rate/rule schedule...57 1030.42 1133.59 75729pa0012596 rating area 3 tobacco user/non-tobacco user...

184
Rate/Rule Schedule Item No. Schedule Item Status Document Name Affected Form Numbers (Separated with commas) Rate Action Rate Action Information Attachments 1 Indiv PPO Federal Rate Templates GSHP-130545596, GSHP- 130545580, GSHP-130545558 New RatesTables_GQO_In div.pdf, 2 Indiv PPO PID Rate Table GSHP-130545596, GSHP- 130545580, GSHP-130545558 New SERFF_Exhibits_GQO _Indiv.pdf, SERFF Tracking #: GSHP-130558343 State Tracking #: GSHP-130558343 Company Tracking #: INDPPO State: Pennsylvania Filing Company: Geisinger Quality Options TOI/Sub-TOI: H15I Individual Health - Hospital/Surgical/Medical Expense/H15I.001 Health - Hospital/Surgical/Medical Expense Product Name: PPO Project Name/Number: Indiv PPO 2017 ACA Filing/IndPPO PDF Pipeline for SERFF Tracking Number GSHP-130558343 Generated 06/14/2016 12:20 PM

Upload: others

Post on 27-Feb-2021

2 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Indiv PPO Federal RateTemplates

GSHP-130545596, GSHP-130545580, GSHP-130545558

New RatesTables_GQO_Indiv.pdf,

2 Indiv PPO PID Rate Table GSHP-130545596, GSHP-130545580, GSHP-130545558

New SERFF_Exhibits_GQO_Indiv.pdf,

SERFF Tracking #: GSHP-130558343 State Tracking #: GSHP-130558343 Company Tracking #: INDPPO

State: Pennsylvania Filing Company: Geisinger Quality Options

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

Product Name: PPO

Project Name/Number: Indiv PPO 2017 ACA Filing/IndPPO

PDF Pipeline for SERFF Tracking Number GSHP-130558343 Generated 06/14/2016 12:20 PM

Page 2: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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

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

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

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

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

HIOS Issuer ID* 75729

Federal TIN* 20-4275139

Rate Effective Date* 1/1/2017

Rate Expiration Date* 12/31/2017

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

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User0-20

249.96 249.96

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User21

393.64 433.00

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User22

393.64 433.00

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User23

393.64 433.00

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User24

393.64 433.00

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User25

395.21 434.57

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User26

403.08 443.23

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User27

412.53 453.86

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User28

427.88 470.79

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User29

440.48 484.56

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User30

446.77 491.65

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User31

456.22 501.88

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User32

465.67 512.12

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User33

471.57 518.81

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User34

477.87 525.50

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User35

481.02 529.04

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User36

484.17 532.59

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User37

487.32 536.13

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User38

490.47 539.67

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User39

496.77 546.36

Page 3: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User40

503.06 553.45

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User41

512.51 563.68

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User42

521.56 573.92

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User43

534.16 587.70

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User44

549.91 605.01

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User45

568.41 625.09

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User46

590.45 649.50

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User47

615.25 676.66

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User48

643.59 708.15

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User49

671.54 738.85

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User50

703.03 773.49

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User51

734.13 807.74

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User52

768.37 845.13

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User53

803.01 883.31

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User54

840.41 924.25

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User55

877.80 965.58

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User56

918.35 1010.06

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User57

959.29 1055.33

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User58

1002.98 1103.36

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User59

1024.63 1126.97

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User60

1068.32 1175.00

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User61

1106.11 1216.72

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User62

1130.91 1243.88

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User63

1162.01 1278.13

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User64

1180.90 1298.99

75729PA0012596 Rating Area 2 Tobacco User/Non-Tobacco User65 and over

1180.90 1298.99

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User0-20

268.49 268.49

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User21

422.83 465.11

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User22

422.83 465.11

Page 4: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User23

422.83 465.11

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User24

422.83 465.11

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User25

424.52 466.80

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User26

432.97 476.10

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User27

443.12 487.52

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User28

459.61 505.70

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User29

473.14 520.50

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User30

479.91 528.11

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User31

490.05 539.10

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User32

500.20 550.09

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User33

506.54 557.28

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User34

513.31 564.47

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User35

516.69 568.28

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User36

520.07 572.08

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User37

523.46 575.89

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User38

526.84 579.69

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User39

533.60 586.88

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User40

540.37 594.49

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User41

550.52 605.48

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User42

560.24 616.48

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User43

573.77 631.28

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User44

590.69 649.88

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User45

610.56 671.45

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User46

634.24 697.66

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User47

660.87 726.84

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User48

691.32 760.66

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User49

721.34 793.64

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User50

755.16 830.85

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User51

788.57 867.64

Page 5: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User52

825.35 907.80

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User53

862.56 948.82

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User54

902.73 992.79

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User55

942.90 1037.19

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User56

986.45 1084.97

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User57

1030.42 1133.59

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User58

1077.36 1185.18

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User59

1100.61 1210.55

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User60

1147.55 1262.13

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User61

1188.14 1306.95

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User62

1214.77 1336.13

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User63

1248.18 1372.91

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User64

1268.47 1395.32

75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

1268.47 1395.32

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User0-20

255.57 255.57

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User21

402.48 442.73

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User22

402.48 442.73

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User23

402.48 442.73

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User24

402.48 442.73

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User25

404.09 444.34

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User26

412.14 453.19

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User27

421.80 464.06

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User28

437.50 481.37

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User29

450.37 495.45

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User30

456.81 502.70

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User31

466.47 513.16

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User32

476.13 523.63

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User33

482.17 530.47

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User34

488.61 537.31

Page 6: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User35

491.83 540.93

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User36

495.05 544.55

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User37

498.27 548.18

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User38

501.49 551.80

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User39

507.93 558.64

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User40

514.37 565.89

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User41

524.03 576.35

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User42

533.29 586.81

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User43

546.16 600.90

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User44

562.26 618.61

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User45

581.18 639.14

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User46

603.72 664.09

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User47

629.08 691.86

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User48

658.05 724.06

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User49

686.63 755.45

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User50

718.83 790.87

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User51

750.62 825.89

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User52

785.64 864.12

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User53

821.06 903.16

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User54

859.29 945.02

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User55

897.53 987.28

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User56

938.98 1032.76

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User57

980.84 1079.05

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User58

1025.52 1128.15

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User59

1047.65 1152.30

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User60

1092.33 1201.40

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User61

1130.97 1244.06

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User62

1156.32 1271.83

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User63

1188.12 1306.85

Page 7: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User64

1207.44 1328.18

75729PA0012596 Rating Area 5 Tobacco User/Non-Tobacco User65 and over

1207.44 1328.18

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User0-20

269.34 269.34

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User21

424.16 466.57

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User22

424.16 466.57

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User23

424.16 466.57

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User24

424.16 466.57

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User25

425.85 468.26

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User26

434.33 477.59

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User27

444.51 489.05

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User28

461.05 507.28

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User29

474.63 522.13

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User30

481.41 529.76

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User31

491.59 540.79

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User32

501.77 551.82

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User33

508.13 559.03

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User34

514.92 566.24

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User35

518.31 570.06

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User36

521.71 573.88

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User37

525.10 577.69

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User38

528.49 581.51

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User39

535.28 588.72

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User40

542.07 596.36

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User41

552.25 607.38

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User42

562.00 618.41

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User43

575.57 633.26

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User44

592.54 651.92

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User45

612.47 673.55

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User46

636.23 699.85

Page 8: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User47

662.95 729.12

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User48

693.49 763.05

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User49

723.60 796.13

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User50

757.53 833.46

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User51

791.04 870.36

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User52

827.94 910.65

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User53

865.27 951.80

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User54

905.56 995.91

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User55

945.86 1040.44

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User56

989.55 1088.37

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User57

1033.66 1137.15

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User58

1080.74 1188.90

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User59

1104.07 1214.35

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User60

1151.15 1266.09

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User61

1191.87 1311.05

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User62

1218.59 1340.32

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User63

1252.09 1377.22

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User64

1272.45 1399.70

75729PA0012596 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

1272.45 1399.70

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User0-20

194.31 194.31

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User21

306.00 336.60

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User22

306.00 336.60

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User23

306.00 336.60

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User24

306.00 336.60

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User25

307.22 337.82

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User26

313.34 344.55

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User27

320.68 352.81

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User28

332.62 365.97

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User29

342.41 376.68

Page 9: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User30

347.30 382.19

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User31

354.65 390.14

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User32

361.99 398.10

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User33

366.58 403.30

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User34

371.48 408.50

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User35

373.93 411.26

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User36

376.37 414.01

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User37

378.82 416.77

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User38

381.27 419.52

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User39

386.17 424.72

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User40

391.06 430.23

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User41

398.41 438.19

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User42

405.44 446.14

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User43

415.24 456.85

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User44

427.48 470.31

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User45

441.86 485.92

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User46

458.99 504.89

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User47

478.27 526.01

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User48

500.30 550.49

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User49

522.03 574.35

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User50

546.51 601.28

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User51

570.68 627.90

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User52

597.30 656.97

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User53

624.23 686.65

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User54

653.30 718.48

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User55

682.37 750.61

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User56

713.89 785.18

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User57

745.71 820.37

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User58

779.68 857.70

Page 10: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User59

796.51 876.06

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User60

830.47 913.40

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User61

859.85 945.83

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User62

879.12 966.95

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User63

903.30 993.57

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User64

917.99 1009.78

75729PA0012603 Rating Area 2 Tobacco User/Non-Tobacco User65 and over

917.99 1009.78

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User0-20

208.72 208.72

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User21

328.69 361.56

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User22

328.69 361.56

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User23

328.69 361.56

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User24

328.69 361.56

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User25

330.00 362.87

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User26

336.58 370.10

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User27

344.46 378.98

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User28

357.28 393.11

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User29

367.80 404.61

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User30

373.06 410.53

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User31

380.95 419.08

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User32

388.84 427.62

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User33

393.77 433.21

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User34

399.03 438.80

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User35

401.66 441.76

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User36

404.29 444.71

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User37

406.91 447.67

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User38

409.54 450.63

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User39

414.80 456.22

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User40

420.06 462.13

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User41

427.95 470.68

Page 11: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User42

435.51 479.23

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User43

446.03 490.73

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User44

459.18 505.19

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User45

474.62 521.96

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User46

493.03 542.33

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User47

513.74 565.01

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User48

537.40 591.31

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User49

560.74 616.95

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User50

587.04 645.87

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User51

613.00 674.47

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User52

641.60 705.69

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User53

670.52 737.57

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User54

701.75 771.76

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User55

732.97 806.27

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User56

766.83 843.41

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User57

801.01 881.21

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User58

837.49 921.31

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User59

855.57 941.03

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User60

892.06 981.13

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User61

923.61 1015.97

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User62

944.32 1038.65

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User63

970.28 1067.25

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User64

986.06 1084.67

75729PA0012603 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

986.06 1084.67

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User0-20

198.67 198.67

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User21

312.88 344.16

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User22

312.88 344.16

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User23

312.88 344.16

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User24

312.88 344.16

Page 12: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User25

314.12 345.41

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User26

320.38 352.29

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User27

327.89 360.74

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User28

340.09 374.19

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User29

350.10 385.15

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User30

355.11 390.78

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User31

362.62 398.91

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User32

370.13 407.05

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User33

374.82 412.36

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User34

379.83 417.68

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User35

382.33 420.50

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User36

384.83 423.32

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User37

387.34 426.13

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User38

389.84 428.95

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User39

394.84 434.27

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User40

399.85 439.90

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User41

407.36 448.03

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User42

414.55 456.17

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User43

424.57 467.12

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User44

437.08 480.88

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User45

451.79 496.84

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User46

469.31 516.24

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User47

489.02 537.83

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User48

511.55 562.86

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User49

533.76 587.26

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User50

558.79 614.79

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User51

583.51 642.01

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User52

610.73 671.74

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User53

638.26 702.08

Page 13: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User54

667.98 734.62

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User55

697.70 767.47

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User56

729.93 802.83

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User57

762.47 838.81

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User58

797.20 876.98

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User59

814.40 895.75

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User60

849.13 933.92

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User61

879.17 967.09

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User62

898.88 988.67

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User63

923.60 1015.89

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User64

938.61 1032.48

75729PA0012603 Rating Area 5 Tobacco User/Non-Tobacco User65 and over

938.61 1032.48

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User0-20

209.37 209.37

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User21

329.72 362.70

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User22

329.72 362.70

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User23

329.72 362.70

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User24

329.72 362.70

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User25

331.04 364.01

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User26

337.63 371.26

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User27

345.55 380.17

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User28

358.40 394.34

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User29

368.96 405.88

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User30

374.23 411.82

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User31

382.14 420.39

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User32

390.06 428.96

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User33

395.00 434.57

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User34

400.28 440.17

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User35

402.92 443.14

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User36

405.55 446.11

Page 14: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User37

408.19 449.08

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User38

410.83 452.04

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User39

416.10 457.65

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User40

421.38 463.58

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User41

429.29 472.16

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User42

436.88 480.73

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User43

447.43 492.27

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User44

460.62 506.78

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User45

476.11 523.59

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User46

494.58 544.04

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User47

515.35 566.79

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User48

539.09 593.16

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User49

562.50 618.88

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User50

588.88 647.90

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User51

614.93 676.58

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User52

643.61 707.91

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User53

672.63 739.89

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User54

703.95 774.18

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User55

735.27 808.80

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User56

769.23 846.06

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User57

803.52 883.98

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User58

840.12 924.20

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User59

858.26 943.98

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User60

894.86 984.21

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User61

926.51 1019.16

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User62

947.28 1041.91

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User63

973.33 1070.60

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User64

989.16 1088.07

75729PA0012603 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

989.16 1088.07

Page 15: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User0-20

243.50 243.50

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User21

383.47 421.81

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User22

383.47 421.81

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User23

383.47 421.81

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User24

383.47 421.81

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User25

384.99 423.34

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User26

392.66 431.78

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User27

401.87 442.13

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User28

416.82 458.62

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User29

429.09 472.04

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User30

435.23 478.94

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User31

444.43 488.91

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User32

453.63 498.88

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User33

459.39 505.40

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User34

465.52 511.92

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User35

468.59 515.37

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User36

471.66 518.82

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User37

474.72 522.27

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User38

477.79 525.73

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User39

483.93 532.24

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User40

490.06 539.15

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User41

499.27 549.12

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User42

508.09 559.09

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User43

520.36 572.51

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User44

535.70 589.38

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User45

553.72 608.94

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User46

575.19 632.71

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User47

599.35 659.17

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User48

626.96 689.85

Page 16: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User49

654.18 719.76

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User50

684.86 753.50

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User51

715.15 786.86

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User52

748.52 823.29

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User53

782.26 860.49

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User54

818.69 900.37

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User55

855.12 940.63

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User56

894.61 983.96

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User57

934.49 1028.06

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User58

977.06 1074.84

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User59

998.15 1097.85

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User60

1040.71 1144.63

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User61

1077.53 1185.28

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User62

1101.68 1211.74

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User63

1131.98 1245.10

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User64

1150.38 1265.42

75729PA0012611 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

1150.38 1265.42

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User0-20

189.29 189.29

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User21

298.09 327.90

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User22

298.09 327.90

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User23

298.09 327.90

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User24

298.09 327.90

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User25

299.28 329.09

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User26

305.24 335.65

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User27

312.40 343.70

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User28

324.02 356.51

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User29

333.56 366.95

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User30

338.33 372.31

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User31

345.48 380.06

Page 17: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User32

352.64 387.81

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User33

357.11 392.88

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User34

361.88 397.95

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User35

364.26 400.63

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User36

366.65 403.31

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User37

369.03 406.00

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User38

371.42 408.68

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User39

376.19 413.75

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User40

380.96 419.11

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User41

388.11 426.86

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User42

394.97 434.61

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User43

404.50 445.04

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User44

416.43 458.16

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User45

430.44 473.36

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User46

447.13 491.84

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User47

465.91 512.41

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User48

487.37 536.26

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User49

508.54 559.51

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User50

532.38 585.74

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User51

555.93 611.68

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User52

581.87 639.99

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User53

608.10 668.91

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User54

636.42 699.91

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User55

664.74 731.21

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User56

695.44 764.89

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User57

726.44 799.17

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User58

759.53 835.54

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User59

775.92 853.42

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User60

809.01 889.79

Page 18: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User61

837.63 921.39

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User62

856.41 941.96

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User63

879.95 967.89

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User64

894.26 983.69

75729PA0012612 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

894.26 983.69

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User0-20

269.34 269.34

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User21

424.16 466.57

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User22

424.16 466.57

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User23

424.16 466.57

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User24

424.16 466.57

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User25

425.85 468.26

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User26

434.33 477.59

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User27

444.51 489.05

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User28

461.05 507.28

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User29

474.63 522.13

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User30

481.41 529.76

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User31

491.59 540.79

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User32

501.77 551.82

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User33

508.13 559.03

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User34

514.92 566.24

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User35

518.31 570.06

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User36

521.71 573.88

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User37

525.10 577.69

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User38

528.49 581.51

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User39

535.28 588.72

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User40

542.07 596.36

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User41

552.25 607.38

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User42

562.00 618.41

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User43

575.57 633.26

Page 19: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User44

592.54 651.92

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User45

612.47 673.55

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User46

636.23 699.85

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User47

662.95 729.12

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User48

693.49 763.05

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User49

723.60 796.13

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User50

757.53 833.46

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User51

791.04 870.36

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User52

827.94 910.65

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User53

865.27 951.80

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User54

905.56 995.91

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User55

945.86 1040.44

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User56

989.55 1088.37

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User57

1033.66 1137.15

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User58

1080.74 1188.90

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User59

1104.07 1214.35

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User60

1151.15 1266.09

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User61

1191.87 1311.05

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User62

1218.59 1340.32

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User63

1252.09 1377.22

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User64

1272.45 1399.70

75729PA0012613 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

1272.45 1399.70

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User0-20

209.37 209.37

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User21

329.72 362.70

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User22

329.72 362.70

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User23

329.72 362.70

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User24

329.72 362.70

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User25

331.04 364.01

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User26

337.63 371.26

Page 20: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User27

345.55 380.17

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User28

358.40 394.34

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User29

368.96 405.88

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User30

374.23 411.82

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User31

382.14 420.39

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User32

390.06 428.96

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User33

395.00 434.57

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User34

400.28 440.17

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User35

402.92 443.14

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User36

405.55 446.11

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User37

408.19 449.08

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User38

410.83 452.04

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User39

416.10 457.65

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User40

421.38 463.58

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User41

429.29 472.16

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User42

436.88 480.73

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User43

447.43 492.27

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User44

460.62 506.78

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User45

476.11 523.59

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User46

494.58 544.04

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User47

515.35 566.79

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User48

539.09 593.16

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User49

562.50 618.88

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User50

588.88 647.90

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User51

614.93 676.58

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User52

643.61 707.91

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User53

672.63 739.89

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User54

703.95 774.18

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User55

735.27 808.80

Page 21: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User56

769.23 846.06

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User57

803.52 883.98

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User58

840.12 924.20

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User59

858.26 943.98

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User60

894.86 984.21

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User61

926.51 1019.16

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User62

947.28 1041.91

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User63

973.33 1070.60

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User64

989.16 1088.07

75729PA0012614 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

989.16 1088.07

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User0-20

326.35 326.35

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User21

513.94 565.33

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User22

513.94 565.33

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User23

513.94 565.33

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User24

513.94 565.33

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User25

515.99 567.38

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User26

526.27 578.69

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User27

538.60 592.57

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User28

558.65 614.67

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User29

575.09 632.65

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User30

583.32 641.91

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User31

595.65 655.27

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User32

607.99 668.63

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User33

615.69 677.37

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User34

623.92 686.10

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User35

628.03 690.73

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User36

632.14 695.35

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User37

636.25 699.98

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User38

640.36 704.61

Page 22: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User39

648.59 713.34

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User40

656.81 722.59

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User41

669.14 735.96

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User42

680.96 749.32

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User43

697.41 767.31

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User44

717.97 789.92

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User45

742.12 816.13

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User46

770.90 847.99

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User47

803.28 883.45

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User48

840.28 924.57

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User49

876.77 964.66

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User50

917.89 1009.88

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User51

958.49 1054.59

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User52

1003.20 1103.42

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User53

1048.43 1153.27

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User54

1097.25 1206.72

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User55

1146.08 1260.68

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User56

1199.01 1318.76

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User57

1252.46 1377.86

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User58

1309.51 1440.56

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User59

1337.77 1471.40

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User60

1394.82 1534.10

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User61

1444.16 1588.57

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User62

1476.54 1624.04

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User63

1517.14 1668.75

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User64

1541.81 1695.99

75729PA0012615 Rating Area 7 Tobacco User/Non-Tobacco User65 and over

1541.81 1695.99

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User0-20

243.50 243.50

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User21

383.47 421.81

Page 23: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User22

383.47 421.81

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User23

383.47 421.81

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User24

383.47 421.81

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User25

384.99 423.34

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User26

392.66 431.78

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User27

401.87 442.13

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User28

416.82 458.62

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User29

429.09 472.04

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User30

435.23 478.94

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User31

444.43 488.91

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User32

453.63 498.88

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User33

459.39 505.40

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User34

465.52 511.92

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User35

468.59 515.37

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User36

471.66 518.82

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User37

474.72 522.27

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User38

477.79 525.73

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User39

483.93 532.24

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User40

490.06 539.15

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User41

499.27 549.12

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User42

508.09 559.09

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User43

520.36 572.51

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User44

535.70 589.38

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User45

553.72 608.94

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User46

575.19 632.71

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User47

599.35 659.17

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User48

626.96 689.85

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User49

654.18 719.76

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User50

684.86 753.50

Page 24: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User51

715.15 786.86

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User52

748.52 823.29

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User53

782.26 860.49

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User54

818.69 900.37

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User55

855.12 940.63

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User56

894.61 983.96

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User57

934.49 1028.06

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User58

977.06 1074.84

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User59

998.15 1097.85

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User60

1040.71 1144.63

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User61

1077.53 1185.28

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User62

1101.68 1211.74

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User63

1131.98 1245.10

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User64

1150.38 1265.42

75729PA0012615 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

1150.38 1265.42

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User0-20

253.69 253.69

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User21

399.52 439.47

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User22

399.52 439.47

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User23

399.52 439.47

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User24

399.52 439.47

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User25

401.11 441.06

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User26

409.10 449.85

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User27

418.69 460.64

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User28

434.27 477.82

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User29

447.06 491.80

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User30

453.45 498.99

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User31

463.04 509.38

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User32

472.62 519.77

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User33

478.62 526.56

Page 25: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User34

485.01 533.35

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User35

488.20 536.95

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User36

491.40 540.54

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User37

494.60 544.14

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User38

497.79 547.73

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User39

504.19 554.52

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User40

510.58 561.72

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User41

520.17 572.10

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User42

529.35 582.49

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User43

542.14 596.47

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User44

558.12 614.05

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User45

576.90 634.43

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User46

599.27 659.20

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User47

624.44 686.76

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User48

653.20 718.72

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User49

681.57 749.89

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User50

713.53 785.04

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User51

745.09 819.80

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User52

779.85 857.75

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User53

815.01 896.51

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User54

852.96 938.06

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User55

890.91 980.01

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User56

932.06 1025.15

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User57

973.61 1071.09

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User58

1017.96 1119.84

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User59

1039.93 1143.81

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User60

1084.28 1192.55

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User61

1122.63 1234.89

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User62

1147.80 1262.46

Page 26: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User63

1179.36 1297.22

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User64

1198.54 1318.39

75729PA0012616 Rating Area 7 Tobacco User/Non-Tobacco User65 and over

1198.54 1318.39

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User0-20

189.29 189.29

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User21

298.09 327.90

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User22

298.09 327.90

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User23

298.09 327.90

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User24

298.09 327.90

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User25

299.28 329.09

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User26

305.24 335.65

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User27

312.40 343.70

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User28

324.02 356.51

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User29

333.56 366.95

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User30

338.33 372.31

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User31

345.48 380.06

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User32

352.64 387.81

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User33

357.11 392.88

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User34

361.88 397.95

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User35

364.26 400.63

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User36

366.65 403.31

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User37

369.03 406.00

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User38

371.42 408.68

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User39

376.19 413.75

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User40

380.96 419.11

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User41

388.11 426.86

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User42

394.97 434.61

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User43

404.50 445.04

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User44

416.43 458.16

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User45

430.44 473.36

Page 27: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User46

447.13 491.84

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User47

465.91 512.41

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User48

487.37 536.26

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User49

508.54 559.51

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User50

532.38 585.74

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User51

555.93 611.68

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User52

581.87 639.99

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User53

608.10 668.91

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User54

636.42 699.91

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User55

664.74 731.21

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User56

695.44 764.89

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User57

726.44 799.17

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User58

759.53 835.54

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User59

775.92 853.42

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User60

809.01 889.79

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User61

837.63 921.39

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User62

856.41 941.96

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User63

879.95 967.89

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User64

894.26 983.69

75729PA0012616 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

894.26 983.69

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User0-20

227.50 227.50

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User21

358.28 394.11

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User22

358.28 394.11

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User23

358.28 394.11

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User24

358.28 394.11

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User25

359.71 395.53

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User26

366.87 403.42

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User27

375.47 413.09

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User28

389.44 428.49

Page 28: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User29

400.91 441.03

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User30

406.64 447.48

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User31

415.24 456.80

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User32

423.84 466.11

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User33

429.21 472.20

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User34

434.94 478.29

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User35

437.81 481.52

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User36

440.68 484.74

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User37

443.54 487.97

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User38

446.41 491.19

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User39

452.14 497.28

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User40

457.87 503.73

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User41

466.47 513.05

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User42

474.71 522.36

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User43

486.18 534.90

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User44

500.51 550.67

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User45

517.35 568.94

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User46

537.41 591.15

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User47

559.98 615.87

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User48

585.78 644.53

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User49

611.21 672.48

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User50

639.88 704.01

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User51

668.18 735.18

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User52

699.35 769.21

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User53

730.88 803.96

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User54

764.91 841.23

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User55

798.95 878.84

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User56

835.85 919.33

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User57

873.11 960.53

Page 29: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User58

912.88 1004.24

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User59

932.58 1025.74

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User60

972.35 1069.44

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User61

1006.75 1107.42

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User62

1029.32 1132.14

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User63

1057.62 1163.31

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User64

1074.82 1182.30

75729PA0012620 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

1074.82 1182.30

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User0-20

250.86 250.86

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User21

395.06 434.56

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User22

395.06 434.56

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User23

395.06 434.56

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User24

395.06 434.56

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User25

396.63 436.14

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User26

404.53 444.83

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User27

414.01 455.49

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User28

429.42 472.48

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User29

442.06 486.31

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User30

448.38 493.42

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User31

457.86 503.69

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User32

467.35 513.96

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User33

473.27 520.68

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User34

479.59 527.39

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User35

482.75 530.95

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User36

485.91 534.50

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User37

489.07 538.06

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User38

492.23 541.61

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User39

498.55 548.33

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User40

504.87 555.44

Page 30: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User41

514.36 565.71

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User42

523.44 575.98

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User43

536.08 589.81

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User44

551.89 607.19

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User45

570.45 627.34

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User46

592.58 651.83

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User47

617.46 679.09

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User48

645.91 710.70

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User49

673.96 741.51

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User50

705.56 776.27

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User51

736.77 810.64

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User52

771.14 848.17

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User53

805.90 886.49

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User54

843.43 927.58

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User55

880.96 969.06

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User56

921.65 1013.70

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User57

962.74 1059.13

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User58

1006.59 1107.33

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User59

1028.32 1131.03

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User60

1072.17 1179.23

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User61

1110.09 1221.10

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User62

1134.98 1248.36

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User63

1166.19 1282.73

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User64

1185.15 1303.67

75729PA0012621 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

1185.15 1303.67

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User0-20

251.64 251.64

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User21

396.30 435.92

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User22

396.30 435.92

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User23

396.30 435.92

Page 31: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User24

396.30 435.92

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User25

397.88 437.50

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User26

405.80 446.22

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User27

415.31 456.92

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User28

430.77 473.96

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User29

443.45 487.83

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User30

449.79 494.97

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User31

459.30 505.27

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User32

468.81 515.57

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User33

474.76 522.31

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User34

481.10 529.05

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User35

484.27 532.61

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User36

487.44 536.18

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User37

490.61 539.75

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User38

493.78 543.31

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User39

500.12 550.05

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User40

506.46 557.18

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User41

515.97 567.49

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User42

525.08 577.79

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User43

537.77 591.66

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User44

553.62 609.10

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User45

572.24 629.31

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User46

594.44 653.88

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User47

619.40 681.22

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User48

647.93 712.93

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User49

676.07 743.84

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User50

707.77 778.71

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User51

739.08 813.19

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User52

773.56 850.84

Page 32: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User53

808.43 889.28

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User54

846.08 930.49

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User55

883.73 972.10

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User56

924.55 1016.88

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User57

965.76 1062.45

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User58

1009.75 1110.80

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User59

1031.54 1134.58

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User60

1075.53 1182.93

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User61

1113.58 1224.93

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User62

1138.54 1252.28

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User63

1169.85 1286.76

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User64

1188.87 1307.76

75729PA0012621 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

1188.87 1307.76

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User0-20

179.05 179.05

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User21

281.97 310.16

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User22

281.97 310.16

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User23

281.97 310.16

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User24

281.97 310.16

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User25

283.09 311.29

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User26

288.73 317.49

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User27

295.50 325.10

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User28

306.49 337.23

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User29

315.52 347.10

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User30

320.03 352.17

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User31

326.79 359.50

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User32

333.56 366.83

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User33

337.79 371.63

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User34

342.30 376.42

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User35

344.56 378.96

Page 33: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User36

346.81 381.49

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User37

349.07 384.03

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User38

351.32 386.57

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User39

355.84 391.36

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User40

360.35 396.44

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User41

367.11 403.77

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User42

373.60 411.10

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User43

382.62 420.97

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User44

393.90 433.38

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User45

407.15 447.76

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User46

422.94 465.24

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User47

440.71 484.69

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User48

461.01 507.25

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User49

481.03 529.24

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User50

503.58 554.06

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User51

525.86 578.59

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User52

550.39 605.37

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User53

575.20 632.72

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User54

601.99 662.05

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User55

628.78 691.65

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User56

657.82 723.52

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User57

687.14 755.94

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User58

718.44 790.34

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User59

733.95 807.26

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User60

765.25 841.66

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User61

792.31 871.55

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User62

810.08 891.00

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User63

832.35 915.53

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User64

845.89 930.48

Page 34: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012622 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

845.89 930.48

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User0-20

197.43 197.43

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User21

310.91 342.00

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User22

310.91 342.00

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User23

310.91 342.00

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User24

310.91 342.00

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User25

312.15 343.24

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User26

318.37 350.08

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User27

325.83 358.48

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User28

337.96 371.84

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User29

347.90 382.73

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User30

352.88 388.32

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User31

360.34 396.41

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User32

367.80 404.49

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User33

372.47 409.77

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User34

377.44 415.06

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User35

379.93 417.86

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User36

382.41 420.66

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User37

384.90 423.45

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User38

387.39 426.25

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User39

392.36 431.54

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User40

397.34 437.13

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User41

404.80 445.22

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User42

411.95 453.30

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User43

421.90 464.18

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User44

434.34 477.86

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User45

448.95 493.72

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User46

466.36 513.00

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User47

485.95 534.45

Page 35: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User48

508.33 559.32

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User49

530.41 583.57

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User50

555.28 610.93

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User51

579.84 637.98

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User52

606.89 667.52

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User53

634.25 697.67

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User54

663.79 730.01

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User55

693.32 762.65

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User56

725.34 797.79

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User57

757.68 833.54

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User58

792.19 871.47

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User59

809.29 890.13

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User60

843.80 928.06

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User61

873.65 961.01

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User62

893.23 982.46

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User63

917.80 1009.51

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User64

932.72 1025.99

75729PA0012623 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

932.72 1025.99

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User0-20

198.05 198.05

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User21

311.89 343.08

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User22

311.89 343.08

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User23

311.89 343.08

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User24

311.89 343.08

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User25

313.13 344.32

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User26

319.37 351.18

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User27

326.85 359.60

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User28

339.02 373.01

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User29

349.00 383.93

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User30

353.99 389.54

Page 36: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User31

361.47 397.65

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User32

368.96 405.76

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User33

373.63 411.06

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User34

378.62 416.36

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User35

381.12 419.17

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User36

383.62 421.98

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User37

386.11 424.78

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User38

388.61 427.59

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User39

393.60 432.89

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User40

398.59 438.51

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User41

406.07 446.62

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User42

413.24 454.72

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User43

423.22 465.64

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User44

435.70 479.36

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User45

450.36 495.27

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User46

467.82 514.61

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User47

487.47 536.13

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User48

509.93 561.08

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User49

532.07 585.40

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User50

557.02 612.85

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User51

581.66 639.98

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User52

608.79 669.61

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User53

636.24 699.86

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User54

665.87 732.30

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User55

695.50 765.05

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User56

727.62 800.29

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User57

760.06 836.16

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User58

794.68 874.21

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User59

811.83 892.92

Page 37: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User60

846.45 930.97

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User61

876.39 964.03

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User62

896.04 985.55

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User63

920.68 1012.68

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User64

935.65 1029.21

75729PA0012623 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

935.65 1029.21

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User0-20

198.28 198.28

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User21

312.26 343.48

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User22

312.26 343.48

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User23

312.26 343.48

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User24

312.26 343.48

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User25

313.50 344.73

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User26

319.75 351.60

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User27

327.24 360.03

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User28

339.42 373.45

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User29

349.41 384.38

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User30

354.41 390.00

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User31

361.90 398.12

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User32

369.39 406.24

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User33

374.08 411.55

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User34

379.07 416.86

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User35

381.57 419.67

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User36

384.07 422.48

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User37

386.57 425.29

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User38

389.07 428.10

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User39

394.06 433.41

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User40

399.06 439.03

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User41

406.55 447.15

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User42

413.73 455.26

Page 38: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User43

423.73 466.19

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User44

436.22 479.93

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User45

450.89 495.86

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User46

468.38 515.22

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User47

488.05 536.76

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User48

510.53 561.74

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User49

532.70 586.10

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User50

557.68 613.58

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User51

582.35 640.74

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User52

609.52 670.41

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User53

637.00 700.69

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User54

666.66 733.17

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User55

696.32 765.96

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User56

728.49 801.24

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User57

760.96 837.15

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User58

795.62 875.24

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User59

812.79 893.98

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User60

847.45 932.07

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User61

877.43 965.17

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User62

897.10 986.72

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User63

921.77 1013.88

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User64

936.76 1030.43

75729PA0012624 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

936.76 1030.43

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User0-20

188.74 188.74

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User21

297.23 326.96

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User22

297.23 326.96

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User23

297.23 326.96

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User24

297.23 326.96

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User25

298.42 328.14

Page 39: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User26

304.36 334.68

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User27

311.49 342.70

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User28

323.09 355.48

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User29

332.60 365.89

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User30

337.35 371.24

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User31

344.49 378.97

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User32

351.62 386.69

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User33

356.08 391.75

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User34

360.83 396.80

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User35

363.21 399.47

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User36

365.59 402.15

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User37

367.97 404.82

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User38

370.35 407.50

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User39

375.10 412.55

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User40

379.86 417.90

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User41

386.99 425.63

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User42

393.83 433.36

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User43

403.34 443.76

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User44

415.23 456.84

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User45

429.20 472.00

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User46

445.84 490.43

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User47

464.57 510.93

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User48

485.97 534.71

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User49

507.07 557.90

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User50

530.85 584.05

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User51

554.33 609.91

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User52

580.19 638.15

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User53

606.34 666.98

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User54

634.58 697.89

Page 40: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User55

662.82 729.10

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User56

693.43 762.69

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User57

724.34 796.87

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User58

757.34 833.13

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User59

773.68 850.96

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User60

806.68 887.23

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User61

835.21 918.73

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User62

853.94 939.24

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User63

877.42 965.10

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User64

891.68 980.85

75729PA0012624 Rating Area 5 Tobacco User/Non-Tobacco User65 and over

891.68 980.85

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User0-20

198.90 198.90

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User21

313.24 344.56

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User22

313.24 344.56

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User23

313.24 344.56

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User24

313.24 344.56

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User25

314.49 345.81

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User26

320.75 352.70

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User27

328.27 361.16

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User28

340.48 374.63

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User29

350.51 385.59

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User30

355.52 391.23

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User31

363.04 399.37

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User32

370.55 407.52

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User33

375.25 412.84

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User34

380.26 418.17

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User35

382.77 420.98

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User36

385.28 423.80

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User37

387.78 426.62

Page 41: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User38

390.29 429.44

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User39

395.30 434.77

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User40

400.31 440.40

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User41

407.83 448.55

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User42

415.03 456.69

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User43

425.06 467.66

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User44

437.59 481.44

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User45

452.31 497.41

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User46

469.85 516.83

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User47

489.58 538.45

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User48

512.14 563.51

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User49

534.37 587.94

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User50

559.43 615.50

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User51

584.18 642.75

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User52

611.43 672.51

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User53

638.99 702.89

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User54

668.75 735.47

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User55

698.51 768.36

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User56

730.77 803.75

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User57

763.35 839.78

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User58

798.12 877.99

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User59

815.34 896.78

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User60

850.11 935.00

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User61

880.18 968.20

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User62

899.92 989.81

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User63

924.66 1017.07

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User64

939.70 1033.67

75729PA0012624 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

939.70 1033.67

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User0-20

179.82 179.82

Page 42: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User21

283.19 311.51

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User22

283.19 311.51

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User23

283.19 311.51

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User24

283.19 311.51

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User25

284.32 312.63

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User26

289.98 318.86

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User27

296.78 326.51

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User28

307.82 338.69

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User29

316.88 348.60

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User30

321.41 353.70

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User31

328.21 361.06

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User32

335.01 368.42

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User33

339.25 373.24

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User34

343.78 378.05

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User35

346.05 380.60

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User36

348.32 383.15

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User37

350.58 385.70

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User38

352.85 388.24

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User39

357.38 393.06

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User40

361.91 398.16

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User41

368.70 405.52

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User42

375.22 412.88

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User43

384.28 422.79

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User44

395.61 435.25

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User45

408.92 449.69

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User46

424.77 467.25

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User47

442.62 486.79

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User48

463.00 509.45

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User49

483.11 531.53

Page 43: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User50

505.76 556.45

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User51

528.14 581.09

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User52

552.77 607.99

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User53

577.69 635.46

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User54

604.60 664.91

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User55

631.50 694.65

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User56

660.67 726.65

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User57

690.12 759.21

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User58

721.55 793.76

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User59

737.13 810.75

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User60

768.56 845.30

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User61

795.74 875.32

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User62

813.58 894.86

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User63

835.96 919.50

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User64

849.55 934.50

75729PA0012624 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

849.55 934.50

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User0-20

255.07 255.07

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User21

401.69 441.86

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User22

401.69 441.86

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User23

401.69 441.86

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User24

401.69 441.86

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User25

403.29 443.46

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User26

411.32 452.29

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User27

420.96 463.14

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User28

436.63 480.41

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User29

449.48 494.47

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User30

455.91 501.70

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User31

465.55 512.15

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User32

475.19 522.59

Page 44: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User33

481.22 529.42

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User34

487.64 536.25

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User35

490.86 539.86

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User36

494.07 543.48

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User37

497.28 547.09

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User38

500.50 550.71

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User39

506.92 557.54

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User40

513.35 564.77

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User41

522.99 575.21

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User42

532.23 585.65

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User43

545.08 599.71

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User44

561.15 617.39

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User45

580.03 637.87

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User46

602.52 662.78

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User47

627.83 690.49

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User48

656.75 722.63

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User49

685.27 753.96

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User50

717.40 789.31

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User51

749.14 824.25

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User52

784.08 862.41

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User53

819.43 901.38

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User54

857.59 943.15

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User55

895.75 985.33

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User56

937.13 1030.72

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User57

978.90 1076.91

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User58

1023.49 1125.92

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User59

1045.58 1150.02

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User60

1090.17 1199.02

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User61

1128.73 1241.60

Page 45: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User62

1154.03 1269.32

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User63

1185.77 1304.26

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User64

1205.05 1325.55

75729PA0012625 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

1205.05 1325.55

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User0-20

242.80 242.80

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User21

382.36 420.60

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User22

382.36 420.60

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User23

382.36 420.60

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User24

382.36 420.60

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User25

383.88 422.12

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User26

391.53 430.53

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User27

400.71 440.85

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User28

415.62 457.30

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User29

427.85 470.68

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User30

433.97 477.56

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User31

443.15 487.50

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User32

452.33 497.44

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User33

458.06 503.94

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User34

464.18 510.44

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User35

467.24 513.88

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User36

470.30 517.33

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User37

473.36 520.77

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User38

476.41 524.21

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User39

482.53 530.71

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User40

488.65 537.59

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User41

497.83 547.53

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User42

506.62 557.47

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User43

518.86 570.86

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User44

534.15 587.68

Page 46: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User45

552.12 607.18

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User46

573.53 630.89

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User47

597.62 657.27

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User48

625.15 687.86

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User49

652.30 717.68

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User50

682.89 751.33

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User51

713.09 784.59

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User52

746.36 820.92

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User53

780.00 858.00

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User54

816.33 897.77

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User55

852.65 937.92

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User56

892.03 981.12

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User57

931.80 1025.09

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User58

974.24 1071.74

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User59

995.27 1094.68

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User60

1037.71 1141.33

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User61

1074.42 1181.86

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User62

1098.51 1208.24

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User63

1128.71 1241.51

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User64

1147.06 1261.77

75729PA0012625 Rating Area 5 Tobacco User/Non-Tobacco User65 and over

1147.06 1261.77

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User0-20

255.87 255.87

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User21

402.95 443.24

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User22

402.95 443.24

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User23

402.95 443.24

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User24

402.95 443.24

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User25

404.55 444.85

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User26

412.61 453.71

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User27

422.28 464.59

Page 47: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User28

438.00 481.92

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User29

450.89 496.02

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User30

457.34 503.28

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User31

467.01 513.75

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User32

476.68 524.23

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User33

482.73 531.08

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User34

489.17 537.93

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User35

492.40 541.56

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User36

495.62 545.18

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User37

498.84 548.81

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User38

502.07 552.43

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User39

508.51 559.28

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User40

514.96 566.54

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User41

524.63 577.01

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User42

533.90 587.49

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User43

546.79 601.59

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User44

562.91 619.32

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User45

581.85 639.87

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User46

604.41 664.86

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User47

629.80 692.66

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User48

658.81 724.89

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User49

687.42 756.32

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User50

719.66 791.78

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User51

751.49 826.84

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User52

786.54 865.12

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User53

822.00 904.20

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User54

860.28 946.11

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User55

898.56 988.42

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User56

940.07 1033.95

Page 48: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User57

981.97 1080.29

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User58

1026.70 1129.45

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User59

1048.86 1153.63

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User60

1093.59 1202.78

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User61

1132.27 1245.50

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User62

1157.66 1273.30

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User63

1189.49 1308.36

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User64

1208.83 1329.71

75729PA0012625 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

1208.83 1329.71

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User0-20

231.32 231.32

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User21

364.29 400.72

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User22

364.29 400.72

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User23

364.29 400.72

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User24

364.29 400.72

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User25

365.74 402.17

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User26

373.03 410.19

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User27

381.77 420.02

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User28

395.98 435.69

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User29

407.64 448.44

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User30

413.47 454.99

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User31

422.21 464.47

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User32

430.95 473.94

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User33

436.42 480.13

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User34

442.24 486.32

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User35

445.16 489.60

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User36

448.07 492.88

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User37

450.99 496.16

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User38

453.90 499.44

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User39

459.73 505.63

Page 49: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User40

465.56 512.19

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User41

474.30 521.66

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User42

482.68 531.13

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User43

494.34 543.88

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User44

508.91 559.91

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User45

526.03 578.49

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User46

546.43 601.07

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User47

569.38 626.21

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User48

595.61 655.35

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User49

621.47 683.77

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User50

650.62 715.82

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User51

679.40 747.52

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User52

711.09 782.13

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User53

743.15 817.46

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User54

777.75 855.35

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User55

812.36 893.60

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User56

849.88 934.76

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User57

887.77 976.65

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User58

928.20 1021.10

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User59

948.24 1042.95

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User60

988.68 1087.40

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User61

1023.65 1126.01

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User62

1046.60 1151.15

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User63

1075.38 1182.84

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User64

1092.86 1202.15

75729PA0012625 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

1092.86 1202.15

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User0-20

252.00 252.00

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User21

396.85 436.54

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User22

396.85 436.54

Page 50: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User23

396.85 436.54

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User24

396.85 436.54

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User25

398.43 438.12

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User26

406.37 446.85

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User27

415.90 457.56

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User28

431.37 474.63

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User29

444.07 488.52

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User30

450.42 495.66

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User31

459.95 505.98

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User32

469.47 516.30

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User33

475.42 523.04

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User34

481.77 529.79

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User35

484.95 533.36

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User36

488.12 536.93

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User37

491.30 540.51

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User38

494.47 544.08

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User39

500.82 550.82

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User40

507.17 557.97

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User41

516.69 568.28

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User42

525.82 578.60

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User43

538.52 592.49

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User44

554.39 609.95

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User45

573.05 630.19

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User46

595.27 654.80

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User47

620.27 682.18

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User48

648.84 713.93

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User49

677.02 744.88

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User50

708.77 779.80

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User51

740.12 814.33

Page 51: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User52

774.64 852.03

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User53

809.57 890.52

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User54

847.27 931.80

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User55

884.97 973.46

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User56

925.84 1018.31

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User57

967.12 1063.95

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User58

1011.17 1112.36

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User59

1032.99 1136.17

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User60

1077.04 1184.59

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User61

1115.14 1226.65

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User62

1140.14 1254.04

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User63

1171.49 1288.56

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User64

1190.54 1309.59

75729PA0012626 Rating Area 2 Tobacco User/Non-Tobacco User65 and over

1190.54 1309.59

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User0-20

270.69 270.69

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User21

426.28 468.91

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User22

426.28 468.91

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User23

426.28 468.91

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User24

426.28 468.91

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User25

427.98 470.61

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User26

436.51 479.99

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User27

446.74 491.50

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User28

463.36 509.83

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User29

477.00 524.75

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User30

483.82 532.42

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User31

494.05 543.50

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User32

504.28 554.58

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User33

510.68 561.83

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User34

517.50 569.08

Page 52: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User35

520.91 572.91

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User36

524.32 576.75

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User37

527.73 580.59

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User38

531.14 584.42

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User39

537.96 591.67

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User40

544.78 599.34

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User41

555.01 610.43

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User42

564.82 621.51

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User43

578.46 636.43

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User44

595.51 655.19

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User45

615.54 676.93

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User46

639.41 703.35

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User47

666.27 732.77

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User48

696.96 766.87

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User49

727.23 800.12

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User50

761.33 837.63

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User51

795.00 874.72

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User52

832.09 915.21

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User53

869.60 956.56

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User54

910.10 1000.90

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User55

950.59 1045.65

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User56

994.50 1093.82

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User57

1038.83 1142.84

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User58

1086.15 1194.85

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User59

1109.60 1220.43

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User60

1156.91 1272.43

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User61

1197.83 1317.62

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User62

1224.69 1347.03

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User63

1258.37 1384.12

Page 53: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User64

1278.83 1406.71

75729PA0012626 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

1278.83 1406.71

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User0-20

257.66 257.66

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User21

405.77 446.35

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User22

405.77 446.35

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User23

405.77 446.35

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User24

405.77 446.35

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User25

407.39 447.96

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User26

415.50 456.89

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User27

425.24 467.85

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User28

441.07 485.29

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User29

454.05 499.50

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User30

460.54 506.80

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User31

470.28 517.35

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User32

480.02 527.90

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User33

486.11 534.80

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User34

492.60 541.70

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User35

495.84 545.35

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User36

499.09 549.00

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User37

502.34 552.65

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User38

505.58 556.30

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User39

512.07 563.20

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User40

518.57 570.50

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User41

528.31 581.05

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User42

537.64 591.60

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User43

550.62 605.81

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User44

566.85 623.66

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User45

585.92 644.35

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User46

608.65 669.51

Page 54: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User47

634.21 697.51

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User48

663.42 729.97

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User49

692.23 761.62

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User50

724.70 797.33

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User51

756.75 832.63

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User52

792.05 871.18

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User53

827.76 910.54

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User54

866.31 952.73

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User55

904.85 995.34

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User56

946.65 1041.19

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User57

988.85 1087.85

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User58

1033.89 1137.36

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User59

1056.20 1161.70

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User60

1101.24 1211.21

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User61

1140.20 1254.22

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User62

1165.76 1282.22

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User63

1197.82 1317.52

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User64

1217.29 1339.02

75729PA0012626 Rating Area 5 Tobacco User/Non-Tobacco User65 and over

1217.29 1339.02

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User0-20

271.53 271.53

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User21

427.62 470.38

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User22

427.62 470.38

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User23

427.62 470.38

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User24

427.62 470.38

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User25

429.32 472.09

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User26

437.88 481.49

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User27

448.14 493.04

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User28

464.82 511.43

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User29

478.50 526.39

Page 55: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User30

485.34 534.09

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User31

495.60 545.21

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User32

505.87 556.32

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User33

512.28 563.59

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User34

519.12 570.86

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User35

522.54 574.71

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User36

525.96 578.56

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User37

529.39 582.41

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User38

532.81 586.26

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User39

539.65 593.53

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User40

546.49 601.22

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User41

556.75 612.34

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User42

566.59 623.46

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User43

580.27 638.43

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User44

597.38 657.24

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User45

617.47 679.05

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User46

641.42 705.56

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User47

668.36 735.07

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User48

699.15 769.28

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User49

729.51 802.63

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User50

763.72 840.26

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User51

797.50 877.46

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User52

834.70 918.09

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User53

872.33 959.56

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User54

912.95 1004.04

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User55

953.58 1048.94

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User56

997.62 1097.26

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User57

1042.09 1146.43

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User58

1089.56 1198.60

Page 56: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User59

1113.08 1224.26

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User60

1160.54 1276.43

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User61

1201.59 1321.75

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User62

1228.53 1351.26

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User63

1262.31 1388.46

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User64

1282.84 1411.12

75729PA0012626 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

1282.84 1411.12

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User0-20

245.49 245.49

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User21

386.60 425.26

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User22

386.60 425.26

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User23

386.60 425.26

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User24

386.60 425.26

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User25

388.14 426.80

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User26

395.87 435.30

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User27

405.15 445.74

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User28

420.22 462.36

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User29

432.60 475.89

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User30

438.78 482.85

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User31

448.06 492.90

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User32

457.34 502.95

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User33

463.14 509.53

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User34

469.32 516.10

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User35

472.41 519.58

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User36

475.51 523.06

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User37

478.60 526.54

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User38

481.69 530.02

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User39

487.88 536.59

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User40

494.06 543.55

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User41

503.34 553.60

Page 57: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User42

512.23 563.65

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User43

524.60 577.18

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User44

540.07 594.19

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User45

558.24 613.91

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User46

579.89 637.88

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User47

604.24 664.55

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User48

632.08 695.48

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User49

659.52 725.63

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User50

690.45 759.65

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User51

720.99 793.28

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User52

754.63 830.01

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User53

788.65 867.51

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User54

825.37 907.72

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User55

862.10 948.31

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User56

901.92 991.99

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User57

942.12 1036.45

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User58

985.03 1083.61

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User59

1006.30 1106.81

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User60

1049.21 1153.97

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User61

1086.32 1194.95

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User62

1110.68 1221.63

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User63

1141.22 1255.26

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User64

1159.77 1275.75

75729PA0012627 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

1159.77 1275.75

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User0-20

271.53 271.53

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User21

427.62 470.38

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User22

427.62 470.38

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User23

427.62 470.38

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User24

427.62 470.38

Page 58: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User25

429.32 472.09

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User26

437.88 481.49

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User27

448.14 493.04

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User28

464.82 511.43

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User29

478.50 526.39

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User30

485.34 534.09

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User31

495.60 545.21

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User32

505.87 556.32

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User33

512.28 563.59

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User34

519.12 570.86

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User35

522.54 574.71

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User36

525.96 578.56

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User37

529.39 582.41

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User38

532.81 586.26

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User39

539.65 593.53

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User40

546.49 601.22

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User41

556.75 612.34

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User42

566.59 623.46

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User43

580.27 638.43

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User44

597.38 657.24

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User45

617.47 679.05

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User46

641.42 705.56

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User47

668.36 735.07

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User48

699.15 769.28

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User49

729.51 802.63

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User50

763.72 840.26

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User51

797.50 877.46

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User52

834.70 918.09

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User53

872.33 959.56

Page 59: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User54

912.95 1004.04

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User55

953.58 1048.94

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User56

997.62 1097.26

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User57

1042.09 1146.43

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User58

1089.56 1198.60

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User59

1113.08 1224.26

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User60

1160.54 1276.43

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User61

1201.59 1321.75

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User62

1228.53 1351.26

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User63

1262.31 1388.46

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User64

1282.84 1411.12

75729PA0012628 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

1282.84 1411.12

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User0-20

329.01 329.01

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User21

518.13 569.95

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User22

518.13 569.95

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User23

518.13 569.95

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User24

518.13 569.95

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User25

520.20 572.02

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User26

530.57 583.41

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User27

543.00 597.40

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User28

563.21 619.68

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User29

579.79 637.82

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User30

588.08 647.14

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User31

600.51 660.62

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User32

612.95 674.09

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User33

620.72 682.90

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User34

629.01 691.70

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User35

633.15 696.37

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User36

637.30 701.03

Page 60: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User37

641.44 705.69

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User38

645.59 710.36

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User39

653.88 719.16

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User40

662.17 728.49

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User41

674.61 741.96

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User42

686.52 755.43

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User43

703.10 773.57

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User44

723.83 796.37

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User45

748.18 822.79

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User46

777.19 854.91

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User47

809.84 890.67

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User48

847.14 932.12

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User49

883.93 972.53

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User50

925.38 1018.13

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User51

966.31 1063.20

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User52

1011.39 1112.43

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User53

1056.99 1162.68

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User54

1106.21 1216.57

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User55

1155.43 1270.97

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User56

1208.80 1329.52

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User57

1262.68 1389.11

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User58

1320.20 1452.32

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User59

1348.69 1483.41

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User60

1406.20 1546.62

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User61

1455.95 1601.54

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User62

1488.59 1637.29

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User63

1529.52 1682.37

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User64

1554.39 1709.83

75729PA0012629 Rating Area 7 Tobacco User/Non-Tobacco User65 and over

1554.39 1709.83

Page 61: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User0-20

245.49 245.49

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User21

386.60 425.26

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User22

386.60 425.26

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User23

386.60 425.26

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User24

386.60 425.26

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User25

388.14 426.80

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User26

395.87 435.30

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User27

405.15 445.74

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User28

420.22 462.36

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User29

432.60 475.89

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User30

438.78 482.85

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User31

448.06 492.90

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User32

457.34 502.95

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User33

463.14 509.53

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User34

469.32 516.10

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User35

472.41 519.58

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User36

475.51 523.06

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User37

478.60 526.54

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User38

481.69 530.02

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User39

487.88 536.59

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User40

494.06 543.55

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User41

503.34 553.60

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User42

512.23 563.65

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User43

524.60 577.18

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User44

540.07 594.19

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User45

558.24 613.91

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User46

579.89 637.88

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User47

604.24 664.55

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User48

632.08 695.48

Page 62: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User49

659.52 725.63

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User50

690.45 759.65

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User51

720.99 793.28

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User52

754.63 830.01

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User53

788.65 867.51

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User54

825.37 907.72

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User55

862.10 948.31

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User56

901.92 991.99

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User57

942.12 1036.45

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User58

985.03 1083.61

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User59

1006.30 1106.81

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User60

1049.21 1153.97

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User61

1086.32 1194.95

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User62

1110.68 1221.63

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User63

1141.22 1255.26

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User64

1159.77 1275.75

75729PA0012629 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

1159.77 1275.75

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User0-20

195.10 195.10

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User21

307.25 337.97

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User22

307.25 337.97

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User23

307.25 337.97

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User24

307.25 337.97

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User25

308.47 339.20

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User26

314.62 345.95

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User27

321.99 354.25

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User28

333.97 367.46

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User29

343.80 378.22

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User30

348.72 383.75

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User31

356.09 391.73

Page 63: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User32

363.47 399.72

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User33

368.08 404.95

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User34

372.99 410.17

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User35

375.45 412.93

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User36

377.91 415.70

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User37

380.37 418.46

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User38

382.82 421.23

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User39

387.74 426.45

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User40

392.66 431.98

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User41

400.03 439.97

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User42

407.10 447.96

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User43

416.93 458.71

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User44

429.22 472.23

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User45

443.66 487.90

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User46

460.86 506.95

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User47

480.22 528.15

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User48

502.34 552.73

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User49

524.16 576.69

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User50

548.73 603.73

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User51

573.01 630.46

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User52

599.74 659.65

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User53

626.77 689.45

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User54

655.96 721.40

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User55

685.15 753.67

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User56

716.80 788.38

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User57

748.75 823.72

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User58

782.85 861.20

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User59

799.75 879.63

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User60

833.86 917.12

Page 64: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User61

863.35 949.69

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User62

882.71 970.89

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User63

906.98 997.62

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User64

921.73 1013.90

75729PA0012630 Rating Area 2 Tobacco User/Non-Tobacco User65 and over

921.73 1013.90

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User0-20

209.57 209.57

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User21

330.03 363.03

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User22

330.03 363.03

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User23

330.03 363.03

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User24

330.03 363.03

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User25

331.35 364.35

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User26

337.95 371.61

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User27

345.87 380.52

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User28

358.74 394.71

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User29

369.30 406.26

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User30

374.58 412.20

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User31

382.50 420.78

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User32

390.42 429.36

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User33

395.37 434.97

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User34

400.65 440.59

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User35

403.29 443.56

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User36

405.93 446.53

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User37

408.57 449.50

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User38

411.21 452.47

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User39

416.49 458.08

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User40

421.77 464.02

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User41

429.69 472.60

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User42

437.29 481.18

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User43

447.85 492.73

Page 65: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User44

461.05 507.25

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User45

476.56 524.08

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User46

495.04 544.54

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User47

515.83 567.32

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User48

539.59 593.72

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User49

563.03 619.46

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User50

589.43 648.50

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User51

615.50 677.21

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User52

644.21 708.57

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User53

673.25 740.58

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User54

704.61 774.90

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User55

735.96 809.55

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User56

769.95 846.85

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User57

804.27 884.80

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User58

840.91 925.06

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User59

859.06 944.87

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User60

895.69 985.13

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User61

927.37 1020.11

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User62

948.17 1042.88

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User63

974.24 1071.60

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User64

990.08 1089.09

75729PA0012630 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

990.08 1089.09

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User0-20

199.48 199.48

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User21

314.15 345.57

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User22

314.15 345.57

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User23

314.15 345.57

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User24

314.15 345.57

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User25

315.40 346.82

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User26

321.69 353.73

Page 66: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User27

329.23 362.21

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User28

341.48 375.72

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User29

351.53 386.71

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User30

356.56 392.37

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User31

364.10 400.54

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User32

371.64 408.70

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User33

376.35 414.05

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User34

381.37 419.39

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User35

383.89 422.21

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User36

386.40 425.04

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User37

388.91 427.87

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User38

391.43 430.69

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User39

396.45 436.04

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User40

401.48 441.69

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User41

409.02 449.86

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User42

416.24 458.03

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User43

426.30 469.02

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User44

438.86 482.84

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User45

453.63 498.86

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User46

471.22 518.34

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User47

491.01 540.02

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User48

513.63 565.15

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User49

535.93 589.65

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User50

561.07 617.30

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User51

585.88 644.63

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User52

613.21 674.47

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User53

640.86 704.94

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User54

670.70 737.62

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User55

700.55 770.60

Page 67: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User56

732.90 806.10

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User57

765.58 842.23

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User58

800.45 880.55

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User59

817.72 899.40

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User60

852.59 937.73

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User61

882.75 971.03

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User62

902.54 992.70

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User63

927.36 1020.03

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User64

942.44 1036.68

75729PA0012630 Rating Area 5 Tobacco User/Non-Tobacco User65 and over

942.44 1036.68

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User0-20

210.22 210.22

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User21

331.07 364.17

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User22

331.07 364.17

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User23

331.07 364.17

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User24

331.07 364.17

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User25

332.39 365.49

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User26

339.01 372.78

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User27

346.95 381.71

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User28

359.86 395.95

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User29

370.46 407.54

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User30

375.76 413.50

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User31

383.70 422.10

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User32

391.65 430.71

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User33

396.61 436.34

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User34

401.91 441.97

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User35

404.56 444.95

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User36

407.21 447.93

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User37

409.85 450.91

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User38

412.50 453.89

Page 68: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User39

417.80 459.51

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User40

423.10 465.47

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User41

431.04 474.08

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User42

438.66 482.69

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User43

449.25 494.28

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User44

462.49 508.84

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User45

478.05 525.73

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User46

496.59 546.25

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User47

517.45 569.10

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User48

541.29 595.58

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User49

564.79 621.40

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User50

591.28 650.54

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User51

617.43 679.34

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User52

646.23 710.79

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User53

675.37 742.90

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User54

706.82 777.33

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User55

738.27 812.10

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User56

772.37 849.51

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User57

806.80 887.58

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User58

843.55 927.97

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User59

861.75 947.83

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User60

898.50 988.22

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User61

930.28 1023.31

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User62

951.14 1046.16

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User63

977.30 1074.96

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User64

993.19 1092.51

75729PA0012630 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

993.19 1092.51

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User0-20

190.06 190.06

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User21

299.31 329.24

Page 69: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User22

299.31 329.24

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User23

299.31 329.24

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User24

299.31 329.24

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User25

300.50 330.43

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User26

306.49 337.01

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User27

313.67 345.10

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User28

325.34 357.97

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User29

334.92 368.44

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User30

339.71 373.83

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User31

346.89 381.61

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User32

354.07 389.39

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User33

358.56 394.48

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User34

363.35 399.57

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User35

365.75 402.26

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User36

368.14 404.96

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User37

370.54 407.65

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User38

372.93 410.34

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User39

377.72 415.43

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User40

382.51 420.82

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User41

389.69 428.60

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User42

396.58 436.38

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User43

406.15 446.86

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User44

418.13 460.03

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User45

432.19 475.29

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User46

448.95 493.85

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User47

467.81 514.50

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User48

489.36 538.44

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User49

510.61 561.79

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User50

534.55 588.13

Page 70: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User51

558.20 614.17

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User52

584.24 642.60

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User53

610.58 671.63

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User54

639.01 702.76

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User55

667.44 734.19

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User56

698.27 768.01

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User57

729.40 802.43

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User58

762.62 838.94

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User59

779.08 856.90

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User60

812.31 893.42

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User61

841.04 925.14

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User62

859.90 945.80

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User63

883.54 971.83

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User64

897.91 987.70

75729PA0012631 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

897.91 987.70

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User0-20

210.22 210.22

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User21

331.07 364.17

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User22

331.07 364.17

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User23

331.07 364.17

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User24

331.07 364.17

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User25

332.39 365.49

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User26

339.01 372.78

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User27

346.95 381.71

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User28

359.86 395.95

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User29

370.46 407.54

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User30

375.76 413.50

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User31

383.70 422.10

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User32

391.65 430.71

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User33

396.61 436.34

Page 71: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User34

401.91 441.97

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User35

404.56 444.95

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User36

407.21 447.93

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User37

409.85 450.91

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User38

412.50 453.89

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User39

417.80 459.51

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User40

423.10 465.47

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User41

431.04 474.08

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User42

438.66 482.69

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User43

449.25 494.28

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User44

462.49 508.84

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User45

478.05 525.73

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User46

496.59 546.25

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User47

517.45 569.10

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User48

541.29 595.58

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User49

564.79 621.40

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User50

591.28 650.54

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User51

617.43 679.34

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User52

646.23 710.79

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User53

675.37 742.90

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User54

706.82 777.33

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User55

738.27 812.10

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User56

772.37 849.51

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User57

806.80 887.58

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User58

843.55 927.97

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User59

861.75 947.83

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User60

898.50 988.22

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User61

930.28 1023.31

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User62

951.14 1046.16

Page 72: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User63

977.30 1074.96

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User64

993.19 1092.51

75729PA0012632 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

993.19 1092.51

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User0-20

254.72 254.72

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User21

401.15 441.26

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User22

401.15 441.26

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User23

401.15 441.26

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User24

401.15 441.26

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User25

402.75 442.86

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User26

410.77 451.68

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User27

420.40 462.52

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User28

436.04 479.76

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User29

448.88 493.80

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User30

455.30 501.03

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User31

464.92 511.45

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User32

474.55 521.88

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User33

480.57 528.70

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User34

486.99 535.52

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User35

490.19 539.13

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User36

493.40 542.74

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User37

496.61 546.35

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User38

499.82 549.96

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User39

506.24 556.78

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User40

512.66 564.00

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User41

522.29 574.43

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User42

531.51 584.86

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User43

544.35 598.90

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User44

560.39 616.55

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User45

579.25 637.01

Page 73: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User46

601.71 661.88

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User47

626.98 689.56

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User48

655.87 721.65

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User49

684.35 752.94

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User50

716.44 788.24

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User51

748.13 823.14

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User52

783.03 861.25

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User53

818.33 900.16

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User54

856.44 941.88

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User55

894.54 984.00

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User56

935.86 1029.33

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User57

977.58 1075.46

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User58

1022.11 1124.40

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User59

1044.17 1148.47

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User60

1088.70 1197.41

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User61

1127.21 1239.93

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User62

1152.48 1267.61

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User63

1184.17 1302.50

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User64

1203.42 1323.77

75729PA0012633 Rating Area 7 Tobacco User/Non-Tobacco User65 and over

1203.42 1323.77

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User0-20

190.06 190.06

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User21

299.31 329.24

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User22

299.31 329.24

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User23

299.31 329.24

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User24

299.31 329.24

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User25

300.50 330.43

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User26

306.49 337.01

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User27

313.67 345.10

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User28

325.34 357.97

Page 74: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User29

334.92 368.44

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User30

339.71 373.83

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User31

346.89 381.61

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User32

354.07 389.39

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User33

358.56 394.48

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User34

363.35 399.57

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User35

365.75 402.26

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User36

368.14 404.96

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User37

370.54 407.65

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User38

372.93 410.34

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User39

377.72 415.43

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User40

382.51 420.82

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User41

389.69 428.60

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User42

396.58 436.38

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User43

406.15 446.86

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User44

418.13 460.03

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User45

432.19 475.29

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User46

448.95 493.85

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User47

467.81 514.50

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User48

489.36 538.44

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User49

510.61 561.79

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User50

534.55 588.13

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User51

558.20 614.17

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User52

584.24 642.60

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User53

610.58 671.63

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User54

639.01 702.76

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User55

667.44 734.19

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User56

698.27 768.01

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User57

729.40 802.43

Page 75: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User58

762.62 838.94

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User59

779.08 856.90

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User60

812.31 893.42

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User61

841.04 925.14

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User62

859.90 945.80

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User63

883.54 971.83

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User64

897.91 987.70

75729PA0012633 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

897.91 987.70

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User0-20

228.43 228.43

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User21

359.74 395.71

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User22

359.74 395.71

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User23

359.74 395.71

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User24

359.74 395.71

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User25

361.17 397.14

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User26

368.36 405.06

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User27

377.00 414.77

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User28

391.03 430.24

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User29

402.54 442.83

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User30

408.29 449.30

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User31

416.93 458.66

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User32

425.56 468.01

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User33

430.96 474.12

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User34

436.71 480.24

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User35

439.59 483.48

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User36

442.47 486.72

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User37

445.35 489.95

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User38

448.22 493.19

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User39

453.98 499.31

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User40

459.74 505.78

Page 76: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User41

468.37 515.13

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User42

476.64 524.49

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User43

488.15 537.08

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User44

502.54 552.91

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User45

519.45 571.25

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User46

539.60 593.56

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User47

562.26 618.38

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User48

588.16 647.16

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User49

613.70 675.21

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User50

642.48 706.87

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User51

670.90 738.17

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User52

702.19 772.34

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User53

733.85 807.24

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User54

768.02 844.65

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User55

802.20 882.42

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User56

839.25 923.07

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User57

876.66 964.44

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User58

916.59 1008.32

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User59

936.38 1029.91

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User60

976.31 1073.80

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User61

1010.84 1111.93

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User62

1033.51 1136.75

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User63

1061.92 1168.04

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User64

1079.19 1187.11

75729PA0012634 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

1079.19 1187.11

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User0-20

251.88 251.88

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User21

396.66 436.33

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User22

396.66 436.33

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User23

396.66 436.33

Page 77: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User24

396.66 436.33

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User25

398.24 437.91

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User26

406.18 446.64

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User27

415.70 457.35

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User28

431.17 474.40

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User29

443.86 488.29

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User30

450.21 495.43

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User31

459.73 505.74

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User32

469.25 516.05

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User33

475.20 522.79

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User34

481.54 529.54

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User35

484.72 533.11

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User36

487.89 536.68

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User37

491.06 540.25

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User38

494.24 543.82

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User39

500.58 550.56

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User40

506.93 557.70

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User41

516.45 568.01

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User42

525.57 578.33

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User43

538.26 592.21

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User44

554.13 609.66

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User45

572.77 629.89

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User46

594.99 654.49

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User47

619.98 681.85

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User48

648.54 713.59

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User49

676.70 744.53

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User50

708.43 779.43

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User51

739.77 813.94

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User52

774.28 851.62

Page 78: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User53

809.18 890.10

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User54

846.86 931.35

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User55

884.55 973.00

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User56

925.40 1017.82

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User57

966.66 1063.44

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User58

1010.68 1111.83

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User59

1032.50 1135.63

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User60

1076.53 1184.02

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User61

1114.61 1226.07

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User62

1139.60 1253.44

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User63

1170.93 1287.95

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User64

1189.97 1308.97

75729PA0012635 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

1189.97 1308.97

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User0-20

252.67 252.67

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User21

397.91 437.70

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User22

397.91 437.70

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User23

397.91 437.70

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User24

397.91 437.70

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User25

399.49 439.28

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User26

407.45 448.04

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User27

417.00 458.78

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User28

432.52 475.89

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User29

445.25 489.82

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User30

451.62 496.98

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User31

461.17 507.33

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User32

470.72 517.67

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User33

476.69 524.44

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User34

483.05 531.20

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User35

486.24 534.78

Page 79: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User36

489.42 538.36

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User37

492.60 541.94

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User38

495.79 545.52

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User39

502.15 552.29

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User40

508.52 559.45

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User41

518.07 569.80

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User42

527.22 580.14

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User43

539.95 594.07

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User44

555.87 611.58

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User45

574.57 631.87

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User46

596.85 656.54

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User47

621.92 683.99

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User48

650.57 715.83

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User49

678.82 746.86

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User50

710.65 781.88

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User51

742.09 816.50

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User52

776.71 854.30

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User53

811.72 892.89

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User54

849.52 934.28

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User55

887.32 976.05

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User56

928.31 1021.02

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User57

969.69 1066.78

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User58

1013.86 1115.32

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User59

1035.74 1139.19

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User60

1079.91 1187.74

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User61

1118.11 1229.92

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User62

1143.17 1257.37

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User63

1174.61 1291.99

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User64

1193.71 1313.08

Page 80: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012635 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

1193.71 1313.08

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User0-20

179.78 179.78

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User21

283.12 311.43

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User22

283.12 311.43

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User23

283.12 311.43

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User24

283.12 311.43

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User25

284.24 312.55

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User26

289.91 318.78

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User27

296.70 326.43

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User28

307.74 338.60

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User29

316.80 348.51

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User30

321.33 353.61

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User31

328.13 360.97

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User32

334.92 368.33

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User33

339.17 373.14

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User34

343.70 377.95

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User35

345.96 380.50

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User36

348.23 383.05

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User37

350.49 385.60

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User38

352.76 388.15

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User39

357.29 392.96

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User40

361.82 398.05

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User41

368.61 405.42

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User42

375.12 412.78

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User43

384.18 422.68

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User44

395.51 435.14

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User45

408.81 449.58

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User46

424.67 467.13

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User47

442.50 486.67

Page 81: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User48

462.89 509.32

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User49

482.99 531.40

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User50

505.64 556.31

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User51

528.00 580.94

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User52

552.63 607.84

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User53

577.55 635.30

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User54

604.44 664.74

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User55

631.34 694.47

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User56

660.50 726.46

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User57

689.94 759.02

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User58

721.37 793.56

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User59

736.94 810.55

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User60

768.36 845.09

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User61

795.54 875.10

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User62

813.38 894.63

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User63

835.74 919.26

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User64

849.33 934.27

75729PA0012636 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

849.33 934.27

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User0-20

198.23 198.23

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User21

312.18 343.40

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User22

312.18 343.40

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User23

312.18 343.40

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User24

312.18 343.40

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User25

313.42 344.64

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User26

319.67 351.51

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User27

327.16 359.94

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User28

339.33 373.36

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User29

349.32 384.29

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User30

354.32 389.90

Page 82: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User31

361.81 398.02

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User32

369.30 406.14

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User33

373.98 411.44

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User34

378.98 416.75

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User35

381.48 419.56

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User36

383.97 422.37

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User37

386.47 425.18

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User38

388.97 427.99

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User39

393.96 433.30

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User40

398.96 438.92

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User41

406.45 447.03

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User42

413.63 455.15

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User43

423.62 466.07

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User44

436.11 479.81

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User45

450.78 495.73

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User46

468.26 515.09

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User47

487.93 536.63

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User48

510.40 561.60

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User49

532.57 585.95

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User50

557.54 613.42

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User51

582.20 640.58

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User52

609.36 670.24

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User53

636.83 700.52

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User54

666.49 732.98

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User55

696.15 765.76

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User56

728.30 801.04

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User57

760.77 836.94

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User58

795.42 875.02

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User59

812.59 893.75

Page 83: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User60

847.24 931.84

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User61

877.21 964.93

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User62

896.87 986.47

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User63

921.54 1013.63

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User64

936.52 1030.17

75729PA0012637 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

936.52 1030.17

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User0-20

198.85 198.85

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User21

313.16 344.47

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User22

313.16 344.47

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User23

313.16 344.47

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User24

313.16 344.47

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User25

314.41 345.72

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User26

320.67 352.61

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User27

328.18 361.07

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User28

340.40 374.53

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User29

350.42 385.49

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User30

355.43 391.13

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User31

362.94 399.27

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User32

370.46 407.41

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User33

375.16 412.74

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User34

380.17 418.06

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User35

382.67 420.88

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User36

385.18 423.70

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User37

387.68 426.51

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User38

390.19 429.33

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User39

395.20 434.66

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User40

400.21 440.29

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User41

407.72 448.43

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User42

414.93 456.58

Page 84: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User43

424.95 467.54

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User44

437.47 481.32

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User45

452.19 497.29

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User46

469.73 516.70

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User47

489.46 538.31

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User48

512.00 563.36

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User49

534.24 587.79

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User50

559.29 615.35

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User51

584.03 642.59

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User52

611.27 672.34

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User53

638.83 702.71

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User54

668.58 735.28

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User55

698.33 768.16

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User56

730.59 803.55

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User57

763.15 839.56

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User58

797.91 877.77

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User59

815.14 896.56

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User60

849.90 934.76

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User61

879.96 967.96

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User62

899.69 989.56

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User63

924.43 1016.81

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User64

939.46 1033.40

75729PA0012637 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

939.46 1033.40

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User0-20

189.13 189.13

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User21

297.85 327.64

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User22

297.85 327.64

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User23

297.85 327.64

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User24

297.85 327.64

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User25

299.04 328.82

Page 85: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User26

305.00 335.38

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User27

312.15 343.42

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User28

323.76 356.23

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User29

333.29 366.65

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User30

338.06 372.01

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User31

345.21 379.76

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User32

352.35 387.50

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User33

356.82 392.56

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User34

361.59 397.63

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User35

363.97 400.31

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User36

366.35 402.99

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User37

368.74 405.67

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User38

371.12 408.35

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User39

375.88 413.41

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User40

380.65 418.77

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User41

387.80 426.52

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User42

394.65 434.26

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User43

404.18 444.69

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User44

416.09 457.79

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User45

430.09 472.98

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User46

446.77 491.45

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User47

465.54 512.00

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User48

486.98 535.83

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User49

508.13 559.06

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User50

531.96 585.27

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User51

555.49 611.19

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User52

581.40 639.48

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User53

607.61 668.37

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User54

635.91 699.35

Page 86: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User55

664.20 730.62

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User56

694.88 764.28

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User57

725.86 798.53

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User58

758.92 834.87

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User59

775.30 852.74

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User60

808.36 889.08

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User61

836.95 920.65

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User62

855.72 941.20

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User63

879.25 967.11

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User64

893.55 982.90

75729PA0012638 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

893.55 982.90

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User0-20

180.03 180.03

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User21

283.52 311.87

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User22

283.52 311.87

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User23

283.52 311.87

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User24

283.52 311.87

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User25

284.65 313.00

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User26

290.32 319.24

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User27

297.13 326.89

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User28

308.18 339.09

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User29

317.26 349.01

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User30

321.79 354.11

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User31

328.60 361.48

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User32

335.40 368.86

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User33

339.65 373.68

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User34

344.19 378.50

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User35

346.46 381.05

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User36

348.73 383.60

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User37

350.99 386.15

Page 87: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User38

353.26 388.70

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User39

357.80 393.52

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User40

362.33 398.62

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User41

369.14 406.00

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User42

375.66 413.37

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User43

384.73 423.29

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User44

396.07 435.77

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User45

409.40 450.22

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User46

425.28 467.80

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User47

443.14 487.37

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User48

463.55 510.05

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User49

483.68 532.16

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User50

506.36 557.11

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User51

528.76 581.78

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User52

553.42 608.71

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User53

578.37 636.21

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User54

605.31 665.70

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User55

632.24 695.47

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User56

661.44 727.50

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User57

690.93 760.11

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User58

722.40 794.70

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User59

737.99 811.71

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User60

769.46 846.30

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User61

796.68 876.35

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User62

814.54 895.91

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User63

836.94 920.58

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User64

850.55 935.61

75729PA0012638 Rating Area 5 Tobacco User/Non-Tobacco User65 and over

850.55 935.61

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User0-20

189.73 189.73

Page 88: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User21

298.79 328.67

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User22

298.79 328.67

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User23

298.79 328.67

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User24

298.79 328.67

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User25

299.98 329.86

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User26

305.95 336.43

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User27

313.12 344.50

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User28

324.78 357.34

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User29

334.34 367.80

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User30

339.12 373.18

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User31

346.29 380.95

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User32

353.46 388.72

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User33

357.94 393.80

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User34

362.72 398.88

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User35

365.11 401.56

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User36

367.50 404.25

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User37

369.89 406.94

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User38

372.28 409.63

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User39

377.06 414.71

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User40

381.84 420.09

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User41

389.02 427.86

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User42

395.89 435.63

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User43

405.45 446.08

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User44

417.40 459.23

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User45

431.44 474.47

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User46

448.17 492.99

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User47

467.00 513.61

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User48

488.51 537.51

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User49

509.72 560.82

Page 89: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User50

533.63 587.11

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User51

557.23 613.10

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User52

583.22 641.49

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User53

609.52 670.47

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User54

637.90 701.54

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User55

666.29 732.92

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User56

697.06 766.68

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User57

728.13 801.04

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User58

761.30 837.49

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User59

777.73 855.42

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User60

810.90 891.87

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User61

839.58 923.54

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User62

858.40 944.15

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User63

882.01 970.15

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User64

896.35 985.98

75729PA0012638 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

896.35 985.98

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User0-20

171.53 171.53

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User21

270.12 297.14

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User22

270.12 297.14

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User23

270.12 297.14

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User24

270.12 297.14

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User25

271.20 298.21

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User26

276.60 304.16

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User27

283.09 311.45

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User28

293.62 323.06

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User29

302.26 332.52

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User30

306.59 337.38

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User31

313.07 344.40

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User32

319.55 351.43

Page 90: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User33

323.60 356.02

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User34

327.93 360.61

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User35

330.09 363.04

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User36

332.25 365.47

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User37

334.41 367.90

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User38

336.57 370.33

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User39

340.89 374.93

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User40

345.21 379.79

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User41

351.70 386.81

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User42

357.91 393.83

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User43

366.55 403.29

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User44

377.36 415.17

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User45

390.05 428.95

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User46

405.18 445.70

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User47

422.20 464.34

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User48

441.65 485.95

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User49

460.82 507.02

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User50

482.43 530.79

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User51

503.77 554.29

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User52

527.27 579.95

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User53

551.04 606.15

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User54

576.71 634.24

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User55

602.37 662.60

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User56

630.19 693.13

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User57

658.28 724.19

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User58

688.27 757.15

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User59

703.12 773.35

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User60

733.11 806.31

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User61

759.04 834.94

Page 91: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User62

776.05 853.58

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User63

797.39 877.08

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User64

810.36 891.40

75729PA0012638 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

810.36 891.40

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User0-20

244.29 244.29

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User21

384.72 423.19

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User22

384.72 423.19

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User23

384.72 423.19

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User24

384.72 423.19

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User25

386.25 424.72

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User26

393.94 433.18

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User27

403.18 443.57

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User28

418.18 460.11

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User29

430.49 473.58

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User30

436.65 480.50

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User31

445.88 490.51

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User32

455.11 500.51

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User33

460.88 507.05

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User34

467.04 513.59

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User35

470.12 517.05

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User36

473.19 520.51

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User37

476.27 523.98

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User38

479.35 527.44

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User39

485.50 533.98

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User40

491.66 540.90

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User41

500.89 550.91

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User42

509.74 560.91

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User43

522.05 574.37

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User44

537.44 591.30

Page 92: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User45

555.52 610.92

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User46

577.07 634.77

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User47

601.30 661.32

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User48

629.00 692.09

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User49

656.32 722.10

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User50

687.09 755.96

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User51

717.49 789.43

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User52

750.96 825.97

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User53

784.81 863.29

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User54

821.36 903.30

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User55

857.90 943.70

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User56

897.53 987.17

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User57

937.54 1031.41

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User58

980.24 1078.34

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User59

1001.40 1101.43

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User60

1044.10 1148.36

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User61

1081.04 1189.14

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User62

1105.27 1215.69

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User63

1135.67 1249.16

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User64

1154.13 1269.55

75729PA0012639 Rating Area 3 Tobacco User/Non-Tobacco User65 and over

1154.13 1269.55

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User0-20

232.54 232.54

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User21

366.20 402.82

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User22

366.20 402.82

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User23

366.20 402.82

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User24

366.20 402.82

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User25

367.66 404.28

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User26

374.99 412.34

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User27

383.78 422.23

Page 93: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User28

398.06 437.97

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User29

409.78 450.79

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User30

415.64 457.38

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User31

424.43 466.90

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User32

433.21 476.43

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User33

438.71 482.65

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User34

444.57 488.88

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User35

447.50 492.17

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User36

450.43 495.47

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User37

453.35 498.76

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User38

456.28 502.06

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User39

462.14 508.28

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User40

468.00 514.88

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User41

476.79 524.40

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User42

485.21 533.92

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User43

496.93 546.74

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User44

511.58 562.85

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User45

528.79 581.52

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User46

549.30 604.23

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User47

572.37 629.50

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User48

598.74 658.79

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User49

624.74 687.36

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User50

654.03 719.58

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User51

682.96 751.44

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User52

714.82 786.23

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User53

747.05 821.75

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User54

781.84 859.84

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User55

816.62 898.29

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User56

854.34 939.67

Page 94: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User57

892.43 981.78

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User58

933.08 1026.46

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User59

953.22 1048.43

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User60

993.87 1093.11

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User61

1029.02 1131.92

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User62

1052.09 1157.19

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User63

1081.02 1189.05

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User64

1098.60 1208.46

75729PA0012639 Rating Area 5 Tobacco User/Non-Tobacco User65 and over

1098.60 1208.46

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User0-20

245.06 245.06

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User21

385.92 424.51

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User22

385.92 424.51

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User23

385.92 424.51

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User24

385.92 424.51

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User25

387.46 426.05

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User26

395.18 434.54

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User27

404.44 444.96

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User28

419.49 461.56

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User29

431.84 475.06

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User30

438.02 482.01

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User31

447.28 492.05

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User32

456.54 502.08

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User33

462.33 508.64

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User34

468.50 515.20

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User35

471.59 518.67

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User36

474.68 522.15

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User37

477.77 525.62

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User38

480.85 529.09

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User39

487.03 535.65

Page 95: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User40

493.20 542.60

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User41

502.47 552.63

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User42

511.34 562.67

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User43

523.69 576.18

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User44

539.13 593.16

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User45

557.27 612.84

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User46

578.88 636.76

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User47

603.19 663.39

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User48

630.98 694.27

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User49

658.38 724.37

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User50

689.25 758.33

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User51

719.74 791.90

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User52

753.31 828.57

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User53

787.27 866.00

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User54

823.93 906.14

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User55

860.60 946.66

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User56

900.35 990.27

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User57

940.48 1034.65

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User58

983.32 1081.73

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User59

1004.54 1104.88

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User60

1047.38 1151.96

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User61

1084.43 1192.87

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User62

1108.74 1219.50

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User63

1139.23 1253.08

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User64

1157.75 1273.53

75729PA0012639 Rating Area 6 Tobacco User/Non-Tobacco User65 and over

1157.75 1273.53

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User0-20

221.55 221.55

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User21

348.90 383.79

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User22

348.90 383.79

Page 96: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User23

348.90 383.79

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User24

348.90 383.79

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User25

350.29 385.18

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User26

357.27 392.86

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User27

365.64 402.28

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User28

379.25 417.28

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User29

390.41 429.49

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User30

396.00 435.77

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User31

404.37 444.84

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User32

412.74 453.91

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User33

417.98 459.84

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User34

423.56 465.78

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User35

426.35 468.92

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User36

429.14 472.06

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User37

431.93 475.20

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User38

434.72 478.34

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User39

440.31 484.27

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User40

445.89 490.55

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User41

454.26 499.62

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User42

462.29 508.69

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User43

473.45 520.90

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User44

487.41 536.25

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User45

503.81 554.05

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User46

523.34 575.68

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User47

545.32 599.75

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User48

570.44 627.66

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User49

595.22 654.88

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User50

623.13 685.58

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User51

650.69 715.93

Page 97: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User52

681.04 749.08

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User53

711.75 782.92

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User54

744.89 819.21

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User55

778.04 855.84

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User56

813.97 895.27

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User57

850.26 935.39

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User58

888.99 977.95

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User59

908.18 998.89

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User60

946.90 1041.45

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User61

980.40 1078.44

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User62

1002.38 1102.51

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User63

1029.94 1132.86

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User64

1046.69 1151.36

75729PA0012639 Rating Area 9 Tobacco User/Non-Tobacco User65 and over

1046.69 1151.36

Page 98: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

HIOS Plan ID

On/Off

Exchange Product Metal Plan Design Marketing Name Network Rating Area Counties Excluded

75729PA0012596 On PPO Gold Geisinger Marketplace PPO 25/50/1000

Geisinger

Marketplace PPO Rating Area 2 Elk

75729PA0012596 On PPO Gold Geisinger Marketplace PPO 25/50/1000

Geisinger

Marketplace PPO Rating Area 3

75729PA0012596 On PPO Gold Geisinger Marketplace PPO 25/50/1000

Geisinger

Marketplace PPO Rating Area 5 Bedford

75729PA0012596 On PPO Gold Geisinger Marketplace PPO 25/50/1000

Geisinger

Marketplace PPO Rating Area 6 Lehigh, Northampton

75729PA0012603 On PPO Silver Geisinger Marketplace PPO 30/50/5000

Geisinger

Marketplace PPO Rating Area 2 Elk

75729PA0012603 On PPO Silver Geisinger Marketplace PPO 30/50/5000

Geisinger

Marketplace PPO Rating Area 3

75729PA0012603 On PPO Silver Geisinger Marketplace PPO 30/50/5000

Geisinger

Marketplace PPO Rating Area 5 Bedford

75729PA0012603 On PPO Silver Geisinger Marketplace PPO 30/50/5000

Geisinger

Marketplace PPO Rating Area 6 Lehigh, Northampton

75729PA0012611 On PPO Gold Geisinger Marketplace PPO 25/50/1000

Geisinger

Marketplace PPO Rating Area 9 Franklin, Fulton, Lebanon

75729PA0012612 On PPO Silver Geisinger Marketplace PPO 30/50/5000

Geisinger

Marketplace PPO Rating Area 9 Franklin, Fulton, Lebanon

75729PA0012613 On PPO Gold Geisinger Marketplace PPO 25/50/1000

Geisinger

Marketplace PPO Rating Area 6

Centre, Columbia, Mifflin,

Montour, Northumberland,

Schuylkill, Snyder, Union

75729PA0012614 On PPO Silver Geisinger Marketplace PPO 30/50/5000

Geisinger

Marketplace PPO Rating Area 6

Centre, Columbia, Mifflin,

Montour, Northumberland,

Schuylkill, Snyder, Union

75729PA0012615 On PPO Gold Geisinger Marketplace PPO 25/50/1000

Geisinger

Marketplace PPO Rating Area 7

75729PA0012615 On PPO Gold Geisinger Marketplace PPO 25/50/1000

Geisinger

Marketplace PPO Rating Area 9

Cumberland, Dauphin,

Franklin, Juniata, Perry

75729PA0012616 On PPO Silver Geisinger Marketplace PPO 30/50/5000

Geisinger

Marketplace PPO Rating Area 7

75729PA0012616 On PPO Silver Geisinger Marketplace PPO 30/50/5000

Geisinger

Marketplace PPO Rating Area 9

Cumberland, Dauphin,

Franklin, Juniata, Perry

75729PA0012620 On PPO Gold Geisinger Marketplace PPO Extra 10/50/500

Geisinger

Marketplace PPO Rating Area 9 Franklin, Fulton, Lebanon

75729PA0012621 On PPO Gold Geisinger Marketplace PPO Extra 10/50/500

Geisinger

Marketplace PPO Rating Area 3

Bradford, Carbon, Pike,

Sullivan, Tioga

75729PA0012621 On PPO Gold Geisinger Marketplace PPO Extra 10/50/500

Geisinger

Marketplace PPO Rating Area 6 Lehigh, Northampton

75729PA0012622 On PPO Silver Geisinger Marketplace PPO Extra 10/50/3500

Geisinger

Marketplace PPO Rating Area 9 Franklin, Fulton, Lebanon

75729PA0012623 On PPO Silver Geisinger Marketplace PPO Extra 10/50/3500

Geisinger

Marketplace PPO Rating Area 3

Bradford, Carbon, Pike,

Sullivan, Tioga

75729PA0012623 On PPO Silver Geisinger Marketplace PPO Extra 10/50/3500

Geisinger

Marketplace PPO Rating Area 6 Lehigh, Northampton

75729PA0012624 On PPO Silver Geisinger Marketplace PPO Select 30/50/5000

Geisinger

Marketplace Select Rating Area 3

Bradford, Carbon,

Lackawanna, Lycoming,

Monroe, Pike, Tioga, Wayne

75729PA0012624 On PPO Silver Geisinger Marketplace PPO Select 30/50/5000

Geisinger

Marketplace Select Rating Area 5

Bedford, Blair, Cambria,

Clearfield, Jefferson,

Somerset

75729PA0012624 On PPO Silver Geisinger Marketplace PPO Select 30/50/5000

Geisinger

Marketplace Select Rating Area 6 Centre

75729PA0012624 On PPO Silver Geisinger Marketplace PPO Select 30/50/5000

Geisinger

Marketplace Select Rating Area 9

Cumberland, Dauphin,

Franklin, Fulton, Lebanon,

Perry

75729PA0012625 On PPO Gold Geisinger Marketplace PPO Select 25/50/1000

Geisinger

Marketplace Select Rating Area 3

Bradford, Carbon,

Lackawanna, Lycoming,

Monroe, Pike, Tioga, Wayne

75729PA0012625 On PPO Gold Geisinger Marketplace PPO Select 25/50/1000

Geisinger

Marketplace Select Rating Area 5

Bedford, Blair, Cambria,

Clearfield, Jefferson,

Somerset

Geisinger Quality Options

Individual

Plan Design Summary

12/24/2014

Page 99: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012625 On PPO Gold Geisinger Marketplace PPO Select 25/50/1000

Geisinger

Marketplace Select Rating Area 6 Centre

75729PA0012625 On PPO Gold Geisinger Marketplace PPO Select 25/50/1000

Geisinger

Marketplace Select Rating Area 9

Cumberland, Dauphin,

Franklin, Fulton, Lebanon,

Perry

75729PA0012626 Off PPO Gold Geisinger Marketplace PPO 25/50/1000 w/PD

Geisinger

Marketplace PPO Rating Area 2 Elk

75729PA0012626 Off PPO Gold Geisinger Marketplace PPO 25/50/1000 w/PD

Geisinger

Marketplace PPO Rating Area 3

75729PA0012626 Off PPO Gold Geisinger Marketplace PPO 25/50/1000 w/PD

Geisinger

Marketplace PPO Rating Area 5 Bedford

75729PA0012626 Off PPO Gold Geisinger Marketplace PPO 25/50/1000 w/PD

Geisinger

Marketplace PPO Rating Area 6 Lehigh, Northampton

75729PA0012627 Off PPO Gold Geisinger Marketplace PPO 25/50/1000 w/PD

Geisinger

Marketplace PPO Rating Area 9 Franklin, Fulton, Lebanon

75729PA0012628 Off PPO Gold Geisinger Marketplace PPO 25/50/1000 w/PD

Geisinger

Marketplace PPO Rating Area 6

Centre, Columbia, Mifflin,

Montour, Northumberland,

Schuylkill, Snyder, Union

75729PA0012629 Off PPO Gold Geisinger Marketplace PPO 25/50/1000 w/PD

Geisinger

Marketplace PPO Rating Area 7

75729PA0012629 Off PPO Gold Geisinger Marketplace PPO 25/50/1000 w/PD

Geisinger

Marketplace PPO Rating Area 9

Cumberland, Dauphin,

Franklin, Juniata, Perry

75729PA0012630 Off PPO Silver Geisinger Marketplace PPO 30/50/5000 w/PD

Geisinger

Marketplace PPO Rating Area 2 Elk

75729PA0012630 Off PPO Silver Geisinger Marketplace PPO 30/50/5000 w/PD

Geisinger

Marketplace PPO Rating Area 3

75729PA0012630 Off PPO Silver Geisinger Marketplace PPO 30/50/5000 w/PD

Geisinger

Marketplace PPO Rating Area 5 Bedford

75729PA0012630 Off PPO Silver Geisinger Marketplace PPO 30/50/5000 w/PD

Geisinger

Marketplace PPO Rating Area 6 Lehigh, Northampton

75729PA0012631 Off PPO Silver Geisinger Marketplace PPO 30/50/5000 w/PD

Geisinger

Marketplace PPO Rating Area 9 Franklin, Fulton, Lebanon

75729PA0012632 Off PPO Silver Geisinger Marketplace PPO 30/50/5000 w/PD

Geisinger

Marketplace PPO Rating Area 6

Centre, Columbia, Mifflin,

Montour, Northumberland,

Schuylkill, Snyder, Union

75729PA0012633 Off PPO Silver Geisinger Marketplace PPO 30/50/5000 w/PD

Geisinger

Marketplace PPO Rating Area 7

75729PA0012633 Off PPO Silver Geisinger Marketplace PPO 30/50/5000 w/PD

Geisinger

Marketplace PPO Rating Area 9

Cumberland, Dauphin,

Franklin, Juniata, Perry

75729PA0012634 Off PPO Gold Geisinger Marketplace PPO Extra 10/50/500 w/PD

Geisinger

Marketplace PPO Rating Area 9 Franklin, Fulton, Lebanon

75729PA0012635 Off PPO Gold Geisinger Marketplace PPO Extra 10/50/500 w/PD

Geisinger

Marketplace PPO Rating Area 3

Bradford, Carbon, Pike,

Sullivan, Tioga

75729PA0012635 Off PPO Gold Geisinger Marketplace PPO Extra 10/50/500 w/PD

Geisinger

Marketplace PPO Rating Area 6 Lehigh, Northampton

75729PA0012636 Off PPO Silver Geisinger Marketplace PPO Extra 10/50/3500 w/PD

Geisinger

Marketplace PPO Rating Area 9 Franklin, Fulton, Lebanon

75729PA0012637 Off PPO Silver Geisinger Marketplace PPO Extra 10/50/3500 w/PD

Geisinger

Marketplace PPO Rating Area 3

Bradford, Carbon, Pike,

Sullivan, Tioga

75729PA0012637 Off PPO Silver Geisinger Marketplace PPO Extra 10/50/3500 w/PD

Geisinger

Marketplace PPO Rating Area 6 Lehigh, Northampton

75729PA0012638 Off PPO Silver Geisinger Marketplace PPO Select 30/50/5000 w/PD

Geisinger

Marketplace Select Rating Area 3

Bradford, Carbon,

Lackawanna, Lycoming,

Monroe, Pike, Tioga, Wayne

75729PA0012638 Off PPO Silver Geisinger Marketplace PPO Select 30/50/5000 w/PD

Geisinger

Marketplace Select Rating Area 5

Bedford, Blair, Cambria,

Clearfield, Jefferson,

Somerset

75729PA0012638 Off PPO Silver Geisinger Marketplace PPO Select 30/50/5000 w/PD

Geisinger

Marketplace Select Rating Area 6 Centre

75729PA0012638 Off PPO Silver Geisinger Marketplace PPO Select 30/50/5000 w/PD

Geisinger

Marketplace Select Rating Area 9

Cumberland, Dauphin,

Franklin, Fulton, Lebanon,

Perry

75729PA0012639 Off PPO Gold Geisinger Marketplace PPO Select 25/50/1000 w/PD

Geisinger

Marketplace Select Rating Area 3

Bradford, Carbon,

Lackawanna, Lycoming,

Monroe, Pike, Tioga, Wayne

75729PA0012639 Off PPO Gold Geisinger Marketplace PPO Select 25/50/1000 w/PD

Geisinger

Marketplace Select Rating Area 5

Bedford, Blair, Cambria,

Clearfield, Jefferson,

Somerset

75729PA0012639 Off PPO Gold Geisinger Marketplace PPO Select 25/50/1000 w/PD

Geisinger

Marketplace Select Rating Area 6 Centre

12/24/2014

Page 100: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

75729PA0012639 Off PPO Gold Geisinger Marketplace PPO Select 25/50/1000 w/PD

Geisinger

Marketplace Select Rating Area 9

Cumberland, Dauphin,

Franklin, Fulton, Lebanon,

Perry

12/24/2014

Page 101: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

RATE PAGES

Company Name: Geisinger Quality Options

Market: Individual

Product: PPO

Effective Date of Rates: Ending date of Rates: 12/31/2017

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays => $25.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00 $50.00 $30.00 $50.00 $30.00 $50.00 $30.00 $50.00 $30.00

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco

0 - 20 $249.96 $249.96 $268.49 $268.49 $255.57 $255.57 $269.34 $269.34 $194.31 $194.31 $208.72 $208.72 $198.67 $198.67 $209.37

21 $393.64 $433.00 $422.83 $465.11 $402.48 $442.73 $424.16 $466.57 $306.00 $336.60 $328.69 $361.56 $312.88 $344.16 $329.72

22 $393.64 $433.00 $422.83 $465.11 $402.48 $442.73 $424.16 $466.57 $306.00 $336.60 $328.69 $361.56 $312.88 $344.16 $329.72

23 $393.64 $433.00 $422.83 $465.11 $402.48 $442.73 $424.16 $466.57 $306.00 $336.60 $328.69 $361.56 $312.88 $344.16 $329.72

24 $393.64 $433.00 $422.83 $465.11 $402.48 $442.73 $424.16 $466.57 $306.00 $336.60 $328.69 $361.56 $312.88 $344.16 $329.72

25 $395.21 $434.57 $424.52 $466.80 $404.09 $444.34 $425.85 $468.26 $307.22 $337.82 $330.00 $362.87 $314.12 $345.41 $331.04

26 $403.08 $443.23 $432.97 $476.10 $412.14 $453.19 $434.33 $477.59 $313.34 $344.55 $336.58 $370.10 $320.38 $352.29 $337.63

27 $412.53 $453.86 $443.12 $487.52 $421.80 $464.06 $444.51 $489.05 $320.68 $352.81 $344.46 $378.98 $327.89 $360.74 $345.55

28 $427.88 $470.79 $459.61 $505.70 $437.50 $481.37 $461.05 $507.28 $332.62 $365.97 $357.28 $393.11 $340.09 $374.19 $358.40

29 $440.48 $484.56 $473.14 $520.50 $450.37 $495.45 $474.63 $522.13 $342.41 $376.68 $367.80 $404.61 $350.10 $385.15 $368.96

30 $446.77 $491.65 $479.91 $528.11 $456.81 $502.70 $481.41 $529.76 $347.30 $382.19 $373.06 $410.53 $355.11 $390.78 $374.23

31 $456.22 $501.88 $490.05 $539.10 $466.47 $513.16 $491.59 $540.79 $354.65 $390.14 $380.95 $419.08 $362.62 $398.91 $382.14

32 $465.67 $512.12 $500.20 $550.09 $476.13 $523.63 $501.77 $551.82 $361.99 $398.10 $388.84 $427.62 $370.13 $407.05 $390.06

33 $471.57 $518.81 $506.54 $557.28 $482.17 $530.47 $508.13 $559.03 $366.58 $403.30 $393.77 $433.21 $374.82 $412.36 $395.00

34 $477.87 $525.50 $513.31 $564.47 $488.61 $537.31 $514.92 $566.24 $371.48 $408.50 $399.03 $438.80 $379.83 $417.68 $400.28

35 $481.02 $529.04 $516.69 $568.28 $491.83 $540.93 $518.31 $570.06 $373.93 $411.26 $401.66 $441.76 $382.33 $420.50 $402.92

36 $484.17 $532.59 $520.07 $572.08 $495.05 $544.55 $521.71 $573.88 $376.37 $414.01 $404.29 $444.71 $384.83 $423.32 $405.55

37 $487.32 $536.13 $523.46 $575.89 $498.27 $548.18 $525.10 $577.69 $378.82 $416.77 $406.91 $447.67 $387.34 $426.13 $408.19

38 $490.47 $539.67 $526.84 $579.69 $501.49 $551.80 $528.49 $581.51 $381.27 $419.52 $409.54 $450.63 $389.84 $428.95 $410.83

39 $496.77 $546.36 $533.60 $586.88 $507.93 $558.64 $535.28 $588.72 $386.17 $424.72 $414.80 $456.22 $394.84 $434.27 $416.10

40 $503.06 $553.45 $540.37 $594.49 $514.37 $565.89 $542.07 $596.36 $391.06 $430.23 $420.06 $462.13 $399.85 $439.90 $421.38

41 $512.51 $563.68 $550.52 $605.48 $524.03 $576.35 $552.25 $607.38 $398.41 $438.19 $427.95 $470.68 $407.36 $448.03 $429.29

42 $521.56 $573.92 $560.24 $616.48 $533.29 $586.81 $562.00 $618.41 $405.44 $446.14 $435.51 $479.23 $414.55 $456.17 $436.88

43 $534.16 $587.70 $573.77 $631.28 $546.16 $600.90 $575.57 $633.26 $415.24 $456.85 $446.03 $490.73 $424.57 $467.12 $447.43

44 $549.91 $605.01 $590.69 $649.88 $562.26 $618.61 $592.54 $651.92 $427.48 $470.31 $459.18 $505.19 $437.08 $480.88 $460.62

45 $568.41 $625.09 $610.56 $671.45 $581.18 $639.14 $612.47 $673.55 $441.86 $485.92 $474.62 $521.96 $451.79 $496.84 $476.11

46 $590.45 $649.50 $634.24 $697.66 $603.72 $664.09 $636.23 $699.85 $458.99 $504.89 $493.03 $542.33 $469.31 $516.24 $494.58

47 $615.25 $676.66 $660.87 $726.84 $629.08 $691.86 $662.95 $729.12 $478.27 $526.01 $513.74 $565.01 $489.02 $537.83 $515.35

48 $643.59 $708.15 $691.32 $760.66 $658.05 $724.06 $693.49 $763.05 $500.30 $550.49 $537.40 $591.31 $511.55 $562.86 $539.09

49 $671.54 $738.85 $721.34 $793.64 $686.63 $755.45 $723.60 $796.13 $522.03 $574.35 $560.74 $616.95 $533.76 $587.26 $562.50

50 $703.03 $773.49 $755.16 $830.85 $718.83 $790.87 $757.53 $833.46 $546.51 $601.28 $587.04 $645.87 $558.79 $614.79 $588.88

51 $734.13 $807.74 $788.57 $867.64 $750.62 $825.89 $791.04 $870.36 $570.68 $627.90 $613.00 $674.47 $583.51 $642.01 $614.93

52 $768.37 $845.13 $825.35 $907.80 $785.64 $864.12 $827.94 $910.65 $597.30 $656.97 $641.60 $705.69 $610.73 $671.74 $643.61

53 $803.01 $883.31 $862.56 $948.82 $821.06 $903.16 $865.27 $951.80 $624.23 $686.65 $670.52 $737.57 $638.26 $702.08 $672.63

54 $840.41 $924.25 $902.73 $992.79 $859.29 $945.02 $905.56 $995.91 $653.30 $718.48 $701.75 $771.76 $667.98 $734.62 $703.95

55 $877.80 $965.58 $942.90 $1,037.19 $897.53 $987.28 $945.86 $1,040.44 $682.37 $750.61 $732.97 $806.27 $697.70 $767.47 $735.27

56 $918.35 $1,010.06 $986.45 $1,084.97 $938.98 $1,032.76 $989.55 $1,088.37 $713.89 $785.18 $766.83 $843.41 $729.93 $802.83 $769.23

57 $959.29 $1,055.33 $1,030.42 $1,133.59 $980.84 $1,079.05 $1,033.66 $1,137.15 $745.71 $820.37 $801.01 $881.21 $762.47 $838.81 $803.52

58 $1,002.98 $1,103.36 $1,077.36 $1,185.18 $1,025.52 $1,128.15 $1,080.74 $1,188.90 $779.68 $857.70 $837.49 $921.31 $797.20 $876.98 $840.12

59 $1,024.63 $1,126.97 $1,100.61 $1,210.55 $1,047.65 $1,152.30 $1,104.07 $1,214.35 $796.51 $876.06 $855.57 $941.03 $814.40 $895.75 $858.26

60 $1,068.32 $1,175.00 $1,147.55 $1,262.13 $1,092.33 $1,201.40 $1,151.15 $1,266.09 $830.47 $913.40 $892.06 $981.13 $849.13 $933.92 $894.86

61 $1,106.11 $1,216.72 $1,188.14 $1,306.95 $1,130.97 $1,244.06 $1,191.87 $1,311.05 $859.85 $945.83 $923.61 $1,015.97 $879.17 $967.09 $926.51

62 $1,130.91 $1,243.88 $1,214.77 $1,336.13 $1,156.32 $1,271.83 $1,218.59 $1,340.32 $879.12 $966.95 $944.32 $1,038.65 $898.88 $988.67 $947.28

63 $1,162.01 $1,278.13 $1,248.18 $1,372.91 $1,188.12 $1,306.85 $1,252.09 $1,377.22 $903.30 $993.57 $970.28 $1,067.25 $923.60 $1,015.89 $973.33

64+ $1,180.90 $1,298.99 $1,268.47 $1,395.32 $1,207.44 $1,328.18 $1,272.45 $1,399.70 $917.99 $1,009.78 $986.06 $1,084.67 $938.61 $1,032.48 $989.16

$1,180.90 $1,298.99 $1,268.47 $1,395.32 $1,207.44 $1,328.18 $1,272.45 $1,399.70 $917.99 $1,009.78 $986.06 $1,084.67 $938.61 $1,032.48 $989.16

75729PA001259675729PA0012596 75729PA0012596

No

Rating Area 6

Geisinger Marketplace PPO

Geisinger Marketplace PPO 25/50/1000

$1,000.00

0.2

$4,000.00

75729PA0012596

Gold

Geisinger Marketplace PPO 25/50/1000

$1,000.00

M-152-115-F Dev. 01/17M-152-115-F Dev. 01/17

Geisinger Marketplace PPO Geisinger Marketplace PPO

Rating Area 2 Rating Area 3 Rating Area 5

No No No

M-152-115-F Dev. 01/17 M-152-115-F Dev. 01/17

Gold

Geisinger Marketplace PPO 25/50/1000

Geisinger Marketplace PPO

75729PA0012596 75729PA0012596

Gold

$1,000.00

0.2

$4,000.00

January 1, 2017

75729PA0012596

0.2

$4,000.00

75729PA0012596

Gold

Geisinger Marketplace PPO 25/50/1000

$1,000.00

0.2

$4,000.00

75729PA0012603

M-152-115-F Dev. 01/17

Rating Area 2

Geisinger Marketplace PPO

No

75729PA0012603

Silver

Geisinger Marketplace PPO 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012603

M-152-115-F Dev. 01/17

Rating Area 3

Geisinger Marketplace PPO

No

75729PA0012603

Silver

Geisinger Marketplace PPO 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012603

M-152-115-F Dev. 01/17

Rating Area 5

Geisinger Marketplace PPO

No

75729PA0012603

Silver

Geisinger Marketplace PPO 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012603

M-152-115-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

No

75729PA0012603

Silver

Geisinger Marketplace PPO 30/50/5000

$5,000.00

0.3

$6,000.00

Page Number: 4 12/24/2014

Page 102: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64+

$50.00 $25.00 $50.00 $30.00 $50.00 $25.00 $50.00 $30.00 $50.00 $25.00 $50.00 $25.00 $50.00 $30.00 $50.00

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$209.37 $243.50 $243.50 $189.29 $189.29 $269.34 $269.34 $209.37 $209.37 $326.35 $326.35 $243.50 $243.50 $253.69 $253.69

$362.70 $383.47 $421.81 $298.09 $327.90 $424.16 $466.57 $329.72 $362.70 $513.94 $565.33 $383.47 $421.81 $399.52 $439.47

$362.70 $383.47 $421.81 $298.09 $327.90 $424.16 $466.57 $329.72 $362.70 $513.94 $565.33 $383.47 $421.81 $399.52 $439.47

$362.70 $383.47 $421.81 $298.09 $327.90 $424.16 $466.57 $329.72 $362.70 $513.94 $565.33 $383.47 $421.81 $399.52 $439.47

$362.70 $383.47 $421.81 $298.09 $327.90 $424.16 $466.57 $329.72 $362.70 $513.94 $565.33 $383.47 $421.81 $399.52 $439.47

$364.01 $384.99 $423.34 $299.28 $329.09 $425.85 $468.26 $331.04 $364.01 $515.99 $567.38 $384.99 $423.34 $401.11 $441.06

$371.26 $392.66 $431.78 $305.24 $335.65 $434.33 $477.59 $337.63 $371.26 $526.27 $578.69 $392.66 $431.78 $409.10 $449.85

$380.17 $401.87 $442.13 $312.40 $343.70 $444.51 $489.05 $345.55 $380.17 $538.60 $592.57 $401.87 $442.13 $418.69 $460.64

$394.34 $416.82 $458.62 $324.02 $356.51 $461.05 $507.28 $358.40 $394.34 $558.65 $614.67 $416.82 $458.62 $434.27 $477.82

$405.88 $429.09 $472.04 $333.56 $366.95 $474.63 $522.13 $368.96 $405.88 $575.09 $632.65 $429.09 $472.04 $447.06 $491.80

$411.82 $435.23 $478.94 $338.33 $372.31 $481.41 $529.76 $374.23 $411.82 $583.32 $641.91 $435.23 $478.94 $453.45 $498.99

$420.39 $444.43 $488.91 $345.48 $380.06 $491.59 $540.79 $382.14 $420.39 $595.65 $655.27 $444.43 $488.91 $463.04 $509.38

$428.96 $453.63 $498.88 $352.64 $387.81 $501.77 $551.82 $390.06 $428.96 $607.99 $668.63 $453.63 $498.88 $472.62 $519.77

$434.57 $459.39 $505.40 $357.11 $392.88 $508.13 $559.03 $395.00 $434.57 $615.69 $677.37 $459.39 $505.40 $478.62 $526.56

$440.17 $465.52 $511.92 $361.88 $397.95 $514.92 $566.24 $400.28 $440.17 $623.92 $686.10 $465.52 $511.92 $485.01 $533.35

$443.14 $468.59 $515.37 $364.26 $400.63 $518.31 $570.06 $402.92 $443.14 $628.03 $690.73 $468.59 $515.37 $488.20 $536.95

$446.11 $471.66 $518.82 $366.65 $403.31 $521.71 $573.88 $405.55 $446.11 $632.14 $695.35 $471.66 $518.82 $491.40 $540.54

$449.08 $474.72 $522.27 $369.03 $406.00 $525.10 $577.69 $408.19 $449.08 $636.25 $699.98 $474.72 $522.27 $494.60 $544.14

$452.04 $477.79 $525.73 $371.42 $408.68 $528.49 $581.51 $410.83 $452.04 $640.36 $704.61 $477.79 $525.73 $497.79 $547.73

$457.65 $483.93 $532.24 $376.19 $413.75 $535.28 $588.72 $416.10 $457.65 $648.59 $713.34 $483.93 $532.24 $504.19 $554.52

$463.58 $490.06 $539.15 $380.96 $419.11 $542.07 $596.36 $421.38 $463.58 $656.81 $722.59 $490.06 $539.15 $510.58 $561.72

$472.16 $499.27 $549.12 $388.11 $426.86 $552.25 $607.38 $429.29 $472.16 $669.14 $735.96 $499.27 $549.12 $520.17 $572.10

$480.73 $508.09 $559.09 $394.97 $434.61 $562.00 $618.41 $436.88 $480.73 $680.96 $749.32 $508.09 $559.09 $529.35 $582.49

$492.27 $520.36 $572.51 $404.50 $445.04 $575.57 $633.26 $447.43 $492.27 $697.41 $767.31 $520.36 $572.51 $542.14 $596.47

$506.78 $535.70 $589.38 $416.43 $458.16 $592.54 $651.92 $460.62 $506.78 $717.97 $789.92 $535.70 $589.38 $558.12 $614.05

$523.59 $553.72 $608.94 $430.44 $473.36 $612.47 $673.55 $476.11 $523.59 $742.12 $816.13 $553.72 $608.94 $576.90 $634.43

$544.04 $575.19 $632.71 $447.13 $491.84 $636.23 $699.85 $494.58 $544.04 $770.90 $847.99 $575.19 $632.71 $599.27 $659.20

$566.79 $599.35 $659.17 $465.91 $512.41 $662.95 $729.12 $515.35 $566.79 $803.28 $883.45 $599.35 $659.17 $624.44 $686.76

$593.16 $626.96 $689.85 $487.37 $536.26 $693.49 $763.05 $539.09 $593.16 $840.28 $924.57 $626.96 $689.85 $653.20 $718.72

$618.88 $654.18 $719.76 $508.54 $559.51 $723.60 $796.13 $562.50 $618.88 $876.77 $964.66 $654.18 $719.76 $681.57 $749.89

$647.90 $684.86 $753.50 $532.38 $585.74 $757.53 $833.46 $588.88 $647.90 $917.89 $1,009.88 $684.86 $753.50 $713.53 $785.04

$676.58 $715.15 $786.86 $555.93 $611.68 $791.04 $870.36 $614.93 $676.58 $958.49 $1,054.59 $715.15 $786.86 $745.09 $819.80

$707.91 $748.52 $823.29 $581.87 $639.99 $827.94 $910.65 $643.61 $707.91 $1,003.20 $1,103.42 $748.52 $823.29 $779.85 $857.75

$739.89 $782.26 $860.49 $608.10 $668.91 $865.27 $951.80 $672.63 $739.89 $1,048.43 $1,153.27 $782.26 $860.49 $815.01 $896.51

$774.18 $818.69 $900.37 $636.42 $699.91 $905.56 $995.91 $703.95 $774.18 $1,097.25 $1,206.72 $818.69 $900.37 $852.96 $938.06

$808.80 $855.12 $940.63 $664.74 $731.21 $945.86 $1,040.44 $735.27 $808.80 $1,146.08 $1,260.68 $855.12 $940.63 $890.91 $980.01

$846.06 $894.61 $983.96 $695.44 $764.89 $989.55 $1,088.37 $769.23 $846.06 $1,199.01 $1,318.76 $894.61 $983.96 $932.06 $1,025.15

$883.98 $934.49 $1,028.06 $726.44 $799.17 $1,033.66 $1,137.15 $803.52 $883.98 $1,252.46 $1,377.86 $934.49 $1,028.06 $973.61 $1,071.09

$924.20 $977.06 $1,074.84 $759.53 $835.54 $1,080.74 $1,188.90 $840.12 $924.20 $1,309.51 $1,440.56 $977.06 $1,074.84 $1,017.96 $1,119.84

$943.98 $998.15 $1,097.85 $775.92 $853.42 $1,104.07 $1,214.35 $858.26 $943.98 $1,337.77 $1,471.40 $998.15 $1,097.85 $1,039.93 $1,143.81

$984.21 $1,040.71 $1,144.63 $809.01 $889.79 $1,151.15 $1,266.09 $894.86 $984.21 $1,394.82 $1,534.10 $1,040.71 $1,144.63 $1,084.28 $1,192.55

$1,019.16 $1,077.53 $1,185.28 $837.63 $921.39 $1,191.87 $1,311.05 $926.51 $1,019.16 $1,444.16 $1,588.57 $1,077.53 $1,185.28 $1,122.63 $1,234.89

$1,041.91 $1,101.68 $1,211.74 $856.41 $941.96 $1,218.59 $1,340.32 $947.28 $1,041.91 $1,476.54 $1,624.04 $1,101.68 $1,211.74 $1,147.80 $1,262.46

$1,070.60 $1,131.98 $1,245.10 $879.95 $967.89 $1,252.09 $1,377.22 $973.33 $1,070.60 $1,517.14 $1,668.75 $1,131.98 $1,245.10 $1,179.36 $1,297.22

$1,088.07 $1,150.38 $1,265.42 $894.26 $983.69 $1,272.45 $1,399.70 $989.16 $1,088.07 $1,541.81 $1,695.99 $1,150.38 $1,265.42 $1,198.54 $1,318.39

$1,088.07 $1,150.38 $1,265.42 $894.26 $983.69 $1,272.45 $1,399.70 $989.16 $1,088.07 $1,541.81 $1,695.99 $1,150.38 $1,265.42 $1,198.54 $1,318.39

75729PA0012603

M-152-115-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

No

75729PA0012603

Silver

Geisinger Marketplace PPO 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012611

M-152-115-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

No

75729PA0012611

Gold

Geisinger Marketplace PPO 25/50/1000

$1,000.00

0.2

$4,000.00

75729PA0012612

M-152-115-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

No

75729PA0012612

Silver

Geisinger Marketplace PPO 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012613

M-152-115-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

No

75729PA0012613

Gold

Geisinger Marketplace PPO 25/50/1000

$1,000.00

0.2

$4,000.00

75729PA0012614

M-152-115-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

No

75729PA0012614

Silver

Geisinger Marketplace PPO 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012615

M-152-115-F Dev. 01/17

Rating Area 7

Geisinger Marketplace PPO

No

75729PA0012615

Gold

Geisinger Marketplace PPO 25/50/1000

$1,000.00

0.2

$4,000.00

75729PA0012615

M-152-115-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

No

75729PA0012615

Gold

Geisinger Marketplace PPO 25/50/1000

$1,000.00

0.2

$4,000.00

75729PA0012616

M-152-115-F Dev. 01/17

Rating Area 7

Geisinger Marketplace PPO

No

75729PA0012616

Silver

Geisinger Marketplace PPO 30/50/5000

$5,000.00

0.3

$6,000.00

Page Number: 5 12/24/2014

Page 103: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64+

$30.00 $50.00 $10/$50 $50.00 $10/$50 $50.00 $10/$50 $50.00 $10/$50 $50.00 $10/$50 $50.00 $10/$50 $50.00 $30.00

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco

$189.29 $189.29 $227.50 $227.50 $250.86 $250.86 $251.64 $251.64 $179.05 $179.05 $197.43 $197.43 $198.05 $198.05 $198.28

$298.09 $327.90 $358.28 $394.11 $395.06 $434.56 $396.30 $435.92 $281.97 $310.16 $310.91 $342.00 $311.89 $343.08 $312.26

$298.09 $327.90 $358.28 $394.11 $395.06 $434.56 $396.30 $435.92 $281.97 $310.16 $310.91 $342.00 $311.89 $343.08 $312.26

$298.09 $327.90 $358.28 $394.11 $395.06 $434.56 $396.30 $435.92 $281.97 $310.16 $310.91 $342.00 $311.89 $343.08 $312.26

$298.09 $327.90 $358.28 $394.11 $395.06 $434.56 $396.30 $435.92 $281.97 $310.16 $310.91 $342.00 $311.89 $343.08 $312.26

$299.28 $329.09 $359.71 $395.53 $396.63 $436.14 $397.88 $437.50 $283.09 $311.29 $312.15 $343.24 $313.13 $344.32 $313.50

$305.24 $335.65 $366.87 $403.42 $404.53 $444.83 $405.80 $446.22 $288.73 $317.49 $318.37 $350.08 $319.37 $351.18 $319.75

$312.40 $343.70 $375.47 $413.09 $414.01 $455.49 $415.31 $456.92 $295.50 $325.10 $325.83 $358.48 $326.85 $359.60 $327.24

$324.02 $356.51 $389.44 $428.49 $429.42 $472.48 $430.77 $473.96 $306.49 $337.23 $337.96 $371.84 $339.02 $373.01 $339.42

$333.56 $366.95 $400.91 $441.03 $442.06 $486.31 $443.45 $487.83 $315.52 $347.10 $347.90 $382.73 $349.00 $383.93 $349.41

$338.33 $372.31 $406.64 $447.48 $448.38 $493.42 $449.79 $494.97 $320.03 $352.17 $352.88 $388.32 $353.99 $389.54 $354.41

$345.48 $380.06 $415.24 $456.80 $457.86 $503.69 $459.30 $505.27 $326.79 $359.50 $360.34 $396.41 $361.47 $397.65 $361.90

$352.64 $387.81 $423.84 $466.11 $467.35 $513.96 $468.81 $515.57 $333.56 $366.83 $367.80 $404.49 $368.96 $405.76 $369.39

$357.11 $392.88 $429.21 $472.20 $473.27 $520.68 $474.76 $522.31 $337.79 $371.63 $372.47 $409.77 $373.63 $411.06 $374.08

$361.88 $397.95 $434.94 $478.29 $479.59 $527.39 $481.10 $529.05 $342.30 $376.42 $377.44 $415.06 $378.62 $416.36 $379.07

$364.26 $400.63 $437.81 $481.52 $482.75 $530.95 $484.27 $532.61 $344.56 $378.96 $379.93 $417.86 $381.12 $419.17 $381.57

$366.65 $403.31 $440.68 $484.74 $485.91 $534.50 $487.44 $536.18 $346.81 $381.49 $382.41 $420.66 $383.62 $421.98 $384.07

$369.03 $406.00 $443.54 $487.97 $489.07 $538.06 $490.61 $539.75 $349.07 $384.03 $384.90 $423.45 $386.11 $424.78 $386.57

$371.42 $408.68 $446.41 $491.19 $492.23 $541.61 $493.78 $543.31 $351.32 $386.57 $387.39 $426.25 $388.61 $427.59 $389.07

$376.19 $413.75 $452.14 $497.28 $498.55 $548.33 $500.12 $550.05 $355.84 $391.36 $392.36 $431.54 $393.60 $432.89 $394.06

$380.96 $419.11 $457.87 $503.73 $504.87 $555.44 $506.46 $557.18 $360.35 $396.44 $397.34 $437.13 $398.59 $438.51 $399.06

$388.11 $426.86 $466.47 $513.05 $514.36 $565.71 $515.97 $567.49 $367.11 $403.77 $404.80 $445.22 $406.07 $446.62 $406.55

$394.97 $434.61 $474.71 $522.36 $523.44 $575.98 $525.08 $577.79 $373.60 $411.10 $411.95 $453.30 $413.24 $454.72 $413.73

$404.50 $445.04 $486.18 $534.90 $536.08 $589.81 $537.77 $591.66 $382.62 $420.97 $421.90 $464.18 $423.22 $465.64 $423.73

$416.43 $458.16 $500.51 $550.67 $551.89 $607.19 $553.62 $609.10 $393.90 $433.38 $434.34 $477.86 $435.70 $479.36 $436.22

$430.44 $473.36 $517.35 $568.94 $570.45 $627.34 $572.24 $629.31 $407.15 $447.76 $448.95 $493.72 $450.36 $495.27 $450.89

$447.13 $491.84 $537.41 $591.15 $592.58 $651.83 $594.44 $653.88 $422.94 $465.24 $466.36 $513.00 $467.82 $514.61 $468.38

$465.91 $512.41 $559.98 $615.87 $617.46 $679.09 $619.40 $681.22 $440.71 $484.69 $485.95 $534.45 $487.47 $536.13 $488.05

$487.37 $536.26 $585.78 $644.53 $645.91 $710.70 $647.93 $712.93 $461.01 $507.25 $508.33 $559.32 $509.93 $561.08 $510.53

$508.54 $559.51 $611.21 $672.48 $673.96 $741.51 $676.07 $743.84 $481.03 $529.24 $530.41 $583.57 $532.07 $585.40 $532.70

$532.38 $585.74 $639.88 $704.01 $705.56 $776.27 $707.77 $778.71 $503.58 $554.06 $555.28 $610.93 $557.02 $612.85 $557.68

$555.93 $611.68 $668.18 $735.18 $736.77 $810.64 $739.08 $813.19 $525.86 $578.59 $579.84 $637.98 $581.66 $639.98 $582.35

$581.87 $639.99 $699.35 $769.21 $771.14 $848.17 $773.56 $850.84 $550.39 $605.37 $606.89 $667.52 $608.79 $669.61 $609.52

$608.10 $668.91 $730.88 $803.96 $805.90 $886.49 $808.43 $889.28 $575.20 $632.72 $634.25 $697.67 $636.24 $699.86 $637.00

$636.42 $699.91 $764.91 $841.23 $843.43 $927.58 $846.08 $930.49 $601.99 $662.05 $663.79 $730.01 $665.87 $732.30 $666.66

$664.74 $731.21 $798.95 $878.84 $880.96 $969.06 $883.73 $972.10 $628.78 $691.65 $693.32 $762.65 $695.50 $765.05 $696.32

$695.44 $764.89 $835.85 $919.33 $921.65 $1,013.70 $924.55 $1,016.88 $657.82 $723.52 $725.34 $797.79 $727.62 $800.29 $728.49

$726.44 $799.17 $873.11 $960.53 $962.74 $1,059.13 $965.76 $1,062.45 $687.14 $755.94 $757.68 $833.54 $760.06 $836.16 $760.96

$759.53 $835.54 $912.88 $1,004.24 $1,006.59 $1,107.33 $1,009.75 $1,110.80 $718.44 $790.34 $792.19 $871.47 $794.68 $874.21 $795.62

$775.92 $853.42 $932.58 $1,025.74 $1,028.32 $1,131.03 $1,031.54 $1,134.58 $733.95 $807.26 $809.29 $890.13 $811.83 $892.92 $812.79

$809.01 $889.79 $972.35 $1,069.44 $1,072.17 $1,179.23 $1,075.53 $1,182.93 $765.25 $841.66 $843.80 $928.06 $846.45 $930.97 $847.45

$837.63 $921.39 $1,006.75 $1,107.42 $1,110.09 $1,221.10 $1,113.58 $1,224.93 $792.31 $871.55 $873.65 $961.01 $876.39 $964.03 $877.43

$856.41 $941.96 $1,029.32 $1,132.14 $1,134.98 $1,248.36 $1,138.54 $1,252.28 $810.08 $891.00 $893.23 $982.46 $896.04 $985.55 $897.10

$879.95 $967.89 $1,057.62 $1,163.31 $1,166.19 $1,282.73 $1,169.85 $1,286.76 $832.35 $915.53 $917.80 $1,009.51 $920.68 $1,012.68 $921.77

$894.26 $983.69 $1,074.82 $1,182.30 $1,185.15 $1,303.67 $1,188.87 $1,307.76 $845.89 $930.48 $932.72 $1,025.99 $935.65 $1,029.21 $936.76

$894.26 $983.69 $1,074.82 $1,182.30 $1,185.15 $1,303.67 $1,188.87 $1,307.76 $845.89 $930.48 $932.72 $1,025.99 $935.65 $1,029.21 $936.76

75729PA0012616

M-152-115-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

No

75729PA0012616

Silver

Geisinger Marketplace PPO 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012620

M-152-240-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

No

75729PA0012620

Gold

Geisinger Marketplace PPO Extra 10/50/500

$500.00

0.2

$5,000.00

75729PA0012621

M-152-240-F Dev. 01/17

Rating Area 3

Geisinger Marketplace PPO

No

75729PA0012621

Gold

Geisinger Marketplace PPO Extra 10/50/500

$500.00

0.2

$5,000.00

75729PA0012621

M-152-240-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

No

75729PA0012621

Gold

Geisinger Marketplace PPO Extra 10/50/500

$500.00

0.2

$5,000.00

75729PA0012622

M-152-240-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

No

75729PA0012622

Silver

Geisinger Marketplace PPO Extra 10/50/3500

$3,500.00

0.3

$7,150.00

75729PA0012623

M-152-240-F Dev. 01/17

Rating Area 3

Geisinger Marketplace PPO

No

75729PA0012623

Silver

Geisinger Marketplace PPO Extra 10/50/3500

$3,500.00

0.3

$7,150.00

75729PA0012623

M-152-240-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

No

75729PA0012623

Silver

Geisinger Marketplace PPO Extra 10/50/3500

$3,500.00

0.3

$7,150.00

75729PA0012624

M-152-246-F Dev. 01/17

Rating Area 3

Geisinger Marketplace Select

No

75729PA0012624

Silver

Geisinger Marketplace PPO Select 30/50/5000

$5,000.00

0.3

$6,000.00

Page Number: 6 12/24/2014

Page 104: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64+

$50.00 $30.00 $50.00 $30.00 $50.00 $30.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00 $50.00

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$198.28 $188.74 $188.74 $198.90 $198.90 $179.82 $179.82 $255.07 $255.07 $242.80 $242.80 $255.87 $255.87 $231.32 $231.32

$343.48 $297.23 $326.96 $313.24 $344.56 $283.19 $311.51 $401.69 $441.86 $382.36 $420.60 $402.95 $443.24 $364.29 $400.72

$343.48 $297.23 $326.96 $313.24 $344.56 $283.19 $311.51 $401.69 $441.86 $382.36 $420.60 $402.95 $443.24 $364.29 $400.72

$343.48 $297.23 $326.96 $313.24 $344.56 $283.19 $311.51 $401.69 $441.86 $382.36 $420.60 $402.95 $443.24 $364.29 $400.72

$343.48 $297.23 $326.96 $313.24 $344.56 $283.19 $311.51 $401.69 $441.86 $382.36 $420.60 $402.95 $443.24 $364.29 $400.72

$344.73 $298.42 $328.14 $314.49 $345.81 $284.32 $312.63 $403.29 $443.46 $383.88 $422.12 $404.55 $444.85 $365.74 $402.17

$351.60 $304.36 $334.68 $320.75 $352.70 $289.98 $318.86 $411.32 $452.29 $391.53 $430.53 $412.61 $453.71 $373.03 $410.19

$360.03 $311.49 $342.70 $328.27 $361.16 $296.78 $326.51 $420.96 $463.14 $400.71 $440.85 $422.28 $464.59 $381.77 $420.02

$373.45 $323.09 $355.48 $340.48 $374.63 $307.82 $338.69 $436.63 $480.41 $415.62 $457.30 $438.00 $481.92 $395.98 $435.69

$384.38 $332.60 $365.89 $350.51 $385.59 $316.88 $348.60 $449.48 $494.47 $427.85 $470.68 $450.89 $496.02 $407.64 $448.44

$390.00 $337.35 $371.24 $355.52 $391.23 $321.41 $353.70 $455.91 $501.70 $433.97 $477.56 $457.34 $503.28 $413.47 $454.99

$398.12 $344.49 $378.97 $363.04 $399.37 $328.21 $361.06 $465.55 $512.15 $443.15 $487.50 $467.01 $513.75 $422.21 $464.47

$406.24 $351.62 $386.69 $370.55 $407.52 $335.01 $368.42 $475.19 $522.59 $452.33 $497.44 $476.68 $524.23 $430.95 $473.94

$411.55 $356.08 $391.75 $375.25 $412.84 $339.25 $373.24 $481.22 $529.42 $458.06 $503.94 $482.73 $531.08 $436.42 $480.13

$416.86 $360.83 $396.80 $380.26 $418.17 $343.78 $378.05 $487.64 $536.25 $464.18 $510.44 $489.17 $537.93 $442.24 $486.32

$419.67 $363.21 $399.47 $382.77 $420.98 $346.05 $380.60 $490.86 $539.86 $467.24 $513.88 $492.40 $541.56 $445.16 $489.60

$422.48 $365.59 $402.15 $385.28 $423.80 $348.32 $383.15 $494.07 $543.48 $470.30 $517.33 $495.62 $545.18 $448.07 $492.88

$425.29 $367.97 $404.82 $387.78 $426.62 $350.58 $385.70 $497.28 $547.09 $473.36 $520.77 $498.84 $548.81 $450.99 $496.16

$428.10 $370.35 $407.50 $390.29 $429.44 $352.85 $388.24 $500.50 $550.71 $476.41 $524.21 $502.07 $552.43 $453.90 $499.44

$433.41 $375.10 $412.55 $395.30 $434.77 $357.38 $393.06 $506.92 $557.54 $482.53 $530.71 $508.51 $559.28 $459.73 $505.63

$439.03 $379.86 $417.90 $400.31 $440.40 $361.91 $398.16 $513.35 $564.77 $488.65 $537.59 $514.96 $566.54 $465.56 $512.19

$447.15 $386.99 $425.63 $407.83 $448.55 $368.70 $405.52 $522.99 $575.21 $497.83 $547.53 $524.63 $577.01 $474.30 $521.66

$455.26 $393.83 $433.36 $415.03 $456.69 $375.22 $412.88 $532.23 $585.65 $506.62 $557.47 $533.90 $587.49 $482.68 $531.13

$466.19 $403.34 $443.76 $425.06 $467.66 $384.28 $422.79 $545.08 $599.71 $518.86 $570.86 $546.79 $601.59 $494.34 $543.88

$479.93 $415.23 $456.84 $437.59 $481.44 $395.61 $435.25 $561.15 $617.39 $534.15 $587.68 $562.91 $619.32 $508.91 $559.91

$495.86 $429.20 $472.00 $452.31 $497.41 $408.92 $449.69 $580.03 $637.87 $552.12 $607.18 $581.85 $639.87 $526.03 $578.49

$515.22 $445.84 $490.43 $469.85 $516.83 $424.77 $467.25 $602.52 $662.78 $573.53 $630.89 $604.41 $664.86 $546.43 $601.07

$536.76 $464.57 $510.93 $489.58 $538.45 $442.62 $486.79 $627.83 $690.49 $597.62 $657.27 $629.80 $692.66 $569.38 $626.21

$561.74 $485.97 $534.71 $512.14 $563.51 $463.00 $509.45 $656.75 $722.63 $625.15 $687.86 $658.81 $724.89 $595.61 $655.35

$586.10 $507.07 $557.90 $534.37 $587.94 $483.11 $531.53 $685.27 $753.96 $652.30 $717.68 $687.42 $756.32 $621.47 $683.77

$613.58 $530.85 $584.05 $559.43 $615.50 $505.76 $556.45 $717.40 $789.31 $682.89 $751.33 $719.66 $791.78 $650.62 $715.82

$640.74 $554.33 $609.91 $584.18 $642.75 $528.14 $581.09 $749.14 $824.25 $713.09 $784.59 $751.49 $826.84 $679.40 $747.52

$670.41 $580.19 $638.15 $611.43 $672.51 $552.77 $607.99 $784.08 $862.41 $746.36 $820.92 $786.54 $865.12 $711.09 $782.13

$700.69 $606.34 $666.98 $638.99 $702.89 $577.69 $635.46 $819.43 $901.38 $780.00 $858.00 $822.00 $904.20 $743.15 $817.46

$733.17 $634.58 $697.89 $668.75 $735.47 $604.60 $664.91 $857.59 $943.15 $816.33 $897.77 $860.28 $946.11 $777.75 $855.35

$765.96 $662.82 $729.10 $698.51 $768.36 $631.50 $694.65 $895.75 $985.33 $852.65 $937.92 $898.56 $988.42 $812.36 $893.60

$801.24 $693.43 $762.69 $730.77 $803.75 $660.67 $726.65 $937.13 $1,030.72 $892.03 $981.12 $940.07 $1,033.95 $849.88 $934.76

$837.15 $724.34 $796.87 $763.35 $839.78 $690.12 $759.21 $978.90 $1,076.91 $931.80 $1,025.09 $981.97 $1,080.29 $887.77 $976.65

$875.24 $757.34 $833.13 $798.12 $877.99 $721.55 $793.76 $1,023.49 $1,125.92 $974.24 $1,071.74 $1,026.70 $1,129.45 $928.20 $1,021.10

$893.98 $773.68 $850.96 $815.34 $896.78 $737.13 $810.75 $1,045.58 $1,150.02 $995.27 $1,094.68 $1,048.86 $1,153.63 $948.24 $1,042.95

$932.07 $806.68 $887.23 $850.11 $935.00 $768.56 $845.30 $1,090.17 $1,199.02 $1,037.71 $1,141.33 $1,093.59 $1,202.78 $988.68 $1,087.40

$965.17 $835.21 $918.73 $880.18 $968.20 $795.74 $875.32 $1,128.73 $1,241.60 $1,074.42 $1,181.86 $1,132.27 $1,245.50 $1,023.65 $1,126.01

$986.72 $853.94 $939.24 $899.92 $989.81 $813.58 $894.86 $1,154.03 $1,269.32 $1,098.51 $1,208.24 $1,157.66 $1,273.30 $1,046.60 $1,151.15

$1,013.88 $877.42 $965.10 $924.66 $1,017.07 $835.96 $919.50 $1,185.77 $1,304.26 $1,128.71 $1,241.51 $1,189.49 $1,308.36 $1,075.38 $1,182.84

$1,030.43 $891.68 $980.85 $939.70 $1,033.67 $849.55 $934.50 $1,205.05 $1,325.55 $1,147.06 $1,261.77 $1,208.83 $1,329.71 $1,092.86 $1,202.15

$1,030.43 $891.68 $980.85 $939.70 $1,033.67 $849.55 $934.50 $1,205.05 $1,325.55 $1,147.06 $1,261.77 $1,208.83 $1,329.71 $1,092.86 $1,202.15

75729PA0012624

M-152-246-F Dev. 01/17

Rating Area 3

Geisinger Marketplace Select

No

75729PA0012624

Silver

Geisinger Marketplace PPO Select 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012624

M-152-246-F Dev. 01/17

Rating Area 5

Geisinger Marketplace Select

No

75729PA0012624

Silver

Geisinger Marketplace PPO Select 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012624

M-152-246-F Dev. 01/17

Rating Area 6

Geisinger Marketplace Select

No

75729PA0012624

Silver

Geisinger Marketplace PPO Select 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012624

M-152-246-F Dev. 01/17

Rating Area 9

Geisinger Marketplace Select

No

75729PA0012624

Silver

Geisinger Marketplace PPO Select 30/50/5000

$5,000.00

0.3

$6,000.00

75729PA0012625

M-152-246-F Dev. 01/17

Rating Area 3

Geisinger Marketplace Select

No

75729PA0012625

Gold

Geisinger Marketplace PPO Select 25/50/1000

$1,000.00

0.2

$4,000.00

75729PA0012625

M-152-246-F Dev. 01/17

Rating Area 5

Geisinger Marketplace Select

No

75729PA0012625

Gold

Geisinger Marketplace PPO Select 25/50/1000

$1,000.00

0.2

$4,000.00

75729PA0012625

M-152-246-F Dev. 01/17

Rating Area 6

Geisinger Marketplace Select

No

75729PA0012625

Gold

Geisinger Marketplace PPO Select 25/50/1000

$1,000.00

0.2

$4,000.00

75729PA0012625

M-152-246-F Dev. 01/17

Rating Area 9

Geisinger Marketplace Select

No

75729PA0012625

Gold

Geisinger Marketplace PPO Select 25/50/1000

$1,000.00

0.2

$4,000.00

Page Number: 7 12/24/2014

Page 105: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64+

$25.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco

$252.00 $252.00 $270.69 $270.69 $257.66 $257.66 $271.53 $271.53 $245.49 $245.49 $271.53 $271.53 $329.01 $329.01 $245.49

$396.85 $436.54 $426.28 $468.91 $405.77 $446.35 $427.62 $470.38 $386.60 $425.26 $427.62 $470.38 $518.13 $569.95 $386.60

$396.85 $436.54 $426.28 $468.91 $405.77 $446.35 $427.62 $470.38 $386.60 $425.26 $427.62 $470.38 $518.13 $569.95 $386.60

$396.85 $436.54 $426.28 $468.91 $405.77 $446.35 $427.62 $470.38 $386.60 $425.26 $427.62 $470.38 $518.13 $569.95 $386.60

$396.85 $436.54 $426.28 $468.91 $405.77 $446.35 $427.62 $470.38 $386.60 $425.26 $427.62 $470.38 $518.13 $569.95 $386.60

$398.43 $438.12 $427.98 $470.61 $407.39 $447.96 $429.32 $472.09 $388.14 $426.80 $429.32 $472.09 $520.20 $572.02 $388.14

$406.37 $446.85 $436.51 $479.99 $415.50 $456.89 $437.88 $481.49 $395.87 $435.30 $437.88 $481.49 $530.57 $583.41 $395.87

$415.90 $457.56 $446.74 $491.50 $425.24 $467.85 $448.14 $493.04 $405.15 $445.74 $448.14 $493.04 $543.00 $597.40 $405.15

$431.37 $474.63 $463.36 $509.83 $441.07 $485.29 $464.82 $511.43 $420.22 $462.36 $464.82 $511.43 $563.21 $619.68 $420.22

$444.07 $488.52 $477.00 $524.75 $454.05 $499.50 $478.50 $526.39 $432.60 $475.89 $478.50 $526.39 $579.79 $637.82 $432.60

$450.42 $495.66 $483.82 $532.42 $460.54 $506.80 $485.34 $534.09 $438.78 $482.85 $485.34 $534.09 $588.08 $647.14 $438.78

$459.95 $505.98 $494.05 $543.50 $470.28 $517.35 $495.60 $545.21 $448.06 $492.90 $495.60 $545.21 $600.51 $660.62 $448.06

$469.47 $516.30 $504.28 $554.58 $480.02 $527.90 $505.87 $556.32 $457.34 $502.95 $505.87 $556.32 $612.95 $674.09 $457.34

$475.42 $523.04 $510.68 $561.83 $486.11 $534.80 $512.28 $563.59 $463.14 $509.53 $512.28 $563.59 $620.72 $682.90 $463.14

$481.77 $529.79 $517.50 $569.08 $492.60 $541.70 $519.12 $570.86 $469.32 $516.10 $519.12 $570.86 $629.01 $691.70 $469.32

$484.95 $533.36 $520.91 $572.91 $495.84 $545.35 $522.54 $574.71 $472.41 $519.58 $522.54 $574.71 $633.15 $696.37 $472.41

$488.12 $536.93 $524.32 $576.75 $499.09 $549.00 $525.96 $578.56 $475.51 $523.06 $525.96 $578.56 $637.30 $701.03 $475.51

$491.30 $540.51 $527.73 $580.59 $502.34 $552.65 $529.39 $582.41 $478.60 $526.54 $529.39 $582.41 $641.44 $705.69 $478.60

$494.47 $544.08 $531.14 $584.42 $505.58 $556.30 $532.81 $586.26 $481.69 $530.02 $532.81 $586.26 $645.59 $710.36 $481.69

$500.82 $550.82 $537.96 $591.67 $512.07 $563.20 $539.65 $593.53 $487.88 $536.59 $539.65 $593.53 $653.88 $719.16 $487.88

$507.17 $557.97 $544.78 $599.34 $518.57 $570.50 $546.49 $601.22 $494.06 $543.55 $546.49 $601.22 $662.17 $728.49 $494.06

$516.69 $568.28 $555.01 $610.43 $528.31 $581.05 $556.75 $612.34 $503.34 $553.60 $556.75 $612.34 $674.61 $741.96 $503.34

$525.82 $578.60 $564.82 $621.51 $537.64 $591.60 $566.59 $623.46 $512.23 $563.65 $566.59 $623.46 $686.52 $755.43 $512.23

$538.52 $592.49 $578.46 $636.43 $550.62 $605.81 $580.27 $638.43 $524.60 $577.18 $580.27 $638.43 $703.10 $773.57 $524.60

$554.39 $609.95 $595.51 $655.19 $566.85 $623.66 $597.38 $657.24 $540.07 $594.19 $597.38 $657.24 $723.83 $796.37 $540.07

$573.05 $630.19 $615.54 $676.93 $585.92 $644.35 $617.47 $679.05 $558.24 $613.91 $617.47 $679.05 $748.18 $822.79 $558.24

$595.27 $654.80 $639.41 $703.35 $608.65 $669.51 $641.42 $705.56 $579.89 $637.88 $641.42 $705.56 $777.19 $854.91 $579.89

$620.27 $682.18 $666.27 $732.77 $634.21 $697.51 $668.36 $735.07 $604.24 $664.55 $668.36 $735.07 $809.84 $890.67 $604.24

$648.84 $713.93 $696.96 $766.87 $663.42 $729.97 $699.15 $769.28 $632.08 $695.48 $699.15 $769.28 $847.14 $932.12 $632.08

$677.02 $744.88 $727.23 $800.12 $692.23 $761.62 $729.51 $802.63 $659.52 $725.63 $729.51 $802.63 $883.93 $972.53 $659.52

$708.77 $779.80 $761.33 $837.63 $724.70 $797.33 $763.72 $840.26 $690.45 $759.65 $763.72 $840.26 $925.38 $1,018.13 $690.45

$740.12 $814.33 $795.00 $874.72 $756.75 $832.63 $797.50 $877.46 $720.99 $793.28 $797.50 $877.46 $966.31 $1,063.20 $720.99

$774.64 $852.03 $832.09 $915.21 $792.05 $871.18 $834.70 $918.09 $754.63 $830.01 $834.70 $918.09 $1,011.39 $1,112.43 $754.63

$809.57 $890.52 $869.60 $956.56 $827.76 $910.54 $872.33 $959.56 $788.65 $867.51 $872.33 $959.56 $1,056.99 $1,162.68 $788.65

$847.27 $931.80 $910.10 $1,000.90 $866.31 $952.73 $912.95 $1,004.04 $825.37 $907.72 $912.95 $1,004.04 $1,106.21 $1,216.57 $825.37

$884.97 $973.46 $950.59 $1,045.65 $904.85 $995.34 $953.58 $1,048.94 $862.10 $948.31 $953.58 $1,048.94 $1,155.43 $1,270.97 $862.10

$925.84 $1,018.31 $994.50 $1,093.82 $946.65 $1,041.19 $997.62 $1,097.26 $901.92 $991.99 $997.62 $1,097.26 $1,208.80 $1,329.52 $901.92

$967.12 $1,063.95 $1,038.83 $1,142.84 $988.85 $1,087.85 $1,042.09 $1,146.43 $942.12 $1,036.45 $1,042.09 $1,146.43 $1,262.68 $1,389.11 $942.12

$1,011.17 $1,112.36 $1,086.15 $1,194.85 $1,033.89 $1,137.36 $1,089.56 $1,198.60 $985.03 $1,083.61 $1,089.56 $1,198.60 $1,320.20 $1,452.32 $985.03

$1,032.99 $1,136.17 $1,109.60 $1,220.43 $1,056.20 $1,161.70 $1,113.08 $1,224.26 $1,006.30 $1,106.81 $1,113.08 $1,224.26 $1,348.69 $1,483.41 $1,006.30

$1,077.04 $1,184.59 $1,156.91 $1,272.43 $1,101.24 $1,211.21 $1,160.54 $1,276.43 $1,049.21 $1,153.97 $1,160.54 $1,276.43 $1,406.20 $1,546.62 $1,049.21

$1,115.14 $1,226.65 $1,197.83 $1,317.62 $1,140.20 $1,254.22 $1,201.59 $1,321.75 $1,086.32 $1,194.95 $1,201.59 $1,321.75 $1,455.95 $1,601.54 $1,086.32

$1,140.14 $1,254.04 $1,224.69 $1,347.03 $1,165.76 $1,282.22 $1,228.53 $1,351.26 $1,110.68 $1,221.63 $1,228.53 $1,351.26 $1,488.59 $1,637.29 $1,110.68

$1,171.49 $1,288.56 $1,258.37 $1,384.12 $1,197.82 $1,317.52 $1,262.31 $1,388.46 $1,141.22 $1,255.26 $1,262.31 $1,388.46 $1,529.52 $1,682.37 $1,141.22

$1,190.54 $1,309.59 $1,278.83 $1,406.71 $1,217.29 $1,339.02 $1,282.84 $1,411.12 $1,159.77 $1,275.75 $1,282.84 $1,411.12 $1,554.39 $1,709.83 $1,159.77

$1,190.54 $1,309.59 $1,278.83 $1,406.71 $1,217.29 $1,339.02 $1,282.84 $1,411.12 $1,159.77 $1,275.75 $1,282.84 $1,411.12 $1,554.39 $1,709.83 $1,159.77

M-152-115-F Dev. 01/17

Rating Area 2

Geisinger Marketplace PPO

Yes

75729PA0012626

Gold

Geisinger Marketplace PPO 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-115-F Dev. 01/17

Rating Area 3

Geisinger Marketplace PPO

Yes

75729PA0012626

Gold

Geisinger Marketplace PPO 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-115-F Dev. 01/17

Rating Area 5

Geisinger Marketplace PPO

Yes

75729PA0012626

Gold

Geisinger Marketplace PPO 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-115-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

Yes

75729PA0012626

Gold

Geisinger Marketplace PPO 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-115-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

Yes

75729PA0012627

Gold

Geisinger Marketplace PPO 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-115-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

Yes

75729PA0012628

Gold

Geisinger Marketplace PPO 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-115-F Dev. 01/17

Rating Area 7

Geisinger Marketplace PPO

Yes

75729PA0012629

Gold

Geisinger Marketplace PPO 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-115-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

Yes

75729PA0012629

Gold

Geisinger Marketplace PPO 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

Page Number: 8 12/24/2014

Page 106: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64+

$50.00 $30.00 $50.00 $30.00 $50.00 $30.00 $50.00 $30.00 $50.00 $30.00 $50.00 $30.00 $50.00 $30.00 $50.00

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$245.49 $195.10 $195.10 $209.57 $209.57 $199.48 $199.48 $210.22 $210.22 $190.06 $190.06 $210.22 $210.22 $254.72 $254.72

$425.26 $307.25 $337.97 $330.03 $363.03 $314.15 $345.57 $331.07 $364.17 $299.31 $329.24 $331.07 $364.17 $401.15 $441.26

$425.26 $307.25 $337.97 $330.03 $363.03 $314.15 $345.57 $331.07 $364.17 $299.31 $329.24 $331.07 $364.17 $401.15 $441.26

$425.26 $307.25 $337.97 $330.03 $363.03 $314.15 $345.57 $331.07 $364.17 $299.31 $329.24 $331.07 $364.17 $401.15 $441.26

$425.26 $307.25 $337.97 $330.03 $363.03 $314.15 $345.57 $331.07 $364.17 $299.31 $329.24 $331.07 $364.17 $401.15 $441.26

$426.80 $308.47 $339.20 $331.35 $364.35 $315.40 $346.82 $332.39 $365.49 $300.50 $330.43 $332.39 $365.49 $402.75 $442.86

$435.30 $314.62 $345.95 $337.95 $371.61 $321.69 $353.73 $339.01 $372.78 $306.49 $337.01 $339.01 $372.78 $410.77 $451.68

$445.74 $321.99 $354.25 $345.87 $380.52 $329.23 $362.21 $346.95 $381.71 $313.67 $345.10 $346.95 $381.71 $420.40 $462.52

$462.36 $333.97 $367.46 $358.74 $394.71 $341.48 $375.72 $359.86 $395.95 $325.34 $357.97 $359.86 $395.95 $436.04 $479.76

$475.89 $343.80 $378.22 $369.30 $406.26 $351.53 $386.71 $370.46 $407.54 $334.92 $368.44 $370.46 $407.54 $448.88 $493.80

$482.85 $348.72 $383.75 $374.58 $412.20 $356.56 $392.37 $375.76 $413.50 $339.71 $373.83 $375.76 $413.50 $455.30 $501.03

$492.90 $356.09 $391.73 $382.50 $420.78 $364.10 $400.54 $383.70 $422.10 $346.89 $381.61 $383.70 $422.10 $464.92 $511.45

$502.95 $363.47 $399.72 $390.42 $429.36 $371.64 $408.70 $391.65 $430.71 $354.07 $389.39 $391.65 $430.71 $474.55 $521.88

$509.53 $368.08 $404.95 $395.37 $434.97 $376.35 $414.05 $396.61 $436.34 $358.56 $394.48 $396.61 $436.34 $480.57 $528.70

$516.10 $372.99 $410.17 $400.65 $440.59 $381.37 $419.39 $401.91 $441.97 $363.35 $399.57 $401.91 $441.97 $486.99 $535.52

$519.58 $375.45 $412.93 $403.29 $443.56 $383.89 $422.21 $404.56 $444.95 $365.75 $402.26 $404.56 $444.95 $490.19 $539.13

$523.06 $377.91 $415.70 $405.93 $446.53 $386.40 $425.04 $407.21 $447.93 $368.14 $404.96 $407.21 $447.93 $493.40 $542.74

$526.54 $380.37 $418.46 $408.57 $449.50 $388.91 $427.87 $409.85 $450.91 $370.54 $407.65 $409.85 $450.91 $496.61 $546.35

$530.02 $382.82 $421.23 $411.21 $452.47 $391.43 $430.69 $412.50 $453.89 $372.93 $410.34 $412.50 $453.89 $499.82 $549.96

$536.59 $387.74 $426.45 $416.49 $458.08 $396.45 $436.04 $417.80 $459.51 $377.72 $415.43 $417.80 $459.51 $506.24 $556.78

$543.55 $392.66 $431.98 $421.77 $464.02 $401.48 $441.69 $423.10 $465.47 $382.51 $420.82 $423.10 $465.47 $512.66 $564.00

$553.60 $400.03 $439.97 $429.69 $472.60 $409.02 $449.86 $431.04 $474.08 $389.69 $428.60 $431.04 $474.08 $522.29 $574.43

$563.65 $407.10 $447.96 $437.29 $481.18 $416.24 $458.03 $438.66 $482.69 $396.58 $436.38 $438.66 $482.69 $531.51 $584.86

$577.18 $416.93 $458.71 $447.85 $492.73 $426.30 $469.02 $449.25 $494.28 $406.15 $446.86 $449.25 $494.28 $544.35 $598.90

$594.19 $429.22 $472.23 $461.05 $507.25 $438.86 $482.84 $462.49 $508.84 $418.13 $460.03 $462.49 $508.84 $560.39 $616.55

$613.91 $443.66 $487.90 $476.56 $524.08 $453.63 $498.86 $478.05 $525.73 $432.19 $475.29 $478.05 $525.73 $579.25 $637.01

$637.88 $460.86 $506.95 $495.04 $544.54 $471.22 $518.34 $496.59 $546.25 $448.95 $493.85 $496.59 $546.25 $601.71 $661.88

$664.55 $480.22 $528.15 $515.83 $567.32 $491.01 $540.02 $517.45 $569.10 $467.81 $514.50 $517.45 $569.10 $626.98 $689.56

$695.48 $502.34 $552.73 $539.59 $593.72 $513.63 $565.15 $541.29 $595.58 $489.36 $538.44 $541.29 $595.58 $655.87 $721.65

$725.63 $524.16 $576.69 $563.03 $619.46 $535.93 $589.65 $564.79 $621.40 $510.61 $561.79 $564.79 $621.40 $684.35 $752.94

$759.65 $548.73 $603.73 $589.43 $648.50 $561.07 $617.30 $591.28 $650.54 $534.55 $588.13 $591.28 $650.54 $716.44 $788.24

$793.28 $573.01 $630.46 $615.50 $677.21 $585.88 $644.63 $617.43 $679.34 $558.20 $614.17 $617.43 $679.34 $748.13 $823.14

$830.01 $599.74 $659.65 $644.21 $708.57 $613.21 $674.47 $646.23 $710.79 $584.24 $642.60 $646.23 $710.79 $783.03 $861.25

$867.51 $626.77 $689.45 $673.25 $740.58 $640.86 $704.94 $675.37 $742.90 $610.58 $671.63 $675.37 $742.90 $818.33 $900.16

$907.72 $655.96 $721.40 $704.61 $774.90 $670.70 $737.62 $706.82 $777.33 $639.01 $702.76 $706.82 $777.33 $856.44 $941.88

$948.31 $685.15 $753.67 $735.96 $809.55 $700.55 $770.60 $738.27 $812.10 $667.44 $734.19 $738.27 $812.10 $894.54 $984.00

$991.99 $716.80 $788.38 $769.95 $846.85 $732.90 $806.10 $772.37 $849.51 $698.27 $768.01 $772.37 $849.51 $935.86 $1,029.33

$1,036.45 $748.75 $823.72 $804.27 $884.80 $765.58 $842.23 $806.80 $887.58 $729.40 $802.43 $806.80 $887.58 $977.58 $1,075.46

$1,083.61 $782.85 $861.20 $840.91 $925.06 $800.45 $880.55 $843.55 $927.97 $762.62 $838.94 $843.55 $927.97 $1,022.11 $1,124.40

$1,106.81 $799.75 $879.63 $859.06 $944.87 $817.72 $899.40 $861.75 $947.83 $779.08 $856.90 $861.75 $947.83 $1,044.17 $1,148.47

$1,153.97 $833.86 $917.12 $895.69 $985.13 $852.59 $937.73 $898.50 $988.22 $812.31 $893.42 $898.50 $988.22 $1,088.70 $1,197.41

$1,194.95 $863.35 $949.69 $927.37 $1,020.11 $882.75 $971.03 $930.28 $1,023.31 $841.04 $925.14 $930.28 $1,023.31 $1,127.21 $1,239.93

$1,221.63 $882.71 $970.89 $948.17 $1,042.88 $902.54 $992.70 $951.14 $1,046.16 $859.90 $945.80 $951.14 $1,046.16 $1,152.48 $1,267.61

$1,255.26 $906.98 $997.62 $974.24 $1,071.60 $927.36 $1,020.03 $977.30 $1,074.96 $883.54 $971.83 $977.30 $1,074.96 $1,184.17 $1,302.50

$1,275.75 $921.73 $1,013.90 $990.08 $1,089.09 $942.44 $1,036.68 $993.19 $1,092.51 $897.91 $987.70 $993.19 $1,092.51 $1,203.42 $1,323.77

$1,275.75 $921.73 $1,013.90 $990.08 $1,089.09 $942.44 $1,036.68 $993.19 $1,092.51 $897.91 $987.70 $993.19 $1,092.51 $1,203.42 $1,323.77

M-152-115-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

Yes

75729PA0012629

Gold

Geisinger Marketplace PPO 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-115-F Dev. 01/17

Rating Area 2

Geisinger Marketplace PPO

Yes

75729PA0012630

Silver

Geisinger Marketplace PPO 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-115-F Dev. 01/17

Rating Area 3

Geisinger Marketplace PPO

Yes

75729PA0012630

Silver

Geisinger Marketplace PPO 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-115-F Dev. 01/17

Rating Area 5

Geisinger Marketplace PPO

Yes

75729PA0012630

Silver

Geisinger Marketplace PPO 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-115-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

Yes

75729PA0012630

Silver

Geisinger Marketplace PPO 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-115-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

Yes

75729PA0012631

Silver

Geisinger Marketplace PPO 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-115-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

Yes

75729PA0012632

Silver

Geisinger Marketplace PPO 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-115-F Dev. 01/17

Rating Area 7

Geisinger Marketplace PPO

Yes

75729PA0012633

Silver

Geisinger Marketplace PPO 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

Page Number: 9 12/24/2014

Page 107: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64+

$30.00 $50.00 $10/$50 $50.00 $10/$50 $50.00 $10/$50 $50.00 $10/$50 $50.00 $10/$50 $50.00 $10/$50 $50.00 $30.00

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco

$190.06 $190.06 $228.43 $228.43 $251.88 $251.88 $252.67 $252.67 $179.78 $179.78 $198.23 $198.23 $198.85 $198.85 $189.13

$299.31 $329.24 $359.74 $395.71 $396.66 $436.33 $397.91 $437.70 $283.12 $311.43 $312.18 $343.40 $313.16 $344.47 $297.85

$299.31 $329.24 $359.74 $395.71 $396.66 $436.33 $397.91 $437.70 $283.12 $311.43 $312.18 $343.40 $313.16 $344.47 $297.85

$299.31 $329.24 $359.74 $395.71 $396.66 $436.33 $397.91 $437.70 $283.12 $311.43 $312.18 $343.40 $313.16 $344.47 $297.85

$299.31 $329.24 $359.74 $395.71 $396.66 $436.33 $397.91 $437.70 $283.12 $311.43 $312.18 $343.40 $313.16 $344.47 $297.85

$300.50 $330.43 $361.17 $397.14 $398.24 $437.91 $399.49 $439.28 $284.24 $312.55 $313.42 $344.64 $314.41 $345.72 $299.04

$306.49 $337.01 $368.36 $405.06 $406.18 $446.64 $407.45 $448.04 $289.91 $318.78 $319.67 $351.51 $320.67 $352.61 $305.00

$313.67 $345.10 $377.00 $414.77 $415.70 $457.35 $417.00 $458.78 $296.70 $326.43 $327.16 $359.94 $328.18 $361.07 $312.15

$325.34 $357.97 $391.03 $430.24 $431.17 $474.40 $432.52 $475.89 $307.74 $338.60 $339.33 $373.36 $340.40 $374.53 $323.76

$334.92 $368.44 $402.54 $442.83 $443.86 $488.29 $445.25 $489.82 $316.80 $348.51 $349.32 $384.29 $350.42 $385.49 $333.29

$339.71 $373.83 $408.29 $449.30 $450.21 $495.43 $451.62 $496.98 $321.33 $353.61 $354.32 $389.90 $355.43 $391.13 $338.06

$346.89 $381.61 $416.93 $458.66 $459.73 $505.74 $461.17 $507.33 $328.13 $360.97 $361.81 $398.02 $362.94 $399.27 $345.21

$354.07 $389.39 $425.56 $468.01 $469.25 $516.05 $470.72 $517.67 $334.92 $368.33 $369.30 $406.14 $370.46 $407.41 $352.35

$358.56 $394.48 $430.96 $474.12 $475.20 $522.79 $476.69 $524.44 $339.17 $373.14 $373.98 $411.44 $375.16 $412.74 $356.82

$363.35 $399.57 $436.71 $480.24 $481.54 $529.54 $483.05 $531.20 $343.70 $377.95 $378.98 $416.75 $380.17 $418.06 $361.59

$365.75 $402.26 $439.59 $483.48 $484.72 $533.11 $486.24 $534.78 $345.96 $380.50 $381.48 $419.56 $382.67 $420.88 $363.97

$368.14 $404.96 $442.47 $486.72 $487.89 $536.68 $489.42 $538.36 $348.23 $383.05 $383.97 $422.37 $385.18 $423.70 $366.35

$370.54 $407.65 $445.35 $489.95 $491.06 $540.25 $492.60 $541.94 $350.49 $385.60 $386.47 $425.18 $387.68 $426.51 $368.74

$372.93 $410.34 $448.22 $493.19 $494.24 $543.82 $495.79 $545.52 $352.76 $388.15 $388.97 $427.99 $390.19 $429.33 $371.12

$377.72 $415.43 $453.98 $499.31 $500.58 $550.56 $502.15 $552.29 $357.29 $392.96 $393.96 $433.30 $395.20 $434.66 $375.88

$382.51 $420.82 $459.74 $505.78 $506.93 $557.70 $508.52 $559.45 $361.82 $398.05 $398.96 $438.92 $400.21 $440.29 $380.65

$389.69 $428.60 $468.37 $515.13 $516.45 $568.01 $518.07 $569.80 $368.61 $405.42 $406.45 $447.03 $407.72 $448.43 $387.80

$396.58 $436.38 $476.64 $524.49 $525.57 $578.33 $527.22 $580.14 $375.12 $412.78 $413.63 $455.15 $414.93 $456.58 $394.65

$406.15 $446.86 $488.15 $537.08 $538.26 $592.21 $539.95 $594.07 $384.18 $422.68 $423.62 $466.07 $424.95 $467.54 $404.18

$418.13 $460.03 $502.54 $552.91 $554.13 $609.66 $555.87 $611.58 $395.51 $435.14 $436.11 $479.81 $437.47 $481.32 $416.09

$432.19 $475.29 $519.45 $571.25 $572.77 $629.89 $574.57 $631.87 $408.81 $449.58 $450.78 $495.73 $452.19 $497.29 $430.09

$448.95 $493.85 $539.60 $593.56 $594.99 $654.49 $596.85 $656.54 $424.67 $467.13 $468.26 $515.09 $469.73 $516.70 $446.77

$467.81 $514.50 $562.26 $618.38 $619.98 $681.85 $621.92 $683.99 $442.50 $486.67 $487.93 $536.63 $489.46 $538.31 $465.54

$489.36 $538.44 $588.16 $647.16 $648.54 $713.59 $650.57 $715.83 $462.89 $509.32 $510.40 $561.60 $512.00 $563.36 $486.98

$510.61 $561.79 $613.70 $675.21 $676.70 $744.53 $678.82 $746.86 $482.99 $531.40 $532.57 $585.95 $534.24 $587.79 $508.13

$534.55 $588.13 $642.48 $706.87 $708.43 $779.43 $710.65 $781.88 $505.64 $556.31 $557.54 $613.42 $559.29 $615.35 $531.96

$558.20 $614.17 $670.90 $738.17 $739.77 $813.94 $742.09 $816.50 $528.00 $580.94 $582.20 $640.58 $584.03 $642.59 $555.49

$584.24 $642.60 $702.19 $772.34 $774.28 $851.62 $776.71 $854.30 $552.63 $607.84 $609.36 $670.24 $611.27 $672.34 $581.40

$610.58 $671.63 $733.85 $807.24 $809.18 $890.10 $811.72 $892.89 $577.55 $635.30 $636.83 $700.52 $638.83 $702.71 $607.61

$639.01 $702.76 $768.02 $844.65 $846.86 $931.35 $849.52 $934.28 $604.44 $664.74 $666.49 $732.98 $668.58 $735.28 $635.91

$667.44 $734.19 $802.20 $882.42 $884.55 $973.00 $887.32 $976.05 $631.34 $694.47 $696.15 $765.76 $698.33 $768.16 $664.20

$698.27 $768.01 $839.25 $923.07 $925.40 $1,017.82 $928.31 $1,021.02 $660.50 $726.46 $728.30 $801.04 $730.59 $803.55 $694.88

$729.40 $802.43 $876.66 $964.44 $966.66 $1,063.44 $969.69 $1,066.78 $689.94 $759.02 $760.77 $836.94 $763.15 $839.56 $725.86

$762.62 $838.94 $916.59 $1,008.32 $1,010.68 $1,111.83 $1,013.86 $1,115.32 $721.37 $793.56 $795.42 $875.02 $797.91 $877.77 $758.92

$779.08 $856.90 $936.38 $1,029.91 $1,032.50 $1,135.63 $1,035.74 $1,139.19 $736.94 $810.55 $812.59 $893.75 $815.14 $896.56 $775.30

$812.31 $893.42 $976.31 $1,073.80 $1,076.53 $1,184.02 $1,079.91 $1,187.74 $768.36 $845.09 $847.24 $931.84 $849.90 $934.76 $808.36

$841.04 $925.14 $1,010.84 $1,111.93 $1,114.61 $1,226.07 $1,118.11 $1,229.92 $795.54 $875.10 $877.21 $964.93 $879.96 $967.96 $836.95

$859.90 $945.80 $1,033.51 $1,136.75 $1,139.60 $1,253.44 $1,143.17 $1,257.37 $813.38 $894.63 $896.87 $986.47 $899.69 $989.56 $855.72

$883.54 $971.83 $1,061.92 $1,168.04 $1,170.93 $1,287.95 $1,174.61 $1,291.99 $835.74 $919.26 $921.54 $1,013.63 $924.43 $1,016.81 $879.25

$897.91 $987.70 $1,079.19 $1,187.11 $1,189.97 $1,308.97 $1,193.71 $1,313.08 $849.33 $934.27 $936.52 $1,030.17 $939.46 $1,033.40 $893.55

$897.91 $987.70 $1,079.19 $1,187.11 $1,189.97 $1,308.97 $1,193.71 $1,313.08 $849.33 $934.27 $936.52 $1,030.17 $939.46 $1,033.40 $893.55

M-152-115-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

Yes

75729PA0012633

Silver

Geisinger Marketplace PPO 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-240-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

Yes

75729PA0012634

Gold

Geisinger Marketplace PPO Extra 10/50/500 w/PD

$500.00

0.2

$5,000.00

M-152-240-F Dev. 01/17

Rating Area 3

Geisinger Marketplace PPO

Yes

75729PA0012635

Gold

Geisinger Marketplace PPO Extra 10/50/500 w/PD

$500.00

0.2

$5,000.00

M-152-240-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

Yes

75729PA0012635

Gold

Geisinger Marketplace PPO Extra 10/50/500 w/PD

$500.00

0.2

$5,000.00

M-152-240-F Dev. 01/17

Rating Area 9

Geisinger Marketplace PPO

Yes

75729PA0012636

Silver

Geisinger Marketplace PPO Extra 10/50/3500 w/PD

$3,500.00

0.3

$7,150.00

M-152-240-F Dev. 01/17

Rating Area 3

Geisinger Marketplace PPO

Yes

75729PA0012637

Silver

Geisinger Marketplace PPO Extra 10/50/3500 w/PD

$3,500.00

0.3

$7,150.00

M-152-240-F Dev. 01/17

Rating Area 6

Geisinger Marketplace PPO

Yes

75729PA0012637

Silver

Geisinger Marketplace PPO Extra 10/50/3500 w/PD

$3,500.00

0.3

$7,150.00

M-152-246-F Dev. 01/17

Rating Area 3

Geisinger Marketplace Select

Yes

75729PA0012638

Silver

Geisinger Marketplace PPO Select 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

Page Number: 10 12/24/2014

Page 108: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64+

$50.00 $30.00 $50.00 $30.00 $50.00 $30.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00 $50.00 $25.00 $50.00

Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$189.13 $180.03 $180.03 $189.73 $189.73 $171.53 $171.53 $244.29 $244.29 $232.54 $232.54 $245.06 $245.06 $221.55 $221.55

$327.64 $283.52 $311.87 $298.79 $328.67 $270.12 $297.14 $384.72 $423.19 $366.20 $402.82 $385.92 $424.51 $348.90 $383.79

$327.64 $283.52 $311.87 $298.79 $328.67 $270.12 $297.14 $384.72 $423.19 $366.20 $402.82 $385.92 $424.51 $348.90 $383.79

$327.64 $283.52 $311.87 $298.79 $328.67 $270.12 $297.14 $384.72 $423.19 $366.20 $402.82 $385.92 $424.51 $348.90 $383.79

$327.64 $283.52 $311.87 $298.79 $328.67 $270.12 $297.14 $384.72 $423.19 $366.20 $402.82 $385.92 $424.51 $348.90 $383.79

$328.82 $284.65 $313.00 $299.98 $329.86 $271.20 $298.21 $386.25 $424.72 $367.66 $404.28 $387.46 $426.05 $350.29 $385.18

$335.38 $290.32 $319.24 $305.95 $336.43 $276.60 $304.16 $393.94 $433.18 $374.99 $412.34 $395.18 $434.54 $357.27 $392.86

$343.42 $297.13 $326.89 $313.12 $344.50 $283.09 $311.45 $403.18 $443.57 $383.78 $422.23 $404.44 $444.96 $365.64 $402.28

$356.23 $308.18 $339.09 $324.78 $357.34 $293.62 $323.06 $418.18 $460.11 $398.06 $437.97 $419.49 $461.56 $379.25 $417.28

$366.65 $317.26 $349.01 $334.34 $367.80 $302.26 $332.52 $430.49 $473.58 $409.78 $450.79 $431.84 $475.06 $390.41 $429.49

$372.01 $321.79 $354.11 $339.12 $373.18 $306.59 $337.38 $436.65 $480.50 $415.64 $457.38 $438.02 $482.01 $396.00 $435.77

$379.76 $328.60 $361.48 $346.29 $380.95 $313.07 $344.40 $445.88 $490.51 $424.43 $466.90 $447.28 $492.05 $404.37 $444.84

$387.50 $335.40 $368.86 $353.46 $388.72 $319.55 $351.43 $455.11 $500.51 $433.21 $476.43 $456.54 $502.08 $412.74 $453.91

$392.56 $339.65 $373.68 $357.94 $393.80 $323.60 $356.02 $460.88 $507.05 $438.71 $482.65 $462.33 $508.64 $417.98 $459.84

$397.63 $344.19 $378.50 $362.72 $398.88 $327.93 $360.61 $467.04 $513.59 $444.57 $488.88 $468.50 $515.20 $423.56 $465.78

$400.31 $346.46 $381.05 $365.11 $401.56 $330.09 $363.04 $470.12 $517.05 $447.50 $492.17 $471.59 $518.67 $426.35 $468.92

$402.99 $348.73 $383.60 $367.50 $404.25 $332.25 $365.47 $473.19 $520.51 $450.43 $495.47 $474.68 $522.15 $429.14 $472.06

$405.67 $350.99 $386.15 $369.89 $406.94 $334.41 $367.90 $476.27 $523.98 $453.35 $498.76 $477.77 $525.62 $431.93 $475.20

$408.35 $353.26 $388.70 $372.28 $409.63 $336.57 $370.33 $479.35 $527.44 $456.28 $502.06 $480.85 $529.09 $434.72 $478.34

$413.41 $357.80 $393.52 $377.06 $414.71 $340.89 $374.93 $485.50 $533.98 $462.14 $508.28 $487.03 $535.65 $440.31 $484.27

$418.77 $362.33 $398.62 $381.84 $420.09 $345.21 $379.79 $491.66 $540.90 $468.00 $514.88 $493.20 $542.60 $445.89 $490.55

$426.52 $369.14 $406.00 $389.02 $427.86 $351.70 $386.81 $500.89 $550.91 $476.79 $524.40 $502.47 $552.63 $454.26 $499.62

$434.26 $375.66 $413.37 $395.89 $435.63 $357.91 $393.83 $509.74 $560.91 $485.21 $533.92 $511.34 $562.67 $462.29 $508.69

$444.69 $384.73 $423.29 $405.45 $446.08 $366.55 $403.29 $522.05 $574.37 $496.93 $546.74 $523.69 $576.18 $473.45 $520.90

$457.79 $396.07 $435.77 $417.40 $459.23 $377.36 $415.17 $537.44 $591.30 $511.58 $562.85 $539.13 $593.16 $487.41 $536.25

$472.98 $409.40 $450.22 $431.44 $474.47 $390.05 $428.95 $555.52 $610.92 $528.79 $581.52 $557.27 $612.84 $503.81 $554.05

$491.45 $425.28 $467.80 $448.17 $492.99 $405.18 $445.70 $577.07 $634.77 $549.30 $604.23 $578.88 $636.76 $523.34 $575.68

$512.00 $443.14 $487.37 $467.00 $513.61 $422.20 $464.34 $601.30 $661.32 $572.37 $629.50 $603.19 $663.39 $545.32 $599.75

$535.83 $463.55 $510.05 $488.51 $537.51 $441.65 $485.95 $629.00 $692.09 $598.74 $658.79 $630.98 $694.27 $570.44 $627.66

$559.06 $483.68 $532.16 $509.72 $560.82 $460.82 $507.02 $656.32 $722.10 $624.74 $687.36 $658.38 $724.37 $595.22 $654.88

$585.27 $506.36 $557.11 $533.63 $587.11 $482.43 $530.79 $687.09 $755.96 $654.03 $719.58 $689.25 $758.33 $623.13 $685.58

$611.19 $528.76 $581.78 $557.23 $613.10 $503.77 $554.29 $717.49 $789.43 $682.96 $751.44 $719.74 $791.90 $650.69 $715.93

$639.48 $553.42 $608.71 $583.22 $641.49 $527.27 $579.95 $750.96 $825.97 $714.82 $786.23 $753.31 $828.57 $681.04 $749.08

$668.37 $578.37 $636.21 $609.52 $670.47 $551.04 $606.15 $784.81 $863.29 $747.05 $821.75 $787.27 $866.00 $711.75 $782.92

$699.35 $605.31 $665.70 $637.90 $701.54 $576.71 $634.24 $821.36 $903.30 $781.84 $859.84 $823.93 $906.14 $744.89 $819.21

$730.62 $632.24 $695.47 $666.29 $732.92 $602.37 $662.60 $857.90 $943.70 $816.62 $898.29 $860.60 $946.66 $778.04 $855.84

$764.28 $661.44 $727.50 $697.06 $766.68 $630.19 $693.13 $897.53 $987.17 $854.34 $939.67 $900.35 $990.27 $813.97 $895.27

$798.53 $690.93 $760.11 $728.13 $801.04 $658.28 $724.19 $937.54 $1,031.41 $892.43 $981.78 $940.48 $1,034.65 $850.26 $935.39

$834.87 $722.40 $794.70 $761.30 $837.49 $688.27 $757.15 $980.24 $1,078.34 $933.08 $1,026.46 $983.32 $1,081.73 $888.99 $977.95

$852.74 $737.99 $811.71 $777.73 $855.42 $703.12 $773.35 $1,001.40 $1,101.43 $953.22 $1,048.43 $1,004.54 $1,104.88 $908.18 $998.89

$889.08 $769.46 $846.30 $810.90 $891.87 $733.11 $806.31 $1,044.10 $1,148.36 $993.87 $1,093.11 $1,047.38 $1,151.96 $946.90 $1,041.45

$920.65 $796.68 $876.35 $839.58 $923.54 $759.04 $834.94 $1,081.04 $1,189.14 $1,029.02 $1,131.92 $1,084.43 $1,192.87 $980.40 $1,078.44

$941.20 $814.54 $895.91 $858.40 $944.15 $776.05 $853.58 $1,105.27 $1,215.69 $1,052.09 $1,157.19 $1,108.74 $1,219.50 $1,002.38 $1,102.51

$967.11 $836.94 $920.58 $882.01 $970.15 $797.39 $877.08 $1,135.67 $1,249.16 $1,081.02 $1,189.05 $1,139.23 $1,253.08 $1,029.94 $1,132.86

$982.90 $850.55 $935.61 $896.35 $985.98 $810.36 $891.40 $1,154.13 $1,269.55 $1,098.60 $1,208.46 $1,157.75 $1,273.53 $1,046.69 $1,151.36

$982.90 $850.55 $935.61 $896.35 $985.98 $810.36 $891.40 $1,154.13 $1,269.55 $1,098.60 $1,208.46 $1,157.75 $1,273.53 $1,046.69 $1,151.36

M-152-246-F Dev. 01/17

Rating Area 3

Geisinger Marketplace Select

Yes

75729PA0012638

Silver

Geisinger Marketplace PPO Select 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-246-F Dev. 01/17

Rating Area 5

Geisinger Marketplace Select

Yes

75729PA0012638

Silver

Geisinger Marketplace PPO Select 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-246-F Dev. 01/17

Rating Area 6

Geisinger Marketplace Select

Yes

75729PA0012638

Silver

Geisinger Marketplace PPO Select 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-246-F Dev. 01/17

Rating Area 9

Geisinger Marketplace Select

Yes

75729PA0012638

Silver

Geisinger Marketplace PPO Select 30/50/5000 w/PD

$5,000.00

0.3

$6,000.00

M-152-246-F Dev. 01/17

Rating Area 3

Geisinger Marketplace Select

Yes

75729PA0012639

Gold

Geisinger Marketplace PPO Select 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-246-F Dev. 01/17

Rating Area 5

Geisinger Marketplace Select

Yes

75729PA0012639

Gold

Geisinger Marketplace PPO Select 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-246-F Dev. 01/17

Rating Area 6

Geisinger Marketplace Select

Yes

75729PA0012639

Gold

Geisinger Marketplace PPO Select 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

M-152-246-F Dev. 01/17

Rating Area 9

Geisinger Marketplace Select

Yes

75729PA0012639

Gold

Geisinger Marketplace PPO Select 25/50/1000 w/PD

$1,000.00

0.2

$4,000.00

Page Number: 11 12/24/2014

Page 109: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

RATE PAGES

Company Name:

Market:

Product:

Effective Date of Rates:

HIOS Plan ID (On Exchange)=>

HIOS Plan ID (Off Exchange)=>

Form # =>

Rating Area =>

Counties Excluded in Rating Area =>

Network =>

Metal =>

Plan Name =>

Deductible =>

Coinsurance =>

Copays =>

OOP Maximum =>

Pediatric Dental (Yes/No) =>

Age Band

0 - 20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64+

Non-Tobacco Tobacco

Page Number: 12 12/24/2014

Page 110: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Silver Plan Rates for Age 21 Non-Smoker, by Geographic Area and Exchange Status

HIOS Plan ID # Rating Area 1 Rating Area 2 Rating Area 3 Rating Area 4 Rating Area 5 Rating Area 6 Rating Area 7 Rating Area 8 Rating Area 9

75729PA0012603 306 328.69 312.88 329.72

75729PA0012612 298.09

75729PA0012614 329.72

75729PA0012616 399.52 298.09

75729PA0012622 281.97

75729PA0012623 310.91 311.89

75729PA0012624 312.26 297.23 313.24 283.19

2017 On-Exchange Silver Plan Rates

Page 111: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Silver Plan Rates for Age 21 Non-Smoker, by Geographic Area and Exchange Status

HIOS Plan ID # Rating Area 1 Rating Area 2 Rating Area 3 Rating Area 4 Rating Area 5 Rating Area 6 Rating Area 7 Rating Area 8 Rating Area 9

75729PA0012603 306 328.69 312.88 329.72

75729PA0012612 298.09

75729PA0012614 329.72

75729PA0012616 399.52 298.09

75729PA0012622 281.97

75729PA0012623 310.91 311.89

75729PA0012624 312.26 297.23 313.24 283.19

75729PA0012630 307.25 330.03 314.15 331.07

75729PA0012631 299.31

75729PA0012632 331.07

75729PA0012633 401.15 299.31

75729PA0012636 283.12

75729PA0012637 312.18 313.16

75729PA0012638 297.85 283.52 298.79 270.12

2017 Off-Exchange Silver Plan Rates

Page 112: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Supporting Document Schedules Satisfied - Item: Actuarial Memorandum and Explanatory Information (A&H)Comments:Attachment(s): Cover Letter - Indiv PPO Filing - signed.pdfItem Status:Status Date:

Satisfied - Item: Consumer Disclosure FormComments:Attachment(s): HIOS Part 2 Consumer Justification Narrative-Individual PPO-2017 Exchange Filing-as of 5.05.16.pdfItem Status:Status Date:

Satisfied - Item: Actuarial Memorandum and CertificationsComments:Attachment(s): Act Memo - 2017 Indiv PPO.pdfItem Status:Status Date:

Satisfied - Item: Unified Rate Review TemplateComments:

Attachment(s):UnifiedRateReviewSubmission_IndivPPO_20160509204549.xmlUnified_Rate_Review_Template_GQO_Indiv.xlsmUnified_Rate_Review_Template_GQO_Indiv.pdf

Item Status:Status Date:

Satisfied - Item: Rate Change Request SummaryComments:Attachment(s): Attachment 1 GQO Individual.pdfItem Status:Status Date:

Satisfied - Item: PA Act Memo Rate ExhibitsComments:

Attachment(s): FINAL 2017 PA Act Memo Exhibits Rev 4-21-2016 GQO Indiv 20160505.xlsxFINAL 2017 PA Act Memo Exhibits Rev 4-21-2016 GQO Indiv 20160505.pdf

SERFF Tracking #: GSHP-130558343 State Tracking #: GSHP-130558343 Company Tracking #: INDPPO

State: Pennsylvania Filing Company: Geisinger Quality Options

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

Product Name: PPO

Project Name/Number: Indiv PPO 2017 ACA Filing/IndPPO

PDF Pipeline for SERFF Tracking Number GSHP-130558343 Generated 06/14/2016 12:20 PM

Page 113: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Item Status:Status Date:

Satisfied - Item: PA BulletinComments:Attachment(s): PA Bulletin GQO Individuals.pdfItem Status:Status Date:

SERFF Tracking #: GSHP-130558343 State Tracking #: GSHP-130558343 Company Tracking #: INDPPO

State: Pennsylvania Filing Company: Geisinger Quality Options

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

Product Name: PPO

Project Name/Number: Indiv PPO 2017 ACA Filing/IndPPO

PDF Pipeline for SERFF Tracking Number GSHP-130558343 Generated 06/14/2016 12:20 PM

Page 114: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Attachment UnifiedRateReviewSubmission_IndivPPO_20160509204549.xml is not a PDF document andcannot be reproduced here.

Attachment Unified_Rate_Review_Template_GQO_Indiv.xlsm is not a PDF document and cannot bereproduced here.

Attachment FINAL 2017 PA Act Memo Exhibits Rev 4-21-2016 GQO Indiv 20160505.xlsx is not a PDFdocument and cannot be reproduced here.

SERFF Tracking #: GSHP-130558343 State Tracking #: GSHP-130558343 Company Tracking #: INDPPO

State: Pennsylvania Filing Company: Geisinger Quality Options

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

Product Name: PPO

Project Name/Number: Indiv PPO 2017 ACA Filing/IndPPO

PDF Pipeline for SERFF Tracking Number GSHP-130558343 Generated 06/14/2016 12:20 PM

Page 115: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59
Page 116: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59
Page 117: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

HIOS Part 2 Consumer Justification Narrative Individual PPO Geisinger Quality Options has proposed an overall base rate increase of 40.68% for Individual PPO members renewing in the Marketplace effective January 1, 2017 through December 1, 2017. The range of proposed rate increases vary from a minimum of 35.0% to a maximum of 73.0%. The overall increase is largely due to the claims experience in ACA compliant individual market plans being much higher than what was assumed in current rates. Other contributing factors include annual claims trend, federally-prescribed ACA fees and changes in the federal risk-adjustment program. The total projected 2017 administrative costs are slightly higher than those used for the current 2016 rates. As required by federal regulations, the projected loss ratio exceeds 80%. There were minimal benefit changes proposed for 2017.

Page 118: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 1 of 11

Actuarial Memorandum – Individual PPO

General Information

Company Identifying Information

Company Legal Name: Geisinger Quality Options State: Pennsylvania

HIOS Issuer ID: 75729

NAIC Number: 12743 Market: Individual

Effective Date: 1/1/2017

Company Contact Information

Primary Contact Name: Sarah MacDerment

Primary Contact Phone: 570-214-2348

Primary Contact email address: [email protected]

Filing Information

HIOS Submission Tracking Number:

Contract Form Number: M-152-115-F Dev. 01/17, M-152-240-F Dev. 01/17, M-152-246-F Dev. 01/17

SERFF Number: GSHP-130558343

Binder ID Number: GSHP-PA17-125064419

Rate History and Proposed Variations in Rate Changes

Rate History The recent historical rate increases are summarized in the table below. Only the last 2 years are included since the plans offered on the Exchange are not comparable to plans offered before 2014.

Year Average Increase SERFF ID#

2015 13.7% GSHP-129625425 2016 20.0% GSHP-130072442

For 2015, the increase was not uniform, but varied by plan. These increases varied from 7.8% to 19.4%. For 2016, the increases also varied by plan and ranged from 15.2% to 21.1% for an overall increase of 20.0%.

Proposed Rate Increase

This filing applies to PPO products, sold on and off exchange in rating areas 2, 3, 5, 6, 7 and 9. There will

be 14 gold plans, 14 silver plans, for a total of 28 plans offered in 2017. As of February 2016, 6,314

covered lives and 4,380 policyholders will be impacted by this filing. The proposed overall rate increase

is 40.7% but is not uniform by plan. The increases range from 35.0% to 73.0%. For 2017, we are

introducing a new, lower cost network. The new plans on the lower cost network are priced at a lower

premium to the member. Table 11 shows the increases at the plan level. These increases vary by plan

due to benefit changes necessary to maintain the desired metal level and cost sharing changes

mandated by ACA as well changes in pricing factors.

Average Rate Change

Page 119: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 2 of 11

The average rate change entered as the “percent rate change requested” in the SERFF Rate Review

Detail Screen is the same as listed in Table 10, cell AC13. It is the change in the Calibrated Plan-adjusted

Index rate (as instructed by the Department).

Membership Count

Table 1 shows the member months in the experience period of calendar year 2015, as well as the

current members as of February 1, 2016 by age range. The projected member months for the rating

period are also included.

Benefit Changes

There are many benefit and cost sharing changes to the plans covered by this filing. Benefits for adult

eye exam were removed as a result of the change in the benchmark plan for Pennsylvania. These

services are estimated to account for .08% of the claims cost. As a result of changes to the AV

calculator, several plan’s cost sharing elements were slightly adjusted to maintain the same metal level.

To meet the metallic level, plans were adjusted by first changing the out-of-pocket maximum, then the

deductible and finally the coinsurance and copays while only adjusting as necessary to meet the metallic

level and still offer a competitive product.

Reason for Rate Increase

The components of this rate increase are:

Single Risk Pool experience which is more adverse than assumed in current rates;

Medical Inflation;

Utilization trend;

Changes in administrative expenses;

Changes in ACA fees;

Changes in covered benefits

Changes in Transitional Reinsurance coverage;

Changes in Risk Adjustment;

Changes in Network.

Each of these components is discussed in detail under the “Projection Factors” section of this document and are displayed in Table 8 of the exhibits.

Experience Period Premium and Claims

Paid Through Date

The Experience Period data provided in the URRT Worksheet 1, Section I and in Table 2 is incurred in

calendar year 2015 and paid through February 2016. Except for premium, the data in Table 2 of the

exhibits is consistent with the data provided in the URRT in Worksheet 1, Section 1.

Premiums (net of MLR Rebate) in Experience Period

Premiums include earned premiums for calendar year 2015 for the Single Risk Pool. Premiums are not

reduced by taxes and/or assessments. Expected risk adjustment receivables are included in the

Page 120: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 3 of 11

experience period premium on Worksheet 1 of the URRT as instructed, but excluded from the Earned

Premium in Table 2. The risk adjustment is excluded from the beginning value in Table 2 since the

calculations at the end of the table add it to premium. MLR rebates are not expected to be paid for this

block of business. Initial estimates of rebates have been completed utilizing the methodology required

for the CY 2015 rebate filing. Estimates suggest that the individual market MLR will be above the

minimum MLR target of 80%.

Allowed and Incurred Claims Incurred During the Experience Period

The Experience Period Claims are based on individual non-grandfathered business incurred and paid

claims with IBNR added for the tail of claims incurred but not paid. Allowed claims are directly from

claim records. For both paid and allowed claims the same IBNR factors were used. The IBNR factors were

based on legal-entity level claims completion tables which include individual and group commercial

experience. This method is appropriate in order to assure proper credibility and because timing of claims

payment to providers does not vary by market or product.

Geisinger has private reinsurance to mitigate the risk of shock claims. The experience period expenses

for reinsurance are included in capitated benefits for CY2015. The reinsurance recoveries are removed

from the ultimate incurred claims in Table 2. They are not included in column M Estimated Reinsurance

Recoveries, only the estimated reinsurance recoveries from the Transitional Reinsurance program are

included in column M.

There were no non-EHB benefits in the experience period.

Geisinger outsources several benefits and therefore has capitation expenses. The capitated expenses

cover chiropractic services, nurse line, and mental health services including autism as well as the

reinsurance expenses for private reinsurance. There are also some additional quality expense in the

capitation category. The capitation amount for the experience period is displayed on Table 2. The

capitation charges are uniform and do not vary by age.

Pharmacy rebates are listed on Table 2. These rebate dollars would be removed from the Ultimate

Incurred Claim liability to the insurer.

The estimated risk adjustment for the experience period are based on an external analysis performed by

an outside consulting firm. They estimated the Risk Adjustment transfer payment based on the

population risk scores relative to an assumed market average risk score and market average premium.

The Experience Period Reinsurance amount was estimated using the 2015 attachment point of $45k

after which reinsurance payments begin, with a cap of $250k where after payments stop for high cost

enrollees. Reimbursement is set at 50% of a member’s claims in that range. These threshold amounts

are applied to each member in the Experience Period and a total reinsurance receivable amount is

calculated. The estimated Reinsurance recovery is displayed on Table 2.

Benefit Categories

Page 121: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 4 of 11

Benefit Category Description

Inpatient Hospital Determined by place of service (Hospital—IP)

Outpatient Hospital Determined by place of service (Hospital—OP)

Professional Determined by place of service (Physician’s office)

Other Medical N/A

Capitation Claims per Financial Department

Prescription Drug Claims per contracted PBM

Credibility of Data

The existing non-grandfathered business shown in the Experience Period data in Table 2 does not reflect

the anticipated risk and composition of the Projection Period. The Credibility Manual Rate is developed

using population segments that are in the Experience Period blended with population segments

(Grandfathered business) that are not in the Experience Period. The Credibility Manual Rate is a

combination of our HMO and PPO experience, giving us an even more credible manual rate. Combining

the HMO and PPO Single Risk Pools also aids in consistency between the products. In order to avoid

double counting the Experience Period and avoid complicated adjustments to reflect the expected

distribution of enrollment in each segment, the credibility of the Experience Period is set to 0.0%. This

approach is consistent with the Actuarial Standard of Practice #25.

The Credibility Manual Rate is developed based on the expected enrollment in each of these segments,

as summarized in the table below. Each segment is described in more detail in the “Adjustments Made

to Data” section below.

Segment % of population

Assumed in Projection Period

ACA Compliant - PPO 100%

Non-ACA Non-GF Conv -PPO 80%

ACA Compliant – HMO/POS 100%

Non-ACA Non-GF – HMO/POS 80%

Non-ACA Non-GF Conv – HMO/POS 60%

Non-ACA GF and Conv – HMO/POS 80%

The credibility manual data is shown in Table 2b. Since the credibility manual data is given a weight of

100%, the “blended” data would be the same as the data in Table 2b.

Adjustments Made to the Data

The following segments are included in the development of the Credibility Manual Rate and adjusted

when appropriate.

ACA Compliant Experience HMO/POS and PPO – This population is represented in the Experience Period

and is expected to continue into the Projection Period. Newly insured members entering the single risk

Page 122: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 5 of 11

pool are expected to have morbidity similar to this population. The Projected Allowed Experience Claims

are adjusted for benefits changes as described in the section below.

Non-ACA Individual Non-Grandfathered Experience HMO/POS and PPO – This population is represented

in the Experience Period and a portion is expected to continue into the Projection Period. The Projected

Allowed Experience Claims are adjusted to represent the essential health benefits.

Non-ACA Individual Non-Grandfathered Conversion Experience HMO/POS and PPO – This population is

represented in the Experience Period and a portion is expected to continue into the Projection Period.

The Projected Allowed Experience Claims are adjusted to represent the essential health benefits.

Non-ACA Individual Grandfathered Experience HMO/POS – This product was withdrawn and a portion of

this population is expected to have transitioned to the ACA Single Risk Pool on April 1, 2016. This

segment is not represented in the Experience Period for the Single Risk Pool. Claims for this segment

need to be adjusted to represent the essential health benefits, as described below.

Morbidity Adjustments

The morbidity of each population segment is expected to continue into the projection period as

represented in the base period experience.

Changes in Benefits

Additional benefits due to Essential Health Benefits requirements are included in both of the non-ACA

Compliant Experience segments listed above:

+ Pediatric Eye Exam: $1.05 PMPM

+ Pediatric Eyewear: $2.31 PMPM

+ 100% coverage of adult physicals: 0.75% of claims

+ Chiropractic Coverage: $1.85 PMPM

+ Extraction of Wisdom Teeth: $0.84 PMPM

+ Pediatric Dental: $2.16 PMPM

Changes in Demographics

Each segment of the Projection Period is expected to have a similar demographic distribution as

represented in the 2015 Base Period. There is no adjustment for demographic changes to any

population segments.

Trend Factors

Experience data was trended using an annual trend of 7.5%. Table 3 shows the breakdown between

service category and cost vs. utilization. Table 3 uses the PMPM by service category to weight to

develop the total composite trend. Trend factors are projected for unit cost and utilization components:

Unit cost trend factors are based on recorded anticipated increases in facility and professional

fees from the Experience to Projection Period. These increases are composited across all

facilities and provider groups.

Utilization trend projections are based on least-square regression modeling, taking into account

historical claims patterns, anticipated economic activity and changes in care patterns.

Page 123: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 6 of 11

Seasonality adjustments are made to the claims to account for changes in work days.

Further adjustments have been made to the trends to reflect expected changes due to new

medical management initiatives that are expected to yield savings in the projection period.

Our trends are analyzed at a higher level than these individual segments and are the same for the

experience data and the credibility manual data. Due to the lack of stability in the ACA experience, we

based our trends on data from our commercial large group experience. Table 4b is provided for this

large group experience.

Inclusion of Capitation Payments

If a capitated benefit is not in the experience period, an adjustment was added to account for those

services (e.g. Pediatric dental).

Historical Experience

Table 4 includes the most recent 36 months of data with run out through February 2016. Allowed

claims are directly from claim records. As mentioned above, Table 4b displays the large group data that

was used to determine the trends used.

Paid to Allowed Ratio

The Projected Paid to Allowed Average Ratio is displayed on Table 5. It is determined for the Projection

Period based on the member weighted average Pricing AV for each plan and the projected member

months in each plan. There are variations between the AV Pricing Values and the AV Calculator values

because of different cost structures and management approaches than what is reflected in the national

average data used in the AV Calculator.

Risk Adjustment and Reinsurance

Experience Period Risk Adjustment and Reinsurance Adjustments PMPM

As stated above, the estimated risk adjustment transfer payment for the experience period was based

on an external analysis performed by an outside consulting firm. The Experience Period Reinsurance

amount was estimated using the 2015 benefits, applied to member level claims as discussed above.

Projected Risk Adjustments PMPM

Our Individual Exchange population has changed significantly between 2014, 2015 and 2016. For

example, our membership grew by approx. 50% between December 2015 and January 2016. It is

unlikely that the result of the risk adjustment program for 2017 will mirror the actual transfer payment

for 2014. The membership is changing each year, both at GHP and market wide. The relationship

between the average risks of these 2 populations is difficult to predict. Also, the risk models used in the

Risk Adjustment program, are being recalibrated for 2017. Other changes include the inclusion of

preventive services in the model and a higher trend on specialty drug. Due to all of this uncertainty, our

Projected Risk Adjustment transfer payment for 2017 is zero for the Individual market.

Projected ACA Reinsurance Recoveries Net of Reinsurance Premium

This is a holdover from prior years. The reinsurance program ends in 2016 so the expected recoveries is

0 for 2017.

Page 124: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 7 of 11

Non-Benefit Expenses and Profit & Risk

Administration Expense Load

Administration expenses are based on activity-based allocation by product for calendar year 2017. This

methodology applies for all variable costs and all fixed costs.

Profit & Risk Margin

The risk margin is set at 5% of premium.

Taxes, Fees, and Subsidies

Table 6 displays the retention items. It provides a breakdown of the administrative expenses and taxes

and fees. For 2017, the federal government will not collect the Health Insurer Provider Fee so it is not

included in this development. The administrative expenses are a consistent percentage of premium and

do not vary by plan. This is a change from our rate developments from prior years.

Projected Loss Ratio

The anticipated loss ratio is 90.0% in aggregate as shown below using the Federally-prescribed MLR

methodology:

MLR Numerator = URRT Projected Claims + Quality Initiatives = 489.88 + .0202*599.21 = 501.99

MLR Denominator = URRT Projected Premiums – Taxes and Fees + Risk Adjustment = 599.21 – 41.10 + -

.15 = 557.96

Federal MLR = 501.99 / 557.96 = 90.0%

The Quality Initiatives amount is based on the latest estimate for this product.

Development of Projected Index Rate, Market-Adjusted Index Rate & Total Allowed Claims

Single Risk Pool

The Single Risk Pool has been established in accordance with the requirements in 45 CFR 156.80(d) as

was discussed previously in the Experience Period Premium and Claims section. The Experience Period

includes transitional policies and the Projection Period includes transitional policies only to the extent

that we anticipate members will transition into the ACA Compliant products.

Index Rate

The Experience Period Index Rate is the based on the manual Allowed Claims PMPM and is the starting

value on Table 5. The Credibility Manual Rate is a combination of our HMO and PPO experience, giving

us an even more credible manual rate. There are no benefits covered in addition to Essential Health

benefits in the policies being offered.

The Projected Index Rate for this Single Risk Pool is the Adjusted Projected Allowed EHB Claims PMPM

and is the manual rate. The projected claims reflect the trend and benefits described earlier in this

memorandum. There are no benefits covered in addition to Essential Health benefits in the policies

being offered.

Market Adjusted Index Rate

The Market Adjusted Index Rate is developed by adjusting the Index Rate for allowable market-wide

modifiers. This includes the Risk Adjustment Program and the Exchange User Fees. The Risk Adjustment

Page 125: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 8 of 11

payments are determined on a PMPM basis and, as described above under the Risk Adjustment and

Reinsurance section, these amounts are converted to an allowed basis. The values are displayed on

Table 5. These PMPMs are represented on a paid basis.

The Market Adjusted Total Allowed Claims are calculated in Table 5. The Projected Index Rate is

converted to paid basis by multiplying by the Projected Paid to Allowed ratio (described above). The

allowable market-wide modifiers (risk adjustment and Exchange User Fees) are added to this paid basis

PMPM. This PMPM is then converted back to an allowed basis, again using the projected paid to

allowed ratio. Any non-EHB claims would then be added to this value. We have none, so this PMPM is

the Market-Adjusted Projected Total Allowed Claims PMPM.

Normalized Market-Adjusted Projected Allowed Total Claims

The Market-Adjusted Projected Allowed Total Claims is normalized using the projected average factors

for age, geography, tobacco, benefit richness (induced demand) and network. These average factors for

2016 and 2017 are displayed on Table 7.

Projected Membership

Members were projected for each plan to be sold in 2017. Sales and marketing were consulted in

developing these projections. Overall, membership is expected to remain at current levels, so February

2016 membership is expected to best represent calendar year 2017. Members from discontinued plans

are assumed to move to the plan where they are mapped, in general. Since all new plans also need

projected members, some members are assumed to migrate to new plans. This movement was

modeled based on internally developed expectations. Projected membership is used to calculate the

normalization factors discussed below.

Plan Factors

Age Factor

The federal age curve, as shown in Table 12, is used to determine a normalization factor to account for

the age mix of business used in generating the Index Rate. The average age factor includes a factor of 0

for non-billable members. The average factors for 2016 and 2017 are shown on Table 7.

Geographic Factor The geographic rating area factors used to determine premium rates are shown on

Table 13. These factors are consistent with the current approved factors, except for region 9. The rating

area factor for region 9 was changed from last year due to expected changes in provider contracting.

The normalization factor is determined using these factors weighted using projected membership by

area.

Tobacco Factor

A standard 10% load is applied for applicants who indicate tobacco usage by affirmatively answering the

question—“Have you used tobacco at least four times a week for the past six months?” This load

assumption was validated using the study “Impact of height, weight, and smoking on medical claims

costs”, a research report done by Milliman to update their Medical Underwriting Guidelines in April

2009. We utilized the 2015 ACA compliant population to determine the percentage of members that

admit to the use of tobacco and pay the increased premium for their entire contract in 2015. The

Page 126: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 9 of 11

average tobacco factor is shown on Table 7. Table 12 shows the age bands, age factors and tobacco

factors where it demonstrates that the tobacco factors are uniform across all age bands.

Benefit Richness (Induced Demand)

Induced Demand factors are applied to each metallic to reflect the expected utilization, not the

expected health status. To ensure revenue neutrality, a normalization factor is applied. The average

benefit richness factor is shown on Table 7.

Network Factor

Only one network rating factor per market is used for each network. For 2017, we are introducing a

Select Network which features efficient cost providers. There are separate HIOS ID’s for these plans. A

network factor of .95 is applied to these plans to represent the cost savings of the providers in this

network. The average network factor is calculated using the projected enrollment in this Select network

and the .95 network factor.

Service Area Composition

All the counties and services areas are defined in the QHP Service Area Template.

Components of Rate Change

Table 8 shows the components of the Rate Change developed in this filing. Please note, that while Table

8 shows a significant impact of the changes to Profit and/or Contingency, this is due to the approved

rate levels for 2016. The approved rates for 2016 represented an expected “profit” of -22.5%.

Insufficient premium levels cannot continue. For 2017, a large component of the rate change is due to

this item returning to an appropriate level.

Plan Rate Development

The projected market-adjusted index rate is used to develop the calibrated plan adjusted index rates in

columns Z and AA of Table 10. Each plan’s rate is developed as the product of the market-adjusted

index rate, the allowable factor and calibration for age and geography.

Each plan is identified as either discontinued, new or modified. There are no discontinued plans.

Column G lists the metallic tier. This is the value we calculated using the HHS Actuarial Value Calculator.

Screen shots of this calculation are provided in the file “GHP Indiv Screen Shots 20160426.pdf.” The

Actuarial Certification, at the end of this document, includes attestation that the Federal AV calculator

was used to determine the metallic values. Please also refer to the “Unique AV Plan Justification”

documents for further details.

Plan Premium Development for 21-Year-Old Non-Tobacco User

The projected calibrated plan-adjusted index rate is used to develop the 21-year-old non-tobacco

premium in the individual market. These rates are displayed on Table 10.

Consumer Adjusted Premium Rate Development

The Consumer Adjusted Premium Rates are developed by applying the following allowable rating factors

to the calibrated Plan Adjusted Index Rates:

Page 127: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 10 of 11

1. Age – reflecting the HHS defined age curve

2. Geographic – as displayed on the previous page

3. Tobacco status – as discussed below.

The final Premium rates for all filed benefit plans are displayed in the QHP Rating Template.

Composite Rating

Composite rating is not used.

Terminated Plans and Products

No products are being terminated. Terminated plans, if any, are noted on Table 10.

Plan Type

All plan offerings meet the plan type definitions available in the URRT Worksheet 2, Section I.

Warning Alerts

The following Warning Alerts are noted in Worksheet 2 as described below.

Plan Adjusted Index Rate row 55: There is no Plan Adjusted Index Rate for non-ACA plans in the

experience period, however there is significant enrollment in the non-ACA plans, bringing down

the overall average Plan Adjusted Index Rate displayed on Worksheet 2.

Total Premium row 57: The total premium calculated on Worksheet 2 does not represent the

Experience data since non-ACA compliant experience does not have a Plan Adjusted Index Rate

in row 55.

Actuarial Certification

I certify that:

1. I am a member of the American Academy of Actuaries, meet the Qualification Standards for

Actuaries Issuing Statements of Actuarial Opinion in the United States promulgated by the

American Academy of Actuaries, and have the education and experience necessary to perform

this work.

2. The projected Index Rate is:

a. In compliance with all applicable state and Federal regulations including 45 CFR

156.80(d)(1)

b. Developed in compliance with the applicable Actuarial Standards of Practice,

c. Is reasonable in relation to the benefits provided and the population anticipated to be

covered,

d. Is neither excessive nor deficient based on available information.

3. The Index Rate is used to develop the plan level rates using only the allowable modifiers in

accordance with 45 CFR 156.80(d)(1) and 45 CFR 156.80(d)(2).

4. The essential health benefits are determined in accordance with 45 CFR Part 156 and that the

percentage of total premium (in Worksheet 2, Sections III and IV of the URRT) that represents

the essential health benefits is calculated in accordance with actuarial standards of practice.

Page 128: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Revised 5/10/16 Page 11 of 11

5. The geographic rating factors reflect only differences in the costs of delivery and do not include

differences for population morbidity by geographic area.

6. The Federal AV Calculator was utilized, with an acceptable alternative methodology when

appropriate, to determine the AV Metal Values shown above and in Worksheet 2, Section I of

the URRT, following ASOP 50. Please refer to the “Unique AV Plan Justification” document for

further details.

I confirm that the rates submitted comply with the ACA rating requirements and with the Single Risk

Pool per market requirement. The URRT does not demonstrate the process used to develop the rates.

Rather it represents information required by Federal regulation to be provided in support of the review

of rate increases, for certification of Qualified Health Plans for Federally-facilitated Marketplaces, 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 certify that rating factors are limited to:

(i) Age (ratio of highest age rate to lowest age rate does not exceed 3:1, and federally

approved age rating curve).

(ii) Tobacco (ratio does not exceed 1.5:1).

(iii) Family size (will limit charge to first three dependent children under 19 and cost-sharing

requirements for families will be equal to two-times the individual cost-sharing

requirements, per federal law).

(iv) Geography (with federally approved regions).

______________________________

Sarah MacDerment

FSA, MAAA

Attesting Actuary

Page 129: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

3839

40

41

42

43

44

45

46

47

48

49

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: Geisinger Quality Options State: PA

HIOS Issuer ID: 75729 Market: Individual

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: $27,068,053 $332.95 100.00%

Incurred Claims in Experience Period $22,854,568 281.12 84.43%

Allowed Claims: $30,400,740 373.95 112.31%

Index Rate of Experience Period $374.00

Experience Period Member Months 81,297

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 47.09 $16,150.17 $63.37 1.000 1.000 1.048 0.996 46.75 $17,734.41 $69.09 75.29 $18,369.07 $115.25

Outpatient Hospital Services 6,146.53 291.49 149.30 1.000 1.000 1.036 1.065 6,975.48 312.74 181.79 10966.66 280.66 256.49

Professional Services 11,492.28 99.28 95.07 1.000 1.000 1.038 1.003 11,563.65 106.92 103.03 14805.31 118.32 145.98

Other Medical Other 0.00 0.00 0.00 1.000 1.000 1.000 1.000 0.00 0.00 0.00 0.00 0.00 0.00

Capitation Benefit Period 12,000.00 12.26 12.26 1.000 1.000 1.050 1.000 12,000.00 13.51 13.51 12000.00 20.88 20.88

Prescription Drug Scripts 11,312.59 57.22 53.94 1.000 1.000 1.060 1.043 12,296.96 64.23 65.82 21378.69 56.19 100.10

Total $373.95 $433.24 $638.70

After Credibility Projected Period Totals

Section III: Projected Experience: Projected Allowed Experience Claims PMPM (w/applied credibility if applicable) 0.00% 100.00% $638.70 $133,122,552

Paid to Allowed Average Factor in Projection Period 0.767

Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM $489.88 $102,104,998

Projected Risk Adjustments PMPM -0.15 (31,264)

Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM $490.03 $102,136,262

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

Projected Incurred Claims $490.03 $102,136,262

Administrative Expense Load 6.36% 38.11 7,943,063

Profit & Risk Load 5.00% 29.96 6,244,546

Taxes & Fees 6.86% 41.10 8,567,058

Single Risk Pool Gross Premium Avg. Rate, PMPM $599.20 $124,890,929

Index Rate for Projection Period $638.70

% increase over Experience Period 79.97%

% Increase, annualized: 34.15%

Projected Member Months 208,428

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

Page 130: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Product-Plan Data Collection

Company Legal Name: Geisinger Quality Options State: PA

HIOS Issuer ID: 75729 Market: Individual

Effective Date of Rate Change(s):

Product/Plan Level Calculations

Section I: General Product and Plan Information

Product Terminated Products

Product ID: 75729PA003

Metal: Not Applicable Gold Silver Gold Silver Gold Silver Gold Silver Gold Gold Silver Silver Silver Gold Gold Gold Gold Gold Silver

AV Metal Value 0.000 0.818 0.720 0.818 0.720 0.818 0.720 0.818 0.720 0.804 0.804 0.717 0.717 0.720 0.818 0.818 0.818 0.818 0.818 0.720

AV Pricing Value 0.010 1.121 0.872 1.121 0.872 1.121 0.872 1.121 0.872 1.048 1.048 0.824 0.824 0.828 1.065 1.130 1.130 1.130 1.130 0.875

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

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

Plan Name

2015 Experience

Geisinger

Marketplace PPO

25/50/1000

Geisinger

Marketplace PPO

30/50/5000

Geisinger

Marketplace PPO

25/50/1000

Geisinger

Marketplace PPO

30/50/5000

Geisinger

Marketplace PPO

25/50/1000

Geisinger

Marketplace PPO

30/50/5000

Geisinger

Marketplace PPO

25/50/1000

Geisinger

Marketplace PPO

30/50/5000

Geisinger

Marketplace PPO

Extra 10/50/500

Geisinger

Marketplace PPO

Extra 10/50/500

Geisinger

Marketplace PPO

Extra 10/50/3500

Geisinger

Marketplace PPO

Extra 10/50/3500

Geisinger

Marketplace PPO

Select 30/50/5000

Geisinger

Marketplace PPO

Select 25/50/1000

Geisinger

Marketplace PPO

25/50/1000 w/PD

Geisinger

Marketplace PPO

25/50/1000 w/PD

Geisinger

Marketplace PPO

25/50/1000 w/PD

Geisinger

Marketplace PPO

25/50/1000 w/PD

Geisinger

Marketplace PPO

30/50/5000 w/PD

Plan ID (Standard Component ID): 75729PA0030001 75729PA0012596 75729PA0012603 75729PA0012611 75729PA0012612 75729PA0012613 75729PA0012614 75729PA0012615 75729PA0012616 75729PA0012620 75729PA0012621 75729PA0012622 75729PA0012623 75729PA0012624 75729PA0012625 75729PA0012626 75729PA0012627 75729PA0012628 75729PA0012629 75729PA0012630

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

Historical Rate Increase - Calendar Year - 2 0.00%

Historical Rate Increase - Calendar Year - 1 0.00%

Historical Rate Increase - Calendar Year 0 0.00%

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 1/1/2017 1/1/2017 1/1/2017

Rate Change % (over prior filing) 0.00% 40.67% 35.04% 51.99% 45.31% 40.67% 35.04% 39.86% 32.62% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Cum'tive Rate Change % (over 12 mos prior) 0.00% 40.67% 35.04% 51.99% 45.31% 40.67% 35.04% 39.86% 32.62% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Proj'd Per Rate Change % (over Exper. Period) #DIV/0! 108.11% 97.20% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Product Rate Increase % 0.00%

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

Plan ID (Standard Component ID): Total 75729PA0030001 75729PA0012596 75729PA0012603 75729PA0012611 75729PA0012612 75729PA0012613 75729PA0012614 75729PA0012615 75729PA0012616 75729PA0012620 75729PA0012621 75729PA0012622 75729PA0012623 75729PA0012624 75729PA0012625 75729PA0012626 75729PA0012627 75729PA0012628 75729PA0012629 75729PA0012630

Inpatient -$7.81 $0.00 -$22.23 -$15.51 -$23.10 -$16.37 -$22.23 -$15.51 -$21.79 -$14.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Outpatient $19.19 $0.00 $54.61 $38.10 $56.76 $40.22 $54.61 $38.10 $53.53 $35.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Professional -$7.02 $0.00 -$19.97 -$13.93 -$20.76 -$14.71 -$19.97 -$13.93 -$19.58 -$12.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Prescription Drug -$5.54 $0.00 -$15.76 -$10.99 -$16.38 -$11.61 -$15.76 -$10.99 -$15.45 -$10.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Other -$4.98 $0.00 -$14.18 -$9.89 -$14.74 -$10.44 -$14.18 -$9.89 -$13.90 -$9.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Capitation -$0.22 $0.00 -$0.63 -$0.44 -$0.66 -$0.47 -$0.63 -$0.44 -$0.62 -$0.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Administration $2.35 $0.00 $6.68 $4.66 $6.95 $4.92 $6.68 $4.66 $6.55 $4.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Taxes & Fees -$12.73 $0.00 -$36.23 -$25.27 -$37.65 -$26.68 -$36.23 -$25.27 -$35.51 -$23.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Risk & Profit Charge $61.69 $0.00 $175.56 $122.48 $182.46 $129.30 $175.56 $122.48 $172.09 $114.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Total Rate Increase $44.93 $0.00 $127.86 $89.21 $132.89 $94.17 $127.86 $89.21 $125.34 $83.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Member Cost Share Increase $7.54 $0.00 $18.26 $18.26 $18.26 $18.26 $18.26 $18.26 $18.26 $18.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Average Current Rate PMPM $79.73 $314.42 $254.61 $255.62 $207.84 $314.42 $254.61 $314.42 $254.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Projected Member Months 208,428 4,956 35,004 1,464 8,784 1,644 9,804 852 2,616 1,944 10,632 16,860 69,156 6,864 1,344 6,252 696 804 900 4,752

Section III: Experience Period Information

Plan ID (Standard Component ID): Total 75729PA0030001 75729PA0012596 75729PA0012603 75729PA0012611 75729PA0012612 75729PA0012613 75729PA0012614 75729PA0012615 75729PA0012616 75729PA0012620 75729PA0012621 75729PA0012622 75729PA0012623 75729PA0012624 75729PA0012625 75729PA0012626 75729PA0012627 75729PA0012628 75729PA0012629 75729PA0012630

Plan Adjusted Index Rate $135.10 $0.00 $358.95 $294.47

Member Months 81,297 47,721 17,003 16,573

Total Premium (TP) $10,983,478 $0 $6,103,227 $4,880,251 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

EHB Percent of TP, [see instructions] 100.00% 100.00% 100.00% 100.00%

state mandated benefits portion of TP that are other

than EHB 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TP 0.00% 0.00% 0.00% 0.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Total Allowed Claims (TAC) $30,400,740 $12,049,282 $8,331,167 $10,020,291

EHB Percent of TAC, [see instructions] 100.00% 100.00% 100.00% 100.00% state mandated benefits portion of TAC that are other

than EHB 0.00% 0.00% 0.00% 0.00%

Other benefits portion of TAC 0.00% 0.00% 0.00% 0.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Allowed Claims which are not the issuer's obligation: $8,408,773 $2,224,734 $2,555,860 $3,628,180Portion of above payable by HHS's funds on

behalf of insured person, in dollars $1,393,394 $0 $1,393,394Portion of above payable by HHS on behalf

of insured person, as % 16.57% 0.00% 38.40% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Total Incurred claims, payable with issuer funds $21,991,967 $9,824,548 $5,775,307 $6,392,112 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Net Amt of Rein $1,789,404.53 $0.00 $812,351.11 $977,053.42

Net Amt of Risk Adj $862,601.00 $0.00 $391,602.27 $470,998.73

Incurred Claims PMPM $270.51 $205.87 $339.66 $385.69 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Allowed Claims PMPM $373.95 $252.49 $489.98 $604.62 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

EHB portion of Allowed Claims, PMPM $373.95 $252.49 $489.98 $604.62 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Section IV: Projected (12 months following effective date)

Plan ID (Standard Component ID): Total 75729PA0030001 75729PA0012596 75729PA0012603 75729PA0012611 75729PA0012612 75729PA0012613 75729PA0012614 75729PA0012615 75729PA0012616 75729PA0012620 75729PA0012621 75729PA0012622 75729PA0012623 75729PA0012624 75729PA0012625 75729PA0012626 75729PA0012627 75729PA0012628 75729PA0012629 75729PA0012630

Plan Adjusted Index Rate $594.53 $747.01 $580.70 $747.01 $580.70 $747.01 $580.70 $747.01 $580.70 $697.94 $697.94 $549.28 $549.28 $551.66 $709.66 $753.11 $753.11 $753.11 $753.11 $583.06

Member Months 208,428 - 4,956 35,004 1,464 8,784 1,644 9,804 852 2,616 1,944 10,632 16,860 69,156 6,864 1,344 6,252 696 804 900 4,752

Total Premium (TP) $123,916,480 $0 $3,702,174 $20,326,665 $1,093,620 $5,100,829 $1,228,082 $5,693,139 $636,451 $1,519,099 $1,356,798 $7,420,513 $9,260,907 $37,986,197 $3,786,595 $953,779 $4,708,421 $524,162 $605,498 $677,796 $2,770,708

EHB Percent of TP, [see instructions] 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

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% 0.00% 0.00%

Other benefits portion of TP 0.00% 100.00% 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% 0.00% 0.00%

Total Allowed Claims (TAC) $133,122,941 $3,165,397 $22,357,051 $935,057 $5,610,340 $1,050,023 $6,261,814 $544,172 $1,670,839 $1,241,633 $6,790,657 $10,768,480 $44,169,930 $4,384,036 $858,413 $3,993,152 $444,535 $513,515 $574,830 $3,035,102

EHB Percent of TAC, [see instructions] 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

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% 0.00% 0.00%

Other benefits portion of TAC 0.00% 100.00% 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% 0.00% 0.00%

Allowed Claims which are not the issuer's obligation $31,017,645 $737,537 $5,209,193 $217,868 $1,307,209 $244,655 $1,459,003 $126,792 $389,305 $289,300 $1,582,223 $2,509,056 $10,291,594 $1,021,480 $200,010 $930,404 $103,577 $119,649 $133,935 $707,179

1/1/2017

PPO Individual Products

75729PA001

0.00%

13.60%

20.00%

37.23%

Page 131: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Portion of above payable by HHS's funds on

behalf of insured person, in dollars $1,393,394 $0 $327,152 $0 $82,096 $0 $91,629 $0 $24,449 $0 $0 $157,576 $646,340 $64,152 $0

Portion of above payable by HHS on behalf

of insured person, as % 4.49% 0.00% 6.28% 0.00% 6.28% 0.00% 6.28% 0.00% 6.28% 0.00% 0.00% 6.28% 6.28% 6.28% 0.00%

Total Incurred claims, payable with issuer funds $102,105,296 $0 $2,427,859 $17,147,858 $717,188 $4,303,131 $805,367 $4,802,811 $417,380 $1,281,533 $952,332 $5,208,434 $8,259,424 $33,878,336 $3,362,556 $658,403 $3,062,747 $340,958 $393,866 $440,895 $2,327,923

Net Amt of Rein $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Net Amt of Risk Adj $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Page 132: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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

1

Geisinger Quality Options – Individual Plans Rate request filing ID # GSHP-130558343 - 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: 40.7% Range of requested rate change: 35%-73% Effective date: 1/1/2017 People impacted: 6,314 Available in: Rating Areas 2, 3, 5, 6, 7 and 9

Key information Jan. 2015-Dec. 2015 financial experience

Premiums $30,294,687 Claims $27,191,521 Administrative expenses $4,578,074

Company made (before taxes) -$1,474,908

NOTE: The preceding financial data includes both ACA and non-ACA data and will differ from the ACA Filing experience period data. The company expects its annual medical costs to increase 7.5%.

Explanation of requested rate change

Geisinger Quality Options has proposed an overall base rate increase of 40.7% for Individual PPO members renewing in the Marketplace effective January 1, 2017 through December 1, 2017. The range of proposed rate increases vary from a minimum of 35.0% to a maximum of 73.0%. The overall increase is largely due to the claims experience in ACA compliant individual market plans being much higher than what was assumed in current rates. Other contributing factors include annual claims trend, federally-prescribed ACA fees and changes in the federal risk-adjustment program. The total projected 2017 administrative costs are slightly higher than those used for the current 2016 rates. As required by federal regulations and using the federally-prescribed MLR methodology, the projected loss ratio exceeds 80%. There were minimal benefit changes proposed for 2017.

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

Claims: 81.8% Administrative: 6.4% Taxes & fees: 6.9% Risk Margin: 5.0%

Page 133: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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 81,297 6,314 208,428

<18 13,158 520 17,165

18-24 6,480 436 14,393

25-29 8,576 449 14,822

30-34 8,755 453 14954

35-39 6,545 404 13336

40-44 7,105 474 15647

45-49 7,650 628 20731

50-54 7,551 777 25649

55-59 6,949 950 31359

60-63 6,468 928 30634

64+ 2,060 295 9738

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

$ 26,205,451.58 $ 23,288,408.31 $ 24,113,896.60 81,297 $ 4,363,372.99 $ 29,870,663.99 $ - $ (466,344.42) $ 996,420.15 $ - 862,601.00$ 1,789,404.53$

2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 373.95$

Loss Ratio 84.43%

*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Composite Weight*

4.79% -0.36% 4.41% 19.34% <- Annualized Trend Factors on URRT

3.58% 6.53% 10.34% 38.52%

3.78% 0.31% 4.10% 24.58%

0.00% 0.00% 0.00% 0.00%

5.00% 3.11%

5.95% 4.26% 10.46% 14.46%

7.51% 100.00%

1.156

* 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 $ 1,628,988.05 1.0000 $ 1,628,988.05 8,691 $ 187.43 $ (7,275.30) $ 2,091,501.06 $ 240.65

Feb-13 $ 1,660,137.17 1.0000 $ 1,660,137.17 8,807 $ 188.50 $ (7,785.63) $ 2,082,737.85 $ 236.49

Mar-13 $ 1,712,035.88 1.0000 $ 1,712,035.88 8,976 $ 190.73 $ (7,320.54) $ 2,156,904.73 $ 240.30

Apr-13 $ 2,006,793.32 1.0000 $ 2,006,793.32 9,196 $ 218.22 $ (9,123.14) $ 2,544,469.12 $ 276.69

May-13 $ 1,883,574.26 1.0000 $ 1,883,574.26 9,365 $ 201.13 $ (10,631.73) $ 2,366,600.00 $ 252.71

Jun-13 $ 1,627,941.53 1.0000 $ 1,627,941.53 9,544 $ 170.57 $ (7,704.76) $ 2,066,931.82 $ 216.57

Jul-13 $ 1,688,734.43 1.0000 $ 1,688,734.43 9,536 $ 177.09 $ (7,913.23) $ 2,125,484.66 $ 222.89

Aug-13 $ 1,845,234.93 1.0000 $ 1,845,234.93 9,615 $ 191.91 $ (7,284.57) $ 2,279,119.48 $ 237.04

Sep-13 $ 2,039,757.70 1.0000 $ 2,039,757.70 9,581 $ 212.90 $ (6,540.76) $ 2,463,508.39 $ 257.12

Oct-13 $ 2,028,814.56 1.0000 $ 2,028,814.56 9,595 $ 211.44 $ (8,151.75) $ 2,506,498.45 $ 261.23

Nov-13 $ 1,769,229.97 1.0000 $ 1,769,229.97 9,480 $ 186.63 $ (7,932.21) $ 2,202,039.51 $ 232.28

Dec-13 $ 1,399,030.23 1.0000 $ 1,399,030.23 9,499 $ 147.28 $ (7,797.07) $ 1,820,729.53 $ 191.68

Jan-14 $ 1,747,841.96 1.0000 $ 1,747,841.96 9,475 $ 184.47 $ (12,794.19) $ 2,223,527.61 $ 234.67

Feb-14 $ 2,028,803.83 1.0000 $ 2,028,803.83 9,394 $ 215.97 $ (13,041.34) $ 2,427,248.05 $ 258.38

Mar-14 $ 2,390,548.88 1.0000 $ 2,390,548.88 9,447 $ 253.05 $ (16,730.28) $ 2,852,072.55 $ 301.90

Apr-14 $ 2,470,151.17 1.0000 $ 2,470,151.17 9,630 $ 256.51 $ (23,296.16) $ 2,982,870.78 $ 309.75

May-14 $ 2,920,716.81 1.0000 $ 2,920,716.81 9,880 $ 295.62 $ (27,021.06) $ 3,439,403.19 $ 348.12

Jun-14 $ 3,210,446.37 1.0000 $ 3,210,446.37 9,818 $ 327.00 $ (29,808.04) $ 3,667,123.79 $ 373.51

Jul-14 $ 2,970,965.66 1.0000 $ 2,970,965.66 9,819 $ 302.57 $ (31,502.63) $ 3,462,597.68 $ 352.64

Aug-14 $ 2,864,935.40 1.0000 $ 2,864,935.40 9,797 $ 292.43 $ (29,356.25) $ 3,292,357.59 $ 336.06

Sep-14 $ 3,085,138.19 1.0000 $ 3,085,138.19 9,759 $ 316.13 $ (32,264.23) $ 3,530,519.69 $ 361.77

Oct-14 $ 4,052,907.62 1.0000 $ 4,052,907.62 9,678 $ 418.78 $ (40,007.40) $ 4,502,585.70 $ 465.24

Nov-14 $ 2,919,245.31 1.0000 $ 2,919,245.31 9,600 $ 304.09 $ (34,899.76) $ 3,306,068.38 $ 344.38

Dec-14 $ 2,705,233.13 1.0000 $ 2,705,233.13 9,319 $ 290.29 $ (46,528.78) $ 3,117,012.42 $ 334.48

Jan-15 $ 2,352,030.74 1.0000 $ 2,352,030.74 7,815 $ 300.96 $ (45,812.20) $ 2,872,202.68 $ 367.52

Feb-15 $ 1,923,767.71 0.9893 $ 1,944,513.57 7,437 $ 261.46 $ (45,713.16) $ 2,360,293.80 $ 317.37

Mar-15 $ 2,403,185.73 0.9946 $ 2,416,300.88 7,207 $ 335.27 $ (40,914.97) $ 2,873,579.22 $ 398.72

Apr-15 $ 2,119,415.95 0.9348 $ 2,267,282.47 7,048 $ 321.69 $ (40,324.61) $ 2,712,870.75 $ 384.91

May-15 $ 2,100,952.11 0.9975 $ 2,106,148.86 6,936 $ 303.65 $ (46,392.48) $ 2,500,229.95 $ 360.47

Jun-15 $ 1,870,234.00 0.9954 $ 1,878,911.85 6,804 $ 276.15 $ (38,494.93) $ 2,234,527.12 $ 328.41

Jul-15 $ 2,049,712.56 0.9939 $ 2,062,228.48 6,697 $ 307.93 $ (34,514.91) $ 2,387,260.86 $ 356.47

Aug-15 $ 2,070,106.52 0.9898 $ 2,091,459.56 6,596 $ 317.08 $ (35,579.67) $ 2,411,781.60 $ 365.64

Sep-15 $ 1,997,899.47 0.9828 $ 2,032,827.44 6,467 $ 314.34 $ (32,409.96) $ 2,320,401.89 $ 358.81

Oct-15 $ 2,035,523.03 0.9714 $ 2,095,368.95 6,337 $ 330.66 $ (39,077.35) $ 2,399,385.58 $ 378.63

Nov-15 $ 1,694,060.42 0.8992 $ 1,884,013.68 6,046 $ 311.61 $ (35,826.33) $ 2,148,632.29 $ 355.38

Dec-15 $ 1,598,570.05 0.8370 $ 1,909,860.10 5,907 $ 323.32 $ (31,283.85) $ 2,183,153.83 $ 369.59

* Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

$ 5,416,252.57

$ 5,436,453.10

$ 4,363,372.99

$ 25,943,796.12

$ 33,029,826.72

$ 27,068,052.58

2 Year Trend Projection Factor

Service Category

Other Medical

Capitation

Prescription Drugs

Total Annual Trend

Inpatient Hospital

Outpatient Hospital

Professional

Page 134: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Table 2b. Experience Period Claims and Premiums

Earned

PremiumPaid Claims

Ultimate

Incurred

Claims

Member

Months

Estimated Cost

Sharing

(Member & HHS)

Allowed Claims

(Non-

Capitated)

########## ############ ############ 275,313 $ 17,450,668.19 #############

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

Loss Ratio

*Express Prescription Drug Rebates as a negative number

Table 3b. Trend Components

Cost* Utilization* Composite Weight*

0.00%

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

Jan-13 ############ 1.0000 $ 22,695,090.54 80,447

Capitation

Service Category

Inpatient Hospital

Outpatient Hospital

Professional

Other Medical

Prescription Drugs

Total Annual Trend

2 Year Trend Projection

############

Page 135: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Feb-13 ############ 1.0000 $ 21,433,439.46 80,937

Mar-13 ############ 1.0000 $ 21,616,966.63 80,241

Apr-13 ############ 1.0000 $ 24,320,389.95 80,438

May-13 ############ 1.0000 $ 24,024,938.01 80,305

Jun-13 ############ 1.0000 $ 22,438,275.16 80,447

Jul-13 ############ 1.0000 $ 24,993,952.69 78,469

Aug-13 ############ 1.0000 $ 23,553,520.75 76,741

Sep-13 ############ 1.0000 $ 21,406,514.22 76,967

Oct-13 ############ 1.0000 $ 25,044,176.57 77,482

Nov-13 ############ 1.0000 $ 23,269,234.30 77,101

Dec-13 ############ 1.0000 $ 22,925,776.02 76,028

Jan-14 ############ 1.0000 $ 20,773,948.84 68,741

Feb-14 ############ 1.0000 $ 20,115,144.84 67,935

Mar-14 ############ 1.0000 $ 20,850,982.61 68,243

Apr-14 ############ 1.0000 $ 20,732,511.05 66,874

May-14 ############ 1.0000 $ 22,156,047.67 66,683

Jun-14 ############ 1.0000 $ 19,887,271.92 65,662

Jul-14 ############ 1.0000 $ 20,111,613.96 63,870

Aug-14 ############ 1.0000 $ 20,420,802.25 64,580

Sep-14 ############ 1.0000 $ 20,448,422.38 63,385

Oct-14 ############ 1.0000 $ 21,476,580.20 63,333

Nov-14 ############ 1.0000 $ 19,072,183.03 63,372

Dec-14 ############ 1.0000 $ 19,670,307.24 63,098

Jan-15 ############ 1.0000 $ 21,011,628.02 61,836

Feb-15 ############ 0.9856 $ 18,909,978.30 62,630

Mar-15 ############ 0.9967 $ 22,172,977.14 61,974

Apr-15 ############ 0.9986 $ 21,055,913.04 61,331

May-15 ############ 0.9981 $ 20,719,008.53 60,676

Jun-15 ############ 0.9974 $ 19,619,772.54 59,632

Jul-15 ############ 0.9925 $ 20,798,317.92 58,878

Aug-15 ############ 0.9680 $ 18,662,681.01 58,991

Sep-15 ############ 0.9868 $ 19,897,521.98 59,978

Oct-15 ############ 0.9597 $ 22,013,595.61 60,674

Nov-15 ############ 0.9413 $ 20,183,174.16 60,275

Dec-15 ############ 0.8997 $ 21,803,230.42 60,104 * Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

############

############

############

Page 136: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Non-EHB

portion of

Allowed

Claims

Total

Prescription

Drug

Rebates*

Total EHB

Capitation

Total Non-EHB

Capitation

Estimated Risk

Adjustment

Estimated

Reinsurance

Recoveries

$ - ########### ########### $ - 11,596,083.00$ 11,319,647.53$

536.20$

97.51%

<- Annualized Trend Factors on URRT

Ultimate

Incurred

PMPM

Estimated

Annual Cost

Sharing

(Member +

HHS)

Prescription

Drug

Rebates**

Allowed

Claims (Net of

Prescription

Drug Rebates)

Allowed PMPM

$ 282.11 ########### ############ $ 339.72

###########

Page 137: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

$ 264.82 ########### ############ $ 316.43

$ 269.40 ########### ############ $ 321.70

$ 302.35 ########### ############ $ 355.45

$ 299.17 ########### ############ $ 352.18

$ 278.92 ########### ############ $ 325.26

$ 318.52 ########### ############ $ 371.66

$ 306.92 ########### ############ $ 356.91

$ 278.13 ########### ############ $ 328.11

$ 323.23 ########### ############ $ 377.76

$ 301.80 ########### ############ $ 348.48

$ 301.54 ########### ############ $ 347.85

$ 302.21 ########### ############ $ 360.69

$ 296.09 ########### ############ $ 346.83

$ 305.54 ########### ############ $ 359.65

$ 310.02 ########### ############ $ 364.03

$ 332.26 ########### ############ $ 382.90

$ 302.87 ########### ############ $ 351.73

$ 314.88 ########### ############ $ 365.65

$ 316.21 ########### ############ $ 364.59

$ 322.61 ########### ############ $ 372.04

$ 339.11 ########### ############ $ 393.92

$ 300.96 ########### ############ $ 345.44

$ 311.74 ########### ############ $ 359.96

$ 339.80 ########### ############ $ 399.20

$ 301.93 ########### ############ $ 357.03

$ 357.78 ########### ############ $ 416.60

$ 343.32 ########### ############ $ 398.85

$ 341.47 ########### ############ $ 393.41

$ 329.01 ########### ############ $ 382.16

$ 353.24 ########### ############ $ 406.43

$ 316.36 ########### ############ $ 367.32

$ 331.75 ########### ############ $ 383.35

$ 362.82 ########### ############ $ 417.67

$ 334.85 ########### ############ $ 385.73

$ 362.76 ########### ############ $ 418.00 ###########

###########

###########

Page 138: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Table 2c. Experience Period Claims and Premiums

Earned

PremiumPaid Claims

Ultimate

Incurred Claims

Member

Months

Estimated Cost

Sharing

(Member &

HHS)

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

Loss Ratio

*Express Prescription Drug Rebates as a negative number

Page 139: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59
Page 140: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Allowed

Claims (Non-

Capitated)

Non-EHB

portion of

Allowed

Claims

Total

Prescription

Drug Rebates*

Total EHB

Capitation

Total Non-

EHB

Capitation

Estimated Risk

Adjustment

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

Page 141: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59
Page 142: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Estimated

Reinsurance

Recoveries

#DIV/0!

#DIV/0!

Page 143: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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) 546.62$ <- Index Rate of Experience Period on URRT Table 5A. Small Group Projected Index Rate with Quarterly Trend 2 Year Trend Projection Factor 1.157

Unadjusted Projected Allowed EHB Claims PMPM 632.36$ 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 -

Change in Morbidity 1.000 <- Adj't. from Experience to Projection Period - Other on URRT Percent of Members Months Renewing in Quarter #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Change in Other 1.010 Base Allowed Claims 638.70$ 638.70$ 638.70$ 638.70$ 638.70$

Change in Demographics 1.000 Months of Trend - 3 6 9 #DIV/0!

Change in Network 1.000 Annual Trend 7.51% 7.51% 7.51% 7.51% 7.51%

Change in Benefits 1.010 Single Risk Pool Projected Allowed Claims 638.70$ 650.37$ 662.26$ 674.37$ -$

Change in Other 1.000

Adjusted Projected Allowed EHB Claims PMPM 638.70$ <- 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] -$ <- Index Rate for Projection Period on URRT - Small Group

Projected Paid to Allowed Ratio 0.767 <- Paid to Allowed Average Factor in Projection Period on URRT

Projected Paid EHB Claims PMPM 489.8828165

Market-wide Adjustments

Projected Paid Net Risk Adjustment PMPM 0.15$

Projected Paid Exchange User Fees PMPM 20.97$

Market-Adjusted Projected Paid EHB Claims PMPM 511.00$

Market-Adjusted Projected Allowed EHB Claims PMPM 666.24$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM -$

Market-Adjusted Projected Paid Total Claims PMPM 511.00$

Market-Adjusted Projected Allowed Total Claims PMPM 666.24$

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

Retention Items - Express in percentages Normalization Factors 2016 2017

Administrative Expenses 6% Average Age Factor 1.633 1.776

General and Claims 4.08% Average Geographic Factor 0.977 0.951

Agent/Broker Fees and Commissions 0.26% Average Tobacco Factor 1.011 1.010

Quality Improvement Initiatives 2.02% Average Benefit Richness (induced demand) 0.841 0.797

Taxes and Fees 3.36% Average Network Factor 1.000 1.002

PCORI Fees (Enter $ amount here: $______________ ) 0.03%

Pa Premium Tax (if applicable) 0.00% Market-Adjusted Projected Allowed Total Claims PMPM 611.69$ 666.24$

Federal Income Tax 3.33%

Health Insurance Providers Fee (only for small group market, prorated for coverage in 2018) 0.00% Normalized Market-Adjusted Projected Allowed Total Claims PMPM 450.92$ 489.05$

Profit/Contingency 5%

Total Retention 15%

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

Projected Required Revenue PMPM 599.21$

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) 263.0518166 370.0622739 $107.01 40.7% Paid-to-Allowed 0.751 0.767

B. Base period allowed claims before normalization 558.92$ 546.62$ -$12.30 -5% URRT Trend (2-Year Trend Factor) 1.1474 1.16 <- URRT W1, S2

C. Normalization factor component of change (146.90)$ -145.3703905 $1.53 $0.01 URRT Morbidity 1 1.000 <- URRT W1, S2

URRT "Other" 1 1.010 <- URRT W1, S2

D. Change in Normalized Allowed Claims Adjustment Components D1. Base period allowed claims after normalization 412.02$ 401.25$ (10.77)$ -4% Risk Adjustment (23.52)$ 0.15$ <- URRT W1, S3

D2. URRT Trend 60.73$ 62.57$ 1.83$ 1% Reinsurance (15.09)$ -$ <- URRT W1, S3

D3. URRT Morbidity -$ -$ -$ 0% Exchange User Fee 12.58$ 20.97$ <- URRT W1, S3

D4. URRT Other -$ 4.65$ 4.65$ 2% Capitation 21.29$ 12.26$ <- URRT W1, S2

D5. Normalized URRT RA/RI on an allowed basis (37.90)$ 0.14$ 38.04$ 14% D6. Normalized Exchange User Fee on an allowed basis 12.35$ 20.07$ 7.72$ 3% Network 0.969 1.00438476 D7. Subtotal - Sum(D1:D6) 447.20$ 488.68$ 41.48$ 16% Pricing AV 0.783 0.797415017

E. Change in Allowable Plan Adjusted Level Components Benefit Richness 0.848 0.80316006 E1. Network (13.86)$ 2.142745561 16.01$ 6% Catastrophic Eligibility 1.000 1 E2. Pricing AV (94.04)$ (99.43)$ (5.40)$ -2% E3. Benefit Richness (51.57)$ (77.04)$ (25.47)$ -10% Administrative Expenses 8.62% 6.36% E4. Catastrophic Eligibility -$ -$ -$ 0% Taxes and Fees 6.30% 3.36% E5. Subtotal - Sum(E1:E4) (159.47)$ (174.33)$ (14.86)$ -6% Profit and/or Contingency -19.80% 5.00%F. Change in Retention Components

F1. Administrative Expenses 22.68$ 23.54$ 0.86$ 0% F2. Taxes and Fees 16.57$ 12.43$ (4.14)$ -2% F3. Profit and/or Contingency (52.08)$ 18.50$ 70.59$ 27% F4. Subtotal - Sum(F1:F3) (12.84)$ 54.47$ 67.31$ 26%

G. Change in Miscellaneous Items -$ -$ -$ 0%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 274.89$ 368.82$ 93.93$ 36%

Page 144: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

PA Rate Template Part IIITable 10. Plan Rates

Carrier Name: Geisinger Quality Options

Plan Type(s): PPO

Market Segment: Individual

Rate Effective Date: 1/1/2017

Market Adjusted Index Rate 666.24$

Plan Number HIOS Plan ID (Standard Component)

Plan Type

(HMO, POS, PPO, EPO,

Indemnity, Other)

Totals

Plan 1 75729PA0012596 PPO

Plan 2 75729PA0012603 PPO

Plan 3 75729PA0012611 PPO

Plan 4 75729PA0012612 PPO

Plan 5 75729PA0012613 PPO

Plan 6 75729PA0012614 PPO

Plan 7 75729PA0012615 PPO

Plan 8 75729PA0012616 PPO

Plan 9 75729PA0012620 PPO

Plan 10 75729PA0012621 PPO

Plan 11 75729PA0012622 PPO

Plan 12 75729PA0012623 PPO

Plan 13 75729PA0012624 PPO

Plan 14 75729PA0012625 PPO

Plan 15 75729PA0012626 PPO

Plan 16 75729PA0012627 PPO

Plan 17 75729PA0012628 PPO

Plan 18 75729PA0012629 PPO

Plan 19 75729PA0012630 PPO

Plan 20 75729PA0012631 PPO

Plan 21 75729PA0012632 PPO

Plan 22 75729PA0012633 PPO

Plan 23 75729PA0012634 PPO

Plan 24 75729PA0012635 PPO

Plan 25 75729PA0012636 PPO

Plan 26 75729PA0012637 PPO

Plan 27 75729PA0012638 PPO

Plan 28 75729PA0012639 PPO

Page 145: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Plan 29

Plan 30

Plan 31

Plan 32

Plan 33

Plan 34

Plan 35

Plan 36

Plan 37

Plan 38

Plan 39

Plan 40

Plan 41

Plan 42

Plan 43

Plan 44

Plan 45

Plan 46

Plan 47

Plan 48

Plan 49

Plan 50

Plan 51

Plan 52

Plan 53

Plan 54

Plan 55

Plan 56

Plan 57

Plan 58

Plan 59

Plan 60

Plan 61

Plan 62

Plan 63

Plan 64

Plan 65

Plan 66

Plan 67

Plan 68

Plan 69

Plan 70

Plan 71

Plan 72

Plan 73

Plan 74

Plan 75

Page 146: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Plan 76

Plan 77

Plan 78

Plan 79

Plan 80

Plan 81

Plan 82

Plan 83

Plan 84

Plan 85

Plan 86

Plan 87

Plan 88

Plan 89

Plan 90

Plan 91

Plan 92

Plan 93

Plan 94

Plan 95

Plan 96

Plan 97

Plan 98

Plan 99

Plan 100

Page 147: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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

0.746

Geisinger Choice Markeptlace PPO 25/50/1000Modified Geisinger Marketplace PPO 25/50/1000Gold 0.8175

Geisinger Choice Marketplace PPO 30/50/5000Modified Geisinger Marketplace PPO 30/50/5000Silver 0.7196

Geisinger Choice Markeptlace PPO 25/50/1000Modified Geisinger Marketplace PPO 25/50/1000Gold 0.8175

Geisinger Choice Marketplace PPO 30/50/5000Modified Geisinger Marketplace PPO 30/50/5000Silver 0.7196

Geisinger Choice Markeptlace PPO 25/50/1000Modified Geisinger Marketplace PPO 25/50/1000Gold 0.8175

Geisinger Choice Marketplace PPO 30/50/5000Modified Geisinger Marketplace PPO 30/50/5000Silver 0.7196

Geisinger Choice Markeptlace PPO 25/50/1000Modified Geisinger Marketplace PPO 25/50/1000Gold 0.8175

Geisinger Choice Marketplace PPO 30/50/5000Modified Geisinger Marketplace PPO 30/50/5000Silver 0.7196

New Geisinger Marketplace PPO Extra 10/50/500Gold 0.804

New Geisinger Marketplace PPO Extra 10/50/500Gold 0.804

New Geisinger Marketplace PPO Extra 10/50/3500Silver 0.7165

New Geisinger Marketplace PPO Extra 10/50/3500Silver 0.7165

New Geisinger Marketplace PPO Select 30/50/5000Silver 0.7196

New Geisinger Marketplace PPO Select 25/50/1000Gold 0.8175

New Geisinger Marketplace PPO 25/50/1000 w/PDGold 0.8175

New Geisinger Marketplace PPO 25/50/1000 w/PDGold 0.8175

New Geisinger Marketplace PPO 25/50/1000 w/PDGold 0.8175

New Geisinger Marketplace PPO 25/50/1000 w/PDGold 0.8175

New Geisinger Marketplace PPO 30/50/5000 w/PDSilver 0.7196

New Geisinger Marketplace PPO 30/50/5000 w/PDSilver 0.7196

New Geisinger Marketplace PPO 30/50/5000 w/PDSilver 0.7196

New Geisinger Marketplace PPO 30/50/5000 w/PDSilver 0.7196

New Geisinger Marketplace PPO Extra 10/50/500 w/PDGold 0.804

New Geisinger Marketplace PPO Extra 10/50/500 w/PDGold 0.804

New Geisinger Marketplace PPO Extra 10/50/3500 w/PDSilver 0.7165

New Geisinger Marketplace PPO Extra 10/50/3500 w/PDSilver 0.7165

New Geisinger Marketplace PPO Select 30/50/5000 w/PDSilver 0.7196

New Geisinger Marketplace PPO Select 25/50/1000 w/PDGold 0.8175

Page 148: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59
Page 149: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59
Page 150: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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

0.797 1.008 1.000 1.002

Approach (1) On/Off 0.871 1.106 1.000 1.002

Approach (1) On/Off 0.771 0.972 1.000 1.002

Approach (1) On/Off 0.871 1.106 1.000 1.002

Approach (1) On/Off 0.771 0.972 1.000 1.002

Approach (1) On/Off 0.871 1.106 1.000 1.002

Approach (1) On/Off 0.771 0.972 1.000 1.002

Approach (1) On/Off 0.871 1.106 1.000 1.002

Approach (1) On/Off 0.771 0.972 1.000 1.002

Approach (1) On/Off 0.814 1.106 1.000 1.002

Approach (1) On/Off 0.814 1.106 1.000 1.002

Approach (1) On/Off 0.729 0.972 1.000 1.002

Approach (1) On/Off 0.729 0.972 1.000 1.002

Approach (1) On/Off 0.771 0.972 1.000 0.952

Approach (1) On/Off 0.871 1.106 1.000 0.952

Approach (1) Off 0.878 1.106 1.000 1.002

Approach (1) Off 0.878 1.106 1.000 1.002

Approach (1) Off 0.878 1.106 1.000 1.002

Approach (1) Off 0.878 1.106 1.000 1.002

Approach (1) Off 0.774 0.972 1.000 1.002

Approach (1) Off 0.774 0.972 1.000 1.002

Approach (1) Off 0.774 0.972 1.000 1.002

Approach (1) Off 0.774 0.972 1.000 1.002

Approach (1) Off 0.817 1.106 1.000 1.002

Approach (1) Off 0.817 1.106 1.000 1.002

Approach (1) Off 0.732 0.972 1.000 1.002

Approach (1) Off 0.732 0.972 1.000 1.002

Approach (1) Off 0.735 0.972 1.000 0.952

Approach (1) Off 0.834 1.106 1.000 0.952

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

Page 151: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59
Page 152: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59
Page 153: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Age Calibration Factor 1.776

Geographic Calibration Factor 0.951

Aggregate Calibration Factor 1.689

Catastrophic

Eligibility

Tobacco

Surcharge

Adjustment

Pure

Premium Admin Costs

Taxes & Fees (not

including Exchange

fees)

Profit or

Contingency

1.000 0.990 533.02$ 6.4% 3.4% 5.0%

1.000 0.990 $637.05 6.4% 3.4% 5.0%

1.000 0.990 $495.22 6.4% 3.4% 5.0%

1.000 0.990 $637.05 6.4% 3.4% 5.0%

1.000 0.990 $495.22 6.4% 3.4% 5.0%

1.000 0.990 $637.05 6.4% 3.4% 5.0%

1.000 0.990 $495.22 6.4% 3.4% 5.0%

1.000 0.990 $637.05 6.4% 3.4% 5.0%

1.000 0.990 $495.22 6.4% 3.4% 5.0%

1.000 0.990 $595.20 6.4% 3.4% 5.0%

1.000 0.990 $595.20 6.4% 3.4% 5.0%

1.000 0.990 $468.43 6.4% 3.4% 5.0%

1.000 0.990 $468.43 6.4% 3.4% 5.0%

1.000 0.990 $470.46 6.4% 3.4% 5.0%

1.000 0.990 $605.20 6.4% 3.4% 5.0%

1.000 0.990 $642.25 6.4% 3.4% 5.0%

1.000 0.990 $642.25 6.4% 3.4% 5.0%

1.000 0.990 $642.25 6.4% 3.4% 5.0%

1.000 0.990 $642.25 6.4% 3.4% 5.0%

1.000 0.990 $497.23 6.4% 3.4% 5.0%

1.000 0.990 $497.23 6.4% 3.4% 5.0%

1.000 0.990 $497.23 6.4% 3.4% 5.0%

1.000 0.990 $497.23 6.4% 3.4% 5.0%

1.000 0.990 $597.63 6.4% 3.4% 5.0%

1.000 0.990 $597.63 6.4% 3.4% 5.0%

1.000 0.990 $470.34 6.4% 3.4% 5.0%

1.000 0.990 $470.34 6.4% 3.4% 5.0%

1.000 0.990 $448.75 6.4% 3.4% 5.0%

1.000 0.990 $579.63 6.4% 3.4% 5.0%

Calibration

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

Page 154: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

$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

$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

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

Page 155: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

$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

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

Page 156: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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

6,314 4,380 263.05$ 370.06$ 40.68%

1,081 673 314.42$ $442.28 40.7%

2,802 1,968 254.61$ $343.82 35.0%

185 132 255.62$ $442.28 73.0%

780 601 207.84$ $343.82 65.4%

271 173 314.42$ $442.28 40.7%

889 604 254.61$ $343.82 35.0%

146 99 314.42$ $442.28 40.7%

160 130 254.61$ $343.82 35.0%

- - -$ $413.23 #DIV/0!

- - -$ $413.23 #DIV/0!

- - -$ $325.22 #DIV/0!

- - -$ $325.22 #DIV/0!

- - -$ $326.62 #DIV/0!

- - -$ $420.17 #DIV/0!

- - -$ $445.90 #DIV/0!

- - -$ $445.90 #DIV/0!

- - -$ $445.90 #DIV/0!

- - -$ $445.90 #DIV/0!

- - -$ $345.22 #DIV/0!

- - -$ $345.22 #DIV/0!

- - -$ $345.22 #DIV/0!

- - -$ $345.22 #DIV/0!

- - -$ $414.91 #DIV/0!

- - -$ $414.91 #DIV/0!

- - -$ $326.54 #DIV/0!

- - -$ $326.54 #DIV/0!

- - -$ $311.56 #DIV/0!

- - -$ $402.42 #DIV/0!

Page 157: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

Page 158: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

- $0.00 #DIV/0!

Page 159: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

% of Total

Covered Lives

17.1%

44.4%

2.9%

12.4%

4.3%

14.1%

2.3%

2.5%

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%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

Page 160: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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%

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%

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%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

Page 161: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

0.0%

Page 162: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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

Carrier Name: Geisinger Quality Options

Plan Type(s): PPO

Market Segment: Individual

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

Totals

Plan 1 75729PA0012596 Geisinger Choice Markeptlace PPO 25/50/1000Modified

Plan 2 75729PA0012603 Geisinger Choice Marketplace PPO 30/50/5000Modified

Plan 3 75729PA0012611 Geisinger Choice Markeptlace PPO 25/50/1000Modified

Plan 4 75729PA0012612 Geisinger Choice Marketplace PPO 30/50/5000Modified

Plan 5 75729PA0012613 Geisinger Choice Markeptlace PPO 25/50/1000Modified

Plan 6 75729PA0012614 Geisinger Choice Marketplace PPO 30/50/5000Modified

Plan 7 75729PA0012615 Geisinger Choice Markeptlace PPO 25/50/1000Modified

Plan 8 75729PA0012616 Geisinger Choice Marketplace PPO 30/50/5000Modified

Plan 9 75729PA0012620 0 New

Plan 10 75729PA0012621 0 New

Plan 11 75729PA0012622 0 New

Plan 12 75729PA0012623 0 New

Plan 13 75729PA0012624 0 New

Plan 14 75729PA0012625 0 New

Plan 15 75729PA0012626 0 New

Plan 16 75729PA0012627 0 New

Plan 17 75729PA0012628 0 New

Plan 18 75729PA0012629 0 New

Plan 19 75729PA0012630 0 New

Plan 20 75729PA0012631 0 New

Plan 21 75729PA0012632 0 New

Plan 22 75729PA0012633 0 New

Plan 23 75729PA0012634 0 New

Plan 24 75729PA0012635 0 New

Plan 25 75729PA0012636 0 New

Plan 26 75729PA0012637 0 New

Plan 27 75729PA0012638 0 New

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

Page 163: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Plan 28 75729PA0012639 0 New

Plan 29 0 0 0

Plan 30 0 0 0

Plan 31 0 0 0

Plan 32 0 0 0

Plan 33 0 0 0

Plan 34 0 0 0

Plan 35 0 0 0

Plan 36 0 0 0

Plan 37 0 0 0

Plan 38 0 0 0

Plan 39 0 0 0

Plan 40 0 0 0

Plan 41 0 0 0

Plan 42 0 0 0

Plan 43 0 0 0

Plan 44 0 0 0

Plan 45 0 0 0

Plan 46 0 0 0

Plan 47 0 0 0

Plan 48 0 0 0

Plan 49 0 0 0

Plan 50 0 0 0

Plan 51 0 0 0

Plan 52 0 0 0

Plan 53 0 0 0

Plan 54 0 0 0

Plan 55 0 0 0

Plan 56 0 0 0

Plan 57 0 0 0

Plan 58 0 0 0

Plan 59 0 0 0

Plan 60 0 0 0

Plan 61 0 0 0

Plan 62 0 0 0

Plan 63 0 0 0

Plan 64 0 0 0

Plan 65 0 0 0

Plan 66 0 0 0

Plan 67 0 0 0

Plan 68 0 0 0

Plan 69 0 0 0

Plan 70 0 0 0

Plan 71 0 0 0

Plan 72 0 0 0

Plan 73 0 0 0

Plan 74 0 0 0

Page 164: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Plan 75 0 0 0

Plan 76 0 0 0

Plan 77 0 0 0

Plan 78 0 0 0

Plan 79 0 0 0

Plan 80 0 0 0

Plan 81 0 0 0

Plan 82 0 0 0

Plan 83 0 0 0

Plan 84 0 0 0

Plan 85 0 0 0

Plan 86 0 0 0

Plan 87 0 0 0

Plan 88 0 0 0

Plan 89 0 0 0

Plan 90 0 0 0

Plan 91 0 0 0

Plan 92 0 0 0

Plan 93 0 0 0

Plan 94 0 0 0

Plan 95 0 0 0

Plan 96 0 0 0

Plan 97 0 0 0

Plan 98 0 0 0

Plan 99 0 0 0

Plan 100 0 0 0

Page 165: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Table 11. Plan Premium Development for 21-Year-Old Non-Tobacco User

1/1/17 Plan

Marketing Name

(If 1/1/16 Plan

Discontinued) Metallic Tier

Exchange

On/Off or

Off 1 2 3 4

- 17 2,265 -

Geisinger Marketplace PPO 25/50/1000Gold On/Off 11 586

Geisinger Marketplace PPO 30/50/5000Silver On/Off 6 1,679

Geisinger Marketplace PPO 25/50/1000Gold On/Off - -

Geisinger Marketplace PPO 30/50/5000Silver On/Off - -

Geisinger Marketplace PPO 25/50/1000Gold On/Off - -

Geisinger Marketplace PPO 30/50/5000Silver On/Off - -

Geisinger Marketplace PPO 25/50/1000Gold On/Off - -

Geisinger Marketplace PPO 30/50/5000Silver On/Off - -

Geisinger Marketplace PPO Extra 10/50/500Gold On/Off - -

Geisinger Marketplace PPO Extra 10/50/500Gold On/Off - -

Geisinger Marketplace PPO Extra 10/50/3500Silver On/Off - -

Geisinger Marketplace PPO Extra 10/50/3500Silver On/Off - -

Geisinger Marketplace PPO Select 30/50/5000Silver On/Off - -

Geisinger Marketplace PPO Select 25/50/1000Gold On/Off - -

Geisinger Marketplace PPO 25/50/1000 w/PDGold Off - -

Geisinger Marketplace PPO 25/50/1000 w/PDGold Off - -

Geisinger Marketplace PPO 25/50/1000 w/PDGold Off - -

Geisinger Marketplace PPO 25/50/1000 w/PDGold Off - -

Geisinger Marketplace PPO 30/50/5000 w/PDSilver Off - -

Geisinger Marketplace PPO 30/50/5000 w/PDSilver Off - -

Geisinger Marketplace PPO 30/50/5000 w/PDSilver Off - -

Geisinger Marketplace PPO 30/50/5000 w/PDSilver Off - -

Geisinger Marketplace PPO Extra 10/50/500 w/PDGold Off - -

Geisinger Marketplace PPO Extra 10/50/500 w/PDGold Off - -

Geisinger Marketplace PPO Extra 10/50/3500 w/PDSilver Off - -

Geisinger Marketplace PPO Extra 10/50/3500 w/PDSilver Off - -

Geisinger Marketplace PPO Select 30/50/5000 w/PDSilver Off - -

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

2/1/16 Number of Covered Lives

Page 166: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Geisinger Marketplace PPO Select 25/50/1000 w/PDGold Off - -

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 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 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

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 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 0 0

0 0 0

0 0 0

Page 167: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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 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 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

Page 168: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

5 6 7 8 9 Total 1 2

171 2,590 271 - 1,000 6,314 -$ 261.05$

65 419 - - 1,081 -$ 279.83$

106 1,011 - - 2,802 -$ 226.60$

- - - 185 185 -$ -$

- - - 780 780 -$ -$

- 271 - - 271 -$ -$

- 889 - - 889 -$ -$

- - 138 8 146 -$ -$

- - 133 27 160 -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

- - - - - -$ -$

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)

Page 169: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

- - - - - -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

Page 170: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

- -$ -$

Page 171: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

3 4 5 6 7 8 9

258.20$ -$ 252.38$ 259.45$ 331.25$ -$ 215.95$

300.59$ -$ 286.12$ 301.53$ -$ -$ -$

243.41$ -$ 231.70$ 244.17$ -$ -$ -$

-$ -$ -$ -$ -$ -$ 252.30$

-$ -$ -$ -$ -$ -$ 205.14$

-$ -$ -$ 301.53$ -$ -$ -$

-$ -$ -$ 244.17$ -$ -$ -$

-$ -$ -$ -$ 365.36$ -$ 310.33$

-$ -$ -$ -$ 295.86$ -$ 251.30$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

2016 21-year-old Non-Tobacco Premium PMPM

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

Page 172: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

Page 173: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

Page 174: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

Average

(weighted by

enrollment by

rating area) 1 2 3 4 5 6

255.01$ -$ 362.70$ 353.04$ -$ 346.93$ 354.88$

299.87$ -$ 393.63$ 422.82$ -$ 402.48$ 424.15$

243.20$ -$ 306.00$ 328.69$ -$ 312.87$ 329.72$

252.30$ -$ -$ -$ -$ -$ -$

205.14$ -$ -$ -$ -$ -$ -$

301.53$ -$ -$ -$ -$ -$ 424.15$

244.17$ -$ -$ -$ -$ -$ 329.72$

362.34$ -$ -$ -$ -$ -$ -$

288.34$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

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)

Page 175: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

Page 176: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$

Page 177: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

7 8 9

Average

(weighted by

enrollment by

rating area) 1 2 3 4

457.78$ -$ 314.56$ 352.06$ 0.0% 38.7% 36.5% 0.0%

-$ -$ -$ 421.82$ 0.0% 40.7% 40.7% 0.0%

-$ -$ -$ 328.41$ 0.0% 35.0% 35.0% 0.0%

-$ -$ 383.46$ 383.46$ 0.0% 0.0% 0.0% 0.0%

-$ -$ 298.09$ 298.09$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ 424.15$ 0.0% 0.0% 0.0% 0.0%

-$ -$ -$ 329.72$ 0.0% 0.0% 0.0% 0.0%

513.93$ -$ 383.46$ 506.79$ 0.0% 0.0% 0.0% 0.0%

399.51$ -$ 298.09$ 382.40$ 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% 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% 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% 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%

-$ -$ -$ -$ 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% 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% 0.0% 0.0%

Change in 21-year-old Non-Tobacco Premium PMPM 2017 21-year-old Non-Tobacco Premium PMPM

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

Page 178: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

-$ -$ -$ -$ 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% 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% 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% 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%

-$ -$ -$ -$ 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% 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% 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% 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%

-$ -$ -$ -$ 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% 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% 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% 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%

-$ -$ -$ -$ 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% 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% 0.0% 0.0%

-$ -$ -$ -$ 0.0% 0.0% 0.0% 0.0%

Page 179: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

-$ -$ -$ -$ 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% 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% 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% 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%

-$ -$ -$ -$ 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% 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% 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% 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%

Page 180: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

5 6 7 8 9

Average

(weighted by

enrollment by

rating area)

37.2% 36.5% 37.9% 0.0% 45.7% 38.1%

40.7% 40.7% 0.0% 0.0% 0.0% 40.7%

35.0% 35.0% 0.0% 0.0% 0.0% 35.0%

0.0% 0.0% 0.0% 0.0% 52.0% 52.0%

0.0% 0.0% 0.0% 0.0% 45.3% 45.3%

0.0% 40.7% 0.0% 0.0% 0.0% 40.7%

0.0% 35.0% 0.0% 0.0% 0.0% 35.0%

0.0% 0.0% 40.7% 0.0% 23.6% 39.9%

0.0% 0.0% 35.0% 0.0% 18.6% 32.6%

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% 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% 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% 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% 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% 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%

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% 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% 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

Page 181: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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% 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% 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% 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% 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% 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%

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% 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% 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% 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% 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% 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%

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% 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% 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% 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% 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% 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%

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% 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% 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% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Page 182: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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% 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% 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% 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% 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% 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%

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% 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% 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% 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% 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% 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%

Page 183: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

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 1.1 Rating Area 1 0.000 0.000

21 1.000 1.1 44 1.397 1.1 Rating Area 2 Cameron, Potter 0.890 0.890

22 1.000 1.1 45 1.444 1.1 Rating Area 3

Tioga, Clinton, Lycoming, Sullivan, Bradford,

Susquehanna, Wyoming, Lackawanna, Wayne,

Pike, Monroe, Carbon, Luzerne

0.956 0.956

23 1.000 1.1 46 1.500 1.1 Rating Area 4 0.000 0.000

24 1.000 1.1 47 1.563 1.1 Rating Area 5Jefferson, Clearfield, Cambria, Somerset, Blair,

Huntingdon0.910 0.910

25 1.004 1.1 48 1.635 1.1 Rating Area 6

Centre, Mifflin, Union, Snyder, Montour,

Northumberland, Columbia, Schuylkill, Lehigh,

Northampton

0.959 0.959

26 1.024 1.1 49 1.706 1.1 Rating Area 7 Adams, York, Lancaster, Berks 1.162 1.162

27 1.048 1.1 50 1.786 1.1 Rating Area 8 0.000 0.000

28 1.087 1.1 51 1.865 1.1 Rating Area 9Fulton, Cumberland, Perry, Juniata, Dauphin,

Lebanon0.987 0.867

29 1.119 1.1 52 1.952 1.1

30 1.135 1.1 53 2.040 1.1

31 1.159 1.1 54 2.135 1.1 Table 14. Network Factors32 1.183 1.1 55 2.230 1.1

33 1.198 1.1 56 2.333 1.1

34 1.214 1.1 57 2.437 1.1 Network Name Rating AreaCurrent

Factor

Proposed

Factor

DOH

Approval

Date

35 1.222 1.1 58 2.548 1.1 Geisinger Marketplace PPO 2,3,5,6,7,9 1.000 1.00238 8/15/2013

36 1.230 1.1 59 2.603 1.1 Geisinger Marketplace Select 3,5,6,9 NA 0.952 4/21/2016

37 1.238 1.1 60 2.714 1.1

38 1.246 1.1 61 2.810 1.1

39 1.262 1.1 62 2.873 1.1

40 1.278 1.1 63 2.952 1.1

41 1.302 1.1 64+ 3.000 1.1

42 1.325 1.1*PA follows the federal default age curve.

Geographic Area Factors2017 Age and Tobacco Factors

2017 Network Factors

Page 184: Rate/Rule Schedule...57 1030.42 1133.59 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 58 1077.36 1185.18 75729PA0012596 Rating Area 3 Tobacco User/Non-Tobacco User 59

PA Bulletin for 2017 ACA Filings

1. Company Name: Geisinger Quality Options

And NAIC #: 12743

2. Market: Individual

3. Products: PPO

4. Average rate change: 40.7%, $192.65

And range: 35% to 73%

5. As of February 2016 covered lives: 6,314

And policyholders: 4,380

6. Current Period (2016) Revenue: $35,882,298

7. Additional Revenue: $14,597,052