2 of the URRT were valued using the AV Calculator, where

possible, otherwise the AV Metal Values were developed under an alternate methodology. Actuarial

certifications required by 45 CFR Part 156, §156.135 are provided in a separate document.

AV PRICING VALUES

The AV Pricing Value represents the cumulative effect of adjustments made by plan to move from the

Market Adjusted Index Rate to the Plan Adjusted Index Rate.

MEMBERSHIP PROJECTIONS

Enrollment is projected based on current and anticipated enrollment by plan. Items impacting these

projections include changes in the size of the market due to introduction of guarantee issue

requirements and the individual mandate.

TERMINATED PLANS

The following plans are terminated:

HIOS ID Plan Name

33871PA0100017 Keystone HMO Bronze Basic


HIOS ID CHANGES

Pursuant to guidance from CMS, the following plans were reclassified from HMO to POS. HIOS IDs for

the following plans are changed effective January 1, 2017. They are shown in the Experience Period

section of the URRT Worksheet 2 using the 2017 HIOS ID numbers.

2016 HIOS ID 2017 HIOS ID Plan Name

33871PA0100010 33871PA0110001 Keystone DPOS Platinum Preferred $10/$20/$100


33871PA0100012 33871PA0110003 Keystone DPOS Gold Preferred $30/$60/$650

33871PA0100013 33871PA0110004 Keystone DPOS Gold Classic $1,000 $25/$50/90%


33871PA0100014 33871PA0110006 Keystone DPOS Silver Classic $2,500 $25/$50/70%

33871PA0100034 33871PA0110007 Keystone DPOS Silver Secure $3,500/$40/$80/$600

33871PA0100019 33871PA0110008 Keystone DPOS Silver Classic $4,250/$40/$80/100%


33871PA0100016 33871PA0110010 Keystone DPOS Bronze Essential $6,850 $50/$100/$700











WARNING ALERTS

There are no warning alerts in URRT Part 1.

ACTUARIAL CERTIFICATION

I, xxxxxxxxxxxxxx, am Director & Actuary of Commercial Markets for the Independence Blue Cross Family of Companies. I am a member of the Society of Actuaries and the American Academy of Actuaries with the education and experience necessary to perform the work necessary and meet the Qualification Standards of the American Academy of Actuaries to render the qualified actuarial opinion contained herein. The developed rates and memorandum have been prepared in conformity with appropriate Actuarial Standards of Practice and the Academy’s Code of Professional Conduct.

The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the premium rates and allowable rating factors. Rather, it represents information required by Federal regulation to be provided in support of the review of gross premium 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 hereby certify that, to the best of my knowledge and judgment, the following:

The projected index rate is:

—In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.08(d)(1) and 147.102);

—Developed in compliance with applicable Actuarial Standards of Practice;

—Reasonable in relation to the benefits provided and the population anticipated to be covered; and

—Neither excessive nor deficient.

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 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.

Geographic rating factors reflect only differences in the costs of delivery of and do not include differences for population morbidity by geographic area.

The AV Calculator was used to determine the AV Metal Values shown in Worksheet 2 of the

Part I Unified Rate Review Template for all plans, unless an alternate methodology was

required. If an alternate methodology was used to calculate the AV Metal Value for at least

one plan offered, a copy of the actuarial certification required by 45 CFR Part 156, §156.135

will be included.

xxxxxxxxxxxxxx xxxxxxxxxxxxxx May 11, 2016

PENNSYLVANIA ACTUARIAL MEMORANDUM

PURPOSES

This Actuarial Memorandum is provided along with the Unified Rate Review Template (URRT) and PA

Actuarial Memorandum Rate Exhibits to provide certain information to support the gross premium for

the single risk pool for small group market health care insurance underwritten by Keystone Health Plan

East in the Commonwealth of Pennsylvania. It is provided as a component of a state rate filing. This

submission may not be appropriate for other purposes.

1. BASIC INFORMATION AND DATA

A. COMPANY INFORMATION

Company Legal Name: Keystone Health Plan East (“KHPE”)

State: Pennsylvania

NAIC #: 95056

Market: Small Group

Marketplace: On and Off Exchange

Effective Date(s): 1/1/2017-3/31/2017, 4/1/2017 – 6/30/2017, 7/1/2017 – 9/30/2017,

10/1/2017 – 12/31/2017

Average Rate Change: 3.7%

Range of Rate Changes: 1.2% - 5.8%

Products: HMO

Rating Areas: Rating Area 8

Metal Levels: Platinum, Gold, Silver, Bronze

Current Members: 125,640

Current Policyholders: 73,044

Number of 2017 Plans: 44

HIOS Issuer ID (5-digit): 33871

Worksheet 1 of the accompanying URRT contains experience period data and development of the

projected Single Risk Pool Gross Premium Average Rate PMPM for the small group market for KHPE.

Worksheet 2 contains experience period data and projections by product for the single risk pool for the

same entities. This memorandum pertains only to plans denoted in Worksheet 2 by Plan IDs starting

with the sequence 33871.

COMPANY CONTACT INFORMATION

Primary Contact Name: xxxxxxxxxxxx

Primary Contact Telephone Number: xxxxxxxxxxxx

Primary Contact Email Address: xxxxxxxxxxxxxxxx xxxxxxxx

B. RATE HISTORY AND PROPOSED VARIATIONS IN RATE CHANGES

January 1, 2014 Initial Filing INAC- 128999672

January 1, 2015 8.40% INAC- 129626509

October 1, 2015 -0.30% INAC- 130111004

January 1, 2016 6.88% INAC- 129955625

The historical rate changes varied by metallic tier based on plan benefits as illustrated via the Pricing AV.

Proposed rate changes vary by metallic tier and plan based on projected experience and plan benefit

changes.

C. AVERAGE RATE CHANGE

The average proposed rate change is 3.7%. The changes to the single risk pool gross premium average

rate per member per month (PMPM) from calendar year 2015 to calendar year 2017 are incorporated

into the pricing and reflected in the Unified Rate Review Template.

The change in 21-year-old Non-Tobacco Premium PMPM calculated in Table 11, Cell AZ13 is 3.7%.

D. MEMBERSHIP COUNT

Table 1 illustrates the Experience Period member-months, Current Period members as of February 1,

2016, and Projected Rating Period Member-months by ages.

E. BENEFIT CHANGES

Benefit changes were made to the following plans to assure compliance with Actuarial Value

requirements.

F. EXPERIENCE PERIOD CLAIMS AND PREMIUMS

Table 2 illustrates the experience period claims and premiums using calendar year data. The data is

consistent with the data reported in Section 1 of Worksheet I of the URRT.

Experience period premium, claims, and member months are obtained from the company’s internal

data warehouse. The claims data is collected for incurred dates from January through December 2015

and paid through January 2016. Earned premiums and member months are for January through

December 2015. The data are for all direct-written individual business of KHPE in the Commonwealth of

Pennsylvania, including out-of-network claims written by KHPE but paid by QCC for POS plans. No

private reinsurance was applicable.

Projected Risk Adjustment PMPM

Non-EHB benefits are illustrated separately in cell H26. Capitation is uniform by age for the experience

period. Net pharmacy rebates are illustrated in cell J26.

Projected Risk Adjustment is accounted for in Projected Incurred Claims before ACA Reinsurance and

Risk Adjustment to reflect anticipated risk adjustment transfer amounts for the projection period. The

amount reflects the projected morbidity for the single risk pool for IBCFOC in the projection period.

The estimated risk adjustment revenue for all of the plans in the risk pool is developed using the

following methodology. We recognize that the HHS payment transfer formula implies that the projected

incurred claims based solely on the experience period single risk pool claims need to be adjusted by the

ratio of the current statewide market’s risk relative to allowable rating factor (ARF) for age compared to

the single risk pool’s risk relative to ARF presented during the experience period. This adjustment,

together with the assumed future changes in population risk morbidity, results in the issuer’s pricing

being consistent with the anticipated morbidity level of the future statewide market.

Estimating the current statewide market’s risk and ARF is difficult, because we do not have access to the

relevant data from other carriers operating in this market. In order to gain insight, we participated in

the Wakely Consulting Group’s risk adjustment reporting project for this market. Our assumptions are

the result of a combination of measurements based on Wakely’s reports and our own actuarial

judgment.

The anticipated risk adjustment transfer revenue is allocated proportionally based on plan premium.

The Projected Risk Adjustment is subtracted from Projected Incurred Claims before ACA Reinsurance

and Risk Adjustment to reflect anticipated receipt of risk adjustment transfer amounts for the projection

period.

When the projected risk adjustment amounts for KHPE and Independence Blue Cross (QCC) are

combined, the result is consistent with the projection made in our initial submission, and is comparable

to the Wakely projection. We also considered 2014 risk transfer results.

Projected ACA Reinsurance Recoveries Net of Reinsurance Premium (Individual Market Only)

The Federal Transitional Reinsurance Program is not applicable for 2017.

G. CREDIBILITY OF DATA

The experience period data is considered 100% credible.

H. TREND IDENTIFICATION

Table 3 identifies the proposed annual medical and prescription drug allowed claims cost and utilization

trends. These data match the data illustrated in Section 2 of Worksheet I of the URRT. Additional

discussion is provided in Section I, Historical Experience.

I. HISTORICAL EXPERIENCE

Table 4 illustrates historical experience from 2014 through 2015 for the product line.

a. Annualized Cost Trend

Annual cost trend reflects changes in costs of medical treatment due to medical inflation and changes in

the distribution of services across network providers. The trend value is developed by reviewing

historical medical costs for the single risk pool and adjusting them for anticipated future provider

contracting reimbursement levels. The data is normalized for changes in age, benefit changes during the

experience period, changes to provider contracts, and prescription drug formulary, and new drugs

brought to market.

b. Annualized Utilization Trend

Annual utilization trend reflects the change in the number of units per 1,000 members for a fixed level

of illness burden and includes changes due to the mix and intensity of services provided and changes

related to shifts in product mix. It also includes effects of selection, if any, since this cannot be reflected

in the relative cost of the various products and plans offered.

J. TERMINATED PLANS

The following plans are terminated:

HIOS ID Plan Name



K. HIOS ID CHANGES

Pursuant to guidance from CMS, the following plans were reclassified from HMO to POS. HIOS IDs for

the following plans are changed effective January 1, 2017. They are shown in the Experience Period

section of the URRT Worksheet 2 using the 2017 HIOS ID numbers.

2016 HIOS ID 2017 HIOS ID Plan Name





















2. RATE DEVELOPMENT AND CHANGE

A. DEVELOPMENT OF PROJECTED INDEX RATE, MARKET-ADJUSTED INDEX RATE, & TOTAL

ALLOWED CLAIMS

Table 5 illustrates the development of the Projected Index Rate and Market-Adjusted Index Rate

beginning with the Experience Period Index Rate.

Changes in Population Risk Morbidity

Experience period allowed claims are adjusted to account for differences in the average morbidity of the

single risk pool population underlying the experience and the anticipated population in the projection

period. This adjustment reflects changes in the small group market-wide morbidity due to one or more

of the following: guarantee issue, the individual mandate, Medicaid and CHIP migration, take-up of

insurance by the previously uninsured, health status of the newly insured, enrollment from prior high

risk pools, subsidy effects, dumping of enrollment from group markets to the individual market, and

market-wide impact of transitional products/plans.

Changes in Other Factors

Experience period allowed claims are adjusted to account for differences in the single risk pool

population underlying the experience and the anticipated population in the projection period pertaining

to several factors not due to changes in morbidity or the costs and utilization of medical care. This

adjustment reflects: additional benefits required to be covered as essential health benefits; recently

mandated benefits required by state law that are not reflected in the experience period data; benefits in

the experience that are removed for the projection period; 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; changes in demographic

characteristics of the single risk pool experience period population and the projection period population

(including age, gender, region, and tobacco use); changes in the provider network (adding or removing a

provider system or introducing a limited network option); and anticipated changes in pharmacy rebates.

B. RETENTION ITEMS

Table 6 illustrates the retention items, expressed as percentages of premium. Administrative expenses

are calculated and applied on a PMPM basis. When expressed as a percentage of premium, these will

vary by premium size. Consistent with conversations with our State regulator, no Pricing load was

applied for the Managed Care Assessment levied pursuant to Article VIII-I of the Pennsylvania Code, as it

will be separately reimbursed.

Administrative Expenses 9.89%

General and Claims 3.68%

Agent/Broker Fees and Commissions 5.74%

Quality Improvement Initiatives 0.47%

Taxes and Fees 4.12%

PCORI Fees 0.05%

PA Premium Tax 0.00%

Federal Income Tax 2.47%

Health Insurance Providers Fee 1.60%

Profit/Contingency 2.00%

Total Retention 16.01%

C. NORMALIZED MARKET-ADJUSTED PROJECTED ALLOWED TOTAL CLAIMS

Table 7 compares the normalization factors used in this filing to those used in the 2016 filing. The

changes in the factors reflect small differences from the projected populations in 2016 and 2017.

D. COMPONENTS OF RATE CHANGE

Table 8 illustrates the components of rate change, based on inputs form other sections of the Rate

Exhibits. The results in Row H are similar to the values in Row A of Table 8.

Data in Table 9 was taken from the 2016 URRT with the exceptions of Risk Adjustment and Reinsurance

which were revised to project company-specific values.

3. PLAN RATE DEVELOPMENT

Table 10 is populated with plan information consistent with entries in the 2017 URRT. Plan mappings,

where applicable, are illustrated in Column F of Table 10.

Attached to this actuarial memorandum are exhibits providing actuarial certifications for the use of

alternate methods of calculating the Actuarial Value, where applicable, as well as required support for

the calculations.

4. PLAN PREMIUM DEVELOPMENT FOR 21-YEAR OLD NON-TOBACCO USER

Table 11 is populated from other sections of the Rate Exhibits, along with the population by age and

rating area for the Projection Period.

5. PLAN FACTORS

Tables 12, 13, and 14 illustrate the factors used in pricing for age, tobacco, geographic rating area, and

network. To be consistent with our Consumer rating, we are proposing to use the tobacco factors

approved for 2016 in 2017 rating in consideration of the additional premium required for Individual

Plans by the terminating of the federal reinsurance program.

6. ACTUARIAL CERTIFICATION

I, xxxxxxxxxxxxxxxxxx, am Director & Actuary of Commercial Markets for the Independence Blue Cross Family of Companies. I am a member of the Society of Actuaries and the American Academy of Actuaries with the education and experience necessary to perform the work necessary and meet the Qualification Standards of the American Academy of Actuaries to render the qualified actuarial opinion contained herein. The developed rates and memorandum have been prepared in conformity with appropriate Actuarial Standards of Practice and the Academy’s Code of Professional Conduct. The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the premium rates and allowable rating factors. Rather, it represents information required by Federal regulation to be provided in support of the review of gross premium 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 hereby certify that, to the best of my knowledge and judgment, the following:

The projected index rate is:

—In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.08(d)(1) and 147.106);

—Developed in compliance with applicable Actuarial Standards of Practice;

—Reasonable in relation to the benefits provided and the population anticipated to be covered; and

—Neither excessive nor deficient.

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 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.

The AV Calculator was used to determine the AV Metal Values illustrated in Worksheet 2 of

the Part I Unified Rate Review Template for all plans, unless an alternate methodology was

required. If an alternate methodology was used to calculate the AV Metal Value for at least

one plan offered, a copy of the actuarial certification required by 45 CFR Part 156, §156.135

will be included.

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

the actuarial memorandum.

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

modification standards in 45 CFR 147.106.

The information presented in the PA Actuarial Memorandum and PA Actuarial

Memorandum Rate Exhibits is consistent with the information presented in the 2017 Rate

Filing Justification.

xxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx May 11, 2016

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 1,494,855 125,640 1,508,556

<18 288,407 23,045 276,697

18-24 146,476 12,023 144,356

25-29 128,636 11,072 132,945

30-34 128,955 11,279 135,432

35-39 115,241 10,136 121,703

40-44 118,421 9,531 114,434

45-49 140,785 11,668 140,093

50-54 156,581 12,994 156,020

55-59 147,479 12,408 148,980

60-63 92,249 8,158 97,952

64+ 31,626 3,327 39,944

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

$671,931,345 $ 508,712,286.58 $550,417,515 1,494,855 $22,793,366 $573,210,881 $ 6,356,088.10 $ (209,279.70) ############## $ - 37,933,070.43$ (3,172,524.16)$

2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 396.44$

Loss Ratio 81.61%

*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Composite Weight*

3.83% 2.40% 6.32% 18.93% <- Annualized Trend Factors on URRT

3.00% 2.40% 5.47% 24.00%

1.65% 2.40% 4.09% 30.85%

1.32% 2.00% 3.35% 0.00%

1.50% 0.23%

4.50% 4.50% 9.20% 25.99%

6.17% 100.00%

1.127

* Express Cost, Utilization, and Weight as percentages

Table 4. Historical Experience

Month-Year Total Annual Premium Incurred Claims Completion Factors*Ultimate Incurred

ClaimsMembers

Ultimate

Incurred PMPM

Estimated Annual

Cost Sharing

(Member + HHS)

Prescription

Drug Rebates**

Allowed Claims (Net of

Prescription Drug Rebates)Allowed PMPM

Jan-13 #DIV/0! #DIV/0! #DIV/0!

Feb-13 #DIV/0! #DIV/0! #DIV/0!

Mar-13 #DIV/0! #DIV/0! #DIV/0!

Apr-13 #DIV/0! #DIV/0! #DIV/0!

May-13 #DIV/0! #DIV/0! #DIV/0!

Jun-13 #DIV/0! #DIV/0! #DIV/0!

Jul-13 #DIV/0! #DIV/0! #DIV/0!

Aug-13 #DIV/0! #DIV/0! #DIV/0!

Sep-13 #DIV/0! #DIV/0! #DIV/0!

Oct-13 #DIV/0! #DIV/0! #DIV/0!

Nov-13 #DIV/0! #DIV/0! #DIV/0!

Dec-13 #DIV/0! #DIV/0! #DIV/0!

Jan-14 $ 40,604,302.32 1.0000 $ 40,604,302.32 316,387 $ 128.34 $ (44,294.18) $ 43,270,404.49 $ 136.76

Feb-14 $ 34,166,292.36 1.0000 $ 34,166,292.36 301,899 $ 113.17 $ (42,265.86) $ 36,832,394.53 $ 122.00

Mar-14 $ 39,338,046.68 1.0000 $ 39,338,046.68 282,712 $ 139.15 $ (39,579.68) $ 42,004,148.85 $ 148.58

Apr-14 $ 41,450,398.48 1.0000 $ 41,450,398.48 257,248 $ 161.13 $ (36,014.72) $ 44,116,500.65 $ 171.49

May-14 $ 40,797,001.60 1.0000 $ 40,797,001.60 242,959 $ 167.92 $ (34,014.26) $ 43,463,103.77 $ 178.89

Jun-14 $ 38,230,510.58 1.0000 $ 38,230,510.58 225,177 $ 169.78 $ (31,524.78) $ 40,896,612.75 $ 181.62

Jul-14 $ 42,003,525.81 1.0000 $ 42,003,525.81 208,509 $ 201.45 $ (29,191.26) $ 44,669,627.98 $ 214.23

Aug-14 $ 38,398,241.23 1.0000 $ 38,398,241.23 195,609 $ 196.30 $ (27,385.26) $ 41,064,343.40 $ 209.93

Sep-14 $ 40,788,043.11 1.0000 $ 40,788,043.11 179,173 $ 227.65 $ (25,084.22) $ 43,454,145.28 $ 242.53

Oct-14 $ 41,520,340.29 1.0000 $ 41,520,340.29 165,793 $ 250.43 $ (23,211.02) $ 44,186,442.46 $ 266.52

Nov-14 $ 35,480,336.72 1.0000 $ 35,480,336.72 153,360 $ 231.35 $ (21,470.40) $ 38,146,438.89 $ 248.74

Dec-14 $ 40,242,044.94 0.9996 $ 40,256,875.96 126,131 $ 319.17 $ (17,658.34) $ 42,908,147.11 $ 340.19

Jan-15 $47,920,822.35 0.9994 $ 47,947,678.83 125,009 $ 383.55 $ (17,501.26) $ 49,820,269.55 $ 398.53

Feb-15 $ 44,150,845.02 0.9990 $ 44,193,848.22 124,735 $ 354.30 $ (17,462.90) $ 46,050,292.23 $ 369.19

Mar-15 $ 47,088,110.55 0.9986 $ 47,152,770.65 124,684 $ 378.18 $ (17,455.76) $ 48,987,557.76 $ 392.89

Apr-15 $ 46,649,913.22 0.9978 $ 46,751,217.97 124,297 $ 376.13 $ (17,401.58) $ 48,549,360.42 $ 390.59

May-15 $ 43,834,781.73 0.9968 $ 43,974,492.82 123,986 $ 354.67 $ (17,358.04) $ 45,734,228.94 $ 368.87

Jun-15 $ 45,917,347.66 0.9944 $ 46,174,635.54 123,538 $ 373.77 $ (17,295.32) $ 47,816,794.87 $ 387.06

Jul-15 $ 46,642,687.61 0.9913 $ 47,053,128.66 123,094 $ 382.25 $ (17,233.16) $ 48,542,134.82 $ 394.35

Aug-15 $ 45,159,671.28 0.9845 $ 45,872,902.32 122,749 $ 373.71 $ (17,184.86) $ 47,059,118.49 $ 383.38

Sep-15 $ 44,059,138.00 0.9777 $ 45,063,479.53 122,919 $ 366.61 $ (17,208.66) $ 45,958,585.21 $ 373.89

Oct-15 $ 46,775,969.09 0.9628 $ 48,581,819.84 122,974 $ 395.06 $ (17,216.36) $ 48,675,416.30 $ 395.82

Nov-15 $ 45,433,595.81 0.9219 $ 49,283,273.13 123,067 $ 400.46 $ (17,229.38) $ 47,333,043.01 $ 384.61

Dec-15 $ 46,784,632.69 0.8534 $ 54,822,664.27 124,688 $ 439.68 $ (17,456.32) $ 48,684,079.90 $ 390.45

* Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

2 Year Trend Projection Factor

Service Category

Other Medical

Capitation

Prescription Drugs

Total Annual Trend

Inpatient Hospital

Outpatient Hospital

Professional

$31,993,226

$22,793,366

$632,859,798

$671,931,345

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) $401.00 <- Index Rate of Experience Period on URRT Table 5A. Small Group Projected Index Rate with Quarterly Trend 2 Year Trend Projection Factor 1.105

Unadjusted Projected Allowed EHB Claims PMPM 443.06$ 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 545,005 342,971 234,694 372,185 1,494,855.00

Change in Morbidity 1.000 <- Adj't. from Experience to Projection Period - Other on URRT Percent of Members Months Renewing in Quarter 36% 23% 16% 25% 100%

Change in Other 1.060 Base Allowed Claims 469.65$ 469.65$ 469.65$ 469.65$ 469.65$

Change in Demographics 1.037 Months of Trend - 3 6 9 4

Change in Network 0.989 Annual Trend 6.17% 6.17% 6.17% 6.17% 6.17%

Change in Benefits 0.996 Single Risk Pool Projected Allowed Claims 469.65$ 476.73$ 483.91$ 491.20$ 478.88$

Change in Other 1.038

Adjusted Projected Allowed EHB Claims PMPM 469.65$ <- 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] 478.88$ <- Index Rate for Projection Period on URRT - Small Group

Projected Paid to Allowed Ratio 0.879956329 <- Paid to Allowed Average Factor in Projection Period on URRT

Projected Paid EHB Claims PMPM 421.3909711

Market-wide Adjustments

Projected Paid Net Risk Adjustment PMPM 16.87$

Projected Paid Exchange User Fees PMPM 0.92$

Market-Adjusted Projected Paid EHB Claims PMPM 439.18$

Market-Adjusted Projected Allowed EHB Claims PMPM 499.10$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM 5.89$

Market-Adjusted Projected Paid Total Claims PMPM 444.37$

Market-Adjusted Projected Allowed Total Claims PMPM 504.99$

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 1.457 1.472

General and Claims 3.68% Average Geographic Factor 1.000 1.000

Agent/Broker Fees and Commissions 5.74% Average Tobacco Factor 1.015 1.011

Quality Improvement Initiatives 0.47% Average Benefit Richness (induced demand) 0.979 0.947

Taxes and Fees 4.12% Average Network Factor 1.044 1.011

PCORI Fees (Enter $ amount here: $______________ ) 0.05%

Pa Premium Tax (if applicable) 0.00% Market-Adjusted Projected Allowed Total Claims PMPM 490.48$ 504.99$

Federal Income Tax 2.47%

Health Insurance Providers Fee (only for small group market, prorated for coverage in 2018) 1.60% Normalized Market-Adjusted Projected Allowed Total Claims PMPM 324.30$ 354.35$

Profit/Contingency 2%

Total Retention 16%

<- Single Pool Gross Premium Avg. Rate, PMPM on URRT

Projected Required Revenue PMPM 529.10$

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) 339.6419632 352.1416905 $12.50 3.7% Paid-to-Allowed 0.87 0.879956329

B. Base period allowed claims before normalization $374.00 401.00$ $27.00 8% URRT Trend (2-Year Trend Factor) 1.165652009 1.13 <- URRT W1, S2

C. Normalization factor component of change (126.72)$ -119.6165634 $7.10 $0.02 URRT Morbidity 1.016 1.000 <- URRT W1, S2

URRT "Other" 1.009530314 1.060 <- URRT W1, S2

D. Change in Normalized Allowed Claims Adjustment Components D1. Base period allowed claims after normalization 247.28$ 281.38$ 34.10$ 10% Risk Adjustment 58.14$ 16.87$ <- URRT W1, S3

D2. URRT Trend 40.96$ 35.77$ (5.19)$ -2% Reinsurance 2.25$ -$ <- URRT W1, S3

D3. URRT Morbidity 4.61$ -$ (4.61)$ -1% Exchange User Fee 0.88$ 0.92$ <- URRT W1, S3

D4. URRT Other 2.79$ 19.03$ 16.24$ 5% Capitation 19.75$ 19.23$ <- URRT W1, S2

D5. Normalized URRT RA/RI on an allowed basis 45.89$ 13.45$ (32.44)$ -10% D6. Normalized Exchange User Fee on an allowed basis 0.67$ 0.74$ 0.07$ 0% Network 1.000 1 D7. Subtotal - Sum(D1:D6) 342.21$ 350.37$ 8.16$ 2% Pricing AV 0.851 0.845790942

E. Change in Allowable Plan Adjusted Level Components Benefit Richness 1.000 1 E1. Network -$ 0 -$ 0% Catastrophic Eligibility 1.000 1 E2. Pricing AV (51.06)$ (54.03)$ (2.97)$ -1% E3. Benefit Richness -$ -$ -$ 0% Administrative Expenses 9.99% 9.89% E4. Catastrophic Eligibility -$ -$ -$ 0% Taxes and Fees 4.29% 4.12% E5. Subtotal - Sum(E1:E4) (51.06)$ (54.03)$ (2.97)$ -1% Profit and/or Contingency 0.00% 2.00%F. Change in Retention Components

F1. Administrative Expenses 33.92$ 34.84$ 0.93$ 0% F2. Taxes and Fees 14.57$ 14.52$ (0.05)$ 0% F3. Profit and/or Contingency -$ 7.04$ 7.04$ 2% F4. Subtotal - Sum(F1:F3) 48.49$ 56.41$ 7.92$ 2%

G. Change in Miscellaneous Items -$ 0%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 339.64$ 352.75$ 13.11$ 4%

PA Rate Template Part IIITable 10. Plan Rates

Carrier Name: KHPE

Plan Type(s): HMO

Market Segment: Small Group

Rate Effective Date: 1/1/2017

Market Adjusted Index Rate 499.10$

Plan Number HIOS Plan ID (Standard Component)

Plan Type

(HMO, POS, PPO, EPO,

Indemnity, Other)

Totals

Plan 1 33871PA0100001 HMO

Plan 2 33871PA0100002 HMO

Plan 3 33871PA0100003 HMO

Plan 4 33871PA0100004 HMO

Plan 5 33871PA0100005 HMO

Plan 6 33871PA0100006 HMO

Plan 7 33871PA0100007 HMO

Plan 8 33871PA0100008 HMO

Plan 9 33871PA0100009 HMO

Plan 10 33871PA0110001 POS

Plan 11 33871PA0110002 POS

Plan 12 33871PA0110003 POS

Plan 13 33871PA0110004 POS

Plan 14 33871PA0110006 POS

Plan 15 33871PA0110009 POS

Plan 16 33871PA0110010 POS

Plan 17 33871PA0100017 HMO

Plan 18 33871PA0110005 POS

Plan 19 33871PA0110008 POS

Plan 20 33871PA0100020 HMO

Plan 21 33871PA0100021 HMO

Plan 22 33871PA0100022 HMO

Plan 23 33871PA0100023 HMO

Plan 24 33871PA0100024 HMO

Plan 25 33871PA0100025 HMO

Plan 26 33871PA0100026 HMO

Plan 27 33871PA0110011 POS

Plan 28 33871PA0110012 POS

Plan 29 33871PA0110013 POS

Plan 30 33871PA0110014 POS

Plan 31 33871PA0110016 POS

Plan 32 33871PA0110019 POS

Plan 33 33871PA0110020 POS

Plan 34 33871PA0110007 POS

Plan 35 33871PA0100035 HMO

Plan 36 33871PA0100036 HMO

Plan 37 33871PA0100037 HMO

Plan 38 33871PA0110015 POS

Plan 39 33871PA0110018 POS

Plan 40 33871PA0110017 POS

Plan 41 33871PA0100044 HMO

Plan 42 33871PA0100045 HMO

Plan 43 33871PA0100046 HMO

Plan 44 33871PA0100047 HMO

Plan 45 33871PA0100048 HMO

Plan 46 33871PA0100049 HMO

Plan 47

Plan 48

Plan 49

Plan 50

Plan 51

Plan 52

Plan 53

Plan 54

Plan 55

Plan 56

Plan 57

Plan 58

Plan 59

Plan 60

Plan 61

Plan 62

Plan 63

Plan 64

Plan 65

Plan 66

Plan 67

Plan 68

Plan 69

Plan 70

Plan 71

Plan 72

Plan 73

Plan 74

Plan 75

Plan 76

Plan 77

Plan 78

Plan 79

Plan 80

Plan 81

Plan 82

Plan 83

Plan 84

Plan 85

Plan 86

Plan 87

Plan 88

Plan 89

Plan 90

Plan 91

Plan 92

Plan 93

Plan 94

Plan 95

Plan 96

Plan 97

Plan 98

Plan 99

Plan 100

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

0.814

Keystone HMO Platinum Preferred $10/$20/$100E Keystone HMO Platinum Preferred $10/$20/$100Platinum 0.915


Keystone HMO Gold Preferred $30/$60/$600E Keystone HMO Gold Preferred $30/$60/$600Gold 0.819

Keystone HMO Gold Classic $1,000 $25/$50/90%E Keystone HMO Gold Classic $1,000 $25/$50/90%Gold 0.785

Keystone HMO Silver Classic $2,000 $25/$50/70%E Keystone HMO Silver Classic $2,000 $25/$50/70%Silver 0.708


Keystone HMO Bronze Essential $6,000 $50/$100/$700E Keystone HMO Bronze Essential $6,000 $50/$100/$700Bronze 0.62

Keystone HMO Gold ProactiveE Keystone HMO Gold ProactiveGold 0.79

Keystone HMO Silver ProactiveE Keystone HMO Silver ProactiveSilver 0.719

Keystone DPOS Platinum Preferred $10/$20/$100E Keystone DPOS Platinum Preferred $10/$20/$100Platinum 0.915


Keystone DPOS Gold Preferred $30/$60/$600E Keystone DPOS Gold Preferred $30/$60/$600Gold 0.819

Keystone DPOS Gold Classic $1,000 $25/$50/90%E Keystone DPOS Gold Classic $1,000 $25/$50/90%Gold 0.785

Keystone DPOS Silver Classic $2,000 $25/$50/70%E Keystone DPOS Silver Classic $2,000 $25/$50/70%Silver 0.708


Keystone DPOS Bronze Essential $6,000 $50/$100/$700E Keystone DPOS Bronze Essential $6,000 $50/$100/$700Bronze 0.62

Keystone HMO Bronze Basic D Keystone HMO Bronze Basic Bronze 0





Keystone HMO Gold Preferred $30/$60/$600E Keystone HMO Gold Preferred $30/$60/$600Gold 0.819




Keystone HMO Bronze Essential $6,000 $50/$100/$700E Keystone HMO Bronze Essential $6,000 $50/$100/$700Bronze 0.62



Keystone DPOS Gold Preferred $30/$60/$600E Keystone DPOS Gold Preferred $30/$60/$600Gold 0.819




Keystone DPOS Bronze Essential $6,000 $50/$100/$700E Keystone DPOS Bronze Essential $6,000 $50/$100/$700Bronze 0.62

Keystone DPOS Silver Secure $3,500 $40/$80/$600E Keystone DPOS Silver Secure $3,500 $40/$80/$600Silver 0.693



Keystone HMO Silver Secure $3,500 $40/$80/$600E Keystone HMO Silver Secure $3,500 $40/$80/$600Silver 0.693



Keystone DPOS Silver Secure $3,500 $40/$80/$600E Keystone DPOS Silver Secure $3,500 $40/$80/$600Silver 0.693

Keystone HMO Gold ProactiveE Keystone HMO Gold ProactiveGold 0.79

Keystone HMO Silver ProactiveE Keystone HMO Silver ProactiveSilver 0.719

HMO Bronze Basic D HMO Bronze Basic Bronze 0



Keystone HMO Silver Secure $3,500 $40/$80/$600E Keystone HMO Silver Secure $3,500 $40/$80/$600Silver 0.693

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

0.846 1.056 1.000 0.989

Approach 1 ON/OFF 1.066 1.056 1.000 1.000

Approach 1 ON/OFF 0.998 1.056 1.000 1.000

Approach 1 ON/OFF 0.819 1.045 1.000 1.000

Approach 1 ON/OFF 0.836 1.060 1.000 1.000

Approach 1 ON/OFF 0.733 1.018 1.000 1.000

Standard AV ON/OFF 0.665 1.062 1.000 1.000

Approach 2 ON/OFF 0.472 1.069 1.000 1.000

Approach 2 ON/OFF 0.737 1.077 1.000 0.952

Approach 2 ON/OFF 0.580 1.056 1.000 0.952

Approach 1 ON/OFF 1.100 1.056 1.000 1.000

Approach 1 ON/OFF 1.048 1.056 1.000 1.000

Approach 1 ON/OFF 0.859 1.044 1.000 1.000

Approach 1 ON/OFF 0.875 1.056 1.000 1.000

Approach 1 ON/OFF 0.769 1.019 1.000 1.000


Approach 2 ON/OFF 0.000 1.068 1.000 1.000


Approach 1 ON/OFF 0.847 1.072 1.000 1.000

Approach 1 ON/OFF 0.715 1.055 1.000 1.000

Standard AV OFF 1.047 1.058 1.000 1.000

Standard AV OFF 0.998 1.058 1.000 1.000

Standard AV OFF 0.818 1.046 1.000 1.000

Standard AV OFF 0.835 1.061 1.000 1.000

Standard AV OFF 0.733 1.021 1.000 1.000

Standard AV OFF 0.665 1.064 1.000 1.000

Standard AV OFF 0.472 1.072 1.000 1.000

Standard AV OFF 1.099 1.058 1.000 1.000

Standard AV OFF 1.047 1.058 1.000 1.000

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

Standard AV OFF 0.858 1.046 1.000 1.000

Standard AV OFF 0.874 1.060 1.000 1.000

Standard AV OFF 0.769 1.021 1.000 1.000

Standard AV OFF 0.697 1.064 1.000 1.000

Standard AV OFF 0.496 1.071 1.000 1.000

Approach 1 ON/OFF 0.653 1.083 1.000 1.000

Approach 1 ON/OFF 0.812 1.083 1.000 1.000

Approach 1 ON/OFF 0.681 1.055 1.000 1.000

Approach 1 ON/OFF 0.622 1.083 1.000 1.000

Standard AV OFF 0.846 1.076 1.000 1.000

Standard AV OFF 0.714 1.059 1.000 1.000

Standard AV OFF 0.652 1.087 1.000 1.000

Standard AV OFF 0.737 1.079 1.000 0.952

Standard AV OFF 0.579 1.059 1.000 0.952

Standard AV OFF 0.000 1.000 1.000 1.000

Standard AV OFF 0.811 1.087 1.000 1.000

Standard AV OFF 0.680 1.059 1.000 1.000

Standard AV OFF 0.621 1.088 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

0.000 1.000 1.000 1.000

Age Calibration Factor 1.472

Geographic Calibration Factor 1.000

Aggregate Calibration Factor 1.472

Catastrophic

Eligibility

Tobacco

Surcharge

Adjustment

Pure

Premium Admin Costs

Taxes & Fees (not

including Exchange

fees)

Profit or

Contingency

1.000 0.989 436.95$ 9.9% 4.1% 2.0%

1.000 0.989 $555.94 6.6% 4.1% 2.0%

1.000 0.989 $520.51 8.4% 4.1% 2.0%

1.000 0.989 $422.15 9.8% 4.1% 2.0%

1.000 0.989 $437.19 9.6% 4.1% 2.0%

1.000 0.989 $368.57 10.9% 4.1% 2.0%

1.000 0.989 $348.50 11.4% 4.1% 2.0%

1.000 0.989 $249.22 14.6% 4.2% 2.0%

1.000 0.989 $373.19 10.8% 4.1% 2.0%

1.000 0.989 $287.71 13.1% 4.1% 2.0%

1.000 0.989 $573.57 7.9% 4.1% 2.0%

1.000 0.989 $546.51 8.1% 4.1% 2.0%

1.000 0.989 $442.80 9.5% 4.1% 2.0%

1.000 0.989 $456.29 9.3% 4.1% 2.0%

1.000 0.989 $386.81 10.5% 4.1% 2.0%

1.000 0.989 $365.74 11.0% 4.1% 2.0%

1.000 0.989 $0.00 0.0% 4.1% 2.0%

1.000 0.989 $0.00 0.0% 4.1% 0.0%

1.000 0.989 $448.30 9.4% 4.1% 2.0%

1.000 0.989 $372.06 10.8% 4.1% 2.0%

1.000 0.989 $546.92 8.1% 4.1% 2.0%

1.000 0.989 $521.05 8.4% 4.1% 2.0%

1.000 0.989 $422.68 9.8% 4.1% 2.0%

1.000 0.989 $437.73 9.6% 4.1% 2.0%

1.000 0.989 $369.10 10.9% 4.1% 2.0%

1.000 0.989 $349.02 11.4% 4.1% 2.0%

1.000 0.989 $249.71 14.6% 4.2% 2.0%

1.000 0.989 $574.11 7.9% 4.1% 2.0%

1.000 0.989 $547.04 8.1% 4.1% 2.0%

Calibration

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

1.000 0.989 $443.33 9.5% 4.1% 2.0%

1.000 0.989 $457.45 9.3% 4.1% 2.0%

1.000 0.989 $387.33 10.5% 4.1% 2.0%

1.000 0.989 $366.26 11.0% 4.1% 2.0%

1.000 0.989 $262.29 14.1% 4.1% 2.0%

1.000 0.989 $348.91 11.4% 4.1% 2.0%

1.000 0.989 $434.21 9.6% 4.1% 2.0%

1.000 0.989 $354.53 11.2% 4.1% 2.0%

1.000 0.989 $332.36 11.8% 4.1% 2.0%

1.000 0.989 $449.46 9.4% 4.1% 2.0%

1.000 0.989 $373.22 10.8% 4.1% 2.0%

1.000 0.989 $350.08 11.3% 4.1% 2.0%

1.000 0.989 $373.71 10.8% 4.1% 2.0%

1.000 0.989 $288.22 13.1% 4.1% 2.0%

1.000 0.989 $0.00 0.0% 4.1% 0.0%

1.000 0.989 $435.38 9.6% 4.1% 2.0%

1.000 0.989 $355.69 11.2% 4.1% 2.0%

1.000 0.989 $333.51 11.8% 4.1% 2.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

1.000 1.000 $0.00 0.0% 0.0% 0.0%

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

125,640 73,044 339.64$ 352.14$ 3.68%

10 10 417.32$ $432.77 3.7%

142 114 398.92$ $413.71 3.7%

160 100 331.47$ $341.21 2.9%

16 14 338.99$ $352.29 3.9%

28 22 298.10$ $301.71 1.2%

24 42 275.72$ $286.92 4.1%

24 10 204.48$ $213.73 4.5%

68 60 290.45$ $305.11 5.0%

470 354 233.48$ $242.11 3.7%

28 6 436.62$ $452.82 3.7%

72 42 417.35$ $432.87 3.7%

84 52 346.27$ $356.43 2.9%

1 - 353.34$ $366.40 3.7%

2 - 311.30$ $315.16 1.2%

16 14 287.95$ $299.63 4.1%

32 12 213.47$ $0.00 -100.0%

2 14 -$ $0.00 #DIV/0!

1 - 344.19$ $360.51 4.7%

1 - 293.73$ $304.32 3.6%

3,405 1,908 417.32$ $433.20 3.8%

15,920 5,925 398.92$ $414.13 3.8%

27,424 19,472 331.47$ $341.63 3.1%

1,538 936 338.99$ $352.72 4.1%

4,644 3,033 298.10$ $302.14 1.4%

1,950 1,215 275.72$ $287.34 4.2%

2,125 1,445 204.48$ $214.15 4.7%

5,364 2,841 436.62$ $453.24 3.8%

18,047 6,455 417.35$ $433.29 3.8%

6,489 6,416 346.27$ $356.85 3.1%

3,703 2,058 353.34$ $367.26 3.9%

2,111 1,332 311.30$ $315.58 1.4%

1,245 765 287.95$ $300.05 4.2%

778 489 213.47$ $223.42 4.7%

1 - 272.43$ $287.26 5.4%

1 - 331.97$ $350.13 5.5%

1 - 281.26$ $291.40 3.6%

3 3 260.86$ $275.06 5.4%

85 40 344.19$ $361.37 5.0%

27 11 293.73$ $305.18 3.9%

49 31 272.43$ $288.12 5.8%

17,593 6,939 290.45$ $305.54 5.2%

11,669 10,532 233.48$ $242.53 3.9%

1 144 -$ $0.00 #DIV/0!

89 52 331.97$ $350.99 5.7%

59 38 281.26$ $292.26 3.9%

138 98 260.86$ $275.91 5.8%

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

% of Total

Covered Lives

0.0%

0.1%

0.1%

0.0%

0.0%

0.0%

0.0%

0.1%

0.4%

0.0%

0.1%

0.1%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

2.7%

12.7%

21.8%

1.2%

3.7%

1.6%

1.7%

4.3%

14.4%

5.2%

2.9%

1.7%

1.0%

0.6%

0.0%

0.0%

0.0%

0.0%

0.1%

0.0%

0.0%

14.0%

9.3%

0.0%

0.1%

0.0%

0.1%

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%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

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

Carrier Name: KHPE

Plan Type(s): HMO

Market Segment: Small Group

Rate Effective Date: 1/1/2017

Plan Number HIOS Plan ID (Standard Component)

1/1/16 Plan

Marketing Name

Discontinued,

New, Modified,

Existing

(D,N,M,E) for

2017

Totals

Plan 1 33871PA0100001 Keystone HMO Platinum Preferred $10/$20/$100E


Plan 3 33871PA0100003 Keystone HMO Gold Preferred $30/$60/$600E

Plan 4 33871PA0100004 Keystone HMO Gold Classic $1,000 $25/$50/90%E

Plan 5 33871PA0100005 Keystone HMO Silver Classic $2,000 $25/$50/70%E


Plan 7 33871PA0100007 Keystone HMO Bronze Essential $6,000 $50/$100/$700E

Plan 8 33871PA0100008 Keystone HMO Gold Proactive E

Plan 9 33871PA0100009 Keystone HMO Silver Proactive E

Plan 10 33871PA0110001 Keystone DPOS Platinum Preferred $10/$20/$100E


Plan 12 33871PA0110003 Keystone DPOS Gold Preferred $30/$60/$600E

Plan 13 33871PA0110004 Keystone DPOS Gold Classic $1,000 $25/$50/90%E

Plan 14 33871PA0110006 Keystone DPOS Silver Classic $2,000 $25/$50/70%E


Plan 16 33871PA0110010 Keystone DPOS Bronze Essential $6,000 $50/$100/$700E

Plan 17 33871PA0100017 Keystone HMO Bronze Basic D





Plan 22 33871PA0100022 Keystone HMO Gold Preferred $30/$60/$600E




Plan 26 33871PA0100026 Keystone HMO Bronze Essential $6,000 $50/$100/$700E


These cells auto-fill using the data entered in Table 9.


Plan 29 33871PA0110013 Keystone DPOS Gold Preferred $30/$60/$600E




Plan 33 33871PA0110020 Keystone DPOS Bronze Essential $6,000 $50/$100/$700E

Plan 34 33871PA0110007 Keystone DPOS Silver Secure $3,500 $40/$80/$600E



Plan 37 33871PA0100037 Keystone HMO Silver Secure $3,500 $40/$80/$600E



Plan 40 33871PA0110017 Keystone DPOS Silver Secure $3,500 $40/$80/$600E

Plan 41 33871PA0100044 Keystone HMO Gold Proactive E

Plan 42 33871PA0100045 Keystone HMO Silver Proactive E

Plan 43 33871PA0100046 HMO Bronze Basic D



Plan 46 33871PA0100049 Keystone HMO Silver Secure $3,500 $40/$80/$600E

Plan 47 0 0 0

Plan 48 0 0 0

Plan 49 0 0 0

Plan 50 0 0 0

Plan 51 0 0 0

Plan 52 0 0 0

Plan 53 0 0 0

Plan 54 0 0 0

Plan 55 0 0 0

Plan 56 0 0 0

Plan 57 0 0 0

Plan 58 0 0 0

Plan 59 0 0 0

Plan 60 0 0 0

Plan 61 0 0 0

Plan 62 0 0 0

Plan 63 0 0 0

Plan 64 0 0 0

Plan 65 0 0 0

Plan 66 0 0 0

Plan 67 0 0 0

Plan 68 0 0 0

Plan 69 0 0 0

Plan 70 0 0 0

Plan 71 0 0 0

Plan 72 0 0 0

Plan 73 0 0 0

Plan 74 0 0 0

Plan 75 0 0 0

Plan 76 0 0 0

Plan 77 0 0 0

Plan 78 0 0 0

Plan 79 0 0 0

Plan 80 0 0 0

Plan 81 0 0 0

Plan 82 0 0 0

Plan 83 0 0 0

Plan 84 0 0 0

Plan 85 0 0 0

Plan 86 0 0 0

Plan 87 0 0 0

Plan 88 0 0 0

Plan 89 0 0 0

Plan 90 0 0 0

Plan 91 0 0 0

Plan 92 0 0 0

Plan 93 0 0 0

Plan 94 0 0 0

Plan 95 0 0 0

Plan 96 0 0 0

Plan 97 0 0 0

Plan 98 0 0 0

Plan 99 0 0 0

Plan 100 0 0 0

Table 11. Plan Premium Development for 21-Year-Old Non-Tobacco User

1/1/17 Plan

Marketing Name

(If 1/1/16 Plan

Discontinued) Metallic Tier

Exchange

On/Off or

Off 1 2 3 4

- - - -

Keystone HMO Platinum Preferred $10/$20/$100Platinum ON/OFF

Keystone HMO Platinum Preferred $20/$40/$150Platinum ON/OFF

Keystone HMO Gold Preferred $30/$60/$600Gold ON/OFF

Keystone HMO Gold Classic $1,000 $25/$50/90%Gold ON/OFF

Keystone HMO Silver Classic $2,000 $25/$50/70%Silver ON/OFF


Keystone HMO Bronze Essential $6,000 $50/$100/$700Bronze ON/OFF

Keystone HMO Gold ProactiveGold ON/OFF

Keystone HMO Silver ProactiveSilver ON/OFF

Keystone DPOS Platinum Preferred $10/$20/$100Platinum ON/OFF

Keystone DPOS Platinum Preferred $20/$40/$150Platinum ON/OFF

Keystone DPOS Gold Preferred $30/$60/$600Gold ON/OFF

Keystone DPOS Gold Classic $1,000 $25/$50/90%Gold ON/OFF

Keystone DPOS Silver Classic $2,000 $25/$50/70%Silver ON/OFF


Keystone DPOS Bronze Essential $6,000 $50/$100/$700Bronze ON/OFF

Keystone HMO Bronze Basic Bronze ON/OFF

Keystone DPOS Gold Classic $2,000 $40/$80/100%Gold ON/OFF


Keystone HMO Platinum Preferred $10/$20/$100Platinum OFF

Keystone HMO Platinum Preferred $20/$40/$150Platinum OFF

Keystone HMO Gold Preferred $30/$60/$600Gold OFF

Keystone HMO Gold Classic $1,000 $25/$50/90%Gold OFF

Keystone HMO Silver Classic $2,000 $25/$50/70%Silver OFF


Keystone HMO Bronze Essential $6,000 $50/$100/$700Bronze OFF

Keystone DPOS Platinum Preferred $10/$20/$100Platinum OFF

These cells auto-fill using the data entered in Table 9.

2/1/16 Number of Covered Lives

Keystone DPOS Platinum Preferred $20/$40/$150Platinum OFF

Keystone DPOS Gold Preferred $30/$60/$600Gold OFF

Keystone DPOS Gold Classic $1,000 $25/$50/90%Gold OFF

Keystone DPOS Silver Classic $2,000 $25/$50/70%Silver OFF


Keystone DPOS Bronze Essential $6,000 $50/$100/$700Bronze OFF

Keystone DPOS Silver Secure $3,500 $40/$80/$600Silver ON/OFF

Keystone HMO Gold Classic $2,000 $40/$80/100%Gold ON/OFF


Keystone HMO Silver Secure $3,500 $40/$80/$600Silver ON/OFF

Keystone DPOS Gold Classic $2,000 $40/$80/100%Gold OFF


Keystone DPOS Silver Secure $3,500 $40/$80/$600Silver OFF

Keystone HMO Gold ProactiveGold OFF

Keystone HMO Silver ProactiveSilver OFF

HMO Bronze Basic Bronze OFF

Keystone HMO Gold Classic $2,000 $40/$80/100%Gold OFF


Keystone HMO Silver Secure $3,500 $40/$80/$600Silver OFF

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

5 6 7 8 9 Total 1 2

- - - 125,640 - 125,640 -$ -$

10 10 -$ -$

142 142 -$ -$

160 160 -$ -$

16 16 -$ -$

28 28 -$ -$

24 24 -$ -$

24 24 -$ -$

68 68 -$ -$

470 470 -$ -$

28 28 -$ -$

72 72 -$ -$

84 84 -$ -$

1 1 -$ -$

2 2 -$ -$

16 16 -$ -$

32 32 -$ -$

2 2 -$ -$

1 1 -$ -$

1 1 -$ -$

3,405 3,405 -$ -$

15,920 15,920 -$ -$

27,424 27,424 -$ -$

1,538 1,538 -$ -$

4,644 4,644 -$ -$

1,950 1,950 -$ -$

2,125 2,125 -$ -$

5,364 5,364 -$ -$

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)

18,047 18,047 -$ -$

6,489 6,489 -$ -$

3,703 3,703 -$ -$

2,111 2,111 -$ -$

1,245 1,245 -$ -$

778 778 -$ -$

1 1 -$ -$

1 1 -$ -$

1 1 -$ -$

3 3 -$ -$

85 85 -$ -$

27 27 -$ -$

49 49 -$ -$

17,593 17,593 -$ -$

11,669 11,669 -$ -$

1 1 -$ -$

89 89 -$ -$

59 59 -$ -$

138 138 -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

3 4 5 6 7 8 9

-$ -$ -$ -$ -$ 339.64$ -$

-$ -$ -$ -$ -$ 417.32$ -$

-$ -$ -$ -$ -$ 398.92$ -$

-$ -$ -$ -$ -$ 331.47$ -$

-$ -$ -$ -$ -$ 338.99$ -$

-$ -$ -$ -$ -$ 298.10$ -$

-$ -$ -$ -$ -$ 275.72$ -$

-$ -$ -$ -$ -$ 204.48$ -$

-$ -$ -$ -$ -$ 290.45$ -$

-$ -$ -$ -$ -$ 233.48$ -$

-$ -$ -$ -$ -$ 436.62$ -$

-$ -$ -$ -$ -$ 417.35$ -$

-$ -$ -$ -$ -$ 346.27$ -$

-$ -$ -$ -$ -$ 353.34$ -$

-$ -$ -$ -$ -$ 311.30$ -$

-$ -$ -$ -$ -$ 287.95$ -$

-$ -$ -$ -$ -$ 213.47$ -$

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

-$ -$ -$ -$ -$ 344.19$ -$

-$ -$ -$ -$ -$ 293.73$ -$

-$ -$ -$ -$ -$ 417.32$ -$

-$ -$ -$ -$ -$ 398.92$ -$

-$ -$ -$ -$ -$ 331.47$ -$

-$ -$ -$ -$ -$ 338.99$ -$

-$ -$ -$ -$ -$ 298.10$ -$

-$ -$ -$ -$ -$ 275.72$ -$

-$ -$ -$ -$ -$ 204.48$ -$

-$ -$ -$ -$ -$ 436.62$ -$

2016 21-year-old Non-Tobacco Premium PMPM


-$ -$ -$ -$ -$ 417.35$ -$

-$ -$ -$ -$ -$ 346.27$ -$

-$ -$ -$ -$ -$ 353.34$ -$

-$ -$ -$ -$ -$ 311.30$ -$

-$ -$ -$ -$ -$ 287.95$ -$

-$ -$ -$ -$ -$ 213.47$ -$

-$ -$ -$ -$ -$ 272.43$ -$

-$ -$ -$ -$ -$ 331.97$ -$

-$ -$ -$ -$ -$ 281.26$ -$

-$ -$ -$ -$ -$ 260.86$ -$

-$ -$ -$ -$ -$ 344.19$ -$

-$ -$ -$ -$ -$ 293.73$ -$

-$ -$ -$ -$ -$ 272.43$ -$

-$ -$ -$ -$ -$ 290.45$ -$

-$ -$ -$ -$ -$ 233.48$ -$

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

-$ -$ -$ -$ -$ 331.97$ -$

-$ -$ -$ -$ -$ 281.26$ -$

-$ -$ -$ -$ -$ 260.86$ -$

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Average

(weighted by

enrollment by

rating area) 1 2 3 4 5 6

339.64$ -$ -$ -$ -$ -$ -$

417.32$ -$ -$ -$ -$ -$ -$

398.92$ -$ -$ -$ -$ -$ -$

331.47$ -$ -$ -$ -$ -$ -$

338.99$ -$ -$ -$ -$ -$ -$

298.10$ -$ -$ -$ -$ -$ -$

275.72$ -$ -$ -$ -$ -$ -$

204.48$ -$ -$ -$ -$ -$ -$

290.45$ -$ -$ -$ -$ -$ -$

233.48$ -$ -$ -$ -$ -$ -$

436.62$ -$ -$ -$ -$ -$ -$

417.35$ -$ -$ -$ -$ -$ -$

346.27$ -$ -$ -$ -$ -$ -$

353.34$ -$ -$ -$ -$ -$ -$

311.30$ -$ -$ -$ -$ -$ -$

287.95$ -$ -$ -$ -$ -$ -$

213.47$ -$ -$ -$ -$ -$ -$

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

344.19$ -$ -$ -$ -$ -$ -$

293.73$ -$ -$ -$ -$ -$ -$

417.32$ -$ -$ -$ -$ -$ -$

398.92$ -$ -$ -$ -$ -$ -$

331.47$ -$ -$ -$ -$ -$ -$

338.99$ -$ -$ -$ -$ -$ -$

298.10$ -$ -$ -$ -$ -$ -$

275.72$ -$ -$ -$ -$ -$ -$

204.48$ -$ -$ -$ -$ -$ -$

436.62$ -$ -$ -$ -$ -$ -$





417.35$ -$ -$ -$ -$ -$ -$

346.27$ -$ -$ -$ -$ -$ -$

353.34$ -$ -$ -$ -$ -$ -$

311.30$ -$ -$ -$ -$ -$ -$

287.95$ -$ -$ -$ -$ -$ -$

213.47$ -$ -$ -$ -$ -$ -$

272.43$ -$ -$ -$ -$ -$ -$

331.97$ -$ -$ -$ -$ -$ -$

281.26$ -$ -$ -$ -$ -$ -$

260.86$ -$ -$ -$ -$ -$ -$

344.19$ -$ -$ -$ -$ -$ -$

293.73$ -$ -$ -$ -$ -$ -$

272.43$ -$ -$ -$ -$ -$ -$

290.45$ -$ -$ -$ -$ -$ -$

233.48$ -$ -$ -$ -$ -$ -$

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

331.97$ -$ -$ -$ -$ -$ -$

281.26$ -$ -$ -$ -$ -$ -$

260.86$ -$ -$ -$ -$ -$ -$

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

7 8 9

Average

(weighted by

enrollment by

rating area) 1 2 3 4

-$ 352.14$ -$ 352.14$ 0.0% 0.0% 0.0% 0.0%

-$ 432.77$ -$ 432.77$ 0.0% 0.0% 0.0% 0.0%

-$ 413.71$ -$ 413.71$ 0.0% 0.0% 0.0% 0.0%

-$ 341.21$ -$ 341.21$ 0.0% 0.0% 0.0% 0.0%

-$ 352.29$ -$ 352.29$ 0.0% 0.0% 0.0% 0.0%

-$ 301.71$ -$ 301.71$ 0.0% 0.0% 0.0% 0.0%

-$ 286.92$ -$ 286.92$ 0.0% 0.0% 0.0% 0.0%

-$ 213.73$ -$ 213.73$ 0.0% 0.0% 0.0% 0.0%

-$ 305.11$ -$ 305.11$ 0.0% 0.0% 0.0% 0.0%

-$ 242.11$ -$ 242.11$ 0.0% 0.0% 0.0% 0.0%

-$ 452.82$ -$ 452.82$ 0.0% 0.0% 0.0% 0.0%

-$ 432.87$ -$ 432.87$ 0.0% 0.0% 0.0% 0.0%

-$ 356.43$ -$ 356.43$ 0.0% 0.0% 0.0% 0.0%

-$ 366.40$ -$ 366.40$ 0.0% 0.0% 0.0% 0.0%

-$ 315.16$ -$ 315.16$ 0.0% 0.0% 0.0% 0.0%

-$ 299.63$ -$ 299.63$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ 360.51$ -$ 360.51$ 0.0% 0.0% 0.0% 0.0%

-$ 304.32$ -$ 304.32$ 0.0% 0.0% 0.0% 0.0%

-$ 433.20$ -$ 433.20$ 0.0% 0.0% 0.0% 0.0%

-$ 414.13$ -$ 414.13$ 0.0% 0.0% 0.0% 0.0%

-$ 341.63$ -$ 341.63$ 0.0% 0.0% 0.0% 0.0%

-$ 352.72$ -$ 352.72$ 0.0% 0.0% 0.0% 0.0%

-$ 302.14$ -$ 302.14$ 0.0% 0.0% 0.0% 0.0%

-$ 287.34$ -$ 287.34$ 0.0% 0.0% 0.0% 0.0%

-$ 214.15$ -$ 214.15$ 0.0% 0.0% 0.0% 0.0%

-$ 453.24$ -$ 453.24$ 0.0% 0.0% 0.0% 0.0%

Change in 21-year-old Non-Tobacco Premium PMPM 2017 21-year-old Non-Tobacco Premium PMPM


-$ 433.29$ -$ 433.29$ 0.0% 0.0% 0.0% 0.0%

-$ 356.85$ -$ 356.85$ 0.0% 0.0% 0.0% 0.0%

-$ 367.26$ -$ 367.26$ 0.0% 0.0% 0.0% 0.0%

-$ 315.58$ -$ 315.58$ 0.0% 0.0% 0.0% 0.0%

-$ 300.05$ -$ 300.05$ 0.0% 0.0% 0.0% 0.0%

-$ 223.42$ -$ 223.42$ 0.0% 0.0% 0.0% 0.0%

-$ 287.26$ -$ 287.26$ 0.0% 0.0% 0.0% 0.0%

-$ 350.13$ -$ 350.13$ 0.0% 0.0% 0.0% 0.0%

-$ 291.40$ -$ 291.40$ 0.0% 0.0% 0.0% 0.0%

-$ 275.06$ -$ 275.06$ 0.0% 0.0% 0.0% 0.0%

-$ 361.37$ -$ 361.37$ 0.0% 0.0% 0.0% 0.0%

-$ 305.18$ -$ 305.18$ 0.0% 0.0% 0.0% 0.0%

-$ 288.12$ -$ 288.12$ 0.0% 0.0% 0.0% 0.0%

-$ 305.54$ -$ 305.54$ 0.0% 0.0% 0.0% 0.0%

-$ 242.53$ -$ 242.53$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ 350.99$ -$ 350.99$ 0.0% 0.0% 0.0% 0.0%

-$ 292.26$ -$ 292.26$ 0.0% 0.0% 0.0% 0.0%

-$ 275.91$ -$ 275.91$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

5 6 7 8 9

Average

(weighted by

enrollment by

rating area)

0.0% 0.0% 0.0% 3.7% 0.0% 3.7%

0.0% 0.0% 0.0% 3.7% 0.0% 3.7%

0.0% 0.0% 0.0% 3.7% 0.0% 3.7%

0.0% 0.0% 0.0% 2.9% 0.0% 2.9%

0.0% 0.0% 0.0% 3.9% 0.0% 3.9%

0.0% 0.0% 0.0% 1.2% 0.0% 1.2%

0.0% 0.0% 0.0% 4.1% 0.0% 4.1%

0.0% 0.0% 0.0% 4.5% 0.0% 4.5%

0.0% 0.0% 0.0% 5.0% 0.0% 5.0%

0.0% 0.0% 0.0% 3.7% 0.0% 3.7%

0.0% 0.0% 0.0% 3.7% 0.0% 3.7%

0.0% 0.0% 0.0% 3.7% 0.0% 3.7%

0.0% 0.0% 0.0% 2.9% 0.0% 2.9%

0.0% 0.0% 0.0% 3.7% 0.0% 3.7%

0.0% 0.0% 0.0% 1.2% 0.0% 1.2%

0.0% 0.0% 0.0% 4.1% 0.0% 4.1%

0.0% 0.0% 0.0% ###### 0.0% -100.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 4.7% 0.0% 4.7%

0.0% 0.0% 0.0% 3.6% 0.0% 3.6%

0.0% 0.0% 0.0% 3.8% 0.0% 3.8%

0.0% 0.0% 0.0% 3.8% 0.0% 3.8%

0.0% 0.0% 0.0% 3.1% 0.0% 3.1%

0.0% 0.0% 0.0% 4.1% 0.0% 4.1%

0.0% 0.0% 0.0% 1.4% 0.0% 1.4%

0.0% 0.0% 0.0% 4.2% 0.0% 4.2%

0.0% 0.0% 0.0% 4.7% 0.0% 4.7%

0.0% 0.0% 0.0% 3.8% 0.0% 3.8%

Change in 21-year-old Non-Tobacco Premium PMPM

0.0% 0.0% 0.0% 3.8% 0.0% 3.8%

0.0% 0.0% 0.0% 3.1% 0.0% 3.1%

0.0% 0.0% 0.0% 3.9% 0.0% 3.9%

0.0% 0.0% 0.0% 1.4% 0.0% 1.4%

0.0% 0.0% 0.0% 4.2% 0.0% 4.2%

0.0% 0.0% 0.0% 4.7% 0.0% 4.7%

0.0% 0.0% 0.0% 5.4% 0.0% 5.4%

0.0% 0.0% 0.0% 5.5% 0.0% 5.5%

0.0% 0.0% 0.0% 3.6% 0.0% 3.6%

0.0% 0.0% 0.0% 5.4% 0.0% 5.4%

0.0% 0.0% 0.0% 5.0% 0.0% 5.0%

0.0% 0.0% 0.0% 3.9% 0.0% 3.9%

0.0% 0.0% 0.0% 5.8% 0.0% 5.8%

0.0% 0.0% 0.0% 5.2% 0.0% 5.2%

0.0% 0.0% 0.0% 3.9% 0.0% 3.9%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 5.7% 0.0% 5.7%

0.0% 0.0% 0.0% 3.9% 0.0% 3.9%

0.0% 0.0% 0.0% 5.8% 0.0% 5.8%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

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

FactorArea Counties

Current

Factor

Proposed

Factor

0-20 0.635 43 1.357 1.225 Rating Area 1

21 1.000 1.125 44 1.397 1.225 Rating Area 2

22 1.000 1.125 45 1.444 1.225 Rating Area 3

23 1.000 1.125 46 1.500 1.225 Rating Area 4

24 1.000 1.125 47 1.563 1.225 Rating Area 5

25 1.004 1.125 48 1.635 1.225 Rating Area 6

26 1.024 1.125 49 1.706 1.225 Rating Area 7

27 1.048 1.125 50 1.786 1.375 Rating Area 8Bucks, Chester, Delaware, Philadelphia,

Montgomery1.000 1.000

28 1.087 1.125 51 1.865 1.375 Rating Area 9

29 1.119 1.125 52 1.952 1.375

30 1.135 1.175 53 2.040 1.375

31 1.159 1.175 54 2.135 1.375 Table 14. Network Factors32 1.183 1.175 55 2.230 1.375

33 1.198 1.175 56 2.333 1.375

34 1.214 1.175 57 2.437 1.375 Network Name Rating AreaCurrent

Factor

Proposed

Factor

DOH

Approval

Date

35 1.222 1.175 58 2.548 1.375 Proactive Rating Area 8 0.989 0.989

36 1.230 1.175 59 2.603 1.375 Keystone Rating Area 8 1.000 1.000

37 1.238 1.175 60 2.714 1.375

38 1.246 1.175 61 2.810 1.375

39 1.262 1.175 62 2.873 1.375

40 1.278 1.225 63 2.952 1.375

41 1.302 1.225 64+ 3.000 1.375

42 1.325 1.225*PA follows the federal default age curve.

Geographic Area Factors2017 Age and Tobacco Factors

2017 Network Factors

Rate Change Request Summary - 2017 Pennsylvania Insurance Department | www.insurance.pa.gov

1

Keystone Health Plan East – Small Group Plans Rate request filing ID # INAC-130539718 - This document is prepared by the insurance company submitting the rate filing as a consumer tool to help explain the rate filing. It is not intended to describe or include all factors or information considered in the review process. For more information, see the filing at http://www.insurance.pa.gov/Consumers/ACARelatedFilings/

Overview

Requested average rate change: 3.7% Range of requested rate change: 1.2% - 5.8% Effective date: January 1, 2017 People impacted: 125,640 Available in: Rating Area 8

Key information Jan. 2015-Dec. 2015 financial experience

Premiums $616,774,973 Claims $528,572,585 Administrative expenses $85,205,678

Company made (before taxes) $2,996,710

The company expects its annual medical costs to increase 6.2%.

Explanation of requested rate change

Scope and Range of the Rate Increase: Keystone Health Plan East ("KHPE”) is increasing premium rates for the Pennsylvania Consumer ACA compliant products by an average of 3.7%. This rate action is effective from January 1, 2017. About 126,000 members will be affected. The actual impact to premium for a specific customer may be different. Financial Experience of the Product: KHPE is required by federal law to pay out a minimum of 80% percent of premium dollars for medical claims—this is referred to as the minimum Medical Loss Ratio (MLR). The rate action proposed in this filing is expected to achieve a Medical Loss Ratio of greater than 80%. Changes in Medical Service Costs: Premium rates for health care insurance are increasing as the cost of health care service rise. Health care service costs increase as health care providers increase their fees, members use more health care services and supplies, and the types of health care services and supplies change, among other factors. Nearly half of the change in health care service costs is driven by changes to health care provider fees.

How it plans to spend your premium This is how the insurance company plans to spend the premium it collects in 2017:

Claims: 84% Administrative: 10% Taxes & fees: 4% Profit: 2%

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

Changes in Benefits: Some plan benefits are mandated by federal and state law. Benefit changes for some plans were also made. All changes in benefits are in compliance with the uniform modifications rules stipulated by the Federal government. Administrative Costs: The premium rates presented in this filing include a 2% contribution to surplus. Furthermore, the Affordable Care Act (ACA) imposes taxes and other levies.

Information for Pennsylvania Bulletin

1. Company Legal Name: Keystone Health Plan East (“KHPE”)

NAIC # 95056

2. Market: Small Group

3. Products: HMO

4. Average Rate Change: 3.7%; $18.64 PMPM

5. Current Members: 125,640

6. Experience Period Revenue $616,774,973

7. Additional Revenue from Increase $22,820,674

URRT Part II – Consumer Friendly Justification

Scope and Range of the Rate Increase:

Keystone Health Plan East ("KHPE) is increasing premium rates for the Pennsylvania Small Group ACA compliant products by an average of 3.7%. This rate action is effective from January 1, 2017. About 126,000 members will be affected. The actual impact to premium for a specific customer may be different.

Financial Experience of the Product:

KHPE is required by federal law to pay out a minimum of 80% percent of premium dollars for medical claims—this is referred to as the minimum Medical Loss Ratio (MLR). The rate action proposed in this filing is expected to achieve a Medical Loss Ratio of greater than 80%.

Changes in Medical Service Costs:

Premium rates for health care insurance are increasing as the cost of health care service rise. Health care service costs increase as health care providers increase their fees, members use more health care services and supplies, and the types of health care services and supplies change, among other factors. Nearly half of the change in health care service costs is driven by changes to health care provider fees.

Changes in Benefits:

Some plan benefits are mandated by federal and state law. Benefit changes for some plans were also made. All changes in benefits are in compliance with the uniform modifications rules stipulated by the Federal government.

Administrative Costs:

The premium rates presented in this filing include a 2% contribution to reserves. Furthermore, the Affordable Care Act (ACA) imposes taxes and other levies.

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

29

30

31

32

33

34

35

36

37

3839

40

41

42

43

44

45

46

47

48

49

50

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: KHPE State: PA

HIOS Issuer ID: 33871 Market: Small Group

Effective Date of Rate Change(s): 1/1/2017

Market Level Calculations (Same for all Plans)

Section I: Experience period data

Experience Period: 1/1/2015 to 12/31/2015

Experience Period

Aggregate Amount PMPM % of Prem

Premiums (net of MLR Rebate) in Experience Period: $671,931,345 $449.50 100.00%

Incurred Claims in Experience Period $550,417,515 368.21 81.92%

Allowed Claims: $599,185,808 400.83 89.17%

Index Rate of Experience Period $401.00

Experience Period Member Months 1,494,855

Section II: Allowed Claims, PMPM basis

Experience Period Projection Period: 1/1/2017 to 12/31/2017 Mid-point to Mid-point, Experience to Projection: 24 months

on Actual Experience Allowed

Adj't. from Experience to

Projection Period Projections, before credibility Adjustment Credibility Manual

Benefit Category

Utilization

Description

Utilization per

1,000

Average

Cost/Service PMPM

Pop'l risk

Morbidity Other Cost Util

Utilization per

1,000

Average

Cost/Service PMPM

Utilization

per 1,000

Average

Cost/Service PMPM

Inpatient Hospital Admits 68.91 $15,618.44 $89.69 1.000 1.060 1.041 1.017 71.32 $17,940.93 $106.63 0.00 $0.00 $0.00

Outpatient Hospital Services 1,924.28 $515.59 82.68 1.000 1.060 1.038 1.017 1,991.60 588.85 97.73 0.00 $0.00 0.00

Professional Services 9,452.57 $135.41 106.67 1.000 1.060 1.017 1.017 9,783.26 148.46 121.04 0.00 $0.00 0.00

Other Medical Services 0.01 $82.00 0.00 1.000 1.060 1.017 1.030 0.01 89.90 0.00 0.00 $0.00 0.00

Capitation Services 12,000.00 17.41 17.41 1.000 1.060 1.021 1.000 12,000.00 19.23 19.23 0.00 $0.00 0.00

Prescription Drug Prescriptions 11,766.31 106.46 104.39 1.000 1.060 1.045 1.045 12,849.10 123.23 131.95 0.00 $0.00 0.00

Total $400.83 $476.59 $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% $476.59 $718,539,496

Paid to Allowed Average Factor in Projection Period 0.880

Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM $419.38 $632,283,377

Projected Risk Adjustments PMPM -16.87 (25,437,372)

Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM $436.25 $657,720,750

Projected ACA reinsurance recoveries, net of rein prem, PMPM 0.00 0

Projected Incurred Claims $436.25 $657,720,750

Administrative Expense Load 9.89% 51.51 77,653,792

Profit & Risk Load 2.00% 10.41 15,696,290

Taxes & Fees 4.30% 22.38 33,743,652

Single Risk Pool Gross Premium Avg. Rate, PMPM $520.54 $784,814,483

Index Rate for Projection Period 499.10$

% increase over Experience Period 15.81%

% Increase, annualized: 7.61%

Projected Member Months 1,507,680

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 1

May 11, 2016

Ms. Johanna Fabian-Marks, Special Deputy & Acting Director

Bureau of Accident and Health Insurance

Pennsylvania Insurance Department

1311 Strawberry Square

Harrisburg, PA 17120

SUBMITTED VIA SERFF

RE: Keystone Health Plan East

Small Group HMO Rate Filing effective 1/1/2016

INAC-130539718

Dear Ms. Fabian-Marks:

Attached is the rating methodology for HMO plans of Keystone Health Plan East

(KHPE), and Direct Point-of-Service (DPOS) plans, of which a large majority of benefit

expenses is attributed to KHPE and the remainder to QCC Insurance Company (QCC),

and offered to small employer groups in the Commonwealth of Pennsylvania. New and

renewing plans are being filed to satisfy market reform requirements of the Affordable

Care Act (ACA)—some plans are included in a concurrent application for certification as

a Qualified Health Plan. This rate filing includes rates for these plans and specifies

compliance with rating requirements of the ACA. The enclosed rating methodology is

for rating periods effective from January 1, 2017 through December 31, 2017.

This rate filing is being submitted along with concurrent form filing(s) and SERFF Plan

Management binder(s):

INLG-130546269

INBC- 130545507

INLG-PA17-125061998

INBC-PA17-125061995

Please contact with any

questions regarding this filing.

Sincerely,

Director and Actuary, Commercial Pricing

cc:

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