filing at a glance · 2020-05-29 · filing at a glance company: oxford health insurance, inc....

Filing at a Glance

Company: Oxford Health Insurance, Inc.

Product Name: 2021 OHI SG SHOP & OFFX Plans

State: New York

TOI: H15G Group Health - Hospital/Surgical/Medical Expense

Sub-TOI: H15G.003 Small Group Only

Filing Type: 2021 Prior Approval ACA Rates

Date Submitted: 05/18/2020

SERFF Tr Num: UHLC-132366075

SERFF Status: Assigned

State Tr Num: 2020050265

State Status: CP-xx-IA

Co Tr Num: CY2021 RATE FILING

ImplementationDate Requested:

01/01/2021

Author(s):

Reviewer(s):

Disposition Date:

Disposition Status:

Implementation Date:

State Filing Description:

SERFF Tracking #: UHLC-132366075 State Tracking #: 2020050265 Company Tracking #: CY2021 RATE FILING

State: New York Filing Company: Oxford Health Insurance, Inc.

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


Project Name/Number: 2021 OHI SG SHOP & OFFX Plans/

PDF Pipeline for SERFF Tracking Number UHLC-132366075 Generated 05/26/2020 10:28 AM

General Information

Company and Contact

Filing Fees

State Specific

Project Name: 2021 OHI SG SHOP & OFFX Plans Status of Filing in Domicile: Not Filed

Project Number: Date Approved in Domicile:

Requested Filing Mode: Review & Approval Domicile Status Comments:

Explanation for Combination/Other: Market Type: Group

Submission Type: New Submission Group Market Size: Small

Group Market Type: Employer Overall Rate Impact:

Filing Status Changed: 05/19/2020

State Status Changed: 05/19/2020 Deemer Date:

Created By: Submitted By:

Corresponding Filing Tracking Number:

PPACA: Non-Grandfathered Immed Mkt Reforms

PPACA Notes: null

Exchange Intentions: Yes, this filing includes Oxford's 2021 SHOP Exchange Filing.

Filing Description:

2021 OHI Small Group SHOP & Off Exchange Plans

Filing Contact Information

Filing Company InformationOxford Health Insurance, Inc.

One Penn Plaza FL 8

New York, NY 10119

(203) 459-6000 ext. [Phone]

CoCode: 78026

Group Code:

Group Name:

FEIN Number: 22-2797560

State of Domicile: New York

Company Type: Insurance

State ID Number: 78026

Fee Required? No

Retaliatory? No

Fee Explanation:

1. Is a parallel filing being submitted for another issuing entity of the same parent organization? Yes/No (If Yes, enter nameof other entity, submission date, and SERFF Tracking Number of the parallel file.): Yes - 2021 OHI Small Group On & Off COCFiling & 2021 OHI Healthy NY COC Filing, 5/18/20, SERFF Tr Num: UHLC-132379631 and UHLC-1323710422. Does this filing contain a dental, vision or health insurance policy or contract that uses a network of health care providers?(If Yes, enter the PNDS Network ID number and name. If the network has not been filed in PNDS, it must be filed within 60days of approval.): Yes - 0112 Freedom, 0076 Liberty, 0173 Metro







3. : n/a4. Type of filing? Enter Form and Rate, Form only, Rate only (Form only should be used ONLY when the filing only containsan application, advertisement, administrative form, or is a group prefiling notification, out-of-state, or a report filing. Formsubmissions with no proposed rate impact are considered form and rate filings and require an actuarial memorandum.): RateOnly5. Is this a Rate only filing? Yes/No [If Yes, enter one: Commission/Fee Schedule, DBL Loss Ratio Monitoring, ExperienceFiling Monitoring, Experience Rating Formula, Medicare Supplement Annual Filing (other than rate adjustment), RateAdjustment, or Other with brief explanation).]: Yes - Prior Approval Rate Adjustment6. Does this submission contain a form subject to Regulation 123 (i.e., the certificate is deemed delivered in New York State)?Yes/No (If Yes, provide a full explanation in the Filing Description field.): No7. Did this insurer prefile group coverage for this group under Section 52.32 prior to this filing? Yes/No (If Yes, enter thestate tracking number assigned and the effective date of coverage.): No8. Does this submission contain any form which is subject to review by the Life Bureau, the Property Bureau or both? Yes/No(If Yes, identify the forms, the Bureau, the date submitted, and the SERFF file number.): No9. Does this filing contain forms that replace any other previously approved forms? Yes/No (If Yes, identify the formnumbers, the file number, and the date of approval of the forms being replaced in the Filing Description field.): No







Rate Information Rate data applies to filing.

Filing Method: Prior Approval

Rate Change Type: Increase

Overall Percentage of Last Rate Revision: 9.620%

Effective Date of Last Rate Revision: 01/01/2020

Filing Method of Last Filing: Prior Approval

SERFF Tracking Number of Last Filing: UHLC-131921153

Company Rate Information

Company

Name:

Company

Rate

Change:

Overall %

Indicated

Change:

Overall %

Rate

Impact:

Written

Premium

Change for

this Program:

Number of Policy

Holders Affected

for this Program:

Written

Premium for

this Program:

Maximum %

Change

(where req'd):

Minimum %

Change

(where req'd):

Oxford HealthInsurance, Inc.

Increase 13.630% 13.630% $656,753,550 503,803 $4,818,519,740 36.430% 6.137%







Rate Review Detail

COMPANY:Company Name: Oxford Health Insurance, Inc.

HHS Issuer Id: 85629

PRODUCTS:

Product Name HIOS Product ID HIOS Submission ID Number of Covered

Lives2021 OHI SG SHOP & OFFX Plans 503803

Trend Factors: 2.2% Quarterly Trend

FORMS:New Policy Forms:

Affected Forms:

Other Affected Forms: OHINY_SG_COC_2021

REQUESTED RATE CHANGE INFORMATION:Change Period: Annual

Member Months: 6,297,069

Benefit Change: None

Percent Change Requested: Min: 6.137 Max: 36.43 Avg: 13.63

PRIOR RATE:Total Earned Premium: 4,818,519,740.00

Total Incurred Claims: 4,178,914,509.00

Annual $: Min: 432.01 Max: 1,312.64 Avg: 765.20

REQUESTED RATE:Projected Earned Premium: 5,475,273,290.00

Projected Incurred Claims: 4,676,313,448.00

Annual $: Min: 503.02 Max: 1,492.85 Avg: 869.50







Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 2021 SG OHI OnOff-Exch RateManual

New 2021 OHI SG RateManual - Final.pdf,2021 OHI SG RateManual - Final.xlsx,







Oxford Health Insurance, Inc.

New York Small Group

On/Off Exchange

Form # OHINY_SG_COC_2021

Rate Manual

Rates Effective January 1, 2021

Page 1 of 85

Oxford Health Insurance, Inc.New York Small GroupOn/Off ExchangeForm # OHINY_SG_COC_2021

Table of Contents

Section Page(s)

Area Factors 3

Base Medical and Prescription Drug Rates - Off-Exchange 4 - 7

Base Medical and Prescription Drug Rates - On-Exchange 8 -11

Ancillary Coverage Rider Rates 12

Medical and Rx Drug Benefits 13 - 14

Pediatric Dental and Vision Benefits 15

Additional Notes 16

Page 2 of 85

Oxford Health Insurance, Inc.New York Small GroupOn/Off ExchangeForm # OHINY_SG_COC_2021Area FactorsArea Factor is "n/a" for counties outside the service area.

CountyDFS Rating

Region Area Factor CountyDFS Rating

Region Area Factor CountyDFS Rating

Region Area Factor

Albany 1 n/a Delaware 3 n/a Broome 6 n/aColumbia 1 n/a Dutchess 3 1.078 Cayuga 6 n/aFulton 1 n/a Orange 3 1.078 Chemung 6 n/aGreene 1 n/a Putnam 3 1.078 Cortland 6 n/aMontgomery 1 n/a Sullivan 3 1.078 Onondaga 6 n/aRensselaer 1 n/a Ulster 3 1.078 Schuyler 6 n/a

Saratoga 1 n/a Bronx 4 0.996 Steuben 6 n/aSchenectady 1 n/a Kings 4 0.996 Tioga 6 n/aSchoharie 1 n/a New York 4 0.996 Tompkins 6 n/a

Warren 1 n/a Queens 4 0.996 Chenango 7 n/aWashington 1 n/a Richmond 4 0.996 Clinton 7 n/a

Allegany 2 n/a Rockland 4 0.996 Essex 7 n/aCattaraugus 2 n/a Westchester 4 0.996 Franklin 7 n/a

Chautauqua 2 n/a Livingston 5 n/a Hamilton 7 n/aErie 2 n/a Monroe 5 n/a Herkimer 7 n/aGenesee 2 n/a Ontario 5 n/a Jefferson 7 n/aNiagara 2 n/a Seneca 5 n/a Lewis 7 n/aOrleans 2 n/a Wayne 5 n/a Madison 7 n/aWyoming 2 n/a Yates 5 n/a Oneida 7 n/a

Oswego 7 n/aOtsego 7 n/aSt. Lawrence 7 n/a

Nassau 8 1.011Suffolk 8 1.011

Page 3 of 85

Oxford Health Insurance, Inc.New York Small GroupOff-ExchangeForm # OHINY_SG_COC_2021Base Medical and Prescription Drug Monthly Rates 2021 Q1

Plan 16-digit HIOS ID Dep 29 RiderDomestic

Partner RiderContraceptive Exclusion Rider Single Rate

Single + Child(ren)

RateSingle +

Spouse Rate

Single + Spouse + Child(ren)

RateG EPO $15/$35 $1750D F NG 85629NY0010240-00 N N N 1,221.81$ 2,077.08$ 2,443.62$ 3,482.16$ G EPO $15/$35 $1750D F NG 85629NY0010253-00 N N Y 1,217.23$ 2,069.29$ 2,434.46$ 3,469.11$ G EPO $15/$35 $1750D F NG 85629NY0010238-00 N Y N 1,221.81$ 2,077.08$ 2,443.62$ 3,482.16$ G EPO $15/$35 $1750D F NG 85629NY0010254-00 N Y Y 1,217.23$ 2,069.29$ 2,434.46$ 3,469.11$ G EPO $15/$35 $1750D F NG 85629NY0010239-00 Y N N 1,241.36$ 2,110.32$ 2,482.72$ 3,537.88$ G EPO $15/$35 $1750D F NG 85629NY0010237-00 Y Y N 1,241.36$ 2,110.32$ 2,482.72$ 3,537.88$ G EPO $15/$35 $1750D F NG 85629NY0010255-00 Y N Y 1,236.78$ 2,102.53$ 2,473.56$ 3,524.83$ G EPO $15/$35 $1750D F NG 85629NY0010256-00 Y Y Y 1,236.78$ 2,102.53$ 2,473.56$ 3,524.83$ G EPO $25/$40 $1,750D F NG 85629NY0010248-00 N N N 1,211.17$ 2,058.99$ 2,422.34$ 3,451.83$ G EPO $25/$40 $1,750D F NG 85629NY0010261-00 N N Y 1,206.59$ 2,051.20$ 2,413.18$ 3,438.78$ G EPO $25/$40 $1,750D F NG 85629NY0010246-00 N Y N 1,211.17$ 2,058.99$ 2,422.34$ 3,451.83$ G EPO $25/$40 $1,750D F NG 85629NY0010262-00 N Y Y 1,206.59$ 2,051.20$ 2,413.18$ 3,438.78$ G EPO $25/$40 $1,750D F NG 85629NY0010247-00 Y N N 1,230.72$ 2,092.23$ 2,461.44$ 3,507.55$ G EPO $25/$40 $1,750D F NG 85629NY0010245-00 Y Y N 1,230.72$ 2,092.23$ 2,461.44$ 3,507.55$ G EPO $25/$40 $1,750D F NG 85629NY0010263-00 Y N Y 1,226.14$ 2,084.44$ 2,452.28$ 3,494.50$ G EPO $25/$40 $1,750D F NG 85629NY0010264-00 Y Y Y 1,226.14$ 2,084.44$ 2,452.28$ 3,494.50$ G EPO $30/$60 $2,250D F NG 85629NY0010645-00 N N N 1,127.67$ 1,917.04$ 2,255.34$ 3,213.86$ G EPO $30/$60 $2,250D F NG 85629NY0010646-00 N N Y 1,123.09$ 1,909.25$ 2,246.18$ 3,200.81$ G EPO $30/$60 $2,250D F NG 85629NY0010647-00 N Y N 1,127.67$ 1,917.04$ 2,255.34$ 3,213.86$ G EPO $30/$60 $2,250D F NG 85629NY0010648-00 N Y Y 1,123.09$ 1,909.25$ 2,246.18$ 3,200.81$ G EPO $30/$60 $2,250D F NG 85629NY0010649-00 Y N N 1,147.22$ 1,950.28$ 2,294.44$ 3,269.58$ G EPO $30/$60 $2,250D F NG 85629NY0010650-00 Y Y N 1,147.22$ 1,950.28$ 2,294.44$ 3,269.58$ G EPO $30/$60 $2,250D F NG 85629NY0010651-00 Y N Y 1,142.64$ 1,942.49$ 2,285.28$ 3,256.53$ G EPO $30/$60 $2,250D F NG 85629NY0010652-00 Y Y Y 1,142.64$ 1,942.49$ 2,285.28$ 3,256.53$ G $50 $1000D F NG 85629NY0010084-00 N N N 1,237.15$ 2,103.16$ 2,474.30$ 3,525.88$ G $50 $1000D F NG 85629NY0010101-00 N N Y 1,232.57$ 2,095.37$ 2,465.14$ 3,512.83$ G $50 $1000D F NG 85629NY0010082-00 N Y N 1,237.15$ 2,103.16$ 2,474.30$ 3,525.88$ G $50 $1000D F NG 85629NY0010102-00 N Y Y 1,232.57$ 2,095.37$ 2,465.14$ 3,512.83$ G $50 $1000D F NG 85629NY0010083-00 Y N N 1,256.70$ 2,136.40$ 2,513.40$ 3,581.60$ G $50 $1000D F NG 85629NY0010081-00 Y Y N 1,256.70$ 2,136.40$ 2,513.40$ 3,581.60$ G $50 $1000D F NG 85629NY0010103-00 Y N Y 1,252.12$ 2,128.61$ 2,504.24$ 3,568.55$ G $50 $1000D F NG 85629NY0010104-00 Y Y Y 1,252.12$ 2,128.61$ 2,504.24$ 3,568.55$ P EPO $20/$40 F NG 85629NY0010036-00 N N N 1,461.92$ 2,485.26$ 2,923.84$ 4,166.47$ P EPO $20/$40 F NG 85629NY0010226-00 N N Y 1,457.34$ 2,477.47$ 2,914.68$ 4,153.42$ P EPO $20/$40 F NG 85629NY0010034-00 N Y N 1,461.92$ 2,485.26$ 2,923.84$ 4,166.47$ P EPO $20/$40 F NG 85629NY0010227-00 N Y Y 1,457.34$ 2,477.47$ 2,914.68$ 4,153.42$ P EPO $20/$40 F NG 85629NY0010035-00 Y N N 1,481.47$ 2,518.50$ 2,962.94$ 4,222.19$ P EPO $20/$40 F NG 85629NY0010033-00 Y Y N 1,481.47$ 2,518.50$ 2,962.94$ 4,222.19$ P EPO $20/$40 F NG 85629NY0010228-00 Y N Y 1,476.89$ 2,510.71$ 2,953.78$ 4,209.14$ P EPO $20/$40 F NG 85629NY0010229-00 Y Y Y 1,476.89$ 2,510.71$ 2,953.78$ 4,209.14$ P EPO $5/$15 F NG 85629NY0010336-00 N N N 1,493.29$ 2,538.59$ 2,986.58$ 4,255.88$ P EPO $5/$15 F NG 85629NY0010213-00 N N Y 1,488.71$ 2,530.80$ 2,977.42$ 4,242.83$ P EPO $5/$15 F NG 85629NY0010341-00 N Y N 1,493.29$ 2,538.59$ 2,986.58$ 4,255.88$ P EPO $5/$15 F NG 85629NY0010214-00 N Y Y 1,488.71$ 2,530.80$ 2,977.42$ 4,242.83$ P EPO $5/$15 F NG 85629NY0010342-00 Y N N 1,512.84$ 2,571.83$ 3,025.68$ 4,311.60$ P EPO $5/$15 F NG 85629NY0010340-00 Y Y N 1,512.84$ 2,571.83$ 3,025.68$ 4,311.60$ P EPO $5/$15 F NG 85629NY0010215-00 Y N Y 1,508.26$ 2,564.04$ 3,016.52$ 4,298.55$ P EPO $5/$15 F NG 85629NY0010216-00 Y Y Y 1,508.26$ 2,564.04$ 3,016.52$ 4,298.55$ S EPO $40/$70 $3000D F NG 85629NY0010300-00 N N N 1,006.71$ 1,711.41$ 2,013.42$ 2,869.12$ S EPO $40/$70 $3000D F NG 85629NY0010312-00 N N Y 1,002.13$ 1,703.62$ 2,004.26$ 2,856.07$ S EPO $40/$70 $3000D F NG 85629NY0010294-00 N Y N 1,006.71$ 1,711.41$ 2,013.42$ 2,869.12$ S EPO $40/$70 $3000D F NG 85629NY0010313-00 N Y Y 1,002.13$ 1,703.62$ 2,004.26$ 2,856.07$ S EPO $40/$70 $3000D F NG 85629NY0010295-00 Y N N 1,026.26$ 1,744.65$ 2,052.52$ 2,924.84$ S EPO $40/$70 $3000D F NG 85629NY0010293-00 Y Y N 1,026.26$ 1,744.65$ 2,052.52$ 2,924.84$ S EPO $40/$70 $3000D F NG 85629NY0010314-00 Y N Y 1,021.68$ 1,736.86$ 2,043.36$ 2,911.79$ S EPO $40/$70 $3000D F NG 85629NY0010315-00 Y Y Y 1,021.68$ 1,736.86$ 2,043.36$ 2,911.79$ B EPO HSA $5,800D 50% F NG 85629NY0010316-00 N N N 857.66$ 1,458.02$ 1,715.32$ 2,444.33$ B EPO HSA $5,800D 50% F NG 85629NY0010325-00 N N Y 853.08$ 1,450.23$ 1,706.16$ 2,431.28$ B EPO HSA $5,800D 50% F NG 85629NY0010310-00 N Y N 857.66$ 1,458.02$ 1,715.32$ 2,444.33$ B EPO HSA $5,800D 50% F NG 85629NY0010326-00 N Y Y 853.08$ 1,450.23$ 1,706.16$ 2,431.28$ B EPO HSA $5,800D 50% F NG 85629NY0010311-00 Y N N 877.21$ 1,491.26$ 1,754.42$ 2,500.05$ B EPO HSA $5,800D 50% F NG 85629NY0010309-00 Y Y N 877.21$ 1,491.26$ 1,754.42$ 2,500.05$ B EPO HSA $5,800D 50% F NG 85629NY0010327-00 Y N Y 872.63$ 1,483.47$ 1,745.26$ 2,487.00$ B EPO HSA $5,800D 50% F NG 85629NY0010328-00 Y Y Y 872.63$ 1,483.47$ 1,745.26$ 2,487.00$ G EPO HSA $1,500D 90% F NG 85629NY0010076-00 N N N 1,154.18$ 1,962.11$ 2,308.36$ 3,289.41$ G EPO HSA $1,500D 90% F NG 85629NY0010072-00 N N Y 1,149.60$ 1,954.32$ 2,299.20$ 3,276.36$ G EPO HSA $1,500D 90% F NG 85629NY0010235-00 N Y N 1,154.18$ 1,962.11$ 2,308.36$ 3,289.41$ G EPO HSA $1,500D 90% F NG 85629NY0010073-00 N Y Y 1,149.60$ 1,954.32$ 2,299.20$ 3,276.36$ G EPO HSA $1,500D 90% F NG 85629NY0010236-00 Y N N 1,173.73$ 1,995.35$ 2,347.46$ 3,345.13$ G EPO HSA $1,500D 90% F NG 85629NY0010234-00 Y Y N 1,173.73$ 1,995.35$ 2,347.46$ 3,345.13$ G EPO HSA $1,500D 90% F NG 85629NY0010074-00 Y N Y 1,169.15$ 1,987.56$ 2,338.30$ 3,332.08$ G EPO HSA $1,500D 90% F NG 85629NY0010075-00 Y Y Y 1,169.15$ 1,987.56$ 2,338.30$ 3,332.08$

Region 3

Page 4 of 85




Single + Child(ren)

RateSingle +

Spouse Rate


Rate

Region 3

S EPO HSA $2,000D 70% F NG 85629NY0010272-00 N N N 992.60$ 1,687.42$ 1,985.20$ 2,828.91$ S EPO HSA $2,000D 70% F NG 85629NY0010277-00 N N Y 988.02$ 1,679.63$ 1,976.04$ 2,815.86$ S EPO HSA $2,000D 70% F NG 85629NY0010270-00 N Y N 992.60$ 1,687.42$ 1,985.20$ 2,828.91$ S EPO HSA $2,000D 70% F NG 85629NY0010278-00 N Y Y 988.02$ 1,679.63$ 1,976.04$ 2,815.86$ S EPO HSA $2,000D 70% F NG 85629NY0010271-00 Y N N 1,012.15$ 1,720.66$ 2,024.30$ 2,884.63$ S EPO HSA $2,000D 70% F NG 85629NY0010269-00 Y Y N 1,012.15$ 1,720.66$ 2,024.30$ 2,884.63$ S EPO HSA $2,000D 70% F NG 85629NY0010279-00 Y N Y 1,007.57$ 1,712.87$ 2,015.14$ 2,871.58$ S EPO HSA $2,000D 70% F NG 85629NY0010280-00 Y Y Y 1,007.57$ 1,712.87$ 2,015.14$ 2,871.58$ S EPO HSA $2250D $25/$50 F NG 85629NY0010288-00 N N N 1,017.06$ 1,729.00$ 2,034.12$ 2,898.62$ S EPO HSA $2250D $25/$50 F NG 85629NY0010296-00 N N Y 1,012.48$ 1,721.21$ 2,024.96$ 2,885.57$ S EPO HSA $2250D $25/$50 F NG 85629NY0010186-00 N Y N 1,017.06$ 1,729.00$ 2,034.12$ 2,898.62$ S EPO HSA $2250D $25/$50 F NG 85629NY0010297-00 N Y Y 1,012.48$ 1,721.21$ 2,024.96$ 2,885.57$ S EPO HSA $2250D $25/$50 F NG 85629NY0010287-00 Y N N 1,036.61$ 1,762.24$ 2,073.22$ 2,954.34$ S EPO HSA $2250D $25/$50 F NG 85629NY0010334-00 Y Y N 1,036.61$ 1,762.24$ 2,073.22$ 2,954.34$ S EPO HSA $2250D $25/$50 F NG 85629NY0010298-00 Y N Y 1,032.03$ 1,754.45$ 2,064.06$ 2,941.29$ S EPO HSA $2250D $25/$50 F NG 85629NY0010299-00 Y Y Y 1,032.03$ 1,754.45$ 2,064.06$ 2,941.29$ G PPO $25/$40 $1,500D F NG 85629NY0050044-00 N N N 1,267.81$ 2,155.28$ 2,535.62$ 3,613.26$ G PPO $25/$40 $1,500D F NG 85629NY0050193-00 N N Y 1,263.23$ 2,147.49$ 2,526.46$ 3,600.21$ G PPO $25/$40 $1,500D F NG 85629NY0050042-00 N Y N 1,267.81$ 2,155.28$ 2,535.62$ 3,613.26$ G PPO $25/$40 $1,500D F NG 85629NY0050194-00 N Y Y 1,263.23$ 2,147.49$ 2,526.46$ 3,600.21$ G PPO $25/$40 $1,500D F NG 85629NY0050043-00 Y N N 1,287.36$ 2,188.52$ 2,574.72$ 3,668.98$ G PPO $25/$40 $1,500D F NG 85629NY0050041-00 Y Y N 1,287.36$ 2,188.52$ 2,574.72$ 3,668.98$ G PPO $25/$40 $1,500D F NG 85629NY0050195-00 Y N Y 1,282.78$ 2,180.73$ 2,565.56$ 3,655.93$ G PPO $25/$40 $1,500D F NG 85629NY0050196-00 Y Y Y 1,282.78$ 2,180.73$ 2,565.56$ 3,655.93$ P PPO $20/$40 F NG 85629NY0050028-00 N N N 1,516.19$ 2,577.52$ 3,032.38$ 4,321.14$ P PPO $20/$40 F NG 85629NY0050185-00 N N Y 1,511.61$ 2,569.73$ 3,023.22$ 4,308.09$ P PPO $20/$40 F NG 85629NY0050026-00 N Y N 1,516.19$ 2,577.52$ 3,032.38$ 4,321.14$ P PPO $20/$40 F NG 85629NY0050186-00 N Y Y 1,511.61$ 2,569.73$ 3,023.22$ 4,308.09$ P PPO $20/$40 F NG 85629NY0050027-00 Y N N 1,535.74$ 2,610.76$ 3,071.48$ 4,376.86$ P PPO $20/$40 F NG 85629NY0050025-00 Y Y N 1,535.74$ 2,610.76$ 3,071.48$ 4,376.86$ P PPO $20/$40 F NG 85629NY0050187-00 Y N Y 1,531.16$ 2,602.97$ 3,062.32$ 4,363.81$ P PPO $20/$40 F NG 85629NY0050188-00 Y Y Y 1,531.16$ 2,602.97$ 3,062.32$ 4,363.81$ P PPO $5/$15 F NG 85629NY0050012-00 N N N 1,550.86$ 2,636.46$ 3,101.72$ 4,419.95$ P PPO $5/$15 F NG 85629NY0050177-00 N N Y 1,546.28$ 2,628.67$ 3,092.56$ 4,406.90$ P PPO $5/$15 F NG 85629NY0050010-00 N Y N 1,550.86$ 2,636.46$ 3,101.72$ 4,419.95$ P PPO $5/$15 F NG 85629NY0050178-00 N Y Y 1,546.28$ 2,628.67$ 3,092.56$ 4,406.90$ P PPO $5/$15 F NG 85629NY0050011-00 Y N N 1,570.41$ 2,669.70$ 3,140.82$ 4,475.67$ P PPO $5/$15 F NG 85629NY0050009-00 Y Y N 1,570.41$ 2,669.70$ 3,140.82$ 4,475.67$ P PPO $5/$15 F NG 85629NY0050179-00 Y N Y 1,565.83$ 2,661.91$ 3,131.66$ 4,462.62$ P PPO $5/$15 F NG 85629NY0050180-00 Y Y Y 1,565.83$ 2,661.91$ 3,131.66$ 4,462.62$ S PPO $40/$70 $3000D F NG 85629NY0050132-00 N N N 1,054.47$ 1,792.60$ 2,108.94$ 3,005.24$ S PPO $40/$70 $3000D F NG 85629NY0050033-00 N N Y 1,049.89$ 1,784.81$ 2,099.78$ 2,992.19$ S PPO $40/$70 $3000D F NG 85629NY0050130-00 N Y N 1,054.47$ 1,792.60$ 2,108.94$ 3,005.24$ S PPO $40/$70 $3000D F NG 85629NY0050034-00 N Y Y 1,049.89$ 1,784.81$ 2,099.78$ 2,992.19$ S PPO $40/$70 $3000D F NG 85629NY0050131-00 Y N N 1,074.02$ 1,825.84$ 2,148.04$ 3,060.96$ S PPO $40/$70 $3000D F NG 85629NY0050129-00 Y Y N 1,074.02$ 1,825.84$ 2,148.04$ 3,060.96$ S PPO $40/$70 $3000D F NG 85629NY0050035-00 Y N Y 1,069.44$ 1,818.05$ 2,138.88$ 3,047.91$ S PPO $40/$70 $3000D F NG 85629NY0050036-00 Y Y Y 1,069.44$ 1,818.05$ 2,138.88$ 3,047.91$ P PPO $20/$40 F NG FAIR 85629NY0050233-00 N N N 1,813.45$ 3,082.87$ 3,626.90$ 5,168.33$ P PPO $20/$40 F NG FAIR 85629NY0050234-00 N N Y 1,808.87$ 3,075.08$ 3,617.74$ 5,155.28$ P PPO $20/$40 F NG FAIR 85629NY0050235-00 N Y N 1,813.45$ 3,082.87$ 3,626.90$ 5,168.33$ P PPO $20/$40 F NG FAIR 85629NY0050236-00 N Y Y 1,808.87$ 3,075.08$ 3,617.74$ 5,155.28$ P PPO $20/$40 F NG FAIR 85629NY0050237-00 Y N N 1,833.00$ 3,116.11$ 3,666.00$ 5,224.05$ P PPO $20/$40 F NG FAIR 85629NY0050238-00 Y Y N 1,833.00$ 3,116.11$ 3,666.00$ 5,224.05$ P PPO $20/$40 F NG FAIR 85629NY0050239-00 Y N Y 1,828.42$ 3,108.32$ 3,656.84$ 5,211.00$ P PPO $20/$40 F NG FAIR 85629NY0050240-00 Y Y Y 1,828.42$ 3,108.32$ 3,656.84$ 5,211.00$ G PPO HSA $1,500D 90% F NG 85629NY0050068-00 N N N 1,204.04$ 2,046.87$ 2,408.08$ 3,431.51$ G PPO HSA $1,500D 90% F NG 85629NY0050001-00 N N Y 1,199.46$ 2,039.08$ 2,398.92$ 3,418.46$ G PPO HSA $1,500D 90% F NG 85629NY0050066-00 N Y N 1,204.04$ 2,046.87$ 2,408.08$ 3,431.51$ G PPO HSA $1,500D 90% F NG 85629NY0050002-00 N Y Y 1,199.46$ 2,039.08$ 2,398.92$ 3,418.46$ G PPO HSA $1,500D 90% F NG 85629NY0050067-00 Y N N 1,223.59$ 2,080.11$ 2,447.18$ 3,487.23$ G PPO HSA $1,500D 90% F NG 85629NY0050065-00 Y Y N 1,223.59$ 2,080.11$ 2,447.18$ 3,487.23$ G PPO HSA $1,500D 90% F NG 85629NY0050003-00 Y N Y 1,219.01$ 2,072.32$ 2,438.02$ 3,474.18$ G PPO HSA $1,500D 90% F NG 85629NY0050004-00 Y Y Y 1,219.01$ 2,072.32$ 2,438.02$ 3,474.18$ S PPO HSA $2000D 30/60 F NG 85629NY0050108-00 N N N 1,061.05$ 1,803.79$ 2,122.10$ 3,023.99$ S PPO HSA $2000D 30/60 F NG 85629NY0050008-00 N N Y 1,056.47$ 1,796.00$ 2,112.94$ 3,010.94$ S PPO HSA $2000D 30/60 F NG 85629NY0050106-00 N Y N 1,061.05$ 1,803.79$ 2,122.10$ 3,023.99$ S PPO HSA $2000D 30/60 F NG 85629NY0050018-00 N Y Y 1,056.47$ 1,796.00$ 2,112.94$ 3,010.94$ S PPO HSA $2000D 30/60 F NG 85629NY0050107-00 Y N N 1,080.60$ 1,837.03$ 2,161.20$ 3,079.71$ S PPO HSA $2000D 30/60 F NG 85629NY0050105-00 Y Y N 1,080.60$ 1,837.03$ 2,161.20$ 3,079.71$ S PPO HSA $2000D 30/60 F NG 85629NY0050019-00 Y N Y 1,076.02$ 1,829.24$ 2,152.04$ 3,066.66$ S PPO HSA $2000D 30/60 F NG 85629NY0050020-00 Y Y Y 1,076.02$ 1,829.24$ 2,152.04$ 3,066.66$

Page 5 of 85




Single + Child(ren)

RateSingle +

Spouse Rate


Rate

Region 3

P EPO $15/$35 $250 D LA G 85629NY0010605-00 N N N 1,258.57$ 2,139.57$ 2,517.14$ 3,586.92$ P EPO $15/$35 $250 D LA G 85629NY0010606-00 N N Y 1,253.99$ 2,131.78$ 2,507.98$ 3,573.87$ P EPO $15/$35 $250 D LA G 85629NY0010607-00 N Y N 1,258.57$ 2,139.57$ 2,517.14$ 3,586.92$ P EPO $15/$35 $250 D LA G 85629NY0010608-00 N Y Y 1,253.99$ 2,131.78$ 2,507.98$ 3,573.87$ P EPO $15/$35 $250 D LA G 85629NY0010609-00 Y N N 1,278.12$ 2,172.81$ 2,556.24$ 3,642.64$ P EPO $15/$35 $250 D LA G 85629NY0010610-00 Y Y N 1,278.12$ 2,172.81$ 2,556.24$ 3,642.64$ P EPO $15/$35 $250 D LA G 85629NY0010611-00 Y N Y 1,273.54$ 2,165.02$ 2,547.08$ 3,629.59$ P EPO $15/$35 $250 D LA G 85629NY0010612-00 Y Y Y 1,273.54$ 2,165.02$ 2,547.08$ 3,629.59$ G EPO $30/$60 $1,250D L G 85629NY0010429-00 N N N 1,133.38$ 1,926.75$ 2,266.76$ 3,230.13$ G EPO $30/$60 $1,250D L G 85629NY0010430-00 N N Y 1,128.80$ 1,918.96$ 2,257.60$ 3,217.08$ G EPO $30/$60 $1,250D L G 85629NY0010431-00 N Y N 1,133.38$ 1,926.75$ 2,266.76$ 3,230.13$ G EPO $30/$60 $1,250D L G 85629NY0010432-00 N Y Y 1,128.80$ 1,918.96$ 2,257.60$ 3,217.08$ G EPO $30/$60 $1,250D L G 85629NY0010433-00 Y N N 1,152.93$ 1,959.99$ 2,305.86$ 3,285.85$ G EPO $30/$60 $1,250D L G 85629NY0010434-00 Y Y N 1,152.93$ 1,959.99$ 2,305.86$ 3,285.85$ G EPO $30/$60 $1,250D L G 85629NY0010435-00 Y N Y 1,148.35$ 1,952.20$ 2,296.70$ 3,272.80$ G EPO $30/$60 $1,250D L G 85629NY0010436-00 Y Y Y 1,148.35$ 1,952.20$ 2,296.70$ 3,272.80$ G EPO $30/$60 $2,000D L NG 85629NY0010653-00 N N N 1,070.39$ 1,819.66$ 2,140.78$ 3,050.61$ G EPO $30/$60 $2,000D L NG 85629NY0010654-00 N N Y 1,065.81$ 1,811.87$ 2,131.62$ 3,037.56$ G EPO $30/$60 $2,000D L NG 85629NY0010655-00 N Y N 1,070.39$ 1,819.66$ 2,140.78$ 3,050.61$ G EPO $30/$60 $2,000D L NG 85629NY0010656-00 N Y Y 1,065.81$ 1,811.87$ 2,131.62$ 3,037.56$ G EPO $30/$60 $2,000D L NG 85629NY0010657-00 Y N N 1,089.94$ 1,852.90$ 2,179.88$ 3,106.33$ G EPO $30/$60 $2,000D L NG 85629NY0010658-00 Y Y N 1,089.94$ 1,852.90$ 2,179.88$ 3,106.33$ G EPO $30/$60 $2,000D L NG 85629NY0010659-00 Y N Y 1,085.36$ 1,845.11$ 2,170.72$ 3,093.28$ G EPO $30/$60 $2,000D L NG 85629NY0010660-00 Y Y Y 1,085.36$ 1,845.11$ 2,170.72$ 3,093.28$ S EPO $25/$50 $4,500D L G 85629NY0010445-00 N N N 918.25$ 1,561.03$ 1,836.50$ 2,617.01$ S EPO $25/$50 $4,500D L G 85629NY0010446-00 N N Y 913.67$ 1,553.24$ 1,827.34$ 2,603.96$ S EPO $25/$50 $4,500D L G 85629NY0010447-00 N Y N 918.25$ 1,561.03$ 1,836.50$ 2,617.01$ S EPO $25/$50 $4,500D L G 85629NY0010448-00 N Y Y 913.67$ 1,553.24$ 1,827.34$ 2,603.96$ S EPO $25/$50 $4,500D L G 85629NY0010449-00 Y N N 937.80$ 1,594.27$ 1,875.60$ 2,672.73$ S EPO $25/$50 $4,500D L G 85629NY0010450-00 Y Y N 937.80$ 1,594.27$ 1,875.60$ 2,672.73$ S EPO $25/$50 $4,500D L G 85629NY0010451-00 Y N Y 933.22$ 1,586.48$ 1,866.44$ 2,659.68$ S EPO $25/$50 $4,500D L G 85629NY0010452-00 Y Y Y 933.22$ 1,586.48$ 1,866.44$ 2,659.68$ S EPO $30/$75 $3,500D L NG 85629NY0010517-00 N N N 924.28$ 1,571.28$ 1,848.56$ 2,634.20$ S EPO $30/$75 $3,500D L NG 85629NY0010518-00 N N Y 919.70$ 1,563.49$ 1,839.40$ 2,621.15$ S EPO $30/$75 $3,500D L NG 85629NY0010519-00 N Y N 924.28$ 1,571.28$ 1,848.56$ 2,634.20$ S EPO $30/$75 $3,500D L NG 85629NY0010520-00 N Y Y 919.70$ 1,563.49$ 1,839.40$ 2,621.15$ S EPO $30/$75 $3,500D L NG 85629NY0010521-00 Y N N 943.83$ 1,604.52$ 1,887.66$ 2,689.92$ S EPO $30/$75 $3,500D L NG 85629NY0010522-00 Y Y N 943.83$ 1,604.52$ 1,887.66$ 2,689.92$ S EPO $30/$75 $3,500D L NG 85629NY0010523-00 Y N Y 939.25$ 1,596.73$ 1,878.50$ 2,676.87$ S EPO $30/$75 $3,500D L NG 85629NY0010524-00 Y Y Y 939.25$ 1,596.73$ 1,878.50$ 2,676.87$ S EPO $40/$70 $3,000D L NG 85629NY0010437-00 N N N 946.64$ 1,609.29$ 1,893.28$ 2,697.92$ S EPO $40/$70 $3,000D L NG 85629NY0010438-00 N N Y 942.06$ 1,601.50$ 1,884.12$ 2,684.87$ S EPO $40/$70 $3,000D L NG 85629NY0010439-00 N Y N 946.64$ 1,609.29$ 1,893.28$ 2,697.92$ S EPO $40/$70 $3,000D L NG 85629NY0010440-00 N Y Y 942.06$ 1,601.50$ 1,884.12$ 2,684.87$ S EPO $40/$70 $3,000D L NG 85629NY0010441-00 Y N N 966.19$ 1,642.53$ 1,932.38$ 2,753.64$ S EPO $40/$70 $3,000D L NG 85629NY0010442-00 Y Y N 966.19$ 1,642.53$ 1,932.38$ 2,753.64$ S EPO $40/$70 $3,000D L NG 85629NY0010443-00 Y N Y 961.61$ 1,634.74$ 1,923.22$ 2,740.59$ S EPO $40/$70 $3,000D L NG 85629NY0010444-00 Y Y Y 961.61$ 1,634.74$ 1,923.22$ 2,740.59$ B EPO HSA $7,000D 100% L NG 85629NY0010557-00 N N N 800.16$ 1,360.27$ 1,600.32$ 2,280.46$ B EPO HSA $7,000D 100% L NG 85629NY0010558-00 N N Y 795.58$ 1,352.48$ 1,591.16$ 2,267.41$ B EPO HSA $7,000D 100% L NG 85629NY0010559-00 N Y N 800.16$ 1,360.27$ 1,600.32$ 2,280.46$ B EPO HSA $7,000D 100% L NG 85629NY0010560-00 N Y Y 795.58$ 1,352.48$ 1,591.16$ 2,267.41$ B EPO HSA $7,000D 100% L NG 85629NY0010561-00 Y N N 819.71$ 1,393.51$ 1,639.42$ 2,336.18$ B EPO HSA $7,000D 100% L NG 85629NY0010562-00 Y Y N 819.71$ 1,393.51$ 1,639.42$ 2,336.18$ B EPO HSA $7,000D 100% L NG 85629NY0010563-00 Y N Y 815.13$ 1,385.72$ 1,630.26$ 2,323.13$ B EPO HSA $7,000D 100% L NG 85629NY0010564-00 Y Y Y 815.13$ 1,385.72$ 1,630.26$ 2,323.13$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010629-00 N N N 801.75$ 1,362.98$ 1,603.50$ 2,284.99$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010630-00 N N Y 797.17$ 1,355.19$ 1,594.34$ 2,271.94$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010631-00 N Y N 801.75$ 1,362.98$ 1,603.50$ 2,284.99$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010632-00 N Y Y 797.17$ 1,355.19$ 1,594.34$ 2,271.94$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010633-00 Y N N 821.30$ 1,396.22$ 1,642.60$ 2,340.71$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010634-00 Y Y N 821.30$ 1,396.22$ 1,642.60$ 2,340.71$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010635-00 Y N Y 816.72$ 1,388.43$ 1,633.44$ 2,327.66$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010636-00 Y Y Y 816.72$ 1,388.43$ 1,633.44$ 2,327.66$ S EPO HSA $2500D $25/$50 L NG 85629NY0010140-00 N N N 944.03$ 1,604.85$ 1,888.06$ 2,690.49$ S EPO HSA $2500D $25/$50 L NG 85629NY0010181-00 N N Y 939.45$ 1,597.06$ 1,878.90$ 2,677.44$ S EPO HSA $2500D $25/$50 L NG 85629NY0010138-00 N Y N 944.03$ 1,604.85$ 1,888.06$ 2,690.49$ S EPO HSA $2500D $25/$50 L NG 85629NY0010182-00 N Y Y 939.45$ 1,597.06$ 1,878.90$ 2,677.44$ S EPO HSA $2500D $25/$50 L NG 85629NY0010139-00 Y N N 963.58$ 1,638.09$ 1,927.16$ 2,746.21$ S EPO HSA $2500D $25/$50 L NG 85629NY0010137-00 Y Y N 963.58$ 1,638.09$ 1,927.16$ 2,746.21$ S EPO HSA $2500D $25/$50 L NG 85629NY0010183-00 Y N Y 959.00$ 1,630.30$ 1,918.00$ 2,733.16$ S EPO HSA $2500D $25/$50 L NG 85629NY0010184-00 Y Y Y 959.00$ 1,630.30$ 1,918.00$ 2,733.16$

Page 6 of 85




Single + Child(ren)

RateSingle +

Spouse Rate


Rate

Region 3

G EPO $25/$50 L NG 85629NY0010693-00 N N N 1,230.42$ 2,091.71$ 2,460.84$ 3,506.70$ G EPO $25/$50 L NG 85629NY0010694-00 N N Y 1,225.84$ 2,083.92$ 2,451.68$ 3,493.65$ G EPO $25/$50 L NG 85629NY0010695-00 N Y N 1,230.42$ 2,091.71$ 2,460.84$ 3,506.70$ G EPO $25/$50 L NG 85629NY0010696-00 N Y Y 1,225.84$ 2,083.92$ 2,451.68$ 3,493.65$ G EPO $25/$50 L NG 85629NY0010697-00 Y N N 1,249.97$ 2,124.95$ 2,499.94$ 3,562.42$ G EPO $25/$50 L NG 85629NY0010698-00 Y Y N 1,249.97$ 2,124.95$ 2,499.94$ 3,562.42$ G EPO $25/$50 L NG 85629NY0010699-00 Y N Y 1,245.39$ 2,117.16$ 2,490.78$ 3,549.37$ G EPO $25/$50 L NG 85629NY0010700-00 Y Y Y 1,245.39$ 2,117.16$ 2,490.78$ 3,549.37$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050225-00 N N N 842.05$ 1,431.49$ 1,684.10$ 2,399.84$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050226-00 N N Y 837.47$ 1,423.70$ 1,674.94$ 2,386.79$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050227-00 N Y N 842.05$ 1,431.49$ 1,684.10$ 2,399.84$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050228-00 N Y Y 837.47$ 1,423.70$ 1,674.94$ 2,386.79$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050229-00 Y N N 861.60$ 1,464.73$ 1,723.20$ 2,455.56$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050230-00 Y Y N 861.60$ 1,464.73$ 1,723.20$ 2,455.56$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050231-00 Y N Y 857.02$ 1,456.94$ 1,714.04$ 2,442.51$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050232-00 Y Y Y 857.02$ 1,456.94$ 1,714.04$ 2,442.51$ G EPO $25/$40 $1,250D M G 85629NY0010469-00 N N N 965.22$ 1,640.87$ 1,930.44$ 2,750.88$ G EPO $25/$40 $1,250D M G 85629NY0010470-00 N N Y 960.64$ 1,633.08$ 1,921.28$ 2,737.83$ G EPO $25/$40 $1,250D M G 85629NY0010471-00 N Y N 965.22$ 1,640.87$ 1,930.44$ 2,750.88$ G EPO $25/$40 $1,250D M G 85629NY0010472-00 N Y Y 960.64$ 1,633.08$ 1,921.28$ 2,737.83$ G EPO $25/$40 $1,250D M G 85629NY0010473-00 Y N N 984.77$ 1,674.11$ 1,969.54$ 2,806.60$ G EPO $25/$40 $1,250D M G 85629NY0010474-00 Y Y N 984.77$ 1,674.11$ 1,969.54$ 2,806.60$ G EPO $25/$40 $1,250D M G 85629NY0010475-00 Y N Y 980.19$ 1,666.32$ 1,960.38$ 2,793.55$ G EPO $25/$40 $1,250D M G 85629NY0010476-00 Y Y Y 980.19$ 1,666.32$ 1,960.38$ 2,793.55$ P EPO $15/$30 M G 85629NY0010453-00 N N N 1,148.26$ 1,952.04$ 2,296.52$ 3,272.54$ P EPO $15/$30 M G 85629NY0010454-00 N N Y 1,143.68$ 1,944.25$ 2,287.36$ 3,259.49$ P EPO $15/$30 M G 85629NY0010455-00 N Y N 1,148.26$ 1,952.04$ 2,296.52$ 3,272.54$ P EPO $15/$30 M G 85629NY0010456-00 N Y Y 1,143.68$ 1,944.25$ 2,287.36$ 3,259.49$ P EPO $15/$30 M G 85629NY0010457-00 Y N N 1,167.81$ 1,985.28$ 2,335.62$ 3,328.26$ P EPO $15/$30 M G 85629NY0010458-00 Y Y N 1,167.81$ 1,985.28$ 2,335.62$ 3,328.26$ P EPO $15/$30 M G 85629NY0010459-00 Y N Y 1,163.23$ 1,977.49$ 2,326.46$ 3,315.21$ P EPO $15/$30 M G 85629NY0010460-00 Y Y Y 1,163.23$ 1,977.49$ 2,326.46$ 3,315.21$ S EPO $30/$80 $3,500D M G 85629NY0010493-00 N N N 791.50$ 1,345.55$ 1,583.00$ 2,255.78$ S EPO $30/$80 $3,500D M G 85629NY0010494-00 N N Y 786.92$ 1,337.76$ 1,573.84$ 2,242.73$ S EPO $30/$80 $3,500D M G 85629NY0010495-00 N Y N 791.50$ 1,345.55$ 1,583.00$ 2,255.78$ S EPO $30/$80 $3,500D M G 85629NY0010496-00 N Y Y 786.92$ 1,337.76$ 1,573.84$ 2,242.73$ S EPO $30/$80 $3,500D M G 85629NY0010497-00 Y N N 811.05$ 1,378.79$ 1,622.10$ 2,311.50$ S EPO $30/$80 $3,500D M G 85629NY0010498-00 Y Y N 811.05$ 1,378.79$ 1,622.10$ 2,311.50$ S EPO $30/$80 $3,500D M G 85629NY0010499-00 Y N Y 806.47$ 1,371.00$ 1,612.94$ 2,298.45$ S EPO $30/$80 $3,500D M G 85629NY0010500-00 Y Y Y 806.47$ 1,371.00$ 1,612.94$ 2,298.45$ B EPO HSA $6,500D $40/$75 M G 85629NY0010509-00 N N N 678.40$ 1,153.28$ 1,356.80$ 1,933.44$ B EPO HSA $6,500D $40/$75 M G 85629NY0010510-00 N N Y 673.82$ 1,145.49$ 1,347.64$ 1,920.39$ B EPO HSA $6,500D $40/$75 M G 85629NY0010511-00 N Y N 678.40$ 1,153.28$ 1,356.80$ 1,933.44$ B EPO HSA $6,500D $40/$75 M G 85629NY0010512-00 N Y Y 673.82$ 1,145.49$ 1,347.64$ 1,920.39$ B EPO HSA $6,500D $40/$75 M G 85629NY0010513-00 Y N N 697.95$ 1,186.52$ 1,395.90$ 1,989.16$ B EPO HSA $6,500D $40/$75 M G 85629NY0010514-00 Y Y N 697.95$ 1,186.52$ 1,395.90$ 1,989.16$ B EPO HSA $6,500D $40/$75 M G 85629NY0010515-00 Y N Y 693.37$ 1,178.73$ 1,386.74$ 1,976.11$ B EPO HSA $6,500D $40/$75 M G 85629NY0010516-00 Y Y Y 693.37$ 1,178.73$ 1,386.74$ 1,976.11$ B EPO HSA $7,000D 100% M G 85629NY0010597-00 N N N 673.11$ 1,144.29$ 1,346.22$ 1,918.36$ B EPO HSA $7,000D 100% M G 85629NY0010598-00 N N Y 668.53$ 1,136.50$ 1,337.06$ 1,905.31$ B EPO HSA $7,000D 100% M G 85629NY0010599-00 N Y N 673.11$ 1,144.29$ 1,346.22$ 1,918.36$ B EPO HSA $7,000D 100% M G 85629NY0010600-00 N Y Y 668.53$ 1,136.50$ 1,337.06$ 1,905.31$ B EPO HSA $7,000D 100% M G 85629NY0010601-00 Y N N 692.66$ 1,177.53$ 1,385.32$ 1,974.08$ B EPO HSA $7,000D 100% M G 85629NY0010602-00 Y Y N 692.66$ 1,177.53$ 1,385.32$ 1,974.08$ B EPO HSA $7,000D 100% M G 85629NY0010603-00 Y N Y 688.08$ 1,169.74$ 1,376.16$ 1,961.03$ B EPO HSA $7,000D 100% M G 85629NY0010604-00 Y Y Y 688.08$ 1,169.74$ 1,376.16$ 1,961.03$ S EPO HSA $3,500D $35/$50 M G 85629NY0010485-00 N N N 747.26$ 1,270.34$ 1,494.52$ 2,129.69$ S EPO HSA $3,500D $35/$50 M G 85629NY0010486-00 N N Y 742.68$ 1,262.55$ 1,485.36$ 2,116.64$ S EPO HSA $3,500D $35/$50 M G 85629NY0010487-00 N Y N 747.26$ 1,270.34$ 1,494.52$ 2,129.69$ S EPO HSA $3,500D $35/$50 M G 85629NY0010488-00 N Y Y 742.68$ 1,262.55$ 1,485.36$ 2,116.64$ S EPO HSA $3,500D $35/$50 M G 85629NY0010489-00 Y N N 766.81$ 1,303.58$ 1,533.62$ 2,185.41$ S EPO HSA $3,500D $35/$50 M G 85629NY0010490-00 Y Y N 766.81$ 1,303.58$ 1,533.62$ 2,185.41$ S EPO HSA $3,500D $35/$50 M G 85629NY0010491-00 Y N Y 762.23$ 1,295.79$ 1,524.46$ 2,172.36$ S EPO HSA $3,500D $35/$50 M G 85629NY0010492-00 Y Y Y 762.23$ 1,295.79$ 1,524.46$ 2,172.36$ G EPO $25/$40 $1,250D ME NG 85629NY0010573-00 N N N 990.39$ 1,683.66$ 1,980.78$ 2,822.61$ G EPO $25/$40 $1,250D ME NG 85629NY0010574-00 N N Y 985.81$ 1,675.87$ 1,971.62$ 2,809.56$ G EPO $25/$40 $1,250D ME NG 85629NY0010575-00 N Y N 990.39$ 1,683.66$ 1,980.78$ 2,822.61$ G EPO $25/$40 $1,250D ME NG 85629NY0010576-00 N Y Y 985.81$ 1,675.87$ 1,971.62$ 2,809.56$ G EPO $25/$40 $1,250D ME NG 85629NY0010577-00 Y N N 1,009.94$ 1,716.90$ 2,019.88$ 2,878.33$ G EPO $25/$40 $1,250D ME NG 85629NY0010578-00 Y Y N 1,009.94$ 1,716.90$ 2,019.88$ 2,878.33$ G EPO $25/$40 $1,250D ME NG 85629NY0010579-00 Y N Y 1,005.36$ 1,709.11$ 2,010.72$ 2,865.28$ G EPO $25/$40 $1,250D ME NG 85629NY0010580-00 Y Y Y 1,005.36$ 1,709.11$ 2,010.72$ 2,865.28$

Page 7 of 85




Single + Child(ren)

RateSingle +

Spouse Rate


Rate

Region 3

S EPO $30/$80 $3,500D ME NG 85629NY0010565-00 N N N 812.14$ 1,380.64$ 1,624.28$ 2,314.60$ S EPO $30/$80 $3,500D ME NG 85629NY0010566-00 N N Y 807.56$ 1,372.85$ 1,615.12$ 2,301.55$ S EPO $30/$80 $3,500D ME NG 85629NY0010567-00 N Y N 812.14$ 1,380.64$ 1,624.28$ 2,314.60$ S EPO $30/$80 $3,500D ME NG 85629NY0010568-00 N Y Y 807.56$ 1,372.85$ 1,615.12$ 2,301.55$ S EPO $30/$80 $3,500D ME NG 85629NY0010569-00 Y N N 831.69$ 1,413.88$ 1,663.38$ 2,370.32$ S EPO $30/$80 $3,500D ME NG 85629NY0010570-00 Y Y N 831.69$ 1,413.88$ 1,663.38$ 2,370.32$ S EPO $30/$80 $3,500D ME NG 85629NY0010571-00 Y N Y 827.11$ 1,406.09$ 1,654.22$ 2,357.27$ S EPO $30/$80 $3,500D ME NG 85629NY0010572-00 Y Y Y 827.11$ 1,406.09$ 1,654.22$ 2,357.27$ S EPO $50/$100 M NG 85629NY0010701-00 N N N 926.50$ 1,575.05$ 1,853.00$ 2,640.53$ S EPO $50/$100 M NG 85629NY0010703-00 N N Y 921.92$ 1,567.26$ 1,843.84$ 2,627.48$ S EPO $50/$100 M NG 85629NY0010705-00 N Y N 926.50$ 1,575.05$ 1,853.00$ 2,640.53$ S EPO $50/$100 M NG 85629NY0010707-00 N Y Y 921.92$ 1,567.26$ 1,843.84$ 2,627.48$ S EPO $50/$100 M NG 85629NY0010709-00 Y N N 946.05$ 1,608.29$ 1,892.10$ 2,696.25$ S EPO $50/$100 M NG 85629NY0010711-00 Y Y N 946.05$ 1,608.29$ 1,892.10$ 2,696.25$ S EPO $50/$100 M NG 85629NY0010713-00 Y N Y 941.47$ 1,600.50$ 1,882.94$ 2,683.20$ S EPO $50/$100 M NG 85629NY0010715-00 Y Y Y 941.47$ 1,600.50$ 1,882.94$ 2,683.20$ S EPO $4,000D 80% L NG Motion 85629NY0010702-00 N N N 878.60$ 1,493.62$ 1,757.20$ 2,504.01$ S EPO $4,000D 80% L NG Motion 85629NY0010704-00 N N Y 874.02$ 1,485.83$ 1,748.04$ 2,490.96$ S EPO $4,000D 80% L NG Motion 85629NY0010706-00 N Y N 878.60$ 1,493.62$ 1,757.20$ 2,504.01$ S EPO $4,000D 80% L NG Motion 85629NY0010708-00 N Y Y 874.02$ 1,485.83$ 1,748.04$ 2,490.96$ S EPO $4,000D 80% L NG Motion 85629NY0010710-00 Y N N 898.15$ 1,526.86$ 1,796.30$ 2,559.73$ S EPO $4,000D 80% L NG Motion 85629NY0010712-00 Y Y N 898.15$ 1,526.86$ 1,796.30$ 2,559.73$ S EPO $4,000D 80% L NG Motion 85629NY0010714-00 Y N Y 893.57$ 1,519.07$ 1,787.14$ 2,546.68$ S EPO $4,000D 80% L NG Motion 85629NY0010716-00 Y Y Y 893.57$ 1,519.07$ 1,787.14$ 2,546.68$ G EPO $1,500D 90% L NG Motion 85629NY0010717-00 N N N 1,090.34$ 1,853.58$ 2,180.68$ 3,107.47$ G EPO $1,500D 90% L NG Motion 85629NY0010718-00 N N Y 1,085.76$ 1,845.79$ 2,171.52$ 3,094.42$ G EPO $1,500D 90% L NG Motion 85629NY0010719-00 N Y N 1,090.34$ 1,853.58$ 2,180.68$ 3,107.47$ G EPO $1,500D 90% L NG Motion 85629NY0010720-00 N Y Y 1,085.76$ 1,845.79$ 2,171.52$ 3,094.42$ G EPO $1,500D 90% L NG Motion 85629NY0010721-00 Y N N 1,109.89$ 1,886.82$ 2,219.78$ 3,163.19$ G EPO $1,500D 90% L NG Motion 85629NY0010722-00 Y Y N 1,109.89$ 1,886.82$ 2,219.78$ 3,163.19$ G EPO $1,500D 90% L NG Motion 85629NY0010723-00 Y N Y 1,105.31$ 1,879.03$ 2,210.62$ 3,150.14$ G EPO $1,500D 90% L NG Motion 85629NY0010724-00 Y Y Y 1,105.31$ 1,879.03$ 2,210.62$ 3,150.14$ S EPO $50/$100 $0D L NG 85629NY0010725-00 N N N 1,073.39$ 1,824.76$ 2,146.78$ 3,059.16$ S EPO $50/$100 $0D L NG 85629NY0010726-00 N N Y 1,068.81$ 1,816.97$ 2,137.62$ 3,046.11$ S EPO $50/$100 $0D L NG 85629NY0010727-00 N Y N 1,073.39$ 1,824.76$ 2,146.78$ 3,059.16$ S EPO $50/$100 $0D L NG 85629NY0010728-00 N Y Y 1,068.81$ 1,816.97$ 2,137.62$ 3,046.11$ S EPO $50/$100 $0D L NG 85629NY0010729-00 Y N N 1,092.94$ 1,858.00$ 2,185.88$ 3,114.88$ S EPO $50/$100 $0D L NG 85629NY0010730-00 Y Y N 1,092.94$ 1,858.00$ 2,185.88$ 3,114.88$ S EPO $50/$100 $0D L NG 85629NY0010731-00 Y N Y 1,088.36$ 1,850.21$ 2,176.72$ 3,101.83$ S EPO $50/$100 $0D L NG 85629NY0010732-00 Y Y Y 1,088.36$ 1,850.21$ 2,176.72$ 3,101.83$ P EPO $500D $5/$35 L NG 85629NY0010733-00 N N N 1,312.65$ 2,231.51$ 2,625.30$ 3,741.05$ P EPO $500D $5/$35 L NG 85629NY0010734-00 N N Y 1,308.07$ 2,223.72$ 2,616.14$ 3,728.00$ P EPO $500D $5/$35 L NG 85629NY0010735-00 N Y N 1,312.65$ 2,231.51$ 2,625.30$ 3,741.05$ P EPO $500D $5/$35 L NG 85629NY0010736-00 N Y Y 1,308.07$ 2,223.72$ 2,616.14$ 3,728.00$ P EPO $500D $5/$35 L NG 85629NY0010737-00 Y N N 1,332.20$ 2,264.75$ 2,664.40$ 3,796.77$ P EPO $500D $5/$35 L NG 85629NY0010738-00 Y Y N 1,332.20$ 2,264.75$ 2,664.40$ 3,796.77$ P EPO $500D $5/$35 L NG 85629NY0010739-00 Y N Y 1,327.62$ 2,256.96$ 2,655.24$ 3,783.72$ P EPO $500D $5/$35 L NG 85629NY0010740-00 Y Y Y 1,327.62$ 2,256.96$ 2,655.24$ 3,783.72$ G EPO $2,000D $20/$40 L NG 85629NY0010741-00 N N N 1,052.58$ 1,789.39$ 2,105.16$ 2,999.85$ G EPO $2,000D $20/$40 L NG 85629NY0010742-00 N N Y 1,048.00$ 1,781.60$ 2,096.00$ 2,986.80$ G EPO $2,000D $20/$40 L NG 85629NY0010743-00 N Y N 1,052.58$ 1,789.39$ 2,105.16$ 2,999.85$ G EPO $2,000D $20/$40 L NG 85629NY0010744-00 N Y Y 1,048.00$ 1,781.60$ 2,096.00$ 2,986.80$ G EPO $2,000D $20/$40 L NG 85629NY0010745-00 Y N N 1,072.13$ 1,822.63$ 2,144.26$ 3,055.57$ G EPO $2,000D $20/$40 L NG 85629NY0010746-00 Y Y N 1,072.13$ 1,822.63$ 2,144.26$ 3,055.57$ G EPO $2,000D $20/$40 L NG 85629NY0010747-00 Y N Y 1,067.55$ 1,814.84$ 2,135.10$ 3,042.52$ G EPO $2,000D $20/$40 L NG 85629NY0010748-00 Y Y Y 1,067.55$ 1,814.84$ 2,135.10$ 3,042.52$ S EPO $5,000D $25/$45 L NG 85629NY0010749-00 N N N 895.52$ 1,522.38$ 1,791.04$ 2,552.23$ S EPO $5,000D $25/$45 L NG 85629NY0010750-00 N N Y 890.94$ 1,514.59$ 1,781.88$ 2,539.18$ S EPO $5,000D $25/$45 L NG 85629NY0010751-00 N Y N 895.52$ 1,522.38$ 1,791.04$ 2,552.23$ S EPO $5,000D $25/$45 L NG 85629NY0010752-00 N Y Y 890.94$ 1,514.59$ 1,781.88$ 2,539.18$ S EPO $5,000D $25/$45 L NG 85629NY0010753-00 Y N N 915.07$ 1,555.62$ 1,830.14$ 2,607.95$ S EPO $5,000D $25/$45 L NG 85629NY0010754-00 Y Y N 915.07$ 1,555.62$ 1,830.14$ 2,607.95$ S EPO $5,000D $25/$45 L NG 85629NY0010755-00 Y N Y 910.49$ 1,547.83$ 1,820.98$ 2,594.90$ S EPO $5,000D $25/$45 L NG 85629NY0010756-00 Y Y Y 910.49$ 1,547.83$ 1,820.98$ 2,594.90$ G Standard HNY 25/40 M G 85629NY0010581-00 N N N 832.38$ 1,415.05$ 1,664.76$ 2,372.28$ G Standard HNY 25/40 M G 85629NY0010582-00 N N Y 827.80$ 1,407.26$ 1,655.60$ 2,359.23$ G Standard HNY 25/40 M G 85629NY0010583-00 N Y N 832.38$ 1,415.05$ 1,664.76$ 2,372.28$ G Standard HNY 25/40 M G 85629NY0010584-00 N Y Y 827.80$ 1,407.26$ 1,655.60$ 2,359.23$ G Standard HNY 25/40 M G 85629NY0010585-00 Y N N 851.93$ 1,448.29$ 1,703.86$ 2,428.00$ G Standard HNY 25/40 M G 85629NY0010586-00 Y Y N 851.93$ 1,448.29$ 1,703.86$ 2,428.00$ G Standard HNY 25/40 M G 85629NY0010587-00 Y N Y 847.35$ 1,440.50$ 1,694.70$ 2,414.95$ G Standard HNY 25/40 M G 85629NY0010588-00 Y Y Y 847.35$ 1,440.50$ 1,694.70$ 2,414.95$

Page 8 of 85




Single + Child(ren)

RateSingle +

Spouse Rate


RateG EPO $15/$35 $1750D F NG 85629NY0010240-00 N N N 1,128.78$ 1,918.93$ 2,257.56$ 3,217.02$ G EPO $15/$35 $1750D F NG 85629NY0010253-00 N N Y 1,124.55$ 1,911.74$ 2,249.10$ 3,204.96$ G EPO $15/$35 $1750D F NG 85629NY0010238-00 N Y N 1,128.78$ 1,918.93$ 2,257.56$ 3,217.02$ G EPO $15/$35 $1750D F NG 85629NY0010254-00 N Y Y 1,124.55$ 1,911.74$ 2,249.10$ 3,204.96$ G EPO $15/$35 $1750D F NG 85629NY0010239-00 Y N N 1,146.84$ 1,949.63$ 2,293.68$ 3,268.49$ G EPO $15/$35 $1750D F NG 85629NY0010237-00 Y Y N 1,146.84$ 1,949.63$ 2,293.68$ 3,268.49$ G EPO $15/$35 $1750D F NG 85629NY0010255-00 Y N Y 1,142.61$ 1,942.44$ 2,285.22$ 3,256.43$ G EPO $15/$35 $1750D F NG 85629NY0010256-00 Y Y Y 1,142.61$ 1,942.44$ 2,285.22$ 3,256.43$ G EPO $25/$40 $1,750D F NG 85629NY0010248-00 N N N 1,118.94$ 1,902.20$ 2,237.88$ 3,188.98$ G EPO $25/$40 $1,750D F NG 85629NY0010261-00 N N Y 1,114.71$ 1,895.01$ 2,229.42$ 3,176.92$ G EPO $25/$40 $1,750D F NG 85629NY0010246-00 N Y N 1,118.94$ 1,902.20$ 2,237.88$ 3,188.98$ G EPO $25/$40 $1,750D F NG 85629NY0010262-00 N Y Y 1,114.71$ 1,895.01$ 2,229.42$ 3,176.92$ G EPO $25/$40 $1,750D F NG 85629NY0010247-00 Y N N 1,137.00$ 1,932.90$ 2,274.00$ 3,240.45$ G EPO $25/$40 $1,750D F NG 85629NY0010245-00 Y Y N 1,137.00$ 1,932.90$ 2,274.00$ 3,240.45$ G EPO $25/$40 $1,750D F NG 85629NY0010263-00 Y N Y 1,132.77$ 1,925.71$ 2,265.54$ 3,228.39$ G EPO $25/$40 $1,750D F NG 85629NY0010264-00 Y Y Y 1,132.77$ 1,925.71$ 2,265.54$ 3,228.39$ G EPO $30/$60 $2,250D F NG 85629NY0010645-00 N N N 1,041.81$ 1,771.08$ 2,083.62$ 2,969.16$ G EPO $30/$60 $2,250D F NG 85629NY0010646-00 N N Y 1,037.58$ 1,763.89$ 2,075.16$ 2,957.10$ G EPO $30/$60 $2,250D F NG 85629NY0010647-00 N Y N 1,041.81$ 1,771.08$ 2,083.62$ 2,969.16$ G EPO $30/$60 $2,250D F NG 85629NY0010648-00 N Y Y 1,037.58$ 1,763.89$ 2,075.16$ 2,957.10$ G EPO $30/$60 $2,250D F NG 85629NY0010649-00 Y N N 1,059.87$ 1,801.78$ 2,119.74$ 3,020.63$ G EPO $30/$60 $2,250D F NG 85629NY0010650-00 Y Y N 1,059.87$ 1,801.78$ 2,119.74$ 3,020.63$ G EPO $30/$60 $2,250D F NG 85629NY0010651-00 Y N Y 1,055.64$ 1,794.59$ 2,111.28$ 3,008.57$ G EPO $30/$60 $2,250D F NG 85629NY0010652-00 Y Y Y 1,055.64$ 1,794.59$ 2,111.28$ 3,008.57$ G $50 $1000D F NG 85629NY0010084-00 N N N 1,142.95$ 1,943.02$ 2,285.90$ 3,257.41$ G $50 $1000D F NG 85629NY0010101-00 N N Y 1,138.72$ 1,935.83$ 2,277.44$ 3,245.35$ G $50 $1000D F NG 85629NY0010082-00 N Y N 1,142.95$ 1,943.02$ 2,285.90$ 3,257.41$ G $50 $1000D F NG 85629NY0010102-00 N Y Y 1,138.72$ 1,935.83$ 2,277.44$ 3,245.35$ G $50 $1000D F NG 85629NY0010083-00 Y N N 1,161.01$ 1,973.72$ 2,322.02$ 3,308.88$ G $50 $1000D F NG 85629NY0010081-00 Y Y N 1,161.01$ 1,973.72$ 2,322.02$ 3,308.88$ G $50 $1000D F NG 85629NY0010103-00 Y N Y 1,156.78$ 1,966.53$ 2,313.56$ 3,296.82$ G $50 $1000D F NG 85629NY0010104-00 Y Y Y 1,156.78$ 1,966.53$ 2,313.56$ 3,296.82$ P EPO $20/$40 F NG 85629NY0010036-00 N N N 1,350.60$ 2,296.02$ 2,701.20$ 3,849.21$ P EPO $20/$40 F NG 85629NY0010226-00 N N Y 1,346.37$ 2,288.83$ 2,692.74$ 3,837.15$ P EPO $20/$40 F NG 85629NY0010034-00 N Y N 1,350.60$ 2,296.02$ 2,701.20$ 3,849.21$ P EPO $20/$40 F NG 85629NY0010227-00 N Y Y 1,346.37$ 2,288.83$ 2,692.74$ 3,837.15$ P EPO $20/$40 F NG 85629NY0010035-00 Y N N 1,368.66$ 2,326.72$ 2,737.32$ 3,900.68$ P EPO $20/$40 F NG 85629NY0010033-00 Y Y N 1,368.66$ 2,326.72$ 2,737.32$ 3,900.68$ P EPO $20/$40 F NG 85629NY0010228-00 Y N Y 1,364.43$ 2,319.53$ 2,728.86$ 3,888.62$ P EPO $20/$40 F NG 85629NY0010229-00 Y Y Y 1,364.43$ 2,319.53$ 2,728.86$ 3,888.62$ P EPO $5/$15 F NG 85629NY0010336-00 N N N 1,379.58$ 2,345.29$ 2,759.16$ 3,931.80$ P EPO $5/$15 F NG 85629NY0010213-00 N N Y 1,375.35$ 2,338.10$ 2,750.70$ 3,919.74$ P EPO $5/$15 F NG 85629NY0010341-00 N Y N 1,379.58$ 2,345.29$ 2,759.16$ 3,931.80$ P EPO $5/$15 F NG 85629NY0010214-00 N Y Y 1,375.35$ 2,338.10$ 2,750.70$ 3,919.74$ P EPO $5/$15 F NG 85629NY0010342-00 Y N N 1,397.64$ 2,375.99$ 2,795.28$ 3,983.27$ P EPO $5/$15 F NG 85629NY0010340-00 Y Y N 1,397.64$ 2,375.99$ 2,795.28$ 3,983.27$ P EPO $5/$15 F NG 85629NY0010215-00 Y N Y 1,393.41$ 2,368.80$ 2,786.82$ 3,971.21$ P EPO $5/$15 F NG 85629NY0010216-00 Y Y Y 1,393.41$ 2,368.80$ 2,786.82$ 3,971.21$ S EPO $40/$70 $3000D F NG 85629NY0010300-00 N N N 930.06$ 1,581.10$ 1,860.12$ 2,650.67$ S EPO $40/$70 $3000D F NG 85629NY0010312-00 N N Y 925.83$ 1,573.91$ 1,851.66$ 2,638.61$ S EPO $40/$70 $3000D F NG 85629NY0010294-00 N Y N 930.06$ 1,581.10$ 1,860.12$ 2,650.67$ S EPO $40/$70 $3000D F NG 85629NY0010313-00 N Y Y 925.83$ 1,573.91$ 1,851.66$ 2,638.61$ S EPO $40/$70 $3000D F NG 85629NY0010295-00 Y N N 948.12$ 1,611.80$ 1,896.24$ 2,702.14$ S EPO $40/$70 $3000D F NG 85629NY0010293-00 Y Y N 948.12$ 1,611.80$ 1,896.24$ 2,702.14$ S EPO $40/$70 $3000D F NG 85629NY0010314-00 Y N Y 943.89$ 1,604.61$ 1,887.78$ 2,690.08$ S EPO $40/$70 $3000D F NG 85629NY0010315-00 Y Y Y 943.89$ 1,604.61$ 1,887.78$ 2,690.08$ B EPO HSA $5,800D 50% F NG 85629NY0010316-00 N N N 792.36$ 1,347.01$ 1,584.72$ 2,258.23$ B EPO HSA $5,800D 50% F NG 85629NY0010325-00 N N Y 788.13$ 1,339.82$ 1,576.26$ 2,246.17$ B EPO HSA $5,800D 50% F NG 85629NY0010310-00 N Y N 792.36$ 1,347.01$ 1,584.72$ 2,258.23$ B EPO HSA $5,800D 50% F NG 85629NY0010326-00 N Y Y 788.13$ 1,339.82$ 1,576.26$ 2,246.17$ B EPO HSA $5,800D 50% F NG 85629NY0010311-00 Y N N 810.42$ 1,377.71$ 1,620.84$ 2,309.70$ B EPO HSA $5,800D 50% F NG 85629NY0010309-00 Y Y N 810.42$ 1,377.71$ 1,620.84$ 2,309.70$ B EPO HSA $5,800D 50% F NG 85629NY0010327-00 Y N Y 806.19$ 1,370.52$ 1,612.38$ 2,297.64$ B EPO HSA $5,800D 50% F NG 85629NY0010328-00 Y Y Y 806.19$ 1,370.52$ 1,612.38$ 2,297.64$ G EPO HSA $1,500D 90% F NG 85629NY0010076-00 N N N 1,066.30$ 1,812.71$ 2,132.60$ 3,038.96$ G EPO HSA $1,500D 90% F NG 85629NY0010072-00 N N Y 1,062.07$ 1,805.52$ 2,124.14$ 3,026.90$ G EPO HSA $1,500D 90% F NG 85629NY0010235-00 N Y N 1,066.30$ 1,812.71$ 2,132.60$ 3,038.96$ G EPO HSA $1,500D 90% F NG 85629NY0010073-00 N Y Y 1,062.07$ 1,805.52$ 2,124.14$ 3,026.90$ G EPO HSA $1,500D 90% F NG 85629NY0010236-00 Y N N 1,084.36$ 1,843.41$ 2,168.72$ 3,090.43$ G EPO HSA $1,500D 90% F NG 85629NY0010234-00 Y Y N 1,084.36$ 1,843.41$ 2,168.72$ 3,090.43$ G EPO HSA $1,500D 90% F NG 85629NY0010074-00 Y N Y 1,080.13$ 1,836.22$ 2,160.26$ 3,078.37$ G EPO HSA $1,500D 90% F NG 85629NY0010075-00 Y Y Y 1,080.13$ 1,836.22$ 2,160.26$ 3,078.37$

Region 4

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Single + Child(ren)

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Spouse Rate


Rate

Region 4

S EPO HSA $2,000D 70% F NG 85629NY0010272-00 N N N 917.02$ 1,558.93$ 1,834.04$ 2,613.51$ S EPO HSA $2,000D 70% F NG 85629NY0010277-00 N N Y 912.79$ 1,551.74$ 1,825.58$ 2,601.45$ S EPO HSA $2,000D 70% F NG 85629NY0010270-00 N Y N 917.02$ 1,558.93$ 1,834.04$ 2,613.51$ S EPO HSA $2,000D 70% F NG 85629NY0010278-00 N Y Y 912.79$ 1,551.74$ 1,825.58$ 2,601.45$ S EPO HSA $2,000D 70% F NG 85629NY0010271-00 Y N N 935.08$ 1,589.63$ 1,870.16$ 2,664.98$ S EPO HSA $2,000D 70% F NG 85629NY0010269-00 Y Y N 935.08$ 1,589.63$ 1,870.16$ 2,664.98$ S EPO HSA $2,000D 70% F NG 85629NY0010279-00 Y N Y 930.85$ 1,582.44$ 1,861.70$ 2,652.92$ S EPO HSA $2,000D 70% F NG 85629NY0010280-00 Y Y Y 930.85$ 1,582.44$ 1,861.70$ 2,652.92$ S EPO HSA $2250D $25/$50 F NG 85629NY0010288-00 N N N 939.61$ 1,597.34$ 1,879.22$ 2,677.89$ S EPO HSA $2250D $25/$50 F NG 85629NY0010296-00 N N Y 935.38$ 1,590.15$ 1,870.76$ 2,665.83$ S EPO HSA $2250D $25/$50 F NG 85629NY0010186-00 N Y N 939.61$ 1,597.34$ 1,879.22$ 2,677.89$ S EPO HSA $2250D $25/$50 F NG 85629NY0010297-00 N Y Y 935.38$ 1,590.15$ 1,870.76$ 2,665.83$ S EPO HSA $2250D $25/$50 F NG 85629NY0010287-00 Y N N 957.67$ 1,628.04$ 1,915.34$ 2,729.36$ S EPO HSA $2250D $25/$50 F NG 85629NY0010334-00 Y Y N 957.67$ 1,628.04$ 1,915.34$ 2,729.36$ S EPO HSA $2250D $25/$50 F NG 85629NY0010298-00 Y N Y 953.44$ 1,620.85$ 1,906.88$ 2,717.30$ S EPO HSA $2250D $25/$50 F NG 85629NY0010299-00 Y Y Y 953.44$ 1,620.85$ 1,906.88$ 2,717.30$ G PPO $25/$40 $1,500D F NG 85629NY0050044-00 N N N 1,171.27$ 1,991.16$ 2,342.54$ 3,338.12$ G PPO $25/$40 $1,500D F NG 85629NY0050193-00 N N Y 1,167.04$ 1,983.97$ 2,334.08$ 3,326.06$ G PPO $25/$40 $1,500D F NG 85629NY0050042-00 N Y N 1,171.27$ 1,991.16$ 2,342.54$ 3,338.12$ G PPO $25/$40 $1,500D F NG 85629NY0050194-00 N Y Y 1,167.04$ 1,983.97$ 2,334.08$ 3,326.06$ G PPO $25/$40 $1,500D F NG 85629NY0050043-00 Y N N 1,189.33$ 2,021.86$ 2,378.66$ 3,389.59$ G PPO $25/$40 $1,500D F NG 85629NY0050041-00 Y Y N 1,189.33$ 2,021.86$ 2,378.66$ 3,389.59$ G PPO $25/$40 $1,500D F NG 85629NY0050195-00 Y N Y 1,185.10$ 2,014.67$ 2,370.20$ 3,377.53$ G PPO $25/$40 $1,500D F NG 85629NY0050196-00 Y Y Y 1,185.10$ 2,014.67$ 2,370.20$ 3,377.53$ P PPO $20/$40 F NG 85629NY0050028-00 N N N 1,400.74$ 2,381.26$ 2,801.48$ 3,992.11$ P PPO $20/$40 F NG 85629NY0050185-00 N N Y 1,396.51$ 2,374.07$ 2,793.02$ 3,980.05$ P PPO $20/$40 F NG 85629NY0050026-00 N Y N 1,400.74$ 2,381.26$ 2,801.48$ 3,992.11$ P PPO $20/$40 F NG 85629NY0050186-00 N Y Y 1,396.51$ 2,374.07$ 2,793.02$ 3,980.05$ P PPO $20/$40 F NG 85629NY0050027-00 Y N N 1,418.80$ 2,411.96$ 2,837.60$ 4,043.58$ P PPO $20/$40 F NG 85629NY0050025-00 Y Y N 1,418.80$ 2,411.96$ 2,837.60$ 4,043.58$ P PPO $20/$40 F NG 85629NY0050187-00 Y N Y 1,414.57$ 2,404.77$ 2,829.14$ 4,031.52$ P PPO $20/$40 F NG 85629NY0050188-00 Y Y Y 1,414.57$ 2,404.77$ 2,829.14$ 4,031.52$ P PPO $5/$15 F NG 85629NY0050012-00 N N N 1,432.78$ 2,435.73$ 2,865.56$ 4,083.42$ P PPO $5/$15 F NG 85629NY0050177-00 N N Y 1,428.55$ 2,428.54$ 2,857.10$ 4,071.36$ P PPO $5/$15 F NG 85629NY0050010-00 N Y N 1,432.78$ 2,435.73$ 2,865.56$ 4,083.42$ P PPO $5/$15 F NG 85629NY0050178-00 N Y Y 1,428.55$ 2,428.54$ 2,857.10$ 4,071.36$ P PPO $5/$15 F NG 85629NY0050011-00 Y N N 1,450.84$ 2,466.43$ 2,901.68$ 4,134.89$ P PPO $5/$15 F NG 85629NY0050009-00 Y Y N 1,450.84$ 2,466.43$ 2,901.68$ 4,134.89$ P PPO $5/$15 F NG 85629NY0050179-00 Y N Y 1,446.61$ 2,459.24$ 2,893.22$ 4,122.83$ P PPO $5/$15 F NG 85629NY0050180-00 Y Y Y 1,446.61$ 2,459.24$ 2,893.22$ 4,122.83$ S PPO $40/$70 $3000D F NG 85629NY0050132-00 N N N 974.18$ 1,656.11$ 1,948.36$ 2,776.41$ S PPO $40/$70 $3000D F NG 85629NY0050033-00 N N Y 969.95$ 1,648.92$ 1,939.90$ 2,764.35$ S PPO $40/$70 $3000D F NG 85629NY0050130-00 N Y N 974.18$ 1,656.11$ 1,948.36$ 2,776.41$ S PPO $40/$70 $3000D F NG 85629NY0050034-00 N Y Y 969.95$ 1,648.92$ 1,939.90$ 2,764.35$ S PPO $40/$70 $3000D F NG 85629NY0050131-00 Y N N 992.24$ 1,686.81$ 1,984.48$ 2,827.88$ S PPO $40/$70 $3000D F NG 85629NY0050129-00 Y Y N 992.24$ 1,686.81$ 1,984.48$ 2,827.88$ S PPO $40/$70 $3000D F NG 85629NY0050035-00 Y N Y 988.01$ 1,679.62$ 1,976.02$ 2,815.82$ S PPO $40/$70 $3000D F NG 85629NY0050036-00 Y Y Y 988.01$ 1,679.62$ 1,976.02$ 2,815.82$ P PPO $20/$40 F NG FAIR 85629NY0050233-00 N N N 1,675.36$ 2,848.11$ 3,350.72$ 4,774.78$ P PPO $20/$40 F NG FAIR 85629NY0050234-00 N N Y 1,671.13$ 2,840.92$ 3,342.26$ 4,762.72$ P PPO $20/$40 F NG FAIR 85629NY0050235-00 N Y N 1,675.36$ 2,848.11$ 3,350.72$ 4,774.78$ P PPO $20/$40 F NG FAIR 85629NY0050236-00 N Y Y 1,671.13$ 2,840.92$ 3,342.26$ 4,762.72$ P PPO $20/$40 F NG FAIR 85629NY0050237-00 Y N N 1,693.42$ 2,878.81$ 3,386.84$ 4,826.25$ P PPO $20/$40 F NG FAIR 85629NY0050238-00 Y Y N 1,693.42$ 2,878.81$ 3,386.84$ 4,826.25$ P PPO $20/$40 F NG FAIR 85629NY0050239-00 Y N Y 1,689.19$ 2,871.62$ 3,378.38$ 4,814.19$ P PPO $20/$40 F NG FAIR 85629NY0050240-00 Y Y Y 1,689.19$ 2,871.62$ 3,378.38$ 4,814.19$ G PPO HSA $1,500D 90% F NG 85629NY0050068-00 N N N 1,112.36$ 1,891.01$ 2,224.72$ 3,170.23$ G PPO HSA $1,500D 90% F NG 85629NY0050001-00 N N Y 1,108.13$ 1,883.82$ 2,216.26$ 3,158.17$ G PPO HSA $1,500D 90% F NG 85629NY0050066-00 N Y N 1,112.36$ 1,891.01$ 2,224.72$ 3,170.23$ G PPO HSA $1,500D 90% F NG 85629NY0050002-00 N Y Y 1,108.13$ 1,883.82$ 2,216.26$ 3,158.17$ G PPO HSA $1,500D 90% F NG 85629NY0050067-00 Y N N 1,130.42$ 1,921.71$ 2,260.84$ 3,221.70$ G PPO HSA $1,500D 90% F NG 85629NY0050065-00 Y Y N 1,130.42$ 1,921.71$ 2,260.84$ 3,221.70$ G PPO HSA $1,500D 90% F NG 85629NY0050003-00 Y N Y 1,126.19$ 1,914.52$ 2,252.38$ 3,209.64$ G PPO HSA $1,500D 90% F NG 85629NY0050004-00 Y Y Y 1,126.19$ 1,914.52$ 2,252.38$ 3,209.64$ S PPO HSA $2000D 30/60 F NG 85629NY0050108-00 N N N 980.26$ 1,666.44$ 1,960.52$ 2,793.74$ S PPO HSA $2000D 30/60 F NG 85629NY0050008-00 N N Y 976.03$ 1,659.25$ 1,952.06$ 2,781.68$ S PPO HSA $2000D 30/60 F NG 85629NY0050106-00 N Y N 980.26$ 1,666.44$ 1,960.52$ 2,793.74$ S PPO HSA $2000D 30/60 F NG 85629NY0050018-00 N Y Y 976.03$ 1,659.25$ 1,952.06$ 2,781.68$ S PPO HSA $2000D 30/60 F NG 85629NY0050107-00 Y N N 998.32$ 1,697.14$ 1,996.64$ 2,845.21$ S PPO HSA $2000D 30/60 F NG 85629NY0050105-00 Y Y N 998.32$ 1,697.14$ 1,996.64$ 2,845.21$ S PPO HSA $2000D 30/60 F NG 85629NY0050019-00 Y N Y 994.09$ 1,689.95$ 1,988.18$ 2,833.15$ S PPO HSA $2000D 30/60 F NG 85629NY0050020-00 Y Y Y 994.09$ 1,689.95$ 1,988.18$ 2,833.15$

Page 10 of 85




Single + Child(ren)

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Spouse Rate


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Region 4

P EPO $15/$35 $250 D LA G 85629NY0010605-00 N N N 1,162.74$ 1,976.66$ 2,325.48$ 3,313.81$ P EPO $15/$35 $250 D LA G 85629NY0010606-00 N N Y 1,158.51$ 1,969.47$ 2,317.02$ 3,301.75$ P EPO $15/$35 $250 D LA G 85629NY0010607-00 N Y N 1,162.74$ 1,976.66$ 2,325.48$ 3,313.81$ P EPO $15/$35 $250 D LA G 85629NY0010608-00 N Y Y 1,158.51$ 1,969.47$ 2,317.02$ 3,301.75$ P EPO $15/$35 $250 D LA G 85629NY0010609-00 Y N N 1,180.80$ 2,007.36$ 2,361.60$ 3,365.28$ P EPO $15/$35 $250 D LA G 85629NY0010610-00 Y Y N 1,180.80$ 2,007.36$ 2,361.60$ 3,365.28$ P EPO $15/$35 $250 D LA G 85629NY0010611-00 Y N Y 1,176.57$ 2,000.17$ 2,353.14$ 3,353.22$ P EPO $15/$35 $250 D LA G 85629NY0010612-00 Y Y Y 1,176.57$ 2,000.17$ 2,353.14$ 3,353.22$ G EPO $30/$60 $1,250D L G 85629NY0010429-00 N N N 1,047.08$ 1,780.04$ 2,094.16$ 2,984.18$ G EPO $30/$60 $1,250D L G 85629NY0010430-00 N N Y 1,042.85$ 1,772.85$ 2,085.70$ 2,972.12$ G EPO $30/$60 $1,250D L G 85629NY0010431-00 N Y N 1,047.08$ 1,780.04$ 2,094.16$ 2,984.18$ G EPO $30/$60 $1,250D L G 85629NY0010432-00 N Y Y 1,042.85$ 1,772.85$ 2,085.70$ 2,972.12$ G EPO $30/$60 $1,250D L G 85629NY0010433-00 Y N N 1,065.14$ 1,810.74$ 2,130.28$ 3,035.65$ G EPO $30/$60 $1,250D L G 85629NY0010434-00 Y Y N 1,065.14$ 1,810.74$ 2,130.28$ 3,035.65$ G EPO $30/$60 $1,250D L G 85629NY0010435-00 Y N Y 1,060.91$ 1,803.55$ 2,121.82$ 3,023.59$ G EPO $30/$60 $1,250D L G 85629NY0010436-00 Y Y Y 1,060.91$ 1,803.55$ 2,121.82$ 3,023.59$ G EPO $30/$60 $2,000D L NG 85629NY0010653-00 N N N 988.88$ 1,681.10$ 1,977.76$ 2,818.31$ G EPO $30/$60 $2,000D L NG 85629NY0010654-00 N N Y 984.65$ 1,673.91$ 1,969.30$ 2,806.25$ G EPO $30/$60 $2,000D L NG 85629NY0010655-00 N Y N 988.88$ 1,681.10$ 1,977.76$ 2,818.31$ G EPO $30/$60 $2,000D L NG 85629NY0010656-00 N Y Y 984.65$ 1,673.91$ 1,969.30$ 2,806.25$ G EPO $30/$60 $2,000D L NG 85629NY0010657-00 Y N N 1,006.94$ 1,711.80$ 2,013.88$ 2,869.78$ G EPO $30/$60 $2,000D L NG 85629NY0010658-00 Y Y N 1,006.94$ 1,711.80$ 2,013.88$ 2,869.78$ G EPO $30/$60 $2,000D L NG 85629NY0010659-00 Y N Y 1,002.71$ 1,704.61$ 2,005.42$ 2,857.72$ G EPO $30/$60 $2,000D L NG 85629NY0010660-00 Y Y Y 1,002.71$ 1,704.61$ 2,005.42$ 2,857.72$ S EPO $25/$50 $4,500D L G 85629NY0010445-00 N N N 848.33$ 1,442.16$ 1,696.66$ 2,417.74$ S EPO $25/$50 $4,500D L G 85629NY0010446-00 N N Y 844.10$ 1,434.97$ 1,688.20$ 2,405.68$ S EPO $25/$50 $4,500D L G 85629NY0010447-00 N Y N 848.33$ 1,442.16$ 1,696.66$ 2,417.74$ S EPO $25/$50 $4,500D L G 85629NY0010448-00 N Y Y 844.10$ 1,434.97$ 1,688.20$ 2,405.68$ S EPO $25/$50 $4,500D L G 85629NY0010449-00 Y N N 866.39$ 1,472.86$ 1,732.78$ 2,469.21$ S EPO $25/$50 $4,500D L G 85629NY0010450-00 Y Y N 866.39$ 1,472.86$ 1,732.78$ 2,469.21$ S EPO $25/$50 $4,500D L G 85629NY0010451-00 Y N Y 862.16$ 1,465.67$ 1,724.32$ 2,457.15$ S EPO $25/$50 $4,500D L G 85629NY0010452-00 Y Y Y 862.16$ 1,465.67$ 1,724.32$ 2,457.15$ S EPO $30/$75 $3,500D L NG 85629NY0010517-00 N N N 853.90$ 1,451.63$ 1,707.80$ 2,433.62$ S EPO $30/$75 $3,500D L NG 85629NY0010518-00 N N Y 849.67$ 1,444.44$ 1,699.34$ 2,421.56$ S EPO $30/$75 $3,500D L NG 85629NY0010519-00 N Y N 853.90$ 1,451.63$ 1,707.80$ 2,433.62$ S EPO $30/$75 $3,500D L NG 85629NY0010520-00 N Y Y 849.67$ 1,444.44$ 1,699.34$ 2,421.56$ S EPO $30/$75 $3,500D L NG 85629NY0010521-00 Y N N 871.96$ 1,482.33$ 1,743.92$ 2,485.09$ S EPO $30/$75 $3,500D L NG 85629NY0010522-00 Y Y N 871.96$ 1,482.33$ 1,743.92$ 2,485.09$ S EPO $30/$75 $3,500D L NG 85629NY0010523-00 Y N Y 867.73$ 1,475.14$ 1,735.46$ 2,473.03$ S EPO $30/$75 $3,500D L NG 85629NY0010524-00 Y Y Y 867.73$ 1,475.14$ 1,735.46$ 2,473.03$ S EPO $40/$70 $3,000D L NG 85629NY0010437-00 N N N 874.56$ 1,486.75$ 1,749.12$ 2,492.50$ S EPO $40/$70 $3,000D L NG 85629NY0010438-00 N N Y 870.33$ 1,479.56$ 1,740.66$ 2,480.44$ S EPO $40/$70 $3,000D L NG 85629NY0010439-00 N Y N 874.56$ 1,486.75$ 1,749.12$ 2,492.50$ S EPO $40/$70 $3,000D L NG 85629NY0010440-00 N Y Y 870.33$ 1,479.56$ 1,740.66$ 2,480.44$ S EPO $40/$70 $3,000D L NG 85629NY0010441-00 Y N N 892.62$ 1,517.45$ 1,785.24$ 2,543.97$ S EPO $40/$70 $3,000D L NG 85629NY0010442-00 Y Y N 892.62$ 1,517.45$ 1,785.24$ 2,543.97$ S EPO $40/$70 $3,000D L NG 85629NY0010443-00 Y N Y 888.39$ 1,510.26$ 1,776.78$ 2,531.91$ S EPO $40/$70 $3,000D L NG 85629NY0010444-00 Y Y Y 888.39$ 1,510.26$ 1,776.78$ 2,531.91$ B EPO HSA $7,000D 100% L NG 85629NY0010557-00 N N N 739.24$ 1,256.71$ 1,478.48$ 2,106.83$ B EPO HSA $7,000D 100% L NG 85629NY0010558-00 N N Y 735.01$ 1,249.52$ 1,470.02$ 2,094.77$ B EPO HSA $7,000D 100% L NG 85629NY0010559-00 N Y N 739.24$ 1,256.71$ 1,478.48$ 2,106.83$ B EPO HSA $7,000D 100% L NG 85629NY0010560-00 N Y Y 735.01$ 1,249.52$ 1,470.02$ 2,094.77$ B EPO HSA $7,000D 100% L NG 85629NY0010561-00 Y N N 757.30$ 1,287.41$ 1,514.60$ 2,158.30$ B EPO HSA $7,000D 100% L NG 85629NY0010562-00 Y Y N 757.30$ 1,287.41$ 1,514.60$ 2,158.30$ B EPO HSA $7,000D 100% L NG 85629NY0010563-00 Y N Y 753.07$ 1,280.22$ 1,506.14$ 2,146.24$ B EPO HSA $7,000D 100% L NG 85629NY0010564-00 Y Y Y 753.07$ 1,280.22$ 1,506.14$ 2,146.24$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010629-00 N N N 740.70$ 1,259.19$ 1,481.40$ 2,111.00$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010630-00 N N Y 736.47$ 1,252.00$ 1,472.94$ 2,098.94$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010631-00 N Y N 740.70$ 1,259.19$ 1,481.40$ 2,111.00$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010632-00 N Y Y 736.47$ 1,252.00$ 1,472.94$ 2,098.94$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010633-00 Y N N 758.76$ 1,289.89$ 1,517.52$ 2,162.47$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010634-00 Y Y N 758.76$ 1,289.89$ 1,517.52$ 2,162.47$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010635-00 Y N Y 754.53$ 1,282.70$ 1,509.06$ 2,150.41$ B EPO HSA $5,750D $25/$75 L NG 85629NY0010636-00 Y Y Y 754.53$ 1,282.70$ 1,509.06$ 2,150.41$ S EPO HSA $2500D $25/$50 L NG 85629NY0010140-00 N N N 872.14$ 1,482.64$ 1,744.28$ 2,485.60$ S EPO HSA $2500D $25/$50 L NG 85629NY0010181-00 N N Y 867.91$ 1,475.45$ 1,735.82$ 2,473.54$ S EPO HSA $2500D $25/$50 L NG 85629NY0010138-00 N Y N 872.14$ 1,482.64$ 1,744.28$ 2,485.60$ S EPO HSA $2500D $25/$50 L NG 85629NY0010182-00 N Y Y 867.91$ 1,475.45$ 1,735.82$ 2,473.54$ S EPO HSA $2500D $25/$50 L NG 85629NY0010139-00 Y N N 890.20$ 1,513.34$ 1,780.40$ 2,537.07$ S EPO HSA $2500D $25/$50 L NG 85629NY0010137-00 Y Y N 890.20$ 1,513.34$ 1,780.40$ 2,537.07$ S EPO HSA $2500D $25/$50 L NG 85629NY0010183-00 Y N Y 885.97$ 1,506.15$ 1,771.94$ 2,525.01$ S EPO HSA $2500D $25/$50 L NG 85629NY0010184-00 Y Y Y 885.97$ 1,506.15$ 1,771.94$ 2,525.01$

Page 11 of 85




Single + Child(ren)

RateSingle +

Spouse Rate


Rate

Region 4

G EPO $25/$50 L NG 85629NY0010693-00 N N N 1,136.73$ 1,932.44$ 2,273.46$ 3,239.68$ G EPO $25/$50 L NG 85629NY0010694-00 N N Y 1,132.50$ 1,925.25$ 2,265.00$ 3,227.62$ G EPO $25/$50 L NG 85629NY0010695-00 N Y N 1,136.73$ 1,932.44$ 2,273.46$ 3,239.68$ G EPO $25/$50 L NG 85629NY0010696-00 N Y Y 1,132.50$ 1,925.25$ 2,265.00$ 3,227.62$ G EPO $25/$50 L NG 85629NY0010697-00 Y N N 1,154.79$ 1,963.14$ 2,309.58$ 3,291.15$ G EPO $25/$50 L NG 85629NY0010698-00 Y Y N 1,154.79$ 1,963.14$ 2,309.58$ 3,291.15$ G EPO $25/$50 L NG 85629NY0010699-00 Y N Y 1,150.56$ 1,955.95$ 2,301.12$ 3,279.09$ G EPO $25/$50 L NG 85629NY0010700-00 Y Y Y 1,150.56$ 1,955.95$ 2,301.12$ 3,279.09$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050225-00 N N N 777.93$ 1,322.48$ 1,555.86$ 2,217.10$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050226-00 N N Y 773.70$ 1,315.29$ 1,547.40$ 2,205.04$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050227-00 N Y N 777.93$ 1,322.48$ 1,555.86$ 2,217.10$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050228-00 N Y Y 773.70$ 1,315.29$ 1,547.40$ 2,205.04$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050229-00 Y N N 795.99$ 1,353.18$ 1,591.98$ 2,268.57$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050230-00 Y Y N 795.99$ 1,353.18$ 1,591.98$ 2,268.57$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050231-00 Y N Y 791.76$ 1,345.99$ 1,583.52$ 2,256.51$ B PPO HSA $6,750D $30/$60 L NG 85629NY0050232-00 Y Y Y 791.76$ 1,345.99$ 1,583.52$ 2,256.51$ G EPO $25/$40 $1,250D M G 85629NY0010469-00 N N N 891.73$ 1,515.94$ 1,783.46$ 2,541.43$ G EPO $25/$40 $1,250D M G 85629NY0010470-00 N N Y 887.50$ 1,508.75$ 1,775.00$ 2,529.37$ G EPO $25/$40 $1,250D M G 85629NY0010471-00 N Y N 891.73$ 1,515.94$ 1,783.46$ 2,541.43$ G EPO $25/$40 $1,250D M G 85629NY0010472-00 N Y Y 887.50$ 1,508.75$ 1,775.00$ 2,529.37$ G EPO $25/$40 $1,250D M G 85629NY0010473-00 Y N N 909.79$ 1,546.64$ 1,819.58$ 2,592.90$ G EPO $25/$40 $1,250D M G 85629NY0010474-00 Y Y N 909.79$ 1,546.64$ 1,819.58$ 2,592.90$ G EPO $25/$40 $1,250D M G 85629NY0010475-00 Y N Y 905.56$ 1,539.45$ 1,811.12$ 2,580.84$ G EPO $25/$40 $1,250D M G 85629NY0010476-00 Y Y Y 905.56$ 1,539.45$ 1,811.12$ 2,580.84$ P EPO $15/$30 M G 85629NY0010453-00 N N N 1,060.82$ 1,803.39$ 2,121.64$ 3,023.34$ P EPO $15/$30 M G 85629NY0010454-00 N N Y 1,056.59$ 1,796.20$ 2,113.18$ 3,011.28$ P EPO $15/$30 M G 85629NY0010455-00 N Y N 1,060.82$ 1,803.39$ 2,121.64$ 3,023.34$ P EPO $15/$30 M G 85629NY0010456-00 N Y Y 1,056.59$ 1,796.20$ 2,113.18$ 3,011.28$ P EPO $15/$30 M G 85629NY0010457-00 Y N N 1,078.88$ 1,834.09$ 2,157.76$ 3,074.81$ P EPO $15/$30 M G 85629NY0010458-00 Y Y N 1,078.88$ 1,834.09$ 2,157.76$ 3,074.81$ P EPO $15/$30 M G 85629NY0010459-00 Y N Y 1,074.65$ 1,826.90$ 2,149.30$ 3,062.75$ P EPO $15/$30 M G 85629NY0010460-00 Y Y Y 1,074.65$ 1,826.90$ 2,149.30$ 3,062.75$ S EPO $30/$80 $3,500D M G 85629NY0010493-00 N N N 731.23$ 1,243.09$ 1,462.46$ 2,084.01$ S EPO $30/$80 $3,500D M G 85629NY0010494-00 N N Y 727.00$ 1,235.90$ 1,454.00$ 2,071.95$ S EPO $30/$80 $3,500D M G 85629NY0010495-00 N Y N 731.23$ 1,243.09$ 1,462.46$ 2,084.01$ S EPO $30/$80 $3,500D M G 85629NY0010496-00 N Y Y 727.00$ 1,235.90$ 1,454.00$ 2,071.95$ S EPO $30/$80 $3,500D M G 85629NY0010497-00 Y N N 749.29$ 1,273.79$ 1,498.58$ 2,135.48$ S EPO $30/$80 $3,500D M G 85629NY0010498-00 Y Y N 749.29$ 1,273.79$ 1,498.58$ 2,135.48$ S EPO $30/$80 $3,500D M G 85629NY0010499-00 Y N Y 745.06$ 1,266.60$ 1,490.12$ 2,123.42$ S EPO $30/$80 $3,500D M G 85629NY0010500-00 Y Y Y 745.06$ 1,266.60$ 1,490.12$ 2,123.42$ B EPO HSA $6,500D $40/$75 M G 85629NY0010509-00 N N N 626.75$ 1,065.48$ 1,253.50$ 1,786.24$ B EPO HSA $6,500D $40/$75 M G 85629NY0010510-00 N N Y 622.52$ 1,058.29$ 1,245.04$ 1,774.18$ B EPO HSA $6,500D $40/$75 M G 85629NY0010511-00 N Y N 626.75$ 1,065.48$ 1,253.50$ 1,786.24$ B EPO HSA $6,500D $40/$75 M G 85629NY0010512-00 N Y Y 622.52$ 1,058.29$ 1,245.04$ 1,774.18$ B EPO HSA $6,500D $40/$75 M G 85629NY0010513-00 Y N N 644.81$ 1,096.18$ 1,289.62$ 1,837.71$ B EPO HSA $6,500D $40/$75 M G 85629NY0010514-00 Y Y N 644.81$ 1,096.18$ 1,289.62$ 1,837.71$ B EPO HSA $6,500D $40/$75 M G 85629NY0010515-00 Y N Y 640.58$ 1,088.99$ 1,281.16$ 1,825.65$ B EPO HSA $6,500D $40/$75 M G 85629NY0010516-00 Y Y Y 640.58$ 1,088.99$ 1,281.16$ 1,825.65$ B EPO HSA $7,000D 100% M G 85629NY0010597-00 N N N 621.86$ 1,057.16$ 1,243.72$ 1,772.30$ B EPO HSA $7,000D 100% M G 85629NY0010598-00 N N Y 617.63$ 1,049.97$ 1,235.26$ 1,760.24$ B EPO HSA $7,000D 100% M G 85629NY0010599-00 N Y N 621.86$ 1,057.16$ 1,243.72$ 1,772.30$ B EPO HSA $7,000D 100% M G 85629NY0010600-00 N Y Y 617.63$ 1,049.97$ 1,235.26$ 1,760.24$ B EPO HSA $7,000D 100% M G 85629NY0010601-00 Y N N 639.92$ 1,087.86$ 1,279.84$ 1,823.77$ B EPO HSA $7,000D 100% M G 85629NY0010602-00 Y Y N 639.92$ 1,087.86$ 1,279.84$ 1,823.77$ B EPO HSA $7,000D 100% M G 85629NY0010603-00 Y N Y 635.69$ 1,080.67$ 1,271.38$ 1,811.71$ B EPO HSA $7,000D 100% M G 85629NY0010604-00 Y Y Y 635.69$ 1,080.67$ 1,271.38$ 1,811.71$ S EPO HSA $3,500D $35/$50 M G 85629NY0010485-00 N N N 690.36$ 1,173.61$ 1,380.72$ 1,967.53$ S EPO HSA $3,500D $35/$50 M G 85629NY0010486-00 N N Y 686.13$ 1,166.42$ 1,372.26$ 1,955.47$ S EPO HSA $3,500D $35/$50 M G 85629NY0010487-00 N Y N 690.36$ 1,173.61$ 1,380.72$ 1,967.53$ S EPO HSA $3,500D $35/$50 M G 85629NY0010488-00 N Y Y 686.13$ 1,166.42$ 1,372.26$ 1,955.47$ S EPO HSA $3,500D $35/$50 M G 85629NY0010489-00 Y N N 708.42$ 1,204.31$ 1,416.84$ 2,019.00$ S EPO HSA $3,500D $35/$50 M G 85629NY0010490-00 Y Y N 708.42$ 1,204.31$ 1,416.84$ 2,019.00$ S EPO HSA $3,500D $35/$50 M G 85629NY0010491-00 Y N Y 704.19$ 1,197.12$ 1,408.38$ 2,006.94$ S EPO HSA $3,500D $35/$50 M G 85629NY0010492-00 Y Y Y 704.19$ 1,197.12$ 1,408.38$ 2,006.94$ G EPO $25/$40 $1,250D ME NG 85629NY0010573-00 N N N 914.98$ 1,555.47$ 1,829.96$ 2,607.69$ G EPO $25/$40 $1,250D ME NG 85629NY0010574-00 N N Y 910.75$ 1,548.28$ 1,821.50$ 2,595.63$ G EPO $25/$40 $1,250D ME NG 85629NY0010575-00 N Y N 914.98$ 1,555.47$ 1,829.96$ 2,607.69$ G EPO $25/$40 $1,250D ME NG 85629NY0010576-00 N Y Y 910.75$ 1,548.28$ 1,821.50$ 2,595.63$ G EPO $25/$40 $1,250D ME NG 85629NY0010577-00 Y N N 933.04$ 1,586.17$ 1,866.08$ 2,659.16$ G EPO $25/$40 $1,250D ME NG 85629NY0010578-00 Y Y N 933.04$ 1,586.17$ 1,866.08$ 2,659.16$ G EPO $25/$40 $1,250D ME NG 85629NY0010579-00 Y N Y 928.81$ 1,578.98$ 1,857.62$ 2,647.10$ G EPO $25/$40 $1,250D ME NG 85629NY0010580-00 Y Y Y 928.81$ 1,578.98$ 1,857.62$ 2,647.10$

Page 12 of 85




Single + Child(ren)

RateSingle +

Spouse Rate


Rate

Region 4

S EPO $30/$80 $3,500D ME NG 85629NY0010565-00 N N N 750.30$ 1,275.51$ 1,500.60$ 2,138.36$ S EPO $30/$80 $3,500D ME NG 85629NY0010566-00 N N Y 746.07$ 1,268.32$ 1,492.14$ 2,126.30$ S EPO $30/$80 $3,500D ME NG 85629NY0010567-00 N Y N 750.30$ 1,275.51$ 1,500.60$ 2,138.36$ S EPO $30/$

filing at a glance · 2020-05-29 · filing at a glance company: oxford health insurance, inc....

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