aetna life insurance company new york small group premium

A - 1

Aetna Life Insurance Company

New York Small Group

Premium Rate Manual

Table of Contents

Description Page

Table of Contents A-1

General A-2

Premium Rate Manual A-3

Product Summary B-1

Plan Relativity Factors

Rate Tables

C-1

D-1

List of Applicable Forms E-1

Appendix I: Commissions Schedule and Incentive Fees F-1

Appendix II: Loss Ratio G-1

A - 2

Aetna Life Insurance Company New York Small Group

Premium Rate Manual

General This rate manual contains worksheets and instructions for calculating the community rates for the New York Small Group Plans available from Aetna Life Insurance Company. It is in accordance with Insurance Law Section 3231 (d) Rate Applications and includes rates for products that will be offered to small groups effective January 1, 2017.

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Aetna Life Insurance Company

New York Small Group

Premium Rate Manual The following Steps are used to calculate premium rates.

1. 2017 Base Rate

Silver Index Premium Rate $894.92

2. Plan Pricing Values

Plan Relativity Factor Table – rate factor for each unique plan design. Base Rate x Plan Relativity Factor = Rate for Unique Plan The product identifier will identify the plan. For each product identifier, there will be a rate relativity factor. The plan factors shown on page C-1 reflect the pricing differential for each plan.

3. Standardized Rating Region Below is a table of New York rating area factors for small group business. Factors reflect differences in cost by geographic area. Base Rate x Plan Relativity Factor x Area Factor = Rate for that Plan for that Rating Area. The rating regions listed below are based on the required ACA standardized rating regions. The NYC Community Plan is specifically designed and available for residents who live or work and access health care in the five boroughs of New York City — Manhattan, Bronx, Staten Island, Queens and Brooklyn and therefore is only offered in Region 4.

Rating Region Counties Area

Factor

Region 1 Albany, Columbia, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington 0.82

Region 2 Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming 0.90

Region 3 Delaware, Dutchess, Orange, Putnam, Sullivan, Ulster 1.00

Region 4 Bronx, Kings, New York, Queens, Richmond, Rockland, Westchester 1.00

Region 5 Livingston, Monroe, Ontario, Seneca, Wayne, Yates 0.70

Region 6 Broome, Cayuga, Chemung, Cortland, Onondaga, Schuyler, Steuben, Tioga, Tompkins 0.79

Region 7 Chenango, Clinton, Essex, Franklin, Hamilton, Herkimer, Jefferson, Lewis, Madison, Oneida, Oswego, Otsego, St. Lawrence

0.82

Region 8 Nassau, Suffolk 1.00

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Premium Rate Manual

4. Effective Date Factor table - premium rate level adjustment factor to reflect differences

in cost by effective date.

Effective Quarter Trend Factor

1Q 2017 1.000000 2Q 2017 1.036822 3Q 2017 1.075068 4Q 2017 1.114796

5. Standardized Census Tiers

All Aetna New York Small Group products will be priced to reflect the tiers and relativities specified by the DFS.

Tier Relativities Single 1.00

Single + Spouse 2.00 Single + Child(ren) 1.70

Single + Spouse + Child(ren) 2.85

6. Dependent Age Adjustment Factor For subscribers who choose to have the Dependent Up to Age 30 rider, the additional adjustment to the rate is as follows:

Non-Student

Age Student

Age Single Parent &

Child(ren) Couple Family

26 26 1.00 1.00 1.00 1.00 30 30 1.03 1.03 1.03 1.03

The rate for an unmarried young adult who chooses coverage under the Young Adult Option would be equal to the rate that would be paid by the young adult's subscriber/parent if that subscriber were billed as a single member.

A - 5


Premium Rate Manual

7. Subscriber Rate

The subscriber rate is equal to Step 1 x Step 2 x Step 3 x Step 4 or Step 5 x Step 6, rounded to the nearest cent.

8. Example of Rate Calculations

Base Rate * Plan Factor * Rating Area Factor * Effective Date factor * Tier Factor* Dep Age Adj. Factor

Notes: In our rating system, the Dep Age Adj. Factor will be loaded with Plan Factor

Region 1 with NY Gold OAEPO 1000 90% - January 2017 Rating Area: NYRA01

Plan Name: NY Gold OAEPO 1000 90% NY Gold OAEPO 1000 90% DEP30 Effective Date: 1Q 2017

Dep Age Age 26 Age 26 Age 26 Age 26 Age 30 Age 30 Age 30 Age 30 Single Couple Parent Family Single Couple Parent Family Base Rate $894.92 $894.92 $894.92 $894.92 $894.92 $894.92 $894.92 $894.92 Plan Factor 0.893 0.893 0.893 0.893 0.893 0.893 0.893 0.893 Area Factor 0.820 0.820 0.820 0.820 0.820 0.820 0.820 0.820 Eff Date Factor 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 Tier Factor 1.000 2.000 1.700 2.850 1.000 2.000 1.700 2.850 Dep Age Factor 1.000 1.000 1.000 1.000 1.030 1.030 1.030 1.030 Total Rate $655.65 $1,311.30 $1,114.61 $1,868.61 $675.32 $1,350.64 $1,148.05 $1,924.67

Region 4 with NY Gold OAEPO 1000 90% - April 2017 Rating Area: NYRA04

Plan Name: NY Gold OAEPO 1000 90% NY Gold OAEPO 1000 90% DEP30 Effective Date: 2Q 2017

Dep Age Age 26 Age 26 Age 26 Age 26 Age 30 Age 30 Age 30 Age 30 Single Couple Parent Family Single Couple Parent Family Base Rate $894.92 $894.92 $894.92 $894.92 $894.92 $894.92 $894.92 $894.92 Plan Factor 0.893 0.893 0.893 0.893 0.893 0.893 0.893 0.893 Area Factor 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 Eff Date Factor 1.037 1.037 1.037 1.037 1.037 1.037 1.037 1.037 Tier Factor 1.000 2.000 1.700 2.850 1.000 2.000 1.700 2.850 Dep Age Factor 1.000 1.000 1.000 1.000 1.030 1.030 1.030 1.030 Total Rate $829.02 $1,658.04 $1,409.33 $2,362.70 $853.89 $1,707.78 $1,451.61 $2,433.58

Page B-1

Aetna Life Insurance Company 17210

Rate Manual Section B

Contents NY Gold OAEPO 1000 90% 2 NY Platinum OAEPO $25 3 NY Silver OAEPO 2000 60% 4 NY Silver OAEPO 2000 80% 5 NY Silver OAEPO 3000 70% 6 NY Bronze OAEPO 3750 50% 7 NY Bronze OAEPO 4500 70% 8 NY Bronze OAEPO 5000 60% 9 NY Silver OAEPO 2800 90% HSA PY 10 NY Bronze OAEPO 5400 50% HSA 11 NY Bronze OAEPO 5400 50% HSA PY 12 NY Bronze OAEPO 5700 70% HSA 13 NY Bronze OAEPO 5700 70% HSA PY 14 NY Gold Savings Plus OAEPO 1000 90% 15 NY Silver Savings Plus OAEPO 2000 80% 16 NY Silver Savings Plus OAEPO 2500 80% 17 NY Bronze Savings Plus OAEPO 4500 60% 18 NY Silver SP OAEPO 2800 90% HSA PY 19 NY Platinum NYC Community PlanSM $20 20 NY Platinum NYC Community PlanSM $30 21 NY Silver OAMC 3000 100/70 HSA 22 NY Silver OAMC 2800 90/70 HSA 23 NY Silver OAMC 3000 100/80 HSA FH 24 NY Silver OAEPO 4500 100% L 25 NY Bronze OAEPO 6850 100% L 26 NY Silver Indemnity 2500 80% 27 NY Gold EPO 1000 90% 28 NY Silver EPO 2000 60% 29 NY Silver EPO 2000 80% 30 NY Bronze EPO 5700 70% HSA PY 31 NY Gold OAEPO AP 1000 90% 32 NY Silver OAEPO AP 2000 80% 33 NY Bronze OAEPO AP 4500 70% 34 NY Gold AWH OAEPO 1000 90% 35 NY Silver AWH OAEPO 2000 80% 36 NY Bronze AWH OAEPO 4500 70% 37 NY Silver AWH OAEPO 2800 90% HSA PY 38 NY Bronze AWH OAEPO 5700 70%HSA PY 39 NY Silver AWH OAEPO 4500 100% L 40 NY Bronze AWH OAEPO 6850 100% L 41

NY Small Group Portfolio | Summary of Benefits



Page B-2

Summary of Features In Network

Pharmacy In-Network

New York NY Gold OAEPO 1000 90%

Deductible

$1,000 Individual Family $2,000

Coinsurance (Member Responsibility)

10%

$0 once out-of-pocket max. is satisfied

Out-of-Pocket Maximum

$5,000 Individual Familiy $10,000

All cost sharing accumulates to the Out of Pocket Maximum above

Primary Care Visit to Treat an Injury or Illness (excludes Preventative and X-rays)

$30 per visit

Specialist Visit $60 per visit All Inpatient Hospital Services

(includes Mental/Behavioral Health and Substance Abuse)

10% after deductible

Emergency Room Services $500 per visit Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services $60 per visit

Imaging (CT/PET Scans, MRIs) 10% after deductible Rehabilitative Speech Therapy $60 per visit Rehabilitative Occupational and Rehabilitative Physical Therapy $60 per visit

Preventive Care/Screening/Immunization 0% Laboratory Outpatient and Professional Services 10% after deductible X-rays and Diagnostic Imaging 10% after deductible

Skilled Nursing Facility 10% after deductible Outpatient Facility Fee (e.g., Ambulatory Surgery Center)


Outpatient Surgery Physician/Surgical Services 10% after deductible

Pharmacy Deductible Individual

$100

Generics $20

Preferred Brand Drugs $40

Non-Preferred Brand Drugs $60



Page B-3


Pharmacy In-Network

New York NY Platinum OAEPO $25

Deductible

$0 Individual Family $0


0%






$25 per visit

Specialist Visit $40 per visit

All Inpatient Hospital Services (includes Mental/Behavioral Health and Substance Abuse)

$500/Admit


Imaging (CT/PET Scans, MRIs) 0% Rehabilitative Speech Therapy $40 per visit Rehabilitative Occupational and Rehabilitative Physical Therapy $40 per visit

Preventive Care/Screening/Immunization 0%

Laboratory Outpatient and Professional Services 0% X-rays and Diagnostic Imaging 0% Skilled Nursing Facility $500/Admit Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

0%

Outpatient Surgery Physician/Surgical Services 0%


$100

Generics $20





Page B-4


Pharmacy In-Network

New York NY Silver OAEPO 2000 60%

Deductible



40%






$30 per visit







Laboratory Outpatient and Professional Services $60 per visit X-rays and Diagnostic Imaging 40% after deductible Skilled Nursing Facility 40% after deductible Outpatient Facility Fee (e.g., Ambulatory Surgery Center)




$100

Generics $20





Page B-5


Pharmacy In-Network


Deductible



20%






$40 per visit











$100

Generics $20





Page B-6


Pharmacy In-Network


Deductible



30%






$40 per visit











$100

Generics $20





Page B-7


Pharmacy In-Network

New York NY Bronze OAEPO 3750 50%

Deductible



50%







Specialist Visit 50% after deductible



Emergency Room Services 50% after deductible Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services 50% after deductible

Imaging (CT/PET Scans, MRIs) 50% after deductible Rehabilitative Speech Therapy 50% after deductible Rehabilitative Occupational and Rehabilitative Physical Therapy 50% after deductible


Laboratory Outpatient and Professional Services 50% after deductible X-rays and Diagnostic Imaging 50% after deductible Skilled Nursing Facility 50% after deductible Outpatient Facility Fee (e.g., Ambulatory Surgery Center)




Integrated with Medical

Generics $20





Page B-8


Pharmacy In-Network


Deductible



30%






$25 per visit after deductible












Generics $20





Page B-9


Pharmacy In-Network


Deductible



40%


















Generics $20





Page 10 of 41


Pharmacy In-Network

New York NY Silver OAEPO 2800 90% HSA PY

Deductible



10%


















Generics $20





Page 11 of 41


Pharmacy In-Network

New York NY Bronze OAEPO 5400 50% HSA

Deductible



50%


















Generics $20





Page 12 of 41


Pharmacy In-Network

New York NY Bronze OAEPO 5400 50% HSA PY

Deductible



50%


















Generics $20





Page 13 of 41


Pharmacy In-Network

New York NY Bronze OAEPO 5700 70% HSA

Deductible



30%


















Generics $20





Page 14 of 41


Pharmacy In-Network

New York NY Bronze OAEPO 5700 70% HSA PY

Deductible



30%


















Generics $20





Page 15 of 41

Summary of Features In Network Non-Designated

Pharmacy In-Network

New York NY Gold Savings Plus OAEPO 1000 90%

Deductible Individual Family

$1,000 $2,000

$3,000 $6,000


10%

30%


Out-of-Pocket Maximum Individual Familiy

$3,000 $6,000

$6,600 $13,200



$30 per visit $50 per visit after deductible

Specialist Visit $50 per visit $70 per visit after deductible

All Inpatient Hospital Services




Emergency Room Services $500 per visit Paid as designated Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services $50 per visit $70 per visit after deductible

Imaging (CT/PET Scans, MRIs) 10% after deductible 30% after deductible

Rehabilitative Speech Therapy $50 per visit $70 per visit after deductible Rehabilitative Occupational and Rehabilitative Physical Therapy $50 per visit $70 per visit after deductible

Preventive Care/Screening/Immunization 0% 0%

Laboratory Outpatient and Professional Services 10% after deductible 30% after deductible

X-rays and Diagnostic Imaging 10% after deductible 30% after deductible

Skilled Nursing Facility 10% after deductible 30% after deductible

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)



Outpatient Surgery Physician/Surgical Services 10% after deductible 30% after deductible


$100

Generics $20





Page 16 of 41


Pharmacy In-Network

New York NY Silver Savings Plus OAEPO 2000 80%


$2,000 $4,000

$4,000 $8,000


20%

40%



$5,800

$11,600

$6,600 $13,200



$40 per visit $50 per visit after deductible

Specialist Visit $60 per visit $75 per visit after deductible





Emergency Room Services $500 per visit Paid as designated Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services $60 per visit $75 per visit after deductible


Rehabilitative Speech Therapy $60 per visit $75 per visit after deductible Rehabilitative Occupational and Rehabilitative Physical Therapy $60 per visit $75 per visit after deductible


Laboratory Outpatient and Professional Services $60 per visit $75 per visit after deductible








$100

Generics $20





Page 17 of 41


Pharmacy In-Network

New York NY Silver Savings Plus OAEPO 2500 80%


$2,500 $5,000

$4,500 $9,000


20%

40%



$6,000

$12,000

$6,600 $13,200



$50 per visit 40% after deductible

Specialist Visit $75 per visit 40% after deductible





Emergency Room Services 20% after deductible Paid as designated Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services $75 per visit 40% after deductible


Rehabilitative Speech Therapy $75 per visit 40% after deductible Rehabilitative Occupational and Rehabilitative Physical Therapy $75 per visit 40% after deductible


Laboratory Outpatient and Professional Services $75 per visit 40% after deductible








$100

Generics $20





Page 18 of 41


Pharmacy In-Network

New York NY Bronze Savings Plus OAEPO 4500 60%


$4,500 $9,000

$6,000 $12,000


40%

50%



$6,850

$13,700

$6,850 $13,700



40% after deductible 50% after deductible

Specialist Visit 40% after deductible 50% after deductible





Emergency Room Services 40% after deductible Paid as designated Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services 40% after deductible 50% after deductible


Rehabilitative Speech Therapy 40% after deductible 50% after deductible Rehabilitative Occupational and Rehabilitative Physical Therapy 40% after deductible 50% after deductible











Generics $20





Page 19 of 41


Pharmacy In-Network

New York NY Silver SP OAEPO 2800 90% HSA PY


$2,800 $5,600

$4,000 $8,000


10%

30%



$5,500

$11,000

$6,450 $12,900









Emergency Room Services 10% after deductible Paid as designated Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services 10% after deductible 30% after deductible













Generics $20





Page 20 of 41


Pharmacy In-Network

New York NY Platinum NYC Community PlanSM $20


$0 $0

$5,000 $10,000


0%

30%



$1,000 $2,000

$5,250 $10,500







$500/Admit


Emergency Room Services $500 per visit Paid as designated Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services $35 per visit 30% after deductible

Imaging (CT/PET Scans, MRIs) $35 per visit 30% after deductible



Laboratory Outpatient and Professional Services 0% 30% after deductible

X-rays and Diagnostic Imaging $35 per visit 30% after deductible

Skilled Nursing Facility $500/Admit 30% after deductible


$150 per visit


Outpatient Surgery Physician/Surgical Services 0% 30% after deductible


$100

Generics $20





Page 21 of 41


Pharmacy In-Network

New York NY Platinum NYC Community PlanSM $30


$0 $0

$5,000 $10,000


0%

30%



$1,000 $2,000

$5,250 $10,500







$1,000/Admit


Emergency Room Services $500 per visit Paid as designated Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services $50 per visit 30% after deductible

Imaging (CT/PET Scans, MRIs) $50 per visit 30% after deductible



Laboratory Outpatient and Professional Services 0% 30% after deductible

X-rays and Diagnostic Imaging $50 per visit 30% after deductible

Skilled Nursing Facility $1,000/Admit 30% after deductible


$150 per visit


Outpatient Surgery Physician/Surgical Services 0% 30% after deductible


$100

Generics $20





Page 22 of 41

Summary of Features In Network Out of Network

Pharmacy In-Network Out-of-Network

New York NY Silver OAMC 3000 100/70 HSA


$3,000 $6,000

$4,000 $8,000


0%

30%



$5,500

$11,000

$8,000 $16,000







0% after deductible


Emergency Room Services 0% after deductible Paid as In-Network Mental/Behavioral Health and Substance Abuse Disorder Outpatient Services 0% after deductible 30% after deductible



Preventive Care/Screening/Immunization 0% 30% after deductible





0% after deductible






Generics $20

$20 + 20%


$40 + 20%


$60 + 20%



Page 23 of 41



New York NY Silver OAMC 2800 90/70 HSA


$2,800 $5,600

$3,500 $7,000


10%

30%



$5,000

$10,000

$7,000 $14,000























Generics $20

$20 + 20%


$40 + 20%


$60 + 20%



Page 24 of 41



New York NY Silver OAMC 3000 100/80 HSA FH


$3,000 $6,000

$4,000 $8,000


0%

20%



$5,500

$11,000

$8,000 $16,000







0% after deductible










0% after deductible






Generics $20

$20 + 20%


$40 + 20%


$60 + 20%



Page 25 of 41


Pharmacy In-Network

New York NY Silver OAEPO 4500 100% L


$4,500 $9,000


0%



$4,500 $9,000



$25 per visit



0% after deductible





0% after deductible




Generics $20





Page 26 of 41


Pharmacy In-Network

New York NY Bronze OAEPO 6850 100% L

Deductible



0%






0% after deductible



0% after deductible





0% after deductible




Generics $20





Page 27 of 41

Summary of Features

Pharmacy

New York NY Silver Indemnity 2500 80%


$2,500 $5,000


20%

$0 once out-of-pocket max is satisfied


$5,500 $11,000









Imaging (CT/PET Scans, MRIs) 20% after deductible

Rehabilitative Speech Therapy 20% after deductible Rehabilitative Occupational and Rehabilitative Physical Therapy 20% after deductible


Laboratory Outpatient and Professional Services 20% after deductible

X-rays and Diagnostic Imaging 20% after deductible

Skilled Nursing Facility 20% after deductible





$100

Generics $20





Page 28 of 41


Pharmacy In-Network

New York NY Gold EPO 1000 90%

Deductible



10%






$30 per visit











$100

Generics $20





Page 29 of 41


Pharmacy In-Network

New York NY Silver EPO 2000 60%

Deductible



40%






$30 per visit











$100

Generics $20





Page 30 of 41


Pharmacy In-Network

New York NY Silver EPO 2000 80%

Deductible



20%






$40 per visit











$100

Generics $20





Page 31 of 41


Pharmacy In-Network

New York NY Bronze EPO 5700 70% HSA PY

Deductible



30%


















Generics $20





Page 32 of 41


Pharmacy In-Network

New York NY Gold OAEPO AP 1000 90%

Deductible



10%






$30 per visit











$100

Generics $20





Page 33 of 41


Pharmacy In-Network

New York NY Silver OAEPO AP 2000 80%

Deductible



20%






$40 per visit











$100

Generics $20





Page 34 of 41


Pharmacy In-Network

New York NY Bronze OAEPO AP 4500 70%

Deductible



30%


















Generics $20





Page 35 of 41


Pharmacy In-Network

New York NY Gold AWH OAEPO 1000 90%

Deductible



10%






$30 per visit











$100

Generics $20





Page 36 of 41


Pharmacy In-Network

New York NY Silver AWH OAEPO 2000 80%

Deductible



20%






$40 per visit











$100

Generics $20





Page 37 of 41


Pharmacy In-Network

New York NY Bronze AWH OAEPO 4500 70%

Deductible



30%


















Generics $20





Page 38 of 41


Pharmacy In-Network

New York NY Silver AWH OAEPO 2800 90% HSA PY

Deductible



10%


















Generics $20





Page 39 of 41


Pharmacy In-Network

New York NY Bronze AWH OAEPO 5700 70%HSA PY

Deductible



30%


















Generics $20





Page 40 of 41


Pharmacy In-Network

New York NY Silver AWH OAEPO 4500 100% L


$4,500 $9,000


0%



$4,500 $9,000



$25 per visit



0% after deductible





0% after deductible




Generics $20





Page 41 of 41


Pharmacy In-Network

New York NY Bronze AWH OAEPO 6850 100% L

Deductible



0%






0% after deductible



0% after deductible





0% after deductible




Generics $20



C-1

Aetna Life Insurance CompanyNew York Small Group

Rate Manual Section CPlan factors

Product NY SG 2017 Plan NameExchange ON/OFF Metallic Tier

Actuarial Value Plan Factors

EPO Gold OAEPO 1000 90% OFF Gold 78.24% 0.893461 EPO Platinum OAEPO $25 OFF Platinum 88.79% 1.065812 EPO Silver OAEPO 2000 60% OFF Silver 71.00% 0.770077 EPO Silver OAEPO 2000 80% OFF Silver 70.65% 0.782254 EPO Silver OAEPO 3000 70% OFF Silver 68.23% 0.744175 EPO Bronze OAEPO 3750 50% OFF Bronze 61.96% 0.656228 EPO Bronze OAEPO 4500 70% OFF Bronze 61.96% 0.634126 EPO Bronze OAEPO 5000 60% OFF Bronze 60.94% 0.628884 EPO Silver OAEPO 2800 90% HSA PY OFF Silver 69.86% 0.781842 EPO Bronze OAEPO 5400 50% HSA OFF Bronze 61.96% 0.600872 EPO Bronze OAEPO 5400 50% HSA PY OFF Bronze 61.96% 0.600872 EPO Bronze OAEPO 5700 70% HSA OFF Bronze 61.95% 0.627916 EPO Bronze OAEPO 5700 70% HSA PY OFF Bronze 61.95% 0.627916 EPO Gold Savings Plus OAEPO 1000 90% OFF Gold 78.06% 0.812552 EPO Silver Savings Plus OAEPO 2000 80% OFF Silver 70.24% 0.710378 EPO Silver Savings Plus OAEPO 2500 80% OFF Silver 68.34% 0.685724 EPO Bronze Savings Plus OAEPO 4500 60% OFF Bronze 61.91% 0.578080 EPO Silver SP OAEPO 2800 90% HSA PY OFF Silver 69.53% 0.702811 EPO Platinum NYC Community PlanSM $20 OFF Platinum 90.05% 0.968800 EPO Platinum NYC Community PlanSM $30 OFF Platinum 89.39% 0.962137 POS Silver OAMC 3000 100/70 HSA OFF Silver 71.93% 0.817402 POS Silver OAMC 2800 90/70 HSA OFF Silver 70.64% 0.785467 POS Silver OAMC 3000 100/80 HSA FH OFF Silver 71.93% 0.817402 EPO Silver OAEPO 4500 100% L OFF Silver 71.40% 0.782449 EPO Bronze OAEPO 6850 100% L OFF Bronze 61.36% 0.697695

Indemnity Silver Indemnity 2500 80% OFF Silver 70.26% 1.020291 EPO Gold EPO 1000 90% OFF Gold 78.24% 0.893461 EPO Silver EPO 2000 60% OFF Silver 71.00% 0.770077 EPO Silver EPO 2000 80% OFF Silver 70.65% 0.782254 EPO Bronze EPO 5700 70% HSA PY OFF Bronze 61.95% 0.627916 EPO Gold OAEPO AP 1000 90% OFF Gold 78.24% 0.862705 EPO Silver OAEPO AP 2000 80% OFF Silver 70.65% 0.755326 EPO Bronze OAEPO AP 4500 70% OFF Bronze 61.96% 0.612297 EPO Gold AWH OAEPO 1000 90% OFF Gold 78.24% 0.767789 EPO Silver AWH OAEPO 2000 80% OFF Silver 70.65% 0.672224 EPO Bronze AWH OAEPO 4500 70% OFF Bronze 61.96% 0.544931 EPO Silver AWH OAEPO 2800 90% HSA PY OFF Silver 69.86% 0.671869 EPO Bronze AWH OAEPO 5700 70%HSA PY OFF Bronze 61.95% 0.539595 EPO Silver AWH OAEPO 4500 100% L OFF Silver 71.40% 0.671255 EPO Bronze AWH OAEPO 6850 100% L OFF Bronze 60.33% 0.581076

C-1

EPO Gold OAEPO 1000 90% DEP30 OFF Gold 78.24% 0.920265 EPO Platinum OAEPO $25 DEP30 OFF Platinum 88.79% 1.097786 EPO Silver OAEPO 2000 60% DEP30 OFF Silver 71.00% 0.793179 EPO Silver OAEPO 2000 80% DEP30 OFF Silver 70.65% 0.805721 EPO Silver OAEPO 3000 70% DEP30 OFF Silver 68.23% 0.766501 EPO Bronze OAEPO 3750 50% DEP30 OFF Bronze 61.96% 0.675915 EPO Bronze OAEPO 4500 70% DEP30 OFF Bronze 61.96% 0.653149 EPO Bronze OAEPO 5000 60% DEP30 OFF Bronze 60.94% 0.647750 EPO Silver OAEPO 2800 90% HSA PY DEP30 OFF Silver 69.86% 0.805297 EPO Bronze OAEPO 5400 50% HSA DEP30 OFF Bronze 61.96% 0.618899 EPO Bronze OAEPO 5400 50% HSA PY DEP30 OFF Bronze 61.96% 0.618899 EPO Bronze OAEPO 5700 70% HSA DEP30 OFF Bronze 61.95% 0.646754 EPO Bronze OAEPO 5700 70% HSA PY DEP30 OFF Bronze 61.95% 0.646754 EPO Gold Savings Plus OAEPO 1000 90% DEP30 OFF Gold 78.06% 0.836928 EPO Silver Savings Plus OAEPO 2000 80% DEP30 OFF Silver 70.24% 0.731690 EPO Silver Savings Plus OAEPO 2500 80% DEP30 OFF Silver 68.34% 0.706296 EPO Bronze Savings Plus OAEPO 4500 60% DEP30 OFF Bronze 61.91% 0.595422 EPO Silver SP OAEPO 2800 90% HSA PY DEP30 OFF Silver 69.53% 0.723895 EPO Platinum NYC Community PlanSM $20 DEP30 OFF Platinum 90.05% 0.997864 EPO Platinum NYC Community PlanSM $30 DEP30 OFF Platinum 89.39% 0.991001 POS Silver OAMC 3000 100/70 HSA DEP30 OFF Silver 71.93% 0.841924 POS Silver OAMC 2800 90/70 HSA DEP30 OFF Silver 70.64% 0.809031 POS Silver OAMC 3000 100/80 HSA FH DEP30 OFF Silver 71.93% 0.841924 EPO Silver OAEPO 4500 100% L DEP30 OFF Silver 71.40% 0.805922 EPO Bronze OAEPO 6850 100% L DEP30 OFF Bronze 61.36% 0.718626

Indemnity Silver Indemnity 2500 80% DEP30 OFF Silver 70.26% 1.050900 EPO Gold EPO 1000 90% DEP30 OFF Gold 78.24% 0.920265 EPO Silver EPO 2000 60% DEP30 OFF Silver 71.00% 0.793179 EPO Silver EPO 2000 80% DEP30 OFF Silver 70.65% 0.805721 EPO Bronze EPO 5700 70% HSA PY DEP30 OFF Bronze 61.95% 0.646754 EPO Gold OAEPO AP 1000 90% DEP30 OFF Gold 78.24% 0.888586 EPO Silver OAEPO AP 2000 80% DEP30 OFF Silver 70.65% 0.777986 EPO Bronze OAEPO AP 4500 70% DEP30 OFF Bronze 61.96% 0.630666 EPO Gold AWH OAEPO 1000 90% DEP30 OFF Gold 78.24% 0.790822 EPO Silver AWH OAEPO 2000 80% DEP30 OFF Silver 70.65% 0.692390 EPO Bronze AWH OAEPO 4500 70% DEP30 OFF Bronze 61.96% 0.561279 EPO Silver AWH OAEPO 2800 90% HSA PY DEP30 OFF Silver 69.86% 0.692026 EPO Bronze AWH OAEPO 5700 70%HSA PY DEP30 OFF Bronze 61.95% 0.555783 EPO Silver AWH OAEPO 4500 100% L DEP30 OFF Silver 71.40% 0.691392 EPO Bronze AWH OAEPO 6850 100% L DEP30 OFF Bronze 60.33% 0.598508


D-1

1Q 2017 Rate SummaryRate Tables - Medical PlansNYRA01NYRA07

New HIOS ID Plan Name Metal Level PlanSingle

Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily

Premium Rate1Q 2017 1Q 2017 1Q 2017 1Q 2017

17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $481.56 $818.66 $963.13 $1,372.4517210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $465.34 $791.08 $930.69 $1,326.2317210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $461.50 $784.54 $922.99 $1,315.2717210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $440.94 $749.60 $881.88 $1,256.6817210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $440.94 $749.60 $881.88 $1,256.6817210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $460.79 $783.34 $921.57 $1,313.2417210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $460.79 $783.34 $921.57 $1,313.2417210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $424.21 $721.17 $848.43 $1,209.0117210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $511.99 $870.39 $1,023.99 $1,459.1817210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $460.79 $783.34 $921.57 $1,313.2417210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $449.32 $763.85 $898.65 $1,280.5817210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $399.89 $679.81 $799.78 $1,139.6817210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $395.97 $673.15 $791.95 $1,128.5217210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $426.41 $724.90 $852.83 $1,215.2817210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $496.01 $843.22 $992.02 $1,413.6317210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $479.30 $814.82 $958.61 $1,366.0117210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $475.34 $808.08 $950.68 $1,354.7217210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $454.17 $772.09 $908.34 $1,294.3817210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $454.17 $772.09 $908.34 $1,294.3817210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $474.61 $806.84 $949.22 $1,352.6417210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $474.61 $806.84 $949.22 $1,352.6417210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $436.94 $742.80 $873.88 $1,245.2817210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $527.35 $896.50 $1,054.70 $1,502.9517210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $474.61 $806.84 $949.22 $1,352.6417210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $462.80 $786.77 $925.61 $1,318.9917210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $411.89 $700.21 $823.77 $1,173.8717210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $407.85 $693.35 $815.71 $1,162.3817210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $439.21 $746.65 $878.41 $1,251.74

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $655.65 $1,114.61 $1,311.30 $1,868.6117210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $596.28 $1,013.67 $1,192.56 $1,699.3917210NY0090198 NY Gold EPO 1000 90% Gold EPO $655.65 $1,114.61 $1,311.30 $1,868.6117210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $633.08 $1,076.24 $1,266.17 $1,804.2917210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $563.43 $957.83 $1,126.86 $1,605.7817210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $675.32 $1,148.05 $1,350.64 $1,924.6717210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $614.17 $1,044.08 $1,228.33 $1,750.3717210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $675.32 $1,148.05 $1,350.64 $1,924.6717210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $652.07 $1,108.53 $1,304.15 $1,858.4117210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $580.33 $986.57 $1,160.66 $1,653.95

17210NY0090173 NY Platinum OAEPO $25 Platinum EPO $782.13 $1,329.62 $1,564.26 $2,229.0717210NY0090174 NY Platinum OAEPO $25 DEP30 Platinum EPO $805.59 $1,369.51 $1,611.19 $2,295.94

17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $565.11 $960.69 $1,130.22 $1,610.5617210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $574.04 $975.88 $1,148.09 $1,636.0317210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $546.10 $928.37 $1,092.20 $1,556.3917210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $573.74 $975.36 $1,147.49 $1,635.1717210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $521.30 $886.21 $1,042.60 $1,485.7017210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $503.21 $855.45 $1,006.42 $1,434.1417210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $515.75 $876.77 $1,031.49 $1,469.8817210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $599.84 $1,019.72 $1,199.68 $1,709.5417210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $576.40 $979.88 $1,152.81 $1,642.7517210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $599.84 $1,019.72 $1,199.68 $1,709.5417210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $748.72 $1,272.83 $1,497.45 $2,133.8717210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $574.19 $976.12 $1,148.38 $1,636.4417210NY0090180 NY Silver EPO 2000 60% Silver EPO $565.11 $960.69 $1,130.22 $1,610.5617210NY0090182 NY Silver EPO 2000 80% Silver EPO $574.04 $975.88 $1,148.09 $1,636.0317210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $554.28 $942.28 $1,108.57 $1,579.7117210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $493.30 $838.61 $986.60 $1,405.9117210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $493.04 $838.17 $986.08 $1,405.1717210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $492.59 $837.40 $985.18 $1,403.8817210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $582.06 $989.51 $1,164.12 $1,658.8817210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $591.27 $1,005.15 $1,182.53 $1,685.1117210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $562.48 $956.22 $1,124.97 $1,603.0817210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $590.95 $1,004.62 $1,181.91 $1,684.2217210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $536.94 $912.80 $1,073.88 $1,530.2817210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $518.30 $881.12 $1,036.61 $1,477.1717210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $531.22 $903.07 $1,062.44 $1,513.9717210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $617.83 $1,050.32 $1,235.67 $1,760.8217210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $593.69 $1,009.28 $1,187.39 $1,692.0317210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $617.83 $1,050.32 $1,235.67 $1,760.8217210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $771.19 $1,311.02 $1,542.37 $2,197.8817210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $591.41 $1,005.40 $1,182.83 $1,685.5317210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $582.06 $989.51 $1,164.12 $1,658.8817210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $591.27 $1,005.15 $1,182.53 $1,685.1117210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $570.91 $970.55 $1,141.83 $1,627.1017210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $508.10 $863.77 $1,016.20 $1,448.0817210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $507.83 $863.32 $1,015.66 $1,447.3217210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $507.37 $862.52 $1,014.73 $1,446.00


D-2



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $499.29 $848.80 $998.59 $1,422.9917210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $482.48 $820.21 $964.96 $1,375.0617210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $478.49 $813.43 $956.98 $1,363.7017210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $457.18 $777.20 $914.35 $1,302.9517210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $457.18 $777.20 $914.35 $1,302.9517210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $477.75 $812.18 $955.51 $1,361.6017210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $477.75 $812.18 $955.51 $1,361.6017210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $439.84 $747.72 $879.67 $1,253.5317210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $530.85 $902.44 $1,061.69 $1,512.9117210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $477.75 $812.18 $955.51 $1,361.6017210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $465.87 $791.98 $931.74 $1,327.7317210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $414.61 $704.84 $829.23 $1,181.6517210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $410.55 $697.94 $821.11 $1,170.0817210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $442.11 $751.60 $884.23 $1,260.0317210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $514.27 $874.27 $1,028.55 $1,465.6817210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $496.95 $844.82 $993.90 $1,416.3117210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $492.84 $837.84 $985.69 $1,404.6117210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $470.89 $800.52 $941.79 $1,342.0417210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $470.89 $800.52 $941.79 $1,342.0417210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $492.09 $836.55 $984.17 $1,402.4517210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $492.09 $836.55 $984.17 $1,402.4517210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $453.03 $770.15 $906.06 $1,291.1417210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $546.77 $929.51 $1,093.54 $1,558.3017210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $492.09 $836.55 $984.17 $1,402.4517210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $479.85 $815.74 $959.69 $1,367.5617210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $427.05 $725.99 $854.10 $1,217.1017210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $422.87 $718.88 $845.74 $1,205.1817210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $455.38 $774.14 $910.76 $1,297.83

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $679.79 $1,155.65 $1,359.59 $1,937.4217210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $618.23 $1,051.00 $1,236.47 $1,761.9717210NY0090198 NY Gold EPO 1000 90% Gold EPO $679.79 $1,155.65 $1,359.59 $1,937.4217210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $656.39 $1,115.87 $1,312.79 $1,870.7217210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $584.18 $993.10 $1,168.35 $1,664.9017210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $700.19 $1,190.32 $1,400.38 $1,995.5417210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $636.78 $1,082.53 $1,273.56 $1,814.8317210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $700.19 $1,190.32 $1,400.38 $1,995.5417210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $676.09 $1,149.35 $1,352.17 $1,926.8417210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $601.70 $1,022.89 $1,203.40 $1,714.85


17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $585.92 $996.06 $1,171.83 $1,669.8617210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $595.18 $1,011.81 $1,190.36 $1,696.2717210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $566.21 $962.56 $1,132.42 $1,613.7017210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $594.87 $1,011.28 $1,189.74 $1,695.3817210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $540.50 $918.84 $1,080.99 $1,540.4117210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $521.74 $886.95 $1,043.47 $1,486.9517210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $534.74 $909.05 $1,069.48 $1,524.0017210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $621.92 $1,057.27 $1,243.85 $1,772.4917210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $597.63 $1,015.97 $1,195.25 $1,703.2417210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $621.92 $1,057.27 $1,243.85 $1,772.4917210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $776.29 $1,319.70 $1,552.59 $2,212.4417210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $595.33 $1,012.06 $1,190.66 $1,696.6917210NY0090180 NY Silver EPO 2000 60% Silver EPO $585.92 $996.06 $1,171.83 $1,669.8617210NY0090182 NY Silver EPO 2000 80% Silver EPO $595.18 $1,011.81 $1,190.36 $1,696.2717210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $574.69 $976.98 $1,149.39 $1,637.8817210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $511.47 $869.49 $1,022.93 $1,457.6817210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $511.20 $869.03 $1,022.39 $1,456.9117210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $510.73 $868.24 $1,021.46 $1,455.5817210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $603.49 $1,025.94 $1,206.99 $1,719.9617210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $613.04 $1,042.16 $1,226.07 $1,747.1617210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $583.20 $991.43 $1,166.39 $1,662.1117210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $612.71 $1,041.62 $1,225.43 $1,746.2417210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $556.71 $946.41 $1,113.42 $1,586.6217210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $537.39 $913.56 $1,074.78 $1,531.5617210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $550.78 $936.33 $1,101.56 $1,569.7217210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $640.58 $1,088.99 $1,281.17 $1,825.6617210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $615.56 $1,046.44 $1,231.11 $1,754.3317210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $640.58 $1,088.99 $1,281.17 $1,825.6617210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $799.58 $1,359.29 $1,599.17 $2,278.8117210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $613.19 $1,042.42 $1,226.38 $1,747.5917210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $603.49 $1,025.94 $1,206.99 $1,719.9617210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $613.04 $1,042.16 $1,226.07 $1,747.1617210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $591.94 $1,006.29 $1,183.87 $1,687.0117210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $526.81 $895.58 $1,053.62 $1,501.4117210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $526.53 $895.10 $1,053.06 $1,500.6217210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $526.05 $894.28 $1,052.10 $1,499.24


D-3



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $517.71 $880.11 $1,035.43 $1,475.4817210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $500.28 $850.47 $1,000.55 $1,425.7917210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $496.14 $843.44 $992.28 $1,414.0017210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $474.04 $805.87 $948.08 $1,351.0217210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $474.04 $805.87 $948.08 $1,351.0217210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $495.38 $842.14 $990.75 $1,411.8217210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $495.38 $842.14 $990.75 $1,411.8217210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $456.06 $775.30 $912.12 $1,299.7717210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $550.43 $935.73 $1,100.85 $1,568.7217210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $495.38 $842.14 $990.75 $1,411.8217210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $483.05 $821.19 $966.11 $1,376.7117210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $429.91 $730.84 $859.82 $1,225.2417210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $425.70 $723.69 $851.40 $1,213.2417210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $458.42 $779.32 $916.85 $1,306.5117210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $533.24 $906.52 $1,066.49 $1,519.7517210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $515.28 $875.98 $1,030.57 $1,468.5617210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $511.02 $868.74 $1,022.05 $1,456.4217210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $488.26 $830.05 $976.53 $1,391.5517210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $488.26 $830.05 $976.53 $1,391.5517210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $510.24 $867.41 $1,020.48 $1,454.1817210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $510.24 $867.41 $1,020.48 $1,454.1817210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $469.74 $798.56 $939.48 $1,338.7617210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $566.94 $963.80 $1,133.88 $1,615.7817210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $510.24 $867.41 $1,020.48 $1,454.1817210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $497.55 $845.83 $995.09 $1,418.0117210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $442.81 $752.77 $885.61 $1,262.0017210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $438.47 $745.40 $876.94 $1,249.6417210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $472.18 $802.70 $944.35 $1,345.70

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $704.87 $1,198.28 $1,409.74 $2,008.8817210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $641.04 $1,089.77 $1,282.08 $1,826.9617210NY0090198 NY Gold EPO 1000 90% Gold EPO $704.87 $1,198.28 $1,409.74 $2,008.8817210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $680.61 $1,157.03 $1,361.21 $1,939.7317210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $605.73 $1,029.73 $1,211.45 $1,726.3217210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $726.02 $1,234.23 $1,452.03 $2,069.1517210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $660.27 $1,122.46 $1,320.54 $1,881.7717210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $726.02 $1,234.23 $1,452.03 $2,069.1517210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $701.02 $1,191.74 $1,402.05 $1,997.9217210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $623.90 $1,060.62 $1,247.79 $1,778.11


17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $607.53 $1,032.80 $1,215.06 $1,731.4617210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $617.14 $1,049.13 $1,234.27 $1,758.8417210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $587.10 $998.06 $1,174.19 $1,673.2217210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $616.81 $1,048.58 $1,233.62 $1,757.9117210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $560.43 $952.74 $1,120.87 $1,597.2317210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $540.98 $919.67 $1,081.97 $1,541.8017210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $554.46 $942.59 $1,108.93 $1,580.2217210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $644.87 $1,096.27 $1,289.73 $1,837.8717210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $619.67 $1,053.44 $1,239.34 $1,766.0717210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $644.87 $1,096.27 $1,289.73 $1,837.8717210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $804.93 $1,368.38 $1,609.86 $2,294.0517210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $617.29 $1,049.39 $1,234.58 $1,759.2817210NY0090180 NY Silver EPO 2000 60% Silver EPO $607.53 $1,032.80 $1,215.06 $1,731.4617210NY0090182 NY Silver EPO 2000 80% Silver EPO $617.14 $1,049.13 $1,234.27 $1,758.8417210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $595.89 $1,013.02 $1,191.79 $1,698.3017210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $530.33 $901.56 $1,060.66 $1,511.4517210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $530.05 $901.09 $1,060.10 $1,510.6517210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $529.57 $900.27 $1,059.14 $1,509.2717210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $625.76 $1,063.79 $1,251.51 $1,783.4117210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $635.65 $1,080.61 $1,271.30 $1,811.6117210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $604.71 $1,028.01 $1,209.42 $1,723.4217210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $635.32 $1,080.04 $1,270.63 $1,810.6517210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $577.25 $981.32 $1,154.49 $1,645.1517210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $557.21 $947.26 $1,114.42 $1,588.0617210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $571.10 $970.86 $1,142.19 $1,627.6317210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $664.21 $1,129.16 $1,328.42 $1,893.0017210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $638.26 $1,085.05 $1,276.52 $1,819.0517210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $664.21 $1,129.16 $1,328.42 $1,893.0017210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $829.08 $1,409.43 $1,658.16 $2,362.8717210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $635.81 $1,080.88 $1,271.62 $1,812.0617210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $625.76 $1,063.79 $1,251.51 $1,783.4117210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $635.65 $1,080.61 $1,271.30 $1,811.6117210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $613.77 $1,043.41 $1,227.54 $1,749.2517210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $546.24 $928.61 $1,092.48 $1,556.7917210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $545.95 $928.12 $1,091.91 $1,555.9717210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $545.45 $927.27 $1,090.91 $1,554.54


D-4



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $536.84 $912.64 $1,073.69 $1,530.0117210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $518.76 $881.90 $1,037.53 $1,478.4717210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $514.47 $874.61 $1,028.95 $1,466.2517210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $491.56 $835.65 $983.12 $1,400.9417210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $491.56 $835.65 $983.12 $1,400.9417210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $513.68 $873.26 $1,027.37 $1,464.0017210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $513.68 $873.26 $1,027.37 $1,464.0017210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $472.91 $803.95 $945.83 $1,347.8017210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $570.77 $970.30 $1,141.53 $1,626.6917210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $513.68 $873.26 $1,027.37 $1,464.0017210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $500.91 $851.54 $1,001.81 $1,427.5817210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $445.79 $757.85 $891.59 $1,270.5217210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $441.43 $750.43 $882.86 $1,258.0717210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $475.36 $808.12 $950.73 $1,354.7917210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $552.95 $940.01 $1,105.90 $1,575.9117210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $534.33 $908.35 $1,068.65 $1,522.8317210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $529.91 $900.84 $1,059.82 $1,510.2417210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $506.31 $860.72 $1,012.61 $1,442.9717210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $506.31 $860.72 $1,012.61 $1,442.9717210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $529.09 $899.46 $1,058.19 $1,507.9217210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $529.09 $899.46 $1,058.19 $1,507.9217210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $487.10 $828.07 $974.20 $1,388.2417210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $587.89 $999.41 $1,175.78 $1,675.4917210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $529.09 $899.46 $1,058.19 $1,507.9217210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $515.93 $877.09 $1,031.87 $1,470.4117210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $459.17 $780.59 $918.34 $1,308.6317210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $454.67 $772.94 $909.35 $1,295.8217210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $489.62 $832.36 $979.25 $1,395.43



17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $629.98 $1,070.97 $1,259.96 $1,795.4517210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $639.94 $1,087.90 $1,279.89 $1,823.8417210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $608.79 $1,034.95 $1,217.58 $1,735.0617210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $639.61 $1,087.33 $1,279.21 $1,822.8817210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $581.14 $987.94 $1,162.29 $1,656.2617210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $560.97 $953.66 $1,121.95 $1,598.7817210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $574.95 $977.42 $1,149.91 $1,638.6117210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $668.70 $1,136.78 $1,337.39 $1,905.7917210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $642.57 $1,092.37 $1,285.14 $1,831.3317210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $668.70 $1,136.78 $1,337.39 $1,905.7917210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $834.68 $1,418.95 $1,669.35 $2,378.8217210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $640.10 $1,088.17 $1,280.20 $1,824.2917210NY0090180 NY Silver EPO 2000 60% Silver EPO $629.98 $1,070.97 $1,259.96 $1,795.4517210NY0090182 NY Silver EPO 2000 80% Silver EPO $639.94 $1,087.90 $1,279.89 $1,823.8417210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $617.91 $1,050.45 $1,235.83 $1,761.0517210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $549.93 $934.88 $1,099.86 $1,567.3017210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $549.64 $934.39 $1,099.28 $1,566.4717210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $549.14 $933.53 $1,098.27 $1,565.0417210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $648.88 $1,103.10 $1,297.76 $1,849.3117210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $659.14 $1,120.54 $1,318.28 $1,878.5517210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $627.06 $1,065.99 $1,254.11 $1,787.1117210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $658.79 $1,119.95 $1,317.59 $1,877.5617210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $598.58 $1,017.58 $1,197.16 $1,705.9517210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $577.80 $982.27 $1,155.61 $1,646.7417210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $592.20 $1,006.74 $1,184.40 $1,687.7717210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $688.76 $1,170.89 $1,377.52 $1,962.9617210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $661.85 $1,125.14 $1,323.70 $1,886.2717210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $688.76 $1,170.89 $1,377.52 $1,962.9617210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $859.72 $1,461.52 $1,719.43 $2,450.1917210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $659.31 $1,120.82 $1,318.61 $1,879.0217210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $648.88 $1,103.10 $1,297.76 $1,849.3117210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $659.14 $1,120.54 $1,318.28 $1,878.5517210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $636.45 $1,081.97 $1,272.90 $1,813.8917210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $566.43 $962.93 $1,132.85 $1,614.3217210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $566.13 $962.42 $1,132.26 $1,613.4717210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $565.61 $961.54 $1,131.22 $1,611.99


D-5

1Q 2017 Rate SummaryRate Tables - Medical PlansNYRA02


Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $528.54 $898.53 $1,057.09 $1,506.3517210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $510.74 $868.26 $1,021.49 $1,455.6217210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $506.52 $861.09 $1,013.04 $1,443.5817210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $483.96 $822.73 $967.92 $1,379.2817210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $483.96 $822.73 $967.92 $1,379.2817210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $505.74 $859.76 $1,011.48 $1,441.3617210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $505.74 $859.76 $1,011.48 $1,441.3617210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $465.60 $791.52 $931.20 $1,326.9717210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $561.94 $955.30 $1,123.89 $1,601.5417210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $505.74 $859.76 $1,011.48 $1,441.3617210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $493.16 $838.37 $986.32 $1,405.5117210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $438.90 $746.13 $877.81 $1,250.8717210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $434.60 $738.83 $869.21 $1,238.6217210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $468.01 $795.63 $936.03 $1,333.8417210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $544.40 $925.48 $1,088.80 $1,551.5417210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $526.06 $894.31 $1,052.13 $1,499.2817210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $521.72 $886.92 $1,043.43 $1,486.8917210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $498.48 $847.41 $996.96 $1,420.6617210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $498.48 $847.41 $996.96 $1,420.6617210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $520.91 $885.55 $1,041.83 $1,484.6017210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $520.91 $885.55 $1,041.83 $1,484.6017210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $479.57 $815.27 $959.14 $1,366.7717210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $578.80 $983.96 $1,157.60 $1,649.5817210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $520.91 $885.55 $1,041.83 $1,484.6017210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $507.96 $863.53 $1,015.91 $1,447.6717210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $452.07 $768.52 $904.14 $1,288.4017210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $447.64 $760.99 $895.29 $1,275.7817210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $482.06 $819.49 $964.11 $1,373.86



17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $620.24 $1,054.41 $1,240.48 $1,767.6917210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $630.05 $1,071.08 $1,260.10 $1,795.6417210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $599.38 $1,018.94 $1,198.76 $1,708.2317210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $629.72 $1,070.52 $1,259.43 $1,794.6917210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $572.16 $972.67 $1,144.32 $1,630.6517210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $552.30 $938.91 $1,104.60 $1,574.0617210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $566.06 $962.31 $1,132.13 $1,613.2817210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $658.36 $1,119.21 $1,316.72 $1,876.3217210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $632.64 $1,075.48 $1,265.27 $1,803.0217210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $658.36 $1,119.21 $1,316.72 $1,876.3217210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $821.77 $1,397.01 $1,643.54 $2,342.0517210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $630.21 $1,071.35 $1,260.41 $1,796.0917210NY0090180 NY Silver EPO 2000 60% Silver EPO $620.24 $1,054.41 $1,240.48 $1,767.6917210NY0090182 NY Silver EPO 2000 80% Silver EPO $630.05 $1,071.08 $1,260.10 $1,795.6417210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $608.36 $1,034.21 $1,216.72 $1,733.8317210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $541.43 $920.43 $1,082.86 $1,543.0717210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $541.14 $919.94 $1,082.28 $1,542.2517210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $540.65 $919.10 $1,081.30 $1,540.8517210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $638.85 $1,086.04 $1,277.70 $1,820.7217210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $648.95 $1,103.22 $1,297.90 $1,849.5117210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $617.36 $1,049.51 $1,234.72 $1,759.4817210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $648.61 $1,102.63 $1,297.22 $1,848.5317210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $589.32 $1,001.85 $1,178.65 $1,679.5717210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $568.87 $967.08 $1,137.74 $1,621.2817210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $583.05 $991.18 $1,166.09 $1,661.6817210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $678.11 $1,152.79 $1,356.22 $1,932.6117210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $651.62 $1,107.75 $1,303.23 $1,857.1117210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $678.11 $1,152.79 $1,356.22 $1,932.6117210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $846.42 $1,438.92 $1,692.85 $2,412.3117210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $649.11 $1,103.49 $1,298.22 $1,849.9717210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $638.85 $1,086.04 $1,277.70 $1,820.7217210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $648.95 $1,103.22 $1,297.90 $1,849.5117210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $626.61 $1,065.24 $1,253.22 $1,785.8417210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $557.67 $948.04 $1,115.34 $1,589.3617210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $557.38 $947.54 $1,114.75 $1,588.5217210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $556.87 $946.67 $1,113.73 $1,587.07


D-6



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $548.01 $931.61 $1,096.01 $1,561.8217210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $529.55 $900.23 $1,059.10 $1,509.2217210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $525.17 $892.79 $1,050.34 $1,496.7417210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $501.78 $853.03 $1,003.56 $1,430.0717210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $501.78 $853.03 $1,003.56 $1,430.0717210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $524.36 $891.42 $1,048.73 $1,494.4417210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $524.36 $891.42 $1,048.73 $1,494.4417210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $482.75 $820.67 $965.49 $1,375.8317210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $582.63 $990.48 $1,165.27 $1,660.5117210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $524.36 $891.42 $1,048.73 $1,494.4417210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $511.32 $869.24 $1,022.64 $1,457.2617210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $455.06 $773.61 $910.13 $1,296.9317210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $450.61 $766.03 $901.22 $1,284.2317210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $485.25 $824.92 $970.50 $1,382.9617210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $564.45 $959.56 $1,128.89 $1,608.6717210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $545.44 $927.24 $1,090.87 $1,554.4917210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $540.93 $919.58 $1,081.85 $1,541.6417210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $516.83 $878.62 $1,033.67 $1,472.9817210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $516.83 $878.62 $1,033.67 $1,472.9817210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $540.09 $918.16 $1,080.19 $1,539.2717210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $540.09 $918.16 $1,080.19 $1,539.2717210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $497.23 $845.29 $994.46 $1,417.1017210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $600.11 $1,020.19 $1,200.23 $1,710.3317210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $540.09 $918.16 $1,080.19 $1,539.2717210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $526.66 $895.32 $1,053.32 $1,500.9817210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $468.72 $796.82 $937.43 $1,335.8417210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $464.13 $789.01 $928.25 $1,322.7617210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $499.81 $849.67 $999.61 $1,424.45



17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $643.08 $1,093.24 $1,286.16 $1,832.7817210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $653.25 $1,110.52 $1,306.50 $1,861.7617210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $621.45 $1,056.46 $1,242.90 $1,771.1317210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $652.90 $1,109.94 $1,305.81 $1,860.7817210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $593.23 $1,008.48 $1,186.45 $1,690.7017210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $572.64 $973.48 $1,145.28 $1,632.0217210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $586.91 $997.74 $1,173.81 $1,672.6917210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $682.60 $1,160.42 $1,365.20 $1,945.4117210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $655.93 $1,115.08 $1,311.86 $1,869.4117210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $682.60 $1,160.42 $1,365.20 $1,945.4117210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $852.03 $1,448.45 $1,704.06 $2,428.2917210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $653.41 $1,110.80 $1,306.82 $1,862.2217210NY0090180 NY Silver EPO 2000 60% Silver EPO $643.08 $1,093.24 $1,286.16 $1,832.7817210NY0090182 NY Silver EPO 2000 80% Silver EPO $653.25 $1,110.52 $1,306.50 $1,861.7617210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $630.76 $1,072.30 $1,261.52 $1,797.6717210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $561.36 $954.32 $1,122.73 $1,599.8917210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $561.07 $953.82 $1,122.14 $1,599.0417210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $560.56 $952.94 $1,121.11 $1,597.5817210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $662.37 $1,126.03 $1,324.74 $1,887.7617210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $672.85 $1,143.84 $1,345.69 $1,917.6117210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $640.09 $1,088.16 $1,280.19 $1,824.2717210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $672.49 $1,143.24 $1,344.98 $1,916.6017210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $611.02 $1,038.74 $1,222.05 $1,741.4217210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $589.82 $1,002.69 $1,179.64 $1,680.9817210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $604.51 $1,027.67 $1,209.03 $1,722.8717210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $703.08 $1,195.23 $1,406.16 $2,003.7717210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $675.61 $1,148.54 $1,351.22 $1,925.4917210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $703.08 $1,195.23 $1,406.16 $2,003.7717210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $877.59 $1,491.91 $1,755.18 $2,501.1417210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $673.01 $1,144.12 $1,346.03 $1,918.0917210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $662.37 $1,126.03 $1,324.74 $1,887.7617210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $672.85 $1,143.84 $1,345.69 $1,917.6117210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $649.68 $1,104.46 $1,299.37 $1,851.6017210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $578.20 $982.95 $1,156.41 $1,647.8817210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $577.90 $982.43 $1,155.80 $1,647.0217210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $577.37 $981.53 $1,154.74 $1,645.51


D-7



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $568.22 $965.98 $1,136.44 $1,619.4317210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $549.08 $933.44 $1,098.17 $1,564.8917210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $544.54 $925.73 $1,089.09 $1,551.9517210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $520.29 $884.49 $1,040.58 $1,482.8217210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $520.29 $884.49 $1,040.58 $1,482.8217210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $543.71 $924.30 $1,087.41 $1,549.5617210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $543.71 $924.30 $1,087.41 $1,549.5617210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $500.55 $850.94 $1,001.11 $1,426.5817210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $604.13 $1,027.02 $1,208.25 $1,721.7617210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $543.71 $924.30 $1,087.41 $1,549.5617210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $530.18 $901.31 $1,060.36 $1,511.0217210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $471.85 $802.15 $943.70 $1,344.7717210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $467.23 $794.29 $934.46 $1,331.6117210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $503.15 $855.35 $1,006.30 $1,433.9717210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $585.27 $994.96 $1,170.54 $1,668.0117210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $565.56 $961.44 $1,131.11 $1,611.8317210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $560.88 $953.50 $1,121.76 $1,598.5117210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $535.90 $911.03 $1,071.80 $1,527.3117210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $535.90 $911.03 $1,071.80 $1,527.3117210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $560.02 $952.03 $1,120.04 $1,596.0517210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $560.02 $952.03 $1,120.04 $1,596.0517210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $515.57 $876.47 $1,031.14 $1,469.3717210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $622.25 $1,057.83 $1,244.50 $1,773.4217210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $560.02 $952.03 $1,120.04 $1,596.0517210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $546.09 $928.35 $1,092.17 $1,556.3517210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $486.01 $826.21 $972.01 $1,385.1217210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $481.25 $818.12 $962.49 $1,371.5517210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $518.24 $881.01 $1,036.48 $1,476.99



17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $666.80 $1,133.56 $1,333.60 $1,900.3917210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $677.35 $1,151.49 $1,354.69 $1,930.4417210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $644.37 $1,095.44 $1,288.75 $1,836.4617210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $676.99 $1,150.88 $1,353.98 $1,929.4217210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $615.11 $1,045.69 $1,230.22 $1,753.0617210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $593.76 $1,009.39 $1,187.52 $1,692.2217210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $608.56 $1,034.55 $1,217.11 $1,734.3917210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $707.78 $1,203.23 $1,415.56 $2,017.1717210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $680.13 $1,156.22 $1,360.26 $1,938.3617210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $707.78 $1,203.23 $1,415.56 $2,017.1717210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $883.46 $1,501.88 $1,766.92 $2,517.8617210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $677.51 $1,151.77 $1,355.03 $1,930.9217210NY0090180 NY Silver EPO 2000 60% Silver EPO $666.80 $1,133.56 $1,333.60 $1,900.3917210NY0090182 NY Silver EPO 2000 80% Silver EPO $677.35 $1,151.49 $1,354.69 $1,930.4417210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $654.03 $1,111.85 $1,308.06 $1,863.9817210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $582.07 $989.52 $1,164.14 $1,658.9117210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $581.76 $989.00 $1,163.53 $1,658.0317210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $581.23 $988.10 $1,162.47 $1,656.5117210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $686.81 $1,167.57 $1,373.61 $1,957.4017210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $697.67 $1,186.03 $1,395.33 $1,988.3517210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $663.71 $1,128.30 $1,327.41 $1,891.5617210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $697.30 $1,185.41 $1,394.60 $1,987.3017210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $633.56 $1,077.06 $1,267.13 $1,805.6517210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $611.57 $1,039.68 $1,223.15 $1,742.9917210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $626.81 $1,065.58 $1,253.63 $1,786.4217210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $729.01 $1,239.32 $1,458.03 $2,077.6917210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $700.53 $1,190.90 $1,401.06 $1,996.5217210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $729.01 $1,239.32 $1,458.03 $2,077.6917210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $909.96 $1,546.94 $1,819.93 $2,593.4017210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $697.84 $1,186.33 $1,395.68 $1,988.8417210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $686.81 $1,167.57 $1,373.61 $1,957.4017210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $697.67 $1,186.03 $1,395.33 $1,988.3517210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $673.65 $1,145.21 $1,347.30 $1,919.9017210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $599.53 $1,019.21 $1,199.07 $1,708.6717210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $599.22 $1,018.67 $1,198.44 $1,707.7717210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $598.67 $1,017.74 $1,197.34 $1,706.21


D-8



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Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $589.22 $1,001.67 $1,178.44 $1,679.2717210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $569.37 $967.94 $1,138.75 $1,622.7217210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $564.67 $959.93 $1,129.33 $1,609.3017210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $539.52 $917.18 $1,079.03 $1,537.6217210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $539.52 $917.18 $1,079.03 $1,537.6217210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $563.80 $958.46 $1,127.60 $1,606.8217210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $563.80 $958.46 $1,127.60 $1,606.8217210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $519.05 $882.39 $1,038.10 $1,479.3017210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $626.45 $1,064.97 $1,252.90 $1,785.3917210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $563.80 $958.46 $1,127.60 $1,606.8217210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $549.77 $934.62 $1,099.55 $1,566.8617210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $489.29 $831.79 $978.57 $1,394.4717210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $484.50 $823.64 $968.99 $1,380.8117210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $521.74 $886.96 $1,043.48 $1,486.9617210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $606.90 $1,031.72 $1,213.79 $1,729.6517210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $586.45 $996.97 $1,172.91 $1,671.4017210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $581.61 $988.73 $1,163.21 $1,657.5817210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $555.70 $944.69 $1,111.40 $1,583.7517210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $555.70 $944.69 $1,111.40 $1,583.7517210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $580.71 $987.21 $1,161.43 $1,655.0317210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $580.71 $987.21 $1,161.43 $1,655.0317210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $534.62 $908.86 $1,069.24 $1,523.6717210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $645.25 $1,096.92 $1,290.49 $1,838.9517210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $580.71 $987.21 $1,161.43 $1,655.0317210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $566.27 $962.65 $1,132.53 $1,613.8617210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $503.97 $856.74 $1,007.93 $1,436.3017210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $499.03 $848.35 $998.06 $1,422.2417210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $537.39 $913.57 $1,074.79 $1,531.57



17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $691.44 $1,175.45 $1,382.89 $1,970.6117210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $702.38 $1,194.04 $1,404.75 $2,001.7717210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $668.19 $1,135.92 $1,336.37 $1,904.3317210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $702.01 $1,193.41 $1,404.01 $2,000.7217210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $637.84 $1,084.33 $1,275.68 $1,817.8417210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $615.70 $1,046.70 $1,231.41 $1,754.7517210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $631.05 $1,072.78 $1,262.09 $1,798.4817210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $733.94 $1,247.69 $1,467.87 $2,091.7217210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $705.26 $1,198.94 $1,410.52 $2,009.9917210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $733.94 $1,247.69 $1,467.87 $2,091.7217210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $916.11 $1,557.38 $1,832.21 $2,610.9017210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $702.55 $1,194.34 $1,405.10 $2,002.2717210NY0090180 NY Silver EPO 2000 60% Silver EPO $691.44 $1,175.45 $1,382.89 $1,970.6117210NY0090182 NY Silver EPO 2000 80% Silver EPO $702.38 $1,194.04 $1,404.75 $2,001.7717210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $678.20 $1,152.94 $1,356.40 $1,932.8617210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $603.58 $1,026.09 $1,207.16 $1,720.2117210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $603.26 $1,025.55 $1,206.53 $1,719.3017210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $602.71 $1,024.61 $1,205.42 $1,717.7317210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $712.19 $1,210.72 $1,424.37 $2,029.7317210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $723.45 $1,229.86 $1,446.89 $2,061.8217210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $688.23 $1,169.99 $1,376.46 $1,961.4617210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $723.07 $1,229.21 $1,446.13 $2,060.7417210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $656.98 $1,116.86 $1,313.95 $1,872.3817210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $634.17 $1,078.10 $1,268.35 $1,807.4017210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $649.98 $1,104.96 $1,299.95 $1,852.4317210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $755.95 $1,285.12 $1,511.91 $2,154.4717210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $726.42 $1,234.91 $1,452.84 $2,070.2917210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $755.95 $1,285.12 $1,511.91 $2,154.4717210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $943.59 $1,604.10 $1,887.18 $2,689.2317210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $723.63 $1,230.17 $1,447.26 $2,062.3417210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $712.19 $1,210.72 $1,424.37 $2,029.7317210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $723.45 $1,229.86 $1,446.89 $2,061.8217210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $698.54 $1,187.53 $1,397.09 $1,990.8517210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $621.69 $1,056.87 $1,243.38 $1,771.8117210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $621.36 $1,056.32 $1,242.72 $1,770.8817210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $620.79 $1,055.35 $1,241.59 $1,769.26


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17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $587.27 $998.36 $1,174.54 $1,673.7217210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $567.49 $964.74 $1,134.98 $1,617.3517210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $562.80 $956.76 $1,125.60 $1,603.9817210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $537.73 $914.15 $1,075.46 $1,532.5417210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $537.73 $914.15 $1,075.46 $1,532.5417210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $561.93 $955.29 $1,123.87 $1,601.5117210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $561.93 $955.29 $1,123.87 $1,601.5117210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $517.34 $879.47 $1,034.67 $1,474.4117210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $624.38 $1,061.45 $1,248.76 $1,779.4917210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $561.93 $955.29 $1,123.87 $1,601.5117210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $547.96 $931.53 $1,095.91 $1,561.6817210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $487.67 $829.04 $975.34 $1,389.8617210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $482.89 $820.92 $965.79 $1,376.2517210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $520.02 $884.03 $1,040.03 $1,482.0517210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $604.89 $1,028.31 $1,209.78 $1,723.9417210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $584.52 $993.68 $1,169.03 $1,665.8717210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $579.68 $985.46 $1,159.37 $1,652.1017210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $553.87 $941.57 $1,107.73 $1,578.5217210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $553.87 $941.57 $1,107.73 $1,578.5217210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $578.79 $983.95 $1,157.59 $1,649.5617210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $578.79 $983.95 $1,157.59 $1,649.5617210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $532.86 $905.85 $1,065.71 $1,518.6417210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $643.11 $1,093.29 $1,286.23 $1,832.8717210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $578.79 $983.95 $1,157.59 $1,649.5617210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $564.40 $959.47 $1,128.79 $1,608.5317210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $502.30 $853.91 $1,004.60 $1,431.5517210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $497.38 $845.55 $994.76 $1,417.5417210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $535.62 $910.55 $1,071.23 $1,526.51





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17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $608.90 $1,035.12 $1,217.79 $1,735.3517210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $588.39 $1,000.26 $1,176.78 $1,676.9117210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $583.52 $991.99 $1,167.05 $1,663.0417210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $557.53 $947.81 $1,115.07 $1,588.9717210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $557.53 $947.81 $1,115.07 $1,588.9717210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $582.63 $990.46 $1,165.25 $1,660.4817210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $582.63 $990.46 $1,165.25 $1,660.4817210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $536.38 $911.85 $1,072.77 $1,528.7017210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $647.37 $1,100.53 $1,294.74 $1,845.0117210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $582.63 $990.46 $1,165.25 $1,660.4817210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $568.13 $965.83 $1,136.27 $1,619.1817210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $505.63 $859.57 $1,011.25 $1,441.0417210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $500.68 $851.15 $1,001.35 $1,426.9317210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $539.16 $916.58 $1,078.33 $1,536.6217210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $627.16 $1,066.18 $1,254.33 $1,787.4117210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $606.04 $1,030.27 $1,212.08 $1,727.2117210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $601.03 $1,021.75 $1,202.06 $1,712.9317210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $574.26 $976.24 $1,148.52 $1,636.6417210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $574.26 $976.24 $1,148.52 $1,636.6417210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $600.11 $1,020.18 $1,200.21 $1,710.3017210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $600.11 $1,020.18 $1,200.21 $1,710.3017210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $552.48 $939.21 $1,104.95 $1,574.5617210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $666.79 $1,133.55 $1,333.59 $1,900.3617210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $600.11 $1,020.18 $1,200.21 $1,710.3017210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $585.18 $994.80 $1,170.36 $1,667.7617210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $520.80 $885.35 $1,041.59 $1,484.2717210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $515.70 $876.68 $1,031.39 $1,469.7317210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $555.34 $944.08 $1,110.68 $1,582.72


17210NY0090173 NY Platinum OAEPO $25 Platinum EPO $988.94 $1,681.19 $1,977.88 $2,818.4717210NY0090174 NY Platinum OAEPO $25 DEP30 Platinum EPO $1,018.61 $1,731.63 $2,037.21 $2,903.03



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17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $631.36 $1,073.31 $1,262.71 $1,799.3717210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $610.09 $1,037.16 $1,220.19 $1,738.7617210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $605.05 $1,028.58 $1,210.10 $1,724.3917210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $578.10 $982.77 $1,156.20 $1,647.5817210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $578.10 $982.77 $1,156.20 $1,647.5817210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $604.12 $1,027.00 $1,208.24 $1,721.7417210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $604.12 $1,027.00 $1,208.24 $1,721.7417210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $556.17 $945.49 $1,112.34 $1,585.0917210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $671.25 $1,141.13 $1,342.50 $1,913.0717210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $604.12 $1,027.00 $1,208.24 $1,721.7417210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $589.09 $1,001.45 $1,178.18 $1,678.9117210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $524.28 $891.27 $1,048.56 $1,494.1917210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $519.14 $882.55 $1,038.29 $1,479.5617210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $559.05 $950.39 $1,118.11 $1,593.3017210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $650.30 $1,105.51 $1,300.60 $1,853.3517210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $628.39 $1,068.27 $1,256.79 $1,790.9217210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $623.20 $1,059.44 $1,246.40 $1,776.1217210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $595.44 $1,012.25 $1,190.89 $1,697.0117210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $595.44 $1,012.25 $1,190.89 $1,697.0117210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $622.24 $1,057.81 $1,244.48 $1,773.3917210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $622.24 $1,057.81 $1,244.48 $1,773.3917210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $572.86 $973.85 $1,145.71 $1,632.6417210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $691.39 $1,175.36 $1,382.78 $1,970.4617210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $622.24 $1,057.81 $1,244.48 $1,773.3917210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $606.76 $1,031.50 $1,213.53 $1,729.2817210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $540.01 $918.01 $1,080.01 $1,539.0217210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $534.72 $909.02 $1,069.44 $1,523.9517210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $575.82 $978.90 $1,151.65 $1,641.10


17210NY0090173 NY Platinum OAEPO $25 Platinum EPO $1,025.42 $1,743.21 $2,050.84 $2,922.4417210NY0090174 NY Platinum OAEPO $25 DEP30 Platinum EPO $1,056.18 $1,795.51 $2,112.36 $3,010.11

17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $740.89 $1,259.51 $1,481.78 $2,111.5417210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $752.61 $1,279.43 $1,505.21 $2,144.9317210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $715.97 $1,217.15 $1,431.94 $2,040.5217210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $752.21 $1,278.76 $1,504.42 $2,143.8017210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $683.45 $1,161.87 $1,366.91 $1,947.8517210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $659.73 $1,121.55 $1,319.47 $1,880.2417210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $676.17 $1,149.50 $1,352.35 $1,927.1017210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $786.42 $1,336.92 $1,572.84 $2,241.3017210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $755.70 $1,284.69 $1,511.40 $2,153.7417210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $786.42 $1,336.92 $1,572.84 $2,241.3017210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $981.62 $1,668.76 $1,963.24 $2,797.6217210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $752.79 $1,279.75 $1,505.59 $2,145.4617210NY0090180 NY Silver EPO 2000 60% Silver EPO $740.89 $1,259.51 $1,481.78 $2,111.5417210NY0090182 NY Silver EPO 2000 80% Silver EPO $752.61 $1,279.43 $1,505.21 $2,144.9317210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $726.70 $1,235.39 $1,453.40 $2,071.0917210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $646.75 $1,099.47 $1,293.49 $1,843.2317210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $646.41 $1,098.89 $1,292.81 $1,842.2517210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $645.81 $1,097.88 $1,291.63 $1,840.5717210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $763.12 $1,297.30 $1,526.23 $2,174.8817210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $775.18 $1,317.81 $1,550.37 $2,209.2717210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $737.45 $1,253.67 $1,474.90 $2,101.7317210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $774.78 $1,317.12 $1,549.55 $2,208.1117210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $703.96 $1,196.73 $1,407.92 $2,006.2817210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $679.53 $1,155.20 $1,359.05 $1,936.6517210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $696.46 $1,183.98 $1,392.92 $1,984.9117210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $810.01 $1,377.03 $1,620.03 $2,308.5417210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $778.37 $1,323.23 $1,556.74 $2,218.3517210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $810.01 $1,377.03 $1,620.03 $2,308.5417210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $1,011.07 $1,718.82 $2,022.14 $2,881.5517210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $775.38 $1,318.14 $1,550.75 $2,209.8317210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $763.12 $1,297.30 $1,526.23 $2,174.8817210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $775.18 $1,317.81 $1,550.37 $2,209.2717210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $748.50 $1,272.45 $1,497.00 $2,133.2317210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $666.15 $1,132.45 $1,332.30 $1,898.5217210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $665.80 $1,131.86 $1,331.60 $1,897.5217210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $665.19 $1,130.82 $1,330.38 $1,895.79


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Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $654.69 $1,112.97 $1,309.38 $1,865.8617210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $632.64 $1,075.48 $1,265.28 $1,803.0217210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $627.41 $1,066.59 $1,254.82 $1,788.1117210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $599.46 $1,019.09 $1,198.92 $1,708.4717210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $599.46 $1,019.09 $1,198.92 $1,708.4717210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $626.44 $1,064.95 $1,252.88 $1,785.3617210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $626.44 $1,064.95 $1,252.88 $1,785.3617210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $576.72 $980.43 $1,153.45 $1,643.6617210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $696.06 $1,183.30 $1,392.12 $1,983.7617210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $626.44 $1,064.95 $1,252.88 $1,785.3617210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $610.86 $1,038.46 $1,221.72 $1,740.9517210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $543.65 $924.21 $1,087.30 $1,549.4117210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $538.33 $915.16 $1,076.66 $1,534.2417210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $579.71 $985.51 $1,159.42 $1,652.1817210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $674.33 $1,146.36 $1,348.66 $1,921.8417210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $651.62 $1,107.75 $1,303.23 $1,857.1117210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $646.23 $1,098.59 $1,292.46 $1,841.7617210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $617.45 $1,049.66 $1,234.89 $1,759.7217210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $617.45 $1,049.66 $1,234.89 $1,759.7217210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $645.24 $1,096.90 $1,290.47 $1,838.9217210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $645.24 $1,096.90 $1,290.47 $1,838.9217210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $594.02 $1,009.84 $1,188.05 $1,692.9717210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $716.94 $1,218.80 $1,433.88 $2,043.2817210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $645.24 $1,096.90 $1,290.47 $1,838.9217210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $629.19 $1,069.62 $1,258.37 $1,793.1817210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $559.96 $951.94 $1,119.92 $1,595.8917210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $554.48 $942.61 $1,108.96 $1,580.2617210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $597.10 $1,015.08 $1,194.21 $1,701.74


17210NY0090173 NY Platinum OAEPO $25 Platinum EPO $1,063.31 $1,807.63 $2,126.62 $3,030.4417210NY0090174 NY Platinum OAEPO $25 DEP30 Platinum EPO $1,095.21 $1,861.86 $2,190.42 $3,121.35

17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $768.27 $1,306.06 $1,536.54 $2,189.5717210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $780.42 $1,326.71 $1,560.84 $2,224.1917210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $742.43 $1,262.13 $1,484.86 $2,115.9217210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $780.01 $1,326.01 $1,560.01 $2,223.0217210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $708.71 $1,204.81 $1,417.42 $2,019.8317210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $684.11 $1,163.00 $1,368.23 $1,949.7317210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $701.16 $1,191.97 $1,402.32 $1,998.3117210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $815.48 $1,386.32 $1,630.97 $2,324.1317210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $783.62 $1,332.16 $1,567.25 $2,233.3317210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $815.48 $1,386.32 $1,630.97 $2,324.1317210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $1,017.90 $1,730.42 $2,035.79 $2,901.0117210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $780.61 $1,327.04 $1,561.23 $2,224.7517210NY0090180 NY Silver EPO 2000 60% Silver EPO $768.27 $1,306.06 $1,536.54 $2,189.5717210NY0090182 NY Silver EPO 2000 80% Silver EPO $780.42 $1,326.71 $1,560.84 $2,224.1917210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $753.55 $1,281.04 $1,507.11 $2,147.6317210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $670.65 $1,140.10 $1,341.29 $1,911.3417210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $670.29 $1,139.50 $1,340.58 $1,910.3317210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $669.68 $1,138.46 $1,339.36 $1,908.5917210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $791.32 $1,345.24 $1,582.64 $2,255.2617210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $803.83 $1,366.51 $1,607.66 $2,290.9217210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $764.70 $1,299.99 $1,529.40 $2,179.4017210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $803.41 $1,365.79 $1,606.81 $2,289.7117210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $729.97 $1,240.95 $1,459.95 $2,080.4217210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $704.64 $1,197.89 $1,409.28 $2,008.2217210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $722.20 $1,227.73 $1,444.39 $2,058.2617210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $839.95 $1,427.91 $1,679.90 $2,393.8517210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $807.13 $1,372.13 $1,614.26 $2,300.3317210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $839.95 $1,427.91 $1,679.90 $2,393.8517210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $1,048.43 $1,782.34 $2,096.87 $2,988.0417210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $804.03 $1,366.85 $1,608.06 $2,291.4917210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $791.32 $1,345.24 $1,582.64 $2,255.2617210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $803.83 $1,366.51 $1,607.66 $2,290.9217210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $776.16 $1,319.47 $1,552.32 $2,212.0617210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $690.77 $1,174.30 $1,381.53 $1,968.6817210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $690.40 $1,173.68 $1,380.80 $1,967.6517210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $689.77 $1,172.61 $1,379.54 $1,965.84


D-13



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $587.27 $998.36 $1,174.54 $1,673.7217210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $567.49 $964.74 $1,134.98 $1,617.3517210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $562.80 $956.76 $1,125.60 $1,603.9817210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $537.73 $914.15 $1,075.46 $1,532.5417210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $537.73 $914.15 $1,075.46 $1,532.5417210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $561.93 $955.29 $1,123.87 $1,601.5117210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $561.93 $955.29 $1,123.87 $1,601.5117210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $517.34 $879.47 $1,034.67 $1,474.4117210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $624.38 $1,061.45 $1,248.76 $1,779.4917210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $561.93 $955.29 $1,123.87 $1,601.5117210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $547.96 $931.53 $1,095.91 $1,561.6817210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $487.67 $829.04 $975.34 $1,389.8617210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $482.89 $820.92 $965.79 $1,376.2517210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $520.02 $884.03 $1,040.03 $1,482.0517210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $604.89 $1,028.31 $1,209.78 $1,723.9417210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $584.52 $993.68 $1,169.03 $1,665.8717210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $579.68 $985.46 $1,159.37 $1,652.1017210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $553.87 $941.57 $1,107.73 $1,578.5217210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $553.87 $941.57 $1,107.73 $1,578.5217210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $578.79 $983.95 $1,157.59 $1,649.5617210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $578.79 $983.95 $1,157.59 $1,649.5617210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $532.86 $905.85 $1,065.71 $1,518.6417210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $643.11 $1,093.29 $1,286.23 $1,832.8717210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $578.79 $983.95 $1,157.59 $1,649.5617210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $564.40 $959.47 $1,128.79 $1,608.5317210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $502.30 $853.91 $1,004.60 $1,431.5517210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $497.38 $845.55 $994.76 $1,417.5417210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $535.62 $910.55 $1,071.23 $1,526.51


17210NY0090173 NY Platinum OAEPO $25 Platinum EPO $953.82 $1,621.49 $1,907.63 $2,718.3817210NY0090169 NY Platinum NYC Community PlanSM $20 Platinum EPO $867.00 $1,473.90 $1,734.00 $2,470.9517210NY0090171 NY Platinum NYC Community PlanSM $30 Platinum EPO $861.04 $1,463.76 $1,722.07 $2,453.9517210NY0090174 NY Platinum OAEPO $25 DEP30 Platinum EPO $982.43 $1,670.13 $1,964.86 $2,799.9317210NY0090170 NY Platinum NYC Community PlanSM $20 DEP30 Platinum EPO $893.01 $1,518.11 $1,786.02 $2,545.0717210NY0090172 NY Platinum NYC Community PlanSM $30 DEP30 Platinum EPO $886.87 $1,507.67 $1,773.73 $2,527.57



D-14



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $608.90 $1,035.12 $1,217.79 $1,735.3517210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $588.39 $1,000.26 $1,176.78 $1,676.9117210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $583.52 $991.99 $1,167.05 $1,663.0417210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $557.53 $947.81 $1,115.07 $1,588.9717210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $557.53 $947.81 $1,115.07 $1,588.9717210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $582.63 $990.46 $1,165.25 $1,660.4817210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $582.63 $990.46 $1,165.25 $1,660.4817210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $536.38 $911.85 $1,072.77 $1,528.7017210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $647.37 $1,100.53 $1,294.74 $1,845.0117210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $582.63 $990.46 $1,165.25 $1,660.4817210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $568.13 $965.83 $1,136.27 $1,619.1817210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $505.63 $859.57 $1,011.25 $1,441.0417210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $500.68 $851.15 $1,001.35 $1,426.9317210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $539.16 $916.58 $1,078.33 $1,536.6217210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $627.16 $1,066.18 $1,254.33 $1,787.4117210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $606.04 $1,030.27 $1,212.08 $1,727.2117210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $601.03 $1,021.75 $1,202.06 $1,712.9317210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $574.26 $976.24 $1,148.52 $1,636.6417210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $574.26 $976.24 $1,148.52 $1,636.6417210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $600.11 $1,020.18 $1,200.21 $1,710.3017210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $600.11 $1,020.18 $1,200.21 $1,710.3017210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $552.48 $939.21 $1,104.95 $1,574.5617210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $666.79 $1,133.55 $1,333.59 $1,900.3617210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $600.11 $1,020.18 $1,200.21 $1,710.3017210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $585.18 $994.80 $1,170.36 $1,667.7617210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $520.80 $885.35 $1,041.59 $1,484.2717210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $515.70 $876.68 $1,031.39 $1,469.7317210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $555.34 $944.08 $1,110.68 $1,582.72


17210NY0090173 NY Platinum OAEPO $25 Platinum EPO $988.94 $1,681.19 $1,977.88 $2,818.4717210NY0090169 NY Platinum NYC Community PlanSM $20 Platinum EPO $898.92 $1,528.17 $1,797.85 $2,561.9317210NY0090171 NY Platinum NYC Community PlanSM $30 Platinum EPO $892.74 $1,517.66 $1,785.48 $2,544.3117210NY0090174 NY Platinum OAEPO $25 DEP30 Platinum EPO $1,018.61 $1,731.63 $2,037.21 $2,903.0317210NY0090170 NY Platinum NYC Community PlanSM $20 DEP30 Platinum EPO $925.89 $1,574.01 $1,851.78 $2,638.7917210NY0090172 NY Platinum NYC Community PlanSM $30 DEP30 Platinum EPO $919.52 $1,563.19 $1,839.05 $2,620.64



D-15



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $631.36 $1,073.31 $1,262.71 $1,799.3717210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $610.09 $1,037.16 $1,220.19 $1,738.7617210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $605.05 $1,028.58 $1,210.10 $1,724.3917210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $578.10 $982.77 $1,156.20 $1,647.5817210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $578.10 $982.77 $1,156.20 $1,647.5817210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $604.12 $1,027.00 $1,208.24 $1,721.7417210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $604.12 $1,027.00 $1,208.24 $1,721.7417210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $556.17 $945.49 $1,112.34 $1,585.0917210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $671.25 $1,141.13 $1,342.50 $1,913.0717210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $604.12 $1,027.00 $1,208.24 $1,721.7417210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $589.09 $1,001.45 $1,178.18 $1,678.9117210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $524.28 $891.27 $1,048.56 $1,494.1917210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $519.14 $882.55 $1,038.29 $1,479.5617210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $559.05 $950.39 $1,118.11 $1,593.3017210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $650.30 $1,105.51 $1,300.60 $1,853.3517210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $628.39 $1,068.27 $1,256.79 $1,790.9217210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $623.20 $1,059.44 $1,246.40 $1,776.1217210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $595.44 $1,012.25 $1,190.89 $1,697.0117210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $595.44 $1,012.25 $1,190.89 $1,697.0117210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $622.24 $1,057.81 $1,244.48 $1,773.3917210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $622.24 $1,057.81 $1,244.48 $1,773.3917210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $572.86 $973.85 $1,145.71 $1,632.6417210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $691.39 $1,175.36 $1,382.78 $1,970.4617210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $622.24 $1,057.81 $1,244.48 $1,773.3917210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $606.76 $1,031.50 $1,213.53 $1,729.2817210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $540.01 $918.01 $1,080.01 $1,539.0217210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $534.72 $909.02 $1,069.44 $1,523.9517210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $575.82 $978.90 $1,151.65 $1,641.10


17210NY0090173 NY Platinum OAEPO $25 Platinum EPO $1,025.42 $1,743.21 $2,050.84 $2,922.4417210NY0090169 NY Platinum NYC Community PlanSM $20 Platinum EPO $932.08 $1,584.54 $1,864.16 $2,656.4317210NY0090171 NY Platinum NYC Community PlanSM $30 Platinum EPO $925.67 $1,573.64 $1,851.34 $2,638.1617210NY0090174 NY Platinum OAEPO $25 DEP30 Platinum EPO $1,056.18 $1,795.51 $2,112.36 $3,010.1117210NY0090170 NY Platinum NYC Community PlanSM $20 DEP30 Platinum EPO $960.04 $1,632.08 $1,920.09 $2,736.1317210NY0090172 NY Platinum NYC Community PlanSM $30 DEP30 Platinum EPO $953.44 $1,620.85 $1,906.88 $2,717.31

17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $740.89 $1,259.51 $1,481.78 $2,111.5417210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $752.61 $1,279.43 $1,505.21 $2,144.9317210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $715.97 $1,217.15 $1,431.94 $2,040.5217210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $752.21 $1,278.76 $1,504.42 $2,143.8017210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $683.45 $1,161.87 $1,366.91 $1,947.8517210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $659.73 $1,121.55 $1,319.47 $1,880.2417210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $676.17 $1,149.50 $1,352.35 $1,927.1017210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $786.42 $1,336.92 $1,572.84 $2,241.3017210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $755.70 $1,284.69 $1,511.40 $2,153.7417210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $786.42 $1,336.92 $1,572.84 $2,241.3017210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $981.62 $1,668.76 $1,963.24 $2,797.6217210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $752.79 $1,279.75 $1,505.59 $2,145.4617210NY0090180 NY Silver EPO 2000 60% Silver EPO $740.89 $1,259.51 $1,481.78 $2,111.5417210NY0090182 NY Silver EPO 2000 80% Silver EPO $752.61 $1,279.43 $1,505.21 $2,144.9317210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $726.70 $1,235.39 $1,453.40 $2,071.0917210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $646.75 $1,099.47 $1,293.49 $1,843.2317210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $646.41 $1,098.89 $1,292.81 $1,842.2517210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $645.81 $1,097.88 $1,291.63 $1,840.5717210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $763.12 $1,297.30 $1,526.23 $2,174.8817210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $775.18 $1,317.81 $1,550.37 $2,209.2717210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $737.45 $1,253.67 $1,474.90 $2,101.7317210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $774.78 $1,317.12 $1,549.55 $2,208.1117210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $703.96 $1,196.73 $1,407.92 $2,006.2817210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $679.53 $1,155.20 $1,359.05 $1,936.6517210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $696.46 $1,183.98 $1,392.92 $1,984.9117210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $810.01 $1,377.03 $1,620.03 $2,308.5417210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $778.37 $1,323.23 $1,556.74 $2,218.3517210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $810.01 $1,377.03 $1,620.03 $2,308.5417210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $1,011.07 $1,718.82 $2,022.14 $2,881.5517210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $775.38 $1,318.14 $1,550.75 $2,209.8317210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $763.12 $1,297.30 $1,526.23 $2,174.8817210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $775.18 $1,317.81 $1,550.37 $2,209.2717210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $748.50 $1,272.45 $1,497.00 $2,133.2317210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $666.15 $1,132.45 $1,332.30 $1,898.5217210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $665.80 $1,131.86 $1,331.60 $1,897.5217210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $665.19 $1,130.82 $1,330.38 $1,895.79


D-16



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $654.69 $1,112.97 $1,309.38 $1,865.8617210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $632.64 $1,075.48 $1,265.28 $1,803.0217210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $627.41 $1,066.59 $1,254.82 $1,788.1117210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $599.46 $1,019.09 $1,198.92 $1,708.4717210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $599.46 $1,019.09 $1,198.92 $1,708.4717210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $626.44 $1,064.95 $1,252.88 $1,785.3617210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $626.44 $1,064.95 $1,252.88 $1,785.3617210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $576.72 $980.43 $1,153.45 $1,643.6617210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $696.06 $1,183.30 $1,392.12 $1,983.7617210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $626.44 $1,064.95 $1,252.88 $1,785.3617210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $610.86 $1,038.46 $1,221.72 $1,740.9517210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $543.65 $924.21 $1,087.30 $1,549.4117210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $538.33 $915.16 $1,076.66 $1,534.2417210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $579.71 $985.51 $1,159.42 $1,652.1817210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $674.33 $1,146.36 $1,348.66 $1,921.8417210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $651.62 $1,107.75 $1,303.23 $1,857.1117210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $646.23 $1,098.59 $1,292.46 $1,841.7617210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $617.45 $1,049.66 $1,234.89 $1,759.7217210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $617.45 $1,049.66 $1,234.89 $1,759.7217210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $645.24 $1,096.90 $1,290.47 $1,838.9217210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $645.24 $1,096.90 $1,290.47 $1,838.9217210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $594.02 $1,009.84 $1,188.05 $1,692.9717210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $716.94 $1,218.80 $1,433.88 $2,043.2817210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $645.24 $1,096.90 $1,290.47 $1,838.9217210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $629.19 $1,069.62 $1,258.37 $1,793.1817210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $559.96 $951.94 $1,119.92 $1,595.8917210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $554.48 $942.61 $1,108.96 $1,580.2617210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $597.10 $1,015.08 $1,194.21 $1,701.74


17210NY0090173 NY Platinum OAEPO $25 Platinum EPO $1,063.31 $1,807.63 $2,126.62 $3,030.4417210NY0090169 NY Platinum NYC Community PlanSM $20 Platinum EPO $966.53 $1,643.09 $1,933.05 $2,754.6017210NY0090171 NY Platinum NYC Community PlanSM $30 Platinum EPO $959.88 $1,631.79 $1,919.76 $2,735.6617210NY0090174 NY Platinum OAEPO $25 DEP30 Platinum EPO $1,095.21 $1,861.86 $2,190.42 $3,121.3517210NY0090170 NY Platinum NYC Community PlanSM $20 DEP30 Platinum EPO $995.52 $1,692.39 $1,991.04 $2,837.2417210NY0090172 NY Platinum NYC Community PlanSM $30 DEP30 Platinum EPO $988.68 $1,680.75 $1,977.35 $2,817.72

17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $768.27 $1,306.06 $1,536.54 $2,189.5717210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $780.42 $1,326.71 $1,560.84 $2,224.1917210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $742.43 $1,262.13 $1,484.86 $2,115.9217210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $780.01 $1,326.01 $1,560.01 $2,223.0217210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $708.71 $1,204.81 $1,417.42 $2,019.8317210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $684.11 $1,163.00 $1,368.23 $1,949.7317210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $701.16 $1,191.97 $1,402.32 $1,998.3117210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $815.48 $1,386.32 $1,630.97 $2,324.1317210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $783.62 $1,332.16 $1,567.25 $2,233.3317210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $815.48 $1,386.32 $1,630.97 $2,324.1317210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $1,017.90 $1,730.42 $2,035.79 $2,901.0117210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $780.61 $1,327.04 $1,561.23 $2,224.7517210NY0090180 NY Silver EPO 2000 60% Silver EPO $768.27 $1,306.06 $1,536.54 $2,189.5717210NY0090182 NY Silver EPO 2000 80% Silver EPO $780.42 $1,326.71 $1,560.84 $2,224.1917210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $753.55 $1,281.04 $1,507.11 $2,147.6317210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $670.65 $1,140.10 $1,341.29 $1,911.3417210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $670.29 $1,139.50 $1,340.58 $1,910.3317210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $669.68 $1,138.46 $1,339.36 $1,908.5917210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $791.32 $1,345.24 $1,582.64 $2,255.2617210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $803.83 $1,366.51 $1,607.66 $2,290.9217210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $764.70 $1,299.99 $1,529.40 $2,179.4017210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $803.41 $1,365.79 $1,606.81 $2,289.7117210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $729.97 $1,240.95 $1,459.95 $2,080.4217210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $704.64 $1,197.89 $1,409.28 $2,008.2217210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $722.20 $1,227.73 $1,444.39 $2,058.2617210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $839.95 $1,427.91 $1,679.90 $2,393.8517210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $807.13 $1,372.13 $1,614.26 $2,300.3317210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $839.95 $1,427.91 $1,679.90 $2,393.8517210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $1,048.43 $1,782.34 $2,096.87 $2,988.0417210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $804.03 $1,366.85 $1,608.06 $2,291.4917210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $791.32 $1,345.24 $1,582.64 $2,255.2617210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $803.83 $1,366.51 $1,607.66 $2,290.9217210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $776.16 $1,319.47 $1,552.32 $2,212.0617210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $690.77 $1,174.30 $1,381.53 $1,968.6817210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $690.40 $1,173.68 $1,380.80 $1,967.6517210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $689.77 $1,172.61 $1,379.54 $1,965.84


D-17



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $411.09 $698.85 $822.18 $1,171.6117210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $397.24 $675.32 $794.49 $1,132.1517210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $393.96 $669.73 $787.92 $1,122.7917210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $376.41 $639.90 $752.83 $1,072.7817210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $376.41 $639.90 $752.83 $1,072.7817210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $393.35 $668.70 $786.71 $1,121.0617210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $393.35 $668.70 $786.71 $1,121.0617210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $362.13 $615.63 $724.27 $1,032.0817210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $437.07 $743.01 $874.13 $1,245.6417210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $393.35 $668.70 $786.71 $1,121.0617210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $383.57 $652.07 $767.14 $1,093.1717210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $341.37 $580.33 $682.74 $972.9017210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $338.03 $574.64 $676.05 $963.3717210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $364.01 $618.82 $728.02 $1,037.4317210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $423.42 $719.82 $846.85 $1,206.7617210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $409.16 $695.57 $818.32 $1,166.1117210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $405.78 $689.82 $811.56 $1,156.4717210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $387.71 $659.10 $775.41 $1,104.9617210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $387.71 $659.10 $775.41 $1,104.9617210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $405.16 $688.76 $810.31 $1,154.6917210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $405.16 $688.76 $810.31 $1,154.6917210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $373.00 $634.10 $746.00 $1,063.0517210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $450.18 $765.30 $900.36 $1,283.0117210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $405.16 $688.76 $810.31 $1,154.6917210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $395.08 $671.63 $790.15 $1,125.9717210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $351.61 $597.74 $703.22 $1,002.0917210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $348.17 $591.88 $696.33 $992.2817210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $374.93 $637.38 $749.86 $1,068.56

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $559.70 $951.50 $1,119.41 $1,595.1517210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $509.02 $865.33 $1,018.04 $1,450.7017210NY0090198 NY Gold EPO 1000 90% Gold EPO $559.70 $951.50 $1,119.41 $1,595.1517210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $540.44 $918.74 $1,080.87 $1,540.2417210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $480.98 $817.66 $961.95 $1,370.7817210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $576.49 $980.04 $1,152.99 $1,643.0117210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $524.29 $891.29 $1,048.58 $1,494.2217210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $576.49 $980.04 $1,152.99 $1,643.0117210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $556.65 $946.30 $1,113.30 $1,586.4517210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $495.41 $842.19 $990.81 $1,411.91


17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $482.41 $820.10 $964.82 $1,374.8717210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $490.04 $833.07 $980.08 $1,396.6117210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $466.18 $792.51 $932.37 $1,328.6217210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $489.78 $832.63 $979.56 $1,395.8717210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $445.01 $756.52 $890.02 $1,268.2817210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $429.57 $730.27 $859.14 $1,224.2717210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $440.27 $748.46 $880.54 $1,254.7717210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $512.06 $870.50 $1,024.11 $1,459.3617210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $492.05 $836.49 $984.10 $1,402.3517210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $512.06 $870.50 $1,024.11 $1,459.3617210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $639.16 $1,086.56 $1,278.31 $1,821.5917210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $490.16 $833.27 $980.32 $1,396.9617210NY0090180 NY Silver EPO 2000 60% Silver EPO $482.41 $820.10 $964.82 $1,374.8717210NY0090182 NY Silver EPO 2000 80% Silver EPO $490.04 $833.07 $980.08 $1,396.6117210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $473.17 $804.39 $946.34 $1,348.5317210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $421.11 $715.89 $842.22 $1,200.1717210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $420.89 $715.51 $841.78 $1,199.5317210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $420.50 $714.86 $841.01 $1,198.4417210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $496.88 $844.70 $993.76 $1,416.1117210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $504.74 $858.06 $1,009.48 $1,438.5117210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $480.17 $816.29 $960.34 $1,368.4817210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $504.47 $857.60 $1,008.95 $1,437.7517210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $458.36 $779.22 $916.73 $1,306.3317210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $442.45 $752.17 $884.91 $1,261.0017210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $453.48 $770.92 $906.96 $1,292.4217210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $527.42 $896.61 $1,054.84 $1,503.1417210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $506.81 $861.58 $1,013.63 $1,444.4217210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $527.42 $896.61 $1,054.84 $1,503.1417210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $658.33 $1,119.16 $1,316.66 $1,876.2417210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $504.87 $858.27 $1,009.73 $1,438.8717210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $496.88 $844.70 $993.76 $1,416.1117210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $504.74 $858.06 $1,009.48 $1,438.5117210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $487.36 $828.52 $974.73 $1,388.9917210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $433.74 $737.36 $867.49 $1,236.1717210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $433.52 $736.98 $867.03 $1,235.5217210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $433.12 $736.30 $866.24 $1,234.39


D-18



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $426.23 $724.59 $852.45 $1,214.7517210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $411.87 $700.18 $823.74 $1,173.8317210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $408.47 $694.39 $816.93 $1,164.1317210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $390.27 $663.46 $780.55 $1,112.2817210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $390.27 $663.46 $780.55 $1,112.2817210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $407.84 $693.33 $815.68 $1,162.3417210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $407.84 $693.33 $815.68 $1,162.3417210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $375.47 $638.30 $750.94 $1,070.0917210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $453.16 $770.37 $906.32 $1,291.5117210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $407.84 $693.33 $815.68 $1,162.3417210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $397.69 $676.08 $795.39 $1,133.4317210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $353.94 $601.70 $707.88 $1,008.7317210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $350.47 $595.80 $700.95 $998.8517210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $377.42 $641.61 $754.83 $1,075.6317210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $439.01 $746.32 $878.03 $1,251.1917210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $424.23 $721.19 $848.45 $1,209.0517210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $420.72 $715.23 $841.44 $1,199.0517210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $401.98 $683.37 $803.96 $1,145.6517210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $401.98 $683.37 $803.96 $1,145.6517210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $420.07 $714.13 $840.15 $1,197.2117210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $420.07 $714.13 $840.15 $1,197.2117210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $386.73 $657.45 $773.47 $1,102.1917210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $466.76 $793.48 $933.51 $1,330.2517210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $420.07 $714.13 $840.15 $1,197.2117210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $409.62 $696.36 $819.25 $1,167.4317210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $364.56 $619.75 $729.11 $1,038.9917210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $360.99 $613.68 $721.97 $1,028.8117210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $388.74 $660.85 $777.47 $1,107.90

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $580.31 $986.53 $1,160.63 $1,653.8917210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $527.76 $897.19 $1,055.52 $1,504.1217210NY0090198 NY Gold EPO 1000 90% Gold EPO $580.31 $986.53 $1,160.63 $1,653.8917210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $560.34 $952.57 $1,120.67 $1,596.9617210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $498.69 $847.77 $997.37 $1,421.2617210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $597.72 $1,016.13 $1,195.44 $1,703.5117210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $543.59 $924.11 $1,087.19 $1,549.2417210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $597.72 $1,016.13 $1,195.44 $1,703.5117210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $577.15 $981.15 $1,154.29 $1,644.8717210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $513.65 $873.20 $1,027.30 $1,463.90


17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $500.17 $850.29 $1,000.35 $1,425.4917210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $508.08 $863.74 $1,016.17 $1,448.0417210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $483.35 $821.69 $966.70 $1,377.5517210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $507.81 $863.29 $1,015.63 $1,447.2717210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $461.40 $784.38 $922.80 $1,314.9917210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $445.39 $757.15 $890.77 $1,269.3517210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $456.48 $776.02 $912.97 $1,300.9817210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $530.91 $902.55 $1,061.82 $1,513.1017210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $510.17 $867.29 $1,020.34 $1,453.9817210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $530.91 $902.55 $1,061.82 $1,513.1017210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $662.69 $1,126.57 $1,325.38 $1,888.6717210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $508.21 $863.96 $1,016.42 $1,448.4017210NY0090180 NY Silver EPO 2000 60% Silver EPO $500.17 $850.29 $1,000.35 $1,425.4917210NY0090182 NY Silver EPO 2000 80% Silver EPO $508.08 $863.74 $1,016.17 $1,448.0417210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $490.59 $834.01 $981.18 $1,398.1917210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $436.62 $742.25 $873.23 $1,244.3617210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $436.39 $741.86 $872.77 $1,243.7017210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $435.99 $741.18 $871.97 $1,242.5617210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $515.18 $875.80 $1,030.36 $1,468.2617210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $523.32 $889.65 $1,046.65 $1,491.4817210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $497.85 $846.35 $995.70 $1,418.8717210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $523.05 $889.18 $1,046.10 $1,490.6917210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $475.24 $807.91 $950.48 $1,354.4417210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $458.75 $779.87 $917.49 $1,307.4317210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $470.18 $799.30 $940.36 $1,340.0117210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $546.84 $929.63 $1,093.68 $1,558.4917210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $525.47 $893.31 $1,050.95 $1,497.6017210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $546.84 $929.63 $1,093.68 $1,558.4917210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $682.57 $1,160.37 $1,365.14 $1,945.3317210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $523.46 $889.87 $1,046.91 $1,491.8517210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $515.18 $875.80 $1,030.36 $1,468.2617210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $523.32 $889.65 $1,046.65 $1,491.4817210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $505.31 $859.03 $1,010.62 $1,440.1317210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $449.71 $764.52 $899.43 $1,281.6917210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $449.48 $764.11 $898.96 $1,281.0117210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $449.07 $763.41 $898.13 $1,279.84


D-19



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $441.95 $751.31 $883.90 $1,259.5617210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $427.06 $726.01 $854.13 $1,217.1317210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $423.53 $720.01 $847.07 $1,207.0717210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $404.67 $687.94 $809.34 $1,153.3117210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $404.67 $687.94 $809.34 $1,153.3117210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $422.88 $718.90 $845.77 $1,205.2217210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $422.88 $718.90 $845.77 $1,205.2217210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $389.32 $661.84 $778.64 $1,109.5617210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $469.88 $798.79 $939.75 $1,339.1517210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $422.88 $718.90 $845.77 $1,205.2217210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $412.36 $701.02 $824.73 $1,175.2417210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $366.99 $623.89 $733.99 $1,045.9317210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $363.40 $617.78 $726.80 $1,035.6917210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $391.34 $665.27 $782.67 $1,115.3117210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $455.21 $773.85 $910.42 $1,297.3417210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $439.88 $747.79 $879.75 $1,253.6517210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $436.24 $741.61 $872.48 $1,243.2817210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $416.81 $708.58 $833.62 $1,187.9117210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $416.81 $708.58 $833.62 $1,187.9117210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $435.57 $740.47 $871.14 $1,241.3717210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $435.57 $740.47 $871.14 $1,241.3717210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $401.00 $681.70 $802.00 $1,142.8517210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $483.97 $822.75 $967.95 $1,379.3217210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $435.57 $740.47 $871.14 $1,241.3717210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $424.73 $722.05 $849.47 $1,210.4917210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $378.00 $642.61 $756.01 $1,077.3117210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $374.30 $636.32 $748.61 $1,066.7617210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $403.08 $685.23 $806.15 $1,148.77

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $601.72 $1,022.92 $1,203.44 $1,714.9017210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $547.23 $930.29 $1,094.46 $1,559.6017210NY0090198 NY Gold EPO 1000 90% Gold EPO $601.72 $1,022.92 $1,203.44 $1,714.9017210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $581.01 $987.71 $1,162.01 $1,655.8717210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $517.08 $879.04 $1,034.17 $1,473.6917210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $619.77 $1,053.61 $1,239.54 $1,766.3517210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $563.65 $958.20 $1,127.29 $1,606.3917210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $619.77 $1,053.61 $1,239.54 $1,766.3517210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $598.44 $1,017.34 $1,196.87 $1,705.5417210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $532.59 $905.41 $1,065.19 $1,517.90


17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $518.62 $881.66 $1,037.25 $1,478.0817210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $526.82 $895.60 $1,053.65 $1,501.4517210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $501.18 $852.01 $1,002.36 $1,428.3617210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $526.55 $895.13 $1,053.09 $1,500.6617210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $478.42 $813.31 $956.84 $1,363.4917210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $461.81 $785.08 $923.63 $1,316.1717210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $473.32 $804.65 $946.64 $1,348.9717210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $550.50 $935.84 $1,100.99 $1,568.9117210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $528.99 $899.28 $1,057.98 $1,507.6217210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $550.50 $935.84 $1,100.99 $1,568.9117210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $687.14 $1,168.13 $1,374.27 $1,958.3417210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $526.96 $895.82 $1,053.91 $1,501.8217210NY0090180 NY Silver EPO 2000 60% Silver EPO $518.62 $881.66 $1,037.25 $1,478.0817210NY0090182 NY Silver EPO 2000 80% Silver EPO $526.82 $895.60 $1,053.65 $1,501.4517210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $508.69 $864.77 $1,017.38 $1,449.7617210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $452.72 $769.63 $905.45 $1,290.2617210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $452.48 $769.22 $904.97 $1,289.5817210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $452.07 $768.52 $904.14 $1,288.4017210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $534.18 $908.11 $1,068.36 $1,522.4217210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $542.63 $922.47 $1,085.26 $1,546.4917210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $516.22 $877.57 $1,032.43 $1,471.2117210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $542.34 $921.98 $1,084.69 $1,545.6817210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $492.77 $837.71 $985.54 $1,404.4017210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $475.67 $808.64 $951.34 $1,355.6617210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $487.52 $828.79 $975.04 $1,389.4417210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $567.01 $963.92 $1,134.02 $1,615.9817210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $544.86 $926.26 $1,089.72 $1,552.8517210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $567.01 $963.92 $1,134.02 $1,615.9817210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $707.75 $1,203.17 $1,415.50 $2,017.0917210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $542.76 $922.70 $1,085.53 $1,546.8817210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $534.18 $908.11 $1,068.36 $1,522.4217210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $542.63 $922.47 $1,085.26 $1,546.4917210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $523.95 $890.72 $1,047.90 $1,493.2617210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $466.30 $792.72 $932.61 $1,328.9717210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $466.06 $792.30 $932.12 $1,328.2717210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $465.63 $791.57 $931.26 $1,327.05


D-20



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $458.28 $779.08 $916.56 $1,306.1017210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $442.85 $752.84 $885.69 $1,262.1117210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $439.19 $746.62 $878.37 $1,251.6817210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $419.62 $713.36 $839.25 $1,195.9317210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $419.62 $713.36 $839.25 $1,195.9317210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $438.51 $745.47 $877.02 $1,249.7517210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $438.51 $745.47 $877.02 $1,249.7517210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $403.71 $686.30 $807.41 $1,150.5617210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $487.24 $828.31 $974.48 $1,388.6417210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $438.51 $745.47 $877.02 $1,249.7517210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $427.60 $726.92 $855.20 $1,218.6717210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $380.56 $646.95 $761.11 $1,084.5917210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $376.83 $640.61 $753.66 $1,073.9717210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $405.80 $689.86 $811.60 $1,156.5317210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $472.03 $802.45 $944.06 $1,345.2917210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $456.13 $775.42 $912.26 $1,299.9717210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $452.36 $769.01 $904.72 $1,289.2317210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $432.21 $734.76 $864.43 $1,231.8117210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $432.21 $734.76 $864.43 $1,231.8117210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $451.67 $767.83 $903.33 $1,287.2517210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $451.67 $767.83 $903.33 $1,287.2517210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $415.82 $706.89 $831.63 $1,185.0817210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $501.86 $853.16 $1,003.72 $1,430.2917210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $451.67 $767.83 $903.33 $1,287.2517210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $440.43 $748.73 $880.86 $1,255.2317210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $391.97 $666.35 $783.95 $1,117.1217210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $388.14 $659.83 $776.27 $1,106.1917210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $417.97 $710.55 $835.94 $1,191.22

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $623.95 $1,060.72 $1,247.91 $1,778.2717210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $567.45 $964.67 $1,134.90 $1,617.2417210NY0090198 NY Gold EPO 1000 90% Gold EPO $623.95 $1,060.72 $1,247.91 $1,778.2717210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $602.48 $1,024.21 $1,204.95 $1,717.0617210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $536.19 $911.52 $1,072.38 $1,528.1417210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $642.67 $1,092.55 $1,285.35 $1,831.6217210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $584.47 $993.61 $1,168.95 $1,665.7517210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $642.67 $1,092.55 $1,285.35 $1,831.6217210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $620.55 $1,054.94 $1,241.10 $1,768.5717210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $552.28 $938.87 $1,104.55 $1,573.99


17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $537.79 $914.24 $1,075.58 $1,532.7017210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $546.29 $928.70 $1,092.59 $1,556.9317210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $519.70 $883.49 $1,039.40 $1,481.1517210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $546.01 $928.21 $1,092.01 $1,556.1117210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $496.10 $843.37 $992.20 $1,413.8817210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $478.88 $814.10 $957.76 $1,364.8117210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $490.81 $834.38 $981.63 $1,398.8217210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $570.84 $970.43 $1,141.68 $1,626.8917210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $548.54 $932.51 $1,097.07 $1,563.3317210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $570.84 $970.43 $1,141.68 $1,626.8917210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $712.53 $1,211.30 $1,425.06 $2,030.7017210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $546.43 $928.93 $1,092.86 $1,557.3217210NY0090180 NY Silver EPO 2000 60% Silver EPO $537.79 $914.24 $1,075.58 $1,532.7017210NY0090182 NY Silver EPO 2000 80% Silver EPO $546.29 $928.70 $1,092.59 $1,556.9317210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $527.49 $896.73 $1,054.97 $1,503.3417210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $469.45 $798.07 $938.91 $1,337.9417210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $469.20 $797.65 $938.41 $1,337.2317210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $468.78 $796.92 $937.55 $1,336.0117210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $553.92 $941.67 $1,107.84 $1,578.6817210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $562.68 $956.56 $1,125.36 $1,603.6417210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $535.29 $910.00 $1,070.58 $1,525.5817210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $562.39 $956.05 $1,124.77 $1,602.8017210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $510.98 $868.67 $1,021.96 $1,456.3017210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $493.25 $838.52 $986.49 $1,405.7517210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $505.54 $859.41 $1,011.07 $1,440.7817210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $587.96 $999.54 $1,175.93 $1,675.7017210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $564.99 $960.49 $1,129.99 $1,610.2317210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $587.96 $999.54 $1,175.93 $1,675.7017210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $733.90 $1,247.64 $1,467.81 $2,091.6317210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $562.82 $956.80 $1,125.64 $1,604.0417210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $553.92 $941.67 $1,107.84 $1,578.6817210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $562.68 $956.56 $1,125.36 $1,603.6417210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $543.31 $923.63 $1,086.62 $1,548.4417210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $483.54 $822.01 $967.07 $1,378.0817210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $483.28 $821.58 $966.56 $1,377.3517210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $482.84 $820.83 $965.68 $1,376.09


D-21



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $463.94 $788.71 $927.89 $1,322.2417210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $448.32 $762.14 $896.64 $1,277.7117210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $444.61 $755.84 $889.23 $1,267.1517210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $424.81 $722.17 $849.62 $1,210.7017210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $424.81 $722.17 $849.62 $1,210.7017210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $443.93 $754.68 $887.86 $1,265.2017210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $443.93 $754.68 $887.86 $1,265.2017210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $408.69 $694.78 $817.39 $1,164.7817210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $493.26 $838.54 $986.52 $1,405.7917210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $443.93 $754.68 $887.86 $1,265.2017210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $432.89 $735.91 $865.77 $1,233.7217210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $385.26 $654.94 $770.52 $1,097.9917210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $381.49 $648.53 $762.97 $1,087.2417210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $410.81 $698.38 $821.63 $1,170.8217210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $477.86 $812.37 $955.73 $1,361.9117210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $461.77 $785.01 $923.54 $1,316.0417210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $457.95 $778.52 $915.90 $1,305.1617210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $437.55 $743.84 $875.11 $1,247.0317210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $437.55 $743.84 $875.11 $1,247.0317210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $457.25 $777.32 $914.49 $1,303.1517210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $457.25 $777.32 $914.49 $1,303.1517210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $420.96 $715.62 $841.91 $1,199.7217210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $508.06 $863.70 $1,016.12 $1,447.9717210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $457.25 $777.32 $914.49 $1,303.1517210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $445.87 $757.98 $891.75 $1,270.7417210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $396.82 $674.59 $793.63 $1,130.9317210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $392.93 $667.98 $785.86 $1,119.8517210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $423.14 $719.33 $846.27 $1,205.94

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $631.67 $1,073.83 $1,263.33 $1,800.2517210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $574.46 $976.59 $1,148.93 $1,637.2217210NY0090198 NY Gold EPO 1000 90% Gold EPO $631.67 $1,073.83 $1,263.33 $1,800.2517210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $609.92 $1,036.87 $1,219.84 $1,738.2717210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $542.82 $922.79 $1,085.63 $1,547.0317210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $650.62 $1,106.05 $1,301.23 $1,854.2517210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $591.70 $1,005.88 $1,183.39 $1,686.3417210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $650.62 $1,106.05 $1,301.23 $1,854.2517210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $628.22 $1,067.97 $1,256.44 $1,790.4217210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $559.10 $950.47 $1,118.20 $1,593.44


17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $544.43 $925.54 $1,088.87 $1,551.6417210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $553.04 $940.17 $1,106.09 $1,576.1717210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $526.12 $894.41 $1,052.24 $1,499.4517210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $552.75 $939.68 $1,105.50 $1,575.3417210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $502.23 $853.79 $1,004.46 $1,431.3517210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $484.80 $824.16 $969.60 $1,381.6717210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $496.88 $844.69 $993.76 $1,416.1017210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $577.89 $982.42 $1,155.78 $1,646.9917210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $555.31 $944.04 $1,110.63 $1,582.6517210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $577.89 $982.42 $1,155.78 $1,646.9917210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $721.33 $1,226.26 $1,442.66 $2,055.8017210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $553.18 $940.41 $1,106.36 $1,576.5717210NY0090180 NY Silver EPO 2000 60% Silver EPO $544.43 $925.54 $1,088.87 $1,551.6417210NY0090182 NY Silver EPO 2000 80% Silver EPO $553.04 $940.17 $1,106.09 $1,576.1717210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $534.01 $907.81 $1,068.01 $1,521.9217210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $475.25 $807.93 $950.51 $1,354.4717210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $475.00 $807.50 $950.01 $1,353.7617210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $474.57 $806.77 $949.14 $1,352.5217210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $560.77 $953.30 $1,121.53 $1,598.1917210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $569.63 $968.38 $1,139.27 $1,623.4617210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $541.91 $921.24 $1,083.81 $1,544.4317210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $569.33 $967.87 $1,138.67 $1,622.6017210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $517.30 $879.40 $1,034.59 $1,474.2917210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $499.34 $848.88 $998.68 $1,423.1217210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $511.78 $870.03 $1,023.57 $1,458.5817210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $595.23 $1,011.89 $1,190.46 $1,696.4017210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $571.97 $972.36 $1,143.95 $1,630.1317210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $595.23 $1,011.89 $1,190.46 $1,696.4017210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $742.97 $1,263.05 $1,485.94 $2,117.4717210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $569.78 $968.62 $1,139.55 $1,623.8617210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $560.77 $953.30 $1,121.53 $1,598.1917210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $569.63 $968.38 $1,139.27 $1,623.4617210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $550.03 $935.04 $1,100.05 $1,567.5717210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $489.51 $832.17 $979.02 $1,395.1117210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $489.25 $831.73 $978.51 $1,394.3717210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $488.81 $830.97 $977.61 $1,393.09


D-22



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $481.03 $817.75 $962.06 $1,370.9317210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $464.83 $790.21 $929.65 $1,324.7617210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $460.98 $783.67 $921.97 $1,313.8117210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $440.45 $748.77 $880.90 $1,255.2817210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $440.45 $748.77 $880.90 $1,255.2817210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $460.27 $782.47 $920.55 $1,311.7817210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $460.27 $782.47 $920.55 $1,311.7817210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $423.74 $720.36 $847.49 $1,207.6717210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $511.42 $869.42 $1,022.85 $1,457.5617210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $460.27 $782.47 $920.55 $1,311.7817210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $448.83 $763.00 $897.65 $1,279.1517210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $399.45 $679.06 $798.89 $1,138.4217210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $395.53 $672.41 $791.07 $1,127.2717210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $425.94 $724.10 $851.88 $1,213.9317210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $495.46 $842.28 $990.92 $1,412.0617210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $478.77 $813.91 $957.54 $1,364.5017210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $474.81 $807.18 $949.63 $1,353.2217210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $453.67 $771.23 $907.33 $1,292.9517210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $453.67 $771.23 $907.33 $1,292.9517210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $474.08 $805.94 $948.17 $1,351.1417210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $474.08 $805.94 $948.17 $1,351.1417210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $436.46 $741.98 $872.91 $1,243.9017210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $526.77 $895.50 $1,053.53 $1,501.2917210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $474.08 $805.94 $948.17 $1,351.1417210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $462.29 $785.89 $924.58 $1,317.5317210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $411.43 $699.43 $822.86 $1,172.5717210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $407.40 $692.58 $814.80 $1,161.0917210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $438.72 $745.82 $877.44 $1,250.35

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $654.92 $1,113.37 $1,309.85 $1,866.5317210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $595.62 $1,012.55 $1,191.23 $1,697.5117210NY0090198 NY Gold EPO 1000 90% Gold EPO $654.92 $1,113.37 $1,309.85 $1,866.5317210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $632.38 $1,075.05 $1,264.76 $1,802.2817210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $562.80 $956.77 $1,125.61 $1,603.9917210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $674.57 $1,146.77 $1,349.14 $1,922.5317210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $613.48 $1,042.92 $1,226.97 $1,748.4317210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $674.57 $1,146.77 $1,349.14 $1,922.5317210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $651.35 $1,107.30 $1,302.70 $1,856.3517210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $579.69 $985.47 $1,159.38 $1,652.11


17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $564.48 $959.62 $1,128.96 $1,608.7717210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $573.41 $974.79 $1,146.81 $1,634.2117210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $545.49 $927.34 $1,090.99 $1,554.6617210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $573.11 $974.28 $1,146.21 $1,633.3517210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $520.72 $885.23 $1,041.44 $1,484.0517210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $502.65 $854.50 $1,005.30 $1,432.5517210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $515.17 $875.80 $1,030.35 $1,468.2517210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $599.17 $1,018.59 $1,198.34 $1,707.6417210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $575.76 $978.80 $1,151.53 $1,640.9217210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $599.17 $1,018.59 $1,198.34 $1,707.6417210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $747.89 $1,271.42 $1,495.79 $2,131.5017210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $573.55 $975.04 $1,147.10 $1,634.6217210NY0090180 NY Silver EPO 2000 60% Silver EPO $564.48 $959.62 $1,128.96 $1,608.7717210NY0090182 NY Silver EPO 2000 80% Silver EPO $573.41 $974.79 $1,146.81 $1,634.2117210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $553.67 $941.24 $1,107.34 $1,577.9617210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $492.75 $837.68 $985.51 $1,404.3517210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $492.49 $837.24 $984.99 $1,403.6117210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $492.04 $836.47 $984.09 $1,402.3217210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $581.42 $988.41 $1,162.83 $1,657.0317210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $590.61 $1,004.04 $1,181.22 $1,683.2417210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $561.86 $955.16 $1,123.72 $1,601.3017210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $590.30 $1,003.51 $1,180.60 $1,682.3517210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $536.34 $911.78 $1,072.69 $1,528.5817210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $517.73 $880.14 $1,035.46 $1,475.5317210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $530.63 $902.07 $1,061.26 $1,512.2917210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $617.15 $1,049.15 $1,234.29 $1,758.8717210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $593.04 $1,008.16 $1,186.07 $1,690.1517210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $617.15 $1,049.15 $1,234.29 $1,758.8717210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $770.33 $1,309.56 $1,540.66 $2,195.4417210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $590.76 $1,004.29 $1,181.51 $1,683.6617210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $581.42 $988.41 $1,162.83 $1,657.0317210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $590.61 $1,004.04 $1,181.22 $1,683.2417210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $570.28 $969.47 $1,140.56 $1,625.2917210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $507.54 $862.81 $1,015.07 $1,446.4817210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $507.27 $862.36 $1,014.54 $1,445.7217210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $506.80 $861.57 $1,013.61 $1,444.39


D-23



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $498.77 $847.91 $997.54 $1,421.5017210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $481.97 $819.35 $963.95 $1,373.6217210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $477.99 $812.58 $955.98 $1,362.2717210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $456.70 $776.39 $913.40 $1,301.5917210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $456.70 $776.39 $913.40 $1,301.5917210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $477.25 $811.33 $954.51 $1,360.1717210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $477.25 $811.33 $954.51 $1,360.1717210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $439.37 $746.94 $878.75 $1,252.2217210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $530.29 $901.49 $1,060.58 $1,511.3217210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $477.25 $811.33 $954.51 $1,360.1717210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $465.38 $791.15 $930.76 $1,326.3417210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $414.18 $704.11 $828.36 $1,180.4117210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $410.12 $697.21 $820.25 $1,168.8517210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $441.65 $750.81 $883.30 $1,258.7117210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $513.74 $873.35 $1,027.47 $1,464.1517210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $496.43 $843.93 $992.86 $1,414.8317210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $492.33 $836.96 $984.66 $1,403.1417210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $470.40 $799.68 $940.80 $1,340.6417210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $470.40 $799.68 $940.80 $1,340.6417210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $491.57 $835.67 $983.14 $1,400.9817210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $491.57 $835.67 $983.14 $1,400.9817210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $452.56 $769.34 $905.11 $1,289.7817210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $546.20 $928.54 $1,092.40 $1,556.6617210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $491.57 $835.67 $983.14 $1,400.9817210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $479.34 $814.88 $958.69 $1,366.1317210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $426.61 $725.23 $853.21 $1,215.8217210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $422.43 $718.13 $844.86 $1,203.9217210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $454.90 $773.33 $909.80 $1,296.47

17210NY0090200 NY Gold OAEPO 1000 90% Gold EPO $679.08 $1,154.44 $1,358.17 $1,935.3917210NY0090167 NY Gold Savings Plus OAEPO 1000 90% Gold EPO $617.59 $1,049.90 $1,235.17 $1,760.1217210NY0090198 NY Gold EPO 1000 90% Gold EPO $679.08 $1,154.44 $1,358.17 $1,935.3917210NY0140001 NY Gold OAEPO AP 1000 90% Gold EPO $655.71 $1,114.70 $1,311.41 $1,868.7617210NY0090196 NY Gold AWH OAEPO 1000 90% Gold EPO $583.56 $992.06 $1,167.13 $1,663.1617210NY0090201 NY Gold OAEPO 1000 90% DEP30 Gold EPO $699.46 $1,189.07 $1,398.91 $1,993.4517210NY0090168 NY Gold Savings Plus OAEPO 1000 90% DEP30 Gold EPO $636.11 $1,081.39 $1,272.23 $1,812.9317210NY0090199 NY Gold EPO 1000 90% DEP30 Gold EPO $699.46 $1,189.07 $1,398.91 $1,993.4517210NY0140002 NY Gold OAEPO AP 1000 90% DEP30 Gold EPO $675.38 $1,148.14 $1,350.76 $1,924.8317210NY0090197 NY Gold AWH OAEPO 1000 90% DEP30 Gold EPO $601.07 $1,021.82 $1,202.14 $1,713.05


17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $585.30 $995.02 $1,170.61 $1,668.1217210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $594.56 $1,010.75 $1,189.12 $1,694.4917210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $565.62 $961.55 $1,131.23 $1,612.0117210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $594.25 $1,010.22 $1,188.49 $1,693.6017210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $539.93 $917.88 $1,079.86 $1,538.8017210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $521.19 $886.02 $1,042.38 $1,485.3917210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $534.18 $908.10 $1,068.36 $1,522.4117210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $621.27 $1,056.17 $1,242.55 $1,770.6317210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $597.00 $1,014.90 $1,194.00 $1,701.4517210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $621.27 $1,056.17 $1,242.55 $1,770.6317210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $775.48 $1,318.32 $1,550.96 $2,210.1217210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $594.71 $1,011.00 $1,189.41 $1,694.9217210NY0090180 NY Silver EPO 2000 60% Silver EPO $585.30 $995.02 $1,170.61 $1,668.1217210NY0090182 NY Silver EPO 2000 80% Silver EPO $594.56 $1,010.75 $1,189.12 $1,694.4917210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $574.09 $975.96 $1,148.18 $1,636.1617210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $510.93 $868.58 $1,021.86 $1,456.1517210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $510.66 $868.12 $1,021.32 $1,455.3817210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $510.19 $867.33 $1,020.39 $1,454.0517210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $602.86 $1,024.87 $1,205.73 $1,718.1617210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $612.40 $1,041.07 $1,224.79 $1,745.3317210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $582.59 $990.40 $1,165.17 $1,660.3717210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $612.07 $1,040.52 $1,224.15 $1,744.4117210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $556.13 $945.42 $1,112.25 $1,584.9617210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $536.83 $912.61 $1,073.65 $1,529.9617210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $550.20 $935.34 $1,100.41 $1,568.0817210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $639.91 $1,087.85 $1,279.82 $1,823.7517210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $614.91 $1,045.35 $1,229.82 $1,752.5017210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $639.91 $1,087.85 $1,279.82 $1,823.7517210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $798.75 $1,357.87 $1,597.49 $2,276.4317210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $612.55 $1,041.33 $1,225.10 $1,745.7617210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $602.86 $1,024.87 $1,205.73 $1,718.1617210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $612.40 $1,041.07 $1,224.79 $1,745.3317210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $591.32 $1,005.24 $1,182.63 $1,685.2517210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $526.26 $894.64 $1,052.51 $1,499.8317210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $525.98 $894.17 $1,051.96 $1,499.0417210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $525.50 $893.35 $1,051.00 $1,497.67


D-24



Premium Rate

Parent & Child(ren)

Premium RateCouple

Premium RateFamily


17210NY0090151 NY Bronze OAEPO 3750 50% Bronze EPO $517.20 $879.25 $1,034.41 $1,474.0317210NY0090153 NY Bronze OAEPO 4500 70% Bronze EPO $499.78 $849.63 $999.57 $1,424.3817210NY0090155 NY Bronze OAEPO 5000 60% Bronze EPO $495.65 $842.61 $991.30 $1,412.6117210NY0090157 NY Bronze OAEPO 5400 50% HSA Bronze EPO $473.57 $805.08 $947.15 $1,349.6917210NY0090159 NY Bronze OAEPO 5400 50% HSA PY Bronze EPO $473.57 $805.08 $947.15 $1,349.6917210NY0090161 NY Bronze OAEPO 5700 70% HSA Bronze EPO $494.89 $841.31 $989.78 $1,410.4417210NY0090162 NY Bronze OAEPO 5700 70% HSA PY Bronze EPO $494.89 $841.31 $989.78 $1,410.4417210NY0090194 NY Bronze Savings Plus OAEPO 4500 60% Bronze EPO $455.61 $774.54 $911.22 $1,298.4917210NY0090165 NY Bronze OAEPO 6850 100% L Bronze EPO $549.89 $934.81 $1,099.77 $1,567.1717210NY0090149 NY Bronze EPO 5700 70% HSA PY Bronze EPO $494.89 $841.31 $989.78 $1,410.4417210NY0140005 NY Bronze OAEPO AP 4500 70% Bronze EPO $482.58 $820.39 $965.16 $1,375.3517210NY0090144 NY Bronze AWH OAEPO 4500 70% Bronze EPO $429.49 $730.12 $858.97 $1,224.0317210NY0090146 NY Bronze AWH OAEPO 5700 70%HSA PY Bronze EPO $425.28 $722.98 $850.56 $1,212.0517210NY0090147 NY Bronze AWH OAEPO 6850 100% L Bronze EPO $457.97 $778.55 $915.95 $1,305.2217210NY0090152 NY Bronze OAEPO 3750 50% DEP30 Bronze EPO $532.72 $905.62 $1,065.44 $1,518.2517210NY0090154 NY Bronze OAEPO 4500 70% DEP30 Bronze EPO $514.78 $875.12 $1,029.55 $1,467.1117210NY0090156 NY Bronze OAEPO 5000 60% DEP30 Bronze EPO $510.52 $867.89 $1,021.04 $1,454.9917210NY0090158 NY Bronze OAEPO 5400 50% HSA DEP30 Bronze EPO $487.78 $829.23 $975.57 $1,390.1817210NY0090160 NY Bronze OAEPO 5400 50% HSA PY DEP30 Bronze EPO $487.78 $829.23 $975.57 $1,390.1817210NY0090163 NY Bronze OAEPO 5700 70% HSA DEP30 Bronze EPO $509.74 $866.55 $1,019.47 $1,452.7517210NY0090164 NY Bronze OAEPO 5700 70% HSA PY DEP30 Bronze EPO $509.74 $866.55 $1,019.47 $1,452.7517210NY0090195 NY Bronze Savings Plus OAEPO 4500 60% DEP30 Bronze EPO $469.28 $797.78 $938.56 $1,337.4517210NY0090166 NY Bronze OAEPO 6850 100% L DEP30 Bronze EPO $566.38 $962.85 $1,132.76 $1,614.1917210NY0090150 NY Bronze EPO 5700 70% HSA PY DEP30 Bronze EPO $509.74 $866.55 $1,019.47 $1,452.7517210NY0140006 NY Bronze OAEPO AP 4500 70% DEP30 Bronze EPO $497.06 $845.00 $994.11 $1,416.6117210NY0090145 NY Bronze AWH OAEPO 4500 70% DEP30 Bronze EPO $442.37 $752.03 $884.74 $1,260.7517210NY0090143 NY Bronze AWH OAEPO 5700 70%HSA PY DEP30 Bronze EPO $438.04 $744.66 $876.08 $1,248.4117210NY0090148 NY Bronze AWH OAEPO 6850 100% L DEP30 Bronze EPO $471.71 $801.91 $943.42 $1,344.38



17210NY0090184 NY Silver OAEPO 2000 60% Silver EPO $606.93 $1,031.79 $1,213.87 $1,729.7617210NY0090186 NY Silver OAEPO 2000 80% Silver EPO $616.53 $1,048.10 $1,233.06 $1,757.1117210NY0090190 NY Silver OAEPO 3000 70% Silver EPO $586.52 $997.08 $1,173.04 $1,671.5817210NY0090188 NY Silver OAEPO 2800 90% HSA PY Silver EPO $616.21 $1,047.55 $1,232.41 $1,756.1917210NY0090202 NY Silver Savings Plus OAEPO 2000 80% Silver EPO $559.88 $951.80 $1,119.76 $1,595.6617210NY0090204 NY Silver Savings Plus OAEPO 2500 80% Silver EPO $540.45 $918.77 $1,080.90 $1,540.2817210NY0090206 NY Silver SP OAEPO 2800 90% HSA PY Silver EPO $553.92 $941.66 $1,107.84 $1,578.6717210NY0100009 NY Silver OAMC 3000 100/70 HSA Silver MC $644.23 $1,095.19 $1,288.46 $1,836.0617210NY0100007 NY Silver OAMC 2800 90/70 HSA Silver MC $619.06 $1,052.41 $1,238.13 $1,764.3317210NY0100011 NY Silver OAMC 3000 100/80 HSA FH Silver MC $644.23 $1,095.19 $1,288.46 $1,836.0617210NY0080009 NY Silver Indemnity 2500 80% Silver Indemnity $804.14 $1,367.04 $1,608.28 $2,291.7917210NY0090192 NY Silver OAEPO 4500 100% L Silver EPO $616.68 $1,048.36 $1,233.37 $1,757.5517210NY0090180 NY Silver EPO 2000 60% Silver EPO $606.93 $1,031.79 $1,213.87 $1,729.7617210NY0090182 NY Silver EPO 2000 80% Silver EPO $616.53 $1,048.10 $1,233.06 $1,757.1117210NY0140003 NY Silver OAEPO AP 2000 80% Silver EPO $595.31 $1,012.02 $1,190.61 $1,696.6317210NY0090175 NY Silver AWH OAEPO 2000 80% Silver EPO $529.81 $900.68 $1,059.62 $1,509.9617210NY0090177 NY Silver AWH OAEPO 2800 90% HSA PY Silver EPO $529.53 $900.20 $1,059.06 $1,509.1617210NY0090178 NY Silver AWH OAEPO 4500 100% L Silver EPO $529.05 $899.38 $1,058.09 $1,507.7817210NY0090185 NY Silver OAEPO 2000 60% DEP30 Silver EPO $625.14 $1,062.74 $1,250.28 $1,781.6517210NY0090187 NY Silver OAEPO 2000 80% DEP30 Silver EPO $635.03 $1,079.54 $1,270.05 $1,809.8217210NY0090191 NY Silver OAEPO 3000 70% DEP30 Silver EPO $604.11 $1,027.00 $1,208.23 $1,721.7317210NY0090189 NY Silver OAEPO 2800 90% HSA PY DEP30 Silver EPO $634.69 $1,078.98 $1,269.38 $1,808.8717210NY0090203 NY Silver Savings Plus OAEPO 2000 80% DEP30 Silver EPO $576.68 $980.35 $1,153.36 $1,643.5317210NY0090205 NY Silver Savings Plus OAEPO 2500 80% DEP30 Silver EPO $556.66 $946.33 $1,113.33 $1,586.4917210NY0090207 NY Silver SP OAEPO 2800 90% HSA PY DEP30 Silver EPO $570.53 $969.91 $1,141.07 $1,626.0217210NY0100010 NY Silver OAMC 3000 100/70 HSA DEP30 Silver MC $663.56 $1,128.05 $1,327.12 $1,891.1417210NY0100008 NY Silver OAMC 2800 90/70 HSA DEP30 Silver MC $637.63 $1,083.98 $1,275.27 $1,817.2617210NY0100012 NY Silver OAMC 3000 100/80 HSA FH DEP30 Silver MC $663.56 $1,128.05 $1,327.12 $1,891.1417210NY0080010 NY Silver Indemnity 2500 80% DEP30 Silver Indemnity $828.26 $1,408.05 $1,656.53 $2,360.5517210NY0090193 NY Silver OAEPO 4500 100% L DEP30 Silver EPO $635.18 $1,079.81 $1,270.37 $1,810.2817210NY0090181 NY Silver EPO 2000 60% DEP30 Silver EPO $625.14 $1,062.74 $1,250.28 $1,781.6517210NY0090183 NY Silver EPO 2000 80% DEP30 Silver EPO $635.03 $1,079.54 $1,270.05 $1,809.8217210NY0140004 NY Silver OAEPO AP 2000 80% DEP30 Silver EPO $613.17 $1,042.38 $1,226.33 $1,747.5217210NY0090176 NY Silver AWH OAEPO 2000 80% DEP30 Silver EPO $545.70 $927.70 $1,091.41 $1,555.2617210NY0090208 NY Silver AWH OAEPO 2800 90% HSA PY DEP30 Silver EPO $545.42 $927.21 $1,090.84 $1,554.4417210NY0090179 NY Silver AWH OAEPO 4500 100% L DEP30 Silver EPO $544.92 $926.36 $1,089.84 $1,553.02

Aetna Life Insurance Company E-1 New York Small Group

List of SG Off-Exchange Forms (2017) Riders OFFHIXSGGR-96830-Deps Age 29 Rider-3 OFFHIXSGGR-96830 Family Planning Rider-3 NYCCP Certificate and Schedules OffHIXSG(NYCCP$20)GR-96830-3-SB OffHIXSG(NYCCP$30)GR-96830-3-SB OffHIXSGNYCCPGR-96830-3 SG Indemnity Certificate and Schedules OffHIXSGINDEMGR-96820-3 OffHIXSG(IndemSilver250080%)GR-96820-3-SB SG OAMC OffHIXSGOAMCGR-96824-3 OffHIXSG(OAMCSilver300010070%HSA)GR-96824-3-SB OffHIXSG(OAMCSilver28009070%HSA)GR-96824-3-SB SG OAMC FH OffHIXSGOAMCGR-96824-FH-3 OffHIXSG(OAMCSilver300010080%HSAFH)GR-96824-3-SB SG EPO, SG EPO Leap, and SG EPO AP Certificate and Schedules OffHIXSGEPOGR-96817-3 OffHIXSG(EPOGold100090%)GR-96817-3-SB OffHIXSG(EPOPlatinum$25)GR-96817-3-SB OffHIXSG(EPOSilver200060%)GR-96817-3-SB OffHIXSG(EPOSilver200080%)GR-96817-3-SB OffHIXSG(EPOSilver300070%)GR-96817-3-SB OffHIXSG(EPOBronze375050%)GR-96817-3-SB OffHIXSG(EPOBronze450070%)GR-96817-3-SB OffHIXSG(EPOBronze500060%)GR-96817-3-SB OffHIXSG(EPOBronze540050%HSA)GR-96817-3-SB OffHIXSG(EPOBronze570070%HSA)GR-96817-3-SB OffHIXSG(EPOSilver4500100%L)GR-96817-3-SB OffHIXSG(EPOBronze6850100%L)GR-96817-3-SB OffHIXSG(EPOGold100090%AP)GR-96817-3-SB OffHIXSG(EPOSilver200080%AP)GR-96817-3-SB OffHIXSG(EPOBronze450070%AP)GR-96817-3-SB SG EPO HSA PY Certificate and Schedules OffHIXSGEPOHSAPYGR-96823-3 OffHIXSG(EPOSilver280090%HSAPY)GR-96823-3-SB OffHIXSG(EPOBronze570070%HSAPY)GR-96823-3-SB OffHIXSG(EPOBronze540050%HSAPY)GR-96823-3-SB

Aetna Life Insurance Company E-2 New York Small Group

SG EPO Savings Plus Certificate and Schedules OffHIXSGNYEPOSAVPLUS-96000-3 OffHIXSG(EPOGold100090%SP)GR-96000-3-SB OffHIXSG(EPOSilver200080%SP)GR-96000-3-SB OffHIXSG(EPOSilver250080%SP)GR-96000-3-SB OffHIXSG(EPOBronze450060%SP)GR-96000-3-SB SG EPO HSA PY Savings Plus Certificate and Schedules OffHIXSGNYEPOSAVPLUSHSAPY-96001-3 OffHIXSG(EPOSilver280090%SPHSAPY)GR-96001-3-SB SG EPO Referral Certificates and Schedules OffHIXSGEPORGR-96826-3 OffHIXSG(EPOGold100090%RR)GR-96826-3-SB OffHIXSG(EPOSilver200060%RR)GR-96826-3-SB OffHIXSG(EPOSilver200080%RR)GR-96826-3-SB SG EPO Referral HSA PY Certificate and Schedule OffHIXSGEPORHSAPYGR-96825-3 OffHIXSG(EPOBronze570070%RRHSAPY)GR-96825-3-SB SG OAEPO AWH and Leap Certificate and Schedules OffHIXSGNYEPOAWHMS-96005-3 OffHIXSG(EPOGold100090%AWHMS)GR-96005-3-SB OffHIXSG(EPOSilver200080%AWHMS)GR-96005-3-SB OffHIXSG(EPOBronze450070%AWHMS)GR-96005-3-SB OffHIXSG(EPOSilver4500100%AWHMSL)GR-96005-3-SB OffHIXSG(EPOBronze6850100%AWHMSL)GR-96005-3-SB SG OAEPO AWH HSA PY Certificate and Schedule OffHIXSGNYEPOAWHMSHSAPY-96006-3 OffHIXSG(EPOSilver280090%AWHMSHSAPY)GR-96006-3-SB OffHIXSG(EPOBronze570070%AWHMSHSAPY)GR-96006-3-SB

Aetna Life Insurance Company F-1 New York Small Group

Appendix I Commissions Schedule and Incentive Fees

The most recent NY SG ALIC Commissions filing was submitted on 4/29/2016, AETN-130522689.

1.0 The following compensation will be payable only as long as the cases remain in force and the producer is recognized by the policyholder and Aetna as the agent of record. 1.1 100 or fewer Full Time Equivalents (i.e., Small Group) New Business: To compensate producers for services performed in connection with the sale and installation, administration and maintenance of all new Medical coverage for employers with 100 or fewer Full Time Equivalents (i.e. Small Group) written with an effective date of May 1, 2016 or later, Aetna will pay commissions of $27 Per Employee Per Month (PEPM). Renewing Business: To compensate producers for services performed in connection with the sale and installation, administration and maintenance of all renewing Medical coverage for employers with 100 or fewer Full Time Equivalents (i.e. Small Group) renewing with an effective date of May 1, 2016 or later, Aetna will pay commissions of $27 Per Employee Per Month (PEPM).


G-1

Appendix II

Projected Loss Ratio The NY Small Group 2017 projected MBR for this filing is 86.6% following the New York State methodology. The expected 2017 MLR for this filing, as defined by PPACA and before any credibility adjustment, is 90.9%.

Individual Formula

(a) Member Months 1,826,942

(b) Earned Premium (pmpm) $618.41

(c) Incurred Claims (pmpm)(1) $535.51

(d) Medical Benefit Ratio (MBR) 86.59% = (c) / (b)

(e) Quality Improvement Activities (pmpm) $4.45 = (b) x 0.72 % (2)

(f) Net Risk Adjustment Receipts (pmpm) $0.00

(g) Taxes and Fees (pmpm) $24.61 = (b) x 3.98% (3)

(h) Adjusted Premium (pmpm) $593.80 = (b) - (g)

(i) Adjusted Claims (pmpm) $539.96 = (c) + (e) - (f)

(j) Medical Loss Ratio (MLR) 90.93% = (i) / (h) (1) Incurred claims include an expected $70.91 risk adjustment transfer. (2) Spending on quality improvement activities is estimated to be 0.72% of premium. (3) Taxes and fees are estimated to be 3.98% of premium. NOTE: Adjustments for QIA and taxes and fees are estimates based on historical experience and projected expenses. Values reflect current actuarial projections and will differ from the final reported MLR.

aetna life insurance company new york small group premium

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