HealthNow New York Inc. 2018 New York State Exchange … · 1.1 The group must produce documentation at time of enrollment that proves ... by the insurance ... New York Inc. 2018

HealthNow New York Inc.

2018 New York State Exchange Rate Submission

Rate Manual Index

Rates Effective 1/1/2018

Index:

Page # Description

1 Overview

2 Region Definition

3 Commission Schedules

4 - 7 Underwriting Guidelines

8 Rate Calculation Examples

9 Expected Medical Loss Ratios

10 - 15 Benefit Summary Small Group Plans - Region 2

16 - 19 Benefit Summary Small Group Plans - Regions 1 & 7

20 - 25 Small Group Rates Effective 2018



Rate Manual - Page 1


Overview:

The rates contained within this rate manual are for use in the small group market. The

group medical and pharmacy rates are effective 1/1/2018 through 12/31/2018 and roll on

a quarterly basis. The rates are guaranteed for one year from the effective date of the

group's policy. For groups, the rates are applicable based on the quarter in which the

effective date for the plan year begins. The county the group is located in from the region

definition should be used to pick the applicable regional rate. The rates included in this

rate manual are filed under HealthNow policy form numbers: CN1C3S0440_0516,

CN1C3S0441_0516, CH1C4F0452_0516, CG1C4S0469_0516.





Region Definition:

Region Counties Individual

1 Albany, Columbia, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady,

Schoharie, Warren, Washington 0.994

2 Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming1.003

7 Clinton, Essex 1.124

Notes:

1. Region #7 includes more counties than listed but HealthNow will only participate within the listed counties.

Geographic Factor

Small Group

1.158

0.968

1.416

Geographic Factor





Small Group Commission Schedules:

Western New York

New/Existing Business

Product Commission

PPO

POS

HMO

Important Notes:

Commission payments for HMO products cannot exceed a total of 4% of the collected premium for each individual group.

Northeastern New York

New/Existing Business

Rating Commission

Community Rated 3.75% HMO, POS, EPO, PPO, HDHP of monthly paid premium.

Important Notes:

Direct Bill COBRA groups are not eligible to receive commissions.

Commission payments for HMO products cannot exceed a total of 4% of the collected premium for each individual group.

Effective first of month following BOR appointment.

3.5% of monthly paid premium for full replacement.





Small Group Underwriting Guidelines

1.0 Group Documentation

NOTE: All documentation must be received and verified before any coverage is issued

1.1 The group must produce documentation at time of enrollment that proves existence and active involvement in

doing business. Groups must have a physical location in our service area. We require a physical address (not a

P.O. Box) for a group address.

Table 1: Forms of Documentation

Required Documentationa

• Schedule C • Schedule 1120 C

• Schedule E • Schedule 1120 E

• Schedule F • Schedule 1120 S

• Schedule K-1 • Form IT-204

• Schedule 1065

Documentation for new businesses may include a copy of a business bank statement, a cancelled business check, assignment of

an EIN number, or other appropriate tax documents that demonstrate eligibil ity.c

approval prior to enrollment.

Alternate Forms of Documentationb

NYS-45

a Additional documentation may be required to prove eligibility of new subscribers. People not listed on the most recent ATT-45 form will not be

accepted for group coverage from BCBSWNY unless alternate documentation is submitted. For new employees, alternate documentation may include

the last 2 weeks of pay stubs or a copy of the group’s payroll including payroll for those new employees. For COBRA and retirees, the last applicable NYS-

45, payroll, or pension records will be accepted to establish eligibility.

b If a NYS-45 is not available, these alternate forms or any combination thereof may be accepted in lieu of the required documentation. In such

instances, a NYS-45 will be required within 90 days.

c Two months of premium must be submitted on a company check with the enrollment paperwork and subscriber applications to Underwriting for

1.2 All new groups may be subject to an on-site inspection by a BlueCross BlueShield Representative prior to the

initial enrollment in order to qualify the group’s ability to meet BlueCross BlueShield Group Eligibility

Requirements.

1.3 The employees of a multiple location group within the BlueCross BlueShield service area may be combined to

determine the size of the group. Employees in locations outside of the BlueCross BlueShield service area will be

counted in determining group size if they are eligible for BlueCross BlueShield coverage. If requested, a multiple

location group purchasing coverage can enroll only the employees who reside within the BlueCross BlueShield

service area and only in products that adhere to the guidelines set forth in Table 2. These groups must have a

facility or office in the service area. The facility or office may be classified as a separate and distinct entity.

1.4 Certain definable segments in a group may be considered for enrollment as a group when all other Employer-

Employee Eligibility requirements are met and the request is from the group. A segment of a group is defined as a

classification of employees from a group who are clearly distinguished from all other employees for reasons other

than obtaining BlueCross BlueShield health insurance coverage. For example: all salaried employees, all hourly

employees, all employees in a specific location, employees of distinct entities acquired by merger, all directors, all

shareholders, all managers, by job duties, by earnings or any combination of these segments. An eligible small

group consists of 1 to 50 employees*. Group size is determined by the number of “eligible” employees in a given

class as elected by the employer. All policies must be available to groups year-round.

*Note: As of 1/1/2016, the small group definition will be updated as per PPACA requirements to 1 to 100 employees.





Small Group Underwriting Guidelines Continued:

2.0 Employee Documentation for Group Coverage

NOTE: Employee documentation may be requested at any time and is subject to verification

2.1 Upon request, the group will be required to provide verification that all persons electing group coverage are

actually employed by the group.

2.2 Full time employees or part time employees working a minimum of 20 hours per week are eligible for

coverage. Groups may choose to impose a higher requirement for hours for part time employees.

2.3 Partners, shareholders, officers, owners, directors, and proprietors will be eligible only when devoting their

services on a full-time basis to the business by working a minimum of 20 hours per week. These individuals must

supply evidence that they work 20 hours per week, such as pay stubs, draws on a company account in lieu of

payroll, and/or personal income tax records.

2.4 The following will be considered eligible employees:

• Must be a legal employee.

• An elected or appointed official if the employer group is a public entity.

• A reservist.

• Temporary and Seasonal employees are eligible at the option of the employer.

• 1099 Employees who are considered an employee per Department of Labor regulations and the Internal

Revenue Code.

2.5 Retiree coverage:

• Retirees are persons previously employed by the group immediately prior to the time they cease to be an

active employee.

• If a group desires to offer coverage to its retirees as well as the currently active employees, we will insure

the retirees as well as the active employees.

• [Commercial Products Only] If a group has coverage for both active employees and retirees and opts to

terminate coverage for the active employees, the retiree coverage will also be terminated.

• The employer must make some contribution to the cost of retiree coverage except if the employer makes

no contribution to the cost of active employee coverage.

• Groups may be required, upon request, to provide proof that the retirees were in fact previously active

employees of the group immediately before retirement.

• New groups which consist solely of retirees will not be offered coverage.

3.0 Chambers of Commerce/Association Groups

3.1 Chambers or Associations which BlueCross BlueShield currently insure may continue. For those Chambers and

Associations which continue, groups may be added or terminated within the Chamber or Association, and

subscribers within those constituent groups may be added or terminated as well – subject to the rules below.

Individuals within new chambers and associations may purchase products from BlueCross Blue Shield on or off the

exchange.

3.2 BlueCross BlueShield must verify that each of the groups joining the Chamber or Association are actively

engaged in their business. The same documentation needed for a group enrolling directly with us will be required

for groups joining a Chamber or Association. All underwriting rules will be applied at the individual group level;

that is, for a Chamber, each group joining through the Chamber is subject to the same underwriting criteria as if

the group had purchased directly from BlueCross BlueShield.

3.3 Chambers and Associations may offer up to two products.






4.0 Group Participation, Location, and Contribution Requirements

NOTE: All groups are subject to review at any time by BlueCross BlueShield to ensure that they meet group

eligibility requirements. Group size determination made on renewal. Fluctuation in size of the group mid-year

does not affect eligibility.

4.1 The group requirements contained in this section establish the basic criteria used by BlueCross BlueShield to

determine which groups will be accepted for enrollment and which groups will be allowed to continue subsequent

to initial enrollment.

4.2 BlueCross BlueShield reserves the right to deny initial or continued enrollment to a group which does not meet

the group eligibility requirements. BlueCross BlueShield also reserves the right to terminate a group, upon

appropriate notice as specified by the insurance contract, if group eligibility requirements are not met and

maintained.

4.3 All eligible employees must live, work, or reside in our service area to be able to offer an Article 44 product.

4.4 The group must be headquartered in the health plan’s service area. In the event that BlueCross BlueShield is

insuring only the local employees of a multi-location group, the group must have an office in the health plan’s

service area.

5.0 Open Enrollment Policies

5.1 The employer must not inhibit free movement of eligible employees at either the initial enrollment period or

at any subsequent open enrollment period.

5.2 Groups are required to have one specified annual open enrollment period. The open enrollment will apply to

all BlueCross BlueShield products. A second open enrollment period (special open enrollment) may be permitted

with the prior approval of BlueCross BlueShield.

5.3 If a special open enrollment is offered for any carrier because of a change in rates, benefits, and/or delivery

system, then BlueCross BlueShield must also be offered the opportunity to make similar changes in benefits, rates,

and/or delivery system, and to participate in the open enrollment.

5.4 Enrollment of a group is contingent upon receiving complete, appropriate paperwork (including a signed group

agreement) a minimum of 15 business days (for Community Rated) or 30 business days (for Experience Rated)

prior to the effective date of the group. Failure to provide this advance notice may result in the movement of the

group’s effective date to the first of the following month.

5.5 Any change in the BlueCross BlueShield benefit package inclusive of all products, including but not limited to

rating tier structure, which is not coincident with the group’s anniversary date must have the prior approval of

BlueCross BlueShield.

5.6 Eligible employees/retirees may only enter the plan during the open enrollment period of each year or within

30 days of first becoming eligible. Employers may set a waiting period for new employees from 0 to 90 days. Entry

will not be permitted at any other time during the year except in accordance with 11 NYCRR Section 360.3 (a)(9)(i-

iii) or Section 4305(K)(5)(B)(ii). The applicable special enrollment periods are outlined in Appendix A.






6.0 Product Offerings

6.1 There are no product offering guidelines for products offered via New York State of Health, the Official Health

Plan Marketplace of New York State.

6.2 There are no product offering guidelines which would limit the products available in a slice offering, when

compared with a sole offering.

Table 3: Product Offerings

Small Group (1 - 50) Large Group (51+)

Products Available(Some product types not available

in all markets)

HMO

POS

EPO

PPO

HMOa

POS

EPO

PPO

Traditional

Comprehensive

Rating Type Community Rated Community or Experience Rated

Group Size (Eligible Employees)

a - HMO products are not available Experience Rated

7.0 General Group Renewal

NOTE: All groups are subject to review at any time by BlueCross BlueShield to ensure that they meet group

eligibility requirements

7.1 Refusal to renew is permitted in the following circumstances:

• Group no longer exists as a business

• Group has perpetuated fraud

• Group misrepresentation of material facts

• Group inability to meet the definition of permissible group under applicable state and federal

requirements.

• BlueCross Blue Shield discontinues a class of contracts or withdraws from the market.

• Failure to meet an insurer’s service area requirements if no employee lives or resides in the service

area.

• Lapsed membership by a participating group in the association if association group coverage.





Small Group Rate Calculation Example:

Rate Calculation Example - Small Group

The following Steps are used to calculate premium rates.

a Index Rate - Quarter 1 2018

511.73

b Plan Level Adjustments

Includes actuarial value, network, risk adjustment,

administrative costs, taxes, and ACA fees.

Specific to Platinum Standard Plan

Region 1 0.991

Region 2 1.046

Region 7 0.980

c Geographic Factors

Reflects aggregate regional cost differences.

Region 1 1.158

Region 2 0.968

Region 7 1.416

d Conversion Factor 1.188

e Standardized Census Tiers - Dependent Coverage to Age 26

Single 1.0000

2 Person 2.0000

Sub + Child(ren) 1.7000

Family Tier 2.8500

f Dependent Coverage to Age 30 Adjustment 1.0021

g Quarterly Rolling Rate

Quarter 1 1.0000

Quarter 2 1.0130

Quarter 3 1.0262

Quarter 4 1.0395

7 Rate Calculation Example

Platinum Standard ; Family ; Age 30 ; Quarter 2

a * b * c * d *e * f * g

Region 1 2,017.64

Region 2 1,780.24

Region 7 2,439.63





Medical Loss Ratios

New York State Loss Ratio

Market Loss Ratio

Individual 85.0%

Small Group 89.7%

Federal Loss Ratio

Market Loss Ratio

Individual 87.3%

Small Group 92.0%





Benefit Summary - Group Plans Region #2:

Available in group market for Region #2 or subset of region (see region definition).

Metal Platinum Platinum Platinum Platinum Platinum Platinum Platinum Platinum

Plan Platinum Standard Platinum Make Available Platinum align Platinum align Platinum focus Platinum focus Platinum HMO 110 Plus Platinum PPO 843

Region Region #2 Region #2 Region #2 Region #2 Region #2 Region #2 Region #2 Region #2

Standard/ NonStandard Standard Standard Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard

Availability (On / Off) Both Both Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange

AV 90% 90% 86% 86% 86% 86% 87% 90%

First Dollar $0 $0 $0 $0 $0 $0 $0 $0

Deductible (single) $0 $0 $0 $1,500 $0 $1,500 $0 $500

OOP Maximum (single) $2,000 $2,000 $3,800 $3,800 $3,800 $3,800 $3,800 $1,000

Deductible Applies to Rx No No No No No No No Yes

Embedded Deductible Yes Yes Yes Yes Yes Yes Yes Yes

Inpatient Hospital

ASA Rehab $500* $500* $500* 50% $500* 50% $500* 20%

Detox $500* $500* $500* 50% $500* 50% $500* 20%

Maternity $500* $500* $500* 50% $500* 50% $500* 20%

Med/Surg $500* $500* $500* 50% $500* 50% $500* 20%

Mental Health $500* $500* $500* 50% $500* 50% $500* 20%

Newborn $500* $500* $500* 50% $500* 50% $500* 20%

Residential Care $500* $500* $500* 50% $500* 50% $500* 20%

SNF $500* $500* $500* 50% $500* 50% $500* 20%

Outpatient Facility

Preventive* $0* $0* $0* $0* $0* $0* $0* $0*

Abortion - Elective $100* $100* $150* 50% $150* 50% $150* 20%

Abortion - Non Elective $100* $100* $150* 50% $150* 50% $150* 20%

Cardiology $15* $15* $30* 50% $30* 50% $30* 20%

Chemotherapy $15* $15* $30* 50% $30* 50% $30* 20%

Diagnostic $35* $35* $30* 50% $30* 50% $30* 20%

Dialysis $15* $15* $30* 50% $30* 50% $30* 20%

Emergency Room $100* $100* $100* $100* $100* $100* $100* 20%

Home Health $15* $15* $30* 50% $30* 50% $30* 20%

Hospice $15* $15* $30* 50% $30* 50% $30* 20%

Infusion Therapy $15* $15* $30* 50% $30* 50% $30* 20%

Laboratory Tests $35* $35* $0* 50% $0* 50% $0* 20%

Mental Health / Substance Abuse $15* $15* $30* 50% $30* 50% $30* 20%

Outpatient Surgery $100* $100* $150* 50% $150* 50% $150* 20%

Pre-Admission Testing $0* $0* $0* 50% $0* 50% $0* 20%

PT / OT / ST $25* $25* $20* 50% $20* 50% $20* 20%

Radiation Therapy $15* $15* $30* 50% $30* 50% $30* 20%

Radiology $35* $35* $30* 50% $30* 50% $30* 20%

Radiology - Advanced $35* $35* $30* 50% $30* 50% $30* 20%

Urgent Care $55* $55* $40* $40 $40* $40 $40* 20%

Other $35* $35* $30* 50% $30* 50% $30* 20%







Metal Platinum Platinum Platinum Platinum Platinum Platinum Platinum Platinum

Plan Platinum Standard Platinum Make Available Platinum align Platinum align Platinum focus Platinum focus Platinum HMO 110 Plus Platinum PPO 843

Professional

Preventive* $0* $0* $0* $0* $0* $0* $0* $0*

Office/Home Visit - PCP $15* $15* $20* 50% $20* 50% $20* 20%

Office/Home Visit - SCP $35* $35* $30* 50% $30* 50% $30* 20%

Advanced Radiology $35* $35* $30* 50% $30* 50% $30* 20%

Allergy Shots $25* $25* $25* 50% $25* 50% $25* 20%

Allergy Tests $25* $25* $25* 50% $25* 50% $25* 20%

Ambulance $100* $100* $100* $100* $100* $100* $100* 20%

Anesthesia $0* $0* $0* 50% $0* 50% $0* 20%

Cardiovascular $15* $15* $30* 50% $30* 50% $30* 20%

Chemotherapy $15* $15* $30* 50% $30* 50% $30* 20%

Chiropractic $35* $35* $20* 50% $20* 50% $20* 20%

Consults $25* $25* $25* 50% $25* 50% $25* 20%

Diabetic Drugs/Supplies $15* $15* $20* 50% $20* 50% $20* 20%

Diabetic Education $15* $15* $20* 50% $20* 50% $20* 20%

Dialysis $15* $15* $30* 50% $30* 50% $30* 20%

DME and Supplies 10%* 10%* 50%* 50% 50%* 50% 50%* 20%

Facility Visits $0* $0* $0* 50% $0* 50% $0* 20%

Hearing Aid 10%* 10%* 50%* 50% 50%* 50% 50%* 20%

Hearing Exam $35* $35* $30* 50% $30* 50% $30* 20%

Home Care $15* $15* $25* 50% $25* 50% $25* 20%

Maternity $15* $15* $20* 50% $20* 50% $20* 20%

Mental Health $35* $35* $30* 50% $30* 50% $30* 20%

Office-Administered Drugs $25* $25* $25* 50% $25* 50% $25* 20%

Pathology / Laboratory $35* $35* $0* 50% $0* 50% $0* 20%

Prosthetics & Orthotics 10%* 10%* 50%* 50% 50%* 50% 50%* 20%

PT/OT/ST $25* $25* $20* 50% $20* 50% $20* 20%

Radiation Therapy $15* $15* $30* 50% $30* 50% $30* 20%

Radiology $35* $35* $30* 50% $30* 50% $30* 20%

Substance Abuse $35* $35* $30* 50% $30* 50% $30* 20%

Surgery - Facility (IP) $0* $0* $0* 50% $0* 50% $0* 20%

Surgery - Facility (OP) $100* $100* $30* 50% $30* 50% $30* 20%

Surgery - Office $25* $25* $25* 50% $25* 50% $25* 20%

Vision - Exam $15* $15* $30* 50% $30* 50% $30* 20%

Vision - Lenses & Frames 10%* 10%* 10%* 50% 10%* 50% 10%* 20%

Other $35* $35* $30* 50% $30* 50% $30* 20%

Drug

Generic $10* $10* $5* $5* $5* $5* $5* $10

Brand $30* $30* $30* $30* $30* $30* $30* $30

Non Formulary $60* $60* 50%* 50%* 50%* 50%* 50%* 50%

Supplies 10%* 10%* $0* 50%* $0* 50%* $0* 20%

Out of Network

First Dollar $0 $0 $0 $0 $0 $0 $0 $0

Deductible (single) $5,000 $5,000 $5,000 $5,000 $5,000 $5,000 $5,000 $5,000

Coinsurance (Member) 50% 20% 50% 50% 50% 50% 50% 50%


*Deductible does not apply.

Deductible applies to all non-Rx services on all plans (except preventive or other indicated services).

Deductible applies to Rx where specified.

**2 Free PCP visits included

Region #2 plans have the varying cost sharing based on whether a member uses the tier 1 or tier 2 medical provider.

There are no pediatric dental benefits on the above plans.

Non-single deductible and OOP Maximum are at 2X single amounts.



Metal

Plan

Region

Standard/ NonStandard

Availability (On / Off)

AV

First Dollar

Deductible (single)

OOP Maximum (single)

Deductible Applies to Rx

Embedded Deductible

Inpatient Hospital

ASA Rehab

Detox

Maternity

Med/Surg

Mental Health

Newborn

Residential Care

SNF

Outpatient Facility

Preventive*

Abortion - Elective

Abortion - Non Elective

Cardiology

Chemotherapy

Diagnostic

Dialysis

Emergency Room

Home Health

Hospice

Infusion Therapy

Laboratory Tests

Mental Health / Substance Abuse

Outpatient Surgery

Pre-Admission Testing

PT / OT / ST

Radiation Therapy

Radiology

Radiology - Advanced

Urgent Care

Other

HealthNow New York Inc. HealthNow New York Inc.

2018 New York State Exchange Rate Submission 2018 New York State Exchange Rate Submission

Rate Manual - Page 11 Rate Manual - Page 12

Rates Effective 1/1/2018 Rates Effective 1/1/2018

Gold Gold Gold Gold Gold Gold Gold Gold Gold

Gold Standard Gold Healthy NY Gold Aqua Gold Complete Gold align Gold align Gold focus Gold focus Gold POS 7100

Region #2 Region #2 Region #2 Region #2 Region #2 Region #2 Region #2 Region #2 Region #2

Standard Standard Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard

Both Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange

82% 82% 82% 78% 76% 76% 76% 76% 76%

$0 $0 $500 $0 $0 $0 $0 $0 $0

$600 $600 $1,010 $2,500 $1,350 $1,350 $1,350 $1,350 $1,350

$4,000 $4,000 $7,350 $2,500 $3,900 $3,900 $3,900 $3,900 $3,900

No No No Yes Yes Yes Yes Yes Yes

Yes Yes Yes No No No No No No

$1000 $1000 25%* $0 $500 50% $500 50% $500

$1000 $1000 25%* $0 $500 50% $500 50% $500

$1000 $1000 25%* $0 $500 50% $500 50% $500

$1000 $1000 25%* $0 $500 50% $500 50% $500

$1000 $1000 25%* $0 $500 50% $500 50% $500

$1000 $1000 25%* $0 $500 50% $500 50% $500

$1000 $1000 25%* $0 $500 50% $500 50% $500

$1000 $1000 25%* $0 $500 50% $500 50% $500

$0* $0* $0* $0* $0* $0* $0* $0* $0*

$100 $100 25% $0 $150 50% $150 50% $150

$100 $100 25% $0 $150 50% $150 50% $150

$25 $25 25% $0 $40 50% $40 50% $40

$25 $25 25% $0 $40 50% $40 50% $40

$40 $40 25% $0 $40 50% $40 50% $40

$25 $25 25% $0 $40 50% $40 50% $40

$150 $150 25% $0 $150 $150 $150 $150 $150

$25 $25 25% $0 $40 50% $40 50% $40

$25 $25 25% $0 $40 50% $40 50% $40

$25 $25 25% $0 $40 50% $40 50% $40

$40 $40 25% $0 $40 50% $40 50% $40

$25 $25 25% $0 $40 50% $40 50% $40

$100 $100 25% $0 $150 50% $150 50% $150

$0 $0 25% $0 $0 50% $0 50% $0

$30 $30 25% $0 $20 50% $20 50% $20

$25 $25 25% $0 $40 50% $40 50% $40

$40 $40 25% $0 $40 50% $40 50% $40

$40 $40 25% $0 $40 50% $40 50% $40

$60 $60 25% $0 $75 $75 $75 $75 $75

$40 $40 25% $0 $40 50% $40 50% $40



Metal

Plan

Professional

Preventive*

Office/Home Visit - PCP

Office/Home Visit - SCP

Advanced Radiology

Allergy Shots

Allergy Tests

Ambulance

Anesthesia

Cardiovascular

Chemotherapy

Chiropractic

Consults

Diabetic Drugs/Supplies

Diabetic Education

Dialysis

DME and Supplies

Facility Visits

Hearing Aid

Hearing Exam

Home Care

Maternity

Mental Health

Office-Administered Drugs

Pathology / Laboratory

Prosthetics & Orthotics

PT/OT/ST

Radiation Therapy

Radiology

Substance Abuse

Surgery - Facility (IP)

Surgery - Facility (OP)

Surgery - Office

Vision - Exam

Vision - Lenses & Frames

Other

Drug

Generic

Brand

Non Formulary

Supplies

Out of Network

First Dollar

Deductible (single)

Coinsurance (Member)






Gold Gold Gold Gold Gold Gold Gold Gold Gold

Gold Standard Gold Healthy NY Gold Aqua Gold Complete Gold align Gold align Gold focus Gold focus Gold POS 7100

$0* $0* $0* $0* $0* $0* $0* $0* $0*

$25 $25 25% $0 $20 50% $20 50% $20

$40 $40 25% $0 $40 50% $40 50% $40

$40 $40 25% $0 $40 50% $40 50% $40

$32.5 $32.5 25% $0 $30 50% $30 50% $30

$32.5 $32.5 25% $0 $30 50% $30 50% $30

$150 $150 25% $0 $150 $150 $150 $150 $150

$0* $0* 25% $0 $0 50% $0 50% $0

$25 $25 25% $0 $40 50% $40 50% $40

$25 $25 25% $0 $40 50% $40 50% $40

$40 $40 25% $0 $20 50% $20 50% $20

$32.5 $32.5 25% $0 $30 50% $30 50% $30

$25 $25 $15* $0 $20 50% $20 50% $20

$25 $25 25% $0 $20 50% $20 50% $20

$25 $25 25% $0 $40 50% $40 50% $40

20% 20% 25% $0 50% 50% 50% 50% 50%

$0 $0 25% $0 $0 50% $0 50% $0

20% 20% 25% $0 50% 50% 50% 50% 50%

$40 $40 25% $0 $40 50% $40 50% $40

$25 $25 25% $0 $30 50% $30 50% $30

$25 $25 25% $0 $20 50% $20 50% $20

$40 $40 25% $0 $40 50% $40 50% $40

$32.5 $32.5 25% $0 $30 50% $30 50% $30

$40 $40 25% $0 $40 50% $40 50% $40

20% 20% 25% $0 50% 50% 50% 50% 50%

$30 $30 25% $0 $20 50% $20 50% $20

$25 $25 25% $0 $40 50% $40 50% $40

$40 $40 25% $0 $40 50% $40 50% $40

$40 $40 25% $0 $40 50% $40 50% $40

$0 $0 25% $0 $0 50% $0 50% $0

$100 $100 25% $0 $40 50% $40 50% $40

$32.5 $32.5 25% $0 $30 50% $30 50% $30

$25 $25 25% $0 $40 50% $40 50% $40

20% 20% 25% $0 20% 50% 20% 50% 20%

$40 $40 25% $0 $40 50% $40 50% $40

$10* $10* $15* $0 $5 $5 $5 $5 $5

$35* $35* $50* $0 $30 $30 $30 $30 $30

$70* $70* 50%* $0 50% 50% 50% 50% 50%

20%* 20%* 25%* $0* $0* 50%* $0* 50%* $0*

$0 $0 $500 $0 $0 $0 $0 $0 $0

$5,000 N/A $5,000 $5,000 $5,000 $5,000 $5,000 $5,000 $5,000

50% N/A 50% 50% 50% 50% 50% 50% 50%

$10,000 N/A $10,000 $10,000 $10,000 $10,000 $10,000 $10,000 $10,000



Metal

Plan

Region



AV

First Dollar

Deductible (single)



Embedded Deductible

Inpatient Hospital

ASA Rehab

Detox

Maternity

Med/Surg

Mental Health

Newborn

Residential Care

SNF

Outpatient Facility

Preventive*

Abortion - Elective


Cardiology

Chemotherapy

Diagnostic

Dialysis

Emergency Room

Home Health

Hospice

Infusion Therapy

Laboratory Tests


Outpatient Surgery


PT / OT / ST

Radiation Therapy

Radiology


Urgent Care

Other





Gold Gold Silver Silver Silver Silver Silver Silver Silver

Gold POS 7100EX Gold PPO 7100 Silver Standard Silver align Silver align Silver focus Silver focus Silver POS 7100 Silver POS 7100 EX


Non-Standard Non-Standard Standard Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard

Off Exchange Off Exchange Both Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange

76% 76% 72% 72% 72% 72% 72% 70% 70%

$0 $0 $0 $0 $0 $0 $0 $0 $0

$1,350 $1,350 $2,000 $1,350 $5,000 $1,350 $5,000 $1,700 $1,700

$3,900 $3,900 $6,750 $6,650 $6,650 $6,650 $6,650 $6,500 $6,500

Yes Yes No Yes Yes Yes Yes Yes Yes

No No Yes No No No No No No

$500 $500 $1500 30% 50% 30% 50% $750 $750

$500 $500 $1500 30% 50% 30% 50% $750 $750

$500 $500 $1500 30% 50% 30% 50% $750 $750

$500 $500 $1500 30% 50% 30% 50% $750 $750

$500 $500 $1500 30% 50% 30% 50% $750 $750

$500 $500 $1500 30% 50% 30% 50% $750 $750

$500 $500 $1500 30% 50% 30% 50% $750 $750

$500 $500 $1500 30% 50% 30% 50% $750 $750

$0* $0* $0* $0* $0* $0* $0* $0* $0*

$150 $150 $100 30% 50% 30% 50% $150 $150

$150 $150 $100 30% 50% 30% 50% $150 $150

$40 $40 $30 30% 50% 30% 50% $50 $50

$40 $40 $30 30% 50% 30% 50% $50 $50

$40 $40 $50 30% 50% 30% 50% $50 $50

$40 $40 $30 30% 50% 30% 50% $50 $50

$150 $150 $250 30% 30% 30% 30% $250 $250

$40 $40 $30 $50 50% $50 50% $50 $50

$40 $40 $30 30% 50% 30% 50% $50 $50

$40 $40 $30 30% 50% 30% 50% $50 $50

$40 $40 $50 30% 50% 30% 50% $50 $50

$40 $40 $30 $0* 50% $0* 50% $50 $50

$150 $150 $100 30% 50% 30% 50% $150 $150

$0 $0 $0 30% 50% 30% 50% $0 $0

$20 $20 $30 $30 50% $30 50% $25 $25

$40 $40 $30 30% 50% 30% 50% $50 $50

$40 $40 $50 30% 50% 30% 50% $50 $50

$40 $40 $50 30% 50% 30% 50% $50 $50

$75 $75 $70 30% 50% 30% 50% $75 $75

$40 $40 $50 $50 50% $50 50% $50 $50



Metal

Plan

Professional

Preventive*



Advanced Radiology

Allergy Shots

Allergy Tests

Ambulance

Anesthesia

Cardiovascular

Chemotherapy

Chiropractic

Consults


Diabetic Education

Dialysis

DME and Supplies

Facility Visits

Hearing Aid

Hearing Exam

Home Care

Maternity

Mental Health




PT/OT/ST

Radiation Therapy

Radiology

Substance Abuse



Surgery - Office

Vision - Exam


Other

Drug

Generic

Brand

Non Formulary

Supplies

Out of Network

First Dollar

Deductible (single)







Gold Gold Silver Silver Silver Silver Silver Silver Silver

Gold POS 7100EX Gold PPO 7100 Silver Standard Silver align Silver align Silver focus Silver focus Silver POS 7100 Silver POS 7100 EX

$0* $0* $0* $0* $0* $0* $0* $0* $0*

$20 $20 $30 $30 50% $30 50% $25 $25

$40 $40 $50 $50 50% $50 50% $50 $50

$40 $40 $50 30% 50% 30% 50% $50 $50

$30 $30 $40 $40 50% $40 50% $37.5 $37.5

$30 $30 $40 $40 50% $40 50% $37.5 $37.5

$150 $150 $150 30% 50% 30% 50% $250 $250

$0 $0 $0* 30% 50% 30% 50% $0 $0

$40 $40 $30 $50 50% $50 50% $50 $50

$40 $40 $30 $50 50% $50 50% $50 $50

$20 $20 $50 $30 50% $30 50% $25 $25

$30 $30 $40 $40 50% $40 50% $37.5 $37.5

$20 $20 $30 $30 50% $30 50% $25 $25

$20 $20 $30 $30 50% $30 50% $25 $25

$40 $40 $30 $50 50% $50 50% $50 $50

50% 50% 30% 30% 50% 30% 50% 50% 50%

$0 $0 $0 30% 50% 30% 50% $0 $0

50% 50% 30% 30% 50% 30% 50% 50% 50%

$40 $40 $50 $50 50% $50 50% $50 $50

$30 $30 $30 $40 50% $40 50% $37.5 $37.5

$20 $20 $30 $30 50% $30 50% $25 $25

$40 $40 $50 $0* $0* $0* $0* $50 $50

$30 $30 $40 $50 50% $50 50% $37.5 $37.5

$40 $40 $50 30% 50% 30% 50% $50 $50

50% 50% 30% 30% 50% 30% 50% 50% 50%

$20 $20 $30 $30 50% $30 50% $25 $25

$40 $40 $30 $50 50% $50 50% $50 $50

$40 $40 $50 30% 50% 30% 50% $50 $50

$40 $40 $50 $0* $0* $0* $0* $50 $50

$0 $0 $0 30% 50% 30% 50% $0 $0

$40 $40 $100 30% 50% 30% 50% $50 $50

$30 $30 $40 $40 50% $40 50% $37.5 $37.5

$40 $40 $30 $50 50% $50 50% $50 $50

20% 20% 30% 30% 50% 30% 50% 30% 30%

$40 $40 $50 $50 50% $50 50% $50 $50

$5 $5 $10* $5 $5 $5 $5 $5 $5

$30 $30 $35* $30 $30 $30 $30 $30 $30

50% 50% $70* 50% 50% 50% 50% 50% 50%

$0* $0* 30%* 30%* 50%* 30%* 50%* $0* $0*

$0 $0 $0 $0 $0 $0 $0 $0 $0

$5,000 $5,000 $5,000 $5,000 $5,000 $5,000 $5,000 $5,000 $5,000

50% 50% 50% 50% 50% 50% 50% 50% 50%

$10,000 $10,000 $10,000 $10,000 $10,000 $10,000 $10,000 $10,000 $10,000



Metal

Plan

Region



AV

First Dollar

Deductible (single)



Embedded Deductible

Inpatient Hospital

ASA Rehab

Detox

Maternity

Med/Surg

Mental Health

Newborn

Residential Care

SNF

Outpatient Facility

Preventive*

Abortion - Elective


Cardiology

Chemotherapy

Diagnostic

Dialysis

Emergency Room

Home Health

Hospice

Infusion Therapy

Laboratory Tests


Outpatient Surgery


PT / OT / ST

Radiation Therapy

Radiology


Urgent Care

Other





Silver Silver Silver Silver Bronze Bronze Bronze Bronze Bronze

Silver PPO 7100 Silver POS 8100 Silver POS 8100EX Silver PPO 8100 Bronze Standard Bronze POS 8100EX Bronze PPO 8100 Bronze align Bronze align


Non-Standard Non-Standard Non-Standard Non-Standard Standard Non-Standard Non-Standard Non-Standard Non-Standard

Off Exchange Off Exchange Off Exchange Off Exchange Both Off Exchange Off Exchange Off Exchange Off Exchange

70% 70% 70% 70% 62% 61% 61% 59% 59%

$0 $0 $0 $0 $0 $0 $0 $0 $0

$1,700 $2,900 $2,900 $2,900 $4,000 $5,500 $5,500 $7,000 $7,350

$6,500 $6,650 $6,650 $6,650 $7,150 $6,550 $6,550 $7,350 $7,350

Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No Yes Yes Yes Yes Yes

$750 $1000 $1000 $1000 50% 20% 20% 50% $0

$750 $1000 $1000 $1000 50% 20% 20% 50% $0

$750 $1000 $1000 $1000 50% 20% 20% 50% $0

$750 $1000 $1000 $1000 50% 20% 20% 50% $0

$750 $1000 $1000 $1000 50% 20% 20% 50% $0

$750 $1000 $1000 $1000 50% 20% 20% 50% $0

$750 $1000 $1000 $1000 50% 20% 20% 50% $0

$750 $1000 $1000 $1000 50% 20% 20% 50% $0

$0* $0* $0* $0* $0* $0* $0* $0* $0*

$150 20% 20% 20% 50% 20% 20% 50% $0

$150 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$250 20% 20% 20% 50% 20% 20% 50% 50%

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$150 20% 20% 20% 50% 20% 20% 50% $0

$0 20% 20% 20% 50% 20% 20% 50% $0

$25 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$75 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0



Metal

Plan

Professional

Preventive*



Advanced Radiology

Allergy Shots

Allergy Tests

Ambulance

Anesthesia

Cardiovascular

Chemotherapy

Chiropractic

Consults


Diabetic Education

Dialysis

DME and Supplies

Facility Visits

Hearing Aid

Hearing Exam

Home Care

Maternity

Mental Health




PT/OT/ST

Radiation Therapy

Radiology

Substance Abuse



Surgery - Office

Vision - Exam


Other

Drug

Generic

Brand

Non Formulary

Supplies

Out of Network

First Dollar

Deductible (single)







Silver Silver Silver Silver Bronze Bronze Bronze Bronze Bronze

Silver PPO 7100 Silver POS 8100 Silver POS 8100EX Silver PPO 8100 Bronze Standard Bronze POS 8100EX Bronze PPO 8100 Bronze align Bronze align

$0* $0* $0* $0* $0* $0* $0* $0* $0*

$25 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$37.5 20% 20% 20% 50% 20% 20% 50% $0

$37.5 20% 20% 20% 50% 20% 20% 50% $0

$250 20% 20% 20% 50% 20% 20% 50% 50%

$0 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$25 20% 20% 20% 50% 20% 20% 50% $0

$37.5 20% 20% 20% 50% 20% 20% 50% $0

$25 20% 20% 20% 50% 20% 20% 50% $0

$25 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

50% 20% 20% 20% 50% 20% 20% 50% $0

$0 20% 20% 20% 50% 20% 20% 50% $0

50% 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$37.5 20% 20% 20% 50% 20% 20% 50% $0

$25 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$37.5 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

50% 20% 20% 20% 50% 20% 20% 50% $0

$25 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$0 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$37.5 20% 20% 20% 50% 20% 20% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

30% 30% 30% 30% 50% 30% 30% 50% $0

$50 20% 20% 20% 50% 20% 20% 50% $0

$5 $5 $5 $5 $10 $15 $15 $10 $10

$30 $30 $30 $30 $35 $50 $50 50% 50%

50% 50% 50% 50% $70 50% 50% 50% 50%

$0* 20%* 20%* 20%* 50%* 20%* 20%* 50%* $0*

$0 $0 $0 $0 $0 $0 $0 $0 $0

$5,000 $5,000 $5,000 $5,000 $5,000 $5,500 $5,500 $7,350 $7,350

50% 50% 50% 50% 50% 50% 50% 50% 50%

$10,000 $10,000 $10,000 $10,000 $10,000 $10,000 $10,000 $10,000 $10,000



Metal

Plan

Region



AV

First Dollar

Deductible (single)



Embedded Deductible

Inpatient Hospital

ASA Rehab

Detox

Maternity

Med/Surg

Mental Health

Newborn

Residential Care

SNF

Outpatient Facility

Preventive*

Abortion - Elective


Cardiology

Chemotherapy

Diagnostic

Dialysis

Emergency Room

Home Health

Hospice

Infusion Therapy

Laboratory Tests


Outpatient Surgery


PT / OT / ST

Radiation Therapy

Radiology


Urgent Care

Other





Bronze Bronze

Bronze focus Bronze focus

Region #2 Region #2

Non-Standard Non-Standard

Off Exchange Off Exchange

59% 59%

$0 $0

$7,000 $7,350

$7,350 $7,350

Yes Yes

Yes Yes

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

$0* $0*

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% 50%

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0



Metal

Plan

Professional

Preventive*



Advanced Radiology

Allergy Shots

Allergy Tests

Ambulance

Anesthesia

Cardiovascular

Chemotherapy

Chiropractic

Consults


Diabetic Education

Dialysis

DME and Supplies

Facility Visits

Hearing Aid

Hearing Exam

Home Care

Maternity

Mental Health




PT/OT/ST

Radiation Therapy

Radiology

Substance Abuse



Surgery - Office

Vision - Exam


Other

Drug

Generic

Brand

Non Formulary

Supplies

Out of Network

First Dollar

Deductible (single)







Bronze Bronze

Bronze focus Bronze focus

$0* $0*

50% $0

50% $0

50% $0

50% $0

50% $0

50% 50%

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

50% $0

$10 $10

50% 50%

50% 50%

50%* $0*

$0 $0

$7,350 $7,350

50% 50%

$10,000 $10,000





Benefit Summary - Group Plans Region #1 and #7:

Available in group market for Region #1 and #7 or subset of these regions (see region definition).

Metal Platinum Platinum Platinum Platinum Platinum Gold Gold Gold

Plan Platinum Standard Platinum PPO Platinum Make Available Platinum EX Platinum Radius Gold Standard Gold Healthy NY Gold EPO high

Region Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7

Standard/ NonStandard Standard Non-Standard Standard Non-Standard Non-Standard Standard Standard Non-Standard

Availability Both Off Exchange Both Off Exchange Off Exchange Both Off Exchange Off Exchange

AV 90% 87% 90% 87% 87% 82% 82% 82%

First Dollar $0 $0 $0 $0 $0 $0 $0 $0

Deductible (single) $0 $0 $0 $0 $0 $600 $600 $0


Deductible Applies to Rx No No No No No No No No

Embedded Deductible Yes Yes Yes Yes Yes Yes Yes Yes

Inpatient Hospital

ASA Rehab $500* $250* $500* $250* $250* $1000 $1000 $500*

Detox $500* $250* $500* $250* $250* $1000 $1000 $500*

Maternity $500* $250* $500* $250* $250* $1000 $1000 $500*

Med/Surg $500* $250* $500* $250* $250* $1000 $1000 $500*

Mental Health $500* $250* $500* $250* $250* $1000 $1000 $500*

Newborn $500* $250* $500* $250* $250* $1000 $1000 $500*

Residential Care $500* $250* $500* $250* $250* $1000 $1000 $500*

SNF $500* $250* $500* $250* $250* $1000 $1000 $500*

Outpatient Facility

Preventive* $0* $0* $0* $0* $0* $0* $0* $0*

Abortion - Elective $100* $100* $100* $100* $100* $100 $100 $200*

Abortion - Non Elective $100* $100* $100* $100* $100* $100 $100 $200*

Cardiology $15* $20* $15* $20* $20* $25 $25 $40*

Chemotherapy $15* $20* $15* $20* $20* $25 $25 $40*

Diagnostic $35* $20* $35* $20* $20* $40 $40 $40*

Dialysis $15* $20* $15* $20* $20* $25 $25 $40*

Emergency Room $100* $100* $100* $100* $100* $150 $150 $100*

Home Health $15* $20* $15* $20* $20* $25 $25 $40*

Hospice $15* $20* $15* $20* $20* $25 $25 $40*

Infusion Therapy $15* $20* $15* $20* $20* $25 $25 $40*

Laboratory Tests $35* $15* $35* $15* $15* $40 $40 $25*

Mental Health / Substance Abuse $15* $20* $15* $20* $20* $25 $25 $40*

Outpatient Surgery $100* $100* $100* $100* $100* $100 $100 $200*

Pre-Admission Testing $0* $0* $0* $0* $0* $0 $0 $0*

PT / OT / ST $25* $15* $25* $15* $15* $30 $30 $25*

Radiation Therapy $15* $20* $15* $20* $20* $25 $25 $40*

Radiology $35* $20* $35* $20* $20* $40 $40 $40*

Radiology - Advanced $35* $20* $35* $20* $20* $40 $40 $40*

Urgent Care $55* $50* $55* $50* $50* $60 $60 $75*

Other $35* $20* $35* $20* $20* $40 $40 $40*







Metal Platinum Platinum Platinum Platinum Platinum Gold Gold Gold

Plan Platinum Standard Platinum PPO Platinum Make Available Platinum EX Platinum Radius Gold Standard Gold Healthy NY Gold EPO high

Professional

Preventive* $0* $0* $0* $0* $0* $0* $0* $0*

Office/Home Visit - PCP $15* $15* $15* $15* $15* $25 $25 $25*

Office/Home Visit - SCP $35* $20* $35* $20* $20* $40 $40 $40*

Advanced Radiology $35* $20* $35* $20* $20* $40 $40 $40*

Allergy Shots $25* $17.5* $25* $17.5* $17.5* $32.5 $32.5 $32.5*

Allergy Tests $25* $17.5* $25* $17.5* $17.5* $32.5 $32.5 $32.5*

Ambulance $100* $100* $100* $100* $100* $150 $150 $100*

Anesthesia $0* $0* $0* $0* $0* $0* $0* $0*

Cardiovascular $15* $20* $15* $20* $20* $25 $25 $40*

Chemotherapy $15* $20* $15* $20* $20* $25 $25 $40*

Chiropractic $35* $15* $35* $15* $15* $40 $40 $25*

Consults $25* $17.5* $25* $17.5* $17.5* $32.5 $32.5 $32.5*

Diabetic Drugs/Supplies $15* $15* $15* $15* $15* $25 $25 $25*

Diabetic Education $15* $15* $15* $15* $15* $25 $25 $25*

Dialysis $15* $20* $15* $20* $20* $25 $25 $40*

DME and Supplies 10%* 50%* 10%* 50%* 50%* 20% 20% 50%*

Facility Visits $0* $0* $0* $0* $0* $0 $0 $0*

Hearing Aid 10%* 50%* 10%* 50%* 50%* 20% 20% 50%*

Hearing Exam $35* $20* $35* $20* $20* $40 $40 $40*

Home Care $15* $17.5* $15* $17.5* $17.5* $25 $25 $32.5*

Maternity $15* $15* $15* $15* $15* $25 $25 $25*

Mental Health $35* $20* $35* $20* $20* $40 $40 $40*

Office-Administered Drugs $25* $17.5* $25* $17.5* $17.5* $32.5 $32.5 $32.5*

Pathology / Laboratory $35* $15* $35* $15* $15* $40 $40 $25*

Prosthetics & Orthotics 10%* 50%* 10%* 50%* 50%* 20% 20% 50%*

PT/OT/ST $25* $15* $25* $15* $15* $30 $30 $25*

Radiation Therapy $15* $20* $15* $20* $20* $25 $25 $40*

Radiology $35* $20* $35* $20* $20* $40 $40 $40*

Substance Abuse $35* $20* $35* $20* $20* $40 $40 $40*

Surgery - Facility (IP) $0* $0* $0* $0* $0* $0 $0 $0*

Surgery - Facility (OP) $100* $20* $100* $20* $20* $100 $100 $40*

Surgery - Office $25* $17.5* $25* $17.5* $17.5* $32.5 $32.5 $32.5*

Vision - Exam $15* $20* $15* $20* $20* $25 $25 $40*

Vision - Lenses & Frames 10%* 10%* 10%* 10%* 10%* 20% 20% 10%*

Other $35* $20* $35* $20* $20* $40 $40 $40*

Drug

Generic $10* $10* $10* $10* $10* $10* $10* $4*

Brand $30* $35* $30* $35* $35* $35* $35* $35*

Non Formulary $60* $70* $60* $70* $70* $70* $70* $70*

Supplies 10%* 50%* 10%* 50%* 50%* 20%* 20%* 50%*

Out of Network

First Dollar $0 $0 $0 $0 $0 $0 $0 $0

Deductible (single) $5,000 $2,000 $5,000 $2,000 $1,000 $5,000 N/A $0

Coinsurance (Member) 50% 20% 20% 20% 20% 50% N/A 0%

OOP Maximum (single) $10,000 $10,000 $10,000 $10,000 $10,000 $10,000 N/A $0

*Deductible does not apply.

Deductible applies to all non-Rx services on all plans (except preventive or other indicated services).

Deductible applies to Rx where specified.

**2 Free PCP visits included

Region #2 plans have the varying cost sharing based on whether a member uses the tier 1 or tier 2 medical provider.

There are no pediatric dental benefits on the above plans.

Non-single deductible and OOP Maximum are at 2X single amounts.



Metal

Plan

Region


Availability

AV

First Dollar

Deductible (single)



Embedded Deductible

Inpatient Hospital

ASA Rehab

Detox

Maternity

Med/Surg

Mental Health

Newborn

Residential Care

SNF

Outpatient Facility

Preventive*

Abortion - Elective


Cardiology

Chemotherapy

Diagnostic

Dialysis

Emergency Room

Home Health

Hospice

Infusion Therapy

Laboratory Tests


Outpatient Surgery


PT / OT / ST

Radiation Therapy

Radiology


Urgent Care

Other





Gold Gold Gold Gold Gold Gold Gold Silver Silver

Gold Radius high Gold EX high Gold HMO Gold PPO Gold EPO Gold Radius Gold EX Silver Standard Silver EPO 6300

Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7

Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard Standard Non-Standard

Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange Both Off Exchange

82% 82% 81% 82% 82% 82% 82% 72% 69%

$0 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $500 $500 $500 $500 $2,000 $1,350

$6,600 $6,600 $6,600 $7,200 $7,200 $7,200 $7,200 $6,750 $5,000

No No No No No No No No Yes

Yes Yes Yes Yes Yes Yes Yes Yes No

$750* $500* $500* 20% 20% 20% 20% $1500 $500

$750* $500* $500* 20% 20% 20% 20% $1500 $500

$750* $500* $500* 20% 20% 20% 20% $1500 $500

$750* $500* $500* 20% 20% 20% 20% $1500 $500

$750* $500* $500* 20% 20% 20% 20% $1500 $500

$750* $500* $500* 20% 20% 20% 20% $1500 $500

$750* $500* $500* 20% 20% 20% 20% $1500 $500

$750* $500* $500* 20% 20% 20% 20% $1500 $500

$0* $0* $0* $0* $0* $0* $0* $0* $0*

$200* $200* $200* 20% 20% 20% 20% $100 $250

$200* $200* $200* 20% 20% 20% 20% $100 $250

$40* $40* $40* $25* $25* $25* $25* $30 $40

$40* $40* $40* $25* $25* $25* $25* $30 $40

$40* $40* $40* 20% 20% 20% 20% $50 $40

$40* $40* $40* $25* $25* $25* $25* $30 $40

$200* $100* $100* $200* $200* $200* $200* $250 $250

$40* $40* $40* $25* $25* $25* $25* $30 $60

$40* $40* $40* $25* $25* $25* $25* $30 $60

$40* $40* $40* $25* $25* $25* $25* $30 $60

$25* $25* $25* $25* $25* $25* $25* $50 $40

$40* $40* $40* $0* $0* $0* $0* $30 $60

$200* $200* $200* 20% 20% 20% 20% $100 $250

$0* $0* $0* 20% 20% 20% 20% $0 $0

$25* $25* $25* $25* $25* $25* $25* $30 $40

$40* $40* $40* $25* $25* $25* $25* $30 $60

$40* $40* $40* 20% 20% 20% 20% $50 $60

$40* $40* $100* 20% 20% 20% 20% $50 $60

$75* $75* $75* $100* $100* $100* $100* $70 $75

$40* $40* $40* $50* $50* $50* $50* $50 $60



Metal

Plan

Professional

Preventive*



Advanced Radiology

Allergy Shots

Allergy Tests

Ambulance

Anesthesia

Cardiovascular

Chemotherapy

Chiropractic

Consults


Diabetic Education

Dialysis

DME and Supplies

Facility Visits

Hearing Aid

Hearing Exam

Home Care

Maternity

Mental Health




PT/OT/ST

Radiation Therapy

Radiology

Substance Abuse



Surgery - Office

Vision - Exam


Other

Drug

Generic

Brand

Non Formulary

Supplies

Out of Network

First Dollar

Deductible (single)







Gold Gold Gold Gold Gold Gold Gold Silver Silver

Gold Radius high Gold EX high Gold HMO Gold PPO Gold EPO Gold Radius Gold EX Silver Standard Silver EPO 6300

$0* $0* $0* $0* $0* $0* $0* $0* $0*

$25* $25* $25* $25* $25* $25* $25* $30 $40

$40* $40* $40* $50* $50* $50* $50* $50 $60

$40* $40* $40* 20% 20% 20% 20% $50 $60

$32.5* $32.5* $32.5* $40* $40* $40* $40* $40 $50

$32.5* $32.5* $32.5* $40* $40* $40* $40* $40 $50

$200* $100* $100* $200* $200* $200* $200* $150 $250

$0* $0* $0* 20% 20% 20% 20% $0* $0

$40* $40* $40* $50* $50* $50* $50* $30 $60

$40* $40* $40* $50* $50* $50* $50* $30 $60

$25* $25* $25* $25* $25* $25* $25* $50 $40

$32.5* $32.5* $32.5* $40* $40* $40* $40* $40 $32.5

$25* $25* $25* $25* $25* $25* $25* $30 $40

$25* $25* $25* $25* $25* $25* $25* $30 $40

$40* $40* $40* $25* $25* $25* $25* $30 $40

50%* 50%* 50%* 20% 20% 20% 20% 30% 50%

$0* $0* $0* 20% 20% 20% 20% $0 $0

50%* 50%* 50%* 20% 20% 20% 20% 30% 50%

$40* $40* $40* $50* $50* $50* $50* $50 $60

$32.5* $32.5* $32.5* $25* $25* $25* $25* $30 $60

$25* $25* $25* $25* $25* $25* $25* $30 $40

$40* $40* $40* $50* $50* $50* $50* $50 $60

$32.5* $32.5* $32.5* $40* $40* $40* $40* $40 $50

$25* $25* $25* $25* $25* $25* $25* $50 $40

50%* 50%* 50%* 20% 20% 20% 20% 30% 50%

$25* $25* $25* $25* $25* $25* $25* $30 $40

$40* $40* $40* $25* $25* $25* $25* $30 $60

$40* $40* $40* 20% 20% 20% 20% $50 $60

$40* $40* $40* $50* $50* $50* $50* $50 $60

$0* $0* $0* 20% 20% 20% 20% $0 $0

$40* $40* $40* 20% 20% 20% 20% $100 $60

$32.5* $32.5* $32.5* $40* $40* $40* $40* $40 $40

$40* $40* $40* $25* $25* $25* $25* $30 $60

10%* 10%* 10%* 20% 20% 20% 20% 30% 20%

$40* $40* $40* $50* $50* $50* $50* $50 $60

$4* $4* $4* $4* $4* $4* $4* $10* $4

$35* $35* $35* $35* $35* $35* $35* $35* $35

$70* $70* $70* $70* $70* $70* $70* $70* $70

50%* 50%* 50%* 20% 20% 20% 20% 30%* 50%

$0 $0 $0 $0 $0 $0 $0 $0 $0

$250 $2,000 $5,000 $5,000 $0 $500 $5,000 $5,000 $0

20% 20% 20% 50% 0% 20% 50% 50% 0%

$6,600 $10,000 $10,000 $10,000 $0 $7,200 $10,000 $10,000 $0



Metal

Plan

Region


Availability

AV

First Dollar

Deductible (single)



Embedded Deductible

Inpatient Hospital

ASA Rehab

Detox

Maternity

Med/Surg

Mental Health

Newborn

Residential Care

SNF

Outpatient Facility

Preventive*

Abortion - Elective


Cardiology

Chemotherapy

Diagnostic

Dialysis

Emergency Room

Home Health

Hospice

Infusion Therapy

Laboratory Tests


Outpatient Surgery


PT / OT / ST

Radiation Therapy

Radiology


Urgent Care

Other





Silver Silver Silver Silver Silver Bronze Bronze Bronze

Silver PPO 8000 Silver EPO 8000 Silver EX 8000 Silver POS 8000 Silver POS Hybrid Bronze Standard Bronze EPO 6300 Bronze PPO

Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7 Regions #1 and #7

Non-Standard Non-Standard Non-Standard Non-Standard Non-Standard Standard Non-Standard Non-Standard

Off Exchange Off Exchange Off Exchange Off Exchange Off Exchange Both Off Exchange Off Exchange

72% 72% 72% 72% 69% 62% 62% 60%

$0 $0 $0 $0 $0 $0 $0 $0

$3,250 $3,250 $3,250 $3,250 $6,350 $4,000 $4,500 $6,650

$6,650 $6,650 $6,650 $6,650 $7,350 $7,150 $6,650 $6,650

Yes Yes Yes Yes No Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes Yes

$0 $0 $0 $0 20% 50% $1500 $0

$0 $0 $0 $0 20% 50% $1500 $0

$0 $0 $0 $0 20% 50% $1500 $0

$0 $0 $0 $0 20% 50% $1500 $0

$0 $0 $0 $0 20% 50% $1500 $0

$0 $0 $0 $0 20% 50% $1500 $0

$0 $0 $0 $0 20% 50% $1500 $0

$0 $0 $0 $0 20% 50% $1500 $0

$0* $0* $0* $0* $0* $0* $0* $0*

$0 $0 $0 $0 20% 50% $750 $0

$0 $0 $0 $0 20% 50% $750 $0

$0 $0 $0 $0 $60* 50% $40 $0

$0 $0 $0 $0 $60* 50% $40 $0

$0 $0 $0 $0 20% 50% $40 $0

$0 $0 $0 $0 $60* 50% $40 $0

$0 $0 $0 $0 $750* 50% $750 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 $60* 50% $40 $0

$0 $0 $0 $0 $0* 50% $60 $0

$0 $0 $0 $0 20% 50% $750 $0

$0 $0 $0 $0 20% 50% $0 $0

$0 $0 $0 $0 $40* 50% $40 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 $60 50% $60 $0

$0 $0 $0 $0 $60 50% $60 $0

$0 $0 $0 $0 $100* 50% $75 $0

$0 $0 $0 $0 $60* 50% $60 $0



Metal

Plan

Professional

Preventive*



Advanced Radiology

Allergy Shots

Allergy Tests

Ambulance

Anesthesia

Cardiovascular

Chemotherapy

Chiropractic

Consults


Diabetic Education

Dialysis

DME and Supplies

Facility Visits

Hearing Aid

Hearing Exam

Home Care

Maternity

Mental Health




PT/OT/ST

Radiation Therapy

Radiology

Substance Abuse



Surgery - Office

Vision - Exam


Other

Drug

Generic

Brand

Non Formulary

Supplies

Out of Network

First Dollar

Deductible (single)







Silver Silver Silver Silver Silver Bronze Bronze Bronze

Silver PPO 8000 Silver EPO 8000 Silver EX 8000 Silver POS 8000 Silver POS Hybrid Bronze Standard Bronze EPO 6300 Bronze PPO

$0* $0* $0* $0* $0* $0* $0* $0*

$0 $0 $0 $0 $40* 50% $40 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 $60 50% $60 $0

$0 $0 $0 $0 $60* 50% $50 $0

$0 $0 $0 $0 $60* 50% $50 $0

$0 $0 $0 $0 $750* 50% $750 $0

$0 $0 $0 $0 20% 50% $0 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 $40* 50% $40 $0

$0 $0 $0 $0 $60* 50% $32.5 $0

$0 $0 $0 $0 $40* 50% $40 $0

$0 $0 $0 $0 $40* 50% $40 $0

$0 $0 $0 $0 $60* 50% $40 $0

$0 $0 $0 $0 20% 50% 50% $0

$0 $0 $0 $0 $60 50% $0 $0

$0 $0 $0 $0 20% 50% 50% $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 $40* 50% $40 $0

$0 $0 $0 $0 $0* 50% $60 $0

$0 $0 $0 $0 $60* 50% $50 $0

$0 $0 $0 $0 $25* 50% $40 $0

$0 $0 $0 $0 20% 50% 50% $0

$0 $0 $0 $0 $40* 50% $40 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 20% 50% $60 $0

$0 $0 $0 $0 $0* 50% $60 $0

$0 $0 $0 $0 20% 50% $0 $0

$0 $0 $0 $0 20% 50% $60 $0

$0 $0 $0 $0 $60* 50% $40 $0

$0 $0 $0 $0 $60* 50% $60 $0

$0 $0 $0 $0 20% 50% 20% $0

$0 $0 $0 $0 $60* 50% $60 $0

$4 $4 $4 $4 $4* $10 $10 $0

$35 $35 $35 $35 $50* $35 $50 $0

$70 $70 $70 $70 $100* $70 $100 $0

$0 $0 $0 $0 20% 50%* 50% $0

$0 $0 $0 $0 $0 $0 $0 $0

$5,000 $0 $5,000 $5,000 $5,000 $5,000 $0 $7,000

50% 0% 50% 50% 50% 50% 0% 50%

$10,000 $0 $10,000 $10,000 $10,000 $10,000 $0 $10,000




Small Group Rates Effective Quarter 1 2018:

Policy form CN1C3S0440_0515 applies to all plans offered below. [Group ON version]

Policy form number CG1C4S0469_0515 applies to the Gold Healthy New York plans.

Policy form number CH1C4F0452_0515 applies to HMO plans Platinum HMO 110 Plus in Region 2 and Platinum HMO in Regions 1 and 7.

Policy form number CN1C3S0441_0515 applies to all remaining plans.

All plans do not include pediatric dental coverage.

All rates can be offered with and without domestic partner coverage.

All rates can be offered with and without family planning coverage.

Rates will roll quarterly from the Q1 rates.

Tier Rates Region #2 Effective Q1:

Age Platinum Standard

Platinum Make

Available Platinum align

26 613.55 614.52 559.23

30 616.63 617.59 562.03

26 1,227.10 1,229.04 1,118.46

30 1,233.26 1,235.18 1,124.06

26 1,043.03 1,044.68 950.69

30 1,048.27 1,049.90 955.46

26 1,748.62 1,751.38 1,593.81

30 1,757.39 1,760.13 1,601.78


Age Platinum Standard Platinum PPO

Platinum Make

Available

26 695.38 784.85 696.47

30 698.86 788.77 699.96

26 1,390.76 1,569.70 1,392.94

30 1,397.72 1,577.54 1,399.92

26 1,182.15 1,334.25 1,184.00

30 1,188.06 1,340.91 1,189.93

26 1,981.83 2,236.83 1,984.94

30 1,991.75 2,248.00 1,994.89



Platinum Make

Available

26 840.82 950.29 842.17

30 845.03 955.04 846.38

26 1,681.64 1,900.58 1,684.34

30 1,690.06 1,910.08 1,692.76

26 1,429.40 1,615.49 1,431.69

30 1,436.55 1,623.57 1,438.85

26 2,396.33 2,708.33 2,400.18

30 2,408.33 2,721.86 2,412.18

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single





Platinum focus

559.23

562.03

1,118.46

1,124.06

950.69

955.46

1,593.81

1,601.78

Platinum EX Platinum Radius Gold Standard

725.80 697.21 610.25

729.42 700.69 613.30

1,451.60 1,394.42 1,220.50

1,458.84 1,401.38 1,226.60

1,233.87 1,185.26 1,037.42

1,240.01 1,191.17 1,042.61

2,068.53 1,987.05 1,739.21

2,078.85 1,996.97 1,747.91


878.04 843.07 736.68

882.43 847.28 740.36

1,756.08 1,686.14 1,473.36

1,764.86 1,694.56 1,480.72

1,492.67 1,433.22 1,252.36

1,500.13 1,440.38 1,258.61

2,502.41 2,402.75 2,099.54

2,514.93 2,414.75 2,110.03











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

Platinum HMO 110 Plus Platinum PPO 843 Gold Standard

590.74 700.97 539.14

593.69 704.47 541.83

1,181.48 1,401.94 1,078.28

1,187.38 1,408.94 1,083.66

1,004.26 1,191.65 916.53

1,009.27 1,197.60 921.11

1,683.61 1,997.77 1,536.55

1,692.02 2,007.74 1,544.22

Gold Healthy NY Gold EPO high Gold Radius high

505.83 701.81 642.45

508.36 705.32 645.66

1,011.66 1,403.62 1,284.90

1,016.72 1,410.64 1,291.32

859.91 1,193.08 1,092.17

864.21 1,199.05 1,097.63

1,441.62 2,000.16 1,830.98

1,448.83 2,010.16 1,840.13


608.95 848.70 776.07

611.98 852.94 779.94

1,217.90 1,697.40 1,552.14

1,223.96 1,705.88 1,559.88

1,035.22 1,442.79 1,319.32

1,040.37 1,450.00 1,325.90

1,735.51 2,418.80 2,211.80

1,744.14 2,430.88 2,222.82











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single





Gold Healthy NY Gold Aqua Gold Complete

447.83 476.62 500.87

450.07 478.99 503.37

895.66 953.24 1,001.74

900.14 957.98 1,006.74

761.31 810.25 851.48

765.12 814.28 855.73

1,276.31 1,358.37 1,427.48

1,282.70 1,365.12 1,434.61

Gold EX high Gold HMO Gold PPO

670.68 640.84 664.08

674.03 644.04 667.40

1,341.36 1,281.68 1,328.16

1,348.06 1,288.08 1,334.80

1,140.15 1,089.42 1,128.94

1,145.85 1,094.87 1,134.58

1,911.44 1,826.40 1,892.63

1,920.99 1,835.52 1,902.10


810.61 774.11 802.55

814.66 777.98 806.55

1,621.22 1,548.22 1,605.10

1,629.32 1,555.96 1,613.10

1,378.03 1,315.99 1,364.34

1,384.92 1,322.57 1,371.14

2,310.24 2,206.21 2,287.26

2,321.78 2,217.24 2,298.67











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

Gold align Gold focus

480.56 480.56

482.96 482.96

961.12 961.12

965.92 965.92

816.96 816.96

821.03 821.03

1,369.59 1,369.59

1,376.43 1,376.43

Gold EPO Gold Radius Gold EX

644.48 595.22 614.66

647.70 598.20 617.73

1,288.96 1,190.44 1,229.32

1,295.40 1,196.40 1,235.46

1,095.62 1,011.88 1,044.92

1,101.09 1,016.95 1,050.14

1,836.77 1,696.38 1,751.78

1,845.95 1,704.87 1,760.53


778.57 718.31 742.07

782.45 721.90 745.79

1,557.14 1,436.62 1,484.14

1,564.90 1,443.80 1,491.58

1,323.57 1,221.13 1,261.52

1,330.17 1,227.23 1,267.85

2,218.92 2,047.18 2,114.90

2,229.98 2,057.42 2,125.50











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single





Gold POS 7100 Gold POS 7100EX

505.21 526.25

507.74 528.88

1,010.42 1,052.50

1,015.48 1,057.76

858.86 894.63

863.16 899.10

1,439.84 1,499.81

1,447.06 1,507.31

Silver Standard Silver EPO 6300 Silver PPO 8000

539.03 595.18 604.19

541.71 598.16 607.22

1,078.06 1,190.36 1,208.38

1,083.42 1,196.32 1,214.44

916.35 1,011.81 1,027.13

920.90 1,016.87 1,032.27

1,536.23 1,696.26 1,721.94

1,543.87 1,704.76 1,730.58


649.58 718.26 729.28

652.82 721.84 732.93

1,299.16 1,436.52 1,458.56

1,305.64 1,443.68 1,465.86

1,104.29 1,221.04 1,239.78

1,109.80 1,227.13 1,245.98

1,851.31 2,047.04 2,078.45

1,860.53 2,057.25 2,088.85











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single




Gold PPO 7100 Silver Standard Silver align

603.13 476.82 430.15

606.14 479.20 432.29

1,206.26 953.64 860.30

1,212.28 958.40 864.58

1,025.32 810.60 731.26

1,030.43 814.64 734.89

1,718.92 1,358.94 1,225.93

1,727.50 1,365.72 1,232.03

Silver EPO 8000 Silver EX 8000 Silver POS 8000

585.81 559.54 536.93

588.74 562.34 539.62

1,171.62 1,119.08 1,073.86

1,177.48 1,124.68 1,079.24

995.88 951.22 912.78

1,000.86 955.98 917.36

1,669.56 1,594.69 1,530.25

1,677.91 1,602.67 1,537.91


706.80 674.66 646.99

710.34 678.04 650.23

1,413.60 1,349.32 1,293.98

1,420.68 1,356.08 1,300.46

1,201.56 1,146.92 1,099.88

1,207.58 1,152.67 1,105.39

2,014.38 1,922.78 1,843.92

2,024.47 1,932.42 1,853.16











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single




Silver focus

430.15

432.29

860.30

864.58

731.26

734.89

1,225.93

1,232.03

Silver POS Hybrid Bronze Standard Bronze EPO 6300

546.59 462.41 522.61

549.33 464.72 525.21

1,093.18 924.82 1,045.22

1,098.66 929.44 1,050.42

929.20 786.09 888.44

933.86 790.02 892.86

1,557.79 1,317.87 1,489.44

1,565.59 1,324.46 1,496.85


658.82 555.82 629.46

662.10 558.60 632.61

1,317.64 1,111.64 1,258.92

1,324.20 1,117.20 1,265.22

1,120.00 944.90 1,070.09

1,125.57 949.62 1,075.44

1,877.63 1,584.08 1,793.96

1,886.98 1,592.01 1,802.94











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single





Silver POS 7100 Silver POS 7100 EX Silver PPO 7100

464.69 483.88 554.02

467.02 486.30 556.79

929.38 967.76 1,108.04

934.04 972.60 1,113.58

789.97 822.60 941.84

793.93 826.71 946.55

1,324.37 1,379.06 1,578.95

1,331.01 1,385.96 1,586.85

Bronze PPO Bronze Value

541.29 481.59

544.00 484.00

1,082.58 963.18

1,088.00 968.00

920.19 818.70

924.80 822.80

1,542.68 1,372.53

1,550.40 1,379.40


652.34 579.28

655.60 582.19

1,304.68 1,158.56

1,311.20 1,164.38

1,108.98 984.78

1,114.52 989.73

1,859.17 1,650.95

1,868.46 1,659.24











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

Silver POS 8100 Silver POS 8100EX Silver PPO 8100

438.99 457.00 522.85

441.17 459.28 525.46

877.98 914.00 1,045.70

882.34 918.56 1,050.92

746.28 776.90 888.85

749.99 780.78 893.29

1,251.13 1,302.45 1,490.13

1,257.34 1,308.95 1,497.56











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single





Bronze Standard Bronze POS 8100EX Bronze PPO 8100

409.87 449.45 514.10

411.93 451.70 516.65

819.74 898.90 1,028.20

823.86 903.40 1,033.30

696.78 764.07 873.97

700.28 767.89 878.31

1,168.13 1,280.93 1,465.18

1,174.00 1,287.34 1,472.45











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

Bronze align Bronze focus

393.27 393.27

395.23 395.23

786.54 786.54

790.46 790.46

668.56 668.56

671.89 671.89

1,120.82 1,120.82

1,126.41 1,126.41











Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single















Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single













Quarterly rolling rate factor: 1.30%



Platinum Make


26 621.52 622.51 566.50

30 624.65 625.62 569.34

26 1,243.05 1,245.02 1,133.00

30 1,249.29 1,251.24 1,138.68

26 1,056.59 1,058.26 963.05

30 1,061.90 1,063.55 967.88

26 1,771.35 1,774.15 1,614.53

30 1,780.24 1,783.02 1,622.60



Platinum Make

Available

26 704.42 795.05 705.52

30 707.94 799.02 709.06

26 1,408.84 1,590.10 1,411.05

30 1,415.89 1,598.05 1,418.12

26 1,197.52 1,351.59 1,199.39

30 1,203.51 1,358.34 1,205.40

26 2,007.59 2,265.91 2,010.74

30 2,017.64 2,277.22 2,020.82



Platinum Make

Available

26 851.75 962.64 853.12

30 856.02 967.46 857.38

26 1,703.50 1,925.29 1,706.23

30 1,712.03 1,934.92 1,714.77

26 1,447.98 1,636.50 1,450.30

30 1,455.22 1,644.67 1,457.55

26 2,427.49 2,743.53 2,431.39

30 2,439.63 2,757.25 2,443.54

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

Platinum focus

566.50

569.34

1,133.00

1,138.68

963.05

967.88

1,614.53

1,622.60


735.23 706.27 618.19

738.90 709.80 621.28

1,470.47 1,412.55 1,236.36

1,477.80 1,419.60 1,242.54

1,249.91 1,200.67 1,050.91

1,256.13 1,206.66 1,056.16

2,095.42 2,012.89 1,761.82

2,105.88 2,022.94 1,770.63


889.46 854.03 746.26

893.90 858.30 749.99

1,778.91 1,708.06 1,492.51

1,787.80 1,716.59 1,499.97

1,512.07 1,451.85 1,268.64

1,519.63 1,459.10 1,274.97

2,534.95 2,433.98 2,126.83

2,547.62 2,446.14 2,137.46












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single


598.42 710.09 546.14

601.41 713.63 548.87

1,196.84 1,420.16 1,092.30

1,202.82 1,427.26 1,097.74

1,017.32 1,207.15 928.45

1,022.39 1,213.16 933.08

1,705.50 2,023.74 1,556.53

1,714.02 2,033.84 1,564.29


505.83 710.94 650.81

508.36 714.49 654.06

1,011.66 1,421.86 1,301.60

1,016.72 1,428.98 1,308.11

859.91 1,208.59 1,106.37

864.21 1,214.63 1,111.90

1,441.62 2,026.16 1,854.78

1,448.83 2,036.29 1,864.05


608.95 859.73 786.16

611.98 864.03 790.08

1,217.90 1,719.46 1,572.31

1,223.96 1,728.06 1,580.16

1,035.22 1,461.55 1,336.48

1,040.37 1,468.85 1,343.14

1,735.51 2,450.24 2,240.56

1,744.14 2,462.48 2,251.72












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single


447.83 482.82 507.38

450.07 485.21 509.92

895.66 965.63 1,014.76

900.14 970.43 1,019.83

761.31 820.78 862.55

765.12 824.87 866.85

1,276.31 1,376.03 1,446.04

1,282.70 1,382.86 1,453.26


679.40 649.17 672.72

682.79 652.41 676.08

1,358.80 1,298.34 1,345.42

1,365.59 1,304.83 1,352.15

1,154.97 1,103.58 1,143.61

1,160.75 1,109.10 1,149.33

1,936.29 1,850.14 1,917.24

1,945.97 1,859.38 1,926.83


821.15 784.17 812.99

825.25 788.09 817.04

1,642.29 1,568.34 1,625.96

1,650.50 1,576.19 1,634.07

1,395.95 1,333.10 1,382.07

1,402.92 1,339.76 1,388.96

2,340.27 2,234.89 2,317.00

2,351.96 2,246.06 2,328.55












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single


486.81 486.81

489.24 489.24

973.61 973.61

978.48 978.48

827.58 827.58

831.71 831.71

1,387.40 1,387.40

1,394.33 1,394.33


652.86 602.95 622.65

656.12 605.97 625.76

1,305.71 1,205.92 1,245.31

1,312.24 1,211.95 1,251.52

1,109.86 1,025.03 1,058.51

1,115.40 1,030.17 1,063.79

1,860.65 1,718.44 1,774.55

1,869.95 1,727.03 1,783.42


788.70 727.65 751.72

792.62 731.29 755.48

1,577.38 1,455.29 1,503.43

1,585.25 1,462.57 1,510.97

1,340.77 1,237.01 1,277.92

1,347.46 1,243.18 1,284.33

2,247.77 2,073.80 2,142.39

2,258.97 2,084.17 2,153.14












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single


511.78 533.09

514.34 535.75

1,023.55 1,066.18

1,028.69 1,071.51

870.02 906.26

874.38 910.79

1,458.56 1,519.31

1,465.87 1,526.90


546.04 602.91 612.04

548.75 605.93 615.11

1,092.07 1,205.84 1,224.09

1,097.51 1,211.87 1,230.23

928.26 1,024.96 1,040.48

932.87 1,030.08 1,045.69

1,556.21 1,718.32 1,744.32

1,563.94 1,726.92 1,753.08


658.03 727.59 738.76

661.30 731.23 742.46

1,316.05 1,455.20 1,477.52

1,322.61 1,462.45 1,484.91

1,118.65 1,236.91 1,255.89

1,124.22 1,243.08 1,262.17

1,875.37 2,073.66 2,105.47

1,884.72 2,084.00 2,116.00












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single


610.97 483.02 435.74

614.02 485.43 437.91

1,221.95 966.04 871.49

1,228.04 970.86 875.82

1,038.65 821.14 740.77

1,043.82 825.23 744.44

1,741.27 1,376.60 1,241.87

1,749.96 1,383.47 1,248.04


593.43 566.82 543.91

596.39 569.65 546.64

1,186.85 1,133.63 1,087.82

1,192.79 1,139.30 1,093.27

1,008.82 963.59 924.65

1,013.87 968.41 929.29

1,691.26 1,615.42 1,550.14

1,699.73 1,623.50 1,557.90


715.98 683.43 655.41

719.58 686.86 658.69

1,431.98 1,366.86 1,310.80

1,439.15 1,373.71 1,317.37

1,217.18 1,161.83 1,114.18

1,223.28 1,167.66 1,119.76

2,040.57 1,947.77 1,867.90

2,050.79 1,957.54 1,877.25












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

Silver focus

435.74

437.91

871.49

875.82

740.77

744.44

1,241.87

1,248.04


553.69 468.42 529.41

556.47 470.76 532.04

1,107.39 936.84 1,058.81

1,112.95 941.52 1,064.07

941.28 796.31 899.99

946.00 800.30 904.47

1,578.05 1,335.00 1,508.80

1,585.94 1,341.68 1,516.31


667.39 563.05 637.64

670.71 565.87 640.83

1,334.77 1,126.10 1,275.29

1,341.41 1,131.72 1,281.67

1,134.56 957.18 1,084.00

1,140.21 961.96 1,089.42

1,902.04 1,604.67 1,817.28

1,911.51 1,612.70 1,826.38












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single


470.74 490.17 561.22

473.09 492.62 564.03

941.46 980.34 1,122.45

946.18 985.25 1,128.05

800.24 833.30 954.08

804.25 837.46 958.86

1,341.59 1,396.99 1,599.47

1,348.31 1,403.98 1,607.48


548.32 487.85

551.07 490.29

1,096.66 975.70

1,102.14 980.59

932.15 829.34

936.83 833.49

1,562.73 1,390.38

1,570.56 1,397.34


660.82 586.81

664.12 589.76

1,321.64 1,173.62

1,328.25 1,179.52

1,123.39 997.58

1,129.01 1,002.60

1,883.34 1,672.41

1,892.75 1,680.81












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single


444.70 462.94 529.65

446.90 465.25 532.29

889.39 925.88 1,059.30

893.81 930.51 1,064.58

755.98 787.00 900.41

759.74 790.93 904.90

1,267.39 1,319.38 1,509.50

1,273.68 1,325.97 1,517.03












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single


415.20 455.29 520.78

417.28 457.57 523.37

830.40 910.58 1,041.56

834.57 915.15 1,046.74

705.84 774.01 885.33

709.38 777.88 889.73

1,183.32 1,297.59 1,484.23

1,189.26 1,304.07 1,491.59












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single


398.38 398.38

400.37 400.37

796.77 796.77

800.74 800.74

677.25 677.25

680.62 680.62

1,135.39 1,135.39

1,141.06 1,141.06












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single













Platinum Make


26 629.59 630.60 573.86

30 632.77 633.75 576.74

26 1,259.21 1,261.21 1,147.73

30 1,265.53 1,267.51 1,153.48

26 1,070.32 1,072.01 975.57

30 1,075.71 1,077.38 980.47

26 1,794.38 1,797.22 1,635.52

30 1,803.38 1,806.20 1,643.69



Platinum Make

Available

26 713.58 805.38 714.69

30 717.14 809.41 718.28

26 1,427.15 1,610.78 1,429.39

30 1,434.30 1,618.82 1,436.56

26 1,213.08 1,369.16 1,214.98

30 1,219.15 1,376.00 1,221.07

26 2,033.69 2,295.36 2,036.88

30 2,043.87 2,306.83 2,047.09



Platinum Make

Available

26 862.82 975.15 864.21

30 867.15 980.04 868.52

26 1,725.65 1,950.32 1,728.41

30 1,734.29 1,960.07 1,737.07

26 1,466.81 1,657.77 1,469.16

30 1,474.14 1,666.05 1,476.50

26 2,459.04 2,779.19 2,463.00

30 2,471.34 2,793.10 2,475.31

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Platinum focus

573.86

576.74

1,147.73

1,153.48

975.57

980.47

1,635.52

1,643.69


744.79 715.45 626.23

748.50 719.03 629.36

1,489.59 1,430.92 1,252.43

1,497.01 1,438.06 1,258.69

1,266.16 1,216.28 1,064.57

1,272.46 1,222.34 1,069.89

2,122.66 2,039.05 1,784.72

2,133.26 2,049.23 1,793.65


901.02 865.14 755.97

905.52 869.46 759.74

1,802.04 1,730.26 1,511.91

1,811.04 1,738.90 1,519.47

1,531.73 1,470.73 1,285.13

1,539.38 1,478.07 1,291.55

2,567.91 2,465.62 2,154.48

2,580.74 2,477.94 2,165.25












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family


606.20 719.32 553.23

609.23 722.91 556.00

1,212.40 1,438.62 1,106.50

1,218.46 1,445.81 1,112.01

1,030.55 1,222.84 940.52

1,035.68 1,228.93 945.21

1,727.68 2,050.05 1,576.77

1,736.30 2,060.28 1,584.63


505.83 720.19 659.27

508.36 723.78 662.56

1,011.66 1,440.34 1,318.52

1,016.72 1,447.55 1,325.11

859.91 1,224.30 1,120.75

864.21 1,230.42 1,126.36

1,441.62 2,052.50 1,878.89

1,448.83 2,062.76 1,888.28


608.95 870.91 796.38

611.98 875.26 800.35

1,217.90 1,741.81 1,592.75

1,223.96 1,750.52 1,600.70

1,035.22 1,480.55 1,353.86

1,040.37 1,487.94 1,360.60

1,735.51 2,482.09 2,269.68

1,744.14 2,494.49 2,281.00












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family


447.83 489.09 513.98

450.07 491.52 516.55

895.66 978.19 1,027.95

900.14 983.05 1,033.08

761.31 831.45 873.76

765.12 835.60 878.12

1,276.31 1,393.92 1,464.84

1,282.70 1,400.84 1,472.15


688.23 657.61 681.46

691.67 660.89 684.87

1,376.47 1,315.22 1,362.91

1,383.34 1,321.80 1,369.72

1,169.99 1,117.92 1,158.48

1,175.84 1,123.52 1,164.27

1,961.46 1,874.19 1,942.16

1,971.27 1,883.55 1,951.88


831.83 794.36 823.56

835.98 798.33 827.66

1,663.64 1,588.73 1,647.10

1,671.95 1,596.68 1,655.31

1,414.09 1,350.43 1,400.04

1,421.15 1,357.18 1,407.02

2,370.69 2,263.95 2,347.12

2,382.54 2,275.26 2,358.83












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family


493.14 493.14

495.60 495.60

986.27 986.27

991.20 991.20

838.33 838.33

842.53 842.53

1,405.44 1,405.44

1,412.46 1,412.46


661.35 610.79 630.74

664.65 613.84 633.89

1,322.68 1,221.60 1,261.50

1,329.30 1,227.71 1,267.79

1,124.29 1,038.35 1,072.27

1,129.90 1,043.57 1,077.62

1,884.84 1,740.78 1,797.62

1,894.26 1,749.48 1,806.60


798.95 737.10 761.49

802.92 740.80 765.30

1,597.89 1,474.21 1,522.97

1,605.86 1,481.58 1,530.61

1,358.20 1,253.09 1,294.53

1,364.98 1,259.34 1,301.02

2,276.99 2,100.76 2,170.24

2,288.34 2,111.27 2,181.13












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family


518.43 540.02

521.02 542.71

1,036.86 1,080.04

1,042.06 1,085.44

881.33 918.04

885.75 922.63

1,477.52 1,539.06

1,484.92 1,546.75


553.14 610.75 619.99

555.89 613.81 623.10

1,106.27 1,221.51 1,240.01

1,111.78 1,227.62 1,246.23

940.32 1,038.28 1,054.00

945.00 1,043.48 1,059.29

1,576.44 1,740.65 1,767.00

1,584.28 1,749.37 1,775.87


666.58 737.04 748.36

669.90 740.74 752.11

1,333.16 1,474.12 1,496.73

1,339.80 1,481.46 1,504.21

1,133.19 1,252.99 1,272.21

1,138.84 1,259.24 1,278.58

1,899.75 2,100.62 2,132.84

1,909.22 2,111.09 2,143.51












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family


618.91 489.30 441.40

622.00 491.74 443.61

1,237.83 978.59 882.82

1,244.00 983.48 887.20

1,052.15 831.81 750.40

1,057.39 835.96 754.12

1,763.90 1,394.49 1,258.01

1,772.71 1,401.45 1,264.26


601.14 574.19 550.98

604.14 577.06 553.75

1,202.28 1,148.37 1,101.96

1,208.30 1,154.11 1,107.48

1,021.93 976.11 936.67

1,027.05 981.00 941.37

1,713.25 1,636.42 1,570.29

1,721.82 1,644.60 1,578.15


725.28 692.32 663.93

728.93 695.79 667.25

1,450.60 1,384.63 1,327.84

1,457.86 1,391.57 1,334.50

1,233.00 1,176.93 1,128.66

1,239.18 1,182.84 1,134.32

2,067.09 1,973.09 1,892.19

2,077.45 1,982.99 1,901.66












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Silver focus

441.40

443.61

882.82

887.20

750.40

754.12

1,258.01

1,264.26


560.89 474.51 536.29

563.70 476.88 538.96

1,121.78 949.02 1,072.58

1,127.42 953.76 1,077.90

953.52 806.66 911.69

958.30 810.70 916.22

1,598.56 1,352.35 1,528.42

1,606.56 1,359.12 1,536.02


676.06 570.37 645.93

679.43 573.23 649.16

1,352.12 1,140.74 1,291.87

1,358.85 1,146.43 1,298.33

1,149.31 969.63 1,098.10

1,155.03 974.47 1,103.58

1,926.76 1,625.53 1,840.90

1,936.36 1,633.66 1,850.12












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family


476.86 496.54 568.52

479.24 499.03 571.36

953.70 993.09 1,137.04

958.48 998.06 1,142.72

810.65 844.13 966.49

814.71 848.35 971.32

1,359.03 1,415.15 1,620.26

1,365.84 1,422.23 1,628.38


555.44 494.19

558.23 496.67

1,110.92 988.39

1,116.47 993.34

944.27 840.12

949.01 844.32

1,583.04 1,408.46

1,590.97 1,415.51


669.41 594.43

672.75 597.42

1,338.82 1,188.88

1,345.52 1,194.85

1,138.00 1,010.55

1,143.68 1,015.63

1,907.83 1,694.15

1,917.35 1,702.66












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family


450.48 468.95 536.54

452.71 471.30 539.21

900.95 937.92 1,073.07

905.43 942.61 1,078.42

765.81 797.24 912.12

769.62 801.22 916.66

1,283.87 1,336.53 1,529.13

1,290.24 1,343.20 1,536.75












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family


420.60 461.21 527.55

422.71 463.51 530.18

841.20 922.42 1,055.10

845.42 927.05 1,060.34

715.02 784.07 896.84

718.60 787.99 901.29

1,198.70 1,314.46 1,503.53

1,204.72 1,321.02 1,510.98












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family


403.56 403.56

405.57 405.57

807.13 807.13

811.15 811.15

686.06 686.06

689.46 689.46

1,150.15 1,150.15

1,155.90 1,155.90












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family

Single

2 Person

Sub + Child(ren)

Family













Platinum Make


26 637.78 638.80 581.32

30 641.00 641.99 584.24

26 1,275.58 1,277.61 1,162.65

30 1,281.98 1,283.99 1,168.47

26 1,084.23 1,085.94 988.25

30 1,089.69 1,091.39 993.21

26 1,817.71 1,820.59 1,656.78

30 1,826.82 1,829.68 1,665.06



Platinum Make

Available

26 722.86 815.85 723.99

30 726.47 819.94 727.62

26 1,445.70 1,631.72 1,447.97

30 1,452.94 1,639.86 1,455.23

26 1,228.85 1,386.96 1,230.77

30 1,235.00 1,393.89 1,236.94

26 2,060.13 2,325.20 2,063.36

30 2,070.44 2,336.82 2,073.70



Platinum Make

Available

26 874.03 987.83 875.44

30 878.43 992.79 879.81

26 1,748.09 1,975.67 1,750.88

30 1,756.83 1,985.55 1,759.65

26 1,485.88 1,679.32 1,488.26

30 1,493.31 1,687.70 1,495.70

26 2,491.01 2,815.32 2,495.02

30 2,503.47 2,829.41 2,507.49Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single

Platinum focus

581.32

584.24

1,162.65

1,168.47

988.25

993.21

1,656.78

1,665.06


754.47 724.76 634.37

758.23 728.38 637.54

1,508.96 1,449.52 1,268.71

1,516.47 1,456.75 1,275.06

1,282.62 1,232.09 1,078.41

1,289.00 1,238.23 1,083.79

2,150.26 2,065.56 1,807.92

2,160.99 2,075.87 1,816.97


912.73 876.39 765.80

917.29 880.76 769.62

1,825.47 1,752.75 1,531.56

1,834.59 1,761.51 1,539.22

1,551.64 1,489.84 1,301.84

1,559.39 1,497.29 1,308.34

2,601.29 2,497.68 2,182.49

2,614.29 2,510.15 2,193.40












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single


614.08 728.67 560.43

617.15 732.30 563.22

1,228.16 1,457.33 1,120.88

1,234.30 1,464.61 1,126.47

1,043.95 1,238.74 952.75

1,049.14 1,244.91 957.50

1,750.14 2,076.70 1,597.26

1,758.87 2,087.06 1,605.23


505.83 729.55 667.84

508.36 733.19 671.18

1,011.66 1,459.07 1,335.66

1,016.72 1,466.37 1,342.33

859.91 1,240.21 1,135.32

864.21 1,246.41 1,141.00

1,441.62 2,079.19 1,903.32

1,448.83 2,089.58 1,912.82


608.95 882.23 806.73

611.98 886.64 810.75

1,217.90 1,764.46 1,613.46

1,223.96 1,773.27 1,621.51

1,035.22 1,499.80 1,371.46

1,040.37 1,507.28 1,378.29

1,735.51 2,514.36 2,299.18

1,744.14 2,526.92 2,310.66












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single


447.83 495.45 520.66

450.07 497.91 523.27

895.66 990.90 1,041.32

900.14 995.83 1,046.51

761.31 842.25 885.12

765.12 846.47 889.54

1,276.31 1,412.04 1,483.88

1,282.70 1,419.05 1,491.28


697.18 666.16 690.32

700.67 669.48 693.77

1,394.36 1,332.32 1,380.63

1,401.32 1,338.99 1,387.53

1,185.20 1,132.46 1,173.54

1,191.13 1,138.12 1,179.41

1,986.96 1,898.55 1,967.41

1,996.90 1,908.04 1,977.26


842.64 804.68 834.27

846.84 808.71 838.42

1,685.26 1,609.39 1,668.51

1,693.69 1,617.43 1,676.83

1,432.47 1,367.99 1,418.24

1,439.62 1,374.82 1,425.31

2,401.51 2,293.38 2,377.63

2,413.51 2,304.84 2,389.50












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single


499.55 499.55

502.05 502.05

999.09 999.09

1,004.08 1,004.08

849.23 849.23

853.48 853.48

1,423.71 1,423.71

1,430.82 1,430.82


669.95 618.73 638.94

673.29 621.82 642.14

1,339.88 1,237.48 1,277.90

1,346.58 1,243.68 1,284.27

1,138.90 1,051.85 1,086.21

1,144.59 1,057.14 1,091.63

1,909.35 1,763.41 1,820.99

1,918.89 1,772.22 1,830.08


809.34 746.68 771.39

813.35 750.43 775.25

1,618.66 1,493.38 1,542.77

1,626.74 1,500.84 1,550.50

1,375.85 1,269.38 1,311.35

1,382.72 1,275.71 1,317.93

2,306.59 2,128.07 2,198.45

2,318.09 2,138.72 2,209.49












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single


525.17 547.04

527.79 549.76

1,050.34 1,094.08

1,055.60 1,099.55

892.79 929.97

897.26 934.63

1,496.73 1,559.07

1,504.23 1,566.86


560.33 618.69 628.05

563.12 621.79 631.20

1,120.65 1,237.39 1,256.13

1,126.23 1,243.58 1,262.43

952.54 1,051.78 1,067.70

957.28 1,057.05 1,073.06

1,596.93 1,763.28 1,789.98

1,604.88 1,772.11 1,798.95


675.25 746.62 758.09

678.61 750.37 761.88

1,350.49 1,493.29 1,516.18

1,357.22 1,500.72 1,523.77

1,147.92 1,269.28 1,288.75

1,153.64 1,275.61 1,295.20

1,924.45 2,127.92 2,160.57

1,934.04 2,138.54 2,171.38












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single


626.95 495.66 447.14

630.08 498.13 449.37

1,253.92 991.31 894.29

1,260.17 996.26 898.73

1,065.83 842.62 760.15

1,071.13 846.82 763.93

1,786.83 1,412.61 1,274.36

1,795.76 1,419.67 1,280.70


608.96 581.65 558.14

612.00 584.56 560.95

1,217.91 1,163.30 1,116.29

1,224.01 1,169.11 1,121.88

1,035.21 988.80 948.85

1,040.40 993.75 953.61

1,735.53 1,657.69 1,590.71

1,744.20 1,665.98 1,598.66


734.71 701.32 672.57

738.40 704.83 675.93

1,469.45 1,402.63 1,345.10

1,476.81 1,409.66 1,351.85

1,249.03 1,192.23 1,143.34

1,255.29 1,198.22 1,149.06

2,093.97 1,998.74 1,916.79

2,104.46 2,008.76 1,926.38












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single

Silver focus

447.14

449.37

894.29

898.73

760.15

763.93

1,274.36

1,280.70


568.18 480.68 543.26

571.02 483.08 545.97

1,136.36 961.35 1,086.52

1,142.08 966.16 1,091.92

965.91 817.14 923.55

970.76 821.24 928.13

1,619.34 1,369.93 1,548.29

1,627.45 1,376.79 1,555.99


684.85 577.78 654.32

688.27 580.68 657.60

1,369.69 1,155.57 1,308.67

1,376.51 1,161.34 1,315.21

1,164.25 982.23 1,112.38

1,170.04 987.14 1,117.93

1,951.81 1,646.66 1,864.83

1,961.54 1,654.90 1,874.17












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single


483.06 503.00 575.91

485.47 505.51 578.79

966.10 1,006.00 1,151.82

970.94 1,011.04 1,157.58

821.19 855.10 979.05

825.30 859.38 983.95

1,376.70 1,433.55 1,641.32

1,383.60 1,440.72 1,649.55


562.66 500.62

565.48 503.12

1,125.36 1,001.24

1,130.98 1,006.26

956.54 851.04

961.35 855.29

1,603.62 1,426.77

1,611.65 1,433.91


678.11 602.16

681.50 605.18

1,356.23 1,204.33

1,363.01 1,210.38

1,152.79 1,023.69

1,158.55 1,028.83

1,932.63 1,716.18

1,942.28 1,724.79












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single


456.34 475.05 543.52

458.59 477.43 546.22

912.67 950.11 1,087.02

917.20 954.86 1,092.44

775.77 807.60 923.97

779.63 811.64 928.58

1,300.57 1,353.90 1,549.00

1,307.01 1,360.66 1,556.73












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single


426.06 467.21 534.41

428.20 469.53 537.08

852.14 934.41 1,068.82

856.41 939.10 1,074.12

724.31 794.26 908.50

727.94 798.23 913.01

1,214.28 1,331.55 1,523.08

1,220.38 1,338.19 1,530.62












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single


408.80 408.80

410.84 410.84

817.63 817.63

821.70 821.70

694.98 694.98

698.42 698.42

1,165.10 1,165.10

1,170.93 1,170.93












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single












Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30


Age

26

30

26

30

26

30

26

30Family

2 Person

Single

2 Person

Sub + Child(ren)

Family

Sub + Child(ren)

Sub + Child(ren)

Family

Single

2 Person

Single

Documents

HealthNow New York Inc. 2018 New York State Exchange … · 1.1 The group must produce documentation at time of enrollment that proves ... by the insurance ... New York Inc. 2018