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Monthly ratesfor individual & family plans

Effective: January 1, 2021

Rate BookFull version: Includes all 19 rating regions

2 2021 monthly rates for individuals and families

This brochure has monthly rate information for Blue Shield medical, dental, vision and individual term life insurance* coverage for all regions. You can purchase a medical plan directly from Blue Shield or from Covered California, California’s health plan marketplace. And starting in 2021, you can buy a Family Dental plan directly from Covered California as well.

Medical plans Choose the medical plan that is best for you from our Trio ACO HMO Network or from our Exclusive PPO Network.

Our Trio ACO HMO NetworkAn accountable care organization (ACO) is a network of doctors and hospitals that work directly with health plan providers, such as Blue Shield, to share the responsibility for providing coordinated care to patients. Within the Trio ACO HMO Network, you will have a primary care physician (PCP) that coordinates your care, communicates with necessary specialists, and provides referrals so you can get care. Your chosen PCP must participate in the Trio ACO HMO Network.

Your PCP will refer you to specialists that are part of the same medical group of professionals. If you need a specialist who is not in your PCP’s medical group, you may be referred out-of-network and still receive covered benefits.

Blue Shield’s Trio HMO is available in 26 counties throughout California and can be purchased directly through Blue Shield or Covered California. The Trio ACO HMO Network offers the same types of doctors and levels of care as traditional HMO plans. To enroll in a Trio HMO plan, you and your dependents must live or work in the Trio HMO plan service area.

Our Exclusive PPO Network Blue Shield offers a variety of PPO health plans that give you access to more than 56,000 doctors and 325 hospitals in our Exclusive PPO Network. So, make sure any physician you visit is in the Exclusive PPO Network to minimize out-of-pocket costs. While Blue Shield’s PPO plans provide limited coverage for some services you receive from providers outside of the plan’s Exclusive PPO Network, you will get the most value from your PPO health plan when you use Exclusive PPO Network providers.

Medical plans available through the followingBlue Shield or

Covered CaliforniaBlue Shield

onlyCovered California

only

HMO plansBlue Shield Platinum 90 Trio HMO ll

Blue Shield Gold 80 Trio HMO ll

Blue Shield Silver 70 Trio HMO ll

Silver 70 Off Exchange Trio HMO† ll




PPO plansBlue Shield Platinum 90 PPO ll

Blue Shield Gold 80 PPO ll

Blue Shield Silver 70 PPO ll

Blue Shield Bronze 60 PPO ll

Blue Shield Bronze 60 HDHP PPO ll

Blue Shield Minimum Coverage PPO ll

Silver 70 Off Exchange PPO ll

Silver 1950 PPO ll

Silver 2600 HDHP PPO ll




Please note: The Minimum Coverage PPO plan is available only to persons under age 30, or those age 30 and above who can provide a certification that they are without affordable coverage or are experiencing financial hardship. Pediatric dental and vision benefits are embedded into all medical plans. Once a person turns age 19, he or she is no longer eligible for pediatric dental and pediatric vision benefits. To obtain dental and vision benefits, they must apply for a separate dental plan and/or vision plan.

* Underwritten by Blue Shield of California Life & Health Insurance Company.

2021 monthly rates for individuals and families 3

Dental, vision and life insurance plansAdd a Blue Shield dental plan, vision plan* and/or life insurance plan* in addition to your health coverage. When your plans come together in one place, you not only make your care more convenient across the whole health experience, you get the added benefit of coordinated care. Coordinated care entails your dental, vision, and health providers working together to improve preventive care and identifying broader risk factors like gum disease and glaucoma.

The combination of coordinated care and Blue Shield’s unparalleled network of providers across plans means you have a wealth of choice for the most comprehensive approach to coverage.

New for 2021, we are pleased to announce our Family Dental Plans that are now available exclusively through Covered California. With Blue Shield Family Dental PPO and HMO plans, you get a first line of defense for your family’s overall health and well-being. From in-network dentist savings to easy, online access to benefits, our Family Dental Plans have something for everyone.

Network of nearly 26,000 DHMO or 48,000 DPPO dental access points in California

One of the largest vision networks in California; Giving you easy access to a mix of more than 7,000 medical and optical retail centers.

Rated “A (Excellent)” from A.M. Best

Dental, vision, dental + vision package, and individual term life insurance plans available through Blue Shield onlyDental PPO Enhanced Dental PPO 50/1250 Enhanced Dental PPO 25/500 Enhanced Dental PPO 50/2000 Enhanced Dental PPO 50/2000 Lifetime Ortho 1500

Dental HMODental Standard HMO Specialty Duo dental + vision package*Ultimate Vision 15/25/120*Ultimate Vision 15/25/150*Individual term life insurance plans*

Dental plans available through Covered California onlyFamily Dental PPO Family Dental HMO



Find your rate

1. Determine plan availabilitySome plans are only available in specific areas. If you are interested in enrolling in a medical PPO plan, it is available for all counties. Medical HMO plans and Family Dental plans availability can vary per region and/or ZIP code. Please refer to Region Ratings by County on page 5 for a helpful chart. For medical HMO plans, you can also use Blue Shield’s Trio ZIP code locator at blueshieldca.com/triocheck.

2. Specify your planFind the plan you selected for you and/or your family in the plans rate chart.

For plans sold through Blue Shield only, you can enroll in a dental plan, vision plan, dental + vision package,* or apply for individual term life insurance coverage* with or without the purchase of a Blue Shield medical plan. If you wish to enroll in a dental plan,† vision plan, or dental + vision package along with a medical plan,‡ add the rate for those products to your medical rate to determine your total rate. If you wish to apply for individual term life insurance coverage, a separate application must be completed.

You can only enroll in a Family Dental plan sold through Covered California if you are also enrolled in a medical plan sold through Covered California. For additional enrollment guidelines, please refer to the Basics of Family Dental Plans notes on page 8.

3. Locate your rate, depending on your ageLocate your age to determine your rate. For family coverage, the rate is a sum of each family member’s individual rate. However, a maximum of the three oldest children will be rated in the total family rate.

Maximum 3-child ruleMedical plans and dental plans sold through Covered California only: Under age 21Dental and vision plans sold through Blue Shield only: Under age 26

Dental, vision, dental + vision, and individual term life plan rates can be found on pages 7-9.

Medical coverage rates can be found on pages 10-65.


† Please note that the Family Dental HMO, Dental HMO and Dental Standard HMO plans’ availability and/or rate per member differ based on region and county. These plans are not available for enrollment in certain counties. Please refer to page 5 for plan specifics.

‡ When enrolling in a Blue Shield medical plan through Covered California, dental and vision plans cannot be bundled with your medical plan for combined billing. Enrollment and billing will be handled separately from your medical plan.


Rating regions by county

County RegionTrio HMO offered?

Family Dental HMO offered?

Alameda 6 ll ll

Alpine 1 ll ll

Amador 1 ll ll

Butte 1 ll ll

Calaveras 1 ll ll

Colusa 1 ll ll

Contra Costa 5 ll ll

Del Norte 1 ll ll

El Dorado 3 ww ll

Fresno 11 ww ll

Glenn 1 ll ll

Humboldt 1 ll ll

Imperial 13 ll ll

Inyo 13 ll ll

Kern 14 ww ll

Kings 11 ww ll

Lake 1 ll ll

Lassen 1 ll ll

Los Angeles (except ZIP codes listed below) 16 ww ll

Los Angeles (ZIP codes starting with 906, 907, 908, 909, 910, 911, 912, 915, 917, 918, and 935)

15 ww ll

Madera 11 ll ll

Marin 2 ww ww

Mariposa 10 ll ll

Mendocino 1 ll ll

Merced 10 ll ll

Modoc 1 ll ll

Mono 13 ll ll

Monterey 9 ll ll

Napa 2 ll ww

Nevada 1 ww ll

Available in all counties shown below:

All PPO medical plans All PPO dental plansAll vision plansAll life insurance plans

Trio HMO plans are available in 26 counties* (full or partial coverage). Family Dental HMO plan is not available in Region 1. To identify the Trio HMO and Family Dental HMO plans’ service area,* use the following guide:

l l Full ww Partial ll Not offered

* Out of Blue Shield’s 19 rating regions, Trio HMO is not offered in region 13.


Rating regions by county (continued)

County RegionTrio HMO offered?

Family Dental HMO offered?

Orange 18 ll ll

Placer 3 ww ll

Plumas 1 ll ll

Riverside 17 ww ll

Sacramento 3 ww ll

San Benito 9 ll ll

San Bernardino 17 ww ll

San Diego 19 ww ll

San Francisco 4 ll ll

San Joaquin 10 ll ll

San Luis Obispo 12 ww ww

San Mateo 8 ll ll

Santa Barbara 12 ll ww

Santa Clara 7 ll ll

Santa Cruz 9 ll ll

Shasta 1 ll ll

Sierra 1 ll ll

Siskiyou 1 ll ll

Solano 2 ww ww

Sonoma 2 ll ww

Stanislaus 10 ww ll

Sutter 1 ll ll

Tehama 1 ll ll

Trinity 1 ll ll

Tulare 10 ww ll

Tuolumne 1 ll ll

Ventura 12 ww ww

Yolo 3 ww ll

Yuba 1 ll ll

l l Full ww Partial ll Not offered


Monthly dental and vision rates

PPO dental plans available direct through Blue ShieldRate per member

Ages 0 through 25 (rate per child for first 3 children –

no cost for 4th child and beyond)*Age 26+

All regions

Enhanced Dental PPO 50/2000 $49.90 $64.30

Enhanced Dental PPO 50/2000 Lifetime Ortho 1500

$54.30 $69.90

Dental PPO $36.40 $43.10



HMO dental plans available direct through Blue ShieldRate per member


no cost for 4th child and beyond)*Age 26+

Regions 1, 2, and 12†

Dental HMO $28.80 $31.40

Dental Standard HMO $14.70 $18.30

All other regionsDental HMO $22.30 $24.30

Dental Standard HMO $11.50 $14.20

Blue Shield dental plans available through Covered CaliforniaRate per member

Regions Family Dental PPO


no cost for 4th child and beyond)‡

Age 19+

1, 4, 9, 13-14, 16 $28.80 $43.70

2, 5-8, 10-11, 15, 17 $30.30 $46.10

3, 12, 18-19 $32.10 $48.80

Rate per member

Regions Family Dental HMO


no cost for 4th child and beyond)‡

Age 19+

15-19 $14.00 $13.40

3-7, 9 $15.20 $14.60

8, 10-11, 13-14 $16.40 $15.80

12 $22.40 $21.50

2 $26.20 $25.20

* Only dependent children ages 0 through 25 count toward the three-child maximum rate cap. If you are enrolling more than one dependent child without an accompanying parent or legal guardian on the policy, each child will be given a separate policy and each child will be charged the child age rate.

† Region 1 is composed of the following counties: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, and Yuba. Region 2 is composed of the following counties: Marin, Napa, Solano, and Sonoma. Region 12 is composed of the following counties: San Luis Obispo, Santa Barbara, and Ventura. The Dental HMO and Enhanced Dental HMO $0 plans are not available in Butte, Humboldt, Lake, Lassen, Nevada, Shasta, Sutter, Tehama, Marin, Napa, San Luis Obispo, and Santa Barbara counties.

‡ A dependent 18 years of age will be charged the age 0-18 rate through the end of the year in which they turn 19, however, that dependent will continue to count toward the three-dependent maximum rate cap until they turn 21.


Monthly dental and vision rates (continued)

Monthly Specialty Duo dental + vision package ratesRate per member

Ages 0 through 25 (rate per child for first 3 children – no cost for 4th child and beyond)*

Age 26+

All regions Specialty Duo dental + vision package

$41.10 $48.30

Please note: Monthly rates for Specialty Duo are in addition to the rates for medical benefits covered by the Blue Shield health plan. However, you will receive one bill that combines your health and dental + vision package rates.

* Only dependent children ages 0 through 25 count toward the three-child maximum rate cap. If you are enrolling more than one dependent child without an accompanying parent or legal guardian in the plan, the three-child maximum rate cap does not apply. Each child will be given a separate policy, and each child will be charged the ages 0 through 25 rate.

Monthly vision plan ratesRate per member

Ages 0 through 25 (rate per child for first 3 children – no cost for 4th child and beyond)*

Age 26+

All regionsUltimate Vision 15/25/120 $6.50 $6.50

Ultimate Vision 15/25/150 $12.00 $12.00

Please note: Monthly rates for vision plans are in addition to the rates for medical benefits covered by the Blue Shield health plan. However, you will receive one bill that combines your health, vision and, if applicable, dental plan rates.

* Only dependent children ages 0 through 25 count toward the three-child maximum rate cap. If you are enrolling more than one dependent child without an accompanying parent or legal guardian in the plan, the three-child maximum rate cap does not apply. Each child will be given a separate policy, and each child will be charged the ages 0 through 25 rate.

Basics of Family Dental Plans• Covered California’s family dental plans make benefits available to both adults and children. Enrollment in

these plans is optional, and there is no tax penalty if you do not enroll in an optional family dental plan.

• Families that wish to purchase a family dental plan must be enrolled in a health insurance (medical) plan purchased through Covered California.

• There must be at least one adult (age 19 or older) enrolled in a family dental plan in order for a child in the family to enroll.

– All adults in the household are not required to enroll.

– If a family chooses to enroll children (younger than 19) in a family dental plan, all children younger than 19 who live in the household must enroll in the same family dental plan.


Coverage amount: $10,000Age range

Male non-nicotine

Male nicotine use

Female non-nicotine

Female nicotine use

1-19 $2.22 $3.44 $1.71 $2.43 20-24 $2.25 $3.50 $1.74 $2.48 25-29 $2.32 $3.63 $1.80 $2.59 30-34 $2.50 $4.00 $1.95 $2.91 35-39 $2.80 $4.64 $2.22 $3.44 40-44 $3.31 $5.30 $2.69 $4.37 45-49 $4.29 $7.58 $3.48 $5.95 50-54 $5.87 $10.74 $4.75 $8.49 55-59 $8.32 $15.64 $6.66 $12.31 60-64 $12.93 $24.86 $9.65 $18.30 65+ All plans terminate at age 65


Male non-nicotine

Male nicotine use

Female non-nicotine

Female nicotine use



Male non-nicotine

Male nicotine use

Female non-nicotine

Female nicotine use

1-19 N/A N/A N/A N/A 20-24 $10.37 $19.75 $6.55 $12.09 25-29 $10.88 $20.75 $6.98 $12.96 30-34 $12.23 $23.47 $8.16 $15.31 35-39 $14.53 $28.06 $10.16 $19.31 40-44 $18.35 $35.71 $13.65 $26.31 45-49 $25.68 $50.37 $19.56 $38.13 50-54 $37.53 $74.06 $29.10 $57.20 55-59 $55.91 $110.82 $43.41 $85.83 60-64 $90.46 $179.93 $65.86 $130.72 65+ All plans terminate at age 65


Male non-nicotine

Male nicotine use

Female non-nicotine

Female nicotine use



Male non-nicotine

Male nicotine use

Female non-nicotine

Female nicotine use



Male non-nicotine

Male nicotine use

Female non-nicotine

Female nicotine use


Monthly life insurance* plan rates

Footnotes:


† Life insurance may be purchased with or without AD&D.

‡ AD&D may only be purchased if a life insurance policy is purchased. Rates in table reflect additional increase to monthly premium. For example a 40-year-old woman who does not use nicotine would pay a monthly premium of $22.87 for $50,000 coverage of life insurance ($17.87) and AD&D ($5.00).

Life† and AD&D benefits are available in the following amounts: $10,000, $15,000, $25,000, $50,000, $75,000, and $100,000.

AD&D coverage amount‡

Age range $10,000 $15,000 $25,000 $50,000 $75,000 $100,000

1-19 $1.00 $1.50 $2.50 N/A N/A N/A20-64 $1.00 $1.50 $2.50 $5.00 $7.50 $10.00 65+ N/A N/A N/A N/A N/A N/A


Monthly rates for Region 1 – PPO plansAge

Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $583.97 $434.47 $369.61 $369.61 $369.61 $369.61

15 $635.87 $473.09 $402.47 $402.47 $402.47 $402.47

16 $655.72 $487.86 $415.03 $415.03 $415.03 $415.03

17 $675.57 $502.63 $427.59 $427.59 $427.59 $427.59

18 $696.94 $518.53 $441.12 $441.12 $441.12 $441.12

19 $718.32 $534.43 $454.65 $454.65 $454.65 $454.65

20 $740.45 $550.90 $468.66 $468.66 $468.66 $468.66

21 $763.35 $567.94 $483.16 $483.16 $483.16 $483.16

22 $763.35 $567.94 $483.16 $483.16 $483.16 $483.16

23 $763.35 $567.94 $483.16 $483.16 $483.16 $483.16

24 $763.35 $567.94 $483.16 $483.16 $483.16 $483.16

25 $766.41 $570.21 $485.09 $485.09 $485.09 $485.09

26 $781.68 $581.57 $494.75 $494.75 $494.75 $494.75

27 $800.00 $595.20 $506.35 $506.35 $506.35 $506.35

28 $829.77 $617.35 $525.19 $525.19 $525.19 $525.19

29 $854.19 $635.52 $540.65 $540.65 $540.65 $540.65

30 $866.41 $644.61 $548.38 $548.38 $548.38 $548.38

31 $884.73 $658.24 $559.98 $559.98 $559.98 $559.98

32 $903.05 $671.87 $571.57 $571.57 $571.57 $571.57

33 $914.50 $680.39 $578.82 $578.82 $578.82 $578.82

34 $926.71 $689.48 $586.55 $586.55 $586.55 $586.55

35 $932.82 $694.02 $590.42 $590.42 $590.42 $590.42

36 $938.93 $698.56 $594.28 $594.28 $594.28 $594.28

37 $945.03 $703.11 $598.15 $598.15 $598.15 $598.15

38 $951.14 $707.65 $602.01 $602.01 $602.01 $602.01

39 $963.35 $716.74 $609.74 $609.74 $609.74 $609.74

40 $975.57 $725.82 $617.47 $617.47 $617.47 $617.47

41 $993.89 $739.46 $629.07 $629.07 $629.07 $629.07

42 $1,011.45 $752.52 $640.18 $640.18 $640.18 $640.18

43 $1,035.87 $770.69 $655.64 $655.64 $655.64 $655.64

44 $1,066.41 $793.41 $674.97 $674.97 $674.97 $674.97

45 $1,102.28 $820.10 $697.68 $697.68 $697.68 $697.68

46 $1,145.03 $851.91 $724.73 $724.73 $724.73 $724.73

47 $1,193.12 $887.69 $755.17 $755.17 $755.17 $755.17

48 $1,248.09 $928.58 $789.96 $789.96 $789.96 $789.96

49 $1,302.28 $968.90 $824.26 $824.26 $824.26 $824.26

50 $1,363.35 $1,014.34 $862.92 $862.92 $862.92 $862.92

51 $1,423.66 $1,059.20 $901.09 $901.09 $901.09 $901.09

52 $1,490.07 $1,108.62 $943.12 $943.12 $943.12 $943.12

53 $1,557.24 $1,158.59 $985.64 $985.64 $985.64 $985.64

54 $1,629.76 $1,212.55 $1,031.54 $1,031.54 $1,031.54 $1,031.54

55 $1,702.28 $1,266.50 $1,077.44 $1,077.44 $1,077.44 $1,077.44

56 $1,780.91 $1,325.00 $1,127.20 $1,127.20 $1,127.20 $1,127.20

57 $1,860.30 $1,384.07 $1,177.45 $1,177.45 $1,177.45 $1,177.45

58 $1,945.03 $1,447.11 $1,231.08 $1,231.08 $1,231.08 $1,231.08

59 $1,987.01 $1,478.34 $1,257.65 $1,257.65 $1,257.65 $1,257.65

60 $2,071.74 $1,541.38 $1,311.28 $1,311.28 $1,311.28 $1,311.28

61 $2,145.03 $1,595.91 $1,357.67 $1,357.67 $1,357.67 $1,357.67

62 $2,193.12 $1,631.69 $1,388.11 $1,388.11 $1,388.11 $1,388.11

63 $2,253.42 $1,676.55 $1,426.28 $1,426.28 $1,426.28 $1,426.28

64+ $2,290.06 $1,703.81 $1,449.47 $1,449.47 $1,449.47 $1,449.47



Silver 70 Off Exchange PPO

Silver 1950 PPO

Silver 2600 HDHP PPO

Bronze 60 PPO

Bronze 60 HDHP PPO

Minimum Coverage PPO

0 to 14 $344.94 $321.14 $311.16 $287.66 $284.41 $277.32

15 $375.61 $349.69 $338.82 $313.23 $309.69 $301.97

16 $387.33 $360.60 $349.39 $323.00 $319.35 $311.40

17 $399.05 $371.52 $359.97 $332.78 $329.02 $320.82

18 $411.68 $383.27 $371.36 $343.31 $339.43 $330.98

19 $424.30 $395.03 $382.75 $353.84 $349.84 $341.13

20 $437.38 $407.20 $394.54 $364.74 $360.62 $351.64

21 $450.91 $419.79 $406.74 $376.02 $371.77 $362.51

22 $450.91 $419.79 $406.74 $376.02 $371.77 $362.51

23 $450.91 $419.79 $406.74 $376.02 $371.77 $362.51

24 $450.91 $419.79 $406.74 $376.02 $371.77 $362.51

25 $452.71 $421.47 $408.37 $377.53 $373.26 $363.96

26 $461.73 $429.87 $416.50 $385.05 $380.69 $371.21

27 $472.55 $439.94 $426.27 $394.07 $389.62 $379.91

28 $490.14 $456.32 $442.13 $408.74 $404.12 $394.05

29 $504.56 $469.75 $455.15 $420.77 $416.01 $405.65

30 $511.78 $476.47 $461.65 $426.79 $421.96 $411.45

31 $522.60 $486.54 $471.42 $435.81 $430.88 $420.15

32 $533.42 $496.62 $481.18 $444.84 $439.81 $428.85

33 $540.19 $502.91 $487.28 $450.48 $445.38 $434.29

34 $547.40 $509.63 $493.79 $456.49 $451.33 $440.09

35 $551.01 $512.99 $497.04 $459.50 $454.30 $442.99

36 $554.62 $516.35 $500.29 $462.51 $457.28 $445.89

37 $558.22 $519.70 $503.55 $465.52 $460.25 $448.79

38 $561.83 $523.06 $506.80 $468.53 $463.23 $451.69

39 $569.04 $529.78 $513.31 $474.54 $469.18 $457.49

40 $576.26 $536.50 $519.82 $480.56 $475.12 $463.29

41 $587.08 $546.57 $529.58 $489.58 $484.05 $471.99

42 $597.45 $556.23 $538.93 $498.23 $492.60 $480.33

43 $611.88 $569.66 $551.95 $510.26 $504.49 $491.93

44 $629.92 $586.45 $568.22 $525.30 $519.36 $506.43

45 $651.11 $606.18 $587.34 $542.98 $536.84 $523.47

46 $676.36 $629.69 $610.11 $564.04 $557.66 $543.77

47 $704.77 $656.14 $635.74 $587.72 $581.08 $566.61

48 $737.23 $686.36 $665.02 $614.80 $607.85 $592.71

49 $769.25 $716.17 $693.90 $641.50 $634.24 $618.45

50 $805.32 $749.75 $726.44 $671.58 $663.98 $647.45

51 $840.94 $782.92 $758.58 $701.28 $693.35 $676.09

52 $880.17 $819.44 $793.96 $734.00 $725.70 $707.63

53 $919.85 $856.38 $829.76 $767.09 $758.41 $739.53

54 $962.69 $896.26 $868.40 $802.81 $793.73 $773.97

55 $1,005.52 $936.14 $907.04 $838.53 $829.05 $808.41

56 $1,051.97 $979.38 $948.93 $877.26 $867.34 $845.74

57 $1,098.86 $1,023.04 $991.23 $916.37 $906.01 $883.45

58 $1,148.91 $1,069.63 $1,036.38 $958.11 $947.27 $923.69

59 $1,173.71 $1,092.72 $1,058.75 $978.79 $967.72 $943.62

60 $1,223.76 $1,139.32 $1,103.90 $1,020.53 $1,008.99 $983.86

61 $1,267.05 $1,179.62 $1,142.95 $1,056.63 $1,044.68 $1,018.66

62 $1,295.46 $1,206.07 $1,168.57 $1,080.32 $1,068.10 $1,041.50

63 $1,331.08 $1,239.23 $1,200.71 $1,110.02 $1,097.47 $1,070.14

64+ $1,352.72 $1,259.38 $1,220.23 $1,128.07 $1,115.31 $1,087.54


Monthly rates for Region 1 – HMO plansAge

Platinum 90 Trio HMO

Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO

Silver 70 Off Exchange Trio HMO

0 to 14 $683.96 $484.11 $402.01 $402.01 $402.01 $402.01 $375.17

15 $744.76 $527.14 $437.74 $437.74 $437.74 $437.74 $408.52

16 $768.00 $543.60 $451.40 $451.40 $451.40 $451.40 $421.27

17 $791.25 $560.05 $465.07 $465.07 $465.07 $465.07 $434.02

18 $816.28 $577.77 $479.78 $479.78 $479.78 $479.78 $447.76

19 $841.31 $595.49 $494.49 $494.49 $494.49 $494.49 $461.49

20 $867.24 $613.84 $509.73 $509.73 $509.73 $509.73 $475.71

21 $894.06 $632.83 $525.50 $525.50 $525.50 $525.50 $490.42

22 $894.06 $632.83 $525.50 $525.50 $525.50 $525.50 $490.42

23 $894.06 $632.83 $525.50 $525.50 $525.50 $525.50 $490.42

24 $894.06 $632.83 $525.50 $525.50 $525.50 $525.50 $490.42

25 $897.64 $635.36 $527.60 $527.60 $527.60 $527.60 $492.38

26 $915.52 $648.01 $538.11 $538.11 $538.11 $538.11 $502.19

27 $936.98 $663.20 $550.72 $550.72 $550.72 $550.72 $513.96

28 $971.85 $687.88 $571.22 $571.22 $571.22 $571.22 $533.09

29 $1,000.46 $708.13 $588.03 $588.03 $588.03 $588.03 $548.78

30 $1,014.76 $718.26 $596.44 $596.44 $596.44 $596.44 $556.63

31 $1,036.22 $733.44 $609.05 $609.05 $609.05 $609.05 $568.40

32 $1,057.68 $748.63 $621.66 $621.66 $621.66 $621.66 $580.17

33 $1,071.09 $758.12 $629.55 $629.55 $629.55 $629.55 $587.53

34 $1,085.39 $768.25 $637.95 $637.95 $637.95 $637.95 $595.37

35 $1,092.55 $773.31 $642.16 $642.16 $642.16 $642.16 $599.30

36 $1,099.70 $778.37 $646.36 $646.36 $646.36 $646.36 $603.22

37 $1,106.85 $783.44 $650.57 $650.57 $650.57 $650.57 $607.14

38 $1,114.00 $788.50 $654.77 $654.77 $654.77 $654.77 $611.07

39 $1,128.31 $798.63 $663.18 $663.18 $663.18 $663.18 $618.91

40 $1,142.61 $808.75 $671.59 $671.59 $671.59 $671.59 $626.76

41 $1,164.07 $823.94 $684.20 $684.20 $684.20 $684.20 $638.53

42 $1,184.64 $838.49 $696.29 $696.29 $696.29 $696.29 $649.81

43 $1,213.25 $858.74 $713.10 $713.10 $713.10 $713.10 $665.50

44 $1,249.01 $884.06 $734.12 $734.12 $734.12 $734.12 $685.12

45 $1,291.03 $913.80 $758.82 $758.82 $758.82 $758.82 $708.17

46 $1,341.10 $949.24 $788.25 $788.25 $788.25 $788.25 $735.63

47 $1,397.42 $989.11 $821.35 $821.35 $821.35 $821.35 $766.53

48 $1,461.79 $1,034.67 $859.19 $859.19 $859.19 $859.19 $801.84

49 $1,525.27 $1,079.60 $896.50 $896.50 $896.50 $896.50 $836.66

50 $1,596.80 $1,130.23 $938.54 $938.54 $938.54 $938.54 $875.90

51 $1,667.43 $1,180.22 $980.05 $980.05 $980.05 $980.05 $914.64

52 $1,745.21 $1,235.27 $1,025.77 $1,025.77 $1,025.77 $1,025.77 $957.31

53 $1,823.89 $1,290.96 $1,072.02 $1,072.02 $1,072.02 $1,072.02 $1,000.46

54 $1,908.83 $1,351.08 $1,121.94 $1,121.94 $1,121.94 $1,121.94 $1,047.05

55 $1,993.76 $1,411.20 $1,171.86 $1,171.86 $1,171.86 $1,171.86 $1,093.64

56 $2,085.85 $1,476.38 $1,225.99 $1,225.99 $1,225.99 $1,225.99 $1,144.16

57 $2,178.83 $1,542.19 $1,280.64 $1,280.64 $1,280.64 $1,280.64 $1,195.16

58 $2,278.08 $1,612.44 $1,338.97 $1,338.97 $1,338.97 $1,338.97 $1,249.60

59 $2,327.25 $1,647.24 $1,367.87 $1,367.87 $1,367.87 $1,367.87 $1,276.57

60 $2,426.49 $1,717.49 $1,426.20 $1,426.20 $1,426.20 $1,426.20 $1,331.01

61 $2,512.32 $1,778.24 $1,476.65 $1,476.65 $1,476.65 $1,476.65 $1,378.09

62 $2,568.65 $1,818.11 $1,509.76 $1,509.76 $1,509.76 $1,509.76 $1,408.99

63 $2,639.28 $1,868.10 $1,551.27 $1,551.27 $1,551.27 $1,551.27 $1,447.73

64+ $2,682.19 $1,898.48 $1,576.49 $1,576.49 $1,576.49 $1,576.49 $1,471.27



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $632.75 $470.77 $400.49 $400.49 $400.49 $400.49

15 $689.00 $512.62 $436.09 $436.09 $436.09 $436.09

16 $710.50 $528.62 $449.70 $449.70 $449.70 $449.70

17 $732.01 $544.62 $463.32 $463.32 $463.32 $463.32

18 $755.17 $561.85 $477.97 $477.97 $477.97 $477.97

19 $778.33 $579.08 $492.63 $492.63 $492.63 $492.63

20 $802.31 $596.92 $507.81 $507.81 $507.81 $507.81

21 $827.13 $615.39 $523.52 $523.52 $523.52 $523.52

22 $827.13 $615.39 $523.52 $523.52 $523.52 $523.52

23 $827.13 $615.39 $523.52 $523.52 $523.52 $523.52

24 $827.13 $615.39 $523.52 $523.52 $523.52 $523.52

25 $830.44 $617.85 $525.61 $525.61 $525.61 $525.61

26 $846.98 $630.15 $536.08 $536.08 $536.08 $536.08

27 $866.83 $644.92 $548.65 $548.65 $548.65 $548.65

28 $899.09 $668.92 $569.07 $569.07 $569.07 $569.07

29 $925.56 $688.62 $585.82 $585.82 $585.82 $585.82

30 $938.79 $698.46 $594.20 $594.20 $594.20 $594.20

31 $958.64 $713.23 $606.76 $606.76 $606.76 $606.76

32 $978.49 $728.00 $619.32 $619.32 $619.32 $619.32

33 $990.90 $737.23 $627.18 $627.18 $627.18 $627.18

34 $1,004.13 $747.08 $635.55 $635.55 $635.55 $635.55

35 $1,010.75 $752.00 $639.74 $639.74 $639.74 $639.74

36 $1,017.37 $756.92 $643.93 $643.93 $643.93 $643.93

37 $1,023.98 $761.85 $648.12 $648.12 $648.12 $648.12

38 $1,030.60 $766.77 $652.31 $652.31 $652.31 $652.31

39 $1,043.84 $776.62 $660.68 $660.68 $660.68 $660.68

40 $1,057.07 $786.46 $669.06 $669.06 $669.06 $669.06

41 $1,076.92 $801.23 $681.62 $681.62 $681.62 $681.62

42 $1,095.94 $815.39 $693.66 $693.66 $693.66 $693.66

43 $1,122.41 $835.08 $710.42 $710.42 $710.42 $710.42

44 $1,155.50 $859.69 $731.36 $731.36 $731.36 $731.36

45 $1,194.37 $888.62 $755.96 $755.96 $755.96 $755.96

46 $1,240.69 $923.08 $785.28 $785.28 $785.28 $785.28

47 $1,292.80 $961.85 $818.26 $818.26 $818.26 $818.26

48 $1,352.35 $1,006.15 $855.96 $855.96 $855.96 $855.96

49 $1,411.08 $1,049.85 $893.13 $893.13 $893.13 $893.13

50 $1,477.25 $1,099.08 $935.01 $935.01 $935.01 $935.01

51 $1,542.59 $1,147.69 $976.36 $976.36 $976.36 $976.36

52 $1,614.55 $1,201.23 $1,021.91 $1,021.91 $1,021.91 $1,021.91

53 $1,687.34 $1,255.39 $1,067.98 $1,067.98 $1,067.98 $1,067.98

54 $1,765.92 $1,313.85 $1,117.72 $1,117.72 $1,117.72 $1,117.72

55 $1,844.49 $1,372.31 $1,167.45 $1,167.45 $1,167.45 $1,167.45

56 $1,929.69 $1,435.69 $1,221.37 $1,221.37 $1,221.37 $1,221.37

57 $2,015.71 $1,499.69 $1,275.82 $1,275.82 $1,275.82 $1,275.82

58 $2,107.52 $1,568.00 $1,333.93 $1,333.93 $1,333.93 $1,333.93

59 $2,153.01 $1,601.85 $1,362.72 $1,362.72 $1,362.72 $1,362.72

60 $2,244.82 $1,670.16 $1,420.83 $1,420.83 $1,420.83 $1,420.83

61 $2,324.23 $1,729.23 $1,471.09 $1,471.09 $1,471.09 $1,471.09

62 $2,376.34 $1,768.00 $1,504.07 $1,504.07 $1,504.07 $1,504.07

63 $2,441.68 $1,816.62 $1,545.43 $1,545.43 $1,545.43 $1,545.43

64+ $2,481.38 $1,846.16 $1,570.56 $1,570.56 $1,570.56 $1,570.56




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $373.76 $347.97 $337.15 $311.69 $308.17 $300.49

15 $406.98 $378.90 $367.12 $339.40 $335.56 $327.20

16 $419.69 $390.73 $378.58 $349.99 $346.03 $337.41

17 $432.39 $402.56 $390.04 $360.58 $356.50 $347.63

18 $446.07 $415.29 $402.38 $371.99 $367.78 $358.63

19 $459.75 $428.03 $414.72 $383.40 $379.06 $369.62

20 $473.92 $441.22 $427.50 $395.21 $390.75 $381.02

21 $488.58 $454.86 $440.72 $407.44 $402.83 $392.80

22 $488.58 $454.86 $440.72 $407.44 $402.83 $392.80

23 $488.58 $454.86 $440.72 $407.44 $402.83 $392.80

24 $488.58 $454.86 $440.72 $407.44 $402.83 $392.80

25 $490.53 $456.68 $442.49 $409.07 $404.44 $394.37

26 $500.30 $465.78 $451.30 $417.22 $412.50 $402.23

27 $512.03 $476.70 $461.88 $426.99 $422.17 $411.65

28 $531.08 $494.44 $479.07 $442.88 $437.88 $426.97

29 $546.72 $508.99 $493.17 $455.92 $450.77 $439.54

30 $554.53 $516.27 $500.22 $462.44 $457.21 $445.83

31 $566.26 $527.19 $510.80 $472.22 $466.88 $455.25

32 $577.99 $538.10 $521.38 $482.00 $476.55 $464.68

33 $585.32 $544.93 $527.99 $488.11 $482.59 $470.57

34 $593.13 $552.21 $535.04 $494.63 $489.04 $476.86

35 $597.04 $555.84 $538.56 $497.89 $492.26 $480.00

36 $600.95 $559.48 $542.09 $501.15 $495.48 $483.14

37 $604.86 $563.12 $545.62 $504.41 $498.70 $486.29

38 $608.77 $566.76 $549.14 $507.67 $501.93 $489.43

39 $616.58 $574.04 $556.19 $514.19 $508.37 $495.71

40 $624.40 $581.32 $563.24 $520.71 $514.82 $502.00

41 $636.13 $592.23 $573.82 $530.48 $524.48 $511.42

42 $647.36 $602.70 $583.96 $539.85 $533.75 $520.46

43 $663.00 $617.25 $598.06 $552.89 $546.64 $533.03

44 $682.54 $635.45 $615.69 $569.19 $562.75 $548.74

45 $705.51 $656.82 $636.40 $588.34 $581.69 $567.20

46 $732.87 $682.30 $661.09 $611.16 $604.25 $589.20

47 $763.65 $710.95 $688.85 $636.82 $629.62 $613.95

48 $798.82 $743.70 $720.58 $666.16 $658.63 $642.23

49 $833.51 $776.00 $751.87 $695.09 $687.23 $670.12

50 $872.60 $812.39 $787.13 $727.68 $719.45 $701.54

51 $911.20 $848.32 $821.95 $759.87 $751.28 $732.57

52 $953.70 $887.90 $860.29 $795.32 $786.32 $766.74

53 $996.70 $927.92 $899.08 $831.17 $821.77 $801.31

54 $1,043.11 $971.14 $940.94 $869.88 $860.04 $838.63

55 $1,089.53 $1,014.35 $982.81 $908.59 $898.31 $875.94

56 $1,139.85 $1,061.20 $1,028.21 $950.55 $939.80 $916.40

57 $1,190.66 $1,108.50 $1,074.04 $992.92 $981.70 $957.25

58 $1,244.89 $1,158.99 $1,122.96 $1,038.15 $1,026.41 $1,000.85

59 $1,271.77 $1,184.01 $1,147.20 $1,060.56 $1,048.57 $1,022.46

60 $1,326.00 $1,234.50 $1,196.12 $1,105.79 $1,093.28 $1,066.06

61 $1,372.90 $1,278.17 $1,238.43 $1,144.90 $1,131.95 $1,103.77

62 $1,403.68 $1,306.83 $1,266.20 $1,170.57 $1,157.33 $1,128.51

63 $1,442.28 $1,342.76 $1,301.02 $1,202.76 $1,189.15 $1,159.54

64+ $1,465.73 $1,364.59 $1,322.17 $1,222.31 $1,208.49 $1,178.40




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $704.30 $498.51 $413.96 $413.96 $413.96 $413.96 $386.33

15 $766.90 $542.82 $450.76 $450.76 $450.76 $450.76 $420.67

16 $790.84 $559.76 $464.83 $464.83 $464.83 $464.83 $433.80

17 $814.78 $576.71 $478.90 $478.90 $478.90 $478.90 $446.93

18 $840.56 $594.95 $494.05 $494.05 $494.05 $494.05 $461.07

19 $866.33 $613.20 $509.20 $509.20 $509.20 $509.20 $475.21

20 $893.03 $632.09 $524.89 $524.89 $524.89 $524.89 $489.86

21 $920.65 $651.64 $541.13 $541.13 $541.13 $541.13 $505.01

22 $920.65 $651.64 $541.13 $541.13 $541.13 $541.13 $505.01

23 $920.65 $651.64 $541.13 $541.13 $541.13 $541.13 $505.01

24 $920.65 $651.64 $541.13 $541.13 $541.13 $541.13 $505.01

25 $924.33 $654.25 $543.29 $543.29 $543.29 $543.29 $507.03

26 $942.75 $667.28 $554.11 $554.11 $554.11 $554.11 $517.13

27 $964.84 $682.92 $567.10 $567.10 $567.10 $567.10 $529.25

28 $1,000.75 $708.34 $588.20 $588.20 $588.20 $588.20 $548.94

29 $1,030.21 $729.19 $605.52 $605.52 $605.52 $605.52 $565.10

30 $1,044.94 $739.62 $614.18 $614.18 $614.18 $614.18 $573.18

31 $1,067.04 $755.26 $627.16 $627.16 $627.16 $627.16 $585.30

32 $1,089.13 $770.90 $640.15 $640.15 $640.15 $640.15 $597.42

33 $1,102.94 $780.67 $648.27 $648.27 $648.27 $648.27 $605.00

34 $1,117.67 $791.10 $656.93 $656.93 $656.93 $656.93 $613.08

35 $1,125.04 $796.31 $661.26 $661.26 $661.26 $661.26 $617.12

36 $1,132.40 $801.52 $665.58 $665.58 $665.58 $665.58 $621.16

37 $1,139.77 $806.74 $669.91 $669.91 $669.91 $669.91 $625.20

38 $1,147.13 $811.95 $674.24 $674.24 $674.24 $674.24 $629.24

39 $1,161.86 $822.38 $682.90 $682.90 $682.90 $682.90 $637.32

40 $1,176.59 $832.80 $691.56 $691.56 $691.56 $691.56 $645.40

41 $1,198.69 $848.44 $704.55 $704.55 $704.55 $704.55 $657.52

42 $1,219.86 $863.43 $716.99 $716.99 $716.99 $716.99 $669.13

43 $1,249.32 $884.28 $734.31 $734.31 $734.31 $734.31 $685.30

44 $1,286.15 $910.35 $755.95 $755.95 $755.95 $755.95 $705.50

45 $1,329.42 $940.97 $781.39 $781.39 $781.39 $781.39 $729.23

46 $1,380.98 $977.47 $811.69 $811.69 $811.69 $811.69 $757.51

47 $1,438.98 $1,018.52 $845.78 $845.78 $845.78 $845.78 $789.33

48 $1,505.27 $1,065.44 $884.74 $884.74 $884.74 $884.74 $825.69

49 $1,570.63 $1,111.71 $923.16 $923.16 $923.16 $923.16 $861.54

50 $1,644.28 $1,163.84 $966.45 $966.45 $966.45 $966.45 $901.94

51 $1,717.02 $1,215.32 $1,009.20 $1,009.20 $1,009.20 $1,009.20 $941.84

52 $1,797.11 $1,272.01 $1,056.28 $1,056.28 $1,056.28 $1,056.28 $985.77

53 $1,878.13 $1,329.35 $1,103.90 $1,103.90 $1,103.90 $1,103.90 $1,030.22

54 $1,965.59 $1,391.26 $1,155.30 $1,155.30 $1,155.30 $1,155.30 $1,078.19

55 $2,053.05 $1,453.17 $1,206.71 $1,206.71 $1,206.71 $1,206.71 $1,126.17

56 $2,147.88 $1,520.29 $1,262.45 $1,262.45 $1,262.45 $1,262.45 $1,178.18

57 $2,243.63 $1,588.06 $1,318.72 $1,318.72 $1,318.72 $1,318.72 $1,230.70

58 $2,345.82 $1,660.39 $1,378.79 $1,378.79 $1,378.79 $1,378.79 $1,286.76

59 $2,396.46 $1,696.23 $1,408.55 $1,408.55 $1,408.55 $1,408.55 $1,314.53

60 $2,498.65 $1,768.56 $1,468.61 $1,468.61 $1,468.61 $1,468.61 $1,370.59

61 $2,587.03 $1,831.12 $1,520.56 $1,520.56 $1,520.56 $1,520.56 $1,419.07

62 $2,645.03 $1,872.17 $1,554.65 $1,554.65 $1,554.65 $1,554.65 $1,450.89

63 $2,717.76 $1,923.65 $1,597.40 $1,597.40 $1,597.40 $1,597.40 $1,490.78

64+ $2,761.96 $1,954.93 $1,623.38 $1,623.38 $1,623.38 $1,623.38 $1,515.02



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $644.84 $479.76 $408.14 $408.14 $408.14 $408.14

15 $702.16 $522.41 $444.42 $444.42 $444.42 $444.42

16 $724.08 $538.71 $458.29 $458.29 $458.29 $458.29

17 $745.99 $555.02 $472.17 $472.17 $472.17 $472.17

18 $769.59 $572.58 $487.10 $487.10 $487.10 $487.10

19 $793.20 $590.14 $502.04 $502.04 $502.04 $502.04

20 $817.64 $608.33 $517.52 $517.52 $517.52 $517.52

21 $842.93 $627.14 $533.52 $533.52 $533.52 $533.52

22 $842.93 $627.14 $533.52 $533.52 $533.52 $533.52

23 $842.93 $627.14 $533.52 $533.52 $533.52 $533.52

24 $842.93 $627.14 $533.52 $533.52 $533.52 $533.52

25 $846.30 $629.65 $535.66 $535.66 $535.66 $535.66

26 $863.16 $642.19 $546.33 $546.33 $546.33 $546.33

27 $883.39 $657.24 $559.13 $559.13 $559.13 $559.13

28 $916.26 $681.70 $579.94 $579.94 $579.94 $579.94

29 $943.24 $701.77 $597.01 $597.01 $597.01 $597.01

30 $956.72 $711.81 $605.55 $605.55 $605.55 $605.55

31 $976.95 $726.86 $618.35 $618.35 $618.35 $618.35

32 $997.18 $741.91 $631.16 $631.16 $631.16 $631.16

33 $1,009.83 $751.32 $639.16 $639.16 $639.16 $639.16

34 $1,023.32 $761.35 $647.69 $647.69 $647.69 $647.69

35 $1,030.06 $766.37 $651.96 $651.96 $651.96 $651.96

36 $1,036.80 $771.38 $656.23 $656.23 $656.23 $656.23

37 $1,043.55 $776.40 $660.50 $660.50 $660.50 $660.50

38 $1,050.29 $781.42 $664.77 $664.77 $664.77 $664.77

39 $1,063.78 $791.45 $673.30 $673.30 $673.30 $673.30

40 $1,077.26 $801.49 $681.84 $681.84 $681.84 $681.84

41 $1,097.49 $816.54 $694.64 $694.64 $694.64 $694.64

42 $1,116.88 $830.96 $706.92 $706.92 $706.92 $706.92

43 $1,143.85 $851.03 $723.99 $723.99 $723.99 $723.99

44 $1,177.57 $876.12 $745.33 $745.33 $745.33 $745.33

45 $1,217.19 $905.59 $770.40 $770.40 $770.40 $770.40

46 $1,264.39 $940.71 $800.28 $800.28 $800.28 $800.28

47 $1,317.50 $980.22 $833.89 $833.89 $833.89 $833.89

48 $1,378.19 $1,025.38 $872.31 $872.31 $872.31 $872.31

49 $1,438.04 $1,069.90 $910.19 $910.19 $910.19 $910.19

50 $1,505.47 $1,120.07 $952.87 $952.87 $952.87 $952.87

51 $1,572.06 $1,169.62 $995.02 $995.02 $995.02 $995.02

52 $1,645.40 $1,224.18 $1,041.43 $1,041.43 $1,041.43 $1,041.43

53 $1,719.57 $1,279.37 $1,088.38 $1,088.38 $1,088.38 $1,088.38

54 $1,799.65 $1,338.95 $1,139.07 $1,139.07 $1,139.07 $1,139.07

55 $1,879.73 $1,398.53 $1,189.75 $1,189.75 $1,189.75 $1,189.75

56 $1,966.55 $1,463.12 $1,244.70 $1,244.70 $1,244.70 $1,244.70

57 $2,054.22 $1,528.34 $1,300.19 $1,300.19 $1,300.19 $1,300.19

58 $2,147.78 $1,597.96 $1,359.41 $1,359.41 $1,359.41 $1,359.41

59 $2,194.14 $1,632.45 $1,388.76 $1,388.76 $1,388.76 $1,388.76

60 $2,287.71 $1,702.06 $1,447.98 $1,447.98 $1,447.98 $1,447.98

61 $2,368.63 $1,762.27 $1,499.19 $1,499.19 $1,499.19 $1,499.19

62 $2,421.73 $1,801.78 $1,532.81 $1,532.81 $1,532.81 $1,532.81

63 $2,488.33 $1,851.32 $1,574.95 $1,574.95 $1,574.95 $1,574.95

64+ $2,528.79 $1,881.42 $1,600.56 $1,600.56 $1,600.56 $1,600.56




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $380.90 $354.62 $343.59 $317.64 $314.05 $306.23

15 $414.76 $386.14 $374.14 $345.88 $341.97 $333.45

16 $427.71 $398.19 $385.81 $356.67 $352.64 $343.86

17 $440.65 $410.25 $397.49 $367.47 $363.32 $354.27

18 $454.59 $423.22 $410.07 $379.10 $374.81 $365.48

19 $468.53 $436.20 $422.64 $390.72 $386.30 $376.69

20 $482.97 $449.65 $435.67 $402.76 $398.21 $388.29

21 $497.91 $463.55 $449.14 $415.22 $410.53 $400.30

22 $497.91 $463.55 $449.14 $415.22 $410.53 $400.30

23 $497.91 $463.55 $449.14 $415.22 $410.53 $400.30

24 $497.91 $463.55 $449.14 $415.22 $410.53 $400.30

25 $499.90 $465.41 $450.94 $416.88 $412.17 $401.90

26 $509.86 $474.68 $459.92 $425.19 $420.38 $409.91

27 $521.81 $485.80 $470.70 $435.15 $430.23 $419.52

28 $541.23 $503.88 $488.22 $451.35 $446.24 $435.13

29 $557.16 $518.72 $502.59 $464.63 $459.38 $447.94

30 $565.13 $526.13 $509.78 $471.28 $465.95 $454.34

31 $577.08 $537.26 $520.56 $481.24 $475.80 $463.95

32 $589.03 $548.38 $531.34 $491.21 $485.65 $473.56

33 $596.50 $555.34 $538.07 $497.43 $491.81 $479.56

34 $604.46 $562.75 $545.26 $504.08 $498.38 $485.97

35 $608.45 $566.46 $548.85 $507.40 $501.66 $489.17

36 $612.43 $570.17 $552.45 $510.72 $504.95 $492.37

37 $616.41 $573.88 $556.04 $514.04 $508.23 $495.58

38 $620.40 $577.59 $559.63 $517.37 $511.52 $498.78

39 $628.36 $585.01 $566.82 $524.01 $518.08 $505.18

40 $636.33 $592.42 $574.00 $530.65 $524.65 $511.59

41 $648.28 $603.55 $584.78 $540.62 $534.50 $521.19

42 $659.73 $614.21 $595.11 $550.17 $543.95 $530.40

43 $675.66 $629.04 $609.49 $563.45 $557.08 $543.21

44 $695.58 $647.59 $627.45 $580.06 $573.50 $559.22

45 $718.98 $669.37 $648.56 $599.58 $592.80 $578.04

46 $746.87 $695.33 $673.71 $622.83 $615.79 $600.45

47 $778.23 $724.53 $702.01 $648.99 $641.65 $625.67

48 $814.08 $757.91 $734.35 $678.89 $671.21 $654.50

49 $849.44 $790.82 $766.24 $708.37 $700.36 $682.92

50 $889.27 $827.91 $802.17 $741.58 $733.20 $714.94

51 $928.60 $864.53 $837.65 $774.39 $765.63 $746.57

52 $971.92 $904.86 $876.73 $810.51 $801.35 $781.39

53 $1,015.74 $945.65 $916.25 $847.05 $837.47 $816.62

54 $1,063.04 $989.69 $958.92 $886.50 $876.47 $854.65

55 $1,110.34 $1,033.73 $1,001.59 $925.94 $915.47 $892.68

56 $1,161.63 $1,081.47 $1,047.85 $968.71 $957.76 $933.91

57 $1,213.41 $1,129.68 $1,094.56 $1,011.89 $1,000.45 $975.54

58 $1,268.68 $1,181.14 $1,144.42 $1,057.98 $1,046.02 $1,019.97

59 $1,296.06 $1,206.63 $1,169.12 $1,080.82 $1,068.60 $1,041.99

60 $1,351.33 $1,258.09 $1,218.97 $1,126.91 $1,114.17 $1,086.42

61 $1,399.13 $1,302.59 $1,262.09 $1,166.77 $1,153.58 $1,124.85

62 $1,430.50 $1,331.79 $1,290.39 $1,192.93 $1,179.44 $1,150.07

63 $1,469.83 $1,368.41 $1,325.87 $1,225.73 $1,211.87 $1,181.69

64+ $1,493.73 $1,390.66 $1,347.43 $1,245.66 $1,231.58 $1,200.91




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $469.57 $332.37 $276.00 $276.00 $276.00 $276.00 $257.58

15 $511.31 $361.91 $300.53 $300.53 $300.53 $300.53 $280.47

16 $527.27 $373.21 $309.91 $309.91 $309.91 $309.91 $289.23

17 $543.23 $384.50 $319.29 $319.29 $319.29 $319.29 $297.98

18 $560.42 $396.67 $329.39 $329.39 $329.39 $329.39 $307.41

19 $577.61 $408.83 $339.50 $339.50 $339.50 $339.50 $316.84

20 $595.41 $421.43 $349.96 $349.96 $349.96 $349.96 $326.60

21 $613.82 $434.47 $360.78 $360.78 $360.78 $360.78 $336.70

22 $613.82 $434.47 $360.78 $360.78 $360.78 $360.78 $336.70

23 $613.82 $434.47 $360.78 $360.78 $360.78 $360.78 $336.70

24 $613.82 $434.47 $360.78 $360.78 $360.78 $360.78 $336.70

25 $616.28 $436.21 $362.23 $362.23 $362.23 $362.23 $338.05

26 $628.55 $444.89 $369.44 $369.44 $369.44 $369.44 $344.78

27 $643.29 $455.32 $378.10 $378.10 $378.10 $378.10 $352.86

28 $667.22 $472.27 $392.17 $392.17 $392.17 $392.17 $365.99

29 $686.87 $486.17 $403.71 $403.71 $403.71 $403.71 $376.77

30 $696.69 $493.12 $409.49 $409.49 $409.49 $409.49 $382.16

31 $711.42 $503.55 $418.15 $418.15 $418.15 $418.15 $390.24

32 $726.15 $513.97 $426.81 $426.81 $426.81 $426.81 $398.32

33 $735.36 $520.49 $432.22 $432.22 $432.22 $432.22 $403.37

34 $745.18 $527.44 $437.99 $437.99 $437.99 $437.99 $408.76

35 $750.09 $530.92 $440.88 $440.88 $440.88 $440.88 $411.45

36 $755.00 $534.39 $443.76 $443.76 $443.76 $443.76 $414.14

37 $759.91 $537.87 $446.65 $446.65 $446.65 $446.65 $416.84

38 $764.82 $541.35 $449.53 $449.53 $449.53 $449.53 $419.53

39 $774.64 $548.30 $455.31 $455.31 $455.31 $455.31 $424.92

40 $784.46 $555.25 $461.08 $461.08 $461.08 $461.08 $430.30

41 $799.20 $565.68 $469.74 $469.74 $469.74 $469.74 $438.38

42 $813.31 $575.67 $478.04 $478.04 $478.04 $478.04 $446.13

43 $832.96 $589.57 $489.58 $489.58 $489.58 $489.58 $456.90

44 $857.51 $606.95 $504.01 $504.01 $504.01 $504.01 $470.37

45 $886.36 $627.37 $520.97 $520.97 $520.97 $520.97 $486.20

46 $920.73 $651.70 $541.17 $541.17 $541.17 $541.17 $505.05

47 $959.40 $679.07 $563.90 $563.90 $563.90 $563.90 $526.26

48 $1,003.60 $710.35 $589.88 $589.88 $589.88 $589.88 $550.51

49 $1,047.18 $741.20 $615.49 $615.49 $615.49 $615.49 $574.41

50 $1,096.29 $775.96 $644.36 $644.36 $644.36 $644.36 $601.35

51 $1,144.78 $810.28 $672.86 $672.86 $672.86 $672.86 $627.95

52 $1,198.18 $848.08 $704.25 $704.25 $704.25 $704.25 $657.24

53 $1,252.20 $886.31 $736.00 $736.00 $736.00 $736.00 $686.87

54 $1,310.51 $927.59 $770.27 $770.27 $770.27 $770.27 $718.86

55 $1,368.82 $968.86 $804.54 $804.54 $804.54 $804.54 $750.84

56 $1,432.05 $1,013.61 $841.70 $841.70 $841.70 $841.70 $785.52

57 $1,495.88 $1,058.80 $879.23 $879.23 $879.23 $879.23 $820.54

58 $1,564.02 $1,107.02 $919.27 $919.27 $919.27 $919.27 $857.91

59 $1,597.78 $1,130.92 $939.12 $939.12 $939.12 $939.12 $876.43

60 $1,665.91 $1,179.14 $979.16 $979.16 $979.16 $979.16 $913.81

61 $1,724.84 $1,220.85 $1,013.80 $1,013.80 $1,013.80 $1,013.80 $946.13

62 $1,763.51 $1,248.22 $1,036.53 $1,036.53 $1,036.53 $1,036.53 $967.34

63 $1,812.00 $1,282.55 $1,065.03 $1,065.03 $1,065.03 $1,065.03 $993.94

64+ $1,841.46 $1,303.40 $1,082.35 $1,082.35 $1,082.35 $1,082.35 $1,010.10



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $613.95 $456.78 $388.59 $388.59 $388.59 $388.59

15 $668.52 $497.38 $423.13 $423.13 $423.13 $423.13

16 $689.39 $512.91 $436.34 $436.34 $436.34 $436.34

17 $710.26 $528.43 $449.55 $449.55 $449.55 $449.55

18 $732.73 $545.15 $463.77 $463.77 $463.77 $463.77

19 $755.20 $561.87 $477.99 $477.99 $477.99 $477.99

20 $778.47 $579.19 $492.72 $492.72 $492.72 $492.72

21 $802.55 $597.10 $507.96 $507.96 $507.96 $507.96

22 $802.55 $597.10 $507.96 $507.96 $507.96 $507.96

23 $802.55 $597.10 $507.96 $507.96 $507.96 $507.96

24 $802.55 $597.10 $507.96 $507.96 $507.96 $507.96

25 $805.76 $599.49 $510.00 $510.00 $510.00 $510.00

26 $821.81 $611.43 $520.15 $520.15 $520.15 $520.15

27 $841.07 $625.76 $532.35 $532.35 $532.35 $532.35

28 $872.37 $649.05 $552.16 $552.16 $552.16 $552.16

29 $898.05 $668.15 $568.41 $568.41 $568.41 $568.41

30 $910.89 $677.71 $576.54 $576.54 $576.54 $576.54

31 $930.16 $692.04 $588.73 $588.73 $588.73 $588.73

32 $949.42 $706.37 $600.92 $600.92 $600.92 $600.92

33 $961.45 $715.32 $608.54 $608.54 $608.54 $608.54

34 $974.30 $724.88 $616.67 $616.67 $616.67 $616.67

35 $980.72 $729.66 $620.73 $620.73 $620.73 $620.73

36 $987.14 $734.43 $624.80 $624.80 $624.80 $624.80

37 $993.56 $739.21 $628.86 $628.86 $628.86 $628.86

38 $999.98 $743.99 $632.92 $632.92 $632.92 $632.92

39 $1,012.82 $753.54 $641.05 $641.05 $641.05 $641.05

40 $1,025.66 $763.09 $649.18 $649.18 $649.18 $649.18

41 $1,044.92 $777.42 $661.37 $661.37 $661.37 $661.37

42 $1,063.38 $791.16 $673.05 $673.05 $673.05 $673.05

43 $1,089.06 $810.26 $689.31 $689.31 $689.31 $689.31

44 $1,121.16 $834.15 $709.63 $709.63 $709.63 $709.63

45 $1,158.88 $862.21 $733.50 $733.50 $733.50 $733.50

46 $1,203.82 $895.65 $761.95 $761.95 $761.95 $761.95

47 $1,254.39 $933.27 $793.95 $793.95 $793.95 $793.95

48 $1,312.17 $976.26 $830.52 $830.52 $830.52 $830.52

49 $1,369.15 $1,018.65 $866.59 $866.59 $866.59 $866.59

50 $1,433.35 $1,066.42 $907.22 $907.22 $907.22 $907.22

51 $1,496.76 $1,113.59 $947.35 $947.35 $947.35 $947.35

52 $1,566.58 $1,165.54 $991.55 $991.55 $991.55 $991.55

53 $1,637.20 $1,218.08 $1,036.25 $1,036.25 $1,036.25 $1,036.25

54 $1,713.44 $1,274.81 $1,084.50 $1,084.50 $1,084.50 $1,084.50

55 $1,789.69 $1,331.53 $1,132.76 $1,132.76 $1,132.76 $1,132.76

56 $1,872.35 $1,393.03 $1,185.08 $1,185.08 $1,185.08 $1,185.08

57 $1,955.81 $1,455.13 $1,237.91 $1,237.91 $1,237.91 $1,237.91

58 $2,044.90 $1,521.41 $1,294.29 $1,294.29 $1,294.29 $1,294.29

59 $2,089.04 $1,554.25 $1,322.23 $1,322.23 $1,322.23 $1,322.23

60 $2,178.12 $1,620.53 $1,378.61 $1,378.61 $1,378.61 $1,378.61

61 $2,255.16 $1,677.85 $1,427.38 $1,427.38 $1,427.38 $1,427.38

62 $2,305.73 $1,715.47 $1,459.38 $1,459.38 $1,459.38 $1,459.38

63 $2,369.13 $1,762.64 $1,499.51 $1,499.51 $1,499.51 $1,499.51

64+ $2,407.65 $1,791.30 $1,523.89 $1,523.89 $1,523.89 $1,523.89




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $362.66 $337.63 $327.14 $302.43 $299.01 $291.56

15 $394.89 $367.64 $356.21 $329.31 $325.59 $317.48

16 $407.22 $379.12 $367.33 $339.59 $335.75 $327.39

17 $419.54 $390.59 $378.45 $349.87 $345.91 $337.30

18 $432.82 $402.95 $390.42 $360.94 $356.86 $347.97

19 $446.09 $415.31 $402.40 $372.01 $367.80 $358.64

20 $459.84 $428.11 $414.80 $383.47 $379.13 $369.69

21 $474.06 $441.35 $427.63 $395.33 $390.86 $381.13

22 $474.06 $441.35 $427.63 $395.33 $390.86 $381.13

23 $474.06 $441.35 $427.63 $395.33 $390.86 $381.13

24 $474.06 $441.35 $427.63 $395.33 $390.86 $381.13

25 $475.96 $443.11 $429.34 $396.91 $392.42 $382.65

26 $485.44 $451.94 $437.89 $404.82 $400.24 $390.27

27 $496.81 $462.53 $448.15 $414.31 $409.62 $399.42

28 $515.30 $479.75 $464.83 $429.72 $424.87 $414.29

29 $530.47 $493.87 $478.52 $442.37 $437.37 $426.48

30 $538.06 $500.93 $485.36 $448.70 $443.63 $432.58

31 $549.43 $511.52 $495.62 $458.19 $453.01 $441.73

32 $560.81 $522.11 $505.88 $467.68 $462.39 $450.87

33 $567.92 $528.74 $512.30 $473.61 $468.25 $456.59

34 $575.51 $535.80 $519.14 $479.93 $474.50 $462.69

35 $579.30 $539.33 $522.56 $483.09 $477.63 $465.74

36 $583.09 $542.86 $525.98 $486.26 $480.76 $468.79

37 $586.89 $546.39 $529.40 $489.42 $483.88 $471.84

38 $590.68 $549.92 $532.82 $492.58 $487.01 $474.88

39 $598.26 $556.98 $539.67 $498.91 $493.27 $480.98

40 $605.85 $564.04 $546.51 $505.23 $499.52 $487.08

41 $617.22 $574.64 $556.77 $514.72 $508.90 $496.23

42 $628.13 $584.79 $566.61 $523.81 $517.89 $504.99

43 $643.30 $598.91 $580.29 $536.46 $530.40 $517.19

44 $662.26 $616.56 $597.40 $552.28 $546.03 $532.43

45 $684.54 $637.31 $617.49 $570.86 $564.40 $550.35

46 $711.09 $662.02 $641.44 $593.00 $586.29 $571.69

47 $740.95 $689.83 $668.38 $617.90 $610.91 $595.70

48 $775.09 $721.60 $699.17 $646.37 $639.06 $623.14

49 $808.74 $752.94 $729.53 $674.43 $666.81 $650.20

50 $846.67 $788.25 $763.74 $706.06 $698.08 $680.69

51 $884.12 $823.11 $797.53 $737.29 $728.95 $710.80

52 $925.36 $861.51 $834.73 $771.69 $762.96 $743.96

53 $967.08 $900.35 $872.36 $806.47 $797.35 $777.50

54 $1,012.12 $942.28 $912.98 $844.03 $834.49 $813.71

55 $1,057.15 $984.21 $953.61 $881.59 $871.62 $849.91

56 $1,105.98 $1,029.67 $997.65 $922.31 $911.88 $889.17

57 $1,155.28 $1,075.57 $1,042.13 $963.42 $952.53 $928.81

58 $1,207.90 $1,124.56 $1,089.59 $1,007.30 $995.91 $971.11

59 $1,233.98 $1,148.83 $1,113.11 $1,029.05 $1,017.41 $992.07

60 $1,286.60 $1,197.82 $1,160.58 $1,072.93 $1,060.79 $1,034.38

61 $1,332.11 $1,240.19 $1,201.63 $1,110.88 $1,098.32 $1,070.97

62 $1,361.97 $1,267.99 $1,228.57 $1,135.78 $1,122.94 $1,094.98

63 $1,399.42 $1,302.86 $1,262.36 $1,167.02 $1,153.82 $1,125.09

64+ $1,422.18 $1,324.04 $1,282.88 $1,185.99 $1,172.58 $1,143.38




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $618.23 $437.59 $363.38 $363.38 $363.38 $363.38 $339.12

15 $673.19 $476.49 $395.68 $395.68 $395.68 $395.68 $369.27

16 $694.20 $491.36 $408.03 $408.03 $408.03 $408.03 $380.79

17 $715.21 $506.23 $420.38 $420.38 $420.38 $420.38 $392.32

18 $737.84 $522.25 $433.68 $433.68 $433.68 $433.68 $404.73

19 $760.47 $538.27 $446.98 $446.98 $446.98 $446.98 $417.14

20 $783.90 $554.85 $460.75 $460.75 $460.75 $460.75 $430.00

21 $808.15 $572.01 $475.00 $475.00 $475.00 $475.00 $443.30

22 $808.15 $572.01 $475.00 $475.00 $475.00 $475.00 $443.30

23 $808.15 $572.01 $475.00 $475.00 $475.00 $475.00 $443.30

24 $808.15 $572.01 $475.00 $475.00 $475.00 $475.00 $443.30

25 $811.38 $574.30 $476.90 $476.90 $476.90 $476.90 $445.07

26 $827.54 $585.74 $486.40 $486.40 $486.40 $486.40 $453.94

27 $846.94 $599.47 $497.80 $497.80 $497.80 $497.80 $464.57

28 $878.46 $621.78 $516.33 $516.33 $516.33 $516.33 $481.86

29 $904.32 $640.08 $531.53 $531.53 $531.53 $531.53 $496.05

30 $917.25 $649.24 $539.13 $539.13 $539.13 $539.13 $503.14

31 $936.65 $662.96 $550.53 $550.53 $550.53 $550.53 $513.78

32 $956.04 $676.69 $561.93 $561.93 $561.93 $561.93 $524.42

33 $968.16 $685.27 $569.05 $569.05 $569.05 $569.05 $531.07

34 $981.09 $694.43 $576.65 $576.65 $576.65 $576.65 $538.16

35 $987.56 $699.00 $580.45 $580.45 $580.45 $580.45 $541.71

36 $994.02 $703.58 $584.25 $584.25 $584.25 $584.25 $545.25

37 $1,000.49 $708.15 $588.05 $588.05 $588.05 $588.05 $548.80

38 $1,006.95 $712.73 $591.85 $591.85 $591.85 $591.85 $552.35

39 $1,019.88 $721.88 $599.45 $599.45 $599.45 $599.45 $559.44

40 $1,032.81 $731.03 $607.05 $607.05 $607.05 $607.05 $566.53

41 $1,052.21 $744.76 $618.45 $618.45 $618.45 $618.45 $577.17

42 $1,070.80 $757.92 $629.38 $629.38 $629.38 $629.38 $587.37

43 $1,096.66 $776.22 $644.58 $644.58 $644.58 $644.58 $601.55

44 $1,128.98 $799.10 $663.58 $663.58 $663.58 $663.58 $619.28

45 $1,166.97 $825.99 $685.90 $685.90 $685.90 $685.90 $640.12

46 $1,212.22 $858.02 $712.50 $712.50 $712.50 $712.50 $664.94

47 $1,263.14 $894.06 $742.43 $742.43 $742.43 $742.43 $692.87

48 $1,321.32 $935.24 $776.63 $776.63 $776.63 $776.63 $724.79

49 $1,378.70 $975.86 $810.35 $810.35 $810.35 $810.35 $756.26

50 $1,443.35 $1,021.62 $848.35 $848.35 $848.35 $848.35 $791.73

51 $1,507.20 $1,066.81 $885.88 $885.88 $885.88 $885.88 $826.75

52 $1,577.51 $1,116.57 $927.20 $927.20 $927.20 $927.20 $865.31

53 $1,648.62 $1,166.91 $969.00 $969.00 $969.00 $969.00 $904.32

54 $1,725.40 $1,221.25 $1,014.13 $1,014.13 $1,014.13 $1,014.13 $946.44

55 $1,802.17 $1,275.59 $1,059.25 $1,059.25 $1,059.25 $1,059.25 $988.55

56 $1,885.41 $1,334.51 $1,108.18 $1,108.18 $1,108.18 $1,108.18 $1,034.21

57 $1,969.46 $1,394.00 $1,157.58 $1,157.58 $1,157.58 $1,157.58 $1,080.31

58 $2,059.16 $1,457.49 $1,210.30 $1,210.30 $1,210.30 $1,210.30 $1,129.52

59 $2,103.61 $1,488.95 $1,236.43 $1,236.43 $1,236.43 $1,236.43 $1,153.90

60 $2,193.32 $1,552.45 $1,289.15 $1,289.15 $1,289.15 $1,289.15 $1,203.11

61 $2,270.90 $1,607.36 $1,334.75 $1,334.75 $1,334.75 $1,334.75 $1,245.66

62 $2,321.81 $1,643.40 $1,364.68 $1,364.68 $1,364.68 $1,364.68 $1,273.59

63 $2,385.66 $1,688.59 $1,402.20 $1,402.20 $1,402.20 $1,402.20 $1,308.61

64+ $2,424.45 $1,716.04 $1,425.00 $1,425.00 $1,425.00 $1,425.00 $1,329.89



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $573.52 $426.70 $363.00 $363.00 $363.00 $363.00

15 $624.50 $464.63 $395.27 $395.27 $395.27 $395.27

16 $643.99 $479.13 $407.61 $407.61 $407.61 $407.61

17 $663.48 $493.63 $419.94 $419.94 $419.94 $419.94

18 $684.47 $509.25 $433.23 $433.23 $433.23 $433.23

19 $705.47 $524.87 $446.52 $446.52 $446.52 $446.52

20 $727.21 $541.04 $460.28 $460.28 $460.28 $460.28

21 $749.70 $557.78 $474.51 $474.51 $474.51 $474.51

22 $749.70 $557.78 $474.51 $474.51 $474.51 $474.51

23 $749.70 $557.78 $474.51 $474.51 $474.51 $474.51

24 $749.70 $557.78 $474.51 $474.51 $474.51 $474.51

25 $752.70 $560.01 $476.41 $476.41 $476.41 $476.41

26 $767.69 $571.16 $485.90 $485.90 $485.90 $485.90

27 $785.68 $584.55 $497.29 $497.29 $497.29 $497.29

28 $814.92 $606.30 $515.79 $515.79 $515.79 $515.79

29 $838.91 $624.15 $530.98 $530.98 $530.98 $530.98

30 $850.91 $633.08 $538.57 $538.57 $538.57 $538.57

31 $868.90 $646.46 $549.96 $549.96 $549.96 $549.96

32 $886.89 $659.85 $561.35 $561.35 $561.35 $561.35

33 $898.14 $668.22 $568.46 $568.46 $568.46 $568.46

34 $910.13 $677.14 $576.06 $576.06 $576.06 $576.06

35 $916.13 $681.60 $579.85 $579.85 $579.85 $579.85

36 $922.13 $686.07 $583.65 $583.65 $583.65 $583.65

37 $928.13 $690.53 $587.45 $587.45 $587.45 $587.45

38 $934.12 $694.99 $591.24 $591.24 $591.24 $591.24

39 $946.12 $703.91 $598.83 $598.83 $598.83 $598.83

40 $958.11 $712.84 $606.43 $606.43 $606.43 $606.43

41 $976.11 $726.23 $617.81 $617.81 $617.81 $617.81

42 $993.35 $739.05 $628.73 $628.73 $628.73 $628.73

43 $1,017.34 $756.90 $643.91 $643.91 $643.91 $643.91

44 $1,047.33 $779.21 $662.89 $662.89 $662.89 $662.89

45 $1,082.56 $805.43 $685.19 $685.19 $685.19 $685.19

46 $1,124.55 $836.67 $711.77 $711.77 $711.77 $711.77

47 $1,171.78 $871.81 $741.66 $741.66 $741.66 $741.66

48 $1,225.76 $911.97 $775.83 $775.83 $775.83 $775.83

49 $1,278.98 $951.57 $809.52 $809.52 $809.52 $809.52

50 $1,338.96 $996.19 $847.48 $847.48 $847.48 $847.48

51 $1,398.19 $1,040.25 $884.96 $884.96 $884.96 $884.96

52 $1,463.41 $1,088.78 $926.25 $926.25 $926.25 $926.25

53 $1,529.38 $1,137.87 $968.00 $968.00 $968.00 $968.00

54 $1,600.60 $1,190.85 $1,013.08 $1,013.08 $1,013.08 $1,013.08

55 $1,671.83 $1,243.84 $1,058.16 $1,058.16 $1,058.16 $1,058.16

56 $1,749.04 $1,301.29 $1,107.04 $1,107.04 $1,107.04 $1,107.04

57 $1,827.01 $1,359.30 $1,156.38 $1,156.38 $1,156.38 $1,156.38

58 $1,910.23 $1,421.22 $1,209.06 $1,209.06 $1,209.06 $1,209.06

59 $1,951.46 $1,451.89 $1,235.15 $1,235.15 $1,235.15 $1,235.15

60 $2,034.68 $1,513.81 $1,287.82 $1,287.82 $1,287.82 $1,287.82

61 $2,106.65 $1,567.35 $1,333.38 $1,333.38 $1,333.38 $1,333.38

62 $2,153.88 $1,602.49 $1,363.27 $1,363.27 $1,363.27 $1,363.27

63 $2,213.11 $1,646.56 $1,400.76 $1,400.76 $1,400.76 $1,400.76

64+ $2,249.09 $1,673.33 $1,423.53 $1,423.53 $1,423.53 $1,423.53




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $338.77 $315.40 $305.59 $282.51 $279.32 $272.36

15 $368.89 $343.43 $332.76 $307.62 $304.14 $296.57

16 $380.40 $354.15 $343.14 $317.23 $313.64 $305.83

17 $391.91 $364.87 $353.53 $326.83 $323.13 $315.08

18 $404.31 $376.41 $364.71 $337.17 $333.35 $325.05

19 $416.71 $387.96 $375.90 $347.51 $343.58 $335.02

20 $429.55 $399.91 $387.48 $358.22 $354.17 $345.35

21 $442.84 $412.28 $399.47 $369.30 $365.12 $356.03

22 $442.84 $412.28 $399.47 $369.30 $365.12 $356.03

23 $442.84 $412.28 $399.47 $369.30 $365.12 $356.03

24 $442.84 $412.28 $399.47 $369.30 $365.12 $356.03

25 $444.61 $413.93 $401.06 $370.77 $366.58 $357.45

26 $453.47 $422.18 $409.05 $378.16 $373.88 $364.57

27 $464.10 $432.07 $418.64 $387.02 $382.65 $373.12

28 $481.37 $448.15 $434.22 $401.42 $396.89 $387.00

29 $495.54 $461.34 $447.00 $413.24 $408.57 $398.40

30 $502.62 $467.94 $453.39 $419.15 $414.41 $404.09

31 $513.25 $477.84 $462.98 $428.01 $423.17 $412.64

32 $523.88 $487.73 $472.57 $436.88 $431.94 $421.18

33 $530.52 $493.92 $478.56 $442.42 $437.41 $426.52

34 $537.61 $500.51 $484.95 $448.33 $443.26 $432.22

35 $541.15 $503.81 $488.15 $451.28 $446.18 $435.07

36 $544.69 $507.11 $491.34 $454.23 $449.10 $437.91

37 $548.24 $510.41 $494.54 $457.19 $452.02 $440.76

38 $551.78 $513.70 $497.73 $460.14 $454.94 $443.61

39 $558.86 $520.30 $504.13 $466.05 $460.78 $449.31

40 $565.95 $526.90 $510.52 $471.96 $466.62 $455.00

41 $576.58 $536.79 $520.10 $480.82 $475.39 $463.55

42 $586.76 $546.28 $529.29 $489.32 $483.78 $471.74

43 $600.93 $559.47 $542.08 $501.13 $495.47 $483.13

44 $618.65 $575.96 $558.05 $515.91 $510.07 $497.37

45 $639.46 $595.34 $576.83 $533.26 $527.23 $514.10

46 $664.26 $618.42 $599.20 $553.94 $547.68 $534.04

47 $692.16 $644.40 $624.37 $577.21 $570.68 $556.47

48 $724.04 $674.08 $653.13 $603.80 $596.97 $582.11

49 $755.48 $703.36 $681.49 $630.02 $622.89 $607.38

50 $790.91 $736.34 $713.45 $659.56 $652.10 $635.87

51 $825.90 $768.91 $745.00 $688.74 $680.95 $663.99

52 $864.42 $804.78 $779.76 $720.87 $712.71 $694.97

53 $903.39 $841.06 $814.91 $753.36 $744.84 $726.30

54 $945.46 $880.22 $852.86 $788.45 $779.53 $760.12

55 $987.53 $919.39 $890.81 $823.53 $814.22 $793.94

56 $1,033.14 $961.86 $931.95 $861.57 $851.82 $830.61

57 $1,079.20 $1,004.73 $973.50 $899.97 $889.80 $867.64

58 $1,128.36 $1,050.50 $1,017.84 $940.97 $930.33 $907.16

59 $1,152.71 $1,073.17 $1,039.81 $961.28 $950.41 $926.74

60 $1,201.87 $1,118.94 $1,084.15 $1,002.27 $990.94 $966.26

61 $1,244.38 $1,158.52 $1,122.50 $1,037.72 $1,025.99 $1,000.44

62 $1,272.28 $1,184.49 $1,147.67 $1,060.99 $1,048.99 $1,022.87

63 $1,307.26 $1,217.06 $1,179.22 $1,090.16 $1,077.83 $1,050.99

64+ $1,328.52 $1,236.85 $1,198.40 $1,107.89 $1,095.36 $1,068.08




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $657.55 $465.42 $386.48 $386.48 $386.48 $386.48 $360.69

15 $716.00 $506.79 $420.84 $420.84 $420.84 $420.84 $392.75

16 $738.35 $522.61 $433.97 $433.97 $433.97 $433.97 $405.01

17 $760.70 $538.43 $447.11 $447.11 $447.11 $447.11 $417.27

18 $784.76 $555.46 $461.25 $461.25 $461.25 $461.25 $430.47

19 $808.83 $572.50 $475.40 $475.40 $475.40 $475.40 $443.67

20 $833.76 $590.14 $490.05 $490.05 $490.05 $490.05 $457.34

21 $859.54 $608.39 $505.21 $505.21 $505.21 $505.21 $471.49

22 $859.54 $608.39 $505.21 $505.21 $505.21 $505.21 $471.49

23 $859.54 $608.39 $505.21 $505.21 $505.21 $505.21 $471.49

24 $859.54 $608.39 $505.21 $505.21 $505.21 $505.21 $471.49

25 $862.98 $610.82 $507.23 $507.23 $507.23 $507.23 $473.37

26 $880.17 $622.99 $517.33 $517.33 $517.33 $517.33 $482.80

27 $900.80 $637.59 $529.46 $529.46 $529.46 $529.46 $494.12

28 $934.32 $661.32 $549.16 $549.16 $549.16 $549.16 $512.51

29 $961.83 $680.79 $565.33 $565.33 $565.33 $565.33 $527.59

30 $975.58 $690.52 $573.41 $573.41 $573.41 $573.41 $535.14

31 $996.21 $705.12 $585.54 $585.54 $585.54 $585.54 $546.45

32 $1,016.84 $719.73 $597.66 $597.66 $597.66 $597.66 $557.77

33 $1,029.73 $728.85 $605.24 $605.24 $605.24 $605.24 $564.84

34 $1,043.49 $738.59 $613.32 $613.32 $613.32 $613.32 $572.39

35 $1,050.36 $743.45 $617.36 $617.36 $617.36 $617.36 $576.16

36 $1,057.24 $748.32 $621.41 $621.41 $621.41 $621.41 $579.93

37 $1,064.11 $753.19 $625.45 $625.45 $625.45 $625.45 $583.70

38 $1,070.99 $758.05 $629.49 $629.49 $629.49 $629.49 $587.47

39 $1,084.74 $767.79 $637.57 $637.57 $637.57 $637.57 $595.02

40 $1,098.50 $777.52 $645.66 $645.66 $645.66 $645.66 $602.56

41 $1,119.12 $792.12 $657.78 $657.78 $657.78 $657.78 $613.88

42 $1,138.89 $806.12 $669.40 $669.40 $669.40 $669.40 $624.72

43 $1,166.40 $825.59 $685.57 $685.57 $685.57 $685.57 $639.81

44 $1,200.78 $849.92 $705.78 $705.78 $705.78 $705.78 $658.67

45 $1,241.18 $878.52 $729.52 $729.52 $729.52 $729.52 $680.83

46 $1,289.31 $912.59 $757.81 $757.81 $757.81 $757.81 $707.23

47 $1,343.47 $950.91 $789.64 $789.64 $789.64 $789.64 $736.93

48 $1,405.35 $994.72 $826.01 $826.01 $826.01 $826.01 $770.88

49 $1,466.38 $1,037.91 $861.88 $861.88 $861.88 $861.88 $804.36

50 $1,535.14 $1,086.59 $902.30 $902.30 $902.30 $902.30 $842.08

51 $1,603.05 $1,134.65 $942.21 $942.21 $942.21 $942.21 $879.32

52 $1,677.83 $1,187.58 $986.17 $986.17 $986.17 $986.17 $920.34

53 $1,753.47 $1,241.12 $1,030.62 $1,030.62 $1,030.62 $1,030.62 $961.83

54 $1,835.12 $1,298.91 $1,078.62 $1,078.62 $1,078.62 $1,078.62 $1,006.63

55 $1,916.78 $1,356.71 $1,126.61 $1,126.61 $1,126.61 $1,126.61 $1,051.42

56 $2,005.31 $1,419.38 $1,178.65 $1,178.65 $1,178.65 $1,178.65 $1,099.98

57 $2,094.71 $1,482.65 $1,231.19 $1,231.19 $1,231.19 $1,231.19 $1,149.01

58 $2,190.12 $1,550.18 $1,287.27 $1,287.27 $1,287.27 $1,287.27 $1,201.35

59 $2,237.39 $1,583.64 $1,315.06 $1,315.06 $1,315.06 $1,315.06 $1,227.28

60 $2,332.80 $1,651.17 $1,371.13 $1,371.13 $1,371.13 $1,371.13 $1,279.62

61 $2,415.32 $1,709.58 $1,419.63 $1,419.63 $1,419.63 $1,419.63 $1,324.88

62 $2,469.47 $1,747.91 $1,451.46 $1,451.46 $1,451.46 $1,451.46 $1,354.58

63 $2,537.37 $1,795.97 $1,491.37 $1,491.37 $1,491.37 $1,491.37 $1,391.83

64+ $2,578.63 $1,825.17 $1,515.62 $1,515.62 $1,515.62 $1,515.62 $1,414.46



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $573.96 $427.03 $363.28 $363.28 $363.28 $363.28

15 $624.98 $464.99 $395.57 $395.57 $395.57 $395.57

16 $644.49 $479.50 $407.92 $407.92 $407.92 $407.92

17 $664.00 $494.02 $420.27 $420.27 $420.27 $420.27

18 $685.00 $509.65 $433.57 $433.57 $433.57 $433.57

19 $706.01 $525.28 $446.86 $446.86 $446.86 $446.86

20 $727.77 $541.46 $460.63 $460.63 $460.63 $460.63

21 $750.28 $558.21 $474.88 $474.88 $474.88 $474.88

22 $750.28 $558.21 $474.88 $474.88 $474.88 $474.88

23 $750.28 $558.21 $474.88 $474.88 $474.88 $474.88

24 $750.28 $558.21 $474.88 $474.88 $474.88 $474.88

25 $753.28 $560.44 $476.78 $476.78 $476.78 $476.78

26 $768.29 $571.61 $486.28 $486.28 $486.28 $486.28

27 $786.29 $585.00 $497.67 $497.67 $497.67 $497.67

28 $815.55 $606.77 $516.19 $516.19 $516.19 $516.19

29 $839.56 $624.64 $531.39 $531.39 $531.39 $531.39

30 $851.57 $633.57 $538.99 $538.99 $538.99 $538.99

31 $869.57 $646.97 $550.39 $550.39 $550.39 $550.39

32 $887.58 $660.36 $561.78 $561.78 $561.78 $561.78

33 $898.83 $668.74 $568.91 $568.91 $568.91 $568.91

34 $910.84 $677.67 $576.50 $576.50 $576.50 $576.50

35 $916.84 $682.13 $580.30 $580.30 $580.30 $580.30

36 $922.84 $686.60 $584.10 $584.10 $584.10 $584.10

37 $928.85 $691.06 $587.90 $587.90 $587.90 $587.90

38 $934.85 $695.53 $591.70 $591.70 $591.70 $591.70

39 $946.85 $704.46 $599.30 $599.30 $599.30 $599.30

40 $958.86 $713.39 $606.90 $606.90 $606.90 $606.90

41 $976.86 $726.79 $618.29 $618.29 $618.29 $618.29

42 $994.12 $739.63 $629.22 $629.22 $629.22 $629.22

43 $1,018.13 $757.49 $644.41 $644.41 $644.41 $644.41

44 $1,048.14 $779.82 $663.41 $663.41 $663.41 $663.41

45 $1,083.40 $806.05 $685.73 $685.73 $685.73 $685.73

46 $1,125.42 $837.31 $712.32 $712.32 $712.32 $712.32

47 $1,172.69 $872.48 $742.24 $742.24 $742.24 $742.24

48 $1,226.71 $912.67 $776.43 $776.43 $776.43 $776.43

49 $1,279.98 $952.31 $810.14 $810.14 $810.14 $810.14

50 $1,340.00 $996.96 $848.14 $848.14 $848.14 $848.14

51 $1,399.27 $1,041.06 $885.65 $885.65 $885.65 $885.65

52 $1,464.54 $1,089.63 $926.97 $926.97 $926.97 $926.97

53 $1,530.57 $1,138.75 $968.75 $968.75 $968.75 $968.75

54 $1,601.85 $1,191.78 $1,013.87 $1,013.87 $1,013.87 $1,013.87

55 $1,673.12 $1,244.81 $1,058.98 $1,058.98 $1,058.98 $1,058.98

56 $1,750.40 $1,302.30 $1,107.89 $1,107.89 $1,107.89 $1,107.89

57 $1,828.43 $1,360.36 $1,157.28 $1,157.28 $1,157.28 $1,157.28

58 $1,911.71 $1,422.32 $1,209.99 $1,209.99 $1,209.99 $1,209.99

59 $1,952.98 $1,453.02 $1,236.11 $1,236.11 $1,236.11 $1,236.11

60 $2,036.26 $1,514.98 $1,288.82 $1,288.82 $1,288.82 $1,288.82

61 $2,108.28 $1,568.57 $1,334.41 $1,334.41 $1,334.41 $1,334.41

62 $2,155.55 $1,603.74 $1,364.33 $1,364.33 $1,364.33 $1,364.33

63 $2,214.82 $1,647.84 $1,401.84 $1,401.84 $1,401.84 $1,401.84

64+ $2,250.84 $1,674.63 $1,424.64 $1,424.64 $1,424.64 $1,424.64




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $339.04 $315.64 $305.83 $282.73 $279.53 $272.57

15 $369.17 $343.70 $333.01 $307.86 $304.38 $296.80

16 $380.69 $354.43 $343.41 $317.47 $313.88 $306.07

17 $392.22 $365.15 $353.80 $327.08 $323.38 $315.33

18 $404.63 $376.71 $365.00 $337.43 $333.61 $325.31

19 $417.04 $388.26 $376.19 $347.78 $343.84 $335.28

20 $429.89 $400.22 $387.78 $358.49 $354.44 $345.62

21 $443.18 $412.60 $399.78 $369.58 $365.40 $356.30

22 $443.18 $412.60 $399.78 $369.58 $365.40 $356.30

23 $443.18 $412.60 $399.78 $369.58 $365.40 $356.30

24 $443.18 $412.60 $399.78 $369.58 $365.40 $356.30

25 $444.96 $414.25 $401.37 $371.06 $366.86 $357.73

26 $453.82 $422.51 $409.37 $378.45 $374.17 $364.86

27 $464.46 $432.41 $418.97 $387.32 $382.94 $373.41

28 $481.74 $448.50 $434.56 $401.74 $397.19 $387.30

29 $495.92 $461.70 $447.35 $413.56 $408.89 $398.70

30 $503.01 $468.30 $453.75 $419.48 $414.73 $404.41

31 $513.65 $478.21 $463.34 $428.35 $423.50 $412.96

32 $524.29 $488.11 $472.93 $437.22 $432.27 $421.51

33 $530.93 $494.30 $478.93 $442.76 $437.75 $426.85

34 $538.02 $500.90 $485.33 $448.67 $443.60 $432.55

35 $541.57 $504.20 $488.53 $451.63 $446.52 $435.40

36 $545.12 $507.50 $491.72 $454.59 $449.45 $438.25

37 $548.66 $510.80 $494.92 $457.54 $452.37 $441.10

38 $552.21 $514.10 $498.12 $460.50 $455.29 $443.96

39 $559.30 $520.70 $504.52 $466.41 $461.14 $449.66

40 $566.39 $527.31 $510.91 $472.33 $466.99 $455.36

41 $577.02 $537.21 $520.51 $481.20 $475.76 $463.91

42 $587.22 $546.70 $529.70 $489.70 $484.16 $472.10

43 $601.40 $559.90 $542.50 $501.52 $495.85 $483.50

44 $619.13 $576.41 $558.49 $516.31 $510.47 $497.76

45 $639.96 $595.80 $577.28 $533.68 $527.64 $514.50

46 $664.77 $618.90 $599.66 $554.37 $548.10 $534.46

47 $692.70 $644.90 $624.85 $577.66 $571.13 $556.90

48 $724.60 $674.61 $653.63 $604.27 $597.43 $582.56

49 $756.07 $703.90 $682.02 $630.51 $623.38 $607.86

50 $791.53 $736.91 $714.00 $660.07 $652.61 $636.36

51 $826.54 $769.50 $745.58 $689.27 $681.48 $664.51

52 $865.09 $805.40 $780.36 $721.42 $713.27 $695.51

53 $904.09 $841.71 $815.54 $753.95 $745.42 $726.86

54 $946.20 $880.91 $853.52 $789.06 $780.14 $760.71

55 $988.30 $920.10 $891.50 $824.17 $814.85 $794.56

56 $1,033.95 $962.60 $932.68 $862.24 $852.49 $831.26

57 $1,080.04 $1,005.51 $974.25 $900.67 $890.49 $868.31

58 $1,129.23 $1,051.31 $1,018.63 $941.70 $931.05 $907.86

59 $1,153.61 $1,074.01 $1,040.62 $962.02 $951.14 $927.46

60 $1,202.80 $1,119.80 $1,084.99 $1,003.05 $991.70 $967.01

61 $1,245.34 $1,159.41 $1,123.37 $1,038.53 $1,026.78 $1,001.22

62 $1,273.27 $1,185.41 $1,148.56 $1,061.81 $1,049.80 $1,023.66

63 $1,308.28 $1,218.00 $1,180.14 $1,091.01 $1,078.67 $1,051.81

64+ $1,329.55 $1,237.81 $1,199.33 $1,108.75 $1,096.21 $1,068.91




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $572.98 $405.56 $336.78 $336.78 $336.78 $336.78 $314.30

15 $623.91 $441.61 $366.71 $366.71 $366.71 $366.71 $342.24

16 $643.39 $455.39 $378.16 $378.16 $378.16 $378.16 $352.92

17 $662.86 $469.18 $389.61 $389.61 $389.61 $389.61 $363.60

18 $683.83 $484.02 $401.93 $401.93 $401.93 $401.93 $375.11

19 $704.81 $498.87 $414.26 $414.26 $414.26 $414.26 $386.61

20 $726.53 $514.24 $427.03 $427.03 $427.03 $427.03 $398.52

21 $749.00 $530.15 $440.23 $440.23 $440.23 $440.23 $410.85

22 $749.00 $530.15 $440.23 $440.23 $440.23 $440.23 $410.85

23 $749.00 $530.15 $440.23 $440.23 $440.23 $440.23 $410.85

24 $749.00 $530.15 $440.23 $440.23 $440.23 $440.23 $410.85

25 $751.99 $532.27 $441.99 $441.99 $441.99 $441.99 $412.49

26 $766.97 $542.87 $450.80 $450.80 $450.80 $450.80 $420.71

27 $784.95 $555.59 $461.36 $461.36 $461.36 $461.36 $430.57

28 $814.16 $576.27 $478.53 $478.53 $478.53 $478.53 $446.59

29 $838.13 $593.23 $492.62 $492.62 $492.62 $492.62 $459.74

30 $850.11 $601.71 $499.66 $499.66 $499.66 $499.66 $466.31

31 $868.09 $614.44 $510.23 $510.23 $510.23 $510.23 $476.17

32 $886.06 $627.16 $520.80 $520.80 $520.80 $520.80 $486.03

33 $897.30 $635.11 $527.40 $527.40 $527.40 $527.40 $492.20

34 $909.28 $643.60 $534.44 $534.44 $534.44 $534.44 $498.77

35 $915.27 $647.84 $537.96 $537.96 $537.96 $537.96 $502.06

36 $921.27 $652.08 $541.49 $541.49 $541.49 $541.49 $505.34

37 $927.26 $656.32 $545.01 $545.01 $545.01 $545.01 $508.63

38 $933.25 $660.56 $548.53 $548.53 $548.53 $548.53 $511.92

39 $945.23 $669.04 $555.57 $555.57 $555.57 $555.57 $518.49

40 $957.22 $677.53 $562.62 $562.62 $562.62 $562.62 $525.06

41 $975.19 $690.25 $573.18 $573.18 $573.18 $573.18 $534.93

42 $992.42 $702.44 $583.31 $583.31 $583.31 $583.31 $544.37

43 $1,016.39 $719.41 $597.40 $597.40 $597.40 $597.40 $557.52

44 $1,046.35 $740.61 $615.01 $615.01 $615.01 $615.01 $573.96

45 $1,081.55 $765.53 $635.70 $635.70 $635.70 $635.70 $593.27

46 $1,123.49 $795.22 $660.35 $660.35 $660.35 $660.35 $616.27

47 $1,170.68 $828.62 $688.08 $688.08 $688.08 $688.08 $642.16

48 $1,224.61 $866.79 $719.78 $719.78 $719.78 $719.78 $671.74

49 $1,277.79 $904.43 $751.04 $751.04 $751.04 $751.04 $700.91

50 $1,337.71 $946.84 $786.26 $786.26 $786.26 $786.26 $733.78

51 $1,396.88 $988.72 $821.03 $821.03 $821.03 $821.03 $766.23

52 $1,462.04 $1,034.84 $859.33 $859.33 $859.33 $859.33 $801.98

53 $1,527.95 $1,081.50 $898.07 $898.07 $898.07 $898.07 $838.13

54 $1,599.11 $1,131.86 $939.90 $939.90 $939.90 $939.90 $877.16

55 $1,670.26 $1,182.22 $981.72 $981.72 $981.72 $981.72 $916.19

56 $1,747.41 $1,236.83 $1,027.06 $1,027.06 $1,027.06 $1,027.06 $958.51

57 $1,825.30 $1,291.96 $1,072.85 $1,072.85 $1,072.85 $1,072.85 $1,001.24

58 $1,908.44 $1,350.81 $1,121.71 $1,121.71 $1,121.71 $1,121.71 $1,046.84

59 $1,949.64 $1,379.97 $1,145.93 $1,145.93 $1,145.93 $1,145.93 $1,069.44

60 $2,032.78 $1,438.81 $1,194.79 $1,194.79 $1,194.79 $1,194.79 $1,115.04

61 $2,104.68 $1,489.71 $1,237.05 $1,237.05 $1,237.05 $1,237.05 $1,154.49

62 $2,151.87 $1,523.11 $1,264.79 $1,264.79 $1,264.79 $1,264.79 $1,180.37

63 $2,211.04 $1,564.99 $1,299.57 $1,299.57 $1,299.57 $1,299.57 $1,212.83

64+ $2,246.99 $1,590.44 $1,320.70 $1,320.70 $1,320.70 $1,320.70 $1,232.55



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $688.05 $511.91 $435.50 $435.50 $435.50 $435.50

15 $749.21 $557.42 $474.21 $474.21 $474.21 $474.21

16 $772.60 $574.82 $489.01 $489.01 $489.01 $489.01

17 $795.98 $592.21 $503.81 $503.81 $503.81 $503.81

18 $821.17 $610.95 $519.75 $519.75 $519.75 $519.75

19 $846.35 $629.69 $535.69 $535.69 $535.69 $535.69

20 $872.43 $649.09 $552.20 $552.20 $552.20 $552.20

21 $899.42 $669.17 $569.27 $569.27 $569.27 $569.27

22 $899.42 $669.17 $569.27 $569.27 $569.27 $569.27

23 $899.42 $669.17 $569.27 $569.27 $569.27 $569.27

24 $899.42 $669.17 $569.27 $569.27 $569.27 $569.27

25 $903.01 $671.85 $571.55 $571.55 $571.55 $571.55

26 $921.00 $685.23 $582.94 $582.94 $582.94 $582.94

27 $942.59 $701.29 $596.60 $596.60 $596.60 $596.60

28 $977.67 $727.39 $618.80 $618.80 $618.80 $618.80

29 $1,006.45 $748.80 $637.02 $637.02 $637.02 $637.02

30 $1,020.84 $759.51 $646.13 $646.13 $646.13 $646.13

31 $1,042.42 $775.57 $659.79 $659.79 $659.79 $659.79

32 $1,064.01 $791.63 $673.45 $673.45 $673.45 $673.45

33 $1,077.50 $801.66 $681.99 $681.99 $681.99 $681.99

34 $1,091.89 $812.37 $691.10 $691.10 $691.10 $691.10

35 $1,099.09 $817.72 $695.65 $695.65 $695.65 $695.65

36 $1,106.28 $823.08 $700.21 $700.21 $700.21 $700.21

37 $1,113.48 $828.43 $704.76 $704.76 $704.76 $704.76

38 $1,120.67 $833.78 $709.32 $709.32 $709.32 $709.32

39 $1,135.06 $844.49 $718.42 $718.42 $718.42 $718.42

40 $1,149.45 $855.20 $727.53 $727.53 $727.53 $727.53

41 $1,171.04 $871.26 $741.20 $741.20 $741.20 $741.20

42 $1,191.73 $886.65 $754.29 $754.29 $754.29 $754.29

43 $1,220.51 $908.06 $772.51 $772.51 $772.51 $772.51

44 $1,256.49 $934.83 $795.28 $795.28 $795.28 $795.28

45 $1,298.76 $966.28 $822.03 $822.03 $822.03 $822.03

46 $1,349.13 $1,003.75 $853.91 $853.91 $853.91 $853.91

47 $1,405.79 $1,045.91 $889.78 $889.78 $889.78 $889.78

48 $1,470.55 $1,094.09 $930.76 $930.76 $930.76 $930.76

49 $1,534.41 $1,141.60 $971.18 $971.18 $971.18 $971.18

50 $1,606.36 $1,195.14 $1,016.72 $1,016.72 $1,016.72 $1,016.72

51 $1,677.41 $1,248.00 $1,061.70 $1,061.70 $1,061.70 $1,061.70

52 $1,755.66 $1,306.22 $1,111.22 $1,111.22 $1,111.22 $1,111.22

53 $1,834.81 $1,365.10 $1,161.32 $1,161.32 $1,161.32 $1,161.32

54 $1,920.25 $1,428.67 $1,215.40 $1,215.40 $1,215.40 $1,215.40

55 $2,005.70 $1,492.25 $1,269.48 $1,269.48 $1,269.48 $1,269.48

56 $2,098.34 $1,561.17 $1,328.12 $1,328.12 $1,328.12 $1,328.12

57 $2,191.88 $1,630.76 $1,387.32 $1,387.32 $1,387.32 $1,387.32

58 $2,291.71 $1,705.04 $1,450.51 $1,450.51 $1,450.51 $1,450.51

59 $2,341.18 $1,741.85 $1,481.82 $1,481.82 $1,481.82 $1,481.82

60 $2,441.02 $1,816.12 $1,545.01 $1,545.01 $1,545.01 $1,545.01

61 $2,527.36 $1,880.36 $1,599.66 $1,599.66 $1,599.66 $1,599.66

62 $2,584.02 $1,922.52 $1,635.53 $1,635.53 $1,635.53 $1,635.53

63 $2,655.08 $1,975.39 $1,680.50 $1,680.50 $1,680.50 $1,680.50

64+ $2,698.25 $2,007.51 $1,707.82 $1,707.82 $1,707.82 $1,707.82




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $406.43 $378.38 $366.62 $338.93 $335.10 $326.75

15 $442.55 $412.02 $399.21 $369.06 $364.88 $355.80

16 $456.37 $424.88 $411.67 $380.58 $376.27 $366.90

17 $470.18 $437.74 $424.13 $392.10 $387.66 $378.01

18 $485.06 $451.59 $437.55 $404.50 $399.93 $389.97

19 $499.93 $465.44 $450.97 $416.91 $412.19 $401.93

20 $515.34 $479.78 $464.86 $429.76 $424.90 $414.32

21 $531.28 $494.62 $479.24 $443.05 $438.04 $427.13

22 $531.28 $494.62 $479.24 $443.05 $438.04 $427.13

23 $531.28 $494.62 $479.24 $443.05 $438.04 $427.13

24 $531.28 $494.62 $479.24 $443.05 $438.04 $427.13

25 $533.40 $496.60 $481.16 $444.82 $439.79 $428.84

26 $544.03 $506.49 $490.74 $453.68 $448.55 $437.38

27 $556.78 $518.36 $502.25 $464.31 $459.06 $447.63

28 $577.50 $537.65 $520.94 $481.59 $476.15 $464.29

29 $594.50 $553.48 $536.27 $495.77 $490.16 $477.96

30 $603.00 $561.39 $543.94 $502.86 $497.17 $484.79

31 $615.75 $573.26 $555.44 $513.49 $507.68 $495.04

32 $628.50 $585.13 $566.94 $524.12 $518.20 $505.29

33 $636.47 $592.55 $574.13 $530.77 $524.77 $511.70

34 $644.97 $600.47 $581.80 $537.86 $531.78 $518.53

35 $649.22 $604.42 $585.63 $541.40 $535.28 $521.95

36 $653.47 $608.38 $589.47 $544.95 $538.79 $525.37

37 $657.72 $612.34 $593.30 $548.49 $542.29 $528.79

38 $661.97 $616.29 $597.14 $552.04 $545.79 $532.20

39 $670.47 $624.21 $604.80 $559.12 $552.80 $539.04

40 $678.97 $632.12 $612.47 $566.21 $559.81 $545.87

41 $691.72 $643.99 $623.97 $576.85 $570.32 $556.12

42 $703.94 $655.37 $635.00 $587.04 $580.40 $565.95

43 $720.94 $671.20 $650.33 $601.21 $594.42 $579.61

44 $742.19 $690.98 $669.50 $618.94 $611.94 $596.70

45 $767.16 $714.23 $692.03 $639.76 $632.53 $616.77

46 $796.92 $741.93 $718.86 $664.57 $657.06 $640.69

47 $830.39 $773.09 $749.05 $692.48 $684.65 $667.60

48 $868.64 $808.70 $783.56 $724.38 $716.19 $698.36

49 $906.36 $843.82 $817.59 $755.84 $747.29 $728.68

50 $948.86 $883.39 $855.93 $791.28 $782.33 $762.85

51 $990.83 $922.46 $893.79 $826.28 $816.94 $796.60

52 $1,037.05 $965.50 $935.48 $864.83 $855.05 $833.76

53 $1,083.81 $1,009.02 $977.65 $903.82 $893.59 $871.34

54 $1,134.28 $1,056.01 $1,023.18 $945.90 $935.21 $911.92

55 $1,184.75 $1,103.00 $1,068.71 $987.99 $976.82 $952.50

56 $1,239.47 $1,153.95 $1,118.07 $1,033.63 $1,021.94 $996.49

57 $1,294.72 $1,205.39 $1,167.91 $1,079.70 $1,067.50 $1,040.91

58 $1,353.70 $1,260.29 $1,221.11 $1,128.88 $1,116.12 $1,088.32

59 $1,382.92 $1,287.49 $1,247.47 $1,153.25 $1,140.21 $1,111.82

60 $1,441.89 $1,342.40 $1,300.66 $1,202.43 $1,188.83 $1,159.23

61 $1,492.89 $1,389.88 $1,346.67 $1,244.96 $1,230.88 $1,200.23

62 $1,526.36 $1,421.04 $1,376.86 $1,272.87 $1,258.48 $1,227.14

63 $1,568.33 $1,460.11 $1,414.72 $1,307.87 $1,293.08 $1,260.89

64+ $1,593.83 $1,483.86 $1,437.73 $1,329.14 $1,314.11 $1,281.39




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $582.17 $412.07 $342.18 $342.18 $342.18 $342.18 $319.34

15 $633.92 $448.69 $372.60 $372.60 $372.60 $372.60 $347.73

16 $653.71 $462.70 $384.22 $384.22 $384.22 $384.22 $358.58

17 $673.49 $476.70 $395.85 $395.85 $395.85 $395.85 $369.43

18 $694.80 $491.79 $408.38 $408.38 $408.38 $408.38 $381.12

19 $716.11 $506.87 $420.90 $420.90 $420.90 $420.90 $392.81

20 $738.18 $522.49 $433.87 $433.87 $433.87 $433.87 $404.91

21 $761.01 $538.65 $447.29 $447.29 $447.29 $447.29 $417.44

22 $761.01 $538.65 $447.29 $447.29 $447.29 $447.29 $417.44

23 $761.01 $538.65 $447.29 $447.29 $447.29 $447.29 $417.44

24 $761.01 $538.65 $447.29 $447.29 $447.29 $447.29 $417.44

25 $764.05 $540.80 $449.08 $449.08 $449.08 $449.08 $419.11

26 $779.27 $551.57 $458.03 $458.03 $458.03 $458.03 $427.46

27 $797.54 $564.50 $468.76 $468.76 $468.76 $468.76 $437.47

28 $827.22 $585.51 $486.21 $486.21 $486.21 $486.21 $453.75

29 $851.57 $602.75 $500.52 $500.52 $500.52 $500.52 $467.11

30 $863.74 $611.36 $507.68 $507.68 $507.68 $507.68 $473.79

31 $882.01 $624.29 $518.41 $518.41 $518.41 $518.41 $483.81

32 $900.27 $637.22 $529.15 $529.15 $529.15 $529.15 $493.83

33 $911.69 $645.30 $535.86 $535.86 $535.86 $535.86 $500.09

34 $923.86 $653.92 $543.01 $543.01 $543.01 $543.01 $506.77

35 $929.95 $658.23 $546.59 $546.59 $546.59 $546.59 $510.11

36 $936.04 $662.54 $550.17 $550.17 $550.17 $550.17 $513.45

37 $942.13 $666.85 $553.75 $553.75 $553.75 $553.75 $516.79

38 $948.22 $671.15 $557.33 $557.33 $557.33 $557.33 $520.13

39 $960.39 $679.77 $564.48 $564.48 $564.48 $564.48 $526.81

40 $972.57 $688.39 $571.64 $571.64 $571.64 $571.64 $533.49

41 $990.83 $701.32 $582.38 $582.38 $582.38 $582.38 $543.50

42 $1,008.34 $713.71 $592.66 $592.66 $592.66 $592.66 $553.11

43 $1,032.69 $730.94 $606.98 $606.98 $606.98 $606.98 $566.46

44 $1,063.13 $752.49 $624.87 $624.87 $624.87 $624.87 $583.16

45 $1,098.90 $777.81 $645.89 $645.89 $645.89 $645.89 $602.78

46 $1,141.51 $807.97 $670.94 $670.94 $670.94 $670.94 $626.16

47 $1,189.46 $841.91 $699.12 $699.12 $699.12 $699.12 $652.46

48 $1,244.25 $880.69 $731.32 $731.32 $731.32 $731.32 $682.51

49 $1,298.28 $918.93 $763.08 $763.08 $763.08 $763.08 $712.15

50 $1,359.16 $962.02 $798.87 $798.87 $798.87 $798.87 $745.54

51 $1,419.28 $1,004.58 $834.20 $834.20 $834.20 $834.20 $778.52

52 $1,485.49 $1,051.44 $873.12 $873.12 $873.12 $873.12 $814.84

53 $1,552.46 $1,098.84 $912.48 $912.48 $912.48 $912.48 $851.57

54 $1,624.75 $1,150.01 $954.97 $954.97 $954.97 $954.97 $891.23

55 $1,697.05 $1,201.18 $997.46 $997.46 $997.46 $997.46 $930.89

56 $1,775.43 $1,256.66 $1,043.53 $1,043.53 $1,043.53 $1,043.53 $973.88

57 $1,854.58 $1,312.68 $1,090.05 $1,090.05 $1,090.05 $1,090.05 $1,017.30

58 $1,939.05 $1,372.47 $1,139.70 $1,139.70 $1,139.70 $1,139.70 $1,063.63

59 $1,980.91 $1,402.10 $1,164.30 $1,164.30 $1,164.30 $1,164.30 $1,086.59

60 $2,065.38 $1,461.89 $1,213.95 $1,213.95 $1,213.95 $1,213.95 $1,132.93

61 $2,138.43 $1,513.60 $1,256.89 $1,256.89 $1,256.89 $1,256.89 $1,173.00

62 $2,186.38 $1,547.53 $1,285.07 $1,285.07 $1,285.07 $1,285.07 $1,199.30

63 $2,246.50 $1,590.09 $1,320.41 $1,320.41 $1,320.41 $1,320.41 $1,232.28

64+ $2,283.03 $1,615.94 $1,341.88 $1,341.88 $1,341.88 $1,341.88 $1,252.31



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $654.92 $487.26 $414.52 $414.52 $414.52 $414.52

15 $713.13 $530.57 $451.37 $451.37 $451.37 $451.37

16 $735.39 $547.13 $465.46 $465.46 $465.46 $465.46

17 $757.65 $563.69 $479.54 $479.54 $479.54 $479.54

18 $781.62 $581.53 $494.72 $494.72 $494.72 $494.72

19 $805.59 $599.36 $509.89 $509.89 $509.89 $509.89

20 $830.42 $617.83 $525.60 $525.60 $525.60 $525.60

21 $856.10 $636.94 $541.86 $541.86 $541.86 $541.86

22 $856.10 $636.94 $541.86 $541.86 $541.86 $541.86

23 $856.10 $636.94 $541.86 $541.86 $541.86 $541.86

24 $856.10 $636.94 $541.86 $541.86 $541.86 $541.86

25 $859.52 $639.49 $544.03 $544.03 $544.03 $544.03

26 $876.65 $652.23 $554.86 $554.86 $554.86 $554.86

27 $897.19 $667.51 $567.87 $567.87 $567.87 $567.87

28 $930.58 $692.35 $589.00 $589.00 $589.00 $589.00

29 $957.98 $712.74 $606.34 $606.34 $606.34 $606.34

30 $971.67 $722.93 $615.01 $615.01 $615.01 $615.01

31 $992.22 $738.21 $628.01 $628.01 $628.01 $628.01

32 $1,012.77 $753.50 $641.02 $641.02 $641.02 $641.02

33 $1,025.61 $763.05 $649.15 $649.15 $649.15 $649.15

34 $1,039.31 $773.25 $657.82 $657.82 $657.82 $657.82

35 $1,046.15 $778.34 $662.15 $662.15 $662.15 $662.15

36 $1,053.00 $783.44 $666.48 $666.48 $666.48 $666.48

37 $1,059.85 $788.53 $670.82 $670.82 $670.82 $670.82

38 $1,066.70 $793.63 $675.15 $675.15 $675.15 $675.15

39 $1,080.40 $803.82 $683.82 $683.82 $683.82 $683.82

40 $1,094.10 $814.01 $692.49 $692.49 $692.49 $692.49

41 $1,114.64 $829.30 $705.50 $705.50 $705.50 $705.50

42 $1,134.33 $843.95 $717.96 $717.96 $717.96 $717.96

43 $1,161.73 $864.33 $735.30 $735.30 $735.30 $735.30

44 $1,195.97 $889.81 $756.98 $756.98 $756.98 $756.98

45 $1,236.21 $919.74 $782.44 $782.44 $782.44 $782.44

46 $1,284.15 $955.41 $812.79 $812.79 $812.79 $812.79

47 $1,338.08 $995.54 $846.92 $846.92 $846.92 $846.92

48 $1,399.72 $1,041.40 $885.94 $885.94 $885.94 $885.94

49 $1,460.51 $1,086.62 $924.41 $924.41 $924.41 $924.41

50 $1,528.99 $1,137.58 $967.76 $967.76 $967.76 $967.76

51 $1,596.63 $1,187.89 $1,010.56 $1,010.56 $1,010.56 $1,010.56

52 $1,671.11 $1,243.31 $1,057.71 $1,057.71 $1,057.71 $1,057.71

53 $1,746.44 $1,299.36 $1,105.39 $1,105.39 $1,105.39 $1,105.39

54 $1,827.77 $1,359.87 $1,156.87 $1,156.87 $1,156.87 $1,156.87

55 $1,909.10 $1,420.38 $1,208.34 $1,208.34 $1,208.34 $1,208.34

56 $1,997.28 $1,485.98 $1,264.15 $1,264.15 $1,264.15 $1,264.15

57 $2,086.32 $1,552.22 $1,320.51 $1,320.51 $1,320.51 $1,320.51

58 $2,181.34 $1,622.92 $1,380.65 $1,380.65 $1,380.65 $1,380.65

59 $2,228.43 $1,657.96 $1,410.46 $1,410.46 $1,410.46 $1,410.46

60 $2,323.45 $1,728.66 $1,470.60 $1,470.60 $1,470.60 $1,470.60

61 $2,405.64 $1,789.80 $1,522.62 $1,522.62 $1,522.62 $1,522.62

62 $2,459.57 $1,829.93 $1,556.76 $1,556.76 $1,556.76 $1,556.76

63 $2,527.21 $1,880.25 $1,599.56 $1,599.56 $1,599.56 $1,599.56

64+ $2,568.30 $1,910.82 $1,625.57 $1,625.57 $1,625.57 $1,625.57




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $386.85 $360.16 $348.96 $322.61 $318.96 $311.02

15 $421.24 $392.17 $379.98 $351.28 $347.31 $338.66

16 $434.39 $404.41 $391.84 $362.25 $358.15 $349.23

17 $447.54 $416.66 $403.70 $373.21 $368.99 $359.80

18 $461.70 $429.84 $416.47 $385.02 $380.67 $371.19

19 $475.85 $443.02 $429.25 $396.83 $392.34 $382.57

20 $490.52 $456.67 $442.48 $409.06 $404.43 $394.36

21 $505.69 $470.80 $456.16 $421.71 $416.94 $406.56

22 $505.69 $470.80 $456.16 $421.71 $416.94 $406.56

23 $505.69 $470.80 $456.16 $421.71 $416.94 $406.56

24 $505.69 $470.80 $456.16 $421.71 $416.94 $406.56

25 $507.71 $472.68 $457.99 $423.40 $418.61 $408.18

26 $517.83 $482.10 $467.11 $431.83 $426.95 $416.32

27 $529.96 $493.40 $478.06 $441.95 $436.95 $426.07

28 $549.69 $511.76 $495.85 $458.40 $453.21 $441.93

29 $565.87 $526.82 $510.44 $471.89 $466.56 $454.94

30 $573.96 $534.35 $517.74 $478.64 $473.23 $461.44

31 $586.10 $545.65 $528.69 $488.76 $483.23 $471.20

32 $598.23 $556.95 $539.64 $498.88 $493.24 $480.96

33 $605.82 $564.02 $546.48 $505.21 $499.49 $487.06

34 $613.91 $571.55 $553.78 $511.95 $506.17 $493.56

35 $617.95 $575.31 $557.43 $515.33 $509.50 $496.81

36 $622.00 $579.08 $561.08 $518.70 $512.84 $500.07

37 $626.04 $582.85 $564.73 $522.08 $516.17 $503.32

38 $630.09 $586.61 $568.38 $525.45 $519.51 $506.57

39 $638.18 $594.15 $575.68 $532.20 $526.18 $513.08

40 $646.27 $601.68 $582.97 $538.94 $532.85 $519.58

41 $658.41 $612.98 $593.92 $549.06 $542.86 $529.34

42 $670.04 $623.81 $604.41 $558.76 $552.45 $538.69

43 $686.22 $638.87 $619.01 $572.26 $565.79 $551.70

44 $706.45 $657.70 $637.26 $589.13 $582.47 $567.96

45 $730.22 $679.83 $658.70 $608.95 $602.06 $587.07

46 $758.54 $706.20 $684.24 $632.56 $625.41 $609.84

47 $790.39 $735.86 $712.98 $659.13 $651.68 $635.45

48 $826.80 $769.75 $745.82 $689.49 $681.70 $664.72

49 $862.71 $803.18 $778.21 $719.44 $711.30 $693.59

50 $903.16 $840.84 $814.70 $753.17 $744.66 $726.11

51 $943.11 $878.04 $850.74 $786.49 $777.59 $758.23

52 $987.11 $919.00 $890.43 $823.18 $813.87 $793.60

53 $1,031.61 $960.43 $930.57 $860.29 $850.56 $829.38

54 $1,079.65 $1,005.15 $973.90 $900.35 $890.17 $868.00

55 $1,127.69 $1,049.88 $1,017.24 $940.41 $929.78 $906.62

56 $1,179.78 $1,098.37 $1,064.22 $983.85 $972.72 $948.50

57 $1,232.37 $1,147.33 $1,111.66 $1,027.70 $1,016.08 $990.78

58 $1,288.50 $1,199.59 $1,162.30 $1,074.51 $1,062.36 $1,035.91

59 $1,316.31 $1,225.49 $1,187.39 $1,097.71 $1,085.30 $1,058.27

60 $1,372.44 $1,277.74 $1,238.02 $1,144.52 $1,131.58 $1,103.40

61 $1,420.99 $1,322.94 $1,281.81 $1,185.00 $1,171.60 $1,142.43

62 $1,452.85 $1,352.60 $1,310.55 $1,211.57 $1,197.87 $1,168.04

63 $1,492.80 $1,389.79 $1,346.59 $1,244.88 $1,230.81 $1,200.16

64+ $1,517.07 $1,412.39 $1,368.48 $1,265.13 $1,250.82 $1,219.67




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $658.73 $466.25 $387.18 $387.18 $387.18 $387.18 $361.34

15 $717.28 $507.70 $421.59 $421.59 $421.59 $421.59 $393.45

16 $739.67 $523.55 $434.75 $434.75 $434.75 $434.75 $405.73

17 $762.06 $539.39 $447.91 $447.91 $447.91 $447.91 $418.02

18 $786.17 $556.46 $462.08 $462.08 $462.08 $462.08 $431.24

19 $810.28 $573.52 $476.25 $476.25 $476.25 $476.25 $444.47

20 $835.25 $591.20 $490.93 $490.93 $490.93 $490.93 $458.16

21 $861.09 $609.48 $506.11 $506.11 $506.11 $506.11 $472.33

22 $861.09 $609.48 $506.11 $506.11 $506.11 $506.11 $472.33

23 $861.09 $609.48 $506.11 $506.11 $506.11 $506.11 $472.33

24 $861.09 $609.48 $506.11 $506.11 $506.11 $506.11 $472.33

25 $864.53 $611.92 $508.14 $508.14 $508.14 $508.14 $474.22

26 $881.75 $624.11 $518.26 $518.26 $518.26 $518.26 $483.67

27 $902.42 $638.74 $530.41 $530.41 $530.41 $530.41 $495.01

28 $936.00 $662.51 $550.15 $550.15 $550.15 $550.15 $513.43

29 $963.56 $682.01 $566.34 $566.34 $566.34 $566.34 $528.54

30 $977.33 $691.76 $574.44 $574.44 $574.44 $574.44 $536.10

31 $998.00 $706.39 $586.59 $586.59 $586.59 $586.59 $547.43

32 $1,018.66 $721.02 $598.73 $598.73 $598.73 $598.73 $558.77

33 $1,031.58 $730.16 $606.33 $606.33 $606.33 $606.33 $565.86

34 $1,045.36 $739.91 $614.42 $614.42 $614.42 $614.42 $573.41

35 $1,052.25 $744.79 $618.47 $618.47 $618.47 $618.47 $577.19

36 $1,059.14 $749.66 $622.52 $622.52 $622.52 $622.52 $580.97

37 $1,066.02 $754.54 $626.57 $626.57 $626.57 $626.57 $584.75

38 $1,072.91 $759.42 $630.62 $630.62 $630.62 $630.62 $588.53

39 $1,086.69 $769.17 $638.72 $638.72 $638.72 $638.72 $596.08

40 $1,100.47 $778.92 $646.81 $646.81 $646.81 $646.81 $603.64

41 $1,121.13 $793.55 $658.96 $658.96 $658.96 $658.96 $614.98

42 $1,140.94 $807.56 $670.60 $670.60 $670.60 $670.60 $625.84

43 $1,168.49 $827.07 $686.80 $686.80 $686.80 $686.80 $640.96

44 $1,202.94 $851.45 $707.04 $707.04 $707.04 $707.04 $659.85

45 $1,243.41 $880.09 $730.83 $730.83 $730.83 $730.83 $682.05

46 $1,291.63 $914.22 $759.17 $759.17 $759.17 $759.17 $708.50

47 $1,345.88 $952.62 $791.06 $791.06 $791.06 $791.06 $738.26

48 $1,407.88 $996.50 $827.50 $827.50 $827.50 $827.50 $772.27

49 $1,469.01 $1,039.78 $863.43 $863.43 $863.43 $863.43 $805.80

50 $1,537.90 $1,088.54 $903.92 $903.92 $903.92 $903.92 $843.59

51 $1,605.93 $1,136.69 $943.90 $943.90 $943.90 $943.90 $880.90

52 $1,680.84 $1,189.71 $987.94 $987.94 $987.94 $987.94 $921.99

53 $1,756.62 $1,243.35 $1,032.47 $1,032.47 $1,032.47 $1,032.47 $963.56

54 $1,838.42 $1,301.25 $1,080.56 $1,080.56 $1,080.56 $1,080.56 $1,008.43

55 $1,920.22 $1,359.15 $1,128.64 $1,128.64 $1,128.64 $1,128.64 $1,053.30

56 $2,008.91 $1,421.92 $1,180.77 $1,180.77 $1,180.77 $1,180.77 $1,101.95

57 $2,098.47 $1,485.31 $1,233.40 $1,233.40 $1,233.40 $1,233.40 $1,151.08

58 $2,194.05 $1,552.96 $1,289.58 $1,289.58 $1,289.58 $1,289.58 $1,203.51

59 $2,241.41 $1,586.48 $1,317.42 $1,317.42 $1,317.42 $1,317.42 $1,229.48

60 $2,336.99 $1,654.14 $1,373.60 $1,373.60 $1,373.60 $1,373.60 $1,281.91

61 $2,419.65 $1,712.65 $1,422.18 $1,422.18 $1,422.18 $1,422.18 $1,327.26

62 $2,473.90 $1,751.04 $1,454.07 $1,454.07 $1,454.07 $1,454.07 $1,357.01

63 $2,541.93 $1,799.19 $1,494.05 $1,494.05 $1,494.05 $1,494.05 $1,394.33

64+ $2,583.26 $1,828.45 $1,518.34 $1,518.34 $1,518.34 $1,518.34 $1,417.00



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $723.97 $538.64 $458.23 $458.23 $458.23 $458.23

15 $788.32 $586.51 $498.96 $498.96 $498.96 $498.96

16 $812.93 $604.82 $514.53 $514.53 $514.53 $514.53

17 $837.53 $623.13 $530.11 $530.11 $530.11 $530.11

18 $864.03 $642.84 $546.88 $546.88 $546.88 $546.88

19 $890.53 $662.56 $563.65 $563.65 $563.65 $563.65

20 $917.98 $682.98 $581.02 $581.02 $581.02 $581.02

21 $946.37 $704.10 $598.99 $598.99 $598.99 $598.99

22 $946.37 $704.10 $598.99 $598.99 $598.99 $598.99

23 $946.37 $704.10 $598.99 $598.99 $598.99 $598.99

24 $946.37 $704.10 $598.99 $598.99 $598.99 $598.99

25 $950.15 $706.92 $601.39 $601.39 $601.39 $601.39

26 $969.08 $721.00 $613.37 $613.37 $613.37 $613.37

27 $991.79 $737.90 $627.74 $627.74 $627.74 $627.74

28 $1,028.70 $765.36 $651.10 $651.10 $651.10 $651.10

29 $1,058.98 $787.89 $670.27 $670.27 $670.27 $670.27

30 $1,074.13 $799.15 $679.85 $679.85 $679.85 $679.85

31 $1,096.84 $816.05 $694.23 $694.23 $694.23 $694.23

32 $1,119.55 $832.95 $708.61 $708.61 $708.61 $708.61

33 $1,133.75 $843.51 $717.59 $717.59 $717.59 $717.59

34 $1,148.89 $854.78 $727.17 $727.17 $727.17 $727.17

35 $1,156.46 $860.41 $731.97 $731.97 $731.97 $731.97

36 $1,164.03 $866.04 $736.76 $736.76 $736.76 $736.76

37 $1,171.60 $871.67 $741.55 $741.55 $741.55 $741.55

38 $1,179.17 $877.31 $746.34 $746.34 $746.34 $746.34

39 $1,194.31 $888.57 $755.93 $755.93 $755.93 $755.93

40 $1,209.46 $899.84 $765.51 $765.51 $765.51 $765.51

41 $1,232.17 $916.74 $779.89 $779.89 $779.89 $779.89

42 $1,253.94 $932.93 $793.66 $793.66 $793.66 $793.66

43 $1,284.22 $955.46 $812.83 $812.83 $812.83 $812.83

44 $1,322.07 $983.63 $836.79 $836.79 $836.79 $836.79

45 $1,366.55 $1,016.72 $864.94 $864.94 $864.94 $864.94

46 $1,419.55 $1,056.15 $898.49 $898.49 $898.49 $898.49

47 $1,479.17 $1,100.51 $936.22 $936.22 $936.22 $936.22

48 $1,547.31 $1,151.20 $979.35 $979.35 $979.35 $979.35

49 $1,614.50 $1,201.19 $1,021.88 $1,021.88 $1,021.88 $1,021.88

50 $1,690.21 $1,257.52 $1,069.80 $1,069.80 $1,069.80 $1,069.80

51 $1,764.97 $1,313.14 $1,117.12 $1,117.12 $1,117.12 $1,117.12

52 $1,847.31 $1,374.40 $1,169.23 $1,169.23 $1,169.23 $1,169.23

53 $1,930.59 $1,436.36 $1,221.94 $1,221.94 $1,221.94 $1,221.94

54 $2,020.49 $1,503.25 $1,278.85 $1,278.85 $1,278.85 $1,278.85

55 $2,110.40 $1,570.14 $1,335.75 $1,335.75 $1,335.75 $1,335.75

56 $2,207.87 $1,642.66 $1,397.45 $1,397.45 $1,397.45 $1,397.45

57 $2,306.29 $1,715.89 $1,459.74 $1,459.74 $1,459.74 $1,459.74

58 $2,411.34 $1,794.04 $1,526.23 $1,526.23 $1,526.23 $1,526.23

59 $2,463.39 $1,832.77 $1,559.17 $1,559.17 $1,559.17 $1,559.17

60 $2,568.44 $1,910.93 $1,625.66 $1,625.66 $1,625.66 $1,625.66

61 $2,659.29 $1,978.52 $1,683.16 $1,683.16 $1,683.16 $1,683.16

62 $2,718.91 $2,022.88 $1,720.90 $1,720.90 $1,720.90 $1,720.90

63 $2,793.67 $2,078.50 $1,768.22 $1,768.22 $1,768.22 $1,768.22

64+ $2,839.10 $2,112.30 $1,796.97 $1,796.97 $1,796.97 $1,796.97




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $427.64 $398.13 $385.76 $356.62 $352.59 $343.81

15 $465.66 $433.52 $420.05 $388.32 $383.93 $374.37

16 $480.19 $447.06 $433.16 $400.44 $395.92 $386.06

17 $494.72 $460.59 $446.27 $412.56 $407.90 $397.74

18 $510.38 $475.16 $460.39 $425.62 $420.80 $410.33

19 $526.03 $489.73 $474.51 $438.67 $433.71 $422.91

20 $542.24 $504.82 $489.13 $452.19 $447.08 $435.94

21 $559.01 $520.44 $504.26 $466.17 $460.90 $449.43

22 $559.01 $520.44 $504.26 $466.17 $460.90 $449.43

23 $559.01 $520.44 $504.26 $466.17 $460.90 $449.43

24 $559.01 $520.44 $504.26 $466.17 $460.90 $449.43

25 $561.25 $522.52 $506.28 $468.04 $462.75 $451.22

26 $572.43 $532.93 $516.36 $477.36 $471.96 $460.21

27 $585.84 $545.42 $528.46 $488.55 $483.03 $471.00

28 $607.64 $565.72 $548.13 $506.73 $501.00 $488.53

29 $625.53 $582.37 $564.26 $521.65 $515.75 $502.91

30 $634.48 $590.70 $572.33 $529.11 $523.12 $510.10

31 $647.89 $603.19 $584.44 $540.30 $534.19 $520.88

32 $661.31 $615.68 $596.54 $551.48 $545.25 $531.67

33 $669.69 $623.48 $604.10 $558.48 $552.16 $538.41

34 $678.64 $631.81 $612.17 $565.93 $559.54 $545.60

35 $683.11 $635.97 $616.20 $569.66 $563.22 $549.20

36 $687.58 $640.14 $620.24 $573.39 $566.91 $552.79

37 $692.05 $644.30 $624.27 $577.12 $570.60 $556.39

38 $696.53 $648.47 $628.31 $580.85 $574.28 $559.98

39 $705.47 $656.79 $636.37 $588.31 $581.66 $567.17

40 $714.42 $665.12 $644.44 $595.77 $589.03 $574.37

41 $727.83 $677.61 $656.54 $606.96 $600.09 $585.15

42 $740.69 $689.58 $668.14 $617.68 $610.70 $595.49

43 $758.58 $706.23 $684.28 $632.60 $625.44 $609.87

44 $780.94 $727.05 $704.45 $651.24 $643.88 $627.85

45 $807.21 $751.51 $728.15 $673.15 $665.54 $648.97

46 $838.52 $780.66 $756.39 $699.26 $691.35 $674.14

47 $873.73 $813.44 $788.16 $728.63 $720.39 $702.45

48 $913.98 $850.92 $824.46 $762.19 $753.58 $734.81

49 $953.67 $887.87 $860.26 $795.29 $786.30 $766.72

50 $998.39 $929.50 $900.61 $832.59 $823.17 $802.67

51 $1,042.55 $970.62 $940.44 $869.41 $859.58 $838.18

52 $1,091.19 $1,015.89 $984.31 $909.97 $899.68 $877.28

53 $1,140.38 $1,061.69 $1,028.69 $950.99 $940.24 $916.83

54 $1,193.49 $1,111.13 $1,076.59 $995.28 $984.03 $959.52

55 $1,246.59 $1,160.58 $1,124.50 $1,039.57 $1,027.81 $1,002.22

56 $1,304.17 $1,214.18 $1,176.43 $1,087.58 $1,075.28 $1,048.51

57 $1,362.31 $1,268.31 $1,228.88 $1,136.07 $1,123.22 $1,095.25

58 $1,424.36 $1,326.08 $1,284.85 $1,187.81 $1,174.38 $1,145.14

59 $1,455.10 $1,354.70 $1,312.58 $1,213.45 $1,199.73 $1,169.85

60 $1,517.15 $1,412.47 $1,368.56 $1,265.20 $1,250.89 $1,219.74

61 $1,570.82 $1,462.43 $1,416.97 $1,309.95 $1,295.14 $1,262.88

62 $1,606.04 $1,495.22 $1,448.73 $1,339.32 $1,324.17 $1,291.20

63 $1,650.20 $1,536.33 $1,488.57 $1,376.14 $1,360.58 $1,326.70

64+ $1,677.03 $1,561.31 $1,512.77 $1,398.52 $1,382.71 $1,348.28




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $535.14 $378.77 $314.53 $314.53 $314.53 $314.53 $293.54

15 $582.70 $412.44 $342.49 $342.49 $342.49 $342.49 $319.63

16 $600.89 $425.31 $353.18 $353.18 $353.18 $353.18 $329.61

17 $619.08 $438.19 $363.87 $363.87 $363.87 $363.87 $339.58

18 $638.66 $452.05 $375.38 $375.38 $375.38 $375.38 $350.33

19 $658.25 $465.92 $386.90 $386.90 $386.90 $386.90 $361.07

20 $678.54 $480.27 $398.82 $398.82 $398.82 $398.82 $372.20

21 $699.52 $495.13 $411.15 $411.15 $411.15 $411.15 $383.71

22 $699.52 $495.13 $411.15 $411.15 $411.15 $411.15 $383.71

23 $699.52 $495.13 $411.15 $411.15 $411.15 $411.15 $383.71

24 $699.52 $495.13 $411.15 $411.15 $411.15 $411.15 $383.71

25 $702.32 $497.11 $412.80 $412.80 $412.80 $412.80 $385.25

26 $716.31 $507.01 $421.02 $421.02 $421.02 $421.02 $392.92

27 $733.10 $518.89 $430.89 $430.89 $430.89 $430.89 $402.13

28 $760.38 $538.20 $446.92 $446.92 $446.92 $446.92 $417.09

29 $782.77 $554.05 $460.08 $460.08 $460.08 $460.08 $429.37

30 $793.96 $561.97 $466.66 $466.66 $466.66 $466.66 $435.51

31 $810.75 $573.85 $476.53 $476.53 $476.53 $476.53 $444.72

32 $827.54 $585.74 $486.40 $486.40 $486.40 $486.40 $453.93

33 $838.03 $593.16 $492.56 $492.56 $492.56 $492.56 $459.69

34 $849.22 $601.09 $499.14 $499.14 $499.14 $499.14 $465.83

35 $854.82 $605.05 $502.43 $502.43 $502.43 $502.43 $468.90

36 $860.41 $609.01 $505.72 $505.72 $505.72 $505.72 $471.96

37 $866.01 $612.97 $509.01 $509.01 $509.01 $509.01 $475.03

38 $871.61 $616.93 $512.30 $512.30 $512.30 $512.30 $478.10

39 $882.80 $624.85 $518.88 $518.88 $518.88 $518.88 $484.24

40 $893.99 $632.77 $525.46 $525.46 $525.46 $525.46 $490.38

41 $910.78 $644.66 $535.32 $535.32 $535.32 $535.32 $499.59

42 $926.87 $656.04 $544.78 $544.78 $544.78 $544.78 $508.42

43 $949.25 $671.89 $557.94 $557.94 $557.94 $557.94 $520.70

44 $977.23 $691.69 $574.38 $574.38 $574.38 $574.38 $536.04

45 $1,010.11 $714.96 $593.71 $593.71 $593.71 $593.71 $554.08

46 $1,049.29 $742.69 $616.73 $616.73 $616.73 $616.73 $575.57

47 $1,093.36 $773.88 $642.63 $642.63 $642.63 $642.63 $599.74

48 $1,143.72 $809.53 $672.24 $672.24 $672.24 $672.24 $627.37

49 $1,193.39 $844.69 $701.43 $701.43 $701.43 $701.43 $654.61

50 $1,249.35 $884.30 $734.32 $734.32 $734.32 $734.32 $685.31

51 $1,304.61 $923.41 $766.80 $766.80 $766.80 $766.80 $715.62

52 $1,365.47 $966.49 $802.57 $802.57 $802.57 $802.57 $749.00

53 $1,427.03 $1,010.06 $838.75 $838.75 $838.75 $838.75 $782.77

54 $1,493.48 $1,057.10 $877.81 $877.81 $877.81 $877.81 $819.22

55 $1,559.94 $1,104.13 $916.87 $916.87 $916.87 $916.87 $855.68

56 $1,631.99 $1,155.13 $959.22 $959.22 $959.22 $959.22 $895.20

57 $1,704.74 $1,206.63 $1,001.98 $1,001.98 $1,001.98 $1,001.98 $935.10

58 $1,782.39 $1,261.59 $1,047.62 $1,047.62 $1,047.62 $1,047.62 $977.70

59 $1,820.86 $1,288.82 $1,070.23 $1,070.23 $1,070.23 $1,070.23 $998.80

60 $1,898.51 $1,343.78 $1,115.87 $1,115.87 $1,115.87 $1,115.87 $1,041.39

61 $1,965.66 $1,391.31 $1,155.34 $1,155.34 $1,155.34 $1,155.34 $1,078.23

62 $2,009.73 $1,422.50 $1,181.25 $1,181.25 $1,181.25 $1,181.25 $1,102.40

63 $2,064.99 $1,461.62 $1,213.73 $1,213.73 $1,213.73 $1,213.73 $1,132.72

64+ $2,098.57 $1,485.38 $1,233.46 $1,233.46 $1,233.46 $1,233.46 $1,151.13



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $570.82 $424.69 $361.29 $361.29 $361.29 $361.29

15 $621.56 $462.44 $393.41 $393.41 $393.41 $393.41

16 $640.96 $476.88 $405.69 $405.69 $405.69 $405.69

17 $660.36 $491.31 $417.97 $417.97 $417.97 $417.97

18 $681.26 $506.86 $431.19 $431.19 $431.19 $431.19

19 $702.15 $522.40 $444.42 $444.42 $444.42 $444.42

20 $723.79 $538.50 $458.11 $458.11 $458.11 $458.11

21 $746.17 $555.15 $472.28 $472.28 $472.28 $472.28

22 $746.17 $555.15 $472.28 $472.28 $472.28 $472.28

23 $746.17 $555.15 $472.28 $472.28 $472.28 $472.28

24 $746.17 $555.15 $472.28 $472.28 $472.28 $472.28

25 $749.16 $557.38 $474.17 $474.17 $474.17 $474.17

26 $764.08 $568.48 $483.62 $483.62 $483.62 $483.62

27 $781.99 $581.80 $494.95 $494.95 $494.95 $494.95

28 $811.09 $603.45 $513.37 $513.37 $513.37 $513.37

29 $834.97 $621.22 $528.48 $528.48 $528.48 $528.48

30 $846.91 $630.10 $536.04 $536.04 $536.04 $536.04

31 $864.81 $643.42 $547.37 $547.37 $547.37 $547.37

32 $882.72 $656.75 $558.71 $558.71 $558.71 $558.71

33 $893.92 $665.08 $565.79 $565.79 $565.79 $565.79

34 $905.85 $673.96 $573.35 $573.35 $573.35 $573.35

35 $911.82 $678.40 $577.13 $577.13 $577.13 $577.13

36 $917.79 $682.84 $580.91 $580.91 $580.91 $580.91

37 $923.76 $687.28 $584.68 $584.68 $584.68 $584.68

38 $929.73 $691.72 $588.46 $588.46 $588.46 $588.46

39 $941.67 $700.61 $596.02 $596.02 $596.02 $596.02

40 $953.61 $709.49 $603.57 $603.57 $603.57 $603.57

41 $971.52 $722.81 $614.91 $614.91 $614.91 $614.91

42 $988.68 $735.58 $625.77 $625.77 $625.77 $625.77

43 $1,012.56 $753.35 $640.89 $640.89 $640.89 $640.89

44 $1,042.40 $775.55 $659.78 $659.78 $659.78 $659.78

45 $1,077.47 $801.64 $681.97 $681.97 $681.97 $681.97

46 $1,119.26 $832.73 $708.42 $708.42 $708.42 $708.42

47 $1,166.27 $867.71 $738.17 $738.17 $738.17 $738.17

48 $1,219.99 $907.68 $772.18 $772.18 $772.18 $772.18

49 $1,272.97 $947.09 $805.71 $805.71 $805.71 $805.71

50 $1,332.67 $991.51 $843.49 $843.49 $843.49 $843.49

51 $1,391.61 $1,035.36 $880.80 $880.80 $880.80 $880.80

52 $1,456.53 $1,083.66 $921.89 $921.89 $921.89 $921.89

53 $1,522.19 $1,132.52 $963.45 $963.45 $963.45 $963.45

54 $1,593.08 $1,185.26 $1,008.32 $1,008.32 $1,008.32 $1,008.32

55 $1,663.97 $1,238.00 $1,053.19 $1,053.19 $1,053.19 $1,053.19

56 $1,740.82 $1,295.18 $1,101.83 $1,101.83 $1,101.83 $1,101.83

57 $1,818.42 $1,352.91 $1,150.95 $1,150.95 $1,150.95 $1,150.95

58 $1,901.25 $1,414.53 $1,203.37 $1,203.37 $1,203.37 $1,203.37

59 $1,942.29 $1,445.07 $1,229.35 $1,229.35 $1,229.35 $1,229.35

60 $2,025.11 $1,506.69 $1,281.77 $1,281.77 $1,281.77 $1,281.77

61 $2,096.75 $1,559.99 $1,327.11 $1,327.11 $1,327.11 $1,327.11

62 $2,143.76 $1,594.96 $1,356.86 $1,356.86 $1,356.86 $1,356.86

63 $2,202.70 $1,638.82 $1,394.17 $1,394.17 $1,394.17 $1,394.17

64+ $2,238.52 $1,665.46 $1,416.84 $1,416.84 $1,416.84 $1,416.84




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $337.18 $313.91 $304.15 $281.18 $278.00 $271.08

15 $367.15 $341.82 $331.19 $306.18 $302.72 $295.18

16 $378.61 $352.49 $341.53 $315.73 $312.16 $304.39

17 $390.07 $363.16 $351.87 $325.29 $321.61 $313.60

18 $402.41 $374.64 $363.00 $335.58 $331.79 $323.53

19 $414.75 $386.13 $374.13 $345.87 $341.96 $333.45

20 $427.54 $398.03 $385.66 $356.53 $352.50 $343.72

21 $440.76 $410.34 $397.59 $367.56 $363.40 $354.35

22 $440.76 $410.34 $397.59 $367.56 $363.40 $354.35

23 $440.76 $410.34 $397.59 $367.56 $363.40 $354.35

24 $440.76 $410.34 $397.59 $367.56 $363.40 $354.35

25 $442.52 $411.99 $399.18 $369.03 $364.86 $355.77

26 $451.34 $420.19 $407.13 $376.38 $372.13 $362.86

27 $461.91 $430.04 $416.67 $385.20 $380.85 $371.36

28 $479.10 $446.04 $432.18 $399.54 $395.02 $385.18

29 $493.21 $459.18 $444.90 $411.30 $406.65 $396.52

30 $500.26 $465.74 $451.26 $417.18 $412.46 $402.19

31 $510.84 $475.59 $460.80 $426.00 $421.18 $410.70

32 $521.42 $485.44 $470.35 $434.82 $429.91 $419.20

33 $528.03 $491.59 $476.31 $440.34 $435.36 $424.52

34 $535.08 $498.16 $482.67 $446.22 $441.17 $430.19

35 $538.61 $501.44 $485.85 $449.16 $444.08 $433.02

36 $542.13 $504.72 $489.03 $452.10 $446.99 $435.86

37 $545.66 $508.01 $492.21 $455.04 $449.89 $438.69

38 $549.18 $511.29 $495.39 $457.98 $452.80 $441.53

39 $556.24 $517.86 $501.76 $463.86 $458.62 $447.20

40 $563.29 $524.42 $508.12 $469.74 $464.43 $452.86

41 $573.87 $534.27 $517.66 $478.56 $473.15 $461.37

42 $584.00 $543.71 $526.80 $487.02 $481.51 $469.52

43 $598.11 $556.84 $539.53 $498.78 $493.14 $480.86

44 $615.74 $573.25 $555.43 $513.48 $507.67 $495.03

45 $636.45 $592.54 $574.12 $530.76 $524.75 $511.69

46 $661.14 $615.52 $596.38 $551.34 $545.11 $531.53

47 $688.90 $641.37 $621.43 $574.50 $568.00 $553.86

48 $720.64 $670.91 $650.06 $600.96 $594.16 $579.37

49 $751.93 $700.05 $678.29 $627.06 $619.97 $604.53

50 $787.19 $732.88 $710.09 $656.46 $649.04 $632.88

51 $822.01 $765.29 $741.50 $685.50 $677.75 $660.87

52 $860.36 $800.99 $776.09 $717.48 $709.36 $691.70

53 $899.15 $837.10 $811.08 $749.82 $741.34 $722.88

54 $941.02 $876.09 $848.85 $784.74 $775.87 $756.55

55 $982.89 $915.07 $886.62 $819.66 $810.39 $790.21

56 $1,028.29 $957.33 $927.57 $857.52 $847.82 $826.71

57 $1,074.13 $1,000.01 $968.92 $895.74 $885.61 $863.56

58 $1,123.05 $1,045.56 $1,013.05 $936.54 $925.95 $902.89

59 $1,147.29 $1,068.13 $1,034.92 $956.76 $945.94 $922.38

60 $1,196.22 $1,113.68 $1,079.05 $997.56 $986.28 $961.72

61 $1,238.53 $1,153.07 $1,117.22 $1,032.84 $1,021.16 $995.74

62 $1,266.30 $1,178.92 $1,142.27 $1,056.00 $1,044.06 $1,018.06

63 $1,301.12 $1,211.34 $1,173.68 $1,085.04 $1,072.77 $1,046.05

64+ $1,322.27 $1,231.03 $1,192.76 $1,102.68 $1,090.21 $1,063.06




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $581.41 $411.53 $341.73 $341.73 $341.73 $341.73 $318.92

15 $633.10 $448.11 $372.11 $372.11 $372.11 $372.11 $347.27

16 $652.86 $462.10 $383.73 $383.73 $383.73 $383.73 $358.11

17 $672.62 $476.08 $395.34 $395.34 $395.34 $395.34 $368.95

18 $693.90 $491.15 $407.85 $407.85 $407.85 $407.85 $380.63

19 $715.18 $506.21 $420.36 $420.36 $420.36 $420.36 $392.30

20 $737.22 $521.81 $433.31 $433.31 $433.31 $433.31 $404.39

21 $760.02 $537.95 $446.71 $446.71 $446.71 $446.71 $416.90

22 $760.02 $537.95 $446.71 $446.71 $446.71 $446.71 $416.90

23 $760.02 $537.95 $446.71 $446.71 $446.71 $446.71 $416.90

24 $760.02 $537.95 $446.71 $446.71 $446.71 $446.71 $416.90

25 $763.06 $540.10 $448.50 $448.50 $448.50 $448.50 $418.56

26 $778.26 $550.86 $457.43 $457.43 $457.43 $457.43 $426.90

27 $796.50 $563.77 $468.15 $468.15 $468.15 $468.15 $436.91

28 $826.14 $584.75 $485.58 $485.58 $485.58 $485.58 $453.17

29 $850.46 $601.96 $499.87 $499.87 $499.87 $499.87 $466.51

30 $862.62 $610.57 $507.02 $507.02 $507.02 $507.02 $473.18

31 $880.86 $623.48 $517.74 $517.74 $517.74 $517.74 $483.18

32 $899.10 $636.39 $528.46 $528.46 $528.46 $528.46 $493.19

33 $910.50 $644.46 $535.16 $535.16 $535.16 $535.16 $499.44

34 $922.66 $653.07 $542.31 $542.31 $542.31 $542.31 $506.11

35 $928.74 $657.37 $545.88 $545.88 $545.88 $545.88 $509.45

36 $934.82 $661.68 $549.46 $549.46 $549.46 $549.46 $512.78

37 $940.90 $665.98 $553.03 $553.03 $553.03 $553.03 $516.12

38 $946.98 $670.28 $556.60 $556.60 $556.60 $556.60 $519.45

39 $959.14 $678.89 $563.75 $563.75 $563.75 $563.75 $526.12

40 $971.30 $687.50 $570.90 $570.90 $570.90 $570.90 $532.79

41 $989.55 $700.41 $581.62 $581.62 $581.62 $581.62 $542.80

42 $1,007.03 $712.78 $591.89 $591.89 $591.89 $591.89 $552.39

43 $1,031.35 $729.99 $606.19 $606.19 $606.19 $606.19 $565.73

44 $1,061.75 $751.51 $624.06 $624.06 $624.06 $624.06 $582.40

45 $1,097.47 $776.80 $645.05 $645.05 $645.05 $645.05 $602.00

46 $1,140.03 $806.92 $670.07 $670.07 $670.07 $670.07 $625.34

47 $1,187.91 $840.81 $698.21 $698.21 $698.21 $698.21 $651.61

48 $1,242.63 $879.54 $730.37 $730.37 $730.37 $730.37 $681.62

49 $1,296.59 $917.74 $762.09 $762.09 $762.09 $762.09 $711.22

50 $1,357.39 $960.77 $797.83 $797.83 $797.83 $797.83 $744.58

51 $1,417.44 $1,003.27 $833.12 $833.12 $833.12 $833.12 $777.51

52 $1,483.56 $1,050.07 $871.98 $871.98 $871.98 $871.98 $813.78

53 $1,550.44 $1,097.41 $911.29 $911.29 $911.29 $911.29 $850.47

54 $1,622.64 $1,148.52 $953.73 $953.73 $953.73 $953.73 $890.07

55 $1,694.84 $1,199.62 $996.17 $996.17 $996.17 $996.17 $929.68

56 $1,773.13 $1,255.03 $1,042.18 $1,042.18 $1,042.18 $1,042.18 $972.62

57 $1,852.17 $1,310.98 $1,088.64 $1,088.64 $1,088.64 $1,088.64 $1,015.97

58 $1,936.53 $1,370.69 $1,138.22 $1,138.22 $1,138.22 $1,138.22 $1,062.25

59 $1,978.33 $1,400.28 $1,162.79 $1,162.79 $1,162.79 $1,162.79 $1,085.18

60 $2,062.69 $1,459.99 $1,212.38 $1,212.38 $1,212.38 $1,212.38 $1,131.45

61 $2,135.65 $1,511.63 $1,255.26 $1,255.26 $1,255.26 $1,255.26 $1,171.48

62 $2,183.54 $1,545.52 $1,283.40 $1,283.40 $1,283.40 $1,283.40 $1,197.74

63 $2,243.58 $1,588.02 $1,318.69 $1,318.69 $1,318.69 $1,318.69 $1,230.67

64+ $2,280.06 $1,613.84 $1,340.14 $1,340.14 $1,340.14 $1,340.14 $1,250.69



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $361.89 $269.25 $229.05 $229.05 $229.05 $229.05

15 $394.06 $293.18 $249.41 $249.41 $249.41 $249.41

16 $406.36 $302.33 $257.20 $257.20 $257.20 $257.20

17 $418.66 $311.48 $264.98 $264.98 $264.98 $264.98

18 $431.90 $321.34 $273.37 $273.37 $273.37 $273.37

19 $445.15 $331.19 $281.75 $281.75 $281.75 $281.75

20 $458.87 $341.40 $290.43 $290.43 $290.43 $290.43

21 $473.06 $351.96 $299.42 $299.42 $299.42 $299.42

22 $473.06 $351.96 $299.42 $299.42 $299.42 $299.42

23 $473.06 $351.96 $299.42 $299.42 $299.42 $299.42

24 $473.06 $351.96 $299.42 $299.42 $299.42 $299.42

25 $474.95 $353.36 $300.61 $300.61 $300.61 $300.61

26 $484.41 $360.40 $306.60 $306.60 $306.60 $306.60

27 $495.76 $368.85 $313.79 $313.79 $313.79 $313.79

28 $514.21 $382.58 $325.47 $325.47 $325.47 $325.47

29 $529.35 $393.84 $335.05 $335.05 $335.05 $335.05

30 $536.92 $399.47 $339.84 $339.84 $339.84 $339.84

31 $548.27 $407.92 $347.02 $347.02 $347.02 $347.02

32 $559.63 $416.36 $354.21 $354.21 $354.21 $354.21

33 $566.72 $421.64 $358.70 $358.70 $358.70 $358.70

34 $574.29 $427.28 $363.49 $363.49 $363.49 $363.49

35 $578.08 $430.09 $365.89 $365.89 $365.89 $365.89

36 $581.86 $432.91 $368.28 $368.28 $368.28 $368.28

37 $585.65 $435.72 $370.68 $370.68 $370.68 $370.68

38 $589.43 $438.54 $373.07 $373.07 $373.07 $373.07

39 $597.00 $444.17 $377.86 $377.86 $377.86 $377.86

40 $604.57 $449.80 $382.65 $382.65 $382.65 $382.65

41 $615.92 $458.25 $389.84 $389.84 $389.84 $389.84

42 $626.80 $466.34 $396.73 $396.73 $396.73 $396.73

43 $641.94 $477.61 $406.31 $406.31 $406.31 $406.31

44 $660.86 $491.68 $418.28 $418.28 $418.28 $418.28

45 $683.10 $508.23 $432.36 $432.36 $432.36 $432.36

46 $709.59 $527.93 $449.12 $449.12 $449.12 $449.12

47 $739.39 $550.11 $467.99 $467.99 $467.99 $467.99

48 $773.45 $575.45 $489.55 $489.55 $489.55 $489.55

49 $807.04 $600.44 $510.80 $510.80 $510.80 $510.80

50 $844.88 $628.59 $534.76 $534.76 $534.76 $534.76

51 $882.25 $656.40 $558.41 $558.41 $558.41 $558.41

52 $923.41 $687.02 $584.46 $584.46 $584.46 $584.46

53 $965.04 $717.99 $610.81 $610.81 $610.81 $610.81

54 $1,009.98 $751.43 $639.25 $639.25 $639.25 $639.25

55 $1,054.92 $784.86 $667.70 $667.70 $667.70 $667.70

56 $1,103.64 $821.11 $698.54 $698.54 $698.54 $698.54

57 $1,152.84 $857.72 $729.68 $729.68 $729.68 $729.68

58 $1,205.35 $896.79 $762.91 $762.91 $762.91 $762.91

59 $1,231.37 $916.14 $779.38 $779.38 $779.38 $779.38

60 $1,283.88 $955.21 $812.62 $812.62 $812.62 $812.62

61 $1,329.29 $989.00 $841.36 $841.36 $841.36 $841.36

62 $1,359.10 $1,011.17 $860.22 $860.22 $860.22 $860.22

63 $1,396.47 $1,038.98 $883.88 $883.88 $883.88 $883.88

64+ $1,419.17 $1,055.87 $898.25 $898.25 $898.25 $898.25




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $213.76 $199.01 $192.83 $178.26 $176.25 $171.86

15 $232.77 $216.71 $209.97 $194.11 $191.92 $187.14

16 $240.03 $223.47 $216.52 $200.17 $197.91 $192.98

17 $247.30 $230.23 $223.08 $206.23 $203.90 $198.82

18 $255.12 $237.52 $230.13 $212.75 $210.35 $205.11

19 $262.94 $244.80 $237.19 $219.28 $216.80 $211.40

20 $271.05 $252.35 $244.50 $226.03 $223.48 $217.91

21 $279.43 $260.15 $252.06 $233.03 $230.39 $224.65

22 $279.43 $260.15 $252.06 $233.03 $230.39 $224.65

23 $279.43 $260.15 $252.06 $233.03 $230.39 $224.65

24 $279.43 $260.15 $252.06 $233.03 $230.39 $224.65

25 $280.55 $261.19 $253.07 $233.96 $231.31 $225.55

26 $286.14 $266.39 $258.11 $238.62 $235.92 $230.04

27 $292.84 $272.64 $264.16 $244.21 $241.45 $235.44

28 $303.74 $282.78 $273.99 $253.30 $250.43 $244.20

29 $312.68 $291.11 $282.06 $260.76 $257.81 $251.39

30 $317.15 $295.27 $286.09 $264.48 $261.49 $254.98

31 $323.86 $301.51 $292.14 $270.08 $267.02 $260.37

32 $330.57 $307.76 $298.19 $275.67 $272.55 $265.76

33 $334.76 $311.66 $301.97 $279.16 $276.01 $269.13

34 $339.23 $315.82 $306.00 $282.89 $279.69 $272.73

35 $341.46 $317.90 $308.02 $284.76 $281.54 $274.53

36 $343.70 $319.98 $310.04 $286.62 $283.38 $276.32

37 $345.94 $322.07 $312.05 $288.49 $285.22 $278.12

38 $348.17 $324.15 $314.07 $290.35 $287.07 $279.92

39 $352.64 $328.31 $318.10 $294.08 $290.75 $283.51

40 $357.11 $332.47 $322.14 $297.81 $294.44 $287.11

41 $363.82 $338.72 $328.19 $303.40 $299.97 $292.50

42 $370.25 $344.70 $333.98 $308.76 $305.27 $297.67

43 $379.19 $353.02 $342.05 $316.22 $312.64 $304.85

44 $390.37 $363.43 $352.13 $325.54 $321.86 $313.84

45 $403.50 $375.66 $363.98 $336.49 $332.68 $324.40

46 $419.15 $390.23 $378.09 $349.54 $345.59 $336.98

47 $436.75 $406.61 $393.97 $364.22 $360.10 $351.13

48 $456.87 $425.35 $412.12 $381.00 $376.69 $367.31

49 $476.71 $443.82 $430.02 $397.54 $393.05 $383.26

50 $499.06 $464.63 $450.18 $416.18 $411.48 $401.23

51 $521.14 $485.18 $470.10 $434.59 $429.68 $418.98

52 $545.45 $507.81 $492.03 $454.87 $449.72 $438.52

53 $570.04 $530.71 $514.21 $475.37 $470.00 $458.29

54 $596.59 $555.42 $538.15 $497.51 $491.88 $479.63

55 $623.13 $580.13 $562.10 $519.65 $513.77 $500.98

56 $651.91 $606.93 $588.06 $543.65 $537.50 $524.12

57 $680.97 $633.99 $614.28 $567.88 $561.46 $547.48

58 $711.99 $662.86 $642.26 $593.75 $587.03 $572.42

59 $727.36 $677.17 $656.12 $606.56 $599.71 $584.77

60 $758.38 $706.05 $684.10 $632.43 $625.28 $609.71

61 $785.20 $731.02 $708.30 $654.80 $647.40 $631.28

62 $802.81 $747.41 $724.18 $669.48 $661.91 $645.43

63 $824.88 $767.96 $744.09 $687.89 $680.11 $663.18

64+ $838.29 $780.45 $756.19 $699.08 $691.17 $673.96




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $541.90 $383.56 $318.51 $318.51 $318.51 $318.51 $297.25

15 $590.06 $417.65 $346.82 $346.82 $346.82 $346.82 $323.67

16 $608.48 $430.69 $357.64 $357.64 $357.64 $357.64 $333.77

17 $626.90 $443.72 $368.47 $368.47 $368.47 $368.47 $343.87

18 $646.73 $457.76 $380.13 $380.13 $380.13 $380.13 $354.75

19 $666.57 $471.80 $391.78 $391.78 $391.78 $391.78 $365.63

20 $687.11 $486.34 $403.86 $403.86 $403.86 $403.86 $376.90

21 $708.36 $501.38 $416.35 $416.35 $416.35 $416.35 $388.56

22 $708.36 $501.38 $416.35 $416.35 $416.35 $416.35 $388.56

23 $708.36 $501.38 $416.35 $416.35 $416.35 $416.35 $388.56

24 $708.36 $501.38 $416.35 $416.35 $416.35 $416.35 $388.56

25 $711.19 $503.39 $418.01 $418.01 $418.01 $418.01 $390.11

26 $725.36 $513.42 $426.34 $426.34 $426.34 $426.34 $397.88

27 $742.36 $525.45 $436.33 $436.33 $436.33 $436.33 $407.21

28 $769.99 $545.00 $452.57 $452.57 $452.57 $452.57 $422.36

29 $792.65 $561.05 $465.89 $465.89 $465.89 $465.89 $434.80

30 $803.99 $569.07 $472.56 $472.56 $472.56 $472.56 $441.01

31 $820.99 $581.10 $482.55 $482.55 $482.55 $482.55 $450.34

32 $837.99 $593.14 $492.54 $492.54 $492.54 $492.54 $459.66

33 $848.62 $600.66 $498.79 $498.79 $498.79 $498.79 $465.49

34 $859.95 $608.68 $505.45 $505.45 $505.45 $505.45 $471.71

35 $865.62 $612.69 $508.78 $508.78 $508.78 $508.78 $474.82

36 $871.28 $616.70 $512.11 $512.11 $512.11 $512.11 $477.93

37 $876.95 $620.71 $515.44 $515.44 $515.44 $515.44 $481.04

38 $882.62 $624.72 $518.77 $518.77 $518.77 $518.77 $484.14

39 $893.95 $632.74 $525.43 $525.43 $525.43 $525.43 $490.36

40 $905.28 $640.77 $532.09 $532.09 $532.09 $532.09 $496.58

41 $922.28 $652.80 $542.09 $542.09 $542.09 $542.09 $505.90

42 $938.58 $664.33 $551.66 $551.66 $551.66 $551.66 $514.84

43 $961.24 $680.38 $564.98 $564.98 $564.98 $564.98 $527.27

44 $989.58 $700.43 $581.64 $581.64 $581.64 $581.64 $542.82

45 $1,022.87 $724.00 $601.21 $601.21 $601.21 $601.21 $561.08

46 $1,062.54 $752.07 $624.52 $624.52 $624.52 $624.52 $582.84

47 $1,107.17 $783.66 $650.75 $650.75 $650.75 $650.75 $607.32

48 $1,158.17 $819.76 $680.73 $680.73 $680.73 $680.73 $635.29

49 $1,208.46 $855.36 $710.29 $710.29 $710.29 $710.29 $662.88

50 $1,265.13 $895.47 $743.60 $743.60 $743.60 $743.60 $693.97

51 $1,321.09 $935.08 $776.49 $776.49 $776.49 $776.49 $724.66

52 $1,382.72 $978.70 $812.71 $812.71 $812.71 $812.71 $758.47

53 $1,445.05 $1,022.82 $849.35 $849.35 $849.35 $849.35 $792.66

54 $1,512.35 $1,070.45 $888.90 $888.90 $888.90 $888.90 $829.57

55 $1,579.64 $1,118.08 $928.46 $928.46 $928.46 $928.46 $866.49

56 $1,652.60 $1,169.73 $971.34 $971.34 $971.34 $971.34 $906.51

57 $1,726.27 $1,221.87 $1,014.64 $1,014.64 $1,014.64 $1,014.64 $946.92

58 $1,804.90 $1,277.52 $1,060.86 $1,060.86 $1,060.86 $1,060.86 $990.05

59 $1,843.86 $1,305.10 $1,083.75 $1,083.75 $1,083.75 $1,083.75 $1,011.42

60 $1,922.49 $1,360.75 $1,129.97 $1,129.97 $1,129.97 $1,129.97 $1,054.55

61 $1,990.49 $1,408.88 $1,169.94 $1,169.94 $1,169.94 $1,169.94 $1,091.85

62 $2,035.12 $1,440.47 $1,196.17 $1,196.17 $1,196.17 $1,196.17 $1,116.33

63 $2,091.08 $1,480.08 $1,229.06 $1,229.06 $1,229.06 $1,229.06 $1,147.02

64+ $2,125.08 $1,504.15 $1,249.04 $1,249.04 $1,249.04 $1,249.04 $1,165.68



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $499.96 $371.97 $316.44 $316.44 $316.44 $316.44

15 $544.40 $405.03 $344.57 $344.57 $344.57 $344.57

16 $561.39 $417.68 $355.32 $355.32 $355.32 $355.32

17 $578.38 $430.32 $366.08 $366.08 $366.08 $366.08

18 $596.68 $443.93 $377.66 $377.66 $377.66 $377.66

19 $614.98 $457.55 $389.24 $389.24 $389.24 $389.24

20 $633.93 $471.65 $401.24 $401.24 $401.24 $401.24

21 $653.54 $486.23 $413.65 $413.65 $413.65 $413.65

22 $653.54 $486.23 $413.65 $413.65 $413.65 $413.65

23 $653.54 $486.23 $413.65 $413.65 $413.65 $413.65

24 $653.54 $486.23 $413.65 $413.65 $413.65 $413.65

25 $656.15 $488.18 $415.30 $415.30 $415.30 $415.30

26 $669.22 $497.90 $423.58 $423.58 $423.58 $423.58

27 $684.91 $509.57 $433.50 $433.50 $433.50 $433.50

28 $710.40 $528.54 $449.64 $449.64 $449.64 $449.64

29 $731.31 $544.10 $462.87 $462.87 $462.87 $462.87

30 $741.77 $551.88 $469.49 $469.49 $469.49 $469.49

31 $757.45 $563.55 $479.42 $479.42 $479.42 $479.42

32 $773.14 $575.22 $489.35 $489.35 $489.35 $489.35

33 $782.94 $582.51 $495.55 $495.55 $495.55 $495.55

34 $793.40 $590.29 $502.17 $502.17 $502.17 $502.17

35 $798.62 $594.18 $505.48 $505.48 $505.48 $505.48

36 $803.85 $598.07 $508.79 $508.79 $508.79 $508.79

37 $809.08 $601.96 $512.10 $512.10 $512.10 $512.10

38 $814.31 $605.85 $515.41 $515.41 $515.41 $515.41

39 $824.77 $613.63 $522.03 $522.03 $522.03 $522.03

40 $835.22 $621.41 $528.64 $528.64 $528.64 $528.64

41 $850.91 $633.08 $538.57 $538.57 $538.57 $538.57

42 $865.94 $644.26 $548.09 $548.09 $548.09 $548.09

43 $886.85 $659.82 $561.32 $561.32 $561.32 $561.32

44 $912.99 $679.27 $577.87 $577.87 $577.87 $577.87

45 $943.71 $702.12 $597.31 $597.31 $597.31 $597.31

46 $980.31 $729.35 $620.47 $620.47 $620.47 $620.47

47 $1,021.48 $759.99 $646.53 $646.53 $646.53 $646.53

48 $1,068.54 $794.99 $676.32 $676.32 $676.32 $676.32

49 $1,114.94 $829.52 $705.69 $705.69 $705.69 $705.69

50 $1,167.22 $868.42 $738.78 $738.78 $738.78 $738.78

51 $1,218.85 $906.83 $771.46 $771.46 $771.46 $771.46

52 $1,275.71 $949.13 $807.44 $807.44 $807.44 $807.44

53 $1,333.22 $991.92 $843.84 $843.84 $843.84 $843.84

54 $1,395.31 $1,038.11 $883.14 $883.14 $883.14 $883.14

55 $1,457.39 $1,084.30 $922.44 $922.44 $922.44 $922.44

56 $1,524.71 $1,134.39 $965.04 $965.04 $965.04 $965.04

57 $1,592.67 $1,184.95 $1,008.06 $1,008.06 $1,008.06 $1,008.06

58 $1,665.22 $1,238.93 $1,053.98 $1,053.98 $1,053.98 $1,053.98

59 $1,701.16 $1,265.67 $1,076.73 $1,076.73 $1,076.73 $1,076.73

60 $1,773.70 $1,319.64 $1,122.64 $1,122.64 $1,122.64 $1,122.64

61 $1,836.44 $1,366.32 $1,162.35 $1,162.35 $1,162.35 $1,162.35

62 $1,877.62 $1,396.95 $1,188.41 $1,188.41 $1,188.41 $1,188.41

63 $1,929.25 $1,435.37 $1,221.09 $1,221.09 $1,221.09 $1,221.09

64+ $1,960.62 $1,458.70 $1,240.95 $1,240.95 $1,240.95 $1,240.95




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $295.32 $274.94 $266.40 $246.28 $243.49 $237.43

15 $321.57 $299.38 $290.07 $268.17 $265.13 $258.53

16 $331.61 $308.73 $299.13 $276.54 $273.41 $266.60

17 $341.65 $318.07 $308.18 $284.91 $281.69 $274.67

18 $352.45 $328.13 $317.93 $293.92 $290.60 $283.36

19 $363.26 $338.20 $327.68 $302.94 $299.51 $292.05

20 $374.46 $348.62 $337.78 $312.27 $308.74 $301.05

21 $386.04 $359.40 $348.23 $321.93 $318.29 $310.36

22 $386.04 $359.40 $348.23 $321.93 $318.29 $310.36

23 $386.04 $359.40 $348.23 $321.93 $318.29 $310.36

24 $386.04 $359.40 $348.23 $321.93 $318.29 $310.36

25 $387.58 $360.84 $349.62 $323.22 $319.56 $311.60

26 $395.30 $368.03 $356.59 $329.66 $325.93 $317.81

27 $404.57 $376.65 $364.94 $337.38 $333.57 $325.26

28 $419.63 $390.67 $378.53 $349.94 $345.98 $337.36

29 $431.98 $402.17 $389.67 $360.24 $356.16 $347.30

30 $438.16 $407.92 $395.24 $365.39 $361.26 $352.26

31 $447.42 $416.55 $403.60 $373.12 $368.90 $359.71

32 $456.68 $425.17 $411.96 $380.84 $376.54 $367.16

33 $462.48 $430.56 $417.18 $385.67 $381.31 $371.81

34 $468.65 $436.31 $422.75 $390.82 $386.40 $376.78

35 $471.74 $439.19 $425.54 $393.40 $388.95 $379.26

36 $474.83 $442.07 $428.32 $395.97 $391.49 $381.75

37 $477.92 $444.94 $431.11 $398.55 $394.04 $384.23

38 $481.01 $447.82 $433.89 $401.12 $396.59 $386.71

39 $487.18 $453.57 $439.47 $406.27 $401.68 $391.68

40 $493.36 $459.32 $445.04 $411.43 $406.77 $396.64

41 $502.62 $467.94 $453.39 $419.15 $414.41 $404.09

42 $511.50 $476.21 $461.40 $426.56 $421.73 $411.23

43 $523.86 $487.71 $472.55 $436.86 $431.92 $421.16

44 $539.30 $502.09 $486.48 $449.73 $444.65 $433.58

45 $557.44 $518.98 $502.84 $464.87 $459.61 $448.16

46 $579.06 $539.10 $522.34 $482.89 $477.43 $465.54

47 $603.38 $561.75 $544.28 $503.17 $497.49 $485.10

48 $631.17 $587.62 $569.35 $526.35 $520.40 $507.44

49 $658.58 $613.14 $594.08 $549.21 $543.00 $529.48

50 $689.47 $641.89 $621.94 $574.96 $568.46 $554.31

51 $719.96 $670.29 $649.45 $600.40 $593.61 $578.83

52 $753.55 $701.55 $679.74 $628.41 $621.30 $605.83

53 $787.52 $733.18 $710.39 $656.73 $649.31 $633.14

54 $824.19 $767.32 $743.47 $687.32 $679.55 $662.62

55 $860.87 $801.47 $776.55 $717.90 $709.78 $692.11

56 $900.63 $838.49 $812.42 $751.06 $742.57 $724.08

57 $940.78 $875.86 $848.63 $784.54 $775.67 $756.35

58 $983.63 $915.76 $887.29 $820.27 $811.00 $790.80

59 $1,004.86 $935.52 $906.44 $837.98 $828.51 $807.87

60 $1,047.71 $975.42 $945.09 $873.71 $863.84 $842.32

61 $1,084.77 $1,009.92 $978.52 $904.62 $894.39 $872.12

62 $1,109.09 $1,032.56 $1,000.46 $924.90 $914.44 $891.67

63 $1,139.59 $1,060.96 $1,027.97 $950.33 $939.59 $916.19

64+ $1,158.12 $1,078.21 $1,044.69 $965.79 $954.87 $931.09




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $452.83 $320.52 $266.16 $266.16 $266.16 $266.16 $248.39

15 $493.09 $349.01 $289.82 $289.82 $289.82 $289.82 $270.47

16 $508.48 $359.90 $298.86 $298.86 $298.86 $298.86 $278.92

17 $523.87 $370.80 $307.91 $307.91 $307.91 $307.91 $287.36

18 $540.44 $382.53 $317.65 $317.65 $317.65 $317.65 $296.45

19 $557.01 $394.26 $327.39 $327.39 $327.39 $327.39 $305.54

20 $574.18 $406.41 $337.48 $337.48 $337.48 $337.48 $314.96

21 $591.94 $418.98 $347.92 $347.92 $347.92 $347.92 $324.70

22 $591.94 $418.98 $347.92 $347.92 $347.92 $347.92 $324.70

23 $591.94 $418.98 $347.92 $347.92 $347.92 $347.92 $324.70

24 $591.94 $418.98 $347.92 $347.92 $347.92 $347.92 $324.70

25 $594.31 $420.65 $349.31 $349.31 $349.31 $349.31 $326.00

26 $606.15 $429.03 $356.27 $356.27 $356.27 $356.27 $332.49

27 $620.35 $439.09 $364.62 $364.62 $364.62 $364.62 $340.28

28 $643.44 $455.43 $378.19 $378.19 $378.19 $378.19 $352.95

29 $662.38 $468.84 $389.32 $389.32 $389.32 $389.32 $363.34

30 $671.85 $475.54 $394.89 $394.89 $394.89 $394.89 $368.53

31 $686.06 $485.60 $403.24 $403.24 $403.24 $403.24 $376.32

32 $700.26 $495.65 $411.59 $411.59 $411.59 $411.59 $384.12

33 $709.14 $501.94 $416.81 $416.81 $416.81 $416.81 $388.99

34 $718.61 $508.64 $422.37 $422.37 $422.37 $422.37 $394.18

35 $723.35 $511.99 $425.16 $425.16 $425.16 $425.16 $396.78

36 $728.08 $515.34 $427.94 $427.94 $427.94 $427.94 $399.38

37 $732.82 $518.70 $430.72 $430.72 $430.72 $430.72 $401.98

38 $737.56 $522.05 $433.51 $433.51 $433.51 $433.51 $404.57

39 $747.03 $528.75 $439.08 $439.08 $439.08 $439.08 $409.77

40 $756.50 $535.45 $444.64 $444.64 $444.64 $444.64 $414.96

41 $770.70 $545.51 $452.99 $452.99 $452.99 $452.99 $422.76

42 $784.32 $555.15 $460.99 $460.99 $460.99 $460.99 $430.22

43 $803.26 $568.55 $472.13 $472.13 $472.13 $472.13 $440.61

44 $826.94 $585.31 $486.04 $486.04 $486.04 $486.04 $453.60

45 $854.76 $605.01 $502.40 $502.40 $502.40 $502.40 $468.86

46 $887.91 $628.47 $521.88 $521.88 $521.88 $521.88 $487.05

47 $925.20 $654.86 $543.80 $543.80 $543.80 $543.80 $507.50

48 $967.82 $685.03 $568.85 $568.85 $568.85 $568.85 $530.88

49 $1,009.85 $714.78 $593.55 $593.55 $593.55 $593.55 $553.93

50 $1,057.20 $748.30 $621.39 $621.39 $621.39 $621.39 $579.91

51 $1,103.97 $781.40 $648.87 $648.87 $648.87 $648.87 $605.56

52 $1,155.46 $817.85 $679.14 $679.14 $679.14 $679.14 $633.81

53 $1,207.56 $854.72 $709.76 $709.76 $709.76 $709.76 $662.38

54 $1,263.79 $894.52 $742.81 $742.81 $742.81 $742.81 $693.23

55 $1,320.02 $934.32 $775.86 $775.86 $775.86 $775.86 $724.08

56 $1,380.99 $977.48 $811.70 $811.70 $811.70 $811.70 $757.52

57 $1,442.56 $1,021.05 $847.88 $847.88 $847.88 $847.88 $791.29

58 $1,508.26 $1,067.56 $886.50 $886.50 $886.50 $886.50 $827.33

59 $1,540.82 $1,090.60 $905.64 $905.64 $905.64 $905.64 $845.19

60 $1,606.52 $1,137.11 $944.25 $944.25 $944.25 $944.25 $881.23

61 $1,663.35 $1,177.33 $977.66 $977.66 $977.66 $977.66 $912.40

62 $1,700.64 $1,203.73 $999.57 $999.57 $999.57 $999.57 $932.86

63 $1,747.40 $1,236.82 $1,027.06 $1,027.06 $1,027.06 $1,027.06 $958.51

64+ $1,775.82 $1,256.94 $1,043.76 $1,043.76 $1,043.76 $1,043.76 $974.09



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $557.04 $414.44 $352.57 $352.57 $352.57 $352.57

15 $606.55 $451.28 $383.91 $383.91 $383.91 $383.91

16 $625.48 $465.36 $395.89 $395.89 $395.89 $395.89

17 $644.41 $479.45 $407.87 $407.87 $407.87 $407.87

18 $664.80 $494.62 $420.78 $420.78 $420.78 $420.78

19 $685.19 $509.78 $433.68 $433.68 $433.68 $433.68

20 $706.31 $525.49 $447.05 $447.05 $447.05 $447.05

21 $728.15 $541.75 $460.87 $460.87 $460.87 $460.87

22 $728.15 $541.75 $460.87 $460.87 $460.87 $460.87

23 $728.15 $541.75 $460.87 $460.87 $460.87 $460.87

24 $728.15 $541.75 $460.87 $460.87 $460.87 $460.87

25 $731.06 $543.91 $462.72 $462.72 $462.72 $462.72

26 $745.63 $554.75 $471.94 $471.94 $471.94 $471.94

27 $763.10 $567.75 $483.00 $483.00 $483.00 $483.00

28 $791.50 $588.88 $500.97 $500.97 $500.97 $500.97

29 $814.80 $606.21 $515.72 $515.72 $515.72 $515.72

30 $826.45 $614.88 $523.09 $523.09 $523.09 $523.09

31 $843.93 $627.88 $534.15 $534.15 $534.15 $534.15

32 $861.40 $640.89 $545.21 $545.21 $545.21 $545.21

33 $872.33 $649.01 $552.13 $552.13 $552.13 $552.13

34 $883.98 $657.68 $559.50 $559.50 $559.50 $559.50

35 $889.80 $662.01 $563.19 $563.19 $563.19 $563.19

36 $895.63 $666.35 $566.88 $566.88 $566.88 $566.88

37 $901.45 $670.68 $570.56 $570.56 $570.56 $570.56

38 $907.28 $675.02 $574.25 $574.25 $574.25 $574.25

39 $918.93 $683.68 $581.62 $581.62 $581.62 $581.62

40 $930.58 $692.35 $589.00 $589.00 $589.00 $589.00

41 $948.05 $705.35 $600.06 $600.06 $600.06 $600.06

42 $964.80 $717.81 $610.66 $610.66 $610.66 $610.66

43 $988.10 $735.15 $625.41 $625.41 $625.41 $625.41

44 $1,017.23 $756.82 $643.84 $643.84 $643.84 $643.84

45 $1,051.45 $782.28 $665.50 $665.50 $665.50 $665.50

46 $1,092.23 $812.62 $691.31 $691.31 $691.31 $691.31

47 $1,138.10 $846.75 $720.35 $720.35 $720.35 $720.35

48 $1,190.53 $885.76 $753.53 $753.53 $753.53 $753.53

49 $1,242.23 $924.22 $786.25 $786.25 $786.25 $786.25

50 $1,300.48 $967.56 $823.12 $823.12 $823.12 $823.12

51 $1,358.00 $1,010.36 $859.53 $859.53 $859.53 $859.53

52 $1,421.35 $1,057.49 $899.63 $899.63 $899.63 $899.63

53 $1,485.43 $1,105.16 $940.18 $940.18 $940.18 $940.18

54 $1,554.60 $1,156.63 $983.97 $983.97 $983.97 $983.97

55 $1,623.78 $1,208.10 $1,027.75 $1,027.75 $1,027.75 $1,027.75

56 $1,698.78 $1,263.90 $1,075.22 $1,075.22 $1,075.22 $1,075.22

57 $1,774.51 $1,320.24 $1,123.15 $1,123.15 $1,123.15 $1,123.15

58 $1,855.33 $1,380.37 $1,174.31 $1,174.31 $1,174.31 $1,174.31

59 $1,895.38 $1,410.17 $1,199.66 $1,199.66 $1,199.66 $1,199.66

60 $1,976.20 $1,470.30 $1,250.81 $1,250.81 $1,250.81 $1,250.81

61 $2,046.11 $1,522.31 $1,295.06 $1,295.06 $1,295.06 $1,295.06

62 $2,091.98 $1,556.44 $1,324.09 $1,324.09 $1,324.09 $1,324.09

63 $2,149.50 $1,599.24 $1,360.50 $1,360.50 $1,360.50 $1,360.50

64+ $2,184.46 $1,625.24 $1,382.62 $1,382.62 $1,382.62 $1,382.62




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $329.04 $306.33 $296.81 $274.39 $271.29 $264.53

15 $358.28 $333.56 $323.19 $298.78 $295.40 $288.05

16 $369.47 $343.97 $333.28 $308.11 $304.62 $297.04

17 $380.65 $354.38 $343.37 $317.43 $313.84 $306.03

18 $392.69 $365.60 $354.23 $327.48 $323.77 $315.71

19 $404.74 $376.81 $365.09 $337.52 $333.70 $325.39

20 $417.21 $388.42 $376.35 $347.92 $343.99 $335.42

21 $430.11 $400.43 $387.99 $358.68 $354.63 $345.80

22 $430.11 $400.43 $387.99 $358.68 $354.63 $345.80

23 $430.11 $400.43 $387.99 $358.68 $354.63 $345.80

24 $430.11 $400.43 $387.99 $358.68 $354.63 $345.80

25 $431.83 $402.04 $389.54 $360.12 $356.05 $347.18

26 $440.44 $410.04 $397.30 $367.29 $363.14 $354.10

27 $450.76 $419.66 $406.61 $375.90 $371.65 $362.39

28 $467.53 $435.27 $421.74 $389.89 $385.48 $375.88

29 $481.30 $448.09 $434.16 $401.37 $396.83 $386.95

30 $488.18 $454.49 $440.36 $407.10 $402.50 $392.48

31 $498.50 $464.10 $449.68 $415.71 $411.01 $400.78

32 $508.82 $473.71 $458.99 $424.32 $419.52 $409.08

33 $515.28 $479.72 $464.81 $429.70 $424.84 $414.26

34 $522.16 $486.13 $471.01 $435.44 $430.52 $419.80

35 $525.60 $489.33 $474.12 $438.31 $433.35 $422.56

36 $529.04 $492.53 $477.22 $441.18 $436.19 $425.33

37 $532.48 $495.74 $480.33 $444.05 $439.03 $428.10

38 $535.92 $498.94 $483.43 $446.92 $441.86 $430.86

39 $542.80 $505.35 $489.64 $452.66 $447.54 $436.39

40 $549.68 $511.76 $495.85 $458.40 $453.21 $441.93

41 $560.01 $521.37 $505.16 $467.00 $461.72 $450.23

42 $569.90 $530.58 $514.08 $475.25 $469.88 $458.18

43 $583.66 $543.39 $526.50 $486.73 $481.23 $469.25

44 $600.87 $559.41 $542.02 $501.08 $495.41 $483.08

45 $621.08 $578.23 $560.25 $517.94 $512.08 $499.33

46 $645.17 $600.65 $581.98 $538.02 $531.94 $518.69

47 $672.27 $625.88 $606.42 $560.62 $554.28 $540.48

48 $703.23 $654.71 $634.36 $586.45 $579.81 $565.38

49 $733.77 $683.14 $661.90 $611.91 $604.99 $589.93

50 $768.18 $715.18 $692.94 $640.61 $633.36 $617.59

51 $802.16 $746.81 $723.59 $668.94 $661.38 $644.91

52 $839.58 $781.65 $757.35 $700.15 $692.23 $674.99

53 $877.43 $816.89 $791.49 $731.71 $723.44 $705.42

54 $918.29 $854.93 $828.35 $765.79 $757.13 $738.27

55 $959.15 $892.97 $865.21 $799.86 $790.82 $771.13

56 $1,003.45 $934.21 $905.17 $836.81 $827.34 $806.74

57 $1,048.19 $975.86 $945.52 $874.11 $864.23 $842.71

58 $1,095.93 $1,020.31 $988.59 $913.92 $903.59 $881.09

59 $1,119.58 $1,042.33 $1,009.93 $933.65 $923.09 $900.11

60 $1,167.33 $1,086.78 $1,052.99 $973.46 $962.46 $938.49

61 $1,208.62 $1,125.22 $1,090.24 $1,007.90 $996.50 $971.69

62 $1,235.71 $1,150.45 $1,114.68 $1,030.50 $1,018.84 $993.47

63 $1,269.69 $1,182.08 $1,145.33 $1,058.83 $1,046.86 $1,020.79

64+ $1,290.34 $1,201.30 $1,163.96 $1,076.05 $1,063.88 $1,037.39



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $380.78 $283.30 $241.01 $241.01 $241.01 $241.01

15 $414.62 $308.48 $262.43 $262.43 $262.43 $262.43

16 $427.56 $318.11 $270.62 $270.62 $270.62 $270.62

17 $440.51 $327.74 $278.81 $278.81 $278.81 $278.81

18 $454.44 $338.11 $287.63 $287.63 $287.63 $287.63

19 $468.38 $348.48 $296.45 $296.45 $296.45 $296.45

20 $482.81 $359.21 $305.59 $305.59 $305.59 $305.59

21 $497.75 $370.32 $315.04 $315.04 $315.04 $315.04

22 $497.75 $370.32 $315.04 $315.04 $315.04 $315.04

23 $497.75 $370.32 $315.04 $315.04 $315.04 $315.04

24 $497.75 $370.32 $315.04 $315.04 $315.04 $315.04

25 $499.74 $371.81 $316.30 $316.30 $316.30 $316.30

26 $509.69 $379.21 $322.60 $322.60 $322.60 $322.60

27 $521.64 $388.10 $330.16 $330.16 $330.16 $330.16

28 $541.05 $402.54 $342.45 $342.45 $342.45 $342.45

29 $556.98 $414.39 $352.53 $352.53 $352.53 $352.53

30 $564.94 $420.32 $357.57 $357.57 $357.57 $357.57

31 $576.89 $429.21 $365.13 $365.13 $365.13 $365.13

32 $588.83 $438.09 $372.69 $372.69 $372.69 $372.69

33 $596.30 $443.65 $377.42 $377.42 $377.42 $377.42

34 $604.26 $449.57 $382.46 $382.46 $382.46 $382.46

35 $608.25 $452.54 $384.98 $384.98 $384.98 $384.98

36 $612.23 $455.50 $387.50 $387.50 $387.50 $387.50

37 $616.21 $458.46 $390.02 $390.02 $390.02 $390.02

38 $620.19 $461.42 $392.54 $392.54 $392.54 $392.54

39 $628.16 $467.35 $397.58 $397.58 $397.58 $397.58

40 $636.12 $473.27 $402.62 $402.62 $402.62 $402.62

41 $648.07 $482.16 $410.18 $410.18 $410.18 $410.18

42 $659.51 $490.68 $417.43 $417.43 $417.43 $417.43

43 $675.44 $502.53 $427.51 $427.51 $427.51 $427.51

44 $695.35 $517.34 $440.11 $440.11 $440.11 $440.11

45 $718.75 $534.75 $454.92 $454.92 $454.92 $454.92

46 $746.62 $555.49 $472.56 $472.56 $472.56 $472.56

47 $777.98 $578.82 $492.41 $492.41 $492.41 $492.41

48 $813.82 $605.48 $515.09 $515.09 $515.09 $515.09

49 $849.16 $631.77 $537.46 $537.46 $537.46 $537.46

50 $888.97 $661.40 $562.67 $562.67 $562.67 $562.67

51 $928.30 $690.66 $587.55 $587.55 $587.55 $587.55

52 $971.60 $722.87 $614.96 $614.96 $614.96 $614.96

53 $1,015.40 $755.46 $642.69 $642.69 $642.69 $642.69

54 $1,062.69 $790.64 $672.62 $672.62 $672.62 $672.62

55 $1,109.97 $825.82 $702.54 $702.54 $702.54 $702.54

56 $1,161.24 $863.97 $734.99 $734.99 $734.99 $734.99

57 $1,213.01 $902.48 $767.76 $767.76 $767.76 $767.76

58 $1,268.26 $943.59 $802.73 $802.73 $802.73 $802.73

59 $1,295.63 $963.95 $820.05 $820.05 $820.05 $820.05

60 $1,350.88 $1,005.06 $855.02 $855.02 $855.02 $855.02

61 $1,398.67 $1,040.61 $885.27 $885.27 $885.27 $885.27

62 $1,430.02 $1,063.94 $905.12 $905.12 $905.12 $905.12

63 $1,469.35 $1,093.20 $930.00 $930.00 $930.00 $930.00

64+ $1,493.24 $1,110.97 $945.13 $945.13 $945.13 $945.13




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $224.92 $209.40 $202.89 $187.57 $185.45 $180.83

15 $244.91 $228.01 $220.93 $204.24 $201.93 $196.90

16 $252.56 $235.13 $227.82 $210.62 $208.23 $203.05

17 $260.20 $242.25 $234.72 $216.99 $214.54 $209.19

18 $268.44 $249.91 $242.14 $223.86 $221.32 $215.81

19 $276.67 $257.58 $249.57 $230.72 $228.11 $222.43

20 $285.19 $265.52 $257.26 $237.83 $235.14 $229.29

21 $294.01 $273.73 $265.22 $245.19 $242.41 $236.38

22 $294.01 $273.73 $265.22 $245.19 $242.41 $236.38

23 $294.01 $273.73 $265.22 $245.19 $242.41 $236.38

24 $294.01 $273.73 $265.22 $245.19 $242.41 $236.38

25 $295.19 $274.82 $266.28 $246.17 $243.38 $237.32

26 $301.07 $280.30 $271.58 $251.07 $248.23 $242.05

27 $308.13 $286.87 $277.95 $256.96 $254.05 $247.72

28 $319.59 $297.54 $288.29 $266.52 $263.50 $256.94

29 $329.00 $306.30 $296.78 $274.36 $271.26 $264.51

30 $333.71 $310.68 $301.02 $278.29 $275.14 $268.29

31 $340.76 $317.25 $307.39 $284.17 $280.96 $273.96

32 $347.82 $323.82 $313.75 $290.06 $286.78 $279.63

33 $352.23 $327.92 $317.73 $293.73 $290.41 $283.18

34 $356.93 $332.30 $321.97 $297.66 $294.29 $286.96

35 $359.29 $334.49 $324.10 $299.62 $296.23 $288.85

36 $361.64 $336.68 $326.22 $301.58 $298.17 $290.74

37 $363.99 $338.87 $328.34 $303.54 $300.11 $292.64

38 $366.34 $341.06 $330.46 $305.50 $302.05 $294.53

39 $371.05 $345.44 $334.70 $309.43 $305.93 $298.31

40 $375.75 $349.82 $338.95 $313.35 $309.80 $302.09

41 $382.81 $356.39 $345.31 $319.23 $315.62 $307.76

42 $389.57 $362.69 $351.41 $324.87 $321.20 $313.20

43 $398.98 $371.45 $359.90 $332.72 $328.96 $320.76

44 $410.74 $382.40 $370.51 $342.53 $338.65 $330.22

45 $424.56 $395.26 $382.97 $354.05 $350.05 $341.33

46 $441.02 $410.59 $397.83 $367.78 $363.62 $354.57

47 $459.54 $427.84 $414.53 $383.23 $378.89 $369.46

48 $480.71 $447.54 $433.63 $400.88 $396.35 $386.48

49 $501.59 $466.98 $452.46 $418.29 $413.56 $403.26

50 $525.11 $488.88 $473.68 $437.90 $432.95 $422.17

51 $548.34 $510.50 $494.63 $457.27 $452.10 $440.84

52 $573.92 $534.31 $517.70 $478.60 $473.19 $461.41

53 $599.79 $558.40 $541.04 $500.18 $494.52 $482.21

54 $627.72 $584.41 $566.24 $523.47 $517.55 $504.67

55 $655.65 $610.41 $591.43 $546.77 $540.58 $527.12

56 $685.94 $638.60 $618.75 $572.02 $565.55 $551.47

57 $716.51 $667.07 $646.33 $597.52 $590.76 $576.05

58 $749.15 $697.46 $675.77 $624.73 $617.67 $602.29

59 $765.32 $712.51 $690.36 $638.22 $631.00 $615.29

60 $797.95 $742.89 $719.80 $665.44 $657.91 $641.53

61 $826.18 $769.17 $745.26 $688.97 $681.18 $664.22

62 $844.70 $786.42 $761.97 $704.42 $696.46 $679.11

63 $867.93 $808.04 $782.92 $723.79 $715.61 $697.79

64+ $882.04 $821.18 $795.65 $735.56 $727.24 $709.13




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $443.83 $314.15 $260.87 $260.87 $260.87 $260.87 $243.46

15 $483.28 $342.07 $284.06 $284.06 $284.06 $284.06 $265.10

16 $498.37 $352.75 $292.92 $292.92 $292.92 $292.92 $273.37

17 $513.45 $363.42 $301.79 $301.79 $301.79 $301.79 $281.64

18 $529.70 $374.92 $311.34 $311.34 $311.34 $311.34 $290.56

19 $545.94 $386.42 $320.88 $320.88 $320.88 $320.88 $299.47

20 $562.77 $398.33 $330.77 $330.77 $330.77 $330.77 $308.70

21 $580.17 $410.65 $341.00 $341.00 $341.00 $341.00 $318.24

22 $580.17 $410.65 $341.00 $341.00 $341.00 $341.00 $318.24

23 $580.17 $410.65 $341.00 $341.00 $341.00 $341.00 $318.24

24 $580.17 $410.65 $341.00 $341.00 $341.00 $341.00 $318.24

25 $582.49 $412.29 $342.37 $342.37 $342.37 $342.37 $319.52

26 $594.10 $420.50 $349.19 $349.19 $349.19 $349.19 $325.88

27 $608.02 $430.36 $357.37 $357.37 $357.37 $357.37 $333.52

28 $630.65 $446.38 $370.67 $370.67 $370.67 $370.67 $345.93

29 $649.21 $459.52 $381.58 $381.58 $381.58 $381.58 $356.11

30 $658.49 $466.09 $387.04 $387.04 $387.04 $387.04 $361.21

31 $672.42 $475.94 $395.22 $395.22 $395.22 $395.22 $368.84

32 $686.34 $485.80 $403.41 $403.41 $403.41 $403.41 $376.48

33 $695.05 $491.96 $408.52 $408.52 $408.52 $408.52 $381.25

34 $704.33 $498.53 $413.98 $413.98 $413.98 $413.98 $386.35

35 $708.97 $501.81 $416.71 $416.71 $416.71 $416.71 $388.89

36 $713.61 $505.10 $419.43 $419.43 $419.43 $419.43 $391.44

37 $718.25 $508.38 $422.16 $422.16 $422.16 $422.16 $393.98

38 $722.89 $511.67 $424.89 $424.89 $424.89 $424.89 $396.53

39 $732.18 $518.24 $430.35 $430.35 $430.35 $430.35 $401.62

40 $741.46 $524.81 $435.80 $435.80 $435.80 $435.80 $406.71

41 $755.38 $534.67 $443.99 $443.99 $443.99 $443.99 $414.35

42 $768.73 $544.11 $451.83 $451.83 $451.83 $451.83 $421.67

43 $787.29 $557.25 $462.74 $462.74 $462.74 $462.74 $431.86

44 $810.50 $573.68 $476.38 $476.38 $476.38 $476.38 $444.58

45 $837.77 $592.98 $492.41 $492.41 $492.41 $492.41 $459.54

46 $870.26 $615.97 $511.51 $511.51 $511.51 $511.51 $477.36

47 $906.81 $641.84 $532.99 $532.99 $532.99 $532.99 $497.41

48 $948.58 $671.41 $557.54 $557.54 $557.54 $557.54 $520.33

49 $989.77 $700.57 $581.75 $581.75 $581.75 $581.75 $542.92

50 $1,036.19 $733.42 $609.03 $609.03 $609.03 $609.03 $568.38

51 $1,082.02 $765.86 $635.97 $635.97 $635.97 $635.97 $593.52

52 $1,132.49 $801.59 $665.64 $665.64 $665.64 $665.64 $621.21

53 $1,183.55 $837.72 $695.65 $695.65 $695.65 $695.65 $649.21

54 $1,238.67 $876.74 $728.04 $728.04 $728.04 $728.04 $679.45

55 $1,293.78 $915.75 $760.44 $760.44 $760.44 $760.44 $709.68

56 $1,353.54 $958.04 $795.56 $795.56 $795.56 $795.56 $742.46

57 $1,413.88 $1,000.75 $831.03 $831.03 $831.03 $831.03 $775.56

58 $1,478.28 $1,046.33 $868.88 $868.88 $868.88 $868.88 $810.88

59 $1,510.19 $1,068.92 $887.63 $887.63 $887.63 $887.63 $828.39

60 $1,574.58 $1,114.50 $925.48 $925.48 $925.48 $925.48 $863.71

61 $1,630.28 $1,153.92 $958.22 $958.22 $958.22 $958.22 $894.26

62 $1,666.83 $1,179.80 $979.70 $979.70 $979.70 $979.70 $914.31

63 $1,712.67 $1,212.24 $1,006.64 $1,006.64 $1,006.64 $1,006.64 $939.45

64+ $1,740.51 $1,231.95 $1,023.01 $1,023.01 $1,023.01 $1,023.01 $954.73



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $413.58 $307.70 $261.77 $261.77 $261.77 $261.77

15 $450.34 $335.05 $285.04 $285.04 $285.04 $285.04

16 $464.40 $345.51 $293.93 $293.93 $293.93 $293.93

17 $478.45 $355.97 $302.83 $302.83 $302.83 $302.83

18 $493.59 $367.23 $312.41 $312.41 $312.41 $312.41

19 $508.73 $378.50 $321.99 $321.99 $321.99 $321.99

20 $524.41 $390.16 $331.92 $331.92 $331.92 $331.92

21 $540.63 $402.23 $342.18 $342.18 $342.18 $342.18

22 $540.63 $402.23 $342.18 $342.18 $342.18 $342.18

23 $540.63 $402.23 $342.18 $342.18 $342.18 $342.18

24 $540.63 $402.23 $342.18 $342.18 $342.18 $342.18

25 $542.79 $403.84 $343.55 $343.55 $343.55 $343.55

26 $553.60 $411.88 $350.39 $350.39 $350.39 $350.39

27 $566.58 $421.53 $358.61 $358.61 $358.61 $358.61

28 $587.66 $437.22 $371.95 $371.95 $371.95 $371.95

29 $604.96 $450.09 $382.90 $382.90 $382.90 $382.90

30 $613.61 $456.53 $388.38 $388.38 $388.38 $388.38

31 $626.58 $466.18 $396.59 $396.59 $396.59 $396.59

32 $639.56 $475.83 $404.80 $404.80 $404.80 $404.80

33 $647.67 $481.87 $409.93 $409.93 $409.93 $409.93

34 $656.32 $488.30 $415.41 $415.41 $415.41 $415.41

35 $660.64 $491.52 $418.15 $418.15 $418.15 $418.15

36 $664.97 $494.74 $420.88 $420.88 $420.88 $420.88

37 $669.29 $497.96 $423.62 $423.62 $423.62 $423.62

38 $673.62 $501.17 $426.36 $426.36 $426.36 $426.36

39 $682.27 $507.61 $431.83 $431.83 $431.83 $431.83

40 $690.92 $514.05 $437.31 $437.31 $437.31 $437.31

41 $703.89 $523.70 $445.52 $445.52 $445.52 $445.52

42 $716.33 $532.95 $453.39 $453.39 $453.39 $453.39

43 $733.63 $545.82 $464.34 $464.34 $464.34 $464.34

44 $755.25 $561.91 $478.03 $478.03 $478.03 $478.03

45 $780.66 $580.82 $494.11 $494.11 $494.11 $494.11

46 $810.94 $603.34 $513.27 $513.27 $513.27 $513.27

47 $845.00 $628.68 $534.83 $534.83 $534.83 $534.83

48 $883.92 $657.64 $559.47 $559.47 $559.47 $559.47

49 $922.31 $686.20 $583.76 $583.76 $583.76 $583.76

50 $965.56 $718.38 $611.14 $611.14 $611.14 $611.14

51 $1,008.27 $750.15 $638.17 $638.17 $638.17 $638.17

52 $1,055.30 $785.15 $667.94 $667.94 $667.94 $667.94

53 $1,102.88 $820.54 $698.05 $698.05 $698.05 $698.05

54 $1,154.23 $858.75 $730.56 $730.56 $730.56 $730.56

55 $1,205.59 $896.97 $763.07 $763.07 $763.07 $763.07

56 $1,261.28 $938.39 $798.31 $798.31 $798.31 $798.31

57 $1,317.50 $980.23 $833.90 $833.90 $833.90 $833.90

58 $1,377.51 $1,024.87 $871.88 $871.88 $871.88 $871.88

59 $1,407.25 $1,047.00 $890.70 $890.70 $890.70 $890.70

60 $1,467.26 $1,091.64 $928.68 $928.68 $928.68 $928.68

61 $1,519.16 $1,130.26 $961.53 $961.53 $961.53 $961.53

62 $1,553.22 $1,155.60 $983.09 $983.09 $983.09 $983.09

63 $1,595.93 $1,187.37 $1,010.12 $1,010.12 $1,010.12 $1,010.12

64+ $1,621.88 $1,206.68 $1,026.55 $1,026.55 $1,026.55 $1,026.55




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $244.30 $227.44 $220.37 $203.73 $201.42 $196.41

15 $266.01 $247.66 $239.96 $221.83 $219.33 $213.86

16 $274.32 $255.39 $247.45 $228.76 $226.17 $220.54

17 $282.62 $263.12 $254.94 $235.68 $233.02 $227.22

18 $291.56 $271.44 $263.00 $243.14 $240.39 $234.40

19 $300.50 $279.77 $271.07 $250.60 $247.76 $241.59

20 $309.76 $288.39 $279.42 $258.32 $255.40 $249.04

21 $319.34 $297.31 $288.06 $266.31 $263.30 $256.74

22 $319.34 $297.31 $288.06 $266.31 $263.30 $256.74

23 $319.34 $297.31 $288.06 $266.31 $263.30 $256.74

24 $319.34 $297.31 $288.06 $266.31 $263.30 $256.74

25 $320.62 $298.50 $289.22 $267.37 $264.35 $257.77

26 $327.01 $304.44 $294.98 $272.70 $269.62 $262.90

27 $334.67 $311.58 $301.89 $279.09 $275.94 $269.06

28 $347.13 $323.17 $313.13 $289.48 $286.20 $279.08

29 $357.34 $332.69 $322.34 $298.00 $294.63 $287.29

30 $362.45 $337.44 $326.95 $302.26 $298.84 $291.40

31 $370.12 $344.58 $333.87 $308.65 $305.16 $297.56

32 $377.78 $351.71 $340.78 $315.04 $311.48 $303.72

33 $382.57 $356.17 $345.10 $319.04 $315.43 $307.58

34 $387.68 $360.93 $349.71 $323.30 $319.64 $311.68

35 $390.24 $363.31 $352.02 $325.43 $321.75 $313.74

36 $392.79 $365.69 $354.32 $327.56 $323.86 $315.79

37 $395.35 $368.07 $356.62 $329.69 $325.96 $317.84

38 $397.90 $370.45 $358.93 $331.82 $328.07 $319.90

39 $403.01 $375.20 $363.54 $336.08 $332.28 $324.01

40 $408.12 $379.96 $368.15 $340.34 $336.49 $328.11

41 $415.78 $387.09 $375.06 $346.73 $342.81 $334.28

42 $423.13 $393.93 $381.69 $352.86 $348.87 $340.18

43 $433.35 $403.45 $390.90 $361.38 $357.29 $348.40

44 $446.12 $415.34 $402.43 $372.03 $367.83 $358.67

45 $461.13 $429.31 $415.97 $384.55 $380.20 $370.73

46 $479.01 $445.96 $432.10 $399.46 $394.95 $385.11

47 $499.13 $464.69 $450.25 $416.24 $411.53 $401.29

48 $522.13 $486.10 $470.99 $435.41 $430.49 $419.77

49 $544.80 $507.21 $491.44 $454.32 $449.18 $438.00

50 $570.35 $530.99 $514.48 $475.63 $470.25 $458.54

51 $595.57 $554.48 $537.24 $496.66 $491.05 $478.82

52 $623.36 $580.34 $562.30 $519.83 $513.96 $501.16

53 $651.46 $606.51 $587.65 $543.27 $537.13 $523.75

54 $681.80 $634.75 $615.02 $568.57 $562.14 $548.14

55 $712.13 $663.00 $642.38 $593.87 $587.15 $572.53

56 $745.03 $693.62 $672.05 $621.30 $614.27 $598.98

57 $778.24 $724.54 $702.01 $648.99 $641.65 $625.68

58 $813.68 $757.54 $733.99 $678.55 $670.88 $654.17

59 $831.25 $773.89 $749.83 $693.20 $685.36 $668.30

60 $866.70 $806.89 $781.81 $722.76 $714.59 $696.79

61 $897.35 $835.43 $809.46 $748.33 $739.86 $721.44

62 $917.47 $854.16 $827.61 $765.10 $756.45 $737.62

63 $942.70 $877.65 $850.37 $786.14 $777.25 $757.90

64+ $958.03 $891.92 $864.19 $798.92 $789.89 $770.22




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $333.20 $235.84 $195.84 $195.84 $195.84 $195.84 $182.77

15 $362.81 $256.80 $213.25 $213.25 $213.25 $213.25 $199.02

16 $374.14 $264.82 $219.91 $219.91 $219.91 $219.91 $205.23

17 $385.46 $272.83 $226.56 $226.56 $226.56 $226.56 $211.44

18 $397.66 $281.47 $233.73 $233.73 $233.73 $233.73 $218.13

19 $409.85 $290.10 $240.90 $240.90 $240.90 $240.90 $224.82

20 $422.48 $299.04 $248.32 $248.32 $248.32 $248.32 $231.75

21 $435.55 $308.29 $256.00 $256.00 $256.00 $256.00 $238.91

22 $435.55 $308.29 $256.00 $256.00 $256.00 $256.00 $238.91

23 $435.55 $308.29 $256.00 $256.00 $256.00 $256.00 $238.91

24 $435.55 $308.29 $256.00 $256.00 $256.00 $256.00 $238.91

25 $437.29 $309.52 $257.03 $257.03 $257.03 $257.03 $239.87

26 $446.00 $315.69 $262.15 $262.15 $262.15 $262.15 $244.65

27 $456.46 $323.08 $268.29 $268.29 $268.29 $268.29 $250.38

28 $473.44 $335.11 $278.27 $278.27 $278.27 $278.27 $259.70

29 $487.38 $344.97 $286.47 $286.47 $286.47 $286.47 $267.34

30 $494.35 $349.91 $290.56 $290.56 $290.56 $290.56 $271.17

31 $504.80 $357.30 $296.71 $296.71 $296.71 $296.71 $276.90

32 $515.26 $364.70 $302.85 $302.85 $302.85 $302.85 $282.64

33 $521.79 $369.33 $306.69 $306.69 $306.69 $306.69 $286.22

34 $528.76 $374.26 $310.79 $310.79 $310.79 $310.79 $290.04

35 $532.24 $376.73 $312.83 $312.83 $312.83 $312.83 $291.95

36 $535.73 $379.19 $314.88 $314.88 $314.88 $314.88 $293.86

37 $539.21 $381.66 $316.93 $316.93 $316.93 $316.93 $295.78

38 $542.70 $384.12 $318.98 $318.98 $318.98 $318.98 $297.69

39 $549.67 $389.06 $323.07 $323.07 $323.07 $323.07 $301.51

40 $556.63 $393.99 $327.17 $327.17 $327.17 $327.17 $305.33

41 $567.09 $401.39 $333.31 $333.31 $333.31 $333.31 $311.07

42 $577.11 $408.48 $339.20 $339.20 $339.20 $339.20 $316.56

43 $591.04 $418.34 $347.39 $347.39 $347.39 $347.39 $324.21

44 $608.47 $430.68 $357.63 $357.63 $357.63 $357.63 $333.76

45 $628.94 $445.17 $369.67 $369.67 $369.67 $369.67 $344.99

46 $653.33 $462.43 $384.00 $384.00 $384.00 $384.00 $358.37

47 $680.77 $481.85 $400.13 $400.13 $400.13 $400.13 $373.42

48 $712.13 $504.05 $418.56 $418.56 $418.56 $418.56 $390.62

49 $743.05 $525.94 $436.74 $436.74 $436.74 $436.74 $407.59

50 $777.89 $550.60 $457.22 $457.22 $457.22 $457.22 $426.70

51 $812.30 $574.95 $477.44 $477.44 $477.44 $477.44 $445.57

52 $850.20 $601.78 $499.71 $499.71 $499.71 $499.71 $466.36

53 $888.52 $628.90 $522.24 $522.24 $522.24 $522.24 $487.38

54 $929.90 $658.19 $546.56 $546.56 $546.56 $546.56 $510.08

55 $971.28 $687.48 $570.88 $570.88 $570.88 $570.88 $532.78

56 $1,016.14 $719.23 $597.25 $597.25 $597.25 $597.25 $557.39

57 $1,061.44 $751.29 $623.87 $623.87 $623.87 $623.87 $582.23

58 $1,109.78 $785.51 $652.29 $652.29 $652.29 $652.29 $608.75

59 $1,133.74 $802.47 $666.37 $666.37 $666.37 $666.37 $621.89

60 $1,182.09 $836.69 $694.79 $694.79 $694.79 $694.79 $648.41

61 $1,223.90 $866.28 $719.36 $719.36 $719.36 $719.36 $671.35

62 $1,251.34 $885.71 $735.49 $735.49 $735.49 $735.49 $686.40

63 $1,285.75 $910.06 $755.72 $755.72 $755.72 $755.72 $705.27

64+ $1,306.65 $924.86 $768.00 $768.00 $768.00 $768.00 $716.74



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $488.38 $363.35 $309.11 $309.11 $309.11 $309.11

15 $531.79 $395.65 $336.59 $336.59 $336.59 $336.59

16 $548.39 $408.00 $347.09 $347.09 $347.09 $347.09

17 $564.98 $420.35 $357.60 $357.60 $357.60 $357.60

18 $582.86 $433.65 $368.91 $368.91 $368.91 $368.91

19 $600.73 $446.95 $380.23 $380.23 $380.23 $380.23

20 $619.25 $460.72 $391.94 $391.94 $391.94 $391.94

21 $638.40 $474.97 $404.07 $404.07 $404.07 $404.07

22 $638.40 $474.97 $404.07 $404.07 $404.07 $404.07

23 $638.40 $474.97 $404.07 $404.07 $404.07 $404.07

24 $638.40 $474.97 $404.07 $404.07 $404.07 $404.07

25 $640.95 $476.87 $405.68 $405.68 $405.68 $405.68

26 $653.72 $486.37 $413.76 $413.76 $413.76 $413.76

27 $669.04 $497.77 $423.46 $423.46 $423.46 $423.46

28 $693.94 $516.29 $439.22 $439.22 $439.22 $439.22

29 $714.37 $531.49 $452.15 $452.15 $452.15 $452.15

30 $724.58 $539.09 $458.62 $458.62 $458.62 $458.62

31 $739.91 $550.49 $468.31 $468.31 $468.31 $468.31

32 $755.23 $561.89 $478.01 $478.01 $478.01 $478.01

33 $764.80 $569.02 $484.07 $484.07 $484.07 $484.07

34 $775.02 $576.61 $490.54 $490.54 $490.54 $490.54

35 $780.12 $580.41 $493.77 $493.77 $493.77 $493.77

36 $785.23 $584.21 $497.00 $497.00 $497.00 $497.00

37 $790.34 $588.01 $500.23 $500.23 $500.23 $500.23

38 $795.45 $591.81 $503.47 $503.47 $503.47 $503.47

39 $805.66 $599.41 $509.93 $509.93 $509.93 $509.93

40 $815.87 $607.01 $516.40 $516.40 $516.40 $516.40

41 $831.20 $618.41 $526.10 $526.10 $526.10 $526.10

42 $845.88 $629.34 $535.39 $535.39 $535.39 $535.39

43 $866.31 $644.54 $548.32 $548.32 $548.32 $548.32

44 $891.84 $663.53 $564.48 $564.48 $564.48 $564.48

45 $921.85 $685.86 $583.47 $583.47 $583.47 $583.47

46 $957.60 $712.46 $606.10 $606.10 $606.10 $606.10

47 $997.82 $742.38 $631.56 $631.56 $631.56 $631.56

48 $1,043.78 $776.58 $660.65 $660.65 $660.65 $660.65

49 $1,089.11 $810.30 $689.34 $689.34 $689.34 $689.34

50 $1,140.18 $848.30 $721.66 $721.66 $721.66 $721.66

51 $1,190.62 $885.82 $753.58 $753.58 $753.58 $753.58

52 $1,246.16 $927.14 $788.74 $788.74 $788.74 $788.74

53 $1,302.34 $968.94 $824.30 $824.30 $824.30 $824.30

54 $1,362.98 $1,014.06 $862.68 $862.68 $862.68 $862.68

55 $1,423.63 $1,059.19 $901.07 $901.07 $901.07 $901.07

56 $1,489.39 $1,108.11 $942.69 $942.69 $942.69 $942.69

57 $1,555.78 $1,157.50 $984.71 $984.71 $984.71 $984.71

58 $1,626.64 $1,210.23 $1,029.56 $1,029.56 $1,029.56 $1,029.56

59 $1,661.75 $1,236.35 $1,051.79 $1,051.79 $1,051.79 $1,051.79

60 $1,732.62 $1,289.07 $1,096.64 $1,096.64 $1,096.64 $1,096.64

61 $1,793.90 $1,334.67 $1,135.43 $1,135.43 $1,135.43 $1,135.43

62 $1,834.12 $1,364.59 $1,160.88 $1,160.88 $1,160.88 $1,160.88

63 $1,884.56 $1,402.11 $1,192.81 $1,192.81 $1,192.81 $1,192.81

64+ $1,915.20 $1,424.91 $1,212.20 $1,212.20 $1,212.20 $1,212.20




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $288.48 $268.57 $260.22 $240.57 $237.85 $231.93

15 $314.12 $292.45 $283.36 $261.95 $258.99 $252.54

16 $323.93 $301.57 $292.20 $270.13 $267.08 $260.43

17 $333.73 $310.70 $301.04 $278.31 $275.16 $268.31

18 $344.29 $320.53 $310.57 $287.11 $283.87 $276.80

19 $354.85 $330.36 $320.09 $295.92 $292.57 $285.29

20 $365.78 $340.54 $329.96 $305.04 $301.59 $294.08

21 $377.10 $351.08 $340.16 $314.47 $310.92 $303.17

22 $377.10 $351.08 $340.16 $314.47 $310.92 $303.17

23 $377.10 $351.08 $340.16 $314.47 $310.92 $303.17

24 $377.10 $351.08 $340.16 $314.47 $310.92 $303.17

25 $378.61 $352.48 $341.52 $315.73 $312.16 $304.39

26 $386.15 $359.50 $348.33 $322.02 $318.38 $310.45

27 $395.20 $367.93 $356.49 $329.57 $325.84 $317.73

28 $409.90 $381.62 $369.76 $341.83 $337.96 $329.55

29 $421.97 $392.85 $380.64 $351.89 $347.91 $339.25

30 $428.01 $398.47 $386.08 $356.92 $352.89 $344.10

31 $437.06 $406.90 $394.25 $364.47 $360.35 $351.38

32 $446.11 $415.32 $402.41 $372.02 $367.81 $358.65

33 $451.76 $420.59 $407.51 $376.74 $372.48 $363.20

34 $457.80 $426.21 $412.96 $381.77 $377.45 $368.05

35 $460.81 $429.02 $415.68 $384.28 $379.94 $370.48

36 $463.83 $431.82 $418.40 $386.80 $382.43 $372.90

37 $466.85 $434.63 $421.12 $389.32 $384.91 $375.33

38 $469.86 $437.44 $423.84 $391.83 $387.40 $377.75

39 $475.90 $443.06 $429.28 $396.86 $392.38 $382.60

40 $481.93 $448.68 $434.73 $401.89 $397.35 $387.46

41 $490.98 $457.10 $442.89 $409.44 $404.81 $394.73

42 $499.65 $465.18 $450.72 $416.67 $411.96 $401.70

43 $511.72 $476.41 $461.60 $426.74 $421.91 $411.41

44 $526.80 $490.45 $475.21 $439.32 $434.35 $423.53

45 $544.53 $506.95 $491.19 $454.10 $448.96 $437.78

46 $565.65 $526.62 $510.24 $471.71 $466.37 $454.76

47 $589.40 $548.73 $531.67 $491.52 $485.96 $473.86

48 $616.55 $574.01 $556.17 $514.16 $508.35 $495.69

49 $643.33 $598.94 $580.32 $536.49 $530.42 $517.21

50 $673.50 $627.02 $607.53 $561.65 $555.29 $541.47

51 $703.29 $654.76 $634.40 $586.49 $579.86 $565.42

52 $736.09 $685.30 $664.00 $613.85 $606.91 $591.79

53 $769.28 $716.20 $693.93 $641.52 $634.27 $618.47

54 $805.10 $749.55 $726.25 $671.40 $663.80 $647.27

55 $840.93 $782.90 $758.56 $701.27 $693.34 $676.08

56 $879.77 $819.06 $793.60 $733.66 $725.37 $707.30

57 $918.99 $855.57 $828.98 $766.37 $757.70 $738.83

58 $960.84 $894.54 $866.73 $801.27 $792.21 $772.49

59 $981.58 $913.85 $885.44 $818.57 $809.31 $789.16

60 $1,023.44 $952.82 $923.20 $853.48 $843.82 $822.81

61 $1,059.64 $986.53 $955.86 $883.66 $873.67 $851.92

62 $1,083.40 $1,008.64 $977.29 $903.48 $893.26 $871.02

63 $1,113.19 $1,036.38 $1,004.16 $928.32 $917.82 $894.97

64+ $1,131.29 $1,053.23 $1,020.49 $943.41 $932.75 $909.52




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $422.24 $298.86 $248.18 $248.18 $248.18 $248.18 $231.61

15 $459.77 $325.43 $270.24 $270.24 $270.24 $270.24 $252.20

16 $474.12 $335.59 $278.67 $278.67 $278.67 $278.67 $260.07

17 $488.47 $345.74 $287.11 $287.11 $287.11 $287.11 $267.94

18 $503.93 $356.68 $296.19 $296.19 $296.19 $296.19 $276.42

19 $519.38 $367.62 $305.27 $305.27 $305.27 $305.27 $284.90

20 $535.39 $378.95 $314.68 $314.68 $314.68 $314.68 $293.68

21 $551.95 $390.67 $324.41 $324.41 $324.41 $324.41 $302.76

22 $551.95 $390.67 $324.41 $324.41 $324.41 $324.41 $302.76

23 $551.95 $390.67 $324.41 $324.41 $324.41 $324.41 $302.76

24 $551.95 $390.67 $324.41 $324.41 $324.41 $324.41 $302.76

25 $554.15 $392.23 $325.71 $325.71 $325.71 $325.71 $303.97

26 $565.19 $400.05 $332.20 $332.20 $332.20 $332.20 $310.03

27 $578.44 $409.42 $339.99 $339.99 $339.99 $339.99 $317.29

28 $599.97 $424.66 $352.64 $352.64 $352.64 $352.64 $329.10

29 $617.63 $437.16 $363.02 $363.02 $363.02 $363.02 $338.79

30 $626.46 $443.41 $368.21 $368.21 $368.21 $368.21 $343.63

31 $639.71 $452.79 $376.00 $376.00 $376.00 $376.00 $350.90

32 $652.95 $462.17 $383.78 $383.78 $383.78 $383.78 $358.17

33 $661.23 $468.03 $388.65 $388.65 $388.65 $388.65 $362.71

34 $670.06 $474.28 $393.84 $393.84 $393.84 $393.84 $367.55

35 $674.48 $477.40 $396.43 $396.43 $396.43 $396.43 $369.97

36 $678.89 $480.53 $399.03 $399.03 $399.03 $399.03 $372.40

37 $683.31 $483.65 $401.62 $401.62 $401.62 $401.62 $374.82

38 $687.73 $486.78 $404.22 $404.22 $404.22 $404.22 $377.24

39 $696.56 $493.03 $409.41 $409.41 $409.41 $409.41 $382.08

40 $705.39 $499.28 $414.60 $414.60 $414.60 $414.60 $386.93

41 $718.63 $508.66 $422.39 $422.39 $422.39 $422.39 $394.19

42 $731.33 $517.64 $429.85 $429.85 $429.85 $429.85 $401.16

43 $748.99 $530.14 $440.23 $440.23 $440.23 $440.23 $410.85

44 $771.07 $545.77 $453.21 $453.21 $453.21 $453.21 $422.96

45 $797.01 $564.13 $468.45 $468.45 $468.45 $468.45 $437.19

46 $827.92 $586.01 $486.62 $486.62 $486.62 $486.62 $454.14

47 $862.69 $610.62 $507.06 $507.06 $507.06 $507.06 $473.22

48 $902.43 $638.75 $530.42 $530.42 $530.42 $530.42 $495.01

49 $941.62 $666.49 $553.45 $553.45 $553.45 $553.45 $516.51

50 $985.78 $697.74 $579.40 $579.40 $579.40 $579.40 $540.73

51 $1,029.38 $728.60 $605.03 $605.03 $605.03 $605.03 $564.65

52 $1,077.40 $762.59 $633.26 $633.26 $633.26 $633.26 $590.99

53 $1,125.97 $796.97 $661.81 $661.81 $661.81 $661.81 $617.63

54 $1,178.41 $834.08 $692.62 $692.62 $692.62 $692.62 $646.39

55 $1,230.84 $871.20 $723.44 $723.44 $723.44 $723.44 $675.16

56 $1,287.69 $911.44 $756.86 $756.86 $756.86 $756.86 $706.34

57 $1,345.09 $952.07 $790.60 $790.60 $790.60 $790.60 $737.83

58 $1,406.36 $995.43 $826.61 $826.61 $826.61 $826.61 $771.43

59 $1,436.72 $1,016.92 $844.45 $844.45 $844.45 $844.45 $788.09

60 $1,497.98 $1,060.28 $880.46 $880.46 $880.46 $880.46 $821.69

61 $1,550.97 $1,097.79 $911.60 $911.60 $911.60 $911.60 $850.76

62 $1,585.74 $1,122.40 $932.04 $932.04 $932.04 $932.04 $869.83

63 $1,629.35 $1,153.26 $957.67 $957.67 $957.67 $957.67 $893.75

64+ $1,655.84 $1,172.02 $973.24 $973.24 $973.24 $973.24 $908.28



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $431.10 $320.74 $272.86 $272.86 $272.86 $272.86

15 $469.42 $349.25 $297.11 $297.11 $297.11 $297.11

16 $484.07 $360.15 $306.39 $306.39 $306.39 $306.39

17 $498.72 $371.05 $315.66 $315.66 $315.66 $315.66

18 $514.50 $382.79 $325.65 $325.65 $325.65 $325.65

19 $530.28 $394.53 $335.63 $335.63 $335.63 $335.63

20 $546.62 $406.69 $345.98 $345.98 $345.98 $345.98

21 $563.53 $419.27 $356.68 $356.68 $356.68 $356.68

22 $563.53 $419.27 $356.68 $356.68 $356.68 $356.68

23 $563.53 $419.27 $356.68 $356.68 $356.68 $356.68

24 $563.53 $419.27 $356.68 $356.68 $356.68 $356.68

25 $565.78 $420.94 $358.10 $358.10 $358.10 $358.10

26 $577.05 $429.33 $365.24 $365.24 $365.24 $365.24

27 $590.58 $439.39 $373.80 $373.80 $373.80 $373.80

28 $612.55 $455.74 $387.71 $387.71 $387.71 $387.71

29 $630.59 $469.16 $399.12 $399.12 $399.12 $399.12

30 $639.60 $475.87 $404.83 $404.83 $404.83 $404.83

31 $653.13 $485.93 $413.39 $413.39 $413.39 $413.39

32 $666.65 $495.99 $421.95 $421.95 $421.95 $421.95

33 $675.10 $502.28 $427.30 $427.30 $427.30 $427.30

34 $684.12 $508.99 $433.01 $433.01 $433.01 $433.01

35 $688.63 $512.34 $435.86 $435.86 $435.86 $435.86

36 $693.14 $515.70 $438.71 $438.71 $438.71 $438.71

37 $697.65 $519.05 $441.57 $441.57 $441.57 $441.57

38 $702.15 $522.40 $444.42 $444.42 $444.42 $444.42

39 $711.17 $529.11 $450.13 $450.13 $450.13 $450.13

40 $720.19 $535.82 $455.83 $455.83 $455.83 $455.83

41 $733.71 $545.88 $464.39 $464.39 $464.39 $464.39

42 $746.67 $555.53 $472.60 $472.60 $472.60 $472.60

43 $764.71 $568.94 $484.01 $484.01 $484.01 $484.01

44 $787.25 $585.71 $498.28 $498.28 $498.28 $498.28

45 $813.73 $605.42 $515.04 $515.04 $515.04 $515.04

46 $845.29 $628.90 $535.02 $535.02 $535.02 $535.02

47 $880.79 $655.31 $557.49 $557.49 $557.49 $557.49

48 $921.37 $685.50 $583.17 $583.17 $583.17 $583.17

49 $961.38 $715.27 $608.49 $608.49 $608.49 $608.49

50 $1,006.46 $748.81 $637.03 $637.03 $637.03 $637.03

51 $1,050.98 $781.93 $665.20 $665.20 $665.20 $665.20

52 $1,100.00 $818.41 $696.23 $696.23 $696.23 $696.23

53 $1,149.59 $855.30 $727.62 $727.62 $727.62 $727.62

54 $1,203.13 $895.13 $761.51 $761.51 $761.51 $761.51

55 $1,256.66 $934.96 $795.39 $795.39 $795.39 $795.39

56 $1,314.71 $978.15 $832.13 $832.13 $832.13 $832.13

57 $1,373.31 $1,021.75 $869.22 $869.22 $869.22 $869.22

58 $1,435.87 $1,068.29 $908.81 $908.81 $908.81 $908.81

59 $1,466.86 $1,091.35 $928.43 $928.43 $928.43 $928.43

60 $1,529.41 $1,137.89 $968.02 $968.02 $968.02 $968.02

61 $1,583.51 $1,178.14 $1,002.26 $1,002.26 $1,002.26 $1,002.26

62 $1,619.01 $1,204.55 $1,024.73 $1,024.73 $1,024.73 $1,024.73

63 $1,663.53 $1,237.67 $1,052.91 $1,052.91 $1,052.91 $1,052.91

64+ $1,690.58 $1,257.80 $1,070.03 $1,070.03 $1,070.03 $1,070.03




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $254.65 $237.07 $229.70 $212.36 $209.95 $204.73

15 $277.28 $258.15 $250.12 $231.23 $228.62 $222.92

16 $285.94 $266.21 $257.93 $238.45 $235.75 $229.88

17 $294.59 $274.26 $265.74 $245.67 $242.89 $236.84

18 $303.91 $282.94 $274.14 $253.44 $250.57 $244.33

19 $313.23 $291.62 $282.55 $261.21 $258.26 $251.83

20 $322.88 $300.60 $291.26 $269.26 $266.22 $259.59

21 $332.87 $309.90 $300.27 $277.59 $274.45 $267.62

22 $332.87 $309.90 $300.27 $277.59 $274.45 $267.62

23 $332.87 $309.90 $300.27 $277.59 $274.45 $267.62

24 $332.87 $309.90 $300.27 $277.59 $274.45 $267.62

25 $334.20 $311.14 $301.47 $278.70 $275.55 $268.69

26 $340.86 $317.34 $307.47 $284.25 $281.04 $274.04

27 $348.85 $324.78 $314.68 $290.91 $287.62 $280.46

28 $361.83 $336.86 $326.39 $301.74 $298.33 $290.90

29 $372.48 $346.78 $336.00 $310.62 $307.11 $299.46

30 $377.81 $351.74 $340.80 $315.06 $311.50 $303.74

31 $385.80 $359.18 $348.01 $321.73 $318.09 $310.17

32 $393.79 $366.61 $355.22 $328.39 $324.67 $316.59

33 $398.78 $371.26 $359.72 $332.55 $328.79 $320.60

34 $404.10 $376.22 $364.52 $336.99 $333.18 $324.89

35 $406.77 $378.70 $366.93 $339.21 $335.38 $327.03

36 $409.43 $381.18 $369.33 $341.43 $337.57 $329.17

37 $412.09 $383.66 $371.73 $343.66 $339.77 $331.31

38 $414.76 $386.14 $374.13 $345.88 $341.97 $333.45

39 $420.08 $391.10 $378.94 $350.32 $346.36 $337.73

40 $425.41 $396.05 $383.74 $354.76 $350.75 $342.01

41 $433.40 $403.49 $390.95 $361.42 $357.33 $348.44

42 $441.05 $410.62 $397.85 $367.81 $363.65 $354.59

43 $451.70 $420.54 $407.46 $376.69 $372.43 $363.16

44 $465.02 $432.93 $419.47 $387.79 $383.41 $373.86

45 $480.66 $447.50 $433.59 $400.84 $396.31 $386.44

46 $499.31 $464.85 $450.40 $416.38 $411.68 $401.42

47 $520.28 $484.38 $469.32 $433.87 $428.97 $418.28

48 $544.24 $506.69 $490.94 $453.86 $448.73 $437.55

49 $567.88 $528.69 $512.26 $473.57 $468.21 $456.55

50 $594.51 $553.48 $536.28 $495.77 $490.17 $477.96

51 $620.80 $577.97 $560.00 $517.70 $511.85 $499.10

52 $649.76 $604.93 $586.12 $541.85 $535.73 $522.39

53 $679.05 $632.20 $612.55 $566.28 $559.88 $545.94

54 $710.68 $661.64 $641.07 $592.65 $585.95 $571.36

55 $742.30 $691.08 $669.60 $619.02 $612.02 $596.78

56 $776.59 $723.00 $700.52 $647.62 $640.29 $624.35

57 $811.20 $755.23 $731.75 $676.49 $668.84 $652.18

58 $848.15 $789.63 $765.08 $707.30 $699.30 $681.89

59 $866.46 $806.67 $781.60 $722.56 $714.39 $696.61

60 $903.41 $841.07 $814.93 $753.38 $744.86 $726.31

61 $935.36 $870.82 $843.75 $780.03 $771.21 $752.00

62 $956.34 $890.35 $862.67 $797.51 $788.50 $768.86

63 $982.63 $914.83 $886.39 $819.44 $810.18 $790.00

64+ $998.61 $929.70 $900.80 $832.77 $823.35 $802.85




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $357.64 $253.14 $210.21 $210.21 $210.21 $210.21 $196.18

15 $389.43 $275.64 $228.89 $228.89 $228.89 $228.89 $213.61

16 $401.58 $284.24 $236.04 $236.04 $236.04 $236.04 $220.28

17 $413.74 $292.85 $243.18 $243.18 $243.18 $243.18 $226.95

18 $426.83 $302.11 $250.87 $250.87 $250.87 $250.87 $234.13

19 $439.92 $311.38 $258.57 $258.57 $258.57 $258.57 $241.31

20 $453.48 $320.97 $266.54 $266.54 $266.54 $266.54 $248.75

21 $467.50 $330.90 $274.78 $274.78 $274.78 $274.78 $256.44

22 $467.50 $330.90 $274.78 $274.78 $274.78 $274.78 $256.44

23 $467.50 $330.90 $274.78 $274.78 $274.78 $274.78 $256.44

24 $467.50 $330.90 $274.78 $274.78 $274.78 $274.78 $256.44

25 $469.37 $332.22 $275.88 $275.88 $275.88 $275.88 $257.47

26 $478.72 $338.84 $281.37 $281.37 $281.37 $281.37 $262.59

27 $489.94 $346.78 $287.97 $287.97 $287.97 $287.97 $268.75

28 $508.17 $359.69 $298.69 $298.69 $298.69 $298.69 $278.75

29 $523.13 $370.28 $307.48 $307.48 $307.48 $307.48 $286.96

30 $530.61 $375.57 $311.88 $311.88 $311.88 $311.88 $291.06

31 $541.83 $383.51 $318.47 $318.47 $318.47 $318.47 $297.21

32 $553.05 $391.46 $325.06 $325.06 $325.06 $325.06 $303.37

33 $560.07 $396.42 $329.19 $329.19 $329.19 $329.19 $307.21

34 $567.55 $401.71 $333.58 $333.58 $333.58 $333.58 $311.32

35 $571.29 $404.36 $335.78 $335.78 $335.78 $335.78 $313.37

36 $575.03 $407.01 $337.98 $337.98 $337.98 $337.98 $315.42

37 $578.77 $409.65 $340.18 $340.18 $340.18 $340.18 $317.47

38 $582.51 $412.30 $342.38 $342.38 $342.38 $342.38 $319.52

39 $589.99 $417.60 $346.77 $346.77 $346.77 $346.77 $323.63

40 $597.47 $422.89 $351.17 $351.17 $351.17 $351.17 $327.73

41 $608.69 $430.83 $357.76 $357.76 $357.76 $357.76 $333.88

42 $619.44 $438.44 $364.08 $364.08 $364.08 $364.08 $339.78

43 $634.40 $449.03 $372.88 $372.88 $372.88 $372.88 $347.99

44 $653.10 $462.27 $383.87 $383.87 $383.87 $383.87 $358.25

45 $675.07 $477.82 $396.78 $396.78 $396.78 $396.78 $370.30

46 $701.25 $496.35 $412.17 $412.17 $412.17 $412.17 $384.66

47 $730.70 $517.20 $429.48 $429.48 $429.48 $429.48 $400.81

48 $764.36 $541.02 $449.26 $449.26 $449.26 $449.26 $419.28

49 $797.56 $564.52 $468.77 $468.77 $468.77 $468.77 $437.49

50 $834.96 $590.99 $490.76 $490.76 $490.76 $490.76 $458.00

51 $871.89 $617.13 $512.46 $512.46 $512.46 $512.46 $478.26

52 $912.56 $645.92 $536.37 $536.37 $536.37 $536.37 $500.57

53 $953.70 $675.04 $560.55 $560.55 $560.55 $560.55 $523.14

54 $998.11 $706.47 $586.65 $586.65 $586.65 $586.65 $547.50

55 $1,042.53 $737.91 $612.76 $612.76 $612.76 $612.76 $571.86

56 $1,090.68 $771.99 $641.06 $641.06 $641.06 $641.06 $598.27

57 $1,139.30 $806.40 $669.64 $669.64 $669.64 $669.64 $624.94

58 $1,191.19 $843.13 $700.14 $700.14 $700.14 $700.14 $653.41

59 $1,216.90 $861.33 $715.25 $715.25 $715.25 $715.25 $667.51

60 $1,268.80 $898.06 $745.75 $745.75 $745.75 $745.75 $695.98

61 $1,313.68 $929.83 $772.13 $772.13 $772.13 $772.13 $720.59

62 $1,343.13 $950.68 $789.44 $789.44 $789.44 $789.44 $736.75

63 $1,380.06 $976.82 $811.15 $811.15 $811.15 $811.15 $757.01

64+ $1,402.50 $992.70 $824.34 $824.34 $824.34 $824.34 $769.32



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $471.66 $350.91 $298.53 $298.53 $298.53 $298.53

15 $513.58 $382.11 $325.07 $325.07 $325.07 $325.07

16 $529.61 $394.03 $335.21 $335.21 $335.21 $335.21

17 $545.64 $405.96 $345.36 $345.36 $345.36 $345.36

18 $562.91 $418.80 $356.28 $356.28 $356.28 $356.28

19 $580.17 $431.65 $367.21 $367.21 $367.21 $367.21

20 $598.05 $444.95 $378.53 $378.53 $378.53 $378.53

21 $616.54 $458.71 $390.23 $390.23 $390.23 $390.23

22 $616.54 $458.71 $390.23 $390.23 $390.23 $390.23

23 $616.54 $458.71 $390.23 $390.23 $390.23 $390.23

24 $616.54 $458.71 $390.23 $390.23 $390.23 $390.23

25 $619.01 $460.55 $391.80 $391.80 $391.80 $391.80

26 $631.34 $469.72 $399.60 $399.60 $399.60 $399.60

27 $646.14 $480.73 $408.97 $408.97 $408.97 $408.97

28 $670.18 $498.62 $424.18 $424.18 $424.18 $424.18

29 $689.91 $513.30 $436.67 $436.67 $436.67 $436.67

30 $699.78 $520.64 $442.92 $442.92 $442.92 $442.92

31 $714.58 $531.65 $452.28 $452.28 $452.28 $452.28

32 $729.37 $542.65 $461.65 $461.65 $461.65 $461.65

33 $738.62 $549.54 $467.50 $467.50 $467.50 $467.50

34 $748.49 $556.88 $473.74 $473.74 $473.74 $473.74

35 $753.42 $560.54 $476.87 $476.87 $476.87 $476.87

36 $758.35 $564.21 $479.99 $479.99 $479.99 $479.99

37 $763.28 $567.88 $483.11 $483.11 $483.11 $483.11

38 $768.21 $571.55 $486.23 $486.23 $486.23 $486.23

39 $778.08 $578.89 $492.48 $492.48 $492.48 $492.48

40 $787.94 $586.23 $498.72 $498.72 $498.72 $498.72

41 $802.74 $597.24 $508.08 $508.08 $508.08 $508.08

42 $816.92 $607.79 $517.06 $517.06 $517.06 $517.06

43 $836.65 $622.47 $529.55 $529.55 $529.55 $529.55

44 $861.31 $640.82 $545.16 $545.16 $545.16 $545.16

45 $890.29 $662.38 $563.50 $563.50 $563.50 $563.50

46 $924.82 $688.07 $585.35 $585.35 $585.35 $585.35

47 $963.66 $716.97 $609.94 $609.94 $609.94 $609.94

48 $1,008.05 $749.99 $638.03 $638.03 $638.03 $638.03

49 $1,051.83 $782.56 $665.74 $665.74 $665.74 $665.74

50 $1,101.15 $819.26 $696.96 $696.96 $696.96 $696.96

51 $1,149.86 $855.50 $727.79 $727.79 $727.79 $727.79

52 $1,203.49 $895.40 $761.74 $761.74 $761.74 $761.74

53 $1,257.75 $935.77 $796.08 $796.08 $796.08 $796.08

54 $1,316.32 $979.35 $833.15 $833.15 $833.15 $833.15

55 $1,374.89 $1,022.93 $870.22 $870.22 $870.22 $870.22

56 $1,438.40 $1,070.17 $910.42 $910.42 $910.42 $910.42

57 $1,502.52 $1,117.88 $951.00 $951.00 $951.00 $951.00

58 $1,570.96 $1,168.80 $994.32 $994.32 $994.32 $994.32

59 $1,604.87 $1,194.02 $1,015.78 $1,015.78 $1,015.78 $1,015.78

60 $1,673.30 $1,244.94 $1,059.10 $1,059.10 $1,059.10 $1,059.10

61 $1,732.49 $1,288.98 $1,096.56 $1,096.56 $1,096.56 $1,096.56

62 $1,771.33 $1,317.88 $1,121.14 $1,121.14 $1,121.14 $1,121.14

63 $1,820.04 $1,354.11 $1,151.97 $1,151.97 $1,151.97 $1,151.97

64+ $1,849.63 $1,376.13 $1,170.70 $1,170.70 $1,170.70 $1,170.70




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $278.60 $259.38 $251.32 $232.33 $229.71 $223.99

15 $303.37 $282.44 $273.65 $252.99 $250.13 $243.90

16 $312.84 $291.25 $282.20 $260.88 $257.93 $251.51

17 $322.31 $300.07 $290.74 $268.78 $265.74 $259.12

18 $332.50 $309.56 $299.94 $277.28 $274.15 $267.32

19 $342.70 $319.05 $309.13 $285.79 $282.56 $275.52

20 $353.26 $328.89 $318.66 $294.59 $291.26 $284.01

21 $364.19 $339.06 $328.52 $303.71 $300.27 $292.79

22 $364.19 $339.06 $328.52 $303.71 $300.27 $292.79

23 $364.19 $339.06 $328.52 $303.71 $300.27 $292.79

24 $364.19 $339.06 $328.52 $303.71 $300.27 $292.79

25 $365.64 $340.41 $329.83 $304.92 $301.47 $293.97

26 $372.93 $347.20 $336.40 $310.99 $307.48 $299.82

27 $381.67 $355.33 $344.29 $318.28 $314.68 $306.85

28 $395.87 $368.56 $357.10 $330.13 $326.40 $318.27

29 $407.53 $379.41 $367.61 $339.85 $336.00 $327.64

30 $413.35 $384.83 $372.87 $344.71 $340.81 $332.32

31 $422.09 $392.97 $380.75 $351.99 $348.01 $339.35

32 $430.83 $401.11 $388.64 $359.28 $355.22 $346.38

33 $436.30 $406.19 $393.56 $363.84 $359.73 $350.77

34 $442.12 $411.62 $398.82 $368.70 $364.53 $355.45

35 $445.04 $414.33 $401.45 $371.13 $366.93 $357.79

36 $447.95 $417.04 $404.08 $373.56 $369.33 $360.14

37 $450.86 $419.75 $406.70 $375.99 $371.74 $362.48

38 $453.78 $422.47 $409.33 $378.42 $374.14 $364.82

39 $459.60 $427.89 $414.59 $383.28 $378.94 $369.51

40 $465.43 $433.32 $419.85 $388.14 $383.75 $374.19

41 $474.17 $441.45 $427.73 $395.42 $390.95 $381.22

42 $482.55 $449.25 $435.29 $402.41 $397.86 $387.95

43 $494.20 $460.10 $445.80 $412.13 $407.47 $397.32

44 $508.77 $473.66 $458.94 $424.28 $419.48 $409.03

45 $525.89 $489.60 $474.38 $438.55 $433.59 $422.80

46 $546.28 $508.59 $492.78 $455.56 $450.41 $439.19

47 $569.22 $529.95 $513.47 $474.69 $469.32 $457.64

48 $595.45 $554.36 $537.13 $496.56 $490.94 $478.72

49 $621.30 $578.43 $560.45 $518.12 $512.26 $499.51

50 $650.44 $605.56 $586.73 $542.42 $536.28 $522.93

51 $679.21 $632.34 $612.68 $566.41 $560.01 $546.06

52 $710.89 $661.84 $641.27 $592.83 $586.13 $571.53

53 $742.94 $691.68 $670.18 $619.56 $612.55 $597.30

54 $777.54 $723.89 $701.38 $648.41 $641.08 $625.12

55 $812.14 $756.10 $732.59 $677.26 $669.61 $652.93

56 $849.65 $791.02 $766.43 $708.55 $700.53 $683.09

57 $887.52 $826.28 $800.60 $740.13 $731.76 $713.54

58 $927.95 $863.92 $837.06 $773.84 $765.09 $746.04

59 $947.98 $882.57 $855.13 $790.55 $781.61 $762.14

60 $988.40 $920.20 $891.60 $824.26 $814.94 $794.64

61 $1,023.37 $952.75 $923.13 $853.41 $843.76 $822.75

62 $1,046.31 $974.11 $943.83 $872.55 $862.68 $841.20

63 $1,075.08 $1,000.90 $969.78 $896.54 $886.40 $864.33

64+ $1,092.56 $1,017.17 $985.55 $911.12 $900.81 $878.38




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $421.08 $298.04 $247.49 $247.49 $247.49 $247.49 $230.97

15 $458.50 $324.53 $269.49 $269.49 $269.49 $269.49 $251.50

16 $472.82 $334.66 $277.90 $277.90 $277.90 $277.90 $259.35

17 $487.13 $344.79 $286.31 $286.31 $286.31 $286.31 $267.20

18 $502.54 $355.70 $295.37 $295.37 $295.37 $295.37 $275.66

19 $517.95 $366.61 $304.43 $304.43 $304.43 $304.43 $284.11

20 $533.91 $377.91 $313.81 $313.81 $313.81 $313.81 $292.87

21 $550.43 $389.59 $323.52 $323.52 $323.52 $323.52 $301.93

22 $550.43 $389.59 $323.52 $323.52 $323.52 $323.52 $301.93

23 $550.43 $389.59 $323.52 $323.52 $323.52 $323.52 $301.93

24 $550.43 $389.59 $323.52 $323.52 $323.52 $323.52 $301.93

25 $552.63 $391.15 $324.81 $324.81 $324.81 $324.81 $303.13

26 $563.64 $398.95 $331.28 $331.28 $331.28 $331.28 $309.17

27 $576.85 $408.30 $339.05 $339.05 $339.05 $339.05 $316.42

28 $598.31 $423.49 $351.67 $351.67 $351.67 $351.67 $328.19

29 $615.93 $435.96 $362.02 $362.02 $362.02 $362.02 $337.86

30 $624.73 $442.19 $367.19 $367.19 $367.19 $367.19 $342.69

31 $637.94 $451.54 $374.96 $374.96 $374.96 $374.96 $349.93

32 $651.15 $460.89 $382.72 $382.72 $382.72 $382.72 $357.18

33 $659.41 $466.73 $387.58 $387.58 $387.58 $387.58 $361.71

34 $668.22 $472.97 $392.75 $392.75 $392.75 $392.75 $366.54

35 $672.62 $476.08 $395.34 $395.34 $395.34 $395.34 $368.95

36 $677.02 $479.20 $397.93 $397.93 $397.93 $397.93 $371.37

37 $681.43 $482.32 $400.52 $400.52 $400.52 $400.52 $373.78

38 $685.83 $485.44 $403.11 $403.11 $403.11 $403.11 $376.20

39 $694.64 $491.67 $408.28 $408.28 $408.28 $408.28 $381.03

40 $703.44 $497.90 $413.46 $413.46 $413.46 $413.46 $385.86

41 $716.65 $507.25 $421.22 $421.22 $421.22 $421.22 $393.11

42 $729.31 $516.21 $428.66 $428.66 $428.66 $428.66 $400.05

43 $746.93 $528.68 $439.02 $439.02 $439.02 $439.02 $409.71

44 $768.94 $544.26 $451.96 $451.96 $451.96 $451.96 $421.79

45 $794.81 $562.57 $467.16 $467.16 $467.16 $467.16 $435.98

46 $825.64 $584.39 $485.28 $485.28 $485.28 $485.28 $452.89

47 $860.31 $608.94 $505.66 $505.66 $505.66 $505.66 $471.91

48 $899.94 $636.99 $528.95 $528.95 $528.95 $528.95 $493.65

49 $939.03 $664.65 $551.92 $551.92 $551.92 $551.92 $515.09

50 $983.06 $695.82 $577.81 $577.81 $577.81 $577.81 $539.24

51 $1,026.54 $726.59 $603.36 $603.36 $603.36 $603.36 $563.09

52 $1,074.43 $760.49 $631.51 $631.51 $631.51 $631.51 $589.36

53 $1,122.87 $794.77 $659.98 $659.98 $659.98 $659.98 $615.93

54 $1,175.16 $831.78 $690.71 $690.71 $690.71 $690.71 $644.61

55 $1,227.45 $868.80 $721.45 $721.45 $721.45 $721.45 $673.29

56 $1,284.14 $908.92 $754.77 $754.77 $754.77 $754.77 $704.39

57 $1,341.39 $949.44 $788.42 $788.42 $788.42 $788.42 $735.79

58 $1,402.48 $992.69 $824.33 $824.33 $824.33 $824.33 $769.31

59 $1,432.76 $1,014.12 $842.12 $842.12 $842.12 $842.12 $785.91

60 $1,493.85 $1,057.36 $878.03 $878.03 $878.03 $878.03 $819.43

61 $1,546.69 $1,094.76 $909.09 $909.09 $909.09 $909.09 $848.41

62 $1,581.37 $1,119.31 $929.47 $929.47 $929.47 $929.47 $867.43

63 $1,624.85 $1,150.08 $955.03 $955.03 $955.03 $955.03 $891.29

64+ $1,651.28 $1,168.78 $970.56 $970.56 $970.56 $970.56 $905.78



Platinum 90 PPO

Gold 80 PPO

Silver 70 PPO

Silver 73 PPO

Silver 87 PPO

Silver 94 PPO

0 to 14 $515.13 $383.26 $326.05 $326.05 $326.05 $326.05

15 $560.92 $417.33 $355.03 $355.03 $355.03 $355.03

16 $578.43 $430.35 $366.11 $366.11 $366.11 $366.11

17 $595.94 $443.38 $377.19 $377.19 $377.19 $377.19

18 $614.79 $457.41 $389.12 $389.12 $389.12 $389.12

19 $633.64 $471.43 $401.06 $401.06 $401.06 $401.06

20 $653.17 $485.96 $413.42 $413.42 $413.42 $413.42

21 $673.37 $500.99 $426.20 $426.20 $426.20 $426.20

22 $673.37 $500.99 $426.20 $426.20 $426.20 $426.20

23 $673.37 $500.99 $426.20 $426.20 $426.20 $426.20

24 $673.37 $500.99 $426.20 $426.20 $426.20 $426.20

25 $676.07 $503.00 $427.91 $427.91 $427.91 $427.91

26 $689.53 $513.02 $436.43 $436.43 $436.43 $436.43

27 $705.69 $525.04 $446.66 $446.66 $446.66 $446.66

28 $731.96 $544.58 $463.28 $463.28 $463.28 $463.28

29 $753.50 $560.61 $476.92 $476.92 $476.92 $476.92

30 $764.28 $568.63 $483.74 $483.74 $483.74 $483.74

31 $780.44 $580.65 $493.97 $493.97 $493.97 $493.97

32 $796.60 $592.67 $504.20 $504.20 $504.20 $504.20

33 $806.70 $600.19 $510.59 $510.59 $510.59 $510.59

34 $817.47 $608.20 $517.41 $517.41 $517.41 $517.41

35 $822.86 $612.21 $520.82 $520.82 $520.82 $520.82

36 $828.25 $616.22 $524.23 $524.23 $524.23 $524.23

37 $833.64 $620.23 $527.64 $527.64 $527.64 $527.64

38 $839.02 $624.24 $531.05 $531.05 $531.05 $531.05

39 $849.80 $632.25 $537.87 $537.87 $537.87 $537.87

40 $860.57 $640.27 $544.69 $544.69 $544.69 $544.69

41 $876.73 $652.29 $554.92 $554.92 $554.92 $554.92

42 $892.22 $663.81 $564.72 $564.72 $564.72 $564.72

43 $913.77 $679.85 $578.36 $578.36 $578.36 $578.36

44 $940.70 $699.88 $595.41 $595.41 $595.41 $595.41

45 $972.35 $723.43 $615.44 $615.44 $615.44 $615.44

46 $1,010.06 $751.49 $639.30 $639.30 $639.30 $639.30

47 $1,052.48 $783.05 $666.16 $666.16 $666.16 $666.16

48 $1,100.96 $819.12 $696.84 $696.84 $696.84 $696.84

49 $1,148.77 $854.69 $727.10 $727.10 $727.10 $727.10

50 $1,202.64 $894.77 $761.20 $761.20 $761.20 $761.20

51 $1,255.84 $934.35 $794.87 $794.87 $794.87 $794.87

52 $1,314.42 $977.94 $831.95 $831.95 $831.95 $831.95

53 $1,373.68 $1,022.02 $869.45 $869.45 $869.45 $869.45

54 $1,437.65 $1,069.62 $909.94 $909.94 $909.94 $909.94

55 $1,501.62 $1,117.21 $950.43 $950.43 $950.43 $950.43

56 $1,570.98 $1,168.81 $994.33 $994.33 $994.33 $994.33

57 $1,641.01 $1,220.92 $1,038.66 $1,038.66 $1,038.66 $1,038.66

58 $1,715.75 $1,276.53 $1,085.97 $1,085.97 $1,085.97 $1,085.97

59 $1,752.79 $1,304.08 $1,109.41 $1,109.41 $1,109.41 $1,109.41

60 $1,827.53 $1,359.69 $1,156.71 $1,156.71 $1,156.71 $1,156.71

61 $1,892.18 $1,407.79 $1,197.63 $1,197.63 $1,197.63 $1,197.63

62 $1,934.60 $1,439.35 $1,224.48 $1,224.48 $1,224.48 $1,224.48

63 $1,987.80 $1,478.93 $1,258.15 $1,258.15 $1,258.15 $1,258.15

64+ $2,020.12 $1,502.97 $1,278.61 $1,278.61 $1,278.61 $1,278.61




Silver 1950 PPO


Bronze 60 PPO

Bronze 60 HDHP PPO


0 to 14 $304.28 $283.29 $274.48 $253.75 $250.88 $244.63

15 $331.33 $308.47 $298.88 $276.31 $273.18 $266.38

16 $341.67 $318.10 $308.21 $284.93 $281.71 $274.69

17 $352.01 $327.72 $317.54 $293.55 $290.23 $283.01

18 $363.15 $338.09 $327.58 $302.84 $299.42 $291.96

19 $374.29 $348.46 $337.63 $312.13 $308.60 $300.91

20 $385.82 $359.20 $348.03 $321.75 $318.11 $310.19

21 $397.76 $370.31 $358.80 $331.70 $327.95 $319.78

22 $397.76 $370.31 $358.80 $331.70 $327.95 $319.78

23 $397.76 $370.31 $358.80 $331.70 $327.95 $319.78

24 $397.76 $370.31 $358.80 $331.70 $327.95 $319.78

25 $399.35 $371.79 $360.23 $333.03 $329.26 $321.06

26 $407.30 $379.20 $367.41 $339.66 $335.82 $327.46

27 $416.85 $388.08 $376.02 $347.62 $343.69 $335.13

28 $432.36 $402.53 $390.01 $360.56 $356.48 $347.60

29 $445.09 $414.38 $401.49 $371.17 $366.97 $357.84

30 $451.45 $420.30 $407.24 $376.48 $372.22 $362.95

31 $461.00 $429.19 $415.85 $384.44 $380.09 $370.63

32 $470.54 $438.08 $424.46 $392.40 $387.96 $378.30

33 $476.51 $443.63 $429.84 $397.38 $392.88 $383.10

34 $482.88 $449.56 $435.58 $402.68 $398.13 $388.22

35 $486.06 $452.52 $438.45 $405.34 $400.75 $390.77

36 $489.24 $455.48 $441.32 $407.99 $403.38 $393.33

37 $492.42 $458.44 $444.19 $410.64 $406.00 $395.89

38 $495.60 $461.41 $447.06 $413.30 $408.62 $398.45

39 $501.97 $467.33 $452.80 $418.60 $413.87 $403.56

40 $508.33 $473.26 $458.54 $423.91 $419.12 $408.68

41 $517.88 $482.14 $467.15 $431.87 $426.99 $416.36

42 $527.03 $490.66 $475.41 $439.50 $434.53 $423.71

43 $539.75 $502.51 $486.89 $450.12 $445.03 $433.94

44 $555.66 $517.32 $501.24 $463.38 $458.14 $446.74

45 $574.36 $534.73 $518.10 $478.97 $473.56 $461.77

46 $596.63 $555.46 $538.20 $497.55 $491.92 $479.67

47 $621.69 $578.79 $560.80 $518.45 $512.58 $499.82

48 $650.33 $605.46 $586.63 $542.33 $536.20 $522.84

49 $678.57 $631.75 $612.11 $565.88 $559.48 $545.55

50 $710.39 $661.37 $640.81 $592.41 $585.72 $571.13

51 $741.81 $690.63 $669.16 $618.62 $611.62 $596.39

52 $776.42 $722.84 $700.37 $647.48 $640.15 $624.21

53 $811.42 $755.43 $731.95 $676.67 $669.01 $652.36

54 $849.21 $790.61 $766.03 $708.18 $700.17 $682.73

55 $886.99 $825.79 $800.12 $739.69 $731.32 $713.11

56 $927.96 $863.93 $837.07 $773.85 $765.10 $746.05

57 $969.33 $902.44 $874.39 $808.35 $799.21 $779.31

58 $1,013.48 $943.55 $914.22 $845.17 $835.61 $814.80

59 $1,035.36 $963.92 $933.95 $863.41 $853.65 $832.39

60 $1,079.51 $1,005.02 $973.78 $900.23 $890.05 $867.89

61 $1,117.69 $1,040.57 $1,008.22 $932.07 $921.53 $898.59

62 $1,142.75 $1,063.90 $1,030.83 $952.97 $942.20 $918.73

63 $1,174.17 $1,093.15 $1,059.17 $979.18 $968.10 $944.00

64+ $1,193.27 $1,110.93 $1,076.39 $995.10 $983.84 $959.35




Gold 80 Trio HMO

Silver 70 Trio HMO

Silver 73 Trio HMO

Silver 87 Trio HMO

Silver 94 Trio HMO


0 to 14 $415.29 $293.95 $244.09 $244.09 $244.09 $244.09 $227.80

15 $452.21 $320.08 $265.79 $265.79 $265.79 $265.79 $248.05

16 $466.32 $330.07 $274.09 $274.09 $274.09 $274.09 $255.79

17 $480.44 $340.06 $282.38 $282.38 $282.38 $282.38 $263.54

18 $495.64 $350.82 $291.32 $291.32 $291.32 $291.32 $271.87

19 $510.84 $361.58 $300.25 $300.25 $300.25 $300.25 $280.21

20 $526.58 $372.72 $309.51 $309.51 $309.51 $309.51 $288.85

21 $542.87 $384.25 $319.08 $319.08 $319.08 $319.08 $297.78

22 $542.87 $384.25 $319.08 $319.08 $319.08 $319.08 $297.78

23 $542.87 $384.25 $319.08 $319.08 $319.08 $319.08 $297.78

24 $542.87 $384.25 $319.08 $319.08 $319.08 $319.08 $297.78

25 $545.04 $385.78 $320.35 $320.35 $320.35 $320.35 $298.97

26 $555.90 $393.47 $326.74 $326.74 $326.74 $326.74 $304.93

27 $568.93 $402.69 $334.39 $334.39 $334.39 $334.39 $312.07

28 $590.10 $417.68 $346.84 $346.84 $346.84 $346.84 $323.69

29 $607.47 $429.97 $357.05 $357.05 $357.05 $357.05 $333.22

30 $616.16 $436.12 $362.15 $362.15 $362.15 $362.15 $337.98

31 $629.18 $445.34 $369.81 $369.81 $369.81 $369.81 $345.13

32 $642.21 $454.56 $377.47 $377.47 $377.47 $377.47 $352.27

33 $650.36 $460.33 $382.26 $382.26 $382.26 $382.26 $356.74

34 $659.04 $466.47 $387.36 $387.36 $387.36 $387.36 $361.51

35 $663.39 $469.55 $389.91 $389.91 $389.91 $389.91 $363.89

36 $667.73 $472.62 $392.47 $392.47 $392.47 $392.47 $366.27

37 $672.07 $475.70 $395.02 $395.02 $395.02 $395.02 $368.65

38 $676.41 $478.77 $397.57 $397.57 $397.57 $397.57 $371.03

39 $685.10 $484.92 $402.68 $402.68 $402.68 $402.68 $375.80

40 $693.79 $491.07 $407.78 $407.78 $407.78 $407.78 $380.56

41 $706.81 $500.29 $415.44 $415.44 $415.44 $415.44 $387.71

42 $719.30 $509.13 $422.78 $422.78 $422.78 $422.78 $394.56

43 $736.67 $521.42 $432.99 $432.99 $432.99 $432.99 $404.09

44 $758.39 $536.79 $445.75 $445.75 $445.75 $445.75 $416.00

45 $783.90 $554.85 $460.75 $460.75 $460.75 $460.75 $430.00

46 $814.30 $576.37 $478.62 $478.62 $478.62 $478.62 $446.67

47 $848.50 $600.58 $498.72 $498.72 $498.72 $498.72 $465.43

48 $887.59 $628.24 $521.69 $521.69 $521.69 $521.69 $486.87

49 $926.13 $655.52 $544.35 $544.35 $544.35 $544.35 $508.01

50 $969.56 $686.26 $569.87 $569.87 $569.87 $569.87 $531.84

51 $1,012.45 $716.62 $595.08 $595.08 $595.08 $595.08 $555.36

52 $1,059.68 $750.05 $622.84 $622.84 $622.84 $622.84 $581.27

53 $1,107.45 $783.86 $650.92 $650.92 $650.92 $650.92 $607.47

54 $1,159.02 $820.37 $681.23 $681.23 $681.23 $681.23 $635.76

55 $1,210.60 $856.87 $711.54 $711.54 $711.54 $711.54 $664.05

56 $1,266.51 $896.45 $744.41 $744.41 $744.41 $744.41 $694.72

57 $1,322.97 $936.41 $777.59 $777.59 $777.59 $777.59 $725.69

58 $1,383.23 $979.06 $813.01 $813.01 $813.01 $813.01 $758.75

59 $1,413.09 $1,000.19 $830.56 $830.56 $830.56 $830.56 $775.12

60 $1,473.34 $1,042.84 $865.98 $865.98 $865.98 $865.98 $808.18

61 $1,525.46 $1,079.73 $896.61 $896.61 $896.61 $896.61 $836.76

62 $1,559.66 $1,103.94 $916.71 $916.71 $916.71 $916.71 $855.52

63 $1,602.55 $1,134.29 $941.92 $941.92 $941.92 $941.92 $879.05

64+ $1,628.60 $1,152.74 $957.23 $957.23 $957.23 $957.23 $893.34

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