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Filing at a Glance

Company: Oxford Health Insurance, Inc.

Product Name: 2022 OHI SG SHOP & OFFX Plans

State: New York

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

Sub-TOI: H15G.003 Small Group Only

Filing Type: 2022 Prior Approval ACA Rates

Date Submitted: 05/12/2021

SERFF Tr Num: UHLC-132808091

SERFF Status: Pending State Action

State Tr Num: 2021050185

State Status: CP-xx-RR

Co Tr Num: CY2022 RATE FILING

EffectiveDate Requested:

01/01/2022

Author(s):

Reviewer(s):

Disposition Date:

Disposition Status:

Effective Date:

State Filing Description:

SERFF Tracking #: UHLC-132808091 State Tracking #: 2021050185 Company Tracking #: CY2022 RATE FILING

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

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


Project Name/Number: 2022 OHI SG SHOP & OFFX Plans/

PDF Pipeline for SERFF Tracking Number UHLC-132808091 Generated 05/24/2021 11:02 AM

General Information

Company and Contact

Project Name: 2022 OHI SG SHOP & OFFX Plans Status of Filing in Domicile: Not Filed

Project Number: Date Approved in Domicile:

Requested Filing Mode: Review & Approval Domicile Status Comments:

Explanation for Combination/Other: Market Type: Group

Submission Type: New Submission Group Market Size: Small

Group Market Type: Employer Overall Rate Impact:

Filing Status Changed: 05/21/2021

State Status Changed: 05/21/2021 Deemer Date:

Created By: Submitted By:

Corresponding Filing Tracking Number:

PPACA: Non-Grandfathered Immed Mkt Reforms

PPACA Notes: null

Exchange Intentions: Yes, this filing includes Oxford's 2022 SHOP Exchange Filing.

Filing Description:

2022 OHI Small Group SHOP & Off Exchange Plans

Filing Contact Information

Filing Company InformationOxford Health Insurance, Inc.

One Penn Plaza FL 8

New York, NY 10119

(203) 459-6000 ext. [Phone]

CoCode: 78026

Group Code:

Group Name:

FEIN Number: 22-2797560

State of Domicile: New York

Company Type: Insurance

State ID Number: 78026







Filing Fees

State Specific

State Fees

Fee Required? No

Retaliatory? No

Fee Explanation:

1. Is a parallel filing being submitted for another issuing entity of the same parent organization? Yes/No (If Yes, enter nameof other entity, submission date, and SERFF Tracking Number of the parallel file.): Yes - 2022 OHI Small Group On & Off COCFiling & 2022 OHI Healthy NY COC Filing, 5/12/21, SERFF Tr Num: UHLC-132822382 and UHLC-1328224202. Does this filing contain a dental, vision or health insurance policy or contract that uses a network of health care providers?(If Yes, enter the PNDS Network ID number and name. If the network has not been filed in PNDS, it must be filed within 60days of approval.): Yes - 0112 Freedom, 0076 Liberty, 0173 Metro3. : n/a4. Type of filing? Enter Form and Rate, Form only, Rate only (Form only should be used ONLY when the filing only containsan application, advertisement, administrative form, or is a group prefiling notification, out-of-state, or a report filing. Formsubmissions with no proposed rate impact are considered form and rate filings and require an actuarial memorandum.): RateOnly5. Is this a Rate only filing? Yes/No [If Yes, enter one: Commission/Fee Schedule, DBL Loss Ratio Monitoring, ExperienceFiling Monitoring, Experience Rating Formula, Medicare Supplement Annual Filing (other than rate adjustment), RateAdjustment, or Other with brief explanation).]: Yes - Prior Approval Rate Adjustment6. Does this submission contain a form subject to Regulation 123 (i.e., the certificate is deemed delivered in New York State)?Yes/No (If Yes, provide a full explanation in the Filing Description field.): No7. Did this insurer prefile group coverage for this group under Section 52.32 prior to this filing? Yes/No (If Yes, enter thestate tracking number assigned and the effective date of coverage.): No8. Does this submission contain any form which is subject to review by the Life Bureau, the Property Bureau or both? Yes/No(If Yes, identify the forms, the Bureau, the date submitted, and the SERFF file number.): No9. Does this filing contain forms that replace any other previously approved forms? Yes/No (If Yes, identify the formnumbers, the file number, and the date of approval of the forms being replaced in the Filing Description field.): No







Rate Information Rate data applies to filing.

Filing Method: Prior Approval

Rate Change Type: Increase

Overall Percentage of Last Rate Revision: 5.290%

Effective Date of Last Rate Revision: 01/01/2021

Filing Method of Last Filing: Prior Approval

SERFF Tracking Number of Last Filing: UHLC-132366075

Company Rate Information

Company

Name:

Company

Rate

Change:

Overall %

Indicated

Change:

Overall %

Rate

Impact:

Written

Premium

Change for

this Program:

Number of Policy

Holders Affected

for this Program:

Written

Premium for

this Program:

Maximum %

Change

(where req'd):

Minimum %

Change

(where req'd):

Oxford HealthInsurance, Inc.

Increase 15.870% 15.870% $741,659,295 446,066 $4,673,361,759 26.270% 11.204%







Rate Review Detail

COMPANY:Company Name: Oxford Health Insurance, Inc.

HHS Issuer Id: 85629

PRODUCTS:

Product Name HIOS Product ID HIOS Submission ID Number of Covered

LivesOff Exchange OHI SG Products 446066

Trend Factors: 2.5% Quarterly Trend

FORMS:New Policy Forms:

Affected Forms:

Other Affected Forms: OHINY_SG_COC_2022

REQUESTED RATE CHANGE INFORMATION:Change Period: Annual

Member Months: 5,832,079

Benefit Change: None

Percent Change Requested: Min: 11.204 Max: 26.27 Avg: 15.87

PRIOR RATE:Total Earned Premium: 4,673,361,759.00

Total Incurred Claims: 4,135,675,043.00

Annual $: Min: 466.06 Max: 1,383.19 Avg: 801.32

REQUESTED RATE:Projected Earned Premium: 5,415,021,053.00

Projected Incurred Claims: 4,538,414,780.00

Annual $: Min: 573.61 Max: 1,556.82 Avg: 928.49







Rate/Rule Schedule

Item

No.

Schedule

Item

Status

Document Name

Affected Form Numbers

(Separated with commas) Rate Action Rate Action Information Attachments

1 2022 SG OHI OnOff-Exch RateManual

New 2022 OHI SG RateManual - Final.pdf,2022 OHI SG RateManual - Final.xlsm,







Oxford Health Insurance, Inc.

New York Small Group

On/Off Exchange

Form # OHINY_SG_COC_2022

Rate Manual

Rates Effective January 1, 2022

Page 1 of 109



On/Off Exchange


Table of Contents

Section Page(s)

Area Factors 3

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

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

Ancillary Coverage Rider Rates 12

Medical and Rx Drug Benefits 13 - 14

Pediatric Dental and Vision Benefits 15

Additional Notes 16

Page 2 of 109



On/Off Exchange


Area FactorsArea Factor is "n/a" for counties outside the service area.

County

DFS Rating

Region Area Factor County

DFS Rating

Region Area Factor County

DFS Rating

Region Area Factor

Albany 1 n/a Delaware 3 n/a Broome 6 n/a

Columbia 1 n/a Dutchess 3 1.055 Cayuga 6 n/a

Fulton 1 n/a Orange 3 1.055 Chemung 6 n/a

Greene 1 n/a Putnam 3 1.055 Cortland 6 n/a

Montgomery 1 n/a Sullivan 3 1.055 Onondaga 6 n/a

Rensselaer 1 n/a Ulster 3 1.055 Schuyler 6 n/a

Saratoga 1 n/a Bronx 4 0.992 Steuben 6 n/a

Schenectady 1 n/a Kings 4 0.992 Tioga 6 n/a

Schoharie 1 n/a New York 4 0.992 Tompkins 6 n/a

Warren 1 n/a Queens 4 0.992 Chenango 7 n/a

Washington 1 n/a Richmond 4 0.992 Clinton 7 n/a

Allegany 2 n/a Rockland 4 0.992 Essex 7 n/a

Cattaraugus 2 n/a Westchester 4 0.992 Franklin 7 n/a

Chautauqua 2 n/a Livingston 5 n/a Hamilton 7 n/a

Erie 2 n/a Monroe 5 n/a Herkimer 7 n/a

Genesee 2 n/a Ontario 5 n/a Jefferson 7 n/a

Niagara 2 n/a Seneca 5 n/a Lewis 7 n/a

Orleans 2 n/a Wayne 5 n/a Madison 7 n/a

Wyoming 2 n/a Yates 5 n/a Oneida 7 n/a

Oswego 7 n/a

Otsego 7 n/a

St. Lawrence 7 n/a

Nassau 8 1.023

Suffolk 8 1.023

Page 3 of 109



Off-Exchange


Base Medical and Prescription Drug Monthly Rates 2022 Q1

Plan 16-digit HIOS ID Dep 29 Rider

Domestic

Partner Rider

Contraceptive

Exclusion Rider Single Rate

Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010316-00 N N N 935.06$ 1,589.60$ 1,870.12$ 2,664.92$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010325-00 N N Y 930.25$ 1,581.42$ 1,860.50$ 2,651.21$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010310-00 N Y N 935.06$ 1,589.60$ 1,870.12$ 2,664.92$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010326-00 N Y Y 930.25$ 1,581.42$ 1,860.50$ 2,651.21$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010311-00 Y N N 955.60$ 1,624.52$ 1,911.20$ 2,723.46$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010309-00 Y Y N 955.60$ 1,624.52$ 1,911.20$ 2,723.46$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010327-00 Y N Y 950.79$ 1,616.34$ 1,901.58$ 2,709.75$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010328-00 Y Y Y 950.79$ 1,616.34$ 1,901.58$ 2,709.75$

NY G FRDM NG 15/35/1750/90 EPO 22 85629NY0010240-00 N N N 1,275.78$ 2,168.83$ 2,551.56$ 3,635.97$

NY G FRDM NG 15/35/1750/90 EPO 22 85629NY0010253-00 N N Y 1,270.97$ 2,160.65$ 2,541.94$ 3,622.26$

NY G FRDM NG 15/35/1750/90 EPO 22 85629NY0010238-00 N Y N 1,275.78$ 2,168.83$ 2,551.56$ 3,635.97$

NY G FRDM NG 15/35/1750/90 EPO 22 85629NY0010254-00 N Y Y 1,270.97$ 2,160.65$ 2,541.94$ 3,622.26$

NY G FRDM NG 15/35/1750/90 EPO 22 85629NY0010239-00 Y N N 1,296.32$ 2,203.75$ 2,592.64$ 3,694.51$

NY G FRDM NG 15/35/1750/90 EPO 22 85629NY0010237-00 Y Y N 1,296.32$ 2,203.75$ 2,592.64$ 3,694.51$

NY G FRDM NG 15/35/1750/90 EPO 22 85629NY0010255-00 Y N Y 1,291.51$ 2,195.57$ 2,583.02$ 3,680.80$

NY G FRDM NG 15/35/1750/90 EPO 22 85629NY0010256-00 Y Y Y 1,291.51$ 2,195.57$ 2,583.02$ 3,680.80$

NY G FRDM NG 1500/90 EPO HSA 22 85629NY0010076-00 N N N 1,207.39$ 2,052.56$ 2,414.78$ 3,441.06$

NY G FRDM NG 1500/90 EPO HSA 22 85629NY0010072-00 N N Y 1,202.58$ 2,044.38$ 2,405.16$ 3,427.35$

NY G FRDM NG 1500/90 EPO HSA 22 85629NY0010235-00 N Y N 1,207.39$ 2,052.56$ 2,414.78$ 3,441.06$

NY G FRDM NG 1500/90 EPO HSA 22 85629NY0010073-00 N Y Y 1,202.58$ 2,044.38$ 2,405.16$ 3,427.35$

NY G FRDM NG 1500/90 EPO HSA 22 85629NY0010236-00 Y N N 1,227.93$ 2,087.48$ 2,455.86$ 3,499.60$

NY G FRDM NG 1500/90 EPO HSA 22 85629NY0010234-00 Y Y N 1,227.93$ 2,087.48$ 2,455.86$ 3,499.60$

NY G FRDM NG 1500/90 EPO HSA 22 85629NY0010074-00 Y N Y 1,223.12$ 2,079.30$ 2,446.24$ 3,485.89$

NY G FRDM NG 1500/90 EPO HSA 22 85629NY0010075-00 Y Y Y 1,223.12$ 2,079.30$ 2,446.24$ 3,485.89$

NY G FRDM NG 1500/90 PPO HSA 22 85629NY0050068-00 N N N 1,259.95$ 2,141.92$ 2,519.90$ 3,590.86$

NY G FRDM NG 1500/90 PPO HSA 22 85629NY0050001-00 N N Y 1,255.14$ 2,133.74$ 2,510.28$ 3,577.15$

NY G FRDM NG 1500/90 PPO HSA 22 85629NY0050066-00 N Y N 1,259.95$ 2,141.92$ 2,519.90$ 3,590.86$

NY G FRDM NG 1500/90 PPO HSA 22 85629NY0050002-00 N Y Y 1,255.14$ 2,133.74$ 2,510.28$ 3,577.15$

NY G FRDM NG 1500/90 PPO HSA 22 85629NY0050067-00 Y N N 1,280.49$ 2,176.84$ 2,560.98$ 3,649.40$

NY G FRDM NG 1500/90 PPO HSA 22 85629NY0050065-00 Y Y N 1,280.49$ 2,176.84$ 2,560.98$ 3,649.40$

NY G FRDM NG 1500/90 PPO HSA 22 85629NY0050003-00 Y N Y 1,275.68$ 2,168.66$ 2,551.36$ 3,635.69$

NY G FRDM NG 1500/90 PPO HSA 22 85629NY0050004-00 Y Y Y 1,275.68$ 2,168.66$ 2,551.36$ 3,635.69$

NY G FRDM NG 25/40/1500/80 PPO 22 85629NY0050044-00 N N N 1,326.99$ 2,255.88$ 2,653.98$ 3,781.92$

NY G FRDM NG 25/40/1500/80 PPO 22 85629NY0050193-00 N N Y 1,322.18$ 2,247.70$ 2,644.36$ 3,768.21$

NY G FRDM NG 25/40/1500/80 PPO 22 85629NY0050042-00 N Y N 1,326.99$ 2,255.88$ 2,653.98$ 3,781.92$

NY G FRDM NG 25/40/1500/80 PPO 22 85629NY0050194-00 N Y Y 1,322.18$ 2,247.70$ 2,644.36$ 3,768.21$

NY G FRDM NG 25/40/1500/80 PPO 22 85629NY0050043-00 Y N N 1,347.53$ 2,290.80$ 2,695.06$ 3,840.46$

NY G FRDM NG 25/40/1500/80 PPO 22 85629NY0050041-00 Y Y N 1,347.53$ 2,290.80$ 2,695.06$ 3,840.46$

NY G FRDM NG 25/40/1500/80 PPO 22 85629NY0050195-00 Y N Y 1,342.72$ 2,282.62$ 2,685.44$ 3,826.75$

NY G FRDM NG 25/40/1500/80 PPO 22 85629NY0050196-00 Y Y Y 1,342.72$ 2,282.62$ 2,685.44$ 3,826.75$

























NY P FRDM NG 20/40/100 EPO 22 85629NY0010036-00 N N N 1,506.23$ 2,560.59$ 3,012.46$ 4,292.76$

NY P FRDM NG 20/40/100 EPO 22 85629NY0010226-00 N N Y 1,501.42$ 2,552.41$ 3,002.84$ 4,279.05$

NY P FRDM NG 20/40/100 EPO 22 85629NY0010034-00 N Y N 1,506.23$ 2,560.59$ 3,012.46$ 4,292.76$

NY P FRDM NG 20/40/100 EPO 22 85629NY0010227-00 N Y Y 1,501.42$ 2,552.41$ 3,002.84$ 4,279.05$

NY P FRDM NG 20/40/100 EPO 22 85629NY0010035-00 Y N N 1,526.77$ 2,595.51$ 3,053.54$ 4,351.30$

NY P FRDM NG 20/40/100 EPO 22 85629NY0010033-00 Y Y N 1,526.77$ 2,595.51$ 3,053.54$ 4,351.30$

NY P FRDM NG 20/40/100 EPO 22 85629NY0010228-00 Y N Y 1,521.96$ 2,587.33$ 3,043.92$ 4,337.59$

NY P FRDM NG 20/40/100 EPO 22 85629NY0010229-00 Y Y Y 1,521.96$ 2,587.33$ 3,043.92$ 4,337.59$

Region 3

Page 4 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3

NY P FRDM NG 20/40/100 PPO 22 85629NY0050028-00 N N N 1,565.72$ 2,661.72$ 3,131.44$ 4,462.30$

NY P FRDM NG 20/40/100 PPO 22 85629NY0050185-00 N N Y 1,560.91$ 2,653.54$ 3,121.82$ 4,448.59$

NY P FRDM NG 20/40/100 PPO 22 85629NY0050026-00 N Y N 1,565.72$ 2,661.72$ 3,131.44$ 4,462.30$

NY P FRDM NG 20/40/100 PPO 22 85629NY0050186-00 N Y Y 1,560.91$ 2,653.54$ 3,121.82$ 4,448.59$

NY P FRDM NG 20/40/100 PPO 22 85629NY0050027-00 Y N N 1,586.26$ 2,696.64$ 3,172.52$ 4,520.84$

NY P FRDM NG 20/40/100 PPO 22 85629NY0050025-00 Y Y N 1,586.26$ 2,696.64$ 3,172.52$ 4,520.84$

NY P FRDM NG 20/40/100 PPO 22 85629NY0050187-00 Y N Y 1,581.45$ 2,688.46$ 3,162.90$ 4,507.13$

NY P FRDM NG 20/40/100 PPO 22 85629NY0050188-00 Y Y Y 1,581.45$ 2,688.46$ 3,162.90$ 4,507.13$

NY P FRDM NG 20/40/100 PPO FAIR 22 85629NY0050233-00 N N N 1,890.91$ 3,214.55$ 3,781.82$ 5,389.09$

NY P FRDM NG 20/40/100 PPO FAIR 22 85629NY0050234-00 N N Y 1,886.10$ 3,206.37$ 3,772.20$ 5,375.38$

NY P FRDM NG 20/40/100 PPO FAIR 22 85629NY0050235-00 N Y N 1,890.91$ 3,214.55$ 3,781.82$ 5,389.09$

NY P FRDM NG 20/40/100 PPO FAIR 22 85629NY0050236-00 N Y Y 1,886.10$ 3,206.37$ 3,772.20$ 5,375.38$

NY P FRDM NG 20/40/100 PPO FAIR 22 85629NY0050237-00 Y N N 1,911.45$ 3,249.47$ 3,822.90$ 5,447.63$

NY P FRDM NG 20/40/100 PPO FAIR 22 85629NY0050238-00 Y Y N 1,911.45$ 3,249.47$ 3,822.90$ 5,447.63$

NY P FRDM NG 20/40/100 PPO FAIR 22 85629NY0050239-00 Y N Y 1,906.64$ 3,241.29$ 3,813.28$ 5,433.92$

NY P FRDM NG 20/40/100 PPO FAIR 22 85629NY0050240-00 Y Y Y 1,906.64$ 3,241.29$ 3,813.28$ 5,433.92$

















NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010272-00 N N N 1,057.11$ 1,797.09$ 2,114.22$ 3,012.76$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010277-00 N N Y 1,052.30$ 1,788.91$ 2,104.60$ 2,999.05$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010270-00 N Y N 1,057.11$ 1,797.09$ 2,114.22$ 3,012.76$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010278-00 N Y Y 1,052.30$ 1,788.91$ 2,104.60$ 2,999.05$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010269-00 Y Y N 1,077.65$ 1,832.01$ 2,155.30$ 3,071.30$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010271-00 Y N N 1,077.65$ 1,832.01$ 2,155.30$ 3,071.30$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010279-00 Y N Y 1,072.84$ 1,823.83$ 2,145.68$ 3,057.59$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010280-00 Y Y Y 1,072.84$ 1,823.83$ 2,145.68$ 3,057.59$

NY S FRDM NG 25/50/2250/80 EPO HSA 22 85629NY0010288-00 N N N 1,076.91$ 1,830.75$ 2,153.82$ 3,069.19$

NY S FRDM NG 25/50/2250/80 EPO HSA 22 85629NY0010296-00 N N Y 1,072.10$ 1,822.57$ 2,144.20$ 3,055.48$

NY S FRDM NG 25/50/2250/80 EPO HSA 22 85629NY0010186-00 N Y N 1,076.91$ 1,830.75$ 2,153.82$ 3,069.19$

NY S FRDM NG 25/50/2250/80 EPO HSA 22 85629NY0010297-00 N Y Y 1,072.10$ 1,822.57$ 2,144.20$ 3,055.48$

NY S FRDM NG 25/50/2250/80 EPO HSA 22 85629NY0010287-00 Y N N 1,097.45$ 1,865.67$ 2,194.90$ 3,127.73$

NY S FRDM NG 25/50/2250/80 EPO HSA 22 85629NY0010334-00 Y Y N 1,097.45$ 1,865.67$ 2,194.90$ 3,127.73$

NY S FRDM NG 25/50/2250/80 EPO HSA 22 85629NY0010298-00 Y N Y 1,092.64$ 1,857.49$ 2,185.28$ 3,114.02$

NY S FRDM NG 25/50/2250/80 EPO HSA 22 85629NY0010299-00 Y Y Y 1,092.64$ 1,857.49$ 2,185.28$ 3,114.02$

NY S FRDM NG 30/60/2000/80 PPO HSA 22 85629NY0050108-00 N N N 1,120.68$ 1,905.16$ 2,241.36$ 3,193.94$

NY S FRDM NG 30/60/2000/80 PPO HSA 22 85629NY0050008-00 N N Y 1,115.87$ 1,896.98$ 2,231.74$ 3,180.23$

NY S FRDM NG 30/60/2000/80 PPO HSA 22 85629NY0050106-00 N Y N 1,120.68$ 1,905.16$ 2,241.36$ 3,193.94$

NY S FRDM NG 30/60/2000/80 PPO HSA 22 85629NY0050018-00 N Y Y 1,115.87$ 1,896.98$ 2,231.74$ 3,180.23$

NY S FRDM NG 30/60/2000/80 PPO HSA 22 85629NY0050107-00 Y N N 1,141.22$ 1,940.08$ 2,282.44$ 3,252.48$

NY S FRDM NG 30/60/2000/80 PPO HSA 22 85629NY0050105-00 Y Y N 1,141.22$ 1,940.08$ 2,282.44$ 3,252.48$

NY S FRDM NG 30/60/2000/80 PPO HSA 22 85629NY0050019-00 Y N Y 1,136.41$ 1,931.90$ 2,272.82$ 3,238.77$

NY S FRDM NG 30/60/2000/80 PPO HSA 22 85629NY0050020-00 Y Y Y 1,136.41$ 1,931.90$ 2,272.82$ 3,238.77$

NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010300-00 N N N 1,065.75$ 1,811.78$ 2,131.50$ 3,037.39$

NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010312-00 N N Y 1,060.94$ 1,803.60$ 2,121.88$ 3,023.68$

NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010294-00 N Y N 1,065.75$ 1,811.78$ 2,131.50$ 3,037.39$

NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010313-00 N Y Y 1,060.94$ 1,803.60$ 2,121.88$ 3,023.68$

NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010295-00 Y N N 1,086.29$ 1,846.70$ 2,172.58$ 3,095.93$

NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010293-00 Y Y N 1,086.29$ 1,846.70$ 2,172.58$ 3,095.93$

NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010314-00 Y N Y 1,081.48$ 1,838.52$ 2,162.96$ 3,082.22$

NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010315-00 Y Y Y 1,081.48$ 1,838.52$ 2,162.96$ 3,082.22$

NY S FRDM NG 40/70/3000/65 PPO 22 85629NY0050132-00 N N N 1,117.77$ 1,900.21$ 2,235.54$ 3,185.64$

NY S FRDM NG 40/70/3000/65 PPO 22 85629NY0050033-00 N N Y 1,112.96$ 1,892.03$ 2,225.92$ 3,171.93$

NY S FRDM NG 40/70/3000/65 PPO 22 85629NY0050130-00 N Y N 1,117.77$ 1,900.21$ 2,235.54$ 3,185.64$

NY S FRDM NG 40/70/3000/65 PPO 22 85629NY0050034-00 N Y Y 1,112.96$ 1,892.03$ 2,225.92$ 3,171.93$

NY S FRDM NG 40/70/3000/65 PPO 22 85629NY0050131-00 Y N N 1,138.31$ 1,935.13$ 2,276.62$ 3,244.18$

NY S FRDM NG 40/70/3000/65 PPO 22 85629NY0050129-00 Y Y N 1,138.31$ 1,935.13$ 2,276.62$ 3,244.18$

NY S FRDM NG 40/70/3000/65 PPO 22 85629NY0050035-00 Y N Y 1,133.50$ 1,926.95$ 2,267.00$ 3,230.47$

NY S FRDM NG 40/70/3000/65 PPO 22 85629NY0050036-00 Y Y Y 1,133.50$ 1,926.95$ 2,267.00$ 3,230.47$

NY B LBTY NG 25/75/5750/70 EPO HSA 22 85629NY0010629-00 N N N 887.86$ 1,509.36$ 1,775.72$ 2,530.40$

Page 5 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3

NY B LBTY NG 25/75/5750/70 EPO HSA 22 85629NY0010630-00 N N Y 883.05$ 1,501.18$ 1,766.10$ 2,516.69$

NY B LBTY NG 25/75/5750/70 EPO HSA 22 85629NY0010631-00 N Y N 887.86$ 1,509.36$ 1,775.72$ 2,530.40$

NY B LBTY NG 25/75/5750/70 EPO HSA 22 85629NY0010632-00 N Y Y 883.05$ 1,501.18$ 1,766.10$ 2,516.69$

NY B LBTY NG 25/75/5750/70 EPO HSA 22 85629NY0010633-00 Y N N 908.40$ 1,544.28$ 1,816.80$ 2,588.94$

NY B LBTY NG 25/75/5750/70 EPO HSA 22 85629NY0010634-00 Y Y N 908.40$ 1,544.28$ 1,816.80$ 2,588.94$

NY B LBTY NG 25/75/5750/70 EPO HSA 22 85629NY0010635-00 Y N Y 903.59$ 1,536.10$ 1,807.18$ 2,575.23$

NY B LBTY NG 25/75/5750/70 EPO HSA 22 85629NY0010636-00 Y Y Y 903.59$ 1,536.10$ 1,807.18$ 2,575.23$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050225-00 N N N 925.66$ 1,573.62$ 1,851.32$ 2,638.13$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050226-00 N N Y 920.85$ 1,565.44$ 1,841.70$ 2,624.42$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050227-00 N Y N 925.66$ 1,573.62$ 1,851.32$ 2,638.13$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050228-00 N Y Y 920.85$ 1,565.44$ 1,841.70$ 2,624.42$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050229-00 Y N N 946.20$ 1,608.54$ 1,892.40$ 2,696.67$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050230-00 Y Y N 946.20$ 1,608.54$ 1,892.40$ 2,696.67$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050231-00 Y N Y 941.39$ 1,600.36$ 1,882.78$ 2,682.96$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050232-00 Y Y Y 941.39$ 1,600.36$ 1,882.78$ 2,682.96$

NY B LBTY NG 7000/100 EPO HSA 22 85629NY0010557-00 N N N 887.19$ 1,508.22$ 1,774.38$ 2,528.49$

NY B LBTY NG 7000/100 EPO HSA 22 85629NY0010558-00 N N Y 882.38$ 1,500.04$ 1,764.76$ 2,514.78$

NY B LBTY NG 7000/100 EPO HSA 22 85629NY0010559-00 N Y N 887.19$ 1,508.22$ 1,774.38$ 2,528.49$

NY B LBTY NG 7000/100 EPO HSA 22 85629NY0010560-00 N Y Y 882.38$ 1,500.04$ 1,764.76$ 2,514.78$

NY B LBTY NG 7000/100 EPO HSA 22 85629NY0010561-00 Y N N 907.73$ 1,543.14$ 1,815.46$ 2,587.03$

NY B LBTY NG 7000/100 EPO HSA 22 85629NY0010562-00 Y Y N 907.73$ 1,543.14$ 1,815.46$ 2,587.03$

NY B LBTY NG 7000/100 EPO HSA 22 85629NY0010563-00 Y N Y 902.92$ 1,534.96$ 1,805.84$ 2,573.32$

NY B LBTY NG 7000/100 EPO HSA 22 85629NY0010564-00 Y Y Y 902.92$ 1,534.96$ 1,805.84$ 2,573.32$

NY G LBTY GT 30/60/1250/100 EPO 22 85629NY0010429-00 N N N 1,175.73$ 1,998.74$ 2,351.46$ 3,350.83$

NY G LBTY GT 30/60/1250/100 EPO 22 85629NY0010430-00 N N Y 1,170.92$ 1,990.56$ 2,341.84$ 3,337.12$

NY G LBTY GT 30/60/1250/100 EPO 22 85629NY0010431-00 N Y N 1,175.73$ 1,998.74$ 2,351.46$ 3,350.83$

NY G LBTY GT 30/60/1250/100 EPO 22 85629NY0010432-00 N Y Y 1,170.92$ 1,990.56$ 2,341.84$ 3,337.12$

NY G LBTY GT 30/60/1250/100 EPO 22 85629NY0010433-00 Y N N 1,196.27$ 2,033.66$ 2,392.54$ 3,409.37$

NY G LBTY GT 30/60/1250/100 EPO 22 85629NY0010434-00 Y Y N 1,196.27$ 2,033.66$ 2,392.54$ 3,409.37$

NY G LBTY GT 30/60/1250/100 EPO 22 85629NY0010435-00 Y N Y 1,191.46$ 2,025.48$ 2,382.92$ 3,395.66$

NY G LBTY GT 30/60/1250/100 EPO 22 85629NY0010436-00 Y Y Y 1,191.46$ 2,025.48$ 2,382.92$ 3,395.66$

NY G LBTY NG 1500/90 EPO HSAM 22 85629NY0010717-00 N N N 1,146.71$ 1,949.41$ 2,293.42$ 3,268.12$

NY G LBTY NG 1500/90 EPO HSAM 22 85629NY0010718-00 N N Y 1,141.90$ 1,941.23$ 2,283.80$ 3,254.41$

NY G LBTY NG 1500/90 EPO HSAM 22 85629NY0010719-00 N Y N 1,146.71$ 1,949.41$ 2,293.42$ 3,268.12$

NY G LBTY NG 1500/90 EPO HSAM 22 85629NY0010720-00 N Y Y 1,141.90$ 1,941.23$ 2,283.80$ 3,254.41$

NY G LBTY NG 1500/90 EPO HSAM 22 85629NY0010721-00 Y N N 1,167.25$ 1,984.33$ 2,334.50$ 3,326.66$

NY G LBTY NG 1500/90 EPO HSAM 22 85629NY0010722-00 Y Y N 1,167.25$ 1,984.33$ 2,334.50$ 3,326.66$

NY G LBTY NG 1500/90 EPO HSAM 22 85629NY0010723-00 Y N Y 1,162.44$ 1,976.15$ 2,324.88$ 3,312.95$

NY G LBTY NG 1500/90 EPO HSAM 22 85629NY0010724-00 Y Y Y 1,162.44$ 1,976.15$ 2,324.88$ 3,312.95$

NY G LBTY NG 25/50/100 EPO ZD 22 85629NY0010693-00 N N N 1,284.81$ 2,184.18$ 2,569.62$ 3,661.71$

NY G LBTY NG 25/50/100 EPO ZD 22 85629NY0010694-00 N N Y 1,280.00$ 2,176.00$ 2,560.00$ 3,648.00$

NY G LBTY NG 25/50/100 EPO ZD 22 85629NY0010695-00 N Y N 1,284.81$ 2,184.18$ 2,569.62$ 3,661.71$

NY G LBTY NG 25/50/100 EPO ZD 22 85629NY0010696-00 N Y Y 1,280.00$ 2,176.00$ 2,560.00$ 3,648.00$

NY G LBTY NG 25/50/100 EPO ZD 22 85629NY0010697-00 Y N N 1,305.35$ 2,219.10$ 2,610.70$ 3,720.25$

NY G LBTY NG 25/50/100 EPO ZD 22 85629NY0010698-00 Y Y N 1,305.35$ 2,219.10$ 2,610.70$ 3,720.25$

NY G LBTY NG 25/50/100 EPO ZD 22 85629NY0010699-00 Y N Y 1,300.54$ 2,210.92$ 2,601.08$ 3,706.54$

NY G LBTY NG 25/50/100 EPO ZD 22 85629NY0010700-00 Y Y Y 1,300.54$ 2,210.92$ 2,601.08$ 3,706.54$

NY P LBTY GT 15/30/250/90 EPO LA 22 85629NY0010605-00 N N N 1,307.49$ 2,222.73$ 2,614.98$ 3,726.35$

NY P LBTY GT 15/30/250/90 EPO LA 22 85629NY0010606-00 N N Y 1,302.68$ 2,214.55$ 2,605.36$ 3,712.64$

NY P LBTY GT 15/30/250/90 EPO LA 22 85629NY0010607-00 N Y N 1,307.49$ 2,222.73$ 2,614.98$ 3,726.35$

NY P LBTY GT 15/30/250/90 EPO LA 22 85629NY0010608-00 N Y Y 1,302.68$ 2,214.55$ 2,605.36$ 3,712.64$

NY P LBTY GT 15/30/250/90 EPO LA 22 85629NY0010609-00 Y N N 1,328.03$ 2,257.65$ 2,656.06$ 3,784.89$

NY P LBTY GT 15/30/250/90 EPO LA 22 85629NY0010610-00 Y Y N 1,328.03$ 2,257.65$ 2,656.06$ 3,784.89$

NY P LBTY GT 15/30/250/90 EPO LA 22 85629NY0010611-00 Y N Y 1,323.22$ 2,249.47$ 2,646.44$ 3,771.18$

NY P LBTY GT 15/30/250/90 EPO LA 22 85629NY0010612-00 Y Y Y 1,323.22$ 2,249.47$ 2,646.44$ 3,771.18$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010445-00 N N N 968.95$ 1,647.22$ 1,937.90$ 2,761.51$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010446-00 N N Y 964.14$ 1,639.04$ 1,928.28$ 2,747.80$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010447-00 N Y N 968.95$ 1,647.22$ 1,937.90$ 2,761.51$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010448-00 N Y Y 964.14$ 1,639.04$ 1,928.28$ 2,747.80$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010449-00 Y N N 989.49$ 1,682.14$ 1,978.98$ 2,820.05$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010450-00 Y Y N 989.49$ 1,682.14$ 1,978.98$ 2,820.05$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010451-00 Y N Y 984.68$ 1,673.96$ 1,969.36$ 2,806.34$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010452-00 Y Y Y 984.68$ 1,673.96$ 1,969.36$ 2,806.34$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010140-00 N N N 1,007.70$ 1,713.09$ 2,015.40$ 2,871.95$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010181-00 N N Y 1,002.89$ 1,704.91$ 2,005.78$ 2,858.24$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010138-00 N Y N 1,007.70$ 1,713.09$ 2,015.40$ 2,871.95$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010182-00 N Y Y 1,002.89$ 1,704.91$ 2,005.78$ 2,858.24$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010139-00 Y N N 1,028.24$ 1,748.01$ 2,056.48$ 2,930.49$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010137-00 Y Y N 1,028.24$ 1,748.01$ 2,056.48$ 2,930.49$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010183-00 Y N Y 1,023.43$ 1,739.83$ 2,046.86$ 2,916.78$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010184-00 Y Y Y 1,023.43$ 1,739.83$ 2,046.86$ 2,916.78$

NY S LBTY NG 30/75/3500/60 EPO 22 85629NY0010517-00 N N N 987.64$ 1,678.99$ 1,975.28$ 2,814.77$

NY S LBTY NG 30/75/3500/60 EPO 22 85629NY0010518-00 N N Y 982.83$ 1,670.81$ 1,965.66$ 2,801.06$

Page 6 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3

NY S LBTY NG 30/75/3500/60 EPO 22 85629NY0010519-00 N Y N 987.64$ 1,678.99$ 1,975.28$ 2,814.77$

NY S LBTY NG 30/75/3500/60 EPO 22 85629NY0010520-00 N Y Y 982.83$ 1,670.81$ 1,965.66$ 2,801.06$

NY S LBTY NG 30/75/3500/60 EPO 22 85629NY0010521-00 Y N N 1,008.18$ 1,713.91$ 2,016.36$ 2,873.31$

NY S LBTY NG 30/75/3500/60 EPO 22 85629NY0010522-00 Y Y N 1,008.18$ 1,713.91$ 2,016.36$ 2,873.31$

NY S LBTY NG 30/75/3500/60 EPO 22 85629NY0010523-00 Y N Y 1,003.37$ 1,705.73$ 2,006.74$ 2,859.60$

NY S LBTY NG 30/75/3500/60 EPO 22 85629NY0010524-00 Y Y Y 1,003.37$ 1,705.73$ 2,006.74$ 2,859.60$

NY S LBTY NG 40/70/3000/65 EPO 22 85629NY0010437-00 N N N 1,008.58$ 1,714.59$ 2,017.16$ 2,874.45$

NY S LBTY NG 40/70/3000/65 EPO 22 85629NY0010438-00 N N Y 1,003.77$ 1,706.41$ 2,007.54$ 2,860.74$

NY S LBTY NG 40/70/3000/65 EPO 22 85629NY0010439-00 N Y N 1,008.58$ 1,714.59$ 2,017.16$ 2,874.45$

NY S LBTY NG 40/70/3000/65 EPO 22 85629NY0010440-00 N Y Y 1,003.77$ 1,706.41$ 2,007.54$ 2,860.74$





NY B MTRO GT 40/75/6500/50 EPO HSA 22 85629NY0010509-00 N N N 753.94$ 1,281.70$ 1,507.88$ 2,148.73$

NY B MTRO GT 40/75/6500/50 EPO HSA 22 85629NY0010510-00 N N Y 749.13$ 1,273.52$ 1,498.26$ 2,135.02$

NY B MTRO GT 40/75/6500/50 EPO HSA 22 85629NY0010511-00 N Y N 753.94$ 1,281.70$ 1,507.88$ 2,148.73$

NY B MTRO GT 40/75/6500/50 EPO HSA 22 85629NY0010512-00 N Y Y 749.13$ 1,273.52$ 1,498.26$ 2,135.02$

NY B MTRO GT 40/75/6500/50 EPO HSA 22 85629NY0010513-00 Y N N 774.48$ 1,316.62$ 1,548.96$ 2,207.27$

NY B MTRO GT 40/75/6500/50 EPO HSA 22 85629NY0010514-00 Y Y N 774.48$ 1,316.62$ 1,548.96$ 2,207.27$

NY B MTRO GT 40/75/6500/50 EPO HSA 22 85629NY0010515-00 Y N Y 769.67$ 1,308.44$ 1,539.34$ 2,193.56$

NY B MTRO GT 40/75/6500/50 EPO HSA 22 85629NY0010516-00 Y Y Y 769.67$ 1,308.44$ 1,539.34$ 2,193.56$

NY B MTRO GT 7000/100 EPO HSA 22 85629NY0010597-00 N N N 757.16$ 1,287.17$ 1,514.32$ 2,157.91$

NY B MTRO GT 7000/100 EPO HSA 22 85629NY0010598-00 N N Y 752.35$ 1,278.99$ 1,504.70$ 2,144.20$

NY B MTRO GT 7000/100 EPO HSA 22 85629NY0010599-00 N Y N 757.16$ 1,287.17$ 1,514.32$ 2,157.91$

NY B MTRO GT 7000/100 EPO HSA 22 85629NY0010600-00 N Y Y 752.35$ 1,278.99$ 1,504.70$ 2,144.20$

NY B MTRO GT 7000/100 EPO HSA 22 85629NY0010601-00 Y N N 777.70$ 1,322.09$ 1,555.40$ 2,216.45$

NY B MTRO GT 7000/100 EPO HSA 22 85629NY0010602-00 Y Y N 777.70$ 1,322.09$ 1,555.40$ 2,216.45$

NY B MTRO GT 7000/100 EPO HSA 22 85629NY0010603-00 Y N Y 772.89$ 1,313.91$ 1,545.78$ 2,202.74$

NY B MTRO GT 7000/100 EPO HSA 22 85629NY0010604-00 Y Y Y 772.89$ 1,313.91$ 1,545.78$ 2,202.74$

NY G LBTY NG 30/60/2000/70 EPO 22 85629NY0010653-00 N N N 1,132.70$ 1,925.59$ 2,265.40$ 3,228.20$

NY G LBTY NG 30/60/2000/70 EPO 22 85629NY0010654-00 N N Y 1,127.89$ 1,917.41$ 2,255.78$ 3,214.49$

NY G LBTY NG 30/60/2000/70 EPO 22 85629NY0010655-00 N Y N 1,132.70$ 1,925.59$ 2,265.40$ 3,228.20$

NY G LBTY NG 30/60/2000/70 EPO 22 85629NY0010656-00 N Y Y 1,127.89$ 1,917.41$ 2,255.78$ 3,214.49$

NY G LBTY NG 30/60/2000/70 EPO 22 85629NY0010657-00 Y N N 1,153.24$ 1,960.51$ 2,306.48$ 3,286.74$

NY G LBTY NG 30/60/2000/70 EPO 22 85629NY0010658-00 Y Y N 1,153.24$ 1,960.51$ 2,306.48$ 3,286.74$

NY G LBTY NG 30/60/2000/70 EPO 22 85629NY0010659-00 Y N Y 1,148.43$ 1,952.33$ 2,296.86$ 3,273.03$

NY G LBTY NG 30/60/2000/70 EPO 22 85629NY0010660-00 Y Y Y 1,148.43$ 1,952.33$ 2,296.86$ 3,273.03$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010469-00 N N N 1,028.68$ 1,748.76$ 2,057.36$ 2,931.74$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010470-00 N N Y 1,023.87$ 1,740.58$ 2,047.74$ 2,918.03$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010471-00 N Y N 1,028.68$ 1,748.76$ 2,057.36$ 2,931.74$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010472-00 N Y Y 1,023.87$ 1,740.58$ 2,047.74$ 2,918.03$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010473-00 Y N N 1,049.22$ 1,783.68$ 2,098.44$ 2,990.28$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010474-00 Y Y N 1,049.22$ 1,783.68$ 2,098.44$ 2,990.28$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010475-00 Y N Y 1,044.41$ 1,775.50$ 2,088.82$ 2,976.57$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010476-00 Y Y Y 1,044.41$ 1,775.50$ 2,088.82$ 2,976.57$

NY G MTRO GT 25/40/600/80 EPO HNY 22 85629NY0010581-00 N N N 882.22$ 1,499.77$ 1,764.44$ 2,514.33$

NY G MTRO GT 25/40/600/80 EPO HNY 22 85629NY0010582-00 N N Y 877.41$ 1,491.59$ 1,754.82$ 2,500.62$

NY G MTRO GT 25/40/600/80 EPO HNY 22 85629NY0010583-00 N Y N 882.22$ 1,499.77$ 1,764.44$ 2,514.33$

NY G MTRO GT 25/40/600/80 EPO HNY 22 85629NY0010584-00 N Y Y 877.41$ 1,491.59$ 1,754.82$ 2,500.62$

NY G MTRO GT 25/40/600/80 EPO HNY 22 85629NY0010585-00 Y N N 902.76$ 1,534.69$ 1,805.52$ 2,572.87$

NY G MTRO GT 25/40/600/80 EPO HNY 22 85629NY0010586-00 Y Y N 902.76$ 1,534.69$ 1,805.52$ 2,572.87$

NY G MTRO GT 25/40/600/80 EPO HNY 22 85629NY0010587-00 Y N Y 897.95$ 1,526.51$ 1,795.90$ 2,559.16$

NY G MTRO GT 25/40/600/80 EPO HNY 22 85629NY0010588-00 Y Y Y 897.95$ 1,526.51$ 1,795.90$ 2,559.16$

NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010573-00 N N N 1,065.71$ 1,811.71$ 2,131.42$ 3,037.27$

NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010574-00 N N Y 1,060.90$ 1,803.53$ 2,121.80$ 3,023.56$

NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010575-00 N Y N 1,065.71$ 1,811.71$ 2,131.42$ 3,037.27$

NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010576-00 N Y Y 1,060.90$ 1,803.53$ 2,121.80$ 3,023.56$

NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010577-00 Y N N 1,086.25$ 1,846.63$ 2,172.50$ 3,095.81$

NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010578-00 Y Y N 1,086.25$ 1,846.63$ 2,172.50$ 3,095.81$

NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010579-00 Y N Y 1,081.44$ 1,838.45$ 2,162.88$ 3,082.10$

NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010580-00 Y Y Y 1,081.44$ 1,838.45$ 2,162.88$ 3,082.10$

NY P MTRO GT 15/30/100 EPO 22 85629NY0010453-00 N N N 1,213.15$ 2,062.36$ 2,426.30$ 3,457.48$

NY P MTRO GT 15/30/100 EPO 22 85629NY0010454-00 N N Y 1,208.34$ 2,054.18$ 2,416.68$ 3,443.77$

NY P MTRO GT 15/30/100 EPO 22 85629NY0010455-00 N Y N 1,213.15$ 2,062.36$ 2,426.30$ 3,457.48$

NY P MTRO GT 15/30/100 EPO 22 85629NY0010456-00 N Y Y 1,208.34$ 2,054.18$ 2,416.68$ 3,443.77$

NY P MTRO GT 15/30/100 EPO 22 85629NY0010457-00 Y N N 1,233.69$ 2,097.28$ 2,467.38$ 3,516.02$

NY P MTRO GT 15/30/100 EPO 22 85629NY0010458-00 Y Y N 1,233.69$ 2,097.28$ 2,467.38$ 3,516.02$

NY P MTRO GT 15/30/100 EPO 22 85629NY0010459-00 Y N Y 1,228.88$ 2,089.10$ 2,457.76$ 3,502.31$

NY P MTRO GT 15/30/100 EPO 22 85629NY0010460-00 Y Y Y 1,228.88$ 2,089.10$ 2,457.76$ 3,502.31$

NY S MTRO GT 30/80/3500/70 EPO 22 85629NY0010493-00 N N N 855.00$ 1,453.50$ 1,710.00$ 2,436.75$

NY S MTRO GT 30/80/3500/70 EPO 22 85629NY0010494-00 N N Y 850.19$ 1,445.32$ 1,700.38$ 2,423.04$

NY S MTRO GT 30/80/3500/70 EPO 22 85629NY0010495-00 N Y N 855.00$ 1,453.50$ 1,710.00$ 2,436.75$

Page 7 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3

NY S MTRO GT 30/80/3500/70 EPO 22 85629NY0010496-00 N Y Y 850.19$ 1,445.32$ 1,700.38$ 2,423.04$

NY S MTRO GT 30/80/3500/70 EPO 22 85629NY0010497-00 Y N N 875.54$ 1,488.42$ 1,751.08$ 2,495.29$

NY S MTRO GT 30/80/3500/70 EPO 22 85629NY0010498-00 Y Y N 875.54$ 1,488.42$ 1,751.08$ 2,495.29$

NY S MTRO GT 30/80/3500/70 EPO 22 85629NY0010499-00 Y N Y 870.73$ 1,480.24$ 1,741.46$ 2,481.58$

NY S MTRO GT 30/80/3500/70 EPO 22 85629NY0010500-00 Y Y Y 870.73$ 1,480.24$ 1,741.46$ 2,481.58$

NY S MTRO GT 35/50/3500/70 EPO HSA 22 85629NY0010485-00 N N N 812.81$ 1,381.78$ 1,625.62$ 2,316.51$

NY S MTRO GT 35/50/3500/70 EPO HSA 22 85629NY0010486-00 N N Y 808.00$ 1,373.60$ 1,616.00$ 2,302.80$

NY S MTRO GT 35/50/3500/70 EPO HSA 22 85629NY0010487-00 N Y N 812.81$ 1,381.78$ 1,625.62$ 2,316.51$

NY S MTRO GT 35/50/3500/70 EPO HSA 22 85629NY0010488-00 N Y Y 808.00$ 1,373.60$ 1,616.00$ 2,302.80$

NY S MTRO GT 35/50/3500/70 EPO HSA 22 85629NY0010489-00 Y N N 833.35$ 1,416.70$ 1,666.70$ 2,375.05$

NY S MTRO GT 35/50/3500/70 EPO HSA 22 85629NY0010490-00 Y Y N 833.35$ 1,416.70$ 1,666.70$ 2,375.05$

NY S MTRO GT 35/50/3500/70 EPO HSA 22 85629NY0010491-00 Y N Y 828.54$ 1,408.52$ 1,657.08$ 2,361.34$

NY S MTRO GT 35/50/3500/70 EPO HSA 22 85629NY0010492-00 Y Y Y 828.54$ 1,408.52$ 1,657.08$ 2,361.34$

NY S MTRO NG 30/80/3500/70 EPO ME 22 85629NY0010565-00 N N N 885.79$ 1,505.84$ 1,771.58$ 2,524.50$

NY S MTRO NG 30/80/3500/70 EPO ME 22 85629NY0010566-00 N N Y 880.98$ 1,497.66$ 1,761.96$ 2,510.79$

NY S MTRO NG 30/80/3500/70 EPO ME 22 85629NY0010567-00 N Y N 885.79$ 1,505.84$ 1,771.58$ 2,524.50$

NY S MTRO NG 30/80/3500/70 EPO ME 22 85629NY0010568-00 N Y Y 880.98$ 1,497.66$ 1,761.96$ 2,510.79$

NY S MTRO NG 30/80/3500/70 EPO ME 22 85629NY0010569-00 Y N N 906.33$ 1,540.76$ 1,812.66$ 2,583.04$

NY S MTRO NG 30/80/3500/70 EPO ME 22 85629NY0010570-00 Y Y N 906.33$ 1,540.76$ 1,812.66$ 2,583.04$

NY S MTRO NG 30/80/3500/70 EPO ME 22 85629NY0010571-00 Y N Y 901.52$ 1,532.58$ 1,803.04$ 2,569.33$

NY S MTRO NG 30/80/3500/70 EPO ME 22 85629NY0010572-00 Y Y Y 901.52$ 1,532.58$ 1,803.04$ 2,569.33$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010701-00 N N N 994.62$ 1,690.85$ 1,989.24$ 2,834.67$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010703-00 N N Y 989.81$ 1,682.67$ 1,979.62$ 2,820.96$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010705-00 N Y N 994.62$ 1,690.85$ 1,989.24$ 2,834.67$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010707-00 N Y Y 989.81$ 1,682.67$ 1,979.62$ 2,820.96$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010709-00 Y N N 1,015.16$ 1,725.77$ 2,030.32$ 2,893.21$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010711-00 Y Y N 1,015.16$ 1,725.77$ 2,030.32$ 2,893.21$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010713-00 Y N Y 1,010.35$ 1,717.59$ 2,020.70$ 2,879.50$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010715-00 Y Y Y 1,010.35$ 1,717.59$ 2,020.70$ 2,879.50$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010702-00 N N N 947.50$ 1,610.75$ 1,895.00$ 2,700.38$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010704-00 N N Y 942.69$ 1,602.57$ 1,885.38$ 2,686.67$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010706-00 N Y N 947.50$ 1,610.75$ 1,895.00$ 2,700.38$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010708-00 N Y Y 942.69$ 1,602.57$ 1,885.38$ 2,686.67$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010710-00 Y N N 968.04$ 1,645.67$ 1,936.08$ 2,758.92$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010712-00 Y Y N 968.04$ 1,645.67$ 1,936.08$ 2,758.92$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010714-00 Y N Y 963.23$ 1,637.49$ 1,926.46$ 2,745.21$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010716-00 Y Y Y 963.23$ 1,637.49$ 1,926.46$ 2,745.21$

NY S LBTY NG 50/100/100 EPO ZD 22 85629NY0010725-00 N N N 1,124.93$ 1,912.38$ 2,249.86$ 3,206.05$

NY S LBTY NG 50/100/100 EPO ZD 22 85629NY0010726-00 N N Y 1,120.12$ 1,904.20$ 2,240.24$ 3,192.34$

NY S LBTY NG 50/100/100 EPO ZD 22 85629NY0010727-00 N Y N 1,124.93$ 1,912.38$ 2,249.86$ 3,206.05$

NY S LBTY NG 50/100/100 EPO ZD 22 85629NY0010728-00 N Y Y 1,120.12$ 1,904.20$ 2,240.24$ 3,192.34$

NY S LBTY NG 50/100/100 EPO ZD 22 85629NY0010729-00 Y N N 1,145.47$ 1,947.30$ 2,290.94$ 3,264.59$

NY S LBTY NG 50/100/100 EPO ZD 22 85629NY0010730-00 Y Y N 1,145.47$ 1,947.30$ 2,290.94$ 3,264.59$

NY S LBTY NG 50/100/100 EPO ZD 22 85629NY0010731-00 Y N Y 1,140.66$ 1,939.12$ 2,281.32$ 3,250.88$

NY S LBTY NG 50/100/100 EPO ZD 22 85629NY0010732-00 Y Y Y 1,140.66$ 1,939.12$ 2,281.32$ 3,250.88$

NY G FRDM NG 1750/100 EPO HSAM 22 85629NY0010757-00 N N N 1,228.35$ 2,088.20$ 2,456.70$ 3,500.80$

NY G FRDM NG 1750/100 EPO HSAM 22 85629NY0010758-00 N N Y 1,223.54$ 2,080.02$ 2,447.08$ 3,487.09$

NY G FRDM NG 1750/100 EPO HSAM 22 85629NY0010759-00 N Y N 1,228.35$ 2,088.20$ 2,456.70$ 3,500.80$

NY G FRDM NG 1750/100 EPO HSAM 22 85629NY0010760-00 N Y Y 1,223.54$ 2,080.02$ 2,447.08$ 3,487.09$

NY G FRDM NG 1750/100 EPO HSAM 22 85629NY0010761-00 Y N N 1,248.89$ 2,123.12$ 2,497.78$ 3,559.34$

NY G FRDM NG 1750/100 EPO HSAM 22 85629NY0010762-00 Y Y N 1,248.89$ 2,123.12$ 2,497.78$ 3,559.34$

NY G FRDM NG 1750/100 EPO HSAM 22 85629NY0010763-00 Y N Y 1,244.08$ 2,114.94$ 2,488.16$ 3,545.63$

NY G FRDM NG 1750/100 EPO HSAM 22 85629NY0010764-00 Y Y Y 1,244.08$ 2,114.94$ 2,488.16$ 3,545.63$









NY S FRDM NG 50/100/100 EPO 22 85629NY0010773-00 N N N 1,185.73$ 2,015.74$ 2,371.46$ 3,379.33$

NY S FRDM NG 50/100/100 EPO 22 85629NY0010774-00 N N Y 1,180.92$ 2,007.56$ 2,361.84$ 3,365.62$

NY S FRDM NG 50/100/100 EPO 22 85629NY0010775-00 N Y N 1,185.73$ 2,015.74$ 2,371.46$ 3,379.33$

NY S FRDM NG 50/100/100 EPO 22 85629NY0010776-00 N Y Y 1,180.92$ 2,007.56$ 2,361.84$ 3,365.62$

NY S FRDM NG 50/100/100 EPO 22 85629NY0010777-00 Y N N 1,206.27$ 2,050.66$ 2,412.54$ 3,437.87$

NY S FRDM NG 50/100/100 EPO 22 85629NY0010778-00 Y Y N 1,206.27$ 2,050.66$ 2,412.54$ 3,437.87$

NY S FRDM NG 50/100/100 EPO 22 85629NY0010779-00 Y N Y 1,201.46$ 2,042.48$ 2,402.92$ 3,424.16$

NY S FRDM NG 50/100/100 EPO 22 85629NY0010780-00 Y Y Y 1,201.46$ 2,042.48$ 2,402.92$ 3,424.16$

NY G FRDM NG 25/50/100 EPO 22 85629NY0010781-00 N N N 1,357.79$ 2,308.24$ 2,715.58$ 3,869.70$

NY G FRDM NG 25/50/100 EPO 22 85629NY0010782-00 N N Y 1,352.98$ 2,300.06$ 2,705.96$ 3,855.99$

NY G FRDM NG 25/50/100 EPO 22 85629NY0010783-00 N Y N 1,357.79$ 2,308.24$ 2,715.58$ 3,869.70$

NY G FRDM NG 25/50/100 EPO 22 85629NY0010784-00 N Y Y 1,352.98$ 2,300.06$ 2,705.96$ 3,855.99$

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NY G FRDM NG 25/50/100 EPO 22 85629NY0010785-00 Y N N 1,378.33$ 2,343.16$ 2,756.66$ 3,928.24$

NY G FRDM NG 25/50/100 EPO 22 85629NY0010786-00 Y Y N 1,378.33$ 2,343.16$ 2,756.66$ 3,928.24$

NY G FRDM NG 25/50/100 EPO 22 85629NY0010787-00 Y N Y 1,373.52$ 2,334.98$ 2,747.04$ 3,914.53$

NY G FRDM NG 25/50/100 EPO 22 85629NY0010788-00 Y Y Y 1,373.52$ 2,334.98$ 2,747.04$ 3,914.53$









NY P LBTY NG 5/35/500/100 EPO 22 85629NY0010733-00 N N N 1,391.26$ 2,365.14$ 2,782.52$ 3,965.09$

NY P LBTY NG 5/35/500/100 EPO 22 85629NY0010734-00 N N Y 1,386.45$ 2,356.96$ 2,772.90$ 3,951.38$

NY P LBTY NG 5/35/500/100 EPO 22 85629NY0010735-00 N Y N 1,391.26$ 2,365.14$ 2,782.52$ 3,965.09$

NY P LBTY NG 5/35/500/100 EPO 22 85629NY0010736-00 N Y Y 1,386.45$ 2,356.96$ 2,772.90$ 3,951.38$

NY P LBTY NG 5/35/500/100 EPO 22 85629NY0010737-00 Y N N 1,411.80$ 2,400.06$ 2,823.60$ 4,023.63$

NY P LBTY NG 5/35/500/100 EPO 22 85629NY0010738-00 Y Y N 1,411.80$ 2,400.06$ 2,823.60$ 4,023.63$

NY P LBTY NG 5/35/500/100 EPO 22 85629NY0010739-00 Y N Y 1,406.99$ 2,391.88$ 2,813.98$ 4,009.92$

NY P LBTY NG 5/35/500/100 EPO 22 85629NY0010740-00 Y Y Y 1,406.99$ 2,391.88$ 2,813.98$ 4,009.92$













NY S LBTY NG 25/45/5000/50 EPO 22 85629NY0010753-00 Y N N 998.74$ 1,697.86$ 1,997.48$ 2,846.41$

NY S LBTY NG 25/45/5000/50 EPO 22 85629NY0010754-00 Y Y N 998.74$ 1,697.86$ 1,997.48$ 2,846.41$

NY S LBTY NG 25/45/5000/50 EPO 22 85629NY0010755-00 Y N Y 993.93$ 1,689.68$ 1,987.86$ 2,832.70$

NY S LBTY NG 25/45/5000/50 EPO 22 85629NY0010756-00 Y Y Y 993.93$ 1,689.68$ 1,987.86$ 2,832.70$

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NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010272-00 N N N 993.80$ 1,689.46$ 1,987.60$ 2,832.33$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010277-00 N N Y 989.28$ 1,681.78$ 1,978.56$ 2,819.45$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010270-00 N Y N 993.80$ 1,689.46$ 1,987.60$ 2,832.33$

NY S FRDM NG 2000/70 EPO HSA 22 85629NY0010278-00 N Y Y 989.28$ 1,681.78$ 1,978.56$ 2,819.45$






















NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010312-00 N N Y 997.41$ 1,695.60$ 1,994.82$ 2,842.62$


NY S FRDM NG 40/70/3000/65 EPO 22 85629NY0010313-00 N Y Y 997.41$ 1,695.60$ 1,994.82$ 2,842.62$














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NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010140-00 N N N 947.36$ 1,610.51$ 1,894.72$ 2,699.98$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010181-00 N N Y 942.84$ 1,602.83$ 1,885.68$ 2,687.10$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010138-00 N Y N 947.36$ 1,610.51$ 1,894.72$ 2,699.98$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010182-00 N Y Y 942.84$ 1,602.83$ 1,885.68$ 2,687.10$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010139-00 Y N N 966.67$ 1,643.34$ 1,933.34$ 2,755.01$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010137-00 Y Y N 966.67$ 1,643.34$ 1,933.34$ 2,755.01$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010183-00 Y N Y 962.15$ 1,635.66$ 1,924.30$ 2,742.13$

NY S LBTY NG 25/50/2500/80 EPO HSA 22 85629NY0010184-00 Y Y Y 962.15$ 1,635.66$ 1,924.30$ 2,742.13$



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NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010469-00 N N N 967.08$ 1,644.04$ 1,934.16$ 2,756.18$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010470-00 N N Y 962.56$ 1,636.36$ 1,925.12$ 2,743.30$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010471-00 N Y N 967.08$ 1,644.04$ 1,934.16$ 2,756.18$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010472-00 N Y Y 962.56$ 1,636.36$ 1,925.12$ 2,743.30$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010473-00 Y N N 986.39$ 1,676.87$ 1,972.78$ 2,811.21$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010474-00 Y Y N 986.39$ 1,676.87$ 1,972.78$ 2,811.21$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010475-00 Y N Y 981.87$ 1,669.19$ 1,963.74$ 2,798.33$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010476-00 Y Y Y 981.87$ 1,669.19$ 1,963.74$ 2,798.33$










NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010574-00 N N Y 997.37$ 1,695.53$ 1,994.74$ 2,842.51$


NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010576-00 N Y Y 997.37$ 1,695.53$ 1,994.74$ 2,842.51$
















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NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010709-00 Y N N 954.37$ 1,622.43$ 1,908.74$ 2,719.95$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010711-00 Y Y N 954.37$ 1,622.43$ 1,908.74$ 2,719.95$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010713-00 Y N Y 949.85$ 1,614.75$ 1,899.70$ 2,707.07$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010715-00 Y Y Y 949.85$ 1,614.75$ 1,899.70$ 2,707.07$













































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NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010449-00 Y N N 1,013.88$ 1,723.60$ 2,027.76$ 2,889.55$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010450-00 Y Y N 1,013.88$ 1,723.60$ 2,027.76$ 2,889.55$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010451-00 Y N Y 1,008.95$ 1,715.22$ 2,017.90$ 2,875.50$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010452-00 Y Y Y 1,008.95$ 1,715.22$ 2,017.90$ 2,875.50$












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NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010701-00 N N N 1,019.14$ 1,732.54$ 2,038.28$ 2,904.55$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010703-00 N N Y 1,014.21$ 1,724.16$ 2,028.42$ 2,890.50$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010705-00 N Y N 1,019.14$ 1,732.54$ 2,038.28$ 2,904.55$

NY S MTRO NG 50/100/100 EPO ZD 22 85629NY0010707-00 N Y Y 1,014.21$ 1,724.16$ 2,028.42$ 2,890.50$


















































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Page 33 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 8

Page 34 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 35 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 36 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 37 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 38 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8




































Page 39 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate





NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010311-00 Y N N 1,003.29$ 1,705.59$ 2,006.58$ 2,859.38$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010309-00 Y Y N 1,003.29$ 1,705.59$ 2,006.58$ 2,859.38$




































































Region 3

Page 40 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3










































































Page 41 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3























































NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010445-00 N N N 1,017.31$ 1,729.43$ 2,034.62$ 2,899.33$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010446-00 N N Y 1,012.26$ 1,720.84$ 2,024.52$ 2,884.94$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010447-00 N Y N 1,017.31$ 1,729.43$ 2,034.62$ 2,899.33$

NY S LBTY GT 25/50/4500/50 EPO 22 85629NY0010448-00 N Y Y 1,012.26$ 1,720.84$ 2,024.52$ 2,884.94$
















Page 42 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3










































































Page 43 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3

































NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010710-00 Y N N 1,016.34$ 1,727.78$ 2,032.68$ 2,896.57$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010712-00 Y Y N 1,016.34$ 1,727.78$ 2,032.68$ 2,896.57$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010714-00 Y N Y 1,011.29$ 1,719.19$ 2,022.58$ 2,882.18$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010716-00 Y Y Y 1,011.29$ 1,719.19$ 2,022.58$ 2,882.18$






































Page 44 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3




































Page 45 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 4

Page 46 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4










































































Page 47 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4










































































Page 48 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4










































































Page 49 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4










































































Page 50 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4




































Page 51 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 8

Page 52 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 53 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 54 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 55 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 56 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8




































Page 57 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010316-00 N N N 1,005.93$ 1,710.08$ 2,011.86$ 2,866.90$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010325-00 N N Y 1,000.75$ 1,701.27$ 2,001.50$ 2,852.14$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010310-00 N Y N 1,005.93$ 1,710.08$ 2,011.86$ 2,866.90$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010326-00 N Y Y 1,000.75$ 1,701.27$ 2,001.50$ 2,852.14$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010311-00 Y N N 1,028.02$ 1,747.63$ 2,056.04$ 2,929.86$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010309-00 Y Y N 1,028.02$ 1,747.63$ 2,056.04$ 2,929.86$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010327-00 Y N Y 1,022.84$ 1,738.82$ 2,045.68$ 2,915.10$

NY B FRDM NG 5800/50 EPO HSA 22 85629NY0010328-00 Y Y Y 1,022.84$ 1,738.82$ 2,045.68$ 2,915.10$


































































Region 3

Page 58 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3










































































Page 59 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3











NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050229-00 Y N N 1,017.90$ 1,730.43$ 2,035.80$ 2,901.02$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050230-00 Y Y N 1,017.90$ 1,730.43$ 2,035.80$ 2,901.02$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050231-00 Y N Y 1,012.72$ 1,721.62$ 2,025.44$ 2,886.26$

NY B LBTY NG 30/60/6750/80 PPO HSA 22 85629NY0050232-00 Y Y Y 1,012.72$ 1,721.62$ 2,025.44$ 2,886.26$




























































Page 60 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3










































































Page 61 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3





























NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010702-00 N N N 1,019.30$ 1,732.81$ 2,038.60$ 2,905.01$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010704-00 N N Y 1,014.12$ 1,724.00$ 2,028.24$ 2,890.25$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010706-00 N Y N 1,019.30$ 1,732.81$ 2,038.60$ 2,905.01$

NY S LBTY NG 4000/80 EPO HSAM 22 85629NY0010708-00 N Y Y 1,014.12$ 1,724.00$ 2,028.24$ 2,890.25$










































Page 62 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3




































Page 63 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 4

Page 64 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4










































































Page 65 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4










































































Page 66 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4










































































Page 67 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4










































































Page 68 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4




































Page 69 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 8

Page 70 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 71 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 72 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 73 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8










































































Page 74 of 109



Off-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8




































Page 75 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate









































































Region 3

Page 76 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3









Page 77 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate





















NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010473-01 Y N N 986.39$ 1,676.87$ 1,972.78$ 2,811.21$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010474-01 Y Y N 986.39$ 1,676.87$ 1,972.78$ 2,811.21$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010475-01 Y N Y 981.87$ 1,669.19$ 1,963.74$ 2,798.33$

NY G MTRO GT 25/40/1250/80 EPO 22 85629NY0010476-01 Y Y Y 981.87$ 1,669.19$ 1,963.74$ 2,798.33$


NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010574-01 N N Y 997.37$ 1,695.53$ 1,994.74$ 2,842.51$


NY G MTRO NG 25/40/1250/80 EPO ME 22 85629NY0010576-01 N Y Y 997.37$ 1,695.53$ 1,994.74$ 2,842.51$













































Region 4

Page 78 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4









Page 79 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate









































































Region 8

Page 80 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8









Page 81 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 3

Page 82 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3








Page 83 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 4

Page 84 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4








Page 85 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 8

Page 86 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8








Page 87 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 3

Page 88 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3








Page 89 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 4

Page 90 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4








Page 91 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 8

Page 92 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8








Page 93 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 3

Page 94 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 3








Page 95 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 4

Page 96 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 4








Page 97 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate










































































Region 8

Page 98 of 109



On-Exchange




Domestic

Partner Rider

Contraceptive


Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Region 8








Page 99 of 109



On/Off Exchange


Ancillary Coverage Rider Monthly Rates

2022

Effective Quarter Single Rate

Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate Effective Quarter Single Rate

Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate Effective Quarter Single Rate

Single +

Child(ren)

Rate

Single +

Spouse Rate

Single +

Spouse +

Child(ren)

Rate

Domestic Partner Q1 -$ -$ -$ -$ Q1 -$ -$ -$ -$ Q1 -$ -$ -$ -$

Q2 -$ -$ -$ -$ Q2 -$ -$ -$ -$ Q2 -$ -$ -$ -$

Q3 -$ -$ -$ -$ Q3 -$ -$ -$ -$ Q3 -$ -$ -$ -$

Q4 -$ -$ -$ -$ Q4 -$ -$ -$ -$ Q4 -$ -$ -$ -$

Dependent Cut-off Age 29 Q1 20.54$ 34.92$ 41.08$ 58.54$ Q1 19.31$ 32.83$ 38.62$ 55.03$ Q1 19.90$ 33.83$ 39.80$ 56.72$

Q2 21.04$ 35.77$ 42.08$ 59.96$ Q2 19.78$ 33.63$ 39.56$ 56.37$ Q2 20.39$ 34.66$ 40.78$ 58.11$

Q3 21.56$ 36.65$ 43.12$ 61.45$ Q3 20.27$ 34.46$ 40.54$ 57.77$ Q3 20.89$ 35.51$ 41.78$ 59.54$

Q4 22.09$ 37.55$ 44.18$ 62.96$ Q4 20.77$ 35.31$ 41.54$ 59.19$ Q4 21.41$ 36.40$ 42.82$ 61.02$

Remove Family Planning Q1 (4.81)$ (8.18)$ (9.62)$ (13.71)$ Q1 (4.52)$ (7.68)$ (9.04)$ (12.88)$ Q1 (4.66)$ (7.92)$ (9.32)$ (13.28)$

Q2 (4.93)$ (8.38)$ (9.86)$ (14.05)$ Q2 (4.64)$ (7.89)$ (9.28)$ (13.22)$ Q2 (4.78)$ (8.13)$ (9.56)$ (13.62)$

Q3 (5.05)$ (8.59)$ (10.10)$ (14.39)$ Q3 (4.75)$ (8.08)$ (9.50)$ (13.54)$ Q3 (4.90)$ (8.33)$ (9.80)$ (13.97)$

Q4 (5.18)$ (8.81)$ (10.36)$ (14.76)$ Q4 (4.87)$ (8.28)$ (9.74)$ (13.88)$ Q4 (5.02)$ (8.53)$ (10.04)$ (14.31)$

Region 3 Region 4 Region 8

Page 100 of 109



On/Off Exchange


Medical and Rx Drug Benefits

INN = In-Network, OON = Out-of-network, Ded = Deductible, Coin = Coinsurance, MOOP = Maximum Out-of-pocket inc. Deductible,

STD = Subject to Deductible, IP = Inpatient, OP = Outpatient, D&C = Subject to Ded and Coin.

The key to the Prescription Drug plans is on a following page.

Plan Name

NY G LBTY GT

30/60/1250/100

EPO 22

NY S LBTY NG

40/70/3000/65

EPO 22

NY P FRDM NG

5/15/100 PPO 22

NY S FRDM NG

40/70/3000/65

EPO 22

NY G FRDM NG

15/35/1750/90 EPO

22

NY G FRDM NG

25/40/1750/80

EPO 22

NY B FRDM NG

5800/50 EPO HSA

22

NY P FRDM NG

20/40/100 EPO

22

NY G FRDM NG

25/40/1500/80

PPO 22

Metal Gold Silver Platinum Silver Gold Gold Bronze Platinum Gold

Preventive 100% 100% 100% 100% 100% 100% 100% 100% 100%

INN Ded $1,250 $3,000 N/A $3,000 $1,750 $1,750 $5,800 N/A $1,500

INN Coin 0% 35% 0% 35% 10% 20% 50% 0% 20%

INN MOOP $6,400 $8,700 $3,250 $8,700 $7,500 $6,000 $7,050 $3,250 $6,800

OON Ded N/A N/A $2,000 N/A N/A N/A N/A N/A $3,000

OON Coin N/A N/A 70% N/A N/A N/A N/A N/A 60%

OON MOOP N/A N/A $5,250 N/A N/A N/A N/A N/A $8,000

Family Ded 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single

Family MOOP 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single

PCP Copay $30 $40 $5 $40 $15 $25 D&C $20 $25

PCP STD? N N N N N N Y N N

Spec Copay $60 $70 $15 $70 $35 $40 D&C $40 $40

Spec STD? N N N N N N Y N N

ER Copay $500 50% $250 50% $500 $500 D&C $250 $500

ER STD? N Y N Y N N Y N N

INN OP Surg Copay - ASC $150 D&C $50 D&C $150 $150 D&C $100 $150

INN OP Surg - ASC STD? Y Y N Y Y Y Y N Y

INN OP Surg Copay - Hospital $250 D&C $100 D&C $300 $250 D&C $300 $250

INN OP Surg - Hospital STD? Y Y N Y Y Y Y N Y

INN IP Copay $500 D&C $200 D&C D&C D&C D&C $400 D&C

INN IP STD? Y Y N Y Y Y Y N Y

INN IP Copay Max $2,000 N/A N/A N/A N/A N/A N/A N/A N/A

IP Copay per Admit / Day Day N/A Admit N/A N/A N/A N/A Admit N/A

PCP Gated? Y N N N N N N N N

Network Liberty Liberty Freedom Freedom Freedom Freedom Freedom Freedom Freedom

Prescription Drugs L L H K I I B H I

Page 101 of 109



On/Off Exchange



Plan Name

Metal

Preventive

INN Ded

INN Coin

INN MOOP

OON Ded

OON Coin

OON MOOP

Family Ded

Family MOOP

PCP Copay

PCP STD?

Spec Copay

Spec STD?

ER Copay

ER STD?

INN OP Surg Copay - ASC

INN OP Surg - ASC STD?

INN OP Surg Copay - Hospital

INN OP Surg - Hospital STD?

INN IP Copay

INN IP STD?

INN IP Copay Max

IP Copay per Admit / Day

PCP Gated?

Network

Prescription Drugs

NY P FRDM NG

5/15/100 EPO 22

NY S LBTY NG

30/75/3500/60

EPO 22

NY G FRDM NG

50/50/1000/90

EPO 22

NY P FRDM NG

20/40/100 PPO

22

NY S MTRO GT

30/80/3500/70

EPO 22

NY S FRDM NG

30/60/2000/80

PPO HSA 22

NY S FRDM NG

40/70/3000/65

PPO 22

NY B LBTY NG

7000/100 EPO

HSA 22

NY S LBTY GT

25/50/4500/50

EPO 22

Platinum Silver Gold Platinum Silver Silver Silver Bronze Silver

100% 100% 100% 100% 100% 100% 100% 100% 100%

N/A $3,500 $1,000 N/A $3,500 $2,000 $3,000 $7,000 $4,500

0% 40% 10% 0% 30% 20% 35% 0% 50%

$3,250 $8,700 $6,200 $3,250 $8,700 $6,900 $8,700 $7,050 $8,700

N/A N/A N/A $3,000 N/A $4,000 $4,000 N/A N/A

N/A N/A N/A 70% N/A 50% 50% N/A N/A

N/A N/A N/A $7,750 N/A $10,500 $10,500 N/A N/A

2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single

2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single

$5 $30 $50 $20 $30 $30 $40 D&C $25

N N N N N Y N Y N

$15 $75 $50 $40 $80 $60 $70 D&C $50

N N N N N Y N Y N

$250 $600 $500 $250 50% 50% 50% D&C D&C

N Y N N Y Y Y Y Y

$50 D&C $150 $100 D&C $150 D&C D&C D&C

N Y Y N Y Y Y Y Y

$100 D&C $250 $300 D&C $250 D&C D&C D&C

N Y Y N Y Y Y Y Y

$200 D&C $250 $400 D&C D&C D&C D&C D&C

N Y Y N Y Y Y Y Y

N/A N/A N/A N/A N/A N/A N/A N/A N/A

Admit N/A Day Admit N/A N/A N/A N/A N/A

N N N N Y N N N Y

Freedom Liberty Freedom Freedom Metro Freedom Freedom Liberty Liberty

H M I H J B K F L

Page 102 of 109



On/Off Exchange



Plan Name

Metal

Preventive

INN Ded

INN Coin

INN MOOP

OON Ded

OON Coin

OON MOOP

Family Ded

Family MOOP

PCP Copay

PCP STD?

Spec Copay

Spec STD?

ER Copay

ER STD?





INN IP Copay

INN IP STD?

INN IP Copay Max


PCP Gated?

Network

Prescription Drugs

NY P FRDM NG

20/40/100 PPO

FAIR 22

NY G FRDM NG

1500/90 PPO HSA

22

NY G LBTY NG

25/50/100 EPO

ZD 22

NY G LBTY NG

30/60/2000/70

EPO 22

NY S FRDM NG

2000/70 EPO HSA

22

NY S MTRO NG

30/80/3500/70

EPO ME 22

NY S FRDM NG

25/50/2250/80

EPO HSA 22

NY B MTRO GT

7000/100 EPO

HSA 22

NY S LBTY NG

25/50/2500/80

EPO HSA 22

NY G FRDM NG

1500/90 EPO HSA

22

NY G MTRO GT

25/40/1250/80

EPO 22

Platinum Gold Gold Gold Silver Silver Silver Bronze Silver Gold Gold

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

N/A $1,500 N/A $2,000 $2,000 $3,500 $2,250 $7,000 $2,500 $1,500 $1,250

0% 10% 0% 30% 30% 30% 20% 0% 20% 10% 20%

$3,250 $5,500 $6,000 $8,400 $7,050 $8,700 $6,900 $7,050 $6,900 $5,500 $6,000

$5,000 $3,000 N/A N/A N/A N/A N/A N/A N/A N/A N/A

80% 60% N/A N/A N/A N/A N/A N/A N/A N/A N/A

$7,750 $8,000 N/A N/A N/A N/A N/A N/A N/A N/A N/A

2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single 2x Single


$20 D&C $25 $30 D&C $30 $25 D&C $25 D&C $25

N Y N N Y N Y Y Y Y N

$40 D&C $50 $60 D&C $80 $50 D&C $50 D&C $40

N Y N N Y N Y Y Y Y N

$250 50% $750 $500 50% 50% $500 D&C $500 50% $500

N Y N N Y Y Y Y Y Y N

$100 D&C $150 D&C D&C D&C $150 D&C $150 D&C $200

N Y N Y Y Y Y Y Y Y Y

$300 D&C $500 D&C D&C D&C $250 D&C $250 D&C $500


$400 D&C $500 D&C D&C D&C D&C D&C D&C D&C D&C


N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Admit N/A Admit N/A N/A N/A N/A N/A N/A N/A N/A

N N N N N N N Y N N Y

Freedom Freedom Liberty Liberty Freedom Metro Freedom Metro Liberty Freedom Metro

H B L L B J B F C B J

Page 103 of 109



On/Off Exchange



Plan Name

Metal

Preventive

INN Ded

INN Coin

INN MOOP

OON Ded

OON Coin

OON MOOP

Family Ded

Family MOOP

PCP Copay

PCP STD?

Spec Copay

Spec STD?

ER Copay

ER STD?





INN IP Copay

INN IP STD?

INN IP Copay Max


PCP Gated?

Network

Prescription Drugs

NY B LBTY NG

25/75/5750/70

EPO HSA 22

NY G FRDM NG

30/60/2250/70

EPO 22

NY G MTRO GT

25/40/600/80

EPO HNY 22

Bronze Gold Gold

100% 100% 100%

$5,750 $2,250 $600

30% 30% 20%

$7,050 $8,700 $4,000

N/A N/A N/A

N/A N/A N/A

N/A N/A N/A

2x Single 2x Single 2x Single

2x Single 2x Single 2x Single

$25 $30 $25

Y N Y

$75 $60 $40

Y N Y

50% $500 $150

Y N Y

D&C D&C $100

Y Y Y

D&C D&C $100

Y Y Y

D&C D&C $1,000

Y Y Y

N/A N/A N/A

N/A N/A Admit

N N Y

Liberty Freedom Metro

G I A

Page 104 of 109



On/Off Exchange



Plan Name

Metal

Preventive

INN Ded

INN Coin

INN MOOP

OON Ded

OON Coin

OON MOOP

Family Ded

Family MOOP

PCP Copay

PCP STD?

Spec Copay

Spec STD?

ER Copay

ER STD?





INN IP Copay

INN IP STD?

INN IP Copay Max


PCP Gated?

Network

Prescription Drugs

NY G MTRO NG

25/40/1250/80

EPO ME 22

NY P MTRO GT

15/30/100 EPO

22

NY S MTRO GT

35/50/3500/70

EPO HSA 22

NY B LBTY NG

30/60/6750/80

PPO HSA 22

NY B MTRO GT

40/75/6500/50

EPO HSA 22

NY S MTRO NG

50/100/100 EPO

ZD 22

NY P LBTY GT

15/30/250/90

EPO LA 22

NY S LBTY NG

50/100/100 EPO

ZD 22

NY S LBTY NG

4000/80 EPO

HSAM 22

NY G LBTY NG

1500/90 EPO

HSAM 22

NY G FRDM NG

1750/100 EPO

HSAM 22

Gold Platinum Silver Bronze Bronze Silver Platinum Silver Silver Gold Gold

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

$1,250 N/A $3,500 $6,750 $6,500 N/A $250 N/A $4,000 $1,500 $1,750

20% 0% 30% 20% 50% 0% 10% 0% 20% 10% 0%

$6,000 $3,250 $7,050 $7,050 $7,050 $8,700 $3,250 $8,700 $7,050 $5,500 $6,800

N/A N/A N/A $10,000 N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A 80% N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A $25,000 N/A N/A N/A N/A N/A N/A N/A



$25 $15 $35 $30 $40 $50 $15 $50 D&C D&C D&C

N N Y Y Y N N N Y Y Y

$40 $30 $50 $60 $75 $100 $30 $100 D&C D&C D&C

N N Y Y Y N N N Y Y Y

$500 $250 $500 50% $500 $1,400 50% $1,400 50% 50% 50%

N N Y Y Y N Y N Y Y Y

$200 $100 $300 D&C $500 $500 D&C $500 D&C D&C D&C

Y N Y Y Y N Y N Y Y Y

$500 $500 $750 D&C $1,000 $700 D&C $700 D&C D&C D&C


D&C $200 D&C D&C D&C $1,000 D&C $1,000 D&C D&C D&C


N/A $800 N/A N/A N/A N/A N/A N/A N/A N/A N/A

N/A Day N/A N/A N/A Admit N/A Admit N/A N/A N/A

N Y Y N Y N Y N N N N

Metro Metro Metro Liberty Metro Metro Liberty Liberty Liberty Liberty Freedom

J J E C D J L J C C B

Page 105 of 109



On/Off Exchange



Plan Name

Metal

Preventive

INN Ded

INN Coin

INN MOOP

OON Ded

OON Coin

OON MOOP

Family Ded

Family MOOP

PCP Copay

PCP STD?

Spec Copay

Spec STD?

ER Copay

ER STD?





INN IP Copay

INN IP STD?

INN IP Copay Max


PCP Gated?

Network

Prescription Drugs

NY S LBTY NG

40/70/4500/60

EPO 22

NY S FRDM NG

50/100/100 EPO

22

NY G FRDM NG

25/50/100 EPO

22

NY S MTRO GT

40/70/3000/65

EPO 22

NY P LBTY NG

5/35/500/100

EPO 22 Tier I

NY P LBTY NG

5/35/500/100

EPO 22 Tier II

NY S LBTY NG

25/45/5000/50

EPO 22 Tier I

NY S LBTY NG

25/45/5000/50

EPO 22 Tier II

NY G LBTY NG

20/40/2000/80

EPO 22 Tier I

NY G LBTY NG

20/40/2000/80

EPO 22 Tier II

G Standard HNY

25/40 M G

Silver Silver Gold Silver Platinum Platinum Silver Silver Gold Gold Gold

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

$4,500 N/A N/A $3,000 $500 $500 $5,000 $5,000 $2,000 $2,000 $600

40% 0% 0% 35% 0% 0% 50% 50% 20% 20% 20%

$8,700 $8,700 $6,000 $8,700 $3,050 $3,050 $8,700 $8,700 $8,500 $8,500 $4,000






$40 $50 $25 $40 $5 $25 $25 $45 $20 $40 $25

N N N N N N N N N N Y

$70 $100 $50 $70 $35 $70 $45 $75 $40 $80 $40

N N N N N N N N N N Y

50% $1,400 $750 50% $250 $250 D&C D&C $500 $500 $150

Y N N Y N N Y Y N N Y

D&C $500 $150 D&C D&C D&C D&C D&C D&C D&C $100

Y N N Y Y Y Y Y Y Y Y

D&C $700 $500 D&C D&C D&C D&C D&C D&C D&C $100


D&C $1,000 $500 D&C D&C D&C D&C D&C D&C D&C $1,000



N/A Admit Admit N/A N/A N/A N/A N/A N/A N/A Admit

N N N Y N N N N N N Y

Liberty Freedom Freedom Metro Liberty Liberty Liberty Liberty Liberty Liberty Metro

L J J L L L L L L L A

Page 106 of 109



On/Off Exchange


Prescription Drug Benefit Key

Format is [Generic]/[Brand Formulary]/[Brand Non-Formulary].

Letter Code Prescription Drug Plan

A $10/$35/$70

B Ded Med/Rx then $10/$40/$80

C Ded Med/Rx then $10/$50/$90

D Ded Med/Rx then $10/$65/$95

E Ded Med/Rx then $10/$65/50%, max $800

F Ded Med/Rx then 0%/0%/0%

G Ded Med/Rx then 30%/30%/30%

H Non-T1 Ded $100 then $5/$35/$70

I Non-T1 Ded $150 then $10/$40/$80

J Non-T1 Ded $150 then $10/$65/$95

K Non-T1 Ded $200 then $10/$40/$80

L Non-T1 Ded $200 then $10/$50/$90

M Non-T1 Ded $200 then $10/$50/50%, max 800%

Page 107 of 109



On/Off Exchange


Pediatric Dental and Vision Benefits

Benefit Category NY Commercial SG - Oxford

EHB - Prev & Diagnostic -Ped Dental (for

children)

* 100% after Med Ded for

traditional plans

* HMO Plans are subject to

Copay

Ped Dental Ded (Applies to - Basic Dental Svcs,

Major Dental Svcs, Orthodontia, or any

combination)

Basic, Major, Preventive &

Diagnostic, Orthodontia

INN Ped Dental Single Ded * $100 if copay

* Ded if D&C

* No ded for HMO

INN Ped Dental Family Ded * $200 if copay

* Ded if D&C

* No ded for HMO

EHB - Basic Dental Svcs (e.g.

Fillings/extractions) for Children

80% after Med or Den Ded

EHB - Major Dental Svcs (e.g. Crowns) for

Children

50% after Med or Den Ded

EHB - Orthodontia (e.g. braces) for Children 50% after Med or Den Ded

Ped Vision Ded ($/N/A/Inc in Med) * N/A if copay/non-HSA plan

* Ded if HSA

Ped Vision Ded (Applies to - Routine Vision

Exam, Vision Materials, or both)

* No services fall under ded

for non-HSA plans

* Vision materials for HSA

EHB - Routine Vision Exam for Children * Lesser of PCP copay or $30

for non-HSA. Does not apply

to ded but does apply to

OOPM

* 100% for HSA (treated like

prev svc) and applies to

OOPM

EHB - Prev Lens copay for Children * 50% for copay

* 50% after Ded for HSA

EHB - Prev Frames Tier 1 for Children * 50% for copay










EHB - Prev Contacts for Children * 50% for copay


Page 108 of 109



On/Off Exchange


Additional Notes

Estimated Commissions as a percent of premium: 3.75%

Expected Requested Loss Ratio (Claims / Premium): 83.8%

To determine the premium rate for a plan design, first look up the rate for that plan design,

demographic tier, area, and effective quarter. Then add the rate for any riders, for the

demographic tier, area, and effective quarter. The total is the final rate.

Sample Calculation of Monthly Rates

2022 Q1: Region 4 NY G FRDM NG 15/35/1750/90 EPO 22

Domestic Partner, Dependent Age Cut-off 29, and Women's Contraceptive riders

Tier:

Medical + Rx

Rate

Domestic

Partner Rider

Dependent

Cut-off Age 29

Remove

Family

Planning Total Rate

Single Rate 1,199.38$ -$ 19.31$ (4.52)$ 1,214.17$

Single + Child(ren) Rate 2,038.95$ -$ 32.83$ (7.68)$ 2,064.10$

Single + Spouse Rate 2,398.76$ -$ 38.62$ (9.04)$ 2,428.34$

Single + Spouse + Child(ren) Rate 3,418.23$ -$ 55.03$ (12.88)$ 3,460.38$

Page 109 of 109

Supporting Document Schedules Satisfied - Item: 2022 Rate Filing ChecklistComments:Attachment(s): 2022 OHI SG Checklist - Final.pdfItem Status:Status Date:

Satisfied - Item: Actuarial MemorandumComments:

Attachment(s):

2022 SG OHI Off-Exch Cover Letter.pdf2022 SG OHI Off-Exch Certification.pdf2022 SG OHI Actuarial Memorandum.pdf2022 OHI SG ActuMemo ExhB Area Factors - Final.xlsx2022 OHI SG ActuMemo ExhB Area Factors - Final.pdf

Item Status:Status Date:

Satisfied - Item: Actuarial Memorandum and CertificationsComments:Attachment(s): 2022 URRT Part III Actuarial Memo OHI SG - Final.pdfItem Status:Status Date:

Satisfied - Item: Actuarial Value CalculationsComments:Attachment(s): 2022 OHI SG AV Screenshots.pdfItem Status:Status Date:

Satisfied - Item: Exhibit 11: General InformationComments:

Attachment(s): 2022 Ex 11 OHI SG - Final.pdf2022 Ex 11 OHI SG - Final.xlsm


Satisfied - Item: Exhibit 13a: Numerical Summary and Rate Indication Calculation







Comments:

Attachment(s): 2022 Ex 13a OHI SG - Final.pdf2022 Ex 13a OHI SG - Final.xlsm


Satisfied - Item: Exhibit 13b: Narrative SummaryComments:Attachment(s): Ex 13B OHI SG - 2022 Narrative Summary.pdfItem Status:Status Date:

Satisfied - Item: Exhibit 13c: Average Premium DetailsComments:

Attachment(s): 2022 Ex 13c OHI SG - Final.pdf2022 Ex 13c OHI SG - Final.xlsm


Satisfied - Item: Exhibit 14: Summary of Requested Percentage ChangesComments:



Bypassed - Item: Exhibit 15a: Product Discontinuance CertificationBypass Reason: No products are being discontinued as part of the 2022 filing process.Attachment(s):Item Status:Status Date:

Satisfied - Item: Exhibit 15b: MHPAEA Compliance CertificationComments:Attachment(s): 2022 Ex 15b OHI SG - Final.pdfItem Status:Status Date:







Satisfied - Item: Exhibit 16: Summary of Policy Form & Product ChangesComments:



Satisfied - Item: Exhibit 17: Claims ExperienceComments:



Satisfied - Item: Exhibit 18: Index Rate/Plan-Design Level AdjustmentComments:



Satisfied - Item: Exhibit 23: Summary of Requested 2020 Premium RatesComments:



Satisfied - Item: Final Notice of Proposed Rate AdjustmentComments:

Attachment(s):2022 Oxford NY_Prior Approval_Final Rate Notification_Subscriber 1.22 - 12.22 - DRAFT.pdfEI20388503 Oxford NYSG Notice of Renewal and Premium Rates (Automated) 1.22 to 12.22 DRAFT.pdfEI20420028 Oxford NYSG Healthy NY Combo Notice of Renewal and Premium Rates 1.22 to 12.22 DRAFT.pdfEI203885014 Oxford Healthy NYSG Employer Notice of Renewal and Rates 1.22 - 12.22 DRAFT.pdf


Satisfied - Item: Initial Notice of Proposed Rate AdjustmentComments:







Attachment(s): 2022 OHI SG ON&OFFX-Rate adjustment notice - initial (Group Certificate Holder) DRAFT.pdf2022 OHI SG ON&OFFX-Rate adjustment notice - initial (Group Policyholder) DRAFT.pdf


Satisfied - Item: Unified Rate Review TemplateComments:

Attachment(s): ny_85629_ohi_sg_URRTPartI_05-12-21.pdfny_85629_ohi_sg_URRTPartI_05-12-21.xlsm








Rate Filing Checklist – Last updated: 4/7/2021

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Checklist for the Filing of 2022 Individual Premium Rates

For On-Exchange Plans and Off-Exchange Plans

1. Under which Section of the New York State Insurance Law is this filing being made? (3231(e)(1), 4308(c), 3231(d), or 4308(b)) 3231e(1) 2. For filings made pursuant to 3231(e)(1) and 4308(c):

a. Did the Company submit a combined filing for “On” and “Off” Exchange rates per the instructions along with a separate form filing that both contain cross references to each other? Yes b. For Individual filings, do the Exhibits only contain Individual plan/experience data per the instructions? n/a c. For Small Group filings, do the Exhibits only contain Small Group plan/experience data per the instructions? Yes

3. Does this filing introduce any new plans (i.e., new 14-digit HIOS IDs)? Yes 4. Has the Company provided two versions (i.e., PDF and Excel) of all rate filing Exhibits? Yes 5. Do the values in Line 10 of Exhibit 18 match the totals in column 15.4 of Exhibit 17 for the applicable Market Segments? Yes 6. Do the values in Line 10A of Exhibit 18 match the totals in column 15.7 of Exhibit 17 for the applicable Market Segments? Yes 7. Do the values in Line 10B of Exhibit 18 match the totals in column 15.3 of Exhibit 17 for the applicable Market Segments? Yes 8. Confirm that the 2022 version (updated in 2021) of the rate filing Exhibits were utilized (Yes/No: Respond “Yes” to confirm). Yes 9. With regard to the “Rate Review Detail” screen in SERFF:

18. Did the Company submit any plans that will be discontinued in the 2022 Plan Year? No a. If yes, did the Company complete and submit Exhibit 15A? n/a

19. Does the Company have a VBP program? No a. If yes, is the program, including any impact on the proposed rates, fully explained in the Actuarial Memorandum? n/a

a. If not, did the Company’s Actuary reach out to DFS and resolve the issue? (Note that any such issues should be resolved prior to submission of the filing by contacting Frank Horn via e-mail at [email protected] or by phone at (518) 473-5454). Yes

premium)? Yes e. Are all items that are not applicable left blank (i.e., Items that are not applicable should be left blank)? Yes f. Have the “Requested Rate Period” data fields been populated with non-zero values? Yes

a. Was it completed in a manner consistent with the Company’s 2021 premium rate filings? Yes b. Do the “Average” percentages look reasonable (e.g., do they fall between “Minimum” and “Maximum” percentages? Yes c. Do the “Minimum” and “Maximum” values appear reasonable in light of changes that are being proposed? Yes d. Are the “Minimum”, “Maximum” and “Average” values stated on an Annualized PMPM basis (as opposed to annual

10. Is the information presented in Exhibit 18 provided at the HIOS SCID level (i.e., are there 14 digits in the HIOS ID?) Yes 11. Does Exhibit 23 contain rates for every distinct 14-digit HIOS ID as opposed to only the “Base” plan rates? Yes 12. Does the Company’s claim experience for 2019 include full run-out through February of 2021? Yes 13. Is the rate manual provided in both PDF and Excel format per our instructions? 14. Does the PMPM value in Cell Q-74 of Exhibit 13C equal the value in Cell D-103 (Line 54 Column D) of Exhibit 18? Yes 15. Does the PMPM value in Cell Z-74 of Exhibit 13C equal the value in Cell D-109 (Line 56 Column D) of Exhibit 18? Yes 16. Does the total premium value in Cell G-24 of Exhibit 14 equal the value in Cell Q-61 of Exhibit 13c? Yes 17. Does the overall rate change calculated in Exhibit 13c accurately represent the Company’s expectation of the rate change? Yes

mailto:[email protected]

May 12, 2021

Mr. Frank Horn, FSA

Chief Actuary – Health

New York State Department of Financial Services

Health Bureau

One Commerce Plaza

Albany, NY 12257

RE: Oxford Health Insurance, Inc.

New York Small Group Off-Exchange and SHOP

Effective January 2022 – December 2022

Dear Mr. Horn,

This rate filing addresses the development of the New York Small Group Off-Exchange and

SHOP rates for plans written by Oxford Health Insurance, Inc. The rates are effective from

January 1, 2022 to December 31, 2022.

Should you have any questions or need any additional information, please contact me at

Sincerely,


New York Small Group Market

Rates Effective January 1, 2022 – December 31, 2022

ACTUARIAL CERTIFICATION

I, am a Fellow of the Society of Actuaries and a Member of the

American Academy of Actuaries.

To the best of my knowledge and based upon the information and data available to me, I certify

that:

(a) The submission is in compliance with all applicable laws and regulations of the State of

New York;

(b) The submission is in compliance with the appropriate Actuarial Standards of Practice

(ASOP’s) including:

ASOP No. 5, Incurred Health and Disability Claims

ASOP No. 8, Regulatory Filings for Health Plan Entities

ASOP No. 12, Risk Clarification

ASOP No. 23, Data Quality

ASOP No. 25, Credibility Procedures Applicable to Accident and Health, Group

Term Life, and Property/ Casualty Coverages

ASOP No. 41, Actuarial Communications

ASOP No. 42, Determining Health and Disability Liabilities other than Liabilities

for Incurred Claims

ASOP No. 45, The Use of Health Status Based Risk Adjustment Methodologies

ASOP No. 50, Determining Actuarial Value and Minimum Value under the ACA

(c) These rates have been established to produce an expected loss ratio that meets the

minimum requirement of the State of New York;

(d) The benefits are reasonable in relation to the premiums charged; and

(e) The premiums are not unreasonable, excessive, inadequate, or unfairly discriminatory.


New York Small Group Off-Exchange and SHOP Rates

HIOS ID: 85629

Effective January 2022 – December 2022

ACTUARIAL MEMORANDUM

I. Introduction

This rate filing addresses the rate development for the New York Small Group plans written by Oxford Health Insurance, Inc. (“OHI”). Rates are effective from January 1, 2022 through December 31, 2022. This rate filing is being submitted under Section 3231(e)(1) of the New York State Insurance Law. II. Determination of the Index Rate

A. Experience Period Claims

Please refer to Exhibit 18 for the development of the index rate. We have used claims incurred between January 1, 2019 and December 31, 2019 paid through February 28, 2021 with an adjustment for claims incurred but not reported (“IBNR”). The experience includes all Small Groups active in the period. The resulting experience period claim PMPM is $617.48.

B. Average AV Pricing Value

We used the UnitedHealthcare proprietary pricing model to determine the pricing actuarial values (“AVs”) for each of the in-force Small Group plans on the OHI license. We also assigned gatekeeper and network factors to each existing in-force plan using our latest estimated adjustments. The estimated gatekeeper adjustment is -3.5%. The estimated Liberty network adjustment is -5.1% versus the Freedom network. The estimated Metro network adjustment is -16.1% versus the Freedom network. We then calculated the average pricing AVs, gatekeeper, and network factors based upon the membership distribution within the experience period. Finally, we calculated the average induced demand adjustment as described in section C. These are shown below.

Pricing Actuarial Value (AV) Excluding Gatekeeper & Network 0.818

Average Gatekeeper and Network Benefit Adjustment 0.973

Average Induced Demand Adjustment 1.074

The resulting average AV pricing value for the experience period is 0.854. C. Average Induced Demand Adjustment

The induced demand adjustments used in the 2022 rate development are shown below and fall

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within the maximum values permitted by DFS.

Bronze 1.00 Silver 1.03 Gold 1.08 Platinum 1.15

We assigned the induced demand factors above to each in-force plan design based upon its HHS calculator metal level and calculated the average induced demand factor of 1.074 for the experience period.

D. Trend Assumptions

The projected annual trend factor is 8.4%. This breaks down into the following components: 4.0% unit cost, 3.5% utilization, and 0.7% trend leveraging. Please note that this trend factor excludes any risk margin. We trended the experience period claim PMPM using the 8.4% annual trend factor and the 37 months between the midpoint of the experience period (July 1, 2019) and the midpoint of the average first quarter 2022 rating period (August 1, 2022). It is appropriate to trend for 37 months because we are setting rates for January, February and March (1st quarter) effective dates as opposed to just the January effective month. Therefore, the midpoint of the rating period assumes an average effective date of February 1, 2022 for groups new or renewing in the first quarter of 2022. The midpoint of the rating period starting February 1, 2022 is August 1, 2022. The trended incurred claim PMPM of $791.68 was calculated by multiplying the experience period incurred claim PMPM of $617.48 by the trend factor of 1.282. E. Projected Average PMPM Claims

We calculated the experience period index rate PMPM adjusted for pricing AV, induced demand and gating and network provisions of $722.82. The trended AV-adjusted experience period index rate PMPM is $926.73.

F. Market-Wide Index Rate Adjustments

The development of the market wide adjustments is described below. The resulting projected index PMPM for the rating period is $922.02.

1. Essential Health Benefits: All of the groups included in the calculation of the index rate are enrolled in ACA plans. We reduced the claims by 1.4% to remove the out-of-network claims from the PPO plans.

2. Provider Network & Fee Schedule Changes: We do not anticipate any material changes to the existing Freedom, Liberty or Metro networks outside of the normal contracting process which is reflected in the unit cost trend projection and the updated network relativities.

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3. Utilization Management Changes: We do not expect any significant changes to our utilization management procedures.

4. Market Wide Adjustment for Impact on Claim Costs from Quality Improvement and

Cost Containment Initiatives: These types of items are included in the trend projection. 5. Expected Covered Membership Risk: We do not expect any significant changes in the

covered membership risk. 6. Federal Risk Adjustment: We have used the Final 2019 CMS risk adjustment results

to normalize the 2019 claims experience. We have used the Final 2019 CMS national reinsurance program results to incorporate the reinsurance recoveries. Consistent with the Department’s instructions, this includes an adjustment for expected 2022 Risk Adjustment Data Validation (RADV). We have set RADV at the maximum 1.0% payment based upon the actual 2017 and 2018 RADV results. RADV payments exceeded 1.0% in both years and increased as a percentage of premium in 2018.

Final 2019 CMS Risk Adjustment 2.9%

Final 2019 CMS Reinsurance Program 0.3%

RADV -1.0%

The resulting multiplicative rating factor for OHI Small Group is 0.979(=1 / [1 + 2.2%]).

7. Credibility Adjustment: There was an average of 524,232 members in OHI Small

Group plans during the experience period. We consider this to be fully credible and therefore have made no adjustments.

8. Distribution of Membership by Rating Region: We are not projecting a significant

change in the distribution of members by rating region.

9. State Mandates: We have increased the index rate by 0.3% to account for the impact of the state mandated changes to fertility preservation (0.1%) and inpatient substance abuse coverage (0.2%). These estimates are based upon company and industry based data and assumptions. It is appropriate to include the impact of these mandates in the claim projection because they were not in effect during the experience period.

10. 2022 Covid-19 Impact: For purposes of this rate filing, we are assuming a 0.2% impact

due to COVID-19 in 2022. This reflects the expected cost of the COVID-19 vaccine and related treatments and testing.

11. Impact of Aging: Because New York does not permit age rating in the Small Group or

Individual markets, we must reflect the impact of population aging in the rates. Consistent with DFS instructions, we have increased the index rate by 0.9% due to the impact of aging between the experience period and 2/28/2021. This estimate is based on the market wide data provided by DFS through the member survey. We applied our filed Large Group age/sex factors to the statewide membership as of 6/30/2019 and 2/28/2021 and calculated the impact of aging to be 0.9%.

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In addition, we have significant data from the department that the aging of the New York Small Group block has occurred consistently for many years. Given the strong probability that the aging will continue into the future, we have included an adjustment that projects the aging forward from 2/28/2021. Using market wide data provided by DFS through the member survey, we project that the impact of aging will increase costs in the New York Small Group market by 0.8% per year on average. Since we are projecting costs forward 17 months from 2/28/2021, the appropriate additional aging adjustment is 1.1% [=(1 + 0.8%)^(17/12)].

12. National Reinsurance Program Charge: CMS has created a national reinsurance pool

which will reimburse carriers for 60% of claimant costs in excess of $1,000,000. The program has no budget impact on the federal government and will be funded by carriers participating in the ACA SG and Individual markets. CMS will compute 60% of all claimant costs over $1,000,000 to arrive at the total cost of the program. We have increased the index rate by 0.4% to reflect the cost of the program in 2019.

13. Distribution of Membership by Group Size: We have increased the index rate by 0.2%

due to group size composition changes. Groups with 1-4 subscribers make up a larger portion of our New York Small Group block today when compared to the experience period. Since this change is occurring in between the experience and rating periods, an adjustment to the claim projection is required. In order to measure the impact of this change, we calculated risk adjusted loss ratios by group size. The distribution of membership by group size in February 2021 is expected to have a 0.2% higher risk adjusted loss ratio than the distribution of membership in CY2019.

III. Determination of the Premium Rates

A. Plan Level Adjustments

1. Pricing Actuarial Values: Consistent with the calculation of the average pricing AV

values for the experience period, we also used the UnitedHealthcare proprietary pricing model to determine the AVs for each of the Small Group plans on the OHI license. Please note that we have updated the cost sharing values for some plans as shown in the Rate Manual. All changes are uniform modifications.

2. Induced Demand Adjustments: The development of the induced demand factors is described in Section II(C). We used the same values to calculate the new plan rates as were used to calculate the average induced demand adjustment for the experience period. These values are as follows:

Bronze 1.00 Silver 1.03 Gold 1.08 Platinum 1.15

3. Provider Network Characteristics: Consistent with the values used to calculate the

average experience period network value, we have assumed 1.000 for Freedom, 0.949

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for Liberty and 0.839 for Metro. These factors apply to total rates.

4. Delivery System Characteristics: Consistent with the values used to calculate the average experience period gatekeeper value, we have assumed 1.00 for non-gatekeeper and 0.965 for gatekeeper. These factors apply to total rates.

5. Utilization Management Practices: We do not expect any significant changes to our utilization management practices.

6. Benefits in Addition to EHB: The plans are 100% EHB with the exception of abortion

coverage. No adjustment has been made since the abortion claims are included in the experience period claims used in the rate determination.

7. Administrative Costs (Excluding Exchange User Fees and Profits): The projected 2022

expense percentage for OHI Small Group is 12.7% excluding exchange user fees and profits. This includes fixed administration (6.10%), commissions (3.75%), and state premium taxes and assessments (2.84%).

8. Profit: The requested rates reflect an 83.8% target loss ratio. This reflects projected

profit of 3.5% for OHI Small Group. The projected loss ratio using federally prescribed MLR methodology is 87.1%.

9. Addition of Out-of-Network Benefit Option: We developed the out-of-network

adjustment factors by separately projecting the out-of-network portions of the experience period claims using the same assumptions used to project the in-network claims when setting the index rate. We used the proprietary UnitedHealthcare pricing model to determine the average out-of-network pricing AV. We determined the new pricing factors by running the out-of-network benefit plan designs through the pricing model and adjusting the projected out-of-network PMPM by the ratio of the new plan pricing AV to the experience period average AV.

B. Census Factors

The requested premium rates reflect the state-mandated tier factors. We calculated the PMPM-to-single conversion factor of 1.228 using the OHI distribution of members and subscribers for the experience period as shown in the table below.

Oxford Small Group Total

Tier

Member

Months

Subscriber

Months Relativity Conversion Factor

Single 2,107,950 2,107,950 1.000

1.228 Parent/Child(ren) 680,107 242,421 1.700

Couple 770,358 385,179 2.000

Family 2,738,553 644,917 2.850

Please note that the conversion factors on Exhibit 13c have been adjusted to account for member distribution changes between the experience period and March 2021 and also for the difference between the member weighting in Exhibit 18 and the subscriber weighting

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in Exhibit 13c.

C. Area Factors

Consistent with the Department’s instructions, we have demonstrated in Exhibit B the development of the area factors. Factors are determined using incurred claims net of risk adjustment. Consistent with the index rate calculation, we used 2019 experience as the starting point for our 2022 area factor development. Credibility assigned to each region is dependent on the regional member months as shown in the chart below.

Regional Member Months Credibility Percentage

Less than 3,000 0%

Between 3,000 and 350,000 Formula based

Greater than 350,000 100%

In regions without full credibility, we are using multiple years of data to increase the credibility of the region. In order to avoid a large rate increase for Region 8, we are proposing to continue our approach of phasing in the area factors over multiple years. We have applied the second 25% of the indicated change in 2022. The 2022 area factors are 1.055 for Region 3 and 0.992 for Region 4 and 1.023 for Region 8.

D. Quarterly Trend Increases

We are requesting 2.5% quarterly increases for the 2nd, 3rd, and 4th quarters of 2022. We calculated this by taking our projected 2022 trend to the ¼ power.

IV. Supporting Details

A. HHS Actuarial Value Calculator Adjustments

HHS metal screenshots are included in the filing. For plans using the NY DFS Standard In-Network benefits, we used the screenshots provided by DFS, without modification. For other plans, we calculated federal metal AVs using the HHS AV calculator. We made some modifications to the inputs and also used multiple runs as described below. We used only permitted factors in determining the metal AVs. We assumed that the difference between EHBs covered by our plans and those included in the calculator’s claim probability distribution tables is negligible.

1. We specially handled the inpatient and outpatient facility copays. Our inpatient copays

cover only the facility portion of the service cost, but the HHS AV calculator inpatient copay line corresponds to both facility and professional charges. Our outpatient facility copay does not cover all services included under outpatient facility in the HHS calculator. Therefore we used the 2-tier function of the HHS calculator to more accurately value these copays. On tier 1, the inpatient and / or outpatient copays are applied (converted to coinsurance if appropriate, as discussed above). On tier 2, inpatient

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and outpatient facility are covered at the plan’s general coinsurance level. We used the following weights, which are derived from our company’s pricing model, on tier 1:

a. 56% if there is an outpatient facility copay but no inpatient facility copay; b. 86% if there is an inpatient facility copay but no outpatient facility copay; c. 73% if there is a copay on both; and, d. 100% if there is a copay on neither.

2. Our Rx plans do not have separate copays for Specialty drugs; we have specialty drugs within tiers 1, 2, and 3. For the Specialty drug copay calculator input, we used the copay for the most-utilized tier of drugs within the specialty class (which is tier 2).

3. For plans with 2-tier outpatient surgery copays (free-standing and hospital), we run the HHS AV calculator twice with each of the cost sharing values and then weight each of the resulting AVs using utilization data from our company’s pricing model.

4. The AV calculator does not support Rx coinsurance up to a maximum dollar amount. Several of our plans have this feature on tier 3 drugs. We have used an effective coinsurance rate of 45% on tier 3 drugs in these plans, which is derived from our company’s pricing model, to simulate this cost-sharing feature.

5. Some plans within this portfolio have different cost-sharing features for family coverage (i.e., when two or more people are covered by the plan) from the cost-sharing features for individual coverage. For all plans, consistent with the Actuarial Value Calculator inputs, we have used only the cost sharing provisions applicable for individuals in the actuarial value calculation.

B. Trend

We develop forward-looking medical expense estimates based on a number of considerations. As a general matter, we review our own recent/emerging claims experience at the state level for several broad medical expense categories (inpatient, professional, pharmacy, etc.), with utilization, unit cost, and benefit leveraging identified for each category. Future trends are developed based on a projection of each component. Forward looking utilization levels are developed based on emerging state level data, supplemented by regional and/or national level utilization data. Macro-economic data is often used to develop assumptions regarding directional changes in national health care consumption rates. The projected annual trend factor is 8.4%. This breaks down into the following components: 4.0% unit cost, 3.5% utilization, and 0.7% trend leveraging. Please note that this trend factor excludes any risk margin.

C. Administrative Costs

The projected 2022 expense percentage for OHI Small Group is 12.7% excluding exchange user fees and profits. The projected 2021 expense percentage in the 2021 OHI Small Group rate filing was 12.6%.

D. Profit Assumptions

The requested rates reflect an 83.8% target loss ratio. The resulting projected pre-tax profit percentage is 3.5%.

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V. Quality Improvement Strategy

We have a number of programs in place to improve quality. These include clinical programs that promote efficient execution of the physician’s treatment plan and medical management focused on providing effective case management, care coordination, and chronic disease management through member interaction to help improve members’ health and effectiveness for general and specific disease. We also maintain wellness/lifestyle coaching programs that are designed to educate and promote health to individuals and communicate clinically effective methods for dealing with a specific chronic disease or condition. VI. Description of Payments Related to Advanced Primary Care Payments

We have not included any practice transformation or care coordination payments in this rate filing.

Confidential and Proprietary - FOIL Protection Requested Exhibit B


New York Small Group Commercial

2022 Pricing

Area Factors

I. 2022 Phase In Calculation

Regions

3 - Mid-Hudson 4 - New York 8 - Long Island Total

(a) 2020 Premium 41,085,806$ 3,288,187,010$ 1,043,235,249$ 4,372,508,065$

(b) 2020 Area Factors 1.100 0.999 0.999 1.000

(c) 2021 Area Factors (Current, Year 1 Phase In) 1.078 0.996 1.011 1.000

(d) = (c) / (b) 2021 Area Factor Change (Current, Year 1 Phase In) -2.0% -0.3% 1.2% 0.00%

(e) = (d) 2022 Area Factor Year 2 Phase In -2.0% -0.3% 1.2% 0.00%

(f) = (b) * [1 + (d) + (e)] 2022 Area Factors (Proposed, Year 2 Phase In) 1.055 0.992 1.023 1.000

(g) = (f) / (f) total Revenue Neutral Area Factors 1.055 0.992 1.023 1.000

(h) = (g) / (c) 2022 Area Factor Change (from 2022) -2.1% -0.3% 1.2% 0.0%

II. 2021 Analysis (for reference)

Regions

3 - Mid-Hudson 4 - New York 8 - Long Island Total

(a) Member Months 54,321 4,710,977 1,531,771 6,297,069

(b) Premium 39,786,442$ 3,383,391,367$ 1,053,975,114$ 4,477,152,923$

(c) Current Area Factors 1.100 0.999 0.999 1.000

(d) Risk/Benefit Normalized Claim PMPMs 707.96$ 718.62$ 763.07$ 727.86$

(e) = (d) / (d) Total Indicated Area Factors 0.973 0.987 1.048 1.000

(f) Assumed Credibility 45% 100% 100%

(g) Area Factor - Credibility Complement 1.045 NA NA

(h) = (e)*(f) + [1-(f)]*(g) Credibility Adjusted Area Factors 1.013 0.987 1.048 1.002

(i) = (h) / (h) Total Revenue Neutral Area Factors 1.011 0.985 1.046 1.002

(j) = (i) / (c) -1 % Change -8.1% -1.4% 4.7% 0.2%

(k) Year 1 Phase in Factor 25% 25% 25% 25%

(l) = (j)*(k) Year 1 Factor Change -2.0% -0.3% 1.2% 0.0%

(m) = (c)*[1+(l)] 2021 Area Factor 1.078 0.996 1.011 1.000

Page 1 of 1UHC-NE Actuarial

Federal Rate Filing Justification Part III Actuarial Memorandum and Certification


NAIC: 78026

State of New York Rate Review

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Section 1: Purpose The following is a rate filing prepared by Oxford Health Insurance, Inc. This filing has been prepared to provide the necessary information required by the Department of Health and Human Services and the state of New York. The purpose of this memorandum is to provide information relevant to the Federal Part I Unified Rate Review Template (URRT). This filing establishes rates intended to be used for non-grandfathered PPACA compliant Small Group health benefit plans sold on and off the Small Business Health Options Program (SHOP) in New York for the 2022 plan year. A 15.9% rate increase is being filed at this time. The rates and other information in this submission are based on the current regulations and guidance from HHS. Changes to this filing may be necessary if there are revisions to the regulations or updated guidance from HHS. This memorandum is intended solely for the information of and use by the Department of Health and Human Services and the New York Department of Financial Services. It will demonstrate compliance with state and federal laws and regulations related to the development of the index rate and allowable rating factors and is not intended to be used for any other purpose.

Section 2: General Information Company Identifying Information Company Legal Name: Oxford Health Insurance, Inc. State: New York HIOS Issuer ID: 85629 Market: Small Business, 1-100 Proposed Effective Date: January 1, 2022

Section 3: Proposed Rate Changes The proposed change in rates for this filing is 15.9% compared to the prior filing. In addition to new rates effective 1/1/2022, we are also filing 2.5% quarterly trend increases for each of the last three quarters in 2022. The rate filing we have made is seeking an increase mainly related to rising medical costs. Medical costs are the single largest component of the premium dollar and a component that has been rising significantly year over year. There are many different medical, or health care, cost trends that contribute to increases in the overall U.S. health care spending each year. These trend factors affect health insurance premiums, which will mean a premium increase to cover costs. We are projecting annual increases in utilization trend (4.0%), unit cost trend (3.3%), and benefit leveraging (0.6%).

Section 4: Experience and Current Period Premium, Claims and Enrollment Paid Through Date The experience period is January 1, 2020 to December 31, 2020, with claims paid through February 28, 2021.

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Current Date The current enrollment and premium is reported as of March 31, 2021.

Support for estimate of incurred but not paid claims Historical claims are categorized both by the month in which they were incurred and the month in which they were adjudicated. For incurral months with sufficient adjudicated claims experience, incurred claims are estimated by applying completion factors derived from the historical claims. Adjustments are made based on specific knowledge of the entity (e.g. catastrophic claims, pended claims, etc.) For incurral months where adjudicated claim experience is not sufficient to rely on completion factors, a PMPM is used to estimate incurred claims. PMPM estimates are based on expected claim seasonality patterns, monthly calendar days and work days, emerging claim trends, and other factors. The same completion factors are applied to both incurred and allowed claims amounts Experience Period Index Rates Please note that we have calculated the index rate consistent with the New York Department of Financial Services rate filing instructions. This is a calculated allowed amount converted to the Freedom, non-gated level.

Section 5: Benefit Categories Claims were assigned to each of the benefit categories based on where services were administered and the types of medical services rendered. The benefit categories were defined by our claims department using standard industry definitions.

Section 6: Projection Factors Trend Twenty five months of annual trend were applied to our 2020 experience to project it to the 2022 rating period. The projected annual trend factor is 8.1%. This breaks down into the following components: 4.0% unit cost, 3.3% utilization, and 0.6% trend leveraging. Please note that this trend factor excludes any risk margin. UnitedHealthcare develops forward-looking medical expense estimates based on a number of considerations. As a general matter, we review our own recent/emerging claims experience at the state level for several broad medical expense categories (inpatient, professional, pharmacy, etc.), with utilization, unit cost, and benefit leveraging identified for each category. Future trends are developed based on a projection of each component. Forward looking utilization levels are developed based on emerging state level data, supplemented by regional and/or national level utilization data. Macro-economic data is often used to develop assumptions regarding directional changes in national health care consumption rates.

COVID-19 An additional adjustment of 7.7% is applied to the experience period claims due to the impact of the COVID-19 pandemic. This adjustment is applied to reflect the net impact of lower utilization during the pandemic and removal of costs associated with COVID-19 testing and treatment during the experience period.

Impact of Aging Because New York does not permit age rating in the Small Group or Individual markets, we must reflect the impact of population aging in the rates. We have increased the index rate by 0.2% due to the impact of aging between the experience period and 2/28/2021. This estimate is based on the market wide data provided by DFS through the member survey. We

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applied our filed Large Group age/sex factors to the statewide membership as of 6/30/2020 and 2/28/2021 and calculated the impact of aging to be 0.2%. In addition, we have significant data from the department that the aging of the New York Small Group block has occurred consistently for many years. Given the strong probability that the aging will continue into the future, we have included an adjustment that projects the aging forward from 2/28/2021. Using market wide data provided by DFS through the member survey, we project that the impact of aging will increase costs in the New York Small Group market by 0.8% per year on average. Since we are projecting costs forward 17 months from 2/28/2021, the appropriate additional aging factor is 1.1% [=(1 + 0.8%)^(17/12)].

Section 7: Credibility Manual Rate Development The legal entity specific experience is considered fully credible so no other experience was used in the rate development.

Section 8: Credibility of Experience There was an average of 486,007 members in OHI Small Group plans during the experience period. We consider this to be fully credible and therefore have made no adjustments.

Section 9: Development of Projected Index Rate The experience period index rate is $729.04 PMPM. Please note that we have calculated the index rate consistent with the New York Department of Financial Services rate filing instructions. This is a calculated allowed amount converted to the Freedom, non-gated level.

Section 10: Development of the Market-wide Adjusted Index Rate Risk Adjustment Payment/Charge We have used the December 2020 Wakely v5 simulation results to normalize the 2020 claims experience. The estimated 2020 risk adjustment receipt for OHI Small Group is 0.7%. This includes an adjustment for expected 2022 Risk Adjustment Data Validation (RADV). We have set RADV at the maximum 1.0% payment based upon the actual 2017 and 2018 RADV results. The resulting multiplicative rating factor for OHI Small Group is 0.993 (=1 / [1 + 0.7%]).

Section 11: Plan Adjusted Index Rate Actuarial Value and Cost Sharing Adjustment UnitedHealthcare has a proprietary pricing model that was used in developing the actuarial value and cost sharing adjustment for each plan. The model calculates plan relativity factors for medical and pharmacy benefits. Historical UnitedHealthcare experience was used to develop the actuarial value and cost sharing adjustment. Provider network, delivery system and utilization management adjustment Any adjustments for these items are included in the plan relativity factors.

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Benefits in Addition to EHBs The plans are 100% EHB with the exception of abortion coverage. Distribution and Administrative Costs Distribution and administrative costs include premium tax, risk adjustment user fees, SG&A, quality improvements, federal income tax, and after-tax income. Administrative Expense Load

The administrative expense load includes general administration (6.10%) and broker commissions (3.75%).

Profit and Risk Margin

The projected profit and risk margin is 3.5% before state and federal income taxes and 2.8% after.

Taxes and Fees

The taxes and fees include state premium tax and assessments (2.84%), and federal income taxes (0.7%).

Section 12: Calibration Not applicable

Section 13: Consumer Adjusted Premium Rate Development The consumer adjusted premium rate is the final premium rate that is charged to an individual. It is developed by calibrating the plan adjusted index rate, and applying the consumer specific geographic rating factors.

Section 14: Projected Loss Ratio The projected loss ratio using the federally prescribed MLR methodology for 2022 is 87.1%.

Section 15: AV Metal Values HHS metal screenshots are included in the filing. For plans using the NY DFS Standard In-Network benefits, we used the screenshots provided by DFS, without modification. For other plans, we calculated federal metal AVs using the HHS AV calculator. We made some modifications to the inputs and also used multiple runs as described below. We used only permitted factors in determining the metal AVs. We assumed that the difference between EHBs covered by our plans and those included in the calculator’s claim probability distribution tables is negligible.

1. We specially handled the inpatient and outpatient facility copays. Our inpatient copays cover only the facility

portion of the service cost, but the HHS AV calculator inpatient copay line corresponds to both facility and professional charges. Our outpatient facility copay does not cover all services included under outpatient facility in the HHS calculator. Therefore we used the 2-tier function of the HHS calculator to more accurately value these copays. On tier 1, the inpatient and / or outpatient copays are applied (converted to coinsurance if

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appropriate, as discussed above). On tier 2, inpatient and outpatient facility are covered at the plan’s general coinsurance level. We used the following weights, which are derived from our company’s pricing model, on tier 1:

a. 56% if there is an outpatient facility copay but no inpatient facility copay; b. 86% if there is an inpatient facility copay but no outpatient facility copay; c. 73% if there is a copay on both; and, d. 100% if there is a copay on neither.

2. Our Rx plans do not have separate copays for Specialty drugs; we have specialty drugs within tiers 1, 2, and 3. For the Specialty drug copay calculator input, we used the copay for the most-utilized tier of drugs within the specialty class (which is tier 2).

3. For plans with 2-tier outpatient surgery copays (free-standing and hospital), we run the HHS AV calculator twice with each of the cost sharing values and then weight each of the resulting AVs using utilization data from our company’s pricing model.

4. The AV calculator does not support Rx coinsurance up to a maximum dollar amount. Several of our plans have this feature on tier 3 drugs. We have used an effective coinsurance rate of 45% on tier 3 drugs in these plans, which is derived from our company’s pricing model, to simulate this cost-sharing feature.

Some plans within this portfolio have different cost-sharing features for family coverage (i.e., when two or more people are covered by the plan) from the cost-sharing features for individual coverage. For all plans, consistent with the Actuarial Value Calculator inputs, we have used only the cost sharing provisions applicable for individuals in the actuarial value calculation.

Section 16: Membership Projections We are not projecting any significant changes in membership.

Section 17: Terminated Plans and Products There are no products being terminated in this rate filing.

Section 18: Plan Type Plan types of EPO and PPO have been used.

Section 19: Reliance Not applicable

Section 20: Actuarial Certification I, am an Associate Director for UnitedHealthcare and a member of the American Academy of Actuaries. I meet the Academy's qualification standards for rendering statements of actuarial opinion with respect to the filing of rates for health insurance products. To the best of my knowledge and judgment, I certify that: o The projected index rate is:

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o In compliance with state and federal statutes and regulations related to the development of the index rate and allowable rating factors (such as 45 CFR 156.80 and 147.102),

o Developed in compliance with the applicable Actuarial Standards of Practice, o Reasonable in relation to the benefits provided and population anticipated to be covered, o Neither excessive, deficient, nor unfairly discriminatory.

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

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

population morbidity by geographic area.

o The AV calculator was used to determine the AV metal values shown in Worksheet 2 of the Part I Unified Rate Review Template for all plans. Some of our plan designs are not directly compatible with the AV calculator. The values were developed in accordance with generally accepted actuarial principles and methodologies.

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

Company Name: Oxford Health Insurance IncNAIC Code: 78026SERFF Tracking #: UHLC-132808091Market Segment: Small Group

A. Insurer Information: A&H - 42 For Profit 78026Company submitting the rate filing request Company Type Org. Type Company NAIC Code

B. Contact Person: Rate filing contact person name, title Contact phone number Contact Email address

C. Actuarial Contact (If different from above): Actuary name, title Actuary phone number Actuary Email address

D. New Rate Information: UHLC-132808091New rate applicability period New rate effective date SERFF Tracking Number

E.

F. Provide responses for the following questions:1.

2.

3.

4.

5.

6

Notes:(1)

(2)

As mentioned in the checklist, this combined non-grandfathered product rate adjustment and form/rate filing can only include minor contract revisions, such as due to changes in the model language, changes to the catastrophic plan due to change in out of pocket maximum, changes to the standard plan designs. Substantial changes need to be submitted as a separate rate and form filing (e.g., a new plan design not replacing an existing plan design, contract language changes not just due to changes in the model language).For purposes of complying with §3231(e)(1)(A) and §4308(c)(2) of the New York Insurance Law, rate applications will be considered to have been submitted after all of the relevant rate applications have been posted on theDepartment's website. Once the rate applications have been posted, the Department will send a blast email instructing insurers to send their initial rate notices to policy/certificate holders. Notices should not be sent priorto having received the blast email from the Department. Note that the 60 (or 80) day review period will begin on the day in which DFS designates as the filing due date and the 30 day consumer comment period will beginon the date DFS sends the blast email to insurers.

Have all the required exhibits been submitted with this rate filing? If any exhibit is not applicable, has an explanation been provided why such exhibit is not applicable?

YesDid the company submit a "Prior Approval Pre-filing" containing a draft of the initial notice and a draft of the narrative summary and numerical summary associated with this rate filing? Indicate Yes or No, and if Yes, please provide the SERFF number of the pre-filing.

Yes - UHLC-13280808345 CFR 154.215 requires companies to submit rate filings via SERFF and HIOS simultaneously. Did the company submit this rate filing in HIOS? If yes, please provide the HIOS submission tracking number. Yes, both filings were submitted together. However, the SERFF submission was uploaded first, so no

HIOS tracker is available.

Confirm that initial notices have not been sent to any impacted policyholders and will not be sent until the Company has received confirmation that all relevant 2022 rate applications have been posted on the Department's website. See note (2).

We can confirm that initial notices have not been sent and will not be sent until the Department notifies us.

January 1, 2022 to December 31, 2022 1/1/2022

Market segment included in filing (e.g., Small Group (including Healthy NY Small Group), Individual - only one market segment per rate adjustment filing): Small Group

ResponseDoes this filing include any revision to contract language that is not yet approved? See note (1). If yes, provide a brief description of the contract language changes included in this filing. Yes, a form filing is being submitted which will incorporate all required changes to the model language for

2022Are there any rate filings submitted and not yet approved that if approved would affect the rate tables included in this rate filing? If yes, mention these filings on Exhibit 16.

No

EXHIBIT 11: GENERAL INFORMATION

Oxford Health Insurance Inc

4 Research Drive, Shelton, CT 06484Company mailing address

Exhibit 11 Updated by DFS 3/20/2020 1

EXHIBIT 13a: NUMERICAL SUMMARY AND RATE INDICATION CALCULATION

NUMERICAL SUMMARY

Oxford Health Insurance Inc78026

SERFF Tracking #: UHLC-132808091Market Segment: Small Group

1 Please complete the Numerical Summary below as well as the Narrative Summary (a separate attachment) for each market segment for which a rate filing is being submitted.2 The Narrative Summary must be in plain English and should clearly and simply explain the reasons for the requested rate adjustment (This should be included in the provided blank template "2022 Exhibit 13b - Narrative Summary.docx")3 The purpose of the Narrative Summary is to provide a written explanation to the company's policyholders to help them understand the reasons why a rate increase is needed. 4 The purpose of the Numerical Summary is to provide a clear and simple overview of the requested rate adjustment. 5 These Summaries (with the exception of the Rate Indication Calculation Section) will be public documents and will be posted on DFS’s website and furnished by DFS to the public upon request. 6 The company should submit these Summaries to DFS ten (10) days before submitting a rate adjustment filing.7 A draft of these Summaries and of the Initial Notice must be included in a "Prior Approval Pre-filing" submitted to DFS via SERFF.8 Once reviewed by DFS, these Summaries must be posted to a location on its website that is publicly available and accessible without the need for a user ID/password. 9 Links should be provided on key pages of the company's website so that the information may be easily located.

10 Any change(s) made to the Narrative Summary/Numerical Summary subsequent to the posting must be submitted to DFS with the specific change(s) identified.11 Rate Change Adjustment calculations between Year 2021 and 2022 should be based on the DFS Membership Survey data as of 3/31/2021.12 This exhibit must be submitted as an Excel file and as a PDF file.

A. Average 2021 and 2022 Premium Rates:1 Weighted Average Monthly Base Premium Rates are as calculated in Row 32 of the appropriate columns in Exhibit 13c (Columns L-P for 2021 and Columns U-Y for 2022)2 Premium Rates for 2022 should be Consistent with the Premium Rates reflected in Exhibit 23.

Average Individual Rate Average Individual Rate Average Individual Rate Average Individual Rate Average Individual RatePlatinum Gold Silver Bronze Catastrophic

2021 Weighted Average Base Premium Rates 1,304.24$ 1,002.77$ 810.58$ 690.51$ 2022 Weighted Average Base Premium Rates 1,483.92$ 1,155.79$ 952.48$ 839.33$

B. Weighted Average Annual Percentage Requested Adjustments:

2021 Weighted Average PMPM Rate 2022 Weighted Average PMPM Rate2021 to 2022 All - Metals All - Metals

Requested Rate Adjustment 15.86993% 801.32$ 928.49$ From Cells Q-74 and Z-74 of Exhibit 13c

C. Weighted Average Annual Percentage Adjustments for each of the Past Two Years [If Applicable]*:2019 to 2020 2020 to 2021

Average Rate Adjustment Requested 15.94187% 13.62978%Average Rate Adjustment Approved 9.62366% 5.29046%

D. Average Medical Loss Ratios [MLR] for All Policies Impacted [Ratios of Incurred Claims to Earned Premiums] [If Applicable]*:2018 2019 2020 Projected 2021 Projected 2022

MLR 86.1% 87.5% 86.2% 95.7% 87.1%

E. Claim Trend Rates and Average Ratios to Earned Premiums [Per Exhibit 18 Supplement for 2020‐2022 and Comparable Exhibits for 2020] [If Applicable]*2020 2021 2022

Annual Claim Trend Rates 8.2% 9.1% 8.4%Expense Ratios 15.5% 12.6% 12.7%Pre Tax Profit Ratios 2.5% 2.0% 3.5%* If no products were offered in a particular year, indicate "N/A" in the applicable box.

Company NAIC Code:

Exhibit 13a Updated by DFS 3/20/2020 1

EXHIBIT 13b: NARRATIVE SUMMARY

United Healthcare Northeast, Page 1 of 2 5/7/2021

We reserve the right to correct typographical errors.

We have prepared this Narrative Summary as further explanation of the letter you recently received from us outlining our annual proposed premium rate adjustment filing(s) with the New York State Department of Financial Services (DFS). This Narrative Summary will remain posted for a minimum of 30 calendar days from the date of our letter to you, our policyholder, or subscriber. Please read this information carefully. If you have any questions, please contact us or DFS within 30 days, as stated in our letter. Background The premium rates charged by an insurer are used mainly to pay for the medical costs and administrative expenses for small group health care benefits coverage. Medical costs are the main part of the premium. Medical costs include items such as doctor visits, inpatient and outpatient care, covered prescription drugs and new mandated benefits. Medical costs also include taxes and assessments associated with medical services. New York state law requires that at least 82 percent of the premium, or 82 cents of each premium dollar, is to be paid towards medical costs. The remaining 18 percent is used for administrative expenses (e.g., claims processing, customer service, system maintenance, operating costs of web portals, consumer education and support tools), taxes and fees (e.g., Section 332 assessment and premium tax), and profit. Current Rate Increase Components The new premiums will apply to all small groups that sign-up or renew during 2022. Please see the attached Numerical Summary with the average requested rate changes. 446,066 members are impacted by this requested rate change. The rate filing we have submitted is seeking an increase mainly related to rising medical costs. Medical costs are the single largest part of the premium dollar and continue to rise significantly. There are many different medical cost trends that contribute to increases in the overall U.S. health care spending each year. These trends cause us to request a higher premium to cover costs. We develop estimates of future medical costs based on a number of considerations. When deciding whether to seek a premium increase or decrease, we review claims data and administrative expenses to determine the expected costs and expenses for the future period. We review recent claims data for utilization (number of services), unit cost (reimbursement cost for a health service), and benefit leveraging (impact of member cost-share). Future trends are developed based on a projection of each item. The projected annual trend factor for 2022 is 8.4 percent. This breaks down into the following components: 4.0 percent unit cost, 3.5 percent utilization and 0.7 percent benefit leveraging. In addition, aging of the New York Small Group market is expected to increase costs by 0.7 percent per year. This is applied to the overall rate level because rating based upon member age is not permitted in the New York Small Group market.

Company: Oxford Health Insurance, Inc. NAIC Code: 78026 SERFF Tracking #: UHLC-132808091

Market Segment: Small Groups SHOP & Off Exchange

EXHIBIT 13b: NARRATIVE SUMMARY

United Healthcare Northeast, Page 2 of 2 5/7/2021

We reserve the right to correct typographical errors.

A part of the medical costs includes a pooling technique established under the Affordable Care Act (ACA) called Federal Risk Adjustment. This attempts to equalize risk within the New York Small Group market and requires carriers to set rates at the statewide average risk level. The estimated risk adjustment value reduces the requested rates by 2.9 percent. Changes in state mandated benefits account for 0.3 percent of the requested rate change. In addition, the requested rate change includes 0.2 percent to reflect the expected cost of the COVID-19 vaccine and related treatments and testing. The requested rate changes also include the impacts of plan relativity changes due to pricing model updates (rate increases or decreases depending on the plan) and benefit changes (rate neutral, increases or decreases depending on the plan). Specific information regarding the benefit changes will be communicated separately to those in impacted plans. Final Rate Increase The Superintendent of the Department of Financial Services may approve (as requested), modify or deny the proposed rate adjustment. Upon renewal, your final premium will account for the rate adjustment approved by the New York State DFS, as well as any chosen changes to your benefit plan design, and your group’s census. If you are a subscriber of a group plan, please contact your employer for information about how this information affects your premium contribution.

EXHIBIT 13C - AVERAGE PREMIUM DETAILS

Company Name: Oxford Health Insurance Inc

NAIC Code: 78026

SERFF Tracking #: UHLC-132808091

Market Segment: Small Group

1 Please complete all of the shaded boxes in rows 24-47 below. The goal of this Exhibit is to calculate the rate change being requested in a consistent manner for all insurers.

2 The "Weighted Average Monthly Base Premiums" in cells C24-G31 should be calculated as a weighted average of the insurer's base premiums (i.e., single adult rates prior to application of tier factors, etc.) using the number of plan subscribers as the weights.

3 Cells L24 - P31, should be a recalculation of cells C24-G31 where any plans (and associated members enrolled in those plans as of 3/31/2021) that will no longer be offered in 2022 are removed.

4 The sum of cells C37-G44 should be equal to the Company's total membership for the relevant market as of 3/31/2021.

5 Cells L37-P44 should be equal to cells C37-G44 less any members that are enrolled in plans that will no longer be offered in 2022.

6 If the Company is not eliminating any plans in 2022, then cells C24-G31 and L24-P31 should be the same, as should cells C37-G44 and L37-P44.

7 The "Conversion Factors" should be the factors that were developed in pricing to convert the "Weighted Average Monthly Base Premiums" to "Weighted Average Monthly PMPM Premium Rates". These factors should be adjusted as necessary to reflect any changes that are not reflected in the Base Premiums.

8 The value in cell Q74 of this Exhibit should match cell D103 (Line 54) of Exhibit 18.

9 The value in cell Z74 of this Exhibit should match cell D109 (Line 56) of Exhibit 18.

2021 Weighted Average Monthly Base Premiums - CALCULATED BASED ON ACTUAL DISTRIBUTION AS OF 3/31/2021 (Weighted by number 2021 Weighted Average Monthly Base Premiums - RE-CALCULATED USING ONLY THE SUBSET OF 2021 PLANS THAT WILL STILL

of subscribers) BE AVAILABLE IN 2022 (weighted by subscribers in those specific plans)

Average Monthly Base Premium assuming 3/31/2021 membership Average Monthly Base Premium paid assuming 3/31/2021 membership and all policies are paid in full for the entire year)

Region Platinum Gold Silver Bronze Catastrophic All Metals Region Platinum Gold Silver Bronze Catastrophic All Metals

1 - Albany Area 1 - Albany Area

2 -Buffalo Area 2 -Buffalo Area

3- Mid-Hudson Area 1,379 1,067 862 709 1000.07 3- Mid-Hudson Area 1,379 1,067 862 709 1000.07

4- NYC Area 1,303 999 808 685 982.38 4- NYC Area 1,303 999 808 685 982.38

5- Rochester Area 5- Rochester Area

6- Syracuse Area 6- Syracuse Area

7- Utica/Watertown Area 7- Utica/Watertown Area

8- Long Island Area 1,308 1,011 815 703 953.39 8- Long Island Area 1,308 1,011 815 703 953.39

9 - All Regions 1304.24 1002.77 810.58 690.51 975.33 9 - All Regions 1304.24 1002.77 810.58 690.51 975.33 To Exhibit 13a (Section A)

2021 Members - as of 3/31/2021 - Actual Distribution (All members as of 3/31/2021 should be included) Members - as of 3/31/2021 - Only those members currently enrolled in plans that will continue to be offered in 2022


1 - Albany Area - - - - - 1 - Albany Area - - - - -

2 -Buffalo Area - - - - - 2 -Buffalo Area - - - - -

3- Mid-Hudson Area 709 1,413 1,804 392 - 4,318 3- Mid-Hudson Area 709 1,413 1,804 392 - 4,318

4- NYC Area 79,068 116,344 105,315 29,976 - 330,703 4- NYC Area 79,068 116,344 105,315 29,976 - 330,703

5- Rochester Area - - - - - 5- Rochester Area - - - - -

6- Syracuse Area - - - - - 6- Syracuse Area - - - - -

7- Utica/Watertown Area - - - - - 7- Utica/Watertown Area - - - - -

8- Long Island Area 17,056 43,046 37,860 13,083 - 111,045 8- Long Island Area 17,056 43,046 37,860 13,083 - 111,045

9 - All Regions 96,833 160,803 144,979 43,451 446,066 9 - All Regions 96,833 160,803 144,979 43,451 446,066 Should equal Cell H-24 of Exhibit 14

2021 Conversion Factor - A 0.8216 Must be less than or equal to 1.000 2021 Conversion Factor - B 0.8216 Must be less than or equal to 1.000

2021 Estimated Aggregate Annualized Premium by Metal and Region - based on membership as of 3/31/2021 2021 Estimated Aggregate Annualized Premium by Metal and Region - based on membership as of 3/31/2021

Aggregate premium that would be collected assuming 3/31/2021 membership and all policies are paid in full for the entire year) Aggregate premium that would be collected assuming 3/31/2021 membership and all policies are paid in full for the entire year) - Adjusted for plan eliminations




3- Mid-Hudson Area 9,640,283 14,866,942 15,327,480 2,739,660 42,574,366 3- Mid-Hudson Area 9,640,283 14,866,942 15,327,480 2,739,660 42,574,366

4- NYC Area 1,015,524,960 1,146,009,103 839,056,440 202,363,344 3,202,953,847 4- NYC Area 1,015,524,960 1,146,009,103 839,056,440 202,363,344 3,202,953,847




8- Long Island Area 219,963,320 428,880,644 304,227,214 90,700,091 1,043,771,269 8- Long Island Area 219,963,320 428,880,644 304,227,214 90,700,091 1,043,771,269

9 - All Regions 1,245,128,563 1,589,756,689 1,158,611,134 295,803,096 4,289,299,482 9 - All Regions 1,245,128,563 1,589,756,689 1,158,611,134 295,803,096 4,289,299,482 Should equal Cell G-24 of Exhibit 14

2021 Weighted Average Monthly PMPM Premium Rates 2021 Weighted Average Monthly PMPM Premium Rates - Reflecting adjustment for eliminated plans




3- Mid-Hudson Area 1,133.08 876.80 708.03 582.41 821.65 3- Mid-Hudson Area 1,133.08 876.80 708.03 582.41 821.65

4- NYC Area 1,070.31 820.85 663.93 562.57 807.11 4- NYC Area 1,070.31 820.85 663.93 562.57 807.11




8- Long Island Area 1,074.71 830.28 669.63 577.72 783.29 8- Long Island Area 1,074.71 830.28 669.63 577.72 783.29

9 - All Regions 1,071.54 823.86 665.96 567.31 801.32 9 - All Regions 1,071.54 823.86 665.96 567.31 801.32 To Exhibit 13a (Section B)

Exhibit 13c Updated by DFS 3/20/2020 1

2022 Weighted Average Monthly Proposed Base Premiums - THESE BASE PREMIUMS SHOULD BE CALCULATED USING THE SAME Change in Weighted Average Monthly Base Premiums

POPULATION OF SUBSCRIBERS THAT WAS USED TO CALCULATE CELLS L22 - P29)

Average Base Premium paid assuming 3/31/2021 membership and all policies are paid in full for the entire year) Average Base Premium paid assuming 3/31/2021 membership and all policies are paid in full for the entire year)




3- Mid-Hudson Area 1539.48 1206.45 992.23 846.92 1139.00 3- Mid-Hudson Area 11.63% 13.05% 15.14% 19.47% 13.89%

4- NYC Area 1478.61 1147.28 945.91 828.81 1133.50 4- NYC Area 13.50% 14.83% 17.05% 21.04% 15.38%




8- Long Island Area 1506.23 1177.14 968.86 863.20 1119.69 8- Long Island Area 15.15% 16.48% 18.87% 22.76% 17.44%

9 - All Regions 1483.92 1155.79 952.48 839.33 1130.12 To Exhibit 13a (Section A) 9 - All Regions 13.78% 15.26% 17.51% 21.55% 15.87%

Members - as of 3/31/2021 - Only those members currently enrolled in plans that will continue to be offered in 2022 Change in Members - as of 3/31/2021 - Change due to current 2021 plans not being offered in 2022.




3- Mid-Hudson Area 709 1,413 1,804 392 4,318 3- Mid-Hudson Area 0.00% 0.00% 0.00% 0.00% 0.00%

4- NYC Area 79,068 116,344 105,315 29,976 330,703 4- NYC Area 0.00% 0.00% 0.00% 0.00% 0.00%




8- Long Island Area 17,056 43,046 37,860 13,083 111,045 8- Long Island Area 0.00% 0.00% 0.00% 0.00% 0.00%

Should equal Cell H-24 of Exhibit 14 9 - All Regions 96,833 160,803 144,979 43,451 446,066 9 - All Regions 0.00% 0.00% 0.00% 0.00% 0.00%

2022 Conversion Factor 0.8216 Must be less than or equal to 1.000 Change in Conversion Factor 0.00000%

2022 Estimated Aggregate Annualized Premium by Metal and Region - based on membership as of 3/31/2021 Change in Aggregate Annualized Premiums - based on membership as of 3/31/2021 (Ignoring any plan eliminations)

Aggregate premium that would be collected assuming 3/31/2021 membership and all policies are paid in full for the entire year) - Adjusted for plan eliminations




3- Mid-Hudson Area 10,761,077 16,806,793 17,647,585 3,273,133 48,488,588 3- Mid-Hudson Area 11.63% 13.05% 15.14% 19.47% 13.89%

4- NYC Area 1,152,627,967 1,315,979,327 982,142,698 244,941,097 3,695,691,089 4- NYC Area 13.50% 14.83% 17.05% 21.04% 15.38%




8- Long Island Area 253,281,862 499,568,285 361,638,416 111,340,118 1,225,828,681 8- Long Island Area 15.15% 16.48% 18.87% 22.76% 17.44%

Should equal Cell G-24 of Exhibit 14 9 - All Regions 1,416,670,906 1,832,354,405 1,361,428,698 359,554,348 4,970,008,358 9 - All Regions 13.78% 15.26% 17.51% 21.55% 15.87%

2022 Weighted Average Monthly PMPM Premium Rates -Reflecting adjustment for eliminated plans Change in Weighted Average PMPM Premiums




3- Mid-Hudson Area 1,264.82 991.20 815.21 695.82 935.78 3- Mid-Hudson Area 11.63% 13.05% 15.14% 19.47% 13.89%

4- NYC Area 1,214.81 942.59 777.15 680.94 931.27 4- NYC Area 13.50% 14.83% 17.05% 21.04% 15.38%




8- Long Island Area 1,237.50 967.12 796.00 709.19 919.92 8- Long Island Area 15.15% 16.48% 18.87% 22.76% 17.44%

9 - All Regions 1,219.17 949.59 782.54 689.58 928.49 To Exhibit 13a (Section B) Total 13.78% 15.26% 17.51% 21.55% 15.87%

Exhibit 13c Updated by DFS 3/20/2020 2

EXHIBIT 13C - SUPPLEMENT - DISTRIBUTION BY RATING TIERS

Company Name: Oxford Health Insurance Inc

NAIC Code: 78026

SERFF Tracking #: UHLC-132808091

Market Segment: Small Group

1 Please complete all of the shaded boxes in rows 28-52 below. The goal of this Exhibit is to provide insight with regard to how the Company's distribution of business by rating tier compares with the assumptions included in the required DFS Rating Tier Factors.

2 The "2021 Weighted Average Monthly Tier Premiums by Metal level" in cells C28-G32 should be calculated as a weighted average of the actual premiums the insurer charges its subscribers (i.e., single adult rates with the tier factor included) using the Company's

actual number of subscribers as of 3/31/2021. FORMULA: For each Metal Level and Rating Tier = (SUM [Monthly premium charged for each Subscriber]) / (Total Number of Subscribers)

3 Cells L28 - P32, should be a recalculation of cells C28-G32 where any plans (and associated members enrolled in those plans as of 3/31/2021) that will no longer be offered in 2022 are removed.

4 Cells T28 - Y32, should be a recalculation of cells L28-P32 where the 2021 Subscriber premiums are replaced with the Proposed 2022 Subscriber Premiums (This calculation should also exclude any members currently in plans that will no longer be offered in 2022).

5 The sum of cells C38-G42 should be equal to the Company's total number of subscribers for the relevant market as of 3/31/2021.

6 Cells L38-P42 should be equal to cells C38-G42 less any subscribers that are enrolled in plans that will no longer be offered in 2022.

7 The sum of cells C48-G52 should be equal to the Company's total number of members for the relevant market as of 3/31/2021.

8 Cells L48-P52 should be equal to cells C48-G52 less any members that are enrolled in plans that will no longer be offered in 2022.

9 If the Company is not eliminating any plans in 2022, then cells C28-G32 and L28-P32 should be the same, as should cells C38-G42 and L38-P42, as well as cells C48-G52 and L48-P52.

DFS RATING TIERS

Single 1.0000

Two Adults 2.0000

Adult + Child(ren) 1.7000

Family 2.8500

2021 Weighted Average Monthly Tier Premiums by Metal level - All Members Child-Only 0.4120 2021 Weighted Average Monthly Tier Premiums by Metal level - Continuing Members Only

Rating Tier Platinum Gold Silver Bronze Catastrophic All Metals Rating Tier Platinum Gold Silver Bronze Catastrophic All Metals

Single Adult 1,294.32 994.34 800.97 680.89 939.70 Single Adult 1,294.32 994.34 800.97 680.89 939.70

2 Adults 2,627.17 2,020.52 1,643.11 1,406.40 1,988.01 2 Adults 2,627.17 2,020.52 1,643.11 1,406.40 1,988.01

Adult plus Child(ren) 2,226.76 1,718.73 1,402.51 1,198.21 1,709.54 Adult plus Child(ren) 2,226.76 1,718.73 1,402.51 1,198.21 1,709.54

Family 3,759.79 2,910.38 2,385.72 2,030.75 2,872.58 Family 3,759.79 2,910.38 2,385.72 2,030.75 2,872.58

Child Only Child Only

All Rating Tiers 2,145.73 1,540.50 1,185.18 1,043.67 1,485.79 All Rating Tiers 2,145.73 1,540.50 1,185.18 1,043.67 1,485.79

2021 Subscribers - as of 3/31/2021 - Actual Distribution (All subscribers as of 3/31/2021 should be included) 2021 Subscribers - as of 3/31/2021 - Only those subscribers currently enrolled in plans that will continue to be offered in 2022


Single Adult 25,120 52,043 56,100 15,338 - 148,601 Single Adult 25,120 52,043 56,100 15,338 - 148,601

2 Adults 6,482 10,060 8,635 2,565 - 27,742 2 Adults 6,482 10,060 8,635 2,565 - 27,742

Adult plus Child(ren) 4,147 6,677 5,149 1,223 - 17,196 Adult plus Child(ren) 4,147 6,677 5,149 1,223 - 17,196

Family 11,109 16,355 13,728 4,503 - 45,695 Family 11,109 16,355 13,728 4,503 - 45,695

Child Only - - - - - Child Only - - - - -

All Rating Tiers 46,858 85,135 83,612 23,629 239,234 All Rating Tiers 46,858 85,135 83,612 23,629 239,234

2021 Members - as of 3/31/2021 - Actual Distribution (All members as of 3/31/2021 should be included) 2021 Members - as of 3/31/2021 - Only those members currently enrolled in plans that will continue to be offered in 2022


Single Adult 25,120 52,048 56,100 15,339 - 148,607 Single Adult 25,120 52,048 56,100 15,339 - 148,607

2 Adults 12,968 20,121 17,272 5,129 - 55,490 2 Adults 12,968 20,121 17,272 5,129 - 55,490

Adult plus Child(ren) 11,804 18,966 14,036 3,307 - 48,113 Adult plus Child(ren) 11,804 18,966 14,036 3,307 - 48,113

Family 46,941 69,668 57,571 19,676 - 193,856 Family 46,941 69,668 57,571 19,676 - 193,856

Child Only - - - - - Child Only - - - - -

All Rating Tiers 96,833 160,803 144,979 43,451 446,066 All Rating Tiers 96,833 160,803 144,979 43,451 446,066

2021 Actual Members Per Policy by Metal and Rating Tier - based on membership as of 3/31/2021 - All Members 2021 Actual Members Per Policy by Metal and Rating Tier - based on membership as of 3/31/2021 - Continuing Members Only


Single Adult 1.0000 1.0001 1.0000 1.0001 1.0000 Single Adult 1.0000 1.0001 1.0000 1.0001 1.0000

2 Adults 2.0006 2.0001 2.0002 1.9996 2.0002 2 Adults 2.0006 2.0001 2.0002 1.9996 2.0002

Adult plus Child(ren) 2.8464 2.8405 2.7260 2.7040 2.7979 Adult plus Child(ren) 2.8464 2.8405 2.7260 2.7040 2.7979

Family 4.2255 4.2597 4.1937 4.3695 4.2424 Family 4.2255 4.2597 4.1937 4.3695 4.2424


Wghtd Avg - All Rating Tiers 2.0665 1.8888 1.7339 1.8389 1.8646 Wghtd Avg - All Rating Tiers 2.0665 1.8888 1.7339 1.8389 1.8646

2021 Implied Members Per Policy by Metal and Rating Tier (Using Required Factors) - based on membership as of 3/31/2021 - All Members 2021 Implied Members Per Policy by Metal and Rating Tier (Using Required Factors) - based on membership as of 3/31/2021 - Continuing Members only


Single Adult 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 Single Adult 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

2 Adults 2.0000 2.0000 2.0000 2.0000 2.0000 2.0000 2 Adults 2.0000 2.0000 2.0000 2.0000 2.0000 2.0000

Adult plus Child(ren) 1.7000 1.7000 1.7000 1.7000 1.7000 1.7000 Adult plus Child(ren) 1.7000 1.7000 1.7000 1.7000 1.7000 1.7000

Family 2.8500 2.8500 2.8500 2.8500 2.8500 2.8500 Family 2.8500 2.8500 2.8500 2.8500 2.8500 2.8500

Child Only 0.4120 0.4120 0.4120 0.4120 0.4120 0.4120 Child Only 0.4120 0.4120 0.4120 0.4120 0.4120 0.4120

Wghtd Avg - All Rating Tiers 1.6389 1.5285 1.4501 1.4973 1.5196 Wghtd Avg - All Rating Tiers 1.6389 1.5285 1.4501 1.4973 1.5196

2021 Ratio of Actual to Expected Members Per Policy by Metal and Rating Tier - based on membership as of 3/31/2021 - All Members 2021 Ratio of Actual to Expected Members Per Policy by Metal and Rating Tier - based on membership as of 3/31/2021 - Continuing Members Only


Single Adult 1.0000 1.0001 1.0000 1.0001 1.0000 Single Adult 1.0000 1.0001 1.0000 1.0001 1.0000

2 Adults 1.0003 1.0000 1.0001 0.9998 1.0001 2 Adults 1.0003 1.0000 1.0001 0.9998 1.0001

Adult plus Child(ren) 1.6743 1.6709 1.6035 1.5906 1.6458 Adult plus Child(ren) 1.6743 1.6709 1.6035 1.5906 1.6458

Family 1.4826 1.4946 1.4715 1.5332 1.4886 Family 1.4826 1.4946 1.4715 1.5332 1.4886


Ratio (Expected/Actual) 1.2609 1.2358 1.1957 1.2281 1.2270 Ratio (Expected/Actual) 1.2609 1.2358 1.1957 1.2281 1.2270

Exhibit 13c Supp Updated by DFS 3/20/2020

2022 Weighted Average Monthly Tier Premiums by Metal level - Continuing Members Only Change in Weighted Average Monthly Tier Premiums


Single Adult 1,472.38 1,146.09 941.86 828.89 1,091.40 Single Adult 13.76% 15.26% 17.59% 21.74% 16.14%

2 Adults 2,990.48 2,329.33 1,929.98 1,708.08 2,302.07 2 Adults 13.83% 15.28% 17.46% 21.45% 15.80%

Adult plus Child(ren) 2,533.68 1,979.98 1,645.66 1,453.33 1,975.95 Adult plus Child(ren) 13.78% 15.20% 17.34% 21.29% 15.58%

Family 4,277.93 3,353.00 2,796.63 2,460.02 3,322.71 Family 13.78% 15.21% 17.22% 21.14% 15.67%


All Rating Tiers 2,441.44 1,775.27 1,391.78 1,267.49 1,721.57 All Rating Tiers 13.78% 15.24% 17.43% 21.45% 15.87%

Change in Subscribers - as of 3/31/2021 - Change due to current 2021 plans not being offered in 2022.

Rating Tier Platinum Gold Silver Bronze Catastrophic All Metals

Single Adult 0.00% 0.00% 0.00% 0.00% 0.00%

2 Adults 0.00% 0.00% 0.00% 0.00% 0.00%

Adult plus Child(ren) 0.00% 0.00% 0.00% 0.00% 0.00%

Family 0.00% 0.00% 0.00% 0.00% 0.00%

Child Only

All Rating Tiers 0.00% 0.00% 0.00% 0.00% 0.00%

Change in Members - as of 3/31/2021 - Change due to current 2021 plans not being offered in 2022.


Single Adult 0.00% 0.00% 0.00% 0.00% 0.00%

2 Adults 0.00% 0.00% 0.00% 0.00% 0.00%


Family 0.00% 0.00% 0.00% 0.00% 0.00%

Child Only

All Rating Tiers 0.00% 0.00% 0.00% 0.00% 0.00%

Change in Actual Members Per Policy


Single Adult 0.00% 0.00% 0.00% 0.00% 0.00%

2 Adults 0.00% 0.00% 0.00% 0.00% 0.00%


Family 0.00% 0.00% 0.00% 0.00% 0.00%

Child Only

Wghtd Avg - All Rating Tiers 0.00% 0.00% 0.00% 0.00% 0.00%

Change in Weighted Average Implied Tier Factors


Single Adult 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

2 Adults 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Adult plus Child(ren) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Family 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Child Only 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Wghtd Avg - All Rating Tiers 0.00% 0.00% 0.00% 0.00% 0.00%

Change in Actual to Expected Members Per Policy Due to Retired Plans


Single Adult 0.00% 0.00% 0.00% 0.00% 0.00%

2 Adults 0.00% 0.00% 0.00% 0.00% 0.00%


Family 0.00% 0.00% 0.00% 0.00% 0.00%

Child Only

Ratio (Expected/Actual) 0.00% 0.00% 0.00% 0.00% 0.00%

Exhibit 13c Supp Updated by DFS 3/20/2020

Company Name: Oxford Health Insurance IncNAIC Code: 78026 NOTE: THIS EXHIBIT SHOULD NOT INCLUDE MEMBERS OR SUBSCRIBERS THAT ARE CURRENTLY ENROLLED IN PLANS THAT WILL NOT BE AVAILABLE IN 202SERFF Tracking #: UHLC-132808091Market Segment: Small Group

12345

6789

10111213 The Total Annualized Premium in Cell G-24 of this Exhibit should equal the total in Cell Q-61 of Exhibit 13c.14 The Total Number of Members and Subscribers in Cells H-24 and I-24 of this Exhibit should equal the totals in Cells Q-45 of Exhibit 13c and Cells Q-43 of Exhibit 13c-Supplement respectively (i.e., Only those members/subscribers currently enrolled in plans that will continue to be offered in 2022).

Totals $4,289,299,482 446,066 239,234

Annualized Premiums as of Total # of Members as of Total # of Subscribers as of

3/31/2021 3/31/2021 3/31/2021 Decrease No Change 0.1% - 4.9% 5.0% - 9.9% 10.0% - 14.9% 15.0% - 19.9% 20.0% - 24.9% 25.0% - 29.9% 30.0% - 39.9% 40.0% - 49.9% 50.0% or higher Lowest Highest Weighted AvgSmall Group 01/01/22 Platinum 3 - Mid-Hudson Area EPO EPO $1,379,500 110 57 0 0 0 0 110 0 0 0 0 0 0 11.20% 14.40% 11.78%Small Group 01/01/22 Platinum 3 - Mid-Hudson Area PPO PPO $1,579,684 110 59 0 0 0 0 110 0 0 0 0 0 0 11.46% 12.54% 11.61%Small Group 01/01/22 Gold 3 - Mid-Hudson Area EPO EPO $3,080,167 296 180 0 0 0 0 266 30 0 0 0 0 0 11.97% 17.36% 13.08%Small Group 01/01/22 Gold 3 - Mid-Hudson Area PPO PPO $1,926,849 175 77 0 0 0 0 175 0 0 0 0 0 0 12.95% 12.97% 12.95%Small Group 01/01/22 Silver 3 - Mid-Hudson Area EPO EPO $4,444,042 530 282 0 0 0 0 326 204 0 0 0 0 0 13.12% 17.90% 15.24%Small Group 01/01/22 Silver 3 - Mid-Hudson Area PPO PPO $509,528 53 24 0 0 0 0 53 0 0 0 0 0 0 13.99% 14.41% 14.12%Small Group 01/01/22 Bronze 3 - Mid-Hudson Area EPO EPO $1,043,899 159 75 0 0 0 0 0 54 105 0 0 0 0 17.58% 21.41% 20.37%Small Group 04/01/22 Platinum 3 - Mid-Hudson Area EPO EPO $1,107,547 84 50 0 0 0 0 84 0 0 0 0 0 0 11.46% 14.29% 11.67%Small Group 04/01/22 Platinum 3 - Mid-Hudson Area PPO PPO $1,263,380 88 52 0 0 0 0 88 0 0 0 0 0 0 11.71% 12.80% 11.86%Small Group 04/01/22 Gold 3 - Mid-Hudson Area EPO EPO $2,204,218 210 91 0 0 0 0 202 8 0 0 0 0 0 12.22% 16.35% 13.07%Small Group 04/01/22 Gold 3 - Mid-Hudson Area PPO PPO $528,030 46 16 0 0 0 0 46 0 0 0 0 0 0 13.20% 13.23% 13.23%Small Group 04/01/22 Silver 3 - Mid-Hudson Area EPO EPO $3,557,846 422 223 0 0 0 0 144 278 0 0 0 0 0 14.15% 17.99% 15.45%Small Group 04/01/22 Silver 3 - Mid-Hudson Area PPO PPO $173,817 18 10 0 0 0 0 18 0 0 0 0 0 0 14.25% 14.67% 14.34%Small Group 04/01/22 Bronze 3 - Mid-Hudson Area EPO EPO $583,763 78 43 0 0 0 0 0 71 7 0 0 0 0 17.85% 21.69% 18.66%Small Group 04/01/22 Bronze 3 - Mid-Hudson Area PPO PPO $75,843 10 4 0 0 0 0 0 10 0 0 0 0 0 18.92% 18.92% 18.92%Small Group 07/01/22 Platinum 3 - Mid-Hudson Area EPO EPO $879,731 65 18 0 0 0 0 65 0 0 0 0 0 0 11.71% 11.77% 11.74%Small Group 07/01/22 Platinum 3 - Mid-Hudson Area PPO PPO $1,636,636 116 66 0 0 0 0 116 0 0 0 0 0 0 11.97% 13.06% 12.00%Small Group 07/01/22 Gold 3 - Mid-Hudson Area EPO EPO $3,025,731 300 172 0 0 0 0 274 26 0 0 0 0 0 12.47% 16.67% 14.03%Small Group 07/01/22 Gold 3 - Mid-Hudson Area PPO PPO $354,652 31 17 0 0 0 0 31 0 0 0 0 0 0 13.46% 13.48% 13.48%Small Group 07/01/22 Silver 3 - Mid-Hudson Area EPO EPO $2,555,570 308 179 0 0 0 0 87 221 0 0 0 0 0 14.41% 18.26% 15.77%Small Group 07/01/22 Silver 3 - Mid-Hudson Area PPO PPO $667,472 70 48 0 0 0 0 70 0 0 0 0 0 0 14.52% 14.93% 14.77%Small Group 07/01/22 Bronze 3 - Mid-Hudson Area EPO EPO $383,298 52 24 0 0 0 0 0 38 14 0 0 0 0 18.11% 21.96% 19.06%Small Group 07/01/22 Bronze 3 - Mid-Hudson Area PPO PPO $30,337 4 4 0 0 0 0 0 4 0 0 0 0 0 19.19% 19.19% 19.19%Small Group 10/01/22 Platinum 3 - Mid-Hudson Area EPO EPO $968,555 81 40 0 0 0 0 81 0 0 0 0 0 0 11.96% 14.81% 13.38%Small Group 10/01/22 Platinum 3 - Mid-Hudson Area PPO PPO $778,045 55 34 0 0 0 0 55 0 0 0 0 0 0 12.22% 13.31% 12.26%Small Group 10/01/22 Gold 3 - Mid-Hudson Area EPO EPO $3,535,334 333 181 0 0 0 0 291 42 0 0 0 0 0 12.73% 16.93% 13.70%Small Group 10/01/22 Gold 3 - Mid-Hudson Area PPO PPO $252,920 22 13 0 0 0 0 22 0 0 0 0 0 0 13.74% 13.74% 13.74%Small Group 10/01/22 Silver 3 - Mid-Hudson Area EPO EPO $2,985,364 354 202 0 0 0 0 45 309 0 0 0 0 0 14.67% 18.52% 15.82%Small Group 10/01/22 Silver 3 - Mid-Hudson Area PPO PPO $467,829 49 14 0 0 0 0 29 20 0 0 0 0 0 14.78% 15.19% 14.95%Small Group 10/01/22 Bronze 3 - Mid-Hudson Area EPO EPO $560,468 82 49 0 0 0 0 0 20 62 0 0 0 0 18.48% 22.24% 20.64%Small Group 10/01/22 Bronze 3 - Mid-Hudson Area PPO PPO $53,090 7 6 0 0 0 0 0 7 0 0 0 0 0 19.46% 19.46% 19.46%Small Group 01/01/22 Platinum 4 - NYC Area EPO EPO $141,530,140 11,672 6,065 0 0 0 0 10,513 1,159 0 0 0 0 0 13.16% 16.41% 13.50%Small Group 01/01/22 Platinum 4 - NYC Area PPO PPO $230,972,891 17,455 8,114 0 0 0 0 17,455 0 0 0 0 0 0 13.42% 14.53% 13.57%Small Group 01/01/22 Gold 4 - NYC Area EPO EPO $327,509,819 33,742 18,256 0 0 0 0 27,419 6,323 0 0 0 0 0 13.94% 19.43% 14.91%Small Group 01/01/22 Gold 4 - NYC Area PPO PPO $85,761,380 8,205 3,710 0 0 0 0 8,205 0 0 0 0 0 0 14.93% 14.97% 14.95%Small Group 01/01/22 Silver 4 - NYC Area EPO EPO $257,583,881 33,022 19,456 0 0 0 0 0 33,022 0 0 0 0 0 15.11% 19.97% 17.19%Small Group 01/01/22 Silver 4 - NYC Area PPO PPO $55,656,112 6,299 2,819 0 0 0 0 0 6,299 0 0 0 0 0 15.99% 16.43% 16.20%Small Group 01/01/22 Bronze 4 - NYC Area EPO EPO $70,565,747 10,549 5,552 0 0 0 0 0 4,613 5,936 0 0 0 0 19.65% 23.55% 21.14%Small Group 01/01/22 Bronze 4 - NYC Area PPO PPO $3,205,159 457 211 0 0 0 0 0 0 457 0 0 0 0 20.62% 20.74% 20.73%Small Group 04/01/22 Platinum 4 - NYC Area EPO EPO $74,788,490 6,106 3,126 0 0 0 0 5,846 260 0 0 0 0 0 13.42% 16.30% 13.57%Small Group 04/01/22 Platinum 4 - NYC Area PPO PPO $145,360,175 11,009 5,026 0 0 0 0 11,009 0 0 0 0 0 0 13.68% 14.79% 13.81%Small Group 04/01/22 Gold 4 - NYC Area EPO EPO $204,589,784 20,938 11,583 0 0 0 0 13,438 7,500 0 0 0 0 0 14.20% 18.45% 14.97%Small Group 04/01/22 Gold 4 - NYC Area PPO PPO $42,506,183 4,044 1,856 0 0 0 0 0 4,044 0 0 0 0 0 15.19% 15.23% 15.22%Small Group 04/01/22 Silver 4 - NYC Area EPO EPO $134,535,021 17,219 10,539 0 0 0 0 0 16,384 835 0 0 0 0 15.37% 20.06% 17.41%Small Group 04/01/22 Silver 4 - NYC Area PPO PPO $26,073,020 2,949 1,384 0 0 0 0 0 2,949 0 0 0 0 0 16.26% 16.69% 16.46%Small Group 04/01/22 Bronze 4 - NYC Area EPO EPO $37,554,101 5,510 2,998 0 0 0 0 0 278 5,232 0 0 0 0 19.92% 23.83% 21.00%Small Group 04/01/22 Bronze 4 - NYC Area PPO PPO $1,080,335 154 80 0 0 0 0 0 0 154 0 0 0 0 20.89% 21.01% 21.01%Small Group 07/01/22 Platinum 4 - NYC Area EPO EPO $66,586,674 5,437 2,875 0 0 0 0 5,244 193 0 0 0 0 0 13.68% 16.57% 13.82%Small Group 07/01/22 Platinum 4 - NYC Area PPO PPO $106,409,921 8,044 3,764 0 0 0 0 7,093 951 0 0 0 0 0 13.94% 15.05% 14.08%Small Group 07/01/22 Gold 4 - NYC Area EPO EPO $166,119,394 17,168 9,836 0 0 0 0 5,773 11,395 0 0 0 0 0 14.46% 18.72% 15.27%Small Group 07/01/22 Gold 4 - NYC Area PPO PPO $34,312,537 3,271 1,538 0 0 0 0 0 3,271 0 0 0 0 0 15.46% 15.49% 15.48%Small Group 07/01/22 Silver 4 - NYC Area EPO EPO $122,590,035 15,585 9,585 0 0 0 0 0 14,709 876 0 0 0 0 16.41% 20.34% 17.61%Small Group 07/01/22 Silver 4 - NYC Area PPO PPO $23,280,497 2,638 1,237 0 0 0 0 0 2,638 0 0 0 0 0 16.52% 16.96% 16.77%Small Group 07/01/22 Bronze 4 - NYC Area EPO EPO $33,105,047 4,860 2,794 0 0 0 0 0 0 4,860 0 0 0 0 20.19% 24.11% 21.30%Small Group 07/01/22 Bronze 4 - NYC Area PPO PPO $1,730,658 247 132 0 0 0 0 0 0 247 0 0 0 0 21.29% 21.29% 21.29%Small Group 10/01/22 Platinum 4 - NYC Area EPO EPO $88,699,857 7,242 3,918 0 0 0 0 6,884 358 0 0 0 0 0 13.94% 16.83% 14.10%Small Group 10/01/22 Platinum 4 - NYC Area PPO PPO $161,440,808 12,103 5,356 0 0 0 0 10,016 2,087 0 0 0 0 0 14.20% 15.32% 14.40%Small Group 10/01/22 Gold 4 - NYC Area EPO EPO $239,672,045 24,583 13,394 0 0 0 0 7,326 17,257 0 0 0 0 0 14.72% 18.99% 15.54%Small Group 10/01/22 Gold 4 - NYC Area PPO PPO $46,063,625 4,393 2,021 0 0 0 0 0 4,393 0 0 0 0 0 15.72% 15.75% 15.74%Small Group 10/01/22 Silver 4 - NYC Area EPO EPO $181,537,361 23,220 14,144 0 0 0 0 0 21,878 1,342 0 0 0 0 16.68% 20.61% 17.93%Small Group 10/01/22 Silver 4 - NYC Area PPO PPO $38,690,348 4,383 2,029 0 0 0 0 0 4,383 0 0 0 0 0 16.79% 17.22% 17.01%Small Group 10/01/22 Bronze 4 - NYC Area EPO EPO $54,694,070 8,080 4,333 0 0 0 0 0 0 8,080 0 0 0 0 20.47% 24.39% 21.71%Small Group 10/01/22 Bronze 4 - NYC Area PPO PPO $834,775 119 70 0 0 0 0 0 0 119 0 0 0 0 21.44% 21.56% 21.56%Small Group 01/01/22 Platinum 8 - Long Island Area EPO EPO $45,531,120 3,682 1,862 0 0 0 0 3,334 348 0 0 0 0 0 14.87% 18.17% 15.15%Small Group 01/01/22 Platinum 8 - Long Island Area PPO PPO $35,129,901 2,631 1,206 0 0 0 0 0 2,631 0 0 0 0 0 15.13% 16.26% 15.24%Small Group 01/01/22 Gold 8 - Long Island Area EPO EPO $141,490,090 14,344 7,526 0 0 0 0 0 14,178 166 0 0 0 0 15.66% 21.23% 16.56%Small Group 01/01/22 Gold 8 - Long Island Area PPO PPO $15,682,585 1,467 610 0 0 0 0 0 1,467 0 0 0 0 0 16.67% 16.70% 16.69%Small Group 01/01/22 Silver 8 - Long Island Area EPO EPO $111,782,007 14,092 8,063 0 0 0 0 0 11,763 2,329 0 0 0 0 16.84% 21.79% 18.93%Small Group 01/01/22 Silver 8 - Long Island Area PPO PPO $8,337,265 929 413 0 0 0 0 0 929 0 0 0 0 0 17.75% 18.18% 17.93%Small Group 01/01/22 Bronze 8 - Long Island Area EPO EPO $33,110,035 4,853 2,737 0 0 0 0 0 0 4,294 559 0 0 0 21.45% 25.41% 22.99%Small Group 01/01/22 Bronze 8 - Long Island Area PPO PPO $389,113 54 19 0 0 0 0 0 0 54 0 0 0 0 22.44% 22.56% 22.49%Small Group 04/01/22 Platinum 8 - Long Island Area EPO EPO $21,672,704 1,742 902 0 0 0 0 0 1,742 0 0 0 0 0 15.13% 18.06% 15.24%Small Group 04/01/22 Platinum 8 - Long Island Area PPO PPO $27,176,386 2,026 921 0 0 0 0 0 2,026 0 0 0 0 0 15.40% 16.53% 15.52%Small Group 04/01/22 Gold 8 - Long Island Area EPO EPO $77,603,670 7,833 4,074 0 0 0 0 0 7,750 83 0 0 0 0 15.92% 20.24% 16.62%Small Group 04/01/22 Gold 8 - Long Island Area PPO PPO $7,168,198 668 283 0 0 0 0 0 668 0 0 0 0 0 16.93% 16.97% 16.96%Small Group 04/01/22 Silver 8 - Long Island Area EPO EPO $46,806,726 5,874 3,389 0 0 0 0 0 5,221 653 0 0 0 0 17.11% 21.88% 19.13%Small Group 04/01/22 Silver 8 - Long Island Area PPO PPO $4,625,854 516 231 0 0 0 0 0 516 0 0 0 0 0 18.01% 18.45% 18.27%Small Group 04/01/22 Bronze 8 - Long Island Area EPO EPO $14,653,782 2,087 1,164 0 0 0 0 0 0 1,988 99 0 0 0 21.73% 25.70% 22.59%Small Group 04/01/22 Bronze 8 - Long Island Area PPO PPO $113,825 16 8 0 0 0 0 0 0 16 0 0 0 0 22.84% 22.84% 22.84%Small Group 07/01/22 Platinum 8 - Long Island Area EPO EPO $17,381,352 1,392 724 0 0 0 0 0 1,392 0 0 0 0 0 15.39% 18.33% 15.52%Small Group 07/01/22 Platinum 8 - Long Island Area PPO PPO $18,265,977 1,365 627 0 0 0 0 0 1,365 0 0 0 0 0 15.66% 16.79% 15.77%Small Group 07/01/22 Gold 8 - Long Island Area EPO EPO $64,359,560 6,522 3,479 0 0 0 0 0 6,355 167 0 0 0 0 16.18% 20.52% 17.05%Small Group 07/01/22 Gold 8 - Long Island Area PPO PPO $7,912,468 747 333 0 0 0 0 0 747 0 0 0 0 0 17.20% 17.23% 17.22%Small Group 07/01/22 Silver 8 - Long Island Area EPO EPO $40,560,570 5,067 2,921 0 0 0 0 0 4,558 509 0 0 0 0 18.17% 22.16% 19.34%Small Group 07/01/22 Silver 8 - Long Island Area PPO PPO $3,851,183 429 208 0 0 0 0 0 429 0 0 0 0 0 18.28% 18.72% 18.50%Small Group 07/01/22 Bronze 8 - Long Island Area EPO EPO $16,977,812 2,439 1,327 0 0 0 0 0 0 2,242 197 0 0 0 22.01% 25.98% 23.06%Small Group 07/01/22 Bronze 8 - Long Island Area PPO PPO $92,483 13 9 0 0 0 0 0 0 13 0 0 0 0 23.12% 23.12% 23.12%Small Group 10/01/22 Platinum 8 - Long Island Area EPO EPO $28,262,450 2,262 1,110 0 0 0 0 0 2,262 0 0 0 0 0 15.66% 18.60% 15.77%Small Group 10/01/22 Platinum 8 - Long Island Area PPO PPO $26,326,640 1,956 886 0 0 0 0 0 1,956 0 0 0 0 0 15.92% 17.06% 16.09%Small Group 10/01/22 Gold 8 - Long Island Area EPO EPO $108,234,025 10,917 5,632 0 0 0 0 0 10,733 184 0 0 0 0 16.45% 20.79% 17.22%Small Group 10/01/22 Gold 8 - Long Island Area PPO PPO $5,863,425 548 257 0 0 0 0 0 548 0 0 0 0 0 17.46% 17.50% 17.49%Small Group 10/01/22 Silver 8 - Long Island Area EPO EPO $81,923,107 10,350 5,952 0 0 0 0 0 8,875 1,475 0 0 0 0 18.44% 22.43% 19.74%Small Group 10/01/22 Silver 8 - Long Island Area PPO PPO $5,416,678 603 260 0 0 0 0 0 603 0 0 0 0 0 18.55% 18.99% 18.76%Small Group 10/01/22 Bronze 8 - Long Island Area EPO EPO $24,744,922 3,590 1,976 0 0 0 0 0 0 3,194 396 0 0 0 22.28% 26.27% 23.58%Small Group 10/01/22 Bronze 8 - Long Island Area PPO PPO $220,535 31 14 0 0 0 0 0 0 31 0 0 0 0 23.40% 23.40% 23.40%

Requested Percentage Rate Change

Percentage Rate Changes should be calculated using membership as of 3/31/2021.This exhibit must be submitted as an Excel file and as a PDF file.

Market Segment Effective Date of New RateMetal Level

(or Catastrophic) Rating Region Product Name Product Street NameDISTRIBUTION OF MEMBERS - Number of Members with Requested Percentage Rate Change at Renewal

The weighted average percentage should be developed based on annualized premium volume or membership for that metal level, and rating region, including any applicable riders.

EXHIBIT 14: SUMMARY OF REQUESTED PERCENTAGE CHANGES

Use this Exhibit for both Individual and Small Group Market Plans. A separate Exhibit should be provided for Individual and Small Group filings.Market segment refers to Individual (which includes Catastrophic) or Small Group.The requested percentage rate change reflects the expected change in premium rates that would apply to the contract holder (or member for Small Group business) on that contract holder's next rate change date for each contract holder within the indicated combination of metal level, rating region, and product name.The "Product Street Name" is the product name as advertised to consumers (i.e., as consumers are likely to refer to this product/metal level when communicating with DFS). A separate row is to be used for each combination of metal level, rating region and product name.

If the percentage changes (lowest and highest and weighted average) are identical for all the rating regions, then separate rows by rating region need not be used, and "All Regions" can be shown in the Rating Region column. If the rate change range information differs by rating region, then separate rows need to be used for each rating region the insurer uses. Rating region names used on this exhibit are to use the standard rating region names developed by DFS (e.g., Albany Area, Buffalo Area, etc.).The "requested rate change" includes the impact of any riders (such as: age 29, domestic partner, family planning, pediatric dental, etc.)."Lowest" should be the smallest percentage change that could affect any contract holder due to the submitted rate filing with that metal level and rating region, including any applicable riders."Highest" should be the largest percentage change that could affect any contract holder due to the submitted rate filing with that metal level and rating region, including any applicable riders.

The effective date is the earliest date that the proposed new rate would become effective if approved. The Effective Date for Individual is 1/1/2022. Effective Dates for Small Group are 1/1/2022, 4/1/2022, 7/1/2022 and 10/1/2022.


Exhibit 15b MHPAEA Compliance Certification

I, _________________________________, certify that the mental health and substance use disorder [name of Company Officer]

(MH/SUD) benefits applicable to this filing by ________________________ comply with the Mental [name of health insurer]

Health Parity and Addiction Equity Act and any regulations promulgated thereunder (MHPAEA). The

medical/surgical and MH/SUD benefits applicable to this filing have been tested for compliance with

MHPAEA’s financial requirements and quantitative treatment limitations rules, including the

Substantially All and Predominant tests. This compliance certification pertains to the medical and

behavioral benefit designs provided by ________________________ and does not opine on the [name of health insurer]

compliance of any wellness or incentive programs that ________________________ may choose to offer. [name of health insurer]

To measure compliance, we created an actuarial cost model of the medical/surgical benefits that included

mapping the underlying experience data allowed healthcare costs for the plans included in this filing

into the six benefit classifications (or sub-classifications allowed for outpatient benefits) that MHPAEA

permits. We tested the financial requirements and quantitative treatment limitations imposed on the

MH/SUD benefits related to this filing and determined that they are no more restrictive than the

predominant financial requirements or treatment limitations applied to substantially all medical or

surgical benefits related to this filing.

I am an officer of ___________________________ with knowledge of the issuer’s comprehensive [name of health insurer]

medical expense products and the laws and regulations applicable to those products. To the best of my

knowledge and belief the above information is true, accurate and complete.

Signature: ___________________________________________________________________________ Printed name and title: _________________________________________________________________ Date: ______________________ Phone: ___________________________________________________ Email Address: _______________________________________________________________________





Company Name: Oxford Health Insurance IncNAIC Code: 78026SERFF Number: UHLC-132808091Market Segment: Small Group

Instructions:1) This Exhibit summarizes all benefit/rate changes filed after the initial rate filing that impacts the rate tables in this current filing.2)3)4) Extend the worksheet to add more rows as needed. Only use the first tab for data entry.5)

Filing Status SERFF # NY State Tracking # Date of Submission Policy Form #Product Name (including Street

Name)Brief Description of Benefit/Rate

Change Approval Date

EXHIBIT 16: SUMMARY OF POLICY FORM AND PRODUCT CHANGES

The product street name is the product name as advertised to consumers (i.e., as consumers are likely to refer to this product/policy form when communicating with DFS).Enter filing status (approved or pending) using the drop down list. For pending files leave the approval date blank.

This form must be submitted as an Excel file and as a PDF file.

List of rate filings that have been approved since the §3231(d) or §4308(b) initial rate filing, or are currently pending with DFS.


1.a Company Name

1.b NAIC Code 1.c SERFF Number

1d.Base medical

policy form number

1e.Product Name

(per Rate Manual)

1f.Product

Street Name as indicated

to consumers2.

Filing Type

3.Effective date of last rate change

4.Market Segment

5A.Rating Region

5B.Product Type (see

"Instructions" tab for examples)

6. Is a rolling

rate structure

used for this base

medical policy form? (Yes or No)

7.Is base medical policy form open

(new sales allowed) or

closed (no new sales)

8.Number of

policyholders affected by

rate change. (For group

business this is number of

groups.)

9.Number of

covered lives affected by rate change

14.1Beginning Date

of the experience

period(mm/dd/yyyy)

14.2Ending Date of the experience

period(mm/dd/yyyy)

14.3Member months for experience period

14.4Earned premiums for experience period ($)

14.5Standardized earned

premiums for experience period ($)

14.6 Claims Paid in calendar year

2020 on claims incurred during calendar year

2020 - before any adjustment for federal

risk adjustment, federal reinsurance, risk

corridors, state stop-loss pools, or

commercial stop-loss payments ($)

14.6a Claims Paid in calendar year 2021 (during the months of January and February

only) on claims incurred during calendar year 2020 - before any

adjustment for federal risk adjustment, federal

reinsurance, risk corridors, state stop-

loss pools, or commercial stop-loss

payments ($)

14.6b Estimated claims remaining to be

paid in the future on claims incurred during





14.6c Rx Rebates associated with claims

reported in Columns 14.6 and 14.6a (enter as

a positive value) ($)

14.6d Estimated Rx Rebates associated

with claims reported in Column 14.6b or not otherwise included in

14.6c (enter as a positive value) ($)

14.7 Total Incurred Claims for

calendar year 2020 Net of Rx Rebates ($)

14.8Adjustment to the

incurred claims for the period due to receipts from state or federal

reinsurance or stop loss pools (enter receipts from the pool as a negative value) ($)


incurred claims for the period due to receipts

from or payments to the federal risk adjustment

pool (enter receipts as a negative value and

payments to the pool as a positive value) ($)

14.10Administrative expenses

for experience period (including commissions and premium taxes, but

excluding federal and state income taxes) ($)

15.1Beginning date of the

experience period(mm/dd/yyyy)

15.2Ending Date of the experience period

(mm/dd/yyyy)

15.3Member months for experience period

15.4Earned premiums for experience period ($)

15.5Standardized earned

premiums for experience period ($)

15.6 Claims Paid in calendar year

2019 on claims incurred during calendar year





15.6a Claims Paid in calendar year 2020 (during the months of January and February

only) on claims incurred during calendar year 2019 - before any

adjustment for federal risk adjustment, federal

reinsurance, risk corridors, state stop-

loss pools, or commercial stop-loss

payments ($)

15.6b All other claim amounts associated with claims incurred

during the 2019 calendar year that are

not included in 15.6 and 15.6a (i.e., Payments through February of

2021 plus any remaining IBNR associated with

claims that were incurred during 2019) - before any adjustment

for federal risk adjustment, federal reinsurance, risk



15.6c Rx Rebates associated with claims

reported in Columns 15.6 and 15.6a (enter as

a positive value) ($)

15.6d Estimated Rx Rebates associated

with claims reported in Column 15.6b or not otherwise included in

15.6c (enter as a positive value) ($)

15.7 Total Incurred claims for

calendar year 2019 Net of Rx Rebates ($)


incurred claims for the period due to receipts from state or federal

reinsurance or stop loss pools (enter receipts from the pool as a negative value) ($)


incurred claims for the period due to receipts

from or payments to the federal risk adjustment

pool (enter receipts as a negative value and

payments to the pool as a positive value) ($)

15.10Administrative expenses

for experience period (including commissions and premium taxes, but

excluding federal and state income taxes) ($)

Oxford Health Insurance 78026 UHLC-132808091 OHINY_SG_C EPO EPO EPO 1/1/2021 SG-ACA-FTE 3 EPO Yes New sales 526 3,388 1/1/2020 12/31/2020 43034.00 30,493,385 32,825,771 26,608,260 3,186,995 778,373 1,893,875 0 $ 28,679,752.82 $ - $ (515,171) $ 4,534,891 1/1/2019 12/31/2019 42,588 $ 29,326,394 $ 33,279,562 $ 25,468,753 $ 2,507,558 $ 547,219 $ 1,487,967 $ - $ 27,035,564.39 $ - $ (850,831) $ 3,583,438 Oxford Health Insurance 78026 UHLC-132808091 OHINY_SG_C PPO PPO PPO 1/1/2021 SG-ACA-FTE 3 PPO Yes New sales 147 854 1/1/2020 12/31/2020 10696.00 10,318,120 11,107,335 6,542,178 783,587 191,379 449,737 0 $ 7,067,406.46 $ - $ (174,320) $ 1,534,482 1/1/2019 12/31/2019 11,406 $ 10,286,223 $ 11,672,796 $ 8,316,920 $ 818,853 $ 178,697 $ 421,387 $ - $ 8,893,081.65 $ - $ (298,429) $ 1,256,890 Oxford Health Insurance 78026 UHLC-132808091 OHINY_SG_C EPO EPO EPO 1/1/2021 SG-ACA-HNY-FTE 3 EPO Yes New sales 17 76 1/1/2020 12/31/2020 1118.00 653,330 703,302 558,445 66,888 16,336 24,160 0 $ 617,508.37 $ - $ (11,038) $ 97,161 1/1/2019 12/31/2019 1,143 $ 625,799 $ 710,156 $ 480,539 $ 47,312 $ 10,325 $ 21,355 $ - $ 516,820.49 $ - $ (18,156) $ 76,467 Oxford Health Insurance 78026 UHLC-132808091 OHINY_SG_C EPO EPO EPO 1/1/2021 SG-ACA-FTE 4 EPO Yes New sales 28,114 242,417 1/1/2020 12/31/2020 3187705.00 2,245,062,198 2,416,783,079 1,637,884,437 196,177,009 47,913,124 122,997,440 0 $ 1,758,977,128.93 $ - $ (37,929,253) $ 333,879,347 1/1/2019 12/31/2019 3,459,502 $ 2,336,166,648 $ 2,651,079,511 $ 1,762,559,023 $ 173,534,966 $ 37,870,192 $ 110,113,556 $ - $ 1,863,850,624.72 $ - $ (67,777,936) $ 285,459,819 Oxford Health Insurance 78026 UHLC-132808091 OHINY_SG_C PPO PPO PPO 1/1/2021 SG-ACA-FTE 4 PPO Yes New sales 9,937 85,770 1/1/2020 12/31/2020 1109247.00 993,403,864 1,069,387,588 781,127,055 93,559,207 22,850,353 63,552,897 0 $ 833,983,717.49 $ - $ (16,783,083) $ 147,736,234 1/1/2019 12/31/2019 1,199,409 $ 1,015,670,002 $ 1,152,581,274 $ 885,219,531 $ 87,155,402 $ 19,019,751 $ 58,444,715 $ - $ 932,949,969.48 $ - $ (29,467,083) $ 124,106,290 Oxford Health Insurance 78026 UHLC-132808091 OHINY_SG_C EPO EPO EPO 1/1/2021 SG-ACA-HNY-FTE 4 EPO Yes New sales 595 2,516 1/1/2020 12/31/2020 36373.00 20,655,160 22,235,037 12,883,894 1,543,164 376,893 940,284 0 $ 13,863,667.13 $ - $ (348,959) $ 3,071,777 1/1/2019 12/31/2019 41,584 $ 22,133,478 $ 25,117,048 $ 15,506,110 $ 1,526,674 $ 333,163 $ 819,560 $ - $ 16,546,387.20 $ - $ (642,147) $ 2,704,524 Oxford Health Insurance 78026 UHLC-132808091 OHINY_SG_C EPO EPO EPO 1/1/2021 SG-ACA-FTE 8 EPO Yes New sales 12,262 96,299 1/1/2020 12/31/2020 1254073.00 874,583,400 941,478,755 735,119,813 88,048,706 21,504,500 54,220,833 0 $ 790,452,187.17 $ - $ (14,775,668) $ 130,065,588 1/1/2019 12/31/2019 1,327,862 $ 886,002,405 $ 1,005,434,618 $ 792,318,762 $ 78,008,740 $ 17,023,693 $ 48,677,785 $ - $ 838,673,410.02 $ - $ (25,705,107) $ 108,262,005 Oxford Health Insurance 78026 UHLC-132808091 OHINY_SG_C PPO PPO PPO 1/1/2021 SG-ACA-FTE 8 PPO Yes New sales 2,252 13,999 1/1/2020 12/31/2020 179118.00 160,133,184 172,381,491 149,372,827 17,891,076 4,369,612 13,223,539 0 $ 158,409,975.49 $ - $ (2,705,374) $ 23,814,558 1/1/2019 12/31/2019 195,175 $ 164,126,401 $ 186,250,471 $ 181,306,281 $ 17,850,738 $ 3,895,531 $ 11,997,636 $ - $ 191,054,913.68 $ - $ (4,761,710) $ 20,054,859 Oxford Health Insurance 78026 UHLC-132808091 OHINY_SG_C EPO EPO EPO 1/1/2021 SG-ACA-HNY-FTE 8 EPO Yes New sales 198 747 1/1/2020 12/31/2020 10715.00 6,000,439 6,459,402 4,033,868 483,155 118,003 345,777 0 $ 4,289,248.95 $ - $ (101,375) $ 892,368 1/1/2019 12/31/2019 12,118 $ 6,446,909 $ 7,315,946 $ 4,657,169 $ 458,527 $ 100,064 $ 299,226 $ - $ 4,916,533.63 $ - $ (187,041) $ 787,758

Data Item for Specified Base Medical Policy Form2020 Experience Period

(NY statewide experience, base medical policy form + associated riders)2019 Experience Period

(NY statewide experience, base medical policy form + associated riders)


Exhibit 18 - Index Rate/Plan-Design Level Adjustment Worksheet

Company Name: Oxford Health Insurance IncNAIC Code: 78026

SERFF Number: UHLC-132808091Market Segment : Small Group

A separate column must be used for each base plan design (i.e., for each separate and distinct 14 digit HIOS ID)

Line # General***ACA Compliant Plans

Only Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 81 Product* XXXXXXX EPO EPO EPO EPO EPO EPO EPO EPO 2 Product ID* XXXXXXX 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY0013 Metal Level (or catastrophic)* XXXXXXX Platinum Platinum Platinum Platinum Gold Gold Gold Gold4 AV Metal Value (HHS Calculator)* XXXXXXX 0.88515 0.88515 0.88515 0.88515 0.80107 0.80107 0.80107 0.80107 5 AV Pricing Value (total, risk pool experience based)* XXXXXXX 0.91881 0.91881 0.91881 0.91881 0.78425 0.78425 0.78425 0.78425 6 Plan Type* XXXXXXX EPO EPO EPO EPO EPO EPO EPO EPO7 Plan Name* XXXXXXX 20/40/100 EPO 22 20/40/100 EPO 22 20/40/100 EPO 22 20/40/100 EPO 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 8 HIOS Plan ID (14 Digits)* XXXXXXX 85629NY0010033 85629NY0010034 85629NY0010035 85629NY0010036 85629NY0010072 85629NY0010073 85629NY0010074 85629NY00100759 Exchange Plan?* XXXXXXX Off Off Off Off Off Off Off Off

9A 2022 Plan Status (as compared to 2021) XXXXXXX Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod* This field should be the same as used in the Unified Rate Review Template, Worksheet 2

Experience Period Index Rate Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 810 Earned Premiums for 2019 Experience Period # 4,470,784,260.04 9,781,747.61 141,673,273.47 14,332,769.97 138,962,554.58 0.00 0.00 0.00 0.00

10A Incurred Claims for 2019 Experience Period # 3,884,437,305.26 9,586,237.89 117,780,081.54 15,359,207.14 135,816,133.16 0.00 0.00 0.00 0.0010B Member-Months for 2019 Experience Period # 6,290,787.00 11,424.00 156,788.00 18,520.00 157,447.00 0.00 0.00 0.00 0.0010C Average PMPM Incurred Claims [(10A)/(10B)] = (Initial Index PMPM) 617.48034 839.13147 751.20597 829.33084 862.61493 0.00000 0.00000 0.00000 0.0000011 Average Pricing Actuarial Value reflected in experience period 0.8542712 AV Adjusted Experience Period Index Rate PMPM = [(10C) / (11)] 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

# Amounts should be prior to any adjustments for Federal Risk Adjustment and Healthy NY Stop-Loss Reimbursements, and should be consistent with the amounts reported in Exhibit 17 for the relevant market categories.

Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 812A Allowed Claims for 2019 Experience Period # 4,511,296,661.85 10,294,861.32 127,759,598.55 16,811,411.06 146,073,376.96 0.00 0.00 0.00 0.00

Market Wide Adjustments to the AV Adjusted Experience Period Index Rate All Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 813 Impact of adjusting experience period data to EHB benefit level ** 0.98639

13A Adjustment to remove CSR Payments** 1.0000014 Market wide adjustment for changes in provider network ** 1.0000015 Market wide adjustment for fee schedule changes ** 1.0000016 Market wide adjustment for utilization management changes ** 1.0000017 Market wide adjustment for impact on claim costs from quality improvement and cost containment initiatives ** 1.0000018 Claim trend projection factor (midpoint of experience period to mid point of rate applicability period) 1.2821119 Federal Risk Adjustment Program Impact (less than 1.00 to reflect a recovery, more than 1.00 to reflect a payment to the pool) ** 0.9787120 Impact of adjustments due to experience period claim data not being sufficiently credible ** 1.0000021 Adjustment for changes in distribution of risk pool membership by rating regions (i.e., standard rating regions) ** 1.0000022 Change in morbidity not reflected in the experience data that is known and quantifiable at the time of the rate filing ** 1.00926

23a Impact of changes in New York State Law that are not reflected in the experience data ** 1.0026023b Covered Lives Assessment Impact – Impact associated with the HCRA Covered Lives Assessment 1.00000

23c2022 Covid-19 Impact – Expected impact associated with worsening morbidity and other costs resulting from

Covid-19 with respect to the 2022 calendar year. ** 1.0017024 Demographic Change 1.0113525 2019 Reinsurance Pool Cost 1.0037426 Impact of Average Group Size Change 1.0016027 1.0000028 Impact of Market Wide Adjustments (= Product L13 through L27) 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559

** Not Included in Claim Trend Adjustment

Plan Level Adjustments Average - All Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 829 Index Rate - After Marketwide Adjustments 922.0192 922.01917 922.01917 922.01917 922.01917 922.01917 922.01917 922.01917 922.0191730 Pricing actuarial value (without induced demand factor) # 0.7980 0.91881 0.91881 0.91881 0.91881 0.78425 0.78425 0.78425 0.7842531 Pricing actuarial value (only the induced demand factor) # 1.0712 1.15000 1.15000 1.15000 1.15000 1.08000 1.08000 1.08000 1.0800032 Impact of provider network characteristics ## 0.9698 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000033 Impact of delivery system characteristics ## 0.9939 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000034 Impact of utilization management practices ## 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000035 Impact on claim costs from quality improvement and cost containment initiatives ## 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000036 Benefits in additional to EHB (greater than 1.00) 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000037 Impact of eligibility categories (catastrophic plans only) 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000038 Addition of Out of Network Benefit Option (e.g., POS or PPO, if applicable) 1.0131 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000039 Impact of Adjustment for NYS Stop Loss reimbursements on SG HNY 0.9987 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000040 Impact of Age 26 / Age 29 1.0014 1.01364 1.00000 1.01364 1.00000 1.00000 1.00000 1.01701 1.0170141 Impact of Family Planning / No Family Planning 1.0000 1.00000 1.00000 1.00000 1.00000 0.99602 0.99602 0.99602 0.9960242 Impact of Dental vs No Dental 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000043 Premium Curve Adjustment 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000044 Adjustment to add CSR Payments on the Plan Level (A common factor to be applied uniformly to all silver plans only - if applicable) ### 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000045 Rating Region Factor 1.0005 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054

46a Motion Rider 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000046b Other 2 (specify) 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000046c Other 3 (specify) 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000046d Other 4 (specify) 1.0000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.0000047 Impact of Plan Wide Adjustments (= Weighted Average Factor using Line 55a) 0.84400 1.07162 1.05720 1.07162 1.05720 0.84407 0.84407 0.85843 0.85843

# Reflects changes that impact an entire standard population (e.g., cost sharing and other changes that are not based on health status, age, gender or occupation).## Beyond what is reflected in Market Wide adjustments### As long as CSR payments are removed from the starting experience in Line 13A in the Marketwide adjustments, Line 44 does NOT need to be revenue neutral (New for 2022 )

48a Adjusted Incurred Claims (Excluding Admin Expense and Profit) 4,895,372,764.75

ExpensesWeighted Average - All

Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 849 Plan Expected Costs 778.18 988.05 974.76 988.05 974.76 778.25 778.25 791.49 791.4950 FIXED EXPENSE: Administrative Costs (excluding Exchange user fees and profits) - to be expressed as a PMPM Amount ### 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000051 VARIABLE EXPENSE: Administrative costs (excluding Exchange user fees and profits) - to be expressed as a percentage ### 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688%52 VARIABLE EXPENSE: Profit/Contribution to surplus margins - to be expressed as a percentage ### 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500%53 Total Expense Load as a percentage of Premium (= [L50 + (L51 + L52) * L56] / L56) 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188%

### The combined factors for Administrative Costs (Fixed and Variable) and Profit/Contribution to surplus margins cannot exceed 18% (equivalent to a factor of 1.2195 ( = 1.00 / 0.82) applied to Line 49). The "FIXED EXPENSE" amount in Line 50 must be entered as a PMPM and "VARIABLE EXPENSE" amounts in Lines 51 and 52 must be entered as a percentage of premium.

2021 Premium Rates and Membership All Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 854 2021 PMPM Rates (First Quarter 2021 rates for Small Group)*** 801.32 1,037.40 1,023.71 1,037.40 1,023.71 805.02 805.02 818.70 818.7055 2021 Members as of 3/31/2021 (The total should tie to the 3/31/2021 Membership Survey Total) 446,066.00 844.00 10,165.00 1,242.00 9,734.00 0.00 0.00 0.00 0.00

55a 2021 Members as of 3/31/2021 - Only those enrolled in plans that will still be available in 2022 446,066.00 844.00 10,165.00 1,242.00 9,734.00 0.00 0.00 0.00 0.00

Calculation of Final 2022 Rates All Plans Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 856 TOTAL PROJECTED INDEX RATE PMPM (= [(L49 + L50) / (1 - L51 - L52)]) 928.49 1,178.90 1,163.04 1,178.90 1,163.04 928.57 928.57 944.37 944.3757 Percent Change in Premium Rates (= L56 / L54) 15.87% 13.64% 13.61% 13.64% 13.61% 15.35% 15.35% 15.35% 15.35%

*** The information in the "General" Section above should also be completed for any 2021 plans that will no longer be available in 2022.*** The Average PMPM rate for "All Plans" should be used for All Non-ACA Compliant Plans Weighted Average PMPM: 928.49

Difference From Line 56 Col D: 0.00Overall Average Impact: 15.87% Percentage Difference: 0.0%







Only1 Product* XXXXXXX 2 Product ID* XXXXXXX 3 Metal Level (or catastrophic)* XXXXXXX 4 AV Metal Value (HHS Calculator)* XXXXXXX 5 AV Pricing Value (total, risk pool experience based)* XXXXXXX 6 Plan Type* XXXXXXX 7 Plan Name* XXXXXXX 8 HIOS Plan ID (14 Digits)* XXXXXXX 9 Exchange Plan?* XXXXXXX

9A 2022 Plan Status (as compared to 2021) XXXXXXX * This field should be the same as used in the Unified Rate Review Template, Worksheet 2

Experience Period Index Rate10 Earned Premiums for 2019 Experience Period # 4,470,784,260.04

10A Incurred Claims for 2019 Experience Period # 3,884,437,305.2610B Member-Months for 2019 Experience Period # 6,290,787.0010C Average PMPM Incurred Claims [(10A)/(10B)] = (Initial Index PMPM) 617.4803411 Average Pricing Actuarial Value reflected in experience period 0.8542712 AV Adjusted Experience Period Index Rate PMPM = [(10C) / (11)] 722.81667

# Amounts should be prior to any adjustments for Federal Risk Adjustment and Healthy NY Stop-Loss Reimbursements, and should be consistent with the amounts reported in

12A Allowed Claims for 2019 Experience Period # 4,511,296,661.85

Market Wide Adjustments to the AV Adjusted Experience Period Index Rate All Plans13 Impact of adjusting experience period data to EHB benefit level ** 0.98639




Covid-19 with respect to the 2022 calendar year. ** 1.0017024 Demographic Change 1.0113525 2019 Reinsurance Pool Cost 1.0037426 Impact of Average Group Size Change 1.0016027 1.0000028 Impact of Market Wide Adjustments (= Product L13 through L27) 1.27559


Plan Level Adjustments Average - All Plans29 Index Rate - After Marketwide Adjustments 922.019230 Pricing actuarial value (without induced demand factor) # 0.798031 Pricing actuarial value (only the induced demand factor) # 1.071232 Impact of provider network characteristics ## 0.969833 Impact of delivery system characteristics ## 0.993934 Impact of utilization management practices ## 1.000035 Impact on claim costs from quality improvement and cost containment initiatives ## 1.000036 Benefits in additional to EHB (greater than 1.00) 1.000037 Impact of eligibility categories (catastrophic plans only) 1.000038 Addition of Out of Network Benefit Option (e.g., POS or PPO, if applicable) 1.013139 Impact of Adjustment for NYS Stop Loss reimbursements on SG HNY 0.998740 Impact of Age 26 / Age 29 1.001441 Impact of Family Planning / No Family Planning 1.000042 Impact of Dental vs No Dental 1.000043 Premium Curve Adjustment 1.000044 Adjustment to add CSR Payments on the Plan Level (A common factor to be applied uniformly to all silver plans only - if applicable) ### 1.000045 Rating Region Factor 1.0005

46a Motion Rider 1.000046b Other 2 (specify) 1.000046c Other 3 (specify) 1.000046d Other 4 (specify) 1.000047 Impact of Plan Wide Adjustments (= Weighted Average Factor using Line 55a) 0.84400

# Reflects changes that impact an entire standard population (e.g., cost sharing and other changes that are not based on health status, age, gender or occupation).## Beyond what is reflected in Market Wide adjustments### As long as CSR payments are removed from the starting experience in Line 13A in the Marketwide adjustments, Line 44 does NOT need to be revenue neutral (New for 2022



Plans49 Plan Expected Costs 778.1850 FIXED EXPENSE: Administrative Costs (excluding Exchange user fees and profits) - to be expressed as a PMPM Amount ### 0.0000051 VARIABLE EXPENSE: Administrative costs (excluding Exchange user fees and profits) - to be expressed as a percentage ### 12.688%52 VARIABLE EXPENSE: Profit/Contribution to surplus margins - to be expressed as a percentage ### 3.500%53 Total Expense Load as a percentage of Premium (= [L50 + (L51 + L52) * L56] / L56) 16.188%

### The combined factors for Administrative Costs (Fixed and Variable) and Profit/Contribution to surplus margins cannot exceed 18% (equivalent to a factor of 1.2195 ( = 1.00 The "FIXED EXPENSE" amount in Line 50 must be entered as a PMPM and "VARIABLE EXPENSE" amounts in Lines 51 and 52 must be entered as a percentag

2021 Premium Rates and Membership All Plans54 2021 PMPM Rates (First Quarter 2021 rates for Small Group)*** 801.3255 2021 Members as of 3/31/2021 (The total should tie to the 3/31/2021 Membership Survey Total) 446,066.00

55a 2021 Members as of 3/31/2021 - Only those enrolled in plans that will still be available in 2022 446,066.00

Calculation of Final 2022 Rates All Plans56 TOTAL PROJECTED INDEX RATE PMPM (= [(L49 + L50) / (1 - L51 - L52)]) 928.4957 Percent Change in Premium Rates (= L56 / L54) 15.87%

*** The information in the "General" Section above should also be completed for any 2021 plans that will no longer be available in 2022.*** The Average PMPM rate for "All Plans" should be used for All Non-ACA Compliant Plans

Overall Average Impact: 15.87%

Plan 9 Plan 10 Plan 11 Plan 12 Plan 13 Plan 14 Plan 15 Plan 16 EPO EPO EPO EPO EPO EPO EPO EPO

85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Gold Gold Gold Gold Gold Gold Gold Gold

0.80107 0.81005 0.81005 0.81005 0.81005 0.81005 0.81005 0.81005 0.78425 0.83788 0.83788 0.83788 0.83788 0.83788 0.83788 0.83788

EPO EPO EPO EPO EPO EPO EPO EPOEPO HSA 22 50/50/1000/90 EPO 22 50/50/1000/90 EPO 22 50/50/1000/90 EPO 22 50/50/1000/90 EPO 22 50/50/1000/90 EPO 22 50/50/1000/90 EPO 22 50/50/1000/90 EPO 22

85629NY0010076 85629NY0010081 85629NY0010082 85629NY0010083 85629NY0010084 85629NY0010101 85629NY0010102 85629NY0010103Off Off Off Off Off Off Off Off

Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod

Plan 9 Plan 10 Plan 11 Plan 12 Plan 13 Plan 14 Plan 15 Plan 1622,072,344.10 5,904,780.48 55,365,527.01 7,290,591.31 65,352,620.42 0.00 0.00 0.0028,048,682.92 5,333,777.73 53,476,144.03 8,296,491.63 64,281,237.10 0.00 0.00 0.00

36,751.00 8,211.00 71,689.00 10,471.00 86,250.00 0.00 0.00 0.00763.20870 649.58930 745.94630 792.33040 745.28971 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 9 Plan 10 Plan 11 Plan 12 Plan 13 Plan 14 Plan 15 Plan 1631,784,575.79 5,989,543.01 59,714,212.01 9,419,139.02 71,992,402.84 0.00 0.00 0.00

Plan 9 Plan 10 Plan 11 Plan 12 Plan 13 Plan 14 Plan 15 Plan 16

1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559

Plan 9 Plan 10 Plan 11 Plan 12 Plan 13 Plan 14 Plan 15 Plan 16922.01917 922.01917 922.01917 922.01917 922.01917 922.01917 922.01917 922.01917

0.78425 0.83788 0.83788 0.83788 0.83788 0.83788 0.83788 0.837881.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.01592 1.00000 1.01592 1.00000 1.00000 1.00000 1.015921.00000 1.00000 1.00000 1.00000 1.00000 0.99627 0.99627 0.996271.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.84745 0.91981 0.90539 0.91981 0.90539 0.90202 0.90202 0.91638

Plan 9 Plan 10 Plan 11 Plan 12 Plan 13 Plan 14 Plan 15 Plan 16781.36 848.08 834.79 848.08 834.79 831.68 831.68 844.920.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000012.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688%3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500%16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188%


2,370.00 594.00 5,573.00 790.00 5,861.00 0.00 0.00 0.002,370.00 594.00 5,573.00 790.00 5,861.00 0.00 0.00 0.00

Plan 9 Plan 10 Plan 11 Plan 12 Plan 13 Plan 14 Plan 15 Plan 16932.28 1,011.89 996.03 1,011.89 996.03 992.32 992.32 1,008.1215.35% 14.99% 14.97% 14.99% 14.97% 14.97% 14.97% 14.98%
































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Gold Silver Silver Silver Silver Silver Silver Silver

0.81005 0.70033 0.70033 0.70033 0.70033 0.70033 0.70033 0.70033 0.83788 0.72342 0.72342 0.72342 0.72342 0.72342 0.72342 0.72342

EPO EPO EPO EPO EPO EPO EPO EPO50/50/1000/90 EPO 22 25/50/2500/80 EPO HSA 25/50/2500/80 EPO HSA 25/50/2500/80 EPO HSA 25/50/2500/80 EPO HSA 25/50/2500/80 EPO HSA 25/50/2500/80 EPO HSA 25/50/2500/80 EPO HSA



Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 240.00 442,574.40 16,182,628.90 951,464.04 13,008,590.49 0.00 0.00 0.000.00 561,300.63 12,325,587.53 594,566.40 11,959,500.97 0.00 0.00 0.000.00 792.00 26,139.00 1,560.00 21,727.00 0.00 0.00 0.00

0.00000 708.71292 471.54013 381.13231 550.44419 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 240.00 660,454.79 15,494,344.57 788,384.37 14,537,443.35 0.00 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.83788 0.72342 0.72342 0.72342 0.72342 0.72342 0.72342 0.723421.08000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030001.00000 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.01592 1.02038 1.00000 1.02038 1.00000 1.00000 1.00000 1.020380.99627 1.00000 1.00000 1.00000 1.00000 0.99523 0.99523 0.995231.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.91638 0.72171 0.70729 0.72171 0.70729 0.70392 0.70392 0.71827



0.00 54.00 2,906.00 172.00 2,273.00 0.00 0.00 0.000.00 54.00 2,906.00 172.00 2,273.00 0.00 0.00 0.00

Plan 17 Plan 18 Plan 19 Plan 20 Plan 21 Plan 22 Plan 23 Plan 241,008.12 793.96 778.10 793.96 778.10 774.39 774.39 790.1714.98% 17.67% 17.71% 17.67% 17.71% 17.71% 17.71% 17.67%
































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Silver Silver Platinum Platinum Platinum Platinum Platinum Platinum

0.70033 0.70856 0.91166 0.91166 0.91166 0.91166 0.88515 0.88515 0.72342 0.73345 0.93876 0.93876 0.93876 0.93876 0.91881 0.91881

EPO EPO EPO EPO EPO EPO EPO EPO25/50/2500/80 EPO HSA 25/50/2250/80 EPO HSA EPO 22 EPO 22 EPO 22 EPO 22 20/40/100 EPO 22 20/40/100 EPO 22



Plan 25 Plan 26 Plan 27 Plan 28 Plan 29 Plan 30 Plan 31 Plan 320.00 28,192,353.50 85,406.28 0.00 0.00 0.00 238,509.93 15,772.800.00 22,468,162.14 40,437.11 0.00 0.00 0.00 160,048.51 30,659.250.00 44,730.00 104.00 0.00 0.00 0.00 285.00 15.00

0.00000 502.30633 388.81837 0.00000 0.00000 0.00000 561.57372 2043.95000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 25 Plan 26 Plan 27 Plan 28 Plan 29 Plan 30 Plan 31 Plan 320.00 28,172,592.92 44,662.95 0.00 0.00 0.00 178,164.09 34,164.22


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.72342 0.73345 0.93876 0.93876 0.93876 0.93876 0.91881 0.918811.03000 1.03000 1.15000 1.15000 1.15000 1.15000 1.15000 1.150000.94872 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.02038 1.00000 1.00000 1.00000 1.01335 1.01335 1.00000 1.000000.99523 1.00000 0.99687 0.99687 0.99687 0.99687 0.99681 0.996811.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.71827 0.75586 1.07678 1.07678 1.09115 1.09115 1.05382 1.05382

Plan 25 Plan 26 Plan 27 Plan 28 Plan 29 Plan 30 Plan 31 Plan 32662.25 696.92 992.81 992.81 1,006.06 1,006.06 971.65 971.650.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000012.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688%3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500%16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188%

Plan 25 Plan 26 Plan 27 Plan 28 Plan 29 Plan 30 Plan 31 Plan 32671.54 712.20 1,042.47 1,042.47 1,056.16 1,056.16 1,020.50 1,020.50

0.00 2,574.00 0.00 0.00 0.00 0.00 0.00 0.000.00 2,574.00 0.00 0.00 0.00 0.00 0.00 0.00

Plan 25 Plan 26 Plan 27 Plan 28 Plan 29 Plan 30 Plan 31 Plan 32790.17 831.53 1,184.58 1,184.58 1,200.39 1,200.39 1,159.32 1,159.3217.67% 16.76% 13.63% 13.63% 13.66% 13.66% 13.60% 13.60%
































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Platinum Platinum Gold Gold Gold Gold Gold Gold

0.88515 0.88515 0.80107 0.80107 0.80107 0.81019 0.81019 0.81019 0.91881 0.91881 0.78425 0.78425 0.78425 0.82868 0.82868 0.82868

EPO EPO EPO EPO EPO EPO EPO EPO20/40/100 EPO 22 20/40/100 EPO 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 15/35/1750/90 EPO 22 15/35/1750/90 EPO 22 15/35/1750/90 EPO 22 85629NY0010228 85629NY0010229 85629NY0010234 85629NY0010235 85629NY0010236 85629NY0010237 85629NY0010238 85629NY0010239

Off Off Off Off Off Off Off OffUniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod

Plan 33 Plan 34 Plan 35 Plan 36 Plan 37 Plan 38 Plan 39 Plan 400.00 0.00 1,937,827.88 24,585,218.16 1,557,105.95 10,343,057.72 156,043,262.56 13,836,680.170.00 0.00 3,493,831.94 25,214,017.16 3,403,701.45 10,596,067.87 133,367,496.37 19,085,815.280.00 0.00 2,814.00 35,980.00 2,515.00 14,710.00 203,739.00 20,827.00

0.00000 0.00000 1241.58918 700.77869 1353.36042 720.33092 654.59974 916.39772

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 33 Plan 34 Plan 35 Plan 36 Plan 37 Plan 38 Plan 39 Plan 400.00 0.00 4,164,465.53 29,151,355.23 3,719,543.54 11,828,916.22 148,980,373.01 21,026,241.95


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.91881 0.91881 0.78425 0.78425 0.78425 0.82868 0.82868 0.828681.15000 1.15000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.01364 1.01364 1.01701 1.00000 1.01701 1.01610 1.00000 1.016100.99681 0.99681 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.06819 1.06819 0.86186 0.84745 0.86186 0.90987 0.89545 0.90987


Plan 33 Plan 34 Plan 35 Plan 36 Plan 37 Plan 38 Plan 39 Plan 401,034.19 1,034.19 821.91 808.22 821.91 869.26 855.58 869.26

0.00 0.00 265.00 1,911.00 266.00 1,053.00 11,274.00 1,370.000.00 0.00 265.00 1,911.00 266.00 1,053.00 11,274.00 1,370.00

Plan 33 Plan 34 Plan 35 Plan 36 Plan 37 Plan 38 Plan 39 Plan 401,175.13 1,175.13 948.14 932.28 948.14 1,000.96 985.10 1,000.9613.63% 13.63% 15.36% 15.35% 15.36% 15.15% 15.14% 15.15%

































0.81019 0.81139 0.81139 0.81139 0.81139 0.81019 0.81019 0.81019 0.82868 0.82192 0.82192 0.82192 0.82192 0.82868 0.82868 0.82868

EPO EPO EPO EPO EPO EPO EPO EPO15/35/1750/90 EPO 22 25/40/1750/80 EPO 22 25/40/1750/80 EPO 22 25/40/1750/80 EPO 22 25/40/1750/80 EPO 22 15/35/1750/90 EPO 22 15/35/1750/90 EPO 22 15/35/1750/90 EPO 22



Plan 41 Plan 42 Plan 43 Plan 44 Plan 45 Plan 46 Plan 47 Plan 48142,867,572.79 8,955,645.32 156,254,723.48 11,469,308.35 125,483,882.27 0.00 0.00 0.00129,966,851.07 7,984,681.88 126,822,055.03 13,274,936.82 115,670,701.94 0.00 0.00 0.00

195,337.00 12,996.00 210,555.00 19,254.00 179,181.00 0.00 0.00 0.00665.34682 614.39534 602.32269 689.46384 645.55227 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 41 Plan 42 Plan 43 Plan 44 Plan 45 Plan 46 Plan 47 Plan 48145,138,016.70 9,223,447.79 144,830,006.14 14,930,317.13 131,514,841.38 0.00 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.82868 0.82192 0.82192 0.82192 0.82192 0.82868 0.82868 0.828681.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.01623 1.00000 1.01623 1.00000 1.00000 1.00000 1.016101.00000 1.00000 1.00000 1.00000 1.00000 0.99623 0.99623 0.996231.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.89545 0.90257 0.88815 0.90257 0.88815 0.89208 0.89208 0.90644



10,933.00 947.00 12,434.00 1,361.00 10,141.00 0.00 0.00 0.0010,933.00 947.00 12,434.00 1,361.00 10,141.00 0.00 0.00 0.00

Plan 41 Plan 42 Plan 43 Plan 44 Plan 45 Plan 46 Plan 47 Plan 48985.10 992.93 977.07 992.93 977.07 981.38 981.38 997.1815.14% 15.21% 15.20% 15.21% 15.20% 15.14% 15.14% 15.14%
































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Gold Gold Gold Gold Gold Silver Silver Silver

0.81019 0.81139 0.81139 0.81139 0.81139 0.71607 0.71607 0.71607 0.82868 0.82192 0.82192 0.82192 0.82192 0.71997 0.71997 0.71997

EPO EPO EPO EPO EPO EPO EPO EPO15/35/1750/90 EPO 22 25/40/1750/80 EPO 22 25/40/1750/80 EPO 22 25/40/1750/80 EPO 22 25/40/1750/80 EPO 22 EPO HSA 22 EPO HSA 22 EPO HSA 22



Plan 49 Plan 50 Plan 51 Plan 52 Plan 53 Plan 54 Plan 55 Plan 560.00 47,898.38 26,851.96 0.00 0.00 1,206,730.88 28,320,666.32 3,639,016.620.00 15,863.28 31,020.82 0.00 0.00 1,213,273.26 20,512,667.77 4,882,127.070.00 77.00 40.00 0.00 0.00 2,060.00 46,016.00 6,998.00

0.00000 206.01662 775.52050 0.00000 0.00000 588.96760 445.77251 697.64605

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 49 Plan 50 Plan 51 Plan 52 Plan 53 Plan 54 Plan 55 Plan 560.00 18,997.19 34,036.36 0.00 0.00 1,525,049.00 26,819,963.88 5,902,337.20


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.82868 0.82192 0.82192 0.82192 0.82192 0.71997 0.71997 0.719971.08000 1.08000 1.08000 1.08000 1.08000 1.03000 1.03000 1.030001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.01610 1.00000 1.00000 1.01623 1.01623 1.01943 1.00000 1.019430.99623 0.99620 0.99620 0.99620 0.99620 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.90644 0.88478 0.88478 0.89914 0.89914 0.75638 0.74197 0.75638



0.00 5.00 0.00 0.00 0.00 134.00 2,840.00 433.000.00 5.00 0.00 0.00 0.00 134.00 2,840.00 433.00

































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Silver Silver Silver Silver Silver Silver Silver Silver

0.71607 0.71607 0.71607 0.71607 0.71607 0.70856 0.70856 0.71213 0.71997 0.71997 0.71997 0.71997 0.71997 0.73345 0.73345 0.72586

EPO EPO EPO EPO EPO EPO EPO EPOEPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 25/50/2250/80 EPO HSA 25/50/2250/80 EPO HSA 40/70/3000/65 EPO 22



Plan 57 Plan 58 Plan 59 Plan 60 Plan 61 Plan 62 Plan 63 Plan 6427,244,958.67 0.00 0.00 0.00 0.00 1,661,756.18 21,991,372.86 6,233,945.7822,106,053.30 0.00 0.00 0.00 0.00 1,656,262.03 17,234,640.08 4,369,416.75

49,030.00 0.00 0.00 0.00 0.00 2,658.00 35,706.00 10,279.00450.86790 0.00000 0.00000 0.00000 0.00000 623.12341 482.68190 425.08189

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 57 Plan 58 Plan 59 Plan 60 Plan 61 Plan 62 Plan 63 Plan 6428,896,600.04 0.00 0.00 0.00 0.00 2,006,018.82 21,642,065.77 5,479,128.35


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.71997 0.71997 0.71997 0.71997 0.71997 0.73345 0.73345 0.725861.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.01943 1.01943 1.01907 1.00000 1.019271.00000 0.99545 0.99545 0.99545 0.99545 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.74197 0.73859 0.73859 0.75294 0.75294 0.77028 0.75586 0.76245



2,861.00 0.00 0.00 0.00 0.00 208.00 2,529.00 564.002,861.00 0.00 0.00 0.00 0.00 208.00 2,529.00 564.00

































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Silver Silver Silver Silver Silver Silver Silver Bronze

0.71213 0.71213 0.70856 0.70856 0.70856 0.70856 0.71213 0.64806 0.72586 0.72586 0.73345 0.73345 0.73345 0.73345 0.72586 0.65595

EPO EPO EPO EPO EPO EPO EPO EPO40/70/3000/65 EPO 22 40/70/3000/65 EPO 22 25/50/2250/80 EPO HSA 25/50/2250/80 EPO HSA 25/50/2250/80 EPO HSA 25/50/2250/80 EPO HSA 40/70/3000/65 EPO 22 EPO HSA 22



Plan 65 Plan 66 Plan 67 Plan 68 Plan 69 Plan 70 Plan 71 Plan 72121,958,600.06 8,769,192.34 0.00 0.00 0.00 0.00 107,268,710.05 4,842,411.0285,807,192.30 7,930,283.90 0.00 0.00 0.00 0.00 89,543,538.14 3,894,487.87

184,818.00 16,042.00 0.00 0.00 0.00 0.00 171,744.00 9,505.00464.27941 494.34509 0.00000 0.00000 0.00000 0.00000 521.37797 409.73044

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 65 Plan 66 Plan 67 Plan 68 Plan 69 Plan 70 Plan 71 Plan 72105,770,209.03 9,876,295.31 0.00 0.00 0.00 0.00 109,187,114.77 5,402,636.87


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.72586 0.72586 0.73345 0.73345 0.73345 0.73345 0.72586 0.655951.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.01927 1.00000 1.00000 1.01907 1.01907 1.00000 1.021971.00000 1.00000 0.99553 0.99553 0.99553 0.99553 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.74803 0.76245 0.75248 0.75248 0.76684 0.76684 0.74803 0.67072



12,191.00 1,247.00 0.00 0.00 0.00 0.00 11,148.00 995.0012,191.00 1,247.00 0.00 0.00 0.00 0.00 11,148.00 995.00

































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Bronze Bronze Silver Silver Silver Silver Bronze Bronze

0.64806 0.64806 0.71213 0.71213 0.71213 0.71213 0.64806 0.64806 0.65595 0.65595 0.72586 0.72586 0.72586 0.72586 0.65595 0.65595

EPO EPO EPO EPO EPO EPO EPO EPOEPO HSA 22 EPO HSA 22 40/70/3000/65 EPO 22 40/70/3000/65 EPO 22 40/70/3000/65 EPO 22 40/70/3000/65 EPO 22 EPO HSA 22 EPO HSA 22



Plan 73 Plan 74 Plan 75 Plan 76 Plan 77 Plan 78 Plan 79 Plan 8092,412,975.73 3,985,366.04 51,935.20 0.00 0.00 0.00 70,094,515.86 0.0077,254,726.00 5,878,285.56 25,014.25 0.00 0.00 0.00 65,850,699.29 0.00

178,058.00 8,878.00 80.00 0.00 0.00 0.00 146,304.00 0.00433.87394 662.11822 312.67813 0.00000 0.00000 0.00000 450.09500 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 73 Plan 74 Plan 75 Plan 76 Plan 77 Plan 78 Plan 79 Plan 80105,608,207.06 7,408,226.28 29,655.84 0.00 0.00 0.00 87,529,436.79 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.65595 0.65595 0.72586 0.72586 0.72586 0.72586 0.65595 0.655951.00000 1.00000 1.03000 1.03000 1.03000 1.03000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.02197 1.00000 1.00000 1.01927 1.01927 1.00000 1.000001.00000 1.00000 0.99549 0.99549 0.99549 0.99549 1.00000 0.994861.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.65631 0.67072 0.74466 0.74466 0.75901 0.75901 0.65631 0.65293



10,872.00 827.00 0.00 0.00 0.00 0.00 9,398.00 0.0010,872.00 827.00 0.00 0.00 0.00 0.00 9,398.00 0.00

































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Bronze Bronze Bronze Silver Platinum Platinum Platinum Platinum

0.64806 0.64806 0.64806 0.70856 0.91166 0.91166 0.91166 0.91166 0.65595 0.65595 0.65595 0.73345 0.93876 0.93876 0.93876 0.93876

EPO EPO EPO EPO EPO EPO EPO EPOEPO HSA 22 EPO HSA 22 EPO HSA 22 25/50/2250/80 EPO HSA EPO 22 EPO 22 EPO 22 EPO 22



Plan 81 Plan 82 Plan 83 Plan 84 Plan 85 Plan 86 Plan 87 Plan 880.00 0.00 0.00 2,182,924.47 79,644,016.25 8,641,770.17 92,808,191.92 9,285,165.430.00 0.00 0.00 1,539,922.56 94,519,352.29 8,437,421.95 90,695,126.71 9,871,619.310.00 0.00 0.00 3,524.00 91,468.00 10,260.00 102,409.00 11,377.00

0.00000 0.00000 0.00000 436.98143 1033.35978 822.36081 885.61676 867.68211

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 81 Plan 82 Plan 83 Plan 84 Plan 85 Plan 86 Plan 87 Plan 880.00 0.00 0.00 2,090,913.55 99,184,872.60 9,289,210.56 95,391,622.61 10,536,293.71


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.65595 0.65595 0.65595 0.73345 0.93876 0.93876 0.93876 0.938761.00000 1.00000 1.00000 1.03000 1.15000 1.15000 1.15000 1.150001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.02197 1.02197 1.01907 1.00000 1.01335 1.00000 1.013350.99486 0.99486 0.99486 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.65293 0.66727 0.66727 0.77028 1.08016 1.09457 1.08016 1.09457

Plan 81 Plan 82 Plan 83 Plan 84 Plan 85 Plan 86 Plan 87 Plan 88602.01 615.24 615.24 710.21 995.93 1,009.22 995.93 1,009.220.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000012.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688%3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500%16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188%

Plan 81 Plan 82 Plan 83 Plan 84 Plan 85 Plan 86 Plan 87 Plan 88597.38 611.06 611.06 725.88 1,045.68 1,059.36 1,045.68 1,059.36

0.00 0.00 0.00 195.00 6,098.00 900.00 6,712.00 1,009.000.00 0.00 0.00 195.00 6,098.00 900.00 6,712.00 1,009.00

Plan 81 Plan 82 Plan 83 Plan 84 Plan 85 Plan 86 Plan 87 Plan 88718.29 734.07 734.07 847.39 1,188.29 1,204.15 1,188.29 1,204.1520.24% 20.13% 20.13% 16.74% 13.64% 13.67% 13.64% 13.67%

































0.80931 0.80931 0.80931 0.80931 0.80931 0.80931 0.80931 0.80931 0.83394 0.83394 0.83394 0.83394 0.83394 0.83394 0.83394 0.83394




Plan 89 Plan 90 Plan 91 Plan 92 Plan 93 Plan 94 Plan 95 Plan 96219,779,541.55 5,038.02 228,717,762.08 9,698.22 18,207,984.95 15,264,121.05 0.00 0.00195,480,160.22 2,260.20 188,804,180.08 32,559.11 17,886,968.62 13,302,334.28 0.00 0.00

314,682.00 6.00 319,761.00 12.00 27,276.00 22,301.00 0.00 0.00621.19905 376.70000 590.45406 2713.25917 655.77682 596.49048 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 89 Plan 90 Plan 91 Plan 92 Plan 93 Plan 94 Plan 95 Plan 96218,879,952.33 3,437.34 212,030,794.26 33,564.14 19,968,308.95 15,348,114.54 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.83394 0.83394 0.83394 0.83394 0.83394 0.83394 0.83394 0.833941.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948720.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01747 1.01747 1.01747 1.017471.00000 0.99591 1.00000 0.99591 1.00000 1.00000 0.99591 0.995911.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.82522 0.82185 0.82522 0.82185 0.83964 0.83964 0.83621 0.83621



19,998.00 0.00 17,598.00 0.00 1,880.00 1,548.00 0.00 0.0019,998.00 0.00 17,598.00 0.00 1,880.00 1,548.00 0.00 0.00


































0.71146 0.71146 0.71146 0.71146 0.71146 0.71146 0.71146 0.71146 0.72405 0.72405 0.72405 0.72405 0.72405 0.72405 0.72405 0.72405




Plan 97 Plan 98 Plan 99 Plan 100 Plan 101 Plan 102 Plan 103 Plan 104131,705,519.22 41,525.40 184,520,270.16 2,897.20 7,499,823.05 6,129,536.62 0.00 0.0097,305,481.10 10,732.74 141,114,824.02 2,119.89 5,812,993.81 4,605,642.50 0.00 0.00

213,304.00 72.00 293,803.00 4.00 12,838.00 10,297.00 0.00 0.00456.18217 149.06583 480.30423 529.97250 452.79590 447.28003 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 97 Plan 98 Plan 99 Plan 100 Plan 101 Plan 102 Plan 103 Plan 104120,318,637.22 26,748.75 172,421,329.00 2,979.06 7,407,218.08 5,738,200.48 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.72405 0.72405 0.72405 0.72405 0.72405 0.72405 0.72405 0.724051.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02037 1.02037 1.02037 1.020371.00000 0.99523 1.00000 0.99523 1.00000 1.00000 0.99523 0.995231.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.70790 0.70453 0.70790 0.70453 0.72232 0.72232 0.71888 0.71888



16,641.00 6.00 21,231.00 0.00 1,331.00 1,256.00 0.00 0.0016,641.00 6.00 21,231.00 0.00 1,331.00 1,256.00 0.00 0.00


































0.71014 0.71014 0.71014 0.71014 0.71014 0.71014 0.71014 0.71014 0.72064 0.72064 0.72064 0.72064 0.72064 0.72064 0.72064 0.72064




Plan 105 Plan 106 Plan 107 Plan 108 Plan 109 Plan 110 Plan 111 Plan 11230,007,490.45 0.00 29,491,792.03 0.00 1,317,112.27 984,393.45 0.00 0.0025,022,782.49 0.00 16,910,173.53 0.00 1,145,605.34 368,554.20 0.00 0.00

52,213.00 0.00 50,211.00 0.00 2,694.00 1,626.00 0.00 0.00479.24430 0.00000 336.78225 0.00000 425.24326 226.66310 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 105 Plan 106 Plan 107 Plan 108 Plan 109 Plan 110 Plan 111 Plan 11229,678,132.25 0.00 21,522,333.07 0.00 1,389,395.45 529,755.75 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.72064 0.72064 0.72064 0.72064 0.72064 0.72064 0.72064 0.720641.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948720.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02120 1.02120 1.02120 1.021201.00000 0.99504 1.00000 0.99504 1.00000 1.00000 0.99504 0.995041.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.68009 0.67671 0.68009 0.67671 0.69451 0.69451 0.69106 0.69106



3,517.00 0.00 3,170.00 0.00 210.00 109.00 0.00 0.003,517.00 0.00 3,170.00 0.00 210.00 109.00 0.00 0.00

































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Platinum Platinum Platinum Platinum Platinum Platinum Platinum Platinum

0.87587 0.87587 0.87587 0.87587 0.87587 0.87587 0.87587 0.87587 0.91399 0.91399 0.91399 0.91399 0.91399 0.91399 0.91399 0.91399

EPO EPO EPO EPO EPO EPO EPO EPO15/30/100 EPO 22 15/30/100 EPO 22 15/30/100 EPO 22 15/30/100 EPO 22 15/30/100 EPO 22 15/30/100 EPO 22 15/30/100 EPO 22 15/30/100 EPO 22 85629NY0010453 85629NY0010454 85629NY0010455 85629NY0010456 85629NY0010457 85629NY0010458 85629NY0010459 85629NY0010460

Both Both Both Both Both Both Both BothUniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod

Plan 113 Plan 114 Plan 115 Plan 116 Plan 117 Plan 118 Plan 119 Plan 12011,661,078.60 0.00 9,205,654.49 0.00 423,590.86 180,540.51 0.00 0.008,750,943.54 0.00 6,241,539.06 0.00 327,512.12 203,212.86 0.00 0.00

15,887.00 0.00 11,992.00 0.00 786.00 248.00 0.00 0.00550.82417 0.00000 520.47524 0.00000 416.68209 819.40669 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 113 Plan 114 Plan 115 Plan 116 Plan 117 Plan 118 Plan 119 Plan 1209,325,930.22 0.00 6,583,874.34 0.00 354,086.69 221,670.11 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.91399 0.91399 0.91399 0.91399 0.91399 0.91399 0.91399 0.913991.15000 1.15000 1.15000 1.15000 1.15000 1.15000 1.15000 1.150000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838820.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01693 1.01693 1.01693 1.016931.00000 0.99604 1.00000 0.99604 1.00000 1.00000 0.99604 0.996041.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.85149 0.84812 0.85149 0.84812 0.86591 0.86591 0.86248 0.86248



1,029.00 0.00 844.00 0.00 86.00 4.00 0.00 0.001,029.00 0.00 844.00 0.00 86.00 4.00 0.00 0.00


































0.80762 0.80762 0.80762 0.80762 0.80762 0.80762 0.80762 0.80762 0.82523 0.82523 0.82523 0.82523 0.82523 0.82523 0.82523 0.82523


85629NY0010469 85629NY0010470 85629NY0010471 85629NY0010472 85629NY0010473 85629NY0010474 85629NY0010475 85629NY0010476Both Both Both Both Both Both Both Both



33,972.00 0.00 37,955.00 0.00 1,200.00 424.00 0.00 0.00343.14034 0.00000 437.16844 0.00000 227.00958 885.31547 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.82523 0.82523 0.82523 0.82523 0.82523 0.82523 0.82523 0.825231.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838820.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01997 1.01997 1.01997 1.019971.00000 0.99532 1.00000 0.99532 1.00000 1.00000 0.99532 0.995321.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.72201 0.71863 0.72201 0.71863 0.73643 0.73643 0.73298 0.73298



2,303.00 0.00 2,044.00 0.00 120.00 45.00 0.00 0.002,303.00 0.00 2,044.00 0.00 120.00 45.00 0.00 0.00


































0.67061 0.67061 0.67061 0.67061 0.67061 0.67061 0.67061 0.67061 0.68371 0.68371 0.68371 0.68371 0.68371 0.68371 0.68371 0.68371

EPO EPO EPO EPO EPO EPO EPO EPO35/50/3500/70 EPO HSA 35/50/3500/70 EPO HSA 35/50/3500/70 EPO HSA 35/50/3500/70 EPO HSA 35/50/3500/70 EPO HSA 35/50/3500/70 EPO HSA 35/50/3500/70 EPO HSA 35/50/3500/70 EPO HSA



Plan 129 Plan 130 Plan 131 Plan 132 Plan 133 Plan 134 Plan 135 Plan 1362,520,820.77 0.00 2,341,488.25 0.00 98,108.97 68,506.26 0.00 0.001,017,800.43 0.00 944,704.21 0.00 12,388.32 14,892.87 0.00 0.00

4,451.00 0.00 4,090.00 0.00 216.00 130.00 0.00 0.00228.66781 0.00000 230.97902 0.00000 57.35333 114.56054 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.68371 0.68371 0.68371 0.68371 0.68371 0.68371 0.68371 0.683711.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838820.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02527 1.02527 1.02527 1.025271.00000 0.99408 1.00000 0.99408 1.00000 1.00000 0.99408 0.994081.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.57050 0.56712 0.57050 0.56712 0.58491 0.58491 0.58145 0.58145


Plan 129 Plan 130 Plan 131 Plan 132 Plan 133 Plan 134 Plan 135 Plan 136523.27 520.07 523.27 520.07 536.96 536.96 533.75 533.75624.00 0.00 689.00 0.00 30.00 25.00 0.00 0.00624.00 0.00 689.00 0.00 30.00 25.00 0.00 0.00


































0.70900 0.70900 0.70900 0.70900 0.70900 0.70900 0.70900 0.70900 0.71921 0.71921 0.71921 0.71921 0.71921 0.71921 0.71921 0.71921




Plan 137 Plan 138 Plan 139 Plan 140 Plan 141 Plan 142 Plan 143 Plan 14442,391,231.20 0.00 50,053,767.77 0.00 1,158,080.42 737,787.54 0.00 0.0021,215,493.32 0.00 26,802,891.93 0.00 981,824.97 154,352.30 0.00 0.00

76,430.00 0.00 89,669.00 0.00 2,141.00 1,316.00 0.00 0.00277.58071 0.00000 298.90923 0.00000 458.58242 117.28898 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.71921 0.71921 0.71921 0.71921 0.71921 0.71921 0.71921 0.719211.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838820.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02402 1.02402 1.02402 1.024021.00000 0.99437 1.00000 0.99437 1.00000 1.00000 0.99437 0.994371.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.60011 0.59674 0.60011 0.59674 0.61453 0.61453 0.61107 0.61107



5,448.00 0.00 5,967.00 0.00 240.00 141.00 0.00 0.005,448.00 0.00 5,967.00 0.00 240.00 141.00 0.00 0.00

































85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001 85629NY001Bronze Bronze Bronze Bronze Bronze Bronze Bronze Bronze

0.64573 0.64573 0.64573 0.64573 0.64573 0.64573 0.64573 0.64573 0.65322 0.65322 0.65322 0.65322 0.65322 0.65322 0.65322 0.65322




Plan 145 Plan 146 Plan 147 Plan 148 Plan 149 Plan 150 Plan 151 Plan 1521,951,654.82 0.00 2,129,442.44 0.00 77,765.43 65,465.32 0.00 0.001,404,102.67 0.00 826,539.13 0.00 5,888.69 21,366.99 0.00 0.00

4,263.00 0.00 4,547.00 0.00 153.00 129.00 0.00 0.00329.36962 0.00000 181.77680 0.00000 38.48817 165.63558 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.65322 0.65322 0.65322 0.65322 0.65322 0.65322 0.65322 0.653221.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838820.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02724 1.02724 1.02724 1.027241.00000 0.99362 1.00000 0.99362 1.00000 1.00000 0.99362 0.993621.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.52918 0.52581 0.52918 0.52581 0.54360 0.54360 0.54013 0.54013




































0.71032 0.71032 0.71032 0.71032 0.71032 0.71032 0.71032 0.71032 0.70901 0.70901 0.70901 0.70901 0.70901 0.70901 0.70901 0.70901




Plan 153 Plan 154 Plan 155 Plan 156 Plan 157 Plan 158 Plan 159 Plan 16044,462,881.89 0.00 54,012,868.51 0.00 2,441,163.39 1,823,451.31 0.00 0.0031,611,818.09 0.00 35,416,985.03 0.00 2,011,592.11 2,098,744.56 0.00 0.00

76,913.00 0.00 87,946.00 0.00 4,365.00 3,172.00 0.00 0.00411.00748 0.00000 402.71286 0.00000 460.84584 661.64709 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 153 Plan 154 Plan 155 Plan 156 Plan 157 Plan 158 Plan 159 Plan 16039,440,141.95 0.00 44,264,364.00 0.00 2,477,556.44 2,425,593.29 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.70901 0.70901 0.70901 0.70901 0.70901 0.70901 0.70901 0.709011.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02080 1.02080 1.02080 1.020801.00000 0.99513 1.00000 0.99513 1.00000 1.00000 0.99513 0.995131.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.69321 0.68983 0.69321 0.68983 0.70763 0.70763 0.70418 0.70418



5,899.00 0.00 7,562.00 0.00 424.00 374.00 0.00 0.005,899.00 0.00 7,562.00 0.00 424.00 374.00 0.00 0.00


































0.64599 0.64599 0.64599 0.64599 0.64599 0.64599 0.64599 0.64599 0.65601 0.65601 0.65601 0.65601 0.65601 0.65601 0.65601 0.65601

EPO EPO EPO EPO EPO EPO EPO EPOEPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22




30,894.00 0.00 44,373.00 0.00 1,905.00 1,740.00 0.00 0.00426.43450 0.00000 369.14375 0.00000 326.82658 412.55949 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 161 Plan 162 Plan 163 Plan 164 Plan 165 Plan 166 Plan 167 Plan 16817,517,842.98 0.00 22,924,586.34 0.00 894,084.01 1,016,246.30 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.65601 0.65601 0.65601 0.65601 0.65601 0.65601 0.65601 0.656011.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02315 1.02315 1.02315 1.023151.00000 0.99458 1.00000 0.99458 1.00000 1.00000 0.99458 0.994581.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.62271 0.61933 0.62271 0.61933 0.63712 0.63712 0.63367 0.63367



3,862.00 0.00 5,160.00 0.00 183.00 169.00 0.00 0.003,862.00 0.00 5,160.00 0.00 183.00 169.00 0.00 0.00


































0.70900 0.70900 0.70900 0.70900 0.70900 0.70900 0.70900 0.70900 0.71921 0.71921 0.71921 0.71921 0.71921 0.71921 0.71921 0.71921

EPO EPO EPO EPO EPO EPO EPO EPO30/80/3500/70 EPO ME 22 30/80/3500/70 EPO ME 22 30/80/3500/70 EPO ME 22 30/80/3500/70 EPO ME 22 30/80/3500/70 EPO ME 22 30/80/3500/70 EPO ME 22 30/80/3500/70 EPO ME 22 30/80/3500/70 EPO ME 22



Plan 169 Plan 170 Plan 171 Plan 172 Plan 173 Plan 174 Plan 175 Plan 17617,122,008.75 5,447.88 26,526,036.93 0.00 854,406.11 832,145.91 0.00 0.007,895,067.04 249.21 13,707,525.59 0.00 282,679.92 370,224.71 0.00 0.00

29,357.00 9.00 45,065.00 0.00 1,660.00 1,550.00 0.00 0.00268.93303 27.69000 304.17232 0.00000 170.28911 238.85465 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.71921 0.71921 0.71921 0.71921 0.71921 0.71921 0.71921 0.719211.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838821.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02319 1.02319 1.02319 1.023191.00000 0.99457 1.00000 0.99457 1.00000 1.00000 0.99457 0.994571.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.62172 0.61834 0.62172 0.61834 0.63614 0.63614 0.63268 0.63268



2,237.00 0.00 3,588.00 0.00 134.00 128.00 0.00 0.002,237.00 0.00 3,588.00 0.00 134.00 128.00 0.00 0.00


































0.80762 0.80762 0.80762 0.80762 0.80762 0.80762 0.80762 0.80762 0.82523 0.82523 0.82523 0.82523 0.82523 0.82523 0.82523 0.82523

EPO EPO EPO EPO EPO EPO EPO EPO25/40/1250/80 EPO ME 22 25/40/1250/80 EPO ME 22 25/40/1250/80 EPO ME 22 25/40/1250/80 EPO ME 22 25/40/1250/80 EPO ME 22 25/40/1250/80 EPO ME 22 25/40/1250/80 EPO ME 22 25/40/1250/80 EPO ME 22




13,983.00 0.00 24,339.00 0.00 1,208.00 561.00 0.00 0.00524.48776 0.00000 396.99099 0.00000 310.31356 587.60146 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.82523 0.82523 0.82523 0.82523 0.82523 0.82523 0.82523 0.825231.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838821.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01927 1.01927 1.01927 1.019271.00000 0.99549 1.00000 0.99549 1.00000 1.00000 0.99549 0.995491.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.74800 0.74463 0.74800 0.74463 0.76242 0.76242 0.75898 0.75898



1,223.00 0.00 1,457.00 0.00 76.00 37.00 0.00 0.001,223.00 0.00 1,457.00 0.00 76.00 37.00 0.00 0.00


































0.83549 0.83549 0.83549 0.83549 0.83549 0.83549 0.83549 0.83549 0.85787 0.85787 0.85787 0.85787 0.85787 0.85787 0.85787 0.85787

EPO EPO EPO EPO EPO EPO EPO EPO25/40/600/80 EPO HNY 22 25/40/600/80 EPO HNY 22 25/40/600/80 EPO HNY 22 25/40/600/80 EPO HNY 22 25/40/600/80 EPO HNY 22 25/40/600/80 EPO HNY 22 25/40/600/80 EPO HNY 22 25/40/600/80 EPO HNY 22



Plan 185 Plan 186 Plan 187 Plan 188 Plan 189 Plan 190 Plan 191 Plan 19218,727,680.20 80,567.00 7,958,155.81 0.00 1,223,565.99 1,216,217.13 0.00 0.0013,789,979.24 26,192.51 6,408,092.91 0.00 747,780.82 1,007,695.84 0.00 0.00

34,761.00 139.00 15,029.00 0.00 2,651.00 2,265.00 0.00 0.00396.70836 188.43532 426.38186 0.00000 282.07500 444.89883 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 185 Plan 186 Plan 187 Plan 188 Plan 189 Plan 190 Plan 191 Plan 19215,688,416.85 33,418.18 7,233,256.68 0.00 866,557.22 1,119,561.04 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.85787 0.85787 0.85787 0.85787 0.85787 0.85787 0.85787 0.857871.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838820.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.82500 0.82500 0.82500 0.82500 0.82500 0.82500 0.82500 0.825001.00000 1.00000 1.00000 1.00000 1.02328 1.02328 1.02328 1.023281.00000 0.99455 1.00000 0.99455 1.00000 1.00000 0.99455 0.994551.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.61922 0.61584 0.61922 0.61584 0.63363 0.63363 0.63018 0.63018



2,023.00 6.00 936.00 0.00 200.00 174.00 0.00 0.002,023.00 6.00 936.00 0.00 200.00 174.00 0.00 0.00


































0.64599 0.64599 0.64599 0.64599 0.64599 0.64599 0.64599 0.64599 0.65601 0.65601 0.65601 0.65601 0.65601 0.65601 0.65601 0.65601

EPO EPO EPO EPO EPO EPO EPO EPOEPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22 EPO HSA 22




30,938.00 0.00 37,437.00 0.00 685.00 633.00 0.00 0.00202.53134 0.00000 183.92981 0.00000 378.97380 90.62488 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.65601 0.65601 0.65601 0.65601 0.65601 0.65601 0.65601 0.656011.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838820.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02713 1.02713 1.02713 1.027131.00000 0.99365 1.00000 0.99365 1.00000 1.00000 0.99365 0.993651.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.53144 0.52806 0.53144 0.52806 0.54586 0.54586 0.54239 0.54239



2,450.00 0.00 2,683.00 0.00 60.00 58.00 0.00 0.002,450.00 0.00 2,683.00 0.00 60.00 58.00 0.00 0.00


































0.86582 0.86582 0.86582 0.86582 0.86582 0.86582 0.86582 0.86582 0.87096 0.87096 0.87096 0.87096 0.87096 0.87096 0.87096 0.87096

EPO EPO EPO EPO EPO EPO EPO EPO15/30/250/90 EPO LA 22 15/30/250/90 EPO LA 22 15/30/250/90 EPO LA 22 15/30/250/90 EPO LA 22 15/30/250/90 EPO LA 22 15/30/250/90 EPO LA 22 15/30/250/90 EPO LA 22 15/30/250/90 EPO LA 22




3,081.00 0.00 13,673.00 0.00 335.00 82.00 0.00 0.00715.29932 0.00000 1014.58193 0.00000 857.64152 82.44829 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.87096 0.87096 0.87096 0.87096 0.87096 0.87096 0.87096 0.870961.15000 1.15000 1.15000 1.15000 1.15000 1.15000 1.15000 1.150000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948720.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.96525 0.965251.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01571 1.01571 1.01571 1.015711.00000 0.99632 1.00000 0.99632 1.00000 1.00000 0.99632 0.996321.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.91771 0.91434 0.91771 0.91434 0.93213 0.93213 0.92870 0.92870



Plan 201 Plan 202 Plan 203 Plan 204 Plan 205 Plan 206 Plan 207 Plan 2081,009.58 1,005.87 1,009.58 1,005.87 1,025.45 1,025.45 1,021.67 1,021.6714.55% 14.55% 14.55% 14.55% 14.57% 14.57% 14.56% 14.56%

































0.64859 0.64859 0.64859 0.64859 0.64859 0.64859 0.64859 0.64859 0.65650 0.65650 0.65650 0.65650 0.65650 0.65650 0.65650 0.65650





10,018.00 0.00 19,231.00 0.00 288.00 312.00 0.00 0.00400.88055 0.00000 470.15718 0.00000 97.16931 151.20708 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.65650 0.65650 0.65650 0.65650 0.65650 0.65650 0.65650 0.656501.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02313 1.02313 1.02313 1.023131.00000 0.99458 1.00000 0.99458 1.00000 1.00000 0.99458 0.994581.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.62317 0.61980 0.62317 0.61980 0.63759 0.63759 0.63414 0.63414



1,959.00 0.00 2,559.00 0.00 100.00 61.00 0.00 0.001,959.00 0.00 2,559.00 0.00 100.00 61.00 0.00 0.00


































0.78153 0.78153 0.78153 0.78153 0.78153 0.78153 0.78153 0.78153 0.77337 0.77337 0.77337 0.77337 0.77337 0.77337 0.77337 0.77337





12,255.00 0.00 18,313.00 0.00 846.00 1,292.00 0.00 0.00555.91927 0.00000 524.77439 0.00000 376.16944 331.19125 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.77337 0.77337 0.77337 0.77337 0.77337 0.77337 0.77337 0.773371.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01725 1.01725 1.01725 1.017251.00000 0.99596 1.00000 0.99596 1.00000 1.00000 0.99596 0.995961.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.83569 0.83232 0.83569 0.83232 0.85011 0.85011 0.84667 0.84667



1,376.00 0.00 2,342.00 0.00 90.00 214.00 0.00 0.001,376.00 0.00 2,342.00 0.00 90.00 214.00 0.00 0.00


































0.78392 0.78392 0.78392 0.78392 0.78392 0.78392 0.78392 0.78392 0.77551 0.77551 0.77551 0.77551 0.77551 0.77551 0.77551 0.77551




Plan 225 Plan 226 Plan 227 Plan 228 Plan 229 Plan 230 Plan 231 Plan 23215,288,220.13 0.00 23,601,103.44 0.00 1,374,741.00 1,205,992.87 0.00 0.0011,475,565.03 0.00 20,146,234.05 0.00 1,163,383.99 745,257.26 0.00 0.00

22,776.00 0.00 35,234.00 0.00 2,305.00 1,937.00 0.00 0.00503.84462 0.00000 571.78390 0.00000 504.72190 384.74820 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.77551 0.77551 0.77551 0.77551 0.77551 0.77551 0.77551 0.775511.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01813 1.01813 1.01813 1.018131.00000 0.99575 1.00000 0.99575 1.00000 1.00000 0.99575 0.995751.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.79502 0.79165 0.79502 0.79165 0.80944 0.80944 0.80600 0.80600



2,601.00 0.00 3,653.00 0.00 176.00 239.00 0.00 0.002,601.00 0.00 3,653.00 0.00 176.00 239.00 0.00 0.00


































0.80678 0.80678 0.80678 0.80678 0.80678 0.80678 0.80678 0.80678 0.87965 0.87965 0.87965 0.87965 0.87965 0.87965 0.87965 0.87965

EPO EPO EPO EPO EPO EPO EPO EPOEPO ZD 22 EPO ZD 22 EPO ZD 22 EPO ZD 22 EPO ZD 22 EPO ZD 22 EPO ZD 22 EPO ZD 22




0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.87965 0.87965 0.87965 0.87965 0.87965 0.87965 0.87965 0.879651.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01599 1.01599 1.01599 1.015991.00000 0.99626 1.00000 0.99626 1.00000 1.00000 0.99626 0.996261.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.90179 0.89842 0.90179 0.89842 0.91621 0.91621 0.91278 0.91278



2,906.00 0.00 3,647.00 0.00 302.00 287.00 0.00 0.002,906.00 0.00 3,647.00 0.00 302.00 287.00 0.00 0.00


































0.70947 0.67096 0.70947 0.67096 0.70947 0.67096 0.70947 0.67096 0.80757 0.67838 0.80757 0.67838 0.80757 0.67838 0.80757 0.67838

EPO EPO EPO EPO EPO EPO EPO EPO50/100/100 EPO ZD 22 EPO HSAM 22 50/100/100 EPO ZD 22 EPO HSAM 22 50/100/100 EPO ZD 22 EPO HSAM 22 50/100/100 EPO ZD 22 EPO HSAM 22

85629NY0010701 85629NY0010702 85629NY0010703 85629NY0010704 85629NY0010705 85629NY0010706 85629NY0010707 85629NY0010708Both Off Both Off Both Off Both Off



0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.80757 0.67838 0.80757 0.67838 0.80757 0.67838 0.80757 0.678381.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.83882 0.94872 0.83882 0.94872 0.83882 0.94872 0.83882 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 0.99516 0.99492 1.00000 1.00000 0.99516 0.994921.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00267 1.00000 1.00267 1.00000 1.00267 1.00000 1.002671.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.69810 0.66503 0.69473 0.66165 0.69810 0.66503 0.69473 0.66165




































0.70947 0.67096 0.70947 0.67096 0.70947 0.67096 0.70947 0.67096 0.80757 0.67838 0.80757 0.67838 0.80757 0.67838 0.80757 0.67838

EPO EPO EPO EPO EPO EPO EPO EPO50/100/100 EPO ZD 22 EPO HSAM 22 50/100/100 EPO ZD 22 EPO HSAM 22 50/100/100 EPO ZD 22 EPO HSAM 22 50/100/100 EPO ZD 22 EPO HSAM 22

85629NY0010709 85629NY0010710 85629NY0010711 85629NY0010712 85629NY0010713 85629NY0010714 85629NY0010715 85629NY0010716Both Off Both Off Both Off Both Off



0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.80757 0.67838 0.80757 0.67838 0.80757 0.67838 0.80757 0.678381.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.83882 0.94872 0.83882 0.94872 0.83882 0.94872 0.83882 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.02065 1.02168 1.02065 1.02168 1.02065 1.02168 1.02065 1.021681.00000 1.00000 1.00000 1.00000 0.99516 0.99492 0.99516 0.994921.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00267 1.00000 1.00267 1.00000 1.00267 1.00000 1.002671.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.71252 0.67945 0.71252 0.67945 0.70907 0.67600 0.70907 0.67600




































0.79974 0.79974 0.79974 0.79974 0.79974 0.79974 0.79974 0.79974 0.78337 0.78337 0.78337 0.78337 0.78337 0.78337 0.78337 0.78337

EPO EPO EPO EPO EPO EPO EPO EPOEPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22




0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.78337 0.78337 0.78337 0.78337 0.78337 0.78337 0.78337 0.783371.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01791 1.01791 1.01791 1.017911.00000 0.99581 1.00000 0.99581 1.00000 1.00000 0.99581 0.995811.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00220 1.00220 1.00220 1.00220 1.00220 1.00220 1.00220 1.002201.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.80485 0.80148 0.80485 0.80148 0.81927 0.81927 0.81583 0.81583




































0.70947 0.70947 0.70947 0.70947 0.70947 0.70947 0.70947 0.70947 0.80757 0.80757 0.80757 0.80757 0.80757 0.80757 0.80757 0.80757

EPO EPO EPO EPO EPO EPO EPO EPO50/100/100 EPO ZD 22 50/100/100 EPO ZD 22 50/100/100 EPO ZD 22 50/100/100 EPO ZD 22 50/100/100 EPO ZD 22 50/100/100 EPO ZD 22 50/100/100 EPO ZD 22 50/100/100 EPO ZD 22




0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.80757 0.80757 0.80757 0.80757 0.80757 0.80757 0.80757 0.807571.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01826 1.01826 1.01826 1.018261.00000 0.99572 1.00000 0.99572 1.00000 1.00000 0.99572 0.995721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.78957 0.78619 0.78957 0.78619 0.80398 0.80398 0.80054 0.80054




































0.86934 0.86934 0.86934 0.86934 0.86934 0.86934 0.86934 0.86934 0.89455 0.89455 0.89455 0.89455 0.89455 0.89455 0.89455 0.89455





0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.89455 0.89455 0.89455 0.89455 0.89455 0.89455 0.89455 0.894551.15000 1.15000 1.15000 1.15000 1.15000 1.15000 1.15000 1.150000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01476 1.01476 1.01476 1.014761.00000 0.99654 1.00000 0.99654 1.00000 1.00000 0.99654 0.996541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.97650 0.97313 0.97650 0.97313 0.99092 0.99092 0.98750 0.98750




































0.77730 0.77730 0.77730 0.77730 0.77730 0.77730 0.77730 0.77730 0.78360 0.78360 0.78360 0.78360 0.78360 0.78360 0.78360 0.78360





0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.78360 0.78360 0.78360 0.78360 0.78360 0.78360 0.78360 0.783601.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01795 1.01795 1.01795 1.017951.00000 0.99580 1.00000 0.99580 1.00000 1.00000 0.99580 0.995801.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.80332 0.79994 0.80332 0.79994 0.81774 0.81774 0.81430 0.81430




































0.68729 0.68729 0.68729 0.68729 0.68729 0.68729 0.68729 0.68729 0.70224 0.70224 0.70224 0.70224 0.70224 0.70224 0.70224 0.70224





0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.70224 0.70224 0.70224 0.70224 0.70224 0.70224 0.70224 0.702241.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02100 1.02100 1.02100 1.021001.00000 0.99508 1.00000 0.99508 1.00000 1.00000 0.99508 0.995081.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.68658 0.68321 0.68658 0.68321 0.70100 0.70100 0.69755 0.69755




































0.81185 0.81185 0.81185 0.81185 0.81185 0.81185 0.81185 0.81185 0.79623 0.79623 0.79623 0.79623 0.79623 0.79623 0.79623 0.79623

EPO EPO EPO EPO EPO EPO EPO EPOEPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22 EPO HSAM 22


New Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan


0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.79623 0.79623 0.79623 0.79623 0.79623 0.79623 0.79623 0.796231.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01672 1.01672 1.01672 1.016721.00000 0.99608 1.00000 0.99608 1.00000 1.00000 0.99608 0.996081.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00206 1.00206 1.00206 1.00206 1.00206 1.00206 1.00206 1.002061.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.86216 0.85878 0.86216 0.85878 0.87658 0.87658 0.87314 0.87314




































0.69423 0.69423 0.69423 0.69423 0.69423 0.69423 0.69423 0.69423 0.71017 0.71017 0.71017 0.71017 0.71017 0.71017 0.71017 0.71017





0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.71017 0.71017 0.71017 0.71017 0.71017 0.71017 0.71017 0.710171.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02076 1.02076 1.02076 1.020761.00000 0.99514 1.00000 0.99514 1.00000 1.00000 0.99514 0.995141.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.69434 0.69097 0.69434 0.69097 0.70876 0.70876 0.70531 0.70531




































0.70947 0.70947 0.70947 0.70947 0.70947 0.70947 0.70947 0.70947 0.80757 0.80757 0.80757 0.80757 0.80757 0.80757 0.80757 0.80757


Off Off Off Off Off Off Off OffNew Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan


0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.80757 0.80757 0.80757 0.80757 0.80757 0.80757 0.80757 0.807571.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01732 1.01732 1.01732 1.017321.00000 0.99594 1.00000 0.99594 1.00000 1.00000 0.99594 0.995941.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.83224 0.82887 0.83224 0.82887 0.84666 0.84666 0.84322 0.84322




































0.80465 0.80465 0.80465 0.80465 0.80465 0.80465 0.80465 0.80465 0.88194 0.88194 0.88194 0.88194 0.88194 0.88194 0.88194 0.88194


Off Off Off Off Off Off Off OffNew Plan New Plan New Plan New Plan New Plan New Plan New Plan New Plan


0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.88194 0.88194 0.88194 0.88194 0.88194 0.88194 0.88194 0.881941.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.08000 1.080001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01513 1.01513 1.01513 1.015131.00000 0.99646 1.00000 0.99646 1.00000 1.00000 0.99646 0.996461.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.95301 0.94964 0.95301 0.94964 0.96743 0.96743 0.96400 0.96400



Plan 321 Plan 322 Plan 323 Plan 324 Plan 325 Plan 326 Plan 327 Plan 3281,048.42 1,044.70 1,048.42 1,044.70 1,064.28 1,064.28 1,060.51 1,060.51

































0.71146 0.71146 0.71146 0.71146 0.71146 0.71146 0.71146 0.71146 0.72405 0.72405 0.72405 0.72405 0.72405 0.72405 0.72405 0.72405





0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667



1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.72405 0.72405 0.72405 0.72405 0.72405 0.72405 0.72405 0.724051.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.03000 1.030000.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.83882 0.838821.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02303 1.02303 1.02303 1.023031.00000 0.99461 1.00000 0.99461 1.00000 1.00000 0.99461 0.994611.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.62590 0.62253 0.62590 0.62253 0.64032 0.64032 0.63687 0.63687


































Plan 337 Plan 338 Plan 339 Plan 340 Plan 341 Plan 342 Plan 343 Plan 344 PPO PPO PPO PPO PPO PPO PPO PPO

85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005Gold Gold Gold Gold Silver Platinum Platinum Platinum

0.80107 0.80107 0.80107 0.80107 0.70665 0.91166 0.91166 0.91166 0.78297 0.78297 0.78297 0.78297 0.72915 0.93876 0.93876 0.93876

PPO PPO PPO PPO PPO PPO PPO PPOPPO HSA 22 PPO HSA 22 PPO HSA 22 PPO HSA 22 30/60/2000/80 PPO HSA PPO 22 PPO 22 PPO 22



Plan 337 Plan 338 Plan 339 Plan 340 Plan 341 Plan 342 Plan 343 Plan 3440.00 0.00 0.00 0.00 0.00 35,297,745.20 228,342,147.57 34,852,088.090.00 0.00 0.00 0.00 0.00 35,109,417.36 201,805,891.42 38,645,053.570.00 0.00 0.00 0.00 0.00 39,011.00 240,574.00 39,722.00

0.00000 0.00000 0.00000 0.00000 0.00000 899.98763 838.85163 972.88791

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 337 Plan 338 Plan 339 Plan 340 Plan 341 Plan 342 Plan 343 Plan 3440.00 0.00 0.00 0.00 0.00 38,924,821.71 223,663,594.68 42,994,674.55


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.78297 0.78297 0.78297 0.78297 0.72915 0.93876 0.93876 0.938761.08000 1.08000 1.08000 1.08000 1.03000 1.15000 1.15000 1.150001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.04525 1.04525 1.04525 1.04525 1.04679 1.04082 1.04082 1.040821.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.01630 1.01630 1.00000 1.01282 1.00000 1.012820.99618 0.99618 0.99618 0.99618 0.99571 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.88097 0.88097 0.89533 0.89533 0.78321 1.13867 1.12425 1.13867

Plan 337 Plan 338 Plan 339 Plan 340 Plan 341 Plan 342 Plan 343 Plan 344812.27 812.27 825.51 825.51 722.14 1,049.87 1,036.58 1,049.870.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000012.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688%3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500%16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188%

Plan 337 Plan 338 Plan 339 Plan 340 Plan 341 Plan 342 Plan 343 Plan 344839.93 839.93 853.61 853.61 739.80 1,099.69 1,086.00 1,099.69

0.00 0.00 0.00 0.00 0.00 2,878.00 15,886.00 2,856.000.00 0.00 0.00 0.00 0.00 2,878.00 15,886.00 2,856.00

Plan 337 Plan 338 Plan 339 Plan 340 Plan 341 Plan 342 Plan 343 Plan 344969.16 969.16 984.96 984.96 861.62 1,252.66 1,236.80 1,252.6615.39% 15.39% 15.39% 15.39% 16.47% 13.91% 13.89% 13.91%
































85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005Platinum Silver Silver Silver Platinum Platinum Platinum Platinum

0.91166 0.70665 0.70665 0.70665 0.88515 0.88515 0.88515 0.88515 0.93876 0.72915 0.72915 0.72915 0.91881 0.91881 0.91881 0.91881

PPO PPO PPO PPO PPO PPO PPO PPOPPO 22 30/60/2000/80 PPO HSA 30/60/2000/80 PPO HSA 30/60/2000/80 PPO HSA 20/40/100 PPO 22 20/40/100 PPO 22 20/40/100 PPO 22 20/40/100 PPO 22



Plan 345 Plan 346 Plan 347 Plan 348 Plan 349 Plan 350 Plan 351 Plan 352217,205,026.48 0.00 0.00 0.00 3,685,870.90 82,155,738.17 6,456,746.03 65,011,359.86228,456,343.44 0.00 0.00 0.00 3,501,182.08 74,680,267.78 6,535,900.21 59,243,036.87

232,706.00 0.00 0.00 0.00 4,236.00 87,743.00 7,420.00 71,476.00981.73809 0.00000 0.00000 0.00000 826.53024 851.12508 880.84908 828.85216

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 345 Plan 346 Plan 347 Plan 348 Plan 349 Plan 350 Plan 351 Plan 352254,357,151.88 0.00 0.00 0.00 4,064,531.43 82,173,671.35 7,310,879.56 66,639,896.21


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.93876 0.72915 0.72915 0.72915 0.91881 0.91881 0.91881 0.918811.15000 1.03000 1.03000 1.03000 1.15000 1.15000 1.15000 1.150001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.04082 1.04679 1.04679 1.04679 1.03950 1.03950 1.03950 1.039501.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.01833 1.01833 1.01312 1.00000 1.01312 1.000001.00000 0.99571 0.99571 0.99571 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.12425 0.78321 0.79757 0.79757 1.11337 1.09896 1.11337 1.09896

Plan 345 Plan 346 Plan 347 Plan 348 Plan 349 Plan 350 Plan 351 Plan 3521,036.58 722.14 735.37 735.37 1,026.55 1,013.26 1,026.55 1,013.260.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000012.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688%3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500%16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188%

Plan 345 Plan 346 Plan 347 Plan 348 Plan 349 Plan 350 Plan 351 Plan 3521,086.00 739.80 753.49 753.49 1,075.41 1,061.72 1,075.41 1,061.72

14,971.00 0.00 0.00 0.00 515.00 6,816.00 555.00 5,369.0014,971.00 0.00 0.00 0.00 515.00 6,816.00 555.00 5,369.00

Plan 345 Plan 346 Plan 347 Plan 348 Plan 349 Plan 350 Plan 351 Plan 3521,236.80 861.62 877.41 877.41 1,224.83 1,208.97 1,224.83 1,208.9713.89% 16.47% 16.45% 16.45% 13.89% 13.87% 13.89% 13.87%
































85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005Silver Silver Silver Silver Gold Gold Gold Gold

0.71213 0.71213 0.71213 0.71213 0.81078 0.81078 0.81078 0.81078 0.72586 0.72586 0.72586 0.72586 0.82433 0.82433 0.82433 0.82433

PPO PPO PPO PPO PPO PPO PPO PPO40/70/3000/65 PPO 22 40/70/3000/65 PPO 22 40/70/3000/65 PPO 22 40/70/3000/65 PPO 22 25/40/1500/80 PPO 22 25/40/1500/80 PPO 22 25/40/1500/80 PPO 22 25/40/1500/80 PPO 22



Plan 353 Plan 354 Plan 355 Plan 356 Plan 357 Plan 358 Plan 359 Plan 36020,088.81 0.00 0.00 0.00 8,671,973.08 95,555,701.09 7,918,672.49 79,802,794.659,326.49 0.00 0.00 0.00 9,098,734.05 84,984,503.76 7,993,017.36 74,172,584.22

28.00 0.00 0.00 0.00 11,465.00 119,563.00 11,252.00 104,601.00333.08893 0.00000 0.00000 0.00000 793.60960 710.79267 710.36415 709.10014

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 353 Plan 354 Plan 355 Plan 356 Plan 357 Plan 358 Plan 359 Plan 36012,564.76 0.00 0.00 0.00 11,002,073.18 100,297,467.43 9,597,205.34 87,583,179.10


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.72586 0.72586 0.72586 0.72586 0.82433 0.82433 0.82433 0.824331.03000 1.03000 1.03000 1.03000 1.08000 1.08000 1.08000 1.080001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.04881 1.04881 1.04881 1.04881 1.04561 1.04561 1.04561 1.045611.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.01838 1.01838 1.01548 1.00000 1.01548 1.000000.99570 0.99570 0.99570 0.99570 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.78117 0.78117 0.79552 0.79552 0.94580 0.93139 0.94580 0.93139



0.00 0.00 0.00 0.00 719.00 8,563.00 749.00 6,740.000.00 0.00 0.00 0.00 719.00 8,563.00 749.00 6,740.00

































85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005Gold Gold Gold Gold Silver Silver Silver Silver

0.80107 0.80107 0.80107 0.80107 0.70665 0.70665 0.70665 0.70665 0.78297 0.78297 0.78297 0.78297 0.72915 0.72915 0.72915 0.72915

PPO PPO PPO PPO PPO PPO PPO PPOPPO HSA 22 PPO HSA 22 PPO HSA 22 PPO HSA 22 30/60/2000/80 PPO HSA 30/60/2000/80 PPO HSA 30/60/2000/80 PPO HSA 30/60/2000/80 PPO HSA



Plan 361 Plan 362 Plan 363 Plan 364 Plan 365 Plan 366 Plan 367 Plan 3683,746,718.17 35,393,834.09 4,711,940.85 25,009,263.44 4,330,829.42 36,650,888.32 4,079,243.23 36,647,436.724,601,017.34 31,077,877.77 6,774,979.44 23,827,470.69 3,781,681.95 28,050,969.74 4,494,924.62 28,447,932.22

5,370.00 47,902.00 6,972.00 35,381.00 6,884.00 55,518.00 6,590.00 57,444.00856.80025 648.78038 971.74117 673.45385 549.34369 505.25901 682.08264 495.22896

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 361 Plan 362 Plan 363 Plan 364 Plan 365 Plan 366 Plan 367 Plan 3685,425,994.26 37,724,666.30 7,756,324.85 28,697,130.81 5,012,846.59 36,660,092.81 5,662,704.85 37,918,946.88


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.78297 0.78297 0.78297 0.78297 0.72915 0.72915 0.72915 0.729151.08000 1.08000 1.08000 1.08000 1.03000 1.03000 1.03000 1.030001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.04525 1.04525 1.04525 1.04525 1.04679 1.04679 1.04679 1.046791.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.01630 1.00000 1.01630 1.00000 1.01833 1.00000 1.01833 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.89876 0.88434 0.89876 0.88434 0.80100 0.78659 0.80100 0.78659


Plan 361 Plan 362 Plan 363 Plan 364 Plan 365 Plan 366 Plan 367 Plan 368856.82 843.13 856.82 843.13 756.69 743.01 756.69 743.01471.00 3,326.00 326.00 2,723.00 638.00 4,916.00 484.00 3,568.00471.00 3,326.00 326.00 2,723.00 638.00 4,916.00 484.00 3,568.00

































85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005Silver Silver Silver Silver Platinum Platinum Platinum Platinum

0.71213 0.71213 0.71213 0.71213 0.91166 0.91166 0.91166 0.91166 0.72586 0.72586 0.72586 0.72586 0.93876 0.93876 0.93876 0.93876

PPO PPO PPO PPO PPO PPO PPO PPO40/70/3000/65 PPO 22 40/70/3000/65 PPO 22 40/70/3000/65 PPO 22 40/70/3000/65 PPO 22 PPO 22 PPO 22 PPO 22 PPO 22



Plan 369 Plan 370 Plan 371 Plan 372 Plan 373 Plan 374 Plan 375 Plan 3763,098,078.04 39,855,820.14 3,051,646.21 26,910,545.60 81,711.69 0.00 0.00 0.003,319,197.73 28,766,254.56 2,152,710.96 22,649,538.35 57,883.31 0.00 0.00 0.00

4,895.00 58,794.00 4,969.00 40,106.00 70.00 0.00 0.00 0.00678.07921 489.27194 433.22821 564.74189 826.90443 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 369 Plan 370 Plan 371 Plan 372 Plan 373 Plan 374 Plan 375 Plan 3764,214,877.80 37,712,835.13 2,818,066.61 28,772,479.92 66,280.52 0.00 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.72586 0.72586 0.72586 0.72586 0.93876 0.93876 0.93876 0.938761.03000 1.03000 1.03000 1.03000 1.15000 1.15000 1.15000 1.150001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.04881 1.04881 1.04881 1.04881 1.04082 1.04082 1.04082 1.040821.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.01838 1.00000 1.01838 1.00000 1.00000 1.00000 1.01282 1.012821.00000 1.00000 1.00000 1.00000 0.99700 0.99700 0.99700 0.997001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.79896 0.78454 0.79896 0.78454 1.12088 1.12088 1.13525 1.13525

Plan 369 Plan 370 Plan 371 Plan 372 Plan 373 Plan 374 Plan 375 Plan 376736.66 723.36 736.66 723.36 1,033.47 1,033.47 1,046.72 1,046.720.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000012.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688%3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500%16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188%

Plan 369 Plan 370 Plan 371 Plan 372 Plan 373 Plan 374 Plan 375 Plan 376752.09 738.40 752.09 738.40 1,082.79 1,082.79 1,096.48 1,096.48456.00 5,207.00 493.00 3,174.00 0.00 0.00 0.00 0.00456.00 5,207.00 493.00 3,174.00 0.00 0.00 0.00 0.00

































85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005 85629NY005Platinum Platinum Platinum Platinum Gold Gold Gold Gold

0.88515 0.88515 0.88515 0.88515 0.81078 0.81078 0.81078 0.81078 0.91881 0.91881 0.91881 0.91881 0.82433 0.82433 0.82433 0.82433

PPO PPO PPO PPO PPO PPO PPO PPO20/40/100 PPO 22 20/40/100 PPO 22 20/40/100 PPO 22 20/40/100 PPO 22 25/40/1500/80 PPO 22 25/40/1500/80 PPO 22 25/40/1500/80 PPO 22 25/40/1500/80 PPO 22 85629NY0050185 85629NY0050186 85629NY0050187 85629NY0050188 85629NY0050193 85629NY0050194 85629NY0050195 85629NY0050196

Off Off Off Off Off Off Off OffUniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod Uniform Mod

Plan 377 Plan 378 Plan 379 Plan 380 Plan 381 Plan 382 Plan 383 Plan 38421,471.90 0.00 0.00 0.00 7,590.68 0.00 0.00 0.0028,549.43 0.00 0.00 0.00 1,087.35 0.00 0.00 0.00

20.00 0.00 0.00 0.00 8.00 0.00 0.00 0.001427.47150 0.00000 0.00000 0.00000 135.91875 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 377 Plan 378 Plan 379 Plan 380 Plan 381 Plan 382 Plan 383 Plan 38430,069.83 0.00 0.00 0.00 2,025.34 0.00 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.91881 0.91881 0.91881 0.91881 0.82433 0.82433 0.82433 0.824331.15000 1.15000 1.15000 1.15000 1.08000 1.08000 1.08000 1.080001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.03950 1.03950 1.03950 1.03950 1.04561 1.04561 1.04561 1.045611.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.01312 1.01312 1.00000 1.00000 1.01548 1.015480.99693 0.99693 0.99693 0.99693 0.99638 0.99638 0.99638 0.996381.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.09558 1.09558 1.10995 1.10995 0.92801 0.92801 0.94238 0.94238

Plan 377 Plan 378 Plan 379 Plan 380 Plan 381 Plan 382 Plan 383 Plan 3841,010.15 1,010.15 1,023.40 1,023.40 855.65 855.65 868.89 868.890.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000012.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688%3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500%16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188%

Plan 377 Plan 378 Plan 379 Plan 380 Plan 381 Plan 382 Plan 383 Plan 3841,058.51 1,058.51 1,072.20 1,072.20 884.58 884.58 898.26 898.26

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.000.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


































0.64530 0.64530 0.64530 0.64530 0.64530 0.64530 0.64530 0.64530 0.65491 0.65491 0.65491 0.65491 0.65491 0.65491 0.65491 0.65491

PPO PPO PPO PPO PPO PPO PPO PPO30/60/6750/80 PPO HSA 30/60/6750/80 PPO HSA 30/60/6750/80 PPO HSA 30/60/6750/80 PPO HSA 30/60/6750/80 PPO HSA 30/60/6750/80 PPO HSA 30/60/6750/80 PPO HSA 30/60/6750/80 PPO HSA



Plan 385 Plan 386 Plan 387 Plan 388 Plan 389 Plan 390 Plan 391 Plan 3922,240,842.35 0.00 3,889,153.11 0.00 240,753.71 0.00 0.00 0.001,558,264.23 0.00 2,692,141.31 0.00 94,662.18 0.00 0.00 0.00

4,306.00 0.00 7,108.00 0.00 515.00 0.00 0.00 0.00361.88208 0.00000 378.74807 0.00000 183.81006 0.00000 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 385 Plan 386 Plan 387 Plan 388 Plan 389 Plan 390 Plan 391 Plan 3922,405,307.40 0.00 3,914,662.14 0.00 186,102.19 0.00 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.65491 0.65491 0.65491 0.65491 0.65491 0.65491 0.65491 0.654911.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.94872 0.948721.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.04511 1.04511 1.04511 1.04511 1.04511 1.04511 1.04511 1.045111.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.02219 1.02219 1.02219 1.022191.00000 0.99480 1.00000 0.99480 1.00000 1.00000 0.99480 0.994801.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000000.64971 0.64633 0.64971 0.64633 0.66412 0.66412 0.66067 0.66067




































0.88515 0.88515 0.88515 0.88515 0.88515 0.88515 0.88515 0.88515 0.91881 0.91881 0.91881 0.91881 0.91881 0.91881 0.91881 0.91881

PPO PPO PPO PPO PPO PPO PPO PPO20/40/100 PPO FAIR 22 20/40/100 PPO FAIR 22 20/40/100 PPO FAIR 22 20/40/100 PPO FAIR 22 20/40/100 PPO FAIR 22 20/40/100 PPO FAIR 22 20/40/100 PPO FAIR 22 20/40/100 PPO FAIR 22



Plan 393 Plan 394 Plan 395 Plan 396 Plan 397 Plan 398 Plan 399 Plan 40028,002,655.30 0.00 60,490,946.99 0.00 1,901,025.20 4,744,278.96 0.00 0.0040,408,026.60 0.00 65,631,744.37 0.00 2,760,941.83 7,484,850.22 0.00 0.00

29,047.00 0.00 57,365.00 0.00 2,057.00 4,872.00 0.00 0.001391.12564 0.00000 1144.10781 0.00000 1342.21771 1536.29931 0.00000 0.00000

722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667 722.81667

Plan 393 Plan 394 Plan 395 Plan 396 Plan 397 Plan 398 Plan 399 Plan 40046,138,003.70 0.00 74,683,879.04 0.00 3,141,610.19 8,455,056.91 0.00 0.00


1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559 1.27559


0.91881 0.91881 0.91881 0.91881 0.91881 0.91881 0.91881 0.918811.15000 1.15000 1.15000 1.15000 1.15000 1.15000 1.15000 1.150001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.25539 1.25539 1.25539 1.25539 1.25539 1.25539 1.25539 1.255391.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.01086 1.01086 1.01086 1.010861.00000 0.99746 1.00000 0.99746 1.00000 1.00000 0.99746 0.997461.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.00054 1.000541.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.00000 1.000001.32720 1.32382 1.32720 1.32382 1.34161 1.34161 1.33820 1.33820

Plan 393 Plan 394 Plan 395 Plan 396 Plan 397 Plan 398 Plan 399 Plan 4001,223.70 1,220.59 1,223.70 1,220.59 1,236.99 1,236.99 1,233.85 1,233.850.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.00000 0.0000012.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688% 12.688%3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500% 3.500%16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188% 16.188%

Plan 393 Plan 394 Plan 395 Plan 396 Plan 397 Plan 398 Plan 399 Plan 4001,269.87 1,266.66 1,269.87 1,266.66 1,283.56 1,283.56 1,280.35 1,280.352,172.00 0.00 4,216.00 0.00 207.00 517.00 0.00 0.002,172.00 0.00 4,216.00 0.00 207.00 517.00 0.00 0.00



Exhibit 18 Supplement



Expense Data - Small Group 2022 Expected 2021 Expected 2020 Expected 2019 Expected 2020 Actual 2019 ActualPeriod assumed - beginning date 1/1/2022 1/1/2021 1/1/2020 1/1/2019 1/1/2020 1/1/2019

Period assumed - ending date 12/31/2022 12/31/2021 12/31/2020 12/31/2019 12/31/2020 12/31/2019Average annual claim trend assumed 8.39% 9.06% 8.22% 9.40% -0.18% 11.67%

Regulatory authority licenses and fees, NOT including New York State 206 assessment expenses - as a % of gross premium 0.01% 0.01% 0.01% 0.01% 0.01% 0.01%New York State 206 Assessment expenses - as a % of gross premium 0.68% 0.70% 0.71% 0.69% 0.65% 0.65%

Risk Adjustment User Fee - as a % of gross premium 0.02964% 0.02266% 0.02199% 0.01915% 0.02082% 0.01816%Administrative expenses for activities that improve health care quality as defined in the NAIC Annual Statement Supplement Health Care Exhibit - as a % of gross premium 0.80% 0.80% 0.80% 0.69% 0.80% 0.80%

Commissions and broker fees - as a % of gross premium 3.75% 3.75% 3.75% 3.75% 4.16% 4.11%Premium Taxes - as a % of gross premium 2.12% 2.11% 2.09% 2.16% 1.97% 1.94%

Other state and federal taxes and assessments (other than income taxes and covered lives assessment) - as a % of gross premium 0.00% 0.00% 2.65% 0.00% 2.05% 0.03%Other administrative expenses - as a % of gross premium 5.30% 5.20% 5.44% 5.68% 5.22% 4.65%

Subtotal 12.688% 12.592% 15.473% 13.002% 14.872% 12.219%

After tax underwriting margin (profit/contribution to surplus) - as a % of gross premium 2.77% 1.58% 2.00% 3.95% 2.89% 2.64%State income tax component - as a % of gross premium 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

State income tax rate assumed (e.g. 3%) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%Federal income tax component - as a % of gross premium 0.74% 0.42% 0.53% 1.05% 0.77% 0.70%

Federal income tax rate assumed (e.g. 30%) 21.00% 21.00% 21.00% 21.00% 21.00% 21.00%Reduction for assumed net investment income - as a % of gross premium (enter as a negative value) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Subtotal 3.500% 2.000% 2.527% 4.998% 3.664% 3.346%

Total 16.188% 14.592% 18.000% 18.000% 18.536% 15.565%

Exhibit 18 Supplement Updated by DFS ‐ 3/20/2020 1

1. Company Name 2. NAIC Code 3. SERFF Number 4. Market5. Current HIOS ID

(14 Digits)6. Previous HIOS ID

(14 Digits)7. Metal Level or

Catastrophic 8. Exchange ["On"/"Off"]

9. Plan Type [Standard or Non-

Standard]

10. Limiting Child

Age? (26 or 30)

11. Domestic Partner

Coverage Included? (yes,

no)

12. Family Planning

Coverage? (included, excluded)

13. Pediatric Dental


no)

14. Out of Network

Benefits? (yes, no)

15. Includes

Benefits in Addition to EHB?

(yes, no)

16. Healthy New York

(yes, no)

17. Child-Only Plan

(yes, no)

18. Tiered Network Plan (yes, no)

19. HSA Plan (yes,

no)20.

PNDS Identifier

21. Company Network

IdentifierRegion 1 - 2019 Rate

(Albany)Region 2 - 2019 Rate

(Buffalo)Region 3 - 2019 Rate

(Mid-Hudson)Region 4 - 2019 Rate

(New York)Region 5 - 2019 Rate

(Rochester)Region 6 - 2019 Rate

(Syracuse)Region 7 - 2019 Rate

(Utica)Region 8 - 2019 Rate

(Long Island)Region 1 - 2019 MMs

(Albany)Region 2 - 2019 MMs

(Buffalo)Region 3 - 2019 MMs

(Mid-Hudson)Region 4 - 2019 MMs

(New York)Region 5 - 2019

MMs (Rochester)Region 6 - 2019 MMs (Syracuse)

Region 7 - 2019 MMs (Utica)

Region 8 - 2019 MMs (Long Island)

Region 1 - 2020 Rate (Albany)

Region 2 - 2020 Rate (Buffalo)

Region 3 - 2020 Rate (Mid-Hudson)

Region 4 - 2020 Rate (New York)

Region 5 - 2020 Rate (Rochester)

Region 6 - 2020 Rate (Syracuse)

Region 7 - 2020 Rate (Utica)

Region 8 - 2020 Rate (Long Island)

Region 1 - 2020 MMs(Albany)

Region 2 - 2020 MMs(Buffalo)

Region 3 - 2020 MMs(Mid-Hudson)

Region 4 - 2020 MMs(New York)

Region 5 - 2020 MMs (Rochester)

Region 6 - 2020 MMs (Syracuse)











Region 1 - 2021 Members as of

3/31/2021 (Albany)


3/31/2021 (Buffalo)

Region 3 - 2021 Members as of 3/31/2021 (Mid-

Hudson)


3/31/2021 (New York)


3/31/2021 (Rochester)


3/31/2021 (Syracuse)


3/31/2021 (Utica)

Region 8 - 2021 Members as of 3/31/2021 (Long

Island)Region 1 - 2022 Rate





(Rochester)

Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010316 85629NY0010316 Bronze Off Non-Standard 26 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 699.97 635.70n/a n/a n/a 635.70 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 769.57 698.91n/a n/a n/a 698.91n/a n/a 1,137.00 97,296.00n/a n/a n/a 37,277.00n/a n/a 794.62 734.12n/a n/a n/a 745.35n/a n/a 64.00 6,778.00n/a n/a n/a 2,556.00n/a n/a 935.06 879.07n/a

Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010325 85629NY0010325 Bronze Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 696.21 632.29n/a n/a n/a 632.29 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 765.45 695.17n/a n/a n/a 695.17n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 790.38 730.20n/a n/a n/a 741.37n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 930.25 874.55n/a

Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010310 85629NY0010310 Bronze Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 699.97 635.70n/a n/a n/a 635.70 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 769.57 698.91n/a n/a n/a 698.91n/a n/a 1,048.00 105,390.00n/a n/a n/a 54,031.00n/a n/a 794.62 734.12n/a n/a n/a 745.35n/a n/a 63.00 7,316.00n/a n/a n/a 3,493.00n/a n/a 935.06 879.07n/a

Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010326 85629NY0010326 Bronze Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 696.21 632.29n/a n/a n/a 632.29 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 765.45 695.17n/a n/a n/a 695.17n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 790.38 730.20n/a n/a n/a 741.37n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 930.25 874.55n/a

Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010311 85629NY0010311 Bronze Off Non-Standard 30 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 716.01 650.27n/a n/a n/a 650.27 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 787.15 714.88n/a n/a n/a 714.88n/a n/a 60.00 6,357.00n/a n/a n/a 2,549.00n/a n/a 812.73 750.85n/a n/a n/a 762.34n/a n/a 7.00 625.00n/a n/a n/a 195.00n/a n/a 955.60 898.38n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010309 85629NY0010309 Bronze Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 716.01 650.27n/a n/a n/a 650.27 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 787.15 714.88n/a n/a n/a 714.88n/a n/a 183.00 6,450.00n/a n/a n/a 3,556.00n/a n/a 812.73 750.85n/a n/a n/a 762.34n/a n/a 14.00 606.00n/a n/a n/a 375.00n/a n/a 955.60 898.38n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010327 85629NY0010327 Bronze Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 712.25 646.86n/a n/a n/a 646.86 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 783.03 711.14n/a n/a n/a 711.14n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 808.49 746.93n/a n/a n/a 758.36n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 950.79 893.86n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010328 85629NY0010328 Bronze Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 712.25 646.86n/a n/a n/a 646.86 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 783.03 711.14n/a n/a n/a 711.14n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 808.49 746.93n/a n/a n/a 758.36n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 950.79 893.86n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010240 85629NY0010240 Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,008.60 915.99n/a n/a n/a 915.99 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,121.27 1,018.31n/a n/a n/a 1,018.31n/a n/a 2,215.00 113,755.00n/a n/a n/a 41,270.00n/a n/a 1,132.01 1,045.81n/a n/a n/a 1,061.82n/a n/a 169.00 7,907.00n/a n/a n/a 2,857.00n/a n/a 1,275.78 1,199.38n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010253 85629NY0010253 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,004.84 912.58n/a n/a n/a 912.58 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,117.15 1,014.57n/a n/a n/a 1,014.57n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,127.77 1,041.89n/a n/a n/a 1,057.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,270.97 1,194.86n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010238 85629NY0010238 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,008.60 915.99n/a n/a n/a 915.99 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,121.27 1,018.31n/a n/a n/a 1,018.31n/a n/a 1,164.00 124,547.00n/a n/a n/a 44,174.00n/a n/a 1,132.01 1,045.81n/a n/a n/a 1,061.82n/a n/a 44.00 8,135.00n/a n/a n/a 3,095.00n/a n/a 1,275.78 1,199.38n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010254 85629NY0010254 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,004.84 912.58n/a n/a n/a 912.58 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,117.15 1,014.57n/a n/a n/a 1,014.57n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,127.77 1,041.89n/a n/a n/a 1,057.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,270.97 1,194.86n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010239 85629NY0010239 Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,024.64 930.56n/a n/a n/a 930.56 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,138.85 1,034.28n/a n/a n/a 1,034.28n/a n/a 77.00 11,957.00n/a n/a n/a 6,911.00n/a n/a 1,150.12 1,062.54n/a n/a n/a 1,078.81n/a n/a 9.00 837.00n/a n/a n/a 524.00n/a n/a 1,296.32 1,218.69n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010237 85629NY0010237 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,024.64 930.56n/a n/a n/a 930.56 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,138.85 1,034.28n/a n/a n/a 1,034.28n/a n/a 12.00 9,609.00n/a n/a n/a 4,766.00n/a n/a 1,150.12 1,062.54n/a n/a n/a 1,078.81n/a n/a 0.00 681.00n/a n/a n/a 372.00n/a n/a 1,296.32 1,218.69n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010255 85629NY0010255 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,020.88 927.15n/a n/a n/a 927.15 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,134.73 1,030.54n/a n/a n/a 1,030.54n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,145.88 1,058.62n/a n/a n/a 1,074.83n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,291.51 1,214.17n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010256 85629NY0010256 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,020.88 927.15n/a n/a n/a 927.15 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,134.73 1,030.54n/a n/a n/a 1,030.54n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,145.88 1,058.62n/a n/a n/a 1,074.83n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,291.51 1,214.17n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010076 85629NY0010076 Gold Off Non-Standard 26 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 958.25 870.27n/a n/a n/a 870.27 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,061.60 964.13n/a n/a n/a 964.13n/a n/a 232.00 24,795.00n/a n/a n/a 6,928.00n/a n/a 1,069.35 987.93n/a n/a n/a 1,003.05n/a n/a 18.00 1,808.00n/a n/a n/a 544.00n/a n/a 1,207.39 1,135.09n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010072 85629NY0010072 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 954.49 866.86n/a n/a n/a 866.86 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,057.48 960.39n/a n/a n/a 960.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,065.11 984.01n/a n/a n/a 999.07n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,202.58 1,130.57n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010235 85629NY0010235 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 958.25 870.27n/a n/a n/a 870.27 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,061.60 964.13n/a n/a n/a 964.13n/a n/a 72.00 23,881.00n/a n/a n/a 5,451.00n/a n/a 1,069.35 987.93n/a n/a n/a 1,003.05n/a n/a 4.00 1,522.00n/a n/a n/a 385.00n/a n/a 1,207.39 1,135.09n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010073 85629NY0010073 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 954.49 866.86n/a n/a n/a 866.86 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,057.48 960.39n/a n/a n/a 960.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,065.11 984.01n/a n/a n/a 999.07n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,202.58 1,130.57n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010236 85629NY0010236 Gold Off Non-Standard 30 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 974.29 884.84n/a n/a n/a 884.84 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,079.18 980.10n/a n/a n/a 980.10n/a n/a 0.00 2,383.00n/a n/a n/a 509.00n/a n/a 1,087.46 1,004.66n/a n/a n/a 1,020.04n/a n/a 0.00 241.00n/a n/a n/a 25.00n/a n/a 1,227.93 1,154.40n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010234 85629NY0010234 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 974.29 884.84n/a n/a n/a 884.84 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,079.18 980.10n/a n/a n/a 980.10n/a n/a 0.00 1,895.00n/a n/a n/a 541.00n/a n/a 1,087.46 1,004.66n/a n/a n/a 1,020.04n/a n/a 0.00 216.00n/a n/a n/a 49.00n/a n/a 1,227.93 1,154.40n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010074 85629NY0010074 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 970.53 881.43n/a n/a n/a 881.43 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,075.06 976.36n/a n/a n/a 976.36n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,083.22 1,000.74n/a n/a n/a 1,016.06n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,223.12 1,149.88n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010075 85629NY0010075 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 970.53 881.43n/a n/a n/a 881.43 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,075.06 976.36n/a n/a n/a 976.36n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,083.22 1,000.74n/a n/a n/a 1,016.06n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,223.12 1,149.88n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050068 85629NY0050068 Gold Off Non-Standard 26 No Included Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 1,023.89 929.87n/a n/a n/a 929.87 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,129.42 1,025.72n/a n/a n/a 1,025.72n/a n/a 39.00 28,313.00n/a n/a n/a 3,227.00n/a n/a 1,115.54 1,030.60n/a n/a n/a 1,046.38n/a n/a 7.00 2,451.00n/a n/a n/a 265.00n/a n/a 1,259.95 1,184.50n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050001 85629NY0050001 Gold Off Non-Standard 26 No Excluded Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 1,020.13 926.46n/a n/a n/a 926.46 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,125.30 1,021.98n/a n/a n/a 1,021.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,111.30 1,026.68n/a n/a n/a 1,042.40n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,255.14 1,179.98n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050066 85629NY0050066 Gold Off Non-Standard 26 Yes Included Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 1,023.89 929.87n/a n/a n/a 929.87 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,129.42 1,025.72n/a n/a n/a 1,025.72n/a n/a 1,617.00 38,508.00n/a n/a n/a 5,279.00n/a n/a 1,115.54 1,030.60n/a n/a n/a 1,046.38n/a n/a 145.00 2,788.00n/a n/a n/a 393.00n/a n/a 1,259.95 1,184.50n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050002 85629NY0050002 Gold Off Non-Standard 26 Yes Excluded Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 1,020.13 926.46n/a n/a n/a 926.46 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,125.30 1,021.98n/a n/a n/a 1,021.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,111.30 1,026.68n/a n/a n/a 1,042.40n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,255.14 1,179.98n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050067 85629NY0050067 Gold Off Non-Standard 30 No Included Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 1,039.93 944.44n/a n/a n/a 944.44 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,147.00 1,041.69n/a n/a n/a 1,041.69n/a n/a 0.00 4,892.00n/a n/a n/a 1,371.00n/a n/a 1,133.65 1,047.33n/a n/a n/a 1,063.37n/a n/a 0.00 236.00n/a n/a n/a 90.00n/a n/a 1,280.49 1,203.81n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050065 85629NY0050065 Gold Off Non-Standard 30 Yes Included Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 1,039.93 944.44n/a n/a n/a 944.44 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,147.00 1,041.69n/a n/a n/a 1,041.69n/a n/a 0.00 4,639.00n/a n/a n/a 747.00n/a n/a 1,133.65 1,047.33n/a n/a n/a 1,063.37n/a n/a 0.00 406.00n/a n/a n/a 65.00n/a n/a 1,280.49 1,203.81n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050003 85629NY0050003 Gold Off Non-Standard 30 No Excluded Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 1,036.17 941.03n/a n/a n/a 941.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,142.88 1,037.95n/a n/a n/a 1,037.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,129.41 1,043.41n/a n/a n/a 1,059.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,275.68 1,199.29n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050004 85629NY0050004 Gold Off Non-Standard 30 Yes Excluded Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 1,036.17 941.03n/a n/a n/a 941.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,142.88 1,037.95n/a n/a n/a 1,037.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,129.41 1,043.41n/a n/a n/a 1,059.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,275.68 1,199.29n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050044 85629NY0050044 Gold Off Non-Standard 26 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,068.50 970.40n/a n/a n/a 970.40 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,186.15 1,077.25n/a n/a n/a 1,077.25n/a n/a 1,155.00 73,127.00n/a n/a n/a 14,973.00n/a n/a 1,174.63 1,085.18n/a n/a n/a 1,101.79n/a n/a 66.00 5,483.00n/a n/a n/a 1,191.00n/a n/a 1,326.99 1,247.52n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050193 85629NY0050193 Gold Off Non-Standard 26 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,064.74 966.99n/a n/a n/a 966.99 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,182.03 1,073.51n/a n/a n/a 1,073.51n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,170.39 1,081.26n/a n/a n/a 1,097.81n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,322.18 1,243.00n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050042 85629NY0050042 Gold Off Non-Standard 26 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,068.50 970.40n/a n/a n/a 970.40 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,186.15 1,077.25n/a n/a n/a 1,077.25n/a n/a 536.00 99,296.00n/a n/a n/a 13,789.00n/a n/a 1,174.63 1,085.18n/a n/a n/a 1,101.79n/a n/a 54.00 7,411.00n/a n/a n/a 1,098.00n/a n/a 1,326.99 1,247.52n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050194 85629NY0050194 Gold Off Non-Standard 26 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,064.74 966.99n/a n/a n/a 966.99 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,182.03 1,073.51n/a n/a n/a 1,073.51n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,170.39 1,081.26n/a n/a n/a 1,097.81n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,322.18 1,243.00n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050043 85629NY0050043 Gold Off Non-Standard 30 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,084.54 984.97n/a n/a n/a 984.97 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,203.73 1,093.22n/a n/a n/a 1,093.22n/a n/a 87.00 7,170.00n/a n/a n/a 2,765.00n/a n/a 1,192.74 1,101.91n/a n/a n/a 1,118.78n/a n/a 2.00 577.00n/a n/a n/a 170.00n/a n/a 1,347.53 1,266.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050041 85629NY0050041 Gold Off Non-Standard 30 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,084.54 984.97n/a n/a n/a 984.97 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,203.73 1,093.22n/a n/a n/a 1,093.22n/a n/a 2.00 6,720.00n/a n/a n/a 1,750.00n/a n/a 1,192.74 1,101.91n/a n/a n/a 1,118.78n/a n/a 0.00 561.00n/a n/a n/a 158.00n/a n/a 1,347.53 1,266.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050195 85629NY0050195 Gold Off Non-Standard 30 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,080.78 981.56n/a n/a n/a 981.56 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,199.61 1,089.48n/a n/a n/a 1,089.48n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,188.50 1,097.99n/a n/a n/a 1,114.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,342.72 1,262.31n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050196 85629NY0050196 Gold Off Non-Standard 30 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,080.78 981.56n/a n/a n/a 981.56 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,199.61 1,089.48n/a n/a n/a 1,089.48n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,188.50 1,097.99n/a n/a n/a 1,114.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,342.72 1,262.31n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010248 85629NY0010248 Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 984.67 894.26n/a n/a n/a 894.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,098.22 997.38n/a n/a n/a 997.38n/a n/a 1,531.00 106,608.00n/a n/a n/a 41,520.00n/a n/a 1,122.15 1,036.70n/a n/a n/a 1,052.57n/a n/a 75.00 7,381.00n/a n/a n/a 2,685.00n/a n/a 1,265.39 1,189.61n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010261 85629NY0010261 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 980.91 890.85n/a n/a n/a 890.85 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,094.10 993.64n/a n/a n/a 993.64n/a n/a 0.00 21.00n/a n/a n/a 62.00n/a n/a 1,117.91 1,032.78n/a n/a n/a 1,048.59n/a n/a 0.00 0.00 n/a n/a n/a 5.00 n/a n/a 1,260.58 1,185.09n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010246 85629NY0010246 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 984.67 894.26n/a n/a n/a 894.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,098.22 997.38n/a n/a n/a 997.38n/a n/a 741.00 141,123.00n/a n/a n/a 39,171.00n/a n/a 1,122.15 1,036.70n/a n/a n/a 1,052.57n/a n/a 55.00 9,810.00n/a n/a n/a 2,569.00n/a n/a 1,265.39 1,189.61n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010262 85629NY0010262 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 980.91 890.85n/a n/a n/a 890.85 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,094.10 993.64n/a n/a n/a 993.64n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,117.91 1,032.78n/a n/a n/a 1,048.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,260.58 1,185.09n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010247 85629NY0010247 Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,000.71 908.83n/a n/a n/a 908.83 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,115.80 1,013.35n/a n/a n/a 1,013.35n/a n/a 62.00 12,958.00n/a n/a n/a 5,284.00n/a n/a 1,140.26 1,053.43n/a n/a n/a 1,069.56n/a n/a 6.00 967.00n/a n/a n/a 388.00n/a n/a 1,285.93 1,208.92n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010245 85629NY0010245 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,000.71 908.83n/a n/a n/a 908.83 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,115.80 1,013.35n/a n/a n/a 1,013.35n/a n/a 159.00 7,348.00n/a n/a n/a 4,027.00n/a n/a 1,140.26 1,053.43n/a n/a n/a 1,069.56n/a n/a 2.00 626.00n/a n/a n/a 319.00n/a n/a 1,285.93 1,208.92n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010263 85629NY0010263 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 996.95 905.42n/a n/a n/a 905.42 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,111.68 1,009.61n/a n/a n/a 1,009.61n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,136.02 1,049.51n/a n/a n/a 1,065.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,281.12 1,204.40n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010264 85629NY0010264 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 996.95 905.42n/a n/a n/a 905.42 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,111.68 1,009.61n/a n/a n/a 1,009.61n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,136.02 1,049.51n/a n/a n/a 1,065.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,281.12 1,204.40n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010645 85629NY0010645 Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 932.80 847.15n/a n/a n/a 847.15 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,014.70 921.53n/a n/a n/a 921.53n/a n/a 64.00 9,319.00n/a n/a n/a 6,135.00n/a n/a 1,044.79 965.24n/a n/a n/a 980.01n/a n/a 12.00 930.00n/a n/a n/a 434.00n/a n/a 1,190.64 1,119.34n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010646 85629NY0010646 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 929.04 843.74n/a n/a n/a 843.74 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,010.58 917.79n/a n/a n/a 917.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,040.55 961.32n/a n/a n/a 976.03n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,185.83 1,114.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010647 85629NY0010647 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 932.80 847.15n/a n/a n/a 847.15 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,014.70 921.53n/a n/a n/a 921.53n/a n/a 47.00 18,347.00n/a n/a n/a 5,670.00n/a n/a 1,044.79 965.24n/a n/a n/a 980.01n/a n/a 0.00 1,675.00n/a n/a n/a 667.00n/a n/a 1,190.64 1,119.34n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010648 85629NY0010648 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 929.04 843.74n/a n/a n/a 843.74 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,010.58 917.79n/a n/a n/a 917.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,040.55 961.32n/a n/a n/a 976.03n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,185.83 1,114.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010649 85629NY0010649 Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 948.84 861.72n/a n/a n/a 861.72 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,032.28 937.50n/a n/a n/a 937.50n/a n/a 0.00 688.00n/a n/a n/a 196.00n/a n/a 1,062.90 981.97n/a n/a n/a 997.00n/a n/a 0.00 59.00n/a n/a n/a 31.00n/a n/a 1,211.18 1,138.65n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010650 85629NY0010650 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 948.84 861.72n/a n/a n/a 861.72 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,032.28 937.50n/a n/a n/a 937.50n/a n/a 0.00 383.00n/a n/a n/a 1,929.00n/a n/a 1,062.90 981.97n/a n/a n/a 997.00n/a n/a 0.00 41.00n/a n/a n/a 173.00n/a n/a 1,211.18 1,138.65n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010651 85629NY0010651 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 945.08 858.31n/a n/a n/a 858.31 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,028.16 933.76n/a n/a n/a 933.76n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,058.66 978.05n/a n/a n/a 993.02n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,206.37 1,134.13n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010652 85629NY0010652 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 945.08 858.31n/a n/a n/a 858.31 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,028.16 933.76n/a n/a n/a 933.76n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,058.66 978.05n/a n/a n/a 993.02n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,206.37 1,134.13n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010084 85629NY0010084 Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,013.04 920.02n/a n/a n/a 920.02 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,122.38 1,019.32n/a n/a n/a 1,019.32n/a n/a 1,174.00 49,762.00n/a n/a n/a 28,512.00n/a n/a 1,146.22 1,058.94n/a n/a n/a 1,075.15n/a n/a 121.00 3,559.00n/a n/a n/a 2,181.00n/a n/a 1,289.94 1,212.70n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010101 85629NY0010101 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,009.28 916.61n/a n/a n/a 916.61 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,118.26 1,015.58n/a n/a n/a 1,015.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,141.98 1,055.02n/a n/a n/a 1,071.17n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,285.13 1,208.18n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010082 85629NY0010082 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,013.04 920.02n/a n/a n/a 920.02 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,122.38 1,019.32n/a n/a n/a 1,019.32n/a n/a 544.00 47,854.00n/a n/a n/a 23,712.00n/a n/a 1,146.22 1,058.94n/a n/a n/a 1,075.15n/a n/a 64.00 3,893.00n/a n/a n/a 1,616.00n/a n/a 1,289.94 1,212.70n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010102 85629NY0010102 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,009.28 916.61n/a n/a n/a 916.61 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,118.26 1,015.58n/a n/a n/a 1,015.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,141.98 1,055.02n/a n/a n/a 1,071.17n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,285.13 1,208.18n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010083 85629NY0010083 Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,029.08 934.59n/a n/a n/a 934.59 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,139.96 1,035.29n/a n/a n/a 1,035.29n/a n/a 35.00 6,268.00n/a n/a n/a 3,900.00n/a n/a 1,164.33 1,075.67n/a n/a n/a 1,092.14n/a n/a 0.00 472.00n/a n/a n/a 318.00n/a n/a 1,310.48 1,232.01n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010081 85629NY0010081 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,029.08 934.59n/a n/a n/a 934.59 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,139.96 1,035.29n/a n/a n/a 1,035.29n/a n/a 40.00 4,549.00n/a n/a n/a 2,518.00n/a n/a 1,164.33 1,075.67n/a n/a n/a 1,092.14n/a n/a 4.00 376.00n/a n/a n/a 214.00n/a n/a 1,310.48 1,232.01n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010103 85629NY0010103 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,025.32 931.18n/a n/a n/a 931.18 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,135.84 1,031.55n/a n/a n/a 1,031.55n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,160.09 1,071.75n/a n/a n/a 1,088.16n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,305.67 1,227.49n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010104 85629NY0010104 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,025.32 931.18n/a n/a n/a 931.18 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,135.84 1,031.55n/a n/a n/a 1,031.55n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,160.09 1,071.75n/a n/a n/a 1,088.16n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,305.67 1,227.49n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010036 85629NY0010036 Platinum Off Non-Standard 26 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,199.07 1,088.97n/a n/a n/a 1,088.97 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,310.40 1,190.08n/a n/a n/a 1,190.08n/a n/a 946.00 97,965.00n/a n/a n/a 34,971.00n/a n/a 1,354.47 1,251.33n/a n/a n/a 1,270.48n/a n/a 65.00 7,055.00n/a n/a n/a 2,614.00n/a n/a 1,506.23 1,416.04n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010226 85629NY0010226 Platinum Off Non-Standard 26 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,195.31 1,085.56n/a n/a n/a 1,085.56 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,306.28 1,186.34n/a n/a n/a 1,186.34n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,350.23 1,247.41n/a n/a n/a 1,266.50n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,501.42 1,411.52n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010034 85629NY0010034 Platinum Off Non-Standard 26 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,199.07 1,088.97n/a n/a n/a 1,088.97 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,310.40 1,190.08n/a n/a n/a 1,190.08n/a n/a 710.00 108,273.00n/a n/a n/a 27,157.00n/a n/a 1,354.47 1,251.33n/a n/a n/a 1,270.48n/a n/a 67.00 8,265.00n/a n/a n/a 1,833.00n/a n/a 1,506.23 1,416.04n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010227 85629NY0010227 Platinum Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,195.31 1,085.56n/a n/a n/a 1,085.56 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,306.28 1,186.34n/a n/a n/a 1,186.34n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,350.23 1,247.41n/a n/a n/a 1,266.50n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,501.42 1,411.52n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010035 85629NY0010035 Platinum Off Non-Standard 30 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,215.11 1,103.54n/a n/a n/a 1,103.54 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,327.98 1,206.05n/a n/a n/a 1,206.05n/a n/a 136.00 11,614.00n/a n/a n/a 5,183.00n/a n/a 1,372.58 1,268.06n/a n/a n/a 1,287.47n/a n/a 11.00 826.00n/a n/a n/a 405.00n/a n/a 1,526.77 1,435.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010033 85629NY0010033 Platinum Off Non-Standard 30 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,215.11 1,103.54n/a n/a n/a 1,103.54 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,327.98 1,206.05n/a n/a n/a 1,206.05n/a n/a 20.00 5,415.00n/a n/a n/a 3,569.00n/a n/a 1,372.58 1,268.06n/a n/a n/a 1,287.47n/a n/a 4.00 454.00n/a n/a n/a 386.00n/a n/a 1,526.77 1,435.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010228 85629NY0010228 Platinum Off Non-Standard 30 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,211.35 1,100.13n/a n/a n/a 1,100.13 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,323.86 1,202.31n/a n/a n/a 1,202.31n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,368.34 1,264.14n/a n/a n/a 1,283.49n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,521.96 1,430.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010229 85629NY0010229 Platinum Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,211.35 1,100.13n/a n/a n/a 1,100.13 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,323.86 1,202.31n/a n/a n/a 1,202.31n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,368.34 1,264.14n/a n/a n/a 1,283.49n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,521.96 1,430.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050028 85629NY0050028 Platinum Off Non-Standard 26 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,271.78 1,155.01n/a n/a n/a 1,155.01 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,386.25 1,258.97n/a n/a n/a 1,258.97n/a n/a 345.00 53,823.00n/a n/a n/a 13,159.00n/a n/a 1,404.75 1,297.79n/a n/a n/a 1,317.64n/a n/a 31.00 4,345.00n/a n/a n/a 993.00n/a n/a 1,565.72 1,471.96n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050185 85629NY0050185 Platinum Off Non-Standard 26 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,268.02 1,151.60n/a n/a n/a 1,151.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,382.13 1,255.23n/a n/a n/a 1,255.23n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,400.51 1,293.87n/a n/a n/a 1,313.66n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,560.91 1,467.44n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050026 85629NY0050026 Platinum Off Non-Standard 26 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,271.78 1,155.01n/a n/a n/a 1,155.01 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,386.25 1,258.97n/a n/a n/a 1,258.97n/a n/a 120.00 77,452.00n/a n/a n/a 6,553.00n/a n/a 1,404.75 1,297.79n/a n/a n/a 1,317.64n/a n/a 9.00 6,222.00n/a n/a n/a 585.00n/a n/a 1,565.72 1,471.96n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050186 85629NY0050186 Platinum Off Non-Standard 26 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,268.02 1,151.60n/a n/a n/a 1,151.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,382.13 1,255.23n/a n/a n/a 1,255.23n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,400.51 1,293.87n/a n/a n/a 1,313.66n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,560.91 1,467.44n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050027 85629NY0050027 Platinum Off Non-Standard 30 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,287.82 1,169.58n/a n/a n/a 1,169.58 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,403.83 1,274.94n/a n/a n/a 1,274.94n/a n/a 0.00 5,938.00n/a n/a n/a 1,232.00n/a n/a 1,422.86 1,314.52n/a n/a n/a 1,334.63n/a n/a 0.00 450.00n/a n/a n/a 105.00n/a n/a 1,586.26 1,491.27n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050025 85629NY0050025 Platinum Off Non-Standard 30 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,287.82 1,169.58n/a n/a n/a 1,169.58 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,403.83 1,274.94n/a n/a n/a 1,274.94n/a n/a 4.00 3,617.00n/a n/a n/a 858.00n/a n/a 1,422.86 1,314.52n/a n/a n/a 1,334.63n/a n/a 0.00 441.00n/a n/a n/a 74.00n/a n/a 1,586.26 1,491.27n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050187 85629NY0050187 Platinum Off Non-Standard 30 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,284.06 1,166.17n/a n/a n/a 1,166.17 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,399.71 1,271.20n/a n/a n/a 1,271.20n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,418.62 1,310.60n/a n/a n/a 1,330.65n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,581.45 1,486.75n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050188 85629NY0050188 Platinum Off Non-Standard 30 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,284.06 1,166.17n/a n/a n/a 1,166.17 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,399.71 1,271.20n/a n/a n/a 1,271.20n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,418.62 1,310.60n/a n/a n/a 1,330.65n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,581.45 1,486.75n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050233 85629NY0050233 Platinum Off Non-Standard 26 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,462.56 1,328.27n/a n/a n/a 1,328.27 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,594.15 1,447.78n/a n/a n/a 1,447.78n/a n/a 71.00 23,843.00n/a n/a n/a 4,491.00n/a n/a 1,680.16 1,552.22n/a n/a n/a 1,575.98n/a n/a 20.00 1,811.00n/a n/a n/a 341.00n/a n/a 1,890.91 1,777.67n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050234 85629NY0050234 Platinum Off Non-Standard 26 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,458.80 1,324.86n/a n/a n/a 1,324.86 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,590.03 1,444.04n/a n/a n/a 1,444.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,675.92 1,548.30n/a n/a n/a 1,572.00n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,886.10 1,773.15n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050235 85629NY0050235 Platinum Off Non-Standard 26 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,462.56 1,328.27n/a n/a n/a 1,328.27 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,594.15 1,447.78n/a n/a n/a 1,447.78n/a n/a 117.00 52,141.00n/a n/a n/a 3,619.00n/a n/a 1,680.16 1,552.22n/a n/a n/a 1,575.98n/a n/a 7.00 3,900.00n/a n/a n/a 309.00n/a n/a 1,890.91 1,777.67n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050236 85629NY0050236 Platinum Off Non-Standard 26 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,458.80 1,324.86n/a n/a n/a 1,324.86 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,590.03 1,444.04n/a n/a n/a 1,444.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,675.92 1,548.30n/a n/a n/a 1,572.00n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,886.10 1,773.15n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050237 85629NY0050237 Platinum Off Non-Standard 30 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,478.60 1,342.84n/a n/a n/a 1,342.84 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,611.73 1,463.75n/a n/a n/a 1,463.75n/a n/a 0.00 1,789.00n/a n/a n/a 317.00n/a n/a 1,698.27 1,568.95n/a n/a n/a 1,592.97n/a n/a 0.00 175.00n/a n/a n/a 32.00n/a n/a 1,911.45 1,796.98n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050238 85629NY0050238 Platinum Off Non-Standard 30 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,478.60 1,342.84n/a n/a n/a 1,342.84 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,611.73 1,463.75n/a n/a n/a 1,463.75n/a n/a 0.00 4,267.00n/a n/a n/a 931.00n/a n/a 1,698.27 1,568.95n/a n/a n/a 1,592.97n/a n/a 0.00 396.00n/a n/a n/a 121.00n/a n/a 1,911.45 1,796.98n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050239 85629NY0050239 Platinum Off Non-Standard 30 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,474.84 1,339.43n/a n/a n/a 1,339.43 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,607.61 1,460.01n/a n/a n/a 1,460.01n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,694.03 1,565.03n/a n/a n/a 1,588.99n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,906.64 1,792.46n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050240 85629NY0050240 Platinum Off Non-Standard 30 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,474.84 1,339.43n/a n/a n/a 1,339.43 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,607.61 1,460.01n/a n/a n/a 1,460.01n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,694.03 1,565.03n/a n/a n/a 1,588.99n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,906.64 1,792.46n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010336 85629NY0010336 Platinum Off Non-Standard 26 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,219.18 1,107.23n/a n/a n/a 1,107.23 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,336.64 1,213.92n/a n/a n/a 1,213.92n/a n/a 964.00 61,417.00n/a n/a n/a 21,574.00n/a n/a 1,383.53 1,278.18n/a n/a n/a 1,297.74n/a n/a 63.00 4,463.00n/a n/a n/a 1,572.00n/a n/a 1,538.94 1,446.78n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010213 85629NY0010213 Platinum Off Non-Standard 26 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,215.42 1,103.82n/a n/a n/a 1,103.82 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,332.52 1,210.18n/a n/a n/a 1,210.18n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,379.29 1,274.26n/a n/a n/a 1,293.76n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,534.13 1,442.26n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010341 85629NY0010341 Platinum Off Non-Standard 26 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,219.18 1,107.23n/a n/a n/a 1,107.23 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,336.64 1,213.92n/a n/a n/a 1,213.92n/a n/a 283.00 75,753.00n/a n/a n/a 19,229.00n/a n/a 1,383.53 1,278.18n/a n/a n/a 1,297.74n/a n/a 10.00 5,349.00n/a n/a n/a 1,353.00n/a n/a 1,538.94 1,446.78n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010214 85629NY0010214 Platinum Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,215.42 1,103.82n/a n/a n/a 1,103.82 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,332.52 1,210.18n/a n/a n/a 1,210.18n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,379.29 1,274.26n/a n/a n/a 1,293.76n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,534.13 1,442.26n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010342 85629NY0010342 Platinum Off Non-Standard 30 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,235.22 1,121.80n/a n/a n/a 1,121.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,354.22 1,229.89n/a n/a n/a 1,229.89n/a n/a 63.00 9,199.00n/a n/a n/a 2,533.00n/a n/a 1,401.64 1,294.91n/a n/a n/a 1,314.73n/a n/a 19.00 794.00n/a n/a n/a 196.00n/a n/a 1,559.48 1,466.09n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010340 85629NY0010340 Platinum Off Non-Standard 30 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 1,235.22 1,121.80n/a n/a n/a 1,121.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,354.22 1,229.89n/a n/a n/a 1,229.89n/a n/a 168.00 10,079.00n/a n/a n/a 1,792.00n/a n/a 1,401.64 1,294.91n/a n/a n/a 1,314.73n/a n/a 14.00 750.00n/a n/a n/a 136.00n/a n/a 1,559.48 1,466.09n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010215 85629NY0010215 Platinum Off Non-Standard 30 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,231.46 1,118.39n/a n/a n/a 1,118.39 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,350.10 1,226.15n/a n/a n/a 1,226.15n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,397.40 1,290.99n/a n/a n/a 1,310.75n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,554.67 1,461.57n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010216 85629NY0010216 Platinum Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 1,231.46 1,118.39n/a n/a n/a 1,118.39 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,350.10 1,226.15n/a n/a n/a 1,226.15n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,397.40 1,290.99n/a n/a n/a 1,310.75n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,554.67 1,461.57n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050012 85629NY0050012 Platinum Off Non-Standard 26 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,296.42 1,177.38n/a n/a n/a 1,177.38 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,416.40 1,286.35n/a n/a n/a 1,286.35n/a n/a 1,695.00 164,858.00n/a n/a n/a 35,552.00n/a n/a 1,436.87 1,327.47n/a n/a n/a 1,347.78n/a n/a 147.00 12,165.00n/a n/a n/a 2,659.00n/a n/a 1,601.77 1,505.85n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050177 85629NY0050177 Platinum Off Non-Standard 26 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,292.66 1,173.97n/a n/a n/a 1,173.97 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,412.28 1,282.61n/a n/a n/a 1,282.61n/a n/a 0.00 4.00 n/a n/a n/a 0.00 n/a n/a 1,432.63 1,323.55n/a n/a n/a 1,343.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,596.96 1,501.33n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050010 85629NY0050010 Platinum Off Non-Standard 26 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,296.42 1,177.38n/a n/a n/a 1,177.38 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,416.40 1,286.35n/a n/a n/a 1,286.35n/a n/a 1,246.00 186,110.00n/a n/a n/a 23,980.00n/a n/a 1,436.87 1,327.47n/a n/a n/a 1,347.78n/a n/a 111.00 13,904.00n/a n/a n/a 1,871.00n/a n/a 1,601.77 1,505.85n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050178 85629NY0050178 Platinum Off Non-Standard 26 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,292.66 1,173.97n/a n/a n/a 1,173.97 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,412.28 1,282.61n/a n/a n/a 1,282.61n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,432.63 1,323.55n/a n/a n/a 1,343.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,596.96 1,501.33n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050011 85629NY0050011 Platinum Off Non-Standard 30 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,312.46 1,191.95n/a n/a n/a 1,191.95 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,433.98 1,302.32n/a n/a n/a 1,302.32n/a n/a 475.00 30,231.00n/a n/a n/a 6,730.00n/a n/a 1,454.98 1,344.20n/a n/a n/a 1,364.77n/a n/a 29.00 2,324.00n/a n/a n/a 503.00n/a n/a 1,622.31 1,525.16n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050009 85629NY0050009 Platinum Off Non-Standard 30 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,312.46 1,191.95n/a n/a n/a 1,191.95 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,433.98 1,302.32n/a n/a n/a 1,302.32n/a n/a 524.00 31,879.00n/a n/a n/a 5,104.00n/a n/a 1,454.98 1,344.20n/a n/a n/a 1,364.77n/a n/a 15.00 2,478.00n/a n/a n/a 385.00n/a n/a 1,622.31 1,525.16n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050179 85629NY0050179 Platinum Off Non-Standard 30 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,308.70 1,188.54n/a n/a n/a 1,188.54 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,429.86 1,298.58n/a n/a n/a 1,298.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,450.74 1,340.28n/a n/a n/a 1,360.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,617.50 1,520.64n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050180 85629NY0050180 Platinum Off Non-Standard 30 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 1,308.70 1,188.54n/a n/a n/a 1,188.54 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,429.86 1,298.58n/a n/a n/a 1,298.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,450.74 1,340.28n/a n/a n/a 1,360.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,617.50 1,520.64n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010272 85629NY0010272 Silver Off Non-Standard 26 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 812.77 738.14n/a n/a n/a 738.14 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 895.24 813.04n/a n/a n/a 813.04n/a n/a 1,233.00 25,333.00n/a n/a n/a 11,323.00n/a n/a 919.64 849.62n/a n/a n/a 862.63n/a n/a 95.00 1,940.00n/a n/a n/a 826.00n/a n/a 1,057.11 993.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010277 85629NY0010277 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 809.01 734.73n/a n/a n/a 734.73 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 891.12 809.30n/a n/a n/a 809.30n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 915.40 845.70n/a n/a n/a 858.65n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,052.30 989.28n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010270 85629NY0010270 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 812.77 738.14n/a n/a n/a 738.14 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 895.24 813.04n/a n/a n/a 813.04n/a n/a 156.00 28,655.00n/a n/a n/a 8,380.00n/a n/a 919.64 849.62n/a n/a n/a 862.63n/a n/a 10.00 2,216.00n/a n/a n/a 614.00n/a n/a 1,057.11 993.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010278 85629NY0010278 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 809.01 734.73n/a n/a n/a 734.73 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 891.12 809.30n/a n/a n/a 809.30n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 915.40 845.70n/a n/a n/a 858.65n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,052.30 989.28n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010269 85629NY0010269 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 828.81 752.71n/a n/a n/a 752.71 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 912.82 829.01n/a n/a n/a 829.01n/a n/a 216.00 1,041.00n/a n/a n/a 486.00n/a n/a 937.75 866.35n/a n/a n/a 879.62n/a n/a 12.00 82.00n/a n/a n/a 40.00n/a n/a 1,077.65 1,013.11n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010271 85629NY0010271 Silver Off Non-Standard 30 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 828.81 752.71n/a n/a n/a 752.71 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 912.82 829.01n/a n/a n/a 829.01n/a n/a 0.00 4,650.00n/a n/a n/a 1,898.00n/a n/a 937.75 866.35n/a n/a n/a 879.62n/a n/a 0.00 303.00n/a n/a n/a 130.00n/a n/a 1,077.65 1,013.11n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010279 85629NY0010279 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 825.05 749.30n/a n/a n/a 749.30 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 908.70 825.27n/a n/a n/a 825.27n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 933.51 862.43n/a n/a n/a 875.64n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,072.84 1,008.59n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010280 85629NY0010280 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 825.05 749.30n/a n/a n/a 749.30 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 908.70 825.27n/a n/a n/a 825.27n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 933.51 862.43n/a n/a n/a 875.64n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,072.84 1,008.59n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010288 85629NY0010288 Silver Off Non-Standard 26 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 843.70 766.23n/a n/a n/a 766.23 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 916.45 832.30n/a n/a n/a 832.30n/a n/a 341.00 27,666.00n/a n/a n/a 8,809.00n/a n/a 942.31 870.55n/a n/a n/a 883.87n/a n/a 28.00 1,785.00n/a n/a n/a 716.00n/a n/a 1,076.91 1,012.42n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010296 85629NY0010296 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 839.94 762.82n/a n/a n/a 762.82 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 912.33 828.56n/a n/a n/a 828.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 938.07 866.63n/a n/a n/a 879.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,072.10 1,007.90n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010186 85629NY0010186 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 843.70 766.23n/a n/a n/a 766.23 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 916.45 832.30n/a n/a n/a 832.30n/a n/a 373.00 30,779.00n/a n/a n/a 7,206.00n/a n/a 942.31 870.55n/a n/a n/a 883.87n/a n/a 20.00 2,062.00n/a n/a n/a 492.00n/a n/a 1,076.91 1,012.42n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010297 85629NY0010297 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 839.94 762.82n/a n/a n/a 762.82 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 912.33 828.56n/a n/a n/a 828.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 938.07 866.63n/a n/a n/a 879.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,072.10 1,007.90n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010287 85629NY0010287 Silver Off Non-Standard 30 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 859.74 780.80n/a n/a n/a 780.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 934.03 848.27n/a n/a n/a 848.27n/a n/a 0.00 2,457.00n/a n/a n/a 463.00n/a n/a 960.42 887.28n/a n/a n/a 900.86n/a n/a 0.00 157.00n/a n/a n/a 51.00n/a n/a 1,097.45 1,031.73n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010334 85629NY0010334 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a 859.74 780.80n/a n/a n/a 780.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 934.03 848.27n/a n/a n/a 848.27n/a n/a 0.00 2,325.00n/a n/a n/a 701.00n/a n/a 960.42 887.28n/a n/a n/a 900.86n/a n/a 0.00 163.00n/a n/a n/a 32.00n/a n/a 1,097.45 1,031.73n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010298 85629NY0010298 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 855.98 777.39n/a n/a n/a 777.39 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 929.91 844.53n/a n/a n/a 844.53n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 956.18 883.36n/a n/a n/a 896.88n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,092.64 1,027.21n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010299 85629NY0010299 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a 855.98 777.39n/a n/a n/a 777.39 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 929.91 844.53n/a n/a n/a 844.53n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 956.18 883.36n/a n/a n/a 896.88n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,092.64 1,027.21n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050108 85629NY0050108 Silver Off Non-Standard 26 No Included Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 903.69 820.71n/a n/a n/a 820.71 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 977.84 888.06n/a n/a n/a 888.06n/a n/a 478.00 38,977.00n/a n/a n/a 8,186.00n/a n/a 983.06 908.21n/a n/a n/a 922.11n/a n/a 43.00 2,929.00n/a n/a n/a 596.00n/a n/a 1,120.68 1,053.57n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050008 85629NY0050008 Silver Off Non-Standard 26 No Excluded Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 899.93 817.30n/a n/a n/a 817.30 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 973.72 884.32n/a n/a n/a 884.32n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 978.82 904.29n/a n/a n/a 918.13n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,115.87 1,049.05n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050106 85629NY0050106 Silver Off Non-Standard 26 Yes Included Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 903.69 820.71n/a n/a n/a 820.71 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 977.84 888.06n/a n/a n/a 888.06n/a n/a 629.00 53,082.00n/a n/a n/a 7,285.00n/a n/a 983.06 908.21n/a n/a n/a 922.11n/a n/a 38.00 4,335.00n/a n/a n/a 543.00n/a n/a 1,120.68 1,053.57n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050018 85629NY0050018 Silver Off Non-Standard 26 Yes Excluded Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 899.93 817.30n/a n/a n/a 817.30 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 973.72 884.32n/a n/a n/a 884.32n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 978.82 904.29n/a n/a n/a 918.13n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,115.87 1,049.05n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050107 85629NY0050107 Silver Off Non-Standard 30 No Included Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 919.73 835.28n/a n/a n/a 835.28 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 995.42 904.03n/a n/a n/a 904.03n/a n/a 401.00 4,136.00n/a n/a n/a 1,298.00n/a n/a 1,001.17 924.94n/a n/a n/a 939.10n/a n/a 26.00 360.00n/a n/a n/a 98.00n/a n/a 1,141.22 1,072.88n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050105 85629NY0050105 Silver Off Non-Standard 30 Yes Included Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 919.73 835.28n/a n/a n/a 835.28 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 995.42 904.03n/a n/a n/a 904.03n/a n/a 0.00 7,144.00n/a n/a n/a 942.00n/a n/a 1,001.17 924.94n/a n/a n/a 939.10n/a n/a 0.00 556.00n/a n/a n/a 82.00n/a n/a 1,141.22 1,072.88n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050019 85629NY0050019 Silver Off Non-Standard 30 No Excluded Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 915.97 831.87n/a n/a n/a 831.87 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 991.30 900.29n/a n/a n/a 900.29n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 996.93 921.02n/a n/a n/a 935.12n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,136.41 1,068.36n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050020 85629NY0050020 Silver Off Non-Standard 30 Yes Excluded Yes Yes Yes No No No Yes 0112 Freedom n/a n/a 915.97 831.87n/a n/a n/a 831.87 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 991.30 900.29n/a n/a n/a 900.29n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 996.93 921.02n/a n/a n/a 935.12n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,136.41 1,068.36n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010300 85629NY0010300 Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 848.89 770.95n/a n/a n/a 770.95 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 907.53 824.21n/a n/a n/a 824.21n/a n/a 2,280.00 115,550.00n/a n/a n/a 32,914.00n/a n/a 932.72 861.70n/a n/a n/a 874.88n/a n/a 159.00 8,586.00n/a n/a n/a 2,403.00n/a n/a 1,065.75 1,001.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010312 85629NY0010312 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 845.13 767.54n/a n/a n/a 767.54 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 903.41 820.47n/a n/a n/a 820.47n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 928.48 857.78n/a n/a n/a 870.90n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,060.94 997.41n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010294 85629NY0010294 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 848.89 770.95n/a n/a n/a 770.95 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 907.53 824.21n/a n/a n/a 824.21n/a n/a 1,619.00 124,536.00n/a n/a n/a 35,840.00n/a n/a 932.72 861.70n/a n/a n/a 874.88n/a n/a 102.00 9,343.00n/a n/a n/a 2,746.00n/a n/a 1,065.75 1,001.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010313 85629NY0010313 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 845.13 767.54n/a n/a n/a 767.54 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 903.41 820.47n/a n/a n/a 820.47n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 928.48 857.78n/a n/a n/a 870.90n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,060.94 997.41n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010295 85629NY0010295 Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0112 Freedom n/a n/a 864.93 785.52n/a n/a n/a 785.52 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 925.11 840.18n/a n/a n/a 840.18n/a n/a 217.00 11,858.00n/a n/a n/a 2,934.00n/a n/a 950.83 878.43n/a n/a n/a 891.87n/a n/a 23.00 959.00n/a n/a n/a 265.00n/a n/a 1,086.29 1,021.24n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010293 85629NY0010293 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a 864.93 785.52n/a n/a n/a 785.52 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 925.11 840.18n/a n/a n/a 840.18n/a n/a 116.00 4,578.00n/a n/a n/a 3,168.00n/a n/a 950.83 878.43n/a n/a n/a 891.87n/a n/a 10.00 329.00n/a n/a n/a 225.00n/a n/a 1,086.29 1,021.24n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010314 85629NY0010314 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 861.17 782.11n/a n/a n/a 782.11 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 920.99 836.44n/a n/a n/a 836.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 946.59 874.51n/a n/a n/a 887.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,081.48 1,016.72n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010315 85629NY0010315 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a 861.17 782.11n/a n/a n/a 782.11 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 920.99 836.44n/a n/a n/a 836.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 946.59 874.51n/a n/a n/a 887.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,081.48 1,016.72n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050132 85629NY0050132 Silver Off Non-Standard 26 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 911.83 828.10n/a n/a n/a 828.10 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 971.95 882.72n/a n/a n/a 882.72n/a n/a 606.00 32,599.00n/a n/a n/a 4,346.00n/a n/a 976.97 902.58n/a n/a n/a 916.39n/a n/a 55.00 2,722.00n/a n/a n/a 397.00n/a n/a 1,117.77 1,050.84n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050033 85629NY0050033 Silver Off Non-Standard 26 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 908.07 824.69n/a n/a n/a 824.69 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 967.83 878.98n/a n/a n/a 878.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 972.73 898.66n/a n/a n/a 912.41n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,112.96 1,046.32n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050130 85629NY0050130 Silver Off Non-Standard 26 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 911.83 828.10n/a n/a n/a 828.10 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 971.95 882.72n/a n/a n/a 882.72n/a n/a 264.00 55,211.00n/a n/a n/a 7,856.00n/a n/a 976.97 902.58n/a n/a n/a 916.39n/a n/a 26.00 4,580.00n/a n/a n/a 601.00n/a n/a 1,117.77 1,050.84n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050034 85629NY0050034 Silver Off Non-Standard 26 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 908.07 824.69n/a n/a n/a 824.69 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 967.83 878.98n/a n/a n/a 878.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 972.73 898.66n/a n/a n/a 912.41n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,112.96 1,046.32n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050131 85629NY0050131 Silver Off Non-Standard 30 No Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 927.87 842.67n/a n/a n/a 842.67 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 989.53 898.69n/a n/a n/a 898.69n/a n/a 24.00 5,187.00n/a n/a n/a 441.00n/a n/a 995.08 919.31n/a n/a n/a 933.38n/a n/a 2.00 445.00n/a n/a n/a 46.00n/a n/a 1,138.31 1,070.15n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050129 85629NY0050129 Silver Off Non-Standard 30 Yes Included Yes Yes Yes No No No No 0112 Freedom n/a n/a 927.87 842.67n/a n/a n/a 842.67 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 989.53 898.69n/a n/a n/a 898.69n/a n/a 0.00 4,223.00n/a n/a n/a 875.00n/a n/a 995.08 919.31n/a n/a n/a 933.38n/a n/a 0.00 342.00n/a n/a n/a 114.00n/a n/a 1,138.31 1,070.15n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050035 85629NY0050035 Silver Off Non-Standard 30 No Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 924.11 839.26n/a n/a n/a 839.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 985.41 894.95n/a n/a n/a 894.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 990.84 915.39n/a n/a n/a 929.40n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,133.50 1,065.63n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050036 85629NY0050036 Silver Off Non-Standard 30 Yes Excluded Yes Yes Yes No No No No 0112 Freedom n/a n/a 924.11 839.26n/a n/a n/a 839.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 985.41 894.95n/a n/a n/a 894.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 990.84 915.39n/a n/a n/a 929.40n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,133.50 1,065.63n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010629 85629NY0010629 Bronze Off Non-Standard 26 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 673.40 611.57n/a n/a n/a 611.57 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 723.27 656.85n/a n/a n/a 656.85n/a n/a 63.00 12,192.00n/a n/a n/a 3,054.00n/a n/a 742.82 686.26n/a n/a n/a 696.76n/a n/a 4.00 1,441.00n/a n/a n/a 514.00n/a n/a 887.86 834.69n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010630 85629NY0010630 Bronze Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 669.64 608.16n/a n/a n/a 608.16 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 719.15 653.11n/a n/a n/a 653.11n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 738.58 682.34n/a n/a n/a 692.78n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 883.05 830.17n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010631 85629NY0010631 Bronze Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 673.40 611.57n/a n/a n/a 611.57 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 723.27 656.85n/a n/a n/a 656.85n/a n/a 54.00 16,434.00n/a n/a n/a 4,916.00n/a n/a 742.82 686.26n/a n/a n/a 696.76n/a n/a 5.00 1,848.00n/a n/a n/a 706.00n/a n/a 887.86 834.69n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010632 85629NY0010632 Bronze Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 669.64 608.16n/a n/a n/a 608.16 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 719.15 653.11n/a n/a n/a 653.11n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 738.58 682.34n/a n/a n/a 692.78n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 883.05 830.17n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010633 85629NY0010633 Bronze Off Non-Standard 30 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 689.44 626.14n/a n/a n/a 626.14 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 740.85 672.82n/a n/a n/a 672.82n/a n/a 0.00 356.00n/a n/a n/a 294.00n/a n/a 760.93 702.99n/a n/a n/a 713.75n/a n/a 0.00 57.00n/a n/a n/a 43.00n/a n/a 908.40 854.00n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010634 85629NY0010634 Bronze Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 689.44 626.14n/a n/a n/a 626.14 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 740.85 672.82n/a n/a n/a 672.82n/a n/a 0.00 358.00n/a n/a n/a 36.00n/a n/a 760.93 702.99n/a n/a n/a 713.75n/a n/a 0.00 31.00n/a n/a n/a 30.00n/a n/a 908.40 854.00n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010635 85629NY0010635 Bronze Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 685.68 622.73n/a n/a n/a 622.73 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 736.73 669.08n/a n/a n/a 669.08n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 756.69 699.07n/a n/a n/a 709.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 903.59 849.48n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010636 85629NY0010636 Bronze Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 685.68 622.73n/a n/a n/a 622.73 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 736.73 669.08n/a n/a n/a 669.08n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 756.69 699.07n/a n/a n/a 709.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 903.59 849.48n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050225 85629NY0050225 Bronze Off Non-Standard 26 No Included Yes Yes Yes No No No Yes 0076 Liberty n/a n/a 695.64 631.78n/a n/a n/a 631.78 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 761.62 691.69n/a n/a n/a 691.69n/a n/a 131.00 4,738.00n/a n/a n/a 794.00n/a n/a 780.16 720.75n/a n/a n/a 731.79n/a n/a 9.00 378.00n/a n/a n/a 46.00n/a n/a 925.66 870.23n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050226 85629NY0050226 Bronze Off Non-Standard 26 No Excluded Yes Yes Yes No No No Yes 0076 Liberty n/a n/a 691.88 628.37n/a n/a n/a 628.37 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 757.50 687.95n/a n/a n/a 687.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 775.92 716.83n/a n/a n/a 727.81n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 920.85 865.71n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050227 85629NY0050227 Bronze Off Non-Standard 26 Yes Included Yes Yes Yes No No No Yes 0076 Liberty n/a n/a 695.64 631.78n/a n/a n/a 631.78 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 761.62 691.69n/a n/a n/a 691.69n/a n/a 130.00 4,980.00n/a n/a n/a 513.00n/a n/a 780.16 720.75n/a n/a n/a 731.79n/a n/a 12.00 566.00n/a n/a n/a 38.00n/a n/a 925.66 870.23n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050228 85629NY0050228 Bronze Off Non-Standard 26 Yes Excluded Yes Yes Yes No No No Yes 0076 Liberty n/a n/a 691.88 628.37n/a n/a n/a 628.37 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 757.50 687.95n/a n/a n/a 687.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 775.92 716.83n/a n/a n/a 727.81n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 920.85 865.71n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050229 85629NY0050229 Bronze Off Non-Standard 30 No Included Yes Yes Yes No No No Yes 0076 Liberty n/a n/a 711.68 646.35n/a n/a n/a 646.35 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 779.20 707.66n/a n/a n/a 707.66n/a n/a 0.00 353.00n/a n/a n/a 155.00n/a n/a 798.27 737.48n/a n/a n/a 748.78n/a n/a 0.00 31.00n/a n/a n/a 30.00n/a n/a 946.20 889.54n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050230 85629NY0050230 Bronze Off Non-Standard 30 Yes Included Yes Yes Yes No No No Yes 0076 Liberty n/a n/a 711.68 646.35n/a n/a n/a 646.35 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 779.20 707.66n/a n/a n/a 707.66n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 798.27 737.48n/a n/a n/a 748.78n/a n/a 0.00 2.00 n/a n/a n/a 0.00 n/a n/a 946.20 889.54n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050231 85629NY0050231 Bronze Off Non-Standard 30 No Excluded Yes Yes Yes No No No Yes 0076 Liberty n/a n/a 707.92 642.94n/a n/a n/a 642.94 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 775.08 703.92n/a n/a n/a 703.92n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 794.03 733.56n/a n/a n/a 744.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 941.39 885.02n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050232 85629NY0050232 Bronze Off Non-Standard 30 Yes Excluded Yes Yes Yes No No No Yes 0076 Liberty n/a n/a 707.92 642.94n/a n/a n/a 642.94 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 775.08 703.92n/a n/a n/a 703.92n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 794.03 733.56n/a n/a n/a 744.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 941.39 885.02n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010557 85629NY0010557 Bronze Off Non-Standard 26 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 643.87 584.75n/a n/a n/a 584.75 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 700.61 636.29n/a n/a n/a 636.29n/a n/a 185.00 25,819.00n/a n/a n/a 13,222.00n/a n/a 741.35 684.91n/a n/a n/a 695.38n/a n/a 17.00 2,529.00n/a n/a n/a 1,316.00n/a n/a 887.19 834.06n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010558 85629NY0010558 Bronze Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 640.11 581.34n/a n/a n/a 581.34 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 696.49 632.55n/a n/a n/a 632.55n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 737.11 680.99n/a n/a n/a 691.40n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 882.38 829.54n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010559 85629NY0010559 Bronze Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 643.87 584.75n/a n/a n/a 584.75 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 700.61 636.29n/a n/a n/a 636.29n/a n/a 719.00 33,258.00n/a n/a n/a 23,679.00n/a n/a 741.35 684.91n/a n/a n/a 695.38n/a n/a 31.00 2,994.00n/a n/a n/a 2,135.00n/a n/a 887.19 834.06n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010560 85629NY0010560 Bronze Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 640.11 581.34n/a n/a n/a 581.34 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 696.49 632.55n/a n/a n/a 632.55n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 737.11 680.99n/a n/a n/a 691.40n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 882.38 829.54n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010561 85629NY0010561 Bronze Off Non-Standard 30 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 659.91 599.32n/a n/a n/a 599.32 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 718.19 652.26n/a n/a n/a 652.26n/a n/a 50.00 755.00n/a n/a n/a 1,076.00n/a n/a 759.46 701.64n/a n/a n/a 712.37n/a n/a 5.00 70.00n/a n/a n/a 108.00n/a n/a 907.73 853.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010562 85629NY0010562 Bronze Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 659.91 599.32n/a n/a n/a 599.32 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 718.19 652.26n/a n/a n/a 652.26n/a n/a 0.00 1,460.00n/a n/a n/a 498.00n/a n/a 759.46 701.64n/a n/a n/a 712.37n/a n/a 0.00 131.00n/a n/a n/a 38.00n/a n/a 907.73 853.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010563 85629NY0010563 Bronze Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 656.15 595.91n/a n/a n/a 595.91 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 714.07 648.52n/a n/a n/a 648.52n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 755.22 697.72n/a n/a n/a 708.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 902.92 848.85n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010564 85629NY0010564 Bronze Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 656.15 595.91n/a n/a n/a 595.91 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 714.07 648.52n/a n/a n/a 648.52n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 755.22 697.72n/a n/a n/a 708.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 902.92 848.85n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010429 85629NY0010429 Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 905.25 822.12n/a n/a n/a 822.12 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,003.69 911.54n/a n/a n/a 911.54n/a n/a 1,815.00 181,063.00n/a n/a n/a 91,009.00n/a n/a 1,050.08 970.12n/a n/a n/a 984.97n/a n/a 101.00 13,285.00n/a n/a n/a 6,612.00n/a n/a 1,175.73 1,105.33n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010430 85629NY0010430 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 901.49 818.71n/a n/a n/a 818.71 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 999.57 907.80n/a n/a n/a 907.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,045.84 966.20n/a n/a n/a 980.99n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,170.92 1,100.81n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010431 85629NY0010431 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 905.25 822.12n/a n/a n/a 822.12 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,003.69 911.54n/a n/a n/a 911.54n/a n/a 564.00 187,907.00n/a n/a n/a 78,161.00n/a n/a 1,050.08 970.12n/a n/a n/a 984.97n/a n/a 39.00 12,357.00n/a n/a n/a 5,202.00n/a n/a 1,175.73 1,105.33n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010432 85629NY0010432 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 901.49 818.71n/a n/a n/a 818.71 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 999.57 907.80n/a n/a n/a 907.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,045.84 966.20n/a n/a n/a 980.99n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,170.92 1,100.81n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010433 85629NY0010433 Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 921.29 836.69n/a n/a n/a 836.69 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,021.27 927.51n/a n/a n/a 927.51n/a n/a 249.00 14,532.00n/a n/a n/a 10,091.00n/a n/a 1,068.19 986.85n/a n/a n/a 1,001.96n/a n/a 26.00 1,116.00n/a n/a n/a 738.00n/a n/a 1,196.27 1,124.64n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010434 85629NY0010434 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 921.29 836.69n/a n/a n/a 836.69 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,021.27 927.51n/a n/a n/a 927.51n/a n/a 32.00 12,763.00n/a n/a n/a 7,072.00n/a n/a 1,068.19 986.85n/a n/a n/a 1,001.96n/a n/a 9.00 927.00n/a n/a n/a 612.00n/a n/a 1,196.27 1,124.64n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010435 85629NY0010435 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 917.53 833.28n/a n/a n/a 833.28 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,017.15 923.77n/a n/a n/a 923.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,063.95 982.93n/a n/a n/a 997.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,191.46 1,120.12n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010436 85629NY0010436 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 917.53 833.28n/a n/a n/a 833.28 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,017.15 923.77n/a n/a n/a 923.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,063.95 982.93n/a n/a n/a 997.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,191.46 1,120.12n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010717 85629NY0010717 Gold Off Non-Standard 26 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,010.20 933.28n/a n/a n/a 947.57n/a n/a 0.00 29.00n/a n/a n/a 1.00 n/a n/a 1,146.71 1,078.04n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010718 85629NY0010718 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,005.96 929.36n/a n/a n/a 943.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,141.90 1,073.52n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010719 85629NY0010719 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,010.20 933.28n/a n/a n/a 947.57n/a n/a 0.00 34.00n/a n/a n/a 53.00n/a n/a 1,146.71 1,078.04n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010720 85629NY0010720 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,005.96 929.36n/a n/a n/a 943.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,141.90 1,073.52n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010721 85629NY0010721 Gold Off Non-Standard 30 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,028.31 950.01n/a n/a n/a 964.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,167.25 1,097.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010722 85629NY0010722 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,028.31 950.01n/a n/a n/a 964.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,167.25 1,097.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010723 85629NY0010723 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,024.07 946.09n/a n/a n/a 960.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,162.44 1,092.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010724 85629NY0010724 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,024.07 946.09n/a n/a n/a 960.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,162.44 1,092.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010693 85629NY0010693 Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,073.32 974.77n/a n/a n/a 974.77n/a n/a 366.00 11,791.00n/a n/a n/a 6,607.00n/a n/a 1,139.98 1,053.18n/a n/a n/a 1,069.30n/a n/a 66.00 1,979.00n/a n/a n/a 861.00n/a n/a 1,284.81 1,207.88n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010694 85629NY0010694 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,069.20 971.03n/a n/a n/a 971.03n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,135.74 1,049.26n/a n/a n/a 1,065.32n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,280.00 1,203.36n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010695 85629NY0010695 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,073.32 974.77n/a n/a n/a 974.77n/a n/a 124.00 18,755.00n/a n/a n/a 6,483.00n/a n/a 1,139.98 1,053.18n/a n/a n/a 1,069.30n/a n/a 23.00 2,667.00n/a n/a n/a 957.00n/a n/a 1,284.81 1,207.88n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010696 85629NY0010696 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,069.20 971.03n/a n/a n/a 971.03n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,135.74 1,049.26n/a n/a n/a 1,065.32n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,280.00 1,203.36n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010697 85629NY0010697 Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,090.90 990.74n/a n/a n/a 990.74n/a n/a 0.00 1,097.00n/a n/a n/a 502.00n/a n/a 1,158.09 1,069.91n/a n/a n/a 1,086.29n/a n/a 0.00 214.00n/a n/a n/a 88.00n/a n/a 1,305.35 1,227.19n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010698 85629NY0010698 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,090.90 990.74n/a n/a n/a 990.74n/a n/a 2.00 957.00n/a n/a n/a 531.00n/a n/a 1,158.09 1,069.91n/a n/a n/a 1,086.29n/a n/a 1.00 209.00n/a n/a n/a 77.00n/a n/a 1,305.35 1,227.19n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010699 85629NY0010699 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,086.78 987.00n/a n/a n/a 987.00n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,153.85 1,065.99n/a n/a n/a 1,082.31n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,300.54 1,222.67n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010700 85629NY0010700 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,086.78 987.00n/a n/a n/a 987.00n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,153.85 1,065.99n/a n/a n/a 1,082.31n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,300.54 1,222.67n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010605 85629NY0010605 Platinum Off Non-Standard 26 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 1,032.36 937.57n/a n/a n/a 937.57 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,134.37 1,030.21n/a n/a n/a 1,030.21n/a n/a 10.00 3,561.00n/a n/a n/a 816.00n/a n/a 1,166.07 1,077.28n/a n/a n/a 1,093.76n/a n/a 5.00 261.00n/a n/a n/a 58.00n/a n/a 1,307.49 1,229.20n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010606 85629NY0010606 Platinum Off Non-Standard 26 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 1,028.60 934.16n/a n/a n/a 934.16 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,130.25 1,026.47n/a n/a n/a 1,026.47n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,161.83 1,073.36n/a n/a n/a 1,089.78n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,302.68 1,224.68n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010607 85629NY0010607 Platinum Off Non-Standard 26 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 1,032.36 937.57n/a n/a n/a 937.57 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,134.37 1,030.21n/a n/a n/a 1,030.21n/a n/a 252.00 7,197.00n/a n/a n/a 614.00n/a n/a 1,166.07 1,077.28n/a n/a n/a 1,093.76n/a n/a 23.00 240.00n/a n/a n/a 49.00n/a n/a 1,307.49 1,229.20n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010608 85629NY0010608 Platinum Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 1,028.60 934.16n/a n/a n/a 934.16 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,130.25 1,026.47n/a n/a n/a 1,026.47n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,161.83 1,073.36n/a n/a n/a 1,089.78n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,302.68 1,224.68n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010609 85629NY0010609 Platinum Off Non-Standard 30 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 1,048.40 952.14n/a n/a n/a 952.14 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,151.95 1,046.18n/a n/a n/a 1,046.18n/a n/a 0.00 121.00n/a n/a n/a 116.00n/a n/a 1,184.18 1,094.01n/a n/a n/a 1,110.75n/a n/a 0.00 6.00 n/a n/a n/a 5.00 n/a n/a 1,328.03 1,248.51n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010610 85629NY0010610 Platinum Off Non-Standard 30 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 1,048.40 952.14n/a n/a n/a 952.14 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,151.95 1,046.18n/a n/a n/a 1,046.18n/a n/a 0.00 128.00n/a n/a n/a 24.00n/a n/a 1,184.18 1,094.01n/a n/a n/a 1,110.75n/a n/a 0.00 24.00n/a n/a n/a 2.00 n/a n/a 1,328.03 1,248.51n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010611 85629NY0010611 Platinum Off Non-Standard 30 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 1,044.64 948.73n/a n/a n/a 948.73 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,147.83 1,042.44n/a n/a n/a 1,042.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,179.94 1,090.09n/a n/a n/a 1,106.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,323.22 1,243.99n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010612 85629NY0010612 Platinum Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 1,044.64 948.73n/a n/a n/a 948.73 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,147.83 1,042.44n/a n/a n/a 1,042.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,179.94 1,090.09n/a n/a n/a 1,106.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,323.22 1,243.99n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010445 85629NY0010445 Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 737.25 669.56n/a n/a n/a 669.56 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 803.63 729.84n/a n/a n/a 729.84n/a n/a 609.00 31,659.00n/a n/a n/a 16,989.00n/a n/a 850.76 785.98n/a n/a n/a 798.00n/a n/a 50.00 2,348.00n/a n/a n/a 1,119.00n/a n/a 968.95 910.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010446 85629NY0010446 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 733.49 666.15n/a n/a n/a 666.15 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 799.51 726.10n/a n/a n/a 726.10n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 846.52 782.06n/a n/a n/a 794.02n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 964.14 906.41n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010447 85629NY0010447 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 737.25 669.56n/a n/a n/a 669.56 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 803.63 729.84n/a n/a n/a 729.84n/a n/a 1,196.00 29,581.00n/a n/a n/a 13,747.00n/a n/a 850.76 785.98n/a n/a n/a 798.00n/a n/a 97.00 2,026.00n/a n/a n/a 1,047.00n/a n/a 968.95 910.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010448 85629NY0010448 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 733.49 666.15n/a n/a n/a 666.15 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 799.51 726.10n/a n/a n/a 726.10n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 846.52 782.06n/a n/a n/a 794.02n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 964.14 906.41n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010449 85629NY0010449 Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 753.29 684.13n/a n/a n/a 684.13 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 821.21 745.81n/a n/a n/a 745.81n/a n/a 0.00 1,704.00n/a n/a n/a 930.00n/a n/a 868.87 802.71n/a n/a n/a 814.99n/a n/a 0.00 146.00n/a n/a n/a 64.00n/a n/a 989.49 930.24n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010450 85629NY0010450 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 753.29 684.13n/a n/a n/a 684.13 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 821.21 745.81n/a n/a n/a 745.81n/a n/a 272.00 733.00n/a n/a n/a 662.00n/a n/a 868.87 802.71n/a n/a n/a 814.99n/a n/a 23.00 53.00n/a n/a n/a 33.00n/a n/a 989.49 930.24n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010451 85629NY0010451 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 749.53 680.72n/a n/a n/a 680.72 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 817.09 742.07n/a n/a n/a 742.07n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 864.63 798.79n/a n/a n/a 811.01n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 984.68 925.72n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010452 85629NY0010452 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 749.53 680.72n/a n/a n/a 680.72 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 817.09 742.07n/a n/a n/a 742.07n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 864.63 798.79n/a n/a n/a 811.01n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 984.68 925.72n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010140 85629NY0010140 Silver Off Non-Standard 26 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 780.82 709.13n/a n/a n/a 709.13 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 847.72 769.88n/a n/a n/a 769.88n/a n/a 309.00 16,583.00n/a n/a n/a 6,473.00n/a n/a 874.64 808.04n/a n/a n/a 820.41n/a n/a 24.00 1,588.00n/a n/a n/a 661.00n/a n/a 1,007.70 947.36n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010181 85629NY0010181 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 777.06 705.72n/a n/a n/a 705.72 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 843.60 766.14n/a n/a n/a 766.14n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 870.40 804.12n/a n/a n/a 816.43n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,002.89 942.84n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010138 85629NY0010138 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 780.82 709.13n/a n/a n/a 709.13 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 847.72 769.88n/a n/a n/a 769.88n/a n/a 32.00 23,965.00n/a n/a n/a 9,513.00n/a n/a 874.64 808.04n/a n/a n/a 820.41n/a n/a 13.00 2,002.00n/a n/a n/a 891.00n/a n/a 1,007.70 947.36n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010182 85629NY0010182 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 777.06 705.72n/a n/a n/a 705.72 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 843.60 766.14n/a n/a n/a 766.14n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 870.40 804.12n/a n/a n/a 816.43n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,002.89 942.84n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010139 85629NY0010139 Silver Off Non-Standard 30 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 796.86 723.70n/a n/a n/a 723.70 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 865.30 785.85n/a n/a n/a 785.85n/a n/a 0.00 614.00n/a n/a n/a 1,368.00n/a n/a 892.75 824.77n/a n/a n/a 837.40n/a n/a 0.00 75.00n/a n/a n/a 97.00n/a n/a 1,028.24 966.67n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010137 85629NY0010137 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a 796.86 723.70n/a n/a n/a 723.70 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 865.30 785.85n/a n/a n/a 785.85n/a n/a 0.00 731.00n/a n/a n/a 55.00n/a n/a 892.75 824.77n/a n/a n/a 837.40n/a n/a 0.00 42.00n/a n/a n/a 12.00n/a n/a 1,028.24 966.67n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010183 85629NY0010183 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 793.10 720.29n/a n/a n/a 720.29 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 861.18 782.11n/a n/a n/a 782.11n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 888.51 820.85n/a n/a n/a 833.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,023.43 962.15n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010184 85629NY0010184 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a 793.10 720.29n/a n/a n/a 720.29 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 861.18 782.11n/a n/a n/a 782.11n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 888.51 820.85n/a n/a n/a 833.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,023.43 962.15n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010517 85629NY0010517 Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 756.50 687.04n/a n/a n/a 687.04 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 817.26 742.21n/a n/a n/a 742.21n/a n/a 1,284.00 55,017.00n/a n/a n/a 22,539.00n/a n/a 856.35 791.14n/a n/a n/a 803.25n/a n/a 115.00 3,878.00n/a n/a n/a 1,906.00n/a n/a 987.64 928.50n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010518 85629NY0010518 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 752.74 683.63n/a n/a n/a 683.63 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 813.14 738.47n/a n/a n/a 738.47n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 852.11 787.22n/a n/a n/a 799.27n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 982.83 923.98n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010519 85629NY0010519 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 756.50 687.04n/a n/a n/a 687.04 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 817.26 742.21n/a n/a n/a 742.21n/a n/a 1,165.00 57,137.00n/a n/a n/a 32,144.00n/a n/a 856.35 791.14n/a n/a n/a 803.25n/a n/a 63.00 5,045.00n/a n/a n/a 2,454.00n/a n/a 987.64 928.50n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010520 85629NY0010520 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 752.74 683.63n/a n/a n/a 683.63 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 813.14 738.47n/a n/a n/a 738.47n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 852.11 787.22n/a n/a n/a 799.27n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 982.83 923.98n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010521 85629NY0010521 Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 772.54 701.61n/a n/a n/a 701.61 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 834.84 758.18n/a n/a n/a 758.18n/a n/a 0.00 2,659.00n/a n/a n/a 1,760.00n/a n/a 874.46 807.87n/a n/a n/a 820.24n/a n/a 0.00 268.00n/a n/a n/a 156.00n/a n/a 1,008.18 947.81n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010522 85629NY0010522 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 772.54 701.61n/a n/a n/a 701.61 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 834.84 758.18n/a n/a n/a 758.18n/a n/a 0.00 1,674.00n/a n/a n/a 1,277.00n/a n/a 874.46 807.87n/a n/a n/a 820.24n/a n/a 0.00 237.00n/a n/a n/a 137.00n/a n/a 1,008.18 947.81n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010523 85629NY0010523 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 768.78 698.20n/a n/a n/a 698.20 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 830.72 754.44n/a n/a n/a 754.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 870.22 803.95n/a n/a n/a 816.26n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,003.37 943.29n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010524 85629NY0010524 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 768.78 698.20n/a n/a n/a 698.20 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 830.72 754.44n/a n/a n/a 754.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 870.22 803.95n/a n/a n/a 816.26n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,003.37 943.29n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010437 85629NY0010437 Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 766.62 696.22n/a n/a n/a 696.22 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 839.47 762.39n/a n/a n/a 762.39n/a n/a 3,010.00 133,699.00n/a n/a n/a 69,803.00n/a n/a 877.06 810.28n/a n/a n/a 822.69n/a n/a 261.00 11,177.00n/a n/a n/a 5,203.00n/a n/a 1,008.58 948.18n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010438 85629NY0010438 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 762.86 692.81n/a n/a n/a 692.81 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 835.35 758.65n/a n/a n/a 758.65n/a n/a 0.00 72.00n/a n/a n/a 0.00 n/a n/a 872.82 806.36n/a n/a n/a 818.71n/a n/a 0.00 6.00 n/a n/a n/a 0.00 n/a n/a 1,003.77 943.66n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010439 85629NY0010439 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 766.62 696.22n/a n/a n/a 696.22 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 839.47 762.39n/a n/a n/a 762.39n/a n/a 1,393.00 200,463.00n/a n/a n/a 81,346.00n/a n/a 877.06 810.28n/a n/a n/a 822.69n/a n/a 116.00 14,824.00n/a n/a n/a 6,291.00n/a n/a 1,008.58 948.18n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010440 85629NY0010440 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 762.86 692.81n/a n/a n/a 692.81 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 835.35 758.65n/a n/a n/a 758.65n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 872.82 806.36n/a n/a n/a 818.71n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,003.77 943.66n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010441 85629NY0010441 Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 782.66 710.79n/a n/a n/a 710.79 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 857.05 778.36n/a n/a n/a 778.36n/a n/a 194.00 8,757.00n/a n/a n/a 6,078.00n/a n/a 895.17 827.01n/a n/a n/a 839.68n/a n/a 19.00 775.00n/a n/a n/a 537.00n/a n/a 1,029.12 967.49n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010442 85629NY0010442 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 782.66 710.79n/a n/a n/a 710.79 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 857.05 778.36n/a n/a n/a 778.36n/a n/a 273.00 6,502.00n/a n/a n/a 6,446.00n/a n/a 895.17 827.01n/a n/a n/a 839.68n/a n/a 18.00 552.00n/a n/a n/a 686.00n/a n/a 1,029.12 967.49n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010443 85629NY0010443 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 778.90 707.38n/a n/a n/a 707.38 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 852.93 774.62n/a n/a n/a 774.62n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 890.93 823.09n/a n/a n/a 835.70n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,024.31 962.97n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010444 85629NY0010444 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 778.90 707.38n/a n/a n/a 707.38 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 852.93 774.62n/a n/a n/a 774.62n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 890.93 823.09n/a n/a n/a 835.70n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,024.31 962.97n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010509 85629NY0010509 Bronze Off Non-Standard 26 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 530.96 482.21n/a n/a n/a 482.21 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 593.08 538.62n/a n/a n/a 538.62n/a n/a 79.00 3,926.00n/a n/a n/a 1,045.00n/a n/a 628.54 580.68n/a n/a n/a 589.57n/a n/a 6.00 323.00n/a n/a n/a 103.00n/a n/a 753.94 708.79n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010510 85629NY0010510 Bronze Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 527.20 478.80n/a n/a n/a 478.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 588.96 534.88n/a n/a n/a 534.88n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 624.30 576.76n/a n/a n/a 585.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 749.13 704.27n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010511 85629NY0010511 Bronze Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 530.96 482.21n/a n/a n/a 482.21 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 593.08 538.62n/a n/a n/a 538.62n/a n/a 30.00 4,730.00n/a n/a n/a 668.00n/a n/a 628.54 580.68n/a n/a n/a 589.57n/a n/a 5.00 376.00n/a n/a n/a 84.00n/a n/a 753.94 708.79n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010512 85629NY0010512 Bronze Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 527.20 478.80n/a n/a n/a 478.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 588.96 534.88n/a n/a n/a 534.88n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 624.30 576.76n/a n/a n/a 585.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 749.13 704.27n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010513 85629NY0010513 Bronze Off Non-Standard 30 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 547.00 496.78n/a n/a n/a 496.78 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 610.66 554.59n/a n/a n/a 554.59n/a n/a 0.00 155.00n/a n/a n/a 23.00n/a n/a 646.65 597.41n/a n/a n/a 606.56n/a n/a 0.00 8.00 n/a n/a n/a 0.00 n/a n/a 774.48 728.10n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010514 85629NY0010514 Bronze Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 547.00 496.78n/a n/a n/a 496.78 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 610.66 554.59n/a n/a n/a 554.59n/a n/a 0.00 75.00n/a n/a n/a 118.00n/a n/a 646.65 597.41n/a n/a n/a 606.56n/a n/a 0.00 5.00 n/a n/a n/a 22.00n/a n/a 774.48 728.10n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010515 85629NY0010515 Bronze Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 543.24 493.37n/a n/a n/a 493.37 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 606.54 550.85n/a n/a n/a 550.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 642.41 593.49n/a n/a n/a 602.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 769.67 723.58n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010516 85629NY0010516 Bronze Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 543.24 493.37n/a n/a n/a 493.37 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 606.54 550.85n/a n/a n/a 550.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 642.41 593.49n/a n/a n/a 602.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 769.67 723.58n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010509 85629NY0010509 Bronze On Non-Standard 26 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 530.96 482.21n/a n/a n/a 482.21 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 593.08 538.62n/a n/a n/a 538.62n/a n/a 0.00 72.00n/a n/a n/a 0.00 n/a n/a 628.54 580.68n/a n/a n/a 589.57n/a n/a 0.00 8.00 n/a n/a n/a 0.00 n/a n/a 753.94 708.79n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010510 85629NY0010510 Bronze On Non-Standard 26 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 527.20 478.80n/a n/a n/a 478.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 588.96 534.88n/a n/a n/a 534.88n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 624.30 576.76n/a n/a n/a 585.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 749.13 704.27n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010511 85629NY0010511 Bronze On Non-Standard 26 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 530.96 482.21n/a n/a n/a 482.21 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 593.08 538.62n/a n/a n/a 538.62n/a n/a 0.00 76.00n/a n/a n/a 0.00 n/a n/a 628.54 580.68n/a n/a n/a 589.57n/a n/a 0.00 3.00 n/a n/a n/a 0.00 n/a n/a 753.94 708.79n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010512 85629NY0010512 Bronze On Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 527.20 478.80n/a n/a n/a 478.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 588.96 534.88n/a n/a n/a 534.88n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 624.30 576.76n/a n/a n/a 585.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 749.13 704.27n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010513 85629NY0010513 Bronze On Non-Standard 30 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 547.00 496.78n/a n/a n/a 496.78 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 610.66 554.59n/a n/a n/a 554.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 646.65 597.41n/a n/a n/a 606.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 774.48 728.10n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010514 85629NY0010514 Bronze On Non-Standard 30 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 547.00 496.78n/a n/a n/a 496.78 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 610.66 554.59n/a n/a n/a 554.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 646.65 597.41n/a n/a n/a 606.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 774.48 728.10n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010515 85629NY0010515 Bronze On Non-Standard 30 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 543.24 493.37n/a n/a n/a 493.37 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 606.54 550.85n/a n/a n/a 550.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 642.41 593.49n/a n/a n/a 602.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 769.67 723.58n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010516 85629NY0010516 Bronze On Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 543.24 493.37n/a n/a n/a 493.37 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 606.54 550.85n/a n/a n/a 550.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 642.41 593.49n/a n/a n/a 602.58n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 769.67 723.58n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010597 85629NY0010597 Bronze Off Non-Standard 26 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 530.53 481.82n/a n/a n/a 481.82 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 588.19 534.18n/a n/a n/a 534.18n/a n/a 1,244.00 21,625.00n/a n/a n/a 6,468.00n/a n/a 623.64 576.15n/a n/a n/a 584.97n/a n/a 108.00 1,841.00n/a n/a n/a 489.00n/a n/a 757.16 711.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010598 85629NY0010598 Bronze Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 526.77 478.41n/a n/a n/a 478.41 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 584.07 530.44n/a n/a n/a 530.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 619.40 572.23n/a n/a n/a 580.99n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 752.35 707.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010599 85629NY0010599 Bronze Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 530.53 481.82n/a n/a n/a 481.82 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 588.19 534.18n/a n/a n/a 534.18n/a n/a 531.00 27,200.00n/a n/a n/a 9,051.00n/a n/a 623.64 576.15n/a n/a n/a 584.97n/a n/a 42.00 1,912.00n/a n/a n/a 705.00n/a n/a 757.16 711.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010600 85629NY0010600 Bronze Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 526.77 478.41n/a n/a n/a 478.41 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 584.07 530.44n/a n/a n/a 530.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 619.40 572.23n/a n/a n/a 580.99n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 752.35 707.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010601 85629NY0010601 Bronze Off Non-Standard 30 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 546.57 496.39n/a n/a n/a 496.39 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 605.77 550.15n/a n/a n/a 550.15n/a n/a 0.00 284.00n/a n/a n/a 312.00n/a n/a 641.75 592.88n/a n/a n/a 601.96n/a n/a 0.00 34.00n/a n/a n/a 26.00n/a n/a 777.70 731.13n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010602 85629NY0010602 Bronze Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 546.57 496.39n/a n/a n/a 496.39 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 605.77 550.15n/a n/a n/a 550.15n/a n/a 6.00 525.00n/a n/a n/a 325.00n/a n/a 641.75 592.88n/a n/a n/a 601.96n/a n/a 0.00 47.00n/a n/a n/a 11.00n/a n/a 777.70 731.13n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010603 85629NY0010603 Bronze Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 542.81 492.98n/a n/a n/a 492.98 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 601.65 546.41n/a n/a n/a 546.41n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 637.51 588.96n/a n/a n/a 597.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 772.89 726.61n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010604 85629NY0010604 Bronze Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 542.81 492.98n/a n/a n/a 492.98 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 601.65 546.41n/a n/a n/a 546.41n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 637.51 588.96n/a n/a n/a 597.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 772.89 726.61n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010597 85629NY0010597 Bronze On Non-Standard 26 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 530.53 481.82n/a n/a n/a 481.82 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 588.19 534.18n/a n/a n/a 534.18n/a n/a 0.00 216.00n/a n/a n/a 54.00n/a n/a 623.64 576.15n/a n/a n/a 584.97n/a n/a 0.00 12.00n/a n/a n/a 0.00 n/a n/a 757.16 711.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010598 85629NY0010598 Bronze On Non-Standard 26 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 526.77 478.41n/a n/a n/a 478.41 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 584.07 530.44n/a n/a n/a 530.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 619.40 572.23n/a n/a n/a 580.99n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 752.35 707.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010599 85629NY0010599 Bronze On Non-Standard 26 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 530.53 481.82n/a n/a n/a 481.82 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 588.19 534.18n/a n/a n/a 534.18n/a n/a 0.00 41.00n/a n/a n/a 161.00n/a n/a 623.64 576.15n/a n/a n/a 584.97n/a n/a 0.00 4.00 n/a n/a n/a 20.00n/a n/a 757.16 711.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010600 85629NY0010600 Bronze On Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 526.77 478.41n/a n/a n/a 478.41 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 584.07 530.44n/a n/a n/a 530.44n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 619.40 572.23n/a n/a n/a 580.99n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 752.35 707.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010601 85629NY0010601 Bronze On Non-Standard 30 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 546.57 496.39n/a n/a n/a 496.39 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 605.77 550.15n/a n/a n/a 550.15n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 641.75 592.88n/a n/a n/a 601.96n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 777.70 731.13n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010602 85629NY0010602 Bronze On Non-Standard 30 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 546.57 496.39n/a n/a n/a 496.39 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 605.77 550.15n/a n/a n/a 550.15n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 641.75 592.88n/a n/a n/a 601.96n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 777.70 731.13n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010603 85629NY0010603 Bronze On Non-Standard 30 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 542.81 492.98n/a n/a n/a 492.98 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 601.65 546.41n/a n/a n/a 546.41n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 637.51 588.96n/a n/a n/a 597.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 772.89 726.61n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010604 85629NY0010604 Bronze On Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 542.81 492.98n/a n/a n/a 492.98 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 601.65 546.41n/a n/a n/a 546.41n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 637.51 588.96n/a n/a n/a 597.98n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 772.89 726.61n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010653 85629NY0010653 Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 863.29 784.02n/a n/a n/a 784.02 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 944.96 858.19n/a n/a n/a 858.19n/a n/a 589.00 15,672.00n/a n/a n/a 10,176.00n/a n/a 991.72 916.20n/a n/a n/a 930.22n/a n/a 95.00 1,603.00n/a n/a n/a 903.00n/a n/a 1,132.70 1,064.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010654 85629NY0010654 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 859.53 780.61n/a n/a n/a 780.61 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 940.84 854.45n/a n/a n/a 854.45n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 987.48 912.28n/a n/a n/a 926.24n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,127.89 1,060.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010655 85629NY0010655 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 863.29 784.02n/a n/a n/a 784.02 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 944.96 858.19n/a n/a n/a 858.19n/a n/a 160.00 31,326.00n/a n/a n/a 13,954.00n/a n/a 991.72 916.20n/a n/a n/a 930.22n/a n/a 26.00 2,410.00n/a n/a n/a 1,217.00n/a n/a 1,132.70 1,064.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010656 85629NY0010656 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 859.53 780.61n/a n/a n/a 780.61 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 940.84 854.45n/a n/a n/a 854.45n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 987.48 912.28n/a n/a n/a 926.24n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,127.89 1,060.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010657 85629NY0010657 Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0076 Liberty n/a n/a 879.33 798.59n/a n/a n/a 798.59 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 962.54 874.16n/a n/a n/a 874.16n/a n/a 0.00 868.00n/a n/a n/a 1,510.00n/a n/a 1,009.83 932.93n/a n/a n/a 947.21n/a n/a 0.00 62.00n/a n/a n/a 114.00n/a n/a 1,153.24 1,084.18n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010658 85629NY0010658 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a 879.33 798.59n/a n/a n/a 798.59 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 962.54 874.16n/a n/a n/a 874.16n/a n/a 0.00 1,468.00n/a n/a n/a 1,638.00n/a n/a 1,009.83 932.93n/a n/a n/a 947.21n/a n/a 0.00 136.00n/a n/a n/a 103.00n/a n/a 1,153.24 1,084.18n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010659 85629NY0010659 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 875.57 795.18n/a n/a n/a 795.18 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 958.42 870.42n/a n/a n/a 870.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,005.59 929.01n/a n/a n/a 943.23n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,148.43 1,079.66n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010660 85629NY0010660 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a 875.57 795.18n/a n/a n/a 795.18 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 958.42 870.42n/a n/a n/a 870.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,005.59 929.01n/a n/a n/a 943.23n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,148.43 1,079.66n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010469 85629NY0010469 Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 759.62 689.87n/a n/a n/a 689.87 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 844.72 767.16n/a n/a n/a 767.16n/a n/a 248.00 23,413.00n/a n/a n/a 6,687.00n/a n/a 894.28 826.19n/a n/a n/a 838.83n/a n/a 33.00 1,772.00n/a n/a n/a 458.00n/a n/a 1,028.68 967.08n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010470 85629NY0010470 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 755.86 686.46n/a n/a n/a 686.46 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 840.60 763.42n/a n/a n/a 763.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 890.04 822.27n/a n/a n/a 834.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,023.87 962.56n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010471 85629NY0010471 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 759.62 689.87n/a n/a n/a 689.87 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 844.72 767.16n/a n/a n/a 767.16n/a n/a 191.00 23,144.00n/a n/a n/a 7,772.00n/a n/a 894.28 826.19n/a n/a n/a 838.83n/a n/a 18.00 1,521.00n/a n/a n/a 502.00n/a n/a 1,028.68 967.08n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010472 85629NY0010472 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 755.86 686.46n/a n/a n/a 686.46 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 840.60 763.42n/a n/a n/a 763.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 890.04 822.27n/a n/a n/a 834.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,023.87 962.56n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010473 85629NY0010473 Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 775.66 704.44n/a n/a n/a 704.44 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 862.30 783.13n/a n/a n/a 783.13n/a n/a 0.00 1,020.00n/a n/a n/a 361.00n/a n/a 912.39 842.92n/a n/a n/a 855.82n/a n/a 0.00 92.00n/a n/a n/a 28.00n/a n/a 1,049.22 986.39n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010474 85629NY0010474 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 775.66 704.44n/a n/a n/a 704.44 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 862.30 783.13n/a n/a n/a 783.13n/a n/a 0.00 420.00n/a n/a n/a 79.00n/a n/a 912.39 842.92n/a n/a n/a 855.82n/a n/a 0.00 37.00n/a n/a n/a 8.00 n/a n/a 1,049.22 986.39n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010475 85629NY0010475 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 771.90 701.03n/a n/a n/a 701.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 858.18 779.39n/a n/a n/a 779.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 908.15 839.00n/a n/a n/a 851.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,044.41 981.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010476 85629NY0010476 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 771.90 701.03n/a n/a n/a 701.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 858.18 779.39n/a n/a n/a 779.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 908.15 839.00n/a n/a n/a 851.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,044.41 981.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010469 85629NY0010469 Gold On Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 759.62 689.87n/a n/a n/a 689.87 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 844.72 767.16n/a n/a n/a 767.16n/a n/a 0.00 349.00n/a n/a n/a 60.00n/a n/a 894.28 826.19n/a n/a n/a 838.83n/a n/a 0.00 35.00n/a n/a n/a 5.00 n/a n/a 1,028.68 967.08n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010470 85629NY0010470 Gold On Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 755.86 686.46n/a n/a n/a 686.46 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 840.60 763.42n/a n/a n/a 763.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 890.04 822.27n/a n/a n/a 834.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,023.87 962.56n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010471 85629NY0010471 Gold On Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 759.62 689.87n/a n/a n/a 689.87 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 844.72 767.16n/a n/a n/a 767.16n/a n/a 20.00 101.00n/a n/a n/a 0.00 n/a n/a 894.28 826.19n/a n/a n/a 838.83n/a n/a 2.00 1.00 n/a n/a n/a 0.00 n/a n/a 1,028.68 967.08n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010472 85629NY0010472 Gold On Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 755.86 686.46n/a n/a n/a 686.46 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 840.60 763.42n/a n/a n/a 763.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 890.04 822.27n/a n/a n/a 834.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,023.87 962.56n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010473 85629NY0010473 Gold On Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 775.66 704.44n/a n/a n/a 704.44 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 862.30 783.13n/a n/a n/a 783.13n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 912.39 842.92n/a n/a n/a 855.82n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,049.22 986.39n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010474 85629NY0010474 Gold On Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 775.66 704.44n/a n/a n/a 704.44 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 862.30 783.13n/a n/a n/a 783.13n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 912.39 842.92n/a n/a n/a 855.82n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,049.22 986.39n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010475 85629NY0010475 Gold On Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 771.90 701.03n/a n/a n/a 701.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 858.18 779.39n/a n/a n/a 779.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 908.15 839.00n/a n/a n/a 851.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,044.41 981.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010476 85629NY0010476 Gold On Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 771.90 701.03n/a n/a n/a 701.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 858.18 779.39n/a n/a n/a 779.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 908.15 839.00n/a n/a n/a 851.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,044.41 981.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010581 85629NY0010581 Gold Off Non-Standard 26 No Included Yes No Yes Yes No No No 0173 Metro n/a n/a 654.34 594.26n/a n/a n/a 594.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 746.83 678.26n/a n/a n/a 678.26n/a n/a 391.00 22,065.00n/a n/a n/a 7,489.00n/a n/a 771.20 712.48n/a n/a n/a 723.38n/a n/a 27.00 1,483.00n/a n/a n/a 513.00n/a n/a 882.22 829.39n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010582 85629NY0010582 Gold Off Non-Standard 26 No Excluded Yes No Yes Yes No No No 0173 Metro n/a n/a 650.58 590.85n/a n/a n/a 590.85 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 742.71 674.52n/a n/a n/a 674.52n/a n/a 95.00 0.00 n/a n/a n/a 0.00 n/a n/a 766.96 708.56n/a n/a n/a 719.40n/a n/a 6.00 0.00 n/a n/a n/a 0.00 n/a n/a 877.41 824.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010583 85629NY0010583 Gold Off Non-Standard 26 Yes Included Yes No Yes Yes No No No 0173 Metro n/a n/a 654.34 594.26n/a n/a n/a 594.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 746.83 678.26n/a n/a n/a 678.26n/a n/a 547.00 10,223.00n/a n/a n/a 2,581.00n/a n/a 771.20 712.48n/a n/a n/a 723.38n/a n/a 43.00 706.00n/a n/a n/a 187.00n/a n/a 882.22 829.39n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010584 85629NY0010584 Gold Off Non-Standard 26 Yes Excluded Yes No Yes Yes No No No 0173 Metro n/a n/a 650.58 590.85n/a n/a n/a 590.85 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 742.71 674.52n/a n/a n/a 674.52n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 766.96 708.56n/a n/a n/a 719.40n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 877.41 824.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010585 85629NY0010585 Gold Off Non-Standard 30 No Included Yes No Yes Yes No No No 0173 Metro n/a n/a 670.38 608.83n/a n/a n/a 608.83 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 764.41 694.23n/a n/a n/a 694.23n/a n/a 0.00 2,151.00n/a n/a n/a 470.00n/a n/a 789.31 729.21n/a n/a n/a 740.37n/a n/a 0.00 173.00n/a n/a n/a 27.00n/a n/a 902.76 848.70n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010586 85629NY0010586 Gold Off Non-Standard 30 Yes Included Yes No Yes Yes No No No 0173 Metro n/a n/a 670.38 608.83n/a n/a n/a 608.83 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 764.41 694.23n/a n/a n/a 694.23n/a n/a 85.00 1,934.00n/a n/a n/a 175.00n/a n/a 789.31 729.21n/a n/a n/a 740.37n/a n/a 0.00 154.00n/a n/a n/a 20.00n/a n/a 902.76 848.70n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010587 85629NY0010587 Gold Off Non-Standard 30 No Excluded Yes No Yes Yes No No No 0173 Metro n/a n/a 666.62 605.42n/a n/a n/a 605.42 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 760.29 690.49n/a n/a n/a 690.49n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 785.07 725.29n/a n/a n/a 736.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 897.95 844.18n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010588 85629NY0010588 Gold Off Non-Standard 30 Yes Excluded Yes No Yes Yes No No No 0173 Metro n/a n/a 666.62 605.42n/a n/a n/a 605.42 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 760.29 690.49n/a n/a n/a 690.49n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 785.07 725.29n/a n/a n/a 736.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 897.95 844.18n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010573 85629NY0010573 Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 791.31 718.64n/a n/a n/a 718.64 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 880.68 799.82n/a n/a n/a 799.82n/a n/a 392.00 11,360.00n/a n/a n/a 3,825.00n/a n/a 917.60 847.73n/a n/a n/a 860.71n/a n/a 31.00 930.00n/a n/a n/a 258.00n/a n/a 1,065.71 1,001.89n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010574 85629NY0010574 Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 787.55 715.23n/a n/a n/a 715.23 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 876.56 796.08n/a n/a n/a 796.08n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 913.36 843.81n/a n/a n/a 856.73n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,060.90 997.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010575 85629NY0010575 Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 791.31 718.64n/a n/a n/a 718.64 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 880.68 799.82n/a n/a n/a 799.82n/a n/a 94.00 16,519.00n/a n/a n/a 5,744.00n/a n/a 917.60 847.73n/a n/a n/a 860.71n/a n/a 1.00 1,026.00n/a n/a n/a 404.00n/a n/a 1,065.71 1,001.89n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010576 85629NY0010576 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 787.55 715.23n/a n/a n/a 715.23 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 876.56 796.08n/a n/a n/a 796.08n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 913.36 843.81n/a n/a n/a 856.73n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,060.90 997.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010577 85629NY0010577 Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 807.35 733.21n/a n/a n/a 733.21 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 898.26 815.79n/a n/a n/a 815.79n/a n/a 24.00 299.00n/a n/a n/a 551.00n/a n/a 935.71 864.46n/a n/a n/a 877.70n/a n/a 2.00 31.00n/a n/a n/a 43.00n/a n/a 1,086.25 1,021.20n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010578 85629NY0010578 Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 807.35 733.21n/a n/a n/a 733.21 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 898.26 815.79n/a n/a n/a 815.79n/a n/a 0.00 293.00n/a n/a n/a 56.00n/a n/a 935.71 864.46n/a n/a n/a 877.70n/a n/a 0.00 26.00n/a n/a n/a 8.00 n/a n/a 1,086.25 1,021.20n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010579 85629NY0010579 Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 803.59 729.80n/a n/a n/a 729.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 894.14 812.05n/a n/a n/a 812.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 931.47 860.54n/a n/a n/a 873.72n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,081.44 1,016.68n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010580 85629NY0010580 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 803.59 729.80n/a n/a n/a 729.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 894.14 812.05n/a n/a n/a 812.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 931.47 860.54n/a n/a n/a 873.72n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,081.44 1,016.68n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010573 85629NY0010573 Gold On Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 791.31 718.64n/a n/a n/a 718.64 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 880.68 799.82n/a n/a n/a 799.82n/a n/a 0.00 31.00n/a n/a n/a 0.00 n/a n/a 917.60 847.73n/a n/a n/a 860.71n/a n/a 0.00 4.00 n/a n/a n/a 0.00 n/a n/a 1,065.71 1,001.89n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010574 85629NY0010574 Gold On Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 787.55 715.23n/a n/a n/a 715.23 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 876.56 796.08n/a n/a n/a 796.08n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 913.36 843.81n/a n/a n/a 856.73n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,060.90 997.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010575 85629NY0010575 Gold On Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 791.31 718.64n/a n/a n/a 718.64 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 880.68 799.82n/a n/a n/a 799.82n/a n/a 0.00 157.00n/a n/a n/a 0.00 n/a n/a 917.60 847.73n/a n/a n/a 860.71n/a n/a 0.00 26.00n/a n/a n/a 0.00 n/a n/a 1,065.71 1,001.89n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010576 85629NY0010576 Gold On Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 787.55 715.23n/a n/a n/a 715.23 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 876.56 796.08n/a n/a n/a 796.08n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 913.36 843.81n/a n/a n/a 856.73n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,060.90 997.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010577 85629NY0010577 Gold On Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 807.35 733.21n/a n/a n/a 733.21 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 898.26 815.79n/a n/a n/a 815.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 935.71 864.46n/a n/a n/a 877.70n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,086.25 1,021.20n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010578 85629NY0010578 Gold On Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 807.35 733.21n/a n/a n/a 733.21 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 898.26 815.79n/a n/a n/a 815.79n/a n/a 0.00 39.00n/a n/a n/a 0.00 n/a n/a 935.71 864.46n/a n/a n/a 877.70n/a n/a 0.00 3.00 n/a n/a n/a 0.00 n/a n/a 1,086.25 1,021.20n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010579 85629NY0010579 Gold On Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 803.59 729.80n/a n/a n/a 729.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 894.14 812.05n/a n/a n/a 812.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 931.47 860.54n/a n/a n/a 873.72n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,081.44 1,016.68n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010580 85629NY0010580 Gold On Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 803.59 729.80n/a n/a n/a 729.80 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 894.14 812.05n/a n/a n/a 812.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 931.47 860.54n/a n/a n/a 873.72n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,081.44 1,016.68n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010453 85629NY0010453 Platinum Off Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 905.14 822.03n/a n/a n/a 822.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,004.98 912.70n/a n/a n/a 912.70n/a n/a 431.00 12,193.00n/a n/a n/a 1,807.00n/a n/a 1,063.86 982.85n/a n/a n/a 997.90n/a n/a 38.00 836.00n/a n/a n/a 143.00n/a n/a 1,213.15 1,140.51n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010454 85629NY0010454 Platinum Off Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 901.38 818.62n/a n/a n/a 818.62 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,000.86 908.96n/a n/a n/a 908.96n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,059.62 978.93n/a n/a n/a 993.92n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,208.34 1,135.99n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010455 85629NY0010455 Platinum Off Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 905.14 822.03n/a n/a n/a 822.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,004.98 912.70n/a n/a n/a 912.70n/a n/a 215.00 8,278.00n/a n/a n/a 2,105.00n/a n/a 1,063.86 982.85n/a n/a n/a 997.90n/a n/a 14.00 639.00n/a n/a n/a 171.00n/a n/a 1,213.15 1,140.51n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010456 85629NY0010456 Platinum Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 901.38 818.62n/a n/a n/a 818.62 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,000.86 908.96n/a n/a n/a 908.96n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,059.62 978.93n/a n/a n/a 993.92n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,208.34 1,135.99n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010457 85629NY0010457 Platinum Off Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 921.18 836.60n/a n/a n/a 836.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,022.56 928.67n/a n/a n/a 928.67n/a n/a 0.00 621.00n/a n/a n/a 196.00n/a n/a 1,081.97 999.58n/a n/a n/a 1,014.89n/a n/a 0.00 67.00n/a n/a n/a 19.00n/a n/a 1,233.69 1,159.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010458 85629NY0010458 Platinum Off Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 921.18 836.60n/a n/a n/a 836.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,022.56 928.67n/a n/a n/a 928.67n/a n/a 0.00 0.00 n/a n/a n/a 94.00n/a n/a 1,081.97 999.58n/a n/a n/a 1,014.89n/a n/a 0.00 0.00 n/a n/a n/a 4.00 n/a n/a 1,233.69 1,159.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010459 85629NY0010459 Platinum Off Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 917.42 833.19n/a n/a n/a 833.19 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,018.44 924.93n/a n/a n/a 924.93n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,077.73 995.66n/a n/a n/a 1,010.91n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,228.88 1,155.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010460 85629NY0010460 Platinum Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 917.42 833.19n/a n/a n/a 833.19 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,018.44 924.93n/a n/a n/a 924.93n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,077.73 995.66n/a n/a n/a 1,010.91n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,228.88 1,155.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010453 85629NY0010453 Platinum On Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 905.14 822.03n/a n/a n/a 822.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,004.98 912.70n/a n/a n/a 912.70n/a n/a 72.00 121.00n/a n/a n/a 0.00 n/a n/a 1,063.86 982.85n/a n/a n/a 997.90n/a n/a 6.00 6.00 n/a n/a n/a 0.00 n/a n/a 1,213.15 1,140.51n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010454 85629NY0010454 Platinum On Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 901.38 818.62n/a n/a n/a 818.62 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,000.86 908.96n/a n/a n/a 908.96n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,059.62 978.93n/a n/a n/a 993.92n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,208.34 1,135.99n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010455 85629NY0010455 Platinum On Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 905.14 822.03n/a n/a n/a 822.03 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,004.98 912.70n/a n/a n/a 912.70n/a n/a 0.00 91.00n/a n/a n/a 140.00n/a n/a 1,063.86 982.85n/a n/a n/a 997.90n/a n/a 0.00 3.00 n/a n/a n/a 17.00n/a n/a 1,213.15 1,140.51n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010456 85629NY0010456 Platinum On Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 901.38 818.62n/a n/a n/a 818.62 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,000.86 908.96n/a n/a n/a 908.96n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,059.62 978.93n/a n/a n/a 993.92n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,208.34 1,135.99n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010457 85629NY0010457 Platinum On Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 921.18 836.60n/a n/a n/a 836.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,022.56 928.67n/a n/a n/a 928.67n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,081.97 999.58n/a n/a n/a 1,014.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,233.69 1,159.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010458 85629NY0010458 Platinum On Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 921.18 836.60n/a n/a n/a 836.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,022.56 928.67n/a n/a n/a 928.67n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,081.97 999.58n/a n/a n/a 1,014.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,233.69 1,159.82n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010459 85629NY0010459 Platinum On Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 917.42 833.19n/a n/a n/a 833.19 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,018.44 924.93n/a n/a n/a 924.93n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,077.73 995.66n/a n/a n/a 1,010.91n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,228.88 1,155.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010460 85629NY0010460 Platinum On Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 917.42 833.19n/a n/a n/a 833.19 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 1,018.44 924.93n/a n/a n/a 924.93n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,077.73 995.66n/a n/a n/a 1,010.91n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,228.88 1,155.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010493 85629NY0010493 Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 614.43 558.01n/a n/a n/a 558.01 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 702.49 637.99n/a n/a n/a 637.99n/a n/a 1,097.00 50,391.00n/a n/a n/a 15,982.00n/a n/a 733.32 677.48n/a n/a n/a 687.85n/a n/a 73.00 4,150.00n/a n/a n/a 1,204.00n/a n/a 855.00 803.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010494 85629NY0010494 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 610.67 554.60n/a n/a n/a 554.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 698.37 634.25n/a n/a n/a 634.25n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 729.08 673.56n/a n/a n/a 683.87n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 850.19 799.28n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010495 85629NY0010495 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 614.43 558.01n/a n/a n/a 558.01 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 702.49 637.99n/a n/a n/a 637.99n/a n/a 955.00 62,251.00n/a n/a n/a 18,940.00n/a n/a 733.32 677.48n/a n/a n/a 687.85n/a n/a 75.00 4,394.00n/a n/a n/a 1,474.00n/a n/a 855.00 803.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010496 85629NY0010496 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 610.67 554.60n/a n/a n/a 554.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 698.37 634.25n/a n/a n/a 634.25n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 729.08 673.56n/a n/a n/a 683.87n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 850.19 799.28n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010497 85629NY0010497 Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 630.47 572.58n/a n/a n/a 572.58 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 720.07 653.96n/a n/a n/a 653.96n/a n/a 0.00 1,580.00n/a n/a n/a 900.00n/a n/a 751.43 694.21n/a n/a n/a 704.84n/a n/a 0.00 146.00n/a n/a n/a 94.00n/a n/a 875.54 823.11n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010498 85629NY0010498 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 630.47 572.58n/a n/a n/a 572.58 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 720.07 653.96n/a n/a n/a 653.96n/a n/a 18.00 1,183.00n/a n/a n/a 223.00n/a n/a 751.43 694.21n/a n/a n/a 704.84n/a n/a 6.00 91.00n/a n/a n/a 44.00n/a n/a 875.54 823.11n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010499 85629NY0010499 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 626.71 569.17n/a n/a n/a 569.17 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 715.95 650.22n/a n/a n/a 650.22n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 747.19 690.29n/a n/a n/a 700.86n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 870.73 818.59n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010500 85629NY0010500 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 626.71 569.17n/a n/a n/a 569.17 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 715.95 650.22n/a n/a n/a 650.22n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 747.19 690.29n/a n/a n/a 700.86n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 870.73 818.59n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010493 85629NY0010493 Silver On Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 614.43 558.01n/a n/a n/a 558.01 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 702.49 637.99n/a n/a n/a 637.99n/a n/a 51.00 154.00n/a n/a n/a 16.00n/a n/a 733.32 677.48n/a n/a n/a 687.85n/a n/a 6.00 12.00n/a n/a n/a 3.00 n/a n/a 855.00 803.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010494 85629NY0010494 Silver On Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 610.67 554.60n/a n/a n/a 554.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 698.37 634.25n/a n/a n/a 634.25n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 729.08 673.56n/a n/a n/a 683.87n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 850.19 799.28n/a

PLAN INFORMATION 2021 MEMBERS (per DFS Membership Survey) 2022 PREMIUM RATES2019 PREMIUM RATES 2019 MEMBER MONTHS 2020 PREMIUM RATES 2020 MEMBER MONTHS 2021 PREMIUM RATES



(14 Digits)6. Previous HIOS ID

(14 Digits)7. Metal Level or

Catastrophic 8. Exchange ["On"/"Off"]

9. Plan Type [Standard or Non-

Standard]

10. Limiting Child

Age? (26 or 30)

11. Domestic Partner


no)

12. Family Planning

Coverage? (included, excluded)

13. Pediatric Dental


no)

14. Out of Network

Benefits? (yes, no)

15. Includes

Benefits in Addition to EHB?

(yes, no)

16. Healthy New York

(yes, no)

17. Child-Only Plan

(yes, no)

18. Tiered Network Plan (yes, no)

19. HSA Plan (yes,

no)20.

PNDS Identifier

21. Company Network

IdentifierRegion 1 - 2019 Rate





(Rochester)Region 6 - 2019 Rate

(Syracuse)Region 7 - 2019 Rate

(Utica)Region 8 - 2019 Rate

(Long Island)Region 1 - 2019 MMs

(Albany)Region 2 - 2019 MMs

(Buffalo)Region 3 - 2019 MMs

(Mid-Hudson)Region 4 - 2019 MMs

(New York)Region 5 - 2019

MMs (Rochester)Region 6 - 2019 MMs (Syracuse)











Region 1 - 2020 MMs(Albany)

Region 2 - 2020 MMs(Buffalo)

Region 3 - 2020 MMs(Mid-Hudson)

Region 4 - 2020 MMs(New York)

Region 5 - 2020 MMs (Rochester)

Region 6 - 2020 MMs (Syracuse)












3/31/2021 (Albany)


3/31/2021 (Buffalo)


Hudson)


3/31/2021 (New York)






3/31/2021 (Utica)


Island)Region 1 - 2022 Rate





(Rochester)

PLAN INFORMATION 2021 MEMBERS (per DFS Membership Survey) 2022 PREMIUM RATES2019 PREMIUM RATES 2019 MEMBER MONTHS 2020 PREMIUM RATES 2020 MEMBER MONTHS 2021 PREMIUM RATES

Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010495 85629NY0010495 Silver On Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 614.43 558.01n/a n/a n/a 558.01 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 702.49 637.99n/a n/a n/a 637.99n/a n/a 56.00 70.00n/a n/a n/a 176.00n/a n/a 733.32 677.48n/a n/a n/a 687.85n/a n/a 8.00 0.00 n/a n/a n/a 16.00n/a n/a 855.00 803.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010496 85629NY0010496 Silver On Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 610.67 554.60n/a n/a n/a 554.60 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 698.37 634.25n/a n/a n/a 634.25n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 729.08 673.56n/a n/a n/a 683.87n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 850.19 799.28n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010497 85629NY0010497 Silver On Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 630.47 572.58n/a n/a n/a 572.58 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 720.07 653.96n/a n/a n/a 653.96n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 751.43 694.21n/a n/a n/a 704.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 875.54 823.11n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010498 85629NY0010498 Silver On Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 630.47 572.58n/a n/a n/a 572.58 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 720.07 653.96n/a n/a n/a 653.96n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 751.43 694.21n/a n/a n/a 704.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 875.54 823.11n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010499 85629NY0010499 Silver On Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 626.71 569.17n/a n/a n/a 569.17 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 715.95 650.22n/a n/a n/a 650.22n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 747.19 690.29n/a n/a n/a 700.86n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 870.73 818.59n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010500 85629NY0010500 Silver On Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 626.71 569.17n/a n/a n/a 569.17 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 715.95 650.22n/a n/a n/a 650.22n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 747.19 690.29n/a n/a n/a 700.86n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 870.73 818.59n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010485 85629NY0010485 Silver Off Non-Standard 26 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 643.32 584.26n/a n/a n/a 584.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 644.64 585.45n/a n/a n/a 585.45n/a n/a 126.00 4,785.00n/a n/a n/a 961.00n/a n/a 692.34 639.62n/a n/a n/a 649.41n/a n/a 13.00 478.00n/a n/a n/a 110.00n/a n/a 812.81 764.14n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010486 85629NY0010486 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 639.56 580.85n/a n/a n/a 580.85 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 640.52 581.71n/a n/a n/a 581.71n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 688.10 635.70n/a n/a n/a 645.43n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 808.00 759.62n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010487 85629NY0010487 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 643.32 584.26n/a n/a n/a 584.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 644.64 585.45n/a n/a n/a 585.45n/a n/a 207.00 5,815.00n/a n/a n/a 926.00n/a n/a 692.34 639.62n/a n/a n/a 649.41n/a n/a 18.00 564.00n/a n/a n/a 100.00n/a n/a 812.81 764.14n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010488 85629NY0010488 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 639.56 580.85n/a n/a n/a 580.85 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 640.52 581.71n/a n/a n/a 581.71n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 688.10 635.70n/a n/a n/a 645.43n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 808.00 759.62n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010489 85629NY0010489 Silver Off Non-Standard 30 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 659.36 598.83n/a n/a n/a 598.83 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 662.22 601.42n/a n/a n/a 601.42n/a n/a 0.00 220.00n/a n/a n/a 62.00n/a n/a 710.45 656.35n/a n/a n/a 666.40n/a n/a 0.00 22.00n/a n/a n/a 8.00 n/a n/a 833.35 783.45n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010490 85629NY0010490 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 659.36 598.83n/a n/a n/a 598.83 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 662.22 601.42n/a n/a n/a 601.42n/a n/a 0.00 8.00 n/a n/a n/a 187.00n/a n/a 710.45 656.35n/a n/a n/a 666.40n/a n/a 0.00 11.00n/a n/a n/a 14.00n/a n/a 833.35 783.45n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010491 85629NY0010491 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 655.60 595.42n/a n/a n/a 595.42 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 658.10 597.68n/a n/a n/a 597.68n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 706.21 652.43n/a n/a n/a 662.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 828.54 778.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010492 85629NY0010492 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 655.60 595.42n/a n/a n/a 595.42 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 658.10 597.68n/a n/a n/a 597.68n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 706.21 652.43n/a n/a n/a 662.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 828.54 778.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010485 85629NY0010485 Silver On Non-Standard 26 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 643.32 584.26n/a n/a n/a 584.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 644.64 585.45n/a n/a n/a 585.45n/a n/a 96.00 58.00n/a n/a n/a 55.00n/a n/a 692.34 639.62n/a n/a n/a 649.41n/a n/a 7.00 16.00n/a n/a n/a 0.00 n/a n/a 812.81 764.14n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010486 85629NY0010486 Silver On Non-Standard 26 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 639.56 580.85n/a n/a n/a 580.85 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 640.52 581.71n/a n/a n/a 581.71n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 688.10 635.70n/a n/a n/a 645.43n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 808.00 759.62n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010487 85629NY0010487 Silver On Non-Standard 26 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 643.32 584.26n/a n/a n/a 584.26 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 644.64 585.45n/a n/a n/a 585.45n/a n/a 0.00 84.00n/a n/a n/a 20.00n/a n/a 692.34 639.62n/a n/a n/a 649.41n/a n/a 0.00 5.00 n/a n/a n/a 2.00 n/a n/a 812.81 764.14n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010488 85629NY0010488 Silver On Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 639.56 580.85n/a n/a n/a 580.85 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 640.52 581.71n/a n/a n/a 581.71n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 688.10 635.70n/a n/a n/a 645.43n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 808.00 759.62n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010489 85629NY0010489 Silver On Non-Standard 30 No Included Yes No Yes No No No Yes 0173 Metro n/a n/a 659.36 598.83n/a n/a n/a 598.83 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 662.22 601.42n/a n/a n/a 601.42n/a n/a 0.00 36.00n/a n/a n/a 0.00 n/a n/a 710.45 656.35n/a n/a n/a 666.40n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 833.35 783.45n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010490 85629NY0010490 Silver On Non-Standard 30 Yes Included Yes No Yes No No No Yes 0173 Metro n/a n/a 659.36 598.83n/a n/a n/a 598.83 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 662.22 601.42n/a n/a n/a 601.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 710.45 656.35n/a n/a n/a 666.40n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 833.35 783.45n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010491 85629NY0010491 Silver On Non-Standard 30 No Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 655.60 595.42n/a n/a n/a 595.42 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 658.10 597.68n/a n/a n/a 597.68n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 706.21 652.43n/a n/a n/a 662.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 828.54 778.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010492 85629NY0010492 Silver On Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0173 Metro n/a n/a 655.60 595.42n/a n/a n/a 595.42 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 658.10 597.68n/a n/a n/a 597.68n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 706.21 652.43n/a n/a n/a 662.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 828.54 778.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010565 85629NY0010565 Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 667.27 606.00n/a n/a n/a 606.00 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 727.02 660.26n/a n/a n/a 660.26n/a n/a 973.00 20,752.00n/a n/a n/a 6,802.00n/a n/a 752.45 695.15n/a n/a n/a 705.79n/a n/a 77.00 1,557.00n/a n/a n/a 588.00n/a n/a 885.79 832.74n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010566 85629NY0010566 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 663.51 602.59n/a n/a n/a 602.59 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 722.90 656.52n/a n/a n/a 656.52n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 748.21 691.23n/a n/a n/a 701.81n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 880.98 828.22n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010567 85629NY0010567 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 667.27 606.00n/a n/a n/a 606.00 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 727.02 660.26n/a n/a n/a 660.26n/a n/a 161.00 33,841.00n/a n/a n/a 10,550.00n/a n/a 752.45 695.15n/a n/a n/a 705.79n/a n/a 11.00 2,712.00n/a n/a n/a 850.00n/a n/a 885.79 832.74n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010568 85629NY0010568 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 663.51 602.59n/a n/a n/a 602.59 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 722.90 656.52n/a n/a n/a 656.52n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 748.21 691.23n/a n/a n/a 701.81n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 880.98 828.22n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010569 85629NY0010569 Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 683.31 620.57n/a n/a n/a 620.57 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 744.60 676.23n/a n/a n/a 676.23n/a n/a 7.00 1,210.00n/a n/a n/a 373.00n/a n/a 770.56 711.88n/a n/a n/a 722.78n/a n/a 0.00 107.00n/a n/a n/a 27.00n/a n/a 906.33 852.05n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010570 85629NY0010570 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 683.31 620.57n/a n/a n/a 620.57 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 744.60 676.23n/a n/a n/a 676.23n/a n/a 0.00 718.00n/a n/a n/a 712.00n/a n/a 770.56 711.88n/a n/a n/a 722.78n/a n/a 0.00 59.00n/a n/a n/a 66.00n/a n/a 906.33 852.05n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010571 85629NY0010571 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 679.55 617.16n/a n/a n/a 617.16 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 740.48 672.49n/a n/a n/a 672.49n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 766.32 707.96n/a n/a n/a 718.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 901.52 847.53n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010572 85629NY0010572 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 679.55 617.16n/a n/a n/a 617.16 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 740.48 672.49n/a n/a n/a 672.49n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 766.32 707.96n/a n/a n/a 718.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 901.52 847.53n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010565 85629NY0010565 Silver On Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a 667.27 606.00n/a n/a n/a 606.00 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 727.02 660.26n/a n/a n/a 660.26n/a n/a 20.00 169.00n/a n/a n/a 9.00 n/a n/a 752.45 695.15n/a n/a n/a 705.79n/a n/a 0.00 11.00n/a n/a n/a 4.00 n/a n/a 885.79 832.74n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010566 85629NY0010566 Silver On Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 663.51 602.59n/a n/a n/a 602.59 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 722.90 656.52n/a n/a n/a 656.52n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 748.21 691.23n/a n/a n/a 701.81n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 880.98 828.22n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010567 85629NY0010567 Silver On Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 667.27 606.00n/a n/a n/a 606.00 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 727.02 660.26n/a n/a n/a 660.26n/a n/a 16.00 0.00 n/a n/a n/a 12.00n/a n/a 752.45 695.15n/a n/a n/a 705.79n/a n/a 2.00 3.00 n/a n/a n/a 10.00n/a n/a 885.79 832.74n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010568 85629NY0010568 Silver On Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 663.51 602.59n/a n/a n/a 602.59 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 722.90 656.52n/a n/a n/a 656.52n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 748.21 691.23n/a n/a n/a 701.81n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 880.98 828.22n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010569 85629NY0010569 Silver On Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a 683.31 620.57n/a n/a n/a 620.57 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 744.60 676.23n/a n/a n/a 676.23n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 770.56 711.88n/a n/a n/a 722.78n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 906.33 852.05n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010570 85629NY0010570 Silver On Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a 683.31 620.57n/a n/a n/a 620.57 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 744.60 676.23n/a n/a n/a 676.23n/a n/a 0.00 14.00n/a n/a n/a 0.00 n/a n/a 770.56 711.88n/a n/a n/a 722.78n/a n/a 0.00 3.00 n/a n/a n/a 0.00 n/a n/a 906.33 852.05n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010571 85629NY0010571 Silver On Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a 679.55 617.16n/a n/a n/a 617.16 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 740.48 672.49n/a n/a n/a 672.49n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 766.32 707.96n/a n/a n/a 718.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 901.52 847.53n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010572 85629NY0010572 Silver On Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a 679.55 617.16n/a n/a n/a 617.16 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 740.48 672.49n/a n/a n/a 672.49n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 766.32 707.96n/a n/a n/a 718.80n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 901.52 847.53n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010701 85629NY0010701 Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 837.49 760.59n/a n/a n/a 760.59n/a n/a 254.00 1,074.00n/a n/a n/a 831.00n/a n/a 858.40 793.05n/a n/a n/a 805.17n/a n/a 29.00 269.00n/a n/a n/a 102.00n/a n/a 994.62 935.06n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010703 85629NY0010703 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 833.37 756.85n/a n/a n/a 756.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 854.16 789.13n/a n/a n/a 801.19n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 989.81 930.54n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010705 85629NY0010705 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 837.49 760.59n/a n/a n/a 760.59n/a n/a 11.00 1,790.00n/a n/a n/a 622.00n/a n/a 858.40 793.05n/a n/a n/a 805.17n/a n/a 0.00 324.00n/a n/a n/a 100.00n/a n/a 994.62 935.06n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010707 85629NY0010707 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 833.37 756.85n/a n/a n/a 756.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 854.16 789.13n/a n/a n/a 801.19n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 989.81 930.54n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010709 85629NY0010709 Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 855.07 776.56n/a n/a n/a 776.56n/a n/a 0.00 9.00 n/a n/a n/a 10.00n/a n/a 876.51 809.78n/a n/a n/a 822.16n/a n/a 0.00 14.00n/a n/a n/a 10.00n/a n/a 1,015.16 954.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010711 85629NY0010711 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 855.07 776.56n/a n/a n/a 776.56n/a n/a 0.00 45.00n/a n/a n/a 64.00n/a n/a 876.51 809.78n/a n/a n/a 822.16n/a n/a 0.00 5.00 n/a n/a n/a 6.00 n/a n/a 1,015.16 954.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010713 85629NY0010713 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 850.95 772.82n/a n/a n/a 772.82n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 872.27 805.86n/a n/a n/a 818.18n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,010.35 949.85n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010715 85629NY0010715 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 850.95 772.82n/a n/a n/a 772.82n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 872.27 805.86n/a n/a n/a 818.18n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,010.35 949.85n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010701 85629NY0010701 Silver On Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 837.49 760.59n/a n/a n/a 760.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 858.40 793.05n/a n/a n/a 805.17n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 994.62 935.06n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010703 85629NY0010703 Silver On Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 833.37 756.85n/a n/a n/a 756.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 854.16 789.13n/a n/a n/a 801.19n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 989.81 930.54n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010705 85629NY0010705 Silver On Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 837.49 760.59n/a n/a n/a 760.59n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 858.40 793.05n/a n/a n/a 805.17n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 994.62 935.06n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010707 85629NY0010707 Silver On Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 833.37 756.85n/a n/a n/a 756.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 854.16 789.13n/a n/a n/a 801.19n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 989.81 930.54n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010709 85629NY0010709 Silver On Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 855.07 776.56n/a n/a n/a 776.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 876.51 809.78n/a n/a n/a 822.16n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,015.16 954.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010711 85629NY0010711 Silver On Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 855.07 776.56n/a n/a n/a 776.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 876.51 809.78n/a n/a n/a 822.16n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,015.16 954.37n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010713 85629NY0010713 Silver On Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 850.95 772.82n/a n/a n/a 772.82n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 872.27 805.86n/a n/a n/a 818.18n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,010.35 949.85n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010715 85629NY0010715 Silver On Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a 850.95 772.82n/a n/a n/a 772.82n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 872.27 805.86n/a n/a n/a 818.18n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,010.35 949.85n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010702 85629NY0010702 Silver Off Non-Standard 26 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 814.02 752.04n/a n/a n/a 763.55n/a n/a 0.00 53.00n/a n/a n/a 6.00 n/a n/a 947.50 890.76n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010704 85629NY0010704 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 809.78 748.12n/a n/a n/a 759.57n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 942.69 886.24n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010706 85629NY0010706 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 814.02 752.04n/a n/a n/a 763.55n/a n/a 0.00 194.00n/a n/a n/a 14.00n/a n/a 947.50 890.76n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010708 85629NY0010708 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 809.78 748.12n/a n/a n/a 759.57n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 942.69 886.24n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010710 85629NY0010710 Silver Off Non-Standard 30 No Included Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 832.13 768.77n/a n/a n/a 780.54n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 968.04 910.07n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010712 85629NY0010712 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 832.13 768.77n/a n/a n/a 780.54n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 968.04 910.07n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010714 85629NY0010714 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 827.89 764.85n/a n/a n/a 776.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 963.23 905.55n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010716 85629NY0010716 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 827.89 764.85n/a n/a n/a 776.56n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 963.23 905.55n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010725 85629NY0010725 Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 994.50 918.77n/a n/a n/a 932.84n/a n/a 9.00 276.00n/a n/a n/a 179.00n/a n/a 1,124.93 1,057.56n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010726 85629NY0010726 Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 990.26 914.85n/a n/a n/a 928.86n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,120.12 1,053.04n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010727 85629NY0010727 Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 994.50 918.77n/a n/a n/a 932.84n/a n/a 0.00 258.00n/a n/a n/a 192.00n/a n/a 1,124.93 1,057.56n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010728 85629NY0010728 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 990.26 914.85n/a n/a n/a 928.86n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,120.12 1,053.04n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010729 85629NY0010729 Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,012.61 935.50n/a n/a n/a 949.83n/a n/a 0.00 14.00n/a n/a n/a 1.00 n/a n/a 1,145.47 1,076.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010730 85629NY0010730 Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,012.61 935.50n/a n/a n/a 949.83n/a n/a 0.00 44.00n/a n/a n/a 35.00n/a n/a 1,145.47 1,076.87n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010731 85629NY0010731 Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,008.37 931.58n/a n/a n/a 945.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,140.66 1,072.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010732 85629NY0010732 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,008.37 931.58n/a n/a n/a 945.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,140.66 1,072.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010757 n/a Gold Off Non-Standard 26 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,228.35 1,154.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010758 n/a Gold Off Non-Standard 26 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,223.54 1,150.28n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010759 n/a Gold Off Non-Standard 26 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,228.35 1,154.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010760 n/a Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,223.54 1,150.28n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010761 n/a Gold Off Non-Standard 30 No Included Yes No Yes No No No Yes 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,248.89 1,174.11n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010762 n/a Gold Off Non-Standard 30 Yes Included Yes No Yes No No No Yes 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,248.89 1,174.11n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010763 n/a Gold Off Non-Standard 30 No Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,244.08 1,169.59n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010764 n/a Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No Yes 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,244.08 1,169.59n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010765 n/a Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 989.26 930.02n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010766 n/a Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 984.45 925.50n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010767 n/a Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 989.26 930.02n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010768 n/a Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 984.45 925.50n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010769 n/a Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,009.80 949.33n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010770 n/a Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,009.80 949.33n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010771 n/a Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,004.99 944.81n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010772 n/a Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,004.99 944.81n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010773 n/a Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,185.73 1,114.72n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010774 n/a Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,180.92 1,110.20n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010775 n/a Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,185.73 1,114.72n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010776 n/a Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,180.92 1,110.20n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010777 n/a Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,206.27 1,134.03n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010778 n/a Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,206.27 1,134.03n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010779 n/a Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,201.46 1,129.51n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010780 n/a Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,201.46 1,129.51n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010781 n/a Gold Off Non-Standard 26 No Included Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,357.79 1,276.49n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010782 n/a Gold Off Non-Standard 26 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,352.98 1,271.97n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010783 n/a Gold Off Non-Standard 26 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,357.79 1,276.49n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010784 n/a Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,352.98 1,271.97n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010785 n/a Gold Off Non-Standard 30 No Included Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,378.33 1,295.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010786 n/a Gold Off Non-Standard 30 Yes Included Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,378.33 1,295.80n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010787 n/a Gold Off Non-Standard 30 No Excluded Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,373.52 1,291.28n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010788 n/a Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0112 Freedom n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,373.52 1,291.28n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010789 n/a Silver Off Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 891.75 838.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010790 n/a Silver Off Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 886.94 833.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010791 n/a Silver Off Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 891.75 838.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010792 n/a Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 886.94 833.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010793 n/a Silver Off Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 912.29 857.66n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010794 n/a Silver Off Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 912.29 857.66n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010795 n/a Silver Off Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 907.48 853.14n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010796 n/a Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 907.48 853.14n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010789 n/a Silver On Non-Standard 26 No Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 891.75 838.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010790 n/a Silver On Non-Standard 26 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 886.94 833.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010791 n/a Silver On Non-Standard 26 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 891.75 838.35n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010792 n/a Silver On Non-Standard 26 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 886.94 833.83n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010793 n/a Silver On Non-Standard 30 No Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 912.29 857.66n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010794 n/a Silver On Non-Standard 30 Yes Included Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 912.29 857.66n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010795 n/a Silver On Non-Standard 30 No Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 907.48 853.14n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010796 n/a Silver On Non-Standard 30 Yes Excluded Yes No Yes No No No No 0173 Metro n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 907.48 853.14n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010733 85629NY0010733 Platinum Off Non-Standard 26 No Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,216.17 1,123.57n/a n/a n/a 1,140.75n/a n/a 1.00 359.00n/a n/a n/a 64.00n/a n/a 1,391.26 1,307.95n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010734 85629NY0010734 Platinum Off Non-Standard 26 No Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,211.93 1,119.65n/a n/a n/a 1,136.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,386.45 1,303.43n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010735 85629NY0010735 Platinum Off Non-Standard 26 Yes Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,216.17 1,123.57n/a n/a n/a 1,140.75n/a n/a 0.00 44.00n/a n/a n/a 43.00n/a n/a 1,391.26 1,307.95n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010736 85629NY0010736 Platinum Off Non-Standard 26 Yes Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,211.93 1,119.65n/a n/a n/a 1,136.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,386.45 1,303.43n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010737 85629NY0010737 Platinum Off Non-Standard 30 No Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,234.28 1,140.30n/a n/a n/a 1,157.74n/a n/a 0.00 16.00n/a n/a n/a 5.00 n/a n/a 1,411.80 1,327.26n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010738 85629NY0010738 Platinum Off Non-Standard 30 Yes Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,234.28 1,140.30n/a n/a n/a 1,157.74n/a n/a 0.00 0.00 n/a n/a n/a 3.00 n/a n/a 1,411.80 1,327.26n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010739 85629NY0010739 Platinum Off Non-Standard 30 No Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,230.04 1,136.38n/a n/a n/a 1,153.76n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,406.99 1,322.74n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010740 85629NY0010740 Platinum Off Non-Standard 30 Yes Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,230.04 1,136.38n/a n/a n/a 1,153.76n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,406.99 1,322.74n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010741 85629NY0010741 Gold Off Non-Standard 26 No Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 975.22 900.97n/a n/a n/a 914.75n/a n/a 1.00 80.00n/a n/a n/a 43.00n/a n/a 1,144.52 1,075.99n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010742 85629NY0010742 Gold Off Non-Standard 26 No Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 970.98 897.05n/a n/a n/a 910.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,139.71 1,071.47n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010743 85629NY0010743 Gold Off Non-Standard 26 Yes Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 975.22 900.97n/a n/a n/a 914.75n/a n/a 6.00 147.00n/a n/a n/a 116.00n/a n/a 1,144.52 1,075.99n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010744 85629NY0010744 Gold Off Non-Standard 26 Yes Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 970.98 897.05n/a n/a n/a 910.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,139.71 1,071.47n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010745 85629NY0010745 Gold Off Non-Standard 30 No Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 993.33 917.70n/a n/a n/a 931.74n/a n/a 0.00 7.00 n/a n/a n/a 5.00 n/a n/a 1,165.06 1,095.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010746 85629NY0010746 Gold Off Non-Standard 30 Yes Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 993.33 917.70n/a n/a n/a 931.74n/a n/a 0.00 13.00n/a n/a n/a 2.00 n/a n/a 1,165.06 1,095.30n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010747 85629NY0010747 Gold Off Non-Standard 30 No Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 989.09 913.78n/a n/a n/a 927.76n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,160.25 1,090.78n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010748 85629NY0010748 Gold Off Non-Standard 30 Yes Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 989.09 913.78n/a n/a n/a 927.76n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 1,160.25 1,090.78n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010749 85629NY0010749 Silver Off Non-Standard 26 No Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 829.70 766.52n/a n/a n/a 778.25n/a n/a 0.00 97.00n/a n/a n/a 76.00n/a n/a 978.20 919.62n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010750 85629NY0010750 Silver Off Non-Standard 26 No Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 825.46 762.60n/a n/a n/a 774.27n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 973.39 915.10n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010751 85629NY0010751 Silver Off Non-Standard 26 Yes Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 829.70 766.52n/a n/a n/a 778.25n/a n/a 22.00 190.00n/a n/a n/a 209.00n/a n/a 978.20 919.62n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010752 85629NY0010752 Silver Off Non-Standard 26 Yes Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 825.46 762.60n/a n/a n/a 774.27n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 973.39 915.10n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010753 85629NY0010753 Silver Off Non-Standard 30 No Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 847.81 783.25n/a n/a n/a 795.24n/a n/a 0.00 0.00 n/a n/a n/a 1.00 n/a n/a 998.74 938.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010754 85629NY0010754 Silver Off Non-Standard 30 Yes Included Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 847.81 783.25n/a n/a n/a 795.24n/a n/a 0.00 0.00 n/a n/a n/a 4.00 n/a n/a 998.74 938.93n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010755 85629NY0010755 Silver Off Non-Standard 30 No Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 843.57 779.33n/a n/a n/a 791.26n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 993.93 934.41n/aOxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010756 85629NY0010756 Silver Off Non-Standard 30 Yes Excluded Yes No Yes No No Yes No 0076 Liberty n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 #VALUE! #VALUE! 0.00 0.00 0.00 #VALUE! n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 843.57 779.33n/a n/a n/a 791.26n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 993.93 934.41n/a



(14 Digits)

Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010316




Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010311Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010309Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010327Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010328Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010240Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010253Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010238Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010254Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010239Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010237Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010255Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010256Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010076Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010072Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010235Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010073Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010236Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010234Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010074Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010075Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050068Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050001Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050066Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050002Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050067Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050065Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050003Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050004Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050044Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050193Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050042Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050194Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050043Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050041Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050195Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050196Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010248Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010261Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010246Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010262Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010247Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010245Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010263Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010264Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010645Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010646Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010647Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010648Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010649Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010650Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010651Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010652Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010084Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010101Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010082Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010102Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010083Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010081Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010103Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010104Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010036Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010226Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010034Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010227Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010035Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010033Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010228Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010229Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050028Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050185Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050026Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050186Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050027Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050025Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050187Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050188Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050233Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050234Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050235Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050236Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050237Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050238Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050239Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050240Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010336Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010213Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010341Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010214Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010342Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010340Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010215Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010216Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050012Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050177Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050010Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050178Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050011Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050009Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050179Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050180Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010272Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010277Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010270Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010278Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010269Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010271Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010279Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010280Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010288Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010296Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010186Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010297Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010287Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010334Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010298Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010299Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0050108Oxford Health Insuran78026 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3/31/2021 (Albany)


3/31/2021 (Buffalo)


Hudson)


3/31/2021 (New York)






3/31/2021 (Utica)


Island)


3/31/2021 (Albany)


3/31/2021 (Buffalo)


Hudson)


3/31/2021 (New York)






3/31/2021 (Utica)


Island)

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n/a n/a 901.34n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00

n/a n/a 906.00n/a n/a 63.00 7,316.00n/a n/a n/a 3,493.00n/a n/a 63.00 7,316.00n/a n/a n/a 3,493.00

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753.53n/a n/a 0.00 47.00n/a n/a n/a 11.00n/a n/a 0.00 47.00n/a n/a n/a 11.00n/a n/a 748.87n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 748.87n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 733.63n/a n/a 0.00 12.00n/a n/a n/a 0.00 n/a n/a 0.00 12.00n/a n/a n/a 0.00n/a n/a 728.97n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 733.63n/a n/a 0.00 4.00 n/a n/a n/a 20.00n/a n/a 0.00 4.00 n/a n/a n/a 20.00n/a n/a 728.97n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 753.53n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 753.53n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 748.87n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 748.87n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,097.50n/a n/a 95.00 1,603.00n/a n/a n/a 903.00n/a n/a 95.00 1,603.00n/a n/a n/a 903.00n/a n/a 1,092.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,097.50n/a n/a 26.00 2,410.00n/a n/a n/a 1,217.00n/a n/a 26.00 2,410.00n/a n/a n/a 1,217.00n/a n/a 1,092.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,117.40n/a n/a 0.00 62.00n/a n/a n/a 114.00n/a n/a 0.00 62.00n/a n/a n/a 114.00n/a n/a 1,117.40n/a n/a 0.00 136.00n/a n/a n/a 103.00n/a n/a 0.00 136.00n/a n/a n/a 103.00n/a n/a 1,112.74n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,112.74n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 996.71n/a n/a 33.00 1,772.00n/a n/a n/a 458.00n/a n/a 33.00 1,772.00n/a n/a n/a 458.00n/a n/a 992.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 996.71n/a n/a 18.00 1,521.00n/a n/a n/a 502.00n/a n/a 18.00 1,521.00n/a n/a n/a 502.00n/a n/a 992.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,016.61n/a n/a 0.00 92.00n/a n/a n/a 28.00n/a n/a 0.00 92.00n/a n/a n/a 28.00n/a n/a 1,016.61n/a n/a 0.00 37.00n/a n/a n/a 8.00 n/a n/a 0.00 37.00n/a n/a n/a 8.00n/a n/a 1,011.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,011.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 996.71n/a n/a 0.00 35.00n/a n/a n/a 5.00 n/a n/a 0.00 35.00n/a n/a n/a 5.00n/a n/a 992.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 996.71n/a n/a 2.00 1.00 n/a n/a n/a 0.00 n/a n/a 2.00 1.00 n/a n/a n/a 0.00n/a n/a 992.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,016.61n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,016.61n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,011.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,011.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 854.80n/a n/a 27.00 1,483.00n/a n/a n/a 513.00n/a n/a 27.00 1,483.00n/a n/a n/a 513.00n/a n/a 850.14n/a n/a 6.00 0.00 n/a n/a n/a 0.00 n/a n/a 6.00 0.00 n/a n/a n/a 0.00n/a n/a 854.80n/a n/a 43.00 706.00n/a n/a n/a 187.00n/a n/a 43.00 706.00n/a n/a n/a 187.00n/a n/a 850.14n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 874.70n/a n/a 0.00 173.00n/a n/a n/a 27.00n/a n/a 0.00 173.00n/a n/a n/a 27.00n/a n/a 874.70n/a n/a 0.00 154.00n/a n/a n/a 20.00n/a n/a 0.00 154.00n/a n/a n/a 20.00n/a n/a 870.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 870.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,032.59n/a n/a 31.00 930.00n/a n/a n/a 258.00n/a n/a 31.00 930.00n/a n/a n/a 258.00n/a n/a 1,027.93n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,032.59n/a n/a 1.00 1,026.00n/a n/a n/a 404.00n/a n/a 1.00 1,026.00n/a n/a n/a 404.00n/a n/a 1,027.93n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,052.49n/a n/a 2.00 31.00n/a n/a n/a 43.00n/a n/a 2.00 31.00n/a n/a n/a 43.00n/a n/a 1,052.49n/a n/a 0.00 26.00n/a n/a n/a 8.00 n/a n/a 0.00 26.00n/a n/a n/a 8.00n/a n/a 1,047.83n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,047.83n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,032.59n/a n/a 0.00 4.00 n/a n/a n/a 0.00 n/a n/a 0.00 4.00 n/a n/a n/a 0.00n/a n/a 1,027.93n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,032.59n/a n/a 0.00 26.00n/a n/a n/a 0.00 n/a n/a 0.00 26.00n/a n/a n/a 0.00n/a n/a 1,027.93n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,052.49n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,052.49n/a n/a 0.00 3.00 n/a n/a n/a 0.00 n/a n/a 0.00 3.00 n/a n/a n/a 0.00n/a n/a 1,047.83n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,047.83n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,175.45n/a n/a 38.00 836.00n/a n/a n/a 143.00n/a n/a 38.00 836.00n/a n/a n/a 143.00n/a n/a 1,170.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,175.45n/a n/a 14.00 639.00n/a n/a n/a 171.00n/a n/a 14.00 639.00n/a n/a n/a 171.00n/a n/a 1,170.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,195.35n/a n/a 0.00 67.00n/a n/a n/a 19.00n/a n/a 0.00 67.00n/a n/a n/a 19.00n/a n/a 1,195.35n/a n/a 0.00 0.00 n/a n/a n/a 4.00 n/a n/a 0.00 0.00 n/a n/a n/a 4.00n/a n/a 1,190.69n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,190.69n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,175.45n/a n/a 6.00 6.00 n/a n/a n/a 0.00 n/a n/a 6.00 6.00 n/a n/a n/a 0.00n/a n/a 1,170.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,175.45n/a n/a 0.00 3.00 n/a n/a n/a 17.00n/a n/a 0.00 3.00 n/a n/a n/a 17.00n/a n/a 1,170.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,195.35n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,195.35n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,190.69n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,190.69n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 828.43n/a n/a 73.00 4,150.00n/a n/a n/a 1,204.00n/a n/a 73.00 4,150.00n/a n/a n/a 1,204.00n/a n/a 823.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 828.43n/a n/a 75.00 4,394.00n/a n/a n/a 1,474.00n/a n/a 75.00 4,394.00n/a n/a n/a 1,474.00n/a n/a 823.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 848.33n/a n/a 0.00 146.00n/a n/a n/a 94.00n/a n/a 0.00 146.00n/a n/a n/a 94.00n/a n/a 848.33n/a n/a 6.00 91.00n/a n/a n/a 44.00n/a n/a 6.00 91.00n/a n/a n/a 44.00n/a n/a 843.67n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 843.67n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 828.43n/a n/a 6.00 12.00n/a n/a n/a 3.00 n/a n/a 6.00 12.00n/a n/a n/a 3.00n/a n/a 823.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00

2021 MEMBERS (Should be consistent with DFS Membership Survey) ‐ Only those members currently enrolled in 2021 plans that will continue to be offered in 20222021 MEMBERS ‐ Only those members currently enrolled in 2021 plans Including plans that will be discontinued in 2022 ***** Columns CH ‐ CO apply to SMALL GROUP ONLY *****



(14 Digits)Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010495Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010496Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010497Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010498Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010499Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010500Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010485Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010486Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010487Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010488Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010489Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010490Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010491Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010492Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010485Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010486Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010487Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010488Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010489Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010490Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010491Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010492Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010565Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010566Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010567Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010568Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010569Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010570Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010571Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010572Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010565Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010566Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010567Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010568Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010569Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010570Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010571Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010572Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010701Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010703Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010705Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010707Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010709Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010711Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010713Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010715Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010701Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010703Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010705Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010707Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010709Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010711Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010713Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010715Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010702Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010704Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010706Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010708Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010710Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010712Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010714Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010716Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010725Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010726Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010727Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010728Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010729Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010730Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010731Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010732Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010757Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010758Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010759Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010760Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010761Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010762Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010763Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010764Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010765Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010766Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010767Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010768Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010769Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010770Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010771Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010772Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010773Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010774Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010775Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010776Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010777Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010778Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010779Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010780Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010781Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010782Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010783Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010784Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010785Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010786Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010787Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010788Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010789Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010790Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010791Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010792Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010793Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010794Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010795Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010796Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010789Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010790Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010791Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010792Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010793Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010794Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010795Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010796Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010733Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010734Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010735Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010736Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010737Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010738Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010739Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010740Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010741Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010742Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010743Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010744Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010745Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010746Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010747Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010748Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010749Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010750Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010751Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010752Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010753Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010754Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010755Oxford Health Insuran78026 UHLC-132808091 Small Group 85629NY0010756





3/31/2021 (Albany)


3/31/2021 (Buffalo)


Hudson)


3/31/2021 (New York)






3/31/2021 (Utica)


Island)


3/31/2021 (Albany)


3/31/2021 (Buffalo)


Hudson)


3/31/2021 (New York)






3/31/2021 (Utica)


Island)

2021 MEMBERS (Should be consistent with DFS Membership Survey) ‐ Only those members currently enrolled in 2021 plans that will continue to be offered in 20222021 MEMBERS ‐ Only those members currently enrolled in 2021 plans Including plans that will be discontinued in 2022 ***** Columns CH ‐ CO apply to SMALL GROUP ONLY *****

n/a n/a 828.43n/a n/a 8.00 0.00 n/a n/a n/a 16.00n/a n/a 8.00 0.00 n/a n/a n/a 16.00n/a n/a 823.77n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 848.33n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 848.33n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 843.67n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 843.67n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 787.55n/a n/a 13.00 478.00n/a n/a n/a 110.00n/a n/a 13.00 478.00n/a n/a n/a 110.00n/a n/a 782.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 787.55n/a n/a 18.00 564.00n/a n/a n/a 100.00n/a n/a 18.00 564.00n/a n/a n/a 100.00n/a n/a 782.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 807.45n/a n/a 0.00 22.00n/a n/a n/a 8.00 n/a n/a 0.00 22.00n/a n/a n/a 8.00n/a n/a 807.45n/a n/a 0.00 11.00n/a n/a n/a 14.00n/a n/a 0.00 11.00n/a n/a n/a 14.00n/a n/a 802.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 802.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 787.55n/a n/a 7.00 16.00n/a n/a n/a 0.00 n/a n/a 7.00 16.00n/a n/a n/a 0.00n/a n/a 782.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 787.55n/a n/a 0.00 5.00 n/a n/a n/a 2.00 n/a n/a 0.00 5.00 n/a n/a n/a 2.00n/a n/a 782.89n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 807.45n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 807.45n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 802.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 802.79n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 858.26n/a n/a 77.00 1,557.00n/a n/a n/a 588.00n/a n/a 77.00 1,557.00n/a n/a n/a 588.00n/a n/a 853.60n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 858.26n/a n/a 11.00 2,712.00n/a n/a n/a 850.00n/a n/a 11.00 2,712.00n/a n/a n/a 850.00n/a n/a 853.60n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 878.16n/a n/a 0.00 107.00n/a n/a n/a 27.00n/a n/a 0.00 107.00n/a n/a n/a 27.00n/a n/a 878.16n/a n/a 0.00 59.00n/a n/a n/a 66.00n/a n/a 0.00 59.00n/a n/a n/a 66.00n/a n/a 873.50n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 873.50n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 858.26n/a n/a 0.00 11.00n/a n/a n/a 4.00 n/a n/a 0.00 11.00n/a n/a n/a 4.00n/a n/a 853.60n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 858.26n/a n/a 2.00 3.00 n/a n/a n/a 10.00n/a n/a 2.00 3.00 n/a n/a n/a 10.00n/a n/a 853.60n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 878.16n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 878.16n/a n/a 0.00 3.00 n/a n/a n/a 0.00 n/a n/a 0.00 3.00 n/a n/a n/a 0.00n/a n/a 873.50n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 873.50n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 963.71n/a n/a 29.00 269.00n/a n/a n/a 102.00n/a n/a 29.00 269.00n/a n/a n/a 102.00n/a n/a 959.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 963.71n/a n/a 0.00 324.00n/a n/a n/a 100.00n/a n/a 0.00 324.00n/a n/a n/a 100.00n/a n/a 959.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 983.61n/a n/a 0.00 14.00n/a n/a n/a 10.00n/a n/a 0.00 14.00n/a n/a n/a 10.00n/a n/a 983.61n/a n/a 0.00 5.00 n/a n/a n/a 6.00 n/a n/a 0.00 5.00 n/a n/a n/a 6.00n/a n/a 978.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 978.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 963.71n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 959.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 963.71n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 959.05n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 983.61n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 983.61n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 978.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 978.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 918.05n/a n/a 0.00 53.00n/a n/a n/a 6.00 n/a n/a 0.00 53.00n/a n/a n/a 6.00n/a n/a 913.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 918.05n/a n/a 0.00 194.00n/a n/a n/a 14.00n/a n/a 0.00 194.00n/a n/a n/a 14.00n/a n/a 913.39n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 937.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 937.95n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 933.29n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 933.29n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,089.96n/a n/a 9.00 276.00n/a n/a n/a 179.00n/a n/a 9.00 276.00n/a n/a n/a 179.00n/a n/a 1,085.30n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,089.96n/a n/a 0.00 258.00n/a n/a n/a 192.00n/a n/a 0.00 258.00n/a n/a n/a 192.00n/a n/a 1,085.30n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,109.86n/a n/a 0.00 14.00n/a n/a n/a 1.00 n/a n/a 0.00 14.00n/a n/a n/a 1.00n/a n/a 1,109.86n/a n/a 0.00 44.00n/a n/a n/a 35.00n/a n/a 0.00 44.00n/a n/a n/a 35.00n/a n/a 1,105.20n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,105.20n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,190.18n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,185.52n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,190.18n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,185.52n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,210.08n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,210.08n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,205.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,205.42n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 958.51n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 953.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 958.51n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 953.85n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 978.41n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 978.41n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 973.75n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 973.75n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,148.88n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,144.22n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,148.88n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,144.22n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,168.78n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,168.78n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,164.12n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,164.12n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,315.60n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,310.94n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,315.60n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,310.94n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,335.50n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,335.50n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,330.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,330.84n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 864.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 859.38n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 864.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 859.38n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 883.94n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 883.94n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 879.28n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 879.28n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 864.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 859.38n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 864.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 859.38n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 883.94n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 883.94n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 879.28n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 879.28n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,348.02n/a n/a 1.00 359.00n/a n/a n/a 64.00n/a n/a 1.00 359.00n/a n/a n/a 64.00n/a n/a 1,343.36n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,348.02n/a n/a 0.00 44.00n/a n/a n/a 43.00n/a n/a 0.00 44.00n/a n/a n/a 43.00n/a n/a 1,343.36n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,367.92n/a n/a 0.00 16.00n/a n/a n/a 5.00 n/a n/a 0.00 16.00n/a n/a n/a 5.00n/a n/a 1,367.92n/a n/a 0.00 0.00 n/a n/a n/a 3.00 n/a n/a 0.00 0.00 n/a n/a n/a 3.00n/a n/a 1,363.26n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,363.26n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,108.95n/a n/a 1.00 80.00n/a n/a n/a 43.00n/a n/a 1.00 80.00n/a n/a n/a 43.00n/a n/a 1,104.29n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,108.95n/a n/a 6.00 147.00n/a n/a n/a 116.00n/a n/a 6.00 147.00n/a n/a n/a 116.00n/a n/a 1,104.29n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,128.85n/a n/a 0.00 7.00 n/a n/a n/a 5.00 n/a n/a 0.00 7.00 n/a n/a n/a 5.00n/a n/a 1,128.85n/a n/a 0.00 13.00n/a n/a n/a 2.00 n/a n/a 0.00 13.00n/a n/a n/a 2.00n/a n/a 1,124.19n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 1,124.19n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 947.80n/a n/a 0.00 97.00n/a n/a n/a 76.00n/a n/a 0.00 97.00n/a n/a n/a 76.00n/a n/a 943.14n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 947.80n/a n/a 22.00 190.00n/a n/a n/a 209.00n/a n/a 22.00 190.00n/a n/a n/a 209.00n/a n/a 943.14n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 967.70n/a n/a 0.00 0.00 n/a n/a n/a 1.00 n/a n/a 0.00 0.00 n/a n/a n/a 1.00n/a n/a 967.70n/a n/a 0.00 0.00 n/a n/a n/a 4.00 n/a n/a 0.00 0.00 n/a n/a n/a 4.00n/a n/a 963.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00n/a n/a 963.04n/a n/a 0.00 0.00 n/a n/a n/a 0.00 n/a n/a 0.00 0.00 n/a n/a n/a 0.00


UnitedHealthcare 4 Research Drive Shelton, CT 06484

<Date> <First Name> <Last Name> <Address> <Address 2> <City>, < State> < ZIP Code>

Dear <First Name>, We want to give you some important information about your health insurance. New York State Department of Financial Services (DFS) has approved new premium rates for your employer’s Oxford Health Insurance, Inc. plan. The new rates are scheduled to begin on <Effective Date> and will be in place for 12 months. The chart below shows:

The new rates could change if:

Your employer makes benefit changes. Benefits are required to be added during the plan year. Your employer is considered a large group (101 or more employees) on the next renewal.

If you have questions about this notice, please talk to your employer’s benefit administrator. We value you as a member and thank you for your continued participation in our plan. Sincerely,

Charles Cerniglia Vice President, Key Account & Small Business Sales and Account Management

Notice of Premium Rate Change <Group Name><Cirrus Group #><Plan ID>

THIS IS NOT A BILL

The premium rates your employer pays now. The new rates that we can charge your employer in 2022.

Remember, the specific monthly premium rate that you pay is determined by your employer.

Monthly premiums for <Plan Design Name> TIERS CURRENT RATES 2022 RENEWAL RATES Single $<Curr single rate> $<Renew Single rate> Couple $<Curr Couple rate> $<Renew Couple rate> Parent/Children $<Curr P/CH rate> $<Renew P/CH rate> Family $<Curr Fam rate> $<Renew Fam rate>

EI20388503 Oxford NYSG Notice of Renewal and Premium Rates (Automated) 5.21 – 12.21

4 Research Drive

Shelton, CT 06484

<Date>

<BA Name>

<Address>

<City>, <State> <ZIP>

NOTICE OF RENEWAL AND <current year> PREMIUM RATES

Dear <BA First Name>,

Your group health insurance coverage is coming up for renewal. Your group policy will be automatically renewed on

<effective date> as long as your group continues to be eligible. Your group’s members will be automatically re-

enrolled unless you choose another policy. Included are changes we’ll be making to your policy, the new premium for

this policy, and some information about options if you wish to change policies.

Premium Rate Changes:

The premium rates for your health insurance policy are changing. The new rates will take effect on <effective date>.

The new rates below have been approved by the New York State Department of Financial Services (DFS). This will

provide an estimate based on current enrollment of your group. This amount may change depending on the individuals

who actually enroll in the policy. To view the rates for your renewing Oxford1 policy please go to the “Review” section of

this package.

You may visit the DFS website at www.dfs.ny.gov for more information regarding this rate change. You may also contact

us by calling Client Services at 1-888-201-4216 or via email at [email protected] or via our employer

website at uhceservices.com for further information about this rate change.

Other Changes to Your Current Health Insurance Policy:

This package includes information about upcoming changes to your renewing Oxford plan.

Your Summary of Benefits and Coverage (SBC) has more information about specific member cost-share and benefit

changes. You will need to send the SBC to your employees and dependents. The SBC should be available on

uhceservices.com within 60 days of <effective date>. If you are unable to successfully retrieve the SBC via

uhceservices.com or if you would prefer to receive a paper copy of the SBC, employers can request a printed copy by

contacting Client Services at 1-888-201-4216. Members can request a printed copy by calling the toll-free number on

their health plan ID card. We will mail a paper copy of the SBC within 7 business days of the request.

How to download your SBC:

Login to uhceservices.com

Select “Plan Documents” from the top navigation bar

Select “View SBC” from the secondary navigation bar

Please refer to the enclosure titled “IMPORTANT NOTICE: Changes to Your <2021> New York Small Group

Plan” for a summary of the main benefit changes that will be implemented upon your renewal. Employees should

refer to their Certificate of Coverage (COC) during the plan year for details about their benefits and processes that

apply to their coverage.

Re: <Group Name>

Group Number: <#>

Current Plans:

<PLAN NAME / CODE>

Renewal date: <Date>


Coverage Options:

If you do not want your group’s current policy to automatically renew, you have the option of choosing a different policy

either from us or from another insurer. You can view your current renewal plan information within the “Review” section of

this package. To choose a new Oxford policy, use our small group online enrollment tool or call Client Services at

1-888-201-4216. You can also talk to your broker or agent.

If you select a new policy, you must send the following documents by <effective date>:

New York Small Group Application and Annual Certification Form (OHI)

This form is included in this renewal package and needs to be completed.

Tax Documentation

Examples of acceptable documents include:

Quarterly Combined Withholding

Wage Reporting and Unemployment Insurance Return Form (NYS-45)

Form 1120S and K1 (S Corporation)

Form 1120 (C Corporation) and Schedule C

If you filed a consolidated tax return as an affiliated group, please send your most recent IRS Form 851. For more

information, see the enclosed Oxford New York Small Group Tax Form Submission document.

If you are not submitting information online, a letter of request on company letterhead that is signed by an

authorized contact must be submitted. It should include requested changes in detail and a signed rate sheet. Send

these documents to:

UnitedHealthcare

Attn: Oxford Mailroom

3315 Central Ave

P.O. Box 29142

Hot Springs, AR 71913

You should also be aware of the following:

Audits:

We may do an audit of your group to make sure it meets eligibility and/or participation requirements. At that time,

additional documentation may be required, and any coverage by Oxford will be conditional upon review of

these documents. Eligibility and participation requirements for small group coverage are available on

uhceservices.com. You can access these requirements by selecting the “Resources” tab from the top navigation

bar. From there, select “Tools and Resources”, then “Group Administration”, then “Oxford New York Small Group

(1-100) Underwriting Requirements”.

If your group doesn’t meet the eligibility and/or participation requirements, we aren’t required to renew your

coverage because of any cashed premium checks. Your payment is sent to a lock box and the administrator

automatically cashes premium checks upon receipt. If your group is not renewed, we will refund any amounts you

have sent toward <current year> premiums.

Age 29 Coverage Option:

Under New York law, you may purchase extended coverage for dependents until they turn 30. This option helps

young adults who don’t have access to employer-sponsored health insurance. If you do not include this option,

eligible young adults may purchase coverage through a parent’s group health insurance under New York’s Young

Adult option without your contribution. The Young Adult option lets young adults continue coverage through a

parent’s group health insurance policy as a subscriber (instead of a dependent) until they turn 30 if certain

conditions are met.

If you currently offer Age 29 optional coverage and remove it as part of your upcoming renewal, please remember to

disenroll any dependents over Age of 26 who will no longer be eligible once you renew. Any ineligible dependents

remaining on the policy will be terminated as part of the renewal process. They may purchase the Young Adult

option, if eligible.


Health Savings Accounts (HSAs) and Actuarial Value:

Visit uhceservices.com if you are offering, or thinking about offering, an HSA plan. You can find information there

on HSA Contribution Requirements under the Affordable Care Act (ACA) and how your contributions can affect the

actuarial value of your health plan.

You may purchase a new policy from us or another insurer directly, or with the help of a broker or agent.

You may request a NYS Small Business employer eligibility determination through the NY State of Health Small Business

Marketplace (the “Marketplace”) by going to www.nystateofhealth.ny.gov. If your employees enroll in a Marketplace

certified policy offered through a variety of different insurance companies including Oxford; and if you meet all the

required IRS guidelines, this Marketplace eligibility determination allows employers to access the federal small business

health care tax credit.

You can only get the federal small business health care tax credit if the Marketplace determines that you are an eligible

employer and only if your employees enroll in a Marketplace certified insurance policy.

You generally can buy coverage for a group at any time throughout the year, but to avoid gaps in coverage, you should

enroll on or before <effective date>; at least one month before your renewal date of <effective date>.

Before You Decide:

Call us or visit our website to check which doctors, other health care providers and prescription medications are covered

by the new policy. This is an important step in selecting a policy that best meets the needs of your group. If you are

considering a new policy from us, our website address is uhceservices.com.

If You Have Questions:

Call your broker or Client Services at 1-888-201-4216, Monday through Friday, from 8 a.m. to 5 p.m. ET. You can

also reach us by email at [email protected] or visit our employer website at uhceservices.com.

Visit www.nystateofhealth.ny.gov to learn more about the New York State of Health Small Business Marketplace, or

call Marketplace Customer Service at 1-855-355-5777.

Getting Help in Other Languages:

Para obtener asistencia en Español, llame al 1-888-201-4216

若需中文協助，請致電1-800-767-3868

한국어로 도움이 필요하시면1-800-544-4249

Sincerely,

Client Services

CC: <Broker>

1Our Oxford small group products are underwritten by Oxford Health Insurance, Inc.

EI20420028 Oxford NYSG /Healthy NY Combo Notice of Renewal and Premium Rates (Automated) 5.21 – 12.21

4 Research Drive

Shelton, CT 06484

<Date>

<BA Name>

<Address>

<City>, <State> <ZIP>

NOTICE OF RENEWAL AND <current year> PREMIUM RATES

Dear <BA First Name>,

Your group health insurance coverage is coming up for renewal.

We must receive your completed Healthy NY Recertification and Plan Selection Form to confirm that your group

continues to meet the Healthy NY program requirements in order to automatically enroll your group’s members in

the new plan effective <effective date>.

For all other New York small group policies, your group’s members will be automatically re-enrolled as long as your

group continues to be eligible or unless you choose another policy.

Included are changes we’ll be making to your policy, the new premium for this policy, and some information about

options if you wish to change policies.


The premium rates for your health insurance policy are changing. The new rates will take effect on <effective date>.

The new rates below have been approved by the New York State Department of Financial Services (DFS). This will

provide an estimate based on current enrollment of your group. This amount may change depending on the individuals

who actually enroll in the policy. To view the rates for your renewing Oxford1 policies please go to the “Review” section

of this package.

You may visit the DFS website at www.dfs.ny.gov for more information regarding this rate change. You may also contact

us by calling Client Services at 1-888-201-4216 or via email at [email protected] or via our employer

website at uhceservices.com for further information about this rate change.


This package includes information about upcoming changes to your renewing Oxford plan. Note that there is only one

Oxford Healthy NY small group cost-share option available for <current year>. The cost-shares for your plan are

remaining the same.

Your Summary of Benefits and Coverage (SBC) has more information about specific member cost-share and benefit

changes. You will need to send the SBC to your employees and dependents. The SBC should be available on

uhceservices.com within 60 days of <effective date>. If you are unable to successfully retrieve the SBC via

uhceservices.com or if you would prefer to receive a paper copy of the SBC, employers can request a printed copy by

contacting Client Services at 1-888-201-4216. Members can request a printed copy by calling the toll-free number on

their health plan ID card. We will mail a paper copy of the SBC within 7 business days of the request.

Re: <Group Name>

Group Number: <#>

Current Plans:

<PLAN NAME / CODE>







We have enclosed notices that outline your <2021> benefit changes, which will be implemented upon your

renewal. Employees should refer to their Certificate of Coverage (COC) during the plan year for details about their

benefits and processes that apply to their coverage.

Coverage Options:

If you do not want your group’s current policy to automatically renew, you have the option of choosing a different policy

either from us or from another insurer. You can view your current renewal plan information within the “Review” section of

this package. To choose a new Oxford policy, use our small group online enrollment tool or call Client Services at

1-888-201-4216. You can also talk to your broker or agent.

If you select a new policy, you must send the following documents by <effective date>:

New York Small Group Application and Annual Certification Form (OHI)

This form is included in this renewal package and needs to be completed.

Tax Documentation

Examples of acceptable documents include:

Quarterly Combined Withholding

Wage Reporting and Unemployment Insurance Return Form (NYS-45)

Form 1120S and K1 (S Corporation)

Form 1120 (C Corporation) and Schedule C

If you filed a consolidated tax return as an affiliated group, please send your most recent IRS Form 851. For more

information, see the enclosed Oxford New York Small Group Tax Form Submission document.

If you are not submitting information online, a letter of request on company letterhead that is signed by an

authorized contact must be submitted. It should include requested changes in detail and a signed rate sheet. Send

these documents to:

UnitedHealthcare

Attn: Oxford Mailroom

3315 Central Ave

P.O. Box 29142

Hot Springs, AR 71913


Audits:

We may do an audit of your group to make sure it meets eligibility and/or participation requirements and/or

contribution requirements for the Healthy NY plan or another plan you select. At that time, additional

documentation may be required, and any coverage by Oxford will be conditional upon review of these

documents. Eligibility and participation requirements for small group coverage are available on uhceservices.com.

You can access these requirements by selecting the “Resources” tab from the top navigation bar. From there, select

“Tools and Resources”, then “Group Administration”, then “Oxford New York Small Group (1-100) Underwriting

Requirements”.

If your group doesn’t meet the eligibility and/or participation requirements, we aren’t required to renew your


automatically cashes premium checks upon receipt. If your group is not renewed, we will refund any amounts you

have sent toward <current year> premiums.



Under New York law, you may purchase extended coverage for dependents until they turn 30. This option helps

young adults who don’t have access to employer-sponsored health insurance. If you do not include this option,

eligible young adults may purchase coverage through a parent’s group health insurance under New York’s Young

Adult option without your contribution. The Young Adult option lets young adults continue coverage through a

parent’s group health insurance policy as a subscriber (instead of a dependent) until they turn 30 if certain

conditions are met.

If you currently offer Age 29 optional coverage and remove it as part of your upcoming renewal, please remember to

disenroll any dependents over Age of 26 who will no longer be eligible once you renew. Any ineligible dependents

remaining on the policy will be terminated as part of the renewal process. They may purchase the Young Adult

option, if eligible.


Visit uhceservices.com if you are offering, or thinking about offering, an HSA plan. You can find information there

on HSA Contribution Requirements under the Affordable Care Act (ACA) and how your contributions can affect the

actuarial value of your health plan.


You may request a NYS Small Business employer eligibility determination through the NY State of Health Small Business

Marketplace (the “Marketplace”) by going to www.nystateofhealth.ny.gov. If your employees enroll in a Marketplace

certified policy offered through a variety of different insurance companies including Oxford; and if you meet all the

required IRS guidelines, this Marketplace eligibility determination allows employers to access the federal small business

health care tax credit.

You can only get the federal small business health care tax credit if the Marketplace determines that you are an eligible

employer and only if your employees enroll in a Marketplace certified insurance policy.

You generally can buy coverage for a group at any time throughout the year, but to avoid gaps in coverage, you should

enroll on or before <effective date>; at least one month before your renewal date of <effective date>.

Before You Decide:

Call us or visit our website to check which doctors, other health care providers and prescription medications are covered

by the new policy. This is an important step in selecting a policy that best meets the needs of your group. If you are

considering a new policy from us, our website address is uhceservices.com.


Call your broker or Client Services at 1-888-201-4216, Monday through Friday, from 8 a.m. to 5 p.m. ET. You can

also reach us by email at [email protected] or visit our employer website at uhceservices.com.

Visit www.nystateofhealth.ny.gov to learn more about the New York State of Health Small Business Marketplace, or

call Marketplace Customer Service at 1-855-355-5777.



若需中文協助，請致電1-800-767-3868


Sincerely,

Client Services

CC: <Broker>

1Our Oxford New York small group products are underwritten by Oxford Health Insurance, Inc.

EI203885014 Oxford Healthy NYSG Notice of Renewal and Premium Rates 5.21 – 12.21

4 Research Drive

Shelton, CT 06484

<Date>

<Benefits Administrator>

<Group Name>

<Group Address>

<City, State, ZIP>

Dear <Benefits Administrator>,

Your group health insurance coverage is coming up for renewal. Your group policy will be automatically renewed

on <effective date> as long as your group continues to be eligible. Once we receive your completed Healthy NY

Recertification and Plan Selection Form and have confirmed that your group continues to meet the Healthy NY

program requirements, we will automatically enroll your group’s members in the new plan effective <effective

date>. Included in this package are changes we will be making to your policy from the prior year.


The premium rates for your health insurance policy are changing. The new rates will take effect on <effective

date>. The new rates below have been approved by the New York State Department of Financial Services (DFS).

This will provide an estimate based on current enrollment of your group. This amount may change depending on

the individuals who actually enroll in the policy. To view the rates for your renewing Oxford1 Healthy New York

small group policy please go to the “Review” section of this package.

You may visit the DFS website at www.dfs.ny.gov for more information regarding this rate change. You may also

contact us by calling Client Services at 1-888-201-4216 or via email at [email protected] or via

our employer website at uhceservices.com for further information about this rate change.


This package includes information about upcoming changes to your renewing Oxford plan.

There is only one Oxford Healthy NY small group cost-share option available for <current year>. The cost-shares

for your plan are remaining the same. Your Summary of Benefits and Coverage (SBC) has more information about

specific member cost-share and benefit changes. You will need to send the SBC to your employees and

dependents. The SBC should be available on uhceservices.com within 60 days of <effective date>. If you are

unable to successfully retrieve the SBC via uhceservices.com or if you would prefer to receive a paper copy of

the SBC, employers can request a printed copy by contacting Client Services at 1-888-201-4216. Members can

request a printed copy by calling the toll-free number on their health plan ID card. We will mail a paper copy of

the SBC within 7 business days of the request.





NOTICE OF RENEWAL AND <effective year> PREMIUM RATES

Re: <Group Name>

Group Number: <#>

Current Plans:

<PLAN NAME / CODE>



Please refer to the enclosure titled IMPORTANT NOTICE: Changes to Your <current year> Healthy New York

Small Group Plan for a summary of the main benefit changes that will be implemented upon your renewal.

Employees should refer to their Certificate of Coverage (COC) during the plan year for details about their benefits

and processes that apply to their coverage.

Coverage Options:

You also have the option of choosing a different policy either from us or from another insurer. To choose a new

Oxford policy directly from us, call Client Services at 1-888-201-4216 or contact your broker or agent.


Audits:

We may do an audit of your group to make sure it meets eligibility, participation and/or contribution

requirements for the Healthy NY plan or another plan you select. At that time, additional documentation

may be required, and any coverage by Oxford will be conditional upon review of these documents. The

materials in this package provide more information about the Healthy NY requirements. Eligibility and

participation requirements for small group coverage are available on uhceservices.com. You can access

these requirements by selecting the “Resources” tab from the top navigation bar. From there, select “Tools

and Resources”, then “Group Administration”, then “Oxford New York Small Group (1-100) Underwriting

Requirements”.

If your group doesn’t meet eligibility and participation requirements, we aren’t required to replace your


automatically cashes premium checks upon receipt. If your group’s members are not automatically enrolled,

we will refund any amounts you have sent toward <current year> premiums.


Under New York law, you may purchase extended coverage for dependents until they turn 30. This option

helps young adults who don’t have access to employer-sponsored health insurance. If you do not include this

option, eligible young adults may purchase coverage through a parent’s group health insurance under New

York’s Young Adult option without your contribution. The Young Adult option lets young adults continue

coverage through a parent’s group health insurance policy as a subscriber (instead of a dependent) until they

turn 30 if certain conditions are met.

If you currently offer Age 29 optional coverage and remove it as part of your upcoming renewal, please

remember to disenroll any dependents over Age of 26 who will no longer be eligible once you renew. Any

ineligible dependents remaining on the policy will be terminated as part of the renewal process. They may

purchase the Young Adult option, if eligible.


Visit uhceservices.com if you are offering, or thinking about offering, an HSA plan. You can find information

there on HSA Contribution Requirements under the Affordable Care Act (ACA) and how your contributions

can affect the actuarial value of your health plan.


You may request a NYS Small Business employer eligibility determination through the NY State of Health Small

Business Marketplace (the “Marketplace”) by going to www.nystateofhealth.ny.gov. If your employees enroll in a

Marketplace certified policy offered through a variety of different insurance companies including Oxford; and if

you meet all the required IRS guidelines, this Marketplace eligibility determination allows employers to access the

federal small business health care tax credit.

You can only get the federal small business health care tax credit if the Marketplace determines that you are an

eligible employer and only if your employees enroll in a Marketplace certified insurance policy.

You generally can buy coverage for a group at any time throughout the year, but to avoid gaps in coverage, you

should enroll on or before <date>; at least one month before your renewal date of <effective date>.


Before You Decide:

Call us or visit our website to check which doctors, other health care providers and prescription medications are

covered by the new policy. This is an important step in selecting a policy that best meets the needs of your group.

If you are considering a new policy from us, our website address is uhceservices.com.


Call your broker or Client Services at 1-888-201-4216, Monday through Friday, from 8 a.m. to 5 p.m. ET. You

can also reach us by email at [email protected] or visit our employer website at

uhceservices.com.

Visit www.nystateofhealth.ny.gov to learn more about the New York State of Health Small Business

Marketplace, or call Marketplace Customer Service at 1-855-355-5777.



若需中文協助，請致電1-800-767-3868


Sincerely,

Client Services

Cc: <Broker>

1Our Oxford Healthy NY small group product is underwritten by Oxford Health Insurance, Inc.

4 Research Drive

Shelton, CT 06484

<Date>

<Benefit Administrator First Name> <Benefit Administrator Last Name>

<Group Name>

<Group Address 1>

<Group Address 2>

<City>, <State> <Zip>

Re: Notice of Proposed Premium Rate Change

< Group ID>, <Product-Medical Marketing Name >, <HIOS ID>

Dear <Benefit Administrator First Name> <Benefit Administrator Last Name>:

Oxford Health Insurance, Inc. (OHI) is filing a request with the New York State Department of Financial

Services (DFS) to approve a change to your group premium rates for 2022. New York Insurance Law

requires that we provide a notice to you when we submit requests for premium rate changes to DFS.

DFS is required by law to review our requested rate change. DFS may approve, modify or disapprove the

requested rate change.

Proposed Premium Rate Changes

If approved, the percentage change to your group’s premium is <Increase>%.

Please note that the final approved rate may differ because DFS may modify the proposed rate. In

addition, while we try to provide you with the most accurate information possible, the final approved rate

may differ based on the benefit plan design and other features that your group policyholder selects on

renewal.

Why We Are Requesting a Rate Change

The requested increase is due to our view of projected claims. Rising medical expenses are the main

reason for the requested increase. A number of factors contribute to these rising costs, including increases

in the cost of medical services and increases in the amount of services used. A part of the medical costs

includes a pooling technique established under the Affordable Care Act (ACA) called Federal Risk

Adjustment. The 2022 risk adjustment amount will be 14% lower due to a Centers for Medicare &

Medicaid Services (CMS) modification. This reduction increases our requested rates by 0.5% We have

prepared a narrative summary that provides a more detailed explanation of the reasons why we are

seeking a premium rate adjustment. This summary will be posted on our website and the DFS website.

Our rate application will also be posted on the DFS website.

30-day Comment Period

You can contact us or DFS to ask for more information or submit comments to DFS about the proposed

rate changes. The comments must be made within 30 days from the date of this notice.

(over, please)

You can contact us for additional information at:

Oxford NY Prior Approval

4 Research Drive

Shelton, CT 06484

1-888-201-4216

Comments or requests for more information on the proposed rate change may be submitted to DFS by

visiting the DFS website or via standard mail as follows:

DFS website: dfs.ny.gov/consumers/health_insurance/health_insurance_premiums

United States Postal Service:

NYS Department of Financial Services

Health Bureau – Premium Rate Adjustments

One Commerce Plaza

Albany, NY 12257

If you choose to submit comments to DFS, please include the following information:

1. The name of your insurer

2. The name of your plan

3. Whether you have individual or group coverage

4. Your HIOS Plan ID number, which is <HIOS ID>

Written comments submitted to DFS will be posted on the DFS website without your personal

information.

Plain-English Summary of Rate Change

We have prepared a plain-English summary that provides a more detailed explanation of the reasons why

a premium rate change is being requested. You can find this information at the following websites:

Oxford client website: uhceservices.com


Notice of Approved Premium Rate

After DFS approves the final premium rate, which may differ from the requested rate noted above, you

will receive final rate information at least 60 days before your 2022 renewal date.

Sincerely,

Chuck Cerniglia

Senior Vice President, Sales and Account Management

Key Accounts and Small Business

NYSG OHI On&Off-Exchange Group Letter

4 Research Drive

Shelton, CT 06484

<Date>

<Subscriber First Name> Subscriber Middle Initial <Subscriber Last Name>

<Group Name>

<Address 1>

<Address 2>

<City>, <State> <Zip>

Re: Notice of Proposed Premium Rate Change

< Group ID>, <Product Name>, <HIOS ID>

Dear <Subscriber First Name> <Subscriber Last Name>:

Oxford Health Insurance, Inc. (OHI) is filing a request with the New York State Department of Financial

Services (DFS) to approve a change to your premium rates for 2022. New York Insurance Law requires

that we provide a notice to you when we submit requests for premium rate changes to DFS.

DFS is required by law to review our requested rate change. DFS may approve, modify or disapprove the

requested rate change.

Proposed Premium Rate Changes

If approved, the percentage change to your group’s premium is <Increase>%.

Please note that the final approved rate may differ because DFS may modify the proposed rate. In

addition, while we try to provide you with the most accurate information possible, the final approved rate

may differ based on the benefit plan design and other features that your group policyholder selects on

renewal.

Why We Are Requesting a Rate Change

The requested increase is due to our view of projected claims. Rising medical expenses are the main

reason for the requested increase. A number of factors contribute to these rising costs, including increases

in the cost of medical services and increases in the amount of services used. A part of the medical costs

includes a pooling technique established under the Affordable Care Act (ACA) called Federal Risk

Adjustment. The 2022 risk adjustment amount will be 14% lower due to a Centers for Medicare &

Medicaid Services (CMS) modification. This reduction increases our requested rates by 0.5%. We have

prepared a narrative summary that provides a more detailed explanation of the reasons why we are

seeking a premium rate adjustment. This summary will be posted on our website and the DFS website.

Our rate application will also be posted on the DFS website.

30-day Comment Period

You can contact us or DFS to ask for more information or submit comments to DFS about the proposed

rate changes. The comments must be made within 30 days from the date of this notice.

(over, please)

You can contact us for additional information at:

Oxford NY Prior Approval

4 Research Drive

Shelton, CT 06484

1-800-444-6222

myuhc.com

Comments or requests for more information on the proposed rate change may be submitted to DFS by

visiting the DFS website or via standard mail as follows:


United States Postal Service:

NYS Department of Financial Services

Health Bureau – Premium Rate Adjustments

One Commerce Plaza

Albany, NY 12257

If you choose to submit comments to DFS, please include the following information:

1. The name of your insurer

2. The name of your plan

3. Whether you have individual or group coverage

4. Your HIOS Plan ID number, which is <HIOS ID>

Written comments submitted to DFS will be posted on the DFS website without your personal

information.

Plain-English Summary of Rate Change

We have prepared a plain-English summary that provides a more detailed explanation of the reasons why

a premium rate change is being requested. You can find this information at the following websites:

Member website: myuhc.com®, then go to Legal > Required State Notices > New York.


Notice of Approved Premium Rate

After DFS approves the final premium rate, which may differ from the requested rate noted above, you

will receive final rate information at least 60 days before your 2022 renewal date.

Sincerely,

Chuck Cerniglia

Senior Vice President, Sales and Account Management

Key Accounts and Small Business

NYSG OHI On&Off-Exchange Subscriber Letter

1

23

4

5

678910111213141516171819202122

23242526272829303132333435363738394041

4243444546474849

5051

A B C D E F G H I J K L M N O P Q R S TPres

Unified Rate Review v5.3 [assistive technology users, please reference cell A1 for instructions] To add a product to Worksheet 2 - Plan Product Info, select the Add Product button or Ctrl + Shift + P.

To add a plan to Worksheet 2 - Plan Product Info, select the Add Plan button or Ctrl + Shift + L.Company Legal Name: OHI State: NY To validate, select the Validate button or Ctrl + Shift + I.

HIOS Issuer ID: 85629 Market: Small Group To finalize, select the Finalize button or Ctrl + Shift + F.

Effective Date of Rate Change(s): 1/1/2022

Section I: Experience Period DataExperience Period: 1/1/2020 to 12/31/2020

Total PMPM$4,145,225,382.93 $710.76

$0.00 $0.00$3,596,340,592.81 $616.65

$29,931,209.53 $5.13$4,341,303,079.58 $744.38

5,832,079

Section II: Projections

Benefit Category Experience Period Index Rate PMPM Cost Utilization Cost Utilization

Trended EHB Allowed Claims PMPM

Inpatient Hospital $169.07 1.046 1.033 1.046 1.033 $197.39Outpatient Hospital $125.60 1.046 1.033 1.046 1.033 $146.64Professional $198.06 1.046 1.033 1.046 1.033 $231.24Other Medical $75.01 1.046 1.033 1.046 1.033 $87.58Capitation $28.18 1.046 1.033 1.046 1.033 $32.90Prescription Drug $133.12 1.046 1.033 1.046 1.033 $155.42Total $729.04 $851.17

Morbidity Adjustment 1.000Demographic Shift 1.013Plan Design Changes 1.000Other 1.077Adjusted Trended EHB Allowed Claims PMPM for 1/1/2022 $928.63

Manual EHB Allowed Claims PMPM $0.00Applied Credibility % 100.00%

Projected Period TotalsProjected Index Rate for 1/1/2022 $928.63 $4,970,763,234.96Reinsurance $0.00 $0.00Risk Adjustment Payment/Charge $6.36 $34,043,757.12Exchange User Fees 0.00% $0.00Market Adjusted Index Rate $922.27 $4,936,719,477.84

Projected Member Months 5,352,792

Information Not Releasable to the Public Unless Authorized by Law: This information has not been publically disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Market Level Calculations (Same for all Plans)

Year 1 Trend Year 2 Trend

Allowed ClaimsReinsuranceIncurred Claims in Experience PeriodRisk AdjustmentExperience Period PremiumExperience Period Member Months

1 of 22

Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells P1 through P6. If screen reader fails to announce a cell after performing a dropdown selection, please press F2 and then ESC to force the screen reader to resume.Product-Plan Data Collection [assistive technology users, please reference cell A1 for instructions] To add a product to Worksheet 2 - Plan Product Info, select the Add Product button or Ctrl + Shift + P.

To add a plan to Worksheet 2 - Plan Product Info, select the Add Plan button or Ctrl + Shift + L.

Company Legal Name: OHI State: NY To validate, select the Validate button or Ctrl + Shift + I.

HIOS Issuer ID: 85629 Market: Small Group To finalize, select the Finalize button or Ctrl + Shift + F.Effective Date of Rate Change(s): 1/1/2022 To remove a product, navigate to the corresponding Product Name/Product ID field and select the Remove Product button or Ctrl + Shift + Q.

To remove a plan, navigate to the corresponding Plan Name/Plan ID field and select the Remove Plan button or Ctrl + Shift + A.

Field # Section I: General Product and Plan Information1.1 Product Name1.2 Product ID1.3 Plan Name NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG 1.4 Plan ID (Standard Component ID) 85629NY0010033 85629NY0010034 85629NY0010035 85629NY0010036 85629NY0010072 85629NY0010073 85629NY0010074 85629NY0010075 85629NY0010076 85629NY0010081 85629NY0010082 85629NY0010083 85629NY0010084 85629NY0010101 85629NY0010102 85629NY0010103 85629NY00101041.5 Metal Platinum Platinum Platinum Platinum Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold1.6 AV Metal Value 0.885 0.885 0.885 0.885 0.801 0.801 0.801 0.801 0.801 0.810 0.810 0.810 0.810 0.810 0.810 0.810 0.8101.7 Plan Category Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing1.8 Plan Type EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO1.9 Exchange Plan? No No No No No No No No No No No No No No No No No

1.10 Effective Date of Proposed Rates 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/20221.11 Cumulative Rate Change % (over 12 mos prior) 13.64% 13.61% 13.64% 13.61% 15.35% 15.35% 15.35% 15.35% 15.35% 14.99% 14.97% 14.99% 14.97% 14.97% 14.97% 14.98% 14.98%1.12 Product Rate Increase %1.13 Submission Level Rate Increase %

Worksheet 1 Totals Section II: Experience Period and Current Plan Level Information2.1 Plan ID (Standard Component ID) Total 85629NY0010033 85629NY0010034 85629NY0010035 85629NY0010036 85629NY0010072 85629NY0010073 85629NY0010074 85629NY0010075 85629NY0010076 85629NY0010081 85629NY0010082 85629NY0010083 85629NY0010084 85629NY0010101 85629NY0010102 85629NY0010103 85629NY0010104

$4,145,225,383 2.2 Allowed Claims $4,145,225,383 $7,289,120 $116,567,686 $15,664,600 $124,562,371 $0 $0 $0 $0 $26,248,011 $5,243,252 $57,156,950 $8,834,023 $60,330,801 $0 $0 $0 $0$0 2.3 Reinsurance $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2.4 Member Cost Sharing $548,884,790 $468,405 $7,853,086 $1,332,089 $8,770,186 $0 $0 $0 $0 $3,276,672 $603,270 $5,335,873 $785,179 $6,399,485 $0 $0 $0 $02.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

$3,596,340,593 2.6 Incurred Claims $3,596,340,593 $6,820,716 $108,714,601 $14,332,511 $115,792,185 $0 $0 $0 $0 $22,971,339 $4,639,982 $51,821,077 $8,048,844 $53,931,315 $0 $0 $0 $0$29,931,210 2.7 Risk Adjustment Transfer Amount $73,266,026 $53,925 $2,231,245 $228,104 $2,127,358 $0 $0 $0 $0 $346,003 $92,248 $998,382 $125,512 $1,064,762 $0 $0 $0 $0

$4,341,303,080 2.8 Premium $4,341,303,080 $7,821,441 $132,069,155 $13,501,650 $125,920,004 $0 $0 $0 $0 $20,480,175 $5,460,257 $59,094,990 $7,429,157 $63,024,109 $0 $0 $0 $05,832,079 2.9 Experience Period Member Months 5,832,079 9,004 136,140 16,933 133,882 0 0 0 0 31,955 7,107 72,110 10,203 79,448 0 0 0 0

2.10 Current Enrollment 446,066 844 10,165 1,242 9,734 0 0 0 0 2,370 594 5,573 790 5,861 0 0 0 02.11 Current Premium PMPM $801.32 $1,037.40 $1,023.71 $1,037.40 $1,023.71 $805.02 $805.02 $818.70 $818.70 $808.22 $880.00 $866.32 $880.00 $866.32 $863.11 $863.11 $876.80 $876.802.12 Loss Ratio 81.47% 86.61% 80.95% 104.39% 90.43% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 110.30% 83.57% 86.23% 106.54% 84.15% #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Per Member Per Month2.13 Allowed Claims $710.76 $809.54 $856.23 $925.09 $930.39 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $821.41 $737.76 $792.64 $865.83 $759.37 #DIV/0! #DIV/0! #DIV/0! #DIV/0!2.14 Reinsurance $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!2.15 Member Cost Sharing $94.11 $52.02 $57.68 $78.67 $65.51 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $102.54 $84.88 $74.00 $76.96 $80.55 #DIV/0! #DIV/0! #DIV/0! #DIV/0!2.16 Cost Sharing Reduction $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!2.17 Incurred Claims $616.65 $757.52 $798.55 $846.42 $864.88 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $718.87 $652.87 $718.64 $788.87 $678.83 #DIV/0! #DIV/0! #DIV/0! #DIV/0!2.18 Risk Adjustment Transfer Amount $12.56 $5.99 $16.39 $13.47 $15.89 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $10.83 $12.98 $13.85 $12.30 $13.40 #DIV/0! #DIV/0! #DIV/0! #DIV/0!2.19 Premium $744.38 $868.66 $970.10 $797.36 $940.53 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $640.91 $768.29 $819.51 $728.13 $793.27 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Section III: Plan Adjustment Factors3.1 Plan ID (Standard Component ID) 85629NY0010033 85629NY0010034 85629NY0010035 85629NY0010036 85629NY0010072 85629NY0010073 85629NY0010074 85629NY0010075 85629NY0010076 85629NY0010081 85629NY0010082 85629NY0010083 85629NY0010084 85629NY0010101 85629NY0010102 85629NY0010103 85629NY00101043.2 Market Adjusted Index Rate3.3 AV and Cost Sharing Design of Plan 1.0716 1.0572 1.0716 1.0572 0.8441 0.8441 0.8584 0.8584 0.8474 0.9198 0.9054 0.9198 0.9054 0.9020 0.9020 0.9164 0.91643.4 Provider Network Adjustment 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00003.5 Benefits in Addition to EHB 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

Administrative Costs3.6 Administrative Expense 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%3.7 Taxes and Fees 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.8 Profit & Risk Load 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%3.9 Catastrophic Adjustment 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

3.10 Plan Adjusted Index Rate $1,179.22 $1,163.37 $1,179.22 $1,163.37 $928.87 $928.87 $944.61 $944.61 $932.50 $1,012.18 $996.33 $1,012.18 $996.33 $992.59 $992.59 $1,008.43 $1,008.43

3.11 Age Calibration Factor 1.00003.12 Geographic Calibration Factor 1.00003.13 Tobacco Calibration Factor 1.00003.14 Calibrated Plan Adjusted Index Rate $1,179.22 $1,163.37 $1,179.22 $1,163.37 $928.87 $928.87 $944.61 $944.61 $932.50 $1,012.18 $996.33 $1,012.18 $996.33 $992.59 $992.59 $1,008.43 $1,008.43

Section IV: Projected Plan Level Information4.1 Plan ID (Standard Component ID) Total 85629NY0010033 85629NY0010034 85629NY0010035 85629NY0010036 85629NY0010072 85629NY0010073 85629NY0010074 85629NY0010075 85629NY0010076 85629NY0010081 85629NY0010082 85629NY0010083 85629NY0010084 85629NY0010101 85629NY0010102 85629NY0010103 85629NY00101044.2 Allowed Claims $5,215,753,155 $10,969,156 $130,335,465 $16,141,815 $124,809,190 $0 $0 $0 $0 $28,536,808 $7,266,469 $67,107,819 $9,664,160 $70,575,799 $0 $0 $0 $04.3 Reinsurance $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $04.4 Member Cost Sharing $1,020,404,489 $890,597 $10,582,068 $1,310,570 $10,133,384 $0 $0 $0 $0 $6,156,806 $1,178,070 $10,879,793 $1,566,793 $11,442,036 $0 $0 $0 $04.5 Cost Sharing Reduction $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $04.6 Incurred Claims $4,195,348,666 $10,078,559 $119,753,398 $14,831,245 $114,675,806 $0 $0 $0 $0 $22,380,002 $6,088,400 $56,228,026 $8,097,367 $59,133,763 $0 $0 $0 $04.7 Risk Adjustment Transfer Amount $34,276,179 $82,342 $978,390 $121,172 $936,906 $0 $0 $0 $0 $182,846 $49,742 $459,385 $66,156 $483,125 $0 $0 $0 $04.8 Premium $4,971,509,129 $11,943,143 $141,908,374 $17,575,099 $135,891,403 $0 $0 $0 $0 $26,520,414 $7,214,784 $66,630,492 $9,595,420 $70,073,805 $0 $0 $0 $04.9 Projected Member Months 5,352,792 10,128 121,980 14,904 116,808 0 0 0 0 28,440 7,128 66,876 9,480 70,332 0 0 0 0

4.10 Loss Ratio 83.81% 83.81% 83.81% 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% 83.81% 83.81% 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0!Per Member Per Month

4.11 Allowed Claims $974.40 $1,083.05 $1,068.50 $1,083.05 $1,068.50 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $1,003.40 $1,019.43 $1,003.47 $1,019.43 $1,003.47 #DIV/0! #DIV/0! #DIV/0! #DIV/0!4.12 Reinsurance $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!4.13 Member Cost Sharing $190.63 $87.93 $86.75 $87.93 $86.75 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $216.48 $165.27 $162.69 $165.27 $162.69 #DIV/0! #DIV/0! #DIV/0! #DIV/0!4.14 Cost Sharing Reduction $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!4.15 Incurred Claims $783.77 $995.12 $981.75 $995.12 $981.75 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $786.92 $854.15 $840.78 $854.15 $840.78 #DIV/0! #DIV/0! #DIV/0! #DIV/0!4.16 Risk Adjustment Transfer Amount $6.40 $8.13 $8.02 $8.13 $8.02 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $6.43 $6.98 $6.87 $6.98 $6.87 #DIV/0! #DIV/0! #DIV/0! #DIV/0!4.17 Premium $928.77 $1,179.22 $1,163.37 $1,179.22 $1,163.37 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $932.50 $1,012.18 $996.33 $1,012.18 $996.33 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Product/Plan Level Calculations

To remove a product, navigate to the corresponding Product Name/Product ID field and select the Remove Product button or Ctrl + Shift + Q.To remove a plan, navigate to the corresponding Plan Name/Plan ID field and select the Remove Plan button or Ctrl + Shift + A.

NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG 85629NY0010137 85629NY0010138 85629NY0010139 85629NY0010140 85629NY0010181 85629NY0010182 85629NY0010183 85629NY0010184 85629NY0010186 85629NY0010213 85629NY0010214 85629NY0010215 85629NY0010216 85629NY0010226 85629NY0010227 85629NY0010228 85629NY0010229 85629NY0010234 85629NY0010235 85629NY0010236 85629NY0010237 85629NY0010238

Silver Silver Silver Silver Silver Silver Silver Silver Silver Platinum Platinum Platinum Platinum Platinum Platinum Platinum Platinum Gold Gold Gold Gold Gold0.700 0.700 0.700 0.700 0.700 0.700 0.700 0.700 0.709 0.912 0.912 0.912 0.912 0.885 0.885 0.885 0.885 0.801 0.801 0.801 0.810 0.810

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPONo No No No No No No No No No No No No No No No No No No No No No

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202217.67% 17.71% 17.67% 17.71% 17.71% 17.71% 17.67% 17.67% 16.76% 13.63% 13.63% 13.66% 13.66% 13.60% 13.60% 13.63% 13.63% 15.36% 15.35% 15.36% 15.15% 15.14%

85629NY0010137 85629NY0010138 85629NY0010139 85629NY0010140 85629NY0010181 85629NY0010182 85629NY0010183 85629NY0010184 85629NY0010186 85629NY0010213 85629NY0010214 85629NY0010215 85629NY0010216 85629NY0010226 85629NY0010227 85629NY0010228 85629NY0010229 85629NY0010234 85629NY0010235 85629NY0010236 85629NY0010237 85629NY0010238$632,096 $17,620,141 $979,239 $13,612,277 $0 $0 $0 $0 $22,862,238 $0 $0 $0 $0 $0 $0 $0 $0 $2,072,176 $23,530,009 $3,374,743 $13,313,439 $123,138,721

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$94,499 $3,602,792 $239,241 $2,460,931 $0 $0 $0 $0 $4,058,655 $0 $0 $0 $0 $0 $0 $0 $0 $262,444 $2,960,978 $457,400 $1,238,989 $12,334,598

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$537,597 $14,017,349 $739,999 $11,151,346 $0 $0 $0 $0 $18,803,582 $0 $0 $0 $0 $0 $0 $0 $0 $1,809,732 $20,569,031 $2,917,344 $12,074,450 $110,804,123

$7,387 $361,177 $19,936 $250,036 $0 $0 $0 $0 $427,241 $0 $0 $0 $0 $0 $0 $0 $0 $30,180 $359,590 $32,234 $178,224 $2,356,554$437,260 $21,378,361 $1,180,045 $14,799,847 $0 $0 $0 $0 $25,288,755 $0 $0 $0 $0 $0 $0 $0 $0 $1,786,362 $21,284,432 $1,907,926 $10,549,196 $139,486,262

786 33,510 1,982 23,365 0 0 0 0 38,358 0 0 0 0 0 0 0 0 2,436 29,404 2,892 14,387 169,88554 2,906 172 2,273 0 0 0 0 2,574 0 0 0 0 0 0 0 0 265 1,911 266 1,053 11,274

$674.74 $661.06 $674.74 $661.06 $657.85 $657.85 $671.54 $671.54 $712.20 $1,042.47 $1,042.47 $1,056.16 $1,056.16 $1,020.50 $1,020.50 $1,034.19 $1,034.19 $821.91 $808.22 $821.91 $869.26 $855.58120.90% 64.48% 61.67% 74.10% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 73.12% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 99.63% 95.03% 150.37% 112.56% 78.12%

$804.19 $525.82 $494.07 $582.59 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $596.02 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $850.65 $800.23 $1,166.92 $925.38 $724.84$0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00

$120.23 $107.51 $120.71 $105.33 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $105.81 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $107.74 $100.70 $158.16 $86.12 $72.61$0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00

$683.97 $418.30 $373.36 $477.27 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $490.21 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $742.91 $699.53 $1,008.76 $839.26 $652.23$9.40 $10.78 $10.06 $10.70 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $11.14 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $12.39 $12.23 $11.15 $12.39 $13.87

$556.31 $637.97 $595.38 $633.42 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $659.28 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $733.32 $723.86 $659.73 $733.25 $821.06

85629NY0010137 85629NY0010138 85629NY0010139 85629NY0010140 85629NY0010181 85629NY0010182 85629NY0010183 85629NY0010184 85629NY0010186 85629NY0010213 85629NY0010214 85629NY0010215 85629NY0010216 85629NY0010226 85629NY0010227 85629NY0010228 85629NY0010229 85629NY0010234 85629NY0010235 85629NY0010236 85629NY0010237 85629NY0010238

0.7607 0.7455 0.7607 0.7455 0.7420 0.7420 0.7571 0.7571 0.7559 1.0768 1.0768 1.0912 1.0912 1.0538 1.0538 1.0682 1.0682 0.8619 0.8474 0.8619 0.9099 0.89550.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$794.15 $778.29 $794.15 $778.29 $774.63 $774.63 $790.40 $790.40 $831.81 $1,184.94 $1,184.94 $1,200.79 $1,200.79 $1,159.63 $1,159.63 $1,175.48 $1,175.48 $948.46 $932.50 $948.46 $1,001.28 $985.43

$794.15 $778.29 $794.15 $778.29 $774.63 $774.63 $790.40 $790.40 $831.81 $1,184.94 $1,184.94 $1,200.79 $1,200.79 $1,159.63 $1,159.63 $1,175.48 $1,175.48 $948.46 $932.50 $948.46 $1,001.28 $985.43

85629NY0010137 85629NY0010138 85629NY0010139 85629NY0010140 85629NY0010181 85629NY0010182 85629NY0010183 85629NY0010184 85629NY0010186 85629NY0010213 85629NY0010214 85629NY0010215 85629NY0010216 85629NY0010226 85629NY0010227 85629NY0010228 85629NY0010229 85629NY0010234 85629NY0010235 85629NY0010236 85629NY0010237 85629NY0010238$600,314 $31,660,244 $1,912,110 $24,763,845 $0 $0 $0 $0 $29,561,446 $0 $0 $0 $0 $0 $0 $0 $0 $3,245,423 $23,010,059 $3,257,670 $12,884,289 $135,763,196

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$166,035 $8,756,598 $528,852 $6,849,190 $0 $0 $0 $0 $7,879,603 $0 $0 $0 $0 $0 $0 $0 $0 $700,199 $4,964,412 $702,841 $2,207,385 $23,259,465

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$434,279 $22,903,646 $1,383,258 $17,914,655 $0 $0 $0 $0 $21,681,843 $0 $0 $0 $0 $0 $0 $0 $0 $2,545,224 $18,045,647 $2,554,829 $10,676,904 $112,503,731

$3,548 $187,124 $11,301 $146,364 $0 $0 $0 $0 $177,142 $0 $0 $0 $0 $0 $0 $0 $0 $20,795 $147,434 $20,873 $87,231 $919,160$514,622 $27,140,935 $1,639,168 $21,228,956 $0 $0 $0 $0 $25,693,092 $0 $0 $0 $0 $0 $0 $0 $0 $3,016,104 $21,384,182 $3,027,485 $12,652,185 $133,317,484

648 34,872 2,064 27,276 0 0 0 0 30,888 0 0 0 0 0 0 0 0 3,180 22,932 3,192 12,636 135,28883.81% 83.81% 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% 83.81% 83.81% 83.81% 83.81%

$926.41 $907.90 $926.41 $907.90 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $957.05 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $1,020.57 $1,003.40 $1,020.57 $1,019.65 $1,003.51$0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00



$794.17 $778.30 $794.17 $778.30 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $831.81 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $948.46 $932.50 $948.46 $1,001.28 $985.43

NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG 85629NY0010239 85629NY0010240 85629NY0010245 85629NY0010246 85629NY0010247 85629NY0010248 85629NY0010253 85629NY0010254 85629NY0010255 85629NY0010256 85629NY0010261 85629NY0010262 85629NY0010263 85629NY0010264 85629NY0010269 85629NY0010270 85629NY0010271 85629NY0010272 85629NY0010277 85629NY0010278 85629NY0010279 85629NY0010280

Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Silver Silver Silver Silver Silver Silver Silver Silver0.810 0.810 0.811 0.811 0.811 0.811 0.810 0.810 0.810 0.810 0.811 0.811 0.811 0.811 0.716 0.716 0.716 0.716 0.716 0.716 0.716 0.716


1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202215.15% 15.14% 15.21% 15.20% 15.21% 15.20% 15.14% 15.14% 15.14% 15.14% 15.20% 15.20% 15.20% 15.20% 17.40% 17.43% 17.40% 17.43% 17.44% 17.44% 17.40% 17.40%

85629NY0010239 85629NY0010240 85629NY0010245 85629NY0010246 85629NY0010247 85629NY0010248 85629NY0010253 85629NY0010254 85629NY0010255 85629NY0010256 85629NY0010261 85629NY0010262 85629NY0010263 85629NY0010264 85629NY0010269 85629NY0010270 85629NY0010271 85629NY0010272 85629NY0010277 85629NY0010278 85629NY0010279 85629NY0010280$20,342,089 $116,336,963 $8,435,969 $131,961,978 $14,225,186 $114,687,418 $0 $0 $0 $0 $898,899 $0 $0 $0 $818,088 $21,418,054 $5,612,774 $24,704,422 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$1,805,873 $11,836,942 $1,017,701 $13,997,031 $1,442,314 $12,444,084 $0 $0 $0 $0 $600,761 $0 $0 $0 $231,658 $4,428,849 $1,307,982 $4,710,318 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$18,536,215 $104,500,021 $7,418,269 $117,964,947 $12,782,873 $102,243,335 $0 $0 $0 $0 $298,139 $0 $0 $0 $586,430 $16,989,205 $4,304,792 $19,994,105 $0 $0 $0 $0

$225,993 $2,049,997 $143,059 $2,426,241 $196,737 $1,877,081 $0 $0 $0 $0 $1,148 $0 $0 $0 $17,663 $401,520 $63,217 $376,239 $0 $0 $0 $0$13,376,673 $121,340,947 $8,467,764 $143,611,127 $11,645,037 $111,105,918 $0 $0 $0 $0 $67,934 $0 $0 $0 $1,045,500 $23,766,291 $3,741,887 $22,269,880 $0 $0 $0 $0

18,945 157,240 11,534 181,035 18,304 149,659 0 0 0 0 83 0 0 0 1,743 37,191 6,548 37,889 0 0 0 01,370 10,933 947 12,434 1,361 10,141 0 0 0 0 5 0 0 0 134 2,840 433 2,861 0 0 0 0

$869.26 $855.58 $861.81 $848.12 $861.81 $848.12 $852.37 $852.37 $866.06 $866.06 $844.92 $844.92 $858.60 $858.60 $708.76 $695.07 $708.76 $695.07 $691.87 $691.87 $705.55 $705.55136.27% 84.69% 86.15% 80.78% 107.95% 90.49% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 431.58% #DIV/0! #DIV/0! #DIV/0! 55.16% 70.30% 113.13% 88.29% #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$1,073.74 $739.87 $731.40 $728.93 $777.16 $766.32 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $10,830.11 #DIV/0! #DIV/0! #DIV/0! $469.36 $575.89 $857.17 $652.02 #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$95.32 $75.28 $88.23 $77.32 $78.80 $83.15 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $7,238.08 #DIV/0! #DIV/0! #DIV/0! $132.91 $119.08 $199.75 $124.32 #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$978.42 $664.59 $643.17 $651.61 $698.36 $683.18 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $3,592.03 #DIV/0! #DIV/0! #DIV/0! $336.45 $456.81 $657.42 $527.70 #DIV/0! #DIV/0! #DIV/0! #DIV/0!$11.93 $13.04 $12.40 $13.40 $10.75 $12.54 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $13.83 #DIV/0! #DIV/0! #DIV/0! $10.13 $10.80 $9.65 $9.93 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$706.08 $771.69 $734.16 $793.28 $636.20 $742.39 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $818.48 #DIV/0! #DIV/0! #DIV/0! $599.83 $639.03 $571.45 $587.77 #DIV/0! #DIV/0! #DIV/0! #DIV/0!


0.9099 0.8955 0.9026 0.8882 0.9026 0.8882 0.8921 0.8921 0.9064 0.9064 0.8848 0.8848 0.8991 0.8991 0.7564 0.7420 0.7564 0.7420 0.7386 0.7386 0.7529 0.75291.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$1,001.28 $985.43 $993.25 $977.40 $993.25 $977.40 $981.69 $981.69 $997.43 $997.43 $973.66 $973.66 $989.40 $989.40 $832.36 $816.52 $832.36 $816.52 $812.78 $812.78 $828.51 $828.51

$1,001.28 $985.43 $993.25 $977.40 $993.25 $977.40 $981.69 $981.69 $997.43 $997.43 $973.66 $973.66 $989.40 $989.40 $832.36 $816.52 $832.36 $816.52 $812.78 $812.78 $828.51 $828.51

85629NY0010239 85629NY0010240 85629NY0010245 85629NY0010246 85629NY0010247 85629NY0010248 85629NY0010253 85629NY0010254 85629NY0010255 85629NY0010256 85629NY0010261 85629NY0010262 85629NY0010263 85629NY0010264 85629NY0010269 85629NY0010270 85629NY0010271 85629NY0010272 85629NY0010277 85629NY0010278 85629NY0010279 85629NY0010280$16,763,035 $131,656,823 $11,588,789 $149,731,912 $16,655,060 $122,119,295 $0 $0 $0 $0 $59,980 $0 $0 $0 $1,568,796 $32,616,125 $5,069,318 $32,857,301 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$2,871,907 $22,555,945 $2,063,709 $26,663,970 $2,965,901 $21,746,769 $0 $0 $0 $0 $10,681 $0 $0 $0 $439,313 $9,133,559 $1,419,571 $9,201,096 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$13,891,129 $109,100,878 $9,525,080 $123,067,942 $13,689,159 $100,372,527 $0 $0 $0 $0 $49,299 $0 $0 $0 $1,129,483 $23,482,566 $3,649,747 $23,656,205 $0 $0 $0 $0

$113,491 $891,359 $77,820 $1,005,470 $111,841 $820,048 $0 $0 $0 $0 $403 $0 $0 $0 $9,228 $191,854 $29,819 $193,272 $0 $0 $0 $0$16,461,057 $129,285,085 $11,287,267 $145,836,126 $16,221,722 $118,941,946 $0 $0 $0 $0 $58,420 $0 $0 $0 $1,338,443 $27,826,958 $4,324,968 $28,032,721 $0 $0 $0 $0

16,440 131,196 11,364 149,208 16,332 121,692 0 0 0 0 60 0 0 0 1,608 34,080 5,196 34,332 0 0 0 083.81% 83.81% 83.81% 83.81% 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% #DIV/0! #DIV/0! #DIV/0! 83.81% 83.81% 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$1,019.65 $1,003.51 $1,019.78 $1,003.51 $1,019.78 $1,003.51 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $999.67 #DIV/0! #DIV/0! #DIV/0! $975.62 $957.05 $975.62 $957.05 #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$174.69 $171.93 $181.60 $178.70 $181.60 $178.70 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $178.02 #DIV/0! #DIV/0! #DIV/0! $273.20 $268.00 $273.20 $268.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$844.96 $831.59 $838.18 $824.81 $838.18 $824.81 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $821.65 #DIV/0! #DIV/0! #DIV/0! $702.41 $689.04 $702.41 $689.04 #DIV/0! #DIV/0! #DIV/0! #DIV/0!$6.90 $6.79 $6.85 $6.74 $6.85 $6.74 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $6.71 #DIV/0! #DIV/0! #DIV/0! $5.74 $5.63 $5.74 $5.63 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$1,001.28 $985.43 $993.25 $977.40 $993.25 $977.40 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $973.66 #DIV/0! #DIV/0! #DIV/0! $832.36 $816.52 $832.36 $816.52 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY B FRDM NG NY B FRDM NG NY B FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY B FRDM NG NY B FRDM NG NY B FRDM NG NY B FRDM NG NY B FRDM NG 85629NY0010287 85629NY0010288 85629NY0010293 85629NY0010294 85629NY0010295 85629NY0010296 85629NY0010297 85629NY0010298 85629NY0010299 85629NY0010300 85629NY0010309 85629NY0010310 85629NY0010311 85629NY0010312 85629NY0010313 85629NY0010314 85629NY0010315 85629NY0010316 85629NY0010325 85629NY0010326 85629NY0010327 85629NY0010328

Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Bronze Bronze Bronze Silver Silver Silver Silver Bronze Bronze Bronze Bronze Bronze0.709 0.709 0.712 0.712 0.712 0.709 0.709 0.709 0.709 0.712 0.648 0.648 0.648 0.712 0.712 0.712 0.712 0.648 0.648 0.648 0.648 0.648


1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202216.74% 16.76% 16.72% 16.73% 16.72% 16.76% 16.76% 16.73% 16.73% 16.73% 20.12% 20.22% 20.12% 16.74% 16.74% 16.71% 16.71% 20.22% 20.24% 20.24% 20.13% 20.13%

85629NY0010287 85629NY0010288 85629NY0010293 85629NY0010294 85629NY0010295 85629NY0010296 85629NY0010297 85629NY0010298 85629NY0010299 85629NY0010300 85629NY0010309 85629NY0010310 85629NY0010311 85629NY0010312 85629NY0010313 85629NY0010314 85629NY0010315 85629NY0010316 85629NY0010325 85629NY0010326 85629NY0010327 85629NY0010328$2,781,180 $26,213,827 $4,946,918 $94,346,397 $8,215,333 $0 $0 $0 $0 $94,073,474 $6,496,073 $97,701,404 $8,541,377 $0 $0 $0 $0 $80,268,686 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$438,701 $4,281,030 $899,190 $16,427,302 $1,624,918 $0 $0 $0 $0 $15,693,248 $1,562,655 $22,214,033 $1,380,655 $0 $0 $0 $0 $17,814,958 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$2,342,479 $21,932,797 $4,047,729 $77,919,094 $6,590,415 $0 $0 $0 $0 $78,380,226 $4,933,418 $75,487,371 $7,160,722 $0 $0 $0 $0 $62,453,729 $0 $0 $0 $0

$31,618 $400,484 $84,921 $1,873,327 $141,564 $0 $0 $0 $0 $1,652,298 $93,378 $1,474,282 $72,744 $0 $0 $0 $0 $1,145,713 $0 $0 $0 $0$1,871,494 $23,704,973 $5,026,550 $110,883,721 $8,379,264 $0 $0 $0 $0 $97,800,800 $5,527,094 $87,263,934 $4,305,745 $0 $0 $0 $0 $67,815,669 $0 $0 $0 $0

2,920 36,816 7,862 161,995 15,009 0 0 0 0 150,744 10,189 160,469 8,966 0 0 0 0 135,710 0 0 0 0208 2,529 564 12,191 1,247 0 0 0 0 11,148 995 10,872 827 0 0 0 0 9,398 0 0 0 0

$725.88 $712.20 $718.64 $704.96 $718.64 $708.99 $708.99 $722.68 $722.68 $704.96 $614.27 $600.58 $614.27 $701.75 $701.75 $715.44 $715.44 $600.58 $597.38 $597.38 $611.06 $611.06123.09% 90.99% 79.19% 69.10% 77.34% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 78.81% 87.78% 85.07% 163.54% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 90.56% #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$952.46 $712.02 $629.22 $582.40 $547.36 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $624.06 $637.56 $608.85 $952.64 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $591.47 #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0!



$640.92 $643.88 $639.35 $684.49 $558.28 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $648.79 $542.46 $543.81 $480.23 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $499.71 #DIV/0! #DIV/0! #DIV/0! #DIV/0!


0.7703 0.7559 0.7625 0.7480 0.7625 0.7525 0.7525 0.7668 0.7668 0.7480 0.6707 0.6563 0.6707 0.7447 0.7447 0.7590 0.7590 0.6563 0.6529 0.6529 0.6673 0.66731.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$847.66 $831.81 $839.08 $823.12 $839.08 $828.07 $828.07 $843.81 $843.81 $823.12 $738.06 $722.21 $738.06 $819.49 $819.49 $835.23 $835.23 $722.21 $718.47 $718.47 $734.32 $734.32

$847.66 $831.81 $839.08 $823.12 $839.08 $828.07 $828.07 $843.81 $843.81 $823.12 $738.06 $722.21 $738.06 $819.49 $819.49 $835.23 $835.23 $722.21 $718.47 $718.47 $734.32 $734.32

85629NY0010287 85629NY0010288 85629NY0010293 85629NY0010294 85629NY0010295 85629NY0010296 85629NY0010297 85629NY0010298 85629NY0010299 85629NY0010300 85629NY0010309 85629NY0010310 85629NY0010311 85629NY0010312 85629NY0010313 85629NY0010314 85629NY0010315 85629NY0010316 85629NY0010325 85629NY0010326 85629NY0010327 85629NY0010328$2,434,311 $29,044,638 $6,602,247 $139,995,395 $14,597,521 $0 $0 $0 $0 $128,018,100 $11,337,099 $121,216,681 $9,422,895 $0 $0 $0 $0 $104,782,411 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$648,866 $7,741,848 $1,809,966 $38,378,894 $4,001,823 $0 $0 $0 $0 $35,095,391 $3,900,494 $41,704,227 $3,241,918 $0 $0 $0 $0 $36,050,067 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$1,785,445 $21,302,790 $4,792,281 $101,616,501 $10,595,699 $0 $0 $0 $0 $92,922,709 $7,436,605 $79,512,453 $6,180,977 $0 $0 $0 $0 $68,732,343 $0 $0 $0 $0

$14,587 $174,045 $39,153 $830,211 $86,567 $0 $0 $0 $0 $759,183 $60,757 $649,620 $50,499 $0 $0 $0 $0 $561,546 $0 $0 $0 $0$2,115,762 $25,243,912 $5,678,877 $120,416,061 $12,555,956 $0 $0 $0 $0 $110,113,875 $8,812,414 $94,222,655 $7,324,489 $0 $0 $0 $0 $81,448,170 $0 $0 $0 $0

2,496 30,348 6,768 146,292 14,964 0 0 0 0 133,776 11,940 130,464 9,924 0 0 0 0 112,776 0 0 0 083.81% 83.81% 83.81% 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% 83.81% 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0!




$847.66 $831.81 $839.08 $823.12 $839.08 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $823.12 $738.06 $722.21 $738.06 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $722.21 #DIV/0! #DIV/0! #DIV/0! #DIV/0!

NY S FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY G LBTY GT NY G LBTY GT NY G LBTY GT NY G LBTY GT NY G LBTY GT NY G LBTY GT NY G LBTY GT NY G LBTY GT NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY GT 85629NY0010334 85629NY0010336 85629NY0010340 85629NY0010341 85629NY0010342 85629NY0010429 85629NY0010430 85629NY0010431 85629NY0010432 85629NY0010433 85629NY0010434 85629NY0010435 85629NY0010436 85629NY0010437 85629NY0010438 85629NY0010439 85629NY0010440 85629NY0010441 85629NY0010442 85629NY0010443 85629NY0010444 85629NY0010445

Silver Platinum Platinum Platinum Platinum Gold Gold Gold Gold Gold Gold Gold Gold Silver Silver Silver Silver Silver Silver Silver Silver Silver0.709 0.912 0.912 0.912 0.912 0.809 0.809 0.809 0.809 0.809 0.809 0.809 0.809 0.711 0.711 0.711 0.711 0.711 0.711 0.711 0.711 0.710


1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202216.74% 13.64% 13.67% 13.64% 13.67% 14.39% 14.38% 14.39% 14.38% 14.41% 14.41% 14.40% 14.40% 17.48% 17.49% 17.48% 17.49% 17.45% 17.45% 17.45% 17.45% 16.35%

85629NY0010334 85629NY0010336 85629NY0010340 85629NY0010341 85629NY0010342 85629NY0010429 85629NY0010430 85629NY0010431 85629NY0010432 85629NY0010433 85629NY0010434 85629NY0010435 85629NY0010436 85629NY0010437 85629NY0010438 85629NY0010439 85629NY0010440 85629NY0010441 85629NY0010442 85629NY0010443 85629NY0010444 85629NY0010445$2,208,649 $87,495,539 $11,102,966 $88,730,696 $11,644,118 $200,057,036 $0 $176,984,803 $0 $19,307,566 $13,737,004 $0 $0 $120,190,801 $18,407 $165,121,411 $0 $9,112,951 $7,515,245 $0 $0 $26,414,735

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$471,988 $4,775,168 $730,239 $4,652,276 $943,966 $20,943,046 $0 $17,624,712 $0 $2,168,666 $1,667,307 $0 $0 $20,645,207 $12,401 $28,131,333 $0 $1,566,219 $1,292,111 $0 $0 $3,982,333

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$1,736,661 $82,720,371 $10,372,727 $84,078,420 $10,700,153 $179,113,991 $0 $159,360,091 $0 $17,138,899 $12,069,697 $0 $0 $99,545,594 $6,006 $136,990,078 $0 $7,546,732 $6,223,134 $0 $0 $22,432,401

$33,602 $1,306,680 $183,927 $1,538,436 $170,055 $3,354,635 $0 $3,359,200 $0 $292,330 $238,476 $0 $0 $2,222,142 $737 $3,101,665 $0 $152,164 $135,169 $0 $0 $500,781$1,988,942 $77,343,439 $10,886,798 $91,061,216 $10,065,692 $198,563,472 $0 $198,833,692 $0 $17,303,255 $14,115,572 $0 $0 $131,530,322 $43,601 $183,589,964 $0 $9,006,684 $8,000,782 $0 $0 $29,641,601

3,026 83,955 12,039 95,265 11,795 273,887 0 266,632 0 24,872 19,867 0 0 206,512 72 283,202 0 15,029 13,221 0 0 49,257195 6,098 900 6,712 1,009 19,998 0 17,598 0 1,880 1,548 0 0 16,641 6 21,231 0 1,331 1,256 0 0 3,517

$725.88 $1,045.68 $1,059.36 $1,045.68 $1,059.36 $793.65 $790.45 $793.65 $790.45 $807.34 $807.34 $804.13 $804.13 $662.89 $659.68 $662.89 $659.68 $676.58 $676.58 $673.37 $673.37 $643.0185.87% 105.18% 93.70% 90.80% 104.54% 88.71% #DIV/0! 78.82% #DIV/0! 97.40% 84.09% #DIV/0! #DIV/0! 74.43% 13.55% 73.38% #DIV/0! 82.40% 76.49% #DIV/0! #DIV/0! 74.42%

$729.89 $1,042.17 $922.25 $931.41 $987.21 $730.44 #DIV/0! $663.78 #DIV/0! $776.28 $691.45 #DIV/0! #DIV/0! $582.00 $255.66 $583.05 #DIV/0! $606.36 $568.43 #DIV/0! #DIV/0! $536.26$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00

$155.98 $56.88 $60.66 $48.84 $80.03 $76.47 #DIV/0! $66.10 #DIV/0! $87.19 $83.92 #DIV/0! #DIV/0! $99.97 $172.24 $99.33 #DIV/0! $104.21 $97.73 #DIV/0! #DIV/0! $80.85$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00


$657.28 $921.25 $904.29 $955.87 $853.39 $724.98 #DIV/0! $745.72 #DIV/0! $695.69 $710.50 #DIV/0! #DIV/0! $636.91 $605.57 $648.27 #DIV/0! $599.29 $605.16 #DIV/0! #DIV/0! $601.77


0.7703 1.0802 1.0946 1.0802 1.0946 0.8698 0.8663 0.8698 0.8663 0.8850 0.8850 0.8814 0.8814 0.7462 0.7426 0.7462 0.7426 0.7614 0.7614 0.7577 0.7577 0.71681.0000 1.0000 1.0000 1.0000 1.0000 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.94871.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$847.66 $1,188.68 $1,204.53 $1,188.68 $1,204.53 $908.05 $904.40 $908.05 $904.40 $923.92 $923.92 $920.16 $920.16 $779.02 $775.26 $779.02 $775.26 $794.88 $794.88 $791.02 $791.02 $748.32

$847.66 $1,188.68 $1,204.53 $1,188.68 $1,204.53 $908.05 $904.40 $908.05 $904.40 $923.92 $923.92 $920.16 $920.16 $779.02 $775.26 $779.02 $775.26 $794.88 $794.88 $791.02 $791.02 $748.32

85629NY0010334 85629NY0010336 85629NY0010340 85629NY0010341 85629NY0010342 85629NY0010429 85629NY0010430 85629NY0010431 85629NY0010432 85629NY0010433 85629NY0010434 85629NY0010435 85629NY0010436 85629NY0010437 85629NY0010438 85629NY0010439 85629NY0010440 85629NY0010441 85629NY0010442 85629NY0010443 85629NY0010444 85629NY0010445$2,282,166 $78,191,526 $11,694,080 $86,064,533 $13,110,363 $220,511,416 $0 $194,047,400 $0 $21,092,411 $17,367,581 $0 $0 $181,313,525 $65,058 $231,324,286 $0 $14,797,436 $13,963,621 $0 $0 $36,984,060

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$608,311 $4,788,342 $716,129 $5,270,474 $802,861 $36,617,513 $0 $32,222,972 $0 $3,502,547 $2,884,012 $0 $0 $50,034,293 $17,953 $63,834,990 $0 $4,083,420 $3,853,325 $0 $0 $10,331,942

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$1,673,855 $73,403,184 $10,977,950 $80,794,059 $12,307,502 $183,893,903 $0 $161,824,427 $0 $17,589,864 $14,483,569 $0 $0 $131,279,232 $47,105 $167,489,296 $0 $10,714,016 $10,110,296 $0 $0 $26,652,118

$13,675 $599,707 $89,690 $660,091 $100,553 $1,502,421 $0 $1,322,113 $0 $143,710 $118,331 $0 $0 $1,072,557 $385 $1,368,395 $0 $87,534 $82,602 $0 $0 $217,749$1,983,526 $86,983,140 $13,008,926 $95,741,363 $14,584,451 $217,915,193 $0 $191,762,755 $0 $20,844,077 $17,163,101 $0 $0 $155,566,546 $55,820 $198,475,653 $0 $12,696,162 $11,980,751 $0 $0 $31,582,893

2,340 73,176 10,800 80,544 12,108 239,976 0 211,176 0 22,560 18,576 0 0 199,692 72 254,772 0 15,972 15,072 0 0 42,20483.81% 83.81% 83.81% 83.81% 83.81% 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% 83.81% 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81%

$975.28 $1,068.54 $1,082.79 $1,068.54 $1,082.79 $918.89 #DIV/0! $918.89 #DIV/0! $934.95 $934.95 #DIV/0! #DIV/0! $907.97 $903.59 $907.97 #DIV/0! $926.46 $926.46 #DIV/0! #DIV/0! $876.32$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00


$715.32 $1,003.10 $1,016.48 $1,003.10 $1,016.48 $766.30 #DIV/0! $766.30 #DIV/0! $779.69 $779.69 #DIV/0! #DIV/0! $657.41 $654.24 $657.41 #DIV/0! $670.80 $670.80 #DIV/0! #DIV/0! $631.51$5.84 $8.20 $8.30 $8.20 $8.30 $6.26 #DIV/0! $6.26 #DIV/0! $6.37 $6.37 #DIV/0! #DIV/0! $5.37 $5.35 $5.37 #DIV/0! $5.48 $5.48 #DIV/0! #DIV/0! $5.16

$847.66 $1,188.68 $1,204.53 $1,188.68 $1,204.53 $908.07 #DIV/0! $908.07 #DIV/0! $923.94 $923.94 #DIV/0! #DIV/0! $779.03 $775.27 $779.03 #DIV/0! $794.90 $794.90 #DIV/0! #DIV/0! $748.34

NY S LBTY GT NY S LBTY GT NY S LBTY GT NY S LBTY GT NY S LBTY GT NY S LBTY GT NY S LBTY GT NY P MTRO GT NY P MTRO GT NY P MTRO GT NY P MTRO GT NY P MTRO GT NY P MTRO GT NY P MTRO GT NY P MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT 85629NY0010446 85629NY0010447 85629NY0010448 85629NY0010449 85629NY0010450 85629NY0010451 85629NY0010452 85629NY0010453 85629NY0010454 85629NY0010455 85629NY0010456 85629NY0010457 85629NY0010458 85629NY0010459 85629NY0010460 85629NY0010469 85629NY0010470 85629NY0010471 85629NY0010472 85629NY0010473 85629NY0010474 85629NY0010475

Silver Silver Silver Silver Silver Silver Silver Platinum Platinum Platinum Platinum Platinum Platinum Platinum Platinum Gold Gold Gold Gold Gold Gold Gold0.710 0.710 0.710 0.710 0.710 0.710 0.710 0.876 0.876 0.876 0.876 0.876 0.876 0.876 0.876 0.808 0.808 0.808 0.808 0.808 0.808 0.808

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPONo No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202216.36% 16.35% 16.36% 16.34% 16.34% 16.34% 16.34% 16.50% 16.50% 16.50% 16.50% 16.49% 16.49% 16.48% 16.48% 17.52% 17.52% 17.52% 17.52% 17.48% 17.48% 17.48%

85629NY0010446 85629NY0010447 85629NY0010448 85629NY0010449 85629NY0010450 85629NY0010451 85629NY0010452 85629NY0010453 85629NY0010454 85629NY0010455 85629NY0010456 85629NY0010457 85629NY0010458 85629NY0010459 85629NY0010460 85629NY0010469 85629NY0010470 85629NY0010471 85629NY0010472 85629NY0010473 85629NY0010474 85629NY0010475$0 $20,489,694 $0 $1,588,184 $706,196 $0 $0 $9,508,583 $0 $7,503,266 $0 $392,717 $118,308 $0 $0 $14,215,738 $0 $15,799,125 $0 $842,313 $100,040 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $3,762,647 $0 $247,053 $187,669 $0 $0 $696,255 $0 $327,099 $0 $27,713 $11,459 $0 $0 $1,582,099 $0 $1,656,622 $0 $73,884 $16,690 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $16,727,047 $0 $1,341,131 $518,527 $0 $0 $8,812,329 $0 $7,176,168 $0 $365,004 $106,849 $0 $0 $12,633,640 $0 $14,142,503 $0 $768,429 $83,350 $0$0 $464,796 $0 $22,563 $18,168 $0 $0 $192,960 $0 $147,428 $0 $8,223 $1,368 $0 $0 $354,364 $0 $358,743 $0 $15,805 $5,850 $0$0 $27,511,639 $0 $1,335,537 $1,075,388 $0 $0 $11,421,458 $0 $8,726,380 $0 $486,727 $80,989 $0 $0 $20,975,081 $0 $21,234,250 $0 $935,507 $346,261 $0

0 44,524 0 2,634 1,667 0 0 14,624 0 10,829 0 817 94 0 0 30,757 0 31,228 0 1,381 499 00 3,170 0 210 109 0 0 1,029 0 844 0 86 4 0 0 2,303 0 2,044 0 120 45 0

$639.80 $643.01 $639.80 $656.70 $656.70 $653.49 $653.49 $804.07 $800.86 $804.07 $800.86 $817.76 $817.76 $814.55 $814.55 $675.91 $672.70 $675.91 $672.70 $689.59 $689.59 $686.39#DIV/0! 59.79% #DIV/0! 98.75% 47.42% #DIV/0! #DIV/0! 75.87% #DIV/0! 80.87% #DIV/0! 73.75% 129.74% #DIV/0! #DIV/0! 59.23% #DIV/0! 65.50% #DIV/0! 80.78% 23.67% #DIV/0!

#DIV/0! $460.19 #DIV/0! $602.96 $423.63 #DIV/0! #DIV/0! $650.20 #DIV/0! $692.89 #DIV/0! $480.68 $1,258.59 #DIV/0! #DIV/0! $462.20 #DIV/0! $505.93 #DIV/0! $609.93 $200.48 #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!#DIV/0! $84.51 #DIV/0! $93.79 $112.58 #DIV/0! #DIV/0! $47.61 #DIV/0! $30.21 #DIV/0! $33.92 $121.91 #DIV/0! #DIV/0! $51.44 #DIV/0! $53.05 #DIV/0! $53.50 $33.45 #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!#DIV/0! $375.69 #DIV/0! $509.16 $311.05 #DIV/0! #DIV/0! $602.59 #DIV/0! $662.68 #DIV/0! $446.76 $1,136.69 #DIV/0! #DIV/0! $410.76 #DIV/0! $452.88 #DIV/0! $556.43 $167.03 #DIV/0!#DIV/0! $10.44 #DIV/0! $8.57 $10.90 #DIV/0! #DIV/0! $13.19 #DIV/0! $13.61 #DIV/0! $10.06 $14.56 #DIV/0! #DIV/0! $11.52 #DIV/0! $11.49 #DIV/0! $11.44 $11.72 #DIV/0!#DIV/0! $617.91 #DIV/0! $507.04 $645.10 #DIV/0! #DIV/0! $781.01 #DIV/0! $805.83 #DIV/0! $595.75 $861.58 #DIV/0! #DIV/0! $681.96 #DIV/0! $679.97 #DIV/0! $677.41 $693.91 #DIV/0!


0.7133 0.7168 0.7133 0.7320 0.7320 0.7284 0.7284 1.0151 1.0111 1.0151 1.0111 1.0323 1.0323 1.0282 1.0282 0.8607 0.8567 0.8607 0.8567 0.8779 0.8779 0.87380.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.83881.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$744.67 $748.32 $744.67 $764.19 $764.19 $760.43 $760.43 $936.98 $933.29 $936.98 $933.29 $952.85 $952.85 $949.07 $949.07 $794.46 $790.77 $794.46 $790.77 $810.34 $810.34 $806.55

$744.67 $748.32 $744.67 $764.19 $764.19 $760.43 $760.43 $936.98 $933.29 $936.98 $933.29 $952.85 $952.85 $949.07 $949.07 $794.46 $790.77 $794.46 $790.77 $810.34 $810.34 $806.55

85629NY0010446 85629NY0010447 85629NY0010448 85629NY0010449 85629NY0010450 85629NY0010451 85629NY0010452 85629NY0010453 85629NY0010454 85629NY0010455 85629NY0010456 85629NY0010457 85629NY0010458 85629NY0010459 85629NY0010460 85629NY0010469 85629NY0010470 85629NY0010471 85629NY0010472 85629NY0010473 85629NY0010474 85629NY0010475$0 $33,335,078 $0 $2,255,146 $1,170,528 $0 $0 $10,682,593 $0 $8,762,010 $0 $907,939 $42,230 $0 $0 $22,452,360 $0 $19,927,323 $0 $1,193,281 $447,480 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $9,312,555 $0 $630,002 $327,001 $0 $0 $918,831 $0 $753,638 $0 $78,094 $3,632 $0 $0 $3,923,926 $0 $3,482,634 $0 $208,546 $78,205 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $24,022,523 $0 $1,625,144 $843,527 $0 $0 $9,763,762 $0 $8,008,372 $0 $829,846 $38,597 $0 $0 $18,528,434 $0 $16,444,689 $0 $984,735 $369,276 $0$0 $196,265 $0 $13,277 $6,892 $0 $0 $79,770 $0 $65,429 $0 $6,780 $315 $0 $0 $151,378 $0 $134,354 $0 $8,045 $3,017 $0$0 $28,466,810 $0 $1,925,803 $999,584 $0 $0 $11,570,106 $0 $9,489,961 $0 $983,371 $45,738 $0 $0 $21,956,286 $0 $19,487,038 $0 $1,166,916 $437,593 $0

0 38,040 0 2,520 1,308 0 0 12,348 0 10,128 0 1,032 48 0 0 27,636 0 24,528 0 1,440 540 0#DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0!

#DIV/0! $876.32 #DIV/0! $894.90 $894.90 #DIV/0! #DIV/0! $865.13 #DIV/0! $865.13 #DIV/0! $879.79 $879.79 #DIV/0! #DIV/0! $812.43 #DIV/0! $812.43 #DIV/0! $828.67 $828.67 #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!#DIV/0! $244.81 #DIV/0! $250.00 $250.00 #DIV/0! #DIV/0! $74.41 #DIV/0! $74.41 #DIV/0! $75.67 $75.67 #DIV/0! #DIV/0! $141.99 #DIV/0! $141.99 #DIV/0! $144.82 $144.82 #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!#DIV/0! $631.51 #DIV/0! $644.90 $644.90 #DIV/0! #DIV/0! $790.72 #DIV/0! $790.72 #DIV/0! $804.11 $804.11 #DIV/0! #DIV/0! $670.45 #DIV/0! $670.45 #DIV/0! $683.84 $683.84 #DIV/0!#DIV/0! $5.16 #DIV/0! $5.27 $5.27 #DIV/0! #DIV/0! $6.46 #DIV/0! $6.46 #DIV/0! $6.57 $6.57 #DIV/0! #DIV/0! $5.48 #DIV/0! $5.48 #DIV/0! $5.59 $5.59 #DIV/0!#DIV/0! $748.34 #DIV/0! $764.21 $764.21 #DIV/0! #DIV/0! $937.00 #DIV/0! $937.00 #DIV/0! $952.88 $952.88 #DIV/0! #DIV/0! $794.48 #DIV/0! $794.48 #DIV/0! $810.36 $810.36 #DIV/0!

NY G MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY B MTRO GT NY B MTRO GT NY B MTRO GT NY B MTRO GT NY B MTRO GT 85629NY0010476 85629NY0010485 85629NY0010486 85629NY0010487 85629NY0010488 85629NY0010489 85629NY0010490 85629NY0010491 85629NY0010492 85629NY0010493 85629NY0010494 85629NY0010495 85629NY0010496 85629NY0010497 85629NY0010498 85629NY0010499 85629NY0010500 85629NY0010509 85629NY0010510 85629NY0010511 85629NY0010512 85629NY0010513

Gold Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Bronze Bronze Bronze Bronze Bronze0.808 0.671 0.671 0.671 0.671 0.671 0.671 0.671 0.671 0.709 0.709 0.709 0.709 0.709 0.709 0.709 0.709 0.646 0.646 0.646 0.646 0.646

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPOYes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202217.48% 19.94% 19.96% 19.94% 19.96% 19.84% 19.84% 19.84% 19.84% 19.12% 19.13% 19.12% 19.13% 19.04% 19.04% 19.04% 19.04% 22.55% 22.59% 22.55% 22.59% 22.36%

85629NY0010476 85629NY0010485 85629NY0010486 85629NY0010487 85629NY0010488 85629NY0010489 85629NY0010490 85629NY0010491 85629NY0010492 85629NY0010493 85629NY0010494 85629NY0010495 85629NY0010496 85629NY0010497 85629NY0010498 85629NY0010499 85629NY0010500 85629NY0010509 85629NY0010510 85629NY0010511 85629NY0010512 85629NY0010513$0 $1,671,776 $0 $2,783,898 $0 $87,109 $62,654 $0 $0 $23,351,079 $0 $29,405,024 $0 $753,350 $223,100 $0 $0 $1,280,333 $0 $1,333,452 $0 $63,806$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $462,606 $0 $597,693 $0 $27,776 $10,208 $0 $0 $4,030,156 $0 $5,126,444 $0 $140,179 $49,625 $0 $0 $316,030 $0 $389,223 $0 $32,628$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $1,209,170 $0 $2,186,205 $0 $59,333 $52,446 $0 $0 $19,320,923 $0 $24,278,580 $0 $613,171 $173,475 $0 $0 $964,303 $0 $944,230 $0 $31,179$0 $55,969 $0 $66,904 $0 $2,416 $1,629 $0 $0 $665,290 $0 $811,812 $0 $24,257 $13,852 $0 $0 $42,287 $0 $45,201 $0 $1,587$0 $3,312,823 $0 $3,960,092 $0 $143,019 $96,406 $0 $0 $39,379,025 $0 $48,051,807 $0 $1,435,785 $819,896 $0 $0 $2,503,024 $0 $2,675,479 $0 $93,962

0 6,081 0 7,052 0 318 195 0 0 67,691 0 82,448 0 2,480 1,424 0 0 5,122 0 5,504 0 1780 624 0 689 0 30 25 0 0 5,448 0 5,967 0 240 141 0 0 440 0 468 0 8

$686.39 $523.27 $520.07 $523.27 $520.07 $536.96 $536.96 $533.75 $533.75 $554.25 $551.04 $554.25 $551.04 $567.93 $567.93 $564.73 $564.73 $475.05 $471.85 $475.05 $471.85 $488.74#DIV/0! 35.89% #DIV/0! 54.29% #DIV/0! 40.80% 53.50% #DIV/0! #DIV/0! 48.25% #DIV/0! 49.69% #DIV/0! 42.00% 20.81% #DIV/0! #DIV/0! 37.89% #DIV/0! 34.71% #DIV/0! 32.63%

#DIV/0! $274.92 #DIV/0! $394.77 #DIV/0! $273.93 $321.30 #DIV/0! #DIV/0! $344.97 #DIV/0! $356.65 #DIV/0! $303.77 $156.67 #DIV/0! #DIV/0! $249.97 #DIV/0! $242.27 #DIV/0! $358.46#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00#DIV/0! $76.07 #DIV/0! $84.76 #DIV/0! $87.35 $52.35 #DIV/0! #DIV/0! $59.54 #DIV/0! $62.18 #DIV/0! $56.52 $34.85 #DIV/0! #DIV/0! $61.70 #DIV/0! $70.72 #DIV/0! $183.30#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00#DIV/0! $198.84 #DIV/0! $310.01 #DIV/0! $186.58 $268.96 #DIV/0! #DIV/0! $285.43 #DIV/0! $294.47 #DIV/0! $247.25 $121.82 #DIV/0! #DIV/0! $188.27 #DIV/0! $171.55 #DIV/0! $175.16#DIV/0! $9.20 #DIV/0! $9.49 #DIV/0! $7.60 $8.35 #DIV/0! #DIV/0! $9.83 #DIV/0! $9.85 #DIV/0! $9.78 $9.73 #DIV/0! #DIV/0! $8.26 #DIV/0! $8.21 #DIV/0! $8.92#DIV/0! $544.78 #DIV/0! $561.56 #DIV/0! $449.75 $494.39 #DIV/0! #DIV/0! $581.75 #DIV/0! $582.81 #DIV/0! $578.95 $575.77 #DIV/0! #DIV/0! $488.68 #DIV/0! $486.10 #DIV/0! $527.88


0.8738 0.6801 0.6761 0.6801 0.6761 0.6973 0.6973 0.6932 0.6932 0.7154 0.7114 0.7154 0.7114 0.7326 0.7326 0.7285 0.7285 0.6309 0.6268 0.6309 0.6268 0.64800.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.83881.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$806.55 $627.76 $624.07 $627.76 $624.07 $643.64 $643.64 $639.85 $639.85 $660.34 $656.65 $660.34 $656.65 $676.22 $676.22 $672.43 $672.43 $582.35 $578.56 $582.35 $578.56 $598.13

$806.55 $627.76 $624.07 $627.76 $624.07 $643.64 $643.64 $639.85 $639.85 $660.34 $656.65 $660.34 $656.65 $676.22 $676.22 $672.43 $672.43 $582.35 $578.56 $582.35 $578.56 $598.13

85629NY0010476 85629NY0010485 85629NY0010486 85629NY0010487 85629NY0010488 85629NY0010489 85629NY0010490 85629NY0010491 85629NY0010492 85629NY0010493 85629NY0010494 85629NY0010495 85629NY0010496 85629NY0010497 85629NY0010498 85629NY0010499 85629NY0010500 85629NY0010509 85629NY0010510 85629NY0010511 85629NY0010512 85629NY0010513$0 $5,802,016 $0 $6,406,392 $0 $285,998 $238,331 $0 $0 $50,655,399 $0 $55,481,051 $0 $2,285,167 $1,342,535 $0 $0 $3,972,327 $0 $4,225,111 $0 $74,182$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $1,835,124 $0 $2,026,283 $0 $90,458 $75,382 $0 $0 $14,223,736 $0 $15,578,750 $0 $641,661 $376,976 $0 $0 $1,377,513 $0 $1,465,173 $0 $25,725$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $3,966,892 $0 $4,380,109 $0 $195,539 $162,949 $0 $0 $36,431,663 $0 $39,902,301 $0 $1,643,505 $965,559 $0 $0 $2,594,814 $0 $2,759,938 $0 $48,457$0 $32,410 $0 $35,786 $0 $1,598 $1,331 $0 $0 $297,648 $0 $326,004 $0 $13,428 $7,889 $0 $0 $21,200 $0 $22,549 $0 $396$0 $4,700,786 $0 $5,190,452 $0 $231,715 $193,096 $0 $0 $43,171,703 $0 $47,284,426 $0 $1,947,562 $1,144,193 $0 $0 $3,074,867 $0 $3,270,540 $0 $57,422

0 7,488 0 8,268 0 360 300 0 0 65,376 0 71,604 0 2,880 1,692 0 0 5,280 0 5,616 0 96#DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81%

#DIV/0! $774.84 #DIV/0! $774.84 #DIV/0! $794.44 $794.44 #DIV/0! #DIV/0! $774.83 #DIV/0! $774.83 #DIV/0! $793.46 $793.46 #DIV/0! #DIV/0! $752.33 #DIV/0! $752.33 #DIV/0! $772.73#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00#DIV/0! $245.08 #DIV/0! $245.08 #DIV/0! $251.27 $251.27 #DIV/0! #DIV/0! $217.57 #DIV/0! $217.57 #DIV/0! $222.80 $222.80 #DIV/0! #DIV/0! $260.89 #DIV/0! $260.89 #DIV/0! $267.96#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00#DIV/0! $529.77 #DIV/0! $529.77 #DIV/0! $543.16 $543.16 #DIV/0! #DIV/0! $557.26 #DIV/0! $557.26 #DIV/0! $570.66 $570.66 #DIV/0! #DIV/0! $491.44 #DIV/0! $491.44 #DIV/0! $504.76#DIV/0! $4.33 #DIV/0! $4.33 #DIV/0! $4.44 $4.44 #DIV/0! #DIV/0! $4.55 #DIV/0! $4.55 #DIV/0! $4.66 $4.66 #DIV/0! #DIV/0! $4.02 #DIV/0! $4.02 #DIV/0! $4.12#DIV/0! $627.78 #DIV/0! $627.78 #DIV/0! $643.65 $643.65 #DIV/0! #DIV/0! $660.36 #DIV/0! $660.36 #DIV/0! $676.24 $676.24 #DIV/0! #DIV/0! $582.36 #DIV/0! $582.36 #DIV/0! $598.15

NY B MTRO GT NY B MTRO GT NY B MTRO GT NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY S MTRO NG NY S MTRO NG NY S MTRO NG 85629NY0010514 85629NY0010515 85629NY0010516 85629NY0010517 85629NY0010518 85629NY0010519 85629NY0010520 85629NY0010521 85629NY0010522 85629NY0010523 85629NY0010524 85629NY0010557 85629NY0010558 85629NY0010559 85629NY0010560 85629NY0010561 85629NY0010562 85629NY0010563 85629NY0010564 85629NY0010565 85629NY0010566 85629NY0010567

Bronze Bronze Bronze Silver Silver Silver Silver Silver Silver Silver Silver Bronze Bronze Bronze Bronze Bronze Bronze Bronze Bronze Silver Silver Silver0.646 0.646 0.646 0.710 0.710 0.710 0.710 0.710 0.710 0.710 0.710 0.646 0.646 0.646 0.646 0.646 0.646 0.646 0.646 0.709 0.709 0.709

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPOYes Yes Yes No No No No No No No No No No No No No No No No Yes Yes Yes

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202222.36% 22.38% 22.38% 17.83% 17.84% 17.83% 17.84% 17.79% 17.79% 17.78% 17.78% 22.26% 22.30% 22.26% 22.30% 22.11% 22.11% 22.13% 22.13% 20.27% 20.29% 20.27%

85629NY0010514 85629NY0010515 85629NY0010516 85629NY0010517 85629NY0010518 85629NY0010519 85629NY0010520 85629NY0010521 85629NY0010522 85629NY0010523 85629NY0010524 85629NY0010557 85629NY0010558 85629NY0010559 85629NY0010560 85629NY0010561 85629NY0010562 85629NY0010563 85629NY0010564 85629NY0010565 85629NY0010566 85629NY0010567$164,315 $0 $0 $38,965,712 $0 $46,244,374 $0 $2,990,310 $1,696,245 $0 $0 $23,289,254 $0 $32,615,267 $0 $525,251 $925,662 $0 $0 $9,737,425 $0 $20,788,064

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$15,889 $0 $0 $7,496,394 $0 $8,156,652 $0 $484,901 $355,525 $0 $0 $5,123,130 $0 $7,679,359 $0 $202,424 $248,912 $0 $0 $1,803,268 $0 $3,091,210

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$148,426 $0 $0 $31,469,318 $0 $38,087,723 $0 $2,505,408 $1,340,721 $0 $0 $18,166,123 $0 $24,935,909 $0 $322,827 $676,750 $0 $0 $7,934,157 $0 $17,696,854

$1,655 $0 $0 $802,482 $0 $975,193 $0 $43,924 $29,926 $0 $0 $340,527 $0 $516,005 $0 $14,579 $16,206 $0 $0 $288,688 $0 $453,259$97,966 $0 $0 $47,499,565 $0 $57,722,419 $0 $2,599,894 $1,771,346 $0 $0 $20,156,038 $0 $30,542,768 $0 $862,914 $959,269 $0 $0 $17,087,679 $0 $26,828,730

193 0 0 78,840 0 90,446 0 4,419 2,951 0 0 39,226 0 57,656 0 1,881 1,958 0 0 28,725 0 44,58027 0 0 5,899 0 7,562 0 424 374 0 0 3,862 0 5,160 0 183 169 0 0 2,237 0 3,588

$488.74 $485.53 $485.53 $647.23 $644.02 $647.23 $644.02 $660.92 $660.92 $657.71 $657.71 $560.32 $557.12 $560.32 $557.12 $574.01 $574.01 $570.80 $570.80 $568.70 $565.49 $568.70148.99% #DIV/0! #DIV/0! 65.15% #DIV/0! 64.89% #DIV/0! 94.76% 74.43% #DIV/0! #DIV/0! 88.63% #DIV/0! 80.29% #DIV/0! 36.79% 69.38% #DIV/0! #DIV/0! 45.66% #DIV/0! 64.87%

$851.37 #DIV/0! #DIV/0! $494.24 #DIV/0! $511.29 #DIV/0! $676.69 $574.80 #DIV/0! #DIV/0! $593.72 #DIV/0! $565.69 #DIV/0! $279.24 $472.76 #DIV/0! #DIV/0! $338.99 #DIV/0! $466.31$0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00



$507.60 #DIV/0! #DIV/0! $602.48 #DIV/0! $638.20 #DIV/0! $588.34 $600.25 #DIV/0! #DIV/0! $513.84 #DIV/0! $529.74 #DIV/0! $458.75 $489.92 #DIV/0! #DIV/0! $594.87 #DIV/0! $601.81


0.6480 0.6439 0.6439 0.7307 0.7271 0.7307 0.7271 0.7459 0.7459 0.7422 0.7422 0.6564 0.6528 0.6564 0.6528 0.6716 0.6716 0.6679 0.6679 0.7412 0.7372 0.74120.8388 0.8388 0.8388 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.8388 0.8388 0.83881.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$598.13 $594.35 $594.35 $762.83 $759.08 $762.83 $759.08 $778.70 $778.70 $774.84 $774.84 $685.27 $681.51 $685.27 $681.51 $701.14 $701.14 $697.27 $697.27 $684.16 $680.47 $684.16

$598.13 $594.35 $594.35 $762.83 $759.08 $762.83 $759.08 $778.70 $778.70 $774.84 $774.84 $685.27 $681.51 $685.27 $681.51 $701.14 $701.14 $697.27 $697.27 $684.16 $680.47 $684.16

85629NY0010514 85629NY0010515 85629NY0010516 85629NY0010517 85629NY0010518 85629NY0010519 85629NY0010520 85629NY0010521 85629NY0010522 85629NY0010523 85629NY0010524 85629NY0010557 85629NY0010558 85629NY0010559 85629NY0010560 85629NY0010561 85629NY0010562 85629NY0010563 85629NY0010564 85629NY0010565 85629NY0010566 85629NY0010567$250,363 $0 $0 $64,272,333 $0 $82,391,487 $0 $4,715,774 $4,159,669 $0 $0 $40,853,666 $0 $54,584,390 $0 $1,980,669 $1,829,143 $0 $0 $21,549,694 $0 $34,564,283

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$86,820 $0 $0 $18,702,350 $0 $23,974,770 $0 $1,372,224 $1,210,405 $0 $0 $14,053,208 $0 $18,776,426 $0 $681,328 $629,205 $0 $0 $6,051,026 $0 $9,705,446

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$163,543 $0 $0 $45,569,983 $0 $58,416,717 $0 $3,343,550 $2,949,263 $0 $0 $26,800,457 $0 $35,807,965 $0 $1,299,341 $1,199,938 $0 $0 $15,498,667 $0 $24,858,837

$1,336 $0 $0 $372,309 $0 $477,267 $0 $27,317 $24,096 $0 $0 $218,961 $0 $292,553 $0 $10,616 $9,804 $0 $0 $126,625 $0 $203,098$193,799 $0 $0 $54,000,657 $0 $69,224,101 $0 $3,962,123 $3,494,892 $0 $0 $31,758,676 $0 $42,432,617 $0 $1,539,726 $1,421,932 $0 $0 $18,365,998 $0 $29,457,846

324 0 0 70,788 0 90,744 0 5,088 4,488 0 0 46,344 0 61,920 0 2,196 2,028 0 0 26,844 0 43,05683.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81%




$598.15 #DIV/0! #DIV/0! $762.85 #DIV/0! $762.85 #DIV/0! $778.72 $778.72 #DIV/0! #DIV/0! $685.28 #DIV/0! $685.28 #DIV/0! $701.15 $701.15 #DIV/0! #DIV/0! $684.18 #DIV/0! $684.18

EPO85629NY001

16.29%

NY S MTRO NG NY S MTRO NG NY S MTRO NG NY S MTRO NG NY S MTRO NG NY G MTRO NG NY G MTRO NG NY G MTRO NG NY G MTRO NG NY G MTRO NG NY G MTRO NG NY G MTRO NG NY G MTRO NG NY G MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT NY G MTRO GT NY B MTRO GT 85629NY0010568 85629NY0010569 85629NY0010570 85629NY0010571 85629NY0010572 85629NY0010573 85629NY0010574 85629NY0010575 85629NY0010576 85629NY0010577 85629NY0010578 85629NY0010579 85629NY0010580 85629NY0010581 85629NY0010582 85629NY0010583 85629NY0010584 85629NY0010585 85629NY0010586 85629NY0010587 85629NY0010588 85629NY0010597

Silver Silver Silver Silver Silver Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Bronze0.709 0.709 0.709 0.709 0.709 0.808 0.808 0.808 0.808 0.808 0.808 0.808 0.808 0.819 0.819 0.819 0.819 0.819 0.819 0.819 0.819 0.646

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPOYes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Yes

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202220.29% 20.16% 20.16% 20.17% 20.17% 18.65% 18.67% 18.65% 18.67% 18.60% 18.60% 18.60% 18.60% 16.87% 16.87% 16.87% 16.87% 16.85% 16.85% 16.84% 16.84% 24.04%

85629NY0010568 85629NY0010569 85629NY0010570 85629NY0010571 85629NY0010572 85629NY0010573 85629NY0010574 85629NY0010575 85629NY0010576 85629NY0010577 85629NY0010578 85629NY0010579 85629NY0010580 85629NY0010581 85629NY0010582 85629NY0010583 85629NY0010584 85629NY0010585 85629NY0010586 85629NY0010587 85629NY0010588 85629NY0010597$0 $533,138 $477,964 $0 $0 $8,604,214 $0 $13,511,263 $0 $585,187 $281,965 $0 $0 $13,239,624 $12,324 $5,677,080 $0 $822,590 $1,179,950 $0 $0 $10,467,654$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $98,146 $120,290 $0 $0 $934,615 $0 $1,300,992 $0 $76,676 $24,172 $0 $0 $1,353,204 $4,091 $595,435 $0 $99,735 $108,678 $0 $0 $2,303,218$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $434,992 $357,675 $0 $0 $7,669,598 $0 $12,210,271 $0 $508,511 $257,792 $0 $0 $11,886,421 $8,233 $5,081,644 $0 $722,855 $1,071,271 $0 $0 $8,164,436$0 $15,200 $13,292 $0 $0 $182,609 $0 $268,570 $0 $10,129 $4,874 $0 $0 $289,834 $1,115 $126,831 $0 $21,883 $21,708 $0 $0 $239,233$0 $899,697 $786,739 $0 $0 $10,808,788 $0 $15,896,865 $0 $599,562 $288,469 $0 $0 $17,155,475 $66,014 $7,507,235 $0 $1,295,284 $1,284,920 $0 $0 $14,160,400

0 1,590 1,444 0 0 15,608 0 22,514 0 874 388 0 0 29,945 95 13,351 0 2,621 2,194 0 0 29,6070 134 128 0 0 1,223 0 1,457 0 76 37 0 0 2,023 6 936 0 200 174 0 0 2,450

$565.49 $582.39 $582.39 $579.18 $579.18 $693.53 $690.32 $693.53 $690.32 $707.21 $707.21 $704.01 $704.01 $582.88 $579.67 $582.88 $579.67 $596.57 $596.57 $593.36 $593.36 $471.35#DIV/0! 47.55% 44.71% #DIV/0! #DIV/0! 69.78% #DIV/0! 75.53% #DIV/0! 83.40% 87.88% #DIV/0! #DIV/0! 68.14% 12.26% 66.57% #DIV/0! 54.88% 81.99% #DIV/0! #DIV/0! 56.70%

#DIV/0! $335.31 $331.00 #DIV/0! #DIV/0! $551.27 #DIV/0! $600.13 #DIV/0! $669.55 $726.71 #DIV/0! #DIV/0! $442.13 $129.73 $425.22 #DIV/0! $313.85 $537.81 #DIV/0! #DIV/0! $353.55#DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00#DIV/0! $61.73 $83.30 #DIV/0! #DIV/0! $59.88 #DIV/0! $57.79 #DIV/0! $87.73 $62.30 #DIV/0! #DIV/0! $45.19 $43.06 $44.60 #DIV/0! $38.05 $49.53 #DIV/0! #DIV/0! $77.79#DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00#DIV/0! $273.58 $247.70 #DIV/0! #DIV/0! $491.39 #DIV/0! $542.34 #DIV/0! $581.82 $664.41 #DIV/0! #DIV/0! $396.94 $86.66 $380.62 #DIV/0! $275.79 $488.27 #DIV/0! #DIV/0! $275.76#DIV/0! $9.56 $9.20 #DIV/0! #DIV/0! $11.70 #DIV/0! $11.93 #DIV/0! $11.59 $12.56 #DIV/0! #DIV/0! $9.68 $11.74 $9.50 #DIV/0! $8.35 $9.89 #DIV/0! #DIV/0! $8.08#DIV/0! $565.85 $544.83 #DIV/0! #DIV/0! $692.52 #DIV/0! $706.09 #DIV/0! $686.00 $743.48 #DIV/0! #DIV/0! $572.90 $694.89 $562.30 #DIV/0! $494.19 $585.65 #DIV/0! #DIV/0! $478.28


0.7372 0.7584 0.7584 0.7542 0.7542 0.8917 0.8877 0.8917 0.8877 0.9089 0.9089 0.9048 0.9048 0.7382 0.7342 0.7382 0.7342 0.7554 0.7554 0.7513 0.7513 0.63360.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.83881.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$680.47 $700.03 $700.03 $696.16 $696.16 $823.08 $819.38 $823.08 $819.38 $838.95 $838.95 $835.17 $835.17 $681.39 $677.70 $681.39 $677.70 $697.26 $697.26 $693.48 $693.48 $584.84

$680.47 $700.03 $700.03 $696.16 $696.16 $823.08 $819.38 $823.08 $819.38 $838.95 $838.95 $835.17 $835.17 $681.39 $677.70 $681.39 $677.70 $697.26 $697.26 $693.48 $693.48 $584.84

85629NY0010568 85629NY0010569 85629NY0010570 85629NY0010571 85629NY0010572 85629NY0010573 85629NY0010574 85629NY0010575 85629NY0010576 85629NY0010577 85629NY0010578 85629NY0010579 85629NY0010580 85629NY0010581 85629NY0010582 85629NY0010583 85629NY0010584 85629NY0010585 85629NY0010586 85629NY0010587 85629NY0010588 85629NY0010597$0 $1,320,818 $1,261,676 $0 $0 $12,352,688 $0 $14,716,162 $0 $782,431 $380,920 $0 $0 $16,272,039 $48,000 $7,528,734 $0 $1,646,186 $1,432,182 $0 $0 $22,118,875$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $370,878 $354,271 $0 $0 $2,158,839 $0 $2,571,896 $0 $136,743 $66,572 $0 $0 $2,312,763 $6,822 $1,070,067 $0 $233,974 $203,558 $0 $0 $7,608,648$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $949,940 $907,405 $0 $0 $10,193,849 $0 $12,144,266 $0 $645,688 $314,348 $0 $0 $13,959,276 $41,177 $6,458,666 $0 $1,412,212 $1,228,625 $0 $0 $14,510,227$0 $7,761 $7,414 $0 $0 $83,284 $0 $99,219 $0 $5,275 $2,568 $0 $0 $114,048 $336 $52,768 $0 $11,538 $10,038 $0 $0 $118,549$0 $1,125,683 $1,075,280 $0 $0 $12,079,762 $0 $14,391,016 $0 $765,143 $372,504 $0 $0 $16,541,812 $48,795 $7,653,552 $0 $1,673,478 $1,455,926 $0 $0 $17,194,692

0 1,608 1,536 0 0 14,676 0 17,484 0 912 444 0 0 24,276 72 11,232 0 2,400 2,088 0 0 29,400#DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% 83.81% 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81%

#DIV/0! $821.40 $821.40 #DIV/0! #DIV/0! $841.69 #DIV/0! $841.69 #DIV/0! $857.93 $857.93 #DIV/0! #DIV/0! $670.29 $666.66 $670.29 #DIV/0! $685.91 $685.91 #DIV/0! #DIV/0! $752.34#DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00#DIV/0! $230.65 $230.65 #DIV/0! #DIV/0! $147.10 #DIV/0! $147.10 #DIV/0! $149.94 $149.94 #DIV/0! #DIV/0! $95.27 $94.75 $95.27 #DIV/0! $97.49 $97.49 #DIV/0! #DIV/0! $258.80#DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00#DIV/0! $590.76 $590.76 #DIV/0! #DIV/0! $694.59 #DIV/0! $694.59 #DIV/0! $707.99 $707.99 #DIV/0! #DIV/0! $575.02 $571.91 $575.02 #DIV/0! $588.42 $588.42 #DIV/0! #DIV/0! $493.55#DIV/0! $4.83 $4.83 #DIV/0! #DIV/0! $5.67 #DIV/0! $5.67 #DIV/0! $5.78 $5.78 #DIV/0! #DIV/0! $4.70 $4.67 $4.70 #DIV/0! $4.81 $4.81 #DIV/0! #DIV/0! $4.03#DIV/0! $700.05 $700.05 #DIV/0! #DIV/0! $823.10 #DIV/0! $823.10 #DIV/0! $838.97 $838.97 #DIV/0! #DIV/0! $681.41 $677.71 $681.41 #DIV/0! $697.28 $697.28 #DIV/0! #DIV/0! $584.85

NY B MTRO GT NY B MTRO GT NY B MTRO GT NY B MTRO GT NY B MTRO GT NY B MTRO GT NY B MTRO GT NY P LBTY GT NY P LBTY GT NY P LBTY GT NY P LBTY GT NY P LBTY GT NY P LBTY GT NY P LBTY GT NY P LBTY GT NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG 85629NY0010598 85629NY0010599 85629NY0010600 85629NY0010601 85629NY0010602 85629NY0010603 85629NY0010604 85629NY0010605 85629NY0010606 85629NY0010607 85629NY0010608 85629NY0010609 85629NY0010610 85629NY0010611 85629NY0010612 85629NY0010629 85629NY0010630 85629NY0010631 85629NY0010632 85629NY0010633 85629NY0010634 85629NY0010635

Bronze Bronze Bronze Bronze Bronze Bronze Bronze Platinum Platinum Platinum Platinum Platinum Platinum Platinum Platinum Bronze Bronze Bronze Bronze Bronze Bronze Bronze0.646 0.646 0.646 0.646 0.646 0.646 0.646 0.866 0.866 0.866 0.866 0.866 0.866 0.866 0.866 0.649 0.649 0.649 0.649 0.649 0.649 0.649

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPOYes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202224.09% 24.04% 24.09% 23.81% 23.81% 23.84% 23.84% 14.55% 14.55% 14.55% 14.55% 14.57% 14.57% 14.56% 14.56% 22.11% 22.15% 22.11% 22.15% 21.96% 21.96% 21.98%

85629NY0010598 85629NY0010599 85629NY0010600 85629NY0010601 85629NY0010602 85629NY0010603 85629NY0010604 85629NY0010605 85629NY0010606 85629NY0010607 85629NY0010608 85629NY0010609 85629NY0010610 85629NY0010611 85629NY0010612 85629NY0010629 85629NY0010630 85629NY0010631 85629NY0010632 85629NY0010633 85629NY0010634 85629NY0010635$0 $11,416,995 $0 $198,849 $252,753 $0 $0 $2,762,230 $0 $7,866,977 $0 $104,182 $50,044 $0 $0 $6,898,780 $0 $12,453,784 $0 $328,210 $153,554 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $2,751,892 $0 $39,686 $70,122 $0 $0 $253,725 $0 $459,355 $0 $13,589 $6,300 $0 $0 $1,695,121 $0 $2,635,657 $0 $79,966 $45,031 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $8,665,103 $0 $159,163 $182,631 $0 $0 $2,508,505 $0 $7,407,622 $0 $90,593 $43,744 $0 $0 $5,203,659 $0 $9,818,127 $0 $248,245 $108,523 $0$0 $302,653 $0 $4,798 $6,461 $0 $0 $57,572 $0 $113,383 $0 $2,651 $2,343 $0 $0 $132,253 $0 $197,864 $0 $4,852 $3,647 $0$0 $17,914,247 $0 $283,993 $382,411 $0 $0 $3,407,757 $0 $6,711,233 $0 $156,936 $138,684 $0 $0 $7,828,177 $0 $11,711,747 $0 $287,190 $215,854 $0

0 36,984 0 596 856 0 0 4,387 0 8,063 0 237 152 0 0 15,309 0 21,404 0 650 394 00 2,683 0 60 58 0 0 324 0 312 0 11 26 0 0 1,959 0 2,559 0 100 61 0

$468.14 $471.35 $468.14 $485.03 $485.03 $481.83 $481.83 $881.32 $878.11 $881.32 $878.11 $895.01 $895.01 $891.80 $891.80 $561.43 $558.22 $561.43 $558.22 $575.12 $575.12 $571.91#DIV/0! 47.57% #DIV/0! 55.11% 46.96% #DIV/0! #DIV/0! 72.39% #DIV/0! 108.54% #DIV/0! 56.77% 31.02% #DIV/0! #DIV/0! 65.37% #DIV/0! 82.44% #DIV/0! 85.00% 49.44% #DIV/0!

#DIV/0! $308.70 #DIV/0! $333.64 $295.27 #DIV/0! #DIV/0! $629.64 #DIV/0! $975.69 #DIV/0! $439.59 $329.24 #DIV/0! #DIV/0! $450.64 #DIV/0! $581.84 #DIV/0! $504.94 $389.73 #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!#DIV/0! $74.41 #DIV/0! $66.59 $81.92 #DIV/0! #DIV/0! $57.84 #DIV/0! $56.97 #DIV/0! $57.34 $41.45 #DIV/0! #DIV/0! $110.73 #DIV/0! $123.14 #DIV/0! $123.02 $114.29 #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!#DIV/0! $234.29 #DIV/0! $267.05 $213.35 #DIV/0! #DIV/0! $571.80 #DIV/0! $918.72 #DIV/0! $382.25 $287.79 #DIV/0! #DIV/0! $339.91 #DIV/0! $458.71 #DIV/0! $381.91 $275.44 #DIV/0!#DIV/0! $8.18 #DIV/0! $8.05 $7.55 #DIV/0! #DIV/0! $13.12 #DIV/0! $14.06 #DIV/0! $11.19 $15.41 #DIV/0! #DIV/0! $8.64 #DIV/0! $9.24 #DIV/0! $7.46 $9.26 #DIV/0!#DIV/0! $484.38 #DIV/0! $476.50 $446.74 #DIV/0! #DIV/0! $776.79 #DIV/0! $832.35 #DIV/0! $662.18 $912.39 #DIV/0! #DIV/0! $511.34 #DIV/0! $547.18 #DIV/0! $441.83 $547.85 #DIV/0!


0.6295 0.6336 0.6295 0.6507 0.6507 0.6466 0.6466 0.9673 0.9638 0.9673 0.9638 0.9825 0.9825 0.9789 0.9789 0.6569 0.6533 0.6569 0.6533 0.6721 0.6721 0.66840.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.94871.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$581.05 $584.84 $581.05 $600.62 $600.62 $596.84 $596.84 $1,009.84 $1,006.19 $1,009.84 $1,006.19 $1,025.71 $1,025.71 $1,021.95 $1,021.95 $685.79 $682.03 $685.79 $682.03 $701.66 $701.66 $697.79

$581.05 $584.84 $581.05 $600.62 $600.62 $596.84 $596.84 $1,009.84 $1,006.19 $1,009.84 $1,006.19 $1,025.71 $1,025.71 $1,021.95 $1,021.95 $685.79 $682.03 $685.79 $682.03 $701.66 $701.66 $697.79

85629NY0010598 85629NY0010599 85629NY0010600 85629NY0010601 85629NY0010602 85629NY0010603 85629NY0010604 85629NY0010605 85629NY0010606 85629NY0010607 85629NY0010608 85629NY0010609 85629NY0010610 85629NY0010611 85629NY0010612 85629NY0010629 85629NY0010630 85629NY0010631 85629NY0010632 85629NY0010633 85629NY0010634 85629NY0010635$0 $24,222,426 $0 $556,306 $537,763 $0 $0 $3,804,260 $0 $3,663,361 $0 $131,187 $310,077 $0 $0 $20,723,224 $0 $27,070,307 $0 $1,082,325 $660,218 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $8,332,246 $0 $191,363 $184,984 $0 $0 $490,908 $0 $472,726 $0 $16,929 $40,013 $0 $0 $7,118,333 $0 $9,298,527 $0 $371,774 $226,782 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $15,890,180 $0 $364,943 $352,778 $0 $0 $3,313,352 $0 $3,190,635 $0 $114,258 $270,064 $0 $0 $13,604,891 $0 $17,771,779 $0 $710,551 $433,436 $0$0 $129,823 $0 $2,982 $2,882 $0 $0 $27,070 $0 $26,068 $0 $933 $2,206 $0 $0 $111,153 $0 $145,196 $0 $5,805 $3,541 $0$0 $18,829,942 $0 $432,459 $418,044 $0 $0 $3,926,339 $0 $3,780,919 $0 $135,396 $320,028 $0 $0 $16,121,864 $0 $21,059,647 $0 $842,006 $513,624 $0

0 32,196 0 720 696 0 0 3,888 0 3,744 0 132 312 0 0 23,508 0 30,708 0 1,200 732 0#DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0!

#DIV/0! $752.34 #DIV/0! $772.65 $772.65 #DIV/0! #DIV/0! $978.46 #DIV/0! $978.46 #DIV/0! $993.84 $993.84 #DIV/0! #DIV/0! $881.54 #DIV/0! $881.54 #DIV/0! $901.94 $901.94 #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!#DIV/0! $258.80 #DIV/0! $265.78 $265.78 #DIV/0! #DIV/0! $126.26 #DIV/0! $126.26 #DIV/0! $128.25 $128.25 #DIV/0! #DIV/0! $302.80 #DIV/0! $302.80 #DIV/0! $309.81 $309.81 #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!#DIV/0! $493.55 #DIV/0! $506.87 $506.87 #DIV/0! #DIV/0! $852.20 #DIV/0! $852.20 #DIV/0! $865.59 $865.59 #DIV/0! #DIV/0! $578.73 #DIV/0! $578.73 #DIV/0! $592.13 $592.13 #DIV/0!#DIV/0! $4.03 #DIV/0! $4.14 $4.14 #DIV/0! #DIV/0! $6.96 #DIV/0! $6.96 #DIV/0! $7.07 $7.07 #DIV/0! #DIV/0! $4.73 #DIV/0! $4.73 #DIV/0! $4.84 $4.84 #DIV/0!#DIV/0! $584.85 #DIV/0! $600.64 $600.64 #DIV/0! #DIV/0! $1,009.86 #DIV/0! $1,009.86 #DIV/0! $1,025.73 $1,025.73 #DIV/0! #DIV/0! $685.80 #DIV/0! $685.80 #DIV/0! $701.67 $701.67 #DIV/0!

15.87%

1.00001.00001.0000

$922.27

NY B LBTY NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG 85629NY0010636 85629NY0010645 85629NY0010646 85629NY0010647 85629NY0010648 85629NY0010649 85629NY0010650 85629NY0010651 85629NY0010652 85629NY0010653 85629NY0010654 85629NY0010655 85629NY0010656 85629NY0010657 85629NY0010658 85629NY0010659 85629NY0010660 85629NY0010693 85629NY0010694 85629NY0010695 85629NY0010696 85629NY0010697

Bronze Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold Gold0.649 0.782 0.782 0.782 0.782 0.782 0.782 0.782 0.782 0.784 0.784 0.784 0.784 0.784 0.784 0.784 0.784 0.807 0.807 0.807 0.807 0.807


1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202221.98% 16.42% 16.43% 16.42% 16.43% 16.41% 16.41% 16.41% 16.41% 16.69% 16.69% 16.69% 16.69% 16.67% 16.67% 16.67% 16.67% 15.14% 15.14% 15.14% 15.14% 15.15%

85629NY0010636 85629NY0010645 85629NY0010646 85629NY0010647 85629NY0010648 85629NY0010649 85629NY0010650 85629NY0010651 85629NY0010652 85629NY0010653 85629NY0010654 85629NY0010655 85629NY0010656 85629NY0010657 85629NY0010658 85629NY0010659 85629NY0010660 85629NY0010693 85629NY0010694 85629NY0010695 85629NY0010696 85629NY0010697$0 $10,310,860 $0 $14,785,434 $0 $1,399,740 $1,282,258 $0 $0 $14,410,708 $0 $29,269,710 $0 $1,927,016 $1,547,501 $0 $0 $15,886,139 $0 $19,222,699 $0 $1,423,806$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $1,410,614 $0 $2,327,044 $0 $101,422 $188,787 $0 $0 $2,303,168 $0 $4,129,499 $0 $539,443 $257,641 $0 $0 $1,063,723 $0 $1,456,372 $0 $97,619$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $8,900,246 $0 $12,458,390 $0 $1,298,318 $1,093,471 $0 $0 $12,107,540 $0 $25,140,211 $0 $1,387,573 $1,289,860 $0 $0 $14,822,415 $0 $17,766,327 $0 $1,326,187$0 $192,605 $0 $305,322 $0 $9,952 $26,016 $0 $0 $320,922 $0 $551,183 $0 $24,795 $34,009 $0 $0 $249,177 $0 $343,657 $0 $17,965$0 $11,400,458 $0 $18,072,268 $0 $589,083 $1,539,900 $0 $0 $18,995,608 $0 $32,624,964 $0 $1,467,629 $2,013,002 $0 $0 $14,748,978 $0 $20,341,331 $0 $1,063,338

0 15,518 0 24,064 0 884 2,312 0 0 26,437 0 45,440 0 2,378 3,106 0 0 18,764 0 25,362 0 1,5990 1,376 0 2,342 0 90 214 0 0 2,601 0 3,653 0 176 239 0 0 2,906 0 3,647 0 302

$571.91 $789.66 $786.45 $789.66 $786.45 $803.35 $803.35 $800.14 $800.14 $749.54 $746.34 $749.54 $746.34 $763.23 $763.23 $760.02 $760.02 $861.61 $858.40 $861.61 $858.40 $875.29#DIV/0! 76.77% #DIV/0! 67.79% #DIV/0! 216.74% 69.83% #DIV/0! #DIV/0! 62.68% #DIV/0! 75.78% #DIV/0! 92.97% 63.01% #DIV/0! #DIV/0! 98.83% #DIV/0! 85.89% #DIV/0! 122.65%

#DIV/0! $664.45 #DIV/0! $614.42 #DIV/0! $1,583.42 $554.61 #DIV/0! #DIV/0! $545.10 #DIV/0! $644.14 #DIV/0! $810.35 $498.23 #DIV/0! #DIV/0! $846.63 #DIV/0! $757.93 #DIV/0! $890.44#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00#DIV/0! $90.90 #DIV/0! $96.70 #DIV/0! $114.73 $81.66 #DIV/0! #DIV/0! $87.12 #DIV/0! $90.88 #DIV/0! $226.85 $82.95 #DIV/0! #DIV/0! $56.69 #DIV/0! $57.42 #DIV/0! $61.05#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00#DIV/0! $573.54 #DIV/0! $517.72 #DIV/0! $1,468.69 $472.95 #DIV/0! #DIV/0! $457.98 #DIV/0! $553.26 #DIV/0! $583.50 $415.28 #DIV/0! #DIV/0! $789.94 #DIV/0! $700.51 #DIV/0! $829.39#DIV/0! $12.41 #DIV/0! $12.69 #DIV/0! $11.26 $11.25 #DIV/0! #DIV/0! $12.14 #DIV/0! $12.13 #DIV/0! $10.43 $10.95 #DIV/0! #DIV/0! $13.28 #DIV/0! $13.55 #DIV/0! $11.23#DIV/0! $734.66 #DIV/0! $751.01 #DIV/0! $666.38 $666.05 #DIV/0! #DIV/0! $718.52 #DIV/0! $717.98 #DIV/0! $617.17 $648.10 #DIV/0! #DIV/0! $786.03 #DIV/0! $802.04 #DIV/0! $665.00


0.6684 0.8357 0.8323 0.8357 0.8323 0.8501 0.8501 0.8467 0.8467 0.8380 0.8344 0.8380 0.8344 0.8532 0.8532 0.8496 0.8496 0.9505 0.9470 0.9505 0.9470 0.96570.9487 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.94871.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$697.79 $919.63 $915.89 $919.63 $915.89 $935.48 $935.48 $931.73 $931.73 $874.85 $871.09 $874.85 $871.09 $890.72 $890.72 $886.96 $886.96 $992.30 $988.65 $992.30 $988.65 $1,008.17

$697.79 $919.63 $915.89 $919.63 $915.89 $935.48 $935.48 $931.73 $931.73 $874.85 $871.09 $874.85 $871.09 $890.72 $890.72 $886.96 $886.96 $992.30 $988.65 $992.30 $988.65 $1,008.17

85629NY0010636 85629NY0010645 85629NY0010646 85629NY0010647 85629NY0010648 85629NY0010649 85629NY0010650 85629NY0010651 85629NY0010652 85629NY0010653 85629NY0010654 85629NY0010655 85629NY0010656 85629NY0010657 85629NY0010658 85629NY0010659 85629NY0010660 85629NY0010693 85629NY0010694 85629NY0010695 85629NY0010696 85629NY0010697$0 $16,569,281 $0 $28,201,495 $0 $1,102,421 $2,621,311 $0 $0 $29,713,981 $0 $41,732,093 $0 $2,047,104 $2,779,875 $0 $0 $33,196,873 $0 $41,661,732 $0 $3,505,085$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $3,755,062 $0 $6,391,247 $0 $249,839 $594,062 $0 $0 $6,670,625 $0 $9,368,625 $0 $459,564 $624,067 $0 $0 $3,995,108 $0 $5,013,819 $0 $421,823$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $12,814,219 $0 $21,810,248 $0 $852,581 $2,027,249 $0 $0 $23,043,356 $0 $32,363,468 $0 $1,587,541 $2,155,808 $0 $0 $29,201,764 $0 $36,647,913 $0 $3,083,263$0 $104,693 $0 $178,191 $0 $6,966 $16,563 $0 $0 $188,265 $0 $264,411 $0 $12,970 $17,613 $0 $0 $238,580 $0 $299,415 $0 $25,190$0 $15,184,914 $0 $25,845,253 $0 $1,010,313 $2,402,300 $0 $0 $27,306,492 $0 $38,350,871 $0 $1,881,244 $2,554,643 $0 $0 $34,604,237 $0 $43,427,960 $0 $3,653,682

0 16,512 0 28,104 0 1,080 2,568 0 0 31,212 0 43,836 0 2,112 2,868 0 0 34,872 0 43,764 0 3,624#DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81%

#DIV/0! $1,003.47 #DIV/0! $1,003.47 #DIV/0! $1,020.76 $1,020.76 #DIV/0! #DIV/0! $952.01 #DIV/0! $952.01 #DIV/0! $969.27 $969.27 #DIV/0! #DIV/0! $951.96 #DIV/0! $951.96 #DIV/0! $967.19#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00#DIV/0! $227.41 #DIV/0! $227.41 #DIV/0! $231.33 $231.33 #DIV/0! #DIV/0! $213.72 #DIV/0! $213.72 #DIV/0! $217.60 $217.60 #DIV/0! #DIV/0! $114.56 #DIV/0! $114.56 #DIV/0! $116.40#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00#DIV/0! $776.05 #DIV/0! $776.05 #DIV/0! $789.43 $789.43 #DIV/0! #DIV/0! $738.29 #DIV/0! $738.29 #DIV/0! $751.68 $751.68 #DIV/0! #DIV/0! $837.40 #DIV/0! $837.40 #DIV/0! $850.79#DIV/0! $6.34 #DIV/0! $6.34 #DIV/0! $6.45 $6.45 #DIV/0! #DIV/0! $6.03 #DIV/0! $6.03 #DIV/0! $6.14 $6.14 #DIV/0! #DIV/0! $6.84 #DIV/0! $6.84 #DIV/0! $6.95#DIV/0! $919.63 #DIV/0! $919.63 #DIV/0! $935.48 $935.48 #DIV/0! #DIV/0! $874.87 #DIV/0! $874.87 #DIV/0! $890.74 $890.74 #DIV/0! #DIV/0! $992.32 #DIV/0! $992.32 #DIV/0! $1,008.19

NY G LBTY NG NY G LBTY NG NY G LBTY NG NY S MTRO NG NY S LBTY NG NY S MTRO NG NY S LBTY NG NY S MTRO NG NY S LBTY NG NY S MTRO NG NY S LBTY NG NY S MTRO NG NY S LBTY NG NY S MTRO NG NY S LBTY NG NY S MTRO NG NY S LBTY NG NY S MTRO NG NY S LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG 85629NY0010698 85629NY0010699 85629NY0010700 85629NY0010701 85629NY0010702 85629NY0010703 85629NY0010704 85629NY0010705 85629NY0010706 85629NY0010707 85629NY0010708 85629NY0010709 85629NY0010710 85629NY0010711 85629NY0010712 85629NY0010713 85629NY0010714 85629NY0010715 85629NY0010716 85629NY0010717 85629NY0010718 85629NY0010719

Gold Gold Gold Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Gold Gold Gold0.807 0.807 0.807 0.709 0.671 0.709 0.671 0.709 0.671 0.709 0.671 0.709 0.671 0.709 0.671 0.709 0.671 0.709 0.671 0.800 0.800 0.800

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPONo No No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No No No No

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202215.15% 15.14% 15.14% 18.37% 18.91% 18.38% 18.93% 18.37% 18.91% 18.38% 18.93% 18.32% 18.85% 18.32% 18.85% 18.32% 18.85% 18.32% 18.85% 15.97% 15.97% 15.97%

85629NY0010698 85629NY0010699 85629NY0010700 85629NY0010701 85629NY0010702 85629NY0010703 85629NY0010704 85629NY0010705 85629NY0010706 85629NY0010707 85629NY0010708 85629NY0010709 85629NY0010710 85629NY0010711 85629NY0010712 85629NY0010713 85629NY0010714 85629NY0010715 85629NY0010716 85629NY0010717 85629NY0010718 85629NY0010719$1,055,155 $0 $0 $1,380,903 $0 $0 $0 $1,095,138 $0 $0 $0 $16,874 $0 $78,431 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$72,742 $0 $0 $139,506 $0 $0 $0 $120,237 $0 $0 $0 $1,957 $0 $3,312 $0 $0 $0 $0 $0 $0 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$982,413 $0 $0 $1,241,396 $0 $0 $0 $974,901 $0 $0 $0 $14,918 $0 $75,119 $0 $0 $0 $0 $0 $0 $0 $0

$17,617 $0 $0 $24,160 $0 $0 $0 $27,656 $0 $0 $0 $213 $0 $1,006 $0 $0 $0 $0 $0 $0 $0 $0$1,042,757 $0 $0 $1,430,025 $0 $0 $0 $1,636,968 $0 $0 $0 $12,628 $0 $59,558 $0 $0 $0 $0 $0 $0 $0 $0

1,490 0 0 2,159 0 0 0 2,423 0 0 0 19 0 109 0 0 0 0 0 0 0 0287 0 0 400 59 0 0 424 208 0 0 24 0 11 0 0 0 0 0 30 0 87

$875.29 $872.09 $872.09 $648.79 $615.24 $645.59 $612.04 $648.79 $615.24 $645.59 $612.04 $662.48 $628.93 $662.48 $628.93 $659.27 $625.72 $659.27 $625.72 $763.52 $760.31 $763.5292.65% #DIV/0! #DIV/0! 85.37% #DIV/0! #DIV/0! #DIV/0! 58.57% #DIV/0! #DIV/0! #DIV/0! 116.17% #DIV/0! 124.03% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

$708.16 #DIV/0! #DIV/0! $639.60 #DIV/0! #DIV/0! #DIV/0! $451.98 #DIV/0! #DIV/0! #DIV/0! $888.11 #DIV/0! $719.55 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!$0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!



$699.84 #DIV/0! #DIV/0! $662.36 #DIV/0! #DIV/0! #DIV/0! $675.60 #DIV/0! #DIV/0! #DIV/0! $664.64 #DIV/0! $546.41 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


0.9657 0.9621 0.9621 0.8322 0.7010 0.8282 0.6974 0.8322 0.7010 0.8282 0.6974 0.8494 0.7162 0.8494 0.7162 0.8453 0.7125 0.8453 0.7125 0.8484 0.8448 0.84840.9487 0.9487 0.9487 0.8388 0.9487 0.8388 0.9487 0.8388 0.9487 0.8388 0.9487 0.8388 0.9487 0.8388 0.9487 0.8388 0.9487 0.8388 0.9487 0.9487 0.9487 0.94871.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$1,008.17 $1,004.41 $1,004.41 $768.15 $731.83 $764.46 $728.07 $768.15 $731.83 $764.46 $728.07 $784.03 $747.70 $784.03 $747.70 $780.25 $743.83 $780.25 $743.83 $885.71 $881.95 $885.71

$1,008.17 $1,004.41 $1,004.41 $768.15 $731.83 $764.46 $728.07 $768.15 $731.83 $764.46 $728.07 $784.03 $747.70 $784.03 $747.70 $780.25 $743.83 $780.25 $743.83 $885.71 $881.95 $885.71

85629NY0010698 85629NY0010699 85629NY0010700 85629NY0010701 85629NY0010702 85629NY0010703 85629NY0010704 85629NY0010705 85629NY0010706 85629NY0010707 85629NY0010708 85629NY0010709 85629NY0010710 85629NY0010711 85629NY0010712 85629NY0010713 85629NY0010714 85629NY0010715 85629NY0010716 85629NY0010717 85629NY0010718 85629NY0010719$3,330,992 $0 $0 $3,853,024 $644,548 $0 $0 $4,084,205 $2,272,305 $0 $0 $235,960 $0 $108,148 $0 $0 $0 $0 $0 $343,493 $0 $996,129

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$400,871 $0 $0 $741,446 $207,297 $0 $0 $785,933 $730,808 $0 $0 $45,406 $0 $20,811 $0 $0 $0 $0 $0 $74,412 $0 $215,794

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$2,930,121 $0 $0 $3,111,578 $437,252 $0 $0 $3,298,272 $1,541,497 $0 $0 $190,553 $0 $87,337 $0 $0 $0 $0 $0 $269,081 $0 $780,335

$23,939 $0 $0 $25,422 $3,572 $0 $0 $26,947 $12,594 $0 $0 $1,557 $0 $714 $0 $0 $0 $0 $0 $2,198 $0 $6,375$3,472,208 $0 $0 $3,687,235 $518,145 $0 $0 $3,908,469 $1,826,682 $0 $0 $225,807 $0 $103,495 $0 $0 $0 $0 $0 $318,863 $0 $924,701

3,444 0 0 4,800 708 0 0 5,088 2,496 0 0 288 0 132 0 0 0 0 0 360 0 1,04483.81% #DIV/0! #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81%

$967.19 #DIV/0! #DIV/0! $802.71 $910.38 #DIV/0! #DIV/0! $802.71 $910.38 #DIV/0! #DIV/0! $819.30 #DIV/0! $819.30 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $954.15 #DIV/0! $954.15$0.00 #DIV/0! #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00



$1,008.19 #DIV/0! #DIV/0! $768.17 $731.84 #DIV/0! #DIV/0! $768.17 $731.84 #DIV/0! #DIV/0! $784.05 #DIV/0! $784.05 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $885.73 #DIV/0! $885.73

NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY P LBTY NG NY P LBTY NG NY P LBTY NG NY P LBTY NG NY P LBTY NG NY P LBTY NG NY P LBTY NG NY P LBTY NG NY G LBTY NG 85629NY0010720 85629NY0010721 85629NY0010722 85629NY0010723 85629NY0010724 85629NY0010725 85629NY0010726 85629NY0010727 85629NY0010728 85629NY0010729 85629NY0010730 85629NY0010731 85629NY0010732 85629NY0010733 85629NY0010734 85629NY0010735 85629NY0010736 85629NY0010737 85629NY0010738 85629NY0010739 85629NY0010740 85629NY0010741

Gold Gold Gold Gold Gold Silver Silver Silver Silver Silver Silver Silver Silver Platinum Platinum Platinum Platinum Platinum Platinum Platinum Platinum Gold0.800 0.800 0.800 0.800 0.800 0.709 0.709 0.709 0.709 0.709 0.709 0.709 0.709 0.869 0.869 0.869 0.869 0.869 0.869 0.869 0.869 0.777


1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202215.97% 15.97% 15.97% 15.96% 15.96% 15.56% 15.56% 15.56% 15.56% 15.57% 15.57% 15.56% 15.56% 16.87% 16.87% 16.87% 16.87% 16.86% 16.86% 16.85% 16.85% 19.90%

85629NY0010720 85629NY0010721 85629NY0010722 85629NY0010723 85629NY0010724 85629NY0010725 85629NY0010726 85629NY0010727 85629NY0010728 85629NY0010729 85629NY0010730 85629NY0010731 85629NY0010732 85629NY0010733 85629NY0010734 85629NY0010735 85629NY0010736 85629NY0010737 85629NY0010738 85629NY0010739 85629NY0010740 85629NY0010741$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 464 0 450 0 15 79 0 0 424 0 87 0 21 3 0 0 124

$760.31 $777.20 $777.20 $774.00 $774.00 $751.64 $748.44 $751.64 $748.44 $765.33 $765.33 $762.12 $762.12 $919.19 $915.98 $919.19 $915.98 $932.88 $932.88 $929.67 $929.67 $737.08#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


0.8448 0.8636 0.8636 0.8599 0.8599 0.8322 0.8287 0.8322 0.8287 0.8474 0.8474 0.8438 0.8438 1.0293 1.0257 1.0293 1.0257 1.0445 1.0445 1.0409 1.0409 0.84670.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.94871.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$881.95 $901.58 $901.58 $897.72 $897.72 $868.80 $865.14 $868.80 $865.14 $884.67 $884.67 $880.91 $880.91 $1,074.57 $1,070.81 $1,074.57 $1,070.81 $1,090.43 $1,090.43 $1,086.68 $1,086.68 $883.94

$881.95 $901.58 $901.58 $897.72 $897.72 $868.80 $865.14 $868.80 $865.14 $884.67 $884.67 $880.91 $880.91 $1,074.57 $1,070.81 $1,074.57 $1,070.81 $1,090.43 $1,090.43 $1,086.68 $1,086.68 $883.94

85629NY0010720 85629NY0010721 85629NY0010722 85629NY0010723 85629NY0010724 85629NY0010725 85629NY0010726 85629NY0010727 85629NY0010728 85629NY0010729 85629NY0010730 85629NY0010731 85629NY0010732 85629NY0010733 85629NY0010734 85629NY0010735 85629NY0010736 85629NY0010737 85629NY0010738 85629NY0010739 85629NY0010740 85629NY0010741$0 $0 $0 $0 $0 $5,055,080 $0 $4,902,556 $0 $166,403 $876,391 $0 $0 $5,157,800 $0 $1,058,322 $0 $259,230 $37,033 $0 $0 $1,416,511$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $972,760 $0 $943,410 $0 $32,021 $168,646 $0 $0 $543,889 $0 $111,600 $0 $27,336 $3,905 $0 $0 $306,538$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $4,082,320 $0 $3,959,147 $0 $134,382 $707,745 $0 $0 $4,613,911 $0 $946,722 $0 $231,894 $33,128 $0 $0 $1,109,973$0 $0 $0 $0 $0 $33,353 $0 $32,346 $0 $1,098 $5,782 $0 $0 $37,696 $0 $7,735 $0 $1,895 $271 $0 $0 $9,069$0 $0 $0 $0 $0 $4,837,570 $0 $4,691,609 $0 $159,243 $838,682 $0 $0 $5,467,507 $0 $1,121,871 $0 $274,795 $39,256 $0 $0 $1,315,324

0 0 0 0 0 5,568 0 5,400 0 180 948 0 0 5,088 0 1,044 0 252 36 0 0 1,488#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81%

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $907.88 #DIV/0! $907.88 #DIV/0! $924.46 $924.46 #DIV/0! #DIV/0! $1,013.72 #DIV/0! $1,013.72 #DIV/0! $1,028.69 $1,028.69 #DIV/0! #DIV/0! $951.96#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $174.71 #DIV/0! $174.71 #DIV/0! $177.90 $177.90 #DIV/0! #DIV/0! $106.90 #DIV/0! $106.90 #DIV/0! $108.48 $108.48 #DIV/0! #DIV/0! $206.01#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $733.18 #DIV/0! $733.18 #DIV/0! $746.57 $746.57 #DIV/0! #DIV/0! $906.82 #DIV/0! $906.82 #DIV/0! $920.21 $920.21 #DIV/0! #DIV/0! $745.95#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $5.99 #DIV/0! $5.99 #DIV/0! $6.10 $6.10 #DIV/0! #DIV/0! $7.41 #DIV/0! $7.41 #DIV/0! $7.52 $7.52 #DIV/0! #DIV/0! $6.09#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $868.82 #DIV/0! $868.82 #DIV/0! $884.69 $884.69 #DIV/0! #DIV/0! $1,074.59 #DIV/0! $1,074.59 #DIV/0! $1,090.46 $1,090.46 #DIV/0! #DIV/0! $883.95

NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY G LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG 85629NY0010742 85629NY0010743 85629NY0010744 85629NY0010745 85629NY0010746 85629NY0010747 85629NY0010748 85629NY0010749 85629NY0010750 85629NY0010751 85629NY0010752 85629NY0010753 85629NY0010754 85629NY0010755 85629NY0010756 85629NY0010757 85629NY0010758 85629NY0010759 85629NY0010760 85629NY0010761 85629NY0010762 85629NY0010763

Gold Gold Gold Gold Gold Gold Gold Silver Silver Silver Silver Silver Silver Silver Silver Gold Gold Gold Gold Gold Gold Gold0.777 0.777 0.777 0.777 0.777 0.777 0.777 0.687 0.687 0.687 0.687 0.687 0.687 0.687 0.687 0.812 0.812 0.812 0.812 0.812 0.812 0.812

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing New New New New New New NewEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPONo No No No No No No No No No No No No No No No No No No No No No

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/202219.91% 19.90% 19.91% 19.82% 19.82% 19.83% 19.83% 20.45% 20.47% 20.45% 20.47% 20.35% 20.35% 20.36% 20.36% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%


0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 269 0 12 15 0 0 173 0 421 0 1 4 0 0 0 0 0 0 0 0 0




0.8432 0.8467 0.8432 0.8619 0.8619 0.8583 0.8583 0.7237 0.7201 0.7237 0.7201 0.7389 0.7389 0.7353 0.7353 0.8622 0.8588 0.8622 0.8588 0.8766 0.8766 0.87310.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$880.28 $883.94 $880.28 $899.80 $899.80 $896.05 $896.05 $755.53 $751.77 $755.53 $751.77 $771.39 $771.39 $767.64 $767.64 $948.79 $945.05 $948.79 $945.05 $964.64 $964.64 $960.79

$880.28 $883.94 $880.28 $899.80 $899.80 $896.05 $896.05 $755.53 $751.77 $755.53 $751.77 $771.39 $771.39 $767.64 $767.64 $948.79 $945.05 $948.79 $945.05 $964.64 $964.64 $960.79

85629NY0010742 85629NY0010743 85629NY0010744 85629NY0010745 85629NY0010746 85629NY0010747 85629NY0010748 85629NY0010749 85629NY0010750 85629NY0010751 85629NY0010752 85629NY0010753 85629NY0010754 85629NY0010755 85629NY0010756 85629NY0010757 85629NY0010758 85629NY0010759 85629NY0010760 85629NY0010761 85629NY0010762 85629NY0010763$0 $3,072,915 $0 $139,543 $174,428 $0 $0 $1,884,876 $0 $4,586,894 $0 $11,124 $44,496 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $664,989 $0 $30,197 $37,747 $0 $0 $561,247 $0 $1,365,810 $0 $3,312 $13,249 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $2,407,926 $0 $109,345 $136,681 $0 $0 $1,323,628 $0 $3,221,084 $0 $7,812 $31,247 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $19,673 $0 $893 $1,117 $0 $0 $10,814 $0 $26,316 $0 $64 $255 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $2,853,405 $0 $129,575 $161,968 $0 $0 $1,568,506 $0 $3,817,000 $0 $9,257 $37,028 $0 $0 $0 $0 $0 $0 $0 $0 $0

0 3,228 0 144 180 0 0 2,076 0 5,052 0 12 48 0 0 0 0 0 0 0 0 0#DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

#DIV/0! $951.96 #DIV/0! $969.05 $969.05 #DIV/0! #DIV/0! $907.94 #DIV/0! $907.94 #DIV/0! $927.01 $927.01 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! $206.01 #DIV/0! $209.70 $209.70 #DIV/0! #DIV/0! $270.35 #DIV/0! $270.35 #DIV/0! $276.03 $276.03 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! $745.95 #DIV/0! $759.34 $759.34 #DIV/0! #DIV/0! $637.59 #DIV/0! $637.59 #DIV/0! $650.98 $650.98 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! $6.09 #DIV/0! $6.20 $6.20 #DIV/0! #DIV/0! $5.21 #DIV/0! $5.21 #DIV/0! $5.32 $5.32 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!#DIV/0! $883.95 #DIV/0! $899.82 $899.82 #DIV/0! #DIV/0! $755.54 #DIV/0! $755.54 #DIV/0! $771.41 $771.41 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

NY G FRDM NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S LBTY NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG 85629NY0010764 85629NY0010765 85629NY0010766 85629NY0010767 85629NY0010768 85629NY0010769 85629NY0010770 85629NY0010771 85629NY0010772 85629NY0010773 85629NY0010774 85629NY0010775 85629NY0010776 85629NY0010777 85629NY0010778 85629NY0010779 85629NY0010780 85629NY0010781 85629NY0010782 85629NY0010783 85629NY0010784 85629NY0010785

Gold Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Silver Gold Gold Gold Gold Gold0.812 0.694 0.694 0.694 0.694 0.694 0.694 0.694 0.694 0.709 0.709 0.709 0.709 0.709 0.709 0.709 0.709 0.805 0.805 0.805 0.805 0.805New New New New New New New New New New New New New New New New New New New New New NewEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPONo No No No No No No No No No No No No No No No No No No No No No

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/20220.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%


0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0




0.8731 0.7319 0.7283 0.7319 0.7283 0.7471 0.7471 0.7434 0.7434 0.8322 0.8289 0.8322 0.8289 0.8467 0.8467 0.8432 0.8432 0.9530 0.9496 0.9530 0.9496 0.96741.0000 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$960.79 $764.09 $760.33 $764.09 $760.33 $779.96 $779.96 $776.09 $776.09 $915.78 $912.15 $915.78 $912.15 $931.73 $931.73 $927.88 $927.88 $1,048.71 $1,044.97 $1,048.71 $1,044.97 $1,064.56

$960.79 $764.09 $760.33 $764.09 $760.33 $779.96 $779.96 $776.09 $776.09 $915.78 $912.15 $915.78 $912.15 $931.73 $931.73 $927.88 $927.88 $1,048.71 $1,044.97 $1,048.71 $1,044.97 $1,064.56


0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!


NY G FRDM NG NY G FRDM NG NY G FRDM NG NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY S MTRO GT NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY S FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY S FRDM NG NY S FRDM NG 85629NY0010786 85629NY0010787 85629NY0010788 85629NY0010789 85629NY0010790 85629NY0010791 85629NY0010792 85629NY0010793 85629NY0010794 85629NY0010795 85629NY0010796 85629NY0050001 85629NY0050002 85629NY0050003 85629NY0050004 85629NY0050008 85629NY0050009 85629NY0050010 85629NY0050011 85629NY0050012 85629NY0050018 85629NY0050019

Gold Gold Gold Silver Silver Silver Silver Silver Silver Silver Silver Gold Gold Gold Gold Silver Platinum Platinum Platinum Platinum Silver Silver0.805 0.805 0.805 0.711 0.711 0.711 0.711 0.711 0.711 0.711 0.711 0.801 0.801 0.801 0.801 0.707 0.912 0.912 0.912 0.912 0.707 0.707New New New New New New New New New New New Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingEPO EPO EPO EPO EPO EPO EPO EPO EPO EPO EPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPONo No No Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No

1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/20220.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 15.39% 15.39% 15.39% 15.39% 16.47% 13.91% 13.89% 13.91% 13.89% 16.47% 16.45%

85629NY0010786 85629NY0010787 85629NY0010788 85629NY0010789 85629NY0010790 85629NY0010791 85629NY0010792 85629NY0010793 85629NY0010794 85629NY0010795 85629NY0010796 85629NY0050001 85629NY0050002 85629NY0050003 85629NY0050004 85629NY0050008 85629NY0050009 85629NY0050010 85629NY0050011 85629NY0050012 85629NY0050018 85629NY0050019$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $35,851,031 $189,055,720 $36,943,766 $211,934,672 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $4,777,653 $18,420,291 $4,066,459 $22,789,748 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $31,073,378 $170,635,429 $32,877,307 $189,144,924 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $612,404 $3,610,899 $600,651 $3,401,970 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $36,248,658 $213,731,961 $35,552,977 $201,365,252 $0 $0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 37,507 211,336 37,436 202,105 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,878 15,886 2,856 14,971 0 0

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $839.93 $839.93 $853.61 $853.61 $739.80 $1,099.69 $1,086.00 $1,099.69 $1,086.00 $739.80 $753.49#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 84.30% 78.51% 90.94% 92.37% #DIV/0! #DIV/0!

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $955.85 $894.57 $986.85 $1,048.64 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $127.38 $87.16 $108.62 $112.76 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $828.47 $807.41 $878.23 $935.87 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $16.33 $17.09 $16.04 $16.83 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $966.45 $1,011.34 $949.70 $996.34 #DIV/0! #DIV/0!


0.9674 0.9640 0.9640 0.7462 0.7421 0.7462 0.7421 0.7634 0.7634 0.7592 0.7592 0.8810 0.8810 0.8953 0.8953 0.7832 1.1387 1.1243 1.1387 1.1243 0.7832 0.79761.0000 1.0000 1.0000 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 0.8388 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$1,064.56 $1,060.81 $1,060.81 $688.77 $684.99 $688.77 $684.99 $704.65 $704.65 $700.77 $700.77 $969.48 $969.48 $985.21 $985.21 $861.86 $1,253.06 $1,237.21 $1,253.06 $1,237.21 $861.86 $877.70

$1,064.56 $1,060.81 $1,060.81 $688.77 $684.99 $688.77 $684.99 $704.65 $704.65 $700.77 $700.77 $969.48 $969.48 $985.21 $985.21 $861.86 $1,253.06 $1,237.21 $1,253.06 $1,237.21 $861.86 $877.70

85629NY0010786 85629NY0010787 85629NY0010788 85629NY0010789 85629NY0010790 85629NY0010791 85629NY0010792 85629NY0010793 85629NY0010794 85629NY0010795 85629NY0010796 85629NY0050001 85629NY0050002 85629NY0050003 85629NY0050004 85629NY0050008 85629NY0050009 85629NY0050010 85629NY0050011 85629NY0050012 85629NY0050018 85629NY0050019$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $38,901,667 $212,014,159 $38,604,295 $199,802,592 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $2,382,285 $12,983,457 $2,364,074 $12,235,638 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $36,519,382 $199,030,702 $36,240,220 $187,566,955 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $298,365 $1,626,089 $296,084 $1,532,430 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $43,275,650 $235,852,376 $42,944,842 $222,267,778 $0 $0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 34,536 190,632 34,272 179,652 0 0#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% 83.81% 83.81% 83.81% #DIV/0! #DIV/0!

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $1,126.41 $1,112.16 $1,126.41 $1,112.16 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $68.98 $68.11 $68.98 $68.11 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $1,057.43 $1,044.06 $1,057.43 $1,044.06 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $8.64 $8.53 $8.64 $8.53 #DIV/0! #DIV/0!#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $1,253.06 $1,237.21 $1,253.06 $1,237.21 #DIV/0! #DIV/0!

NY S FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG NY S FRDM NG 85629NY0050020 85629NY0050025 85629NY0050026 85629NY0050027 85629NY0050028 85629NY0050033 85629NY0050034 85629NY0050035 85629NY0050036 85629NY0050041 85629NY0050042 85629NY0050043 85629NY0050044 85629NY0050065 85629NY0050066 85629NY0050067 85629NY0050068 85629NY0050105 85629NY0050106 85629NY0050107 85629NY0050108 85629NY0050129

Silver Platinum Platinum Platinum Platinum Silver Silver Silver Silver Gold Gold Gold Gold Gold Gold Gold Gold Silver Silver Silver Silver Silver0.707 0.885 0.885 0.885 0.885 0.712 0.712 0.712 0.712 0.811 0.811 0.811 0.811 0.801 0.801 0.801 0.801 0.707 0.707 0.707 0.707 0.712

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingPPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

No No No No No No No No No No No No No No No No No No No No No No1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022

16.45% 13.89% 13.87% 13.89% 13.87% 16.89% 16.89% 16.86% 16.86% 15.42% 15.41% 15.42% 15.41% 15.40% 15.39% 15.40% 15.39% 16.45% 16.46% 16.45% 16.46% 16.87%

85629NY0050020 85629NY0050025 85629NY0050026 85629NY0050027 85629NY0050028 85629NY0050033 85629NY0050034 85629NY0050035 85629NY0050036 85629NY0050041 85629NY0050042 85629NY0050043 85629NY0050044 85629NY0050065 85629NY0050066 85629NY0050067 85629NY0050068 85629NY0050105 85629NY0050106 85629NY0050107 85629NY0050108 85629NY0050129$0 $3,747,998 $75,422,965 $5,633,391 $58,977,743 $0 $0 $0 $0 $6,820,060 $94,791,210 $9,208,176 $70,287,309 $4,190,918 $33,259,962 $5,790,263 $27,481,460 $5,882,616 $37,293,328 $6,114,263 $31,904,427 $4,088,199$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $446,926 $6,813,378 $599,522 $6,793,296 $0 $0 $0 $0 $1,063,753 $14,377,057 $2,048,238 $10,202,687 $736,375 $6,178,177 $859,076 $3,957,763 $1,319,859 $8,585,430 $1,156,187 $7,788,579 $1,083,386$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $3,301,072 $68,609,587 $5,033,869 $52,184,447 $0 $0 $0 $0 $5,756,307 $80,414,153 $7,159,938 $60,084,622 $3,454,543 $27,081,784 $4,931,188 $23,523,697 $4,562,757 $28,707,898 $4,958,076 $24,115,848 $3,004,812$0 $70,546 $1,406,154 $110,091 $1,103,184 $0 $0 $0 $0 $112,127 $1,630,268 $131,501 $1,217,757 $69,018 $600,034 $77,531 $399,582 $92,393 $719,379 $64,305 $536,004 $55,830$0 $4,175,682 $83,231,385 $6,516,363 $65,298,345 $0 $0 $0 $0 $6,636,899 $96,496,825 $7,783,643 $72,079,981 $4,085,201 $35,516,479 $4,589,142 $23,651,575 $5,468,786 $42,580,606 $3,806,261 $31,726,504 $3,304,616

0 4,479 84,125 7,170 67,327 0 0 0 0 8,472 113,621 10,022 89,255 5,386 45,404 6,263 31,579 8,086 60,996 5,835 47,641 5,0980 515 6,816 555 5,369 0 0 0 0 719 8,563 749 6,740 471 3,326 326 2,723 638 4,916 484 3,568 456

$753.49 $1,075.41 $1,061.72 $1,075.41 $1,061.72 $735.19 $735.19 $748.88 $748.88 $901.47 $887.78 $901.47 $887.78 $856.82 $843.13 $856.82 $843.13 $756.69 $743.01 $756.69 $743.01 $752.09#DIV/0! 77.74% 81.06% 75.97% 78.59% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 85.29% 81.95% 90.46% 81.97% 83.16% 74.98% 105.67% 97.81% 82.05% 66.30% 128.10% 74.75% 89.42%

#DIV/0! $836.79 $896.56 $785.69 $875.99 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $805.01 $834.28 $918.80 $787.49 $778.11 $732.53 $924.52 $870.24 $727.51 $611.41 $1,047.86 $669.68 $801.92#DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00#DIV/0! $99.78 $80.99 $83.62 $100.90 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $125.56 $126.54 $204.37 $114.31 $136.72 $136.07 $137.17 $125.33 $163.23 $140.75 $198.15 $163.48 $212.51#DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00#DIV/0! $737.01 $815.57 $702.07 $775.09 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $679.45 $707.74 $714.42 $673.18 $641.39 $596.46 $787.35 $744.92 $564.28 $470.65 $849.71 $506.20 $589.41#DIV/0! $15.75 $16.72 $15.35 $16.39 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $13.24 $14.35 $13.12 $13.64 $12.81 $13.22 $12.38 $12.65 $11.43 $11.79 $11.02 $11.25 $10.95#DIV/0! $932.28 $989.38 $908.84 $969.87 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $783.39 $849.29 $776.66 $807.57 $758.49 $782.23 $732.74 $748.97 $676.33 $698.09 $652.32 $665.95 $648.22


0.7976 1.1134 1.0990 1.1134 1.0990 0.7812 0.7812 0.7955 0.7955 0.9458 0.9314 0.9458 0.9314 0.8988 0.8843 0.8988 0.8843 0.8010 0.7866 0.8010 0.7866 0.79901.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$877.70 $1,225.22 $1,209.37 $1,225.22 $1,209.37 $859.66 $859.66 $875.39 $875.39 $1,040.79 $1,024.94 $1,040.79 $1,024.94 $989.07 $973.11 $989.07 $973.11 $881.44 $865.60 $881.44 $865.60 $879.24

$877.70 $1,225.22 $1,209.37 $1,225.22 $1,209.37 $859.66 $859.66 $875.39 $875.39 $1,040.79 $1,024.94 $1,040.79 $1,024.94 $989.07 $973.11 $989.07 $973.11 $881.44 $865.60 $881.44 $865.60 $879.24

85629NY0050020 85629NY0050025 85629NY0050026 85629NY0050027 85629NY0050028 85629NY0050033 85629NY0050034 85629NY0050035 85629NY0050036 85629NY0050041 85629NY0050042 85629NY0050043 85629NY0050044 85629NY0050065 85629NY0050066 85629NY0050067 85629NY0050068 85629NY0050105 85629NY0050106 85629NY0050107 85629NY0050108 85629NY0050129$0 $6,954,350 $90,850,086 $7,494,493 $71,563,103 $0 $0 $0 $0 $9,192,824 $107,815,933 $9,576,392 $84,862,711 $6,025,091 $41,860,217 $4,170,233 $34,271,007 $7,810,132 $59,097,756 $5,924,928 $42,892,757 $5,593,510$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $564,631 $7,376,210 $608,485 $5,810,280 $0 $0 $0 $0 $1,614,878 $18,939,732 $1,682,259 $14,907,602 $1,307,641 $9,085,030 $905,076 $7,437,925 $2,115,358 $16,006,503 $1,604,754 $11,617,413 $1,533,427$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$0 $6,389,719 $83,473,876 $6,886,008 $65,752,823 $0 $0 $0 $0 $7,577,946 $88,876,201 $7,894,133 $69,955,109 $4,717,450 $32,775,187 $3,265,156 $26,833,083 $5,694,774 $43,091,253 $4,320,173 $31,275,344 $4,060,083$0 $52,204 $681,985 $56,259 $537,203 $0 $0 $0 $0 $61,912 $726,122 $64,495 $571,536 $38,542 $267,775 $26,676 $219,227 $46,527 $352,057 $35,296 $255,521 $33,171$0 $7,571,849 $98,916,960 $8,159,954 $77,917,424 $0 $0 $0 $0 $8,979,904 $105,318,742 $9,354,587 $82,897,153 $5,590,201 $38,838,760 $3,869,226 $31,797,337 $6,748,336 $51,063,350 $5,119,427 $37,061,439 $4,811,219

0 6,180 81,792 6,660 64,428 0 0 0 0 8,628 102,756 8,988 80,880 5,652 39,912 3,912 32,676 7,656 58,992 5,808 42,816 5,472#DIV/0! 83.81% 83.81% 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% 83.81% 83.81% 83.81% 83.81% 83.81% 83.81% 83.81% 83.81% 83.81% 83.81% 83.81% 83.81%

#DIV/0! $1,125.30 $1,110.75 $1,125.30 $1,110.75 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $1,065.46 $1,049.24 $1,065.46 $1,049.24 $1,066.01 $1,048.81 $1,066.01 $1,048.81 $1,020.13 $1,001.79 $1,020.13 $1,001.79 $1,022.21#DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00#DIV/0! $91.36 $90.18 $91.36 $90.18 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $187.17 $184.32 $187.17 $184.32 $231.36 $227.63 $231.36 $227.63 $276.30 $271.33 $276.30 $271.33 $280.23#DIV/0! $0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00#DIV/0! $1,033.94 $1,020.56 $1,033.94 $1,020.56 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $878.30 $864.92 $878.30 $864.92 $834.65 $821.19 $834.65 $821.19 $743.83 $730.46 $743.83 $730.46 $741.97#DIV/0! $8.45 $8.34 $8.45 $8.34 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $7.18 $7.07 $7.18 $7.07 $6.82 $6.71 $6.82 $6.71 $6.08 $5.97 $6.08 $5.97 $6.06#DIV/0! $1,225.22 $1,209.37 $1,225.22 $1,209.37 #DIV/0! #DIV/0! #DIV/0! #DIV/0! $1,040.79 $1,024.94 $1,040.79 $1,024.94 $989.07 $973.11 $989.07 $973.11 $881.44 $865.60 $881.44 $865.60 $879.24

PPO85629NY005

14.75%

NY S FRDM NG NY S FRDM NG NY S FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY G FRDM NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG NY B LBTY NG 85629NY0050130 85629NY0050131 85629NY0050132 85629NY0050177 85629NY0050178 85629NY0050179 85629NY0050180 85629NY0050185 85629NY0050186 85629NY0050187 85629NY0050188 85629NY0050193 85629NY0050194 85629NY0050195 85629NY0050196 85629NY0050225 85629NY0050226 85629NY0050227 85629NY0050228 85629NY0050229 85629NY0050230 85629NY0050231

Silver Silver Silver Platinum Platinum Platinum Platinum Platinum Platinum Platinum Platinum Gold Gold Gold Gold Bronze Bronze Bronze Bronze Bronze Bronze Bronze0.712 0.712 0.712 0.912 0.912 0.912 0.912 0.885 0.885 0.885 0.885 0.811 0.811 0.811 0.811 0.645 0.645 0.645 0.645 0.645 0.645 0.645

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingPPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO PPO

No No No No No No No No No No No No No No No No No No No No No No1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022

16.89% 16.87% 16.89% 13.88% 13.88% 13.90% 13.90% 13.86% 13.86% 13.88% 13.88% 15.41% 15.41% 15.41% 15.41% 21.22% 21.25% 21.22% 21.25% 21.10% 21.10% 21.11%

85629NY0050130 85629NY0050131 85629NY0050132 85629NY0050177 85629NY0050178 85629NY0050179 85629NY0050180 85629NY0050185 85629NY0050186 85629NY0050187 85629NY0050188 85629NY0050193 85629NY0050194 85629NY0050195 85629NY0050196 85629NY0050225 85629NY0050226 85629NY0050227 85629NY0050228 85629NY0050229 85629NY0050230 85629NY0050231$41,998,850 $3,062,082 $28,246,697 $1,902 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $2,948,521 $0 $2,960,433 $0 $213,169 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$8,982,936 $645,138 $5,970,120 $126 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $905,542 $0 $775,815 $0 $77,030 $0 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$33,015,914 $2,416,944 $22,276,576 $1,775 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $2,042,979 $0 $2,184,617 $0 $136,139 $0 $0

$756,627 $60,759 $446,927 $79 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $49,379 $0 $55,422 $0 $4,256 $0 $0$44,785,329 $3,596,395 $26,453,941 $4,696 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $2,922,778 $0 $3,280,498 $0 $251,887 $0 $0

63,331 5,652 37,551 4 0 0 0 0 0 0 0 0 0 0 0 5,663 0 5,623 0 508 0 05,207 493 3,174 0 0 0 0 0 0 0 0 0 0 0 0 433 0 616 0 61 2 0

$738.40 $752.09 $738.40 $1,082.79 $1,082.79 $1,096.48 $1,096.48 $1,058.51 $1,058.51 $1,072.20 $1,072.20 $884.58 $884.58 $898.26 $898.26 $589.64 $586.44 $589.64 $586.44 $603.33 $603.33 $600.1272.50% 66.09% 82.81% 37.18% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 68.74% #DIV/0! 65.49% #DIV/0! 53.15% #DIV/0! #DIV/0!

$663.16 $541.77 $752.22 $475.44 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $520.66 #DIV/0! $526.49 #DIV/0! $419.62 #DIV/0! #DIV/0!$0.00 $0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! #DIV/0!



$707.16 $636.30 $704.48 $1,173.97 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $516.12 #DIV/0! $583.41 #DIV/0! $495.84 #DIV/0! #DIV/0!


0.7845 0.7990 0.7845 1.1209 1.1209 1.1352 1.1352 1.0956 1.0956 1.1100 1.1100 0.9280 0.9280 0.9424 0.9424 0.6848 0.6813 0.6848 0.6813 0.7000 0.7000 0.69641.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9487 0.9487 0.9487 0.9487 0.9487 0.9487 0.94871.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$863.29 $879.24 $863.29 $1,233.47 $1,233.47 $1,249.21 $1,249.21 $1,205.63 $1,205.63 $1,221.48 $1,221.48 $1,021.20 $1,021.20 $1,037.04 $1,037.04 $714.92 $711.26 $714.92 $711.26 $730.78 $730.78 $727.03

$863.29 $879.24 $863.29 $1,233.47 $1,233.47 $1,249.21 $1,249.21 $1,205.63 $1,205.63 $1,221.48 $1,221.48 $1,021.20 $1,021.20 $1,037.04 $1,037.04 $714.92 $711.26 $714.92 $711.26 $730.78 $730.78 $727.03

85629NY0050130 85629NY0050131 85629NY0050132 85629NY0050177 85629NY0050178 85629NY0050179 85629NY0050180 85629NY0050185 85629NY0050186 85629NY0050187 85629NY0050188 85629NY0050193 85629NY0050194 85629NY0050195 85629NY0050196 85629NY0050225 85629NY0050226 85629NY0050227 85629NY0050228 85629NY0050229 85629NY0050230 85629NY0050231$62,712,389 $6,047,370 $38,227,218 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $4,786,638 $0 $6,809,629 $0 $689,298 $22,600 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$17,192,224 $1,657,850 $10,479,761 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $1,651,815 $0 $2,349,927 $0 $237,869 $7,799 $0

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0$45,520,165 $4,389,520 $27,747,456 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $3,134,823 $0 $4,459,702 $0 $451,429 $14,801 $0

$371,902 $35,863 $226,698 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $25,612 $0 $36,436 $0 $3,688 $121 $0$53,941,623 $5,201,603 $32,880,874 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $3,714,781 $0 $5,284,769 $0 $534,945 $17,539 $0

62,484 5,916 38,088 0 0 0 0 0 0 0 0 0 0 0 0 5,196 0 7,392 0 732 24 083.81% 83.81% 83.81% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0!

$1,003.66 $1,022.21 $1,003.66 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $921.22 #DIV/0! $921.22 #DIV/0! $941.66 $941.66 #DIV/0!$0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!

$275.15 $280.23 $275.15 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $317.90 #DIV/0! $317.90 #DIV/0! $324.96 $324.96 #DIV/0!$0.00 $0.00 $0.00 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0!

$728.51 $741.97 $728.51 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $603.31 #DIV/0! $603.31 #DIV/0! $616.71 $616.71 #DIV/0!$5.95 $6.06 $5.95 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $4.93 #DIV/0! $4.93 #DIV/0! $5.04 $5.04 #DIV/0!

$863.29 $879.24 $863.29 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! $714.93 #DIV/0! $714.93 #DIV/0! $730.80 $730.80 #DIV/0!

NY B LBTY NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG NY P FRDM NG 85629NY0050232 85629NY0050233 85629NY0050234 85629NY0050235 85629NY0050236 85629NY0050237 85629NY0050238 85629NY0050239 85629NY0050240

Bronze Platinum Platinum Platinum Platinum Platinum Platinum Platinum Platinum0.645 0.885 0.885 0.885 0.885 0.885 0.885 0.885 0.885

Renewing Renewing Renewing Renewing Renewing Renewing Renewing Renewing RenewingPPO PPO PPO PPO PPO PPO PPO PPO PPO

No No No No No No No No No1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022 1/1/2022

21.11% 14.98% 14.98% 14.98% 14.98% 14.99% 14.99% 14.98% 14.98%

85629NY0050232 85629NY0050233 85629NY0050234 85629NY0050235 85629NY0050236 85629NY0050237 85629NY0050238 85629NY0050239 85629NY0050240$0 $43,703,598 $0 $67,469,178 $0 $3,636,489 $7,411,349 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0$0 $5,690,951 $0 $7,914,786 $0 $546,283 $1,298,077 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0$0 $38,012,647 $0 $59,554,392 $0 $3,090,206 $6,113,272 $0 $0$0 $485,317 $0 $1,054,537 $0 $36,091 $91,755 $0 $0$0 $28,726,301 $0 $62,418,884 $0 $2,136,272 $5,431,049 $0 $0

0 28,405 0 55,877 0 2,106 5,198 0 00 2,172 0 4,216 0 207 517 0 0

$600.12 $1,269.87 $1,266.66 $1,269.87 $1,266.66 $1,283.56 $1,283.56 $1,280.35 $1,280.35#DIV/0! 130.13% #DIV/0! 93.83% #DIV/0! 142.25% 110.69% #DIV/0! #DIV/0!

#DIV/0! $1,538.59 #DIV/0! $1,207.46 #DIV/0! $1,726.73 $1,425.81 #DIV/0! #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0!#DIV/0! $200.35 #DIV/0! $141.65 #DIV/0! $259.39 $249.73 #DIV/0! #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0!#DIV/0! $1,338.24 #DIV/0! $1,065.81 #DIV/0! $1,467.33 $1,176.08 #DIV/0! #DIV/0!#DIV/0! $17.09 #DIV/0! $18.87 #DIV/0! $17.14 $17.65 #DIV/0! #DIV/0!#DIV/0! $1,011.31 #DIV/0! $1,117.08 #DIV/0! $1,014.37 $1,044.83 #DIV/0! #DIV/0!

85629NY0050232 85629NY0050233 85629NY0050234 85629NY0050235 85629NY0050236 85629NY0050237 85629NY0050238 85629NY0050239 85629NY0050240

0.6964 1.3272 1.3238 1.3272 1.3238 1.3416 1.3416 1.3382 1.33820.9487 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.00001.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000

9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85% 9.85%2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84% 2.84%3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50%

1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000$727.03 $1,460.49 $1,456.75 $1,460.49 $1,456.75 $1,476.34 $1,476.34 $1,472.59 $1,472.59

$727.03 $1,460.49 $1,456.75 $1,460.49 $1,456.75 $1,476.34 $1,476.34 $1,472.59 $1,472.59

85629NY0050232 85629NY0050233 85629NY0050234 85629NY0050235 85629NY0050236 85629NY0050237 85629NY0050238 85629NY0050239 85629NY0050240$0 $34,961,839 $0 $67,863,311 $0 $3,368,150 $8,412,240 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0$0 $2,838,587 $0 $5,509,891 $0 $273,464 $682,998 $0 $0$0 $0 $0 $0 $0 $0 $0 $0 $0$0 $32,123,252 $0 $62,353,420 $0 $3,094,687 $7,729,242 $0 $0$0 $262,448 $0 $509,430 $0 $25,284 $63,148 $0 $0$0 $38,066,214 $0 $73,889,115 $0 $3,667,219 $9,159,190 $0 $0

0 26,064 0 50,592 0 2,484 6,204 0 0#DIV/0! 83.81% #DIV/0! 83.81% #DIV/0! 83.81% 83.81% #DIV/0! #DIV/0!

#DIV/0! $1,341.38 #DIV/0! $1,341.38 #DIV/0! $1,355.94 $1,355.94 #DIV/0! #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0!#DIV/0! $108.91 #DIV/0! $108.91 #DIV/0! $110.09 $110.09 #DIV/0! #DIV/0!#DIV/0! $0.00 #DIV/0! $0.00 #DIV/0! $0.00 $0.00 #DIV/0! #DIV/0!#DIV/0! $1,232.48 #DIV/0! $1,232.48 #DIV/0! $1,245.85 $1,245.85 #DIV/0! #DIV/0!#DIV/0! $10.07 #DIV/0! $10.07 #DIV/0! $10.18 $10.18 #DIV/0! #DIV/0!#DIV/0! $1,460.49 #DIV/0! $1,460.49 #DIV/0! $1,476.34 $1,476.34 #DIV/0! #DIV/0!

Rating Area Data Collection [assistive technology users, please reference cell A2 for instructions]Specify the total number of Rating Areas in your State by selecting the Create Rating Areas button or Ctrl + Shift + R.Press TAB and directional arrow keys to read through the document. If macros are disabled, press and hold the ALT key and press the F, then I, and then N key. After that, select the Enable All Content option by pressing enter. (note that you can also press the C key to select "Enable All Content") Instructions can be found in cells C1 through C4. If screen reader fails to announce a cell after performing a dropdown selection, please press F2 and then ESC to force the screen reader to resume.Select only the Rating Areas you are offering plans within and add a factor for each area.

To validate, select the Validate button or Ctrl + Shift + I.To finalize, select the Finalize button or Ctrl + Shift + F.

Rating Area Rating FactorRating Area 3 1.0554Rating Area 4 0.9922Rating Area 8 1.0226

Specify the total number of Rating Areas in your State by selecting the Create Rating Areas button or Ctrl + Shift + R.Select only the Rating Areas you are offering plans within and add a factor for each area.To validate, select the Validate button or Ctrl + Shift + I.To finalize, select the Finalize button or Ctrl + Shift + F.