Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Federal Rate Template New Ind_16-50_Revised_KHP_HMO_FedRatesTemplate_RateRule_20160923.pdf, Ind_16-50_Revised_KHP_HMO_FedRatesTemplate_RateRule_20160923.xls,

2 Rates and PA Plan Design New Ind_16-50_Revised_KHP_HMO_PIDRates_RateRule_20160923.pdf,Ind_16-50_Revised_KHP_HMO_PIDRates_RateRule_20160923.xlsx,

SERFF Tracking #: CABC-130539563 State Tracking #: CABC-130539563 Company Tracking #: 16-50

State: Pennsylvania Filing Company: Keystone Health Plan Central

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

Product Name: Rates - KHPC Ind HMO

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number CABC-130539563 Generated 10/14/2016 11:51 AM

Attachment Ind_16-50_Revised_KHP_HMO_FedRatesTemplate_RateRule_20160923.xls is not a PDFdocument and cannot be reproduced here.

Attachment Ind_16-50_Revised_KHP_HMO_PIDRates_RateRule_20160923.xlsx is not a PDF documentand cannot be reproduced here.

SERFF Tracking #: CABC-130539563 State Tracking #: CABC-130539563 Company Tracking #: 16-50

State: Pennsylvania Filing Company: Keystone Health Plan Central

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

Product Name: Rates - KHPC Ind HMO

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number CABC-130539563 Generated 10/14/2016 11:51 AM

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

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

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

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

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

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090004 Rating Area 6 No Preference 0-20 152.33

53789PA0090004 Rating Area 6 No Preference 21 239.89

53789PA0090004 Rating Area 6 No Preference 22 239.89

53789PA0090004 Rating Area 6 No Preference 23 239.89

53789PA0090004 Rating Area 6 No Preference 24 239.89

53789PA0090004 Rating Area 6 No Preference 25 240.85

53789PA0090004 Rating Area 6 No Preference 26 245.65

53789PA0090004 Rating Area 6 No Preference 27 251.40

53789PA0090004 Rating Area 6 No Preference 28 260.76

53789PA0090004 Rating Area 6 No Preference 29 268.43

53789PA0090004 Rating Area 6 No Preference 30 272.27

53789PA0090004 Rating Area 6 No Preference 31 278.03

53789PA0090004 Rating Area 6 No Preference 32 283.79

53789PA0090004 Rating Area 6 No Preference 33 287.39

53789PA0090004 Rating Area 6 No Preference 34 291.22

53789PA0090004 Rating Area 6 No Preference 35 293.14

53789PA0090004 Rating Area 6 No Preference 36 295.06

53789PA0090004 Rating Area 6 No Preference 37 296.98

53789PA0090004 Rating Area 6 No Preference 38 298.90

53789PA0090004 Rating Area 6 No Preference 39 302.74

53789PA0090004 Rating Area 6 No Preference 40 306.58

53789PA0090004 Rating Area 6 No Preference 41 312.33

53789PA0090004 Rating Area 6 No Preference 42 317.85

53789PA0090004 Rating Area 6 No Preference 43 325.53

53789PA0090004 Rating Area 6 No Preference 44 335.12

53789PA0090004 Rating Area 6 No Preference 45 346.40

53789PA0090004 Rating Area 6 No Preference 46 359.83

53789PA0090004 Rating Area 6 No Preference 47 374.95

53789PA0090004 Rating Area 6 No Preference 48 392.22

53789PA0090004 Rating Area 6 No Preference 49 409.25

53789PA0090004 Rating Area 6 No Preference 50 428.44

53789PA0090004 Rating Area 6 No Preference 51 447.39

53789PA0090004 Rating Area 6 No Preference 52 468.26

53789PA0090004 Rating Area 6 No Preference 53 489.37

53789PA0090004 Rating Area 6 No Preference 54 512.16

53789PA0090004 Rating Area 6 No Preference 55 534.95

53789PA0090004 Rating Area 6 No Preference 56 559.66

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090004 Rating Area 6 No Preference 57 584.61

53789PA0090004 Rating Area 6 No Preference 58 611.23

53789PA0090004 Rating Area 6 No Preference 59 624.43

53789PA0090004 Rating Area 6 No Preference 60 651.06

53789PA0090004 Rating Area 6 No Preference 61 674.09

53789PA0090004 Rating Area 6 No Preference 62 689.20

53789PA0090004 Rating Area 6 No Preference 63 708.15

53789PA0090004 Rating Area 6 No Preference 64 719.66

53789PA0090004 Rating Area 6 No Preference 65 and over 719.66

53789PA0090004 Rating Area 7 No Preference 0-20 153.85

53789PA0090004 Rating Area 7 No Preference 21 242.29

53789PA0090004 Rating Area 7 No Preference 22 242.29

53789PA0090004 Rating Area 7 No Preference 23 242.29

53789PA0090004 Rating Area 7 No Preference 24 242.29

53789PA0090004 Rating Area 7 No Preference 25 243.26

53789PA0090004 Rating Area 7 No Preference 26 248.10

53789PA0090004 Rating Area 7 No Preference 27 253.92

53789PA0090004 Rating Area 7 No Preference 28 263.37

53789PA0090004 Rating Area 7 No Preference 29 271.12

53789PA0090004 Rating Area 7 No Preference 30 275.00

53789PA0090004 Rating Area 7 No Preference 31 280.81

53789PA0090004 Rating Area 7 No Preference 32 286.63

53789PA0090004 Rating Area 7 No Preference 33 290.26

53789PA0090004 Rating Area 7 No Preference 34 294.14

53789PA0090004 Rating Area 7 No Preference 35 296.07

53789PA0090004 Rating Area 7 No Preference 36 298.01

53789PA0090004 Rating Area 7 No Preference 37 299.95

53789PA0090004 Rating Area 7 No Preference 38 301.89

53789PA0090004 Rating Area 7 No Preference 39 305.77

53789PA0090004 Rating Area 7 No Preference 40 309.64

53789PA0090004 Rating Area 7 No Preference 41 315.46

53789PA0090004 Rating Area 7 No Preference 42 321.03

53789PA0090004 Rating Area 7 No Preference 43 328.78

53789PA0090004 Rating Area 7 No Preference 44 338.47

53789PA0090004 Rating Area 7 No Preference 45 349.86

53789PA0090004 Rating Area 7 No Preference 46 363.43

53789PA0090004 Rating Area 7 No Preference 47 378.69

53789PA0090004 Rating Area 7 No Preference 48 396.14

53789PA0090004 Rating Area 7 No Preference 49 413.34

53789PA0090004 Rating Area 7 No Preference 50 432.72

53789PA0090004 Rating Area 7 No Preference 51 451.87

53789PA0090004 Rating Area 7 No Preference 52 472.94

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090004 Rating Area 7 No Preference 53 494.27

53789PA0090004 Rating Area 7 No Preference 54 517.28

53789PA0090004 Rating Area 7 No Preference 55 540.30

53789PA0090004 Rating Area 7 No Preference 56 565.26

53789PA0090004 Rating Area 7 No Preference 57 590.45

53789PA0090004 Rating Area 7 No Preference 58 617.35

53789PA0090004 Rating Area 7 No Preference 59 630.67

53789PA0090004 Rating Area 7 No Preference 60 657.57

53789PA0090004 Rating Area 7 No Preference 61 680.83

53789PA0090004 Rating Area 7 No Preference 62 696.09

53789PA0090004 Rating Area 7 No Preference 63 715.23

53789PA0090004 Rating Area 7 No Preference 64 726.86

53789PA0090004 Rating Area 7 No Preference 65 and over 726.86

53789PA0090004 Rating Area 9 No Preference 0-20 150.81

53789PA0090004 Rating Area 9 No Preference 21 237.49

53789PA0090004 Rating Area 9 No Preference 22 237.49

53789PA0090004 Rating Area 9 No Preference 23 237.49

53789PA0090004 Rating Area 9 No Preference 24 237.49

53789PA0090004 Rating Area 9 No Preference 25 238.44

53789PA0090004 Rating Area 9 No Preference 26 243.19

53789PA0090004 Rating Area 9 No Preference 27 248.89

53789PA0090004 Rating Area 9 No Preference 28 258.15

53789PA0090004 Rating Area 9 No Preference 29 265.75

53789PA0090004 Rating Area 9 No Preference 30 269.55

53789PA0090004 Rating Area 9 No Preference 31 275.25

53789PA0090004 Rating Area 9 No Preference 32 280.95

53789PA0090004 Rating Area 9 No Preference 33 284.51

53789PA0090004 Rating Area 9 No Preference 34 288.31

53789PA0090004 Rating Area 9 No Preference 35 290.21

53789PA0090004 Rating Area 9 No Preference 36 292.11

53789PA0090004 Rating Area 9 No Preference 37 294.01

53789PA0090004 Rating Area 9 No Preference 38 295.91

53789PA0090004 Rating Area 9 No Preference 39 299.71

53789PA0090004 Rating Area 9 No Preference 40 303.51

53789PA0090004 Rating Area 9 No Preference 41 309.21

53789PA0090004 Rating Area 9 No Preference 42 314.67

53789PA0090004 Rating Area 9 No Preference 43 322.27

53789PA0090004 Rating Area 9 No Preference 44 331.77

53789PA0090004 Rating Area 9 No Preference 45 342.93

53789PA0090004 Rating Area 9 No Preference 46 356.23

53789PA0090004 Rating Area 9 No Preference 47 371.20

53789PA0090004 Rating Area 9 No Preference 48 388.29

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090004 Rating Area 9 No Preference 49 405.16

53789PA0090004 Rating Area 9 No Preference 50 424.16

53789PA0090004 Rating Area 9 No Preference 51 442.92

53789PA0090004 Rating Area 9 No Preference 52 463.58

53789PA0090004 Rating Area 9 No Preference 53 484.48

53789PA0090004 Rating Area 9 No Preference 54 507.04

53789PA0090004 Rating Area 9 No Preference 55 529.60

53789PA0090004 Rating Area 9 No Preference 56 554.06

53789PA0090004 Rating Area 9 No Preference 57 578.76

53789PA0090004 Rating Area 9 No Preference 58 605.12

53789PA0090004 Rating Area 9 No Preference 59 618.18

53789PA0090004 Rating Area 9 No Preference 60 644.55

53789PA0090004 Rating Area 9 No Preference 61 667.34

53789PA0090004 Rating Area 9 No Preference 62 682.31

53789PA0090004 Rating Area 9 No Preference 63 701.07

53789PA0090004 Rating Area 9 No Preference 64 712.46

53789PA0090004 Rating Area 9 No Preference 65 and over 712.46

53789PA0090007 Rating Area 6 No Preference 0-20 210.74

53789PA0090007 Rating Area 6 No Preference 21 331.88

53789PA0090007 Rating Area 6 No Preference 22 331.88

53789PA0090007 Rating Area 6 No Preference 23 331.88

53789PA0090007 Rating Area 6 No Preference 24 331.88

53789PA0090007 Rating Area 6 No Preference 25 333.21

53789PA0090007 Rating Area 6 No Preference 26 339.85

53789PA0090007 Rating Area 6 No Preference 27 347.81

53789PA0090007 Rating Area 6 No Preference 28 360.76

53789PA0090007 Rating Area 6 No Preference 29 371.38

53789PA0090007 Rating Area 6 No Preference 30 376.69

53789PA0090007 Rating Area 6 No Preference 31 384.65

53789PA0090007 Rating Area 6 No Preference 32 392.62

53789PA0090007 Rating Area 6 No Preference 33 397.59

53789PA0090007 Rating Area 6 No Preference 34 402.90

53789PA0090007 Rating Area 6 No Preference 35 405.56

53789PA0090007 Rating Area 6 No Preference 36 408.21

53789PA0090007 Rating Area 6 No Preference 37 410.87

53789PA0090007 Rating Area 6 No Preference 38 413.52

53789PA0090007 Rating Area 6 No Preference 39 418.83

53789PA0090007 Rating Area 6 No Preference 40 424.14

53789PA0090007 Rating Area 6 No Preference 41 432.11

53789PA0090007 Rating Area 6 No Preference 42 439.74

53789PA0090007 Rating Area 6 No Preference 43 450.36

53789PA0090007 Rating Area 6 No Preference 44 463.64

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090007 Rating Area 6 No Preference 45 479.24

53789PA0090007 Rating Area 6 No Preference 46 497.82

53789PA0090007 Rating Area 6 No Preference 47 518.73

53789PA0090007 Rating Area 6 No Preference 48 542.63

53789PA0090007 Rating Area 6 No Preference 49 566.19

53789PA0090007 Rating Area 6 No Preference 50 592.74

53789PA0090007 Rating Area 6 No Preference 51 618.96

53789PA0090007 Rating Area 6 No Preference 52 647.83

53789PA0090007 Rating Area 6 No Preference 53 677.04

53789PA0090007 Rating Area 6 No Preference 54 708.57

53789PA0090007 Rating Area 6 No Preference 55 740.10

53789PA0090007 Rating Area 6 No Preference 56 774.28

53789PA0090007 Rating Area 6 No Preference 57 808.80

53789PA0090007 Rating Area 6 No Preference 58 845.63

53789PA0090007 Rating Area 6 No Preference 59 863.89

53789PA0090007 Rating Area 6 No Preference 60 900.73

53789PA0090007 Rating Area 6 No Preference 61 932.59

53789PA0090007 Rating Area 6 No Preference 62 953.50

53789PA0090007 Rating Area 6 No Preference 63 979.72

53789PA0090007 Rating Area 6 No Preference 64 995.64

53789PA0090007 Rating Area 6 No Preference 65 and over 995.64

53789PA0090007 Rating Area 7 No Preference 0-20 212.85

53789PA0090007 Rating Area 7 No Preference 21 335.20

53789PA0090007 Rating Area 7 No Preference 22 335.20

53789PA0090007 Rating Area 7 No Preference 23 335.20

53789PA0090007 Rating Area 7 No Preference 24 335.20

53789PA0090007 Rating Area 7 No Preference 25 336.54

53789PA0090007 Rating Area 7 No Preference 26 343.25

53789PA0090007 Rating Area 7 No Preference 27 351.29

53789PA0090007 Rating Area 7 No Preference 28 364.36

53789PA0090007 Rating Area 7 No Preference 29 375.09

53789PA0090007 Rating Area 7 No Preference 30 380.45

53789PA0090007 Rating Area 7 No Preference 31 388.50

53789PA0090007 Rating Area 7 No Preference 32 396.54

53789PA0090007 Rating Area 7 No Preference 33 401.57

53789PA0090007 Rating Area 7 No Preference 34 406.93

53789PA0090007 Rating Area 7 No Preference 35 409.62

53789PA0090007 Rating Area 7 No Preference 36 412.30

53789PA0090007 Rating Area 7 No Preference 37 414.98

53789PA0090007 Rating Area 7 No Preference 38 417.66

53789PA0090007 Rating Area 7 No Preference 39 423.02

53789PA0090007 Rating Area 7 No Preference 40 428.39

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090007 Rating Area 7 No Preference 41 436.43

53789PA0090007 Rating Area 7 No Preference 42 444.14

53789PA0090007 Rating Area 7 No Preference 43 454.87

53789PA0090007 Rating Area 7 No Preference 44 468.28

53789PA0090007 Rating Area 7 No Preference 45 484.03

53789PA0090007 Rating Area 7 No Preference 46 502.80

53789PA0090007 Rating Area 7 No Preference 47 523.92

53789PA0090007 Rating Area 7 No Preference 48 548.05

53789PA0090007 Rating Area 7 No Preference 49 571.85

53789PA0090007 Rating Area 7 No Preference 50 598.67

53789PA0090007 Rating Area 7 No Preference 51 625.15

53789PA0090007 Rating Area 7 No Preference 52 654.31

53789PA0090007 Rating Area 7 No Preference 53 683.81

53789PA0090007 Rating Area 7 No Preference 54 715.65

53789PA0090007 Rating Area 7 No Preference 55 747.50

53789PA0090007 Rating Area 7 No Preference 56 782.02

53789PA0090007 Rating Area 7 No Preference 57 816.88

53789PA0090007 Rating Area 7 No Preference 58 854.09

53789PA0090007 Rating Area 7 No Preference 59 872.53

53789PA0090007 Rating Area 7 No Preference 60 909.73

53789PA0090007 Rating Area 7 No Preference 61 941.91

53789PA0090007 Rating Area 7 No Preference 62 963.03

53789PA0090007 Rating Area 7 No Preference 63 989.51

53789PA0090007 Rating Area 7 No Preference 64 1005.59

53789PA0090007 Rating Area 7 No Preference 65 and over 1005.59

53789PA0090007 Rating Area 9 No Preference 0-20 208.64

53789PA0090007 Rating Area 9 No Preference 21 328.56

53789PA0090007 Rating Area 9 No Preference 22 328.56

53789PA0090007 Rating Area 9 No Preference 23 328.56

53789PA0090007 Rating Area 9 No Preference 24 328.56

53789PA0090007 Rating Area 9 No Preference 25 329.88

53789PA0090007 Rating Area 9 No Preference 26 336.45

53789PA0090007 Rating Area 9 No Preference 27 344.33

53789PA0090007 Rating Area 9 No Preference 28 357.15

53789PA0090007 Rating Area 9 No Preference 29 367.66

53789PA0090007 Rating Area 9 No Preference 30 372.92

53789PA0090007 Rating Area 9 No Preference 31 380.80

53789PA0090007 Rating Area 9 No Preference 32 388.69

53789PA0090007 Rating Area 9 No Preference 33 393.62

53789PA0090007 Rating Area 9 No Preference 34 398.88

53789PA0090007 Rating Area 9 No Preference 35 401.50

53789PA0090007 Rating Area 9 No Preference 36 404.13

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090007 Rating Area 9 No Preference 37 406.76

53789PA0090007 Rating Area 9 No Preference 38 409.39

53789PA0090007 Rating Area 9 No Preference 39 414.65

53789PA0090007 Rating Area 9 No Preference 40 419.90

53789PA0090007 Rating Area 9 No Preference 41 427.79

53789PA0090007 Rating Area 9 No Preference 42 435.35

53789PA0090007 Rating Area 9 No Preference 43 445.86

53789PA0090007 Rating Area 9 No Preference 44 459.00

53789PA0090007 Rating Area 9 No Preference 45 474.44

53789PA0090007 Rating Area 9 No Preference 46 492.84

53789PA0090007 Rating Area 9 No Preference 47 513.54

53789PA0090007 Rating Area 9 No Preference 48 537.20

53789PA0090007 Rating Area 9 No Preference 49 560.53

53789PA0090007 Rating Area 9 No Preference 50 586.81

53789PA0090007 Rating Area 9 No Preference 51 612.77

53789PA0090007 Rating Area 9 No Preference 52 641.35

53789PA0090007 Rating Area 9 No Preference 53 670.27

53789PA0090007 Rating Area 9 No Preference 54 701.48

53789PA0090007 Rating Area 9 No Preference 55 732.70

53789PA0090007 Rating Area 9 No Preference 56 766.54

53789PA0090007 Rating Area 9 No Preference 57 800.71

53789PA0090007 Rating Area 9 No Preference 58 837.18

53789PA0090007 Rating Area 9 No Preference 59 855.25

53789PA0090007 Rating Area 9 No Preference 60 891.72

53789PA0090007 Rating Area 9 No Preference 61 923.26

53789PA0090007 Rating Area 9 No Preference 62 943.96

53789PA0090007 Rating Area 9 No Preference 63 969.92

53789PA0090007 Rating Area 9 No Preference 64 985.68

53789PA0090007 Rating Area 9 No Preference 65 and over 985.68

53789PA0090008 Rating Area 6 No Preference 0-20 214.44

53789PA0090008 Rating Area 6 No Preference 21 337.71

53789PA0090008 Rating Area 6 No Preference 22 337.71

53789PA0090008 Rating Area 6 No Preference 23 337.71

53789PA0090008 Rating Area 6 No Preference 24 337.71

53789PA0090008 Rating Area 6 No Preference 25 339.06

53789PA0090008 Rating Area 6 No Preference 26 345.81

53789PA0090008 Rating Area 6 No Preference 27 353.92

53789PA0090008 Rating Area 6 No Preference 28 367.09

53789PA0090008 Rating Area 6 No Preference 29 377.89

53789PA0090008 Rating Area 6 No Preference 30 383.30

53789PA0090008 Rating Area 6 No Preference 31 391.40

53789PA0090008 Rating Area 6 No Preference 32 399.51

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090008 Rating Area 6 No Preference 33 404.57

53789PA0090008 Rating Area 6 No Preference 34 409.98

53789PA0090008 Rating Area 6 No Preference 35 412.68

53789PA0090008 Rating Area 6 No Preference 36 415.38

53789PA0090008 Rating Area 6 No Preference 37 418.08

53789PA0090008 Rating Area 6 No Preference 38 420.78

53789PA0090008 Rating Area 6 No Preference 39 426.19

53789PA0090008 Rating Area 6 No Preference 40 431.59

53789PA0090008 Rating Area 6 No Preference 41 439.70

53789PA0090008 Rating Area 6 No Preference 42 447.46

53789PA0090008 Rating Area 6 No Preference 43 458.27

53789PA0090008 Rating Area 6 No Preference 44 471.78

53789PA0090008 Rating Area 6 No Preference 45 487.65

53789PA0090008 Rating Area 6 No Preference 46 506.56

53789PA0090008 Rating Area 6 No Preference 47 527.84

53789PA0090008 Rating Area 6 No Preference 48 552.15

53789PA0090008 Rating Area 6 No Preference 49 576.13

53789PA0090008 Rating Area 6 No Preference 50 603.15

53789PA0090008 Rating Area 6 No Preference 51 629.82

53789PA0090008 Rating Area 6 No Preference 52 659.20

53789PA0090008 Rating Area 6 No Preference 53 688.92

53789PA0090008 Rating Area 6 No Preference 54 721.01

53789PA0090008 Rating Area 6 No Preference 55 753.09

53789PA0090008 Rating Area 6 No Preference 56 787.87

53789PA0090008 Rating Area 6 No Preference 57 822.99

53789PA0090008 Rating Area 6 No Preference 58 860.48

53789PA0090008 Rating Area 6 No Preference 59 879.05

53789PA0090008 Rating Area 6 No Preference 60 916.54

53789PA0090008 Rating Area 6 No Preference 61 948.96

53789PA0090008 Rating Area 6 No Preference 62 970.23

53789PA0090008 Rating Area 6 No Preference 63 996.91

53789PA0090008 Rating Area 6 No Preference 64 1013.12

53789PA0090008 Rating Area 6 No Preference 65 and over 1013.12

53789PA0090008 Rating Area 7 No Preference 0-20 216.59

53789PA0090008 Rating Area 7 No Preference 21 341.08

53789PA0090008 Rating Area 7 No Preference 22 341.08

53789PA0090008 Rating Area 7 No Preference 23 341.08

53789PA0090008 Rating Area 7 No Preference 24 341.08

53789PA0090008 Rating Area 7 No Preference 25 342.45

53789PA0090008 Rating Area 7 No Preference 26 349.27

53789PA0090008 Rating Area 7 No Preference 27 357.46

53789PA0090008 Rating Area 7 No Preference 28 370.76

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090008 Rating Area 7 No Preference 29 381.67

53789PA0090008 Rating Area 7 No Preference 30 387.13

53789PA0090008 Rating Area 7 No Preference 31 395.32

53789PA0090008 Rating Area 7 No Preference 32 403.50

53789PA0090008 Rating Area 7 No Preference 33 408.62

53789PA0090008 Rating Area 7 No Preference 34 414.08

53789PA0090008 Rating Area 7 No Preference 35 416.81

53789PA0090008 Rating Area 7 No Preference 36 419.53

53789PA0090008 Rating Area 7 No Preference 37 422.26

53789PA0090008 Rating Area 7 No Preference 38 424.99

53789PA0090008 Rating Area 7 No Preference 39 430.45

53789PA0090008 Rating Area 7 No Preference 40 435.91

53789PA0090008 Rating Area 7 No Preference 41 444.09

53789PA0090008 Rating Area 7 No Preference 42 451.94

53789PA0090008 Rating Area 7 No Preference 43 462.85

53789PA0090008 Rating Area 7 No Preference 44 476.50

53789PA0090008 Rating Area 7 No Preference 45 492.53

53789PA0090008 Rating Area 7 No Preference 46 511.63

53789PA0090008 Rating Area 7 No Preference 47 533.12

53789PA0090008 Rating Area 7 No Preference 48 557.67

53789PA0090008 Rating Area 7 No Preference 49 581.89

53789PA0090008 Rating Area 7 No Preference 50 609.18

53789PA0090008 Rating Area 7 No Preference 51 636.12

53789PA0090008 Rating Area 7 No Preference 52 665.80

53789PA0090008 Rating Area 7 No Preference 53 695.81

53789PA0090008 Rating Area 7 No Preference 54 728.22

53789PA0090008 Rating Area 7 No Preference 55 760.62

53789PA0090008 Rating Area 7 No Preference 56 795.75

53789PA0090008 Rating Area 7 No Preference 57 831.22

53789PA0090008 Rating Area 7 No Preference 58 869.08

53789PA0090008 Rating Area 7 No Preference 59 887.84

53789PA0090008 Rating Area 7 No Preference 60 925.70

53789PA0090008 Rating Area 7 No Preference 61 958.45

53789PA0090008 Rating Area 7 No Preference 62 979.94

53789PA0090008 Rating Area 7 No Preference 63 1006.88

53789PA0090008 Rating Area 7 No Preference 64 1023.24

53789PA0090008 Rating Area 7 No Preference 65 and over 1023.24

53789PA0090008 Rating Area 9 No Preference 0-20 212.30

53789PA0090008 Rating Area 9 No Preference 21 334.33

53789PA0090008 Rating Area 9 No Preference 22 334.33

53789PA0090008 Rating Area 9 No Preference 23 334.33

53789PA0090008 Rating Area 9 No Preference 24 334.33

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090008 Rating Area 9 No Preference 25 335.67

53789PA0090008 Rating Area 9 No Preference 26 342.35

53789PA0090008 Rating Area 9 No Preference 27 350.38

53789PA0090008 Rating Area 9 No Preference 28 363.42

53789PA0090008 Rating Area 9 No Preference 29 374.12

53789PA0090008 Rating Area 9 No Preference 30 379.46

53789PA0090008 Rating Area 9 No Preference 31 387.49

53789PA0090008 Rating Area 9 No Preference 32 395.51

53789PA0090008 Rating Area 9 No Preference 33 400.53

53789PA0090008 Rating Area 9 No Preference 34 405.88

53789PA0090008 Rating Area 9 No Preference 35 408.55

53789PA0090008 Rating Area 9 No Preference 36 411.23

53789PA0090008 Rating Area 9 No Preference 37 413.90

53789PA0090008 Rating Area 9 No Preference 38 416.58

53789PA0090008 Rating Area 9 No Preference 39 421.92

53789PA0090008 Rating Area 9 No Preference 40 427.27

53789PA0090008 Rating Area 9 No Preference 41 435.30

53789PA0090008 Rating Area 9 No Preference 42 442.99

53789PA0090008 Rating Area 9 No Preference 43 453.69

53789PA0090008 Rating Area 9 No Preference 44 467.06

53789PA0090008 Rating Area 9 No Preference 45 482.77

53789PA0090008 Rating Area 9 No Preference 46 501.50

53789PA0090008 Rating Area 9 No Preference 47 522.56

53789PA0090008 Rating Area 9 No Preference 48 546.63

53789PA0090008 Rating Area 9 No Preference 49 570.37

53789PA0090008 Rating Area 9 No Preference 50 597.11

53789PA0090008 Rating Area 9 No Preference 51 623.53

53789PA0090008 Rating Area 9 No Preference 52 652.61

53789PA0090008 Rating Area 9 No Preference 53 682.03

53789PA0090008 Rating Area 9 No Preference 54 713.80

53789PA0090008 Rating Area 9 No Preference 55 745.56

53789PA0090008 Rating Area 9 No Preference 56 779.99

53789PA0090008 Rating Area 9 No Preference 57 814.76

53789PA0090008 Rating Area 9 No Preference 58 851.87

53789PA0090008 Rating Area 9 No Preference 59 870.26

53789PA0090008 Rating Area 9 No Preference 60 907.37

53789PA0090008 Rating Area 9 No Preference 61 939.47

53789PA0090008 Rating Area 9 No Preference 62 960.53

53789PA0090008 Rating Area 9 No Preference 63 986.94

53789PA0090008 Rating Area 9 No Preference 64 1002.98

53789PA0090008 Rating Area 9 No Preference 65 and over 1002.98

53789PA0090011 Rating Area 6 No Preference 0-20 186.90

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090011 Rating Area 6 No Preference 21 294.33

53789PA0090011 Rating Area 6 No Preference 22 294.33

53789PA0090011 Rating Area 6 No Preference 23 294.33

53789PA0090011 Rating Area 6 No Preference 24 294.33

53789PA0090011 Rating Area 6 No Preference 25 295.51

53789PA0090011 Rating Area 6 No Preference 26 301.40

53789PA0090011 Rating Area 6 No Preference 27 308.46

53789PA0090011 Rating Area 6 No Preference 28 319.94

53789PA0090011 Rating Area 6 No Preference 29 329.36

53789PA0090011 Rating Area 6 No Preference 30 334.07

53789PA0090011 Rating Area 6 No Preference 31 341.13

53789PA0090011 Rating Area 6 No Preference 32 348.19

53789PA0090011 Rating Area 6 No Preference 33 352.61

53789PA0090011 Rating Area 6 No Preference 34 357.32

53789PA0090011 Rating Area 6 No Preference 35 359.67

53789PA0090011 Rating Area 6 No Preference 36 362.03

53789PA0090011 Rating Area 6 No Preference 37 364.38

53789PA0090011 Rating Area 6 No Preference 38 366.74

53789PA0090011 Rating Area 6 No Preference 39 371.45

53789PA0090011 Rating Area 6 No Preference 40 376.16

53789PA0090011 Rating Area 6 No Preference 41 383.22

53789PA0090011 Rating Area 6 No Preference 42 389.99

53789PA0090011 Rating Area 6 No Preference 43 399.41

53789PA0090011 Rating Area 6 No Preference 44 411.18

53789PA0090011 Rating Area 6 No Preference 45 425.02

53789PA0090011 Rating Area 6 No Preference 46 441.50

53789PA0090011 Rating Area 6 No Preference 47 460.04

53789PA0090011 Rating Area 6 No Preference 48 481.23

53789PA0090011 Rating Area 6 No Preference 49 502.13

53789PA0090011 Rating Area 6 No Preference 50 525.68

53789PA0090011 Rating Area 6 No Preference 51 548.93

53789PA0090011 Rating Area 6 No Preference 52 574.54

53789PA0090011 Rating Area 6 No Preference 53 600.44

53789PA0090011 Rating Area 6 No Preference 54 628.40

53789PA0090011 Rating Area 6 No Preference 55 656.36

53789PA0090011 Rating Area 6 No Preference 56 686.68

53789PA0090011 Rating Area 6 No Preference 57 717.29

53789PA0090011 Rating Area 6 No Preference 58 749.96

53789PA0090011 Rating Area 6 No Preference 59 766.15

53789PA0090011 Rating Area 6 No Preference 60 798.82

53789PA0090011 Rating Area 6 No Preference 61 827.07

53789PA0090011 Rating Area 6 No Preference 62 845.62

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090011 Rating Area 6 No Preference 63 868.87

53789PA0090011 Rating Area 6 No Preference 64 882.99

53789PA0090011 Rating Area 6 No Preference 65 and over 882.99

53789PA0090011 Rating Area 7 No Preference 0-20 188.77

53789PA0090011 Rating Area 7 No Preference 21 297.28

53789PA0090011 Rating Area 7 No Preference 22 297.28

53789PA0090011 Rating Area 7 No Preference 23 297.28

53789PA0090011 Rating Area 7 No Preference 24 297.28

53789PA0090011 Rating Area 7 No Preference 25 298.46

53789PA0090011 Rating Area 7 No Preference 26 304.41

53789PA0090011 Rating Area 7 No Preference 27 311.54

53789PA0090011 Rating Area 7 No Preference 28 323.14

53789PA0090011 Rating Area 7 No Preference 29 332.65

53789PA0090011 Rating Area 7 No Preference 30 337.41

53789PA0090011 Rating Area 7 No Preference 31 344.54

53789PA0090011 Rating Area 7 No Preference 32 351.68

53789PA0090011 Rating Area 7 No Preference 33 356.14

53789PA0090011 Rating Area 7 No Preference 34 360.89

53789PA0090011 Rating Area 7 No Preference 35 363.27

53789PA0090011 Rating Area 7 No Preference 36 365.65

53789PA0090011 Rating Area 7 No Preference 37 368.03

53789PA0090011 Rating Area 7 No Preference 38 370.40

53789PA0090011 Rating Area 7 No Preference 39 375.16

53789PA0090011 Rating Area 7 No Preference 40 379.92

53789PA0090011 Rating Area 7 No Preference 41 387.05

53789PA0090011 Rating Area 7 No Preference 42 393.89

53789PA0090011 Rating Area 7 No Preference 43 403.40

53789PA0090011 Rating Area 7 No Preference 44 415.29

53789PA0090011 Rating Area 7 No Preference 45 429.27

53789PA0090011 Rating Area 7 No Preference 46 445.91

53789PA0090011 Rating Area 7 No Preference 47 464.64

53789PA0090011 Rating Area 7 No Preference 48 486.04

53789PA0090011 Rating Area 7 No Preference 49 507.15

53789PA0090011 Rating Area 7 No Preference 50 530.93

53789PA0090011 Rating Area 7 No Preference 51 554.42

53789PA0090011 Rating Area 7 No Preference 52 580.28

53789PA0090011 Rating Area 7 No Preference 53 606.44

53789PA0090011 Rating Area 7 No Preference 54 634.68

53789PA0090011 Rating Area 7 No Preference 55 662.92

53789PA0090011 Rating Area 7 No Preference 56 693.54

53789PA0090011 Rating Area 7 No Preference 57 724.46

53789PA0090011 Rating Area 7 No Preference 58 757.46

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090011 Rating Area 7 No Preference 59 773.81

53789PA0090011 Rating Area 7 No Preference 60 806.80

53789PA0090011 Rating Area 7 No Preference 61 835.34

53789PA0090011 Rating Area 7 No Preference 62 854.07

53789PA0090011 Rating Area 7 No Preference 63 877.56

53789PA0090011 Rating Area 7 No Preference 64 891.83

53789PA0090011 Rating Area 7 No Preference 65 and over 891.83

53789PA0090011 Rating Area 9 No Preference 0-20 185.03

53789PA0090011 Rating Area 9 No Preference 21 291.39

53789PA0090011 Rating Area 9 No Preference 22 291.39

53789PA0090011 Rating Area 9 No Preference 23 291.39

53789PA0090011 Rating Area 9 No Preference 24 291.39

53789PA0090011 Rating Area 9 No Preference 25 292.55

53789PA0090011 Rating Area 9 No Preference 26 298.38

53789PA0090011 Rating Area 9 No Preference 27 305.38

53789PA0090011 Rating Area 9 No Preference 28 316.74

53789PA0090011 Rating Area 9 No Preference 29 326.06

53789PA0090011 Rating Area 9 No Preference 30 330.73

53789PA0090011 Rating Area 9 No Preference 31 337.72

53789PA0090011 Rating Area 9 No Preference 32 344.71

53789PA0090011 Rating Area 9 No Preference 33 349.08

53789PA0090011 Rating Area 9 No Preference 34 353.75

53789PA0090011 Rating Area 9 No Preference 35 356.08

53789PA0090011 Rating Area 9 No Preference 36 358.41

53789PA0090011 Rating Area 9 No Preference 37 360.74

53789PA0090011 Rating Area 9 No Preference 38 363.07

53789PA0090011 Rating Area 9 No Preference 39 367.73

53789PA0090011 Rating Area 9 No Preference 40 372.39

53789PA0090011 Rating Area 9 No Preference 41 379.39

53789PA0090011 Rating Area 9 No Preference 42 386.09

53789PA0090011 Rating Area 9 No Preference 43 395.41

53789PA0090011 Rating Area 9 No Preference 44 407.07

53789PA0090011 Rating Area 9 No Preference 45 420.77

53789PA0090011 Rating Area 9 No Preference 46 437.08

53789PA0090011 Rating Area 9 No Preference 47 455.44

53789PA0090011 Rating Area 9 No Preference 48 476.42

53789PA0090011 Rating Area 9 No Preference 49 497.11

53789PA0090011 Rating Area 9 No Preference 50 520.42

53789PA0090011 Rating Area 9 No Preference 51 543.44

53789PA0090011 Rating Area 9 No Preference 52 568.79

53789PA0090011 Rating Area 9 No Preference 53 594.43

53789PA0090011 Rating Area 9 No Preference 54 622.11

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090011 Rating Area 9 No Preference 55 649.80

53789PA0090011 Rating Area 9 No Preference 56 679.81

53789PA0090011 Rating Area 9 No Preference 57 710.11

53789PA0090011 Rating Area 9 No Preference 58 742.46

53789PA0090011 Rating Area 9 No Preference 59 758.48

53789PA0090011 Rating Area 9 No Preference 60 790.83

53789PA0090011 Rating Area 9 No Preference 61 818.80

53789PA0090011 Rating Area 9 No Preference 62 837.16

53789PA0090011 Rating Area 9 No Preference 63 860.18

53789PA0090011 Rating Area 9 No Preference 64 874.16

53789PA0090011 Rating Area 9 No Preference 65 and over 874.16

53789PA0090012 Rating Area 6 No Preference 0-20 190.60

53789PA0090012 Rating Area 6 No Preference 21 300.16

53789PA0090012 Rating Area 6 No Preference 22 300.16

53789PA0090012 Rating Area 6 No Preference 23 300.16

53789PA0090012 Rating Area 6 No Preference 24 300.16

53789PA0090012 Rating Area 6 No Preference 25 301.36

53789PA0090012 Rating Area 6 No Preference 26 307.36

53789PA0090012 Rating Area 6 No Preference 27 314.57

53789PA0090012 Rating Area 6 No Preference 28 326.27

53789PA0090012 Rating Area 6 No Preference 29 335.88

53789PA0090012 Rating Area 6 No Preference 30 340.68

53789PA0090012 Rating Area 6 No Preference 31 347.88

53789PA0090012 Rating Area 6 No Preference 32 355.09

53789PA0090012 Rating Area 6 No Preference 33 359.59

53789PA0090012 Rating Area 6 No Preference 34 364.39

53789PA0090012 Rating Area 6 No Preference 35 366.79

53789PA0090012 Rating Area 6 No Preference 36 369.19

53789PA0090012 Rating Area 6 No Preference 37 371.59

53789PA0090012 Rating Area 6 No Preference 38 374.00

53789PA0090012 Rating Area 6 No Preference 39 378.80

53789PA0090012 Rating Area 6 No Preference 40 383.60

53789PA0090012 Rating Area 6 No Preference 41 390.81

53789PA0090012 Rating Area 6 No Preference 42 397.71

53789PA0090012 Rating Area 6 No Preference 43 407.31

53789PA0090012 Rating Area 6 No Preference 44 419.32

53789PA0090012 Rating Area 6 No Preference 45 433.43

53789PA0090012 Rating Area 6 No Preference 46 450.24

53789PA0090012 Rating Area 6 No Preference 47 469.15

53789PA0090012 Rating Area 6 No Preference 48 490.76

53789PA0090012 Rating Area 6 No Preference 49 512.07

53789PA0090012 Rating Area 6 No Preference 50 536.08

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090012 Rating Area 6 No Preference 51 559.79

53789PA0090012 Rating Area 6 No Preference 52 585.91

53789PA0090012 Rating Area 6 No Preference 53 612.32

53789PA0090012 Rating Area 6 No Preference 54 640.84

53789PA0090012 Rating Area 6 No Preference 55 669.35

53789PA0090012 Rating Area 6 No Preference 56 700.27

53789PA0090012 Rating Area 6 No Preference 57 731.48

53789PA0090012 Rating Area 6 No Preference 58 764.80

53789PA0090012 Rating Area 6 No Preference 59 781.31

53789PA0090012 Rating Area 6 No Preference 60 814.63

53789PA0090012 Rating Area 6 No Preference 61 843.44

53789PA0090012 Rating Area 6 No Preference 62 862.35

53789PA0090012 Rating Area 6 No Preference 63 886.06

53789PA0090012 Rating Area 6 No Preference 64 900.47

53789PA0090012 Rating Area 6 No Preference 65 and over 900.47

53789PA0090012 Rating Area 7 No Preference 0-20 192.51

53789PA0090012 Rating Area 7 No Preference 21 303.16

53789PA0090012 Rating Area 7 No Preference 22 303.16

53789PA0090012 Rating Area 7 No Preference 23 303.16

53789PA0090012 Rating Area 7 No Preference 24 303.16

53789PA0090012 Rating Area 7 No Preference 25 304.37

53789PA0090012 Rating Area 7 No Preference 26 310.43

53789PA0090012 Rating Area 7 No Preference 27 317.71

53789PA0090012 Rating Area 7 No Preference 28 329.53

53789PA0090012 Rating Area 7 No Preference 29 339.24

53789PA0090012 Rating Area 7 No Preference 30 344.09

53789PA0090012 Rating Area 7 No Preference 31 351.36

53789PA0090012 Rating Area 7 No Preference 32 358.64

53789PA0090012 Rating Area 7 No Preference 33 363.18

53789PA0090012 Rating Area 7 No Preference 34 368.04

53789PA0090012 Rating Area 7 No Preference 35 370.46

53789PA0090012 Rating Area 7 No Preference 36 372.89

53789PA0090012 Rating Area 7 No Preference 37 375.31

53789PA0090012 Rating Area 7 No Preference 38 377.74

53789PA0090012 Rating Area 7 No Preference 39 382.59

53789PA0090012 Rating Area 7 No Preference 40 387.44

53789PA0090012 Rating Area 7 No Preference 41 394.71

53789PA0090012 Rating Area 7 No Preference 42 401.69

53789PA0090012 Rating Area 7 No Preference 43 411.39

53789PA0090012 Rating Area 7 No Preference 44 423.51

53789PA0090012 Rating Area 7 No Preference 45 437.76

53789PA0090012 Rating Area 7 No Preference 46 454.74

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090012 Rating Area 7 No Preference 47 473.84

53789PA0090012 Rating Area 7 No Preference 48 495.67

53789PA0090012 Rating Area 7 No Preference 49 517.19

53789PA0090012 Rating Area 7 No Preference 50 541.44

53789PA0090012 Rating Area 7 No Preference 51 565.39

53789PA0090012 Rating Area 7 No Preference 52 591.77

53789PA0090012 Rating Area 7 No Preference 53 618.44

53789PA0090012 Rating Area 7 No Preference 54 647.24

53789PA0090012 Rating Area 7 No Preference 55 676.04

53789PA0090012 Rating Area 7 No Preference 56 707.27

53789PA0090012 Rating Area 7 No Preference 57 738.80

53789PA0090012 Rating Area 7 No Preference 58 772.45

53789PA0090012 Rating Area 7 No Preference 59 789.12

53789PA0090012 Rating Area 7 No Preference 60 822.77

53789PA0090012 Rating Area 7 No Preference 61 851.88

53789PA0090012 Rating Area 7 No Preference 62 870.98

53789PA0090012 Rating Area 7 No Preference 63 894.93

53789PA0090012 Rating Area 7 No Preference 64 909.47

53789PA0090012 Rating Area 7 No Preference 65 and over 909.47

53789PA0090012 Rating Area 9 No Preference 0-20 188.69

53789PA0090012 Rating Area 9 No Preference 21 297.16

53789PA0090012 Rating Area 9 No Preference 22 297.16

53789PA0090012 Rating Area 9 No Preference 23 297.16

53789PA0090012 Rating Area 9 No Preference 24 297.16

53789PA0090012 Rating Area 9 No Preference 25 298.34

53789PA0090012 Rating Area 9 No Preference 26 304.29

53789PA0090012 Rating Area 9 No Preference 27 311.42

53789PA0090012 Rating Area 9 No Preference 28 323.01

53789PA0090012 Rating Area 9 No Preference 29 332.52

53789PA0090012 Rating Area 9 No Preference 30 337.27

53789PA0090012 Rating Area 9 No Preference 31 344.40

53789PA0090012 Rating Area 9 No Preference 32 351.54

53789PA0090012 Rating Area 9 No Preference 33 355.99

53789PA0090012 Rating Area 9 No Preference 34 360.75

53789PA0090012 Rating Area 9 No Preference 35 363.12

53789PA0090012 Rating Area 9 No Preference 36 365.50

53789PA0090012 Rating Area 9 No Preference 37 367.88

53789PA0090012 Rating Area 9 No Preference 38 370.26

53789PA0090012 Rating Area 9 No Preference 39 375.01

53789PA0090012 Rating Area 9 No Preference 40 379.77

53789PA0090012 Rating Area 9 No Preference 41 386.90

53789PA0090012 Rating Area 9 No Preference 42 393.73

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 1/1/2017

Rate Expiration Date* 3/31/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090012 Rating Area 9 No Preference 43 403.24

53789PA0090012 Rating Area 9 No Preference 44 415.13

53789PA0090012 Rating Area 9 No Preference 45 429.09

53789PA0090012 Rating Area 9 No Preference 46 445.73

53789PA0090012 Rating Area 9 No Preference 47 464.45

53789PA0090012 Rating Area 9 No Preference 48 485.85

53789PA0090012 Rating Area 9 No Preference 49 506.95

53789PA0090012 Rating Area 9 No Preference 50 530.72

53789PA0090012 Rating Area 9 No Preference 51 554.20

53789PA0090012 Rating Area 9 No Preference 52 580.05

53789PA0090012 Rating Area 9 No Preference 53 606.20

53789PA0090012 Rating Area 9 No Preference 54 634.43

53789PA0090012 Rating Area 9 No Preference 55 662.66

53789PA0090012 Rating Area 9 No Preference 56 693.26

53789PA0090012 Rating Area 9 No Preference 57 724.17

53789PA0090012 Rating Area 9 No Preference 58 757.15

53789PA0090012 Rating Area 9 No Preference 59 773.50

53789PA0090012 Rating Area 9 No Preference 60 806.48

53789PA0090012 Rating Area 9 No Preference 61 835.01

53789PA0090012 Rating Area 9 No Preference 62 853.73

53789PA0090012 Rating Area 9 No Preference 63 877.20

53789PA0090012 Rating Area 9 No Preference 64 891.47

53789PA0090012 Rating Area 9 No Preference 65 and over 891.47

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* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090004 Rating Area 6 No Preference 0-20 155.25

53789PA0090004 Rating Area 6 No Preference 21 244.49

53789PA0090004 Rating Area 6 No Preference 22 244.49

53789PA0090004 Rating Area 6 No Preference 23 244.49

53789PA0090004 Rating Area 6 No Preference 24 244.49

53789PA0090004 Rating Area 6 No Preference 25 245.47

53789PA0090004 Rating Area 6 No Preference 26 250.36

53789PA0090004 Rating Area 6 No Preference 27 256.23

53789PA0090004 Rating Area 6 No Preference 28 265.76

53789PA0090004 Rating Area 6 No Preference 29 273.58

53789PA0090004 Rating Area 6 No Preference 30 277.50

53789PA0090004 Rating Area 6 No Preference 31 283.36

53789PA0090004 Rating Area 6 No Preference 32 289.23

53789PA0090004 Rating Area 6 No Preference 33 292.90

53789PA0090004 Rating Area 6 No Preference 34 296.81

53789PA0090004 Rating Area 6 No Preference 35 298.77

53789PA0090004 Rating Area 6 No Preference 36 300.72

53789PA0090004 Rating Area 6 No Preference 37 302.68

53789PA0090004 Rating Area 6 No Preference 38 304.63

53789PA0090004 Rating Area 6 No Preference 39 308.55

53789PA0090004 Rating Area 6 No Preference 40 312.46

53789PA0090004 Rating Area 6 No Preference 41 318.33

53789PA0090004 Rating Area 6 No Preference 42 323.95

53789PA0090004 Rating Area 6 No Preference 43 331.77

53789PA0090004 Rating Area 6 No Preference 44 341.55

53789PA0090004 Rating Area 6 No Preference 45 353.04

53789PA0090004 Rating Area 6 No Preference 46 366.74

53789PA0090004 Rating Area 6 No Preference 47 382.14

53789PA0090004 Rating Area 6 No Preference 48 399.74

53789PA0090004 Rating Area 6 No Preference 49 417.10

53789PA0090004 Rating Area 6 No Preference 50 436.66

53789PA0090004 Rating Area 6 No Preference 51 455.97

53789PA0090004 Rating Area 6 No Preference 52 477.24

53789PA0090004 Rating Area 6 No Preference 53 498.76

53789PA0090004 Rating Area 6 No Preference 54 521.99

53789PA0090004 Rating Area 6 No Preference 55 545.21

53789PA0090004 Rating Area 6 No Preference 56 570.40

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090004 Rating Area 6 No Preference 57 595.82

53789PA0090004 Rating Area 6 No Preference 58 622.96

53789PA0090004 Rating Area 6 No Preference 59 636.41

53789PA0090004 Rating Area 6 No Preference 60 663.55

53789PA0090004 Rating Area 6 No Preference 61 687.02

53789PA0090004 Rating Area 6 No Preference 62 702.42

53789PA0090004 Rating Area 6 No Preference 63 721.73

53789PA0090004 Rating Area 6 No Preference 64 733.46

53789PA0090004 Rating Area 6 No Preference 65 and over 733.46

53789PA0090004 Rating Area 7 No Preference 0-20 156.80

53789PA0090004 Rating Area 7 No Preference 21 246.93

53789PA0090004 Rating Area 7 No Preference 22 246.93

53789PA0090004 Rating Area 7 No Preference 23 246.93

53789PA0090004 Rating Area 7 No Preference 24 246.93

53789PA0090004 Rating Area 7 No Preference 25 247.92

53789PA0090004 Rating Area 7 No Preference 26 252.86

53789PA0090004 Rating Area 7 No Preference 27 258.79

53789PA0090004 Rating Area 7 No Preference 28 268.42

53789PA0090004 Rating Area 7 No Preference 29 276.32

53789PA0090004 Rating Area 7 No Preference 30 280.27

53789PA0090004 Rating Area 7 No Preference 31 286.20

53789PA0090004 Rating Area 7 No Preference 32 292.12

53789PA0090004 Rating Area 7 No Preference 33 295.83

53789PA0090004 Rating Area 7 No Preference 34 299.78

53789PA0090004 Rating Area 7 No Preference 35 301.75

53789PA0090004 Rating Area 7 No Preference 36 303.73

53789PA0090004 Rating Area 7 No Preference 37 305.71

53789PA0090004 Rating Area 7 No Preference 38 307.68

53789PA0090004 Rating Area 7 No Preference 39 311.63

53789PA0090004 Rating Area 7 No Preference 40 315.58

53789PA0090004 Rating Area 7 No Preference 41 321.51

53789PA0090004 Rating Area 7 No Preference 42 327.19

53789PA0090004 Rating Area 7 No Preference 43 335.09

53789PA0090004 Rating Area 7 No Preference 44 344.97

53789PA0090004 Rating Area 7 No Preference 45 356.57

53789PA0090004 Rating Area 7 No Preference 46 370.40

53789PA0090004 Rating Area 7 No Preference 47 385.96

53789PA0090004 Rating Area 7 No Preference 48 403.74

53789PA0090004 Rating Area 7 No Preference 49 421.27

53789PA0090004 Rating Area 7 No Preference 50 441.03

53789PA0090004 Rating Area 7 No Preference 51 460.53

53789PA0090004 Rating Area 7 No Preference 52 482.02

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090004 Rating Area 7 No Preference 53 503.75

53789PA0090004 Rating Area 7 No Preference 54 527.21

53789PA0090004 Rating Area 7 No Preference 55 550.66

53789PA0090004 Rating Area 7 No Preference 56 576.10

53789PA0090004 Rating Area 7 No Preference 57 601.78

53789PA0090004 Rating Area 7 No Preference 58 629.19

53789PA0090004 Rating Area 7 No Preference 59 642.77

53789PA0090004 Rating Area 7 No Preference 60 670.18

53789PA0090004 Rating Area 7 No Preference 61 693.89

53789PA0090004 Rating Area 7 No Preference 62 709.44

53789PA0090004 Rating Area 7 No Preference 63 728.95

53789PA0090004 Rating Area 7 No Preference 64 740.79

53789PA0090004 Rating Area 7 No Preference 65 and over 740.79

53789PA0090004 Rating Area 9 No Preference 0-20 153.70

53789PA0090004 Rating Area 9 No Preference 21 242.05

53789PA0090004 Rating Area 9 No Preference 22 242.05

53789PA0090004 Rating Area 9 No Preference 23 242.05

53789PA0090004 Rating Area 9 No Preference 24 242.05

53789PA0090004 Rating Area 9 No Preference 25 243.01

53789PA0090004 Rating Area 9 No Preference 26 247.85

53789PA0090004 Rating Area 9 No Preference 27 253.66

53789PA0090004 Rating Area 9 No Preference 28 263.10

53789PA0090004 Rating Area 9 No Preference 29 270.85

53789PA0090004 Rating Area 9 No Preference 30 274.72

53789PA0090004 Rating Area 9 No Preference 31 280.53

53789PA0090004 Rating Area 9 No Preference 32 286.34

53789PA0090004 Rating Area 9 No Preference 33 289.97

53789PA0090004 Rating Area 9 No Preference 34 293.84

53789PA0090004 Rating Area 9 No Preference 35 295.78

53789PA0090004 Rating Area 9 No Preference 36 297.72

53789PA0090004 Rating Area 9 No Preference 37 299.65

53789PA0090004 Rating Area 9 No Preference 38 301.59

53789PA0090004 Rating Area 9 No Preference 39 305.46

53789PA0090004 Rating Area 9 No Preference 40 309.33

53789PA0090004 Rating Area 9 No Preference 41 315.14

53789PA0090004 Rating Area 9 No Preference 42 320.71

53789PA0090004 Rating Area 9 No Preference 43 328.46

53789PA0090004 Rating Area 9 No Preference 44 338.14

53789PA0090004 Rating Area 9 No Preference 45 349.51

53789PA0090004 Rating Area 9 No Preference 46 363.07

53789PA0090004 Rating Area 9 No Preference 47 378.32

53789PA0090004 Rating Area 9 No Preference 48 395.74

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090004 Rating Area 9 No Preference 49 412.93

53789PA0090004 Rating Area 9 No Preference 50 432.29

53789PA0090004 Rating Area 9 No Preference 51 451.41

53789PA0090004 Rating Area 9 No Preference 52 472.47

53789PA0090004 Rating Area 9 No Preference 53 493.77

53789PA0090004 Rating Area 9 No Preference 54 516.77

53789PA0090004 Rating Area 9 No Preference 55 539.76

53789PA0090004 Rating Area 9 No Preference 56 564.69

53789PA0090004 Rating Area 9 No Preference 57 589.86

53789PA0090004 Rating Area 9 No Preference 58 616.73

53789PA0090004 Rating Area 9 No Preference 59 630.04

53789PA0090004 Rating Area 9 No Preference 60 656.91

53789PA0090004 Rating Area 9 No Preference 61 680.15

53789PA0090004 Rating Area 9 No Preference 62 695.40

53789PA0090004 Rating Area 9 No Preference 63 714.52

53789PA0090004 Rating Area 9 No Preference 64 726.14

53789PA0090004 Rating Area 9 No Preference 65 and over 726.14

53789PA0090007 Rating Area 6 No Preference 0-20 214.80

53789PA0090007 Rating Area 6 No Preference 21 338.27

53789PA0090007 Rating Area 6 No Preference 22 338.27

53789PA0090007 Rating Area 6 No Preference 23 338.27

53789PA0090007 Rating Area 6 No Preference 24 338.27

53789PA0090007 Rating Area 6 No Preference 25 339.62

53789PA0090007 Rating Area 6 No Preference 26 346.39

53789PA0090007 Rating Area 6 No Preference 27 354.51

53789PA0090007 Rating Area 6 No Preference 28 367.70

53789PA0090007 Rating Area 6 No Preference 29 378.52

53789PA0090007 Rating Area 6 No Preference 30 383.94

53789PA0090007 Rating Area 6 No Preference 31 392.05

53789PA0090007 Rating Area 6 No Preference 32 400.17

53789PA0090007 Rating Area 6 No Preference 33 405.25

53789PA0090007 Rating Area 6 No Preference 34 410.66

53789PA0090007 Rating Area 6 No Preference 35 413.37

53789PA0090007 Rating Area 6 No Preference 36 416.07

53789PA0090007 Rating Area 6 No Preference 37 418.78

53789PA0090007 Rating Area 6 No Preference 38 421.48

53789PA0090007 Rating Area 6 No Preference 39 426.90

53789PA0090007 Rating Area 6 No Preference 40 432.31

53789PA0090007 Rating Area 6 No Preference 41 440.43

53789PA0090007 Rating Area 6 No Preference 42 448.21

53789PA0090007 Rating Area 6 No Preference 43 459.03

53789PA0090007 Rating Area 6 No Preference 44 472.56

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090007 Rating Area 6 No Preference 45 488.46

53789PA0090007 Rating Area 6 No Preference 46 507.40

53789PA0090007 Rating Area 6 No Preference 47 528.72

53789PA0090007 Rating Area 6 No Preference 48 553.07

53789PA0090007 Rating Area 6 No Preference 49 577.09

53789PA0090007 Rating Area 6 No Preference 50 604.15

53789PA0090007 Rating Area 6 No Preference 51 630.87

53789PA0090007 Rating Area 6 No Preference 52 660.30

53789PA0090007 Rating Area 6 No Preference 53 690.07

53789PA0090007 Rating Area 6 No Preference 54 722.21

53789PA0090007 Rating Area 6 No Preference 55 754.34

53789PA0090007 Rating Area 6 No Preference 56 789.18

53789PA0090007 Rating Area 6 No Preference 57 824.36

53789PA0090007 Rating Area 6 No Preference 58 861.91

53789PA0090007 Rating Area 6 No Preference 59 880.52

53789PA0090007 Rating Area 6 No Preference 60 918.06

53789PA0090007 Rating Area 6 No Preference 61 950.54

53789PA0090007 Rating Area 6 No Preference 62 971.85

53789PA0090007 Rating Area 6 No Preference 63 998.57

53789PA0090007 Rating Area 6 No Preference 64 1014.80

53789PA0090007 Rating Area 6 No Preference 65 and over 1014.80

53789PA0090007 Rating Area 7 No Preference 0-20 216.95

53789PA0090007 Rating Area 7 No Preference 21 341.65

53789PA0090007 Rating Area 7 No Preference 22 341.65

53789PA0090007 Rating Area 7 No Preference 23 341.65

53789PA0090007 Rating Area 7 No Preference 24 341.65

53789PA0090007 Rating Area 7 No Preference 25 343.02

53789PA0090007 Rating Area 7 No Preference 26 349.85

53789PA0090007 Rating Area 7 No Preference 27 358.05

53789PA0090007 Rating Area 7 No Preference 28 371.38

53789PA0090007 Rating Area 7 No Preference 29 382.31

53789PA0090007 Rating Area 7 No Preference 30 387.78

53789PA0090007 Rating Area 7 No Preference 31 395.98

53789PA0090007 Rating Area 7 No Preference 32 404.18

53789PA0090007 Rating Area 7 No Preference 33 409.30

53789PA0090007 Rating Area 7 No Preference 34 414.77

53789PA0090007 Rating Area 7 No Preference 35 417.50

53789PA0090007 Rating Area 7 No Preference 36 420.23

53789PA0090007 Rating Area 7 No Preference 37 422.97

53789PA0090007 Rating Area 7 No Preference 38 425.70

53789PA0090007 Rating Area 7 No Preference 39 431.17

53789PA0090007 Rating Area 7 No Preference 40 436.63

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090007 Rating Area 7 No Preference 41 444.83

53789PA0090007 Rating Area 7 No Preference 42 452.69

53789PA0090007 Rating Area 7 No Preference 43 463.62

53789PA0090007 Rating Area 7 No Preference 44 477.29

53789PA0090007 Rating Area 7 No Preference 45 493.35

53789PA0090007 Rating Area 7 No Preference 46 512.48

53789PA0090007 Rating Area 7 No Preference 47 534.00

53789PA0090007 Rating Area 7 No Preference 48 558.60

53789PA0090007 Rating Area 7 No Preference 49 582.86

53789PA0090007 Rating Area 7 No Preference 50 610.19

53789PA0090007 Rating Area 7 No Preference 51 637.18

53789PA0090007 Rating Area 7 No Preference 52 666.91

53789PA0090007 Rating Area 7 No Preference 53 696.97

53789PA0090007 Rating Area 7 No Preference 54 729.43

53789PA0090007 Rating Area 7 No Preference 55 761.89

53789PA0090007 Rating Area 7 No Preference 56 797.08

53789PA0090007 Rating Area 7 No Preference 57 832.61

53789PA0090007 Rating Area 7 No Preference 58 870.53

53789PA0090007 Rating Area 7 No Preference 59 889.32

53789PA0090007 Rating Area 7 No Preference 60 927.25

53789PA0090007 Rating Area 7 No Preference 61 960.04

53789PA0090007 Rating Area 7 No Preference 62 981.57

53789PA0090007 Rating Area 7 No Preference 63 1008.56

53789PA0090007 Rating Area 7 No Preference 64 1024.95

53789PA0090007 Rating Area 7 No Preference 65 and over 1024.95

53789PA0090007 Rating Area 9 No Preference 0-20 212.65

53789PA0090007 Rating Area 9 No Preference 21 334.89

53789PA0090007 Rating Area 9 No Preference 22 334.89

53789PA0090007 Rating Area 9 No Preference 23 334.89

53789PA0090007 Rating Area 9 No Preference 24 334.89

53789PA0090007 Rating Area 9 No Preference 25 336.23

53789PA0090007 Rating Area 9 No Preference 26 342.92

53789PA0090007 Rating Area 9 No Preference 27 350.96

53789PA0090007 Rating Area 9 No Preference 28 364.02

53789PA0090007 Rating Area 9 No Preference 29 374.74

53789PA0090007 Rating Area 9 No Preference 30 380.10

53789PA0090007 Rating Area 9 No Preference 31 388.13

53789PA0090007 Rating Area 9 No Preference 32 396.17

53789PA0090007 Rating Area 9 No Preference 33 401.19

53789PA0090007 Rating Area 9 No Preference 34 406.55

53789PA0090007 Rating Area 9 No Preference 35 409.23

53789PA0090007 Rating Area 9 No Preference 36 411.91

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090007 Rating Area 9 No Preference 37 414.59

53789PA0090007 Rating Area 9 No Preference 38 417.27

53789PA0090007 Rating Area 9 No Preference 39 422.63

53789PA0090007 Rating Area 9 No Preference 40 427.99

53789PA0090007 Rating Area 9 No Preference 41 436.02

53789PA0090007 Rating Area 9 No Preference 42 443.73

53789PA0090007 Rating Area 9 No Preference 43 454.44

53789PA0090007 Rating Area 9 No Preference 44 467.84

53789PA0090007 Rating Area 9 No Preference 45 483.58

53789PA0090007 Rating Area 9 No Preference 46 502.33

53789PA0090007 Rating Area 9 No Preference 47 523.43

53789PA0090007 Rating Area 9 No Preference 48 547.54

53789PA0090007 Rating Area 9 No Preference 49 571.32

53789PA0090007 Rating Area 9 No Preference 50 598.11

53789PA0090007 Rating Area 9 No Preference 51 624.56

53789PA0090007 Rating Area 9 No Preference 52 653.70

53789PA0090007 Rating Area 9 No Preference 53 683.17

53789PA0090007 Rating Area 9 No Preference 54 714.98

53789PA0090007 Rating Area 9 No Preference 55 746.80

53789PA0090007 Rating Area 9 No Preference 56 781.29

53789PA0090007 Rating Area 9 No Preference 57 816.12

53789PA0090007 Rating Area 9 No Preference 58 853.29

53789PA0090007 Rating Area 9 No Preference 59 871.71

53789PA0090007 Rating Area 9 No Preference 60 908.88

53789PA0090007 Rating Area 9 No Preference 61 941.03

53789PA0090007 Rating Area 9 No Preference 62 962.13

53789PA0090007 Rating Area 9 No Preference 63 988.59

53789PA0090007 Rating Area 9 No Preference 64 1004.66

53789PA0090007 Rating Area 9 No Preference 65 and over 1004.66

53789PA0090008 Rating Area 6 No Preference 0-20 218.57

53789PA0090008 Rating Area 6 No Preference 21 344.20

53789PA0090008 Rating Area 6 No Preference 22 344.20

53789PA0090008 Rating Area 6 No Preference 23 344.20

53789PA0090008 Rating Area 6 No Preference 24 344.20

53789PA0090008 Rating Area 6 No Preference 25 345.58

53789PA0090008 Rating Area 6 No Preference 26 352.46

53789PA0090008 Rating Area 6 No Preference 27 360.72

53789PA0090008 Rating Area 6 No Preference 28 374.15

53789PA0090008 Rating Area 6 No Preference 29 385.16

53789PA0090008 Rating Area 6 No Preference 30 390.67

53789PA0090008 Rating Area 6 No Preference 31 398.93

53789PA0090008 Rating Area 6 No Preference 32 407.19

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090008 Rating Area 6 No Preference 33 412.35

53789PA0090008 Rating Area 6 No Preference 34 417.86

53789PA0090008 Rating Area 6 No Preference 35 420.61

53789PA0090008 Rating Area 6 No Preference 36 423.37

53789PA0090008 Rating Area 6 No Preference 37 426.12

53789PA0090008 Rating Area 6 No Preference 38 428.87

53789PA0090008 Rating Area 6 No Preference 39 434.38

53789PA0090008 Rating Area 6 No Preference 40 439.89

53789PA0090008 Rating Area 6 No Preference 41 448.15

53789PA0090008 Rating Area 6 No Preference 42 456.06

53789PA0090008 Rating Area 6 No Preference 43 467.08

53789PA0090008 Rating Area 6 No Preference 44 480.85

53789PA0090008 Rating Area 6 No Preference 45 497.02

53789PA0090008 Rating Area 6 No Preference 46 516.30

53789PA0090008 Rating Area 6 No Preference 47 537.98

53789PA0090008 Rating Area 6 No Preference 48 562.77

53789PA0090008 Rating Area 6 No Preference 49 587.21

53789PA0090008 Rating Area 6 No Preference 50 614.74

53789PA0090008 Rating Area 6 No Preference 51 641.93

53789PA0090008 Rating Area 6 No Preference 52 671.88

53789PA0090008 Rating Area 6 No Preference 53 702.17

53789PA0090008 Rating Area 6 No Preference 54 734.87

53789PA0090008 Rating Area 6 No Preference 55 767.57

53789PA0090008 Rating Area 6 No Preference 56 803.02

53789PA0090008 Rating Area 6 No Preference 57 838.82

53789PA0090008 Rating Area 6 No Preference 58 877.02

53789PA0090008 Rating Area 6 No Preference 59 895.95

53789PA0090008 Rating Area 6 No Preference 60 934.16

53789PA0090008 Rating Area 6 No Preference 61 967.20

53789PA0090008 Rating Area 6 No Preference 62 988.89

53789PA0090008 Rating Area 6 No Preference 63 1016.08

53789PA0090008 Rating Area 6 No Preference 64 1032.59

53789PA0090008 Rating Area 6 No Preference 65 and over 1032.59

53789PA0090008 Rating Area 7 No Preference 0-20 220.75

53789PA0090008 Rating Area 7 No Preference 21 347.64

53789PA0090008 Rating Area 7 No Preference 22 347.64

53789PA0090008 Rating Area 7 No Preference 23 347.64

53789PA0090008 Rating Area 7 No Preference 24 347.64

53789PA0090008 Rating Area 7 No Preference 25 349.03

53789PA0090008 Rating Area 7 No Preference 26 355.99

53789PA0090008 Rating Area 7 No Preference 27 364.33

53789PA0090008 Rating Area 7 No Preference 28 377.89

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090008 Rating Area 7 No Preference 29 389.01

53789PA0090008 Rating Area 7 No Preference 30 394.57

53789PA0090008 Rating Area 7 No Preference 31 402.92

53789PA0090008 Rating Area 7 No Preference 32 411.26

53789PA0090008 Rating Area 7 No Preference 33 416.48

53789PA0090008 Rating Area 7 No Preference 34 422.04

53789PA0090008 Rating Area 7 No Preference 35 424.82

53789PA0090008 Rating Area 7 No Preference 36 427.60

53789PA0090008 Rating Area 7 No Preference 37 430.38

53789PA0090008 Rating Area 7 No Preference 38 433.16

53789PA0090008 Rating Area 7 No Preference 39 438.72

53789PA0090008 Rating Area 7 No Preference 40 444.29

53789PA0090008 Rating Area 7 No Preference 41 452.63

53789PA0090008 Rating Area 7 No Preference 42 460.63

53789PA0090008 Rating Area 7 No Preference 43 471.75

53789PA0090008 Rating Area 7 No Preference 44 485.66

53789PA0090008 Rating Area 7 No Preference 45 502.00

53789PA0090008 Rating Area 7 No Preference 46 521.46

53789PA0090008 Rating Area 7 No Preference 47 543.36

53789PA0090008 Rating Area 7 No Preference 48 568.39

53789PA0090008 Rating Area 7 No Preference 49 593.08

53789PA0090008 Rating Area 7 No Preference 50 620.89

53789PA0090008 Rating Area 7 No Preference 51 648.35

53789PA0090008 Rating Area 7 No Preference 52 678.60

53789PA0090008 Rating Area 7 No Preference 53 709.19

53789PA0090008 Rating Area 7 No Preference 54 742.22

53789PA0090008 Rating Area 7 No Preference 55 775.24

53789PA0090008 Rating Area 7 No Preference 56 811.05

53789PA0090008 Rating Area 7 No Preference 57 847.20

53789PA0090008 Rating Area 7 No Preference 58 885.79

53789PA0090008 Rating Area 7 No Preference 59 904.91

53789PA0090008 Rating Area 7 No Preference 60 943.50

53789PA0090008 Rating Area 7 No Preference 61 976.87

53789PA0090008 Rating Area 7 No Preference 62 998.78

53789PA0090008 Rating Area 7 No Preference 63 1026.24

53789PA0090008 Rating Area 7 No Preference 64 1042.92

53789PA0090008 Rating Area 7 No Preference 65 and over 1042.92

53789PA0090008 Rating Area 9 No Preference 0-20 216.38

53789PA0090008 Rating Area 9 No Preference 21 340.76

53789PA0090008 Rating Area 9 No Preference 22 340.76

53789PA0090008 Rating Area 9 No Preference 23 340.76

53789PA0090008 Rating Area 9 No Preference 24 340.76

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090008 Rating Area 9 No Preference 25 342.12

53789PA0090008 Rating Area 9 No Preference 26 348.94

53789PA0090008 Rating Area 9 No Preference 27 357.11

53789PA0090008 Rating Area 9 No Preference 28 370.40

53789PA0090008 Rating Area 9 No Preference 29 381.31

53789PA0090008 Rating Area 9 No Preference 30 386.76

53789PA0090008 Rating Area 9 No Preference 31 394.94

53789PA0090008 Rating Area 9 No Preference 32 403.12

53789PA0090008 Rating Area 9 No Preference 33 408.23

53789PA0090008 Rating Area 9 No Preference 34 413.68

53789PA0090008 Rating Area 9 No Preference 35 416.41

53789PA0090008 Rating Area 9 No Preference 36 419.13

53789PA0090008 Rating Area 9 No Preference 37 421.86

53789PA0090008 Rating Area 9 No Preference 38 424.58

53789PA0090008 Rating Area 9 No Preference 39 430.04

53789PA0090008 Rating Area 9 No Preference 40 435.49

53789PA0090008 Rating Area 9 No Preference 41 443.67

53789PA0090008 Rating Area 9 No Preference 42 451.50

53789PA0090008 Rating Area 9 No Preference 43 462.41

53789PA0090008 Rating Area 9 No Preference 44 476.04

53789PA0090008 Rating Area 9 No Preference 45 492.05

53789PA0090008 Rating Area 9 No Preference 46 511.14

53789PA0090008 Rating Area 9 No Preference 47 532.60

53789PA0090008 Rating Area 9 No Preference 48 557.14

53789PA0090008 Rating Area 9 No Preference 49 581.33

53789PA0090008 Rating Area 9 No Preference 50 608.59

53789PA0090008 Rating Area 9 No Preference 51 635.51

53789PA0090008 Rating Area 9 No Preference 52 665.16

53789PA0090008 Rating Area 9 No Preference 53 695.15

53789PA0090008 Rating Area 9 No Preference 54 727.52

53789PA0090008 Rating Area 9 No Preference 55 759.89

53789PA0090008 Rating Area 9 No Preference 56 794.99

53789PA0090008 Rating Area 9 No Preference 57 830.43

53789PA0090008 Rating Area 9 No Preference 58 868.25

53789PA0090008 Rating Area 9 No Preference 59 886.99

53789PA0090008 Rating Area 9 No Preference 60 924.82

53789PA0090008 Rating Area 9 No Preference 61 957.53

53789PA0090008 Rating Area 9 No Preference 62 979.00

53789PA0090008 Rating Area 9 No Preference 63 1005.92

53789PA0090008 Rating Area 9 No Preference 64 1022.27

53789PA0090008 Rating Area 9 No Preference 65 and over 1022.27

53789PA0090011 Rating Area 6 No Preference 0-20 190.49

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber eligible for the

rate

Required:

Enter the rate of an Individual Non-Tobacco or

No Preference enrollee on a plan

53789PA0090011 Rating Area 6 No Preference 21 299.99

53789PA0090011 Rating Area 6 No Preference 22 299.99

53789PA0090011 Rating Area 6 No Preference 23 299.99

53789PA0090011 Rating Area 6 No Preference 24 299.99

53789PA0090011 Rating Area 6 No Preference 25 301.19

53789PA0090011 Rating Area 6 No Preference 26 307.19

53789PA0090011 Rating Area 6 No Preference 27 314.39

53789PA0090011 Rating Area 6 No Preference 28 326.09

53789PA0090011 Rating Area 6 No Preference 29 335.69

53789PA0090011 Rating Area 6 No Preference 30 340.49

53789PA0090011 Rating Area 6 No Preference 31 347.69

53789PA0090011 Rating Area 6 No Preference 32 354.89

53789PA0090011 Rating Area 6 No Preference 33 359.39

53789PA0090011 Rating Area 6 No Preference 34 364.19

53789PA0090011 Rating Area 6 No Preference 35 366.59

53789PA0090011 Rating Area 6 No Preference 36 368.99

53789PA0090011 Rating Area 6 No Preference 37 371.39

53789PA0090011 Rating Area 6 No Preference 38 373.79

53789PA0090011 Rating Area 6 No Preference 39 378.59

53789PA0090011 Rating Area 6 No Preference 40 383.39

53789PA0090011 Rating Area 6 No Preference 41 390.59

53789PA0090011 Rating Area 6 No Preference 42 397.49

53789PA0090011 Rating Area 6 No Preference 43 407.09

53789PA0090011 Rating Area 6 No Preference 44 419.09

53789PA0090011 Rating Area 6 No Preference 45 433.19

53789PA0090011 Rating Area 6 No Preference 46 449.98

53789PA0090011 Rating Area 6 No Preference 47 468.88

53789PA0090011 Rating Area 6 No Preference 48 490.48

53789PA0090011 Rating Area 6 No Preference 49 511.78

53789PA0090011 Rating Area 6 No Preference 50 535.78

53789PA0090011 Rating Area 6 No Preference 51 559.48

53789PA0090011 Rating Area 6 No Preference 52 585.58

53789PA0090011 Rating Area 6 No Preference 53 611.98

53789PA0090011 Rating Area 6 No Preference 54 640.48

53789PA0090011 Rating Area 6 No Preference 55 668.98

53789PA0090011 Rating Area 6 No Preference 56 699.88

53789PA0090011 Rating Area 6 No Preference 57 731.08

53789PA0090011 Rating Area 6 No Preference 58 764.37

53789PA0090011 Rating Area 6 No Preference 59 780.87

53789PA0090011 Rating Area 6 No Preference 60 814.17

53789PA0090011 Rating Area 6 No Preference 61 842.97

53789PA0090011 Rating Area 6 No Preference 62 861.87

HIOS Issuer ID* 53789

Federal TIN* 23-2399845

Rate Effective Date* 4/1/2017

Rate Expiration Date* 6/30/2017

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

Required:

Enter the 14-character Plan ID

Required:

Select the Rating Area ID

Require:

Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a

plan

Required:

Select the age of a subscriber e