filing at a glance · plan design summary plan design marketing name. rate pages page number: 2...

Filing at a Glance

Company: QCC Insurance Company

Product Name: QCC Small Group PPO effective 1-1-2017

State: Pennsylvania

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

Sub-TOI: H15G.003 Small Group Only

Filing Type: Rate - Small Group Base Rate Modification

Date Submitted: 05/09/2016

SERFF Tr Num: INAC-130539936

SERFF Status: Reopened-Approved

State Tr Num: INAC-130539936

State Status: Approved

Co Tr Num: QCC SMALL GROUP 1-1-2017

ImplementationDate Requested:

01/01/2017

Author(s): Yuliya Tsyman, David Walker

Reviewer(s): Rashmi Mathur (primary)

Disposition Date: 10/17/2016

Disposition Status: Approved

Implementation Date:

State Filing Description:

Binder#: INLG-PA17-125061997; On/Off Exchange; rri=4.35% ari=5.0%

SERFF Tracking #: INAC-130539936 State Tracking #: INAC-130539936 Company Tracking #: QCC SMALL GROUP 1-1-2017

State: Pennsylvania Filing Company: QCC Insurance Company

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


Project Name/Number: /

PDF Pipeline for SERFF Tracking Number INAC-130539936 Generated 10/19/2016 08:06 AM

General Information

Company and Contact

Filing Fees

Project Name: Status of Filing in Domicile:

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: 10/18/2016

State Status Changed: 10/17/2016 Deemer Date:

Created By: Tony Mazur Submitted By: David Walker

Corresponding Filing Tracking Number: INLG-130545865,INLG-130546269, INLG-130546608

State TOI: H15G Group Health - Hospital/Surgical/MedicalExpense

State Sub-TOI: H15G.003 Small Group Only

PPACA: Not PPACA-Related

PPACA Notes: null

Include Exchange Intentions: No

Filing Description:

This is the QCC small group PPO filing for rates effective 1-1-2017.

Filing Contact InformationHugh Lakshman, Director & Actuary -Commercial Markets

[email protected]

1901 Market Street

39th Floor

Philadelphia, PA 19103

215-241-4754 [Phone]

215-241-2544 [FAX]

Filing Company InformationQCC Insurance Company

1901 Market Street

Philadelphia, PA 19103

(215) 241-2215 ext. [Phone]

CoCode: 93688

Group Code: 936

Group Name: Independence BlueCross

FEIN Number: 23-2184623

State of Domicile:Pennsylvania

Company Type: LAH

State ID Number:

Fee Required? No

Retaliatory? No

Fee Explanation:







Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Rate Files 16884.WR-II Rev. 1.17, 16884-BC.SG.ON, 16884-BC.SG.OFF, 16884-BC.SG.ON.HSA.HRA, 16884-BC.SG.OFF.HSA.HRA,PREV/SCH-I Rev. 1.17

New 31609QCC State v1-108082016 (Q1)Form_RV withSilver.xlsx, 31609QCCState v1-1 08082016(Q2) Form_RV withSilver.xlsx, 31609QCCState v1-1 08082016(Q3) Form_RV withSilver.xlsx, 31609QCCState v1-1 08082016(Q4) Form_RV withSilver.xlsx, 31609QCCState v1-1 08082016(Q1) Form_RV withSilver.pdf, 31609QCCState v1-1 08082016(Q2) Form_RV withSilver.pdf, 31609QCCState v1-1 08082016(Q3) Form_RV withSilver.pdf, 31609QCCState v1-1 08082016(Q4) Form_RV withSilver.pdf,2017QCC31609RatesTemplateExcel09152016 (SG andInd) RV.pdf,2017QCC31609RatesTemplateExcel09152016 (SG andInd) RV.xls,







Attachment 31609QCC State v1-1 08082016 (Q1) Form_RV with Silver.xlsx is not a PDF document andcannot be reproduced here.




Attachment 2017QCC31609RatesTemplateExcel 09152016 (SG and Ind) RV.xls is not a PDF documentand cannot be reproduced here.







12/24/2014

Company On/Off Metal Network RatingExchange HIOS Plan ID Level Area

QCC ON 31609PA0150001 Platinum Personal Choice PPO Platinum Preferred $10/$20/$150 PPO 8QCC ON 31609PA0150002 Platinum Personal Choice PPO Platinum Preferred $20/$40/$150 PPO 8QCC ON 31609PA0150003 Gold Personal Choice PPO Gold Preferred $35/$70/$600 PPO 8QCC ON 31609PA0150004 Gold Personal Choice PPO Gold Classic $1,000 $15/$30/80% PPO 8QCC ON 31609PA0150005 Silver Personal Choice PPO Silver Classic$2,500 $30/$60/80% PPO 8QCC ON 31609PA0150006 Platinum Personal Choice PPO Platinum HSA-50 $1,600/100% PPO 8QCC ON 31609PA0150007 Gold Personal Choice PPO Gold HSA-25 $2,400/100% PPO 8QCC ON 31609PA0150008 Gold Personal Choice PPO Gold HSA-0 $1,900/100% PPO 8QCC ON 31609PA0150009 Gold Personal Choice PPO Gold HSA-50 $2,650/70% PPO 8QCC ON 31609PA0150010 Silver Personal Choice PPO Silver HSA-0 $2,100/70% PPO 8QCC ON 31609PA0150011 Silver Personal Choice PPO Silver HSA-0 $2,700/90% PPO 8QCC ON 31609PA0150012 Bronze Personal Choice PPO Bronze HSA-0 $5,200/50% PPO 8QCC ON 31609PA0150013 Bronze Personal Choice PPO Bronze HSA-0 $6,550/100% PPO 8QCC ON 31609PA0150014 Platinum Personal Choice PPO Platinum HRA-50 $1,850/100% PPO 8QCC ON 31609PA0150015 Gold Personal Choice PPO Gold HRA-25$2,900/100% PPO 8QCC OFF 31609PA0150025 Platinum Personal Choice PPO Platinum Preferred $10/$20/$150 PPO 8QCC OFF 31609PA0150026 Platinum Personal Choice PPO Platinum Preferred $20/$40/$150 PPO 8QCC OFF 31609PA0150027 Gold Personal Choice PPO Gold Preferred $35/$70/$600 PPO 8QCC OFF 31609PA0150028 Gold Personal Choice PPO Gold Classic $1,000 $15/$30/80% PPO 8QCC OFF 31609PA0150029 Silver Personal Choice PPO Silver Classic$2,500 $30/$60/80% PPO 8QCC OFF 31609PA0150030 Platinum Personal Choice PPO Platinum HSA-50 $1,600/100% PPO 8QCC OFF 31609PA0150031 Gold Personal Choice PPO Gold HSA-25 $2,400/100% PPO 8QCC OFF 31609PA0150032 Gold Personal Choice PPO Gold HSA-0 $1,900/100% PPO 8QCC OFF 31609PA0150033 Gold Personal Choice PPO Gold HSA-50 $2,650/70% PPO 8QCC OFF 31609PA0150034 Silver Personal Choice PPO Silver HSA-0 $2,100/70% PPO 8QCC OFF 31609PA0150035 Silver Personal Choice PPO Silver HSA-0 $2,700/90% PPO 8QCC OFF 31609PA0150036 Bronze Personal Choice PPO Bronze HSA-0 $5,200/50% PPO 8QCC OFF 31609PA0150037 Bronze Personal Choice PPO Bronze HSA-0 $6,550/100% PPO 8QCC OFF 31609PA0150038 Platinum Personal Choice PPO Platinum HRA-50 $1,850/100% PPO 8QCC OFF 31609PA0150039 Gold Personal Choice PPO Gold HRA-25 $2,900/100% PPO 8QCC ON 31609PA0150022 Gold Personal Choice PPO Gold Classic $2,000 $40/$80/100% PPO 8QCC ON 31609PA0150024 Silver Personal Choice PPO Silver Secure$3,000 $30/$60/$600 PPO 8QCC ON 31609PA0150023 Silver Personal Choice PPO Silver Classic$3,300 $40/$80/100% PPO 8QCC ON 31609PA0150046 Silver Personal Choice PPO Silver HSA-0 $3,200/100% PPO 8QCC OFF 31609PA0150047 Gold Personal Choice PPO Gold Classic $2,000 $40/$80/100% PPO 8QCC OFF 31609PA0150049 Silver Personal Choice PPO Silver Secure$3,000 $30/$60/$600 PPO 8QCC OFF 31609PA0150048 Silver Personal Choice PPO Silver Classic$3,300 $40/$80/100% PPO 8QCC OFF 31609PA0150050 Silver Personal Choice PPO Silver HSA-0 $3,200/100% PPO 8

QCC Insurance Company

Plan Design Summary

Plan Design Marketing Name

RATE PAGES

Page Number: 2 04/15/2015

Company Name: QCC Insurance CompanyProduct: PPOEffective Date of Rates: January 1, 2017 - March 31, 2017

Plan ID (On Exchange)=>Plan ID (Off Exchange)=>

Form # =>Rating Area =>

Network =>Metal =>

Plan Name =>Deductible =>

Coinsurance =>Copays =>

OOP Maximum =>Dental (Yes/No)

Age Band Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco0-20 $305.90 $305.90 $292.45 $292.45 $241.06 $241.0621 $481.73 $541.95 $460.56 $518.13 $379.62 $427.0722 $481.73 $541.95 $460.56 $518.13 $379.62 $427.0723 $481.73 $541.95 $460.56 $518.13 $379.62 $427.0724 $481.73 $541.95 $460.56 $518.13 $379.62 $427.0725 $483.66 $544.12 $462.40 $520.20 $381.13 $428.7826 $493.30 $554.96 $471.61 $530.56 $388.73 $437.3227 $504.86 $567.96 $482.66 $543.00 $397.84 $447.5728 $523.64 $589.10 $500.63 $563.20 $412.64 $464.2229 $539.06 $606.44 $515.36 $579.78 $424.79 $477.8930 $546.77 $642.45 $522.73 $614.21 $430.86 $506.2731 $558.33 $656.04 $533.79 $627.20 $439.97 $516.9732 $569.89 $669.62 $544.84 $640.19 $449.09 $527.6833 $577.12 $678.11 $551.75 $648.30 $454.78 $534.3734 $584.82 $687.17 $559.12 $656.96 $460.85 $541.5035 $588.68 $691.70 $562.80 $661.29 $463.89 $545.0736 $592.53 $696.23 $566.49 $665.62 $466.93 $548.6437 $596.39 $700.75 $570.17 $669.95 $469.96 $552.2138 $600.24 $705.28 $573.85 $674.28 $473.00 $555.7839 $607.95 $714.34 $581.22 $682.94 $479.08 $562.9140 $615.66 $754.18 $588.59 $721.03 $485.15 $594.3141 $627.22 $768.34 $599.65 $734.57 $494.26 $605.4742 $638.30 $781.91 $610.24 $747.54 $502.99 $616.1643 $653.71 $800.80 $624.98 $765.60 $515.14 $631.0544 $672.98 $824.40 $643.40 $788.16 $530.32 $649.6545 $695.62 $852.14 $665.04 $814.68 $548.17 $671.5046 $722.60 $885.19 $690.84 $846.27 $569.42 $697.5447 $752.95 $922.36 $719.85 $881.82 $593.34 $726.8448 $787.63 $964.85 $753.01 $922.44 $620.67 $760.3249 $821.84 $1,006.75 $785.71 $962.50 $647.62 $793.3450 $860.38 $1,183.02 $822.56 $1,131.01 $677.99 $932.2451 $898.43 $1,235.35 $858.94 $1,181.04 $707.98 $973.4852 $940.34 $1,292.97 $899.01 $1,236.14 $741.01 $1,018.8953 $982.74 $1,351.26 $939.54 $1,291.86 $774.42 $1,064.8254 $1,028.50 $1,414.19 $983.29 $1,352.02 $810.48 $1,114.4155 $1,074.27 $1,477.12 $1,027.04 $1,412.18 $846.54 $1,164.0056 $1,123.89 $1,545.34 $1,074.48 $1,477.41 $885.64 $1,217.7657 $1,173.99 $1,614.23 $1,122.38 $1,543.27 $925.12 $1,272.0558 $1,227.46 $1,687.75 $1,173.50 $1,613.56 $967.26 $1,329.9859 $1,253.95 $1,724.19 $1,198.83 $1,648.39 $988.14 $1,358.6960 $1,307.43 $1,797.71 $1,249.95 $1,718.69 $1,030.28 $1,416.6361 $1,353.67 $1,861.30 $1,294.17 $1,779.48 $1,066.72 $1,466.7462 $1,384.02 $1,903.03 $1,323.18 $1,819.37 $1,090.64 $1,499.6363 $1,422.08 $1,955.36 $1,359.57 $1,869.40 $1,120.63 $1,540.8664 $1,445.19 $1,987.15 $1,381.67 $1,899.80 $1,138.85 $1,565.92

65+ $1,445.19 $1,987.15 $1,381.67 $1,899.80 $1,138.85 $1,565.92

Platinum

No

31609PA0150003

16884.WR-I Rev. 1.168

PlatinumPersonal Choice PPO Platinum Preferred $10/$20/$150

Personal Choice Network Personal Choice Network Personal Choice Network Gold

$20/$40$2,000

$35/$70$6,850

Personal Choice PPO Gold Preferred $35/$70/$600$00%

31609PA0150001 31609PA0150002

8 8

No No

16884.WR-I Rev. 1.16 16884.WR-I Rev. 1.16

Personal Choice PPO Platinum Preferred $20/$40/$150$00%

$00%

$2,500$10/$20

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$241.21 $241.21 $209.21 $209.21 $263.20 $263.20$379.86 $427.34 $329.46 $370.65 $414.49 $466.30$379.86 $427.34 $329.46 $370.65 $414.49 $466.30$379.86 $427.34 $329.46 $370.65 $414.49 $466.30$379.86 $427.34 $329.46 $370.65 $414.49 $466.30$381.38 $429.05 $330.78 $372.13 $416.15 $468.17$388.97 $437.60 $337.37 $379.54 $424.44 $477.49$398.09 $447.85 $345.28 $388.44 $434.39 $488.68$412.91 $464.52 $358.13 $402.89 $450.55 $506.87$425.06 $478.19 $368.67 $414.75 $463.82 $521.79$431.14 $506.59 $373.94 $439.38 $470.45 $552.78$440.25 $517.30 $381.85 $448.67 $480.39 $564.46$449.37 $528.01 $389.75 $457.96 $490.34 $576.15$455.07 $534.71 $394.70 $463.77 $496.56 $583.46$461.15 $541.85 $399.97 $469.96 $503.19 $591.25$464.19 $545.42 $402.60 $473.06 $506.51 $595.15$467.22 $548.99 $405.24 $476.16 $509.82 $599.04$470.26 $552.56 $407.87 $479.25 $513.14 $602.94$473.30 $556.13 $410.51 $482.35 $516.46 $606.84$479.38 $563.27 $415.78 $488.54 $523.09 $614.63$485.46 $594.69 $421.05 $515.79 $529.72 $648.91$494.57 $605.85 $428.96 $525.48 $539.67 $661.09$503.31 $616.56 $436.54 $534.76 $549.20 $672.77$515.47 $631.45 $447.08 $547.67 $562.46 $689.02$530.66 $650.06 $460.26 $563.82 $579.04 $709.33$548.51 $671.93 $475.74 $582.79 $598.52 $733.19$569.79 $697.99 $494.19 $605.39 $621.74 $761.63$593.72 $727.30 $514.95 $630.81 $647.85 $793.61$621.07 $760.81 $538.67 $659.87 $677.69 $830.17$648.04 $793.85 $562.06 $688.53 $707.12 $866.22$678.43 $932.84 $588.42 $809.08 $740.28 $1,017.89$708.43 $974.10 $614.45 $844.87 $773.03 $1,062.91$741.48 $1,019.54 $643.11 $884.28 $809.09 $1,112.49$774.91 $1,065.50 $672.10 $924.14 $845.56 $1,162.65$811.00 $1,115.12 $703.40 $967.18 $884.94 $1,216.79$847.08 $1,164.74 $734.70 $1,010.22 $924.31 $1,270.93$886.21 $1,218.54 $768.64 $1,056.88 $967.01 $1,329.63$925.71 $1,272.85 $802.90 $1,103.99 $1,010.11 $1,388.91$967.88 $1,330.83 $839.47 $1,154.27 $1,056.12 $1,452.17$988.77 $1,359.56 $857.59 $1,179.19 $1,078.92 $1,483.51

$1,030.93 $1,417.53 $894.16 $1,229.47 $1,124.93 $1,546.78$1,067.40 $1,467.67 $925.79 $1,272.96 $1,164.72 $1,601.49$1,091.33 $1,500.58 $946.55 $1,301.50 $1,190.83 $1,637.39$1,121.34 $1,541.84 $972.57 $1,337.29 $1,223.58 $1,682.42$1,139.57 $1,566.91 $988.38 $1,359.03 $1,243.47 $1,709.77$1,139.57 $1,566.91 $988.38 $1,359.03 $1,243.47 $1,709.77

No$6,550

No

PlatinumPersonal Choice PPO Platinum HSA-50 $1,600/100%

$1,6000%

$0 after ded

31609PA0150006

16884.WR-I Rev. 1.16

31609PA0150004

Personal Choice Network

31609PA0150005

16884.WR-I Rev. 1.168

Personal Choice Network Silver

Personal Choice PPO Silver Classic$2,500 $30/$60/80%$2,500

20%$30 no ded/$60 no ded

$6,400No

16884.WR-I Rev. 1.168

Personal Choice Network Gold

8

$1,00020%

$15 no ded/$30 no ded$5,500

Personal Choice PPO Gold Classic $1,000 $15/$30/80%

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$232.08 $232.08 $252.44 $252.44 $192.96 $192.96$365.48 $411.17 $397.54 $447.23 $303.88 $341.86$365.48 $411.17 $397.54 $447.23 $303.88 $341.86$365.48 $411.17 $397.54 $447.23 $303.88 $341.86$365.48 $411.17 $397.54 $447.23 $303.88 $341.86$366.95 $412.82 $399.13 $449.02 $305.09 $343.23$374.26 $421.04 $407.08 $457.97 $311.17 $350.07$383.03 $430.91 $416.62 $468.70 $318.46 $358.27$397.28 $446.94 $432.13 $486.14 $330.32 $371.60$408.98 $460.10 $444.85 $500.45 $340.04 $382.54$414.83 $487.42 $451.21 $530.17 $344.90 $405.26$423.60 $497.73 $460.75 $541.38 $352.19 $413.83$432.37 $508.03 $470.29 $552.59 $359.49 $422.40$437.85 $514.47 $476.25 $559.60 $364.05 $427.75$443.70 $521.35 $482.62 $567.07 $368.91 $433.47$446.62 $524.78 $485.80 $570.81 $371.34 $436.32$449.55 $528.22 $488.98 $574.55 $373.77 $439.18$452.47 $531.65 $492.16 $578.28 $376.20 $442.04$455.39 $535.09 $495.34 $582.02 $378.63 $444.89$461.24 $541.96 $501.70 $589.49 $383.49 $450.61$467.09 $572.18 $508.06 $622.37 $388.36 $475.74$475.86 $582.93 $517.60 $634.06 $395.65 $484.67$484.27 $593.23 $526.74 $645.26 $402.64 $493.23$495.96 $607.55 $539.46 $660.84 $412.36 $505.14$510.58 $625.46 $555.37 $680.32 $424.52 $520.03$527.76 $646.51 $574.05 $703.21 $438.80 $537.53$548.23 $671.58 $596.31 $730.48 $455.82 $558.38$571.25 $699.78 $621.36 $761.16 $474.96 $581.83$597.57 $732.02 $649.98 $796.23 $496.84 $608.63$623.52 $763.81 $678.21 $830.80 $518.42 $635.06$652.76 $897.54 $710.01 $976.26 $542.73 $746.25$681.63 $937.24 $741.41 $1,019.45 $566.73 $779.26$713.43 $980.96 $776.00 $1,067.00 $593.17 $815.61$745.59 $1,025.19 $810.98 $1,115.10 $619.91 $852.38$780.31 $1,072.93 $848.75 $1,167.03 $648.78 $892.07$815.03 $1,120.67 $886.52 $1,218.96 $677.65 $931.77$852.68 $1,172.43 $927.46 $1,275.26 $708.95 $974.80$890.69 $1,224.69 $968.81 $1,332.11 $740.55 $1,018.26$931.26 $1,280.48 $1,012.94 $1,392.79 $774.28 $1,064.64$951.36 $1,308.12 $1,034.80 $1,422.85 $790.99 $1,087.62$991.93 $1,363.90 $1,078.93 $1,483.53 $824.72 $1,134.00

$1,027.01 $1,412.14 $1,117.09 $1,536.00 $853.90 $1,174.11$1,050.04 $1,443.80 $1,142.14 $1,570.44 $873.04 $1,200.43$1,078.91 $1,483.50 $1,173.54 $1,613.62 $897.05 $1,233.44$1,096.44 $1,507.63 $1,192.62 $1,639.86 $911.63 $1,253.50$1,096.44 $1,507.63 $1,192.62 $1,639.86 $911.63 $1,253.50

$6,550No

31609PA0150009

16884.WR-I Rev. 1.168


Personal Choice PPO Gold HSA-50 $2,650/70%$2,650

30%30% after ded

$6,550No

GoldPersonal Choice PPO Gold HSA-0 $1,900/100%

$1,9000%

$0 after ded

31609PA0150008

16884.WR-I Rev. 1.168


31609PA0150007

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$184.72 $184.72 $204.75 $204.75 $138.99 $138.99$290.90 $327.27 $322.45 $362.75 $218.88 $246.24$290.90 $327.27 $322.45 $362.75 $218.88 $246.24$290.90 $327.27 $322.45 $362.75 $218.88 $246.24$290.90 $327.27 $322.45 $362.75 $218.88 $246.24$292.07 $328.58 $323.74 $364.20 $219.76 $247.23$297.89 $335.12 $330.19 $371.46 $224.13 $252.15$304.87 $342.98 $337.93 $380.17 $229.39 $258.06$316.21 $355.74 $350.50 $394.31 $237.92 $267.66$325.52 $366.21 $360.82 $405.92 $244.93 $275.54$330.18 $387.96 $365.98 $430.02 $248.43 $291.90$337.16 $396.16 $373.72 $439.12 $253.68 $298.08$344.14 $404.36 $381.46 $448.21 $258.94 $304.25$348.50 $409.49 $386.29 $453.89 $262.22 $308.11$353.16 $414.96 $391.45 $459.96 $265.72 $312.22$355.49 $417.70 $394.03 $462.99 $267.47 $314.28$357.81 $420.43 $396.61 $466.02 $269.22 $316.34$360.14 $423.16 $399.19 $469.05 $270.97 $318.39$362.47 $425.90 $401.77 $472.08 $272.72 $320.45$367.12 $431.37 $406.93 $478.14 $276.23 $324.57$371.78 $455.43 $412.09 $504.81 $279.73 $342.67$378.76 $463.98 $419.83 $514.29 $284.98 $349.10$385.45 $472.17 $427.24 $523.37 $290.02 $355.27$394.76 $483.58 $437.56 $536.01 $297.02 $363.85$406.39 $497.83 $450.46 $551.81 $305.78 $374.58$420.07 $514.58 $465.61 $570.38 $316.06 $387.18$436.36 $534.54 $483.67 $592.50 $328.32 $402.19$454.68 $556.99 $503.99 $617.38 $342.11 $419.08$475.63 $582.65 $527.20 $645.82 $357.87 $438.39$496.28 $607.95 $550.10 $673.87 $373.41 $457.43$519.56 $714.39 $575.89 $791.85 $390.92 $537.52$542.54 $745.99 $601.36 $826.88 $408.21 $561.29$567.85 $780.79 $629.42 $865.45 $427.25 $587.47$593.44 $815.99 $657.79 $904.47 $446.52 $613.96$621.08 $853.99 $688.43 $946.59 $467.31 $642.55$648.72 $891.99 $719.06 $988.70 $488.10 $671.14$678.68 $933.18 $752.27 $1,034.37 $510.65 $702.14$708.93 $974.78 $785.80 $1,080.48 $533.41 $733.44$741.22 $1,019.18 $821.60 $1,129.70 $557.71 $766.85$757.22 $1,041.18 $839.33 $1,154.08 $569.75 $783.40$789.51 $1,085.58 $875.12 $1,203.29 $594.04 $816.81$817.44 $1,123.98 $906.08 $1,245.86 $615.05 $845.70$835.77 $1,149.18 $926.39 $1,273.79 $628.84 $864.66$858.75 $1,180.78 $951.87 $1,308.81 $646.13 $888.44$872.70 $1,199.98 $967.34 $1,330.10 $656.64 $902.88$872.70 $1,199.98 $967.34 $1,330.10 $656.64 $902.88

$6,550No

BronzePersonal Choice PPO Bronze HSA-0 $5,200/50%

$5,20050%

50% after ded

31609PA0150012

16884.WR-I Rev. 1.168

$6,550No

31609PA0150011

16884.WR-I Rev. 1.168


Personal Choice PPO Silver HSA-0 $2,700/90%$2,700

10%10% after ded

$6,550No

SilverPersonal Choice PPO Silver HSA-0 $2,100/70%

$2,10030%

30% after ded

31609PA0150010

16884.WR-I Rev. 1.168

Personal Choice Network Personal Choice Network

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$148.96 $148.96 $263.20 $263.20 $232.08 $232.08$234.58 $263.90 $414.49 $466.30 $365.48 $411.17$234.58 $263.90 $414.49 $466.30 $365.48 $411.17$234.58 $263.90 $414.49 $466.30 $365.48 $411.17$234.58 $263.90 $414.49 $466.30 $365.48 $411.17$235.52 $264.96 $416.15 $468.17 $366.95 $412.82$240.21 $270.24 $424.44 $477.49 $374.26 $421.04$245.84 $276.57 $434.39 $488.68 $383.03 $430.91$254.99 $286.86 $450.55 $506.87 $397.28 $446.94$262.50 $295.31 $463.82 $521.79 $408.98 $460.10$266.25 $312.84 $470.45 $552.78 $414.83 $487.42$271.88 $319.46 $480.39 $564.46 $423.60 $497.73$277.51 $326.07 $490.34 $576.15 $432.37 $508.03$281.03 $330.21 $496.56 $583.46 $437.85 $514.47$284.78 $334.62 $503.19 $591.25 $443.70 $521.35$286.66 $336.82 $506.51 $595.15 $446.62 $524.78$288.54 $339.03 $509.82 $599.04 $449.55 $528.22$290.41 $341.23 $513.14 $602.94 $452.47 $531.65$292.29 $343.44 $516.46 $606.84 $455.39 $535.09$296.04 $347.85 $523.09 $614.63 $461.24 $541.96$299.80 $367.25 $529.72 $648.91 $467.09 $572.18$305.43 $374.15 $539.67 $661.09 $475.86 $582.93$310.82 $380.76 $549.20 $672.77 $484.27 $593.23$318.33 $389.95 $562.46 $689.02 $495.96 $607.55$327.71 $401.45 $579.04 $709.33 $510.58 $625.46$338.74 $414.95 $598.52 $733.19 $527.76 $646.51$351.87 $431.04 $621.74 $761.63 $548.23 $671.58$366.65 $449.15 $647.85 $793.61 $571.25 $699.78$383.54 $469.84 $677.69 $830.17 $597.57 $732.02$400.20 $490.24 $707.12 $866.22 $623.52 $763.81$418.96 $576.07 $740.28 $1,017.89 $652.76 $897.54$437.49 $601.55 $773.03 $1,062.91 $681.63 $937.24$457.90 $629.62 $809.09 $1,112.49 $713.43 $980.96$478.55 $658.00 $845.56 $1,162.65 $745.59 $1,025.19$500.83 $688.64 $884.94 $1,216.79 $780.31 $1,072.93$523.12 $719.29 $924.31 $1,270.93 $815.03 $1,120.67$547.28 $752.51 $967.01 $1,329.63 $852.68 $1,172.43$571.67 $786.05 $1,010.11 $1,388.91 $890.69 $1,224.69$597.71 $821.86 $1,056.12 $1,452.17 $931.26 $1,280.48$610.62 $839.60 $1,078.92 $1,483.51 $951.36 $1,308.12$636.65 $875.40 $1,124.93 $1,546.78 $991.93 $1,363.90$659.17 $906.36 $1,164.72 $1,601.49 $1,027.01 $1,412.14$673.95 $926.68 $1,190.83 $1,637.39 $1,050.04 $1,443.80$692.48 $952.17 $1,223.58 $1,682.42 $1,078.91 $1,483.50$703.74 $967.65 $1,243.47 $1,709.77 $1,096.44 $1,507.63$703.74 $967.65 $1,243.47 $1,709.77 $1,096.44 $1,507.63

$6,550No

31609PA0150015

16884.WR-I Rev. 1.168


Personal Choice PPO Gold HRA-25$2,900/100%$2,900

0%$0 after ded

$6,550No

PlatinumPersonal Choice PPO Platinum HRA-50 $1,850/100%

$1,8500%

$0 after ded

31609PA0150014

16884.WR-I Rev. 1.168

31609PA0150013

16884.WR-I Rev. 1.168

Personal Choice Network Bronze

Personal Choice PPO Bronze HSA-0 $6,550/100%$6,550

0%$0 after ded

$6,550No


RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$306.64 $306.64 $293.19 $293.19 $241.79 $241.79$482.89 $543.25 $461.71 $519.43 $380.77 $428.37$482.89 $543.25 $461.71 $519.43 $380.77 $428.37$482.89 $543.25 $461.71 $519.43 $380.77 $428.37$482.89 $543.25 $461.71 $519.43 $380.77 $428.37$484.82 $545.43 $463.56 $521.51 $382.30 $430.08$494.48 $556.29 $472.80 $531.90 $389.91 $438.65$506.07 $569.33 $483.88 $544.36 $399.05 $448.93$524.90 $590.52 $501.88 $564.62 $413.90 $465.64$540.36 $607.90 $516.66 $581.24 $426.09 $479.35$548.08 $644.00 $524.05 $615.75 $432.18 $507.81$559.67 $657.61 $535.13 $628.77 $441.32 $518.55$571.26 $671.23 $546.21 $641.80 $450.45 $529.28$578.50 $679.74 $553.13 $649.93 $456.17 $536.00$586.23 $688.82 $560.52 $658.61 $462.26 $543.15$590.09 $693.36 $564.22 $662.95 $465.31 $546.73$593.96 $697.90 $567.91 $667.29 $468.35 $550.31$597.82 $702.44 $571.60 $671.63 $471.40 $553.89$601.68 $706.98 $575.30 $675.97 $474.44 $557.47$609.41 $716.06 $582.68 $684.65 $480.54 $564.63$617.14 $755.99 $590.07 $722.84 $486.63 $596.12$628.72 $770.19 $601.15 $736.41 $495.77 $607.31$639.83 $783.79 $611.77 $749.42 $504.52 $618.04$655.28 $802.72 $626.55 $767.52 $516.71 $632.97$674.60 $826.38 $645.02 $790.14 $531.94 $651.63$697.30 $854.19 $666.72 $816.73 $549.84 $673.55$724.34 $887.31 $692.57 $848.40 $571.16 $699.67$754.76 $924.58 $721.66 $884.03 $595.15 $729.06$789.53 $967.17 $754.90 $924.76 $622.56 $762.64$823.81 $1,009.17 $787.69 $964.91 $649.60 $795.76$862.44 $1,185.86 $824.62 $1,133.86 $680.06 $935.08$900.59 $1,238.31 $861.10 $1,184.01 $710.14 $976.45$942.60 $1,296.08 $901.27 $1,239.24 $743.27 $1,022.00$985.10 $1,354.51 $941.90 $1,295.11 $776.78 $1,068.07

$1,030.97 $1,417.59 $985.76 $1,355.42 $812.95 $1,117.81$1,076.85 $1,480.67 $1,029.62 $1,415.73 $849.12 $1,167.55$1,126.59 $1,549.06 $1,077.18 $1,481.12 $888.34 $1,221.47$1,176.81 $1,618.11 $1,125.20 $1,547.15 $927.94 $1,275.92$1,230.41 $1,691.81 $1,176.45 $1,617.62 $970.21 $1,334.04$1,256.97 $1,728.33 $1,201.84 $1,652.54 $991.15 $1,362.84$1,310.57 $1,802.03 $1,253.09 $1,723.00 $1,033.42 $1,420.95$1,356.92 $1,865.77 $1,297.42 $1,783.95 $1,069.97 $1,471.21$1,387.35 $1,907.60 $1,326.51 $1,823.95 $1,093.96 $1,504.20$1,425.50 $1,960.06 $1,362.98 $1,874.10 $1,124.04 $1,545.56$1,448.67 $1,991.93 $1,385.13 $1,904.57 $1,142.31 $1,570.69$1,448.67 $1,991.93 $1,385.13 $1,904.57 $1,142.31 $1,570.69

$6,850Yes

GoldPersonal Choice PPO Gold Preferred $35/$70/$600

$00%

$35/$70

31609PA015002716884.WR-I Rev. 1.16

8

$2,500Yes

31609PA015002616884.WR-I Rev. 1.16

8Personal Choice Network


$00%

$20/$40$2,000

Yes


$00%

$10/$20

31609PA015002516884.WR-I Rev. 1.16

8Personal Choice Network Personal Choice Network

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$241.94 $241.94 $209.94 $209.94 $263.77 $263.77$381.01 $428.64 $330.62 $371.95 $415.39 $467.31$381.01 $428.64 $330.62 $371.95 $415.39 $467.31$381.01 $428.64 $330.62 $371.95 $415.39 $467.31$381.01 $428.64 $330.62 $371.95 $415.39 $467.31$382.54 $430.36 $331.94 $373.44 $417.05 $469.18$390.16 $438.93 $338.56 $380.87 $425.36 $478.53$399.30 $449.22 $346.49 $389.80 $435.32 $489.74$414.16 $465.93 $359.38 $404.31 $451.53 $507.97$426.36 $479.65 $369.96 $416.21 $464.82 $522.92$432.45 $508.13 $375.25 $440.92 $471.46 $553.97$441.60 $518.88 $383.19 $450.25 $481.43 $565.68$450.74 $529.62 $391.12 $459.57 $491.40 $577.40$456.46 $536.34 $396.08 $465.40 $497.63 $584.72$462.55 $543.50 $401.37 $471.61 $504.28 $592.53$465.60 $547.08 $404.02 $474.72 $507.60 $596.43$468.65 $550.66 $406.66 $477.83 $510.93 $600.34$471.70 $554.24 $409.31 $480.94 $514.25 $604.24$474.74 $557.82 $411.95 $484.04 $517.57 $608.15$480.84 $564.99 $417.24 $490.26 $524.22 $615.96$486.94 $596.50 $422.53 $517.60 $530.86 $650.31$496.08 $607.70 $430.47 $527.32 $540.83 $662.52$504.84 $618.43 $438.07 $536.64 $550.39 $674.22$517.04 $633.37 $448.65 $549.60 $563.68 $690.51$532.28 $652.04 $461.88 $565.80 $580.29 $710.86$550.19 $673.98 $477.42 $584.83 $599.82 $734.78$571.52 $700.11 $495.93 $607.51 $623.08 $763.27$595.53 $729.52 $516.76 $633.03 $649.25 $795.33$622.96 $763.13 $540.56 $662.19 $679.16 $831.97$650.01 $796.26 $564.04 $690.95 $708.65 $868.10$680.49 $935.68 $590.49 $811.92 $741.88 $1,020.09$710.59 $977.07 $616.61 $847.83 $774.70 $1,065.21$743.74 $1,022.64 $645.37 $887.38 $810.83 $1,114.90$777.27 $1,068.75 $674.47 $927.39 $847.39 $1,165.16$813.47 $1,118.52 $705.87 $970.58 $886.85 $1,219.42$849.66 $1,168.29 $737.28 $1,013.76 $926.31 $1,273.68$888.91 $1,222.25 $771.34 $1,060.59 $969.10 $1,332.51$928.53 $1,276.73 $805.72 $1,107.87 $1,012.30 $1,391.91$970.83 $1,334.89 $842.42 $1,158.33 $1,058.40 $1,455.31$991.78 $1,363.70 $860.60 $1,183.33 $1,081.25 $1,486.72

$1,034.07 $1,421.85 $897.30 $1,233.79 $1,127.36 $1,550.12$1,070.65 $1,472.15 $929.04 $1,277.43 $1,167.24 $1,604.95$1,094.66 $1,505.15 $949.87 $1,306.07 $1,193.41 $1,640.93$1,124.76 $1,546.54 $975.99 $1,341.99 $1,226.22 $1,686.05$1,143.03 $1,571.69 $991.86 $1,363.81 $1,246.16 $1,713.47$1,143.03 $1,571.69 $991.86 $1,363.81 $1,246.16 $1,713.47

$6,400Yes

31609PA015003016884.WR-I Rev. 1.16



$1,6000%

$0 after ded$6,550

Yes

SilverPersonal Choice PPO Silver Classic$2,500 $30/$60/80%

$2,50020%

$30 no ded/$60 no ded

31609PA015002916884.WR-I Rev. 1.16

8

31609PA015002816884.WR-I Rev. 1.16


GoldPersonal Choice PPO Gold Classic $1,000 $15/$30/80%

$1,00020%

$15 no ded/$30 no ded$5,500

Yes


RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$232.65 $232.65 $253.01 $253.01 $193.54 $193.54$366.38 $412.18 $398.44 $448.24 $304.78 $342.88$366.38 $412.18 $398.44 $448.24 $304.78 $342.88$366.38 $412.18 $398.44 $448.24 $304.78 $342.88$366.38 $412.18 $398.44 $448.24 $304.78 $342.88$367.85 $413.83 $400.03 $450.03 $306.00 $344.25$375.17 $422.07 $408.00 $459.00 $312.10 $351.11$383.97 $431.96 $417.56 $469.76 $319.41 $359.34$398.26 $448.04 $433.10 $487.24 $331.30 $372.71$409.98 $461.23 $445.85 $501.58 $341.05 $383.68$415.84 $488.61 $452.23 $531.37 $345.93 $406.47$424.64 $498.95 $461.79 $542.60 $353.24 $415.06$433.43 $509.28 $471.35 $553.84 $360.56 $423.66$438.92 $515.74 $477.33 $560.86 $365.13 $429.03$444.79 $522.62 $483.70 $568.35 $370.01 $434.76$447.72 $526.07 $486.89 $572.10 $372.45 $437.62$450.65 $529.51 $490.08 $575.84 $374.88 $440.49$453.58 $532.96 $493.27 $579.59 $377.32 $443.35$456.51 $536.40 $496.45 $583.33 $379.76 $446.22$462.37 $543.29 $502.83 $590.82 $384.64 $451.95$468.23 $573.59 $509.20 $623.77 $389.51 $477.15$477.03 $584.36 $518.77 $635.49 $396.83 $486.11$485.45 $594.68 $527.93 $646.71 $403.84 $494.70$497.18 $609.04 $540.68 $662.33 $413.59 $506.65$511.83 $627.00 $556.62 $681.86 $425.78 $521.58$529.05 $648.09 $575.34 $704.80 $440.11 $539.13$549.57 $673.22 $597.66 $732.13 $457.18 $560.04$572.65 $701.50 $622.76 $762.88 $476.38 $583.56$599.03 $733.81 $651.44 $798.02 $498.32 $610.44$625.05 $765.68 $679.73 $832.67 $519.96 $636.95$654.36 $899.74 $711.61 $978.46 $544.34 $748.47$683.30 $939.54 $743.09 $1,021.74 $568.42 $781.58$715.18 $983.37 $777.75 $1,069.41 $594.94 $818.04$747.42 $1,027.70 $812.81 $1,117.62 $621.76 $854.92$782.22 $1,075.56 $850.66 $1,169.66 $650.71 $894.73$817.03 $1,123.41 $888.51 $1,221.71 $679.67 $934.54$854.77 $1,175.30 $929.55 $1,278.14 $711.06 $977.71$892.87 $1,227.70 $970.99 $1,335.11 $742.76 $1,021.29$933.54 $1,283.61 $1,015.22 $1,395.92 $776.59 $1,067.81$953.69 $1,311.32 $1,037.13 $1,426.06 $793.35 $1,090.86$994.36 $1,367.24 $1,081.36 $1,486.87 $827.18 $1,137.38

$1,029.53 $1,415.60 $1,119.61 $1,539.46 $856.44 $1,177.61$1,052.61 $1,447.34 $1,144.71 $1,573.98 $875.64 $1,204.01$1,081.56 $1,487.14 $1,176.19 $1,617.26 $899.72 $1,237.12$1,099.14 $1,511.32 $1,195.31 $1,643.55 $914.34 $1,257.23$1,099.14 $1,511.32 $1,195.31 $1,643.55 $914.34 $1,257.23

$6,550Yes


$2,65030%

30% after ded

31609PA015003316884.WR-I Rev. 1.16


$6,550Yes

31609PA015003216884.WR-I Rev. 1.16



$1,9000%

$0 after ded$6,550

Yes


$2,4000%

$0 after ded

31609PA015003116884.WR-I Rev. 1.16


RATE PAGES

Page Number: 10 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$185.30 $185.30 $205.32 $205.32 $139.56 $139.56$291.81 $328.29 $323.34 $363.76 $219.78 $247.25$291.81 $328.29 $323.34 $363.76 $219.78 $247.25$291.81 $328.29 $323.34 $363.76 $219.78 $247.25$291.81 $328.29 $323.34 $363.76 $219.78 $247.25$292.98 $329.60 $324.64 $365.22 $220.66 $248.24$298.81 $336.17 $331.10 $372.49 $225.05 $253.18$305.82 $344.04 $338.86 $381.22 $230.33 $259.12$317.20 $356.85 $351.47 $395.41 $238.90 $268.76$326.54 $367.35 $361.82 $407.05 $245.93 $276.67$331.20 $389.17 $366.99 $431.22 $249.45 $293.10$338.21 $397.39 $374.75 $440.34 $254.72 $299.30$345.21 $405.62 $382.52 $449.46 $260.00 $305.49$349.59 $410.77 $387.37 $455.15 $263.29 $309.37$354.26 $416.25 $392.54 $461.23 $266.81 $313.50$356.59 $419.00 $395.13 $464.27 $268.57 $315.57$358.93 $421.74 $397.71 $467.31 $270.32 $317.63$361.26 $424.48 $400.30 $470.35 $272.08 $319.70$363.60 $427.22 $402.89 $473.39 $273.84 $321.76$368.26 $432.71 $408.06 $479.47 $277.36 $325.89$372.93 $456.84 $413.23 $506.21 $280.87 $344.07$379.94 $465.42 $420.99 $515.72 $286.15 $350.53$386.65 $473.64 $428.43 $524.83 $291.20 $356.72$395.99 $485.08 $438.78 $537.50 $298.24 $365.34$407.66 $499.38 $451.71 $553.35 $307.03 $376.11$421.37 $516.18 $466.91 $571.96 $317.36 $388.76$437.72 $536.20 $485.02 $594.14 $329.66 $403.84$456.10 $558.72 $505.39 $619.10 $343.51 $420.80$477.11 $584.46 $528.67 $647.62 $359.33 $440.18$497.83 $609.84 $551.62 $675.74 $374.94 $459.30$521.17 $716.61 $577.49 $794.05 $392.52 $539.72$544.23 $748.31 $603.04 $829.17 $409.88 $563.59$569.61 $783.22 $631.17 $867.85 $429.00 $589.88$595.29 $818.53 $659.62 $906.98 $448.34 $616.47$623.01 $856.65 $690.34 $949.21 $469.22 $645.18$650.74 $894.76 $721.06 $991.45 $490.10 $673.89$680.79 $936.09 $754.36 $1,037.25 $512.74 $705.01$711.14 $977.82 $787.99 $1,083.48 $535.59 $736.44$743.53 $1,022.36 $823.88 $1,132.83 $559.99 $769.99$759.58 $1,044.43 $841.66 $1,157.29 $572.08 $786.61$791.97 $1,088.96 $877.55 $1,206.64 $596.47 $820.15$819.99 $1,127.48 $908.59 $1,249.32 $617.57 $849.16$838.37 $1,152.76 $928.97 $1,277.33 $631.42 $868.20$861.42 $1,184.46 $954.51 $1,312.45 $648.78 $892.07$875.43 $1,203.72 $970.02 $1,333.79 $659.33 $906.58$875.43 $1,203.72 $970.02 $1,333.79 $659.33 $906.58

$6,550Yes

31609PA015003616884.WR-I Rev. 1.16



$5,20050%

50% after ded$6,550

Yes


$2,70010%

10% after ded

31609PA015003516884.WR-I Rev. 1.16


31609PA015003416884.WR-I Rev. 1.16



$2,10030%

30% after ded$6,550

Yes

RATE PAGES

Page Number: 11 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$149.53 $149.53 $263.77 $263.77 $232.65 $232.65$235.49 $264.92 $415.39 $467.31 $366.38 $412.18$235.49 $264.92 $415.39 $467.31 $366.38 $412.18$235.49 $264.92 $415.39 $467.31 $366.38 $412.18$235.49 $264.92 $415.39 $467.31 $366.38 $412.18$236.43 $265.98 $417.05 $469.18 $367.85 $413.83$241.14 $271.28 $425.36 $478.53 $375.17 $422.07$246.79 $277.64 $435.32 $489.74 $383.97 $431.96$255.97 $287.97 $451.53 $507.97 $398.26 $448.04$263.51 $296.45 $464.82 $522.92 $409.98 $461.23$267.28 $314.05 $471.46 $553.97 $415.84 $488.61$272.93 $320.69 $481.43 $565.68 $424.64 $498.95$278.58 $327.33 $491.40 $577.40 $433.43 $509.28$282.11 $331.48 $497.63 $584.72 $438.92 $515.74$285.88 $335.91 $504.28 $592.53 $444.79 $522.62$287.77 $338.12 $507.60 $596.43 $447.72 $526.07$289.65 $340.34 $510.93 $600.34 $450.65 $529.51$291.53 $342.55 $514.25 $604.24 $453.58 $532.96$293.42 $344.77 $517.57 $608.15 $456.51 $536.40$297.18 $349.19 $524.22 $615.96 $462.37 $543.29$300.95 $368.67 $530.86 $650.31 $468.23 $573.59$306.60 $375.59 $540.83 $662.52 $477.03 $584.36$312.02 $382.23 $550.39 $674.22 $485.45 $594.68$319.56 $391.46 $563.68 $690.51 $497.18 $609.04$328.98 $403.00 $580.29 $710.86 $511.83 $627.00$340.04 $416.55 $599.82 $734.78 $529.05 $648.09$353.23 $432.71 $623.08 $763.27 $549.57 $673.22$368.07 $450.88 $649.25 $795.33 $572.65 $701.50$385.02 $471.65 $679.16 $831.97 $599.03 $733.81$401.74 $492.13 $708.65 $868.10 $625.05 $765.68$420.58 $578.30 $741.88 $1,020.09 $654.36 $899.74$439.18 $603.88 $774.70 $1,065.21 $683.30 $939.54$459.67 $632.05 $810.83 $1,114.90 $715.18 $983.37$480.39 $660.54 $847.39 $1,165.16 $747.42 $1,027.70$502.77 $691.30 $886.85 $1,219.42 $782.22 $1,075.56$525.14 $722.06 $926.31 $1,273.68 $817.03 $1,123.41$549.39 $755.41 $969.10 $1,332.51 $854.77 $1,175.30$573.88 $789.09 $1,012.30 $1,391.91 $892.87 $1,227.70$600.02 $825.03 $1,058.40 $1,455.31 $933.54 $1,283.61$612.97 $842.84 $1,081.25 $1,486.72 $953.69 $1,311.32$639.11 $878.78 $1,127.36 $1,550.12 $994.36 $1,367.24$661.72 $909.86 $1,167.24 $1,604.95 $1,029.53 $1,415.60$676.55 $930.26 $1,193.41 $1,640.93 $1,052.61 $1,447.34$695.16 $955.84 $1,226.22 $1,686.05 $1,081.56 $1,487.14$706.46 $971.39 $1,246.16 $1,713.47 $1,099.14 $1,511.32$706.46 $971.39 $1,246.16 $1,713.47 $1,099.14 $1,511.32

$6,550

Personal Choice PPO Gold HRA-25 $2,900/100%$2,900

0%$0 after ded

$6,550Yes

31609PA015003816884.WR-I Rev. 1.16



$1,8500%

$0 after ded$6,550

Yes


$6,5500%

$0 after ded

31609PA015003716884.WR-I Rev. 1.16


Gold

16884.WR-I Rev. 1.16


31609PA0150039

8

Yes

RATE PAGES

Page Number: 12 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$231.30 $231.30 $189.05 $189.05 $213.36 $213.36$364.26 $409.79 $297.72 $334.93 $335.99 $377.99$364.26 $409.79 $297.72 $334.93 $335.99 $377.99$364.26 $409.79 $297.72 $334.93 $335.99 $377.99$364.26 $409.79 $297.72 $334.93 $335.99 $377.99$365.71 $411.43 $298.91 $336.27 $337.34 $379.51$373.00 $419.62 $304.86 $342.97 $344.06 $387.07$381.74 $429.46 $312.01 $351.01 $352.12 $396.14$395.95 $445.44 $323.62 $364.07 $365.23 $410.88$407.60 $458.55 $333.15 $374.79 $375.98 $422.98$413.43 $485.78 $337.91 $397.04 $381.35 $448.09$422.17 $496.05 $345.06 $405.44 $389.42 $457.57$430.92 $506.33 $352.20 $413.84 $397.48 $467.04$436.38 $512.75 $356.67 $419.08 $402.52 $472.96$442.21 $519.59 $361.43 $424.68 $407.90 $479.28$445.12 $523.02 $363.81 $427.48 $410.59 $482.44$448.04 $526.44 $366.19 $430.28 $413.27 $485.60$450.95 $529.87 $368.58 $433.08 $415.96 $488.75$453.86 $533.29 $370.96 $435.87 $418.65 $491.91$459.69 $540.14 $375.72 $441.47 $424.03 $498.23$465.52 $570.26 $380.48 $466.09 $429.40 $526.02$474.26 $580.97 $387.63 $474.85 $437.47 $535.90$482.64 $591.23 $394.48 $483.23 $445.19 $545.36$494.30 $605.51 $404.00 $494.90 $455.95 $558.53$508.87 $623.36 $415.91 $509.49 $469.38 $575.00$525.99 $644.33 $429.91 $526.63 $485.18 $594.34$546.39 $669.32 $446.58 $547.06 $503.99 $617.39$569.33 $697.43 $465.33 $570.03 $525.16 $643.32$595.56 $729.56 $486.77 $596.29 $549.35 $672.96$621.42 $761.24 $507.91 $622.19 $573.21 $702.18$650.56 $894.52 $531.72 $731.12 $600.09 $825.12$679.34 $934.09 $555.24 $763.46 $626.63 $861.62$711.03 $977.67 $581.15 $799.08 $655.86 $901.81$743.08 $1,021.74 $607.35 $835.10 $685.43 $942.47$777.69 $1,069.32 $635.63 $873.99 $717.35 $986.35$812.29 $1,116.90 $663.91 $912.88 $749.27 $1,030.24$849.81 $1,168.49 $694.58 $955.04 $783.88 $1,077.83$887.69 $1,220.58 $725.54 $997.62 $818.82 $1,125.88$928.13 $1,276.17 $758.59 $1,043.06 $856.11 $1,177.16$948.16 $1,303.72 $774.96 $1,065.57 $874.59 $1,202.57$988.59 $1,359.32 $808.01 $1,111.01 $911.89 $1,253.85

$1,023.56 $1,407.40 $836.59 $1,150.31 $944.15 $1,298.20$1,046.51 $1,438.95 $855.34 $1,176.10 $965.31 $1,327.31$1,075.29 $1,478.52 $878.86 $1,208.44 $991.86 $1,363.80$1,092.77 $1,502.56 $893.15 $1,228.09 $1,007.97 $1,385.98$1,092.77 $1,502.56 $893.15 $1,228.09 $1,007.97 $1,385.98

31609PA0150023

No$3,200

0%$2,000 $3,000

Personal Choice PPO Gold Classic $2,000 $40/$80/100% Personal Choice PPO Silver Secure$3,000 $30/$60/$600

No

16884.WR-I Rev. 1.168


No


Gold

31609PA0150022 31609PA0150024

Silver

16884.WR-I Rev. 1.168


$3,3000%

$40 no ded/$80 no ded$6,800

0%

$7,150$30 no ded/$60 no ded

16884.WR-I Rev. 1.168


Personal Choice PPO Silver Classic$3,300 $40/$80/100%

RATE PAGES

Page Number: 13 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$227.60 $227.60 $232.04 $232.04 $189.79 $189.79$358.42 $403.22 $365.41 $411.09 $298.88 $336.24$358.42 $403.22 $365.41 $411.09 $298.88 $336.24$358.42 $403.22 $365.41 $411.09 $298.88 $336.24$358.42 $403.22 $365.41 $411.09 $298.88 $336.24$359.85 $404.83 $366.88 $412.74 $300.07 $337.58$367.02 $412.90 $374.18 $420.96 $306.05 $344.30$375.62 $422.58 $382.95 $430.82 $313.22 $352.37$389.60 $438.30 $397.21 $446.86 $324.88 $365.49$401.07 $451.21 $408.90 $460.01 $334.44 $376.25$406.81 $478.00 $414.75 $487.33 $339.22 $398.59$415.41 $488.10 $423.52 $497.63 $346.40 $407.02$424.01 $498.21 $432.29 $507.94 $353.57 $415.44$429.39 $504.53 $437.77 $514.38 $358.05 $420.71$435.12 $511.27 $443.61 $521.25 $362.84 $426.33$437.99 $514.64 $446.54 $524.68 $365.23 $429.14$440.86 $518.01 $449.46 $528.12 $367.62 $431.95$443.72 $521.37 $452.38 $531.55 $370.01 $434.76$446.59 $524.74 $455.31 $534.98 $372.40 $437.57$452.33 $531.48 $461.15 $541.85 $377.18 $443.19$458.06 $561.12 $467.00 $572.07 $381.96 $467.90$466.66 $571.66 $475.77 $582.82 $389.14 $476.69$474.91 $581.76 $484.17 $593.11 $396.01 $485.11$486.38 $595.81 $495.87 $607.44 $405.57 $496.83$500.71 $613.37 $510.48 $625.34 $417.53 $511.47$517.56 $634.01 $527.66 $646.38 $431.58 $528.68$537.63 $658.60 $548.12 $671.45 $448.31 $549.18$560.21 $686.26 $571.14 $699.65 $467.14 $572.25$586.02 $717.87 $597.45 $731.88 $488.66 $598.61$611.46 $749.04 $623.40 $763.66 $509.88 $624.61$640.14 $880.19 $652.63 $897.37 $533.79 $733.96$668.45 $919.12 $681.50 $937.06 $557.40 $766.43$699.63 $962.00 $713.29 $980.77 $583.41 $802.18$731.18 $1,005.37 $745.45 $1,024.99 $609.71 $838.35$765.23 $1,052.18 $780.16 $1,072.72 $638.10 $877.39$799.28 $1,099.00 $814.87 $1,120.45 $666.49 $916.43$836.19 $1,149.76 $852.51 $1,172.20 $697.28 $958.76$873.47 $1,201.02 $890.51 $1,224.46 $728.36 $1,001.50$913.25 $1,255.72 $931.08 $1,280.23 $761.54 $1,047.11$932.97 $1,282.83 $951.17 $1,307.86 $777.97 $1,069.71$972.75 $1,337.53 $991.73 $1,363.64 $811.15 $1,115.33

$1,007.16 $1,384.84 $1,026.81 $1,411.87 $839.84 $1,154.78$1,029.74 $1,415.89 $1,049.84 $1,443.52 $858.67 $1,180.67$1,058.05 $1,454.82 $1,078.70 $1,483.22 $882.28 $1,213.14$1,075.26 $1,478.48 $1,096.23 $1,507.33 $896.63 $1,232.86$1,075.26 $1,478.48 $1,096.23 $1,507.33 $896.63 $1,232.86

$6,550


$3,2000%

$0 after ded


16884.WR-I Rev. 1.16

No

8

31609PA015004631609PA0150047

16884.WR-I Rev. 1.168


Personal Choice PPO Gold Classic $2,000 $40/$80/100%$2,000


$3,200Yes

31609PA015004916884.WR-I Rev. 1.16


SilverPersonal Choice PPO Silver Secure$3,000 $30/$60/$600

$7,150Yes

$3,0000%


RATE PAGES

Page Number: 14 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco$214.09 $214.09 $228.17 $228.17$337.15 $379.30 $359.32 $404.23$337.15 $379.30 $359.32 $404.23$337.15 $379.30 $359.32 $404.23$337.15 $379.30 $359.32 $404.23$338.50 $380.81 $360.75 $405.85$345.24 $388.40 $367.94 $413.93$353.34 $397.50 $376.56 $423.63$366.48 $412.30 $390.58 $439.40$377.27 $424.43 $402.07 $452.33$382.67 $449.63 $407.82 $479.19$390.76 $459.14 $416.45 $489.32$398.85 $468.65 $425.07 $499.46$403.91 $474.59 $430.46 $505.79$409.30 $480.93 $436.21 $512.55$412.00 $484.10 $439.08 $515.92$414.70 $487.27 $441.96 $519.30$417.39 $490.44 $444.83 $522.68$420.09 $493.61 $447.71 $526.06$425.49 $499.95 $453.46 $532.81$430.88 $527.83 $459.20 $562.53$438.97 $537.74 $467.83 $573.09$446.73 $547.24 $476.09 $583.21$457.52 $560.46 $487.59 $597.30$471.00 $576.98 $501.96 $614.90$486.85 $596.39 $518.85 $635.59$505.73 $619.52 $538.97 $660.24$526.97 $645.54 $561.61 $687.97$551.24 $675.27 $587.48 $719.66$575.18 $704.60 $612.99 $750.91$602.15 $827.96 $641.74 $882.39$628.79 $864.59 $670.12 $921.42$658.12 $904.92 $701.38 $964.40$687.79 $945.71 $733.00 $1,007.88$719.82 $989.75 $767.14 $1,054.81$751.85 $1,033.79 $801.27 $1,101.75$786.58 $1,081.54 $838.28 $1,152.64$821.64 $1,129.76 $875.65 $1,204.02$859.06 $1,181.21 $915.53 $1,258.86$877.61 $1,206.71 $935.30 $1,286.03$915.03 $1,258.17 $975.18 $1,340.87$947.40 $1,302.67 $1,009.68 $1,388.30$968.64 $1,331.88 $1,032.31 $1,419.43$995.27 $1,368.50 $1,060.70 $1,458.46

$1,011.45 $1,390.75 $1,077.95 $1,482.17$1,011.45 $1,390.75 $1,077.95 $1,482.17

31609PA0150048 31609PA015005016884.WR-I Rev. 1.16 16884.WR-I Rev. 1.16

8 8Personal Choice Network Personal Choice Network

Silver SilverPersonal Choice PPO Silver Classic$3,300 $40/$80/100% Personal Choice PPO Silver HSA-0 $3,200/100%

$6,800 $6,550Yes Yes

$3,300 $3,2000% 0%

$40 no ded/$80 no ded $0 after ded

Silver Plan Rates for Age 21 Non-Smoker, by Geograp

HIOS Plan ID # Rating Area 1 Rating Area 2 Rating Area 3 Rating Area 431609PA015000531609PA015001031609PA015001131609PA015002331609PA015002431609PA0150046

2017 On-Exchange

phic Area and Exchange Status

Rating Area 5 Rating Area 6 Rating Area 7 Rating Area 8 Rating Area 9$329.46 $290.90 $322.45 $335.99 $297.72 $358.42

e Silver Plan Rates



2017 Off-Exchange



e Silver Plan Rates

12/24/2014




Plan Design Summary


RATE PAGES


Company Name: QCC Insurance CompanyProduct: PPOEffective Date of Rates: April 1, 2017 - June 30, 2017



Network =>Metal =>




Age Band Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco0-20 $314.77 $314.77 $300.93 $300.93 $248.05 $248.0521 $495.70 $557.67 $473.91 $533.15 $390.62 $439.4522 $495.70 $557.67 $473.91 $533.15 $390.62 $439.4523 $495.70 $557.67 $473.91 $533.15 $390.62 $439.4524 $495.70 $557.67 $473.91 $533.15 $390.62 $439.4525 $497.69 $559.90 $475.81 $535.28 $392.19 $441.2126 $507.60 $571.05 $485.29 $545.95 $400.00 $450.0027 $519.50 $584.43 $496.66 $558.74 $409.37 $460.5528 $538.83 $606.18 $515.14 $579.54 $424.61 $477.6829 $554.69 $624.03 $530.31 $596.60 $437.11 $491.7530 $562.62 $661.08 $537.89 $632.02 $443.36 $520.9531 $574.52 $675.06 $549.27 $645.39 $452.73 $531.9632 $586.42 $689.04 $560.64 $658.75 $462.11 $542.9833 $593.85 $697.78 $567.75 $667.10 $467.97 $549.8634 $601.78 $707.10 $575.33 $676.01 $474.22 $557.2135 $605.75 $711.76 $579.12 $680.47 $477.34 $560.8836 $609.72 $716.42 $582.91 $684.92 $480.47 $564.5537 $613.68 $721.08 $586.70 $689.38 $483.59 $568.2238 $617.65 $725.73 $590.50 $693.83 $486.72 $571.8939 $625.58 $735.05 $598.08 $702.74 $492.97 $579.2440 $633.51 $776.05 $605.66 $741.93 $499.22 $611.5441 $645.41 $790.62 $617.03 $755.87 $508.59 $623.0342 $656.81 $804.59 $627.93 $769.22 $517.58 $634.0343 $672.67 $824.02 $643.10 $787.80 $530.08 $649.3444 $692.50 $848.31 $662.06 $811.02 $545.70 $668.4945 $715.80 $876.85 $684.33 $838.30 $564.06 $690.9846 $743.56 $910.86 $710.87 $870.82 $585.94 $717.7747 $774.78 $949.11 $740.73 $907.39 $610.55 $747.9248 $810.48 $992.83 $774.85 $949.19 $638.67 $782.3749 $845.67 $1,035.95 $808.50 $990.41 $666.41 $816.3550 $885.33 $1,217.32 $846.41 $1,163.81 $697.66 $959.2851 $924.49 $1,271.17 $883.85 $1,215.29 $728.51 $1,001.7152 $967.61 $1,330.47 $925.08 $1,271.98 $762.50 $1,048.4453 $1,011.24 $1,390.45 $966.78 $1,329.33 $796.87 $1,095.7054 $1,058.33 $1,455.20 $1,011.80 $1,391.23 $833.98 $1,146.7355 $1,105.42 $1,519.95 $1,056.83 $1,453.14 $871.09 $1,197.7556 $1,156.48 $1,590.16 $1,105.64 $1,520.25 $911.33 $1,253.0757 $1,208.03 $1,661.04 $1,154.93 $1,588.02 $951.95 $1,308.9358 $1,263.05 $1,736.70 $1,207.53 $1,660.35 $995.31 $1,368.5559 $1,290.32 $1,774.19 $1,233.60 $1,696.19 $1,016.80 $1,398.0960 $1,345.34 $1,849.84 $1,286.20 $1,768.53 $1,060.15 $1,457.7161 $1,392.93 $1,915.28 $1,331.70 $1,831.08 $1,097.65 $1,509.2862 $1,424.16 $1,958.22 $1,361.55 $1,872.13 $1,122.26 $1,543.1163 $1,463.32 $2,012.06 $1,398.99 $1,923.61 $1,153.12 $1,585.5464 $1,487.10 $2,044.78 $1,421.73 $1,954.89 $1,171.86 $1,611.33

65+ $1,487.10 $2,044.78 $1,421.73 $1,954.89 $1,171.86 $1,611.33

Platinum

No

31609PA0150003

16884.WR-I Rev. 1.168


Personal Choice Network Personal Choice Network Personal Choice Network Gold

$20/$40$2,000

$35/$70$6,850


31609PA0150001 31609PA0150002

8 8

No No

16884.WR-I Rev. 1.16 16884.WR-I Rev. 1.16


$00%

$2,500$10/$20

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$248.20 $248.20 $215.28 $215.28 $270.83 $270.83$390.87 $439.73 $339.02 $381.39 $426.51 $479.82$390.87 $439.73 $339.02 $381.39 $426.51 $479.82$390.87 $439.73 $339.02 $381.39 $426.51 $479.82$390.87 $439.73 $339.02 $381.39 $426.51 $479.82$392.44 $441.49 $340.37 $382.92 $428.22 $481.74$400.25 $450.29 $347.15 $390.55 $436.75 $491.34$409.63 $460.84 $355.29 $399.70 $446.98 $502.86$424.88 $477.99 $368.51 $414.58 $463.62 $521.57$437.39 $492.06 $379.36 $426.78 $477.27 $536.92$443.64 $521.28 $384.78 $452.12 $484.09 $568.80$453.02 $532.30 $392.92 $461.68 $494.33 $580.83$462.40 $543.32 $401.06 $471.24 $504.56 $592.86$468.27 $550.21 $406.14 $477.22 $510.96 $600.38$474.52 $557.56 $411.57 $483.59 $517.78 $608.40$477.65 $561.23 $414.28 $486.78 $521.20 $612.41$480.77 $564.91 $416.99 $489.96 $524.61 $616.41$483.90 $568.58 $419.70 $493.15 $528.02 $620.42$487.03 $572.26 $422.42 $496.34 $531.43 $624.43$493.28 $579.61 $427.84 $502.71 $538.26 $632.45$499.54 $611.93 $433.26 $530.75 $545.08 $667.72$508.92 $623.42 $441.40 $540.71 $555.32 $680.26$517.91 $634.44 $449.20 $550.27 $565.13 $692.28$530.41 $649.76 $460.05 $563.56 $578.77 $709.00$546.05 $668.91 $473.61 $580.17 $595.84 $729.90$564.42 $691.42 $489.54 $599.69 $615.88 $754.45$586.31 $718.23 $508.53 $622.94 $639.77 $783.71$610.93 $748.39 $529.88 $649.11 $666.64 $816.63$639.08 $782.87 $554.29 $679.01 $697.34 $854.25$666.83 $816.87 $578.36 $708.49 $727.63 $891.34$698.10 $959.89 $605.48 $832.54 $761.75 $1,047.40$728.98 $1,002.34 $632.27 $869.37 $795.44 $1,093.73$762.98 $1,049.10 $661.76 $909.92 $832.55 $1,144.75$797.38 $1,096.40 $691.59 $950.94 $870.08 $1,196.36$834.51 $1,147.46 $723.80 $995.23 $910.60 $1,252.07$871.65 $1,198.51 $756.01 $1,039.51 $951.12 $1,307.79$911.91 $1,253.87 $790.93 $1,087.52 $995.05 $1,368.19$952.56 $1,309.77 $826.18 $1,136.00 $1,039.41 $1,429.18$995.94 $1,369.42 $863.82 $1,187.75 $1,086.75 $1,494.28

$1,017.44 $1,398.98 $882.46 $1,213.38 $1,110.21 $1,526.53$1,060.83 $1,458.64 $920.09 $1,265.13 $1,157.55 $1,591.63$1,098.35 $1,510.24 $952.64 $1,309.88 $1,198.49 $1,647.93$1,122.98 $1,544.09 $974.00 $1,339.24 $1,225.36 $1,684.88$1,153.86 $1,586.55 $1,000.78 $1,376.07 $1,259.06 $1,731.21$1,172.61 $1,612.35 $1,017.05 $1,398.44 $1,279.53 $1,759.36$1,172.61 $1,612.35 $1,017.05 $1,398.44 $1,279.53 $1,759.36

No$6,550

No


$1,6000%

$0 after ded

31609PA0150006

16884.WR-I Rev. 1.16

31609PA0150004


31609PA0150005

16884.WR-I Rev. 1.168




$6,400No

16884.WR-I Rev. 1.168


8

$1,00020%

$15 no ded/$30 no ded$5,500

Personal Choice PPO Gold Classic $1,000 $15/$30/80%

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$238.81 $238.81 $259.76 $259.76 $198.56 $198.56$376.08 $423.09 $409.07 $460.20 $312.69 $351.78$376.08 $423.09 $409.07 $460.20 $312.69 $351.78$376.08 $423.09 $409.07 $460.20 $312.69 $351.78$376.08 $423.09 $409.07 $460.20 $312.69 $351.78$377.59 $424.79 $410.71 $462.04 $313.94 $353.18$385.11 $433.25 $418.89 $471.25 $320.19 $360.22$394.14 $443.40 $428.71 $482.29 $327.70 $368.66$408.80 $459.90 $444.66 $500.24 $339.89 $382.38$420.84 $473.44 $457.75 $514.97 $349.90 $393.64$426.85 $501.55 $464.29 $545.55 $354.90 $417.01$435.88 $512.16 $474.11 $557.08 $362.41 $425.83$444.91 $522.77 $483.93 $568.62 $369.91 $434.65$450.55 $529.39 $490.07 $575.83 $374.60 $440.16$456.57 $536.46 $496.61 $583.52 $379.61 $446.04$459.57 $540.00 $499.88 $587.36 $382.11 $448.98$462.58 $543.53 $503.16 $591.21 $384.61 $451.92$465.59 $547.07 $506.43 $595.05 $387.11 $454.85$468.60 $550.61 $509.70 $598.90 $389.61 $457.79$474.62 $557.68 $516.25 $606.59 $394.61 $463.67$480.63 $588.78 $522.79 $640.42 $399.62 $489.53$489.66 $599.83 $532.61 $652.45 $407.12 $498.73$498.31 $610.43 $542.02 $663.97 $414.31 $507.54$510.35 $625.17 $555.11 $680.01 $424.32 $519.79$525.39 $643.60 $571.47 $700.05 $436.83 $535.11$543.06 $665.25 $590.70 $723.60 $451.52 $553.12$564.13 $691.05 $613.60 $751.67 $469.04 $574.57$587.82 $720.08 $639.38 $783.24 $488.73 $598.70$614.90 $753.25 $668.83 $819.32 $511.25 $626.28$641.60 $785.96 $697.87 $854.89 $533.45 $653.48$671.69 $923.57 $730.60 $1,004.57 $558.46 $767.89$701.40 $964.42 $762.92 $1,049.01 $583.17 $801.85$734.12 $1,009.41 $798.50 $1,097.94 $610.37 $839.26$767.21 $1,054.91 $834.50 $1,147.44 $637.89 $877.10$802.94 $1,104.04 $873.36 $1,200.88 $667.59 $917.94$838.67 $1,153.17 $912.23 $1,254.31 $697.30 $958.79$877.40 $1,206.43 $954.36 $1,312.24 $729.51 $1,003.07$916.52 $1,260.21 $996.90 $1,370.74 $762.03 $1,047.79$958.26 $1,317.61 $1,042.31 $1,433.18 $796.73 $1,095.51$978.95 $1,346.05 $1,064.81 $1,464.11 $813.93 $1,119.16

$1,020.69 $1,403.45 $1,110.22 $1,526.55 $848.64 $1,166.88$1,056.79 $1,453.09 $1,149.49 $1,580.54 $878.66 $1,208.16$1,080.49 $1,485.67 $1,175.26 $1,615.98 $898.36 $1,235.24$1,110.20 $1,526.52 $1,207.57 $1,660.41 $923.06 $1,269.21$1,128.24 $1,551.34 $1,227.21 $1,687.41 $938.07 $1,289.85$1,128.24 $1,551.34 $1,227.21 $1,687.41 $938.07 $1,289.85

$6,550No

31609PA0150009

16884.WR-I Rev. 1.168



30%30% after ded

$6,550No


$1,9000%

$0 after ded

31609PA0150008

16884.WR-I Rev. 1.168


31609PA0150007

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$190.08 $190.08 $210.69 $210.69 $143.02 $143.02$299.34 $336.76 $331.80 $373.27 $225.23 $253.38$299.34 $336.76 $331.80 $373.27 $225.23 $253.38$299.34 $336.76 $331.80 $373.27 $225.23 $253.38$299.34 $336.76 $331.80 $373.27 $225.23 $253.38$300.54 $338.10 $333.13 $374.77 $226.13 $254.39$306.52 $344.84 $339.76 $382.23 $230.63 $259.46$313.71 $352.92 $347.72 $391.19 $236.04 $265.54$325.38 $366.06 $360.66 $405.75 $244.82 $275.43$334.96 $376.83 $371.28 $417.69 $252.03 $283.53$339.75 $399.21 $376.59 $442.49 $255.63 $300.37$346.94 $407.65 $384.55 $451.85 $261.04 $306.72$354.12 $416.09 $392.52 $461.21 $266.44 $313.07$358.61 $421.37 $397.49 $467.06 $269.82 $317.04$363.40 $426.99 $402.80 $473.29 $273.43 $321.28$365.79 $429.81 $405.46 $476.41 $275.23 $323.39$368.19 $432.62 $408.11 $479.53 $277.03 $325.51$370.58 $435.44 $410.77 $482.65 $278.83 $327.63$372.98 $438.25 $413.42 $485.77 $280.63 $329.74$377.77 $443.88 $418.73 $492.01 $284.24 $333.98$382.56 $468.63 $424.04 $519.45 $287.84 $352.61$389.74 $477.43 $432.00 $529.20 $293.25 $359.23$396.63 $485.87 $439.63 $538.55 $298.43 $365.57$406.20 $497.60 $450.25 $551.56 $305.63 $374.40$418.18 $512.27 $463.52 $567.81 $314.64 $385.44$432.25 $529.50 $479.12 $586.92 $325.23 $398.41$449.01 $550.04 $497.70 $609.68 $337.84 $413.86$467.87 $573.14 $518.60 $635.29 $352.03 $431.24$489.42 $599.54 $542.49 $664.55 $368.25 $451.10$510.67 $625.58 $566.05 $693.41 $384.24 $470.69$534.62 $735.10 $592.59 $814.81 $402.26 $553.10$558.27 $767.62 $618.80 $850.86 $420.05 $577.57$584.31 $803.43 $647.67 $890.55 $439.64 $604.51$610.65 $839.65 $676.87 $930.69 $459.46 $631.76$639.09 $878.75 $708.39 $974.04 $480.86 $661.18$667.53 $917.85 $739.91 $1,017.38 $502.26 $690.60$698.36 $960.25 $774.09 $1,064.37 $525.46 $722.50$729.49 $1,003.05 $808.59 $1,111.81 $548.88 $754.71$762.72 $1,048.74 $845.42 $1,162.46 $573.88 $789.08$779.18 $1,071.38 $863.67 $1,187.55 $586.27 $806.12$812.41 $1,117.06 $900.50 $1,238.19 $611.27 $840.49$841.15 $1,156.58 $932.35 $1,281.99 $632.89 $870.22$860.00 $1,182.51 $953.26 $1,310.73 $647.08 $889.73$883.65 $1,215.02 $979.47 $1,346.77 $664.87 $914.20$898.02 $1,234.78 $995.39 $1,368.67 $675.68 $929.06$898.02 $1,234.78 $995.39 $1,368.67 $675.68 $929.06

$6,550No


$5,20050%

50% after ded

31609PA0150012

16884.WR-I Rev. 1.168

$6,550No

31609PA0150011

16884.WR-I Rev. 1.168



10%10% after ded

$6,550No


$2,10030%

30% after ded

31609PA0150010

16884.WR-I Rev. 1.168


RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$153.28 $153.28 $270.83 $270.83 $238.81 $238.81$241.38 $271.56 $426.51 $479.82 $376.08 $423.09$241.38 $271.56 $426.51 $479.82 $376.08 $423.09$241.38 $271.56 $426.51 $479.82 $376.08 $423.09$241.38 $271.56 $426.51 $479.82 $376.08 $423.09$242.35 $272.64 $428.22 $481.74 $377.59 $424.79$247.18 $278.07 $436.75 $491.34 $385.11 $433.25$252.97 $284.59 $446.98 $502.86 $394.14 $443.40$262.38 $295.18 $463.62 $521.57 $408.80 $459.90$270.11 $303.87 $477.27 $536.92 $420.84 $473.44$273.97 $321.92 $484.09 $568.80 $426.85 $501.55$279.76 $328.72 $494.33 $580.83 $435.88 $512.16$285.56 $335.53 $504.56 $592.86 $444.91 $522.77$289.18 $339.78 $510.96 $600.38 $450.55 $529.39$293.04 $344.32 $517.78 $608.40 $456.57 $536.46$294.97 $346.59 $521.20 $612.41 $459.57 $540.00$296.90 $348.86 $524.61 $616.41 $462.58 $543.53$298.83 $351.13 $528.02 $620.42 $465.59 $547.07$300.76 $353.40 $531.43 $624.43 $468.60 $550.61$304.63 $357.94 $538.26 $632.45 $474.62 $557.68$308.49 $377.90 $545.08 $667.72 $480.63 $588.78$314.28 $385.00 $555.32 $680.26 $489.66 $599.83$319.83 $391.80 $565.13 $692.28 $498.31 $610.43$327.56 $401.26 $578.77 $709.00 $510.35 $625.17$337.21 $413.09 $595.84 $729.90 $525.39 $643.60$348.56 $426.98 $615.88 $754.45 $543.06 $665.25$362.08 $443.54 $639.77 $783.71 $564.13 $691.05$377.28 $462.17 $666.64 $816.63 $587.82 $720.08$394.66 $483.46 $697.34 $854.25 $614.90 $753.25$411.80 $504.46 $727.63 $891.34 $641.60 $785.96$431.11 $592.78 $761.75 $1,047.40 $671.69 $923.57$450.18 $619.00 $795.44 $1,093.73 $701.40 $964.42$471.18 $647.87 $832.55 $1,144.75 $734.12 $1,009.41$492.42 $677.08 $870.08 $1,196.36 $767.21 $1,054.91$515.36 $708.61 $910.60 $1,252.07 $802.94 $1,104.04$538.29 $740.14 $951.12 $1,307.79 $838.67 $1,153.17$563.15 $774.33 $995.05 $1,368.19 $877.40 $1,206.43$588.25 $808.85 $1,039.41 $1,429.18 $916.52 $1,260.21$615.05 $845.69 $1,086.75 $1,494.28 $958.26 $1,317.61$628.32 $863.94 $1,110.21 $1,526.53 $978.95 $1,346.05$655.12 $900.79 $1,157.55 $1,591.63 $1,020.69 $1,403.45$678.29 $932.65 $1,198.49 $1,647.93 $1,056.79 $1,453.09$693.50 $953.56 $1,225.36 $1,684.88 $1,080.49 $1,485.67$712.57 $979.78 $1,259.06 $1,731.21 $1,110.20 $1,526.52$724.14 $995.71 $1,279.53 $1,759.36 $1,128.24 $1,551.34$724.14 $995.71 $1,279.53 $1,759.36 $1,128.24 $1,551.34

$6,550No

31609PA0150015

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No


$1,8500%

$0 after ded

31609PA0150014

16884.WR-I Rev. 1.168

31609PA0150013

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No


RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$315.53 $315.53 $301.69 $301.69 $248.80 $248.80$496.89 $559.01 $475.10 $534.49 $391.82 $440.79$496.89 $559.01 $475.10 $534.49 $391.82 $440.79$496.89 $559.01 $475.10 $534.49 $391.82 $440.79$496.89 $559.01 $475.10 $534.49 $391.82 $440.79$498.88 $561.24 $477.00 $536.63 $393.38 $442.56$508.82 $572.42 $486.51 $547.32 $401.22 $451.37$520.75 $585.84 $497.91 $560.15 $410.62 $461.95$540.12 $607.64 $516.44 $580.99 $425.90 $479.14$556.03 $625.53 $531.64 $598.10 $438.44 $493.25$563.98 $662.67 $539.24 $633.61 $444.71 $522.53$575.90 $676.68 $550.65 $647.01 $454.11 $533.58$587.83 $690.70 $562.05 $660.41 $463.52 $544.63$595.28 $699.45 $569.17 $668.78 $469.39 $551.54$603.23 $708.80 $576.78 $677.71 $475.66 $558.91$607.21 $713.47 $580.58 $682.18 $478.80 $562.59$611.18 $718.14 $584.38 $686.64 $481.93 $566.27$615.16 $722.81 $588.18 $691.11 $485.07 $569.95$619.13 $727.48 $591.98 $695.58 $488.20 $573.64$627.08 $736.82 $599.58 $704.51 $494.47 $581.00$635.03 $777.91 $607.18 $743.80 $500.74 $613.41$646.96 $792.52 $618.59 $757.77 $510.14 $624.93$658.39 $806.52 $629.51 $771.15 $519.16 $635.97$674.29 $826.00 $644.72 $789.78 $531.69 $651.32$694.16 $850.35 $663.72 $813.06 $547.37 $670.52$717.52 $878.96 $686.05 $840.41 $565.78 $693.08$745.34 $913.04 $712.66 $873.00 $587.72 $719.96$776.65 $951.39 $742.59 $909.67 $612.41 $750.20$812.42 $995.22 $776.80 $951.57 $640.62 $784.76$847.70 $1,038.44 $810.53 $992.90 $668.44 $818.84$887.45 $1,220.25 $848.54 $1,166.74 $699.78 $962.20$926.71 $1,274.22 $886.07 $1,218.35 $730.74 $1,004.76$969.94 $1,333.67 $927.40 $1,275.18 $764.82 $1,051.63

$1,013.67 $1,393.79 $969.21 $1,332.67 $799.30 $1,099.04$1,060.87 $1,458.70 $1,014.35 $1,394.73 $836.53 $1,150.22$1,108.08 $1,523.60 $1,059.48 $1,456.79 $873.75 $1,201.40$1,159.26 $1,593.98 $1,108.42 $1,524.07 $914.11 $1,256.89$1,210.93 $1,665.03 $1,157.83 $1,592.01 $954.85 $1,312.92$1,266.09 $1,740.87 $1,210.57 $1,664.53 $998.35 $1,372.73$1,293.42 $1,778.45 $1,236.70 $1,700.46 $1,019.90 $1,402.36$1,348.57 $1,854.29 $1,289.43 $1,772.97 $1,063.39 $1,462.16$1,396.27 $1,919.88 $1,335.04 $1,835.68 $1,101.00 $1,513.88$1,427.58 $1,962.92 $1,364.97 $1,876.84 $1,125.69 $1,547.82$1,466.83 $2,016.90 $1,402.51 $1,928.45 $1,156.64 $1,590.38$1,490.67 $2,049.69 $1,425.30 $1,959.80 $1,175.45 $1,616.24$1,490.67 $2,049.69 $1,425.30 $1,959.80 $1,175.45 $1,616.24

$6,850Yes


$00%

$35/$70

31609PA015002716884.WR-I Rev. 1.16

8

$2,500Yes

31609PA015002616884.WR-I Rev. 1.16



$00%

$20/$40$2,000

Yes


$00%

$10/$20

31609PA015002516884.WR-I Rev. 1.16

8Personal Choice Network Personal Choice Network

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$248.96 $248.96 $216.03 $216.03 $271.42 $271.42$392.06 $441.07 $340.21 $382.73 $427.43 $480.86$392.06 $441.07 $340.21 $382.73 $427.43 $480.86$392.06 $441.07 $340.21 $382.73 $427.43 $480.86$392.06 $441.07 $340.21 $382.73 $427.43 $480.86$393.63 $442.84 $341.57 $384.26 $429.14 $482.78$401.47 $451.66 $348.37 $391.92 $437.69 $492.40$410.88 $462.24 $356.54 $401.11 $447.95 $503.94$426.17 $479.45 $369.81 $416.03 $464.62 $522.70$438.72 $493.56 $380.69 $428.28 $478.30 $538.08$444.99 $522.87 $386.14 $453.71 $485.14 $570.03$454.40 $533.92 $394.30 $463.30 $495.39 $582.09$463.81 $544.98 $402.47 $472.90 $505.65 $594.14$469.69 $551.89 $407.57 $478.89 $512.06 $601.67$475.97 $559.26 $413.01 $485.29 $518.90 $609.71$479.10 $562.95 $415.73 $488.49 $522.32 $613.73$482.24 $566.63 $418.46 $491.69 $525.74 $617.75$485.38 $570.32 $421.18 $494.88 $529.16 $621.76$488.51 $574.00 $423.90 $498.08 $532.58 $625.78$494.78 $581.37 $429.34 $504.48 $539.42 $633.82$501.06 $613.80 $434.79 $532.61 $546.26 $669.17$510.47 $625.32 $442.95 $542.61 $556.52 $681.73$519.48 $636.37 $450.78 $552.20 $566.35 $693.78$532.03 $651.74 $461.66 $565.54 $580.03 $710.53$547.71 $670.95 $475.27 $582.21 $597.12 $731.48$566.14 $693.52 $491.26 $601.79 $617.21 $756.08$588.10 $720.42 $510.31 $625.13 $641.15 $785.41$612.80 $750.68 $531.74 $651.39 $668.08 $818.39$641.02 $785.26 $556.24 $681.39 $698.85 $856.09$668.86 $819.35 $580.39 $710.98 $729.20 $893.27$700.23 $962.81 $607.61 $835.47 $763.39 $1,049.67$731.20 $1,005.40 $634.49 $872.42 $797.16 $1,096.10$765.31 $1,052.30 $664.09 $913.12 $834.35 $1,147.23$799.81 $1,099.74 $694.02 $954.28 $871.96 $1,198.95$837.06 $1,150.95 $726.34 $998.72 $912.57 $1,254.78$874.30 $1,202.17 $758.66 $1,043.16 $953.17 $1,310.61$914.69 $1,257.69 $793.71 $1,091.34 $997.20 $1,371.15$955.46 $1,313.76 $829.09 $1,139.99 $1,041.65 $1,432.27$998.98 $1,373.60 $866.85 $1,191.92 $1,089.10 $1,497.51

$1,020.54 $1,403.25 $885.56 $1,217.65 $1,112.61 $1,529.83$1,064.06 $1,463.08 $923.32 $1,269.57 $1,160.05 $1,595.07$1,101.70 $1,514.84 $955.98 $1,314.48 $1,201.08 $1,651.49$1,126.40 $1,548.80 $977.42 $1,343.95 $1,228.01 $1,688.52$1,157.37 $1,591.39 $1,004.29 $1,380.90 $1,261.78 $1,734.95$1,176.18 $1,617.26 $1,020.62 $1,403.36 $1,282.29 $1,763.16$1,176.18 $1,617.26 $1,020.62 $1,403.36 $1,282.29 $1,763.16

$6,400Yes

31609PA015003016884.WR-I Rev. 1.16



$1,6000%

$0 after ded$6,550

Yes


$2,50020%


31609PA015002916884.WR-I Rev. 1.16

8

31609PA015002816884.WR-I Rev. 1.16



$1,00020%

$15 no ded/$30 no ded$5,500

Yes


RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$239.40 $239.40 $260.34 $260.34 $199.15 $199.15$377.01 $424.13 $409.99 $461.24 $313.62 $352.82$377.01 $424.13 $409.99 $461.24 $313.62 $352.82$377.01 $424.13 $409.99 $461.24 $313.62 $352.82$377.01 $424.13 $409.99 $461.24 $313.62 $352.82$378.51 $425.83 $411.63 $463.09 $314.88 $354.24$386.05 $434.31 $419.83 $472.31 $321.15 $361.29$395.10 $444.49 $429.67 $483.38 $328.68 $369.76$409.80 $461.03 $445.66 $501.37 $340.91 $383.52$421.87 $474.60 $458.78 $516.13 $350.94 $394.81$427.90 $502.78 $465.34 $546.77 $355.96 $418.25$436.95 $513.42 $475.18 $558.34 $363.49 $427.10$446.00 $524.05 $485.02 $569.90 $371.02 $435.94$451.65 $530.69 $491.17 $577.12 $375.72 $441.47$457.68 $537.78 $497.73 $584.83 $380.74 $447.37$460.70 $541.32 $501.01 $588.69 $383.25 $450.31$463.72 $544.87 $504.29 $592.54 $385.76 $453.26$466.73 $548.41 $507.57 $596.39 $388.26 $456.21$469.75 $551.95 $510.85 $600.25 $390.77 $459.16$475.78 $559.04 $517.41 $607.96 $395.79 $465.05$481.81 $590.22 $523.97 $641.86 $400.81 $490.99$490.86 $601.30 $533.81 $653.92 $408.34 $500.21$499.53 $611.93 $543.24 $665.47 $415.55 $509.05$511.60 $626.71 $556.36 $681.54 $425.59 $521.34$526.68 $645.18 $572.76 $701.63 $438.13 $536.71$544.40 $666.88 $592.03 $725.23 $452.87 $554.77$565.51 $692.75 $614.99 $753.36 $470.43 $576.28$589.26 $721.84 $640.82 $785.00 $490.19 $600.48$616.40 $755.09 $670.34 $821.16 $512.77 $628.15$643.17 $787.88 $699.45 $856.82 $535.04 $655.42$673.33 $925.83 $732.24 $1,006.84 $560.13 $770.18$703.11 $966.78 $764.63 $1,051.37 $584.91 $804.24$735.91 $1,011.88 $800.30 $1,100.42 $612.19 $841.76$769.09 $1,057.50 $836.38 $1,150.03 $639.79 $879.71$804.91 $1,106.75 $875.33 $1,203.58 $669.58 $920.68$840.72 $1,155.99 $914.28 $1,257.14 $699.38 $961.64$879.55 $1,209.39 $956.51 $1,315.20 $731.68 $1,006.06$918.76 $1,263.30 $999.15 $1,373.83 $764.30 $1,050.91$960.61 $1,320.84 $1,044.66 $1,436.41 $799.11 $1,098.78$981.34 $1,349.35 $1,067.21 $1,467.41 $816.36 $1,122.49

$1,023.19 $1,406.89 $1,112.72 $1,529.99 $851.17 $1,170.36$1,059.38 $1,456.65 $1,152.08 $1,584.10 $881.28 $1,211.76$1,083.14 $1,489.31 $1,177.91 $1,619.62 $901.04 $1,238.93$1,112.92 $1,530.26 $1,210.29 $1,664.16 $925.81 $1,272.99$1,131.02 $1,555.15 $1,229.97 $1,691.21 $940.86 $1,293.69$1,131.02 $1,555.15 $1,229.97 $1,691.21 $940.86 $1,293.69

$6,550Yes


$2,65030%

30% after ded

31609PA015003316884.WR-I Rev. 1.16


$6,550Yes

31609PA015003216884.WR-I Rev. 1.16



$1,9000%

$0 after ded$6,550

Yes


$2,4000%

$0 after ded

31609PA015003116884.WR-I Rev. 1.16


RATE PAGES

Page Number: 10 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$190.67 $190.67 $211.28 $211.28 $143.60 $143.60$300.27 $337.81 $332.72 $374.31 $226.15 $254.42$300.27 $337.81 $332.72 $374.31 $226.15 $254.42$300.27 $337.81 $332.72 $374.31 $226.15 $254.42$300.27 $337.81 $332.72 $374.31 $226.15 $254.42$301.47 $339.16 $334.05 $375.81 $227.05 $255.44$307.48 $345.91 $340.71 $383.29 $231.58 $260.52$314.69 $354.02 $348.69 $392.28 $237.00 $266.63$326.40 $367.20 $361.67 $406.87 $245.82 $276.55$336.00 $378.01 $372.31 $418.85 $253.06 $284.69$340.81 $400.45 $377.64 $443.72 $256.68 $301.60$348.02 $408.92 $385.62 $453.11 $262.11 $307.98$355.22 $417.39 $393.61 $462.49 $267.53 $314.35$359.73 $422.68 $398.60 $468.35 $270.93 $318.34$364.53 $428.32 $403.92 $474.61 $274.55 $322.59$366.93 $431.15 $406.58 $477.74 $276.35 $324.72$369.34 $433.97 $409.25 $480.86 $278.16 $326.84$371.74 $436.79 $411.91 $483.99 $279.97 $328.97$374.14 $439.61 $414.57 $487.12 $281.78 $331.09$378.94 $445.26 $419.89 $493.37 $285.40 $335.35$383.75 $470.09 $425.22 $520.89 $289.02 $354.05$390.95 $478.92 $433.20 $530.67 $294.45 $360.70$397.86 $487.38 $440.85 $540.05 $299.65 $367.07$407.47 $499.15 $451.50 $553.09 $306.88 $375.93$419.48 $513.86 $464.81 $569.39 $315.93 $387.02$433.59 $531.15 $480.45 $588.55 $326.56 $400.04$450.41 $551.75 $499.08 $611.37 $339.22 $415.55$469.33 $574.92 $520.04 $637.05 $353.47 $433.00$490.95 $601.41 $544.00 $666.40 $369.75 $452.95$512.26 $627.52 $567.62 $695.33 $385.81 $472.62$536.29 $737.39 $594.24 $817.08 $403.90 $555.37$560.01 $770.01 $620.52 $853.22 $421.77 $579.93$586.13 $805.93 $649.47 $893.02 $441.44 $606.98$612.56 $842.26 $678.75 $933.28 $461.34 $634.35$641.08 $881.49 $710.36 $976.74 $482.83 $663.89$669.61 $920.71 $741.97 $1,020.20 $504.31 $693.43$700.54 $963.24 $776.24 $1,067.32 $527.61 $725.46$731.76 $1,006.18 $810.84 $1,114.90 $551.13 $757.80$765.09 $1,052.00 $847.77 $1,165.68 $576.23 $792.31$781.61 $1,074.71 $866.07 $1,190.85 $588.67 $809.42$814.94 $1,120.54 $903.00 $1,241.63 $613.77 $843.93$843.77 $1,160.18 $934.94 $1,285.55 $635.48 $873.78$862.68 $1,186.19 $955.90 $1,314.37 $649.73 $893.37$886.40 $1,218.81 $982.19 $1,350.51 $667.59 $917.94$900.81 $1,238.62 $998.16 $1,372.47 $678.45 $932.87$900.81 $1,238.62 $998.16 $1,372.47 $678.45 $932.87

$6,550Yes

31609PA015003616884.WR-I Rev. 1.16



$5,20050%

50% after ded$6,550

Yes


$2,70010%

10% after ded

31609PA015003516884.WR-I Rev. 1.16


31609PA015003416884.WR-I Rev. 1.16



$2,10030%

30% after ded$6,550

Yes

RATE PAGES

Page Number: 11 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$153.87 $153.87 $271.42 $271.42 $239.40 $239.40$242.32 $272.61 $427.43 $480.86 $377.01 $424.13$242.32 $272.61 $427.43 $480.86 $377.01 $424.13$242.32 $272.61 $427.43 $480.86 $377.01 $424.13$242.32 $272.61 $427.43 $480.86 $377.01 $424.13$243.29 $273.70 $429.14 $482.78 $378.51 $425.83$248.13 $279.15 $437.69 $492.40 $386.05 $434.31$253.95 $285.69 $447.95 $503.94 $395.10 $444.49$263.40 $296.32 $464.62 $522.70 $409.80 $461.03$271.15 $305.05 $478.30 $538.08 $421.87 $474.60$275.03 $323.16 $485.14 $570.03 $427.90 $502.78$280.84 $329.99 $495.39 $582.09 $436.95 $513.42$286.66 $336.83 $505.65 $594.14 $446.00 $524.05$290.29 $341.10 $512.06 $601.67 $451.65 $530.69$294.17 $345.65 $518.90 $609.71 $457.68 $537.78$296.11 $347.93 $522.32 $613.73 $460.70 $541.32$298.05 $350.21 $525.74 $617.75 $463.72 $544.87$299.99 $352.49 $529.16 $621.76 $466.73 $548.41$301.93 $354.76 $532.58 $625.78 $469.75 $551.95$305.80 $359.32 $539.42 $633.82 $475.78 $559.04$309.68 $379.36 $546.26 $669.17 $481.81 $590.22$315.50 $386.48 $556.52 $681.73 $490.86 $601.30$321.07 $393.31 $566.35 $693.78 $499.53 $611.93$328.82 $402.81 $580.03 $710.53 $511.60 $626.71$338.52 $414.68 $597.12 $731.48 $526.68 $645.18$349.90 $428.63 $617.21 $756.08 $544.40 $666.88$363.47 $445.26 $641.15 $785.41 $565.51 $692.75$378.74 $463.96 $668.08 $818.39 $589.26 $721.84$396.19 $485.33 $698.85 $856.09 $616.40 $755.09$413.39 $506.40 $729.20 $893.27 $643.17 $787.88$432.78 $595.07 $763.39 $1,049.67 $673.33 $925.83$451.92 $621.39 $797.16 $1,096.10 $703.11 $966.78$473.00 $650.38 $834.35 $1,147.23 $735.91 $1,011.88$494.33 $679.70 $871.96 $1,198.95 $769.09 $1,057.50$517.35 $711.35 $912.57 $1,254.78 $804.91 $1,106.75$540.37 $743.00 $953.17 $1,310.61 $840.72 $1,155.99$565.32 $777.32 $997.20 $1,371.15 $879.55 $1,209.39$590.52 $811.97 $1,041.65 $1,432.27 $918.76 $1,263.30$617.42 $848.95 $1,089.10 $1,497.51 $960.61 $1,320.84$630.75 $867.28 $1,112.61 $1,529.83 $981.34 $1,349.35$657.65 $904.26 $1,160.05 $1,595.07 $1,023.19 $1,406.89$680.91 $936.25 $1,201.08 $1,651.49 $1,059.38 $1,456.65$696.17 $957.24 $1,228.01 $1,688.52 $1,083.14 $1,489.31$715.32 $983.56 $1,261.78 $1,734.95 $1,112.92 $1,530.26$726.95 $999.55 $1,282.29 $1,763.16 $1,131.02 $1,555.15$726.95 $999.55 $1,282.29 $1,763.16 $1,131.02 $1,555.15

$6,550


0%$0 after ded

$6,550Yes

31609PA015003816884.WR-I Rev. 1.16



$1,8500%

$0 after ded$6,550

Yes


$6,5500%

$0 after ded

31609PA015003716884.WR-I Rev. 1.16


Gold

16884.WR-I Rev. 1.16


31609PA0150039

8

Yes

RATE PAGES

Page Number: 12 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$238.01 $238.01 $194.53 $194.53 $219.54 $219.54$374.82 $421.67 $306.35 $344.65 $345.74 $388.96$374.82 $421.67 $306.35 $344.65 $345.74 $388.96$374.82 $421.67 $306.35 $344.65 $345.74 $388.96$374.82 $421.67 $306.35 $344.65 $345.74 $388.96$376.32 $423.36 $307.58 $346.02 $347.12 $390.51$383.82 $431.79 $313.70 $352.92 $354.04 $398.29$392.81 $441.91 $321.06 $361.19 $362.33 $407.63$407.43 $458.36 $333.00 $374.63 $375.82 $422.79$419.42 $471.85 $342.81 $385.66 $386.88 $435.24$425.42 $499.87 $347.71 $408.56 $392.41 $461.09$434.42 $510.44 $355.06 $417.20 $400.71 $470.84$443.41 $521.01 $362.41 $425.84 $409.01 $480.59$449.03 $527.62 $367.01 $431.24 $414.19 $486.68$455.03 $534.66 $371.91 $437.00 $419.73 $493.18$458.03 $538.19 $374.36 $439.88 $422.49 $496.43$461.03 $541.71 $376.81 $442.75 $425.26 $499.68$464.03 $545.23 $379.26 $445.63 $428.02 $502.93$467.03 $548.76 $381.71 $448.51 $430.79 $506.18$473.02 $555.80 $386.62 $454.27 $436.32 $512.68$479.02 $586.80 $391.52 $479.61 $441.85 $541.27$488.02 $597.82 $398.87 $488.62 $450.15 $551.44$496.64 $608.38 $405.92 $497.25 $458.10 $561.18$508.63 $623.07 $415.72 $509.26 $469.17 $574.73$523.62 $641.44 $427.97 $524.27 $483.00 $591.67$541.24 $663.02 $442.37 $541.91 $499.25 $611.58$562.23 $688.73 $459.53 $562.92 $518.61 $635.29$585.84 $717.66 $478.83 $586.56 $540.39 $661.98$612.83 $750.72 $500.89 $613.58 $565.28 $692.47$639.44 $783.32 $522.64 $640.23 $589.83 $722.54$669.43 $920.46 $547.14 $752.32 $617.49 $849.05$699.04 $961.18 $571.35 $785.60 $644.80 $886.60$731.65 $1,006.02 $598.00 $822.25 $674.88 $927.96$764.63 $1,051.37 $624.96 $859.32 $705.31 $969.80$800.24 $1,100.33 $654.06 $899.33 $738.15 $1,014.96$835.85 $1,149.29 $683.16 $939.35 $771.00 $1,060.12$874.46 $1,202.38 $714.72 $982.74 $806.61 $1,109.09$913.44 $1,255.98 $746.58 $1,026.55 $842.56 $1,158.53$955.04 $1,313.18 $780.58 $1,073.30 $880.94 $1,211.29$975.66 $1,341.53 $797.43 $1,096.47 $899.96 $1,237.44

$1,017.26 $1,398.73 $831.44 $1,143.23 $938.33 $1,290.21$1,053.24 $1,448.21 $860.85 $1,183.67 $971.52 $1,335.85$1,076.86 $1,480.68 $880.15 $1,210.20 $993.31 $1,365.80$1,106.47 $1,521.39 $904.35 $1,243.48 $1,020.62 $1,403.35$1,124.46 $1,546.13 $919.05 $1,263.70 $1,037.22 $1,426.17$1,124.46 $1,546.13 $919.05 $1,263.70 $1,037.22 $1,426.17

31609PA0150023

No$3,200

0%$2,000 $3,000


No

16884.WR-I Rev. 1.168


No


Gold

31609PA0150022 31609PA0150024

Silver

16884.WR-I Rev. 1.168


$3,3000%

$40 no ded/$80 no ded$6,800

0%

$7,150$30 no ded/$60 no ded

16884.WR-I Rev. 1.168



RATE PAGES

Page Number: 13 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$234.20 $234.20 $238.77 $238.77 $195.29 $195.29$368.81 $414.91 $376.01 $423.01 $307.54 $345.99$368.81 $414.91 $376.01 $423.01 $307.54 $345.99$368.81 $414.91 $376.01 $423.01 $307.54 $345.99$368.81 $414.91 $376.01 $423.01 $307.54 $345.99$370.29 $416.57 $377.52 $424.70 $308.77 $347.37$377.66 $424.87 $385.04 $433.16 $314.92 $354.29$386.52 $434.83 $394.06 $443.32 $322.30 $362.59$400.90 $451.01 $408.72 $459.81 $334.30 $376.09$412.70 $464.29 $420.76 $473.35 $344.14 $387.16$418.60 $491.86 $426.77 $501.46 $349.06 $410.15$427.45 $502.26 $435.80 $512.06 $356.44 $418.82$436.31 $512.66 $444.82 $522.66 $363.82 $427.49$441.84 $519.16 $450.46 $529.29 $368.44 $432.91$447.74 $526.09 $456.48 $536.36 $373.36 $438.69$450.69 $529.56 $459.49 $539.90 $375.82 $441.59$453.64 $533.03 $462.49 $543.43 $378.28 $444.48$456.59 $536.49 $465.50 $546.96 $380.74 $447.37$459.54 $539.96 $468.51 $550.50 $383.20 $450.26$465.44 $546.89 $474.53 $557.57 $388.12 $456.04$471.34 $577.40 $480.54 $588.66 $393.04 $481.47$480.19 $588.24 $489.57 $599.72 $400.42 $490.52$488.68 $598.63 $498.21 $610.31 $407.49 $499.18$500.48 $613.09 $510.25 $625.05 $417.34 $511.24$515.23 $631.16 $525.29 $643.48 $429.64 $526.31$532.57 $652.39 $542.96 $665.13 $444.09 $544.01$553.22 $677.69 $564.02 $690.92 $461.31 $565.11$576.45 $706.16 $587.71 $719.94 $480.69 $588.84$603.01 $738.69 $614.78 $753.10 $502.83 $615.97$629.20 $770.76 $641.47 $785.81 $524.67 $642.72$658.70 $905.71 $671.56 $923.39 $549.27 $755.25$687.84 $945.78 $701.26 $964.23 $573.57 $788.66$719.92 $989.89 $733.97 $1,009.21 $600.32 $825.44$752.38 $1,034.52 $767.06 $1,054.71 $627.39 $862.66$787.42 $1,082.70 $802.78 $1,103.83 $656.60 $902.83$822.45 $1,130.87 $838.50 $1,152.94 $685.82 $943.00$860.44 $1,183.11 $877.23 $1,206.20 $717.50 $986.56$898.80 $1,235.85 $916.34 $1,259.97 $749.48 $1,030.54$939.74 $1,292.14 $958.08 $1,317.35 $783.62 $1,077.48$960.02 $1,320.03 $978.76 $1,345.79 $800.53 $1,100.73

$1,000.96 $1,376.32 $1,020.49 $1,403.18 $834.67 $1,147.67$1,036.36 $1,425.00 $1,056.59 $1,452.81 $864.20 $1,188.27$1,059.60 $1,456.95 $1,080.28 $1,485.38 $883.57 $1,214.91$1,088.74 $1,497.01 $1,109.98 $1,526.23 $907.87 $1,248.32$1,106.43 $1,521.35 $1,128.03 $1,551.05 $922.62 $1,268.61$1,106.43 $1,521.35 $1,128.03 $1,551.05 $922.62 $1,268.61

$6,550


$3,2000%

$0 after ded


16884.WR-I Rev. 1.16

No

8

31609PA015004631609PA0150047

16884.WR-I Rev. 1.168




$3,200Yes

31609PA015004916884.WR-I Rev. 1.16



$7,150Yes

$3,0000%


RATE PAGES

Page Number: 14 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco$220.30 $220.30 $234.78 $234.78$346.93 $390.30 $369.73 $415.95$346.93 $390.30 $369.73 $415.95$346.93 $390.30 $369.73 $415.95$346.93 $390.30 $369.73 $415.95$348.32 $391.86 $371.21 $417.62$355.26 $399.66 $378.61 $425.93$363.58 $409.03 $387.48 $435.92$377.11 $424.25 $401.90 $452.14$388.21 $436.74 $413.73 $465.45$393.76 $462.67 $419.65 $493.09$402.09 $472.46 $428.52 $503.51$410.42 $482.24 $437.40 $513.94$415.62 $488.36 $442.94 $520.46$421.17 $494.88 $448.86 $527.41$423.95 $498.14 $451.82 $530.88$426.72 $501.40 $454.77 $534.36$429.50 $504.66 $457.73 $537.83$432.27 $507.92 $460.69 $541.31$437.82 $514.44 $466.61 $548.26$443.38 $543.14 $472.52 $578.84$451.70 $553.34 $481.39 $589.71$459.68 $563.11 $489.90 $600.13$470.78 $576.71 $501.73 $614.62$484.66 $593.71 $516.52 $632.74$500.97 $613.68 $533.90 $654.02$520.39 $637.48 $554.60 $679.39$542.25 $664.26 $577.90 $707.92$567.23 $694.86 $604.52 $740.53$591.86 $725.03 $630.77 $772.69$619.62 $851.97 $660.35 $907.98$647.02 $889.66 $689.56 $948.14$677.21 $931.16 $721.72 $992.37$707.74 $973.14 $754.26 $1,037.11$740.69 $1,018.45 $789.38 $1,085.40$773.65 $1,063.77 $824.51 $1,133.70$809.39 $1,112.91 $862.59 $1,186.06$845.47 $1,162.52 $901.04 $1,238.94$883.98 $1,215.47 $942.08 $1,295.37$903.06 $1,241.70 $962.42 $1,323.33$941.57 $1,294.65 $1,003.46 $1,379.76$974.87 $1,340.45 $1,038.96 $1,428.56$996.73 $1,370.50 $1,062.25 $1,460.59

$1,024.14 $1,408.19 $1,091.46 $1,500.75$1,040.79 $1,431.08 $1,109.19 $1,525.16$1,040.79 $1,431.08 $1,109.19 $1,525.16




$6,800 $6,550Yes Yes

$3,300 $3,2000% 0%




2017 On-Exchange



e Silver Plan Rates



2017 Off-Exchange



e Silver Plan Rates

12/24/2014




Plan Design Summary


RATE PAGES


Company Name: QCC Insurance CompanyProduct: PPOEffective Date of Rates: July 1, 2017 - September 30, 2017



Network =>Metal =>




Age Band Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco0-20 $323.92 $323.92 $309.68 $309.68 $255.25 $255.2521 $510.11 $573.87 $487.68 $548.64 $401.98 $452.2222 $510.11 $573.87 $487.68 $548.64 $401.98 $452.2223 $510.11 $573.87 $487.68 $548.64 $401.98 $452.2224 $510.11 $573.87 $487.68 $548.64 $401.98 $452.2225 $512.15 $576.17 $489.64 $550.84 $403.58 $454.0326 $522.35 $587.64 $499.39 $561.81 $411.62 $463.0827 $534.59 $601.42 $511.09 $574.98 $421.27 $473.9328 $554.49 $623.80 $530.11 $596.38 $436.95 $491.5729 $570.81 $642.16 $545.72 $613.93 $449.81 $506.0430 $578.97 $680.29 $553.52 $650.39 $456.24 $536.0831 $591.22 $694.68 $565.23 $664.14 $465.89 $547.4232 $603.46 $709.06 $576.93 $677.89 $475.54 $558.7633 $611.11 $718.05 $584.25 $686.49 $481.57 $565.8434 $619.27 $727.64 $592.05 $695.66 $488.00 $573.4035 $623.35 $732.44 $595.95 $700.24 $491.21 $577.1836 $627.43 $737.23 $599.85 $704.83 $494.43 $580.9537 $631.51 $742.03 $603.75 $709.41 $497.65 $584.7338 $635.59 $746.82 $607.65 $713.99 $500.86 $588.5139 $643.76 $756.41 $615.46 $723.16 $507.29 $596.0740 $651.92 $798.60 $623.26 $763.49 $513.72 $629.3141 $664.16 $813.60 $634.96 $777.83 $523.37 $641.1342 $675.89 $827.97 $646.18 $791.57 $532.62 $652.4643 $692.22 $847.97 $661.79 $810.69 $545.48 $668.2144 $712.62 $872.96 $681.29 $834.59 $561.56 $687.9145 $736.60 $902.33 $704.22 $862.66 $580.45 $711.0546 $765.16 $937.32 $731.53 $896.12 $602.96 $738.6347 $797.30 $976.69 $762.25 $933.76 $628.29 $769.6548 $834.03 $1,021.68 $797.36 $976.77 $657.23 $805.1149 $870.24 $1,066.05 $831.99 $1,019.19 $685.77 $840.0750 $911.05 $1,252.70 $871.00 $1,197.63 $717.93 $987.1551 $951.35 $1,308.11 $909.53 $1,250.61 $749.68 $1,030.8252 $995.73 $1,369.13 $951.96 $1,308.94 $784.66 $1,078.9053 $1,040.62 $1,430.85 $994.88 $1,367.95 $820.03 $1,127.5454 $1,089.08 $1,497.49 $1,041.21 $1,431.66 $858.22 $1,180.0555 $1,137.54 $1,564.12 $1,087.54 $1,495.36 $896.40 $1,232.5656 $1,190.08 $1,636.36 $1,137.77 $1,564.43 $937.81 $1,289.4957 $1,243.13 $1,709.31 $1,188.49 $1,634.17 $979.61 $1,346.9758 $1,299.76 $1,787.16 $1,242.62 $1,708.60 $1,024.23 $1,408.3259 $1,327.81 $1,825.74 $1,269.44 $1,745.48 $1,046.34 $1,438.7260 $1,384.43 $1,903.60 $1,323.58 $1,819.92 $1,090.96 $1,500.0761 $1,433.40 $1,970.93 $1,370.39 $1,884.29 $1,129.55 $1,553.1362 $1,465.54 $2,015.12 $1,401.12 $1,926.54 $1,154.88 $1,587.9563 $1,505.84 $2,070.53 $1,439.64 $1,979.51 $1,186.63 $1,631.6264 $1,530.32 $2,104.20 $1,463.04 $2,011.70 $1,205.93 $1,658.15

65+ $1,530.32 $2,104.20 $1,463.04 $2,011.70 $1,205.93 $1,658.15

31609PA0150001 31609PA0150002

8 8

No No

16884.WR-I Rev. 1.16 16884.WR-I Rev. 1.16


$00%

$2,500$10/$20 $20/$40

$2,000$35/$70$6,850



Personal Choice Network Personal Choice Network Personal Choice Network GoldPlatinum

No

31609PA0150003

16884.WR-I Rev. 1.168

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$255.42 $255.42 $221.53 $221.53 $278.70 $278.70$402.23 $452.51 $348.87 $392.48 $438.90 $493.77$402.23 $452.51 $348.87 $392.48 $438.90 $493.77$402.23 $452.51 $348.87 $392.48 $438.90 $493.77$402.23 $452.51 $348.87 $392.48 $438.90 $493.77$403.84 $454.32 $350.26 $394.05 $440.66 $495.74$411.88 $463.37 $357.24 $401.90 $449.44 $505.62$421.54 $474.23 $365.61 $411.32 $459.97 $517.47$437.23 $491.88 $379.22 $426.62 $477.09 $536.72$450.10 $506.36 $390.38 $439.18 $491.13 $552.53$456.53 $536.43 $395.97 $465.26 $498.16 $585.33$466.19 $547.77 $404.34 $475.10 $508.69 $597.71$475.84 $559.11 $412.71 $484.94 $519.22 $610.09$481.87 $566.20 $417.94 $491.08 $525.81 $617.82$488.31 $573.76 $423.53 $497.64 $532.83 $626.07$491.53 $577.54 $426.32 $500.92 $536.34 $630.20$494.74 $581.32 $429.11 $504.20 $539.85 $634.33$497.96 $585.11 $431.90 $507.48 $543.36 $638.45$501.18 $588.89 $434.69 $510.76 $546.87 $642.58$507.62 $596.45 $440.27 $517.32 $553.90 $650.83$514.05 $629.71 $445.85 $546.17 $560.92 $687.13$523.70 $641.54 $454.23 $556.43 $571.45 $700.03$532.96 $652.87 $462.25 $566.26 $581.55 $712.40$545.83 $668.64 $473.41 $579.93 $595.59 $729.60$561.92 $688.35 $487.37 $597.03 $613.15 $751.11$580.82 $711.51 $503.77 $617.11 $633.78 $776.38$603.35 $739.10 $523.30 $641.05 $658.36 $806.49$628.69 $770.14 $545.28 $667.97 $686.01 $840.36$657.65 $805.62 $570.40 $698.74 $717.61 $879.07$686.21 $840.60 $595.17 $729.08 $748.77 $917.24$718.38 $987.78 $623.08 $856.73 $783.88 $1,077.84$750.16 $1,031.47 $650.64 $894.63 $818.56 $1,125.51$785.16 $1,079.59 $680.99 $936.36 $856.74 $1,178.02$820.55 $1,128.26 $711.69 $978.58 $895.36 $1,231.13$858.76 $1,180.80 $744.83 $1,024.15 $937.06 $1,288.46$896.98 $1,233.34 $777.98 $1,069.72 $978.76 $1,345.79$938.41 $1,290.31 $813.91 $1,119.13 $1,023.96 $1,407.95$980.24 $1,347.83 $850.19 $1,169.01 $1,069.61 $1,470.71

$1,024.88 $1,409.22 $888.92 $1,222.26 $1,118.33 $1,537.70$1,047.01 $1,439.64 $908.10 $1,248.64 $1,142.47 $1,570.89$1,091.66 $1,501.03 $946.83 $1,301.89 $1,191.19 $1,637.88$1,130.27 $1,554.12 $980.32 $1,347.94 $1,233.32 $1,695.82$1,155.61 $1,588.96 $1,002.30 $1,378.16 $1,260.97 $1,733.84$1,187.39 $1,632.66 $1,029.86 $1,416.06 $1,295.65 $1,781.51$1,206.69 $1,659.20 $1,046.60 $1,439.08 $1,316.70 $1,810.48$1,206.69 $1,659.20 $1,046.60 $1,439.08 $1,316.70 $1,810.48



$5,500

16884.WR-I Rev. 1.168


8

31609PA0150004


31609PA0150005

16884.WR-I Rev. 1.168




$6,400NoNo

$6,550No


$1,6000%

$0 after ded

31609PA0150006

16884.WR-I Rev. 1.16

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$245.75 $245.75 $267.31 $267.31 $204.33 $204.33$387.01 $435.39 $420.96 $473.58 $321.78 $362.00$387.01 $435.39 $420.96 $473.58 $321.78 $362.00$387.01 $435.39 $420.96 $473.58 $321.78 $362.00$387.01 $435.39 $420.96 $473.58 $321.78 $362.00$388.56 $437.13 $422.64 $475.47 $323.06 $363.45$396.30 $445.84 $431.06 $484.94 $329.50 $370.69$405.59 $456.29 $441.16 $496.31 $337.22 $379.37$420.68 $473.27 $457.58 $514.78 $349.77 $393.49$433.07 $487.20 $471.05 $529.93 $360.07 $405.08$439.26 $516.13 $477.79 $561.40 $365.22 $429.13$448.55 $527.04 $487.89 $573.27 $372.94 $438.20$457.84 $537.96 $497.99 $585.14 $380.66 $447.28$463.64 $544.78 $504.31 $592.56 $385.49 $452.95$469.83 $552.05 $511.04 $600.47 $390.64 $459.00$472.93 $555.69 $514.41 $604.43 $393.21 $462.02$476.02 $559.33 $517.78 $608.39 $395.78 $465.05$479.12 $562.97 $521.14 $612.34 $398.36 $468.07$482.22 $566.60 $524.51 $616.30 $400.93 $471.10$488.41 $573.88 $531.25 $624.22 $406.08 $477.15$494.60 $605.89 $537.98 $659.03 $411.23 $503.76$503.89 $617.26 $548.09 $671.40 $418.95 $513.22$512.79 $628.17 $557.77 $683.27 $426.35 $522.28$525.18 $643.34 $571.24 $699.77 $436.65 $534.90$540.66 $662.30 $588.08 $720.39 $449.52 $550.66$558.85 $684.59 $607.86 $744.63 $464.65 $569.19$580.52 $711.13 $631.43 $773.51 $482.66 $591.26$604.90 $741.00 $657.96 $806.00 $502.94 $616.10$632.76 $775.14 $688.26 $843.12 $526.10 $644.48$660.24 $808.80 $718.15 $879.74 $548.95 $672.46$691.20 $950.40 $751.83 $1,033.76 $574.69 $790.20$721.78 $992.44 $785.08 $1,079.49 $600.11 $825.16$755.45 $1,038.74 $821.71 $1,129.85 $628.11 $863.65$789.50 $1,085.57 $858.75 $1,180.78 $656.42 $902.58$826.27 $1,136.12 $898.74 $1,235.77 $686.99 $944.61$863.04 $1,186.68 $938.73 $1,290.76 $717.56 $986.65$902.90 $1,241.49 $982.09 $1,350.38 $750.70 $1,032.22$943.15 $1,296.83 $1,025.87 $1,410.57 $784.17 $1,078.23$986.11 $1,355.90 $1,072.60 $1,474.82 $819.89 $1,127.34

$1,007.39 $1,385.16 $1,095.75 $1,506.66 $837.58 $1,151.68$1,050.35 $1,444.23 $1,142.48 $1,570.90 $873.30 $1,200.79$1,087.50 $1,495.32 $1,182.89 $1,626.47 $904.19 $1,243.26$1,111.89 $1,528.84 $1,209.41 $1,662.94 $924.46 $1,271.14$1,142.46 $1,570.88 $1,242.66 $1,708.66 $949.88 $1,306.09$1,161.03 $1,596.42 $1,262.87 $1,736.45 $965.33 $1,327.33$1,161.03 $1,596.42 $1,262.87 $1,736.45 $965.33 $1,327.33


31609PA0150007

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No

$6,550No

31609PA0150009

16884.WR-I Rev. 1.168



30%30% after ded

$6,550No


$1,9000%

$0 after ded

31609PA0150008

16884.WR-I Rev. 1.168

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$195.60 $195.60 $216.81 $216.81 $147.18 $147.18$308.04 $346.54 $341.44 $384.12 $231.77 $260.74$308.04 $346.54 $341.44 $384.12 $231.77 $260.74$308.04 $346.54 $341.44 $384.12 $231.77 $260.74$308.04 $346.54 $341.44 $384.12 $231.77 $260.74$309.27 $347.93 $342.81 $385.66 $232.70 $261.79$315.43 $354.86 $349.63 $393.34 $237.33 $267.00$322.82 $363.18 $357.83 $402.56 $242.90 $273.26$334.84 $376.69 $371.15 $417.54 $251.94 $283.43$344.70 $387.78 $382.07 $429.83 $259.35 $291.77$349.62 $410.81 $387.53 $455.35 $263.06 $309.10$357.02 $419.49 $395.73 $464.98 $268.62 $315.63$364.41 $428.18 $403.92 $474.61 $274.19 $322.17$369.03 $433.61 $409.04 $480.63 $277.66 $326.25$373.96 $439.40 $414.51 $487.05 $281.37 $330.61$376.42 $442.30 $417.24 $490.26 $283.23 $332.79$378.89 $445.19 $419.97 $493.47 $285.08 $334.97$381.35 $448.09 $422.70 $496.68 $286.93 $337.15$383.82 $450.98 $425.43 $499.88 $288.79 $339.33$388.74 $456.78 $430.90 $506.30 $292.50 $343.68$393.67 $482.25 $436.36 $534.54 $296.21 $362.85$401.07 $491.31 $444.55 $544.58 $301.77 $369.67$408.15 $499.99 $452.41 $554.20 $307.10 $376.20$418.01 $512.06 $463.33 $567.58 $314.52 $385.28$430.33 $527.15 $476.99 $584.31 $323.79 $396.64$444.81 $544.89 $493.04 $603.97 $334.68 $409.98$462.06 $566.02 $512.16 $627.40 $347.66 $425.88$481.46 $589.79 $533.67 $653.75 $362.26 $443.77$503.64 $616.96 $558.25 $683.86 $378.95 $464.21$525.51 $643.75 $582.50 $713.56 $395.40 $484.37$550.16 $756.47 $609.81 $838.49 $413.95 $569.17$574.49 $789.93 $636.79 $875.58 $432.26 $594.35$601.29 $826.78 $666.49 $916.42 $452.42 $622.08$628.40 $864.05 $696.54 $957.74 $472.82 $650.12$657.66 $904.29 $728.97 $1,002.34 $494.83 $680.40$686.93 $944.52 $761.41 $1,046.94 $516.85 $710.67$718.65 $988.15 $796.58 $1,095.30 $540.72 $743.50$750.69 $1,032.20 $832.09 $1,144.12 $564.83 $776.64$784.88 $1,079.21 $869.99 $1,196.23 $590.56 $812.01$801.82 $1,102.51 $888.77 $1,222.06 $603.30 $829.54$836.02 $1,149.52 $926.67 $1,274.17 $629.03 $864.92$865.59 $1,190.18 $959.45 $1,319.24 $651.28 $895.51$884.99 $1,216.87 $980.96 $1,348.82 $665.88 $915.59$909.33 $1,250.33 $1,007.93 $1,385.90 $684.19 $940.76$924.12 $1,270.66 $1,024.32 $1,408.44 $695.31 $956.06$924.12 $1,270.66 $1,024.32 $1,408.44 $695.31 $956.06


$6,550No

31609PA0150011

16884.WR-I Rev. 1.168



10%10% after ded

$6,550No


$2,10030%

30% after ded

31609PA0150010

16884.WR-I Rev. 1.168

$6,550No


$5,20050%

50% after ded

31609PA0150012

16884.WR-I Rev. 1.168

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$157.73 $157.73 $278.70 $278.70 $245.75 $245.75$248.40 $279.45 $438.90 $493.77 $387.01 $435.39$248.40 $279.45 $438.90 $493.77 $387.01 $435.39$248.40 $279.45 $438.90 $493.77 $387.01 $435.39$248.40 $279.45 $438.90 $493.77 $387.01 $435.39$249.39 $280.57 $440.66 $495.74 $388.56 $437.13$254.36 $286.15 $449.44 $505.62 $396.30 $445.84$260.32 $292.86 $459.97 $517.47 $405.59 $456.29$270.01 $303.76 $477.09 $536.72 $420.68 $473.27$277.96 $312.70 $491.13 $552.53 $433.07 $487.20$281.93 $331.27 $498.16 $585.33 $439.26 $516.13$287.89 $338.28 $508.69 $597.71 $448.55 $527.04$293.86 $345.28 $519.22 $610.09 $457.84 $537.96$297.58 $349.66 $525.81 $617.82 $463.64 $544.78$301.56 $354.33 $532.83 $626.07 $469.83 $552.05$303.54 $356.66 $536.34 $630.20 $472.93 $555.69$305.53 $359.00 $539.85 $634.33 $476.02 $559.33$307.52 $361.33 $543.36 $638.45 $479.12 $562.97$309.50 $363.67 $546.87 $642.58 $482.22 $566.60$313.48 $368.34 $553.90 $650.83 $488.41 $573.88$317.45 $388.88 $560.92 $687.13 $494.60 $605.89$323.41 $396.18 $571.45 $700.03 $503.89 $617.26$329.13 $403.18 $581.55 $712.40 $512.79 $628.17$337.08 $412.92 $595.59 $729.60 $525.18 $643.34$347.01 $425.09 $613.15 $751.11 $540.66 $662.30$358.69 $439.39 $633.78 $776.38 $558.85 $684.59$372.60 $456.43 $658.36 $806.49 $580.52 $711.13$388.25 $475.60 $686.01 $840.36 $604.90 $741.00$406.13 $497.51 $717.61 $879.07 $632.76 $775.14$423.77 $519.12 $748.77 $917.24 $660.24 $808.80$443.64 $610.00 $783.88 $1,077.84 $691.20 $950.40$463.26 $636.99 $818.56 $1,125.51 $721.78 $992.44$484.87 $666.70 $856.74 $1,178.02 $755.45 $1,038.74$506.73 $696.76 $895.36 $1,231.13 $789.50 $1,085.57$530.33 $729.20 $937.06 $1,288.46 $826.27 $1,136.12$553.93 $761.65 $978.76 $1,345.79 $863.04 $1,186.68$579.51 $796.83 $1,023.96 $1,407.95 $902.90 $1,241.49$605.35 $832.35 $1,069.61 $1,470.71 $943.15 $1,296.83$632.92 $870.26 $1,118.33 $1,537.70 $986.11 $1,355.90$646.58 $889.05 $1,142.47 $1,570.89 $1,007.39 $1,385.16$674.15 $926.96 $1,191.19 $1,637.88 $1,050.35 $1,444.23$698.00 $959.75 $1,233.32 $1,695.82 $1,087.50 $1,495.32$713.65 $981.27 $1,260.97 $1,733.84 $1,111.89 $1,528.84$733.27 $1,008.25 $1,295.65 $1,781.51 $1,142.46 $1,570.88$745.19 $1,024.64 $1,316.70 $1,810.48 $1,161.03 $1,596.42$745.19 $1,024.64 $1,316.70 $1,810.48 $1,161.03 $1,596.42


31609PA0150013

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No

$6,550No

31609PA0150015

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No


$1,8500%

$0 after ded

31609PA0150014

16884.WR-I Rev. 1.168

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$324.70 $324.70 $310.46 $310.46 $256.03 $256.03$511.33 $575.25 $488.91 $550.02 $403.20 $453.60$511.33 $575.25 $488.91 $550.02 $403.20 $453.60$511.33 $575.25 $488.91 $550.02 $403.20 $453.60$511.33 $575.25 $488.91 $550.02 $403.20 $453.60$513.38 $577.55 $490.87 $552.22 $404.81 $455.42$523.61 $589.06 $500.64 $563.22 $412.88 $464.49$535.88 $602.86 $512.38 $576.42 $422.55 $475.37$555.82 $625.30 $531.45 $597.88 $438.28 $493.06$572.18 $643.71 $547.09 $615.48 $451.18 $507.58$580.36 $681.93 $554.91 $652.02 $457.63 $537.72$592.64 $696.35 $566.65 $665.81 $467.31 $549.09$604.91 $710.77 $578.38 $679.60 $476.99 $560.46$612.58 $719.78 $585.71 $688.21 $483.03 $567.57$620.76 $729.39 $593.54 $697.41 $489.49 $575.15$624.85 $734.20 $597.45 $702.00 $492.71 $578.94$628.94 $739.00 $601.36 $706.60 $495.94 $582.73$633.03 $743.81 $605.27 $711.19 $499.16 $586.52$637.12 $748.62 $609.18 $715.79 $502.39 $590.31$645.30 $758.23 $617.00 $724.98 $508.84 $597.89$653.48 $800.52 $624.83 $765.41 $515.29 $631.23$665.76 $815.55 $636.56 $779.79 $524.97 $643.09$677.52 $829.96 $647.81 $793.56 $534.24 $654.45$693.88 $850.00 $663.45 $812.73 $547.14 $670.25$714.33 $875.06 $683.01 $836.68 $563.27 $690.01$738.37 $904.50 $705.99 $864.83 $582.22 $713.22$767.00 $939.58 $733.36 $898.37 $604.80 $740.88$799.21 $979.04 $764.17 $936.10 $630.20 $772.00$836.03 $1,024.14 $799.37 $979.23 $659.23 $807.56$872.34 $1,068.61 $834.08 $1,021.75 $687.86 $842.63$913.24 $1,255.71 $873.19 $1,200.64 $720.12 $990.16$953.64 $1,311.25 $911.82 $1,253.75 $751.97 $1,033.96$998.12 $1,372.42 $954.35 $1,312.23 $787.05 $1,082.19

$1,043.12 $1,434.29 $997.38 $1,371.39 $822.53 $1,130.98$1,091.70 $1,501.08 $1,043.82 $1,435.26 $860.83 $1,183.65$1,140.27 $1,567.88 $1,090.27 $1,499.12 $899.14 $1,236.31$1,192.94 $1,640.29 $1,140.63 $1,568.36 $940.67 $1,293.42$1,246.12 $1,713.42 $1,191.47 $1,638.28 $982.60 $1,351.08$1,302.88 $1,791.46 $1,245.74 $1,712.90 $1,027.36 $1,412.61$1,331.00 $1,830.13 $1,272.63 $1,749.87 $1,049.53 $1,443.11$1,387.76 $1,908.17 $1,326.90 $1,824.49 $1,094.29 $1,504.65$1,436.85 $1,975.67 $1,373.84 $1,889.03 $1,132.99 $1,557.87$1,469.06 $2,019.96 $1,404.64 $1,931.38 $1,158.40 $1,592.79$1,509.46 $2,075.50 $1,443.26 $1,984.49 $1,190.25 $1,636.59$1,533.99 $2,109.25 $1,466.73 $2,016.75 $1,209.60 $1,663.20$1,533.99 $2,109.25 $1,466.73 $2,016.75 $1,209.60 $1,663.20


$2,500Yes

31609PA015002616884.WR-I Rev. 1.16



$00%

$20/$40$2,000

Yes


$00%

$10/$20

31609PA015002516884.WR-I Rev. 1.16

8

$6,850Yes


$00%

$35/$70

31609PA015002716884.WR-I Rev. 1.16

8

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$256.20 $256.20 $222.31 $222.31 $279.31 $279.31$403.46 $453.89 $350.09 $393.86 $439.85 $494.83$403.46 $453.89 $350.09 $393.86 $439.85 $494.83$403.46 $453.89 $350.09 $393.86 $439.85 $494.83$403.46 $453.89 $350.09 $393.86 $439.85 $494.83$405.07 $455.70 $351.49 $395.43 $441.61 $496.81$413.14 $464.78 $358.50 $403.31 $450.41 $506.71$422.82 $475.68 $366.90 $412.76 $460.97 $518.59$438.56 $493.38 $380.55 $428.12 $478.12 $537.88$451.47 $507.90 $391.75 $440.72 $492.20 $553.72$457.92 $538.06 $397.36 $466.89 $499.23 $586.60$467.61 $549.44 $405.76 $476.77 $509.79 $599.00$477.29 $560.81 $414.16 $486.64 $520.35 $611.41$483.34 $567.93 $419.41 $492.81 $526.94 $619.16$489.80 $575.51 $425.01 $499.39 $533.98 $627.43$493.02 $579.30 $427.81 $502.68 $537.50 $631.56$496.25 $583.10 $430.62 $505.97 $541.02 $635.70$499.48 $586.89 $433.42 $509.26 $544.54 $639.83$502.71 $590.68 $436.22 $512.55 $548.06 $643.97$509.16 $598.27 $441.82 $519.14 $555.09 $652.24$515.62 $631.63 $447.42 $548.09 $562.13 $688.61$525.30 $643.49 $455.82 $558.38 $572.69 $701.54$534.58 $654.86 $463.87 $568.25 $582.80 $713.94$547.49 $670.68 $475.08 $581.97 $596.88 $731.18$563.63 $690.45 $489.08 $599.12 $614.47 $752.73$582.59 $713.67 $505.54 $619.28 $635.15 $778.06$605.19 $741.35 $525.14 $643.30 $659.78 $808.23$630.60 $772.49 $547.20 $670.32 $687.49 $842.17$659.65 $808.07 $572.40 $701.19 $719.16 $880.97$688.30 $843.16 $597.26 $731.64 $750.39 $919.23$720.57 $990.79 $625.27 $859.74 $785.58 $1,080.17$752.45 $1,034.61 $652.92 $897.77 $820.33 $1,127.95$787.55 $1,082.88 $683.38 $939.65 $858.59 $1,180.56$823.05 $1,131.70 $714.19 $982.01 $897.30 $1,233.79$861.38 $1,184.40 $747.45 $1,027.74 $939.09 $1,291.24$899.71 $1,237.10 $780.71 $1,073.48 $980.87 $1,348.70$941.26 $1,294.24 $816.77 $1,123.06 $1,026.18 $1,410.99$983.22 $1,351.93 $853.18 $1,173.12 $1,071.92 $1,473.89

$1,028.01 $1,413.51 $892.04 $1,226.55 $1,120.74 $1,541.02$1,050.20 $1,444.02 $911.29 $1,253.03 $1,144.94 $1,574.29$1,094.98 $1,505.60 $950.15 $1,306.46 $1,193.76 $1,641.42$1,133.71 $1,558.86 $983.76 $1,352.67 $1,235.99 $1,699.48$1,159.13 $1,593.81 $1,005.82 $1,383.00 $1,263.70 $1,737.58$1,191.00 $1,637.63 $1,033.48 $1,421.03 $1,298.45 $1,785.36$1,210.37 $1,664.26 $1,050.27 $1,444.14 $1,319.55 $1,814.39$1,210.37 $1,664.26 $1,050.27 $1,444.14 $1,319.55 $1,814.39


31609PA015002816884.WR-I Rev. 1.16



$1,00020%

$15 no ded/$30 no ded$5,500

Yes$6,400

Yes

31609PA015003016884.WR-I Rev. 1.16



$1,6000%

$0 after ded$6,550

Yes


$2,50020%


31609PA015002916884.WR-I Rev. 1.16

8

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$246.35 $246.35 $267.91 $267.91 $204.94 $204.94$387.96 $436.46 $421.91 $474.64 $322.74 $363.08$387.96 $436.46 $421.91 $474.64 $322.74 $363.08$387.96 $436.46 $421.91 $474.64 $322.74 $363.08$387.96 $436.46 $421.91 $474.64 $322.74 $363.08$389.51 $438.20 $423.59 $476.54 $324.03 $364.53$397.27 $446.93 $432.03 $486.03 $330.48 $371.79$406.58 $457.41 $442.16 $497.43 $338.23 $380.51$421.71 $474.43 $458.61 $515.94 $350.81 $394.67$434.13 $488.39 $472.11 $531.13 $361.14 $406.28$440.34 $517.39 $478.86 $562.66 $366.30 $430.41$449.65 $528.33 $488.99 $574.56 $374.05 $439.51$458.96 $539.27 $499.11 $586.46 $381.80 $448.61$464.78 $546.11 $505.44 $593.89 $386.64 $454.30$470.98 $553.41 $512.19 $601.83 $391.80 $460.37$474.09 $557.05 $515.57 $605.79 $394.38 $463.40$477.19 $560.70 $518.94 $609.76 $396.96 $466.43$480.30 $564.35 $522.32 $613.72 $399.55 $469.47$483.40 $567.99 $525.69 $617.69 $402.13 $472.50$489.61 $575.29 $532.44 $625.62 $407.29 $478.57$495.81 $607.37 $539.19 $660.51 $412.46 $505.26$505.12 $618.78 $549.32 $672.92 $420.20 $514.75$514.05 $629.71 $559.02 $684.80 $427.62 $523.84$526.46 $644.92 $572.53 $701.34 $437.95 $536.49$541.98 $663.93 $589.40 $722.02 $450.86 $552.31$560.21 $686.26 $609.23 $746.31 $466.03 $570.89$581.94 $712.88 $632.86 $775.25 $484.10 $593.03$606.38 $742.82 $659.44 $807.81 $504.44 $617.93$634.32 $777.04 $689.81 $845.02 $527.67 $646.40$661.86 $810.78 $719.77 $881.72 $550.59 $674.47$692.90 $952.73 $753.52 $1,036.09 $576.41 $792.56$723.55 $994.88 $786.85 $1,081.92 $601.90 $827.61$757.30 $1,041.29 $823.56 $1,132.39 $629.98 $866.22$791.44 $1,088.23 $860.69 $1,183.44 $658.38 $905.27$828.30 $1,138.91 $900.77 $1,238.56 $689.04 $947.43$865.15 $1,189.58 $940.85 $1,293.67 $719.70 $989.59$905.11 $1,244.53 $984.30 $1,353.42 $752.94 $1,035.30$945.46 $1,300.01 $1,028.18 $1,413.75 $786.51 $1,081.45$988.52 $1,359.22 $1,075.01 $1,478.14 $822.33 $1,130.70

$1,009.86 $1,388.56 $1,098.22 $1,510.05 $840.08 $1,155.11$1,052.92 $1,447.77 $1,145.05 $1,574.44 $875.90 $1,204.37$1,090.17 $1,498.98 $1,185.55 $1,630.14 $906.89 $1,246.97$1,114.61 $1,532.59 $1,212.13 $1,666.68 $927.22 $1,274.93$1,145.26 $1,574.73 $1,245.46 $1,712.51 $952.72 $1,309.98$1,163.88 $1,600.34 $1,265.72 $1,740.36 $968.21 $1,331.28$1,163.88 $1,600.34 $1,265.72 $1,740.36 $968.21 $1,331.28

$6,550Yes

31609PA015003216884.WR-I Rev. 1.16



$1,9000%

$0 after ded$6,550

Yes


$2,4000%

$0 after ded

31609PA015003116884.WR-I Rev. 1.16


$6,550Yes


$2,65030%

30% after ded

31609PA015003316884.WR-I Rev. 1.16


RATE PAGES

Page Number: 10 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$196.21 $196.21 $217.42 $217.42 $147.78 $147.78$309.00 $347.62 $342.39 $385.19 $232.72 $261.81$309.00 $347.62 $342.39 $385.19 $232.72 $261.81$309.00 $347.62 $342.39 $385.19 $232.72 $261.81$309.00 $347.62 $342.39 $385.19 $232.72 $261.81$310.23 $349.01 $343.76 $386.73 $233.65 $262.86$316.41 $355.97 $350.61 $394.43 $238.31 $268.09$323.83 $364.31 $358.82 $403.68 $243.89 $274.38$335.88 $377.87 $372.18 $418.70 $252.97 $284.59$345.77 $388.99 $383.13 $431.02 $260.41 $292.97$350.71 $412.09 $388.61 $456.62 $264.14 $310.36$358.13 $420.80 $396.83 $466.27 $269.72 $316.93$365.54 $429.51 $405.05 $475.93 $275.31 $323.49$370.18 $434.96 $410.18 $481.96 $278.80 $327.59$375.12 $440.77 $415.66 $488.40 $282.52 $331.96$377.60 $443.67 $418.40 $491.62 $284.38 $334.15$380.07 $446.58 $421.14 $494.84 $286.25 $336.34$382.54 $449.48 $423.88 $498.06 $288.11 $338.53$385.01 $452.39 $426.62 $501.27 $289.97 $340.71$389.96 $458.20 $432.09 $507.71 $293.69 $345.09$394.90 $483.75 $437.57 $536.03 $297.42 $364.34$402.32 $492.84 $445.79 $546.09 $303.00 $371.18$409.42 $501.54 $453.66 $555.74 $308.36 $377.74$419.31 $513.65 $464.62 $569.16 $315.80 $386.86$431.67 $528.80 $478.32 $585.94 $325.11 $398.26$446.19 $546.59 $494.41 $605.65 $336.05 $411.66$463.50 $567.78 $513.58 $629.14 $349.08 $427.62$482.96 $591.63 $535.15 $655.56 $363.74 $445.58$505.21 $618.88 $559.80 $685.76 $380.50 $466.11$527.15 $645.76 $584.11 $715.54 $397.02 $486.35$551.87 $758.82 $611.51 $840.82 $415.64 $571.50$576.28 $792.39 $638.55 $878.01 $434.02 $596.78$603.16 $829.35 $668.34 $918.97 $454.27 $624.62$630.36 $866.74 $698.47 $960.40 $474.75 $652.78$659.71 $907.10 $731.00 $1,005.12 $496.86 $683.18$689.07 $947.46 $763.53 $1,049.85 $518.97 $713.58$720.89 $991.23 $798.79 $1,098.34 $542.94 $746.54$753.03 $1,035.41 $834.40 $1,147.30 $567.14 $779.82$787.33 $1,082.57 $872.41 $1,199.56 $592.97 $815.34$804.32 $1,105.94 $891.24 $1,225.45 $605.77 $832.94$838.62 $1,153.10 $929.24 $1,277.71 $631.60 $868.46$868.28 $1,193.89 $962.11 $1,322.90 $653.95 $899.18$887.75 $1,220.66 $983.68 $1,352.56 $668.61 $919.33$912.16 $1,254.22 $1,010.73 $1,389.75 $686.99 $944.61$926.99 $1,274.62 $1,027.16 $1,412.35 $698.16 $959.97$926.99 $1,274.62 $1,027.16 $1,412.35 $698.16 $959.97

31609PA015003416884.WR-I Rev. 1.16



$2,10030%

30% after ded$6,550

Yes$6,550

Yes

31609PA015003616884.WR-I Rev. 1.16



$5,20050%

50% after ded$6,550

Yes


$2,70010%

10% after ded

31609PA015003516884.WR-I Rev. 1.16


RATE PAGES

Page Number: 11 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$158.34 $158.34 $279.31 $279.31 $246.35 $246.35$249.36 $280.53 $439.85 $494.83 $387.96 $436.46$249.36 $280.53 $439.85 $494.83 $387.96 $436.46$249.36 $280.53 $439.85 $494.83 $387.96 $436.46$249.36 $280.53 $439.85 $494.83 $387.96 $436.46$250.35 $281.65 $441.61 $496.81 $389.51 $438.20$255.34 $287.26 $450.41 $506.71 $397.27 $446.93$261.33 $293.99 $460.97 $518.59 $406.58 $457.41$271.05 $304.93 $478.12 $537.88 $421.71 $474.43$279.03 $313.91 $492.20 $553.72 $434.13 $488.39$283.02 $332.55 $499.23 $586.60 $440.34 $517.39$289.01 $339.58 $509.79 $599.00 $449.65 $528.33$294.99 $346.61 $520.35 $611.41 $458.96 $539.27$298.73 $351.01 $526.94 $619.16 $464.78 $546.11$302.72 $355.70 $533.98 $627.43 $470.98 $553.41$304.71 $358.04 $537.50 $631.56 $474.09 $557.05$306.71 $360.38 $541.02 $635.70 $477.19 $560.70$308.70 $362.73 $544.54 $639.83 $480.30 $564.35$310.70 $365.07 $548.06 $643.97 $483.40 $567.99$314.69 $369.76 $555.09 $652.24 $489.61 $575.29$318.68 $390.38 $562.13 $688.61 $495.81 $607.37$324.66 $397.71 $572.69 $701.54 $505.12 $618.78$330.40 $404.74 $582.80 $713.94 $514.05 $629.71$338.38 $414.51 $596.88 $731.18 $526.46 $644.92$348.35 $426.73 $614.47 $752.73 $541.98 $663.93$360.07 $441.09 $635.15 $778.06 $560.21 $686.26$374.04 $458.19 $659.78 $808.23 $581.94 $712.88$389.75 $477.44 $687.49 $842.17 $606.38 $742.82$407.70 $499.43 $719.16 $880.97 $634.32 $777.04$425.40 $521.12 $750.39 $919.23 $661.86 $810.78$445.35 $612.36 $785.58 $1,080.17 $692.90 $952.73$465.05 $639.45 $820.33 $1,127.95 $723.55 $994.88$486.75 $669.28 $858.59 $1,180.56 $757.30 $1,041.29$508.69 $699.45 $897.30 $1,233.79 $791.44 $1,088.23$532.38 $732.02 $939.09 $1,291.24 $828.30 $1,138.91$556.07 $764.59 $980.87 $1,348.70 $865.15 $1,189.58$581.75 $799.91 $1,026.18 $1,410.99 $905.11 $1,244.53$607.68 $835.57 $1,071.92 $1,473.89 $945.46 $1,300.01$635.36 $873.62 $1,120.74 $1,541.02 $988.52 $1,359.22$649.08 $892.48 $1,144.94 $1,574.29 $1,009.86 $1,388.56$676.76 $930.54 $1,193.76 $1,641.42 $1,052.92 $1,447.77$700.69 $963.45 $1,235.99 $1,699.48 $1,090.17 $1,498.98$716.40 $985.06 $1,263.70 $1,737.58 $1,114.61 $1,532.59$736.10 $1,012.14 $1,298.45 $1,785.36 $1,145.26 $1,574.73$748.07 $1,028.60 $1,319.55 $1,814.39 $1,163.88 $1,600.34$748.07 $1,028.60 $1,319.55 $1,814.39 $1,163.88 $1,600.34

8

Yes

16884.WR-I Rev. 1.16


31609PA0150039

Gold

$6,550Yes

31609PA015003816884.WR-I Rev. 1.16



$1,8500%

$0 after ded$6,550

Yes


$6,5500%

$0 after ded

31609PA015003716884.WR-I Rev. 1.16


$6,550


0%$0 after ded

RATE PAGES

Page Number: 12 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$244.93 $244.93 $200.19 $200.19 $225.92 $225.92$385.71 $433.93 $315.25 $354.66 $355.78 $400.26$385.71 $433.93 $315.25 $354.66 $355.78 $400.26$385.71 $433.93 $315.25 $354.66 $355.78 $400.26$385.71 $433.93 $315.25 $354.66 $355.78 $400.26$387.25 $435.66 $316.51 $356.08 $357.21 $401.86$394.97 $444.34 $322.82 $363.17 $364.32 $409.86$404.23 $454.75 $330.39 $371.68 $372.86 $419.47$419.27 $471.68 $342.68 $385.52 $386.74 $435.08$431.61 $485.56 $352.77 $396.87 $398.12 $447.89$437.78 $514.39 $357.81 $420.43 $403.82 $474.48$447.04 $525.27 $365.38 $429.32 $412.35 $484.52$456.30 $536.15 $372.95 $438.21 $420.89 $494.55$462.08 $542.95 $377.67 $443.77 $426.23 $500.82$468.25 $550.20 $382.72 $449.69 $431.92 $507.51$471.34 $553.82 $385.24 $452.66 $434.77 $510.85$474.43 $557.45 $387.76 $455.62 $437.62 $514.20$477.51 $561.08 $390.28 $458.58 $440.46 $517.54$480.60 $564.70 $392.81 $461.55 $443.31 $520.89$486.77 $571.95 $397.85 $467.47 $449.00 $527.58$492.94 $603.85 $402.89 $493.55 $454.69 $557.00$502.20 $615.19 $410.46 $502.81 $463.23 $567.46$511.07 $626.06 $417.71 $511.70 $471.42 $577.48$523.41 $641.18 $427.80 $524.05 $482.80 $591.43$538.84 $660.08 $440.41 $539.50 $497.03 $608.86$556.97 $682.29 $455.23 $557.65 $513.75 $629.35$578.57 $708.75 $472.88 $579.28 $533.68 $653.75$602.87 $738.51 $492.74 $603.61 $556.09 $681.21$630.64 $772.53 $515.44 $631.41 $581.71 $712.59$658.02 $806.08 $537.82 $658.83 $606.97 $743.54$688.88 $947.21 $563.04 $774.18 $635.43 $873.72$719.35 $989.11 $587.95 $808.43 $663.54 $912.37$752.91 $1,035.25 $615.38 $846.14 $694.49 $954.93$786.85 $1,081.92 $643.12 $884.29 $725.80 $997.98$823.49 $1,132.30 $673.07 $925.47 $759.60 $1,044.45$860.14 $1,182.69 $703.02 $966.65 $793.40 $1,090.93$899.87 $1,237.31 $735.49 $1,011.29 $830.05 $1,141.31$939.98 $1,292.47 $768.27 $1,056.38 $867.05 $1,192.19$982.79 $1,351.34 $803.27 $1,104.49 $906.54 $1,246.49

$1,004.01 $1,380.51 $820.61 $1,128.33 $926.11 $1,273.40$1,046.82 $1,439.38 $855.60 $1,176.45 $965.60 $1,327.70$1,083.85 $1,490.29 $885.86 $1,218.06 $999.76 $1,374.66$1,108.15 $1,523.71 $905.72 $1,245.37 $1,022.17 $1,405.48$1,138.62 $1,565.60 $930.63 $1,279.62 $1,050.28 $1,444.13$1,157.13 $1,591.06 $945.75 $1,300.42 $1,067.34 $1,467.61$1,157.13 $1,591.06 $945.75 $1,300.42 $1,067.34 $1,467.61



16884.WR-I Rev. 1.168


$3,3000%

$40 no ded/$80 no ded$6,800

0%

$7,150$30 no ded/$60 no ded

16884.WR-I Rev. 1.168

31609PA0150023

No$3,200

0%$2,000 $3,000


No

16884.WR-I Rev. 1.168


No


Gold

31609PA0150022 31609PA0150024

Silver

RATE PAGES

Page Number: 13 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$241.00 $241.00 $245.71 $245.71 $200.96 $200.96$379.53 $426.97 $386.94 $435.30 $316.48 $356.04$379.53 $426.97 $386.94 $435.30 $316.48 $356.04$379.53 $426.97 $386.94 $435.30 $316.48 $356.04$379.53 $426.97 $386.94 $435.30 $316.48 $356.04$381.05 $428.68 $388.49 $437.05 $317.75 $357.46$388.64 $437.22 $396.22 $445.75 $324.07 $364.58$397.75 $447.47 $405.51 $456.20 $331.67 $373.13$412.55 $464.12 $420.60 $473.18 $344.01 $387.01$424.69 $477.78 $432.98 $487.11 $354.14 $398.41$430.77 $506.15 $439.17 $516.03 $359.20 $422.06$439.88 $516.85 $448.46 $526.94 $366.80 $430.99$448.98 $527.56 $457.75 $537.85 $374.40 $439.91$454.68 $534.25 $463.55 $544.67 $379.14 $445.49$460.75 $541.38 $469.74 $551.95 $384.21 $451.44$463.79 $544.95 $472.84 $555.58 $386.74 $454.42$466.82 $548.52 $475.93 $559.22 $389.27 $457.39$469.86 $552.08 $479.03 $562.86 $391.80 $460.37$472.89 $555.65 $482.12 $566.50 $394.33 $463.34$478.97 $562.79 $488.31 $573.77 $399.40 $469.29$485.04 $594.17 $494.51 $605.77 $404.46 $495.46$494.15 $605.33 $503.79 $617.15 $412.06 $504.77$502.88 $616.03 $512.69 $628.05 $419.34 $513.69$515.02 $630.90 $525.07 $643.22 $429.46 $526.09$530.20 $649.50 $540.55 $662.18 $442.12 $541.60$548.04 $671.35 $558.74 $684.45 $457.00 $559.82$569.30 $697.39 $580.41 $711.00 $474.72 $581.53$593.21 $726.68 $604.78 $740.86 $494.66 $605.96$620.53 $760.15 $632.64 $774.99 $517.44 $633.87$647.48 $793.16 $660.12 $808.64 $539.91 $661.39$677.84 $932.03 $691.07 $950.22 $565.23 $777.19$707.82 $973.26 $721.64 $992.25 $590.23 $811.57$740.84 $1,018.66 $755.30 $1,038.54 $617.77 $849.43$774.24 $1,064.58 $789.35 $1,085.36 $645.62 $887.72$810.30 $1,114.16 $826.11 $1,135.90 $675.68 $929.07$846.35 $1,163.73 $862.87 $1,186.45 $705.75 $970.41$885.44 $1,217.49 $902.72 $1,241.25 $738.35 $1,015.23$924.92 $1,271.76 $942.97 $1,296.58 $771.26 $1,060.48$967.04 $1,329.68 $985.92 $1,355.63 $806.39 $1,108.79$987.92 $1,358.39 $1,007.20 $1,384.90 $823.80 $1,132.72

$1,030.05 $1,416.31 $1,050.15 $1,443.95 $858.93 $1,181.02$1,066.48 $1,466.41 $1,087.29 $1,495.03 $889.31 $1,222.80$1,090.39 $1,499.29 $1,111.67 $1,528.55 $909.25 $1,250.21$1,120.37 $1,540.51 $1,142.24 $1,570.58 $934.25 $1,284.59$1,138.59 $1,565.56 $1,160.81 $1,596.12 $949.44 $1,305.48$1,138.59 $1,565.56 $1,160.81 $1,596.12 $949.44 $1,305.48

$7,150Yes

$3,0000%

$30 no ded/$60 no ded$40 no ded/$80 no ded$3,200

Yes

31609PA015004916884.WR-I Rev. 1.16



31609PA015004716884.WR-I Rev. 1.16



$2,0000%

No

8

31609PA0150046

16884.WR-I Rev. 1.16

$6,550


$3,2000%

$0 after ded


RATE PAGES

Page Number: 14 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco$226.70 $226.70 $241.60 $241.60$357.01 $401.64 $380.48 $428.04$357.01 $401.64 $380.48 $428.04$357.01 $401.64 $380.48 $428.04$357.01 $401.64 $380.48 $428.04$358.44 $403.24 $382.00 $429.75$365.58 $411.28 $389.61 $438.31$374.15 $420.92 $398.74 $448.58$388.07 $436.58 $413.58 $465.28$399.49 $449.43 $425.76 $478.98$405.21 $476.12 $431.84 $507.42$413.78 $486.19 $440.97 $518.15$422.34 $496.25 $450.11 $528.88$427.70 $502.55 $455.81 $535.58$433.41 $509.26 $461.90 $542.73$436.27 $512.61 $464.95 $546.31$439.12 $515.97 $467.99 $549.89$441.98 $519.33 $471.03 $553.46$444.84 $522.68 $474.08 $557.04$450.55 $529.39 $480.16 $564.19$456.26 $558.92 $486.25 $595.66$464.83 $569.41 $495.38 $606.84$473.04 $579.47 $504.13 $617.56$484.46 $593.47 $516.31 $632.48$498.74 $610.96 $531.53 $651.12$515.52 $631.52 $549.41 $673.03$535.52 $656.01 $570.72 $699.13$558.01 $683.56 $594.69 $728.49$583.71 $715.05 $622.08 $762.05$609.06 $746.10 $649.10 $795.14$637.62 $876.73 $679.54 $934.36$665.82 $915.51 $709.59 $975.69$696.88 $958.22 $742.69 $1,021.21$728.30 $1,001.41 $776.18 $1,067.24$762.22 $1,048.05 $812.32 $1,116.94$796.13 $1,094.68 $848.47 $1,166.64$832.91 $1,145.25 $887.66 $1,220.53$870.03 $1,196.30 $927.23 $1,274.94$909.66 $1,250.79 $969.46 $1,333.01$929.30 $1,277.79 $990.39 $1,361.78$968.93 $1,332.27 $1,032.62 $1,419.85

$1,003.20 $1,379.40 $1,069.15 $1,470.07$1,025.69 $1,410.33 $1,093.12 $1,503.03$1,053.90 $1,449.11 $1,123.17 $1,544.36$1,071.03 $1,472.67 $1,141.44 $1,569.48$1,071.03 $1,472.67 $1,141.44 $1,569.48

$6,800 $6,550Yes Yes

$3,300 $3,2000% 0%







2017 On-Exchange



e Silver Plan Rates



2017 Off-Exchange



e Silver Plan Rates

12/24/2014




Plan Design Summary


RATE PAGES


Company Name: QCC Insurance CompanyProduct: PPOEffective Date of Rates: October 1, 2017 - December 31, 2017



Network =>Metal =>




Age Band Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco0-20 $333.31 $333.31 $318.66 $318.66 $262.65 $262.6521 $524.90 $590.51 $501.82 $564.55 $413.63 $465.3322 $524.90 $590.51 $501.82 $564.55 $413.63 $465.3323 $524.90 $590.51 $501.82 $564.55 $413.63 $465.3324 $524.90 $590.51 $501.82 $564.55 $413.63 $465.3325 $527.00 $592.87 $503.83 $566.81 $415.28 $467.1926 $537.50 $604.68 $513.87 $578.10 $423.56 $476.5027 $550.09 $618.85 $525.91 $591.65 $433.48 $487.6728 $570.56 $641.88 $545.48 $613.67 $449.62 $505.8229 $587.36 $660.78 $561.54 $631.73 $462.85 $520.7130 $595.76 $700.02 $569.57 $669.24 $469.47 $551.6331 $608.36 $714.82 $581.61 $683.40 $479.40 $563.2932 $620.95 $729.62 $593.66 $697.55 $489.32 $574.9633 $628.83 $738.87 $601.18 $706.39 $495.53 $582.2534 $637.23 $748.74 $609.21 $715.83 $502.15 $590.0235 $641.43 $753.67 $613.23 $720.54 $505.46 $593.9136 $645.62 $758.61 $617.24 $725.26 $508.76 $597.8037 $649.82 $763.54 $621.26 $729.98 $512.07 $601.6938 $654.02 $768.48 $625.27 $734.70 $515.38 $605.5739 $662.42 $778.34 $633.30 $744.13 $522.00 $613.3540 $670.82 $821.75 $641.33 $785.63 $528.62 $647.5641 $683.42 $837.19 $653.37 $800.38 $538.55 $659.7242 $695.49 $851.97 $664.92 $814.52 $548.06 $671.3743 $712.29 $872.55 $680.97 $834.19 $561.30 $687.5944 $733.28 $898.27 $701.05 $858.78 $577.84 $707.8645 $757.95 $928.49 $724.63 $887.68 $597.28 $731.6746 $787.35 $964.50 $752.74 $922.10 $620.44 $760.0447 $820.42 $1,005.01 $784.35 $960.83 $646.50 $791.9748 $858.21 $1,051.30 $820.48 $1,005.09 $676.28 $828.4549 $895.48 $1,096.96 $856.11 $1,048.74 $705.65 $864.4250 $937.47 $1,289.02 $896.26 $1,232.35 $738.74 $1,015.7751 $978.93 $1,346.03 $935.90 $1,286.86 $771.42 $1,060.7052 $1,024.60 $1,408.83 $979.56 $1,346.90 $807.41 $1,110.1853 $1,070.79 $1,472.34 $1,023.72 $1,407.62 $843.80 $1,160.2354 $1,120.66 $1,540.90 $1,071.39 $1,473.17 $883.10 $1,214.2655 $1,170.52 $1,609.47 $1,119.07 $1,538.72 $922.39 $1,268.2956 $1,224.59 $1,683.81 $1,170.76 $1,609.79 $965.00 $1,326.8757 $1,279.18 $1,758.87 $1,222.94 $1,681.55 $1,008.02 $1,386.0258 $1,337.44 $1,838.98 $1,278.65 $1,758.14 $1,053.93 $1,449.1559 $1,366.31 $1,878.67 $1,306.25 $1,796.09 $1,076.68 $1,480.4360 $1,424.57 $1,958.79 $1,361.95 $1,872.68 $1,122.59 $1,543.5661 $1,474.96 $2,028.07 $1,410.13 $1,938.92 $1,162.30 $1,598.1662 $1,508.03 $2,073.54 $1,441.74 $1,982.39 $1,188.36 $1,633.9963 $1,549.50 $2,130.56 $1,481.38 $2,036.90 $1,221.04 $1,678.9264 $1,574.69 $2,165.20 $1,505.46 $2,070.02 $1,240.89 $1,706.22

65+ $1,574.69 $2,165.20 $1,505.46 $2,070.02 $1,240.89 $1,706.22

31609PA0150001 31609PA0150002

8 8

No No

16884.WR-I Rev. 1.16 16884.WR-I Rev. 1.16


$00%

$2,500$10/$20 $20/$40

$2,000$35/$70$6,850



Personal Choice Network Personal Choice Network Personal Choice Network GoldPlatinum

No

31609PA0150003

16884.WR-I Rev. 1.168

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$262.82 $262.82 $227.95 $227.95 $286.78 $286.78$413.89 $465.63 $358.98 $403.86 $451.63 $508.08$413.89 $465.63 $358.98 $403.86 $451.63 $508.08$413.89 $465.63 $358.98 $403.86 $451.63 $508.08$413.89 $465.63 $358.98 $403.86 $451.63 $508.08$415.55 $467.49 $360.42 $405.47 $453.44 $510.12$423.83 $476.80 $367.60 $413.55 $462.47 $520.28$433.76 $487.98 $376.21 $423.24 $473.31 $532.47$449.90 $506.14 $390.21 $438.99 $490.92 $552.29$463.15 $521.04 $401.70 $451.91 $505.37 $568.54$469.77 $551.98 $407.45 $478.75 $512.60 $602.30$479.70 $563.65 $416.06 $488.87 $523.44 $615.04$489.64 $575.32 $424.68 $499.00 $534.28 $627.78$495.84 $582.62 $430.06 $505.32 $541.05 $635.74$502.47 $590.40 $435.81 $512.07 $548.28 $644.23$505.78 $594.29 $438.68 $515.45 $551.89 $648.47$509.09 $598.18 $441.55 $518.82 $555.50 $652.72$512.40 $602.07 $444.42 $522.19 $559.12 $656.96$515.71 $605.96 $447.29 $525.57 $562.73 $661.21$522.33 $613.74 $453.04 $532.32 $569.96 $669.70$528.96 $647.97 $458.78 $562.01 $577.18 $707.05$538.89 $660.14 $467.40 $572.56 $588.02 $720.33$548.41 $671.80 $475.65 $582.67 $598.41 $733.05$561.65 $688.02 $487.14 $596.75 $612.86 $750.75$578.21 $708.31 $501.50 $614.34 $630.93 $772.88$597.66 $732.14 $518.37 $635.00 $652.15 $798.89$620.84 $760.53 $538.47 $659.63 $677.44 $829.87$646.91 $792.47 $561.09 $687.34 $705.90 $864.72$676.72 $828.98 $586.94 $719.00 $738.41 $904.56$706.10 $864.97 $612.42 $750.22 $770.48 $943.84$739.21 $1,016.42 $641.14 $881.57 $806.61 $1,109.09$771.91 $1,061.38 $669.50 $920.57 $842.29 $1,158.15$807.92 $1,110.89 $700.73 $963.51 $881.58 $1,212.17$844.34 $1,160.97 $732.33 $1,006.95 $921.32 $1,266.82$883.66 $1,215.03 $766.43 $1,053.84 $964.23 $1,325.81$922.98 $1,269.10 $800.53 $1,100.73 $1,007.13 $1,384.81$965.61 $1,327.72 $837.51 $1,151.57 $1,053.65 $1,448.77

$1,008.66 $1,386.90 $874.84 $1,202.91 $1,100.62 $1,513.35$1,054.60 $1,450.07 $914.69 $1,257.70 $1,150.75 $1,582.28$1,077.36 $1,481.38 $934.43 $1,284.84 $1,175.59 $1,616.44$1,123.31 $1,544.55 $974.28 $1,339.63 $1,225.72 $1,685.37$1,163.04 $1,599.18 $1,008.74 $1,387.02 $1,269.08 $1,744.98$1,189.11 $1,635.03 $1,031.36 $1,418.12 $1,297.53 $1,784.11$1,221.81 $1,679.99 $1,059.72 $1,457.11 $1,333.21 $1,833.16$1,241.67 $1,707.31 $1,076.94 $1,480.80 $1,354.89 $1,862.97$1,241.67 $1,707.31 $1,076.94 $1,480.80 $1,354.89 $1,862.97



$5,500

16884.WR-I Rev. 1.168


8

31609PA0150004


31609PA0150005

16884.WR-I Rev. 1.168




$6,400NoNo

$6,550No


$1,6000%

$0 after ded

31609PA0150006

16884.WR-I Rev. 1.16

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$252.88 $252.88 $275.06 $275.06 $210.25 $210.25$398.23 $448.01 $433.16 $487.31 $331.11 $372.49$398.23 $448.01 $433.16 $487.31 $331.11 $372.49$398.23 $448.01 $433.16 $487.31 $331.11 $372.49$398.23 $448.01 $433.16 $487.31 $331.11 $372.49$399.83 $449.80 $434.89 $489.26 $332.43 $373.98$407.79 $458.76 $443.56 $499.00 $339.05 $381.43$417.35 $469.52 $453.95 $510.70 $347.00 $390.37$432.88 $486.99 $470.85 $529.70 $359.91 $404.90$445.62 $501.33 $484.71 $545.30 $370.51 $416.82$451.99 $531.09 $491.64 $577.68 $375.80 $441.57$461.55 $542.32 $502.03 $589.89 $383.75 $450.91$471.11 $553.55 $512.43 $602.11 $391.70 $460.25$477.08 $560.57 $518.93 $609.74 $396.66 $466.08$483.45 $568.06 $525.86 $617.88 $401.96 $472.31$486.64 $571.80 $529.32 $621.95 $404.61 $475.42$489.83 $575.55 $532.79 $626.03 $407.26 $478.53$493.01 $579.29 $536.25 $630.10 $409.91 $481.64$496.20 $583.03 $539.72 $634.17 $412.56 $484.76$502.57 $590.52 $546.65 $642.31 $417.86 $490.98$508.94 $623.45 $553.58 $678.14 $423.15 $518.36$518.50 $635.16 $563.98 $690.87 $431.10 $528.10$527.66 $646.38 $573.94 $703.08 $438.72 $537.43$540.40 $661.99 $587.80 $720.06 $449.31 $550.41$556.33 $681.51 $605.13 $741.28 $462.55 $566.63$575.05 $704.43 $625.49 $766.22 $478.12 $585.69$597.35 $731.75 $649.74 $795.93 $496.66 $608.41$622.44 $762.49 $677.03 $829.36 $517.52 $633.96$651.11 $797.61 $708.22 $867.57 $541.36 $663.16$679.38 $832.25 $738.97 $905.24 $564.87 $691.96$711.24 $977.96 $773.63 $1,063.74 $591.35 $813.11$742.70 $1,021.22 $807.85 $1,110.79 $617.51 $849.08$777.35 $1,068.86 $845.53 $1,162.61 $646.32 $888.69$812.39 $1,117.04 $883.65 $1,215.02 $675.46 $928.75$850.23 $1,169.06 $924.80 $1,271.60 $706.91 $972.00$888.06 $1,221.08 $965.95 $1,328.18 $738.37 $1,015.25$929.08 $1,277.48 $1,010.57 $1,389.53 $772.47 $1,062.15$970.49 $1,334.43 $1,055.61 $1,451.47 $806.90 $1,109.49

$1,014.70 $1,395.21 $1,103.70 $1,517.58 $843.66 $1,160.03$1,036.60 $1,425.32 $1,127.52 $1,550.34 $861.87 $1,185.07$1,080.80 $1,486.10 $1,175.60 $1,616.45 $898.62 $1,235.60$1,119.03 $1,538.67 $1,217.18 $1,673.63 $930.41 $1,279.31$1,144.12 $1,573.17 $1,244.47 $1,711.15 $951.27 $1,307.99$1,175.58 $1,616.43 $1,278.69 $1,758.20 $977.42 $1,343.96$1,194.69 $1,642.71 $1,299.48 $1,786.79 $993.32 $1,365.81$1,194.69 $1,642.71 $1,299.48 $1,786.79 $993.32 $1,365.81


31609PA0150007

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No

$6,550No

31609PA0150009

16884.WR-I Rev. 1.168



30%30% after ded

$6,550No


$1,9000%

$0 after ded

31609PA0150008

16884.WR-I Rev. 1.168

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$201.28 $201.28 $223.10 $223.10 $151.44 $151.44$316.97 $356.59 $351.34 $395.26 $238.49 $268.30$316.97 $356.59 $351.34 $395.26 $238.49 $268.30$316.97 $356.59 $351.34 $395.26 $238.49 $268.30$316.97 $356.59 $351.34 $395.26 $238.49 $268.30$318.24 $358.02 $352.74 $396.84 $239.45 $269.38$324.58 $365.15 $359.77 $404.74 $244.22 $274.74$332.18 $373.71 $368.20 $414.23 $249.94 $281.18$344.55 $387.61 $381.91 $429.64 $259.24 $291.65$354.69 $399.03 $393.15 $442.29 $266.87 $300.23$359.76 $422.72 $398.77 $468.55 $270.69 $318.06$367.37 $431.66 $407.20 $478.46 $276.41 $324.78$374.98 $440.60 $415.63 $488.37 $282.14 $331.51$379.73 $446.18 $420.90 $494.56 $285.71 $335.71$384.80 $452.14 $426.53 $501.17 $289.53 $340.20$387.34 $455.12 $429.34 $504.47 $291.44 $342.44$389.87 $458.10 $432.15 $507.77 $293.35 $344.68$392.41 $461.08 $434.96 $511.08 $295.25 $346.92$394.94 $464.06 $437.77 $514.38 $297.16 $349.16$400.02 $470.02 $443.39 $520.98 $300.98 $353.65$405.09 $496.23 $449.01 $550.04 $304.79 $373.37$412.69 $505.55 $457.44 $560.37 $310.52 $380.38$419.98 $514.48 $465.52 $570.27 $316.00 $387.10$430.13 $526.91 $476.77 $584.04 $323.63 $396.45$442.81 $542.44 $490.82 $601.26 $333.17 $408.14$457.70 $560.69 $507.33 $621.48 $344.38 $421.87$475.45 $582.43 $527.01 $645.59 $357.74 $438.23$495.42 $606.89 $549.14 $672.70 $372.76 $456.64$518.25 $634.85 $574.44 $703.69 $389.93 $477.67$540.75 $662.42 $599.38 $734.25 $406.87 $498.41$566.11 $778.40 $627.49 $862.80 $425.95 $585.68$591.15 $812.83 $655.25 $900.97 $444.79 $611.58$618.72 $850.75 $685.81 $942.99 $465.54 $640.11$646.62 $889.10 $716.73 $985.51 $486.52 $668.97$676.73 $930.50 $750.11 $1,031.40 $509.18 $700.12$706.84 $971.91 $783.49 $1,077.29 $531.84 $731.28$739.49 $1,016.80 $819.67 $1,127.05 $556.40 $765.05$772.46 $1,062.13 $856.21 $1,177.29 $581.21 $799.16$807.64 $1,110.50 $895.21 $1,230.92 $607.68 $835.56$825.07 $1,134.47 $914.54 $1,257.49 $620.80 $853.59$860.26 $1,182.85 $953.53 $1,311.11 $647.27 $889.99$890.68 $1,224.69 $987.26 $1,357.49 $670.16 $921.47$910.65 $1,252.15 $1,009.40 $1,387.92 $685.19 $942.13$935.69 $1,286.58 $1,037.15 $1,426.09 $704.03 $968.04$950.91 $1,307.50 $1,054.02 $1,449.27 $715.47 $983.78$950.91 $1,307.50 $1,054.02 $1,449.27 $715.47 $983.78


$6,550No

31609PA0150011

16884.WR-I Rev. 1.168



10%10% after ded

$6,550No


$2,10030%

30% after ded

31609PA0150010

16884.WR-I Rev. 1.168

$6,550No


$5,20050%

50% after ded

31609PA0150012

16884.WR-I Rev. 1.168

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$162.31 $162.31 $286.78 $286.78 $252.88 $252.88$255.60 $287.55 $451.63 $508.08 $398.23 $448.01$255.60 $287.55 $451.63 $508.08 $398.23 $448.01$255.60 $287.55 $451.63 $508.08 $398.23 $448.01$255.60 $287.55 $451.63 $508.08 $398.23 $448.01$256.62 $288.70 $453.44 $510.12 $399.83 $449.80$261.73 $294.45 $462.47 $520.28 $407.79 $458.76$267.87 $301.35 $473.31 $532.47 $417.35 $469.52$277.84 $312.57 $490.92 $552.29 $432.88 $486.99$286.02 $321.77 $505.37 $568.54 $445.62 $501.33$290.11 $340.87 $512.60 $602.30 $451.99 $531.09$296.24 $348.08 $523.44 $615.04 $461.55 $542.32$302.38 $355.29 $534.28 $627.78 $471.11 $553.55$306.21 $359.80 $541.05 $635.74 $477.08 $560.57$310.30 $364.60 $548.28 $644.23 $483.45 $568.06$312.34 $367.00 $551.89 $648.47 $486.64 $571.80$314.39 $369.41 $555.50 $652.72 $489.83 $575.55$316.43 $371.81 $559.12 $656.96 $493.01 $579.29$318.48 $374.21 $562.73 $661.21 $496.20 $583.03$322.57 $379.02 $569.96 $669.70 $502.57 $590.52$326.66 $400.15 $577.18 $707.05 $508.94 $623.45$332.79 $407.67 $588.02 $720.33 $518.50 $635.16$338.67 $414.87 $598.41 $733.05 $527.66 $646.38$346.85 $424.89 $612.86 $750.75 $540.40 $661.99$357.07 $437.41 $630.93 $772.88 $556.33 $681.51$369.09 $452.13 $652.15 $798.89 $575.05 $704.43$383.40 $469.67 $677.44 $829.87 $597.35 $731.75$399.50 $489.39 $705.90 $864.72 $622.44 $762.49$417.91 $511.94 $738.41 $904.56 $651.11 $797.61$436.05 $534.17 $770.48 $943.84 $679.38 $832.25$456.50 $627.69 $806.61 $1,109.09 $711.24 $977.96$476.69 $655.45 $842.29 $1,158.15 $742.70 $1,021.22$498.93 $686.03 $881.58 $1,212.17 $777.35 $1,068.86$521.42 $716.96 $921.32 $1,266.82 $812.39 $1,117.04$545.71 $750.35 $964.23 $1,325.81 $850.23 $1,169.06$569.99 $783.73 $1,007.13 $1,384.81 $888.06 $1,221.08$596.32 $819.93 $1,053.65 $1,448.77 $929.08 $1,277.48$622.90 $856.48 $1,100.62 $1,513.35 $970.49 $1,334.43$651.27 $895.50 $1,150.75 $1,582.28 $1,014.70 $1,395.21$665.33 $914.83 $1,175.59 $1,616.44 $1,036.60 $1,425.32$693.70 $953.84 $1,225.72 $1,685.37 $1,080.80 $1,486.10$718.24 $987.58 $1,269.08 $1,744.98 $1,119.03 $1,538.67$734.34 $1,009.72 $1,297.53 $1,784.11 $1,144.12 $1,573.17$754.53 $1,037.48 $1,333.21 $1,833.16 $1,175.58 $1,616.43$766.80 $1,054.35 $1,354.89 $1,862.97 $1,194.69 $1,642.71$766.80 $1,054.35 $1,354.89 $1,862.97 $1,194.69 $1,642.71


31609PA0150013

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No

$6,550No

31609PA0150015

16884.WR-I Rev. 1.168



0%$0 after ded

$6,550No


$1,8500%

$0 after ded

31609PA0150014

16884.WR-I Rev. 1.168

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$334.11 $334.11 $319.46 $319.46 $263.46 $263.46$526.16 $591.93 $503.09 $565.97 $414.89 $466.75$526.16 $591.93 $503.09 $565.97 $414.89 $466.75$526.16 $591.93 $503.09 $565.97 $414.89 $466.75$526.16 $591.93 $503.09 $565.97 $414.89 $466.75$528.26 $594.30 $505.10 $568.23 $416.55 $468.62$538.79 $606.14 $515.16 $579.55 $424.85 $477.95$551.41 $620.34 $527.23 $593.14 $434.81 $489.16$571.93 $643.43 $546.85 $615.21 $450.99 $507.36$588.77 $662.37 $562.95 $633.32 $464.26 $522.30$597.19 $701.70 $571.00 $670.93 $470.90 $553.31$609.82 $716.54 $583.08 $685.11 $480.86 $565.01$622.45 $731.37 $595.15 $699.30 $490.82 $576.71$630.34 $740.65 $602.70 $708.17 $497.04 $584.02$638.76 $750.54 $610.75 $717.63 $503.68 $591.82$642.97 $755.49 $614.77 $722.35 $507.00 $595.72$647.18 $760.43 $618.79 $727.08 $510.32 $599.62$651.38 $765.38 $622.82 $731.81 $513.64 $603.52$655.59 $770.32 $626.84 $736.54 $516.95 $607.42$664.01 $780.21 $634.89 $746.00 $523.59 $615.22$672.43 $823.73 $642.94 $787.60 $530.23 $649.53$685.06 $839.20 $655.02 $802.40 $540.19 $661.73$697.16 $854.02 $666.59 $816.57 $549.73 $673.42$714.00 $874.65 $682.69 $836.29 $563.01 $689.68$735.04 $900.43 $702.81 $860.94 $579.60 $710.01$759.77 $930.72 $726.45 $889.91 $599.10 $733.90$789.24 $966.82 $754.63 $924.42 $622.34 $762.36$822.39 $1,007.42 $786.32 $963.24 $648.47 $794.38$860.27 $1,053.83 $822.54 $1,007.62 $678.35 $830.97$897.63 $1,099.59 $858.26 $1,051.37 $707.80 $867.06$939.72 $1,292.11 $898.51 $1,235.45 $741.00 $1,018.87$981.29 $1,349.27 $938.25 $1,290.10 $773.77 $1,063.94

$1,027.06 $1,412.21 $982.02 $1,350.28 $809.87 $1,113.57$1,073.36 $1,475.88 $1,026.29 $1,411.15 $846.38 $1,163.77$1,123.35 $1,544.61 $1,074.09 $1,476.87 $885.79 $1,217.96$1,173.33 $1,613.33 $1,121.88 $1,542.58 $925.21 $1,272.16$1,227.53 $1,687.85 $1,173.70 $1,613.83 $967.94 $1,330.92$1,282.25 $1,763.09 $1,226.02 $1,685.78 $1,011.09 $1,390.25$1,340.65 $1,843.40 $1,281.86 $1,762.56 $1,057.14 $1,453.57$1,369.59 $1,883.19 $1,309.53 $1,800.60 $1,079.96 $1,484.95$1,428.00 $1,963.49 $1,365.37 $1,877.39 $1,126.01 $1,548.27$1,478.51 $2,032.95 $1,413.67 $1,943.79 $1,165.84 $1,603.04$1,511.65 $2,078.52 $1,445.36 $1,987.37 $1,191.98 $1,638.98$1,553.22 $2,135.68 $1,485.11 $2,042.02 $1,224.76 $1,684.04$1,578.48 $2,170.41 $1,509.26 $2,075.23 $1,244.67 $1,711.43$1,578.48 $2,170.41 $1,509.26 $2,075.23 $1,244.67 $1,711.43


$2,500Yes

31609PA015002616884.WR-I Rev. 1.16



$00%

$20/$40$2,000

Yes


$00%

$10/$20

31609PA015002516884.WR-I Rev. 1.16

8

$6,850Yes


$00%

$35/$70

31609PA015002716884.WR-I Rev. 1.16

8

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$263.62 $263.62 $228.76 $228.76 $287.40 $287.40$415.15 $467.05 $360.24 $405.27 $452.61 $509.18$415.15 $467.05 $360.24 $405.27 $452.61 $509.18$415.15 $467.05 $360.24 $405.27 $452.61 $509.18$415.15 $467.05 $360.24 $405.27 $452.61 $509.18$416.81 $468.92 $361.69 $406.90 $454.42 $511.22$425.12 $478.26 $368.89 $415.00 $463.47 $521.40$435.08 $489.47 $377.54 $424.73 $474.33 $533.62$451.27 $507.68 $391.59 $440.53 $491.98 $553.48$464.56 $522.63 $403.11 $453.50 $506.47 $569.77$471.20 $553.66 $408.88 $480.43 $513.71 $603.61$481.16 $565.37 $417.52 $490.59 $524.57 $616.37$491.13 $577.07 $426.17 $500.75 $535.43 $629.13$497.35 $584.39 $431.57 $507.10 $542.22 $637.11$504.00 $592.20 $437.34 $513.87 $549.46 $645.62$507.32 $596.10 $440.22 $517.26 $553.08 $649.87$510.64 $600.00 $443.10 $520.64 $556.70 $654.13$513.96 $603.90 $445.98 $524.03 $560.33 $658.38$517.28 $607.81 $448.86 $527.42 $563.95 $662.64$523.92 $615.61 $454.63 $534.19 $571.19 $671.15$530.57 $649.94 $460.39 $563.98 $578.43 $708.58$540.53 $662.15 $469.04 $574.57 $589.29 $721.88$550.08 $673.85 $477.32 $584.72 $599.70 $734.64$563.36 $690.12 $488.85 $598.84 $614.19 $752.38$579.97 $710.46 $503.26 $616.49 $632.29 $774.56$599.48 $734.37 $520.19 $637.24 $653.56 $800.61$622.73 $762.85 $540.37 $661.95 $678.91 $831.66$648.89 $794.89 $563.06 $689.75 $707.42 $866.59$678.78 $831.50 $589.00 $721.52 $740.01 $906.51$708.25 $867.61 $614.58 $752.86 $772.14 $945.88$741.47 $1,019.52 $643.40 $884.67 $808.35 $1,111.49$774.26 $1,064.61 $671.86 $923.80 $844.11 $1,160.65$810.38 $1,114.27 $703.20 $966.90 $883.49 $1,214.79$846.91 $1,164.51 $734.90 $1,010.48 $923.32 $1,269.56$886.35 $1,218.74 $769.12 $1,057.54 $966.31 $1,328.68$925.79 $1,272.97 $803.34 $1,104.60 $1,009.31 $1,387.80$968.55 $1,331.76 $840.45 $1,155.62 $1,055.93 $1,451.90

$1,011.73 $1,391.13 $877.91 $1,207.13 $1,103.00 $1,516.62$1,057.81 $1,454.49 $917.90 $1,262.12 $1,153.24 $1,585.70$1,080.65 $1,485.89 $937.72 $1,289.36 $1,178.13 $1,619.93$1,126.73 $1,549.25 $977.70 $1,344.34 $1,228.37 $1,689.01$1,166.58 $1,604.05 $1,012.29 $1,391.89 $1,271.82 $1,748.75$1,192.74 $1,640.02 $1,034.98 $1,423.10 $1,300.34 $1,787.96$1,225.54 $1,685.11 $1,063.44 $1,462.23 $1,336.09 $1,837.13$1,245.45 $1,712.51 $1,080.72 $1,486.01 $1,357.82 $1,867.00$1,245.45 $1,712.51 $1,080.72 $1,486.01 $1,357.82 $1,867.00


31609PA015002816884.WR-I Rev. 1.16



$1,00020%

$15 no ded/$30 no ded$5,500

Yes$6,400

Yes

31609PA015003016884.WR-I Rev. 1.16



$1,6000%

$0 after ded$6,550

Yes


$2,50020%


31609PA015002916884.WR-I Rev. 1.16

8

RATE PAGES





Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$253.50 $253.50 $275.68 $275.68 $210.88 $210.88$399.21 $449.11 $434.14 $488.40 $332.09 $373.60$399.21 $449.11 $434.14 $488.40 $332.09 $373.60$399.21 $449.11 $434.14 $488.40 $332.09 $373.60$399.21 $449.11 $434.14 $488.40 $332.09 $373.60$400.81 $450.91 $435.87 $490.36 $333.42 $375.10$408.79 $459.89 $444.56 $500.13 $340.06 $382.57$418.37 $470.67 $454.98 $511.85 $348.03 $391.54$433.94 $488.18 $471.91 $530.90 $360.98 $406.11$446.71 $502.55 $485.80 $546.52 $371.61 $418.06$453.10 $532.39 $492.75 $578.98 $376.93 $442.89$462.68 $543.65 $503.17 $591.22 $384.90 $452.25$472.26 $554.91 $513.58 $603.46 $392.87 $461.62$478.25 $561.95 $520.10 $611.11 $397.85 $467.47$484.64 $569.45 $527.04 $619.28 $403.16 $473.71$487.83 $573.20 $530.52 $623.36 $405.82 $476.84$491.03 $576.96 $533.99 $627.44 $408.47 $479.96$494.22 $580.71 $537.46 $631.52 $411.13 $483.08$497.41 $584.46 $540.94 $635.60 $413.79 $486.20$503.80 $591.97 $547.88 $643.76 $419.10 $492.44$510.19 $624.98 $554.83 $679.66 $424.41 $519.91$519.77 $636.72 $565.25 $692.43 $432.38 $529.67$528.95 $647.97 $575.23 $704.66 $440.02 $539.03$541.73 $663.61 $589.12 $721.68 $450.65 $552.05$557.69 $683.18 $606.49 $742.95 $463.93 $568.32$576.46 $706.16 $626.89 $767.95 $479.54 $587.44$598.81 $733.55 $651.21 $797.73 $498.14 $610.22$623.96 $764.35 $678.56 $831.23 $519.06 $635.85$652.71 $799.57 $709.81 $869.52 $542.97 $665.14$681.05 $834.29 $740.64 $907.28 $566.55 $694.02$712.99 $980.36 $775.37 $1,066.13 $593.12 $815.54$744.52 $1,023.72 $809.67 $1,113.29 $619.35 $851.61$779.26 $1,071.48 $847.44 $1,165.23 $648.24 $891.34$814.39 $1,119.78 $885.64 $1,217.76 $677.47 $931.52$852.31 $1,171.93 $926.88 $1,274.47 $709.02 $974.90$890.24 $1,224.07 $968.13 $1,331.17 $740.57 $1,018.28$931.35 $1,280.61 $1,012.84 $1,392.66 $774.77 $1,065.31$972.87 $1,337.70 $1,057.99 $1,454.74 $809.31 $1,112.80

$1,017.18 $1,398.63 $1,106.18 $1,521.00 $846.17 $1,163.49$1,039.14 $1,428.82 $1,130.06 $1,553.83 $864.44 $1,188.60$1,083.45 $1,489.75 $1,178.25 $1,620.09 $901.30 $1,239.29$1,121.78 $1,542.44 $1,219.93 $1,677.40 $933.18 $1,283.12$1,146.93 $1,577.02 $1,247.28 $1,715.01 $954.10 $1,311.89$1,178.46 $1,620.39 $1,281.57 $1,762.16 $980.34 $1,347.96$1,197.63 $1,646.74 $1,302.41 $1,790.82 $996.27 $1,369.88$1,197.63 $1,646.74 $1,302.41 $1,790.82 $996.27 $1,369.88

$6,550Yes

31609PA015003216884.WR-I Rev. 1.16



$1,9000%

$0 after ded$6,550

Yes


$2,4000%

$0 after ded

31609PA015003116884.WR-I Rev. 1.16


$6,550Yes


$2,65030%

30% after ded

31609PA015003316884.WR-I Rev. 1.16


RATE PAGES

Page Number: 10 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$201.90 $201.90 $223.72 $223.72 $152.06 $152.06$317.96 $357.70 $352.32 $396.35 $239.47 $269.40$317.96 $357.70 $352.32 $396.35 $239.47 $269.40$317.96 $357.70 $352.32 $396.35 $239.47 $269.40$317.96 $357.70 $352.32 $396.35 $239.47 $269.40$319.23 $359.13 $353.72 $397.94 $240.43 $270.48$325.59 $366.29 $360.77 $405.87 $245.22 $275.87$333.22 $374.87 $369.23 $415.38 $250.96 $282.33$345.62 $388.82 $382.97 $430.84 $260.30 $292.84$355.79 $400.27 $394.24 $443.52 $267.96 $301.46$360.88 $424.03 $399.88 $469.86 $271.80 $319.36$368.51 $433.00 $408.33 $479.79 $277.54 $326.11$376.14 $441.97 $416.79 $489.73 $283.29 $332.87$380.91 $447.57 $422.07 $495.94 $286.88 $337.09$386.00 $453.55 $427.71 $502.56 $290.71 $341.59$388.54 $456.54 $430.53 $505.87 $292.63 $343.84$391.09 $459.53 $433.35 $509.18 $294.55 $346.09$393.63 $462.52 $436.17 $512.50 $296.46 $348.34$396.17 $465.50 $438.98 $515.81 $298.38 $350.59$401.26 $471.48 $444.62 $522.43 $302.21 $355.10$406.35 $497.78 $450.26 $551.57 $306.04 $374.90$413.98 $507.12 $458.71 $561.93 $311.79 $381.94$421.29 $516.08 $466.82 $571.85 $317.30 $388.69$431.47 $528.55 $478.09 $585.66 $324.96 $398.07$444.19 $544.13 $492.18 $602.93 $334.54 $409.81$459.13 $562.43 $508.74 $623.21 $345.79 $423.60$476.94 $584.25 $528.47 $647.38 $359.20 $440.02$496.97 $608.78 $550.67 $674.57 $374.29 $458.50$519.86 $636.83 $576.04 $705.64 $391.53 $479.62$542.43 $664.48 $601.05 $736.29 $408.53 $500.45$567.87 $780.82 $629.24 $865.20 $427.69 $588.07$592.99 $815.36 $657.07 $903.47 $446.61 $614.09$620.65 $853.40 $687.72 $945.61 $467.44 $642.73$648.63 $891.87 $718.72 $988.24 $488.52 $671.71$678.84 $933.40 $752.19 $1,034.27 $511.26 $702.99$709.04 $974.93 $785.66 $1,080.29 $534.01 $734.27$741.79 $1,019.97 $821.95 $1,130.18 $558.68 $768.18$774.86 $1,065.43 $858.59 $1,180.56 $583.58 $802.43$810.15 $1,113.96 $897.70 $1,234.34 $610.16 $838.98$827.64 $1,138.01 $917.08 $1,260.98 $623.34 $857.09$862.93 $1,186.53 $956.18 $1,314.75 $649.92 $893.64$893.46 $1,228.51 $990.01 $1,361.26 $672.91 $925.25$913.49 $1,256.05 $1,012.20 $1,391.78 $687.99 $945.99$938.61 $1,290.59 $1,040.03 $1,430.05 $706.91 $972.00$953.87 $1,311.57 $1,056.95 $1,453.30 $718.40 $987.81$953.87 $1,311.57 $1,056.95 $1,453.30 $718.40 $987.81

31609PA015003416884.WR-I Rev. 1.16



$2,10030%

30% after ded$6,550

Yes$6,550

Yes

31609PA015003616884.WR-I Rev. 1.16



$5,20050%

50% after ded$6,550

Yes


$2,70010%

10% after ded

31609PA015003516884.WR-I Rev. 1.16


RATE PAGES

Page Number: 11 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$162.93 $162.93 $287.40 $287.40 $253.50 $253.50$256.59 $288.66 $452.61 $509.18 $399.21 $449.11$256.59 $288.66 $452.61 $509.18 $399.21 $449.11$256.59 $288.66 $452.61 $509.18 $399.21 $449.11$256.59 $288.66 $452.61 $509.18 $399.21 $449.11$257.61 $289.82 $454.42 $511.22 $400.81 $450.91$262.75 $295.59 $463.47 $521.40 $408.79 $459.89$268.90 $302.52 $474.33 $533.62 $418.37 $470.67$278.91 $313.77 $491.98 $553.48 $433.94 $488.18$287.12 $323.01 $506.47 $569.77 $446.71 $502.55$291.23 $342.19 $513.71 $603.61 $453.10 $532.39$297.38 $349.43 $524.57 $616.37 $462.68 $543.65$303.54 $356.66 $535.43 $629.13 $472.26 $554.91$307.39 $361.18 $542.22 $637.11 $478.25 $561.95$311.50 $366.01 $549.46 $645.62 $484.64 $569.45$313.55 $368.42 $553.08 $649.87 $487.83 $573.20$315.60 $370.83 $556.70 $654.13 $491.03 $576.96$317.65 $373.24 $560.33 $658.38 $494.22 $580.71$319.71 $375.66 $563.95 $662.64 $497.41 $584.46$323.81 $380.48 $571.19 $671.15 $503.80 $591.97$327.92 $401.70 $578.43 $708.58 $510.19 $624.98$334.08 $409.24 $589.29 $721.88 $519.77 $636.72$339.98 $416.47 $599.70 $734.64 $528.95 $647.97$348.19 $426.53 $614.19 $752.38 $541.73 $663.61$358.45 $439.10 $632.29 $774.56 $557.69 $683.18$370.51 $453.88 $653.56 $800.61 $576.46 $706.16$384.88 $471.48 $678.91 $831.66 $598.81 $733.55$401.05 $491.28 $707.42 $866.59 $623.96 $764.35$419.52 $513.91 $740.01 $906.51 $652.71 $799.57$437.74 $536.23 $772.14 $945.88 $681.05 $834.29$458.26 $630.11 $808.35 $1,111.49 $712.99 $980.36$478.54 $657.99 $844.11 $1,160.65 $744.52 $1,023.72$500.86 $688.68 $883.49 $1,214.79 $779.26 $1,071.48$523.44 $719.73 $923.32 $1,269.56 $814.39 $1,119.78$547.81 $753.24 $966.31 $1,328.68 $852.31 $1,171.93$572.19 $786.76 $1,009.31 $1,387.80 $890.24 $1,224.07$598.62 $823.10 $1,055.93 $1,451.90 $931.35 $1,280.61$625.30 $859.79 $1,103.00 $1,516.62 $972.87 $1,337.70$653.78 $898.95 $1,153.24 $1,585.70 $1,017.18 $1,398.63$667.90 $918.36 $1,178.13 $1,619.93 $1,039.14 $1,428.82$696.38 $957.52 $1,228.37 $1,689.01 $1,083.45 $1,489.75$721.01 $991.39 $1,271.82 $1,748.75 $1,121.78 $1,542.44$737.17 $1,013.62 $1,300.34 $1,787.96 $1,146.93 $1,577.02$757.45 $1,041.49 $1,336.09 $1,837.13 $1,178.46 $1,620.39$769.76 $1,058.42 $1,357.82 $1,867.00 $1,197.63 $1,646.74$769.76 $1,058.42 $1,357.82 $1,867.00 $1,197.63 $1,646.74

8

Yes

16884.WR-I Rev. 1.16


31609PA0150039

Gold

$6,550Yes

31609PA015003816884.WR-I Rev. 1.16



$1,8500%

$0 after ded$6,550

Yes


$6,5500%

$0 after ded

31609PA015003716884.WR-I Rev. 1.16


$6,550


0%$0 after ded

RATE PAGES

Page Number: 12 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$252.03 $252.03 $205.99 $205.99 $232.47 $232.47$396.89 $446.51 $324.39 $364.94 $366.10 $411.86$396.89 $446.51 $324.39 $364.94 $366.10 $411.86$396.89 $446.51 $324.39 $364.94 $366.10 $411.86$396.89 $446.51 $324.39 $364.94 $366.10 $411.86$398.48 $448.29 $325.69 $366.40 $367.56 $413.51$406.42 $457.22 $332.18 $373.70 $374.89 $421.75$415.95 $467.94 $339.97 $382.46 $383.67 $431.63$431.42 $485.35 $352.62 $396.69 $397.95 $447.69$444.13 $499.64 $363.00 $408.37 $409.67 $460.87$450.48 $529.31 $368.19 $432.62 $415.52 $488.24$460.00 $540.50 $375.97 $441.77 $424.31 $498.56$469.53 $551.69 $383.76 $450.92 $433.10 $508.89$475.48 $558.69 $388.62 $456.63 $438.59 $515.34$481.83 $566.15 $393.81 $462.73 $444.45 $522.22$485.01 $569.88 $396.41 $465.78 $447.37 $525.67$488.18 $573.61 $399.00 $468.83 $450.30 $529.11$491.36 $577.34 $401.60 $471.88 $453.23 $532.55$494.53 $581.07 $404.20 $474.93 $456.16 $535.99$500.88 $588.54 $409.39 $481.03 $462.02 $542.87$507.23 $621.36 $414.58 $507.86 $467.88 $573.15$516.76 $633.03 $422.36 $517.39 $476.66 $583.91$525.89 $644.21 $429.82 $526.53 $485.08 $594.23$538.59 $659.77 $440.20 $539.25 $496.80 $608.58$554.46 $679.22 $453.18 $555.14 $511.44 $626.52$573.12 $702.07 $468.43 $573.82 $528.65 $647.59$595.34 $729.29 $486.59 $596.07 $549.15 $672.71$620.35 $759.92 $507.03 $621.11 $572.21 $700.96$648.92 $794.93 $530.38 $649.72 $598.57 $733.25$677.10 $829.45 $553.42 $677.94 $624.57 $765.09$708.85 $974.67 $579.37 $796.63 $653.86 $899.05$740.21 $1,017.79 $605.00 $831.87 $682.78 $938.82$774.74 $1,065.27 $633.22 $870.67 $714.63 $982.61$809.67 $1,113.29 $661.76 $909.93 $746.84 $1,026.91$847.37 $1,165.13 $692.58 $952.30 $781.62 $1,074.73$885.08 $1,216.98 $723.40 $994.67 $816.40 $1,122.56$925.96 $1,273.19 $756.81 $1,040.62 $854.11 $1,174.40$967.23 $1,329.94 $790.55 $1,087.00 $892.19 $1,226.76

$1,011.29 $1,390.52 $826.56 $1,136.51 $932.82 $1,282.63$1,033.12 $1,420.54 $844.40 $1,161.05 $952.96 $1,310.32$1,077.17 $1,481.11 $880.41 $1,210.56 $993.60 $1,366.19$1,115.27 $1,533.50 $911.55 $1,253.38 $1,028.74 $1,414.52$1,140.28 $1,567.88 $931.98 $1,281.48 $1,051.81 $1,446.23$1,171.63 $1,611.00 $957.61 $1,316.72 $1,080.73 $1,486.00$1,190.67 $1,637.19 $973.17 $1,338.13 $1,098.30 $1,510.16$1,190.67 $1,637.19 $973.17 $1,338.13 $1,098.30 $1,510.16



16884.WR-I Rev. 1.168


$3,3000%

$40 no ded/$80 no ded$6,800

0%

$7,150$30 no ded/$60 no ded

16884.WR-I Rev. 1.168

31609PA0150023

No$3,200

0%$2,000 $3,000


No

16884.WR-I Rev. 1.168


No


Gold

31609PA0150022 31609PA0150024

Silver

RATE PAGES

Page Number: 13 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco$247.99 $247.99 $252.83 $252.83 $206.79 $206.79$390.53 $439.35 $398.16 $447.93 $325.66 $366.36$390.53 $439.35 $398.16 $447.93 $325.66 $366.36$390.53 $439.35 $398.16 $447.93 $325.66 $366.36$390.53 $439.35 $398.16 $447.93 $325.66 $366.36$392.10 $441.11 $399.75 $449.72 $326.96 $367.83$399.91 $449.90 $407.71 $458.68 $333.47 $375.15$409.28 $460.44 $417.27 $469.43 $341.29 $383.95$424.51 $477.57 $432.80 $486.89 $353.99 $398.24$437.01 $491.63 $445.54 $501.23 $364.41 $409.96$443.26 $520.83 $451.91 $530.99 $369.62 $434.30$452.63 $531.84 $461.46 $542.22 $377.43 $443.49$462.00 $542.85 $471.02 $553.45 $385.25 $452.67$467.86 $549.74 $476.99 $560.46 $390.14 $458.41$474.11 $557.08 $483.36 $567.95 $395.35 $464.53$477.23 $560.75 $486.55 $571.69 $397.95 $467.59$480.36 $564.42 $489.73 $575.43 $400.56 $470.65$483.48 $568.09 $492.92 $579.18 $403.16 $473.71$486.61 $571.76 $496.10 $582.92 $405.77 $476.78$492.85 $579.10 $502.47 $590.41 $410.98 $482.90$499.10 $611.40 $508.84 $623.33 $416.19 $509.83$508.48 $622.88 $518.40 $635.04 $424.00 $519.40$517.46 $633.89 $527.56 $646.26 $431.49 $528.58$529.95 $649.19 $540.30 $661.86 $441.91 $541.34$545.58 $668.33 $556.22 $681.37 $454.94 $557.30$563.93 $690.82 $574.94 $704.30 $470.25 $576.05$585.80 $717.61 $597.23 $731.61 $488.48 $598.39$610.40 $747.75 $622.32 $762.34 $509.00 $623.52$638.52 $782.19 $650.98 $797.46 $532.45 $652.25$666.25 $816.16 $679.25 $832.09 $555.57 $680.57$697.49 $959.05 $711.11 $977.77 $581.62 $799.73$728.35 $1,001.48 $742.56 $1,021.02 $607.35 $835.10$762.32 $1,048.19 $777.20 $1,068.65 $635.68 $874.06$796.69 $1,095.45 $812.24 $1,116.83 $664.34 $913.46$833.79 $1,146.46 $850.06 $1,168.84 $695.27 $956.00$870.89 $1,197.48 $887.89 $1,220.85 $726.21 $998.54$911.12 $1,252.78 $928.90 $1,277.23 $759.75 $1,044.66$951.73 $1,308.63 $970.31 $1,334.17 $793.62 $1,091.23$995.08 $1,368.24 $1,014.50 $1,394.94 $829.77 $1,140.93

$1,016.56 $1,397.77 $1,036.40 $1,425.05 $847.68 $1,165.56$1,059.91 $1,457.38 $1,080.60 $1,485.82 $883.83 $1,215.26$1,097.40 $1,508.93 $1,118.82 $1,538.37 $915.09 $1,258.25$1,122.00 $1,542.76 $1,143.90 $1,572.87 $935.61 $1,286.46$1,152.86 $1,585.18 $1,175.36 $1,616.11 $961.33 $1,321.83$1,171.59 $1,610.95 $1,194.47 $1,642.39 $976.97 $1,343.33$1,171.59 $1,610.95 $1,194.47 $1,642.39 $976.97 $1,343.33

$7,150Yes

$3,0000%

$30 no ded/$60 no ded$40 no ded/$80 no ded$3,200

Yes

31609PA015004916884.WR-I Rev. 1.16



31609PA015004716884.WR-I Rev. 1.16



$2,0000%

No

8

31609PA0150046

16884.WR-I Rev. 1.16

$6,550


$3,2000%

$0 after ded


RATE PAGES

Page Number: 14 04/15/2015




Network =>Metal =>




Age Band0-202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364

65+

Non-Tobacco Tobacco Non-Tobacco Tobacco$233.27 $233.27 $248.61 $248.61$367.36 $413.28 $391.51 $440.45$367.36 $413.28 $391.51 $440.45$367.36 $413.28 $391.51 $440.45$367.36 $413.28 $391.51 $440.45$368.83 $414.93 $393.08 $442.21$376.18 $423.20 $400.91 $451.02$384.99 $433.12 $410.30 $461.59$399.32 $449.24 $425.57 $478.77$411.08 $462.46 $438.10 $492.86$416.96 $489.92 $444.36 $522.13$425.77 $500.28 $453.76 $533.17$434.59 $510.64 $463.16 $544.21$440.10 $517.12 $469.03 $551.11$445.98 $524.02 $475.29 $558.47$448.92 $527.48 $478.43 $562.15$451.85 $530.93 $481.56 $565.83$454.79 $534.38 $484.69 $569.51$457.73 $537.84 $487.82 $573.19$463.61 $544.74 $494.09 $580.55$469.49 $575.12 $500.35 $612.93$478.30 $585.92 $509.75 $624.44$486.75 $596.27 $518.75 $635.47$498.51 $610.67 $531.28 $650.82$513.20 $628.67 $546.94 $670.00$530.47 $649.83 $565.34 $692.54$551.04 $675.03 $587.27 $719.40$574.19 $703.38 $611.93 $749.61$600.64 $735.78 $640.12 $784.15$626.72 $767.73 $667.92 $818.20$656.11 $902.15 $699.24 $961.45$685.13 $942.05 $730.17 $1,003.98$717.09 $986.00 $764.23 $1,050.81$749.42 $1,030.45 $798.68 $1,098.19$784.32 $1,078.44 $835.87 $1,149.33$819.22 $1,126.42 $873.07 $1,200.47$857.05 $1,178.45 $913.39 $1,255.92$895.26 $1,230.98 $954.11 $1,311.90$936.04 $1,287.05 $997.57 $1,371.66$956.24 $1,314.83 $1,019.10 $1,401.26$997.02 $1,370.90 $1,062.56 $1,461.02

$1,032.29 $1,419.39 $1,100.14 $1,512.70$1,055.43 $1,451.22 $1,124.81 $1,546.61$1,084.45 $1,491.12 $1,155.74 $1,589.14$1,102.08 $1,515.37 $1,174.53 $1,614.98$1,102.08 $1,515.37 $1,174.53 $1,614.98

$6,800 $6,550Yes Yes

$3,300 $3,2000% 0%







2017 On-Exchange



e Silver Plan Rates



2017 Off-Exchange



e Silver Plan Rates

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

If macros are disabled, press and hold the ALT key and pres If you are a community rating state, select Family Option under Age and fill in all columns.If you are not community rating state, select 0-20 under Age and provide an Individual Rate for every age band.If Tobacco is Tobacco User/Non-Tobacco User, you must give a rate for Tobacco Use and Non-Tobacco Use.To add a new sheet, press the Add Sheet button, or Ctrl + Shift + H. All plans must have the same dates on a sheet.

HIOS Issuer ID* 31609Federal TIN* 23-2184623

Rate Effective Date* 1/1/2017Rate Expiration Date* 3/31/2017

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

Required:Enter the 14-character Plan ID

Required:Select the Rating Area ID

Require:Select if Tobacco use of subscriber is used to

determine if a person is eligible for a rate from a plan

Required:Select the age of a subscriber eligible for the

rate

Required:Enter the rate of an Individual Non-Tobacco

or No Preference enrollee on a plan

Required:Enter the rate of an Individual tobacco

enrollee on a plan

31609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 0-20 305.90 305.9031609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 21 481.73 541.9531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 22 481.73 541.9531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 23 481.73 541.9531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 24 481.73 541.9531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 25 483.66 544.1231609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 26 493.30 554.9631609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 27 504.86 567.9631609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 28 523.64 589.1031609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 29 539.06 606.4431609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 30 546.77 642.4531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 31 558.33 656.0431609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 32 569.89 669.6231609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 33 577.12 678.1131609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 34 584.82 687.1731609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 35 588.68 691.7031609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 36 592.53 696.2331609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 37 596.39 700.7531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 38 600.24 705.2831609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 39 607.95 714.3431609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 40 615.66 754.1831609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 41 627.22 768.3431609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 42 638.30 781.9131609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 43 653.71 800.8031609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 44 672.98 824.4031609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 45 695.62 852.1431609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 46 722.60 885.1931609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 47 752.95 922.3631609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 48 787.63 964.8531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 49 821.84 1006.7531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 50 860.38 1183.0231609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 51 898.43 1235.3531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 52 940.34 1292.9731609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 53 982.74 1351.2631609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 54 1028.50 1414.1931609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 55 1074.27 1477.1231609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 56 1123.89 1545.3431609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 57 1173.99 1614.2331609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 58 1227.46 1687.7531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 59 1253.95 1724.1931609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 60 1307.43 1797.7131609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 61 1353.67 1861.3031609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 62 1384.02 1903.0331609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 63 1422.08 1955.3631609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 64 1445.19 1987.1531609PA0150001 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 1445.19 1987.1531609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 0-20 292.45 292.4531609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 21 460.56 518.1331609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 22 460.56 518.1331609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 23 460.56 518.1331609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 24 460.56 518.1331609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 25 462.40 520.20

31609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 26 471.61 530.5631609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 27 482.66 543.0031609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 28 500.63 563.2031609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 29 515.36 579.7831609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 30 522.73 614.2131609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 31 533.79 627.2031609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 32 544.84 640.1931609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 33 551.75 648.3031609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 34 559.12 656.9631609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 35 562.80 661.2931609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 36 566.49 665.6231609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 37 570.17 669.9531609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 38 573.85 674.2831609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 39 581.22 682.9431609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 40 588.59 721.0331609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 41 599.65 734.5731609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 42 610.24 747.5431609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 43 624.98 765.6031609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 44 643.40 788.1631609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 45 665.04 814.6831609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 46 690.84 846.2731609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 47 719.85 881.8231609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 48 753.01 922.4431609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 49 785.71 962.5031609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 50 822.56 1131.0131609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 51 858.94 1181.0431609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 52 899.01 1236.1431609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 53 939.54 1291.8631609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 54 983.29 1352.0231609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 55 1027.04 1412.1831609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 56 1074.48 1477.4131609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 57 1122.38 1543.2731609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 58 1173.50 1613.5631609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 59 1198.83 1648.3931609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 60 1249.95 1718.6931609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 61 1294.17 1779.4831609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 62 1323.18 1819.3731609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 63 1359.57 1869.4031609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 64 1381.67 1899.8031609PA0150002 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 1381.67 1899.8031609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 0-20 241.06 241.0631609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 21 379.62 427.0731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 22 379.62 427.0731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 23 379.62 427.0731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 24 379.62 427.0731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 25 381.13 428.7831609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 26 388.73 437.3231609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 27 397.84 447.5731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 28 412.64 464.2231609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 29 424.79 477.8931609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 30 430.86 506.2731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 31 439.97 516.9731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 32 449.09 527.6831609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 33 454.78 534.3731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 34 460.85 541.5031609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 35 463.89 545.0731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 36 466.93 548.6431609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 37 469.96 552.2131609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 38 473.00 555.7831609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 39 479.08 562.9131609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 40 485.15 594.3131609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 41 494.26 605.4731609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 42 502.99 616.1631609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 43 515.14 631.0531609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 44 530.32 649.6531609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 45 548.17 671.5031609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 46 569.42 697.5431609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 47 593.34 726.8431609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 48 620.67 760.3231609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 49 647.62 793.3431609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 50 677.99 932.24

31609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 51 707.98 973.4831609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 52 741.01 1018.8931609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 53 774.42 1064.8231609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 54 810.48 1114.4131609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 55 846.54 1164.0031609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 56 885.64 1217.7631609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 57 925.12 1272.0531609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 58 967.26 1329.9831609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 59 988.14 1358.6931609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 60 1030.28 1416.6331609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 61 1066.72 1466.7431609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 62 1090.64 1499.6331609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 63 1120.63 1540.8631609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 64 1138.85 1565.9231609PA0150003 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 1138.85 1565.9231609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 0-20 241.21 241.2131609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 21 379.86 427.3431609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 22 379.86 427.3431609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 23 379.86 427.3431609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 24 379.86 427.3431609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 25 381.38 429.0531609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 26 388.97 437.6031609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 27 398.09 447.8531609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 28 412.91 464.5231609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 29 425.06 478.1931609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 30 431.14 506.5931609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 31 440.25 517.3031609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 32 449.37 528.0131609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 33 455.07 534.7131609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 34 461.15 541.8531609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 35 464.19 545.4231609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 36 467.22 548.9931609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 37 470.26 552.5631609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 38 473.30 556.1331609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 39 479.38 563.2731609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 40 485.46 594.6931609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 41 494.57 605.8531609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 42 503.31 616.5631609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 43 515.47 631.4531609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 44 530.66 650.0631609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 45 548.51 671.9331609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 46 569.79 697.9931609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 47 593.72 727.3031609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 48 621.07 760.8131609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 49 648.04 793.8531609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 50 678.43 932.8431609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 51 708.43 974.1031609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 52 741.48 1019.5431609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 53 774.91 1065.5031609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 54 811.00 1115.1231609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 55 847.08 1164.7431609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 56 886.21 1218.5431609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 57 925.71 1272.8531609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 58 967.88 1330.8331609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 59 988.77 1359.5631609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 60 1030.93 1417.5331609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 61 1067.40 1467.6731609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 62 1091.33 1500.5831609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 63 1121.34 1541.8431609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 64 1139.57 1566.9131609PA0150004 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 1139.57 1566.9131609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 0-20 209.21 209.2131609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 21 329.46 370.6531609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 22 329.46 370.6531609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 23 329.46 370.6531609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 24 329.46 370.6531609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 25 330.78 372.1331609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 26 337.37 379.5431609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 27 345.28 388.4431609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 28 358.13 402.8931609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 29 368.67 414.75

31609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 30 373.94 439.3831609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 31 381.85 448.6731609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 32 389.75 457.9631609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 33 394.70 463.7731609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 34 399.97 469.9631609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 35 402.60 473.0631609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 36 405.24 476.1631609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 37 407.87 479.2531609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 38 410.51 482.3531609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 39 415.78 488.5431609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 40 421.05 515.7931609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 41 428.96 525.4831609PA0150005 Rating Area 8 Tobacco User/Non-Tobacco User 42 436.54 534.7631609PA0150005 Rating 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31609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 34 482.62 567.0731609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 35 485.80 570.8131609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 36 488.98 574.5531609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 37 492.16 578.2831609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 38 495.34 582.0231609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 39 501.70 589.4931609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 40 508.06 622.3731609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 41 517.60 634.0631609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 42 526.74 645.2631609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 43 539.46 660.8431609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 44 555.37 680.3231609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 45 574.05 703.2131609PA0150008 Rating Area 8 Tobacco User/Non-Tobacco User 46 596.31 730.4831609PA0150008 Rating 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388.36 475.7431609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 41 395.65 484.6731609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 42 402.64 493.2331609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 43 412.36 505.1431609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 44 424.52 520.0331609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 45 438.80 537.5331609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 46 455.82 558.3831609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 47 474.96 581.8331609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 48 496.84 608.6331609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 49 518.42 635.0631609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 50 542.73 746.2531609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 51 566.73 779.2631609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 52 593.17 815.6131609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 53 619.91 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31609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 59 790.99 1087.6231609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 60 824.72 1134.0031609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 61 853.90 1174.1131609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 62 873.04 1200.4331609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 63 897.05 1233.4431609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 64 911.63 1253.5031609PA0150009 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 911.63 1253.5031609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 0-20 184.72 184.7231609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 21 290.90 327.2731609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 22 290.90 327.2731609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 23 290.90 327.2731609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 24 290.90 327.2731609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 25 292.07 328.5831609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 26 297.89 335.1231609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 27 304.87 342.9831609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 28 316.21 355.7431609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 29 325.52 366.2131609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 30 330.18 387.9631609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 31 337.16 396.1631609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 32 344.14 404.3631609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 33 348.50 409.4931609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 34 353.16 414.9631609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 35 355.49 417.7031609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 36 357.81 420.4331609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 37 360.14 423.1631609PA0150010 Rating Area 8 Tobacco User/Non-Tobacco User 38 362.47 425.9031609PA0150010 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305.78 374.5831609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 45 316.06 387.1831609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 46 328.32 402.1931609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 47 342.11 419.0831609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 48 357.87 438.3931609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 49 373.41 457.4331609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 50 390.92 537.5231609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 51 408.21 561.2931609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 52 427.25 587.4731609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 53 446.52 613.9631609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 54 467.31 642.5531609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 55 488.10 671.1431609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 56 510.65 702.1431609PA0150012 Rating Area 8 Tobacco User/Non-Tobacco User 57 533.41 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31609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 42 549.20 672.7731609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 43 562.46 689.0231609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 44 579.04 709.3331609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 45 598.52 733.1931609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 46 621.74 761.6331609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 47 647.85 793.6131609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 48 677.69 830.1731609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 49 707.12 866.2231609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 50 740.28 1017.8931609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 51 773.03 1062.9131609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 52 809.09 1112.4931609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 53 845.56 1162.6531609PA0150014 Rating Area 8 Tobacco User/Non-Tobacco User 54 884.94 1216.7931609PA0150014 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User/Non-Tobacco User 48 597.57 732.0231609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 49 623.52 763.8131609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 50 652.76 897.5431609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 51 681.63 937.2431609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 52 713.43 980.9631609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 53 745.59 1025.1931609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 54 780.31 1072.9331609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 55 815.03 1120.6731609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 56 852.68 1172.4331609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 57 890.69 1224.6931609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 58 931.26 1280.4831609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 59 951.36 1308.1231609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco User 60 991.93 1363.9031609PA0150015 Rating Area 8 Tobacco User/Non-Tobacco 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31609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 21 364.26 409.7931609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 22 364.26 409.7931609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 23 364.26 409.7931609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 24 364.26 409.7931609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 25 365.71 411.4331609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 26 373.00 419.6231609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 27 381.74 429.4631609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 28 395.95 445.4431609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 29 407.60 458.5531609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 30 413.43 485.7831609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 31 422.17 496.0531609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 32 430.92 506.3331609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 33 436.38 512.7531609PA0150022 Rating 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User/Non-Tobacco User 47 569.33 697.4331609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 48 595.56 729.5631609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 49 621.42 761.2431609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 50 650.56 894.5231609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 51 679.34 934.0931609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 52 711.03 977.6731609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 53 743.08 1021.7431609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 54 777.69 1069.3231609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 55 812.29 1116.9031609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 56 849.81 1168.4931609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 57 887.69 1220.5831609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 58 928.13 1276.1731609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco User 59 948.16 1303.7231609PA0150022 Rating Area 8 Tobacco User/Non-Tobacco 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User 27 352.12 396.1431609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 28 365.23 410.8831609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 29 375.98 422.9831609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 30 381.35 448.0931609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 31 389.42 457.5731609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 32 397.48 467.0431609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 33 402.52 472.9631609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 34 407.90 479.2831609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 35 410.59 482.4431609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 36 413.27 485.6031609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 37 415.96 488.7531609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 38 418.65 491.9131609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 39 424.03 498.2331609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 40 429.40 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31609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 46 503.99 617.3931609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 47 525.16 643.3231609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 48 549.35 672.9631609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 49 573.21 702.1831609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 50 600.09 825.1231609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 51 626.63 861.6231609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 52 655.86 901.8131609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 53 685.43 942.4731609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 54 717.35 986.3531609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 55 749.27 1030.2431609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 56 783.88 1077.8331609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 57 818.82 1125.8831609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 58 856.11 1177.1631609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 59 874.59 1202.5731609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 60 911.89 1253.8531609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 61 944.15 1298.2031609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 62 965.31 1327.3131609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 63 991.86 1363.8031609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 64 1007.97 1385.9831609PA0150023 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 1007.97 1385.9831609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 0-20 189.05 189.0531609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 21 297.72 334.9331609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 22 297.72 334.9331609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 23 297.72 334.9331609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 24 297.72 334.9331609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 25 298.91 336.2731609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 26 304.86 342.9731609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 27 312.01 351.0131609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 28 323.62 364.0731609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 29 333.15 374.7931609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 30 337.91 397.0431609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 31 345.06 405.4431609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 32 352.20 413.8431609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 33 356.67 419.0831609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 34 361.43 424.6831609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 35 363.81 427.4831609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 36 366.19 430.2831609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 37 368.58 433.0831609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 38 370.96 435.8731609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 39 375.72 441.4731609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 40 380.48 466.0931609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 41 387.63 474.8531609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 42 394.48 483.2331609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 43 404.00 494.9031609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 44 415.91 509.4931609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 45 429.91 526.6331609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 46 446.58 547.0631609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 47 465.33 570.0331609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 48 486.77 596.2931609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 49 507.91 622.1931609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 50 531.72 731.1231609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 51 555.24 763.4631609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 52 581.15 799.0831609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 53 607.35 835.1031609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 54 635.63 873.9931609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 55 663.91 912.8831609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 56 694.58 955.0431609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 57 725.54 997.6231609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 58 758.59 1043.0631609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 59 774.96 1065.5731609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 60 808.01 1111.0131609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 61 836.59 1150.3131609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 62 855.34 1176.1031609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 63 878.86 1208.4431609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 64 893.15 1228.0931609PA0150024 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 893.15 1228.0931609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 0-20 227.60 227.6031609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 21 358.42 403.2231609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 22 358.42 403.2231609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 23 358.42 403.2231609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 24 358.42 403.22

31609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 25 359.85 404.8331609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 26 367.02 412.9031609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 27 375.62 422.5831609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 28 389.60 438.3031609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 29 401.07 451.2131609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 30 406.81 478.0031609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 31 415.41 488.1031609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 32 424.01 498.2131609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 33 429.39 504.5331609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 34 435.12 511.2731609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 35 437.99 514.6431609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 36 440.86 518.0131609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 37 443.72 521.3731609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 38 446.59 524.7431609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 39 452.33 531.4831609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 40 458.06 561.1231609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 41 466.66 571.6631609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 42 474.91 581.7631609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 43 486.38 595.8131609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 44 500.71 613.3731609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 45 517.56 634.0131609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 46 537.63 658.6031609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 47 560.21 686.2631609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 48 586.02 717.8731609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 49 611.46 749.0431609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 50 640.14 880.1931609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 51 668.45 919.1231609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 52 699.63 962.0031609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 53 731.18 1005.3731609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 54 765.23 1052.1831609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 55 799.28 1099.0031609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 56 836.19 1149.7631609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 57 873.47 1201.0231609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 58 913.25 1255.7231609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 59 932.97 1282.8331609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 60 972.75 1337.5331609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 61 1007.16 1384.8431609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 62 1029.74 1415.8931609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 63 1058.05 1454.8231609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 64 1075.26 1478.4831609PA0150046 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 1075.26 1478.48











rate




enrollee on a plan


31609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 55 517.65 711.7731609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 56 541.56 744.6431609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 57 565.70 777.8431609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 58 591.47 813.2631609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 59 604.23 830.8231609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 60 630.00 866.2531609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 61 652.28 896.8931609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 62 666.91 917.0031609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 63 685.25 942.2131609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 64 696.39 957.5331609PA0160001 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 696.39 957.5331609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 0-20 150.87 150.8731609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 21 237.59 267.2931609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 22 237.59 267.2931609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 23 237.59 267.2931609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 24 237.59 267.2931609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 25 238.54 268.3631609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 26 243.30 273.7131609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 27 249.00 280.1231609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 28 258.26 290.5531609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 29 265.87 299.1031609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 30 269.67 316.8631609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 31 275.37 323.5631609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 32 281.07 330.2631609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 33 284.64 334.4531609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 34 288.44 338.9231609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 35 290.34 341.1531609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 36 292.24 343.3831609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 37 294.14 345.6231609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 38 296.04 347.8531609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 39 299.84 352.3231609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 40 303.64 371.9631609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 41 309.35 378.9531609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 42 314.81 385.6431609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 43 322.41 394.9631609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 44 331.92 406.6031609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 45 343.09 420.2831609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 46 356.39 436.5831609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 47 371.36 454.9131609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 48 388.47 475.8731609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 49 405.33 496.5331609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 50 424.34 583.4731609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 51 443.11 609.2831609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 52 463.78 637.7031609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 53 484.69 666.4531609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 54 507.26 697.4931609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 55 529.83 728.5231609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 56 554.31 762.1731609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 57 579.02 796.1531609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 58 605.39 832.4131609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 59 618.46 850.3831609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 60 644.83 886.6431609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 61 667.64 918.0031609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 62 682.61 938.5831609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 63 701.38 964.3931609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 64 712.77 980.0731609PA0160002 Rating Area 8 Tobacco User/Non-Tobacco User 65 and over 712.77 980.07

Supporting Document Schedules Satisfied - Item: REDACTED FILING DOCUMENTSComments:

Attachment(s): R-QCC Small Group Pennsylvania Actuarial Memorandum 2017 August 12_Redacted.pdfR-31609qccurrtptiii_SG_08122016_Redacted.pdf

Item Status:Status Date:

Satisfied - Item: Non-Confidential PDF FilesComments:

Attachment(s):

QCC Small Group Rate Change Request Summary 2017 August 12.pdf2017 SG Actuarial Memorandum Rate Exhibits QCC (Entity-Specific Gross Premium) 08052016 RV2.pdfREDACTED QCC cover letter sm grp August 12.pdf31609qccurrtptii_SG_08122016.pdfQCC PA Small Group Bulletin Information August 12.pdf31609qccurrtpt1_SG_08122016.pdf

Item Status:Status Date:







PENNSYLVANIA ACTUARIAL MEMORANDUM

PURPOSES

This Actuarial Memorandum is provided along with the Unified Rate Review Template (URRT) and PA

Actuarial Memorandum Rate Exhibits to provide certain information to support the gross premium for

the single risk pool for small group market health care insurance underwritten by QCC Insurance

Company in the Commonwealth of Pennsylvania. It is provided as a component of a state rate filing.

This submission may not be appropriate for other purposes.

1. BASIC INFORMATION AND DATA

A. COMPANY INFORMATION

Company Legal Name: QCC Insurance Company (“QCC”)

State: Pennsylvania

NAIC #: 93688

Market: Small Group

Marketplace: On and Off Exchange

Effective Date(s): 1/1/2017 – 3/31/2017, 4/1/2017 – 6/30/2017, 7/1/2017 – 9/30/2017,

10/1/2017 – 12/31/2017

Average Rate Change: 5.0%

Range of Rate Changes: 4.1% - 11.9%

Products: PPO

Rating Areas: Rating Area 8

Metal Levels: Platinum, Gold, Silver, Bronze

Current Members: 74,616

Current Policyholders: 35,577

Number of 2017 Plans: 38

HIOS Issuer ID (5-digit): 31609

Worksheet 1 of the accompanying URRT contains experience period data and development of the

projected Single Risk Pool Gross Premium Average Rate PMPM for the small group market for QCC.

Worksheet 2 contains experience period data and projections by product for the single risk pool for the

same entities. This memorandum pertains only to plans denoted in Worksheet 2 by Plan IDs starting

with the sequence 31609.

COMPANY CONTACT INFORMATION

Primary Contact Name:

Primary Contact Telephone Number:

Primary Contact Email Address:

B. RATE HISTORY AND PROPOSED VARIATIONS IN RATE CHANGES

January 1, 2014 Initial Filing INAC- 128999784

January 1, 2015 8.50% INAC- 129626740

October 1, 2015 -0.30% INAC- 130111048

January 1, 2016 6.51% INAC- 129939280

The historical rate changes varied by metallic tier based on plan benefits as illustrated via the Pricing AV.

Proposed rate changes vary by metallic tier and plan based on projected experience and plan benefit

changes.

C. AVERAGE RATE CHANGE

The average proposed rate change is 5.0%. The changes to the single risk pool gross premium average

rate per member per month (PMPM) from calendar year 2015 to calendar year 2017 are incorporated

into the pricing and reflected in the Unified Rate Review Template.

The change in 21-year-old Non-Tobacco Premium PMPM calculated in Table 11, Cell AZ13 is 5.2%.

D. MEMBERSHIP COUNT

Table 1 illustrates the Experience Period member-months, Current Period members as of February 1,

2016, and Projected Rating Period Member-months by ages.

E. BENEFIT CHANGES

Benefit changes were made to the following plans to assure compliance with Actuarial Value

requirements.

F. EXPERIENCE PERIOD CLAIMS AND PREMIUMS

Table 2 illustrates the experience period claims and premiums using calendar year data. The data is

consistent with the data reported in Section 1 of Worksheet I of the URRT.

Experience period premium, claims, and member months are obtained from the company’s internal

data warehouse. The claims data is collected for incurred dates from January through December 2015

and paid through January 2016. Earned premiums and member months are for January through

December 2015. The data are for all direct-written small group business of QCC in the Commonwealth

of Pennsylvania. No private reinsurance was applicable.

Projected Risk Adjustment PMPM

Non-EHB benefits are illustrated separately in cell H26. Capitation is uniform by age for the experience

period. Net pharmacy rebates are illustrated in cell J26.

Projected Risk Adjustment is accounted for in Projected Incurred Claims before ACA Reinsurance and

Risk Adjustment to reflect anticipated risk adjustment transfer amounts for the projection period. The

amount reflects the projected morbidity for the single risk pool for IBCFOC in the projection period.

The estimated risk adjustment revenue for all of the plans in the risk pool is developed using the

following methodology. We recognize that the HHS payment transfer formula implies that the projected

incurred claims based solely on the experience period single risk pool claims need to be adjusted by the

ratio of the current statewide market’s risk relative to allowable rating factor (ARF) for age compared to

the single risk pool’s risk relative to ARF presented during the experience period. This adjustment,

together with the assumed future changes in population risk morbidity, results in the issuer’s pricing

being consistent with the anticipated morbidity level of the future statewide market.

Estimating the current statewide market’s risk and ARF is difficult, because we do not have access to the

relevant data from other carriers operating in this market. In order to gain insight, we participated in

the Wakely Consulting Group’s risk adjustment reporting project for this market. Our assumptions are

the result of a combination of measurements based on Wakely’s reports and our own actuarial

judgment.

The anticipated risk adjustment transfer revenue is allocated proportionally based on plan premium.

The Projected Risk Adjustment is subtracted from Projected Incurred Claims before ACA Reinsurance

and Risk Adjustment to reflect anticipated receipt of risk adjustment transfer amounts for the projection

period.

When the projected risk adjustment amounts for KHPE and Independence Blue Cross (QCC) are

combined, the result is consistent with the projection made in our initial submission, and is comparable

to the Wakely projection. We also considered 2014 risk transfer results.

Projected ACA Reinsurance Recoveries Net of Reinsurance Premium (Individual Market Only)

The Federal Transitional Reinsurance Program is not applicable for 2017.

G. CREDIBILITY OF DATA

The experience period data is considered 100% credible.

H. TREND IDENTIFICATION

Table 3 identifies the proposed annual medical and prescription drug allowed claims cost and utilization

trends. These data match the data illustrated in Section 2 of Worksheet I of the URRT. Additional

discussion is provided in Section I, Historical Experience.

I. HISTORICAL EXPERIENCE

Table 4 illustrates historical experience from 2014 through 2015 for the product line.

a. Annualized Cost Trend

Annual cost trend reflects changes in costs of medical treatment due to medical inflation and changes in

the distribution of services across network providers. The trend value is developed by reviewing

historical medical costs for the single risk pool and adjusting them for anticipated future provider

contracting reimbursement levels. The data is normalized for changes in age, benefit changes during the

experience period, changes to provider contracts, and prescription drug formulary, and new drugs

brought to market.

b. Annualized Utilization Trend

Annual utilization trend reflects the change in the number of units per 1,000 members for a fixed level

of illness burden and includes changes due to the mix and intensity of services provided and changes

related to shifts in product mix. It also includes effects of selection, if any, since this cannot be reflected

in the relative cost of the various products and plans offered.

J. TERMINATED PLANS

The following plans, available in 2016, will be terminated effective January 1, 2017:

HIOS ID Plan Name

31609PA0150017 Personal Choice PPO Gold HRA 50

31609PA0150018 Personal Choice PPO Silver HRA 25



2. RATE DEVELOPMENT AND CHANGE

A. DEVELOPMENT OF PROJECTED INDEX RATE, MARKET-ADJUSTED INDEX RATE, & TOTAL

ALLOWED CLAIMS

Table 5 illustrates the development of the Projected Index Rate and Market-Adjusted Index Rate

beginning with the Experience Period Index Rate.

Changes in Population Risk Morbidity

Experience period allowed claims are adjusted to account for differences in the average morbidity of the

single risk pool population underlying the experience and the anticipated population in the projection

period. This adjustment reflects changes in the small group market-wide morbidity due to one or more

of the following: guarantee issue, the individual mandate, Medicaid and CHIP migration, take-up of

insurance by the previously uninsured, health status of the newly insured, enrollment from prior high

risk pools, subsidy effects, dumping of enrollment from group markets to the individual market, and

market-wide impact of transitional products/plans.

Changes in Other Factors

Experience period allowed claims are adjusted to account for differences in the single risk pool

population underlying the experience and the anticipated population in the projection period pertaining

to several factors not due to changes in morbidity or the costs and utilization of medical care. This

adjustment reflects: additional benefits required to be covered as essential health benefits; recently

mandated benefits required by state law that are not reflected in the experience period data; benefits in

the experience that are removed for the projection period; anticipated changes in the average

utilization of services due to differences in average cost sharing requirements during the experience

period and average cost sharing requirements in the projection period; changes in demographic

characteristics of the single risk pool experience period population and the projection period population

(including age, gender, region, and tobacco use); changes in the provider network (adding or removing a

provider system or introducing a limited network option); and anticipated changes in pharmacy rebates.

B. RETENTION ITEMS

Table 6 illustrates the retention items, expressed as percentages of premium. Administrative expenses

are calculated and applied on a PMPM basis. When expressed as a percentage of premium, these will

vary by premium size.

Administrative Expenses 10.08%

General and Claims 3.92%

Agent/Broker Fees and Commissions 5.74%

Quality Improvement Initiatives 0.42%

Taxes and Fees 5.34%

PCORI Fees 0.05%

PA Premium Tax 2.00%

Federal Income Tax 1.71%

Health Insurance Providers Fee 1.60%

Profit/Contingency 2.00%

Total Retention 17.41%

C. NORMALIZED MARKET-ADJUSTED PROJECTED ALLOWED TOTAL CLAIMS

Table 7 compares the normalization factors used in this filing to those used in the 2016 filing. The

changes in the factors reflect small differences from the projected populations in 2016 and 2017.

D. COMPONENTS OF RATE CHANGE

Table 8 illustrates the components of rate change, based on inputs form other sections of the Rate

Exhibits. The results in Row H are similar to the values in Row A of Table 8.

Data in Table 9 was taken from the 2016 URRT with the exceptions of Risk Adjustment and Reinsurance

which were revised to project company-specific values.

3. PLAN RATE DEVELOPMENT

Table 10 is populated with plan information consistent with entries in the 2017 URRT. Plan mappings,

where applicable, are illustrated in Column F of Table 10.

Attached to this actuarial memorandum are exhibits providing actuarial certifications for the use of

alternate methods of calculating the Actuarial Value, where applicable, as well as required support for

the calculations.

4. PLAN PREMIUM DEVELOPMENT FOR 21-YEAR OLD NON-TOBACCO USER

Table 11 is populated from other sections of the Rate Exhibits, along with the population by age and

rating area for the Projection Period.

5. PLAN FACTORS

Tables 12, 13, and 14 illustrate the factors used in pricing for age, tobacco, geographic rating area, and

network. To be consistent with our Consumer rating, we are proposing to use the tobacco factors

approved for 2016 in 2017 rating in consideration of the additional premium required for Individual

Plans by the terminating of the federal reinsurance program.

6. ACTUARIAL CERTIFICATION

I, , am Director & Actuary of Commercial Markets for the Independence Blue Cross Family of Companies. I am a member of the Society of Actuaries and the American Academy of

Actuaries with the education and experience necessary to perform the work necessary and meet the Qualification Standards of the American Academy of Actuaries to render the qualified actuarial opinion contained herein. The developed rates and memorandum have been prepared in conformity with appropriate Actuarial Standards of Practice and the Academy’s Code of Professional Conduct.

The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the premium rates and allowable rating factors. Rather, it represents information required by Federal regulation to be provided in support of the review of gross premium rate increases, for certification of qualified health plans for Federally facilitated exchanges, and for certification that the index rate is developed in accordance with Federal regulation and used consistently and only adjusted by the allowable modifiers.

I hereby certify that, to the best of my knowledge and judgment, the following:

The projected index rate is: —In compliance with all applicable State and Federal Statutes and Regulations (45 CFR

156.08(d)(1) and 147.106); —Developed in compliance with applicable Actuarial Standards of Practice; —Reasonable in relation to the benefits provided and the population anticipated to be

covered; and —Neither excessive nor deficient.

The index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 45 CFR 156.80(d)(2) were used to generate plan level rates.

The percent of total premium that represents essential health benefits included in Worksheet 2, Sections III and IV were calculated in accordance with actuarial standards of practice.

The AV Calculator was used to determine the AV Metal Values illustrated in Worksheet 2 of

the Part I Unified Rate Review Template for all plans, unless an alternate methodology was

required. If an alternate methodology was used to calculate the AV Metal Value for at least

one plan offered, a copy of the actuarial certification required by 45 CFR Part 156, §156.135

will be included.

All factor, benefit, and other changes from the prior approved filing have been disclosed in

the actuarial memorandum.

New plans cannot be considered modifications of existing plans under the uniform

modification standards in 45 CFR 147.106.

The information presented in the PA Actuarial Memorandum and PA Actuarial

Memorandum Rate Exhibits is consistent with the information presented in the 2017 Rate

Filing Justification.

May 11, 2016

GENERAL OVERVIEW

PURPOSES

This Actuarial Memorandum is provided along with the Unified Rate Review Template (URRT) to provide

certain information to support the gross premium for the single risk pool for small group market health

care insurance underwritten by QCC Insurance Company in the Commonwealth of Pennsylvania. It is

provided as a component of an application for certification as a Qualified Health Plan and a state rate

filing. This submission may not be appropriate for other purposes.

GENERAL INFORMATION

COMPANY IDENTIFYING INFORMATION

Company Legal Name: QCC Insurance Company (“QCC”)

State: Pennsylvania

HIOS Issuer ID (5-digit): 31609

Market: Small Group

Effective Date(s): 1/1/2017-3/31/2017, 4/1/2017 – 6/30/2017, 7/1/2017 – 9/30/2017,

10/1/2017 – 12/31/2017

Worksheet 1 of the accompanying URRT contains experience period data and development of the

projected Single Risk Pool Gross Premium Average Rate PMPM for the small group market for QCC.

Worksheet 2 contains experience period data and projections by product for the single risk pool for the

same entities.

COMPANY CONTACT INFORMATION

Primary Contact Name:

Primary Contact Telephone Number:

Primary Contact Email Address:

PROPOSED RATE INCREASE

The changes to the single risk pool gross premium average rate per member per month (PMPM) from

calendar year 2015 to calendar year 2017 were incorporated into the pricing and reflected in the Unified

Rate Review Template. The changes are driven by factors including: changes in market-wide population

risk morbidity and covered services, increasing unit costs for medical services, increasing utilization of

medical services, increasing fees and taxes imposed by the federal government, anticipated costs to

administer the plan, anticipated revenue or payments due to market-wide risk adjustment, and the

discontinuance of net reinsurance payments from the Federal Transitional Reinsurance Program.

The weighted average increase across QCC plans based on projected membership, inclusive of the

impact of benefit and cost sharing changes, is 5.0%. The minimum increase is 4.1% and the maximum

increase is 11.9%.

WORKSHEET 1: DATA COLLECTION TEMPLATE

SECTION I: EXPERIENCE PERIOD PREMIUM AND CLAIMS

PAID THROUGH DATE

Experience period premium, claims, and member months are obtained from the company’s internal

data warehouse. The claims data is collected for incurred dates from January through December 2015

and paid through January 2016. Earned premiums and member months are for January through

December 2015. The data are for all direct-written small group business of QCC in the Commonwealth

of Pennsylvania

PREMIUMS (NET OF MLR REBATE) IN EXPERIENCE PERIOD

Earned Premiums (net of MLR Rebate) in Experience Period are developed by summing the earned

premium reported in the company’s internal data warehouse and adjusting for MLR rebates, if any, for

the period. Although 2015 federal MLR rebate calculations are not final as of the writing of this

memorandum, no federal MLR rebates are expected for calendar year 2015, so no adjustment to earned

premium for MLR rebates is needed.

The calculation for federal minimum loss ratio rebates is based on 2013, 2014, and 2015 experience of

earned premium, incurred claims, quality improvement expenses, and taxes. The three years of

experience is blended for all segments.

ALLOWED AND INCURRED CLAIMS INCURRED DURING THE EXPERIENCE PERIOD

Paid-to-Date and Incurred Claims, and Member Months

Insurer fee-for-service claims expenses and member liabilities for dates of service in January 2015

through December 2015 and paid through January 2016 are sourced from the IBCFOC’s internal data

warehouse. The claims and member liabilities are completed with incurred but not reported (IBNR)

adjustments to develop ultimate incurred insurer fee-for-service claims expenses and member liabilities

for the January through December 2015 period. Capitation amounts are also sourced from the internal

data warehouse for the January through December 2015 period but they are not adjusted for IBNR.

Allowed Claims

Allowed claims are determined by separately obtaining paid-to-date fee-for-service claims and member

cost-sharing amounts, applying claim lag factors to those amounts to estimate ultimate incurred fee-for-

service claims and member-sharing amounts and adding them together with capitation amounts.

Allowed claims do not include ineligible claims, payments for services other than medical care provided,

recovery payments related to internal large claim pooling mechanisms, or active live reserves.

IBNR Development

Medical fee for service incurred but not reported (IBNR) claims are modeled through the use of standard

claim lag methodologies. A range of results is developed, and a provision for adverse deviation is

applied. The provision for adverse deviation is dependent on many factors such as stability, size, product

mix, etc.

The completion factors are developed annually in the 2Q – 3Q period. We do not believe our IBNR is

unusually high or unusually low for incurred 2015 paid through January 2016.

Experience Period Index Rate

The Index Rate of Experience Period is estimated by removing cost and utilization trend from the Index

Rate for Projection Period.

SECTION II: ALLOWED CLAIMS, PMPM BASIS

BENEFIT CATEGORIES

Utilization and Unit Cost data for allowed claims in the experience period are provided in Section II. The

data is provided by benefit category using a standardized indicator from the internal data warehouse

that assigns each claim line to a category based on the type of provider and the location of the service.

The utilization and unit cost data are provided for the following categories: Inpatient Hospital admits,

Outpatient Hospital visits, Professional visits, Other Medical visits, Capitation per member per month

(PMPM), and Prescription Drug scripts.

Experience Period capitation is reported as a per member per month (PMPM) value. In order to

complete the URRT, the Utilization per 1,000 statistics for capitated services only is reported as 1,000 so

that the appropriate capitation PMPM is reported.

PROJECTION FACTORS

The estimated incurred claims experience on an allowed basis for January 2015 through December 2015

is projected to the future rating period by several factors. Factors were calculated from the combined

experience of QCC and KHPE.

Changes in Population Risk Morbidity

Experience period allowed claims are adjusted to account for differences in the average morbidity of

the single risk pool population underlying the experience and the anticipated population in the

projection period. This adjustment reflects changes in the small group market-wide morbidity due to

one or more of the following: guarantee issue, the individual mandate, Medicaid and CHIP migration,

take-up of insurance by the previously uninsured, health status of the newly insured, enrollment from

prior high risk pools, subsidy effects, dumping of enrollment from group markets to the individual

market, and market-wide impact of transitional products/plans.

Changes in Other Factors

Experience period allowed claims are adjusted to account for differences in the single risk pool

population underlying the experience and the anticipated population in the projection period pertaining

to several factors not due to changes in morbidity or the costs and utilization of medical care. This

adjustment reflects: additional benefits required to be covered as essential health benefits; recently

mandated benefits required by state law that are not reflected in the experience period data; benefits in

the experience that are removed for the projection period; anticipated changes in the average

utilization of services due to differences in average cost sharing requirements during the experience

period and average cost sharing requirements in the projection period; changes in demographic

characteristics of the single risk pool experience period population and the projection period population

(including age, gender, region, and tobacco use); changes in the provider network (adding or removing a

provider system or introducing a limited network option); and anticipated changes in pharmacy rebates.

Trend Factors

a. Annualized Cost Trend

Annual cost trend reflects changes in costs of medical treatment due to medical inflation and changes in

the distribution of services across network providers. The trend value is developed by reviewing

historical medical costs for the single risk pool and adjusting them for anticipated future provider

contracting reimbursement levels. The data is normalized for changes in age, benefit changes during the

experience period, changes to provider contracts, and prescription drug formulary, and new drugs

brought to market.

b. Annualized Utilization Trend

Annual utilization trend reflects the change in the number of units per 1,000 members for a fixed level

of illness burden and includes changes due to the mix and intensity of services provided and changes

related to shifts in product mix. It also includes effects of selection, if any, since this cannot be reflected

in the relative cost of the various products and plans offered.

CREDIBILITY MANUAL RATE DEVELOPMENT

The experience period claims for the single risk pool are determined to be fully credible; therefore no

credibility adjustment is required.

SECTION III: PROJECTED EXPERIENCE

PAID TO ALLOWED RATIO

The Projected Allowed Experience Claims PMPM shown in Worksheet 1 represents projected allowed

claims experience PMPM for the projected portfolio of plans. The Paid to Allowed Average Factor in

Projection Period adjusts the allowed down to Projected Incurred Claims before ACA reinsurance and

risk adjustment for the population anticipated to be covered in the projection period. The Projected

Incurred Claims before ACA reinsurance and risk adjustment represents the net amount of incurred

insurer claim liability expected in the projection period, net of member cost sharing and cost sharing

paid by HHS on behalf of low-income members. It reflects the average benefit level anticipated during

the projection period. The ratio was calculated using incurred (before ACA reinsurance and risk

adjustment) and allowed PMPMs from worksheet two of the URRT.

RISK ADJUSTMENT AND REINSURANCE

Projected Risk Adjustment PMPM

Projected Risk Adjustment is accounted for in Projected Incurred Claims before ACA Reinsurance and

Risk Adjustment to reflect anticipated risk adjustment transfer amounts for the projection period. The

amount reflects the projected morbidity for the single risk pool for IBCFOC in the projection period.

The estimated risk adjustment revenue for all of the plans in the risk pool is developed using the

following methodology. We recognize that the HHS payment transfer formula implies that the projected

incurred claims based solely on the experience period single risk pool claims need to be adjusted by the

ratio of the current statewide market’s risk relative to allowable rating factor (ARF) for age compared to

the single risk pool’s risk relative to ARF presented during the experience period. This adjustment,

together with the assumed future changes in population risk morbidity, results in the issuer’s pricing

being consistent with the anticipated morbidity level of the future statewide market.

Estimating the current statewide market’s risk and ARF is difficult, because we do not have access to the

relevant data from other carriers operating in this market. In order to gain insight, we participated in

the Wakely Consulting Group’s risk adjustment reporting project for this market. Our assumptions are

the result of a combination of measurements based on Wakely’s reports and our own actuarial

judgment.

The anticipated risk adjustment transfer revenue is allocated proportionally based on plan premium.

The Projected Risk Adjustment is subtracted from Projected Incurred Claims before ACA Reinsurance

and Risk Adjustment to reflect anticipated receipt of risk adjustment transfer amounts for the projection

period.

When the projected risk adjustment amounts for KHPE and QCC are combined, the result is consistent

with the projection made in our initial submission, and is comparable to the Wakely projection. We also

considered 2014 risk transfer results.

Projected ACA Reinsurance Recoveries Net of Reinsurance Premium (Individual Market Only)

With the expiration of the reinsurance program at the end of the 2016 benefit year, there are no

projected reinsurance recoveries or reinsurance premium assumed in the rates.

NON-BENEFIT EXPENSES AND PROFIT & RISK

Administrative Expense Load

An Administrative Expense Load is applied to Projected Incurred Claims to reflect expenses related to

quality improvement and fraud detection/recovery and other expenses of operating a business, broker

commissions, and premium payment processing fees.

Profit & Risk Load/Contribution to Surplus

A Profit & Risk Load/Contribution to Surplus for the single risk pool is applied to Projected Incurred

Claims for the projection period, if applicable.

Taxes and Fees

A Taxes & Fees load is applied to Projected Incurred Claims to pass through fees and taxes levied by the

federal and state governments.

PROJECTED LOSS RATIO

The projected loss ratio for the single risk pool is estimated to exceed 80% reflecting premium

adjustments permitted by the federal MLR calculation.

SINGLE RISK POOL

The single risk pool reflects all covered lives for every small group non-grandfathered product and plan combination for QCC in the state of Pennsylvania. It is established according to the Single Risk Pool requirements in 45 CFR § 156.80(d).

INDEX RATE

The Index Rate is defined as the EHB portion of projected allowed claims divided by all projected single risk pool lives. The Index Rate is the same value for all non-grandfathered plans for QCC small group Plans in Pennsylvania. The Index Rate reflects the twelve month projection for calendar year 2017. It has been developed following the specifications of 45 CFR § 156.80(d)(1).

MARKET ADJUSTED INDEX RATE

The Market Adjusted Index rate is calculated as the Index Rate adjusted for all allowable market-wide

modifiers defined in the market rating rules: federal reinsurance program adjustment, risk adjustment

and exchange user fees. The Market Adjusted Index Rate reflects the average demographic

characteristics of the single risk pool.

PLAN ADJUSTED INDEX RATE

The Plan Adjusted Index Rate is calculated as the issuer Market Adjusted Index Rate adjusted for all

allowable plan level modifiers defined in the market rating rule. These include actuarial value and cost

sharing adjustment, provider network, delivery system and utilization management adjustment,

adjustment for benefits in addition to the EHBs, impact of specific eligibility categories for the

catastrophic plan and administrative costs.

CALIBRATION

The plan adjusted index rate is projected for all products using the same anticipated age distribution

and the mandated age curve. Therefore the consumer adjusted premium rate is the plan adjusted index

rate divided by the average age, geographic and tobacco factors for the expected distribution. The

average age of the combined small group risk pool population is 46.

The Average Age factor is the weighted average age factor based on the projected membership. The

Tobacco Factor is calculated as the projected average factor for tobacco users multiplied by the

projected tobacco use prevalence.

There is only one geographic rating area for this filing. The geographic rating area factor for this filing is

1.0.

WORKSHEET 2: PRODUCT-PLAN DATA COLLECTION

AV METAL VALUES

The AV Metal Values included in Worksheet 2 of the URRT were valued using the AV Calculator, where

possible, otherwise the AV Metal Values were developed under an alternate methodology. Actuarial

certifications required by 45 CFR Part 156, §156.135 are provided in a separate document.

AV PRICING VALUES

The AV Pricing Value represents the cumulative effect of adjustments made by plan to move from the

Market Adjusted Index Rate to the Plan Adjusted Index Rate.

MEMBERSHIP PROJECTIONS

Enrollment is projected based on current and anticipated enrollment by plan. Items impacting these

projections include changes in the size of the market due to introduction of guarantee issue

requirements and the individual mandate.

TERMINATED PLANS

The following plans, available in 2016, will be terminated effective January 1, 2017:

HIOS ID Plan Name





WARNING ALERTS

There are no warning alerts in URRT Part 1.

ACTUARIAL CERTIFICATION

I, , am Director & Actuary of Commercial Markets for the Independence Blue Cross Family of Companies. I am a member of the Society of Actuaries and the American Academy of Actuaries with the education and experience necessary to perform the work necessary and meet the Qualification Standards of the American Academy of Actuaries to render the qualified actuarial opinion contained herein. The developed rates and memorandum have been prepared in conformity with appropriate Actuarial Standards of Practice and the Academy’s Code of Professional Conduct.

The Part I Unified Rate Review Template does not demonstrate the process used by the issuer to develop the premium rates and allowable rating factors. Rather, it represents information required by Federal regulation to be provided in support of the review of gross premium rate increases, for certification of qualified health plans for Federally facilitated exchanges, and for certification that the index rate is developed in accordance with Federal regulation and used consistently and only adjusted by the allowable modifiers. I hereby certify that, to the best of my knowledge and judgment, the following:

The projected index rate is:

—In compliance with all applicable State and Federal Statutes and Regulations (45 CFR 156.08(d)(1) and 147.102);

—Developed in compliance with applicable Actuarial Standards of Practice;

—Reasonable in relation to the benefits provided and the population anticipated to be covered; and

—Neither excessive nor deficient.

The index rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 45 CFR 156.80(d)(2) were used to generate plan level rates.

The percent of total premium that represents essential health benefits included in Worksheet 2, Sections III and IV were calculated in accordance with actuarial standards of practice.

Geographic rating factors reflect only differences in the costs of delivery of and do not include differences for population morbidity by geographic area.

The AV Calculator was used to determine the AV Metal Values shown in Worksheet 2 of the

Part I Unified Rate Review Template for all plans, unless an alternate methodology was

required. If an alternate methodology was used to calculate the AV Metal Value for at least

one plan offered, a copy of the actuarial certification required by 45 CFR Part 156, §156.135

will be included.

May 11, 2016

Rate Change Request Summary - 2017 Pennsylvania Insurance Department | www.insurance.pa.gov

1

QCC Insurance Company – Small Group Plans Rate request filing ID # INAC- 130539936 - This document is prepared by the insurance company submitting the rate filing as a consumer tool to help explain the rate filing. It is not intended to describe or include all factors or information considered in the review process. For more information, see the filing at http://www.insurance.pa.gov/Consumers/ACARelatedFilings/

Overview

Requested average rate change: 5.0% Range of requested rate change: 4.1% - 11.9% Effective date: January 1, 2017 People impacted: 74,616 Available in: Rating Area 8

Key information Jan. 2015-Dec. 2015 financial experience

Premiums $437,196,684 Claims $390,342,631 Administrative expenses $75,330,956

Company made (before taxes) -$28,476,903

The company expects its annual medical costs to increase 8%.

Explanation of requested rate change

Scope and Range of the Rate Increase: QCC Insurance Company ("QCC”) is increasing premium rates for the Pennsylvania Consumer ACA compliant products by an average of 5.0%. This rate action is effective from January 1, 2017. The actual impact to premium for a specific customer may be different. About 75,000 members will be affected. Rates for two plans are increasing by more than 10%, affecting about 5,400 members. Financial Experience of the Product: QCC is required by federal law to pay out a minimum of 80% percent of premium dollars for medical claims—this is referred to as the minimum Medical Loss Ratio (MLR). The rate action proposed in this filing is expected to achieve a Medical Loss Ratio of greater than 80%. Changes in Medical Service Costs: Premium rates for health care insurance are increasing as the cost of health care service rise. Health care service costs increase as health care providers increase their fees, members use more health care services and supplies, and the types of health care services and supplies change, among other factors.

How it plans to spend your premium This is how the insurance company plans to spend the premium it collects in 2017:

Claims: 83% Administrative: 10% Taxes & fees: 5% Profit: 2%

http://www.insurance.pa.gov/

Nearly half of the change in health care service costs is driven by changes to health care provider fees. Changes in Benefits: Some plan benefits are mandated by federal and state law. Benefit changes for some plans were also made. All changes in benefits are in compliance with the uniform modifications rules stipulated by the Federal government. Administrative Costs: The premium rates presented in this filing include a 2% contribution to reserves. Furthermore, the Affordable Care Act (ACA) imposes taxes and other levies.

PA Rate Template Part I

Data Relevant to the Rate Filing

Table 1. Number of Members

Member-months Members Member-months

Experience PeriodCurrent Period

(as of Feb. 1, 2016)

Projected Rating

Period

Total 864,448 74,616 894,516

<18 197,316 16,365 196,189

18-24 99,827 8,502 101,919

25-29 52,694 4,876 58,450

30-34 52,223 4,747 56,913

35-39 53,540 4,748 56,925

40-44 61,690 5,090 61,016

45-49 77,368 6,616 79,313

50-54 87,571 7,359 88,220

55-59 89,911 7,754 92,951

60-63 63,249 5,543 66,449

64+ 29,058 3,017 36,171

Table 2. Experience Period Claims and Premiums

Earned Premium Paid ClaimsUltimate Incurred

ClaimsMember Months

Estimated Cost

Sharing

(Member & HHS)

Allowed Claims

(Non-Capitated)

Non-EHB

portion of

Allowed Claims

Total Prescription

Drug Rebates*

Total EHB

CapitationTotal Non-EHB Capitation

Estimated Risk

Adjustment

Estimated

Reinsurance

Recoveries

$428,296,353 $ 372,944,124.95 $406,632,382 864,448 $48,475,084 $455,107,466 $ 5,046,490.29 $ (121,022.72) $ 1,233,221.06 $ - 37,933,070.43$ (3,172,524.16)$

2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 521.92$

Loss Ratio 88.14%

*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Composite Weight*

5.10% 4.00% 9.30% 18.93% <- Annualized Trend Factors on URRT

4.00% 4.00% 8.16% 24.00%

2.20% 4.00% 6.29% 30.85%

2.20% 4.00% 6.29% 0.00%

1.50% 0.23%

4.50% 4.50% 9.20% 25.99%

8.05% 100.00%

1.168

* Express Cost, Utilization, and Weight as percentages

Table 4. Historical Experience

Month-Year Total Annual Premium Incurred Claims Completion Factors*Ultimate Incurred

ClaimsMembers

Ultimate

Incurred PMPM

Estimated Annual

Cost Sharing

(Member + HHS)

Prescription

Drug Rebates**

Allowed Claims (Net of

Prescription Drug Rebates)Allowed PMPM

Jan-13 #DIV/0! #DIV/0! #DIV/0!

Feb-13 #DIV/0! #DIV/0! #DIV/0!

Mar-13 #DIV/0! #DIV/0! #DIV/0!

Apr-13 #DIV/0! #DIV/0! #DIV/0!

May-13 #DIV/0! #DIV/0! #DIV/0!

Jun-13 #DIV/0! #DIV/0! #DIV/0!

Jul-13 #DIV/0! #DIV/0! #DIV/0!

Aug-13 #DIV/0! #DIV/0! #DIV/0!

Sep-13 #DIV/0! #DIV/0! #DIV/0!

Oct-13 #DIV/0! #DIV/0! #DIV/0!

Nov-13 #DIV/0! #DIV/0! #DIV/0!

Dec-13 #DIV/0! #DIV/0! #DIV/0!

Jan-14 $ 26,987,700.93 1.0000 $ 26,987,700.93 147,243 $ 183.29 $ (20,614.02) $ 32,295,398.35 $ 219.33

Feb-14 $ 23,456,163.04 1.0000 $ 23,456,163.04 141,504 $ 165.76 $ (19,810.56) $ 28,763,860.46 $ 203.27

Mar-14 $ 26,961,075.44 1.0000 $ 26,961,075.44 135,347 $ 199.20 $ (18,948.58) $ 32,268,772.86 $ 238.42

Apr-14 $ 26,892,132.93 1.0000 $ 26,892,132.93 120,937 $ 222.36 $ (16,931.18) $ 32,199,830.35 $ 266.25

May-14 $ 28,291,585.85 1.0000 $ 28,291,585.85 115,003 $ 246.01 $ (16,100.42) $ 33,599,283.27 $ 292.16

Jun-14 $ 27,378,404.87 1.0000 $ 27,378,404.87 107,637 $ 254.36 $ (15,069.18) $ 32,686,102.29 $ 303.67

Jul-14 $ 29,740,000.38 1.0000 $ 29,740,000.38 101,208 $ 293.85 $ (14,169.12) $ 35,047,697.80 $ 346.29

Aug-14 $ 28,074,087.73 1.0000 $ 28,074,087.73 95,954 $ 292.58 $ (13,433.56) $ 33,381,785.15 $ 347.89

Sep-14 $ 29,487,795.70 1.0000 $ 29,487,795.70 90,079 $ 327.35 $ (12,611.06) $ 34,795,493.12 $ 386.28

Oct-14 $ 31,871,006.88 1.0000 $ 31,871,006.88 85,356 $ 373.39 $ (11,949.84) $ 37,178,704.30 $ 435.57

Nov-14 $ 29,522,177.34 1.0000 $ 29,522,177.34 79,826 $ 369.83 $ (11,175.64) $ 34,829,874.76 $ 436.32

Dec-14 $ 32,863,054.39 0.9996 $ 32,875,459.36 71,459 $ 460.06 $ (10,004.26) $ 38,170,751.81 $ 534.16

Jan-15 $ 32,309,094.13 0.9994 $ 32,329,002.41 70,883 $ 456.09 $ (9,923.62) $ 36,348,684.46 $ 512.80

Feb-15 $ 30,811,430.03 0.9990 $ 30,843,700.88 70,886 $ 435.12 $ (9,924.04) $ 34,851,020.36 $ 491.65

Mar-15 $ 34,386,983.59 0.9984 $ 34,441,608.35 71,302 $ 483.04 $ (9,982.28) $ 38,426,573.92 $ 538.93

Apr-15 $ 32,814,106.30 0.9977 $ 32,891,297.43 71,301 $ 461.30 $ (9,982.14) $ 36,853,696.63 $ 516.87

May-15 $ 33,116,024.58 0.9964 $ 33,237,000.19 71,540 $ 464.59 $ (10,015.60) $ 37,155,614.91 $ 519.37

Jun-15 $ 34,454,919.93 0.9938 $ 34,669,616.42 71,588 $ 484.29 $ (10,022.32) $ 38,494,510.26 $ 537.72

Jul-15 $ 34,287,028.85 0.9908 $ 34,606,777.60 72,000 $ 480.65 $ (10,080.00) $ 38,326,619.17 $ 532.31

Aug-15 $ 33,017,075.37 0.9826 $ 33,601,024.54 72,128 $ 465.85 $ (10,097.92) $ 37,056,665.70 $ 513.76

Sep-15 $ 34,153,937.57 0.9751 $ 35,025,377.59 72,522 $ 482.96 $ (10,153.08) $ 38,193,527.89 $ 526.65

Oct-15 $ 36,701,611.69 0.9622 $ 38,145,266.23 73,026 $ 522.35 $ (10,223.64) $ 40,741,202.01 $ 557.90

Nov-15 $ 34,484,307.80 0.9298 $ 37,085,979.87 73,230 $ 506.43 $ (10,252.20) $ 38,523,898.13 $ 526.07

Dec-15 $ 36,095,862.16 0.8613 $ 41,908,532.43 74,042 $ 566.01 $ (10,365.88) $ 40,135,452.49 $ 542.06 * Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

2 Year Trend Projection Factor

Service Category

Other Medical

Capitation

Prescription Drugs

Total Annual Trend

Inpatient Hospital

Outpatient Hospital

Professional

$63,692,369

$48,475,084

$375,426,284

$428,296,353

Table 2b. Experience Period Claims and Premiums Table 2c. Experience Period Claims and Premiums

Earned

PremiumPaid Claims

Ultimate

Incurred

Claims

Member

Months

Estimated Cost

Sharing

(Member & HHS)

Allowed Claims

(Non-

Capitated)

Non-EHB

portion of

Allowed

Claims

Total

Prescription

Drug

Rebates*

Total EHB

Capitation

Total Non-

EHB

Capitation

Estimated Risk

Adjustment

Estimated

Reinsurance

Recoveries

Earned

PremiumPaid Claims

Ultimate

Incurred Claims

Member

Months

Estimated Cost

Sharing

(Member &

HHS)

Allowed

Claims (Non-

Capitated)

Non-EHB

portion of

Allowed

Claims

Total

Prescription

Drug Rebates*

Total EHB

Capitation

Total Non-

EHB

Capitation

Estimated Risk

Adjustment

Estimated

Reinsurance

Recoveries

2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) #DIV/0! 2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) #DIV/0!

Loss Ratio #DIV/0! Loss Ratio #DIV/0!

*Express Prescription Drug Rebates as a negative number *Express Prescription Drug Rebates as a negative number

Table 3b. Trend Components

Cost* Utilization* Composite Weight*

0.00% <- Annualized Trend Factors on URRT

0.00%

0.00%

0.00%

0.00%

0.00% 0.00%

1.000* Express Cost, Utilization, and Weight as percentages

Table 4b. Historical Experience

Month-YearTotal Annual

Premium

Incurred

Claims

Completion

Factors*

Ultimate Incurred

ClaimsMembers

Ultimate

Incurred

PMPM

Estimated

Annual Cost

Sharing

(Member +

HHS)

Prescription

Drug

Rebates**

Allowed

Claims (Net of

Prescription

Drug Rebates)

Allowed

PMPM




































Dec-15 #DIV/0! #DIV/0! #DIV/0!* Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

Prescription Drugs

Total Annual Trend

2 Year Trend Projection

Capitation

Service Category

Inpatient Hospital

Outpatient Hospital

Professional

Other Medical

PA Rate Template Part IIRate Development and Change

Table 5. Development of the Projected Index Rate, Market-Adjusted Index Rate, and Total Allowed Claims

2015 Total Allowed EHB Claims PMPM + EHB Capitation PMPM (net of prescription drug rebates) 521.92$ <- Index Rate of Experience Period on URRT Table 5A. Small Group Projected Index Rate with Quarterly Trend 2 Year Trend Projection Factor 1.168

Unadjusted Projected Allowed EHB Claims PMPM 609.38$ January April July October Total Single Risk Pool

Single Risk Pool Adjustment Factors <- Adj't. from Experience to Projection Period - Pop'l risk Morbidity on URRT # of Member Months Renewing in Quarter 356,976 205,913 128,688 172,871 864,448.00

Change in Morbidity 1.000 <- Adj't. from Experience to Projection Period - Other on URRT Percent of Members Months Renewing in Quarter 41% 24% 15% 20% 100%

Change in Other 1.070 Base Allowed Claims 652.27$ 652.27$ 652.27$ 652.27$ 652.27$

Change in Demographics 1.043 Months of Trend - 3 6 9 3

Change in Network 1.000 Annual Trend 8.05% 8.05% 8.05% 8.05% 8.05%

Change in Benefits 0.996 Single Risk Pool Projected Allowed Claims 652.27$ 665.03$ 678.03$ 691.29$ 666.95$

Change in Other 1.030

Adjusted Projected Allowed EHB Claims PMPM 652.27$ <- Index Rate for Projection Period on URRT - Individual (Small Group 1rst Qtr)

Adjusted Projected Allowed EHB Claims PMPM [will only populate for small group filings] 666.95$ <- Index Rate for Projection Period on URRT - Small Group

Projected Paid to Allowed Ratio 0.879956329 <- Paid to Allowed Average Factor in Projection Period on URRT

Projected Paid EHB Claims PMPM 586.8874645

Market-wide Adjustments

Projected Paid Net Risk Adjustment PMPM (88.06)$

Projected Paid Exchange User Fees PMPM 0.95$

Market-Adjusted Projected Paid EHB Claims PMPM 499.78$

Market-Adjusted Projected Allowed EHB Claims PMPM 567.96$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM 6.70$

Market-Adjusted Projected Paid Total Claims PMPM 505.67$

Market-Adjusted Projected Allowed Total Claims PMPM 574.66$

Table 6. Retention Table 7. Normalized Market-Adjusted Projected Allowed Total Claims

Retention Items - Express in percentages Normalization Factors 2016 2017

Administrative Expenses 10% Average Age Factor 1.457 1.492

General and Claims 3.92% Average Geographic Factor 1.000 1.000

Agent/Broker Fees and Commissions 5.74% Average Tobacco Factor 1.015 1.011

Quality Improvement Initiatives 0.42% Average Benefit Richness (induced demand) 0.979 0.961

Taxes and Fees 5.34% Average Network Factor 1.000 1.000

PCORI Fees (Enter $ amount here: $______________ ) 0.05%

Pa Premium Tax (if applicable) 2.00% Market-Adjusted Projected Allowed Total Claims PMPM 490.48$ 574.66$

Federal Income Tax 1.71%

Health Insurance Providers Fee (only for small group market, prorated for coverage in 2018) 1.60% Normalized Market-Adjusted Projected Allowed Total Claims PMPM 338.72$ 396.30$

Profit/Contingency 2%

Total Retention 17%

<- Single Pool Gross Premium Avg. Rate, PMPM on URRT

Projected Required Revenue PMPM 612.25$

Table 8. Components of Rate Change Table 9. Year-over-Year Data to Support Table 8

Rate Components 2016 2017 Difference Percent Change 2016 2017

A. Calibrated Plan Adjusted Index Rate (PMPM) 368.4178279 386.8380652 $18.42 5.0% Paid-to-Allowed 0.87 0.879956329

B. Base period allowed claims before normalization $510.00 521.92$ $11.92 3% URRT Trend (2-Year Trend Factor) 1.170906988 1.17 <- URRT W1, S2

C. Normalization factor component of change (157.80)$ -161.984619 -$4.18 -$0.01 URRT Morbidity 1.016 1.000 <- URRT W1, S2

URRT "Other" 1.009530314 1.070 <- URRT W1, S2

D. Change in Normalized Allowed Claims Adjustment Components D1. Base period allowed claims after normalization 352.20$ 359.94$ 7.74$ 2% Risk Adjustment (55.52)$ (88.06)$ <- URRT W1, S3

D2. URRT Trend 60.19$ 60.32$ 0.12$ 0% Reinsurance 2.22$ -$ <- URRT W1, S3

D3. URRT Morbidity 6.60$ -$ (6.60)$ -2% Exchange User Fee 0.97$ 0.95$ <- URRT W1, S3

D4. URRT Other 3.99$ 29.58$ 25.59$ 7% Capitation 1.37$ 1.53$ <- URRT W1, S2

D5. Normalized URRT RA/RI on an allowed basis (42.31)$ (69.02)$ (26.71)$ -7% D6. Normalized Exchange User Fee on an allowed basis 0.77$ 0.75$ (0.03)$ 0% Network 1.000 1 D7. Subtotal - Sum(D1:D6) 381.45$ 381.56$ 0.12$ 0% Pricing AV 0.828 0.840918257

E. Change in Allowable Plan Adjusted Level Components Benefit Richness 1.000 0.960838856 E1. Network -$ 0 -$ 0% Catastrophic Eligibility 1.000 1 E2. Pricing AV (65.62)$ (60.70)$ 4.92$ 1% E3. Benefit Richness -$ (12.57)$ (12.57)$ -3% Administrative Expenses 9.99% 10.08% E4. Catastrophic Eligibility -$ -$ -$ 0% Taxes and Fees 4.29% 5.36% E5. Subtotal - Sum(E1:E4) (65.62)$ (73.27)$ (7.64)$ -2% Profit and/or Contingency 0.00% 1.99%F. Change in Retention Components

F1. Administrative Expenses 36.79$ 38.99$ 2.20$ 1% F2. Taxes and Fees 15.81$ 20.72$ 4.91$ 1% F3. Profit and/or Contingency -$ 7.72$ 7.72$ 2% F4. Subtotal - Sum(F1:F3) 52.60$ 67.42$ 14.83$ 4%

G. Change in Miscellaneous Items -$ 0%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 368.42$ 375.72$ 7.30$ 2%

PA Rate Template Part IIITable 10. Plan Rates

Age Calibration Factor 1.492

Carrier Name: QCC Geographic Calibration Factor 1.000

Plan Type(s): PPO Aggregate Calibration Factor 1.492

Market Segment: Small Group

Rate Effective Date: 1/1/2017

Market Adjusted Index Rate 567.96$

Plan Number HIOS Plan ID (Standard Component)

Plan Type

(HMO, POS, PPO, EPO,

Indemnity, Other)

1/1/16 Plan

Marketing Name

Discontinued, New,

Modified, Existing

(D,N,M,E) for 2017

1/1/17 Plan

Marketing Name

(If 1/1/16 Plan

Discontinued)

Metallic

Tier

Metallic Tier

Actuarial

Value

Standard AV,

Approach (1),

Approach (2)

Exchange

On/Off or

Off

Pricing AV

(company-

determined

AV)

Benefit

Richness

(induced

demand)

Benefits in

addition to

EHB

Provider

Network

Catastrophic

Eligibility

Tobacco

Surcharge

Adjustment

Pure

Premium Admin Costs

Taxes & Fees (not

including Exchange

fees)

Profit or

Contingency

Total

Covered Lives @

2/1/2016

Total

Policyholders @

2/1/2016

2016

Calibrated Plan

Adjusted Index

Rate PMPM

2017

Calibrated Plan

Adjusted Index

Rate PMPM

Proposed Rate

Change

Compared to

Prior 12

months

% of Total

Covered Lives

Totals 0.805 0.841 1.000 1.000 1.000 1.000 0.989 478.90$ 10.1% 5.3% 2.0% 74,616 35,577 368.42$ 386.84$ 5.00%

Plan 1 31609PA0150001 PPO Personal Choice PPO Platinum Preferred $10/$20/$150E Personal Choice PPO Platinum Preferred $10/$20/$150Platinum 0.898 Approach 1 ON/OFF 0.935 1.155 1.000 1.000 1.000 0.989 $606.56 8.3% 5.3% 2.0% 66 42 462.00$ $481.73 4.3% 0.1%

Plan 2 31609PA0150002 PPO Personal Choice PPO Platinum Preferred $20/$40/$150E Personal Choice PPO Platinum Preferred $20/$40/$150Platinum 0.886 Approach 1 ON/OFF 0.928 1.109 1.000 1.000 1.000 0.989 $578.08 8.5% 5.3% 2.0% 172 100 441.69$ $460.56 4.3% 0.2%

Plan 3 31609PA0150003 PPO Personal Choice PPO Gold Preferred $35/$70/$600E Personal Choice PPO Gold Preferred $35/$70/$600Gold 0.814 Approach 1 ON/OFF 0.875 0.955 1.000 1.000 1.000 0.989 $469.20 9.8% 5.4% 2.0% 192 128 363.27$ $379.62 4.5% 0.3%

Plan 4 31609PA0150004 PPO Personal Choice PPO Gold Classic $1,000 $15/$30/80%E Personal Choice PPO Gold Classic $1,000 $15/$30/80%Gold 0.786 Approach 2 ON/OFF 0.820 1.019 1.000 1.000 1.000 0.989 $469.52 9.8% 5.4% 2.0% 26 8 360.93$ $379.86 5.2% 0.0%

Plan 5 31609PA0150005 PPO Personal Choice PPO Silver Classic $2,500 $30/$60/80%E Personal Choice PPO Silver Classic $2,500 $30/$60/80%Silver 0.704 Approach 2 ON/OFF 0.750 0.953 1.000 1.000 1.000 0.989 $401.74 10.9% 5.4% 2.0% 38 26 316.45$ $329.46 4.1% 0.1%

Plan 6 31609PA0150006 PPO Personal Choice PPO Platinum HSA-50 $1,500/100%E Personal Choice PPO Platinum HSA-50 $1,500/100%Platinum 0.889 Standard AV ON/OFF 0.920 0.999 1.000 1.000 1.000 0.989 $516.08 9.2% 5.4% 2.0% 2 - 397.51$ $414.49 4.3% 0.0%

Plan 7 31609PA0150007 PPO Personal Choice PPO Gold HSA-25 $2,200/100%E Personal Choice PPO Gold HSA-25 $2,200/100%Gold 0.819 Standard AV ON/OFF 0.825 0.971 1.000 1.000 1.000 0.989 $450.16 10.1% 5.4% 2.0% 126 74 349.63$ $365.48 4.5% 0.2%

Plan 8 31609PA0150008 PPO Personal Choice PPO Gold HSA-0 $1,700/100%E Personal Choice PPO Gold HSA-0 $1,700/100%Gold 0.781 Standard AV ON/OFF 0.825 1.064 1.000 1.000 1.000 0.989 $493.28 9.5% 5.4% 2.0% 2 - 380.60$ $397.54 4.5% 0.0%

Plan 9 31609PA0150009 PPO Personal Choice PPO Gold HSA-50 $2,200/70%E Personal Choice PPO Gold HSA-50 $2,200/70%Gold 0.799 Standard AV ON/OFF 0.825 0.792 1.000 1.000 1.000 0.989 $367.30 11.6% 5.4% 2.0% 56 28 290.11$ $303.88 4.7% 0.1%

Plan 10 31609PA0150010 PPO Personal Choice PPO Silver HSA-25 $2,400/50%E Personal Choice PPO Silver HSA-25 $2,400/50%Silver 0.683 Standard AV ON/OFF 0.760 0.819 1.000 1.000 1.000 0.989 $349.85 12.0% 5.4% 2.0% 58 50 260.78$ $290.90 11.6% 0.1%


Plan 12 31609PA0150012 PPO Personal Choice PPO Bronze HSA-0 $4,000/50%E Personal Choice PPO Bronze HSA-0 $4,000/50%Bronze 0.62 Standard AV ON/OFF 0.620 0.726 1.000 1.000 1.000 0.989 $252.98 15.2% 5.4% 2.0% 98 50 205.15$ $218.88 6.7% 0.1%

Plan 13 31609PA0150013 PPO Personal Choice PPO Bronze HSA-0 $6,550/100%E Personal Choice PPO Bronze HSA-0 $6,550/100%Bronze 0.612 Standard AV ON/OFF 0.620 0.787 1.000 1.000 1.000 0.989 $274.10 14.3% 5.4% 2.0% 12 10 220.20$ $234.58 6.5% 0.0%

Plan 14 31609PA0150014 PPO Personal Choice PPO Platinum HRA-50 $1,500/100%E Personal Choice PPO Platinum HRA-50 $1,500/100%Platinum 0.882 Standard AV ON/OFF 0.770 1.193 1.000 1.000 1.000 0.989 $516.08 9.2% 5.4% 2.0% 2 2 397.51$ $414.49 4.3% 0.0%

Plan 15 31609PA0150015 PPO Personal Choice PPO Gold HRA-25 $2,200/100%E Personal Choice PPO Gold HRA-25 $2,200/100%Gold 0.803 Standard AV ON/OFF 0.825 0.971 1.000 1.000 1.000 0.989 $450.16 10.1% 5.4% 2.0% 2 - 349.63$ $365.48 4.5% 0.0%

Plan 16 31609PA0150017 PPO Personal Choice PPO Gold HRA-50 $2,200/70%D Personal Choice PPO Gold HRA-50 $2,200/70%Gold 0.787 Standard AV ON/OFF 0.000 1.000 1.000 1.000 1.000 0.989 $0.00 0.0% 0.0% 0.0% 8 8 290.11$ $0.00 -100.0% 0.0%

Plan 17 31609PA0150018 PPO Personal Choice PPO Silver HRA-25 $2,400/50%D Personal Choice PPO Silver HRA-25 $2,400/50%Silver 0.72 Standard AV ON/OFF 0.000 1.000 1.000 1.000 1.000 0.989 $0.00 0.0% 0.0% 0.0% 2 4 260.78$ $0.00 -100.0% 0.0%

Plan 18 31609PA0150022 PPO Personal Choice PPO Gold Classic $2,000 $40/$80/100%E Personal Choice PPO Gold Classic $2,000 $40/$80/100%Gold 0.783 Approach 2 ON/OFF 0.860 0.928 1.000 1.000 1.000 0.989 $448.41 10.2% 5.4% 2.0% 1 - 346.06$ $364.26 5.3% 0.0%

Plan 19 31609PA0150023 PPO Personal Choice PPO Silver Classic $3,300 $40/$80/100%E Personal Choice PPO Silver Classic $3,300 $40/$80/100%Silver 0.699 Approach 2 ON/OFF 0.760 0.961 1.000 1.000 1.000 0.989 $410.38 10.8% 5.4% 2.0% 10 7 322.22$ $335.99 4.3% 0.0%

Plan 20 31609PA0150024 PPO Personal Choice PPO Silver Secure $3,000 $30/$60/$600E Personal Choice PPO Silver Secure $3,000 $30/$60/$600Silver 0.698 Standard AV ON/OFF 0.970 0.659 1.000 1.000 1.000 0.989 $358.88 11.9% 5.4% 2.0% 18 11 280.54$ $297.72 6.1% 0.0%

Plan 21 31609PA0150025 PPO Personal Choice PPO Platinum Preferred $10/$20/$150E Personal Choice PPO Platinum Preferred $10/$20/$150Platinum 0.898 Standard AV OFF 0.935 1.158 1.000 1.000 1.000 0.989 $608.02 8.3% 5.3% 2.0% 14,205 5,768 462.00$ $482.89 4.5% 19.0%

Plan 22 31609PA0150026 PPO Personal Choice PPO Platinum Preferred $20/$40/$150E Personal Choice PPO Platinum Preferred $20/$40/$150Platinum 0.886 Standard AV OFF 0.928 1.112 1.000 1.000 1.000 0.989 $579.53 8.5% 5.3% 2.0% 12,892 6,960 441.69$ $461.71 4.5% 17.3%

Plan 23 31609PA0150027 PPO Personal Choice PPO Gold Preferred $35/$70/$600E Personal Choice PPO Gold Preferred $35/$70/$600Gold 0.814 Standard AV OFF 0.875 0.957 1.000 1.000 1.000 0.989 $470.63 9.8% 5.4% 2.0% 12,017 5,998 363.27$ $380.77 4.8% 16.1%

Plan 24 31609PA0150028 PPO Personal Choice PPO Gold Classic $1,000 $15/$30/80%E Personal Choice PPO Gold Classic $1,000 $15/$30/80%Gold 0.786 Standard AV OFF 0.820 1.022 1.000 1.000 1.000 0.989 $470.95 9.8% 5.4% 2.0% 2,469 1,292 360.93$ $381.01 5.6% 3.3%

Plan 25 31609PA0150029 PPO Personal Choice PPO Silver Classic $2,500 $30/$60/80%E Personal Choice PPO Silver Classic $2,500 $30/$60/80%Silver 0.704 Standard AV OFF 0.750 0.957 1.000 1.000 1.000 0.989 $403.15 10.9% 5.4% 2.0% 2,045 1,108 316.45$ $330.62 4.5% 2.7%

Plan 26 31609PA0150030 PPO Personal Choice PPO Platinum HSA-50 $1,500/100%E Personal Choice PPO Platinum HSA-50 $1,500/100%Platinum 0.889 Standard AV OFF 0.920 1.001 1.000 1.000 1.000 0.989 $517.20 9.2% 5.4% 2.0% 2,470 1,115 397.51$ $415.39 4.5% 3.3%

Plan 27 31609PA0150031 PPO Personal Choice PPO Gold HSA-25 $2,200/100%E Personal Choice PPO Gold HSA-25 $2,200/100%Gold 0.819 Standard AV OFF 0.825 0.974 1.000 1.000 1.000 0.989 $451.26 10.1% 5.4% 2.0% 7,376 3,107 349.63$ $366.38 4.8% 9.9%

Plan 28 31609PA0150032 PPO Personal Choice PPO Gold HSA-0 $1,700/100%E Personal Choice PPO Gold HSA-0 $1,700/100%Gold 0.781 Standard AV OFF 0.825 1.067 1.000 1.000 1.000 0.989 $494.39 9.5% 5.4% 2.0% 3,514 1,523 380.60$ $398.44 4.7% 4.7%

Plan 29 31609PA0150033 PPO Personal Choice PPO Gold HSA-50 $2,200/70%E Personal Choice PPO Gold HSA-50 $2,200/70%Gold 0.799 Standard AV OFF 0.825 0.795 1.000 1.000 1.000 0.989 $368.39 11.6% 5.4% 2.0% 216 106 290.11$ $304.78 5.1% 0.3%

Plan 30 31609PA0150034 PPO Personal Choice PPO Silver HSA-25 $2,400/50%E Personal Choice PPO Silver HSA-25 $2,400/50%Silver 0.683 Standard AV OFF 0.760 0.822 1.000 1.000 1.000 0.989 $350.94 12.0% 5.4% 2.0% 5,342 421 260.78$ $291.81 11.9% 7.2%

Plan 31 31609PA0150035 PPO Personal Choice PPO Silver HSA-0 $2,400/90%E Personal Choice PPO Silver HSA-0 $2,400/90%Silver 0.697 Standard AV OFF 0.760 0.921 1.000 1.000 1.000 0.989 $393.36 11.1% 5.4% 2.0% 0 2,176 308.47$ $323.34 4.8% 0.0%

Plan 32 31609PA0150036 PPO Personal Choice PPO Bronze HSA-0 $4,000/50%E Personal Choice PPO Bronze HSA-0 $4,000/50%Bronze 0.62 Standard AV OFF 0.620 0.729 1.000 1.000 1.000 0.989 $254.02 15.2% 5.4% 2.0% 3,473 1,818 205.15$ $219.78 7.1% 4.7%

Plan 33 31609PA0150037 PPO Personal Choice PPO Bronze HSA-0 $6,550/100%E Personal Choice PPO Bronze HSA-0 $6,550/100%Bronze 0.612 Standard AV OFF 0.620 0.790 1.000 1.000 1.000 0.989 $275.16 14.3% 5.4% 2.0% 5,564 2,591 220.20$ $235.49 6.9% 7.5%

Plan 34 31609PA0150038 PPO Personal Choice PPO Platinum HRA-50 $1,500/100%E Personal Choice PPO Platinum HRA-50 $1,500/100%Platinum 0.882 Standard AV OFF 0.920 1.001 1.000 1.000 1.000 0.989 $517.20 9.2% 5.4% 2.0% 166 87 397.51$ $415.39 4.5% 0.2%

Plan 35 31609PA0150039 PPO Personal Choice PPO Gold HRA-25 $2,200/100%E Personal Choice PPO Gold HRA-25 $2,200/100%Gold 0.803 Standard AV OFF 0.825 0.974 1.000 1.000 1.000 0.989 $451.26 10.1% 5.4% 2.0% 1,226 539 349.63$ $366.38 4.8% 1.6%

Plan 36 31609PA0150040 PPO PPO Gold HRA D PPO Gold HRA Gold 0.788 Standard AV OFF 0.000 1.000 1.000 1.000 1.000 0.989 $0.00 0.0% 0.0% 0.0% 1 - -$ $0.00 #DIV/0! 0.0%

Plan 37 31609PA0150041 PPO Personal Choice PPO Gold HRA-50 $2,200/70%D Personal Choice PPO Gold HRA-50 $2,200/70%Gold 0.787 Standard AV OFF 0.000 1.000 1.000 1.000 1.000 0.989 $0.00 0.0% 0.0% 0.0% 90 48 290.11$ $0.00 -100.0% 0.1%

Plan 38 31609PA0150042 PPO Personal Choice PPO Silver HRA-25 $2,400/50%D Personal Choice PPO Silver HRA-25 $2,400/50%Silver 0.72 Standard AV OFF 0.000 1.000 1.000 1.000 1.000 0.989 $0.00 0.0% 0.0% 0.0% 93 53 260.78$ $0.00 -100.0% 0.1%

Plan 39 31609PA0150043 PPO PPO Silver HRA D PPO Silver HRA Silver 0.7 Standard AV OFF 0.000 1.000 1.000 1.000 1.000 0.989 $0.00 0.0% 0.0% 0.0% 1 - -$ $0.00 #DIV/0! 0.0%

Plan 40 31609PA0150044 PPO PPO Bronze HRA Premier D PPO Bronze HRA Premier Bronze 0.618 Standard AV OFF 0.000 1.000 1.000 1.000 1.000 0.989 $0.00 0.0% 0.0% 0.0% 1 - -$ $0.00 #DIV/0! 0.0%

Plan 41 31609PA0150045 PPO PPO Bronze HRA D PPO Bronze HRA Bronze 0.603 Standard AV OFF 0.000 1.000 1.000 1.000 1.000 0.989 $0.00 0.0% 0.0% 0.0% 1 - -$ $0.00 #DIV/0! 0.0%


Plan 43 31609PA0150047 PPO Personal Choice PPO Gold Classic $2,000 $40/$80/100%E Personal Choice PPO Gold Classic $2,000 $40/$80/100%Gold 0.783 Standard AV OFF 0.820 0.977 1.000 1.000 1.000 0.989 $449.96 10.1% 5.4% 2.0% 165 79 346.06$ $365.41 5.6% 0.2%

Plan 44 31609PA0150048 PPO Personal Choice PPO Silver Classic $3,300 $40/$80/100%E Personal Choice PPO Silver Classic $3,300 $40/$80/100%Silver 0.699 Standard AV OFF 0.760 0.965 1.000 1.000 1.000 0.989 $411.94 10.8% 5.4% 2.0% 94 57 322.22$ $337.15 4.6% 0.1%

Plan 45 31609PA0150049 PPO Personal Choice PPO Silver Secure $3,000 $30/$60/$600E Personal Choice PPO Silver Secure $3,000 $30/$60/$600Silver 0.698 Standard AV OFF 0.760 0.844 1.000 1.000 1.000 0.989 $360.44 11.8% 5.4% 2.0% 140 93 280.54$ $298.88 6.5% 0.2%

Plan 46 31609PA0150050 PPO Personal Choice PPO Silver HSA-0 $2,700/100%E Personal Choice PPO Silver HSA-0 $2,700/100%Silver 0.703 Standard AV OFF 0.760 1.035 1.000 1.000 1.000 0.989 $441.76 10.3% 5.4% 2.0% 146 80 342.46$ $359.32 4.9% 0.2%

Plan 47 0.000 1.000 1.000 1.000 1.000 1.000 $0.00 0.0% 0.0% 0.0% - $0.00 #DIV/0! 0.0%

Calibration

45 CFR Part 156.8 (d) (2) Allowable Factors

PA Rate Template Part IVTable 11. Plan Premium Development for 21-Year-Old Non-Tobacco User

Carrier Name: QCC

Plan Type(s): PPO

Market Segment: Small Group

Rate Effective Date: 1/1/2017

Plan Number HIOS Plan ID (Standard Component)

1/1/16 Plan

Marketing Name

Discontinued,

New, Modified,

Existing

(D,N,M,E) for

2017

1/1/17 Plan

Marketing Name

(If 1/1/16 Plan

Discontinued)

Metallic

Tier

Exchange

On/Off or

Off 1 2 3 4 5 6 7 8 9 Total 1 2 3 4 5 6 7 8 9

Average

(weighted by

enrollment by

rating area) 1 2 3 4 5 6 7 8 9

Average

(weighted by

enrollment by

rating area) 1 2 3 4 5 6 7 8 9

Average

(weighted by

enrollment by

rating area)

Totals - - - - - - - 74,616 - 74,616 -$ -$ -$ -$ -$ -$ -$ 368.42$ -$ 368.42$ -$ -$ -$ -$ -$ -$ -$ 386.84$ -$ 386.84$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.2% 0.0% 5.2%

Plan 1 31609PA0150001 Personal Choice PPO Platinum Preferred $10/$20/$150E Personal Choice PPO Platinum Preferred $10/$20/$150Platinum ON/OFF 66 66 -$ -$ -$ -$ -$ -$ -$ 462.00$ -$ 462.00$ -$ -$ -$ -$ -$ -$ -$ 481.73$ -$ 481.73$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.3% 0.0% 4.3%

Plan 2 31609PA0150002 Personal Choice PPO Platinum Preferred $20/$40/$150E Personal Choice PPO Platinum Preferred $20/$40/$150Platinum ON/OFF 172 172 -$ -$ -$ -$ -$ -$ -$ 441.69$ -$ 441.69$ -$ -$ -$ -$ -$ -$ -$ 460.56$ -$ 460.56$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.3% 0.0% 4.3%

Plan 3 31609PA0150003 Personal Choice PPO Gold Preferred $35/$70/$600E Personal Choice PPO Gold Preferred $35/$70/$600Gold ON/OFF 192 192 -$ -$ -$ -$ -$ -$ -$ 363.27$ -$ 363.27$ -$ -$ -$ -$ -$ -$ -$ 379.62$ -$ 379.62$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5% 0.0% 4.5%

Plan 4 31609PA0150004 Personal Choice PPO Gold Classic $1,000 $15/$30/80%E Personal Choice PPO Gold Classic $1,000 $15/$30/80%Gold ON/OFF 26 26 -$ -$ -$ -$ -$ -$ -$ 360.93$ -$ 360.93$ -$ -$ -$ -$ -$ -$ -$ 379.86$ -$ 379.86$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.2% 0.0% 5.2%

Plan 5 31609PA0150005 Personal Choice PPO Silver Classic $2,500 $30/$60/80%E Personal Choice PPO Silver Classic $2,500 $30/$60/80%Silver ON/OFF 38 38 -$ -$ -$ -$ -$ -$ -$ 316.45$ -$ 316.45$ -$ -$ -$ -$ -$ -$ -$ 329.46$ -$ 329.46$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.1% 0.0% 4.1%

Plan 6 31609PA0150006 Personal Choice PPO Platinum HSA-50 $1,500/100%E Personal Choice PPO Platinum HSA-50 $1,500/100%Platinum ON/OFF 2 2 -$ -$ -$ -$ -$ -$ -$ 397.51$ -$ 397.51$ -$ -$ -$ -$ -$ -$ -$ 414.49$ -$ 414.49$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.3% 0.0% 4.3%

Plan 7 31609PA0150007 Personal Choice PPO Gold HSA-25 $2,200/100%E Personal Choice PPO Gold HSA-25 $2,200/100%Gold ON/OFF 126 126 -$ -$ -$ -$ -$ -$ -$ 349.63$ -$ 349.63$ -$ -$ -$ -$ -$ -$ -$ 365.48$ -$ 365.48$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5% 0.0% 4.5%



Plan 10 31609PA0150010 Personal Choice PPO Silver HSA-25 $2,400/50%E Personal Choice PPO Silver HSA-25 $2,400/50%Silver ON/OFF 58 58 -$ -$ -$ -$ -$ -$ -$ 260.78$ -$ 260.78$ -$ -$ -$ -$ -$ -$ -$ 290.90$ -$ 290.90$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 11.6% 0.0% 11.6%


Plan 12 31609PA0150012 Personal Choice PPO Bronze HSA-0 $4,000/50%E Personal Choice PPO Bronze HSA-0 $4,000/50%Bronze ON/OFF 98 98 -$ -$ -$ -$ -$ -$ -$ 205.15$ -$ 205.15$ -$ -$ -$ -$ -$ -$ -$ 218.88$ -$ 218.88$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.7% 0.0% 6.7%

Plan 13 31609PA0150013 Personal Choice PPO Bronze HSA-0 $6,550/100%E Personal Choice PPO Bronze HSA-0 $6,550/100%Bronze ON/OFF 12 12 -$ -$ -$ -$ -$ -$ -$ 220.20$ -$ 220.20$ -$ -$ -$ -$ -$ -$ -$ 234.58$ -$ 234.58$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.5% 0.0% 6.5%

Plan 14 31609PA0150014 Personal Choice PPO Platinum HRA-50 $1,500/100%E Personal Choice PPO Platinum HRA-50 $1,500/100%Platinum ON/OFF 2 2 -$ -$ -$ -$ -$ -$ -$ 397.51$ -$ 397.51$ -$ -$ -$ -$ -$ -$ -$ 414.49$ -$ 414.49$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.3% 0.0% 4.3%

Plan 15 31609PA0150015 Personal Choice PPO Gold HRA-25 $2,200/100%E Personal Choice PPO Gold HRA-25 $2,200/100%Gold ON/OFF 2 2 -$ -$ -$ -$ -$ -$ -$ 349.63$ -$ 349.63$ -$ -$ -$ -$ -$ -$ -$ 365.48$ -$ 365.48$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5% 0.0% 4.5%

Plan 16 31609PA0150017 Personal Choice PPO Gold HRA-50 $2,200/70%D Personal Choice PPO Gold HRA-50 $2,200/70%Gold ON/OFF 8 8 -$ -$ -$ -$ -$ -$ -$ 290.11$ -$ 290.11$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% ##### 0.0% -100.0%

Plan 17 31609PA0150018 Personal Choice PPO Silver HRA-25 $2,400/50%D Personal Choice PPO Silver HRA-25 $2,400/50%Silver ON/OFF 2 2 -$ -$ -$ -$ -$ -$ -$ 260.78$ -$ 260.78$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% ##### 0.0% -100.0%

Plan 18 31609PA0150022 Personal Choice PPO Gold Classic $2,000 $40/$80/100%E Personal Choice PPO Gold Classic $2,000 $40/$80/100%Gold ON/OFF 1 1 -$ -$ -$ -$ -$ -$ -$ 346.06$ -$ 346.06$ -$ -$ -$ -$ -$ -$ -$ 364.26$ -$ 364.26$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.3% 0.0% 5.3%

Plan 19 31609PA0150023 Personal Choice PPO Silver Classic $3,300 $40/$80/100%E Personal Choice PPO Silver Classic $3,300 $40/$80/100%Silver ON/OFF 10 10 -$ -$ -$ -$ -$ -$ -$ 322.22$ -$ 322.22$ -$ -$ -$ -$ -$ -$ -$ 335.99$ -$ 335.99$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.3% 0.0% 4.3%

Plan 20 31609PA0150024 Personal Choice PPO Silver Secure $3,000 $30/$60/$600E Personal Choice PPO Silver Secure $3,000 $30/$60/$600Silver ON/OFF 18 18 -$ -$ -$ -$ -$ -$ -$ 280.54$ -$ 280.54$ -$ -$ -$ -$ -$ -$ -$ 297.72$ -$ 297.72$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.1% 0.0% 6.1%

Plan 21 31609PA0150025 Personal Choice PPO Platinum Preferred $10/$20/$150E Personal Choice PPO Platinum Preferred $10/$20/$150Platinum OFF 14,205 14,205 -$ -$ -$ -$ -$ -$ -$ 462.00$ -$ 462.00$ -$ -$ -$ -$ -$ -$ -$ 482.89$ -$ 482.89$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5% 0.0% 4.5%

Plan 22 31609PA0150026 Personal Choice PPO Platinum Preferred $20/$40/$150E Personal Choice PPO Platinum Preferred $20/$40/$150Platinum OFF 12,892 12,892 -$ -$ -$ -$ -$ -$ -$ 441.69$ -$ 441.69$ -$ -$ -$ -$ -$ -$ -$ 461.71$ -$ 461.71$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5% 0.0% 4.5%

Plan 23 31609PA0150027 Personal Choice PPO Gold Preferred $35/$70/$600E Personal Choice PPO Gold Preferred $35/$70/$600Gold OFF 12,017 12,017 -$ -$ -$ -$ -$ -$ -$ 363.27$ -$ 363.27$ -$ -$ -$ -$ -$ -$ -$ 380.77$ -$ 380.77$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.8% 0.0% 4.8%

Plan 24 31609PA0150028 Personal Choice PPO Gold Classic $1,000 $15/$30/80%E Personal Choice PPO Gold Classic $1,000 $15/$30/80%Gold OFF 2,469 2,469 -$ -$ -$ -$ -$ -$ -$ 360.93$ -$ 360.93$ -$ -$ -$ -$ -$ -$ -$ 381.01$ -$ 381.01$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.6% 0.0% 5.6%

Plan 25 31609PA0150029 Personal Choice PPO Silver Classic $2,500 $30/$60/80%E Personal Choice PPO Silver Classic $2,500 $30/$60/80%Silver OFF 2,045 2,045 -$ -$ -$ -$ -$ -$ -$ 316.45$ -$ 316.45$ -$ -$ -$ -$ -$ -$ -$ 330.62$ -$ 330.62$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5% 0.0% 4.5%

Plan 26 31609PA0150030 Personal Choice PPO Platinum HSA-50 $1,500/100%E Personal Choice PPO Platinum HSA-50 $1,500/100%Platinum OFF 2,470 2,470 -$ -$ -$ -$ -$ -$ -$ 397.51$ -$ 397.51$ -$ -$ -$ -$ -$ -$ -$ 415.39$ -$ 415.39$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5% 0.0% 4.5%

Plan 27 31609PA0150031 Personal Choice PPO Gold HSA-25 $2,200/100%E Personal Choice PPO Gold HSA-25 $2,200/100%Gold OFF 7,376 7,376 -$ -$ -$ -$ -$ -$ -$ 349.63$ -$ 349.63$ -$ -$ -$ -$ -$ -$ -$ 366.38$ -$ 366.38$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.8% 0.0% 4.8%

Plan 28 31609PA0150032 Personal Choice PPO Gold HSA-0 $1,700/100%E Personal Choice PPO Gold HSA-0 $1,700/100%Gold OFF 3,514 3,514 -$ -$ -$ -$ -$ -$ -$ 380.60$ -$ 380.60$ -$ -$ -$ -$ -$ -$ -$ 398.44$ -$ 398.44$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.7% 0.0% 4.7%

Plan 29 31609PA0150033 Personal Choice PPO Gold HSA-50 $2,200/70%E Personal Choice PPO Gold HSA-50 $2,200/70%Gold OFF 216 216 -$ -$ -$ -$ -$ -$ -$ 290.11$ -$ 290.11$ -$ -$ -$ -$ -$ -$ -$ 304.78$ -$ 304.78$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.1% 0.0% 5.1%

Plan 30 31609PA0150034 Personal Choice PPO Silver HSA-25 $2,400/50%E Personal Choice PPO Silver HSA-25 $2,400/50%Silver OFF 5,342 5,342 -$ -$ -$ -$ -$ -$ -$ 260.78$ -$ 260.78$ -$ -$ -$ -$ -$ -$ -$ 291.81$ -$ 291.81$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 11.9% 0.0% 11.9%

Plan 31 31609PA0150035 Personal Choice PPO Silver HSA-0 $2,400/90%E Personal Choice PPO Silver HSA-0 $2,400/90%Silver OFF 0 0 -$ -$ -$ -$ -$ -$ -$ 308.47$ -$ 308.47$ -$ -$ -$ -$ -$ -$ -$ 323.34$ -$ 323.34$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.8% 0.0% 4.8%

Plan 32 31609PA0150036 Personal Choice PPO Bronze HSA-0 $4,000/50%E Personal Choice PPO Bronze HSA-0 $4,000/50%Bronze OFF 3,473 3,473 -$ -$ -$ -$ -$ -$ -$ 205.15$ -$ 205.15$ -$ -$ -$ -$ -$ -$ -$ 219.78$ -$ 219.78$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.1% 0.0% 7.1%

Plan 33 31609PA0150037 Personal Choice PPO Bronze HSA-0 $6,550/100%E Personal Choice PPO Bronze HSA-0 $6,550/100%Bronze OFF 5,564 5,564 -$ -$ -$ -$ -$ -$ -$ 220.20$ -$ 220.20$ -$ -$ -$ -$ -$ -$ -$ 235.49$ -$ 235.49$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.9% 0.0% 6.9%

Plan 34 31609PA0150038 Personal Choice PPO Platinum HRA-50 $1,500/100%E Personal Choice PPO Platinum HRA-50 $1,500/100%Platinum OFF 166 166 -$ -$ -$ -$ -$ -$ -$ 397.51$ -$ 397.51$ -$ -$ -$ -$ -$ -$ -$ 415.39$ -$ 415.39$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.5% 0.0% 4.5%

Plan 35 31609PA0150039 Personal Choice PPO Gold HRA-25 $2,200/100%E Personal Choice PPO Gold HRA-25 $2,200/100%Gold OFF 1,226 1,226 -$ -$ -$ -$ -$ -$ -$ 349.63$ -$ 349.63$ -$ -$ -$ -$ -$ -$ -$ 366.38$ -$ 366.38$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.8% 0.0% 4.8%

Plan 36 31609PA0150040 PPO Gold HRA D PPO Gold HRA Gold OFF 1 1 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Plan 37 31609PA0150041 Personal Choice PPO Gold HRA-50 $2,200/70%D Personal Choice PPO Gold HRA-50 $2,200/70%Gold OFF 90 90 -$ -$ -$ -$ -$ -$ -$ 290.11$ -$ 290.11$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% ##### 0.0% -100.0%

Plan 38 31609PA0150042 Personal Choice PPO Silver HRA-25 $2,400/50%D Personal Choice PPO Silver HRA-25 $2,400/50%Silver OFF 93 93 -$ -$ -$ -$ -$ -$ -$ 260.78$ -$ 260.78$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% ##### 0.0% -100.0%

Plan 39 31609PA0150043 PPO Silver HRA D PPO Silver HRA Silver OFF 1 1 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Plan 40 31609PA0150044 PPO Bronze HRA Premier D PPO Bronze HRA Premier Bronze OFF 1 1 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Plan 41 31609PA0150045 PPO Bronze HRA D PPO Bronze HRA Bronze OFF 1 1 -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


Plan 43 31609PA0150047 Personal Choice PPO Gold Classic $2,000 $40/$80/100%E Personal Choice PPO Gold Classic $2,000 $40/$80/100%Gold OFF 165 165 -$ -$ -$ -$ -$ -$ -$ 346.06$ -$ 346.06$ -$ -$ -$ -$ -$ -$ -$ 365.41$ -$ 365.41$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.6% 0.0% 5.6%

Plan 44 31609PA0150048 Personal Choice PPO Silver Classic $3,300 $40/$80/100%E Personal Choice PPO Silver Classic $3,300 $40/$80/100%Silver OFF 94 94 -$ -$ -$ -$ -$ -$ -$ 322.22$ -$ 322.22$ -$ -$ -$ -$ -$ -$ -$ 337.15$ -$ 337.15$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.6% 0.0% 4.6%

Plan 45 31609PA0150049 Personal Choice PPO Silver Secure $3,000 $30/$60/$600E Personal Choice PPO Silver Secure $3,000 $30/$60/$600Silver OFF 140 140 -$ -$ -$ -$ -$ -$ -$ 280.54$ -$ 280.54$ -$ -$ -$ -$ -$ -$ -$ 298.88$ -$ 298.88$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.5% 0.0% 6.5%

Plan 46 31609PA0150050 Personal Choice PPO Silver HSA-0 $2,700/100%E Personal Choice PPO Silver HSA-0 $2,700/100%Silver OFF 146 146 -$ -$ -$ -$ -$ -$ -$ 342.46$ -$ 342.46$ -$ -$ -$ -$ -$ -$ -$ 359.32$ -$ 359.32$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 4.9% 0.0% 4.9%

Plan 47 0 0 0 0 0 0 - -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Change in 21-year-old Non-Tobacco Premium PMPM

These cells auto-fill using the data entered in Table 9.

2/1/16 Number of Covered Lives 2016 21-year-old Non-Tobacco Premium PMPM

(in small group market, average monthly premium weighted for quarterly trend)

2017 21-year-old Non-Tobacco Premium PMPM

(in small group market, average monthly premium weighted for quarterly trend)

PA Rate Template Part VConsumer Factors

Table 12. Age and Tobacco Factors Table 13. Geographic Factors

Age BandAge

Factor

Tobacco

FactorAge Band

Age

Factor

Tobacco

FactorArea Counties

Current

Factor

Proposed

Factor

0-20 0.635 43 1.357 1.225 Rating Area 1

21 1.000 1.125 44 1.397 1.225 Rating Area 2

22 1.000 1.125 45 1.444 1.225 Rating Area 3

23 1.000 1.125 46 1.500 1.225 Rating Area 4

24 1.000 1.125 47 1.563 1.225 Rating Area 5

25 1.004 1.125 48 1.635 1.225 Rating Area 6

26 1.024 1.125 49 1.706 1.225 Rating Area 7

27 1.048 1.125 50 1.786 1.375 Rating Area 8Bucks, Chester, Delaware, Philadelphia,

Montgomery1.000 1.000

28 1.087 1.125 51 1.865 1.375 Rating Area 9

29 1.119 1.125 52 1.952 1.375

30 1.135 1.175 53 2.040 1.375

31 1.159 1.175 54 2.135 1.375 Table 14. Network Factors32 1.183 1.175 55 2.230 1.375

33 1.198 1.175 56 2.333 1.375

34 1.214 1.175 57 2.437 1.375 Network Name Rating AreaCurrent

Factor

Proposed

Factor

DOH

Approval

Date

35 1.222 1.175 58 2.548 1.375 PPO Rating Area 8 1.000 1

36 1.230 1.175 59 2.603 1.375

37 1.238 1.175 60 2.714 1.375

38 1.246 1.175 61 2.810 1.375

39 1.262 1.175 62 2.873 1.375

40 1.278 1.225 63 2.952 1.375

41 1.302 1.225 64+ 3.000 1.375

42 1.325 1.225*PA follows the federal default age curve.

Geographic Area Factors2017 Age and Tobacco Factors

2017 Network Factors

May 11, 2016

Ms. Johanna Fabian-Marks, Special Deputy & Acting Director

Bureau of Accident and Health Insurance

Pennsylvania Insurance Department

1311 Strawberry Square

Harrisburg, PA 17120

SUBMITTED VIA SERFF

RE: QCC Insurance Company

Small Group PPO Rate Filing effective 1/1/2017

INAC-130539936

Dear Ms. Fabian-Marks:

QCC Insurance Company is introducing new and renewing PPO plans in the small

employer group market of the Commonwealth of Pennsylvania to satisfy market reform

requirements of the Affordable Care Act (ACA)—some plans are included in a

concurrent application for certification as a Qualified Health Plan. This rate filing

includes rates for these plans and specifies compliance with rating requirements of the

ACA. The proposed effective date for the enclosed rates is January 1, 2017.

This rate filing is being submitted along with concurrent form filing(s) and SERFF Plan

Management binder(s):

INLG-130545865

INLG-PA17-125061997

Please contact XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX with any

questions regarding this filing.

Sincerely,

XXXXXXXXXXXXXXXXX

Director and Actuary, Commercial Pricing

cc: XXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXX

URRT Part II – Consumer Friendly Justification

Scope and Range of the Rate Increase:

QCC Insurance Company ("QCC”) is increasing premium rates for the Pennsylvania Small Group ACA compliant products by an average of 5.0%. This rate action is effective from January 1, 2017. The actual impact to premium for a specific customer may be different. About 75,000 members will be affected. Rates for two plans are increasing by more than 10%, affecting about 5,400 members.

Financial Experience of the Product:

QCC is required by federal law to pay out a minimum of 80% percent of premium dollars for medical claims—this is referred to as the minimum Medical Loss Ratio (MLR). The rate action proposed in this filing is expected to achieve a Medical Loss Ratio of greater than 80%.

Changes in Medical Service Costs:

Premium rates for health care insurance are increasing as the cost of health care service rise. Health care service costs increase as health care providers increase their fees, members use more health care services and supplies, and the types of health care services and supplies change, among other factors. Nearly half of the change in health care service costs is driven by changes to health care provider fees.

Changes in Benefits:

Some plan benefits are mandated by federal and state law. Benefit changes for some plans were also made. All changes in benefits are in compliance with the uniform modifications rules stipulated by the Federal government.

Administrative Costs:

The premium rates presented in this filing include a 2% contribution to reserves. Furthermore, the Affordable Care Act (ACA) imposes taxes and other levies.

Information for Pennsylvania Bulletin

1. Company Legal Name: QCC Insurance Company

NAIC # 93688

2. Market: Small Group

3. Products: PPO

4. Average Rate Change: 5.0%; $27.84 PMPM

5. Current Members: 74,616

6. Experience Period Revenue $437,196,684

7. Additional Revenue from Increase $21,859,834

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3

4

5

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7

8

9

10

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12

13

14

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16

17

18

19

20

21

22

23

24

25

26

27

28

29

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31

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37

3839

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50

A B C D E F G H I J K L M N O P Q R S T U V W X Y

Ac

tioUnified Rate Review v3.3

Company Legal Name: QCC State: PA

HIOS Issuer ID: 31609 Market: Small Group

Effective Date of Rate Change(s): 1/1/2017

Market Level Calculations (Same for all Plans)

Section I: Experience period data

Experience Period: 1/1/2015 to 12/31/2015

Experience Period

Aggregate Amount PMPM % of Prem

Premiums (net of MLR Rebate) in Experience Period: $428,296,353 $495.46 100.00%

Incurred Claims in Experience Period $406,632,382 470.40 94.94%

Allowed Claims: $456,340,687 527.90 106.55%

Index Rate of Experience Period $522.00

Experience Period Member Months 864,448

Section II: Allowed Claims, PMPM basis

Experience Period Projection Period: 1/1/2017 to 12/31/2017 Mid-point to Mid-point, Experience to Projection: 24 months

on Actual Experience Allowed

Adj't. from Experience to

Projection Period Projections, before credibility Adjustment Credibility Manual

Benefit Category

Utilization

Description

Utilization per

1,000

Average

Cost/Service PMPM

Pop'l risk

Morbidity Other Cost Util

Utilization per

1,000

Average

Cost/Service PMPM

Utilization

per 1,000

Average

Cost/Service PMPM

Inpatient Hospital Admits 70.46 $16,618.41 $97.58 1.036 1.060 1.051 1.037 78.50 $19,458.12 $127.28 0.00 $0.00 $0.00

Outpatient Hospital Services 3,630.85 $417.61 126.36 1.036 1.060 1.040 1.037 4,044.70 478.79 161.38 0.00 $0.00 0.00

Professional Services 20,841.85 $96.86 168.23 1.036 1.060 1.022 1.037 23,217.42 107.24 207.49 0.00 $0.00 0.00

Other Medical Services 0.04 $57.68 0.00 1.036 1.060 1.022 1.040 0.04 63.86 0.00 0.00 $0.00 0.00

Capitation Services 12,000.00 1.44 1.44 1.036 1.060 1.000 1.000 12,432.00 1.53 1.58 0.00 $0.00 0.00

Prescription Drug Prescriptions 12,914.73 124.77 134.28 1.036 1.060 1.045 1.045 14,610.93 144.43 175.85 0.00 $0.00 0.00

Total $527.90 $673.59 $0.00

After Credibility Projected Period Totals

Section III: Projected Experience: Projected Allowed Experience Claims PMPM (w/applied credibility if applicable) 100.00% 0.00% $673.59 $603,126,086

Paid to Allowed Average Factor in Projection Period 0.880

Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM $592.73 $530,724,617

Projected Risk Adjustments PMPM 87.11 77,997,597

Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM $505.62 $452,727,020

Projected ACA reinsurance recoveries, net of rein prem, PMPM 0.00 0

Projected Incurred Claims $505.62 $452,727,020

Administrative Expense Load 10.08% 61.71 55,250,335

Profit & Risk Load 2.00% 12.25 10,964,329

Taxes & Fees 5.34% 32.69 29,274,758

Single Risk Pool Gross Premium Avg. Rate, PMPM $612.26 $548,216,442

Index Rate for Projection Period 666.95$

% increase over Experience Period 23.58%

% Increase, annualized: 11.16%

Projected Member Months 895,392

Information Not Releasable to the Public Unless Authorized by Law: This information has not been publically disclosed and may be privileged and confidential. It is for internal government use only and must not be

disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Annualized Trend

Factors

1 of 3

Action

Keyboard Product-Plan Data Collection

Company Legal Name: QCC State: PA

HIOS Issuer ID: 31609 Market: Small Group

Effective Date of Rate Change(s):

Product/Plan Level Calculations

Section I: General Product and Plan Information

Product

Product ID:

Metal: Gold Platinum Platinum Gold Gold Silver Platinum Gold Gold Gold Silver Silver Bronze Bronze Platinum Gold Gold

AV Metal Value 0.788 0.898 0.886 0.814 0.786 0.704 0.889 0.819 0.781 0.799 0.683 0.697 0.620 0.612 0.882 0.803 0.787

AV Pricing Value 0.000 1.080 1.029 0.835 0.836 0.715 0.919 0.801 0.878 0.654 0.623 0.698 0.450 0.488 0.919 0.801 0.000

Plan Category Terminated Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Terminated

Plan Type: PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

Plan Name

PPO Gold HRA

Personal Choice

PPO Platinum

Preferred

$10/$20/$150

Personal Choice

PPO Platinum

Preferred

$20/$40/$150

Personal Choice

PPO Gold

Preferred

$35/$70/$600

Personal Choice

PPO Gold Classic

$1,000

$15/$30/80%

Personal Choice

PPO Silver Classic

$2,500

$30/$60/80%

Personal Choice

PPO Platinum HSA-

50 $1,600/100%

Personal Choice

PPO Gold HSA-25

$2,400/100%

Personal Choice

PPO Gold HSA-0

$1,900/100%

Personal Choice

PPO Gold HSA-50

$2,650/70%

Personal Choice

PPO Silver HSA-0

$2,100/70%

Personal Choice

PPO Silver HSA-0

$2,700/90%

Personal Choice

PPO Bronze HSA-0

$5,200/50%

Personal Choice

PPO Bronze HSA-0

$6,550/100%

Personal Choice

PPO Platinum HRA-

50 $1,850/100%

Personal Choice

PPO Gold HRA-

25$2,900/100%

Personal Choice

PPO Gold HRA 50

Plan ID (Standard Component ID): 31609PA0150040 31609PA0150001 31609PA0150002 31609PA0150003 31609PA0150004 31609PA0150005 31609PA0150006 31609PA0150007 31609PA0150008 31609PA0150009 31609PA0150010 31609PA0150011 31609PA0150012 31609PA0150013 31609PA0150014 31609PA0150015 31609PA0150017

Exchange Plan? No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Historical Rate Increase - Calendar Year - 2

Historical Rate Increase - Calendar Year - 1

Historical Rate Increase - Calendar Year 0

Effective Date of Proposed Rates 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017 1/1/2017

Rate Change % (over prior filing) -100.00% 4.27% 4.27% 4.50% 5.24% 4.11% 4.27% 4.53% 4.45% 4.75% 11.55% 4.53% 6.69% 6.53% 4.27% 4.53% -100.00%

Cum'tive Rate Change % (over 12 mos prior) -100.00% 4.27% 4.27% 4.50% 5.24% 4.11% 4.27% 4.53% 4.45% 4.75% 11.55% 4.53% 6.69% 6.53% 4.27% 4.53% -100.00%

Proj'd Per Rate Change % (over Exper. Period) -100.00% 30.58% 20.56% 26.43% 54.87% 15.12% #DIV/0! 8.70% #DIV/0! -6.61% 43.56% 37.70% 11.88% -6.40% #DIV/0! 38.06% -100.00%

Product Rate Increase %

Section II: Components of Premium Increase (PMPM Dollar Amount above Current Average Rate PMPM)

Plan ID (Standard Component ID): Total 31609PA0150040 31609PA0150001 31609PA0150002 31609PA0150003 31609PA0150004 31609PA0150005 31609PA0150006 31609PA0150007 31609PA0150008 31609PA0150009 31609PA0150010 31609PA0150011 31609PA0150012 31609PA0150013 31609PA0150014 31609PA0150015 31609PA0150017

Inpatient $0.99 $0.00 $6.49 $6.47 -$0.06 $0.47 -$0.53 $6.48 -$0.10 $1.71 -$1.70 $2.21 -$1.36 -$9.22 -$8.01 $6.48 -$0.10 $0.00

Outpatient $8.22 $0.00 $15.52 $15.07 $6.97 $7.49 $5.47 $14.12 $6.63 $9.08 $3.78 $7.36 $4.51 -$5.37 -$3.85 $14.12 $6.63 $0.00

Professional $13.31 $0.00 $23.22 $22.47 $11.65 $12.31 $9.34 $20.88 $11.11 $14.44 $7.02 $11.37 $8.08 -$5.14 -$3.11 $20.88 $11.11 $0.00

Prescription Drug $36.48 $0.00 $50.94 $48.77 $34.41 $34.93 $28.87 $44.09 $32.93 $37.89 $25.17 $27.52 $27.38 $9.48 $12.21 $44.09 $32.93 $0.00

Other -$4.70 $0.00 -$7.05 -$6.27 -$4.45 -$4.36 -$2.68 -$4.56 -$3.93 -$4.79 -$1.94 -$0.75 -$2.57 -$0.15 -$0.51 -$4.56 -$3.93 $0.00

Capitation $1.73 $0.00 $0.53 $0.72 $1.23 $1.25 $1.66 $0.97 $1.20 $0.97 $1.70 $1.94 $1.54 $2.21 $2.11 $0.97 $1.20 $0.00

Administration -$14.54 $0.00 -$24.80 -$21.19 -$13.50 -$13.04 -$5.36 -$13.30 -$11.13 -$14.91 -$2.10 $3.81 -$4.95 $5.35 $3.81 -$13.30 -$11.13 $0.00

Taxes & Fees $7.82 $0.00 $10.00 $9.69 $7.49 $7.58 $6.69 $9.03 $7.27 $8.02 $6.13 $6.57 $6.45 $3.71 $4.13 $9.03 $7.27 $0.00

Risk & Profit Charge $18.51 $0.00 $22.83 $21.83 $18.00 $18.01 $15.62 $19.64 $17.32 $18.84 $14.41 $13.79 $15.28 $10.38 $11.13 $19.64 $17.32 $14.41

Total Rate Increase $67.82 $0.00 $97.68 $97.56 $61.74 $64.62 $59.09 $97.35 $61.30 $71.25 $52.46 $73.83 $54.37 $11.27 $17.89 $97.35 $61.30 $14.41

Member Cost Share Increase -$1.30 $0.00 $0.00 $0.00 -$4.61 -$1.44 -$1.71 $0.00 -$4.29 -$5.08 -$2.79 $22.44 -$0.16 -$0.45 -$0.88 $0.00 -$4.29 $0.00

Average Current Rate PMPM $551.47 $0.00 $691.06 $660.68 $543.38 $539.88 $473.34 $594.59 $522.98 $569.30 $433.95 $390.08 $461.41 $306.87 $329.38 $594.59 $522.98 $433.95

Projected Member Months 893,040 0 792 2,064 2,304 312 456 24 1,512 24 672 696 192 1,176 144 24 24 0

Section III: Experience Period Information

Warning Alert Wsht 1 Total Plan ID (Standard Component ID): Total 31609PA0150040 31609PA0150001 31609PA0150002 31609PA0150003 31609PA0150004 31609PA0150005 31609PA0150006 31609PA0150007 31609PA0150008 31609PA0150009 31609PA0150010 31609PA0150011 31609PA0150012 31609PA0150013 31609PA0150014 31609PA0150015 31609PA0150017

OK 495.46$ Plan Adjusted Index Rate $495.46 $468.32 $550.56 $570.09 $448.06 $366.02 $427.09 $0.00 $501.75 $0.00 $485.55 $302.39 $349.46 $291.94 $373.99 $0.00 $395.04 $402.67

OK 864,448 Member Months 864,448 914 462 685 842 63 497 0 489 0 94 315 52 492 41 0 11 31

OK $428,296,353 Total Premium (TP) $428,296,376 $428,043 $254,357 $390,510 $377,270 $23,059 $212,265 $0 $245,358 $0 $45,641 $95,254 $18,172 $143,634 $15,333 $0 $4,345 $12,483

EHB Percent of TP, [see instructions] 98.89% 98.87% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% state mandated benefits portion of TP that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TP 1.11% 1.13% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66%

OK $456,340,687 Total Allowed Claims (TAC) $456,340,687 $556,313 $193,401 $173,576 $173,853 $13,797 $145,890 $0 $220,714 $0 $64,944 $260,251 $49,917 $31,116 $4,113 $0 $16 $1,504

EHB Percent of TAC, [see instructions] 98.90% 98.87% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% state mandated benefits portion of TAC that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TAC 1.10% 1.13% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66%

Allowed Claims which are not the issuer's obligation: $67,358,305 $46,173 $20,907 $24,120 $31,452 $3,927 $52,919 $0 $56,599 $0 $28,824 $69,191 $11,682 $25,503 $1,946 $0 $0 $1,225Portion of above payable by HHS's funds on

behalf of insured person, in dollars $0Portion of above payable by HHS on behalf

of insured person, as % 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% #DIV/0! 0.00% #DIV/0! 0.00% 0.00% 0.00% 0.00% 0.00% #DIV/0! #DIV/0! 0.00%OK $406,632,382 Total Incurred claims, payable with issuer funds $388,982,382 $510,140 $172,494 $149,456 $142,401 $9,870 $92,971 $0 $164,115 $0 $36,120 $191,059 $38,235 $5,613 $2,166 $0 $16 $279

Net Amt of Rein -$3,172,524.16 -$3,354.38 -$1,695.54 -$2,513.95 -$3,090.14 -$231.21 -$1,823.99 $0.00 -$1,794.63 $0.00 -$344.98 -$1,156.05 -$190.84 -$1,805.64 -$150.47 $0.00 -$40.37 -$113.77

Net Amt of Risk Adj $37,933,070.43 -$100,311.49 -$27,512.15 -$109,949.98 -$134,013.09 -$13,422.55 -$49,617.89 $0.00 $53,813.70 $0.00 -$22,849.98 $136,521.88 $2,576.29 -$99,657.31 -$8,541.73 $0.00 -$2,689.72 -$6,669.47

OK 470.40$ Incurred Claims PMPM $449.98 $558.14 $373.36 $218.18 $169.12 $156.66 $187.07 #DIV/0! $335.61 #DIV/0! $384.25 $606.54 $735.29 $11.41 $52.83 #DIV/0! $1.43 $9.01

OK 527.90$ Allowed Claims PMPM $527.90 $608.66 $418.62 $253.40 $206.48 $219.00 $293.54 #DIV/0! $451.36 #DIV/0! $690.89 $826.19 $959.94 $63.24 $100.31 #DIV/0! $1.43 $48.52

EHB portion of Allowed Claims, PMPM $522.07 $601.78 $415.85 $251.72 $205.11 $217.56 $291.60 #DIV/0! $448.38 #DIV/0! $686.33 $820.74 $953.60 $62.83 $99.65 #DIV/0! $1.42 $48.20

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Personal Choice Exchange PPO Small Group

31609PA015

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4.16%

5.20%

Section IV: Projected (12 months following effective date)

Warning Alert Wsht 1 Total Plan ID (Standard Component ID): Total 31609PA0150040 31609PA0150001 31609PA0150002 31609PA0150003 31609PA0150004 31609PA0150005 31609PA0150006 31609PA0150007 31609PA0150008 31609PA0150009 31609PA0150010 31609PA0150011 31609PA0150012 31609PA0150013 31609PA0150014 31609PA0150015 31609PA0150017

OK 612.26$ Plan Adjusted Index Rate $578.80 $0.00 $718.89 $687.29 $566.50 $566.86 $491.65 $618.54 $545.41 $593.25 $453.47 $434.11 $481.19 $326.63 $350.06 $618.54 $545.41 $0.00

OK 895,392 Member Months 893,040 - 792 2,064 2,304 312 456 24 1,512 24 672 696 192 1,176 144 24 24 -

WARNING $548,216,442 Total Premium (TP) $516,891,935 $0 $569,361 $1,418,567 $1,305,216 $176,860 $224,192 $14,845 $824,660 $14,238 $304,732 $302,141 $92,388 $384,117 $50,409 $14,845 $13,090 $0

EHB Percent of TP, [see instructions] 98.89% 98.87% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34% 99.34%

state mandated benefits portion of TP that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Other benefits portion of TP 1.11% 1.13% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66% 0.66%

WARNING 603,126,086 Total Allowed Claims (TAC) $534,101,278 $0 $385,460 $599,537 $542,066 $77,142 $152,559 $0 $774,552 $0 $530,868 $655,317 $210,448 $84,033 $16,355 $0 $36 $0

EHB Percent of TAC, [see instructions] 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87% 98.87%

state mandated benefits portion of TAC that are other

than EHB 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TAC 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13% 1.13%

Allowed Claims which are not the issuer's obligation $60,051,725 $0 -$5,694 $19,464 $168,031 $22,695 $51,200 $1,094 $127,038 $1,413 $88,946 $99,201 $22,616 $234,083 $26,888 $1,094 $2,016 $0

Portion of above payable by HHS's funds on

behalf of insured person, in dollars $0Portion of above payable by HHS on behalf

of insured person, as % 0.00% #DIV/0! 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% #DIV/0!

OK 452,727,020 Total Incurred claims, payable with issuer funds $474,049,554 $0 $391,155 $580,073 $374,036 $54,447 $101,360 -$1,094 $647,514 -$1,413 $441,922 $556,116 $187,832 -$150,050 -$10,532 -$1,094 -$1,981 $0

#DIV/0! - Net Amt of Rein $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Net Amt of Risk Adj $34,037,474 $0 -$113,820 -$623,069 -$586,451 -$84,361 -$77,170 -$2 -$71,897 -$2 $59,565 $250,965 $89,735 -$265,964 -$28,819 -$2 -$10,258 $0

OK 505.62$ Incurred Claims PMPM $530.83 #DIV/0! $493.88 $281.04 $162.34 $174.51 $222.28 -$45.57 $428.25 -$58.87 $657.62 $799.02 $978.29 -$127.59 -$73.14 -$45.57 -$82.52 #DIV/0!

WARNING 673.59$ Allowed Claims PMPM $598.07 #DIV/0! $486.69 $290.47 $235.27 $247.25 $334.56 $0.00 $512.27 $0.00 $789.98 $941.55 $1,096.08 $71.46 $113.58 $0.00 $1.50 #DIV/0!

EHB portion of Allowed Claims, PMPM $591.31 #DIV/0! $481.19 $287.19 $232.61 $244.46 $330.78 $0.00 $506.48 $0.00 $781.06 $930.91 $1,083.70 $70.65 $112.29 $0.00 $1.48 #DIV/0!

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filing at a glance · plan design summary plan design marketing name. rate pages page number: 2...

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