Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 Federal Rates Template Revised Previous State Filing Number:UPMC-130071359Percent Rate Change Request:6.7

RatesTablesTempalte_v6_0.xls,RatesTablesTempalte_v6_0.pdf,

2 PID Rates Template Revised Previous State Filing Number:UPMC-130071359Percent Rate Change Request:6.7

PA Plan DesignSummary and RateTables-1.xlsx, PA PlanDesign Summary andRate Tables-1.pdf,

SERFF Tracking #: UPMC-130536846 State Tracking #: UPMC-130536846 Company Tracking #:

State: Pennsylvania Filing Company: UPMC Health Coverage, Inc.

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

Product Name: 2017 SG Health Coverage

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number UPMC-130536846 Generated 06/13/2016 02:52 PM

Attachment RatesTablesTempalte_v6_0.xls is not a PDF document and cannot be reproduced here.

Attachment PA Plan Design Summary and Rate Tables-1.xlsx is not a PDF document and cannot bereproduced here.

SERFF Tracking #: UPMC-130536846 State Tracking #: UPMC-130536846 Company Tracking #:

State: Pennsylvania Filing Company: UPMC Health Coverage, Inc.

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

Product Name: 2017 SG Health Coverage

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number UPMC-130536846 Generated 06/13/2016 02:52 PM

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 fouIf 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* 62560Federal TIN* 46-2824537

Rate Effective Date* 1/1/2017Rate Expiration Date* 12/31/2017

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

62560PA0020055 Rating Area 1 No Preference 0-20 129.3862560PA0020055 Rating Area 1 No Preference 21 203.7462560PA0020055 Rating Area 1 No Preference 22 203.7462560PA0020055 Rating Area 1 No Preference 23 203.7462560PA0020055 Rating Area 1 No Preference 24 203.7462560PA0020055 Rating Area 1 No Preference 25 204.5662560PA0020055 Rating Area 1 No Preference 26 208.6362560PA0020055 Rating Area 1 No Preference 27 213.5262560PA0020055 Rating Area 1 No Preference 28 221.4762560PA0020055 Rating Area 1 No Preference 29 227.9962560PA0020055 Rating Area 1 No Preference 30 231.2562560PA0020055 Rating Area 1 No Preference 31 236.1462560PA0020055 Rating Area 1 No Preference 32 241.0362560PA0020055 Rating Area 1 No Preference 33 244.0962560PA0020055 Rating Area 1 No Preference 34 247.3562560PA0020055 Rating Area 1 No Preference 35 248.9862560PA0020055 Rating Area 1 No Preference 36 250.6162560PA0020055 Rating Area 1 No Preference 37 252.2462560PA0020055 Rating Area 1 No Preference 38 253.8762560PA0020055 Rating Area 1 No Preference 39 257.1262560PA0020055 Rating Area 1 No Preference 40 260.3862560PA0020055 Rating Area 1 No Preference 41 265.2762560PA0020055 Rating Area 1 No Preference 42 269.9662560PA0020055 Rating Area 1 No Preference 43 276.4862560PA0020055 Rating Area 1 No Preference 44 284.6362560PA0020055 Rating Area 1 No Preference 45 294.2162560PA0020055 Rating Area 1 No Preference 46 305.6162560PA0020055 Rating Area 1 No Preference 47 318.4562560PA0020055 Rating Area 1 No Preference 48 333.1262560PA0020055 Rating Area 1 No Preference 49 347.59

62560PA0020055 Rating Area 1 No Preference 50 363.8862560PA0020055 Rating Area 1 No Preference 51 379.9862560PA0020055 Rating Area 1 No Preference 52 397.7162560PA0020055 Rating Area 1 No Preference 53 415.6362560PA0020055 Rating Area 1 No Preference 54 434.9962560PA0020055 Rating Area 1 No Preference 55 454.3562560PA0020055 Rating Area 1 No Preference 56 475.3362560PA0020055 Rating Area 1 No Preference 57 496.5262560PA0020055 Rating Area 1 No Preference 58 519.1362560PA0020055 Rating Area 1 No Preference 59 530.3462560PA0020055 Rating Area 1 No Preference 60 552.9662560PA0020055 Rating Area 1 No Preference 61 572.5162560PA0020055 Rating Area 1 No Preference 62 585.3562560PA0020055 Rating Area 1 No Preference 63 601.4562560PA0020055 Rating Area 1 No Preference 64 611.2262560PA0020055 Rating Area 1 No Preference 65 and over 611.2262560PA0020055 Rating Area 2 No Preference 0-20 129.3862560PA0020055 Rating Area 2 No Preference 21 203.7462560PA0020055 Rating Area 2 No Preference 22 203.7462560PA0020055 Rating Area 2 No Preference 23 203.7462560PA0020055 Rating Area 2 No Preference 24 203.7462560PA0020055 Rating Area 2 No Preference 25 204.5662560PA0020055 Rating Area 2 No Preference 26 208.6362560PA0020055 Rating Area 2 No Preference 27 213.5262560PA0020055 Rating Area 2 No Preference 28 221.4762560PA0020055 Rating Area 2 No Preference 29 227.9962560PA0020055 Rating Area 2 No Preference 30 231.2562560PA0020055 Rating Area 2 No Preference 31 236.1462560PA0020055 Rating Area 2 No Preference 32 241.0362560PA0020055 Rating Area 2 No Preference 33 244.0962560PA0020055 Rating Area 2 No Preference 34 247.3562560PA0020055 Rating Area 2 No Preference 35 248.9862560PA0020055 Rating Area 2 No Preference 36 250.6162560PA0020055 Rating Area 2 No Preference 37 252.2462560PA0020055 Rating Area 2 No Preference 38 253.8762560PA0020055 Rating Area 2 No Preference 39 257.1262560PA0020055 Rating Area 2 No Preference 40 260.3862560PA0020055 Rating Area 2 No Preference 41 265.2762560PA0020055 Rating Area 2 No Preference 42 269.9662560PA0020055 Rating Area 2 No Preference 43 276.4862560PA0020055 Rating Area 2 No Preference 44 284.6362560PA0020055 Rating Area 2 No Preference 45 294.2162560PA0020055 Rating Area 2 No Preference 46 305.6162560PA0020055 Rating Area 2 No Preference 47 318.4562560PA0020055 Rating Area 2 No Preference 48 333.1262560PA0020055 Rating Area 2 No Preference 49 347.5962560PA0020055 Rating Area 2 No Preference 50 363.8862560PA0020055 Rating Area 2 No Preference 51 379.9862560PA0020055 Rating Area 2 No Preference 52 397.71

62560PA0020055 Rating Area 2 No Preference 53 415.6362560PA0020055 Rating Area 2 No Preference 54 434.9962560PA0020055 Rating Area 2 No Preference 55 454.3562560PA0020055 Rating Area 2 No Preference 56 475.3362560PA0020055 Rating Area 2 No Preference 57 496.5262560PA0020055 Rating Area 2 No Preference 58 519.1362560PA0020055 Rating Area 2 No Preference 59 530.3462560PA0020055 Rating Area 2 No Preference 60 552.9662560PA0020055 Rating Area 2 No Preference 61 572.5162560PA0020055 Rating Area 2 No Preference 62 585.3562560PA0020055 Rating Area 2 No Preference 63 601.4562560PA0020055 Rating Area 2 No Preference 64 611.2262560PA0020055 Rating Area 2 No Preference 65 and over 611.2262560PA0020055 Rating Area 4 No Preference 0-20 129.3862560PA0020055 Rating Area 4 No Preference 21 203.7462560PA0020055 Rating Area 4 No Preference 22 203.7462560PA0020055 Rating Area 4 No Preference 23 203.7462560PA0020055 Rating Area 4 No Preference 24 203.7462560PA0020055 Rating Area 4 No Preference 25 204.5662560PA0020055 Rating Area 4 No Preference 26 208.6362560PA0020055 Rating Area 4 No Preference 27 213.5262560PA0020055 Rating Area 4 No Preference 28 221.4762560PA0020055 Rating Area 4 No Preference 29 227.9962560PA0020055 Rating Area 4 No Preference 30 231.2562560PA0020055 Rating Area 4 No Preference 31 236.1462560PA0020055 Rating Area 4 No Preference 32 241.0362560PA0020055 Rating Area 4 No Preference 33 244.0962560PA0020055 Rating Area 4 No Preference 34 247.3562560PA0020055 Rating Area 4 No Preference 35 248.9862560PA0020055 Rating Area 4 No Preference 36 250.6162560PA0020055 Rating Area 4 No Preference 37 252.2462560PA0020055 Rating Area 4 No Preference 38 253.8762560PA0020055 Rating Area 4 No Preference 39 257.1262560PA0020055 Rating Area 4 No Preference 40 260.3862560PA0020055 Rating Area 4 No Preference 41 265.2762560PA0020055 Rating Area 4 No Preference 42 269.9662560PA0020055 Rating Area 4 No Preference 43 276.4862560PA0020055 Rating Area 4 No Preference 44 284.6362560PA0020055 Rating Area 4 No Preference 45 294.2162560PA0020055 Rating Area 4 No Preference 46 305.6162560PA0020055 Rating Area 4 No Preference 47 318.4562560PA0020055 Rating Area 4 No Preference 48 333.1262560PA0020055 Rating Area 4 No Preference 49 347.5962560PA0020055 Rating Area 4 No Preference 50 363.8862560PA0020055 Rating Area 4 No Preference 51 379.9862560PA0020055 Rating Area 4 No Preference 52 397.7162560PA0020055 Rating Area 4 No Preference 53 415.6362560PA0020055 Rating Area 4 No Preference 54 434.9962560PA0020055 Rating Area 4 No Preference 55 454.35

62560PA0020055 Rating Area 4 No Preference 56 475.3362560PA0020055 Rating Area 4 No Preference 57 496.5262560PA0020055 Rating Area 4 No Preference 58 519.1362560PA0020055 Rating Area 4 No Preference 59 530.3462560PA0020055 Rating Area 4 No Preference 60 552.9662560PA0020055 Rating Area 4 No Preference 61 572.5162560PA0020055 Rating Area 4 No Preference 62 585.3562560PA0020055 Rating Area 4 No Preference 63 601.4562560PA0020055 Rating Area 4 No Preference 64 611.2262560PA0020055 Rating Area 4 No Preference 65 and over 611.2262560PA0020055 Rating Area 5 No Preference 0-20 129.3862560PA0020055 Rating Area 5 No Preference 21 203.7462560PA0020055 Rating Area 5 No Preference 22 203.7462560PA0020055 Rating Area 5 No Preference 23 203.7462560PA0020055 Rating Area 5 No Preference 24 203.7462560PA0020055 Rating Area 5 No Preference 25 204.5662560PA0020055 Rating Area 5 No Preference 26 208.6362560PA0020055 Rating Area 5 No Preference 27 213.5262560PA0020055 Rating Area 5 No Preference 28 221.4762560PA0020055 Rating Area 5 No Preference 29 227.9962560PA0020055 Rating Area 5 No Preference 30 231.2562560PA0020055 Rating Area 5 No Preference 31 236.1462560PA0020055 Rating Area 5 No Preference 32 241.0362560PA0020055 Rating Area 5 No Preference 33 244.0962560PA0020055 Rating Area 5 No Preference 34 247.3562560PA0020055 Rating Area 5 No Preference 35 248.9862560PA0020055 Rating Area 5 No Preference 36 250.6162560PA0020055 Rating Area 5 No Preference 37 252.2462560PA0020055 Rating Area 5 No Preference 38 253.8762560PA0020055 Rating Area 5 No Preference 39 257.1262560PA0020055 Rating Area 5 No Preference 40 260.3862560PA0020055 Rating Area 5 No Preference 41 265.2762560PA0020055 Rating Area 5 No Preference 42 269.9662560PA0020055 Rating Area 5 No Preference 43 276.4862560PA0020055 Rating Area 5 No Preference 44 284.6362560PA0020055 Rating Area 5 No Preference 45 294.2162560PA0020055 Rating Area 5 No Preference 46 305.6162560PA0020055 Rating Area 5 No Preference 47 318.4562560PA0020055 Rating Area 5 No Preference 48 333.1262560PA0020055 Rating Area 5 No Preference 49 347.5962560PA0020055 Rating Area 5 No Preference 50 363.8862560PA0020055 Rating Area 5 No Preference 51 379.9862560PA0020055 Rating Area 5 No Preference 52 397.7162560PA0020055 Rating Area 5 No Preference 53 415.6362560PA0020055 Rating Area 5 No Preference 54 434.9962560PA0020055 Rating Area 5 No Preference 55 454.3562560PA0020055 Rating Area 5 No Preference 56 475.3362560PA0020055 Rating Area 5 No Preference 57 496.5262560PA0020055 Rating Area 5 No Preference 58 519.13

62560PA0020055 Rating Area 5 No Preference 59 530.3462560PA0020055 Rating Area 5 No Preference 60 552.9662560PA0020055 Rating Area 5 No Preference 61 572.5162560PA0020055 Rating Area 5 No Preference 62 585.3562560PA0020055 Rating Area 5 No Preference 63 601.4562560PA0020055 Rating Area 5 No Preference 64 611.2262560PA0020055 Rating Area 5 No Preference 65 and over 611.2262560PA0020055 Rating Area 6 No Preference 0-20 129.3862560PA0020055 Rating Area 6 No Preference 21 203.7462560PA0020055 Rating Area 6 No Preference 22 203.7462560PA0020055 Rating Area 6 No Preference 23 203.7462560PA0020055 Rating Area 6 No Preference 24 203.7462560PA0020055 Rating Area 6 No Preference 25 204.5662560PA0020055 Rating Area 6 No Preference 26 208.6362560PA0020055 Rating Area 6 No Preference 27 213.5262560PA0020055 Rating Area 6 No Preference 28 221.4762560PA0020055 Rating Area 6 No Preference 29 227.9962560PA0020055 Rating Area 6 No Preference 30 231.2562560PA0020055 Rating Area 6 No Preference 31 236.1462560PA0020055 Rating Area 6 No Preference 32 241.0362560PA0020055 Rating Area 6 No Preference 33 244.0962560PA0020055 Rating Area 6 No Preference 34 247.3562560PA0020055 Rating Area 6 No Preference 35 248.9862560PA0020055 Rating Area 6 No Preference 36 250.6162560PA0020055 Rating Area 6 No Preference 37 252.2462560PA0020055 Rating Area 6 No Preference 38 253.8762560PA0020055 Rating Area 6 No Preference 39 257.1262560PA0020055 Rating Area 6 No Preference 40 260.3862560PA0020055 Rating Area 6 No Preference 41 265.2762560PA0020055 Rating Area 6 No Preference 42 269.9662560PA0020055 Rating Area 6 No Preference 43 276.4862560PA0020055 Rating Area 6 No Preference 44 284.6362560PA0020055 Rating Area 6 No Preference 45 294.2162560PA0020055 Rating Area 6 No Preference 46 305.6162560PA0020055 Rating Area 6 No Preference 47 318.4562560PA0020055 Rating Area 6 No Preference 48 333.1262560PA0020055 Rating Area 6 No Preference 49 347.5962560PA0020055 Rating Area 6 No Preference 50 363.8862560PA0020055 Rating Area 6 No Preference 51 379.9862560PA0020055 Rating Area 6 No Preference 52 397.7162560PA0020055 Rating Area 6 No Preference 53 415.6362560PA0020055 Rating Area 6 No Preference 54 434.9962560PA0020055 Rating Area 6 No Preference 55 454.3562560PA0020055 Rating Area 6 No Preference 56 475.3362560PA0020055 Rating Area 6 No Preference 57 496.5262560PA0020055 Rating Area 6 No Preference 58 519.1362560PA0020055 Rating Area 6 No Preference 59 530.3462560PA0020055 Rating Area 6 No Preference 60 552.9662560PA0020055 Rating Area 6 No Preference 61 572.51

62560PA0020055 Rating Area 6 No Preference 62 585.3562560PA0020055 Rating Area 6 No Preference 63 601.4562560PA0020055 Rating Area 6 No Preference 64 611.2262560PA0020055 Rating Area 6 No Preference 65 and over 611.2262560PA0020065 Rating Area 1 No Preference 0-20 197.0162560PA0020065 Rating Area 1 No Preference 21 310.2562560PA0020065 Rating Area 1 No Preference 22 310.2562560PA0020065 Rating Area 1 No Preference 23 310.2562560PA0020065 Rating Area 1 No Preference 24 310.2562560PA0020065 Rating Area 1 No Preference 25 311.4962560PA0020065 Rating Area 1 No Preference 26 317.7062560PA0020065 Rating Area 1 No Preference 27 325.1462560PA0020065 Rating Area 1 No Preference 28 337.2462560PA0020065 Rating Area 1 No Preference 29 347.1762560PA0020065 Rating Area 1 No Preference 30 352.1362560PA0020065 Rating Area 1 No Preference 31 359.5862560PA0020065 Rating Area 1 No Preference 32 367.0362560PA0020065 Rating Area 1 No Preference 33 371.6862560PA0020065 Rating Area 1 No Preference 34 376.6462560PA0020065 Rating Area 1 No Preference 35 379.1362560PA0020065 Rating Area 1 No Preference 36 381.6162560PA0020065 Rating Area 1 No Preference 37 384.0962560PA0020065 Rating Area 1 No Preference 38 386.5762560PA0020065 Rating Area 1 No Preference 39 391.5462560PA0020065 Rating Area 1 No Preference 40 396.5062560PA0020065 Rating Area 1 No Preference 41 403.9562560PA0020065 Rating Area 1 No Preference 42 411.0862560PA0020065 Rating Area 1 No Preference 43 421.0162560PA0020065 Rating Area 1 No Preference 44 433.4262560PA0020065 Rating Area 1 No Preference 45 448.0062560PA0020065 Rating Area 1 No Preference 46 465.3762560PA0020065 Rating Area 1 No Preference 47 484.9262560PA0020065 Rating Area 1 No Preference 48 507.2662560PA0020065 Rating Area 1 No Preference 49 529.2862560PA0020065 Rating Area 1 No Preference 50 554.1062560PA0020065 Rating Area 1 No Preference 51 578.6162560PA0020065 Rating Area 1 No Preference 52 605.6162560PA0020065 Rating Area 1 No Preference 53 632.9162560PA0020065 Rating Area 1 No Preference 54 662.3862560PA0020065 Rating Area 1 No Preference 55 691.8562560PA0020065 Rating Area 1 No Preference 56 723.8162560PA0020065 Rating Area 1 No Preference 57 756.0762560PA0020065 Rating Area 1 No Preference 58 790.5162560PA0020065 Rating Area 1 No Preference 59 807.5862560PA0020065 Rating Area 1 No Preference 60 842.0162560PA0020065 Rating Area 1 No Preference 61 871.8062560PA0020065 Rating Area 1 No Preference 62 891.3462560PA0020065 Rating Area 1 No Preference 63 915.8562560PA0020065 Rating Area 1 No Preference 64 930.74

62560PA0020065 Rating Area 1 No Preference 65 and over 930.7462560PA0020065 Rating Area 2 No Preference 0-20 197.0162560PA0020065 Rating Area 2 No Preference 21 310.2562560PA0020065 Rating Area 2 No Preference 22 310.2562560PA0020065 Rating Area 2 No Preference 23 310.2562560PA0020065 Rating Area 2 No Preference 24 310.2562560PA0020065 Rating Area 2 No Preference 25 311.4962560PA0020065 Rating Area 2 No Preference 26 317.7062560PA0020065 Rating Area 2 No Preference 27 325.1462560PA0020065 Rating Area 2 No Preference 28 337.2462560PA0020065 Rating Area 2 No Preference 29 347.1762560PA0020065 Rating Area 2 No Preference 30 352.1362560PA0020065 Rating Area 2 No Preference 31 359.5862560PA0020065 Rating Area 2 No Preference 32 367.0362560PA0020065 Rating Area 2 No Preference 33 371.6862560PA0020065 Rating Area 2 No Preference 34 376.6462560PA0020065 Rating Area 2 No Preference 35 379.1362560PA0020065 Rating Area 2 No Preference 36 381.6162560PA0020065 Rating Area 2 No Preference 37 384.0962560PA0020065 Rating Area 2 No Preference 38 386.5762560PA0020065 Rating Area 2 No Preference 39 391.5462560PA0020065 Rating Area 2 No Preference 40 396.5062560PA0020065 Rating Area 2 No Preference 41 403.9562560PA0020065 Rating Area 2 No Preference 42 411.0862560PA0020065 Rating Area 2 No Preference 43 421.0162560PA0020065 Rating Area 2 No Preference 44 433.4262560PA0020065 Rating Area 2 No Preference 45 448.0062560PA0020065 Rating Area 2 No Preference 46 465.3762560PA0020065 Rating Area 2 No Preference 47 484.9262560PA0020065 Rating Area 2 No Preference 48 507.2662560PA0020065 Rating Area 2 No Preference 49 529.2862560PA0020065 Rating Area 2 No Preference 50 554.1062560PA0020065 Rating Area 2 No Preference 51 578.6162560PA0020065 Rating Area 2 No Preference 52 605.6162560PA0020065 Rating Area 2 No Preference 53 632.9162560PA0020065 Rating Area 2 No Preference 54 662.3862560PA0020065 Rating Area 2 No Preference 55 691.8562560PA0020065 Rating Area 2 No Preference 56 723.8162560PA0020065 Rating Area 2 No Preference 57 756.0762560PA0020065 Rating Area 2 No Preference 58 790.5162560PA0020065 Rating Area 2 No Preference 59 807.5862560PA0020065 Rating Area 2 No Preference 60 842.0162560PA0020065 Rating Area 2 No Preference 61 871.8062560PA0020065 Rating Area 2 No Preference 62 891.3462560PA0020065 Rating Area 2 No Preference 63 915.8562560PA0020065 Rating Area 2 No Preference 64 930.7462560PA0020065 Rating Area 2 No Preference 65 and over 930.7462560PA0020065 Rating Area 4 No Preference 0-20 197.0162560PA0020065 Rating Area 4 No Preference 21 310.25

62560PA0020065 Rating Area 4 No Preference 22 310.2562560PA0020065 Rating Area 4 No Preference 23 310.2562560PA0020065 Rating Area 4 No Preference 24 310.2562560PA0020065 Rating Area 4 No Preference 25 311.4962560PA0020065 Rating Area 4 No Preference 26 317.7062560PA0020065 Rating Area 4 No Preference 27 325.1462560PA0020065 Rating Area 4 No Preference 28 337.2462560PA0020065 Rating Area 4 No Preference 29 347.1762560PA0020065 Rating Area 4 No Preference 30 352.1362560PA0020065 Rating Area 4 No Preference 31 359.5862560PA0020065 Rating Area 4 No Preference 32 367.0362560PA0020065 Rating Area 4 No Preference 33 371.6862560PA0020065 Rating Area 4 No Preference 34 376.6462560PA0020065 Rating Area 4 No Preference 35 379.1362560PA0020065 Rating Area 4 No Preference 36 381.6162560PA0020065 Rating Area 4 No Preference 37 384.0962560PA0020065 Rating Area 4 No Preference 38 386.5762560PA0020065 Rating Area 4 No Preference 39 391.5462560PA0020065 Rating Area 4 No Preference 40 396.5062560PA0020065 Rating Area 4 No Preference 41 403.9562560PA0020065 Rating Area 4 No Preference 42 411.0862560PA0020065 Rating Area 4 No Preference 43 421.0162560PA0020065 Rating Area 4 No Preference 44 433.4262560PA0020065 Rating Area 4 No Preference 45 448.0062560PA0020065 Rating Area 4 No Preference 46 465.3762560PA0020065 Rating Area 4 No Preference 47 484.9262560PA0020065 Rating Area 4 No Preference 48 507.2662560PA0020065 Rating Area 4 No Preference 49 529.2862560PA0020065 Rating Area 4 No Preference 50 554.1062560PA0020065 Rating Area 4 No Preference 51 578.6162560PA0020065 Rating Area 4 No Preference 52 605.6162560PA0020065 Rating Area 4 No Preference 53 632.9162560PA0020065 Rating Area 4 No Preference 54 662.3862560PA0020065 Rating Area 4 No Preference 55 691.8562560PA0020065 Rating Area 4 No Preference 56 723.8162560PA0020065 Rating Area 4 No Preference 57 756.0762560PA0020065 Rating Area 4 No Preference 58 790.5162560PA0020065 Rating Area 4 No Preference 59 807.5862560PA0020065 Rating Area 4 No Preference 60 842.0162560PA0020065 Rating Area 4 No Preference 61 871.8062560PA0020065 Rating Area 4 No Preference 62 891.3462560PA0020065 Rating Area 4 No Preference 63 915.8562560PA0020065 Rating Area 4 No Preference 64 930.7462560PA0020065 Rating Area 4 No Preference 65 and over 930.7462560PA0020065 Rating Area 5 No Preference 0-20 197.0162560PA0020065 Rating Area 5 No Preference 21 310.2562560PA0020065 Rating Area 5 No Preference 22 310.2562560PA0020065 Rating Area 5 No Preference 23 310.2562560PA0020065 Rating Area 5 No Preference 24 310.25

62560PA0020065 Rating Area 5 No Preference 25 311.4962560PA0020065 Rating Area 5 No Preference 26 317.7062560PA0020065 Rating Area 5 No Preference 27 325.1462560PA0020065 Rating Area 5 No Preference 28 337.2462560PA0020065 Rating Area 5 No Preference 29 347.1762560PA0020065 Rating Area 5 No Preference 30 352.1362560PA0020065 Rating Area 5 No Preference 31 359.5862560PA0020065 Rating Area 5 No Preference 32 367.0362560PA0020065 Rating Area 5 No Preference 33 371.6862560PA0020065 Rating Area 5 No Preference 34 376.6462560PA0020065 Rating Area 5 No Preference 35 379.1362560PA0020065 Rating Area 5 No Preference 36 381.6162560PA0020065 Rating Area 5 No Preference 37 384.0962560PA0020065 Rating Area 5 No Preference 38 386.5762560PA0020065 Rating Area 5 No Preference 39 391.5462560PA0020065 Rating Area 5 No Preference 40 396.5062560PA0020065 Rating Area 5 No Preference 41 403.9562560PA0020065 Rating Area 5 No Preference 42 411.0862560PA0020065 Rating Area 5 No Preference 43 421.0162560PA0020065 Rating Area 5 No Preference 44 433.4262560PA0020065 Rating Area 5 No Preference 45 448.0062560PA0020065 Rating Area 5 No Preference 46 465.3762560PA0020065 Rating Area 5 No Preference 47 484.9262560PA0020065 Rating Area 5 No Preference 48 507.2662560PA0020065 Rating Area 5 No Preference 49 529.2862560PA0020065 Rating Area 5 No Preference 50 554.1062560PA0020065 Rating Area 5 No Preference 51 578.6162560PA0020065 Rating Area 5 No Preference 52 605.6162560PA0020065 Rating Area 5 No Preference 53 632.9162560PA0020065 Rating Area 5 No Preference 54 662.3862560PA0020065 Rating Area 5 No Preference 55 691.8562560PA0020065 Rating Area 5 No Preference 56 723.8162560PA0020065 Rating Area 5 No Preference 57 756.0762560PA0020065 Rating Area 5 No Preference 58 790.5162560PA0020065 Rating Area 5 No Preference 59 807.5862560PA0020065 Rating Area 5 No Preference 60 842.0162560PA0020065 Rating Area 5 No Preference 61 871.8062560PA0020065 Rating Area 5 No Preference 62 891.3462560PA0020065 Rating Area 5 No Preference 63 915.8562560PA0020065 Rating Area 5 No Preference 64 930.7462560PA0020065 Rating Area 5 No Preference 65 and over 930.7462560PA0020065 Rating Area 6 No Preference 0-20 197.0162560PA0020065 Rating Area 6 No Preference 21 310.2562560PA0020065 Rating Area 6 No Preference 22 310.2562560PA0020065 Rating Area 6 No Preference 23 310.2562560PA0020065 Rating Area 6 No Preference 24 310.2562560PA0020065 Rating Area 6 No Preference 25 311.4962560PA0020065 Rating Area 6 No Preference 26 317.7062560PA0020065 Rating Area 6 No Preference 27 325.14

62560PA0020065 Rating Area 6 No Preference 28 337.2462560PA0020065 Rating Area 6 No Preference 29 347.1762560PA0020065 Rating Area 6 No Preference 30 352.1362560PA0020065 Rating Area 6 No Preference 31 359.5862560PA0020065 Rating Area 6 No Preference 32 367.0362560PA0020065 Rating Area 6 No Preference 33 371.6862560PA0020065 Rating Area 6 No Preference 34 376.6462560PA0020065 Rating Area 6 No Preference 35 379.1362560PA0020065 Rating Area 6 No Preference 36 381.6162560PA0020065 Rating Area 6 No Preference 37 384.0962560PA0020065 Rating Area 6 No Preference 38 386.5762560PA0020065 Rating Area 6 No Preference 39 391.5462560PA0020065 Rating Area 6 No Preference 40 396.5062560PA0020065 Rating Area 6 No Preference 41 403.9562560PA0020065 Rating Area 6 No Preference 42 411.0862560PA0020065 Rating Area 6 No Preference 43 421.0162560PA0020065 Rating Area 6 No Preference 44 433.4262560PA0020065 Rating Area 6 No Preference 45 448.0062560PA0020065 Rating Area 6 No Preference 46 465.3762560PA0020065 Rating Area 6 No Preference 47 484.9262560PA0020065 Rating Area 6 No Preference 48 507.2662560PA0020065 Rating Area 6 No Preference 49 529.2862560PA0020065 Rating Area 6 No Preference 50 554.1062560PA0020065 Rating Area 6 No Preference 51 578.6162560PA0020065 Rating Area 6 No Preference 52 605.6162560PA0020065 Rating Area 6 No Preference 53 632.9162560PA0020065 Rating Area 6 No Preference 54 662.3862560PA0020065 Rating Area 6 No Preference 55 691.8562560PA0020065 Rating Area 6 No Preference 56 723.8162560PA0020065 Rating Area 6 No Preference 57 756.0762560PA0020065 Rating Area 6 No Preference 58 790.5162560PA0020065 Rating Area 6 No Preference 59 807.5862560PA0020065 Rating Area 6 No Preference 60 842.0162560PA0020065 Rating Area 6 No Preference 61 871.8062560PA0020065 Rating Area 6 No Preference 62 891.3462560PA0020065 Rating Area 6 No Preference 63 915.8562560PA0020065 Rating Area 6 No Preference 64 930.7462560PA0020065 Rating Area 6 No Preference 65 and over 930.7462560PA0020066 Rating Area 1 No Preference 0-20 149.7162560PA0020066 Rating Area 1 No Preference 21 235.7662560PA0020066 Rating Area 1 No Preference 22 235.7662560PA0020066 Rating Area 1 No Preference 23 235.7662560PA0020066 Rating Area 1 No Preference 24 235.7662560PA0020066 Rating Area 1 No Preference 25 236.7062560PA0020066 Rating Area 1 No Preference 26 241.4162560PA0020066 Rating Area 1 No Preference 27 247.0762560PA0020066 Rating Area 1 No Preference 28 256.2762560PA0020066 Rating Area 1 No Preference 29 263.8162560PA0020066 Rating Area 1 No Preference 30 267.58

62560PA0020066 Rating Area 1 No Preference 31 273.2462560PA0020066 Rating Area 1 No Preference 32 278.9062560PA0020066 Rating Area 1 No Preference 33 282.4462560PA0020066 Rating Area 1 No Preference 34 286.2162560PA0020066 Rating Area 1 No Preference 35 288.0962560PA0020066 Rating Area 1 No Preference 36 289.9862560PA0020066 Rating Area 1 No Preference 37 291.8762560PA0020066 Rating Area 1 No Preference 38 293.7562560PA0020066 Rating Area 1 No Preference 39 297.5262560PA0020066 Rating Area 1 No Preference 40 301.3062560PA0020066 Rating Area 1 No Preference 41 306.9562560PA0020066 Rating Area 1 No Preference 42 312.3862560PA0020066 Rating Area 1 No Preference 43 319.9262560PA0020066 Rating Area 1 No Preference 44 329.3562560PA0020066 Rating Area 1 No Preference 45 340.4362560PA0020066 Rating Area 1 No Preference 46 353.6362560PA0020066 Rating Area 1 No Preference 47 368.4862560PA0020066 Rating Area 1 No Preference 48 385.4662560PA0020066 Rating Area 1 No Preference 49 402.2062560PA0020066 Rating Area 1 No Preference 50 421.0662560PA0020066 Rating Area 1 No Preference 51 439.6862560PA0020066 Rating Area 1 No Preference 52 460.1962560PA0020066 Rating Area 1 No Preference 53 480.9462560PA0020066 Rating Area 1 No Preference 54 503.3362560PA0020066 Rating Area 1 No Preference 55 525.7362560PA0020066 Rating Area 1 No Preference 56 550.0162560PA0020066 Rating Area 1 No Preference 57 574.5362560PA0020066 Rating Area 1 No Preference 58 600.7062560PA0020066 Rating Area 1 No Preference 59 613.6762560PA0020066 Rating Area 1 No Preference 60 639.8362560PA0020066 Rating Area 1 No Preference 61 662.4762560PA0020066 Rating Area 1 No Preference 62 677.3262560PA0020066 Rating Area 1 No Preference 63 695.9462560PA0020066 Rating Area 1 No Preference 64 707.2662560PA0020066 Rating Area 1 No Preference 65 and over 707.2662560PA0020066 Rating Area 2 No Preference 0-20 149.7162560PA0020066 Rating Area 2 No Preference 21 235.7662560PA0020066 Rating Area 2 No Preference 22 235.7662560PA0020066 Rating Area 2 No Preference 23 235.7662560PA0020066 Rating Area 2 No Preference 24 235.7662560PA0020066 Rating Area 2 No Preference 25 236.7062560PA0020066 Rating Area 2 No Preference 26 241.4162560PA0020066 Rating Area 2 No Preference 27 247.0762560PA0020066 Rating Area 2 No Preference 28 256.2762560PA0020066 Rating Area 2 No Preference 29 263.8162560PA0020066 Rating Area 2 No Preference 30 267.5862560PA0020066 Rating Area 2 No Preference 31 273.2462560PA0020066 Rating Area 2 No Preference 32 278.9062560PA0020066 Rating Area 2 No Preference 33 282.44

62560PA0020066 Rating Area 2 No Preference 34 286.2162560PA0020066 Rating Area 2 No Preference 35 288.0962560PA0020066 Rating Area 2 No Preference 36 289.9862560PA0020066 Rating Area 2 No Preference 37 291.8762560PA0020066 Rating Area 2 No Preference 38 293.7562560PA0020066 Rating Area 2 No Preference 39 297.5262560PA0020066 Rating Area 2 No Preference 40 301.3062560PA0020066 Rating Area 2 No Preference 41 306.9562560PA0020066 Rating Area 2 No Preference 42 312.3862560PA0020066 Rating Area 2 No Preference 43 319.9262560PA0020066 Rating Area 2 No Preference 44 329.3562560PA0020066 Rating Area 2 No Preference 45 340.4362560PA0020066 Rating Area 2 No Preference 46 353.6362560PA0020066 Rating Area 2 No Preference 47 368.4862560PA0020066 Rating Area 2 No Preference 48 385.4662560PA0020066 Rating Area 2 No Preference 49 402.2062560PA0020066 Rating Area 2 No Preference 50 421.0662560PA0020066 Rating Area 2 No Preference 51 439.6862560PA0020066 Rating Area 2 No Preference 52 460.1962560PA0020066 Rating Area 2 No Preference 53 480.9462560PA0020066 Rating Area 2 No Preference 54 503.3362560PA0020066 Rating Area 2 No Preference 55 525.7362560PA0020066 Rating Area 2 No Preference 56 550.0162560PA0020066 Rating Area 2 No Preference 57 574.5362560PA0020066 Rating Area 2 No Preference 58 600.7062560PA0020066 Rating Area 2 No Preference 59 613.6762560PA0020066 Rating Area 2 No Preference 60 639.8362560PA0020066 Rating Area 2 No Preference 61 662.4762560PA0020066 Rating Area 2 No Preference 62 677.3262560PA0020066 Rating Area 2 No Preference 63 695.9462560PA0020066 Rating Area 2 No Preference 64 707.2662560PA0020066 Rating Area 2 No Preference 65 and over 707.2662560PA0020066 Rating Area 4 No Preference 0-20 149.7162560PA0020066 Rating Area 4 No Preference 21 235.7662560PA0020066 Rating Area 4 No Preference 22 235.7662560PA0020066 Rating Area 4 No Preference 23 235.7662560PA0020066 Rating Area 4 No Preference 24 235.7662560PA0020066 Rating Area 4 No Preference 25 236.7062560PA0020066 Rating Area 4 No Preference 26 241.4162560PA0020066 Rating Area 4 No Preference 27 247.0762560PA0020066 Rating Area 4 No Preference 28 256.2762560PA0020066 Rating Area 4 No Preference 29 263.8162560PA0020066 Rating Area 4 No Preference 30 267.5862560PA0020066 Rating Area 4 No Preference 31 273.2462560PA0020066 Rating Area 4 No Preference 32 278.9062560PA0020066 Rating Area 4 No Preference 33 282.4462560PA0020066 Rating Area 4 No Preference 34 286.2162560PA0020066 Rating Area 4 No Preference 35 288.0962560PA0020066 Rating Area 4 No Preference 36 289.98

62560PA0020066 Rating Area 4 No Preference 37 291.8762560PA0020066 Rating Area 4 No Preference 38 293.7562560PA0020066 Rating Area 4 No Preference 39 297.5262560PA0020066 Rating Area 4 No Preference 40 301.3062560PA0020066 Rating Area 4 No Preference 41 306.9562560PA0020066 Rating Area 4 No Preference 42 312.3862560PA0020066 Rating Area 4 No Preference 43 319.9262560PA0020066 Rating Area 4 No Preference 44 329.3562560PA0020066 Rating Area 4 No Preference 45 340.4362560PA0020066 Rating Area 4 No Preference 46 353.6362560PA0020066 Rating Area 4 No Preference 47 368.4862560PA0020066 Rating Area 4 No Preference 48 385.4662560PA0020066 Rating Area 4 No Preference 49 402.2062560PA0020066 Rating Area 4 No Preference 50 421.0662560PA0020066 Rating Area 4 No Preference 51 439.6862560PA0020066 Rating Area 4 No Preference 52 460.1962560PA0020066 Rating Area 4 No Preference 53 480.9462560PA0020066 Rating Area 4 No Preference 54 503.3362560PA0020066 Rating Area 4 No Preference 55 525.7362560PA0020066 Rating Area 4 No Preference 56 550.0162560PA0020066 Rating Area 4 No Preference 57 574.5362560PA0020066 Rating Area 4 No Preference 58 600.7062560PA0020066 Rating Area 4 No Preference 59 613.6762560PA0020066 Rating Area 4 No Preference 60 639.8362560PA0020066 Rating Area 4 No Preference 61 662.4762560PA0020066 Rating Area 4 No Preference 62 677.3262560PA0020066 Rating Area 4 No Preference 63 695.9462560PA0020066 Rating Area 4 No Preference 64 707.2662560PA0020066 Rating Area 4 No Preference 65 and over 707.2662560PA0020066 Rating Area 5 No Preference 0-20 149.7162560PA0020066 Rating Area 5 No Preference 21 235.7662560PA0020066 Rating Area 5 No Preference 22 235.7662560PA0020066 Rating Area 5 No Preference 23 235.7662560PA0020066 Rating Area 5 No Preference 24 235.7662560PA0020066 Rating Area 5 No Preference 25 236.7062560PA0020066 Rating Area 5 No Preference 26 241.4162560PA0020066 Rating Area 5 No Preference 27 247.0762560PA0020066 Rating Area 5 No Preference 28 256.2762560PA0020066 Rating Area 5 No Preference 29 263.8162560PA0020066 Rating Area 5 No Preference 30 267.5862560PA0020066 Rating Area 5 No Preference 31 273.2462560PA0020066 Rating Area 5 No Preference 32 278.9062560PA0020066 Rating Area 5 No Preference 33 282.4462560PA0020066 Rating Area 5 No Preference 34 286.2162560PA0020066 Rating Area 5 No Preference 35 288.0962560PA0020066 Rating Area 5 No Preference 36 289.9862560PA0020066 Rating Area 5 No Preference 37 291.8762560PA0020066 Rating Area 5 No Preference 38 293.7562560PA0020066 Rating Area 5 No Preference 39 297.52

62560PA0020066 Rating Area 5 No Preference 40 301.3062560PA0020066 Rating Area 5 No Preference 41 306.9562560PA0020066 Rating Area 5 No Preference 42 312.3862560PA0020066 Rating Area 5 No Preference 43 319.9262560PA0020066 Rating Area 5 No Preference 44 329.3562560PA0020066 Rating Area 5 No Preference 45 340.4362560PA0020066 Rating Area 5 No Preference 46 353.6362560PA0020066 Rating Area 5 No Preference 47 368.4862560PA0020066 Rating Area 5 No Preference 48 385.4662560PA0020066 Rating Area 5 No Preference 49 402.2062560PA0020066 Rating Area 5 No Preference 50 421.0662560PA0020066 Rating Area 5 No Preference 51 439.6862560PA0020066 Rating Area 5 No Preference 52 460.1962560PA0020066 Rating Area 5 No Preference 53 480.9462560PA0020066 Rating Area 5 No Preference 54 503.3362560PA0020066 Rating Area 5 No Preference 55 525.7362560PA0020066 Rating Area 5 No Preference 56 550.0162560PA0020066 Rating Area 5 No Preference 57 574.5362560PA0020066 Rating Area 5 No Preference 58 600.7062560PA0020066 Rating Area 5 No Preference 59 613.6762560PA0020066 Rating Area 5 No Preference 60 639.8362560PA0020066 Rating Area 5 No Preference 61 662.4762560PA0020066 Rating Area 5 No Preference 62 677.3262560PA0020066 Rating Area 5 No Preference 63 695.9462560PA0020066 Rating Area 5 No Preference 64 707.2662560PA0020066 Rating Area 5 No Preference 65 and over 707.2662560PA0020066 Rating Area 6 No Preference 0-20 149.7162560PA0020066 Rating Area 6 No Preference 21 235.7662560PA0020066 Rating Area 6 No Preference 22 235.7662560PA0020066 Rating Area 6 No Preference 23 235.7662560PA0020066 Rating Area 6 No Preference 24 235.7662560PA0020066 Rating Area 6 No Preference 25 236.7062560PA0020066 Rating Area 6 No Preference 26 241.4162560PA0020066 Rating Area 6 No Preference 27 247.0762560PA0020066 Rating Area 6 No Preference 28 256.2762560PA0020066 Rating Area 6 No Preference 29 263.8162560PA0020066 Rating Area 6 No Preference 30 267.5862560PA0020066 Rating Area 6 No Preference 31 273.2462560PA0020066 Rating Area 6 No Preference 32 278.9062560PA0020066 Rating Area 6 No Preference 33 282.4462560PA0020066 Rating Area 6 No Preference 34 286.2162560PA0020066 Rating Area 6 No Preference 35 288.0962560PA0020066 Rating Area 6 No Preference 36 289.9862560PA0020066 Rating Area 6 No Preference 37 291.8762560PA0020066 Rating Area 6 No Preference 38 293.7562560PA0020066 Rating Area 6 No Preference 39 297.5262560PA0020066 Rating Area 6 No Preference 40 301.3062560PA0020066 Rating Area 6 No Preference 41 306.9562560PA0020066 Rating Area 6 No Preference 42 312.38

62560PA0020066 Rating Area 6 No Preference 43 319.9262560PA0020066 Rating Area 6 No Preference 44 329.3562560PA0020066 Rating Area 6 No Preference 45 340.4362560PA0020066 Rating Area 6 No Preference 46 353.6362560PA0020066 Rating Area 6 No Preference 47 368.4862560PA0020066 Rating Area 6 No Preference 48 385.4662560PA0020066 Rating Area 6 No Preference 49 402.2062560PA0020066 Rating Area 6 No Preference 50 421.0662560PA0020066 Rating Area 6 No Preference 51 439.6862560PA0020066 Rating Area 6 No Preference 52 460.1962560PA0020066 Rating Area 6 No Preference 53 480.9462560PA0020066 Rating Area 6 No Preference 54 503.3362560PA0020066 Rating Area 6 No Preference 55 525.7362560PA0020066 Rating Area 6 No Preference 56 550.0162560PA0020066 Rating Area 6 No Preference 57 574.5362560PA0020066 Rating Area 6 No Preference 58 600.7062560PA0020066 Rating Area 6 No Preference 59 613.6762560PA0020066 Rating Area 6 No Preference 60 639.8362560PA0020066 Rating Area 6 No Preference 61 662.4762560PA0020066 Rating Area 6 No Preference 62 677.3262560PA0020066 Rating Area 6 No Preference 63 695.9462560PA0020066 Rating Area 6 No Preference 64 707.2662560PA0020066 Rating Area 6 No Preference 65 and over 707.2662560PA0020067 Rating Area 1 No Preference 0-20 192.7162560PA0020067 Rating Area 1 No Preference 21 303.4862560PA0020067 Rating Area 1 No Preference 22 303.4862560PA0020067 Rating Area 1 No Preference 23 303.4862560PA0020067 Rating Area 1 No Preference 24 303.4862560PA0020067 Rating Area 1 No Preference 25 304.7062560PA0020067 Rating Area 1 No Preference 26 310.7762560PA0020067 Rating Area 1 No Preference 27 318.0562560PA0020067 Rating Area 1 No Preference 28 329.8962560PA0020067 Rating Area 1 No Preference 29 339.6062560PA0020067 Rating Area 1 No Preference 30 344.4562560PA0020067 Rating Area 1 No Preference 31 351.7462560PA0020067 Rating Area 1 No Preference 32 359.0262560PA0020067 Rating Area 1 No Preference 33 363.5762560PA0020067 Rating Area 1 No Preference 34 368.4362560PA0020067 Rating Area 1 No Preference 35 370.8662560PA0020067 Rating Area 1 No Preference 36 373.2862560PA0020067 Rating Area 1 No Preference 37 375.7162560PA0020067 Rating Area 1 No Preference 38 378.1462560PA0020067 Rating Area 1 No Preference 39 382.9962560PA0020067 Rating Area 1 No Preference 40 387.8562560PA0020067 Rating Area 1 No Preference 41 395.1362560PA0020067 Rating Area 1 No Preference 42 402.1162560PA0020067 Rating Area 1 No Preference 43 411.8362560PA0020067 Rating Area 1 No Preference 44 423.9662560PA0020067 Rating Area 1 No Preference 45 438.23

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62560PA0020069 Rating Area 1 No Preference 27 243.3162560PA0020069 Rating Area 1 No Preference 28 252.3662560PA0020069 Rating Area 1 No Preference 29 259.7962560PA0020069 Rating Area 1 No Preference 30 263.5162560PA0020069 Rating Area 1 No Preference 31 269.0862560PA0020069 Rating Area 1 No Preference 32 274.6562560PA0020069 Rating Area 1 No Preference 33 278.1362560PA0020069 Rating Area 1 No Preference 34 281.8562560PA0020069 Rating Area 1 No Preference 35 283.7162560PA0020069 Rating Area 1 No Preference 36 285.5662560PA0020069 Rating Area 1 No Preference 37 287.4262560PA0020069 Rating Area 1 No Preference 38 289.2862560PA0020069 Rating Area 1 No Preference 39 292.9962560PA0020069 Rating Area 1 No Preference 40 296.7162560PA0020069 Rating Area 1 No Preference 41 302.2862560PA0020069 Rating Area 1 No Preference 42 307.6262560PA0020069 Rating Area 1 No Preference 43 315.0562560PA0020069 Rating Area 1 No Preference 44 324.3362560PA0020069 Rating Area 1 No Preference 45 335.2562560PA0020069 Rating Area 1 No Preference 46 348.2562560PA0020069 Rating Area 1 No Preference 47 362.8762560PA0020069 Rating Area 1 No Preference 48 379.5962560PA0020069 Rating Area 1 No Preference 49 396.0762560PA0020069 Rating Area 1 No Preference 50 414.6462560PA0020069 Rating Area 1 No Preference 51 432.9862560PA0020069 Rating Area 1 No Preference 52 453.1862560PA0020069 Rating Area 1 No Preference 53 473.6162560PA0020069 Rating Area 1 No Preference 54 495.6762560PA0020069 Rating Area 1 No Preference 55 517.7262560PA0020069 Rating Area 1 No Preference 56 541.6462560PA0020069 Rating Area 1 No Preference 57 565.7862560PA0020069 Rating Area 1 No Preference 58 591.5562560PA0020069 Rating Area 1 No Preference 59 604.3262560PA0020069 Rating Area 1 No Preference 60 630.0962560PA0020069 Rating Area 1 No Preference 61 652.3862560PA0020069 Rating Area 1 No Preference 62 667.0062560PA0020069 Rating Area 1 No Preference 63 685.3462560PA0020069 Rating Area 1 No Preference 64 696.4962560PA0020069 Rating Area 1 No Preference 65 and over 696.4962560PA0020069 Rating Area 2 No Preference 0-20 147.4362560PA0020069 Rating Area 2 No Preference 21 232.1762560PA0020069 Rating Area 2 No Preference 22 232.1762560PA0020069 Rating Area 2 No Preference 23 232.1762560PA0020069 Rating Area 2 No Preference 24 232.1762560PA0020069 Rating Area 2 No Preference 25 233.0962560PA0020069 Rating Area 2 No Preference 26 237.7462560PA0020069 Rating Area 2 No Preference 27 243.3162560PA0020069 Rating Area 2 No Preference 28 252.3662560PA0020069 Rating Area 2 No Preference 29 259.79

62560PA0020069 Rating Area 2 No Preference 30 263.5162560PA0020069 Rating Area 2 No Preference 31 269.0862560PA0020069 Rating Area 2 No Preference 32 274.6562560PA0020069 Rating Area 2 No Preference 33 278.1362560PA0020069 Rating Area 2 No Preference 34 281.8562560PA0020069 Rating Area 2 No Preference 35 283.7162560PA0020069 Rating Area 2 No Preference 36 285.5662560PA0020069 Rating Area 2 No Preference 37 287.4262560PA0020069 Rating Area 2 No Preference 38 289.2862560PA0020069 Rating Area 2 No Preference 39 292.9962560PA0020069 Rating Area 2 No Preference 40 296.7162560PA0020069 Rating Area 2 No Preference 41 302.2862560PA0020069 Rating Area 2 No Preference 42 307.6262560PA0020069 Rating Area 2 No Preference 43 315.0562560PA0020069 Rating Area 2 No Preference 44 324.3362560PA0020069 Rating Area 2 No Preference 45 335.2562560PA0020069 Rating Area 2 No Preference 46 348.2562560PA0020069 Rating Area 2 No Preference 47 362.8762560PA0020069 Rating Area 2 No Preference 48 379.5962560PA0020069 Rating Area 2 No Preference 49 396.0762560PA0020069 Rating Area 2 No Preference 50 414.6462560PA0020069 Rating Area 2 No Preference 51 432.9862560PA0020069 Rating Area 2 No Preference 52 453.1862560PA0020069 Rating Area 2 No Preference 53 473.6162560PA0020069 Rating Area 2 No Preference 54 495.6762560PA0020069 Rating Area 2 No Preference 55 517.7262560PA0020069 Rating Area 2 No Preference 56 541.6462560PA0020069 Rating Area 2 No Preference 57 565.7862560PA0020069 Rating Area 2 No Preference 58 591.5562560PA0020069 Rating Area 2 No Preference 59 604.3262560PA0020069 Rating Area 2 No Preference 60 630.0962560PA0020069 Rating Area 2 No Preference 61 652.3862560PA0020069 Rating Area 2 No Preference 62 667.0062560PA0020069 Rating Area 2 No Preference 63 685.3462560PA0020069 Rating Area 2 No Preference 64 696.4962560PA0020069 Rating Area 2 No Preference 65 and over 696.4962560PA0020069 Rating Area 4 No Preference 0-20 147.4362560PA0020069 Rating Area 4 No Preference 21 232.1762560PA0020069 Rating Area 4 No Preference 22 232.1762560PA0020069 Rating Area 4 No Preference 23 232.1762560PA0020069 Rating Area 4 No Preference 24 232.1762560PA0020069 Rating Area 4 No Preference 25 233.0962560PA0020069 Rating Area 4 No Preference 26 237.7462560PA0020069 Rating Area 4 No Preference 27 243.3162560PA0020069 Rating Area 4 No Preference 28 252.3662560PA0020069 Rating Area 4 No Preference 29 259.7962560PA0020069 Rating Area 4 No Preference 30 263.5162560PA0020069 Rating Area 4 No Preference 31 269.0862560PA0020069 Rating Area 4 No Preference 32 274.65

62560PA0020069 Rating Area 4 No Preference 33 278.1362560PA0020069 Rating Area 4 No Preference 34 281.8562560PA0020069 Rating Area 4 No Preference 35 283.7162560PA0020069 Rating Area 4 No Preference 36 285.5662560PA0020069 Rating Area 4 No Preference 37 287.4262560PA0020069 Rating Area 4 No Preference 38 289.2862560PA0020069 Rating Area 4 No Preference 39 292.9962560PA0020069 Rating Area 4 No Preference 40 296.7162560PA0020069 Rating Area 4 No Preference 41 302.2862560PA0020069 Rating Area 4 No Preference 42 307.6262560PA0020069 Rating Area 4 No Preference 43 315.0562560PA0020069 Rating Area 4 No Preference 44 324.3362560PA0020069 Rating Area 4 No Preference 45 335.2562560PA0020069 Rating Area 4 No Preference 46 348.2562560PA0020069 Rating Area 4 No Preference 47 362.8762560PA0020069 Rating Area 4 No Preference 48 379.5962560PA0020069 Rating Area 4 No Preference 49 396.0762560PA0020069 Rating Area 4 No Preference 50 414.6462560PA0020069 Rating Area 4 No Preference 51 432.9862560PA0020069 Rating Area 4 No Preference 52 453.1862560PA0020069 Rating Area 4 No Preference 53 473.6162560PA0020069 Rating Area 4 No Preference 54 495.6762560PA0020069 Rating Area 4 No Preference 55 517.7262560PA0020069 Rating Area 4 No Preference 56 541.6462560PA0020069 Rating Area 4 No Preference 57 565.7862560PA0020069 Rating Area 4 No Preference 58 591.5562560PA0020069 Rating Area 4 No Preference 59 604.3262560PA0020069 Rating Area 4 No Preference 60 630.0962560PA0020069 Rating Area 4 No Preference 61 652.3862560PA0020069 Rating Area 4 No Preference 62 667.0062560PA0020069 Rating Area 4 No Preference 63 685.3462560PA0020069 Rating Area 4 No Preference 64 696.4962560PA0020069 Rating Area 4 No Preference 65 and over 696.4962560PA0020069 Rating Area 5 No Preference 0-20 147.4362560PA0020069 Rating Area 5 No Preference 21 232.1762560PA0020069 Rating Area 5 No Preference 22 232.1762560PA0020069 Rating Area 5 No Preference 23 232.1762560PA0020069 Rating Area 5 No Preference 24 232.1762560PA0020069 Rating Area 5 No Preference 25 233.0962560PA0020069 Rating Area 5 No Preference 26 237.7462560PA0020069 Rating Area 5 No Preference 27 243.3162560PA0020069 Rating Area 5 No Preference 28 252.3662560PA0020069 Rating Area 5 No Preference 29 259.7962560PA0020069 Rating Area 5 No Preference 30 263.5162560PA0020069 Rating Area 5 No Preference 31 269.0862560PA0020069 Rating Area 5 No Preference 32 274.6562560PA0020069 Rating Area 5 No Preference 33 278.1362560PA0020069 Rating Area 5 No Preference 34 281.8562560PA0020069 Rating Area 5 No Preference 35 283.71

62560PA0020069 Rating Area 5 No Preference 36 285.5662560PA0020069 Rating Area 5 No Preference 37 287.4262560PA0020069 Rating Area 5 No Preference 38 289.2862560PA0020069 Rating Area 5 No Preference 39 292.9962560PA0020069 Rating Area 5 No Preference 40 296.7162560PA0020069 Rating Area 5 No Preference 41 302.2862560PA0020069 Rating Area 5 No Preference 42 307.6262560PA0020069 Rating Area 5 No Preference 43 315.0562560PA0020069 Rating Area 5 No Preference 44 324.3362560PA0020069 Rating Area 5 No Preference 45 335.2562560PA0020069 Rating Area 5 No Preference 46 348.2562560PA0020069 Rating Area 5 No Preference 47 362.8762560PA0020069 Rating Area 5 No Preference 48 379.5962560PA0020069 Rating Area 5 No Preference 49 396.0762560PA0020069 Rating Area 5 No Preference 50 414.6462560PA0020069 Rating Area 5 No Preference 51 432.9862560PA0020069 Rating Area 5 No Preference 52 453.1862560PA0020069 Rating Area 5 No Preference 53 473.6162560PA0020069 Rating Area 5 No Preference 54 495.6762560PA0020069 Rating Area 5 No Preference 55 517.7262560PA0020069 Rating Area 5 No Preference 56 541.6462560PA0020069 Rating Area 5 No Preference 57 565.7862560PA0020069 Rating Area 5 No Preference 58 591.5562560PA0020069 Rating Area 5 No Preference 59 604.3262560PA0020069 Rating Area 5 No Preference 60 630.0962560PA0020069 Rating Area 5 No Preference 61 652.3862560PA0020069 Rating Area 5 No Preference 62 667.0062560PA0020069 Rating Area 5 No Preference 63 685.3462560PA0020069 Rating Area 5 No Preference 64 696.4962560PA0020069 Rating Area 5 No Preference 65 and over 696.4962560PA0020069 Rating Area 6 No Preference 0-20 147.4362560PA0020069 Rating Area 6 No Preference 21 232.1762560PA0020069 Rating Area 6 No Preference 22 232.1762560PA0020069 Rating Area 6 No Preference 23 232.1762560PA0020069 Rating Area 6 No Preference 24 232.1762560PA0020069 Rating Area 6 No Preference 25 233.0962560PA0020069 Rating Area 6 No Preference 26 237.7462560PA0020069 Rating Area 6 No Preference 27 243.3162560PA0020069 Rating Area 6 No Preference 28 252.3662560PA0020069 Rating Area 6 No Preference 29 259.7962560PA0020069 Rating Area 6 No Preference 30 263.5162560PA0020069 Rating Area 6 No Preference 31 269.0862560PA0020069 Rating Area 6 No Preference 32 274.6562560PA0020069 Rating Area 6 No Preference 33 278.1362560PA0020069 Rating Area 6 No Preference 34 281.8562560PA0020069 Rating Area 6 No Preference 35 283.7162560PA0020069 Rating Area 6 No Preference 36 285.5662560PA0020069 Rating Area 6 No Preference 37 287.4262560PA0020069 Rating Area 6 No Preference 38 289.28

62560PA0020069 Rating Area 6 No Preference 39 292.9962560PA0020069 Rating Area 6 No Preference 40 296.7162560PA0020069 Rating Area 6 No Preference 41 302.2862560PA0020069 Rating Area 6 No Preference 42 307.6262560PA0020069 Rating Area 6 No Preference 43 315.0562560PA0020069 Rating Area 6 No Preference 44 324.3362560PA0020069 Rating Area 6 No Preference 45 335.2562560PA0020069 Rating Area 6 No Preference 46 348.2562560PA0020069 Rating Area 6 No Preference 47 362.8762560PA0020069 Rating Area 6 No Preference 48 379.5962560PA0020069 Rating Area 6 No Preference 49 396.0762560PA0020069 Rating Area 6 No Preference 50 414.6462560PA0020069 Rating Area 6 No Preference 51 432.9862560PA0020069 Rating Area 6 No Preference 52 453.1862560PA0020069 Rating Area 6 No Preference 53 473.6162560PA0020069 Rating Area 6 No Preference 54 495.6762560PA0020069 Rating Area 6 No Preference 55 517.7262560PA0020069 Rating Area 6 No Preference 56 541.6462560PA0020069 Rating Area 6 No Preference 57 565.7862560PA0020069 Rating Area 6 No Preference 58 591.5562560PA0020069 Rating Area 6 No Preference 59 604.3262560PA0020069 Rating Area 6 No Preference 60 630.0962560PA0020069 Rating Area 6 No Preference 61 652.3862560PA0020069 Rating Area 6 No Preference 62 667.0062560PA0020069 Rating Area 6 No Preference 63 685.3462560PA0020069 Rating Area 6 No Preference 64 696.4962560PA0020069 Rating Area 6 No Preference 65 and over 696.4962560PA0020070 Rating Area 1 No Preference 0-20 109.8762560PA0020070 Rating Area 1 No Preference 21 173.0262560PA0020070 Rating Area 1 No Preference 22 173.0262560PA0020070 Rating Area 1 No Preference 23 173.0262560PA0020070 Rating Area 1 No Preference 24 173.0262560PA0020070 Rating Area 1 No Preference 25 173.7162560PA0020070 Rating Area 1 No Preference 26 177.1762560PA0020070 Rating Area 1 No Preference 27 181.3262560PA0020070 Rating Area 1 No Preference 28 188.0762560PA0020070 Rating Area 1 No Preference 29 193.6162560PA0020070 Rating Area 1 No Preference 30 196.3862560PA0020070 Rating Area 1 No Preference 31 200.5362560PA0020070 Rating Area 1 No Preference 32 204.6862560PA0020070 Rating Area 1 No Preference 33 207.2862560PA0020070 Rating Area 1 No Preference 34 210.0462560PA0020070 Rating Area 1 No Preference 35 211.4362560PA0020070 Rating Area 1 No Preference 36 212.8162560PA0020070 Rating Area 1 No Preference 37 214.2062560PA0020070 Rating Area 1 No Preference 38 215.5862560PA0020070 Rating Area 1 No Preference 39 218.3562560PA0020070 Rating Area 1 No Preference 40 221.1262560PA0020070 Rating Area 1 No Preference 41 225.27

62560PA0020070 Rating Area 1 No Preference 42 229.2562560PA0020070 Rating Area 1 No Preference 43 234.7962560PA0020070 Rating Area 1 No Preference 44 241.7162560PA0020070 Rating Area 1 No Preference 45 249.8462560PA0020070 Rating Area 1 No Preference 46 259.5362560PA0020070 Rating Area 1 No Preference 47 270.4362560PA0020070 Rating Area 1 No Preference 48 282.8862560PA0020070 Rating Area 1 No Preference 49 295.1762560PA0020070 Rating Area 1 No Preference 50 309.0162560PA0020070 Rating Area 1 No Preference 51 322.6862560PA0020070 Rating Area 1 No Preference 52 337.7362560PA0020070 Rating Area 1 No Preference 53 352.9562560PA0020070 Rating Area 1 No Preference 54 369.3962560PA0020070 Rating Area 1 No Preference 55 385.8362560PA0020070 Rating Area 1 No Preference 56 403.6562560PA0020070 Rating Area 1 No Preference 57 421.6462560PA0020070 Rating Area 1 No Preference 58 440.8562560PA0020070 Rating Area 1 No Preference 59 450.3662560PA0020070 Rating Area 1 No Preference 60 469.5762560PA0020070 Rating Area 1 No Preference 61 486.1862560PA0020070 Rating Area 1 No Preference 62 497.0762560PA0020070 Rating Area 1 No Preference 63 510.7462560PA0020070 Rating Area 1 No Preference 64 519.0562560PA0020070 Rating Area 1 No Preference 65 and over 519.0562560PA0020070 Rating Area 2 No Preference 0-20 109.8762560PA0020070 Rating Area 2 No Preference 21 173.0262560PA0020070 Rating Area 2 No Preference 22 173.0262560PA0020070 Rating Area 2 No Preference 23 173.0262560PA0020070 Rating Area 2 No Preference 24 173.0262560PA0020070 Rating Area 2 No Preference 25 173.7162560PA0020070 Rating Area 2 No Preference 26 177.1762560PA0020070 Rating Area 2 No Preference 27 181.3262560PA0020070 Rating Area 2 No Preference 28 188.0762560PA0020070 Rating Area 2 No Preference 29 193.6162560PA0020070 Rating Area 2 No Preference 30 196.3862560PA0020070 Rating Area 2 No Preference 31 200.5362560PA0020070 Rating Area 2 No Preference 32 204.6862560PA0020070 Rating Area 2 No Preference 33 207.2862560PA0020070 Rating Area 2 No Preference 34 210.0462560PA0020070 Rating Area 2 No Preference 35 211.4362560PA0020070 Rating Area 2 No Preference 36 212.8162560PA0020070 Rating Area 2 No Preference 37 214.2062560PA0020070 Rating Area 2 No Preference 38 215.5862560PA0020070 Rating Area 2 No Preference 39 218.3562560PA0020070 Rating Area 2 No Preference 40 221.1262560PA0020070 Rating Area 2 No Preference 41 225.2762560PA0020070 Rating Area 2 No Preference 42 229.2562560PA0020070 Rating Area 2 No Preference 43 234.7962560PA0020070 Rating Area 2 No Preference 44 241.71

62560PA0020070 Rating Area 2 No Preference 45 249.8462560PA0020070 Rating Area 2 No Preference 46 259.5362560PA0020070 Rating Area 2 No Preference 47 270.4362560PA0020070 Rating Area 2 No Preference 48 282.8862560PA0020070 Rating Area 2 No Preference 49 295.1762560PA0020070 Rating Area 2 No Preference 50 309.0162560PA0020070 Rating Area 2 No Preference 51 322.6862560PA0020070 Rating Area 2 No Preference 52 337.7362560PA0020070 Rating Area 2 No Preference 53 352.9562560PA0020070 Rating Area 2 No Preference 54 369.3962560PA0020070 Rating Area 2 No Preference 55 385.8362560PA0020070 Rating Area 2 No Preference 56 403.6562560PA0020070 Rating Area 2 No Preference 57 421.6462560PA0020070 Rating Area 2 No Preference 58 440.8562560PA0020070 Rating Area 2 No Preference 59 450.3662560PA0020070 Rating Area 2 No Preference 60 469.5762560PA0020070 Rating Area 2 No Preference 61 486.1862560PA0020070 Rating Area 2 No Preference 62 497.0762560PA0020070 Rating Area 2 No Preference 63 510.7462560PA0020070 Rating Area 2 No Preference 64 519.0562560PA0020070 Rating Area 2 No Preference 65 and over 519.0562560PA0020070 Rating Area 4 No Preference 0-20 109.8762560PA0020070 Rating Area 4 No Preference 21 173.0262560PA0020070 Rating Area 4 No Preference 22 173.0262560PA0020070 Rating Area 4 No Preference 23 173.0262560PA0020070 Rating Area 4 No Preference 24 173.0262560PA0020070 Rating Area 4 No Preference 25 173.7162560PA0020070 Rating Area 4 No Preference 26 177.1762560PA0020070 Rating Area 4 No Preference 27 181.3262560PA0020070 Rating Area 4 No Preference 28 188.0762560PA0020070 Rating Area 4 No Preference 29 193.6162560PA0020070 Rating Area 4 No Preference 30 196.3862560PA0020070 Rating Area 4 No Preference 31 200.5362560PA0020070 Rating Area 4 No Preference 32 204.6862560PA0020070 Rating Area 4 No Preference 33 207.2862560PA0020070 Rating Area 4 No Preference 34 210.0462560PA0020070 Rating Area 4 No Preference 35 211.4362560PA0020070 Rating Area 4 No Preference 36 212.8162560PA0020070 Rating Area 4 No Preference 37 214.2062560PA0020070 Rating Area 4 No Preference 38 215.5862560PA0020070 Rating Area 4 No Preference 39 218.3562560PA0020070 Rating Area 4 No Preference 40 221.1262560PA0020070 Rating Area 4 No Preference 41 225.2762560PA0020070 Rating Area 4 No Preference 42 229.2562560PA0020070 Rating Area 4 No Preference 43 234.7962560PA0020070 Rating Area 4 No Preference 44 241.7162560PA0020070 Rating Area 4 No Preference 45 249.8462560PA0020070 Rating Area 4 No Preference 46 259.5362560PA0020070 Rating Area 4 No Preference 47 270.43

62560PA0020070 Rating Area 4 No Preference 48 282.8862560PA0020070 Rating Area 4 No Preference 49 295.1762560PA0020070 Rating Area 4 No Preference 50 309.0162560PA0020070 Rating Area 4 No Preference 51 322.6862560PA0020070 Rating Area 4 No Preference 52 337.7362560PA0020070 Rating Area 4 No Preference 53 352.9562560PA0020070 Rating Area 4 No Preference 54 369.3962560PA0020070 Rating Area 4 No Preference 55 385.8362560PA0020070 Rating Area 4 No Preference 56 403.6562560PA0020070 Rating Area 4 No Preference 57 421.6462560PA0020070 Rating Area 4 No Preference 58 440.8562560PA0020070 Rating Area 4 No Preference 59 450.3662560PA0020070 Rating Area 4 No Preference 60 469.5762560PA0020070 Rating Area 4 No Preference 61 486.1862560PA0020070 Rating Area 4 No Preference 62 497.0762560PA0020070 Rating Area 4 No Preference 63 510.7462560PA0020070 Rating Area 4 No Preference 64 519.0562560PA0020070 Rating Area 4 No Preference 65 and over 519.0562560PA0020070 Rating Area 5 No Preference 0-20 109.8762560PA0020070 Rating Area 5 No Preference 21 173.0262560PA0020070 Rating Area 5 No Preference 22 173.0262560PA0020070 Rating Area 5 No Preference 23 173.0262560PA0020070 Rating Area 5 No Preference 24 173.0262560PA0020070 Rating Area 5 No Preference 25 173.7162560PA0020070 Rating Area 5 No Preference 26 177.1762560PA0020070 Rating Area 5 No Preference 27 181.3262560PA0020070 Rating Area 5 No Preference 28 188.0762560PA0020070 Rating Area 5 No Preference 29 193.6162560PA0020070 Rating Area 5 No Preference 30 196.3862560PA0020070 Rating Area 5 No Preference 31 200.5362560PA0020070 Rating Area 5 No Preference 32 204.6862560PA0020070 Rating Area 5 No Preference 33 207.2862560PA0020070 Rating Area 5 No Preference 34 210.0462560PA0020070 Rating Area 5 No Preference 35 211.4362560PA0020070 Rating Area 5 No Preference 36 212.8162560PA0020070 Rating Area 5 No Preference 37 214.2062560PA0020070 Rating Area 5 No Preference 38 215.5862560PA0020070 Rating Area 5 No Preference 39 218.3562560PA0020070 Rating Area 5 No Preference 40 221.1262560PA0020070 Rating Area 5 No Preference 41 225.2762560PA0020070 Rating Area 5 No Preference 42 229.2562560PA0020070 Rating Area 5 No Preference 43 234.7962560PA0020070 Rating Area 5 No Preference 44 241.7162560PA0020070 Rating Area 5 No Preference 45 249.8462560PA0020070 Rating Area 5 No Preference 46 259.5362560PA0020070 Rating Area 5 No Preference 47 270.4362560PA0020070 Rating Area 5 No Preference 48 282.8862560PA0020070 Rating Area 5 No Preference 49 295.1762560PA0020070 Rating Area 5 No Preference 50 309.01

62560PA0020070 Rating Area 5 No Preference 51 322.6862560PA0020070 Rating Area 5 No Preference 52 337.7362560PA0020070 Rating Area 5 No Preference 53 352.9562560PA0020070 Rating Area 5 No Preference 54 369.3962560PA0020070 Rating Area 5 No Preference 55 385.8362560PA0020070 Rating Area 5 No Preference 56 403.6562560PA0020070 Rating Area 5 No Preference 57 421.6462560PA0020070 Rating Area 5 No Preference 58 440.8562560PA0020070 Rating Area 5 No Preference 59 450.3662560PA0020070 Rating Area 5 No Preference 60 469.5762560PA0020070 Rating Area 5 No Preference 61 486.1862560PA0020070 Rating Area 5 No Preference 62 497.0762560PA0020070 Rating Area 5 No Preference 63 510.7462560PA0020070 Rating Area 5 No Preference 64 519.0562560PA0020070 Rating Area 5 No Preference 65 and over 519.0562560PA0020070 Rating Area 6 No Preference 0-20 109.8762560PA0020070 Rating Area 6 No Preference 21 173.0262560PA0020070 Rating Area 6 No Preference 22 173.0262560PA0020070 Rating Area 6 No Preference 23 173.0262560PA0020070 Rating Area 6 No Preference 24 173.0262560PA0020070 Rating Area 6 No Preference 25 173.7162560PA0020070 Rating Area 6 No Preference 26 177.1762560PA0020070 Rating Area 6 No Preference 27 181.3262560PA0020070 Rating Area 6 No Preference 28 188.0762560PA0020070 Rating Area 6 No Preference 29 193.6162560PA0020070 Rating Area 6 No Preference 30 196.3862560PA0020070 Rating Area 6 No Preference 31 200.5362560PA0020070 Rating Area 6 No Preference 32 204.6862560PA0020070 Rating Area 6 No Preference 33 207.2862560PA0020070 Rating Area 6 No Preference 34 210.0462560PA0020070 Rating Area 6 No Preference 35 211.4362560PA0020070 Rating Area 6 No Preference 36 212.8162560PA0020070 Rating Area 6 No Preference 37 214.2062560PA0020070 Rating Area 6 No Preference 38 215.5862560PA0020070 Rating Area 6 No Preference 39 218.3562560PA0020070 Rating Area 6 No Preference 40 221.1262560PA0020070 Rating Area 6 No Preference 41 225.2762560PA0020070 Rating Area 6 No Preference 42 229.2562560PA0020070 Rating Area 6 No Preference 43 234.7962560PA0020070 Rating Area 6 No Preference 44 241.7162560PA0020070 Rating Area 6 No Preference 45 249.8462560PA0020070 Rating Area 6 No Preference 46 259.5362560PA0020070 Rating Area 6 No Preference 47 270.4362560PA0020070 Rating Area 6 No Preference 48 282.8862560PA0020070 Rating Area 6 No Preference 49 295.1762560PA0020070 Rating Area 6 No Preference 50 309.0162560PA0020070 Rating Area 6 No Preference 51 322.6862560PA0020070 Rating Area 6 No Preference 52 337.7362560PA0020070 Rating Area 6 No Preference 53 352.95

62560PA0020070 Rating Area 6 No Preference 54 369.3962560PA0020070 Rating Area 6 No Preference 55 385.8362560PA0020070 Rating Area 6 No Preference 56 403.6562560PA0020070 Rating Area 6 No Preference 57 421.6462560PA0020070 Rating Area 6 No Preference 58 440.8562560PA0020070 Rating Area 6 No Preference 59 450.3662560PA0020070 Rating Area 6 No Preference 60 469.5762560PA0020070 Rating Area 6 No Preference 61 486.1862560PA0020070 Rating Area 6 No Preference 62 497.0762560PA0020070 Rating Area 6 No Preference 63 510.7462560PA0020070 Rating Area 6 No Preference 64 519.0562560PA0020070 Rating Area 6 No Preference 65 and over 519.05

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Exchange Product MetalPlan Design Marketing Name

Network Rating Area Counties Excluded

62560PA0020055 Both HMO Silver UPMC Small Business Advantage Silver HMO $3,000 $20/$50 - Standard Network SHOP 28 County HMO - 28C Standard Referral w/Dental Advantage 1, 2, 4, 5

62560PA0020065 Both HMO Platinum UPMC Small Business Advantage Platinum HMO $10/$25 - Standard Network SHOP 28 County HMO - 28C Standard Referral w/Dental Advantage 1, 2, 4, 5

62560PA0020066 Both HMO Gold UPMC Small Business Advantage Gold HMO $1,000 $20/$45 - Standard Network SHOP 28 County HMO - 28C Standard Referral w/Dental Advantage 1, 2, 4, 5

62560PA0020067 Both HMO Platinum UPMC Small Business Advantage Platinum HMO $500 $20/$40 - Standard Network SHOP 28 County HMO - 28C Standard Referral w/Dental Advantage 1, 2, 4, 5

62560PA0020068 Both HMO Gold UPMC Small Business Advantage Gold HMO $2,000 $20/$40 - Standard Network SHOP 28 County HMO - 28C Standard Referral w/Dental Advantage 1, 2, 4, 5

62560PA0020069 Both HMO Gold UPMC Small Business Advantage Gold HMO $1,500 $10/$40 - Standard Network SHOP 28 County HMO - 28C Standard Referral w/Dental Advantage 1, 2, 4, 5

62560PA0020070 Both HMO Bronze UPMC Small Business Advantage Bronze HMO $6,850 - Standard Network SHOP 28 County HMO - 28C Standard Referral w/Dental Advantage 1, 2, 4, 5

UPMC Health Coverage, Inc.

Small Group

Plan Design Summary

12/24/2014

RATE PAGES

Company Name: UPMC Health Coverage, Inc.

Market: Small Group

Product: HMO

Effective Date of Rates: Ending 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 Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

0 - 20 $129.38 $129.38 $129.38 $129.38 $129.38 $129.38 $129.38 $129.38 $129.38 $129.38 $197.01 $197.01 $197.01 $197.01 $197.01 $197.01 $197.01 $197.01 $197.01 $197.01

21 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25

22 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25

23 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25

24 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $203.74 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25 $310.25

25 $204.56 $204.56 $204.56 $204.56 $204.56 $204.56 $204.56 $204.56 $204.56 $204.56 $311.49 $311.49 $311.49 $311.49 $311.49 $311.49 $311.49 $311.49 $311.49 $311.49

26 $208.63 $208.63 $208.63 $208.63 $208.63 $208.63 $208.63 $208.63 $208.63 $208.63 $317.70 $317.70 $317.70 $317.70 $317.70 $317.70 $317.70 $317.70 $317.70 $317.70

27 $213.52 $213.52 $213.52 $213.52 $213.52 $213.52 $213.52 $213.52 $213.52 $213.52 $325.14 $325.14 $325.14 $325.14 $325.14 $325.14 $325.14 $325.14 $325.14 $325.14

28 $221.47 $221.47 $221.47 $221.47 $221.47 $221.47 $221.47 $221.47 $221.47 $221.47 $337.24 $337.24 $337.24 $337.24 $337.24 $337.24 $337.24 $337.24 $337.24 $337.24

29 $227.99 $227.99 $227.99 $227.99 $227.99 $227.99 $227.99 $227.99 $227.99 $227.99 $347.17 $347.17 $347.17 $347.17 $347.17 $347.17 $347.17 $347.17 $347.17 $347.17

30 $231.25 $231.25 $231.25 $231.25 $231.25 $231.25 $231.25 $231.25 $231.25 $231.25 $352.13 $352.13 $352.13 $352.13 $352.13 $352.13 $352.13 $352.13 $352.13 $352.13

31 $236.14 $236.14 $236.14 $236.14 $236.14 $236.14 $236.14 $236.14 $236.14 $236.14 $359.58 $359.58 $359.58 $359.58 $359.58 $359.58 $359.58 $359.58 $359.58 $359.58

32 $241.03 $241.03 $241.03 $241.03 $241.03 $241.03 $241.03 $241.03 $241.03 $241.03 $367.03 $367.03 $367.03 $367.03 $367.03 $367.03 $367.03 $367.03 $367.03 $367.03

33 $244.09 $244.09 $244.09 $244.09 $244.09 $244.09 $244.09 $244.09 $244.09 $244.09 $371.68 $371.68 $371.68 $371.68 $371.68 $371.68 $371.68 $371.68 $371.68 $371.68

34 $247.35 $247.35 $247.35 $247.35 $247.35 $247.35 $247.35 $247.35 $247.35 $247.35 $376.64 $376.64 $376.64 $376.64 $376.64 $376.64 $376.64 $376.64 $376.64 $376.64

35 $248.98 $248.98 $248.98 $248.98 $248.98 $248.98 $248.98 $248.98 $248.98 $248.98 $379.13 $379.13 $379.13 $379.13 $379.13 $379.13 $379.13 $379.13 $379.13 $379.13

36 $250.61 $250.61 $250.61 $250.61 $250.61 $250.61 $250.61 $250.61 $250.61 $250.61 $381.61 $381.61 $381.61 $381.61 $381.61 $381.61 $381.61 $381.61 $381.61 $381.61

37 $252.24 $252.24 $252.24 $252.24 $252.24 $252.24 $252.24 $252.24 $252.24 $252.24 $384.09 $384.09 $384.09 $384.09 $384.09 $384.09 $384.09 $384.09 $384.09 $384.09

38 $253.87 $253.87 $253.87 $253.87 $253.87 $253.87 $253.87 $253.87 $253.87 $253.87 $386.57 $386.57 $386.57 $386.57 $386.57 $386.57 $386.57 $386.57 $386.57 $386.57

39 $257.12 $257.12 $257.12 $257.12 $257.12 $257.12 $257.12 $257.12 $257.12 $257.12 $391.54 $391.54 $391.54 $391.54 $391.54 $391.54 $391.54 $391.54 $391.54 $391.54

40 $260.38 $260.38 $260.38 $260.38 $260.38 $260.38 $260.38 $260.38 $260.38 $260.38 $396.50 $396.50 $396.50 $396.50 $396.50 $396.50 $396.50 $396.50 $396.50 $396.50

41 $265.27 $265.27 $265.27 $265.27 $265.27 $265.27 $265.27 $265.27 $265.27 $265.27 $403.95 $403.95 $403.95 $403.95 $403.95 $403.95 $403.95 $403.95 $403.95 $403.95

42 $269.96 $269.96 $269.96 $269.96 $269.96 $269.96 $269.96 $269.96 $269.96 $269.96 $411.08 $411.08 $411.08 $411.08 $411.08 $411.08 $411.08 $411.08 $411.08 $411.08

43 $276.48 $276.48 $276.48 $276.48 $276.48 $276.48 $276.48 $276.48 $276.48 $276.48 $421.01 $421.01 $421.01 $421.01 $421.01 $421.01 $421.01 $421.01 $421.01 $421.01

44 $284.63 $284.63 $284.63 $284.63 $284.63 $284.63 $284.63 $284.63 $284.63 $284.63 $433.42 $433.42 $433.42 $433.42 $433.42 $433.42 $433.42 $433.42 $433.42 $433.42

45 $294.21 $294.21 $294.21 $294.21 $294.21 $294.21 $294.21 $294.21 $294.21 $294.21 $448.00 $448.00 $448.00 $448.00 $448.00 $448.00 $448.00 $448.00 $448.00 $448.00

46 $305.61 $305.61 $305.61 $305.61 $305.61 $305.61 $305.61 $305.61 $305.61 $305.61 $465.37 $465.37 $465.37 $465.37 $465.37 $465.37 $465.37 $465.37 $465.37 $465.37

47 $318.45 $318.45 $318.45 $318.45 $318.45 $318.45 $318.45 $318.45 $318.45 $318.45 $484.92 $484.92 $484.92 $484.92 $484.92 $484.92 $484.92 $484.92 $484.92 $484.92

48 $333.12 $333.12 $333.12 $333.12 $333.12 $333.12 $333.12 $333.12 $333.12 $333.12 $507.26 $507.26 $507.26 $507.26 $507.26 $507.26 $507.26 $507.26 $507.26 $507.26

49 $347.59 $347.59 $347.59 $347.59 $347.59 $347.59 $347.59 $347.59 $347.59 $347.59 $529.28 $529.28 $529.28 $529.28 $529.28 $529.28 $529.28 $529.28 $529.28 $529.28

50 $363.88 $363.88 $363.88 $363.88 $363.88 $363.88 $363.88 $363.88 $363.88 $363.88 $554.10 $554.10 $554.10 $554.10 $554.10 $554.10 $554.10 $554.10 $554.10 $554.10

51 $379.98 $379.98 $379.98 $379.98 $379.98 $379.98 $379.98 $379.98 $379.98 $379.98 $578.61 $578.61 $578.61 $578.61 $578.61 $578.61 $578.61 $578.61 $578.61 $578.61

52 $397.71 $397.71 $397.71 $397.71 $397.71 $397.71 $397.71 $397.71 $397.71 $397.71 $605.61 $605.61 $605.61 $605.61 $605.61 $605.61 $605.61 $605.61 $605.61 $605.61

53 $415.63 $415.63 $415.63 $415.63 $415.63 $415.63 $415.63 $415.63 $415.63 $415.63 $632.91 $632.91 $632.91 $632.91 $632.91 $632.91 $632.91 $632.91 $632.91 $632.91

54 $434.99 $434.99 $434.99 $434.99 $434.99 $434.99 $434.99 $434.99 $434.99 $434.99 $662.38 $662.38 $662.38 $662.38 $662.38 $662.38 $662.38 $662.38 $662.38 $662.38

55 $454.35 $454.35 $454.35 $454.35 $454.35 $454.35 $454.35 $454.35 $454.35 $454.35 $691.85 $691.85 $691.85 $691.85 $691.85 $691.85 $691.85 $691.85 $691.85 $691.85

56 $475.33 $475.33 $475.33 $475.33 $475.33 $475.33 $475.33 $475.33 $475.33 $475.33 $723.81 $723.81 $723.81 $723.81 $723.81 $723.81 $723.81 $723.81 $723.81 $723.81

57 $496.52 $496.52 $496.52 $496.52 $496.52 $496.52 $496.52 $496.52 $496.52 $496.52 $756.07 $756.07 $756.07 $756.07 $756.07 $756.07 $756.07 $756.07 $756.07 $756.07

58 $519.13 $519.13 $519.13 $519.13 $519.13 $519.13 $519.13 $519.13 $519.13 $519.13 $790.51 $790.51 $790.51 $790.51 $790.51 $790.51 $790.51 $790.51 $790.51 $790.51

59 $530.34 $530.34 $530.34 $530.34 $530.34 $530.34 $530.34 $530.34 $530.34 $530.34 $807.58 $807.58 $807.58 $807.58 $807.58 $807.58 $807.58 $807.58 $807.58 $807.58

60 $552.96 $552.96 $552.96 $552.96 $552.96 $552.96 $552.96 $552.96 $552.96 $552.96 $842.01 $842.01 $842.01 $842.01 $842.01 $842.01 $842.01 $842.01 $842.01 $842.01

61 $572.51 $572.51 $572.51 $572.51 $572.51 $572.51 $572.51 $572.51 $572.51 $572.51 $871.80 $871.80 $871.80 $871.80 $871.80 $871.80 $871.80 $871.80 $871.80 $871.80

62 $585.35 $585.35 $585.35 $585.35 $585.35 $585.35 $585.35 $585.35 $585.35 $585.35 $891.34 $891.34 $891.34 $891.34 $891.34 $891.34 $891.34 $891.34 $891.34 $891.34

63 $601.45 $601.45 $601.45 $601.45 $601.45 $601.45 $601.45 $601.45 $601.45 $601.45 $915.85 $915.85 $915.85 $915.85 $915.85 $915.85 $915.85 $915.85 $915.85 $915.85

64+ $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74

65 and over $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $611.22 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74 $930.74

62560PA0020055 62560PA0020055 62560PA0020055 62560PA0020055 62560PA0020055

December 31, 2017

Silver Silver Silver Silver

62560PA002005562560PA0020055 62560PA0020055

January 1, 2017

62560PA0020055 62560PA0020055

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

UPMC Small Business

Advantage Silver HMO

$3,000 $20/$50 -

Standard Network

UPMC Small Business

Advantage Silver HMO

$3,000 $20/$50 -

Standard Network

UPMC Small Business

Advantage Silver HMO

$3,000 $20/$50 -

Standard Network

UPMC Small Business

Advantage Silver HMO

$3,000 $20/$50 -

Standard Network

7150/14300 7150/14300 7150/14300

$20/ $50 $20/ $50 $20/ $50 $20/ $50

3000/6000

0%

7150/14300

$20/ $50

0% 0% 0% 0%

Yes

61 2 4

Yes Yes Yes

HMOF03 HMOF03

Yes

5

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

3000/6000 3000/6000 3000/6000 3000/6000

7150/14300

Silver

UPMC Small Business

Advantage Silver HMO

$3,000 $20/$50 -

Standard Network

HMOF03 HMOF03HMOF03

62560PA0020065 62560PA0020065 62560PA0020065 62560PA0020065 62560PA0020065

62560PA0020065 62560PA0020065 62560PA0020065 62560PA0020065 62560PA0020065

1 2 4 5 6

HMOF03 HMOF03 HMOF03 HMOF03 HMOF03

Platinum Platinum Platinum Platinum Platinum

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

0/0 0/0 0/0 0/0 0/0

UPMC Small Business

Advantage Platinum

HMO $10/$25 -

Standard Network

UPMC Small Business

Advantage Platinum

HMO $10/$25 -

Standard Network

UPMC Small Business

Advantage Platinum

HMO $10/$25 -

Standard Network

UPMC Small Business

Advantage Platinum

HMO $10/$25 -

Standard Network

UPMC Small Business

Advantage Platinum

HMO $10/$25 -

Standard Network

$10/ $25 $10/ $25 $10/ $25 $10/ $25 $10/ $25

0% 0% 0% 0% 0%

Yes Yes Yes Yes Yes

1250/2500 1250/2500 1250/2500 1250/2500 1250/2500

Page Number: 2 12/24/2014

RATE PAGES

Company Name: UPMC Health Coverage, Inc.

Market: Small Group

Product: HMO

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+

65 and over

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$149.71 $149.71 $149.71 $149.71 $149.71 $149.71 $149.71 $149.71 $149.71 $149.71 $192.71 $192.71 $192.71 $192.71 $192.71 $192.71 $192.71 $192.71 $192.71 $192.71

$235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48

$235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48

$235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48

$235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $235.76 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48 $303.48

$236.70 $236.70 $236.70 $236.70 $236.70 $236.70 $236.70 $236.70 $236.70 $236.70 $304.70 $304.70 $304.70 $304.70 $304.70 $304.70 $304.70 $304.70 $304.70 $304.70

$241.41 $241.41 $241.41 $241.41 $241.41 $241.41 $241.41 $241.41 $241.41 $241.41 $310.77 $310.77 $310.77 $310.77 $310.77 $310.77 $310.77 $310.77 $310.77 $310.77

$247.07 $247.07 $247.07 $247.07 $247.07 $247.07 $247.07 $247.07 $247.07 $247.07 $318.05 $318.05 $318.05 $318.05 $318.05 $318.05 $318.05 $318.05 $318.05 $318.05

$256.27 $256.27 $256.27 $256.27 $256.27 $256.27 $256.27 $256.27 $256.27 $256.27 $329.89 $329.89 $329.89 $329.89 $329.89 $329.89 $329.89 $329.89 $329.89 $329.89

$263.81 $263.81 $263.81 $263.81 $263.81 $263.81 $263.81 $263.81 $263.81 $263.81 $339.60 $339.60 $339.60 $339.60 $339.60 $339.60 $339.60 $339.60 $339.60 $339.60

$267.58 $267.58 $267.58 $267.58 $267.58 $267.58 $267.58 $267.58 $267.58 $267.58 $344.45 $344.45 $344.45 $344.45 $344.45 $344.45 $344.45 $344.45 $344.45 $344.45

$273.24 $273.24 $273.24 $273.24 $273.24 $273.24 $273.24 $273.24 $273.24 $273.24 $351.74 $351.74 $351.74 $351.74 $351.74 $351.74 $351.74 $351.74 $351.74 $351.74

$278.90 $278.90 $278.90 $278.90 $278.90 $278.90 $278.90 $278.90 $278.90 $278.90 $359.02 $359.02 $359.02 $359.02 $359.02 $359.02 $359.02 $359.02 $359.02 $359.02

$282.44 $282.44 $282.44 $282.44 $282.44 $282.44 $282.44 $282.44 $282.44 $282.44 $363.57 $363.57 $363.57 $363.57 $363.57 $363.57 $363.57 $363.57 $363.57 $363.57

$286.21 $286.21 $286.21 $286.21 $286.21 $286.21 $286.21 $286.21 $286.21 $286.21 $368.43 $368.43 $368.43 $368.43 $368.43 $368.43 $368.43 $368.43 $368.43 $368.43

$288.09 $288.09 $288.09 $288.09 $288.09 $288.09 $288.09 $288.09 $288.09 $288.09 $370.86 $370.86 $370.86 $370.86 $370.86 $370.86 $370.86 $370.86 $370.86 $370.86

$289.98 $289.98 $289.98 $289.98 $289.98 $289.98 $289.98 $289.98 $289.98 $289.98 $373.28 $373.28 $373.28 $373.28 $373.28 $373.28 $373.28 $373.28 $373.28 $373.28

$291.87 $291.87 $291.87 $291.87 $291.87 $291.87 $291.87 $291.87 $291.87 $291.87 $375.71 $375.71 $375.71 $375.71 $375.71 $375.71 $375.71 $375.71 $375.71 $375.71

$293.75 $293.75 $293.75 $293.75 $293.75 $293.75 $293.75 $293.75 $293.75 $293.75 $378.14 $378.14 $378.14 $378.14 $378.14 $378.14 $378.14 $378.14 $378.14 $378.14

$297.52 $297.52 $297.52 $297.52 $297.52 $297.52 $297.52 $297.52 $297.52 $297.52 $382.99 $382.99 $382.99 $382.99 $382.99 $382.99 $382.99 $382.99 $382.99 $382.99

$301.30 $301.30 $301.30 $301.30 $301.30 $301.30 $301.30 $301.30 $301.30 $301.30 $387.85 $387.85 $387.85 $387.85 $387.85 $387.85 $387.85 $387.85 $387.85 $387.85

$306.95 $306.95 $306.95 $306.95 $306.95 $306.95 $306.95 $306.95 $306.95 $306.95 $395.13 $395.13 $395.13 $395.13 $395.13 $395.13 $395.13 $395.13 $395.13 $395.13

$312.38 $312.38 $312.38 $312.38 $312.38 $312.38 $312.38 $312.38 $312.38 $312.38 $402.11 $402.11 $402.11 $402.11 $402.11 $402.11 $402.11 $402.11 $402.11 $402.11

$319.92 $319.92 $319.92 $319.92 $319.92 $319.92 $319.92 $319.92 $319.92 $319.92 $411.83 $411.83 $411.83 $411.83 $411.83 $411.83 $411.83 $411.83 $411.83 $411.83

$329.35 $329.35 $329.35 $329.35 $329.35 $329.35 $329.35 $329.35 $329.35 $329.35 $423.96 $423.96 $423.96 $423.96 $423.96 $423.96 $423.96 $423.96 $423.96 $423.96

$340.43 $340.43 $340.43 $340.43 $340.43 $340.43 $340.43 $340.43 $340.43 $340.43 $438.23 $438.23 $438.23 $438.23 $438.23 $438.23 $438.23 $438.23 $438.23 $438.23

$353.63 $353.63 $353.63 $353.63 $353.63 $353.63 $353.63 $353.63 $353.63 $353.63 $455.22 $455.22 $455.22 $455.22 $455.22 $455.22 $455.22 $455.22 $455.22 $455.22

$368.48 $368.48 $368.48 $368.48 $368.48 $368.48 $368.48 $368.48 $368.48 $368.48 $474.34 $474.34 $474.34 $474.34 $474.34 $474.34 $474.34 $474.34 $474.34 $474.34

$385.46 $385.46 $385.46 $385.46 $385.46 $385.46 $385.46 $385.46 $385.46 $385.46 $496.19 $496.19 $496.19 $496.19 $496.19 $496.19 $496.19 $496.19 $496.19 $496.19

$402.20 $402.20 $402.20 $402.20 $402.20 $402.20 $402.20 $402.20 $402.20 $402.20 $517.74 $517.74 $517.74 $517.74 $517.74 $517.74 $517.74 $517.74 $517.74 $517.74

$421.06 $421.06 $421.06 $421.06 $421.06 $421.06 $421.06 $421.06 $421.06 $421.06 $542.02 $542.02 $542.02 $542.02 $542.02 $542.02 $542.02 $542.02 $542.02 $542.02

$439.68 $439.68 $439.68 $439.68 $439.68 $439.68 $439.68 $439.68 $439.68 $439.68 $565.99 $565.99 $565.99 $565.99 $565.99 $565.99 $565.99 $565.99 $565.99 $565.99

$460.19 $460.19 $460.19 $460.19 $460.19 $460.19 $460.19 $460.19 $460.19 $460.19 $592.39 $592.39 $592.39 $592.39 $592.39 $592.39 $592.39 $592.39 $592.39 $592.39

$480.94 $480.94 $480.94 $480.94 $480.94 $480.94 $480.94 $480.94 $480.94 $480.94 $619.10 $619.10 $619.10 $619.10 $619.10 $619.10 $619.10 $619.10 $619.10 $619.10

$503.33 $503.33 $503.33 $503.33 $503.33 $503.33 $503.33 $503.33 $503.33 $503.33 $647.93 $647.93 $647.93 $647.93 $647.93 $647.93 $647.93 $647.93 $647.93 $647.93

$525.73 $525.73 $525.73 $525.73 $525.73 $525.73 $525.73 $525.73 $525.73 $525.73 $676.76 $676.76 $676.76 $676.76 $676.76 $676.76 $676.76 $676.76 $676.76 $676.76

$550.01 $550.01 $550.01 $550.01 $550.01 $550.01 $550.01 $550.01 $550.01 $550.01 $708.02 $708.02 $708.02 $708.02 $708.02 $708.02 $708.02 $708.02 $708.02 $708.02

$574.53 $574.53 $574.53 $574.53 $574.53 $574.53 $574.53 $574.53 $574.53 $574.53 $739.58 $739.58 $739.58 $739.58 $739.58 $739.58 $739.58 $739.58 $739.58 $739.58

$600.70 $600.70 $600.70 $600.70 $600.70 $600.70 $600.70 $600.70 $600.70 $600.70 $773.27 $773.27 $773.27 $773.27 $773.27 $773.27 $773.27 $773.27 $773.27 $773.27

$613.67 $613.67 $613.67 $613.67 $613.67 $613.67 $613.67 $613.67 $613.67 $613.67 $789.96 $789.96 $789.96 $789.96 $789.96 $789.96 $789.96 $789.96 $789.96 $789.96

$639.83 $639.83 $639.83 $639.83 $639.83 $639.83 $639.83 $639.83 $639.83 $639.83 $823.65 $823.65 $823.65 $823.65 $823.65 $823.65 $823.65 $823.65 $823.65 $823.65

$662.47 $662.47 $662.47 $662.47 $662.47 $662.47 $662.47 $662.47 $662.47 $662.47 $852.78 $852.78 $852.78 $852.78 $852.78 $852.78 $852.78 $852.78 $852.78 $852.78

$677.32 $677.32 $677.32 $677.32 $677.32 $677.32 $677.32 $677.32 $677.32 $677.32 $871.90 $871.90 $871.90 $871.90 $871.90 $871.90 $871.90 $871.90 $871.90 $871.90

$695.94 $695.94 $695.94 $695.94 $695.94 $695.94 $695.94 $695.94 $695.94 $695.94 $895.87 $895.87 $895.87 $895.87 $895.87 $895.87 $895.87 $895.87 $895.87 $895.87

$707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44

$707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $707.26 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44 $910.44

62560PA0020066 62560PA0020066 62560PA0020066 62560PA0020066 62560PA0020066

62560PA0020066 62560PA0020066 62560PA0020066 62560PA0020066 62560PA0020066

1 2 4 5 6

HMOF03 HMOF03 HMOF03 HMOF03 HMOF03

Gold Gold Gold Gold Gold

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

1000/2000 1000/2000 1000/2000 1000/2000 1000/2000

UPMC Small Business

Advantage Gold HMO

$1,000 $20/$45 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$1,000 $20/$45 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$1,000 $20/$45 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$1,000 $20/$45 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$1,000 $20/$45 -

Standard Network

$20 / $45 $20 / $45 $20 / $45 $20 / $45 $20 / $45

0% 0% 0% 0% 0%

Yes Yes Yes Yes Yes

3500/7000 3500/7000 3500/7000 3500/7000 3500/7000

62560PA0020067 62560PA0020067 62560PA0020067 62560PA0020067 62560PA0020067

62560PA0020067 62560PA0020067 62560PA0020067 62560PA0020067 62560PA0020067

1 2 4 5 6

HMOF03 HMOF03 HMOF03 HMOF03 HMOF03

Platinum Platinum Platinum Platinum Platinum

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

500/1000 500/1000 500/1000 500/1000 500/1000

UPMC Small Business

Advantage Platinum

HMO $500 $20/$40 -

Standard Network

UPMC Small Business

Advantage Platinum

HMO $500 $20/$40 -

Standard Network

UPMC Small Business

Advantage Platinum

HMO $500 $20/$40 -

Standard Network

UPMC Small Business

Advantage Platinum

HMO $500 $20/$40 -

Standard Network

UPMC Small Business

Advantage Platinum

HMO $500 $20/$40 -

Standard Network

$20/ $40 $20/ $40 $20/ $40 $20/ $40 $20/ $40

0% 0% 0% 0% 0%

Yes Yes Yes Yes Yes

1000/2000 1000/2000 1000/2000 1000/2000 1000/2000

Page Number: 3 12/24/2014

RATE PAGES

Company Name: UPMC Health Coverage, Inc.

Market: Small Group

Product: HMO

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+

65 and over

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$146.90 $146.90 $146.90 $146.90 $146.90 $146.90 $146.90 $146.90 $146.90 $146.90 $147.43 $147.43 $147.43 $147.43 $147.43 $147.43 $147.43 $147.43 $147.43 $147.43

$231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17

$231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17

$231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17

$231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $231.33 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17 $232.17

$232.26 $232.26 $232.26 $232.26 $232.26 $232.26 $232.26 $232.26 $232.26 $232.26 $233.09 $233.09 $233.09 $233.09 $233.09 $233.09 $233.09 $233.09 $233.09 $233.09

$236.88 $236.88 $236.88 $236.88 $236.88 $236.88 $236.88 $236.88 $236.88 $236.88 $237.74 $237.74 $237.74 $237.74 $237.74 $237.74 $237.74 $237.74 $237.74 $237.74

$242.43 $242.43 $242.43 $242.43 $242.43 $242.43 $242.43 $242.43 $242.43 $242.43 $243.31 $243.31 $243.31 $243.31 $243.31 $243.31 $243.31 $243.31 $243.31 $243.31

$251.46 $251.46 $251.46 $251.46 $251.46 $251.46 $251.46 $251.46 $251.46 $251.46 $252.36 $252.36 $252.36 $252.36 $252.36 $252.36 $252.36 $252.36 $252.36 $252.36

$258.86 $258.86 $258.86 $258.86 $258.86 $258.86 $258.86 $258.86 $258.86 $258.86 $259.79 $259.79 $259.79 $259.79 $259.79 $259.79 $259.79 $259.79 $259.79 $259.79

$262.56 $262.56 $262.56 $262.56 $262.56 $262.56 $262.56 $262.56 $262.56 $262.56 $263.51 $263.51 $263.51 $263.51 $263.51 $263.51 $263.51 $263.51 $263.51 $263.51

$268.11 $268.11 $268.11 $268.11 $268.11 $268.11 $268.11 $268.11 $268.11 $268.11 $269.08 $269.08 $269.08 $269.08 $269.08 $269.08 $269.08 $269.08 $269.08 $269.08

$273.66 $273.66 $273.66 $273.66 $273.66 $273.66 $273.66 $273.66 $273.66 $273.66 $274.65 $274.65 $274.65 $274.65 $274.65 $274.65 $274.65 $274.65 $274.65 $274.65

$277.13 $277.13 $277.13 $277.13 $277.13 $277.13 $277.13 $277.13 $277.13 $277.13 $278.13 $278.13 $278.13 $278.13 $278.13 $278.13 $278.13 $278.13 $278.13 $278.13

$280.83 $280.83 $280.83 $280.83 $280.83 $280.83 $280.83 $280.83 $280.83 $280.83 $281.85 $281.85 $281.85 $281.85 $281.85 $281.85 $281.85 $281.85 $281.85 $281.85

$282.69 $282.69 $282.69 $282.69 $282.69 $282.69 $282.69 $282.69 $282.69 $282.69 $283.71 $283.71 $283.71 $283.71 $283.71 $283.71 $283.71 $283.71 $283.71 $283.71

$284.54 $284.54 $284.54 $284.54 $284.54 $284.54 $284.54 $284.54 $284.54 $284.54 $285.56 $285.56 $285.56 $285.56 $285.56 $285.56 $285.56 $285.56 $285.56 $285.56

$286.39 $286.39 $286.39 $286.39 $286.39 $286.39 $286.39 $286.39 $286.39 $286.39 $287.42 $287.42 $287.42 $287.42 $287.42 $287.42 $287.42 $287.42 $287.42 $287.42

$288.24 $288.24 $288.24 $288.24 $288.24 $288.24 $288.24 $288.24 $288.24 $288.24 $289.28 $289.28 $289.28 $289.28 $289.28 $289.28 $289.28 $289.28 $289.28 $289.28

$291.94 $291.94 $291.94 $291.94 $291.94 $291.94 $291.94 $291.94 $291.94 $291.94 $292.99 $292.99 $292.99 $292.99 $292.99 $292.99 $292.99 $292.99 $292.99 $292.99

$295.64 $295.64 $295.64 $295.64 $295.64 $295.64 $295.64 $295.64 $295.64 $295.64 $296.71 $296.71 $296.71 $296.71 $296.71 $296.71 $296.71 $296.71 $296.71 $296.71

$301.19 $301.19 $301.19 $301.19 $301.19 $301.19 $301.19 $301.19 $301.19 $301.19 $302.28 $302.28 $302.28 $302.28 $302.28 $302.28 $302.28 $302.28 $302.28 $302.28

$306.51 $306.51 $306.51 $306.51 $306.51 $306.51 $306.51 $306.51 $306.51 $306.51 $307.62 $307.62 $307.62 $307.62 $307.62 $307.62 $307.62 $307.62 $307.62 $307.62

$313.91 $313.91 $313.91 $313.91 $313.91 $313.91 $313.91 $313.91 $313.91 $313.91 $315.05 $315.05 $315.05 $315.05 $315.05 $315.05 $315.05 $315.05 $315.05 $315.05

$323.17 $323.17 $323.17 $323.17 $323.17 $323.17 $323.17 $323.17 $323.17 $323.17 $324.33 $324.33 $324.33 $324.33 $324.33 $324.33 $324.33 $324.33 $324.33 $324.33

$334.04 $334.04 $334.04 $334.04 $334.04 $334.04 $334.04 $334.04 $334.04 $334.04 $335.25 $335.25 $335.25 $335.25 $335.25 $335.25 $335.25 $335.25 $335.25 $335.25

$346.99 $346.99 $346.99 $346.99 $346.99 $346.99 $346.99 $346.99 $346.99 $346.99 $348.25 $348.25 $348.25 $348.25 $348.25 $348.25 $348.25 $348.25 $348.25 $348.25

$361.57 $361.57 $361.57 $361.57 $361.57 $361.57 $361.57 $361.57 $361.57 $361.57 $362.87 $362.87 $362.87 $362.87 $362.87 $362.87 $362.87 $362.87 $362.87 $362.87

$378.22 $378.22 $378.22 $378.22 $378.22 $378.22 $378.22 $378.22 $378.22 $378.22 $379.59 $379.59 $379.59 $379.59 $379.59 $379.59 $379.59 $379.59 $379.59 $379.59

$394.65 $394.65 $394.65 $394.65 $394.65 $394.65 $394.65 $394.65 $394.65 $394.65 $396.07 $396.07 $396.07 $396.07 $396.07 $396.07 $396.07 $396.07 $396.07 $396.07

$413.15 $413.15 $413.15 $413.15 $413.15 $413.15 $413.15 $413.15 $413.15 $413.15 $414.64 $414.64 $414.64 $414.64 $414.64 $414.64 $414.64 $414.64 $414.64 $414.64

$431.43 $431.43 $431.43 $431.43 $431.43 $431.43 $431.43 $431.43 $431.43 $431.43 $432.98 $432.98 $432.98 $432.98 $432.98 $432.98 $432.98 $432.98 $432.98 $432.98

$451.55 $451.55 $451.55 $451.55 $451.55 $451.55 $451.55 $451.55 $451.55 $451.55 $453.18 $453.18 $453.18 $453.18 $453.18 $453.18 $453.18 $453.18 $453.18 $453.18

$471.91 $471.91 $471.91 $471.91 $471.91 $471.91 $471.91 $471.91 $471.91 $471.91 $473.61 $473.61 $473.61 $473.61 $473.61 $473.61 $473.61 $473.61 $473.61 $473.61

$493.89 $493.89 $493.89 $493.89 $493.89 $493.89 $493.89 $493.89 $493.89 $493.89 $495.67 $495.67 $495.67 $495.67 $495.67 $495.67 $495.67 $495.67 $495.67 $495.67

$515.86 $515.86 $515.86 $515.86 $515.86 $515.86 $515.86 $515.86 $515.86 $515.86 $517.72 $517.72 $517.72 $517.72 $517.72 $517.72 $517.72 $517.72 $517.72 $517.72

$539.69 $539.69 $539.69 $539.69 $539.69 $539.69 $539.69 $539.69 $539.69 $539.69 $541.64 $541.64 $541.64 $541.64 $541.64 $541.64 $541.64 $541.64 $541.64 $541.64

$563.75 $563.75 $563.75 $563.75 $563.75 $563.75 $563.75 $563.75 $563.75 $563.75 $565.78 $565.78 $565.78 $565.78 $565.78 $565.78 $565.78 $565.78 $565.78 $565.78

$589.42 $589.42 $589.42 $589.42 $589.42 $589.42 $589.42 $589.42 $589.42 $589.42 $591.55 $591.55 $591.55 $591.55 $591.55 $591.55 $591.55 $591.55 $591.55 $591.55

$602.15 $602.15 $602.15 $602.15 $602.15 $602.15 $602.15 $602.15 $602.15 $602.15 $604.32 $604.32 $604.32 $604.32 $604.32 $604.32 $604.32 $604.32 $604.32 $604.32

$627.82 $627.82 $627.82 $627.82 $627.82 $627.82 $627.82 $627.82 $627.82 $627.82 $630.09 $630.09 $630.09 $630.09 $630.09 $630.09 $630.09 $630.09 $630.09 $630.09

$650.03 $650.03 $650.03 $650.03 $650.03 $650.03 $650.03 $650.03 $650.03 $650.03 $652.38 $652.38 $652.38 $652.38 $652.38 $652.38 $652.38 $652.38 $652.38 $652.38

$664.60 $664.60 $664.60 $664.60 $664.60 $664.60 $664.60 $664.60 $664.60 $664.60 $667.00 $667.00 $667.00 $667.00 $667.00 $667.00 $667.00 $667.00 $667.00 $667.00

$682.88 $682.88 $682.88 $682.88 $682.88 $682.88 $682.88 $682.88 $682.88 $682.88 $685.34 $685.34 $685.34 $685.34 $685.34 $685.34 $685.34 $685.34 $685.34 $685.34

$693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49

$693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $693.98 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49 $696.49

62560PA0020068 62560PA0020068 62560PA0020068 62560PA0020068 62560PA0020068

62560PA0020068 62560PA0020068 62560PA0020068 62560PA0020068 62560PA0020068

1 2 4 5 6

HMOF03 HMOF03 HMOF03 HMOF03 HMOF03

Gold Gold Gold Gold Gold

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

2000/4000 2000/4000 2000/4000 2000/4000 2000/4000

UPMC Small Business

Advantage Gold HMO

$2,000 $20/$40 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$2,000 $20/$40 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$2,000 $20/$40 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$2,000 $20/$40 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$2,000 $20/$40 -

Standard Network

$20 / $40 $20 / $40 $20 / $40 $20 / $40 $20 / $40

0% 0% 0% 0% 0%

Yes Yes Yes Yes Yes

3000/6000 3000/6000 3000/6000 3000/6000 3000/6000

62560PA0020069 62560PA0020069 62560PA0020069 62560PA0020069 62560PA0020069

62560PA0020069 62560PA0020069 62560PA0020069 62560PA0020069 62560PA0020069

1 2 4 5 6

HMOF03 HMOF03 HMOF03 HMOF03 HMOF03

Gold Gold Gold Gold Gold

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

1500/3000 1500/3000 1500/3000 1500/3000 1500/3000

UPMC Small Business

Advantage Gold HMO

$1,500 $10/$40 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$1,500 $10/$40 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$1,500 $10/$40 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$1,500 $10/$40 -

Standard Network

UPMC Small Business

Advantage Gold HMO

$1,500 $10/$40 -

Standard Network

$10 / $40 $10 / $40 $10 / $40 $10 / $40 $10 / $40

0% 0% 0% 0% 0%

Yes Yes Yes Yes Yes

3500/7000 3500/7000 3500/7000 3500/7000 3500/7000

Page Number: 4 12/24/2014

RATE PAGES

Company Name: UPMC Health Coverage, Inc.

Market: Small Group

Product: HMO

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+

65 and over

Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco

$109.87 $109.87 $109.87 $109.87 $109.87 $109.87 $109.87 $109.87 $109.87 $109.87

$173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02

$173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02

$173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02

$173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02 $173.02

$173.71 $173.71 $173.71 $173.71 $173.71 $173.71 $173.71 $173.71 $173.71 $173.71

$177.17 $177.17 $177.17 $177.17 $177.17 $177.17 $177.17 $177.17 $177.17 $177.17

$181.32 $181.32 $181.32 $181.32 $181.32 $181.32 $181.32 $181.32 $181.32 $181.32

$188.07 $188.07 $188.07 $188.07 $188.07 $188.07 $188.07 $188.07 $188.07 $188.07

$193.61 $193.61 $193.61 $193.61 $193.61 $193.61 $193.61 $193.61 $193.61 $193.61

$196.38 $196.38 $196.38 $196.38 $196.38 $196.38 $196.38 $196.38 $196.38 $196.38

$200.53 $200.53 $200.53 $200.53 $200.53 $200.53 $200.53 $200.53 $200.53 $200.53

$204.68 $204.68 $204.68 $204.68 $204.68 $204.68 $204.68 $204.68 $204.68 $204.68

$207.28 $207.28 $207.28 $207.28 $207.28 $207.28 $207.28 $207.28 $207.28 $207.28

$210.04 $210.04 $210.04 $210.04 $210.04 $210.04 $210.04 $210.04 $210.04 $210.04

$211.43 $211.43 $211.43 $211.43 $211.43 $211.43 $211.43 $211.43 $211.43 $211.43

$212.81 $212.81 $212.81 $212.81 $212.81 $212.81 $212.81 $212.81 $212.81 $212.81

$214.20 $214.20 $214.20 $214.20 $214.20 $214.20 $214.20 $214.20 $214.20 $214.20

$215.58 $215.58 $215.58 $215.58 $215.58 $215.58 $215.58 $215.58 $215.58 $215.58

$218.35 $218.35 $218.35 $218.35 $218.35 $218.35 $218.35 $218.35 $218.35 $218.35

$221.12 $221.12 $221.12 $221.12 $221.12 $221.12 $221.12 $221.12 $221.12 $221.12

$225.27 $225.27 $225.27 $225.27 $225.27 $225.27 $225.27 $225.27 $225.27 $225.27

$229.25 $229.25 $229.25 $229.25 $229.25 $229.25 $229.25 $229.25 $229.25 $229.25

$234.79 $234.79 $234.79 $234.79 $234.79 $234.79 $234.79 $234.79 $234.79 $234.79

$241.71 $241.71 $241.71 $241.71 $241.71 $241.71 $241.71 $241.71 $241.71 $241.71

$249.84 $249.84 $249.84 $249.84 $249.84 $249.84 $249.84 $249.84 $249.84 $249.84

$259.53 $259.53 $259.53 $259.53 $259.53 $259.53 $259.53 $259.53 $259.53 $259.53

$270.43 $270.43 $270.43 $270.43 $270.43 $270.43 $270.43 $270.43 $270.43 $270.43

$282.88 $282.88 $282.88 $282.88 $282.88 $282.88 $282.88 $282.88 $282.88 $282.88

$295.17 $295.17 $295.17 $295.17 $295.17 $295.17 $295.17 $295.17 $295.17 $295.17

$309.01 $309.01 $309.01 $309.01 $309.01 $309.01 $309.01 $309.01 $309.01 $309.01

$322.68 $322.68 $322.68 $322.68 $322.68 $322.68 $322.68 $322.68 $322.68 $322.68

$337.73 $337.73 $337.73 $337.73 $337.73 $337.73 $337.73 $337.73 $337.73 $337.73

$352.95 $352.95 $352.95 $352.95 $352.95 $352.95 $352.95 $352.95 $352.95 $352.95

$369.39 $369.39 $369.39 $369.39 $369.39 $369.39 $369.39 $369.39 $369.39 $369.39

$385.83 $385.83 $385.83 $385.83 $385.83 $385.83 $385.83 $385.83 $385.83 $385.83

$403.65 $403.65 $403.65 $403.65 $403.65 $403.65 $403.65 $403.65 $403.65 $403.65

$421.64 $421.64 $421.64 $421.64 $421.64 $421.64 $421.64 $421.64 $421.64 $421.64

$440.85 $440.85 $440.85 $440.85 $440.85 $440.85 $440.85 $440.85 $440.85 $440.85

$450.36 $450.36 $450.36 $450.36 $450.36 $450.36 $450.36 $450.36 $450.36 $450.36

$469.57 $469.57 $469.57 $469.57 $469.57 $469.57 $469.57 $469.57 $469.57 $469.57

$486.18 $486.18 $486.18 $486.18 $486.18 $486.18 $486.18 $486.18 $486.18 $486.18

$497.07 $497.07 $497.07 $497.07 $497.07 $497.07 $497.07 $497.07 $497.07 $497.07

$510.74 $510.74 $510.74 $510.74 $510.74 $510.74 $510.74 $510.74 $510.74 $510.74

$519.05 $519.05 $519.05 $519.05 $519.05 $519.05 $519.05 $519.05 $519.05 $519.05

$519.05 $519.05 $519.05 $519.05 $519.05 $519.05 $519.05 $519.05 $519.05 $519.05

62560PA0020070 62560PA0020070 62560PA0020070 62560PA0020070 62560PA0020070

62560PA0020070 62560PA0020070 62560PA0020070 62560PA0020070 62560PA0020070

1 2 4 5 6

HMOF03 HMOF03 HMOF03 HMOF03 HMOF03

Bronze Bronze Bronze Bronze Bronze

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

SHOP 28 County HMO -

28C Standard Referral

w/Dental Advantage

6850/13700 6850/13700 6850/13700 6850/13700 6850/13700

UPMC Small Business

Advantage Bronze

HMO $6,850 - Standard

Network

UPMC Small Business

Advantage Bronze

HMO $6,850 - Standard

Network

UPMC Small Business

Advantage Bronze HMO

$6,850 - Standard

Network

UPMC Small Business

Advantage Bronze HMO

$6,850 - Standard

Network

UPMC Small Business

Advantage Bronze HMO

$6,850 - Standard

Network

$35/ $0 $35/ $0 $35/ $0 $35/ $0 $35/ $0

0% 0% 0% 0% 0%

Yes Yes Yes Yes Yes

7150/14300 7150/14300 7150/14300 7150/14300 7150/14300

Page Number: 5 12/24/2014

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

62560PA0020055 $ 203.74 $ 203.74 $ 203.74 $ 203.74 $ 203.74

2017 On-Exchange Silver Plan Rates

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

62560PA0020055 $ 203.74 $ 203.74 $ 203.74 $ 203.74 $ 203.74

2017 Off-Exchange Silver Plan Rates

Supporting Document Schedules Satisfied - Item: Transmittal Letter (A&H)Comments:Attachment(s): UPMC Health Coverage Small Group Transmittal Letter UPMC-130536846.pdfItem Status:Status Date:

Satisfied - Item: Unified Rate Review TemplateComments:

Attachment(s): Unified_Rate_Review_Template.xlsmUnified_Rate_Review_Template.pdf

Item Status:Status Date:

Satisfied - Item: PA Actuarial Memorandum Rate ExhibitsComments:

Attachment(s): FINAL 2017 PA Actuarial Memorandum Rate Exhibits Rev 4-21-2016.xlsxFINAL 2017 PA Actuarial Memorandum Rate Exhibits Rev 4-21-2016.pdf

Item Status:Status Date:

Satisfied - Item: PA Bulletin InformationComments:Attachment(s): UPMC Health Coverage Small Group PA Bulletin Info UPMC-130536846.pdfItem Status:Status Date:

Satisfied - Item: Rate Change Request SummaryComments:Attachment(s): UPMC Health Coverage Small Group Rate Change Request Summary UPMC-130536846.pdfItem Status:Status Date:

Satisfied - Item: Part II Consumer JustificationComments:Attachment(s): UPMC Health Coverage Small Group Part II Justification UPMC-130536846.pdf

SERFF Tracking #: UPMC-130536846 State Tracking #: UPMC-130536846 Company Tracking #:

State: Pennsylvania Filing Company: UPMC Health Coverage, Inc.

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

Product Name: 2017 SG Health Coverage

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number UPMC-130536846 Generated 06/13/2016 02:52 PM

Item Status:Status Date:

Satisfied - Item: Actuarial Memorandum and Certifications - RedactedComments:Attachment(s): UPMC Health Coverage Small Group Actuarial Memorandum UPMC-130536846 Redacted.pdfItem Status:Status Date:

SERFF Tracking #: UPMC-130536846 State Tracking #: UPMC-130536846 Company Tracking #:

State: Pennsylvania Filing Company: UPMC Health Coverage, Inc.

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

Product Name: 2017 SG Health Coverage

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number UPMC-130536846 Generated 06/13/2016 02:52 PM

Attachment Unified_Rate_Review_Template.xlsm is not a PDF document and cannot be reproducedhere.

Attachment FINAL 2017 PA Actuarial Memorandum Rate Exhibits Rev 4-21-2016.xlsx is not a PDFdocument and cannot be reproduced here.

SERFF Tracking #: UPMC-130536846 State Tracking #: UPMC-130536846 Company Tracking #:

State: Pennsylvania Filing Company: UPMC Health Coverage, Inc.

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

Product Name: 2017 SG Health Coverage

Project Name/Number: /

PDF Pipeline for SERFF Tracking Number UPMC-130536846 Generated 06/13/2016 02:52 PM

April 27, 2016

Ms. Johanna Fabian-MarksCommonwealth of Pennsylvania Insurance DepartmentInsurance Product Regulation & Market EnforcementActuarial Review DivisionBureau of Accident & Health Insurance1311 Strawberry SquareHarrisburg, PA 17120

Dear Ms. Fabian-Marks,

UPMC Health Coverage, Inc. respectfully requests approval of a rate filing for Small GroupOn and Off Exchange HMO products. The rates are proposed for effective dates of 1/1/2017 throughthrough 12/31/2017.

Company Name/NAIC #: UPMC Health Coverage, Inc./22350Market: Small GroupOn or Off Exchange: On and OffEffective Date of Coverage: 1/1/2017Average Rate Change Requested: 6.7%Range of Rate Change Requested: 5.9% - 8.3%Products Offered: Small Group HMORating Areas Where Plans are Offered: 1, 2, 4, 5Metal Levels Offered: Bronze, Silver, Gold, PlatinumCurrently Enrolled Lives: 1,197Currently Enrolled Policyholders: 711Number of Plans Offered in 2017: 12Corresponding Contract Form #: HMOF03Binder ID#: UPMC-PA17-125059925HIOS Issuer ID #: 62560Submission Tracking #: UPMC-130536846

If you have any questions or require additional information, please call me at 412-454-7849 or email me atlovelymt@upmc.edu.

Sincerely,

Michael Lovely, ASA, MAAA

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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: UPMC Health Coverage State: PA

HIOS Issuer ID: 62560 Market: Small Group

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

Market Level Calculations (Same for all Plans)

Section I: Experience period data

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

Experience Period

Aggregate Amount PMPM % of Prem

Premiums (net of MLR Rebate) in Experience Period: 8,381,646.57$ $388.36 100.00%

Incurred Claims in Experience Period 7,263,252.87$ 336.54 86.66%

Allowed Claims: 8,274,664.48$ 383.41 98.72%

Index Rate of Experience Period $382.80

Experience Period Member Months 21,582

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 55.60 $13,410.10 $62.14 0.970 1.000 1.003 0.985 52.36 $13,495.03 $58.89 54.64 $14,554.54 $66.27

Outpatient Hospital Visits 1,700.31 405.76 57.49 0.970 1.000 1.026 1.017 1,707.47 427.45 60.82 4212.24 367.78 129.10

Professional Visits 4,237.98 180.40 63.71 0.970 1.000 1.010 0.991 4,035.24 183.96 61.86 1966.13 382.23 62.63

Other Medical Visits 3,505.70 406.12 118.64 0.970 1.000 1.031 1.000 3,400.53 431.71 122.34 5265.66 165.01 72.41

Capitation Other 0.00 0.00 0.00 0.970 1.000 1.000 1.000 0.00 0.00 0.00 0.00 0.00 0.00

Prescription Drug Prescriptions 11,065.33 86.75 80.00 0.970 1.000 1.070 1.021 11,192.64 99.32 92.64 11766.29 122.85 120.45

Total $381.98 $396.54 $450.86

After Credibility Projected Period Totals

Section III: Projected Experience: Projected Allowed Experience Claims PMPM (w/applied credibility if applicable) 0.00% 100.00% $450.86 $17,897,386

Paid to Allowed Average Factor in Projection Period 0.815

Projected Incurred Claims, before ACA rein & Risk Adj't, PMPM $367.50 $14,588,448

Projected Risk Adjustments PMPM 13.14 521,641

Projected Incurred Claims, before reinsurance recoveries, net of rein prem, PMPM $354.36 $14,066,807

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

Projected Incurred Claims $354.36 $14,066,807

Administrative Expense Load 14.58% 58.30 2,314,282

Profit & Risk Load -6.59% (26.35) (1,046,168)

Taxes & Fees 3.42% 13.66 542,371

Single Risk Pool Gross Premium Avg. Rate, PMPM $399.97 $15,877,292

Index Rate for Projection Period $461.25

% increase over Experience Period 2.99%

% Increase, annualized: 1.48%

Projected Member Months 39,696

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 2

Product-Plan Data Collection

Company Legal Name: UPMC Health Coverage State: PA

HIOS Issuer ID: 62560 Market: Small Group

Effective Date of Rate Change(s):

Product/Plan Level Calculations

Section I: General Product and Plan Information

Product

Product ID:

Metal: Catastrophic Silver Platinum Gold Platinum Gold Gold Bronze

AV Metal Value 0.000 0.719 0.915 0.818 0.896 0.804 0.806 0.620

AV Pricing Value 0.010 0.750 1.142 0.868 1.117 0.852 0.855 0.637

Plan Category Terminated Renewing New New New New New New

Plan Type: HMO HMO HMO HMO HMO HMO HMO HMO

Plan Name Terminated

Products

Business

Advantage Silver

HMO $3,000

Business

Advantage

Platinum HMO

Business

Advantage Gold

HMO $1,000

Business

Advantage

Platinum HMO

Business

Advantage Gold

HMO $2,000

Business

Advantage Gold

HMO $1,500

Business

Advantage Bronze

HMO $6,850 -

Plan ID (Standard Component ID): 62560PA0020034 62560PA0020055 62560PA0020065 62560PA0020066 62560PA0020067 62560PA0020068 62560PA0020069 62560PA0020070

Exchange Plan? No Yes Yes Yes Yes Yes Yes Yes

Historical Rate Increase - Calendar Year - 2

Historical Rate Increase - Calendar Year - 1

Historical Rate Increase - Calendar Year 0

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

Rate Change % (over prior filing) 0.00% 8.20% 8.44% 6.80% 0.00% 0.00% 0.00% 0.00%

Cum'tive Rate Change % (over 12 mos prior) 0.00% 8.20% 8.44% 6.80% 0.00% 0.00% 0.00% 0.00%

Proj'd Per Rate Change % (over Exper. Period) -100.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Product Rate Increase %

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

Plan ID (Standard Component ID): Total 62560PA0020034 62560PA0020055 62560PA0020065 62560PA0020066 62560PA0020067 62560PA0020068 62560PA0020069 62560PA0020070

Inpatient $0.00 $0.00 $3.48 $5.44 $3.38 $0.00 $0.00 $0.00 $0.00

Outpatient $0.00 $0.00 $3.18 $4.98 $3.09 $0.00 $0.00 $0.00 $0.00

Professional $0.00 $0.00 $3.77 $5.89 $3.66 $0.00 $0.00 $0.00 $0.00

Prescription Drug $0.00 $0.00 $4.38 $6.85 $4.26 $0.00 $0.00 $0.00 $0.00

Other $0.00 $0.00 $5.87 $9.17 $5.70 $0.00 $0.00 $0.00 $0.00

Capitation $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Administration $0.00 $0.00 $3.34 $5.22 $3.25 $0.00 $0.00 $0.00 $0.00

Taxes & Fees $0.00 $0.00 $0.41 $0.64 $0.40 $0.00 $0.00 $0.00 $0.00

Risk & Profit Charge $0.00 $0.00 -$1.51 -$2.36 -$1.47 $0.00 $0.00 $0.00 $0.00

Total Rate Increase $0.00 $0.00 $22.92 $35.82 $22.27 $0.00 $0.00 $0.00 $0.00

Member Cost Share Increase $0.00 $0.00 $18.50 $6.23 $15.76 $0.00 $0.00 $0.00 $0.00

Average Current Rate PMPM $139.53 $0.00 $279.31 $424.40 $327.45 $0.00 $0.00 $0.00 $0.00

Projected Member Months 39,696 0 2,352 5,772 7,428 5,772 7,428 7,428 3,516

Section III: Experience Period Information

Plan ID (Standard Component ID): Total 62560PA0020034 62560PA0020055 62560PA0020065 62560PA0020066 62560PA0020067 62560PA0020068 62560PA0020069 62560PA0020070

Plan Adjusted Index Rate $247.55 $247.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Member Months 21,582 21,582 0 0 0 0 0 0 0

Total Premium (TP) $5,342,525 $5,342,525 $0 $0 $0 $0 $0 $0 $0

EHB Percent of TP, [see instructions] 99.59% 99.59% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

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%

Other benefits portion of TP 0.41% 0.41% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Total Allowed Claims (TAC) $8,274,664 $8,274,664 $0 $0 $0 $0 $0 $0 $0

EHB Percent of TAC, [see instructions] 99.59% 99.59% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 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%

Other benefits portion of TAC 0.41% 0.41% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Allowed Claims which are not the issuer's obligation: $1,011,412 $1,011,412 $0 $0 $0 $0 $0 $0 $0Portion of above payable by HHS's funds on

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

insured person, as % 0.00% 0.00% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Total Incurred claims, payable with issuer funds $7,263,253 $7,263,253 $0 $0 $0 $0 $0 $0 $0

Net Amt of Rein $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Net Amt of Risk Adj $70,932.20 $70,932.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Incurred Claims PMPM $336.54 $336.54 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Allowed Claims PMPM $383.41 $383.41 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

EHB portion of Allowed Claims, PMPM $381.82 $381.82 #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 62560PA0020034 62560PA0020055 62560PA0020065 62560PA0020066 62560PA0020067 62560PA0020068 62560PA0020069 62560PA0020070

Plan Adjusted Index Rate $413.20 $340.17 $518.00 $393.62 $506.70 $386.23 $387.62 $288.87

Member Months 39,696 - 2,352 5,772 7,428 5,772 7,428 7,428 3,516

Total Premium (TP) $16,402,242 $0 $800,081 $2,989,875 $2,923,794 $2,924,654 $2,868,907 $2,879,264 $1,015,667

EHB Percent of TP, [see instructions] 99.76% 99.76% 99.76% 99.76% 99.76% 99.76% 99.76% 99.76%

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%

Other benefits portion of TP 0.24% 100.00% 0.24% 0.24% 0.24% 0.24% 0.24% 0.24% 0.24%

Total Allowed Claims (TAC) $18,354,162 $1,021,238 $2,999,170 $3,279,911 $2,996,299 $3,276,817 $3,276,820 $1,503,908

EHB Percent of TAC, [see instructions] 99.76% 99.76% 99.76% 99.76% 99.76% 99.76% 99.76% 99.76%

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%

Other benefits portion of TAC 0.24% 100.00% 0.24% 0.24% 0.24% 0.24% 0.24% 0.24% 0.24%

Allowed Claims which are not the issuer's obligation $3,822,741 $317,875 $331,079 $694,226 $388,064 $741,505 $732,003 $617,989

Portion of above payable by HHS's funds on

behalf of insured person, in dollars $0 $0 $0 $0 $0 $0 $0 $0

Portion of above payable by HHS on behalf of

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

Total Incurred claims, payable with issuer funds $14,531,421 $0 $703,363 $2,668,091 $2,585,684 $2,608,235 $2,535,312 $2,544,817 $885,919

Net Amt of Rein $0 $0 $0 $0 $0 $0 $0 $0

Net Amt of Risk Adj $521,641 $30,907 $75,849 $97,611 $75,849 $97,611 $97,611 $46,203

1/1/2017

SHOP HMO

62560PA002

0.00%

0.00%

0.00%

8.20%

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 21,582 3,019 39,696

<18 3,298 460 6,048

18-24 2,013 294 3,866

25-29 1,761 251 3,300

30-34 1,594 235 3,090

35-39 1,745 230 3,024

40-44 1,527 225 2,958

45-49 1,991 288 3,787

50-54 2,892 357 4,694

55-59 2,609 395 5,194

60-63 1,509 199 2,617

64+ 643 85 1,118

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

$ 8,308,996.05 $ 7,484,397.81 $ 7,577,339.51 21,582 $ 1,011,411.60 $ 8,588,751.11 $ 13,075.70 $ (314,086.63) $ - $ - 72,650.52$ -$

2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates) 382.80$

Loss Ratio 86.66%

*Express Prescription Drug Rebates as a negative number

Table 3. Trend Components

Cost* Utilization* Composite Weight*

0.36% -1.68% -1.32% 16.83% <- Annualized Trend Factors on URRT

3.02% 2.00% 5.08% 15.40%

1.12% -1.06% 0.06% 18.23%

3.55% 0.00% 3.55% 28.36%

0.00% 0.00%

8.01% 2.42% 10.62% 21.18%

3.83% 100.00%

1.078

* 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 $ 23,999.35 1.0000 $ 23,999.35 42 $ 571.41 (611) $ 30,192.36 $ 718.87

Feb-13 $ 11,092.61 1.0000 $ 11,092.61 36 $ 308.13 (524) $ 12,109.88 $ 336.39

Mar-13 $ 2,821.43 1.0000 $ 2,821.43 14 $ 201.53 (204) $ 3,339.60 $ 238.54

Apr-13 $ 2,832.79 1.0000 $ 2,832.79 14 $ 202.34 (204) $ 3,144.60 $ 224.61

May-13 $ 3,872.81 1.0000 $ 3,872.81 13 $ 297.91 (189) $ 4,210.14 $ 323.86

Jun-13 $ 5,109.11 1.0000 $ 5,109.11 12 $ 425.76 (175) $ 5,176.52 $ 431.38

Jul-13 $ 5,448.82 1.0000 $ 5,448.82 12 $ 454.07 (175) $ 5,918.01 $ 493.17

Aug-13 $ 7,967.38 1.0000 $ 7,967.38 2 $ 3,983.69 (29) $ 8,286.27 $ 4,143.14

Sep-13 $ 1,153.53 1.0000 $ 1,153.53 2 $ 576.77 (29) $ 1,274.42 $ 637.21

Oct-13 $ 1,773.43 1.0000 $ 1,773.43 2 $ 886.72 (29) $ 1,921.51 $ 960.76

Nov-13 $ 1,825.70 1.0000 $ 1,825.70 2 $ 912.85 (29) $ 1,911.59 $ 955.80

Dec-13 $ 3,062.55 1.0000 $ 3,062.55 2 $ 1,531.28 (29) $ 3,208.44 $ 1,604.22

Jan-14 $ 22,789.01 1.0000 $ 22,789.01 102 $ 223.42 (1,484) $ 28,743.53 $ 281.80

Feb-14 $ 38,661.61 1.0000 $ 38,661.61 139 $ 278.14 (2,023) $ 47,627.74 $ 342.65

Mar-14 $ 60,711.97 1.0000 $ 60,711.97 187 $ 324.66 (2,721) $ 65,539.18 $ 350.48

Apr-14 $ 102,444.28 1.0000 $ 102,444.28 227 $ 451.30 (3,304) $ 114,779.45 $ 505.64

May-14 $ 89,122.00 1.0000 $ 89,122.00 245 $ 363.76 (3,566) $ 105,300.90 $ 429.80

Jun-14 $ 72,304.00 1.0000 $ 72,304.00 285 $ 253.70 (4,148) $ 80,751.39 $ 283.34

Jul-14 $ 146,035.28 1.0000 $ 146,035.28 377 $ 387.36 (5,487) $ 155,641.45 $ 412.84

Aug-14 $ 173,455.67 1.0000 $ 173,455.67 384 $ 451.71 (5,588) $ 187,393.11 $ 488.00

Sep-14 $ 205,938.12 1.0000 $ 205,938.12 391 $ 526.70 (5,690) $ 219,236.62 $ 560.71

Oct-14 $ 227,092.98 1.0000 $ 227,092.98 393 $ 577.84 (5,719) $ 241,140.14 $ 613.59

Nov-14 $ 135,255.64 1.0000 $ 135,255.64 377 $ 358.77 (5,487) $ 148,427.02 $ 393.71

Dec-14 $ 115,782.23 1.0000 $ 115,782.23 375 $ 308.75 (5,457) $ 135,955.74 $ 362.55

Jan-15 $ 305,331.47 0.9986 $ 305,773.16 624 $ 490.02 (9,081) $ 326,457.87 $ 523.17

Feb-15 $ 252,479.82 0.9985 $ 252,857.13 797 $ 317.26 (11,599) $ 283,014.03 $ 355.10

Mar-15 $ 452,573.55 0.9981 $ 453,457.37 1,118 $ 405.60 (16,270) $ 500,303.72 $ 447.50

Apr-15 $ 572,469.62 0.9972 $ 574,104.24 1,433 $ 400.63 (20,855) $ 636,136.03 $ 443.92

May-15 $ 541,040.93 0.9962 $ 543,100.26 1,494 $ 363.52 (21,742) $ 580,435.46 $ 388.51

Jun-15 $ 643,534.73 0.9950 $ 646,754.53 1,609 $ 401.96 (23,416) $ 704,152.97 $ 437.63

Jul-15 $ 599,361.45 0.9911 $ 604,716.66 2,055 $ 294.27 (29,907) $ 664,457.33 $ 323.34

Aug-15 $ 625,532.94 0.9888 $ 632,645.48 2,138 $ 295.91 (31,115) $ 692,311.22 $ 323.81

Sep-15 $ 750,937.63 0.9852 $ 762,248.49 2,217 $ 343.82 (32,264) $ 823,133.93 $ 371.28

Oct-15 $ 750,779.59 0.9804 $ 765,752.90 2,368 $ 323.38 (34,462) $ 845,748.96 $ 357.16

Nov-15 $ 917,570.85 0.9706 $ 945,376.73 2,423 $ 390.17 (35,262) $ 1,009,536.74 $ 416.65

Dec-15 $ 1,072,785.23 0.9591 $ 1,118,538.97 3,306 $ 338.34 (48,113) $ 1,209,011.84 $ 365.70

* Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

2 Year Trend Projection Factor

Service Category

Other Medical

Capitation

Prescription Drugs

Total Annual Trend

Inpatient Hospital

Outpatient Hospital

Professional

$ 11,960.47

$ 191,617.64

$ 983,460.81

$ 78,331.40

$ 1,344,573.45

$ 8,308,996.05

Table 2b. Experience Period Claims and Premiums

Earned

PremiumPaid Claims

Ultimate

Incurred

Claims

Member

Months

Estimated Cost

Sharing

(Member & HHS)

Allowed Claims

(Non-

Capitated)

Non-EHB

portion of

Allowed

Claims

Total

Prescription

Drug

Rebates*

Total EHB

Capitation

Total Non-EHB

Capitation

Estimated Risk

Adjustment

########## ############ ############ 275,693 $ 16,434,921.75 ############# $ 848,191.82 ########### $ - $ - 5,023,247.04$

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*

0.32% -1.47% -1.15% 16.24% <- Annualized Trend Factors on URRT

2.64% 1.75% 4.43% 28.33%

0.98% -0.92% 0.05% 14.98%

3.10% 0.00% 3.10% 16.30%

0.00% 0.00%

7.00% 2.12% 9.26% 24.15%

3.82% 100.00%

1.078

* Express Cost, Utilization, and Weight as percentages

Table 4b. Historical Experience

Month-YearTotal Annual

Premium

Incurred

Claims

Completion

Factors*

Ultimate Incurred

ClaimsMembers

Ultimate

Incurred

PMPM

Estimated

Annual Cost

Sharing

(Member +

HHS)

Prescription

Drug

Rebates**

Allowed

Claims (Net of

Prescription

Drug Rebates)

Allowed

PMPM

Jan-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Feb-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Mar-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Apr-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

May-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Jun-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Jul-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Aug-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Sep-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Oct-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Nov-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Dec-13 $ - 1.0000 $ - - #DIV/0! - $ - #DIV/0!

Jan-14 $ 932,897.42 1.0000 $ 932,897.42 2,350 $ 396.98 (20,985) ############ $ 471.50

Feb-14 ############ 1.0000 $ 1,593,859.04 3,237 $ 492.39 (28,906) ############ $ 559.68

Mar-14 ############ 1.0000 $ 1,857,665.63 4,511 $ 411.81 (40,283) ############ $ 473.86

Apr-14 ############ 1.0000 $ 2,275,784.07 5,481 $ 415.21 (48,945) ############ $ 473.32

May-14 ############ 1.0000 $ 3,031,698.13 5,935 $ 510.82 (52,999) ############ $ 566.91

Jun-14 ############ 1.0000 $ 2,640,772.86 6,332 $ 417.05 (56,545) ############ $ 469.23

Jul-14 ############ 1.0000 $ 3,965,635.82 8,880 $ 446.58 (79,298) ############ $ 504.05

Aug-14 ############ 1.0000 $ 4,227,954.25 9,223 $ 458.41 (82,361) ############ $ 510.91

Sep-14 ############ 1.0000 $ 4,580,012.08 9,468 $ 483.74 (84,549) ############ $ 537.03

Oct-14 ############ 1.0000 $ 5,021,963.63 10,120 $ 496.24 (90,371) ############ $ 554.62

Nov-14 ############ 1.0000 $ 4,615,328.24 10,327 $ 446.92 (92,220) ############ $ 490.51

Dec-14 ############ 1.0000 $ 5,998,043.36 13,774 $ 435.46 (123,001) ############ $ 478.24

Jan-15 ############ 0.9986 $ 7,017,057.14 16,103 $ 435.76 (143,799) ############ $ 487.98

Feb-15 ############ 0.9985 $ 6,676,928.19 16,844 $ 396.40 (150,416) ############ $ 442.81

Mar-15 ############ 0.9981 $ 7,447,785.15 17,430 $ 427.30 (155,649) ############ $ 480.32

Apr-15 ############ 0.9972 $ 8,633,598.84 18,759 $ 460.24 (167,517) ############ $ 511.42

May-15 ############ 0.9962 $ 8,318,929.48 19,595 $ 424.54 (174,983) ############ $ 470.55

Jun-15 ############ 0.9950 $ 8,578,971.04 20,016 $ 428.61 (178,742) ############ $ 474.75

Jul-15 ############ 0.9911 $ 9,689,892.07 23,632 $ 410.03 (211,033) ############ $ 462.71

Aug-15 ############ 0.9888 $ 9,264,361.66 24,531 $ 377.66 (219,061) ############ $ 426.47

Sep-15 ############ 0.9852 $ 10,035,338.79 25,454 $ 394.25 (227,303) ############ $ 440.47

Oct-15 ############ 0.9804 $ 11,454,513.44 27,392 $ 418.17 (244,610) ############ $ 467.32

Nov-15 ############ 0.9706 $ 11,808,571.01 28,376 $ 416.15 (253,397) ############ $ 460.31

Dec-15 ############ 0.9591 $ 13,699,127.15 37,561 $ 364.72 (335,418) ############ $ 418.62

* Express Completion Factor as a percentage

**Express Prescription Drug Rebates as a negative number

############ ###########

Prescription Drugs

Total Annual Trend

2 Year Trend Projection

$ - $ -

############ ###########

Capitation

Service Category

Inpatient Hospital

Outpatient Hospital

Professional

Other Medical

Table 2c. Experience Period Claims and Premiums

Estimated

Reinsurance

Recoveries

Earned

PremiumPaid Claims

Ultimate

Incurred Claims

Member

Months

Estimated Cost

Sharing

(Member &

HHS)

Allowed

Claims (Non-

Capitated)

Non-EHB

portion of

Allowed

Claims

Total

Prescription

Drug Rebates*

Total EHB

Capitation

-$

454.59$ 2015 Total Allowed EHB Claims + EHB Capitation PMPM (net of prescription drug rebates)

93.70% Loss Ratio

*Express Prescription Drug Rebates as a negative number

Total Non-

EHB

Capitation

Estimated Risk

Adjustment

Estimated

Reinsurance

Recoveries

#DIV/0!

#DIV/0!

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) 454.59$ <- Index Rate of Experience Period on URRT Table 5A. Small Group Projected Index Rate with Quarterly Trend 2 Year Trend Projection Factor 1.078

Unadjusted Projected Allowed EHB Claims PMPM 489.98$ 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 13,785 7,169 24,437 88,901 134,292.00

Change in Morbidity 0.970 <- Adj't. from Experience to Projection Period - Other on URRT Percent of Members Months Renewing in Quarter 10% 5% 18% 66% 100%

Change in Other 0.949 Base Allowed Claims 450.94$ 450.94$ 450.94$ 450.94$ 450.94$

Change in Demographics 1.000 Months of Trend - 3 6 9 7

Change in Network 1.000 Annual Trend 3.83% 3.83% 3.83% 3.83% 3.83%

Change in Benefits 0.949 Single Risk Pool Projected Allowed Claims 450.94$ 455.19$ 459.49$ 463.82$ 461.25$

Change in Other 1.000

Adjusted Projected Allowed EHB Claims PMPM 450.94$ <- 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] 461.25$ <- Index Rate for Projection Period on URRT - Small Group

Projected Paid to Allowed Ratio 0.815116112 <- Paid to Allowed Average Factor in Projection Period on URRT

Projected Paid EHB Claims PMPM 375.9707185

Market-wide Adjustments

Projected Paid Net Risk Adjustment PMPM (13.14)$

Projected Paid Exchange User Fees PMPM 6.84$

Market-Adjusted Projected Paid EHB Claims PMPM 369.67$

Market-Adjusted Projected Allowed EHB Claims PMPM 453.52$ <- Market-Adjusted Index Rate

Projected Allowed Non-EHB Claims PMPM 1.12$

Market-Adjusted Projected Paid Total Claims PMPM 370.58$

Market-Adjusted Projected Allowed Total Claims PMPM 454.64$

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

Retention Items - Express in percentages Normalization Factors 2016 2017

Administrative Expenses 15% Average Age Factor 1.670 1.670

General and Claims 9.30% Average Geographic Factor 1.000 1.000

Agent/Broker Fees and Commissions 4.65% Average Tobacco Factor 1.000 1.000

Quality Improvement Initiatives 0.62% Average Benefit Richness (induced demand) 1.000 1.000

Taxes and Fees 1.78% Average Network Factor 1.000 1.000

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

Pa Premium Tax (if applicable) 0.00% Market-Adjusted Projected Allowed Total Claims PMPM 458.77$ 454.64$

Federal Income Tax 0.00%

Health Insurance Providers Fee (only for small group market, prorated for coverage in 2018) 1.73% Normalized Market-Adjusted Projected Allowed Total Claims PMPM 274.77$ 272.30$

Profit/Contingency -7%

Total Retention 10%

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

Projected Required Revenue PMPM 410.68$

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) 229.7484416 245.2512755 $15.50 6.7% Paid-to-Allowed 0.806533333 0.815116112

B. Base period allowed claims before normalization 442.21$ 454.59$ $12.38 5% URRT Trend (2-Year Trend Factor) 1 1.08 <- URRT W1, S2

C. Normalization factor component of change (177.36)$ -182.3216345 -$4.97 -$0.02 URRT Morbidity 1 0.970 <- URRT W1, S2

URRT "Other" 1 0.949 <- URRT W1, S2

D. Change in Normalized Allowed Claims Adjustment Components

D1. Base period allowed claims after normalization 264.86$ 272.27$ 7.42$ 3% Risk Adjustment -$ (13.14)$ <- URRT W1, S3

D2. URRT Trend -$ 21.24$ 21.24$ 9% Reinsurance -$ -$ <- URRT W1, S3

D3. URRT Morbidity -$ (8.81)$ (8.81)$ -4% Exchange User Fee 14.27$ 6.84$ <- URRT W1, S3

D4. URRT Other -$ (14.58)$ (14.58)$ -6% Capitation -$ -$ <- URRT W1, S2

D5. Normalized URRT RA/RI on an allowed basis -$ (9.66)$ (9.66)$ -4%

D6. Normalized Exchange User Fee on an allowed basis 10.59$ 5.03$ (5.57)$ -2% Network 1.000 1

D7. Subtotal - Sum(D1:D6) 275.45$ 265.49$ (9.96)$ -4% Pricing AV 0.679 0.827610025

E. Change in Allowable Plan Adjusted Level Components Benefit Richness 0.726 0.979313911

E1. Network -$ 0 -$ 0% Catastrophic Eligibility 1.000 1

E2. Pricing AV (88.30)$ (45.77)$ 42.53$ 19%

E3. Benefit Richness (51.21)$ (4.55)$ 46.67$ 20% Administrative Expenses 9.00% 14.58%

E4. Catastrophic Eligibility -$ -$ -$ 0% Taxes and Fees 7.73% 1.78%

E5. Subtotal - Sum(E1:E4) (139.51)$ (50.31)$ 89.20$ 39% Profit and/or Contingency 0.00% -6.59%

F. Change in Retention Components

F1. Administrative Expenses 20.68$ 35.75$ 15.07$ 7%

F2. Taxes and Fees 17.76$ 4.36$ (13.40)$ -6%

F3. Profit and/or Contingency -$ (16.16)$ (16.16)$ -7%

F4. Subtotal - Sum(F1:F3) 38.44$ 23.95$ (14.49)$ -6%

G. Change in Miscellaneous Items -$ -$ -$ 0%

H. Sum of Components of Rate Change (should approximate the change shown in line A) 174.38$ 239.13$ 64.74$ 28%

PA Rate Template Part IIITable 10. Plan Rates

Carrier Name: UPMC Health Coverage, Inc.

Plan Type(s): HMOMarket Segment: Small GroupRate Effective Date: 1/1/2017

Market Adjusted Index Rate 453.52$

Plan Number HIOS Plan ID (Standard Component)

Plan Type

(HMO, POS, PPO, EPO,

Indemnity, Other)

1/1/16 Plan

Marketing Name

Discontinued, New,

Modified, Existing

(D,N,M,E) for 2017

Totals

Plan 1 62560PA0020053 HMO UPMC Small Business Advantage Platinum HMO $20/$40 - Standard NetworkD

Plan 2 62560PA0020054 HMO UPMC Small Business Advantage Gold HMO $1,000 $10/$25 - Standard NetworkD

Plan 3 62560PA0020055 HMO UPMC Small Business Advantage Silver HMO $3,000 $20/$50 - Standard NetworkM

Plan 4 62560PA0020059 HMO UPMC Small Business Advantage Platinum HMO $20/$40 - Standard NetworkD

Plan 5 62560PA0020060 HMO UPMC Small Business Advantage Gold HMO $1,000 $10/$25 - Standard NetworkD

Plan 6 62560PA0020061 HMO UPMC Small Business Advantage Silver HMO $3,000 $10/$40 - Standard NetworkD

Plan 7 62560PA0020065 HMO UPMC Small Business Advantage Platinum HMO $10/$25 - Standard NetworkN

Plan 8 62560PA0020066 HMO UPMC Small Business Advantage Gold HMO $1,000 $20/$45 - Standard NetworkN

Plan 9 62560PA0020067 HMO UPMC Small Business Advantage Platinum HMO $500 $20/$40 - Standard NetworkN

Plan 10 62560PA0020068 HMO UPMC Small Business Advantage Gold HMO $2,000 $20/$40 - Standard NetworkN

Plan 11 62560PA0020069 HMO UPMC Small Business Advantage Gold HMO $1,500 $10/$40 - Standard NetworkN

Plan 12 62560PA0020070 HMO UPMC Small Business Advantage Bronze HMO $6,850 - Standard NetworkN

1/1/17 Plan

Marketing Name

(If 1/1/16 Plan

Discontinued) Metallic Tier

Metallic Tier

Actuarial

Value

Standard AV,

Approach (1),

Approach (2)

Exchange

On/Off or

Off

Pricing AV

(company-

determined

AV)

Benefit

Richness

(induced

demand)

Benefits in

addition to

EHB

0.828 0.828 0.979 1.002

UPMC Small Business Advantage Platinum HMO $10/$25 - Standard NetworkPlatinum 0.9149 Standard AV On and Off 0.915 1.124 1.002

UPMC Small Business Advantage Gold HMO $1,000 $20/$45 - Standard NetworkGold 0.8181 Standard AV On and Off 0.818 0.955 1.002

Silver 0.719 Standard AV On and Off 0.719 0.939 1.002

UPMC Small Business Advantage Platinum HMO $10/$25 - Standard NetworkPlatinum 0.9149 Standard AV On and Off 0.915 1.124 1.002

UPMC Small Business Advantage Gold HMO $1,000 $20/$45 - Standard NetworkGold 0.8181 Standard AV On and Off 0.818 0.955 1.002

UPMC Small Business Advantage Silver HMO $3,000 $20/$50 - Standard NetworkSilver 0.719 Standard AV On and Off 0.719 0.939 1.002

Platinum 0.9149 Standard AV On and Off 0.915 1.124 1.002

Gold 0.8181 Standard AV On and Off 0.818 0.955 1.002

Platinum 0.8958 Standard AV On and Off 0.896 1.123 1.002

Gold 0.8035 Standard AV On and Off 0.804 0.954 1.002

Gold 0.8064 Standard AV On and Off 0.806 0.954 1.002

Bronze 0.6198 Standard AV On and Off 0.620 0.925 1.002

Age Calibration Factor 1.669631359

Geographic Calibration Factor 1

Aggregate Calibration Factor 1.670

Provider

Network

Catastrophic

Eligibility

Tobacco

Surcharge

Adjustment

Pure

Premium Admin Costs

Taxes & Fees (not

including Exchange

fees)

Profit or

Contingency

Total

Covered Lives @

2/1/2016

1.000 1.000 1.000 369.50$ 14.6% 1.8% -6.6% 1,197

1.000 1.000 1.000 $467.42 14.6% 1.8% -6.6% 168

1.000 1.000 1.000 $355.19 14.6% 1.8% -6.6% 797

1.000 1.000 1.000 $306.96 14.6% 1.8% -6.6% 56

1.000 1.000 1.000 $467.42 14.6% 1.8% -6.6% 10

1.000 1.000 1.000 $355.19 14.6% 1.8% -6.6% 163

1.000 1.000 1.000 $306.96 14.6% 1.8% -6.6% 3

1.000 1.000 1.000 $467.42 14.6% 1.8% -6.6% -

1.000 1.000 1.000 $355.19 14.6% 1.8% -6.6% -

1.000 1.000 1.000 $457.22 14.6% 1.8% -6.6% -

1.000 1.000 1.000 $348.52 14.6% 1.8% -6.6% -

1.000 1.000 1.000 $349.78 14.6% 1.8% -6.6% -

1.000 1.000 1.000 $260.67 14.6% 1.8% -6.6% -

Calibration

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

Total Policyholders

@ 2/1/2016

2016

Calibrated Plan

Adjusted Index

Rate PMPM

2017 Calibrated

Plan Adjusted

Index Rate

PMPM

Proposed Rate

Change

Compared to

Prior 12

months

% of Total

Covered Lives

711 229.75$ 245.25$ 6.75%

106 286.36$ $310.25 8.3% 14.0%

461 221.54$ $235.75 6.4% 66.6%

49 189.14$ $203.74 7.7% 4.7%

8 286.81$ $310.25 8.2% 0.8%

85 222.69$ $235.75 5.9% 13.6%

2 190.42$ $203.74 7.0% 0.3%

- -$ $310.25 #DIV/0! 0.0%

- -$ $235.75 #DIV/0! 0.0%

- -$ $303.48 #DIV/0! 0.0%

- -$ $231.33 #DIV/0! 0.0%

- -$ $232.16 #DIV/0! 0.0%

- -$ $173.01 #DIV/0! 0.0%

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

Carrier Name: UPMC Health Coverage, Inc.

Plan Type(s): HMO

Market Segment: Small Group

Rate Effective Date: 1/1/2017

Plan Number HIOS Plan ID (Standard Component)

1/1/16 Plan

Marketing Name

Discontinued,

New, Modified,

Existing

(D,N,M,E) for

2017

1/1/17 Plan

Marketing Name

(If 1/1/16 Plan

Discontinued) Metallic Tier

Totals

Plan 1 62560PA0020053 UPMC Small Business Advantage Platinum HMO $20/$40 - Standard NetworkD UPMC Small Business Advantage Platinum HMO $10/$25 - Standard NetworkPlatinum

Plan 2 62560PA0020054 UPMC Small Business Advantage Gold HMO $1,000 $10/$25 - Standard NetworkD UPMC Small Business Advantage Gold HMO $1,000 $20/$45 - Standard NetworkGold

Plan 3 62560PA0020055 UPMC Small Business Advantage Silver HMO $3,000 $20/$50 - Standard NetworkM Silver

Plan 4 62560PA0020059 UPMC Small Business Advantage Platinum HMO $20/$40 - Standard NetworkD UPMC Small Business Advantage Platinum HMO $10/$25 - Standard NetworkPlatinum

Plan 5 62560PA0020060 UPMC Small Business Advantage Gold HMO $1,000 $10/$25 - Standard NetworkD UPMC Small Business Advantage Gold HMO $1,000 $20/$45 - Standard NetworkGold

Plan 6 62560PA0020061 UPMC Small Business Advantage Silver HMO $3,000 $10/$40 - Standard NetworkD UPMC Small Business Advantage Silver HMO $3,000 $20/$50 - Standard NetworkSilver

Plan 7 62560PA0020065 UPMC Small Business Advantage Platinum HMO $10/$25 - Standard NetworkN Platinum

Plan 8 62560PA0020066 UPMC Small Business Advantage Gold HMO $1,000 $20/$45 - Standard NetworkN Gold

Plan 9 62560PA0020067 UPMC Small Business Advantage Platinum HMO $500 $20/$40 - Standard NetworkN Platinum

Plan 10 62560PA0020068 UPMC Small Business Advantage Gold HMO $2,000 $20/$40 - Standard NetworkN Gold

Plan 11 62560PA0020069 UPMC Small Business Advantage Gold HMO $1,500 $10/$40 - Standard NetworkN Gold

Plan 12 62560PA0020070 UPMC Small Business Advantage Bronze HMO $6,850 - Standard NetworkN Bronze

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

Exchange

On/Off or

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

178 9 - 850 160 - - - - 1,197 242.82$

On and Off 62 - - 103 3 - - - - 168 286.36$

On and Off 85 - - 636 76 - - - - 797 221.54$

On and Off 7 3 - 42 4 - - - - 56 189.14$

On and Off 1 1 - 5 3 - - - - 10 286.81$

On and Off 20 5 - 64 74 - - - - 163 222.69$

On and Off 3 - - - - - - - - 3 190.42$

On and Off - - - - - - - - - - -$

On and Off - - - - - - - - - - -$

On and Off - - - - - - - - - - -$

On and Off - - - - - - - - - - -$

On and Off - - - - - - - - - - -$

On and Off - - - - - - - - - - -$

2/1/16 Number of Covered Lives

2 3 4 5 6 7 8 9

Average

(weighted by

enrollment by

rating area)

207.50$ -$ 228.84$ 215.89$ -$ -$ -$ -$ 229.03$

-$ -$ 287.08$ 276.36$ -$ -$ -$ -$ 286.62$

-$ -$ 222.10$ 213.81$ -$ -$ -$ -$ 221.25$

179.52$ -$ 189.62$ 182.54$ -$ -$ -$ -$ 188.51$

272.21$ -$ 287.53$ 276.80$ -$ -$ -$ -$ 282.71$

211.35$ -$ 223.25$ 214.91$ -$ -$ -$ -$ 219.03$

-$ -$ -$ -$ -$ -$ -$ -$ 190.42$

-$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$

2016 21-year-old Non-Tobacco Premium PMPM

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

1 2 3 4 5 6 7 8 9

Average

(weighted by

enrollment by

rating area)

260.32$ 233.36$ -$ 243.63$ 237.74$ -$ -$ -$ -$ 245.25$

310.25$ -$ -$ 310.25$ 310.25$ -$ -$ -$ -$ 310.25$

235.75$ -$ -$ 235.75$ 235.75$ -$ -$ -$ -$ 235.75$

203.74$ 203.74$ -$ 203.74$ 203.74$ -$ -$ -$ -$ 203.74$

310.25$ 310.25$ -$ 310.25$ 310.25$ -$ -$ -$ -$ 310.25$

235.75$ 235.75$ -$ 235.75$ 235.75$ -$ -$ -$ -$ 235.75$

203.74$ -$ -$ -$ -$ -$ -$ -$ -$ 203.74$

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$

-$ -$ -$ -$ -$ -$ -$ -$ -$ -$

2017 21-year-old Non-Tobacco Premium PMPM

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

1 2 3 4 5 6 7 8 9

Average

(weighted by

enrollment by

rating area)

7.1% 12.5% 0.0% 6.4% 10.1% 0.0% 0.0% 0.0% 0.0% 7.0%

8.3% 0.0% 0.0% 8.1% 12.3% 0.0% 0.0% 0.0% 0.0% 8.2%

6.4% 0.0% 0.0% 6.1% 10.3% 0.0% 0.0% 0.0% 0.0% 6.6%

7.7% 13.5% 0.0% 7.4% 11.6% 0.0% 0.0% 0.0% 0.0% 8.1%

8.2% 14.0% 0.0% 7.9% 12.1% 0.0% 0.0% 0.0% 0.0% 9.7%

5.9% 11.5% 0.0% 5.6% 9.7% 0.0% 0.0% 0.0% 0.0% 7.6%

7.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 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

PA Rate Template Part V

Consumer Factors

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

Age

Band

Age

Factor

Tobacco

Factor

Age

Band

Age

Factor

Tobacco

FactorArea Counties

Current

Factor

Proposed

Factor

0-20 0.635 43 1.357 1.000 Rating Area 1Erie, Crawford, Warren, Venango, Forest, Clarion,

Mckean1.000 1.000

21 1.000 1.000 44 1.397 1.000 Rating Area 2 Elk, Cameron, Potter 0.949 1.000

22 1.000 1.000 45 1.444 1.000 Rating Area 3

23 1.000 1.000 46 1.500 1.000 Rating Area 4

Allegheny, Armstrong, Beaver, Butler, Fayette,

Greene, Indiana, Lawrence, Washington,

Westmoreland

1.003 1.000

24 1.000 1.000 47 1.563 1.000 Rating Area 5Cambria, Blair, Clearfield, Bedford, Somerset,

Jefferson, Huntingdon0.965 1.000

25 1.004 1.000 48 1.635 1.000 Rating Area 6 Centre 1.299 1.000

26 1.024 1.000 49 1.706 1.000 Rating Area 7

27 1.048 1.000 50 1.786 1.000 Rating Area 8

28 1.087 1.000 51 1.865 1.000 Rating Area 9

29 1.119 1.000 52 1.952 1.000

30 1.135 1.000 53 2.040 1.000

31 1.159 1.000 54 2.135 1.000 Table 14. Network Factors32 1.183 1.000 55 2.230 1.000

33 1.198 1.000 56 2.333 1.000

34 1.214 1.000 57 2.437 1.000 Network Name Rating AreaCurrent

Factor

Proposed

Factor

DOH

Approval

Date

35 1.222 1.000 58 2.548 1.000 Standard 1, 2, 4, 5 1.000 1.000 4/18/2016

36 1.230 1.000 59 2.603 1.000

37 1.238 1.000 60 2.714 1.000

38 1.246 1.000 61 2.810 1.000

39 1.262 1.000 62 2.873 1.000

40 1.278 1.000 63 2.952 1.000

41 1.302 1.000 64+ 3.000 1.000

42 1.325 1.000

*PA follows the federal default age curve.

Geographic Area Factors2017 Age and Tobacco Factors

2017 Network Factors

Company Name/NAIC #: UPMC Health Coverage, Inc./22350Market: Small GroupProducts Offered: Small Group HMOAverage Rate Change Requested: 6.7% ($15.50)Range of Rate Change Requested: 5.9% - 8.3% ($13.06 - $23.88)Currently Enrolled Lives: 1,197Currently Enrolled Policyholders: 711Experience Period Revenue: $8,381,647Additional Revenue From Rate Increase: $615,400

UPMC Health PlanSmall Group Exchange HMO Rate Filing

On April 27, 2016, UPMC Health Coverage, Inc. submitted for approval a rate

filing for use with Small Group On and Off Exchange HMO customers.

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

UPMC Health Coverage, Inc. – Small Group PlansRate request filing ID # UPMC-130536846- This document is a consumer tool to help explain the rate filing and the request made by

the insurance company. 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/Pages/default.aspx

OverviewRequested average rate change: 6.7%

Range of requested rate change: 5.9% - 8.3%

Effective date: 1/1/2017

People impacted: 1,197

Available in: 1, 2, 4, 5

Key information

Jan. 2015-Dec. 2015 financial experience

Premiums $ 8,381,647

Claims $ 7,263,253

Administrative expenses $ 1,383,156

Company made (before taxes) $ (264,762)

The company expects its annual medical costs to increase 3.8%.

Explanation of requested rate changeThe cost of the population is higher than what was assumed when 2016 rates were set.

Additional premium is needed to account for that in addition to the higher cost and utilization of medical services each year.

How it plans to spend your premium

This is how the insurance company plans

to spend the premium it collects in 2017:

Claims: 88.95%

Administrative: 14.58%

Taxes & fees: 3.42%

Profit: -6.95%

The number of individuals affected by these rate increases is 1,197.

The rate increase is 6.7%.

Jan. 2015-Dec. 2015 financial experience

Premiums $ 8,381,647

Claims $ 7,263,253

Administrative expenses $ 1,383,156

Company made (before taxes) $ (264,762)

Cost and utilization increases are expected to increase by approximately 3.8% for 2017.

No changes in benefits contributed significantly to the increase.

No major changes in administrative costs were anticipated and thus did not affect the increase.

General Info

The purpose of this actuarial memorandum is to provide certain information related to a rate submission for

the company identified below. The relevant index rate is developed in accordance with federal regulations,

and plan specific premiums are generated using the allowable modifiers in accordance with the single risk

pool rule.

Company Identifying Information:

Company Legal Name: UPMC Health Coverage, Inc.

NAIC #: 22350

State: PA

HIOS Issuer ID: 62560

Market: Small Group

Effective Date: 1/1/2017

Company Contact Information:

[This information redacted for publication.]

Filing Information:

Rate Filing SERFF Tracking #: UPMC-130536846

Form Filing SERFF Tracking #: UPMC-130489190

Binder SERFF Tracking #: UPMC-PA17-125059925

Rate History

Year Rate Change

2014 0.0%

2015 0.0%

2016 0.0%

Proposed Rate Increase(s)

Reasons for Rate Increase(s):

The rate increase is 7.7% The major reasons for the increase include the

following:

• The single risk pool experience is more adverse than what is assumed in the current rates

• Increasing cost and utilization trends

• Wider variation in induced demand by network than what is assumed in the current rates

Actuarial Memorandum

SERFF Tracking #

UPMC-129629126

UPMC-129640441

UPMC-130071359

Benefit Changes

There are no benefits changes for 2017.

Experience Period Premium and Claims

Paid Through Date:

The reported claims during the experience period have a paid through date of March 2016.

Premiums (net of MLR Rebate) in Experience Period:

Allowed and Incurred Claims Incurred During the Experience Period:

Month

1/1/2015

2/1/2015

3/1/2015

4/1/2015

5/1/2015

6/1/2015

7/1/2015

8/1/2015

9/1/2015

10/1/2015

11/1/2015

12/1/2015

Private Reinsurance:

Private reinsurance is utilized. Recoveries are subtracted from experience period claims. The average PMPM

was subtracted from each plan rather than using individual plan-level recoveries for each.

Non-EHB Claims:

Benefits that were offered outside EHB include routine foot care, acupuncture, and private duty nursing.

The experience period allowed claims for these benefits was $0.61 PMPM.

0.9706

0.9591

0.9804

Worksheet I, Section I of the URRT contains calendar year 2015 claims experience for the captioned company

and market, paid through March 2016. Allowed medical claims and pediatric vision claims are pulled directly

from our data warehouse. Pediatric dental claims are administered and paid by Dominion Dental. We receive a

separate report from Dominion with the claim detail. We used the standard Development/Completion Factor

Method to calculate IBNR. Factors were calculated using our entire fully insured block of business. Because of

the changes in membership in our community rated plans year to year, we felt it would be better to use a more

established and consistent data set. Because three months run out is available the impact of IBNR is minimal.

Completion Factor

0.9986

0.9985

0.9981

0.9972

0.9962

0.9950

0.9911

0.9888

0.9852

Worksheet I, Section I of the URRT contains calendar year 2015 premium for the captioned company and

market. An amount has been added for estimated risk adjustment. No adjustments were made for MLR rebates

as we do not anticipate owing them.

Pharmacy Rebates:

Pharmacy rebates reduced the total allowed claims by $314,087.

Experience Period Loss Ratio:

The experience period loss ratio, defined as the ratio of incurred claims to earned premium, is 86.66%.

Benefit Categories

Medical claims are split into 9 categories in our data warehouse. They are mapped into the categories on the

URRT as follows:

Drug claims are on separate tables and directly mapped into the Prescription Drugs category.

Projection Factors

Changes in the Morbidity of the Population Insured:

We expect a morbidity trend of -3% when comparing our experience period population to our projected

population. These numbers were derived from a consultant's (Optum Consulting) estimate using drug claims

to project risk scores.

Changes in Benefits:

The selection of a new EHB Benchmark plan for 2017 required 3 changes to be made to existing plans:

• Fertility treatment via IUI will now be covered.

• Benefit limit increase of 26 visits for pulmonary and cardiac (In 2016, the pulmonary was 24 visits

and cardiac was 12 weeks; in 2017 both benefits will have 36 visit limits, not combined).

• Benefit limit for nutritional counseling increasing from a 2-visit limit to a 6-visit limit.

Changes in Demographics:

We used the individual risk pool data because of our small group community-rated risk pool does not have

enough membership to be deemed credible. The average age for our 2015 experience period individual risk

pool was 42.2 with an average premium factor of 1.67. This is comparable to our 2016 experience so far with

age 42.5 and premium factor 1.74. Due to the stability of the population no demographic adjustment has been

made to the rates.

PCP Professional

Specialist Professional

Diagnostic Other Medical

ER Other Medical

Other Other Medical

Catastrophic Inpatient Hospital

Outpatient Outpatient Hospital

Behavioral Outpatient Hospital

UPMC Benefit Category URRT Benefit Category

Inpatient Inpatient Hospital

Other Adjustments:

No other adjustments to the experience period data were needed.

Trend Factors (cost/utilization):

Historical allowed claims were used to develop year over year trend factors for use in the projected rates.

Because of the large change in membership year over year, the data specific to the block of business

associated with this filing was deemed too volatile to use for trend development. The entire block of

commercial business was included in Table 3 and 3b for trend development. The total impact for adjustments

to benefit changes was negligible, and did not have a significant impact on the trend calculation.

Quarterly Trend:

No quarterly trends will be applied.

Credibility Manual Rate Development

Source and Appropriateness of Manual Rate Used:

The experience period data for groups enrolled in a community rated plan was used. The data for the entire

block would not be appropriate as the majority of groups enrolled in grandmothered plans would not join the

single risk pool until 2018.

Adjustments Made to the Data:

Adjustments include the items listed under "Changes in Benefits" above as part of the new EHB Benchmark

plans.

Inclusion of Capitation Payments:

No benefits are projected to be paid for via capitation.

Credibility of Experience

The experience period data has a credible membership amount. However, most of this membership will not

be joining the community rated single risk pool until 2018. Therefore 0% credibility is used.

Projected Index Rate

The Projected Index Rate is calculated by first applying 2 years of 3.8% annual trend to the manual rate.

Adjustments are then applied to get from the single risk pool population with broad plan offerings to

the plan offerings of this specific segment.

Projected Market Adjusted Index Rate

The Projected Index Rate is adjusted by adding estimates for Risk Adjustment and Marketplace Fees (with

impacts and costs spread across the whole risk pool) to obtain the Projected Market Adjusted Index Rate.

Projected Allowed Claims

The projected index rate was added with the projected allowed amounts for non-EHB benefits to obtain the

Projected Allowed Claims.

Risk Adjustment and Reinsurance

Experience period Risk Adjustment PMPM was estimated to be $18.22. An exact amount is not yet known so

estimates from a consultant were used.

The projected risk adjustment assumes any membership changes involve members of average risk. Thus the

total dollar impact of these membership fluctuations was estimated to remain unchanged. $1.56 PMPY has

been subtracted as a projected amount for the Risk Adjustment Administration Fee.

The net amount after accounting for the fee is subtracted from the Projected Index Rate as part of the

calculation of the Market Adjusted Index Rate. For the URRT, it was entered as a positive number because the

calculation subtracts the value. Table 6 of the PA Actuarial Memorandum Rate Exhibits adds this amount so it

was entered as a negative value. The effect is a decrease in premium.

No adjustments for the Traditional Reinsurance Program under PPACA were made as no recoveries are paid

to the small group market.

Non-Benefit Expenses and Profit & Risk

9.30%

4.65%

0.62%

0.05%

0.00%

0.00%

1.73%

-6.59%

9.8%

$ 410.68

Administrative Expenses are from our 2015 Supplemental Health Care Exhibit. They are broken out by lines of

business and market segments matching this filing and thus are appropriate for use.

Taxes and Fees decreased from 2016 to 2017 to account for the suspension of the Health Insurance Tax for

2017. A PCORI amount of $0.19 PMPM has been added. As noted above in the "Projected Market Index Rate"

section, Marketplace user fees are applied as an adjustment to the Index Rate at the market level. The

member-weighted average of 3.5% for Marketplace enrollees combined with 0% for non-Marketplace

enrollees calculates to 1.6%.

Projected Required Revenue PMPM

Administrative Expenses

General and Claims

Agent/Broker Fees and Commissions

Quality Improvement Initiatives

Taxes and Fees

PCORI Fee ($0.19 PMPM)

Health Insurance Providers Fee

PA Premium Tax (if applicable)

Federal Income Tax

Profit/Contingency

Total Retention

Retention Items - Express in percentages

Table 6. Retention PMPM

Normalization Factors

Average Age Factor:

The average age factor was calculated using our current Individual market population with the HHS Age

Factors. It was assumed this represents the age distribution of the entire single risk-pool. The Individual

population was used for this calculation as the small group population does not have enough membership to

be credible. The number of members under each age bracket was multiplied by the corresponding HHS Age

Factor. These were then summed and divided by the total number of members to obtain the average age

factor. The weighted average age of this population is 42.2 and the average factor is 1.670. This does

not match the HHS Age Factor because the distribution of HHS Age Factors is not linear.

Average Geographic Factor:

Credible data is not available for all areas in which these plans are sold. Because of this we have set all of

the geographic factors to 1.

Average Tobacco Factor:

A tobacco load is not applied for this market segment.

Average Benefit Richness Factor:

This adjustment was used to keep relativities between plans similar to what they were in the previous year.

This will minimize rate increase variations by plan and consumer confusion that could result. In addition,

our current MLR is much higher for Platinum plans compared to the rest of the plans which suggests a wider

variation is necessary than what is indicated in the company-determined Pricing AV.

Paid to Allowed Ratio

The Paid to Allowed Average Factor is the weighted average based on membership of the HHS AV Metal

Values as developed using the HHS AV Calculator.

Projected Loss Ratio

The projected period loss ratio, defined as the ratio of incurred claims to earned premium, is 88.9%.

AV Metal Values

Metal values were determined using the final 2017 HHS AV Calculator.

AV Pricing Values

The allowable modifiers that make up AV Pricing Values have been included in Table 10 of the PA Rate Filing

Exhibits.

Pricing AV (company-determined AV)

Pricing AVs were determined using the final 2017 HHS AV Calculator.

Benefit Richness (induced demand)

This adjustment was used to keep relativities between plans similar to what they were in the previous year.

This will minimize rate increase variations by plan and consumer confusion that could result. In addition,

our current MLR is much higher for Platinum plans compared to the rest of the plans which suggests a wider

variation is necessary than what is indicated in the company-determined Pricing AV.

Benefits in addition to EHB

Benefits that will be offered outside EHB include routine foot care and acupuncture. The projected allowed

claims for these benefits is $1.12 PMPM.

Provider Network

Network 2017 Factor

Standard 1.00

DOH must approve networks every year which does not happen before the submission of these rate filings.

In Table 14 the date the network was submitted for approval was entered instead.

Tobacco Callibration

The average tobacco factor was calculated using the most updated membership data available. A separate

data pull was utilized because our data warehouse is still working on making the tobacco indicator reliable

enough for use.

Geographic Factors

Credible data is not available for all areas for which these plans are sold. Because of this we have set all of

the geographic factors to 1.

Composite Rating

No composite rating is used with these plans.

Consumer Adjusted Premium Rate Development

Plan Adjusted Index Rate is divided by the age calibration factor then multiplied by the specific age,

geographic, and tobacco factors for the consumer to develop the Consumer Adjusted Premium Rate.

Membership Projections

Membership projections were developed based on our anticipated competitive positioning in the market

combined with our current enrollment distribution by plan.

Warning Alerts

When validating the URRT, an error appears because the Product ID of the Termnated Product and

the SHOP HMO product match.

When validating the URRT, a warning appears indicating that cell G16 and H30 on Worksheet 1 do not

match due to a minimal difference.

Warnings appear in cells A55 and A57 of Worksheet 2 of the URRT. This is because the average Plan

Adjusted Index Rate and total premium are calculated from the filed 2015 Plan Adjusted Index Rate

for the SCID listed in cell G20.

Effective Rate Review Information

The Pennsylvania Insurance Department is responsible for conductive effective rate review for all submitted

rates.

Actuarial Certification

I, Michael Lovely, am a Member of the American Academy of Actuaries. I am currently a Manager in the

Actuarial Services department for UPMC Health Plan. I certify that:

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

memorandum.

• New plans cannot be considered modificaMons of exisMng plans under the uniform modificaMon

standards in 45 CFR 147.106.

• The informaMon presented in the PA Actuarial Memorandum and PA Actuarial Memorandum Rate Exhibits

is consistent with the information presented in the 2017 Rate Filing Justification.

• The projected Index Rate is:

a. In compliance with all applicable state and Federal statutes and regulations (45 CFR 156.80 and 147.102)

b. Developed in compliance with the applicable Actuarial Standards of Practice

c. Reasonable in relation to the benefits provided and the population anticipated to be covered

d. Neither excessive nor deficient

• The Index Rate and only the allowable modifiers as described in 45 CFR 156.80(d)(1) and 156.80(d)(2) were

used to generate plan level rates.

• The percent of total premium that represents EHB included in Worksheet 2, Sections III and IV, was

calculated in accordance with actuarial standards of practice.

• The geographic rating factors reflect only differences in the costs of delivery and do not include differences

for population morbidity by geographic area.

• The AV Calculator was used to determine the AV Metal Values shown in Worksheet 2 of the Part I URRT for

all plans except those specified in the certification.

4/27/2016

Michael Lovely ASA, MAAA DateUPMC Health Plan